Module 2 Collecting Subjective Data

1. What are the ASSESSMENT METHODS?

2. Gathering data using the five senses, Noticing the stimuli and
selecting, organizing, and interpreting data
3. A planned communication or a conversation with a purpose to give
information, to identify problems of mutual concern, evaluate change,
teach, provide support, or provide counseling or therapy
4. Is a systematic data-collection method that uses observational skills
to detect health problems
5. Techniques used
6. Two approaches in interviewing
7. highly structured and elicits specific information
8. rapport-building; the nurse allows the client to control the purpose,
subject matter and pacing
kinds of interview questions
9. directive, strictive and requires short answers giving specific
information
10. non-directive, lead/invite clients to discover and explore their
thoughts and feelings
11. 3 basic phases in interview
12. Introductory phase
13. Special considerations during interview
History of past illness
14. How does it feel, look, smell, sound, etc.?
15. When did it begin; is it better, worse, or the same since it
began?
16. How long it lasts? Does it recur?
17. How bad is it on a scale of 1-10
18. What makes it better? What makes it worse?
19. aggravating, relieving factors
20. meaning of COLDSPA

Module 3 Collecting Objective Data

Equipments needed
For all examinations
1. to protect examiner in any part of the examination when the examiner
may have contact with blood, body fluids, secretions, excretions, and
contaminated items or when disease – causing agents could be
transmitted to or from the client.
For vital signs
2. measure diastolic and systolic BP
3. auscultate blood sounds when measuring BP
4. measure body temperature
5. time heart rate, pulse rate and respiratory rate
Standard precaution
6. Refers to handwashing with antimicrobial soap and water,
handwashing with antiseptic soap, using an antiseptic handrub
(waterless product the is alcohol- based), or performing surgical hand
antisepsis
7. is indicated when hands are visibly soiled
8. is permitted if hands are not visibly soiled or not come in contact with
surfaces
9. Wear when touching contaminated items, Change
between tasks and procedures on the same patient
10. Wear to protect mucous membranes of the eyes, nose, and
mouth during procedures and patient care activities that generate
splashes or sprays of blood, body fluids, secretions and excretions
11. Wear a clean, non- sterile. to protect skin and prevent soiling
of clothing during procedures
12. Handle used in a manner that prevents skin and
mucous membrane exposures, contamination and transfer of
microorganisms to other patients and environments. Ensure that
single-used items are discarded properly.
13. Ensure that the hospital has adequate procedures for routine
care, cleaning and disinfection of environmental surfaces, beds,
bedrails, bedside equipment, and other frequently touched surfaces,
and ensure that these procedures are being followed
14. Handle, transport, and process used and soiled properly

Positioning the Client

15. Good for evaluation of the head, neck, lungs, chest, back,
breasts, axillae, heart, vital signs, and upper extremities, Promotes
full expansion of the lungs, Allows examiner to assess symmetry of
upper body parts
16. Client is asked to lie down with the legs together on the exam
table (or bed).A small pillow may be placed under the head to
promote comfort, If client has trouble breathing, HOB may need to be
raised, Allows the abdominal muscles to relax and provides easy
access to peripheral pulse sites, Facilitates assessment of the neck,
 head, chest, breast, axillae, abdomen, heart, lungs, and all
extremities
17. Client lies down on the exam table or bed with knees bent , the
legs separated and the feet flat on the bed, More comfortable than
supine for clients with pain in the back or abdomen, Facilitates
assessment of the head, neck, chest, axillae, lungs, heart,
extremities, breasts and peripheral status.Abdomen should not be
assessed because the abdominal muscles are contracted in this
position
18. Client lie on her right or left side with the lower arm placed
behind the body and the upper arm flexed at the shoulder and elbow,
Lower leg is slightly flexed at the shoulder and elbow. The lower leg is
slightly flexed at the knee while upper leg is flexed at a sharper angle
and pulled forward, Useful for assessing the rectal and vaginal areas,
Clients with joint problems and elderly clients may have some
difficulty assuming and maintaining this position
19. Client stands still in normal, comfortable, resting posture, Allows
examiner to assess posture, balance and gait. Used also for
examining the male genitalia
20. Client lies down on his abdomen with head to the side Used
primarily to assess hip joint; the back can also be assessed, Clients
with cardiac and respiratory problems cannot tolerate this position
21. Client kneels on the exam table with the weight of the body
supported by the chest and knees, 90-degree angle should exist
between the body and the hips, Arms are placed above the head,
with the head turned to one side, Useful for examining the rectum,
Since this position may be embarrassing and uncomfortable,
therefore, clients should be kept In the position for a limited time
possible, Contraindicated for elderly clients and those with respiratory
and cardiac problems
22. Client lies on his or her back with the hips at the edge of the
examination table and the feet supported by stirrups, Used to
examine the female genitalia, reproductive tracts, and the rectum,
Client may require assistance in getting into this position, Elderly
clients may not be able to assume this position for very long or at all,
It is best to keep client well draped during the examination and to
perform the examination ASAP

