ASSESSMENT

Objective Cues:

Altered
attention span;
distractibility
Memory deficit
Disorientation;
cognitive
dissonance;
delusional
thinking
Sleep
disturbances
Impaired ability
to make
decisions/proble
m-solve;
inability to
follow complex
commands/ment
al tasks, loss of
impulse control

Diagnosis:
Disturbed
Thought Process
related to CNS
infection by HIV

OBJECTIVES OF
CARE

NURSING
INTERVENTIONS

At the end of 8
Maintain a pleasant
hours of patient
interaction, I shall environment with
appropriate auditory,
be able to:

Maintain
usual reality
orientation
and optimal
cognitive
functioning.

visual, and cognitive

stimuli.

Provide cues for

reorientation. Put
radio, television,
calendars, clocks,
room with an outside
view if necessary.
Use patients name.
Identify yourself.
Maintain consistent
personnel and
structured schedules
as appropriate.
Discuss use of
datebooks, lists,
other devices to
keep track of
activities.
Encourage family
and SO to socialize
and provide
reorientation with
current news, family

RATIONALE
Providing normal
environmental
stimuli can help in
maintaining some
sense of reality
orientation.
Frequent
reorientation to
place and time
may be necessary,
especially during
fever and/or acute
CNS involvement.
Sense of continuity
may reduce
associated anxiety.

IMPLEMENTATION

Maintained
pleasant
environment

Provided cues
for
reorientation
successfully

Maintained
consistent
personnel
and
structured
schedules

Discuss used
of tools to
track
activities

These techniques
help patient
manage problems
of forgetfulness.

Familiar contacts
are often helpful
in maintaining
reality orientation,
especially if
patient is
hallucinating.

EVALUATION

Patient
maintained
usual reality
orientation
and cognitive
functioning.

events.