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 or impairment in their thought processes.
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.
Mild cognitive impairment (MCI) exceeds the normal, expected changes related to age. The defining element of MCI, according to Ronald C. Petersen, is a single sphere of slowly progressive cognitive impairment that is not attributable to motor or sensory deficits and to which other areas of involvement may eventually be added before social or occupational impairment supervenes (Mehta & Chawla, 2019).
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:
Physical changes
Biochemical changes
Psychological conflicts
Maturational
Situational (Personal, Environmental)
Caring for clients with cognitive impairment presents unique challenges that require a comprehensive and individualized approach. Nursing care plans involve a systematic process of assessment, diagnosis, planning, implementation, and evaluation. They are tailored to the specific needs and abilities of each client, recognizing that cognitive impairment varies in its presentation and progress. Management of these clients focuses not only on medical interventions but also on creating a supportive and nurturing environment that fosters a sense of security, engagement, and comfort.
The following are the nursing priorities for clients with cognitive impairment:
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. The following signs and symptoms characterize cognitive impairment:
Nursing diagnosis is a critical step in providing effective care to clients with cognitive disorders. This process involves a systematic assessment and analysis of the client’s condition, which helps the nurse identify the client’s unique nursing care needs. It is essential to maintain open communication with the client and their caregivers to ensure that care plans are client-centered and responsive to changing needs and preferences.
The following are the common goals and expected outcomes:
Nursing interventions are crucial in supporting clients 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.
Nursing assessment is crucial for clients 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. Assess attention span/distractibility and ability to make decisions or problem-solving.
This determines the ability of the client to participate in planning/executing care. Attention span can be measured by asking the client to repeat increasingly lengthy strings of information, such as digit sequences, sentences, or spatial locations. A reduced attention span may explain poor performance across a number of domains like language memory due to limited processing.
2. Assist with testing/reviewing results and evaluating mental status according to age and developmental capacity.
This is to assess the degree of impairment. The prevalence of mild cognitive impairment increases with age, with a prevalence of 10% in those aged 70 to 79 years and 25% in those aged 80 to 89 years. Clients with mild cognitive impairment may often present with vague and subjective symptoms of declining cognitive performance, which may be difficult to distinguish from the typical performance decline in healthy older adults.
3. Interview significant others (SOs) or caregivers to determine the client’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. The Alzheimer’s Association released guidelines, including an algorithm, to help clinicians in the primary care setting detect cognitive impairment and determine whether referral or further testing is required, and this includes the use of structured cognitive assessment tools for clients and their significant others or informants.
4. Perform periodic neurological/behavioral assessments, as indicated, and compare with baseline.
Early recognition of changes promotes proactive modifications to the plan of care. Few clients have undergone baseline testing before the onset of impairment, therefore the healthcare professional will have to determine whether a particular score represents a significant change from the client’s presumed baseline. Such determinations are not exact, and serial testing eventually will be needed to establish whether the client’s cognitive function is improving, staying stable, or progressing to full-blown clinical dementia.
5. Assess the severity of the level of impairment.
Cognitive impairment can be mild, severe, or anything in between. With mild impairment, there are changes in cognitive functions, but the client can still do their everyday activities. Severe levels of impairment, such as dementia, can lead to a point where the client is incapable of living independently because of the inability to plan and carry out regular tasks and apply judgment.
6. Utilize screening tools for the client’s cognitive abilities.
There are various screening tools used by clients, families, and healthcare providers to assess the client’s cognitive abilities. Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Dementia Severity Rating Scale (DSRS), AD-8, and General Practitioner Assessment of Cognition (GPCOG) can be used to gather information from caretaker/family members. The Mini-Mental State Examination (MMSE) is used for the evaluation of clients with Alzheimer disease because of its main focus on testing memory.
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. Mood disorders, medical illnesses, and medications may affect cognition in such a way that a client will meet the criteria for mild cognitive impairment. Nonamnestic forms of MCI may be caused by cerebrovascular disease, Lewy body dementia, Parkinson disease, frontotemporal dementias, atypical Alzheimer disease, or no specific underlying pathology.
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. Cognitive alterations and deficits that are observed in substance use disorders contribute directly and indirectly to the overall tremendous public health burden that these disorders place on society. The typical cognitive domains contributing to this understanding of addiction are attention, response inhibition, decision-making, and working memory (Ramey & Regier, 2018).
