Effective nursing care planning and management is important for patients with impaired thought process or cognitive impairment as they aim to promote safety, optimize functioning, and enhance quality of life for these individuals. Get to know the nursing assessment, nursing diagnosis, and interventions for patients with cognitive impairment.
Table of Contents
- Goals and outcomes
- Nursing assessment and rationales
- Nursing Interventions and Rationales
- Recommended Resources
- See also
What is cognitive impairment?
Impairment in cognition describes an individual with altered perception and cognition that interferes with daily living. The alteration can result in cognitive and perceptual deficits, including difficulty concentrating, organizing thoughts, and communicating effectively. Disturbances in thought processes can be caused by various conditions, such as mental illness, substance abuse, brain injury, or medication side effects.
The focus of nursing management is to reduce impairment in thinking and promote reality orientation. Often, confusion in older adults is erroneously attributed to aging. Confusion in an older adult can be caused by a single factor or multiple factors such as depression, dementia, medication side effects, or metabolic disorders. Depression causes impaired thinking in older adults more frequently than dementia.
Disturbances in thought process can be caused by various factors including psychiatric disorders, neurological conditions, substance abuse, medication side effects, and systemic illnesses affecting the brain. Here are some factors that may cause cognitive impairment:
- Head injuries
- Substance abuse
- Late-life depression
Situational (Personal, Environmental)
- Abuse (physical, sexual, mental)
- Childhood trauma
Signs and Symptoms
Common signs and symptoms of cognitive impairment or disturbed thought process may include memory loss, confusion, disorientation, difficulty concentrating, impaired judgment, language difficulties, changes in behavior or personality, and problems with problem-solving and decision-making abilities. Cognitive impairment is characterized by the following signs and symptoms:
- Memory impairment. Significant difficulty in retaining new information or recalling previously learned information.
- Cognitive disorientation. Altered perception of time, place, and person, often resulting in confusion about surroundings and events.
- Impaired attention and concentration. Difficulty focusing, sustaining attention, and staying engaged in activities.
- Executive dysfunction. Challenges in planning, organizing, and executing complex tasks, resulting in difficulties with problem-solving and decision-making.
- Aphasia. Language impairments involving difficulties with speech production, comprehension, or word finding.
- Changes in behavior and personality. Observable alterations in mood, emotions, social interactions, or impulse control.
- Apraxia. Difficulty performing purposeful movements or using objects correctly despite intact motor function.
- Agnosia. Inability to recognize or identify objects, people, or familiar sensory stimuli.
- Disrupted visuospatial abilities. Impairments in perceiving and interpreting spatial relationships, depth perception, or object recognition.
- Psychomotor disturbances. Changes in motor activity, such as agitation, restlessness, or slowed movements.
Goals and outcomes
The following are the common goals and expected outcomes:
- The patient will maintain reality orientation and communicate clearly with others
- The patient will recognize changes in thinking/behavior.
- The patient will recognize and clarifies possible misinterpretations of the behaviors and verbalization of others.
- The patient will identify situations that occur before hallucinations/delusions.
- The patient will use coping strategies to deal effectively with hallucinations/delusions.
- The patient will participate in unit activities.
- The patient will express delusional material less frequently.
- The patient will appropriately interact and cooperates with staff and peers in a therapeutic community setting.
Nursing assessment and rationales
Nursing assessment is crucial for patients with cognitive impairment or disturbed thought processes as it helps identify their specific needs, tailor care interventions, and monitor changes in cognitive function, allowing for individualized and effective care.
1. Identify factors present [acute/chronic brain syndrome (recent stroke, Alzheimer’s disease), brain injury or increased intracranial pressure, anoxic event, acute infections, malnutrition, sleep or sensory deprivation, chronic mental illness (schizophrenia)].
Identifying the factors present is important to know the causative/contributing factors.
2. Determine alcohol/other drug use.
Drugs can have direct effects on the brain, or have side effects, dose-related effects, and/or cumulative effects that alter thought patterns and sensory perception.
3. Assess dietary intake/nutritional status.
This helps in identifying contributing factors.
4. Assess attention span/distractibility and ability to make decisions or problem-solving.
This determines the ability of the p[atient to participate in planning/executing care.
5. Review laboratory values for abnormalities such as metabolic alkalosis, hypokalemia, anemia, elevated ammonia levels, and signs of infection.
Monitoring laboratory values aids in identifying contributing factors.
