Retno Lestari

Apa Hubungannya Kognitif dan Jiwa?

Stimulus

Persepsi

Emosi +/-

Muncul Perilaku

Proses tdp di otak

The Brain in Action

Hearing Words Speaking Words Seeing Words Thinking about Words

Different mental activities take place in different parts of the brain. Positron emission tomography (PET) scans can measure this activity. Chemicals tagged with a tracer “light up” activated regions shown in red and yellow.

Inside the Human Brain

Slide 13

Kognitif

Kemampuan berpikir dan memberi rasional, termasuk proses menilai, orientasi, persepsi dan memperhatikan (Stuart&Sundeen, 1995)

Rentang Respons Kognitif

Respons Adaptif

Respons Maladaptif

- Decisiveness

- Memori baik

- Orientasi peran

- Persepsi akurat

- Perhatian terfokus

- Koheren, berpikiran logis

- Periodic indecisiveness

- Pelupa

- Kadang2 bingung

- Kadang2 mispersepsi

- Pikiran kacau

- Kadang2 pikiran jernih

- Tdk mampu buat keputusan

- Kerusakan memori dan penilaian

- Disorientasi

- Mispersepsi

- Perhatian tdk fokus

- Sulit memberi alasan logis

Cognitive responses

Maladaptive cognitive responses include an inability to make decisions, impaired memory and judgment, disorientation, misperceptions, decreased attention span, and difficulties with logical reasoning.

• Latin demens (without mind),

• Sindrom klinis o/k ggn organik– karakteristik onset lambat – Pe fs. kognitif– Disfs. ADL

• 10% > 65th,

• > 50 % > 85th

Non-Reversible Types of DementiaNon-Reversible Types of Dementia

Alzheimer’s disease

Vascular Dementia

Dementia with Lewy bodiesDementia with Lewy bodies

Fronto-Temporal Dementia

Others:Others:

Parkinson’s Disease

Huntington’s DiseaseHuntington’s Disease

Creutzfeldt Jakob Creutzfeldt Jakob DiseaseDisease

Progressive Progressive Supranuclear PalsySupranuclear Palsy

Korsakoff’s Korsakoff’s SyndromeSyndrome

Infection-Related Infection-Related Dementia (HIV, Dementia (HIV, Syphilis)Syphilis)

Reversible DementiaReversible Dementia

MalnutrisiMalnutrisi

DehidrasiDehidrasi

Disfungsi MetabolikDisfungsi Metabolik

Defisiensi Vitamin B12Defisiensi Vitamin B12

DepresiDepresi

DeliriumDelirium

Perubahan OtakPerubahan Otak Saat lahir, otak Saat lahir, otak > 100 trilliun sel syaraf/neurons > 100 trilliun sel syaraf/neurons Dementia Dementia neurons pd bbrp bagian mati o/k neurons pd bbrp bagian mati o/k

peny.ttt peny.ttt Massa otak dpt ber< s.d 50% Massa otak dpt ber< s.d 50%

Beberapa tipe:Beberapa tipe: Alzheimer’s (~55%),Alzheimer’s (~55%), vascular dementia (~20%), dementia with Lewy vascular dementia (~20%), dementia with Lewy

bodiesbodies (~15%), and frontotemporal dementia (~5%). (~15%), and frontotemporal dementia (~5%). Parkinson’s with dementia, Creutzfeldt-Jakob and Parkinson’s with dementia, Creutzfeldt-Jakob and

Huntington’s disease.Huntington’s disease.

Masalah psikiatriMasalah psikiatri

AgitationAgitation

WanderingWandering

InsomniaInsomnia

Catastrophic Catastrophic reactionsreactions

PsychosisPsychosis

DepressionDepression

AnxietyAnxiety

AgnosiaAgnosia

AphasiaAphasia

ApraxiaApraxia

Deficits in abstract Deficits in abstract thinkingthinking

Psychometric testsPsychometric tests ‘ ‘Mini-Mental State Examination’ Mini-Mental State Examination’ Sensitif thd kultur dan sosialSensitif thd kultur dan sosial dpt berubah, harus dikaji lgdpt berubah, harus dikaji lg

Brain-imagingBrain-imaging Structural imaging Structural imaging ((CT CT and and MRI scansMRI scans) ) functional imaging functional imaging ((PET and SPET scansPET and SPET scans))