3. Assess dietary intake/nutritional status.
This helps in identifying contributing factors. A high salt diet has been independently linked to an increased risk of cerebrovascular disease and dementia. Therefore, dietary salt, although not currently identified as one of the risk factors targeted for the prevention of dementia, may also contribute to cognitive impairment (Ramey & Regier, 2018).
4. 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. However, no specific laboratory studies are indicated for cognitive impairment. Most practitioners perform at least a basic workup to rule out treatable conditions that may cause dementia, such as thyroid disease and cobalamin deficiency.
5. Assess for signs of a depressive disorder.
Depressive disorders are prevalent in older adults, who frequently exhibit vague somatic symptoms and anxiety and report an inability to concentrate and poor memory. Depression may certainly be accompanied by cognitive dysfunction that abates with successful treatment of the depression.
Research in other populations with chronic conditions suggests that disease management, especially the performance of self-management behaviors like healthy diets and exercise, may be influenced by the way that an individual views the nature and cause of a disease or its symptoms. Healthcare professionals agree that, even as disease-modifying pharmacological treatments become available, lifestyle modifications will be required to stabilize or reverse the course of cognitive impairment (Kim et al., 2022).
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. Correcting (to the extent possible) any sensory and motor manifestations compounding the cognitive symptoms is important for minimizing their impact on cognitive impairment.
2. Reorient to time/place/person, as needed.
The inability to maintain orientation is a sign of deterioration. Accordingly, a multi-component family reorientation strategy has recently been proposed to achieve better outcomes. Family reorientation messages refer to the use of family members’ voices in orienting clients to reality, providing a familiar, reassuring comfort, and assisting in counteracting inattention, and disorganized thinking in addition to memory and perceptual disturbances (Elcokany & Ahmed, 2019).
3. Have the client write their name periodically; keep this record for comparison and report differences.
These are important measures to prevent further deterioration and maximize the level of function. The act of rewriting one’s name engages cognitive functions such as memory, fine motor skills, and concentration. Regular cognitive stimulation can help slow down the progression of cognitive decline and improve overall brain function.
4. Present reality concisely and briefly and do not challenge illogical thinking. Avoid vague or evasive remarks.
Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions. Validation therapy is a technique used for older adults who are confused. The focus is on the emotional aspect of the communication. It does not reinforce incorrect perceptions but focuses on validating the client’s feelings (Ernstmeyer & Christman, 2021).
5. Be consistent in setting expectations, enforcing rules, and so forth.
Clear, consistent limits provide a secure structure for the client. Predictability is often reassuring for clients with cognitive impairment, as it reduces confusion and anxiety, contributing to a sense of stability. Clear boundaries can prevent confusion and frustration that might lead to agitation or challenging behavior.
6. Reduce provocative stimuli, negative criticism, arguments, and confrontations.
This is to avoid triggering fight/flight responses. Negative stimuli or criticism can trigger agitation and challenging behaviors in clients with cognitive impairment. This can include verbal outbursts, physical aggression, or withdrawal. By minimizing provocative stimuli, these reactions can be prevented, creating a calmer and safer environment.
7. Do not flood the client 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. Memories, especially if they involve significant life events or traumatic experiences, can evoke strong emotions. To cope with the flood of information, some clients may withdraw from social interactions, preferring to isolate themselves to avoid emotional turmoil.
8. Identify specific conflicts that remain unresolved, and assist the client in identifying possible solutions.
Unless these underlying conflicts are resolved, any improvement in coping behaviors must be viewed as only temporary. Conflict can cause stress and anxiety. By resolving conflicts, clients experience emotional relief and a sense of calm, contributing to their overall emotional well-being. Additionally, engaging in conflict resolution exercises the brain’s problem-solving abilities.
9. Recognize and support the client’s accomplishments (projects completed, responsibilities fulfilled, or interactions initiated).
Recognizing the client’s accomplishments can lessen anxiety and the need for delusions as a source of self-esteem. This is especially crucial for clients with cognitive impairments who may face challenges in completing tasks. Recognition of their accomplishments helps them feel valued and competent. Positive feedback also triggers the release of neurotransmitters like dopamine, which can improve the client’s mood and emotional state.
10. Teach the client 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. However, research has found that if the thought is stopped without replacing it with a more positive one, negative thoughts tend to increase. Thought-m is more about noticing these thoughts and then gently redirecting the mind to a more helpful, positive one (Fritscher, 2022).
11. Encourage the client to engage in regular physical activity and exercise.
Physical activity and exercise are beneficial for brain health, according to a growing body of evidence. In a prospective study, it was suggested that engaging in moderate exercise of any frequency in midlife or late life was associated with reduced odds of having cognitive impairment. According to one study, aerobic exercise was associated with a slight improvement in cognition.
