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The nurse must possess strong cognitive, interpersonal, and technical skills in order to elicit appropriate information and make relevant observations during the data collection process. This process often begins prior to initial contact between the nurse and the client, primarily through the nurse’s review of biographical data and medical records. Upon meeting the client, the nurse continues data collection through interview, observation, and examination. A variety of sources and methods are used in compiling a comprehensive database.
Types of Data
Client data include information that the client communicates concerning perceptions of his or her own health status, as well as specific observations made by the nurse. These two types of information are referred to as subjective and objective data. Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The data (also referred to as symptoms) are obtained through interviews with the client. They are called subjective because they rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another.
Objective data are observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing. These data (also called signs) can be seen, heard, or felt by someone other than the person experiencing them. Assessments that are comprehensive and accurate include both subjective and objective data.
Sources of Data
A comprehensive database should include data from every possible source (see the accompanying display). The client should always be considered the primary source of information; however, other sources should not be overlooked. The client’s family and significant others can also provide useful information, especially if the client is unable to verbalize or relate information. In addition, other health care professionals who have cared for the client may contribute valuable information. Medical records should also be reviewed, including the medical history and physical examination; results of laboratory and diagnostic tests and various health care professionals should also be consulted. Pertinent literature should be investigated in order to pursue relevant information and plan appropriate nursing interventions. Written standards are valuable sources of data for comparison, for example, a standard table of infant growth to determine if an infant’s weight and height are within normal growth range. Another valuable source of data is knowledge about the client’s normal parameters of functioning. The nurse’s knowledge based on experience is another important source of data.