[Lacyanne64]

hello..
i have been having a lot of trouble on my OB care plan and I have been reading all of the posts I can find on here about the, especially the "sticky" one
...I'm finished with all of my interventions, goals, and evaluations parts but as far as the r/t and aeb's...I understand what many of you are saying, but still cannot figure it out on my specific care plan...
I have 5 nsg dx for my ob care plan, and our teacher specified that even if it is an "at risk" dx we still must have r/t and aeb...but I'm not sure that to use for those..
here are my dx:

risk for infection ??
risk for constipation ??
risk for deficient fluid volue r/t: pp hemorrage
acute pain...here I put r/t: perineal tear, aeb: facial mask of pain, c/o pain
fatigue... on this one I put r/t: labor, aeb: pt verbalization of fatigue
I have no idea if my guesses are correct or what to put on all of these, I have been using my books, cards, and websites..but I am still feeling unsure!
I would appreciate any advice...I desperately need!
Thanks!!!

[Daytonite]

This is what I just posted for you on the "CAREPLANS HELP PLEASE! (with the R\T and AEB)" thread, but I'll post it here too since I still have it on my clipboard.

The reason you are stuck is because you have backed into this whole care plan. Instead of building your care plan from the top down (the preferred way), you've started somewhere in the middle and gone off into, I don't know where. Let me explain.

The construction of a nursing care plan follows the steps of the nursing process. Those steps are:

1. Assessment
2. Nursing Diagnosis
3. Planning (goals and nursing interventions)
4. Implementation
5. Evaluation

In essence, what you are trying to do is:

1. Planning (goals and nursing interventions)
2. Evaluation
3. Nursing Diagnosis
4. And, I don't know where Assessment and Implementation are fitting in

If you read the care planning information on this thread and this thread: http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html which is on the Nursing Student Assistance Forum carefully you will find information telling you that the items that follow the words "AEB" of your nursing diagnostic statements are in actuality the abnormal assessment items that you discovered in the data collection, or Assessment, phase of the nursing process. Now, you haven't mentioned anything about that in your post. I know you must have done it though. It's usually the first thing the nursing instructors talk about when they teach students about the nursing process and one of the first things you do when you see your patient. Abnormal assessment items are also called symptoms, problems and NANDA (North American Nursing Diagnosis Association) calls them defining characteristics. If you have a currently published care plan or nursing diagnosis book you will see these defining characteristics listed with each nursing diagnosis. Those defining characteristics become (1) the items following the "AEB" part of your nursing diagnosis statement and (2) the problems, needs, symptoms that you develop goals and nursing interventions for.

And, there's more! The "R/T" part of your nursing diagnostic statements are short phrases that state the etiology (cause) of those "AEB" things. So, "R/T" and "AEB" are closely linked to each other. Again, most currently published care plan or nursing diagnosis books will also list related factors, the NANDA term for these "R/T" things, that go with each nursing diagnosis so we don't have to sit there scratching our heads trying to figure out the etiologies of these problems. Most nursing instructors (and NANDA) have a pretty hard and fast rule about NOT using medical diagnoses for the related factors, or "R/T" items.

I don't know how you are going to fix this rut you are in. My suggestion would be to look at each of your nursing interventions and determine just what it was in your assessment of the patient that made you think that each of those interventions needed to be done. Those "what it was's" then become your AEB items. You really should use a care plan or nursing diagnosis book to help you with the "R/T" part of these diagnostic statements. I've posted links to online specific nursing diagnosis pages on the Gulanick/Myers and Ackley/Ladwig care plan constructors for you so you can get the same information that is in their books.

Now, I don't want to say your teacher was wrong, but I've been doing care plans a long time. There is no way you can have AEB items on "at risk" diagnoses that I know of. The reason is because the AEB items have to be assessment data that exists. By definition, being "at risk" means the problem does not exist--yet, so no real assessment data is available. You might want to clarify this point with your instructors. If your teacher is, indeed, asking for this information you might want to review your class notes on exactly how this is to be done or make a special appointment to discuss it with them.

