ANXIETY ⊗ Vague sense of impending doom ⊗ Subjective response to stress ⊗ Is a state of apprehension, uneasiness, uncertainty or tension experienced by an individual

in response to an unknown object or situation. Signs and symptoms:

Nursing Management: ⊗ Calm ⊗ Administer medications ⊗ Listen ⊗ Minimize environmental stimuli ANXIETY DISORDERS

Mild ⊗ Physical - ↑PR, RR, BP, pupillary dilatation, sweating ⊗ Cognitive - Attentive and alert ⊗ Emotional - Minimal use of defenses Moderate ⊗ Physical - Nausea, Anorexia, Vomiting, Diarrhea, Constipation, Restlessness ⊗ Cognitive - narrowed perceptual field & selective inattention ⊗ Emotional - use of any defense mechanism available SEVERE ⊗ Physical - s/sx becomes the flow of attention ⊗ Cognitive – perceptual field is greatly narrowed, focus of attention is trivial events ⊗ Emotional – defense mechanism operate PANIC ⊗ Physical – s/sx of exhaustion ignored ⊗ Cognitive – personality disorganized ⊗ Emotional – defense mechanism fail Nursing Diagnoses: ⊗ Ineffective individual coping ⊗ Anxiety

Panic Disorder ⊗ An individual may suddenly experience frightening and uncomfortable symptoms ⊗ May include terror, sense of unreality or fear of loosing control ⊗ Attack: 1 minute and 1 hour Phobic Disorder ⊗ Phobia is an irrational fear of an object, place, activity or situation. ⊗ Avoidance will allow the individual to be free from anxiety. Examples:  Agoraphobia - fear of open places and of being alone in public places.  Social phobia - irrational fear of criticism, humiliation or embarrassment.  Acrophobia - fear of heights  Algophobia - fear of pain  Claustrophobia - fear of enclosed place  Thanatophobia - fear of crowds  Pathophobia - fear of disease  Monophobia - fear of being alone Generalized Anxiety Disorder (GAD) ⊗ Unrealistic, excessive anxiety and is unable to control worry. ⊗ Clients may experience: fatigue, irritability, restlessness, muscle tension, sleep disturbance

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Obsessive Compulsive Disorder ⊗ Is characterized by recurrent obsessions and compulsions that interfere with normal life. Obsession ⊗ Refers to persistent, painful intrusive thought, emotion or urge that one is unable to suppress or ignore. Compulsion ⊗ Refers to repetitious uncontrollable act and sometimes a purposeful act to prevent a certain mistake in an event or situation. Post-Traumatic Stress Disorder (PTSD) ⊗ Is the delayed reaction of the person who has been involved or exposed to a traumatic events. ⊗ Symptoms of this disorder are:  intense psychological distress  feeling of detachment or estrangement from others  insomnia  decreased concentration  avoidance of thoughts and feelings  recurrent distressing dreams  inability to recall an important aspect of the trauma Nursing Interventions ⊗ Calm and nonjudgmental approach to convey acceptance. ⊗ Use short and simple sentences or words. ⊗ Help the client develop an increase tolerance to anxiety. ⊗ Help the client to:  develop a problem-solving and coping skills of the client.  develop the ability to remain calm in anxiety-producing situations. ⊗ Approach: kind-firmness ⊗ Systematic desensitization (phobic disorders)

⊗ Clients with ritualistic behavior (obsessive-compulsive disorder) should not be prohibited or reprimanded. ⊗ Biofeedback, change of the scenery, therapeutic touch, hypnosis, massage or relaxation exercises. ⊗ Administer medications, as ordered. ANXIETY RELATED DISORDERS Somatization Disorder ⊗ Free floating anxiety disorder ⊗ Clients:  express emotional turmoil or conflict through physical symptoms.  usually seek for repeated medical attention.  may exhibit antisocial behavior and may attempt suicide. ⊗ Associated with anxiety and depression Conversion Disorder ⊗ A condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms. ⊗ Conscious counterpart of malingering ⊗ Examples: Paralysis, blindness, loss of touch or pain sensation, dyspnea, seizures or convulsions Hypochondriasis ⊗ An individual presents an unrealistic or exaggerated physical complaints. ⊗ The person becomes, preoccupied with the fear of developing or having already a disease or illness in spite of medical reassurance. Body Dysmorphic Disorder ⊗ Preoccupation with an imagined defect in his or her appearance. ⊗ Slight physical abnormality = excessive concern / anxiety Dissociative Amnesia ⊗ Inability to recall extensive amount of important information ⊗ Caused by trauma ⊗ Characterized by:  Disorientation

