CAREPLANS HELP PLEASE! (with the R\T and AEB) - page 9

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... Read More

  1. Visit  Daytonite profile page
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    Quote from natkat
    any advice on prioritizing diagnoses? i know the basic abc - airway, breathing, circulation. but after that, what is more important; elimination? safety? pain? mobility?
    nursing diagnoses are often prioritized according to a specific system of priority. each of you must be attentive to your instructors when you are being given information at the beginning of your nursing programs on care plan construction and the nursing process. the most common prioritizing system used is maslow, however, there might be another system that your instructors might be wanting you to use. if you are not sure, you should ask your instructors to be sure you have your school program instructions correct. your grade on care plans may depend upon this.

    each of the nursing diagnoses has a definition. that definition tells you what the intent of the diagnosis is and, therefore, will direct you as to what specific need it is addressing in the patient. maslow is very clear in his hierarchy of needs as to what is to be placed first and in what order of importance. you can find a nice pyramid of these broken down for you on page 1325 of nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig if you happen to have a copy of this book. the authors also go on to classify the nursing diagnoses into the major maslow groupings. you can see a very detailed explanation of maslow's hierarchy at this website: http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs.

    the major groupings in maslow's system are:
    1. physiological needs
    2. safety and security needs
    3. love and belonging needs
    4. self-esteem needs
    5. self-actualization needs
    they are actually sequenced in his pyramid with the physiological needs at the bottom and self-actualization needs at the top. the importance of this is that the person, according to maslow, will first seek to fulfill essential needs--physiological needs being the first because they are minimally needed for the organism to survive. the nursing diagnoses that address the physiological needs should be sequenced first and in this order:
    1. oxygen - those diagnoses that address oxygen to the brain are sequenced first, followed by those oxygenating the lung, then the heart and finally the other tissues of the body. some of the activity tolerance diagnoses are included here because they involve oxygenation.
    2. food - this includes nutrition, food, fluid and electrolytes to not only the entire system, but to the cells as well. diagnoses involving wound and wound healing should be sequenced with this group.
    3. elimination - bowel and bladder
    4. temperature control - fevers, hyperthermia, hypothermia
    5. sex
    6. movement - all the diagnoses pertaining to mobility and movement
    7. rest - sleep
    8. comfort - pain, self-care and hygiene
    again, i strongly urge you to clarify with your nursing instructors exactly how they want you to prioritize. i have found that some student's instructors are requiring them to move nursing diagnoses such as acute pain to the top of the list of priority. this is contrary to maslow, but needs to be done by those students because their nursing program is requiring it to be done that way.
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  3. Visit  anonymurse profile page
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    Quote from Natkat
    Any advice on prioritizing diagnoses? I know the basic ABC - airway, breathing, circulation. But after that, what is more important; elimination? safety? pain? mobility?
    You can justify something by asking yourself simply "Of these situations described by my NDXs, what are the associated interventions (including calling a doc)? And which intervention is most important to saving my pt's life?" So cross that one off. Then go through the same thing with the rest.

    When you do it this way, you will have reasoned things through in a way that you can instantly defend. I'm not saying your instructor will always agree, but most of the time it would make her look really bad to disagree if you correctly reason things out this way.

    Now if you have specific instructions to go by Orem or Maslow and justify things that way, then you know how to proceed. Sometimes "elimination" will not feel right, but you can point to the theory if that's what's demanded, and say "I would have done X but you told us to stick with theory Y."

    The NCLEX way really is the common sense way without theories. Safety is always a great first thing to look for. You want to preserve what you have, especially life and limb. This reminds us that "do no harm" takes precedence over all other ethical considerations. It all ties together.
  4. Visit  crystalcoastlvr profile page
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    Quote from Natkat
    Any advice on prioritizing diagnoses? I know the basic ABC - airway, breathing, circulation. But after that, what is more important; elimination? safety? pain? mobility?
    Hi, just wanted to offer some help. I would have to say safety would be your next highest priority. Good luck.

    jules:spin:
  5. Visit  Daytonite profile page
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    Safety is never a priority over physiological needs! Elimination, pain and mobility are physiological needs. Safety comes after them.
  6. Visit  crystalcoastlvr profile page
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    Quote from Daytonite
    Safety is never a priority over physiological needs! Elimination, pain and mobility are physiological needs. Safety comes after them.
    Okay let me just say this, if someone is having a seizure and they're having an uncontrolled bowel movement,,,,,,,,guess what MY priority problem after ABC's will be.........SAFETY! That is what is great about autonomy.

    jules
  7. Visit  Daytonite profile page
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    Quote from crystalcoastlvr
    Okay let me just say this, if someone is having a seizure and they're having an uncontrolled bowel movement,,,,,,,,guess what MY priority problem after ABC's will be.........SAFETY! That is what is great about autonomy.

    jules
    Jules, dear heart! I admire your spunk. After addressing the Ineffective Breathing Pattern of your seizure patient and probable Acute Confusion, you are more likely to also be cleaning up incontinent urine. I'm not saying that you don't watch to make sure the patient doesn't bite their tongue or bash their head against a side rail. You do that, too. But when it comes to sequencing it on paper, there is a way you have to do it. And Risk for Injury still will still go to the bottom of the list. But it doesn't mean that you will wait to pad the side rails and put a tongue blade where it can be reached if needed.

