Nursing Dx

Taxonomy II: Perception/Cognition—Class 4 Cognition (00129)
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior

Related Factors
Alzheimer’s disease [dementia of the Alzheimer’s type]
Korsakoff ’s psychosis
Multi-infarct dementia
Cerebrovascular accident
Head injury

Defining Characteristics
OBJECTIVE
Clinical evidence of organic impairment
Altered interpretation/response to stimuli
Progressive/long-standing cognitive impairment

No change in level of consciousness
Impaired socialization
Impaired memory (short-term, long-term)
Altered personality

Desired Outcome/Evaluation
Criteria—Client Will:
• Remain safe and free from harm.
Family/SO Will:
• Verbalize understanding of disease process/prognosis and client’s needs.
• Identify/participate in interventions to deal effectively with situation.
• Provide for maximal independence while meeting safety needs of client.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impairment:
• Evaluate responses on diagnostic examinations (e.g., memory impairments, reality orientation, attention span, calculations).
• Test ability to receive and send effective communication.
• Note deterioration/changes in personal hygiene or behavior.
• Talk with SO(s) regarding baseline behaviors, length of time since onset/progression of problem, their perception of prognosis, and other pertinent information and concerns for client.
• Evaluate response to care providers/receptiveness to interventions.
• Determine anxiety level in relation to situation. Note behavior that may be indicative of potential for violence.

NURSING PRIORITY NO. 2. To prevent further deterioration/ maximize level of function:
• Provide calm environment, eliminate extraneous noise/stimuli.
• Ascertain interventions previously used/tried and evaluate effectiveness.
• Avoid challenging illogical thinking because defensive reactions may result.
• Encourage family/SO(s) to provide ongoing orientation/ input to include current news and family happenings.
• Maintain reality-oriented relationship/environment (e.g., clocks, calendars, personal items, seasonal decorations). Encourage participation in resocialization groups.

• Allow client to reminisce, exist in own reality if not detrimental to well-being.
• Provide safety measures (e.g., close supervision, identification bracelet, medication lockup, lower temperature on hot water tank).

NURSING PRIORITY NO. 3. To assist SO(s) to develop coping strategies:
• Determine family resources, availability and willingness to participate in meeting client’s needs.
• Identify appropriate community resources (e.g., Alzheimer’s or brain injury support group, respite care) to provide support and assist with problem-solving.
• Evaluate attention to own needs, including grieving process.
• Refer to ND risk for Caregiver Role Strain.

NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Determine ongoing treatment needs and appropriate resources.
• Develop plan of care with family to meet client’s and SO’s individual needs.
• Provide appropriate referrals (e.g.,Meals on Wheels, adult day care, home care agency, respite care).

Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, including current level of function and rate of anticipated changes.
PLANNING
• Plan of care and who is involved in planning.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs/referrals and who is responsible for actions to be taken.
• Available resources, specific referrals made