Cognitive Disorders

1. Cognitive Disorders Recognize the signs & symptoms Psychopathology of Alzheimer’s dis Nursing diagnoses & care plan

2. Category • Delirium: alterations in consciousness & cognition; reduced ability to focus, sustain, or shift attention; sensory misperception; psychomotor agitation. • Dementia: memory & cognition disturbances. Gradual in onset and progressive in course • Amnestic disorder: memory impairment (inability to learn, to recall) • Others

3. Delirium • Etiology – • physical dis. - Ac or chr. Illness ie. fever … • substance Abuse - • unknown • Tx – • Causes; med.; environment • Px - poor

4. Common causes of delirium • Substances – CNS stimulants/ depressants • Infections – meningitis, pneumonia … • Meta. Dis – hypoxia, hypoglycemia, electrolyte imbalance, Vit B1 deficiency (Wernicke’s encephalopahty), hyper/ hypothermia • Drugs – digitalis, lithium, • Neurological dis – seizures, head trauma … • Tumor – • Psychosocial stressors -

5. Dementia • S/S – confused, impaired judgment/ attention span, alteration in memory/ perception, … • Alzheimer’s dis • 50-75% of dementia • F > M • Average victim living – 8-10 years

6. 4 As in dementia • Amnesia • memory impairment • Aphasia • language disturbance • Apraxia • unable to perform motor activities • Agnosia • difficulty in identifying objects

7. Alzheimer’s disease • Etiology - Genetic; Toxin; Infection; Cholinergic function deficit • Tx –Med. • Tacrine (Cognex), may hurt liver • donepezil (Aricept), less hepatoxity, enhance cholinergic function • NSAIDs, • steroids, Vit E, antioxidants • Family considerations

8. Parkinson’s Disease • S/S –involuntary movements, tremor, bradykinesia, rigidity, monotone, confused, depressed, disoriented • Etiology – extrapyramidal system, dopamine deficiency • 2% of 65 y/o and older; F = M

9. Huntington’s Disease • S/S – uncontrollable, hyperkinetic, memory loss, paranoia, irritability, … • Onset – 25-45 y/o; F = M • Incidence – 5/100,000 • Etiology – 50% genetic • Complications – heart failure, pulmonary complications -> death

10. Alcoholic Dementia • Victim – 15-20 years history of drinking • Etiology -> toxic to neurons; nutritional deficit; damage to major organs • S/S – amnesia, slowness of thinking, impaired judgment, Wernicke’s encephalopathy, Korsakoff’s psychosis (neurodegenerative processes; confusion, short-term memory loss)

11. Acute onset; duration is hours to days Fluctuating levels of consciousness Disorientation is most severe at night Visual, tactile hallucinations Could be life-threatening Insidious & progressive; M to years Short/long term memory are affected No or slow change on EEG Aphasia & agnosia Confabulations or preservation Delirium & Dementia

12. Onset slow & progressive Hide cognitive losses with confabulation Affect is shallow & labile Disorientation Attention & concentration poor Unstable personality “near miss” answers Relatively rapid, can trace to distressing event/ situation Can recall recent events Pervasive depression Oriented to P. P. T Personality remains stable “Don’t know” answers Changes in appetite, BW, & sleep pattern Dementia & Depression

13. Common N. Dx • Health maintenance, Altered • Self-care deficit • Social interaction, impaired • Thought processes, altered • Communication, impaired • Coping, ineffective individual/ family

14. Nursing Care • N-Pt R – • Psychopharmacology – • Antipsychotics: Atypical > typical • Antidepressant: SSRI > TCA • antianxiety agents: Ativan, Serax, BuSpar • Milieu management – stimuli, routine, safe, stress reduction (inc. physical stressors), reminiscence group

15. Nursing Care (cont’d) • Break tasks into very small steps • Speak slowly & in a face-to-face position • Allow the client to have familiar objects around him/her -> reality orientation, self-worth, dignity • Encourage caregivers to express feelings • Provide a list of community resources, support groups, …

