Objective vs Subjective Nursing Review
Subjective vs Objective Data in Nursing
Patient data collection and documentation is one of the most crucial responsibilities for nurses at all levels. Subjective and objective nursing data are the two main forms of patient data that nurses collect, and it is important to understand the differences.
Subjective data is what the patient reports but is not clearly seen. Objective Data is what is acutually observed or seen.
The distinction between objective and subjective data is basic, yet, some nurses complicate matters by overanalyzing things.
Furthermore, laboratory findings and vital signs are all objective data used to determine a patient’s condition.
When these statistics are paired with subjective data from the patient, physicians and nurses determine the patient’s proper diagnosis or construct an image of the patient’s health.
Subjective data is the type of data acquired when a patient describes their symptoms, including feelings, impressions, and concerns that the nurses are unable to assess with their five senses.
This type of information is vital because it provides healthcare personnel with context for why patients arrived at the hospital and hearing them is crucial to fully comprehend the situation. Because a patient knows themselves better than anyone else, understanding the patient’s comprehensive perspective on their illness and listening to what ails them will improve their outcome.
The patient is recognized as the primary source of subjective data, whereas secondary sources include the patient’s relatives or caregivers, as well as other members of the healthcare team.
The nurse should always remember that subjective nursing assessment data should contain any information provided by the patient and that subjective data is information conveyed to the nurse by the patient as felt or perceived.
Although the data may appear inappropriate to others, it should be captured as subjective nursing data if the patient experiences, states, or interprets it.
Nurses should avoid getting caught up in the overthinking process and instead simplify. When interpreting data becomes complicated, the nurse should ask whether the patient told them this information or if they can measure or detect it themselves.
If the nurse answered yes to the first question but no to the second, the information acquired by the nurse was most likely subjective.
The Importance of Subjective Data in Nursing
Since the patient is the major source of subjective data in nursing, this information is very important and can help to create a more comprehensive view of what the patient is going through, making it an important aspect of developing a care plan.
Subjective data might reveal difficulties with a patient’s psychological, physiological, or sociological well-being that a healthcare professional may overlook. Subjective data can also help alert the nurse to concerns that the patient may be having, as well as certain patient abilities that may be beneficial when interacting with and providing care to the patients.
Although the importance of subjective data in the assessment and management of patients is often underestimated, the most important aspect of these patient statements is that they define the severity, irritability, and nature of the condition of the patient, which cannot be determined by anyone other than the patient.
Nursing Skills in Obtaining Subjective Data
Subjective data is gathered by verbal or written communication, depending on the patient’s health status. Whether the nurse speaks directly with the patient to acquire main subjective nursing data or indirectly with the patient’s family, caregivers, or other healthcare team members to get secondary subjective nursing data, communication is necessary.
Five essential skills for accurately gathering and interpreting subjective nursing data are listed below.
- Focus on creating a relaxing and calm environment. The stress or uncertainty that comes with illness can make an individual feel uneasy or nervous, as no one desires to be in a hospital or a health clinic. Patients rest and feel more comfortable addressing their difficulties or worries in a quiet and pleasant environment.
- Constantly pay attention to what the patient has to say. The patient is the best source of patient information. There would be times that the patient may state something inappropriate about his situation. For instance, the nurse must document the patient’s complaint that his left lower leg is itchy although he just received a left above-the-knee amputation. The patient feels leg discomfort, and the nurse must record what he says so that a thorough treatment plan may be developed.
- Ask open-ended questions to the patient. Most patients express their worries openly, while others are hesitant despite a pleasant atmosphere. To encourage communication, nurses must learn to ask questions, particularly open-ended queries. Instead of asking, “Does your shoulder hurt?” try asking, “Can you describe where and how you perceive the pain?”.
- Acknowledge the boundaries and limits of the patient. Patients may feel as if their personal space is being invaded or that healthcare providers are being overly intrusive when asking them questions. Listening to the patients entails more than just hearing what they have to say. Give importance to how their mood shifts, and if it appears that they require some time to reflect or organize their emotions, provide it to them.
- Follow the nurse’s instincts. As nurses improve their ability to gather subjective data in the field of nursing, they will realize that objective data appears to integrate with subjective data made by patients or others. This is normal and an indication of a nurse’s development and critical thinking. Trust the nursing instincts and aim to establish trust with the patient and widen the communication line even more if a patient reports something but the nurse senses he is concealing or hesitant.
Examples of Subjective Data in Nursing
The following are some examples of subjective data in nursing:
|Nasal Congestion or Runny Nose||Feeling Sleepy or Dizzy||Numbness or tingling sensation|
|Chills||Itching||Pain and discomfort|
|Constipation and Diarrhea||Level of Consciousness||Shortness of Breath|
|Headache||Loss of Appetite||Sore Throat|
|Tinnitus||Anosmia or Ageusia||Sweating|
|Dizziness or Vertigo||Muscle or Body Aches||Vomiting|
|Exhaustion and Fatigue||Nausea||Numbness|
In nursing, objective data is an aspect of the health assessment process that involves gathering information through measurements or observations. Objective data are gathered through use of all the senses except for taste.
