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45 Cards in this Set
- Front
- Back
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What is the Mini-Cog and its characteristics?
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o Tests registration, recall and executive function
o Three-item recall: listen and remember 3 unrelated words, and then repeat the words o Clock Drawing Test: instruct patient to draw the face of a clock, either on a blank sheet of paper or on a sheet with the clock circle drawn on the page; ask the patient to place the numbers on the clock face, and to draw the hands of the clock at 11:10. o Ask the patient to repeat the 3 previously stated words. |
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What are the scores of the mini-cog and what do they mean?
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1. Unsuccessful recall of all 3 items after the clock drawing test distractor: dementia
2. Successful recall of all 3 items: no dementia 3. Recall of 1-2 items: classified based on clock drawing test 4. Abnormal clock drawing test: dementia 5. Normal clock drawing test: no dementia |
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What are the 3 limitations of the mini-cog test?
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1. Visual impairment
2. Hearing impairment 3. Inability to draw clock due to physical impairment |
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What is the CAM and what are the four features of delirium?
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o Documented, and assessed at every shift. Notify healthcare members of any change in LOC
o Standardized diagnostic algorithm (short form) o Four features of delirium: 1. Mental status change from baseline (acute onset or fluctuating changes): Make sure that it is an accurate onset, and has not been going on for a whole 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness: you will not see an altered LOC with depression or dementia. You only see an altered LOC in dementia when the pt is at the end of life or end stage |
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Using the CAM, how is delirium identified with the 4 features?
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a. Features #1 and #2, and
b. Either #3 or #4, or both |
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What is the first feature of the CAM and what are its 3 characteristics?
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-Mental Status Change from Baseline
1. Assess for memory impairment, disorientation, paranoid behavior 2. Confirm baseline with a reliable source 3. Document baseline mental status in patient’s record and refer to it in subsequent screenings |
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What is the second feature of the CAM and what are its 6 characteristics?
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- Inattention
1. Assess for ability to focus on a task or conversation 2. Easily distracted by noises 3. Recite WORLD backwards 4. Count backward from 20 to 5. Recite days of the week 6. Patients with mild dementia can perform simple attentional tests |
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What is the third feature of the CAM and what are its 4 characteristics?
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- Disorganized thinking
1. Ask standardized questions: “Do you know what year it is? What season? What month? Where are we?” 2. Patient with delirium may exhibit illogical flow of ideas, rambling speech, paranoid statements, hallucinations 3. These signs may be baseline for a patient with dementia 4. Difficulty to diagnose delirium superimposed on dementia • Look at the attributes and features you, family members, or other healthcare workers can pick up on |
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What is the fourth feature of the CAM and what are its 4 characteristics?
- What are the 3 types of delirium and their characteristics? |
- Altered level of Consciousness
1. Hyperactive delirium: restlessness, agitation, increased motor activity, yelling, pulling out tubes & lines, severe disorientation, combative behaviors: Lots of increased agitation and restlessness, and combative behaviors 2. Hypoactive delirium: ranging from lethargic to comatose, withdrawn, flat affect, reduced number & speed of spontaneous movement; The nice patient who never bothers the nurses (can range from comatose to lethargy) 3. Mixed delirium: fluctuations between hyper, hypo, and normal state (most common form) 4. Clinicians frequently do not recognize hypoactive delirium due to its subtle presentation |
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What is the scoring of the Pittsburgh Sleep Index?
What are the 3 testing criteria? |
- measures 7 areas of sleep on a scale of 0-to-3; score of 5 or more = poor sleep quality
1. Subjective measure of sleep 2. Self-reporting can both empower the patient as well as reflect inaccurate information 3. Can be used as both an initial assessment and an ongoing comparative measurement with older adults across all heath care settings. |
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What are the 3 characteristics of disorganized thinking?
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1. Describes a range of disturbances in a person’s ability to think
2. Includes changes in attention span, concentration, intelligence, judgment, learning abilities, memory, orientation, perception, problem solving, psychomotor abilities, reaction time, verbal recall, and social behaviors 3. Can be seen in diseases (depression or dementia) |
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What are the 3 characteristics of delirium and what can cause it?
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1. when missed, can be fatal
2. Medical emergency, pts. are sent home with delirium and pass away w/in 6 months because the root of the problem is not found 3. Acute process and when it is missed it can be fatal -Can be due to: anesthesia, dehydration, alcohol, relocation stress |
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What are the characteristics of Dementia and how is it assessed?
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1. symptoms are confused with delirium and depression
2. Gradual decline in function and memory; has no cure 3. It is important to rule out delirium and depression prior to a diagnosis of dementia 4. Important to ask if there has ever been a diagnosis of dementia in the family 5. Pseudodementia: Depression can show up as dementia -Always complete the Geriatric Dementia Screen |
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What are the 15 normal age related changes in sleep?
