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 achieves normal sleep pattern.
* Assess how sleep is altered. Establish whether patient has difficulty falling asleep, awakens during the night or early in the morning, or is experiencing insomnia. It is important to determine an accurate baseline for planning interventions.
* Decrease stimuli before patient goes to bed by suggesting a warm bath, turning down television or radio, and dimming the lights. Sleep and rest will be encouraged when loud stimuli are minimized.
* Decrease intake of caffeinated substances (e.g., tea, colas, coffee). Caffeine stimulates CNS and may interfere with patient’s ability to rest and sleep.
* Evaluate sedative effects of medications and schedule administration to diminish daytime sedation and promote sleep at night. This discourages sleeping during day and promotes restful night sleep.
* If patient is experiencing hypersomnia, discourage sleep during the day. Limit the time patient spends in his or her room and provide stimulating activities. Structured expectations provide a focus for activities, and contact also provides opportunity to examine feelings the patient may be avoiding through excessive sleep.