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?

Specializes in med/surg, telemetry, IV therapy, mgmt.
yabyosh said:

Hi please help me on my case... Please give me pathophy of myelomeningocele secondary to hydrocephalus..... please...... send me private message....

Hi, yabyosh, and welcome to allnurses!

I am posting this so that all members of allnurses can benefit from the information.

Myelomeningocele is one of three major types of spinal cord defects. In myelomeningocele (spinal bifida cystica), an external sac contains meninges, cerebrospinal fluid, and a portion of the spinal cord or nerve roots. Hydrocephalus is a complication of the myelomenigocele and occurs in 85% of the infants who have a spinal cord defects (page 597, Pathophysiology: the Biologic Basis for Disease in Adults and Children, third edition, by Kathryn l. Mccance and Sue E. Heuther).

From Pathophysiology: a 2-in-1 Reference for Nurses by Springhouse, page 135 on spina bifida:

"Neural tube closure normally occurs at 24 days gestation in the cranial region and continues distally, with closure of the lumbar regions by 28 days. . .

In more severe forms of spina bifida, however, incomplete closure of one or more vertebrae causes protrusion of the spinal contents in an external sac or cystic lesion (spina bifida cystica). Spina bifida cystica has two classifications: Myelomeningocele (meningomyelocele) and menigocele.

In meylomenigocele, the external sac contains meninges, cerebrospinal fluid (csf), and a protion of the spinal cord or nerve roots distal to the conus medullaris. When the spinal nerve roots end at the sac, motor and sensory functions below the sac are terminated.
In meningocele, less severe than myelomeningocele, the sac contains only meninges and csf. Meningocele may produce no neurologic symptoms."

From Pathophysiology: the Biologic Basis for Disease in Adults and Children, third edition, by Kathryn l. Mccance and Sue E. Heuther, page 493 on the pathophysiology of hydrocephalus:

"The obstruction of csf flow associated with hydrocephalus produces dilation of the ventricles proximal to the obstruction. Obstructed csf is under pressure, causing atrophy of the cerebral cortex and degeneration of the white matter tracts. There is selective preservation of gray matter. When excess csf fills a defect caused by atrophy, a degenerative disorder, or a surgical excision, this fluid is not under pressure; therefore atrophy and degenerative changes are not induced."

Links to articles on this that have some very good information including pathophysiology are:

I have a patient a 63 years old woman conscious, coherent, cold and clammy, with a temperature of 95 deg.F. She had a foley catheter in place with concentrated urine of 25cc per hour, and an iv of 5% dextrose in water. Her lips were cracked and her skin was dry and scaling. She has a pneumonia and she had already been in the hospital for 9 days. She also refused to eat for the past 2 days and had not a bowel movement for 5 days. Can somebody help me to make a nursing care plan for this problem? I'm really having a hard time to make a ncp for this one. Thanks.

Specializes in LPN presently trying to pass the nclex.

Need nursing care plan for a patient with pregnancy induced hypertension.

Specializes in med/surg, telemetry, IV therapy, mgmt.
malex107 said:
Need nursing care plan for a patient with pregnancy induced hypertension.

You will not find one on the internet or allnurses to copy. Besides, that would be plagiarism. Begin by investigating the causes and pathophysiology of hypertension in pregnancy. The nursing problems (nursing diagnoses) will be based upon the symptoms that the patient gets. For more direction in how to go about constructing the care plan, see this thread:

This thread has weblinks to ob websites:

Could you please share your care plan/mini maps?

Thanks Beth

We had to buy a book called "Careplans Made Easy" and it lists all NANDA approved nursing diagnoses, their implications, and when you would use them. Remember from lecture that a risk for nursing diagnosis has two parts (the diagnosis and r/t, which stands for related to) a risk for diagnosis does not have AEB- as evidenced by- because it is a risk and is not currently happening. For example, risk for imbalanced nutrition r/t decreased LOC following trauma. Also recall that an actual diagnosis has three parts, the diagnosis itself, r/t, and AEB. The actual nursing diagnosis has these three parts because it is actually occurring. An example of this would be acute pain r/t surgical procedure AEB patient writhing in bed and states, "pain is 9/10." When writing a care plan, try to break each portion down. First, find an appropriate diagnosis, then decide what it is related to. Pain, for example, can be related to a lot of things. Pain can be caused by injury, surgical procedure, illness, medical procedures, etc. Once you've figured out the diagnosis and what it is related to, figure out how you know it's occurring. Your signs and symptoms are your AEB. You know your patient is in pain because they are screaming, moaning, writhing in bed, or telling you that they are in pain. Careplans get easier with time, as does picking out nursing diagnoses and phrasing them. Just hang in there and keep practicing.

+ Add a Comment