Nurs 201 Unit 1

Neurocogntive disorder (NCD)

acquired decline in cognitive functioning

Which is being described delirium or dementia ?

• Affects attention and awareness

• Caused by acute illness or med toxicity

• Quick onset

• Reversible

Delirium

Which is being described delirium or dementia ?

• Affects memory and cognitive functions

• Caused by anatomical changes in brain

• Slow onset

• Irreversible

Dementia

What are the main characteristics of delirium

• Fluctuating LOC

• confusion towards day to day events and routines

• disordered speech

• Disoriented to time , place or event

• personality changes and affect

• disorganized thinking

• hallucinations , delusions , paranoia

• difficulty focusing ,maintaining or shifting attention

Do the following sx describe delirium or dementia ?

• unawareness of environment

• low ability to focus

• impaired memory and judgment

• disorientation , rambling speech

• sudden intense emotional swings

• auditory or visual hallucinations

• Inappropriate behavior

• fearful and paranoid

• irritable and agitated

• hyperacitivity , hyperalertness

What are predisposing factors that make delirium more likely

• Brain disorder (dementia , stroke , Parkinson )

• older age

• sensory impairment

• ETOH withdrawal

• meds

• vitamin deficient

What are toxic and metabolic things that can cause delirium ?

• polypharmacy (being on multiple meds )

• lyte imbalances

• hypoxia / hypoglycemia

• ETOH or substance withdrawal

what are infectious and acute physiological things that can cause delirium ?

• uti or pneumonia

• sepsis

• acute urinary retention

• fecal impaction

• uncontrolled acute pain

what are environmental and physiological things that can cause delirium

• ICU environment

• sensory overload

• sleep deprivation

• physical restraints

• recent surgery or trauma

Apraxia

impaired ability to execute motor functions with appropriate tool despite intact motor abilities

• mainly has to do with tools and not knowing what their for

• ex : using toothbrush as a comb

Agnosia

inability to recognize names of objects

• ex: they know that a toothbrush is used to brush teeth but they don’t know the name of the item

Amnesia

Damage to the brain’s hippocampus prevents new info from being recorded

What is dementia ?

Acquired , persistent loss of cognitive ability compared to the patient’s prior level of functioning

• LOC is not affected

• Severe cognitive deficits that impair pt’s ability to do everyday tasks independently

• neurodegenerative and irreversible

• first sx is memory loss

dementia testing : clock test

can show early executive function deficit

what is executive function deficit

inability to think abstractly and to plan , initiate , sequence , monitor and stop complex behavior

Cues and safety interventions for Alzheimer’s disease

Cue : gradual , progressive short term memory loss and spatial disorientation

safety : environmental safety and communication strategies

Cue and safety intervention for Vascular Dementia

Cue : step wise cognitive decline (sudden drops following TIA)

• stair step

Safety : strict BP control , anticoagulation and cardiovascular risk management

Patients with Lewy body dementia cannot have what type of med ?

Antipsychotics —> block dopamine receptors

• patients with LBD already have low levels of dopamine

What are the 4 common types of dementia

• alzheimer's dementia

• vascular dementia

• Lewy body dementia

• frontotemporal dementia (FTD)

Cue and safety interventions for Lewy body dementia ( LBD )

cue : early vivid visual hallucinations and parkinsonian tremors / gait

safety : extreme sensitivity to antipsychotics

Cues and safety interventions for Frontotemporal Dementia ( FTD)

Cue : early , drastic personality changes and loss of social inhibition .

safety : high risk for impulsive behavior and intense early caregiver strain

Cues and safety interventions for Huntington's Disease Dementia

Cue : early personality shift (irritation , depression ) loss of impulse control before severe memory loss

safety : high suicide risk so prioritize suicide screening

Cause , Cue and safety interventions for Wernicke-Korsakoff dementia

Cue: confabulation

Caused by : Heavy ETOH that causes thiamine (vitamin B12) deficiency .

Safety: administer IV thiamine before glucose / dextrose to avoid causing irreversible encephalopathy

what is confabulation and what dementia is it a cue for ?

Cue for wernicke-korsakoff syndrome

inventing realistic stories to cover memory gaps

• patient is not doing this to be untruthful , they genuinely believe what they are inventing

Cue and Safety interventions for prion / Creutzfeldt Jakob (CJD)

Cue : rapidly progressive fatal cognitive decline (weeks to months ) paired with myoclonus (sudden involuntary muscle jerks)

safety : infection precautions bc CSF is infectious and early palliative care

Cues and safety intervention for Normal pressure Hydrocephalus (NPH)

Cue : wet , wobbly and wacky ( urinary icon. , gait ataxia and cognitive decline )

Safety : can be reversed thru CSF tap testing and surgical VP shunt placement to restore cognitive function

Cues and safety intervention for Parkinsons Disease Dementia

Cue : Cognitive decline occurring more than 1 yr after established motor sx (rigidity tremor )

Safety : balance dopamine replacement therapy against the risk of worsening psychosis or delirium

