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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 17: Eating Disorders Instructor’s Manual Thoughts About Teaching the Topic These topics can be examined effectively alongside anxiety disorder topics. Films on anorexia nervosa, bulimia nervosa, and obesity caused by compulsive eating are excellent vehicles for assisting learners to meet chapter objectives and for promoting discussion. Because caring for patients with eating disorders requires considerable nursing skill, behavioural rehearsals in the form of role-playing can help prepare learners for common, recurrent clinical situations. Since it is often difficult for the normal-weight individual who has no eating problems to empathize with a patient with an eating disorder, role-playing and case studies can be helpful in raising awareness. Key Terms and Concepts anorexia nervosa binge eating disorder bulimia nervosa ethnic psychopharmacology ideal body weight Objectives Discuss four theories of eating disorders. Compare and contrast the signs and symptoms (clinical picture) of anorexia nervosa and bulimia nervosa. Identify three life-threatening conditions, stated in terms of nursing diagnoses, for a patient with an eating disorder. Identify three realistic outcome criteria for (a) a patient with anorexia nervosa and (b) a patient with bulimia nervosa. Describe therapeutic interventions appropriate for anorexia nervosa and bulimia nervosa in the acute phase and long-term phase of treatment. Explain the basic premise of cognitive-behavioural therapy in the treatment of eating disorders. Differentiate between the long-term prognoses of anorexia nervosa, bulimia nervosa, and binge eating disorder. Chapter Outline Teaching Strategies Clinical Picture The main types of eating disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder. Epidemiology Most eating disorders begin in the early teens to mid-20s, com- monly following puberty, although bulimia generally occurs in later adolescence. Anorexia nervosa may start early (between ages 7 and 12), but bulimia nervosa is rarely seen in children younger than 12 years. For women, the lifetime incidence of anorexia nervosa, bulimia nervosa, and binge eating disorder are 0.9%, 1.5%, and 3.5%, respectively; and the lifetime incidence for men is 0.3%, 0.5%, and 2% (Hudson, Hiripi, Pope, et al., 2007). While anorexia can be found in all cultures, bulimia and binge eating disorder are more common in countries most influenced by Western culture. Co-Morbidity Depression, bipolar disorder and anxiety are common co-morbid conditions in people with all types of eating disorders. Obsessivecompulsive disorder is common (25%) among patients with eating disorders. Other co-morbid disorders include anxiety disorder and substance abuse disorder, and personality disorders in particular are common (up to 70%). Although patients with eating disorders are at risk of medical complications that may result in death, the major cause of death among those affected by eating disorders is suicide. Patients diagnosed with anorexia nervosa or bulimia nervosa may have a suicide rate that is 6.7 times greater than the norm for their age group (Pompili, Girardi, Tatarelli, et al., 2006). A history of trauma and sexual abuse is more common in those with eating disorders than in the general population. Etiology Eating disorders are actually entities or syndromes and are not considered to be specific diseases (Halmi, 2008). Experts tend to agree that there is no single cause of eating disorders. Eating disorders typically develop from a complex interaction of psychological risk factors, sociocultural influences, and biological or genetic predispositions (Striegel-Moore & Bulik, 2007; Mazzeo & Bulik, 2008). A number of theories attempt to explain eating disorders. Genetic Genetic theories explore genetic vulnerabilities as a basis for predisposing people to eating disorders. A twin study showed a 56% concordance rate for anorexia nervosa in monozygotic twins. Neurobiological Research demonstrates that altered brain serotonin function contributes to the dysregulation of appetite, mood, and impulse control of eating disorders. A number of theories exist: an eating disorder causes depression or is a variant of a depressive disorder; biological relatives of patients with eating disorders show increased frequency of depression; neuroendocrine abnormalities have been documented in patients with eating disorders; cholecystokinin is at low levels in people with bulimia. These theories and findings may help explain the drive toward dieting, hunger, preoccupation with food, and tendency toward binge eating. Psychological Factors Psychological theories explore issues of control in anorexia and affective instability and poor impulse control in bulimia. Environmental Factors Sociocultural models and theory consider our present societal ideal of being thin and the influence of role conflict. Studies have shown that culture influences the