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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.
Mood and affect: Client has rapid and unpredictable mood shifts with a wide range of emotions. lack of attention and concentration • Impaired judgment and insight: impaired judgment. varied insight • Roles and relationships: usually no long-term effect unless previous problems existed • Self-concept: how the person sees him. confusion. thirst. • Thought process and content: difficult to assess thought process accurately due to disorientation and impaired cognition. • Sensorium and intellectual processes: sensory misperceptions.or herself • Physiologic and self-care considerations: trouble sleeping. 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. may ignore body cues such as hunger.
wanders at night. recognizes familiar people. • Medications such as tacrine (Cognex). anxiety about loss of cognitive abilities) • Moderate (confusion.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. such as names of past presidents. 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. can’t do complex tasks. is treated to prevent further deterioration. but clinical picture similar for all: • Alzheimer’s disease • Vascular dementia (may have sudden onset. delusional. agnosia. by the end of this stage. DEMENTIA Dementia involves multiple cognitive deficits. difficulty finding words. such as vascular dementia. loses objects. donepezil (Aricept). apraxia. . as in vascular dementia. which is rare. Dementia is progressive unless the underlying cause is treatable. requires assistance and supervision) • Severe (personality and emotional changes. CLINICAL COURSE • Mild (excessive forgetfulness. forgets names of spouse and children. TREATMENT AND PROGNOSIS • Underlying cause. oriented to person and place. and galantamine (Reminyl) (stops progression for 2 to 4 months only) can be used to slow progression. progressive memory loss. rivastigmine (Exelon). primarily memory impairment. • Recognize differing beliefs about elders. or disturbance in executive functioning. requires assistance with activities of daily living) ETIOLOGY Various causes. and at least one of the following: aphasia.
cannot attend social events. cannot generalize knowledge from one situation to another. even feeding self Data Analysis Nursing diagnoses include: • Risk for Injury • Disturbed Sleep Pattern • Risk for Deficient Fluid Volume • Risk for Imbalanced Nutrition . chronic confusion. sequence. withdrawn • Thought processes and content: initially loses ability to think abstractly. then impossible • May demonstrate uninhibited behavior: inappropriate jokes. client at risk for wandering. disorientation (eventually even to person). agnosia. so cannot plan. cannot write or draw simple objects. injuring self. making unassisted ambulation unsafe. apathetic. perseveration. undressing in public. drink. or stop complex behavior. urinate. verbal or physical aggression possible. emotional outbursts. sexual comments. then insight fades altogether. ignoring body cues to eat. sense of self deteriorates until client doesn’t recognize own reflection in mirror • Roles and relationships: can no longer work. finally. may become emotionally listless. 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. Later. eventually confined to home. Family members often become caregivers but feel loved one has become a stranger. confabulation to fill in memory gaps. initiate. worsens over time. ability to concentrate or pay attention deteriorates until unable to do either. delusions of persecution are common. cannot fulfill roles at home. loss of abilities to do personal hygiene. sad about “getting old”. etc.• Symptomatic treatment of behaviors such as delusions. labile moods. judgment impaired due to cognitive deficits. outbursts. unable to perceive harm • Self-concept: initially client is frustrated at losing things or forgetting. visual hallucinations common • Judgment and insight: initially recognizes he or she is losing abilities. catastrophic emotional responses. monitor. depending on client’s cognitive abilities • General appearance: aphasia. eventual loss of language • Motor behavior: apraxia. getting lost. cannot solve problems. slurring.. cannot imitate demonstrated tasks. and labile moods. • Sensorium and intellectual processes: initially memory deficits that worsen over time. hallucinations. • Physiologic and self-care considerations: disturbances in sleep–wake cycle. familiarity with strangers • Mood and affect: initially anxious and fearful over lost abilities. profanity. gait disturbance.
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. as well as proper nutrition • Structuring the environment and routine • Providing emotional support • Promoting interaction and involvement (reminiscence. and activity. and elimination • Function as independently as possible. 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%). Caregivers need: • Education about dementia and care needed by client . The client will: • Be free of injury • Maintain an adequate balance of activity and rest. time away. nutrition. going along) Evaluation Ongoing evaluation is necessary to revise plan of care as client’s abilities diminish. hygiene. 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. distraction. either daughters (29%) or wives (23%).
with no hope for improvement . 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. role strain may lead to neglect or abuse. Without intervention.• • • • 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.
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