more than one r/t?

Kuriin, BSN, RN · Sep 22, 2013

Dx that is not a "Risk for," requires a r/t. You can have more than one similarly to as evidenced by.

jbedwards · Sep 22, 2013

I just have to say I LOVE that I called my instructor asking for help in this matter & she tells me that I can only have one r/t, & that I should use the r/t impaired gastric motility BECAUSE that is the reason that he came into the hospital. His MAIN issue the day that I had him was the r/t accumulation of fluid within joints & he was dx with osteoarthritis while I was there!!! Unfortunately, I have to do as she says in order to pass...but I hate the idea that some student might get her who has no idea what they are doing & will start basing their care maps solely off of the admitting diagnosis because that is what she teaches!!

jbedwards · Sep 22, 2013

Dx that is not a "Risk for," requires a r/t. You can have more than one similarly to as evidenced by.

I appreciate you letting me know that! I actually was never told that!

Kuriin, BSN, RN · Sep 22, 2013

Sorry about that, I meant that Risk For diagnoses do not use AEB. Your professor is both correct and not correct. It's based on priority. If doesn't have impaired gastric motility by the time you see him but he has something else presenting, then your professor should accept something that is deemed higher on the priority list.

Esme12, ASN, BSN, RN · Sep 22, 2013

I have a question. If I am using a nursing dx of acute pain for my patient in my care map, am I able to use more than one r/t? (Ex: acute pain r/t accumulation of fluid within joints, dysfunctional gastric mobility, & changes in myocardial contractility). If there was more than one issue that was causing the pain, do I address all of those in the r/t portion, or would I leave the dx as acute pain without a r/t & address all of those underneath in my supporting data?

I can't answer your question without knowing the patients story. Without knowing the patient particulars.....it impossible to say whether or not you are right.

Why is this patient admitted? Want is their main c/o? Each reason for painshould be individually addresses WITH SUPPORTING EVIDENCE.

Take...acute pain r/t accumulation of fluid within joints. What evidence do you have to support this? X-ray's? Did the aspirate the joint? Ultrasound? What is osteoarthritis? Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, is a group of mechanical abnormalities involving degradation of joints.

Don't fall into the fatal flaw of choosing your nursing diagnosis and trying to retro fit the patient into what you want instead of letting the patient drive your diagnosis. Just because the MD diagnosed this patient with a new MEDICAL diagnosis while you are standing there doesn't mean that is your nursing evidence to support your NURSING diagnosis.

Your patient may be experiencing pain from multiple sources...but you must have supporting evidence that your patient is experiencing pain because of THAT reason and have....tell me what evidence you have that your patients pain is due to changes in myocardial contractility.

What is the most acute pain that the patient is experiencing right now and why they were admitted....what condition needs to be assessed right now......remember what GrnTea has already told you....

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

I think you are approaching this from the wrong angle