AMS dx help

[vgutierrez39]

Hi,

Im trying to find a dx for my patient. My patient has altered mental status due to opioid overdose, with a high ammonia level. Im in critical so could I use ABCs but would they be risks? Acute confusion r/t drug abuse? hepatic encephalopathy r/t increased ammonia levels?

thanks!

[Rose_Queen, BSN, MSN, RN]

Are you trying to find nursing diagnoses? If so, throw out hepatic encephalopathy immediately as that is a medical diagnosis. What you should be using for nursing diagnoses are those on the NANDA approved list. If you don't have a reference book providing that information, it would be a wise investment to get one.

The key to nursing diagnoses is that they are based on the nursing assessment of the patient. They may be related to the nursing assessment data that relates to the medical diagnosis (such as neuro status), but then again they can also be completely independent (patient admitted for one thing, but a priority in the nursing care may be something completely different).