Subjective and Objective Data

• subjective data is also known as symptoms or cover data only apparent to the person affected
• objective data is also known as signs or over data and is detectable by an observed and can be measured and tested
• client is the best source of data mainly subjective data
• observing is a conscious deliberate skill use to gather data by using the senses
• pre introductory phase is where the nurse reviews the medical record before meeting with the client
• introductory phase is where the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential
• working phase is the longest phase where the nurse elicits the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level 
• summary and closing phase is also known as summarize/restate, this is where the nurse summarizes information obtained during the working phase and validates problems and goals with the client
• directive interview is a highly structured interview controleld by the nurse and elicits specific information where the nurse uses directive questions
• non directive interview is also known as rapport building interview and is controlled by the client
• information gathering interview is the combination of non-directive and directive interview
• interviewing is used to obtain a valid nursing health history requires professional, interpersonal, and interviewing skills
• open ended questions is used to elicit the client's feelings and perceptions
• close ended questions is used to obtain facts and to focus on specifc information
• laundry list is another way to ask questions is to provide the client with a list of words to choose from in describing symptoms, conditions, or feelings
• rephrasing helps you clarify information the client has stated; it also enables you and the client to reflect on what was said.
• well placed phrases can encourage client verbalization by using well-placed phrases
• inferring can help you from what the client tells you and what you observe in the client’s behavior may elicit more data or verify existing data.
• providing information is another important thing to do throughout the interview is to provide the client with information as questions and concerns arise.
• provocative/palliative what provokes or relieves the pain?
• quality describe the character of the pain (sharp, stapping, aching)
• radiates is the pain localized or does it spread to other areas?
• severity how bad is the pain? Does it interfere with your ADLs or sleep? Rate it on a scale of 1-10 with 10 being the wort
• timing when does the pain occur, and how long does it last? How long before it recurs?
• examining is carried out systematically and is a physical examination
• cephalocaudal is also known as the head to toe approach
• screening examination is also called the review of systems and it is the a brief review of essential functioning or various body parts or systems
• complete health history lays the groundwork for identifying nursing problems and provides a focus for the physical examination
• biographical data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant other
• when interacting with an anxious client provide the client with simple , organized information in a structured format. Explain who you are, along with your role and purpose
• when iteracting with angry client approach this client in a calm, reassuring, in-control manner. Allow them to ventilate feelings. However, if the client is out of control, do not argue with or touch the client
• when interacting with depressed client express interest in and understanding of the client and respond in a neutral manner
• when interacting with manipulative client provide structure and set limits. Differentiate between manipulation and a reasonable request.
• when interacting with a seductive client set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors.
• when discussing sensitive issues first, be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality, then recognize that these factors may affect the client’s health and may need to be discussed with someone
• physical examination is a systematic way of collecting objective data from a client using the four examination techniques used to assess or identify current health status
• there are 4 assessment techniques namely: inspection, palpation, percussion, auscultation
• the asssessment technique for abdomen are namely: inspection, asucultation, percussion, palpation
• standing for assessment of posture, gait & balance
• sitting is where the client is in seated position, back unsupported and legs hanging freely, this is used for head neck posterior and anterior thorax breast Breasts axillae heart vital signs, upper extremities lower extremities and reflexes