What Exactly Is Subjective Nursing Data?
What Exactly Is Objective Nursing Data?
|Subjective nursing data are collected from sources other than the nurse's observations. This type of data represents the patient's perceptions, feelings, or concerns as obtained through the nursing interview. The patient is considered the primary source of subjective data. Other sources, including the patient's family or caregivers, and other members of the healthcare team, are called secondary sources.||Objective data in nursing refers to information that can be measured through physical examination, observation, or diagnostic testing. Examples of objective data include, but are not limited to, physical findings or patient behaviors observed by the nurse, laboratory test results, and vital signs.|
What Are Some Examples Of Subjective Data In Nursing?
What Are Some Examples Of Objective Data In Nursing?
Congestion or Runny Nose
Exhaustion and Fatigue
Feeling Sleepy or Dizzy
Level of Consciousness
Loss of Appetite
Loss of Taste or Smell
Muscle or Body Aches
Shortness of Breath
Blood Urea and Creatinine Levels
Full Blood Count
Height and Weight
X-Ray or Computed Tomography (CT) Scans
Why Is Subjective Data Important In Nursing?
Why Is Objective Data Important In Nursing?
|Because the patient is the primary source of subjective data in nursing, this data can paint a more thorough picture of what the patient is experiencing, making it an essential part of care plan development. Subjective data may signal possible issues with the patient's psychological, physiological, and sociological wellness. Subjective data signals the nurse about things that may be problematic for the patient and can also indicate specific patient strengths that could be useful when communicating with and caring for patients.||Objective nursing data is an essential part of patient assessments. Objective data is the view of the patient's status through the eyes of the assessing nurse. While a patient may state, "My stomach hurts," the nurse may observe changes in his vital signs or abnormal lab results that signal abnormal changes in the patient's body and give practitioners an idea of where to start the diagnosis process.|
What Should Be Included In Subjective Nursing Assessment Data?
What Should Be Included In Objective Nursing Assessment Data?
|Any information the patient provides should be included in the subjective nursing assessment data. Keep in mind, that subjective data is information relayed to the nurse as experienced or felt by the patient. It is vital for nurses to be careful to document everything the patient says. For example, feelings, concerns, or the patient's perception of his well-being are each important. In some cases, and as you will observe in a few examples later in this article, all subjective data should be recorded. Even if the data may seem incorrect in someone else's view, if the patient feels it, says, or perceives it, it should be documented as subjective nursing data.||Measurable data, such as vital signs, the patient's height and weight, and laboratory or diagnostic test results should always be included in the objective nursing assessment data. Whether the nurse observes a sign, reviews a medical test result, or gathers information while performing parts of the assessment, the data should be included in the objective nursing assessment data documentation.|
How Do Nurses Obtain Subjective Data?
How Do Nurses Obtain Objective Data?
|Subjective nursing data is gathered via verbal or written communication. The patient offers a primary source of subjective data. Family members, caregivers, or significant others may offer secondary references to subjective data.||Objective nursing data is information the nurse obtains using senses, such as sight, hearing, smelling, and feeling. Nurses may also obtain objective data from patient charts, laboratory test results, or other diagnostic test results. Any information that is measurable, such as vital signs or the patient's weight are objective nursing data collected during the nursing assessment.|
5 Key Skills Required To Accurately Obtain And Assess Subjective Nursing Data
5 Key Skills Required To Accurately Obtain And Assess Objective Nursing Data
|Subjective nursing data are collected through means of communication. Whether the nurse communicates directly with the patient to obtain primary subjective nursing data or the patient's family, caregivers, or other healthcare team members to obtain secondary subjective nursing data, the skills necessary to obtain and assess this type of data involve some type of communication. The following are five key skills related to accurately obtaining and assessing subjective nursing data.
1. Learn to create a comfortable atmosphere:Ideally, no one wants to be in a hospital or physician's office. The frustration or fear that comes with illness can leave patients feeling uncomfortable or anxious. Having an atmosphere that is calming and welcoming helps patients relax and feel more at ease discussing their problems or concerns.
