ZARRAH ROSE S.

ALIANZA BSN3A ^_^ ◊ Assessment

• History
CHAPTER 21 COGNITIVE DISORDERS ♣ obtain information related to medical illness, alcohol or other drugs
Cognition=brain’s ability to process, retain & use information
Cognitive abilities=include reasoning, judgment, perception, attention ♣ information about drugs should include prescribed medications, alcohol
Cognitive disorder=is a disruption or impairment in higher level functions of the brain • General Appearance & Motor Behavior
DELIRIUM ♣ have disturbances of psychomotor behavior
A syndrome that involves a disturbance of consciousness accompanied by a change in cognition ♣ may be restless, hyperactive, frequently pricking at bedclothes or making sudden, uncoordinated
Develops over a short period of time attempts to get out of bed
Clients have difficulty paying attention, are easily distracted and disoriented and may have sensory disturbances such ♣ may have slowed motor behavior, appearing sluggish and lethargic with little movement
as illusions, misinterpretations or hallucinations
DSM-IV-TR Diagnostic criteria: Symptoms of Delirium
♣ speech becomes less coherent and more difficult to understand
difficulty with attention ♣ may perseverate on a single topic or detail
easily distractible
disoriented
♣ clients may call out or scream especially at night
sensory disturbances • Mood & affect
can have sleep-awake disturbances ♣ often have rapid, unpredictable mood shifts
changes in psychomotor activity
anxiety, fear, irritability, euphoria or apathy ♣ wide range of emotional responses is possible such as anxiety, fear, irritability
♥ Etiology ♣ fearful and feel threatened, they may become combative to defend themselves
MOST COMMON CAUSES OF DELIRIUM • Thought process & content
physiologic or metabolic hypoxemia, electrolyte disturbances, renal or hepatic failure, hypoglycemia,
hyperglycemia, dehydration, sleep deprivation, thyroid or glucocorticoid
♣ thought processes often are disorganized and make no sense
disturbances, thiamine or Vitamin B12 deficiency, vitamin C, niacin, or protein ♣ thought may also be fragmented (disjointed and incomplete)
deficiency, cardiovascular shock, brain tumor, head injury and exposure to ♣ may exhibit delusions, believing their altered sensory perceptions are real
gasoline, paint solvent, insecticides and related substances
infection systemic: meningitis, encephalitis, HIV, syphilis • Sensorium & intellectual process
drug-related intoxication: anticholinergics, lithium, alcohol, sedatives and hypnotics; ♣ initial sign is an altered level of consciousness that is seldom stable
withdrawal: alcohol, sedatives, hypnotics; reactions to anesthesia, prescription
medication or illicit drugs
♣ oriented to person but frequently disoriented to time and place
◊ Risk factors include: ♣ demonstrate decreased awareness of the environment
♣ noises, people or sensory misperceptions easily distract them
• increased severity of physical illness
• older age ♣ can’t focus, sustain or shift attention effectively and there is impaired recent and immediate
memory
• baseline cognitive impairment
♥ Treatment and Prognosis ♣ frequently experience misinterpretations, illusions and hallucinations
Identify and treat any causal or contributing medical conditions • Judgment & Insight
◊ Psychopharmacology ♣ judgment is impaired
• Sedation=to prevent inadvertent self-injury ♣ can’t perceive potentially harmful situations or act in their own best interests
• Antipsychotic medications such as haloperidol (Haldol)=used to decrease agitation ♣ insight depends on the severity of the delirium
• sedatives and benzodiazepines are avoided because they may worsen delirium ♣ with mild delirium may recognize that they are confused
♥ Other Medical Treatment ♣ with severe delirium may have no insight to the situation
◊ adequate nutritious foods and fluid intake • Self-concept
◊ intravenous fluids or even total parenteral nutrition if client’s physical condition has deteriorated and cannot ♣ often are frightened or feel threatened
eat nor drink ♣ may feel helpless or powerless to do anything to change it
◊ physical restraints so that needed medical treatments can continue ♣ may feel guilt, shame, and humiliation
DRUGS CAUSING DELIRIUM
anticonvulsants, anticholinergics, antihistamines, antihypertensives, antineoplastics, antipsychotics, aspirin,
• Roles & Relationships
barbiturates, benzodiazepines, cardiac glycosides, cimetidine (tagamet), hypoglycemic agents, insulin, narcotics, ♣ unlikely to fulfill their roles
propranolol (inderal), reserpine, steroids, thiazide diuretics ♣ have no longstanding problems with roles or relationships
♥ APPLICATION OF THE NURSING PROCESS
 • Physiologic consideration Echolalia=echoing what is heard
♣ disturbed sleep-wake cycles, falling asleep, daytime sleepiness, nighttime agitation or even a Palilalia=repeating words or sounds over and over
DSM-IV-TR Diagnostic criteria: Symptoms of Dementia
complete reversal of the usual daytime waking/nighttime sleeping pattern
Loss of memory
Data Analysis Deterioration of language function
◊ Nursing diagnosis commonly used when working with clients who somatize: Loss of ability to think abstractly and to plan, initiate,
• risk for injury sequence, monitor or stop complex behaviors
• acute confusion ♥ Onset and Clinical Course
• disturbed sensory perception ◊ Dementia is described in stages as follows:
• disturbed thought process • Mild= forgetfulness is the hallmark of mild dementia
• disturbed sleep pattern • Moderate=Confusion is apparent along with progressive memory loss.
