Data Collection in Client Care (Nursing) Part 2

Client and Family Teaching

The nurse must remember at all times that the client and family are important members of the healthcare team. It is vital that they know what is to be done and what to expect. The nurse has the responsibility to teach the client about every procedure and to answer questions before any procedure is done.

Key Concept It is important for you as a nurse to realize that medical procedures and terminology are all foreign to the client. It may be difficult to remember how much you have learned during your nursing program. Try to remember how you felt when you first heard medical language or observed medical and laboratory procedures. Explain terms to the client and the family so they can understand. This will help the client to be more comfortable and will improve the accuracy of the test or procedure.

NCLEX Alert An NCLEX situation commonly incorporates various new educational topics that a client must learn about to improve his/her health status. These topics are individualized and include areas such as nutritional or dietary concerns, observation of wounds after discharge, or demonstration of self-injection of insulin. Part of these lessons will include putting medical terminology into phrases, examples, or language that is understood by the client. You may be asked to choose the best response that addresses the client’s needs for instruction.

Endoscopy

An endoscope is a long, slender, flexible tube with a fiberoptic scope (similar to a TV camera) on the end. The provider passes this tube through a body orifice to examine internal body areas. The use of endoscopes can help determine a client’s digestive or respiratory structure and function. Specially trained providers examine areas such as the esophagus (esophagoscopy), stomach (gastroscopy), large intestine (colonoscopy), or rectum (sigmoidoscopy). A bronchoscope is used to examine the trachea, bronchi, and lungs (bronchoscopy). Minor surgical procedures can also be performed via endoscopy. Procedures such as polyp removal and biopsy are common. These procedures are minimally invasive, because they do not require an incision.

Endoscopy is also used for surgery and tests of internal areas of the body, via a tiny incision. Abdominal surgery is done using the laparoscope; joint surgery uses the arthro-scope. These procedures are invasive, but much less invasive than traditional incisional surgery.

Biopsy

If a growth or body tissue appears questionable, a biopsy is performed to determine the presence of cancer or other disorders. The provider obtains a piece of tissue or a small amount of fluid and sends it to a laboratory, where it is examined microscopically. A biopsy specimen may be obtained with an endoscope or needle or by making an incision through the skin. A special syringe or cutting device may also be used to withdraw a specimen. The examiner may obtain a biopsy specimen of a woman’s cervix during a pelvic examination.

X-ray and Other Examinations

Many tests that do not require surgery can yield valuable diagnostic information about the status of the body’s internal organs and structures. They include x-ray and fluoroscopy examinations of all body areas (e.g., upper and lower gastrointestinal series, kidney films, or x-ray examinations of bones to determine fractures and other pathology), ultrasonography (ultrasound), CT scan, magnetic resonance imaging (MRI), and electroencephalogram (EEG). The positron emission tomography (PET) scan combines intravenous (IV) administration of radioactive isotopes and the E-CAT scan to image tissues and their functioning. (Unlike MRI and CT imaging, the PET scan can provide data regarding body structure and function, as well as biochemical information, such as utilization of fatty acids, glucose, oxygen, and protein. PET imaging can also differentiate between new tumor growth and dead tissue).

Spirometry and pulmonary function tests help to determine a client’s respiratory status. Tests such as the electrocardiogram (ECG or EKG) and the stress test help evaluate a client’s cardiovascular status. These procedures are for the most part noninvasive, requiring no incisions or injections. However, some of these procedures require a very small incision (called a “stab wound”) or the injection of dye (contrast media). Some dyes are radioactive. Box 47-2 describes necessary precautions when dye is used.

Lumbar Puncture

A lumbar puncture (LP), also called a spinal tap, may be done to determine the status of the client’s nervous system. Lumbar puncture can determine intracranial pressure (within the head and spinal cord) and the presence of abnormal components, such as blood, pathogens, or pus in the cerebrospinal fluid, or it can be done to inject drugs or spinal anesthesia.

Arteriography

An arteriogram is a procedure in which a catheter is inserted into a blood vessel in order to visualize a particular area via fiberoptics. Contrast media may be used, in combination with x-ray. Many areas of the body are examined and treated using arteriography, particularly the heart and large blood vessels. This procedure is often used to place a stent (a device that expands and keeps a vessel open), to perform angioplasty (a procedure to enlarge the lumen of a blood vessel), place tubes or filters, embolize tumors (introduction of a substance to occlude a vessel or obstruct a tumor), or drain an abscess.

