Cognitive and Eating Disorder

• Reasoning

• Judgment

• Attention

• Perception

• Comprehension

• Memory

Cogntive Abilities

Delirium

• Disturbances of consciousness

• Short period of time and fluctuating

• Older acutely ill clients

• Easily distracted and disoriented

• Sensory Disturbances

Risk factors of delirium

• Physical illness: surgery, disease, fatigue

• Older age

• Cognitive impairment: dementia

• Febrile illness/drug-related: children

Hyperactive delirium symptoms

• Hallucination/illness

• Easily irritated

• Delusions

• Confusion/disorientation

• Language difficulty

• Disorganized thoughts

• Misinterpretation

Hypoactive delirium symptoms

• Fear/anxiety

• Gloomy

• Sluggish

• Withdrawn

• Silence

• Apathy

Etiology (Videbeck) of delirium

• Physiologic or metabolic

• Infection

• Drug-related

• Nursing Consideration

  • It is very important to know the cause of delirium for the team to identify the appropriate treatment plan

Pathophysiology theories of delirium

• Delirium

  • Drugs

  • Coritsol

  • Inflammatory conditions

  • Oxidative impairment

  • Neurotransmitters

    • Dopamine

    • GABA

    • Serotonin

    • Ach

Nursing consideration of delirium for psychopharma

• It is very important to know the cause of delirium for the team to identify the appropriate treatment plan

• Not indicated for hypoactive

• Symptomatic for hyperactive

  • Haloperidol (Antipsychotic) for hallucination/illusion

  • Sedatives for calming effect

Acute confusion

Managing confusion will help patient manage personal daily activities, prevent from any forms of injury, manifest good social behaviors/interaction, and reduce psychotic episodes

Nursing Care Plan Assessment

• History - drug-use, alcohol intake, and medications

• Motor behavior - hyper or hypo

• Mood and affect - observe fluctuations

• Thought process - disorganized and fragmented

• Sensorium and Intellectual Process - Disorientation, confusion, delusion, hallucination, illusion

• Judgment and Insight - Impaired reasoning

• Roles and Relationship - Role impairment

• Self-concept - Feel bad about self

• Physiologic and Self-care considerations - Sleep, eating, void, hygiene, leisure

Nursing Care Plan Goal

• Free from Injury

• Intact with reality

• Normal Sleep-Wake Cycle

• Maintain proper nutrition

• Good hydration

• Optimum level of functioning

Promote client safety

Priority focus of delirium nursing intervention

Therapeutic communication

Manage client’s confusion for delirium

Controlling environment (milieu management)

Intervention for environment in nursing

Routine

Promote sleep and priority

Dementia

A mental disorder that involves multiple cognitive deficits, initially, memory impairment, and later, the following cognitive disturbances (Videback)

Aphasia

Deterioration of language function

Agnosia

Inablitiy to recognize name of objects

Apraxia

Impaired motor function

Echolalia

involuntary repetition of words, phrases, or sounds spoken by others

Palilalia

a rare speech disorder characterized by the involuntary, self-repetition of words, phrases, or sentences just spoken

Disturbance in executive functioning

Inability to think abstractly

Comparison of Delirium and Dementia

Comparison of forgetfulness or dementia

Dementia

According to Alzheimer’s Disease Association of the Philippines (ADAP) As one gets older, it is normal to be a little bit forgetful. If forgetting becomes more frequent, affecting routine daily activities and decision-making, and often accompanied by changes in personality or behavior, it’s _____

• Memory

• Language

• Judgment

• Reason

Signs and symptoms of dementia (ADAP)

Affects social and occupational functioning:

• activities of daily living

• behavior

• cognition

Dementia - early stage

• Become forgetful, especially things that just happened (hallmark beginning)

• Some difficulty with communication

• Difficulty in keeping things and handling personal finances

• Mood and behavior:

  • less active and motivated and lose interest in activities and hobbies

  • may react unusually angrily or aggressively on occasion

Dementia - Mild Stage

• Become very forgetful, especially of recent events and names of unfamiliar people (Progressive Memory loss)

• Can still comprehending time, date, place and events with some difficulties

• Need help with personal care (i.e. toileting, dressing)

• Unable to prepare food, cook, clean or shop (Complex tasks)

• Unable to live alone safely without considerable support

Dementia - Late Stage

• Unaware of time and place

• May not understand what is happening around them

• Unable to recognize relatives, and friends

• Unable to eat and walk without assistance

• Increasing need for assisted self-care

• May have bladder and bowel incontinence

• Behaviour changes (e.g. wandering, repeated questioning, calling out, clinging, disturbed sleeping, hallucinations)

• Inappropriate behaviour (e.g. disinhibition, aggression)

Reversible types of dementia

Caused by tumors, hypothyroidism, drugs or psychiatric related

Irreversible types of dementia

Examples are alzheimer’s disease, vascular dementia, parkinson’s disease

Parkinosn’s

Trigerred by the individual’s existing medical condition of parkinson’s

• slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and postural instability.

