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Cognitive disorders  behavior therapy  ect
 

Cognitive disorders behavior therapy ect

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it about cognitive behavior therapy

it about cognitive behavior therapy

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    Cognitive disorders  behavior therapy  ect Cognitive disorders behavior therapy ect Presentation Transcript

    • Cognitive Disorders ECT Phyllis M. Connolly, PhD, RN, CS NURS 127A
    • Questions for consideration
      • What are the similarities and differences between delirium, dementia, and depression?
      • What is a catastropic reaction and what interventions are helpful?
      • What is a positive client outcome for altered thought processes?
      • What the indications for ECT?
    • Cognitive Impairments
      • 2.4 million Americans suffer from dementing illnesses
      • 7.3 million by 2040
      • Alzheimer’s Disease
      • Dementias
        • Vascular--interruption of blood flow to brain
        • Parkinson’s--involves extrapyramidal
        • Diffuse Lewy Body Disease
        • Huntington’s Disease
      • Creutzfeldt-Jakob Disease
      • Alcoholic Dementia
      • TIA
    • Medications Causing or Contributing to Dementia or Delirium
      • Analgesics
        • Codeine
        • Meperidine
        • Morphine
        • Pentzcocine
        • Indomethacin
      • Antihistamines
        • Dephenhydramine
        • Hydroxyzine
      • Antihypertensives
        • Clonidine
        • Hydralazine
        • Methyldopa
        • Propranolol
        • Reserpine
      • Antimicrobials
        • Gentamicin
        • Isoniazid
    • Medications Causing or Contributing to Dementia or Delirium Cont.
      • Antiparkinsonism
        • Amantadine
        • Bromocriptine
        • Carbidopa
        • L-Dopa
      • Cardiovascular
        • Atorpine
        • Digitalis
        • Diuretics
        • Lidocaine
      • Hypoglycemics
        • Insulin
        • Sulfonyureas
      • Psychotropics
        • Benzodiazepines
        • Lithium
        • Tricyclics
        • Haloperidol
        • Thiothixene
        • Chlorpromazine
        • Barbituates
        • Chloral hydrate
      • Others
        • Cimetidine
        • Steroids
        • Trihexyphenidyl & other anticholinergics
    • Dementia
      • Constellation of symptoms resulting in impairment of short and long term memory
      • Onset slow or insidious
      • Progressive ends in death
      • Deterioration in judgment & abstract reasoning
      • Social & occupational functioning significantly affected
      • Most common cause Alzheimer’s
    • Four As of Alzheimer’s Disease
      • Amnesia--inability to learn new information or to recall previously learned information
      • Agnosia--failure to recognize or identify objects despite intact sensory function
      • Aphasia--language disturbance that manifest in both understanding & expressing the spoken word
      • Apraxia--inability to carry out motor activities despite intact motor function
    • Alzheimer’s: Etiology
      • Senile plaques & neurofibrillary tangles
      • Dystrophic neurites(thickened, swollen neuronal processes)
      • Abnormal amyloid deposits
      • Genetic--10-15% of cases
      • Toxin model--aluminum salts
      • Infectious agent model--virus
      • Cholinergic deficit model
    • Alzheimer’s Disease: Behavioral Symptoms
      • Hallucinations
      • Delusions
      • Dysphoria & depression
      • Fearfulness
      • Repetitive purposeless acts
      • Avoidance behavior
      • Motor restlessness
      • Apathy
      • Verbal and physical aggression
      • Resistance to interventions
        • Hygiene
        • Nutrition
        • Safety
    • Stressors for Persons with Cognitive Impairments
      • Fatigue
      • Change of environment, routine or caregiver
      • Overwhelming or competing stimuli
      • Demands that exceed capacity to function
      • Physical stressors
    • Catastropic Reaction
      • Excessive distress exhibited by patients in situations that are confusing or frightening ex. Showering
      • Interventions
        • Remain calm
        • Remove patient from whatever is upsetting
        • Use distraction rather than confrontation
    • Impaired Cognitive Functioning
      • Key Elements of Care
        • Communication
        • Orientation
        • Structure
        • Stimulation
        • Safety
    • Altered Thought Processes
      • Client Outcomes
        • Demonstrates improved reality orientation
        • Responds coherently to simple requests
        • Follows simple directions
      • Interventions
        • Baseline mental status & functioning
        • Avoid making demands
        • Ask only one question & make only one request at a time
        • Provide a structured routine
        • Provide familiar objects
        • Avoid agreeing with confused thinking but DO NOT ARGUE--try to distract
        • Incorporate orientation cues from the environment
        • Keep environment simple & uncluttered
    • Delirium
      • Alterations in consciousness
      • Changes in cognition
      • Usually caused by medical condition or substance induced
      • Develop over short period of time
      • Treatable
      • 30% CCU environments, “CCU psychosis”
      • Disoriented
      • Disorganized thinking and speech
      • Altered perceptions: illusions, delusions & hallucinations
      • EEG changes
      • Neurological abnormalities
    • Delirium: Treatment
      • Identify & correct cause
        • anemia
        • dehydration
        • nutritional deficiencies
        • electrolyte imbalance
      • Monitor closely
      • Safety high priority
      • Control behavioral symptoms
      • Well lighted room, visible clock & calendar
    • Comparison Dementia, Delirium & Depression
    • Psychotherapeutic Management
