Objective Data

1. General - provides information on the patient as a whole.

1. Race, sex, apparent age in relation to stated age.
2. Nutritional status-well hydrated and developed or obesity, cachexia-include weight.
3. Apparent health status-general good health or mild, moderate, severe debilitation.
4. Posture and motor activity-erect, symmetrical, and balanced gait and muscle development or ataxic, circumducted, scissor, or spastic gait; slumped or bent-over posture; mild, moderate, or hyperactive motor responses.
5. Behavior- alert; oriented to person, time, place; hears and comprehends instructions, or tense, anxious, angry; uses abusive language; slightly or largely unresponsive; delusions, hallucinations.
6. Odors-noncontributory, or acetone, alcohol, fetid breath, incontinent of urine or feces.


2. Physical assessment - requires knowledge of normal findings, organization, and keen senses, i.e., visual, auditory, touch, smell. For abnormal findings, refer to the Assessment section of each health problem discussed under the categories of human functioning.
1. Components
1. Inspection - uses observations to detect deviations from normal.
2. Auscultation - used to perceive and interpret sounds arising from various organs, particularly heart, lungs, and bowel.

3. Palpation - used to assess for discomfort, temperature, pulsations, size, consistency, and texture.
4. Percussion - technique used to elicit vibrations produced by underlying organ structures; used less frequently in nursing practice.
1. Flat - normal percussion note over muscle or bone.

2. Dull - normal percussion note over organs such as liver.

3. Resonance - normal percussion note over lungs.

4. Tympany -normal percussion note over stomach or bowel.
2. Approach - head to toe
1. General appearance - well or poorly developed or nourished. Color (black, white, jaundiced, pale). In distress (acutely or chronically)?
2. Vital signs - blood pressure (which arm or both, orthostatic change). Pulse (regular or irregular, orthostatic change). Respirations (labored or unlabored, wheeze). Temperature (axillary, rectal, tympanic membrane, or oral). Weight. Height.
3. Skin, hair, and nails - pigmentation, scars, lesions, bruises, turgor. Describe or draw rashes.
1. Skin color:
1. Red-fever, allergic reaction, carbon monoxide (CO) poisoning.
2. White (pallor)-excessive blood loss, fright.
3. Blue (cyanosis)-hypoxemia, peripheral vasoconstriction.
4. Mottled-cardiovascular embarrassment.
2. Skin temperature:
1. Hot, dry-excessive body heat (heatstroke).
2. Hot, wet-reaction to increased internal or external temperature.
3. Cool, dry-exposure to cold.
4. Cool, clammy-shock.
4. Head - scalp, skull (configuration), scars, tenderness, bruits.
5. Neck - suppleness. Trachea, larynx, thyroid, blood vessels (jugular veins, carotid arteries).
6. Nodes - any cervical, supraclavicular, axillary, epitrochlear, inguinal lymphadenopathy? If so, size of nodes (in centimeters), consistency (firm, rubbery, tender), mobile or fixed.
7. Eyes:
1. External eye. Conjunctivae, sclerae, lids, cornea, pupils (including reflexes), visual fields, extraocular motions.
2. Fundus. Disk, blood vessels, pigmentation.
8. Ears- shape of pinnae, external canal, tympanic membrane, acuity, air conduction versus bone conduction (Rinne test), lateralization (Weber’s test).
9. Nose - septum, mucosa, polyps.
10. Mouth and throat-lips, teeth, tongue (size, papillation), buccal mucosa, palate, tonsils, oropharynx.
11. Chest
1. Inspection. Contour, symmetry, expansion.
2. Palpation. Expansion, rib tenderness, tactile fremitus.
3. Percussion. Diaphragmatic excursion, dullness.
4. Auscultation. Crackles, rubs, wheezes, egophony, pectoriloquy.
1. Use diaphragm or bell. Normal sounds over alveoli—vesicular. Large airway or abnormal sounds—bronchial or bronchovesicular.
2. Adventitious sounds - crackles or wheezes.

