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

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?

[Daytonite, BSN, RN]

nursey23 said:

Hello guys.. I hope I can get some help regarding the diagnosis of my assigned situation. I have the NANDA book but this is the first time I'm making a care plan and I am not certain which problem should be diagnosed/focused first.

The situation goes like : patient is a female, admitted from a mva. Her bf who was with her died in the accident. When you, the nurse attended to her, you noticed that both her legs were in a cast. She won't talk to anyone or eat anything.

Thanks guys ?

You need to review the information on this thread on allnurses:

I wrote two rather lengthy posts today to questions on how to write care plans. I would just be repeating the information. Please read these threads:

After reading this information, if you are still having trouble, ask a specific question and post it in it's own thread on the student assistance forum (https://allnurses.com/general-students-c38/).

[arual56]

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!!

If you ask at your local bookstore or Med school book store, they should have "Sparks and Taylor's Nursing Diagnosis Cards." These are cards, separated by diagnosis that give you easily accessible Nursing Diagnosis. They are not very expensive, a lot less than the books, and are much easier to work with in my opinion.

[Pbe]

Sorry RNinJune2007. That part of class thru me too but I always tried to do one part at a time. I think that stressgal has the best examples to go by but I do understand you when you say that's all good until you have to do it yourself. Try to get the first part before you start thinking about the second part. Just break it down a little at a time.........Good Luck!

[nursing twin, CNA]

I was required to buy Nursing Diagnosis Handbook by Ackely and Ladwig seventh edition and it's great for diagnosis b/c say your person has a hip fracture...You just go to that hip fx in the beginning and it will give you a list of potential diagnosis for that condition. Then I prioritize what is most important for that patient. Remember abc's these should be a top priority. Did that person complain of their pain all shift and rate it high? Then I would give acute pain r/t injury as manifested by pt reports pain 8/10. My instructor would ask us to give one diagnosis we think is important and one the patient thinks is important. I think it's helpful to consider what the patient is concerned about because I think we tend to concentrate on our own viewpoint. I don't know what policy your hospital has but we can bring labs and other data home as long as it has no identifiers on it. I usually go to the copy machine and then take scissors to cut the info out. It saves you time from writing down numerical data. I usually go through the nursing notes on that patient and look at their chart to get their past med hx and all that stuff you need to fill out depending on your care plan. I usually have to look at my assessment book and then I use the internet to pull information about a disease, type of surgery or pathopysiology quickly. It takes a lot of time for a good care plan so spread it out in days if you can. Learn from the feedback your instructor gives you. Lastly I think it's helpful to remember that you need to mention a medical condition throughout your care plan. Say a person had a cardiac issue and you mentioned in their history. Don't forget to say it again in other areas that pertain to it such as assessment...Etc.

[nursing twin, CNA]

Oh yeah forgot to mention cut and paste is your friend. Saving drug info that is used for almost everyone...Ducostate, acetaminophen... Assessment that is normal. My teacher gave me this great advice to save time. We had so many hip fx that were similar.

[Daytonite, BSN, RN]

nursing twin said:

I don't know what policy your hospital has but we can bring labs and other data home as long as it has no identifiers on it. I usually go to the copy machine and then take scissors to cut the info out. It saves you time from writing down numerical data. I usually go through the nursing notes on that patient and look at their chart to get their past med hx and all that stuff you need to fill out depending on your care plan. I usually have to look at my assessment book and then I use the internet to pull information about a disease, type of surgery or pathopysiology quickly. It takes a lot of time for a good care plan so spread it out in days if you can.

This pretty much describes step #1, the process of assessment, when putting together a care plan. All the information is the foundation that is needed to put together the nursing diagnosis, outcomes and interventions. This past week another student asked what information they should be collecting from their patient's charts. I gave a very lengthy reply based on information from a number of resources since there seems to be some confusion about what actually constitutes assessment data. You can find that information on this thread on post #5 on the nursing student assistance forum:

[tinesia]

Boy careplans careplans, I know I had such a difficult time with those I do remember my instructor saying that you may not always have AEB or AMB because the Dx may be risk for or potential for so the patient may not be showing evidence/manifestations of the issue. For example the dx may be Risk for infection r/t invasive procedure, decreased immune response etc, etc, however if it was an Actual infection r/t invasive procedures, decreased immune response AEB diarrhea, increased WBC count of #, positive bacterial culture etc etc.

