writing a care plan

[Jaxs]

Can someone help me figure out how to write the care plan. If I have tissue perfusion ineffective cerebral, what is the concept or rules for the R/T and AEB? Do I change the order of the words to be Ineffective cerebral tissue perfusion related to what is the cause and AEB what are the symptoms?

Thanks for the help

[Daytonite, BSN, RN]

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 2007-2008 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/te aeb s

the nanda taxonomy contains all the nursing diagnoses, their definitions, related factors (etiologies) and defining characteristics (symptoms). it can be found in these places:

• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

regarding the diagnosis you want to use, the correct wording for it is: ineffective tissue perfusion: cerebral.

[Jaxs]

:bow:I cannot thank you enough for taking so much time to explain that so clearly! Why don't our teachers? They somehow expect us to come up with it without the direction. It is often like a scavenger hunt. What would I do without all you wonderful guardian angels! Thanks

[tsprague]

Im getting ready to start ob rotation and have to write a paper to a pretend friend about everything from her first doctors appointment to her newborns first doctors appointment. Any help I can get about this would be greatly appreciated.