Nursing Care of the Client with Alterations in Neurological Integrity/Cognitive Abilities

1. Nursing Care of the Client with Alterations in Neurological Integrity/Cognitive Abilities NUR 108 Spring 2007

2. Can you imagine not knowing where the bathroom in your home is… :>) lee;

3. Or how to hold a spoon, or even how to get dressed in the morning? :>) lee;

4. Most of all, can you imagine not being able to recognize your loved ones? :>) lee;

5. Three most cognitive problems in adults • Delirium (acute confusion) • Dementia • Depression • These problems often occur together :>) lee;

6. Thought Process • Cognition • Systematic way a person thinks, reasons, and uses language • Normal function • Perceiving, thinking, learning, and remembering :>) lee;

7. Altered cognitive function Etiology • Inadequate blood flow • Altered nutrition • Fluid and electrolyte imbalance • Infectious process • Inadequate sleep and rest • Inability to organize incoming stimuli • Environmental stress • Pharmacological agents :>) lee;

8. Cognitive assessment • Mini mental state exam • Depression scale • Glascow coma scale • LOC :>) lee;

9. :>) lee;

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11. :>) lee;

12. DementiaDiagnostic Studies • Computed tomography (CT) or magnetic resonance imaging (MRI) can be used in the evaluation of patients with dementia • Currently, there are no recommended genetic markers or cerebrospinal fluid (CSF) markers :>) lee;

13. Differential diagnosis • Confusion • Temporary/permanent alteration of thought • Dementia • Specific reversible/irreversible dysfunction and progressive deterioration of the brain • Depression • Mental state characterized by lack of hope :>) lee;

14. DementiaClinical Manifestations • Early (mild) • Forgetfulness beyond what is seen in a normal person • Short-term memory impairment • Difficulty recognizing numbers • Loss of initiative and interests • Decreased judgment • Geographic disorientation :>) lee;

15. DementiaClinical Manifestations • Middle (moderate) • Impaired ability to recognize close family or friends • Agitation • Wandering, getting lost • Loss of remote memory • Confusion • Impaired comprehension :>) lee;

16. DementiaClinical Manifestations • Middle (moderate) • Forgets how to do simple tasks • Apraxia • Receptive and expressive aphasia • Insomnia • Delusions • Illusions, hallucinations • Behavioral problems :>) lee;

17. DementiaClinical Manifestations • Late (severe) • Little memory • Cannot understand words • Difficulty eating and swallowing • Repetitious words or sounds • Unable to perform self-care activities • Immobility • Incontinence :>) lee;

18. Dementia • A syndrome characterized by • Dysfunction or loss of memory • Orientation • Attention • Language • Judgment and reasoning • Changes in behavior :>) lee;

19. Etiology of dementia • Both from treatable/untreatable causes • Treatable etiologies are potentially reversible • Two most common • Neurodegenerative disorders 60-80% • Alzheimer’s disease • Vascular disorders • Vascular dementia can be prevented :>) lee;

20. Reversible Express realistic perception Return to previous level of cognition Absence of injury Improved sleep patterns Irreversible Experience adequate support to compensate Participate in safe, protected environment Improve family coping strategies Goals for the client with dementia :>) lee;

21. Interventions - reversible • Orient patient to environment • Introduce self • Provide physical contact • Reduce noise, light, distractions • Provide “reality orientation” • Explain procedures :>) lee;

22. Interventions - irreversible • Establish stable environment • Employ “validation therapy” • Provide safety • Encourage patient and family to accept level of functioning • Use patient name frequently :>) lee;

23. Ten years ago few Americans had heard of Alzheimer’s disease… :>) lee;

24. Yet today this progressive, irreversible brain disease is recognized as one of the most devastating diseases of our time… and of our future :>) lee;

25. Statistics • Currently affects as many as 4-5 million people • As society ages, more and more people will have Alzheimer’s disease (AD) • By 2030 AD will affect >8 million and by 2050 >14 million :>) lee;

26. Who Gets Alzheimer’s Disease? 1 out of every 10 (10%) of people over the age 65 have AD People in their 40s and 50s get AD Nearly ½ people over 85 have AD 4th leading cause of death 3rd most expensive disease following heart disease and cancer :>) lee;

27. DiseaseJoe Adcock, baseball player Mabel Albertson, actor Dana Andrews, actorRudolph Bing, opera impresario James Brooks, artistCharles Bronson actor, film director Abe Burrows,authorCarroll Campbell, Former Rebublican Senator Joyce Chen, chefPerry Como, Singer entertainer Aaron Copland, composerWillem DeKooning, artist James Doohan, actorThomas Dorsey, singer Tom Fears, professional football player and coach Louis Feraud, fashion designer Arlene Francis, actorMike Frankovich, film producer John Douglas French, physicianBarry Goldwater, Senator of Arizona Rita Hayworth, actressRaul Silva Henriquez, Roman Catholic cardinal, human rights advocate Charlton Heston actor and political activistMervyn Leroy, director Jack Lord, actorRoss MacDonald, author Burgess Meredith, actorIris Murdoch, author Edmond O’Brien, actorArthur O’Connell, actor Marv Owen, baseball playerMolly Picon, actor Otto Preminger, directorBill Quackenbush, professional hockey player Ronald Reagan, 40th President of USAHarry Ritz, performer Sugar Ray Robinson, boxerNorman Rockwell, artist Simon Scott, actorIrving Shulman, screenwriter Betty Schwartz, Olympic gold medal winner in track events Famous People with Alzheimer's :>) lee;