16. Delirium – acute, night, causes, 25-65% of elderly hospitalized clients, Dementia – chr, gradual in onset, progressive in course, elderly, 4As (amnesia, apraxia, aphasia, agnosia) Cognitive disorder Amnestic disorder Others

18. Eating Disorders Criteria for diagnoses Signs & symptoms Etiology Issues in treatment Care plan

19. Significance • Eating disorder strikes earlier in adolescence; prevalence is 0.5-2% in US. • The average age dropped from 14.5 years in 2001 to 12 years in 2003 • Eating disorders ranked as the nation’s 3rd worst health problem for girls younger than 18, trailing obesity and asthma • High-achieving children from successful, middle-class families were most vulnerable • culture bound syndrome in White society

20. Anorexia Nervosa (Dx) • Refusal to maintain BW at a minimum level • Fear of gaining weight • Overvaluing of shape or weight or denial of seriousness of low weight • Absence of at least 3 consecutive menstrual cycles • Restricting & binge-eating/purging type

21. Anorexia Nervosa • Insidious onset on the “perfect little girl” • Category: dieter & purgers • Socially isolated/withdrawal • Competitive & obsessive about their activities • Complications: hypotension, bradycardia, hypothermia, constipation, dry skin,… • Mortality rate : 8-18%

22. Etiology • Biological – G-I problems, serotonin level • Sociocultural – thin ideal • Family – genetics, enmeshed R, conflict… • Cognitive – attention calling, controlling • Behavioral - reinforced • Psychodynamic – Freud’s basic drive

23. Interesting numbers

24. Nursing Diagnoses • Altered nutrition: less than body requirements • Decreased cardiac output • Risk for injury (electrolyte imbalance) • Body image disturbance • Anxiety • Low self-esteem

25. Nursing Care • IPR – enemy vs. ally • Close observation • Body weight, eating behavior, activity level • Self-esteem – listening, strengths, • Making contract with the client • Health education – weightlifting > running • Family involvement, social skill training • Others: anxiety, depression …

26. Bulimia Nervosa (dx) • Uncontrolled binge eating • Control shape and weight by extreme dieting, excessive exercising, self-induced vomiting, taking laxatives or diuretics, using diet pills, abuse of enemas • Persistent over concern with body shape and weight

27. Bulimia Nervosa • Adolescent or early adulthood; female • Chronic & intermittent • Anxious, lonely, bored, uncontrollable craving for food • Medical complications • Depression

28. Etiology • Biological – hypothalamic dysfunction • Sociocultural – • Family – enmeshed, noncohesive • Cognitive & behavioral – low self-esteem, extreme concerns about body shape and weight, strict dieting, binge eating, compensatory behavior • Psychodynamic -

29. Nursing Diagnoses • Altered nutrition: less than body requirements • Powerlessness • Fluid volume deficit • Ineffective individual coping • Disturbance in body image • Anxiety

30. Nursing Care • N-Pt R – help-seeking vs. manipulation • Pt’s feeling about their behaviors • Respect vs. embarrassment • Reinforce the strengths • Health education – sense of control • Social skill training vs. loneliness • Psychopharmacology - antidepressants

31. Dieting Myths • Myth 1: Skipping meals is a good way to lose weight • Myth 2: fasting is a good way to cleanse the body • Myth 3: Eating after 8pm causes weight gain • Myth 4: Certain foods, like grapefruit or cabbage soup, can burn fat.

