NCLEX-RN: Psychiatric Nursing

Psychiatric Nursing: Substance-Related Disorders/ Addictive Disorders

Focus topic: Psychiatric Nursing

Definition: Substance dependence includes any process by which an individual ingests any mind-altering, non prescribed chemical that produces physiological and/or psychological dependence. Withdrawal symptoms are usually manifested when the substance is not taken.

Characteristics
A. Psychological dependence: emotional dependence, desire, or compulsion to continue taking the substance or drug to experience “normal” functioning.
B. Tolerance: the need for greatly increased amounts of the substance to achieve the desired effect.
C. Physiological dependence: physical need for the substance manifested by appearance of withdrawal symptoms when the substance is withheld.
D. Withdrawal from substance causes substance specific syndrome leads to impairment in areas of functioning.

Psychiatric Nursing: Alcohol Abuse

Focus topic: Psychiatric Nursing

Definition: The abuse of any alcoholic substance combined with physical and psychological addiction.

Characteristics
A. Alcohol consumption is permitted by law and supported by most people in our society as a recreational activity.
B. A fine line exists between the social drinker and the addicted or problem drinker.
C. The greatest difference involves the degree of compulsion to drink and the inability to survive the trials of everyday living without the ingestion of alcohol.
D. An estimated 17 million Americans have alcohol use disorders including alcoholism and harmful drinking that does not reach the level of dependence.
E. Alcoholism is involved in thousands of deaths and injuries (auto accidents) every year.
F. The legal definition of intoxication in most states is 0.10% or higher blood alcohol level (in California, it is 0.08%).
G. Alcoholism decreases life span 10 to 12 years.
H. Suicide accounts for a significant percentage of deaths among alcoholics.
I. Loss to industry caused by alcoholism is estimated at $15 billion a year (affecting primarily the 35-to-55 age group) and overall costs of alcohol-related problems is estimated to be over $70 billion per year.
J. Major U.S. social concern is the dramatic rise in teenage alcoholism (estimated to affect 3 million adolescents).

Dynamics of Alcoholism
A. Alcoholic disease implies the consumption of alcohol to the point where it interferes with the individual’s physical, emotional, and social functioning.

  •  The syndrome consists of two phases: problem drinking and alcohol addiction.
  •  Dependence on other drugs is very common.

B. A genetic or familial predisposition to dependence may exist. Genetically determined genes determine the type of dependence an individual may develop.

  • Genetic influences are the same for both men and women.
  • Children of alcoholics have a four times higher risk of becoming alcoholic.

C. Alcohol blocks synaptic transmission, depresses the central nervous system (CNS), and releases inhibitions. It acts initially as a stimulant but is actually a depressant.

  •  Chronic excessive use can lead to brain damage.
  • High blood levels may cause malfunctions in cardiovascular and respiratory systems.

D. Psychological effects of alcohol appear to be the gratification of oral impulses and the reduction of superego forces; abuse leads to shame and guilt and impaired ego formation.
E. Alcohol may be said to be a defense against overwhelming psychological needs and conflicts; therefore, the client needs to work on problems causing his or her distress.

F. Illnesses associated with chronic alcoholism.

  •  Wernicke-Korsakoff ’s syndrome (related to thiamine deficiency).
  • Delirium tremens.
  •  Gastritis, esophagitis, and pancreatitis.
  •  Malnutrition resulting in beriberi, pellagra, cerebellar degeneration, and anemia.
  •  Laënnec’s cirrhosis, hepatitis, and fatty liver.
  •  Peripheral neuropathy (related to vitamin B deficiency).
  •  Osteoporosis.
  • Individual is prone to infection.
  • Blood dyscrasias.
  • Sexual dysfunction.

Personality Characteristics of an Alcoholic
A. Dependent personality with resentment toward authority.
B. High self-expectations and low frustration tolerance.
C. Life usually characterized by patterns of failure.
D. False sense of success, power, and confidence from use of alcohol.
E. Apparent need to ease suffering, reduce anxiety, and cope with life stresses through use of alcohol.
F. Decreased ability to function intellectually, emotionally, and socially as need for alcohol increases.
G. Difficulty in interpersonal relationships.
H. Tendency to work, play, and engage in sex more than is normal.
I. Risk-taking propensity.

