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Dementia/Physical Aggression Please review Rosdahl, Chapter 93, Cognitive Impairment in the Aging Adult.

Ron Jackson, 87 years old

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

Psychosis Mood and Affect Coping Clinical Judgment

NCLEX Client Need Categories

Percentage of Items from Each Category/Subcategory

Safe and Effective Care Environment •Management of Care •Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity •Basic Care and Comfort •Pharmacological and Parenteral Therapies •Reduction of Risk Potential •Physiological Adaptation

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights

17-23% 9-15% 6-12% 6-12% 6-12% 12-18% 9-15% 11-17%

Covered in Case Study

Part I: History of Present Problem History of Present Problem: Ron Jackson is an 87-year-old Caucasian male with a medical history of hypertension and Alzheimer's disease who was brought to the emergency department (ED) by paramedics for evaluation of hallucinations, increased agitation, and aggressive behavior toward Shirley, his elderly wife. His daughter was visiting and witnessed Ron becoming angry for no apparent reason, telling Shirley she had to leave the house. He then pushed her, causing her to fall to the ground. 1. What is the priority concern at this point?

-Seeing as that Mr. Jackson is having a crisis and cannot decipher what is reality and what is not, safety is the priority concern right now. His behavior can be a hindrance to himself and others right now. The best way to try and put him at ease is to communicate in a calm and collective manner. 2. What type of precautions should be instituted upon arrival at the emergency department? Why? -Standard and safety precautions because he is being admitted for infection control and he is seeing hallucinations and showing aggressive behavior towards his wife. Ron has become progressively more agitated the past year and was started on quetiapine. Shirley confirms that Ron has been more verbally abusive the past week, believing that she divorced him and that she needs to get out of the house, but no physical aggression took place until today. Ron currently complains of a headache and insists that he got this because “the Koreans beat me up real good in the ambulance!” 3. What is quetiapine? What classification of medication is quetiapine? What’s the brand name? -Quetiapine, also known by the brand name Seroquel, is an anti-psychotic medication that is used to treat mental conditions. 4. What are some side effects of quetiapine? Is it possible that the dementia and physical aggression could be due to side effects of the quetiapine? -Side effects include constipation, drowsiness, dry mouth, tiredness, and upset stomach. Characteristics of dementia can show up due to the use of quetiapine.

5. Is quetiapine an appropriate medication for a client like Mr. Jackson? Why or why not? No it is not appropriate due to his aggressive behavior. 6. Name some common signs and symptoms of cognitive impairment? Does Mr. Jackson have a sign/symptom that could be causing his dementia/physical aggression to worsen? - Indecisiveness and forgetfulness are common signs of cognitive impairment. The symptoms that Mr. Jackson is displaying are hallucinations, increased agitation, and aggressive behavior toward his wife Shirley. The use of quetiapine could also be causing these symptoms to be stronger. 7. Why is Mr. Jackson at risk for increased confusion once he arrives at the emergency department (ED)? -It is possible that he is feeling overstimulated. There a lot of lights, sounds, and people in the ED and that could have a negative effect on him. He also feels that Koreans beat him up on the way there and there are multiple trying to hold conversations with him to calm him down.

Personal/Social History: Ron lives at home with Shirley, his wife of 62 years and has three children. Ron is a Korean War veteran who saw active duty and is a retired salesman. Because his wife has been struggling to care for him, his family is in the process of making arrangements for him to reside at a local memory care unit. 8. After reading the above personal/social history on Mr. Jackson list the important information identified? Why do you feel the information would be important to the nurse collecting the data? -Important information: Ron is a Korean War veteran who saw active duty. -His wife has been struggling to care for him. -His family is in the process of making arrangements for him to reside at a local memory care unit. 9. Below is a list of Mr. Jackson’s home medicationand diagnosis from past medical history (PMH). Please complete the medication sheet in its entirety. All columns must be complete. Please be sure that the action of the medication is written in your own words. Name 3 side effects excluding nausea, vomiting, and diarrhea. Does the medication have an antidote? If so what is it? What assessments should be done prior to administering this medication? Are there medication incompatibilities? What test and labs should be monitored while taking this medication and why.

Past Medical History (PMH): Hyperlipidemia Hypertension Alzheimer's disease Agitation/Delusions

Home Meds: Donepezil 10 mg PO at HS Aspirin 325 mg PO daily Memantine 10 mg PO BID Simvastatin 20 mg PO HS Triamterene-HCTZ 75-50 mg PO daily Quetiapine 50 mg PO BID

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights

Client’s Initials ____ Allergies:

Time/ Route

PO HS

_

Drug Branded Name Generic Name

Donepezil

_

_

Client’s Dose Usual? WNL

Drug Category

WNL

C

WNL

D

High blood pressure Decreases the chances of a heart attack happening.

