Axis Organizational Framework for DSM V TR (Diagnostic and Statistical Manual of Mental

Disorders Text Revision)

I Clinical Disorders
II Personality Disorders and Mental Retardation
III General Medical Conditions
IV Psychosocial and Environmental Problems
V Global Assessment of Functioning (GAF)

Personality Disorders
 Include various inflexible maladaptive behavior patterns or traits that may impair functioning
and relationships
 The client usually remains in touch with reality and typically has a lack of insight into his or
her behavior
 Stress exacerbates manifestations of the personality disorder
 Symptoms are described as ego syntonic meaning comfortable for the individual but
uncomfortable for others
 In severe cases, the personality disorder may deteriorate to a psychotic state
 Established during adolescence or early adulthood and stabilizes overtime causing the
individual distress or impairment

Key Concepts:
 Personality disorders are characterized by long-standing problems in behavior, mood,
perception and relationships; behaviors typically involve self-centeredness, rigidity and
inflexibility and poor ability to self regulate (external locus of control)
 Individuals with personality disorders generally do not perceive a problem with their
behavior; they become distressed because of other people's reactions or behavior toward them.
A. Generally, individuals with personality disorders do not seek psychiatric treatment and usually
are not hospitalized, unless they have a coexisting psychiatric disorder coded on Axis I.
B. Although they experience problem in social and occupational functioning, individuals remain
in the mainstream of society
Characteristics:
1. Poor impulse control
2. Mood characteristics
3. Impaired judgement
4. Impaired reality besting
5. Impaired object relations
6. Impaired self perception
7. Impaired thought processes
8. Impaired stimulus barrier

Characteristics:
1. Poor impulse control
A. Acting out to manage internal pain
B. Forms of acting out include physical and verbal attacks, such as yelling and swearing and
self- injurious behaviors such as cutting own skin, banging the head, punching self, manipulation,
substance abuse, promiscuous sexual behaviors and suicidal attempts
C. The client may be preoccupied with such things as self, religion or sex
2. Mood Characteristics

A. May experience abandonment and depression

B. Moods may include rage, guilt and fear and emptiness

3. Impaired judgement

A. Difficulty with problem solving

 B.Inability to perceive the consequences of the behavior
4. Impaired reality testing: Distortion of reality and often projection of own feelings into others
5. Impaired object relations: Rigid and inflexible, with difficulty in intimate relationships
6. Impaired self-perception: Distorted self- perception and experience self hate or self idealization
7. Impaired thought processes
A. Concrete or diffuse thinking
B. Difficulty concentrating
C.Impaired memory
8. Impaired Stimulus Barrier
A. Inability to regulate incoming sensory stimuli
B. Increased excitability
C. Excessive response to noise and light
D. Poor attention span
E. Agitated
F. Insomnia

Clustered into 3 broad groups:

 Cluster A personality disorder types: Odd, Eccentric Types
 Cluster B personality disorder types: Dramatic, Emotional, Erratic Types
 Cluster C personality disorder types: Anxious, Fearful Types

Cluster A Types:
- Clients are withdrawn and engage in Odd and Eccentric behaviors

 Schizoid personality disorder

 Schizotypal personality disorder
 Paranoid personality disorder

Cluster A: Odd, Eccentric

1. Schleold personality characterized by an inability to form warm, close social relationships
A. Social detachment and lack of close relationships
B. Interest in solitary activities
C. Aloof and indifferent
D. Restricted expression of emotions
E. Lack of interest in others
 Maintain comfortable distance; initiate structured social interactions; positive therapeutic
nurse client relationship
2. Schizotypal personality disorder characterized by the display of abnormal or highly unusual
thoughts, perception, speech, and behavior patterns
A. Paranoia
B. Odd thinking and speech
C. Relationship deficit
D. Magical thinking
E. Suspicious
- Maintain comfortable distance and be calm
- Administer psychotropics as ordered
- Start structured social interactions
3. Paranoid Personality disorder characterized by suspiciousness and mistrust of others (paranoia); the
individual interprets other people's motives as threatening
A. May be suspicious and distrusting
B. May be argumentative
C. May be hostile, aloof
D. May be rigid, critical and controlling of others
E. May have thoughts of grandiosity
 Establish rapport, minimize risk of aggression; support adaptation
Cluster B Types:
- Clients seek attention and engage in erratic, dramatic and emotional behavior
 Borderline
 Histrionic
 Antisocial
 Narcissistic

