[k.lvn.mom]

fluid volume excess r/t generalized edema AEB +1 bilateral tibia pitting edema.

24 y/o F post op- c-section

thank you

[Daytonite]

Hi, k.LVN2b. . .you've got a problem with your nursing diagnostic statement here. Your R/T part of the statement is supposed to be the etiology of the problem. Generalized edema is actually a symptom. It is something that you would notice on assessment of the patient. So, it really doesn't belong as a related item in your nursing diagnostic statement.

Do you have a care plan book or a book of nursing diagnoses that you can refer to in order to help you with this? With Excess Fluid Volume the related factors that NANDA lists are:

• Compromised regulatory mechanism
• Excess fluid intake
• Excess sodium intake

You need to have a cause for this 1+ bilateral tibia pitting edema that needs to go into that R/T part of your nursing diagnostic statement. To put it another way, generalized edema is not the cause of your patient's 1+ bilateral tibia pitting edema. Why do you suppose she has edema in her legs? Her kidneys are either not removing fluid like they are supposed to or perhaps she has a sodium imbalance causing her to retain fluid. But, you need to investigate a little further why this edema is occurring. The doctor's progress notes may have a clue to the reason.

Goals and outcomes are the predicted results of our nursing actions that we perform for the symptoms that the patient is having. So, what are the interventions that you are performing for this patient's pitting edema in her legs? The desired result of those actions is _______. That is your patient goal. Goals/outcomes describe patient states that follow and are influenced by your interventions.

• http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=22
• http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_031.php

You will find two threads on the nursing student forums that will help you in writing nursing diagnostic statements and care plans:

• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)

You will also get better responses to questions like this if you post on the Nursing Student Assistance Forum or the General Nursing Student Discussion Forum. I just happened to come across your post by accident as I don't often look through the posts on the General Nursing Discussion Forum. Good luck with writing the rest of your care plan.

[k.lvn.mom]

Ok Daytonite, this is prob the stupids question you are going to hear from a student about to graduate LVN school in 7 weeks. But since i go to clown school for nurses, i obviously don't know the answer, and none of my instr. have bothered to correct me.
When writing a nrsg dx, you have to use the r/t that NANDA says goes with that dx? ex: Fluid volume excess has to use one of the following for a r/t Compromised regulatory mechanism
Excess fluid intake
Excess sodium intake
Or can i make up my own?

[Daytonite]

No, you don't have to use what NANDA says goes with a diagnosis, HOWEVER, you do have to keep whatever you do write with your diagnosis within the meaning of what the diagnosis is about. In their publication NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008, which is a pocket sized book, they publish all current 188 nursing diagnoses, the definition of each, related factors (you know them as the R/T part of a nursing diagnostic statement) and the defining characteristics (the AEB part of a nursing diagnostic statement but these are actually the signs and symptoms of each particular diagnosis). These are all based on hundreds of nurses who have done research and study of them, put their information together and developed these guidelines. They published them so that we nurses don't have to sit there scratching our heads trying to come up with something to put in the R/T or AEB part of a nursing diagnostic statement and so it helps us to better understand what underlies the problem in the patients who have that particular nursing diagnosis. Choosing an etiology, or related factor, involves some critical thinking and an understanding of the pathophysiology of what is going on with the patient's disease process.

The overall main idea in writing nursing diagnostic statements as students and as new nurses is to help see the relationship between the nursing diagnosis, related factors and defining characteristics and help to learn and develop an understanding of the critical thinking that goes into it. The R/T part of the nursing diagnostic statement is the cause of the problem (in this case Excess Fluid Volume). The actual definition of this is "Increased isotonic fluid retention" (page 91). The word, isotonic, refers to "having equal pressure" (page 1028, Taber's Cyclopedic Medical Dictionary, 18th edition, published in 1997 by F.A. Davis Company.) This nursing diagnosis is specifically referring to osmotic pressure. We know, however, that blood pressure and changes in the vascular system can also be responsible for fluid retention. There are lots of people who have swollen feet and legs due to cardiovascular problems rather than electrolyte problems. There are other nursing diagnoses that are appropriate to use for patients with those underlying etiologies of their edema. It is important when choosing a nursing diagnosis that you understand the underlying pathophysiology of what is going on with the patient. That is why I asked: why do you suppose she has this edema in her legs? I was trying to stimulate your thinking on this.

As I said previously, NANDA lists the following as related factors for this diagnosis:

• Compromised regulatory mechanism
• Excess fluid intake
• Excess sodium intake

But I did find another care plan author who used:

• renal dysfunction
• loss of plasma proteins

as R/T items for this diagnosis of Excess fluid Volume. The loss of plasma proteins would cause fluid to be pulled into the patient's intracellular spaces in order for osmotic fluid pressures to become equalized and result in the edema. This is very definitely a valid related factor that can go along with this nursing diagnosis (and I've written it into my NANDA book). That meets the definition of this nursing diagnosis (increased isotonic fluid retention). When someone looses a lot of plasma proteins they develop anasarca, a condition where there is severe generalized edema throughout the entire body. You might see this in patients who have the medical conditions of nephrotic syndrome, pre-eclampsia or eclampsia. You would write a nursing diagnosis for something like this as:

Excess Fluid Volume R/T loss of plasma proteins AEB generalized body edema

The reason I wouldn't just use the +1 bilateral tibia pitting edema is because there should be edema in other areas of the body as well, not just the legs. Instead of using "generalized body edema" as the AEB item you could start to specifically list out all the areas of the body that you noticed the edema in. Some instructors might not want you to use the term anasarca saying that it is medical diagnosis. You might want to check with your instructors on that before using it.

Hope that helps clear things up for you a little bit. Your question was far from stupid. This business of nursing diagnosis is incredibly complex and takes persistence, time and a lot of working with it to master. Even I am always learning something new about it. I commend your courage to have posted on this. A good many others would have just skipped over it rather than tried to gain an understanding of it. I call that the old "sweep the dirt under the carpet" solution! You may manage to make it disappear for the moment, but it is, in reality, still there and eventually has to be dealt with.

[k.lvn.mom]

Thank you for all your help, you really simplified things for me to understand. I went to the bookstore today and bought the book of NANDA definitions and classifications. I think that it will help...

Thanks again

[anonymurse]

Simple test: substitute the words "because of" for your R/T and see if it makes sense. Now in the case of a medical diagnosis, you'd say "secondary to" instead of "related to," but it's the same thing.

You might be looking at the "defining characteristics" lists in your nursing Dx book. Those are just conditions that must be present (major) or may be present (minor), but they are NOT the R/Ts. For those, you'll want to look at the items listed under "related factors."

Both Doenges and Carpenito are useful and usable. Townsend's "Nursing Diagnoses in Psychiatric Nursing" is pure magic for getting a firm handle on so many psychosocial things seen on the floor.