Category: Nursing

Assessing and Treating Clients with Dementia

The Alzheimer’s Association defines dementia as “a general term for a decline in mental ability severe enough to interfere with daily life” (Alzheimer’s Association, 2016). This term encompasses dozens of cognitive disorders of impaired memory formation, recall, and communication. The care and treatment of clients with dementia is dependent on multiple factors, including the stage of dementia, comorbidities, family support, and even the care setting. In your role, as the psychiatric mental health nurse practitioner, you must be prepared to not only treat clients with these various cognitive disorders, but also the multiple behavioral issues that often accompany them. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with dementia.

Examine Case Study: An Elderly Iranian Man w/ Alzheimer’s Disease

You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point there will be three decisions. I will choose one out of the three and give the outcome. At each decision point these are the thoughts to ponder:

Decision #1

Which decision did you select?

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

***Also include how ethical considerations might impact your treatment plan and communication with clients. ***

Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).

2. Write paper addressing all section listed based on the decision tree.

Case Study: An Elderly Iranian Man with Alzheimer’s Disease

BACKGROUND

Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.

According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”

Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.

SUBJECTIVE

During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so the PMHNP performs a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.

MENTAL STATUS EXAM

Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When the PMHNP asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

Combining Nurse Leader With Advocacy

Rate yourself using the results from the “Nurse Manager Skills Inventory”:

http://www.aone.org/resources/nurse-manager-skills-inventory.pdf

Write a reflection of 750-1,000 words in which you identify your strengths and weaknesses related to the four content areas below:

Personal and professional accountability

Career planning

Personal journey disciplines

Reflective practice reference behaviors/tenets

Discuss how you will use your current leadership skill set to advocate for change in your workplace.

Identify one personal goal for your leadership growth and discuss your implementation plan to achieve that goal.

While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success

High blood pressure

High blood pressure
 – according to American Heart Association (AHA) HTN is when force of the blood flowing through blood vessels is constantly too high (AHA, 2017).

Interventions
: part of a heart education would be ways to control blood pressure (measuring it every day, diet, follow up appointments with cardiologist). Smoking cessation program (support program will be needed since patient is not willing to quit)

Coronary artery disease

Coronary artery disease
 – with certain risk factors overtime blood flow in vessels becomes restricted because of plaque buildup. Compromised blood flow depletes heart of oxygen and nutrients leading to weakening of the heart muscle and congestive heart failure. Heart is not able to pump efficiently enough to meet body’s needs. Body starts to retain fluid and that is called “congestion” (Mayo Clinic, 2017).

Interventions
: getting heart educator to talk to the patient, nutrition consult. Making sure patient understands medications purpose, schedule and taking them as prescribed. Assessing patient’s home situation to make sure appropriate living conditions to be able to follow diet, medication plan and dr’s appointments.

IV morphine sulphate

IV morphine sulphate is an opiod. Usually indicator for its use is a pain. However it works for brain respiratory center, lowering breathing rate and anxiety.

medical/nursing interventions to prevent the development of heart failure

Obesity Intervention – 
Establish short and long term goals, encourage calorie intake appropriate for body type and lifestyle, encourage Mrs. J to keep a daily log of food and liquid consumption. Encourage Mrs. J to be more aware of nutritional habits that may contribute to weight gain. Encourage Mrs. J to exercise and encourage consultation of a dietician for further assessment and recommendations regarding a weight loss program. Educate Mrs. J of the importance of routine follow-up MD visits.

High Blood Pressure – 
Mrs. J has been smoking two packs of cigarettes daily for the last forty years. Smoking cause’s blood pressure to rise but the chemicals in the tobacco causes damage to the lining of the artery walls causing arteries to narrow, increasing the blood pressure. Educating the patient with the outcome of smoking is beneficial. Mrs. J needs to be educated on the importance of taking her blood pressure on daily and keeping a log of the blood pressure reading. Mrs. J should be placed on a low sodium cardiac diet. Educating Mrs. J on the importance of taking her medication on a daily basis as prescribed to prevent organ damage. Informing Mrs. J that lifestyle adjustment must be made to reduce the risk of cardiovascular morbidity. This is not a short term goal and it will take time for patients to get use to the lifestyle change and nursing follow is important for the patient to feel supported and follow the program.

Atrial Fibrillation – 
Atrial fibrillation is the loss of synchrony between the atria and ventricles. The goal is to maintain adequate cardiac output and tissue perfusion to make sure Mrs. J does not develop a thromboembolism. Monitoring the heart rate is very important and making sure that the systolic rate does not go below 90mmHg. Mrs. J should be educated on reporting any chest discomfort in which oxygen therapy would be beneficial. Continuous cardiac monitoring is imperative. Also making sure Mrs. J receives education on medications such as Amiodarone or Digoxin to control the atrial fibrillation. Educate Mrs. J how to obtain her own pulse and recognize symptoms of toxicity.

Coronary Artery Disease – 
is the accumulation of plaque buildup on the coronary arteries which leads to blockage. The heart is deprived of oxygen due to the blockage and is unable to pump efficiently. Very important to access patient level of consciousness, evaluate for chest pain, assess heart rate, blood pressure, peripheral pulses, and evaluate skin color and temperature. Provide oxygen in conjunction with medication therapy. Monitor fluid volume to prevent overloading the heart and lungs Reduce anxiety by providing Mrs. J to share her fears or concerns. Provide a quiet environment and uninterrupted sleep.

