care plans

[mwilli31]

: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

[xtxrn, ASN, RN]

Forgot the rest...

AEB is how you know the rationale.

So..

Risk for Fall RT decreased circulation AEB diminished pedal pulse

OK... but a lot of people have decreased pedal pulses and are not at risk for falls.

What else about decreased circulation could lead to a higher risk of falling?

AEB is the objective finding supporting the nursing diagnosis.

ie: Risk for falls r/t decreased sensation AEB pt being unaware of blisters on feet.

[xtxrn, ASN, RN]

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

Not necessarily.

Example: 2* (secondary to)

--Risk for falls r/t decreased sensation AEB pt unaware of blisters on feet.

-------The nurse can't make the patient feel the blisters....

--Impaired communication r/t expressive aphasia (symptom- not a diagnosis) AEB inability to make needs known

------the nurse can't fix the aphasia, but can obtain a speech therapy eval/treat & alternate communication techniques

--Risk for dehydration r/t impaired swallowing AEB coughing when drinking fluids

------the nurse can't fix the coughing- BUT can get recommendations from speech therapy for swallow studies/thickened liquids, etc.

[AgentBeast, MSN, RN]

Risk for diagnoses don't have supporting evidence otherwise they would be actual diagnosis. There are risk factors that put them at risk for becoming actual diagnosis.

Secondly you can't have Risk for dehydration related to Impaired swallowing. That's Nursing diagnosis related to another nursing diagnosis. Even more so it's a risk for diagnosis prioritized over an actual diagnosis.