Chapter 18 A The primary initial deficit occurs in cognition, although there may be changes in mood and behavior B Includes disorders associated with 1. Temporary or permanent changes in brain tissue that were formerly classified as organic brain syndrome or organic mental disorders (e.g., delirium, dementia) 2. Persistent disturbances in memory resulting from a medical condition or substance use 3. Psychosis that may be acute and short-term or chronic and debilitating; includes schizophrenia, delusional paranoid, and schizoaffective disorders; brief psychotic and shared psychotic disorders; and psychotic disorders caused by medical conditions or substance use A Provide a safe, familiar environment, direct supervision as necessary, and a consistent caregiver to foster trust B Reorient to time, place, person, and situation (e.g., clocks, calendar, incorporation of statements into ordinary conversation that reorient the client); however, avoid excessive use of reorientation because it may cause anxiety; keep statements short, simple, and concrete and use nonverbal cues C Keep involved in reality-based activities and in the home situation as long as possible D Allow to assume as much responsibility for self-care as possible E Provide a quiet environment but do not understimulate; reduce unfamiliar stimuli; promote relationships F Plan care so that the client can be approached when receptive G Attempt to follow familiar routines; keep schedule of activities flexible to make use of the client’s lability of mood and easy distractibility H Provide prompting for completion of activities of daily living (ADLs) I Encourage adequate nutritional intake; set limits on hyperorality; monitor intake and output I&O J Provide diversional activities including exercises that are enjoyable and realistic K Observe for changing physiologic and neurologic signs and symptoms L Protect from physical harm to self or others related to confusion, aggression, or fluid and electrolyte imbalance M Support and educate family caregivers; maintain nonjudgmental attitude N Encourage the responsible others to obtain periodic relief from total care; refer to community agencies that provide homecare helpers or respite care if appropriate O Support family’s decision to place client in a long-term facility 1. Temporary, reversible syndrome from which the client usually recovers after treatment 2. Occurs secondary to a physical disorder or drug response 3. Clinical manifestations develop over a short period (hours or days), and cognitive impairment fluctuates during a 24-hour period (1) Intracranial or nervous system (e.g., meningitis or encephalitis) (2) Systemic (e.g., infection, acute or chronic respiratory disorders) c. Circulatory disturbances resulting in impairment of blood flow to the brain d. Metabolic disorders: electrolyte imbalances resulting from dehydration, diarrhea, or vomiting; fever; endocrine imbalances e. Ingestion of psychoactive substances, accumulative central nervous system (CNS) effect of prescribed medications or street drugs, or withdrawal syndromes (e.g., alcohol withdrawal delirium) f. Multiple etiologies (e.g., combination of medical condition and substance interaction) B Behavioral/clinical findings (Table 18-1: Comparison of Clinical Findings of Delirium and Dementia) Table 18-1 Comparison of Clinical Findings of Delirium and Dementia 1. Confusion, hallucinations (perception in absence of an external stimulus), illusions (misinterpretation of an actual stimulus), and delusions (fixed false belief) 2. Disorientation and confusion as to time, place, person, and situation 3. Memory defects for both recent and remote events and facts 4. Slurring or rapid speech that may occur concurrently with an indistinct pronunciation or use of words 5. Tremors, incoordination, imbalance, and incontinence 6. Physical signs and symptoms such as hyperthermia, tachycardia, and gastrointestinal (GI) changes (e.g., anorexia, nausea, vomiting, diarrhea) 1. See General Nursing Care of Clients with Disorders Related to Alterations in Cognition and Perception, Nursing Care of Clients with Dementia, and Nursing Care of Clients with Amnestic Disorders 2. Implement prescribed measures to reduce causative factors 3. Reassure family members that symptoms associated with delirium may subside with treatment 4. Assign a one-to-one