{"id":664,"date":"2019-05-22T20:51:22","date_gmt":"2019-05-23T00:51:22","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/the-complete-subjective-health-assessment\/"},"modified":"2024-06-05T16:25:12","modified_gmt":"2024-06-05T20:25:12","slug":"the-complete-subjective-health-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/the-complete-subjective-health-assessment\/","title":{"raw":"The Complete Subjective Health Assessment","rendered":"The Complete Subjective Health Assessment"},"content":{"raw":"The complete subjective health assessment is commonly referred to as a [pb_glossary id=\"727\"]health history[\/pb_glossary]<\/strong>. It provides an overview of the client\u2019s current and past health and illness state. You conduct it by interviewing the client as illustrated in Figure 1<\/strong>, asking them questions, and listening to their narrative.\r\n\r\n[caption id=\"attachment_662\" align=\"aligncenter\" width=\"550\"]\"A Figure 1:<\/strong> Nurse interviewing the client[\/caption]\r\n\r\nThis 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.\r\n\r\n \r\n
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Points of Consideration<\/p>\r\n\r\n<\/header>\r\n

\r\n\r\nClients are sometimes accompanied by [pb_glossary id=\"733\"]care partners[\/pb_glossary]<\/strong>. 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 \u201cinformal caregivers\u201d or \u201cfamily caregivers,\u201d but \u201ccare partner\u201d is a more inclusive term that acknowledges the energy, work, and importance of their role.\r\n\r\n<\/div>\r\n<\/div>\r\nThe 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 2<\/strong>.\r\n\r\n[caption id=\"attachment_662\" align=\"aligncenter\" width=\"700\"]\"Highlights Figure 2<\/strong>: The nursing process[\/caption]\r\n\r\nAs illustrated in Figure 2<\/strong>, the assessment phase of the nursing process involves collecting [pb_glossary id=\"729\"]subjective data[\/pb_glossary]<\/strong> (information that the client shares) and [pb_glossary id=\"731\"]objective data[\/pb_glossary]<\/strong> (information that you collect when performing a physical exam). See Table 1<\/strong>\u00a0for 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.\r\n\r\nTable 1:<\/strong> Overview and examples of subjective and objective data\r\n\r\n\r\n\r\n\r\n\r\n
Data<\/strong><\/td>\r\nExample<\/strong><\/td>\r\n<\/tr>\r\n
 \r\n\r\nSubjective<\/strong>\r\n\r\nInformation that the client shares with you spontaneously or in response to your questions.\r\n\r\n <\/td>\r\n\r\n
    \r\n \t
  • The client states, \u201cI have had a rash on my ankle and leg for the last two weeks.\u201d<\/li>\r\n \t
  • The parent states, \u201cMy eight-month-old son is having trouble breathing.\u201d<\/li>\r\n \t
  • The client\u2019s reason for seeking care is \u201cdiarrhea for 10 days.\u201d<\/li>\r\n \t
  • The client types, \u201cI feel sick to my stomach.\u201d<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n
 \r\n\r\nObjective<\/strong>\r\n\r\nInformation that you observe when conducting a physical assessment, and lab and diagnostic results.\r\n\r\n <\/td>\r\n\r\n
    \r\n \t
  • 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.<\/li>\r\n \t
  • You observe the client sitting upright, leaning forward, breathing fast with eyes wide open.<\/li>\r\n \t
  • You take the client\u2019s blood pressure and report it as 112\/84 mm Hg and pulse at 84 beats per minute.<\/li>\r\n \t
  • Lab test results: K+ 4.0 mmol\/L, fasting glucose 4.8 mmol\/L.<\/li>\r\n \t
  • Chest X-ray report: Lungs well inflated and clear. No evidence of pneumonia or pulmonary edema.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n \r\n\r\nAs the word \u201csubjective\u201d 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, [pb_glossary id=\"735\"]symptoms[\/pb_glossary]<\/strong> are something that the client feels, as illustrated in Figure 3<\/strong> (e.g., nausea, pain, fatigue). You won\u2019t know about a symptom unless the client tells you. [pb_glossary id=\"737\"]Signs[\/pb_glossary]<\/strong> are something that the health professional can observe, such as a rash, bruising, or skin perspiration, also illustrated in Figure 3<\/strong>. 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\u2019t observe.\r\n
    <\/div>\r\n
    \r\n\r\n[caption id=\"attachment_663\" align=\"aligncenter\" width=\"550\"]\"To Figure 3<\/strong>: Symptom versus sign[\/caption]\r\n\r\n
    \r\n

    Reflective questions<\/h2>\r\n<\/header>\r\n
      \r\n \t
    1. What type of data do you collect when completing a complete subjective health assessment?<\/li>\r\n \t
    2. How do you differentiate symptoms from signs?<\/li>\r\n<\/ol>\r\n<\/div>\r\n
      \r\n

      Test Yourself<\/h2>\r\n
      \r\n

      [h5p id=\"4\"]<\/p>\r\n\r\n<\/div>\r\n<\/div>","rendered":"

      The complete subjective health assessment is commonly referred to as a