NANDA-I Definition
Irreversible, long-standing, and/or progressive deterioration of
intellect and personality characterized by decreased ability to
interpret
environmental stimuli; decreased capacity for intellectual
thought processes; and manifested by disturbances of memory,
orientation, and behavior
Defining Characteristics
Major (Must Be Present)
Progressive or long-standing:
Cognitive or intellectual losses
Loss of memory
Inability to make choices,
decisions
Loss of time sense
Inability to solve problems,
reason
Altered perceptions
Poor judgment
Loss of language abilities
Affective or personality losses
Loss of affect
Diminished inhibition
Loss of tact, control of
temper
Loss of recognition (others,
environment, self)
Increasing self-preoccupation
Psychotic features
Antisocial behavior
Loss of energy reserve
Cognitive or planning losses
Loss of general ability to plan
Progressively lowered stress
threshold
Impaired ability to set goals,
plan
Purposeful wandering
Violent, agitated, or anxious
behavior
Compulsive repetitive
behavior
Purposeless behavior
Withdrawal or avoidance
behavior
Related Factors
Pathophysiologic (Hall, 1991)
Related to progressive degeneration of the cerebral cortex secondary to:
Alzheimer’s disease*
Multi-infarct dementia (MID)*
Combination
Related to disturbance in cerebral metabolism, structure, or integrity
secondary to:
Pick’s disease Creutzfeldt–Jakob disease
Toxic substance injection Degenerative neurologic disease
Brain tumors Huntington’s chorea
End-stage diseases Psychiatric disorders
(AIDS, cirrhosis, cancer, renal failure, cardiac failure, chronic
obstructive pulmonary disease)
Goal
The person will participate to the maximum level of independence
in a therapeutic milieu as evidenced by the following indicators:
• Decreased frustration
• Diminished episodes of combativeness
• Increased hours of sleep at night
• Stabilized or increased weight
Interventions
Refer to Interventions Under Acute Confusion
Assess Who the Person Was Before the Onset of Confusion
• Educational level, career
• Hobbies, lifestyle
• Coping styles
Observe the Client to Determine Baseline Behaviors
• Best time of day
• Response time to a simple question
• Amount of distraction tolerated
• Judgment
• Insight into disability
• Signs/symptoms of depression
• Routine
Promote the Client’s Sense of Integrity (Miller, 2009)
• Adapt communication to the client’s level:
• Avoid “baby talk” and a condescending tone of voice.
• Use simple sentences and present one idea at a time.
• If the client does not understand, repeat the sentence using
the same words.
• Use positive statements; avoid “don’ts.”
• Unless a safety issue is involved, do not argue.
• Avoid general questions, such as, “What would you like to do?”
Instead, ask, “Do you want to go for a walk or work on your
rug?”
• Be sensitive to the feelings the client is trying to express.
• Avoid questions you know the client cannot answer.
• If possible, demonstrate to reinforce verbal communication.
• Use touch to gain attention or show concern unless a negative
response is elicited.
• Maintain good eye contact and pleasant facial expressions.
• Determine which sense dominates the client’s perception
of the world (auditory, kinesthetic, olfactory, or gustatory).
Communicate
through the preferred sense.
Promote the Client’s Safety
• Ensure that the client carries identification.
• Adapt the environment so that the client can pace or walk if
desired.
• Keep the environment uncluttered.
• Reevaluate whether treatment is needed. If needed, provide the
following to promote safety.
Intravenous Therapy
• Camouflage tubing with loose gauze.
• Consider an intermittent access device instead of continuous
IV therapy.
• If dehydration is a problem, institute a regular schedule for
offering oral fluids.
• Use the least restrictive sites.
Urinary Catheters
• Evaluate causes of incontinence.
• Institute a specific treatment depending on type. Refer to
Impaired Urinary Elimination.
• Place urinary collection bag at the end of the bed with catheter
between rather than draped over legs. Velcro bands can hold
the catheter against the leg.
Gastrointestinal Tubes
• Check frequently for pressure against nares.
• Camouflage gastrostomy tube with a loosely applied abdominal
binder.
• If the client is pulling out tubes, use mitts instead of wrist
restraints.
• Evaluate if restlessness is associated with pain. If analgesics are
used, adjust dosage to reduce side effects.
• Put the client in a room with others who can help watch him
or her.
• Enlist the aid of family or friends to watch the client during
confused periods.
• Give the client something to hold (e.g., stuffed animal).
If Combative, Determine the Source of the Fear and Frustration
• Fatigue
• Misleading or inappropriate stimuli
• Change in routine, environment, caregiver
• Pressure to exceed functional capacity
• Physical stress, pain, infection, acute illness, discomfort
If a Dysfunctional Episode or Sudden Functional Loss Has
Occurred
• Address the client by surname.
• Assume a dependent position to the client.
