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113 Cards in this Set

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Concepts Related to Sexuality
* Human being are sexual beings.
* Sexuality is a basic human need and an innate part of the total personality.
* Sexuality influences our thoughts, actions, and interactions.
* Sexuality is involved in aspects of physical and mental health.
* Society’s attitude toward sexuality is changing.
* Client’s are more open to seeking assistance in matters pertaining to sexuality.
* Nurse’s need to integrate information on sexuality into the care they give.
Concepts Related to Sexuality
* Sense of maleness or femaleness (gender identity)
* Desire for contact, warmth, tenderness, love
* Encompassing the total sense of self
* Integral part of life
* Evident in a person’s manner of relating
* Determined by the individual, local community, and society at large
* Sexual behavior is learned and reinforced from life experience
* Examination of sexual behavior aids understanding of sociocultural, ethnic, and gender issues
* Sexual expression is influenced by gender identity and gender roles
* Acceptability of sexual behaviors is influenced by societal values
* Sexual behavior is influenced by social conditioning
* Widely divergent patterns of sexuality are seen in various world cultures
* Sexual response involves a combination of biological, psychosocial, and cultural variables
* Sexuality is developmental across the life span
SENSE OF MALENESS OR FEMALENESS IS CALLED?
GENDER IDENTITY
Normal Sexual Behavior
* Consensual and mutually satisfying
* Between two consenting adults
* Not forceful
* Private
* Not psychologically or physically harmful
Mild Alteration in the Dimension of Sexuality
* Sexual behavior impaired by Anxiety stemming from:
* Personal judgement
* Societal judgement
Moderate Alteration in Dimension of Sexuality
* Dysfunction in Sexual Performance
* Sexual arousal disorders
* Orgasmic disorders
* Sexual desire disorders
Moderate to Severe Alteration in Dimension of sexuality
* Gender dysfunctions
* Transsexualism
* Gender identity disorder of childhood
SEVERE ALTERATION IN DIMENSION OF SEXUALITY
* HARMFUL, FORCEFUL, OR NON-PRIVATE SEX
* PEDOPHILIA
* EXHIBITIONISM
* SEXUAL SADISM
Sexual Conditions
* Sexual Disorders
* Sexual Dysfunction
Sexual Dysfunction
* Sexual Desire Disorders
* Sexual Arousal Disorders
* Orgasmic Disorders
* Sexual Pain Disorders
Sexual Dysfunction
Etiology
Physical/biologic
* Disease processes
* Medications
Psychologic/behavioral
* Earlier experiences
* Anxiety/stress
* Misinformation
Couple-oriented factors
Sexual Dysfunction Disorders
* Sexual desire disorders
* Sexual arousal disorders
- Female arousal
- Male erectile disorder
* Orgasmic disorders
- Delay or absence of orgasm
- Premature ejaculation
Sexual Dysfunction Disorders
* Sexual pain disorders
* Sexual dysfunction due to medical condition
* Substance-induced
* Not otherwise specified
Discharge Criteria
Sexual Dysfunctions
* Expresses satisfaction with sexuality
* Evidences knowledge of disorder
* Uses strategies appropriate to treat disorder
* Communicates with partner
* Copes with frustrations/setbacks
Assessment
Sexual Dysfunctions
* Nurse: Examine own feelings
* Establish rapport before progressing to sexuality information
* Sexual history
Nursing Diagnoses
Sexual Dysfunctions
* Impaired adjustment
* Anxiety
* Impaired comfort
* Impaired verbal communication
* Ineffective coping
* Defensive coping
* Fear
* Hopelessness
* Deficient knowledge
* Chronic pain
* Ineffective role performance
* Situational low self-esteem
* Sexual dysfunction
* Ineffective sexuality pattern
* Social isolation
Client Outcomes
Sexual Dysfunctions
Individualized
Examples:
* Verbalize problem.
* Identify feelings.
* Schedule physical examination.
* Participate in sex therapy.
* Practice recommended strategies
Planning
Sexual Dysfunctions
Based on:
* Realistic criteria
* Mutually selected goals
* Client willingness to participate
Implementation
Sexual Dysfunctions
* View problem as couple oriented
* Education
* Counseling
* Identification of strategies
* Referral
* Support
Nursing Interventions
Sexual Dysfunctions
* Teach sexual response cycle.
* Teach about sexual dysfunction.
* Help enhance communication skills related
to intimacy/sexuality.
* Support exploration of fears/anxiety.
* Encourage positive self-talk, body image, exercises to increase self esteem.
* Refer as appropriate
Medical Testing (Male)
* Nocturnal penile tumescence
* Plethysography
* Testosterone and prolactin levels
* Penile Brachial Index
* Ultrasound
Medical Testing (Female)
* Plethysmography
* Estradiol level
* Testosterone level
Treatment Modalities (Male)
* Sildenafil (Viagra)
* Apomorphine (Spontane)
* SSRIs
* Hormone replacement
* Yohimbine
* Intracorpal injections
* Prosthetic device
* Stop-start technique
Treatment Modalities (Female)
* Yohimbine
* Estrogen
* Testosterone
* EROS-CTD
* Vaginal dilators and relaxation
Treatment Modalities
* Sensate focus
* Homework assignments
* Supportive counseling
* Education
* Cognitive restructuring
* Masturbation training
* PLISSIT
Sexual Disorders
* Repetitive or preferred sexual fantasies or behaviors that involve any of the following:
* The preference for use of a non-human object.
* Repetitive sexual activity with humans that involves real or simulated suffering or humiliation.
* Repetitive sexual activity with non-consenting partners
Sexual Disorders
* Gender Identity Disorder
* Paraphilias
* Sexual Addictions
Gender Identity
* Personal or private sense of identity as masculine, feminine, or ambivalent
* Sex role assignment
* Gender identity continuously constructed and maintained through lifetime
* Stability dependent on social expectations, demands, and feedback regarding self
Patterns of Sexual Expression
* Heterosexuality
* Homosexuality
* Bisexuality
Alterations in Gender Identity
* Transsexualism
* Gender identity disorder of childhood
* Nontranssexual cross-gender disorder
Transsexualism
* TWO OR MORE YEAR’S DURATION
Transsexualism
* Persistent discomfort about sex assignment
* Feeling of trapped in the wrong body
* Persistent preoccupation with eliminating primary and secondary sex characteristics
* Two or more year’s duration
* Confused learning about gender roles
* Sex-change surgery often sought
* Functioning improved 2/3 p surgery
Gender Identity Disorder of Childhood
* Persistent/intense distress at one’ sex
* Person insists they are of opposite sex
* Preoccupation with other sex clothing and behavior
* Assertion that will grow up to have sexual anatomy of other sex
* Cross-dressing may precede disorder
Paraphilias
* Exhibitionism
* Fetishism
* Frotteurism
* Pedophilia
* Sexual masochism
* Sexual sadism
* Fetishism/Transvestic fetishism
* Voyeurism
* Not otherwise specified
Etiology of paraphilia
* Biologic factors
- Chromosomal
- Hormonal
* Experiential factors
- History of sexual abuse
* Environmental factors
