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Chapter_024.pptx

Chapter 24

Cognitive and Neurologic Function

Function of neurotransmitters is altered due to a decreased number of neurons in various areas of the brain.

Changes in neuron function are associated with accumulation of lipofuscin granules and neuritic plaques in the cell body of some neurons.

Physiologic changes in the CNS include sensory motor changes, the reticular activating system (RAS) and neuroendocrine system are altered.

Age-Related Cellular and Structural Changes of the Neurologic System (1 of 2)

Hippocampus changes include: structural changes, synapse loss in the neurons, decreased microvascular integrity, reduction in glucose metabolism, and alterations in the neuroglia cells

Reduction in the turnover of cerebrospinal fluid (CSF)

Neurodegenerative and neurochemical changes in the cerebellum

Age-Related Cellular and Structural Changes of the Neurologic System (2 of 2)

Sleep disorders (sleep-wake cycle)

Altered ability to learn new information quickly, memory storage, and memory retrieval

Altered vision, hearing loss, decreased taste and smell, vibratory sensations, and position sense

Balance issues and postural hypotension

Decreased ability to feel pain and cope with temperature changes

Changes may contribute to diseases causing cognitive decline.

How These Changes Affect the Older Adult

Mental status assessment: attention, memory, orientation, perceptions, thought processes, thought content, insight, judgment, affect, mood, language, and higher cognitive functions

Neurologic assessment: cranial nerves, gait, balance, distal deep tendon reflexes, plantar responses, primary sensory modalities in lower extremities, and cerebrovascular integrity

Include functional assessment

Assessment of Cognitive Function

Dementia Severity Rating Scale (DSRS)

Covers the areas of memory, orientation, judgment, community affairs, home activities, personal care, speech and language recognition, feeding, incontinence, and mobility or walking

Normal score instrument is 4 or less; score increases as older person’s cognition decreases.

Cognitive Function Screening Instrument: Functional Assessment

Montreal Cognitive Assessment (MoCA): a quick screening tool for mild cognitive impairment (MCI) and early Alzheimer’s dementia

Assesses the domains of attention and concentration, executive functions, memory, language, visuospatial abilities, conceptual thinking, calculations, and orientation

Mini cog—screens for cognitive impairment

Cognitive Function Screening Instrument: Mental Status Examination

Geriatric Depression Scale (GDS) may be used with healthy older adults, as well as those who are acutely ill, and those with mild to moderate cognitive impairment.

Consists of 15-items; 10 indicate the presence of depression when answered positively, while the rest (question numbers 1, 5, 7, 11, 13) indicate depression when answered negatively.

Cognitive Function Screening Instrument: Depression Assessment

Myth: forgetfulness as an inevitable consequence of aging

Fact: memory and delayed recall are not substantially decreased in older persons.

Older persons experience no more memory loss than younger persons.

Decline in cognitive function is effect of disease, not effect of normal aging process.

Cognitive Function and Memory in Typical Aging

The three Ds: depression, delirium, and dementia

Cranial tumors, subdural hematomas, and normal pressure hydrocephalus

Accurate assessment and diagnosis are essential for ensuring appropriate treatment.

Cognitive Disorders Associated With Altered Thought Processes

The rate of depression increases with age.

Associated with higher suicide rates than in younger person with depression

Manifestations include: fatigue, constipation, psychomotor retardation, depressed mood, loss of interest, energy, libido, or pleasure, changes in appetite, weight, and sleep patterns, agitation, anxiety, or crying

May be a response to chronic illness, drugs may contribute to it and may be related to cognitive impairment and dementia

Depression

Presents as a disturbance in attention (decreased awareness of the environment) with a reduced ability to focus, sustain, or shift attention

Cognitive changes (poor memory, disorientation, speech disturbance) or perceptual disturbances are distinct from a preexisting, established, or evolving dementia.

The onset of the disturbance is rapid (hours to days) and typically fluctuates over the course of the day.

Underlying illness may cause the delirium.

