Disoriented Elderly Patient: Quick Nursing Notes

Presentation and Orientation

Patient: older adult, disoriented, believes it is 1974; location referenced as Fulton at her house.
Initial approach: ask what she is thinking about to increase comfort and establish rapport.

Cognitive status: determine current thought content; use simple, open questions to gauge orientation.
Comfort and skin: ensure bed is free of wrinkles to prevent skin breakdown; monitor for skin integrity.
Safety and devices: IV line present; ensure IV does not obstruct movement or increase fall risk; plan for safe mobility.
Mobility risk: recognize elevated fall risk due to age; maintain fall precautions.
Anthropometrics (brief note): patient weight discussed as 118 lbs in transcript; consider weight in positioning and device checks if clinically relevant.

Bed setup: keep bed in a safe position; lower bed height if possible; ensure path to nurse call is clear.
Hygiene and supports: use bedpan appropriately; maintain skin moisture and positioning to reduce breakdown.
Monitoring: observe for confusion escalation and respond with calm, consistent cues.

Recognize and respond to cues: acknowledge statements, avoid arguing about reality, and use supportive language.
Identity and rapport: attempt to learn the patient’s name if possible and address her directly and respectfully.
Documentation mindset: note orientation, comfort level, safety needs, IV status, and skin integrity.

For disoriented elderly patients: prioritize reality orientation, comfort, safety, and IV integrity.
Key safety checks: bed wrinkles, skin integrity, IV patency/position, fall precautions.
Use open-ended, calming questions to assess cognition and comfort; maintain dignity and calm presence.