Diagnosis of Mr Lee: Chronic Left heart failure

-        What cannot be precisely measured (Vitals, blood test results => Objective Data)
-        Any data that is not directly from the nurse/healthcare professionals  => Objective Data

-        Primary Source => Patient

-        Secondary Source => Caregivers, other members of the healthcare team

 

Examples of Subjective Data:

1.     Pain Scale

2.     Colour (From the patient)

3.     Feel (From the patient)

4.     Description of reported symptoms (E.g. chills, diarrhoea, coughing, dizziness, SOB)

5.     Patient's perceptions, feelings, and concerns

 Why is Subjective Data important?

-        This data can paint a more thorough picture of what the patient is experiencing, making it an essential part of care plan development

-        May signal possible issues with the patient’s psychological, physiological, and sociological wellness

-        It alerts nurses about things that can be problematic when dealing with patients as well as indicating specific patient’s strengths that can be useful when communicating and caring for them

 

Mr Lee’s Subjective Data:

·      Patient’s complaints (Primary Source)

-        Crushing chest pain

-        Radiation of pain to jaw and left upper arm 

-        Dyspnoea upon exertion for the last two months

-        Claims that he is unable to walk home from the bus stop without feeling breathless

-        Needs to sleep with two pillows under the head

·      Daughter (Secondary Source)

-        Non-compliant with medication