Risk for Visturbed Thought Processes | NCP Hyperthyroidism

Nursing Diagnosis: risk for disturbed Thought Processes

Risk factors may include
Physiological changes: increased CNS stimulation and accelerated mental activity
Altered sleep patterns
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Distorted Thought Self-Control
Maintain usual reality orientation.
Recognize changes in thinking and behavior and causative factors.

Nursing intervention with rationale:
1. Assess thinking processes, such as memory; attention span; and orientation to person, place, time, and situation.
Rationale: Determines extent of interference with sensory processing.

2. Note changes in behavior.
Rationale: May be hypervigilant, restless, extremely sensitive, or crying, or may develop frank psychosis.

3. Assess level of anxiety.
Rationale: Anxiety may alter thought processes and ability to think clearly.

4. Provide quiet environment: decreased stimuli, cool room, and dim lights. Limit procedures and personnel.
Rationale: Reduction of external stimuli may decrease hyperactivity and hyperreflexia, CNS irritability, and auditory and visual hallucinations.

5. Reorient to person, place, time, and situation, as indicated.
Rationale: Helps establish and maintain awareness of reality and environment.

6. Present reality concisely and briefly without challenging illogical thinking.
Rationale: Limits defensive reaction.

7. Provide clock, calendar, and room with outside window; alter level of lighting to simulate day and night.
Rationale: Promotes continual orientation cues to assist client in maintaining sense of normalcy.

8. Encourage visits by family and SO. Provide support as needed.
Rationale: Aids in maintaining socialization and orientation. Note: Client’s agitation and psychotic behavior may precipitate family quarrels and conflicts.

9. Provide safety measures, such as padded side rails, close supervision, or use of soft restraints as last resort, as necessary.
Rationale: Prevents injury to client who may be hallucinating and disoriented.

10. Administer medication, as indicated, such as sedatives and anti-anxiety agents and antipsychotic drugs.
Rationale: Promotes relaxation and reduces CNS hyperactivity and agitation to enhance thinking ability.