By the end of this lesson, you will know the definition of subjective data in nursing, the difference between subjective and objective data, and how to gather detailed information in subjective data.
What is Subjective Data?
Can you think of the last time you were sick? If it was a common cold, did you have a runny nose, cough and body chills? Maybe you had pain? How bad was it? When did it begin? Where was it located? At the doctor’s office, you probably spoke with someone who asked you these types of questions. You may not have realized at the time just how important your responses were for the doctor to know how to help you get better.Subjective data in nursing is part of the health assessment that involves collecting information through communication. Patients are first asked the reason for visiting the doctor.
Then whatever they say is classified as the subjective data. Patients often complain about physical symptoms pertaining to how they feel. This can be pain, discomfort, itching or any type of abnormal sensations. They state problems they are experiencing with their bodies, such as coughing, vomiting or muscle spasms.In other cases, patients may mention health concerns surrounding their beliefs, attitudes and perception. They may think they have a particular illness because they had it before or researched their symptoms on the Internet. Other patients may feel they are healthy and just want a doctor’s check-up.
Regardless of the many issues patients may bring up, it’s important to listen to what they are saying when gathering the subjective data.
The Difference Between Subjective and Objective Data
Objective data is another type of information that is collected from patients. It can be defined as the data medical professionals obtain through observations by seeing, hearing, smelling and touching. This can include patient behaviors, actions and information gathered from test measurements or the physical examination.
You may have heard someone use the phrase ‘signs and symptoms’ when talking about patient problems. The signs refer to the objective data, while the symptoms refer to the subjective data. Here is a way to help you distinguish between them. Notice the words ‘subjective’ and ‘says’ both begin with the letter ‘S,’ while ‘objective’ and ‘observes’ begin with the letter ‘O.’Sometimes the data can be subjective and objective at the same time. Check out these examples of both subjective data (what the patient says) and objective data (what the nurse observes):
- A patient says she is shivering as the nurse observes her shaking in the chair.
- A patient says he has a fever as the nurse observes the elevated temperature on the thermometer.
- A patient says she has stomach pain as the nurse observes her clutching her abdomen.
There can also be times when the subjective and objective data do not match. The patient may state having a certain symptom or belief, but observations of them reveal something different. Have you ever heard of white coat syndrome? Sometimes the blood pressure of healthy patients can rise when they are anxious about seeing a doctor. When gathering the subjective data, they may say they feel calm; however, the objective data from the elevated blood pressure reading may indicate that they are actually nervous.
The Details of Subjective Data
Let’s go back to our example with the common cold. If you had described your symptoms as having a runny nose, cough and body chills, these would be part of the subjective data. However, you probably were asked for more details about your symptoms. The answers you gave would be included in the subjective data. These questions could have been:
- What color was the mucus when you blew your nose?
- Did you have a dry or wet cough?
- When did the body chills begin?
Your answers to these questions would help point the doctor in a better direction in identifying your problem.Another example can be seen when obtaining more details for a patient complaining about pain.
Since this is a common patient complaint, an acronym ‘OLD CARTS’ can be used to help make sure all areas are covered.
- O – Onset (When did the pain begin?)
- L – Location (Where is the pain?)
- D – Duration (How long did the pain last?)
- C – Characteristics (Describe the pain?)
- A – Aggravating factors (What makes the pain worse?)
- A – Alleviating factors (What makes the pain better?)
- R – Related symptoms (What other symptoms are present?)
- T – Treatment (What has helped the pain before?)
- T – Thought (What does the patient think the pain could be?)
- S – Severity- (How bad is the pain to the patient?)
‘OLD CARTS’ can also be used to obtain the subjective data about any problem. The patient may not be able to answer all the questions presented but an attempt to gain a more thorough description of their symptoms can be gathered. For example, a patient may say his problem is difficulty sleeping at night. Using OLD CARTS as a guide, he may be able to answer all the questions except for treatment, since he denies having this problem before.
The details of the subjective data means collecting information through communication and can bring more insight into what is going on with the patient. Additional information about the runny nose, cough and body chills is needed since a patient with the flu can have the same symptoms. Obtaining all key factors is also important because it can help distinguish between minor and major health problems.
A patient complaining of mild chest pain may not be aware that what he thinks is indigestion could actually be a heart attack. Subjective data is different from objective data, which is the data medical professionals obtain through observations by seeing, hearing, smelling and touching.
Study this lesson on subjective data in nursing, then assess your ability to:
- Describe and give an example of subjective data collected from a patient
- Differentiate between subjective and objective data
- Convey the purpose and meaning of OLD CARTS