In sequencing nursing diagnoses, you always sequence existing problems before "at risk" problems for the same reason. So, your list of diagnoses should be sequenced in this order:

1. Acute Pain R/T perineal injury AEB verbalization of pain and facial mask http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=40 http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_052.php
2. Fatigue R/T labor of childbirth AEB verbalization of a lack of energy http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=19 http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_028.php
3. Risk for Deficient Fluid Volume R/T [excessive loss of blood, depressed immunity] http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=21 http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_030.php
4. Risk for Infection R/T [tissue trauma, multiple vaginal examinations, prolonged rupture of membranes] http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=32 http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_042.php
5. Risk for Constipation R/T [decreased muscle tone, dehydration, inadequate fluid intake, decreased physical activity, pain upon defecation] http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=13 http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_019.php

To illustrate what I've said above, let me use the second diagnosis Fatigue R/T labor of childbirth AEB verbalization of a lack of energy. The defining characteristic, or data assessment item, is that the patient verbalized, or said, that she had no energy. I'm thinking that what she actually said was "I'm tired" and that's what you should really put after the AEB. Goal: By discharge patient will report that she has an improved sense of energy. Nursing interventions: (1) Limit the number of visitors that the patient is getting. (2) Provide information about daily vitamin and iron dietary sources. (3) Encourage patient to engage in a short period of a quiet, relaxing activity before HS. (4) Limit interruptions of patient's night sleep to feeding of the baby only and plan any medications or treatments around those times. Do you see how it all relates and flows together?

When doing the nursing interventions for the "at risk" diagnoses you kind of need to work with an AEB item that is implied. For example, with Risk for Deficient Fluid Volume R/T excessive loss of blood, I know, you know, and your instructor knows that we're implying the potential for postpartum hemorrhage. And, the signs and symptoms of postpartum hemorrhage would be: a soft boggy fundus, excessive bright red lochia, bright red clots, tachycardia, falling blood pressure and her skin might get cool and pale as she proceeds to go into shock. All those symptoms that I've underlined would normally be data assessment items that you would pick up as AEB items if there really were hemorrhage and a Deficient Fluid Volume situation existed. So, your goal would be to prevent the hemorrhage. Your nursing interventions will be aimed at monitoring for and detecting, as well as preventing, if you can, any of those symptoms. Got it? Make sense? So, you're going to have interventions that assess the fundus and the character and amount of lochia, you will monitor her for any bright red lochia or clots, monitor for elevation of heart rate above a baseline of XX, monitor B/P for a drop below a baseline of XX and note the color and temperature of her skin. You see how each intervention specifically addresses each of the symptoms of hemorrhage?

Make sure you clarify with your instructor(s) exactly how they want you to write those "Risk for" diagnostic statements so you do the assignment as they want it.

I hope my explanation has helped. Good luck!

[Rain'sWhisper]

Hi---I, too, am working on a careplan tonight and I find myself stuck.

My patient has esophageal cancer and completed a course of chemo 5 days ago. The reason for his return to hospital is diarrhea and a syncopal episode. Tests are being done to find the cause of the diarrhea, although they think it is due to the chemo but want to rule out other things.

Some tests are back, neg (like C.diff) but still waiting for others. Patient has temp 99.0 and absolute Neutrophil count is high, as is neutrophil auto.
It seems to me that there is an infection so I can't use "Risk of..." but there is no "Infection" nursing dx. I don't know what to do with this ....any help would be appreciated.-----Oh....and the etiology of the infection is unknown at this point.

RW

[Lacyanne64]

Thanks so much for replying Daytonite. You are very helpful! I understand what you are saying. I have done the assessment part, it had to be over a pt we have taken care of, so I made sure I had all that information at the time. I see what you mean by I was going backward and then getting all mixed up...I have been sitting everyday just rifling through my papers, writing different things on different ones because I honsetly didn't understand it. Not to say negative things about my instructor, but she didn't offer a lot of direction at first and just said it's due by this date, have it done. I did ask her a few days ago, after I had read some things about the "at risk" for dx, if we must have aeb for those and she said yes. So I'm not sure what she means by it, but I will talk to her about that. As for everything else, you have made it all very clear to me now. I feel like now I'll be able to take all of my scribbled on papers and rewrite them into a successful care plan. I can't tell you how much I appreciate your help!! I am going to review my care plan books again and use the websites like you said. Hopefully I can relay this information to some fellow students who are also struggling with this first care plan.
Thanks a million and one!!!