2. Listen:The best source of patient data is the patient. Listen to what he says. If your patient says, "My right foot hurts," but his right foot was amputated, document it. He perceives foot pain, and it is your responsibility to document what he says so a proper care plan can be formed to treat him.
3. Ask questions:Some patients talk openly about their concerns, but others are apprehensive. Learn to ask questions to promote communication. The best type of question to ask is an open-ended question. For example, instead of saying, "Does your leg hurt," ask, "Can you tell me where you hurt?"
4. Respect your patient's personal boundaries:Have you ever experienced a situation when you felt like someone was invading your personal space or being too pushy when they asked you questions? Imagine being sick or in an unfamiliar place and having that happen. Your patient may feel the same way. Listening to your patients means doing more than hearing the words they say. Pay attention to how their attitude changes, and if you feel like they need some space to think or gather their thoughts, allow it.
5. Trust your nursing instincts:As you continue to hone your skill of collecting subjective data in nursing, you will find that objective data seems to merge with subjective reports provided by the patient or others. This is natural and is a sign of growth and critical thinking for nurses. If a patient reports something to you and you feel he is withholding or apprehensive, trust your instincts and work to build trust with the patient and open the line of communication further.
|Objective nursing data is gathered and assessed using any of the nurse's symptoms. The following are key skills necessary to accurately obtain and assess objective nursing data.
1. Observation:Perhaps the most important skill needed to assess objective data during a patient assessment is observation. After all, objective data is anything that can be measured or observed. Keen observation of patients helps nurses differentiate between what the patient is saying and what he may be feeling but afraid to say. For instance, if a patient fears being admitted to the hospital, she may say her pain has subsided or that she is no longer dizzy. If the nurse observes the patient guarding her side or holding onto the wall when she walks, the nurse's observation contradicts what the patient has reported.
2. Vital Signs:Accurate measurement of vital signs is a crucial part of the objective nursing assessment. Nurses must learn how to take vital signs and identify when measurements are out of the normal range.
3. Learn to read reports:Although physicians or other practitioners are responsible for relaying a medical diagnosis to a patient, it is essential for nurses to understand how to read a report. Many times, nurses receive laboratory or diagnostic test results before the physician and are responsible for making sure the doctor gets the results and follows up with the patient.
4. Know normal values for common laboratory tests:When laboratories finalize tests, the results are sent to the office of the ordering physician or hospital. The lab results form will have the patient's result as well as normal reference ranges. Although normal ranges and abnormal results are highlighted on the results, it is always a good idea for nurses to be aware of at least common tests. A few examples would be normal white blood cell counts, electrolyte ranges, or what a routine urinalysis should yield. You don't have to memorize the manual for laboratory diagnostics. Still, knowledge of normal results will help you as you scan through patient data and begin to summarize and document objective findings.
5. Don't be afraid to ask your nurse leader or other team members to confirm information:The old saying, "No man is an island" is something every nurse should remember. It takes teams of dedicated healthcare professionals to provide high-quality patient care and improve patient outcomes. Collecting objective data requires you to see, hear, feel, and smell. Even the most experienced nurses can find themselves questioning their judgment or reasoning. If you are unsure about something you observe, set your pride aside and ask your team member or leader to assist you.
3 Pros Of Subjective Nursing Data
3 Pros Of Objective Nursing Data
|1. The best source of information about a patient’s status is the patient. Subjective data are information obtained directly from the patient, the patient’s family, or from other healthcare providers who have observed changes or symptoms in the patient.
2. As nurses gather subjective nursing data, we find information that will help us perform better as patient advocates. Nurses can use subjective data to get to know their patients and learn about their needs. When we understand what patients want or need, it becomes easier to advocate to have those needs met.
3. Gathering subjective data helps foster communication and trust in the nurse-patient relationship. The skill of actively gathering subjective data from patients allows us to create an atmosphere conducive to trust and communication, which strengthens relationships and improves patient outcomes.
|1. Objective nursing data are based upon measurable facts and, therefore, cannot be argued or denied.
