Nursing Care Plans

Problem: Disturbed Thought Process

Nursing Diagnosis: Disturbed thought process related to Physiological changes: accumulation of toxins (e.g., urea, ammonia), metabolic acidosis, hypoxia; electrolyte
imbalances, calcifications in the brain
Taxonomy: Cognitive-Perceptual Pattern
Cause Analysis: Neurologic changes occurs in Chronic Renal Failure, because of accumulation of toxns in the body which may include brain due to decreased excretion of
nitrogenous wastes. As renal failure progresses, the kidney could no longer convert vitamin D to its active form, 1,25-dyhydroxycholecalciferol which will interfere
calcium absorption in the intestines and facilitates phosphate retention. Thus, mineralization of the bone with calcium and phosphate is impaired. Demineralization of the
bone frees more calcium into the blood leading to calcifications of the blood vessels including cranial nerves. (p887, Medical-Surgical Nursing by Black et. al)
Cues Goal Nursing Intervention Rationale Evaluation
Independent
 Disorientation to
person, place, time LTO: After 2 to 3 days of Assess extent of impairment in thinking ability, memory, Uremic syndrome’s effect can begin with
 Memory deficit; effective nursing intervention pt and orientation. Note attention span. minor confusion/irritability and progress to
altered attention would regain/maintain optimal altered personality or inability to assimilate
span, decreased level of mentation. information and participate in care. Awareness
ability to grasp of changes provides opportunity for evaluation
ideas and intervention.
 Impaired ability to
make decisions, STO: After 4 to 8 hrs of effective Ascertain from SO patient’s usual level of mentation. Provides comparison to evaluate
problem-solve nursing intervention pt would identify progression/resolution of impairment.
ways to compensate for cognitive
 Changes in
impairment/memory deficits. Provide SO with information about patient’s status. Some improvement in mentation may be
sensorium:
somnolence, expected with restoration of more normal
stupor, coma levels of BUN, electrolytes, and serum pH.
 Changes in
behavior: Provide quiet/calm environment and judicious use of Minimizes environmental stimuli to reduce
irritability, television, radio, and visitation. sensory overload/confusion while preventing
withdrawal, sensory deprivation.
depression,
psychosis Reorient to surroundings, person, and so forth. Provide Provides clues to aid in recognition of reality.
calendars, clocks, outside window.

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

Communicate information/instructions in simple, short May aid in reducing confusion, and increases
possibility that communications will be
sentences. Ask direct, yes/no questions. Repeat
explanations as necessary.
Establish a regular schedule for expected activities.
Promote adequate rest and undisturbed periods for sleep.
Collaborative
Monitor laboratory studies, e.g., BUN/Cr, serum
electrolytes, glucose level, and ABGs (Po2, pH).
Provide supplemental O2 as indicated.
Avoid use of barbiturates and opiates.
PREPARE FOR DIALYSIS.
understood/remembered.
Aids in maintaining reality orientation and
may reduce fear/confusion.
Sleep deprivation may further impair cognitive
abilities.
Correction of elevations/imbalances can have
profound effects on cognition/mentation.
Correction of hypoxia alone can improve
cognition.
Drugs normally detoxified in the kidneys will
have increased half-life/cumulative effects,
worsening confusion.
Marked deterioration ofthought processesmay indicate
worsening ofazotemiaand generalcondition, requiringprompt
intervention toregainhomeostasis.