ASKEP GANGGUAN KOGNITIF

& MENTAL ORGANIK

• Kognisi: kemampuan otak memproses, mempertahankan,
dan menggunakan informasi
• Kemampuan kognitif: pemikiran, penilaian, persepsi,
perhatian, pemahaman, memori
• Kemampuan kognitif: membuat keputusan, menyelesaikan
masalah, menginterpretasikan lingkungan, mempelajari
informasi baru
• Gangguan kognitif: gangguan atau kerusakan pada fungsi
otak yang lebih tinggi yang memberikan efek merusak pada
kemampuan fungsi kehidupan sehari-hari, lupa nama
anggota keluarga, tidak mampu melakukan tugas harian
dan mempertahankan higiene
• Kategori primer gangguan kognitif: delirium, demensia,
gangguan amnestik
 DELIRIUM
• Sindrom mencakup gangguan kesadaran yang disertai
perubahan kognisi
• Kondisi kebingungan akut
• Onset tiba-tiba, dalam jam atau beberapa hari
• Penyebab: penyakit, obat-obatan, infeksi, pembedahan,
penyalahgunaan alkohol, hipoksia, defisiensi vitamin,
gangguan endokrin, lesi SSP, dehidrasi
 Tanda dan gejala
 Ketidakmampuan fokus pada topik, mudah terdistraksi
 Penurunan memori, terutama peristiwa yang baru saja
berlangsung
 Disorientasi (tempat, waktu, orang)
 Kesulitan berbicara atau mengingat kata-kata
 Berbicara melantur
 Kesulitan memahami pembicaraan, kesulitan membaca
atau menulis
 Halusinasi
 Agitasi, iritabel
 Gangguan pola tidur
 Emosi yang ekstrim, cth: takut, cemas, marah, depresi
 Penatalaksanaan
• Mengatasi penyebab atau pencetus, contoh: menghentikan obat
penyebab delirium, mengatasi infeksi.
Perawatan suportif
• Mencegah komplikasi dengan menjaga kepatenan jalan nafas,
pemberian cairan dan nutrisi, menangani nyeri, mempertahankan
orientasi terhadap lingkungan, dll
Pendekatan non farmakologi:
• Jam dan kalender tersedia untuk mempertahankan orientasi pasien
• Lingkungan yang tenang, nyaman
• Secara teratur mengingatkan secara verbal lokasi berada dan apa yang
terjadi
• Pelibatan keluarga
• Menghindari perubahan lingkungan dan caregiver
• Menyediakan periode istirahat/tidur di malam hari tanpa gangguan
• Usahakan menghindari tidur di siang hari untuk menjaga siklus
tidur bangun
• Hindari restrain fisik dan pemasangan kateter
• Sediakan nutrisi dan cairan adekuat
• Gunakan penerangan yang adekuat, musik, massage, tenik
relaksasi untuk menurunkan agitasi
• Beri kesempatan melakukan aktivitas sehari-hari
• Sediakan kacamata, alat bantu dengar, dan lain2 yang dibutuhkan
 Perbedaan Delirium & Dementia
DELIRIUM DEMENTIA
Onset tiba-tiba, dengan titik awal yang pasti Lambat dan bertahap, titik awal tidak pasti

Durasi Hari-minggu, meskipun bisa lebih lama Biasanya menetap

Penyebab Infeksi, dehidrasi, penggunaan atau Biasanya gangguan otak kronik (Alzheimer
putus obat tertentu, dll disease, Lewy body dementia, vascular
dementia (sumbatan pembuluh darah otak,
stroke) dll)
Perjalanan penyakit Biasanya bisa pulih kembali Perlahan-lahan berkembang progresif
Efek di malam hari Hampir selalu memburuk Sering memburuk
Perhatian Sangat terganggu Tidak terganggu sampai demensia menjadi
parah
Tingkat kesadaran Terganggu secara bervariasi Tidak terganggu sampai demensia menjadi
cukup parah
Orientasi waktu dan tempat Berbeda-beda Terganggu
Penggunaan bahasa Lambat, sering tidak koheren, tidak Kadang-kadang kesulitan menemukan kata
sesuai yang tepat
Memori Berbeda-beda Hilang, terutama kejadian yang baru
berlangsung
Kebutuhan penanganan medis Segera Dibutuhkan tetapi tidak urgent
ALZHEIMER
 ALZHEIMER DISEASE (AD)
• Sekitar 70% dari kasus demensia pada lansia
• Insiden meningkat dengan usia.
• Terjadi hingga 30% pada orang berusia> 85 tahun
• Ditandai dengan: hilangnya secara progresif neuron kortikal,
Pembentukan plak amiloid (beta-amyloid adalah komponen
utama) dan intraneuronal neurofibrillary tangles
(hyperphosphorylated tau proteins adalah komponen utama)

CASE: 70 years old female present with progressive memory loss for past
1 year. She also complaints of difficulty in naming objects and driving car
and house keeping. For the past 1 month she has difficulty in dressing
,eating and gets agitated easily and wanders around at night. MMSE:
15/30, Neurological exam: normal, Vision & hearing: normal
Pathology
Enzymes act on the APP (amyloid precursor protein) and cut
it into fragments. The beta-amyloid fragment is crucial in
the formation of senile plaques in AD.
KRITERIA DIAGNOSTIK DEMENSIA TIPE ALZEIMER