Delirium

Advanced age, central nervous system (CNS) diseases, infection, polypharmacy, hypoalbuminemia, electrolyte imbalances, trauma history, gastrointestinal or genitourinary disorders, cardiopulmonary disorders, and sensory changes

Risk Factors for Delirium

Difficulty maintaining concentration or attention to external stimuli and language disturbance, including slurred, forced, or rambling speech

Disorganized thinking demonstrated by tangential reasoning and conversation often the presenting symptom

Also clouding of consciousness or fluctuation of awareness, misperceptions, illusions, or hallucinations, disorientation to persons, place, and time, memory problems, increased or decreased physical activity, and impaired judgment

Delirium Clinical Manifestations

Confusion Assessment Method (CAM)

Rapid diagnosis and treatment of underlying cause

Provide a therapeutic environment, decrease stress, maintain comfort.

Clear communication, consistent caregivers

Provide physical activity.

If causing injury to the patient or others it should be treated with drugs.

Delirium Management

Includes: Alzheimer’s disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD)

Syndrome of gradual and progressive cognitive decline

Alteration in memory in addition to acquired persistent alteration in intellectual function compromising multiple cognitive domains

May involve language deficits, apraxia, agnosia, agraphia, and impaired executive function

Dementia

Phenomenon that occurs when other pathologic conditions masquerade as dementia

Identify and treat underlying causes of dementia symptoms; even if disorders are identified and treated, not all individuals with dementia symptoms will improve

Reversible Dementia

Most common form of dementia

Progressive, neurodegenerative disease characterized by the presence of neurofibrillary tangles composed of misplaced proteins within brain, cortical amyloid plaques, and granulovascular degeneration of neurons in pyramidal cell layer of hippocampus

Sixth leading cause of death in the United States, costing billions in health care

Alzheimer’s Disease (AD)

Age is the single most important risk factor.

Genetics, particularly in one type of early-onset AD occurring in people ages 30–60, but affecting less than 5% of all who have AD

AD that develops after age 60 is a combination of lifestyle, genetics, and environmental factors.

A genetic factor which increase the risk of developing the disease is related to the apolipoprotein E (APOE) gene found on chromosome 19.

AD Risk Factors

Repeated questions and statements, forgetting to pay bills or take medications, increasing problems with orientation, and geographic disorientation

Symptoms: pervasive forgetfulness and memory loss, language deterioration, impaired ability to mentally manipulate visual information, poor judgment, confusion, restlessness, and mood swings

Autopsy remains the gold standard for the definitive diagnosis of AD.

MRI and CT are used to identify hippocampal atrophy associated with diagnosis.

AD Clinical Manifestations

No cure for AD, but medications can slow progression of disease

Cholinesterase inhibitors: mild to moderate disease and are used to delay or prevent symptoms from becoming worse

Memantine is used to treat moderate to severe Alzheimer’s disease and the main effect is to delay the progression of some of the symptoms.

Help patients and their families through progression of the disorder and focus on maintaining cognitive and global functioning early in the disease process.

AD Treatment and Nursing Management

Second most common dementia

Loss of cognitive function resulting from ischemic, hypoperfusive, or hemorrhagic brain lesions resulting from cerebrovascular disease or cardiovascular pathologic conditions

Some recovery of function may occur over time, but never full recovery.

Vascular Dementia (VaD)

Arteriosclerosis, blood dyscrasias, cardiac decompensation, hypertension, atrial fibrillation, cardiac valve replacements, systemic emboli for other reasons, diabetes mellitus, peripheral vascular disease, obesity, smoking, and vasospasms in segments of the brain

VaD Risk Factors

May have gradual onset (memory, motor, or sensory perceptual function deficits) or abrupt onset ( immediate symptoms like one-sided weakness, gait abnormalities, or focal neurologic signs)

Usual progression of VaD follows a stepwise decline rather than the slow, steady decline of AD.

Symptoms depend on the area of infarct and not all brain attacks result in intellectual impairment; some affect movement, vision, or other functions.

Either CT or MRI usually reveals one or more areas of cerebral infarction.

Treatment for VaD is the same as for AD.

VaD Clinical Manifestations, Diagnostic Tests, and Treatment

Progressive, degenerative brain disorder causing a decline in thinking, reasoning, and independent functioning

Lewy bodies can be found in persons with Alzheimer and those with Parkinson.

