DATA COLLECTION, DOCUMENTATION AND
ANALYSIS
• DATA COLLECTION
• COLLECTING SUBJECTIVE DATA
• COLLECTING OBJECTIVE DATA
• VALIDATION
• DOCUMENTATION OF DATA
DATA COLLECTION PROCESS
1. General Survey
 The nurse’s objective observation of the
patient begins with the first moments of the
encounter and continues throughout the
interaction. This cues collected enable the
nurse to select appropriate subjective
questions.
 The first step in head-to-toe assessment.
 Determines the reasons client is seeking
health care.
 Involves observation of the clients general
appearance, level of comfort,
measurement of vital signs, height and
weight.
 Provides information about characteristics of
illness, a clients hygiene and body image,
emotional state, recent changes in weight and
development status.
“VITAL SIGNS”
 Integral part of the assessment. These
includes BP, HR, RR, TEMPERATURE and PAIN
(5th vital sign).
Blood Pressure: Steps to Ensure Accurate
Measurement
 Instruct the pt. to avoid smoking or
drinking caffeinated beverages for 30
minutes.
 Examining room is quiet and comfortably
warm
 Ask pt. to sit quietly for at least 5 minutes
in a chair, rather on examining table . Feet
flat on floor uncrossed. Hands supported
at heart level.
 Make sure the arm selected is free of
clothing. There should be no arterio-venous
fistulas for dialysis.
 Palpate the brachial artery to confirm that it
has a viable pulse.
 Position the arm so that the brachial artery, at
the antecubital crease, is heart level
 If the patient is:
 SEATED – rest arm on a table above the
patient’s waist.
 STANDING – support arm at the mid-chest
level
Adult normal range: 90/60-120/80 mmHg
Elevated: Hypertension (>120/80 mmHg)
Below: Hypotension (<90/60 mmHg)
Classification:
Hypotension: <90/60 mmHg
Normal: 120/80 mmHg
Prehypertension: 120-139/80-89 mmHg
S1 HTN: MTOET 140/90 mmHg
S2 HTN: MTOET 169/90 mmHg
ERRORS THAT RESULT IN FALSE HIGH/LOW
READING:
FALSE HIGH READING
1. Cuff too small (Narrow)
2. Cuff too loose or uneven
3. Arm below heart level
4. Arm not supported
5. Inflating or deflating cuff too slowly (high
diastolic)
6. Deflating cuff too quickly (low systolic and
high diastolic)
FALSE LOW READING
1. Cuff too large (wide)
2. Repeating assessments too quickly
3. Inaccurate level of inflation
4. Pressing stethoscope too tightly against
pulse.
HEART RATE AND RHYTHM (PULSE RATE)
 The arterial pulse rate results when the
ventricular heart contraction pushes a
pressure wave of blood throughout the
arterial system.
  Adult Normal Range: 60-100 bpm
 Elevated: Tachycardia (>160 bpm)
 Below: Bradycardia (<60bpm)
 Normal Ranges:
Infant: 120-160 bpm, Toddler: 90-140 bpm,
Preschooler: 80-110 bpm, Adolescent: 60-90
bpm
RESPIRATORY RATE
 Observe the rate, rhythm, depth, and effort of
breathing. Count the number of respirations
(one respiration includes an inspiration and
an expiration) in 1 minute.
Adult Normal Range: 12-20 cpm
Elevated: Tachypnea (>20 cpm)
Below: Bradypnea (<12 cpm)
Normal Ranges:
NB: 30-60 cpm, Infant: 30-50 cpm
Toddler: 25-32 cpm, Adolescent: 16-20 cpm
TEMPERATURE
 Usual Normal Range: 36°C-37.5°C
 Elevated: Hyperthermia (>37.5°C)
 Below: Hypothermia (<36°C)
 Routes and Normal Ranges
 Oral: 35.9°C-37.7°C
- Rectal: 36.3°C-37.9°C
- Axillary: 35.4°C-37°C
- Tympanic: 36.7°C-38.3°C
- Temporal: 36.3°C-37.9°C
PAIN
 The International Association for the Study of
Pain defines pain as “an unpleasant sensory
and emotional experience”. The experience of
pain is complex and multifactorial. Pain
involves sensory, emotional, and cognitive
processing but may lack a specific physical
etiology.
(“OLD CART”)
TYPES OF PAIN
 NOCICEPTIVE PAIN OR SOMATIC PAIN
 Sharp or aching pain
 NEUROPATHIC PAIN
 Pain due to damage to the nerve (ex.