The senses of vision, auditory, olfactory, and tactile are used in the healthcare setting to obtain information about the patient. Objective data is also distinct from subjective data in that there is little potential for dispute.
While a patient’s subjective remark leaves a lot of space for interpretation and misinterpretation, objective evidence is the polar opposite and cannot be disputed. Vital signs, physical examinations, and laboratory or diagnostic tests can all provide objective data that is observable and quantifiable.
Furthermore, objective data is more comfortable for most nurses than subjective data since it is clear and concise. Many developed countries have most if not all of the technologies they need to rely primarily on objective data.
Inspection, palpation, percussion, and auscultation are four objective evaluation techniques that can be used to collect objective data.
Observing a patient’s posture, directly palpating a lump on a patient’s breast, listening to a patient’s heart, tapping on the body to elicit sounds, and collecting or analyzing laboratory and diagnostic tests such as complete blood count, stool analysis, X-rays, and so on are all forms of objective evaluation.
Following the gathering of subjective data from the patient, an objective assessment is usually performed.
The Importance of Objective Data in Nursing
Objective nursing data is an important aspect of patient assessments as it provides the assessing nurse with a view of the condition of the patient.
While a patient may complain that his head hurts, the nurse may notice changes in his vital signs or abnormal diagnostic test results that indicate aberrant changes in the patient’s body and support healthcare practitioners determine where to begin the diagnosing process.
The objective assessment’s goal is to detect the patient’s normal and abnormal results. The aberrant findings are warning signs that something is wrong with the patient.
Recognizing and responding to these unusual signals is an important aspect of the nursing process for ensuring patient safety and effective treatment. Failure to detect or respond to unusual signs might have serious repercussions for the patient.
Nursing Skills in Obtaining Objective Data
The following are essential skills for correctly obtaining and evaluating objective nursing data.
- Practise careful observation. Observation is perhaps the most crucial skill for evaluating objective data during a nursing assessment. Objective data, admittedly, is anything that can be quantified or viewed. Nurses can distinguish between what the patient is saying and what he may be feeling but is frightened to express through careful observation. For example, when a patient is afraid of being brought to the hospital, she may claim that her pain has gone away or that she is no longer unsteady. However, if the nurse notices the patient shielding her side or leaning against the wall as she walks, this opposes what the patient has said.
- Perform accurate measurement of vital signs. The objective nursing assessment requires accurate measurement of a patient’s vital signs. Nurses must learn to take vital signs and detect whether values are abnormally high or low.
- Understand how to read medical reports. Although physicians or other healthcare professionals are in charge of communicating a patient’s medical diagnosis, nurses must also be able to read medical reports, as they are often the first to acquire laboratory or diagnostic test results. Nurses are also responsible for ensuring that the doctor receives the information and follows up with the patient.
- Learn the usual ranges for various laboratory studies. The patient’s results as well as typical reference ranges are included on the laboratory test results sheet sent to the ordering physician or hospital. Although abnormal results and normal ranges are marked on the reports, nurses should be familiar with at least common ones. Normal white blood cell counts, electrolyte ranges, and the results of a routine urinalysis are just a few examples. For laboratory diagnoses, nurses do not need to memorize the manual, but knowing what to expect will help the nurse sift through patient data and start summarizing and documenting the objective data of the patient.
- Don’t be hesitant to validate data with the charge nurse or other team members. Offer high-quality patient care and enhancing health satisfaction, requires a group of skilled healthcare professionals. Even the most competent nurses sometimes find themselves questioning their assessment or rationale when collecting objective data. When in doubt about an observation, nurses should put their egos aside and seek assistance from a team member or supervisor.
Examples of Objective Data in Nursing
The following are some examples of objective data in nursing:
|Bleeding||Ambulation||Blood Urea and Creatinine Levels|
|Blood Pressure||Body temperature||Behavior|
|Complete Blood Count||Cardiac rate||Height and Weight|
|General appearance||Respiratory rate||Wound appearance and odor|
|Computed Tomography (CT) Scans||X-ray results||Oxygen Saturation rate|
|Adventitious breath sounds such as crackles, rales, etc.||Heart murmurs||Ear discharge|
Differences Between Subjective and Objective Data
When it comes to distinguishing between subjective and objective nursing data, the boundaries can be somewhat blurry. It is critical for nurses to differentiate between subjective and objective data and to document them accurately. The main differences between subjective and objective data in nursing are as follows.
- Subjective data are symptoms that the patient experiences, whereas objective data does not.
- Although objective data may seem to oppose what the patient is saying, this does not imply that the subjective data is incorrect.
- Subjective data can be obtained directly from the patient or indirectly from family, caregivers, or other team members. The nurse collects objective nursing data from measurable sources such as laboratory or diagnostic tests, as well as vital signs.
- It is not necessary to prove subjective data in nursing. Rather, it is a description of the patient’s feelings, thoughts, and perceptions of what is true. Nursing data that is objective is supported by facts rather than emotions or thoughts.
