Chapter 47 Data Collection in Client Care

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 47

Data Collection in Client Care

Chapter 47

Data Collection in Client Care


Collecting Data and Physical ExaminationCollecting Data and Physical Examination

• Identifies and clarifies a client’s health status

• Medical diagnosis

– Primary healthcare provider

– *Emphasizes disease process

– *Identifies the disease or disorder

– Estimates disease’s

• Course

• Outcome (prognosis)


Collecting Data and Physical Examination, cont.Collecting Data and Physical Examination, cont.

• Nursing diagnosis

– Concise problem-centered description of actual or potential health problems

– Based on nursing process

• For unusual problems that may arise, provide needed care measures within nurses scope of practice

– Stated in terms of NANDA groupings


Data Collection to Assist in DiagnosisData Collection to Assist in Diagnosis

• Nursing history or interview

• Physical findings

• Observation/assessment findings

– Documented in language all members of healthcare team understand


Data CollectionData Collection

• **COLDSPA

– Character

– Onset

– Location

– Duration

– Severity

– Pattern

– Associated Factors


Nursing Care Plan and Data CollectionNursing Care Plan and Data Collection

• Nursing care plan

– All members of the healthcare team participate in carrying out the plan.

• Factors that influence data collection

– Risk factors for disease and illness

– Course of the disease, body’s response to the disease

– Laboratory tests and special diagnostic procedures


Data CollectionData Collection

• Risk factors for disease

– Diet, immobility, lack of exercise, age, obesity, smoking and use of smokeless tobacco, excessive use of alcohol and other drugs, heredity, and race

• Course of the disease

– Acute disease

– Chronic disease

– Primary disease

– Secondary disease


Factors That Influence the Course of the Disease or DisorderFactors That Influence the Course of the Disease or Disorder

• Acute disease

– Develops suddenly and runs its course in days or weeks

• Chronic disease

– Continues for months, years, or life

• Acuity

– Level of severity


Factors That Influence the Course of the Disease or Disorder, cont.Factors That Influence the Course of the Disease or Disorder, cont.

• Complication

– Unexpected event in the disease’s course that often delays recovery

• Primary disease

– Occurs independently by itself

• Secondary disease

– Direct result of or dependent on another disorder


Body’s Response to DiseaseBody’s Response to Disease

• Signs

– Objective evidence (data) of disease that can be seen or measured

• Symptoms

– Subjective evidence (data) of disease; sensations that only the client knows and can report


Body’s Response to Disease, cont.Body’s Response to Disease, cont.

• Inflammation

– Body’s response to some type of injury

• Infection

– Invasion of cells, tissues, or organs by pathogens

• Malaise

– Overall feeling of illness



• Exudate

– Excess of fluid and cells usually present in or oozing from tissues

• Purulent

– Contains pus

– D/t presence of bacteria

• Suppuration

– Formation of pus



• Abscess

– Collection of pus in a localized area

• Necrosis

– Tissue death

• Granulation tissue

– New tissue

• Ulcer

– Local unhealed area of epithelial tissue

– Healed area-scar or keloid



• Wound sinus

– Canal or passage leading to an abscess

• Fistula

– Abnormal tube like passage that connects two internal organs, or connects an internal organ to the surface of the body

• Chronic inflammation

– Persists over a long period of time

– Does not follow the usual healing process



• Subacute inflammation

– Midway in severity between acute and chronic

• Acute inflammation

– Heals and leaves no aftermath or other related disorders (sequelae)


Examples of Laboratory TestsExamples of Laboratory Tests• Urinalysis (UA)

• *Complete blood count (CBC)

• *Urine drug/alcohol screen (UTox)

• *Urine pregnancy test (UPT)

• *Culture and sensitivity

(C&S)

*Type and crossmatch

(T&X)

• Stool examinations

– *Blood (guaiac or Hemoccult)

– Ova and parasites (O&P)

• Blood tests

• *Metabolic panel

– baseline data, differentiate mental illness from other disorders, evaluate clients with total body situations (ETOH, drug toxicity, assess # of organs at once)

• Blood chemistries


*Selected Diagnostic Tests*Selected Diagnostic Tests

• Skin tests

– Patch/scratch

• Musculoskeletal tests

• Neurologic tests

• Cardiovascular tests

– Stress test

– Echocardiogram

– Cardiac catheterization


*Selected Diagnostic Tests*Selected Diagnostic Tests• Respiratory tests

– Chest radiograph

– Pulse oximeter

– Bronchoscopy

– ABG

• Gastrointestinal tests

– Oral endoscopy

– Barium enema

• Urologic tests

– Urinalysis (UA)

• Gynecologic tests


Xrays and other examsXrays and other exams

• Spirometry

• Pulmonary function tests

– Help determine respiratory status


Special Types of Diagnostic ProceduresSpecial Types of Diagnostic Procedures

• Determine abnormalities or disorders of various body systems

• *Endoscopy (endoscope)

– Long, slender, flexible tube with a fiberoptic scope (similar to a TV camera) on the end

– Passed through body orifice to examine internal body areas

– Esophagoscopy

– Sigmoidoscopy


Lumbar Puncture (LP), Spinal TapLumbar Puncture (LP), Spinal Tap

• Indicates some disorders and conditions of nervous system

– Determines intracranial pressure (ICP)

– Indicates presence of abnormal components

– Used to administer drugs or spinal anesthesia


Preparing the Client for Diagnostic ProceduresPreparing the Client for Diagnostic Procedures

• **Informed consent is required for most procedures.

