SUBJECTIVE DATA: what the patient says, how the patient tells you they're feeling, if there is pain, what the patient tell you the duration of the pain is, when it started, what makes it better, what makes it worse. Medication history of the patient, look at the patient social economical background. Identify if patient have allergies. Level of the physical activity, if the patient is able to do their ADLs on their own or require assistance. Explore Family history, surgical history and if they have any history of smoking or drinking.
OBJECTIVE DATA: comes from your vital signs, what you see, what you hear, what you smell, what you observed. Ex: the patient facial expression, body language, how they present from head to toe, any laboratory test, any diagnostic test (definitive data that is measurable).
ASSESSMENT AND ANALYSIS: look at the subjective data and objective data and cluster them in their individual original categories but rely more so on the objective data along with what you determine is necessary from the subjective data to formulate your nursing diagnosis. After you formulate your nursing diagnosis, you are going to identify the problem mainly from the objective data and what you deem important from the subjective data ( that's the information you collected from the patient and the health assessment).
PLANNING OF CARE: what interventions are you going to employ to treat this patient. Interventions must be a complete with goals ( not just, they are gonna improve breathing) Ex: when are they gonna improve breathing, 2hrs from now, 2wks from now, 2yrs from now….if breathing is the problem. Interventions must be a complete realistic goals and goals must be measurable and must be able to evaluate the goals (Ex: if the patient couldn't walk 2 days ago and you expect this on the diagnosis that the patient supposed to be able to walk, and should say that, within 2 days the patient will walk and should be able to go back and evaluate if the intervention such as passive active range of motion, PT involvement, able to see if that was the cause that impacted the change in the patient status). Medication used for treatment, any special therapy that's involve, patient education and community referral source or referral that can help to maintain this patient in optimal health.
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