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Medical Surgical Nursing 7th Edition
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Altered cognitive states are common diagnoses as?
delirium or dementia depending on the onset, duration, contributing factors, response to intervention, and progression. It is possible to have both dementia and delirium at the same time.
delirium
an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech and that usually gets resolved when the underlying problem is corrected. Examples of factors that may cause delirium in the older adult are infection, fever, and drug effects.
The diagnostic and statistical manual of mental disorders, 5th edition (DSM-5)
is published by the American Psychiatric Association. The DSM-5 provides guidelines for the diagnosis and classification of mental disorders.
Neurocognitive disorders (NCDs)
Include delirium, as well as major NCDs, mild in NCDs, and their subtypes based on cause. NCDs exist along a continuum from mild to moderate depending on the severity of impairment.
Each of the neurocognitive disorders affects one or more domains of cognitive function.
These domains are complex attention, executive function, learning and memory, language, perceptual- motor function, and social cognition.
Complex attention disorders
Complex attention disorders result in difficulty staying on task and sorting through multiple stimuli.
Executive function
allows people to plan, make decisions, carry out plans, and evaluate activities. Therefore a person with impaired executive function has difficulty with multitasking and carrying out multiple steps.
cognitive impairment
loss of ability to think logically; concentration and memory are affected.
altered cognition
Physiologic factor that frequently hinders effective communication. These onsets are commonly diagnosed as delirium or dementia depending on the onset, duration, contributing factors, response to interventions, and progression.
altered mental function
develops suddenly or gradually depending on the underlying pathology.
social cognition
the processes by which people come to understand others. Is concerned with recognizing emotions. They may have personality changes and become insensitive to the feeling of others. These disturbances can be mild or major.
altered cognitive states.
Are commonly diagnosed as delirium or dementia depending on the onset, duration, contributing factors, response to intervention, and progression.
examples of factors that may cause delirium in the older adult are?
Infection, fever, and drug effects.
complex attention
disorders result in difficulty staying on task and sorting through multiple stimuli.
learning and memory
May affect short term and long term memory, which can affect all aspects of functioning. A person might forget appointments, leave food on a hot stove, be unable to dress or shop, or become lost.
Language disorders
Can affect the ability to understand or use words.
Perceptual-motor dirsorders
can affect the ability to perform usual activities, such as driving a car. Various defects in vision may be present. S
Social cognition
is concerned with recognizing emotions. When social cognition is disturbed, people may say or do socially inappropriate things. They may have personality changes and become insensitive to the feelings of others. These disturbances can be mild or major.
Delirium
Is a decline from a person's usual attention and awareness (orientation to the environment). People with delirium may have difficulty focusing or paying attention; consequently, they are easily distracted. Engaging them in a conversation may be difficult, and often questions must be repeated. Delirium develops over a short period of time and tends to vary in severity throughout the day. In addition to altered attention and awareness, the patient has an additional disturbance such as memory deficit, disorientation, or a language or perceptual problem. Speech may be slurred and disjointed with aimless repetitions. Individuals may misinterpret what is happening in the environment and may develop delusional thinking and experience hallucinations.
Examples are they may think that the banging of a door is a gunshot. A common delusion is that someone is trying to steal from them. Sleep wake disturbances are common. A delirious person may be hyperactive, hypoactive, or alternate between the two. The level of consciousness may fluctuate from drowsiness to stupor or coma. At the other extreme, the individual may be extremely alert and agitated.
diagnoses of delirum
evidence must exist that the symptoms can be explained by the medical condition, substance intoxication or withdrawal, exposure to a toxin, or multiple causes. Example of medical conditions that can cause delirium are infection, liver or kidney failure, fluid and electrolyte imbalances, and hypoxia.
