0133427269 Module23 Cognition LectureOutline

The Concept of Cognition Cognition ( complex set of mental activities through which individuals acquire, process, store, retrieve, and apply information Normal presentation Physiology review Nervous system must be intact Individual must have progressed through one or more stages of cognitive development Cognition is primarily a function of the brain Neurons (carry and process information Neurotransmitters ( chemical messengers Theories of cognitive development Piaget Cognitive development is orderly, sequential process, called schemes Variety of new experiences needed for intellectual abilities can develop Given nurturing experiences, childs ability to think matures naturally Four major phases Sensorimotor Preoperational Concrete operational Formal operational Vygotskystheory Vygotsky believed children embedded in social contexts that influence learning Sociocultural theory ( socially mediated activity in which children build knowledge through cooperative dialog with adults Information processing theory Information processing theory views attention, memory ( most important part of learning Mind is a continuously evolving computational system Application to nursing Cognitive theory essential to pediatric nursing Nurse understands clients thought processes to design appropriate teaching plans, stimulating activities Range of normal cognitive development is broad Genetic considerations and nonmodifiable risk factors Under normal conditions, cognitive skills become increasingly complex as individuals advance from childhood to adulthood Genetics factors may be involved in age-related cognitive changes Normal, healthy aging not characterized by cognitive and mental disorders Normal age-related changes Information processing speed Ability to divide attention Ability to switch attention Ability to maintain sustained attention Ability to filter irrelevant information Short-term memory remains stable Long-term memory exhibits more substantial age-related changes Aspects of language well preserved Visuospatial task ability decreases Abstraction and mental flexibility decreases slightly Accumulation of practical experience, or wisdom, continues Methods for coping with age-associated cognitive changes Participating in daily activities ( reading, playing cards, completing puzzles Keeping lists and calendars Using memory training Avoiding distractions Establishing routines Always putting objects in the same place Engaging in regular physical activity Staying social and seeking support from family and friends Refusing to accept common stereotypes about aging Remaining positive about the future Alterations to cognition Normal cognition is contingent on normal brain function ( disruption of nearly any physiological system may cause cognitive impairment See CONCEPTS RELATED TO COGNITION, p. 1579 Cognitive dysfunction may be accompanied by Psychosis Delusions Hallucinations Learning disabilities Definition (group of disorders that impair an individuals ability to receive and process information Alterations and manifestations Unaccountable gap between expected level of performance and actual achievement See Table 23-2 COMMON LEARNING DISABILITIES, p. 1578 Prevalence Difficult to determine School-age children 3.9 of boys 2.0 of girls Genetic considerations and nonmodifiable risk factors Genetics seems to be a major factor in learning disabilities Example in a family where there are reading disabilities, 35 45 of the family members will be affected Prevention Most are unavoidable Some are congenital and can be avoided with healthy pregnancies and deliveries Early detection and intervention are important Intellectual disability Definition ( significant limitations in intellectual functioning and adaptive behavior prior to age 18 it is a form of developmental disability Intellectual functioning ( general intelligence, IQ below 70 - 75 Adaptive behaviors ( conceptual skills, social skills, practical skills Alterations and manifestations Can result from prenatal errors in CNS development, external factors that damage the CNS, or pre- or postnatal changes in biological environment Down syndrome Fragile X syndrome Fetal alcohol syndrome Prevalence Most prevalent developmental disability 6.5 million diagnosed with some degree of impairment Genetic considerations and nonmodifiable risk factors Caused by any condition that inhibits brain development before birth, during birth, or in childhood years Inherited gene disorders or prenatal gene abnormalities such as Down syndrome or