Mental Health Nursing II
NURS 2310
Unit 15
Cognitive Impairment and
Thought Disorders
Key Terms
Psychosis = Disorganization of the personality,
deterioration in social functioning, and loss of
contact with or distortion of reality; may
include hallucinations and/or delusions
Hallucinations = False sensory perceptions not
associated with real external stimuli affecting
any or all of the five senses
Illusions = Misinterpretations/misperceptions of
real external stimuli
Delusions = False personal beliefs not consistent
with intelligence or culture; belief continues to
exist in spite of proof to the contrary
Paranoia = Extreme suspiciousness of others
and of their actions/perceived intentions
Depersonalization = Feelings of unreality
Anhedonia = Inability to experience pleasure
Religiosity = Excessive demonstration of or
obsession with religious ideas/behavior
Magical thinking = Belief that one’s thoughts or
behaviors can control certain situations/people
Neologisms = Invented words that have
symbolic meaning to self but are meaningless
to others
Echolalia = Repetition of words one hears in
attempt to identify with the speaker
Echopraxia = Imitation of movements made by
others in an attempt to identify with them
Perseveration = Persistent repetition of the
same word/idea in response to different
questions or other prompts
Looseness of associations = Shifting of ideas
from one unrelated subject to another
Word salad = Random arrangement of groups
of words that lacks any logical connection
Circumstantiality = Delay in reaching the point
of communication due to unnecessary/tedious
details; inability to track the discussion topic
Tangentiality = Inability to get to the point of
communication; unrelated topics are
introduced and original discussion is lost
Clang associations = Word choice is determined
by sound instead of meaning (i.e. rhyming)
Mutism = Refusal or inability to speak
Catatonia = A state of stupor (extreme
psychomotor retardation) or excitement
(extreme psychomotor agitation) that is
usually associated with a psychotic disorder
Waxy flexibility = Passive yielding of ones’ body
to positioning/posturing by others
Cognitive Impairment
Delirium
Cognitive disturbance manifested by
disorientation, agitation, memory
impairment, and inability to reason or
partake in goal-directed activity
 Develops within several hours or days; onset
may be more abrupt (i.e. following head
injury or seizure)
 May be caused by systemic illness, metabolic
imbalance, ingestion of toxins, drug or
alcohol overdose, withdrawal from
drugs/alcohol or medication

Symptoms of Delirium
Rambling, incoherent speech
 Extreme distractibility
 Hallucinations and/or illusions
 Sleep disturbances with vivid nightmares
 Hyperactivity/hypervigilance or catatonic
stupor
 Emotional instability (irritability, murmuring,
moaning, fleeing or lashing out)
 Autonomic manifestations (tachycardia,
sweating, dilated pupils)

Progression of Delirium
Brief in duration (1 week to 1 month)
 Symptoms diminish within 3 days to 1 week
of resolution of underlying cause (full
recovery may take up to 2 weeks)
 May transition into a permanent cognitive
disorder (i.e. dementia) if left unresolved
 CBC, BMP, chemistry panel used to diagnose
underlying cause
 Treated by determination/correction of
underlying cause (i.e. fluid/electrolyte status
corrections, treatment of hypoxia, anoxia, or
diabetic problems)

Neurocognitive Disorder (NCD)
Previously termed dementia
 Progressive decline in cognitive function due
to damage or disease in the brain beyond
what might be expected from normal aging
 Develops slowly over several months or years
 Progression is typically irreversible
 Diagnosed by evaluation (i.e. mental status
exam/MSE, CT scan, ruling out of other
underlying causes of symptomology)
 Treatment focused on symptom management
 Categorized as primary or secondary NCD

Primary NCD
The neurocognitive disorder itself is the major
sign of an organic brain disease that is not
directly related to another organic illness
 Alzheimer’s disease is the most common
cause of primary NCD; vascular insufficiency
(as in stroke) is another common cause

Secondary NCD
Occurs as a result of a physical disease or
injury (directly related to another condition)
 Causes include HIV, cerebral trauma;
substance abuse

Symptoms of NCD
Impairment in abstract thinking/judgment;
lack of impulse control
 Uninhibited/inappropriate behavior; disregard
of social conduct; personality changes
 Neglectful of personal appearance/hygiene
 Apraxia (inability to carry out motor activities)
 Aphasia (inability to express needs)
 Irritability, mood instability, sudden outbursts
 Unable to comprehend own limitations; at risk
for accidents or wandering away from home

Stages of NCD related to Alzheimer’s
Stage 1 = no apparent symptoms
 Stage 2 = forgetfulness
 Stage 3 = mild cognitive decline (interference
with work performance)
 Stage 4 = mild-to-moderate cognitive decline;
confusion (confabulation common)
 Stage 5 = moderate cognitive decline; early
NCD (begins to lose independence)
 Stage 6 = moderate-to-severe cognitive
decline; middle NCD (disorientation)
 Stage 7 = severe cognitive decline; late NCD
(bedfast, aphasic, and immobile)

Medications for Clients with NCD

Cholinesterase inhibitors
– Treats cognitive impairment
– Side effects: dizziness, headache, GI upset
– Examples: tacrine (Cognex), donepezil (Aricept),
and rivastigmine (Exelon)

Antipsychotic agents
– Treats agitation, aggression, hallucinations,
thought disturbances, and wandering
– Side effects: headache, dizziness, drowsiness
– Examples: risperidone (Risperdal), olanzapine
(Zyprexa), quetiapine (Seroquel), and
haloperidol (Haldol)

Antidepressants
– Treats depression, depression-related insomnia
– Side effects: headache, drowsiness/dizziness
– trazodone (Desyrel), mirtazapine (Remeron)

Anxiolytics
– Treats anxiety
– Side effects: drowsiness/dizziness, GI upset
– lorazepam (Ativan)

