Case study 1.
Read Rob’s story, outlined on page 325-326 of your course textbook (Scoot, Shannon & Davies, 2017, p. 325-326).
Rob is experiencing symptoms and signs of Alzheimer’s disease. Alzheimer’s disease is a chronic disease which causes degeneration of neurones. The disease progresses slowly and it is the cause of 70% of all cases of dementia worldwide (Khan, Elhassan, and Qureshi 2014, p. 47). Early symptoms of Alzheimer’s disease are difficulty remembering recent events and memory loss. As the disease advances, symptoms such as language problems, disorientation, mood swings and lack of motivation develop. Rob is not able to remember where he left some tools he had used recently. He also experienced difficulty in driving which led to him causing an accident. Alzheimer’s disease leads to loss of neurons and synapses in the cerebral cortex. This leads to atrophy of affected brain regions especially temporal and parietal lobes. Frontal lobe and cingulate gyrus may also be affected. The disease result due to deposition of insoluble beta amyloid plaques and neurofibrillary tangles outside and around the neurons. Beta amyloid plaques are formed when gamma secretase and beta secretase divide the amyloid precursor protein into smaller fragments through proteolysis. According to hall (2015), amyloid precursor protein is a transmembrane protein which is important in the growth and repair of neurones after injury. Therefore, division impairs its function. Neurofibrillary tangles result due to chemical changes in tau protein. Tau protein is important in stabilizing microtubules. In Alzheimer’s disease tau protein becomes hyper phosphorylated and pair with other threads creating neurofibrillary tangles which disintegrate neuron’s transport system (Serrano-Pozo 2015). The disease mechanism result due to deposition of toxic proteins around the neurons which induces apoptosis therefore, progressive neuron degeneration. Psychosocial factors such as low educational achievements, non-mentally stimulating activities and lack of physical exercises have been found to contribute to Alzheimer’s disease (sachdev et.al 2017 p. 11-23).
Appropriate assessment tool for Alzheimer’s disease is the Alzheimer's disease assessment scale-cognitive subscale ( ADAS-Cog test).This tool mainly measures language and memory. It consists of 11 parts and takes approximately 30 minutes to administer. It measures two-part scale, the cognitive function and non-cognitive functions such as behavior and mood. The 11 parts of ADAS are: word recall task which can be tested by giving the patient a list of ten words and asking the patient to recall as many words as possible. This helps in testing short term memory. Naming objects and fingers can be tested by presenting different items to the patient asking him to name them. Following commands like making a fist, Constructional praxis to test visuospatial abilities, Ideational praxis, orientation and word recognition task are other items to remember test directions, spoken language comprehension and finally word finding difficulty (Solomon, Feaster, and Miller 2016, p. 286).
Self-care deficit related to cognitive decline and physical limitation is one of the priority nursing diagnoses. The patient can be helped to remember as many tasks as possibly by maintaining regular daily activities and dividing tasks to smaller parts (Ackley, Ladwig and Makic 2016).
Altered thought process related to irreversible neuronal damage can be intervened through multidisciplinary involvement and also pharmacological intervention (Livingstong et.al 2017, pp.2673-2734). Risk of injury related to weakness and inability to recognize or identify hazards in the environment is another priority nursing diagnosis. Individuals can be helped to avoid injuries by providing a safe environment and removing all unnecessary items in the patient environment.
Poor care and support can breach the rights of people with Alzheimer’s therefore caregivers should be advocates to these patients due to their forgetfulness and decline cognition.
Eating diet lacking one or more nutrients can lead to a condition called malnutrition. Important nutrients are carbohydrates, proteins vitamins and minerals. Malnutrition is common in old people especially those who are 65 years and above. This is due to several factors which can be either intrinsic or extrinsic. Diseases such as gastroenteritis and chronic illnesses can lead to malnutrition (Cederholm.et.al 2015 p.335-340). These diseases affect digestion and absorption of nutrients thus reducing nutrients available for use. They can also increase metabolic demand, decrease food intake or directly lead to nutritional loss for example in conditions such as diarrhoea. The digestive system undergoes changes in old people. This results in decreased nutrients absorption and malnutrition can result. Old people also have decreased appetite and therefore intake of less food. They also have health problems with a wide range of food therefore influencing their nutrition. Psychosocial factors such as poverty and food prices have an influence in individual's nutrition (Bokhari.et.al 2018 p.351). Poor socioeconomic status inhibits purchase of nutritious foods such s meat and milk. This forces poor people to opt for affordable food even though they are not of any nutritious benefit. Agricultural productivity is also a contributing factor to malnutrition. Food shortages can be caused by natural calamities such as famine and floods. Poverty can also be a cause as farmers cannot afford to buy fertilizers, pesticides or storage facilities. Loneliness can also contribute to malnutrition. From Dulcie's story, it is clear that she is not eating a balanced diet now that she is living alone. She takes simple meals which may contribute largely to her nutritional status deteriorating. Therefore, living with other family members can help stimulate appetite.
