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Physiological needs vs Psychological needs

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• Physiological needs always takes precedence over psychological concerns

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Biological structure and Mental disease

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• Alteration in amygdala (impaired emotions) • Alteration in frontal lobe (impaired reasoning ability) • Alteration in parietal lobe (impaired orientation ability and impaired visuospatial skills) • Alteration in hippocampus (impaired memory)

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Suicidal Caution

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• Suicidal ideation may be seen with dementia but is not usually associated with delirium

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Dysnomia

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• impaired ability to name an object

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Sundown syndrome

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• Disorientation that worsens at end of day

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To increase the level of orientation of the client with Dementia

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• Non-verbal stimuli may be more effective than verbal stimuli • "Put traditional seasonal decorations within the client's view" -It is important that decorations be traditional, as the client is more likely to have intact remote memory that allows for recognition of objects from the distant past • "Repeat reorienting stimuli frequently" • "Speak directly into the client's ear when telling him the day of the month and time" (x) -The nurse should not assume that the client with dementia has a hearing deficit • "Keep the client's TV tuned to a 24-hour news station during the daytime hours" -Instead of reorienting the client, the news station would likely increase disorientation because the client would not be able to process the events in a normal cognitive manner. Additionally, constant stimulation would probably be overtaxing to the client

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Donepezil (Aricept)

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• A cholinesterase inhibitor • Slow down cognitive deterioration in individuals with mild to moderate dementia • When the activity of chilnesterase is inhibited, the amount of acetylcholine in the synapse is increased.

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Fluoxetine (Prozac) Paroxetine (Paxil)

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• SSRI • Antidepressant

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Trazodone

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• Tetracyclic antiedepressant

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Caregiver role strain

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• Resentment (분함, 억울함) • Isolation • Alienation (소외)

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[Delirium]

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• Acute, reversible cognitive disorder • Develops over a short period of time (usually hours to days) • Behavior tends to fluctuate during the course of the day • Can persist up to three to six months • Evidence from history, physical examination, and/or laboratory findings suggests that the disturbance is caused by the direct physiological consequences of a GENERAL MEDICAL CONDITION • Client tends to act OUT OF IMPULSE

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Clients with Delirium

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Disoriented to • Place • Time

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Characteristics of Delirium

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• Delirium is characterized by a disturbance of consciousness and a state of awareness that may range from hypervigilance(위험을 감지하는 감각이 극도로 민감한 상태) to stupor(인사불성) or semicoma

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Symptoms of Delirium

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• Decreased consciousness of environment • Decreased ability to focus and sustain attention • Disorientation • Memory impairment • Impaired speech • Altered sensory perception • Problems with the sleep wake cycle • Psychomotor changes and/or emotional problems

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Delirium: If untreated?

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Can lead to • Seizures • Stupor (인사불성, 정신혼미) • Coma • Death

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Nursing Intervention for Delirious client

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• Delirious clients may be at hight risk for injury • Therfore, the nurse should stay with the client and they should be monitored closely

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Types of Delirium

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• Delirium due to GENERAL MEDICAL CONDITION • Substance-intoxication delirium • Substance-withdrawal delirium • Delirium due to multiple etiologies • Delirium not otherwise specified

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Delirium & Psychosis?

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• Delirium may or may not be accompanied by psychosis

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Delirium is commonly seen in

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• ICU • Medical-surgical units • Geriatric units • Emergency departments • Alcohol/drug treatment centers • Oncology units • In general, hospitalized patients

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[Dementia]

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• A chronic, usually progressive irreversible brain disorder

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Symptoms of Dementia

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• Impairments in memory • Deterioration in language/speech • Motor dysfunction • Sensory deficits • Diminished ability to perform activities of daily living • Disturbance in executive functioning • Reduced or absence of abstract thinking • Impaired judgment

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Hallmarks of Dementia

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• Aphasia • Apraxia • Agnosia • Disuturbance in EXECUTIVE FUNCTIONING

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Aphasia

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• Loss of the ability to understand or use language speech

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Apraxia

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• Inability to carry out skilled and purposeful movement; the inability to use objects properly

