help with my care plans

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I really need help with my care plans.:cry: My nursing diagnoses are : impaired liver function r/t Hepatitis C and risk for falls r/t lack of coordination. Any suggestions??

BahoRN

97 Posts

Has 5 years experience.

I assume you need help with your "As Evidenced By"?

Remember, your AEB is anything and everything you see, hear, smell...It can be something your patient says, lab work values, an order the Doctor has issued.

Example: Activity Intolerance r/t pneumonia AEB the patients states he has no energy, the patient starts sweating and shaking when performing ADLs, and the Doctor has ordered PT evaluations.

Hope that helps.

FLArn

503 Posts

Specializes in Hospice, LTC, Rehab, Home Health. Has 20 years experience.

mosby's used to have an index card style care planning guide arranged by nursing diagnosis. It's been a while since I've needed them -- lent mine to a CNA O worked with and she never returned them.

guest358111

12 Articles; 123 Posts

I didn't think that you could use a medical diagnosis as your r/t...would it look better to say "Impaired Liver Function r/t disease process secondary to Hepatitis C? Maybe it is fine the way it is, but I thought that the r/t can't be a medical diagnosis...

But maybe that was just the first part that couldn't be medical.... Just my input. :D

BahoRN

97 Posts

Has 5 years experience.
I didn't think that you could use a medical diagnosis as your r/t...would it look better to say "Impaired Liver Function r/t disease process secondary to Hepatitis C? Maybe it is fine the way it is, but I thought that the r/t can't be a medical diagnosis...

But maybe that was just the first part that couldn't be medical.... Just my input. :D

You are absolutely right! No medical diagnosis as your "related to".

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