* Hereditary predisposition
Fetishism
* Presence of intense sexually arousing fantasies, sexual urges, or behaviors involving the use of inanimate objects
Pedophilia
* Involves sexual activity with a prepubescent child (generally 13 years or younger)
* Incidence unknown, due to the illegal nature
* Person at least 16 years and at least 5 years older than the child
* Typical pedophile is a somewhat conservative, married male
* Pedophilia within family is Incest
Exhibitionism
* Intentional display of the genitals in a public place
* Sometime individual masturbates while exposing himself
* Illegal
* Done more for shock value
* Behavior triggered by stress
* Usual perpetrators are sedate, middle-class males
Voyeurism
* Viewing by stealth of other people in intimate situations
* Called “peeping tom’s”
* Becomes a paraphilia only when “peeping” becomes compulsive and preferable to other sexual activity
* Male, who wishes no contact with those on whom he is spying. Shy, socially unskilled and without close friends
Transvestitism (ususally heterosesxal)
* Involves sexual satisfaction by means of dressing in the clothing of the opposite gender
* Behavior related to fetishism, but goes beyond the use of on particular object
* Behavior develops early in life
* No sexual orientation issues
* Usually heterosexual
Sexual Sadism and Masochism
* Two related paraphilias
* Sadism = involves the giving of psychological and/or physical pain or domination to achieve sexual gratification
* Masochism = involves the receiving of psychological and/or physical pain
* S/M fall outside the DSM-IV
* Both in homosexuals and heterosexuals
Frotteurism
* Involves touching, rubbing against, or fondling an unfamiliar woman to achieve sexual satisfaction
* Behavior usually occurs in busy, public places where he can escape after touching his victim
Sexual Addictions
* Not outlined in DSM-IV
* Recurrent, compulsive, self-destructive behavior
* Pattern includes PREOCCUPATION, RITUALIZATION, COMPULSIVE SEXUAL BEHAVIOR AND DESPAIR
* Progressive, requires more and more
* All aspects of life is affected
Sexual Addiction Disorders
* Promiscuity
* Compulsive masturbation
* Voyeurism
* Exhibitionism
* Pedophilia
Sexual Addiction
* Recurrent, compulsive, self-destructive behavior
* Pattern includes preoccupation, ritualization, compulsive sexual behavior and despair
Development of Addiction
* First: acting out inner conflict or stress
* Second: acting on the addiction for its own sake
Treatment of Paraphilias
* Behavior management groups
* Confrontation among peers
* Medication - reduce sexual desire, decrease testosterone levels to prepubescent level (patient consent or court ordered)
Nursing Implications
* Knowledge of sexual function - dysfunction
* Knowledge of sexual practices
* Develop self-awareness concerning personal values, biases, comfort level
* Awareness of interrelationship between physiologic, emotional, sociocultural variables in sexuality
* Maintain non-judgmental approach*****
Discharge Criteria Paraphilias
* State nature of paraphilia: impact on self and others
* Identify triggers
* Develop relapse prevention strategies
* Communicate and problem solve appropriately
* Practice coping strategies
* Identify support systems
Assessment paraphilias
* Perceptual disturbances
* Cognitive distortions
- Denial
- Rationalization
* Disturbances in feelings
- Lack of remorse
* Relating disturbances
A CHARACTERISTIC OF PARAPHILIA IS THAT _____ GETS HURT...
SOMEONE ELSE
Nursing Diagnoses Paraphilias
* Ineffective coping
* Ineffective denial
* Interrupted family processes
* Deficient knowledge
* Noncompliance
* Ineffective sexuality pattern
* Impaired social interaction
* Risk for other-directed violence
Outcome IdentificatioN Parahpilias
* State two sexually inappropriate behaviors.
* Identify triggers.
* Describe two coping strategies.
* List relapse prevention strategies.
* Actively participate in group therapy.
* Verbalize two appropriate sexual outlets.
* Explain importance of medication compliance
Planning Paraphilias
* Involve client
* Client-centered outcomes
- Mutually agreed on
- Realistic
* Affected by cognitive distortions
Nursing Interventions Paraphilias
* Help client confront cognitive distortions
- Direct questions
- Confrontation
- Journal writing
* Educate client and significant others
- About disorder
- Treatment
- Methods of relapse prevention
* Enhance compliance with treatment.
* Provide results of research.
* Teach coping strategies, assertiveness, problem solving.
* Promote social skills development
Pharmacologic Treatment
* Depo-Provera
* Lupron-Depot
- Flutamide
* SSRIs
Psychotherapy/Psycheducation
* Address cognitive distortions
* Triggers
* Relapse prevention strategies
* Treatment compliance
* Self-esteem
* Coping strategies
* Problem solving
Organic Mental Disorder
mental or emotional condition that is physiologic in nature; results in potentially permanent tissue damage (sometimes referred to as brain syndrome)
Organic Mental Syndrome
mental or emotional condition of no specific, know etiology
Functional Disorder
mental or emotional condition thought to be psychological in nature
Cognition
the ability to think and reason, the distinguishing feature of human beings
Orientation
the ability to relate self to the sphere of time, place, and person
Confusion
a condition characterized by disorientation,memory deficits, poor reality testing, and inappropriate verbal statements
Neuropsychiatric Disorder
Those disease processes, toxic exposures, traumatic injuries, or other causes that change the structures in the CNS and produce psychiatric as well as neurologic symptoms
Neuropsychiatric Disorder
Characterized by deficits in cognition or memory that represent a clear-cut deterioration from a previous level of functioning
Neuropsychiatric Disorder
Classified as “Organic Mental Disorder” by DSM-IV, because each is attributable to biologically based disturbances in the CNS that impair the individual’s ability to interact with the environment in predictable ways
COGNITION
BASED ON A SYSTEM OF INTERRELATED ABILITIES, SUCH AS PERCEPTION, REASONING, JUDGEMENT, INTUITION, AND MEMORY, THAT ALLOW ONE TO BE AWARE OF ONESELF AND ONE’S SURROUNDINGS
MEMORY
IS A FACET OF COGNITION CONCERNED WITH RETAINING AND RECALLING PAST EXPERIENCES, WHETHER THEY OCCURRED IN THE PHYSICAL ENVIRONMENT OR INTERNALLY AS COGNITIVE EVENTS
Types of Organic Mental Disorders or Syndromes
* Delirium
* Dementia
* Amnestic Syndrome
* Organic Delusional Disorder
* Organic Hallucinosis
* Organic Affective Disorder
* Organic Anxiety Disorder
Delirium
* Short development time
* Fluctuating consciousness
* COGNITION IMPAIRED
– DISORIENTATION TO TIME AND PLACE
– INABILITY TO FOCUS
– INCOHERENT SPEECH
* Continual aimless activity
Delirium
* Impaired consciousness and cognition; reduced ability to maintain attention
* Hallucinations, illusions
* Incoherence
* Agitation or somnolence
* Disorientation and confusion