32. Dieting Myths (cont’d) • Myth 5: Eating red meat makes it harder to lose weight. • Myth 6: You must avoid all fast food when dieting • Myth 7: Low-fat and no-fat foods are much lower in calories

34. Sexual Disorders Nurses’ role in assessing the problems Categories of sexual disorders Causes of the disorders Related issues

35. Issues involved • Legal – consent vs. coercion • Moral – norms, standards, values • Effect – level of functioning, self-concept, self-esteem, relationships with others • Sexuality – experience of one’s sexual self • Diverse sexual expression = f (genetics, individual preferences, experiences, culture, and health)

36. Categories • Sexual dysfunction disorders • Sexual response cycle. • Emotional, physiological, medications, chemicals • Paraphilias • Pedophilia, exhibitionism, voyeurism, incest, fetishism, frotteurism, sexual masochism, sexual sadism • Lifelong, chr. disorder • Gender identity disorders – transexualism • Depression due to difficulty finding an accepting partner

37. Criteria for gender identity disorder-Children • A strong & persistent cross-gender identification • Stated desire or insistence that he/she is the other sex • In boys, dressing in female attire; in girls, wearing only masculine clothing • Make-believe play or fantasies of being the other sex • Desire to participate in games & pastimes of other sex • Prefers playmates of other sex • Feelings of discomfort with own sex or inappropriateness in gender role of own sex

38. Criteria for gender identity disorder-Adolescents & Adults • A strong & persistent cross-gender identification • Stated desire to be the other sex • Frequently passes as the other sex • Desires to be treated as the other sex • Conviction that he/she has typical feelings & reactions of other sex • Feelings of discomfort with own sex or inappropriateness in gender role of own sex

39. Female sexual dysfunction

40. Male sexual dysfunction

41. Biological Causes of Sexual Disorders • General illness – cold, fatigue, influenza, renal and urologic disorders • Severe and persistent dis – DM, MS, • Hormonal disorder – hypopituitary dis. DM. • Alcohol and drug use • Pain – arthritis, back pain, obesity, vaginal infection, • Age – • Others – radiation therapy

42. Drug-induced sexual dysfunction • Alcohol – libido, sperm production • Tobacco – small peripheral vasculature • CNS depressants – benzodiazepine ie Valium • Barbiturates – phenobarbital, secobarbital • Antipsychotics – Thorazine, Mellaril, Stelazine • Antidepressants – Elavil, Tofranil, Norpramin, • Anticonvulsant – Dilantin, • Others – Lithium, Marijuana, Cocaine, Inderal,

43. Psychological Causes of Sexual Disorders • Ignorance, lack of knowledge • Anxiety, fear of failure , poor body image • Partner’s or self’s demand for performance • Judgmental thought • Poor relationship choices – lack of trust, power struggles • Childhood or adult sexual abuse or trauma • Major life change, lose partner

44. Nursing diagnoses • Altered family process • Altered sexuality patterns • Anxiety • Ineffective coping • Knowledge deficit • Social isolation • Potential for violence: self-directed or other

45. Nursing Care • Nurse-patient Relationship – accepting, empathic, nonjudgmental, • Self-awareness – discuss feelings with colleagues • Communication tech – • Sexuality – comfort level, privacy • Referrals – commonly used • Support groups for perpetrators and victims • Legal obligation – mandatory report of sexual abuse of children

46. Dealing with the sexually inappropriate client • Set limit – firm, clear, consistent • Documentation – • client’s behavior (from the 1st episode throughout the history) • N’s actions taken • Consult with supervisor – getting support • Removing self from any contact with the client • Legal action

47. Tips for Communication • Giving rationale for question • Giving statements of “generally”“normally” • Identifying sexual dysfunction • Identifying sexual myths • Identifying feelings about masturbation, homosexuality • Obtaining and giving information • Closing the history – other questions?

48. Conclusions • Sexual dysfunctions r/t psychological, physiological, & pharmacological factors • Paraphilias involve sexual activity with objects, children, and consenting or nonconsenting adults • Efforts to achieve sexual pleasure do not give individuals the right to violate the rights of others through coercion & control • Gender identity disorder in adults involves persistent discomfort with one’s biological sex. • N helps the pt to discuss his feelings about himself & his problems. N ’s primary role is referral;

50. Psychiatric Nursing & Special Populations Care for victims of violent behavior Care for the child & adolescent Care for the pregnancy Care for the elderly