fragile X PKU Prevention During pregnancy, avoid smoking, alcohol, malnutrition, environmental toxins, illness Prematurity and low birth weight forecast disability Diseases such as whooping cough, chickenpox, measles can damage brain, as can head injuries and near drowning Children living in poverty are at higher risk Dementia Definition ( progressive loss of cognitive function Alterations and manifestations Caused by neuronal death and subsequent changes to brain structure Common etiologies ( Alzheimer disease, vascular dementia, dementia with Lewy bodies, frontotemporal dementia ( see Table 23-4, p. 1584 Some conditions mimic dementia ( age-related cognitive decline, mild cognitive impairment, depression, delirium Those with dementia experience variety of limitations from mild to severe ( akathisia, carphologia, ataxia, dysphagia, aphasia, echolalia Prevalence Not a natural part of aging, but more common in older adults Less than 2 ages 65 69 ( 37 over age 90 Genetic considerations and nonmodifiable risk factors Genetic factors contribute to some cases of dementia Early-onset Alzheimer disease caused by three heritable gene mutations Other nonmodifiable risk factors include age, female gender, diabetes, Parkinson disease, multiple sclerosis, Down syndrome, kidney disease, HIV, and some learning disablities Prevention To reduce risk Follow treatment plans for medical conditions Healthy diet with fruits and vegetables Control weight Dont smoke Limit alcohol intake Case Study Part 1 ( Victor Wallace is a 74-year-old Caucasian male who was diagnosed with moderate Alzheimer disease , p. 1586 See ALTERATIONS AND THERAPIES Cognition, p. 1586 Assessment Nursing assessment Assess for depression, especially with dramatic life changes See Table 236 COMMON MENTAL STATUS ASSESSMENTS, p. 1587 See MENTAL STATUS ASSESSMENT, pp. 15881589 See ASSESSMENT INTERVIEW Cognition, p. 1590 Lifespan and cultural considerations Many factors complicate assessment ( intellectual disability, pediatric clients Language barriers Older adults ( hearing problems Diagnostic tests Multiple tests to rule out other conditions IQ tests Brain imaging Genetic testing Case Study Part 2 ( Mr. Wallace begins experiencing increased agitation and wandering , p. 1590 Senses and cognition Clients out of contact with reality may display delusional, illusional, and hallucinatory speech and behaviors Interventions and therapies Independent Create a safe environment Educate clients and families about diagnosis Preserve clients dignity Collaborative Community resources Clients need support from a variety of community resources Government resources ( Medicare, Medicaid, Social Security, early intervention Nongovernmental advocacy groups Pharmacologic therapy Alzheimer disease ( acetylcholinesterase inhibitors and NMDA Agitation ( atypical antipsychotics Anxiety and depression (anxiolytics See MEDICATIONS Cognitive Alterations, p. 1592 Review The Concept of Cognition Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( After his wandering episode, Mr. Wallaces condition rapidly declines , p. 1593 Exemplar 23.1 Alzheimer Disease Overview Alzheimer disease (AD) ( most common cause of dementia Usually manifests after age 65 Pathophysiology and etiology Familial AD (FAD0( strong hereditary component, also called early-onset AD Sporadic AD ( shows no clear pattern of inheritance, although genetic factors may be involved Pathophysiological changes degenerative ( results in gross atrophy of cerebral cortex Neurofibrillary tangles ( thick, insoluble clots of protein inside damaged brain cells, neurons Protein in neurons becomes distorted, twisted (Tau) Results in lost communication between neurons Death of neurons results, contributing to development of dementia Amyloid plaques forms around amyloid core in spaces between neurons Insoluble deposits disrupt transmission of nerve impulses Galanin ( neuropeptide thought to play role in pathophysiology of AD Rescues neurons in distress ( slowing down cells, immobilizing them so repairs can be made Excess galanin inhibits access to memory Blood flow to affected areas decreases Atrophy of cortical area of brain, eventually ventricles enlarge Structural and chemical changes See Table 237 CEREBRAL EFFECTS OF AD, p. 1595 Etiology Cholinergic hypothesis Emerged in 1980s Low levels of acetylcholine produce memory deficits Amyloid hypothesis Considered more likely explanation AD arises when brain cannot properly process amyloid precursor protein Tau hypothesis Also considered more likely explantion Abnormal tau proteins