Perkembangan beberapa defisit kognitif: 1. penurunan

memori; 2, gangguan kognitif lainnya
gangguan ini menyebabkan disfungsi dalam kegiatan
sosial atau pekerjaan
Perjalanan penyakit menunjukkan onset bertahap dan
penurunan
Defisit tidak berhubungan dengan: 1. kondisi SSP lainnya
2. kondisi yang diakibatkan zat/obat tertentu
Tidak terjadi secara khusus selama delirium
Tidak berhubungan dengan gangguan kejiwaan lainnya
 PEMERIKSAAN
• Pemeriksaan neurologi dan neuropsikologi
• Brain imaging: Atropi otak akibat hilangnya neuron secara luas
dan atropi hipokampus
Nama Responden : Nama Pewawancara :
Umur Responden : Tanggal Wawancara :
Pendidikan : Jam mulai :
MINI MENTAL STATE EXAMINATION (MMSE)
Nilai Maksimum Nilai Responden
ORIENTASI
5 Sekarang (hari-tanggal-bulan-tahun) berapa dan musim apa?
5 Sekarang kita berada di mana?
(Nama rumah sakit atau instansi)
(Instansi, jalan, nomor rumah, kota, kabupaten, propinsi)
REGISTRASI
3 Pewawancara menyebutkan nama 3 buah benda, misalnya: (bola, kursi, sepatu). Satu detik untuk tiap
benda. Kemudian mintalah responden mengulang ketiga nama benda tersebut.
Berilah nilai 1 untuk tiap jawaban yang benar, bila masih salah ulangi penyebutan ketiga nama tersebut
sampai responden dapat mengatakannya dengan benar:
Hitunglah jumlah percobaan dan catatlah : ______ kali
ATENSI DAN KALKULASI
5 Hitunglah berturut-turut selang 7 angka mulai dari 100 ke bawah. Berhenti setelah 5 kali hitungan (93-
86-79-72-65). Kemungkinan lain ejaan kata dengan lima huruf, misalnya 'DUNIA' dari akhir ke awal/
dari kanan ke kiri :'AINUD'
Satu (1) nilai untuk setiap jawaban benar.
MENGINGAT
3 Tanyakan kembali nama ketiga benda yang telah disebut di atas.
Berikan nilai 1 untuk setiap jawaban yang benar
BAHASA
9 a. Apakah nama benda ini? Perlihatkan pensil dan arloji (2 nilai)
b. Ulangi kalimat berikut :"JIKA TIDAK, DAN ATAU TAPI" (1 nilai)
c. Laksanakan 3 perintah ini :
Peganglah selembar kertas dengan tangan kananmu, lipatlah kertas itu pada
pertengahan dan letakkan di lantai (3 nilai)
d. Bacalah dan laksanakan perintah berikut
"PEJAMKAN MATA ANDA" (1 nilai)
e. Tulislah sebuah kalimat ! (1 nilai)
f. Tirulah gambar ini ! (1 nilai)
Jam selesai :
Tempat wawancara :
TANDA:
kehilangan memori yang
mengganggu fungsi sehari-hari
Kesulitan dalam perencanaan
atau pemecahan masalah
Kesulitan menyelesaikan tugas
sehari-hari di rumah, di tempat
kerja atau di waktu luang
Kebingungan dengan waktu atau
tempat
Kesulitan memahami gambar
visual dan hubungan spasial
Perubahan mood dan kepribadian
Penurunan dalam pengambilan
keputusan/penilaian
Lupa tempat menyimpan sesuatu
dan kehilangan kemampuan
menelusuri
masalah baru dengan kata-kata
dalam berbicara atau menulis
Menarik diri dari pekerjaan atau
kegiatan sosial
Tahapan alzheimer/alzheimer stage
• gejala sangat bervariasi.
• Tidak semua orang akan mengalami gejala yang sama
atau perkembangan pada tingkat yang sama.
• Seven-stage framework dikembangkan oleh Barry
Reisberg, M.D., clinical director of the New York University
School of Medicine’s Silberstein Aging and Dementia
Research Center. Source: Alzheimer’s Association
Tahap 1: tidak ada kerusakan (fungsi normal)
•tidak ada masalah memori. Pemeriksaan tidak
menunjukkan bukti gejala demensia.