No known risk factors

Dementia With Lewy Body (DLB)

Often marked by prominent fluctuations in attention and ability to communicate and by severity of psychiatric symptoms, particularly visual hallucinations and decreased attention and deficits in verbal fluency

Extrapyramidal features also found: rigidity, bradykinesia, flexed posture, and shuffling gait

No laboratory tests or diagnostic value from MRI

Symptomatic treatment when psychiatric and behavioral symptoms become distressing

LBD Clinical Manifestations, Diagnostic Studies, and Treatment

Syndrome of exclusion associated with non-AD pathologic conditions and relatively rare in clinical setting

Focal atrophy of frontal and anterior temporal regions

Poorly understood risk factors

Frontotemporal Dementia (FTD)

Behavioral variant frontotemporal dementia (Pick disease): progressive behavior/personality decline where there is a change in personality, emotions, behavior, and judgment

Primary progressive aphasia: progressive language decline where there are early changes in language ability that include speaking, reading, writing, and understanding

Progressive motor decline characterized by difficulties with physical movement that include shaking, difficulty walking, frequent falls, and poor coordination

FTD Clinical Manifestations

Focal atrophy of the prefrontal or temporal regions with CT or MRI

PET scanning may assist in confirmation of clinical diagnosis.

Currently there are no treatments for FTD.

Benefit from speech therapists, physical therapists, day care, respite care, and the judicious use of drugs to control symptoms.

FTD Diagnostic Studies and Management

Which of the following best describes Lewy body dementia?

Progressive decline in behavior, language, and motor skills

Rigidity, bradykinesia, and shuffling gait

Brain tissue is affected by small emboli.

Increased problems with memory and orientation, poor judgment, and confusion

Occurs rapidly; may be a response to infection or electrolyte imbalance

Quick Quiz!

ANS: B

Answer to Quick Quiz

Rare but potentially reversible condition but if left untreated, it leads to permanent cognitive impairment

Majority of cases related to prior cerebral insults such as traumatic injury, viral insult, or previous surgery.

Triad of symptoms: gait disturbance, urinary incontinence, and cognitive dysfunction

Treatment: placing a shunt to drain CSF

Normal Pressure Hydrocephalus (NPH)

Pressure created by bleeding between cranium and cerebral cortex can cause cognitive impairment and neurologic deficits.

Caused by brain atrophy and corresponding vascular changes that occur with normal aging, falls, and subsequent head injuries

Can be acute or chronic

Treatments for both types include evacuation of hematoma, usually with use of burr holes and a closed drainage system.

Subdural Hematomas

Do not have typical signs of increased intracranial pressure, instead have personality changes, and slowly progressive hemiparesis.

Often misdiagnosed with depression or dementia

Diagnosis made after head CT or MRI and biopsy

Treatment depends on biopsy results: surgery, radiation, or chemotherapy.

Prognosis is generally poor.

Intracranial Tumors

History, physical examination, behavioral observation, and functional and mental status examinations

CT, MRI, EEG, and PET

CSF studies CBC; electrolytes; urinalysis; liver, kidney, and thyroid function tests; serum B12 levels; folate; syphilis serology; and drug studies can determine reversible causes and treatable medical diagnoses.

The DSM-5 classification

Diagnostic Assessment of Cognitive Disorders

Nonpharmacological: Need-driven Dementia-compromised Behavior Model

Pharmacological: antidepressants, and cholinesterase inhibitors

Individual responses to medications vary considerably.

“Start low, go slow, and titrate upward until benefits or side effects are seen”

Treatment of Behavioral and Psychological Symptoms of Dementia

Baseline physical examine

Geriatric Depression Scale (GDS)

Level of consciousness: Glasgow Coma Scale

Mental Status exam

Pupil assessment

Neurologic assessment

Behavioral assessment

Can you name 10 nursing diagnoses for cognitive disorders?

