Needing care plan help, too!

Daytonite, BSN, RN · Jan 26, 2008

when you do a "risk for" diagnosis, the aeb part of the diagnostic statement, of course, is not written. however, i'm going to tell you that it is "silent" and you really need to have those symptoms of whatever risk problem you have in the back of your mind clearly laid out even though they are not written into your nursing diagnostic statement, such that the nursing diagnostic statement really reads risk for injury r/t polydrug effect and altered mobility [aeb the signs and symptoms of the side effects of multiple drugs being given together and anticipated mobility problems]. so, even though the risk is "polydrug effect" you really are going to be monitoring and perhaps doing things to prevent those expected sides effects from happening. you'll have to check references on the compatibility of these drugs. try using this website: http://www.drugstore.com/pharmacy/drugchecker/. so, your interventions will be to monitor for the signs and symptoms of those effects, primarily. then, perhaps, to perform interventions to prevent some of the effects from occurring. the same applies to the altered mobility. you would list out what the specific signs of altered mobility are that you want to specifically monitor the patient for as well as how you plan to prevent them (ex: pressure ulcer or contractures). am i making sense and stating this clearly so you understand what i am saying?

ginger58, ASN, RN · Jan 26, 2008

I'll give you a little help. I hope this isn't a real patient on all those meds!!! Look at how many of those drugs cause sedation. Most of them look like prn meds. Why is she on four anti-nausea meds? Can any of those drugs be eliminated? What does she have for long term pain control versus prn doses for breakthrough pain? She really is at risk for falling. Polydrug=many drugs and she certainly on a lot that can sedate. I'd keep her where she can easily be observed.

DivaMomto3 · Jan 27, 2008

Yes, she was a very real patient. I, however, never got to see her as she was discharged by the time I got to clinical yesterday. I was really looking forward to working with her though. So, I ended up with a 73 y/o white male admitted with an infection from his Diverticulitis. He's been living with it for 20 years and has remained, for the most part, infection free. Heck, he was teaching me about his condition, lol. He admitted to having had a slice of pecan pie over the holidays and that is probably what caused his infection. So, now I have to come up with 2 more care plans by tomorrow morning. I know I am doing one on his pain he came in with but not sure about a second. I will have to play with this one.

Thank you, Daytonite, for your guidance! I love reading your responses to care plan questions. You should write a care plan book! :)

Daytonite, BSN, RN · Jan 27, 2008

So, what exactly are you looking for help with? I'm at a loss here as to what to help you with.

DivaMomto3 · Jan 27, 2008

Well, I was going to do Acute pain R/T constipation and maybe Constipation R/T disease process but not sure how strong they are. It's hard because I didn't have to do much for him. He was primarily there to be monitored for his white cell count. I guess I am not sure what direction to take with this.

Daytonite, BSN, RN · Jan 28, 2008

you've got a problem with using acute pain r/t constipation. do you have a nursing diagnosis reference? you really need to read the nanda information on these diagnoses carefully. the r/t (related factors) that nanda lists for acute pain needs to be an "injury agent". how is constipation injuring and causing pain? additionally, there is a nursing diagnosis for constipation. you really should use that if this patient has a problem with constipation. it's more focused to the problem at hand.

please remember that you are diagnosing. diagnoses are based upon the symptoms that the patient is having. they are not something that you arbitrarily pull out of the air. look at what nanda says are the symptoms (defining characteristics) listed for the diagnosis of constipation (they are listed on this website: [color=#3366ff]constipation) and see if your patient doesn't have one or more of them. if they do, then, bingo!, you've got the right diagnosis and those symptoms are the "aeb" part of your 3-part diagnostic statement. as i just posted to another thread for someone writing their first care plan: just about everything you do on the care plan is focused on the symptoms the patient has. the care plan is a problem solving process. if the patient's problem is constipation, his symptoms are a result and that's where you focus your attention and interventions.

DivaMomto3 · Jan 28, 2008

I actually got to looking at that and realized I was heading in the wrong direction. I changed it to Acute pain R/T infection. His WBC count was 14.6. I am also going to do a teaching care plan on diet for him.

I do have this question: If I am doing Acute pain R/T Infection, since the infection is what is causing his pain, can by outcome/goal be for him to be infection free by discharge or do i have to directly relate it to the pain?

Daytonite, BSN, RN · Jan 28, 2008

infection does not cause pain. you need to know the pathology of infection. the inflammation that precedes and accompanies the infection is what causes the pain. the cardinal signs of infection are redness, heat, swelling and pain. the pain is due to the inflammatory response of the infection. therefore, your nursing diagnosis should be acute pain r/t inflammatory response aeb xxx (patient's symptoms go here).

a long term goal is to be free of the infection. a short term goal, since acute pain is pain lasting less than 6 months, could be to be free of the pain. your goals are always the anticipated results of your nursing interventions and focus on solving the patient's response to their problem and it's symptoms or the underlying cause of their problem. see post #157 on https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128.html for an explanation on how to write goal statements.

DivaMomto3 · Jan 28, 2008

By george, I think I may be well on my way to understanding this finally! LOL Thank you so much for all your guidance!