Cognitive Impairment Nursing Care Plans Diagnosis and Interventions
Cognitive impairment is a medical term used to describe patients who have survived debilitating and critical illnesses but have persistent neurological deficits.
The brains of these patients are oftentimes compromised and would have problems about:
- Memory
- Attention
- Processing speed
- Executive functioning – This includes higher cognitive faculties such as organizing, planning, and problem-solving.
Patients with cognitive impairment almost always have long-term consequences due to the organ involved, which will depend on the degree or severity of the damage.
These patients would have difficulties fulfilling activities of daily living, such as school tasks and job roles. Those with severe enough impairments would need significant support from other people or institutions, to function and sustain life.
Incidences and Statistics
The prevalence and incidence rates of cognitive impairment vary, but they are common worldwide. Statistically, cognitive impairment ranges from 5.1% to 4.1%, with a median of 19% worldwide. The incidence rate ranges from 22 to 76.8 for every 1000 person-years, with a median of 53.97 for every 1000 person-years.
Possible Causes of Cognitive Impairment
Unfortunately, there is inadequate research exploring the plausible causes of cognitive impairment after bouts of critical illness. However, expert opinion suggests that these factors, or a combination of them, may precede its development:
- Inadequate oxygenation of the brain
- Delirium or dementia
- Infections
- Glucose dysregulation
- Certain illnesses that can directly affect the brain (e.g., dehydration)
- Patient response to medications (e.g., anesthetics)
- Vitamin deficiency
- Stroke
- Brain injury
Related Factors to Cognitive Impairment
Patients who have higher probabilities of developing cognitive impairments include those with the following risk factors:
- The presence of pre-existing cognitive issues makes them notably susceptible
- Advanced age
- Presence of long-term delirium episodes
- Patients on assisted ventilation
- Diagnosis of sepsis or acute respiratory distress syndrome (i.e., ARDS)
- Patients with prolonged and complicated hospital and ICU stays
- Family history
- Presence and severity of brain injury
- Exposure to toxins
- Physical inactivity
- Chronic conditions (e.g., Parkinson’s disease, cardiovascular disease, stroke, diabetes, etc.)
Signs and symptoms of Cognitive impairment
Clinical manifestations of cognitive impairment can be subtle or overt, and their severity is related to how severe they are. Patient survivors with cognitive impairment are likely to have the following characteristics:
- Obvious problems with memory such as remembering names, looking up words, and recalling items from a sample list (e.g., shopping list, etc.)
- Overlooking significant and mundane events such as doctor’s appointments or social activities (e.g., parties, weddings, etc.)
- Loss of focus in conversations. Patients often ramble when speaking.
- Poor decision-making skills for simple or complex tasks
- Readily becomes exhausted by simple tasks and responsibilities that were previously easily done by the patient.
- Difficulties in managing financial transactions or using medications, thereby resulting in reckless oversights.
- Acts mindlessly without due consideration of the consequences.
- Memory loss
- Vision problems
- Mood or behavior changes
Diagnosis of Cognitive Impairment
Aside from a thorough history and physical examination, the care provider would employ a variety of techniques to screen for cognitive impairments. There are four stages, and they are:
- Pre-procedure. At this stage, the care provider will select the appropriate technique to evaluate the patient’s level of impairment. Conditions such as sensitivity, specificity, positive and negative projecting values, availability of screening tools, and the risk of falsely negative and positive results are crucial before any method is used. Patients with multiple handicaps, such as aphasia, are not permitted to take the tests.
- Technique. Different tools can be utilized to ascertain the degree of cognitive impairment. Nevertheless, the ideal tool should have:
- Short administration time
- Applicable sensitivity and specificity
- Allowance for screening various neuropsychological capabilities
The following are sample tools used in evaluating impairment:
- MMSE. This acronym stands for mini-mental state examination. It takes 10 minutes to take a 30-point test assessing the cognitive domains of orientation, recall, attention, calculation, language, and constructional praxis. This is the most common cognitive test utilized.
