The Nursing Process: Your role (A,B

Four step process; 1. Data Collection (Assessment) - A systematic gathering and review of information about the patient, which is communicated to appropriate members of the healthcare team 2. Planning - Involves assisting the RN in the development of nursing diagnosis, goals, and interventions for patient's plan of care and maintaining patient safety 3. Define Implementation - The provision of nursing care required to accomplish established patient goals 4. Evaluation - Compares the actual outcomes of nursing care to expected outcomes, which are then communicated to the healthcare team Is this Objective or Subjective Data? 1. Something to patient states 2. Symptoms: includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure 3. The nurse cannot experience subjective symptoms - subjective data Is this Subjective or Objective data? 1. Data the nurse can verify 2. Signs: vital signs, height, weight