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1. Sleep diminishes when aging
2. Dream sleep (REM) declines from 40% in early childhood to 25% by age 70 - 85% of dreaming occurs in REM 3. Decrease in deep sleep, increase in light sleep 4. More frequent arousals (nocturnal awakenings); restroom, hormonal changes, sleep apnea, pain (arthritis) 5. Diuretic use split up twice a day 6. Awake longer during arousals 7. Takes longer to fall asleep (sleep latency) 8. Increase in early morning awakenings 9. Daytime napping and somnolence 10. Our goal is to keep the older adult at the optimal level of functioning as independent as possible 11. Direct correlation between REM disorders and PTSD 12. Elders have a great problem in Jet lag 13. Reduction in the circadian rhythm responses to external stimuli, such as changes in light throughout the course of the day 14. Reduction in total sleep time and sleep efficiency 15. Evidence-based resources: 1. Nursing Standard of Practice Protocol: Excessive Sleepiness (Epworth Sleepiness Scale) 2. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders: See notes |
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What are the risk factors (3 types of..) for insomnia?
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o Difficulty falling asleep for at least one month with impairment in daytime functioning
1. Transient insomnia: lasts a few nights 2. Short-term insomnia: less than a month 3. Chronic (comorbid): a month or longer -All types can be related to psychological, medical, environmental conditions |
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What are the characteristics of RLS?
What are the 2 types of RLS? |
1. Affects sleep as it is similar to akathesia
2. Sensorineurological disorder: unpleasant leg sensations and need to move legs 3. Creeping, crawling, tingling sensations; moving will help with these sensations but decreases sleep 4. Worsening of symptoms at night 5. Temporarily relieved by movement 6. 10% - 20% prevalence over age 65 1. Primary RLS: younger ages; genetic basis 2. Secondary RLS: may result from medical conditions with iron deficiency |
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What are the 4 nursing interventions of RLS?
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1. Give Dopamine Agonists to help transport dopamine in the brain
2. Iron supplement 3. Interventions: see if a patient is anemic; a good assessment on the patients diet to assure adequate Fe 4. Look at labs and H&H |
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What are the 6 characteristics of Sleep Apnea?
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1. Complete cessation of respiration during sleep; stop breathing
2. obstructive sleep apnea: most common (70% men, 56% women); airway occluded due to collapse of hypopharynx, enlarged tonsils, deviated septum, etc.; Related to a thick shortening in the neck 3. Episodes are terminated by a brief awakening 4. Loud periodic snoring 5. Gasping and choking 6. Poor memory and intellectual functioning |
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What are the risk factors for sleep apnea?
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1. Increasing age
2. Short, thick neck circumference 3. Male gender 4. Anatomic abnormalities of upper airway: head and neck surgeries or cancers 5. Family history: Genetic 6. Excess weight (obesity) 7. Use of alcohol and sedatives 8. Smoking, hypertension 9. Impairment in functioning and decrease in memory |
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What are the assessments for sleep apnea?
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1. Polysomnography: sleep study
2. Examine nasal and pharyngeal airways for lesions , obstruction 3. Medical review 4. If partner is present, obtain a report on sleep behaviors 5. Patient cannot usually experience the apnea |
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What are the interventions for sleep apnea?
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1. Partners are not sleeping together due to the fear of the apnea
2. Weight loss 3. Avoidance of alcohol and sedatives 4. Smoking cessation 5. Avoid supine sleep 6. Counseling regarding impaired judgment, driving 7. Continuous positive airway pressure (CPAP): very cumbersome and uncomfortable |
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What are the characteristics of PLMS?
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1. Associated with restless legs syndrome
2. Flextion of the toe or ankles, causes cramping and painful voluntary movements 3. Nocturnal myoclonus movements 4. Repeated rhythmical extensions of the big toe and dorsiflexion of the ankle 5. Contributing factors: increase in BMI; caffeine and tobacco use; sedentary lifestyle 6. Currently determining if Obesity is a culprit |
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What are the 3 causation of RLS and PLMS?
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1. More common in women than men
2. May be due to impairment in dopamine transport in the substantia nigra due to decreased intracellular iron 3. Antidepressants and neuroleptics can aggravate RLS - These can cause EPS; ensure to monitor and be sure that the right dossing is being given |
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What are the 4 treatments for RLS and PLMS?
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1. Oral iron supplementation for people with serum iron levels lower than 45ug/L
2. Dopamine receptor agonists (pramipexole, ropinirole) 3. Gabapentin (Neurontin); has less of an effect over the course of treatment 4. Warm baths and exercise |
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What are the 9 non-pharmacologic interventions for sleeping disorders?
