SHARE

Alzheimer’s disease—or senile dementia of the Alzheimer’s type—is a chronic, progressive, irreversible, and degenerative brain/neurologic disorder that begins insidiously accompanied by profound effects on memory, cognition, ability for self-care and disturbances in behavior and affect (Smeltzer & Bare, 2004). Alzheimer’s disease (AD) is ubiquitous to the geriatric stage of the life of man. Patients with AD manifest not only progressive memory impairment, cognitive deficits and functional alterations but also a variety of neuropsychiatric disturbances such as agitation, aggression, hallucination and delusion. These symptoms ultimately affect up to 75% of individuals with dementia and, once present, tend to be sustained or recurrent (Street et al., 2000).

 Dr. Barnwell (Matt Barry) told Duke (James Garner) that “Senile dementia is irreversible. It’s degenerative. After a certain point, its victims don’t come back.” Duke believes, “She remembers doc. I read to her and she remembers. Not always, but she remembers.” After finding out about her illness, before the disease totally stole her memory, Allie (Gena Rowlands) wrote her love story in a notebook with an instruction “read this to me, and I’ll come back to you.”

–   The Notebook, 2004

Tomey & Alligood (2001), believed that a person strives to reach own goals—but not in the case of patients suffering from Alzheimer’s Disease with memory impairment, they may even forget what a goal is. It is the doctor and the nurse function to define what goal is appropriate for them. Patients as said to achieve their maximum potential through the learning process (Tomey & Alligood, 2001), but for AD, where learning is not only that easy but not possible as well; their actions are usually occur in concurrence with feelings—since feelings are not influenced by rationality (Tomey & Alligood, 2001).  It is thus the function of the nurse to utilize the therapeutic use of oneself and the knowledge about the concept of Alzheimer disease. Ability on education and communication skills is imperative to facilitate the teaching and learning process. Rehabilitation is a process of learning to live within limitations (Tomey & Alligood, 2001), but in the care of Alzheimer’s disease, rehabilitation can be achieved with the help and support of the care providers. The possibility is raised that a reconceptualization of the nurse can be a person whose effectiveness is enhanced through a sense of shared humanity with patients (Taylor, 1992).

Illness is directed by feelings-out-of-awareness—thus healing may be hastened by helping people move in the direction of self-awareness towards healing (Tomey & Alligood, 2001). The process of reflection, repetition, reminding and retelling the past will help the victims to have the chance of moving from the unlabeled threat of Alzheimer’s disease and geriatric conditions. Once people are brought to terms with their true feelings and motivations, they become free to release their own powers of healing and properly labeled threat with which helps people deal constructively (Tomey & Alligood, 2001). By promoting self-awareness, the nursing process will be easy and feasible.

Nursing Process

Nursing Care Plan for Alzheimer’s Disease

Nursing AssessmentOld and aged patients with AD are usually agitated and increasingly forgetful. They can perform physical ADLs independently but depends on others for domestic chores. They might be oriented to time, person and places but irrational to the consequences of every events that’s why they are asking the same question over and over again repeatedly. They are weak and high risk for fall and functional disabilities.
Nursing DiagnosesAltered health maintenance; Knowledge deficit; Impaired communication; Altered verbal and thought process; Ineffective individual and family coping; Impaired home maintenance management; Potential/Actual for physical injury; Impaired physical mobility; Altered protection; Potential/Actual for trauma; Anxiety; Activity intolerance; Sleep pattern disturbance; Potential for disuse syndrome; Altered role performance; Chronic low self-esteem; Impaired social interaction; Social isolation; Spiritual distress; Self-care deficit; Hygiene; Altered sensory-perceptual;  Altered compliance; Altered nutrition less than body requirements.
PlanningNursing interventions are intended to sustain the physical safety of the patient; to support cognitive functions; to reduce agitation and anxiety; to improve communication; to promote independence in self-care tasks; to provide for the needs of the patient for intimacy, self-esteem and socialization; to maintain sufficient nutrition; to manage disturbances on sleep patterns; and to support and educate family caregivers.
ImplementationPromoting physical safety: 1. Remove all environmental hazards. Turn on nightlights.2. Monitor food, intake and medication intake of patient.3. Diversional activities and encouragement hasten wandering behavior caused by forgetfulness and short attention span.4. Avoid restraints as it may increase agitation.5. Provide identification band.Supporting cognitive functions:

1. Provide calm and predictable environment with routine activities that helps the patient interpret his or her surroundings and activities.

