Sherpath: Chapter 31 cognitive And Sensory
Alterations Exam Study Guide
Organizing/Linking Relevant Cues:
Medical diagnosis of recent CVA or stroke
Alterations in orientation (not oriented to person, place, and/or time)
Confusion that occurs quickly or over several days
Electrolytes abnormal
Dehydrated - ANSWER Cause:
Is a result of cerebral (brain) hypoxia and can be from many reasons, such as CVA,
shock, delirium, electrolyte imbalance, fluid imbalance, and many more
ICNP Diagnosis/Hypothesis:
Acute Confusion
Risk for Acute Confusion (has not occurred but is likely)
Organizing/Linking Relevant Cues:
Medical diagnosis of Alzheimer disease or dementia
Activities of daily living (ADLs) not completed
Walking requires assistance
Sitting requires assistance
Wanders without awareness of surroundings
Agitation with aggressive behavior (hit caregiver unexpectedly while being ambulated)
Sundowning
Poor judgment
Memory loss
Change in personality
Computation of numbers reduced
Verbal and/or physical behaviors repetitive - ANSWER Cause:
Any irreversible, chronic condition or disease that causes progressive cerebrum (brain)
deterioration
ICNP Diagnosis/Hypothesis:
Chronic Confusion
Organizing/Linking Relevant Cues:
Medical diagnosis of delirium
,Temperature elevated (high fever)
Drug and alcohol overdose
Electrolytes abnormal
Disoriented to person, place, and/or time that occurs quickly or over several days
Processing information incorrectly
Hallucinations
Stays up all night
Agitation - ANSWER Cause:
Any reversible condition or disease affecting the cerebrum (brain) that causes a sudden
onset of confusion or disorientation
ICNP Diagnosis/Hypothesis:
Delirium
Risk for Delirium (has not occurred but is likely)
Organizing/Linking Relevant Cues:
Medical diagnosis of dementia
Disoriented to person, place, and/or time
Short-term memory decreased (inability to remember what ate for breakfast)
Long-term memory decreased (inability to remember important dates like birthday or
wedding date; phone number; or address)
Forgetfulness (did not take antihypertensive medications twice in the past week; patient
states, "I forgot about them.")
Family members' or friends' names forgotten
Medical history forgotten - ANSWER Cause:
Any condition or disease that causes deterioration or loss of short-term (frontal lobe)
and/or long-term memory (temporal lobe)
ICNP Diagnosis/Hypothesis:
Impaired Memory
Organizing/Linking Relevant Cues:
Deafness
Hard of hearing
Conductive hearing loss
Sensorineural hearing loss
Presbycusis
Works in high-risk occupation for hearing loss
States that cannot hear nurse
Asks nurse to repeat words, phrases, and directions
Talks loudly
Wears hearing aid
Uses sign language
Describes ringing in ears
Takes ototoxic medication - ANSWER Cause:
, Any condition, disease, or medication that causes damage to the temporal lobe and/or
the ear, including the outer, middle, inner, cochlea, and/or cranial nerve VIII
(vestibulocochlear)
ICNP Diagnosis/Hypothesis:
Impaired Hearing
Organizing/Linking Relevant Cues:
Medical condition of anosmia
History of sinus infection, nasal polyps, allergies, common cold
History of smoking, cocaine use, substance abuse
Older adult
May not eat because cannot smell food odors
Cannot smell or identify common odors - ANSWER Cause:
Any condition or disease that causes damage to cranial nerve I (olfactory) and/or
temporal lobe
ICNP Diagnosis/Hypothesis:
Impaired Sense of Smell
Organizing/Linking Relevant Cues:
Cannot taste foods
May lose weight from not eating
States that food doesn't "taste right" or is bland
Uses a lot of salt or spices - ANSWER Cause:
Any condition or disease that damages or decreases gustatory (chemoreceptors) cells
(taste buds) and/or damages cranial nerves VII (facial) and IX (glossopharyngeal),
insula, and/or frontal lobe
ICNP Diagnosis/Hypothesis:
Impaired Sense of Taste
Organizing/Linking Relevant Cues:
Medical diagnosis of peripheral neuropathy, diabetes
Inability to discern hot/cold, sharp/dull touch
Wounds that the patient does not recall happening
Sensation, especially to hands and feet, decreased
Extremities with tingling and numbness - ANSWER Cause:
Any condition or disease that causes damage to the skin and tactile receptors
ICNP Diagnosis/Hypothesis:
Impaired Tactile Perception
Organizing/Linking Relevant Cues:
Medical diagnosis of myopia, hyperopia, presbyopia, macular degeneration, cataracts,