- Mini-Cog. This involves the patient drawing a clock with the recall of three words done in 2-4 minutes. This test would evaluate the cognitive domains of orientation and recall. This tool shares similarities with the MMSE in terms of sensitivity and specificity but is quicker to administer.
- 6 item-screen (6CIT). This is a two-minute test challenging the patient’s cognitive domains of orientation and recall. Questions focus on counting backward from 20, stating in reverse the months of the year, and learning an address. This test is faster than the MMSE and more sensitive for dementia.
- Short portable mental status questionnaire (SPMSQ) – This is a 10-item exam assessing the cognitive domains of orientation, recall, attention, calculation, constructional praxis, and information. This tool is not sensitive to dementia.
- Saint Louis University Mental status examination (SLUMS) – This is a 30-item test challenging the cognitive domains of orientation, recall, attention, calculation, language, constructional praxis, and fluency. It has better sensitivity than the MMSE for mild dementia.
- Post-procedure. After the assessment, intermittent patient re-evaluation is needed to gauge an improving or worsening condition. Patient education (e.g., medications, need for caregivers, etc.) is also implemented to assist the patient and family in taking on the challenges of cognitive impairment.
- Diagnostics and laboratory exams. Further workup may be done on the patient to rule out other conditions that may present other than the initial diagnosis of cognitive impairment. Procedures such as an MRI and EEG may be used to evaluate function, structure, and brain activity. Lab exams such as the CBC, and a liver function test may be done to check for pathophysiologic causes of impairment. A review of the patient’s medications may be done to check for possible toxicities and untoward side effects that may cause or aggravate impairment.
Treatment of Cognitive Impairment
Patients with cognitive impairment can result from various issues, some of them reversible but while others are not. However, strategies can be done to 1. Improve latent impairment; or 2. Reduce its effects. The possible approaches include:
- Exercise – Some studies stipulate that exercise can potentially improve thinking faculties. However, doctor consultation is needed before such activities to gauge the applicability and appropriateness of such intervention.
- Brain exercises – Activities such as crossword puzzles, chess, and other mental challenges can be appropriate to re-train the brain of a cognitively impaired patient.
- Adaptive devices and strategies – Because of the effects of the impairment, the utilization of such techniques can assist in limiting its impacts and maximizing the remaining strengths of the patient.
- Social support – Patients with cognitive impairments would need all types of assistance, including social support to function in society.
- Anxiety and depression – Because of the debilitating effects of cognitive impairment, patients with this condition are highly susceptible to anxiety and depression. Furthermore, anxiety and depression can further reduce the remaining cognitive abilities of the patient. However, once impairment-induced anxiety and depression are resolved, so will the latent cognitive problems resolve gradually.
- Rehabilitation – Enrolling patients in cognitive rehabilitation sessions, complemented with professional psychological assistance will ensure that the mental faculty of the patient is maintained, and further degeneration is prevented.
- Medical evaluation – Medical evaluation is warranted to check for and rule out any other medical reasons for cognitive impairment. It will also guide treatment goals and will act as counter-checking for the effectiveness of the therapeutic regimen. The patient may be referred to specialists in cognitive impairment such as neurologists or neuropsychologists.
- Treating etiologies – Patients with cognitive impairment may have other conditions that worsen their symptoms. Timely evaluation and management of such conditions are warranted to prevent further compromise and promote quality of life.
Nursing Management of Cognitive Impairment
Possible nursing focus and management would include the following:
- Orientation of the patient to reality will promote patient familiarity and resumption of activities of daily living.
- Include significant others and caregivers in patient reorientation to promote continuity of care.
- Utilize positive feedback. Positive feedback promotes the patient’s self-esteem, therefore enhances want for proper behavior.
- Use simple terms. The use of common language promotes easier understanding of instructions and reduces patient confusion.
- Prevent the patient from coming up with false ideas. Because of impaired thought processes, patients tend to dwell on misconceptions. The nurse should ensure to always reorient the patient to reality.
