Question

Lorraine Terrance, an 83-year-old widow who has lived alone since her husband died 6 months ago, is in the early stages of Alzheimer’s disease. She has a history of cardiovascular disease and hypertension and has been admitted to the local hospital for observation after complaints of chest pain. At present, she is very anxious and agitated. The admitting nurse received a telephone call from Mrs. Terrence’s daughter, who lives out of town. The daughter states that her mother has experienced anxiety and depression for many years and her symptoms have worsened since her father died. The daughter does not know what medications her mother currently takes, and she is concerned that her mother lives alone and wants her to move to a nursing home. The provider orders the following medications: Alprazolam (Xanax) for anxiety, Citalopram (celexa) for depression, and Zolpidem (Ambien) for sleep.

Mrs. Terrence’s two sons come to visit her in the hospital. They complain to the nurse that their mother seems oversedated. In denial about her mental status, the sons request that their mother’s medication be discontinued, but the nurses are concerned that if she is agitated, she may pull out her IV lines and Foley catheter as well as possibility strike out at staff.

1. How does the nurse handle this situation while respecting the family’s concerns, based on his or her knowledge and skills of patient-centered care?

Mrs. Terrence receives alprazolam 0.25 mg PO at 2:00 PM. Later, when the nurse brings in her supper tray, the patient seems relaxed. The supper tray contains raost beef, salad, chocolate pie, and hot tea. Visitors arrive at 5:00 PM and remark to the nurse that Mrs. Terrence is agitated and wringing her hands. She says that she is afraid to verbalize her anxiety to the nursing staff. The nurse prepares to give Mrs. Terrence another dose of medication.

1. What does the nurse prepare and why?

2. What foods on the supper tray contribute to the patient’s safety?

3. What patient teaching is necessary?

Answer 1

1. How does the nurse handle this situation while respecting the family’s concerns, based on his or her knowledge and skills of patient-centered care?

answer:

The nurse has to handle this situation with total calm and extreme emotional fortitude with due respect to the family's concerns ,empathizing with them and emphasizing the need for the patient care.

Explanation:

The nurse is being faced with the challenge of compromised family coping ,family denial of patient's illness and deficient family knowledge in taking care of the patients with Alzheimer's dementia

The nurse must first respectfully listen to the concerns of the family members regarding the patient and provide them an opportunity to vent their feelings and take cognizance of the same.

She should remain calm and patient and provide the family members the necessary education and knowledge about Alzheimer's dementia that the patient is suffering from explaining to them the patient’s manifestations and the course of the disease. Providing the family with the knowledge regarding the disease will enhance their understanding of the patient's behaviour and help them to understand and cope up with the patient’s disease,help them to rationalize the need of anti anxiety and sedative medications and accept the patient's medical management for the same

The nurse should emphasize and acknowledge the concerns of the family members and at the same time explain to them the possible harms that can happen if the patient's agitation is not controlled by suitable medications including the risk of injury, falls,fractures, self-harm and aggravation of the hypertension and chest pain.

The need for patients sedative medications and anti anxiety drugs to promote patient safety and prevent risk for injury should be emphasized to the family members as a part of the nursing education and family teaching plan during interaction with the family.

The nurse handles the situation calmly, empathises and educates the family and continues to provide patient centered care with the family agreement and education

What does the nurse prepare and why?

answer:

The nurse prepares anti-anxiety medication in consultation with the physician for the drug and dosage in order to calm the patient, The patient has received 0.25 milligram alprazolam at 2 p.m. and is again anxious at 5.00pm. So the nurse must prepare to administer anti anxiety drug to the patient in order to avoid patient aggressiveness, patient agitation and panic behaviour after consulting the physician for the drug and dose.

Alprazolam is recommended to be given in the dosages of 0.25 -0.5 milligrams per dose two to three times a day with a maximum dose of 4 milligram per day in elderly patients.

Alternatively as the patient has finished her supper, the nurse may also consider the administration of  the sedative Zolpidem[ambien] instead of alprazolam in order to help the patient relax and go to sleep.

The reasons for the same:

The patients of Alzheimer's dementia are prone to agitation in new places, noisy places, crowds or in presence of visitors as this can cause excessive sensory stimulation and disturbed thought process leading to patient confusion and patient behavioural changes. The patient is at risk of falls, self-injury,agitation or aggressive behaviour if the anxiety is not controlled.The nurse upon recognising the signs of anxiety in the patient must give anti anxiety drugs to the patient in order to promote patient safety and prevent risk for injury.

Also as the patient has a history of hypertension ,cardiovascular disease and is admitted for chest pain, increase in patient anxiety may aggravate the patient’s chest pain and cause medical complications related to cardiovascular disease.