Dysrhythmias
Cardiac infraction
Hypovolemia (deficient fluid volume)
Aortic stenosis
Infections
Pneumonia
Urinary tract infections
Bacteremia
Septicemia
Medications
Alcohol
Amphetamines
Analgec\sics
Anticholinergics
Antidepressants
Antihistaines
Antiparkinsonian agents
First-generation H2- receptor blocker (example Cimetidine (Tagamet)
Diuretics
Neuroleptics (haloperidol (haldol))
Sedatives or hypnotic agents (benzodiazepines (diazepam, valium, barbiturantes))
Metabolic conditions
Electrolyte and fluid imbalance
Hepatic, renal, and pulmonary failure
Diabetes, hyperthyroidism, hypothyroidism, or other endocrine disorders
Nutritional deficiencies
Hypothermia and heat stroke
Poisons
Heavy metals
Solvents
Pesticides
Carbon Monoxide
Trauma
Head injury
Burns
Hip fracture
Other Systemic Causes
Neoplasm
Postoperative state
CENTRAL NERVOUS SYSTEM CAUSES
Infections
Meningitis
Encephalitis
HIV, human immunodeficiency virus.
antipsychotic drugs
drugs used to treat schizophrenia and other forms of severe thought disorder.
haloperidol (Haldol), risperidone (Risperdal), aripiprazole (Abilify), quetiapine Seroquel), and olanzapine (Zyprexa)
Nonneuroleptics
Carbamazepine, sodium valproate, trazodone, and citalopram.
Mild Neurocognitive Disorder
Is a modest decline from one's usual function in one or more cognitive domains. The individual functions well enough to live independently. The disorder can be caused by various types of dementia. Behavioral symptoms are agitation, apathy, sleep disturbances, depression, anxiety, hallucinations, an ddelusions.
Mild Neurocognitive disorder
neurocognitive disorder in which the decline in cognitive functioning is modest and does not interfere with the ability to be independent.
Major Neurocognitive disorder
neurocognitive disorder in which the decline in cognitive functioning is substantial and interferes with the ability to be independent.
Dementia
is not a disease in itself; it is a clinical syndrome, a collection of symptoms that occur with many types of diseases. The onset and progression vary with the subtype.
The most prevalent types of dementia are caused by?
Alzheimer disease (AD), vascular disease, frontotemporal dementia (FTD), Lewy body disease, and Parkinson disease. Other conditions that are associated with dementia include traumatic brain injury, substance use and medication effect, human immunodeficiency virus (HIV) infection, prion disease, Huntington disease, and specific or multiple medical condition.
gait disturbance
An abnormal way of walking, such as shuffling feet.
Alzheimer's disease
Insidious onset. Gradual, steady progression in cognitive and behavioral symptoms. Decline in memory and learning and at least one other cognitive domain. Depression and apathy common in early stage. Irritability, agitation, combativeness, delusions, hallucinations, and wandering may occur in later stages. Final stage marked by gait disturbance, dysphagia, incontinence, muscle spasm, and possible seizures. Patients become mute and totally dependent for care.
Frontotemporal lobe degeneration
Insidious onset. Progression is gradual but faster than AD. Two variants (forms) exist: behavioral and language. Behavioral symptoms: disinhibition, apathy, loss of sympathy or empathy, repeated or
Characteristic changes in the brain include deposits of amyloid (a protein). Neurofibrillary tangles (example; tangled microtubules in neurons) associated with altered tau protein, and a deficiency of neurotransmitters, especially acetylcholine. Neurotransmitters are chemicals that transmit signals in the brain.
vascular dementia
results from damage to brain cells caused by inadequate blood supply. They often have a series of small strokes that cause progressive damage.
Lewy body disease
is characterized by the precense of a protein called synuclein, first seen in the substantia nigra and later inthe cerebral cortex.
Parkinson disease
is associated with a deficiency of dopamine.
Frontotemporal dementia
is manifested by behavioral symptoms and/or language disorders, depending on the areas of the brain affected. Atrophy of the frontal lobes is associated with behavioral changes, whereas problems with language disorders, depending on the areas of the brain affected. Atrophy of the frontal lobes is associated with behavioral changes, whereas problems with language are the result of temporal lobe changes. At this time there is no cure for dementia; it is generally considered irreversible.
Galantamine (Razadyne)
Cholinesterase Inhibitor (Alzheimer's)
Focused assessment for collecting data about a person with NCD.
