COLLECTING SUBJECTIVE AND OBJECTIVE DATA

OBJECTIVES:
 To identify the different important information in collecting subjective and objective data,
 To identify and discuss the different nursing roles in client’s data collection
 To enumerate and discuss the phases of interview
 To identify the two (2) types of communication techniques to be used in data collection
 To enumerate the components in taking patient’s health history and discuss its special
nursing considerations
 To identify and discuss the different techniques in collecting objective data (physical
examination)
 To enumerate and identify the necessary preparations, equipment, skills and steps in
performing physical examination

SUBJECTIVE DATA
(Interview and Health History)
 Collecting subjective data is an integral part of interviewing the client to obtain a nursing
health history.
 Can be elicited and verified only by the client
 Provide clues to possible physiologic, psychological, and sociologic problems
 Provide the nurse with information that may reveal a client’s risk for a problem as well as
areas of strengths for the client.

Subjective data consist of:

 Sensations and symptoms
 Feelings
 Desires
 Preferences
 Beliefs
 Ideas
 Values
 Personal information
 Covert data
 The information is obtained through interviewing. Therefore, effective interviewing skills
are vital for accurate and thorough collection of subjective data.

Interviewing
Obtaining a valid nursing health history requires professional, interpersonal, and interviewing skills.
The nursing interview is a communication process that has two focuses:
a. Establishing rapport and a trusting relationship with the client
b. Gathering information on the client’s developmental, psychological, physiologic,
sociocultural, and spiritual statuses

PHASES OF THE INTERVIEW

1. Pre-introductory phase
2. Introductory phase
3. Working phase
4. Summary and closing phase
COMMUNICATION DURING THE INTERVIEW
The client interview involves two types of communication:
a. Non-verbal
b. Verbal

Nonverbal Communication
 Appearance
 Demeanor
 Facial expressions
 Attitude
 Silence
 Posture and Listening

NONVERBAL COMMUNICATION TO AVOID:

 Excessive or Insufficient Eye Contact
 Distraction and Distance
 Standing
 Vital information may not be revealed if the client believes that the interviewer is
untrustworthy, judgmental, or disinterested.

Verbal Communication
 Open-Ended Questions
 Closed-Ended Questions
 Laundry List
 Rephrasing
 Well-Placed Phrases
 Inferring
 Providing Information

VERBAL COMMUNICATION TO AVOID

 Biased or Leading Question
 Rushing Through the Interview
 Reading the Questions

SPECIAL CONSIDERATIONS DURING THE INTERVIEW:

1. Gerontologic Variations in Communication
2. Cultural Variations in Communication
3. Emotional Variations in Communication
 INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATES

WHEN INTERACTING WITH AN ANXIOUS CLIENT

 Provide the client with simple, organized information in a structured format.
 Explain who you are, along with your role and purpose.
 Ask simple, concise questions.
 Avoid becoming anxious like the client.
 Do not hurry, and decrease any external stimuli.
WHEN INTERACTING WITH AN ANGRY CLIENT
 Approach this client in a calm, reassuring, in-control manner.
 Allow him to ventilate feelings. However, if the client is out of control, do not argue with or
touch the client.
 Obtain help from other health care professionals as needed.
 Avoid arguing and facilitate personal space so that the client does not feel threatened or
cornered.
WHEN INTERACTING WITH A DEPRESSED CLIENT
 Express interest in and understanding of the client and respond in a neutral manner.
 Do not try to communicate in an upbeat, encouraging manner. This will not help the
depressed client.
WHEN INTERACTING WITH A MANIPULATIVE CLIENT
 Provide structure and set limits. Differentiate between manipulation and a reasonable
request.
 If you are not sure whether you are being manipulated, obtain an objective opinion from
other nursing colleagues.
WHEN INTERACTING WITH A SEDUCTIVE CLIENT
 Set firm limits on overt sexual client behavior and avoid responding to subtle seductive
behaviors.
 Encourage client to use more appropriate methods of coping in relating to others.

WHEN DISCUSSING SENSITIVE ISSUES (E.G., SEXUALITY, DYING, SPIRITUALITY)

 First, be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality;
then recognize that these factors may affect the client’s health and may need to be
discussed with someone.
 Ask simple questions in a nonjudgmental manner.
 Allow time for ventilation of client’s feelings as needed.
 If you do not feel comfortable or competent discussing personal, sensitive topics, you may
make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or
other specialists as needed.