Cognitive Disorders: Assessment and Diagnosis

Reduced stamina resulting from physical illness

Disrupted family routines resulting from cognitive impairment

Inadequate nutrition resulting from poor oral intake

Inadequate role performance resulting from cognitive impairment

Anxiety resulting from misinterpretation of environmental cues

Inadequate bathing self-care resulting from cognitive impairment

Bowel incontinence resulting from cognitive decline and misinterpretation of physiologic needs

Caregiver role tension resulting from older adult’s cognitive decline and behavioral problems

Confusion (acute or chronic) resulting from physiologic, emotional, or environmental processes

Inadequate dressing self-care resulting from cognitive impairment

Fatigue resulting from increased physical, emotional, and environmental demands

Fear resulting from cognitive impairment

Inadequate feeding self-care resulting from increased cognitive impairment

Functional urinary incontinence resulting from inability to interpret physiologic and environmental cues

Potential for injury resulting from altered ability to interpret the environment

Decreased mobility resulting from neurologic deficits

Reduced social interaction resulting from cognitive impairment

Compromised family’s ability to cope because of the needs of the older adult with cognitive impairment

Disabling family’s ability to cope resulting from lack of social supports

Need for health teaching resulting from lack of previous exposure to disease process

Decreased self-esteem resulting from awareness of cognitive deficits

Spiritual tribulation resulting from the effect of cognitive impairment on individual and family

The patient/family will do the following:

Exhibit no episodes of acute confusion

Maintain continence

Demonstrate the ability to cope by accessing community agencies and support services

Exhibit reduced fear and anxiety

Demonstrate fewer inappropriate behaviors such as agitation, combative behavior, and mood changes

Demonstrate increased socialization

Maintain physical and spiritual health

Participate in activities and care

Cognitive Disorders: Planning and Expected Outcomes

Use simple and direct therapeutic verbal and nonverbal communication.

Assess the physical health and the ability of individuals.

Support the ongoing nutrition of individuals with dementia.

Provide reality orientation.

Manage problem behaviors by modifying factors that may contribute to these behaviors.

Maintain social interaction and human contact in a variety of ways.

Provide social and emotional support to the family.

Create a feeling of security and provide a safe environment.

Cognitive Disorders: Intervention

Evaluation is a continual process.

Careful observation and recording of moods, behaviors, and memory provide clues to minor changes in the individual’s condition.

Successful and unsuccessful interventions should be communicated to other caregivers and family members to aid in continuity of care.

Cognitive Disorders: Evaluation

Tendency for people with dementia to become more confused and agitated around late afternoon to nightfall

Symptoms: depleted cognition, reduced attention, altered sleeping and waking patterns, and disturbed psychomotor behavior are more evident in the evening

Behavioral interventions—redirection, provision of companionship and empathy, environmental modifications in lighting, and noise reduction

Sundown Syndrome

The most challenging behavior to manage in persons with cognitive impairments

May wander in response to need to use bathroom or combat boredom

Interventions: ensure an environment safe for wandering, inform neighbors and police of problem, have the person wear a medical alert bracelet, observe potential wandering trigger behaviors, and maintain regular activity and exercise

Wandering

May reflect individual’s basic insecurity about progressive memory and sensory losses.

Interventions: secure valuables in locked locations, avoid the use of confrontation and the application of logic, look in wastebaskets before emptying, do not whisper or behave in a secretive manner, mark all personal items with that individual’s name

Paranoia or Suspiciousness

Most often visual but may be auditory

Evaluate for medical causes: overmedication, toxicity, fever, infection, or a combination of causes may trigger response

If hallucination is disturbing to older person, offering protection and security may help calm patient.

Reasoning or logic is ineffective.

Behavior modification is treatment of choice.

Hallucinations and Delusions

Outbursts or overreaction toward minor stresses

Precipitated by emotional and sensory overload and aggravated by fatigue, overstimulation, inability to meet expectations, or misinterpretation of actions or words

Interventions: removing the individual from the environment, provide a calming atmosphere to distract the individual, use a calm tone of voice, touch, and reassurance, temporarily separating the individual from the causative source

Catastrophic Reactions

Physical and mental strain placed on caregivers can be significantly reduced if available resources are identified and used:

Family support groups

Respite services

Adult day care

Home health care

Legal services

Community mental health centers

Psychiatric hospitals

Resources for Families

Leading causes: undiagnosed and/or untreated depression

Risk factors include the following: recent death of a loved one, physical illness, uncontrollable pain, or fear of a prolonged illness, perceived poor health, social isolation and loneliness, and major changes in social roles (e.g., retirement).

