Exam 3
the nurse finds a client with schizophrenia lying under a bench in the hall. The client says "God told me to lay here" what is the best response by the nurse?
"I didnt hear anyone talking; what else did you hear god say?"
Cardinal symptoms of delirium
- inability to direct, focus, sustain, and shift attention - abrupt onset with clinical features that fluctuate with periods of lucidity - disorganized thinking and poor executive functioning - agitation, anxiety, disorientation
Anosognosia
A condition in which a person with an illness seems unaware of the existence of his or her illness. Resistant to help
Depressant toxicity
Agitation, confusion, lethargy, nystagmus, dysrhythmia, rapid/ weak pulse
Alzheimer's pathophysiology
Amyloid plaques and neurofibrillary tangles, loss of connection between neurons, neuron death
Flumazenil
Antidote to depressants. Short half life may require many doses.
2nd generation drugs
Aripiprazole Clozapine- side effect neutropenia Lurasidone Olanzapine Risperidone Quetiapine Ziprasidone
Signs of alcohol use
Ascites, jaundice, fatigue, abdominal discomfort
The home health care nurse visits an older adult couple living independently. The wife cares for the husband, who has mild Alzheimer's Disease. Which intervention would the nurse implement for them?
Assess the wife for caregiver burden
meds for alcohol withdrawal
Benzos and barbs for seizures. Lorazepam iv for those who can't take po meds. Chlordiazoxide for those who can take po meds. Phenobarbital. Sedation for hyperactivity- dexmedetomidine. Propranolol and clonidine to stabilize vitals
Depressant withdrawal
Benzos and barbs. Hyperactivity during withdrawal, manifestations similar to alcohol withdrawal
Delirium tremens meds
Benzos, carbamazepine, valproate, chlorpromazine, haloperidol, chlordiazepoxide
A client with Alzheimer's dementia has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports that the client has increasing restlessness and agitation accompanied by nausea. Which advice would the nurse give the partner?
Bring the partner to the clinic for testing and a physical examination - the client is probably not having med issues, more likely a UTI
Alcohol screening tools
Cage, audit, niaaa, ciwaa
1st generation drugs
Chlorpromazine- Fluphenazine- Haloperidol- QT elongation (can cause fatal torsades) Loxapine Perphenazine Pimozide Thioridazine Trifluoperazine
delirium assessment tool
Confusion Assessment Method (CAM)
Treatment of neuroleptic malignant syndrome
Cooling blanket, antipyretic, antihypertensive, ekg monitoring. give bromocriptine, dantrolene (muscle relaxer)
Disulfiram
Daily oral medication to sustain abstinence of alcohol; type of aversion therapy Causes nausea, vomiting, sweating, palpitations, and hypotension if alcohol is consumed
Signs of iv drug use
Damaged veins, endocarditis, hepatitis/ hiv
Drug abuse screening tool
Dast
Signs of opiate and stimulant use
Decreased appetite, emancipated appearance, excessive diarrhea, dilated pupils(stimulant), pinpoint (opioids), restless, sweaty
Retrogenesis
Degenerative changes occur in reverse order in which they were acquired
Predictors of onset of delirium
Dementia, stress, surgery, sleep deprivation, pain, depression, disease burden, sedation, analgesia, anesthesia
Nursing management dementia
Distract, redirect, reassure, quiet/ non stimulating environment, safety, nutrition (feeding). Infection- uti, pneumonia
Alzheimer's causes
Exact cause unknown. Likely multiple factors. DM, head trauma, tbi, genetics
First generation have which side effect more often
Extra pyramidal symptoms
Nursing management delirium
Fluid/ electrolytes, neuro status monitoring, limit decision making, quiet/ non stimulating environment
Down Syndrome (Trisomy 21)
GI or heart defects. Immune disorders, spinal problems
AD Meds
Galantamine- early onset AD Donepizil- GI side fix Rivastigmine (Exelon)- GI side fx (available in a patch) N-Methyl-D-Aspartate (NMDA) Receptor Antagonist- memantine (namenda) protects brain nerve cells from glutamate
Chronic effects of alcohol abuse
Gastritis, pancreatitis, portal Htn, esophageal varices, ascites, thrombocytopenia (can't clot), jaundice
Opioid withdrawal symptom management
Gi meds for nausea or fluids. Acetaminophen for pain. Sedatives
Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care, because these clients have a need to do what?
