Chapter 22. Confusion. Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier, Inc.

Transcription

1 Chapter 22 Confusion 1

2 Delirium Definition: short-term confusional state with sudden onset and is typically reversible 2

3 Delirium May be difficult to engage in a conversation, and questions often must be repeated several times Impaired recent memory is common, along with disorientation and language problems May misinterpret what is going on in the environment; may develop delusional thinking and experience hallucinations 3

4 If you are working in a long-term facility and a normal resident begins To show signs of delirium.. Ax. What? 4

5 Dementia Several types of dementia Alzheimer s disease* vascular dementia* Pick s disease Huntington s disease Creutzfeldt-Jakob disease 5

6 Dementia Chronic and irreversible; memory impairment and many other cognitive deficits Impaired intellectual function, problem-solving ability, judgment, memory and orientation, and inappropriate behavior 6

7 Interventions: Delirium 7

8 Disturbed Thought Processes Private room with continual supervision. Near Nurses station Lighting soft and diffuse to avoid shadows that may be misinterpreted and add to patient s fears Familiar objects, such as pictures, a clock, and a large calendar, placed in the room can help orient the patient to time and person 8

9 Figure

10 Disturbed Thought Processes Communication with a confused patient should be simple and direct Anyone dealing with a delirious patient should be calm, warm, and reassuring 10

11 Disturbed Thought Processes Hallucinating patients need one-to-one nursing observation and repeated verbal reorientation Frequent orientation to the surroundings and the situation is important Simple, direct statements better than questions 11

12 Disturbed Sleep Pattern Sleep deprivation can cause or contribute to disorientation and confusion Presence of a family member may help calm an agitated and confused patient 12

13 Figure

14 Risk for Injury Patient may pull on tubes, try to get out of bed unassisted, or attempt to leave the setting Ask a family member to remain with the patient or assign a staff member to do so Avoid arguing with delirious patients 14

15 Interventions: Dementia 15

16 Imbalanced Nutrition: Less Than Body Requirements Assist with meals: cutting food or total feeding Finger foods high in protein and carbohydrates allow patients to feed themselves more easily Small, frequent meals less confusing to patients. Remove distractions from the eating area 16

17 Disturbed Sleep Pattern Sleep and awakening are often reversed Try to keep them awake during the day and get them to sleep at night 17

18 Risk for Injury A safe, structured environment is essential for a person with dementia Lock doors and move locks if necessary 18

19 Disturbed Thought Processes/Impaired Verbal Communication Communication should be simple and direct Patients must be approached gently, calmly, and quietly Nonverbal communication is extremely important Look for cues from actions and facial expressions because patients often are not able to express their needs verbally When patients resist activities such as bathing or dressing, avoid confrontations 19

20 Figure

21 Nursing Care Guidelines for working with dementia patients They usually forget things relatively quickly They are usually unable to learn new things 21

22 CDA: Principles Accept that the patient may no longer be able to make adult decisions and behave as a healthy adult would. Offer limited choices to simplify decision making Adapt the environment to the patient rather than trying to adapt the patient to the environment Encourage self-care at whatever level the patient can function. If the patient can eat independently with the hands but not with utensils, provide finger foods 22

23 Cause unknown Multiple Sclerosis (MS) Aggravated by cold Most common in young adults, northern temp climates 23

24 MS Myelin sheath covering nerves in CNS destroyed* 24

25 MS Slow paralysis Slowly developing speech and vision disturbance 25

26 S/S: Difficult to dx Remissions and exacerbations* Disabilities develop with time 26

27 S/S: Difficulty walking Blurred/double vision Slurred speech 27

28 S/S: Bowel/Bladder problem Emotional ups/downs 28

29 Diagnostic Tests MRI - best to detect change in myelin sheath 29

30 Medical Treatment Build up general health Balance activity/rest* Balanced diet Avoid exposure P.T. - maintain strength 30

31 Nursing Considerations Body positioning Prevent respiratory complications* Energy conservation* 31

32 Parkinson s Disease 2nd most common neuro disease - elderly Progressive brain ds Bradykinesia Fine rhythmic tremor 32

33 Blinking Eating Talking Walking Affects Automatic Maintaining posture Movements 33

34 Features: Tremors (pillrolling)* Rigidity Slow voluntary movemt Shuffling, unsteady gait Unstable posture Masklike appearance* 34

35 Parkinson s Mental changes often accompany Usually affects men around age 60 Cause unknown Disruption of dopamine 35

36 Medical TX Levodopa (L-Dopa)* - replaces missing dopamine - No vitamins, esp B-6* - No MAO inhibitors 36

37 Other Parkinson meds: Symmetrel* Parlodel* Sinemet - Carbidopa/Levodopa Permax Eldepryl 37

38 Medical TX P.T. Nutrition important - Protein may lower L-Dopa absorption Carbs and fat good for calories Easy to eat foods Watch out for herbal remedies* 38

