Question

Mr. Kelly is a new patient. He is 55 years old, has had a leg amputation, and now uses a prosthesis. He sometimes has a rash on his stump. What are some subjective assessment data the nurse might use in evaluating whether to use Risk for Infection as a nursing diagnosis? Select all that apply.

a. Vital signs

b. Patient states, "There is no need to wash my hands before dressing the stump. It's my germs!"

c. Observation of dirty wound dressing.

d. Patient states, "I eat one good meal at the homeless shelter a day"

e. White blood cell count.

Answer 1

Subjective assessment data that the nurse might use in evaluating whether to use Risk for Infection as a nursing diagnosis for Mr. Kelly include the patient's statements about hand hygiene and nutritional status.

Step-by-step explanation:

In evaluating whether to use Risk for Infection as a nursing diagnosis for Mr. Kelly, the nurse can collect subjective assessment data. Some subjective assessment data that the nurse might use include:

1. Patient states, "There is no need to wash my hands before dressing the stump. It's my germs!": This statement indicates a lack of understanding about the importance of hand hygiene and suggests poor infection control practices.
2. Patient states, "I eat one good meal at the homeless shelter a day": Poor nutrition can weaken the immune system and increase the risk of infection.

Vital signs and the white blood cell count are objective assessment data, not subjective. Observation of a dirty wound dressing is also objective rather than subjective assessment data. Therefore, the nurse should consider the patient's statements about hand hygiene and nutritional status as subjective assessment data when evaluating the risk for infection.