development of self-concept and satisfaction with body size. According to Statistics Canada (2011), the percentage of Canadians who are overweight or obese has risen dramatically in recent years. Currently, almost a quarter of adult Canadians are obese (24.3% of men; 23.9% of women). Record numbers of men and women are on diets to reduce body weight, but no study has been able to explain why only an estimated 0.3% to 3% of the population develops an eating disorder. Although a causal link between cultural norms of thinness and eating disorders has not been proven, all patients with eating disorders have low self-esteem that is negatively impacted by their inability to conform to an impossible cultural standard of beauty, a standard that is reinforced through media on a near constant, unavoidable, basis. ANOREXIA NERVOSA Application of the Nursing Process Assessment General Assessment Anorexia nervosa and bulimia nervosa are two separate syndromes that present two clinical pictures on assessment. Box 17-2 lists several thoughts and behaviours associated with anorexia nervosa, and Table 17-1 identifies clinical signs and symptoms of anorexia nervosa found on assessment, together with their causes. The patient with anorexia nervosa often enters the health care system via admission to the ICU with electrolyte imbalance. The nurse should assess for poor hydration, lanugo, and low blood pressure, pulse, and temperature consistent with malnutrition. Explore the patient’s perception of the problem, eating habits and history of dieting, methods used to achieve control, value attached to specific weight and shape, interpersonal and social functioning, and mental status. Self-Assessment The nurse often has difficulty relating empathetically to the patient who “chooses” to engage in behaviours that put life at risk. Giving encouragement may cross the line to authoritarianism and a parental role. Frustration is experienced as the patient resists weight gain. Assessment Guidelines: Anorexia Nervosa The patient and family will need to be assessed in order to provide ongoing monitoring, teaching, and support to help address the issues of physical and psychological health and ongoing treatment for the eating disorder. Diagnosis Useful diagnoses include Imbalanced nutrition: less than body requirements, Decreased cardiac output, Risk for injury, Disturbed body image, Anxiety, Chronic low self-esteem, Deficient knowledge, Ineffective coping, Powerlessness, and Hopelessness. Outcomes Identification Examples of outcome criteria include: Patient will normalize eating patterns as evidenced by eating 75% of three meals per day plus two snacks; patient will achieve 85% to 90% of ideal body weight; patient will demonstrate improved self-acceptance as evidenced by verbal and nonverbal data; patient will participate in long-term treatment to prevent relapse; and similar goals. Table 17-2 Planning Type of treatment is partly determined by severity of weight loss. Another factor to consider is the experienced disruption of the patient’s life. Outpatient therapy is the mainstay of treatment, but hospital admission may be required if an anorectic patient is experiencing extreme electrolyte imbalance or weighs below 85% of ideal body weight. Brief hospitalization can address only acute complications such as electrolyte imbalance, dysrhythmias, limited weight restoration, and acute psychiatric symptoms such as depression. Refeeding syndrome is a severe and potentially catastrophic complication in which the demands the replenished circulatory system place on the nutritionally depleted cardiac mass result in cardiovascular collapse. Implementation Basic Level Interventions: Acute Care Typical admission is for a crisis state. The nurse is challenged to establish trust in a very short time and monitor the eating pattern as well. Psychosocial Interventions Focus should be on the eating behaviour and underlying feelings of anxiety, dysphoria, low self-esteem, and lack of control. When possible, the distortions in body image are avoided because attempts to change this perception are often misinterpreted. The basic-level nurse on an inpatient unit will focus on issues that are important to the patient, dependent on the assessment. Any acute psychiatric symptoms such as suicidal ideation are addressed immediately, and a weight restoration program is begun. The treatment goal is set at 90% of ideal body weight, the weight at which most women menstruate. As patients begin the weightrestoration program, they will participate in milieu therapy and attend individual and group psychotherapy along with nutritional counselling. Cognitive therapy addresses distortions of thinking. Psychopharmacological Interventions Selective serotonin reuptake inhibitors (SSRIs) have been reported to improve the rate of weight gain and reduce relapse. Olanzapine (Zyprexa) has been reported to decrease agitation and resistance to treatment. Health Teaching and Health Promotion Self-care activities are an important