2. This type of data helps nurses get to the bottom of what is going on with a patient even in times when the patient may not be able to explain his thoughts or feelings clearly.
3. Objective data in nursing are one of the key resources used in preparing nursing care plans. Although subjective data is considered, as previously stated, objective data is clearly measurable and observable, making it an essential part of patient care.
3 Cons Of Subjective Nursing Data
3 Cons Of Objective Nursing Data
|1. While it is important to gather subjective nursing data, if a patient is worried or afraid about the consequences of reporting symptoms, she may vaguely report symptoms or deny them altogether.
2. Because subjective data is "personal" and related to what the patient is experiencing, thinking, or feeling independent of the nurse, the use of this data can leave some patients feeling as though their confidence has not been protected. It is crucial that nurses understand the importance of protecting the patient's privacy while still using subjective nursing data to provide appropriate care. Anything the patient says directly should be documented in quotations.
3. Although collecting subjective nursing data is a vital part of the nursing assessment and often an excellent way to develop nurse-patient rapport, patients who are shy or prefer to keep things to themselves may be offended by constant questioning. In this situation, it is necessary for the nurse to be compassionate and calm and to offer explanations for why she is asking questions or seeking information.
|1. Objective nursing data is undoubtedly an excellent source of patient information. Although one of the pros of this type of data is that it, typically, cannot be denied, it can leave questions in the minds of practitioners. This is especially true when subjective data and objective data do not agree. Nurses must be careful to document both objective and subjective data carefully and to seek clarification for any questions that may arise.
2. Because objective data is measurable and observable, nurses may feel if the patient reports something that the objective data contradicts, the patient is wrong. This is an incorrect assumption. For example, in an earlier example, I mentioned that if a patient complains of foot pain, but he clearly had that foot amputated, both his complaint (subjective data) and his history of amputation (objective data) should be documented. In so-doing, the nurse creates a record in the patient's chart that he is experiencing phantom pain, which should be addressed by the healthcare team.
3. Because objective data in nursing is one of the primary sources of information used to create nursing care plans, nurses must take care to not overlook subjective data. This is an example of why it is important to collect both subjective and objective nursing data when performing a nursing assessment.
Patient Scenario:Mr. Smith is a thirty-year-old, white male presenting to the outpatient clinic with complaints of nausea and vomiting for two days. He reports the last time he vomited was about an hour before arriving at the clinic. Mr. Smith states he feels weak and shaky. He is sweating but complains of being cold. BP 142/84, P 72, R 18, T 100.5; Denies pain; no changes in medications since last clinic visit.
What is the Subjective Data:The examples of subjective data in nursing in this scenario are the patient’s complaints of nausea, vomiting, feeling shaky and cold, and denying pain.
What is the Objective Data:In this scenario, the objective nursing data are Mr. Smith’s age, vital signs, and being sweaty.
What Makes this Data Subjective:The information Mr. Smith conveyed to the nurse is considered subjective data because they are his view of what he has experienced. If the nurse had witnessed Mr. Smith vomiting, she could have recorded that as an objective sign. However, the last time the patient vomited was before his arrival to the clinic.
What Makes this Data Objective:Objective data in nursing are data that can be measured by someone other than the patient. The nurse takes Mr. Smith's vital signs and records them and observes he is sweating.
Patient Scenario:Nurse Rebecca is conducting a nursing assessment on her patient, Ruby. Ruby's vital signs are stable as follows: BP 118/72, P 68, R20, T 98.2. She reports having a headache rating of 4 on the pain scale and complains of burning and itching sensations on her right forearm. Nurse Rebecca observes a patch of skin on Ruby's right forearm approximately six centimeters, round, that appears raised, bumpy, and red.
What is the Subjective Data:The subjective data in this scenario are Ruby’s complaints of a headache, the level of pain she reports, and her complaint of burning and itching on her right arm.
What is the Objective Data:Objective nursing data are Ruby’s vital signs and the nurse’s observation of the irritated area on Ruby’s right arm.
