7.4 : Data Collection III

The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.

The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.

The methods of physical examinations are inspection, palpitation, percussion, and auscultation. Inspection is examining the patient through visualization. Palpation exerts minimal pressure via touching body parts and identifying the organ's size, contour, and tenderness. Percussion is a tapping technique over internal organs, joints, and muscles, assessing the density of underlying tissues for fluid, air, or solid fill. Finally, auscultation is listening to various sounds in organs using a stethoscope.

A complete assessment includes a patient's height, weight, vital signs, and a head-to -toe examination of all body systems. The data from a hands-on physical assessment allows for collection of valuable objective information needed to form an accurate diagnostic conclusion. Problems in data collection include:

• An inappropriate organization or omission of pertinent data
• The inclusion of irrelevant or duplicate data
• Failing to record observed behavior
• Collecting erroneous or misinterpreted data
• Failing to establish rapport
• Failing to update data