    When it comes to putting this stuff down on paper, I have to tell you that I've been doing it for 30 years. When I am posting answers to care plan questions I am formulating my answers with the idea that they are nursing school assignments that are going to be turned in to professors or nursing instructors. So, they must demonstrate critical thinking and follow the nursing process. I won't argue the practical side of care giving because I've been an acute hospital nurse and LTC nurse for many years and I am well aware of the practicalities of nursing. But, kiddo, when you are learning the nursing process and critical thinking in preparation for the NCLEX you have got to understand why some of these things fall into sequence before others. What you put on paper is a tad different than what you do in the clinical area. You can't confuse your physical actions with mental thinking and processing.
  8. Visit  Lacyanne64 profile page
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    Great websites!
    Last edit by Lacyanne64 on Apr 22, '07 : Reason: Posted in another area.
  9. Visit  Daytonite profile page
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    lacyanne64. . .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/des...ns-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/me...ex.cfm?plan=40 http://www1.us.elsevierhealth.com/ev...replan_052.php
    2. fatigue r/t labor of childbirth aeb verbalization of a lack of energy http://www1.us.elsevierhealth.com/me...ex.cfm?plan=19 http://www1.us.elsevierhealth.com/ev...replan_028.php
    3. risk for deficient fluid volume r/t [excessive loss of blood, depressed immunity] http://www1.us.elsevierhealth.com/me...ex.cfm?plan=21 http://www1.us.elsevierhealth.com/ev...replan_030.php
    4. risk for infection r/t [tissue trauma, multiple vaginal examinations, prolonged rupture of membranes] http://www1.us.elsevierhealth.com/me...ex.cfm?plan=32 http://www1.us.elsevierhealth.com/ev...replan_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/me...ex.cfm?plan=13 http://www1.us.elsevierhealth.com/ev...replan_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!
  10. Visit  minky84 profile page
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    I was wondering if any NANDA can be used as a risk for. I have a patient that is at risk for ineffective breathing pattern because of all the morphine he's on, but he's not there yet. Any thoughts?Thanks

    Bren
  11. Visit  Daytonite profile page
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    Quote from minky84
    I was wondering if any NANDA can be used as a risk for. I have a patient that is at risk for ineffective breathing pattern because of all the morphine he's on, but he's not there yet. Any thoughts?Thanks

    Bren
    Yes, you can do this.
  12. Visit  ishy25 profile page
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    ei guyst his is my first time to make a nsg. dianosis im not quite sure if i made this right, and im have a hard time formulating goals (SHORT TERM OR LONG TERM GOALS) anyways im making 3 care plans for an 1YR OLD boy who has a acute gatritis
    here are my diagnosis

    deficient fluid volume related to intake insufficient to replace fluid loss as evidenced by vomting.

    constipation related to poor eating habits as evedinced by lack of food intake.

    imbalanced nutrtion less than body requirements related to loss of appetite as evedinced by poor intake of nutritious food


    hmmm..im really having a hard time formulating the short and long term goals if this could you give me some??..thx.
  13. Visit  Daytonite profile page
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    Quote from ishy25
    ei guyst his is my first time to make a nsg. dianosis im not quite sure if i made this right, and im have a hard time formulating goals (short term or long term goals) anyways im making 3 care plans for an 1yr old boy who has a acute gatritis
    here are my diagnosis

    deficient fluid volume related to intake insufficient to replace fluid loss as evidenced by vomting.

    constipation related to poor eating habits as evedinced by lack of food intake.

    imbalanced nutrtion less than body requirements related to loss of appetite as evedinced by poor intake of nutritious food


    hmmm..im really having a hard time formulating the short and long term goals if this could you give me some??..thx.
    i wrote a couple of posts about goals on another sticky thread about careplans on the nursing student assistance forum. here is a link: http://allnurses.com/forums/f205/des...ns-170689.html. you need to read some of the information on that thread.