BOX 47-2. Precautions When Tests Are Performed Using Dye

In any procedure in which a dye or contrast medium is used, a skin test may be done first, to determine if the client is sensitive to that dye. Ask if the client is allergic to shellfish or iodine. (If so, notify the physician immediately Many dyes contain iodine or similar chemicals.)

During, and for about one-half hour after the test, be alert for signs of anaphylaxis (an exaggerated and life-threatening allergic reaction). Data collection includes noting untoward signs such as:

♦    Restlessness, apprehension, agitation

♦    Weakness

♦    Perspiration; cold, clammy skin

♦    Tingling sensations, numbness

♦    Sneezing, nose itching

♦    Rash, generalized pruritus (itching)

♦    Watery, itchy eyes

♦    Throbbing in the ears

♦    Difficult breathing, wheezing, choking sensation, coughing

♦    Rapid, thready, or irregular pulse; heart palpitations

♦    Lowered blood pressure

♦    Swelling or edema

♦    Flushed skin

♦    Incontinence

♦    Seizure or stroke

♦    Coma

Usually an anaphylactic reaction involves either respiratory or cardiovascular symptoms but not both. If you observe any of these symptoms, notify the team leader or the physician immediately. Death can result very quickly (within 1-2 minutes) if the allergy is severe and it is not treated at once.

In addition, after the use of dye, the nurse should do the following:

♦    Encourage fluid intake—the client should drink 2 to 3 liters of fluid within the next 24 hours (to help the body excrete the dye).

♦    Monitor urine output—report output of less than 30 mL per hour (because the dye can be harmful to the kidneys and may impair kidney function).

♦    Report any untoward symptoms or severe client complaints.

Ultrasound Imaging (Sonography)

Ultrasound (very high frequency sound) is used to examine nearly every structure in the body. Ultrasonic waves are produced by a transducer, which creates “echoes.” These echoes are directed at body tissues and some are relayed back to the transducer, depending on their density. The computer converts these echoes to a “picture,’ which is used to visualize structures in the body and to determine abnormalities. Ultrasonography is particularly useful in obstetrics, to visualize the fetus, and to determine size and a multiple pregnancy. It is used to diagnose tumors in many areas of the body, including heart and blood vessels, abdominopelvic organs, and eyes. Ultrasonography can visualize kidney stones, gallstones, or bladder stones.

Preparing the Client for Diagnostic Procedures

Clients must completely understand what is to be done in a procedure. Informed consent is required for most procedures. This means that the client has had a full explanation of the test, the reasons for the test, what to expect during the procedure, and possible adverse effects of the test before signing the permission form for the test. Clients who know what to expect are likely to be less apprehensive and more relaxed during the examination.

When assisting with all tests and examinations, follow Standard Precautions to protect yourself, clients, and other healthcare staff. In areas of high radiation exposure (e.g., Radiology Department), healthcare workers and clients wear lead shields to protect vital organs from overexposure to radiation. (The staff in these areas can instruct you as to specific precautions.) Many diagnostic tests are discussed throughout this book in connection with specific body disorders.

Key Concept Remember that before and after any interaction with a client, including data collection, it is important to wash or sanitize your hands. This helps to prevent the spread of infection.

Nursing Responsibilities in Diagnostic Examinations

The nurse has a number of responsibilities before and during special diagnostic examinations. These include assisting the client to maintain NPO (nothing by mouth) status or to eat a special meal before the examination; giving special medications before the examination; and reassuring the client and answering questions. The nurse often transports the client to a designated area of the facility for special tests. It is the nurse’s responsibility to make sure that the client’s record is up to date before the test; sometimes, a special checklist is used. The nurse assists the client to dress properly (usually in a hospital gown) and assures that the client either voids or does not void before the test, as ordered. The nurse often helps to position and drape the client and may remain during the test. In some cases, frequent vital sign monitoring and other special nursing care is required after the test.

