High Priority Nursing Diagnoses and Potential Interventions

Nursing diagnoses are potential or current problems that nurses base their care around to best serve and care for their patients. Below is a set of most prominent nursing diagnoses that should be addressed in the care of a patient with Alzheimer's disease. Included are also some suggestions on what to do as a nurse to address and help manage these problems.

1. Risk for violence: self-directed or other-directed
This problem can be due to many other problems, including impaired perception of reality, impaired frustration tolerance, decreased self-esteem, perceived threat to self, impaired coping skills, drug intoxication, physical discomfort, etc.

Assessment to detect and monitor this nursing diagnosis:
-assess cognitive factors that may contribute to violent behaviors such as impairment in judgment, delusional thought patterns, and impaired concentration or decreased response to redirection
-assess for physical factors that may foster violence (discomfort, sensory overload, noise, etc.)
-assess emotional factors that can lead to violence (inability to cope, expressions of low self-esteem, noncompliance with treatment plan, history of aggressive behaviors)
-evaluate the impact of the medication regimen on behaviors

Therapeutic interventions:
-involve the patient on a cognitive level as much as possible
-reorient, reduce stimuli, and keep constant schedules with patient
-attempt feedback on behavior inappropriateness
-allow patient with more personal space and independence if possible
-provide with diversional activities
-permit verbalization of patient feelings
-offer acceptable alternatives to unacceptable behaviors
-initiate safety measures

2. Self-care deficit: bathing, dressing, feeding
This problem can occur in the presence of impaired memory, disorientation, impaired judgment, or impaired sense of social self.

Assessments to detect and monitor problem:
-assess for cognitive deficits or behaviors that could create difficulty in performing personal hygiene
-assess level of independence in completing self-care

Therapeutic interventions:
-instruct caregiver in strategies to improve self-care activities
-stay with patient during self-care activities if judgement is impaired
-allow enough time with limited distractions in environment
-follow established routine for self-care
-provide easy-to-read reminders of self-care activities
-assist with care as needed, but always encourage patient independence
-limit number of choices of food on plates or trays
-provide easy-to-eat finger foods if motor coordination is impaired

3. Impaired social interaction
This problem can occurs with impaired sense of social self, memory deficits, disturbed thought processes, social isolation, and impaired judgment.

Assessments to detect and monitor problem:
-assess for cognitive deficits or behaviors that inter ere with forming relationships with others
-assess for previous patterns of interactions
-assess patient's potential to interact in a community day care situation

Therapeutic interventions:
-provide regular opportunities for frequent, brief contacts within a nurse-patient relationship
-encourage regular opportunities for interpersonal contacts and relationships
-assist caregiver with supporting participation in social activities as appropriate
-redirect patient when behaviors become socially embarrassing or when the patient expresses delusional ideas
-discuss subjects with patient that is of interest but does not require short-term recall
-consider impact of environment on social interactions, avoiding overstimulating environments
-involve the patient in a daily schedule that allows for social activity as well as quiet time
-provide information on community day care programs

4. Impaired home maintenance
This problem can become present due to impaired memory, disorientation, or impaired judgment in the patient.

Assessments to detect and monitor problem:
-determine the adequacy of the home environment
-assess patient's ability to recognize dangers or hazards in the home
-assess frequency of disorientation, wandering, and becoming lost in familiar surroundings
-assess family's and/or caregiver's understanding of patient needs and deficits, resources, and family's ability to cope and find support systems

Therapeutic interventions:
-involve the patient, family and/or caregiver in all home planning
-discuss need to wear identification bracelet at all times
-suggest daily supervised exercise or a walking program
-identify and encourage the correction of obstacles and hazards in the home
-provide information about home security devices
-recommend procedures for getting help in case patient becomes lost
-help family to identify and mobilize available support networks (home health services, support groups, church groups, senior citizen organizations, etc.)
-provide literature and references related to caring for cognitively impaired people in the home

5. Caregiver role strain
This problem can sometimes be overlooked, but it is an important aspect of patient care. This problem can occur when caregivers have knowledge deficit regarding management of care, personal and social life disruptions due to caregiving, multiple competing roles, no respite from caregiver demands, or do not have community resources available.

