Nurse's Pocket Guide

impaired ENVIRONMENTAL INTERPRETATION SYNDROME
• Determine presence of medical conditions and/or behaviors
leading to client’s current situation to identify potentially
useful interventions and therapies.
• Note presence/reports of client’s misinterpretation of environmental
information (e.g., sensory, cognitive, or social cues).
• Discuss history and progression of condition, length of
time since onset, future expectations, and incidents of
injury/accidents.
• Review client’s behavioral changes with SO(s) to note differences
in viewpoint, as well as to identify additional impairments
(e.g., decreased agility, reduced ROM of joints, loss of
balance, decline in visual acuity, failure to eat, loss of interest
in personal grooming, and forgetfulness resulting in
unsafe actions).
• Identify actual and/or potential environmental dangers and
client’s level of awareness (if any) of threat.
• Test ability to receive and send effective communication.
Client may be nonverbal or require assistance with/interpretation
of verbalizations.
• Review with client/SO(s) previous/usual habits for activities,
such as sleeping, eating, self-care, to include in plan of care.
• Determine anxiety level in relation to situation. Note behavior
that may be indicative of potential for violence.
• Evaluate responses on diagnostic examinations (e.g., memory
impairments, reality orientation, attention span, calculations).
A combination of tests (e.g., Confusion Assessment
Method [CAM], Mini-Mental State Examination [MMSE],
Alzheimer’s Disease Assessment Scale [ADAS-cog], Brief
Dementia Severity Rating Scale [BDSRS], and Neuro Psychiatric
Inventory [NPI]) is often needed to determine client’s
overall condition relating to chronic/irreversible condition.
NURSING PRIORITY NO.2.To promote safe environment:
• Collaborate in management of treatable conditions (e.g., infections,
malnutrition, electrolyte imbalances, and adverse medication
reactions) that may contribute to/exacerbate confusion.
• Provide calm environment; eliminate extraneous noise/stimuli
that may increase client’s level of agitation/confusion.
• Keep communication/questions simple. Use concrete terms
and words that client can recognize. (Refer to ND impaired
verbal Communication for additional interventions.)
• Use family/other interpreter, as needed, to comprehend
client’s communications.
• Provide/promote use of glasses, hearing aids, and adequate
lighting to optimize sensory input.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
284 Cultural Collaborative Community/Home Care