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Alzheimer's Disease and its Assessment: Nursing Case Study with NCP

Sunday, 11 May 2014

Alzheimer's disease is an acquired syndrome of decline in short- and long-term memory and other cognitive functions. It's progressive and disabling; no cure or definitive treatment exists. It accounts for 60% to 80% of all cases of dementia and isn't an inherent aspect of aging. Memory loss is associated with impairment in abstract thinking and judgment. Alzheimer's disease is diagnosed by clinical findings and confirmed by autopsy.

Alzheimer's disease

Pathophysiology
Neuropathological findings of Alzheimer's disease include extracellular deposition of amyloid-beta protein, intracellular neurofibrillary tangles, and loss of neurons. Amyloid-beta protein is thought to interfere with neuronal function by stimulating free radical production, which can result in neuronal cell death. Hyperphosphorylated neurofibrillary tangles deposit in neurons, leading to cell death. Neuronal cell death and synapse loss affect neurotransmitter pathways; deficient production of acetylcholine, serotonin, and norepinephrine occurs.

Complications
Injury secondary to violent behavior or wandering
Pneumonia and other infections
Malnutrition
Dehydration
Aspiration
Death
Assessment
Health perception and management
Confusion, disorientation, and memory loss attributed to another reason such as aging
Family reports of the patient's mental decline

Nutrition and metabolism
Anorexia
Omission of meals
Weight loss
Fatigue and malaise
Dysphagia (in later stages)

Elimination
Constipation
Urinary and fecal incontinence (in later stages)

Activity and exercise
Limits activity to familiar environments
Increasing inability to perform activities of daily living
Deterioration in personal hygiene and appearance
Increasing difficulty performing complex tasks
Demonstrates wandering behavior or loss of locomotion

Cognition and perception
Progressively impaired judgment
Progressively impaired ability to orient self in the environment
Loss of immediate, recent, and remote memory, including episodic (events) and semantic (knowledge) memory
Incongruent, inconsistent, often depressed affect
Progressively reduced conceptualization, attention, arousal, concentration, and abstract thinking
Progressively impaired expressive language and increased receptive aphasia
Repetitive actions or perseveration

Sleep and rest
Nocturnal restlessness with insomnia
Altered sleep‑wake cycle
Growing difficulty in awakening as the disease progresses

Self-perception and self-concept
Attempt to sustain an internal center of control, dignity, and self‑esteem
Sexuality and reproduction
Rejection of intimate contact

Roles and relationships
Altered family dynamics resulting from role reversals and increased patient dysfunction
Increased social withdrawal (isolationism)

Coping and stress management
Defense mechanisms, such as rationalization, denial, and projection
Apathy, depression, and helplessness
Primary emotional lability, characterized by irritability, anger, fear, and agitation
Symptoms of ego disintegration, including hallucinations, illusions, and suicidal ideation

Values and beliefs
Altered value system resulting from defective mental faculties
Physical Examination

General appearance and nutrition
Unkempt
Poor personal hygiene
Malnourished
Dehydrated

Mental status and behavior
Confusion
Disorientation
Labile affect
Irritability
Clinical depression

Integumentary
Poor skin turgor

Gastrointestinal
Fecal incontinence

Neurologic
Cognitive dysfunction
Memory loss
Language disintegration

Musculoskeletal
Decreased activity tolerance
Lack of coordination
Immobility
Limited range of motion

Renal and urinary
Urine retention
Urinary incontinence

Diagnostic studies
Postmortem brain biopsy is the only definitive diagnostic test, which rules out other differential diagnoses. Diagnosis is made on clinical assessment.
Nursing care plan
Nursing diagnosis
Nursing priorities

Chronic confusion related to degenerative loss of cerebral tissue
     Provide a safe, structured environment.
     Promote an optimum level of functioning.
     Establish effective communication patterns.

Imbalanced nutrition: Less than body requirements related to memory loss, difficulty swallowing, and inadequate food intake
     Stabilize and improve nutritional status.