Assessment
A. Assess inability to control alcohol consumption.

  •  Episodic drinking.
  • Continuous excessive drinking.
  •  Sneaking drinks.
  •  Morning drinking.
  • Blackouts.
  •  Arguments about drinking.
  •  Absence at work or school due to hangovers and drinking episodes.
  •  Difficulty with interpersonal relationships due to drinking habits.
  • Alcohol-related police record.

B. Recognize physical condition due to improper nutrition.

  •  Cirrhosis.
  •  Anemia.
  •  Peripheral neuropathy.
  • Brain damage.
  •  Delirium tremens.

C. Evaluate accidents or physical injuries caused by intoxication.
D. Determine level of acute intoxication.

  • Drowsiness, ataxia, nystagmus.
  •  Respiratory depression, stupor, possible coma, and death.

Alcohol Withdrawal Symptoms
A. Hangover: mild alcohol withdrawal (usually the day after); symptoms include headache, nausea, vomiting, restlessness, irritability and the “shakes.”
B. General withdrawal symptoms from heavy drinking.

  • Nausea and vomiting.
  •  Insomnia.
  •  Anorexia.
  •  Anxiety.
  •  Hyper alertness and irritability.
  •  Restlessness.
  • Chronic tremors of hands, tongue, and eyelids.
  •  Malaise and weakness.
  •  Sweating.
  •  Elevated temperature.
  • Depressed mood.
  •  Headache.
  • C. Delirium tremens: an acute condition usually manifested within 24 to 72 hours after the last ingestion of alcohol. May appear 7 to 10 days later during drinking periods when no food is ingested.
    LIFE THREATENING.
  •  Marked tremors/seizures.
  •  Hallucinations/illusions.
  •  Paranoia.
  • Disorientation and severe agitation.
  •  Tachycardia.
  •  Tachypnea.
  •  Diaphoresis.
  •  Diarrhea and vomiting.
  •  Convulsions (grand mal).
  •  Death (10% to 15% from cardiac failure).

Implementation
A. Nursing attitudes.

  •  Maintain a nonjudgmental attitude toward the alcoholic.
  • Be firm and consistent in approach.
  •  Be accepting toward the individual, not his or her deviant behavior.
  •  Be supportive of attempts to change life patterns.

B. Acute treatment phase. Utilize Withdrawal Assessment Scoring Guidelines (CIWA-Ar)

  •  Provide adequate diet and fluid intake.
  •  Provide vitamin therapy, especially vitamin B6 and B complex.
  •  Promote rest, provide reassurance.
  •  Control environment to decrease stimuli and provide for safety.

Psychiatric Nursing: ALCOHOL WITHDRAWAL ASSESSMENT SCORING GUIDELINES (CIWA-AR)

Focus topic: Psychiatric Nursing

Psychiatric Nursing
  •  Institute measures to control nausea and insomnia.
  • Observe signs of infection or physiological problems, including seizures.
  •  Orient as needed.
  •  Assess mental status including presence of tactile and auditory hallucinations, altered sensorium, confusion, and anxiety.
  •  Administer tranquilizer as ordered or per CIWA protocol, usually a benzodiazepine.
  •  Observe vital signs.

C. Long-term treatment phase.

  •  Set up a controlled and structured environment until client is able to manage his or her own circumstances.
    a. Set behavior limits and confront the client who is manipulative.
    b. Suggest group involvement for the client who experiences loneliness.
    c. Remember that client needs support, firmness, and a reality-oriented approach.
  •  Treatment techniques.
    a. Client must first go through detoxification acute nursing care to cope with toxic state and return to a nonalcoholic state.
    b. Help client accept the fact that alcoholism is an illness.
    c. Help client accept that life must be managed without the support of alcohol.
    d. Provide activities such as group and family therapy and introduction to concepts of recovery.
    (1) Focus on the underlying emotional problems.
    (2) Offer assistance in handling anxiety.
    (3) Focus on relieving feelings of inferiority and low self-esteem.
    e. Provide for rehabilitation or long-term supportive care.
    (1) Encourage client to continue psychotherapy on an outpatient basis.
    (2) Refer client to recovery program, such as Alcoholics Anonymous. Encourage identification of sponsor and daily meeting attendance during initial abstinence.
    (3) Encourage client to continue taking prescribed medication such as Antabuse (disulfiram) alcohol sensitizing drug that causes vomiting and cardiovascular symptoms if the person drinks alcohol.
    (4) Suggest social or vocational rehabilitation community programs that are available.

