Download Cognitive Percept Lecture-S14

Cognitive Perceptual Health Patterns
Brenda McMillan RN, MS
 iPad Test Could Diagnose Signs Of Dementia In Three Months
(England, 2012)
 Under the process, GPs carry out initial memory tests using
iPad-compatible software that differentiates between patients
with normal and abnormal memory in ten minutes.
 Those who need further investigation are then sent to a
specialist brain health center where brain scans and more
detailed computer tests are carried out using a speciallydesigned program.
Sensory Perception Case Scenario 1
Patrick Matthews, an active and popular college baseball
star, was treated in your emergency department after being
hit in the face with a baseball. He talked a great deal to the
staff about his concerns, and the staff all commented on
how likable he was. Patrick’s eyes needed to be patched,
and he received instructions to stay in an environment with
minimal activity. His father has brought Patrick back to the
hospital today. Patrick has refused to engage in
conversation and has cut off contact with his friends. On the
second night after the injury, Patrick showed signs of
hallucinations that a roommate was talking to him and
delusions that he was being poisoned through his meals.
You have been assigned to give nursing care to Patrick the
next morning.
Sensory Perception Case Scenario
Review the above scenario and reflect on the following areas of
Critical Thinking:
 1. Determine what additional information you might need.
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 2. Identify any specific concerns that you have about
communicating with Patrick.
 3. Considering the information and your concerns, describe
how you feel about being assigned to Patrick.
 4. Examine the possible sources for disturbances in sensory
perception that you believe are critical for Patrick.
 5. Prioritize the areas you need to address in determining your
nursing care.
Lifespan Considerations
 Newborn and Infant
 Toddler and Preschooler
 Child and Adolescent
 Adult and Older Adult
FACTORS AFFECTING SENSORY PERCEPTION
 Environment
 Previous Experience
 Lifestyle and Habits
 Illness
 Medications
 Age
 Variations in Stimulation
INTERNAL FACTORS AFFECTING SENSORY
PERCEPTION
Information
Environment
Altered Sensory Reception
Deprived Environments
Overstimulated Environments
. Case Scenario 2
Charlie Brisco is 62 years old and in the intensive care unit (ICU)
after a car accident. He sustained internal injuries and many
lacerations on his face and arms. He has an IV, urinary catheter,
heart monitor, and nasogastric (NG) tube. The pumps and
monitors give off soft beeps. The ICU has been busy and noisy
since Charlie was admitted
Normal Cognitive Processes
 Cognition is the systematic way in which a person thinks,
reasons, and uses language.
 Each instant of awareness can be defined as a thought, and
awareness itself can be defined as consciousness.
 Attention is the ability to concentrate on and take in specific
sensory stimuli.
 Memory is the ability to recall a thought at least once and
usually again.
 Learning is the capability of the nervous system to store
memories.
 Communication is the exchange of information between at
least two people and involves the use of language to store,
process, and transmit thought content.
Normal Cognitive Function
 Perception of Information
Consciousness
 Thoughts
 Memory
 Speech
Characteristics of Normal Cognition
 Intelligence
Reality Perception
 Orientation
 Recall and Recognition
 Language
NORMAL COGNITIVE PATTERNS
 Attending
Perceiving
 Thinking
 Learning
 Communicating
Lifespan Considerations
 Newborns and Infants
 Toddler and Preschool
 School-Age Child and Adolescent School-age
children
 Adolescence
 Adult and Older Adult
Play activities that incorporate imagination and creativity help to develop
cognitive abilities in
preschoolers.
School-age children delight in learning and show an intense interest in
every experience.
Cognitive development is an ongoing
process as adults encounter
educational, career, and life
experiences.
FACTORS AFFECTING COGNITIVE FUNCTION
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Physiologic Factors
Blood Flow
Nutrition and Metabolism
Fluid and Electrolyte Balance
Sleep and Rest
Self-Concept
Infectious Processes
Degenerative Processes
Pharmacologic Agents
Head Trauma
Environmental Factors
Culture, Values, and Beliefs
Patients might be at risk for cognitive dysfunction related to unfamiliar
environments and procedures.
Deprived Environment: Isolation from routine
environments may contribute to sensory deprivation.
The simple act of touching a patient, or talking, or
listening may provide sensory stimulation
Cognitive-Perceptual Health Pattern
Marjory Gordan
 Describes sensory-perceptual and cognitive pattern.
 Includes the adequacy of sensory modes, such as vision,
hearing, taste, touch, and smell and the compensation or
prostheses currently used.
 Reports of pain perception and how pain is managed are
included.
 Also included are cognitive functional abilities such as
language, memory, judgment, and decision making.
Pattern Assessment
1. Does intracranial pressure fluctuate after a single
activity? a. Yes (Decreased Intracranial Adaptive
Capacity) b. No
2. Does the patient have a problem with appropriate
responses to stimuli? a. Yes (Confusion) b. No
3. Does the patient have a problem with fluctuating
levels of consciousness (in the presence of inappropriate
responses to stimuli)? a. Yes (Acute Confusion) b. No
(Chronic Confusion)
4. Does the patient indicate difficulty in making choices
between options for care? a. Yes (Decisional Conflict
[Specify]) b. No (Readiness for Enhanced Knowledge)
5. Is the patient delaying decision making regarding care
options? a. Yes (Decisional Conflict [Specify]) b. No
(Readiness for Enhanced Knowledge)
Pattern Assessment
 6. Has the patient been disoriented to person, place, and time for more than 3
m 7. Can the patient respond to simple directions or instructions? a. Yes (Readiness
for Enhanced Knowledge) b. No (Impaired Environmental Interpretation Syndrome)
 8. Does the patient indicate lack of information regarding his or her problem? a.
Yes (Deficient Knowledge [Specify]) b. No (Readiness for Enhanced Knowledge)
 9. Can the patient restate the regimen he or she needs to follow for improved
health? a. Yes b. No (Deficient Knowledge [Specify])
 10. Can the patient remember events occurring within the past 4 hours? a. Yes
b. No (Impaired Memory)
 11. Review the mental status examination. Is the patient fully alert? a. Yes b. No
(Disturbed Thought Process or Disturbed Sensory Perception)
 12. Does the patient or his or her family indicate that the patient has any
memory problems? a. Yes (Disturbed Thought Process) b. No
Pattern Assessment
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12. Does
the patient or his or her family indicate that the patient has any
memory problems? a. Yes (Disturbed Thought Process) b. No
 13. Review sensory examination. Does the patient display any sensory
problems? a. Yes (Disturbed Sensory Perception [Specify]) b. No
 14. Does the patient use both sides of his or her body? a. Yes b. No (Unilateral
Neglect)
 15. Does the patient look at, and seem aware of, the affected body side? a. Yes b.
No (Unilateral Neglect)
 16. Does the patient verbalize that he or she is experiencing pain? a. Yes (Acute
Pain; Chronic Pain) b. No
 17. Has the pain been experienced for more than 6 months? a. Yes (Chronic
Pain) b. No (Acute Pain)
 18. Does the patient display any distraction behavior (moaning, crying, pacing,
or restlessness)? a. Yes (Pain) b. No
Adult Assessment/Nursing History
COGNITIVE– PERCEPTUAL PATTERN
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Hearing difficulty? Aid?
 Vision? Wear glasses? Last checked?
 Any change in memory lately?
 Easy/ difficult to make decisions?
