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MED SURG #3 - Carrington

Terms in this set (24)

Delirium
State of temporary but acute mental confusion
Common problem

Life threatening

Possibly preventable syndrome

Highest in hospitalized older adults
*In the hospital setting, 15% to 53% of older adults experience delirium postoperatively, and 70% to 87% experience delirium in the intensive care setting.
Dementia
Dysfunction or loss of memory, orientation, language, judgment and reasoning

Personality changes & behavioral problems common

Diagnosed when two or more brain functions are affected
*Umbrella term that encompasses several types-Alzheimer's most common
Behaviors = Agitation, delusions, hallucinations, delusions
Person's ability to work, perform ADL's or fulfill social obligations are affected
Dementia Etiology & Patho
Not a normal part of aging
As lifespan increases, # affected increases
Cause: treatable & untreatable conditions
Neurodegenerative conditions most commonAlzheimer's = most common type of dementia
Vascular causes second most common
Ischemic, ischemic-hypoxic, hemorrhagic
Stroke
At risk: patient's with dysrhythmias, HTN, DM, ↑cholesterol, CAD
Clinical Manifestations Dementia
Onset may be gradual or abrupt
Memory loss, trouble with words and numbers, mild disorientation
Spouse or family may report changes
Related to recent events
Remote events intact
Gradual - alzheimer's
Abrupt - stroke
DX Studies Dementia
Goal: determine the cause

Rule out potential medical conditions

Physical examination & thorough history

Mental status (Cognitive testing), labs, CT or MRI
Causes of Dementia
Neurodegenerative=alzheimer's, Parkinson's, Down's syndrome
Vascular=stroke, subarchnoid hemorrhage
Toxic, metabolic=alcoholism, vitamin B deficiency, hypothyroidism
Immune/infectious=AIDS, meningitis, SLE, encephalitis, MS
Systemic=hepatic encephalopathy, uremic encephalopathy
Trauma/tumors=head injury, primary or metastatic tumors
Drugs=tranquilizers, anticholinergics, opiods,illegal (herion, cocaine)
Alzheimer's Disease
Chronic, progressive, degenerative
Affects approximately 6 million
Economic impact >$150 billion year
Early or late onset
Familial connections
Alzheimer's Etiology & Patho
Amyloid plaques-clusters of insoluble deposits of protein plaques, remenants of microglia & astrocytes. Develop first in hippocampus (forms & stores short term memory), then cerebral cortex (language & reasoning)
Neurofibrillary tangles-twisted protein threads inside nerve cells. Main component=Tau (provides support for intracelluar structure [railroad ties]; when altered it twists together in helical fashion & forms the twisted threads
Loss of connection-structural damage & death of neurons. Brain atrophies & shrinks
Clinical Manifestations of Alzheimer's
Pathologic changes may precede clinical manifestations by 5-20
Memory loss
Difficulty performing familiar tasks
Problems with language
Disorientation to time, place
Poor or decreased judgment
Problems with abstract thinking
Misplacing things
Changes in mood or behavior
Changes in personality
Loss of initiative
Become more pronounced with time
Progression leads to dysphasia, apraxia, visual agnosia, dysgraphia
Clinical Manifestations of Alzheimer's - Later Stages
Failure to recognize family
Agression, tendancy to wander
Inability to communicate
Inability to perform ADL's
Dx Studies Alzheimer's
Same as Dementia --- Goal: determine the cause
Rule out potential medical conditions
Physical examination & thorough history
Mental status (Cognitive testing), labs, CT or MRI
**Absolute diagnosis is by autopsy
Collaborative Care Alzheimer's
No cure