Tahap 2: penurunan kognitif sangat ringan

(mungkin perubahan normal berkaitan dengan
usia atau tanda-tanda awal penyakit Alzheimer)
•Penderita mungkin merasakan adanya
kehilangan memori - melupakan kata-kata yang
biasa digunakan atau lokasi benda sehari-hari.
Namun tidak ada gejala demensia terdeteksi
selama pemeriksaan medis atau oleh teman-
teman, keluarga atau rekan kerja.
Tahap 3. Penurunan kognitif ringan
(tahap awal Alzheimer dapat didiagnosis dalam beberapa kasus)
Teman, keluarga atau rekan kerja mulai menyadari kesulitan pasien.
Selama wawancara medis secara rinci, dokter mungkin dapat
mendeteksi masalah dalam memori atau konsentrasi. Kesulitan
umum tahap 3 meliputi:
masalah dengan kata atau nama yang tepat
Kesulitan mengingat nama ketika diperkenalkan kepada orang-
orang baru
Memiliki kesulitan lebih besar dalam melakukan tugas-tugas sosial
atau pekerjaan
Lupa materi/informasi yang baru saja dibaca
Kehilangan atau lupa tempat menyimpan benda berharga
Peningkatan masalah dengan perencanaan atau pengorganisasian
Tahap 4: Penurunan kognitif sedang
Pada titik ini, wawancara medis mampu mendeteksi
gejala:
•Lupa peristiwa yang baru saja terjadi
•Menurunnya kemampuan aritmatika, misal:
menghitung mundur 100 dikurangi 7
•kesulitan yang lebih besar dalam melakukan tugas-
tugas yang kompleks, seperti perencanaan makan
malam untuk para tamu, membayar tagihan atau
mengelola keuangan
•Lupa tentang data diri sendiri
•Menjadi murung atau menarik diri, terutama situasi
yang menantang secara mental dan sosial
Tahap 5: Penurunan kognitif cukup berat
•Kesenjangan dalam memori dan berpikir menjadi
sangat nyata, dan individu mulai butuh bantuan dengan
kegiatan sehari-hari.
•Tidak dapat mengingat alamat atau telepon sendiri,
almamater
•Menjadi bingung tentang di mana berada atau hari apa
•Memiliki masalah dengan aritmatika mental; seperti
menghitung mundur dari 40 dikurangi 4 atau dari 20
dikurangi 2
•Butuh bantuan memilih pakaian yang tepat untuk musim
atau acara tertentu
•Masih ingat hal penting tentang diri sendiri dan keluarga
•Belum memerlukan bantuan dengan makan atau
menggunakan toilet
Tahap 6: penurunan kognitif berat
kesulitan mengingat terus memburuk, perubahan
kepribadian yang signifikan mungkin muncul dan
individu butuh bantuan ekstensif dengan kegiatan
sehari-hari. Pada tahap ini, individu dapat:
Kehilangan kesadaran sebagian besar
pengalaman dan peristiwa yang baru terjadi serta
lingkungan
Mengingat riwayat pribadi secara tidak sempurna,
meskipun mereka umumnya ingat nama sendiri
Kadang lupa nama pasangan atau caregiver utama
tetapi umumnya dapat membedakan wajah yang
akrab dan asing
Butuh bantuan berpakaian dengan benar; tanpa
pengawasan, dapat membuat kesalahan seperti
menggunakan piyama pada siang hari atau salah
menggunakan sepatu
Mengalami gangguan siklus bangun tidur normal
Butuh bantuan detail dengan toileting (mengguyur, menyeka
dan membuang tisu dengan benar)
Peningkatan inkontinensia urin atau feces
Mengalami perubahan kepribadian yang signifikan dan
gejala perilaku, termasuk kecurigaan dan delusi (misalnya,
percaya bahwa caregiver adalah seorang penipu);
halusinasi (melihat atau mendengar hal-hal yang tidak
benar-benar ada); atau kompulsif, perilaku berulang seperti
tangan meremas-remas atau merobek tisu
Cenderung keluyuran dan tersesat
Tahap 7: penurunan kognitif sangat berat
•Merupakan tahap akhir dari penyakit ketika individu
kehilangan kemampuan untuk berespon terhadap
lingkungan, untuk bercakap-cakap dan, akhirnya, untuk
mengontrol gerakan.
•Individu mungkin masih mengatakan kata-kata atau
frasa.
•Individu pada tahap ini perlu dibantu dengan banyak
perawatan sehari-hari, termasuk makan atau
menggunakan toilet.
•Mungkin kehilangan kemampuan untuk tersenyum,
duduk tanpa bantuan dan untuk menahan kepala
tegak.
•Refleks menjadi abnormal.
•Otot menjadi kaku.
•Menelan terganggu.
 Perbedaan demensia dan alzheimer
DEMENSIA ALZHEIMER
Pengertian Gangguan pada otak akibat penyakit Salah satu jenis demensia.
atau kondisi lain Bentuk paling umum dari
demensia
Penyebab Beragam, termasuk: alzheimer, Belum diketahui dengan
stroke, masalah tiroid, reaksi terhadap pasti. Sementara: Plak
obat, tumor otak amiloid
onset ≥ 65 tahun ≥ 65 tahun tapi dapat
terjadi lebih awal seperti
30 tahun
Gejala Masalah pada memori, fokus, Kesulitan mengingat
perhatian, persepsi penglihatan, informasi yang baru saja
pengambilan keputusan, penilaian, dipelajari, disorientasi,
pemahaman perubahan mood dan
perilaku mungkin terjadi
seiring dengan
perkembangan penyakit.
 Penatalaksanaan
• Aricept: Donepezil  menghambat kolinesterase 
memperlambat pemecahan neurotransmiter 
memperlambat gejala alzheimer, tidak mencegah atau
menyembuhkan alzheimer
• Celexa: Citalopram  mengurangi cemas, depresi
• Depakote: Sodium Valproat  mengatasi agresi berat
• Exelon: Rivastigmine  memperlambat gejala alzheimer
• Belum ada pengobatan yang mampu menghentikan
kemunduran sel otak pada alzeimer
• Penelitian: vitamin E, diet
The U.S. Food and Drug Administration (FDA) has approved five
medications to treat the symptoms of Alzheimer's disease

Drug name Brand name Approved For FDA Approved

1. donepezil Aricept All stages 1996
2. galantamine Razadyne Mild to moderate 2001
3. memantine Namenda Moderate to severe 2003
4. rivastigmine Exelon All stages 2000
5. donepezil and Namzaric Moderate to severe
2014
memantine

