Nursing Diagnosis

[realitybit]

Hi,

We're just starting to make a care plan so I still need a lot of help. Our instructor gave us something to work on as a practice. He only gave us the assessment which as follows: confused, wandering around, murmuring words, orientation level is 0. So, from these assessment we have to come up a care plan. I have some ideas but I just can't formulate the nursing diagnosis. He said if it's not in NANDA then it is not a nursing diagnosis. I understand that and I already found some nursing diagnosis that I thought would relate to the assessment above. My problem is I have difficulty putting two together for the nursing diagnosis: from the problem itself to "related to" and signs and symptoms since the assessment lacks lot of information about the patient. I really needed your help just to enlighten me up a little bit. Thanks.

[UcStudentNurse]

Problem (nanda) -> "releated to" pull this directly from your nursing diagnosis book if you have one, Etiology (whats the cause) -> "as manafested by" Symptoms.

P+E+S as they told us, use that formula for a actualy diagnosis. I dont have my Nursing diagnosis book with me or I would write a dx for you. But look at the confusion is there a NANDA for that. Sorry I cant be more help, we are not on care plans yet but have spent alot of time on nursing diagnosis.

[realitybit]

Thank you for your reply. There's two for confusion in NANDA. Acute Confusion and Chronic Confusion. That's what throws me off. I don't know which one I will use.

[Mandychelle79, ASN, RN]

Does it list any of the patients medical dx? If not I would go with Acute confusion.

[UcStudentNurse]

If nothing else is listed wouldn't you go with "some time of confusion NANDA sorry don't have book" related to unknown etiology as manifested by pt confused, murmuring words, and orient level 0?

Unless the vital signs suggest something else, but im just going off the info given confusion, murmuring....

[realitybit]

Thanks UCStudentNurse for your reply. That's all that I have. There's two Confusion on NANDA, Acute and Chronic. I just don't know which one to use but I might make a care plan for both. We'll see what more informations I can get from NANDA. Thanks again.

[realitybit]

Does it list any of the patients medical dx? If not I would go with Acute confusion.

Thanks Mandychelle79 for your reply. There's no medical Dx given. Those four assessments are all that was given. I'm leaning towards Chronic confusion but I will look at the Acute Confusion, too. Or, I might just do both. I don't know. This is my first time making a care plan after just one example from our teacher so I think he won't be too hard on me, lol. Thanks again.

[UcStudentNurse]

Ok read the definition for both see what fits the client best, then look at the Major symptom list. There has to be one major for it to be an appropriate dx. That's how my book is organized we use the carpineto moyette (spelling)