THE PHYSICAL EXAMINATION

The physical examination is a tool that healthcare providers use to distinguish between normal and abnormal body structure and function. Each provider, however, has different goals when performing the examination. A physician will look for abnormalities to establish a medical diagnosis, monitor a disease’s progression, or evaluate changes in the client’s condition. The physician’s examination may be extensive and thorough, or it may focus on a particular body area. A physical therapist will examine the client’s functional abilities and ability to move, to develop a therapy plan and monitor the client’s progress. A dentist or dental hygienist will examine only the client’s mouth structures. Occupational therapists often determine the client’s level of functioning in self-care.

Nurses have several goals when examining clients. The primary purpose is to determine the client’s physical condition, and to identify potential or actual problems that can be prevented or treated. Because nurses assess physical, emotional, psychological, developmental, and spiritual aspects, their examination can help determine how a client’s physical condition affects overall health and functioning. This information lays the groundwork for nursing diagnosis and then for developing a nursing care plan to meet client needs. The LPN/LVN helps to collect data needed to develop the care plan.

Key Concept Remember to explain to the client what you are doing and why.

If a client complains of physical symptoms, the affected body area is examined for signs that might explain the symptoms. For example, if the client complains of constipation and gas pains, the nurse will inspect and then auscultate (listen to) the abdomen in all four quadrants with a stethoscope. The nurse will also lightly palpate the abdomen to determine physical clues about the source of the pain. (Deep palpation should be avoided by the nurse unless he or she has had specific training.) Another important purpose of the examination is to evaluate the outcomes of nursing and medical treatments, such as the client’s response to medications or physical therapy.

Key Concept Palpation is done only after inspection and auscultation, to prevent pockets of gas from moving in the intestines and being mistaken for normal bowel sounds.

Because nurses collaborate with other healthcare professionals to provide care, each healthcare worker must report and record continuing assessments promptly so other providers may act as needed. Carefully documented data about physical findings portrays a picture of the client’s condition over time.

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

•    Distinguish between normal and abnormal

•    Identify potential problems

•    Promptly report changes and unusual or abnormal findings to the appropriate person

•    Deliver client care within the prescribed scope of practice

As does the primary healthcare provider, nurses examine the client’s entire body regularly to determine changes or may focus on a particular body part when the client has a complaint. For example, the nurse may examine only the abdomen when the client complains of constipation.

Examination Abilities and Techniques

Effective oral and written communication skills are essential to successfully interview the client and accurately document findings. Knowledge of the body’s normal structure and function (see Unit 4) is crucial, in order to understand the relevance of findings. Objectivity ensures that all examiners approach the physical examination without previously set expectations.

The healthcare examiner uses five techniques to find information:

•    Observation: the technique of looking at the client or watching for general characteristics, such as overall appearance, skin color, grooming, body posture, gait, mood, interactions with others, and other factors that do not require closer scrutiny or the use of measurement aids (e.g., a stethoscope).

•    Inspection: careful, close, and detailed visual examination of a body part (Fig. 47-1A)

•    Auscultation: listening for sounds from within the body, usually with the aid of a stethoscope or an ultrasound (Doppler) (Fig. 47-1B)

•    Palpation: feeling body tissues or parts with the hands or fingers (Fig. 47-1C)

•    Percussion: tapping or striking the fingers or a special “percussion hammer” against the body; the resulting sounds indicate the location and density of body tissues or organs. Percussion requires a high level of expertise, developed with experience.

Common abbreviations used in documentation are listed in Table 37 4. A list of Joint Commission “Do Not Use” abbreviations appears in Table 37-5.

Examination Tools

Several tools are used during the physical examination. Although the examiner’s own eyes, ears, hands, and nose may be the most important tools, the examiner also uses items such as the thermometer, stethoscope, sphygmomanometer, and tongue blade. For example, the client is asked to perform a number of activities to test the function of the cranial nerves (see In Practice: Data Gathering in Nursing 47-1).

For more complex examinations, primary care providers use an ophthalmoscope (instrument to look at the retinas of the eyes through the pupils), an otoscope (instrument to examine the ear canals and eardrum), a tuning fork (for checking hearing), and a reflex hammer (to test deep tendon reflexes; see In Practice: Nursing Care Guidelines 47-1). A vaginal speculum and a nasal speculum are other instruments used for specialized examinations. Primary care providers may also use some type of device to test the tactile senses of sharp, soft, hot, or cold and use substances to test smell and taste. Figure 47-2 shows several instruments used in physical examinations.

