Case Study Student-Dementia- Unfolding Reasoning PDF

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Dementia UNFOLDING Reasoning

William “Butch” Welka, 72 years old

Primary Concept Cognition Interrelated Concepts (In order of emphasis) • • • • • • •

Pain Mood and Affect Psychosis Clinical Judgment Patient Education Communication Collaboration

NCLEX Client Need Categories       •

Percentage of Items from Each Category/Subcategory

Covered in Case Study

Safe and Effective Care Environment Management of Care

17-23%

Safety and Infection Control Health Promotion and Maintenance

9-15% 6-12%

Psychosocial Integrity

6-12%

✓ ✓

Physiological Integrity Basic Care and Comfort

6-12%

✓

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✓

2 •

Pharmacological and Parenteral Therapies

12-18%

•

Reduction of Risk Potential

9-15%

•

Physiological Adaptation

11-17%

✓ ✓ ✓

History of Present Problem: William “Butch” Welka is a 72-year-old male with a history of heart failure, COPD, hypertension, diabetes type II and dementia who has been hospitalized for exacerbation of heart failure three times the past six months. He is now a resident of Pineville Estates, a local long-term care facility the past four months because his dementia progressed and his wife Rita was unable to care for him. When Rita visited Butch this morning, she reports to the nurse that he is more confused and is concerned because Butch is easily angered. Butch insists that he sees his friend Roger, who served with him in the Navy, is in the room, but he died ten years ago. Rita approaches the nursing station with tears in her eyes and states, “What is happening to my husband? This just isn’t like Butch to act like this! Please do something to help him!”

Personal/Social History: Butch has been married to Rita for 51 years. They have three adult children who visit him weekly. Rita comes to visit Butch every day after work. Butch was a salesman for 35 years before he retired seven years ago. Butch believes he is at Pineville Estates for rehab, but his family is concerned that it is no longer safe at home if he were alone. Rita was just awarded guardianship due to his declining mental status.

1.

What data from the histories are RELEVANT and have clinical significance to the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem:  History of heart failure, COPD, HTN, DM II and dementia  Has been hospitalized for exacerbation of heart failure three times the past six months.  Angry, confused, and hallucinating

Clinical Significance:  All these conditions affect the vascular components of the body and increase the risk of stroke. COPD and HF can also cause him to not receive enough oxygen and blood flow to the brain which could cause the dementia to advance at a quicker rate.  End stages of HF S&S include confusion and impaired thinking. COPD could be the cause of the HF exacerbations.  S&S of end stage heart failure and is also a S&S of vascular dementia.

RELEVANT Data from Social History:  Married for 51 years  3 adult children that visit regularly  Wife visits daily  Thinks he in rehab  Wife awarded guardianship

Clinical Significance:  Has support at home  Has family that visit routinely, routine is important for dementia patients  Has continued support at the hospital  Could be upset when he finds out why he is in the hospital  Wife is the person in charge of decisions related to his care

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2. • • • • •

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: 1. Fluticasone/salmeterol 1. COPD Long Acting 1. Will demonstrate a COPD Hypertension Beta-2 decreased inflammation diskus 1 puff every 12 agonist/Corticosteroid and histamine response Heart failure hours combination inhaler; in lung tissues AEB Diabetes type II 2. Albuterol MDI 2 puffs Dementia anti-asthmatic; antiincreasing ability to every 4 hours PRN inflammatory exchange gases. shortness of breath 2. COPD Autonomic 2. Will decrease acute 3. Lisinopril 10 mg PO nervous system agent; exacerbations of COPD. daily 3. Will decrease Beta-adrenergic 4. Atenolol 25 mg PO BID hypertension AEB agonist 5. Furosemide 20 mg PO decreased BP (sympathomimetic); daily 4. Will manage HTN in Bronchodilator 6. Hydrochlorothiazide 25 combination with other (respiratory smooth mg 1tab PO daily anti-hypertensives AEB muscle relaxant ) 7. Metformin 1000 mg PO stable BP readings 3.HTN Long-acting BID 5. To decrease edema angiotensin converting 8. Glyburide 10 mg PO caused by HF, decrease enzyme inhibitor; BID HTN AEB decreased antihypertensive 9. Memantine 5 mg PO 4. HTN & HF (off label swelling and stable BP daily levels use) Cardio Selective6. Will demonstrate Beta blocker; reduced reabsorption of antihypertensive water and decreased BP 5. HF Electrolytic and and water retention water balance agent; which can cause edema loop diuretic; AEB less edema antihypertensive. 7. Will demonstrate 6. HF Electrolytic and reduced BS reading water balance agent AEB decreased levels of thiazide; diuretic; BS antihypertensive. 8. Will demonstrate 7. DM reduction in blood Antihyperglycemic; glucose AEB FSBS biguanide readings 8. DM Second 9. Will demonstrate a generation reduction in dementia sulfonylurea; S&S AEB decreased antihyperglycemic glutamate 9. Dementia N-methylD-aspartate (NMDA) receptor antagonist/antidementi a

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3.

