confused careplan

PvNurse2009 · Aug 10, 2009

your "related to" is generally what causes your nursing diagnoses and your "as evidenced by" is your patient's signs and symptoms that support the NDx. For example: Alteration in comfort r/t pain aeb patient complains of pain as a 6 on a scale of 1-10

Daytonite, BSN, RN · Aug 11, 2009

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem r/t etiology aeb symptoms

problem- this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology- also called the related factor (r/t) by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms- also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.