Rash, anaphylaxis, gastric bleeding No antidote

Assess for pain and fever

No incompatibilities

Platelets; aspirin is a blood thinner

WNL

B

Alzheimer’s

Monitor cognitive function and monitor CBC lab values.

No incompatibilities

CBC

X

Decrease signs and symptoms of cognitive decline but doesn’t slow the progression of the disease. Hypertension

Body aches, hypotension, urinary frequency. Antidote: discontinue medication and force Fluids via IV Constipation, difficulty sleeping, confusion, flushing of the skin

Monitor AST, ALT, and level of fatigue

No incompatibilities

Cholesterol and CK levels

Hyperkalemia,

Serum K+,

No

Platelets, I and

Aricept

PO daily

Aspirin

Acetylsalicylic acid PO BID

Memantine

Namenda

PO at HS

Simvastatin

WNL

Lowers chances of strokes in pts who have an elevated bp.

Zocor

PO

Triamterene

Practical Nursing Program Medication Sheet Student: Main Side Diagnosis for this Effects What should Medication you do RX Incompatibilities before giving Why did your Antidote this RX? client get this? How does it work? Alzheimer’s No Muscle Assess for cognitive cramps, hot incompatibilities Reduces signs impairment flashes, and symptoms and HR. weakness. of Alzheimer’s No antidote disease

WNL

C

Hyperlipidemia

Tests & Labs (WHY) (Normals) PT’s. CK Levels; may increase

Daily

HCTZ Dyrenium

PO BID

Quetiapine

Seroquel

WNL

C

Expels fluid and retains potassium.

low BP, light sensitivity, CHF

BUN, Creatinine

incompatibilities

O’s, BP, hyper/hypokalemia

Agitations/ Delusions

NMS, dizziness, Steven Johnson symdrome

Mental status, BP

No incompatibilities

Before: AST, ALT, CBC, Lipid panels

Decreases psychotic episodes.

No antidote

You are assigned as the nurse for Mr. Jackson. After shift report you visit Mr. Jackson and collect the data listed below.

Patient Care Begins: Current VS: T: 98.0 F/36.7 C (oral) P: 78 (regular) R: 18 (regular) BP: 148/90 O2 sat: 98% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: “Those Koreans banged my head in the ambulance.” “That’s a stupid question!” Quality: “My head hurts all over!” Region/Radiation: “It just hurts!” Severity: “All the time.” Timing:

10. What should the nurse do after collecting the vital signs and pain

assessment? Are there any abnormal vital signs or pain assessment? Remember, all vital signs are (Reduction of Risk Potential/Health Promotion and Maintenance) -After collecting the vital signs and pain assessment, the nurse should talk to Mr. Jackson in a calm and soft voice. It is also important that the nurse introduces themselves. The blood pressure is up some but that can be due to the overstimulation. The abnormal part of the pain assessment is that he says he is hurting and has a headache but he is not really connected to reality at the moment. The nurse collects the following head-to-toe assessment of Mr. Jackson as well as performing the Mental Status Examination (MSE) Current Assessment: GENERAL APPEARANCE: RESP:

Thin elderly male, appears stated age, sitting upright on stretcher, appears tense Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory Effort

CARDIAC:

Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk capillary refill

NEURO: GI:

Oriented to person only, denies hallucinations Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four Quadrants

GU:

Voiding without difficulty, urine clear/yellow

SKIN:

Skin integrity intact, skin turgor elastic, no tenting present

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

Disheveled appearance; cooperative at times, other times irritable Variable; at times pacing and agitated; at other times sits quietly Able to understand what the patient is saying Variable; quiet and calm with sudden episodes of anger, anxiety, and irritability Variable: looks calm, then may suddenly appear angry

Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights

THOUGHT PROCESS: THOUGHT CONTENT:

Able to understand what the patient is saying Paranoid and persecutory delusions/ideation; “Koreans” are harming him; delusions “believes wife divorced him” PERCEPTION: Denies hallucinations INSIGHT: Grossly impaired; attributes H/A to an attack by “Koreans”; not aware of illness or reason for ER visit JUDGMENT: Grossly impaired COGNITION: Oriented to person only. Significant short- and long-term memory deficits SUICIDAL/HOMICIDAL: High risk for physical aggression toward others; recently assaultive toward wife; unable to assess suicide ideation at this time

11. Are there any abnormalities found during the head-to-toe-assessment? No 12.Are there any abnormalities noted after performing the mental status exam (MSE)? If so, why would the information collected from the MSE be important to the nurse when caring for Mr. Jackson? -Yes; it is important because the nurse has to develop a plan of care for the patient The nurse (you) receives the following lab results. Lab Results: Current: Last Adm:

WBC 5.8 6.5

Complete Blood Count (CBC HGB PLTs 14.5 154 14.2 188

% Neuts 69 75

Bands 0 0

13.When considering the above labs are there any labs that out of the normal range? Please use your LPN notes to answer this question. (Reduction of Risk Potential/Physiologic Adaptation) -Neuts is 69, normal range 59

14.Why is it important for the nurse to assess the WBC, Hgb, Platelets, Neutrophils, and Bands? Please supply an answer to each of the above lab results. -WBCs fight off infections and the levels can indicated which type of infection is going on. Hgb carries oxygenated blood throughout the body. Platelets aid in blood clotting. Neutrophils work in the same way as WBC’s and help against infection. Bands are immature neutrophils.

