Unit 4 Objective Knowledge Check
Human Immunodeficiency virus infection (HAND)
25% will develop minor neurocognitive deficits 5% will have major deficits Symptoms: memory lapses, decreased ability to concentrate and comprehend, impaired motor skills
Dementia with Lewy Bodies
2nd in prevalence to Alzheimer's disease Cardinal: cognitive impairment, visual hallucinations, extrapyramidal signs progressive cognitive impairment and fluctuating attention and alertness recurrent visual and auditory hallucinations Parkinsonian features REM sleep Behavior disorder Quick Disease Progression Tends to be underdiagnosed and confused with alzheimer's Adverse effects if neuroleptic drugs given
vascular neurocognitive disorder
65 years and older cerebrovascular disease abrupt onset symptoms associated with the area of infarction or microvascular disease Risk Factors: hypertension, diabetes mellitus, previous stroke, cardiac arrhythmias, coronary artery disease, tobacco use, and alcohol or substance use Treatment: focuses on the patient's medical problems and health care issues. Geared towards interventions designed to minimize the risk factors and subsequently reduce vascular damage
Discuss the DSM-5 criteria for the major neurocognitive disorder.
A. Evidence of significant cognitive decline from previous levels of performance in one or more cognitive domains based on: 1. concern of the individual, a knowledgeable information, or a clinician 2. a substantial impairment cognitive performance, preferably documented by standardized neuropsychological testing or in its absence another quantified clinical assessment. B. cognitive deficits interfere with independence in everyday activities C. cognitive deficits do not occur exclusively in the context of a delirium D. cognitive deficits are not better explained by another mental disorder
Describe DSM-5 criteria for Bulimia Nervosa.
A. recurrent episodes of binge eating 1. eating in a discrete period of time (2hrs), an amount of food that is definitely larger than what most individuals would eat 2. a sense of lack of control over eating during the episode B. recurrent inappropriate compensatory behavior in order to prevent weight gain (vomiting, misuse of laxatives, diuretics, fasting, excessive exercise) C. binge eating and inappropriate compensatory behaviors occur at least a week for 3 months D. self evaluation is unduly influenced by body shape and weight E. disturbance does not occur exclusively during episodes of anorexia nervosa
Describe DSM-5 criteria for anorexia nervosa.
A. restrictions of energy intake relative to requirements leading to significant low body weight B. Intense fear of gain weight or becoming fat, o persistent behavior that interferes with weight gain C. disturbance in the way in which one's body weight or shape is experienced Subtypes: restricting and binge eating/purging
Discuss possible etiologies for Anorexia Nervosa.
Biologic Factors: serotonin Levels Sociocultural factors: physical attractiveness family factors cognitive and behavioral factors psychodynamic factors: control
Discuss possible etiologies for Bulimia Nervosa.
Biologic factors sociocultural factors family factors cognitive and behavioral factors psychodynamic factors
Identify subjective signs for Bulimia Nervosa.
Body shape concerns fear of weight gain anxiety and depression screenings self induced vomiting: - fingers, toothbrush, or eating utensils - marker food - ipecac syrup - diuretic and laxative use
Prion Disease
CJD, bovine spongiform encephalopathy (mad cow) dementia with psychiatric features rapid course with death in 12 months contact precautions Symptoms: dementia, personality changes, ataxia, seizures, myoclonic, impaired vision, and blindness No treatment, just symptom alleviation
Sexual Masochism Disorder
Can be consensual Recurrent, intense sexually arousing fantasies, urges, or behaviors involving the act of being humiliated, beaten, restrained, or otherwise made to suffer Example: humilcation, urination/defecation, hippophilia/erotic asphyxiation Increased risk of death
Fetishistic Disorder
Can be consensual recurrent, intense sexually arousing fantasies, urges, or behaviors that involve using nonliving objects (shoes or bras)
frontotemporal neurocognitive disorder
Caused by atrophy of the frontal and anterior temporal lobes of the brain Pick Disease Diagnosed in 50's and 60's Can have changes in Behavior or problems with language Symptoms: inappropriate social behavior, lack of social tact, lack of empathy, easily distracted, lack of insight, hpyersexulaity, changes in eating habits, agitation, blunted emotions, neglect of self and personal responsibilities, repetitive or compulsive behavior (hoarding/anhedonia) Poor prognosis due to rapid progress
Discuss psychotherapeutic management examples for patients with neurocognitive disorders.
