1.1: The Complete Subjective Health Assessment

The complete subjective health assessment is commonly referred to as a health history. It provides an overview of the client’s current and past health and illness state. You conduct it by interviewing the client as illustrated in Figure 1.1, asking them questions, and listening to their narrative.

Figure 1.1: Nurse interviewing the client

 

This information is often shared verbally with you or in the way that the client can best communicate. It is also sometimes collected through a standardized form that the client completes. In some cases, it also includes information shared by a family member, friend, or another health professional when the client is unable to communicate.

Points of Consideration

Clients are sometimes accompanied by care partners. Care partners are family and friends who are involved in helping to care for the client. You may hear care partners being referred to as “informal caregivers” or “family caregivers,” but “care partner” is a more inclusive term that acknowledges the energy, work, and importance of their role.

The complete subjective health assessment is part of assessment, the first component of the nursing process (assessment, analysis/diagnosis, planning, implementation and evaluation) outlined in Figure 1.2.

 

Figure 1.2: The nursing process

As illustrated in Figure 1.2, the assessment phase of the nursing process involves collecting subjective data (information that the client shares) and objective data (information that you collect when performing a physical exam). See Table 1.1 for an overview and examples of subjective and objective data. This book focuses on subjective data collection in the context of the complete subjective health assessment.

Table 1.1: Overview and examples of subjective and objective data

Data	Example
Subjective Information that the client shares with you spontaneously or in response to your questions.	The client states, “I have had a rash on my ankle and leg for the last two weeks.” The parent states, “My eight-month-old son is having trouble breathing.” The client’s reason for seeking care is “diarrhea for 10 days.” The client types, “I feel sick to my stomach.”
Objective Information that you observe when conducting a physical assessment, and lab and diagnostic results.	You observe that a client has a bright red rash on the dorsal side of the foot, the lateral malleolus, and anterior and lateral side of the lower leg. You observe the client sitting upright, leaning forward, breathing fast with eyes wide open. You take the client’s blood pressure and report it as 112/84 mm Hg and pulse at 84 beats per minute. Lab test results: K+ 4.0 mmol/L, fasting glucose 4.8 mmol/L. Chest X-ray report: Lungs well inflated and clear. No evidence of pneumonia or pulmonary edema.

As the word “subjective” suggests, this type of data refers to information that is spontaneously shared with you by the client or is in response to questions that you ask the client. Subjective data can include information about both symptoms and signs. In the context of subjective data, symptoms are something that the client feels, as illustrated in Figure 1.3 (e.g., nausea, pain, fatigue). You won’t know about a symptom unless the client tells you. Signs are something that the health professional can observe, such as a rash, bruising, or skin perspiration, also illustrated in Figure 1.3. Although you can observe signs, in the context of a subjective assessment, the client shares this subjective information with you. For example, a rash is both subjective and objective data as it could be something that the client shares with you, but it is also something that you can observe. On the other hand, if the client says that the rash is itchy, that would be considered subjective data and, in this case, it would be a symptom because it is something the client feels and you can’t observe.

Figure 1.3: Symptom versus sign

 

 

Test Yourself

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