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LATEST UPDATE 2026
subjective data
what the patient tells you
objective data
what the nurse is getting data
primary subjective data
data right from the patient
primary objective data
I observed it
secondary subjective data
caregiver/parent observations
secondary objective data
observe charted info, info from the doctor or aid, lab results
examples of subjective data
sore throat, ear pain, shortness of breath, headache, no PND
examples of objective data
lung sounds, pink/moist pharynx, positive cough, history of URI
diagnostic reasoning
the process of analyzing health data and drawing conclusions to identify diagnoses
,diagnostoc reasoning steps
1. attending to cues
2. formulate diagnostic process
3. gather data relative to hypothesis
4. evaluate each hypothesis w/ the new collected data to form final diagnosis
nursing process
Assessment
Diagnosis
Planning
Implementation
Evaluation
1st level priority
Emergent, life threatening, and immediate
ex: not breathing
2nd level priority
urgent
ex: acute mental status change, acute pain, untreated med problems, abnormal labs
3rd level priority
needs attention but not priority
ex: education, mobility, rest, coping
complete database
head to toe physical, comprehensive, health history, primary care
focused data base
, focusing on 1 or 2 areas (difficult breathing, listening to the lungs)
follow up database
problem that is established (having it looked at again)
emergent database
requires immediate attention and care, only gathering enough info to save a life
internal factors that affect communication
empathy, ability to listen, beliefs, biases, judgement
external factors that affect communication
eye contact, body language, talking, privacy, good lighting, limit distractions, personal
clothing
specials considerations for infant that can affect communication
caregiver provides information, use non judgemental questions avoiding "why" search
for signs of abuse, growth milestones
specials considerations for toddler that can affect communication
caregiver provides information, use non judgemental questions avoiding "why", try to
make small talk, use simple words, search for signs of abuse, growth milestones
specials considerations for school aged child that can affect communication
caregiver provides information, use non judgemental questions avoiding "why" , try to
make small talk, use simple words, search for signs of abuse, growth milestones
complete health history
A comprehensive history of a patient's past and present health status, usually gathered
during the patient's initial visit to a health care facility.
biographical data