In desperate need of some help!!

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this week during clinicals we had no patients so i recieved a fake one. this has been a challange for me since i have to create my own supporting data. i have been able to adlib all of my data for all of my other dx except for:

risk for infection r/t compromised immunity secondary to current drug regimen aeb wbc count of 2,000 on 3/3/2008.

my fake pt is 6years old with wilms tumor on chemo. i am using my blood profiles for my objective data but what do i use for subjective data?

please help!:bowingpur

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Specializes in psych,and detox,and Ltc.

It is my understanding if you have a diagnoses RISK FOR you just have r/t there is no AEB...........

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Risk for.... does not require an AEB because its only a risk and not an actual problem yet:nurse:

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In my earlier submission I put aeb on my for Risk Dx, so I don't need that part great!

:anpom:

What can I use for subjective data to support my Dx of Risk for infection?:plsebeg:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

when you are doing a care plan on a "fake patient" you need to substitute textbook information about the medical disease for your assessment information. you extrapolate and make up subjective data that fits in with the assessment data. you still need to follow the steps of the nursing process, however, and in the sequence they occur in writing your care plan.

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

anticipated problems (the "risk for" nursing diagnoses") cannot have any aeb items. the aeb items are actually symptoms that the patient has that support using a nursing diagnosis. since "risk for" diagnoses are problems that do not yet exist, there cannot be any symptoms! however, when you are putting the nursing interventions and goals together for these nursing problems you do need to have some kind of potential problem in the back of your mind since the nursing interventions that you will develope need to focus on some potential problem you think is going to occur. i advise students to have a defined problem in mind when writing a "risk for" diagnosis although it isn't stated in the diagnostic statement.

the 3-part nursing diagnosis statement has this structural format:

p - e - s

p
= problem

e
= etiology

s
= symptoms

or

problem - etiology(ies) - symptoms

these are, in nanda language

nursing diagnosis - related factor(s) - defining characteristic(s)

in a care plan they look like this:

problem [related to]etiology(ies)[as evidenced by]symptom(s)

or

nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)

for more on how to write a care plan see:

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