Borderline
Personality Disorder
Characterized by instability in interpersonal relationships, unstable mood and self image and impulsive
and unpredictable behavior
A. Unclear identity
B. Unstable and intense
C. Extreme shifts in mood
D. Easily angered
E. Easily bored
F. Argumentative
G. Depression
H. Self-destructive behavior
I. Manipulation
J. Inability to tolerate anxiety
K. Intolerance to being alone
L. Chronic feelings of emptiness and fear of being alone
M. Splitting - sees others as all good or all bad; creates conflict between individuals by playing. one
person against another
N. Projection - is unable to recognize negative feelings in himself and instead believes these

Nursing Implementation
 Adopt an objective, matter-of-fact manner when interacting with client
 Maintain clear, consistent verbal and non-verbal communication
 Provide daily structure for ADL
 Maintain focus on reality and reality-based topics
 Help client with problem solving for life loses identified as sources of stress
 Help to clearly identify feelings that are implied
 Gradually involve client in group situations, providing support when necessary and provide
positive feedback for socially appropriate behavior

Borderline
o C - chronic feelings of emptiness
o L - lack of control
o I - Impulsive and self damaging
o N - Neurotic
o G - Gestures, threats of self mutilation
- Set clear realistic expectations in the nurse-client relationship (They tend to CLING)
- Reduce self destructive behavior
- Encourage verbalization

Histrionic
Personality Disorder
 Characterized by overly dramatic and intensely expressive behavior
A. Lively and dramatic and enjoys being the center of attention
B. Has poor and shallow interpersonal relations
C. May be sexually seductive or provocative

D. Dramatizes his or her life and may appear theatrical

E. Overly concerned with appearance
F. Easily bored
- Consistency, understanding, supportive environment, help develop adaptive coping increase self
worth

Histrionic
o K - Keep self the center of attention
o S - Self dramatization (flamboyant)
o P - Pose seduction and intimacy
- Consistency, understanding, supportive environment; increase self worth

Antisocial
Personality Disorder
 Comprises a pattern of irresponsible and antisocial behavior, selfishness, an inability to
maintain lasting relationships, poor sexual adjustment, a failure to accept social norms, and a
tendency toward irritability and aggressiveness
A. Perceives the world as hostile
B. Superficial charm, yet can become hostile
C. No shame or guilt
D. Self-centered
E. Unreliable
F. Easily bored
G. Poor work history
H. Inability to tolerate frustration
I. View others as objects to be manipulated
J. Poor judgment
K. Impulsive

Anti-Social
o E - exploitation of others
o V - violate laws and rights of others
o I - impulsive risky behaviors
o L - lack of loyalty, honesty and fidelity
- Use firm and consistent limits to maladaptive behaviors
- Facilitate trust and rapport in a structured environment

Narcissistic
Personality Disorder
 Characterized by an increased sense of self- importance and preoccupation with fantasies and
unlimited success
A. Need for admiration and inflation of accomplishments
B. Overestimation of abilities and underestimation of contribution of others
C. Lack of empathy and sensitivity to needs of others

Narcissistic
o S - sense of grandiose
o E - excessive self admiration
o L - Lacks empathy but arrogant
o F - fantasies of unlimited power, beauty or brilliance
Set clear realistic expectations in nurse client relationship; assist building of self esteem
Implementation
 Prevent self-harm. Observe client frequently and develop no-harm contract.
 Act as role model for appropriate expression of feelings and negative emotions
 Avoid rescuing or rejecting the client
 Set Limit; reinforce consequences of manipulative behaviors
 Reinforce consequences for disregard of rights of others
 Give positive feedback for achieving goals and independent behaviors
 Explore client's feelings of rejection, being alone, fear of abandonment
 Encourage client's participation in follow-up treatment

Cluster C Types: Anxious and Fearful Type/Disorder

 Obsessive Compulsive Personality disorder
 Avoidant Personality disorder
 Dependent Personality disorder

