Monday, January 4, 2010

Nursing care plans for Dementia, Dementia is a chronic disturbance involving multiple cognitive deficits, including memory impairment. Dementia is characterized by chronicity and deterioration of selective mental functions. Onset is insidious over months to years in most cases. Dementia is usually progressive, more common in the elderly, and rarely reversible even if underlying disease can be corrected. Dementia can be classified as cortical or subcortical. 
Type of Dementia 
There are three types of cortical dementia: 

  • Primary degenerative dementia (eg, Alzheimer dementia), accounting for about 50–60% of cases. 
  • atherosclerotic (multi-infarct) dementia, 15–20% of cases (this figure is probably low because of the tendency to overuse the diagnosis of Alzheimer dementia) 
  • Mixtures of the first two types or dementia due to miscellaneous causes, 15–20% of cases . Examples of primary degenerative dementia are Alzheimer dementia (most common) and Pick, Creutzfeldt-Jakob, and Huntington dementias (less common). 

In all types, loss of impulse control (sexual and language) is common. The tenuous level of functioning makes the individual most susceptible to minor physical and psychological stresses. The course depends on the underlying cause, and the general trend is steady deterioration. 
Pseudodementia is a term applied to depressed patients who appear to be demented. These patients are often identifiable by their tendency to complain about memory problems vociferously rather than try to cover them up. They usually say they can’t complete cognitive tasks but with encouragement can often do so. They can be considered to have depression-induced reversible dementia that remits when the depression resolves. 

Causes of dementia 
CNS pathology: head trauma, hypertensive cerebral changes, seizures, tumors 
Endocrinopathies: thyroidism, parathyroidism 
Hypothermia or hyperthermia 
Substance intoxication or abstinence and withdrawal states 
Exposure to certain metals, toxins, or drugs 
Metabolic: diabetic acidosis, hypoglycemia, acid-base imbalances 
Hepatic encephalopathy 
Thiamine deficiency 
Postoperative states 
Psychosocial stressors: relocation stress, sensory deprivation or overload, sleep deprivation, immobilization. 

Primary Dementia : 

  • Primary dementias are degenerative disorders that are progressive, irreversible, and not due to any other condition. Specific disorders are dementia of the Alzheimer’s type (DAT) and vascular dementia (formerly multi-infarct dementia). DAT demonstrates progression of symptoms from the initial stage, which is characterized by mild cognitive deficits in the area of short-term memory and accomplishment of goal-directed activity, to the final stage in which profound impairment occurs in the areas of cognition and self-care abilities. Research is ongoing; however, DAT is believed to have multiple causative factors. 
  • Genetic factors: Familial Alzheimer’s disease is associated with abnormal genes on chromosomes 1, 14, and 21. In particular, with genes located on these chromosomes (1 and 14) that encode for amyloid precursor protein which leads to accumulation of the amyloid beta-peptide in plaques. A specific cholesterol-bearing protein, apolipoprotein E4 (Apo E4), is found on chromosome 19 twice as often in people with DAT as in the general population. 
  • Biochemical and brain structural factors: The neurotransmitter acetylcholine has been implicated in terms of relative deficit and/or receptor abnormalities as related to Alzheimer’s disease. Autopsy findings reveal presence of brain changes, that is, the presence of amyloid plaques and neurofibrillary tangles associated with nerve cell destruction. Additional areas of investigation include: 
  • Slow viral infection. 
  • Autoimmune processes. 
  • Head trauma. 

Secondary Dementia: 
Occur as a result of another pathologic process. 