♥ Outcome Identification • Severe= personality and emotional changes occur. Forget names of his/ her spouse and children and
◊ Treatment outcomes may include the following: require assistance in ADL
• client will be free of injury ♥ Etiology
• client will demonstrate increased orientation and reality contact ◊ Most common types of dementia:
• client will maintain an adequate balance of activity and rest • Alzheimer’s disease
♥ Intervention ♣ progressive brain disorder that has a gradual onset but causes an increasing decline in functioning,
NURSING INTERVENTIONS FOR DELIRIUM including loss of speech, loss of motor function and profound personality and behavioral changes.
1. promoting client’s safety
teach client to request assistance for activities ♣ Abnormal APOE gene and linkages to chromosomes 21, 14 and 19
provide close supervision to ensure safety during these activities ♣ enlargement of third & fourth ventricles
promptly respond to client’s call for assistance
2. managing client’s confusion • Vascular dementia
speak to client in calm manner ♣ symptoms similar to Alzheimer’s but onset is abrupt, following by rapid changes in functioning;
allow time for client to comprehend and respond plateau, or leveling off period
allow client to make decisions • Pick’s Disease
provide orienting verbal cues when talking to client
use supportive touch if appropriate ♣ degenerative brain disease that affects the frontal and temporal lobes
3. controlling environment to reduce sensory overload ♣ Early signs include personality changes, loss of social skills and inhibitions, emotional blunting,
keep environmental noise to minimum and language abnormalities
monitor client’s response to visitors
validate client’s anxiety and fears but do not reinforce misperceptions ♣ 50 – 60 years old (onset) and 2-5 years (death)
4. promoting sleep and proper nutrition • Creutzfeldt- Jakob disease
monitor sleep and elimination pattern ♣ a CNS disorder that develops in 40- 60 years old.
monitor food and fluid intake
provide periodic assistance to bathroom if client does not make requests • HIV infection
discourage daytime napping to help sleep at night ♣ invasion of nervous tissue by HIV
encourage some exercises during day
• Parkinson’s disease
CLIENT / FAMILY EDUCATION FOR DELIRIUM ♣ slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and
Monitor chronic health conditions postural instability.
Visit physician regularly
Avoid alcohol & recreational drugs
♣ Results from loss of neurons of basal ganglia.
• Huntington’s disease
DEMENTIA
A mental disorder that involves multiple cognitive deficits, primarily memory impairment and at least one of the ♣ inherited, dominant gene disease that involves cerebral atrophy, demyelination, and enlargement of
following cognitive disturbances: brain ventricles.
1. Aphasia= deterioration of language function ♣ There are choreiform movements that are continuous during waking hours and involve facial
2. Apraxia=impaired ability to execute motor functions contortions, twisting, turning and tongue movements.
3. Agnosia=inability to recognize or name objects • Head trauma
4. Disturbance in executive functioning=ability to think abstractly and to plan, initiate, sequence, monitor and stop ♥ Treatment and Prognosis
complex behavior Acetylcholine, dopamine, norepinephrine are decreased in dementia
Memory impairment=early sign of dementia ◊ Treatments include acetylcholine precursors, cholinergic agonists and cholinesterase inhibitors
 ◊ Cholinesterase inhibitors= have modest therapeutic effects and temporarily slow progress of dementia. ♣ Work performance suffers; deteriorating roles
• Tacrine ( Cognex)- elevates liver enzymes ♣ Inability to participate in meaningful conversations or social events
• Donepezil ( Aricept) ♣ Family members assume caregiver roles; role reversal
• Rivastigmine (Exelon) • Physiologic consideration
• Galantamine (Reminyl) ♣ Disturbed sleep- wake cycles
◊ Antipsychotics: Haloperidol ( Haldol), Olanzapine (Zyprexa), Risperidone (Risperdal) ♣ Ignore hunger or thirst
◊ Lithium carbonate, Carbamazepine ( Tegretol) and Valproic acid ( Depakote)= stabilize affective lability ♣ Bladder and bowel incontinence
and diminish aggressive outbursts ♣ Neglect bathing and grooming
◊ Benzodiazepines=may cause delirium and worsen compromised cognitive abilities ◊ Data Analysis
DRUGS USED TO TREAT DEMENTIA • Nursing diagnosis commonly used:
Name Nursing considerations ♣ risk for injury
Tacrine ( Cognex Monitor liver enzymes ♣ disturbed sleep pattern
Donepezil ( Aricept) Monitor for nausea, diarrhea & insomnia
Rivastigmine (Exelon) Monitor for nausea, vomiting, abdominal pain ♣ impaired memory
Galantamine (Reminyl) Monitor for nausea, vomiting, loss of appetite ◊ Outcome Identification
• Treatment outcomes may include the following:
♥ APPLICATION OF THE NURSING PROCESS • client will be free of injury
◊ Assessment • client will function as independently as possible
Mental status examination=provide information about the client’s cognitive abilities • client will maintain an adequate balance of activity and rest
• History ◊ Intervention
• General Appearance & Motor Behavior NURSING INTERVENTIONS FOR DEMENTIA
♣ Slurred speech; total loss of language function 1. Promoting client’s safety
Offer unobtrusive assistance
♣ Apraxia=loss of ability to perform familiar tasks such as combing hair Identify environmental triggers
♣ Cannot imitate tasks others demonstrate; gait disturbance; neglect hygiene 2. Promoting adequate sleep, proper nutrition and hygiene and activity
• Mood & affect Prepare desirable foods
Monitor bowel elimination
♣ Anxiety and fear; not express feelings; labile mood; emotional outbursts; anger and hostility; Remind client to urinate; provide pads or diapers
catastrophic emotional reactions; withdrawal, lethargic, apathetic, little attention Encourage mild physical activity such as walking
• Thought process & content 3. Structuring environment and routine
Encourage to follow regular routine and habits
♣ Loss ability to plan, sequence, monitor, initiate or stop complex behavior Monitor amount of environmental stimulation and adjust when needed.
