Care plan "aeb" same as objective/subjective ??

[StudentNurzNK]

With my care plans for class, I have to make a diagnosis statement, then list subjective and objective signs of statement. I have noticed lately that I have been repetitive, and am wondering if I am missing something. Example, my plan is for "excess fluid volume r/t impaired kidney function aeb ascites, edema and oliguria". The signs I am listing are "ascites in abd., pitting edema in lower extremities, oliguria, low HCT and HGB, elevated BUN and elevated BP". I think I am doing something wrong with the "as evidenced by" part. Is it supposed to be basically the same thing as your signs? If so, how do you pick out only one or two...just going by most important? Not all of mine have ended up this way, but I am wondering if it is ok f I do it this way? Thanks soooo much for any input!

[Daytonite, BSN, RN]

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

• problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
  
• etiology - also called the related factor by nanda. this is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. ask yourself "why did this happen?" or "how did this problem come about?" "what caused this to become a problem in the first place?" and dig deep. consider the medical diagnosis, the medical treatments that were ordered and the patient's ability to perform their adls. pathophysiologies need to be examined to find these etiologies if they are of a physiologic origin. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
  
• symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.
  

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the symptoms can be objective and subjective. i don't understand what you mean by repetitive and why this bothers you. if person a has pneumonia and has a productive cough, rapid, shallow respirations, chills, headache, fever, dyspnea, decreased breath sounds, crackles and rhonchi, and tachycardia and person b who also has pneumonia has the exact same symptoms, so what? the doctor is still going to document all of them on both charts and call it pneumonia for both of them. the same applies to nursing diagnoses. if your patients have similar symptoms that fit the diagnosis of excess fluid volume, so be it. document it and apply the diagnosis and its symptoms to both patients.

i think i am doing something wrong with the "as evidenced by" part. is it supposed to be basically the same thing as your signs?

yes. the signs and symptoms, or abnormal assessment data that you link to a particular nursing problem (nursing diagnosis) are proof that the problem exists.

how do you pick out only one or two...just going by most important?

why does it only have to be one or two? i'd list all the signs and symptoms of the problem the patient has. you know why? because your care plan will probably involve treating each of them. if you had to pick only one or two, use maslow and pick the ones that if they go untreated are going to cause the worst damage to the patient.

[CRIMSON]

AEB is the symptoms (subj/obj) you are citing as backup for the problem (r/t)