NURSING B29 Gerontology Community Nursing. UNIT 2 Care of the Cognitively Impaired Elder in the Community

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1 NURSING B29 Gerontology Community Nursing UNIT 2 Care of the Cognitively Impaired Elder in the Community INTRODUCTION The goal of this unit is for the learner to be able to differentiate between delirium, dementia, and depression in the cognitively impaired older adult. An overview of essential assessment criteria which encompasses common changes in the older adult will be emphasized. Various standardized screening instruments will be explored to assess the older adult s environment, sleep patterns, functional status, mental status, and pressure ulcer risk. Based on a comprehensive Geriatric assessment, the learner will be able to integrate these findings in order to develop an appropriate nursing care plan for this vulnerable population, and their caregivers. The roles of provider of care, manager of care, and member of the profession will be emphasized to support participation in health promotion, disease prevention, and illness management for the Gerontological client and their families OBJECTIVES Upon completion of Unit 2, the student will be able to: A. Theory 1. Define cognitive impairment, differentiate between delirium, dementia, and depression in the elderly, and incorporate appropriate nursing strategies to optimize functional abilities. B. Clinical 1. Assess older adults mental status, and analyze their cognitive abilities and mood. 2. Incorporate data from various screening tools used in evaluating the cognitively impaired client s environment, sleep patterns, functional status, mental status, and pressure ulcer risk into the plan of care. 3. Implement appropriate nursing strategies to minimize the loss of independence associated with functional decline. 4. Maintain a safe environment for the cognitively impaired older adult. 5. Implement effective communication strategies when caring for elderly clients who are cognitively impaired. 6. Differentiate the type of cognitive impairment, delirium, dementia, or depression, in the clinical setting, and relate appropriate nursing interventions. GERI / COMM UNIT 2_ Fall 2009 CMG / TJH 1

2 Nursing B Gerontology Community Nursing UNIT 2 Care of the Cognitively Impaired Elder in the Community Column I Theory Objectives Column II Suggested Learning Activities Column III Clinical Objectives Column IV Clinical Activities (Expected Competencies/Skills) Objective 1 Define cognitive impairment, differentiate between delirium, dementia, and depression in the elderly, and incorporate appropriate nursing strategies to optimize functional abilities. A. Normal aging of the brain B. Cognitive Impairment 1. Definition, Etiology, & Risk factors. 2. Confusion 3. The three D s a. Delirium 1. Subtypes a. Hypoactive b. Hyperactive c. Mixed 2. Risk Factors 3. Assessment 4. Prevention &Treatment b. Dementia 1. Types a. Alzheimer Disease b. Vascular, c. Lewy Body Disease d. Creutzfeldt-Jacob e. Wernicke Encephalophathy f. Parkinsons Disease 2. Risk Factors 3. Assessment 4. Prevention &Treatment Required Reading Eliopoulos Ch 25, 32 & 33 Lecture / Discussion Care of the Cognitively Impaired Elder Internet Resources Alzheimer s Association Alzheimer s Caregiver Support Online Geriatrics Al-Alon Family Group Headquarters Study Guide 2.1 Interventions for Working with Older Adults with Cognitive Impairment Study Guide 2.2 Management of the client with Delirium Assess older adults mental status, and analyze their cognitive abilities and mood. Incorporate data from various screening tools used in evaluating the cognitively impaired client s environment, sleep patterns, functional status, mental status, and pressure ulcer risk into the plan of care. (See Unit 1: Environment Safety, Katz Index, MMSE, Moore s Functional Dementia Scale, Fulmer Spices, and Braden Scale Assessment. Implement appropriate nursing strategies to minimize the loss of independence associated with functional decline. Maintain a safe environment for the cognitively impaired older adult. Implement effective communication strategies when caring for elderly clients who are cognitively impaired Create and implement an appropriate plan of care for the cognitively impaired older adult. Study Guide 2.3 Assess a cognitively impaired client using Maslow s Hierarchy on Cognitive Impairment Worksheet GERI / COMM UNIT 2_ Fall 2009 CMG / TJH 2

3 Nursing B Gerontology Community Nursing Module 2 Care of the Cognitively Impaired Elder in the Community Column I Theory Objectives Column II Suggested Learning Activities Column III Clinical Objectives Column IV Clinical Activities (Expected Competencies/Skills) c. Depression 1. Risk Factors 2. Assessment 3. Prevention &Treatment 4. Summarize therapeutic nursing strategies used when working with the cognitively impaired elderly adult and the caregiver. a. Safety b. Consistency c. Redirection d. Communication e. Therapeutic activities f. Maximizing functional potential and independence. g. ADL s Differentiate the type of cognitive impairment, delirium, dementia, or depression, in the clinical setting, and relate appropriate nursing interventions. GERI / COMM UNIT 2_ Fall 2009 CMG / TJH 3

