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Disturbed Thought Processes

The patient was experiencing disturbed thought processes due to a mental disorder as shown by memory deficits and hearing voices. The nursing plan was to provide interventions over 8 hours and 2 weeks to help the patient compensate for cognitive impairment and maintain reality orientation through reorientation, structured activity, a calm environment, and reality-based interactions. The evaluation found improvements in identifying ways to cope with deficits and demonstrating behaviors to minimize changes in thinking, showing the goals were partially met.

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Jason Avellano
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7K views

Disturbed Thought Processes

The patient was experiencing disturbed thought processes due to a mental disorder as shown by memory deficits and hearing voices. The nursing plan was to provide interventions over 8 hours and 2 weeks to help the patient compensate for cognitive impairment and maintain reality orientation through reorientation, structured activity, a calm environment, and reality-based interactions. The evaluation found improvements in identifying ways to cope with deficits and demonstrating behaviors to minimize changes in thinking, showing the goals were partially met.

Uploaded by

Jason Avellano
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ASSESSME NT Subjective : My mga bumubulong sakin.

Mga Manliligaw ko as verbalized by the patient

DIAGNOS IS Disturbed thought processes r/t mental disorder as manifeste d by memory deficit

PLANNING Short Term Goal After 8 hours of nursing intervention, the patient will: -Identify ways to compensate for cognitive impairment and memory deficits Demonstrate behaviors to minimize changes in mentation Long Term Goal: After 2 weeks of RLE Rotation, the patient will maintain usual reality orientation.

INTERVENTION 1. Assess attention span/distractibility and ability to make decisions or problem solve. 2. Test ability to receive, send, and appropriately interpret communications. 3. Perform periodic neurologic assessment, as indicated. 4. Reorient to time, place, and person as needed. 5. Provide safety measures such as side rails, padding as necessary and close supervision as indicated. 6. Schedule structured activity and rest periods. 7. Maintain a pleasant, quiet environment and approach client in a slow, calm manner. 8. Give simple directions, using short words and simple sentences. 10. Allow ample time for client to respond to questions and comments and make simple decisions. 11. Maintain reality oriented relationship and environment (clocks, calendar, personal items).

RATIONA Self-Care Deficit LE -Determines ability to participate in planning and executing care. -To assess degree of impairment.

EVALUATION Short Term Goal

Objective: Disorientati on to person, place and time -Memory deficit, altered attention span, and decreased ability to grasp ideas -Impaired ability to make decisions and

After 8 hours of nursing intervention, the patient was able to: -Early recognition -Identify ways to of changes compensate for promotes proactive cognitive modifications to impairment and plan of care. memory deficits -Inability to -Demonstrate maintain behaviors to orientation is a sign minimize changes of deterioration. in mentation -To prevent further deterioration. Long Term Goal After 2 weeks of -Provides RLE rotation, the stimulation while patient was able to reducing fatigue. maintain usual reality orientation. -Client may respond with anxious or aggressive behaviors if startled or overstimulated. -May aid in reducing confusion, and increases possibility that

problem solve -Disordered thought sequencing

communications will be understood and remembered.

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