MedSurg II-Alz

cdunbar4's version from 2017-03-08 23:45

Dementia Manis TBL 60-3

Question Answer
Early/mild (memory)Forgetfulness beyond what is seen in a normal person
Early (learning)short-term memory impairment, especially for new learning
Early (deciphering)difficulty recognizing what numbers mean
Early (mood)loss of initiative and interest
Early (judgment)decreased
Early (location recognition)geographic disorientation
Middle/moderate-familyimpaired ability to recognize family/friends
Middle/Moderate-disorientationwandering, getting lost, confusion
Middle/Moderate-understandingimpaired comprehension
Middle/Moderate-learningforgets how to do simple tasks
Middle/Moderate-brain/speechreceptive & excessive aphasia; apraxia
Middle/Moderate-sleep, visualsinsomnia; delusions; hallucinations; illusions
Middle/Moderatebehavioral problems
Late (severe)- memorylittle, unable to process new info.
Late (severe)- comprehensioncan't understand words
Late (severe)-ADLsdifficulty eating & swallowing
Late (severe)-speechrepetitious words or sounds
Late (severe)- ADLscan't perform ADL's; immobility
Late (severe)-GUincontinence

Normal forgetfulness vs. memory loss TBL 60-5

Question Answer
normal misplacing sometimes misplaces items; occasionally forgets to run an errand
normal memory lossmomentarily forget's acquaintance's name; may forget event from a distant past
normal forgetfulnessoccasionally has to search for a word; occasionally forgets to run an errand
normal reaction to mistakeswhen driving, may forget where to turn, but quickly orients self. Jokes about memory loss.
Mild cognitive impairment memory loss-misplacementfrequently misplaces items and freq. forgets names, slow to recall them.
Mild cognitive impairment memory loss-learninghas increasing difficulty finding words; forgets recent events or newly learned info.
Mild cognitive impairment memory loss-daily activitiesforgets important events & appts.; gets lost temporarily; can't follow a map
Mild cognitive impairment memory loss- concernsworries about memory loss; family/friends notice relapses
Alzheimer's memory loss- itemforgets what an item is used for or puts it in inappropriate place
Alzheimer's memory loss-isolationMay not remember knowing a person; starts to lose language skills & may withdraw from social interaction
Alzheimer's memory loss-awarenessloses sense of time; does not know what day it is; may have little or no awareness of cognitive problems
Alzheimer's memory loss- orientationgets easily disoriented or lost in familiar places, sometimes for hours; has seriously impaired recent memory & difficulty learning & remembering new info.

Collaborative care

Question Answer
Aims of collaborative mgmtimprove or condition decline in cognition; control undesirable behavioral manis; support for caregiver
Drug therapydrugs can slow rate of decline of disease and worsening of symptoms, but there is no cure.
Cholinesterase inhibitors (3 generic names)donzepil, rivastigmine and galantamine
MOA Cholinesterase inhibitors: donzepil, rivastigmine & galantamineblocks enzyme that breaks down acetylcholine in synaptic cleft (↑'s amount of Ach in transmission)
Drug: memantine MOAprotect's the brain's nerve cells against the excessive glutamate that is released by cells damaged by AD.
What other aspect gets treated with medications other than increasing the availability of Acytelcholine?Depression, if treated may improve cognitive ability.
Depression of AD treatment drug classSSRIs
fluvoxamine; sertraline; citalopram are all in which drug class?SSRI
tranzadoneantidepressant used to help with problems r/t sleep
Antipsychotics uses for ADmanagement of behavioral problems (agitation, aggression) that occurs with AD patients. FDA warns that they are not indicated for tx of dementia-related psychosis.
drug used to help with sleepzolpidem
Gingko Bilbobasome people try to use it to improve cognition, but there is no evidence to prove this. Nurse's should watch for s/s bleeding and could alter blood glucose.

