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NR202 Test 5 Nursing management of patient's with acute dysfunction in cognitive


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What is cognition
The mental process characterized by knowing, thinking, learning, and judging
Described as: a person "knows the world" and interacts with it.
A mental capacity that has impact on physical, social, psychological, and spiritual aspects of life
Human feature distinguishing living from existing
How do you know a person is cognitively processing appropriately
Cognitive procesing has a direct relationship to activities of daily living
Following the direction of a conversation or solving a mental process like adding numbers, understanding directions.
Cognitive disorders-describe what is affected
Affect one or more of the brain regions
usually cerebral cortex and limbic system
Define Delirium
Transient disorder, secondary to another condition.
Essential feature of delirium is disturbance in consciousness and is generally marked by cognitive difficulties.
-Age groups
-When do symptoms appear
Occurs in all age groups, more prevalent in elderly
Symptoms appear quite suddenly, once cause is treated, subsides rapidly
Duration-usually one week, rarely more than a month
Delirium: what are the four essential elements
1. Disordered attention or arousal
2. Cognitive dysfunction
3. Acute development of signs and symptoms (from hours to a few days)
4. A medical cause, not a psychiatric cause
What are the symptoms of delirium
1. Impairment of recent memory
2. Disorientation to time and place
3. Difficulty sustaining and shifting position
4. Disorganized thinking
5. Disorientation and confusion are usually worse at night and during early morning
6. Hallucinations, illusions
7. State of mental confusion and excitement (restless)
What are the autonomic manifestations
1. Tachycardia
2. Sweating
3. Flushed Face
4. Dilated Pupils or constricted
5. Elevated blood pressure
6. Fever
What are the risk factors for delirium
1. Advanced age, bone fractures, medications
2. Change in vital signs; hypotension; hyperthermia; hypothermia
3. Electrolyte or metabolic imbalences

4. Postcardiotomy; AIDS; drug withdrawal
5. Post surgical patients
6. Pre-existing dementia; sensory deprivation
7. Pre-existing illness; tremors, pain

8. Fluid volume deficit; admission to long term care institution
Nursing assessment of Delirium: Name 3 areas
1. Physical needs
2. Cognitive and perceptional disturbances
3. Mood and physical behaviors
Potential Nursing diagnoses for Delirious Patient
1. Risk for injury
2. Self-Care deficit
3. Disturbed sleep pattern
4. Acute confusion
5. Fear
6. Disturbed sensory perception
7. Disturbed thought processes
8. Risk for violence, directed at others
Nursing care of delirium
1. Assessment is critical
2. Treat as medical patient 1st
3. Prompt stabilization of cardiopulmonary disorders is a priority
4. Evaluation of the patients mental status
5. Gather assessment data and history from people accompanying patient to hospital
Nursing interventions: Taking care of a patient with delirium
1. Ensure pt safety
2. Nursing interventions are specifically tailored to meet the needs of the individual
3. Most delirious patients respond best to one to one care giving
4. Keep conversation simple
5. Deliver care in calm, yet decisive tones
6. Minimize perceptual disorders
7. Look to eliminate causitive factor
Define Dementia
1. Is marked by progressive deterioration in intellectual functioning, memory, and ability to solve problems and new skills
2. Judgement, moral, and ethical behavior decline as personality is altered.
Dementia Alzheimer's type
Caregivers usually seek medical care when they observe behavioral difficulties occuring.
What are the cardinal symptoms in Alzheimer's disease?
1. Aphasia-Loss of language ability
2. Apraxia-Loss of purposeful movement impairment
3. Agnosia-Loss of sensory ability like hearing the telephone ring
4. Memory impairment
5. Disturbances in executive functioning; planning, organizing, abstract thinking, sequencing
-not remember numbers, get lost in the mall
1. Disregard for conventional rules of social conduct
2. Neglect of personal appearance and hygiene
3. Aimless pacing, wandering away
4. Irritability and moodiness, with sudden outbursts over trivial issues
Describe 4 stages of alzheimer's disease
Stage 1 (Mild) forgetfulness-Aware of the problem, depression is common
Stage 2 (Moderate) confusion
Memory loss pronounced. Denial and depression increase. Problems with stress/fatigue. Functions of part of the brain don't work, deteriorate
Stage 3 (Moderate-Severe) Ambulatory dementia. Toileting communication goes down, losses, depression fades
Stage 4 (Late) End stage-Family recognition disappears-mute, forget how to eat, swallow, chew
Goals for care of the patient
1. Protecting the dignity of the patient
2. Preserving Functional Status
3. Promoting Quality of life
Identify Nursing Diagnoses for Dementia or Alzheimer's disease
1. Risk for injury
2. Disturbed sleep pattern
3. Risk for self directed violence
4. Risk of violence, directed at others
5. Altered thought process
6. Self esteem disturbance
7. Self-Care deficit
8. Impaired communication
What interventions can be done for a safe environment
1. Minimizing tripping and falling
2. Keep client from wandering into other client's rooms
3. Decrease sensory overload
4. Prevent escalation of anger
5. When attention span is short, client can be distracted to more productive topics and activities
6. Keep interactions pleasant, calm and reassuring; keep on an adult level
7. Attempt to understand patient's feelings
8. Help patient maintain self-esteem
9. Avoid why questions
10. Set up fairly structured routines
11. Repeat messages as necessary
What medications are used for alzheimer's disease?