Obsessive-Compulsive Personality Disorder

 Characterized by difficulty expressing warm and tender emotions, perfectionism,
stubbornness, the need to control others and a devotion to work
A. Overly conscientious
B. Inflexible and preoccupied with details and rules
C. Extremely devoted to work to the exclusion of leisure activities and friendships
D. Miserly and stubborn
E. Hoarding behavior
F. Engage in rituals
- Assist in coping with compulsive behavior (accept rituals as interruption will increase anxiety);
- Reduce anxiety
- SET LIMITS to destructive acts
- Encourage alternative activity

Avoidant Personality Disorder

 Characterized by social withdrawal and extreme sensitivity to potential rejection
A. Feelings of inadequacy
B. Hypersensitive to reactions of others and poor reaction to criticism
C. Social isolation
D. Lack of support system

Avoidant
o F - fears criticism and rejection
o E - escapes intimate relationships
o A - avoidance of positive social events
o R - reluctant to engage in new activities
- Facilitate trust through reliable and dependent nurse client relationship

Dependent
Personality Disorder
 Characterized by an intense lack of self-confidence, low self esteem, and inability to function
independently, such that the individual passively allows others to make decisions and assume
responsibility for major areas in the person's life; the dependent client has great difficulty
making decisions
 Lacks self confidence
- Reduce anxiety
- Facilitate expression of ideas and feelings
- Offer assistance only when needed

Implementation
 Establish caring, consistent therapeutic relationship and clear expectations for responsible
behavior
 Encourage client to identify positive self-attributes
 Teach how to be assertive
 Provide positive feedback when client interacts in social situations appropriately
 Teach stress management and relaxation techniques to cope with anxiety

General Interventions
1. Maintain safety against self-destructive behaviors
2. Allow the client to make choices and be as independent as possible
3. Encourage the client to discuss feelings rather than act them out
4. Provide consistency in response to the client's acting out behaviors

5. Discuss expectations and responsibilities with the client

6. Discuss the consequences that will follow certain behaviors
7. Inform the client that harm to self, others and property is unacceptable
8. Identify splitting behavior
9. Assist the client to deal directly with anger
10. Develop a written safety or behavioral contract with the client
11. Encourage the client to keep a journal recording daily feelings
12. Encourage the client to participate in group activities and praise non manipulative behaviors
13. Set and maintain limits to decrease manipulative behavior
14. Remove the client from group situations in which attention-seeking behaviors occur
15. Provide realistic praise for positive behaviors in social situations

For the family of the client with personality disorder

 Help family members define and maintain boundaries
 Provide positive feedback for efforts to define self functioning
 Encourage clear definitions of acceptable behavior
 Encourage parents to work on areas of conflict in their relationship
 Teach family members to use stress reduction techniques to handle anxiety

Client and Family Teaching:

Guidelines for Clients with Personality Disorders
Provide info about the client's specific disorder and treatment:
o Personality disorder persists throughout life and affects client's functioning especially social
and occupational roles
o May be suspicious and mistrustful, may form dependent relationships or may take advantage
of others in relationships
o May lack the motivation to change aspects of self- functioning but may respond to problem
solving approach

Provide ways that family functioning can improve:

 Advise family that it may be beneficial for each family member to improve self-functioning
rather than focus on changing client
 Stress that maintaining clear expectations of each family member's role is helpful in defining
boundaries
 Reinforce that expectations about acceptable behavior for all family members should be
clearly specified and maintained

Cognitive
Impairment Disorders
 A group of disorders characterized by deficits in cognition and memory that represents a
significant change from the client's previous level of functioning
A. The higher brain functions can be affected
B. Personality and behavioral changes are also common in these disorders

Cognitive-Disorders (Formerly Organic Mental Disorders)

 Autism Spectrum Disorders (ASDs)
 Attention Deficit/Hyperactivity Disorder
 Delirium
 Dementia
 Alzheimer's Disease
 Amnestic Disorders

Attention-Deficit Hyperactivity Disorder

 Persistent pattern of inattention or hyperactivity with impulsivity

Subtypes
 Combined Type (most common)-6 or more symptoms of inattention and 6 or more symptoms
of hyperactivity and impulsivity
 Predominantly inattentive type -6 or more symptoms of inattention but fewer than 6 symptoms
of hyperactivity with impulsivity
 Predominantly hyperactive and impulsive type - 6 or more symptoms of hyperactivity and
impulsivity and fewer than 6 symptoms of inattention
 Most children stabilizes in early adolescence and in most cases symptoms subside between
late adolescence and early adulthood
 Few individuals experience full range of ADHD symptoms into middle adulthood
 2%-6% of population has ADHD