[Beads4u]

Care plans are exactly that when the patient comes under your care... For example:

Alteration in Comfort: Pain r/t surgical incision as evidenced by pt pain level 8/10 Wong Baker scale

One place that helped me my 1st semester was the following website..

https://www.rncentral.com/nursing-library/careplans/

[mahaljea]

Wow... Awesome. I got new ideas from here... By the way I'm a 4th year nursing student from Philippines... I really love the links you shared... GOD bless us all.

[Texas-teacher, APRN]

Thanks for the resource! I teach freshmen RN students adn am ALWAYS looking for nre resources for them. They will be grateful!

[cutegurl]

Anyone there who could help me to make a care plans about threatened abortion and lady partsl bleeding. I don't have any references. I really need help because tomorrow is my deadline to submit it.

[Daytonite, BSN, RN]

cutegurl said:

Anyone there who could help me to make a care plans about threatened abortion and lady partsl bleeding. I don't have any references. I really need help because tomorrow is my deadline to submit it.

The steps of a care plan are as follows:

The Steps of the Nursing Process (Written Care Plan)

1. Assessment (collect data)

2. Nursing diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)

3. Planning (write measurable goals/outcomes and nursing interventions)

4. Implementation (initiate the care plan)

5. Evaluation (determine if goals/outcomes have been met)

For the assessment of a patient with lady partsl bleeding and threatened abortion you would look for the following signs and symptoms:

• A history of:

  • pelvic inflammatory disease
  • gonorrhea
  • muliparity
  • maternal age over 35
  • previous cesarean sections
  • previous history of abortions, d&cs, cervical conization
  • infertility and use of reproductive techniques or medications
  • multiple gestation (twins, triplets, etc.)

• hypertension or hypotension
• urine is positive for protein
• elevated wbc
• low hemoglobin and hematocrit levels
• sudden decline in estrogen and progesterone levels (with spontaneous abortion)
• low hcg titer (in ectopic pregnancies)
• pallor, cold, clammy, skin
• faintness
• syncope
• dizziness
• anxiety, apprehension, fear
• nausea and/or vomiting
• abdominal pain, colicky abdominal pain, one-sided abdominal pain (as in a tubal rupture)

• time of conception (4-5 weeks after conception may indicate the possibility of an ectopic pregnancy)

• tachycardia

• delayed capillary refill

• hypothermia

• abnormal labs
  • urine is positive for protein
  • elevated wbc
  • low hemoglobin and hematocrit levels
  • sudden decline in estrogen and progesterone levels (with spontaneous abortion)
  • low hcg titer (in ectopic pregnancies)

Your nursing diagnosis is determined by the presence of any of the above abnormal signs or symptoms (and any others you might have found during your assessment). However, some ideas for nursing diagnoses would include:

• deficient fluid volume

• ineffective tissue perfusion, uteroplacental

• fear

• acute pain

• knowledge deficit, learning need

• risk for maternal injury

In the planning step you develop your nursing interventions and goals for the patient. Your interventions are always directed toward the symptoms the patient is having as determined from your assessment. In general, your goals will reflect what your nursing interventions are and will be centered around:

• maintaining the patient's circulating volume of fluid

• assisting with the efforts to sustain the pregnancy if it is possible

• to prevent complications

• to provide emotional support to the patient/couple

• provide information about short and long term implications of the hemorrhage

Those first three steps are the major part of the care plan. The last two are based upon how the care plan works and your evaluation of it and reformulation of interventions and goals. Steps 4 and 5 are ongoing.

You should be able to find references for all the above in an ob textbook and/or by looking up the following conditions in a textbook or on the internet: spontaneous abortion, ectopic pregnancy, hydatidiform mole (gestational trophoblastic disease), placenta previa and abruptio placentae.