39 Nursing Considerations Encourage self-care Food prep Safety Meds on time Prevent complications Adaptive devices DX Selfcare defecit * 39

40 Guillain-Barre Syndrome Cause unknown (Polyneuritis) Inflammation of nerve roots and spinal cord Rapid progressive symmetrical loss of motor function 40

41 Guillain- Barre Varying degrees of motor weakness and absent reflexes Sensory nerves remain intact Weakness to paralysis 41

42 Guillain-Barre Usually begins in lower extremities & ascends Recovery slow Often complete 42

43 Suctioning ** Nursing Care Watch for signs of increased res. Distress Pulse?, Res?,Breath sounds? Immobility tx Emotional support Ventilation Nutrition Elimination 43

44 Amyotrophic Lateral Sclerosis (ALS) Lou Gehrigs Disease Rapidly progressive Destruction of cortical, brain stem, spinal cord motor neurons 44

45 Occur between ALS in men Always fatal 45

46 Early S/S: Weakness Fatigue Spasticity of upper ext 46

47 Progressive S/S: Muscle atrophy Flaccid quadriplegia Resp muscle paralysis Intellectual / Sensory function retained Depression highly likeable 47

48 Myasthenia Gravis An autoimmune response that for some reason Blocks acetylcholine in the synapse 48

49 Myasthenic Crisis Occurs rapidly Precipitating factors-temp extremes/infections Dysphagia Dysarthria / Dysphasia Ptosis, Diplopia Resp distress 49

50 Myasthenic Crisis Maintain open airway Meds on time!! 50

51 Medical Tx of MG Anticholinesterase - Prostigmin - Mestinon Must be given on time! 51

52 Nursing Considerations Airway / secretions Feeding Pt teaching 52

53 Bell s Palsy Acute paralysis of Facial Nerve (CN #7) Often begins with pain behind the ear or on the face Drawing sensation and then paralysis Most recover in weeks/months S&S Facial droop Eye on affected side does not close Affected side of mouth cannot be controlled Speaking and eating issues Taste impaired 53

54 Bell s Palsy Medical Treatment Prednisone and Analgesics Artificial tears Eye shield at night When function returns: Facial exercises Nursing Interventions Much concern about appearance 54

55 Huntington Disease Inherited degenerative neurologic disorder Any child of an affected parent has a 50% chance of inheriting the disease Usually begins in middle adulthood with abnormal movements, emotional disturbance, and intellectual decline Symptoms progress steadily: increasing disability and death in 15 to 20 years Medical and nursing care are supportive only; there is no cure 55

56 Trigeminal Neuralgia AKA: Tic Douloureux Characterized by: Intense pain along Trigeminal Nerve (CN # 5) Abrupt onset Usually unilateral Lasts from seconds to a few minutes No associated motor/sensory deficit Pain may be crippling, restricting pt. routine 56

57 Trigeminal Neuralgia Attacks may have triggers: Ingestion of hot/cold liquids Chewing Shaving Washing face Breeze Cause: Undetermined; trauma; nerve compression 57

58 Trigeminal Neuralgia Medical Treatment Pharmacologic management To suppress pain episodes Phenytoin (Dilantin); carbamazepine (Tegretol) During attack Alcohol or phenol injected into nerve Pain relief may last 8 16 months Surgical Intervention: For debilitating pain Electrocoagulation 58

59 Meningitis Cause Bacterial or viral infection of the Meningies S&S Headache Nuchal rigidity Positive Kernig s sign and Brudzinski s sign ICP 59

60 Meningitis Tx Antibiotics if.. 60

61 Meningitis Inflammation of the meningeal coverings of the brain and spinal cord caused by either viruses or bacteria Signs and symptoms Headache, nuchal rigidity, irritability, diminished level of consciousness, photophobia, hypersensitivity, and seizure activity Positive Kernig sign and Brudzinski sign 61

62 Meningitis Medical diagnosis Lumbar puncture to obtain CSF for lab analysis Medical treatment Bacterial infections usually respond to antimicrobial therapy, but no specific drugs effective against most viral infections Anticonvulsants used to control seizure activity if necessary 62

63 Meningitis: Nursing Care Assessment Assess vital signs and neurologic status frequently to determine further deterioration or onset of complications Health Promotion Pts. with meningitis and those in contact 63

64 Meningitis: Nursing Care Nursing Diagnosis/Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Acute Pain Risk for Injury Deficient Fluid Volume 64

65 Nursing Considerations Baseline Neuro assessment Droplet precautions Seizure precautions HOB Quiet environment; dark room Control fever Admin antibiotics Admin stool softeners Do not flex neck Avoid hip flexion 65