NURSING DIAGNOSIS: Altered thought processes*

related to:
  1. HIV encephalopathy (AIDS dementia complex) associated with the direct effect of HIV on the central nervous system;
  2. 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);
  3. fluid and electrolyte imbalances and hypoxemia if present;
  4. depression and severe anxiety.

*The diagnostic label of acute or chronic confusion may be more appropriate depending on the client's symptoms.

Desired Outcome
The client will experience improvement in thought processes as evidenced by:
  1. improved verbal response time
  2. longer attention span
  3. improved memory
  4. improved reasoning ability and judgment
  5. decreased apathy
  6. decreased agitation
  7. absence of hallucinations.
Nursing Actions and Selected Purposes/Rationales
  1. 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).
  2. Ascertain from significant others client's usual level of cognitive and emotional functioning.
  3. 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).
  4. Implement measures to improve client's thought processes:
    1. perform actions to improve tissue oxygenation (see Diagnoses 1, action b and 8, action b.6)
    2. perform actions to prevent or treat fluid and electrolyte imbalances (see Diagnosis 2, action b)
    3. administer the following medications if ordered:
      1. antimicrobials to treat HIV and opportunistic infections
      2. antineoplastic agents to treat neoplastic conditions affecting the central nervous system
      3. antipsychotic agents (e.g. haloperidol, perphenazine, risperidone, chlorpromazine) to reduce restlessness, agitation, or hallucinations
      4. antimania/mood stabilizing agents (e.g. lithium; anticonvulsants such as carbamazepine, valproic acid, and gabapentin)
      5. central nervous system stimulants (e.g. dextroamphetamine sulfate, methylphenidate [Ritalin]) to reduce apathy and withdrawn behavior.
  5. If client shows evidence of altered thought processes:
    1. reorient client to person, place, and time as necessary; avoid repeatedly asking questions about orientation that client cannot answer
    2. address client by name
    3. place familiar objects, clock, and calendar within client's view
    4. approach client in a slow, calm manner; allow adequate time for communication
    5. repeat instructions as necessary using clear, simple language and short sentences
    6. keep environmental stimuli to a minimum
    7. avoid touch and proximity if this appears to increase anxiety
    8. maintain a consistent and fairly structured routine and write out schedule of activities for client to refer to if desired
    9. have client perform only one activity at a time and allow adequate time for performance of activities
    10. encourage client to make lists of planned activities, questions, and concerns
    11. use distraction rather than confrontation to manage negative behavior
    12. set limits on negative behavior and avoid arguing about the established limits
    13. if client is experiencing hallucinations, allow significant others to remain with client in order to provide constant reassurance
    14. encourage significant others to be supportive of client; instruct them in methods of dealing with client's altered thought processes
    15. discuss physiological basis for altered thought processes with client and significant others; inform them that cognitive and emotional functioning may improve with drug therapy
    16. consult appropriate health care provider (e.g. psychiatric nurse clinician, physician) if altered thought processes persist or worsen.