"r/t" help for nursing dx

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Hello everyone! I am a paramedic bridging through to RN and needless to say I am a little lost on the care planning. I have my dx books and care planning guides yet I am still having trouble with the r/t criteria. A little background: pt is 51 y/o M admitted for pneumonia sepsis requiring thoracotomy and chest tube placement for drain. pt c/o pain at surgical site. Vitals within desired limits exception of pain 9/10. A few questions that need clarifying are:

1.) Can a nursing dx be the r/t criteria for another nursing dx? ie: acute pain r/t impaired tissue integrity? This leads me to the next question...

2.) Is "surgical procedure" a medical diagnosis? ie: Impaired skin integrity r/t surgical procedure aeb thoracotomy incision site. (can you use the procedure as evidence?)

Any input in appreciated!

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As far as I know (because sometimes care plans elude me as well) is that your r/t should be something that nursing interventions will work on. So it can't be the medical diagnosis or another NANDA. Ultimately, when you do your work up, all your interventions should be directed at "fixing" the r/t.

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Can a nursing dx be the r/t criteria for another nursing dx? ie: acute pain r/t impaired tissue integrity?

I would say that you could; however it sounds like you are talking about the result of tissue integrity due to the surgical procedure wound correct? (not because they are immobile and developing pressure sores)

For example

Acute pain rt/

  1. disruption of tissue associated with the surgical procedure;
  2. delayed wound healing associated with factors such as decreased nutritional status and inadequate blood supply to wound area;
  3. irritation of skin associated with contact with wound drainage, pressure from tubes, and use of tape.



    1. 2.) Is "surgical procedure" a medical diagnosis? ie: Impaired skin integrity r/t surgical procedure aeb thoracotomy incision site. (can you use the procedure as evidence?)

      3. I--I wouldn't say you can use the procedure as evidence because its not something you walk into a pt.s room and instantly can observe. AEB's should be objective most of the time I would say and not something they are admitted for. So in your case I guess the best way to "explain" is to just show you what I would put instead and let you see the difference.

      Impaired skin intergrity r/t thoractomy incision site AEB redness surrounding site, wound draining, and abnormal swelling at surgical site.

      Let me know if it helped or you have any questions....

      --Amanda

      BTW!! could you maybe help me out with my question please!! Maybe your good in that area!!

      https://allnurses.com/nursing-student-assistance/drug-calculations-can-879395.html#post7543630

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I guess the best way to put it is your Related to is exactly what it sounds like, what is causing this? (no medical Dx). And your AEB's are "what is the evidence supporting your reason for choosing that nursing diagnosis".

Impaired skin integrity r/t surgical procedure aeb thoracotomy incision site.

That basically means skin irritation/wounds because of a surgical procedure and I know he has skin irration/wounds because I looked at his chart and it says he had a thoractomy.

I am not sure how to best explain it, but if you follow up with questions that might help me help you more

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Hello everyone! I am a paramedic bridging through to RN and needless to say I am a little lost on the care planning. I have my dx books and care planning guides yet I am still having trouble with the r/t criteria. A little background: pt is 51 y/o M admitted for pneumonia sepsis requiring thoracotomy and chest tube placement for drain. pt c/o pain at surgical site. Vitals within desired limits exception of pain 9/10. A few questions that need clarifying are:

1.) Can a nursing dx be the r/t criteria for another nursing dx? ie: acute pain r/t impaired tissue integrity? This leads me to the next question...

2.) Is "surgical procedure" a medical diagnosis? ie: Impaired skin integrity r/t surgical procedure aeb thoracotomy incision site. (can you use the procedure as evidence?)

Any input in appreciated!

No you can't use the procedure as evidence. The evidence creteria is signs and symptoms... What you see or what the pt is c/o.

I.e impaired skin integrity r/t, the cause ,which is an incision on the chest aeb the signs and symptoms which are , ie incision site measuring 2cm, pt c/o irritation on the site, redness etc. Hope this helps...

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No you can't use the procedure as evidence. The evidence creteria is signs and symptoms... What you see or what the pt is c/o.

I.e impaired skin integrity r/t, the cause ,which is an incision on the chest aeb the signs and symptoms which are , ie incision site measuring 2cm, pt c/o irritation on the site, redness etc. Hope this helps...

2. Acute pain r/t tissue trauma from an incision of the.......aeb grimacing, statements that chest hurts and pain level of 9/10..

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R/t are the pathophysiology of the problem

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What care plan books do you have?

Every NANDA I diagnosis has a definition, defining characteristics, and factors that are related to the diagnosis your patient must fit this definition AND you must have proof on why you think they have this issue. The rules for constructing a 3-part nursing diagnostic statement are as follows. . .

  1. P. Stands for the problem. The problem is written as the nursing diagnosis. The words you use in writing the nursing diagnosis have already been determined for you by NANDA-I, the North American Nursing Diagnosis Association, International. You merely need to look them up in the most recent copy of one of their publications such as NANDA-I Nursing Diagnoses: Definitions & Classification or in any of the many currently printed nursing care plan or nursing diagnose reference books that are in publication containing this information. A nursing diagnosis is only a shortened label of the nursing problem which is more broadly defined and expressed in the definition contained in these references.
  2. E. Stands for the etiology. An etiology is the origin of cause of this identified nursing problem (P). It cannot be stated as a medical diagnosis. In the NANDA taxonomy you will find etiologies listed for many of the nursing diagnoses under the headings of "related factors". For physiological nursing problems (nursing diagnoses) you will need to know the pathophysiology of the disease process in order to determine the correct etiology, or related factor.
  3. S. Stands for the symptoms. Symptoms are the manifestations of the identified nursing problem (P). In the NANDA taxonomy you will find symptoms listed for many of the nursing diagnoses under the headings of "defining characteristics". Symptoms are proof that the problem exists. You will not have symptoms for "Risk for" diagnoses because these are not actual problems, but anticipated problems. Symptoms are determined by performing a thorough assessment of the patient and finding what is abnormal. Symptoms are abnormal findings.

In constructing the nursing diagnostic statement, these three elements are linked together in this way:

P related to E as evidenced by S

or

(P) R/T (E) AEB (S)

My friend GrnTea says it best.....

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))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

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No you can't use the procedure as evidence. The evidence creteria is signs and symptoms... What you see or what the pt is c/o.

I.e impaired skin integrity r/t, the cause ,which is an incision on the chest aeb the signs and symptoms which are , ie incision site measuring 2cm, pt c/o irritation on the site, redness etc. Hope this helps...

Sorry to be late to this party! Thanks for the shout-out, Esme.

This is incorrect. If you look at the NANDA-I 2012-2014, which is the only authoritative work on nursing diagnosis, you will see that, for example, acute pain can be related to (that means, caused by) a surgical procedure. (See below)

OP, you are responsible for some components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

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))__."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." A surgical procedure is a physical injury.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

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