      • Nurse-Patient Relationship
      • Psychopharmacology
        • Antipsychotics
        • Antidepressants
        • Antianxiety
        • Treatment of cognitive impairment
          • cholinergic enhancers
          • metabolic enhancers/vasodilators
          • Nootropic agents
        • Milieu management
          • Safety
    • Validation Therapy
      • Enter client’s world rather than force to relate to an external world which is no longer comprehensible
      • Increase the client’s sense of being understood by others
      • Reduces agitation and catastrophic reaction
      •  quality of life
      Schober, Glod, Jones, 1998, p .252
    • Tips for Working with Persons with Dementia
      • Person wears identification bracelet
      • Install special locks, safety devices on doors, stove & other potentially dangerous objects
      • Check frequently for burns, bruises, or abrasions
      • Assess for signs of abuse
      • Only use restraints after other methods are ineffective--need MD order
      • Look directly at person when speaking
      • Identify yourself prior to interaction
      • Use simple short phrases
      • Ask specific rather than general questions
      • Distract if asking same question repeatedly
      • Assist in word finding
      • Reassure that you intend to help
      • Avoid arguing
      • Convey patience and understanding
      Promote Safety Communication
    • Tips for Dementia Care Cont.
      • Establish regular & predictable routine
      • Breakdown complex tasks into small simple steps
      • Consistent care by regular staff
      • Use large clock & calendar
      •  distraction & stimulation, avoid clutter & unnecessary objects
      • Post lists of daily activities
      • Person wear glasses & hearing aid
      • Avoid medications if possible
      • Check person frequently
      Decrease Confusion
    • Tips for Dementia Care Cont.
      • Encourage regular exercise
      • Ensure nutrition & hydration
      • Assist with ADLs
      • Assess frequently for physical pain, constipation, & discomfort
      • Evaluate agitation and worsening behavior carefully
      • Suggest day treatment for clients living at home
      • Teach ways to manage uncooperative behavior
      • Teach about causes and course of dementia
      • Monitor & assess level of stress on the family
      • Encourage use of social support to decrease caregiver stress
      • Help families mourn the loss of their loved one
      Physical & Emotional Wellbeing Family Education Schober, Glod, Jones, 1998, p. 251
    • Modern ECT
      • Causes changes in monoamine neurotransmitter system
      • Electric current (70 - 150 volts) passes through the brain from .5 to 2 seconds
      • Seizure must last approximately 30 - 60 seconds for therapeutic value
      • ECT has cumulative effect, needing 220 - 250 seconds
      • Oximeter-monitor anesthetic to assure oxygenation
      • 2 - 3 times/week up to 6 - 12 treatments
      • May require periodic or maintenance ECT treatments
    • Disorders, Depressive Symptoms, & Conditions Responding to ECT
    • Preparation for ECT
      • Physical exam, blood ct., chemistry, urinalysis, & baseline memory abilities
      • Consent form “informed”
      • Eliminate benzodiazepines prior
      • Trained electrotherapist & anesthesiologist
      • Nursing responsibilities
        • NPO 8 hours prior to ECT
        • Atropine 1 hr. prior to treatment
        • Have patient urinate before treatment
        • Remove hairpins & dentures
        • Take vital signs
        • Reduce anxiety--be positive
    • Procedures During ECT
      • IV inserted
      • Electrodes placed on head
      • Bite-block inserted
      • Brevital IV
      • Anective IV, neuromuscular blocking agent
      • Ventilate 100% O 2
      • Electrical impulse 150 volts, 0.5 - 2 sec.
      • Monitor, heart rate, rhythm,BP, EEG
    • Nursing Care After ECT
      • Ventilate with 100% O 2 until breathing unassisted
      • Monitor for respiratory problems
      • Reorient patient, time, place, person
      • If agitation may need benzodiazepine
      • Constant observation
      • Document all aspects of treatment
      • Monitor seizure activity, EEG
    • Contraindications for ECT
      • Very High Risk
        • Recent myocardial infarction
        • Recent CVA
        • Intracranial mass lesion
      • No absolutes
      • High Risk
        • Angina pectoris
        • Congestive heart failure
        • Extremely loose teeth
        • Severe pulmonary disease
        • Severe osteoporosis
        • Major bone fractures
        • Glaucoma
        • Retinal detachment
        • Thrombophlebitis
        • Pregnancy
        • Use of MAOIs
        • Use of clozapine
    • Disadvantages ECT
      • Temporary relief
      • Memory impairment, before and after ECT
      • Physiological effects
        • hypertension
        • arrhythmias
        • alterations in cardiac output
        • hemodynamic changes
        • increases in myocardial o 2 consumption-ischemia
        • seizures
    • Other Somatic Therapies
      • Psychosurgery
      • Insulin-Coma
      • Metrazol-induced convulsions
    • Psychosurgery
      • Types
        • Cingulotomy
        • Subcaudate tractotomy
        • Capsulotomy
      • Outcomes, psychosurgeries
        • Suicide rate of 1300 persons dropped 15% to 1% post op
      • Contraindications
        • <20 yrs or >65 yrs
        • brain pathology, atrophy or tumor
        • personality disorders: borderline, paranoid, antisocial, histrionic
        • substance abuse
      • Adverse Reactions
        • Altered personality
        • infection, hemorrhage, hemiplegia,seizures, suicide, wt. gain
    • Phototherapy: Seasonal Affective Disorder
      • Light box
      • Phototherapy visor
      • Head-mounted light unit
      • Dawn stimulator