Risk for injury related to wandering behavior or decline in judgment
     Prevent injury while maximizing independence.


Risk for constipation related to memory loss about toileting behavior, inadequate diet, or inadequate fluid intake
     Establish an effective elimination pattern.


Risk for caregiver role strain related to progressive needs of the Alzheimer's disease patient
     Provide support and assistance from community agencies.


Other potential nursing diagnoses: Bathing or hygiene self-care deficit: bathing/hygiene related to disease progression ■ Dressing/grooming self-care deficit related to disease progression ■ Toileting self-care deficit related to disease progression ■ Feeding self-care deficit related to disease progression ■ Anxiety related to situational crisis ■ Interrupted family processes related to disease ■ Ineffective health maintenance related to perceptual or cognitive impairment ■ Impaired memory related to the disease process ■ Grieving related to change in health status ■ Wandering related to disease progression




Chronic confusion related to degenerative loss of cerebral tissue
Expected outcome
The patient will remain free from injury, communicate needs as clearly as possible, and wear identification jewelry.
Suggested NOC Outcomes
Cognition; Cognitive orientation; Concentration; Decision-making; Distorted thought self-control; Identity; Information processing; Memory; Neurological status: Consciousness
Nursing interventions
Intervention type
Intervention
Rationale
Collaborative
Assess the patient's level of cognitive functioning using a functional rating scale for symptoms of dementia or a Mini–Mental Status Examination.
Prepare the patient for psychological testing.
Information obtained from the patient and his family provides a guide for planning care.
Psychological testing provides information necessary to structure a therapeutic regimen.
Independent
Assign the patient to a room close to the nursing station or with surveillance for frequent observation.
Close observation allows for improved patient safety.
Independent
Minimize hazards in the environment.
Decreasing possible hazards helps prevent possible injury.
Independent
Maintain consistency in nursing routines.

Consistency in routines provides structure in an unfamiliar environment and may help minimize confusion.
Independent
Promote self‑care within the scope of the patient's abilities; assist when necessary. Identify specific needs in the care plan.
Allowing the patient to provide self-care preserves self-esteem. Identifying needs in the care plan promotes consistency with appropriate care.
Independent
Establish and maintain a therapeutic relationship by communicating with the patient in a calm, reassuring, affirming, and nonthreatening manner.
Trust must be established to achieve any goal because of the patient's suspicions and increasing paranoia.

Independent
Give simple, specific directions for accomplishing tasks; use eye contact and unobtrusive guidance.
The effects of memory loss and a reduced attention span can be minimized with clear directions and appropriate guidance.
Independent
Orient the patient to reality frequently and repetitively.
Although repetitive reorientation may not reduce disorientation, it may reduce the patient's anxiety.
Independent
Administer and document medications as ordered. Evaluate their effect, and observe for adverse reactions.
Medication may improve the patient's status. Noting adverse reactions prompts appropriate adjustments to treatment.
Independent
Use aids to improve language skills, and use verbal repetition and pictures to improve recall.
Both methods may assist the patient with word recall.
Independent
Minimize communication barriers. Be aware that anxiety, cultural influences, spiritual beliefs, and language difficulties may contribute to paranoia and withdrawal.
Knowing and understanding the patient's cultural background and beliefs can enhance communication.
Independent
Encourage social interaction by including the patient in unit activities when possible, allowing maximum flexibility in visiting hours, and providing occupational therapy referrals.
Continued social interaction reinforces reality and contributes to a sense of self‑worth and identity.

Independent
Prevent excessive stimulation and promote a regular sleep‑wake pattern.

Moderate stimulation helps orient the patient; excessive stimulation and sleep deprivation contribute to confusion.
Independent
Be attentive. Keep your verbal and nonverbal responses to the patient consistent.
Consistent verbal and nonverbal responses reduce cognitive dissonance.
Independent
When talking with the patient, encourage reminiscences.