1) Cholinesterase inhibitors : Donepezil, galantamine and rivastigmine

 bekerja dengan menghambat kolinesterase  memperlambat
pemcecahan neurotransmiter utama
2) Memantine, an NMDA (N-methyl-D-aspartate) receptor antagonist 
mengatur aktivitas glutamat, yaitu neurotransmiter penting dalam
memori dan belajar
 DEMENSIA
 Demensia: sekelompok gejala yang mempengaruhi
kemampuan intelektual dan sosial cukup parah untuk
mengganggu fungsi sehari-hari.
 Kehilangan memori umumnya terjadi pada demensia, tetapi
kehilangan memori saja tidak berarti memiliki demensia.
 Ada banyak penyebab gejala demensia.
 Penyakit Alzheimers adalah penyebab paling umum dari
demensia progresif
 DEMENSIA menyebabkan perubahan kepribadian, memori,
suasana hati, perilaku, bahasa, pemikiran
Epidemiologi
• 5-8% pada usia 65-70
• 10-20% pada usia 75-80
• 40-50% pada usia> 85 tahun
• Bentuk demensia paling umum: alzheimer: 50-75%
• Demensia dengan lewy bodies: 15-35%
• Demensia vaskuler: 5-20%
 KRITERIA DIAGNOSIS
Gambaran penting dari demensia adalah perkembangan beberapa defisit
kognitif yang meliputi:
gangguan memori, dan setidaknya salah satu dari gangguan kognitif
berikut:
aphasia (gangguan bahasa): ketidakmampuan memahami kata-kata
tertulis atau yang diucapkan atau untuk menulis atau berbicara
apraxia (gangguan kemampuan untuk melakukan kegiatan motorik
meskipun fungsi motorik normal, cth: cara makan, menyisir rambut),
agnosia (kegagalan untuk mengenali atau mengidentifikasi objek
meskipun fungsi sensorik utuh, misal: mengenali meja), dan
disfungsi eksekutif (kesulitan dalam perencanaan, pengorganisasian,
pengurutan, mengurutkan, meringkas)
Defisit juga harus cukup parah dan harus menunjukan penurunan dari
tingkat fungsi sebelumnya yang lebih tinggi
Gejala tidak terjadi secara khusus hanya saat delirium
Diagnosis demensia bisa disertai dengan kondisi lain seperti:
• Awal (sebelum usia 65) atau onset lambat (setelah 65)
• Dengan Gangguan Perilaku (misalnya, keluyuran);
• Dengan Delirium
• Dengan Delusi (jika delusi yang paling menonjol);
• Dengan Depressed mood
• Tanpa komplikasi (jika kondisi di atas tidak mendominasi
kondisi klinis).
 Perbedaan Delirium & Dementia
DELIRIUM DEMENTIA
Onset tiba-tiba, dengan titik awal yang pasti Lambat dan bertahap, titik awal tidak pasti