Suicide

Evaluate suicidal ideation, prior attempts, a suicide plan, the plan’s lethality, the availability of the implements of the plan, coexisting substance abuse, and the pervasiveness of the despair a patient is experiencing

Can you name five nursing diagnoses for person at risk for suicide?

Suicide: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Identify and verbalize thoughts and feelings related to his or her emotional state

Report an absence of suicidal ideation

Demonstrate effective coping skills for managing stress and frustration

Experience behavior control with assistance of others

Express satisfaction with spiritual well-being

Suicide: Planning and Expected Outcomes

Take appropriate safety measures.

Arrange, if necessary for inpatient hospitalization (voluntary or involuntary) if patient safety cannot be ensured in an outpatient setting.

Write a “no-suicide contract” with the patient.

Help develop suicide prevention plans once patient is past immediate danger of suicidal behavior.

Suicide: Intervention

Despite excellent nursing assessment and intervention, older adults do continue to commit suicide at a distressingly high rate.

Focus may shift to assist the survivors of the suicide in coping with the resulting grief and trauma.

Suicide: Evaluation

Progressive degenerative disorder of the basal ganglia involving the dopaminergic nigrostriatal pathway

Degeneration of the dopaminergic nigrostriatal pathway causes dopamine depletion in the basal ganglia, while the ACh-secreting neurons remain active, creating an imbalance between excitatory and inhibitory neural activity in neurotransmitters.

Characterized by a slowing in the initiation and execution of movement (bradykinesia), increased muscle tone (rigidity), tremors at rest, and impaired postural reflexes

Parkinson’s Disease (PD)

Autosomal-dominant form of parkinsonian syndrome related to genetic defect of chromosome 4

Environmental factors: postencephalitic parkinsonism, drug-induced, toxin-induced parkinsonian syndrome, exposure to agriculture pesticides and herbicides, and trauma to midbrain

Other related causes: hydrocephalus, hypoxia, infections, stroke, tumor, and traumas

PD Risk Factors

Signs and symptoms begin subtly fatigue and a slight resting tremor.

Classic manifestations of PD are tremors at rest, muscle rigidity, bradykinesia, and postural abnormalities.

Short stepped, shuffling, and propulsive gait, postural disturbance; and trunk tilting forward

Muscle rigidity also affects the eyes, mouth, and voice and contributes to the staring gaze.

Absence of perspiration, heat intolerance, constipation, anxiety, depression, sleep disturbances, and dysphagia

PD Clinical Manifestations

No specific studies used to diagnose PD

Diagnosis based primarily on clinical features of disorder, confirmed when the individual’s symptoms improve with antiparkinsonian drugs

CBC, blood chemistry profile, EEG, upper gastrointestinal series, video fluoroscopy

Treatment includes drugs, surgery, and rehabilitation aimed at optimizing the patient’s functional level, relieving clinical manifestations, and decreasing risk for injury.

PD Diagnostic Studies and Management

Used primarily to relieve symptoms

Monoamine oxidase (MAO) inhibitors, dopaminergics, dopamine agonists, anticholinergics, and catechol-O-methyltransferase inhibitors can be given with dopaminergics.

Fluctuating response of individuals to antiparkinsonian drugs is called the on–off response.

PD Drugs

Alleviate symptoms of PD in patients who have not responded to medication therapy.

Ablation (destruction)

Deep brain stimulation (DBS)

Transplantation

PD Surgical Therapy

The patient will do the following:

Maintain an effective communication pattern

Maintain physical functioning and mobility and will not sustain injury

Maintain effective coping

Maintain socialization

Verbalize satisfactory effects from drugs and safely manage the medication schedule

Can you name four nursing diagnoses for PD?

PD: Diagnosis and Planning and Expected Outcomes

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

Teach patients importance of performing active range-of-motion exercises twice a day, walking at least four times a day, and using assistive device when recommended to prevent injury.