part of the plan. Activities include learning constructive coping skills, improving social skills, and developing problem-solving and decision-making skills. Eating out in a restaurant is practised; preparing a meal and eating forbidden foods are also explored. Milieu Management Focus is on establishing more adaptive behavioural patterns that include normalization of eating. This requires precise mealtimes, adherence to selected menu, observation during and following meals, regularly scheduled weighing, and patient privileges correlated with weight gain and treatment-plan adherence. To ensure there is no self-induced vomiting, close monitoring of bathroom use after meals and after visits is necessary. Advanced-Practice Foci are on weight maintenance and achievement of a sense of Interventions self-worth and self-acceptance not exclusively based on appearance, achieving a balance between dependence and independence, and improving communication within families. A combination of individual, group, couples, and family therapy gives the best chance for successful outcomes. Psychotherapy Whatever the treatment setting, the goals of treatment remain the same: weight restoration with normalization of eating habits and beginning treatment of psychological, interpersonal, and social issues that are integral to the experience of the patient. In the acute weight restoration phase, interventions are determined by the unstable weight, and a cognitive-behavioural approach is necessary. Critical pathways are useful for hospitalized patients and those treated via a psychiatric home care program. Evaluation Goals are daily guides to reaching successful outcomes and must be continually re-evaluated for appropriateness. BULIMIA NERVOSA DSM-5 lists subtypes of the disorder as purging and nonpurging types. Application of the Nursing Process Assessment General Assessment Patients with bulimia nervosa often do not appear physically or emotionally ill. Weight is usually at or slightly below ideal body weight. Inspect for enlarged parotid glands, dental erosion, and caries if patient has induced vomiting. History may reveal poor impulse control, compulsivity, or chaotic interpersonal relationships. Patient is sensitive to others’ perceptions of the illness and may experience shame and feeling out of control. Self-Assessment Building trust with the patient is essential but difficult because the nurse often feels the patient is not being honest when active bingeing or purging is not reported (due to feelings of shame). Assessment Guidelines: Bulimia Nervosa Medical stabilization is the first priority; a thorough medical examination is vital. Medical evaluation includes laboratory testing of glucose level, electrolyte levels, thyroid function, complete blood count, and ECG. Box 17-8 lists several thoughts and behaviours associated with bulimia nervosa, and Table 17-4 identifies possible signs and symptoms found on assessment and their causes. Diagnosis Useful diagnoses include Risk for injury, Decreased cardiac output, Disturbed body image, Powerlessness, Chronic low selfesteem, Anxiety, and Ineffective coping. Problems resulting from purging are a first priority because electrolyte and fluid balance and cardiac function are affected. Outcomes Identification Examples of outcomes include the following: Patient will refrain from binge eating; will abstain from purging; will demonstrate new skills for managing stress, anxiety, shame; will be free of self-directed harm, and similar goals. Table 17-5 Planning General hospital admission is reserved for life-threatening complications such as fluid and electrolyte imbalance. Admission to an inpatient psychiatric unit for severe psychiatric symptoms (i.e., acute suicidal risk) provides short-term care. Referrals are provided for continued outpatient treatment. Implementation Acute Care Medically compromised patients will be referred to an inpatient setting where they can participate in a cognitive-behavioural model of treatment, which is highly effective for the treatment of bulimia. Therapy will help the patient restructure eating to interrupt the cycle of eating and purging to begin to incorporate more normalized eating habits. The patient receives education, support, and therapy for the bulimia and for co-morbid disorders such as substance dependence and depression. Milieu Management Structured to interrupt the binge–purge cycles via observation during and after meals to prevent purging and promote normalization of eating and appropriate exercise. Psychopharmacological Interventions Antidepressants, especially SSRIs, may be useful. Counselling Patients with bulimia are usually more ego-dystonic and therefore will more readily establish a therapeutic alliance with the nurse. This alliance allows the basic-level nurse, along with other members of the interdisciplinary team, to provide services and give the patient necessary feedback regarding distorted beliefs. Health Teaching and Health Promotion Teaching is directed toward