Help with care plan for my confused patient

[BekkahE]

Hi guys,

I have to write a care plan for my patient that has post op deliruem, is confused and has a underlying cognitive impairment.

I have chosen to focus on the safety issue and have come up with:

*altered thought process r/t failure in memory and lack of self protective behaviour to address needs for safety,

* Risk for injury r/t unpredictable behaviour and inability to interpert environmental stimuli,

* sleep pattern disturbance r/t alterations in usual sleep habits.

I am just not sure what i would assess to put in the assessment column. I know i would do vitals and maybe a mini mental state exam (9/30) but im not sure what else i would assess to come up with these nursing diagnoises.

any help would be much appreciated! : )

Thanks

[Stevie Boy]

The best thing to do is not assume that the patient is making it hard on you for no apparent reason

A baseline that involves the types of behavior or cognitive deficits the patient had prior to the proceedure and medications that may have been used prop during and post op

Patients also may have had medications they are normally on D/C'd or Held which makes the understanding of Psychotropics and Psychoactive and SSRI's ect important

The ability to metabolize the types of medications that are being used for pain also is critical

Even something as benign as a UTI can drastically affect the LOC in the elderly (Confusion)

The idea is to make sure the patient is recovering and not becoming less responsive per what was normal prior to the procedure