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 Purposeless wandering  Impairment in ability to perform ADL ⊗ Rapid recovery generally occur

 More common in women ⊗ Narcissistic (boastful / superiority complex)  Grandiosity and need for constant admiration  Exploitation of others for fulfillment of own desire Anxious or Fearful Personality Disorder (Type C) ⊗ Avoidant (inferiority complex)  Social inhibition  Feelings of inadequacy and sensitivity  Low self-esteem  Social withdrawal in spite of a desire for affection and acceptance ⊗ Dependent (submissive)  Submissive clinging behavior related to excessive need to be cared for by others  Lack of self-confidence  Perceive self as helpless and stupid ⊗ Obsessive-Compulsive (perfectionist)  Preoccupied with orderliness, perfectionism, inflexibility, need to be in control  Formal and serious interpersonal relationship  Judgmental of self and others ⊗ Passive-Aggressive  Intentional inefficiency  Passive resistance to demands for adequate performance in both occupational and social functioning Nursing Diagnosis: • Ineffective individual coping • Self-esteem disturbance DISORDERS COMMONLY DIAGNOSED TO CHILDREN AUTISM ⊗ Characterized by:

PERSONALITY DISORDERS ⊗ Are pervasive and inflexible patterns of functioning that is stable overtime, and leads to distress or impairment. Types of Personality Disorders: Eccentric Personality Disorder (Type A) ⊗ Paranoid (Suspicious and distrustful)  Persons who display pervasive and long stand suspiciousness  More common in men ⊗ Schizoid (Socially distant and detached)  Pattern of detachment from social relationship  Chooses solitary activities  Topics are inanimate objects and ideas ⊗ Schizotypal (Odd and eccentric)  “mild schizophrenia”  Acute discomfort in close relationships  Cognitive or perceptual distortion Dramatic-Erratic Personality Disorder (Type B) ⊗ Antisocial (aggressive and manipulative)  Pattern of disregard for the violation of the rights of others  Low self-esteem

⊗ Borderline (destructive and unstable)
   Characterized by patterns of instability in relationships, self image and mood Self-mutilating behavior Affective instability

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⊗ ⊗ ⊗ ⊗ ⊗

 impairment in communication skills  presence of stereotyped behavior, interests and activities.  associated with impairment on social interactions treatable but not curable more common among boys usually diagnosed at age 2 Main problem: Interpersonal functioning Most acceptable cause: Biological factors - brain anoxia, intake of drugs

⊗ Repeat instructions as necessary. ⊗ Haloperidol - symptomatic relief for hyperactivity, stereotypical and selfdestructive behavior MENTAL RETARDATION ⊗ Not a mental illness. ⊗ Problem of inadequate mental functioning. ⊗ Onset: 18 ⊗ IQ below 70 ⊗ Manifested by sub-average intellectual functioning in: ⊗ Communication Self-care Home living Social skills Health and safety Causes ⊗ HIV/ AIDS / rubella infection ⊗ Alcoholic mother ⊗ Thyroid deficiency ⊗ Excessive lead poisoning ⊗ Damage to the brain ⊗ Neurological / neurodevelopmental impairment ⊗ Exact gestational age is not reached (premature) ⊗ Opiate intoxication ⊗ Nutritional deficiency (lack in Folic Acid) ⊗ Anoxia ⊗ Toxemia (pregnancy-induced hypertension) ⊗ Environmental factors ⊗ Severe RH incompatibility Levels: Level IQ Implication

Signs and Symptoms ⊗ Odd play ⊗ Not cuddly ⊗ Echolalia ⊗ Crying tantrums ⊗ Head towards anything ⊗ Inanimate object attachment ⊗ Loves to spin objects / self ⊗ Difficulty interacting with others ⊗ Wants blocks ⊗ Acts as deaf ⊗ Resists normal teaching method / routine changes ⊗ No fear of danger ⊗ Insensitive to pain ⊗ No eye contact ⊗ Giggling or silly laughing Nursing Interventions ⊗ Environment: safe & consistent ⊗ Encourage the client to participate for self-care ⊗ Speak calmly when giving instructions ⊗ Use simple words or phrases