2. Limit environmental stimuli. Follow a regular routine of activities. A quiet, pleasant manner of speaking with clear and simple explanation, use of memory aids and cues help to minimize confusion and disorientation and give the patient a sense of security.

3. Provide clocks and calendars to promote orientation to time.

4. Color coding the doors may help in identifying his or her room.

Reducing anxiety and agitation:

1. Reinforce a positive self-image through constant emotional support.

2. The environment should be kept uncluttered, familiar and noise free. Excitement and confusion can be upsetting and may precipitate a combative, agitated state known as a catastrophic reaction. During such a reaction, the patient responds by screaming, crying or becoming abusive (physically or verbally). This may be the patient’s only way of expressing an inability to cope with the environment. When this occurs, it is important to remain calm and unhurried.

3. Diversional activities such as listening to music, stroking, rocking or distraction may calm down the patient. Frequently, the patient forgets what triggered the reaction.

4. Structured routine activities are helpful to aid with patient’s forgetfulness.

5. Be familiarized and predict the patient’s responses to certain stimuli will help the nurse and caregivers to avoid untoward situations.

6. Dementia education for caregivers will get the family’s support, participation and cooperation with the care.

Improving communication:

1. Use clear, easy-to-understand and concise sentences in conveying messages because the patient frequently forgets the meaning of words or has difficulty organizing and expressing thoughts.

2. The nurse must remain unhurried, reduce noise and avoid distractions to promote the patient’s interpretation of messages.

3. Provide list of reminders and written instructions.

4. Be aware to non-verbal cues and language since patient often used it to communicate.

5. Tactile stimuli, such as a hug or a hand pat, are usually interpreted as signs of affection, concern and security.

Promoting independence in self-care activities:

1. Routine, predictable and simplified daily activities organized into short, free and easy achievable steps so that the patient experiences a sense of accomplishment. Follow the SMART rule.

2. Provide a room for patient’s independence rather than dependence, direct supervision is a must but preserve the person’s autonomy and dignity during the nursing care.

3. The patient is encouraged to make choices and decision when appropriate and encouragement is needed to participate in self-care activities.

Providing patient’s needs for socialization, self-esteem, and intimacy:

1. Letters, phone calls and visits from old friends and socialization can be comforting.

2. Plan for a brief and non-stressful visits and socialization, limiting visitors to one or two at a time helps to reduce over-stimulation.

3. Program recreational activities not contraindicated to patient and encourage enjoying simple activities.

4. Simple expressions of love, such as touching and holding, are often meaningful. Encourage love ones and relatives bonding and affectionate time together.

Maintaining adequate nutrition:

1. Mealtime should be simple and calm without confrontations, AD patients may perceive this as a pleasant time, social occasion or an upsetting activity.

2. Prepare a meal served with patient’s food of choice that look so appetizing and taste good.

3. Serve one dish at a time to avoid patient’s playing with food.

4. Cut food into small pieces to avoid choking.

5. Serve gelatins instead of liquids.

6. Check food temperature to prevent accidents and burns. Foods should be served warm.

7. Adaptive equipment can be use if lack of coordination interferes with self-feeding.

8. Apron and smock gown but never a bib can be use to protect clothing, especially when eating with fingers.

9. As deficits progress, it is necessary to feed the patient.

Managing sleep pattern disturbances:

1. Assess patient’s physical and psychological conditions, sleep pattern disturbances usually arise due to unmet needs.

2. It is imperative that caregivers seek to learn the needs of the patient who is exhibiting sleeping problems, because further health decline can ensue if the source of the problem is not corrected.

