Getting subjective data

[MizMaverick]

I am doing a care plan (I am new at this yet), and my patient is a quadriplegic who cannot speak. Any idea on what can I put down for subjective data? (During my clinical's there hasn't been any family coming in to visit so I can't ask them) Thanks in advance!

[RN403, BSN, RN]

Objective data is what you can see. Subjective data is what the patient tells you.

If the patient is unable to speak or communicate what they are feeling or experiencing then I would put "unable to assess due to xyz."

[MizMaverick]

Ok, thank you for your response.

[MizMaverick]

Is there any technical term to put in a long term goal when there isn't one? All the NOC relate to teaching and having the client relay it back, but my client can't speak.

[MizMaverick]

Is there any technical verbage I can put on the LTG if there isn't one that fits? My client is a quadriplegic who cannot speak, so educating and having her to tell me what she would do is impossible. Anybody have this problem? Thanks in advance!

[akulahawkRN, ADN, RN, EMT-P]

You might want to consider teaching the patient's family or determining if there's another nursing outcome that is more appropriate but perhaps not listed. It's difficult to gauge teaching effectiveness with patients like this unless there's some other means by which you can communicate both ways.

[Esme12, ASN, BSN, RN]

Is your patient non responsive? Even patient that are quads can communicate. How does the patient make their needs known?

[Esme12, ASN, BSN, RN]

Does this patient not communicate at all? Even quadriplegics can indicate some needs and affirmation or decline to questions asked.

duplicate threads merged

[akulahawkRN, ADN, RN, EMT-P]

As Esme has said, unless your patient is unresponsive, even these patients usually are able to communicate somehow so that their basic needs can be met. Look for how your patient communicates and remember, because your patient can not speak, spoken language won't be the way your patient communicates with you though it's very possible that your patient understands everything that is said.

[KelRN215, BSN, RN]

Non-verbal does not mean unable to communicate and even if she couldn't communicate back to you that doesn't mean she doesn't understand you. Look at something like ALS. Those patients become completely quadriplegic and non-verbal but understand everything going on around them since the disease does not affect their mind. What else is going on with this patient? Is she comatose or simply alert but nonverbal? I assure you there are long term goals for this patient.

[nurseprnRN, BSN, RN]

Who says it has to be a goal that involves communication? I can think of about a bazillion long term goals (or if it helps you to think of it in other terms, "outcomes") for someone with quadriplegia (or tetraplegia, as it is called now).