Durasi Hari-minggu, meskipun bisa lebih lama Biasanya menetap

Penyebab Infeksi, dehidrasi, penggunaan atau Biasanya gangguan otak kronik
putus obat tertentu, dll (Alzheimer disease, Lewy body
dementia, vascular dementia (sumbatan
pembuluh darah otak, stroke) dll)
Perjalanan penyakit Biasanya bisa pulih kembali Perlahan-lahan berkembang progresif
Efek di malam hari Hampir selalu memburuk Sering memburuk
Perhatian Sangat terganggu Tidak terganggu sampai demensia
menjadi parah
Tingkat kesadaran Terganggu secara bervariasi Tidak terganggu sampai demensia
menjadi cukup parah
Orientasi waktu dan tempat Berbeda-beda Terganggu
Penggunaan bahasa Lambat, sering tidak koheren, tidak Kadang-kadang kesulitan menemukan
sesuai kata yang tepat
Memori Berbeda-beda Hilang, terutama kejadian yang baru
berlangsung
Kebutuhan penanganan Segera Dibutuhkan tetapi tidak urgent
medis
 LEWY BODY DEMENTIA
• Lewy body dementia  deposit protein, yang disebut lewy
bodies, berkembang pada sel-sel saraf di daerah otak yang
terlibat dalam pemikiran, memori dan gerakan.
• Tanda dan gejala: halusinasi visual, gangguan pergerakan,
regulasi buruk fungsi tubuh, masalah kognitif, kesulitan tidur,
perhatian berfluktuasi, depresi.
• Penyebab Lewy tubuh demensia tidak diketahui, tetapi
gangguan mungkin terkait dengan Alzheimer atau penyakit
Parkinson.
• Faktor risiko: usia lebih dari 60 tahun, laki-laki, memiliki anggota
keluarga dengan Lewy body dementia.
• Komplikasi: demensia berat, kematian, rata-rata sekitar delapan
tahun setelah timbulnya kondisi
Pemeriksaan pada demensia
TREATMENTS AND DRUGS FOR DEMENTIA
• Cholinesterase inhibitors  increasing the levels of
chemical messengers  for memory, thought and judgment
(neurotransmitters) in the brain.
• Parkinson's disease medications  carbidopa-levodopa
(Sinemet)  reduce parkinsonian symptoms. However, these
medications may also cause increased confusion,
hallucinations and delusions.
• etc
 Pendekatan non farmakologi
• Modifikasi lingkungan: mengurangi
kebisingan
• Modifikasi respon pemberi
perawatan/caregiver. Menghindari
mengoreksi dan menguji dengan tebak-
tebakan. Menenangkan dan
memvalidasi kekhawatiran dapat
membantu
• Modifikasi tugas dan buat rutinitas
harian. Buat tugas dalam langkah-
langkah yang lebih mudah dan berfokus
pada keberhasilan. Kegiatan harian
yang rutin dan terstruktur juga
membantu mengurangi kebingungan
 TERAPI ALTERNATIF
• Terapi musik
• Terapi hewan peliharaan
• Aromatherapy
• Massage therapy
• Life review therapy
• Reminiscence therapy
 Gaya hidup dan penatalaksanaan di rumah
• Enhance communication/tingkakan komunikasi  maintain eye
contact, speak slowly, in simple sentences, and don't rush the response.
Present only one idea or instruction at a time. Use gestures and
cues/isyarat, such as pointing to objects.
• Encourage exercise/anjurkan olahraga. Benefits of exercise include
improved physical function, more controlled behavior and fewer
depression symptoms. Some research shows physical activity may slow
the progression of impaired thinking (cognitive) function in people with
dementia.
• Encourage participation in games and thinking activities/dorong
partisipasi dalam permainan atau aktivitas berpikir. Participating in
games involve using thinking skills may help slow mental decline in
people with dementia.
• Establish a nighttime ritual/tetapkan rutinitas aktivitas malam hari.
Behavior issues may be worse at night. Try to establish going-to-bed
rituals that are calming and away from the noise of television, meal
cleanup and active family members. Leave night lights on to prevent
disorientation.
• Limiting caffeine during the day/batasi kafein di siang hari, discouraging
daytime napping and offering opportunities for exercise during the day
may help prevent nighttime restlessness.
ASUHAN KEPERAWATAN DEMENSIA
Assessment
•Assess the onset and characteristics of symptoms (determine
type and stage of disorder).
•Establish cognitive status, using standard measurement tools:
MMSE.
•Determine self-care abilities.
•Assess threats to physical safety (eg, wandering, poor reality
testing).
•Assess affect and emotional responsiveness.
•Assess ability and level of support available to caregivers.
Nursing Diagnosis for Dementia
Impaired Thought Processes: Gangguan proses pikir
Goal 1:
•The client can expect an trusting relationships
Outcomes:
•Clients show a sense of fun, friendly facial expressions would
shake hands with eye contact, would sit side by side.
Intervention:
•Greet clients with both verbal and non-verbal.
•Introduce yourself politely.
•Explain the purpose of the meeting.
•Honest and keep promises.
•Show empathy and accept the nature of the client.
•Pay attention to the basic needs of the clients and note.
Goal 2:
•The client is able to recognize / oriented to time and place.
Outcomes:
•The client is able to say which one is around, the client is able to
mention the days and places visited.
Interventions:
•Give a chance for patients to recognize private property, for
example: a bed, closet, clothes etc..
•Give the patient the opportunity to get to know the time by using a
large clock, a calendar that has a daily sheet with great writing.
•Give the patient the opportunity to name and immediate family
members.
•Give an opportunity for clients to know where he is.
•Give praise when the patient if the patient is able to answer
correctly.
Goal 3:
•Patients were able to perform daily activities optimally.
Outcomes:
•Patients were able to meet their daily needs independently.
Interventions:
•Observation of the patient's ability to perform daily activities.
•Give the patient the opportunity to choose activities that can
be done.
•Help the patient to engage in activities that have been chosen.
•Give credit if the patient can perform activities.
•Ask if the patient feeling able to perform its activities.
•Together with the patient to make a schedule of daily activities.
• Impaired Verbal Communication
related to cerebral impairment as demonstrated by altered
memory, judgment, and word finding
• Bathing or Hygiene Self-Care Deficit
related to cognitive impairment as demonstrated by
inattention and inability to complete ADLs
• Impaired Social Interaction
related to cognitive impairment
• Risk for Violence: Self-directed or Other-directed
related to suspicion and inability to recognize people or
places
Chronic Confusion: kebingunan kronik
Suggested NOC Labels
•Cognitive Orientation
•Information Processing
•Memory
•Neurological Status: Consciousness