Remembering past events helps the patient maintain self‑identity. Distant memory may remain even when recent memory is impaired.

[Additional individualized interventions]

Suggested NIC Interventions
Anxiety reduction; Calming technique; Cognitive stimulation; Dementia management; Family involvement promotion; Mood management
Imbalanced nutrition: Less than body requirements related to memory loss, difficulty swallowing, and inadequate food intake
Expected outcome
The patient will attain or maintain optimal weight.
Suggested NOC Outcomes
Nutritional status: Food & fluid intake; Nutritional status: Nutrient intake; Weight control
Nursing interventions
Intervention type
Intervention
Rationale
Collaborative
Assess present nutritional status: Weigh the patient and record customary dietary intake on admission.
Assessing the patient's nutritional status provides necessary information for determining actual deficits; an appropriate dietary regimen may then be formulated.
Independent
Offer a balanced diet consisting of small meals at regular intervals and nutritious snacks between meals.


Provide finger foods when possible.

Regularly scheduled meals help maintain a structured environment. Small quantities may appeal to the patient and provide a sense of achievement when all the food is consumed.
Finger foods are easier to handle than food that must be eaten with a utensil.
Independent
Prepare the tray in advance—cut the meat, provide a spoon, open containers, and so forth—with appropriate portions of food arranged so that the patient may eat unassisted.

The patient may develop coordination difficulties, which impairs his ability to use utensils. Preparing food servings in advance decreases the patient's frustration and prevents the humiliation of being unable to provide self‑care.
Independent
Provide time and privacy for meals.
The patient who has difficulty chewing or swallowing will need more time to eat. Lack of coordination may result in socially unacceptable eating habits.
Independent
Monitor and record daily weight and intake, including the amount and type of food. Adjust the dietary plan accordingly.
Evaluating weight and intake provides guidelines for modifying the dietary plan.

Independent
Provide dietary information to the home caregiver.

The patient will probably continue to need assistance in menu selection, cooking, and eating after discharge. The person shopping, cooking, and offering meals to the patient may need instruction in the patient's specific dietary needs.

[Additional individualized interventions]

Suggested NIC Interventions
Diet staging; Fluid monitoring; Nutrition management; Nutritional monitoring; Weight gain assistance
Risk for injury related to wandering behavior or decline in judgment
Expected outcome
The patient will be appropriately dressed for the temperature, walk about only when attended, and avoid injury.
Suggested NOC Outcomes
Fall prevention behavior; Personal safety behavior; Risk control; Safe home environment
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Consider alarms or other audible signal to monitor patient activity.

An alarm or signal alerts the staff to patient activity and may minimize injury. If unattended, the patient may become lost, even in familiar surroundings.
Independent
Prepare an identity card, a bracelet, necklace, or a name tag for the patient. Include his name, address, phone number, medical problem, and other pertinent information.
Should the patient wander, identification information can help in the patient's prompt return.

Independent
Ensure that the patient is dressed appropriately for the temperature.


Provide shoes that fit well.

The patient may not make appropriate choices about dress and may have a reduced ability to identify or verbalize discomfort. Loose shoes may be lost or may contribute to injuries from falls.
Independent
Avoid using restraints.

Restraints increase the patient's agitation and paranoia and may contribute to injury.
Independent
Review the patient's home environment with the family. Recommend specific safety measures to prepare for home care.
An unprepared home environment may contribute to injuries.
Independent
Encourage a regular exercise program as tolerated.

Regular exercise decreases restlessness and agitation, promotes muscle tone, and contributes to a sense of well-being. Overactivity, however, may contribute to fatigue and confusion.

Watch for nonverbal cues to injury, such as grimacing, rubbing, panting, or protecting an injured area, and note repetitive use of words or seemingly inappropriate statements. Alert the family to cues observed.

The patient may be unable to identify or express discomfort but may reveal illness or injury through nonverbal cues.
Because aphasia may make expressions of discomfort convoluted, such words as cold or hurt, especially if repeated, may warrant investigation.