join and twist forming neurofibrillary tangles Other hypotheses AD due to excessive myelin sheath breakdown Oxidative stress plays a role Risk factors Increases with age Family history Female gender History of traumatic head injury Prevention Weight control Preventive foods ( vitamin E, omega-3 fatty acids, antioxidants, vitamin C, vitamin B12, folate Drinking green tea and red wine Mental stimulation, education Clinical manifestations Warning signs Memory loss that affects job skills Difficulty performing familiar tasks Problems with language Disorientation to time or place Poor or decreased judgment Problems with abstract thinking Likelihood of misplacing things Changes in mood or behavior Changes in personality Loss of initiative Stages ( see Table 23-8 THE SEVEN STAGES OF AD, p. 1597 Stage 1 No impairment Stage 2 Normal aged forgetfulness Stage 3 Mild cognitive impairment Stage 4 Mild or early stage AD Stage 5 Moderate AD Stage 6 Moderately severe AD Stage 7 Severe AD See CLINICAL MANIFESTATIONS AND THERAPIES Alzheimer Disease, pp. 15991600 Collaboration Diagnostic tests No definitive tests for AD Differential diagnosis is used to rule out other causes of symptoms Pharmacologic therapy No cure for AD Goals of medication to improve ability, slow decline Cholinesterase inhibitors may slow progression of disorder Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Reminyl) Angiotensin-converting enzyme inhibitors may also slow progression Memantine (Namenda) Antidepressants Atypical antipsychotics Nonpharmacologic therapy Speech therapists Dietitians, nutritionists Physical therapists Occupational therapists Social workers Pastoral counselors Complementary and alternative therapy Dietary supplements ( See Table 23-9 COMMON SUPPLEMENTS TAKEN BY CLIENTS WITH AD, p. 1598 Music therapy Therapeutic touch Aromatherapy Therapy pets Nursing process Assessment Health history Family history of AD Personal history of stroke, cardiovascular disease, brain injury, brain infection Changes in behavior, cognition, memory, or communication abilities Alternations in mood Disrupted sleep patterns Difficulty performing activities pf daily living Drug and alcohol abuse Possible exposure to environmental toxins Physical assessment Mental status examinations Mini-Mental Status Exam Diagnosis for early stages Impaired Memory (stage 1 AD) Chronic Confusion Risk for Injury Anxiety Hopelessness Imbalanced Nutrition Less Than Body Requirements Ineffective Denial Diagnosis for later stages Risk for Aspiration Self-Care Deficit (Bathing, Dressing, Feeding, and/or Toileting) Impaired Social Interaction Impaired Verbal Communication Functional Urinary Incontinence Impaired Physical Mobility Wandering Impaired Swallowing Risk for Compromised Human Dignity Risk for Caregiver Role Strain Planning Client will remain free of injury Client will navigate home environment with modifications as needed Client will participate in grooming, hygiene activities with prompting and supervision Client will obtain minimum 7 hours uninterrupted sleep at night Client to utilize memory aids (appropriate outcome for stage 1 clients) Implementation Early diagnosis ( client participation Promote effective coping strategies Complementary therapies, such as meditation, massage, exercise Suggest using calendar, lists, having someone else provide reminders Recommend a medication box labeled with days, times Safety concerns ( microwave versus stove, program phone, Lifeline program Suggest cues such as alarm Suggest client carry wallet card with ID, phone numbers of family, caregivers Prevent injury Label rooms, drawers, other items as needed Remove potential hazards from environment Keep environmental stimuli to a minimum Begin each interaction by identifying yourself, calling client by name See Box 231 THE CLIENT WITH AD RECOMMENDED COMMUNICATION STRATEGIES p. 1601 Limit questions to those that require a simple yes or no Orient to environment, person, time as able Provide boundaries by affixing red or yellow tape to floor Provide continuity in nursing staff Repeat explanations simply and as needed to decrease anxiety Prevent injury Decreasing risk of falls Assess usual environments for hazards Observe areas of special concern, such as bathroom, kitchen, stairs ( modify as needed Evaluate muscle strength and gait Check shoes for fit and support Inquire about alcohol use, medications that affect balance or cause mobility problems Use night-light, increase daytime lighting in dark areas Keep traffic areas free from clutter Decreasing injuries related to