NR 507
Week 7 – Part 1, 2 & 3
Threaded Discussions and Quiz
, NR 507 Week 7 Case Study Discussions
You are at the local mall & you see a patient who appears to be homeless by his physical
appearance & you witness the person “walk 50 feet to a table sit down, & after 5 seconds he
gets up & walks to a tree & urinates on it” He repeats this action 5 times apparently
oblivious to his surroundings. When the police come he ignores them as if they aren’t there.
Later, you go to work & sitting in exam room 3 is the same person! Now, he is your patient,
when you talk to him he has no recollection of his behavior by the mall.
Subjective: No chief complaint listed. Assuming that when approached by police at the mall, &
witnessing the patient ignore them, that the police brought him or called EMS for possible
psychiatric problem & / or medical clearance. Patient denies memory of his actions.
Objective: Witnessed patient's repetitive behavior & unawareness, no other objective findings
noted.
Assessment: Complete history & physical including family & social history.
Differential diagnosis #1: Alteration in awareness-
Pathophysiology: "Diseased superior colliculi have a disturbance in the move component of
selective attention, which manifests as a slowness in orienting attention. Primary
pathophysiologic mechanisms that operate in cognitive system disorders are: (1) direct
destruction because of direct ischemia & hypoxia or indirect destruction as a result of
compression & (2) the effects of toxins & chemicals or metabolic derangement. Disinhibition
resulting in over activity, such as seen in some drug withdrawal states, is a pathologic
mechanism that can produce detection deficits or a hypervigilant state." (McCance, Huethers, &
Brashers, 2013).
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, Clinical Manifestations: Selective attention deficits, domain specific declarative deficits,
working memory deficits.
treatment / plan: CBC, CMP, CT brain, Reversible treatment, rehabilitative measures.
Education / prevention: Educate patient & family on diagnosis, treatment plan. Prevention is
dependent on causative agents.
Differential diagnosis #2: Acute Confusional State
Pathophysiology: "Acute confusional states arise from disruption of a widely distributed neural
network involving the reticular activating system of the upper brainstem & its projections to the
thalamus, basal ganglion, & specific association areas of the cortex & limbic areas. Delirium is
an acute state of brain dysfunction associated with right middle temporal gyrus or left temporo-
occipital junction disruption.21 These areas receive extensive input from the limbic areas &
modulate motivational & affective aspects of attention. Several neurotransmitters are involved,
including increased levels of acetylcholine, dopamine, & serotonin, & increased or decreased
levels of gamma-aminobutyric acid. Inflammatory cytokines, including interleukins, interferon,
& tumor necrosis factor-alpha, may contribute to delirium by altering the blood-brain barrier
permeability & further affecting the neurotransmission & subsequent neurobehavioral &
cognitive symptoms." (McCance, Huethers, Brashers, 2013).
Clinical Manifestations: Abrupt onset. confusion, inability to focus, delusions, hallucinations.
"Because of the dysfunction of the anterior cingulate gyrus, tha ability to focus, sustain, or shift
attention is seriously impaired or completely lost." (McCance, Huethers, & Brashers, 2013).
Tachycardia, diaphoresis, hyperthermia.
treatment / plan: CBC, CMP, CT brain, EKG, UA & drug screen, if findings are negative then
lumbar puncture may be indicated.
Education / prevention: Educate family & patient (if possible) of diagnosis & treatment plan.
Prevention depends on cause.
Differential diagnosis #3: Acute delirium- possible, but less likely.
Pathophysiology: "Delirium is an acute state of brain dysfunction associated with right middle
temporal gyrus or left temporo-occipital junction disruption." (McCance, Huethers, & Brashers,
2013).
Clinical Manifestations: Acute confusion, Inability to maintain focus, delusions, hallucinations,
unable to concentrate. Impaired decision making, ritualistic behavior.
treatment / plan: CBC, CMP, ETOH, UA, Urine drug screen, CT brain, EKG. If CT is negative,
then MRI of the brain.
This study source was downloaded by 100000902171055 from CourseHero.com on 11-27-2025 22:09:19 GMT -06:00
https://www.coursehero.com/file/52790504/NR-507-Week-7-Case-Study-Discussions-Part-1docx/
Week 7 – Part 1, 2 & 3
Threaded Discussions and Quiz
, NR 507 Week 7 Case Study Discussions
You are at the local mall & you see a patient who appears to be homeless by his physical
appearance & you witness the person “walk 50 feet to a table sit down, & after 5 seconds he
gets up & walks to a tree & urinates on it” He repeats this action 5 times apparently
oblivious to his surroundings. When the police come he ignores them as if they aren’t there.