♣ Delusions of persecutions 4. Providing emotional support
• Sensorium & intellectual process Be kind, respectful, calm
Use supportive touch when appropriate
♣ Confabulation= make up answers to fill in memory gaps 5. Promoting interaction and involvement
♣ Agnosia=another hallmark of dementia Plan activities geared to client’s interests and abilities
Reminisce the past
♣ Lose of visual spatial relationships
Remain alert to nonverbal behavior
♣ Impaired attention span, confused; disoriented • Promoting interaction and involvement
♣ Hallucinations ( usually visual hallucinations)
♣ Reminiscence therapy=thinking about or relating personally significant past experiences
• Judgment & Insight
♣ Poor judgment; insight is limited
♣ Distraction=shifting the client’s attention and energy to a more neutral topic
♣ Underestimate risks and unrealistically appraise their abilities ♣ Time away=leaving clients for a short period and then returning to them to re-engage in interaction
• Self-concept ♣ Going along=providing emotional reassurance without correcting their misperception or delusion.
CAREGIVER EDUCATION FOR DEMENTIA
♣ Angry or frustrated with themselves Encourage clients to follow usual routing
♣ Sadness at their bodies for getting old Encourage independence as much as possible
♣ Loss of self- awareness Encourage clients to participate in activities of interest
♣ Fail to recognize own reflections ♥ Mental Health Promotion
• Roles & Relationships ◊ People with elevated levels of homocysteine are at increased risk for dementia .
 ◊ Folate, vit. B12 , and betaine reduce plasma homocysteine levels ◊ Drink 6-8 glasses of water daily
◊ Participate in brain- stimulating activities such as reading
♥ Related Disorders
◊ Amnestic disorders=disturbance in memory that results directly from physiologic effects of a general
medical condition or alcohol and drugs
◊ Korsakoff’s syndrome=alcohol- induced amnestic disorder results from a chronic thiamine or vitamin B
deficiency
COMPARISON OF DELIRIUM AND DEMENTIA
Indicator Delirium Dementia
Onset Rapid Gradual
Duration Brief Progressive deterioration
Level of consciousness Impaired, fluctuates Not affected
Memory Short-term memory impaired Short-then-long term memory impaired
Speech Slurred, rumbling Normal in early stage, aphasia later
Thought process Temporarily disorganized Impaired thinking
Perception Visual/tactile hallucinations, delusions Absent; can have paranoia, hallucinations
Mood Anxious, fearful, weeping Depressed & anxious in early stage

SEE PAGE 479 TO 480 & 492 TO 493 FOR NURSING CARE PLAN…
ALZHEIMER’S DISEASE
progressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss
of speech, loss of motor function and profound personality and behavioral changes.
Abnormal APOE gene and linkages to chromosomes 21, 14 and 19
enlargement of third & fourth ventricle
Acetyl butiryl=increase as Alzheimer’s progress & found in neuritic plates
♥ Etiology
◊ Genetics
◊ Environment
♥ Onset and Clinical Course
◊ Stages
• Stage I=no cognitive impairment
• Stage II=mild cognitive decline
• Stage III
• Stage IV=mild or early stage; supervision is required
• Stage V=moderately severe; there is total dependence of client
♥ Treatment
◊ Cholinesterase inhibitors
• Dopenezil
• Galantamin
◊ Adverse effects
• Insomia, fatigue, rashes, nausea & vomiting
♥ Diet
◊ Antioxidant foods
• Fruit & vegetables like squash & bell peppers
◊ Avoid refined foods like white bread