 Subjective data can be elicited and verified only by the

client.
 Subjective data is obtained through interviewing or
questioning.
 Therefore, effective communication and interviewing
skills are vital for accurate and thorough collection of
subjective data.
 Obtaining valid nursing history requires professional,
interpersonal and interviewing skills.
 Nursing interview has two focuses:
o Establishing rapport
o Gathering information on client’s status
1. Pre-introductory Phase
2. Introductory Phase
3. Working Phase
4. Summary and Closing Phase
Nonverbal Communication – as important as verbal
communication. It strongly influences how the client
perceives the questions you ask.
o Appearance
o Demeanor
o Facial Expression
o Attitude
o Silence
o Listening
Verbal Communication – essential to a client interview.
o Open-ended Questions
o Close-ended Questions
o Laundry List
o Rephrasing
o Well-placed Phrases
o Inferring
o Providing Information
 Gerontologic Variations in Communication
 Cultural Variations in Communication
 Emotional Variations in Communication
 Excellent way to begin the assessment process
because it provides the foundation for identifying
nursing problems and provides focus for the physical
examination.
 Eight (8) Sections:
1. Biographical data
2. Reasons for seeking health care
3. History of present health concern
4. Personal health history
5. Family health history
6. ROS for current health problems
7. Lifestyle and health practices profile
8. Developmental level
Usually includes information that identifies the patient.
o Name, address, number, gender, etc.
o Culture, ethnicity, religion, languages
o Education level, working status
 What is your major health problem at this time?
 How do you feel about having to seek health care?
 Why are you here?
 How can I help you?”
 C - Character (feel, look, smell, sound)
 O - Onset (When did it start?)
 L - Location (Where is it? Does it radiate?
 D - Duration (How long does it last?)
 S - Severity (Scaling)
 P - Pattern (What makes it better/worse?)
 A - Associated Factors (Other symptoms)
Focuses on questions related to client’s personal history
from the earliest beginnings to the present.
o Problems at birth
o Childhood illnesses
o Immunizations
o Surgeries
o Accidents
 To determine genetically based problems or
predispositions.
 Uses genogram to trace family history
 Skin, hair, nails  Thorax, lungs
 Head and neck  Heart, neck vessels
 Eyes  Peripheral vascular
 Ears  Abdomen
 Mouth, throat, nose,  Musculoskeletal
sinuses  Neurologic
 Breasts, regional  Genitalia
lymphatics  Anus, rectum
Client’s human responses, which include nutritional
habits, activity and exercise patterns, sleep and rest
patterns, self-concept and self-care activities, social and
community activities, relationships, values and beliefs
system, education and work, stress level and coping
style, and environment.
 Description of typical day
 Nutrition and Weight Management
 Activity level and exercise
 Sleep and rest
 Substance use
 Self concept and self-care responsibilities
 Social activities
 Relationships
 Education and work
 Stress levels and coping styles
 Environment
 Freud’s Stages of Psychosexual Development
 Erikson’s Theory of Psychosocial Development
 Piaget’s Stages of Cognitive Development
 Kohlberg’s Stages of Moral Development
Objective Data is the physical data we can observe from
the patient using our senses. Objective findings come in
either a measurement or a direct observation. Objective
data cannot be argued, as it is measured and observed
through vitals, tests, and physical exams.
 Types and operation of equipment needed for
particular examination (sphygmomanometer, penlight,
otoscope, stethoscope, etc.)
 Preparation of the setting, oneself and the client for
the physical assessment.
 Performance of the four (4) assessment techniques:
o Inspection
o Palpation
o Percussion
o Auscultation
 Each part of physical examination requires specific
pieces of equipment.
 Collect the necessary equipment and place it in the
area where the examination will be performed.
 Wear appropriate PPEs.
 Provide privacy and comfort for the patient.
 Adequate lighting, firm examination table.

 Prepare yourself for physical assessment.

 Wash hands and wear PPEs as needed.

 Establish rapport during interview.

 Respect patient’s desires.
Proper positioning of patient is very important during
assessment procedure to fully visualize or evaluate the
body part being assessed.
There are four basic techniques that must be mastered
before you can perform a thorough and complete
assessment of the client.

o Inspection
o Palpation
o Percussion
o Auscultation
 Involves using the senses of vision, smell and hearing
to observe and detect any normal or abnormal
findings.
 Inspection should come first because the latter
techniques can potentially alter the appearance of
what is being inspected.
 A few body systems require the use of special
equipment like ophthalmoscope for the eyes and
otoscope for the ears.
Using parts of the hand, touch and feel for the following:
o Texture (rough/smooth)
o Temperature (warm/cold)
o Moisture (dry/wet)
o Mobility (fixed/movable/still/vibrating)
o Consistency (hard/ soft/filled)
o Strength of pulses (weak/strong/thready)
o Size (small/large)
o Degree of tenderness
1. Light Palpation – place your dominant hand lightly
on the surface of the structure. Little to no depression
(less than 1 cm). Use circular motion.
2. Moderate Palpation – 1-2 cms. Easily palpate organs
and masses. Note the consistency, size and mobility.
3. Deep Palpation – 2.5 – 5 cms. Place your dominant
hand on the skin surface and your nondominant hand
on top. Very deep organs.
4. Bimanual palpation – use two hands. One hand to
apply pressure the other hand to feel the structure.
Tapping body parts to produce sound waves. These
sound waves or vibrations enable the examiner to
assess underlying structures.
o Direct – direct tapping of body part with one or
two fingertips to elicit tenderness.
o Blunt – used to detect tenderness over organs by
placing one hand flat on the body surface and
using the fist of the other hand to strike the back
of the hand.
o Indirect – tapping done produces a sound that
varies with the density of underlying structures.
 Assessment technique that requires the use of
stethoscope to listen for heart sound, movement of
blood through the cardiovascular system, movement
of the bowel, and movement of air through the
respiratory tract.
 Sounds are classified according to the intensity, pitch,
duration and quality of the sound.