Care Plans Help Please! (with the R\T and AEB)

What Members Are Saying (AI-Generated Summary)

Members are discussing how to create a nursing care plan for a complex patient with Acute MI, previous MI, severe LV dysfunction, HIT, and CRF requiring HD. They are debating the prioritization of nursing diagnoses based on patient symptoms and assessment data, emphasizing the importance of using defining characteristics to determine appropriate diagnoses. Recommendations for nursing diagnosis resources, such as the Nursing Diagnosis Handbook, are also shared among members.

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?

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.

Specializes in teaching, research, and evidence-based practice.

This is what I used to tell my students and it always seemed to help:

The "related to" is typically the pathophysiology of the medical diagnosis. So, for example, a patient with chronic kidney disease, the medical diagnosis, might have a nursing diagnosis of "Fluid Volume Overload." This is because they have a decreased glomerular filtration rate (among other things, but I'm keeping it simple for example). So, the statement would be "Fluid Volume Overload r/t decreased glomerular filtration rate."

Your "as evidenced by" would be the manifestations (or symptoms) of having a decreased glomerular filtration rate. For example, "2+ pitting edema in bilateral lower extremities."

So, putting it all together, your statement would be:

"Fluid Volume overload r/t decreased glomerular filtration rate AEB 2+ pitting edema in bilateral lower extremities."

Nursing diagnosis statements are a way to identify problems and intervene within the nursing scope of practice without making a medical diagnosis. Nurses understand the pathophysiology of medical conditions, but it is not in our scope to diagnose. We can, however, recognize signs and symptoms of medical conditions and provide nursing interventions based on our assessment. In this case, nursing interventions to treat the edema might be:

  • Elevating the lower extremities
  • Monitoring intake and output
  • Assessing the edema (increasing or decreasing?)
  • Administering Lasix per orders

So, when you catch yourself stating something like "related to congestive heart failure," which is a medical diagnosis, convert it to the pathophysiology of that particular medical diagnosis like "related to impaired pumping ability of the heart" or something along those lines.

Hope this helps!

+ Join the Discussion