NUR 233 EXAM 2 QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED
neurocognitive disorders
alterations in cognitive functioning due to underlying physiological changes caused by
brain pathology
-delirium
-mild neurocognitive disorders
-major neurocognitive disorders
Delirium
Acute and reversible
RAPID ONSET
ALWAYS SECONDARY TO ILLNESS- MUST FIND OUT MEDICALLY WHAT IS TO
RESOLVE
-PRIORITY/MEDICAL EMERGENCY to prevent irreversible and serious damage
delirium risk factors
ALWAYS SECONDARY TO
-pain
-infection/uti/pneumonia
-dehydration
-hypoxia
-immobilization
,-poor/inadequate nutrition
-environmental noises/ lack of orienting material
-movement to new area
-sleep deprivation
-sensory problems
-restraint use
-Drugs/medications
-surgery
Delirium manifestations
RAPID ONSET/ fluctuate in intensity
-inability to direct/sustain focus
-shift in attention
-disorientation/confusion
-anxiety
-illusions
-hallucinations
-mood swings
-hyperactive
-reduced vigilance
-reduced response to environment
-incoherence
-physical aggression
-tachycardia
,-agitation
-poor memory
-poor self care/skin integrity
-poor nutrition
-sweating/dilated pupils/flushed skin
-hypertension
lethargy to hyper vigilance
-eyes constantly scanning room
-delusional thinking
-distraction
Hallucinations
FALSE SENSORY EXPERIENCES (not there)
-sees spiders crawling over wall or on them
-My thoughts are jumbled
-psychomotor agitation due to fear and anxiety
Illusions
ERRORS IN PERCEPTION OF SENSORY STIMULI
-may mistake folded blankets for white rats
-cord of window blind for a snake
-stimulus is real, person misinterprets it
-explain and clarify illusions to individual
Delirium assessment
, PERFORM MEDICAL EVALUATION FIRST
-information from family/friends
-review medication history/drug use
-any underlying illnesses/diseases
-blood work
-urinalysis
-CBC/CRP
-safety/fall risk
-exit seeking
-assess risk for poly pharmacy (using multiple drugs)
delirium physical needs
patient becomes disoriented
-may wander or try and pull out IV lines
-fall out of bed
-want to go home or think hospital is home
-SIMPLE ENVIRONMENT/CLEAR
-Clocks/calendars
-visual/auditory aides
-interact with patient
-poor self care=
delirium assessment guidelines
-dont assume confusion is bc of dementia
- assess acute onset/fluctuating levels
SOLUTIONS VERIFIED
neurocognitive disorders
alterations in cognitive functioning due to underlying physiological changes caused by
brain pathology
-delirium
-mild neurocognitive disorders
-major neurocognitive disorders
Delirium
Acute and reversible
RAPID ONSET
ALWAYS SECONDARY TO ILLNESS- MUST FIND OUT MEDICALLY WHAT IS TO
RESOLVE
-PRIORITY/MEDICAL EMERGENCY to prevent irreversible and serious damage
delirium risk factors
ALWAYS SECONDARY TO
-pain
-infection/uti/pneumonia
-dehydration
-hypoxia
-immobilization
,-poor/inadequate nutrition
-environmental noises/ lack of orienting material
-movement to new area
-sleep deprivation
-sensory problems
-restraint use
-Drugs/medications
-surgery
Delirium manifestations
RAPID ONSET/ fluctuate in intensity
-inability to direct/sustain focus
-shift in attention
-disorientation/confusion
-anxiety
-illusions
-hallucinations
-mood swings
-hyperactive
-reduced vigilance
-reduced response to environment
-incoherence
-physical aggression
-tachycardia
,-agitation
-poor memory
-poor self care/skin integrity
-poor nutrition
-sweating/dilated pupils/flushed skin
-hypertension
lethargy to hyper vigilance
-eyes constantly scanning room
-delusional thinking
-distraction
Hallucinations
FALSE SENSORY EXPERIENCES (not there)
-sees spiders crawling over wall or on them
-My thoughts are jumbled
-psychomotor agitation due to fear and anxiety
Illusions
ERRORS IN PERCEPTION OF SENSORY STIMULI
-may mistake folded blankets for white rats
-cord of window blind for a snake
-stimulus is real, person misinterprets it
-explain and clarify illusions to individual
Delirium assessment
, PERFORM MEDICAL EVALUATION FIRST
-information from family/friends
-review medication history/drug use
-any underlying illnesses/diseases
-blood work
-urinalysis
-CBC/CRP
-safety/fall risk
-exit seeking
-assess risk for poly pharmacy (using multiple drugs)
delirium physical needs
patient becomes disoriented
-may wander or try and pull out IV lines
-fall out of bed
-want to go home or think hospital is home
-SIMPLE ENVIRONMENT/CLEAR
-Clocks/calendars
-visual/auditory aides
-interact with patient
-poor self care=
delirium assessment guidelines
-dont assume confusion is bc of dementia
- assess acute onset/fluctuating levels
