Subjective Nursing Assessment

Introduction The purpose of this paper is to show the correlation between subjective data and objective data and how they contribute to the plan and implementing nursing care. To perform this frameworks, I will first explicit the components of the subjective data including health history, secondly I will explicit the objective data including physical assessment components, next I will provide some education base of the finding and finally I will provide a reflection base on the assessment process.
Health history assessment and physical assessment
Subjective data
Demographic data Mr. JK was assessed on Friday, October 16, 2015 at 10:30 am in your clinical setting were appointment was schedule by phone. Mr. JK is a 54 year
JK report abdominal pain. The contour of the abdomen is flat, and symmetric. The umbilicus is midline with no lesion. The color is uniform to the rest of the skin. The bowel sound is active on all four quadrants, there is no venous bruit, and there is a tympany sound at the superior level and a dullness sound at the lower level, palpation show slight tenderness

Musculoskeletal Mr. JK denies problem; “I don’t exercise enough”. The contour of the joints is symmetric. ROM was performing on shoulder, neck, wrist, elbow, hip, and knee. The result how that muscle strength is equal bilaterally and movements against resistance are smooth.
Neurologic
Mr. JK denies falls and balance problem; he is right handed; can sense touch and temperature. His hearing is normal with no lateralization, ovula is midline, tongue is midline and he has proper gait. All cranial nerve (CN 2-12) are intact and finding of all systems demonstrate Brenden scale score of 23.
JK work environment he should wear some protective devise that can help protect excessive exposure to the high temperature and again need to drink additional water in hot or cool weather and follow up with checkup.
Reflection
This assessment was conducted in the respectful and professional standard with all the characteristics of the helping person I have learned such as, positive regard, which is the ability to appreciate, and respect another person’s worth and dignity with a nonjudgement attitude; empathy, which is the capacity to respond to another’s feeling and experience as if they were your own; genuineness, which is the ability to represent oneself honestly and spontaneously; concreteness, which means speaking to the client in specific terms rather than in vague generalities. What went well was the communication. It was really easy to interact with Mr. JK because he openly expresses his emotions and was congenial and easy-going. I do experience one communication barrier during this assessment related to sensitive issues. I felt uncomfortable with some questions and to overcome them, I took time to reflect and come to terms with them. In the future I will be aware that such questions will arise during assessment and be preparing to easily