Improve or slow decline

Control behaviors

Support caregiver
Medications Alzheimers
Goal: slow disease progression

Cholinesterase inhibitors
Aricept
Exelon

Protect against excess glutamate
Namenda
Delirium
Common in older adults who have a short-term illness such as
Lung or heart disease
Infection
Poor nutrition
Drug interaction
Demographic characteristics
Age 65 or older
Male gender
Patients who experience delirium are at increased risk for:
Longer hospitalization
Further functional decline
Institutionalization
usually develops over a 2- to 3-day period
Delirium Etiology & Patho
Poorly understood
Contributors
Cholinergic deficiency
Excess release of dopamine
↑ and ↓ in serotonergic activity
Chronic stress
Delirium - Precipitating Factors
Cognitive status :
Dementia
Cognitive impairment
History of delirium
Depression
Environmental:
Admission to ICU
Use of physical restraints
Pain (especially untreated)
Emotional stress
Prolonged sleep deprivation
Sensory:
Sensory deprivation
Sensory overload
Decreased oral intake :
Dehydration
Malnutrition
Drugs :
Sedative-hypnotics
Opioids
Anticholinergic drugs
Treatment with multiple drugs
Alcohol or drug withdrawal
Coexisting medical conditions :
Severe acute or terminal illness
Chronic renal or hepatic disease
History of stroke
Neurologic disease
Infection/sepsis
Fracture or trauma
Surgery :
Orthopedic surgery
Cardiac surgery
Prolonged cardiopulmonary bypass
Noncardiac surgery
Clinical Manifestations Delirium (Early)
Early manifestations often include:
Inability to concentrate
Irritability
Insomnia
Loss of appetite
Restlessness
Confusion
Clinical Manifestations Delirium (Late)
Later manifestations may include:
Agitation
Misperception
Misinterpretation
Hallucinations
DX Studies Delirium
Medical history
Psychologic history
Physical examination
Review medications
Cognitive measures (e.g., Confusion Assessment Method [CAM]) : The Confusion Assessment Method (CAM) tool: 4 features
1) Acute onset & fluctuating course
2) Inattention (difficulty focusing)
3) Disorganized thinking
4) Altered level of consciousness (vigilant, lethargic, stupor, etc)
DX Studies Delirium
Laboratory tests to explore the cause
Serum electrolytes, BUN, creatinine
Complete blood count (CBC)
Drug and alcohol levels
Electrocardiogram (ECG)
Urine analysis
Liver and thyroid function tests
Oxygen saturation level
Lumbar puncture
RN management Delirium
Nurse's role
Prevention
Early recognition
Reorientation and behavioral interventions
Create a safe and quiet environment.
Provide reassurance
Pay attention to environmental stimuli
Clocks, calendars, noise, and light levels
**Patient groups at risk include those with neurologic disorders (e.g., stroke, dementia, CNS infection, Parkinson's disease), sensory impairment, and advanced age. If the patient uses eyeglasses or a hearing aid, these should be made readily available because sensory deprivation can precipitate delirium.
Avoid the use of restraints.
Drug Therapy Delirium
Treated with low-dose antipsychotics (use with caution)
Haloperidol (Haldol)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Short-acting benzodiazepines (e.g., lorazepam [Ativan])
**In addition to sedation, other side effects with antipsychotics include hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of the face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects.
Effects of Aging on MS System
Decreased bone density
Decreased muscle mass and strength
Decreased flexibility
Functional problems
*The bone remodeling process is altered in the aging adult. Increased bone resorption and decreased bone formation cause a loss of bone density, contributing to development of osteopenia and osteoporosis.
Muscle mass and strength also decrease with aging. Almost 30% of muscle mass is lost by age 70. A loss of motor neurons can cause additional problems with skeletal muscle movement.
Tendons and ligaments become less flexible, and movement becomes more rigid.
Many of the functional problems experienced by the aging adult are related to changes of the musculoskeletal system. Although some changes begin in early adulthood, obvious signs of musculoskeletal impairment may not appear until later adult years. Alterations may affect the older adult's ability to complete self-care tasks and pursue other customary activities. Effects of musculoskeletal changes may range from mild discomfort and decreased ability to perform activities of daily living to severe, chronic pain and immobility. The risk for falls also increases in the older adult due in part to a loss of strength. Aging can also bring changes in the patient's balance, thus making the person unsteady, and proprioception (awareness of self in relation to the environment) may be altered.
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