caregiver during restless or agitated periods 5. Provide a safe, quiet environment with increased supervision 6. Reorient to time, place, person, and situation 7. Communicate with simple direct statements in calm voice; use nonverbal cues 2. Remains oriented ×4 (time, place, person, and situation) to time, place, person, and situation 3. Assumes increased responsibility for self-care 4. Maintains a diet high in calories, protein, and vitamins 5. Avoids intake of pharmacologic substance associated with delirium 6. Continues to visit health care provider for treatment and amelioration of underlying cause 1. Not associated with expected aging processes 2. Dementia of the Alzheimer type and vascular dementia are the two most common causes; death occurs after years of mental and physical decline; Alzheimer disease is the fourth leading cause of death in the United States a. Anatomic changes in the brain from trauma, tumors, and degeneration of tissue (e.g., atrophy, widening ventricles, senile plaques caused by deposits of amyloid protein, neurofibrillary tangles) b. Infections such as tertiary syphilis and acquired immunodeficiency syndrome (AIDS) c. Circulatory disturbances causing anoxia and permanent brain damage (e.g., cerebral arteriosclerosis, brain attack) d. Nutritional deprivation of brain cells (e.g., pellagra) e. Toxins (e.g., chronic alcohol abuse) f. Decreased level of neurotransmitters, especially acetylcholine g. Chromosomal defects (e.g., Huntington disease) h. Immunologic defects creating prolonged inflammatory response in brain tissue B Behavioral/clinical findings (Table 18-1: Comparison of Clinical Findings of Delirium and Dementia) 1. Dementia has an insidious onset with symptoms following a progressively downhill course 2. Early recognition of cognitive deficits may lead to anger, anxiety, and depression; as cognitive deficits progress and self-awareness declines, symptoms may be replaced by apathy and social withdrawal; anxiety may occur when cognitive abilities are overwhelmed and confusion increases 3. Progression moves from mild forgetfulness for recent events and mild expressive aphasia to inability to perform ADLs and mutism a. Aphasia (language disturbance) b. Apraxia (impaired motor activities) c. Agnosia (inability to recognize familiar objects) e. Ataxia (impaired coordination) f. Disturbance in planning, organizing, sequencing, and abstracting (executive function) g. Emotional lability or flat affect h. Hallucinations, illusions, and delusions i. Sundowning phenomenon: agitated behaviors of physical aggression between 2 and 9 PM; nighttime sleeplessness and wandering between midnight and 6 AM 4. “4 As” of dementia of the Alzheimer type: amnesia, apraxia, agnosia, aphasia 1. The same as those for delirium with greater emphasis on preventing further damage (see Therapeutic Interventions under Delirium) 2. Medications for depression, agitation, and cognitive decline a. Antidepressants: may improve overall level of functioning (see Chapter 16, Related Pharmacology: Psychotropic Medications, Antidepressants) b. Antipsychotics: may decrease agitation and aggressive behavior (see Chapter 16, Related Pharmacology: Psychotropic Medications, Antipsychotic Agents) c. Antidementia agents: provide a temporary improvement in cognitive function but progression of disease continues (see Chapter 16, Related Pharmacology: Psychotropic Medications, Anti-Alzheimer Agents)
Nursing Care of Clients with Disorders Related to Alterations in Cognition and Perception
Overview
General Nursing Care of Clients with Disorders Related to Alterations in Cognition and Perception
Major Disorders Related to Alterations in Cognition and Perception
Delirium
Data Base
Delirium
Dementia
Acute onset (hours/days)
Chronic
Rapidly progressive
Insidious
Intense anxiety and irritability
Short attention span
Tremors/hyperreflexia
Recent memory loss; later long-term loss
Insomnia
Impaired new learning
Hyperactivity
Lack of initiative/apathy
Fever and tachycardia
Blunted or labile affect
Hypertension
Loss of judgment
Hallucinations and delusions
Motor disturbances
Seizures
Exaggeration of traits
Death
Lower personal care standards
Nursing Care of Clients with Delirium
Assessment/Analysis
Planning/Implementation
Evaluation/Outcomes
Dementia
Data Base
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