Nursing Aspects In Care Of Patients With Dementia

Problems/Needs

A. Physical problems :

Nursing Management

1. Urinary incontinence or inappropriate urination

Other possible causes of incontinence should be identified before contributing the problems to dementia.

• Avoid giving the dementia patients fluids after 6.00 p.m. at night and then the patient be toileted prior to being taken to bed.

• If nocturnal incontinence continues to be a problem, it might be necessary to toilet half way through the night.

• If cold cause recurrent urinary tract infection and that in itself could lead to other problems with regard to the patients care. The only solution which could give some relief to this distressing condition is regular toileting

• Locate bed near a bathroom when possible.Take patient to the toilet at regular intervals.

• Establish bladder /bowel training programme

• Promote patient participation to level of ability.

2. Faecal smearing:

This is due to constipation and improper evacuation of his or her bowel

• Provide the patient with laxative

• Arrange for regular toileting. Regular bowel evacuation does indeed relieve this condition to a fair extent.

• Maintain personal hygiene.

• Adequate bowel elimination is essential for physiologic functioning and daily comfort of older clients.

3. Lack of personal hygiene

• Encourage adequate fluid intake during the day, diet high in fiber and fruit juices

• Provide good skin care

• Record frequency of voiding/bowel movements

• Help him to brush and take bath.

• Give back massage to prevent bed sore.

• Change position.

• Observe skin for injuries, bruises or abrasion.

4. Nutritional Problems

Changing in eating pattern is very important to deal during the care of dementia patients. This change may lead to weight loss or weight gain. The dementia suffers can indulge in inappropriate feeding habits such as stuffing their mouth with hot food resulting in burns or choking.

They often suffer from dehydration because they cannot recognize the discomfort of thirst or remember when they had their last drink

• Assess patients/families knowledge of nutritional needs

• Ask likes & dislikes.

• Don't make the patient to hurry up. Provide enough time for eating

• Ensure adequate hydration. Hence the patient can be given with diluted juices because they are palatable and provide needed calories.

• Provide roughage and green leafy vegetables

• Provide finger foods

• Observe swallowing ability, monitor oral activity

5. Impaired sleep:

• Discourage day time sleep

• Keep him busy with activities / exercises

• Encourage warm bath at night

• Keep the room calm.

• Allow to do some interested activities like reading books etc.

• Increase interaction time between patient and family/staff during day

• Avoid use of continuous restraints

• Evaluate level of stress/orientation as day progresses

• Adhere to regular bed time schedule

• Reduce fluid intake in the evening

B. Emotional problems

Encourage the family members to be with the patient.

• Listen to the patient's feelings.

• Give reassurance to the client.

1. Anxiety

2. Wandering :

Wandering is defined as moving about in an apparently aimless or disoriented manner. Wandering is a behaviour that causes great concern to care givers.

The nurses observe patients carefully to identify situations that contribute to wandering behaviour. The various points to deal the wandering behaviours are:

• Provide familiar objects, signs and pictures

• The elderly person must always be secured and protected under some ones observation and protected to prevent wandering away from home.

• Decrease excessive stimulation

• Decrease stress in the environment especially during the night.

• Provide meaningful activity.

• Safe areas can be provided where patients can move freely.

• The physical environment can provide safety and security and promote a degree of orientation than can help lessen anxiety and agitation and promote functions confused elders.

C. Cognitive impairment

1. Confusion

• Assess degree of cognitive impairment

• Maintain a pleasant ,quiet environment

• Approach in a slow, calm manner

• Address patient by name

• Face the individual when conversing

• Give simple directions, one at a time, step by step instructions, using short words and simple sentences

• Focus on appropriate behaviour, give verbal feedback, positive reinforcement

• Identify potential dangers to client in environment.

• Place identification bracelet on clients

• Avoid unfamiliar situation

• Decrease noise levels by call light

• Give one simple direction at a time

• Use symbols rather than written signs to assist clients to locate room, bathroom

2. Ineffective communication

• Pleasant ,calm, supportive tone of voice should be used

• Verbal communication should be clear, concise & unhurried

• Nonverbal techniques especially touch may be reassuring to the patient

• Pictures & symbols can be used for locating bathrooms, bedrooms or other areas in the setting

• Environmental clues can prevent unwanted behaviour. Creative use of environmental cue is putting a stop sign on an exit door.

