2. Cognitive Perceptual Health Patterns Brenda McMillan RN, MS

14.  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.

15. 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 1

16. 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. Sensory Perception Case Scenario

17.  Newborn and Infant  Toddler and Preschooler  Child and Adolescent  Adult and Older Adult Lifespan Considerations

19.  Environment  Previous Experience  Lifestyle and Habits  Illness  Medications  Age  Variations in Stimulation FACTORS AFFECTING SENSORY PERCEPTION

21.  Information  Environment  Altered Sensory Reception  Deprived Environments  Overstimulated Environments INTERNAL FACTORS AFFECTING SENSORY PERCEPTION

23. . Case Scenario 2 Charlie Brisco is 62 years old and in the intensive care unit (ICU) after a car accident. He sustained internal injuries and many lacerations on his face and arms. He has an IV, urinary catheter, heart monitor, and nasogastric (NG) tube. The pumps and monitors give off soft beeps. The ICU has been busy and noisy since Charlie was admitted

26.  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 Processes

27.  Perception of Information  Consciousness  Thoughts  Memory  Speech Normal Cognitive Function

28.  Intelligence  Reality Perception  Orientation  Recall and Recognition  Language Characteristics of Normal Cognition

29.  Attending  Perceiving  Thinking  Learning  Communicating NORMAL COGNITIVE PATTERNS

30.  Newborns and Infants  Toddler and Preschool  School-Age Child and Adolescent School-age children  Adolescence  Adult and Older Adult Lifespan Considerations

32. Play activities that incorporate imagination and creativity help to develop cognitive abilities in preschoolers.

33. School-age children delight in learning and show an intense interest in every experience.

34. Cognitive development is an ongoing process as adults encounter educational, career, and life experiences.

36. Physiologic Facto rs  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 FACTORS AFFECTING COGNITIVE FUNCTION

37. Patients might be at risk for cognitive dysfunction related to unfamiliar environments and procedures.

38. Deprived Environment: Isolation from routine environments may contribute to sensory deprivation.

39. The simple act of touching a patient, or talking, or listening may provide sensory stimulation

40.  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. Cognitive-Perceptual Health Pattern Marjory Gordan

42. Pattern Assessment

43.  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 Pattern Assessment

44.  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 Pattern Assessment

45.  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

46.  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. Adult Assessment/Nursing History COGNITIVE– PERCEPTUAL PATTERN

47. 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– PERCEPTUAL PATTERN

48. Parents (self)  Problems with vision, hearing, touch, other senses?  Difficulties making decisions? Judgments? Infant and Young Child Assessment of COGNITIVE– PERCEPTUAL PATTERN

49.  Infant/ child: responsiveness, cognitive-perceptual development ______________  Child: eye contact, speech pattern, posturing ______  Smiling response (infant) ____________  Social interaction (child): Aggressive/ withdrawn? __________  Response to vocalizations? Requests? ______ Infant and Young Child Assessment of COGNITIVE– PERCEPTUAL PATTERN SCREENING EXAMINATION FORMAT

50. 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 Family Assessment of COGNITIVE– PERCEPTUAL PATTERN

51. 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. Community Assessment of COGNITIVE– PERCEPTUAL PATTERN

52.  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)? Critical Care Assessment COGNITIVE– PERCEPTUAL PATTERN

53. 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. Documentation COGNITIVE– PERCEPTUAL PATTERN

54.  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 Nursing Diagnoses COGNITIVE– PERCEPTUAL PATTERN

55.  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 Nursing Diagnoses COGNITIVE– PERCEPTUAL PATTERN

56.  Risk for Cognitive Impairment  Readiness for Enhanced Decision Making  Decisional Conflict (Specify)  Gordon, Marjory (2010-10-25). Manual of Nursing Diagnosis. Jones & Bartlett Learning. Kindle Edition.  Can you tell the difference between each f these diagnoses. Review definitions. Nursing Diagnoses COGNITIVE– PERCEPTUAL PATTERN

58. Important Differences in Acute Confusion and Dementia

59. Case Scenario 3 Calling the Physician Concerning a Patient’s Change in Mental Status Mr. Knaack, age 77 years, has had cognitive changes over the 3 hours that you have been caring for him. He has gone from being oriented to time, place, and person to confusion about where he is or why he is here. SITUATION: Mr. Knaack has demonstrated cognitive changes over a short period of time. His speech is slightly slurred, he is lethargic, and has some left-sided weakness. His blood pressure is 155/96, pulse 82. BACKGROUND: Mr. Knaack, age 77 years, was admitted last night following a home repair accident in which he fell from a ladder. He was admitted for observation with a moderate headache and numerous bruises.