PATIENT’S HEALTH HISTORY

The health history is consisting of the following sections:

a. Biographical data
b. Reasons for seeking health care
c. History of present health concern
d. Personal or past health history
e. Family health history
f. Review of body systems for current health problems
 g. Lifestyle and health practices profile
h. Developmental level

OBJECTIVE DATA
(Physical Examination)
 Objective data include information about the client that the nurse directly observes
during interaction with the client and information elicited through physical
assessment (examination) techniques.
 To become proficient with physical assessment skills, the nurse must have basic
knowledge in three areas:
a. Types and operation of equipment needed for the particular examination
b. Preparation of the setting, oneself, and the client for the physical assessment
c. Performance of the four assessment techniques: inspection, palpation,
percussion, and auscultation

EQUIPMENT NEEDED FOR PHYSICAL EXAMINATION:

1. For all examinations- gowns and gloves

2. Vital signs- sphygmomanometer, thermometers, watch with second hand, pain rating
scale
3. Nutritional status- weighing scale, skinfold caliper, flexible tape, skin marking pen
4. Skin, hair, and nail- examination light, penlight, mirror, metric ruler, magnifying glass,
Wood’s light, Braden Scale for predicting pressure sore, Risk Pressure Ulcer Scale for
healing (PUSH)
5. Head and neck- stethoscope and a class of water
6. Eye- penlight, Snellen E chart to test, newspaper, Opaque card to test for strabismus
Ophthalmoscope to view the red reflex and to examine the retina of the eye
7. Ear- Tuning fork to test for bone and air conduction of sound; Otoscope to view the ear
canal and tympanic membrane
8. Mouth, Throat, Nose, and Sinus- penlight to provide light, 4 × 4-inch small gauze pad,
tongue depressor, otoscope with wide-tip attachment
9. Thoracic and Lung- stethoscope (diaphragm), metric ruler and skin marking pen
10. Heart and Neck Vessel- stethoscope (bell and diaphragm), two metric rulers
11. Peripheral Vascular- sphygmomanometer and stethoscope; flexible metric measuring
tape, tuning fork to detect vibratory sensation, doppler ultrasound device and
conductivity gel
12. Abdominal- Stethoscope, flexible metric measuring tape and skin marking pen to
measure size, two small pillows to place under knees and head
13. Musculoskeletal- flexible metric measuring tape, goniometer to measure degree of
flexion and extension of joints
14. Neurologic- cotton-tipped applicators to put salt or sugar on tongue to test taste,
newspaper, ophthalmoscope, flexible metric measuring tape, objects to feel, such as a
coin or key to test for stereognosis (ability to recognize objects by touch), feflex
(percussion) hammer, cotton ball and paper clip to test for light, sharp, and dull touch
and two-point discrimination, substances to smell and taste to test for smell and taste
perception, Snellen E chart, penlight, tongue depressor to test for rise of uvula and gag
reflex, tuning fork
15. Male Genitalia and Rectum- gloves and water-soluble lubricant, penlight for scrotal
illumination, specimen card for occult blood
 16. Female Genitalia and Rectum- vaginal speculum and water-soluble lubricant, Bifid
spatula, endocervical broom to obtain endocervical swab and cervical
scrape and vaginal pool sample, large swabs for vaginal examination, liquid Pap medium,
pH paper, feminine napkins

PREPARING THE PHYSICAL SETTING

• Comfortable, warm room temperature: Provide a warm blanket if the room temperature cannot
be adjusted.
• Private area free of interruptions from others: Close the door or pull the curtains if possible.
• Quiet area free of distractions: Turn off the radio, television, or other noisy equipment.
 Adequate lighting: It is best to use sunlight (when available).
 Firm examination table or bed at a height that prevents stooping: A roll-up stool may be useful
when it is necessary for the examiner to sit for parts of the assessment.
 A bedside table/tray to hold the equipment needed for the examination

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) AND HEALTHCARE INFECTION
CONTROL PRACTICES ADVISORY COMMITTEE (HICPAC) ISOLATION PRECAUTION GUIDELINES
STANDARD PRECAUTIONS
Hand Hygiene
Personal Protective Equipment (PPE)
Gloves
Gowns
Mouth, Nose, Eye Protection
Respiratory Hygiene/Cough Etiquette

PHYSICAL EXAMINATION TECHNIQUES

These techniques are:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation

The different positions that can be used during physical examination:

a. Sitting
b. Supine
c. Prone
d. Dorsal recumbent
e. Sim’s
f. Standing
g. Lithotomy
h. Knee-chest

Inspection
  Inspection involves using the senses of vision, smell, and hearing to observe and detect
any normal or abnormal findings.
 Inspection precedes palpation, percussion, and auscultation because the latter techniques
can potentially alter the appearance of what is being inspected.
 Use the following guidelines as you practice the technique of inspection:
a. Make sure the room is a comfortable temperature. A too cold or too-hot room can
alter the normal behavior of the client and the appearance of the client’s skin.
b. Use good lighting, preferably sunlight. Fluorescent lights can alter the true color of the
skin. In addition, abnormalities may be overlooked with dim lighting.
c. Look and observe before touching. Touch can alter appearance and distract you from a
complete, focused observation.
d. Completely expose the body part you are inspecting while draping the rest of the
client as appropriate.
e. Note the following characteristics while inspecting the client: color, patterns, size,
location, consistency, symmetry, movement, behavior, odors, or sounds.
f. Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or
both sides of any individual body part.