glaucoma, diabetic retinopathy
Alterations Exam Study Guide
Organizing/Linking Relevant Cues:
Medical diagnosis of recent CVA or stroke
Alterations in orientation (not oriented to person, place, and/or time)
Confusion that occurs quickly or over several days
Electrolytes abnormal
Dehydrated - ANSWER Cause:
Is a result of cerebral (brain) hypoxia and can be from many reasons, such as CVA,
shock, delirium, electrolyte imbalance, fluid imbalance, and many more
ICNP Diagnosis/Hypothesis:
Acute Confusion
Risk for Acute Confusion (has not occurred but is likely)
Organizing/Linking Relevant Cues:
Medical diagnosis of Alzheimer disease or dementia
Activities of daily living (ADLs) not completed
Walking requires assistance
Sitting requires assistance
Wanders without awareness of surroundings
Agitation with aggressive behavior (hit caregiver unexpectedly while being ambulated)
Sundowning
Poor judgment
Memory loss
Change in personality
Computation of numbers reduced
Verbal and/or physical behaviors repetitive - ANSWER Cause:
Any irreversible, chronic condition or disease that causes progressive cerebrum (brain)
deterioration
ICNP Diagnosis/Hypothesis:
Chronic Confusion
Organizing/Linking Relevant Cues:
Medical diagnosis of delirium
,Temperature elevated (high fever)
Drug and alcohol overdose
Electrolytes abnormal
Disoriented to person, place, and/or time that occurs quickly or over several days
Processing information incorrectly
Hallucinations
Stays up all night
Agitation - ANSWER Cause:
Any reversible condition or disease affecting the cerebrum (brain) that causes a sudden
onset of confusion or disorientation
ICNP Diagnosis/Hypothesis:
Delirium
Risk for Delirium (has not occurred but is likely)
Organizing/Linking Relevant Cues:
Medical diagnosis of dementia
Disoriented to person, place, and/or time
Short-term memory decreased (inability to remember what ate for breakfast)
Long-term memory decreased (inability to remember important dates like birthday or
wedding date; phone number; or address)
Forgetfulness (did not take antihypertensive medications twice in the past week; patient
states, "I forgot about them.")
Family members' or friends' names forgotten
Medical history forgotten - ANSWER Cause:
Any condition or disease that causes deterioration or loss of short-term (frontal lobe)
and/or long-term memory (temporal lobe)
ICNP Diagnosis/Hypothesis:
Impaired Memory
Organizing/Linking Relevant Cues:
Deafness
Hard of hearing
Conductive hearing loss
Sensorineural hearing loss
Presbycusis
Works in high-risk occupation for hearing loss
States that cannot hear nurse
Asks nurse to repeat words, phrases, and directions
Talks loudly
Wears hearing aid
Uses sign language
Describes ringing in ears
Takes ototoxic medication - ANSWER Cause:
, Any condition, disease, or medication that causes damage to the temporal lobe and/or
the ear, including the outer, middle, inner, cochlea, and/or cranial nerve VIII
(vestibulocochlear)
ICNP Diagnosis/Hypothesis:
Impaired Hearing
Organizing/Linking Relevant Cues:
Medical condition of anosmia
History of sinus infection, nasal polyps, allergies, common cold
History of smoking, cocaine use, substance abuse
Older adult
May not eat because cannot smell food odors
Cannot smell or identify common odors - ANSWER Cause:
Any condition or disease that causes damage to cranial nerve I (olfactory) and/or
temporal lobe
ICNP Diagnosis/Hypothesis:
Impaired Sense of Smell
Organizing/Linking Relevant Cues:
Cannot taste foods
May lose weight from not eating
States that food doesn't "taste right" or is bland
Uses a lot of salt or spices - ANSWER Cause:
Any condition or disease that damages or decreases gustatory (chemoreceptors) cells
(taste buds) and/or damages cranial nerves VII (facial) and IX (glossopharyngeal),
insula, and/or frontal lobe
ICNP Diagnosis/Hypothesis:
Impaired Sense of Taste
Organizing/Linking Relevant Cues:
Medical diagnosis of peripheral neuropathy, diabetes
Inability to discern hot/cold, sharp/dull touch
Wounds that the patient does not recall happening
Sensation, especially to hands and feet, decreased
Extremities with tingling and numbness - ANSWER Cause:
Any condition or disease that causes damage to the skin and tactile receptors
ICNP Diagnosis/Hypothesis:
Impaired Tactile Perception
Organizing/Linking Relevant Cues:
Medical diagnosis of myopia, hyperopia, presbyopia, macular degeneration, cataracts,
glaucoma, diabetic retinopathy
