Question

Case Scenario # 5

An 82-year-old male patient, recently diagnosed with Alzheimer’s disease, has been admitted to the hospital for pneumonia. The patient’s oldest daughter visits and expresses her concern to you that her father will have to move in with her family so she can take care of him. Her mother passed away 5 years ago, and her father has been living on his own since that time; however, his Alzheimer’s disease is progressing and he needs assistance. It is financially and emotionally difficult for the daughter to place him in an assisted living type of facility. She also promised her mother before her death that she would take care of him. The daughter is feeling terribly stressed at the thought of how this will disrupt her family’s home life in addition to her father having to move from his home of 54 years.

Major nursing responsibilities associated with assisting patients to manage stress include assessing a patient’s ability to cope with stressors, identifying personal factors that could interfere with coping, promoting effective coping and stress management, and implementing nursing interventions to modify coping as the situation warrants.

    1.   Clarify how you will proceed with this assessment.

   2.   Identify potential stressors to the people in the situation.

   3.   Identify factors that may affect the daughter’s coping behaviors.

   4.   Explore factors that place this family at risk for dysfunctional coping.

   5.   Describe possible manifestations of altered coping in this scenario.

   6.   Based on the information, plan appropriate nursing interventions.

Answer 1

1.

Cognitive and neuropsychological tests measure memory, language skills, math skills, visual and spatial skills, and other abilities related to mental functioning to help them diagnose a patient's condition accurately. For example, people with Alzheimer's disease often show changes in so-called executive functions (such as problem-solving), memory, and the ability to perform once-automatic tasks.

Detailed neuropsychological testing is time-consuming and requires special training, and it usually occurs during a separate appointment with a neuropsychologist. However, during a regular neurology doctor visit, tests such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) provide a quick way to assess cognitive skills in people with suspected deficits.

2.

potential stressors due to threat of life can be there.Some stressors involve traumatic events or situations in which a person is exposed to actual or threatened death or serious injury. Stressors in this category include exposure to military combat, threatened or actual physical assaults (e.g., physical attacks, sexual assault, robbery, childhood abuse), terrorist attacks, natural disasters (e.g., earthquakes, floods, hurricanes), and automobile accidents Some individuals who are exposed to stressors of extreme magnitude develop post-traumatic stress disorder (PTSD): a chronic stress reaction characterized by experiences and behaviors that may include intrusive and painful memories of the stressor event, jumpiness, persistent negative emotional states, detachment from others, angry outbursts, and avoidance of reminders of the

These tests examine orientation, memory, and attention, as well as the ability to name objects, follow verbal and written commands, and copy a complex shape. Doctors also use a variety of other tests and rating scales to identify specific types of cognitive problems and abilities.

3.

Gender, age, educational level, and marital status are variables known to have an influence on coping

4.

the death of her mother may be at risk of dysfunctional coping

5.

Among the more commonly used adaptive coping mechanisms are:

· Support: Talking about a stressful event with a supportive person can be an effective way to manage stress. Seeking external support instead of self-isolating and internalizing the effects of stress can greatly reduce the negative effects of a difficult situation.

· Relaxation: Any number of relaxing activities can help people cope with stress. Relaxing activities may include practicing meditation, progressive muscle relaxation or other calming techniques, sitting in nature, or listening to soft music.

· Problem-solving: This coping mechanism involves identifying a problem that is causing stress and then developing and putting into action some potential solutions for effectively managing it.

· Physical activity: Exercise can serve as a natural and healthy form of stress relief. Running, yoga, swimming, walking, dance, team sports, and many other types of physical activity can help people cope with stress and the aftereffects of traumatic events.

6.

Alzheimer’s Disease Nursing Care Plan

Subjective Data:

· Difficulty finding words during a conversation

· Difficulty remembering names

· Poor short-term memory

· Forgetting details of personal history (life events, phone number, etc.)

· Inability to recognize faces

Objective Data:

· Difficulty dressing or performing ADLs

· Loss of bladder and bowel control

· Personality changes

· Inappropriate behaviors (aggression, sexual gestures, etc.)

· Wandering or pacing

Nursing Interventions and Rationales

· Perform complete nursing assessment

Get a baseline for interventions and monitor progression of disease

· Assess neurological status and level of confusion routinely, per facility protocols

Help determine necessary interventions and progression of disease.

· Assess for depression or reclusiveness

Clients in the earlier stages who are still able to understand that they are losing their sense of reality may become depressed and withdrawn.

· Routinely assess client for organic contributors to behavior:

o Dehydration

o Poor nutrition

o Infection (systemic, urinary)

Many organic factors may contribute to an increase in client’s confusion or changes in mental status. It is important not to ignore them, since it could be related to infection or dehydration, which is treatable.

· Communicate effectively

o Speak in a slow and low, comforting voice

o Call client by name

o Speak face-to-face

Helps increase the possibility of the client understanding what is being communicated. Repeating the name helps the client maintain a sense of self-identity.

