Nursing diagnosis: Chronic Confusion related to irreversible neuronal degeneration
Possibly evidenced by
Disturbed interpretation or response to stimuli
Progressive, long-standing cognitive impairment; impaired short-term memory
Disturbed personality; impaired socialization
Clinical evidence of organic impairment
Desired Outcomes/Evaluation Criteria— Client Will
Experience a decrease in level of frustration, especially when participating in daily activities.
Caregiver Performance: Direct Care
Verbalize understanding of disease process and client’s needs.
Identify and participate in interventions to deal effectively with situation.
Provide for maximal independence while meeting safety need of client.
Initiate behaviors or lifestyle changes to maximize client’s cognitive functioning.
Nursing intervention with rationale:
1. Assess degree of cognitive impairment including changes in orientation to person, place, and time and attention span and thinking ability. Talk with SO and caregiver about changes from usual behavior and length of time problem has existed.
Rationale: Provides baseline for future evaluation and comparison and influences choice of interventions. Note: Repeated evaluation of orientation may actually heighten negative responses and client’s level of frustration.
2. Maintain a pleasant, quiet environment.
Rationale: Reduces distorted input, whereas crowds, clutter, and noise generate sensory overload that stresses the impaired neurons.
3. Approach in a slow, calm manner.
Rationale: This nonverbal gesture lessens the chance of misinterpretation and potential agitation. Hurried approaches can startle and threaten the confused client who misinterprets or feels threatened by imaginary people and/or situations.
4. Face the individual when conversing.
Rationale: Maintains reality, expresses interest, and arouses attention, particularly in persons with perceptual disturbances.
5. Address client by name.
Rationale: Names form our self-identity and establish reality and individual recognition. Client may respond to own name long after failing to recognize family or caregiver.
6. Use lower voice register and speak slowly to client.
Rationale: Increases the chance for comprehension. High-pitched, loud tones convey stress and anger, which may trigger memory of previous confrontations and provoke an angry response.
7. Give simple directions, one at a time, or step-by-step instructions, using short words and simple sentences.
Rationale: As the disease progresses, the communication centers in the brain become impaired, hindering the individual’s ability to process and comprehend complex messages. Simplicity is the key to communicating, both verbally and nonverbally, with the cognitively impaired person.
8. Pause between phrases or questions.
Rationale: Invites a verbal response and may increase comprehension.
9. Focus on appropriate behavior. Give verbal feedback and positive reinforcement such as a pat on the back or applause. Use touch judiciously and respect individual’s personal space and response.
Rationale: Reinforces correctness and appropriate behavior. A focus on inappropriate behavior can encourage repetition. Although touch frequently transcends verbal interchange, and conveys warmth and acceptance, the individual may misinterpret the meaning of touch. Intrusion into personal space may be interpreted as threatening because of the client’s distorted perceptions.
10. Administer medications, as individually indicated, for example: Acetylcholinesterase (AChE) inhibitors, such as donepezil (Aricept), rivastigmine (Exelon), or galantamine (Razadyne)
Rationale: Cholinesterase inhibitors prevent the breakdown of acetylcholine, a chemical messenger important for learning and memory. These medications are being used for the treatment of mild to moderate cognitive impairment by delaying progression of symptoms in Alzheimer’s disease.