NURSING DIAGNOSIS: Altered thought processes*

related to damage to cerebral tissue associated with cerebral ischemia.

*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 attention span, memory, and problem-solving abilities
  2. improved level of orientation
  3. reduction in instances of inappropriate responses.
Nursing Actions and Selected Purposes/Rationales
  1. Assess client for altered thought processes (e.g. shortened attention span, impaired memory, decreased ability to problem solve, confusion, inappropriate responses).
  2. Ascertain from significant others client's usual level of cognitive and emotional functioning.
  3. Implement measures to improve cerebral tissue perfusion (see Diagnosis 1, action b) in order to reduce cerebral ischemia and subsequently improve thought processes.
  4. If client shows evidence of altered thought processes:
    1. reorient to person, place, and time as necessary
    2. address client by name
    3. place familiar objects, clock, and calendar within client's view
    4. face client when conversing with him/her
    5. approach client in a slow, calm manner; allow adequate time for communication
    6. repeat instructions as necessary using clear, simple language and short sentences
    7. keep environmental stimuli to a minimum but avoid sensory deprivation
    8. maintain a consistent and fairly structured routine
    9. provide written or taped information whenever possible for client to review as often as necessary
    10. have client perform only one activity at a time and allow adequate time for performance of activities
    11. encourage client to make lists of planned activities, questions, and concerns
    12. assist client to problem solve if necessary
    13. implement measures to stop emotional outbursts and inappropriate responses if they occur (e.g. provide distraction by clapping hands, handing client an object to look at or hold, or turning on the radio or television)
    14. maintain realistic expectations of client's ability to learn, comprehend, and remember information provided
    15. encourage significant others to be supportive of client; instruct them in methods of dealing with client's altered thought processes
    16. discuss physiological basis for altered thought processes with client and significant others; inform them that cognitive and emotional functioning may improve gradually during the next 6-12 months
    17. consult physician if altered thought processes worsen.