Etiology
 Uncertain but may be related to illness or trauma affecting the brain at any stage of
development
 Neurochemical etiology because ADHD respond to medications classified as CNS stimulants
 Predisposing factors: exposure to toxins, medications, chronic otitis media, head trauma,
perinatal complications, neurologic infections and mental disorder
 Genetic transmission is unknown

Nursing Process for the Child with ADHD

Assessment Findings

 Behaviors are observed-unusual of typical childhood behavior, difference in quality of motor

activity, developmentally inappropriate inattention, impulsivity and hyperactivity
 Most behaviors are observed at an early age but learning disabilities may become apparent
when the child goes to school

Symptoms of Inattention - 6 or more that have persisted

for at least 6 months
 Fails to give close attention to details
 Makes careless mistakes
 Usually has difficulty sustaining attention in tasks or play
 Does not seem to listen when spoken to
 Does not follow through on instructions
  Fails to finish schoolwork, chores or workplace activities
 Has difficulty organizing
 Avoids or dislikes tasks that require mental effort
 Loses things necessary for tasks
 Easily distracted
 Forgetful of daily activities

Symptoms of Hyperactivity and Impulsivity - 6 or more

symptoms that are persistent for at least 6 months and are
inconsistent with child's developmental level
 Fidgets or squirms
 Leaves his seat in the classroom
 Runs or climbs excessively or during inappropriate times
 Has difficulty playing or engaging in leisure activities quietly
 Always "on the go"
 Talks excessively
 Blurts out answers before questions are complete
 Has difficulty waiting his turn
 Interrupts or intrudes on others
 Some symptoms cause impairment were present before the age of 7
 Present in two or more settings (home and school)
 Clear evidence of social, academic, or occupational dysfunctioning
 Symptoms are not attributable to any other mental disorder

Nursing Diagnosis
 Delayed growth and development

Planning and Outcome Identification

 The child will function at her full capacity both at home and school

Implementation
 Promote full capacity functioning
 Actively participate in all aspects of managing ADHD
 Allow parents to vent their feelings
 Assist parents in understating the importance and longevity of treatment
 Teach parents and child about the nature of the disorder provide reading and refer to support
group
 Teach about the treatment plan
A. Medications - methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine),
dextroamphetamine with amphetamine (Adderall), magnesium pemoline Cylert), atomoxetine
(Strattera) and antidepressants
B. Family counseling and education
C. Behavioral and psychotherapy
D Proper classroom placement
E. Environmental manipulation

Outcome Evaluation
 The child functions at her fullest capacity both at home and at school as evidenced by her
ability to perform self care activities, cooperate and participate in academics
Client and Family Teaching: Medications for ADHD
 Take medications as prescribed
 To take once-daily extended release forms (should be swallowed as a whole and not crushed
or chewed)
 Explain that some medications require 2 to 3 weeks to achieve the desired effect (start at low
dose and increased until the desired effect is achieved)

Do Not Crush
 S - (SA) - sustained release or sustained action
 ER - (XR) - ex. Metformin XR
 CR - (CD) - controlled release or controlled delivery
 EC - ex. Dulcolax EC - Enteric coated or EN
 LA - (XL) Long Acting
 Seniors Erroneously Crush Enteric Coated Laxatives
 Effervescent - Alka-Seltzer

(Methylphenidate) Ritalin, Concerta

 Suggest small frequent meals and finger food snacks to help compensate for anorexia induced
by medication
 Given earlier in the day (before 6 pm).
 Carefully monitor growth, methylphenidate may retard growth
 Medication "Holidays and vacations" on weekends and during the summer or other non school
periods.
 Monitor CBC and platelet counts-on long term therapy.
 Adverse effects: nervousness, restlessness, dizziness, impaired thinking, headache, anorexia
and dry mouth.
 Advise parents and child to avoid use of alcohol and OTC meds while taking because the
combination can barve dangerous effects