60. ASSESSMENT: The family is staying with the patient, but they are concerned about his changing mentation and stability. I am also concerned that his change in mental status might indicate increasing intracranial pressure, possibly a subdural hematoma or possibly a stroke. RECOMMENDATION: Could you come and evaluate Mr. Knaack within the next hour and provide orders for how to proceed?

61. CRITICAL THINKING CHALLENGE Consider advantages and disadvantages of providing this information to the physician over the phone or via a text message. Discuss the rationale for requesting that the physician come and evaluate Mr. Knaack rather than just providing orders over the phone. Are there other data you could collect to support your assessment that Mr. Knaack may have increased intracranial pressure or a stroke? What could you do if the physician does not agree to see the patient and you are still worried about his declining neurologic status? Is there any time when a change in mental status would not require contacting the physician?

62.  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. CONFUSION, ACUTE AND CHRONIC DEFINITIONS

63.  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 (DELIRIUM) General Considerations:

64.  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

65. 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 4

66. 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. Cognitive Processes Case Scenario

68.  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. Have you selected the correct diagnosis?

69. Acute Confusion (Delirium) Nursing Interventions

85.  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 Chronic Confusion

86.  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%20SM MSE-GDS%20Reference%20Card.pdf http://health.gov.bc.ca/pharmacare/adti/clinician/pdf/ADTI%20SM MSE-GDS%20Reference%20Card.pdf Mini-Mental Status Exam

89.  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 This diagnosis is related to memory only. Other cognitive functioning may be normal. Have You Selected the Correct Diagnosis?

91. Chronic Confusion (Dementia) Nursing Interventions

100.  DEFINITION Inability to remember or recall bits of information or behavioral skills (impaired memory may be attributed to patho- physiological 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 Impaired Memory

101.  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. Impaired Memory

102.  This diagnosis is very similar to other diagnoses in this pattern; for example, Confusion and Disturbed Thought Process. However, this diagnosis relates specifically to memory problems. Have You Selected the Correct Diagnosis?

103. Case Scenario 5: ETHICAL/LEGAL ISSUE MISTREATMENT OF PATIENT BY STAFF Mr. Schooner, 80 years old, has entered a long-term care facility because of his forgetfulness, wandering behavior, and inability to care for himself. He is in good physical health but has a history of progressive dementia. Although his family members were reluctant to admit him, they were exhausted from the constant care that Mr. Schooner required. At the long-term care facility, Mr. Schooner becomes agitated, has increased wandering, and talks loudly, which disturbs the staff and the other residents. You overhear a staff member saying to him, “If you don’t sit still and be quiet, I’m going to tie you to your bed and put tape on your mouth!” You are aware that such behavior on the part of healthcare staff is not reflective of nursing philosophy, but you have to work closely with this staff

104. CRITICAL THINKING CHALLENGE Identify your concerns about Mr. Schooner. How could the move to this facility and his cognitive dysfunction be contributing to his behavior? Describe your feelings about the staff member. What ethical concerns do you face in this situation? Identify possible approaches to this state of affairs. Recognizing the patient’s dependence and the staff member’s behavior, define what you feel is your ethically appropriate behavior.

105.  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 Social Isolation

106. 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. Social Isolation

107.  Deficient Knowledge Deficient knowledge, particularly as related to mutuality, would be the most appropriate alternate diagnosis if the individual verbalized or demonstrated an inability to attend to significant others’ social actions in the context of independent and dependent aspects of their role.  Impaired Verbal Communication would be the most appropriate diagnosis if the individual is unable to receive or send communication. Certainly Impaired Verbal Communication could be related to Impaired Social Interaction and would be the primary problem that has to be resolved. Impaired Social Interaction Have You Selected the Correct Diagnosis?

108.  Deficient Knowledge Deficient, particularly as related to mutuality, would be the most appropriate alternate diagnosis if the individual verbalized or demonstrated an inability to attend to significant others’ social actions in the context of independent and dependent aspects of their role.  Impaired Verbal Communication would be the most appropriate diagnosis if the individual is unable to receive or send communication. Certainly Impaired Verbal Communication could be related to Impaired Social Interaction and would be the primary problem that has to be resolved. Impaired Social Interaction  Impaired Social Interaction can be either too much or too little in terms of social activity and is more focused on the individual’s choice. In Social Isolation, the patient sees this problem as being caused by others. Have You Selected the Correct Diagnosis?