Cairan tubuhCairan tubuh CSFCSF

TREATMENT AgitasiTREATMENT Agitasi

PerilakuPerilaku

Lingk. Nyaman dan Lingk. Nyaman dan amanaman

Stimulus fs. kognitifStimulus fs. kognitif

MusicMusic

Terapi cahayaTerapi cahaya

Siang hari exercise, Siang hari exercise,

<i istirahat siang<i istirahat siang

MedicationsMedications

Typical antipsychotics Typical antipsychotics (Haldol) (Haldol)

Atypical antipsychotics Atypical antipsychotics (Risperdal) (Risperdal)

Antidepressants -- watch Antidepressants -- watch for agitated depression, for agitated depression, harus dikajiharus dikaji

benzodiazepinesbenzodiazepines

Delirium Delirium – Core Features – Core Features (DSM-IV)(DSM-IV)

Gangguan kesadaranGangguan kesadaran (i.e., lingkungan), < (i.e., lingkungan), < kemampuan u/ fokus, pertahankan perhatiankemampuan u/ fokus, pertahankan perhatian

Perubahan kognitifPerubahan kognitif (i.e., memory deficit, (i.e., memory deficit, disorientation, language disturbance), ggn disorientation, language disturbance), ggn persepsipersepsi

Gangguan tsb berlangsung dlm waktu Gangguan tsb berlangsung dlm waktu pendekpendek (berjam2 s.d berhari2), fluktuasi (berjam2 s.d berhari2), fluktuasi

EPIDEMIOLOGY AND RISK EPIDEMIOLOGY AND RISK FACTORSFACTORS

25% of medical 25% of medical inpatients are inpatients are deliriousdelirious

ElderlyElderly

DementiaDementia

Renal failureRenal failure

Liver failureLiver failure

ImmobilizationImmobilization

Foley catheterFoley catheter

InfectedInfected

Anticholinergic Anticholinergic medicationsmedications

PolypharmacyPolypharmacy

NarcoticsNarcotics

BenzodiazepinesBenzodiazepines

METABOLIC CAUSESMETABOLIC CAUSES

HypernatremiaHypernatremia

HypercalcemiaHypercalcemia

Hypo-, hyper-glycemiaHypo-, hyper-glycemia

Uremia (uremic encephalopathy)Uremia (uremic encephalopathy)

Liver failure (hepatic encephalopathy)Liver failure (hepatic encephalopathy)

INFECTIOUS CAUSESINFECTIOUS CAUSES

Urinary tract infectionUrinary tract infection

PneumoniaPneumonia

SepsisSepsis

Delirium may be the first sign of infection, Delirium may be the first sign of infection, predating fever, leukocytosispredating fever, leukocytosis

MANAGEMENT OF DELIRIUMMANAGEMENT OF DELIRIUM

Find the cause(s)Find the cause(s)

Usually multifactorialUsually multifactorial

Look for medication toxicityLook for medication toxicity

Re-orient patientRe-orient patient

Quiet, unstimulating environmentQuiet, unstimulating environment

Antipsychotic medications for agitationAntipsychotic medications for agitation

Benzodiazepines often makes delirium worseBenzodiazepines often makes delirium worse

1:1 observation/restraints only when needed1:1 observation/restraints only when needed

Examples: Nursing DiagnosisExamples: Nursing Diagnosis

Altered thought processes r/t severe dehydration Altered thought processes r/t severe dehydration as e/b hypervigilance, distractibility, visual as e/b hypervigilance, distractibility, visual hallucinations, and disorientation to time, place, hallucinations, and disorientation to time, place, and personand personAltered thought processes r/t barbiturate ingestion Altered thought processes r/t barbiturate ingestion e/b altered sleep patterns, delusions, e/b altered sleep patterns, delusions, disorientation, and decreased ability to grasp disorientation, and decreased ability to grasp ideasideasAltered thought processes r/t brain disorder e/b Altered thought processes r/t brain disorder e/b inaccurate interpretation of environment, deficit in inaccurate interpretation of environment, deficit in recent memory, impaired ability to reason, and recent memory, impaired ability to reason, and confabulationconfabulation

PengkajianPengkajian

Faktor PredisposisiFaktor Predisposisi PenuaanPenuaan

Kumulatif degeneratif jaringan di otakKumulatif degeneratif jaringan di otakpenuaanpenuaan