Atomoxetine (Strattera)
 Should not be taken with Monoamine oxidase inhibitor (MAOI) or within 2 weeks of
discontinuing atomoxetine
 Should not be taken by clients with narrow-angle glaucoma
 Growth should be monitored because client lose an average of 1 lb over a 9 week period
 Increase heart when taking albuterol
 Grapefruit, smoking, alcohol, drugs, caffeine, can affect the way atomoxetine works
 Adverse effects: constipation, dry mouth, nausea, decreased appetite, dizziness, insomnia,
decreased libido, ejaculatory problems, impotence, urinary hesitation or urine retention or
difficulty in micturition (act of urinating), and dysmenorrhea

Autism Spectrum Disorder

 Complex neurodevelopmental disorder composed of qualitative alterations in social
interaction and verbal impairment with repetitive, restrictive and stereotype behavioral
patterns
 Range from mild to severe types (autism, Asperger's syndrome, Rett syndrome)
 Symptoms are usually noticed by parents by age of 3
 Accompanied by intellectual and social behavior deficits
 Child exhibits peculiar and bizarre characteristics with social interactions, communications
and behaviors
  Some children with autism excel in particular areas (art, music, memory, mathematics, puzzle
building, chess)
 Diagnosis is established on the basis of symptoms and the use of screening tools

Etiology
 Unknown
 May be linked to wide range of antepartum, intrapartum and newborn conditions and exposure
to hazardous chemicals; genetic predispositions
 Accompanied by intellectual and social behavior deficits
 Child exhibits peculiar and bizarre characteristics with social interactions, communications
and behaviors
 Some children with autism excel in particular areas (art, music, memory, mathematics, puzzle
building chess)

 Diagnosis is established on the basis of symptoms and the use of screening tools
Assessment
1. Social
 Abnormal or lack of social play
 Impairment in peer relationships
 Lack of awareness of the existence or feelings of others
 Abnormal or lack of imitation of others
 Abnormal or lack of comfort-seeking behaviors
2. Communication
 Abnormal nonverbal communication
 Does not use gestures to communicate
 Lack of impaired, or a normal speech (monotone voice)
 Echolalia-meaningless repetition of words just spoken by another person
3. Behavior
 Self injurious behaviors
 Repetitive body movements (head banging or bead rocking)
 Persistent preoccupation or attachment to objects; range of interests restricted
 Must maintain routine; any environmental change produces marked distress

Interventions
 Determine child's routines, habits and preferences and maintain consistency as much as
possible
 Determine the specific ways in which the child communicates and use these methods
 Avoid placing demands on the child
 Implement safety precautions as necessary for self-injurious behaviors such as head
banging
 Provide support to parents
 Initiate referrals to special programs as required
 Ensuring a safety environment for a child with autism is a priority

Diagnosing
 Made by careful screening to rule out other possible causes of symptoms
 Work up:
A. Mental status examination and neuropsychological testing
B. Comprehensive blood work: CBC, blood chemistry panel, Vitamin B12, and folate levels, thyroid
panel and liver and renal function tests
C. Brain imaging studies: Computed tomography (CT), positron emission tomography (PET) and
magnetic resonance imaging (MRI)
 Depressive disorders in elderly clients may manifest with symptoms similar to those of
cognitive impairment disorders; therefore, depressive disorder should be ruled out
Delirium
  Characterized by a disturbed consciousness and change in cognition that develops over a short
period of time; onset is acute and symptoms occur rapidly
 Direct physiologic consequence of a general medical condition, substance intoxication or
withdrawal, use of medication, or toxic exposure or a combination of these factors

Common Symptoms:
 Impaired consciousness and attention, disorientation
 Disorganized thinking and rambling speech
 Disturbance in the sleep wake cycle, such as daytime sleepiness and nighttime agitation
 Psychomotor changes (hyperactivity and agitation, or hypoactivity and somnolence)
 Misinterpretation of situations and reality illusions and hallucinations
 Labile mood - rapid exaggerated changes in mood

Hallucinations
 Sense perception
 Occurs with one of the five senses
 There is no external stimuli that exist

Types of Hallucinations
 Auditory - hearing voices when none are present
 Gustatory - experiencing taste in the absence of stimuli
 Olfactory - smelling smells that do not exist
 Tactile hallucinations - feeling touch sensations in the absence of stimuli
 Visual - seeing things that are not there

