Possibly evidenced by
Disorientation to time, place, person
Change in usual response to stimuli
Motor incoordination, alterations in posture, inability to tell position of body parts (proprioception)
Altered communication patterns
Visual and auditory distortions
Poor concentration, altered thought processes or bizarre thinking
Exaggerated emotional responses, change in behavior pattern
Desired Outcomes/Evaluation Criteria—Client Will
Regain or maintain usual LOC and perceptual functioning.
Acknowledge changes in ability and presence of residual involvement.
Demonstrate behaviors and lifestyle changes to compensate for, or overcome, deficit.
Nursing intervention with rationale:
1. Evaluate and continually monitor changes in orientation, ability to speak, mood and affect, sensorium, and thought process.
Rationale: Upper cerebral functions are often the first to be affected by altered circulation and oxygenation. Damage may occur at time of initial injury or develop later because of swelling or bleeding. Motor, perceptual, cognitive, and personality changes may develop and persist, with gradual normalization of responses, or changes may remain permanently to some degree.
2. Assess sensory awareness, including response to touch, hot/cold, dull/sharp, and awareness of motion and location of body parts. Note problems with vision and other senses.
Rationale: Information is essential to client safety. All sensory systems may be affected, with changes involving increased or decreased sensitivity or loss of sensation and the ability to perceive and respond appropriately to stimuli.
3. Observe behavioral responses—hostility, crying, inappropriate affect, agitation, and hallucinations.
Rationale: Individual responses may be variable, but commonalities, such as emotional lability, increased irritability or frustration, apathy, and impulsiveness, exist during recovery from brain injury. Documentation of behavior provides information needed for development of structured rehabilitation.
4. Document specific changes in abilities, such as focusing and tracking with both eyes, following simple verbal instructions, answering “yes” or “no” to questions, and feeding self with dominant hand.
Rationale: Helps localize areas of cerebral dysfunction, and identifies signs of progress toward improved neurological function.
5. Eliminate extraneous noise and stimuli, as necessary.
Rationale: Reduces anxiety, exaggerated emotional responses, and confusion associated with sensory overload.
6. Speak in calm, quiet voice. Use short, simple sentences. Maintain eye contact.
Rationale: Client may have limited attention span or understanding during acute and recovery stages, and these measures can help client attend to communication.
7. Ascertain and validate client’s perceptions and provide feedback. Reorient client frequently to environment, staff, and procedures, especially if vision is impaired.
Rationale: Assists client to differentiate reality in the presence of altered perceptions. Cognitive dysfunction and visual deficits potentiate disorientation and anxiety.
8. Provide meaningful stimulation: verbal (talk to client), olfactory (e.g., oil of clove, coffee), tactile (touch, hand holding), and auditory (tapes, television, radio, visitors). Avoid physical or
emotional isolation of client.
Rationale: Carefully selected sensory input may be useful for coma stimulation as well as for documenting progress during cognitive retraining.
9. Provide structured therapies, activities, and environment. Provide written schedule for client to refer to on a regular basis.
Rationale: Promotes consistency and reassurance, reducing anxiety associated with the unknown. Promotes sense of control and cognitive retraining.
10. Provide for client’s safety, such as padded side rails or bed enclosed with safety netting, assistance with ambulation, and protection from hot or sharp objects. Document perceptual deficit and compensatory activities on chart and at bedside.
Rationale: Agitation, impaired judgment, poor balance, and sensory deficits increase risk of client injury.