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http://1nurses.com Here's a Nursing lecture on Cognitive Disorders Nursing Resource on the Web. Visit 1nurses.com for more Nursing resources.

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Cognitive Disorders Nursing Resource Cognitive Disorders Nursing Resource Presentation Transcript

  • Brought to you by : http://1nurses.com
  • Disclaimer
    • All information and pictures presented in this slideshow were meant for EDUCATIONAL purposes only. 1Nurses.com does not claim any liability from the use of this slide and does not guarantee any action that might result from the use of this material. 1Nurses.com does not claim any ownership for the images and articles presented in this report. All articles and Images are the respective Copyright of the respective owners.
    • “ The ability to think and to reason is one of the distinguishing features of a human being”
  • COGNITION
    • Is the brain’s ability to process, retain and use information.
  • COGNITIVE ABILITIES
    • P erception
    • O rientation
    • R easoning
    • M emory
    • A ttention
  • COGNITIVE DISORDER
    • Delirium
    • Dementia
    • Amnestic disorder
    • Other cognitive disorder
  • DELIRIUM
    • “ acute confusional state”
    • Is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition.
    • Develops over a short period , sometimes a matter of hours and fluctuates or changes during the course of the day.
  • DSM CRITERIA for DELIRIUM
    • Disturbances of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus or sustain or shift attention.
    • Change in cognition (such as memory deficit, disorientation, language disturbance, perceptual disturbance)
    • Development over a short period of time (usually hours to days) and with a tendency to fluctuate during the course of the day.
  • KEY SYMPTOMS OF DELIRIUM
    • F EARFULNESS
    • D ISORIENTATION
    • A GITATION
  • ETIOLOGY:
    • UNKNOWN
    • General Medical condition
      • CHF, Pneumonia, Uremia, Malnutrition, dehydration, cancer, CVA and etc.
    • Substance
    • Prescription drug intoxication like anticholinergic drugs combination (elavil, antihistamines, antispasmodics, analgesics, steroids, sedatives, cardiovascular drugs (digoxin and diuretics) and cimetidine.)
  • MANAGEMENT:
    • Treatment of underlying disease and judicious use of medications and manipulation of the environment.
    • Symptomatic relief through supportive therapy
      • Good nutrition
      • Hydration
      • Rest
      • Comfort measures
      • Emotional support
  • Psychopharmacology
    • Hypoactive delirium – no specific meds
    • Hyperactive – sedation
      • Haloperidol (.5 to 1mg)
      • NO benzodiazepine
      • Except if caused by alcohol – benzo
    • Restraints
  • APPLICATION OF THE NURSING PROCESS
    • Nursing care focus:
      • Physiologic and psychological needs
      • Safety
  • Assessment
    • History
      • Medical illness
      • Alcohol and other drugs
  • General Appearance
    • Psychomotor disturbances
      • Hyperactive
      • Hypoactive
      • Speech
        • Less coherent
  • Mood and Affect
    • Rapid and unpredictable mood shifts
      • Fearfulness, anger, euphoria, apathy, irritability, anxiety.
        • No connection to the environment.
  • Sensorium and Intellectual processes
    • Altered LOC – Initial sign , fluctuates through out the day.
    • Oriented to person but disoriented to time and place
    • Impaired recent memory
    • Alteration in Perception
  • Insight and Judgment
    • Mild
      • Aware
    • Severe
      • No insight to the situation
  • Physiologic and Self care
    • Disturbed Sleep – Wake cycle
  • Diagnosis
    • Primary
      • Risk for Injury
      • Acute confusion
    • Additional
      • Disturbed Sensory Perception
      • Disturbed Thought Process
      • Disturbed Sleeping Pattern
  • INTERVENTION
    • Promoting Clients Safety
      • Meds should be used judiciously
      • Teach the client to ask assistance if not close supervision
    • Managing Confusion
      • Give realistic Reassurance
        • “ I know things are upsetting and confusing to you right now, but your confusion should clear as you get better.”
      • Speak in short. Simple, clear, low voice
      • Orienting cues
      • Touch
      • Reduce Environmental Stimuli
      • Well lighted room
    • Promoting Sleep and Proper Nutrition
  • Evaluation
    • Returns to their previous level of functioning
    • Understands that health care practices are necessary to avoid recurrence
  • DEMENTIA
    • Is a complex and devastating problem that is a major cause of disability in the older adult population.