Na

Basic Metabolic Panel (BMP) K Gluc.

Creat.

Current: Last Adm:

142 144

3.3 3.5

114 121

1.3 1.2

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:

The blood glucose levels have an effect on the patient’s cognitive impairment. The client’s glucose being elevated can contribute to his confusion. Na monitors kidney function K is important to monitor to prevent hypo/hyperkalemia Cr monitors kidney function

Glucose Na K Cr

Current: Last Adm:

Color: Yellow Yellow

Clarity: Clear Clear

Sp. Gr. 1.020 1.020

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

RBCs Neg Neg

Improving Improving Worsening Worsening

WBCs Neg Neg

Bacteria Neg Neg

Epithelial None None

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:

UA

All labs are normal

TREND: Improve/Worsening/Stable:

stable

Part II: Put it All Together to THINK Like a Nurse! 1.

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: Episode of dementia

Pathophysiology of Problem in OWN Words: Slow deterioration of cognition due to various brain disorders, toxins, and mental disorders.

Primary Concept:

Collaborative Care: Medical Management State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome: 2.

Violence precautions

The client is a threat to himself and others around him

Keep patient and others safe.

Continue home medications

It will help keep the client at a stable state.

Lorazepam 0.5 mg. po PRN every 4 hours x 24 hours

Sedation

The patient will have safer interactions with the staff and be more calm. Confusion will lessen.

Acetaminophen 2 tabs (325 mg) every 4 hours PRN pain. Not to exceed 4000 mg in 24 hours Consult: Mental Health/Behavioral Health professional Referral to social work for help with memory care facility placement after d/c from hospital

Pain and agitation lessen. Reduces pain and lessens agitation Talk to a specialist who can help him manage his behaviors.

Patient will be able to get more help with condition.

More control over current condition in the present and future Adjust to the progression of the disease he has

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Managementof Care) Nursing PRIORITY: How the medication is affecting the patient

PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

-Monitor abnormal effects of the medication -Establish a trusting relationship -Being genuine -Show empathy

-Monitoring the effects of the medications allows the nurse to see what changes the client may experience.

Therapeutic effects are expected and we will treat any adverse reactions.

4.

What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

Showing compassion, empathy, and patience with the client.

PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

CARE/COMFORT: Caring/compassion as a nurse -Establish a trusting relationship -Being genuine -Show empathy

It is important to establish a trusting relationship with a dementia patient because a lot of times they can’t realize what is reality. They can become hesitant to trust others. Being genuine and showing empathy will calm and soothe the patient when he is having one of his episodes.

Provide as much comfort as possible

Rapport: a close harmonious relationship Trust: belief in the nurse Respect: a feeling of knowledge of the parent’s feelings. Genuineness: truly being passionate and kind hearted. Empathy: understanding and sharing feelings of the client

Displaying these traits will help the family and others feel more at ease.

Physical comfort measures Speaking with client in a low, calm voice, only touching the client when it is appropriate to and the client is comfortable.

EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: • Rapport • Trust • Respect • Genuineness • Empathy

Evaluation: Sixty Minutes Later… You go into the patient’s room to re-evaluate his status. He states to you, “There are people who want to get me!” Ron becomes agitated and looks you in the eye and angrily states, “Who the hell are you and what are you doing in my house!" You tell him that he is at the hospital and in a safe place. He replies, "I am at home and what the hell are you doing here!" He suddenly takes his right arm and attempts to punch you What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: The client is still experiencing confusion and is more -Client states “there are people who want to aggravated than when he first arrived. The client’s condition isn’t get me!” improving and he should be reassessed. Care plans may need to be -Client is agitated and looks you in the eye and angrily states, “who the hell are you and altered also what are you doing in my house!” -Takes his right arm and attempts to punch you and narrowly misses your face. 1.

2.

Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation)

Evaluation of Current Status:

Modifications to Current Plan of Care:

The client’s status has not improved and is getting worse.

The medication that the client is getting should be reassessed.

3.

Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care)

CURRENT Nursing PRIORITY:

Providing comfort to the client

PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

-Etablish a trusting relationship -Being genuine -Show empathy

It is important to establish a trusting relationship with a dementia patient because a lot of times they can’t realize what is reality. They can...