Assessment Objective  BP: 200/140  PR: 123 BPM  ABG: pH 7.36 pCO2 25.

4 HCO3 14 (metabolic acidosis) Subjective  Altered sleeping patterns  Altered mental status, changes in cognition (disorientation to persons)  Use of verbal slurs “Yawa ka.”  Inappropriate facial grimace/affect Irritability “Hindi ako makahinga, sinasakal niyo na ako”  Crying, helplessness “Panginoon ko!”

Diagnosis Disturbed thought process

Planning After 10 minutes of effective nursing interventions, client will be able to maintain usual reality orientation After 8 hours of effective nursing interventions, client will recognize changes in thinking and behaviour and causative factors

Interventions
 Assess thinking process, such as memory, attention span; and orientation to person, place, time, and situation.  Note changes in behaviour.

Rationale
 Determines extent of interference with sensory processing.  May be hypervigilant, restlessness, extremely sensitive, or crying or may develop signs of frank psychosis.  Anxiety may alter thought processes and ability to think clearly.  Reduction of external stimuli may decrease hyperactivity and hyperreflexia, CNS irritability and auditory and visual hallucinations.  Helps establish and maintain awareness of reality and environment.  Limits defensive reaction.  Promotes continual orientation cues to assist client in maintaining sense of normalcy.  Aids in maintaining socialization and orientation.  Prevents injury to client who may be hallucinating or disoriented.  Promotes relaxation and reduces CNS hyperactivity and agitation, to enhance thinking ability.

Evaluation Goals partially met.

 Assess for level of anxiety.  Provide quiet environment: decrease stimuli, cool room and dim lights. Limit procedures and personnel.  Reorient to person, place, time and situation as indicated.  Present reality concisely and briefly without challenging illogical thinking.  Provide clock, calendar, provide good level of lighting to stimulate day and night.  Encourage visits by family and SO. Provide support as needed.  Provide safety measures (side rails, close supervision, or use of soft restraints as last resort, as necessary.  Administer medication as indicated such as sedatives and anti-anxiety agents (Diazepam 5mg TIV, Propanolol 10 mg tab TID)