Observe the behavior and to collect data about mental status. May use standarized tools for a focused assessment of orientation and memory. Orientation is commonly based on the patient's ability to state his or her name, location, and date and time. The inability to accurately report one's name, location, and time labels a person disoriented or confused. However, for patients in long term care, uncertainty about days of the week and dates is not unusual. Note the patient's response to questions and instructions to determine use of language. If a change is cognitive status is recent, note any events surrounding the change example infection, relocation, major loss. Also record other symptoms such as depression, apathy, agitation, restlessness, and wandering. If the patient has exhibited aggression or agitation, ask what factors trigger these behaviors. In the community the patient or family may be able to supply information about acute or chronic illnesses and current medications. in long term care settings, the health care provider's health history should give this info.
Medications that cause confusion in older adults
Anticholinergic drugs, digoxin, H2 receptor blockers, benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs), and many antidysrhythmic and antihypertensive drugs. Also ask about any drugs prescribed for neurocognitive symptoms.
clinical features in delirium
onset: Sudden
duration: Hours to days
mood: Labile, suspicious, mood swings
behavior: Variable; hyperactive or hypoactive
cognition
Position tubes out of sight. Place the bed in the low position. Postpone activities that are flexible. If the confused patient does not need to stay in bed, allow him or her to sit in a chair or even to visit the nurses station in a wheelchair. Avoid arguing with delirious patients. Give a gentle explanation of what is being done and the reason why it is being done.
inadequate nutrition in people with dementia
people with dementia eventually may need help with eating. Assistance with meals may mean cutting food or toatl feeding. Foods that can be managed with a single utensil may facilitate self feeding. Finger foods high in protein and cargo allow patient to feed themselves more easily. Because of the patient's short attention span, he or she may actually consume more if given small, frequent meals. Remove distractions from the eating area. Group meals may be helpful because patients often imitate the behavior of others. Offer fluids frequently during the day.
Sleep disturbance in dementia
Sleep and awakening hours are often reversed in patients with dementia. Providing stimulation to keep them awake during the day may help them to sleep at night. Schedule tests and treatments during the morning and early afternoon to allow the patient time to wind down by bedtime. Some caregivers have found that a quiet hour in the evening with soft music playing promotes sleep at night. However, sometimes the patient persists in nighttime awakening. When that occurs, assist the patient to the toilet, offer fluids and/or snack, and provide comfort measures. Offer reassurance in a soft, soothing manner. The patient may go back to sleep afterward. Avoid regular use of sedatives; however, prolonged periods of wakefulness can lead to delirium. If a sleeping aid is needed, trazodone (Oleptrol) is preferred.
Potential for injury for dementia patient.
Nothing harmful should be left around. Falls and injuries may be prevented with environmental modifications, careful observations, muscle strengthening, and a fall prevention program. Avoid restraints, if possible; they may aggravate agitation and have been associated with injuries ssuch as skin tear, obstructed circulations
Behavioral disturbances and inability to communicate effectively
the pt is disoriented and their thinking ability is impaired. They are confused by what is going on around them. Communication should be simple and direct. Approach them gently, calmly, and quietly. They tend to copy the behavior of people around them; consequently, a caregiver who is anxious or upset can easily convey these feelings to a patient. Nonverbal communication is extremely important. Cues from the patients actions and facial expressions are important because patients are frequently unable to express their needs verbally. When patients resist activities such as bathing or dressing, avoid confrontations, which only provoke agitation and possible violence, instead, come back at another time. A consistent schedule of care given by the same caregivers provide security for the patient with dementia. Assisting them in a nonconfrontational manner, and redirecting activities without constantly reminding them of their deficits is a better approach.
Guidelines for working with patients with dementia
Two important concepts are helpful to keep in mind when taking care of patients with dementia.
- They usually forget things relatively quickly and
- They are usually unable to learn new things. For example, if persons with dementia start to become agitated, it may be effective to divert their attention somewhere else. Thye may be gently guided to another activity; usually within a relatively short period they will forget what is bothering them and focus on the new activity.
what does agitation indicate?
pain, hunger, stress, fear, or the need for toileting.
CDA (cognitive developmental approach)
can also guide care for pt's with dementia. The CDA adapts interventions based on the patient's cognitive abilities. Eliminating unrealizing expectations and allowing the patient to do as much as he or she is able is believed to reduce patient stress and frustration
