| 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: Alteration in brain function Alteration in sleep Alcohol or drug abuse Hypoxia Metabolic imbalances Delirium Disrupted perception Evidenced by: Hallucinations Restlessness Decreased level of consciousness Impaired cognition Disrupted psychomotor functioning Inability to perform purposeful behavior Inappropriate verbal responses | Underlying cause treated when possible. Patient will regain orientation to person, place, time, and situation with an appropriate level of consciousness. Patient will initiate lifestyle changes to prevent reoccurrence of acute confusion/delirium. Patient will verbalize contributing factors of fluctuations in cognition. | 1. Provide constant orientation to person, place, and time as needed. Reorient as needed to person, place, time, and situation. Challenging illogical thinking may cause defensive reactions. Hence, presenting reality will help the client by eliminating confusion. 2. Prevent sun downing. The nurse can encourage the client to get plenty of exposure to light, maintain a routine of activities, limit napping during the daytime, and provide familiar objects. 3. Educate caregivers to monitor the client at home. Caregivers must know when to contact the healthcare provider for a sudden change or worsening in cognition and behavior. 4. Provide a stable and calm environment. Prevent worsening confusion and potential agitation by providing an environment that is quiet without over stimulation that allows for rest. | |
| Impaired Verbal Communication Related to: Cognitive dysfunction Central nervous system impairment Psychotic disorder Physiological condition As evidenced by: Difficulty expressing thoughts verbally Difficulty comprehending information Incongruent facial expressions/body language Disorientation Aphasia Anarthria Dysarthria Dysphonia Slurred speech | Patient will establish a method to communicate clearly to meet their needs. Patient will participate in speech therapy or other therapy to assist with effective communication. Patient will utilize devices and equipment to augment verbal communication. | 1. Explain all procedures and tasks before initiating. Patients experiencing AMS may become agitated or fearful of healthcare professionals, equipment, or procedures. The nurse must communicate their movements and actions even if the patient is unable to effectively verbalize their thoughts in order to support a therapeutic relationship. 2. Allow time to respond to communication. Patients with AMS may need more time to comprehend speech and formulate thoughts. Allowing them ample time to respond assists with effective communication. 3. Limit distractions and stimulation. Patients with AMS may find it easier to communicate in a calm environment. Keep the patient engaged by limiting distractions and unnecessary stimuli like television. 4. Utilize family members to convey information. Patients with AMS may feel more comfortable if a familiar face is present to aid in communication between the healthcare team and the patient. | ||
| Subjective Data: Chest Pain Dyspnea Sense of impending doom Objective Data: Arrhythmias Capillary refill >3 seconds Altered respiratory rate Use of accessory muscles to breathe Abnormal arterial blood gases Unstable blood pressure Tachycardia or bradycardia Cyanosis | Ineffective Cerebral Tissue Perfusion Related to: Decrease cerebral blood flow Metabolic conditions Primary intracranial disease A systemic disease affecting the central nervous system (CNS) Exogenous toxins Drug withdrawal As evidenced by: Decreased Glasgow coma scale (GCS) Decreased level of consciousness (LOC) Diminished reflexes Alterations in pulse rate Alterations in blood pressure Increased intracranial pressure Decrease cerebral perfusion pressure Behavioral changes | Patient will maintain adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient will maintain cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient will demonstrate appropriate lifestyle modifications to support adequate tissue perfusion. Patient will have an improvement in cerebral perfusion as evidenced by intact orientation to person, place, and time. | 1. Determine the appropriate level of care. Collaborate with the interdisciplinary team to determine the appropriate level of care. Patients with AMS related to cerebral perfusion likely require monitoring in the neuro-ICU by specially trained nurses. 2. Administer fluids and electrolytes as prescribed. Fluid resuscitation aims to improve cerebral tissue perfusion and hemodynamics. To compensate for losses and keep circulation and cellular function intact, provide fluids and electrolytes as needed. 3. Prepare the client for surgical procedure as indicated. The client may be a candidate for a surgical procedure such as carotid endarterectomy or evacuation of cerebral hematoma or lesion. The nurse must prepare for a possible surgical procedure to improve tissue perfusion in the brain. |
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