Open Resources for Nursing (Open RN)
This section outlines the steps of the nursing process when providing care for adults with cognitive impairments.
Assessment
Nurses provide care for older adults in a wide variety of settings including acute care facilities, clinics, adult day care facilities, retirement communities, long-term care facilities, private homes, and community-based residential facilities (CBRF). It is vital for nurses to notice any signs of changing mental status based on the client’s baseline. Any new or sudden changes that indicate possible delirium should be urgently reported to the health care provider for further assessment of potential underlying health conditions. See the following box to view a delirium evaluation tool used by hospitals.
View the Delirium Evaluation Bundle shared by the Agency for Healthcare Research and Quality (AHRQ).
When assessing an adult client with a previously diagnosed cognitive impairment, there are several assessments to include on admission. Their medical history should be reviewed and a medication reconciliation completed. A general survey provides a quick, overall assessment of the way an individual interacts with their environment and their overall mobility status. A comprehensive neurological assessment should be performed to establish a client’s baseline neurological status. After a baseline status is determined, routine focused neurological assessments are performed to monitor for changes, such as asking the client to state their name, place, and the date, as appropriate.
Read more information about performing a neurological exam in the “Neurological Assessment” chapter of the Open RN Nursing Skills, 2e textbook.
Additional assessments include functional status and the client’s ability to perform activities of daily living (ADLs). A decline in the ability to perform self-care and maintain ADLs can affect the individual’s well-being. Functional declines can bring about feelings of inadequacy and lead to depression. The ability to live independently relies on maintenance of self-care skills, including bathing, dressing, and toileting. Other factors that must be considered include the ability to adequately handle finances; maintain a clean, safe environment; and to shop and prepare meals. When deficits in these areas occur, resources should be recommended to assist the individual to meet these needs.
Cognitive changes, including disorientation, poor judgment, loss of language skills, and memory impairment, should be assessed objectively using standardized tools. Common standardized tools used to assess a client’s mental status include the Mini Mental State Exam (MMSE) and the Mini-Cog.[1] See Figure 12[2] for an image of one of the questions included on the MMSE.
Cultural Considerations
Nurses provide culturally competent care for all individuals. Being aware of personal biases related to ageism and cognitive impairments is necessary when providing care for older adults experiencing confusion, memory deficits, and impaired judgment. Ageism is the stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs. Ageism is widely prevalent and stems from the assumption that all members of a group (i.e., older adults) are the same and involves stereotyping and discrimination against individuals or groups based on their age. Ageism has harmful effects on the health of older adults; research has shown that older adults with negative attitudes about aging may live 7.5 years less than those with positive attitudes. Some of this prejudice arises from observable biological declines and may be distorted by awareness of disorders such as dementia, which may be mistakenly thought to reflect normal aging. Socially ingrained ageism can become self-fulfilling by promoting stereotypes of social isolation, physical and cognitive decline, lack of physical activity, and economic burden in older adults.[3]
These biases in health care personnel, clients, and family members can prevent early recognition and treatment of health problems like dementia, delirium, and depression.
Diagnoses
Commonly used NANDA-I nursing diagnoses for older adults experiencing cognitive impairment include the following:
- Self-Care Deficit
- Risk for Injury
- Impaired Memory
- Impaired Coping
- Social Isolation
A common NANDA-I diagnosis related to cognitive impairment caused by dementia is Self-Care Deficit, defined as, “The inability to independently perform or complete cleansing activities; to put on or remove clothing; to eat; or to perform tasks associated with bowel and bladder elimination.” An associated condition with this nursing diagnosis is “Alteration in cognitive functioning.”[4]
An example of a related PES statement is, “Self-Care Deficit related to altered cognitive functioning as evidenced by impaired ability to access the bathroom, to put clothing on lower extremities, and to maintain appearance.”
Outcome Identification
An example of a broad, overall goal for an older adult experiencing cognitive impairment due to dementia is, “The client will perform self-care activities within the level of their own ability daily.”
An example of a SMART expected outcome criteria for a client with cognitive impairment resulting in Self Care Deficit is, “The client will remain free of body odor during their hospital stay.”
Planning Interventions
There are many nursing interventions that can be implemented for older adults with impaired cognitive function based on their individual needs. Interventions focus on maintaining safety, meeting physical and psychological needs, and promoting quality of life. As always, refer to an evidence-based nursing care planning resource when customizing interventions for specific clients. For interventions targeted for common symptoms of dementia, see the “Alzheimer’s Disease” section in this chapter. See Table 6.4 for general nursing interventions to implement for clients with cognitive impairments.
