<sup id="x1bnr"></sup>

<em id="x1bnr"></em>

<sup id="x1bnr"><menu id="x1bnr"></menu></sup>
<sup id="x1bnr"><menu id="x1bnr"></menu></sup>

<dl id="x1bnr"><menu id="x1bnr"></menu></dl>

        <sup id="x1bnr"><menu id="x1bnr"></menu></sup>

        <em id="x1bnr"><ol id="x1bnr"></ol></em>
        购买

        ¥15.0

        加入VIP
        • 专属下载券
        • 上传内容扩展
        • 资料优先审核
        • 免费资料无限下载

        上传资料

        关闭

        关闭

        关闭

        封号提示

        内容

        首页 长照体系内谵妄症的评估与处置PPT课件

        长照体系内谵妄症的评估与处置PPT课件.ppt

        长照体系内谵妄症的评估与处置PPT课件

        简介:本文档为《长照体系内谵妄症的评估与处置PPT课件ppt》,可适用于高等教育领域

        長照體系內譫妄症的評估與處置台大醫院老年醫學部陳人豪課程內容譫妄症(delirium)ndash流行病學ndash致病機轉與病因ndash診斷與評估ndash預防與治療長照體系內譫妄症*譫妄症注意力和急性認知功能?#31995;K的一種症候群ndash急性混亂狀態(acuteconfusionalstate)ndash典型的多因性(如同其他老年病症候群)在臨床上常被忽略*譫妄症的流行病學老年人譫妄症ndash社區盛行率:ndash在急診的盛行率:(但被忽略)ndash在入住院時的盛行率:ndash住院中的發生率:ndash?#20013;g後的發生率:ndash加護病房的發生率:ndash護理之家急性後期照護:可高達InouyeSKNEnglJMed():*譫妄症的預後急性後期機構ndash入住時的盛行率:其中會完全恢復ndash入住後個月仍有譫妄症:健康指標(healthoutcome)ndash有譫妄症的住院病人:?入住護理之家ndash急性後期機構病人:日常生活功能恢復較差ndash急性後期機構病人:?併發症或再住院ndash?死亡率LyonsWLJAmMedDirAssoc():ndash*「精神疾病診斷與統計手冊第五版」診斷準則注意力(引導、集?#23567;?#32173;持及轉移能力?#26723;?及清醒度(對環境的定向力變差)的?#31995;K該?#31995;K在短時間內發展(通常是幾個小時到幾天)表現出與之前在注意力與清醒度?#31995;?#25913;變且傾向在小時內呈現起伏的病程表現認知功能?#31995;K(例如:記憶力缺損、無定向?#23567;?#21450;語言?#31995;K、視覺空間能力或感官功能?#31995;K)A、C的?#31995;K無法以已有的神經認知症(neurocognitivedisorder)來解釋且並?#21069;l生在清醒程度?#20048;?#35722;差(例如:昏迷)*從病史、理學檢查及實驗室檢查的結果顯示該?#31995;K是由內科疾病、物質中毒或戒斷暴露到毒素、或多重病因所造成*「混亂評估法」(ConfusionAssessmentMethod,CAM)由美國精神醫學會出版之「精神疾病診斷與統計手冊第三版的修正版」發展出來篩檢譫妄症的工具包括四個要件病患一定要符合前兩個要件加上至少第三或第四個要件其中之一才能診斷譫妄症:急性發作的症狀且其病程時好時壞注意力不集中無組織的思考意識?#31995;K敏感度:特異度:InouyeSK,etalAnnInternMed:():*譫妄症的?#20048;?#24230;混亂評估法?#20048;?#24230;(短表)(CAMSeverity(CAMS)shortform)急性發作的症狀且其病程時好時壞(無:有:)注意力不集中(無:輕微:顯著:)無組織的思考(無:輕微:顯著:)意識?#31995;K(無:輕微:顯著:)ndash總分:Fourdifferentriskgroups:None:,Low(mild):,Moderate:,High(severe):pointsInouyeSKAnnInternMed():*譫妄症的臨床表現可依精神活?#26377;?#24907;分成四型高活?#26377;?hyperactive)ndash躁動(agitation)、增加警戒狀態(vigilance)ndash較易被察覺、較低的死亡?#23454;?#27963;?#26377;?hypoactive):最常見ndash?#20154;?#31934;神活動功能減低ndash不易被察覺常被忽略或誤診或被不適當治療ndash預後較差混?#38386;?mixed)ndash表現上具有上述兩種?#38382;?#30340;譫妄症正常型LiptzinB,etalBrJPsychiatry:*致病機轉十分複雜至今仍不是很清楚並無最後共通途徑可能由數個病理機轉相互連結ndash神經傳導物質調控異常(neurotransmitterdisturbance)?膽鹼缺乏(acetylcholinedeficiency)?多巴胺(dopamine)??血清素(serotonin)?,gamma胺基酪酸(GABA)?ndash壓力引起下視丘腦垂腺腎上腺軸過度活動(stressrelatedhypothalamicpituitaryadrenalaxisoveractivity)細胞激素(cytokine)?血漿酯酶(esterase)活性?#26723;蚘oungJ,etalBMJ():*前置因子(Predisposingfactor)認知功能?#31995;K失智症多重疾病功能?#31995;K年紀大慢性腎臟病營養不良血清白蛋白偏低憂鬱症知覺?#31995;K物質濫用史*誘發因子(Precipitatingfactor)藥物及藥物改變(包括停藥)並發的各種疾病電解質失調或代謝異常?#20013;g疼痛控制不佳中風感染留置管約束酗酒或娛樂性藥物的使用重大精神社會壓力源*譫妄症:多因性模式Hazzardrsquosgeriatricmedicineandgerontology,thEd*造成譫妄症的原因藥物(Drugs)電解質失調(Electrolytes)藥物戒斷(Lackofdrugs)感染(Infections)感覺輸入減少(Reducedsensoryinput):失明、失聰、環境昏暗顱內疾病(Intracranialdisorder):中風、腦膜?#20303;?#30322;癇尿滯留及糞石箝塞(Urinaryretention,fecalimpaction)心臟疾病(Myocardial):心肌梗塞、心律不整、心衰竭*譫妄症的評估確立診斷ndash鑑別診斷:譫妄症、失智症、憂鬱症ndash失智症是譫妄症的危險因子反之亦然確立可能造成譫妄症的原因及會造成立即生命危險的病因*Evaluation:MedicalHistoryBaselineleveloffunctionChangesinmentalstatusHistoryforidentifyingacuteorganicillnessesDrugreviews,includingalcohol,benzodiazepineSocialhabitsReviewofsystems*Evaluation:PhysicalExaminationVitalsignsandoxygensaturationGeneralmedicalevaluationndashSignsofinfectionsndashSignsoforganfailurendashSuprapubicandrectalexaminationNeurologicalexaminationndashMentalstatusexaminationndashSpeech,thought,perception,activity*Timecourseofcognitivechanges,includingbaselinecognitivestatusandtheacuityofchangeInformationgatheredfromreliableinformants,includingthefamily,caregiversornursesEvaluation:LaboratoryTestsFormostpatients:ndashCBC,bloodsugar,renalandliverfunctiontests,electrolytes(Na,Ca),urinalysis,chestxrayndashConsiderECG,cardiacenzymes,TSH,ABG,druglevels,vitaminBForselectedpatients:ndashNeuroimaging:headtraumaornewfocalneurologicfindingsndashEEGandCSFstudy:seizureorsignsofmeningitis*PrinciplesofManagementManagementofdeliriumrequiresndashInterdisciplinaryeffortbydoctors,nurses,familyndashMultifactorialapproachbecausedeliriumusuallyresultsfromconcurrentmultiplefactorsndashCorrectionofallreversiblecontributionfactorsndashAvoidanceofnewprecipitantsIdentifyandtreatpredisposingandprecipitatingfactorspromptly*AvoidcomplicationsofdeliriumndashRemoveunnecessaryindwellingdevicesndashMonitorbowelandurinaryoutputndashAchievepropersleephygieneandavoidsedativesndashMonitorfornosocomialcomplications,includingaspiration,pressuresores,UTIOptimizemedicationregimen*NonpharmacologicStrategiesEnvironmentndashProvidequiet,wellfitsurroundingsndashProvideorientingstimuli(eg,clocks,calendar,familiarobjects)ndashEncouragefamilyinvolvementndashProvideregularreorientingcommunicationndashLimitroomandstaffchanges*ActivitiesduringdaytimendashCognitiveactivitiesndashEncourageearlymobilizationandrehabilitationCorrectsensorydeficits:eyeglasses,lighting,hearingaidsorcerumenremovalSleepndashProvideuninterruptedsleeptimeatnightndashNormalizesleepwakecycle*PreventdehydrationndashAdequateintakeofnutritionandfluidsndashFeedingbyhandifnecessaryUsesittersAvoiduseofrestraintsandurinarycathetersAvoidpsychoactivedrugs*PharmacologicStrategiesRemoveoffendingandunnecessarydrugsReserveforpatientsatriskforinterruptionofessentialmedicalcareorpatientswhoposesafetyhazardtothemselvesorstaffStartlowdosesandadjustuntileffectachievedMaintaineffectivedoseforndashdays*TypicalAntipsychoticsForacuteagitationoraggressionHaloperidolndashmgpo(peakeffect:hours)twicedailywithadditionaldoseseveryhoursasneededndashmgim(peakeffect:minutes),observeafterminutesandrepeatthesameortwicetheorigindosesndashTitrateupwardasneeded(uptomgday)Goal:AmanageablepatientObserveforakathisia,extrapyramidaleffectsandprolongedQTc*AtypicalAntipsychoticsStudiedonlyinsmalluncontrolledstudiesAssociatedwithincreasedriskofndashStrokendashMortalityamongolderpatientswithdementiaObserveforextrapyramidaleffectsandprolongedQTcndashRisperidonemgdaypo(qdbid)ndashQuetiapinemgdaypo(qdbid)ndashOlanzapinemgpo(qd)*BenzodiazepinesReserveforalcoholbenzodiazepinewithdrawalAdjunctstoantipsychotics(agitationinsomnia)ndashLorazepammgpo,withadditionaldoseseveryhoursasneeded*PhysicalRestraintThehighestrelativeriskoftheprecipitatingfactorsfordelirium*SignificantassociationwiththeseverityofdeliriumdaggerMisconceivedreasonforphysicalrestraintuseamongdeliriouspatientstopreventinjuryRestraintreduction:notassociatedwith??fallsRestraintfreecare:thestandardofcare*InouyeSK,etalJAMA():ndashdaggerMcCuskerJ,etalJAmGeriatrSoc():ndash*PreventionofDeliriumPrimarypreventionofdelirium:themosteffectivestrategytoreducedeliriumAvoidmedicationsknowntoprecipitatedeliriumMulticomponentapproachesriskreductionfordeliriuminhospitalizedolderpatients*YaleDeliriumPreventionTrialToevaluateeffectivenessofinterventionprotocolstargetedtowardsixriskfactorsndashCognitiveimpairmentndashSleepdeprivationndashImmobilityndashVisualimpairmentndashHearingimpairmentndashDehydrationInouyeSK,etalNEnglJMed():*DeliriuminLongtermCareAmericanMedicalDirectorsAssociation(AMDA)clinicalpracticeguidelineinforldquodeliriumandacuteproblematicbehaviorinthelongtermcaresettingrdquondashRecognitionndashAssessmentndashTreatmentndashMonitoring*RecognitionStep:Identifythepatientrsquoscurrentbehavior,mood,cognitionandfunctionReviewthehistory,observethepatientinvarioussituations,andidentifyanddocumentpertinentdetailsabouthowthepatientlooks,thinks,andactsAssessmentprocessshouldbecoordinatedamongstafffromvariousdisciplinesinvolved*KeyElementsinEvaluatingMentalStatus*Step:IdentifyandclarifyproblematicbehaviorandalteredmentalfunctionndashSymptoms,currentdiagnoses,historyandmedicationsReviewthepatientrsquosmedical,surgical,familyandsocialhistorypertinentbehavioralhistorybaselinefunctionalstatusandanypriordiagnosticworkupandmanagement*Checkavailabletransferinformationandanypertinentconsultationreportsforrelateddiagnoses(delirium,dementia,bipolardisorder,orpsychosis)Reviewcurrentordersfortreatmentsandmedicationsthataddresscognition,mood,problematicbehavior,orpsychiatricdisorders,andformedicationswithanticholinergicpropertiesorsideeffects,whichareknowntoadverselyaffectbehaviorandmentalfunction*?DefinebehavioralissuesndashNatureandrelevantfactorsndashSeverityndashCourse?IdentifydeliriumndashRequireahighindexofsuspicionndashShouldbeconsideredinanypatientwhohasachangeinbehaviorormentalfunction,regardlessofwhethertheyalsohavedementiandashUsescreeninginstruments(eg,CAM)*Step:AssessthepatientforindividualriskfactorsforproblematicbehavioranddeliriumndashHavingdementiaisthemostcommonriskfactorforthedevelopmentofdeliriumAvoidusingindwellingurinarycathetersandminimizeuseofothermedicaldevices(eg,intravenouscatheters)thatmayrestrictmobilityorfunctionAvoidusingrestraints*MinimizethenumberandreducethedoseofmedicationswithcentralnervoussystemeffectsorpotentialsideeffectsPaycarefulattentiontofluidandelectrolytebalanceinolderpatientswhoaretakingdiureticswhohavediarrhea,pneumonia,orurinarytractinfectionorwhoareotherwiseatriskfordehydrationIdentifyandmanagetreatablecausesofanemia*Optimizesensoryfunction(eg,providecorrectivelensesforimpairedvision,hearingaides)Optimizesleep(eg,addressreversiblecausesofsleepimpairment,minimizenighttimenoises)Avoidunnecessaryisolationorrestriction(eg,forinfectioncontrolpurposes)*AssessmentStep:DeterminetheurgencyofthesituationandtheneedforadditionalevaluationandtestingSimplygivingmedicationstotrytocontrolbehavior,orroutinelyrequestingtheimmediatetransferofpatientstotheemergencyroomorhospital,areoftennothelpfulSomesituationsmayrequiremoreurgentevaluationandmanagement*AssessmentStep:DeterminetheurgencyofthesituationandtheneedforadditionalevaluationandtestingSimplygivingmedicationstotrytocontrolbehavior,orroutinelyrequestingtheimmediatetransferofpatientstotheemergencyroomorhospital,areoftennothelpfulSomesituationsmayrequiremoreurgentevaluationandmanagement*SituationsRequiringUrgentEvaluation?MedicalissuesndashMarkedlyabnormalvitalsigns(systolicBP,PRor,RR,temp℃or℃)ndashNewonsetrespiratorydistress,withincreasinghypoxiaanddyspneandashSignsofseriousunderlyingconditionpossiblycausingdelirium(eg,symptomsofstroke)?PsychiatricsymptomsndashEscalatingphysicallyaggressivebehaviororthreatsofviolencendashIntermittentorpersistentchangetoselforothers*Step:Identifythecause(s)ofproblematicbehaviorandalteredmentalfunctionAsystematicapproachndashAdetaileddescriptionofcurrentbehavior,functionandmentalstatusinpropercontextndashCarefulphysicalassessmentbynursingstaff,supplementedbyapractitionerassessmentandpertinentlaboratorytestingasneeded*Considerunmetcomfortneeds,environmentalissuesandnonspecificbehavioralandpsychologicalsymptomsofdementia(BPSD)Certainphysicalimpairments(eg,aphasia,impairmentofvisionandhearing)maycontributetobehavioralsymptoms*Step:AssessthepatientformedicalillnesseswithorwithoutdeliriumAdditionalmedical,neurological,psychologicalorpsychiatricassessmentifaboveevaluationsandtestsdonotrevealaspecificcauseStepwiseapproachmaybemoreusefulandcosteffectivethanthesimultaneousorderingofmanytestsInfections,particularlypneumoniaandurinarytractinfection,arecommonininstitutionalizedelderly*ConditionsThatMayAffectBehaviorandMentalFunctionAcuteorabruptonsetorconditionchangeMedicationrelatedadverseconsequencesFluidandelectrolyteimbalanceInfectionsHypoglycemiaormarkedhyperglycemiaAcuterenalfailure,hypoxia,COretentionCardiacarrhythmia,myocardialinfarctionorheartfailureHeadtraumaStrokeorseizurePain,acuteorchronic*UrinaryoutletobstructionAlcoholordrugabuseorwithdrawalPostoperativestateAcuteorabruptonsetorconditionchangeHypoorhyperthyroidismNeoplasmNutritionaldeficiency(eg,folate,thiamine,vitaminB)AnemiaChronicconstipationfecalimpactionSensorydeficits*DiagnosticTeststoHelpAssessCauses*?Almostanymedicationiftimecourseisappropriate*Step:ConsiderpossiblepsychiatricillnessesConsiderpsychiatricillnessiftheassessmentdoesnotrevealacausendashPsychosisfromschizophrenia,schizoaffectivedisorders,majordepression,dementia,bipolaraffectivedisordersandmaniandashMooddisordersndashPersonalitydisorders*Step:ConsiderdementiarelatedcausesEnvironmentaltriggersBPSD:restlessness,aggression,delusion,hallucinations,repetitivevocalization,wandering*TreatmentStep:EstablishaworkingdiagnosisandvalidateconclusionsIdentifytherationaleforandgoalsoftreatmentndashWhyisthepatientrsquosbehaviorproblematicndashWhydoesthepatientrsquosbehaviorrequireaninterventionndashHowwasthelikelycausedeterminedndashHowwilltheproposedinterventionsaddressthecausesorfactorscontributingtotheproblematicbehaviorinordertomoderateitndashHowwilltheproposedinterventionsimprovethepatientrsquoswellbeingandqualityoflife*DeterminetheneedfortransferndashManycasescanbemanagedeffectivelyinafacility,tothepatientrsquosbenefitndashHospitalizationisonlysometimeshelpfulandmaybetraumaticforthepatient**Step:InitiateacareplanfortreatmentndashA:WhataretheantecedentstothebehaviorB:WhatisthebehaviorC:Whataretheconsequencesofthebehavior*AddresskeyaspectsofthepatientrsquoscarendashRiskassessmentndashCauseidentificationandmanagementndashNeedforstaffsupportandforinformingthepatientandfamilyndashPreventionandmanagementofcoexistingconditionsandcomplicationsndashChangestothecurrenttreatmentregimenndashMonitoringparameters*Step:ProvidesymptomaticandcausespecificmanagementSymptomaticinterventionsareoftenhelpfulincombinationwithcausespecificapproachesndashPreventandmanagecomplicationsandfunctionalproblemsndashAddressrelevantethicalissuesndashTreatunderlyingcausesndashTreatdeliriumandpsychosisaggressivelyndashAddresswanderingandsleepdisturbancesndashAddressapathyandmooddisordersndashAddresssexuallyinappropriatebehavior*ndashSymptomatic(mostlynonpharmacologic)approachestoaddressingproblematicbehavior?Addresspainanddiscomfort?Minimizesleepdisruption?Encourageindependencetotheextentofthepatientrsquostolerance?Provideactivitiesforthosewithdisruptivebehavior?Involvethepatientdailyroutineinacalm,quietenvironment?Usedifferentapproachtobathing,feedingandotheractivitiesofdailyliving*Step:UsemedicationsappropriatelytoaddressproblematicbehaviorndashRationalapproachbasedonunderstandingmechanismsofactionandtargetingmedicationstotheidentifiedorlikelyunderlyingcausesndashNomagicbulletsndashRiskandcomplications?Shorthalflifebenzodiazepines(eg,lorazepam):oversedation,ldquoreboundrdquoeffectsaftereachdose*ndashSystematicapproach?Obtainandreviewthedetailsofthesituation(Steps)?Determinethemostlikelycauses?Identifywhatthestaffhasalreadydone,orcoulddo,totrytounderstandandaddressthesituation?Considerwhetherthepatientrsquosbehaviororconditionispresentinganimminentorhighlevelofdangertohimselforherselfortoothers*ndashAntipsychotics?Initiatetreatmentaggressivelyandtaperthedosesasunderlyingcausesareaddressedandsymptomsstabilizeorsubside?Makeindividualizeddecisionsaboutthepotentialbenefitsandrisks*MonitoringStep:MonitorandadjustinterventionsasindicatedndashMonitorthepatientrsquosprogressperiodically(Steps)ndashInitiateormodifyinterventions(Steps)ndashDocumentthepatientrsquoscourseinenoughdetail(treatmenteffect,diagnosisvalidity)ndashAdjustmedicationdosesonthebasisofsymptomsandadverseconsequences*ndashReviewthesituation,revisitthesteps,reconsiderthediagnosesandinterventionsifproblematicbehaviororalteredmentalfunctiondoesnotatleastbegintostabilizeorimprovewithinhoursofinitiatinginterventionsndashMayaddanothermedicationasanadjunctifamaximumrecommendeddoseortolerateddoseofonemedicationisreachedwithpartialimprovementofsymptomsorimprovementofonesymptombutnotothersndashConsiderpsychiatricconsultation,butattendingphysicianmustremaininvolved*Step:ReviewtheeffectivenessandcontinuedappropriatenessofallmedicationsndashAfterdeliriumhavesubsided,reviewthesituationandconsiderwhethertheunderlyingcauseshaveimprovedorresolvedandinterventionremainappropriatendashOncethecauseofdeliriumhasbeenidentifiedandmanagedeffectively,itmaybepossibletotaperorstopanymedicationsthatwereusedtotreatrelatedbehavioralsymptoms*ndashMaybeappropriatetoreduceorstoptheintervention(s),atleastforatrialperiodndashIfsymptomsendureorrecurmorethanoccasionallywhilethepatientisonastabledoseofpsychopharmacologicmedications,reconsiderthediagnosisandappropriatenessofcurrentmedicationregimenndashIfsymptomsarelittleornodifferentasthedoseisreduced,additionalattempteddosereductionmaybeindicated*Step:Prevent,identifyandaddressanycomplicationsoftheconditionsandtreatmentsndashFluidandelectrolyteimbalanceandpressureulcersinapatientwithdeliriumndashFallingasaresultofbenzodiazepine,andotherpsychopharmacologicmedicationusendashHyperglycemiaorcardiaceventsrelatedtotheuseofsomeatypicalantipsychoticsndashOversedationasasideeffectofbenzodiazepine*TakeHomeMessageDelirium,ageriatricsyndromendashCommonamongolderpersonsndashResultinginfunctionaldeclinendashAssociatedwithsubstantialmorbiditymortalityndashDetectedbyusingCAMndashMultifactorial,withunderlyingcausesusuallyfoundbyacomprehensivehistory,physicalexamination,andfocusedlaboratorystudies*ndashSuccessfulpreventionandmanagementinterventionsincludeamulticomponentinterventionndashThebestmanagementispreventionndashPhysicalrestraintsshouldnotbeusedinpatientswithdelirium,andrarelyshouldpharmacologicalrestraintsbeused*Reference陳人豪:譫妄症。於臺灣老年學暨老年醫學會等主編:老年醫學叢書系列:老年病症候群。臺北臺灣老年醫學會:。JAmMedDirAssocClinicalPracticeGuideline:DeliriumandAcuteProblematicBehaviorintheLongTermCareSettingpInouyeSKDeliriuminolderpersonsNEnglJMed():LyonsWLDeliriuminpostacuteandlongtermcareJAmMedDirAssoc():Timecourseofcognitivechanges,includingbaselinecognitivestatusandtheacuityofchangeInformationgatheredfromreliableinformants,includingthefamily,caregiversornurses

