11 Jan 2023

Collection of Data
o Gathering of information about the client
— Includes physical, psychological, emotion,
COLLECTION socio-cultural, spiritual factors that may affect
client’s health status
of — Includes past health history of client (allergies,
OBJECTIVE DATA past surgeries, chronic diseases, use of folk
healing methods)
— Includes current/present problems of client
(pain, nausea, sleep pattern, religious
practices, medication or treatment the client is
taking now)

Learning Objectives: Types of data:

At the end of this lesson, students should be able
to:
1. Identify the different types of equipment used in
an assessment and the proper ways to use them
2. Identify different position in carrying out the
physical assessment
3. Discuss different techniques for performing
inspection, palpation, percussion and
auscultation
Subjective data (symptoms or covert data): are
the verbal statements provided by the Patient.
Statements about nausea and descriptions of pain
and fatigue are examples of subjective data.
Objective data (signs or overt data): are
detectable by an observer or can be measured or
tested against an accepted standard. They can be
seen, heard, felt, or smelt, and they are obtained
by observation or physical examination.
For example: discoloration of the skin

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Objective Data
Objective data is the collection of medical
data that is measurable and substantiated.
This subset of data can be collected using
the five senses in a clinical setting.
The phrase "signs and symptoms" is
considered the "signs" of the patient's
reason for care.
Objective Data
Observation is the main component of
acquiring objective data.
 Healthcare professionals collect objective
data during their assessment period of the
patient. Whenever a nurse interacts with
their patient, they are compiling objective
information.
11 Jan 2023
Objective Data
Presentation
– Often represented as a numerical value or a
clinical term.
– These data points are considered unbiased
and reliable.
– Used to monitor the progression of a patient.
– Can be combined with subjective data to
form a more complete patient profile.
Data Collection
Methods:
1. Observing: to observe is to gather data by using
the senses.
2. Interviewing: an interview is a planned
communication or conversation with a purpose.
3. Examining: Performance of a physical
examination. The physical examination is often
guided by data provided by the patient. A head-to-
toe approach is frequently used to provide
systematic approach that helps to avoid omitting
important data
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COLLECTION OF Positions
OBJECTIVE DATA I. Sitting position
Areas Assessed:
1. Physical Examination Head and neck, back, posterior thorax and
• Preparation lungs, anterior thorax and lungs, breasts,
• Positioning axially, heart, vital signs, and upper
• Techniques extremities
2. Diagnostic test and Procedures
3. Other Sources e.g. client chart Rationale:
Sitting upright provides full expansion of
lungs and provides better visualization of
symmetry of upper body parts.

Preparation Positions
II. Supine position
o Environment o Positioning Areas Assessed: Head and neck
- Ensure privacy - Ensures accessibility to the anterior thorax and lungs, breasts,
- Quite, warm room body part being assessed.
- Special needs of the client axillae, heart, abdomen, extremities,
- Surface for placement of equipment o Draping and pulses
- Prevents chilling.
o Equipment - Prevents unnecessary
- Maintenance exposure.
Rationale: This is most normally
- Isolation precautions relaxed position. It prevents
- Adequate number of gloves contracture of abdominal muscles and
provides easy access to pulse sites

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Positions Positions
III. Dorsal position V. Sims’ position
Areas Assessed: Head and neck, anterior thorax and Areas Assessed: Rectum and vagina
lungs, Breasts, axillae and heart.
Rationale: Flexion of hip and knee improves
Rationale: Clients with painful disorders are more exposure of rectal area.
comfortable with knees flexed

Positions Positions
IV. Lithotomy position VI. Prone position
Areas Assessed: Musculoskeletal system
Areas Assessed: Female genitalia
and genital tract Rationale: This position is used only to assess
extension of hip joint.
Rationale: This position provides
maximal exposure of genitalia and
facilitates insertion of vaginal
speculum.

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Positions Techniques for

VII. Knee-chest position
Areas Assessed: Rectum.
Rationale: This position provides maximal
exposure of rectal area.
Examination
Inspection- observing, listening or smelling to
gather data
Palpation-assessment that uses sense of
touch
Percussion-act of striking one object against
another to produce a sound
Auscultation-act of listening with a
stethoscope to sounds produced with in the
body.

TECHNIQUES INSPECTION

The Art of Physical Examination

Deliberate, purposeful, observations
Using Techniques of :
in a systematic manner
• Inspection
Nurse use the physical senses:
• Palpation
visualizing, hearing, and smelling
• Percussion
• Auscultation

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Instrumentation or Equipment PALPATION

used for Inspection
• Ophthalmoscope- Examine the eyes
• Otoscope- examine the ears, mouth and nostrils
• Tuning fork – hearing
• Nasal speculum-visualized the turbinate of the
nose
• Stethoscope

Two Types of Palpation

Light Palpation – is performed to feel for surface abnormalities.
Instrumentation or Equipment
- Depress the skin ½ to ¾ (1 to 2 cm) with your finger pads,
used for vision screening using the lightest touch possible.

Snellen chart Deep Palpation- is used to feel internal organs and masses for
– used to check eye sight size, shape, tenderness.
– a card held 20 feet (6 meters) - Depress skin 1 ½” to 2” (4 to 5cm) with firm, deep pressure.
away.

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PERCUSSION AUSCULTATION
Percussion- the act of striking one object
against another to produce a sound Auscultation- act of listening with a stethoscope
– Percussion tones are used to assess location, to sounds produced with in the body.
shape, size and density of tissue
Four characteristics assessed by auscultation
Percussion Tones
• Resonance Pitch- ranging from high to low
• Hyper resonance Loudness- ranging from soft to loud
• Tympany Quality- gurgling or swishing
• Dullness Duration (short, medium, long)
• Flatness

PERCUSSION AUSCULTATION
Assess underlying structures for Auscultation
location, size, and density of - Listening to sounds produced by the body
underlying tissue.
Instrument: stethoscope (to skin)
• Direct Diaphragm –high pitched sounds
• Heart
• Indirect • Lungs
• Abdomen
• Blunt percussion Bell – low pitched sounds
• Blood vessels

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Diagnostic test &

Procedures
Examples of objective data:
– Diagnostic tests consist of procedures such REFERENCES

as bloodwork, X-rays, CT scans, and any

other test.
– Include any lab values, kidney function labs,
liver function tests, and metabolic panels.
– Vital signs include the patient's heart rate,
respiratory rate, blood pressure, and pulse
oximetry.
Dillon, P.M. (2015). Nursing Health Assessment A
CRITICAL THINKING, CASE STUDIES
APPROACH. 2nd edition. F. A. Davis Company,
Philadelphia, PA 19103
Weber, Janet R (2017). Health Assessment in
Nursing, 6th Edition. Lippincott Williams &
Wilkins

Other Sources:
Client Chart
Client medical charts display a patient's
key medical information so practitioners can
make more accurate diagnoses and develop
treatment plans with better outcomes.

The information found in patient charts

includes demographics, medications, family
history and lifestyle.