Subjective and Objective Data - EDAPT (WEEK 2)
Which questions are asked by the health examiner to obtain subjective data? Select all that apply.
(does it hurt when I press here) and intensity (scale of 1-10) of pain, or to expand the data base (can you tell me about it).
Examples of objective data include:
Breath sounds Strength of peripheral pulses Appearance of the individual Vital signs Description of a surgical incision
Which data collected from the client is subjective? Select all that apply.
Feelings Sensations List of foods eaten in the past 3 days Past medical history
Which is an example of objective data?
Hearing a popping sound when the left knee is extended
Select the words or phrases used to document subjective data from a recent health assessment. History of Present Illness: The client presents with sudden onset of blurred vision, diplopia (double vision), bilateral arm weakness with L > R, and left eye ptosis (droop). Lumbar puncture revealed increased protein in the cerebrospinal fluid (CSF). Social History: Denies alcohol and tobacco use; retired teacher; lives with spouse and two cats. Allergies: Acnotex and Bactrim DS
History of Present Illness: Sudden onset of blurred vision, diplopia (double vision), bilateral arm weakness with L > R Social History: Denies alcohol and tobacco use; lives with spouse and two cats. Allergies: Acnotex and Bactrim DS
What is subjective data?
Information provided by the client or family
Select the words or phrases used to document objective data from a recent follow-up health assessment. Client denies trouble breathing, states cough is persistent, and sputum production is decreasing. Lung sounds are clear to auscultation except crackles in left lower lobe which are decreased since last assessment. Incentive spirometer and coughing with deep breathing completed with client voicing irritation with the intervention; crackles decreased after pulmonary hygiene. Oxygen saturation 96% on room air. BP 148/92, T 100.6 °F tympanic, HR 114 bpm, RR 24 per minute.
Lung sounds are clear to auscultation except crackles in left lower lobe, decreased since last assessment, Incentive spirometer and coughing with deep breathing completed, Oxygen saturation 96% , BP 148/92, T 100.6 °F , HR 114 bpm, RR 24 per minute.
After completing an initial assessment of a client, the nurse has charted that their respirations are eupneic and their pulse is 58 beats per minute. This is _________ type of data.
Objective
Information is being recorded when the examiner documents a person's temperature is 102.1 °F and heart rate is 126 beats per minute.
Objective
What the health examiner learns using the assessment techniques of inspection, palpation, percussion, and auscultation.
Objective data
Examples of subjective data include:
Reason for seeking care. Recalled dietary intake. Description of pain. Suicidal thoughts. Past medical and surgical history. How many episodes of vomiting occurred in the past 12 hours.
Which excerpt from the healthcare provider's admission assessment does the nurse interpret as objective data? Select all that apply.
Source of information: 17-year-old client and their mother. Mother frequently interrupts the client to contradict what they are saying. Client's clothes are wrinkled and dirty.
A client tells the nurse that they are very nervous, nauseated, and "feel hot." What type of data is this?
Subjective
Consider the following scenario, and then determine which data are objective and which are subjective. Mrs. Johnson (pronouns: she/her/hers) has been hospitalized for gallbladder surgery. During the morning assessment, the nurse obtains the following information: Vitals: T 101.4 °F, P 97, R 18, BP 132/90. Mrs. Johnson feels warm to the touch but is shivering slightly and complaining of being cold. When the nurse asks her how she slept last night, she replies, "Not well at all. I feel like I only slept an hour all night." Mrs. Johnson appears to not want to move in bed and is guarding her abdomen. When the nurse her about her pain on a scale of 0-10, with 10 being the worst pain imaginable and 0 being no pain at all, she replies with a pain score of 8.
Subjective Data: Mrs. Johnson replies, "Not well at all. I feel like I only slept an hour all night." Mrs. Johnson is complaining of being cold. Objective Data: Mrs. Johnson is shivering slightly. Mrs. Johnson feels warm to the touch. T = 101.4 °F Mrs. Johnson is guarding her abdomen.
What is assessment?
is the collection of data about the individual's health state.
Health assessment data falls into what two general categories?
subjective data and objective data
Select the subjective words or phrases present in the plan of care documentation. Upon assessment of vital signs, the client's blood pressure was 190/92. They were questioned about their medication adherence, and slowly during the course of the client interview, it was shared that they had not refilled or taken their hypertension medications in over one year. This client did not appear to understand the severity of their health issues at this time. They are a poor historian and seemed to have a lack of understanding of how quickly this event could have taken a much worse route. Client education and support for the current situation as well as a lengthy discussion about the consequences of non-adherence to medications was completed.
they had not refilled or taken their hypertension medications in over one year.
Including that the person said they have felt sick for the last two days is an example of documenting subjectivefirst-handobjective
Subjective data
What the person shares about themselves.
Subjective data
Indicate if each actions made by the examiner during the physical assessment is completed to gather subjective and/or objective data. Each action may fall into more than one category.
Subjective: Listening Objective: Listening Touching Looking Smelling
Which data is an example of objective information obtained during the health assessment of the client who fell down the steps and hurt their ankle?
Swelling and bruising of the left ankle