What Makes this Data Subjective:Pain, itching, and burning are symptoms felt by the patient
What Makes this Data Objective:Although Nurse Rebecca cannot feel the itching or burning sensations reported by the patient, she can observe the appearance of irritated skin, which is an example of objective data. Further, vital signs are measurable data, which means they are also objective nursing data examples.
Patient Scenario:Mr. Orlando is brought to the emergency room via ambulance following a fall at the nursing home. His vital signs are BP 150/96, P 88, R 18, T 99.4. Mr. Orlando's left lower leg is swollen and tender to the touch, as evidenced by him grimacing and telling the nurse, "Please don't touch my leg! It hurts so bad!" Initial x-rays indicate a fractured right tibia. Mr. Orlando rates the pain in his leg as a 10 on the pain scale.
What is the Subjective Data:In this scenario, the subjective datum is Mr. Orlando’s complaint of pain as a 10 on the pain scale.
What is the Objective Data:The objective data are Mr. Orlando’s vital signs, the observation that his leg is swollen and tender, his grimacing reaction, and the x-ray results.
What Makes this Data Subjective:Despite the nurse's observations which support Mr. Orlando's report of pain, only Mr. Orlando can determine to what extreme he is feeling the pain. Because the information comes from Mr. Orlando, not from a measurable or observable source, it is subjective nursing data.
What Makes this Data Objective:The fact that the nurse can see Mr. Orlando's leg is swollen, he grimaces when his leg is touched are observable, and therefore, objective data. His vital signs are measurable making them objective nursing data. The x-ray result is a measurement of normal vs. abnormal bone structures, not a reported symptom from Mr. Orlando, which means it is objective.
Patient Scenario:Marcy arrived at the wound clinic ten minutes ago for a follow-up appointment and wound assessment. She complains of pain in her right heel, which is the location of the wound being assessed. Marcy also reports feeling pressure on the top of her foot as well as experiencing nausea and some fever off and on for the last few days. Nurse Allen removes the bandage from Marcy's heel and notes the following: Bandage to right heel is saturated; wound drainage is dark yellow, blood-tinged with strong odor; wound measures six centimeters round, 0.5 centimeters deep. VS: BP 138/80, P 74, R 20, T 100. Red streaks noted on right calf extended from the heel of foot, and 2+ edema to the right lower extremity.
What is the Subjective Data:Marcy’s report of pain in her right heel, feeling pressure on the top of her foot, and the nausea and fever are examples of subjective data in nursing in this scenario.
What is the Objective Data:There are several examples of objective nursing data in this sample scenario. The saturated bandage, appearance and smell of drainage from the wound, wound measurement, vital signs, redness extended from the foot upward to the calf, and edema in the right lower extremity are all objective data.
What Makes this Data Subjective:The patient’s report of pain, pressure, and nausea are subjective data because only the patient can feel the sensation of pain or pressure and nauseous sensation. The report of fever off and on is subjective because the nurse did not measure the temperature on the previous days.
What Makes this Data Objective:The nurse observes the patient's bandage is saturated. She can physically see the drainage and smell the odor from the wound. She is also able to measure the wound, assess vital signs, and observe the red streaks on the patient's calf as well as the edema in the lower leg. Each of these signs is measurable and observable making them examples of objective data in nursing.
Patient Scenario:Mallory is a nineteen-year-old with a history of bipolar depression, premenstrual dysphoric disorder, and attempted suicide. She has presented to the mental health crisis center today, brought by her mother, who reports Mallory is demonstrating behaviors, including self-harm. Mallory reports having feelings of extreme self-loathing, difficulty sleeping, loss of appetite, and thoughts of self-harm. She states at times she feels like the world would be a better place without her. She denies any definitive plan for self-harm or suicide. Nurse Parks notes several small, cuts in Mallory's skin along the top of her forearm. When questioned what happened, Mallory states, "I was thinking about cutting my wrists, but I didn't want to." Nurse Parks documents Mallory has a flat affect. Mallory denies pain, discomfort, and states she has no questions or concerns. She does not respond to painful stimuli.