Psychiatric Nursing: Substance Dependence

Focus topic: Psychiatric Nursing

Definition: Substance dependence is a state of dependency on drugs other than alcohol or tobacco that involves alteration of perception or mood and is produced by repeated consumption of the drug, causing tolerance to the substance and withdrawal symptoms. Withdrawal may range from discomfort to life threatening. Many individuals mix substances. It is important to identify if there is multiple drug use as well as consumption of alcohol, which increases risk for overdose and death.

Generalized Personality Characteristics
A. Difficulty forming intimate relationships.
B. Feelings of insecurity and inadequacy.
C. Rebellious toward authority.
D. Self-centered.
E. Copes through escapism.
F. Difficulty with sexuality and sexual identification.

Specific Drug Addictions
A. Opioid addiction.

  •  The most common types of opioids are heroin, Avinza (morphine), Vicodin (hydrocodone), Dilaudid (hydromorphone), Actiq (fentanyl), and OxyContin (oxycodone).
  •  Emotional dependence on the drug (to alter mood) occurs first, followed by physical dependence on the drug.
  •  Opioids (narcotics) have a sedative or depressant effect on the CNS.
  •  Tolerance level increases, so greater amounts of the drug are necessary to produce desired effects.
  •  Addiction tends to be chronic, with a high rate of relapse.
  •  Withdrawal symptoms.
    a. Anxiety.
    b. Nausea and vomiting.
    c. Sneezing, yawning, watery eyes, and runny nose.
    d. Tremor and profuse perspiration.
    e. Stomach cramps, muscle aches, and dehydration.

B. Sedative–hypnotics, anxiolytics–barbiturate addiction.

  •  Common drugs include Valium (diazepam), Ativan (lorazepam), Soma (carisoprodol), Xanax (alprazolam), Luminal (phenobarbital), and Fiorinal (aspirin, butalbital, and caffeine).
  •  CNS depressants danger of death from overdose and withdrawal. They are often implicated in suicide attempts.
  •  Psychological dependence occurs, followed by tolerance and physical dependence.
  • Drug may have been prescribed for relief of chronic pain, anxiety, or sleeplessness.
  • Withdrawal may result in delirium, seizures, and death.
  • Overdoses and acute withdrawal are medical emergencies and require hospitalization. Onset of withdrawal symptoms depends on a number of factors including half-life of the substance used.

C. Amphetamines—Benzedrine and Dexedrine.

  •  All produce a “high.”
  •  All are CNS stimulants, so overuse may result in brain damage, mental status changes, capillary bleeding, cardiac changes, and death.
  •  Large doses produce a hyperactive and agitated state.
  •  Amphetamines are emotionally addictive, especially for persons who harbor insecurities,
  •  Amphetamines affect individual’s physical condition as the drug reduces appetite and awareness of body needs.

D. Lysergic acid diethylamide (LSD)—“acid.”

  •  LSD is a hallucinogenic drug and mimics hallucinations seen in psychoses.
  •  LSD produces changes in perception and logical thought processes.
  •  Drug not considered addictive perse, but individuals may become emotionally dependent on it.
  •  Experiences with LSD range from ecstasy to terror, and the results are unpredictable.

E. Cannabis (marijuana).

  •  Marijuana was considered to have low abuse potential but now most professionals agree that this is not the case.
  •  It produces a “dreamy” state and feelings of euphoria, hilarity, and well-being.
  •  Moods vary according to environmental stimuli.
  • Marijuana changes perception of space and time, which seem distorted and extendible.
  •  High dosage may produce hallucinations and delusions.

F. Cocaine.

  • Cocaine is classified as a stimulant.
  •  Usual method of ingestion is by sniffing, intravenous (IV), or smoking.
  •  Use may cause strong psychological dependence.
  •  Physical dependence may occur, especially if used repeatedly.
  • Chronic users often abuse or are dependent on a narcotic, alcohol, or anti-anxiety drug to lessen the withdrawal symptoms of cocaine.