cognitive impairments Secure items that may be mistakenly ingested, such as cleaning agents, houseplants Modify potentially unsafe areas such as unenclosed porches Provide double lock systems for outside doors and for doors to rooms that are off limits Protect from fire hazards Fence the yard with a locked gate to prevent wandering Modify controls on the oven and stove Adjust the water heater to a safe temperature Plan a calling system for emergencies have children call same time every day as a check Ensure impaired family member has no access to objects in the home such as knives, guns Do not allow client to drive Promote balance between rest and activity Monitor for early behaviors of fatigue, agitation Remove from situations that are causing increased anxiety Keep daily routine as consistent as possible Schedule rest periods, quiet times throughout the day Provide quiet activities in afternoon, early evening If confusion, agitation persist, escalate, assess for physical causes Use therapeutic touch, gentle hand massage Facilitate stress management for caregivers Usually spouses, family members Economic, psychosocial stressors Fear Fatigue Teach caregivers self-care techniques Have caregivers list and regularly take part in physical activities they enjoy Refer caregivers to local AD support groups Refer caregivers to Meals on Wheels, home health, respite care, other community services Ensure family knows that hospice care available during end stages of AD Evaluation Client remains free from injury Clients nutritional intake meets his nutritional intake meets his nutritional and metabolic needs Client maintains and follows her medication regimen Client effectively uses memory aids Caregiver utilizes available community resources. Review Alzheimer Disease Relate Link Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case study Exemplar 23.2 Confusion Definitions Confusion ( alteration in cognition that makes it difficult to think clearly, focus attention, or make decisions frequently a symptom, not a diagnosis Delirium ( acute disorder of cognition that affects functional independence interchangeable with acute confusion Pathophysiology and etiology Onset Delirium often as abrupt onset ( reversible by treating its cause Dementia ( gradual and irreversible Etiology Delirium and in-hospital, postsurgical clients Can occur at any stage of developmental process Risk factors and prevention Older adults, particularly men, are at higher risk Vision and hearing changes contribute Older adults due to chronic medical problems, polypharmacy Clinical manifestations Reduced awareness, impaired thinking skills, changes in behavior Acute loss of cognitive functioning Features Fluctuations in alertness Distractibility Disorganized thinking, speech Severe ( hallucinations See Table 23-10 MANIFESTATIONS OF DELIRIUM, p. 1606 Lifespan and cultural considerations Children and older adults at greater risk for delirium Cultural conceptions about time, place, and person differ ( must be taken into account when assessing for delirium Collaboration Diagnostic tests Detailed neurological exam Drug and alcohol screening Laboratory testing of blood and urine Tests for presence of infection Screening for depression Surgery In some cases, surgery can reverse the underlying cause Removal of brain tumor or insertion of shunt to relieve hydrocephalus Pharmacologic therapy Medications may be used to treat causative condition Antipsychotics, antidepressants Or medications that are causing symptoms may be discontinued Nonpharmacologic therapy Physical interventions ( oxygen administration, fluids and electrolytes, appropriate nutrition Environmental interventions ( enhancing clients comfort, preventing over- or understimulation, maintaining safety, promoting consistency Cognitive interventions ( orienting client to person, place, and time providing reassurance of safety Nursing process Assessment Change in mental status needs to be aggressively evaluated Confusion Assessment Method Signs of depression Risk factors Diagnosis Risk for Injury Disturbed Sleep Pattern Self-Care Deficit (Bathing, Dressing, Feeding, and/or Toileting) Acute Confusion Impaired Social Interaction Impaired Memory Impaired Verbal Communication Risk for Compromised Human Dignity Planning Client will remain free from injury Client will be oriented to time, place, date and person Client will return to baseline cognitive status Able to perform activities of daily living Client will demonstrate the ability to communicate in a clear and logical manner Client will