Sedative-hypnotics
– Treats insomnia
– Side effects: headache, drowsiness/dizziness
– zolpidem (Ambien), eszopiclone (Lunesta)
Nursing Care for Clients with
Cognitive Impairment

Promote client safety
– remain with client at all times to monitor
behavior and provide reorientation and
assurance
– maintain room in low level of stimuli

Frequently orient client to reality
– use clocks and calendars with large numbers
– allow client to have personal belongings
Preserve the dignity of the client
 Help client’s family/primary caregivers to
facilitate care
 Assist in dealing with caregiver burnout


Keep explanations simple
– use face-to-face interaction
– speak slowly and do not shout

Discourage rumination of delusional thinking
– talk about real events and real people
Monitor for medication side effects
 Allow plenty of time for client to perform
tasks
 Follow usual routine as closely as possible
with regard to ADLs
 Provide guidance and support for
independent actions by talking the client
through the task one step at a time

Thought Disorders
Brief Psychotic Disorder
Sudden onset of psychotic symptoms that
last at least 1 day but less than 1 month
 May or may not be preceded by a severe
psychosocial stressor
 Full recovery to premorbid level of function

Schizophreniform Disorder
Identical to schizophrenia with the exception
of duration (symptoms last at least 1 month
but less than 6 months)
 Prognosis is good, with full recovery to
premorbid level of function likely

Schizoaffective Disorder

Diagnosis of both schizophrenia and a mood
disorder, such as MDD
Delusional Disorder
Presence of one or more nonbizarre
delusions that persist for at least 1 month
 Hallucinations are not present or are not
prominent
 Behavior is not bizarre
 Delusions may be erotomanic, grandiose,
jealous, persecutory, or somatic in nature

Types of Delusional Disorder

Erotomanic = Belief that someone (usually
famous) is in love with oneself
 Grandiose = Irrational ideas regarding one’s
own worth, talent, knowledge, or power
 Jealous = Belief that one’s sexual partner is
unfaithful in the absence of substantiation
 Persecutory = Belief that one is being
treated malevolently in some way
 Somatic = Belief that one suffers from a
physical defect, disorder, or disease (such as
an internal parasite or infestation of insects
in/on the skin)
Schizophrenia
Disturbance in thought processes, perception,
and affect that results in severe deterioration
of social/occupational functioning
 Symptoms categorized as positive or negative

– Positive symptoms = in excess of normal function
 Hallucinations, delusions, disorganized behavior,
disorganized thinking and speech
 Good response to antipsychotic medications
– Negative symptoms = deficit in normal function
 Affective flattening, alogia (poverty of speech),
avolition (inability to initiate goal-directed activity),
apathy, anhedonia, social isolation
 Poor response to treatment/medication
Phases of Schizophrenia

Phase I: Premorbid Phase
– indifferent to social relationships
– appear cold and aloof
– does not always progress to schizophrenia

Phase II: Prodromal Phase
– social withdrawal
– peculiar or eccentric behavior
– bizarre ideas
– unusual perceptual experiences
– neglectful of personal hygiene and grooming
– lack of initiate, interests, or energy
– phase may last for many years

Phase III: Schizophrenia
– delusions and/or hallucinations
– disorganized speech
– disorganized or catatonic behavior
– affective flattening
– marked decrease in level of functioning
– persists for at least 6 months

Phase IV: Residual Phase
– usually follows active phase of the disease
– flat affect and impairment in role functioning
– residual impairment usually increases after each
exacerbation with active disorder
Medication Management of
Schizophrenia

Typical antipsychotic agents
– Side effects: nausea, sedation, EPS
– Examples: chlorpromazine (Thorazine),
fluphenazine (Prolixin), and haloperidol (Haldol)

Atypical antipsychotic agents
– Side effects: drowsiness, dizziness, constipation,
dry mouth, headache, nausea/vomiting, EPS
– Examples: quetiapine (Seroquel), olanzapine
(Zyprexa), clozapine (Clozaril), ziprasidone
(Geodon), aripiprazole (Abilify), risperidone
(Risperdal), and paliperidone (Invega)
Communicating with Clients
with Thought Disorder
Use nonconfrontational speech and
mannerisms
 Encourage communication and expression of
feelings and fears
 Decrease stimuli and offer quiet activity
 Seek clarification of statements
 Provide recognition for constructive self-care
activities
 Make adjustments in food preparation and
service for patients with paranoia
 Establish therapeutic rapport by listening,
sharing observations, and accepting silence

Patient Education for Clients
with Cognitive Impairment or
Thought Disorder
Nature of the illness (causes, symptoms)
 Management of the illness

– ways to ensure client safety
– how to maintain reality orientation
– providing assistance with ADLs
– nutritional information
– difficult behaviors
– medication administration
– matters related to hygiene and toileting

Support services
– financial/legal assistance
– support groups and respite care
Nursing Process for Clients
with Cognitive Impairment
or Thought Disorder

Assessment
– information gathered from a number of sources
because client is likely to be a poor historian

Diagnosis
– disturbed thought processes R/T delusions (or
concrete thinking or paranoia) AEB bizarre
statements and behaviors
– disturbed sensory perception R/T hallucinations
(or illusions) AEB inability to tolerate group
therapy, talking to self, or looking for or at
something that is not there
– self-care deficit R/T withdrawal and loss of
motivation and judgment AEB poor hygiene, poor
grooming, and avoiding others

Planning
– development of the nursing care plan

Intervention
– rapport building
– limit-setting
– communicating expectations
– client/family education

Evaluation
– focus is on short-term goals as opposed to longterm goals
– resolution of identified problems is unrealistic
– outcomes must be measured in terms of slowing
down the process rather than stopping or curing
the problem