3. Crackles - discontinuous noises heard on auscultation; caused by popping open of air spaces; usually associated with increased fluid in the lungs; formerly called rales and rhonchi.
4. Wheezes-high-pitched, whistling sounds made by air flowing through narrowed airways formerly called rales and rhonchi.
12. Breasts - symmetry, retraction, lesions, nipples (inverted, everted), masses, tenderness, discharge.
13. Heart:
1. Inspection. Point maximal impulse, chest contour.
2. Palpation. Point maximal impulse, thrills, lifts, thrusts.
3. Auscultation. Heart sounds, gallops, murmurs, rubs. Use diaphragm for high-pitched sounds of normal heart sounds (S₁ and S₂) and bell for abnormal sounds (S₃ and S₄).
14. Abdomen:
1. Inspection. Scars (draw these), contour, masses, vein pattern.
2. Auscultation. Bowel sounds, rubs, bruits. Use diaphragm. Auscultate after inspection and before palpation and percussion. Listen to each quadrant for at least 1 min. If bowel sounds are present, they will be heard in lower right quadrant (area of ileocecal valve).
3. Percussion - organomegaly, hepatic dullness.
4. Palpation - tenderness, masses, rigidity, liver, spleen, kidneys.
5. Hernia - femoral, inguinal, ventral.
15. Genitalia:
1. Male. Penile lesions, scrotum, testes. Circumcised?
2. Female. Labia, Bartholin’s and Skene’s glands, vagina, cervix. Bimanual examination of internal genitalia.
16. Rectum - perianal lesions, sphincter tone, tenderness, masses, prostate, stool color, occult blood.
17. Extremities - pulses (symmetry, bruits, perfusion). Joints (mobility, deformity). Cyanosis, edema. Varicosities. Muscle mass.
18. Back - contour spine, tenderness. Sacral edema.
19. Neurological:
1. Mental status. Alertness, memory, judgment, mood.
2. Cranial nerves (I—XII). See Figure 7-1.
3. Cerebellum. Gait, finger-nose, heel-shin, tremors.
4. Motor. Muscle mass, strength; deeptendon reflexes. Pathological or primitive reflexes.
5. Sensory. Touch, pain, vibration. Heat and cold as indicated.


3. Routine laboratory studies - see Appendix A for normal ranges.
1. Hematology:
1. Complete blood count - detects presence of anemia, infection, allergy, and leukemia.
2. Prothrombin time - increase may indicate need for vitamin K therapy.
3. Serology (VDRL) - determines presence of syphilis; false-positive result may indicate collagen dysfunction.
2. Urinalysis:
1. Specific gravity - measures ability of kidney to concentrate urine. Fixed specific gravity indicates renal tubular dysfunction.
2. Albumin and pus - indicate renal infection.

3. Sugar and acetone - presence indicates metabolic disorder.
3. Chest x-ray - detects tuberculosis or other pulmonary dysfunctions, as well as changes in size or configuration of heart.
4. Electrocardiogram (ECG) - detects rhythm and conduction disturbances, presence of myocardial ischemia or necrosis, and ventricular hypertrophy.
5. Blood chemistries - detect deviation in electrolyte balance, presence of tissue damage, and adequacy of glomerular filtration.


4. Preventive Care
5. Checkup visits recommended every 1 to 3 years until age 65 and then yearly thereafter. See Table 7-1 for suggested timelines.
6. Individuals with special risk factors may need more frequent and additional types of preventive care.
1. 1. Diabetes - eye, foot exams; urine, blood sugar tests.
2. Drug abuse - AIDS, TB tests; hepatitis immunization.
3. Alcoholism - influenza, pneumococcal immunizations; TB test.
4. Overweight - blood sugar test.
5. Homeless, recent refugees or immigrant - TB test.
6. High-risk sexual behavior - AIDS, syphilis, gonorrhea, chlamydia (every year for sexually active women), hepatitis tests.
7. Pregnancy - Rubella blood test (prior to first pregnancy).
7. Adult immunizations - prevention of disease and reduction in the severity of disease (Table 7-2).