- Acute Confusion related to Disturbance in cerebral metabolism and accumulation of toxins in the brain as evidenced by Cognitive dysfunction and Neurobehavioral manifestations
- Disturbed Thought processes related to Insufficient oxygen supply to the brain secondary to encephalopathy and Alcohol or substance abuse as evidenced by Incorrect perception of stimuli and Disorientation
- Disturbed Thought processes related to Insufficient oxygen supply to the brain secondary to encephalopathy and Alcohol or substance abuse as evidenced by Incorrect perception of stimuli and Disorientation
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Hallucinations Paranoia Objective data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to Disturbance in cerebral metabolism and accumulation of toxins in the brain as evidenced by Cognitive dysfunction and Neurobehavioral manifestations | Patient will have decreased episodes of delirium as evidenced by reduced agitation and combativeness, and improved follow-through with commands. Patient will remain alert and oriented x4. | 1. Assist in the treatment of the underlying conditions. Once the underlying cause is determined, administer necessary interventions. Lactulose is often given to reduce ammonia in the blood. Oxygenation can be given for hypoxia. Antibiotics can be administered to treat infectious processes. Drug intoxication or withdrawal can be treated with medications. 2. Reorient the patient as necessary. Increased reorientation may be required to decrease anxiety and provide safety. This can seem repetitive but is necessary for the confused patient. 3. Promote a calm environment. The patient suffering from encephalopathy tends to misinterpret high levels of auditory and visual stimulation. Prevent overstimulation by eliminating loud noises and constant interruptions. 4. Encourage family members to engage in the reorientation process. The presence of family members will increase the patient’s degree of comfort and promote a trusting relationship. They can help with supporting the patient to cooperate with care. 5. Provide optimal fluids and electrolytes. Electrolyte imbalances can worsen bodily functions. Ensure adequate glucose levels to support brain functions and fluid intake to restore hemodynamic processes. | Patient’s episodes of delirium are decreased as evidenced by reduced agitation and combativeness, and improved follow-through with commands. Patient remained alert and oriented. |
| Subjective data: Verbalizes irrelevant information’s Objective data: -Difficulty communicating verbally -Impaired interpretation of events -Impaired judgment -Impaired decision making -Inadequate emotional responses -Disorientation | Disturbed Thought processes related to Insufficient oxygen supply to the brain secondary to encephalopathy and Alcohol or substance abuse as evidenced by Incorrect perception of stimuli and Disorientation | Patient will maintain a realistic perspective and be able to communicate clearly with others. Patient acknowledges and understands potential misinterpretations of other people’s verbalizations and behaviours. | 1. Maintain safety. The patient may not be able to make rational decisions and is at risk for poor judgment calls. As a top priority, maintain their safety by implementing fall precautions and keeping sharp objects out of reach. 2. Encourage the patient’s family to participate in patient care. Patients with disturbed thought processes need to feel secure and safe. Involving the family in patient care can prevent anxiety and combative behavior. 3. Give simple instructions. Allow the patient to participate in care by giving them simple directions to follow, using short sentences, and allowing them to make decisions using yes/no questions. 4. Do not force. Respect the patient’s space and do not force activities or communication. This may cause the patient to feel threatened and they may withdraw. | Patient maintained a realistic perspective and be able to communicate clearly with others. Patient acknowledged and understood the potential misinterpretations of other people’s verbalizations and behaviors. |
| Subjective data: Dyspnoea Diaphoresis Visual disturbances Headaches Objective data: -Altered respiratory patterns -Cyanosis -Confusion -Irritability -Abnormal arterial blood gas values or blood pH -Vital signs changes -Increased heart rate -Decreased oxygen saturation | Impaired Gas Exchange related to Decreased cerebral blood flow and Presence of toxins in the brain as evidenced by Abnormal arterial blood gas levels and altered level of consciousness | Patient will demonstrate improved ventilation and adequate oxygen with arterial blood gas levels within normal limits. Patient will demonstrate an alert level of consciousness without signs of confusion. | 1. Ensure the patient is positioned upright. An upright sitting position helps reduce compression of the diaphragm and promotes adequate lung expansion to ensure adequate oxygenation. Semi-fowler’s positioning also helps reduce increased intracranial pressure. 2. Administer supplemental oxygen as indicated. Supplemental oxygen may be needed to prevent hypoxia. 3. Treat the underlying condition. Alterations in gas exchange in encephalopathy are due to the underlying disease process, such as the buildup of toxins, brain injury, brain swelling from hypertension, infections, vitamin deficiencies, and more. 4. Assist with endotracheal and mechanical ventilation as indicated. For patients with severe gas exchange impairment, ventilatory support may be needed. | Patient demonstrated improved ventilation and adequate oxygen with arterial blood gas levels within normal limits. Patient demonstrated an alert level of consciousness without signs of confusion. |