Help with Nursing Diagnosis

there are two types of nursing diagnosis:

1. acurate which are three parts

nursing diagnosis - problem stated

related to (r/t) - underlying cause, pathophysiology or/and psychosocial issue

as evidence by (aeb) - subjective, objective data

ex: impaired gas exchange

r/t sorth of breath, or decreased cardiac output, or excess fluid in lungs (or all of those)

aeb vs t 98.9 bp 138/80 rr 24 hr 70 ;

sat oxygen 92% (specify what was used- nc, mask, nb mask, venti mask or room air how many liter per minute or percent)

head to toe assessment: level of orientation: alert but disoriented 2x (place , person)

circumoval eyenosis, shallow breathing, sob on excretion, nasal flaming,

how is pt capillary refile, lab values, meds,

subjective describtion from pt, caregiver, family

never put current status here

it is active infection, actual, visible problem (need) of pt to "fix"

2. risk for

nursing diagnosis - problem stated "risk for...", no visible evidence just suspect for...

r/t - current status

never put aeb, there are no evidence, you suspect something to happen

ex: risk for infection

r/t surgical procedure or immunosuppresion, or both

current status vs; t, hr, rr, bp; awake or confuse (mental status); head to toe assessment, surgical site assessment, lab values, meds,

subjective data,

i put you sample what we use for out care plan:

Nursing Dx:

R/T

Objective data:

subjective data:

current status ____________________________________________________

hope it helps,

good luck to you and others, :)