Communication: genuine, honest, and respectful. accept patient's insistence, do not revert to reality orientation, do not create an untrue reality, attempt to address the patient's feelings, build trust, don't challenge scheduling: structured and predictable, patient centered, singular activities toileting: meticulous attention to personal hygine, schedule bathroom breaks every 2 hours nutrition: tailor dietary needs, serve smaller meals several times per day, finger foods, favorite foods, beverage supplements wandering: safe return armbands, lanyard with flash drive of emergency information
Distinguish between dementia and delirium.
Delirium - dementia rapid onset - slow onset acute development - chronic development results of another illness - primary illness Short term memory impaired - short term lost/long term impaired LOC fluctuating - LOC no change slurred speech - normal speech hallucinations - misidentifications anxiety and fear - wide range of emotions appears bewildered/frightened - appearance matches feelings
Describe Binge Eating Disorder.
Eating more rapidly than normal eating until feeling uncomfortably full eating large amounts of food when not feeling physically eating alone because of feeling embarrassed by how much is being eaten feeling disgusted with oneself, depressed, or very guilty afterward Risk Factors: childhood obesity, perfectionism, substance abuse, distorted body image, abuse history, PTSD Characteristics: normal to overweight, predominantly female sex, average age early 20s, eating in secret Treatment: CBT, Lisdexamfetamine, Antiepileptics (topiramate, zonisamide), SSRIs (fluoxetine)
Identify subjective signs of Anorexia Nervosa.
Fear Intense focus on weight helplessness psychological symptoms: depression, anxiety, irritability, social withdrawal, suicidal ideation
Sexual Dysfunction: arousal
Female sexual arousal disorder: inability to attain or maintain until completion Erectile Dysfunction: inability to attain or maintain until completion of the sexual activity
Parkinson Disease
Gradual onset Cognitive Decline: sleep disturbance depression anxiety hallucinations Symptoms: shuffling gait, resting tremors, difficulty starting/stopping movement, rigidity, masklike facial expressions, Bradykinesia, resting tremor, postural instability Medications: Levadopa
Sexual Disfunction
Impairment in: desire, arousal, orgasm, or pain during sex/masturbation Caused by: biological (medical impairments), psychological and psychosocial (stress), substances (drugs), and medications (prescriptions)
Sexual Dysfunction: orgasm
Male Delayed: decrease in or absence of an orgasm Premature: early orgasm Female Anorgasmia: inability or absence of an orgasm
What medications are used in the treatment of Alzheimer's disease?
Memantine (moderate to severe) Namzaric (moderate to severe) Tacrine (mild to moderate) Donepezil (mild to moderate Rivastigmine (mild to moderate) Galantamine (mild to moderate)
What are the stages of Alzheimer's disease?
Mild: memory loss confusion about location of familiar places taking longer to accomplish normal daily tasks trouble handling money/paying bills compromised judgment, oten leading to bad decisions loss of spontaneity and sense of initiative mood/personality changes; increased anxiety moderate: increasing memory loss/confusion shortened attention span problems recognizing friends/family difficulty with language/problems with reading/writing/working with #'s difficulty organising thoughts and thinking logically inability to adapt to new situations restlessness, agitation, anxiety, tearfulness, wondering, especially in the late afternoon or at night (sundowning) repetitive statements or movements hallucinations, delusions, suspiciousness paranoia, irritability loss of impulse control Severe: cannot recognize family/loved ones cannot communicate effectively completely dependent on others all sense of self vanished
What are the common causes of Alzheimer's disease?
