Dementia: Physical Aggression Case Study PDF

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Dementia/Physical Aggression

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

Covered in Case Study

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

✓ ✓ ✓

6-12% 12-18%

✓ ✓

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

• Reduction of Risk Potential • Physiological Adaptation

9-15% 11-17%

✓ ✓

Part I: Recognizing RELEVANT Clinical Data 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. 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!”

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. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem:  Hypertension  Alzheimer’s  Hallucinations  Increased agitation  Aggressive behavior towards wife  Verbally abusive  Complains of headache

Clinical Significance:  Assess if the patient is on medications that can interact with treatment  This is his baseline  What is causing these hallucinations, are they command hallucinations?  Danger to wife and others  Abusive to others and wife  Why is his head hurting? Is it related to the meds?

RELEVANT Data from Social History:  Korean war veteran  Wife struggles to care for him  Family is working on getting him onto memory care unit.

Clinical Significance:  Related to his “ Koreans beat him real good” statement  Needs to include this is discharge planning  Give resources to family include family in care plan

1. Identify the relationship between the PMH and home medications. Which medication treats which condition? Draw a line to connect the PMH to the correct medication. Past Medical History (PMH): Hyperlipidemia: (Simvastatin) Hypertension: (Aspirin, Triamterene) Alzheimer's disease: (Donepezil, Memantine) Agitation/Delusions: ( Quetiapine)

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

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2. Is there a relationship between any problem in his past medical history and the present problem? If so, describe. - Yes, he is a war veteran; which means he can be suffering from PTSD and this can also explain his recent increase in agitation and hallucinations.

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:

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:

Clinical Significance:

-

-

All of the vitals

Vitals are with in normal limits bedside BP. The nurse should focus on talking to the patients in calm tone of voice. BP elevated can be due to agitated state and medication should be given as ordered to help with lowering it to a more appropriate level.

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:

Oriented to person only, denies hallucinations

GI:

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: THOUGHT PROCESS: THOUGHT CONTENT: PERCEPTION: INSIGHT:

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 Able to understand what the patient is saying Paranoid and persecutory delusions/ideation; “Koreans” are harming him; delusions “believes wife divorced him” Denies hallucinations Grossly impaired; attributes H/A to an attack by “Koreans”; not aware of illness or reason

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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 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: • Oriented to person only • Denies hallucinations • Appears tense

Clinical Significance: • The patient is not alert and oriented so might be difficult to adhere to treatment regimen due to confusion. The patient was brought in for hallucinations so if they have passed or is he denying them despite experiencing them. Assess the tense appearance and behavior this could lead to aggression.

RELEVANT Mental Status Exam Data:  Disheveled appearance  Cooperative at times  Pacing and agitated at times  Paranoid  Judgment impaired  High risk for physical aggression  Orientated to person only  Suicidal ideation

Clinical Significance:  Disheveled appearance, very irritable and cooperative only at times. His motor activity fluctuates with at times being calm and sitting and other times agitated and pacing. His thought content is him having persecutory delusions of being harmed which adds to him being violent thinking that he needs to protect himself. He is only orientates to person and has memory deficits. High risk for hurting others such as his wife who he has physically and verbally abused recently.

Lab Results: Complete Blood Count (CBC)

Current: Last Adm:

WBC 5.8 6.5

HGB 14.5 14.2

PLTs 154 188

% Neuts 69 75

Bands 0 0

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:



All labs



WBC help fight infection increased level can show Improving from last time that he has an infection present. Hemoglobin shows they were draw. us oxygen level in body. Platelets help blood clot.

Basic Metabolic Panel (BMP)

Current: Last Adm:

Na 142 144

K 3.3 3.5

Gluc. 114 121

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

Creat. 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: 

All labs



TREND:

Improve/Worsening/Stable: Determine electrolyte imbalances and  Improving from the las time they kidney function as well as we can see how were drawn. Except for K+ watch decrease or increase of each electrolyte plays out for hypokalemia. a role in the body systems.

Urinalysis + UA Micro Current: Last Adm:

Color: Yellow Yellow

Clarity: Sp. Gr. Clear 1.020 Clear 1.020

Protein Neg Neg

Nitrite Neg Neg

LET Neg Neg

RBCs Neg Neg

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): 

Urine analysis

Clinical Significance: 

All the labs are within normal limits

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:

Pathophysiology of Problem in OWN Words:

Primary Concept:

Episode of dementia

Possible damage to brain cells that lead to failure of those brain cells to communicate with each other leading to the change in his behavior.