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Agnosia

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• Inability to recognize familiar situations, people or stimuli • NOT related to impairment in sensory organs • Tactile agnosia, auditory agnosia

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Confabulation

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To protect the ego

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Disturbance in Executive Functioning

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• Planning • Organizing • Sequencing (순서정하기, prioritization) • Abstracting

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Course of Dementia

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• Insidious (서서히 퍼지는) and progressive • Charaterized by gradual onset and continuing cognitive deline

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Cognitive deficit of Dementia cause

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• a significant impairment in social, occupational, and/or vocational functioning • a significant decline from previous level of functioning

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May or May not be accompanied by

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• behavioral changes • psychosis • mood changes

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Types of Dementia

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• Dementia of the Alzheimer's type • Vascular dementia (formerly multi-infarct dementia) • Dementia due to other general medical conditions • Substance-induced persisting dementia • Dementia due to multiple etiologies • Dementia due to substance withdrawal • Dementia not otherwise specified

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Pseudodementia (=Masquerade 진실을 숨기는 가장)

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Depression • rapid progression • intact attention and concentration • Diminished appetite • Symptoms diminish as the they progresses • Oriented to time and place with no wandering

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Reversible form of dementia

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• Imbalance in electrolytes can have catastrophic effects on the body, including confusion, memory loss, and disorientation. The secondary dementia symptoms are reversible with the restoration of the electrolyte balance

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Priority nursing intervention for late stage Alzheimer's dimentia

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Assist the client in consuming fluids and food to prevent electrolyte imbalance • Nutritional deficits are common among clients diagnosed with late-stage Alzheimer's dementia. These clients must be assisted in consuming fluids and food to prevent electrolyte imbalance. Meeting this physical need would be prioritized over meeting psychological needs

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Nursing intervention of "Assist with ambulation to avoid injury from falls" for late stage Alzheimer's dementia????

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• It's common for clients diagnosed with late-stage Alzheimer's dementia to be confined to a wheelchair or bed; ambulation and the need for assistance would not be expected

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Which nursing intervention should be implemented first for primary dementia patient with a nursing diagnosis of altered thought process R/T disorientation and confusion • Assess client's level of disorientation and confusion • Remove potentially harmful objects from the client's room

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• Assessing the client's level of disorientation and confusion is necessary to determine specific requirements for safety. The nurse then may remove potentially harmful objects form the client's room, if needed • Assessing the client's level of disorientation and confusion should be the first nursing intervention • Assessment of a client diagnosed with dementia is necessary to formulate a plan of care and to determine specific interventions and requirements for safety

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[Amnestic Disorder] 기억상실증

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• Development of memory impairment • Inability to learn new information • Inability to recall previously learned information

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Amnestic disorder vs Dementia

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Amnestic disorders differ from dementia in that • no impairment in abstract thinking or judgment • no personality change

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Medical Conditions associated with Amnestic Disorder

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• Cerebral anoxia • Cardiac Arrhythmias • Migraine • Cerebrovascular disease

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Amnestic disorder can result from the use of

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• Toxins • Medications • Sedatives • Alcohols

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Characteristics of Amnestic disorder

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• Can be transient lasting for one month or less • Or chronic lasting for more than one month

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Diagnosis is not made if

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• problems with memory occurred exclusively during a state of Delirium • cognitive deficits are present that are representative of dementia

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Types of Amnestic Disorders

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• Amnestic disorder due to General Medical Disorder • Substance-induced persisting amnestic disorder • Amnestic disorder not otherwise specified

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[Other Cognitive Disorders]

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• Cognitive dysfunction caused by a direct physiological effect of a general medical condition that does not meet criteria for any of the specific delirium, dementia, or amnestic disorders

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Types of Other Cognitive Disorders

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• Mild neurocognitive disorder • Postconcussional disorder (뇌진탕) • Substance-induced cognitive disorder

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Mild Neurocognitive Disorder

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• Diagnosed secondary to results of neuropsychological testing or clinical assessment

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Post-concussional Disorder (뇌진탕)

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• Occurs after head trauma

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Substance-induced cognitive disorder