28. Famous Celebrities :>) lee;

29. Alzheimer’s Disease • Alzheimer’s disease (AD) is a chronic, progressive, degenerative disease of the brain • Most common form of dementia • Accounts for 60-80% of all cases of dementia • Expectation • 22 million people will suffer from Alzheimer’s by 2025 :>) lee;

30. Etiology • Unknown • Destruction of brain cells • Pathologic changes occur 5-20 years before evidence of symptoms • Genetic component • Specifically with early onset :>) lee;

31. Family history of dementia Family history – Downs Family history - Parkinson’s Maternal age > 40 years Head trauma (with LOC) History of depression History of hypothyroidism History of severe headache NSAID use or statin use RELATIVE RISK FACTORS FOR ALZHEIMER’S DISEASE :>) lee;

32. Alzheimer’s DiseaseEtiology and Pathophysiology • Characteristic findings in AD are the presence of abnormal clumps (neuritic or senile plaques) and tangled bundles of fibers (neurofibrillary tangles) in the brain :>) lee;

33. Alzheimer’s DiseaseEtiology and Pathophysiology • The neuritic plaque is a cluster of degenerating axonal and dendritic nerve terminals that contain amyloid-beta protein • Neurofibrillary tangles are seen in the cytoplasm of abnormal neurons in those areas of the brain most affected by AD :>) lee;

34. Pathologic Changes :>) lee; Fig. 58-1

35. Etiologic Theories :>) lee; Fig. 58-3

36. Alzheimer’s Disease (AD) A = Cerebral cortex B = Basal forebrain C = Hippocampus :>) lee;

37. Alzheimer’s Disease (AD) A = Cerebral cortex Involved in conscious thought and language :>) lee;

38. Alzheimer’s Disease (AD) B = Basal forebrain Has large number of neurons containing acetylcholine, a chemical important in nerve transmission and memory and learning :>) lee;

39. Alzheimer’s Disease (AD) C = Hippocampus Essential to memory storage The earliest signs of Alzheimer’s are found in this area :>) lee;

40. Alzheimer’s DiseaseClinical Manifestations Alzheimer’s disease gradually strips away one’s mental and physical capacities :>) lee;

41. Alzheimer’s Disease: Diagnostic Studies • Brain imaging tests • Computed tomography (CT): atrophy or shrinking of the brain • Magnetic Resonance Imaging (MRI): anatomic and biochemical changes • Magnetic Resonance Spectroscopy (MRS): provides information about chemical composition of tissue • Single-photon emission computed tomography (SPECT): used to visualized blood flow or oxygen or glucose metabolism • Positron emission tomography (PET): measures metabolic activity of brain regions to assess cell death or damage. :>) lee;

42. Clinical manifestations • Subtle memory change • Hygiene deteriorates • Agitation • Delusions • Dysphasia • Visual agnosia • Loss of long-term memory • Loss of communication • Loss of ability to perform ADL’s :>) lee;

43. Collaborative Care • No cure • Diagnosis of exclusion • Confirmation made on autopsy • Medications to help alleviate • Memory loss • Depression • Behavioral problems • Sleep disturbances :>) lee;

44. Alzheimer’s DiseaseDrug Therapy • Cholinesterase inhibitors • Are used in the treatment of mild and moderate dementia • Have been shown to either improve or stabilize cognitive decline in some people with AD • Do not reverse the progression of the disease :>) lee;

45. Cholinesterase Inhibitors Fig. 58-4 :>) lee;

46. Nursing Diagnosis • Disturbed thought process • Self-care deficit • Risk for injury • Wandering • Ineffective coping • Nutrition, less than body requirements • Risk for infection • **Care giver role strain :>) lee;

47. Alzheimer’s DiseaseAcute Intervention • The nurse is in an important position to assess for depression and suicidal ideation • Antidepressant drugs and counseling may be appropriate interventions • The nurse must assess family members and their abilities to accept and cope with the diagnosis :>) lee;

48. Alzheimer’s DiseaseNursing Management • When interacting with the patient • Use a calm, reassuring, nonthreatening approach • Smile • Approach the patient from the front • Address the patient by name • Limit decision making • Have tolerance :>) lee;

49. Alzheimer’s DiseaseNursing Management • When interacting with the patient • Frequently reorient the patient • Acknowledge patient fears • Respond to tone, not content • Remove stimuli for hallucinations, fears • Don’t argue with delusions • Don’t reinforce delusions :>) lee;

50. Alzheimer’s DiseaseAmbulatory and Home Care • Effective management of the disease can slow the progression of the disease and ↓ the burden on the patient, caregiver, and family • Adult day care is available to the person with AD :>) lee;