Mod. 9 ATI ch. 17, 25, 28 Flashcards
Neurocognitive disorders
disruption of thinking, memory, processing, and problem solving
Types of cognitive disorders recognized by. the DSM-5
Delirium
Mild neurocognitive disorder (NCD)
Major neurocognitive disorder (dementia)
NCD further classified into;
NCD due to Alzheimer’s (most common type of NCD)
***note depression can mimic early stages of Alzheimer’s disease
NCD due to Parkinson’s
NCD due to Huntington’s disease
Risk Factors for delirium
- physiological changes, including neurologic: (Parkinson’s, Huntingtons)
- metabolic: hepatic/ renal failure, electrolyte imbalances, nutrition)
- cardio. & respiratory diseases:
- infections: HIV/ AIDS
- surgery
- substance use or withdrawal
Other risk factors for delirium
- older age
- multiple co-morbidities
- severity of disease
- polypharmacy
- ICUs
- aphasia
- restraint use
- change in environment
Risk factors for neurocognitive disorder and AD
advanced age prior head trauma cardiovascular disease lifestyle factors family history*
Defense mechanisms
Denial
Confabulation- client makes up stories to fill in the gaps when they don’t remember. This is done to preserve self-esteem
Perseveration- avoids answering questions by repeating phrases or behavior
Diagnostic procedures to rule out other pathologies
no real diagnostic for NCD
~ chest and head x-ray ~ EEG ~ ECG ~ liver function studies ~ thyroid function tests ~ neuroimaging (CT and positron emission tomography of brain) ~ urinalysis ~ blood electrolytes ~ folate and vitamin B12 levels ~ vision and hearing tests ~ lumbar puncture
NCD screening tools
- confusion assessment method (CAM)- for delirium
- neelon-champagne (NEECHAM) Confusion scale- delirium
- functional dementia scale- gives info. on client’s ability to perform self-care, extent of memory loss, mood changes, degree of danger to self/others
- brief interview for mental status (BIMS)- for long-term care clients
- mini-mental status exam (MMSE)
- functional assessment screening tool (FAST)
- Global deterioration scale
- blessed dementia scale-behavioral info. based on an interview with a secondary source
Delirium
> Rapid (hours or days)
impairments in memory, judgment, ability to focus, ability to calculate (can fluctuate throughout the day)
disorientation/ confusion worse at night and early morning***
LOC usually altered and can rapidly fluctuate
restlessness, anxiety, motor agitation, fluctuating moods are common
personality change is rapid
hallucinations and illusions can be present
change in reality can cause fear, panic, and anger
vital signs can be unstable
medical emergency
4 types of delirium
- hyperactive with agitation and restlessness
- hypoactive with apathy and quietness
- mixed, having a combination of hyper and hypo manifestations
- unclassified for those whose manifestations do not classify into the other categories
Neurocognitive disorder
^ gradual deterioration of function over months or years
impairments in:
^ memory
^ judgment
^ speech (aphasia)
^ ability to recognize familiar objects (agnosia)
^ executive functioning (managing daily tasks)
^ movement (apraxia)
^ impairments do not change throughout the day
^ LOC usually unchanged
^ restlessness and agitation are common (sundowning can occur)
^ personality change is gradual
^ VS should be stable
Medications for delirium
pharmacological management focuses on underlying cause
medications for anxiety. or agitation can be used
Monitor signs of delirium
tachycardia
elevated bp
sweating
dilated pupils
Neurocognitive meds. (Alzheimers)
donepezil
rivastigmine
galantamine
increase acetylcholine. Allows clients to improve self-care abilities and slow cognitive deterioration IN THE MILD TO MODERATE STAGES
Memantine
MODERATE TO SEVERE stages of alzheimers
block the entry of calcium into nerve cells, thus slowing brain-cell death
- can be used with cholinesterase inhibitors.
- Adverse. effect: dizziness, headache, confusion, constipation
Medications for mental health issues in Children/ adolescents
CNS stimulants
SNRIs
tricyclic antidepressants
alpha2- adrenergic agonists
atypical antipsychotics
SSRIs
Medications for intermittent explosive disorders
lithium
mood- stabilizing antiepileptics
beta-adrenergic blockers
If toxicity happens with CNS stimulants
treat;
hallucinations with chlorpromazine (typical antipsychotic)
seizures with diazepam
administer fluids
SNRIs: things to know
for ADHD in children/ adolescents
Atomoxetine, Bupropion
- monitor height and weight, with or after meals, encourage regular mealtimes and avoid unhealthy choices
- take with food if GI disturbances occur
- monitor for signs of depression (changed in mood, excessive sleeping, agitation, and irritability)
- hepatotoxicity: signs of flu-like symptoms, yellowing skin, abdominal pain
- insomnia, headache, irritability
- administer one daily dose or in two divided doses
- can take a few days - 6 weeks. AVOID alcohol and OTC meds.
