Altered Mental Status - 69 y/o Male (Neuman's (Psychological:…
Altered Mental Status
- 69 y/o Male
Patient often lost focus while assessing cranial nerves. Occasional mumbled speech. Difficulty bringing spoon to mouth when eating; often missed, hitting chin or cheeks.
History of alcohol abuse
“If you ever [start a relationship], give it your all, son. Give one-hundred percent to that girl and don’t make the same mistakes I did, drinking all the goddam time.”
“I had a girl once (patient started crying). She was the best thing that ever happened to me.”
“Now I’m here without anyone, sh*tting in a diaper”
Acute confusion related to alcohol abuse as evidenced by inappropriate responses and fluctuating cognition.
Patient will maintain functional capacity and demonstrate appropriate motor behavior by the end of shift.
Promote early mobilization and rehabilitation.
Impaired mobility is a risk factor for developing delirium (Brouquet et al, 2010)
Use gentle, caring communication; provide reassurance of safety; give simple explanations of procedures (Bourne, 2008).
Clients with delirium often respond to caring even though they may not understand the verbal message
Modulate sensory exposure and establish a calm environment.
Environments with too much or too little stimulation may precipitate delirium; noise reduction, appropriate lighting based on time of day, reduced clutter, and quiet music are strategies that may impact delirium (Schreier, 2010).
Patient was able to participate in some ADLs such as oral care and brushing hair, however, the patient struggled to bring spoon to mouth during lunch (last meal before end of shift).
Goal Partially Met
Planning for the patient to demonstrate appropriate motor behavior was unattainable in time period given. More time to evaluate progress needed.
Patient’s statements about failed relationship and loneliness suggested intra-personal stressors pertaining to past decisions about alcohol.
Patient had one sister who he refused to call when attempting to locate post-discharge housing (
). The patient was previously living in Leisurely Village, however, was being asked to leave due to being two months behind on rent (
Patient displayed appropriate developmental stage for age (69 yrs).
Patient stated no spiritual or religious preference when interviewed.