PREPARING FOR THE

EXAMINATION

How well you PREPARE the physical

setting, yourself, and the client can affect
the quality of the data you elicit. As an
examiner, you must make sure that you
have prepared for all three aspects before
beginning an examination.

Practicing with a friend, relative, or

classmate will help you to achieve
proficiency in all three aspects of
preparation.
PHYSICAL SETTINGS

❖hospital room
❖outpatient clinic
❖physician’s office
❖school health office
❖employee health office
❖client’s home.
It is important that the nurse strive to ensure that the examination setting meets the
following conditions:
✓ Comfortable, warm room temperature—Provide a warm
blanket if the room temperature cannot be adjusted.
✓ Private area free of interruptions from others—Close the door
or pull the curtains if possible.
✓ Quiet area free of distractions—Turn off the radio, television, or
other noisy equipment.
✓ Adequate lighting—It is best to use sunlight (when available).
However, good overhead lighting is sufficient.
A portable lamp is helpful for illuminating the skin and for
viewing shadows or contours.
✓ Firm examination table or bed at a height that prevents
stooping—A roll-up stool may be useful when it is necessary for
the examiner to sit for parts of the assessment.
✓ A bedside table/tray to hold the equipment needed for the
examination
✓ Assess your own feelings and
anxieties before examining the client.
Anxiety is easily conveyed to the
client, who may already feel uneasy
and self-conscious about the
examination.

✓ Self-confidence in performing a
physical assessment can be achieved
by practicing the techniques

✓ Prevent transmission of infectious

agents.
Approaching and Preparing the Client
The nurse–client relationship should be established during the
client interview before the physical examination takes place.
This is important because it helps to alleviate any tension or
anxiety that the client is experiencing. At the end of the interview,
explain to the client that the physical assessment will
follow and describe what the examination will involve. For
example, you might say to a client, “Mr. Smith, based on the
information you have given me, I believe that a complete
physical examination should be performed so I can better
assess your health status. This will require you to remove your
clothing and to put on this gown. You may leave on your underwear
until it is time to perform the genital examination.”
 Purposes of data validation:
• ensure that data collection is complete
• ensure that objective and subjective data agree
• obtain additional data that may have been overlooked
• avoid jumping to conclusion
• differentiate cues and inferences
 Data Requiring Validation
Not every piece of data you collect must be verified. For
example: you would not need to verify or repeat the client’s pulse,
temperature, or blood pressure unless certain conditions exist.
Conditions that require data to be rechecked and validated include:

•Discrepancies or gaps between the subjective

and objective data. For example, a male client
tells you that he is very happy despite
learning that he has terminal cancer.
 Data Requiring Validation
• Discrepancies or gaps between what the client says at one time and
then another time. For example, your female patient says she has
never had surgery, but later in the interview she mentions that her
appendix was removed at a military hospital when she was in the
navy

• Findings those are very abnormal and inconsistent with

other findings. For example, the client has a temperature
of 104o F degree. The client is resting comfortably. The
client’s skin is warm to touch and not flushed.
 Methods of validation
• Recheck your own data through a repeat assessment. For example, take the
client’s temperature again with a different thermometer.
• Clarify data with the client by asking additional questions. For example: if a
client is holding his abdomen the nurse may assume he is having abdominal
pain, when actually the client is very upset about his diagnosis and is
feeling

• Verify the data with another health care

professional. For example, ask a more
experienced nurse to listen to the abnormal heart
sounds you think you have just heard.

• Compare you objective findings with your

subjective findings to uncover discrepancies. For
example, if the client state that she “never gets
any time in the sun” yet has dark, wrinkled,
suntanned skin, you need to validate the client’s
ORGANIZING DATA
The nurse uses a written or
computerized format that
organizes the assessment data
systematically. The format may
be modified according to the
client's physical status.
 Body System Model

The BODY SYSTEMS MODEL (also

called the Medical Model or Review Of
Systems) focuses on the client’s major
anatomic systems. The framework
allows nurses to collect data about
past and present condition of each
organ or body system and to examine
thoroughly all body systems for actual
and potential problems.
 Gordon’s Functional Health Patterns:
The client’s strengths, talents and functional health patterns are an
integral part of the assessment data. An assessment of functional health
focuses on client’s normal function and his or her altered function or
risk for altered function.

• Health perception-health management pattern.

• Nutritional-metabolic pattern
• Elimination pattern
• Activity-exercise pattern
• Sleep-rest pattern
• Cognitive-perceptual pattern
• Self-perception-concept pattern
• Role-relationship pattern
• Sexuality-reproductive pattern
• Coping-stress tolerance pattern
• Value-belief pattern
PURPOSES OF DOCUMENTATION
• Offers a basis for determining the educational needs
of the client, family, and significant others.
• Provides a basis for determining eligibility for care
and reimbursement. Careful recording of data can
support financial reimbursement or gain additional
reimbursement for transitional or skilled care needed
by the client.
• Constitutes a permanent legal record of the care that
was or was not given to the client.
• Provides access to significant epidemiologic data for
future investigations and research and educational
endeavors.
GUIDELINES FOR DOCUMENTATION

• Document legibly or print neatly in unerasable ink

• Use correct grammar and spelling
• Avoid wordiness that creates redundancy
• Use phrases instead of sentences to record data
• Record data findings, not how they were obtained
• Write entries objectively without making premature
judgments or diagnosis
GUIDELINES FOR DOCUMENTATION
• Record the client’s understanding and perception of
problems
• Avoid recording the word “normal” for normal
findings
• Record complete information and details for all
client symptoms or experiences
• Include additional assessment content when
applicable
• Support objective data with specific observations
obtained during the physical examination
DOCUMENTATION