        用户评价(0)

        关闭

        新课改视野下建构高中语文教学实验成果报告(32KB)

        抱歉,积分不足下载失败,请?#38498;?#20877;试!

        提示

        试读已结束,如需要继续阅读或者下载,敬请购买!

        评分:

        /70

        ¥15.0

        立即购买

        VIP

        免费
        邮箱

        河北福彩排列7开奖结果
        <sup id="x1bnr"></sup>

        <em id="x1bnr"></em>

        <sup id="x1bnr"><menu id="x1bnr"></menu></sup>
        <sup id="x1bnr"><menu id="x1bnr"></menu></sup>

        <dl id="x1bnr"><menu id="x1bnr"></menu></dl>

              <sup id="x1bnr"><menu id="x1bnr"></menu></sup>

              <em id="x1bnr"><ol id="x1bnr"></ol></em>
              <sup id="x1bnr"></sup>

              <em id="x1bnr"></em>

              <sup id="x1bnr"><menu id="x1bnr"></menu></sup>
              <sup id="x1bnr"><menu id="x1bnr"></menu></sup>

              <dl id="x1bnr"><menu id="x1bnr"></menu></dl>

                    <sup id="x1bnr"><menu id="x1bnr"></menu></sup>

                    <em id="x1bnr"><ol id="x1bnr"></ol></em>