Care Plans Help Please! (with the R\T and AEB)

Nursing Students General Students Nursing Q/A

Hello! I'm struggling with one of my classes, when the teacher gives examples it makes sense but when we're left on our own, it's extremely difficult to know where to start.

Specifically, trying to understand the nursing DX r\t (what it's related to), aeb (then the signs and symptoms).

Does anyone have any pointers to make this easier?

RNinJune2007 said:
Hello! I did very well my first unit, taught by a certain teacher. This unit is taught by another and the majority of my class is COMPLETELY lost! When the teacher gives examples, it makes sense but when we're left on our own, it's extremely difficult to know where to start!

It will be the nursing DX r\t (what it's related to), aeb (then the signs and symptoms)

Does anyone have any pointers to make this easier??

Thanks in advance!!

My teacher now is all about care plans and nursing dx. He says that related to part is objective information and the evidence by is related to what you see and what is causing the problem. I hope this helps

Specializes in Neuro, Critical Care.

Welcome guys ?

We are doing "mini mind maps" but basically the same thing as a care plan....

I have several saved on my computer if anyone is interested, the few dxs I can think of off the top of my head are:

Gastric bypass

Total knee replacement

Metatastic cancer..or cancer

Intestinal blockage

So if anyone wants to see the care plans/mini mind maps I have for those just let me know. ?

Specializes in CCU, MICU, Tele, L&D.

Care plan that I wrote, hope it helps someone. It is not one of my best, but hope it helps!

Aeb can "Not" be used with an at "Risk for" dx.

Assessment and evaluation must go with the nursing dx.

Nursing interventions must have time period (example is prn or q4h per md order)

Assessment

Sudden onset; shaking chill; rapidly rising fever of >101. Cough productive of purulent sputum (pink, thick).

Pleuritic chest pain aggravated by respiration/coughing

Dyspnea on exertion, no nasal flaring, or use of accessory muscles. all pulse sites palpable. IV antibiotics administered to patient as ordered by physician of vancomycim 0.5gm q6h

Oxygen per cannula, 5L with nebulizer q4h. Respirations 28 and shallow. Apical pulse is

Weak at rate of 92. Pale and dry oral mucosa. Diaphoretic. Checks flushed, and hot. Inspiratory crackles in upper and lower chest. Fatigue and anxiety expressed. Non-smoker. no Hx of asthma. Hx of chest cold x2 weeks. Husband not at bed side. Side rails up x4. Call light within reach.

Nursing Diagnosis

Infection related to invading bacterial/viral organisms secondary to pneumonia as evidence by sputum pink and tick, Dyspnea, crackles in upper and lower field.

Desired Outcome

Throughout the hospital stay, the patient skin will:

Improvement of infection aeb , normal WBC, negative sputum culture on repeat culture

Nursing Intervention

Assess for predisposing factors; medication chronic illness

Assess vital signs closely monitoring temperature fluctuations

Obtain freash sputum for gram stain, and culture and sensitivity

Monitor gram stain, sputum, culture and sensitivity

Monitor WBC count

Assess hydration, Rationale

High doses of some medications have reduced resistance to infections

Continued fever may caused by drug allergy, drug resistant bacteria, super infections, inadequate lung drainage.

Determines correct antibiotics coverage for pt

Determines correct antibiotics for resistant bacteria

> levels indicate infection

Water loss is > with fever.

Evaluation

No change in the following:

Sudden onset; shaking chill; rapidly rising fever of >101. Cough productive of purulent sputum (pink, thick).

Pleuritic chest pain aggravated by respiration/coughing Dyspnea on exertion, no nasal flaring, or use of accessory muscles. all pulse sites palpable. IV antibiotics administered to patient as ordered by physician of vancomycim 0.5gm q6h Oxygen per cannula, 5L with nebulizer q4h. Respirations 28 and shallow. Apical pulse is weak at rate of 92. Pale and dry oral mucosa. Diaphoretic. Checks flushed, and hot. Inspiratory crackles in upper and lower chest. Fatigue and anxiety expressed. Non-smoker. no Hx of asthma. Hx of chest cold x2 weeks. Husband not at bed side. Side rails up x4. Call light within reach.

Goal NOT met

As evidence by:

No lab values obtained for ABG, WBC, sputum culture.

Specializes in RN.

