care plan help

  1. I have a care plan due next week on one of my patients at a children's hospital. This patient was hospitalized for diabetic ketoacidosis with blood sugars above the 300s. Basically she had the flu a week before and she also said she thought that if she didn't eat carbs she wouldn't have to take her insulin.. therefore she just increased her protein and fat intake. I'm having trouble with nursing diagnoses. Mainly with the as evidenced by part. For example these are the four diagnoses I have
    Risk for ineffective breathing pattern r/t hyperglycemia as evidenced by DKA
    Imbalance nutrition: less than body requirements r/t catabolism of protein and fat for fuel as evidenced by DKA and high blood sugar levels
    Risk for infection r/t hyperglycemia and suppressed inflammatory response as evidence by DKA
    Deficient knowledge r/t prevention of diabetic ketoacidosis as evidenced by verbal confusion on how the body produces energy

    I guess my question is are my "as evidenced by" statements right? I don't know what else to say but as evidenced by DKA and I feel like it just sounds repetitive and that I may need more information. Thanks!
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    About mel2067

    Joined: Oct '07; Posts: 8


  3. by   ChiSmile6
    [font=franklin gothic medium]first, your ineffective breathing pattern diagnosis needs to go more along the lines of specific s/s observed in ur pt. your pt i am assuming has kussmaul breathing (deep and rapid) b/c this usually accompanies dka. i would write the dx more like this.. ineffective breathing pattern r/t dka manifested by _____(what you observed in your patient) ___. oh crap i just realized you had risk for before that dx..hmm..well did you actually witness altered breathing on your pt? if so then i wouldn't do risk for but i am assuming you pick that one for a reason...
    [font=franklin gothic medium]
    [font=franklin gothic medium]also, it seems as though your evidenced by and related to's should be switched around a little for example
    [font=franklin gothic medium]imbalanced nutrition: less than body requirements r/t catabolism of protein and fat for fuel as evidenced by dka and high blood sugar levels
    [font=franklin gothic medium]would sound better like this...
    [font=franklin gothic medium]imbalanced nutrition: less than body requirements r/t dka as evidenced by high blood sugars and catabolism of protein and fat for fuel
    [font=franklin gothic medium]*the evidenced by's should point to specific findings observed (subjective or objective data)
    [font=franklin gothic medium]
    [font=franklin gothic medium]you can also do ineffective health maintenance as a dx because this pt does not seem to know much about their condition and may need teaching regarding it...
    [font=franklin gothic medium]
    [font=franklin gothic medium]what book are you using for writing your diagnoses? not nanda i am assuming? that is what i use.
    [font=franklin gothic medium]
    [font=franklin gothic medium]i hope i helped..a little atleast!!!!
  4. by   ptspook1
    My teachers would not accept AEB DKA... my teachers would prefer:

    Risk for ineffective breathing pattern r/t hyperglycemia secondary to DKA AEB patient stating "sometimes it's hard to breath" or pt 30 RPM or difficulty performing ADL's.

    We are also not allowed to do r/t DKA as that is a medical diagnosis... it has to be r/t hyperglycemia secondary to DKA (our teachers are soooooo picky about these stupid diagnosis). Also by putting secondary to DKA you dont run the risk of repeating yourself because it makes you think..... WHAT PHYSICAL EVIDENCE MADE ME PICK THIS DIAGNOSIS.

    My teachers also told me that when you do Risk for diagnosis the AEB is not quite as important, but they usually want you to put a reson that you chose that particular diagnosis in there over another one. If you think really hard you can probably come up with something that made you think that particular diagnosis fit better than others. If not.... you should probably pick a different one.

    However sounds to me that Knowledge deficit should be number 1 priority!! Thinking that you dont need to take insulin if you dont eat carbs is a BIG knowledge deficit.

    Remember your AEB needs to be something that you can physically witness or the patient can verbalize. Your goals ALWAYS need to be measurable... That's the part they always get me on!

