High School

Ms. J. is a 74-year-old woman who is admitted directly to the medical unit after visiting her physician because of shortness of breath, increased swelling in her ankles and calves, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). She takes 81 mg of aspirin every day, metoprolol 50 mg twice a day, furosemide 40 mg every day, and metformin 2,000 mg every day. Ms. J.'s vital sign values on admission were as follows:
- Blood Pressure: 162/96 mm Hg
- Heart Rate: 88 beats/min
- Oxygen Saturation: 91% on room air
- Respiratory Rate: 28 breaths/minute
- Temperature: 97.8 degrees F orally

Her weight is up 10 pounds since the last office visit three weeks prior. The patient states, "I am so short of breath" and "My ankles are so swollen I have to wear my house slippers." Ms. J. also shares, "I am so tired and weak that I can't get out of the house to shop for groceries," and "Sometimes I'm afraid to get out of bed because I get so dizzy." She confides, "I would like to learn more about my health so I can take better care of myself."

The physical assessment findings of Ms. J. are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet. Laboratory results indicate a decreased serum potassium level of 3.4 mEq/L. The patient's daughter enters the room as the nurse completes the physical assessment. She confides, "We are so worried about mom living at home by herself when she is so tired all the time!"

Question:
List two or more items of subjective data from the patient scenario.

Answer :

Ms. J.'s subjective data includes her reports of feeling very short of breath, having significantly swollen ankles, experiencing extreme tiredness and weakness, and feeling fearful due to dizziness. These personal accounts are central to understanding her condition and guiding her care.

The question is asking to identify subjective data from the patient scenario provided. Subjective data refers to information that is reported directly by the patient and cannot be measured or observed by healthcare professionals. In Ms. J.'s case, several items of subjective data are reported:

  • "I am so short of breath" - This indicates the patient's perception of her breathing difficulty.
  • "My ankles are so swollen I have to wear my house slippers." - This is a statement about the physical sensation and difficulty caused by the swelling.
  • "I am so tired and weak that I can't get out of the house to shop for groceries," - Expresses the patient's feeling of fatigue and weakness impeding daily activities.
  • "Sometimes I'm afraid to get out of bed because I get so dizzy." - The patient relays fear related to symptomatic dizziness.

These statements provide vital insights into the patient's condition from their perspective and are crucial for forming a comprehensive care plan.