What is the Subjective Data:The feelings of self-loathing, reported difficulty sleeping, loss of appetite, and thoughts of self-harm are subjective data. Denial of pain is also subjective. The mother's report that Mallory is demonstrating self-harming behaviors is a type of secondary subjective data.
What is the Objective Data:The objective nursing data for this scenario are the patient’s affect and the cuts seen on her arms, as observed by the nurse.
What Makes this Data Subjective:A patient's thoughts and feelings are always subjective data. Loss of appetite and difficulty sleeping are symptoms the patient experiences independent of the nurse's observations, making them subjective nursing data, as well.
What Makes this Data Objective:The only data the nurse can observe or measure in this example are the patient’s affect and the cuts she observes on her arms.
Patient Scenario:Mr. Walters is a patient on the Med-Surg floor who was admitted for an exacerbation of congestive heart failure. He used the call light to ask his nurse to come into his room. When Nurse Dedra entered, Mr. Walters states, "My blood pressure is so high. I can feel my heart beating in my ears." He complains of dizziness and nausea. Upon assessment, Nurse Dedra notes the following vital signs: BP 168/90, P 90, R 20, T 98.6. Mr. Walters denies pain at present, but states "A little while ago, it felt like an elephant was sitting on my chest."
What is the Subjective Data:The subjective nursing data examples in this scenario are the feeling of Mr. Walters’ heart beating in his ears, dizziness, nausea, denial of pain, and the presence of a feeling of pressure in his chest.
What is the Objective Data:Mr. Walters’ vital signs are the objective data.
What Makes this Data Subjective:Subjective data is anything the patient can feel or experience and then report to the nurse. Any symptom, thought, feeling, or sensation is considered subjective nursing data.
What Makes this Data Objective:Because Mr. Walters stated, "My blood pressure is so high," it can be easy to mistake the statement as subjective data. However, it is likely that Mr. Walters has experienced elevated blood pressure before and associates the feeling of his heart beating in his ears with high blood pressure. His blood pressure, like the other vital signs, are measurable, making them objective nursing data examples.
Patient Scenario:Mrs. Jefferys presents to the emergency room with complaints of fever, chills, headaches, malaise, shortness of breath, and loss of appetite. She reports being recently exposed to someone with COVID-19 and states she knows she has the virus because of her symptoms. Rapid test results for COVID-19 verify Mrs. Jefferys does have the COVID-19 virus. Her vital signs are BP 130/80, P 72, R 22, T 100.6. Oxygen saturation is 94%.
What is the Subjective Data:In this example scenario, the subjective data include Mrs. Jefferys' complaints of fever, chills, headaches, malaise, shortness of breath, and loss of appetite. Mrs. Jefferys' report of exposure to COVID-19 is also considered subjective data.
What is the Objective Data:The objective data in this example are Mrs. Jefferys’s vital signs, oxygen saturation, and the positive COVID-19 test.
What Makes this Data Subjective:Although her exposure to COVID-19 recently is not a symptom, it is still considered subjective data because it lets the nurse know there is a possibility that Mrs. Jefferys' symptoms are associated with the virus. By taking and recording this part of the subjective data, the nurse has something to support the decision to do a COVID-19 test.
What Makes this Data Objective:Vital signs and oxygen saturation are measurable. The result for the COVID-19 test validates the patient's concerns and supports the subjective data she reported to the nurse.
Patient Scenario:Mr. Bratton is accompanied by his wife to an office visit with his primary care provider. In triage, Mrs. Bratton tells the nurse, "He just isn't himself. He sleeps all day and doesn't eat half of what I cook. I'm worried about him." Mr. Bratton reports feeling "down in the dumps" and states he doesn't have much of an appetite. In addition to the statements made by Mr. And Mrs. Bratton, Nurse Smith notes the following on Mr. Bratton's chart: Vital signs are stable; denies complaints of pain or discomfort; weight last office visit was 199 pounds; today's weight is 186 pounds; skin is pale with fair turgor, mucous membranes pink and moist.
