HELP w/ Nursing interventions & Goals for a Care Map

Daytonite, BSN, RN · Oct 7, 2009

first of all, there are problems with the construction of your diagnostic statements. the construction of the 3-part diagnostic statement follows this format:

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

dx: activity intolerance r/t bed rest, pain, dehydration, & smoking amb sob, electrocardiographic changes (sr w/ decreased st)

i would check with your instructor about the use of dehydration as an etiology. it is generally used as a medical diagnosis and medical diagnoses can't be used in nursing diagnostic statements.

dx: imbalanced nutrition: less than body requirements r/t inability to ingest or digest food or absorb nutrients as a result of biological factors amb s/p colectomy, ileostomy, n/v, dehydration, & colon cancer

the amb part of the diagnostic statement must be evidence, or symptoms, of the problem which in this case is imbalanced nutrition: less than body requirements, or not eating enough to meet their metabolic needs. a s/p colectomy, ileostomy, n/v, dehydration, & colon cancer are not evidence of this problem. a colectomy and ileostomy are medical interventions. dehydration and colon cancer are medical conditions and cannot be used in nursing diagnostic statements as symptoms of a nursing problem. evidence of this problem would be things like a weight loss, a calorie count of the patient's food intake that shows they are consuming less calories than they should be taking in, eating only 50% of the food on their diet trays, evidence of anorexia, hair loss, vitamin deficiencies, etc.

nursing interventions are the treatments you order for the symptoms of the nursing problems the patient is having. your goals very simply will be what you predict will happen as a result of those nursing interventions being performed. the reason you are at a loss determining interventions for the imbalanced nutrition is because you haven't identified the symptoms of the problem to begin with. identify those and then determine what you will do for them. for activity intolerance one of your symptoms is sob. that is not quite accurate. the problem is actually that the patient becomes sob after taking a certain number of steps and then can tolerate no more activity and must then stop. so, interventions focus on gradually increasing the number of steps or the length the patient walks each day to build up their tolerance to activity. if that is not possible then short periods of activity are planned with rest periods in between in order to minimize those ekg changes.