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 Infection Preventionist/ Occ Health.

I am writing a care plan and I would like some help. I have my three nursing diagnoses:

Activity Intolerance related to impaired oxygen intake/ transport secondary to diminished red blood cell count and chronic obstructive pulmonary disease

Risk for injury related to inconsistent use of assistive device- cane and related to altered cerebral function secondary to tissue hypoxia

Risk for infection related to compromised host defenses secondary to immunosuppressive medication therapy

We have to choose a priority diagnosis and work it up. I was thinking of choosing the activity intolerance (because it has to do with the airway, and that is always the priority). Am I thinking about this correctly?

Thanks in advance ?

RNinJune2007 said:
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 when we're left on our own, it's extremely difficult to know where to start!

It will be 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??

Thanks in advance!!

Hey - I am currently a pn student - level 3 out 4 - hoping to graduate 12/06! I've been through nsg process class, and, you are absolutely right! Care plans are tough! My whole class agrees - it seems so easy and makes perfect sense while the teacher is explaining it in class, but once you get home and try to come up with stuff on your own! Good luck! Your med/surg book is a good source for ideas...So is www.Careplans.Com (for examples) we were never given an actual care plan book, but we do have the textbook called Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales. It's good to use if you need NANDA dx! I have found that when coming up with a care plan it is always good to know the med dx and its pathophysiology. That way, you have a better understanding of your pts needs. Ex: med dx: 3rd degree burn. If you know patho of burns, you will know that pt suffers from fluid loss (fluid volume, deficient), pain, is at risk for infection, impaired skin integrity, possible smoke inhalation (airway, ineffective), etc. Then think of your interventions (what you can do for your pt) and why you would do this ex: encourage fluid intake if possible, or iv fluids if NPO (to replace fluids & electrolytes), monitor strict I&0 with urinary outputs q2h (ensure fluid balance), etc. Then you want to set your goals in a timely manner (pt will report 50% reduction in pain w/I 8hrs) and monitor your pt closely and eval pt and yourself to make sure your goals were met. Is pt able to rest w/o pain during my shift? Sounds like a lot, and it is hard (I'm still struggling) but I'm sure you'll get through it! Don't overthink it or you'll just hurt yourself! Lol!

Hello,

Are careplans different for Rn's and LPN's? I'm done with mine (thank-you GOD), ya'll's sound completely different than ours were. A LOT more complicated. We couldn't use actual medical Dx on ours. We had to use nursing Dx only. For instance one of mine was "Airway clearance ineffective R/T retained secretions". Your goal is ALWAYS opposite your problem. "Pt. Will maintain patent airway AEB breath sounds clear/clearing".

BSNDec06 said:
I am writing a care plan and I would like some help. I have my three nursing diagnoses:

Activity Intolerance related to impaired oxygen intake/ transport secondary to diminished red blood cell count and chronic obstructive pulmonary disease

Risk for injury related to inconsistent use of assistive device- cane and related to altered cerebral function secondary to tissue hypoxia

Risk for infection related to compromised host defenses secondary to immunosuppressive medication therapy

We have to choose a priority diagnosis and work it up. I was thinking of choosing the activity intolerance (because it has to do with the airway, and that is always the priority). Am I thinking about this correctly?

Thanks in advance ?

Go back to the basics. Check for ABCP (airway, breathing, circulation, pain.) I would put impaired 02 intake 1st, then risk for Infection, then risk for injury. But I see a whole different set of problems just on what you wrote. Hope this helps. Donna

LadyStar42 said:
Go back to the basics. Check for ABCP (airway, breathing, circulation, pain.) I would put impaired 02 intake 1st, then risk for Infection, then risk for injury. But I see a whole different set of problems just on what you wrote. Hope this helps. Donna

Hi - I'm a student lpn - hoping to graduate 12/2006...I agree with your prioritizing - I would definitely stick to impaired o2 first, (ABCP) - I can think of a bunch of other nsg dx's along with interventions and goal before I would worry about activity intolerance...airway is always 1st!

