It is the gathering of information about client's physical heath, mental outlook, social circumstances, family and community life, and other factors.
To prepare the data base, it is necessary to gather data. Data base is part of the client oriented record.
There are two types of data:
- Subjective Data
- Objective Data
STEPS IN NURSING PROCESS
Subjective Data is basically what patients tell you about what they are experiencing, feeling, seeing, hearing or thinking. They are personal expression of clients about themselves and environment. This data is obtained by the nurse when writing up the nursing history. It is also obtained during daily contact with the client. It is essential to write exactly what client says. In case of young clients, the data may be gathered from parents/guardians.
Objective Data is the information about the client obtained by the health practitioner/nurse by observation via senses (e.g. eye, ear, nose, tongue, skin). This data is usually gathered during the physical examination or functional' assessment. Objective data gathering is also a continuous process, requiring daily and sometimes hourly or even minute to minute updating depending on the condition of the client.