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Assessment- Objective & Subjective Data

Review of clinical record

1. Client records contain information collected by many members of the healthcare team,

such as demographics, past medical history, diagnostic test results and consultations

2. Reviewing the client’s record before beginning an assessment prevents the nurse from

repeating questions that the client has already been asked and identifies information that

needs clarification.

Interview

1. The purpose of an interview is to gather and provide information, identify problems of

concerns, and provide teaching and support.

2. The goals of an interview are to develop a rapport with the client and to collect data

3. An interview has 3 major stages:

1. Opening: purpose is to establish rapport by creating goodwill and trust; this is often

achieved through a self – introduction, nonverbal gestures (a handshake), and small talk

about the weather, local sports team, or recent current event; the purpose of the

interview is also explained to the client at this time.

2. Body: during this phase, the client responds to open and closed-ended questions asked

by the nurse.

3. Closing: either the client or the nurse may terminate the interview, it is important fro the

nurse to try to maintain the rapport and trust that was developed thus far during the

interview process.

4. Types of questions

1. Closed questions used in directive interview

Re____ short factual answers; e.g. “Do you have pain?”

Answers usually reveal limited amounts of information

Useful with clients who are highly stressed and/or have difficulty communicating

2. Open-ended questions used in nondirective interview

Encourage clients to express and clarify their thoughts and feelings; e.g. “How have

you been sleeping lately?’

Specify the broad area to be discussed and invite longer answers

Useful at the start of an interview or to change the subject

3. Leading questions

Direct the client’s answer; e.g. “You don’t have any questions about your medications,

do you?”

Suggests what answer is expected

Can result in client giving inaccurate data to please the nurse

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Can limit client choice of topic for discussion

Nursing History

1. Collection of information about the effect of the client’s illness on daily functioning and

ability to cope with the stressor (the human response)

2. Subjective data

May be called “covert data”

Not measurable or observable

Obtained from client (primary source), significant others, or health professionals

(secondary sources).

For example, the client states, “I have a headache”

3. Objective data

May be called “overt data”

Can be detected by someone other than the client

Includes measurable and observable client behavior

For example, a blood pressure reading of 190/110 mmHg.

Physical assessment

1. Systematic collection of information about the body systems through the use of

observation, inspection, auscultation, palpation and percussion

2. A body system format for physical assessment is found below:

General assessement

Integumentary system

Head, ears, eyes, nose, throat

Breast and axillae

Thorax and lungs

Cardiovascular system

Nervous system

Abdomen and gastrointestinal system

Anus and rectum

Genitourinary system

Reproductive system

Musculoskeletal system

Psychosocial assessment

1. Helpful framework for organizing data

2. A suggested format for psychosocial assessment is found below:

Vocation/education/financial

Home and Family

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Social, leisure, spiritual and cultural

Sexual

Activities of daily living

Health Habits

Psychological

3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be

helpful for guiding data collection

Consultation

1. The nurse collects data from multiple sources: primary (client) and secondary (family

members, support persons, healthcare professionals and records)

2. Consultation with individuals who can contribute to the client’s database is helpful in

achieving the most complete and accurate information about a client

3. Supplemental information from secondary sources (any source other then the client) can

help verify information, provide information for a client who cannot do so, and convey

information about the client’s status prior to admission

Review of literature

1. A professional nurse engages in continued education to maintain knowledge of current

information related to health care

2. Reviewing professional journals and textbooks can help provide additional data to

support or help analyze the client database