Later, you go to work & sitting in exam room 3 is the same person! Now, he is your patient,
when you talk to him he has no recollection of his behavior by the mall.
Subjective: No chief complaint listed. Assuming that when approached by police at the mall, &
witnessing the patient ignore them, that the police brought him or called EMS for possible
psychiatric problem & / or medical clearance. Patient denies memory of his actions.
Objective: Witnessed patient's repetitive behavior & unawareness, no other objective findings
noted.
Assessment: Complete history & physical including family & social history.
Differential diagnosis #1: Alteration in awareness-
Pathophysiology: "Diseased superior colliculi have a disturbance in the move component of
selective attention, which manifests as a slowness in orienting attention. Primary
pathophysiologic mechanisms that operate in cognitive system disorders are: (1) direct
destruction because of direct ischemia & hypoxia or indirect destruction as a result of
compression & (2) the effects of toxins & chemicals or metabolic derangement. Disinhibition
resulting in over activity, such as seen in some drug withdrawal states, is a pathologic
mechanism that can produce detection deficits or a hypervigilant state." (McCance, Huethers, &
Brashers, 2013).
This study source was downloaded by 100000902171055 from CourseHero.com on 11-27-2025 22:09:19 GMT -06:00
https://www.coursehero.com/file/52790504/NR-507-Week-7-Case-Study-Discussions-Part-1docx/
, Clinical Manifestations: Selective attention deficits, domain specific declarative deficits,
working memory deficits.
treatment / plan: CBC, CMP, CT brain, Reversible treatment, rehabilitative measures.
Education / prevention: Educate patient & family on diagnosis, treatment plan. Prevention is
dependent on causative agents.
Differential diagnosis #2: Acute Confusional State
Pathophysiology: "Acute confusional states arise from disruption of a widely distributed neural
network involving the reticular activating system of the upper brainstem & its projections to the
thalamus, basal ganglion, & specific association areas of the cortex & limbic areas. Delirium is
an acute state of brain dysfunction associated with right middle temporal gyrus or left temporo-
occipital junction disruption.21 These areas receive extensive input from the limbic areas &
modulate motivational & affective aspects of attention. Several neurotransmitters are involved,
including increased levels of acetylcholine, dopamine, & serotonin, & increased or decreased
levels of gamma-aminobutyric acid. Inflammatory cytokines, including interleukins, interferon,
& tumor necrosis factor-alpha, may contribute to delirium by altering the blood-brain barrier
permeability & further affecting the neurotransmission & subsequent neurobehavioral &
cognitive symptoms." (McCance, Huethers, Brashers, 2013).
Clinical Manifestations: Abrupt onset. confusion, inability to focus, delusions, hallucinations.
"Because of the dysfunction of the anterior cingulate gyrus, tha ability to focus, sustain, or shift
attention is seriously impaired or completely lost." (McCance, Huethers, & Brashers, 2013).
Tachycardia, diaphoresis, hyperthermia.
treatment / plan: CBC, CMP, CT brain, EKG, UA & drug screen, if findings are negative then
lumbar puncture may be indicated.
Education / prevention: Educate family & patient (if possible) of diagnosis & treatment plan.
Prevention depends on cause.
Differential diagnosis #3: Acute delirium- possible, but less likely.
Pathophysiology: "Delirium is an acute state of brain dysfunction associated with right middle
temporal gyrus or left temporo-occipital junction disruption." (McCance, Huethers, & Brashers,
2013).
Clinical Manifestations: Acute confusion, Inability to maintain focus, delusions, hallucinations,
unable to concentrate. Impaired decision making, ritualistic behavior.
treatment / plan: CBC, CMP, ETOH, UA, Urine drug screen, CT brain, EKG. If CT is negative,
then MRI of the brain.
This study source was downloaded by 100000902171055 from CourseHero.com on 11-27-2025 22:09:19 GMT -06:00
https://www.coursehero.com/file/52790504/NR-507-Week-7-Case-Study-Discussions-Part-1docx/
