Cognitive Disorders Flashcards
assessment guidelines for delirium
determine fluctuating LOC and risk for injury
ask family for baseline LOC and cognition
determine whether or not underlying cause
assess VS and neuro status for comfort care
4 cardinal features of delirium
acute onset/fluctuating course
inattention
disorganized thinking
altered LOC
nurs dx for delirium
acute confusion risk for injury disturbed thought process fear self-care deficit impaired verbal communication
s/s of delirium
agitation, confusion, sun downing (night time exacerbation of symptoms)
Hallucinations
Increased HR
mgmt. of delirium
speak in simple concrete phrases comprehensive nurse assessment use reality orientation (clocks, calendars, family pics) have pt. wear glasses/hearing aids utilize same staff whenever possible
communication guidelines for delirium
always identify yourself use short, simple words focus on one thing at a time talk about familiar things focus on reality when pt. is delusional
short term outcomes of delirium are r/t
ongoing change in condition (VS, skin turgor, urine-specific gravity)
long term outcomes of delirium are r/t
individual safety, AAOx3, underlying cause identified/treated
what is dementia
impaired cognitive function, slowly deteriorating social and occupational functioning, levels of alertness are generally not disturbed.
what are the stages of Alzheimer’s
Stage 1 - mild - forgetfulness
Stage 2 - moderate - confusion
Stage 3 - moderate to severe - unable to identify objects/people
Stage 4 - late - end-stage
how many stages of Alzheimer’s
4
early signs of Alzheimer’s
memory loss effecting job skills diff. performing usual tasks problems w/language disoriented to time and place poor or decreased judgment problems thinking abstractly misplacing things (keys) changes in mood/behavior/personality loss of initiative
signs of Alzheimer’s progression
Dysphasia Apraxia Visual agnosia Dysgraphia Some long-term memory loss Wandering
signs of late stage Alzheimer’s
long-term memory loss
unable to communicate
cannot perform ADL’s
require total care (incontinence)
dx of Alzheimer’s
health hx, physical exam, neuro assess, mental assess, lab tests
CT, MRI, SPECT, PET
monitor early stages/trt. response
nurse dx r/t Alzheimer’s
chronic confusion
risk for injury
impaired verbal communication/memory
care-giver role strain
targeted areas of trt. for Alzheimer’s
Injury Communication Agitation level Caregiver role strain Self-care needs
communication guidelines for Alzheimer’s
identify yourself call the person by their name speak slowly using short, simple words/phrases use face-to-face contact focus on 1 thing at a time talk about familiar things encourage reminiscing about happy times with delusions reinforce reality, acknowledge pt. feelings be close to the person when talking have the pt. wear glasses/hearing aids
with an Alzheimer’s pt. never do this
rush/hurry criticize/correct/argue talk as though the person isn't present take challenging behaviors personally use condescending terms
mgmt. of Alzheimer’s is aimed at
improve/control decline in cognition control undesirable behaviors (may be aggressive or angry) provide care for the caregiver community supports pharmacology
when creating a SAFE environment for Alzheimer’s consider this
gradually restrict driving remove rugs min. sensory stimulation give support/chg. topic when verbally upset label things install safety bars supervise smoking
mgmt. of wandering r/t Alzheimer’s
place mattress on floor or use bed monitor medic-alert bracelet and ID notify police, tell neighbors install complex locks explore GPS devices
engaging activities for Alzheimer patients
picture magazines/children’s books when reading is compromised
familiar/simple group activities
physical activity during the day
objective data r/t Alzheimer
disheveled appearance
early, late, middle neuro
subjective data r/t a;Alzheimer
past health hx meds nutrition info elimination info sleep-rest pattern
What is the last thing to change in alzheimers
Thought, long term memory in tact, short term memory is the problem