Neural loss: plaques and tangles cholinergic neurons hallmark sign is atrophied brain Neurofibrillary tangles: abnormal accumulations of TAU Proteins collect inside neurons Neurofibrillary tangles: blocks the neuron's transport system, which impedes synaptic connections between neurons B-amyloid plaques: amyloid precursor proteins partly inside and partly outside the neurons breakdown of larger protein Genetics: 60-80 percent risk factor mutations of genes Hormones: natural decrease of sex steroid with age and deteriorating cognition
Frotteuristic Disorder
Not Consensual Recurrent, intense sexually arousing fantasies, urges, or behaviors that involve touching and rubbing against a nonconsenting person
Pedophilic Disorder
Not Consensual Victim: Child who is 13 years or younger Opposite-sex and/or same-sex children Pedophile: must be 16 or older and at least 5 years older than the victim can be delusional, physically aggressive, use coercion or use authority maybe heterosexual may use defense mechanisms: denial/rationalization Potential Risk Factors: antisocial personality disorder, history of sexual abuse
Exhibitionistic Disorder
Not Consensual recurrent, intense sexually arousing fantasies, urges, or behaviors involving exposing one's genitals to unsuspecting strangers
What is gender dysphoria?
Not a sexual Disfunction Clinical inconsistency between a person's birth gender and his or her desired gender Gender: attitudes, feelings, and behaviors that a given individual or social culture ascribes to person's biological sex Biological Sex: the biological indicates of male and female (sex chromosome, sex hormones, genitalia Etiology: no identified origin but it is thought to be caused by genes, hormonal influences in the womb, and environmental factors
Meds/treatment for sexual disorder and gender dysphoria
Paraphilic Disorders SSRIs Fluoxetine: pedophilic, fetishistic, exhibitionistic, and voyeuristic disorders Paroxetine: voyeuristic Disorders Fluvoxamine: exhibitionism disorders Escitalopram: transvestic and fetishistic disorders Steroidal Antiandrogens Medroxyprogesterone acetate: pedophilic disorder Gonadotrophin releasing hormone analogs triptorelin leuprorelin, goserelin: pedophilic disorder Other Treatments: CBT EMDR
What is the nurse's role in the psychotherapeutic management of caring for a client with a sexual disorder or gender dysphoria?
Perform an assessment provide privacy assess for signs of self harm and risk for suicide (high among gender dysphoric adolescents) Offer referrals make sure physical needs are met (wound care; nutritional status) Be accepting, empathic, and nonjudgmental establish a trusting, supportive rapport avoid projecting
Describe care, including treatment, nursing interventions, and nurse-patient relationships for patients with eating disorders.
Psychotherapeutic management Goals: Anorexia: increasing weight to at least 90% of the average body weight for the patient's height Bulimia: stabilize weight without purging\ Both: help patients reestablish appropriate eating behavior and increase self esteem Multidisciplinary approach cognitive behavioral therapy guided self help family based therapy Psychopharmacology Atypical antipsychotics: zyprexa SSRIs and SNRIs Fluoxetine: only FDA approved medication for bulimia. helpful with reducing binging, purging, and depression in bulimic patients. Helpful with mood disturbances Vitamin and electrolyte supplementation Milieu Support, observe, family involvement, consistency, alternative therapies, dietitians, group therapy
Sexual Disfunction: Desire
Sexual Aversion: avoid sexual activity Hypoactive sexual drive: low sexual activity
What is the difference between sexual dysfunctions and paraphilic disorders?
Sexual Dysfunction: a significant disturbance in a person's ability to respond sexually or to experience sexual pleasure Paraphilic Disorder: characterized by intense sexual urges focused on abnormal sexual activities or preferences. Do not have to engage for a diagnosis physically
Global Deterioration Scale
Stage 1: no cognitive decline experiences no problems in daily living Stage 2: very mild cognitive decline forgets names and locations o fobjects may have trouble finding words Stage 3: mild congitive delcine has difficulty traveling to new locations has difficulty handling problems with work Stage 4: moderate cognitive delicne has difficulty with ocmplex taseks (finances, shopping, planning fo geusts) Stage 5: moderalty severe congitive decline needs help to choose clothing needs promtping to bathe Stage 6: severe cognitive decline needs help putting on clothing requires assistance bathing; may have a fear of bathing has decreased ability to use the toilet or is incontinent stage 7: very severe cognitive decline vocabulary becomes limited, eventually no or only single words are spoken loses ability to walk and sit becomes unable to smile
What patients are most at risk for developing Alzheimer's?
