Care Plan for Cognitive Problems

Category / Primary Body System

• Neurological System

Problem

• Patient has alteration in cognitive function related to [specific condition, e.g., dementia, stroke, traumatic brain injury].

Goal

• Patient will continue to recognize caregivers and/or family members for 90 days.

Plan/Approach

1. Medication Management

   • Administer medications as ordered to manage cognitive function and related symptoms.

2. Patient Autonomy and Engagement

   • Allow the patient to make choices (e.g., daily clothing) if possible to promote autonomy and engagement.

3. Psychological Support

   • Arrange for psychiatric consults as needed to address any underlying psychological issues.

4. Effective Communication

   • Use simple phrases when communicating with the patient to ensure understanding.
   • Give the patient time to express feelings as necessary to validate their emotions and reduce frustration.

5. Family Involvement

   • Encourage family participation in the patient’s care, if available, to provide emotional support and continuity.

6. Monitoring and Consistency

   • Monitor the patient for increased confusion that is not baseline, and notify the MD/RNP if any changes are observed.
   • Utilize consistent caregivers whenever possible to provide stability and familiarity.

Rationale

1. Medication Management

   • Administering medications as prescribed helps manage cognitive symptoms and improve overall cognitive function.

2. Patient Autonomy and Engagement

   • Allowing the patient to make choices promotes a sense of control and autonomy, which can positively impact cognitive health.

3. Psychological Support

   • Addressing psychological issues through consults can improve the patient’s overall well-being and cognitive function.

4. Effective Communication

   • Using simple phrases and allowing time for expression reduces confusion and frustration, promoting better communication and understanding.

5. Family Involvement

   • Involving family in care provides emotional support and helps maintain the patient’s connection to familiar faces, which can enhance cognitive function.

6. Monitoring and Consistency

   • Regular monitoring for changes in cognitive status allows for timely interventions. Consistent caregivers help provide a stable environment, reducing confusion and anxiety.

Actions

1. Medication Management

   • Administer prescribed medications on schedule, monitoring for effectiveness and any side effects.
   • Document medication administration and patient response in the medical record.

2. Patient Autonomy and Engagement

   • Encourage the patient to make daily choices, such as selecting clothes or activities, to promote engagement and autonomy.

3. Psychological Support

   • Schedule psychiatric consults as needed and follow up on recommendations from mental health professionals.

4. Effective Communication

   • Use clear, simple phrases when speaking with the patient, ensuring they understand instructions and responses.
   • Allow adequate time for the patient to express their feelings, listening actively and validating their emotions.

5. Family Involvement

   • Encourage family members to participate in the patient’s care, providing support during visits and involvement in daily routines.
   • Educate the family on effective communication strategies and ways to support the patient’s cognitive function.

6. Monitoring and Consistency

   • Monitor the patient’s cognitive status regularly, noting any increases in confusion or changes from baseline.
   • Notify the MD/RNP of any significant changes in the patient’s cognitive function.
   • Assign consistent caregivers to the patient whenever possible to provide a familiar and stable environment.