Subjective and Objective CHARTING SUBJECTIVE OBSERVATIONS Subjective data

Subjective and Objective CHARTING

SUBJECTIVE OBSERVATIONS Subjective data is gathered from the patient telling you something that you cannot use your five senses to measure. If a patient tells you they have had diarrhea for the past two days, that is subjective, you cannot know that information any other way besides being told that is what happened.

CONT. Pain is subjective because the patient is telling you what their pain is. Ask yourself, did the patient tell me this information or can I measure or observe this information by myself? Is this something I can observe using my five senses? Has the patient told me this information and can I verify it?

OBJECTIVE OBSERVATIONS This is the information that we can gather using our 5 senses. It is either a measurement or an observation. Temperature is a perfect example of objective data. The temperature of a person can be gathered using a thermometer.

CONT. Other examples of objective data: Heart rate Blood pressure Respirations Wound appearance Ambulation description.

CASE STUDY 1 You have a 48 year old male patient who comes in stating, “I feel like I can’t breathe. ” Patients’ respirations are 28 breaths per minute and their heart rate is 115 beats per minute. The patient then grabs his chest and says, “My chest hurts so bad, please help!” You ask the patient to rate the pain on a scale from 0 -10, 10 being the worst pain ever. The patient replies, “ 10, it hurts so badly!” You then ask the patient to describe what the pain feels like, the patient reports that his pain feels like pressure. Your patient then starts to become diaphoretic and pale. You take an EKG that shows Sinus Tachycardia. The pulse oximeter shows 100% on room air and the patients’ blood pressure is 120/80 mm. Hg.

CASE STUDY 1 Let’s break this down: Objective data: 48 year old male Respirations 28 Heart rate 115 Patient is diaphoretic and pale EKG showing sinus tachycardia Pulse ox 100% on room air Blood pressure 120/80 mm. Hg. Subjective data: Patient experiencing shortness of breath Chest pain that is a pressure feeling and is 10/10

CASE STUDY 2 A patient tells you they got their finger cut with a razor about 20 minutes ago and then shows you the cut on their finger, the cut is one inch long located on the left pinky finger about 1 centimeter deep. The patient states, “My finger is bleeding, can you get me gauze for the blood? ”

CASE STUDY 2 Let’s break this down: Objective: 1 inch cut on left pinky finger, 1 cm deep. Currently bleeding Subjective: The finger got cut by a razor Happened about 20 minutes ago

CASE STUDY 3 Your patient is holding their stomach and moaning. They say, “I can’t take this pain anymore! It feels like someone is cutting my belly with a jagged hot knife!” The patients face is red and sweaty, their heart rate is 115 bmp and their respirations shallow. The patients abdomen is hard, round, distended and when you percuss over each quadrant you hear a dull short tones. The patient then informs you they feel dizzy. You perform an EKG and the results are normal sinus rhythm (NSR). The patient start to cry and plead for you to help them. You re-assure them that they are in the right place and you are so happy to be taking care of them. They dry their tears and thank you.

CASE STUDY 3 Let’s break this down: Objective: Face is red and sweaty Heart rate 115 bmp Shallow respirations Abdomen hard, round, distended Percussed dull noises Patient holding abdomen and moaning NSR EKG Subjective: Burning sharp pain Dizziness