- Practice close monitoring of the cognitively impaired patient. These types of patients would need watchful checking to promote patient safety.
- Comprehensive pain assessment. The cognitively impaired patient would have challenges in letting others know of their pain and discomfort levels. The nurse should focus on recognizing usual and unusual cues, both verbal and non-verbal, to evaluate pain characteristics so that appropriate interventions are implemented.
Cognitive Impairment Nursing Diagnosis
Nursing Care Plan for Cognitive Impairment 1
Nursing Diagnosis: Impaired Verbal Communication related to cognitive impairment secondary to cerebral palsy as evidenced by difficulty vocalizing words and difficulty in discerning and maintaining the usual communication pattern.
Desired Outcomes:
- The patient will be able to verbalize needs known to healthcare providers and family members.
- The patient will be able to establish methods that will help him or her to communicate to meet his or her needs.
- The patient will be compliant in speech therapy or other therapy that will help him or her to have effective communication.
| Nursing Interventions for Cognitive Impairment | Rationale |
| 1. Assess the patient’s needs and pay attention to the patient’s nonverbal cues. | The nurse should give the patient enough time to attend to all the details of patient care and the nurse should note that care measures may take a long time for the patient to complete in the presence of a communication deficit. |
| 2. Keep a calm and unhurried manner when communicating with the patient and provide ample time for the patient to respond. | Hurrying the patient when speaking will make it less clear and may cause impaired communication. |
| 3. Decrease distractions such as television and radio at a minimum when talking to the patient. | Decreasing the distractions maintains the child’s focus and will help decrease stimuli going to the patient’s brain for interpretation. |
| 4. Offer the patient alternative means of communication. | Alternative ways of communication such as flashcards, whiteboards, hand signs, or a picture board will help the patient express himself/herself if speaking is difficult to obtain. |
| 5. Refer the patient to a speech therapist as indicated and as needed. | A speech therapist will help the patient with cerebral palsy to learn how to speak slowly and speech therapy will help the patient to know how to coordinate his or her lips and tongue for speech sounds. |
Nursing Care Plan for Cognitive Impairment 2
Nursing Diagnosis: Disturbed Thought Process related to cognitive impairment secondary to Parkinson’s disease as evidenced by inaccurate interpretation of the environment, changes in lifestyle, distractibility, memory impairment, and inability to perform usual activities.
Desired Outcomes:
- The patient will be able to identify factors that cause depressive reactions.
- The patient will be able to use techniques that will effectively reduce the amount and frequency of depressive episodes.
- The patient will be able to comply with the therapeutic regimen that will help with his or her condition.
Nursing Care Plan for Cognitive Impairment 3
Nursing Diagnosis: Chronic Confusion related to cognitive impairment secondary to amnestic disorder as evidenced by difficulty doing tasks, poor attention span, and difficulty following a conversation.
Desired Outcomes:
- The patient remains content and he or she will be safe from harm.
- The patient will be able to function at his or her maximal cognitive level.
- The patient will actively participate in activities of daily living at the maximum functional ability.
- The patient’s significant others will verbalize understanding of the disease process and prognosis including the patient’s needs.
| Nursing Interventions for Cognitive Impairment | Rationale |
| 1. Assess the patient’s functioning, including the patient’s social situation, physical condition, and psychological functioning. | The nurse should assess the patient’s background to help the nurse understand the patient’s behavior. |
| 2. Assess the level of impairment that the patient is experiencing. | Assessing the level of impairment or confusion will help in determining the amount of reorientation and intervention the patient needs to evaluate reality accurately. |
| 3. Assess the patient’s ability to receive and send effective communications. | The patient’s ability to reply or respond to verbal directions may vary with the degree of orientation. |
| 4. Advise the family members or significant others about the progression of the condition and other concerns. | These will help in determining areas of physical care in which the patient needs support from the family and significant others. |
| 5. Assess the patient’s level of anxiety in connection with the current situation and observe behavior that may suggest a potential for violence. | A patient who experiences confusion, disorientation, suspiciousness, and impaired judgment may cause inappropriate behaviors toward self or others. |
| 6. Provide a calm environment and promote reality-oriented relationships and environment. | A calm environment should be provided because any noise and stimuli can be misinterpreted by a confused patient. It is also important to orient the patient to the environment to increase his or her ability to trust others. |
Nursing Care Plan for Cognitive Impairment 4
Nursing Diagnosis: Self-care deficit related to cognitive impairment secondary to dementia as evidenced by the patient’s inability to perform activities of daily living.