Nursing mgmt

Question Answer
Nursing Assessment: Important Health Info.head trauma, stroke, exposure to metals; prveious CNS infx; family hx of dementia. Meds: use of any drug to decrease sx
Nursing Assessment: functional health patternshealth perception-mgmt; nutritional-metabolic; elimination; activity-exercise; sleep-rest; cognitive-perceptual
Nursing DiagnosisImpaired memory; self-care deficit; risk for injury; wandering
Planning goalsmaintain functional ability for as long as possible; safe env't with a minimum of injuries; meet their personal care needs; maintain dignity.
Goals for care providerreduce caregiver stress; maintain personal, emotional & physical health; cope with the long-term effects of caregiving
Implementation: health promotionTBI is a risk factor for developing AD, so promote safety in activities. Recognize & treat depression early. Warn patients of early s/s.
Implementation: acute interventionDepression, denial, anxiety, fear & isolation is not unusual for patient to get, especially early on. Important job of nurse to assess for this. May need drug therapy/counseling. Inform family that there is not tx for AD, ongoing monitoring for both client & family is required.
Ambulatory & home care nursing care required depends on the stages of the disease, which varies. Depression is at early stage, inform that the progression is variable & care depends on which area of the brain is affected.
Behavioral problems (affect 90% of patients with AD)repetitiveness; delusions; illusions; hallucinations; agitation; aggression; altered sleep; wandering & resisting care.
Behavior problems are a patient's way of dealing with a precipitating factor.Could be in pain, frustrated, temp. extreme, anxiety. Careful intervention according to physical changes.
Intervention for a client who continues to pull out tubes, or dresssings.Cover with stretch tube gauze or remove them from their visual field.
sundowningpatient becomes more confused & agitated in the late afternoon or evening. Etiology unknown
Nursing interventions sundowningquiet, calm environment; maximize exposure to daylight; evaluate meds that cause sleep issues; limit naps & caffeine; consult with health care provider regarding drug therapy
Safety plan for patient is required as patient is at riskWandering is major concern; Medic Alert bracelet; decrease any stressful stimuli or triggers that may cause them to want to remove themselves from an area
Pain management, why is it hard to decipher pain with these patients?They have a difficult time expressing physical complaints, you must relay on cue's in behavior such as agitation or withdrawal.
Eating & swallowing difficultiesundernutrition d/t inability to feed themselves in later stages of AD.
Types of foods to give to help with difficulty swallowingpureed foods, thickened liquids & nutritional supplements. Patients may need reminders to chew their food, also good to decrease distractions during mealtime. Easy grip utensils & finger foods.
If oral feeding is no longer possible, what other routes may be used?NG for short periods. PEG (although can become dislodged, weigh positive/negative outcomes)
Oral careinspect mouth regularly; help with oral care to those who cannot perform self-care
Skin carenote any rashes, areas of redness & skin breakdown (malnutrition can put pt at higher risk)
urinary & fecal incontinence during middle & late stagesUse behavioral retraining of bladder and bowl function (scheduled toileting)
Constipationd/t immobility and decreased fluid intake. Increase fiber & stool softeners
Caregiver supportAssess stressors, identify coping strategies; support groups

Dos and Don'ts

Question Answer
DOtreat them with respect & dignity. Treat them like adults; provide reassurance
DO use gentle touch & direct eye contact; give directions using gestures or pictures; simplifiy tasks
Doanticipate challenging behaviors; focus on one thing at a time; avoid questions or topics that require extensive thought, memory or words
DOuse distraction, change subject, redirect to another activity
DO NOTcriticize, correct, argue
DO NOTrush or hurry patient
DO NOTtalk about them as if they were not there
DO NOTtake challenging behaviors personally (the behaviors are d/t the disease)
DO NOT use terms such as "honey" or "sweetie"


Question Answer
Nurseassess pt. memory & level of function
Nurseteach pt. & caregivers memory enhancement aids
Nursemonitor for physiologic probs. associated with AD: pain, swallowing, UTI, pneumonia, skin brkdwn & constipation
Nurseassess nutritional intake & fluid intake, develop plan to ensure adequate intake
Nurseevaluate pt. risk & safety factors
Nursedetermine precipitating factors for behavioral changes & develop strategies to address diff. behavior
Nursemake referrals for community services such as adult day care & respite care
LPN/LVNmonitor for behavioral changes that may indicate physiologic problems
LPN/LVNcheck pt. env't for potential safety hazards
LPN/LVNadminister enteral feedings to pt.s who can't swallow
LPN/LVNadminister ordered drug therapy
NAPassist pt. to toilet, commode or bedpan
NAPprovide personal hygiene, skin care, oral care
NAPhelp pt.s with eating
NAPassist patients with daily activities
NAPuse bed alarms & surveillance to decrease falls

Assessing for delirium

Question Answer
Feature 1: acute onset & fluctuating coursePositive response to ?s: Is there evidence of acute changes in mental status from pt. baseline? Did abnormal behavior fluctuate during the day?
Feature 2: inattentionpositive response to ?: Did pt. have diff. focusing attention, such as keeping track of what is being said?
Feature 3: Disorganized thinkingAnsers yes to: Was pt's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching of subjects?
Feature 4: altered LOCIs shown by an answer other than "alert" to the following ?: Overall, how would you rate this pt's LOC? Alert, vigilant, lethargic, stupor or coma?
CAM ?s are usually obtained from a family member or a nurse, what does CAM stand for?Confusion assessment method: diagnostic algorithm for delirium
How is delirium diagnosed with the CAM method?presence of features of 1 and 2 and either 3 or 4

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