    • It is not a normal aging process
    • Is characterized by the development of multiple cognitive deficits and usually accompanied by mood disturbances.
    • Course is GRADUAL in onset with an unabated cognitive decline.
    • The symptoms of dementia remain even delirium has cleared.
  • DSM CRITERIA for DEMENTIA
    • Multiple Cognitive deficits:
    • Memory impairment (amnesia)
    • At least one of the following cognitive disturbances:
      • Aphasia
      • Apraxia
      • Agnosia
      • Disturbance In executive functioning (PLOC)
    • Significant impairment in social or occupational functioning.
  • Amnesia
    • Early sign
    • Initially RECENT memory and in later stages it affects REMOTE memory
  • Aphasia
    • Deterioration of language function.
    • Begins with the inability to name familiar objects or people then progress to speech that becomes vague or empty with excessive use of “ It ” and “ Thing ”
    • Echolalia and Palilalia
  • Apraxia
    • Impaired ability to execute motor functions despite intact motor abilities.
    • Inability to perform routine self care activities
  • Agnosia
    • Inability to recognize or name objects despite intact sensory abilities.
    • They may look at the table and chairs but unable to name them.
  • ONSET & CLINICAL COURSE
    • MILD
      • Forgetfulness – hallmark sign
      • Difficulty finding words
      • Frequently loses objects – anxiety
      • Occupational and Social settings are less enjoyable
      • Most people remain in the community
    • MODERATE
      • Confusion is apparent with progressive memory loss
      • No longer perform complex task but remains oriented to PPT
      • End stage
        • Loses the ability to live independently
        • Remains in the community but with caregiver
    • SEVERE
      • Personality and Emotional changes occur
      • Delusional, wander at night, forget the names of his or her spouse and children.
      • Requires assistance in ADL
      • Lives in Nursing Facility
  • ETIOLOGY:
    • Vascular injury
    • Degenerative disease
    • Neoplastic
    • Demyelinating disease
    • Infectious
    • Inflammatory
    • Toxic
    • Metabolic
  • APPLICATION OF THE NURSING PROCESS
  • Assessment
    • Folstein Mini Mental State examination (MMSE)
      • Administered in 5 to 10 minutes
      • Consists of variety of questions that cover the memory, orientation, attention, constructional abilities.
    • Interviews of family, friends or caregivers
  • Mood and Affect
    • Anxiety and Fear at first
    • Labile mood
    • Catastrophic emotional reactions in response to environmental changes
      • Verbal or physical aggression
      • Wandering at night
      • Agitation
    • Withdrawn
  • Thought Process and Content
    • Ability to think abstractly is impaired
    • As dementia progresses
      • Delusion of Persecution is common
        • The client may accuse others of stealing objects he or she has lost
        • May believe that she is being cheated or pursued
  • Sensorium and Intellectual Process
    • Recent – Remote
    • Confabulation
    • Visual Hallucination
  • Physiologic and Self Care
    • Disturbed sleep – wake cycle
      • Nap during the day and wanders at night
    • Some clients ignore internal cues like hunger or thirst or difficulty eating and drinking (severe)
    • Neglect bathing and grooming
  • Diagnosis
    • Risk for Injury
    • Risk for Deficient Fluid Volume
    • Risk for Imbalanced Nutrition
    • Chronic Confusion
    • Impaired Environmental Interpretation Syndrome
    • Impaired Memory
    • Impaired Social Interaction
    • Impaired Verbal Communication
    • Ineffective Role Performance
  • Intervention
    • Focus on demonstrating caring, keeping clients involved by relating to the environment
    • Promoting Client’s Safety
      • Protecting against injury
      • Meeting physiologic needs
      • Managing the risk posed by the environment including internal stimuli such as Delusion and Hallucination
    • Promoting Adequate Sleep and Proper nutrition, hygiene and activity
      • Provide foods that clients like
      • Sitting with the client
      • Nutritious snacks
      • Minimizing noise
      • Foods should be cut
      • Finger foods
      • Tube Feedings
      • Monitor bowel elimination
      • Urinary Pattern
      • Balance between rest and activity
    • Structured Environment and Routine
      • Client’s preference
    • Emotional Support
      • Empathic caring
      • Supportive Touch
    • Promoting Interaction and Involvement
      • Reminiscence Therapy
        • Thinking about or relating personally significant past experiences
          • Photo albums
      • Distraction
      • Time away (5 – 10 mins.)