Have sameness and consistency in their environment
CIWAA scale interpretation
Higher score means higher risk for seizure and need for meds
A client with a history of alcoholism if found to have wernicke encephalopathy associated with Korsakoff syndrome. what does the nurse anticipate will be prescribed?
IV infusions of thiamine
hyperactive delirium
Increased psychomotor activity, such as rapid speech, irritability, and restlessness
A healthcare provider prescribes disulfiram for a client who abuses alcohol. The nurse teachers the client that disulfiram will have which action?
It causes severe adverse reaction if alcohol is consumed. Example, N/V, hypotension, headache, tachycardia, tachypnea, flushing
Aphasia
Loss of language ability. Difficulty finding words -> speaks only a few words -> babbling or mutism
fetal alcohol spectrum disorder
Manifestations in baby: small upper lip, short nose, small head circumference, joint/ bone deformities, heart defects, slow physical growth
Strattera (atomoxetine) for ADHD
May take up to 6 weeks for therapeutic response. Used in pts with anxiety, active substance use disorders or tics. Side effects: GI disturbances, urinary retention, dizziness, fatigue, insomnia. Increased risk of liver injury and elevation in hr bp. Monitor liver panel and vitals. Extreme caution in pts w depression, may increase suicidal ideation.
AD manifestations
Memory loss, Less personal hygiene, decreased concentration, unpredictable behavior, delusions and hallucinations
Stimulant toxicity
Meth, cocaine, adhd drugs. Sympathetic overdrive. No antidote. Gastric lavage and activate charcoal which binds to stimulant
Stimulant meds for ADHD
Methylphenidate (Ritalin) Mixed amphetamine salts (Adderall). Risk of misuse and insomnia is a common side effect. Take med no later than 4pm. Other side effects: appetite suppression, headache, abdominal pain, lethargy
Dementia Assessment Tool
Mini mental state examination (MMSE)
Alzheimer's assessment tools
Mini-Cog, MMSE. Imaging- ct, mri, pet to see nerve cells
Opioid toxicity
Morphine, codeine, fentanyl, methadone, heroin. Agitation, confusion, lethargy, nystagmus, dysrhythmia, rapid/ weak pulse
Diminish alcohol cravings
Naltrexone, nalmefene, acamprosate, citalopram, ondansetron
1st generation drug side effects
Nms, eps
Chronic conditions in adults with Down syndrome
Obesity, sleep apnea, Alzheimer's, hypothyroidism congenital heart disease, cervical spine disease
Delirium meds
Only for severe agitation. Dexmedetomidine (Precedex)- for sedation in ICU. Haloperidol- Risperidone- Olanzapine (zyprexa)- Quetiapine- Lorazepam- short acting
Schizophrenia overview
Onset at 15-25 years old. More common in males. Delusions, hallucinations, disorganized speech, Catalonia, negative symptoms, functional impairment
Alcohol withdrawal
Peaks at 24-98 hours. Usually 48. Signs: agitation, anxiety, increased hr, diaphoresis, nausea, tremors, hyperactivity
Schizophrenia manifestations
Positive symptoms- delusions, illusions, hallucinations, alterations in speech Negative symptoms- less initiative, pleasure in activities, lack of emotional expression Cognitive symptoms- impaired memory, information processing, concrete thinking
FASD in adults
Problems w learning, memory, attention span, inappropriate sexual behavior
Phases of schizophrenia
Prodromal— onset, mild changes Acute- exacerbation of symptoms Stabilization- symptoms diminish, move toward previous level of function Maintenance- new baseline
What is Alzheimer's disease?
Progressive, irreversible, degenerative neurological disease characterized by loss of cognitive function and disturbed behavior. Forgetfulness progressing to inability to recognize familiar faces, places and objects
Treatment of extrapyramidal symptoms
Reduce dose. Goal is to restore dopamine and relax muscles. Benadryl, anticholinergic benztropine.
AD, dementia behavioral problems
Repetitiveness, delusions, hallucinations, aggression, altered sleep patterns, wandering, hoarding, resisting care
Alterations in behavior
Rigidity, motor restlessness, hard to speak or move, repitive behavior, echopraxia, little or no response to stimuli
The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain what?
