Possibly evidenced by
Memory deficit or changes in remote, recent, immediate memory
Distractibility, altered attention span and concentration
Disorientation to time, place, person, circumstances, events
Impaired ability to make decisions, problem-solve, reason, abstract, conceptualize
Personality changes; inappropriate social behavior
Desired Outcomes/Evaluation Criteria—Client Will
Distorted Thought Self-Control
Maintain or regain usual mentation and reality orientation.
Recognize changes in thinking and behavior.
Participate in therapeutic regimen and cognitive retraining.
Nursing intervention with rationale:
1. Assess attention span and distractibility. Note level of anxiety.
Rationale: Attention span and ability to attend or concentrate may be severely shortened, which both causes and potentiates anxiety, affecting thought processes.
2. Confer with SO to compare past behaviors and preinjury personality with current responses.
Rationale: Recovery from head injury often includes a prolonged phase of agitation, angry responses, and disordered thought sequences. It is helpful to know about client’s past behaviors in order to determine if current behaviors can be attributed solely to the brain injury. Note: SOs often have difficulty accepting and dealing with client’s aberrant behavior and may require assistance in coping with situation.
3. Maintain consistency in staff assigned to client to the extent possible.
Rationale: Provides client with feelings of stability, familiarity, and control of situation.
4. Present reality concisely and briefly; avoid challenging illogical thinking.
Rationale: Client may be totally unaware of injury (amnesic) or of extent of injury and therefore deny reality of injury. Structured reality orientation can reduce defensive reactions.
5. Provide information about injury process in relationship to symptoms. Explain procedures and reinforce explanations given by others.
Rationale: Loss of internal structure (changes in memory, reasoning, and ability to conceptualize) and fear of the unknown affect processing and retention of information and can compound
anxiety, confusion, and disorientation.
6. Review necessity of recurrent neurological evaluations.
Rationale: Understanding that assessments are done frequently to prevent or limit complications and that they do not necessarily reflect seriousness of client’s condition, may help reduce anxiety.
7. Reduce provocative stimuli, negative criticism, arguments, and confrontations.
Rationale: Reduces risk of triggering fight-or-flight response. Aggression, anger, and self-control are common problems in braininjured clients, who may become violent or physically or verbally abusive.
8. Listen with regard to client’s verbalizations in spite of speech pattern or content.
Rationale: Conveys interest and worth to individual, enhancing selfesteem and encouraging continued efforts.
9. Promote socialization within individual limitations.
Rationale: Reinforcement of positive behaviors, such as appropriate interaction with others, may be helpful in relearning internal structure.
10. Encourage SO to provide current news and family happenings.
Rationale: Promotes maintenance of contact with usual events, enhancing reality orientation and normalization of thinking.