• Maintain eye contact

• Give time for comprehension

• Repeat key words & phrases

• Use gestures, pictures & facial expression to convey more meaning

• Listening carefully can help decipher a patients words substitution & generally understand what the patient is trying to say.

• Use short small sentences

• Repeat sentences as often as needed & periodically summarize what has been said

• Continuous praise & encouragement promote successful communication with Alzhiemer's disease patients.

• To question, ask one specific question at a time requiring yes or no or multiple choice answer.

• Use soft voice while conversing

• Music therapy is a very effective method to enable communication for patients in third stage because it helps to preserve quality of life

• Simplify the verbal message using more than five or six words at a time .

• Accompany words with touch & visual clues to decrease confusion & increase clarity of message

Identify hearing & vision impairments

• Maintain eye contact-Determine in which language the client can communicate more effectively by asking family ; & use interpreter if necessary

• Approach from the front, make eye contact, address the person by name, and speak in a calm voice.

• Talk first; pause ; touch second, reducing the person's threat.

• Avoid verbal testing or questioning beyond the client's capacity

• Do not argue or insist that the client accept your reality.

• Be aware of memory impairments in addition to communication difficulties.

• Assessment of specific receptive & expressive language abilities helps in understanding the client's communication difficulties & facilitate communication.

Lubinski 1991 discusses the following needs for improved communication

1. To develop & maintain a sense of identity to permit elderly patients to be participants in their care

2. To vent anxieties

3. To relieve loneliness

4. To diminish depression

5. To exercise some power or influence

6. To meet basic desire & need

3. Reduce disorientation

• Assess patient's level of disorientation /confusion to determine specific requirement for safety

• Orient to him to time, place & persons with the help of a clock, calendar & physical setup

• Remove dangerous articles like lighter, matches, cigarettes & sharp objects

• Provide padded side rails

• Call him by name

• Orient patient to reality and surroundings at frequent times

4. Memory:

• Repeat the routine activity

• Speak slowly, clearly in simple sentences

• Convey warmth & concern

• Encourage him to speak clearly

• Create comfortable environment

• Provide opportunities to recall past events

• Encourage to use written cues such as calender, lists or a notebook

• Keep environment changes to a necessary minimum

• Provide single step instructions for the client when instructions are needed

5. Spiritual needs

• Make them understand that change is due to disease

• Tell relatives not to get irritated if the patient forgets to inform important message Give appreciation for complete work

6. Support to families

• Allow patient to attend regular prayers

• Don't get irritated with extra time spent by patient for prayers

• Provide guidance & counseling

• The nursing professionals should help & advice the caregivers to cope with their emotional problems.

• A very important aspect is to promote communication between caregivers & individuals with dementia.

• Note physical /mental condition ,therapeutic regimen of care receiver

• Identify strength of care giver and care receiver

• Provide information or demonstrate techniques for teaching with acting out disoriented behaviour

• Discuss care giver's view and concerns about situation

• Determine available supports and resources currently used

7. Therapeutic needs

• Give medicines as prescribed

• Help he patient to express his physical complaints

• Provide reassurance

8. Prevention from injuries

• Provide adequate furniture in the room Electricity connection should be covered Provide bell within reach of the client Adequate light should be provided

• Pleasant & quiet environment should be provided

9. Impaired social interaction

• Do not allow the client to embarrass himself/herself I in front of others

• Intervene as soon as you observe embarrassing behaviour

• Praise the client for appropriate behaviour

• Determine the client's interests, hobbies and favorite activities before hospitalization

• Assess the client's current capability of engaging in former hobbies or activities. Make these activities available as much as possible

• Approach the client with a calm, positive attitude

• Begin with small, short term activities, initially one-one staff, and gradually progress to small groups

• Encourage small group activities or discussion of an activity with clients who share similar interests

• Allow the client to ventilate feelings of despair and hopelessness