Nursing diagnosis- Care Plan Help- Please

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I've turned in a care plan and my instructor wants me to do another dx

Pt was admitted for altered mental status. Hey bf reports that she spent 2 days without getting off couch before she became unresponsive. Paramedics report that pt was breathing and only responded to painful stimuli. It was first believed that pt suffered from stroke but that has been ruled out. There is evidence of renalfailure and UTI. Patient is diabetic, HTN, drinker, obese, and has severe back injuries with pain 8-10 out of 10. I am aware that UTI can cause mental alterations and confussion but this was not indicated by her H&P. At this time the reason for her altered mental status and unresponsiveness is unknown.

She presented during my assessment alert and orientated to person, place, time, and event. She did however exibit confusion and STM loss.

I've done diagnosis for acute pain (back 8-10 out of 10), skin integrity (pressure ulcers and skin tears), fluid imbalance (edema, crackles bilateral, imbalanced I&Os).

My instructor was happy with my dxs but wants me to do 1 more regarding her neuro issue that she was admitted for. I suggested acute confussion and she stated "I don't think that's the best one".

Does anyone have any other suggestions for me? I explained to her that I was having a hard time with choosing a dx because the related to factor is unknown. She said it was ok to do r/t unknown reason.

THANK YOU!!!

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Specializes in Complex pedi to LTC/SA & now a manager.

Do you have a copy of NANDA 2012-2014? (It's pretty low cost on amazon or B&N) Remember the assessment is used to determine the nursing diagnosis. Many people look at medical diagnosis and try to create a nursing diagnosis to match.

Looking at the definitions in my copy of NANDA 2012-2014, three diagnoses pop up 1. Chronic Confusion, 2. Risk for Ineffective Cerebral Tissue Perfusion or even 3. Impaired Memory

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I do have a copy of the Nanda book. I am having a haard time relating cerebral tissue perfussion to this pt. I feel that confussion is my best dx, but like I mentioned my instructor stated she didn't think so. I will look over the impaired memory. I don't know why I'm making this difficult on myself! I've written many careplans I think I'm just having a mental block or maybe missing an important assessment.

Thank you for your input.

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Specializes in Complex pedi to LTC/SA & now a manager.

I'm sure you didn't put your full assessment in the couple of sentences above. Try looking at the domains in NANDA then look at the definitions and defining characteristics. Impaired memory may be more appropriate than acute confusion

Try posting which defining characteristics for each dx your patient meets. Wait a bit, GrnTea will come by and offer her expertise especially since you have done the leg work so far. :) She always finds the care plan posts and offers her wisdom.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I do have a copy of the Nanda book. I am having a hard time relating cerebral tissue perfusion to this pt. I feel that confusion is my best dx, but like I mentioned my instructor stated she didn't think so. I will look over the impaired memory. I don't know why I'm making this difficult on myself! I've written many careplans I think I'm just having a mental block or maybe missing an important assessment.

Thank you for your input.

What can cause confusion...what were her labs? Here is what I see in the information you gave.....that concerns me
Hey bf reports that she spent 2 days without getting off couch before she became unresponsive. Paramedics report that pt was breathing and only responded to painful stimuli. It was first believed that pt suffered from stroke but that has been ruled out. There is evidence of renal failure and UTI. Patient is diabetic, HTN, drinker, obese, and has severe back injuries with pain 8-10 out of 10.
Did she have a blood alcohol done? what was her glucose? What were her kidney function tests.

Your answer might be in her labs...now you have told me about her history what is her assessment now? tell me about HER. What condition can cause sonorous respirations and it not be a stroke....alcohol or elevated glucose? What pain meds does she take at home was a drug screen done?

Tell me what your assessment showed....then we can proceed

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JustBeachyNurse, thanks for the shout-out and the NANDA-I commercial. :)

First, OP, it's "confusion" and "perfusion"-- watch your spelling!

I think I'd take a look at page 266, Risk for acute confusion. Esme has given you some really good hints as to why this patient could be at risk (to which I would add, what is she taking for that chronic back pain and has anybody checked to see how much she took in the day(s) before admission?), and I think you should be able to defend it to your instructor even if the patient is now awake and alert.

Also, just because there is no mention in physician H&P about a UTI and confusion linkage in this patient doesn't mean it's not a definite possibility, because we know about it as nurses and it's recognized in NANDA-I. She could very well have decreased cerebral perfusion if she has DM-- if you have one lousy artery, you probably have lots of them-- but without a definite medical diagnosis on that, it would be speculative.

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