UNIT 3 - OBJECTIVES

1. Describe the definition, scope, attributes, and healthcare context of concepts including
Cognition, Perfusion, and Gas Exchange.
2. Describe the physiological processes of cognition, perfusion, and gas exchange from the
wellness perspective.
3. Describe and define normal assessment findings in cognition, perfusion, and gas exchange
across the lifespan.
4. Recognize how the main concepts relate to the scope, attributes, criteria, and roles in nursing
care to all of their interrelated concepts across the lifespan.
5. Identify risk factors for alterations in perfusion, cognition, and gas exchange.
6. Identify primary and secondary methods of prevention for the concepts of cognition,
perfusion, and gas exchange.
7. Identify how Cognition, Perfusion, and Gas Exchange influence nursing and health care with
respect to their interrelated concepts.

Concept 33 – COGNITION p. 320

Definition: The process of thought that embodies perception, attention, visual-

spatial cognition, language, learning, memory, and executive function with the
higher-order thinking skills of comprehension, insight, problem solving, reasoning,
decision making, creativity, and metacognition

Six domains of cognitive function include perceptual motor function, language,

learning and memory, social cognition, complex attention, and executive function.

Three related terms—

1. Perception – is the interpretation of the environment and is

dependent on the acuity of sensory input.

2. Memory – broadly refers to the retention and recall of past

experiences and learning. It is not a single, unified mental ability but
rather a series of different neural subsystems, each of which has a
unique localization in the brain.
 3. executive function – refers to the higher thinking processes that allow
for flexibility, adaptability, and goal directedness. Executive function
determines the contents of consciousness, supervises voluntary
activity, and is future oriented.

Scope: cognition may be described as intact or impaired.

Intact – means that an individual exhibits cognitive behavior that are considered
to be within the range of normal for age and culture.

Impaired – can be mild to severe.

Impaired cognition signifies an observable or measurable disturbance in one or

more of the cognitive processes resulting from an abnormality within the brain or
a factor interfering with normal brain function.

Higher-order cognitive function - is characterized by learning, comprehension,

insight problem solving, reasoning, decision making, creativity, and metacognition.

Basic cognitive functioning includes perception, pattern recognition, and

attention.

According to Piaget, cognitive development is an orderly and sequential process

that occurs in four stages:
1. sensorimotor (birth to age 2 years)
2. preoperational (ages 2 to 7 years)
3. concrete operational (ages 7 to 11 years)
4. formal operational (age 11 years and older)

Variations and Context

Categories:

Delirium - is the most frequent complication of hospitalization in the elderly

population. A number of underlying conditions can lead to delirium such as
dehydration, electrolyte imbalances, fever, hypoxia, sleep deprivation, adverse
effect of medications, and illicit drug use, to name a few.
Neurocognitive Disorders – aka dementia.

Cognitive Impairment – Not dementia.

Focal Cognitive Disorders

Intellectual Disability – below average IQ

Mild: I Q 55 – 70
Moderate: IQ 50 -55
Severe: IQ25-40
Profound: IQ 25

Learning Disability -

Individuals with cognitive impairment are at a higher risk for injury due to falls.

The primary age group at risk

 elderly population
 any individual from all population groups
 women with poor health status, dependency, lack of social support
 Men with history of stroke or diabetes.

Individual Risk Factors

 personal behaviors
 environmental exposures
 congenital (present at birth) or genetic conditions
 other health-related conditions.

Assessment
 1. History
a. Adults – health history (intracranial disease or trauma, substance
abuse, medications, etc.
b. Infants and children – birth history, 3 generation family health history

2. Examination
a. General appearance – posture and body movements.
b. Behavior – assess level of consciousness.
c. Assessment – see below

Common Cognitive Assessment Tools

Global Cognitive Performance

 Mini-Mental State Examination (MMSE): a 30-item, 10-minute
questionnaire to measure cognitive impairment and progression of disease.

 Severe Impairment Battery (SIB): Used with significantly cognitively

impaired patients to assess lower levels of cognitive function; in other
words, provides differentiating clarity among individuals who score less
than 12 on the MMSE.

Executive Functioning
 Controlled Oral Word Association Test (COWAT) Assesses ability to generate
a list of as many words starting with a designated letter as possible in 1 min.
Tests attention, thought process, judgment, aphasia and memory, ability to
adhere to a set of rules to assess attention, thought process, and judgment.

 Behavioral Dyscontrol Scale (BDS) Nine-item screening test to evaluate the

capacity of an older adult related to independent functioning. The tool
evaluates motor control processes and insight regarding accuracy of
performance.

Motor Speed
  Hand Tapping Test: Used to evaluate motor speed and involves tapping the
hands. Slowed tapping speed is associated with cognitive impairment.

Episodic Memory
 Three Words Three Shapes Test: Measures memory, recall, and recognition
using verbal and nonverbal information.

 Fuld Object Memory Evaluation: Tests for recognition, memory, and learning
in older adults. Ten objects in a bag are presented to individuals who are
asked to identify the objects by touch (stereognosis) and then allowed to
see if they were correct. After a few minutes, they are asked to recall the
things in the bag.

Cognitive Impairment

 Global Deterioration Rating Scale (GDRS) Behavioral rating scale assessment

for three phases of cognitive impairment: forgetfulness, confusion, and
dementia.

3. Diagnostic Tests
There are no laboratory tests that diagnose cognitive impairment, although
laboratory tests are critical in determining the presence of associated
disease or contributing factors. For example, a laboratory test can detect an
electrolyte imbalance, which may be the underlying cause associated with
an acute state of confusion.

