Collecting Subjective and Objective Data

Subjective Data

Objectives

Explain what subjective data is in a health assessment

Discuss the purpose of each of the four phases of a client interview

• Pre-introductory

• Introductory

• Working

• Summary

Describe effective verbal and nonverbal communication techniques

Describe ways to adapts an interview for the older client, a client with emotional issues, and cultural considerations

Identify the major categories of a complete health history

Describe the process for performing a review of systems

Explain how a nurse would use the “COLDSPA” mnemonic to analyze a client symptom

Discuss appropriate interview techniques for a special population

What is Subjective Data?

Data from the client’s point of view

What the client is telling you

• Symptoms

  • Diarrhea for the past 2 days

  • Cough for 2 weeks

  • Feelings, perceptions, concerns

  • Pain is subjective

Ask yourself, can I measure or observe the information yourself?

Collecting Subjective Data

Interview

• What is the purpose? (explain it to the patient)

• Several phases

  • Pre-introductory

  • Introductory

  • Working

  • Summary

Pre-introductory Phase

The nurse is receiving a 64-year-old client from the emergency department admitted with pneumonia what should the nurse do?

Review the medical record

• Gain information about PMH

• Reason for seeking health care

• Previous admissions

• Discharge instructions

Having biographical information may assist with interview

Introductory Phase

Introduce yourself to the client

• Build rapport and trust

Explain the purpose of the interview

Discuss type of questions that may be asked

Explain why you may be taking notes

Assure confidentiality

• HIPAA (Health Insurance Portability and Accountability Act)

Make sure comfort and privacy is ensured

Continue to develop trust with nonverbal and verbal communication

Working Phase

Why are they seeking health care?

• Biographical data

• Reasons for seeking care

  • Severe abdominal pain

  • Annual physical

  • Always a reason

• History of present health concern

  • When did it start?

  • How long has this been a concern?

• Past health history

  • Risk factors

  • Resurgence of an issue

• Family history

• Review of body systems for current health problems

  • Go through each major body system and ask subjective questions

  • Subjective questions

  • Cardiac, respiratory, etc.

• Lifestyle and health practices and development level

Nurse needs to use several skills

Pay attention

Summary and Closing

Summarize the information obtained

Validate problems and goals with the client

Be sure to follow up with any further questions

Leave time for questions

Nonverbal Communication

Nonverbal communication may strongly influence how the client perceives the questions that are asked

What are some examples of nonverbal communication

• Appearance

• Demeanor

• Facial expression - friendly

• Attitude - non-judgemental

• Silence - time to organize thoughts, give patient time to think

• Listening - actively, eye contact, follow-up questions (verbal), shaking head, get down to patient eye level

Listening

Takes practice

Key to subjective assessment

Do not project personal thoughts and biases

Tips

• Be present and engaged

• Keep an open mind and seek to understand

• Empathize and clarify

• Listen to learn

Verbal Communication

Ask open ended questions - used for broad information

• Typically begins with “how” or “what”

• Things that need a description

• When should you ask open ended questions?    

  • Upon admission

  • History taking

Ask closed-ended questions - used for specifics

• Laundry list

  • Provides a list of words to describe symptoms

  • “Can you describe the pain, dull, sharp, achy”

• Rephrasing

  • Helps to clarify information

• Inferring

  • What you observe in the client’s behavior

  • Need to be careful to not lead patient

  • “I see you keep rubbing your chest, is it bothering you at this moment?”

Providing Information

Special Considerations

Gerontology

• Need to assess hearing and visual acuity

  • Do they have hearing aids

  • Do they have glasses, need large print

• May have more health concerns

• Speak clearly and use straightforward language

  • Avoid medical jargon (really with all populations)

  • “Has your stomach been bothering you?” “Do you have any chest pain?”

• Showing respect is important

Cultural

• May need to seek help from expert

• May need an interpreter

  • Important to make sure the patient is aware of what’s going on

  • Family might influence the conversation

  • Medical language is complex

• May be reluctant to share information

• Variations in nonverbal/verbal communication

  • Some cultures direct eye contact is disrespectful

  • Might be a spokesperson for the family

Working with an Interpreter

Allow for extra time

Determine whether simultaneous or consecutive mode of interpretation will be utilized

• Simultaneous - speaking while the nurse is speaking

• Consecutive - nurse speaks, interpreter speaks

During the interview:

• Introduce yourself and the interpreter

• Sit and look directly at the client when asking questions or speaking to the client

• Avoid technical/medical jargon

• Summarize at the end of the interview and ask for clarifications or further explanations

Emotional Considerations

Client may be:

• Depressed

  • Express interest in and understanding of the client and response in a neutral manner

• Angry

  • Approach the client in a calm, reassuring, in-control manner

• Manipulative

  • Provide structure and set limits

• Anxious

  • Provide the client with simple, organized information in a structured format

Complete Health History

Lays the groundwork for identifying nursing problems and provides a focus for the physical exam

May give specific cues to health problems

Compose of 8 sections

• Biographical

• Reason for seeking health care

• History of present health concern

• Personal health history

• Family health history

• Review of systems

  • Address each body system

  • Document client’s descriptions and note any denials

• Lifestyle and health promotion

  • Human responses

  • Describes how they are managing their lives

  • Use open-ended questions but may need to follow up with specific questions

• Development level

Biographical Data

Identifies the client

• Name

• Adress

• Phone #

• Date of Birth

Race or ethnic background

Primary and secondary languages (spoken and read)

Marital status

Religious or spiritual practices

Educational level

Occupation

Significant others or support persons (availability)

Reasons for Seeking Health Care

Two main questions

• What is your major health problem or concern currently?