Safety within the environment
Naloxone
Short acting antidote to opioids. Nalmefene lasts longer
Side effects of antipsychotics
Td, nms, eps, sedation, weight gain, agranulocytosis, hepatotoxicity
Vitamin deficiency in alcoholism
Thiamine- wernickes encephalopathy causing altered gait and ocular motor abnormalities. Korsakoff's syndrome is more severe and chronic form of wernickes Folic acid- aids in production of RBcs. Lack of leads to anemia
THINK (delirium)
Toxic situations Hypoxemia Infection, immobility Non pharmacological interventions K, electrolyte imbalances
late ad manifestations
Unable to communicate, cannot perform adls, becomes unresponsive and incontinent
Persevation
Unintentional repetition of a word or phrase
Alterations in speech
Word salad, clang association, neologisms, echolalia
2nd generation drug overview
a-typical. Blocks dopamine and serotonin receptors. Reduces negative and positive symptoms. Side effects- weight gain, dyslipidemia, type 2 dm
What is dementia?
acquired neurological syndrome characterized by progressive deterioration in intellectual functions, judgment, thinking, visuospatial skills, constructional abilities, language, memory, emotions and behavior.
delirium tremens
alcohol withdrawal delirium. 2-3 after last drink and can last 2-3 days. Tachycardia, high bp, convulsions, seizures, fever, hallucinations, confusion
schizophrenia is associated with both positive and negative symptoms. while assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion?
auditory hallucinations
Sundowning
becoming restless and agitated in the late afternoon, evening, or night
alpha 2 adrenergic agonists for ADHD
clonidine- guanfacine-
dysphasia
difficulty speaking
meds for alcohol abstinence
disulfiram, naltrexone, acamprosate
Opioid withdrawal
dysphoric mood, nausea or vomiting, muscle aches, diarrhea, fever, yawning, insomnia, pupillary dilation or sweating, and weepiness or runny nose
what would be a priority concern for a client admitted with withdrawals from cocaine?
impaired judgement
Agraphia/dysgraphia
inability to write
ADHD symptoms
inattention, hyperactivity, impulsivity
a school nurse is asked to present an educational program on ADHD to the staff of an elementary school. what should the nurse emphasize about this disorder?
its major clinical manifestation is easy distractibility
hypoactive delirium
lethargy, slowed speech, decreased alertness, apathy
Apraxia
loss of purposeful movement in the absence of motor or sensory impairment. For example, Patient becomes unable to put clothes on properly
a client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. which is the priority nursing action during the first 48 hours after the clients admission?
monitor vital signs. pulse and temp will increase before client demonstrates other signs of withdrawal
which physical skin finding indicates opioid abuse?
needle marks.
A client with diagnosis of schizophrenia who's receiving haloperidol has a sudden change in health status. BP unstable, hr 128, rr 26, temp 105F, diaphoresis, severe muscle rigidity, decreasing level of consciousness.
neuroleptic malignant syndrome
the nurse is planning care for a school aged child with ASD who has been hospitalized for some tests. which intervention should the nurse plan to implement
placing the child in a private room to decrease stimulation
Which characteristic mental change occurs with delirium and differentiates it from dementia?
rapid onset of confusion
Neuroleptic Malignant Syndrome
side effect of antipsychotic. Hyperthermia, tachycardia, sweating, muscle rigidity, tremors, renal failure, leukocytosis (high WBC), AMS
Extrapyramidal symptoms
side effect of antipsychotic. Tardive dyskinesia (repetitive, involuntary movements) , akathisia (pacing), bradykinesia (slow movement)
What is delirium?
state of temporary, acute mental confusion
Agnosia
the inability to recognize familiar objects. Seen in severe AD. Leads to need for total care because patient cannot recognize toilet/ soap
Hyperorality
the need to taste, chew, and put everything in one's mouth
Confabulation
the unintended false recollection of episodic memories
1st generation drug overview
typical. Blocks dopamine receptors. Reduce positive symptoms, agitation, aggression. Elevated prolactin secretion.
Autism symptoms
unresponsive, uncommunicative, repetitive speech, rigid in routines or rituals, resistant to change