2025/2026, 100% Verified.
what the person says about himself or herself
Subjective data
what you observe by inspecting, percussing, palpating, and auscultating
Objective data
is the process of analyzing health data and drawing conclusions to identify diagnoses. It has 4 major
components
Diagnostic reasoning
piece of information, a sign or symptom, or a piece of laboratory data
Cues
includes a complete health history & results of a full physical examination (used when meeting the
patient for the 1st time)
Complete database
"mini-database", smaller in scope & more focused than the complete database. Concerns mainly one
problem, one cue complex, or one body system
Focused (episodic) database
the status of any identified problems should be evaluated at regular & appropriate intervalsa
Follow-up database
calls for a rapid collection of the data, often compiled while life-saving measures are occurring
(diagnosis must be swift & sure)
Emergency database
,self awareness of your cultural beliefs, and biases or misconceptions of cultural differences
Cultural competence
not forcing your cultures onto others (ex. saying "Happy Holidays"instead of "Merry Christmas")
Cultural safety
values, beliefs, experience, biases, family/friends, tradition --> influence the way we behave and our
own biases
What drives who we are?
the main purpose is to collect subjective data, regarding the clients current state of health
Goal of an interview
concentrated watching (close, careful, scrutiny, 1st of the individual as a whole and then following
each body system) always performed 1st* (looky not touchy!)
Inspection
follows & often confirms points you noted during inspection. apply a sense of touch to assess
texture, temp, moisture & organ location & size, as well as any swelling, vibration or pulsation,
rigidity or spasticity, presence of lumps or masses & presence of tenderness or pain
Palpation
, listening to sounds produced by parts of the body, such as the heart and blood vessels, the lungs,
and abdomen
Auscultation
tapping the person's skin with short, sharp strokes to assess underlying structures (ex. enlarged
livers) (hollow or solid)
Percussion
physical appearance, body structure, mobility, behaviours
General Survey
Temp, pulse, respiration, blood pressure, oxygen saturation
Vital signs
normal 37.2 C° --> allows stable cellular metabolism
Temperature
or fever, (>38C°) caused by pyrogens secreted by toxic bacteria breakdown
Hyperthermia