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Subjective VS Objective data

Students   (557,080 Views | 9 Replies)

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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 only 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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Daytonite has 40 years experience as a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

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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 is a link to head to toe assessment in 5 minutes, a great guide to physical assessment of the patient.

 

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Achoo! is a LPN and specializes in Urgent Care.

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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.

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428 Posts; 7,868 Profile Views

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

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Daytonite has 40 years experience as a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

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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, 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.

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AggieNurse99 has 12 years experience as a BSN and specializes in Telemetry, Med/Surg, Infusion, Vascular Access.

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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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21 Posts; 1,722 Profile Views

The easiest way for me to remember is

Subjective= pt stated (symptoms)

Objective=Observed (by yourself, labs, during assessment,etc)

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428 Posts; 7,868 Profile Views

Daytonite said:
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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marcitweets has 5 years experience and specializes in cardiac, med surg.

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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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I am a patient rather than a medical professional. I got here because I am curious as to how to better communicate subjective data to medical professionals assigned to my care. I want to know how to present my subjective information to 5 medical professionals so that when I review the information each nurse has communicated to other medical professionals the same course of care is indicated.

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