3. Adequate sleep and physical exercise are essential. If sleep is interrupted or the patient is unable to fall asleep, music, warm milk, or a back rub may help the person relax.

4. During daytime, the patient should be given sufficient opportunity to participate in passive exercise activities, because a regular pattern of activity and rest will enhance nighttime.

Supporting and educating family caregivers:

1. The family can be referred to a group that provides the opportunity to congregate with others who are experiencing the same condition.

2. The nurse should be aware and sensitive to the highly emotional issues that the family experience and empathize with the family’s ordeal.

3. Support and education of the caregivers are essential components of care.

 

EvaluationActive participation may help the patient to maintain cognitive, functional and social interaction abilities for a longer period. Physical activity and communication have also been demonstrated to slow some of the cognitive decline of Alzheimer’s disease. Forgetfulness, disinterest, dental problems, incoordination, overstimulation and choking can all serve as barriers to good nutrition. Many patients with Alzheimers disease exhibit sleep disturbances, wandering and behaviors that may be deemed inappropriate. These behaviors are most likely to occur when there are underlying physical or psychological needs that are unmet. Side rails are always secured for patient’s safety. Always observe therapeutic environment. Provide adequate time for sleep, rest and activities through well-planned nursing interventions. Significant others always observed therapeutic communication with full of encouragements. It is imperative that family members are always supportive and participative in the activities and nursing interventions.

Doenges, Moorhouse & Curr (2008); Smeltzer & Bare (2004)

Nursing is helping the clients to move in the direction of self-awareness (Anonuevo et al., 2000), in AD cases—nurse-patient interaction, therapeutic and safe environment, nursing care and psychological interventions such as counseling, reflections, repetitions, reminding and retelling will help the AD victims bring back to health, may be not to the old health-self she had before but be able to achieve her potentials after the disease. Keys to the nursing process are encouragement of self-awareness, changes in behavior and reflections. In acute or chronic biological/psychological illness, patients need medical interventions—as the illness decreases, so to the need for medical services. However, this decrease, in turn, necessitates an increase in the requirement for nurturing and rehabilitative nursing. The moment the crisis is addressed, the need for medical intervention is replaced with the need for nurturing, support and education. It is thus argued that post-crisis patients’ needs are reasonably a nursing concern.

References:

  • Anonuevo, C.A. et al. (2000). Theoretical Foundations of Nursing. Philippines: UP Open University, 104–105, 22–36, 156–167, 169–178. Doenges, M.E., Moorhouse, M.F. & Curr, A.C. (2008).
  • Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales, 11th ed. Philadelphia: F.A. Davis. Smeltzer, S.C. & Bare, B.G. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th Ed., 205–211; 2075–2092; 181–182. PA: Lippincott Williams & Wilkins.
  • Street, J.S. et al. (2000). Olanzapine Treatment of Psychotic and Behavioral Symptoms in Patients With Alzheimer Disease in Nursing Care Facilities: A Double-blind, Randomized, Placebo-Controlled Trial. Archives of General Psychiatry, 57, 968–976. Taylor, B.J. (1992).
  • From Helper to Human: A Reconceptualization of the Nurse as Person. Journal of Advanced Nursing, 17(9), 1042–1049. Tomey, A.M. & Alligood, M.R. (2002).
  • Nursing Theorists and Their Work. 5th ed. Missouri: Mosby, 136–139, 98–108, 501–517, 299–316.
SHARE
She is currently working as a medical-surgical nurse at Ministry of Health, Sultanate of Oman. A writer, blogger, researcher, correspondent and publication consultant for nursing journal and health-related educational websites. Her field of specialization focused on Intensive Care and Emergency Management. She is now taking up MAN major in Adult Health Nursing at the University of the Philippines Open University. A nursing professor for 8 years in the Philippines and served as a staff nurse at UST hospital. A caring and devoted nurse who introduced a “Pinay Nightingale” in the land of the pharaohs. A nurse by profession, an educator by devotion and a writer / researcher by passion.