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 Easiest way for you to learn things? Any difficulty
learning?
 Any discomfort? Pain? How do you manage it?
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Gordon, Marjory (2010-10-25). Manual of Nursing Diagnosis (p. 13). Jones & Bartlett Learning. Kindle Edition.
Adult Assessment/Nursing History
COGNITIVE– PERCEPTUAL PATTERN
 During history and examination: Orientation ______ Grasp
ideas and questions (abstract, concrete)? __________
 Language spoken; voice and speech pattern _____________
 Vocabulary level ________________________________
 Eye contact ___ Attention span (distraction) ____________
 Nervous (5) or relaxed (1) (rate from 1 to 5) ___________
 Assertive (5) or passive (1) (rate from 1 to 5) ___________
 Interaction with family member, guardian, other (if present)
____________
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Gordon, Marjory (2010-10-25). Manual of Nursing Diagnosis (p. 15). Jones & Bartlett Learning. Kindle Edition.
Infant and Young Child Assessment of
COGNITIVE– PERCEPTUAL PATTERN
Parent’s report of
 General responsiveness of the infant/ child?
 Infant’s response to talking? Noise? Objects? Touch?
 Infant’s following of objects with eyes? Response to crib toys?
 Learning (changes noted)? What is being taught to the infant/
child?
 Noises/ vocalizations? Speech pattern? Words? Sentences?
 Use of stimulation? Talking, games, what else?
 Vision, hearing, touch, kinesthesia of the infant/ child?
 Child’s ability to tell name, time, address, telephone number?
 Infant’s/ child’s ability to identify needs (hunger, thirst, pain,
discomfort)?
Infant and Young Child Assessment of
COGNITIVE– PERCEPTUAL PATTERN
Parents (self)
 Problems with vision, hearing, touch, other senses?
 Difficulties making decisions? Judgments?
Infant and Young Child Assessment of
COGNITIVE– PERCEPTUAL PATTERN
SCREENING EXAMINATION FORMAT
 Infant/ child: responsiveness, cognitive-perceptual
development ______________
 Child: eye contact, speech pattern, posturing ______
 Smiling response (infant) ____________
 Social interaction (child): Aggressive/ withdrawn?
__________
 Response to vocalizations? Requests? ______
Family Assessment of
COGNITIVE– PERCEPTUAL PATTERN
History
 Visual or hearing problems? How managed?
 Any big decisions family has had to make? How made?
Examination
 If indicated, language spoken at home
 Grasp of ideas and questions (abstract or concrete)
 Vocabulary level
Community Assessment of
COGNITIVE– PERCEPTUAL PATTERN
History
 Do most groups speak English? Bilingual?
 Educational level of population?
 Schools seen as good or need improving? Adult education desired or
available?
 Types of problems that require community decisions? Decision-making
process? What is best way to get things done/ changed in community?
Examination
 School facilities, dropout rate.
 Community government structure, decision-making lines.
Critical Care Assessment
COGNITIVE– PERCEPTUAL PATTERN
 Sensory deficits (hearing, vision)?
 Client/ family decisional conflict (need for decisions,
client’s decision-making competency, treatment
preferences documented)?
 Impaired thought processes (confusion: general or
nocturnal; hallucinations)?
 Sensory deprivation or overload (monitors, isolation)?
 Pain (report of severe discomfort/ pain, guarding
behavior, muscle tension, heart rate increases)?
 Knowledge sufficient to reduce fear/ anxiety
(understanding of situation, treatments, care)?
Documentation
COGNITIVE– PERCEPTUAL PATTERN
NURSING HISTORY
 First hospital admission of a 55-year-old, married, obese,
administrator of a Spanish center. Sitting upright in bed, tense
posture and expression. Five-year history of slightly elevated
blood pressure. One-year PTA dizziness lasted 12 hours and
started on medication; two other episodes relieved by rest.
Seeks treatment at emergency room for dizziness and
numbness of left arm.
COGNITIVE PERCEPTUAL PATTERN
 Sight corrected with glasses, changed 1 year ago; no change in
hearing, taste, smell. No perceived change in memory, “I
couldn’t take it if I started losing my mind, like with a stroke.”
Learning ability: sees self as slower than in college, alert
manner, grasps questions easily. Takes no sedatives,
tranquilizers, other drugs. No headache at present.
Nursing Diagnoses
COGNITIVE– PERCEPTUAL PATTERN
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Acute Pain (Specify Type/ Location)
Chronic Pain (Specify Type/ Location)
Ineffective Pain Self-Management (Acute/ Chronic)
Impaired Comfort
Readiness for Enhanced Comfort
Uncompensated Sensory Loss (Specify Type/ Degree)
Sensory Overload
Sensory Deprivation
Unilateral Neglect
Nursing Diagnoses
COGNITIVE– PERCEPTUAL PATTERN
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Deficient Knowledge (Specify Area)
Readiness for Enhanced Knowledge
Ineffective Activity (Task) Planning
Disturbed Thought Processes
Attention– Concentration Deficit
Acute Confusion, Risk for Acute Confusion
Chronic Confusion
Impaired Environmental Interpretation Syndrome,
Uncompensated Memory Loss
Impaired Memory
Nursing Diagnoses
COGNITIVE– PERCEPTUAL PATTERN
 Risk for Cognitive Impairment
 Readiness for Enhanced Decision Making
 Decisional Conflict (Specify)
 Gordon, Marjory (2010-10-25). Manual of Nursing Diagnosis . Jones & Bartlett
Learning. Kindle Edition.
 Can you tell the difference between each f these diagnoses. Review definitions.
Important Differences in Acute Confusion and Dementia
Case Scenario 3
Calling the Physician Concerning a Patient’s Change in Mental Status
Mr. Knaack, age 77 years, has had cognitive changes over the 3 hours
that you have been caring for him. He has gone from being oriented to
time, place, and person to confusion about where he is or why he is
here.
SITUATION: Mr. Knaack has demonstrated cognitive changes over a
short period of time. His speech is slightly slurred, he is lethargic, and
has some left-sided weakness. His blood pressure is 155/96, pulse 82.
BACKGROUND: Mr. Knaack, age 77 years, was admitted last night
following a home repair accident in which he fell from a ladder. He was
admitted for observation with a moderate headache and numerous
bruises.
ASSESSMENT: The family is staying with the patient, but they are
concerned about his changing mentation and stability. I am also
concerned that his change in mental status might indicate
increasing intracranial pressure, possibly a subdural hematoma or
possibly a stroke.
RECOMMENDATION: Could you come and evaluate Mr. Knaack
within the next hour and provide orders for how to proceed?
CRITICAL THINKING CHALLENGE • Consider advantages and
disadvantages of providing this information to the physician over the
phone or via a text message.
• Discuss the rationale for requesting that the physician come and
evaluate Mr. Knaack rather than just providing orders over the phone.
• Are there other data you could collect to support your assessment that
Mr. Knaack may have increased intracranial pressure or a stroke?
• What could you do if the physician does not agree to see the patient
and you are still worried about his declining neurologic status?
• Is there any time when a change in mental status would not require
contacting the physician?
CONFUSION, ACUTE AND CHRONIC
DEFINITIONS
 Acute Confusion Abrupt onset of a cluster of global,
transient changes and disturbances in attention, cognition,
psychomotor activity, level of consciousness, and/or sleepwake cycle.
 Chronic Confusion Irreversible, long-standing and/ or
progressive deterioration of intellect and personality
characterized by decreased ability to interpret
environmental stimuli and decreased capacity for
intellectual thought processes and manifested by
disturbances of memory.
Acute Confusion (DELIRIUM)
General Considerations:
 1.
Acute confusion or delirium can result from
transient biochemical disruptions frequently caused by
medications, infections, dehydration, electrolyte
imbalances, and metabolic disturbances.
 2.
It usually lasts less than 5 days when the underlying
causes are treated.
 3.
Early detection and treatment can prevent
unnecessarily long hospital stays.
 4.
Behavior patterns of acutely confused clients
include hyperactivity, hypoactivity, and mixed.
Acute Confusion
 DEFINITION Abrupt onset of reversible disturbance of consciousness,
attention, cognition, and perception that develop over a short period of
time
 DEFINING CHARACTERISTICS ♦ Fluctuation in cognition ♦ Fluctuation in
level of consciousness ♦ Fluctuation in sleep– wake cycle ♦ Fluctuation
in psychomotor activity ♦ Increased agitation or restlessness ♦
Misperceptions ♦ Lack of motivation to initiate goal-directed behavior ♦
Lack of motivation to follow through with goal-directed behavior ♦ Lack
of motivation to initiate purposeful behavior ♦ Lack of motivation to
follow through with purposeful behavior ♦ Hallucinations
 OUTCOME Cognitive Orientation ♦ Demonstrates ability to identify
person, place and time, accurately
 ETIOLOGICAL OR RELATED FACTORS ♦ Alcohol abuse ♦ Drug abuse ♦
Delirium ♦ Fluctuation in sleep– wake cycle
 HIGH-RISK POPULATIONS ♦ Dementia ♦ Over 60 years of age ♦
Hospitalized elderly ♦ Elderly relocation (e.g., nursing home)
Cognitive Processes Case Scenario 4
You are a nurse working on a general surgical unit of a hospital. A
patient returns to the unit after repair of a broken hip. She
appears agitated and confused despite a pain control regimen of
morphine. The patient’s daughter, Donna, comes to visit and looks
acutely anxious. Donna tells you that her mother lived in a nursing
home for 16 months before falling two nights ago after getting up
to go to the bathroom. Donna says she thinks that the nurses at
the home ignored her mother’s call light because “Mom would
never get up at night without calling a nurse.” While you are
talking with Donna, the patient moans, pulls at intravenous
tubing, and calls for “Dorothy.”
Cognitive Processes Case Scenario
Reflect on the following areas of Critical Thinking:
1. Describe your immediate impressions of this situation.
2. Determine how the information in the scenario and your
own knowledge and values contributed to these
impressions.
3. Given the situation as presented, formulate and prioritize
your plans for nursing interventions.
4. Organize your plans for assessing the patient’s cognitive
function.
Have you selected the correct diagnosis?
 Disturbed Sensory Perception An alteration in one of the senses
could create a short-term confusion that is correctable. If a
sensory deficit is found, the most correct diagnosis is Disturbed
Sensory Perception.
 Disturbed Thought Process The individual has a problem with
cognitive operation and engages in nonreality thinking. Other
functioning is normal.
 Confusion causes problems in both mental and physical
functioning.
 Impaired Memory This diagnosis is related to memory only.
Other cognitive functioning may be normal.
Acute Confusion (Delirium)
Nursing Interventions
1.
Assess for Causative and Contributing Factors
Vision impairment Severe illness Dehydration (blood urea nitrogen/
creatine over 18).
-Pre-existing cognitive impairment
-Environmental Factors Room changes
Presence of medical or chemical restraint
Absence of watch or clock
Absence of support system
Ensure that a thorough diagnostic workup has been completed.
-Psychiatric Evaluation Evaluate for depression
Acute Confusion (Delirium)
Nursing Interventions
2.
Promote the Client’s Sense of Integrity
- Examine knowledge and attitudes about confusion, especially in the
aged.
-Educate family, significant others, and caregivers about the situation and
coping methods (Young, 2001):
-Explain the cause of the confusion.
-Explain that the client does not realize the situation.
-Explain the need to remain patient, flexible, and calm.
-Stress the need to respond to the client as an adult.
-Explain that the behavior is part of a disorder and is not
voluntary.
-Differentiating between acute (reversible) and chronic
(irreversible) confusion is important for family and caregivers
(Miller, 2009).
Acute Confusion (Delirium)
Nursing Interventions
-Maintain standards of empathic, respectful care.
-Be an advocate when other caregivers are insensitive to the
client’s needs.
-Function as a role model with coworkers.
-Provide other caregivers with up-to-date information on
confusion.
-Expect empathic, respectful care and monitor its
administration.
-Attempt to obtain information for conversation (likes,
dislikes; interests, hobbies; work history).
-Interview early in the day.
-Encourage significant others and caregivers to speak slowly
with a low voice pitch and at an average volume (unless
hearing deficits are present), with eye contact, and as if
expecting the client to understand.
Acute Confusion (Delirium)
Nursing Interventions
-Communication can be enhanced with useful and
meaningful topics as one adult to another.
-Provide respect and promote sharing.
-Pay attention to what the client says.
-Pick out meaningful comments and continue talking.
-Call the client by name and introduce yourself each time you
make contact; use touch if welcomed.
-Use the name the client prefers; avoid “Pops” or “Mom,”
which can increase confusion and is unacceptable.
-Convey to the client that you are concerned and friendly
(through smiles, an unhurried pace, humor, and praise; do
not argue).
Acute Confusion (Delirium)
Nursing Interventions
-Focus on the feeling behind the spoken word or action. This
demonstrates unconditional positive regard and
communicates acceptance and affection to a person who has
difficulty interpreting the environment (Hall, 1994).
Acute Confusion (Delirium)
Nursing Interventions
3.
Provide Sufficient and Meaningful Sensory Input
-Reduce abrupt changes in schedule or relocation.
-Keep the client oriented to time and place.
-Refer to time of day and place each morning.
-Provide the client with a clock and calendar large enough to see.
-Ensure corrective lenses are available and used.
-Use nightlights or dim lights at night.
-Use indirect lighting and turn on lights before dark.
-Provide the client with the opportunity to see daylight and dark
through a window, or take the client outdoors.
-Single out holidays with cards or pins (e.g., wear a red heart for
Valentine’s Day). Sensory input is carefully planned to promote
orientation.
Acute Confusion (Delirium)
Nursing Interventions
-Reduce or eliminate: Fatigue
-Change in routine, environment, or caregiver High-stimulus activity
(e.g., crowds) or images (e.g., frightening pictures or movies)
-Frustration from trying to function beyond capabilities or from
being restrained
-Pain, discomforts, illness, or side effects from medications
-Competing or misleading stimuli (e.g., mirrors, television,
costumes). Studies have shown that these factors contribute to
delirium (Feldt & Griffin, 1999; Sanberg et al., 2001; Segatore &
Adams, 2001).
Acute Confusion (Delirium)
Nursing Interventions
-Use adaptive devices to diminish sensory impediments (e.g., lighting,
glasses, hearing aids).
-Encourage the family to bring in familiar objects from home (e.g.,
photographs with nonglare glass, afghan).
Ask the client to tell you about the picture.
Focus on familiar topics. R: “Functional or baseline behavior is
likely to occur when the external demands (stressors) on the
individual are adjusted to the level to which the person has
adapted” Hall, 1991.
Acute Confusion (Delirium)
Nursing Interventions
- In teaching a task or activity— such as eating— break it into small, brief
steps by giving only one instruction at a time.
-Remove covers from food plate and cups. Locate the napkin and
utensils. Add sugar and milk to coffee.
-Add condiments to food (sugar, salt, pepper). Cut foods. Offer
simple explanations of tasks.
- Allow the client to handle equipment related to each task. Allow
the client to participate in the task, such as washing his face.
Acute Confusion (Delirium)
Nursing Interventions
-Acknowledge that you are leaving and say when you will return.
-Memory loss and diminished intellectual functioning create a need
for consistency.
- Sensory input is carefully planned to reduce excess stimuli, which
increase confusion (Miller, 2009).
Acute Confusion (Delirium)
Nursing Interventions
4.
Promote a Well Role
-Allow former habits (e.g., reading in the bathroom). Encourage the
wearing of dentures.
-Ask the client/ significant other about his usual grooming routine and
encourage him to follow it.
-Provide privacy at all times; when it is necessary to expose a body
surface, take precautions to cover all other areas (e.g., if washing a back,
use towels or blankets to cover legs and front torso).
-Provide for personal hygiene according to the client’s preferences (hair
grooming, showers or bath, nail care, cosmetics, deodorants, fragrances).
-Discourage the use of nightclothes during the day; have the client wear
shoes, not slippers.
Acute Confusion (Delirium)
Nursing Interventions
- Promote mobility as much as possible. Have the client eat meals out of
bed, unless contraindicated.
-Promote socialization during meals (e.g., set up lunch for four)
-Plan an activity each day to look forward to (e.g., bingo, ice cream
sundae gathering).
- Encourage participation in decision-making (e.g., selecting what he
wishes to wear).
Acute Confusion (Delirium)
Nursing Interventions
-Discuss Current Events, Seasonal Events (Snow, Water Activities); Share Your
Interests (Travel, Crafts) R: Strategies that emphasize normalcy can contribute
to positive self-esteem and reduce confusion.
-Do Not Endorse Confusion
-Do not argue with the client.
-Determine the best response to confused statements. Sometimes the
confused client may be comforted by a response that reduces his or her
fear; for example, “I want to see my mother,” when his or her mother has
been dead for 20 years. The nurse may respond with, “I know that your
mother loved you.”
-Direct the client back to reality; do not allow him or her to ramble.
-Adhere to the schedule; if changes are necessary, advise the client of
them.
Acute Confusion (Delirium)
Nursing Interventions
-Avoid talking to coworkers about other topics in the client’s presence.
-Provide simple explanations that cannot be misinterpreted.
-Remember to acknowledge your entrance with a greeting and your exit
with a closure (“ I will be back in 10 minutes”).
- Avoid open-ended questions.
-Replace five- or six-step tasks with two- or three-step tasks.
-R: Unconditional positive regard communicates acceptance and affection
to a person who has difficulty interpreting the environment.
-R: Careful listening is critical to evaluate responses to prevent escalation
of anxiety and to detect physiologic discomforts (Miller, 2009).
Acute Confusion (Delirium)
Nursing Interventions
5.
Prevent Injury to the Individual
-Follow institutional procedures for protecting confused persons (e.g.,
sitters).
-Explore other alternatives instead of restraints (Rateau, 2000).
-Put the client in a room with others who can help watch him.
-Enlist the aid of family or friends to watch the client during confused
periods.
- If the client is pulling out tubes, use mitts instead of wrist restraints.
-Refer to Risk for Injury for strategies for assessing and manipulating the
environment for hazards.
-Register with an emergency medical system, including the “wanderers’
list” with the local police department.
-R: Restraints are a violation of a client’s rights and increase anxiety. All
attempts to protect the client should be used instead.
Acute Confusion (Delirium)
Nursing Interventions
6.
Initiate Referrals, as Needed
-Refer caregivers to appropriate community resources.
- R: Additional community services may be needed for management at
home.
Chronic Confusion
 DEFINITION Irreversible long-standing and/ or progressive
deterioration of intellect and personality, characterized by
decreased ability to interpret environmental stimuli and
decreased capacity for intellectual thought processes, and
manifested by disturbances of memory, orientation, and behavior
 DEFINING CHARACTERISTICS ♦ Clinical evidence of organic
impairment ♦ Altered interpretation or response to stimuli ♦
Progressive or long-standing cognitive impairment ♦ No change in
level of consciousness ♦ Impaired socialization ♦ Impaired
memory (short term, long term) ♦ Altered personality
 OUTCOME Cognition ♦ Ability to execute complex mental
processes (if no resolution, see Risk for Injury)
 HIGH-RISK POPULATIONS ♦ Alzheimer’s disease
Mini-Mental Status Exam
 Mini–mental state examination
 The mini–mental state examination (MMSE) or Folstein test is a
brief 30-point questionnaire test that is used to screen for
cognitive impairment. It is commonly used in medicine to screen
for dementia. It is also used to estimate the severity of cognitive
impairment and to follow the course of cognitive changes in an
individual over time, thus making it an effective way to
document an individual's response to treatment.
 http://health.gov.bc.ca/pharmacare/adti/clinician/pdf/ADTI%20SM
MSE-GDS%20Reference%20Card.pdf
Have You Selected the Correct Diagnosis?
 Disturbed Sensory Perception An alteration in one of the senses
could create a short-term confusion that is correctable. If a
sensory deficit is found, the most correct diagnosis is Disturbed
Sensory Perception.
 Disturbed Thought Process The individual has a problem with
cognitive operation and engages in non-reality thinking. Other
functioning is normal.
 Confusion causes problems in both mental and physical
functioning.
 Impaired Memory This diagnosis is related to memory only.
Other cognitive functioning may be normal.
Chronic Confusion (Dementia)
Nursing Interventions
1.
Refer to Interventions Under Acute Confusion
2.
Assess Who the Person Was Before the Onset of Confusion Educational
level, career Hobbies, lifestyle Coping styles NIC Dementia Management:
Multisensory Therapy, Cognitive Stimulation, Calming Technique, Reality
Orientation, Environmental Management: Safety R: Assessing the client’s
personal history can provide insight into current behavior patterns and
3.
Observe the Client to Determine Baseline Behaviors Best time of day
Response time to a simple question Amount of distraction tolerated Judgment
Insight into disability Signs/ symptoms of depression Routine R: Baseline
behavior can be used to develop a plan for activities and daily care routines
Hall, 1994. Promote the Client’s Sense of Integrity (Miller, 2009)
4.
Adapt communication to the client’s level:
Avoid “baby talk” and a condescending tone of voice. Use simple sentences and
present one idea at a time. If the client does not understand, repeat the
sentence using the same words. Use positive statements; avoid “don’ts.” Unless
a safety issue is involved, do not argue.
Chronic Confusion (Dementia)
Nursing Interventions
Avoid questions you know the client cannot answer.
If possible, demonstrate to reinforce verbal communication.
Use touch to gain attention or show concern unless a negative response is
elicited.
Maintain good eye contact and pleasant facial expressions.
Determine which sense dominates the client’s perception of the world
(auditory, kinesthetic, olfactory, or gustatory).
Communicate through the preferred sense. R: Alzheimer’s disease-related
dementia affects communication abilities (i.e., receptive and expressive; Hall,
1994).
Chronic Confusion (Dementia)
Nursing Interventions
5.
Promote the Client’s Safety
Ensure that the client carries identification.
Adapt the environment so the client can pace or walk if desired.
Keep the environment uncluttered.
R: Confused persons are at high risk for injury. Reevaluate whether treatment is
needed.
Chronic Confusion (Dementia)
Nursing Interventions
6.
If Combative, Determine the Source of the Fear and Frustration
Fatigue
Misleading or inappropriate stimuli
Change in routine, environment, caregiver
Pressure to exceed functional capacity
Physical stress, pain, infection, acute illness, discomfort
R: Fatigue is the most frequent cause of dysfunctional episodes.
Physical stressors can precipitate a dysfunctional episode (e.g., urinary tract
infections, caffeine, constipation).
Chronic Confusion (Dementia)
Nursing Interventions
7.
If a Dysfunctional Episode or Sudden Functional Loss Has Occurred
Address the client by surname.
Assume a dependent position to the client.
Distract the client with cues that require automatic social behavior (e.g., “Mrs.
Smith, would you like some juice now?”).
After the episode has passed, discuss the episode with the client.
Document antecedents, behavior observed, and consequences.
R: These strategies can reduce aggression and may prevent future episodes with
careful recording of the episode.
Chronic Confusion (Dementia)
Nursing Interventions
8.
Ensure Physical Comfort and Maintenance of Basic Health Needs
Refer to Self-Care Deficits.
9.
Select Modalities Involving the Five Senses (Hearing, Sight, Smell, Taste,
and Touch) That Provide Favorable Stimuli for the Client
R: Multisensory stimulation with or without a specially designed room has
shown to increase interest in newspapers, motivation, energy levels, smiling,
and personal cleanliness as well as decreased wandering, anxiety, hostility, and
incontinence (Ball & Haight, 2005; Bryant, 1991; Loew & Silverstone, 1971).
Chronic Confusion (Dementia)
Nursing Interventions
Music Therapy
1.
Determine the client’s preferences.
2.
Play this music before the usual level of agitation for at least 30 minutes;
assess response.
3.
Evaluate response, as some music can agitate individuals. Provide soft,
soothing music during meals.
4.
Arrange group songfests with consideration to cultural/ ethical
orientation.
5.
Play music during other therapies (physical, occupational, and speech).
6.
Have the client exercise to music.
7.
Organize guest entertainment.
8.
Use client-developed songbooks (large print and decorative covers).
9.
R: Music therapy at least 30 minutes before the client’s usual peak level
of agitation can reduce agitation (Gerdner, 1999).
Chronic Confusion (Dementia)
Nursing Interventions
Recreation Therapy
1.
Encourage arts and crafts
2.
Suggest creative writing
3.
Provide puzzles
4.
Organize group games
Chronic Confusion (Dementia)
Nursing Interventions
Sensory Training
1.
Stimulate vision (with brightly colored items of different shape, pictures,
colored decorations, kaleidoscopes).
2.
Stimulate smell (with flowers, soothing aromas from lavender or scented
lotion).
3.
Stimulate hearing (play music with soothing sounds such as ocean or
rain).
4.
Stimulate touch (massage, vibrating recliner, fuzzy objects, velvet, silk,
stuffed animals).
5.
Stimulate taste (spices, salt, sugar, sour substances).
Impaired Memory
 DEFINITION Inability to remember or recall bits of information or
behavioral skills (impaired memory may be attributed to pathophysiological or situational causes that are either temporary or
permanent)
 DEFINING CHARACTERISTICS ♦ Observed or reported
experiences of forgetting ♦ Inability to determine whether a
behavior was performed ♦ Inability to learn or retain new skills or
information ♦ Inability to perform a previously learned skill ♦
Inability to recall factual information ♦ Inability to recall recent or
past events ♦ Forgetting to perform a behavior at a scheduled
time
 OUTCOME Memory ♦ Ability cognitively to retrieve and report
previously stored information with or without compensation
 ETIOLOGICAL OR RELATED FACTORS ♦ Acute or chronic hypoxia
♦ Anemia ♦ Decreased cardiac output ♦ Fluid and electrolyte
imbalance ♦ Neurological disturbances ♦ Excessive
environmental disturbances
Impaired Memory
 EXPECTED OUTCOME
Will verbalize recall of [immediate information/recent
information /remote information] by [date].
 TARGET DATES
For some patients, this may be a permanent problem,
so dates would be stated in terms of weeks and
months. For other patients, it would be appropriate to
check for progress within 3 days.
Have You Selected the Correct Diagnosis?
 This diagnosis is very similar to other diagnoses in
this pattern; for example, Confusion and Disturbed
Thought Process. However, this diagnosis relates
specifically to memory problems.
Case Scenario 5: ETHICAL/LEGAL ISSUE
MISTREATMENT OF PATIENT BY STAFF Mr. Schooner, 80 years old,
has entered a long-term care facility because of his forgetfulness,
wandering behavior, and inability to care for himself. He is in good
physical health but has a history of progressive dementia. Although
his family members were reluctant to admit him, they were
exhausted from the constant care that Mr. Schooner required. At the
long-term care facility, Mr. Schooner becomes agitated, has
increased wandering, and talks loudly, which disturbs the staff and
the other residents. You overhear a staff member saying to him, “If
you don’t sit still and be quiet, I’m going to tie you to your bed and
put tape on your mouth!” You are aware that such behavior on the
part of healthcare staff is not reflective of nursing philosophy, but
you have to work closely with this staff
CRITICAL THINKING CHALLENGE
• Identify your concerns about Mr. Schooner. How could the
move to this facility and his cognitive dysfunction be
contributing to his behavior?
• Describe your feelings about the staff member. What ethical
concerns do you face in this situation?
• Identify possible approaches to this state of affairs.
• Recognizing the patient’s dependence and the staff
member’s behavior, define what you feel is your ethically
appropriate behavior.
Social Isolation
 DEFINITION Feelings of aloneness attributed to
interpersonal interaction below level desired or required for
personal integrity
 DEFINING CHARACTERISTICS Diagnostic Cues ♦
Verbalization of isolation from others and one or more of
the following: ♦ Lack of contact with, or absence of,
significant others ♦ Absent or limited contact with
community ♦ Low contact with peers Supporting Cues ♦
Apathy ♦ Seclusion
 OUTCOME Social Involvement ♦ Interacts and participates
in activities with others
 ETIOLOGICAL OR RELATED FACTORS ♦ Impaired mobility ♦
Therapeutic isolation ♦ Sociocultural dissonance ♦
Insufficient community resources ♦ Body image disturbance
♦ Fear (environmental hazards, violence)
 HIGH-RISK POPULATIONS ♦ Frail older persons ♦
Therapeutic isolation ♦ Disfigurement
Social Isolation
EXPECTED OUTCOME
 Will identify [number] of behaviors that will increase
social interactions by [date]. Will participate in
[number] of social activities by [date].
TARGET DATES A target date range of 2 to 7 days
would be acceptable depending on the exact social
interaction chosen.
Have You Selected the Correct Diagnosis?
 Deficient Knowledge Deficient knowledge, particularly as
related to mutuality, would be the most appropriate
alternate diagnosis if the individual verbalized or
demonstrated an inability to attend to significant others’
social actions in the context of independent and
dependent aspects of their role.
 Impaired Verbal Communication would be the most
appropriate diagnosis if the individual is unable to receive
or send communication. Certainly Impaired Verbal
Communication could be related to Impaired Social
Interaction and would be the primary problem that has to
be resolved. Impaired Social Interaction
Have You Selected the Correct Diagnosis?
 Deficient Knowledge Deficient , particularly as related to
mutuality, would be the most appropriate alternate
diagnosis if the individual verbalized or demonstrated an
inability to attend to significant others’ social actions in the
context of independent and dependent aspects of their
role.
 Impaired Verbal Communication would be the most
appropriate diagnosis if the individual is unable to receive or
send communication. Certainly Impaired Verbal
Communication could be related to Impaired Social
Interaction and would be the primary problem that has to
be resolved. Impaired Social Interaction
 Impaired Social Interaction can be either too much or too
little in terms of social activity and is more focused on the
individual’s choice. In Social Isolation, the patient sees this
problem as being caused by others.
Risk for Injury
 DEFINITION Presence of risk factors for trauma to the body
 RISK FACTORS:
 Cognitive Factors ♦ Excess alcohol-ingestion pattern ♦ Impaired judgment
(disease, drugs, impaired reality testing, risk-taking behavior) ♦ Sensoryperceptual loss or deterioration (temperature, touch, position-sense, vision,
hearing) ♦ Disorientation ♦ Unfamiliar setting ♦ Inability to use call light;
inappropriate call-for-aid mechanisms Mobility Factors ♦ Impaired mobility
(specify; e.g., muscle weakness, paralysis, balancing difficulties,
coordination) ♦ Report of dizziness, vertigo, syncope Safety Factors ♦
Smoking in bed or near oxygen ♦ Lack of safety precautions, safety
education ♦ History of previous trauma, accidental injury (falling, car
accidents) ♦ Entering unlighted rooms ♦ Use of cracked dishware or glasses
♦ Use of thin or worn potholders or mitts ♦ Driving mechanically unsafe
vehicles; driving after consuming alcoholic beverages, drugs
Risk for Injury
 RISK FACTORS
 Cognitive Factors ♦ Driving at excessive speeds or without
necessary visual aids ♦ Nonuse or misuse of seat restraints,
headgear for cyclists and passengers ♦ Overexposure to sun or sun
lamps Child Supervision ♦ Bathing in very hot water; unsupervised
bathing of young children ♦ Experimenting with chemicals or
gasoline; contact with acid or alkali ♦ Play or work near vehicle
pathways (driveways, roads, railroad tracks) ♦ Children playing with
matches, candles, cigarettes, fireworks, gunpowder, sharp-edged
toys ♦ Children riding in front seat of automobile; unrestrained
babies riding in car ♦ Children playing without gates at top of stairs
♦ Highly flammable children’s toys or clothing
Risk for Injury
 RISK FACTORS:
 Environment ♦ Sliding on coarse bed linen and
struggling within bed restraints ♦ High beds ♦
Slippery, littered, or obstructed floors, stairs,
walkways (wet, highly waxed, snow, ice) ♦
Unanchored rugs, unsturdy or absent stair rails;
unsteady ladders or chairs ♦ Bathtub without hand
grips or anti-slip equipment ♦ Unanchored electric
wires ♦ Knives stored uncovered ♦ Guns or
ammunition stored in unlocked area ♦ Large icicles
hanging from roof ♦ Overloaded fuse boxes or
Risk for Injury
 RISK FACTORS:
 Environment ♦ High-crime neighborhood, unsafe roads, or road-crossing
conditions ♦ Exposure to dangerous machinery, contact with rapidly
moving machinery, industrial belts, pulleys ♦ Inadequately stored
combustible or corrosive materials (matches, oily rags, lye) ♦ Unsafe
window protection in homes with young children ♦ Insufficient finances to
purchase safety equipment or make repairs
 OUTCOME Physical Injury ♦ Absence of injuries from accidents and trauma
 EXPECTED OUTCOME Will identify [number] of behaviors that will increase
social interactions by [date]. Will participate in [number] of social activities
by [date].
 TARGET DATES A target date range of 2 to 7 days would be acceptable
depending on the exact social interaction chosen.
Impaired Verbal Communication
 DEFINITION Reduced or absent ability to use language in
human interaction
 DEFINING CHARACTERISTICS Diagnostic Cues ♦ Difficulty
expressing thoughts verbally (stuttering, slurring, trouble
forming words or sentences) or unable to speak and/ or ♦
Reports difficulty understanding speech communications
Supporting Cues ♦ Inappropriate verbalization ♦ Dyspnea ♦
Unable to speak dominant language
 OUTCOME Communication ♦ Reception, interpretation,
and expression of spoken, written and nonverbal messages
 ETIOLOGICAL OR RELATED FACTORS ♦ Psychological
barrier (psychosis, lack of stimuli) ♦ Developmental or age
related
 HIGH-RISK POPULATIONS ♦ Physical barrier (brain tumor,
tracheostomy, intubation) ♦ Cultural difference ♦
Impaired Verbal Communication
EXPECTED OUTCOME
 Impaired Verbal Will communicate needs in a manner that is
understood by caregivers via [state specific method (e.g., orally,
esophageal speech, or computer)] by [date]. Readiness for
Enhanced Will verbalize increased satisfaction with
communication by [date].
TARGET DATES
 The target date for resolution of this diagnosis will be longrange. However, 7 days would be appropriate for initial
evaluation. Readiness for Enhanced This positive diagnosis is
appropriate for both short- and long-term goals. An appropriate
target date for initial evaluation of progress would be 1 to 3 days.
Have You Selected the Correct Diagnosis?
 Impaired Verbal Social Isolation can occur because of the
reduced ability or inability of an individual to use language
as a means of communication. The primary diagnosis
would be Impaired Verbal Communication, because
resolution of the problem would assist in alleviating Social
Isolation.
 Disturbed Sensory Perception (Auditory) If the individual
has difficulty in hearing, then he or she would also reflect
Impaired Verbal Communication. The primary problem
would be the auditory difficulty, because correction of this
deficit would help improve communication.
Total Self-Care Deficit (Specify Level)
 DEFINITION Inability to complete feeding, bathing, toileting,
dressing, and grooming of self
 DEFINING CHARACTERISTICS Diagnostic Cues Observation or
valid report of inability to eat, bathe, toilet, dress, and groom self
independently (see defining characteristics for each deficit on pp.
199– 206) Functional Level Classification Level I: Requires use of
equipment or devices Level II: Requires help from another
person( s) for assistance, supervision, teaching Level III: Requires
help from another person( s) and equipment or device Level IV:
Dependent; does not participate in self-care
 OUTCOME Self-Care ♦ Completes feeding, bathing, toileting,
dressing, and grooming of self (specify level to be attained)
 ETIOLOGICAL OR RELATED FACTORS ♦ Decreased activity
tolerance, strength, and/ or endurance ♦ Pain or discomfort ♦
Uncompensated perceptual-cognitive impairment (specify) ♦
Uncompensated neuromuscular impairment (specify) ♦
Uncompensated musculoskeletal impairment (specify) ♦ Severe
anxiety ♦ Depression ♦ Environmental barriers
Total Self-Care Deficit (Specify Level)
 EXPECTED OUTCOME Will return-demonstrate, with
100 percent accuracy, [specify] self-care by [date].
 TARGET DATES Overcoming a self-care deficit will
take a significant investment of time; however, 7 days
from the date of diagnosis would be appropriate to
check for progress.
Have You Selected the Correct
Diagnosis?
 Activity Intolerance This diagnosis implies that the individual is
freely able to move but cannot endure or adapt to the increased
energy or oxygen demands made by the movement or activity.
Activity Intolerance can be a contributing factor to the Impaired
Physical Mobility This diagnosis is quite often a contributing factor
to the development of Self-Care Deficit. It is probable that any time
a patient has Impaired Physical Mobility, he or she will also have
some degree of Self-Care Deficit.
 Disturbed Thought Process If the patient is exhibiting impaired
attention span; impaired ability to recall information; impaired
perception, judgment, and decision making; or impaired conceptual
and reasoning ability, the most proper diagnosis would be Disturbed
Thought Process. Most likely, Self-Care Deficit would be a
companion diagnosis.
Have You Selected the Correct
Diagnosis?
 Ineffective Individual Coping or Compromised or Disabled
Family Coping Suspect one of these diagnoses if there are major
differences between reports by the patient and the family of
health status, health perception, and health care behavior.
Verbalizations by the patient or the family regarding inability to
cope also require looking at these diagnoses.
 Interrupted Family Processes Through observing family
interactions and communication, the nurse may assess that
Interrupted Family Processes should be considered. Poorly
communicated messages, rigidity of family functions and roles,
and failure to accomplish expected family developmental tasks
are a few observations to alert the nurse to this possible
diagnosis.
Impaired Home Maintenance
 DEFINITION Inability to independently maintain a safe, growthpromoting immediate environment (specify mild, moderate,
severe, potential, chronic)
 DEFINING CHARACTERISTICS Diagnostic Cues ♦ Household
members express difficulty in maintaining their home in a
comfortable fashion ♦ Household members request assistance
with home maintenance and one or more of the following: ♦
Disorderly surroundings; repeated hygienic disorders,
infestations, or infections ♦ Offensive odors; accumulation of dirt,
food wastes, or hygienic wastes ♦ Inappropriate household
temperature; unwashed or unavailable cooking equipment,
clothes, or linen ♦ Overtaxed family members (e.g., exhausted,
anxious) ♦ Lack of necessary equipment or aids ♦ Presence of
vermin or rodents ♦ Household members describe outstanding
debts or financial crises OUTCOME Self-Care: Instrumental
Activities of Daily Living ♦ Performs activities needed to function
in the home or community independently with or without
assistive device
Impaired Home Maintenance
 ETIOLOGICAL OR RELATED FACTORS ♦ Individual or family
member illness or injury ♦ Support system deficit ♦ Insufficient
family organization or planning ♦ Insufficient finances,
outstanding debts; financial crises ♦ Unfamiliarity with
neighborhood resources ♦ Impaired cognitive or emotional
functioning ♦ Knowledge deficit (specify area) ♦ Lack of role
modeling
 HIGH-RISK POPULATIONS ♦ Chronic debilitating illness with
fatigue ♦ History of lack of role models for home management
 EXPECTED OUTCOME Will demonstrate alterations necessary to
reduce Impaired Home Maintenance by [date]. Will describe a
plan to improve household safety by [date]. Describes plan for
allocation of family responsibilities to maintain home in a safe
comfortable condition by [date].
 TARGET DATES Target dates will depend on the severity of the
Impaired Home Maintenance. Acceptable target dates for the first
evaluation of progress toward meeting this outcome would be 5
Have You Selected the Correct Diagnosis?
 Activity Intolerance If the nurse observes or validates reports of the
patient’s inability to complete required tasks because of insufficient energy,
then Activity Intolerance would be the more appropriate diagnosis.
 Deficient Knowledge The problem with home maintenance may be due to
the family’s lack of education regarding the care needed and the
environment that is essential to promote this care. If the patient or family
verbalizes less-than-adequate understanding of home maintenance, then
Deficient Knowledge is the more appropriate diagnosis.
 Disturbed Thought Process If the patient is exhibiting impaired attention
span; impaired ability to recall information; impaired perception, judgment,
and decision making; or impaired conceptual and reasoning ability, the most
proper diagnosis would be Disturbed Thought Process. Most likely, Impaired
Home Management would be a companion diagnosis.
Have You Selected the Correct Diagnosis?
 Ineffective Individual Coping or Compromised or Disabled
Family Coping Suspect one of these diagnoses if there are major
differences between reports by the patient and the family of
health status, health perception, and health care behavior.
Verbalizations by the patient or the family regarding inability to
cope also require looking at these diagnoses.
 Interrupted Family Processes Through observing family
interactions and communication, the nurse may assess that
Interrupted Family Processes should be considered. Poorly
communicated messages, rigidity of family functions and roles,
and failure to accomplish expected family developmental tasks
are a few observations to alert the nurse to this possible
diagnosis.
Impaired Environmental Interpretation Syndrome
 DEFINITION Consistent lack of orientation to person, place, time, or
circumstances over more than 3 to 6 months that necessitates a
protective environment
 DEFINING CHARACTERISTICS ♦ Consistent disorientation in known and
unknown environments for more than 3 to 6 months ♦ Chronic
confusional states ♦ Loss of occupational or social functioning from
memory decline ♦ Inability to follow simple directions, instructions ♦
Inability to reason ♦ Inability to concentrate ♦ Slow in responding to
questions
 OUTCOME Cognitive Orientation ♦ Demonstrates ability to identify
person, place and time, accurately
 ETIOLOGICAL OR RELATED FACTORS ♦ Depression ♦ Alcoholism
 HIGH-RISK POPULATIONS ♦ Dementia (Alzheimer’s, multi-infarct
dementia, Pick’s disease, AIDS dementia) ♦ Parkinson’s disease ♦
Huntington’s disease
 TARGET DATES This is a long-term diagnosis, so an appropriate target
date would be expressed in terms of weeks or months.
Have You Selected the Correct Diagnosis?
 This diagnosis refers to a long-term problem
(3 to 6 months) that results in the patient’s
having to be admitted to a protective
environment.
Acute Pain (Specify Type and Location)
 DEFINITION Verbal or coded report of the presence of indicators of
severe discomfort (pain) with a duration of less than 6 months; specify
type and location (joint pain, low back, cervical, knee pain)
 DEFINING CHARACTERISTICS Diagnostic Cues ♦ Report of severe
discomfort (pain) and one or more of the following: ♦ Guarding
behavior, protecting area ♦ Muscle tension increased ♦ Facial mask of
pain (eyes lack luster, “beaten look,” fixed or scattered movement,
grimace) ♦ Restless, irritable ♦ Autonomic responses not seen in
chronic, stable pain (diaphoresis, blood pressure and pulse rate change,
pupillary dilation, increased or decreased respiratory rate) ♦ Distraction
behavior (moaning, crying, pacing, seeking out other people and/ or
activities, restless) ♦ Focus on self ♦ Narrowed focus (altered time
perception, withdrawal from social contact, impaired thought process)
♦ Listless to rigid; antalgic positioning to avoid pain
Acute Pain (Specify Type and Location)
 OUTCOME
 Pain Level ♦ Severity: Absence of pain reports
 ETIOLOGICAL OR RELATED FACTORS ♦ Knowledge deficit (pain
management)
 HIGH-RISK POPULATIONS ♦ Postsurgical (e.g., incisional pain) ♦
Arthritis (e.g., joint pain) ♦ Cardiac (e.g., chest pain) ♦ Injuring
agents (biological, chemical, physical, psychological-stress
related); posttrauma, postinjury
Chronic Pain (Specify Type and Location)
(1986, 1996)
 DEFINITION Severe discomfort (pain) with a duration of more than 6
months; specify type and location (joint pain, low back, cervical, knee pain)
 DEFINING CHARACTERISTICS Diagnostic Cues ♦ Verbal report or observed
evidence of severe discomfort (pain) ♦ Severe discomfort (pain)
experienced for more than 6 months and one or more of the following: ♦
Guarded movement ♦ Altered ability to continue previous activities ♦ Fear
of reinjury ♦ Facial mask (of pain) ♦ Physical and social withdrawal ♦
Anorexia ♦ Weight changes ♦ Delayed sleep onset, sleep deprivation
 OUTCOME Pain Level ♦ Severity: absence of pain reports
 ETIOLOGICAL OR RELATED FACTORS ♦ Knowledge deficit (chronic pain
management)
 HIGH-RISK POPULATIONS ♦ Chronic physical, psychosocial disability
(specify; e.g., cancer)
Ineffective Pain Self-Management (Chronic, Acute)
 DEFINITION Lack of use, or insufficient use, of techniques to reduce pain
(e.g., pain medication requests, timing, positioning, distraction)
 DEFINING CHARACTERISTICS Diagnostic Cues ♦ Communication (verbal
or coded) of pain descriptors ♦ Delayed requests for medication, lack of
use of positioning, distraction, and other pain-management techniques
and one or more of the following: ♦ Guarding behavior, protecting area
♦ Self-focusing ♦ Narrowed focus of attention (e.g., altered time
perception, withdrawal from social contact, impaired thought process)
♦ Distraction behavior (moaning, crying, pacing, seeking out other
people and/ or activities, restless) ♦ Facial mask of pain (eyes lack luster,
“beaten look,” fixed or ♦ Severity: absence of pain reports
 ETIOLOGICAL OR RELATED FACTORS ♦ Insufficient knowledge (specify)
 HIGH-RISK POPULATIONS ♦ Postsurgical (e.g., incisional pain; phantom
pain) ♦ Arthritis (e.g., joint pain) ♦ Cardiac (e.g., chest pain) ♦ Injuring
agents (biological, chemical, physical, psychological-stress related) ♦
Posttrauma
A patient with a history of cerebrovascular
accident with residual left hemiparesis and
dysphagia is hospitalized for malnutrition.
Which of the following could contribute to
his altered sensory perception? Select all that
apply:
a. Overstimulation caused by IV pump and
bed alarms
b. Nutrition imbalance caused by poor oral
intake at home
c. Loss of peripheral vision on the left
d. Loss of self-esteem related to chronic
health
1. a, b, c, d. Overstimulation may heighten cognitive
dysfunction and may be caused by a new
environment, particularly in geriatric populations.
Helplessness and loss of self-esteem may lead to
depression and withdrawal. Sensory reception may be
affected by loss of peripheral vision on the
Left.
An elderly patient is experiencing signs of sensory
perception dysfunction related to the hospital
environment. What nursing interventions could reduce
her risk factors?
a. Lengthy verbal explanations of procedures
b. Controlling the patient’s pain
c. Use of bright lights to minimize visual problems
d. Placing the patient in a shared room for
companionship
b. Pain control will help the patient be better able to focus
on other sensory inputs. Lengthy explanations add to
sensory overstimulation and should not be used with
patients experiencing sensory perception dysfunction.
Lights should be dimmed to decrease sensory
overstimulation. Roommates and their visitors should be
quiet as they create more noise and the patient may
misinterpret overheard conversations, thus contributing to
sensory dysfunction.
A patient is admitted to your skilled nursing facility with
moderate confusion following a hospitalization. Which of
the following should be done first?
a. Clean patient’s glasses and confirm that they are hers
b. Assess current pain level
c. Secure a bed alarm to prevent falls
d. Administer Haldol 0.5 mg IV to decrease agitation
b. Pain can alter an individual’s ability to cope and perceive.
Assessment is the first step in the nursing process. Cleaning the
glasses may be important to minimize altered sensory
perception, and a bed alarm may be indicated intervention
based on the patient’s confusion, but both would be done
following an assessment. Agitation is not stated as an issue at
this time.
You are assigned a patient who is impulsive and unsteady on
her feet. Which of the following would be appropriate to
delegate to the nursing assistant that you are working with?
a. Encourage patient to ambulate
b. Provide bedside commode to maximize independence
c. Turn out all lights to decrease sensory stimulation
d. Assist with bathing and oral hygiene
d. A nursing assistant can encourage independence while providing a
safe setting for ADLs and can assist with sensory aids through touch.
The nurse should first assess the patient’s gait and safety prior to
ambulation. Safety should take precedence over independence in
mobilization, and assistance should be available when out of bed.
Lights should be dim to decrease sensory overstimulation, but nightlights should remain on to assist with safety; this would not be
appropriate use of delegation.
Charlie Brisco is 62 years old and in the intensive
care unit (ICU) after a car accident. He
sustained internal injuries and many lacerations
on his face and arms. He has an IV, urinary
catheter, heart monitor, and nasogastric (NG)
tube. The pumps and monitors give off soft
beeps. The ICU has been busy and noisy since
Charlie was admitted.
A nurse is caring for an elderly patient with altered mental status.
Which of the following are potentially related to impaired
cognition? Select all that apply:
a. Stroke
b. Hypoglycemia (low blood sugar)
c. Hyponatremia (low sodium level)
d. Inadequate sleep
e. Urinary tract infection
a, b, c, d, e. Impaired blood flow to the brain, inadequate or
impaired use of glucose, low sodium levels, impaired rest or
sleep, and infectious processes all may be related to impaired
cognition.
In assessing an elderly patient diagnosed with delirium, which
of the following data would support this diagnosis? Select all
that apply:
a. Patient mental status changes began yesterday
b. Patient believes that the year is 1990
c. Patient is lethargic
d. Patient has no history of drug/alcohol use
a, b, c. Delirium is characterized by acute onset of mental
impairment including confusion and reduced level of
consciousness. Aging, dementia, and drug/alcohol use are also
predisposing factors.
A nurse is setting up the room for a patient with cognitive
impairments related to a brain lesion. Which intervention would best
create a supportive environment for this patient?
a. Posting a sign to remind the patient to call for assistance before
rising
b. Placing a large clock next to the bed
c. Leaving the bed in a locked, low position
d. Limiting visitors and loud stimuli
c. Leaving the bed low and locked will best provide a safe
environment for the patient with cognitive impairment.
Posting a sign may not be appropriate for a confused patient.
A large clock may help with orientation to surroundings but is
not the best answer because safety would be a priority.
Limiting visitors and loud stimuli may decrease confusion but
would not ultimately keep the patient safest.
The nurse is discharging a patient with impaired cognition to home. Which
of the following elements would be important? Select all that apply:
a. Teaching family caregivers effective communication techniques
b. Delaying discharge until cognition improves
c. Discussing options for occupational and speech therapists
d. Providing resources for respite care for family members
a, c, d. Preparing family members for discharge with resources
and techniques to best manage the well-being of this patient is a
priority. It is not appropriate to delay discharge based on the
information given.