Tacrine (cognex)
Donepezil (Aricept)
Rivastigmine (exelon)
Galantamine (Reminyl)
Cyclandelate (Cyclan)
Memantine HCL (Namenda)
Medications used for Alzhemier's
(Cholinesterase inhibitors)-Explain
Cholinesterase inhibitors
Acetylcholinesterase (AChE) is enzyme that inactivates neurotransmitter acetylcholine (ACh). AChE is found in high concentrations in the brain. the medications inhibit the enzyme, thus increasing ACh in brain. Increase in ACh activity helps maintain cognitive functioning and delay its decline
Other meds for Alzheimer's-what are they for, what are the side effects
Tacrine (Cognex)-S.E. include considerabe gastrointestinal distress and liver enzyme levels elevated in 50% of Pts.
Donepezil HCL (Aricept)-Better side efffect profile
Rivastigmine (Exelon)--mild to moderate dementia
Galantamine (Reminyl)-some nausea and diarrhea
Cholinesterase inhibitors are oral meds, taken one or two times a day, most frequent side effects are nausea and diarhea. Mild to moderate dementia.
Namenda-give other name and explain the action
Memantine (Namenda)--moderate to severe Alzheimer's. NMDA antagonist. Theory-Blocks overproduction of a harmful brain chemical called glutamate. In dementia, there is a chronic release of glutamate that causes a permanent increased intracellular calcium concentration that leads to neuronal degeneration. The med acts like magnesium and prevents this overload of calcium, improving cognition and activities of daily living
Describe Amnestic Disorder
Is characterized by loss in both short term memory (including the ability to learn information) and longterm memory, sufficient to cause some impairment in the person's functioning. Always secondary to underlying causes, such as general medical condition, substance induced, etc.
Amnestic disorder is diagnosed when there is severe memory impairment without other significant cognitive impairments (aphasia, agnosia, or disturbances in executive functioning or impaired consciousness.
1. Which problem is not considered a causative agent in delirium?
A. Elevated blood urea nitrogen levels
B. Infection
C. Anticholinergic drugs
D. Down syndrome
D. Down syndrome
Down syndrome is responsible for cognitive disorder attributable to chromosomal abnormality rather than to disturbed brain metabolism.
2. The term "perceptual disturbance" refers to difficulty
A. processing information about one's internal and external environment.
B. changing one's way of thinking to accommodate new information.
C. performing purposeful mot
A. processing information about one's internal and external environment.
Perceptual distortion refers to impaired ability to process intellectual, sensory and emotional data in a logical meaningful way.
3. Which event would a client with early (stage 1) Alzheimer's disease have greatest difficulty remembering?
A. High school graduation
B. The birth of one's children
C. A story of a teenage escapade
D. What the client ate for bre
D. What the client ate for breakfast
Initially, recent memory is impaired while remote memory remains intact.
4. A client has been diagnosed with delirium caused by a metabolic disorder. He begs the nurse to get someone to take away the huge snake in the hallway before it comes into his room. The nurse looks to where he is pointing and sees the hose of the vacuu
B. a visual illusion.
Illusions are errors in the perception of a sensory stimulus.
5. A client with delirium strikes out at staff. The nurse can most correctly hypothesize that this behavior is related to
A. anger.
B. fear.
C. meanness.
D. lack of social concern.
B. fear.
Clients with delirium often misinterpret reality, perceiving threat where none actually exists. Delirious clients who are fearful may strike out at others, seemingly without provocation.
6. Which cause of dementia has a clear genetic link?
A. Dementia from advanced alcoholism
B. Multiinfarct dementia
C. Creutzfeldt-Jacob disease
D. Alzheimer's disease
D. Alzheimer's disease
Family members of people with Alzheimer's disease have a risk of acquiring the disease that is higher than that of the general population.
