1st care plan for near syncope and chf

[kcottrill]

Help from anyone would be great. I'm a first year nursing student and my second week of clinicals was last week. We need to do a plan of care on our patient and when I was going over my clinical prep tool to fill in the care plan I couldn't find where I wrote the assessment-objective data for this patient. Would it be his v/s taken while in the e.r.? I know the subjective data is what the patient states is wrong " I almost passed out a couple of times today and I'm not feeling well". his current medical condition was near snycope and worsened orthopnea.

[CT Pixie, BSN, RN]

His objective data would be his vital signs, his dx, anything YOU or the other medical personal saw, heard, touched, etc. His vitals in the ER would be objective data..yes.