COMPARING SUBJECTIVE AND OBJECTIVE DATA
SUBJECTIVE OBJECTIVE
Description Data elicited and verified by
the client
Sources Client
Family and significant
others
Client record
Other health care
professionals
Methods used to obtain data Client interview
Skills needed to obtain data Interview and therapeutic
communication skills
Caring and empathy
Listening skills
Examples “I have a headache”
“It frightens me”
“I am not hungry”
Source: Nurse’s Handbook of Health Assessment
Data directly or indirectly
observed through
measurement
Observations and physical
assessment findings of the
nurse or other health care
professionals
Documentation of assessment
made in client record
Observations made by client’s
family or significant others
Observation and physical
examination
Inspection
Palpation
Percussion
Auscultation
Respiration 16 breaths per
minute
BP 180/100, apical pulse
80 and irregular
x-ray film reveals fractured
pelvis
Janet R. Weber
INSPECTION - using the sense of vision, smell, and hearing to observe the condition
of various body parts, including any deviations from normal
- is the visual examination that is assessing using the sense of sight
- it should be deliberate, purposeful, and systematic
- the nurse inspects with the naked eye and with a lighted instrument
such as an otoscope (used to view the ear)
- in addition to visual observation, olfactory (smell) and auditory
(hearing) cues are noted
- Nurses frequently use visual inspection to assess moisture, color and
texture of body surfaces, as well as shape, position, size, color and
symmetry of the body
- Lighting must be sufficient for the nurse to see clearly: either natural
or artificial light can be used.
- When using auditory senses it is important to have a quiet
environment for accurate hearing
- Observation can be combined with the other assessment techniques

TECHNIQUE:

1) Expose body parts being observed while keeping the rest of the client’s
body properly draped.
2) Always look before touching.
3) The good lighting. Tangential light is best. Be alert for the effect of bluish-
red tinted or fluorescent lights that interfere with observing bruises,
cyanosis (bluish discoloration of a body part), erythema.
4) Provide a warm room for the client (a hot environment may alter skin color
and appearance)
5) Observe for color, size, location, texture, symmetry, odor and sounds

Sources: Mr. Lasurias

Fundamentals of Nursing
7th edition by KOZIER
Nursing Handbook of Health Assessment
Janet R. Weber
AUSCULTATION

Auscultation is listening for various breath, heart, vasculature, and towel sounds
using a stethoscope.

TECHNIQUE:

Use a good stethoscope that has the following

• Snug – fitting earplugs
• Tubing not longer than 15 inches and internal diameter not greater than 1
inch.
• Diaphragm and bell

Auscultation is the process of listening to sounds produced within the body.

• Direct Auscultation – is the use of unaided ear, for example, to listen to

respiration wheeze or the grating of a moving joint.
• Indirect Auscultation – is the use of a stethoscope, which transmits the
sounds to the nurse’s ear.
- a stethoscope is used primarily to listen to sounds from within the
body, such as bowel sounds or valve sounds of the heart and blood
pressure.

* Auscultated sounds are described according to their pitch intensity, duration, and
quality

* The pitch is the frequency of vibrations (the number of vibrations per second)
* Low-pitched sounds, such as some heart sounds, have fewer vibrations per second than
high-pitched sounds, such as bronchial sounds.
* The intensity (amplitude) refers to the loudness or softness of a sound.
* Some body sounds are loud, for example, bronchial sounds heard from the trachea;
others are soft, for example, normal breath sounds heard in the lungs.
* The duration of the sound is its length (long or short)
* The quality of sound is a subjective description of a sound, for example, whistling,
gurgling, or snapping.

Source: Fundamentals of Nursing 7th edition

Barbara Kozier
Glenoria Erb
 Audrey Berman
Shirley Snyber

PALPATION

Definition:
Palpation is touching and feeling body parts with your hands to determine the
following characteristics:

o Texture (roughness / smoothness)

o Temperature (warm / hot / cold)
o Moisture (dry / wet / moist)
o Motion (stillness / vibration)
o Consistency of structures (solid / fluid filled)

- is the examination of the body using the sense of touch

- the pads of the fingers are used because their concentration of nerve endings makes
them highly sensitive to tactile discrimination.

Technique:

o Examiner’s fingers should be short

o The most sensitive part of the hand should be used to detect
various sensations.
a. fingertips for fine discrimination pulsations
b. palmar surface for vibratory sensations (fremitus)
c. dorsal surface for temperature
o Light palpation precedes deep palpation
o Tender areas are palpated last. (painful areas)
o Three different types of palpation may be used depending on the
purpose of the exam.

Source: Nurse’s Handbook of Health Assessment by Weber