Metoprolol

Metoprolol is a beta blocker. Beta blockers prevent norepinephrine (adrenalin) from acting on beta receptors in blood vessels and in the heart. This causes blood vessels to relax. By relaxing the vessels, beta blockers help to lower blood pressure and reduce chest pain. Metoprolol tends to lower heart rate and is used for arrhythmias. Additionally, blood pressure medications will help control the blood pressure, reduce the cardiac workload and increase the supply of blood and oxygen to the heart

Cardiovascular conditions that may lead to heart failure

Obesity – 
Mrs. J is overweight (210.5 lb). Obesity can cause congestive heart failure. Left Ventricular hypertrophy is very common in patients with obesity.

High Blood Pressure – 
Mrs. J has a history of high blood pressure. The history of years of high blood pressure probably caused damage to the artery walls. The constant pushing on the walls of the arteries probably weakened her heart.

Atrial Fibrillation
 – Mrs. J is currently having atrial fibrillation. This means that the heart is not pumping enough blood to meet the needs of the body. This can lead to heart failure because the heart is beating so fast and working so hard that the heart doesn’t fill-up properly to pump blood to the body. The blood then can back up in the pulmonary veins which cause fluid buildup which Mrs. J is currently experiencing. Mrs. J is also has fatigue and dyspnea due to lack of rich oxygenated blood that is not being delivered to her body and brain (American Heart Association, 2015).

Coronary Artery Disease –
 Coronary artery disease is the most common form of heart disease and heart failure. It is the accumulation of fatty deposits buildup that causes reduction in blood flow, weakening the heart, and causing permanent damage to the heart.

Vasotec
 – is angiotensin converting enzyme (ACE) inhibitor class of medication. By blocking this enzyme it lets vessels to relax and pump more blood, more efficiently into the body

Nursing Interventions and Medication Rationale 

What nursing interventions are appropriate for Mrs. J. at the time of her admission?

Mrs.  J. is being admitted to the ICU due to acute decompensated heart failure. The subjective and objective data obtained is the following: Mrs. J is overweight based on her height and weight (5 feet 9 inches and weighs 210.5 pounds). For three days she has been experiencing a low grade fever (99.68), pharyngitis, and malaise. She denies pain but feels that she cannot breathe due to dyspnea. She claims that her heart is running away which indicates tachycardia (HR 118 and irregular). Her heart rate is working harder to compensate for the low blood pressure of 90/58. Her peripheral pulses are +1, demonstrating jugular distention, and ventricular rate of 132 with atrial fibrillation. She has crackles at auscultation, decreased breath sounds on right lower lobe, coughing frothy blood-tinged sputum, with and a very low oxygen saturation level of 82%. This patient is having left sided heart failure based on the subjective and objective data obtained.

Intervention: 
Place patient on continuous oxygen 2-4 LPM via n/c.

Rationale:
 To alleviate dyspnea symptoms and allow patient not to work as hard breathing

Intervention: 
Establish guidelines and goals of daily activity.

Rationale:
 Patient will most likely be more willing to cooperate if she is included in the goals being set.

Intervention: 
 Assess patient’s mentation regularly.

Rationale:
 This is to determine if the patient is becoming more severe. Anxiety and confusion are late signs when a patient is having decreased cardiac output.

Intervention:
 Keep patient semi to high-fowlers position.

Rationale:
 This will help alleviate some of the shortness of breath.

Intervention:
 Asses heart rate and blood pressure frequently.

Rationale:
 Sinus tachycardia and increased arterial blood pressure are in the early stages and the blood pressure decreases as the condition worsens.

Intervention: 
Assess peripheral pulses frequently.

Rationale: 
weak pulses are indicators of low cardiac output.

Intervention: 
Assess skin color and temperature.

Rationale:
 Cold and clammy skin is an indicator of low cardiac output and desaturation.

Intervention:
 Assess fluid balance and weight gain.

Rationale:
 A compromised regulatory system can result in sodium and fluid retention.

Intervention:
 Continuous assessment of lung sounds.

Rationale:
  Crackles are indicative of fluid accumulation and secondary to left ventricular failure.

Intervention: 
Asses urine input and output.

Rationale: 
Decreased urine output is an indicator of lack of renal perfusion.

Intervention:
 Assess for chest pain.

Rationale:
 Indicates lack of oxygen supply. (Ackley & Ladwig, 2011).

 

What is the rationale for the administration of each of the following medications?

IV furosemide (Lasix) – Furosemide is a loop diuretic and used to decrease fluid volume (pre-load). Patient is demonstrating. It is also used as an adjunct therapy. Mrs. J has crackles and coughing frothy blood-tinged sputum that is indicative of pulmonary edema. Nurse must check patient’s urine input and output and electrolytes due to possible dehydration, depletion of potassium, and metabolic alkalosis.

Enalapril (Vasotec) – is an angiotensin-converting enzyme (ACE) inhibitor. Enalapril is used for congestive heart failure which is a weakness of the heart that leads to buildup of fluid in the lungs and the surrounding tissues. Patient has crackles, and she is coughing frothy blood-tinged sputum (McKenry, 2006).

Metoprolol (Lopressor) – Lopressor is a beta blocker and the standard use for heart failure. Beta blockers are used in patients with heart failure because it helps improve the hearts ability to relax, decrease the production of harmful substances produced by the body in response to heart failure, and slows down the heart rate. Mrs. J has a ventricular rate of 132 and atrial fibrillation (WebMD, 2015).

IV morphine sulphate (Morphine)- Morphine is an opioid and it is used to alleviate Mrs. J’s dyspnea. Morphine lowers the breathing rate in the brains respiratory center. This will help Mrs. J’s heart not work so hard. Morphine does this by widening the blood vessels in the extremities which will allow the heart not to work hard and use less oxygen. It is also great use for anxiety. Mrs. J is experiencing anxiety due to dyspnea and fear of complications (McKenry, 2006).