Week 4: Dementia and Delirium/Disorders of Hematology Cancer/Hemostasis

Modifiable risk factors of Dementia:

-low educational attainment

-midlife hypertension

-midlife obesity

-hearing loss

-late life depression

-diabetes

-physical inactivity

-smoking

-social isolation

Normal Aging Points:

-MILD changes in memory and rate

-deficits are NOT progressive

-delayed recall or forgetting remains stable

What needs to happen to diagnose Dementia:

a decline present from previous level of function and be severe enough to interfere with daily function and independence

S/s of Dementia:

difficulty in:

-retaining new information (memory)

-handling complex tasks

-reasoning

-spatial ability and orientation

-language

-behavior

Parkinson Disease Dementia:

-cognitive dysfunction and dementia are common

-visual hallucinations and delusions

-dementia emerges 5-8 yrs after onset

Huntington Disease:

inherited progressive neurodegenerative disorder characterized by choreiform movements, psychiatric problems, and dementia

-autosomal DOMINANT

Vascular Dementia:

any dementia that is primarily caused by cerebrovascular disease or impaired cerebral blood flow

Stage 1 Dementia:

-no dementia

-no cognitive decline

-people w/NO dementia are considered stage 1

Stage 2 Dementia:

-no dementia

-very mild cognitive decline

-forgets names

-misplaces objects

Stage 3 Dementia:

-no dementia

-mild cognitive decline

-increased forgetfulness

-slight difficulty concentrating

-decreased work performance

-average duration is 2-7 yrs

Stage 4 Dementia:

-early stage dementia

-moderate cognitive decline

-difficulty concentrating

-forgets recent events

-difficulty completing tasks

-cannot manage finances, travel alone

-average duration is 2 yrs

Stage 5 Dementia:

-mid stage dementia

-moderately severe cognitive decline

-major memory deficients

-needs assistance w/ADLS

-forgets address/time/date/location

-average duration is 1.5 yrs

Stage 6 Dementia:

-mid stage dementia

-severe cognitive decline

-cannot do ADLS w/o help

-forgets family members

-incontinence

-difficulty speaking

-delusions, compulsions, anxiety

-average duration is 2.5 yrs

Stage 7 Dementia:

-late stage dementia

-very severe cognitive decline

-cannot speak

-loss of motor skills

-cannot walk

-average duration is 1.5-2.5 yrs

Treatment/goal for Dementia:

To preserve function and autonomy for as long as possible and to maintain quality of life for both the patient and the caregivers

What diet has shown to help w/Dementia?

mediterranean diet

-high fruits, veg, whole grains, nuts, seeds

Montreal Cognitive Assessment results:

-18 to 25: mild cognitive impairment

-10 to 17: moderate impairment

-less than 10: severe impairment

lower number equals more impairement

What is PT?

prothrombin time

-measures the time it takes for plasma to clot after tissue factor

-evaluates EXTRINSIC

What is INR?

A standardized system of reporting Prothrombin Time (PT)

What is PTT?

partial thromboplastin time

-evaluates intrinsic of cascade

Heparin-induced thrombocytopenia (HIT):

immune reaction as result of heparin, causes destruction of platelets

Disseminated intravascular coagulation (DIC):

-clotting system becomes OVERACTIVE, leads to widespread clots in body

-life threatening= bleeding and clotting at same time

How long is heparin administered for HIT to occur?

longer than 1 week

Expected findings for blood disorders:

-unusual spontaneous bleeding from gums/nose

-oozing, flowing of blood from incisions

-petechiae

-hematuria

-cyanosis in nail beds

Nursing considerations for disseminated intravascular coagulation (DIC):

-treat underlying cause (remember this is a complication) like sepsis, hemorrhage

-monitor for signs of microemboli

-prevent patient from trauma

-consider heparin if clotting is too high

S/s of small vessel clotting (microemboli)

-cyanotic nail beds

-pain

-indication of life threatening emergency/organ loss

Nursing consideration for all thrombo disorders:

-assess for s/s of organ failure or intracranial bleed (LOC, oliguria)

-administer fluid volume replacement

-avoid use of NSAIDs

-protect patient from injury

-implement bleeding precautions (no needles)

Nursing considerations for unfractionated heparin:

-monitor for s/s of thrombocytopenia/hemorrhage

-rotate injection sites

-avoid taking aspirin

4 Stages of Hemostasis:

1) blood vessel constriction

2) platelet activation (primary hemostasis)

3) coagulation cascade (secondary hemostasis)

4) fibrinolysis and clot dissolution

What do results of PT or PTT mean?

