Confused?

tlc2u · Oct 11, 2009

i'm really confused as to how i'd use the nursing diagnosis handbook (ladwig, ackley), to look up nursing diagnosis.

i have a p/t who overdosed, causing hypoxic encephalopathy, about 2 years ago. the p/t is now in ltc, and is fully responsive, but cannot perform adl at all, or move for the most part. the p/t also has a history of pulmonary embolisms.

encephalopathy means brain disease and is not necessarily a diagnosis you would expect to find in your nursing diagnosis book.

somewhere in your book should be a complete listing of nursing diagnosis condensed to just 1-2 pages. glance over the list and determine what your patients most important problems are and choose the approriate nursing diagnosis. then look through the book for the complete information on those diagnoses. if i remember correctly my book may have been set up in alphabetical order.

website for 2008-2009 nursing diagnosis list each alphabet on a seperate page

http://nursinglink.monster.com/training/articles/1275-nursing-diagnosis-list

website set up like a page of your nursing diagnosis book.

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=12

this is similar to what you should see on a page for a nursing diagnosis in your book.

this shows nursing diagnosis of:

chronic confusion r/t (related to) [scroll down the page to look at the related factors]

chronic confusion r/t {ex. "related factor" - alzheimer's disease or "defining characteristic" - distorted thought control aeb (as evidenced by) impaired short term memory or patient unable to remember what they had for breakfast and recognizes her daughter one minute but not the next.

in nursing school some of our instructors would not let us use the medical diagnosis as our r/t we needed more what you find under the category of "defining characteristics". or even the pathophysiology of alzheimer's disease instead of stating alzheimer's diseaese we would need to say r/t plaques and tangles of the brain.

i don't know if you have to list interventions and outcomes with your nursing diagnosis or not. for some instructors we did and others not.

for this alzheimers patient your intervention would be whatever you as the nurse is doing to reduce the patients chronic confusion. maybe you are keeping her day as routine as possible. maybe you are having only one family member come in the room at a time instead of the whole family which may cause the patient more confusion as to who is who. then the outcome you would want would be decreased confusion.

i hope this makes sense and is helpful.

i am not at home to look at my book but in the front of my book there are 2 short sections if i remember correctly. 1 lists nursing diagnosis by medical diagnosis or disease processes and another section is listed by problems or body systems. like nursing diagnosis for respiratory or renal problems etc. try looking in your book for nursing diagnosis for respiratory problems or adl problems etc. since that seems to be what your patient may have.

Daytonite, BSN, RN · Oct 12, 2009

did you read the first section of the book where it explains how to put together a care plan and diagnose? rather than go to section ii (the cross reference) and try to find diagnoses for hypoxic encephalopathy or pulmonary embolism what you really need to do is follow adpie which are the steps of the nursing process (this is explained in section i of the book). "a" is for assessment. assessment begins the entire process of care planning, or determining the abnormal data that your patient has. nursing problems are based on abnormal data. after assessing your patient you may find that there is evidence of things that aren't even related to the hypoxia or pulmonary embolism. i am very familiar with section ii cross reference in the ackley/ladwig book and it also lists symptoms as well as medical diseases. the appendix of the book lists maslow's hierarchy of needs to help you with prioritizing the diagnoses.

look more closely at the information in this book.

assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking