Download Cognitive Percept Lecture

Cognitive Perceptual Health
Patterns
 iPad Test Could Diagnose Signs Of Dementia In
Three Months (England, 2012)
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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
specially-designed 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.
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
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Newborn and Infant
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Toddler and Preschooler
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Child and Adolescent
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Adult and Older Adult
FACTORS AFFECTING SENSORY PERCEPTION
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Environment
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Previous Experience
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Lifestyle and Habits
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Illness
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Medications
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Age
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Variations in Stimulation
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INTERNAL FACTORS AFFECTING SENSORY
PERCEPTION
Information
Environment
Altered Sensory Reception
Deprived Environments
Overstimulated Environments
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.
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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
Communication
Lifespan Considerations
 Newborns and Infants
 Toddler and Preschool
 School-Age Child and Adolescent School-age children
 Adolescence
 Adult and Older Adult
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
ensory stimulation
provide
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Cognitive-Perceptual Health Pattern
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.
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)
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
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
Hearing difficulty? Aid?
Vision? Wear glasses? Last checked?
Any change in memory lately?
Easy/ difficult to make decisions?
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) ___________
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Interaction with family member, guardian, other (if present) ____________
Gordon, Marjory (2010-10-25). Manual of Nursing Diagnosis (p. 15). Jones & Bartlett
Learning. Kindle Edition.
Assessment of
Infant and Young Child
Parent’s report of
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General responsiveness of the infant/ child?
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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 Status
Parents (self)
Problems with vision, hearing, touch, other senses?
Difficulties making decisions? Judgments?
Infant/ child: responsiveness, cognitive-perceptual development ______________
Child: eye contact, speech pattern, posturing ______
Smiling response (infant) ____________
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Social interaction (child): Aggressive/ withdrawn? __________
Response to vocalizations? Requests? ______
Family Assessment
COGNITIVE–
History
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Visual or hearing problems? How managed?
Any big decisions family has had to make? How made?
Examination
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If indicated, language spoken at home
Grasp of ideas and questions (abstract or concrete)
Vocabulary level
Community Assessment PATTERN
History
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Do most groups speak English? Bilingual?
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Educational level of population?
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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
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School facilities, dropout rate.
Community government structure, decision-making lines.
Critical Care Assessment
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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 PATTERN
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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
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– PPTUAL PATTERN
Risk for Cognitive Impairment
Readiness for Enhanced Decision Making
Decisional Conflict (Specify)
Testing primarily on Acute and Chronic Confusion.
diagnoses
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Generally need to know Definition of other
Gordon, Marjory (2010-10-25). Manual of Nursing Diagnosis . Jones & Bartlett Learning.
Kindle Edition.
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 sleep-wake cycle.
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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.
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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
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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
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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)
Acute Confusion (Delirium) Nursing Diagnoses
u selected the correct diagnosis?
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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)
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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 Exa
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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%20SMMSE-GDS%20Reference
%20Card.pdf
Hae You Selected
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Chronic Confusion (Dementia) Nursing Diagnoses
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
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Impaired Memory This diagnosis is related to memory only. Other cognitive functioning
may be normal.
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
EXPECTED OUTCOME
Will verbalize recall of [immediate information/recent information /remote
information] by [date].
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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.
Social Isolation
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
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.
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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) ♦ Sensory-perceptual 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;
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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, un-sturdy 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 electrical outlets; faulty electrical plugs,
frayed wires; defective appliances ♦ Pot handles facing toward front of stove ♦ Potential
igniting gas leaks; delayed lighting of fast burner or oven; grease waste collected on
stoves
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
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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 ♦ Anatomical defects (cleft palate) ♦ Decrease in circulation to brain
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 communication. Will verbalize increased satisfaction with
communication by [date]. \
TARGET DATES
The target date for resolution of this diagnosis will be long-range. 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?
Total Self-Care Deficit (Specify Level)
Total Self-Care Deficit
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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)
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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?
Have You Selected the Correct Diagnosis?
Impaired Home Maintenance
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Impaired Home Maintenance
DEFINITION Inability to independently maintain a safe, growth-promoting 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 Mai
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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 to 7 days.
Have You Selected the Correct Diagnosis?
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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)
Acute Pain
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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)
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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); post-trauma, post injury
Chronic PainC Pain (Specify Type and Location)
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(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)
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Ineffective Pain Management: Chronic
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
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.