· Limit choices for independent decisions appropriate to stage of disease progression

Progressively reducing the client’s need for decision making helps reduce frustration and stress.

· Avoid allowing client to watch television or violence on television

Clients often have difficulty distinguishing fiction from reality and may cause aggressive or violent behaviors or unwarranted fears.

· Monitor for non-verbal cues and anticipate client’s needs

o Grimacing

o Crying

o Pointing

As the disease progresses, clients have more difficulty communicating verbally. Anticipating needs helps reduce stress and prevent frustration and anxiety.

· Orient client to environment as often as needed

o Calendars

o Pictures

o Signs

Helps client feel safer and reassured of their surroundings. Promotes awareness of environment.

· Provide structured and guided activities that client can accomplish with minimal challenge

This helps to keep the mind active, and incorporate a sense of accomplishment. Make sure the activity is not sp challenging so as to cause frustration or stress.

· Maintain schedule and routine

Helps the client maintain an awareness of time of day and offers a sense of security and reality.

· Assist with ADLs as needed

Advanced stages of the disease may diminish the client’s ability to perform simple tasks like dressing, bathing, combing hair and feeding. Provide whatever assistance the client needs to maintain a sense of dignity.

· Provide an opportunity for clients to interact with others, but avoid forcing interaction

Helps prevent clients from feeling isolated or alone. Gives them an opportunity to share stories or memories and maintain or develop social relationships. Forced interaction may cause aggression or inappropriate behaviors.

· Monitor client’s wandering habits and determine specific reasons, if any, for wandering

Clients may wander because they are thirsty or hungry, or are looking for a bathroom. Assess needs and provide assistance or direction within a safe environment.

· Educate family about disease process and resources for coping

o Therapy or counseling for families

o Support groups for families or caregivers

o Respite care options

o Home modifications

Help families cope and be prepared for the changes in their loved one.

Help families adapt to the needs of the clients.

Help reduce stress and anxiety that may be transferred to the client.

· Administer medications appropriately and as needed

o Cholinesterase inhibitors (donepezil)

o NMDA receptor antagonist (memantine)

o Antipsychotics (olanzapine, quetiapine)

o Benzodiazepines (lorazepam, temazepam)

o SSRI antidepressants (citalopram, paroxetine)

Some medications may be given regularly for management of memory loss and delay progression of the disease.

Other medications may be given PRN to treat behaviors and symptoms such as depression, anxiety or loss of appetite.

· Minimize environmental hazards and make pathways clear and illuminated

Promote safety and prevent injury.

Generalized Anxiety Disorder Nursing Care Plan

Subjective Data:

· Persistent worry

· Overthinking plans and worst-case solutions

· Indecisiveness

· Difficulty sleeping

· Perceiving situations as threatening

· Inability to relax

· Difficulty concentrating

· Fatigue

· Abdominal pain

· Headaches

· Chest pain or tightness

· Shortness of breath

Objective Data:

· Muscle tension

· Sweating

· Vomiting

· Diarrhea

Nursing Interventions and Rationales

· Assess vitals

Determine baseline for effectiveness of interventions and to rule out other medical conditions such as hypertension or fever.

· Obtain 12-lead EKG

Get an EKG to rule out cardiac etiology of symptoms. “Anxiety attacks” or “panic attacks” from GAD may mimic the symptoms of a coronary event with chest pain or tightness and shortness of breath.

· Determine if client is having homicidal or suicidal ideations

Maintain safety for client and others around them

· Establish trust with the client

o Listen to their concerns

o Avoid giving immediate suggestions

o Be respectful of client’s space

Especially when a client has a high level of anxiety, establishing trust can help the client calm down and make treatment more effective.

Never say “calm down” or “just relax”, it’s not that easy.

· Maintain a calm and comforting demeanor while working with client

Clients often have the feeling of being out of control. Being around someone who is calm and in control of the present situation may help the client feel safer and more at ease.

· Be present

o Stay with the client during levels of high anxiety or “panic attacks”

The presence of someone the client trusts provides positive encouragement to handle situations. Being present also helps ensure the client’s safety.

· Provide opportunities for client to assist with decision making, but avoid decisions that may require concentrated thought or may be life-changing

Allowing the client to help make minor decisions can help them regain control of their emotions. For example, start with giving them a choice between music therapy or guided imagery.

· Use desensitization approaches carefully

o Systematically expose client to small stressors to develop coping techniques

o Pair each situation with a positive or calming affect (relaxation or exercise)

Desensitization helps the client take control of worry or fears. Start small with safe situations and work up to those that cause higher anxiety.

Many times this is coordinated by a psychiatric/mental health provider.

· Administer medications appropriately (benzodiazepines)

Medications can be a quick response to high stress or anxiety and help calm the client during therapy or desensitization. Monitor for signs of addiction or withdrawal.

· Avoid allowing personal thoughts, feelings or anxiety to interfere with care

Anxiety is somewhat contagious and contributing your own emotions can make a client’s symptoms and worry more exacerbated.