Provide protective environment; prevent injury.
Assist with self-care.
Promote interaction with others.
Identify resources available for assistance.
Support family involvement in therapy.
Signs of physical agitation are abating and no physical injury occurs.
Improved sense of self-esteem, lessened depression, and elevated mood are noted.
Approaches and socializes appropriately with others, individually and in group activities.
Adequate nutritional intake is achieved/maintained.
Client/family displays effective coping skills and appropriate use of resources.
Plan in place to meet needs after discharge.
1.Assess client's level of disorientation to determine specific requirements for safety.
Knowledge of client's level of functioning is necessary to formulate appropriate
plan of care.
2. Obtain a drug history, if possible, to determine
a. Type of substance(s) used.
b. Time of last ingestion and amount consumed.
c. Length and frequency of consumption.
d. Amount consumed on a daily basis.
3.Obtain urine sample for laboratory analysis of substance content. Subjective history
is often not accurate. Knowledge regarding substance ingestion is important for
accurate assessment of client condition.
4.Place client in quiet, private room. Excessive stimuli increase client agitation.
5. Institute necessary safety precautions:
a. Observe client behaviors frequently; assign staff on one-to-one basis if
condition is warranted; accompany and assist client when ambulating; use
wheelchair for transporting long distances.
b. Be sure that side rails are up when client is in bed.
c. Pad headboard and side rails of bed with thick towels to protect client in
case of seizure.
d. Use mechanical restraints as necessary to protect client if excessive
hyperactivity accompanies the disorientation.
Client safety is a nursing priority.
6.Ensure that smoking materials and other potentially harmful objects are stored
outside client's access. Client...