Examination Format

A common format for the physical examination is the head-to-toe method. It begins with a general appearance examination, then moves to the head, and proceeds to the neck, chest, breasts, abdomen, arms, legs, back, and perineum. As the examiner moves to each area, the focus is not only on the structures, but also on the functions of these body areas. The head-to-toe method flows smoothly and provides the examiner with a mental road map of directions to follow while conducting the examination.

FIGURE 47-1 · Techniques used in data collection. (A) Inspecting the mouth using a tongue blade and penlight. The nurse wears gloves for this procedure. (B) Auscultating the chest using the stethoscope. (C) Lightly palpating the throat using the fingertips.

IN PRACTICE: DATA GATHERING IN NURSING 47-1

GROSS FUNCTIONING OF CRANIAL NERVES

The gross functioning of most of the cranial nerves can be observed by simple actions. For example, the examiner asks the client:

Action To follow a moving finger	Cranial Nerve Evaluated III Oculomotor
with the eyes (with or	IV Trochlear
without moving the head)	VI Abducens
To move or clench the jaw	V Mandibular branch of
	the trigeminal
To smile or make a funny face	VII Facial
To stand with the eyes closed	VIII Vestibular division of the vestibulocochlear
To swallow	IX Glossopharyngeal
To shrug the shoulders and turn the head	XI Accessory
To stick out the tongue and move it from side to side	XII Hypoglossal

IN PRACTICE :NURSING CARE GUIDELINES 47-1

MEASURING REFLEXES

Some reflexes can be observed because they occur spontaneously, such as automatic constriction of the pupil when a light is shined into the eye. Other reflexes must be specifically elicited.

To elicit deep tendon reflexes:

1.    A reflex hammer is used in adults; a finger will work well to elicit most infant reflexes.

2.    The hammer is held between thumb and index finger.

3.    Extremity is positioned so the tendon is slightly stretched.

4.    The client is asked to relax. (May require distraction techniques, to assist the client to relax.)

5.    Tendon is struck briskly using a full swinging motion.

6.    This is repeated on the other side of the body

7.    Results from both sides are compared.

8.    Normally reflexes should be the same on both sides.

9.    Reflexes are graded on a scale from 0 to 4 + . A reflex graded 2+ is considered normal. Above this, reflexes are considered hyperactive (very brisk). Below this level, they are considered hypoactive (weak) or absent (written as "0”).

10.    All findings are documented.

11.    The appropriate person is notified of abnormal findings or a change from previous readings.

The other common format used in the physical examination is similar to the head-to-toe but focuses instead on body systems (e.g., musculoskeletal, nervous, cardiovascular, respiratory, digestive). (This textbook is organized in relationship to body systems.)

A variation of this format is the focused physical examination, in which one body system is thoroughly examined because the client has a particular complaint or problem in that area. For example, the client admitted to the Emergency Department complaining of chest pain and severe shortness of breath will have a focused cardiovascular and respiratory examination. The examination of a pregnant woman will focus on her pregnancy and fetus. Table 47-4 compares the techniques.

FIGURE 47-2 • Basic equipment and supplies used for physical examination and data gathering. Left-to-right (clockwise)—gloves, penlight (with measurements for papillary size or purified protein derivative [PPD] test evaluation), percussion hammer (to test reflexes), tuning fork (to test hearing, bone conduction, sense of touch), stethoscope (for auscultation), tongue blade (for mouth examination), cotton-tipped applicator and cotton ball (various uses, such as obtaining specimens), ophthalmoscope (for eye examinations); otoscope (for ear and nose examinations), bottom: measuring tape. 

Each examiner develops an examination method that is thorough but brief, accurate, and easy to use. When techniques are correct, findings agree among healthcare providers. The primary healthcare provider is expected to interpret the findings, based on data collected by all members of the team. As the nurse’s expertise and knowledge grow, an understanding of the meaning of these findings will also develop. Some healthcare agencies require all nurses to use the same method of data collection and provide documentation data sheets or electronic pages for recording these findings.

Preparing for the Physical Examination

Before any examination, it is necessary to explain the purpose of it to the client (Fig. 47-3), answer questions, and provide privacy for the client. Ask the client to empty the bladder or bowel if necessary. (See Table 48-1 for examination positions.)

Performing the Physical Examination

Guidelines for performing the head-to-toe data collection of an adult and special considerations for the child follow.