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Chapter 15 Assessing
admits that her parents are worried and that she has
been skipping meals as she is so busy with work, tennis
and study. Clarify in your mind the difference and the
relationship between subjective and objective data by
answering the following questions:
1. Can you differentiate between the objective and sub-
jective data that you have gathered as part of your
health assessment of Claire?
2. Why are the subjective data so important in the
assessment phase?
Physiological (survival) needs:
Food,
fluids, oxygen, elimination, warmth,
physical comfort
Safety and security needs:
Things
necessary for physical safety (e.g. a
walking cane) and psychological
security (e.g. a child’s favourite toy)
Love and belonging needs:
Family
and significant others
Self-esteem needs:
Things that
make people feel good about
themselves and confident in their
abilities (e.g. being well groomed,
having accomplishments
recognised)
Self-actualisation needs:
Need to
grow, change and accomplish goals
TABLE 15-1 Examples of assessment frameworks
Human needs (Maslow)
Functional health patterns (Gordon)
Head-to-toe
Health perception/health
management:
Perception of
well-being and adherence to
preventive health practices
Nutritional–metabolic:
Patterns of
food and fluid intake, electrolyte
balance, general ability to heal
Elimination:
Patterns of excretory
function (bowel, bladder, skin) and
person’s perception
Activity/exercise:
Pattern of exercise,
recreation and factors that interfere
with desired or expected individual
patterns
Cognitive–perceptual:
Adequacy of
vision, hearing, taste, touch, smell,
pain perception, cognitive functional
abilities
Sleep/rest:
Quality, quantity and
patterns of sleep and rest-relaxation
during 24-hour day
Self-perception/self-concept:
Attitudes about self, perception of
abilities, body image and identity
Role/relationship:
Perception of
major roles and responsibility in
current life situation
Sexuality and reproductive:
Perceived satisfaction or
dissatisfaction with sexuality and
reproductive state
Coping/stress tolerance:
General
coping pattern, stress tolerance and
ability to control or manage
situations
Values/beliefs:
Values, goals or
beliefs that guide choices or
decisions
Head and face:
Symmetry, cranial
nerves, hair
Eyes:
Visual acuity, colour vision,
extraocular muscles, internal and
external structures
Ears and nose:
Otoscopic exam,
nostril patency, olfactory sense
Mouth and throat:
Breath odour,
mucous membranes, gag reflex
Neck:
range of motion (ROM),
musculature, carotid arteries, jugular
veins, lymph nodes
Upper extremities:
Nail beds, joints,
ROM, pulses
Back, posterior and lateral thoraxes:
Spine, thoracic expansion,
diaphragmatic excursion
Heart:
Pulsations, thrills, apical
pulse, cardiac landmarks
Breasts:
Colour, vascularity,
thickening, oedema, size, lymph
nodes, gynaecomastia
Abdomen:
Contour, symmetry,
pigmentation, colour, scars, striae,
visible peristalsis, masses,
pulsations, bowel sounds
Inguinal area:
Lymph nodes, inguinal
hernias, femoral pulses
Lower extremities:
Colour, capillary
refill, ulcerations, hair distribution,
varicose veins, oedema,
popliteal/dorsalis pedis/posterior
tibial pulses, ROM, muscle size,
tone, temperature
Genitalia, anus and rectum:
External
and internal genitalia
Characteristics of data
Data are not only subjective or objective, they also have
additional characteristics. When collecting and recording
personal data, nurses and midwives ensure that the data are
complete, factual and accurate, and relevant.
Complete
It is important that as much health data as possible are identi-
fied in order to understand the problem(s) and develop a plan
