Student Nurses Community

NURSING CARE PLAN Impaired Environmental interpretation

ASSESSMENT

OBJECTIVE:
Chronic
confusional
states
Consistent
disorientation
Inability to
follow simple
directions
Slow in
responding to
questions

DIAGNOSIS

Impaired
Environmental
Interpretation
Syndrome
related to
dementia

INFERENCE

PLANNING

Neuropathologic
conditions

loss of mental
functions (thinking,
memory, and
reasoning)

Executive
functioning skills are
affected

Consistent lack of
orientation to
person, place, time
or circumstance

Impaired
Environmental
Interpretation

Persons daily
functioning is
affected

After 72 hours of
nursing
interventions,
the patient will
be able to:
Be free of
harm
Sustain or
demonstrate
improvement
in cognition

INTERVENTIONS

Independent:
Determine
presence of
conditions or
behaviors that
lead to clients
current problem
Note presence or
reports of clients
misinterpretation
of environmental
information,,
history and
progression of
condition, length
of time since
onset, future
expectations, and
incidents of injury
or accidents
Obtain information
regarding recent
changes or
disruptions in
clients health or

RATIONALE

EVALUATION

These can provide

clues for likelihood
for improvements
as well as help to
identify potentially
useful
interventions and
therapies

After 72 hours
of nursing
interventions,
goal met.
Patient was
able to be free
of harm and
injury, and was
able to
demonstrate
improvement
in terms of
cognition.

Identifies specific
areas of concern
and potential risks
Decline in physical
health or
disruption in daily
living situation
can exacerbate
symptoms,
causing agitation
or delirium.
Client may be
nonverbal or
require assistance
with or
interpretation of
verbalizations

Student Nurses Community

routine
Test ability to
receive and send
effective
communication

Places client at
risk and requires
prompt
interventions for
safety of all.

Determine anxiety
level in relation to
situation. Note
behaviour that
may be indicative
of potential for
violence

Highlights
problems that
may impact client
care and safety or
add to clients
difficulties in
interpretation of
sensory input.

Identify potential
environmental
dangers, and
evaluate clients
level of awareness
of threat.

To incorporate into
plan of care to the
extent possible
and lessen
confusion

Identify
previous/usual
patterns for
activities
(sleeping, eating,
self-care, etc)
Implement
behavioural and
environmental
management
interventions

To manage
disorientation,
provide
opportunity for
client interaction
using cognitive
skills, preserve
clients dignity
and safety
To optimize
sensory input for
communication

Student Nurses Community

Provide and
promote use of
glasses, hearing
aids, and
adequate lighting
Incorporate
previous/usual
patterns for
activities to the
extent possible.
Simplify clients
tasks and
routines.
Provide safety
measures (close
supervision,
locking doors to
unprotected
areas/stairwells/to
xic substances,
etc.).
Provide safe and
secure walking
area
Place identity tags
in clothes and
belongings.
Provide bracelet
or necklace

and to reduce
disorientation in
surroundings
To keep
environment
predictable and
prevent client
from feeling
overwhelmed
Impaired
judgment and
inattention to
detail place client
at increased risk
for injury to self
and others
To ensure safety
To facilitate
identification and
safe return if
client wanders
away or gets lost
Although
restraints may
reduce falls, they
can increase
patients agitation
and distress and
possibly case

Student Nurses Community

Avoid use of
restraints. Use
vest restraints (if
required)

entrapment and
death