Assessments to detect and monitor problem:
-assess caregiver-care recipient relationship
-assess family communication patterns
-assess family resources and support systems
-determine caregiver's knowledge and ability to provide patient care

Therapeutic interventions:
-provide information and instruction on disease process and management strategies
-encourage caregiver to identify available family and friends who can assist with caregiving
-suggest that caregiver use available community resources
-consult a social worker for referral for community resources and/or financial aid as needed
-encourage the caregiver to set aside time for self
-acknowledge to caregiver his or her role and its value

Source:
Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. 8th ed. Philadelphia: Elsevier Mosby. Print.

List of Nursing Diagnoses

Here is a list of potential/current patient and caregiver problems that nurses should address or keep in mind:

Anxiety
Caregiver role strain
Ineffective coping
Interrupted family processes
Fear
Grieving
Hopelessness
Powerlessness
Deficient knowledge
Risk for suicide
Risk for violence
Chronic confusion
Impaired dentition
Deficient fluid volume
Ineffective health maintenance
Impaired home maintenance
Impaired memory
Imbalanced nutrition: less than body requirements
Self-care deficit
Ineffective therapeutic regimen management
Disturbed sensory perception
Risk for impaired skin integrity
Risk for infection
Impaired tissue integrity
Risk for aspiration
Impaired swallowing
Impaired verbal communication

Source: Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. 8th ed. Philadelphia: Elsevier Mosby. Print.

Nursing Perspective: Monitoring to Promote Maintenance of Health

As a nurse, it is important to encourage patients to come back for regular check-ups and keep the medical team informed on the progression of their disease. This allows for safer treatment options and keep the patient in a better state of health for longer. Nurses need to keep track of how the disease progresses over time, which means that behavioral and cognitive tests should be done on a regular basis to establish this trend. It is also important to include both the patient and their family members/caregivers in the process to get a full picture of the patient's progression.

Management of Alzheimer's Disease Symptoms

Alzheimer’s disease treatment involves a handful of medications that help to manage the symptoms of Alzheimer’s disease. It is important to note that this medications can’t change the progression of the disease and is not by any means a cure. Therefore, a major nursing goal for someone with Alzheimer’s disease is to help them manage their behavioral and psychological symptoms that are a result of their disease. 

These symptoms are commonly presented not only in patients with Alzheimer’s disease, but also in patients with other forms of dementia. As a result, these symptoms are categorized under BPSD (behavioral and psychological symptoms of dementia), and includes but are not limited to presentation of agitation, aggression, depression, and psychosis. 

These symptoms can be controlled with medications designed for both Alzheimer’s disease or for general symptoms of BPSD (such as antipsychotics, antidepressants, anticonvulsants, and mood stabilizers). 

However, non pharmacological treatments are also important for managing symptoms. This would include addressing the cause of the symptom and relating it to the experience a person with Alzheimer’s disease might be expressing. Management of symptoms may also look like working with the patient on ways to minimize challenges and obstacles to his or her comfort and ease of mind. It is also pertinent to look at ways of changing daily activities to help encourage independence in a patient with Alzheimer’s disease while still keeping safety and comfort as a top priority. 

Source: Yaffe K, Fox P, Newcomer R, et al. Patient and caregiver characteristics and nursing home placement in patients with demential. Jama J Am Med Assoc. 2002;287(16):2090-2097

Medications and How They Work

The current method of treatment for Alzheimer’s disease is focused around slowing the progression of the disease since a cure for Alzheimer’s disease has not been discovered yet.

The FDA (U.S. Food and Drug Administration) has approved 5 medications for this treatment of symptoms (see Figure above).

These 5 medications can be divided into 2 categories based on how they work in the body. 

The first category, cholinesterase inhibitors, includes four of the five drugs: donepezil (Aricept), galantine (Razadyne), rivastigmine (Exelon), and tacrine Cognez), and the second category, NMDA receptor antagonists, includes memantine (Namenda).

In order to understand how these drugs work on the brain, we must first understand how a normal brain works. The brain is similar to mass communication system, with chemicals that are passed between brain cells  (these chemicals are called neurotransmitters) that serves as messengers to pass the information along from cell to cell. In Alzheimer’s disease, this communication pathway is damaged causing the brain to lose information (memory loss, etc.) and make it more difficult for the brain to learn new things. 

Cholinesterase inhibitors prevent a very important neurotransmitter (Acetylcholine) from being broken down (by a protein called cholinesterase). This allows the neurotransmitter to stay active in the brain longer, promoting continued communication among the brain cells.