helping the patient learn how to cope with challenges such as meal planning and eating out, use relaxation techniques, develop coping skills, and recognize the impact of cognitive distortions and the physical and emotional effects of bingeing and purging. Advanced-Practice Interventions Psychotherapy Cognitive-behavioural therapy is most effective. Reduction in purging by the sixth session predicts a successful outcome. Focus is on changing dysfunctional attitudes to ones of self-acceptance and correcting faulty perceptions of weight and shape. The patient needs help to change faulty perceptions and accept treatment of co-morbid disorders at the same time. Evaluation Evaluation is accomplished by comparing desired outcomes to the actual outcomes. Binge Eating Disorder Binge eating disorder refers to obesity associated with binge eating that serves the function of mood regulation. Goal of treatment is modification of disordered eating and control of depressive symptoms, resulting in a more appropriate weight. Not all obesity is the result of binge eating. Cognitive-behavioural therapy and interpersonal therapy have been determined to be effective in eliminating binge eating; however, on average, these therapies do not produce clinically significant weight loss (Wilson, Wilfley, Agras, et al., 2010). Many candidates for bariatric surgery for obesity treatment have binge eating disorder. A range of awareness, journaling, motivational interviewing as well as pharmacological treatment with SSRIs are being studied. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 18: Cognitive Disorders Instructor’s Manual Thoughts About Teaching the Topic Although teaching students the nursing care for cognitively impaired patients has long been considered part of psychiatric nursing, it is likely that the material may be better placed in other courses. For example, delirium is more often encountered on acute medical-surgical units, in the ICU, or on a chemical detoxification unit than on a “psych” floor. Patients with dementia are more often encountered in long-term residential care settings, in adult day care, or in the home. The challenge for the psychiatric nursing instructor will be to arrange clinical observations or experiences to give learners contact with the cognitively impaired patient at the time the theory is presented. The placement on the unit of material deserves special consideration. Faculty usually prefer not to break the continuity of the experience on the psychiatric unit. Key Terms and Concepts agnosia agraphia Alzheimer’s disease (AD) alexia aphasia apraxia catastrophic reactions cognitive disorders confabulation delirium dementia hypermetamorphosis hyperorality perseveration primary dementia pseudodementia secondary dementia sundowning Objectives Compare and contrast the clinical picture of delirium with that of dementia and brain injury. Discuss three critical needs of a person with delirium, stated in terms of nursing diagnoses. Identify three outcomes for patients with delirium. Summarize the essential nursing interventions for a patient with delirium. Recognize the signs and symptoms occurring in the stages of Alzheimer’s disease. Give an example of the following symptoms assessed during the progression of Alzheimer’s disease: (a) amnesia, (b) apraxia, (c) agnosia, and (d) aphasia. Formulate three nursing diagnoses suitable for a patient with Alzheimer’s disease, and define two outcomes for each. Formulate a teaching plan for a caregiver of a patient with Alzheimer’s disease, including interventions for communication, health maintenance, and a safe environment. Compose a list of appropriate referrals in the community—including a support group, hotline for information, and respite services—for people with dementia and their caregivers. Chapter Outline Teaching Strategies Cognitive Disorders Although primarily an intellectual and perceptual process, cognition is closely integrated with an individual’s emotional and spiritual values. Cognitive disorders result from change in the brain and are marked by disturbances in orientation, memory, intellect, judgement, and affect. These disorders may be described as ranging from minor to major in terms of the level of impairment. There are three main cognitive disorders: delirium, dementia, and amnestic disorders (note: amnestic disorders are not discussed here). DELIRIUM: CLINICAL PICTURE Delirium is characterized by a disturbance of consciousness and a change in cognition (e.g., impaired attention span, disorientation, confusion; alterations in thinking, memory, perception) that develop over a short period of time and fluctuate throughout the day. It is always secondary to another condition and transient, and recovery occurs when the cause is corrected. Delirium fluctuates in intensity. Mild delirium tends to become more pronounced in the evening (sundowning). Nursing concerns centre on assisting with proper health management to eradicate the underlying cause, preventing physical harm