Palpation

 Palpation consists of using parts of the hand to touch and feel for the following
characteristics:
a. Texture (rough/smooth)
b. Temperature (warm/cold)
c. Moisture (dry/wet)
d. Mobility (fixed/movable/still/vibrating)
e. Consistency (soft/hard/fluid filled)
f. Strength of pulses (strong/weak/thready/bounding)
g. Size (small/medium/large)
h. Shape (well defined/irregular)
i. Degree of tenderness
 Three different parts of the hand—the fingerpads, ulnar/ palmar surface, and dorsal surface
—are used during palpation.
 Each part of the hand is particularly sensitive to certain characteristics. Specific instructions
on how to perform the four types of palpation follow:
1. Light palpation: To perform light palpation, place your dominant hand lightly on the
surface of the structure. There should be very little or no depression (less than 1 cm).
Feel the surface structure using a circular motion. Use this technique to feel for pulses,
tenderness, surface skin texture, temperature, and moisture.
2. Moderate palpation: Depress the skin surface 1 to 2 cm (0.5 to 0.75 inch) with your
dominant hand, and use a circular motion to feel for easily palpable body organs and
masses. Note the size, consistency, and mobility of structures you palpate.
3. Deep palpation: Place your dominant hand on the skin surface and your non-dominant
hand on top of your dominant hand to apply pressure. This should result in a surface
depression between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep
organs or structures that are covered by thick muscle.
4. Bimanual palpation: Use two hands, placing one on each side of the body part (e.g.,
uterus, breasts, spleen) being palpated. Use one hand to apply pressure and the other
 hand to feel the structure. Note the size, shape, consistency, and mobility of the
structures you palpate.

Parts of Hand to Use When Palpating

a. Finger pads: fine discriminations for pulses, texture, size, consistency, shape,
crepitus
b. Ulnar or palmar surface: vibrations, thrills, fremitus
c. Dorsal (back) surface: temperature

Percussion
 Percussion involves tapping body parts to produce sound waves. These sound waves or
vibrations enable the examiner to assess underlying structures.
 Percussion has several different assessment uses, including:
a. Eliciting pain
b. Determining location, size, and shape
c. Determining density
d. Detecting abnormal masses
e. Eliciting reflexes

The three (3) types of percussion:

1. Direct
2. Blunt
3. Indirect or mediate percussion

Sounds (Tones) Elicited by Percussion

  The following techniques help to develop proficiency in the technique of indirect percussion:
• Place the middle finger of your non-dominant hand on the body part you are going to
percuss.
• Keep your other fingers off the body part being percussed because they will damp the
tone you elicit.
• Use the pad of your middle finger of the other hand (ensure that this fingernail is
short) to strike the middle finger of your non-dominant hand that is placed on the
body part.
• Withdraw your finger immediately to avoid damping the tone.
• Deliver two quick taps and listen carefully to the tone.
• Use quick, sharp taps by quickly flexing your wrist, not your forearm.

Auscultation
 Auscultation is a type of assessment technique that requires the use of a stethoscope to
listen for heart sounds, movement of blood through the cardiovascular system, movement of
the bowel, and movement of air through the respiratory tract.
 A stethoscope is used because these body sounds are not audible to the human ear (e.g., lung
sounds, bruits, bowel sounds, and so forth).
 To use a stethoscope, follow these guidelines:
1. Place the earpieces into the outer ear canal. They should fit snugly but comfortably to
promote effective sound transmission.
2. Angle the binaurals down toward your nose. This will ensure that sounds are transmitted to
your eardrums.
3. Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should
be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly
against the body part being auscultated.
4. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1
inch wide. Hold the bell lightly against the body part being auscultated.

Some Do’s and Don’ts:

• Warm the diaphragm or bell of the stethoscope before placing it on the client’s skin.
• Explain what you are listening for and answer any questions the client has. This will help to
alleviate anxiety.
• Do not apply too much pressure when using the bell—too much pressure will cause the bell to
work like the diaphragm.
• Avoid listening through clothing, which may obscure or alter sounds.

These guidelines should be followed as you practice the technique of auscultation:

• Eliminate distracting or competing noises from the environment (e.g., radio, television,
machinery).
• Expose the body part you are going to auscultate. Do not auscultate through the client’s clothing
Or gown. Rubbing against the clothing obscures the body sounds.
• Use the diaphragm of the stethoscope to listen for high-pitched sounds, such as normal heart
sounds, breath sounds, and bowel sounds, and press the diaphragm firmly
on the body part being auscultated.
• Use the bell of the stethoscope to listen for low-pitched sounds such as abnormal heart sounds
and bruits (abnormal loud, blowing, or murmuring sounds). Hold the bell lightly on the body part
being auscultated.

Prepared by:
Prof. Harley L. dela Cruz, MAN, RN

Reference:
Weber, J. R., & Kelley, J. H. (2017). Health assessment in nursing (6th ed.).
Lippincott Williams and Wilkins.