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In order to continue enjoying our site, we ask that you confirm your identity as a human. Thank you very much for your cooperation. Written By: Darby Faubion BSN, RN One of the most important duties nurses of all levels have is gathering and documenting patient data. The two main types of patient data nurses gather are subjective and objective nursing data. Perhaps you are a new nurse and have questioned, "What’s the difference between subjective vs. objective nursing data?" Maybe you have been a nurse for some time and want to brush up on your assessment and documentation skills. Whichever of these applies to you, it is necessary to know the difference between subjective and objective data. In this article, I will present information to you to help you develop an understanding of the difference between subjective vs. objective nursing data with 10 real-life examples. RECOMMENDED ONLINE MSN PROGRAMS The assessment phase is the first phase of the nursing process. Data is gathered during this phase, allowing nurses and other healthcare providers to create a holistic view of the patient. The data gathered is used to develop personalized treatment plans, provide a basis upon which patient progress is measured, determine continuing treatment plan options or changes, improve communication between the patient and interdisciplinary healthcare team, and enhance patient outcomes. The two primary types of data collected during the assessment phase of the nursing process are subjective nursing data and objective nursing data. Subjective and objective data in nursing come from various sources. It is essential for nurses to develop the proper skills and methods to obtain data in order to provide high-quality patient care and help improve patient outcomes. It is necessary for nurses to understand the difference between subjective vs. objective nursing data for several reasons. The following are a few of the top reasons nurses should learn the difference between these two types of data. • Understanding the difference between subjective vs. objective nursing data helps nurses create accurate documentation. • When nurses learn to differentiate between objective and subjective data in nursing, they can discuss their findings and collaborate with team members effectively. • Understanding the difference between subjective and objective nursing data helps nurses differentiate between what the patient is reporting and what the medical evidence suggests.
1. Subjective data are symptoms felt by the patient while objective data is not felt by the patient. 2. Objective data are observable and may appear to contradict what the patient says, but it does not mean the subjective data is wrong. 3. Subjective data can come from a primary source (the patient) or a secondary source (patient’s family, caregivers, or other team members). The nurse gathers objective nursing data from measurable sources including, but not limited to, laboratory or diagnostic tests and vital signs. 4. Subjective data in nursing does not have to be proven. Instead, it is a report of what the patient feels, thinks, and perceives to be true. Objective nursing data, on the other hand, is based upon facts, not feelings or opinions. 5. Subjective data may lead nurses to conclude one nursing diagnosis while the objective data may point to a different nursing diagnosis. For this reason, it is essential for nurses to weigh both objective and subjective nursing data when developing nursing diagnoses and care plans. 6. Depending on the patient’s response to treatment, objective nursing data may change more quickly than subjective nursing data. 7. Subjective nursing data may suggest the patient is experiencing a symptom related to an illness or disease. However, the objective data obtained from the laboratory or diagnostic testing may not indicate the original assumption requiring further testing. On the other hand, patients are more likely to have subjective nursing data that support objective nursing data than vice versa. 8. Subjective vs. Objective nursing data tend to cross lines, especially when nurses are unsure how to differentiate between them. The key difference between subjective and objective nursing data is the source from which the data is gathered. The following 10 real-life examples will help you clearly understand the difference between subjective vs. objective data in nursing.
Several tools are used to record assessment data such as patient flow charts, vital signs sheets, nurses’ notes, intake and output forms, shift report forms, and patient surveys. A subjective history is an accumulation of pertinent information about the patient with the patient being the primary source of that information. A patient's history can include short-term and long-term data as it relates to the patient and is used to gauge objective assessments and establish care plans. A subjective observation in nursing is a sign that cannot be measured. For example, feelings of nausea, headaches, or aching muscles. The patient may be able to express how bad a pain feels to her on a pain scale, but it is impossible for a nurse to measure the pain on the patient's behalf. Subjective symptoms are information that the patient can relay to the nurse, but the nurse cannot measure. For example, complaints of pain, headache, nausea, chills, or fatigue are examples of subjective symptoms. Objective clinical findings is the term used to describe anything related to a patient's status that can be measured. For example, atrophy, decreased range of motion, laboratory results, radiological test results, and alterations in vital signs. Review of Systems (ROS) is considered subjective data in nursing. The review of systems serves as a guide to help nurses and other healthcare practitioners identify underlying illness or potential problems. Once a review of systems is complete, the nurse can follow up with an objective nursing assessment. Height and weight are measurable and, therefore, are considered objective nursing data. A patient’s complaint of labored or difficult respiration is subjective. However, the nurse may observe objective signs that accompany the patient’s subjective report of labored respiration such as cyanosis, difficulty lying flat, or gasping for breath. Headaches are an example of subjective data. Although the nurse may observe signs that indicate the patient has a headache, such as the patient rubbing his head or avoiding bright lights, only the patient can feel the headache. Anxiety is another example of subjective nursing data. Nausea, like headaches and anxiety, is subjective. While the report of nausea may be accompanied by objective signs such as vomiting, nausea is only felt by the patient, making it subjective. Objective data is anything related to the patient that can be measured. Therefore, vital signs are a perfect example of objective data in nursing. Technically, coughing is considered subjective nursing data. The patient reports coughing and can tell the nurse how often and whether the cough is productive or nonproductive. Because the nurse can document objective findings of cough if he observes the patient coughing, some nurses may argue that coughing can be both subjective or objective data. Edema is defined as a palpable swelling produced by the accumulation of fluid in intercellular tissue. The words "palpable" and "swelling" in this definition indicate something observable or measurable, which means edema is classified as objective data in nursing. Blood pressure is measurable and, therefore, objective data in nursing. Age is classified as objective nursing data. Pain is one of the best examples of subjective nursing data available. It is not uncommon for nurses to observe signs that indicate a patient is experiencing pain. However, only the patient can say where he is hurting or rate the pain, making it subjective. As with a headache or toothache, the nurse may see signs which could make her believe the patient's throat is sore such as talking in a whisper or avoiding swallowing food, the nurse cannot measure throat pain. Therefore, the report of a sore throat is subjective data.
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