- Subjective data may prompt nurses to identify one nursing diagnosis, whereas objective data may indicate a different nursing diagnosis. As a result, while generating nursing diagnoses and treatment plans, nurses must consider both objective and subjective nursing data.
- Objective nursing data may vary more rapidly than subjective nursing data based on the patient’s treatment response.
- Subjective nursing data could indicate that the patient is suffering from a symptom of an illness or condition. However, objective evidence from laboratory or diagnostic testing may not support the original diagnosis, necessitating more screening. Patients, on the other hand, are more probable than not to have subjective nursing data that backs up objective nursing data.
- Nursing data that is subjective vs. objective tends to overlap, particularly when nurses are uncertain how to distinguish between the two. The source from which the data is acquired is the main distinction between subjective and objective nursing data.
Patient Scenarios: Objective versus Subjective Nursing Data
The following scenarios will assist nurses in distinguishing between subjective and objective information in nursing.
Objective vs Subjective Data Nursing Examples 1
Ms. Jackson, a forty-year-old Caucasian woman, was brought to the emergency department with nausea and vomiting for three days. She claims that she last threw up around half an hour before arriving at the hospital. Ms. Jackson describes herself as frail and wobbly. She is sweating profusely yet is chilly. Her blood pressure is 146/85, her pulse rate is 78, her respiratory rate is 18, and her temperature is 100.8°F. She denies any discomfort or medication changes since her last outpatient appointment.
Objective vs Subjective Data Nursing Examples 2
“I can’t breathe,” says a 46-year-old male patient at the emergency department, whose respirations are 25 per minute and his pulse rate is 115 beats per minute. When asked to rate the pain on a scale of 0-10, with 10 being the greatest pain imaginable, the patient responds with a ten.
Then, the patient holds his chest and says, “my chest aches so terribly, please save me.” When asked to describe how the pain seems, the patient responds that it feels like pressure. The patient becomes diaphoretic and cyanotic after that.
The result of an ECG reveals Sinus Tachycardia. the pulse oximeter reads 98%, and the patient’s blood pressure is 125/82 mmHg.
|Subjective Data||The patient’s statement of shortness of breath, and chest pain with a 10 out of 10 pressure feeling are the subjective data in this case.|
|Rationale||Shortness of breath is subjective since the patient conveys it to the nurse, but if the nurse observed accessory muscle use, the accessory muscle use would be objective but the perception of shortness of breath would remain subjective.|
|Objective Data||46-year-old male, respirations 25, heart rate 115, diaphoretic and cyanotic, sinus tachycardia in ECG reading, 98% pulse oximeter reading, blood pressure of 125/82 mmHg are all objective nursing information in this scenario.|
|Rationale||The diaphoresis and cyanotic skin condition are objective in because the nurse can see them on the patient.|
Objective vs Subjective Data Nursing Examples 3
After the right knee operation, the patient who is 5 days post-operative must begin walking with a walker. “I’m hesitant to apply too much pressure on my right leg, as I don’t want to perforate my stitches,” the patient says as the nurse untangles all the wires and IV tubing and begins walking with the patient down the corridor.
The nurse reassures the patient, explaining that the sooner the patient begins to walk after surgery, the better. The patient follows the nurse’s recommendations and begins to exert increasing pressure on the right leg.
The patient walks down the corridor and back at about 25 feet with ease, but says, “I’m out of breath and need to sit down.” The nurse places the patient on a chair and pulls over to check the oxygen saturation, which is 95%.
The patient is breathing at a rate of 24 breaths per minute, and her skin is rosy, warm, and dry. The nurse also notices that the patient is not using auxiliary muscles when breathing. The patient recovers his confidence and is walked back to his bed. The patient expresses fatigue from the stroll and wishes to rest.
|Subjective Data||The patient feels out of breath when walking with a walker and feels exhausted after.|
|Rationale||As earlier explained in this article, all statements from the patient about his or her feelings and condition are considered subjective.|
|Objective Data||The patient is 5 days post-operative, has a shuffling gait, is hesitant to walk on the right leg, can ambulate for 25 feet with ease, has 95% oxygen saturation, non-labored 24 breaths per minute, and the patient’s skin appearance are all objective information.|
|Rationale||The patient’s hesitancy of walking on the right leg is objective data because the patient shows measurable indicators of fear in addition to telling the nurse that he or she is worried. In this scenario, the patient walks with a shuffling gait, gains confidence after learning the necessity of walking, and the patient’s fear causes increased respiratory rate.|
To make a clinical judgment, objective data are combined with the patient’s subjective assessment. An accurate nursing care plan is a result of closely considering the data, interpreting the cues as a whole, deciding on the most important issues to fix, and determining the best way to address these concerns based on the available information.
Developing excellent clinical judgment as a healthcare professional is critical to achieving patient safety and maintaining competency. Prioritization and timing of assessment approaches will be guided by it.
The nurse will use both subjective and objective evaluation to identify which data should be investigated and assessed further.
As a nurse, it is necessary to analyze both objective and subjective findings gathered during an assessment carefully prior to creating a nursing diagnosis and making a suitable patient-centered care plan.
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Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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