[donster]

Originally Posted by Daytonite

Now, I don't want to say your teacher was wrong, but I've been doing care plans a long time. There is no way you can have AEB items on "at risk" diagnoses that I know of. The reason is because the AEB items have to be assessment data that exists. By definition, being "at risk" means the problem does not exist--yet, so no real assessment data is available. You might want to clarify this point with your instructors. If your teacher is, indeed, asking for this information you might want to review your class notes on exactly how this is to be done or make a special appointment to discuss it with them.

This is exactly what I thought of when I read the post. I remember distinctly an instructor telling me that if I had evidence of a problem, then it wouldn't be a "risk" diagnosis. Risk diagnoses, therefore, would be only a two-part statement.

[Daytonite]

Rain'sWhisper. . .you have to not think in terms of medical diagnoses. I know it's very easy to do that, but nursing diagnoses are based upon the defining characteristics, or symptoms, that you find in your patient. So, you can't think about an infection, but the symptoms that lead you to that analysis. With infection we can make objective and subjective observations about the patient and use those to form our nursing diagnoses.

So, your patient has diarrhea. Do you have any other descriptors for it? Based on what you've given, the assessment data includes:

• diarrhea
• fever of 99.0
• high Neutrophil count

Are there any symptoms of dehydration or electrolyte imbalance along with the diarrhea? Is it possible that the patient is dehydrated, because his fever could be related to dehydration? Also, since he has diarrhea and esophageal cancer, what's going on with his nutritional status? Is he eating? There is a nursing diagnosis of Hyperthermia (fever), but the only related factors I could see that you might possibly use with it are "medications" (as in a superimposed infection) or "illness" (your mystery illness). There is a valid nursing diagnosis of Risk for Infection, but what would be the etiology (cause) of this infection? Here are some possible nursing diagnoses I see:

• Diarrhea R/T effects of chemotherapy AEB [you need descriptors of the character and frequency of the diarrhea stools here]
• Hyperthermia R/T unknown illness AEB fever of 99.0

Two others I might use depending on being able to know more about this patient's immune system status are:

• Ineffective Protection R/T compromised immune system AEB fever of 99.0
• Risk for Infection R/T suppressed immune system [I would only use an etiology of suppressed immune system if you can know for sure that this patient's immune system is compromised secondary to the chemotherapy]

[Rain'sWhisper]

Thanks for your reply, Daytonite!

My patient's hydration status is good---no signs of dehydration, he is getting D5NS 150ml/hr, his electrolytes were a bit low 2 days ago but all wnl today.

Nutrition---his albumin is low, total protein is low, calcium low---all other labs are wnl----between this, the fact that he only ate 10% of his meal, the diarrhea, and his cancer--------I'd say his nutritional status is Less than Required, right?

[Daytonite]

Yes. You should probably consider a diagnosis of Imbalanced Nutrition: less than body requirements R/T inability to ingest and digest (?) food and inability to absorb nutrients (?) AEB food intake of 10% and low calcium levels. His inability to ingest food is probably related to the cancer of his esophagus. His inability to absorb and digest nutrients may be due to the diarrhea or the neoplastic process. He needs protein and calcium replacement as well as more food. Also, with the process of cancer, the cancer cells require a huge calorie requirement which is why people with cancer have a weight loss even though they seem to be eating. It's never a good sign when your body is low on protein. It's usually indicative of renal problems. With a low albumin and low total protein, does he have any edema? Without protein in the blood, fluid goes into the cells and tissues of the body and these patients will plump up with anasarca. I forgot to ask if he was having night sweats with the low grade fever? Is it possible that he has kidney failure secondary to the chemo, or metastasis?