What are tricyclic antidepressants used for in children/ adolescents
- depression
- autism spectrum disorder
- ADHD
- panic disorder, separation anxiety disorder
- social phobia
- OCD
Anticholinergic side effects
dry mouth urinary hesitancy/ retention constipation tachycardia blurred vision photophobia
effects can take 1 to 3 weeks, to 6 weeks for max effects
How to reduce anticholinergic effects
chew gum
sipping water
wear sunglasses
diet high in fiber
2-3 L per day of fluid
void before taking medication
tricyclic toxicity signs
resulting in cholinergic blockade and cardiac toxicity
evidenced by;
dysrhythmias, mental confusion, and agitation
followed by;
seizures, coma, and possible death
Use for Alpha2- adrenergic agonists in children and adolescents
(think adrenergic agonist mimics parasympathetic)
ADHD
Tic disorders
conduct and oppositional defiant disorders
Things to know for alpha2-adrenergic agonists
! discontinuation can cause rebound htn- should be tapered off
! report CNS effects
! participate in regular exercise and eat healthy
! assess use of alcohol or other CNS depressants
! monitor BP and pulse at baseline, with treatment, and each dose change
Atypical antipsychotics in children and adolescents
mainly block serotonin and dopamine receptors to a lesser degree.
also block receptors for norepinephrine, histamine, and acetylcholine
used for;
- autism spectrum disorder
- conduct disorder
- OCD
- relief of psychotic manifestations
Nursing considerations with atypical antipsychotics in children
administer by oral or IM;
risperidone= oral, olanzapine= oral disintegration tab., quetiapine= for adolescents= oral immediate release, aripiprazole= oral tab/ disintegrated tab/ oral solution
SSRIs used in the treatment for;
- intermittent explosive disorder
- autism spectrum disorder
- OCD
- major depressive disorder
- bulimia nervosa
- generalized anxiety disorder
fluoxetine, sertraline, fluvoxamine
Need to know about SSRIs in children/ adolescents
*** agitation and hallucinations can be a sing of serotonin syndrome
(also; anxiety, sleep disturbances, tremors, tension headache)
- take with food to minimize GI effects
- monitor weight
- can increase suicidal ideation
- MAOIs., SNRIs, buspirone, St. John’s wort = serotonin syndrome
- effects in 1-3 weeks; MAX effect by 12 weeks
Disorders that can appear during childhood/ adolescence
+ depressive disorders
+ anxiety disorders: (including panic)
+ trauma- and stressor-relate disorders: PTSD
+ substance use disorders
+ feeding and eating disorders
+ disruptive, impulse control, and conduct disorders
+ neurodevelopmental disorders
+ bipolar and related disorders
+ schizophrenia spectrum and other psychotic disorders
+ nonsuicidal self-injury and suicidal behavior disorder: (suicide leading cause in ages 10 - 24)
+ impulse control disorders: intermittent explosive disorder
Risk factors for mental health disorders in children
- genetic (schiz., bipolar, autism, ADHD, intellectual dev.disorder)
- biochemical
- social and environmental
- cultural and ethnic
- witnessing or experiencing traumatic events
Disruptive, Impulsive control, Conduct disorders
> oppositional disorders
disruptive mood dysregulation disorder
intermittent explosive disorder
conduct disorder (childhood or adolescent onset)
Oppositional defiant disorder
antisocial behaviors; ~ negativity ~ disobedience ~ hostility ~ defiant behaviors (especially towards authority figures) ~ stubborness ~ argumentativeness ~ limit testin ~ unwillingness to compromise ~ refusal to accept responsibility for misbehavior
- can exhibit low self-esteem, mood lability, and low frustration threshold
- can develop into conduct disorder
Disruptive mood dysregulation disorder
- exhibit recurrent temper outbursts: verbally, physically, aggression
- outburst not appropriate for developmental level
- outbursts present three or more times per week, in at least two settings
- mood between outbursts is angry and irritable
- onset is ages 6 -18
- manifestations not due to other mental disorders
Intermittent explosive disorder
recurrent violent and aggressive behavior w/ possibility of hurting people, property, or animals
^ dx as early as 6, but typically 13 to 21
^ more males affected
^ physical or verbal aggression
^ overreaction to normal events followed by shame/ regret
^ can lead to htn, DM. cannot have healthy relationships
Conduct Disorder
categories
aggression to people and animals
destruction of property
deceitfulness or theft
serious violations of rules
Neurodevelopmental Disorders
- ADHD: 3 types; must be dx before age 12
- Autism spectrum disorder
- Intellectual developmental disorder
- Specific learning disorder
Meds. for ADHD
CNS stimulants
SNRIs
Meds. for autism
SSRIs antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole)
Meds. for intermittent explosive disorder
SSRIs (fluoxetine)
- Mood stabilizers (lithium)
- Antipsychotics (clozapine, haloperidol)
- beta blockers
Meds. for Oppositional defiant disorder
no meds. generally prescribed
Meds for conduct disorders
- second and third gen. antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole)
- TCS
- antianxiety meds.
- mood stabilizers
- antipsychotics
meds. for Anxiety
usually none are prescribed for kids
SSRIs can be used
meds. for PTSD
antianxiety meds.
SSRIs
meds. for Disruptive mood dysregulation disorder
antidepressant therapy