obtain adequate sleep and rest Client will exhibit reduced anxiety, agitation and restlessness Implementation Therapeutic environment Preventing access to potential hazards Promoting consistency by assigning the same caregivers Providing adequate pain management Evaluation Client sustains no injuries Client is oriented to time, place, date, and person Client demonstrates an absence of confusion Client communicates clearly and transitions logically between topics Client is able to perform activities of daily living. Review Confusion Link the Concepts and Exemplars Ready Go to Companion Skills Manual Relate Go to Nursing Student Resources Reflect Case Study Exemplar 23.3 Schizophrenia Overview Schizophrenia ( most common psychotic disorder Combination of Disordered thinking Perceptual disturbances Behavioral abnormalities Affective disruptions Impaired social competency Affected individuals usually have a normal childhood, subtle changes during puberty, and then severe signs and symptoms in late teen and early adult years Schizophrenia is associated with psychosis ( abnormal mental state characterized by Delusions Hallucinations Illusions Paranoia Psychosis may be acute or chronic Acute ( lasts for hours or days Chronic ( months or years Pathophysiology and etiology Abnormal brain development in people with schizophrenia Abnormal development and migration of neurons in the brain Neurons in cerebral cortex also seem to function incorrectly Myelin sheath development in adolescence Abnormalities in neurotransmitter levels and/or function Abnormalities in brain structure Some parts of the brain appear enlarged others show decreased volume and/or activity Reduced blood flow to the thalamus See Table 2311 TYPICAL CNS ABNORMALITIES OBSERVED IN INDIVIDUALS WITH SCHIZOPHRENIA, p. 1611 Etiology Exact causes are not understood Genetics seem to be one important factor ( individuals with a parent, brother or sister with schizophrenia have 10 times higher risk Diagnosed worldwide, approximately 1 of populations Onset, progression variable Some symptoms decline with age Disorder may progress through relapse, remission versus long-term, stable course Risk factors Biological factors Genetic factors Advanced paternal age Social-environmental factors Communication deviance Double-bind theory Family interactions Bidirectional influence Viruses, birth complications, malnutrition Prevention Reducing stress Getting adequate sleep Avoiding illegal drug use Community-based programs that involve educations and social support Family-based programs Clinical manifestations Major manifestations may be positive or negative symptoms Positive symptoms (presence of unusual behaviors Negative symptoms ( absence of typical behaviors See Table 2312 POSITVE AND NEGATIVE SYMPTOMS OF SCHIZOPHRENIA, p. 1613 Positive symptoms Thought disorders Disorganized thinking Sensory overload Thought blocking Neologisms Loose association Clang Perseveration Disorganized behavior ( inability to start or finish goal-oriented activities Movement disorders ( additional body movements or catatonia Negative symptoms Flat affect Alogia Avolition Anhedonia Neglect of personal hygiene Concrete thinking Memory impairment Poor problem solving Lack of focus Physical and psychological toll of schizophrenia ( life expectancy 25 years shorter than general population Subtypes, specifiers, and dimensions DSM-5 has eliminated subtypes Now describes schizophrenia in terms of specifiers Schizophrenia with catatonia, for example Also includes dimensional approach rating the core symptom from 0 to 4 Related disorders Schizoaffective disorder Brief psychotic disorder Schizophreniform disorder Comorbid disorders At least 47 have problems with drugs, alcohol Panic disorder, PTSD, and generalized anxiety Mood disorders depression seen in the majority OCD High rates of comorbid medical illness, e.g., type 2 diabetes Lifespan and cultural considerations Childhood ( early-onset schizophrenia (EOS) Males more than females Unusual childhood behavior Hallucinations Chronic course of development Collaboration Multidisciplinary team Highly individualized See Box 232 DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA, p. 1617 Diagnostic tests Psychological evaluation Blood tests to rule out other conditions Imaging studies Pharmacologic therapy Primary goal ( reduce psychotic symptoms, not cure See MEDICATIONS Schizophrenia, p. 1618 Conventional antipsychotics ( phenothiazines, phenothiazine-like agents Thorazine Hallucinations, delusions diminish within days Other symptoms may