Burning)
 PSYCHOGENIC AND IDIOPATHIC PAIN
 Due to emotions, mental problems,
depression
GENERAL APPEARANCE
 APPARENT STATE OF HEALTH
 Try to make a general judgment based on
observations throughout the encounter.
Support it with the significant details.
Does the patient look his or her age?
Appear ill? Unhappy? Fatigued?
 LEVEL OF CONSCIOUSNESS
 Is the patient awake, alert, and responsive
to you and others in the environment? If
not, promptly assess the level of
consciousness. Orientation can be
checked by asking about person, place,
and time.
 FACIAL EXPRESSION
 Observe the facial expression at rest,
during conversation about specific topics,
during the physical examination, and in
interaction with others. Watch for eye
contact. Is it natural? Sustained and
unblinking? Averted quickly? Absent? Are
the movements of the face symmetric? Is
there ptosis? An uneven smile?
 ODORS OF THE BODY AND BREATH
 Odors can be important diagnostic clues,
such as the fruity odor of diabetes or the
scent of alcohol.
 Unpleasant odor may result from physical
exercise, poor hygiene, or certain disease
state. Poor oral hygiene my cause bad
breath.
 POSTURE, GAIT, MOTOR ACTIVITY, AND
SPEECH
 What is the patient’s preferred posture?
Assess the patient before calling his or her
name in the waiting room. How is the
patient sitting? Does that change when
you are in the room with the patient?
  Is the patient restless or quiet? How often
does the patient change position? How
fast are the movements?
 Is there any apparent involuntary motor
activity? Are some body parts immobile?
Stiff? Jerky? Which ones?
 Does the patient walk smoothly, with
comfort, self-confidence, and balance, or
is there a limp or discomfort, fear of
falling, loss of balance, or any movement
disorder? Does the patient utilize an
assistive device to ambulate? Cane?
Walker? Brace?
 Is the patient’s speech articulate?
Garbled? Rapid or slow?
 Fatigue is a nonspecific symptom with many
causes. It refers to a sense of weariness or
loss of energy that patients describe in
various ways.
 Use open-ended questions to explore the
attributes of the patient’s fatigue, and
encourage the patient to fully describe what
he or she is experiencing. Important clues
about etiology often emerge from a good
psychosocial history, exploration of sleep
patterns, and a thorough review of systems.
 Weakness is different from fatigue. It denotes
a demonstrable loss of muscle power and will
be discussed later with other neurologic
symptoms.
 SIGNS OF DISTRESS
● Cardiac or respiratory distress
● Pain
● Anxiety or depression
 SKIN COLOR AND OBVIOUS LESSIONS
 Pallor, cyanosis, jaundice, rashes, bruises
 DRESS, GROOMING AND PROPER HYGIENE
 How is the patient dressed? Is clothing
appropriate to the temperature and
weather? Is it clean, properly buttoned,
and zipped? How does it compare with
clothing worn by people of comparable
age and social group?
 Has the patient added additional holes on
the belt to enlarge? To make smaller?
 Glance at the patient’s shoes. Have holes
been cut in them? Are the laces tied? Or is
the patient wearing slippers?
 Is the patient wearing any unusual
jewelry? Where? Is there any body
piercing? Tattoos? Where? When and
where were they obtained?
 Note the patient’s hair, fingernails, and
use of cosmetics. They may be clues to the
patient’s personality, mood, or lifestyle.
Nail polish and hair coloring that have
“grown out” may signify decreased
interest in personal appearance.
 Do personal hygiene and grooming seem
appropriate to the patient’s age, lifestyle,
occupation, and socioeconomic group?
These are norms that vary widely based
on each individual.
HEALTH PROMOTION
 TEMPERATURE
• Correctly take a temperature and normal
range.
• Routes and Instruments
• Risk factors (strokes such as excessive
exercise in hot)
• Risk factors of hypothermia (exposure to
cold temperature)
 PULSE
• Check pulse before taking cardiac
medications
• Pulse rate prior to exercise
• Teach checking of carotid pulse by 2 or 3
finger on the site for one full minute
 RESPIRATION
• Explain to the person assessing the
respirations at home that this includes a
full inspiration and a full expiration for a
full minute, which is measured with a
watch with a second hand.
 BLOOD PRESSURE
• Monitoring a patient’s blood pressure at
home may be necessary.