mental health nursing ii nurs 2310 unit 15 cognitive impairment and thought disorders
TRANSCRIPT
Mental Health Mental Health Nursing IINursing II
NURS 2310NURS 2310
Unit 15Unit 15
Cognitive Impairment Cognitive Impairment and Thought Disordersand Thought Disorders
Key TermsKey TermsPsychosis = Disorganization of the personality,
deterioration in social functioning, and loss of contact with or distortion of reality; may include hallucinations and/or delusions
Hallucinations = False sensory perceptions not associated with real external stimuli affecting any or all of the five senses
Illusions = Misinterpretations/misperceptions of real external stimuli
Delusions = False personal beliefs not consistent with intelligence or culture; belief continues to exist in spite of proof to the contrary
Paranoia = Extreme suspiciousness of others and of their actions/perceived intentions
Depersonalization = Feelings of unrealityAnhedonia = Inability to experience pleasureReligiosity = Excessive demonstration of or
obsession with religious ideas/behaviorMagical thinking = Belief that one’s thoughts
or behaviors can control certain situations/people
Neologisms = Invented words that have symbolic meaning to self but are meaningless to others
Echolalia = Repetition of words one hears in attempt to identify with the speaker
Echopraxia = Imitation of movements made by others in an attempt to identify with them
Perseveration = Persistent repetition of the same word/idea in response to different questions or other prompts
Looseness of associations = Shifting of ideas from one unrelated subject to another
Word salad = Random arrangement of groups of words that lacks any logical connection
Circumstantiality = Delay in reaching the point of communication due to unnecessary/tedious details; inability to track the discussion topic
Tangentiality = Inability to get to the point of communication; unrelated topics are introduced and original discussion is lost
Clang associations = Word choice is determined by sound instead of meaning (i.e. rhyming)
Mutism = Refusal or inability to speakCatatonia = A state of stupor (extreme
psychomotor retardation) or excitement (extreme psychomotor agitation) that is usually associated with a psychotic disorder
Waxy flexibility = Passive yielding of ones’ body to positioning/posturing by others
DeliriumDelirium Cognitive disturbance manifested by
disorientation, agitation, memory impairment, and inability to reason or partake in goal-directed activity
Develops within several hours or days; onset may be more abrupt (i.e. following head injury or seizure)
May be caused by systemic illness, metabolic imbalance, ingestion of toxins, drug or alcohol overdose, withdrawal from drugs/alcohol or medication
Symptoms of DeliriumSymptoms of Delirium Rambling, incoherent speech Extreme distractibility Hallucinations and/or illusions Sleep disturbances with vivid nightmares Hyperactivity/hypervigilance or catatonic
stupor Emotional instability (irritability,
murmuring, moaning, fleeing or lashing out)
Autonomic manifestations (tachycardia, sweating, dilated pupils)
Progression of DeliriumProgression of Delirium Brief in duration (1 week to 1 month) Symptoms diminish within 3 days to 1
week of resolution of underlying cause (full recovery may take up to 2 weeks)
May transition into a permanent cognitive disorder (i.e. dementia) if left unresolved
CBC, BMP, chemistry panel used to diagnose underlying cause
Treated by determination/correction of underlying cause (i.e. fluid/electrolyte status corrections, treatment of hypoxia, anoxia, or diabetic problems)
Neurocognitive Disorder (NCD)Neurocognitive Disorder (NCD) Previously termed dementia Progressive decline in cognitive function due
to damage or disease in the brain beyond what might be expected from normal aging
Develops slowly over several months or years Progression is typically irreversible Diagnosed by evaluation (i.e. mental status
exam/MSE, CT scan, ruling out of other underlying causes of symptomology)
Treatment focused on symptom management Categorized as primary or secondary NCD
Primary NCDPrimary NCD The neurocognitive disorder itself is the
