Subjective Data Sheet, Essay Example

Subjective Data Sheet

In the data sheet, record subjective data from your client. Include all pertinent (positive and negative) information, with appropriate use of the seven variables (COLDSPA) for each problem.

 Current Symptoms

Client states no problems exist with breathing while resting, although he occasionally experiences shortness of breath during exercise. The client also complains of occasional acute stomach pains after having eaten a big meal – heartburn is a common ailment occurring roughly three times a month. Patient complains of periodic dizziness or disorientation with no clear pattern to identify potential cause or frequency. At best guess, patient E.A. believes disorientation occurs 4-5 times per week mostly during the evenings. Finally, patient complains of having various infections on his foot.

C: infection on foot is red with noticeable puss

O: roughly 2 months

L: over the last two toes on the right foot

D: comes and goes after treatment

S: goes through a cycle of roughly 3 months

P: physician prescribes antibiotic to get rid of infection

A: No other symptoms for the infection

Client says that infection reoccurs every three months and is sensitive to the touch. The consistency of the infection maintains a similarity over that time period.

Family History

The patient E.A. has a history of diabetes and hypertension. Both of the patient’s parents has a history of hypertension that led to a heart attack in the father. The father also was diagnosed with prostate cancer relatively early at the age of 55. The patient’s mother contracted lupus. The patient’s grandparents on father’s side both had history of hypertension and diabetes and both died of a stroke, grandmother at age 74 and grandfather at age 69. The patient’s grandparents on mother’s side also had a history of hypertension. The grandmother died of pneumonia at age 81 and the father died of lung cancer at 78.

Lifestyle and Health Practices

The patient exercises 4-5 times per week and tries to maintain a healthy, low fat, high fiber diet that was prescribed by a previous physician. Exercise can primarily be categorized as mild-to-moderate physical activity for roughly 30-minutes each session. The patient E.A. does not smoke but does drink socially 1-2 times per week. E.A. also works around 50hrs per week in a high-stress position. The patient E.A. tries to maintain stress levels at a minimum with exercise, yoga and 1 massage per week.

References

Weber, J. & Kelly, J. (2010). Lab Manual to Accompany Health assessment in nursing (4^th ed.) Philadelphia, PA: Lippincott Williams & Wilkins.