DEMENTIA
* LOSS OF INTELLECTUAL ABILITIES INTERFERING WITH FUNCTIONAL ABILITY
* IMPAIRED MEMORY AND ORIENTATION
* DIFFICULTIES WITH REASONING AND JUDGEMENT
* PERSONALITY CHANGES
Irreversible Dementias
* Alzheimer’s
* Vascular dementia
* Parkinson’s dementia
* Pick’s disease
* Creutzfeldt-Jakob disease
* Diffuse Lewy body disease
* Progressive supranuclear palsy
* Down syndrome dementia
Reversible Dementia
* Vitamin B12 deficiency
* Depression
* Medication Interactions
* Fluid/Electrolyte Imbalance
Amnestic Syndrome
* Impaired short and long term memory
* Absence of clouded consciousness or impaired intellectual ability
Organic Delusional Disorder
* Presence of delusions in normal state of consciousness
* Absence of deterioration or intellectual functioning
Organic Hallucinosis
* Persistent hallucinations in normal state of consciousness
* Absence of deteriorated intellectual functioning, mood disorder, or delusions
Organic Affective Disorder
* Disturbance in mood: either manic or depressive
* Absence of impaired intellectual ability, hallucinations, or delusions
Organic Anxiety Syndrome
* State of anxiety with normal consciousness
* Absence of impaired intellectual ability, hallucinations, or delusions
BASIC CONCEPTS - DELERIUM
* DELIRIUM IS AN ACUTE BRAIN SYNDROME THAT HAS A RAPID ONSET; WITH PROMPT TREATMENT, IT IS USUALLY REVERSIBLE
* DEMENTIA IS A CHRONIC BRAIN SYNDROME THAT HAS A GRADUAL ONSET AND IS USUALLY PROGRESSIVE, CAUSING IRREVERSIBLE TISSUE DAMAGE
* DELIRIUM MAY OCCUR AT ANY AGE
* DEMENTIA IS MOST COMMON AFTER AGE 65
* DELIRIUM MAY OCCUR IN THOSE PERSONS ALREADY SUFFERING FROM DEMENTIA AND MAY BECOME A DEMENTIA IF UNTREATED
* DEPRESSION MAY MIMIC SYMPTOMS OF DELIRIUM AND DEMENTIA
-
General Characteristic of Organic Mental Disorders
* Deficits in orientation
* Deficits in memory
* Deficits in intellectual function (problem solving, reasoning)
* Deficits in judgement
* Deficits in affect
Factors Associated with Delirium and Dementia
* Hypoxias resulting from anemia; occult bleeding; deficiencies of iron, folic acid, or vitamin B12; dehydration; hyperthermia or hypothermia; lung pathology; hypotension or hypertension; or increased intacranial pressure
* Metabolic disorders resulting from hormonal imbalance, endocrine dysfunction, or nutritional factors
* Toxins and infections resulting from kidney pathology, hepatic pathology, drug interactions, alcoholism, or viral or bacteriological factors
* Structural changes resulting from tumors, trauma, surgery, or childbirth
* Environmental factors resulting from sensory overload or deprivation, sensory changes caused by poor eyesight, hearing, or isolation
Diagnostic Characteristics for Delirium
* Disturbance of consciousness: reduced clarity of awareness; decreased ability to focus, sustain, or shift attention
* Developing over a short period of time -- usually hours to days, fluctuating during the course of the day
* Cognitive changes: memory deficit, disorientation, language disturbance; developmental of perceptual disturbances not accounted for by other conditions
* History, physical examination, or laboratory tests indicating change as a direct cause of physiologic effects
Causes of Delirium
* Substance intoxication delirium
* Substance withdrawal delirium
* Multiple etiologies (due to more than one medical condition, substance effect, or medication side effect)
* Not otherwise specified
Associated Findings with Delirium -- Behavioral
* Attention wandering
* Perseveration
* Easily distracted
* Recent memory changes
* Dysomia (distortion of sense of smell), dysgraphia (inability to write)
* Speech is rambling, irrelevant, incoherent
* Misinterpretations, illusions, and hallucinations
Associated Findings with Delirium -- Physical
* Daytime sleepiness
* Nighttime agitation
* Difficulty falling asleep
* Anxiety, fear, irritability, anger, euphoria, and apathy
* Rapid unpredictable shifts from one emotional state to another
* Abnormal electroencephalogram
Risk Factors for Delirium
* Advanced age
* Preexisting dementia
* Functional dependence
* Preexisting illness
* Bone fracture
* Infection
* Medications (both number and type)
* Pain
* Changes in vital signs (including hypotension and hper or hypothermia
* Electrolyte and metabolic imbalance
* Admission to a long term care facility
* Postcardiotomy
* Acquired immunodeficiency syndrome
Interventions for Patient with Delirium
* Identify etiologic factors
* Monitor neuro status
* Provide unconditional Positive regard
* Verbally acknowledge patient fears and feelings
* Provide optimistic but realistic assurance
* Maintain hazard free environment
* Allow patient to maintain rituals that limit anxiety
* Provide patient information (for now and future)
* Avoid demand for abstract thinking
* Limit need for decision-making
* Place ID bracelet on patient
Interventions for Patient with Delerium
* Administer PRN meds for anxiety/agitation
* Encourage visitation by sig others as appropriate
* Recognize and accept pt perception or interpretation of reality (delusions or hallucinations
* State your perceptions in a calm, reassuring, non-argumentative manner
* Respond to theme or feeling tome, rather than content of delusion or hallucination
* Remove stimuli that create patient misinterpretation
* Maintain well-lit environment that reduces sharp contracts/shadows
* Assist with nutrition, elimination, hydration, personal hygiene needs
* Provide appropriate level of supervision
* Use physical restraint as needed
* Avoid frustrating patient by quizzing with orientation questions that cannot be answered
* Provide caregivers familiar with patient
* Use environmental cues to stimulate memory, reorient, promote appropriate behavior
* Provide environment with low-stimulation
* Encourage aids that increase sensory input (glasses, hearing aids, and dentures)
* Approach pt slowly and from the front
* Address pt by name when initiating inter-action
* Reorient pt to health care provider with each interaction
* Use simple, direct, descriptive statements
* Prepare pt for upcoming changes
* Provide new information slowly and in small doses
Dementia
* Several cognitive deficits (one of which is memory) that are due to the direct physiologic effects of a general medical condition, to the persisting effects of a substance, or to multiple biologic etiologies
* Several types of dementia
* All types share a common symptom presentation
* Differentiated based on etiology
Essential feature of _____ is the development of multiple cognitive deficits, which include memory impairment and at least one of the following cognitive disturbances: aphasia (alterations in language ability), apraxia (impaired ability to execute motor activities despite intact motor functioning), agnosia (failure to recognize or identify objects despite intact sensory functioning), or disturbance in executive functioning (ability to think abstractly, plan, initiate, sequence, monitor, and stop complex behavior)