Patho of alzhemiers

Caused by acetylcholine deficit (ACh)

Amyloid beta plaque accumulate causing neurofibrillary tangles

What classification is donepezil (aricept )

reversible indirect acting cholinergic agent

what is the moa of donepezil

inhibits acetylcholinesterase (enzyme that breaks down acetylcholine ) to increase acteylcholine in the brain

what forms of azlhemier’s is donepezil used for ?

all forms , mild to severe

what are the side effects of donepezil ?

mainly GI

• N/V

• Diarrhea

• low appetite

• bradycardia

What class is memantine (Namenda )

NMDA receptor antagonist

what is the MOA of memantine (Namenda) and what does it do ?

blocks excess glutamate to protect neurons

• slows memory loss

what are the side effects of mematine (Namenda)

• dizziness

• HA

• constipation

Memantine (Namenda ) can be given with what other medication to treat dementia

Donepezil

• can come in a combination pill

what types of Alzheimer's does memantine (Namenda) treat ?

moderate to severe

What is Parkinsons Disease

Chronic slowly progressive , neurodegenerative disorder

• degeneration of dopamine cells —> decreased levels of dopamine

• decreased dopamine —> increased acetylcholine

What is dysphonia and how does it present in a patient with Parkinson’s

altered voice production

• causes a soft, raspy, breathy, or monotone voice

What is dyskinesia

involuntary muscle movements of face , eyelids , mouth , tongue , arms , hands , legs and squirming movements

what is hypokinesia ?

slow movements

What are the 4 symptoms of Parkinson’s Disease ?

• Tremors

• Rigidity

• Bradykinesa

• Postural instability

How is Parkinson’s diagnosed ?

no specific test —> diagnosed based on sx present and response to anti Parkinson's medications

• 2/4 sx have to be present

• if sx improve after taking anti Parkinsons medication

How do tremors present in patients with parkinson’s

generally 1st sx pt experiences

• Pill rolling tremors that are slow , one sided and appear while the patients hand is at rest

• disappear with purposeful movement or while the patient is sleeping

• as disease progresses tremors will remain worse on the hand where it started

How does bradykinesia present in patients with Parkinson’s

• Decreased arm swing with walking

• decreased swallowing of saliva

• decreased blinking

• blank facial expression

• stooped posture WH

Bradykinesia increases the risk of what ?

aspiration and falls

how does rigidity present in patients with parkinson’s

• Cogwheel rigidity

• Resistance to passive movement (stay stiff if someone else tries to move muscle )

• Stiff, jerky movements

what is cogwheel rigidity ?

Jerky, ratchet-like resistance when the limb is moved passively.

What does rigidity put a patient with parkinson's at risk for ?

falls

what is postural instability and how does it present in a patient with parkinson’s

• Faster walking speed

• move feet forward towards center of gravity

• Shuffling and propulsive gait

what is propulsive gait ? what disease is it characterized by ?

Rigid stooped posture with head and neck forward

• question mark shaped

what does postural instability put a parkinson’s patient at risk for ?

falls

What urinary complication can patients with Parkinson’s disease experience, and what does it increase their risk for?

Chronic urinary retention→ increased risk of UTIs

what classification is benztropine ?

anticholinergic

what is the moa of benztropine and what is it used for ?

moa :decreases acetylcholine by blocking acetylcholine and histamine receptors

used for : decreasing muscle rigidity and tremors

what are the side effects of benztropine ?

Anticholinergic = everything gets DRY + things STOP moving

• Dry mouth

• Dry eyes

• Blurred vision

• Urinary retention

• Constipation

what patient teaching should the nurse include for benztropine ?

• chew gum for dry mouth

• wear sunglasses for dry eyes

• increase fiber and fluid for urine retention and constipation

what are key things to remember about benztropine ?

• Do not give to patient with glaucoma

• No alcohol

• Do not stop abruptly

what classification is rasagline (azilect) ?

MAO-B inhibitor

what is the moa of rasagline (azilect ) and what is it used for ?

Increases dopamine by blocking MAO (enzyme that breaks down tyramine )

used for improving shaking , stiffness and decreases amount of “off time” periods of slow movement

what is a key thing to remember about rasagline ?

Avoid foods with tyramine (aged cheese , chocolate , wine and beer)

• med blocks MAO which breaks down tyramine → too much tyramine is a HTN emergency

what classification is carbidopa / levodopa (sinemet) ?

dopamine agonist

what is the MOA of carbidopa/levodopa (sinemet ) and what is it used for

Use : decreases muscle rigidity and tremors.

MOA: Increases dopamine . Levodopa crosses the blood-brain barrier and converts to dopamine. Carbidopa prevents levodopa from being broken down before reaching the brain.

