Altered thought processes*
- HIV encephalopathy (AIDS dementia complex) associated with the direct effect of HIV on the central nervous system;
- opportunistic infections and/or neoplasms involving the central nervous system (e.g. toxoplasmic encephalitis, cryptococcal meningitis, progressive multifocal leukoencephalopathy, cytomegalovirus [CMV] encephalitis, primary central nervous system lymphoma);
- fluid and electrolyte imbalances and hypoxemia if present;
- depression and severe anxiety.
*The diagnostic label of acute or chronic confusion may be more appropriate depending on the client's symptoms.
|The client will experience improvement in thought processes as evidenced by:|
- improved verbal response time
- longer attention span
- improved memory
- improved reasoning ability and judgment
- decreased apathy
- decreased agitation
- absence of hallucinations.
|Nursing Actions and Selected Purposes/Rationales|
- Assess client for altered thought processes (e.g. slowed verbal responses, decreased ability to concentrate, impaired memory, poor reasoning ability or judgment, apathy, agitation, hallucinations).
- Ascertain from significant others client's usual level of cognitive and emotional functioning.
- Prepare client for diagnostic studies that may be done to determine the cause of altered thought processes (e.g. computed tomography [CT] or magnetic resonance imaging [MRI] of the brain, toxoplasma and cryptococcal serology studies, cerebrospinal fluid analysis, brain biopsy, neuropsychological tests).
- Implement measures to improve client's thought processes:
- perform actions to improve tissue oxygenation (see Diagnoses 1, action b and 8, action b.6)
- perform actions to prevent or treat fluid and electrolyte imbalances (see Diagnosis 2, action b)
- administer the following medications if ordered:
- antimicrobials to treat HIV and opportunistic infections
- antineoplastic agents to treat neoplastic conditions affecting the central nervous system
- antipsychotic agents (e.g. haloperidol, perphenazine, risperidone, chlorpromazine) to reduce restlessness, agitation, or hallucinations
- antimania/mood stabilizing agents (e.g. lithium; anticonvulsants such as carbamazepine, valproic acid, and gabapentin)
- central nervous system stimulants (e.g. dextroamphetamine sulfate, methylphenidate [Ritalin]) to reduce apathy and withdrawn behavior.
- If client shows evidence of altered thought processes:
- reorient client to person, place, and time as necessary; avoid repeatedly asking questions about orientation that client cannot answer
- address client by name
- place familiar objects, clock, and calendar within client's view
- approach client in a slow, calm manner; allow adequate time for communication
- repeat instructions as necessary using clear, simple language and short sentences
- keep environmental stimuli to a minimum
- avoid touch and proximity if this appears to increase anxiety
- maintain a consistent and fairly structured routine and write out schedule of activities for client to refer to if desired
- have client perform only one activity at a time and allow adequate time for performance of activities
- encourage client to make lists of planned activities, questions, and concerns
- use distraction rather than confrontation to manage negative behavior
- set limits on negative behavior and avoid arguing about the established limits
- if client is experiencing hallucinations, allow significant others to remain with client in order to provide constant reassurance
- encourage significant others to be supportive of client; instruct them in methods of dealing with client's altered thought processes
- discuss physiological basis for altered thought processes with client and significant others; inform them that cognitive and emotional functioning may improve with drug therapy
- consult appropriate health care provider (e.g. psychiatric nurse clinician, physician) if altered thought processes persist or worsen.