I'm not sure when you first wrote this. Did you find the help you need? I have the Ackley orange book someone mentioned. I love it. It helps a lot. I have done a few care plans if you'd like to see them. It's hard at first. The floor I'm doing my clinicals on doesn't even do a full care plan. They have a paper they mark off. It's interesting how different it is from floor to floor. Good luck!

I always use a care plan book to write my nursing dx. It makes it so much easier. Usually the care plan books include a list of problems r/t to the patient's main complaint and they even include goals and interventions.

We use the same Care plan reference (Cox). I find it quite sufficient. You can't expect to find everything you need in a book. You have to be able to formulate things on your own. I'm not saying you don't...please don't get me wrong. I'm just so frustrated with students trying to find the easy way put and trying to short-circuit the learning process. If you're a new student I can understand why you would need to reference more often. But looking for a care plan ready to turn in to be graded without your own thoughts and the nursing process behind itself is fruitless and will lead to nothing but failure, whether in school or on the floor. It takes time to learn this....and your own mental energy. I've seen too many people flunk out of our nursing program due to the same problem. It does come in time. And soon it becomes like breathing---completely involuntary. To be a nurse is to think like a nurse. Ask instructors for help--that's what they are there for.

Specializes in Pediatrics.

Well, you need a book to give you the NANDAS for your Dx's. I've been using the Nurse's pocket guide to Dx, interventions, rationales by Doenges. And your textbooks should be giving you interventions for specific diagnoses. I know some people use the online care plan builders, but I think you will learn a lot more doing it yourself. And that will pay off immediately with better grades-because you will really understand it. Just a couple,tips, and sorry if they are really obvious:

Dx=Nanda, it must be Nanda usually, DON'T get creative. There are defining characteristics for each Nanda Dx, and your patient should be manifesting at least a 2-3 of those to get the Dx. You get your defining characteristics by doing a good assessment, clustering the data according to body systems, and seeing what problems pop out.

Related to=etiology, but NOT the medical diagnosis. Think of what the signs and symptoms are of the medical Dx that got the person that Dx. If they have pneumonia it could be impaired gas exchange related to thick mucous secretions in lungs or something like that.

Manifested by/As evidenced by: your medical diagnosis can go there, but all the signs and symptoms that you would want to see normalize after your interventions should go here. Your outcomes should specifically address each and every one of these manifested bys, except maybe the medical Dx. If you write good, exhaustive manifested bys (or aebs as you call them) in your diagnosis, they literally lead you all the way through the care plan to evaluation. The normal/healthy version of all your manifested bys become your outcomes, and your interventions are directly related to those outcomes, and you evaluate your interventions in relation to whether the manifested bys/aebs from the Dx got normalized into the outcomes or not.

Hi June 07, I think the RNotes have NANDA approved Dx in it and also there are some things in the back of Tabers. I am in the LPN program and struggle with care plans all the time. It does get better as you go along. Your AEB is what s/s the patient presents with or c/o. I was taught that you don't use AEB for "Risk for" NDX. I don't know if this is the same across the boards. Springhouse publications has these NDX cards that you can carry along, and they are great to use to. Hope this helps and good luck to ya;-)

Specializes in Vents, Telemetry, Home Care, Home infusion.

P.S.:

New term for us oldtimers-- guessing AEB short for "as exhibited by"

Specializes in Med-Surg, Psych.

Can anyone direct me to an online source of approved NANDA diagnoses? I understand new ones have been added for 2006.

Thanks!

NRSKarenRN said:
P.S.:

New term for us oldtimers-- guessing AEB short for "as exhibited by"

our aeb=as evidenced by. Same difference though ;)

Specializes in RN.

I have the Ackley book that some of them have mentioned here. I really like it because it also has NIC and NOC in it. I have the 6th edition and I know there is a 7th edition, but 6 seems to have everything the same. I really like it. We hand in care plans every week after clinicals. What amazes me is the floor I'm on doesn't use care plans like this. They have a sheet with lists and you just go thru and check stuff off. So I'm not quite sure how they actually do a plan of care. I can send you a sample of mine if you'd like. I'm not sure how to check my mail on here, but if you'd like, you can email me and I'll send it. Send me something on here and hopefully I'll get it. For something that sounds simple, its not that easy. So many technicalities. Good luck! Ann

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