Question

Scenario

You are the nurse working triage in the emergency department (ED). This afternoon a woman brings in her father, ALI, a 72-year-old who is a retired doctor. The daughter reports that over the past several months she has noticed her father has progressively had problems with his mental capacity. These changes have developed gradually but seem to be getting worse. At times he is alert, and at other times he seems disoriented, depressed, and tearful. He is forgetting things and doing things out of the ordinary, such as placing the milk in the cupboard and sugar in the refrigerator. He had difficulty finding objects in the kitchen and at times forgets where his room is.

This morning he thought it was nighttime and wondered what his daughter was doing at his house. He could not pour his coffee, and he seems to be getting more agitated. ALI reports that he has been having memory problems for the past year and at times has difficulty remembering the names of family members and friends.

A review of his past medical history (PMH) is significant for hypercholesterolemia and coronary artery disease (CAD). He had a myocardial infarction (MI) 5 years ago. ALI’s vital signs (VS) today are all within normal limits (WNL).

Q: Discuss four nursing interventions for patients who are experiencing disturbed thought processes, impaired memory, and disturbed sensory perceptions.

Answer 1

Ans) Nursing Intervention & Rationale:

- Assist with treatment for underlying problems, such as anorexia, brain injury/increased intracranial pressure, sleep disorders, biochemical imbalances. Cognition/thinking often improves with treatment/correction of medical/psychiatric problems.

- Reorient to time/place/persin, as needed. Inability to maintain orientation is a sign of deterioration.

- Have patient write name periodically; keep this record for comparison and report differences. These are important measures to prevent further deterioration and maximize level of function.

- Provide safety measures (e.g., side rails, padding, as necessary; close supervision, seizure precautions), as indicated. It is always necessary to consider the safety of the patient.

- Schedule structured activity and rest periods. This provides stimulation while reducing fatigue.

- Maintain a pleasant and quiet environment and approach patient in a slow and calm manner. Patient may respond with anxious or aggressive behaviors if startled or overstimulated.

- Present reality concisely and briefly and do not challenge illogical thinking. Avoid vague or evasive remarks. Delusional patients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.

- Be consistent in setting expectations, enforcing rules, and so forth. Clear, consistent limits provide a secure structure for the patient.

- Reduce provocative stimuli, negative criticism, arguments, and confrontations. This is to avoid triggering fight/flight responses.

- Refrain from forcing activities and communications. Patient may feel threatened and may withdraw or rebel.

- Do not flood patient with data regarding his or her past life. Individuals who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state.

- Identify specific conflicts that remain unresolved, and assist patient to identify possible solutions. Unless these underlying conflicts are resolved, any improvement in coping behaviors must be viewed as only temporary.