Client Outcomes
•Remains content and free from harm
•Functions at maximal cognitive level
•Participates in activities of daily living at the maximum of functional ability
NIC Interventions
Suggested NIC Labels
•Dementia Management
•Environmental Management
•Reality Orientation
•Surveillance: Safety
Nursing Interventions and Rationales
• Determine client's cognitive level using a screening tool such as the
Mini Mental State Exam (MMSE).
• Gather information about client pre-dementia functioning, including
social situation, physical condition, and psychological functioning.
• Assess the client for signs of depression: insomnia, poor appetite,
flat affect, and withdrawn behavior.
• Ensure that client is in a safe environment by removing potential
hazards such as sharp objects and harmful liquids.
• Place an identification bracelet on client. Clients with dementia
wander and can become lost; identification bracelets increase client
safety.
• Avoid exposing client to unfamiliar situations and people as much
as possible. Maintain continuity of caregivers. Maintain routines of
care through established mealtimes, bathing, and sleeping
schedules. Send familiar person with client when client goes for
diagnostic testing or into unfamiliar environments.
• Keep environment quiet and nonstimulating; avoid using buzzers
and alarms if possible. Minimize sights and sounds that have a
high potential for misinterpretation such as buzzers, alarms, and
overhead paging systems.
• Begin each interaction with client by identifying self and calling
client by name. Approach client with a caring, loving, and
accepting attitude and speak calmly and slowly.
• Touch client gently, stroking hand or arm in a soothing fashion if
acceptable in client's culture.
• Give one simple direction at a time and repeat as necessary.
• Break down self-care tasks into simple steps (e.g., instead of
saying, "Take a shower," say to client, "Please follow me. Sit
down on the bed. Take off your shoes. Now take off your
socks.").
• Keep questions simple; yes or no questions are often preferable
to open-ended questions.
• If eating in the dining room causes increased agitation, let client
leave and eat in a quieter environment with a smaller number of
people.
• Provide finger food if patient has difficulty using eating utensils or
if unable to sit to eat.
• Provide boundaries by placing red or yellow tape on the floor or
by using a stop sign. Boundaries help the client identify safe
areas; older clients can more easily see red and yellow than
other colors.
• Assess the etiology of wandering before or rather than
attempting to control the wandering.
• Write client's name in large block letters in the room and on
client's clothing and possessions. Use symbols rather than
words to identify areas such as the bathroom or kitchen.
• Limit visitors to two and provide them with guidelines on
appropriate topics to discuss and how to best communicate with
client.
• Set up scheduled quiet periods in a recliner or room. Use
blankets and other environmental cues to define rest periods.
• Provide quiet activities, such as listening to classical or religious
music, or other cues that promote relaxation in the afternoon or
early evening. An increase in confusion and agitation, referred to
as sundowning syndrome, may occur in the late afternoon and
early evening. Quiet activities can provide a calming
environment.
• Provide simple activities for the client, such as folding washcloths
and sorting or stacking activities. Avoid misleading and
frightening stimuli, which may include television, mirrors, and
pictures of people or animals.
• Consider using doll therapy. Ask family members to bring a large,
safe doll or stuffed animal such as a teddy bear.
• If client becomes increasingly confused and agitated, perform
the following steps:
• Monitor client for physiological causes, including acute hypoxia,
pain, medication effects, malnutrition, infections such as urinary
tract infection, fatigue, electrolyte disturbances, and
constipation.
• Monitor for psychological causes, including changes in
environment, caregiver, and routine; demands to perform
beyond capacity; and multiple competing stimuli (including
discomfort).
• Avoid confrontations with the client; allow client to dissipate
energy by performing repetitive tasks or by pacing.
• If client is delusional or hallucinating, do not confront him or her with
reality. Use validation therapy to verbally reflect back the emotions
that the client appears to be experiencing. Use statements such as,
"It must be frightening to see a fire at the end of your bed," "I can
see that you are afraid," "I will stay with you," or "Can you tell me
more about what is going on right now?" Orienting the client to
reality can increase agitation; validation therapy conveys empathy
and understanding and can help determine the internal stimulus that
is creating the change in behavior (Feil, 1993).
• Decrease stimuli in the environment (e.g., turn off television, take
client to a quiet place). Institute activities associated with pleasant
emotions, such as playing soft music the client likes, looking through
a photo album, providing favorite food, or using simulated presence
therapy.
• Avoid using restraints if at all possible
• Use low dose regular dosing of psychotropic or antianxiety drugs
only as a last resort. They are effective in managing symptoms of
psychosis and aggressive behavior. Start with the lowest possible
dose.
• Avoid use of anticholinergic medications such as Benadryl.
Anticholinergic medications have a high side effect profile that
includes disorientation, urinary retention, and excessive drowsiness
(Nurses Drug Alert, 1995).
• For predictable difficult times, such as during bathing and grooming,
try the following:
• Massage the client's hands lovingly or use therapeutic touch to relax the
client.
• Use positive behavioral reinforcement for each of the small steps
involved in bathing, such as praising client for walking toward the
shower, sitting in the shower chair, and removing items of clothing.
• Treat the client with the utmost respect and give individualized care.
• Use reminiscence and life review therapeutic interventions; ask
questions about client's work, child rearing, or time spent in the
service. Ask questions such as "What was really important to
you as you look back?" Reminiscence and life review can help
an older person reframe and accept life events (Burnside,
Haight, 1994).

