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

Cognitive ImpairmentCognitive Impairment

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

Thought DisordersThought Disorders

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)

Communicating with Communicating with Clients with Thought Clients with Thought

DisorderDisorder

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