Consultation with speech pathologist necessary if patient develops dysphagia

Assessment of nutritional status and self-feeding abilities crucial for preventing aspiration, respiratory complication, and nutritional imbalance

Referral to community agencies

PD: Intervention

Evaluation of nursing interventions focuses on maintenance of function and engagement in activities for as long as possible.

Evaluation based on documentation of achievement of expected outcomes, as evidenced by older adult patient exhibiting intact skin, appropriate body weight, effective communication, effective coping, and knowledge of appropriate self-care practices

PD: Evaluation

The nurse is providing care for an older adult with Parkinson’s disease. Which of the following is a priority nursing intervention?

Reorient patient to surroundings frequently.

Be alert for signs of depression.

Administer BuSpar to help with bradykinesia.

Place the patient on fall precautions.

Quick Quiz!

ANS: D

Answer to Quick Quiz

Disruption in the normal blood supply to the brain tissue

Signs of a stroke: sudden numbness of face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking or dizziness, loss of coordination or balance; sudden severe headache with no known cause

Transient ischemic attack (TIA) consists of same symptoms but lasts less than 24 hours.

Stroke (1 of 2)

Medical emergency treat immediately to prevent permanent neurologic deficits and disability

Symptoms of thrombotic stroke may be sudden but typically progress gradually over minutes to hours referred to as a stroke-in-evolution.

3-hour window of treatment from onset of signs or symptoms of acute ischemic stroke

Symptoms of a hemorrhagic stroke occur more suddenly.

Stroke (2 of 2)

Advanced age is one of the most significant risk factors.

Genetics and race

Lifestyle factors are high blood pressure, diabetes, cigarette smoking, and heart disease caused by atherosclerosis, obesity, and physical inactivity, cocaine use.

Another risk factor is atrial fibrillation.

Hypertension is the most important modifiable risk factor for both ischemic and hemorrhagic strokes.

Stroke Risk Factors

Ischemic strokes can be categorized as: thrombotic, cardioembolic, and lacunar strokes Causes: atherosclerosis, inflammatory disease processes, and a break from a thrombus outside the brain or in the cardiovascular system.

Hemorrhagic strokes are divided into subarachnoid and intracerebral hemorrhages Causes: hypertension, a ruptured aneurysm, vascular malformations, bleeding into a tumor, hemorrhages associated with bleeding disorders or anticoagulation, head trauma, and illicit drug use

Types of Strokes and Their Causes

Depend on the vessel involved, the degree of obstruction of the vessel, and collateral blood supply

Hemiparesis, loss of speech, and paresthesias involving one side of the body

Cerebral hemorrhage: severe occipital or nuchal headache, vertigo or syncope, paresthesias, transient paralysis, epistaxis, and retinal hemorrhages

Common findings: headaches, vomiting, seizures, mental status changes (including coma), fevers, and electrocardiogram (ECG) changes

Stroke Clinical Manifestations

Noncontrast CT scan of the head, standard MRI or a diffuse-weighted MRI, or diffuse-weighted imaging (DWI)

ECG, chest x-ray study, and cardiac monitoring

CBC, electrolyte and glucose levels, and liver and kidney function tests

May need EEG or lumbar puncture

Stroke Diagnostic Tests

Patients with ischemic strokes confirmed by CT receive thrombolytic agents within 3 hours of onset to dissolve clot and reperfuse compromised brain tissue.

Other drugs: anticoagulants and antiplatelet therapy, lipid lowering drugs, antispasmotics, and antihypertensives

Stroke Management: Medical and Pharmacologic Therapy

Endarterectomy

Extracranial-intracranial bypass

Management of arteriovenous malformation

Management of cerebral aneurysms

Management of intracranial bleeding and evacuation of hematomas

Stroke Surgical Management

The patient will do the following:

Not die

Have minimum residual deficits and complications

Have reduced increased ICP

Not suffer evolution, extension, or completion of the stroke

Can you name eight nursing diagnoses for stroke?

Stroke: Diagnosis and Planning and Expected Outcomes

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

Position patient at a 30–45-degree angle to prevent elevation of ICP and protect airway.

Monitor vital signs.

Continuous monitoring for signs of complications

Encourage ROM and turn every 2 hours.