One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in Butch’s life? COPD likely occurred first. COPD can eventually cause heart failure due to chronic lowered oxygen levels, which will create increased blood pressure in the lung’s arteries. DM will also cause damage to the vessels if not well controlled. He likely has CAD or is a high risk for CAD as well. This causes damages to the vascular system ad the heart becomes weaker. This will make the body’s blood harder to pump throughout the body (HTN). Body tissues and organs such as the brain do not perfuse adequately leading to oxygen deficits in the brain, increasing the risk of dementia.

Patient Care Begins: Current VS: T: 99.8 F/37.7 C (oral) P: 60 (regular) R: 16 (regular) BP: 115/72 O2 sat: 96% room air

4.

P-Q-R-S-T Pain Assessment: “Standing and moving.” Provoking/Palliative: “Dull” Quality: “Lower back” Region/Radiation: “4/10” Severity: “It is always there.” Timing:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: T: 99.8 O2: 96% Pain: Lower back, 4/10, dull

Clinical Significance: May have a UTI based on slightly elevated temp, location of pain and sudden confusion. Confusion could also be due to an exacerbation of COPD, r/t lower O2.

Mental Status Examination (MSE): APPEARANCE: MOTOR BEHAVIOR: SPEECH:

Dressed in t-shirt and pants. His pants are urine soaked. Wearing a sweater even though it is summer. Ambulates with a walker, shuffling gait Clear

MOOD/AFFECT:

Pleasant, except when talking about being at Pineville Estates, becomes agitated Anxiety increases, and angry affect displayed; emotionally labile – can become easily angered

THOUGHT PROCESS: THOUGHT CONTENT:

Generally coherent conversation; can make himself understood Preoccupied with not wanting to be at Pine Estates. Talks about how they are not helping him. Wants to go home and get his hunting license so he can go hunting. Reports having seen a friend, Roger, from the Navy climbing down the side of the building yesterday. No other current evidence of hallucinations Insight – poor- not understanding why he needs to be at a facility and not at home. (thinks he is here for rehab) Unable to recognize own deficits in functioning Judgment Poor-often asks his wife to bring him take-out food (which she does), then he eats an additional dinner in the cafeteria. Alert and Oriented to person and place. Not oriented to time or purpose. Believes it is 2017. Able to recognize it is spring. Short-term memory impaired: Doesn’t always remember that he has eaten; sometimes forgets when wife visits.

PERCEPTION: INSIGHT/JUDGMENT:

COGNITION:

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5 Long-term memory seems to be intact. Remembers personal history Attention span is adequate when tested. Able to state months backwards INTERACTIONS: Pleasant when spoken to. Hesitant to initiate conversation. SUICIDAL/HOMICIDAL: “If I don’t get out of here soon, I might just walk into traffic.”

5.

What MSE assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?

(Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: 1. Appearance: Urine soaked pants; sweater in summer

Clinical Significance: 1.-Incontinent and possibly unaware of it. If he has a fever, he may have chills, explaining the sweater.

2. Speech: Clear

2.-Loss of muscular coordination, S&S of dementia or a SA of his meds

3. Motor behavior: Shuffling gait

3.-Able to communicate somewhat effectively and make his needs known when aware

4. Mood & affect: Agitated & angered at mention of his current residence 5. Thought Process: Generally coherent 6. Thought content: Wants to go home; wants to go hunting 7. Perception: Hallucinations of seeing Navy friend that has died 8. Insight/Judgement: Unable to recognize decrease in function; does not remember eating; does not know why he is at facility. 9. Cognition: Limited to person and place, short term memory impaired

4.-Agitation, anxiety, anger could be due to fear of not knowing why he is at the facility. 5.-Thought process is intact 6.-Wants to be at home where he is familiar with his surroundings and calm 7.- Hallucinations and confusion can indicate signs of delirium which could be due to an infection 8.-Does not understand why he needs to adhere to treatments and what is best for himself 9.-Shows a progression in dementia 10.- Shows discomfort in surroundings, lack of confidence due to not understanding why he is there. May be more likely to engage if at home. 11.-Frustrated with current circumstances and scared.

10. Interactions: Hesitant to initiate conversation 11. Suicidal/homicidal: “I might walk into traffic

Current Assessment: GENERAL Calm, body relaxed, no grimacing, appears to be resting comfortably in chair. APPEARANCE: Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

6 RESP: CARDIAC:

Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort Pink, warm & dry, no edema, heart sounds strong and regular, S1 S2 with no murmurs or abnormal beats, pulses 3+, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill Alert & oriented to person, place, but not to time or date and situation/purpose (Oriented x2), difficulty falling asleep and wakes up 1-2 times during the night Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants Voiding without difficulty, incontinent of urine. Reported that he just changed himself. Skin integrity intact, tenting of the skin

NEURO: GI: GU: SKIN:

6.

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: Neuro: (Oriented x2), difficulty falling asleep and wakes up 1-2 times during the night

Clinical Significance: Decreased orientation and trouble sleeping are common S&S of dementia. Assess Neuro status frequently to detect any new changes

GU: Incontinent of urine

Incontinence is abnormal. Could be due to infection or decline is cognition. Can cause skin breakdown.