6. Assist with testing/review results evaluating mental status according to age and developmental capacity.
This is to assess the degree of impairment.
7. Interview SO or caregiver to determine the patient’s usual thinking ability, changes in behavior, length of time the problem has existed, and other pertinent information.
This is to provide a baseline for comparison.
8. Perform periodic neurological/behavioral assessments, as indicated, and compare with baseline.
Early recognition of changes promotes proactive modifications to the plan of care.
Nursing Interventions and Rationales
Nursing interventions play a crucial role in supporting patients with cognitive impairment or disturbed thought processes by ensuring their safety, facilitating effective communication, promoting cognitive functioning, and enhancing their overall well-being and quality of life.
1. Assist with treatment for underlying problems, such as anorexia, brain injury/increased intracranial pressure, sleep disorders, and biochemical imbalances.
Cognition/thinking often improves with treatment/correction of medical/psychiatric problems.
2. Reorient to time/place/person, as needed.
The inability to maintain orientation is a sign of deterioration.
3. Have the patient write name periodically; keep this record for comparison and report differences.
These are important measures to prevent further deterioration and maximize the level of function.
5. Schedule structured activities and rest periods.
This provides stimulation while reducing fatigue.
6. Maintain a pleasant and quiet environment and approach patients in a slow and calm manner.
A patient may respond with anxious or aggressive behaviors if startled or overstimulated.
7. Present reality concisely and briefly and do not challenge illogical thinking. Avoid vague or evasive remarks.
Delusional patients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.
8. Be consistent in setting expectations, enforcing rules, and so forth.
Clear, consistent limits provide a secure structure for the patient.
9. Reduce provocative stimuli, negative criticism, arguments, and confrontations.
This is to avoid triggering fight/flight responses.
10. Refrain from forcing activities and communications.
Patients may feel threatened and may withdraw or rebel.
11. Do not flood the patient with data regarding his or her past life.
Individuals who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state.
12. Identify specific conflicts that remain unresolved, and assist the patient to identify possible solutions.
Unless these underlying conflicts are resolved, any improvement in coping behaviors must be viewed as only temporary.
13. Provide a nutritionally well-balanced diet, incorporating the patient’s preferences as able. Encourage the patient to eat. Provide a pleasant environment and allow sufficient time to eat.
These enhance intake and general well-being.
14. Recognize and support the patient’s accomplishments (projects completed, responsibilities fulfilled, or interactions initiated).
Recognizing the patient’s accomplishments can lessen anxiety and the need for delusions as a source of self-esteem.
15. Use touch cautiously, particularly if thoughts reveal ideas of persecution.
Patients who are suspicious may perceive touch as threatening and may respond with aggression.
16. Use the techniques of consensual validation and seeking clarification when communication reflects an alteration in thinking. (Examples:”Could you clarify what you mean?” or “I’m not quite following, could you please explain?”)
These techniques reveal to the patient how he or she is being perceived by others, while the responsibility for not understanding is accepted by the nurse.
17. Engage the patient in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups.
A distrustful patient can best deal with one person initially. The gradual introduction of others when the patient can tolerate is less threatening.
18. Encourage the patient to verbalize true feelings. Avoid becoming defensive when angry feelings are directed at him or her.
Verbalization of feelings in a non-threatening environment may help the patient come to terms with long-unresolved issues.
19. Teach the patient to intervene, using thought-stopping techniques, when irrational or negative thoughts prevail.
Thought stopping involves using the command “stop!” or loud noise (such as hand clapping) to interrupt unwanted thoughts. This noise or command distracts the individual from the undesirable thinking that often precedes undesirable emotions or behaviors.
20. Encourage the patient to participate in resocialization activities/groups when available.
This is to maximize the level of function.
21. Assist in identifying ongoing treatment needs/rehabilitation programs for the individual.
This measure is important to maintain gains and continue progress if able.
22. Identify problems related to aging that are remediable and assist the patient to seek appropriate assistance/access resources.
These encourage problem-solving to improve conditions rather than accept the status quo.
23. Assist the patient and SO develop a plan of care when problems are progressive/long-term.
Advanced planning addressing home care, transportation, assistance with care activities, support and respite for caregivers, enhance management of patients in a home setting.
24. Refer to community resources (e.g., daycare programs, support groups, drug/alcohol rehabilitation, and mental health treatment programs).
These measures are necessary to promote wellness.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.