take 78 weeks Long term Numerous adverse effects Extrapyramidal side effects Dystonias ( severe muscle spasms Akathisia ( inability to rest, relax Tardive dyskinesia ( unusual tongue and face movements Medications to combat EPS Cogentin ( dystonia Conventional nonphenothiazine antipsychotics Similar side effects Less sedation Atypical antipsychotics treat positive, negative symptoms Broader spectrum of action ( clozapine Block dopamine, alpha-adrenergic and serotonin receptors Side effects Weight gain Menstrual disorders Decreased libido Osteoporosis Impotence Altered glucose metabolism Dopamine system stabilizers Positive, negative characteristics Headaches, nausea/vomiting, fever, constipation, anxiety First episode ( low doses Nonpharmacologic therapy Psychiatric/psychosocial rehabilitation Need to create opportunities for people with persistent psychiatric disability to increase skill levels Collaborative partnerships Ongoing process Focus on value of hope, optimism, promotion of choices, self-determination, individual responsibility Nurse as resource Teach skills Coach skills Identify supports in community of choice Group therapy Effective psychosocial treatment Highly structured to spontaneous Narrow topic range to broader topics Teaching, social support Assertive community treatment Assigned to team that delivers services when, where client needs them Comprehensive, integrated community services Hospitalization Often for first psychotic episode Violence toward others Suicide risk Electroconvulsive therapy (ECT) In combination with medications Unremitting depressive symptoms Complementary and alternative therapies Transcranial magnetic stimulation ( causes cells in cerebral cortex to fire Omega-3 fatty acids ( reduce positive, negative symptoms, and side effects of dyskinesia Aromatherapy ( olfactory receptors open directly to brain Acupuncture Nursing process Assessment Health history Early behaviors Direct observation Interviews with family members Cultural influences Physical Ability to identify smells Disturbed sleep patterns Polydipsia ( hyponatremia Diagnosis Risk for Injury Imbalanced Nutrition Less Than Body Requirements Risk for Imbalanced Nutrition More Than Body Requirements Ineffective Health Maintenance Self-Care Deficit (Bathing and/or Dressing) Acute Confusion Impaired Memory Impaired Verbal Communication Impaired Social Interaction Ineffective Coping Noncompliance Planning Broad outcomes ( see Box 23-3, p. 1622 Reducing or eliminating symptoms Improving quality of life, adaptive functioning, including improving family relationships Enabling recovery by helping clients attain personal life goals Implementation Prevent Injury Prevention of violence toward self or others Altered cognition Compromised social relationships Risk for injury Provide symptomatic treatment Promote control of symptoms Orienting client to time and place Avoiding overwhelming or overstimulating client Educate clients and significant others Parents may be confused, frightened, overwhelmed Desired outcomes for clients and family Verbalize accurate understanding of disorder Education in group setting Not responsible for client developing schizophrenia Balance protective behaviors while encouraging independence Practical solutions Do things with client, not for client Set expectations, limits on inappropriate behavior Encourage client to stick with treatment program Develop an advance directive Permission to treat in case of future acute episode Utilize effective communication skills Implement problem-solving process to manage family issues High emotional energy family ( higher relapse rates Negotiate individual roles, responsibilities within the family Rules that must be followed Treatment Participate in family therapy In conjunction with medication ( significantly lower rehospitalization rate See CLIENT TEACHING Family Communication, p. 1623 Demonstrate client advocacy Take steps to advocate for clients Ensure that all interventions and therapies are in clients best interest Evaluation Client maintains and follows the medication regimen Client demonstrates utilization of available community resources Client communicates clearly and transitions logically between topics Client reports an absence of hallucinations and/or delusions Client is able to perform ADLs Client refrains from use of nicotine, alcohol, and illicit drugs Client engages in paid work in a structured setting Review Schizophrenia Relates Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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