      • Going Along
        • Providing emotional reassurance
  • DELIRIUM DEMENTIA Onset Acute, often at night Insidious Course Fluctuating , with lucid intervals, during day: worse at night Stable over course of the day Duration Hours to week Months to years
  • Awareness Reduced Clear Alertness Abnormally LOW or HIGH Usually Normal Attention Lacks direction and selectivity; distractibility; fluctuates over course of the day Relatively unaffected Orientation Usually impaired for time; tendency to mistake unfamiliar to familiar place and persons Often impaired
  • Memory Immediate and recent memory impairments Recent and remote memory impairments – the most prominent symptom Thinking Disorganized Impoverished Perception Illusions and Hallucinations (usually visual) Often absent Sometimes: Hallucinations Delusions Illusions
  • Speech Incoherent, hesitant, slow or rapid Difficulty finding words Sleep wake cycle Always disrupted Fragmented sleep Physical Illness or Drug toxicity Either or both present Often absent, especially in Alzheimer’s type
  • Reversible Dementia
    • SLE (encephalopathy)
    • Syphilis
    • Alcohol abuse
    • Hypo and Hyperthyroidism
    • B12 and folate deficiency
  • Non Reversible Dementia
    • Alzheimer’s Disease
    • Parkinson’s disease
    • Pick’s disease
    • Creutzfeldt Jakob Disease
    • Vascular or multiinfarct dementia
    • Alcoholic Dementia
    • TIA
  • ALZHEIMER’S DISEASE
    • Commonly seen in the elderly ( 65 years old)
    • Most prevalent of all non reversible dementia (50 – 75%)
    • Age related progressive disorder of the CNS
    • Alois Alzheimer , post mortem revealed brain atrophy and distortions in the cortical neurofibrils = ALZHEIMER’S TANGLE or Neurofibrillary tangles
  • 4A’s
        • mnesia
        • gnosia praxia
        • phasia
    A
  • ETIOLOGY:
    • UNKNOWN
    • Presence of senile plaques and NFT
    • Dystrophic neuritis; thickened swollen neuronal process
      • Abnormal amyloid deposits within the senile plaques and around the blood vessels
    • Genetics
    • Toxins
      • Aluminum
    • Infection
      • Slow growing virus
    • Cholinergic deficit
      • Loss of cholinergic neurons in the brain(nucleus basalis of meynert)
      • Reduction in Acetylcholine
  • Impairment In ADL based on stages of AD
  • Mild
    • Difficulty with
      • Balancing checkbook
      • Preparing complex meal
      • Managing medication schedule
  • Moderate
    • Difficulty with
      • Simple food preparation
      • Household clean up
      • Yardwork
      • Some aspects of self care
  • Severe
    • Needs considerable assistance with
      • Personal care
      • Feeding
      • Grooming
      • Toileting
  • Profound
    • Oblivious to surrounding and totally dependent to the caregiver
  • Terminal
    • Bed bound, requiring constant care
  • TREATMENT
    • Donezepil (Aricept) od
    • Tacrine (Cognex) qid
    • Rivastigmine
    • Galantamine
    • Ginkgo Biloba
    • NSAID’s
    • Vitamin E
    • Estrogen
    • Calcium Channel Blockers prevents influx
  • PARKINSON’S DISEASE
    • A hypokinetic disorder , is a progressive, chronic, degenerative disease involving an area in the brain called the EPS
    • ETIOLOGY: deficiency of the DOPAMINE and a subsequent decrease in the DOPAMINE transmission to the basal ganglia.
    • S/Sx: BTR
  • DIFFUSE LEWY BODY DISEASE
    • Similar to AD but typically occurs in earlier life and is associated more often with Hallucination and Extra Pyramidal Symptoms
    • Evolves rapidly
    • Pathological feature: Presence of multiple Lewy bodies (eosinophilic cytoplasmic inclusions) in cortical and subcortical neurons.