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[Toxic Substances] • Lead • Aluminum • Heavy metals [Substance Abuse] • Alcohol • Anxiolytics • Opioids [Withdrawal states] • Reduction or abrupt termination in use of substance • Alcohol • Sedatives • Hypnotics • Anxiolytics • Illicit drugs

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[Etiology, Causes]

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• Cause of Delirium • Cause of Dementia

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Etiology of Derilirum

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• Caused by pathophysiological effects of medical problems, substances • Multiple etiologies • May be due to hypoxia and/or neurotransmission dysregulation • The precise effect on the brain is dependent on etiology

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Etiology of Dementia

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• Cause is related to pathophysiological insult or changes to cerebral tissue/ neuronal function • Pathophysiological effects are dependent on precise etiology of dementia

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[Examples] Etiology of Dementia

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• Decreased cerebral blood flow • Brain hypoxia • Vitamin Deficiency • Infections • Endocrine and metabolic disorders • Hepatic and Renal Failure • Neurological degeneration • Autoimmune disorders • Traumatic brain injury • Brain tumors

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Decreased cerebral blood flow

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• Cardiac dysrhythmias or arrest • Shock • Hypertension • Congestive hear failure • Cerebrovascular attack • Transient ischemic attacks • Pulmonary embolism • Systemic lupus erythematosus

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Brain Hypoxia

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• COPD (Chronic Obstructive Pulmonary Disease) • Asthma • Emphysema (폐기종) • Anemia (빈혈증)

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Vitamin Deficiency

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• Deficiencies in thiamine, niacin, and/or folic acid • Caused by alcoholism, pernicious anemia, Wernicke's disease, Korsakoff's syndrome

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Wernicke's - Korsakoff's disease

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• Wernicke-Korsakoff syndrome is a brain disorder due to thiamine (vitamin B1) deficiency.

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Infections

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• Sepsis (염증, 패혈증) • Subacute bacterial endocarditis • Pneumonia • Urinary tract infection • HIV (Human Immunodeficiency Virus)

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Endocrine and Metabolic Disorders

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• Hypoglycemia • Insulin shock • Hypothyroidism • Adrenal Deficiency • Electrolyte imbalance • Acidosis • Alkalosis

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Hepatic and Renal Failure

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• Hepatic encephalopathy (간성 뇌증) • End-stage renal disease

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Neurological degeneration

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• Alzheimer's disease • Creutzfeldt-Jakob disease • Parkinson's disease • Huntington's chorea • Multiple sclerosis

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[Assessment]

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• Delirium (Has a sudden onset and an identifiable cause) • Dementia (Complicated or multiple causes)

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Positive diagnosis of Delirium

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• A thorough history and physical and medical evaluation • An abnormal EEG (Electorencephalogram) confirm cerebral dysfunction • Several examinations should be done throughout the day to detect fluctuations in levels of consciousness that characterize the syndrome • Abnormal laboratory and diagnostic testing (X-ray, MRI, CAT scan) that identify underlying etiology of deliriu • Rule out of other disorders that may mimic the symptoms of delirium (acute stress disorder, mood disorders, anxiety disorders, psychotic disorders)

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Signs and Symptoms of Delirium

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• Fluctuating levels of consciousness (Periods of coherence ~ Periods of confusion) • Sundown Syndrome (disorientation worsens at the end of the day) • Alternating patterns of hyperactive (typical of drug withdrawal) to hypoactive (typical of metabolic imbalance) • Sleep pattern disturbances • Speech/language problems • Affective Changes • Cognitive Changes

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Types of Speech/language problems

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• Dysarthria (problem with articulation) • Dysnomia (impaired ability to name an object)

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Cognitive Changes

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• Disorganized thought process such as frightening delusions • Diminished ability to focus attention, easily distracted • Disorientation to person, place, and/or time • Impairment in recent and remote memory (recent memory loss is more common) •

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Parkinson's disease

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• There is a loss of nerve cells located in the substantia nigra • Diminished dopamine activity results in involuntary muscle movements, slowness, and rigidity • Tremor in the upper extremities is characteristic • Dementia, which closely resembles that of Alzheimer's disease, is observed in 60% of clients with Parkinson's disease

Mental Health Nursing – Delirium, Dementia, and Other Cognitive Mental Disorders – Flashcards

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