• How do you feel about having to seek health care?

History of Present Health Concern

Provides a detailed description. of the client’s health problem

Have client explain in detail the problem

• Include onset, progression, and duration

• What makes the problem better or worse

• Any treatments that have been tried

• Effect on ADL’s

To help remember use the mnemonic COLDSPA

• Character - describe the sign or symptom (describe it or laundry list)

• Onset - When did it begin?

• Location - Where is it?

• Duration - How long does it last?

• Severity - How bad is it? (scale of 1-10, face scale with the smiles, nonverbal tools)

• Pattern - What makes it better or worse? What have you done for it?

• Associated factors - What other symptoms occur with it?

Personal Health History

Earliest to current

• Childhood illness

• Immunizations

• Adult illnesses

• Surgeries

• Allergies (confirm and verify)

• Medication use

• Pregnancies

Family Health History

Genetic predisposition

Includes as many genetic relatives as the client can remember

Use a genogram

After data collection provide a brief summary

Review of Systems

Address each body system

Ask specific questions

If client doesn’t have it, write denies

Use only subjective data, do not include the examiners observations

Document the client’s descriptions and document any denials

Review the following systems:

• Skin, hair, and nails

• Head and neck

• Eyes, ears, mouth, throat, nose, sinuses

• Thorax, lungs, breasts

• Heart, neck vessels, peripheral vascular system

• Abdomen

• Male and female genitalia, anus

• Musculoskeletal and neurological

Lifestyle and Health Practices

Look at human responses

Use open-ended questions

• Follow-up with specific questions

Areas discussed:

• Typical day

• Nutrition (access, typical diet)

• Activity level (exercise, sports, what kind)

• Sleep (how long, well rested, wake up throughout)

• Substance use (prescriptions, other medications not prescribed, alcohol and if so how often and how much of what, smoking, vaping, other substances, herbal medications)

• Self-care (check-ups, safe at home)

• Social activities and relationships (for fun)

• Education/work (reveal about stress levels)

• Stress (coping mechanisms)

• Environment and values (exposures)

Special Populations

Newborns

• Initial assessment of the newborn occurs immediately after delivery

• Information is obtained from the delivery record information

• Interview the parent

  • Friendly, non-judgemental approach

  • Explain the purpose of the interview

  • Parents may be anxious or nervous especially if the infant is sick

  • Be aware of barriers

Older Adult

• Interview Techniques

  • May be reluctant to admit health problems

  • Nurse needs to develop techniques to stress positive habits

  • Make sure to address the client with appropriate title “Mrs.” or “Mr.”

Interviewing Parents

• When trust and rapport is established

• Parents are source of information and education

• Introductory stage

• Encouraging talk

Interview children and adolescents

• Children

  • Treat them as an equal in conversation

  • Evaluate level of readiness

  • Direct communication best when used with indirect techniques as well

  • Talk at eye level and engage in play and verbalization

• Adolescents

  • What would be important when interview an adolescent?

    • Do they want a parent present

    • Have they gone through puberty

    • Asking questions to them directly

    • Mental health assessment

    • Normalize uncomfortable questions that everyone is asked these

Objective Data

Objectives

Determine the various pieces of equipment needed to perform a physical examination

Explain how to prepare oneself, the physical environment, and the client for a physical examination

Describe standard precautions and isolation precautions

Discuss how to approach a client for objective data in special populations

Describe various client positions used for different parts of the physical examination

Discuss correct inspection, palpation, percussion, and auscultation examination techniques

Discuss the purpose of the bell and diaphragm of the stethoscope

Equipment

Stethoscope

Pen light

BP cuff

Watch

Preparing for Examination

Can occur in a variety of settings

Ensure that the client is

• Comfortable, warm temperature

• Private area free of interruption

• Quiet area with adequate lighting

• Firm examination table or bed

• Bedside table/tray to hold equipment

Prepare yourself

• Practice makes perfect

• Prevent transmission of infectious agents

Standard Precautions

Hand hygiene

Gloves - avoid blood and body fluids

Mask, eye protection, face shield - prevent splash

Gown - contact precautions

Patient care equipment - equipment may be left in the room depending on the isolation

