8.2 Neurocognitive Disorders Nursing Process

Question 1

Patient History

Answer 1

• Type, Frequency, Severity of Mood Swings
• Personality/Behavioral Changes
• Language difficulties
• Appropriateness of social behavior
• Medication use
• Exposure to toxins

Question 2

Physical Assessment

Answer 2

• Signs of damaged nervous system
• Evidence of disease that could affect mental function

Testing
- Mental status
- Alertness
- Muscle strength
- Reflexes
- Sensory perception
- Language skills
- Coordination

Question 3

Diagnostics

Answer 3

Blood/Urine Samples for..
- Infection
- Hepatic/Renal Dysfunction
- Diabetes/Hypoglycemia
- Metabolic/Endocrine disorders
- Nutritional Deficiency

EEG (Electroencephalogram) - Measures brain electrical activity

CT Scan - Size and shape of brain

Lumbar Puncture - Examine CSF for infection/hemorrhage

Positron Emission Tomography (PET) - Reveals metabolic activity of the brain

Question 4

Outcomes

Answer 4

• Patient does not experience physical injury
• No harm to self or others
• Maintain orientation to reality
• Able to communicate consistently with caregiver
• Fulfills ADL’s
• Discuss positive aspects of life

Question 5

Risk for Trauma

Answer 5

• Ensure safe environment
• Prevent injuries

Interventions
- Adjust furniture and bed position and help with ambulation
- Maintain low stimuli for agitated patients
- Patients who wander, keep them on a structured schedule and provide safe enclosed space for wandering

Question 6

Disturbed Thought Process

Answer 6

• Disruption in cognitive operations and activities

Goal
- Maintain reality orientation

Intervention
- Clocks, calendars
- Promote security
- Discourage delusional thinking and re-assure patient is safe (if they have delusions)

Question 7

Impaired Memory

Answer 7

• Inability to remember or recall bits of information or behavior skills

Question 8

Disturbed Sensory Perception

Answer 8

• Incoming stimuli is diminished, exaggerated, distorted or impaired

Question 9

Impaired verbal communication

Answer 9

• Decreased or absent ability to receive, process, transmit, or use system of symbols.
• Ensure that their needs are known, anticipated, and fulfilled.

Interventions
- Keep interactions calm and re-assuring
- Use non-verbal gestures
- Maintain consistency

Question 10

Implementation

Answer 10

Education
- Ways to ensure patient safety
- How to maintain reality orientation
- Help with ADL’s
- Nutritional guidance
- Medication administration
- How to maintain hygiene and toileting

Question 11

Evaluation

Answer 11

• Has the patient sustained injury
• Does the patient maintain orientation to time and place
• Can the patient fulfill basic needs