G. “Crack.”

  •  The most addictive drug known; a form of hydro chloride cocaine.
  •  It is smoked in cigarettes or glass water pipes.
  •  Crack is cheap and quickly addictive because there is a rapid high, then a “downer” that makes the person desire more crack.
  •  Symptoms include paranoia, depression, and physical symptoms.

H. Phencyclidine (PCP)—“elephant tranquilizer,” “angel dust.”

  •  PCP may also be ingested, injected, taken intravenously, or sniffed.
  •  Reactions vary from a sense of well-being to acute anxiety to total disorientation and hallucinations.
  •  PCP is considered an extremely dangerous “street” drug.
  •  Psychological dependence may occur.
  •  Cardinal signs of PCP use are blank stare, ataxia, muscle rigidity, nystagmus, and tendency toward violence.
  •  Cerebral cellular destruction and atrophy occur with even small amounts.
  • Overdoses or “bad trips” are characterized by erratic, unpredictable behavior; withdrawal symptoms; disorientation; self-mutilation; or self-destructive behavior.
  • Overdoses are treated with sedatives, decreased environmental stimuli, and protecting client from harming self and others. Cannot be “talked down.”

Assessment
A. Establish name and action of drug used.
B. Assess when addiction or abuse began in client’s life.
C. Determine amount of drug used.
D. Determine other drugs used.
E. Assess physical condition of client by physical exam and blood and urine lab work.
F. Assess psychological network in which client lives.
G. Evaluate rehabilitative potential and support systems.

Implementation
A. Support client during withdrawal, which is the first step in treatment and may be accomplished abruptly (“cold turkey”) or gradually over a period of days depending on substance used.
B. Use of the Clinical Opiate Withdrawal Scale (COWS) is commonly used for assessment of clients withdrawing from opiates. It elicits an aggregate score for heart rate, sweating, restlessness, pupil size, joint and muscle pain, nasal discharge and tearing, GI distress, tremor, yawning, anxiety, and piloerection. Treatment options are determined based on score.
C. Administer medications—e.g., Dolophine (methadone), Buprenex (buprenorphine), and Catapres (clonidine) if ordered, to reduce the physical reaction and complications to withdrawal.
D. Provide other medical and psychiatric treatment if physical and emotional deterioration or complication including alterations in nutrition, gastrointestinal disturbance, seizures, anxiety, and craving.

E. Encourage client to participate in recovery programs by professional or community resources.
F. Provide client with information concerning rehabilitation programs designed to help client reenter the mainstream of society.

  •  Various self-help groups such as Narcotics Anonymous offer aid in rehabilitation.
  •  Therapeutic communities and group therapy programs also provide support.

G. Provide support to client during adverse reaction, hallucinations, acute anxiety, and panic reactions to drug experiences or withdrawal.

  •  Place client in a quiet, safe environment with close supervision to prevent complications associated with LSD for example.
  •  Reassure client that this reaction is the result of the drug and of short duration.
  •  Provide careful reality orientation by nurse.
  •  Use nonthreatening, supportive approach.
  •  Reassure client that he or she will not be allowed to harm himself or herself.
  •  Refer client to drug counseling when the acute experience is over.

Psychiatric Nursing: Cognitive Impairment Disorders

Focus topic: Psychiatric Nursing

Definition: Cognitive disorders are disorders with organic etiology that may be reversible (delirium) or irreversible (dementia), and include clinically significant deficits in cognition or memory that result in significant changes in a client’s level of functioning and disturbed behavior. Delirium is considered a medical condition while dementia a psychiatric condition.

Psychiatric Nursing: DELIRIUM VERSUS DEMENTIA

Focus topic: Psychiatric Nursing

Psychiatric Nursing

Psychiatric Nursing: Delirium

Focus topic: Psychiatric Nursing

Characteristics
A. Characterized by a disturbance or fluctuation of consciousness and a change in cognition that develops over a short period.
B. Approximately 10% of all hospitalized elderly have delirium and many develop delirium while hospitalized.
C. Global intellectual impairment with rapid onset.
D. Thinking, memory, attention, and perception are disturbed and impaired, but may vary are not stable.
E. Condition may last hours or weeks; usually resolves in a few days with treatment.
F. Etiology.

