connk

Thanks for your replies. I actually filled out the entire care plan and used "pertinent negatives," (i.e., patient denies, pain, burning upon urination, etc) for the subj. data portion. I guess you can actually have negative subjective data, but still have risk factors for nursing diagnoses. Who knew?:)

I am doing a care plan for my patient with a 1st degree laceration post vag. delivery. I have NOTHING to report in the subjective data section. My nursing diagnosis is Risk for infection d/t laceration r/t lady partsl delivery. Patient reports no pain, there is no redness, edema, ecchymosis, discharge, etc. I am stuck!