Interventions
 Ask client directly about hallucination
 Avoid reacting to hallucination as if it were real
 Decrease stimuli or move client to another area
 Focus on reality based topics.
 Do not negate client's experience
 Avoid touching client
 Respond verbally to anything real that client talks about
 Attempt to engage client's attention through a concrete activity
 Monitor for signs of increasing anxiety or agitation, which may indicate that hallucinations are
increasing

Illusions
 Misinterpretation of environmental stimuli
 Misinterpretation of reality or misperception of reality

Types
 Delirium due to medical condition
 Substance induced delirium or substance withdrawal delirium
 Delirium due to multiple etiologies
 Delirium not otherwise specified

Causes of delirium
6 risk factors associated with delirium:
o Advanced age
o Preexisting illness
o Infection/ or electrolyte and metabolic imbalance
o Bone fractures
o Brain damage or dementia
Managing delirium
 Treatment usually occurs in an acute care medical surgical setting
 Client typically undergoes comprehensive diagnostic assessment, and physiologic symptoms
are readily treated
 Objectives of the treatment include:
A. Identification of the immediate cause
B. Correction of the underlying cause
C. Symptom management
D. Supportive and safety measures

Dementia
 Characterized by multiple cognitive deficits that include memory impairment and at least one
of the following cognitive disturbances: aphasia (language expression and comprehension),
apraxia (execute or carry out skills movement and gestures), agnosia (inability to recognize
and identify persons or objects using one or more of the senses) or a disturbance in executive
functioning
 The deficits must be severe enough to cause impairment in occupational or social functioning
and must represent a decline in the client's previous level of functioning
 Most common type of dementia is Alzheimer's disease

Delirium Dementia
Consciousness Clouded; reduced clarity Not clouded Common Symptoms:
Memory Impaired Impaired Aphasia - loss of language ability
Orientation Orientation May be disoriented
 Abrupt
 Fluctuates Apraxia - impaired ability to carry out
 Slow and
during-the progressiv motor activities despite intact motor
Course
course of the e function -
day  Does not Confabulation - filling in memory gaps with
 Brief course fluctuate
 Often
detailed fantasy believed by the affected
reversible and individual
temporary Sundown syndrome - increased
Change in cognition: Change in cognition: disorientation and confusion at night
Memory deficit Aphasia Perseveration phenomenon - repetitive
Disorientation Apraxia
Cognition
Language disturbance Agnosia behaviors, including pacing and echoing
Disturbances in other's words
executive functioning Memory losses (initially loss of recent
3Rs 3Rs memory; eventually remote memory
Management Routine Routine
Repeat Repeat impairment)
Reinforce Reinforce Disorientation to time, place and person
Decreased ability to concentrate or to learn
new material
Difficulty making decisions
Poor judgment (the client may not be aware of environmental considerations of safety and security

Types of Dementia:
 Dementia of the Alzheimer's Type - over 65 yrs old

 Vascular (multi-infarct) dementia- occurs when blood clots block small blood vessels in the
brain and destroy brain tissue

 Other types are associated with general medical conditions such as Parkinson's disease, Pick's
disease, Huntington's chorea, Creutzfeldt-Jacob disease and HIV I
Causes of Dementia:
 Can develop as result of chronic delirium caused by untreated or untreatable acute condition

 Vascular disease

 About 40% of those with Parkinson's disease develop dementia

 Genetic disorders: Picks's disease and Huntington's Chorea

 HIV infection can affect the CNS causing HIV encephalopathy or AIDS dementia complex

 Structural disorders of the brain

Dementia of Alzheimer's Type

Stage Behavior Affect Cognitive Changes
 Difficulty completing  Anxious  Recent memory
tasks  Depressed Losses
 Decline in goal  Frustrated  Time
directed activity  Suspicious disorientation
 Lack of attention to  Fearful  Decreased ability
personal appearance to concentrate
Mild and ADL  Difficulty making
 Withdrawal from usual decisions
social activities  Poor judgment
 Frequent searching for
misplaced objects;
may accuse others of
stealing

 Socially inappropriate  Labile mood  Recent and remote

behavior  Flat, apathetic memory Losses
 Selfcare deficits  Catastrophic (amnesia)
 Wandering and pacing agitation  Confabulation
 Hoarding objects  Paranoia  Disorientation to
Moderat  Hyperorality: Lip time, place and
e smacking, excessive person
chewing, sucking or  Some degree of
food craving agnosia, apraxia
 Disturbance in sleep- and aphasia
wake cycle