Neurologic deficit/ assess with extra emphasis.

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

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

Violence precautions

-

Patient is at risk for self-harm to others

-

Patients and staff will be safe

-

Patient will remain stable and medical conditions will be under control such as hypertension and agitation. Give sedatives if agitation worsens.

-

Patients confusion will decrease and be more calm around family and staff.

-

Agitation will decrease and pain will be managed and controlled and help calm patient down.

-

Patient and family will be informed and up to date on the plan for discharge.

Continue home medications

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

Acetaminophen 2 tabs (325 mg) every 4 hours PRN pain. Not to exceed 4000 mg in 24 hours

-

Reduce pain

-

Help agitation and violence, place under control

Consult: Mental Health/Behavioral Health professional

Help family with stress of placement into a memory care facility where they can offer full time care for him.

Referral to social work for help with memory care facility placement after d/c from hospital

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: Maintain patient, staff and other patients safety, keep patient in a stress free environment PRIORITY Nursing Interventions: Rationale: - The main concern at this time is to ensure the - Patient and staff safety patients safety and the safety of the staff that - Administer medication are caring for him. - Consult case manager for referral of

Expected Outcome: - The patient and the staff will remain safe throughout the stay of the patient.

memory care facility.

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

Psychosocial PRIORITIES: PRIORITY Nursing Interventions: CARE/COMFORT: Caring/compassion as a nurse

Physical comfort measures

Establishing therapeutic rapport and showing compassion towards the patient. Rationale: It is important as a nurse to show care and empathy when treating patients compassion is key when there is a patient with dementia as well as patience. The patient might not be aware of what he is saying. With his delusions the patient can’t build trust as easily and comfort from anyone will make him feel safe and in turn build his trust.

-

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Expected Outcome: The staff will continue to provide compassionate care and accommodate the patient despite violent crisis.

-

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

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Rapport: building close relationship with the patient. Trust: the patient believes in you that you will provide the best care Respect: the patient and nurse will respect and acknowledge each other. Genuineness: meaning what is said Empathy: understand the other side put yourself in the patients shoes

-

The nurse will reflect these characteristics when caring for patient.

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 and narrowly misses your face… 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: - Delusions: there are people who want to get me. - Agitated: yells at the nurse asking who she is - Patient believes he is at home. - Tries to punch the nurse

Clinical Significance: Patient continues to be agitated and is a danger to himself and others. He still very confused and is unaware of his surroundings. He runs a risk of hurting the staff.

-

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: - Not improved

Modifications to Current Plan of Care: - Continue to use therapeutic approach and reorient patient. Modify place of stay for example in a room where there is not much noise and he is in his own room away from distractions or triggers.

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

CURRENT Nursing PRIORITY:

Medication administration and continuous safety evaluation maybe place on 1:1 for possible self-harm during a dementia episode.

PRIORITY Nursing Interventions:

Rationale:

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Expected Outcome:

-

Patient safety. Trusting relationship

-

Make sure that everyone who is involved in taking care of the patient is safe from harm. the patient attempted to hit the nurse even after continued trusting relationship. Important to know how to deescalate the patient and reorient while knowing that this behavior is derived from his dementia.

The staff will understand how to continue a trusting relationship with the patient and understand triggers.

Use Reflection to Develop Clinical Judgment What did you do well in this case study?

What knowledge deficits did you identify?

-

-

Was able to identify priority of care such as safety. Patient has cognitive impairment due to dementia and I was able to link a lot of his behavior to the current episode that brough him into the hospital.

What did you learn?

-

The patient is unable to learn he is unaware of current health such as the dementia he has other health factors that are relevant to current hospitalization. He is taking medication to calm him which can impair the adherence to the care plan. How will you apply learning caring for future patients?

I learned that dementia can also be accompanied by PTSD in veterans. This bringing on an onset of hallucinations and flashbacks in a dementia episode.

I will focus on gaining the patients trust while they are in the facility and help them reorient once their episode has subsided. Always remember that they act upon their dementia.

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