  •  Any acute disease or injury that interferes with cerebral function and often is temporary and reversible.
  •  Includes infections (urinary tract infections; UTIs), circulatory disturbances, metabolic and endocrine disorders, neoplasms, and tumors.
  •  Injuries include brain trauma, invasive trauma.
  •  Other causes are toxic exposure, drugs, or systemic intoxication.

Assessment
A. Assess for clouding of consciousness—a cardinal symptom.
B. Assess for intellectual deficits and changes.

  •  Recent memory loss.
  •  Poor abstract thinking.
  •  Poor problem-solving ability.

C. Assess for presence of hallucinations (visual most common), delusions, and confusion.
D. Assess for loss of contact with reality.

  • Inattentive and distractible.
  • Disorientation to time and place, but not usually to person.

E. Check for increased motor activity with no defined purpose (groping, sudden movements, restlessness, wandering).
F. Assess emotional stability.

  •  Reactions are blunted.
  •  Fearful or suspicious.
  •  Apathetic.
  • Anxious.
  •  Euphoric.

G. Assess alterations in adjustment: tend to be worse at night, more fearful, moaning and calling out.

Implementation
A. Provide adequate nutritional and fluid intake as ordered by treatment plan.
B. Keep client in a quiet, safe, structured environment.
C. Observe and monitor vital signs as necessary.

D. Provide for safety, including falls.
E. Implement treatment plan for elimination of causative factors.
F. Provide reality orientation approach with client.
G. Set limits on inappropriate behavior.
H. Express directions in a simple and concrete manner.
I. Observe client for signs of fever, shock, and increased intracranial pressure such as restlessness, acute anxiety, pain, and changes in vital signs.
J. Reassure and involve family as is appropriate.
K. Prevention and early detection are key.

Psychiatric Nursing: Dementia

Focus topic: Psychiatric Nursing

Characteristics
A. Organic condition characterized by development of multiple cognitive deficits.
B. Common cognitive disturbances include at least one of the following: aphasia, apraxia (impaired ability to carry out motor activities, despite intact motor function), agnosia (loss of sensory ability to recognize objects), or a disturbance in executive functioning.

  • Difficulty thinking abstractly, planning, initiating, and completing complex multi step tasks. Eventually, simple tasks become difficult.
  • Causes difficulties in social and occupational functioning.

C. Insidious onset but slow, progressive deterioration occurs.
D. Etiology is specifically unknown: results from wide variety of sources.

  • Prenatal causes: congenital cranial anomaly, congenital spastic paraplegia.
  •  Infection: central nervous system, syphilis, meningoencephalitis, human immunodeficiency virus (HIV).
  • Intoxication: drug or poison, alcohol.
  •  Trauma: brain trauma by gross force, brain surgery.
  •  Circulatory disorder: cerebral arteriosclerosis.
  •  Disturbance of innervation: convulsions.
  • Disturbances of metabolism, growth, or nutrition.
    a. Senile brain disease: dementia.
    b. Glandular problems.
    c. Pellagra.
  • New growths: brain neoplasm.

Psychiatric Nursing: Types of Degenerative Conditions

Focus topic: Psychiatric Nursing

Dementia, Alzheimer’s Type
A. Most common form of dementia: accounts for majority of known cases.

  •  More than 5 million in the United States have Alzheimer’s disease.
  •  By 2050, over 14 million will develop this disease.

B. Unknown etiology but diffuse atrophy of cerebral cortex occurs.
C. Usually begins after age 60 but can be observed at age 40. Dementia, Alzheimer’s type (DAT) average course is 5 to 10 years but there is variance.
D. Symptoms gradually and progressively worsen, irreversible.
E. Clients may live for 10 years or longer but will eventually progress to requiring total care. The impact to families’ emotional and economic well being is dramatic.
F. Three clinical stages of DAT.

  •  Early stage: Client is forgetful, confused, irritable; family begins to notice changes.
  •  Middle stage: Increased memory loss, recall of recent events diminishes, activities of daily living (ADLs) become difficult to accomplish. Aggressiveness and social inappropriateness present. Wandering increases.
  •  Late stage: severely disoriented, delusional, and paranoid. Client may not speak, forgets family members, and soon becomes helpless.

Pick’s Disease
A. Rare here do degenerative process of frontal lobe not associated with normal aging.
B. Becomes well advanced in 2 to 3 years.
C. Characterized by changes in personality early in course of illness.
D. Similar to Alzheimer’s disease but involvement spares parietal lobes.
E. These clients act dull and lack initiative; otherwise, their disease resembles Alzheimer’s disease.