Monitor lower extremities for thrombophlebitis.

Encourage the use of the unaffected arm for ADLs.

Teach the patient to put clothing on the affected side first.

Stroke: Intervention (1 of 2)

Have the patient resume an oral diet after successful swallow evaluation or provide appropriate dysphagia diet.

Collaborate with occupational and physical therapists.

Try alternate methods of communication with patients who have aphasia.

Teach the patient with homonymous hemianopia to adapt to the deficit by turning the head side to side to fully scanning the visual field.

Educate the patient and family about: stroke and prevention, community resources, physical care, and the need for psychosocial support and medications

Stroke: Intervention (2 of 2)

Maintenance and improvement of cerebral tissue perfusion

Avoidance of respiratory complications

Prevention of aspiration from food, fluids, and secretions; contractures and edema in the affected extremity

Maintenance of skin integrity

Achievement of independence

Pain management

Stroke: Evaluation (1 of 2)

Increased ability to communicate, express feelings, and understand others

Prevention of fecal and urinary incontinence

Establishment of a normal voiding pattern

Compensation for sensory deficits and physical and intellectual losses

Participation by family members in the rehabilitation process

Stroke: Evaluation (2 of 2)

An older adult is admitted to the hospital with slurred speech, left-sided weakness, and confusion. Which of the following interventions should the nurse do first?

Conduct a neurologic assessment.

Inquire about risk factors.

Ascertain the exact time symptoms started.

Place the patient on aspiration precautions.

Quick Quiz!

ANS: C

Answer to Quick Quiz

Most common is obsessive-compulsive disorder (OCD) Obsessive symptoms: persistent intrusive thoughts, Compulsive symptoms: repetitive behavior performed in an attempt to reduce anxiety

Generalized anxiety disorder (GAD) is excessive worry that is beyond the individual’s control and may be evidenced by symptoms such as restlessness, fatigue, decreased concentration, irritability, muscle tension, or disturbed sleep.

Phobic disorder is manifested by a persistent, irrational fear provoked by the feared object or situation.

Anxiety Disorders

Assess for behavioral clues such as pacing, irritability, and fidgeting

Assess associated changes: sleeping habits and appetite, the presence or absence of depression, and any complaints of physical pain

Can you name two nursing diagnoses for anxiety disorders?

Anxiety Disorders: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Identify his or her own anxiety and coping patterns

Report an increase in psychologic and physiologic comfort

Demonstrate effective coping skills

Demonstrate the use of appropriate relaxation techniques

Anxiety Disorders: Planning and Expected Outcomes

Assist patients in examining their own “worst-case scenario,” and develop strategies to be used to cope.

Provide relaxation strategies: progressive muscle relaxation, breathing techniques, therapeutic use of music, and exercise

Help patients to identify increasing anxiety early in the anxiety cycle so they can take steps to reduce it to a lower level.

Provide family education.

Moderate to panic-level anxiety may need antianxiety medications.

Continued distress may benefit from psychotherapy.

Behavior modification techniques are effective with phobic disorders.

Anxiety Disorders: Intervention

Monitor progress toward achievement of expected outcomes and document the results.

Effectiveness of health teaching evident in patient’s ability to use relaxation techniques and constructive problem solving

Anxiety Disorders: Evaluation

Thought disorder characterized by altered perceptions of reality, alterations in thought processes, and declines in ADLs and occupational and social functioning

Person has been dealing with disorder for a long time but may experience exacerbations of the schizophrenic symptoms with the stress of the aging process.

Presentation is more likely to include delusions and hallucinations and less likely to include disorganized and negative symptoms.

Schizophrenia

Refer to general psychiatric nursing textbook for assessment process.

Can you name four nursing diagnoses for schizophrenia?

Schizophrenia: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Develop a trusting relationship

Maintain contact with mental health caregivers

Experience a decrease in hallucinations and distress

Get adequate sleep

Schizophrenia: Planning and Expected Outcomes

Comprehensive approach to maintenance of ADLs, nutrition, hygiene, health promotion, and reality orientation

Providing adequate family or social support, responding to patient symptoms, using touch appropriately and with patient permission, and dealing with aggressive behavior

Schizophrenia: Intervention

Based on achievement of the identified expected outcomes

Document progress toward achievement of the objectives, as well as the level of safety achieved

Schizophrenia: Evaluation

Involve nonbizarre delusions.