NMDA (N-methyl-D-aspartate) receptor antagonists focus on slowing the process of cell damage in Alzheimer’s disease as apposed to promoting communication directly. NMDA receptor antagonists prevents a different neurotransmitter (glutamate) from working on its targeting brain cell (also known as a neuron). In Alzheimer’s disease, there is too much glutamate release from damaged cells, leading to a faster progression of cell damage. NMDA receptor antagonists prevent glutamate from doing its job as effectively, which can slow down the progressive cell damage process.

Figure: FDA-approved drugs. (n.d.). Retrieved February 6, 2015.

Source: Current Alzheimer's Treatments. (n.d.). Retrieved February 6, 2015, from http://www.alz.org/research/science/alzheimers_disease_treatments.asp#how

I'm Not Gonna Miss You -- Glen Campbell

Singer Glen Campbell was diagnosed with Alzheimer's disease in 2011 and wrote this song " I'm Not Gonna Miss You" in light of the diagnosis.

Source: UpWorthy

Nurse's Perspective: Managing Alzheimer's Disease

Because Alzheimer’s disease has no cure, nursing care of patients with Alzheimer’s is focused around maintaining the patient’s quality of life, maximizing their independence doing daily activities, maximally enhancing and prolonging cognition, mood, and behavior, and encouraging continued interpersonal relationships and social interactions. Other elements include frequent monitoring of the patient’s health and cognitive function, encouraging and educating optimal support systems, introducing drug related and non-drug related treatments to manage the symptoms associated with Alzheimer’s, and evaluating the patients and their families’ motivations for volunteering in clinical trials (to help us further understand Alzheimer’s disease).

Source: Management and Patient Care (2009). Retrieved February 21, 2015, from http://www.alz.org/health-care-professionals/medical-management-patient-care.asp

Music Therapy and Alzheimer's Disease [Alive Inside Documentary]

Here is a promo video for the amazing documentary, Alive Inside, which talks about the potential of music therapy for treatment of the elderly, especially in cases of dementia, Alzheimer's disease, or other forms of memory loss. According to the documentary (and as can be seen above) music has the ability to stimulate multiple parts of the brain and can improve memory recall.

Source: YouTube

Signs and Symptoms of Alzheimer's Disease

Alzheimer's disease, like many other forms of dementia, can be hard to recognize in an aging adult because the symptoms are very relative to the individual's past mental state. Also, as a progressive disease, the changes in the behaviors can be slow enough to be hard to notice.

A lot of the symptoms listed below are ones that all people can have for short amounts of time or to a certain degree (especially occurring with advanced age). This also makes the line between early signs of Alzheimer's diseases and the normal aging process even harder to discern. 

One of the first signs of Alzheimer's disease is memory loss. This can be hard to determine because everyone occasionally forgets the name of a restaurant they recently tried or some of the items on a long shopping list they left at home. With Alzheimer's however, the memory loss is more severe and debilitating. In the early stages, newly learned information is easily forgotten. Also, once a person with Alzheimer's forgets this information, it usually isn't remembered later. Normal daily function is impaired by forgetting important dates or tasks. A person with Alzheimer's disease may heavily rely on memory aides (such as Post-It notes or alarms) and may also ask the same questions over and over again. The person becomes more dependent on family members and friends to help organize and navigate effectively through life.

People with Alzheimer's disease may also have difficulty with solving problems or making effective plans. Especially, these patients may notice having a harder time working with numbers (making lists, recipes, or tracking bills). This is usually relative and the deficit occurs in comparison to the person's previous abilities. 

Going hard in hand with number, patients with Alzheimer's disease also become easily confused with time or location. They can forget where they are or how they got there. The passage of time itself is sometimes hard to comprehend. This is different from occasionally having trouble with remembering the day of the week.

Alzheimer's disease also affects a person's ability to understand and interpret images and spatial orientations, as well as the ability to converse and string together words. This then leads to difficulty in reading, depth perception, and color determination. All of these symptoms greatly impede a person's ability to stay independent and perform daily activities.

Finally, changes in personality and withdrawal from social and work activities may also be a sign of Alzheimer's disease. Increased confusion, suspicion, depression, fear or anxiety could be a sign of Alzheimer's disease. People with Alzheimer's may also show decreased or poor judgment, such as frivolous spending or bad personal hygiene. 

All in all, the symptoms of Alzheimer's are quite relative, but they all work to impede the patient's ability to live independently. 

Source:

Know the 10 Signs - Early Detection Matters. (2009). Retrieved February 7, 2015, from http://www.alz.org/national/documents/checklist_10signs.pdf