major sign of an organic brain disease that is not directly related to another organic illness
Alzheimer’s disease is the most common cause of primary NCD; vascular insufficiency (as in stroke) is another common cause
Secondary NCD Occurs as a result of a physical disease or
injury (directly related to another condition) Causes include HIV, cerebral trauma;
substance abuse
Symptoms of NCDSymptoms of NCD Impairment in abstract thinking/judgment;
lack of impulse control Uninhibited/inappropriate behavior; disregard
of social conduct; personality changes Neglectful of personal appearance/hygiene Apraxia (inability to carry out motor activities) Aphasia (inability to express needs) Irritability, mood instability, sudden outbursts Unable to comprehend own limitations; at risk
for accidents or wandering away from home
Stages of NCD related to Stages of NCD related to Alzheimer’sAlzheimer’s
Stage 1 = no apparent symptoms Stage 2 = forgetfulness Stage 3 = mild cognitive decline
(interference with work performance) Stage 4 = mild-to-moderate cognitive
decline; confusion (confabulation common) Stage 5 = moderate cognitive decline; early
NCD (begins to lose independence) Stage 6 = moderate-to-severe cognitive
decline; middle NCD (disorientation) Stage 7 = severe cognitive decline; late
NCD (bedfast, aphasic, and immobile)
Medications for Clients with NCDMedications for Clients with NCD Cholinesterase inhibitors
– Treats cognitive impairment– Side effects: dizziness, headache, GI upset– Examples: tacrine (Cognex), donepezil
(Aricept), and rivastigmine (Exelon) Antipsychotic agents
– Treats agitation, aggression, hallucinations, thought disturbances, and wandering
– Side effects: headache, dizziness, drowsiness– Examples: risperidone (Risperdal),
olanzapine (Zyprexa), quetiapine (Seroquel), and haloperidol (Haldol)
Antidepressants– Treats depression, depression-related
insomnia– Side effects: headache, drowsiness/dizziness– trazodone (Desyrel), mirtazapine (Remeron)
Anxiolytics– Treats anxiety– Side effects: drowsiness/dizziness, GI upset– lorazepam (Ativan)
Sedative-hypnotics– Treats insomnia– Side effects: headache, drowsiness/dizziness– zolpidem (Ambien), eszopiclone (Lunesta)
Nursing Care for Clients Nursing Care for Clients with Cognitive Impairmentwith Cognitive Impairment
Promote client safety– remain with client at all times to monitor
behavior and provide reorientation and assurance
– maintain room in low level of stimuli Frequently orient client to reality
– use clocks and calendars with large numbers
– allow client to have personal belongings Preserve the dignity of the client Help client’s family/primary caregivers
to facilitate care Assist in dealing with caregiver burnout
Keep explanations simple– use face-to-face interaction– speak slowly and do not shout
Discourage rumination of delusional thinking– talk about real events and real people
Monitor for medication side effects Allow plenty of time for client to perform
tasks Follow usual routine as closely as possible
with regard to ADLs Provide guidance and support for
independent actions by talking the client through the task one step at a time
Brief Psychotic DisorderBrief Psychotic Disorder Sudden onset of psychotic symptoms that
last at least 1 day but less than 1 month May or may not be preceded by a severe
psychosocial stressor Full recovery to premorbid level of function
Schizophreniform DisorderSchizophreniform Disorder Identical to schizophrenia with the
exception of duration (symptoms last at least 1 month but less than 6 months)
Prognosis is good, with full recovery to premorbid level of function likely
Schizoaffective DisorderSchizoaffective DisorderDiagnosis of both schizophrenia and a mood disorder, such as MDD
Delusional DisorderDelusional DisorderPresence of one or more nonbizarre delusions that persist for at least 1 monthHallucinations are not present or are not prominentBehavior is not bizarreDelusions may be erotomanic, grandiose, jealous, persecutory, or somatic in nature
