Nursing Care Plan

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Medical Diagnoses: Disturbed Thought Process, Neurophysiological changes

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt’s facial expressions and body language demonstrate confusion and frustration.

 

 

 

Objective

   

Pt demonstrates periods of orientation and periods of confusion

   

Pt demonstrates unusual mood swings.

   

   


Problem

   

Disturbed Thought Processes

Long Term:

 

Pt will remain oriented to time, person, place, and circumstance by discharge.


   

*Orient client, call client by name, and introduce self on each contact. Promptly display a clock and calendar.

   

Rationale: “External, written reminders are more effective than verbal reinforcement for memory aids” (Ackley & Ladwig, 2008, p. 836).

   

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R/T

   

Neurophysiological changes

 

Short Term:

 

Pt will remain free from actual or potential harm by self or other throughout this shift, by 1900.

 

*Report any new onset or sudden increase in confusion

 

Rationale: “Postoperative acute confusion is a significant problem among older surgical clients” (Ackley & Ladwig, 2008, p. 835).

 

*Stay with the client if they are agitated and likely to be injured.

Rationale: “One-on-one contact from staff to client is the first step to successful de-escalation” (Ackley & Ladwig, 2008, p. 8356).

 

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AEB

 

Pt demonstrates periods of confusion

 

Pt’s daughter states her mother “doesn’t seem to be herself”

 

Pt daughter states that her mother is experiencing mood swings

 

 

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*I = Implementation.  Check those interventions/actions/orders that were implemented.

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.


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