So the nurse must administer appropriate anti anxiety drugs or the sedative drugs in order to calm the patient

What foods on the supper tray contribute to the patient’s safety?

answer:

The foods on the supper tray that contribute to the Patient's Safety are

1. roast beef:

The beef provides high calorie nutrient dense food to the patient to take care of the patient's nutritional needs and protein needs which are required for health maintenance and proper immune functioning. Roasting decreases the fat content of the food making it healthy.

It contributes to the patient's safety in that it prevents the patient's risk of malnutrition and poor immunity due to lack of proteins and good nutrition

2. Salad

The use of fruits and vegetable salad in the diet of the patient increases the fibre content of the food decreasing the fats making it very important in the safety of the patient by decreasing the patient's blood lipids and cholesterol levels as the patient has hypertension and cardiovascular disease.

Also as the patient is elderly and has Alzheimer's dementia, high fibre intake tends to decrease the constipation, promote regular bowel movement and keep the patient protected from the stress of straining at stools.

Thus it contributes to patient's safety in that it decreases the risk of hyperlipidemia, hypercholesterolemia and thus decreases the risk of myocardial infarction and stroke for the patient and also protects the patient from the risk of constipation

3. chocolate pie.

The chocolate pie is high calorie nutrient dense food which provides the patient necessary energy to carry out her daily activities. The cocoa in the chocolate pie has phyto flavonoids. considered to improve the cognition in patients of dementia and have general calming ,anti-anxiety effects.

The chocolate pie contributes to the patient's safety in that it provides patient necessary energy required for the body functioning and also can prevent the worsening of cognitive decline for the patient and also has a calming anti-anxiety effect.

4. hot tea.

The consumption of hot tea sips along with the roasted beef is recommended in the patients of Alzheimer's dementia as the patients have problems with swallowing and risk of choking.

The hot tea contributes to the patient's safety by preventing choking risk while the patient is eating by adding to the liquid content of the supper.Precautions should be taken to avoid spillage of the hot tea

Additionally,the use of a fortified milk with Vitamin D is advised in the tea for the elderly patients in order to prevent patient’s risk of calcium deficiency, osteoporosis and risk of fracture and increase the food contribution in the patient's safety

Thus all the foods on the patient's supper tray contribute to the patient safety,chocolate pie in particular as it can calm the patient and improve the cognition. Due precautions should be taken to take care that the patient does not hurt herself by spilling the hot tea.

What patient teaching is necessary?

answer:

Patient teaching is very important in patients of dementia in order to help the patient cope with the disease and improve her quality of life

1.Patient should be educated in a calm and quiet voice,small sentences and trained to a simple routine in order to be able to perform the activities of daily living.

2.The patient should be reassured that the patient is well cared for and that help will be provided as an when the patient needs help.

3.The Patient should be trained into regular exercise as also with use of assistive devices if required as this reduces patient anxiety and promotes good health and wellness.

4.Teaching the patient to eat small bites of food and drink sips of tea or coffee or liquids while eating so as to prevent the risk of choking is important.

5.Self care and getting enough sleep with use of memory aids is important patient teaching.

6. Taking medications regularly and getting regular checkups and avoiding risky activities should be taught to the patient

7.Patient teaching regarding health care proxy status and power of attorney should be given early in the course of the disease before the patient dementia worsens

family teaching and education

The patient teaching and patient care in dementia is incomplete without family teaching and education

1. The family of the patient should keep the patient in familiar surroundings so that the patient can adopt a simple routine.  

2.The family needs to be taught about dealing with the patient with calm, patience and flexibility at home ,avoiding major changes around the patient.

2 family education and teaching in order to educate them to eliminate the potential hazards in the surroundings of the patient at home like the slippery rugs, wet surfaces, loose electrical cords, clutter should be done.

3. Advising the family not to allow the patient to cook or drive or be sent outside the house alone without supervision.

4. Placement of identity card with adress and contact number in the pocket of the patient in case the patient wanders and gets lost

5. labelling of the patient's personal belongings and the scheduling of the daily routine on a chart in order to boost the patient memory and provide visual reminders.

6. Ensure safety of the patient surroundings in order to prevent risk of injury , falls and fractures

7. Family education about the support groups of Alzheimer's dementia and the patient's need for a dedicated caregiver at home or institutional care in view of her increasing dementia.

8.Family education regarding the establishment of the healthcare proxy status and the power of attorney of the patient should be given to the family before the dementia worsens

9. stress relieving measures for the family members must be taught as they can to suffer from burnout due to taking care of the patient of dementia

Extreme patience and calm must be observed by dealing with patient teachings and education and teaching of the patient's family.