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Cognitive Perceptual Health Patterns 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 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 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 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 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 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 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? 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) ____________ 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 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 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) ____________ \ Social interaction (child): Aggressive/ withdrawn? __________ Response to vocalizations? Requests? ______ Family Assessment COGNITIVE– 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 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 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 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 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 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. 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) Acute Confusion (Delirium) Nursing Diagnoses u 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) 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 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 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 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]. 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. . 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; 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 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 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? Have You Selected the Correct Diagnosis? Impaired Home Maintenance 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 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? 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 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); post-trauma, post injury Chronic PainC 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) I 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.