Desired Outcomes:
- The patient will be able to perform tasks and activities of daily living within the patient’s level of ability.
- The patient will be able to maintain independence by doing activities of daily living.
- The patient will be able to demonstrate the proper use of the adaptive equipment provided.
| Nursing Interventions for Cognitive Impairment | Rationale |
| 1. Check the patient’s strength to accomplish the activity of daily living efficiently and cautiously daily using proper assessment tools. | It is important to assess the patient’s strength because the patient may need help with some self-care measures. |
| 2. Determine and check the specific cause of each deficit including visual problems, weakness, and cognitive impairment. | Several etiological factors may need more explicit interventions that will help in self-care. Determining the specific cause and deficit will help the nurse to formulate interventions. |
| 3. Recognize the patient’s need for assistive devices and always prioritize the patient’s safety. | Devices that can help assist the patient will help the patient in performing usual activities. |
| 4. Assess the patient’s choice of food, personal care items, and other things. | It is important to assess the patient’s choice because the patient should be eager to submit himself or herself to a treatment regimen that will support his or her individual preferences. |
| 5. Assess the patient’s need for home health care after discharge. | The patient may be advised to have a shortened hospital stay that will help the patient to be more debilitated on discharge and therefore require more assistance at home. |
| 6. Monitor for the presence of impulsive behavior or actions that may indicate altered judgment. | This intervention will imply the demand for supplementary management that will guarantee the patient’s safety and security. |
Nursing Care Plan for Cognitive Impairment 5
Nursing Diagnosis: Risk for Injury related to cognitive impairment secondary to Alzheimer’s disease.
Desired Outcomes:
- The patient will be maintained safe from environmental hazards that result from cognitive impairment.
- The patient’s family will help and follow ways to ensure the patient’s safety.
- The patient’s environment will be kept safe with no injuries and injuries obtained.
- The patient’s family will be able to identify and eliminate hazards for the patient’s safety.
| Nursing Interventions for Cognitive Impairment | Rationale |
| 1. Assess the patient’s environment and surroundings for the presence of hazards and remove them. | Patients with cognitive impairment due to Alzheimer’s disease have decreased awareness of potential dangers. The nurse should remove all potential and obvious hazards to allow the patient to move as freely as possible. |
| 2. Advise the patient’s family to remove hazards including, locking up knives and sharp objects, cleaning supplies, insecticides, other household chemicals, weapons, power tools, smoking materials, and breakable items. | This will help in avoiding or preventing accidents, injuries, ingestion, or burns. |
| 3. Advise and instruct the family to keep pathways clear, move the furniture around the house against the wall, remove small rugs, and lock wheels on beds and chairs. | This intervention will help in preventing the patient’s risk of falls and injury. |
| 4. Advise the patient’s family to provide non-slip footwear without laces when possible. | This will help the patient with Alzheimer’s disease to prevent tripping and falls. |
| 5. Provide adequate lighting and clear pathways in halls, stairways, and bathrooms. | A room or house with adequate lighting is needed to prevent injury and this will also allow the patient to see and find his or her way in the room without danger, tripping, or falling. |
| 6. Divert the patient’s attention when agitated or if the patient shows dangerous behaviors. | It is important to repeat instructions as necessary to promote safety because the patient may show a short attention span and be forgetful. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.