What is the Subjective Data:In this scenario, there are examples of primary and secondary subjective data. The primary subjective data are Mr. Bratton's report of feeling down, having a decreased appetite, and denying pain. The secondary subjective data are the symptoms reported by Mrs. Bratton.
What is the Objective Data:The objective data in this example include Mr. Bratton’s vital signs, weight, and the appearance of his skin and mucous membranes.
What Makes this Data Subjective:This data is subjective because it is reported either by Mr. Bratton or his wife, Mrs. Bratton.
What Makes this Data Objective:These data are examples of objective data in nursing because the nurse can observe or measure them. Vital signs are assessed using medical equipment. The patient's weight is measured and compared to the previous visit. The nurse observes the appearance of Mr. Bratton's skin and mucous membranes and examines the turgor of his skin.
Patient Scenario:Mrs. Young is a resident at St. Mary's Nursing Home. She has a diagnosis of Alzheimer's and is in late stages of the disease. When Nurse Meaghan makes her morning rounds, she finds Mrs. Young sitting in her recliner crying. Mrs. Young states, "I'm so sad. All my babies have left me. My head hurts and I have a toothache." Nurse Meaghan sits with Mrs. Young and tries to calm her, then performs a nursing assessment. Mrs. Young's vital signs are stable. She denies any facial tenderness and states the only pain she has is a headache and toothache. Mrs. Young's natural teeth were extracted years ago and she refuses to wear dentures. Nurse Meaghan notes slight swelling around Mrs. Young's lower left jaw and observes reddening of the oral mucosa.
What is the Subjective Data:The subjective nursing data for this example are the statements Mrs. Young makes to the nurse: “I am sad.” and “My head hurts and I have a toothache.”
What is the Objective Data:Some objective nursing data in Mrs. Young’s case include the fact that Mrs. Young is crying, and she appears sad. Other objective data include Mrs. Young’s vital signs, swelling around the lower left jaw, and reddening of the oral mucosa.
What Makes this Data Subjective:It is necessary for nurses to acknowledge any statement a patient makes. Although Alzheimer's disease affects memory and may complicate communication, especially as the disease progresses, it is vital for nurses to treat each patient with the same respect and attention. The direct statements Mrs. Young made to Nurse Meaghan are from her perspective and, therefore, subjective nursing data examples.
What Makes this Data Objective:Although Nurse Meaghan cannot feel the emotions Mrs. Young feels, she can visualize her crying and observes her behavior as sad. Vital signs are measurable. The swelling around her jaw and reddening of the oral mucosa are observable.
Patient Scenario:Olivia is a twelve-month-old brought into the pediatric clinic by her mother. Olivia's mother reports the child has had vomiting and diarrhea for two days, is refusing to eat or drink, and that her skin feels hot. Olivia's vital signs are BP 90/54, P150, R 26, T 101.4. Nurse Walker observes a rash on Olivia's skin that is red with a rough appearance like sandpaper. Olivia has a raspy cry and Nurse Walker observes Olivia refuse her bottle when it is offered. Per the pediatrician's order, Nurse Walker performs a strep test. The test is positive for streptococcus.
What is the Subjective Data:The subjective data is the mother’s report that Olivia has been vomiting and had diarrhea for two days, refuses to drink, and her skin feels hot.
What is the Objective Data:The objective data in this scenario are Olivia’s vital signs, the rash on her skin, her raspy cry, refusing the bottle, and the positive strep test.
What Makes this Data Subjective:In this scenario, the patient is unable to communicate on her behalf as she is not old enough to talk. The source of subjective data is the mother and is called secondary subjective nursing data. Although this behavior is observable, because the report of symptoms is coming from the patient's caregiver, not the nurse, the data is subjective not objective.
What Makes this Data Objective:Because vital signs are measurable, they are objective data. The nurse observes Olivia refusing her bottle and sees the rash on her skin, which make these signs objective data. She hears the raspy cry and receives a positive strep test, which are also examples of objective data in nursing.