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]

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.

[cutegurl]

Hello daytonite! Thank you very much for helping me. I owe you a lot. You're so kind. You make it easier for me to make a Care plans.

[prettynpink00029, LPN]

cardiacRN2006 said:

We use AMB-as maniested by..

I love that link. I never had problems with making care plans, but that website practically does it for you!!!! Awesome!

Could you provide me with the link to the AMB you are speaking of..thanks for any and all our help!!

[Orangeapple]

I am in my third year of nursing school and I completely understand how you feel...I bought a book called "Nursing Care Plans" by: Gulanick/Myers. 6th Edition at Barnes and Nobles. This book saved my life last semester. It gives you all the rationales and everything. I would recommend it to anyone.. Good Luck

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!!

[ari3sdog]

Formula

symptoms + disease = evidence

For example...

SOB (symptoms) r/t asthma (disease) as evidence by respiratory 30 breathes per minute (evidence)

Remember that we can't diagnose. That's why it's not Asthma r/t SOB. Asthma can be only diagnose by the physician. SOB is nursing diagnose because you have evidence to prove it (respiratory 30 breathes per minute)

You should buy a nursing care plan and practice how to use it...

I know this forum is old. I just wanted to post at least 15 in order for me to get in the chat room. LOL

[pancha]

Hi Elk. I'm a nursing student and I would really appreciate it if I could take a peek at those mini maps and dx. Thanks alot...........

[Daytonite, BSN, RN]

Hi, pancha and welcome to allnurses!

There are links to samples of minimaps that are posted into allnurses threads listed on the posts of this thread on another student nurse forum of allnurses:

[lpn2rnstudent, LPN, RN]

I need some help!!

I had a complex patient that I am attempting to do a brief care plan on. My instructor wants 2 nursing diagnoses. My patient presented with Acute MI, with a hx of previous MI and severe LV dysfunction. My pt. developed HIT while in the hospital and also has CRF requiring HD 3x/week.

I chose my first nursing dx as:

Quote

Decreased cardiac output r/t altered heart rate and rhythm as evidenced by dyspnea with exertion, + 2 pitting edema in bilateral lower extremities, and crackles in the bases of the lungs bilaterally.

I cannot decide which to proceed with when doing my next nursing dx. According to maslow the first physiological need is o2- which would include circulation and obviously my patients hit status has put her at risk for injury. Yet elimination is right up there at the top of the list and my patient has crf. I would assume that the real issues would take priority over the issues of which my patient is at risk right?

Oh my, I have been out of lpn school for over 10 years and I feel over my head!!

If I were to go with renal failure do you all feel that the nursing dx:

Quote

Impaired urinary elimination r/t effects of disease, need for dialysis aeb azotemia et anuria.

Would work?

Thanks so much in advance.

[Daytonite, BSN, RN]

Any nursing diagnosis you use is always based upon the symptoms (abnormal assessment data, defining characteristics) your patient has, not necessarily upon their medical diagnoses. Renal failure is not a nursing diagnosis, but the symptoms of it can be used to help you determine a nursing diagnosis, the most common being fluid volume excess. You need to go to a textbook and read up on crf. These patients have many long-term problems that include anemia, peripheral neuropathies, platelet dysfunctions (patient already has hit as well!), pulmonary edema, and electrolyte imbalances. They usually require special diets and fluid restrictions. Look at the medications this patient is receiving as well to get an idea of some of the problems the physician is already addressing that he hasn't formally listed in his h&p. Nutrition and fluid are big nursing problems in renal patients, so is tissue perfusion to the kidneys (which is why they are in renal failure in the first place). They are at risk for infection and injury. This patient is at risk for hemorrhage.

You need to go through your assessment of this patient again and list out the things you found that were abnormal. Those are the defining characteristics that will determine which nursing diagnoses you use. And, you are correct. Actual problems always take precedence over anticipated ("Risk for") problems.

You might also want to look at

I can't give you much more help without your having listed any specific symptoms (abnormal assessment data, defining characteristic) this patient has.

[danggirl]

Yes a good careplan book would help but as you get out into the work force all facilities have different ways they want you to write them. For school, I'm assuming it is stll the same old stuff. So you have a list of potential diagnosis Altered nutrition, Impaired Mobility, Alteration in fluid balance....pick one that states the person's problem. Then ask WHAT is causing this problem the R/T poor po intake, use of one leg, intractable vomiting. Then AEB (how know it) decline from baseline weight, unsteady gait, or decreased urine output greater than po intake.

Basically it it WHAT the problem is in general

then related to WHAT is causing the problem

then AEB HOW you know.

Go to your local hospital and see if they have any pre-printed careplan cards or see how they developed them online. Good luck to you.

[Daytonite, BSN, RN]

Nursing diagnosis is based upon the assessment of the patient that you do. This is part of the nursing process. The process of a nurse determining a nursing diagnosis is no different than the process a doctor uses to determine a medical diagnosis or that a plumber uses to figure out why your plumbing isn't working correctly. What is different is that each nursing diagnosis has a set of criteria that the patient must have in order for a nurse to say "This patient has xxx nursing diagnosis". Each medical diagnosis has a defined set of criteria that the patient must meet before the doctor can put that medical diagnosis on the patient. The criteria for most nursing diagnoses has been defined by NANDA, the north american nursing diagnosis association. Some nursing schools have come up with their own nursing diagnoses and the criteria that define them; they instruct their students to use them instead of the NANDA diagnoses. There is no guesswork here. There is a specific process (the nursing process) involved in choosing nursing diagnoses for your patients and using them to plan the patient's goals and care. This concept is written about in the first pages of every single care plan book on the market. Please take time to read those few pages to understand how the nursing process is put into action to diagnose.

Please note this definition of the words diagnosis and criteria:

Diagnosis: the resulting decision or opinion after the process of examination or investigation of the facts

Criteria: Standards, rules or tests by which a judgment of something is made

[shannonFNP, BSN, MSN, RN]

I totally recommend this book called Nursing Diagnosis Handbook by Judith m. Wilkinson. It is fabulous!!! It has a complete NANDA approved nursing diagnosis list. You can look them in the index to find the page. Under each diagnosis it gives you the 1. Defining characteristics, 2. Related factors, 3. Suggestions for use, 4. Suggested alternative diagnoses, 5. Noc outcomes, 6. Goals/evaluation criteria, 7. Nic interventions, and 8. Nursing activities.

You can also look up the possible diagnosis' by condition such as "Dying patient" or "Chest trauma."

I love this book soooooo much! I'm a beginnning nursing student, so this book is like a bible to me.