due to confusion, aggression, or electrolyte and fluid imbalance, and using supportive measures to relieve distress. (Dementia develops more slowly and is characterized by multiple cognitive deficits, including memory impairment. In a majority of cases, dementias are primary, progressive, and irreversible). Epidemiology Delirium is the most common complication of hospitalization in older patients (Rice, Bennett, Gomez, et al., 2011). The reported incidence of delirium in hospitalized patients ranges from 3% to 56% (Michaud, Büla, Berney, et al., 2007), from 11% to 42% in medically ill older patients (Cerejeira & Mukactova-Ludinska, 2011), and from 4% to 65% in postoperative patients, depending on the type of surgery (Rudolph & Marcantonio, 2011). This high degree of variability of reported incidence of delirium is most likely due to its underrecognition by both nurses and doctors who work in acute care settings and hospitals. Co-Morbidity and Etiology Delirium is always secondary to another physiological condition and is a transient disorder. Common causes are noted in Box 18-1. Application of the Nursing Process Assessment 1. Four cardinal features of delirium: Acute onset and fluctuating course Inattention Disorganized thinking Disturbance of consciousness General Assessment Clinicians who suspect delirium and note its symptoms should undertake a thorough examination to determine and treat causation, including mental and neurological status examinations as well as a physical examination. Blood tests and a urinalysis should be done. In addition, the patient’s medication regimen should be examined. A failure to quickly detect and treat delirium is associated with a significant increase in morbidity and mortality (Rice, Bennett, Gomez, et al., 2011). Note duration of onset (often abrupt) and orientation to time, place, and person. Ability to focus is usually impaired. There are fluctuating levels of consciousness (usually worse at night and early morning). The Mini-Mental State Examination is a useful tool. Assessment should include cognitive and perceptual ability, physical needs, and mood and behaviour. Cognitive and Perceptual Disturbances Cognitive disturbances are distractibility, attention deficits, and difficulty remembering recent events. Perceptual disturbances include illusions and visual and tactile hallucinations, which cause increased anxiety. Physical Needs Physical safety is primary. Delirious patients wander, pull out lines and catheters, and climb out of bed over side rails. Patients who cannot recognize and interpret reality are usually highly anxious. Make physical environment as simple and clear as possible; elevate head of bed slightly; help patient use glasses, hearing aids, and adequate lighting to maintain orientation. Clocks and calendars may be helpful. Spending time with the patient when not engaged in a technical nursing intervention is helpful. Skin breakdown is possible due to selfcare deficits, poor nutrition, bed rest, and incontinence. Observe for autonomic signs of tachycardia, sweating, flushed face, dilated pupils, elevated BP; report them. Note sleep– wake cycles, level of consciousness, hypervigilance, and effects of medications. Moods and Physical Behaviours Mood often is labilethe individual may swing dramatically from euphoria to apathy to anger. Physical behaviours are usually congruent with the mood of the moment, with confusion and fear being common. Self-Assessment Feeling challenged by the magnitude of the patient’s symptoms is common. Negative feelings may occur when the delirium is secondary to substance use or abuse. Assessment Guidelines: Delirium The Assessment Guidelines: Delirium box lists 12 steps to help the nurse assess delirium, beginning with “Assess for acute onset and fluctuating levels of consciousness, which are key in delirium.” Diagnosis Useful diagnoses include Risk for injury, Deficient fluid volume, Disturbed sleep pattern, Impaired verbal communication, Acute confusion, Fear, Self-care deficit, Impaired social interaction, and Disturbed sensory perception. Outcomes Identification • Table 18-3 includes outcomes for acute confusion from the Nursing Outcomes Classification (NOC) (Moorhead, Johnson, Maas, et al., 2012). Although the person can demonstrate a wide variety of needs, Risk for injury is always present. Appropriate outcomes are as follows: During periods of lucidity, patient will be oriented to time, place, and person with the aid of nursing interventions, such as the provision of clocks, calendars, maps, and other types of orienting information. Patient will remain free from falls and injury while confused, with the aid of nursing safety measures while in the hospital. Implementation Management involves treating the underlying organic causes. Nursing concerns, therefore, centre on the following: Preventing physical harm due to confusion, aggression, or electrolyte and fluid imbalance Performing a comprehensive nursing assessment to aid in identifying the cause Assisting