For Anthropometric Measurements

23. measure skinfold thickness of subcutaneous tissue
24. measure height and weight
25. to measure mid-arm circumference
For skin, hair and nail examination
26. measure size of skin lesions
27. enlarge visibility of lesion
28. test for fungus
For head and neck examination
29. help client swallow during examination of the thyroid gland
For eye examination
30. test pupillary constriction
31. view the red reflex and to examine the retina of the eye
32. test near vision
33. test distant vision
34. test for strabismus
For ear examination
35. view ear canal and tympanic membrane
36. test for bone and air conduction of sound
For mouth, throat, nose and sinus examination
37. provide light to view the mouth and throat and to transilluminate
the sinuses
38. grasp tongue to examine mouth
39. view internal nose; may use nasal speculum
40. depress the tongue to view the throat, check looseness of
teeth, view cheeks and check strength of the tongue
For thoracic and lung examination
41. auscultate breath sounds
42. measure diaphragmatic excursion
For heart and neck vessel examination
43. auscultate breath sounds
44. measure jugular venous pressure
For abdominal examination
45. detect bowel sounds
46. mark area of percussion of organs to measure the size
47. placed under the knees and head to promote relaxation of the
abdomen
For female genetalia examination
48. Inspect cervix through dilatation of the vaginal canal
49. obtain endocervical swab and cervical scrape and vaginal pool
sample
 For anus, rectum and prostate examination
50. promote comfort of client
51. test for occult blood
For peripheral vascular examination
52. auscultate vascular sounds and measure BP
53. measure size of extremities for edema
54. detect light, blunt, and sharp touch
55. detect vibratory sensation
56. detect pressure and weak pulses not easily heard with a
stethoscope
For musculoskeletal examination
57. measure size of extremities
58. measure degree of flexion and extension of joints
For neurologic examination
59. test vibratory sensation
60. test for light, sharp,
61. and dull touch and two-point discrimination
62. test for smelling perception
63. test for taste perception
64. test for rise of uvula and gag reflex
65. test for stereognosis (ability to recognize objects by touch)
66. test deep tendon reflex

Performance of the 4 examination/assessment techniques

67. Involves using the senses of vision, smell and hearing to
observe and detect any normal or abnormal findings, Precedes
palpation, percussion, and auscultation
Types of inspection
68. involves directly looking at your patient.
69. involves using equipment to enhance visualization.

70. Consists of using parts of the hand to touch and feel for the
following characteristics
71. What are the characteristics?
Three parts of the hand
72. fine discriminations: pulses, texture, size, consistency, shape,
crepitus
73. vibration, thrills, fremitus
74. temperature
 NOTE: In general, the examiner’s fingernails should be short and the
hands should be a comfortable temperature. Standard precautions
should be followed. Proceed from light palpation, to moderate
palpation and finally to deep palpation.
Types of palpation
75. Light palpation is best for assessing surface characteristics,
such as temperature, texture, mobility, shape, and size. It is also
useful in assessing pulses, areas of edema, and areas of tenderness.
Closing your eyes while palpating may help you concentrate better on
what you are feeling.
76. Depress the skin surface 1 to 2 cm (0.5-0.75 in.) with your
dominant hand and use circular motion to feel for easily palpable
body organs and masses. Note size, consistency, and mobility of
structures.
77. is used to assess organ size, detect masses, and further
assess areas of tenderness. To assess for rebound tenderness, press
down firmly with your dominant hand and then lift it up quickly. An
increase in the patient’s pain when you release the pressure signals
rebound tenderness.
78. Use two hands, placing one on each side of the body part (e.g.,
uterus, breasts, spleen) being palpated. Use one hand to apply
pressure and the other hand to feel the structure. Note the size,
shape, consistency, and mobility of the structures you palpate.

79. Tapping body parts to produce sound waves. These sound

waves or vibrations enable the examiner to assess underlying
structures
Different assessment uses
80. helps to detect inflamed underlying structures. If an inflamed
area is percussed, the client’s response may indicate or the client will
report that the area feels tender, sore, or painful.
81. Percussion note changes between borders of an organ and it
neighboring organ can elicit information about location, size and
shape.
82. Percussion helps to determine whether an underlying structure
is filled with air or fluid or is a solid structure.
83. Percussion can detect superficial abnormal structures or
masses. Percussion vibrations penetrate approximately 5 cm deep.
Deep masses do not produce any change in the normal percussion
vibrations.
84. DTR are elicited using the percussion hammer
Types of percussion
85. direct tapping of body part with 1 or 2 fingertips to elicit sound
or possible tenderness (e.g., tenderness over the sinuses).
86. Is the most commonly used method of percussion. This type of
tapping produces a sound or tone that varies with the density of
underlying structures.
87. used to detect tenderness over organs (e.g., kidneys) by
placing one hand flat on the body surface and using the fist of the
other hand to strike the back of the hand flat on the body surface.
Direct or indirect
88. involves striking a body surface with the ulnar surface of your
fist.
89. involves placing your non-dominant hand over the body surface
and then striking that hand with the ulnar surface of your other fist.

90. Requires the use of a stethoscope to listen for heart sounds,

movement of blood through the cardiovascular system, movement of
the bowel, and movement of air through the respiratory tract.
91. Sounds detected are classified according to?