Nursing Diagnosis and the Nursing Process
Data Collection: Subjective vs. Objective
Accurate assessment relies on distinguishing between what the patient reports and what the nurse observes.
Subjective Data
- Reported by the patient (e.g., pain scale, nausea, feelings of anxiety).
- Always document using direct quotes when possible.
- Considered covert data.
Objective Data
- Observable and measurable (e.g., vital signs, lab values, physical assessment).
- Gathered via physical examination and diagnostic testing.
- Considered overt data.
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