Aside from the delusion, thinking is normal.

Do not respond well to antipsychotic medications.

Different types are designated based on the predominant delusional theme: Erotomanic type, Grandiose type, Jealous type, Persecutory type, Somatic type, Mixed type, and Unspecified type

Delusional Disorders

Erotomanic type: delusions that another person, usually of higher status, is in love with the individual

Grandiose type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person

Jealous type: delusions that the individual’s sexual partner is unfaithful

Types of Delusional Disorders (1 of 2)

Persecutory type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way

Somatic type: delusions that the person has some physical defect or general medical condition

Mixed type: delusions characteristic of more than one of the above but with no one theme predominant

Unspecified type

Types of Delusional Disorders (2 of 2)

Characterized by below-average intellectual functioning

An alteration in ability to cope with life’s demands and to function independently including: communication, self-care ability, performance of ADLs, interpersonal relationships, occupational functioning, and health and safety behaviors

Intellectual Disability

Assess level of functioning.

Can you name three nursing diagnoses for intellectual disability?

Intellectual Disability: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Demonstrate ability to maintain personal safety

Demonstrate ability to care for self independently within limitations

Intellectual Disability: Planning and Expected Outcomes

Customize care plan to a patient’s intellectual abilities

Customize care routines to their level of intellectual functioning.

Use clear, simple instructions.

Documentation focuses on achievement of the expected outcomes and on the adaptations that are required as a result of age-related changes superimposed on the mental retardation.

Intellectual Disability: Intervention and Evaluation

Affect patient brain function, behavior, or experience.

Appropriate for use in long term care settings for the three Ds: “danger, to the resident or others; distress for the resident; dysfunction of the resident including interference with basic nursing care.”

Find the lowest effective dose with the least adverse effects.

Be aware of drug-drug interactions, drug-food interactions, nonadherence issues, and substance abuse and dependency issues.

Drug Management: Psychotropic Drugs

AKA anxiolytics

Benzodiazepines (BZs) have two categories: short acting and long acting

BZs should be given in the lowest possible dose for the shortest possible time (<30 days).

When used for longer periods, patients may experience withdrawal symptoms that can be as severe as seizures; taper when DC.

Drug Management: Antianxiety Agents

Monoamine oxidase inhibitors (MAOIs)

Tricyclics

Selective serotonin reuptake inhibitors (SSRIs)

Norepinephrine dopamine reuptake inhibitor

Selective serotonin norepinephrine reuptake inhibitors (SNRIs)

Nonadrenergic-specific serotonergic antidepressant

Commonly used until patients have been free of the symptoms of depression for 6 months to 2 years, then gradually stop taking the drug to prevent the development of rebound depression

Drug Management: Antidepressants

Lithium: higher risk for neurotoxicity and cognitive impairment in older adults, monitor blood levels and renal, liver, and thyroid studies

Anticonvulsants may cause confusion, cognitive impairments, or ataxia that can lead to falls

Drug Management: Mood Stabilizers

AKA Neuroleptics used in schizophrenia, acute psychosis, and delirium; may be used to treat the agitation and aggression sometimes seen in dementia

Side effects include: extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome

Drug Management: Antipsychotic Medications

Anafranil

Antiparkinsonian agents

Sedative-hypnotic agents

Drug Management: Other Psychoactive Medications

100

Human resources: specialists prepared to assess and care for individuals who often have multiple, complex, physical and mental or emotional problems

Physical resources: community mental health centers, hospitals, clinics, nursing facilities, and dementia units

Financial resources: resources needed to pay for mental health care (e.g., Medicare, Medicaid, and health insurance coverage)

Mental Health Resources

101

Nurses and family members must advocate for older persons who have mental illnesses or disorders and who are not being adequately diagnosed and treated.

There will be increased emphasis on improving the quality of care in long-term care facilities.

Primary need is to focus more on mental illnesses or disorders, psychosocial issues, and communication skills.

Trends and Needs

102