Help! Is this a nursing diagnosis??

  1. 0
    Hi. I have my Nursing Dx as:

    Disturbed thought processes related to Alzheimer’s diagnosis

    This is sufficient?? I thought that you had to have BLANK related to BLANK.

    My teacher says I need to have
    Disturbed thought processes related to Alzheimer’s diagnosis as evidenced by........ as evidenced by WHAT?? Alzheimer's is Alzheimers's. We know the patient has lose of memory, lack of correct responses and so forth... not sure why I need as evidenced by. I did not see this in any other book or textbook and in my other sections of my care plan I go into detail as to what her mental apptitude is. The teacher is trying to help me for a final nursing care plan that has to be done so I am not complaining. I just do not understand. I thought that was sufficient. Your two cents?? Thanks and help!


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  4. 9 Comments so far...

  5. 0
    Quote from Epona
    We know the patient has lose of memory, lack of correct responses and so forth... not sure why I need as evidenced by.
    Because your teacher wants it. She's going for overkill.

    Seriously, I hate care plan stuff. It seems self-evident to me that an immobile stoke patient will be turned Q2H so he doesn't get bedsores, but it needs to be "Risk for impaired skin integrity" 2 "immobility" r/t CVA. It does make for standard documentation and a nursing taxonomy.
  6. 1
    They were telling us in nursing school we cannot use medical diagnosis for "related to" part. So instead of Alzheimer should be something like "altered mental status" or something like that, evidenced by memory loss, delusional ideas and whatever else you have. Using medical diagnosis, you are passing a buck to medicine instead of concentrating on nursing part and what you can do about it.
    ImJenn likes this.
  7. 0
    Quote from Epona
    My teacher says I need to have Disturbed thought processes related to Alzheimer’s diagnosis as evidenced by........ as evidenced by WHAT?? Alzheimer's is Alzheimers's. We know the patient has lose of memory, lack of correct responses and so forth... not sure why I need as evidenced by.

    Because it's not a complete nursing diagnosis without the "as evidenced by" unless it is an at Risk diagnosis.

    How do you know the thought process is disturbed? Give the teacher some examples...


    Also, like the PP said, you cannot use medical diagnosis here.
  8. 0
    "As evidenced by repetitive questioning and necessity for frequent orientation by staff."
  9. 0
    At my school, we can't use medical dx so I wouldn't be able to use Alzheimers. I would use altered mental statues AEB loss of memory etc etc (what you had listed above). That is just the format.
  10. 0
    Take it from a former care plan nurse..........NO medical dx. And you do need the "as evidenced by" part for a actual nursing dx (as opposed to a risk for dx) like this
    Disturbed thought process r/t impaired memory as evidenced by frequent repeated questions, pt not oriented to time or place, and frequent yelling out. then go on to list your goals and orders. In real life your coworkers may never look at this but you can bet who ever does your surveys will.
  11. 0
    the related to is the etiology - WHAT is causing disturbed thought processes? What is the Alzheimers doing to the brain? You could do something like
    Disturbed Thought Processing r/t biological changes of brain functioning AEB ....
    The AEB is your signs/symptoms. You should go to your assessment for this part. What did you assess in the patient that demonstrated they were having a disturbed thought process? For instance in a Schizophrenic pt it might be delusions that someone is out to harm them/comments of paranoia.

    For another nurse (in theory) to act on your careplan they have to know WHY they patient is having the nursing dx so they can appropriately intervene... for instance if it's impaired skin integrity... why? Do they have an incision? immobility (pressure ulcer)? diarrhea?
  12. 0
    Oh.........and at the end, under your "result" column, do NOT write "goal met." I've seen countless students do this and not understand why they had to redo the care plan. Write out how the goal was met and how you know the goal was met.
  13. 0
    Quote from Epona
    Hi. I have my Nursing Dx as:

    Disturbed thought processes related to Alzheimer’s diagnosis

    This is sufficient?? I thought that you had to have BLANK related to BLANK.

    My teacher says I need to have
    Disturbed thought processes related to Alzheimer’s diagnosis as evidenced by........ as evidenced by WHAT?? Alzheimer's is Alzheimers's. We know the patient has lose of memory, lack of correct responses and so forth... not sure why I need as evidenced by. I did not see this in any other book or textbook and in my other sections of my care plan I go into detail as to what her mental apptitude is. The teacher is trying to help me for a final nursing care plan that has to be done so I am not complaining. I just do not understand. I thought that was sufficient. Your two cents?? Thanks and help!




    Would a nurse's pocket guide help?
    Last edit by middleageNP on Apr 23, '07


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