NCP Disturbed Thought Processes - Disorientation

Nursing Diagnosis: Disturbed Thought Processes - Disorientation
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 experiences reduced disorientation to time, place, person, and situation.
* Patient interacts with others appropriately.
* Patient is assisted in assuming self-care responsibilities to the limits of his or her ability.

Ongoing Assessment

* Assess degree of disorientation to time, place, person, and situation regularly and frequently. This will determine the amount of reorientation and intervention the patient will need to evaluate reality accurately.

Therapeutic Interventions

* Orient to surroundings and reality as needed:
o Use patient’s name when speaking to him or her. This decreases chances for misinterpretation.
o Speak slowly and clearly. Present information in a matter-of-fact manner.
o Refer to the time of day, date, and recent events in your interactions with the patient. Encourage patient to check calendar and clock often to get oriented to time.
o Encourage patient to have familiar personal belongings in his or her environment. These decrease the sense of alienation patient may feel in an environment that is strange. Familiar personal possessions increase the patient’s comfort level.
o Be matter-of-fact and respectful when correcting patient’s misperceptions of reality.
Orientation to one’s environment increases one’s ability to trust others. Increased orientation ensures a greater degree of safety for the patient.
* Use the words "you" and "I," instead of "we." This increases orientation and encourages patient to maintain his or her sense of separateness and personal boundary.