While performing cares, obtaining vital signs, or collecting other data, the nursing assistant may notice subjective or objective signs of discomfort in the client.

Subjective signs of discomfort are what the person reports to you such as, “My stomach hurts,” or “I feel achy when I walk.” Subjective reports cannot be verified objectively and must be reported based on what the person communicates. For this reason, when documenting subjective data, write exactly what the client said in quotations. For example, a nursing assistant might document: The client stated, “My stomach hurts.”

Objective data are observable and verifiable. Nursing assistants may suspect a client is experiencing discomfort based on nonverbal signs, such as grimacing, guarding the injured body part, rocking, rubbing the area, or moaning. When a client is unable to verbally communicate, noticing objective signs of pain is integral for providing comfort measures and improving their quality of life. Review the Pain Assessment in Advanced Dementia (PAINAD) in Chapter 6 (“Pain”) that is used to observe and document objective signs of pain.