The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patient’s description of pain
D. Electrocardiographic (ECG) waveforms
Correct Answer: C. Patient’s description of pain
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Subjective data provide clues to possible physiologic, psychological, and sociologic problems. They also provide the nurse with information that may reveal a client’s risk for a problem as well as areas of strengths for the client. The information is obtained through interviewing. Vital signs, laboratory test results, and ECG waveforms are examples of objective data.
Option A: Vital sign monitoring is a fundamental component of nursing care. A patient’s pulse, respirations, blood pressure, and body temperature are essential in identifying clinical deterioration and that these parameters must be measured consistently and recorded accurately.
Option B: Many other tests are reported as numbers or values. Laboratory test results reported as numbers are not meaningful by themselves. Their meaning comes from comparison to reference values. Reference values are the values expected for a healthy person. They are sometimes called “normal” values.
Option D: The standard 12-lead electrocardiogram (ECG) is one of the most commonly used medical studies in the assessment of cardiovascular disease. It is the most important test for interpretation of the cardiac rhythm, detection of myocardial ischemia and infarction, conduction system abnormalities, preexcitation, long QT syndromes, atrial abnormalities, ventricular hypertrophy, pericarditis, and other conditions.