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

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)