Question

A 78-yr-old woman was transferred to the intensive care unit after emergency abdominal surgery. The nurse notes the patient is disoriented and confused, has incoherent speech, is restless, and agitated. Which action by the nurse is most appropriate?

Reorient the patient.

Answer 1

The nurse should reorient the 78-year-old woman by asking simple questions regarding time, place, and identity to assess her orientation. Additionally, she should create a comfortable environment and monitor for any signs of complications, such as infection, and address them as necessary.

Step-by-step explanation:

The most appropriate action by the nurse for a 78-year-old woman who is disoriented, confused, demonstrating incoherent speech, and displaying restlessness and agitation after surgery is to reorient the patient. The nurse can start by asking the patient simple questions about their awareness of time, place, and person, such as "Do you know what the date is?", "Do you know where you are?", and "What is your name?". This will help to assess the patient’s orientation and immediate recall abilities. Additionally, the nurse should ensure the patient's environment is comfortable, minimize stimuli that could be causing agitation, and engage in calming communication.

Further care involves frequent reassessment and communication with the medical team regarding the patient’s mental status, as well as continued monitoring for any signs of infection or other complications indicated by changes in vital signs or symptoms. If the confusion persists, it may be necessary to look into other potential causes such as medication effects, metabolic imbalances, or infections like a septic condition, and manage those accordingly.