Retno Lestari

Apa Hubungannya Kognitif dan

Jiwa?
Stimulus

Persepsi Proses tdp di

otak
Emosi +/-

Muncul
Perilaku

Inside the Human Brain

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.

Slide 13

Kognitif

Kemampuan berpikir dan

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

Rentang Respons Kognitif

Respons
Adaptif
- Decisiveness
- Memori baik
- Orientasi peran
- Persepsi akurat
- Perhatian
terfokus
- Koheren,
berpikiran logis

Respons
Maladaptif
- Periodic
indecisiveness

- Tdk mampu buat

keputusan

- Pelupa

- Kerusakan
memori dan
penilaian

- Kadang2
bingung
- Kadang2
mispersepsi
- Pikiran kacau
- Kadang2
pikiran jernih

- Disorientasi
- Mispersepsi
- Perhatian tdk
fokus
- Sulit memberi

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 Dementia

Others:
Alzheimers disease
Vascular Dementia
Dementia with Lewy bodies
Fronto-Temporal Dementia

Parkinsons Disease
Huntingtons Disease
Creutzfeldt Jakob
Disease
Progressive
Supranuclear Palsy
Korsakoffs
Syndrome
Infection-Related
Dementia (HIV,
Syphilis)

Reversible Dementia
Malnutrisi
Dehidrasi
Disfungsi Metabolik
Defisiensi Vitamin B12
Depresi
Delirium

Perubahan Otak

Saat lahir, otak > 100 trilliun sel syaraf/neurons

Dementia neurons pd bbrp bagian mati o/k
peny.ttt
Massa otak dpt ber< s.d 50%

Beberapa tipe:

Alzheimers (~55%),
vascular dementia (~20%), dementia with Lewy
bodies
(~15%), and frontotemporal dementia (~5%).
Parkinsons with dementia, Creutzfeldt-Jakob and
Huntingtons disease.

Masalah psikiatri
Agitation
Wandering
Insomnia
Catastrophic
reactions

Psychosis
Depression
Anxiety
Agnosia
Aphasia
Apraxia
Deficits in abstract
thinking

Psychometric tests

Mini-Mental State Examination

Sensitif thd kultur dan sosial
dpt berubah, harus dikaji lg

Brain-imaging

Structural imaging (CT and MRI scans)

functional imaging (PET and SPET scans)

Cairan tubuh

CSF

TREATMENT Agitasi
Perilaku
Lingk. Nyaman dan
aman
Stimulus fs. kognitif
Music
Terapi cahaya
Siang hari exercise,
<i istirahat siang

Medications
Typical antipsychotics
(Haldol)
Atypical antipsychotics
(Risperdal)
Antidepressants -- watch
for agitated depression,
harus dikaji
benzodiazepines

Delirium Core Features

(DSM-IV)

Gangguan kesadaran (i.e., lingkungan), <

kemampuan u/ fokus, pertahankan perhatian
Perubahan kognitif (i.e., memory deficit,
disorientation, language disturbance), ggn
persepsi
Gangguan tsb berlangsung dlm waktu
pendek (berjam2 s.d berhari2), fluktuasi

EPIDEMIOLOGY AND RISK

FACTORS
25% of medical
inpatients are
delirious
Elderly
Dementia
Renal failure
Liver failure
Immobilization

Foley catheter
Infected
Anticholinergic
medications
Polypharmacy
Narcotics
Benzodiazepines

METABOLIC CAUSES
Hypernatremia
Hypercalcemia
Hypo-, hyper-glycemia
Uremia (uremic encephalopathy)
Liver failure (hepatic encephalopathy)

INFECTIOUS CAUSES
Urinary tract infection
Pneumonia
Sepsis
Delirium may be the first sign of infection,
predating fever, leukocytosis

MANAGEMENT OF DELIRIUM
Find the cause(s)
Usually multifactorial
Look for medication toxicity
Re-orient patient
Quiet, unstimulating environment
Antipsychotic medications for agitation
Benzodiazepines often makes delirium worse
1:1 observation/restraints only when needed

Examples: Nursing Diagnosis

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

Pengkajian
Faktor Predisposisi

Penuaan
Kumulatif degeneratif jaringan di otakpenuaan
Racun dlm jar. Otak, kimia toksik/logam
beratrespons kognitif maladaptif

