What step of the nursing process includes data collection through a health history physical examination and interview?

The complete subjective health assessment is commonly referred to as a . It provides an overview of the client’s current and past health and illness state. You conduct it by interviewing the client as illustrated in Figure 1.1, asking them questions, and listening to their narrative.

Figure 1.1: Nurse interviewing the client

This information is often shared verbally with you or in the way that the client can best communicate. It is also sometimes collected through a standardized form that the client completes. In some cases, it also includes information shared by a family member, friend, or another health professional when the client is unable to communicate.

Clients are sometimes accompanied by . Care partners are family and friends who are involved in helping to care for the client. You may hear care partners being referred to as “informal caregivers” or “family caregivers,” but “care partner” is a more inclusive term that acknowledges the energy, work, and importance of their role.

The complete subjective health assessment is part of assessment, the first component of the nursing process (assessment, analysis/diagnosis, planning, implementation and evaluation) outlined in Figure 1.2.

Figure 1.2: The nursing process

As illustrated in Figure 1.2, the assessment phase of the nursing process involves collecting (information that the client shares) and (information that you collect when performing a physical exam). See Table 1.1 for an overview and examples of subjective and objective data. This book focuses on subjective data collection in the context of the complete subjective health assessment.

Data	Example
Subjective Information that the client shares with you spontaneously or in response to your questions.	The client states, “I have had a rash on my ankle and leg for the last two weeks.” The parent states, “My eight-month-old son is having trouble breathing.” The client’s reason for seeking care is “diarrhea for 10 days.” The client types, “I feel sick to my stomach.”
Objective Information that you observe when conducting a physical assessment, and lab and diagnostic results.	You observe that a client has a bright red rash on the dorsal side of the foot, the lateral malleolus, and anterior and lateral side of the lower leg. You observe the client sitting upright, leaning forward, breathing fast with eyes wide open. You take the client’s blood pressure and report it as 112/84 mm Hg and pulse at 84 beats per minute. Lab test results: K+ 4.0 mmol/L, fasting glucose 4.8 mmol/L. Chest X-ray report: Lungs well inflated and clear. No evidence of pneumonia or pulmonary edema.

Table 1.1: Overview and examples of subjective and objective data

As the word “subjective” suggests, this type of data refers to information that is spontaneously shared with you by the client or is in response to questions that you ask the client. Subjective data can include information about both symptoms and signs. In the context of subjective data, are something that the client feels, as illustrated in Figure 1.3 (e.g., nausea, pain, fatigue). You won’t know about a symptom unless the client tells you. are something that the health professional can observe, such as a rash, bruising, or skin perspiration, also illustrated in Figure 1.3. Although you can observe signs, in the context of a subjective assessment, the client shares this subjective information with you. For example, a rash is both subjective and objective data as it could be something that the client shares with you, but it is also something that you can observe. On the other hand, if the client says that the rash is itchy, that would be considered subjective data and, in this case, it would be a symptom because it is something the client feels and you can’t observe.

Figure 1.3: Symptom versus sign

A term often used in reference to, or in place of, the complete subjective health assessment.

Care partners are family and friends who are involved in helping to care for the client

Information that the client shares with the health professional.

Information that the health professional collects when performing a physical exam.

Something that the client feels.

Something that the health professional observes.

• it is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm.
• it includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.

Purpose: To establish a data base (all the information about the client):

• nursing health history
• physical assessment
• the physician’s history & physical examination
• results of laboratory & diagnostic tests
• material from other health personnel

4 Types of Assessment:

a. Initial assessment – assessment performed within a specified time on admission

Ex: nursing admission assessment

b. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment

Ex: problem on urination-assess on fluid intake & urine output hourly

c. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.

Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.

d. time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

Activities:

1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data

Assessment = Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record

I. Collection of data

• gathering of information about the client
• includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status
• includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
• includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)

Types of Data:

• also referred to as Symptom/Covert data
• information from the client’s point of view or are described by the person experiencing it.
• information supplied by family members, significant others, other health professionals are considered subjective data.

Example: pain, dizziness, ringing of ears/Tinnitus

• also referred to as Sign/Overt data
• those that can be detected, observed or measured/tested using accepted standard or norm.

Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Methods of Data Collection:

• a planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.
• it is used while taking the nursing history of a client

1. Observation – use to gather data by using the 5 senses and instruments.

• systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
• should be conducted systematically:

1. Cephalocaudal approach – head-to-toe assessment
2. Body System approach – examine all the body system
3. Review of System approach – examine only particular area affected

Source of data:

1. Primary source – data directly gathered from the client using interview and physical examination.
2. Secondary source – data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals.

In the Assessment Phase, obtain a Nursing Health History – a structured interview designed to collect specific data and to obtain a detailed health record of a client.

Components of a Nursing Health History:

• Biographic data – name, address, age, sex, martial status, occupation, religion.
• Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization.
• History of present Illness – includes: usual health status, chronological story, family history, disability assessment.
• Past Health History – includes all previous immunizations, experiences with illness.
• Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).
• Review of systems – review of all health problems by body systems
• Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies.
• Social data – include family relationships, ethnic and educational background, economic status, home and neighborhood conditions.
• Psychological data – information about the client’s emotional state.
• Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors.

II. Validation of Data – the act of “double-checking” or verifying data to confirm that it is accurate and complete.

Purposes of data validation:

1. ensure that data collection is complete
2. ensure that objective and subjective data agree
3. obtain additional data that may have been overlooked
4. avoid jumping to conclusion
5. differentiate cues and inferences

Cues – subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.

Inferences – the nurse interpretation or conclusion based on the cues.

Example: red, swollen wound = infected wound
Dry skin = dehydrated

III. Organization of Data – uses a written or computerized format that organizes assessment data systematically.

– Maslow’s basic needs

– Body System Model

– Gordon’s Functional Health Patterns:

1. Health perception-health management pattern.
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern

IV. Analyze data – compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern:

Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern

V. Communicate/Record/Document Data

• nurse records all data collected about the client’s health status
• data are recorded in a factual manner not as interpreted by the nurse
• record subjective data in client’s word; restating in other words what client says might change its original meaning.

What Do You Think?