•
Multicultural
•Assess for the influence of cultural beliefs, norms, and values
on the family or caregiver understanding of chronic confusion or
dementia.
•Inform client family or caregiver of the meaning of and reasons
for common behavior observed in clients with dementia.
•Refer family to social services or other supportive services to
assist with meeting the demands of caregiving for the client with
dementia.
•Encourage family to make use of support groups or other
service programs.
•Validate the family members’ feelings with regard to the impact
of client behavior on family lifestyle. Validation lets the client
know that the nurse has heard and understands what was said,
and it promotes the nurse-client relationship (Stuart, Laraia,
2001; Giger, Davidhizer, 1995).
Home Care Interventions
•Keeping the client as independent as possible is important.
Community-based care  GOAL: maintaining safety for the
client
•Provide support to family of client with chronic and disabling
condition.
•If client will require extensive supervision on an ongoing basis,
evaluate client for day care programs. Day care programs
provide safe, structured care for the client and respite for the
family.
•Encourage family to include client in family activities when
possible. These steps help the client maintain dignity and lead
to familiar socialization of the client.
•Assess family caregivers for caregiver burden.
Client/Family Teaching
•Recommend that the family develop a memory aid wallet or booklet for client that
contains pictures and text that chronicle the client's life  helps dementia clients make
more factual statements and stay on topic, decreases the number of confused
•Teach family how to converse with a memory-impaired person. Guidelines: Ask client to
have a conversation with you.
– Guide conversation to specific, nonthreatening topics and redirect the
conversation back on topic when client begins to ramble.
– Reassure and help out when the client gets stuck or cannot find the right words.
– Smile and act interested in what client is saying even if unsure what it means.
– Thank client for talking.
– Avoid quizzing client or asking a lot of specific questions.
– Avoid correcting or contradicting something that was stated even if it is wrong.
•Teach family how to set up environment
•Discuss with the family what to expect as the dementia progresses.
•Counsel the family about resources available with regard to end-of-life decisions and
legal concerns.
•Inform family that as dementia progresses, hospice care may be available in the
terminal stages in the home to help the caregiver.
Risk for Injury related to the difficulty of balance,
weakness, cognitive impairment and wandering behavior
Goal: Risk of injury does not occur
Outcomes:
•Increasing activity levels.
•Can adapt to the environment to reduce the risk of trauma / injury.
•Not injured.
Interventions:
•Assess the degree of hearing ability, impulsive behavior and a decrease in
visual perception. Help families identify the risk of hazards that may arise.
•Eliminate sources of environmental hazards.
•Divert attention when agitated behavior / dangerous, climbing fences bed.
•Assess for medication side effects, signs of poisoning (extrapyramidal
signs, orthostatic hypotension, visual disturbances, gastrointestinal
disorders).
•Avoid continuous use of restrain. Give the family a chance to live with the
client during the period of acute agitation.
 Discuss restriction of driving when recommended.
 Assess patient’s home for safety: remove throw rugs, label
rooms, and keep the house well lit.
 Assess community for safety.
 Alert neighbors about the patient’s wandering behavior.
 Alert police and have current pictures taken.
 Provide patient with a MedicAlert bracelet.
 Install complex safety locks on doors to outside or
basement.
 Install safety bars in bathroom.
 Closely observe patient while he is smoking.
 Encourage physical activity during the daytime.
 Give patient a card with simple instructions (address and
phone number) should the patient get lost.
 Use night-lights.
 Install alarm and sensor devices on doors.
Impaired Communication
•Outcome: Demonstrate congruent verbal and nonverbal
communication.
Interventions:
•Speak slowly and use short, simple words and phrases.
•Consistently identify yourself, and address the person by
name at each meeting.
•Focus on one piece of information at a time. Review what has
been discussed with patient.
•If patient has vision or hearing disturbances, have him wear
prescription eyeglasses and/or a hearing device.
•Keep environment well lit.
•Use clocks, calendars, and familiar personal effects in the
patient’s view.
• If patient becomes verbally aggressive, identify and
acknowledge feelings.
• If patient becomes aggressive, shift the topic to a safer,
more familiar one.
• If patient becomes delusional, acknowledge feelings and
reinforce reality. Do not attempt to challenge the content
of the delusion.
Bathing or Hygiene Self-Care Deficit
•Outcome: Independence in self-Care
•Interventions:
Assess and monitor patient’s ability to perform ADLs.
Encourage decision making regarding ADLs as much as possible.