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Mild/moron Moderate/Imbecile Severe/Idiot

51-70 36-50 20-35

Below 20

o Difficulty adapting to school o Educable – needs assistance Poor awareness of needs of others Trainable – needs moderate supervision o Unable to learn academic skills o Poor motor development and minimal speech o Needs complete and close supervision o Has minimal capacity for sensorimotor function o Needs custodial care with a totally structured environment

Causes: Intranatal factors Signs and Symptoms ⊗ Obstinacy ⊗ Negativism ⊗ Egocentrism

⊗ Fighting syndrome ⊗ Aggressiveness ⊗ Tolerance is low ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗
Difficulty concentrating Excessive talking Fidgeting Interrupt/intrudes on others Child exhibits hyperactivity Indulges in destructive behavior Temper tantrums

Principles of Nursing Care ⊗ Protective care Education of the family  Their involvement is an important factor in the plan of care to promote progress and to minimize the stress. ⊗ Repetition ⊗ Role modeling ⊗ Restructuring ⊗ Focus of Education  Reading  Arithmetic  Writing ATTENTION DEFICIT HYPERACTIVITY DISORDER ⊗ Common in boys ⊗ Usually diagnosed before age 7 ⊗ Problems: ⊗ Inattention ⊗ Hyperactivity ⊗ Impulsivity

Nursing Diagnosis • Potential for injury Principles of Nursing Care: ⊗ Provide nutrition and safety ⊗ Environment: structured enable appropriate reaction to the environmental stimuli ⊗ Plan a firm and consistent environment in which limits and standards are set. Drug of choice : Methylphenidate (Ritalin)

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DISORDERS COMMONLY DIAGNOSED TO ADULTS EATING DISORDERS ⊗ More common among females. Causes: ⊗ Psychological factors  Parental factors (domineering parents)  Individual factors (conflict about growing up)  Sociocultural factors Anorexia Nervosa ⊗ Main sign: Morbid fear of gaining weight ⊗ Other signs:  Sensitivity to cold temperatures  Amenorrhea  Deliberate self-starvation with weight loss

loss of interests in activities

   

Denial of hunger Obvious thinness but feels fat Lanugo all over the body Loss of scalp hair

Bulimia Nervosa ⊗ Extreme measures to lose weight  uses diet pills, diuretics or laxatives  purges after eating  extreme exercise ⊗ Signs of purging  swelling of the cheeks or jaw area  cuts and calluses on the back of the hands and knuckles  teeth that look clear ⊗ Peculiar signs  depression

Findings: (for both) ⊗ Weight loss of 15% or more of original body weight ⊗ Amenorrhea ⊗ Social withdrawal and poor family and individual coping ⊗ History of high activity and achievement in academics, athletics ⊗ Electrolyte imbalance ⊗ Depression / distorted body image Nursing Diagnosis: ⊗ Body image disturbance ⊗ Ineffective individual coping Nursing Interventions: ⊗ Establish a trusting relationship ⊗ Monitor vital signs ⊗ Reinforce:  dietician’s prescription to accomplish realistic weight gain

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⊗ ⊗ ⊗ ⊗ ⊗ ⊗

treatment plan that establishes privileges and restrictions based on compliance Decrease emphasis on foods, eating, weight loss or gain Weigh client daily at the same time Remain with the client after meal and for 1st four hours Set limit on time allotted for eating Encourage client to express feelings Promote feeling of control by  participation in treatment  independent decision making 

SEXUAL DISORDERS ⊗ Sexuality - is the result of biologic, psychological, social and experimental factors that mold an individual's sexual development, self-concept, body image and behavior. Phases of the Sexual Response Cycle ⊗ Desire  the ability, interest and willingness to receive sexual stimulation ⊗ Excitement / Arousal  Result of psychological stimulation  Example is fantasizing during the desire phase and foreplay which involves petting and fondling of erogenous zones or areas of the body that are particularly sensitive to erotic stimulation. ⊗ Plateau ⊗ Orgasm  formerly termed as climax  the shortest stage in the sexual response cycle  occurs when stimulation proceeds through the plateau stage to a point where the body suddenly discharges accumulated sexual tension ⊗ Resolution phase  the final phase of sexual response  organs and body systems gradually return to the unaroused state