Table 6.4 General Nursing Interventions for Cognitive Impairments
| Therapeutic Communication: Provide nursing care in a timely manner with an attitude of caring and compassion while maintaining the dignity of the individual. Establish a therapeutic relationship based on trust by sitting at the level of the client and engaging in eye contact. |
| Reminiscence Therapy: Allow individuals opportunities to share their past experiences and stories. This allows expression of personal identity and supports the individual’s coping and self-esteem. |
| Touch: When appropriate, touch provides comfort for individuals. It provides sensory stimulation to avoid sensory deprivation and demonstrates caring and warmth. It is important to assess the individual’s reaction to touch before implementing therapeutic gentle touch. |
| Reality Orientation: This technique provides awareness of person, place, and time for those who are cognitively able. It restores a sense of reality, decreases confusion and disorientation, and promotes a healing environment. Older adults experiencing a change in environment or stressful situation benefit from the use of environmental cues for orientation, such as clocks, calendars, and whiteboards noting who is providing care and when they will return. |
| Validation Therapy: This technique is used for older adults who are confused. The focus is on the emotional aspect of their communication. This therapy avoids reorientation to time and place, even when incorrect, because this can trigger agitation in confused individuals. It does not reinforce incorrect perception but focuses on validating their feelings.[5] |
Implementing Interventions
When implementing interventions for clients with cognitive impairments, safety receives priority. Implement fall precautions, wandering precautions, and environmental safety precautions as appropriate.
Evaluation
It is important to routinely evaluate the effectiveness of customized interventions for clients with cognitive impairments. Review the SMART outcomes established for each specific client to determine if interventions are effectively promoting safety while also maintaining physiological and psychological needs and promoting quality of life. Modify the care plan when needed to meet these outcome criteria.
- Alzheimer’s Association. (2021). https://www.alz.org/ ↵
- “InterlockingPentagons.svg” by Jfdwolff[2] is licensed under CC BY-SA 3.0 ↵
- World Health Organization. (2024). Health Topics: Ageism. https://www.who.int/health-topics/ageism ↵
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York. ↵
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Scenario A
You are a nurse providing care for Mrs. Lyn, a 47-year-old client admitted with metastatic lung cancer receiving hospice care. The client's condition has declined significantly over the past week; she is actively dying. Over the last 24 hours, Mrs. Lyn has declined rapidly and is now unresponsive but appears to be resting comfortably. You enter the client's room and find Mr. Lyn weeping at the client's bedside.
- What actions would you take to comfort Mr. Lyn?
- Mrs. Lyn develops labored breathing. What medication is helpful to administer to treat dyspnea at end of life?
- Mrs. Lyn's breathing becomes less labored with medication, but her respiratory rate becomes irregular. Mr. Lyn tells the nurse, "My daughter lives six hours away and would like to be here when the time comes. How much longer does she have to live?" What is the nurse's best response?
- The daughter arrives and seems hesitant to talk to or touch her mother. What tasks can the nurse coach family members to do at the end of a client's life?
- Mrs. Lyn dies the following evening. What postmortem care should the nurse provide?
Scenario B
Terry, a 42-year-old male client, was recently diagnosed with advanced colon cancer and underwent a colon resection a few days ago. While changing his colostomy bag, he comments to the nurse, “I still can’t believe this is happening to me.”
- According to Kubler-Ross’ theory of grief/loss, what stage of grief is Terry currently experiencing?
- The nurse responds, “This is a difficult time for you.” Terry replies, “Yes, it is. My parents want me to do every kind of experimental treatment possible, but I just want to live my life until the time comes.” The nurse asks, “You have some tough decisions to make. Has anyone talked to you about palliative care yet?” Terry asks, “I’ve never heard of palliative care. What is it?” How would you explain palliative care to him?
- Terry states, “I don’t want my parents telling my doctor what to do. It is my decision.” The nurse asks, “Do you have any advance directives in place?” Terry responds, “What are advance directives?” How would you explain advance directives to Terry?
- The nurse identifies “Grieving related to anticipatory loss as evidenced by disbelief and feeling of shock” as a nursing diagnosis for Terry. Identify a SMART outcome.
- The nurse plans interventions to enhance Terry’s coping. List sample nursing interventions that may help Terry to cope with this new diagnosis.
Test your knowledge using this NCLEX Next Generation-style bowtie question. You may reset and resubmit your answers to this question an unlimited number of times.[1]