12. Assist in identifying ongoing treatment needs/rehabilitation programs for the individual.
This measure is essential to maintain gains and continue progress if able. Social isolation can be minimized through referral to senior community centers or a day treatment program. Cognitive retraining and rehabilitative strategies offer considerable promise in cognitive impairment and are being explored.
13. Identify problems related to aging that are remediable and assist the client in seeking proper assistance/access to resources.
These encourage problem-solving to improve conditions rather than accept the status quo. Many experts suggest that mentally challenging activities, such as crossword puzzles and brain teasers, may be helpful for clients. Such exercises should be kept to a level of difficulty that is reasonable for the client.
14. Assist the client and SO in developing 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. Several studies have focused on the importance of including caregivers in interventions, especially those caring for clients with dementia, and since having a cognitive impairment often affects the entire family, it is important to include relatives in the process of interventions (Stigen et al., 2021).
15. Encourage smoking cessation.
It was found that young cigarette smokers experienced significant impairment in cognitive function compared to nonsmokers. Cigarette smoking affects cognitive abilities and can trigger demonstrable abnormalities in brain neurocognition (Riaz et al., 2021).
16. 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. Cognitive impairment, such as Alzheimer disease and dementia, can create havoc not only in the client but also in the family, friends, and the community. Therefore, management encompasses the role of the healthcare providers, clients, family and friends, and also policymakers. Healthcare policymakers must explore policy changes and initiatives that will increase support, expand, research, and ultimately improve the quality of life for people with cognitive impairment and their families (Dhakal & Bobrin, 2023).
17. Perform sensory stimulation as recommended.
Sensory stimulation is considered one of the therapeutic tools used to prevent cognitive impairments. Its main goal is to provide a similar environment that is close to the real world which cognitively stimulates critically ill clients in a safe and controlled manner. Using auditory stimulation as a non-pharmacological intervention can avoid sensory deprivation that could slow down the client’s recovery. A family member’s voice can grasp the client’s attention without much effort.
18. Refer the client for occupational therapy as appropriate.
Occupational therapy can help facilitate the client’s cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Research showed that ten sessions of occupational therapy improved the daily functioning of clients with dementia and diminished the burden of care on their primary caregivers.
Environmental barriers in the home environment can compromise the performance of everyday occupations and modifying the environment is a common compensatory intervention to enhance independent living.
1. Provide safety measures (e.g., side rails, padding, as necessary; close supervision, seizure precautions), as indicated.
It is always necessary to consider the safety of the client. The physical home environment is altered based on the needs of the client who lives and performs occupations in the home with an aim to enable occupational performance. However, the occupational therapist also needs to be aware of how many environmental modifications can be done before the environment becomes unfamiliar to the client.
2. Schedule structured activities and rest periods.
This provides stimulation while reducing fatigue. Activities that challenge the brain, such as puzzles or memory games, can help maintain cognitive abilities and slow down the progression of cognitive impairment. Some individuals may become overstimulated, therefore, proper rest can provide a break to prevent sensory overload and promote a sense of calm.
3. Maintain a pleasant and quiet environment and approach clients in a slow and calm manner.
A client may respond with anxious or aggressive behaviors if startled or overstimulated. A calm and positive environment fosters a sense of security. Clients with cognitive impairment may already feel disoriented or confused; creating a pleasant environment can help establish a stable and secure atmosphere.
4. Refrain from forcing activities and communications.
Clients may feel threatened and may withdraw or rebel. Feeling overwhelmed or distressed can lead to agitation or even aggressive behavior. The client might express their frustration physically or verbally, especially if they are unable to communicate their feelings effectively.
5. Encourage the use of assistive devices as recommended.
The use of assistive devices is also a means to increase occupational performance. This is described as the ‘traditional way’ of working in community service when providing occupational therapy.
6. Consider the use of assistive technology.
Innovative Assistive Technology (IAT) is an important tool for maintaining independence and quality of life for community-living older adults with cognitive impairment. IAT includes sensor-based surveillance and monitoring systems, mobile technology such as wearable fall detectors, and activity bracelets as well as tablets with health information or alarm functions (Thordardottir et al., 2019).
Communication has been defined as a context-dependent construct, which is closely related to well-being and distinct from functional linguistic skills of an individual. The verbal content strongly declines in the course of dementia, whereas non-verbal relationship channels can be preserved for a longer time (Schnabel et al., 2019).