109.  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

110.  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

111.  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, unsturdy 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

112.  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. Risk for Injury

113.  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 Impaired Verbal Communication

114. 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 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. Impaired Verbal Communication

115.  Impaired Verbal Social Isolation can occur because of the reduced ability or inability of an individual to use language as a means of communication. The primary diagnosis would be Impaired Verbal Communication, because resolution of the problem would assist in alleviating Social Isolation.  Disturbed Sensory Perception (Auditory) If the individual has difficulty in hearing, then he or she would also reflect Impaired Verbal Communication. The primary problem would be the auditory difficulty, because correction of this deficit would help improve communication. Have You Selected the Correct Diagnosis?

116.  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)

117.  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. Total Self-Care Deficit (Specify Level)

118.  Activity Intolerance This diagnosis implies that the individual is freely able to move but cannot endure or adapt to the increased energy or oxygen demands made by the movement or activity. Activity Intolerance can be a contributing factor to the Impaired Physical Mobility This diagnosis is quite often a contributing factor to the development of Self-Care Deficit. It is probable that any time a patient has Impaired Physical Mobility, he or she will also have some degree of Self-Care Deficit.  Disturbed Thought Process If the patient is exhibiting impaired attention span; impaired ability to recall information; impaired perception, judgment, and decision making; or impaired conceptual and reasoning ability, the most proper diagnosis would be Disturbed Thought Process. Most likely, Self-Care Deficit would be a companion diagnosis. Have You Selected the Correct Diagnosis?

119.  Ineffective Individual Coping or Compromised or Disabled Family Coping Suspect one of these diagnoses if there are major differences between reports by the patient and the family of health status, health perception, and health care behavior. Verbalizations by the patient or the family regarding inability to cope also require looking at these diagnoses.  Interrupted Family Processes Through observing family interactions and communication, the nurse may assess that Interrupted Family Processes should be considered. Poorly communicated messages, rigidity of family functions and roles, and failure to accomplish expected family developmental tasks are a few observations to alert the nurse to this possible diagnosis. Have You Selected the Correct Diagnosis?

120.  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 Maintenance

121.  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. Impaired Home Maintenance

122.  Activity Intolerance If the nurse observes or validates reports of the patient’s inability to complete required tasks because of insufficient energy, then Activity Intolerance would be the more appropriate diagnosis.  Deficient Knowledge The problem with home maintenance may be due to the family’s lack of education regarding the care needed and the environment that is essential to promote this care. If the patient or family verbalizes less-than-adequate understanding of home maintenance, then Deficient Knowledge is the more appropriate diagnosis.  Disturbed Thought Process If the patient is exhibiting impaired attention span; impaired ability to recall information; impaired perception, judgment, and decision making; or impaired conceptual and reasoning ability, the most proper diagnosis would be Disturbed Thought Process. Most likely, Impaired Home Management would be a companion diagnosis. Have You Selected the Correct Diagnosis?

123.  Ineffective Individual Coping or Compromised or Disabled Family Coping Suspect one of these diagnoses if there are major differences between reports by the patient and the family of health status, health perception, and health care behavior. Verbalizations by the patient or the family regarding inability to cope also require looking at these diagnoses.  Interrupted Family Processes Through observing family interactions and communication, the nurse may assess that Interrupted Family Processes should be considered. Poorly communicated messages, rigidity of family functions and roles, and failure to accomplish expected family developmental tasks are a few observations to alert the nurse to this possible diagnosis. Have You Selected the Correct Diagnosis?

124.  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. Impaired Environmental Interpretation Syndrome

125.  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. Have You Selected the Correct Diagnosis?

126.  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)

127.  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); posttrauma, postinjury Acute Pain (Specify Type and Location)

128.  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) Chronic Pain (Specify Type and Location) (1986, 1996)

129.  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 Ineffective Pain Self-Management (Chronic, Acute)

130. A patient with a history of cerebrovascular accident with residual left hemiparesis and dysphagia is hospitalized for malnutrition. Which of the following could contribute to his altered sensory perception? Select all that apply: a.Overstimulation caused by IV pump and bed alarms b. Nutrition imbalance caused by poor oral intake at home c. Loss of peripheral vision on the left d. Loss of self-esteem related to chronic health

131. 1. a, b, c, d. Overstimulation may heighten cognitive dysfunction and may be caused by a new environment, particularly in geriatric populations. Helplessness and loss of self-esteem may lead to depression and withdrawal. Sensory reception may be affected by loss of peripheral vision on the Left.