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1. Small glass of milk
2. Small turkey sandwich --> Tryptophan 3. Something with protein or tryptophan 4. Cognitive behavioral therapy; meditation; yoga 5. Exercise during the day; daytime light, nighttime dark 6. Comfortable bed; no TV in bedroom; control noise 7. Routine bedtime and wake-up 7 days a week 8. Dietary restrictions of caffeine, alcohol, spicy foods, fluid intake in the evening hours 9. Light bedtime snack if hungry with protein, tryptophan |
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What are the consequences surrounding pharmacological interventions?
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1. Sedatives and hypnotics, benzodiazepines should be avoided in older adults with sleep problems
2. Increased risk for cognitive impairment and falls, decline in functional status 3. Reserve meds for when non-pharm alternatives do not work 4. Control pain: Chronic arthritic pain would be tolerated better if small doses of medication are given throughout the day |
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What are the "4 A's" of dementia and their meanings?
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1. Aphasia: inability to produce or comprehend language
2. Apraxia: loss of ability to execute or carry out learned purposeful movements; lose the ability to move any more 3. Agnosia: inability to recognize objects, persons, sounds, shapes, and smells; Confabulation 4. Agraphia: inability to write |
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What are the 3 types of Acetycholinesterase inhibitors used for dementia and their mechanisms of action?
Why are they used? |
1. Aricept (Donepezil): can be prescribed in all stages and in combination with Namenda; Used to help patients improve their memory after ECT
2. Razadyne (Galantamine): mild-to-moderate stages 3. Exelon (Rivastigmine): mild-to-moderate stages; available as transdermal patch - may slow down the progression of AD by stimulating a motor response |
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What is the MOA for Namenda?
What other medication can it be used in combination with? |
-glutamate pathway modifier:
1. Blocks overstimulation of glutamate, which contributes to neurodegeneration 2. Neurotransmitter involved with learning and memory 3. Used in moderate-to-severe stages but prescribers are using it earlier in combination with Aricept |
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What are the 23 nursing interventions for dementia?
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1. Implement interventions according to the patient’s level of functioning
2. Always institute safety measures 3. Assess the caregiver’s needs and concerns 4. Provide family, caregiver education and support 5. Review and coordinate community resources, respite services 6. Monitor for medication side effects 7. Assess for depression 8. Assess for malnutrition and dehydration 9. Monitor for adequate nutritional and fluid intake 10. Assess for pain 11. Assess for constipation and fecal impaction 12. Assess for pressure ulcer risk 13. Collaborate with team members 14. Monitor laboratory results 15. Perform an environmental assessment with necessary adaptation 16. Communicate simply and directly in a calm manner; reassure 17. Use distraction to ensure safety 18. Monitor and maintain physical health 19. Provide for social interaction according to tolerance 20. Small, frequent meals 21. Use of clocks, calendars, personal items 22. Providing patients with a routine or task that can be mimicked to comfort the patients 23. Combativeness is when the nurses request medications from the MDs |
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What are the 5 characteristics of minimizing patient agitation?
What are the 3 characteristics of Agitation? |
1. Assess for underlying cause: delirium superimposed on dementia
2. Evaluate patterns of behavior: timing of procedures, meds, therapies 3. Review all medications for adverse reactions or drug-drug interactions 4. No FDA-approved meds for management of agitation in dementia 5. Adverse outcomes with use of antipsychotics and anxiolytics Agitation: refers to an “unpleasant state of extreme restlessness, increased tension, and irritability” 1. Can complicate care delivery and impact outcomes 2. Can be caused by delirium, environmental stimuli, hunger, pain, fear, need for toileting, caregiver behaviors 3. AN ethical concern of not medicating patients with dementia with pschotropic drugs for the nurses convenience - Always know and document why you used the medication or nonpharmaceudical measure has help with the patient |
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What are the non-pharmacologic strategies for managing agitation?
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1. Include family, significant others in care process
2. Approach patient in a calm manner 3. Communicate clearly and slowly 4. Provide reassurance and consistency 5. Modify the environment to calm the patient 6. Divert attention through beneficial activities 7. Place on toileting schedule 8. Ensure relief from pain, hunger, thirst 9. Avoid physical restraints |
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What is sundown syndrome?
What are the 4 nursing interventions? |
- Increase in confusion and agitation around late afternoon to nightfall; Can resemble delirium
1. Reduced attention, impaired sleep/waking patterns, disturbed psychomotor behavior 2. Identify physiologic factors, such as thirst, hunger, pain, elimination needs 3. Reduce environmental stimuli, increase lighting 4. Offer reassurance, companionship, rest |
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What is MCI and when does it occur and what are its characteristics?
