(3) Objective data are sometimes called signs, and subjective data are
sometimes called symptoms.
(4) Data means more than signs or symptoms; it also includes demographics,
or patient information that is not related to a disease process.
b. The purposes for a physical assessment are:
To obtain baseline physical and mental data on the patient.
To supplement, confirm, or question data obtained in the nursing history.
(3) To obtain data that will help the nurse establish nursing diagnoses and
plan patient care.
(4) To evaluate the appropriateness of the nursing interventions in resolving
the patient's identified pathophysiology problems.
CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL
a. Establish a Positive Nurse/Patient Rapport. This relationship will decrease
the stress the patient may have in anticipation of what is about to be done to him.
b. Explain the Purpose for the Physical Assessment. The purpose of the
nursing assessment is to gather information about the patient's health so that you can plan
individualized care for that patient. All other steps in the nursing process depend on the
collection of relevant, descriptive data. The data must be factual, not interpretive.
c. Obtain an Informed, Verbal Consent for the Assessment. The chief source
of data is usually the patient unless the patient is too ill, too young, or too confused to
communicate clearly. Patients often appreciate detailed concern for their problems and
may even enjoy the attention they receive.
d. Ensure Confidentiality of All Data. If possible, choose a private place where
others cannot overhear or see the patient. Explain what information is needed and how it
will be used. It is also important to convey where the data will be recorded and who will
see it. In some situations, you should explain to the patient his rights to privileged
communication with health care providers.
e. Provide Privacy From Unnecessary Exposure. Assure as much privacy as
possible by using drapes appropriately and closing doors.
f. Communicate Special Instructions to the Patient. As you proceed with the
examination, inform the patient of what you intend to do and how he can help, especially
when you anticipate possible embarrassment or discomfort.