  • Infection-related dementias Acquired immunodeficiency syndrome Chronic meningitis Creutzfeldt-Jakob disease Progressive multifocal leukoencephalopathy Postencephalitic dementia syndrome Syphilis Subacute sclerosing panencephalitis Tuberculosis 
  • Subcortical degenerative disorders Huntington’s disease Parkinson’s disease Wilson’s disease Thalamic dementia 
  • Hydrocephalic dementias 
  • Vascular dementias 
  • Traumatic conditions, such as posttraumatic encephalopathy and subdural hematoma 
  • Neoplastic dementias Glioma Meningioma Meningeal carcinomatosis Metastatic deposits 
  • Inflammatory conditions, such as sarcoidosis, systemic lupus erythematosus, and temporal arteritis 
  • Toxic conditions, such as alcohol-related syndrome and iatrogenic dementias (anticonvulsant, anticholinergic, antihypertensive, psychotropic drugs) 
  • Metabolic disorders Anemias Deficiency states (minerals and vitamins) Cardiac or pulmonary failure Hepatic encephalopathy Porphyria (deficiency in enzymes involved in heme synthesis) Uremia 

Clinical Manifestations for dementia 
Not all of these features will be present in every person, nor will every person go through every stage and phase of dementia Slow, insidious onset, Impaired long- and short-term memory, Deterioration of cognitive abilities judgment, abstract thinking, Often irreversible if untreated, Personality changes, No or slow EEG changes. 
Early dementia 
Appear more apathetic, with less sparkle. Lose interest in hobbies or activities. Be unwilling to try new things. Be unable to adapt to change. Show poor judgement and make poor decisions. Be slower to grasp complex ideas and take longer with routine jobs. Blame others for ‘stealing’ lost items. Become more self-centred and less concerned with others and their feelings. Become more forgetful of details of recent events. Be more likely to repeat themselves or lose the thread of their conversation. Be more irritable or upset if they fail at something. Have difficulty handling money. 

Moderate dementia 
Be very forgetful of recent events. Memory for the distant past seems better, but some details may be forgotten or confused. Be confused regarding time and place. Become lost if away from familiar surroundings. Forget names of family or friends, or confuse one family member with another. Forget saucepans and kettles on the stove. May leave gas unlit. Wander around streets, perhaps at night, sometimes becoming lost. Behave inappropriately – for example, going outdoors in their nightwear. See or hear things that are not there. Become very repetitive. Be neglectful of hygiene or eating. Become angry, upset or distressed through frustration. 

Severe dementia 
Be unable to remember – for even a few minutes – that they have had, for example, a meal. Lose their ability to understand or use speech. Be incontinent. Show no recognition of friends and family. Need help with eating, washing, bathing, using the toilet or dressing. Fail to recognise everyday objects. Be disturbed at night. Be restless, perhaps looking for a long dead relative. Be aggressive, especially when feeling threatened or closed in. Have difficulty walking, eventually perhaps becoming confined to a wheelchair. Have uncontrolled movements. 

Dementia Treatment 

  • Treatment is generally community focused; the goal of treatment is to maintain the quality of life as long as possible despite the progressive nature of the disease. Effective treatment is based on: Diagnosis of primary illness and concurrent psychiatric disorders Assessment of auditory and visual impairment Measurement of the degree, nature, and progression of cognitive deficits Assessment of functional capacity and ability for self-care Family and social system assessment 
  • Environmental strategies in order to assist in maintaining the safety and functional abilities of the patient as long as possible. 
  • Pharmacologic therapy used for the person with DAT is directed toward the use of anticholinesterase drugs to slow the progression of the disorder by increasing the relative amount of acetylcholine. Available drugs include donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon) and tacrine (Cognex). An NMDA-receptor antagonist memantine (Namenda) may be provided in an attempt to improve cognition. Other drugs may be used for behavioral control and symptom reduction. Agitation management: neuroleptic drugs Psychosis: neuroleptic drugs Depression: antidepressants, ECT 
  • Hypertension management in vascular dementia is important in reducing the severity of symptoms. 
  • Family education is a treatment strategy because statistics indicate that family caregivers provide care for patients with DAT in 7 out of 10 cases. The family and the treatment team collaborate in the delivery of care. 