Skin: Tenting of the skin

Indicative of dehydration

Lab Results: Current: Most Recent:

7.

Basic Metabolic Panel (BMP ) K Gluc. 3.4 225 3.5 182

Na 140 140

Creat. 1.2 1.1

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):    

Na 140 K 3.4 Gluc 225 Create 1.2

Clinical Significance:  

 

Current:

WBC 6.0

TREND:

Essential electrolyte Indicates hypokalemia, Potassium is an important electrolyte for nerve and muscle cell functioning Indicates hyperglycemia, multiple dinners and meals are affecting blood sugar Within normal levels but shows a possible decline in kidney function

Complete Blood Count (CBC) HGB PLTs 15.2 202

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% Neuts 55

Improve/Worsening/Stable:  Stable  Worsening  Worsening  Stable

Bands 0%

7 Most Recent:

8.

5.8

14.5

198

52

0%

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):     

Clinical Significance:

WBC 6.0 HGB 15.2 PLT 202 % Neut 55 Bands 0%

    

TREND: Improve/Worsening/Stable:  Stable  Stable  Stable  Stable  Stable

Fight infection but WNL Carry Oxygen, WNL Helps blood to clot, WNL Type of WBC, WBL WNL

Misc. HGB A1C Current: Most Recent:

9.

7.8 5.5

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

HGB 7.8

Large increase for A1C. Could cause kidney issues

Worsening

Current: Most Recent:

Color: Yellow Yellow

Clarity: Sp. Gr. Clear 1.015 Clear 1.018

Urinalysis + UA Micro Protein Nitrite LET Neg Neg Neg Neg Neg Neg

RBCs 0 0

WBCs 4 0

Bacteria Trace None

Epithelial Few None

10.What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

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Need to assess UA frequently d/t trending issues with WBC’s, bacteria, and epithelial current lab results

All values are normal

Color: Stable Clarity: Stable SP gravity: Stable Protein: Stable Nitrite: Stable LET: Stable RBC: Stable WBC: Worsening Bacteria: Worsening Epithelial: Worsening

11.Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation)

Lab:

Hgb A1C Value:

Normal Value: 4-5.9% Critical Value:

9%

Clinical Significance: Critical Levels >9% indicate poor diabetes control and damage to the eyes and other systems start to happen 7.8% is close to the critical value. This can indicate kidney damage.

Nursing Assessments/Interventions Required: Patient is close to critical Hgb A1C values. Patient/family education is essential. His wife continues to bring him meals without checking if he has been fed or what his current A1C is. Possible change in medication may be needed as well.

Clinical Reasoning Begins… 12. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation)

Problem:

Pathophysiology of Problem in OWN Words:

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Primary Concept:

9 Cognition Dementia

Dementia is a symptom of a variety of specific structural brain diseases and multiple system degenerations. Although the cause is not fully understood, as it could be familial or environmental. Dementia causes the brain to shrink and is common among the elderly.

13.Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders:

Rationale:

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Expected Outcome:

10 Neuropsychiatric evaluation

Urinalysis (UA)

Haloperidol 2.5 mg PO BID

Acetaminophen 325mg two tablets PO every 6 hours PRN

Insulin glargine 10 units sub q HS

Neuro eval: Measures the progression of dementia, assesses for delirium & possible cause of hallucinations, and assesses for suicide potential. UA: Continuous monitoring of UA will continue to evaluate if the patient has a Urinary tract infection or inflammation of the GU. Haloperidol: Antipsychotic which relieves positive symptoms of a psychotic episode (hallucinations).

If the patient has an infection of the GU, antibiotics can be started treat the infection.

Acetaminophen is a mild analgesic and antipyretic.

Absence of hallucinations

Insulin is an exogenous hormone replacement for the management of diabetes.

Reduction in the patient’s temp and pain.

Memantine increased to treat increasing symptoms if dementia

Management of hyperglycemia.

Donepezil is in addition to treat dementia. Increase memantine to 10 mg PO daily

Demonstrate decrease in the rapid progression of dementia, to treat the factors that are contributing to confusion and/or delirium, to evaluate potential for suicide/self-harm.

Trazodone: Antidepressant to deal with feelings of hopelessness and helplessness.

Increasing memantine treats dementia by blocking the glutamate receptors on NMDA. Decrease in dementia S&S. Donepezil inhibits AChesterase. Decrease the S&S of dementia from two different angles so that the patient can continue as independently as possible.

Donepezil 5 mg PO daily

Trazodone 50 mg PO at HS PRN

Improvement in mood and decreased or nonexistent suicidal ideations. Trazadone is used off-label as a sleep aid, which will help the patient’s insomnia.

14.PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders:

Order of Priority:

Rationale:

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11 • Neuropsychiatric evaluation • Urinalysis (UA) • Haloperidol 2.5 mg PO BID • Acetaminophen 325mg two tablets PO every 6 hours PRN • Insulin glargin...