* Cognitive effects must be sufficiently severe to cause impairment in social or occupational functioning
* Cognitive effects must represent a decline from a previously higher level of functioning
* These symptoms are common to all presentations of the symptoms of dementia, regardless of underlying patho

* Often dementia is used to describe irreversible and progressive conditions
* ***Not all presentations of dementia symptoms are irreversible
* Once evaluated and treated, sometimes dementia symptoms resolve
Factors Associated with Dementia
* All stressors for delirium, if untreated or untreatable can become dementia
* Vascular diseases such as arteriosclerosis, atherosclerosis, and cerebrovascular accidents
* Neurologic diseases such as Huntington¡¦s chorea, Parkinson¡¦s disease, neurosyphilis, Pick¡¦s disease, multi-infarct dementia, Alzheimer¡¦s disease, and cerebral atrophy
Diagnosis
* Not all dementia¡¦s are Alzheimer¡¦s
* Catch all phrase
* Unfair label in some cases
* 20 to 50% diagnosed incorrectly
* Look at causative factors
* Cognitive Assessment Tools (p 308-309)
Elder Assessment in MH
* Purpose of psychosocial assessment - characterize the patient¡¦s functioning in a particular social environment
* Necessary to initiate appropriate treatment and management
* Provides basis for setting treatment goals
* Patient and caregiver - look at problem, decide what is wrong, look at cause, plan eliminate/alleviate or reduce problem

* Must understand aging is ongoing, life process
* Elderly experience task losses
* Chronological age does not tell us much about a person
* Ability to function and interact on a day-to-day basis = far better criterion
Assessment Interview
* Attempts to give caregiver understanding of patient problem
* 1. Background information
* 2. Family hx c cultural background
* 3. Economic status c income sources
* 4. Education and work hx
* 5. Life style + perception of current life situation
* 6. Current living arrangements

* 7. Interests, pleasures, activities
* 8. Friendships and social interaction patterns
* 9. Medical hx or information
* 10. Drugs and dosages
* 11. General psych information (mental status, complaints, past hx, therapy goals, attitudes, self concept)
* 12. Goals/plans for future
* 13. Physical assessment
Interventions - Biological
* Check skin for dehydration
* Monitor for electrolyte imbalances
* Provide well-balanced meals individualized to patient¡¦s needs
* Assess for pain and provide comfort measures
* Allow for naps: use nighttime activities to decrease restlessness
* Administer neuroleptics one hour before activity
Interventions - Social
* Reinforce communication with others, social remarks and gestures
* Institute pet or stuffed animal therapy
* Maintain simple, consistent routines
* Minimize environmental distractions
* Institute protective measures
Interventions - Psychological
* Communicate slowly and clearly
* Encourage expression of negative feelings
* Distract from hallucinations
* Distract from situations that produce catastrophic reactions
* Identify triggers for delusions/do not comfort

Dementia Psychoeducation
* When caring for the patient with dementia, be sure to include the caregivers/family, as appropriate and address following topics in teaching plan:
* Psychopharmacologic agents (if used) including drug, action, frequency, possible adverse reactions
* Rest and activity
* Consistency in routines

* Nutrition and hydration
* Sleep and comfort measures
* Protective environment
* Communication and social interaction
* Diversional measures
* Community resources
Dementia Outcomes - Biological
* Decreased sleep disturbances
* Minimized side effects of medications
* Increased activity, exercise
* Improved nutritional status
* Maintained weight
* Maintained hydration
* Improved oral hygiene
* Decreased incontinence
* Decreased constipation
Dementia Outcomes - Social
* Increased social participation
* Increased sense of belonging
* Decreased isolation
* Decreased family/caregiver stress
* Increased family knowledge and skills
* Maintained cultural relatedness
* Maintained sense of familiar surroundings
* Maintained spiritual needs
Dementia Outcomes - Psychological
* Enhanced cognitive functioning
* Decreased agitation
* Decreased depression
* Improved self-worth
* Decreased hallucinations, illusions, and delusions
* Decreased anxiety
* Decreased catastrophic reactions
* Maintained possible self-care skills and independence
Delirium, Depression, Dementia Comparison
* **Table - p393
A
* Degenerative and progressive
* Diagnosis of AD made on clinical symptoms and verification
* Etiology is ONLY confirmed at autopsy
* Neurodegenerative atrophy of the brain
* Irreversible
* Have identified neurofibrillary plaques and tangles (accumulation of twisted filaments inside brain cells)

* Confusion in diagnosis and lack of clinical and pathologic standards make diagnosis difficult
* In end stages, individual in weakened state and susceptible to infection and other complications
* Epidemiologic information only rough estimate
* Insidious - symptoms begin slowly and progress
Alzheimer¡¦s Disease
Etiologic Theories
* Angiopathy and blood-brain incompetence
* Neurotransmitter deficiencies
* Abnormal brain proteins
* Genetic defects

AD Stages (p 395-396)
* Stage One - Early Symptoms (mild forgetfulness and difficulty c calculations) Anxiety is the sensory perception alteration - narrows perception - notice mild behavior problems
* Stage Two - Moderate (behavior problems, becoming agitated, hitting people, aimless pacing, wandering, very confused, mild incontinence, sundowning)