• Explain the procedure and the need for the procedure.

• Nursing responsibilities

– Assist the client to maintain NPO status, special diet, or medications before examination.

– Transport the client.

– Update client record.

– Position and drape the client.

– Frequent vital sign monitoring.


Responsibilities Relating to Diagnostic Examinations/ProceduresResponsibilities Relating to Diagnostic Examinations/Procedures

• Client responsibilities

– Maintain nothing by mouth (NPO) status

– Eat a special meal before the examination

– Take specific medications prior to the examination

• Nursing responsibilities

– Reassure client

– Teach and answer questions

– Use therapeutic listening skills


Physical ExaminationPhysical Examination

• The goals of data gathering and physical assessment performed by nurses are to:

– Distinguish between normal and abnormal.

– Identify potential problems.

– Promptly report changes, unusual or abnormal findings to the appropriate person.

– Deliver client care within the prescribed scope of practice.


Examination TechniquesExamination Techniques

• Inspection

– Careful, close, and detailed visual examination of a body part

• Palpation

– Feeling body tissues or parts with hands or fingers

• Auscultation

– Listening with stethoscope or ultrasound blood-flow detector (Doppler)

• Percussion

– Tapping or striking the fingers against body; resulting sounds indicate the place and density of body tissues or organs


Examination ToolsExamination Tools


Tools Used in an ExaminationTools Used in an Examination

• Ophthalmoscope

– Instrument to look at retinas of eyes through pupils

• *Otoscope

– Instrument to examine ear canals and eardrum

• Tuning fork

– Checking hearing

• Reflex hammer

– Test reflexes


Tools Used in an Examination, cont.Tools Used in an Examination, cont.

• Speculum

– Vaginal speculum

– Nasal speculum

• Neurological testing

– Devices to test the tactile senses of sharp, soft, hot, or cold, eg, pin, ice, hot pack, cotton swab, etc.

– Test for ability to smell and taste substances


ExaminationExamination

• Preparing for the physical examination

• Performing the physical examination

– Head-to-toe method

– Body systems

– Focused physical examination

• One body system is thoroughly examined*

• Caring for the client following any examination or testing.



General ExaminationGeneral Examination• Emaciation

– Physical wasting

• Skin assessment

– Turgor

• Skin resiliency and plumpness

– Erythema

• Redness

– Pallor

– Edema

– Temp

– Ecchymosis

• Bleeding into the tissues under the skin, leaving small bruises


Skin Color VariationsSkin Color Variations


Normal and Abnormal FingernailsNormal and Abnormal Fingernails


General Examination, cont. General Examination, cont.

• Skin assessment, cont.

– Anasarca

– Serous

• Containing clear fluid

– Purulent

• Consisting of or secreting pus

– Serosanguineous

• Fluid composed of serum and blood


Primary Skin LesionsPrimary Skin Lesions


Head and Neck AssessmentHead and Neck Assessment

• Cognitive function

– Ability to think and reason

– Baseline mental status

– *Glascow Coma Scale

• Dysphasia

– Difficulty in understanding or expressing language

• Conjunctivitis

– Commonly called pink eye; inflammation of the conjunctiva


Head and Neck Assessment, cont.Head and Neck Assessment, cont.

• Accommodation

– Adjustment, as the accommodation of the lens of the eye

• Strabismus

– Deviation of the eye; squint

• Diplopia

– Double vision

• Rinne and Weber test

• Snellen Chart

– 20/20 vision


Musculoskeletal AssessmentMusculoskeletal Assessment

• Homans’ sign

– Test for thrombophlebitis in which pain occurs behind the knee when the foot is flexed upward (dorsiflexion)

• Thrombophlebitis

– Formation of a blood clot in a vein, with inflammation

Abduction

Adduction


Curvatures of the SpineCurvatures of the Spine• Lordosis

– Abnormal increase in the lumbar curvature of the spine

– Also known as “swayback”

• Kyphosis

– Abnormal increase in the thoracic curvature of the spine

– Hunchback appearance, commonly R/T osteoporosis

• Scoliosis

– Lateral curvature of the spine

– Sometimes is S-shaped


Cardiovascular AssessmentCardiovascular Assessment

• Heart Sounds

• Pulse

– Rate

– equality


Types of Lung Sounds (Adventitious Sounds)Types of Lung Sounds (Adventitious Sounds)

• Crackles (also known as “rales”)

– Small airway obstruction, may be local or generalized

• Rhonchi: larger airway obstruction heard by auscultation, deep sound, may be local or generalized

• Wheezes (may be inspiratory and/or expiratory)

– Whistling respiratory sound, typical of asthma

• Stridor: shrill and harsh sound heard on expiration


Abnormal (Adventitious) Lung SoundsAbnormal (Adventitious) Lung Sounds


Abdominal AssessmentAbdominal Assessment

• Stool Guaic

• Striae

– Stretch marks

• Herniation

– Condition in which there is an abnormal protrusion of an organ or tissue through the structure usually containing it

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Chapter 47 Data Collection in Client Care