4 Unit 2 Care of the Cognitively Impaired Elder in the Community Study Guide 2.1 Interventions for Working with Older Adults with Cognitive Impairment NURSING ASSESSMENT: 1. Identify strengths / weakness in: Physical Cognitive Social Emotional Environmental Behavioral 2. Determine stage of dementia 3. Assess family / caregivers INTERVENTIONS: Nursing goal: maintain optimum health, protect from injury, and provide physical & intellectual stimulation. 1. Communication verbal & nonverbal strategies for stage of illness. Chart words and techniques that client responds to. 2. Sensory function: glasses, hearing aids, dentures 3. Reassure those who overreact to unfamiliar situations by speaking slowly, calmly (low pitched clear tone) & reducing environmental distractions. Explain and repeat instructions unless causes distress. 4. Offer support & recognize feelings as resident copes with continual losses. 5. Offer reassurance, convey warmth, and approach in relaxed, open, friendly manner. 6. Provide routine with consistency (including same caregivers), allow flexibility. 7. Depending on the stage of dementia, validate instead of re-orienting. 8. Use diversion to redirect gestures & repetitious conversation (distraction is effective intervention). 9. Provide physical activities/exercise (encourage relaxing activities in evening before bedtime). 10. Be alert for signs of depression. 11. Prompt to share stories. 12. Provide for nutritional/fluid needs. 13. Avoid chemical/physical restraints. 14. Keep things simple. 15. Use appropriate environmental cues (clock, calendar, daily schedule). 16. Avoid excessive questioning and confrontation. 17. Maximize environmental safety. 18. Prompt ADL s with memory aids and verbal cues. 19. Analyze behavior for meaning. 20. Refer family to community resources 4

5 OTHER STRATEGIES: 1. Pet therapy 2. Reality orientation 3. Validation therapy - involves responding to cues from person regarding feeling not focusing on fact or reality orientation. 4. Re-motivation meet to cover different topics 5. Reminiscence thinking about & reflecting on the past (Thanksgiving, pictures) 6. Life review structured reminiscence of life accomplishments using life stages recognizing that one has lived the best way one could (usually one-to-one, by mental health specialist) 7. Memory enhancement decrease anxiety by making lists, organizing 8. Enhancing personal choice wants to participate or not 9. Involvement gardening 10. Other stimulation crossword puzzles, reading, traveling EDUCATE CLIENT / CAREGIVER: 1. Disease & stage 2. Behavioral management & communication strategies 3. Community resources, ie., respite 4. Legal/financial issues 5. Advanced directives 6. Long term care options 7. Family/social support 8. Monitor for acute illnesses & effects of meds 9. Monitor for depression 10. Drug therapies 11. Specific interventions: Managing: wandering (allow to wander & hoard use ID bracelet) Eating, toileting, inappropriate behavior, correcting potential safety hazards Home safety: unplug stove, install locks, night lights, store firearms/chemicals out of reach, hand rails, supervised smoking, lock car steering wheel 12. Refer to Alzheimer s Association, 36 hour Day, respite, living will NURSING DIAGNOSES: Chronic confusion Self care deficit Feeding r/t altered cognition Toileting and /altered urinary elimination: Incontinence r/t altered cognition Risk for injury due to wandering, poor judgment secondary to altered cognition Altered nutrition: less than body requirements Sleep pattern disturbance Impaired Communication Interrupted Family Processes Caregiver Role Strain 5

6 Module 2 Care of the Cognitively Impaired Elder in the Community Study Guide 2.2 Management of the Client with Delirium The goal of nursing interventions is to establish a meaningful environment, help maintain body awareness, and help client to cope with confusion, hallucinations, illusions, and delusions. INTERVENTIONS: 1. Know baseline mental status, functional status, living conditions, medications 2. Correct underlying cause. 3. Compensate for sensory deficits: provide hearing aids, dentures, and glasses 4. Encourage fluids, avoid long periods of NPO 5. Avoid use of sleeping medications, instead use alternative measures like warm milk, herbal tea, soft music 6. Minimize use of catheters, restraints, or immobilizing devices. 7. Use least restrictive devices 8. Fall risk reduction like activate bed exit and chair alarms, volunteers to sit with clients, moving the client near nursing station for close observation. 9. Normalize the environment, providing familiar items, routines, clocks, calendars. 10. Place in front of window to see day and night 11. Minimize environmental changes 12. Allow to sit in chair for short periods to improve perception of environment 13. Avoid sudden body changes fever, pain, trauma, or acute onset of illness may cause confusion 14. If agitated / demonstrating unsafe behavior, ask in soft / calm voice what client needs are, reassure client will be safe 15. Safety measures to protect tubes hide tubes ie. Stockinette, or use intermittent infusion 16. Help with hallucinations, delusions, and illusions by verifying statements, identifying facts, and describing reality in slow/calm manner 17. Identify correctable factors that may cause confusion : fatigue, unmet toileting needs, increased noise, decreased light, sedatives and pain medication, fewer staff 18. Explain all treatments in simple language 19. Avoid awakening during night and use of physical/chemical restraints 20. When no longer confused, discuss episode 21. Do not argue with client, enter client s world, and meet need behind behavior 22. Support family/friends 6

7 Unit 2 Care of the Cognitively Impaired Elder in the Community Study Guide 2.3 Maslow s Hierarchy on Cognitive Impairment Worksheet Name Resident s initials and Location 1. From the data obtained with the MMSE, Moore s Functional Dementia Scale, Environmental Assessment, Fulmer Spices, Katz Index, Braden Scale, and your interactions with the resident, discuss the patient s needs according to Maslow s Hierarchy. Physiological Needs (Oxygenation, Elimination, Nutrition, Mobility and Activity, Comfort and Rest) Safety Needs (Environmental and Personal) Love and Belonging Needs (Communication, Spiritual and Sexual) 2. Identify the two priority nursing diagnoses for the resident using correct NANDA terminology. 7

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