  • HUNTINGTON’S DISEASE (huntington’s Chorea)
    • Involves both motor and cognitive disorder
    • Kinetic opposite of PD
    • Characterized by uncontrollable quick, jerky and purposeless writhing movements.
    • Disturbance in gait and slurred speech are noted in the beginning and progress into neurological and intellectual deterioration.
    • Memory loss, paranoia, irritability, impaired impulse control and lack of tongue and breathing control.
    • Usually begins between the ages 25 to 45 average duration of 15 to 20 years
    • Hereditary
    • Symptomatic approach
  • PICKS’S DISEASE
    • Clinical presentation is similar to AD and are usually treated in the same way.
    • Associated with aging and is without race and gender basis
    • Onset is slow with an average duration of 5 to 7 years.
    • Characterized by shrinkage of the frontal lobe.
  • CREUTZFELDT – JAKOB DISEASE
    • Also known as “Prion disease”
    • Is a non inflammatory dementia that accounts for fewer than 1% of all cases of dementia.
    • Prion is an infectious particle, smaller than a virus.
    • It is rapidly progressive disorder of the CNS involving severe neurological impairment with marked dysfunction.
    • Affects the cerebral cortex
    • Early symptoms are vision and hearing loss, impaired cognition, myoclonus, ataxia, muscle wasting, tremor, hallucinations and illusions.
  • VASCULAR OR MULTI INFARCT DEMENTIA
    • Multiple large and small cerebral infarcts.
    • CV disease maybe the leading cause of acquired intellectual impairment in the age 85 and older population.
  • ALCOHOLIC DEMENTIA
    • Typically occurs 15 to 20 years of continues drinking.
    • Alcoholic dementia has three primary symptoms:
      • Alcohol is directly toxic to the neurons
      • Alcoholism causes destructive nutritional deficit
      • Alcoholism causes end organ failure which in turn affects the CNS.
  • TRANSIENT ISCHEMIC ATTACKS
    • The chief importance of TIA is a precursor of a major stroke, MI or death.
    • The syndrome is caused by microembolism to the brain from atherosclerotic plaques in the aortocranial arteries in about 90% of TIA. 10 % for mural thrombi, valvular disease of the heart, vegetation of the heart valve, polycythemia, or some other blood clotting disorder.
  • PSYCHOTHERAPEUTIC MANAGEMENT
  • TNPR
    • Delirium HIGHEST PRIORITY : interventions to maintain life
    • Dementia HIGHEST PRIORITY : Providing Nursing Care to maintain optimal level of functioning
    • Must learn the background and lifestyle of the patient.
    • One on One basis by using the title and last name.
    • Use praise, touch and affection whenever possible.
    • Should be dressed in his or her own clothing during the day with his or her hair combed. Make up, shaved.
    • Safety
  • PSYCHOPHARMACOLOGY
    • Antipsychotics
    • Antidepressants
    • Antianxiety
  • MILIEU
    • They should be in the safe environment free from injury, stress and anxiety.
    • Warm caring atmosphere
    • Routine the patient can follow daily
    • Close supervision during bathing, eating and other activities.
    • All sharps or hazardous materials should be removed,
    • The doors should be monitored to prevent escape.
  • 3 milieu related issues
    • STRESS – cause of anxious behavior
      • The work of HALL “Progressively Lowered Stress Threshold” (PLST)
      • Stressors includes:
        • Fatigue
        • Change of routine
        • Excessive demands
        • Overwhelming stimuli
        • Physical stressors
      • SAFETY
    • WANDERING
  • CBQ
    • Nursing Management
    • Never Change the environment
    • Don’t educate new skills
      • olor
      • lock
      • alendar
    C
    • Ginko Biloba – delays AD
      • SE: Bleeding
    • Etiology: Unknown, ACH, Senile plaques, Aluminum Toxicity
  • 3 stages
    • Forgetfulness
      • Agnosia, amnesia
    • Wandering
      • Sundown syndrome – restless and anxiety
        • Management:
          • Avoid catnap, coffee, increase fluid, diuretics
          • Medical bracelet
          • Warm bath, warm milk
          • DOC: Serax and Ativan
    • Kleuver Bucy like syndrome
      • Decrease social and sexual inhibition
      • Hyperorality - REGRESSION
  • Nursing Care Plan, Nursing Resource,Nursing Community
    • Your #1 Nurses’Portal http://1nurses.com