[Additional individualized interventions]

Suggested NIC Interventions
Environmental management; Fall prevention; Surveillance: Safety
Risk for constipation related to memory loss about toileting behavior, inadequate diet, or inadequate fluid intake
Expected outcome
The patient will demonstrate knowledge of bathroom location and will regularly eliminate soft, formed stools.
Suggested NOC Outcomes
Bowel elimination; Hydration; Symptom control
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Place the patient in a bed close to the bathroom. Identify the bathroom clearly—symbols or color codes may be helpful. Frequently remind the patient of its location.
A patient with Alzheimer's disease may forget the location of the bathroom.

Independent
Prompt the patient at regular intervals to use the toilet. With an incontinent patient, use standard precautions.

The patient may neglect toileting because of memory loss. Reminders, with assistance at regular intervals, promote a regular elimination pattern and help prevent accidents.
Independent
Encourage a therapeutic diet with ample fluid and fiber intake.
Proper diet promotes effective elimination. Ample fluids and fiber help prevent constipation.
Independent
Observe the patient for nonverbal clues that signal the need for elimination.
Nonverbal clues can alert the nurse or caregiver to toileting needs and help prevent accidents, especially if the patient is unable to verbalize the need to eliminate.
Independent
Administer and document use of elimination aids (stool softener, laxative, or cathartic) as ordered.
Evaluate their effect and observe for adverse effects.

Such aids may help promote regular elimination. Noting the effects of medication prompts appropriate actions if treatment isn't effective or causes adverse effects.
Independent
Monitor and document the frequency of elimination.

Noting the frequency of elimination helps identify a regular bowel pattern and minimizes problems.

[Additional individualized interventions]

Suggested NIC Interventions
Bowel management; Constipation/impaction management; Fluid management
Risk for caregiver role strain related to progressive needs of the Alzheimer's disease patient
Expected outcome
The caregiver will be involved in teaching and providing care, will arrange a plan for care and mutual support, and will identify community support resources.
Suggested NOC Outcomes
Caregiver emotional health; Caregiver lifestyle disruption; Role performance
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Involve the caregiver and available family members in all teaching. Assess family roles, resources, and coping behaviors.

Teaching the caregiver and family about the patient's needs promotes understanding of the patient's condition and helps them cope with the situation.
Independent
Offer support, understanding, and reassurance to the family. Support efforts to provide care for the patient in the home setting. Provide examples of caregiving schedules.
Encourage family members to give each other breaks and "holidays." Encourage the use of adult day-care programs.
Maintaining a stable home environment with familiar caregivers helps give the patient a sense of worth, reduces isolation, and may minimize disorientation.
Frequent breaks from caregiving help increase family cohesiveness and prevent burnout.
Collaborative
Involve a social worker or discharge planner in decisions regarding home care or nursing home placement.
If appropriate, encourage family members to express their feelings about the decision to place the patient in a nursing home.
The social worker or discharge planner may offer special expertise in answering questions about long‑term care.
Family members may feel guilt, relief, anguish, or other conflicting emotions and will need support if this decision becomes necessary.
Independent
Provide information about community resources, such as home care, financial and legal assistance, and an Alzheimer's support group. Encourage use of all available resources.
Community support may help lessen the family's burden and promote healthy adaptations to change. A social service referral may decrease inappropriate use of resources and help avert family crises.

[Additional individualized interventions]

Suggested NIC Interventions
Caregiver support; Counseling; Respite care; Role enhancement; Support group
Teaching checklist
Diagnosis and disease process and treatment plan
Minimization of environmental hazards and prevent injury
Recommendations for promoting self‑care and maintaining independence
Identification devices
Wandering prevention
Purpose, dosage, administration schedule, and adverse effects of prescribed medications
Techniques for maintaining or improving language skills
Recommendations for meeting nutrition and elimination needs
Available community resources
Date, time, and location of follow-up appointments

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