1. Use validated instruments to assess the client’s communication needs.
The CODEM instrument, an observational tool to assess Communication Behavior in Dementia, considers both the verbal content and the non-verbal relationship aspect inherent in communication behavior. CODEM allows communication resources and deficits of acutely ill older clients to be detected at different stages of the communication process. This may enable the healthcare team to accommodate their communication behavior in a specific manner leading to more efficient and enriching social interactions.
2. Use touch cautiously, notably if thoughts reveal ideas of persecution.
Clients who are suspicious may perceive touch as threatening and may respond with aggression. When appropriate, touch provides comfort for clients. It provides sensory stimulation to avoid sensory deprivation and demonstrates caring and warmth. It is important to assess the client’s reaction to touch before implementing therapeutic gentle touch.
3. 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 client how others are perceiving him or her, while the responsibility for not understanding is accepted by the nurse. Consensual validation acknowledges the client’s feelings and experiences, validating their emotions. Seeking clarification ensures that both the caregiver and the client have a clear understanding of the communication.
4. Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups.
A distrustful client can best deal with one person initially. The gradual introduction of others when the client can tolerate is less threatening. Ideally, the activities should be interactive rather than passive, and they should be administered in a fashion that does not cause excessive frustration. If the activity is not enjoyable or stimulating for the client, it is unlikely to offer much cognitive benefit.
5. Encourage the client 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 client come to terms with long-unresolved issues. Establishing a therapeutic relationship based on trust by sitting at the level of the client and engaging in eye contact shows an attitude of caring and compassion while maintaining the dignity of the client.
6. Encourage the client to participate in resocialization activities/groups when available.
This is to maximize the level of function. A study showed certain activities lower the risk of mild cognitive impairment in cognitively normal clients older than 70 years. These included playing games, reading magazines, being engaged in crafts, computer use, and social activities. Among these, being social and using computers were shown to reduce the risk of MCI the most in clients.
7. Recommend the use of information and communication technologies.
According to a study regarding the use of ICTs in the daily life of clients with cognitive impairment, popular devices included telephones or mobile and smartphones, smart TVs, and tablets, as well as desktops and laptops. Clients perceive ICTs as useful because these could improve feelings of belongingness, support interaction with loved ones, and allow the client to be engaged in hobbies, passions, or daily activities. Clients can stay connected to children, siblings, and others with whom they have a close relationship, even without interactive conversation (Blok et al., 2020).
Cognitive decline is particularly feared among people because of the possibility of losing self-sufficiency and the need to depend on others. Therefore, people should be made aware that cognitive impairment can be largely prevented with a long life proper nutrition, and a healthy lifestyle.
1. Provide a nutritionally well-balanced diet, incorporating the client’s preferences as much as possible. Encourage the client to eat. Provide a pleasant environment and allow sufficient time to eat.
These enhance intake and general well-being. A study found that the risk of developing MCI is lower in clients who consume a Mediterranean diet, which is high in vegetables and unsaturated fats.
2. Encourage the intake of dietary supplements as prescribed.
A randomized study involving older adults diagnosed with cognitive impairment determined that dietary supplementation with an oily emulsion of DHA-phospholipids containing melatonin and tryptophan yielded significant improvements in several measures of cognitive function as compared with supplementation with the placebo.
3. Provide foods rich in folate, vitamin E, and fatty acids.
Folate has been studied as a solitary intervention; cognitive improvement in general intelligence, attention span, and visuospatial metrics within six months has been reported in mild cognitive impairment. Two other large studies examined the effect of vitamin E on the progression rate of Alzheimer disease and showed slower functional decline with a focus on the ADL. Omega-3 fatty acids are credited with anti-inflammatory and neuroprotective properties that can cause slower cognitive decline, less agitation, and lower depression scores (Vlachos & Scarmeas, 2019).
4. Recommend the use of olive oil and natural flavorings such as garlic and curcumin.
Olive oil is a staple of the Mediterranean diet and is a natural product rich in oleic acid. It has been associated with beneficial effects on human health which is attributable to its composition that gives its antioxidant and anti-inflammatory properties. Garlic also exhibits antioxidant properties that may have protective actions against neurotoxic effects (Dominguez et al., 2021).
Recommended nursing diagnosis and nursing care plan books and resources.
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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:
Resources to further your research about cognitive impairments:
Gil Wayne ignites the minds of future nurses through his work as a part-time nurse instructor, writer, and contributor for Nurseslabs, striving to inspire the next generation to reach their full potential and elevate the nursing profession.
