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Cognition involves the brain’s ability to process, retain, and use information Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory Disruption of these functions impairs the person’s ability to make decisions, solve problems, interpret the environment, and learn new information
DELIRIUM Delirium is a syndrome that involves disturbance of consciousness accompanied by a change in cognition It develops over a short period of time and fluctuates over time It causes difficulty in paying attention, distractibility, and disorientation. Sensory disturbances include illusions, misinterpretations, hallucinations, disturbances in the sleep–wake cycle, anxiety, fear, irritability, euphoria, and apathy. Ten to fifteen percent of persons hospitalized for a general medical condition have delirium. It is more common in acutely ill geriatric clients and children with high fevers or taking certain medications. ETIOLOGY Delirium is caused by an underlying physiologic, metabolic, or cerebral disturbance, or by drug intoxication/withdrawal. TREATMENT AND PROGNOSIS • Treatment of the underlying medical condition will usually resolve delirium. • Clients with head injury or encephalitis may have cognitive, emotional, or behavioral impairment due to brain damage from the disease or injury. • Delirious clients who are quiet and resting need no other medication for delirium. Those who are restless or a safety risk may require low-dose antipsychotic medication. Sedatives and benzodiazepines may worsen the delirium. • Alcohol withdrawal is managed medically with benzodiazepines. • IV fluids or total parenteral nutrition may be needed. • Occasionally, restraints are necessary so that tubes and catheters aren’t pulled out. Use judiciously and for short periods because restraints may increase agitation. APPLICATION OF THE NURSING PROCESS: DELIRIUM Assessment • Assessment is ongoing and continuous because the client’s level of consciousness and orientation may fluctuate. • Thorough history of prescribed and over-the-counter medications needed • General appearance and motor behavior: may be restless, picking at covers, agitated, getting out of bed, or sluggish and lethargic; speech is less coherent as delirium worsens.
or the urge to urinate or defecate • Data Analysis Primary nursing diagnoses include: • Risk for Injury • Acute Confusion Additional diagnoses based on individual client assessment: • Disturbed Sleep Pattern • Disturbed Thought Processes • Disturbed Sensory Perceptions • Risk for Imbalanced Nutrition • Sensory-Perceptual Alterations • Risk for Deficient Fluid Volume Outcomes The client will: • Be free of injury • Demonstrate increased orientation and reality contact • Maintain an adequate balance of activity and rest • Maintain adequate nutrition and fluid balance • Return to optimal level of functioning (predelirium) Intervention • Promoting safety • Managing confusion • Promoting sleep and nutrition Evaluation Client and family education necessary to prevent recurrence (see PowerPoint slide) . disorientation.or herself • Physiologic and self-care considerations: trouble sleeping.Mood and affect: Client has rapid and unpredictable mood shifts with a wide range of emotions. thirst. • Thought process and content: difficult to assess thought process accurately due to disorientation and impaired cognition. may ignore body cues such as hunger. • Sensorium and intellectual processes: sensory misperceptions. lack of attention and concentration • Impaired judgment and insight: impaired judgment. confusion. varied insight • Roles and relationships: usually no long-term effect unless previous problems existed • Self-concept: how the person sees him.
anxiety about loss of cognitive abilities) • Moderate (confusion. agnosia. and galantamine (Reminyl) (stops progression for 2 to 4 months only) can be used to slow progression. • Recognize differing beliefs about elders. such as names of past presidents. TREATMENT AND PROGNOSIS • Underlying cause. loses objects. donepezil (Aricept). recognizes familiar people. by the end of this stage. progression may be arrested with treatment) • Pick’s disease • Creutzfeldt-Jakob disease • Dementia due to HIV • Parkinson’s disease • Huntington’s disease • Dementia due to head trauma CULTURAL CONSIDERATIONS • Take into account whether client would be expected to know certain information. primarily memory impairment. as in vascular dementia. requires assistance with activities of daily living) ETIOLOGY Various causes. delusional. or disturbance in executive functioning.COMMUNITY-BASED CARE: DELIRIUM Referral may be necessary for community-based care or rehabilitation if client has lingering cognitive problems resulting from the medical condition. rivastigmine (Exelon). • Medications such as tacrine (Cognex). such as vascular dementia. and at least one of the following: aphasia. DEMENTIA Dementia involves multiple cognitive deficits. requires assistance and supervision) • Severe (personality and emotional changes. . progressive memory loss. difficulty finding words. forgets names of spouse and children. oriented to person and place. wanders at night. which is rare. apraxia. but clinical picture similar for all: • Alzheimer’s disease • Vascular dementia (may have sudden onset. is treated to prevent further deterioration. CLINICAL COURSE • Mild (excessive forgetfulness. Dementia is progressive unless the underlying cause is treatable. can’t do complex tasks.
