Collecting Subjective Data

• Types of Assessment

  Initial, Problem-Focused, Time-Lapsed, Emergency
• Type of Assessment

  Initial Assessment - performed within specified time after admission to a health care agency; purpose is to establish complete database for problem identification and care planning
• Type of Assessment

  Problem-Focused - ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.
• Type of Assessment

  Emergency - done during psychiatric or physiological crisis of the client to identify life threatening problems.
• Type of Assessment

  Time-Lapsed - done several months (scheduled) after initial assessment to compare the client’s status to baseline data previously obtained.
• Types of Data

  Subjective and Objective
• Type of Data

  Subjective –data from client’s point of view, and include perceptions, feelings, and concerns; collected by interview; also known as SYMPTOMS or COVERT data.
• Type of Data

  Objective - observable and measurable, obtained through both physical examination and the results of lab and diagnostic testing; also referred to as SIGNS or OVERT data.
• Sources of Data

  Primary and Secondary
• Data Collection Methods

  Observation, Interviewing, Physical Assessment
• Data Gathering Method

  Interviewing - planned communication or a conversation with a purpose.
• Types of Interview Questions

  Closed, Open-Ended, Neutral, Leading
• Types of Interview Questions

  Closed - restrictive; less effort and information from client
• Types of Interview Questions

  Open-Ended > specify broad topics to discuss; invite longer answers; get more info from the client
• Type of Interview Questions

  Neutral - the client can answer without direction or pressure from the nurse, is open ended, and is used in nondirective interviews.
• Types of Interview Questions

  Leading - are those that suggest a particular answer; used in a directive interview, and thus directs the client’s answer.
• Factors in Interview Setting

  Time, Place, Seating Arrangement, Distance, Language
• Health History - provides a comprehensive portrait of the pt’s past and present health.
• Components of Health History

  Biographic/Demographic Data, Chief Complaint, Present Health, Current Medications, Family History, Review of Systems
• Demographic Data


  Name, Address and phone number, Age and Birthdate, Birthplace, Gender, Marital Status, Race or Ethnic origin, Occupation
• Chief Complaint 


  This is a brief spontaneous statement in the patient’s own words that describes the reason for the visit.
• Sign - an objective abnormality that can be detected on physical examination or in laboratory studies.
• Symptom – a subjective sensation that the person feels from the disorder
• History of Present Illness


  For the ill person, this is a chronological record of the reason for seeking care, from the time the symptom first started until now (describes information relevant to C.C.)
• COLDSPA

  Character, Onset, Location, Duration, Severity, Pattern, Associated factors
• COLDSPA

  Character: describe the sign/symptom. How does it feel (sharp, dull, aching, throbbing), look (shiny, bumpy, red swollen, bruised), sound (loud, soft, rasping), smell (foul, sweet, pungent)
• COLDSPA

  Onset - When did it begin?
• COLDSPA

  Location - Where is it? Does it radiate?
• COLDSPA

  Duration - How long does it last? Does it recur?
• COLDSPA

  Severity: How bad is it?
• COLDSPA

  Pattern: What makes it better? Worse?
• COLDSPA

  Associated factors: What other symptoms occur with it?
• Past Health History


  Events may have residual effects on the current state of health; Previous experience with illness may give clues on how the patient responds to illness and to the significance of illness for him or her; Include: date, problem, hospitalizations, symptoms, treatment, current status – ongoing? Resolved?
• Family Health History


  Ask about the age & health or age and cause of death of blood relatives such as parents, grandparents, siblings; Ask about close family members such as spouse & children, if there is prolonged contact with any communicable diseases.
• Genogram - a standard format used to represent client’s family history
• Current Medication


  Note all prescription and over-the-counter medications and herbal remedies; Ask specifically for vitamins, birth control pills, aspirin, antacids
• Review of Systems (ROS) - Each body system is addressed, client is asked questions to draw out current health problems or problems in the recent past to that may still affect the client or are recurring; The order of the examination is from head to toe.
• Developmental Level - Developmental delay: strong indicators where the client is functioning much below the usual behavior for his age-point areas for nursing diagnoses & intervention
• Young Adult: Intimacy vs. Isolation (18-25) > ability to form close, caring  relationships with friends of both sexes & various ages; having established identity apart from the childhood family otherwise social & emotional isolation may occur leading to addiction, sexual promiscuity.
• Middle Adulthood: Generativity vs. Stagnation (25-45) > able to share self with others, mentoring & sharing to future generations

  providing wisdom & experience