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!
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)
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.
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).