NCP Disturbed Thought Processes - Altered Perceptions of Surrounding Stimuli Confusion; Disorientation; Inappropriate Social Behavior

Nursing Diagnosis: Disturbed Thought Processes - Altered Perceptions of Surrounding Stimuli
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
* Presence
* 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:
o Memory
o Judgment
o Comprehension
o Concentration
* 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 Dementia
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 Hypertension
o Hepatic disease
o Epilepsy
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 will demonstrate reality-based perceptions, as evidenced by decreased verbalizations of hallucinations and delusions and decreased threats to self and others.

Ongoing Assessment

* Assess and observe patient’s ability to verbalize own needs and trust those around him or her.
* Assess patient’s memory (recent and remote).
* Assess and observe patient’s judgment and awareness of safety.
* Assess ability to concentrate, follow instructions, and problem solve on an ongoing basis.
* Assess patient’s communication patterns. Observe for the presence of delusions and/or hallucinations. Delusions are false beliefs that have no basis in reality.They may be fixed (persistent) or transient (episodic). Hallucinations are perceptions of external stimuli without the actual presence of those stimuli. Hallucinations may be visual, auditory, olfactory, tactile, and gustatory and are perceived by patient as real.

Therapeutic Interventions

* Encourage patient to communicate own thoughts and perceptions with significant others in the environment. Validation of patient’s needs, thoughts, and perceptions will encourage trust and openness.
* Clarify patient’s misperceptions of events and situations that may result from memory impairment. Clarification is necessary and more easily accepted when offered in a respectful manner.
* Orient to time, place, person, and situation as needed. The patient’s ability to orient himself or herself may be impaired by memory loss.
* Minimize situations that provoke anxiety. Anxiety may impair patient’s ability to communicate, problem solve, and reason.
* Provide protective supervision. The patient’s safety is a priority. The patient may be unable to accurately assess potentially dangerous items and situations such as wet floors, electrical appliances, and verbal threats from other patients as a result of severe impairment in judgment.
* If patient is experiencing delusional thinking, assist him or her in recognizing the delusions. Acknowledge the delusions without agreeing to the content of the delusions. Delusions can be anxiety-provoking and distressing for patient. It is important to acknowledge this distress but to convey that one does not accept the delusions as real.
* If patient is experiencing hallucinations (e.g., as indicated by inappropriate gestures, laughter, talking to oneself without the presence of others):
o Communicate verbally with patient by using concrete and direct words and avoiding gesturing so the patient is not threatened by the care provider.
o Encourage patient to inform staff when experiencing hallucinations. Contact from care provider can often distract the patient from the hallucination.
o Discuss content of the hallucinations to determine appropriate interventions. The nurse may be able to take measures that will reduce the frequency of the hallucination (e.g., leaving the lights on, or the door open).
o Determine whether the hallucinations are resulting in thoughts and/or plans to harm himself or herself or others. This enables the nurse to take protective measures for the safety of the patient and others.