Remember: Levodopa = makes dopamine | Carbidopa = protects levodopa

When is carbidopa/levodopa (sinemet) most beneficial for a parkinson’s patient ?

first year or two of treatment

what are side effects of carbidopa/levodopa (sinemet)

drowsiness

dyskinesia

dark urine and dark swear

decreased BP

carbidopa/levodopa (sinemet) puts patients at an increased risk for ?

falls

what is a key thing to remember about carbidopa/levodopa (sinemet)

• it can take up to 3 wks to be effective

• No MAOs

Why must carbidopa/levodopa (Sinemet) be given on time?

Due to end-of-dose “wearing off.”

• When medication levels are therapeutic (“ON”), the patient can initiate movement.

• When levels drop (“OFF”), the patient may become very rigid and have difficulty initiating movement.

what is the normal range for serum creatinine

0.5-1.2

what is the function of creatinine

• waste product formed by normal breakdown of creatinine

• supplies energy to muscles

• assess kidney function

what are causes of high creatinine ?

kidney disease

dehydration

rhabdomyolysis (muscle breakdown )

what are the causes of low creatinine

low muscle mass (elderly or malnourished individuals )

what are special considerations for creatinine ?

body builders / athletes may have higher creatinine due to increased muscle mass

creatinine key facts

• it is a muscle metabolism by product

• filtered out by kidneys so levels reflect kidney health

• high levels = possible kidney dysfunction

• low levels = low muscle mass or liver issues

what is the normal range for glucose ?

70-110

what is the function of glucose

• main source of energy for body’s cells

• comes from carbs and regulated by insulin and glucagon

What are the sx and tx for hyperglycemia

Sx: polyuria , polydipsia , polyphagia

Tx : administer insulin (promotes uptake of glucose into cells)

what are sx and tx for hypoglycemia

Sx: shaky , sweaty , tremors , tachycardia , confusion

Tx: give carbs and recheck in 15 . if pt unconscious give glucagon or IV dextrose

what are key nursing considerations for glucose ?

• asses glucose before giving insulin

• know peak , onset and duration before giving insulin

what is the normal range of hemoglobin for women

11.7 - 15.5

what is the normal range of hemoglobin for men

14 - 17.3

what is the function of hemoglobin?

Transports O2 and helps maintain pH

What are the causes , sx and tx for anemia (low hemoglobin )

causes : blood loss , decreased blood cell production

sx : fatigue , weakness , pallor , SOA , tachycardia and dizzy

tx: blood transfusion , iron supplements , iron rich diet

what are key nursing considerations for hemoglobin ?

• monitor CBC

• educate patient on iron rich foods such as red meat , spinach and legumes

• monitor for transfusion reactions

what is the normal range for potassium

3.5 - 5

what is the function of potassium

muscle contractions especially cardiac muscles

What are the causes , sx and tx for hypokalemia ?

causes : loop and thiazide diuretics , GI losses ( vomiting , diarrhea , NG suction)

sx : muscle weakness , constipation , flattened t waves

tx : oral or IV potassium , monitor renal function , increased diet of bananas , potatoes , spinach

what are the causes , sx and tx for hyperkalemia

causes: kidney failure (most common) , potassium sparing diuretic , tissue trauma , burns and acidosis

sx: muscle cramps , peaked t waves , bradycardia

tx : calcium gluconate (stabilizes heart) , kayexalate (k+ goes into stool ) , dialysis , avoid foods high in K+

Key nursing considerations with potassium

• monitor K+ with diuretics , renal disease or insulin

• use cardiac monitoring

• check renal function (BUN , creatinine , urine output )

• Dilute IV potassium

what is the normal range for sodium

135 - 145

what are the causes of hypernatremia ?

dehydration (water loss ) and fever

what are the sx of hypernatremia

• thirst , muscle twitching , seizures , coma

• dry mucuous membranes

• decreased urine output

• tachycardia

• dry and flushed skin

what is the tx for hypernatremia

• fluid replacement with hypotonic fluids

• oral rehydration

• slow correction of sodium to prevent cerebral edema

special considerations for hypernatremia

• monitor vs

• strict I & O

• administer IV fluids

• monitor labs

what is the normal range for platelets

1500,000 - 450,000

what are causes of decreased platelets (thrombocytopenia) ?

some anemias , sepsis , bleeding , chronic liver disease and burns

what are sx of decreased platelets (thrombocytopenia)?

• petechiae (tiny dots from bleeding under skin )

• ecchymosis (big bruise from bleeding under skin)

• mucosal

• bleeding

• fatigue

• weakness

• dizziness.

what are nursing considerations for decreased platelets (thrombocytopenia)

• Monitor for signs of bleeding (petechiae, ecchymosis, bleeding gums).

• Watch for internal bleeding → abdominal pain, dark urine, or dark/tarry stools.

• Avoid aspirin and NSAIDs → can further impair platelet function.

• Use a soft toothbrush and electric razor to prevent bleeding.

• Platelet transfusion may be needed.

• Treat the underlying cause.

what is the normal range of WBC

4,500 to 11,000

what is leukocytosis and what does it mean ?

Elevated WBC

• body is responding to infection , inflammation or another stressor