Practical Dementia Care - Research Paper Example

?Clinical Reasoning Case Study The Case Mrs. Archer has been admitted to your facility for respite care while her daughter (her primary carer) has a 6 week holiday. She weighs 45 kilograms and has paper thin skin. She is in the early stages of dementia and you notice she does not eat very much food or drink very much. Her daughter tells you she often gets very red and sore genitalia because she sometimes has urinary tract infections. She also tells you Mrs. Archer is very unsteady on her feet and tends to pull back on her walking frame. Identification of Nursing Care Problems In the given situation, several problems regarding Mrs. Archer’s health status arise. The height was not mentioned to have a clearer view on the patient’s body mass index but the photo shows a dishevelled thin woman with sunken eyelids who appears weak and cold. It was stated that she is currently suffering from early stage of dementia manifesting her inability to perform basic activities of daily living such as eating and maintaining personal hygiene. Dementia is the occurrence of significant deficiency of global cognitive ability in a formerly unimpaired person, further than what might be accepted from normal degeneration. It is a non-specific syndrome that affects areas of cognition such as attention, memory, language, and one’s ability in problem solving (Thompson, 2006, p.19). In UK alone, 820,000 people are suffering from dementia while more than 35 million people are currently estimated to have dementia and 4.6 million new cases are diagnosed each year worldwide (Ferri et al., 2005). The elderly with dementia usually go through three stages. During the early stage, one may be challenged in remembering things that they would usually know such as common daily tasks, where they put their things or even how to get home. The next stage is more serious and can be noticed by their family and friends where they may find themselves unable to accomplish their activities of daily living including nutrition and personal hygiene. The last part is when the body is also affected where the patient becomes weak and their ability to communicate may diminish (Thompson, 2006, p.19.) Considering her physique and cerebral impairment, the following NANDA nursing diagnoses (Nursing Diagnosis List, 2012) were formulated: 1. Nutritional insufficiency related to cognitive impairment (dementia) as demonstrated by weight of 45 kilograms, poor consumption of food and drinks, and emaciated appearance. 2. Impaired physical mobility related to cognitive impairment as demonstrated by unsteady gait. 3. Alteration of protective mechanisms related to malnutrition as evidenced by paper thin skin and recurrence of urinary tract infection. 4. Risk of infection in urinary tract related to poor hygiene as demonstrated by very red and sore genitalia and history of urinary tract infections. 5. Risk of injury to skin related to malnutrition as demonstrated by emaciated appearance and paper thin skin. 6. Risk of accident related to cognitive impairment (dementia) as evidenced by unsteady gait. Other nursing diagnoses that may be derived related to dementia are: (1) Impaired Verbal Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding; (2) Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inability to complete ADLs; and (3) Impaired Social Interaction related to cognitive impairment. Justification This study cited several identified nursing diagnosis, both actual and risk problems, taking into higher priority the actual problems related to nutrition and safety. Nutritional insufficiency related to cognitive impairment (dementia) is on the top of the list as it is under the basic physiologic needs of human. According to Maslow, the basic physiologic needs related to survival must be met first. This includes oxygen, water, food, sleep, shelter (Rosdahl and Kowalski, 2008). Therefore, as Mrs. Archer fails to eat and drink adequately, she is depriving herself on the fulfilment of these basic needs. Reflecting with the situation, it can be considered that her poor consumption of foods and drink may be related to dementia (Thompson, 2006, p.21) or due to regular aging process as the elderly tends to have poor appetite and lesser variety on their diet due to diminishing taste or sensory loss, dysphagia, and teeth loss (Rolfes et al., 2009). This priority nursing problem is strongly supported by the observation that “she does not eat very much food or drink very much,” her dishevelled and emaciated appearance, her body weight of only 45 kilograms and noticeable sunken eyelids. On the other hand, impaired physical mobility follows as the second priority need in Maslow’s hierarchy is unmet. Safety covers physical safety, security, stability and order (Rosdahl and Kowalski, 2008). The daughter’s statement, “Mrs. Archer is very unsteady on her feet and tends to pull back on her walking frame,” supports this nursing diagnosis. It can be analyzed that this physical mobility impairment may be related to dementia and malnutrition. Goal Setting General objective: At the end of six weeks nursing care, the patient will be able to demonstrate progressive weight gain or stable body weight. Specific objectives: 1. To assess the level of nutritional insufficiency. 2. To be able to consume diet in accordance to her daily recommended energy and nutrient intake (RENI). 