Subjective Data, The patient states, “I have a headache.”, The patient says, “I feel dizzy when I stand up.”, The patient reports feeling nauseated., The patient states, “I haven’t slept well in three nights.”, The patient rates their pain as 8 out of 10., The patient states, “I feel short of breath.”, The patient says, “My legs feel weak.”, The patient reports having diarrhea three times today., The patient states, “I am allergic to penicillin.”, The patient stated, “I have trouble sleeping at night.”, Objective Data, The patient’s blood pressure is 150/90 mmHg., The nurse observes swelling in both ankles., The patient’s temperature is 102.2°F., The nurse observes the patient coughing., The patient’s pulse is 112 beats/minute., The nurse observes the patient using accessory muscles to breathe., Redness around a surgical incision, The nurse measures urine output of 200 mL., The patient is grimacing while moving., The nurse reads in the chart that the patient’s blood glucose was 210 mg/dL this morning.

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