Sexual Dysfunction Disorders ⊗ Sexual Desire Disorders: have little or no sexual desire or have an aversion to sexual contact. ⊗ Sexual Arousal Disorder: Individuals cannot complete the physiologic requirements for sexual intercourse Examples  Women cannot maintain lubrication  Men cannot maintain an erection ⊗ Orgasm Disorders: Inability to achieve orgasm phase Example: Premature ejaculation ⊗ Sexual Pain Disorders: Individuals suffer genital pain (dyspareunias) Example: Vaginismius Paraphilia (Sexual Deviation) ⊗ A term which generally refers to abnormal sexual behavior ⊗ Lasts for 6 months leading to distress or impairment to functioning. Examples Anilingus Bestiality or Zoophilia Coprophilia Cunnillingus Exhibitionism tongue brushing the anus contact with the animals smearing feces on the partner tongue brushing the vulva  Involves exposing one’s genitals to unsuspecting strangers. Victims are usually women or children.  They are stimulated by the effect of shocking the victim. inserting the penis into the mouth inanimate / non-living objects or articles  Touching or rubbing against the unsuspecting people.  Usually occurs in crowded places where escape is into the crowd is possible.  Sexual gratification from experiencing pain

Fellatio Fetishism Frotteurism


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Necrophilia Partialism Pedophilia

Sadism Telephone Scatalogia

Transvestism Urophilia Voyeurism

Involves the acts of being humiliated beaten, restrained, or otherwise made to suffer  involves the use of corpses  inserting the penis into the other parts of the body  use of prepubertal children  could be an actual sexual act or a fantasy  child is generally 13 years of age or younger inflicting pain  Involves telephoning someone and making lewd, obscene remarks or conversation.  AKA sex on phone sexual excitement through wearing the clothing of a woman urinating on the partner Act of observing unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity Includes cyber-voyeurism 

SUBSTANCE-RELATED DISORDERS Alcoholism ⊗ Is a chronic disease or a disorder characterized by excessive alcohol intake and interference in the individual’s health, interpersonal relationship and economic functioning. (WHO) ⊗ Considered to be present when there is .1% or 10 ml for every 1000 ml of blood Signs of use: ⊗ .1-.2% - low coordination ⊗ .2-.3% - presence of ataxia, tremors, irritability, stupor ⊗ .3 and above - unconsciousness Progression: ⊗ Pre-alcoholic Phase - starts with social drinking; tolerance begins to develop ⊗ Prodromal Stage - alcohol becomes a need; blockout's occur; denial begins to develop ⊗ Crucial - cardinal symptoms of alcoholism develops (loss of control over drinking) ⊗ Chronic Phase - the person becomes intoxicated all day Outcome: ⊗ Brain damage ⊗ Alcoholic hallucinosis ⊗ Death Behavioral problems: ⊗ Denial

Gender Identity Disorder ⊗ AKA Transexualism ⊗ Believe that they were born as the wrong sex ⊗ Leads to persistent discomfort and feels inappropriate in the role of the assigned sex. Nursing Interventions: ⊗ Attitude:  Accepting  Empathic  Non-judgmental ⊗ Accept his feelings related to sexuality ⊗ Have a private area to discuss fears or concerns about sexuality ⊗ Intervene to discuss self-esteem issues, anxiety, guilt, and empathy for victims. ⊗ Employ limit setting. ⊗ Referral to the correct clinic.

⊗ Dependency ⊗ Demanding

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⊗ Destructive ⊗ Domineering
Alcohol Withdrawal ⊗ Occurs when an individual abruptly stops drinking after alcohol has become a necessity of life to maintain functioning. ⊗ Symptoms include:  autonomic hyperactivity  grand mal seizures  psychomotor agitation and anxiety  increased hand tremors  sleep disturbances (insomnia and nightmares)  illusions hallucinations  hyperthermia  tachycardia (impending delirium tremens) Alcohol Withdrawal Delirium ⊗ AKA delirium tremens  experienced within 24 to 72 hours after the last intake: o agitation o elevated vital signs o illusions and hallucinations o restlessness o hyperalertness o incoherent speech ⊗ serious medical complications may occur if the client is left untreated Korsakoff's Psychosis ⊗ Is a form of amnesia ⊗ characterized  short-term memory loss  Disorientation  inability to learn new skills  confabulation ⊗ Deficiency in vitamin B complex, especially B1 and B12.

