Assessment

Objective:
-Inability to
reason or
concentrate
-Slow in
responding to
questions
-Restlessness

Diagnosis
Impaired
environmental
interpretation
syndrome related
to psychological
conflict as
evidenced by
restlessness

Planning

Intervention

Short term:
After 30 minutes of
nursing interventions,
the patient will be
able to gradually
improve
concentration within
a conversation

Independent:
-Determined
presence of medical
condition

Long term:
Within the shift, the
patient will be free
from any harm as
evidenced by
decreased
restlessness

-Tested ability to
receive and send
effective
communication

-Reviewed clients
behavioral changes

-Kept
communication
simple
-Maintained realityoriented
environment
-Provided safety and
protection against
hazards
-Provided
educational
materials such as
visual aids, movies,
etc

Rationale
-To identify potentially
useful interventions
and therapies
-To note differences in
viewpoint, as well as
to identify additional
impairments
-Client may be
nonverbal or require
assistance
with/interpretation of
verbalizations
-To lessen possibility
of slow response
-To help patient
identify environment
easily
-To decrease risk of
harm towards patient
-To assist in coping
with long-term care
issues

Evaluation
Short term:
After 30 minutes of
nursing
interventions, the
patient was able to
gradually improve
concentration within
a conversation
Long term:
Within the shift, the
patient was free
from any harm as
evidenced by
decreased
restlessness

Assessment
Objective:
-Difficulty in
using facial and
body
expressions
-Message
inappropriate to
content
-Use of nonverbal cues
(such as blank
stare and
wandering)

Diagnosis
Impaired verbal
communication
related to altered
perception as
evidenced by

Planning
Short term:
After 30 minutes
of nursing
interventions,
patient will be
able to verbalize
an understanding
of the
communication
difficulty
Long term:
Within the shift,
the patient will be
able to
demonstrate
congruent verbal
and nonverbal
communication

Intervention
Independent:
- Evaluated mental
status
- Ascertained clients
attention before
communicating
- Maintained eye
contact
-Kept communication
simple
- Validated meaning of
nonverbal
communication
- Stayed with client until
effective communication
is reestablished
-Planned for alternative
methods of
communication
-Provided reality
orientation

Rationale
-To have a baseline for
the plan of care
-To facilitate a good verbal
communication
-To provide consistency in
communication
-To increase ability to
communicate effectively
-Do not make
assumptions without
verification
-To be consistent in plan
of care

-To determine if other

methods will be effective
-To remain contact with
reality

Evaluation
Short term:
After 30 minutes of
nursing
interventions,
patient was able to
verbalize an
understanding of
the communication
difficulty
Long term:
Within the shift, the
patient was able to
demonstrate
congruent verbal
and nonverbal
communication