Complications for dementia 
Without accurate diagnosis and treatment, secondary dementias may become permanent. 
Falls with serious orthopedic or cerebral injuries. 
Self-inflicted injuries. 
Aggression or violence toward self, others, or property. 
Wandering events, in which the person can get lost and potentially suffer exposure, hypothermia, injury, and even death. 
Serious depression is demonstrated in caregivers who receive inadequate support. 
Caregiver stress and burden may result in patient neglect or abuse. 

Nursing Process Nursing Care Plans For Dementia 
Nursing Assessment Nursing Care Plans For Dementia 
Assess the onset and characteristics of symptoms (determine type and stage of disorder). Establish cognitive status using standard measurement tools. Determine self-care abilities. Assess threats to physical safety (eg, wandering, poor reality testing). Assess affect and emotional responsiveness. Assess ability and level of support available to caregivers. 

Nursing Diagnosis Nursing Care Plans for Dementia 

  • Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding 
  • Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs 
  • Risk for Injury related to cognitive impairment and wandering behavior 
  • Impaired Social Interaction related to cognitive impairment 
  • Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places Interventions and Evaluation 

Nursing Care Plans For Dementia

Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding

Demonstrate congruent verbal and nonverbal communication.
·      Speak slowly and use short, simple words and phrases.
·      Consistently identify yourself, and address the person by name at each meeting.
·      Focus on one piece of information at a time. Review what has been discussed with patient.
·      If patient has vision or hearing disturbances, have him wear prescription eyeglasses and/or a hearing device.
·      Keep environment well lit.
·      Use clocks, calendars, and familiar personal effects in the patient's view.
·      If patient becomes verbally aggressive, identify and acknowledge feelings.
·      If patient becomes aggressive, shift the topic to a safer, more familiar one.
·      If patient becomes delusional, acknowledge feelings and reinforce reality. Do not attempt to challenge the content of the delusion.

·        Demonstrates decreased anxiety and increased feelings of security in supportive environment

Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs

Independence in Self-Care
·      Assess and monitor patient's ability to perform ADLs.
·      Encourage decision making regarding ADLs as much as possible.
·      Label clothes with patient's name, address, and telephone number.
·      Use clothing with elastic and Velcro for fastenings rather than buttons or zippers, which may be too difficult for patient to manipulate.
·      Monitor food and fluid intake.
·      Weigh patient weekly.
·      Provide food that patient can eat while moving.
·      Sit with patient during meals and assist by cueing.
·      Initiate a bowel and bladder program early in the disease process to maintain continence and prevent constipation or urine retention

Maintains maximum degree of orientation and self-care within level of ability
Risk for Injury related to cognitive impairment and wandering behavior

Safety appears
·      Discuss restriction of driving when recommended.
·      Assess patient's home for safety: remove throw rugs, label rooms, and keep the house well lit.
·      Assess community for safety.
·      Alert neighbors about the patient's wandering behavior.
·      Alert police and have current pictures taken.
·      Provide patient with a MedicAlert bracelet.
·      Install complex safety locks on doors to outside or basement.
·      Install safety bars in bathroom.
·      Closely observe patient while he is smoking.
·      Encourage physical activity during the daytime.
·      Give patient a card with simple instructions (address and phone number) should the patient get lost.
·      Use night-lights.
·      Install alarm and sensor devices on doors.

Safety precautions and close surveillance maintained; no injury

Impaired Social Interaction related to cognitive impairment
Socialization increase
·      Provide magazines with pictures as reading and language abilities diminish.
·      Encourage participation in simple, familiar group activities, such as singing, reminiscing, doing puzzles, and painting.
·      Encourage participation in simple activities that promote the exercise of large muscle groups.

Attends group activities; sings, exercises with group
Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places

Risk for violence is not appears
·      Respond calmly and do not raise your voice.
·      Remove objects that might be used to harm self or others.
·      Identify stressors that increase agitation.
·      Distract patient when an upsetting situation develops.

Decreased occurrence of acting-out behaviors

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