Risk for Disturbed Thought Processes | Nursing Care Plan for Renal Dialysis

Nursing diagnosis: risk for disturbed Thought Processes

Risk factors may include
Physiological changes—presence of uremic toxins, electrolyte imbalances, hypervolemia or fluid shifts, hyperglycemia (infusion of a dialysate with a high glucose concentration)

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Cognition
Regain usual or improved level of mentation.
Recognize changes in thinking and behavior and demonstrate behaviors to prevent or minimize changes.

Nursing intervention with rationale:
1. Assess for behavioral changes or change in level of consciousness (LOC)—disorientation, lethargy, decreased concentration, memory loss, and altered sleep patterns.
Rationale: May indicate level of uremic toxicity, response to or developing complication of dialysis such as “dialysis dementia,” and need for further assessment and intervention.

2. Keep explanations simple and reorient frequently as needed. Provide “normal” day or night lighting patterns, clock, and calendar.
Rationale: Improves reality orientation.

3. Provide a safe environment, restrain as indicated, and pad side rails during procedure, as appropriate.
Rationale: Prevents client trauma and inadvertent removal of dialysis lines or catheter.

4. Drain peritoneal dialysate promptly at end of specified equilibration period.
Rationale: Prompt outflow will decrease risk of hyperglycemia or hyperosmolar fluid shifts affecting cerebral function.

5. Investigate reports of headache, associated with onset of dizziness, nausea and vomiting, confusion or agitation, hypotension, tremors, or seizure activity.
Rationale: May reflect development of disequilibrium syndrome, which can occur near completion of or following HD and is thought to be caused by ultrafiltration or by the too-rapid removal of urea from the bloodstream not accompanied by equivalent removal from brain tissue. The hypertonic cerebrospinal fluid (CSF) causes a fluid shift into the brain, resulting in cerebral edema and increased intracranial pressure.

6. Monitor changes in speech pattern, development of dementia, and myoclonus activity during HD.
Rationale: Occasionally, accumulation of aluminum may cause dialysis dementia, progressing to death if untreated.

7. Monitor BUN/Cr and serum glucose levels, and determine urea reduction ratio (URR).
Rationale: Follows progression or resolution of azotemia. Pre- and postdialysis BUN levels are used to determine efficacy of procedure. URR greater than 65% is desirable (NKUDIC, 2005).

8. Alternate or change dialysate concentrations and add insulin, as indicated.
Rationale: Hyperglycemia may develop secondary to glucose crossing peritoneal membrane and entering circulation. May require initiation of insulin therapy.

9. Administer normal saline intravenously (IV), as appropriate.
Rationale: Volume restoration may be sufficient to reverse effects of disequilibrium syndrome.

10. Administer medication, as indicated, such as phenytoin (Dilantin), mannitol (Osmitrol), and barbiturates.
Rationale: If disequilibrium syndrome occurs during dialysis, medication may be needed to control seizures in addition to a change in dialysis prescription or discontinuation of therapy. After the procedure, an osmotic diuresis may be required to reduce cerebral edema, along with anticonvulsant therapy and barbiturates to slow brain metabolism.

Disturbed Thought Processes | Nursing Diagnosis for Renal Failure

Nursing diagnosis: Disturbed Thought Process related to physiological changes—accumulation of toxins, such as urea, ammonia; metabolic acidosis; hypoxia; electrolyte imbalances;
calcifications in the brain

Possibly evidenced by
Disorientation to person, place, time, situation
Memory deficit, altered attention span, decreased ability to grasp ideas
Impaired ability to make decisions, problem-solve
Changes in sensorium—somnolence, stupor, coma
Changes in behavior—irritability, withdrawal, depression, psychosis

Desired Outcomes/Evaluation Criteria—Client Will
Cognition
Regain or maintain optimal level of mentation.
Identify ways to compensate for cognitive impairment and memory deficits.

Nursing intervention with rationale:
1. Assess extent of impairment in thinking ability, memory, and orientation. Note attention span.
Rationale: Uremic syndrome’s effect can begin with minor confusion or irritability and progress to altered personality, inability to assimilate information or participate in care. Awareness of changes provides opportunity for evaluation and intervention.

2. Ascertain from significant other (SO) client’s usual level of mentation.
Rationale: Provides comparison to evaluate progression or resolution of impairment.

3. Provide SO with information about client’s status.
Rationale: Some improvement in mentation may be expected with restoration of more normal levels of BUN, electrolytes, and serum pH.

4. Provide quiet, calm environment and judicious use of TV, radio, and visitation.
Rationale: Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation.

5. Reorient to surroundings, person, and so forth. Provide calendars, clocks, and outside window.
Rationale: Provides clues to aid in recognition of reality.

6. Present reality concisely and briefly, and do not challenge illogical thinking.
Rationale: Confrontation potentiates defensive reactions and may lead to client mistrust and heightened denial of reality.

7. Communicate information and instructions in simple, short sentences. Ask direct, yes or no questions. Repeat explanations as necessary.
Rationale: May aid in reducing confusion and increases possibility that communications will be understood and remembered.