-measures how long it takes for blood to clot

-increase time to clot means thin

-decrease time means blood is already thick

Medications/conditions that prolong PT:

-extrinsic

-Warfarin

-Vit K deficiency

-Disseminated intravascular coagulation (DIC)

-Advanced liver disease

Warfarin:

anticoagulant

-oral

-reversal agent is vit k

-takes longer to see effects

Nursing considerations for Warfarin overdose:

-administer vit K

-for emergency: administer fresh frozen plasma

Medications/conditions that prolong PTT:

intrinsic:

-unfractionated heparin sodium (standard heparin)

-severe liver disease

-disseminated intravasular coagulation (DIC)

Heparin:

-parenteral anticoagulant

-rapid onset and short duration of action

-aPTT should be 1.5-2.5x the normal range

What is the reversal agent for heparin?

PROTAMINE SULFATE

Low molecular weight heparin (LMWH):

also known as Lovenox

-smaller fragments of heparin

INR range for people not taking anticoagulation:

0.8-1.1

INR range for most patients taking anticoagulation:

2.0-3.0

INR range for patients taking anticoagulant for mechanical heart valve:

2.5-4.5

What is reference range for platelets?

150,000 to 400,000

What does high/low range indicate?

greater than 400,000= thrombocytosis

less than 150,000= thrombocytopenia

Thrombocytopenia degrees:

-less than 50,000 = prolonged bleeding w/minor trauma

-initiate protocols

-less than 20,000= spontaneous hemorrhage

-can just bleed at anytime

S/s of thrombocytopenia:

-petechiae, purpura, ecchymosis

-spontaneous bleeding of gums

-oozing blood in IV site

-frank or occult blood in stool

-neurological changes (headache, confusion, blurred vision)

When would you give a platelet transfusion?

platelets not given till 10,000 or lower

What is mood?

patient describes their feelings

-PATIENT STATES MOOD

What is affect?

patient's observable emotional expression, including their facial expressions, body language, and vocal tone

Nursing considerations for delirium:

-rule out underlying cause, can be caused by: substance intoxication, withdrawal, med side effect, fluid/electrolyte imbalance

-recognize that delirium can occur from medical emergency

-dont write off as just a behavior

I WATCH DEATH acronym:

-infectious

-withdrawal

-acute metabolic

-trauma

-CNS disease

-hypoxia

-deficiencies (vit/mineral)

-environmental

-acute vascular

-toxins/drugs

-heavy metals

nursing care for neutropenia

monitor for signs of infection

cbc w differential, cultures, xray

thorough assessment

inspect IV sites

monitor temp q4h

sepsis= low BP and inc HR

Broad spectrum antibiotics FAST

G-CSF (filgrastim)

difference between CLL and AML

CLL= from ineffective mature lymphocytes

s/s none early B symptoms later

incurable but remission w chemo

AML= uncontrolled proliferation of myeloblasts

s/s: bruising, freq infections, dec appetite

LOW RBC hgb/hct platelets HIGH WBC

care: support, manage side effects

hodgkins vs non-hodgkins

hodgkins= abnormal Reed-sternberg cells

non-nodgkins= any lymphoma WITHOUT reed-sternberg cells

s/s for both: LN swelling, low energy, b symp,

Late: pruritus, SOB, coughing, anemia

CT & PET scan

nursing care for hodgkins lymphoma

treatment is based on stage

manage symptoms of treatment (pain, fear, svcs..)

nursing care for non hodgkins lymphoma

manage symptoms (pain, pancytopenia, anxiety…)

multiple myeloma

malignant plasms cells

s/s CRAB - hypercalcemia, renal failure, anemia, bone pain (fractures)

HIGH calcium, M protein, Benc Jones protein

MRI/CT

treat symptoms of disease and side effects of treatment