LadyStar42 said:

Hello,

Are careplans different for Rn's and LPN's? I'm done with mine (thank-you GOD), ya'll's sound completely different than ours were. A LOT more complicated. We couldn't use actual medical Dx on ours. We had to use nursing Dx only. For instance one of mine was "Airway clearance ineffective R/T retained secretions". Your goal is ALWAYS opposite your problem. "Pt. Will maintain patent airway AEB breath sounds clear/clearing".

I'm a student lpn - from what I understand, care plans are the same for all nurses. I think it's just maybe where you're at, which facility you work for and what their policies are as to how your plan is worded. We were taught to think of it as an exact recipe for other nurses who come after us on the next shift to follow (by listing interventions and evaluations write in the care plan) (Ex. Keep pts head elevated at least 30 degrees while in bed, Check Pulse Ox q4hrs & PRN, Suction q4hrs & PRN, O2 at 2L, If O2 sat >95% remove O2...etc.) Where I'm at, in Wilkes-Barre, PA, we were taught to use AEB in our nsg dx as well (Ex: Airway clearance ineffective R/T retained secretions AEB gurgling breath sounds), whereas you are writing your AEB in your goal, which I agree makes a whole lotta sense! As for the Med dx, no, we are not allowed to use it in our care plans either, except for maybe as the R/T section (Ex: Gas exchange impaired R/T COPD AEB continuous O2 sats reading below 90%). But I believe that keeping the med dx in the back of your head and understanding it's patho, it really helps you to know your pts needs and meet your goals.

Thanks to you 2, for suggesting that your goal is always opposite your prob! I just never thought of it that way! This thinking will definitely come in handy! In school, we have to write a care plan for every pt we see while on clinical rotation!

For your care plans for school, do you also have to have short-term and long term goal? (Ex: short-term: Pt will maintain patent airway by the end of my shift (8 hrs) AEB breath sounds clearing...long-term Pt will continue to maintain patent airway by time of pts D/C from facility AEB...) Or are my teachers just sticklers for details?

I purchased "Nursing Diagnosis cards" They are put out by lippincott. ISBN#1-58255-218-5. They have everything on them by diagnosis, including r/t, aeb, outcomes, ect...Made my life livable when I had a care plan to write!

kdeclet said:

I'm a student lpn - from what I understand, care plans are the same for all nurses. I think it's just maybe where you're at, which facility you work for and what their policies are as to how your plan is worded. We were taught to think of it as an exact recipe for other nurses who come after us on the next shift to follow (by listing interventions and evaluations write in the care plan) (Ex. Keep pts head elevated at least 30 degrees while in bed, Check Pulse Ox q4hrs & PRN, Suction q4hrs & PRN, O2 at 2L, If O2 sat >95% remove O2...etc.) Where I'm at, in Wilkes-Barre, PA, we were taught to use AEB in our nsg dx as well (Ex: Airway clearance ineffective R/T retained secretions AEB gurgling breath sounds), whereas you are writing your AEB in your goal, which I agree makes a whole lotta sense! As for the Med dx, no, we are not allowed to use it in our care plans either, except for maybe as the R/T section (Ex: Gas exchange impaired R/T COPD AEB continuous O2 sats reading below 90%). But I believe that keeping the med dx in the back of your head and understanding it's patho, it really helps you to know your pts needs and meet your goals.

Thanks to you 2, for suggesting that your goal is always opposite your prob! I just never thought of it that way! This thinking will definitely come in handy! In school, we have to write a care plan for every pt we see while on clinical rotation!

For your care plans for school, do you also have to have short-term and long term goal? (Ex: short-term: Pt will maintain patent airway by the end of my shift (8 hrs) AEB breath sounds clearing...long-term Pt will continue to maintain patent airway by time of pts D/C from facility AEB...) Or are my teachers just sticklers for details?

We have to do most of that stuff as well. We are not allowed to use MDdx at all, but I agree that you need to keep it in mind. We do not do the short term goal, they are all long term as in, what should the goal be before d/c?

I had one teacher (one only) who told me that our goal is always opposite. She said that the goal should be the last thing that we do so that we can make sure it is the opposite of the problem.

? I think your teachers may be sticklers for details. I had one like that, in my goal it Always had to start with "Pt. will" whatever....drove me nuts. She was the only one who wanted it that way. A lot of the careplan grade is teacher preference.