    Hope this helps!
  5. by   Daytonite
    you have very serious problems here that i suspect are going to take more than just a post from me to fix. back in october when you asked for care plan help ( i gave you the steps of the nursing process. i'm posting them again because i don't think you're following them and in order to write a care plan, you must follow these steps in the sequence they occur:
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    the other very major problem you have is that you are not constructing your 3-part nursing diagnostic statements properly. this is partly because you do not understand or follow the nursing process.

    the 3-part nursing diagnosis statement has this structural format:

    p - e - s

    p = problem
    e = etiology
    s = symptoms

    problem - etiology(ies) - symptoms

    these are, in nanda language

    nursing diagnosis - related factor(s) - defining characteristic(s)

    in a care plan they look like this:

    problem [related to] etiology(ies)[as evidenced by] symptom(s)


    nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)

    the related factor is the underlying cause of the problem or the cause of the signs and symptoms that the patient is having. to help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. to help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". "by taking away this factor, will the symptoms go away?" remember this important rule: you cannot list any medical diagnosis as a related factor. you have to state a medical condition in some other scientific terms. as an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". they essentially mean the same thing--the difference is in the phrasing of the words.

    the defining characteristics are always the signs and symptoms that come from that list you created from your assessment activities. these will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.

    the first thing you needed to do in writing your care plan was to sort through the assessment information that you collected on this patient. you also needed to look up information on dka, particularly the signs and symptoms, treatment and pathophysiology. before you can even begin to determine the patient's problems (nursing diagnoses) you have to determine which of the assessment data is abnormal. these are the patient's symptoms, or what nanda calls defining characteristics. these symptoms, or defining characteristics, are what the nursing diagnoses, goals, and nursing interventions are based upon in the remainder of the care plan.

    let's dissect your nursing diagnoses. . .
    imbalanced nutrition: less than body requirements r/t catabolism of protein and fat for fuel as evidenced by dka and high blood sugar levels
    can't use dka as a related factor. it is a medical diagnosis. only symptoms, or defining characteristics, can be listed as aeb items.

    deficient knowledge r/t prevention of diabetic ketoacidosis as evidenced by verbal confusion on how the body produces energy
    first of all, you must specify a subject when you use deficient knowledge. in this case the subject you are wanting to teach the patient is "diabetes". secondly, deficient knowledge is the "absence or deficiency of cognitive information related to a specific topic" (page 130, nanda-i nursing diagnoses: definitions & classification 2007-2008). does "prevention of diabetic ketoacidosis" sound like an etiology, or cause, of a deficiency of cognitive knowledge to you? it is because the patient just hasn't had the facts (information) that they have inadequate knowledge of diabetes. diabetic ketoacidosis is a medical diagnosis and shouldn't be part of the nursing diagnosis anyway. to see a list of related factors for this diagnosis, see this website: [color=#3366ff]deficient knowledge (specify). your aeb information is ok. the diagnosis should be written as: deficient knowledge (diabetes) r/t lack of information aeb verbal statement by patient of confusion on how the body produces energy.
    risk for ineffective breathing pattern r/t hyperglycemia as evidenced by dka
    first, "risk for" diagnoses are for anticipated problems--problems you are expecting might occur, but are not actually present. therefore, they are listed last and after the actual problems that the patient has. since they are non-existent problems, they cannot have any actual symptoms, so there can be no aeb items in the diagnostic statements unless you have a crystal ball. the diagnostic statements for these diagnoses only contain the nursing diagnosis label and the risk factor. you can see the information for the nursing diagnosis [color=#3366ff]ineffective breathing pattern. the risk factors you would use for risk for ineffective breathing pattern would be the same as the related factors for ineffective breathing pattern. the bad news is that hyperglycemia cannot be a related factor (etiology) of this nursing problem. this nursing problem is inspiration and/or expiration that does not provide adequate ventilation (page 26, nanda-i nursing diagnoses: definitions & classification 2007-2008). hyperglycemia is not the direct cause of this. the most likely cause would be respiratory muscle fatigue. when you plan the nursing care for this, you must have a specific problem in mind that you expect will occur. why? because your nursing interventions are going to be to monitor for the signs and symptoms of it and prevent it, so you and anyone else reading the care plan need to know what you're looking for!

    risk for infection r/t hyperglycemia and suppressed inflammatory response as evidence by dka
    i'll buy the suppressed inflammatory response, but how are you tying the hyperglycemia to infection? i know how, but do you? again, no aeb evidence and dka is a medical diagnosis anyway and not a symptom. what infection did you have in mind here that fits these etiologies? this statement should read risk for infection r/t hyperglycemia and suppressed inflammatory response.
    you need to go back and re-write these nursing diagnostic statements. actually, i would suggest that you start from scratch with step #1 of the nursing process and work the first three steps. everything in the care plan has to relate to the symptoms that the patient has and those symptoms come from the assessment information.