judgment impaired due to cognitive deficits. cannot generalize knowledge from one situation to another. drink. Family members often become caregivers but feel loved one has become a stranger. familiarity with strangers • Mood and affect: initially anxious and fearful over lost abilities. • Sensorium and intellectual processes: initially memory deficits that worsen over time. finally. profanity. verbal or physical aggression possible. depending on client’s cognitive abilities • General appearance: aphasia. outbursts. ability to concentrate or pay attention deteriorates until unable to do either. so cannot plan. perseveration. cannot imitate demonstrated tasks. withdrawn • Thought processes and content: initially loses ability to think abstractly. apathetic. eventually confined to home. sequence. even feeding self Data Analysis Nursing diagnoses include: • Risk for Injury • Disturbed Sleep Pattern • Risk for Deficient Fluid Volume • Risk for Imbalanced Nutrition . getting lost. labile moods. eventual loss of language • Motor behavior: apraxia. hallucinations. then insight fades altogether. which vary among clients APPLICATION OF THE NURSING PROCESS: DEMENTIA Assessment • May need to assess in small increments of time • Obtain information from family and records. visual hallucinations common • Judgment and insight: initially recognizes he or she is losing abilities. worsens over time. Later. etc. confabulation to fill in memory gaps. or stop complex behavior.. client at risk for wandering. sad about “getting old”. cannot attend social events. urinate. chronic confusion. disorientation (eventually even to person). • Physiologic and self-care considerations: disturbances in sleep–wake cycle. unable to perceive harm • Self-concept: initially client is frustrated at losing things or forgetting. cannot write or draw simple objects. sense of self deteriorates until client doesn’t recognize own reflection in mirror • Roles and relationships: can no longer work. agnosia. ignoring body cues to eat. undressing in public. may become emotionally listless. then impossible • May demonstrate uninhibited behavior: inappropriate jokes. delusions of persecution are common. slurring. monitor. making unassisted ambulation unsafe. cannot solve problems. cannot fulfill roles at home. initiate. loss of abilities to do personal hygiene. injuring self. and labile moods. catastrophic emotional responses. gait disturbance.• Symptomatic treatment of behaviors such as delusions. sexual comments. emotional outbursts.
hygiene. given his or her limitations • Feel respected and supported • Remain involved in his or her surroundings • Interact with others Intervention Interventions are organized around a psychosocial model of dementia care and include: • Promoting safety • Promoting adequate sleep. time away. and activity. distraction. either daughters (29%) or wives (23%). hydration.• • • • • • Chronic Confusion Impaired Environmental Interpretation Syndrome Impaired Memory Impaired Socialization Impaired Verbal Communication Ineffective Role Performance Outcomes Outcomes for clients with dementia differ from other clients’ because of the progressive deterioration. going along) Evaluation Ongoing evaluation is necessary to revise plan of care as client’s abilities diminish. as well as proper nutrition • Structuring the environment and routine • Providing emotional support • Promoting interaction and involvement (reminiscence. Caregivers need: • Education about dementia and care needed by client . nutrition. COMMUNITY-BASED CARE: DEMENTIA Many persons with dementia are in the community for most of their lives: • Family homes • Adult day care centers • Residential facilities • Specialized Alzheimer’s units ROLE OF THE CAREGIVER Most caregivers are women (72%). and elimination • Function as independently as possible. The client will: • Be free of injury • Maintain an adequate balance of activity and rest.
• • • • Help dealing with own feelings of loss Respite to care for own needs Support groups Assistance from agencies Role strain in caregivers is common because of too many conflicting demands and expectations (including expectations they have of themselves). Caregivers may feel unappreciated and may become socially isolated and unwilling to accept help from others. with no hope for improvement . role strain may lead to neglect or abuse. Use of drugs and alcohol is common. RELATED DISORDERS • Amnestic disorder • Korsakoff’s syndrome SELF-AWARENESS ISSUES • Inability to “teach” a client with dementia • Feelings of frustration or hopelessness • Knowledge that there is progressive deterioration until death. Without intervention.
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