Subjective data

Purpose of Assessment

• Gather subjective + objective data.

• Identify strengths, actual & potential health problems, risks, learning needs, support systems, and discharge/referral needs.

Skills of Assessment

• Cognitive → critical thinking, analysis.

• Problem-solving → applying nursing process.

• Psychomotor → hands-on skills.

• Affective/Interpersonal → empathy, therapeutic communication.

• Ethical → confidentiality, professionalism.

Nursing vs. Medical Diagnosis

• Medical diagnosis → disease/treatment focus.

• Nursing diagnosis (PES statement) → human response focus.

PES Statement:

• P = Problem (diagnostic label)

• E = Etiology (related factors)

• S = Signs/Symptoms (defining characteristics)

Collecting Data

• Subjective (covert): not measurable, what patient tells you (e.g., pain, fatigue).

• Objective (overt): measurable, observed (e.g., vital signs, lab values).

• Sources:

  • Primary → patient.

  • Secondary → family, records, healthcare team.

The Interview & Health History

Internal Factors (nurse’s qualities)

• Liking others, empathy, active listening.

External Factors (environment)

• Privacy, quiet space, good lighting, comfortable temperature, minimal distractions, equal-status seating (eye level), avoid standing/note overload.

Four Phases of Interview

• Pre-introductory

  • Review records, SBAR report, plan.

• Introductory

  • Greet, introduce self/role.

  • Use surname.

  • State purpose/timeframe.

  • Ensure confidentiality.

Four Phases of Interview

1. Working Phase

   • Open-ended questions (encourage detail).

   • Closed/direct questions (clarify specifics).

   • Actively listen, observe nonverbals.

2. Summary/Closing

   • Summarize key points.

   • Clarify, allow patient input.

   • Teaching/next steps.

   • Thank patient.

SOLER communication technique:

• S = Sit facing patient.

• O = Open posture.

• L = Lean in slightly.

• E = Eye contact (intermittent).

• R = Relax.

Using Interpreters

• Before: clarify role, pronunciation of name.

• During: address patient, not interpreter; avoid jargon; watch nonverbals.

Types of Health History

• Initial/Comprehensive → baseline, new patient.

• Ongoing/Partial → follow-up.

• Focused/Problem-Oriented → specific concern.

• Emergency → urgent, rapid.

Components of Health History

• Biographical Data: name, age, gender, DOB, contact, referral, occupation, culture, religion, marital status, insurance, advance directives.

• Reason for Seeking Care (chief complaint).

• History of Present Illness (HPI): use COLDSPA or PQRSTU.

  • C: Character/quality

  • O: Onset

  • L: Location

  • D: Duration

  • S: Severity

  • P: Pattern (provoking/relieving)

  • A: Associated factors

  • PQRSTU = Precipitating/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing, Understanding perception.

Components of Health History

• Past Health History: hospitalizations, surgeries, chronic illnesses, injuries, allergies, meds, immunizations, transfusions, travel, childhood illnesses, last exam.

• Family History: immediate & extended relatives (genetics, chronic conditions).

• Review of Systems (ROS): HEENT, respiratory, CV, GI, GU, musculoskeletal, neuro, integumentary, endocrine, immune, hematologic, breasts, general health.

• Psychosocial History: daily life, sleep, activity, nutrition, habits, socioeconomic status, religion/spirituality, roles/relationships, environment.

• Lifestyle & Health Practices: risk factors, safety, coping, support systems.

• Developmental Level: current stage, past milestones.

Documentation Tips

• Be accurate, objective, concise.

• Use short phrases, standard abbreviations.

• Record pertinent negatives (e.g., “denies chest pain”).

• Avoid vague terms (“normal,” “usual”).

• Date & sign all documentation.

Levels of Care

• Primary → prevention, wellness, general care.

• Secondary → specialty, acute care, diagnosis/treatment.

• Tertiary → advanced/specialized care, rehabilitation, long-term management.