Wernicke's Encephalopathy ⊗ An inflammatory hemorrhagic degenerative condition of the brain ⊗ caused by B1 deficiency ⊗ Symptoms include:  double vision  involuntary and rapid eye movements  lack of muscular coordination  decreased mental function Nursing Diagnosis: Ineffective individual coping Principles of Nursing Care: ⊗ Well lighted room ⊗ Diet as tolerated ⊗ Monitor vital signs ⊗ Administration of glucose ⊗ Vitamins Alcohol Detoxification: ⊗ Drug of Choice: Disulfiram (Antabuse) - delays the metabolism of alcohol ⊗ Avoid alcohol-containing products ⊗ 3 S’s of detoxification:  Safety  Sedation  Supplement (Multivitamins, Vitamin B-complex, Vitamin C) DRUG-RELATED DISORDERS Cocaine-Related Disorders (Stimulants) ⊗ Cocaine is a white powdered stimulant substance ⊗ Usually sniffed, snorted, smoked in a pipe or injected into a vein or subcutaneous tissue. ⊗ Poor man’s cocaine:
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Shabu (sha-boo)

⊗ Signs of use:  panic attacks  insomnia  loss of appetite  impaired thinking  cocaine psychosis  agitation  dilation of the pupils  diaphoresis  increase VS ⊗ Classic sign: Perforated nasal septum ⊗ Can cause a sudden heart attack even in healthy young people. Cannabis-Related Disorders (Cannabinoids) Marijuana ⊗ Can act as stimulant or depressant and is often considered to be a mild hallucinogen with some sedative properties ⊗ Is not physically addicting but may lead to psychological dependence ⊗ Plant : cannabis sativa ⊗ Active component is Tetrahydocannabinol ⊗ Routes of use:  Orally (capsules, tablets, on sugar cubes)  With food  Smoked in a pipe or rolled as cigarette. ⊗ Acts within 15 minutes ⊗ Effects lasts approximately 2 to 4 hours ⊗ Physiologic symptoms include  increased appetite  excitement  drowsiness  lowered body temperature  depression

 unsteady gait  reduced coordination and reflexes  inability to think clearly  impaired judgment ⊗ Classic sign: bloodshot eyes ⊗ In large doses, it may cause:  Hallucination  Suicidal ideations  Delusions of invulnerability Long-term Goals: ⊗ Community resources ⊗ Other coping means aside from denial ⊗ Personal responsibility for not drinking / drugs taking ⊗ Isolation ⊗ Nutrition ⊗ Group therapy SCHIZOPHRENIA AND OTHER PSYCHOSES SCHIZOPHRENIA • Is a serious psychiatric disorder • One of the most profound disabling illness • Not a single disease entity but a combination of disorders • "split mind" • characterized by: o impaired communication o loss of contact into reality o deterioration from a previous level of functioning • Nursing Diagnosis: Altered thought process • Most acceptable theory: Biologic Theory Manifestations: Eugene Bleuler
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• Associative looseness • Autism • Apathy • Ambivalence • Auditory hallucination Types Distinguishing features Disorganized Peculiar / bizarre behavior Incoherence Stereotyping Prognosis: Poor Defense Mechanism: Regression Hallucinations Ideas of reference Delusion of persecution Suspiciousness Prognosis: Good Defense Mechanism: Projection Catatonic Wax flexibility Stupor Negativism – mutism, rigidity, lack of response Prognosis: Good Defense Mechanism: Repression

Patients with minimal symptoms

Nursing Interventions ⊗ Assist with ADL ⊗ Encourage activity ⊗ Present reality

General Nursing Interventions: ⊗ Establish:  a trusting relationship and provide acceptance  a clear, consistent and open communication ⊗ Set limits ⊗ Decrease environmental stimuli ⊗ Observe for suicidal ideation ⊗ Administer medications, as ordered. MOOD DISORDERS Precipitating Factors ⊗ Loss of a loved one ⊗ Major life events ⊗ Role strain ⊗ Decreased coping resources ⊗ Physiological changes Common Types of Mood Disorder ⊗ Bipolar I Disorder: May experience one or more of symptoms of manic episode ⊗ Bipolar II Disorder: May experience one or more symptoms of major depressive episode with hypomania ⊗ Major Depressive Disorder: May be coded as mild, moderate or severe with or without psychotic features. ⊗ Dysthymic Disorder  Lesser severe than major depression  No symptoms such as impaired communication, delusions and hallucinations ⊗ Cyclothymic Disorder ⊗ DNOS (Depression Not Otherwise Specified) - lasts for 2 days-2 weeks


