Professional Documents
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BEHAVIOR: BEHAVIOR:
have difficulty paying attention impaired memory (prominent early sign)
easily distracted and disoriented
have illusions, misinterpretations and hallucinations recent memory is impaired
common in acutely ill old clients
may exhibit aphasia, agnosia & disturbance in executive functioning
RISK FACTORS:
increased severity of physical illness, older age, baseline cognitive impairment
language function deteriorates
ETIOLOGY:
results from an identifiable physiologic, metabolic, or cerebral disturbance/disease loses ability to perform self care activities
drug intoxication
withdrawal
(box 21.1 page 466) STAGES:
1. Mild- forgetfulness; hallmark of beginning of mild dementia (exceeds usual forgetfulness
SIGNS & SYMPTOMS: common in aging people)
difficulty w/ attention 2. Moderate- confusion & progressive memory loss; cannot perform complex task but still oriented
easily distractible to time & place
disoriented 3. Severe- personality and emotional changes occur; may be delusional, wanders at night; forget
have sensory disturbances such as illusions, misinterpretations & hallucinations names of immediate family; usually is brought to a nsg care facility
can have sleep-wake cycle disturbances
change in psychomotor activity ETIOLOGY:
may experience anxiety, fear, irritability, euphoria, or apathy APOE gene = AD
PSYCHOPHARMACOLOGY: HIV
Haloperidol @ 0.5-1mg ( HALDOL)
- decreases agitation Creutzfeldt-Jakob Disease
sedatives and benzodiazepines are avoided except in DELIRIUM INDUCED by ALCOHOL WITHDRWAL
SIGNS & SYMPTOMS:
PSYCHOTHERAPY: loss of memory
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ASSESSMENT:
1. mental status examination
2. HISTORY- interview w/ family, friends & caregivers
3. MOOD & AFFECT 3. GEN. APPEARANCE & MOTOR BEHAVIOUR
• have rapid and unpredictable mood shifts • conversation becomes repetitive
• anxiety, fear, irritability, anger, euphoria & apathy • speech may become slurred then total loss of language function
• gait disturbance
4. THOUGHT PROCESS & CONTENT • uninhibited behavior
• disorganized & makes no sense • neglecting personal hygiene
• thoughts are fragmented • profanity that was never done before
9. SELF CONCEPT
•may be angry or frustrated
•Loses awareness of self then slowly fail to recognize their own reflections.
NURSING OUTCOMES:
• the client will be free of injury
• the client will maintain an adequate balance of activity and rest, nutrition, hydration, &
elimination.
• the client will function as independently as possible given his or her limitations
• the client will feel respected and supported
• the client will remain involved in his or her surroundings
• the client will interact with others in the environment
NURSING INTERVENTION:
• Promoting client’s safety and protecting from injury
• promoting adequate sleep, proper nutrition, hygiene, & activity
• structuring environment and routine
• providing emotional support
• promoting interaction & involvement