* Stage Three - Terminal or Severe (client totally dependent on caregivers, loss of communication, don¡¦t recognize family) Aspiration is #1 problem in stage 3
Alzheimer¡¦s Disease
Stage 1: Mild
* Insidious changes
* Recent memory impairment
¡V Neologisms
* Cognitive losses in:
¡V Communicating
¡V Calculating
¡V Recognition
* Sensory/motor functions intact
* Self-awareness leads to depression.
Alzheimer¡¦s Disease
Stage 2: Moderate
* Cognitive decline increases amnesia, disorientation, apraxia, aphasia, agnosia, perseveration.
* Behavior problems:
¡V Catastrophic reactions
¡V Wandering/pacing
¡V Sundowning
* Self-care deficit
* Poor judgment
* Sleep disturbance
Alzheimer¡¦s Disease
Stage 3: Severe
* Loss of meaningful communication
* Total dependence on caregivers
* Incontinence
* Secondary illnesses related to immobility
Vascular Dementia
* AKA Multi-infarct Dementia
* Seen in approximately 20% of patients with dementia
* Results when a series of small strokes damage or destroy brain tissue (referred to as ¡§ministrokes¡¨ or TIA (transient ischemic attacks)
* Several TIA¡¦s may occur before symptoms of MID occur

* Most often a blood clot or plaques block the vessels that supply the blood to the brain, causing a stroke
* Damage to the brain in MID usually apparent on computed tomography scans or MRI
* At autopsy, multifocal lesions may be found rather than the more generalized cortical atrophy of AD

* Behavioral changes of MID are similar to in AD: memory loss, depression, emotional lability, or emotional incontinence (inappropriate laughing or crying), wandering or getting lost in familiar places, bladder or bowel incontinence, difficulty following instructions, gait changes such as small shuffling steps, and problems handling daily activities such as money management

* Symptoms begin more suddenly with MID than with AD
* Clinical progression of symptoms is often intermittent and fluctuating, or ¡§step like¡¨ deterioration
* Cognitive and functional status improving and plateauing for a period of time, followed by a rapid decline in function after another series of small strokes

* Treatment/nursing interventions aimed at reducing the primary risk factors for MID
* Teaching on diet, exercise, meds, control hypertension, daily asa
Dementia Caused by Other General Medical Conditions
* Cerebra pathology
* Elderly more vulnerable (75% elders affected by one or more chronic medical illnesses)
* 50% to 60% of patients with dementia have a disorder for which no specific medical treatment is available

Dementia caused by Head Trauma
* Single head trauma = not progressive
* repeated head injury (e.g. boxing) may lead to progressive dementia
* ¡§Punch-drunk syndrome¡¨
Dementia caused by Parkinson¡¦s Disease
* Neurologic syndrome of unknown origin
* Disorder of movement
* Slow, progressive course
* In patients with dementia caused by Parkinson¡¦s, anticholinergic meds are contraindicated; likely to increase level of confusion
Dementia caused by HIV
* Called AIDS dementia complex (ADC)
* Dementia seen in 2/3 of AIDS patients, but neuropathology seen in 90% of patients
* HIV-1 directly invades the CNS
* Likely to increase in the next decades
Dementia caused by Huntington¡¦s Disease
* Progressive, genetically transmitted auto-somal dominant disorder, characterized by choreiform movements and mental abnormalities
* Usual onset 30 and 50
* Life expectancy 15 to 20 years p diagnosis
* Dementia syndrome characterized by: insidious changes in behavior and personality

* Typically, frontal dementia
* Person demonstrates prominent behavioral problems and disruption in attention
* Choreic symptoms treated with Haldol (possible tardive dyskinesia)
Dementia caused by Pick¡¦s Disease
* Rare form of dementia
* Clinically similar to AD
* Etiology unknown
* Affects frontal and temporal lobes of the brain
* Not distinguishable from AD until autopsy until distinctive intraneuronal Pick bodies can be identified
Substance-Induced Dementia
* Dementia resulting from the persisting effects of a substance/toxin
* Drugs of abuse are most common toxins in young adults
* Prescription drugs are most common toxins in the elderly
* Most dementias in this category are related to chronic alcohol abuse
* Alcoholic dementia is directly related to the toxic effects of alcohol
Amnestic Disorder
* See previous notes
Caregiver Criteria
* Knowledge of disease
* Uses positive interactions during caregiving
* Plans and develops resources for self-care
* Legal and financial plans for client and self
* Backup system in case of emergency
Assessment
* Provide appropriate environment
* Establish rapport
* Tools
¡V Mini-Mental State Examination (MMSE)
¡V Dementia Mood Assessment Scale (DMAS)
¡V Blessed Dementia Rating Scale (DRS)
Assessment
* Perception and organization
* Attention span
* Language
* Memory
* Emotional control
* Reasoning and judgment
* Emotional state
Assessment
Mood and State of Mind
Assessments required before:
* Admission to a SNF
* Use of psychotropic medication
* Use of restraint

Document:
* Direct quotes from client.
* MSE results on regular basis.
Assessment
Depression
* Variable onset, abrupt
* Reversible with treatment
* Clear sensorium
* Normal attention span
* Selective memory impairment
* Intact thinking but displays:
¡V Hopelessness
¡V Helplessness
Assessment
Functional ability
* ADLs
* IADLs
Behavior related to:
* Mood
* Perceptual/cognitive deficit
* Day/night reversal
* Poor impulse control
Assessment
Physical Manifestations
* Altered nutritional status
* Aspiration
* Gait changes
* Feeling cold
* Incontinence
Nursing Diagnoses
Cluster around:
* Safety and health risks
* Perceptual/cognitive disturbance
* Disruption in coping abilities
Outcome Identification
Consider:
* Client outcomes
* Caregiver outcomes
Planning
Consider:
* Short-term plans
* Long-term plans
Implementation
* Inform client/family/caregivers about plan.
* Promote independence as long as possible.
* Keep all interactions calm, reassuring.
* Time activity to coincide with client calm state.
* Empathize with client¡¦s feelings.
* Validate client¡¦s feelings with words.
Implementation
* Maintain client self-esteem.
* Avoid negative responses to failures.
* Provide simple choices.
* Provide structured routines.
* Praise success.
* Simplify communication.
Implementation
* Repeat as needed.
* Break tasks into separate components.
* Provide short, simple activities.
* Allow time to be by self.
* Be flexible to reduce frustration.
Treatment
* Interdisciplinary team
* Medication
¡V HS sedation: Trazadone
¡V Anxiety: Alprazolam, risperidone
¡V Aggression: Anticonvulsants
¡V Dementia: Donepezil, rivastigimine, tacrine
* Therapeutic activities
Levels of Care
* Acute care
* Day care
* In-home care
* Residential care
* Skilled nursing facility
* Hospice



SCHIZOPHRENIA
Judie Stickel, RN, MS, CNS
Laramie County Community College
2004
SCHIZOPHRENIA
* Most COMMON psychotic disorder
* Most SEVERE psychotic disorder
* Affects 1% of the population
* Not a SINGLE disease of the brain
* A HETEROGENEOUS disorder with common features

Schizophrenia
* Results in disturbances in thought processes, perception, and affect.
* Severe deterioration of social and occupational functioning.
* Group of mental disorders that feature: Withdrawal, Affective Problems, Interrupted Thought Processes.
ć May appear dull & colorless; dependent & apathetic; emotionally isolated.


