When documenting subjective data, the nurse should do which of the following?

Reasons Why Nurses Need To Understand The Difference Between Subjective VS. Objective Data In Nursing

SUBJECTIVE VS. OBJECTIVE DATA IN NURSING: SIDE-BY-SIDE COMPARISON

The following is a side-by-side comparison of subjective vs. objective nursing data.

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?

Chills
Congestion or Runny Nose
Constipation
Coughing
Diarrhea
Dizziness
Exhaustion and Fatigue
Feeling Sleepy or Dizzy
Itching
Level of Consciousness
Loss of Appetite
Loss of Taste or Smell
Muscle or Body Aches
Nausea
Numbness
Pain
Shortness of Breath
Sore Throat
Sweating
VomitingAmbulation
Bleeding
Blood Urea and Creatinine Levels
Blood Pressure
Body Temperature
Demeanor
Full Blood Count
Heart Rate
Height and Weight
Overall Appearance
Respiratory Rate
Wound Appearance
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.

Which of the following is the correct description for subjective data?

Subjective data is anecdotal information that comes from opinions, perceptions or experiences. Examples of subjective data in health care include a patient's pain level and their descriptions of symptoms.

Which data should be documented as subjective in the patient's chart?

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.

How should subjective data be documented in the patient's medical record?

How should subjective data be documented in the patient's medical record? Subjective data should be documented within quotation marks. As perceived by an examiner, which is an objective finding such as a fever, a rash, or the whisper heard over the chest in pleural effusion?

Which client information would the nurse report as subjective data?

Subjective data include the patient's feelings, perceptions, and reported symptoms.