Confusion; Disorientation; Inappropriate Social Behavior; Altered Mood States; Delusions; Impaired Cognitive Processes
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Cognitive Ability
* Distorted Thought Control
* Safety Behavior: Personal
* Mood Equilibrium
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Delusion Management
* Dementia Management
* Behavior Management
NANDA Definition: Disruption in cognitive operations and activities
Cognitive processes include those mental processes by which knowledge is acquired. These mental processes include reality orientation, comprehension, awareness, and judgment. A disruption in these mental processes may lead to inaccurate interpretations of the environment and may result in an inability to evaluate reality accurately. Alterations in thought processes are not limited to any one age group, gender, or clinical problem. The nurse may encounter the patient with a thought disorder in the hospital or community, but patients with significant thought disorders are likely to be hospitalized or housed in extended care facilities until their symptoms can be reduced sufficiently for them to be safe in a community setting. Wherever the patient is encountered, the nurse is responsible for effecting a treatment plan that responds to the specific needs of the patient for structure and safety, as well as effective treatment for the presenting symptoms. This care plan discusses management in the acute phase of the disorder for the hospitalized patient.
* Defining Characteristics: Disorientation to one or more of the following: time, person, place, situation
* Altered behavioral patterns (e.g., regression, poor impulse control)
* Altered mood states (e.g., lability, hostility, irritability, inappropriate affect)
* Impaired ability to perform self-maintenance activities (e.g., grooming, hygiene, food and fluid intake)
* Altered sleep patterns
* Altered perceptions of surrounding stimuli caused by impairment in the following cognitive processes:
* Ability to reason, problem solve, calculate, and conceptualize
* Altered perceptions of surrounding stimuli caused by hallucinations, delusions, confabulation, and ideas of reference
* Related Factors: Organic mental disorders (non-substance-induced):
o Primary degenerative (e.g., Alzheimer’s disease, Pick’s disease)
o Multi-infarct (e.g. cerebral arteriosclerosis)
* Organic mental disorders associated with other physical disorders:
o Huntington’s chorea
o Multiple sclerosis
o Parkinson’s disease
o Cerebral hypoxia
o Hepatic disease
o Adrenal, thyroid, or parathyroid disorders
o Head trauma
o Central nervous system (CNS) infections (e.g., encephalitis, syphilis, meningitis)
o Intracranial lesions (benign or malignant)
o Sleep deprivation
* Organic mental disorders (substance-induced):
o Organic mental disorders attributed to the ingestion of alcohol (e.g., alcohol withdrawal; dementia associated with alcoholism)
o Organic mental disorders attributed to the ingestion of drugs or mood-altering substances
* Schizophrenic disorders
* Personality disorders in which there is evidence of altered thought processes
* Affective disorders in which there is evidence of altered thought processes
* Expected Outcomes Patient demonstrates socially appropriate behavior, as evidenced by a decrease in suspiciousness, aggression, and provocative behavior.
* Regularly assess patient’s behavior and social interactions for appropriateness. Age, gender, cultural, and personal norms may influence an individual’s behavior. It is not the nurse’s responsibility to generate value judgments on aspects of personal preference. It may be helpful to use considerations of safety when evaluating an individual’s behavior.
* Evaluate the patient’s ability and willingness to respond to verbal direction and limits. A patient who has developed a level of trust in a care provider, as well as a relationship with him or her, may be able to accept direction. The patient’s ability and/or willingness to respond to verbal direction and/or limits may vary with patient’s mood, perceptions, degree of reality orientation, and environmental stressors.
* Observe for statements reflecting a desire or fantasy to inflict harm on self or others. Confusion, disorientation, impaired judgment, suspiciousness, and loss of social inhibitions all may result in socially inappropriate and/or harmful behavior to self or others.
* Maintain routine interactions, activities, and close observation without increasing patient’s suspiciousness. Patients with impaired judgment and loss of social inhibitions require close observation to discourage inappropriate behavior and prevent harm or injury to self and others.
* Develop an open and honest relationship in which expectations are respectfully and clearly verbalized. Make only those promises that can be kept. Keeping promises establishes a sense of trust and reliability between patient and the care provider.
* Verbalize acceptance of patient despite the inappropriateness of his or her behavior. Honesty, openness, and verbalized acceptance of patient increase his or her self-respect and esteem.
* Provide role modeling for patient through appropriate social and professional interactions with other patients and staff. Role modeling provides patient with an opportunity to observe socially appropriate behavior.
* Encourage patient to assume responsibility for own behavior but verbalize your willingness to assist in maintaining appropriate behavior when patient appears to need structure. Encouraging the patient to assume responsibility for own behavior will increase his or her sense of independence; however, the nurse’s intervention will provide a feeling of security and reassurance.
* Provide situations in which group interactions with other patients allows feedback regarding patient’s behavior. It is important for patient to learn socially appropriate behavior through group interactions. This provides an opportunity for the patient to observe the impact his or her behavior has on those around him or her. It also facilitates the development of acceptable social skills.
* Provide positive reinforcement for efforts and appropriate behavior. Confront the patient gently and respectfully when behavior is inappropriate, and withdraw attention that reinforces negative behavior.