Racun dlm jar. Otak, kimia toksik/logam Racun dlm jar. Otak, kimia toksik/logam beratberatrespons kognitif maladaptifrespons kognitif maladaptif

NeurobiologiNeurobiologi

Penyakit alzheimerPenyakit alzheimer

Gangguan metabolik (liver kronis, GGK, def. Vit, Gangguan metabolik (liver kronis, GGK, def. Vit, malnutrisi)malnutrisi)

Anoreksia nervosa/bulimia nervosaAnoreksia nervosa/bulimia nervosa Genetik Genetik

Penyakit otak degeneratif herediter, mis Penyakit otak degeneratif herediter, mis Huntington’s diseaseHuntington’s disease

Stressor PresipitasiStressor Presipitasi Hipoksia: anemia hipoksia, hipoksemia Hipoksia: anemia hipoksia, hipoksemia suplai darah ke suplai darah ke

otak<<<otak<<< Gangguan metabolismeGangguan metabolisme

malproduksi endokrinmalproduksi endokrin produksi hormon<<</>>>, produksi hormon<<</>>>, mis. Hipotiroidisme, hipertiroidisme, hipoglikemia, mis. Hipotiroidisme, hipertiroidisme, hipoglikemia, hiperglikemiahiperglikemia

Racun, infeksiRacun, infeksi

Gagal ginjal, sifilisGagal ginjal, sifilis Perubahan strukturPerubahan struktur

Tumor, traumaTumor, trauma Stimulasi sensori: stimulus <</>>Stimulasi sensori: stimulus <</>>

Lingk < stimulusLingk < stimulus halusinasi halusinasi

Penerangan dan aktivitas di ICU yg konstanPenerangan dan aktivitas di ICU yg konstan bingung, bingung, delusi, halusinasidelusi, halusinasi

PerilakuPerilaku DemensiaDemensia

Respons kognitif maladaptif ditandai dengan Respons kognitif maladaptif ditandai dengan hilangnya kemampuan intelektual (kerusakan hilangnya kemampuan intelektual (kerusakan memori, penilaian, berpikir abstrak)memori, penilaian, berpikir abstrak)

Delirium Delirium

Proses berpikir terganggu, ditandai dengan: Proses berpikir terganggu, ditandai dengan: gangguan perhatian, memori, pikiran dan orientasigangguan perhatian, memori, pikiran dan orientasi

Sumber KopingSumber Koping: klien, keluarga, teman: klien, keluarga, teman

Mekanisme kopingMekanisme koping Dipengaruhi pengalaman masa laluDipengaruhi pengalaman masa lalu Regresi, rasionalisasi, denial, inteletualisasiRegresi, rasionalisasi, denial, inteletualisasi

Masalah KeperawatanMasalah Keperawatan AnsietasAnsietas Komunikasi, kerusakan verbalKomunikasi, kerusakan verbal Defisit perawatan diriDefisit perawatan diri Gangguan proses pikirGangguan proses pikir Gangguan sensori persepsiGangguan sensori persepsi

OutcomeOutcome: klien dapat mencapai : klien dapat mencapai fungsi kognitif yang optimalfungsi kognitif yang optimal

IntervensiIntervensi DemensiaDemensia

OrientasiOrientasi Tujuan membantu klien berfungsi di Tujuan membantu klien berfungsi di

lingklingk Tulis nama petugas pd kamar klien yg Tulis nama petugas pd kamar klien yg

jelas, besar dan terbacajelas, besar dan terbaca Orientasikan barang pribadi, waktu, Orientasikan barang pribadi, waktu,

tempat, orangtempat, orang Penerangan di malam hariPenerangan di malam hari Jam besar, kalender harianJam besar, kalender harian Kontak personal dan fisikKontak personal dan fisik Aktifitas kelompokAktifitas kelompok

KomunikasiKomunikasi Komunikasi verbal: jelas, ringkas, tdk buru2Komunikasi verbal: jelas, ringkas, tdk buru2 Topik percakapan dipilih klienTopik percakapan dipilih klien Pertanyaan tertutupPertanyaan tertutup Pelan dan diplomatis dlm menghadapi persepsi Pelan dan diplomatis dlm menghadapi persepsi

yg salahyg salah Empati, hangat, perhatianEmpati, hangat, perhatian

Penguatan kopingPenguatan koping Kaji sumber kecemasan, koping masa laluKaji sumber kecemasan, koping masa lalu

