Confused/Disoriented/crazy pt - subjective data????

[jconway45]

I am working on a care plan and it's been a long day.

My care plan requires objective and subjective data. I have all of the objective data but I am having trouble finding subjective data.

My pt was A&O x1 - only oriented to self, not date/time/place. How do I get reliable subjective data? (or that my instructor will approve of?)

I asked about pain - she denied, 0/10.

She talked to me about how she slept with her mailman and shot her husband and his girlfriend. Oh yah, she was calling for her cat named Willy. She said he was under the bed. Do I put that on my care plan?

She didn't talk about family or support systems.

I'm stuck. Any feed back would be helpful

[PvNurse2009]

Lol sounds like a psych patient. It's ok to put "the crazy" things that she says in your careplan for subjective data, as long as it supports your diagnosis.

[MEDICJOHN]

Well, objective is easy right, its what you see, well, sound like, in this case, subjective is very close to that, being, what the pt says. Therefore, (mind you im only first semester, i may be way off) I would include specific quotes that pt says. "Pt displays not linear speach, tangential speach patterns, refers to objects or people who are not present." So, I'm guessinng just including what the pt says, in quotes sometimes. Perhaps, pts reaction to my question of blah blah blah, was "........" to show that his responses were not consistent with the question. I have not had psych yet so maybe im wasting your time. but i like psych and love getting into their minds.

Perhaps describe pts demeanor, his actions, pacing, rocking, anger outbursts, non sensical speech. Sudden changes in flow of conversations????? Just thought Id give it a try...

[Daytonite, BSN, RN]

if you look at a dictionary definition of "subjective" you will find this: "of, affected by, or produced by the mind or a particular state of mind; of subject, or person thinking, rather than the attributes of the object through of. . .determined by and emphasizing the ideas, thoughts, feeling, etc. of the artist, writer, or speaker. . . 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).

compare that to the definition of "objective": "of or having to do with a known or perceived object as distinguished from something existing only in the mind of the subject, or person thinking. . .real. . .actual. . .determined by and emphasizing the features and characteristics of the object, or thing dealt with, rather than the thoughts, feelings, etc of the artist, writer, or speaker. . .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).

so, based on what you posted, your patient's objective data (what you observed) is:

• only oriented to self
  
• pain of 0/10
  

your patient's subjective data (what the patient told you) is:

• she states she slept with her mailman and shot her husband and his girlfriend
  
• she was calling for her cat named willy. she said he was under the bed
  

do i put that on my care plan?

yes. word it like the patient stated it:

• "i slept with my mailman."
  
  
• "i shot my husband and his girlfriend."
  
  
• something like. . .observed calling for her cat under the bed (no cat was there). "willy! willy! come here."
  
  

these are symptoms of delusional behavior. the nursing diagnosis that can be used for this is

acute confusion

or

disturbed thought processes

depending on any other symptoms that might also be present. a lot also depends on the medical diagnosis as well. the pathophysiology of the medical diagnosis will be extremely helpful in determining the related factor (etiology) of the nursing diagnosis that you end up using. since you haven't supplied that information it's a bit hard to help you out with the nursing diagnosis.