7. What is the usual course of Alzheimer's disease?
A. A single short episode followed by years of normal function
B. Remissions and exacerbations
C. Progressive deterioration
D. No usual course exists
C. Progressive deterioration
The usual progression of Alzheimer's disease is steadily downward.
8. A client with Alzheimer's disease looks confused when the phone rings and seems not to recognize what the stimulus is. He also cannot recall many common household objects by name, such as a pencil or glass. The nurse can document this as
A. apr
B. agnosia.
Agnosia is the loss of the ability to recognize familiar objects.
9. The family of a client with Alzheimer's disease mentions to the nurse that seeing his loss of function when he was once such a competent individual has been very difficult. A nursing diagnosis that might be considered for such a family would be
B. anticipatory grieving.
Anticipatory grieving involves working through potential loss.
10. A nursing diagnosis appropriate for a client with Alzheimer's disease, regardless of the stage, would be
A. risk for injury.
B. acute confusion.
C. imbalanced nutrition.
D. impaired environmental interpretation syndrome.
A. risk for injury.
Memory loss, agnosia, poor judgment, and the other symptoms of Alzheimer's disease contribute to placing the client at risk for injuries such as burns and falling down stairs.
1. The physician mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess nightly
A. agitation.
B. lethargy.
C. depression.
D. elevated mood.
A. agitation.
Sundowning involves increased disorientation and agitation occurring at night.
2. The nurse caring for a client with Alzheimer's disease can anticipate that the family will need information about therapy with
A. antihypertensives.
B. benzodiazepines.
C. immunosuppressants.
D. acetylcholinesterase inhibitors
D. acetylcholinesterase inhibitors.
Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. Acetylcholinesterase inhibitor drugs prevent the chemical that destroys acetylcholine from acting, thus leaving more available acetylcholine.
3. A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. The client has difficulty answering the questions asked by the nurse. The daughter reports that her mother had been orie
A. delirium.
Delirium is characterized by a disturbance of consciousness, a change in cognition (such as impaired attention span), and a fluctuating level of consciousness that develop over a short period of time.
4. A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. The client has difficulty answering the questions asked by the nurse. The daughter reports that her mother had been orie
D. suggesting the social worker talk to the family about institutionalization.
It is quite possible that the client's problem is delirium, which is a reversible disorder. Institutionalization should not be necessary.
5. A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. The client has difficulty answering the questions asked by the nurse. The daughter reports that her mother had been orie
D. "I would like to have your mother wear them. It will help her to be less confused."
Clients with cognitive disorders usually profit from being able to see and hear clearly. Confusion is reduced through the use of glasses and hearing aids.
6. The nurse is expected to perform an assessment of a client suspected to be in the earliest stage of Alzheimer's disease. What finding would be out of character if the client truly has stage 1 Alzheimer's disease?
A. Willingness to respond direc
A. Willingness to respond directly to questions posed by nurse
During stage 1 Alzheimer's disease the client is aware of memory impairment and may attempt to disguise it or cover it by being evasive or using confabulation.
7. A client with Alzheimer's disease can no longer perform hygiene and grooming. She often objects to being led to the shower and does not participate in washing herself. She puts her arms into the legs of her slacks, and so forth. She tests doors and wa
C. stage 3, moderate-severe.
Moderate-severe Alzheimer's disease requires a high level of supervision because of the severe memory loss the client is experiencing. Wandering and inability to meet self-care needs become problematic.
8. An intervention the nurse might suggest to the family members of a client with Alzheimer's disease who wish to manage problems associated with bowel and bladder function would be to
A. label the bathroom door.
B. provide toileting on an a
A. label the bathroom door.
Labeling doors and various items can be helpful for a client who has forgotten where things are and what certain items are. The other options are essentially the opposite of helpful interventions: a schedule for toileting, use of disposable adult diapers, and matter-of-fact acceptance of incontinence.
9. Activities that might be planned for a client with Alzheimer's disease include
A. looking at picture books.
B. independent walks outdoors.
C. crafts that require fine motor skills.
D. making client responsible for setting out
A. looking at picture books.
The only activity the client with Alzheimer's disease might be able to accomplish independently would be looking at pictures.
10. The family members of a client with stage 1 Alzheimer's disease have jobs and cannot provide adequate supervision for the client. A reasonable alternative for the nurse to explore with them would be
A. day care.
B. acute care hospitaliza
A. day care.
Day care is a good option for clients with early-stage Alzheimer's disease. It provides supervision, a protected environment, and supportive interactions.

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