Common Features
* Thought disturbances
* Preoccupation with frightening inner experiences
* Disturbances of affect
* Disturbances of behavior
* Disturbances of socialization
THEORIES of ETIOLOGY
* Genetic
* Neurochemical
* Neuropathological
* Viral
* Immunological
* Structural Abnormalities
Schizophrenia
Positive Symptoms
* Hallucinations
* Delusions
* Thought disorder
Causation: ? „´ dopamine
Treatment
* Hospitalization
* Typical antipsychotics
* Reduced stimuli
* Interactive therapy

Schizophrenia
Bleuler
Schizophrenia (Split Mindedness)
* Incongruence among thought, emotion, behavior
* Four As:
- Affect
- Autism
- Ambivalence
- Associations
Schneider
First-Rank Symptoms
* Hallucinations
* Thought withdrawal
* Thought broadcasting
* Delusions
* Somatic experiences
Second-Rank Symptoms
* Perceptual disorders
* Perplexity
* Mood changes
* Emotional impoverishment
Schizophrenia: Etiology
* Culture
* Family environment
* Stress

Not casual, may influence individual response
Etiology
Multiple Risk Factors
* Genetic inheritance
* Stress Diathesis Model
* Selected factors activate genetic vulnerability
- Winter birth
- Viral infection 28th-30th week of pregnancy
- Rh incompatibility
- Starvation during pregnancy
- Oxygen deprivation at birth
Etiology
Multiple Risk Factors
* Dopamine hypothesis
* Excess dopamine
* Possibilities:
- „´ Level in nigrostriatum
- „´ Dopamine-craving cells that overreact
- „µ Activity of dopamine antagonists
Typical Antipsychotics
* Reduce positive symptoms
* Cause movement disorders
Etiology
Multiple Risk Factors
Other possible neurotransmitter involvement:
* Serotonin
* Acetylcholine
* Norepinephrine
* Cholecystokinin
* Glutamate
* GABA

Atypical Antipsychotics
* Block serotonin receptors
Reduce negative symptoms
* Do not affect movement
* Influence glutamate
Improve cognition
* Improve TD
* Have few anticholinergic side effects
Nurse¡¦s Role
Psychopharmacology
* Administer
* Assess effects and side effects
* Promote education
* Teach lifelong skills for community living
* Monitor quality of life issues
Treatment
* Antipsychotic medications are primary treatment
* Two types of antipsychotic medications: traditional and aytpical
* Traditional antipsychotics primarily treat positive symptoms
* Traditional antipsychotics associated with numerous and distressing extrapyramidal side effects


* Atypical antispychotics treat both positive and negative symptoms
* Atypical antipsychotics typically cause fewer side effects
* Continuity of care is essential
* Discharge care within the community setting
Etiology
Multiple Risk Factors
* Selye: Medical Model
* Callista Roy: Adaptation Model
* Neuroanatomic factors
* Neurochemical factors
* Neuroendocrinology factors
* Immunologic factors
* Early head trauma or encephalitis
* Substance use/abuse
Important Tests
MRI
* Identifies subtle brain changes.
PET
* Determines brain activity.
BEAM
* Measures brain activity.
EEG
* Reveals electrical activity.
Important Tests
Eye Tracking and Auditory Tests
* Information processing deficits
Electrodermal Activity (EDA)
* Extent of negative symptoms
Neurologic Examination
Neuropsychologic Tests
Etiology
Multiple Factors
Psychoanalytic and Developmental
* Distorted mother-child relationship
* Ego disorganization
* Faulty reality interpretation
Etiology
Multiple Factors
Familial Factors
* Repressed unhappiness
* Double-bind patterns
* Parental marital schism
* Destructive, expressed emotion
- Communication
Etiology
Multiple Factors
Cultural and Environmental
* Low socioeconomic status
* „µ Social support
Etiology
Multiple Factors
Learning and Behavioral Theory
* Poor parental models teach faulty coping
and poor IPR skills
Epidemiology
Outcomes related to:
* Later-onset, premorbid functioning
* Age, gender
* Subtype
* Fetal exposure to disease and trauma
* Marital status, reproduction, mortality
* Socioeconomic class
* Culture, geography, seasonal influences
Relapse Prevention and Research
* Denial of illness
* Noncompliance
* Lack of family support
* Inability to cope with health system
* Medication failures

Schizophrenia
DSM-IV-TR Criteria
Subtypes of Schizophrenia
* Paranoid
* Disorganized
* Catatonic
* Undifferentiated
* Residual
Premorbid Behavior/Stages (viewed in four phases)
* Phase I: Schizoid Personality. Indifferent, cold, and aloof, these individuals are loners. They do not enjoy close relationships with others.
* Phase II: Prodromal Phase. Individuals are socially withdrawn and have behavior that is peculiar/eccentric. Impaired role function, hygiene and disturbances in communication, ideation, and perception.