    first of all you've got a couple of problems with your nursing diagnostic statements that have to be fixed. your nursing diagnosis statements needs to follow this format: pes where p=the patient's problem (it's also the nursing diagnosis), e=etiology, or what is causing the patient's problem, and s=symptoms. i don't know what kind of reference books you are using in the philippines in helping you to write these nursing diagnoses, but nanda (north american nursing diagnosis association) publications are very clear in listing what each of these pes things are in order to give nurses a guide when they are first learning to put nursing diagnoses together.

    deficient fluid volume related to intake insufficient to replace fluid loss as evidenced by vomiting. if i break this nursing diagnosis down, this is what i get:
    • p (problem) = deficient fluid volume (definition: decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium.)
    • e (etiology) = intake insufficient to replace fluid loss
    • s (symptoms) = vomiting

    so this patient is dehydrated. the dehydration is due to a loss of fluid volume or you shouldn't be using this diagnosis. so, "active fluid volume loss" should be the etiology part of this nursing diagnosis. what are the symptoms of dehydration? dry mucous membranes, poor skin turgor, decreased pulse volume, decreased blood pressure, thirst, decreased urine output, darkly colored concentrated urine, weakness, a fever, confusion and an elevated hematocrit level. does this patient have any of those symptoms? if so, those are the things that should be listed after the words "as evidenced by". vomiting is not a symptom of dehydration, but it could be an etiology. your goals for this patient would then be things that match up with the etiology and the symptoms.
    so your nursing diagnosis should look more like this, deficient fluid volume related to active fluid volume loss as evidenced by dry mucous membranes, poor skin turgor, decreased pulse volume, decreased blood pressure, thirst, decreased urine output, darkly colored concentrated urine, weakness, a fever, confusion and an elevated hematocrit level. long term goal: by discharge the patient's urine will return to light yellow or straw color and will be wetting 10 diapers in a 24 hour period. short term goal: within 24 hours the patient's blood pressure and temperature will have returned to normal levels. http://www1.us.elsevierhealth.com/me...ex.cfm?plan=21 http://www1.us.elsevierhealth.com/ev...replan_030.php
    constipation related to poor eating habits as evidenced by lack of food intake.
    • p (problem) = constipation (definition: decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.)
    • e (etiology)= poor eating habits
    • s (symptoms) = lack of food intake
    everything is fine here until you get to the symptom part of the statement. what are the symptoms of constipation? can you describe what a constipated stool looks like? lack of food is not a symptom of constipation. symptoms of constipation include things like hard formed stools, hypoactive bowel sounds, nausea, severe flatus, the oozing of liquid stool (not diarrhea), manually being able to feel stool in the rectum with one's finger, anorexia, and abdominal pain. does your patient have any of those symptoms? if not, then you can't use this diagnosis. http://www1.us.elsevierhealth.com/me...ex.cfm?plan=13 http://www1.us.elsevierhealth.com/ev...replan_019.php

    and finally, imbalanced nutrition: less than body requirements related to loss of appetite as evidenced by poor intake of nutritious food.
    • p (problem) = imbalanced nutrition: less than body requirements (definition: intake of nutrients insufficient to meet metabolic needs.)
    • e (etiology) = loss of appetite
    • s (symptoms) = poor intake of nutritious food
    i think your etiology is ok although it's not one that nanda lists. however, "poor intake of nutritious food" pretty much describes what a loss of appetite is and it is not a symptoms that fits with this diagnosis. nanda lists out the symptoms for this diagnosis and you might be surprised to find that many of them are the same ones that are in your other nursing diagnoses: abdominal pain, hyperactive bowel sounds, pale mucous membranes, poor muscle tone, sore mouth and weakness of the muscles of the mouth. imbalanced nutrition: less than body requirements related to loss of appetite as evidenced by lack of food intake. long term goal: by discharge patient will return to a weight of _____. short term goal: in 24 hours patient will eat a diet of ____ calories. http://www1.us.elsevierhealth.com/me...ex.cfm?plan=37 http://www1.us.elsevierhealth.com/ev...replan_049.php

    everything that goes into making up the nursing diagnosis statement is related. the goals are related to the etiologies and the symptoms of the nursing diagnoses. if you are not able to show the relationship between all these factors, then you have either chosen the wrong nursing diagnosis or you don't have enough assessment data in the first place. i strongly suggest that you look at the information that you have about this baby again to see if he/she has any of the symptoms i mentioned. if so, you need to be incorporating those symptoms into the formulation of your nursing diagnoses as i have tried to show you. to use any nursing diagnosis you must have patient symptoms to support using it. without those symptoms you have no direction for your nursing interventions and no way to go with any goals. please read the other thread on care plans that i linked you to above. good luck!
  14. Visit  ishy25 profile page
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    wow!! thank you so much..really helped me a lot...


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