6.4 Applying the Nursing Process

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.

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.

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^[4]:

• Bathing Self-Care Deficit
• Dressing Self-Care Deficit
• Feeding Self-Care Deficit
• Toileting Self-Care Deficit
• Risk for Injury
• Impaired Memory
• Ineffective Coping
• Social Isolation

An example of a related PES statement is, “Toileting Self-Care Deficit related to altered cognitive functioning as evidenced by impaired ability to reach the toilet and manipulate clothing for urinating.”

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

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.