with proper health management to eradicate the underlying cause Using supportive measures to relieve distress—a calm approach is helpful The Nursing Interventions Classification (NIC) (Bulechek, Butcher, & Dochterman, et al., 2008) can be used as a guide to develop interventions for a person experiencing delirium (Box 18-2). Evaluation • Long-term outcome criteria for a person experiencing delirium include the following: Patient will remain safe. Patient will be oriented to time, place, and person by time of discharge. Underlying cause will be treated and ameliorated. DEMENTIA Dementia develops more slowly and is characterized by multiple cognitive deficits that include memory impairment. Primary dementia is irreversible. Reversible cases are usually secondary to other processes (e.g., tumours, trauma, infections, toxic disturbances, vitamin deficiencies), and appropriate treatment leads to improvement in dementia symptoms. Some secondary dementias, such as HIV encephalopathy, are progressive. Examples of primary dementias include Alzheimer’s disease, Pick’s disease, and multi-infarct dementias. There is no cure. Primary dementias are progressive. The person shows a progressive decline in ADLs, memory, and personality disorganization. Clinical Picture Dementia is the general term used to describe a decline in cognitive functioning that interferes with daily living. Alzheimer’s disease is the most common cause of dementia in older adults. Epidemiology More than 500,000 Canadians are currently living with dementia. Of these, 71,000 are under the age of 65. Among Canadians over the age of 65, 1 in 11 has dementia. Alzheimer’s disease accounts for close to 70% of all dementias in Canada (Alzheimer Society of Canada, 2010b). • Women comprise 72% of all Canadians living with the Alzheimer’s subtype of neurocognitive disorder. The Alzheimer’s subtype of neurocognitive disorder attacks indiscriminately, striking men and women, people of various ethnicities, rich and poor, and individuals with varying degrees of intelligence. Although Alzheimer’s can occur at a younger age (early onset), most of those with the disease are 65 years of age or older (late onset). The second most common type of dementia is related to cerebrovascular disease, accounting for 20% of all dementias (Sadock & Sadock, 2008). Other common causes of dementia are head trauma, alcohol abuse, and movement disorders such as Parkinson’s disease; these account for 1% to 5% of all cases (Sadock & Sadock, 2008). Etiology Although the cause of AD is unknown, most experts agree that, like other chronic and progressive conditions, it is a result of multiple factors—genetics, lifestyle, and environment. However, the greatest risk factor is advancing age (Alzheimer’s Association, 2012; Lehne, 2013). Biological Factors Alzheimer’s Tangles -amyloid protein deposits are found in the brain of patients with Alzheimer’s disease (AD). Neurofibrillary tangles form in the hippocampus, the area of the brain responsible for shortterm memory and emotions. Neuritic plaques are cores of degenerated neuron material that are found. Granulovascular degeneration, filling brain cells with fluid and granular material, is also noted. Genetic Family members of patients with dementia of the Alzheimer’s type have a higher risk of acquiring the disease than the general population. At least four genes are involved in the transmission of AD. Environmental Factors Risk factors include increasing age, Down syndrome, and head injury. Folic acid deficiency and elevated homocysteine levels may also be risk factors. There are modifiable risk factors being explored (diet and activity). Application of the Nursing Process Assessment General Assessment Patients may deny early memory loss and compensate by using social graces. Later, denial, confabulation, perseveration, and avoidance of answering questions are noted as defensive maneuvers, and the symptoms of aphasia, apraxia, agnosia, memory impairment, and disturbances in executive functioning develop. Diagnostic Tests The diagnosis of AD is made after all other possibilities have been ruled out via diagnostic testing. CT, PET, and other scans reveal brain atrophy and rule out neoplasms. Complete physical examinations and neurological examinations are necessary. Depression and other illnesses may cause pseudodementia and must be investigated. Stages of Alzheimer’s Disease The National Institute on Aging (2012) has proposed revisions from the current seven-stage classification. The recommendations are that AD be identified in three stages: preclinical AD, mild cognitive impairment (MCI) due to AD, and dementia due to AD. The first stage occurs prior to any symptoms and is identified through AD biomarkers, such as βamyloid and tau; at present, further scientific evidence about biomarkers is needed before use in the clinical setting. In practice a seven-stage classification persists. See Table 18-5 (seven-stage classification). Self-Assessment Understanding the process of the