Creuzfeldt-Jakob

Rare form of dementia caused by the abnormality of prion, a protein found in the brain, which is toxic to brain cells

Hunington’s disease

Progressive brain disorder caused by a single defective gene on chromosome 4, affecting the central are of the brain

Fronototemporal

Also known as Pick’s disease. Relatively rare form which affect the brain where language and behavior are controlled

Normal-pressure hydrocephalus

When excess cerebrospinal fluid (CSF) accumulates in the brain’s ventricles affecting its tissue. Can be reversed or controlled

Wernicke-Korsakoff Syndrome

Chronic memory disorder caused by severe deficiency of thiamine (vitamine B1). Commonly linked with alcohol misuse

Mixed

A combination of two or more types of dementia in an individual. Most common is Alzheimer’s disease with vascular dementia

Alzheimer’s disease

The most prevalent type of dementia. Approximately 50-70%

Vascular or dementia

The second most common type of dementia is caused by multiple strokes due to interrupted blood flow to the brain. Approximately 20-30%

Global impact of dementia

The world’s older population currently comprises nearly 900 million people. Most live in what are currently relatively poor countries

Nursing consideration of dementia

Proper identification of the underlying condition is vital for the treatment plan.

Total assistance

Dementia is a progressive deterioration of cognitive and physical abilities until death. Later stages of Dementia require ___

Cholinesterase inhibitors

Donepezil (Aricept)

Rivastigine (Exelon)

Memantine (Namenda)

• Medications for dementia

Dementia Nursing care plan assessment

• History - interview family members

• Motor behavior - inability to sustain meaningful conversation

  • Unusual behaviors (dec. motor and uninhibited)

• Mood and affect

  • Anxiety and Labile mood

  • Emotional Outburst

  • Wandering at night

  • Loss of personal control

  • Apathetic

• Through process

  • impaired abstract and logical thinking

  • Delusions and persecutions

• Sensorium and Intellectual Process

  • Confabulation

  • Impaired attention span

  • Confusion

  • Hallucinations

• Judgment and Insight - Underestimating risks of disease

• Roles and relationship - Affected work performance

  • Families being caregivers

  • Impaired House and Family responsibilities

• Physiologic and self-care considerations - sleep, eating, void, hygiene, leisure

Dementia Nursing care plan goal

• Free from Injury

• Rest-Activity Balance

• Maintain proper nutrition

• Good hydration

• Regular Voiding

• Independent Functioning

• Respected and Supported

• Community involvement

Promote client safety

Promoting adequate sleep and proper nutrition, hygiene and activity

Eating, bathing, dressing, transferring, toileting, walking or moving around

Intervention for dementia

• Providing emotional support

• Promoting interaction and involvement

Establishing trust

• Person with dementia may have cognitive impairments which will limit your communications

• Make an effort to communicate with both the person and the carers

• Make sure the person can see and hear properly (e.g. spectacles may no longer be of the right prescription, or a hearing aid may not be working properly

• Speak clearly, slowly and with eye contact

• Pay attention to body language - people whose language is impaired often communicate through non-verbal means

• Provide the carer and family with opportunities to express their worries and concerns about the person’s illness

• Listen carefully to the concerns of the carer and family members

• Highlight the positive aspects of the family – Congratulate the family for taking such good care of the person if appropriate

• Be flexible in your approach with the carer and family. The family may come to you with needs you did not expect.

Reminiscence therapy

• With the family

• Remote memory of the patient

• Use of photo album or music or movies

• Conversations and active listening

Caregiver burden

• The hidden patient

• Emotionally and physically exhausting

• Round the clock care

• Stressful

• Role Strain

• Unappreciated

• Most of the caregivers are immediate family members

Caregiver burden management

• Having a stress –free caregiver will tolerate the burden of assisting Dementia patient, in turn, will make the patient sustain optimum state of well being and slowing down the deterioration of cognition.

• Include in decision making

• Constant education about dementia

• Stress management

• Communication and endorsement

Ethical consideration

• Maintain dignity

• Emotional support

• End of life care

Anorexia Nervosa

• 14 to 18 years old

• Starts with denial and anxiety

• Unable to identify or to explain their emotions about life events

• Noticeable changes in mood

• Social isolation

Restricting

Binge eating and purging

Subtypes of anorexia nervosa

Medical complications of anorexia nervosa

• Clients with the lowest body weights and longest durations of illness tended to relapse and have the poorest outcomes

Medical complications related to weight loss

• Musculoskeletal - Loss of muscle mass

• Metabolic – Hypothyroidism, hypoglycemia, and dec. insulin sensitivity

• Cardiac - Bradycardia, hypotension, cardiac arrhythmias

• Gastrointestinal - Delayed gastric emptying, bloating, constipation, abdominal pain, gas, and diarrhea

• Reproductive - Amenorrhea and low levels of luteinizing and follicle-stimulating hormones

• Dermatologic - Dry, cracking skin due to dehydration, edema, and acrocyanosis (i.e., blue hands and feet)

• Hematologic - Leukopenia, anemia, thrombocytopenia

• Neuropsychiatric - Abnormal taste sensation, apathetic depression and sleep disturbances

