Cultural safety refers to the creation of safe spaces for patients to interact with health professionals without judgment or discrimination. It is important to conduct a health history in a culturally safe manner. For example, the symptom the patient reports, “I feel itchy all over,” is documented in association with the signof an observed raised red rash located on the upper back and chest. Subjective data and objective data are often recorded together during an assessment. An example of objective data is recording a blood pressure reading of 140/86. Examples of objective data are vital signs, physical examination findings, and laboratory results. Objective data is obtained during the physical examination component of the assessment process. Objective data is information observed through your senses of hearing, sight, smell, and touch while assessing the patient. If data is gathered from someone other than the patient, the nurse should document where the information is obtained. When obtaining a health history, care partners may contribute important information related to the health and needs of the patient. For example, parents are care partners for children spouses are often care partners for each other, and adult children are often care partners for their aging parents. Care partners are family and friends who are involved in helping to care for the patient. Patients are often accompanied by their care partners. Secondary sources of data include information from the patient’s chart, family members, or other health care team members. When documenting subjective data in a progress note, it should be included in quotation marks and start with verbiage such as, “The patient reports…” or “The patient’s wife states…” An example of subjective data is when the patient reports, “I feel dizzy.”Ī patient is considered the primary source of subjective data. Subjective data is considered a symptom because it is something the patient reports. Subjective datais information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance. Information obtained while performing a health history is called subjective data. Obtaining a patient’s health history is a component of the Assessment phase of the nursing process. Before discussing the components of a health history, let’s review some important concepts related to assessment and communicating effectively with patients. Addressing Barriers and Adapting Communicationĭuring a health history, the nurse collects subjective data from the patient, their caregivers, and/or family members using focused and open-ended questions.
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