 Decreased ability to  Flat, apathetic  Progression of

ambulate or engage in  Occasional cognitive changes
motor activities catastrophic with increased
 Decreased swallowing reactions may severity of
Severe ability continue amnesia, agnosia,
 Complete selfcare apraxia and
deficits aphasia
  Inability to recognize
caregiver

Alzheimer's Disease
 Onset of dementia is slow and progressive
 Advancing age is the chief risk factor
 Possible causes:
A. Familial alzheimer's disease has an early onset (age 30-40)
B. Genetic mutation on chromosome 1, 14, 21 have been identified as increasing the risk
C. E-4 allele of the lipid carrying plasma protein apolipoprotein E
D. Nearly all individuals with down syndrome develop neuropathology changes of Alzheimer's by the
fifth decade of Life
E. Other contributing factors: Low education level, female gender and presence of depression and brain
injury
F. Evident at autopsy (gold standard diagnosis); Harmonized Protocol for Hippocampal Segmentation
(Har?) through use of MRI
 Age 65-75 - 5% to 8%
 Age 75-86 -15% to 20%
 Age 85 years and older -25% to 50%
 rreversible form of senile dementia caused by nerve cell deterioration
 Client experiences cognitive deterioration and progressive loss of ability to carry out ADL
 Experiences a steady decline in physical and mental functioning

Stages and major characteristic of Alzheimer's Disease

 Stage 1 (mild) - forgetfulness
 Stage 2 (moderate) - confusion
 Stage 3 (moderate to severe) - ambulatory dementia
 Stage 4 (Late) - end stage

Managing Dementia
 Family focus on treatment and management is vital
 Community focused management - community nurses provide home health visits
 Pharmacologic intervention - increasing acetylcholine levels and helping to maintain neuronal
functioning
 Experimental therapies include use of NSAIDs (Non-Steroidal Inflammatory Drugs) to reduce
risk of Alzheimer's and antioxidant (vitamin E) therapy to protect neurons

Medications for behavior modification in Dementia

Classification Drug Behavior Treated
A. Benzodiazepines (BZA). A. Lorazepam (Ativan) Anxiety and agitation
B. Non BZA anti-anxiety agents B. Buspirone (Buspar)
C. Anticonvulsants C. Carbamazepine (Tegretol)
Valproic acid (Depakote)
Antipsychotics: A. Haloperidol (Haldol) Hallucinations and combative
B. Risperidone (Risperdal) behavior
A. Typical
B. Atypical
Antidepressants (SSRI- Nefazodone (Serzone) Depression
Selective Serotonin Reuptake
Inhibitors)

Medications for treating symptoms of dementia

Classification Drug Rationale for Use

Anticholinesterase Drugs
Antioxidants
NMDA N-Methyl-D- Aspartate
receptor Antagonists
Donepezil (Aricept) Interfere with the enzyme
Galantamine hydrobromide acetylcholinesterase which acts
(Reminyl) to breakdown acetylcholine,
Rivastigmine tartrate (Exelon) allowing acetylcholine to
remain longer at synapses
Combats the oxidation process
Vit. E that synthesizes cytotoxic free
radicals. There is some evidence
that this will delay symptoms
Prevents the release of
Memantine glutamate, which is thought to
be a factor in the degeneration
of neurons

Provide basic human needs and safety

Listen to what the person is NOT saying (take non-verbal cues)
Encourage periodic rest periods and sleep
Assist in ADL
Sing and dance as necessary
Engage in reminiscing activities
Call person by name and always introduce yourself at the start
Actively involve client in activities and simple decision makings
Redirect inappropriate behavior like anger
Exaggerate facial expression and gesture in communicating face to face

Amnestic Disorders
 Characterized by a disturbance in memory that is due to either the direct physiologic effects of
a general medical condition or the persisting effects of a substance

Common Symptoms
 Impaired ability to learn new information or an inability to recall previously learned info or
past events
 Confabulation
 Profound amnesia
 Apathy, Lack of initiative and emotional blandness
 Lack of insight into memory deficits
 Disorientation to self (rarely occurs; more common in(dementia)
 Onset may be acute or insidious and slow

