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 exhibits appropriate affect and decreased lability and hostility.
* Assess mood and affect regularly. Affect is defined as an emotion that is immediately expressed and observed. Affect is inappropriate when it is not in conjunction with the content of the patient’s speech and/or ideation. Lability is defined as repeated, abrupt, and rapid changes in affect. Mood is defined as a pervasive and sustained emotion. Frequent and regular assessment of patient’s mood and affect will assist in determining the predominance of a particular affect or mood and any deviations. This assessment will also determine the presence of any lability or hostility.
* Assess for environmental and situational factors that may contribute to the change in mood or affect. It is important to remember that patients with thought disorders may also experience fluctuations in mood and affect based on external stimuli, including environmental and situational factors.
* Demonstrate acceptance of patient as an individual. It is important to communicate to patient one’s acceptance of him or her regardless of his or her behavior.
* Demonstrate tolerance of fluctuations in affect and mood. Address inappropriate affect and mood in a calm, yet firm, manner. Calmness communicates self-control and tolerance of the patient and his or her affect and mood. Addressing and setting limits for inappropriate behavior communicate clear expectations for patient.
* Identify environmental stimuli that cause increased restlessness or agitation for the patient. Remove patient when possible from external stimuli that appear to exacerbate irritable and hostile behavior. The patient’s ability to recognize irritating stimuli and remove himself or herself from the source may be impaired. Removing patient from external stimuli that exacerbate fluctuations in mood and affect encourages a sense of protection and security for patient.
* Encourage involvement in group activities as tolerated. Involvement in group activities is determined by various factors, including the group size, activity level, and patient’s tolerance level. Remain aware that patient’s fluctuations in mood and affect will affect his or her ability to respond appropriately to others and his or her capacity to handle complex and multiple stimuli.