Objective Data

Subjective Data

55 year old  (identifying information)

Height: 5'10''  (nutrition)

Weight: 300 pounds  (nutrition)

BP 160/95, pulse 86, Respiration 16  (activity/safety)

Alert and oriented  (cognition/perception)

Heart sounds within normal limits, regular  (activity/safety)

Lungs are clear bilaterally  (activity/safety)

Abdomen is rounded, bowel sounds present in all four quadrants, no tenderness on palpation  (nutrition, elimination)

No edema is noted in extremities  (activity/safety)

Strength and mobility appear within normal limits  (activity/safety)

Unmarried  (identifying information)

No vitamins or special diet  (nutrition)

No difficulty eating  (nutrition)

No regular exercise  (activity/safety)

No difficulty with ADL’s  (activity/safety)

Short of Breath when walking  (activity/safety)

Computer programmer  (identifying information)

No falls  (activity/safety)

Hearing and vision ok  (cognition/perception)

Wears glasses  (cognition/perception)

No pain  (cognition/perception)

Difficulty sleeping  (sleep/rest)

Loss of Friends  (roles/relationships)

Stress on the job  (coping and stress)

Glass of wine in the evening  (nutrition)

Currently on no medications  (medical history)

Family history of heart disease  (medical history)