* Phase III: Schizophrenia. Active phase of disorder. Psychotic symptoms are prominent, including delusions, hallucinations, impairment in work, social relations, and self care.
* Phase IV: Residual Phase. SX similar to prodromal phase with flat affect and impaired role function being prominent.
Paranoid Schizophrenia
* Characterized by paranoid delusions.
* Client may be argumentative, hostile, and aggressive.
Disorganized Schizophrenia
* Chronic variety with flat or inappropriate affect.
* Silliness and incongruous giggling is common.
* Behavior is bizarre.
* Social interaction is impaired.
Catatonic Schizophrenia
* Catatonic Stupor: Characterized by extreme psychomotor retardation. The individual is usually mute. Posturing is common.
* Catatonic Excitement: Extreme psychomotor agitation. Purposeless movements that must be curtailed to prevent injury to client & others.
Undifferentiated Schizophrenia
* Bizarre behavior that does not meet the criteria outlined for the other types of schizophrenia.
* Delusions and hallucinations are prominent.
Residual Schizophrenia
* Category used with the individual who has a history of at least one episode of schizophrenia with prominent psychotic symptoms.
* Also known as ambulatory schizophrenia.
* This is the stage that follows an acute episode.
Related Disorders
* Schizophreniform
* Schizoaffective
* Delusional
* Brief psychotic disorder
* Shared psychotic disorder
* Psychotic disorder due to a general medical condition
Schizoaffective Disorder
* Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders, either mania or depression.
Brief Psychotic Disorder
* Sudden onset of psychotic symptoms following a severe psychological stressor.
* Symptoms last less than one month and the individual returns to the full premorbid level of functioning.
Delusional Disorder (existence of prominent, nonbizarre delusions)
* Erotomanic ¡V believes someone of higher status is in love with him/her.
* Grandiose ¡V irrational ideas regarding own worth, talent, knowledge, power.
* Jealous ¡V irrational idea that person¡¦s sex partner is unfaithful.
* Persecutory ¡V believes he/she is being malevolently treated in some way.
* Somatic ¡V irrational belief of physical defect, disorder, or disease.
Shared Psychotic Disorder
* Delusional system develops in a second person as a result of a close relationship with another person who already has a psychotic disorder with prominent delusions.
Psychotic Disorder Due to General Medical Conditions
* Symptoms of this disorder include prominent hallucinations and delusions that can be directly attributed to a general medical condition.
Substance-Induced Psychotic Disorder
* The presence of prominent hallucinations and delusions that are judged to be directly attributable to the physiological effects of a substance.
Self-Management
* Accept fact that it¡¦s a prolonged illness.
* Identify strengths and limitations.
* Set clear, realistic goals.
* Gradually return to responsibilities.
* Establish regular, consistent routine.
* Establish quiet, relaxed routine.
* Reduce stress.
Self-Management
* Work on trusting staff.
* Take medication regularly.
* Identify relapse signs early.
* Avoid street drugs.
* Eat well.
* Get sufficient rest.
* Exercise regularly.
* Check reality with trusted person.
* Accept setbacks.
Symptom Profile
Perceptual Disturbances
* Negative self-perception
* Hallucinations
* Reduce stress.
* Increase medication.
* Reduce distractions.
* Occupy mind.
Symptom Profiles
Thought Disturbances
* Delusions
- Do not agree
- Empathy
* Circumstantially
* Tangentiality
* Autistic thinking
* Perseveration
* Poverty of thought
* Loose association
Teaching Tips
* Simplify material.
* Reduce distractions.
* Give verbal and visual information.
* Clear, direct terms.
* Present small segments.
* Reinforce frequently.
* Do not offer confusing choices.
Symptom Profiles