Types of Amnestic Disorders

 Amnestic disorder due to general medical condition
 Substance induced persisting amnestic disorder
 Amnestic disorder not otherwise specified

Causes
 Head trauma, hypoxia and acute CNS infections
 Chronic thiamine (Vit. B1) deficiency associated with alcoholism (Korsakoff's Syndrome)
also causes this disorder

Management
 Similar to that of delirium if the amnestic disorder is an acute problem
 When the disorder is chronic, treatment is similar to that of dementia
Nursing Process Overview: Care of Client with Cognitive
Impairment Disorder

Assessment
 Review client's history and physical examination for signs and symptoms
 Asses for dementia using standardized tools:
A. Mini Mental Status Exam (MMSE)
B. Functional Activities Questionnaire (FAQ)
C. Clock Drawing Test, Short Portable Mental Status Questionnaire, Modified MMSE, and the Seven
Minute Screen
 Assess for depression
 Ask the client pertinent questions to determine degree of cognitive impairment
 Interview the client, caregiver, family members, making direct observations about the client's
status in the following areas:
1. Behavior
2. Affect
3. Cognitive responses
 Spend time with family or caregiver to elicit the following info:
1. Primary caregiver
2. Available support systems
3. Knowledge base
4. Spiritual support system
5. Specific concerns

Implementation
 Maintain client's safety
 Address client's cognitive deficits
 Maintain client's level of functioning for performing activities of daily living (ADL)
 Avoid and minimize catastrophic reactions
 Provide appropriate information to the caregiver and family caring for the client with
cognitive impairment disorder
 Use reminiscence technique
 Use validation therapy when client no long responds to reality orientation techniques

Reality Orientation Validation Therapy

To establish or maintain the To establish a connection
Purpose client's awareness of her current between the nurse and client by
environment validating emotional memories
Useful as a first attempt to help Useful when reality orientation
the client regain awareness of is resisted or ineffective; may be
Appropriate Use the current environment, helpful as a calming method
especially when she is suffering when the client misperceives her
from a temporary loss of environment
awareness
 Establish eye contact  Establish eye contact
with the client, with the client,
introduce yourself and introduce yourself and
state the client's name,
 state the client's name, smile
smile Use short, simple
sentences when  Validate the client's
Specific Techniques providing orienting feelings
information
  Repeat part of what the
 Structure the client said
environment using
clocks, calendars,  Reflect what seems to
orientation boards, be the client's
seasonal decorations underlying feelings
and family pictures
 Continue to talk with
the client about the
topic

 AS the client becomes

calmer, redirect her to
the appropriate current
activity

Client and Family Teaching Guidelines for clients with dementia

 Provide information about dementia (symptoms and the progressive nature of the disease)
 Dementia is a chronic, progressive disease that alters the clients thinking, personality and
behavior
 The client may be depressed, anxious, fearful or suspicious at times; medications can help
relieve some of these symptoms, especially in the early stage of illness
 The client's memory will be impaired and he will require frequent reminders to perform daily
tasks
 The client may be prone to wandering and pacing and will require supervision; appropriate
exercise may help reduce these activities

Provide the caregiver and family with helpful home care

measures
 Use memory aids and structure the client's daily routine
 Maintain good nutrition
 Respond to the client's memory impairment and losses by attempting to gently reorient him as
long as this is not upsetting
 Maintain a regular bedtime routine to promote sleep. Eliminate caffeine after 2 provide a quiet
environment, use a nightlight, perform toileting prior to bed
 Provide directions and instructions with simple words, using gestures when helpful and
needed
 Institute safety measures: remove or lock up objects or cleaning agents that can harm the
client; remove throw rugs and extension cords; paint hot water faucets red; secure all doors
and windows
 Keep in mind that wandering is expected. Prepare for this by having the client wear an
identification bracelet and registering him with the police
 Remove the client from upsetting situations to prevent catastrophic reactions

Help the caregiver and family to plan for the terminal stage of
dementia:
 The client will gradually experience a Loss of ambulation, caregiver recognition and
conversation; eventually, his disease will progress to a vegetative state
 A holistic type approach may be used in the late stage (palliative measures, comfort, limited
medications and medical interventions)