Label clothes with patient’s name, address, and telephone number.

Use clothing with elastic and Velcro for fastenings rather than

buttons or zippers, which may be too difficult for patient to

manipulate.
Monitor food and fluid intake.

Weigh patient weekly.

Provide food that patient can eat while moving.

Sit with patient during meals and assist by cueing.

Initiate a bowel and bladder program early in the disease process to

maintain continence and prevent constipation or urine retention

Impaired Social Interaction
•Outcome: Socialization increase
Interventions:
•Provide magazines with pictures as reading and language
abilities diminish.
•Encourage participation in simple, familiar group activities,
such as singing, reminiscing, doing puzzles, and painting.
•Encourage participation in simple activities that promote
the exercise of large muscle groups.
Risk for Violence: Self-directed or Other-directed
Outcome: Risk for violence is not appears
Interventions:
•Respond calmly and do not raise your voice.
•Remove objects that might be used to harm self or others.
•Identify stressors that increase agitation.
•Distract patient when an upsetting situation develops.
Latihan
1. A client who developed delirium following surgery asks if
having delirium is the beginning of Alzheimer disease. The
nurse explains the differences between delirium and
dementia. Which of the following statements by the client
requires further teaching?
A.“So I developed delirium because I had surgery.”
B.“If I have dementia I will slowly get worse
C.“In dementia there are quick changes in the levels of
consciousness, too.”
D.“I might have developed permanent brain damage.”
• Rationale:
A. “So I developed delirium because I had surgery.” This is
correct information about delirium. Physical changes contribute
to the development of delirium.
B. “If I have dementia I will slowly get worse.” This is correct.
The onset of dementia is slow and seen over several months.
C. “In dementia there are quick changes in the levels of
consciousness, too.” This is an incorrect answer. While a client
with delirium has fluctuating changes in levels of
consciousness, the client with dementia does not.
D. “I might have developed permanent brain damage.” This is
accurate information. The client with delirium may develop
permanent neurological damage if the cause of the delirium is
not treated.
2. A client is diagnosed with vascular dementia. Which of the
following explanations will assist the family to understand the
cause of this type of dementia?
A.Strands of protein are tangled together.
B.Blood vessels in the brain are bleeding.
C.Acetylcholine production is decreased.
D.Fragments mix with molecules to make plaques in the
brain.
Rationale:
A. Strands of protein are tangled together. Tangles are found in
client with Alzheimer disease. Proteins that are intended to
provide stability in the neuron are tangled together.
B. Blood vessels in the brain are bleeding. Vascular dementia is
caused by bleeding and ischemia in the brain. Risk factors for
Vascular dementia are similar to those for cerebral vascular
accident (CVA).
C. Acetylcholine production is decreased. This is thought to be a
cause of Alzheimer disease. There is less of the enzyme needed
to produce acetylcholine in the brains of clients with Alzheimer
disease.
D. “Fragments mix with molecules to make plaques in the brain.
Plaques are found in the brains of clients with Alzheimer disease.
Proteins mix together to form plaques. The more plaques present
the more signs of degeneration are present in the client.”
An 80-year-old client who lives with her daughter tells the
nurse, “No one lets me eat with them. I have to hide my
food under the bed.” The nurse plans a family meeting to
discuss:
A.Family eating patterns.
B.Current living arrangement.
C.Cultural values of the family.
D.Adequate nutrition for the family.
• Rationale:
A. Family eating patterns. People with dementia may make
paranoid accusations against family members. The initial
assessment would include asking the family if the mother is
a member at each meal and if there is a schedule for
meals.
B. Current living arrangement is not the presenting problem
in this question.
C. Cultural values of the family are an important aspect but
not the priority at this family session.
D. Adequate nutrition for the family. The client’s concern
was not the availability of food but the pattern of eating.
The client’s nutrition would be monitored but the primary
concern is the participation of the client with the family.
A client with dementia has a disturbed sleep pattern. Which
of the following interventions should the nurse utilize for the
client?
A. Encourage TV watching during the day.
B. Give sleep medication.
C. Promote mild exercise.
D. Awaken the client when napping.
• Rationale:
A. Encourage TV watching during the day. Watching TV is
a passive activity. This will not assist the client with
dementia have an effective sleep pattern. Their ability to
interact and understand with the environment is
compromised.
B. Give sleep medication is not desirable for the aged
client.
C. Promote mild exercise. Mild exercise is the therapeutic
and stimulates the client.
D. Awaken the client when napping. Allow the adult to
nap. Older adults nap during the day but if possible limit
napping in the evening.
The nurse is planning nursing interventions to improve self-
esteem for a group of clients diagnosed with Alzheimer
disease. Which of the following therapeutic strategies will
the nurse include in the treatment plan? (Select all that
apply.)
A. Life review or reminiscence therapy
B. Music therapy
C. Pet therapy
D. Watching TV
E. Puzzles, board games
• Rationale:
A. Life review or reminiscence therapy focuses on
strengths and does not dwell on loss.
B. Music therapy is used to reduce the effects of stress and
improve the quality of life for clients.
C. Pet therapy gives the client the opportunity to nurture,
touch, and stroke animals.
D. Watching TV is a passive act and does not encourage
self-esteem.
E. Puzzles and board games are challenging and could
cause agitation in the clients.
• A 69-year-old client is admitted and diagnosed with delirium. Later
in the day, he tries to get out of the locked unit. He yells, "Unlock
this door. I've got to go see my doctor. I just can't miss my monthly
Friday appointment." Which of the following responses by the nurse
is most appropriate?
1. "Please come away from the door. I'll show you your room."
2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse."
3. "The door is locked to keep you from getting lost."
4. "I want you to come eat your lunch before you go the doctor."
Answer: 2. Loss of orientation, especially for time and place, is common in
delirium. The nurse should orient the client by telling him the time, date,
place, and who the client is with. Taking the client to his room and telling
him why the door is locked does not address his disorientation. Telling
the client to eat before going to the doctor reinforces his disorientation.
• The nurse is attempting to draw blood from a woman with a
diagnosis of delirium who was admitted last evening. The client
yells out, "Stop; leave me alone. What are you trying to do to me?
What's happening to me?" Which response by the nurse is most
appropriate?
1. "The tests of your blood will help us figure out what is happening
to you."
2. "Please hold still so I don't have to stick you a second time."
3. "After I get your blood, I'll get some medicine to help you calm
down."
4. "I'll tell you everything after I get your blood tests to the
laboratory."
Answer: 1. Explaining why blood is being taken responds to the client's
concerns or fears about what is happening to her. Threatening more pain
or promising to explain later ignores or postpones meeting the client's
need for information. The client's statements do not reflect loss of self
control requiring medication intervention.
The client with dementia states to the nurse, "I know you. You're
Margaret, the girl who lives down the street from me." Which of the
following responses by the nurse is most therapeutic?
1. "Mrs. Jones, I'm Rachel, a nurse here at the hospital."
2. "Now Mrs. Jones, you know who I am."
3. "Mrs. Jones, I told you already, I'm Rachel and I don't live down
the street."
4. "I think you forgot that I'm Rachel, Mrs. Jones."
•Answer: 1. Because of the client's short-term memory impairment, the
nurse gently corrects the client by stating her name and who she is. This
approach decreases anxiety, embarrassment, and shame and maintains
the client's self-esteem. Telling the client that she knows who the nurse is
or that she forgot can elicit feelings of embarrassment and shame.
Saying, "I told you already" sounds condescending, as if blaming the
client for not remembering.
• While educating the daughter of a client with dementia about the
illness, the daughter complains to the nurse that her mother
distorts things. The nurse understands that the daughter needs
further teaching about dementia when she makes which
statement?
1. "I tell her reality, such as, 'That noise is the wind in the trees.'"
2. "I understand the misperceptions are part of the disease."
3. "I turn off the radio when we're in another room."
4. "I tell her she is wrong and then I tell her what's right."
• Answer: 4. Telling the client that she is wrong and then telling her what
is right is argumentative and challenging. Arguing with or challenging
distortions is least effective because it increases defensiveness.
Telling the client about reality indicates awareness of the issues and is
appropriate. Acknowledging that misperceptions are part of the
disease indicates an understanding of the disease and an awareness
of the issues. Turning off the radio helps to limit environmental stimuli
and indicates an awareness of the issues.
• The client with Alzheimer's disease may have delusions about
being harmed by staff and others. When the client expresses
fear of being killed by staff, which of the following responses is
most appropriate?
1. "What makes you think we want to kill you?"
2. "We like you too much to want to kill you."
3. "You are in the hospital. We are nurses trying to help you."
4. "Oh, don't be so silly. No one wants to kill you here."
Answer: 3. The nurse needs to present reality without arguing with the
delusions. Therefore, stating that the client is in the hospital and the
nurses are trying to help is most appropriate. The client doesn't
recognize the delusion or why it exists. Telling the client that the staff
likes him too much to want to kill him is inappropriate because the
client believes the delusions and doesn't know that they are false
beliefs. It also restates the word, kill, which may reinforce the client's
delusions. Telling the client not to be silly is condescending and
disparaging and therefore inappropriate.
A priority nursing diagnosis for the client experiencing altered perception,
extreme agitation, and acute confusion is:
1. Risk for Injury. Due to the client’s altered perception and acute
confusion, the client is at immediate risk for injury. Client safety is the
highest priority.
2. Altered Role Performance. The client may have an altered role
performance due to the cognitive changes; however, this is not the priority
diagnosis.
3. Impaired Verbal Communication. The client’s impaired verbal
communication may increase the risk for injury as the client may not be
able to express needs or comprehend what is being said.
4. Disturbed Sensory Perception. The client with an alteration in sensory
perception may be at increased risk for injury due to an inability to
correctly identify safety factors within the environment.