a. A comprehensive patient assessment yields both subjective and objective findings. Subjective findings are obtained from the health history and body systems review. Objective findings are collected from the physical examination.
(1) Subjective data are apparent only to the person affected and can be described or verified only by that person. Pain, itching, and worrying are examples of subjective data.
(2) Objective data are detectable by an observer or can be tested by using an accepted standard. A blood pressure reading, discoloration of the skin, and seeing the patient in the act of crying are examples of objective data.
(3) Objective data are sometimes called signs, and subjective data are sometimes called symptoms.
(4) Data means more than signs or symptoms; it also includes demographics, or patient information that is not related to a disease process.
b. The purposes for a physical assessment are:
(1) To obtain baseline physical and mental data on the patient.
(2) To supplement, confirm, or question data obtained in the nursing history.
(3) To obtain data that will help the nurse establish nursing diagnoses and plan patient care.
(4) To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.
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