132. An elderly patient is experiencing signs of sensory perception dysfunction related to the hospital environment. What nursing interventions could reduce her risk factors? a. Lengthy verbal explanations of procedures b. Controlling the patient’s pain c. Use of bright lights to minimize visual problems d. Placing the patient in a shared room for companionship

133. b. Pain control will help the patient be better able to focus on other sensory inputs. Lengthy explanations add to sensory overstimulation and should not be used with patients experiencing sensory perception dysfunction. Lights should be dimmed to decrease sensory overstimulation. Roommates and their visitors should be quiet as they create more noise and the patient may misinterpret overheard conversations, thus contributing to sensory dysfunction.

134. A patient is admitted to your skilled nursing facility with moderate confusion following a hospitalization. Which of the following should be done first? a. Clean patient’s glasses and confirm that they are hers b. Assess current pain level c. Secure a bed alarm to prevent falls d. Administer Haldol 0.5 mg IV to decrease agitation

135. b. Pain can alter an individual’s ability to cope and perceive. Assessment is the first step in the nursing process. Cleaning the glasses may be important to minimize altered sensory perception, and a bed alarm may be indicated intervention based on the patient’s confusion, but both would be done following an assessment. Agitation is not stated as an issue at this time.

136. You are assigned a patient who is impulsive and unsteady on her feet. Which of the following would be appropriate to delegate to the nursing assistant that you are working with? a. Encourage patient to ambulate b. Provide bedside commode to maximize independence c. Turn out all lights to decrease sensory stimulation d. Assist with bathing and oral hygiene

137. d. A nursing assistant can encourage independence while providing a safe setting for ADLs and can assist with sensory aids through touch. The nurse should first assess the patient’s gait and safety prior to ambulation. Safety should take precedence over independence in mobilization, and assistance should be available when out of bed. Lights should be dim to decrease sensory overstimulation, but night- lights should remain on to assist with safety; this would not be appropriate use of delegation.

138. Charlie Brisco is 62 years old and in the intensive care unit (ICU) after a car accident. He sustained internal injuries and many lacerations on his face and arms. He has an IV, urinary catheter, heart monitor, and nasogastric (NG) tube. The pumps and monitors give off soft beeps. The ICU has been busy and noisy since Charlie was admitted.

139. A nurse is caring for an elderly patient with altered mental status. Which of the following are potentially related to impaired cognition? Select all that apply: a.Stroke b. Hypoglycemia (low blood sugar) c. Hyponatremia (low sodium level) d. Inadequate sleep e. Urinary tract infection

140. a, b, c, d, e. Impaired blood flow to the brain, inadequate or impaired use of glucose, low sodium levels, impaired rest or sleep, and infectious processes all may be related to impaired cognition.

141. In assessing an elderly patient diagnosed with delirium, which of the following data would support this diagnosis? Select all that apply: a. Patient mental status changes began yesterday b. Patient believes that the year is 1990 c. Patient is lethargic d. Patient has no history of drug/alcohol use

142. a, b, c. Delirium is characterized by acute onset of mental impairment including confusion and reduced level of consciousness. Aging, dementia, and drug/alcohol use are also predisposing factors.

143. A nurse is setting up the room for a patient with cognitive impairments related to a brain lesion. Which intervention would best create a supportive environment for this patient? a.Posting a sign to remind the patient to call for assistance before rising b. Placing a large clock next to the bed c. Leaving the bed in a locked, low position d. Limiting visitors and loud stimuli

144. c. Leaving the bed low and locked will best provide a safe environment for the patient with cognitive impairment. Posting a sign may not be appropriate for a confused patient. A large clock may help with orientation to surroundings but is not the best answer because safety would be a priority. Limiting visitors and loud stimuli may decrease confusion but would not ultimately keep the patient safest.

145. The nurse is discharging a patient with impaired cognition to home. Which of the following elements would be important? Select all that apply: a.Teaching family caregivers effective communication techniques b. Delaying discharge until cognition improves c. Discussing options for occupational and speech therapists d. Providing resources for respite care for family members

146. a, c, d. Preparing family members for discharge with resources and techniques to best manage the well-being of this patient is a priority. It is not appropriate to delay discharge based on the information given.