disease is helpful to the nurse contending with the patient’s confusion, psychotic states, and violent and aggressive behaviour. Staff burnout is helped by setting realistic patient goals, avoiding the hopeless stance, and involving staff in research. Diagnosis Patient safety is of paramount importance; wandering, falls, accidents, ingestion of noxious substances, and seizures may occur. Useful diagnoses include Risk for injury, Impaired verbal communication, Impaired environmental interpretation syndrome, Impaired memory, Chronic confusion, Ineffective coping, Self-care deficit, and Disturbed sensory perception. For the family, consider Caregiver role strain and Anticipatory grieving. See Table 18-6. Outcomes Identification Outcome criteria must be identified for each nursing diagnosis. Examples are Risk for injury: Patient will remain safe in the hospital or at home; Self-care deficit: Patient will participate in self-care at optimal level; Impaired environmental interpretation syndrome: Client will remain nonaggressive when experiencing paranoid ideation; Caregiver role strain: Family members will name two organizations within their area that can offer support; Family will state they have outside help that allows them to take personal time for themselves. Box 184 Planning Planning is geared toward the patient’s immediate needs and caregiver needs, including useful community resources. Implementation The nurse’s attitude of unconditional positive regard is the single most effective tool in caring for patients with dementia. It promotes cooperation, reduces catastrophic outbreaks, and increases family members’ satisfaction with care. Management of depression, hallucinations, delusions, agitation, insomnia, and wandering is important. Staff should facilitate the highest level of functioning the patient is capable of. Supportive intervention with the family who are losing a loved one to dementia is critical. Box 18-5 Counselling and Communication Techniques Provide only one visual cue at a time; know that the patient may lack understanding of assigned tasks; remember that relevant information is retained best; break tasks into small steps; give only one instruction at a time; and report, record, and document all data. Other guidelines are given in Table 177. Health Teaching and Health Promotion Health teaching and support are vital components of care for the family of patients with dementia. Families need information about communicating with the patient and structuring for self-care activities, as well as where to get information, support, and legal and financial guidance. (Computer Line and the Alzheimer Society of Canada are two resources.) Referral to Community Supports The Alzheimer Society of Canada is a national umbrella agency that provides various forms of assistance to people with the disease and their families. Although many families manage the care of their loved one through death, other families need help along the way. There are many factors that family members need help with. The Alzheimer Society of Canada can provide families with information about locating and return of missing people with AD, housekeeping, home health aids, prevention of caregiver emotional and physical fatigue, how and when to place the ill member, and legal and financial matters. Assisting patients to cope with their environment is the basis of nursing therapy. Safety, activities that increase socialization, and planning for minimization of fatigue are important considerations. Psychopharmacological Interventions Cognitive Impairment Various drugs are in use to address the cognitive impairment associated with AD. Tacrine (THA, Cognex), a cholinesterase inhibitor, may delay Alzheimer’s progress but has a high incidence of liver adverse effects. Donepezil (Aricept) inhibits acetylcholine breakdown and appears to slow deterioration in cognitive function but without the liver toxicity attributed to tacrine. Rivastigmine (Exelon), a brain-selective acetylcholinesterase inhibitor, and galantamine (Reminyl), a reversible cholinesterase inhibitor, are newer drugs. Memantine (Ebixa), a drug that works by affecting NMDA receptors, was approved by Health Canada in 2004. The Future of Drug Therapy Clinical trials of an amyloid vaccine cleared plaques of people with AD; it did not alleviate the progression of the disease. Additional research is ongoing. Integrative Therapy Some alternative treatments being investigated are ginkgo biloba, as discussed in the Integrative Therapy box in the chapter. According to Kidd (2008), omega-3 fatty acids, other antioxidant nutrients, and vitamins—especially folate, B6, B12, C, and E—may also be helpful in the treatment of AD. Evaluation Goals will need to be altered as the patient’s condition deteriorates. Frequent evaluation and reformulation of outcome criteria and short-term goals help diminish staff and family frustration. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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