care plans

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:nurse:I am a transition student and I am having a hard time understanding the "related to" part of the nursing DX. I can usually come up with the Dx but then I'm stumped. Then when I'm doing the rationale the point about getting to the "celllular" level is also foggy. Help please....care planning is not my friend

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what care plan book do you have? mine (Ackley) has the related factors listed with the diagnosis, you just have to pick the one that most appropriate. my last care plan had "hyperthermia r/t illness" and "risk for caregiver role strain r/t increased needs of care receiver" The Ackley book also lists rationales with citations.. it's very useful.

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I'm not really certain what you mean by "cellular level" but your R/T is in your N ANDA book under related factors. For example I am working on a care plan for hyperthermia. The Pt has pneumonia. She cannont thermoregulate because of the medical diagnosis of pneumonia. You can NEVER use a medical diagnosis in your nursing diagnosis, but according to NANDA, illness or dz process is an acceptable Related factor. So my nursing diagnosis is Hyperthermia r/t illness AEB oral temp of 102.3

Does this help????

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I have the same question... but yes it does help, at this point anything is! LOL Thanks!

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I used hypogylcemia R/T insufficient glucose available after birth AEB baby jittery and BS 45

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An example would be

"Risk for Fall" RT decreased circulation ... The related to should be the reason why you made the diagnosis. Why did you pick At risk for fall? Because their circulation is decreased.

Another example:

Ineffective Airway Breathing RT inability to clear secretions.

RT is the rationale for your diagnosis.

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Forgot the rest...

AEB is how you know the rationale.

So..

Risk for Fall RT decreased circulation AEB diminished pedal pulse

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Specializes in Emergency Nursing.

The Related To is ALWAYS something a NURSE can do something about.

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actually, maybe not. if the cause of the nursing assessed-problem is a medical diagnosis, the nurse may not be able to do anything about that. but the nurse can implement any number of nursing interventions (this is called, writing a nursing plan of care) to address it.

example: activity intolerance related to congestive heart failure, as evidenced by dyspnea on exertion. the medical plan of care (diuretics, inotropes, whatever) addresses the chf. meanwhile, you modify her activities to minimize exertion, sit her up to minimize pulmonary congestion, teach her about keeping her o2 on, maximize safety so she won't be tempted to do something like leap out of bed, monitor spo2 with activity and at rest, check h&h so you learn about her oxygen-carrying capacity, watch vs and i&o, all sorts of patient/family teaching stuff .... you get the idea.

it's also important to realize that there are probably a lot of things due to the chf, and you know about them by looking at things nurses assess. this is why a nursing plan of care for chf patient includes so many things. in the above example, a nursing diagnosis could be activity intolerance as evidenced by sob, related to chf, anemia, deconditioning, and/or a host of other things.

the nanda book lists a bazillion choices for what could be causing the symptoms you made your nursing diagnosis from. it's the ultimate cheat sheet for care planning and i don't know why more people don't use it.

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Bump.

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Specializes in LTC, Nursing Management, WCC.
actually, maybe not. if the cause of the nursing assessed-problem is a medical diagnosis, the nurse may not be able to do anything about that. but the nurse can implement any number of nursing interventions (this is called, writing a nursing plan of care) to address it.

example: activity intolerance related to congestive heart failure, as evidenced by dyspnea on exertion.

i would never get away with putting chf as a direct r/t in school. medical diagnosis or complications can be secondary to, so as it is currently being taught the r/t is something the nurse can address through interventions in hopes of reversing or improving the situation.

activity intolerance r/t generalized weakness secondary to congestive heart failure aeb dyspnea and fatigue

now in the real world, we do things differently.... to a point. :)

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