Huntington’s Chorea
A. Genetically transmitted disorder caused by a single autosomal dominant gene.
B. Onset of symptoms—age 40 to 50 years.
C. Progressive mental and physical deterioration inevitable.
D. Characterized by personality changes with psychotic behavior, intellectual impairment, and, finally, total dementia.

Korsakoff ’s Syndrome
A. A disorder that occurs in chronic alcoholism and is often associated with Wernicke’s encephalopathy.

  •  Wernicke’s encephalopathy.
    a. Acute, life-threatening neurologic condition that can occur as a result of chronic alcoholism (inadequate diet leading to thiamine deficiency).

b. Usual symptoms are cloudy consciousness, impaired mentation, ataxia, peripheral neuropathy.
c. Treatment is oral vitamin B complex and thiamine 100 mg intramuscularly (IM) stat if client presents with the above symptoms and has a history of alcohol abuse.

  •  Korsakoff ’s syndrome is a chronic condition that remains after Wernicke’s encephalopathy is treated.

B. Most important feature is recent memory impairment, especially in learning new information.

  •  Confabulation (making up stories) accompanies memory impairment.
  •  Memories for past events are not usually affected.

C. Syndrome improves with adequate diet (especially including vitamin B complex and thiamine) but many do not recover fully.

Vascular Dementia
A. Type of dementia involving intermittent emboli or infarcts that destroy brain tissue. (Also called ischemic vascular dementia.) Hypertension is also implicated.
B. This form is the second most commonly occurring type of dementia.
C. Characteristics include abrupt onset with numerous remissions and exacerbations; client may also have a history of diseases affecting other organs.

Creutzfeldt–Jakob Disease
A. Suspected to be caused by an infection of a prion spread after transplant (cornea) or injection of human growth hormone.
B. A new variant of this disease known as mad cow disease (bovine spongiform encephalopathy [BSE]) was identified in 1996 and may be linked to eating contaminated beef.

Dementia with Lewy Bodies
A. This form of dementia is named for the development of Lewy bodies in the cerebral cortex.

  •  The appearance of Parkinsonism symptoms is caused by effects on the extra pyramidal tract of the CNS.
  •  Symptoms include intermittent confusion, lapses of consciousness, and psychiatric problems.

B. Clients may have this form of dementia alone (less common) or concurrent with DAT (20% to 30%).

Dementia Due to HIV Disease
A. Presence of a dementia that is a direct consequence of HIV disease.
B. Involves diffuse, multifocal destruction of white matter and subcortical structures.
C. Characterized by forgetfulness, slowness, poor concentration, difficulties with problem solving, and hallucinations.

Assessment
A. Assess onset, which is generally slow.
B. Evaluate if illness is stabilized or in remission.
C. Assess for increasing deterioration.
D. Look for the following symptoms:

  • Cognitive impairment.
    a. Disorientation.
    b. Severe loss of memory.
    c. Judgment impairment.
    d. Loss of capacity to learn.
    e. Perceptual disturbances.
    f. Decreased attention span.
    g. Paranoid ideation.
  • Affective impairment.
    a. Decreased motivation, interests, and self-concern.
    b. Loss of normal inhibitions.
    c. Loss of insight.
    d. Labile mood, irritableness, and explosiveness.
    e. Depression.
    f. Withdrawal.
    g. Anxiety.
  • Behavioral impairment.
    a. Sun downing—a syndrome of restlessness, confusion, and disorientation that typically begins in late afternoon and gradually worsens. Clients wander or exhibit other aberrant motor activities (such as pacing).
    b. Ritualistic, stereotyped behavior to deal with environment.
    c. Possible combativeness or verbal aggression.
    d. Possible inappropriate and regressive behavior.
    e. Alterations in sexual drives and activity.
    f. Neurotic or psychotic behavior as client’s defenses break down.

E. Assess psychological reactions to organic brain disorder.

  •  Change in self-concept.
  •  Anger and frustration as reactions to forced change in life role.
  •  Denial used as defense.
  •  Depression.
  •  Acceptance of limitations.
  •  Assumption of “sick” role by dependency and lack of motivation.

