CAREPLANS HELP PLEASE! (with the R\T and AEB)

I was looking for another NANDA list and I found this page. It's helped me, so maybe it will help someone else too

http://en.wikipedia.org/wiki/List_of_nursing_diagnoses

*edit, woops! Forgot to mention, if you see an asterisk by the diagnosis, it's not NANDA supported. Otherwise, good to go .

most of my classmates used the nursing dx book to do careplans. And one of the hospitals we were at would have what we need listed on the patients clipboard.

I have the "Nursing Diagnosis" manual by Carpenito-Moyet. It pretty much spells it out for you- I absolutely love it! It's pretty simple- let's say your patient is constipated... so you look up Constipation in the table of contents... this book gives you the assessment data your patient should be manifesting in order to consider it constipation... then it gives you your "R/T" options like immobility, effects of medications, etc. The "AEB" is pretty much your assessment data stated all over again.

An easy way to remember it is...

1)Decide if this need is ACTUAL or RISK FOR
2)Write Actual/Risk for _____ [insert need here]
3)Think of a way to word the client's R/T without using a MEDICAL diagnosis, such as "Diabetes" or "Congestive Heart Failure." In my program, we are allowed to use a medical diagnosis only in this form: "R/T ineffective circulation secondary to diabetes" The "secondary to" is a great way to make your diagnosis sound really smart
4)Decide what assessment data best reflects your need and put that as your AEB. My program requires that we use at least 3 pieces of data.

Hope this helps!

Hi,
My name is Mary . I will graduate Dec 2006 . I would like to thank all of you for the info on careplans.
May God keep us all Strong
Best wishes from Georgia
Mary

care plans require a lot of practice and studying, try laying your hands on some case studies. there are some very good care plan books around that could help too.

Hi everyone, I just wanted to thank you all again for the help. This is my first care plan. Quick version: A 20 yr old in traction for 3 weeks on bedrest.

My first diagnosis is Impaired tissue integrity/ or would skin sound better.

I was wondering if related to surgical procedure is ok??

And AEB- presence of insicion..... (I'm confused on what manifestations I should use for a surgical incision)


I just really need to get a good understanding. I'm going to sit down with some books tonight after I put my baby to bed.

I posted a long answer for you in the Nursing Student Assistant Forum here http://allnurses.com/forums/1765694-post47.html under the thread "Careplan help for a patient in traction for CapeCoral Chick". It was only meant to get you started. Please feel free to post any new questions you have to the new thread.

can you share it to me...im doing care plans most of the time now..thanks ndc2006

i wish i would of spent the money on a nursing care plan book when i was in nursing school!

Like I tell my students when I have them, I don't go from forward to back on my Nanda's but backwards to forwards.

I think...okay what is the probelm as I see it (and remember, just ONE probelm at a time). SO in my brain I say..hmmmm I am worried about skin, and the fact the pts buttocks are getting red.

Okay good...now were on onto something..what did I do or what do I want to do? Okay get them off the area, turn frequently, have it checked every shift, use pillows and bed position changes to float the area, and even request a air bed. Okay COOL...I have my implementations already, and I will know if they work by less redness and no breakdown...WOW, got my evaluation/goals of care!

Now I work backwards...Got my implementations and evaluation so lets fill in the gaps. This person has a red buttock area...okay that is my as evidenced by! "Presence of warm moist reddened bilateral buttock areas" COOL got my AEB! Two more steps to fill in!

Related to..hmmmm why is this happening...of course, mobility is bed bound...easy! So now one step left....hit the Nanda Dx's and find one that fits!!!!!! Impared Skin Integrity! Perfect! Now lets take all this and move it all forward....

Impared skin intergity r/t decreased mobility (bed bound), AEB moist warm reddened areas on bilateral buttocks. Implementation: turn pt q 1-2 hours, use of pillows to float the area as much as possible, monitor skin q shift and alert wound care PRN, discuss use of air mattress with the MD. Evaluation/Goals: Pt will have lessening of redness on bilateral buttocks and keep intact skin.

I find if you go backwards things seem a little to the point better then trying to fill in the gaps from front to last! Break it down...what did you see (that will typically be your first thing but will be you AEB), what do you want to do (IMplementations), how do you know it works (evaluation), Why is this happening (keep it simple...remember one probelm at a time per NANDA dx and that is you r/t), and find a NANDA dx! Then fit it all in .

I have taught this to students and had them ace care plans! Heck, I could have also gone dietary on this one, but that would be a whole new nanda care plan as it should be...only address on simple probelm at a time, and keep it simple...simple breaks things down into workable things that you actually can achieve in your evaluation/goal area!

Good luck and feel free to ask me questions on it...gotta find my old NANDA book! LOL!