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, LTO: After 2 to 3 days of Assess extent of impairment in thinking ability, memory, Uremic syndrome’s effect can begin with
time effective nursing intervention pt and orientation. Note attention span. minor confusion/irritability and progress to
 Memory deficit; would regain/maintain optimal altered personality or inability to assimilate
altered attention level of mentation. information and participate in care. Awareness
span, decreased of changes provides opportunity for evaluation
ability to grasp and intervention.
ideas
 Impaired ability STO: After 4 to 8 hrs of effective Ascertain from SO patient’s usual level of mentation. Provides comparison to evaluate
to make nursing intervention pt would identify progression/resolution of impairment.
ways to compensate for cognitive
decisions,
impairment/memory deficits. Provide SO with information about patient’s status. Some improvement in mentation may be
problem-solve
 Changes in expected with restoration of more normal
sensorium: levels of BUN, electrolytes, and serum pH.
somnolence,
stupor, coma Provide quiet/calm environment and judicious use of Minimizes environmental stimuli to reduce
 Changes in television, radio, and visitation. sensory overload/confusion while preventing
behavior: sensory deprivation.
irritability,
withdrawal, Reorient to surroundings, person, and so forth. Provide Provides clues to aid in recognition of reality.
depression, calendars, clocks, outside window.
psychosis
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 of thought processes may
indicate worsening of azotemia and general
condition, requiring prompt intervention to
regain homeostasis.