What are the 3 symptoms of MCI? |
- Mild cognitive impairment (MCI) is the stage between normal forgetting and the development of AD: problems with thinking and memory do not interfere with everyday activities; person is aware of forgetting; not everyone with MCI develops AD
-MCI symptoms 1. forgetting recent events or conversations 2. difficulty performing more than one task at a time & solving problems 3. taking longer to perform more difficult tasks |
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What are the 5 challenges when caring for a client with delirium superimposed on dementia?
What are the 3 ways a nurse cares for a patient with dementia in relation to the challenges above? |
1. Difficult to recognize due to overlapping symptoms
2. Difficult to ascertain baseline mental status 3. Clinicians may attribute s/s of delirium to a worsening of dementia 4. Recognition of condition 5. Patients with Parkinson’s dementia (Lewy body) often have fluctuating cognition, referred to as “Pseudodelirium” 1. Assume delirium until it is ruled out 2. Know your patient’s medical history 3. Communicate and collaborate with the healthcare team to manage complexity of care |
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What are the 8 preventions of delirium?
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1. Prevent nosocomial infections
2. Maintain fluid and electrolyte balance 3. Avoid specific meds that pose risks to the older adult 4. Remedy nutritional deficiencies 5. Correct sensory deficits: use assistive devices 6. Reorient patient 7. Promote mobilization (may see improvement in Katz score) 8. Perform range of motion exercises |
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What are the 10 nursing interventions and treatments for patients with delirium?
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1. Remove unnecessary catheters, tubes
2. Implement a toileting schedule 3. Provide familiar objects; family visits 4. Non-pharmacologic sleep protocol 5. Pain assessments and relief from pain 6. Institute fall precaution measures 7. Provide sunlight 8. Decrease sensory overload/note deprivation 9. Offer food and fluids as tolerated and prescribed 10. After ambulating there is evidence of improving CAD scores and the patient can become more oriented |
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What is Pseudodementia?
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1. Clinical condition that masquerades as dementia, such as depression
2. Potential for reversal 3. Dementia secondary to depression is usually reversible |
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What are the 4 goals of pharmacological management?
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1. Minimize agitation
2. Maintain function 3. Low dose 4. Short-term use |
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What are the 4 clinical features of dementia?
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1. Cognitive deficits
2. Impaired executive function 3. Language deficits 4. Mood and personality changes |
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What are the 8 nursing diagnosis for delirium?
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- Main issues for delirium is a MEDICAL EMERGENCY!! Make sure to get the Foley Catheters and the IV lines. It is important to get the patients to talk and moving again with the use of PT and OT if needed
1. Risk for injury 2. Acute confusion 3. Deficient fluid volume 4. Impaired physical mobility 5. Disturbed sleep pattern 6. Impaired verbal communication 7. Self-care deficit (specify) 8. Disturbed thought processes |
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What are the expected outcomes of delirium?
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1. Return to premorbid level of functioning
2. Remain safe and free from injury 3. Regain orientation x 4 by discharge 4. Underlying cause treated and remedied 5. Avoid residual disability |
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What are the consequences of delirium?
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1. Medical emergency: because we want to get to the root of the problem and treat it
2. Lengthens hospital stay 3. Increases costs and medical complications 4. Can lead to persistent cognitive decline: We will see fluctuations in function throughout the day 5. Safety issues |
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What are the 14 nursing assessments to determine delirium?
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1. Paramount to the collaborative plan of care
2. Accurately document the baseline data and presentation of abnormal behaviors (CAM) 3. Assess for fluctuating levels of consciousness, agitation, hypervigilance, lethargy 4. Speak to family, caregivers, providers to establish baseline 5. Rule out other pathology (UTI): Always rule out UTI 6. Assess for vasomotor instability 7. Assess for sleep disturbance 8. Perform skin assessments: Look all over the patient’s body to ensure that there is not an ulcer 9. Note self-care deficits, incontinence, temperature fluctuations, tremors 10. MMSE: note mood, physical behaviors, visual, auditory, and tactile hallucinations, illusions (sign of toxicity) 11. Nutritional and hydration needs 12. Alcohol and other substances (Short Michigan Alcoholism Screening Test-Geriatric Version): assess for usage 13. Withdrawal symptoms and behaviors due to alcoholism and drug use 14. Identify and treat underlying cause/s |
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What are the 16 risk factors for developing delirium?
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1. Advanced age
2. Neurological disorders 3. Infections 4. Polypharmacy 5. Metabolic and electrolyte disturbances 6. Sensory changes 7. Sleep deprivation and impairment 8. Hospitalization 9. Drug intoxication and/or withdrawal: Do an assessment to determine if the patient has been using alcohol or drugs and administer medication to prevent withdrawl 10. Alcohol 11. Invasive procedures 12. Postoperative status 13. Changes in environment 14. Malnutrition and dehydration 15. Undiagnosed pain 16. Hypoxia |
