Objectives Identify observational techniques for determining the health status of a patient.
Unit 102.1 Observational Techniques Observation of Patient – observe physical signs and alertness – listen to patient and ask questions
Objective Data can be observed or tested by healthcare provider overt, not concealed Examples: – observe that a patient refused to eat – measure an increased temperature – observe drainage from a wound – skin is warm to the touch – vomited 300 cc
Subjective Data information perceived only by the affected person Examples: – feels nervous – pain in the abdomen – nauseated – feels chilled
Senses to Collect Data Look – observe visible signs that indicate a problem Listen – patient’s complaints, description of the problem in their words Feel – degree’s in body temperature, pulse quality Smell – unusual odors
Collecting Data Inspection visual examination – signs of movement and posture – skin color signs of distress – ability to maintain health practices (hygiene, dress) – gait
Collecting Data Auscultation listening with use of a stethoscope – blood pressure – heart sounds and/or rate – lung sounds – bowel sounds – detecting bruits
Collecting Data Palpation examination of body parts through feeling with fingertips and hands to – assess skin temperature – determine pulse rate, quality,rhythm, absence or presence – lumps/masses – abdominal tenderness/distention
Collecting Data Percussion tapping body parts with your fingers and listening to sounds produced to – detect presence of air – evaluate amount of fluid in a body cavity – determine size, borders and consistency of body organs or masses
Purpose of Systematic Physical Assessment to determine physical and emotional changes through step by step observation NOTE: – apparent state of health, does patient seem acutely ill?
Signs of Distress NOTE: dyspnea (difficulty breathing) vomiting pallor pain crying evidence of nervousness
Skin Color NOTE: – pink indicates adequate oxygen levels – pallor (pale) major organs being challenged with fluid or blood loss, peripheral blood is being shunted to the core of the body to self protect them – ashen (gray) body systems begin to suffer due to decreasing oxygen level in blood
Skin Color NOTE: – cyanotic (blue) indicates that body systems are in critical state due to an excessive amount of blood not carrying oxygen – flushed (pink/red) harmful levels of carbon monoxide or increased carbon dioxide levels are present Ketoacidosis (high blood glucose levels) will cause flushing, as will hypertension (high blood pressure)
Stature & Build NOTE: – large/small body frame – obesity – congenital anomalies (changes from normal at birth)
Posture, Motor Activity and Gait NOTE: – deformities – spine curvature – gait shuffling stable
Dress, Grooming and Hygiene NOTE: – if appropriate – clean – neat
Odors Body and Breath NOTE: – breath for acetone odor (may be diabetic) – alcohol odor (may be cause of problem) – urine odor (incontinence) – poor hygiene (emotional disturbances or social issues)
Relationships, Manner and Mood NOTE are they: – pleasant – smiling – making eye contact – initiating conversation – crying – appropriate conversation – following directions – depressed – anxious – agitated – elated – flat
State of Awareness and Consciousness NOTE, are they: – alert – oriented to: person place time and significant others – drowsy – is response time appropriate
Support or Monitoring Devices NOTE, does the patient use a: – walker – wheelchair – prosthesis – hearing aid – glasses – dentures – are these supports and devices working properly and is the patient knowledgeable in using them?
Reporting Observed Data – reporting should be done promptly, accurately, and objectively – identify need for emergency care – may play role in treatment plan by others – may indicate a need for medication changes – to know if patient is improving or not – documentation important for 3rd party payment (Insurance)
Knowledge Assessment Compare and contrast objective and subjective data and give examples of each. Define and give examples of when inspection, auscultation, palpitation, and percussion are used. Describe items of a physical assessment. (Example skin color, stature and build)