⊗ Priority: safety of others ⊗ Deal with the HID ⊗ Offer sealed foods / unopened medicines ⊗ Never displace outbursts of emotions ⊗ Explain procedures in simple ways ⊗ Never argue with the patient ⊗ Priority: nutrition & circulation ⊗ Provide distraction ⊗ Encourage activity

Undifferentiated • Patients whose manifestation cannot be easily fitted into one or the other type Residual

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Clinical Symptoms of Major Depressive Episode ⊗ Affect flat ⊗ Weight change (gain or loss) ⊗ Energy loss ⊗ Sad feelings / Social withdrawal ⊗ Obvious sleep disturbances ⊗ Memory loss ⊗ Emotional blunting Clinical Symptoms of Manic Episode ⊗ Talkative or pressured to keep talking ⊗ Inflated self-esteem or grandiosity ⊗ Psychomotor agitation ⊗ Exhibit flight of ideas ⊗ Decreased need for help ⊗ Distractibility Summary: Appearance DM Attitude therapies Activity Mania Elated Projection Matter of fact Depression Sad Introjection Kind firmness Monotonous Risk for injury: selfdirected Group therapy Antidepressants ECT

⊗ ⊗ ⊗ ⊗ ⊗ ⊗

ultimate form of self-destruction "cry for help“ reunion wish or fantasy progressive failure to adapt feelings of anger or hostility a way to end feelings of hopelessness and helplessness an attempt "to save face" or seek a release to a better life

Risk Factors ⊗ Sex (more female attempts suicide but more male commits suicide) ⊗ Unsuccessful previous attempt ⊗ Identification with a dead family member ⊗ Chronic ⊗ Illness (e.g. Cancer) ⊗ Depression/Dependent personality ⊗ Age (18-25 and 40)/Alcoholism) ⊗ Lethality of previous attempt/Looses Nursing Diagnosis: Risk for injury-Self directed Nursing care: ⊗ Safe environment ⊗ Always take overt or covert threats or attempts seriously ⊗ Ventilation of feelings ⊗ Encourage activities

Non-stimulating Never give anything that requires attention Priority NDx Risk for injury: Directed at others Nursing Management Individual therapies Lithium Diet

⊗ Monitor closely (one-on-one, 24/7) ⊗ Empathy (show acceptance & appreciation)

Suicide ⊗ thought or act of taking one’s own life

Alzheimer’s Disease A chronic, progressive degenerative cognitive disorder.

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Marked by Dementia Main Pathology: presence of senile plaques - destroys neurons (decreased acethylcholline) Signs and Symptoms: ⊗ Aphasia – deterioration of language function ⊗ Apraxia – impaired motor function ⊗ Agnosia – inability to recognize objects / people ⊗ Executive functioning - loss of abstract thinking 3 PHASES: ⊗ Forgetfulness - difficulty of remembering appointments ⊗ Advance - difficulty of remembering past events but not recent events ⊗ Terminal - death occurs in 1 year Nursing Diagnosis: Altered thought processes Nursing Care: ⊗ Priority: safety & security ⊗ Always reorient the client (clock & calendar) ⊗ Use color instead of numbers & letters ⊗ Consistency – 1 nurse to lessen confusion

Depression - stage of silence Acceptance - "Yes, it's me" Nursing Diagnosis: Ineffective individual coping Nursing Care: ⊗ Be physically present ⊗ Be non-judgmental ⊗ Encourage verbalization of feelings ⊗ Allow the patient to cry ⊗ Recognize your own thoughts about death and dying

CONCEPTS ON DEATH AND DYING DEATH/D YING: Elizabeth Kubler-Ross Stages: Denial - "NO NOT ME" Anger - "WHY ME" Bargaining - "IF ONLY"

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