• Distract the client with cues that require automatic social
behavior (e.g., “Mrs. Smith, would you like some juice now?”).
• After the episode has passed, discuss the episode with the client.
• Document antecedents, behavior observed, and consequences.
Ensure Physical Comfort and Maintenance of Basic Health Needs
• Refer to Self-Care Deficits.
Select Modalities Involving the Five Senses (Hearing, Sight, Smell,
Taste, and Touch) That Provide Favorable Stimuli for the Client
Music Therapy
• Determine the client’s preferences. Play this music before the
usual level of agitation for at least 30 min; assess response.
• Evaluate response, as some music can agitate individuals.
• Provide soft, soothing music during meals.
• Arrange group songfests with consideration to cultural/ethical
orientation.
• Play music during other therapies (physical, occupational, and
speech).
• Have the client exercise to music.
• Organize guest entertainment.
• Use client-developed songbooks (large print and decorative
covers).
Recreation Therapy
• Encourage arts and crafts
• Suggest creative writing
• Provide puzzles
• Organize group games
Remotivation Therapy
• Organize group sessions into five steps (Dennis, 1984):
Step 1: Create a climate of acceptance (approx. 5 min).
• Maintain a relaxed atmosphere; introduce leaders and participants.
• Provide large-letter name tags and names on chairs.
• Maintain assigned places for every session.
Step 2: Creating a bridge to reality (approx. 15 min).
• Use a prop (visual, audio, song, picture, object, poem) to
introduce the theme of the session.
Step 3: Share the world we live in (approx. 15 min).
• Discuss the topic as a group.
• Promote stimulation of senses.
Step 4: Appreciate the work of the world (approx. 20 min).
• Discuss how the topic relates to their past experiences (work,
leisure).
Step 5: Create a climate of appreciation (approx. 5 min).
• Thank each member individually.
• Announce the next session’s topic and meeting date.
• Use associations and analogies (e.g., “If ice is cold, then fire
is. . . ?” “If day is light, then night is . . .?”).
• Choose topics for remotivation sessions based on suggestions
from group leaders and group interests. Examples are pets,
bodies of water, canning fruits and vegetables, transportation,
and holidays.
Sensory Training
• Stimulate vision (with brightly colored items of different
shape, pictures, colored decorations, kaleidoscopes).
• Stimulate smell (with flowers, soothing aromas from lavender
or scented lotion).
• Stimulate hearing (play music with soothing sounds such as
ocean or rain).
• Stimulate touch (massage, vibrating recliner, fuzzy objects,
velvet, silk, stuffed animals).
• Stimulate taste (spices, salt, sugar, sour substances).
Reminiscence Therapy
• Consider instituting reminiscence therapy on a one-to-one or
group basis. Discuss the purpose and Goals with the client care
team. Prepare well before initiating.
Implement Techniques to Lower the Stress Threshold (Hall &
Buckwalter, 1987; Miller, 2009)
Reduce Competing or Excessive Stimuli
• Keep the environment simple and uncluttered.
• Use simple written cues to clarify directions for use of radio
and television.
• Eliminate or minimize unnecessary noise.
Plan and Maintain a Consistent Routine
• Attempt to assign the same caregivers.
• Elicit from family members specific methods that help or
hinder care.
• Arrange personal care items in order of use (clothes, toothbrush,
mouthwash, and so forth).
• Determine a daily routine with the client and family.
• Write down the sequence for all caregivers.
• Reduce the stress when change is anticipated:
• Keep the change as simple as possible (e.g., minimal holiday
decorations).
• Ensure the client is well rested.
• Institute change during the client’s best time of day if possible.
Focus on the Client’s Ability Level
• Do not request performance of function beyond ability.
• Express unconditional positive regard for the client.
• Modify environment to compensate for ability (e.g., use of
Velcro fasteners, loose clothing, elastic waistbands).
• Use simple sentences; demonstrate activity.
• Do not ask questions that the client cannot answer.
• Avoid open-ended questions (e.g., “What do you want to eat?”
“When do you want to take a bath?”).
• Avoid using pronouns; name objects.
• Offer simple choices (e.g., “Do you want a cookie or crackers?”).
• Use finger foods (e.g., sandwiches) to encourage self-feeding.
Minimize Fatigue (Hall, 1994)
• Provide rest periods twice daily.
• Choose a rest activity with the client, such as reading or listening
to music.
• Encourage napping in recliner chairs, not in bed.
• Plan high-stress or fatiguing activities during the best time of
day for the client.
• Allow the person to cease an activity at any time.
• Incorporate regular exercise in the daily plan.
• Be alert to expressions of fatigue and increased anxiety; immediately
reduce stimuli.
Initiate Health Teaching and Referrals, as Needed
• Support groups
• Community-based programs (e.g., day care, respite care)
• Alzheimer’s association (www.alz.org)
• Long-term care facilities
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