Help w. Altered Mental Status Care Plan

  1. I need Help....I have a pt that had a possible OD to methodone. the pt. diagnosis was Altered Mental Status and I am having difficulty coming up w/ interventions, a care plan and a concept map for her condition. She has had a previousm medical history of the following Seizure disorder, pseudo tumor, fusions, stents, chronic back pain, CV4-03, Asthma, Depression, Hysterectomy, Gastric Bypass, Tonsilectomy and she is on medication for depression, seziures and anticogulants.

    I don't know where to start b/c this is my first med surg class?????
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    About Blessone

    Joined: Feb '06; Posts: 90


  3. by   emtb2rn
    What're the s/s for this pt? The dx of altered mental (that's the medical dx, right?) opens up the door for safety, respiratory, neurosensory, ego integrity and teaching/learning nursing dx's off the top of my head. Methadone OD? Methadone for addiction or pain? That'll play in as well. Do you have a dx/intervention/rationale book? If not, check out Doenges Pocket Guide (version 10). It rocks, but you have to determine what your dx's are going to be. I (far and away no expert) always look at safety, a/b/c's and what is going to endanger my patient the most. The priorities then kinda fall into place.

    Don't know if this helped much but good luck.
  4. by   Daytonite
    you should be following the directions for developing a concept map that you were given by your instructors. from the concept map you will be able to formulate your nursing diagnoses and your nursing interventions. that is what the concept map is designed to do for you. don't you have instructions for how to develop a nursing concept map? here is a website that explains how a concept map is put together:
    in a nutshell, a concept map follows the same sequence you would go through if you were writing any care plan. it does it in a more visual way using boxes and connecting lines. bottom line, however, is that it is a tool to help you follow the same steps of the nursing process to write a care plan that students who don't use concept maps still have to go through. those steps are:
    1. assessment
    2. nursing diagnosis
    3. planning
    4. implementation
    5. evaluation
    what i don't see in your post is any of your patient's assessment data, the starting point. that data forms the supporting evidence for any of the nursing diagnoses you will choose. that data is also the basis for the nursing interventions you will use. your patient's medical diagnoses are only important insofar as some of the signs and symptoms your patient exhibits with respect to each of the medical diagnoses can also be used by you as supporting evidence (aebs) for nursing diagnoses. however, there will also have been other data you should have collected. things such as abnormal lab results, abnormal x-rays, and nursing assessment related to the patient's ability to perform their adls is also extremely important. i am asking myself some questions about your patient that you should be asking as well. why is this patient on seizure medication? is (s)he experiencing any side effects of those medications and how does that affect his/her daily life? why is the patient on anticoagulants? what changes in his/her daily life have to be made to protect the patient from injury from accidental bleeding and hemorrhage? these are all things that need to be included in the concept map, and consequently, the care plan.

    you may also find that reviewing the information about assessments and writing care plans in these threads to be helpful: