Care Planning Question

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I have a question about care planning... the 'related to' part of the diagnosis statement, can it relate to a medical diagnosis the Dr. made even if I do not observe any symptoms? I have to write and actual and a risk for. I'm thinking I can use it in the risk for, but not the actual. Any help is appreciated :)

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Specializes in med/surg, telemetry, IV therapy, mgmt.

We're not supposed to use medical diagnoses as etiologies (related to) of nursing diagnoses. The exception is to add that the etiology is due to or secondary to the medical disease. For example, Impaired gas exchange R/T alveolar-capillary membranes changes secondary to emphysema AEB abnormal blood gasses and dyspnea.

We cannot write, for example, Risk for Emphysema. With "Risk for" diagnoses you are anticipating nursing problems. A medical disease/condition is not a nursing problem. What are the causes of the medical disease? That is a risk factor you can try to care plan to prevent from getting worse. With "Risk for" diagnoses, the R/T stands for "risk factors" not related factors as in the actual problems.

Your nursing interventions for "Risk for" diagnoses are:

  • strategies to prevent the problem from happening in the first place
  • monitoring for the specific signs and symptoms of this problem
  • reporting any symptoms that do occur to the doctor or other concerned professional

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Thank you for your response. So, to be clear is this wrong: Risk for injury r/t seizure disorder? This is my first one and I am trying to 'get it down.' I have picked a few nursing diagnoses to work with, but I feel like they are dead ends. Like what kind of intervention or goals could one have for someone who is incontinent in diapers and can not get to the bathroom because they can not walk? My goal for the patient clearly cannot be will toilet on own... I feel stuck.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

so, to be clear is this wrong: risk for injury r/t seizure disorder? this is my first one and i am trying to 'get it down.'

yes. reword it as
risk for injury r/t uncontrolled movement (or activity) while convulsing
. see post #8 for some interventions
https://allnurses.com/general-nursing-student/nursing-interventions-290552.html

like what kind of intervention or goals could one have for someone who is incontinent in diapers and can not get to the bathroom because they can not walk? my goal for the patient clearly cannot be will toilet on own...

goals are what you expect will happen as a result of your intervention if they are performed as you have ordered them. what is the problem of someone who is incontinent, in diapers and can't get to the bathroom because they cannot walk? i see several problems and nursing diagnoses there:

the weblinks below each diagnosis include suggestions for interventions and goals. assess the ability the patient does have to know when he does need to toilet. does the patient need any assistive aids such as a raised toilet seat, walker, safety rails, etc? set up a toileting schedule for the staff to follow with the patient such as checking the patient frequently, perhaps every hour, and assist him to the bathroom if he needs to go. praise him when he is continent. if getting to the bathroom at times is difficult, obtain a bedside commode and provide privacy. keep the call bell in reach so the patient can call for assistance to toilet. do you want this patient to be drinking a lot of fluids after a certain hour in the evening? they'll be peeing all night. if they were using a bedpan at night would they be more inclined to empty their bladder lying down using a bedpan or getting up to the bathroom and sitting up on a toilet? don't you also want to do good skin care, especially if you find them incontinent? these are all interventions and i am sure many of them are in your textbooks somewhere.

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