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 participates in activities of daily living (ADLs) and self-care measures to the limits of his or her ability.
* Regularly assess patient’s ability and motivation to initiate, perform, and maintain self-care activities. Assessment can identify areas of physical care in which the patient needs assistance. These areas of physical care include nutrition, elimination, sleep, rest, exercise, bathing, grooming, and dressing. It is important to distinguish between ability and motivation in the initiation, performance, and maintenance of self-care activities. Patients may have the ability and minimal motivation, or motivation and minimal ability.
* Obtain history from patient, family, and friends regarding patient’s dietary habits. Information about patient’s dietary habits is important in determining the presence of food allergies. It can also determine patient’s personal food preferences, cultural dietary restrictions, and ability to verbalize hunger.
* Obtain accurate weight and maintain ongoing records through patient’s length of treatment. Weigh patient on a scheduled basis (e.g., weekly or monthly). Accurate records of patient’s body weight help determine significant fluctuations.
* Maintain adequate records of the patient’s intake and output, elimination patterns, and any associated concerns verbalized by patient. The patient with impaired thought processes may be unable to self-monitor intake, output, and elimination patterns.
* Monitor laboratory values and report any significant changes. Laboratory data provide objective information regarding the adequacy of patient’s nutritional status.
* Obtain information from patient’s family regarding personal grooming and hygiene habits. This information will assist in developing a specific plan for grooming and hygiene activities.
* Obtain dietary consultation and determine the number of calories patient will require to maintain adequate nutritional intake based on body weight and structure. The patient with an altered thought process may be impaired in maintaining adequate nutritional intake.
* Encourage adequate fluid intake and physical exercise. Both ongoing exercise and adequate fluid intake help prevent constipation.
* Assist patient with bathing, grooming, and dressing as needed. The patient with impaired thought processes may be unable to perform grooming activities.
* Provide patient with positive reinforcement for his or her efforts in maintaining self-care activities. Positive reinforcement is perceived by patient as support.