Clinical Management

Primary Prevention –
 promoting healthy lifestyle – including optimal nutrition, exercise, social
activity, etc.
 Teaching and community programs (e.g., substance abuse prevention,
decrease in high-
risk behaviors, healthy pregnancies, healthy aging)
 • Genetic testing
• Promoting practice that reduces the risk for delirium.

Secondary Prevention – (screening)

 Mini-mental examination

64: DEMENTIA AND DELIRIUM p.1573 (Lewis’ Med-Surg e-book)

Dementia is a disorder characterized by a decline from the previous level of

function in 1 or more cognitive domains: complex attention, executive function,
language, learning and memory, perceptual-motor, and social cognition.

Alzheimer disease (AD) is a chronic, progressive, irreversible neurodegenerative

brain disease. It most often affects persons age 65 and older.
AD progresses slowly. It has a long preclinical phase, which may last up to 20
years. The average clinical duration is 4 to 8 years. Some patients have lived for 20
years after diagnosis.

The greatest risk factor for AD is age. Most people with AD are diagnosed at age
65 or older. While age is the greatest risk factor, AD is not a normal part of aging
and age alone does not cause the disease.

Head trauma is a risk factor for dementia.

Early Warning Signs of AD

 1. Memory Loss
2. Problems with abstract thinking
3. Difficulty doing familiar tasks
4. Poor or decreased judgment
5. Problems with language
6. Misplacing things
7. Changes in mood
8. Changes in Personality
9. Loss of initiative

Assessments

1. The Mini-Cog – a brief assessment tool for cognitive impairment.

Decreasing Risk for Cognitive Decline

 1. Avoid harmful substances
2. Challenge your mind
3. Exercise regularly
4. Stay socially active
5. Avoid trauma to the brain
6. Take care of mental health
7. Treat diabetes
8. Take care of your heart
9. Get enough sleep
10.Get the right fuel

Behavior problems occur in about 90% of patients with AD. These problems
include repetitiveness or asking the same question repeatedly, delusions,
hallucinations, agitation, aggression, altered sleeping patterns, wandering,
hoarding, and resisting care. Many times, these behaviors are unpredictable and
may challenge caregivers. Caregivers must be aware that these behaviors are not
intentional and are often difficult to control. Behavior problems are often the
reason that patients are placed in a facility.

Delirium

Delirium is a state of confusion that develops over days to hours. The patient has
decreased ability to direct, focus, sustain, and shift attention and awareness.
Deficits in memory, orientation, language, visuospatial ability, or perception may
be present. The patient may be hypoactive or hyperactive. Emotional problems
include fear, depression, euphoria, or perplexity. Sleep may be disturbed.

Risk Factors
 Age 65 years and older
 Male gender
 Cognitive impairment
 Dementia
 Depression
 History of delirium
  Dehydration
 Malnutrition
 Alcohol and drug use
 Pain
 Sleep deprivation
 Stress
 History of falls
 Hypoxia
 History of stroke
 Terminal illness
 Sensory overload
 Vision or hearing impairment

Mnemonic for Causes of Delirium

Dementia, dehydration
Electrolyte imbalances, emotional stress
Lung, liver, heart, kidney, brain
Infection, intensive care unit
Rx drugs
Injury, immobility
Untreated pain, unfamiliar environment
Metabolic disorders

Sherpath Passport QUIZ

1. Which symptom distinguishes delirium from dementia?

 Rapid onset of symptoms, often at night
 Abrupt progression of disease
 Accelerated, incoherent speech

2. When a patient’s cognition is being assessed, which functional

characteristic would the nurse evaluate?
 Ability to count backward from 100 by 7
 Ability to name the last three presidents
3. A patient undergoing the Mini-Cog test is being assessed for cognitive
impairment. After the clock drawing test, the patient puts the numbers in
correct sequence on the clock and recalls two words that the nurse asked
the patient to remember. What is the test score for this patient?
 Answer: 4. – 2 points for the clock and 2 points for the 2 words

4. Which action would the nurse take when a patient with cognitive
dysfunction due to stroke is unable to learn the self-care techniques taught
by the nurse?
 Encourage the caregiver to be more involved in-patient care
activities.

5. The nurse is conducting a teaching session on health strategies to decrease

the risk for developing Alzheimer disease (AD). Which statement made by a
participant indicates the need for further education?
 "Drinking a few glasses of wine each day has been shown to decrease
the incidence of AD."

6. Which cognitive function typically declines with age? Select all that apply.
One, some, or all responses may be correct.
 Short-term recall memory
 Mental performance speed
 Synthesis of new information

7. Which nursing intervention would the nurse use with a patient who has
been diagnosed with the mild cognitive impairment stage of Alzheimer
disease?
 Use a calendar and family pictures as memory aids.

8. Which symptom would the nurse assess if an older adult is showing signs of
dementia? Select all that apply. One, some, or all responses may be correct.
 Abrupt changes in behavior
 Memory loss
 Cognitive dysfunction
9. Which finding would the nurse identify as supporting a diagnosis of
dementia in a patient with behavioral changes?
 Difficulty with normal conversation
 Loss of memory

10. Which cognitive change is characteristic of a patient experiencing hypoxia?

 Restlessness
 Apprehension
 Memory changes

11. Which assessment factor is included in a Mini-Cog study?

 Ask patients to draw and read the hands of a clock and point out a
specific time.

12. Which cognitive function remains constant with aging?

 Long-term recall memory

13. Which intervention would help to promote mental health in a group of

patients who have a high risk of developing Alzheimer disease?
 Solve crossword puzzles.
 Learn new skills.
 Exercise regularly.

14. An older adult patient with cognitive impairment will benefit from which
nursing action?
 Offering a careful explanation of the treatment plan.