Implementation
A. Meet client’s physical needs and provide for safety.

  •  Avoid fostering dependence.
  •  Establish routine for activities of daily living.
  •  Assure the environment is safe. Prevent use of appliances, for example, to prevent injury.

B. Help client maintain contact with reality.

  •  Give feedback.
  •  Avoid small chatter.
  •  Personalize interaction.
  •  Supply stimulation to motivate client.
  •  Keep client from becoming bored and distracted.

C. Assist client in accepting the diagnosis.

  •  Be supportive.
  •  Maintain therapeutic communication.
  •  During denial phase, listen and accept; do not argue.
  •  Assist development of awareness.
  •  Help client develop the ability to cope with his or her altered identity.

D. Focus interactions with client and establish consistent contact.

  •  Have short, frequent contacts with client.
  •  Use concrete ideas in communicating with client.
  •  Maintain reality orientation by allowing client to talk about his or her past and to confabulate  filling in memory gap with a made-up response (lie) to protect one’s self-esteem.
  •  Acknowledge client as an individual.

E. Provide activities that increase success of client.

  •  Social groups.
  •  Occupational therapy.
  •  Allow client, as interested, to do small chores around unit.

F. Monitor medications for dementia management.

  •  Acetylcholinesterase inhibitors.
    a. Inhibits the enzyme acetylcholinesterase, which slows the breakdown of acetylcholine, thereby allowing more information to be transmitted from one cell to another.
    b. Memory and general cognitive activity increases, thus slowing the progression of dementia, especially early in the process of the disease.
    c. Commonly used drugs in the category are Aricept (donepezil), which slows breakdown of brain chemical acetylcholine vital for transmission of nerve signals, Exelon (rivastigmine), and Razadyne (galantamine).
    d. These drugs have both positive and negative results and must be individualized for the client.
  •  Namenda (memantine) for treatment of moderate to severe Alzheimer’s.
    a. Temporarily delays worsening of symptoms.
    b. Side effects: headache, constipation, confusion, dizziness.
  • Depressive symptoms for dementia.
    a. SSRIs appear to be more efficacious  Celexa (citalopram), Prozac (fluoxetine), and Zoloft (sertraline).
    b. Evidence fewer side effects than other antidepressants.
  •  Psychosis and dementia.
    a. If psychotic thoughts are present, medication may be required. It is important to differentiate medication side effects (Namenda for example) from disease process.
    b. When psychosis is associated with violence or dangerous behavior, medication, often short-acting benzodiazepines starting with low doses, is often utilized but sparingly and for short periods of time.
    c. For chronic aggressive behavior, Risperdal (risperidone) may be effective. Dosing is individualized and always at lowest dose to achieve benefits. Goal should be to reduce or discontinue medication if possible.
    d. Seroquel (quetiapine) is also effective and does not worsen cognition.
  •  Anger and aggression.
    a. For an acute episode, redirection or other non medicinal strategies should be attempted before medication is utilized.
    b. For gradually evolving tendencies or if a comorbidity of a mood disorder is present, Depakote (valproic acid) (125 mg bid with gradual increases as needed) may be administered.

G. Provide supportive environment.

  •  Ensure a consistent staff and environmental structure.
  •  Do not change schedule suddenly.
  •  Provide handrails, walkers, wheelchairs, etc., as necessary.
  •  Ensure that the floor is not slippery and that the environment is well lighted.

H. Assess client’s disabilities and develop a nursing plan to deal with them.

  •  Update conferences with treatment team.
  •  Involve client in treatment planning as able.
  •  Communicate client needs to rehabilitation team.

I. Involve family and community in treatment and rehabilitation program.

  •  Plan visits by client to social community events.
  •  Encourage family involvement.
  •  Establish communication with family by using a friendly, warm approach.
  •  Encourage and arrange community groups (church groups, volunteer societies, and school groups) to visit on units.
  •  Refer family to support services.

J. Assist client to function at the highest level possible.

  •  Increase self-esteem.
  •  Avoid dependency.
  •  Allow and encourage personalization of client’s room and environment.
  •  Dress client in his or her own clothing.
  •  Maintain client’s cleanliness: clothes, hair, and person.
  •  Do not isolate client from others on the unit.

FURTHER READING/STUDY:

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