Nursing Dx

Taxonomy II: Perception/Cognition—Class 4 Cognition (00128)
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and/or sleep/wake cycle

Related Factors
Over 60 years of age
Dementia
Alcohol abuse, drug abuse
Delirium [including febrile epilepticum (following or instead of an epileptic attack), toxic and traumatic]
[Medication reaction/interaction; anesthesia/surgery; metabolic imbalances]
[Exacerbation of a chronic illness, hypoxemia]
[Severe pain]
[Sleep deprivation]

Defining Characteristics
SUBJECTIVE
Hallucinations [visual/auditory]
[Exaggerated emotional responses]
OBJECTIVE
Fluctuation in cognition
Fluctuation in sleep/wake cycle
Fluctuation in level of consciousness
Fluctuation in psychomotor activity [tremors, body movement]
Increased agitation or restlessness
Misperceptions, [inappropriate responses]
Lack of motivation to initiate and/or follow through with goaldirected or purposeful behavior

Desired Outcomes/Evaluation
Criteria—Client Will:
• Regain/maintain usual reality orientation and level of consciousness.
• Verbalize understanding of causative factors when known.
• Initiate lifestyle/behavior changes to prevent or minimize recurrence of problem.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify factors present, including substance abuse, seizure history, recent ECT therapy, episodes of fever/pain, presence of acute infection (especially urinary tract infection in elderly client), exposure to toxic substances, traumatic events; change in environment, including unfamiliar noises, excessive visitors.
• Investigate possibility of drug withdrawal, exacerbation of psychiatric conditions (e.g., mood disorder, dissociative disorders, dementia).
• Evaluate vital signs for indicators of poor tissue perfusion (i.e., hypotension, tachycardia, tachypnea).
• Determine current medications/drug use—especially antianxiety agents, barbiturates, lithium, methyldopa, disulfiram, cocaine, alcohol, amphetamines, hallucinogens, opiates (associated with high risk of confusion)—and schedule of use as combinations increase risk of adverse reactions/interactions (e.g., cimetidine + antacid, digoxin + diuretics, antacid + propranolol).
• Assess diet/nutritional status.
• Note presence of anxiety, fear, other physiological reactions.
• Monitor laboratory values, noting hypoxemia, electrolyte imbalances, BUN/Cr, ammonia levels, serum glucose, signs of infection, and drug levels (including peak/trough as appropriate).
• Evaluate sleep/rest status, noting deprivation/oversleeping. Refer to ND disturbed Sleep Pattern, as appropriate.

NURSING PRIORITY NO. 2. To determine degree of impairment:
• Talk with SO(s) to determine historic baseline, observed changes, and onset/recurrence of changes to understand and clarify current situation.
• Evaluate extent of impairment in orientation, attention span, ability to follow directions, send/receive communication, appropriateness of response.
• Note occurrence/timing of agitation, hallucinations, violent behaviors. (“Sundown syndrome” may occur, with client oriented during daylight hours but confused during night.)
• Determine threat to safety of client/others.

NURSING PRIORITY NO. 3. To maximize level of function, prevent further deterioration:
• Assist with treatment of underlying problem (e.g., drug intoxication/ substance abuse, infectious process, hypoxemia, biochemical imbalances, nutritional deficits, pain management).

• Monitor/adjust medication regimen and note response. Eliminate nonessential drugs as appropriate.
• Orient client to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.
• Encourage family/SO(s) to participate in reorientation as well as providing ongoing input (e.g., current news and family happenings).
• Maintain calm environment and eliminate extraneous noise/ stimuli to prevent overstimulation. Provide normal levels of essential sensory/tactile stimulation—include personal items/pictures, and so on.
• Encourage client to use vision/hearing aids when needed.
• Give simple directions. Allow sufficient time for client to respond, to communicate, to make decisions.
• Provide for safety needs (e.g., supervision, siderails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices).
• Note behavior that may be indicative of potential for violence and take appropriate actions.
• Administer psychotropics cautiously to control restlessness, agitation, hallucinations.
• Avoid/limit use of restraints—may worsen situation, increase likelihood of untoward complications.
• Provide undisturbed rest periods. Administer short-acting, nonbenzodiazepine sleeping medication (e.g., Benadryl) at bedtime.

NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Explain reason for confusion, if known.
• Review drug regimen.
• Assist in identifying ongoing treatment needs.
• Stress importance of keeping vision/hearing aids in good repair and necessity of periodic evaluation to identify changing client needs.
• Discuss situation with family and involve in planning to meet identified needs.
• Provide appropriate referrals (e.g., cognitive retraining, substance abuse support groups, medication monitoring program,Meals on Wheels, home health, and adult day care).

Documentation Focus
ASSESSMENT/REASSESSMENT
• Nature, duration, frequency of problem.
• Current and previous level of function, effect on independence/ lifestyle (including safety concerns).

PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.
• Available resources and specific referrals.