Kurangi agitasiKurangi agitasi Beri penjelasan, pilihanBeri penjelasan, pilihan Jadual harianJadual harian Penyaluran energiPenyaluran energi Saat agitasi: senyum, sikap bersahabatSaat agitasi: senyum, sikap bersahabat

Keluarga dan MasyarakatKeluarga dan Masyarakat Siapkan kelg dan fasilitas di masySiapkan kelg dan fasilitas di masy Perlu bantuan dlm merawat 24 jam di rumahPerlu bantuan dlm merawat 24 jam di rumah Home careHome care

DeliriumDelirium

Kebutuhan fisiologisKebutuhan fisiologis keb dasarkeb dasar nutrisi, cairan nutrisi, cairan Ggn tidurGgn tidurfarmako dan non farmakofarmako dan non farmako Disorientasi o/k ruangan yg terangDisorientasi o/k ruangan yg terang Orientasikan pd situasi lingkOrientasikan pd situasi lingk Dukungan kelgDukungan kelg

HalusinasiHalusinasi Lindungi klien dan orla dari perilaku merusakLindungi klien dan orla dari perilaku merusak Ruangan: aman, barang minimalRuangan: aman, barang minimal Perawatan 1-1 dan pengawasan ketatPerawatan 1-1 dan pengawasan ketat Orientasikan realita berulangOrientasikan realita berulang Dukungan, rasa aman, orientasi realita Dukungan, rasa aman, orientasi realita

konsisten konsisten dari kelg dan petugas dari kelg dan petugas

KomunikasiKomunikasi Pesan jelas, sederhana, beri pilihan terbatasPesan jelas, sederhana, beri pilihan terbatas ““Sekarang bulan Februari”Sekarang bulan Februari” ““bapak mau mandi sebelum makan?”bapak mau mandi sebelum makan?” Sulit: “jam berapa bapak ingin mandi?”Sulit: “jam berapa bapak ingin mandi?”

Pendidikan KesehatanPendidikan Kesehatan Mulai saat klien bertanya tentang apa yg Mulai saat klien bertanya tentang apa yg

terjadi padanyaterjadi padanya Penjelasan diulang beberapa kaliPenjelasan diulang beberapa kali Beri petunjuk tertulisBeri petunjuk tertulis Libatkan anggota keluargaLibatkan anggota keluarga

EvaluasiEvaluasi demensia demensia

Klien melakukan perawatan mandiri seoptimal Klien melakukan perawatan mandiri seoptimal mungkinmungkin

Keluarga tetap memelihara hubungan dengan Keluarga tetap memelihara hubungan dengan klienklien

DeliriumDelirium

Klien kembali pd fungsi sblmnyaKlien kembali pd fungsi sblmnya

Klien dpt memelihara tingkat optimal persepsi Klien dpt memelihara tingkat optimal persepsi sensorisensori

Berperan dlm aktivitas sehari2Berperan dlm aktivitas sehari2

Memelihara keseimbangan fisiologisMemelihara keseimbangan fisiologis

Nursing Care

Care for physiological needs Respond to hallucinations Respond to wandering Decrease agitation Administer medications Reinforce coping mechanisms Communicate therapeutically Provide health education, involving

family and community

Remember that elderly people

are very sensitive

to medications. Administer with

care, and monitor closely.

Reality Orientation When talking to people with

dementia, it is not necessary to tell them the entire reality

Example: “I am looking for my mother. Has she come yet?”

Non-therapeutic response: Your mother died 20 years ago.

Empathetic response: It sounds like you miss your mother. Can you tell me about her while we have lunch?

Nursing Interventions Highest priority is to maintain life and attend

to physical needs Nutrition and fluid balance Ensure safety- May need restraint in acute

care settings Sedatives may be needed for sleep

deprivation Communicate with clear messages and

simple instructions Maintain dignity Decrease anxiety

Keep lights on if pt fears dark or shadows Orientate to time, place and person

Evaluation

Patient Outcome/Goal Patient will achieve the optimum

level of cognitive functioning Nursing Evaluation

Evaluation involves feedback from patient, significant others, peers, and supervisors

Was nursing care adequate, effective, appropriate, efficient, and flexible?