The most appropriate tool to assess malnutrition in old people is the MNA tool. It is used to screen for malnutrition or risk of malnutrition in people with 65 years and above. It consists of six questions. They include; asking the patient whether there has been a decline in food intake for the last three months due to loss of appetite or any other digestive problems. Two points are given if there is no decrease in food intake, 1 point if there is moderate decrease and 0 if there is severe decrease in food intake. Another question is asking about weight loss within the last three months. Score of zero is given if there is a loss of more than 3 kg, 1 point if the patient doesn't know, 2 points if weight loss is between 1 and 3 kgs and 3 points if no weight loss. Mobility is another part. A score of zero is given if the patient is on bed or chair bound, 1 point if the patient is able to get out of bed and 2 points if the patient can go out. If the patient has suffered from any psychological stress or an acute disease, 0 point is given and two points if no history of psychological stress or an acute disease. If the patient has suffered from neurological problems such as severe dementia or depression, 0 is given. If the patient has mild dementia 1 point is given and two points if the patient has no psychological problems. Finally, body mass index is done. If the patient has a BMI of less than 10 a score of zero is given.1 point is given if the BMI is between 10 and 21, 2 points if BMI is between 21 and 23 and 3 points if the BMI is more than 23. In total, between 12 and 14 points indicate normal nutrition, between 8 and 10 points indicate risk of malnutrition and between 0 and 7 points shows malnutrition (Marshall.et.al 2017).
Imbalanced nutritional intake less than body requirement related to poor appetite and changes in the digestive system is one of the priorities of care. This can be intervened by serving food in a pleasing manner to stimulate appetite.
Activity intolerance related to decreased energy levels is also another priority of care. Old people can be helped by encouraging them to perform their duties slowly and having rest periods in between.
Risk of injury related to poor muscle tone and low immunity. Old people have decreased immunity and malnutrition makes it worse. Therefore, patients should be encouraged to avoid situations that can predispose them to injuries.
People have a right not to be malnourished. Old people find it difficult to fight for their rights therefore, health professionals should be their advocates. They should be encouraged on what to eat and what not to eat in order to maintain normal nutritional status.
Falls are a common and serious health problem with consequences especially in elderly. They are significant in causing mortalities and morbidities and are class of preventable injuries. The cause of falls is usually multifactorial and therefore requires multidisciplinary approach in the management. Falls are caused by a number of factors which may be either intrinsic or extrinsic. Intrinsic factors include; existence of an ailment or disease for example stroke (Pasquetti, Apicella, and Mangone 2014, p.222). Extrinsic factors include environmental factors such as poor lighting. Intrinsic factors such as balance and gait can cause falls. This may result from diseases such as stroke, Parkinsonism, arthritic changes and neuromuscular diseases. Medication side effects given for other conditions may contribute to falls. Medications such as sedatives, polypharmacy and cardiovascular medications are of great importance. Visual conditions such as glaucoma, cognitive problems such as dementia and cardiovascular conditions such as orthostatic hypotension are also important in causing falls in elderly. Extrinsic factors such as poor lighting and eyesight deterioration with age can cause falls as old people cannot see clearly especially in dim light and therefore may not see hazards around them. Stairs with inadequate handrails are also a risk factor. Old people have reduced balance and therefore require some support especially in climbing stairs. Doorways without adequate headroom and floors with low friction can also cause falls. Low friction floors cause poor traction and individual instability. People with joint problems such as arthritis require additional support when walking. Walking aids such as walking sticks or walking frames are important to them. Therefore, lack of these walking aids my lead to falls (Ungar et.al 2016, pp.877-882).
The Morse fall scale is a rapid assessment tool used to assess patient’s likelihood of falling. It consists of six parts, they include: History of falling by scoring 25 if the patient has fallen during hospitalization and 0 if no history of fall. Secondary diagnosis, a score of 15 is given if the patient has more than one medical diagnosis and 0 if none. Ambulatory aid, a score of 15 is given if the patient is using a wheel chair or if he cannot get out of bed. A score of 30 is given if patient ambulate using crutches and score of 0 if no ambulatory aid is used. Gait, a score of zero if normal gait, score 15 if weak and 20 if impaired. Intravenous therapy, score 20 if on IV or heparin lock, 0 if not. Mental status score of 0 if oriented and 15 if forgets limitations. The patient is then classified as being of no risk, low risk or high risk and appropriate intervention implemented (Sadro et.al 2016, pp.34-40).
Risk of falls related to altered mobility and associated medical condition is one of the priorities of care. This can be intervened by providing a safe environment for the patient and ambulatory aids (Milos et.al 2014, p. 40).
Activity intolerance related to functional changes accompanying the aging process is another nursing diagnosis. The patient can be encouraged to perform activities more slowly to conserve energy and teaching the patient how to schedule her activities (Doenges, Moorhouse and Murr 2016).
Disturbed thought process related to aging process is one of the priorities of care. Protecting the patient from sensory overload and allowing frequent rest will helpful.
Elderly people have decline in memory and cognitive process and therefore their rights can be affected as they cannot fight for themselves.
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