Please help with subjective care plan data

  1. 0
    I am writing up my care plan on Risk for Infection r/t invasive procedure and diabetes. Pt had an ORIF. I can't think of any subjective data that would support risk for infection. For the objective I have her vitals and lab work...please help!
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  4. 0
    Since subjective is what you see, incision, possible that they are incontinent? that could contaminate the wound, maybe you noticed a dr not washing their hands or using sanitizer when they came in (I noticed this once and politely offered the dr some purell from my pocket one lol)
  5. 0
    Thanks Zookeeper- I would never have thought about people not using the sanitizer! Good call. Thank you!
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    Subjective data is also anything the patient states, i.e. "I have pain in the incision site" or "I feel itchy" or "It looks to me like my legs are getting red"

    We were taught:
    OBJECTIVE DATA: What you, as the nurse (nursing student) can observe with your five senses

    SUBJECTIVE DATA: What the patient states about his/her condition.
  7. 0
    A Risk for Infection is a problem that doesn't even exist yet so there shouldn't even be any actual data available. Your interventions are to monitor for the signs and symptoms of infection. Because it's all hypothetical, you'll have to make up the subjective data that would most likely go along with the symptoms of infection.
  8. 0
    :smackingf geeesh I mixed up subjective & objective, I think that means I need more sleep lol
  9. 0
    what if the patient is a young child and the mother speaks for him?
    Ex:
    1)sam eats a variety of fruits and veggies,
    2)sam is sometimes difficult for others to understand
  10. 1
    Quote from sblivefree
    what if the patient is a young child and the mother speaks for him?
    ex:
    1)sam eats a variety of fruits and veggies,
    2)sam is sometimes difficult for others to understand
    then it is objective data. this was discussed quite a bit on this thread
    http://allnurses.com/forums/f205/sub...ta-252736.html

    also: objective: ". . .in medicine, designating or of a symptom or condition perceptible to others besides the patient" (page 1012, webster's new world dictionary of the american language, college edition, 1966). subjective: . . . in medicine, designating or of a symptom or condition perceptible only to the patient" (page 1452, webster's new world dictionary of the american language, college edition, 1966).
    sblivefree likes this.


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