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    Subjective and Objective Data

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    Marielle Ventula
    This document compares subjective and objective data in health assessments. [1] Subjective data is obtained from the client through interviews and relies on self-reported information, while objective data is directly observed or measured through physical exams. [2] Sources of subjective data include the client, family, and records, while objective data comes from observations, exams, and documentation. [3] Subjective data is obtained through interviews, while objective data requires skills like observation, palpation, and auscultation.

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    Subjective and Objective Data

    Uploaded by

    Marielle Ventula
    960 views4 pages
    This document compares subjective and objective data in health assessments. [1] Subjective data is obtained from the client through interviews and relies on self-reported information, while objective data is directly observed or measured through physical exams. [2] Sources of subjective data include the client, family, and records, while objective data comes from observations, exams, and documentation. [3] Subjective data is obtained through interviews, while objective data requires skills like observation, palpation, and auscultation.

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    This document compares subjective and objective data in health assessments. [1] Subjective data is obtained from the client through interviews and relies on self-reported information, while objective data is directly observed or measured through physical exams. [2] Sources of subjective data include the client, family, and records, while objective data comes from observations, exams, and documentation. [3] Subjective data is obtained through interviews, while objective data requires skills like observation, palpation, and auscultation.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    960 views4 pages

    Subjective and Objective Data

    Uploaded by

    Marielle Ventula
    This document compares subjective and objective data in health assessments. [1] Subjective data is obtained from the client through interviews and relies on self-reported information, while objective data is directly observed or measured through physical exams. [2] Sources of subjective data include the client, family, and records, while objective data comes from observations, exams, and documentation. [3] Subjective data is obtained through interviews, while objective data requires skills like observation, palpation, and auscultation.

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    The document discusses different subjective and objective assessment techniques used in nursing including inspection, auscultation, palpation and others. It provides details on how to perform each technique.

    The different types of assessment techniques discussed are inspection, auscultation, palpation and percussion.

    The steps to perform inspection as an assessment technique are: 1) Expose body parts being observed while keeping the rest of the client's body properly draped. 2) Always look before touching. 3) Use good lighting. 4) Provide a warm room for the client. 5) Observe for color, size, location, texture, symmetry, odor and sounds.

    COMPARING SUBJECTIVE AND OBJECTIVE DATA

    SUBJECTIVE OBJECTIVE

    Description Data elicited and verified by Data directly or indirectly


    the client observed through
    measurement

    Sources Client Observations and physical


    Family and significant assessment findings of the
    others nurse or other health care
    Client record professionals
    Other health care Documentation of assessment
    professionals made in client record
    Observations made by client’s
    family or significant others

    Methods used to obtain data Client interview Observation and physical


    examination

    Skills needed to obtain data Interview and therapeutic Inspection


    communication skills Palpation
    Caring and empathy Percussion
    Listening skills Auscultation

    Examples “I have a headache” Respiration 16 breaths per


    “It frightens me” minute
    “I am not hungry” BP 180/100, apical pulse
    80 and irregular
    x-ray film reveals fractured
    pelvis

    Source: Nurse’s Handbook of Health Assessment


    Janet R. Weber
    INSPECTION - using the sense of vision, smell, and hearing to observe the condition
    of various body parts, including any deviations from normal
    - is the visual examination that is assessing using the sense of sight
    - it should be deliberate, purposeful, and systematic
    - the nurse inspects with the naked eye and with a lighted instrument
    such as an otoscope (used to view the ear)
    - in addition to visual observation, olfactory (smell) and auditory
    (hearing) cues are noted
    - Nurses frequently use visual inspection to assess moisture, color and
    texture of body surfaces, as well as shape, position, size, color and
    symmetry of the body
    - Lighting must be sufficient for the nurse to see clearly: either natural
    or artificial light can be used.
    - When using auditory senses it is important to have a quiet
    environment for accurate hearing
    - Observation can be combined with the other assessment techniques

    TECHNIQUE:

    1) Expose body parts being observed while keeping the rest of the client’s
    body properly draped.
    2) Always look before touching.
    3) The good lighting. Tangential light is best. Be alert for the effect of bluish-
    red tinted or fluorescent lights that interfere with observing bruises,
    cyanosis (bluish discoloration of a body part), erythema.
    4) Provide a warm room for the client (a hot environment may alter skin color
    and appearance)
    5) Observe for color, size, location, texture, symmetry, odor and sounds

    Sources: Mr. Lasurias


    Fundamentals of Nursing
    7th edition by KOZIER
    Nursing Handbook of Health Assessment
    Janet R. Weber
    AUSCULTATION

    Auscultation is listening for various breath, heart, vasculature, and towel sounds
    using a stethoscope.

    TECHNIQUE:

    Use a good stethoscope that has the following


    • Snug – fitting earplugs
    • Tubing not longer than 15 inches and internal diameter not greater than 1
    inch.
    • Diaphragm and bell

    Auscultation is the process of listening to sounds produced within the body.

    • Direct Auscultation – is the use of unaided ear, for example, to listen to


    respiration wheeze or the grating of a moving joint.
    • Indirect Auscultation – is the use of a stethoscope, which transmits the
    sounds to the nurse’s ear.
    - a stethoscope is used primarily to listen to sounds from within the
    body, such as bowel sounds or valve sounds of the heart and blood
    pressure.

    * Auscultated sounds are described according to their pitch intensity, duration, and
    quality

    * The pitch is the frequency of vibrations (the number of vibrations per second)
    * Low-pitched sounds, such as some heart sounds, have fewer vibrations per second than
    high-pitched sounds, such as bronchial sounds.
    * The intensity (amplitude) refers to the loudness or softness of a sound.
    * Some body sounds are loud, for example, bronchial sounds heard from the trachea;
    others are soft, for example, normal breath sounds heard in the lungs.
    * The duration of the sound is its length (long or short)
    * The quality of sound is a subjective description of a sound, for example, whistling,
    gurgling, or snapping.

    Source: Fundamentals of Nursing 7th edition


    Barbara Kozier
    Glenoria Erb
    Audrey Berman
    Shirley Snyber

    PALPATION

    Definition:
    Palpation is touching and feeling body parts with your hands to determine the
    following characteristics:

    o Texture (roughness / smoothness)


    o Temperature (warm / hot / cold)
    o Moisture (dry / wet / moist)
    o Motion (stillness / vibration)
    o Consistency of structures (solid / fluid filled)

    - is the examination of the body using the sense of touch


    - the pads of the fingers are used because their concentration of nerve endings makes
    them highly sensitive to tactile discrimination.

    Technique:

    o Examiner’s fingers should be short


    o The most sensitive part of the hand should be used to detect
    various sensations.
    a. fingertips for fine discrimination pulsations
    b. palmar surface for vibratory sensations (fremitus)
    c. dorsal surface for temperature
    o Light palpation precedes deep palpation
    o Tender areas are palpated last. (painful areas)
    o Three different types of palpation may be used depending on the
    purpose of the exam.

    Source: Nurse’s Handbook of Health Assessment by Weber

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