Cognition Exemplar

Cognition

Exemplars:
- Delirium
- Psychosocial Assessment

Learning Outcomes to NCLEX Blueprint

Clinical Features of Delirium:
- Identify and understand the clinical features associated with delirium.
Performing Psychosocial Assessment:
- Recognize norms and alterations to cognition during the assessment process.
Risk Factors for Altered Cognition and Delirium:
- Discuss how various risk factors may contribute to changes in cognition and the occurrence of delirium.
Common Nursing Diagnoses for Clients with Altered Cognition:
- List typical nursing diagnoses applicable to patients experiencing cognitive alterations.
Nursing Interventions for Safe and Effective Care:
  - Identify specific nursing interventions designed to ensure safety and effective care for patients with altered cognition:
  - Psychological Integrity
  - Physiologic Adaptation
  - Safety
  - Pharmacological Therapies
  - Management of Care
  - Health Promotion and Maintenance

Definition of Cognition

Cognition:
  - A complex integration of mental processes and intellectual functions, serving the purposes of:
    - Reasoning
    - Perception
    - Learning
    - Memory
    - Personality

Age and Other Risk Factors

Myths about Aging:
- Ageism, the belief that negative attributes are inherently associated with older age.
Health Conditions:
  - Various conditions can influence cognition including:
    - Infections
    - Oxygenation issues
    - Perfusion abnormalities
    - Fluid and electrolyte imbalances
    - Mental illnesses
    - Sensory changes
    - Sleep disturbances
Medications:
- The impact of medications on cognitive functions.
Environmental Changes:
- Modifications in the environment that could affect cognition.

Clinical Features of Altered Cognition

Confusion:
  - Indicators of confusion may include the following:
    - Lack of awareness or orientation to time, place, or self
    - Inability to think as swiftly or clearly as usual
    - Experiences of clouded or unclear consciousness and disorientation
    - Difficulties paying attention, remembering, and making decisions
    - Behavioral symptoms such as agitation, aggression, fearfulness, anxiety, withdrawal, paranoia, and hallucinations
Delirium:
  - Characteristics include:
    - Acute and fluctuating course
    - Rapid onset
    - Duration: Hours to less than 1 month
    - Triggers: surgery, infections, drugs, etc.
    - Potentially reversible
    - Treatment strategy: Remove or treat underlying cause, reorientation to reality
    - Symptoms: lethargy or hypervigilance, impaired orientation, hypo/hyperactivity, incoherent speech, fearful affect
Dementia:
  - Features include:
    - Chronic and progressive course
    - Slow progression
    - Duration: Months to years
    - Causes often unknown
    - Not reversible
    - Treatment focuses on managing signs and symptoms
    - Approaches: validation vs. reorientation
    - Symptoms: awake but only oriented to the person, word-finding issues, slowed responses, labile affect, inability to perform activities of daily living (ADLs)

Example Question on Delirium Assessment

Situational Question:
  - A nurse is conducting an admission assessment for a client suffering from delirium due to an acute urinary tract infection (UTI).
  - Expected Findings:
    - History of gradual memory loss
    - Family members report changes in personality
    - Presence of hallucinations
    - Unchanged levels of consciousness
    - Signs of restlessness

Clinical Decision Making in Confusion Cases

Scenario:
- An older patient presents with acute confusion after taking tranquilizers for a week; vital signs are normal.
Nursing Actions:
  - A. Consider age-related physiological changes that may impact drug metabolism and pharmacokinetics.
  - B. Do not adjust medication unless the confusion is directly attributed to an infection.
  - C. Document the timing of confusion episodes and administer medication preemptively if necessary.
  - D. Avoid restricting phone calls as this may exacerbate confusion.

Assessment Tools in Nursing Process

Previous Knowledge Required:
  - Level of consciousness (LOC)
  - Orientation
  - General survey skills
Assessment Tools:
- Mini-Mental State Exam (MMSE)
- Glasgow Coma Scale (GCS)
Psychosocial Focused Assessment:
  - Evaluation factors including:
    - Appearance
    - General Attitude
    - Mood and Affect

Potential Reversible Causes of Acute Confusion

Scenario:
- A recently widowed older adult, dehydrated and admitted for IV fluid replacement, presents with acute confusion during the evening shift.
Possible Reversible Causes to Consider:
  - Electrolyte imbalance
  - Sensory deprivation
  - Hypoglycemia
  - Effects of medication/drugs

Assessment of Confusion and Agitation

Behavioral Observations:
- A nurse takes a health history from the daughter of a confused and agitated patient, diagnosed with Alzheimer’s disease a year prior. The patient was confused and hallucinating last evening.
Nursing Assessment Outcome:
  - The nurse suspects:
    - A. Normal aging
    - B. Delirium
    - C. Depression
    - D. Worsening dementia

Glasgow Coma Scale Assessment

Behavioural Responses and Scoring System:
  - Eye Opening Response:
    - 4. Spontaneously
    - 3. In response to speech
    - 2. In response to pain
    - 1. No response
  - Verbal Response:
    - 5. Oriented to time, person, and place
    - 4. Confused
    - 3. Uses inappropriate words
    - 2. Incomprehensible sounds
    - 1. No response
  - Motor Response:
    - 6. Obeys commands
    - 5. Localizes pain
    - 4. Withdraws in response to pain
    - 3. Abnormal flexion
    - 2. Abnormal extension
    - 1. No response

Analysis in Nursing Process

Nursing Diagnoses Considered:
  - Risk for Falls
  - Risk for Injury
  - Self-Care Deficit
  - Altered Nutrition
  - Confusion
  - Impaired Memory
  - Impaired Verbal Communication

Nursing Interventions in Cognitive Care

Safety Measures:
  - Investigate and address the cause of confusion
  - Ensure environmental safety through:
    - Use of visual cues and prompts for navigation
    - Prevention of wandering
    - Protection of IV sites
    - Frequent monitoring such as checks and utilization of sitters
    - Accessibility of personal items, adequate lighting
  - Creating a Calm Environment:
    - Consistent staffing to establish trust and routine
  - Nutrition and Hydration Support:
    - Promote proper nutrition and fluid intake
  - Engagement Diversions:
    - Patient-centered approaches to understand individual needs
    - Identify triggers that provoke negative behaviors
    - Minimize the use of multiple medications (polypharmacy)
    - Implement nonpharmacological strategies:
      - Aromatherapy
      - Validation and reorientation techniques
      - Utilizing pets, music, reminiscence, and meaningful activities to stimulate senses without overwhelming
      - Encourage patient participation in care while maintaining safety
      - Involve family in care planning and execution
  - Effective Communication:
    - Understand that client behavior may communicate specific needs
    - Limit the number of choices given
    - Frame directions simply and one question at a time
    - Utilize clocks for reorientation; employ sensory devices as needed
    - Avoid interruptions and allow time for responses; assist with word retrieval when necessary
    - Consider the use of communication boards as a tool
Community Resources:
  - National Council on Aging
  - Meals on Wheels
  - Respite care services
  - Transportation assistance programs
  - Senior centers
  - Alzheimer’s Association resources

Summary of Key Learning Points

Identified the clinical features of delirium.
Discussed methods for performing a psychosocial assessment, recognizing norms and alterations in cognition.
Reviewed risk factors that may lead to alterations in cognition and development of delirium.
Listed common nursing diagnoses applicable for clients with altered cognition.
Identified specific nursing interventions that promote safe and effective care for clients experiencing cognitive changes.