8. Establish a regular schedule for expected activities.
Rationale: Aids in maintaining reality orientation and may reduce fear and confusion.

9. Promote adequate rest and undisturbed periods for sleep.
Rationale: Sleep deprivation may further impair cognitive abilities.

10. Prepare for dialysis.
Rationale: Marked deterioration of thought processes may indicate worsening of azotemia and general condition, requiring prompt intervention to regain homeostasis.

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.

Disturbed Thought Processes | Nursing Care Plan for Anorexia/Bulimia

Nursing diagnosis: disturbed Thought Processes related to Severe malnutrition, electrolyte imbalance, Psychological conflicts—sense of low self-worth, perceived lack of control

Possibly evidenced by
Impaired ability to make decisions, problem-solve
Non–reality-based verbalizations
Ideas of reference
Altered sleep patterns—may go to bed late (stay up to binge and purge) and get up early
Altered attention span, distractibility
Perceptual disturbances with failure to recognize hunger, fatigue, anxiety, and depression

Desired Outcomes/Evaluation Criteria—Client Will
Distorted Thought Control
Verbalize understanding of causative factors and awareness of impairment.
Demonstrate behaviors to change or prevent malnutrition.
Display improved ability to make decisions and problem-solve.

Nursing intervention with rationale:
1. Be aware of client’s distorted thinking ability.
Rationale: Allows caregiver to have more realistic expectations of client and provide appropriate information and support.

2. Listen to but avoid challenging irrational or illogical thinking. Present reality concisely and briefly.
Rationale: It is difficult to respond logically when thinking ability is physiologically impaired. Client needs to hear reality, but challenging client leads to distrust and frustration. Note: Even though client may gain weight, she or he may continue to struggle with attitudes and behaviors typical of eating disorders, major depression, and substance dependence.

3. Adhere strictly to nutritional regimen.
Rationale: Improved nutrition is essential to improved brain functioning.

4. Review electrolyte and renal function tests.
Rationale: Imbalances negatively affect cerebral functioning and require correction before therapeutic interventions can begin.

Disturbed Thought Processes | Nursing Care Plan for Craniocerebral Trauma

Nursing diagnosis: Disturbed Thought Processes related to physiological changes, psychological conflicts

Possibly evidenced by

Memory deficit or changes in remote, recent, immediate memory

Distractibility, altered attention span and concentration

Disorientation to time, place, person, circumstances, events

Impaired ability to make decisions, problem-solve, reason, abstract, conceptualize

Personality changes; inappropriate social behavior

Desired Outcomes/Evaluation Criteria—Client Will

Distorted Thought Self-Control

Maintain or regain usual mentation and reality orientation.

Recognize changes in thinking and behavior.

Participate in therapeutic regimen and cognitive retraining.

Nursing intervention with rationale:

1. Assess attention span and distractibility. Note level of anxiety.

Rationale: Attention span and ability to attend or concentrate may be severely shortened, which both causes and potentiates anxiety, affecting thought processes.

2. Confer with SO to compare past behaviors and preinjury personality with current responses.

Rationale: Recovery from head injury often includes a prolonged phase of agitation, angry responses, and disordered thought sequences. It is helpful to know about client’s past behaviors in order to determine if current behaviors can be attributed solely to the brain injury. Note: SOs often have difficulty accepting and dealing with client’s aberrant behavior and may require assistance in coping with situation.

3. Maintain consistency in staff assigned to client to the extent possible.

Rationale: Provides client with feelings of stability, familiarity, and control of situation.

4. Present reality concisely and briefly; avoid challenging illogical thinking.

Rationale: Client may be totally unaware of injury (amnesic) or of extent of injury and therefore deny reality of injury. Structured reality orientation can reduce defensive reactions.

5. Provide information about injury process in relationship to symptoms. Explain procedures and reinforce explanations given by others.

Rationale: Loss of internal structure (changes in memory, reasoning, and ability to conceptualize) and fear of the unknown affect processing and retention of information and can compound

anxiety, confusion, and disorientation.

6. Review necessity of recurrent neurological evaluations.

Rationale: Understanding that assessments are done frequently to prevent or limit complications and that they do not necessarily reflect seriousness of client’s condition, may help reduce anxiety.

7. Reduce provocative stimuli, negative criticism, arguments, and confrontations.

Rationale: Reduces risk of triggering fight-or-flight response. Aggression, anger, and self-control are common problems in braininjured clients, who may become violent or physically or verbally abusive.

8. Listen with regard to client’s verbalizations in spite of speech pattern or content.

Rationale: Conveys interest and worth to individual, enhancing selfesteem and encouraging continued efforts.

9. Promote socialization within individual limitations.

Rationale: Reinforcement of positive behaviors, such as appropriate interaction with others, may be helpful in relearning internal structure.

10. Encourage SO to provide current news and family happenings.

Rationale: Promotes maintenance of contact with usual events, enhancing reality orientation and normalization of thinking.