Subjective VS Objective data

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    Ok, I really feel like an idiot. We are just starting Nursing Diagnosis & for part of an assignment I have to read a case study & separate subjective from objective data.
    Now, I know that subjective is "symptoms"; that it is what ony the patient can know, right? Obviously, if my case study says, "Patient states..." that is subjective but what about, "He lived alone in an apartment" or "He is observed to need assistance"
    Then with objective data, is something like past medical history included, such as "hypertension, obesity, chronic obstructive pulmonary
    disease"? If VS or testing results are not included in my case study, what would be examples of objective data?

    Please help. I have all kinds of tests to study for & assignments to complete this weekend & this one assignment is really stumping me. Am I making it too hard?
    Dixie
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    Now, I know that subjective is "symptoms"; that it is what ony the patient can know, right? Obviously, if my case study says, "Patient states..." that is subjective but what about, "He lived alone in an apartment" or "He is observed to need assistance"
    Then with objective data, is something like past medical history included, such as "hypertension, obesity, chronic obstructive pulmonary
    disease"? If VS or testing results are not included in my case study, what would be examples of objective data?

    Actually what the patient states you would put in quotes as your subjective data. " I can't breathe good". My leg hurts", " I can only sleep in a chiar" stuff like that.

    Everything you observe, past history, medications, test results,vital signs would be objective.
    AEMTCHICKEL likes this.
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    dixie. . .first off let me give you the definitions of subjective and objective data.

    objective data is information that you can perceive using your owns senses. you can see, hear, smell, feel, sometimes taste, and sometimes measure objective data.

    subjective data is information supplied to you by the subject, or patient. they are things that you cannot yourself perceive with your senses of sight, sound, smell, or touch. for example, pain. a patient tells you they have a pain in their leg. that is subjective data. it is based on the patient's statement. you cannot see, hear, smell, or feel the patient's pain. however, you can see a grimace on the face of someone in pain. the grimace on their face would be an objective observation.

    to get back to what you posted, you kind of have the two mixed up. anything the patient says and is surrounded by quotation marks in a case study should be taken as being subjective data. where your case study says, "he is observed to need assistance", you are being told that the observer actually viewed that, so it should be taken as objective data.

    yes, past medical history is included in a case history. is is part of the review of symptoms. a review of symptoms is done before a physical exam.

    when you are doing case studies, it is helpful to look at a medical resource that can give you the signs and symptoms of any diseases that might be mentioned that the patient in the case study has. otherwise, you just have to work with the information that you are given. you should have in your mind what is generally assessed during a physical exam and nursing assessment. besides doing a physical examination, nurses also assess a patient's ability to perform activities of daily living (adls). so, your patient in this case study who was observed to need assistance was assessed by someone with regard to his abilities to perform adls. i hope you were given a little more information than that, however, if you are to develop something more complex like a plan of care from that information.

    here are some links to case studies that were done by students on actual patients. might give you some ideas of how case studies are organized and put together.
    http://learn.sdstate.edu/craigg/ersp01.html
    http://learn.sdstate.edu/craigg/ercases.html

    here is a link to head to toe assessment in 5 minutes, a great guide to physical assessment of the patient
    http://www.mededcenter.com/module_vi...+118#headtotoe

    this page has a link you can click on, "write ups" where you can see two examples of what a phycians's history and physical exam look like in the sequence they should be written. nursing exams of patient follow a similar sequence.
    http://medicine.ucsd.edu/clinicalmed/introduction.htm
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    Thank you both for your assistance. It did help. I suspect that I am making it harder than it needs to be. I am training to be a LPN so won't be writing care plans & or coming up with diagnoses but I know I'll be involved so need to understand the whole process.
    I was given more information that I mentioned. I just didn't state it all because I didn't want anyone to think I was asking you to give me the answers.
    Oh, the links were great!
    One more question if you have the time, what book do you feel is best for care plans? I picked up one & the organization is so weird that I can't make head nor tale of it. I suspect that I'll be needing something for the rest of my life.
    Dixie
    Last edit by midcom on Dec 10, '06 : Reason: misspellings
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    the one book that i think will work really well for a student is nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig, i've heard a lot of students on the forums rave about it as well. when i was searching it as well as others on barnes and nobel, it was rated higher than any of the others in sales ranking. it is organized by nursing diagnosis.

    i also have care plan books by carpenito and doenges. these are care plans by medical diagnoses.

    you can get an idea of what the ackley and ladwig book is organized like before making a decision to buy by looking at a couple of the nursing diagnosis pages from their companion online constructor:
    http://www1.us.elsevierhealth.com/ev...replan_048.php - nausea
    http://www1.us.elsevierhealth.com/ev...replan_063.php - impaired skin integrity
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    Something that always helps me is to remember that objective data is verifiable. Another person can repeat the observation, you can perform some type of test, etc. Subjective data is what comes out of the patient or family's mouth.
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    The easiest way for me to remember is
    Subjective= pt stated (symptoms)
    Objective=Observed (by yourself, labs, during assessment,etc)
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    Quote from Daytonite
    The one book that I think will work really well for a student is Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig, I've heard a lot of students on the forums rave about it as well. When I was searching it as well as others on Barnes and Nobel, it was rated higher than any of the others in sales ranking. It is organized by nursing diagnosis.
    I'm happy to read this as I have this book on my PDA. I really like it but at my age, I just can't get used to reading on that tiny screen when doing homework. I need a book where I can see all I need at one time. Now my problem, do I spring for the book knowing the information will be identical or try to find something else almost as good so I have two references?

    Thanks for the suggestions.
    Dixie
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    you can view 75 of the most commonly used diagnoses from the book at this website.
    http://www1.us.elsevierhealth.com/ev...e/constructor/

    at least you can adjust the size of the text on the computer screen! i have some of the same problems myself. glasses on or glasses off, a decision i often have to make. i do so mislike the term baby boomer. i'm not a baby anymore and i sure have elderly problems to prove it!
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    subjective data is what the patient says, objective can be measured by the nurse (i.e.. b/p, hr), and /or what you observe.


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