Emotional Disturbances
* Flattened affect
* Poor eye contact

Behavioral Disturbances
* Risk for violence
Biologic Profiles
* Diffused, nonlocalized areas of dysfunction
* Impaired stimulus
* Inhibition
Assessment
* Subjective client reporting
* Objective
- Observation
- Rating scales
- Biologic indicators
* Mental status examination
* Positive and negative symptoms
Useful Nursing Diagnoses
* Disturbed sensory perception
* Disturbed thought processes
* Impaired verbal communication
* Ineffective coping
* Interrupted family processes
* Risk for violence
* Self-care deficit
* Social isolation
Outcome Identification
* Demonstration of reality-based thinking
* Reduction in hallucinations
* Absence of delusions
* Socialization with staff and peers
* Adherence to medication regimen
* Participation in discharge planning
Planning
Geared to:
* Whole person
* Social environment
* Family
* Medical interventions
* Socialization
* Education for client and family
Implementation
* Establish relationship.
* Consider cost of plan.
* Provide:
- Stimulation.
- Structure.
- Socialization.
- Support.
Nursing Interventions for Schizophrenia
* Safety
* Acceptance
* Medication
* Medication Education
* Adherence
* Intervening in hallucinations
* Intervening in delusions
* Social skills
* Self-care
* Education
Interventions
* Assess/monitor risk factors.
* Minimize environmental stimuli.
* Provide low-key interactions.
* Use clear, concrete communication.
* Identify hallucination triggers.
* Praise reality-based perceptions.
Interventions
* Educate about:
- Symptoms
- Medication
- Compliance
- Post discharge services
* Distract from delusions.
* Focus on feelings.
* Provide structured activities initially.
Interventions
* Assist with hygiene as needed.
* Set hygiene goals.
* Assess self-concept.
* Role model social behaviors.
* Spend time with client in nonchallenging activity.
* Keep appointments.
* Listen actively.
Treatment Modalities
* Psychopharmacology
* Electroconvulsive therapy
* Milieu therapy
* Psychosocial rehabilitation
* Individual therapy
- Supportive
- Re-educative
- Reconstructive
Treatment Modalities
* Group therapy
* Family therapy
* Behavior therapy
* Cognitive therapy
* Occupational therapy
* Recreational therapy
Reducing and Managing Violence
* Reduce stress.
* Clarify expectations concerning rules.
* Avoid behaviors that may be misinterpreted.
* Determine etiology.
* Avoid blame, ridicule, teasing.
* Avoid whispering.
Reducing and Managing Violence
* Respect boundaries.
* Intervene early.
* Use deescalation skills.
- Nonthreatening verbal and nonverbals
* Medicate (po or IM) prn.
Dementai
* COGNITIVE EFFECTS MUST BE SUFFICIENTLY SEVERE TO CAUSE IMPAIRMENT IN SOCIAL OR OCCUPATIONAL FUNCTIONING
* COGNITIVE EFFECTS MUST REPRESENT A DECLINE FROM A PREVIOUSLY HIGHER LEVEL OF FUNCTIONING
* THESE SYMPTOMS ARE COMMON TO ALL PRESENTATIONS OF THE SYMPTOMS OF DEMENTIA, REGARDLESS OF UNDERLYING PATHO
-
* Often dementia is used to describe irreversible and progressive conditions
* ***Not all presentations of dementia symptoms are irreversible
* Once evaluated and treated, sometimes dementia symptoms resolve
-
Factors Associated with Dementia
* All stressors for delirium, if untreated or untreatable can become dementia
* Vascular diseases such as arteriosclerosis, atherosclerosis, and cerebrovascular accidents
* Neurologic diseases such as Huntington’s chorea, Parkinson’s disease, neurosyphilis, Pick’s disease, multi-infarct dementia, Alzheimer’s disease, and cerebral atrophy
Diagnosis of Dementia
* Not all dementia’s are Alzheimer’s
* Catch all phrase
* Unfair label in some cases
* 20 to 50% diagnosed incorrectly
* Look at causative factors
* Cognitive Assessment Tools (p 308-309)
WHAT PERECENTATGE OF DEMENTIA'S ARE DIAGNOSED INCORRECTLY?
20-50
Elder Assessment in MH
* Purpose of psychosocial assessment - characterize the patient’s functioning in a particular social environment
* Necessary to initiate appropriate treatment and management
* Provides basis for setting treatment goals
* Patient and caregiver - look at problem, decide what is wrong, look at cause, plan eliminate/alleviate or reduce problem
* Must understand aging is ongoing, life process
* Elderly experience task losses
* Chronological age does not tell us much about a person
* ABILITY TO FUNCTION AND INTERACT ON A DAY-TO-DAY BASIS = FAR BETTER CRITERION
Assessment Interview
* Attempts to give caregiver understanding of patient problem
* 1. Background information
* 2. Family hx c cultural background
* 3. Economic status c income sources
* 4. Education and work hx
* 5. Life style + perception of current life situation
* 6. Current living arrangements
* 7. Interests, pleasures, activities
* 8. Friendships and social interaction patterns
* 9. Medical hx or information
* 10. Drugs and dosages
* 11. General psych information (mental status, complaints, past hx, therapy goals, attitudes, self concept)
* 12. Goals/plans for future
* 13. Physical assessment
INTERVENTIONS - BIOLOGICLA
* CHECK SKIN FOR DEHYDRATION
* MONITOR FOR ELECTROLYTE IMBALANCES
* PROVIDE WELL-BALANCED MEALS INDIVIDUALIZED TO PATIENT’S NEEDS
* ASSESS FOR PAIN AND PROVIDE COMFORT MEASURES
* ALLOW FOR NAPS: USE NIGHTTIME ACTIVITIES TO DECREASE RESTLESSNESS
* ADMINISTER NEUROLEPTICS ONE HOUR BEFORE ACTIVITY
Interventions - Social
* Reinforce communication with others, social remarks and gestures
* Institute pet or stuffed animal therapy
* Maintain simple, consistent routines
* Minimize environmental distractions
* Institute protective measures
Interventions - Psychological
* Communicate slowly and clearly
* Encourage expression of negative feelings
* Distract from hallucinations
* Distract from situations that produce catastrophic reactions
* Identify triggers for delusions/do not comfort
Dementia Psychoeducation
* When caring for the patient with dementia, be sure to include the caregivers/family, as appropriate and address following topics in teaching plan:
* Psychopharmacologic agents (if used) including drug, action, frequency, possible adverse reactions
* Rest and activity
* Consistency in routines
* Nutrition and hydration
* Sleep and comfort measures
* Protective environment
* Communication and social interaction
* Diversional measures
* Community resources
Dementia Outcomes - Biological
* Decreased sleep disturbances
* MINIMIZED SIDE EFFECTS OF MEDICATIONS
* Increased activity, exercise
* Improved nutritional status
* Maintained weight
* Maintained hydration
* Improved oral hygiene
* Decreased incontinence
* Decreased constipation
Dementia Outcomes - Social
* Increased social participation
* Increased sense of belonging
* Decreased isolation
* Decreased family/caregiver stress
* Increased family knowledge and skills
* Maintained cultural relatedness
* Maintained sense of familiar surroundings
* Maintained spiritual needs
Dementia Outcomes - Psychological
* Enhanced cognitive functioning
* Decreased agitation
* Decreased depression
* Improved self-worth
* Decreased hallucinations, illusions, and delusions
* Decreased anxiety
* Decreased catastrophic reactions
* Maintained possible self-care skills and independence
Delirium, Depression, Dementia Comparison
* **Table - p393
-
Alzheimer's Type Dementia
* Degenerative and progressive
* Diagnosis of AD made on clinical symptoms and verification
* Etiology is ONLY confirmed at autopsy
* Neurodegenerative atrophy of the brain
* Irreversible
* Have identified neurofibrillary plaques and tangles (accumulation of twisted filaments inside brain cells)
* Confusion in diagnosis and lack of clinical and pathologic standards make diagnosis difficult
* In end stages, individual in weakened state and susceptible to infection and other complications
* Epidemiologic information only rough estimate
* Insidious - symptoms begin slowly and progress
Alzheimer’s Disease
Etiologic Theories
* Angiopathy and blood-brain incompetence
* Neurotransmitter deficiencies
* Abnormal brain proteins
* Genetic defects
AD STAGES (P 395-396)
* STAGE ONE - EARLY SYMPTOMS (MILD FORGETFULNESS AND DIFFICULTY C CALCULATIONS) ANXIETY IS THE SENSORY PERCEPTION ALTERATION - NARROWS PERCEPTION - NOTICE MILD BEHAVIOR PROBLEMS
* STAGE TWO - MODERATE (BEHAVIOR PROBLEMS, BECOMING AGITATED, HITTING PEOPLE, AIMLESS PACING, WANDERING, VERY CONFUSED, MILD INCONTINENCE, SUNDOWNING)
* STAGE THREE - TERMINAL OR SEVERE (CLIENT TOTALLY DEPENDENT ON CAREGIVERS, LOSS OF COMMUNICATION, DON’T RECOGNIZE FAMILY) ASPIRATION IS #1 PROBLEM IN STAGE 3
The "36-hour day" refers to what stage?
2
Alzheimer’s Disease
Stage 1: Mild
* Insidious changes
* Recent memory impairment
– Neologisms
* Cognitive losses in:
– Communicating
– Calculating
– Recognition
* Sensory/motor functions intact
* Self-awareness leads to depression
Alzheimer’s Disease
Stage 2: Moderate
* Cognitive decline increases amnesia, disorientation, apraxia, aphasia, agnosia, perseveration.
* Behavior problems:
– Catastrophic reactions
– Wandering/pacing
– Sundowning
* Self-care deficit
* Poor judgment
* Sleep disturbance
Alzheimer’s Disease
Stage 3: Severe
* Loss of meaningful communication
* Total dependence on caregivers
* Incontinence
* Secondary illnesses related to immobility
Vascular Dementia
* AKA Multi-infarct Dementia
* Seen in approximately 20% of patients with dementia
* Results when a series of small strokes damage or destroy brain tissue (referred to as “ministrokes” or TIA (transient ischemic attacks)
* Several TIA’s may occur before symptoms of MID occur
* Most often a blood clot or plaques block the vessels that supply the blood to the brain, causing a stroke
* Damage to the brain in MID usually apparent on computed tomography scans or MRI
* At autopsy, multifocal lesions may be found rather than the more generalized cortical atrophy of AD
* Behavioral changes of MID are similar to in AD: memory loss, depression, emotional lability, or emotional incontinence (inappropriate laughing or crying), wandering or getting lost in familiar places, bladder or bowel incontinence, difficulty following instructions, gait changes such as small shuffling steps, and problems handling daily activities such as money management
* Symptoms begin more suddenly with MID than with AD
* Clinical progression of symptoms is often intermittent and fluctuating, or “step like” deterioration
* Cognitive and functional status improving and plateauing for a period of time, followed by a rapid decline in function after another series of small strokes
* Treatment/nursing interventions aimed at reducing the primary risk factors for MID
* Teaching on diet, exercise, meds, control hypertension, daily asa