Patient placement     

• Isolation

Occupational health and blood-borne pathogens

Isolation

MRSA, VRE, MDRO - gown and gloves

C. diff - gown and gloves, contact, soap and water

Influenza - droplet, mask

TB - airborne, N95, negative pressure room

COVID - droplet, mask, aerosolized procedures make it airborne

Hand sanitizers cannot destroy spores

Approaching the Client

Establish nurse-client relationship

Explain the procedure and the physical assessment that will follow, describing the steps of the examination

Respect client’s requests and desires

Explain the importance of the examination

Begin exam with less intrusive procedures

Explain procedure being performed

Explain to client why position changes are necessary

Special Populations

Newborn

• Purpose is to identify normal physiologic and developmental changes

• Make sure the parent/caregiver understands what will occur during the exam

• Make sure the infant is undressed

• Complete the least invasive assessments first while the infant is quiet

Children and Adolescents

• Complete less invasive procedures first

• Allow them to play with the equipment first

• Age-appropriate distractions

• If child in uncooperative

  • Ask a parent for help

  • Provide a reward like a sticker

  • Give two concrete choices, which one first

  • Take a break

• Physical assessment

Older Adults

• Physical assessment may take longer due to physical or cognitive conditions

• May need to limit the time given to complete or do over several sessions

• In older adult you may need to be formal

• Keep voice at an appropriate tone

• Do not assume they can not answer a question because of a cognitive impairment

• To complete a comprehensive assessment of an older adult if requires expertise and experiences

Client Positioning

Sitting

Supine - on back

Dorsal recumbent - one back, knees flexed, feet flat

Sims’ position - lies on side with lower arm behind body and upper arm flexed

Standing

Prone - lies on abdomen

Knee-chest position - child’s pose

Lithotomy position - in stirrups

Physical Exam Techniques

4 Basic Techniques

• Inspection

• Palpation

• Percussion

• Auscultation

Ask yourself after exam

• Did I inspect, palpate, percuss, and auscultate any deviations?

• Do I need follow-up questions?

• Do I need to perform physical assessment on other related body systems?

• Do I need to validate my findings with someone else (instructor, colleague)?

Inspection

Used the moment you meet the client

Make sure room is comfortable with good lighting

Completely expose part being examined while draping the rest of client as appropriate

Why inspect first? other techniques could alter the presentation

What should you note? Hygiene,

• Abdomen - body positioning (guarding, comfortable), bruising or marks, wounds (location, size, consistency, color), expressions, behaviors, symmetry

Palpation

Consists of using parts of the hand to touch and feel for the following characteristics:

• Texture (rough or smooth)

• Temperature (warm, cool, cold) - back of hand, check for symmetry

• Moisture (dry/wet)

• Strength of pulses (strong, bounding, weak) - check for symmetry, both radial, both pedal

• Size (small, medium, large, or an exact measurement)

• Shape (well-defined/irregular)

• Degree of tenderness

• Consistency (soft, hard, fluid-filled) - bumps, sore, painful

• Mobility (fixed/mobile) - range of motion

Use three different parts of the hand

• Finger pads

  • Pulse

  • Texture

  • Moisture

• Ulnar (side)

  • Feel for vibrations

  • Respiratory

• Dorsal (back)

  • Temperature

Light to Deep

• Light:

  • Place dominant hand lightly on surface

  • Less than 1cm depression

  • Use circular motion

  • Finger pads

• Moderate

  • Depress 1-2 cm

  • Use circular motion

  • Finger pads

• Deep

  • Place dominant hand on skin surface and your non-dominant hand on top

  • Depress 2.5-5cm (1-2 inches)

• Bimanual

  • Use two hands, placing one on each side of the body part (ex uterus, breasts, spleen) being palpated. Use one hand to apply pressure and the other to feel the structures

Percussion

Tapping various body parts to produce sound waves

May elicit pain

Determine the location, size, and shape

May determine abnormal masses

Elicit reflexes

Motion should be quick and forceful

Process

• Place the middle finger of your nondominant hand on the body part you are going to percuss

• Keep your other fingers off the body part

• Use the pad of your middle finger on the other hand to strike the middle finger of your non dominant hand

• Withdraw your finger immediately

• Deliver two quick taps

Types of PErcussion

• Direct

  • Tapping with 1-2 fingertips directly on skin

• Blunt

  • Detect tenderness over organs

  • Ex. CVA tenderness

  • Whole hand of the area and use fist to produce sound

• Indirect

  • Most used

  • Increased density = decreased sound

  • Sounds elicited

    • Resonance

    • Tympany

    • Dullness

Auscultation

Requires the use of a stethoscope

Want to eliminate distracting/competing noises

Warm the diaphragm/bell of the stethoscope

Expose the body part

    Avoid listening through clothes

Explain what you are listening for

• Listening for heat sounds, bowel sounds, and movement of air through lungs

Using the Stethoscope

Place earpieces into outer ear canal

Angle the binaurals (metal tubing) down toward the nose

Use diaphragm to detect high-pitched sounds

• Lungs

• Heart

• Bowel sounds

Use bell for low-pitched sounds

• Heart murmurs

• Blood flow