Types of Delusional DisorderTypes of Delusional DisorderErotomanic = Belief that someone (usually famous) is in love with oneselfGrandiose = Irrational ideas regarding one’s own worth, talent, knowledge, or powerJealous = Belief that one’s sexual partner is unfaithful in the absence of substantiationPersecutory = Belief that one is being treated malevolently in some waySomatic = Belief that one suffers from a physical defect, disorder, or disease (such as an internal parasite or infestation of insects in/on the skin)
SchizophreniaSchizophrenia Disturbance in thought processes, perception,
and affect that results in severe deterioration of social/occupational functioning
Symptoms categorized as positive or negative– Positive symptoms = in excess of normal function
Hallucinations, delusions, disorganized behavior, disorganized thinking and speech
Good response to antipsychotic medications
– Negative symptoms = deficit in normal function Affective flattening, alogia (poverty of speech), avolition
(inability to initiate goal-directed activity), apathy, anhedonia, social isolation
Poor response to treatment/medication
Phases of SchizophreniaPhases of Schizophrenia Phase I: Premorbid Phase
– indifferent to social relationships– appear cold and aloof– does not always progress to schizophrenia
Phase II: Prodromal Phase– social withdrawal– peculiar or eccentric behavior– bizarre ideas– unusual perceptual experiences– neglectful of personal hygiene and
grooming– lack of initiate, interests, or energy– phase may last for many years
Phase III: Schizophrenia– delusions and/or hallucinations– disorganized speech– disorganized or catatonic behavior– affective flattening– marked decrease in level of functioning– persists for at least 6 months
Phase IV: Residual Phase– usually follows active phase of the disease– flat affect and impairment in role
functioning– residual impairment usually increases after
each exacerbation with active disorder
Medication Management of Medication Management of SchizophreniaSchizophrenia
Typical antipsychotic agents– Side effects: nausea, sedation, EPS– Examples: chlorpromazine (Thorazine),
fluphenazine (Prolixin), and haloperidol (Haldol) Atypical antipsychotic agents
– Side effects: drowsiness, dizziness, constipation, dry mouth, headache, nausea/vomiting, EPS
– Examples: quetiapine (Seroquel), olanzapine (Zyprexa), clozapine (Clozaril), ziprasidone (Geodon), aripiprazole (Abilify), risperidone (Risperdal), and paliperidone (Invega)
Use nonconfrontational speech and mannerisms
Encourage communication and expression of feelings and fears
Decrease stimuli and offer quiet activity Seek clarification of statements Provide recognition for constructive self-
care activities Make adjustments in food preparation and
service for patients with paranoia Establish therapeutic rapport by listening,
sharing observations, and accepting silence
Patient Education for Clients Patient Education for Clients with Cognitive Impairment or with Cognitive Impairment or
Thought DisorderThought Disorder
Nature of the illness (causes, symptoms) Management of the illness
– ways to ensure client safety– how to maintain reality orientation– providing assistance with ADLs– nutritional information– difficult behaviors– medication administration– matters related to hygiene and toileting
Support services– financial/legal assistance– support groups and respite care
Nursing Process for Nursing Process for Clients with Cognitive Clients with Cognitive
Impairment or Thought Impairment or Thought DisorderDisorder
Assessment– information gathered from a number of
sources because client is likely to be a poor historian
Diagnosis– disturbed thought processes R/T delusions
(or concrete thinking or paranoia) AEB bizarre statements and behaviors
– disturbed sensory perception R/T hallucinations (or illusions) AEB inability to tolerate group therapy, talking to self, or looking for or at something that is not there
– self-care deficit R/T withdrawal and loss of motivation and judgment AEB poor hygiene, poor grooming, and avoiding others
Planning– development of the nursing care plan
Intervention– rapport building– limit-setting– communicating expectations– client/family education
Evaluation– focus is on short-term goals as opposed to
long-term goals– resolution of identified problems is
unrealistic– outcomes must be measured in terms of
slowing down the process rather than stopping or curing the problem