Specializes in PICU, NICU, Peds LTC, Case Management.

I have the "Nursing Diagnosis" manual by Carpenito-Moyet. It pretty much spells it out for you- I absolutely love it! It's pretty simple- let's say your patient is constipated... so you look up Constipation in the table of contents... this book gives you the assessment data your patient should be manifesting in order to consider it constipation... then it gives you your "R/T" options like immobility, effects of medications, etc. The "AEB" is pretty much your assessment data stated all over again.

An easy way to remember it is...

1)Decide if this need is ACTUAL or RISK FOR

2)Write Actual/Risk for _____ [insert need here]

3)Think of a way to word the client's R/T without using a MEDICAL diagnosis, such as "Diabetes" or "Congestive Heart Failure." In my program, we are allowed to use a medical diagnosis only in this form: "R/T ineffective circulation secondary to diabetes" The "secondary to" is a great way to make your diagnosis sound really smart :)

4)Decide what assessment data best reflects your need and put that as your AEB. My program requires that we use at least 3 pieces of data.

Hope this helps!

Hi everyone, I just wanted to thank you all again for the help. This is my first care plan. Quick version: A 20 yr old in traction for 3 weeks on bed rest.

My first diagnosis is Impaired tissue integrity/ or would skin sound better.

I was wondering if related to surgical procedure is ok??

And AEB- presence of incision..... (I'm confused on what manifestations I should use for a surgical incision)

I just really need to get a good understanding. I'm going to sit down with some books tonight after I put my baby to bed.

ELKMNin06 said:
Welcome guys:)

We are doing "mini mind maps" but basically the same thing as a care plan....

I have several saved on my computer if anyone is interested, the few dxs I can think of off the top of my head are:

Gastric bypass

Total knee replacement

Metatastic cancer..or cancer

Intestinal blockage

So if anyone wants to see the care plans/mini mind maps I have for those just let me know:)

Can you share it to me... I'm doing care plans most of the time now..Thanks ndc2006

Specializes in Education, Acute, Med/Surg, Tele, etc.

Like I tell my students when I have them, I don't go from forward to back on my Nanda's but backwards to forwards.

I think...okay what is the problem as I see it (and remember, just ONE problem at a time). SO in my brain I say..hmmmm I am worried about skin, and the fact the pts buttocks are getting red.

Okay good...now were on onto something..what did I do or what do I want to do? Okay get them off the area, turn frequently, have it checked every shift, use pillows and bed position changes to float the area, and even request a air bed. Okay COOL...I have my implementations already, and I will know if they work by less redness and no breakdown...WOW, got my evaluation/goals of care!

Now I work backwards...Got my implementations and evaluation so lets fill in the gaps. This person has a red buttock area...okay that is my as evidenced by! "Presence of warm moist reddened bilateral buttock areas" COOL got my AEB! Two more steps to fill in!

Related to..hmmmm why is this happening...of course, mobility is bed bound...easy! So now one step left....hit the Nanda Dx's and find one that fits!!!!!! Impaired Skin Integrity! Perfect! Now lets take all this and move it all forward....

Impaired skin integrity r/t decreased mobility (bed bound), AEB moist warm reddened areas on bilateral buttocks. Implementation: turn pt q 1-2 hours, use of pillows to float the area as much as possible, monitor skin q shift and alert wound care PRN, discuss use of air mattress with the MD. Evaluation/Goals: Pt will have lessening of redness on bilateral buttocks and keep intact skin.

I find if you go backwards things seem a little to the point better then trying to fill in the gaps from front to last! Break it down...what did you see (that will typically be your first thing but will be you AEB), what do you want to do (Implementations), how do you know it works (evaluation), Why is this happening (keep it simple...remember one problem at a time per NANDA dx and that is you r/t), and find a NANDA dx! Then fit it all in :).

I have taught this to students and had them ace care plans! Heck, I could have also gone dietary on this one, but that would be a whole new nanda care plan as it should be...only address on simple problem at a time, and keep it simple...simple breaks things down into workable things that you actually can achieve in your evaluation/goal area!

Good luck and feel free to ask me questions on it...gotta find my old NANDA book! LOL!

+ Add a Comment