Question

M.Y, an 80 year old asian, american man was diagnosed with Alzheimer’s disease (AD) 3 years ago. Today his wife brings him to the emergency department because he wandered from his home, fell, and injured his left hip.

Subjective data:

Can state his name

Confused as to place and time

Denies memory of wandering or falling

Agitated, trying to get up

Denies pain

Objective Data:

Physical examination

Left leg shorter than right leg

Tense and anxious

1. What precipitating factors may have resulted in M.Y’s fall?
2. What precautions need to be taken regarding the inpatient care of M.Y?
3. Delegation Decision: what nursing activities can the RN delegate to unlicensed assistive personnel?
4. Evidence based practice: M.Y’s wife asks you if she should give her husband gingko to help his memory. How would you respond?

Answer 1

A. Alzheimer's disease patient commonly experienced problems with perception and balance which leads to falls. Here M. Y is confused, tensed and anxious and wandered .His left leg is shorter than right leg. These all are the precipitating factors of his fall.

B. Inpatient care of M. Y should include continuous surveillance and monitoring.

He should not be left unattended.

Help him to perform the activities of daily living.

Range of motion exercises according to the physicians advice.

Nutritional needs should be met.

Psychological support during conscious state .

Provide individualized care.

Keep the environment and patient surroundings safe

Establish a daily routine.Allow flexibility for spontaneous activities or particularly difficult days.

Allow the person with dementia to do as much as possible with the least amount of assistance while treatment progressing.

Provide best understand clear, one-step communication.

Avoid multiple or prolonged naps during the day. This can minimize the risk of getting days and nights reversed.

Turn off the TV and minimize other distractions at mealtime and during conversations to make it easier for the person with dementia to focus.

C.

selected care tasks such as ambulation, feeding, mouth care, and bathing.

data gathering such as intake and output and vital signs.

Assistance for the patient for activities of daily living.

Ensure the safety and fall prevention for the patient.

D. Ginkgo biloba is a herbal extract which is used to treat memory loss associated with mild cognitive impairment or Alzheimer's disease. In a hospital setting the decision is from the physician after considering the various factors, drug interactions and so on.