Angelite Nurses

Overview

1. A group of disorders with a known or presumed etiology.
2. Frequently manifest as dementia or delirium.
3. May be substance induced (drugs or alcohol) or caused by a disease process; etiology may be unknown.
4. It is important for the nurse to assess behaviors rather than focus on medical diagnoses.
5. Behaviors related to impaired brain functioning may be temporary or permanent, with increasing degeneration and eventual loss of brain function.
6. Not exclusive to old age, may complicate illnesses in any age group.

Types

1. Delirium/Rapid Development
1. Manifested by reduced awareness of environment, disorders of perception, thought, speech, and attention deficits.
2. Usually of brief duration.
3. May occur postoperatively or following head injury, intoxication from drugs/alcohol, acute disease, or injury.
2. Dementia/Gradual Development
1. Loss of intellectual abilities resulting in impaired social and occupational functioning.
2. May be temporary, or progressive loss may occur.
3. Found predominantly in elderly.
4. Personality changes are usually an exaggeration of former character traits (e.g., suspicious, nontrusting person becomes paranoid); but alteration can also occur (e.g., formerly neat and orderly person pays no attention to hygiene, becomes sloppy and dirty).
5. Memory impairment; short-term memory loss may be most obvious.
6. Organic etiology may be known; conditions include intoxication, infections, tumors, circulatory disorders (cerebral atherosclerosis), trauma, Huntington's chorea, Korsakoff's syndrome, Creutzfeld-Jakob disease, neurosyphilis.
7. Specific etiology may not be known (e.g., Alzheimer's disease, Pick's disease).
8. Frequently these clients cannot perform basic ADL.

Assessment

1. Mental status assessment, especially orientation to time and place, memory, and judgment
2. Nutritional status
3. Ability to perform ADL, self-care
4. Presence of confabulation (making up information to fill in memory gaps)
5. Behavioral/social changes
6. Disorders of perception
7. Impaired motor skills, coordination
8. Change in sleep patterns
9. Elimination: constipation/incontinence
10. Family response to client's condition

Analysis
Nursing diagnoses for clients with these disorders may include

1. Anxiety
2. Impaired verbal communication
3. Ineffective individual/family coping
4. Altered family processes
5. High risk for fluid volume deficit
6. High risk for injury
7. Nutrition less than body requirements
8. Self-care deficits
9. Self-esteem disturbance
10. Sleep pattern disturbance
11. Altered thought processes
12. High risk for violence

Planning/Implementation


Goals

1. Client will
1. Be protected from injury.
2. Retain optimal cognitive function and self-care abilities.
3. Have fear/anxiety minimized.
4. Maintain adequate nutrition/hydration.
2. Family will communicate feelings about client.

Interventions

1. Institute safety measures: side rails, frequent checks, restraints only as last resort and for protection of client as ordered by physician.
2. Maintain reality orientation.
1. Client may not be capable of reality testing.
2. Continue to address client by name.
3. Maintain awareness of client's limitations in this area.
4. Do not tell client to "remember"; severe memory loss may make client incapable of memory.
3. Assist/support with self-care needs; arrange for necessary assistive devices, help with feeding; encourage fluids.
4. Avoid "insight" therapy and discussion of impaired mental functioning as this may increase anxiety.
5. Provide spouse/family with information about client's capabilities.
6. Provide support for spouse/family; encourage continued interaction with client.

Evaluation

1. Client
1. Remains free from injuries.
2. Retains cognitive functions and self-care ability as far as possible; interacts with others appropriately.
3. Maintains appropriate weight.
2. Family
1. Expresses sense of loss or frustration related to client's condition.
2. Continues contact with client.