Assessment Guidelines Dementia 1.

Identify the underlying cause; for example, does the client have a history of: y Depression y Substance abuse y Pernicious anemia 2. How well is the family prepared and informed about the progress of the clients dementia (e.g., the phases and course of Alzheimers disease [AD], vascular dementia, AIDSrelated dementia, multiple sclerosis, lupus, brain injury)? 3. How is the family coping with the client? What are the main issues at this time? 4. What resources are available to the family? Does the family get help from other family members, friends, and community resources? Are the caregivers aware of community support groups and resources? 5. Obtain the data necessary to provide appropriate safety measures for the client 6. How safe is the clients home environment (e.g., wandering, eating inedible objects, falls, provocative behaviors toward others)? 7. For what client behaviors could the family use teaching and guidance (e.g., catastrophic reaction, lability of mood, aggressive behaviors, nocturnal delirium [increased confusion and agitation at night; sundowning])? 8. Identify family supports in the community

Basic workup for dementia y y y y y y y y y y y y y Chest and skull radiograph studies Electroencephalography Electrocardiography Urinalysis Sequential multiple analyzer: 12-test serum profile Thyroid function tests Folate levels Veneral disease research laboratories (VDRL), HIV tests Serum creatine assay Electrolyte assessment Vitamin b12 levels Vision and hearing evaluation Neuroimaging (when diagnostic issues are not clear)

NURSING DIAGNOSES WITH INTERVENTIONS Discussion of potential nursing diagnoses The care of a client with dementia requires a great deal of patience and creativity. These clients have enormous needs, and put enormous demands on staff caring for demented clients, and on families who carry the burden at home. As some of these disease progress, most notably AD, so do the demand on the staff, caregivers, and family. Safety is always a major concern. Risk for injury might be related to impaired mobility, sensory deficits, history of accidents, or lack of knowledge of safety precautions. As time goes on, the person loses the ability to perform tasks that were once familiar and routine. The inability of the person to care for basic needs covers all areas (e.g., bathing, hygiene, grooming, feeding, and toileting). Therefore, self care deficit usually involves many functions. The goals are set up so that individuals can do as much for themselves as possible during each phase of the dementia. Impaired verbal communication is often related to diminished comprehension, difficulty recognizing objects, aphasia, cerebral impairment, and severe memory impairment. Therefore, family and health care workers need to know ways to interact with a person with this nursing diagnosis. The burden of caring for a family member with dementia can be enormous, especially over prolonged periods of time. Family members need a great deal of support, education, and guidance from community agencies and well-informed health care workers. Families might experience disable family coping, which should always be addressed when it is recognized. Therefore, risk for and/or caregiver role strain should be part of the initial assessment, and must be continuously assessed as the dementia progresses. Most families will need information, support, and periods of respite. Overall guidelines for nursing interventions 1. Educate family on safety features for impaired family member living at home-for example: y Precautions for wandering (e.g., Medic-Alert bracelet, home safe program, effective locks) y Home safety features (e.g., eliminating slippery rugs, labeling of rooms and drawers, installing complex locks on the top of doors) y Selfcare-guidelines on maintaining optimum nutrition, bowel and bladder training, optimum sleep patterns, and working to optimum ability in activities of daily living 2. Educate family (and staff) on effective communication strategies with a confused client, for example:

Teaching alternative modes of communication when client is aphasic Teaching basic communication techniques with confused clients (for example: introduce self each time; use simple, short sentences; maintain eye contact; focus on one topic at a time; talk about familiar and simple topics) 3. Family/caregiver support is a priority. Provides names and telephone numbers of support groups, respite care, day care, protective services, recreational services, meals on wheels, hospice services, and so on that are within the family/ caregivers community. Encourage the use of support groups for caregivers. 4. Provide family with information on all medications client is taking (use for each, potential side and toxic effects, any interactions that could occur) and name and number of whom to call with future questions. y y

SELECTED NURSING DIAGNOSES AND NURSING CARE PLANS 1. RISK FOR INJURY At risk of injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources Related to (etiology) y y y y         Sensory dysfunction Cognitive or emotional difficulties Chemical (drugs, alcohol) Biochemical Confusion, disorientation Faulty judgment Loss of short-term memory Lack of knowledge of safety precautions Previous falls Unsteady gait Wandering Provocative behavior

As evidenced by (assessment findings/diagnostic cues) y y y y y Getting into fights with others Choking on inedible object Wandering Burns Falls

y y

Getting lost Poisoningwrong medication, wrong dose

Outcome criteria y y y Highest level of functioning will be supported Optimum health is maintained (nutrition, sleep, elimination) Free of fractures, bruises, contusions, burns, and falls

Long-term goals y y y With guidance and environmental manipulation, client will not hurt himself/herself if falls occur With the aid of an identification bracelet, neighborhood or hospital alert, and enrollment in the safe return program, client will be returned within 3 hours of wandering Client will ingest only correct doses of prescribed medication and appropriate food and fluids