3. To create a meal plan with the patient in order to promote autonomy and independence. Nursing Interventions and Rationale 1. Assess Mrs. Archer’s knowledge of nutritional needs. Rationale: Assessment provides basis for the lever of assistance that will be given to the patient. It identifies needs to assist in formulating individual teaching plan. Food and preparation preferences will be identified in this stage and rapport will be established as well. 2. Determine amount of daily activity the patient performs. Rationale: Determining the activities will give the caregiver an idea on energy expenditure thus aiding in formulation of meals in accordance to their required nutritional intake (Rolfes, et al., 2009). 3. Create a meal plan or menu with the patient. Rationale: Dementia impairs the ability to plan and prepare meals, to eat a balanced diet, or to remember to eat at all (Rabins et al., 2006). Allowing participation of client in meal selection promotes autonomy and independence, nevertheless, close supervision in meal planning must be given to prevent unnecessary nutritional intake and to ensure that the meal plan is in accordance to the caloric requirement of the patient. This meal plan must be adjusted according to the daily activity that the patient performs taking into account that geriatric patients have low metabolic rate. 3. Avoid solo dining or separating patient from other people in the facility. Rationale: Separation can result to emotional dilemma which may lead to irritability, low self esteem, and even refusal to eat. If patient develops socially unacceptable and embarrassing eating habits related to progress of dementia, acceptance is the key goal to maintain a positive mood and efficient relationship (Rolfes, et al., 2009). 4. Offer small meals and/or snacks of one or two foods around the clock, as indicated. Rationale: Small, frequent feedings may enhance proper food intake and prevent gorging or overwhelming from large servings. Offering one or two foods will give the patient limited choice thus decreasing the probability of confusion (Rabins, et al., 2006). 5. Cut foods and provide soft or finger foods. Rationale: As dementia progresses, coordination such as cutting, picking, or chewing foods decreases necessitating the help of caregivers. Cutting of foods must be done in the kitchen out of the view of others to maintain the patient’s dignity and self esteem. Soft and finger foods are preferably served for easier chewing and swallowing (Rabins et al., 2006). 6. Weigh patient weekly. Rationale: Weekly weighing will provide basis for progress in patient’s nutritional status and will help identify any weight problems (Rabins et al., 2006). 7. Refer to dietitian or nutritionist, as indicated. Rationale: Assistance may be needed to develop nutritionally balanced diet individualized to meet client needs or food preferences (Rabins et al., 2006). As study by Stockdell and Amella (2008) suggests the performance of Edinburgh Feeding Evaluation in Dementia (EdFED) scale, as appropriate, if client demonstrates weight loss or decline in mealtime function as dementia progresses. This scale aids in assessing eating and feeding problems in late stage of dementia. This action was not included in Mrs. Archer’s care plan since her dementia is still on the early stage. Evaluating Outcomes By the end of the six weeks nursing care, Mrs. Archer will be able to demonstrate progressive weight gain or stable body weight. Evaluation criteria will include some if not all of the following: 1. Complete six weeks weight monitoring record showing progress on patient’s weight heavier than 45 kilograms. 2. Creation of a meal plan according to patient’s preference and in congruence with her energy expenditure and metabolic rate. 3. Able to consume meals served with only few, if not totally absence, of leftovers. As caregivers, one must always put in mind that nursing interventions must be a holistic approach corresponding to multi-dimensional needs of a person. In Mrs. Archer’s case, her nutrition and safety are of greatest priority yet her social, emotional and spiritual needs must never be neglected. Elderly, especially those suffering with cognitive impairment, most of the time lacks self esteem and autonomy therefore, in any intervention, one must be sensitive enough to act and speak with them as individuals with dignity and independence. Bibliography Ferri, C.P. et al. (2005). Global prevalence of dementia: a Delphi consensus study. The Lancet: Alzheimer’s Disease International, World Alzheimer’s Report 2009. North American Nursing Diagnosis Association. (2012). Nursing Diagnosis List 2012-2014 [Internet], NANDA Nursing Diagnosis List. Available from: < http://www.nandanursing diagnosis list.org/> [Accessed 6 September 2012]. Rabins, P. et al. (2006). Practical Dementia Care. New York, Oxford University Press, Inc. Rolfes, S. et al. (2009). Understanding Normal and Clinical Nutrition. 2nd ed. Belmont, CA, USA, Wadsworth Cengage Learning, pp. 566-568. Rosdahl, T. and Kowalski, M. (2008). Textbook of Basic Nursing. 9th ed. Philadelphia, United States of America, Lippincott Williams & Wilkins, pp.44-47. Stockdell, R. and Amella, E. (2008) The Edinburgh Feeding Evaluation in Dementia Scale: Determining how much help people with dementia need at mealtime. American Journal of Nursing, August, 108(8), pp.46-54. Thompson, S. (2006). Dementia And Memory: A Handbook for Students And Professionals. Hampshire, England, Ashgate Publishing Limited, pp.19-27. Read More