Medical complications related to purging and laxatives

• Metabolic - hypokalemia, hypochloremic alkalosis, hypomagnesemia, and elevated blood urea nitrogen

• Gastrointestinal - Esophageal and gastric erosion or rupture, dysfunctional bowel, and superior mesenteric artery syndrome

• Dental - Erosion of dental enamel (perimyolysis)

• Neuropsychiatric – Seizures, mild neuropathies, fatigue, and weakness

• Severe fluid, electrolyte, and metabolic imbalances

• Cardiovascular complications

• Severe weight loss and its consequences

• Risk for Suicide

Major life- threatening complications that indicate the need for hospital admission include:

• Weight restoration

• Nutritional rehabilitation

• Rehydration

• Correction of electrolyte imbalances

Severely malnourished clients may require total parenteral nutrition, tube feedings, or hyperalimentation (IV nutrition) to receive adequate nutritional intake

Medical management focuses on:

• Amitriptyline (Elavil)

• Cyproheptadine (Periactin)

Medications for weight gain

Olanzapine (Zyprexa)

Medications for bizarre body image distortion (psychosis)

Fluoxetine (Prozac)

Medications for relapse prevention

Psychotherapy for anorexia nervosa

• Family therapy

• Individual therapy

• Targets coping skills, self-esteem, self-acceptance, interpersonal relationships, assertiveness, can improve overall functioning and life satisfaction.

Individual therapy

• For clients contraindicated to family therapy

• For older clients

• For clients with individual issues

Bulimia Nervosa

• Late adolescence (18 yo) or early adulthood

• Begins during or after a diet regimen

• People who eat restrictively, which leads to purging and binging

• Storing foods and goes to food stores

Bulimia Nervosa Outcomes

• Clients with a comorbid personality disorder tend to have poorer outcomes than those without

• Hospital admission is indicated if binging and purging behaviors are out of control and the client’s medical status is compromised

• The death rate from bulimia is estimated at 3% or less.

Cognitive-behavioral therapy

• Food focus on interrupting the cycle of dieting, binging, and purging

• Altering dysfunctional thoughts and beliefs about food, weight, body image, and overall selfconcept

• Desipramine (Norpramin)

• Imipramine (Tofranil)

• Amitriptyline (Elavil)

• Nortriptyline (Pamelor)

• Phenelzine (Nardil)

• Fluoxetine (Prozac)

Psychopharmacology for bulimia nervosa

Binge-purge type vs bulimia

Nursing care plan assessment bulmia nervosa

• History - According to Family Members

  • Anorexia - shift in mood

  • Bulimia - impulsive behavior

• Appearance

  • Anorexia – Low weight

  • Bulimia – Normal weight

• Motor Behavior

  • Anorexia - slow, lethargic, and fatigued turns away, avoiding discussing the problem

  • Bulimia - appears normal and willing

• Mood and Affect

  • Avoiding “bad” or fattening foods gives them a sense of power and control over their bodies

  • Eating, binging, or purging leads to anxiety, depression, and feeling out of control.

  • Most of the time, for Anorexia: Serious; Bulimia: Cheerful

  • Suicide are common to those with history of sexual abuse

• Thought Process

  • Preoccupied with their attempts to avoid eating or eating “bad” or “wrong” foods

  • Delusional Body image disturbance

  • Paranoid ideas for those who are suggesting them to eat

• Sensorium and Intellectual Processes - Only with complications of malnutrition: confusion, slowed mental processes, difficulty with focus and attention

• Judgment and Insight

  • For Anorexia, they do not believe they have a problem

  • For Bulimia, they recognize the problem; ashamed of their binging / purging

• Self-concept

  • Low self esteem, helpless, powerless, and ineffective

  • See themselves badly if not able to follow food restrictions

  • Doesn’t see any other achievements in life, but only achievements whenever they have controlled food

• Roles and Relationships - Eating disorder interferes with roles relationships

• Physiologic and Self-Care Considerations

  • Relates directly to the severity of self-starvation and purging

  • Exercises excessively

  • Sleep disturbances

  • Dental and oral cavity problems

Nursing care plan goal bulmia nervosa

• Physiologic outcomes

  • Treat malnutrition

  • Treat medical complications

• Psychological outcomes

  • Nutritional Eating patterns

  • Eliminate compensatory behaviors

  • Coping mechanism about food

  • Verbalize feelings of guilt, anger, anxiety, and food control

  • Accept Body image

Nutritional rehabilitation for anorexia

• Gradual increases in calories

• Avoid food rituals

• Purging supervision (1-2 hrs after meals)

Nutritional rehabilitation for bulimia

• outpatient

• Eat with Family and Friends

• Eat a planned Menu

Emotions and coping

• Recognize emotions towards eating as anxiety / guilt

• Self-monitoring - increase client’s awareness of their eating patterns

Body Image

• Emphasize on health

• Focus on other strengths aside from food control

Client and family education

• Nutritional education and prevention of complications

• Distraction Delaying Techniques – for binging / purging

• Emotional support, love, and attention and concern about client’s health