Women old age
Dementia
a slow deterioration of cognitive abilities that affect learning and memory, complex attention, perception, language, behavior, affect, and motor movements
What are the clinical symptoms of patients with delirium?
acute fluctuations in attention, cognition, and awareness, slurred speech, disorientation, confusion acute onset (hallmark sign)
What are common conditions leading to dementia?
alzheimer disease (most common) dementia with lewy bodies Frontotemporal dementia Parkinson disease dementia Vascular dementia
Huntington Disease
autosomal dominant 30-40 Y/O Symptoms: chorea, slowed cognition, attention deficit, aphasia, short term memory loss, depression Increased suicide rate Pneumonia is primary cause of death treatment: Supportive; tetrabenazine and deuterobenzene for tardive dyskinesia and HD chorea; antipsychotics ease chorea and control hallucinations, delusions, and aggression
Identify objective signs of Anorexia Nervosa.
deliberate weight loss enamel loss hypotension bradycardia hypothermia slowed abdominal peristalsis abnormal labs cachexia osteopenia/osteoporosis
Identify objective signs for Bulimia Nervosa.
enlarged parotid and salivary glands Russell's Sign (scrapping on knuckles) dental erosion fluid and electrolyte abnormalities: dehydration, reflex constipation, and rebound edema dizziness fatigue amenorrhea weight range varies
Sexual Dysfunction: pain
genito-pelvic pain/penetration: pain during intercourse not caused by drugs, lack of lubrication, or size Solution: treat underlying cause; therapy, medication, lifestyle changes
What are the three types of delirium?
hyperactive: alcohol withdrawal or intoxication, drug abuse, restless, agitated, hallucinations, delusions hypoactive: hepatic encephalopathy, hypercapnia, common in older adults, mimic depression, delayed responses, apathy, lethargy, fatigue, quickly falling back to sleep, and stupor mixed: symptoms of hyper and hypoactive delirium, fluctuating levels of activity
Traumatic Brain Injury
leading neurocognitive disease under 45 sustained from trauma to the head amnesia, neuro deficits emotinal, behavioral and social distrubances Give family and patient support chronic condition Symptoms: irritability, frustration, anxiety, lability, apathy, suspiciousness, aggression, headache, fatigue, sleep disturbances, vertigo, tinnitus, anosmia, forgetfulness, seizures, hemiparesis, cranial nerve deficits
Describe Milieu management for patients with neurocognitive disorders.
make patient conformable room temperature and lightening to patient's preference seek to reduce noxious sounds television is okay if it's what patient wants
What are the etiologies of delirium?
medical condition, medication, substance intoxication/withdrawal, exposure to a toxin EX: pneumonia, myocardial infarction, urinary tract infection
Discuss the clinical findings of Alzheimer's disease.
memory loss word finding difficulty difficulty concentrating misinterpreting the environment delusions illusions somatic preoccupations misidentification sundowning loss of the ability to care for oneself The 4 A's: Apahsia (deterioration of language function) Apraxia (impaired motor function) Agnosia (inability to recognize names of objects) Executive functioning (inability to think abstractly)
Delirum
most common complication in hospitalized older adults ICU psychosis reversible with treatment Medical emergency Treat: hydration, access to eyeglasses/hearing aids, early ambulation, adequate sleep, and social engagement.
Voyeuristic Disorder
recurrent, intense sexually arousing fantasies, ureges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity
Sexual Sadism Disorder
recurrent, intense sexually arousing fantasies, urges, or behaviors involving acts in which the psychological or physical suffering of a victim is sexuadlly exciting to the person Partners can be consenting (yay) or coerced (boo)
Transvestite Disorder
recurrent, intense sexually arousing fantasies, urges, or behaviors involving cross dressing or dressing as the opposite sex different dressing what appears to be outside of society norms sexual arousal has to be reported from the act
Nursing Diagnosis for sexual disorders
sexual dysfunction related to physical or psychosocial abuse Ineffective sexuality pattern related to conflicts with sexual orientation or variant preferences disturbed personal identity related parenting patterns that encourage culturally unacceptable behaviors for assigned gender Impaired social interaction related to socially and culturally unacceptable behavior Low self esteem related to rejection by peers
alcohol induced Neurocognitive disorder
wenicke-korsakoff syndrome: confusion, ataxia, nystagmus, Thiamine deficiency Confabulation, antegrade amnesia, fatigue, apathy, diplopia, concentration difficulties Wernicke encephalopathy: medical emergency Triad: confusion, ataxia, abnormal extraocular movements thiamine replacement is crucial