Neurobiologi
Penyakit alzheimer
Gangguan metabolik (liver kronis, GGK, def. Vit,
malnutrisi)
Anoreksia nervosa/bulimia nervosa

Genetik
Penyakit otak degeneratif herediter, mis
Huntingtons disease

Stressor Presipitasi
Hipoksia: anemia hipoksia, hipoksemia suplai darah ke
otak<<<
Gangguan metabolisme
malproduksi endokrin produksi hormon<<</>>>,
mis. Hipotiroidisme, hipertiroidisme, hipoglikemia,
hiperglikemia
Racun, infeksi
Gagal ginjal, sifilis
Perubahan struktur
Tumor, trauma
Stimulasi sensori: stimulus <</>>
Lingk < stimulus halusinasi
Penerangan dan aktivitas di ICU yg konstan bingung,
delusi, halusinasi

Perilaku
Demensia
Respons kognitif maladaptif ditandai dengan
hilangnya kemampuan intelektual (kerusakan
memori, penilaian, berpikir abstrak)
Delirium
Proses berpikir terganggu, ditandai dengan:
gangguan perhatian, memori, pikiran dan orientasi
Sumber Koping: klien, keluarga, teman
Mekanisme koping
Dipengaruhi pengalaman masa lalu
Regresi, rasionalisasi, denial, inteletualisasi

Masalah Keperawatan

Ansietas
Komunikasi, kerusakan verbal
Defisit perawatan diri
Gangguan proses pikir
Gangguan sensori persepsi

Outcome: klien dapat mencapai

fungsi kognitif yang optimal

Intervensi
Demensia
Orientasi
Tujuan membantu klien berfungsi di
lingk
Tulis nama petugas pd kamar klien yg
jelas, besar dan terbaca
Orientasikan barang pribadi, waktu,
tempat, orang
Penerangan di malam hari
Jam besar, kalender harian
Kontak personal dan fisik
Aktifitas kelompok

Komunikasi
Komunikasi verbal: jelas, ringkas, tdk buru2

Topik percakapan dipilih klien

Pertanyaan tertutup
Pelan dan diplomatis dlm menghadapi persepsi
yg salah
Empati, hangat, perhatian
Penguatan koping
Kaji sumber kecemasan, koping masa lalu
Kurangi agitasi

Beri penjelasan, pilihan

Jadual harian
Penyaluran energi
Saat agitasi: senyum, sikap bersahabat

Keluarga dan Masyarakat

Siapkan kelg dan fasilitas di masy
Perlu bantuan dlm merawat 24 jam di rumah
Home care
Delirium
Kebutuhan fisiologis
keb dasar nutrisi, cairan
Ggn tidurfarmako dan non farmako
Disorientasi o/k ruangan yg terang
Orientasikan pd situasi lingk
Dukungan kelg

Halusinasi
Lindungi klien dan orla dari perilaku merusak
Ruangan: aman, barang minimal
Perawatan 1-1 dan pengawasan ketat
Orientasikan realita berulang
Dukungan, rasa aman, orientasi realita
konsisten dari kelg dan petugas
Komunikasi
Pesan jelas, sederhana, beri pilihan terbatas
Sekarang bulan Februari
bapak mau mandi sebelum makan?
Sulit: jam berapa bapak ingin mandi?

Pendidikan Kesehatan
Mulai saat klien bertanya tentang apa yg
terjadi padanya
Penjelasan diulang beberapa kali
Beri petunjuk tertulis
Libatkan anggota keluarga

Evaluasi
demensia
Klien melakukan perawatan mandiri seoptimal
mungkin
Keluarga tetap memelihara hubungan dengan
klien
Delirium
Klien kembali pd fungsi sblmnya
Klien dpt memelihara tingkat optimal persepsi
sensori
Berperan dlm aktivitas sehari2
Memelihara keseimbangan fisiologis

Nursing Care

Remember that
elderly people
are very
sensitive
Care for physiological needs
to medications.
Respond to hallucinations Administer with
care, and
Respond to wandering
monitor
Decrease agitation
closely.

Administer medications
Reinforce coping mechanisms
Communicate therapeutically
Provide health education, involving
family and community

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?