Running Head: Nursing Care Study

E.S. is a 94 year old female, born July 30, 1909. She is widowed. She is of Catholic religion. She stated that her mother was from Germany and her father was from Ireland. She is an only child, and never finished school because she married at a young age. Her date of admission was July 8, 2002 with the diagnosis of left hip fracture and dementia. She was hospitalized for the left hip fracture on July 2, 2002, and then transferred to the nursing facility due to the inability of client to care for herself, as evidenced by inability to remember if she took her medication and needing assistance when toileting. Her code status is a DNR, comfort measures only. Antibiotics for infections are ok, but no feeding tubes or IV fluids. She has full upper and partial lower dentures. She receives a bed bath and has her nails and hair done once a week. She uses a wheelchair for ambulation, she needs assistance to help rise from her wheelchair to stand, and is unable to walk. Activity level is limited to those of which can be done in a wheelchair. She needs stand-by assistance with toileting and helping with transfers to and from her wheelchair.

Patient and Chart Information

Chronological Development of Clients Number One Medical Diagnosis

E.S.'s primary medical diagnosis is dementia. Her hip fracture may have been caused by changes in muscle coordination/balance, which is a symptom of dementia (Doenges, Moorhouse, & Geissler, 2002). She now uses a wheelchair for ambulation and needs assistance to transfer to and from her wheelchair. Her hip fracture has now healed, but she is still unable to care for herself due to her decline in cognitive abilities.

Current Signs and Symptoms

Current signs and symptoms of client's primary diagnosis of dementia include forgetfulness, inability to determine whether or not a task had been performed, as evidenced by not being able to remember if she had cleaned her teeth or taken her medications. Inability to recall factual information or recent/past events, as evidenced by inability to orient herself to residence, or if her son had returned from his vacation. She has expressed fear of further mental/physical deterioration by stating that she cannot stand the thought of, "not being able to do anything but lay there and depend on everyone to take care of me, and can't talk." She has been diagnosed with depression which is often associated with dementia (from chart). She tries to remember the names of people in her photographs and then gets frustrated as evidenced by client stating "I'm just going to put this away and never look at it again." She is unable to orient herself to time (does not know the season, or what year it is). Client has edema in her ankles related to her immobility. She is also underweight and has difficulty swallowing.

Textbook Information

Dementia is a general term for a permanent or progressive organic mental disorder that is characterized by personality changes, confusion, disorientation, deterioration of intellectual functioning, and impaired control of memory, judgment, and impulses. The most common type of dementia is Alzheimer's disease (AD). Its cause is unknown. The most prominent symptoms are cognitive dysfunctions, including decline in memory, learning, attention, judgment, orientation, and language skills. The symptoms are progressive, and all victims experience a steady decline in cognitive and physical abilities, lasting between 7 and 15 years and ending in death. In the last stage, the client requires total assistance, is unable to communicate, is incontinent, and may be unable to walk. There is no cure (Kozier, Erb, Berman, & Burke, p. 422). Dementia may result from many illnesses, including AIDS, chronic alcoholism, Alzheimer's disease, vitamin B12 deficiency, carbon monoxide poisoning, cerebral anoxia, hypothyroidism, subdural hematoma, multiple brain infarcts, and others. A limited benefit is obtained in some patients treated with donepezil, tacrine, or gingko biloba (Venes, 2001). New studies suggest hormone replacement therapy (HRT) may decrease the risk or delay the onset of Alzheimer's disease (AD), which is the most common form of dementia among the elderly. Increasing evidence supports a role for estrogen in brain regions involved in learning and memory and in the protection and regulation of cholinergic neurons, which degenerate in AD (Fillit, H., September 23, 2002).

Compare and Contrast

Client clearly shows signs of confusion, disorientation, deterioration of intellectual functioning as evidenced by inability to orient to place and time. She has difficulty recalling factual information such as whether or not she has cleaned her teeth that morning or if her meds have been given to her already or not. However, she is able to perform ADL's such as combing her hair and cleaning her teeth when she is reminded. She shows no signs of aggressive behavior or suspiciousness which are symptoms of dementia. She is able to remember things that were very important to her, such as stories about her children and her husband. She expresses interest in being with others and joining in group activities showing a desire not to be isolated from others. Her disease is progressive and her prognosis is poor. Her cognitive and physical abilities will continue to decline. She will become more and more dependent on others for ADL's until she is totally dependent, and will probably end in death.

Medical History and Health Assessment

Systems Review

Head and Neck

No headaches, head injury, neck pain or dizziness. No lumps or swelling in the neck. Client has difficulty swallowing (dysphagia). She has never smoked, and does not drink alcohol. Head is normocephalic. Temporomandibular joint moves smoothly with no limitation or tenderness. Facial expression is appropriate for reported mood. Facial structures are symmetrical. No involuntary movements (tics) in the facial muscles. Head position is centered midline, and accessory neck muscles are symmetric. No enlargement of salivary or lymph glands. Trachea is centered midline. Thyroid is not palpable.

Eyes. Client has glaucoma Eyebrows show a loss of the outer one-half of hair, bilaterally. bilaterally, move symmetrically as facial expression changes, no scaling or lesions. Eyelid skin is intact and pink without redness, swelling, discharge, or lesions bilaterally. Eyelashes are evenly distributed along the lid margins and curve outward, bilaterally. Eyeballs are aligned normally in their sockets with no protrusion or sunken appearance bilaterally. Conjunctivae are clear, semi-moist. Sclera are white, with a gray spot approximately 1 cm in diameter on right eye. Pupils are equal, round, pin sized, and are not reactive to light or accommodation (client receives Isopto Carpine drops, left eye). Client was unable to comply with visual field test (cranial nerve II), due to mental status. Extra ocular muscles, corneal light reflex not present. Diagnostic positions test reveals failure to follow from 12 to 2 o'clock, indicating weakness of an extraocular muscle (EOM) or dysfunction of the cranial nerve that innervates it. Cranial nerves III, IV, and VI (ocularmotor, trochlear, abducens) intact. Unable to test red reflex or observe internal eye structures due to constriction of pupils. Cover test reveals a normal steady, fixed gaze. Lens appears opaque.

Ears. No lesions, swelling, redness present in external auditory meatus, bilaterally. No tenderness bilaterally. Both ear canals are filled with crusty, flaky, yellow cerumen, obstructing visual of tympanic membrane. Client unable to hear whispered words (cranial nerve VIII). With both the Weber and Rinne test, client was unable to hear the tuning fork. Client stated she could feel the vibrations but couldn't hear anything. She was able to hear the tuning fork when placed right next to external auditory meatus, bilaterally.

Nose. Frequent nasal discharge. Discharge is watery. Nose is symmetric, in the midline, and in proportion to other facial features. Patency test reveals no obstructions. Nasal mucosa is normal red color and has smooth moist surface, some swelling. No polyps or benign growths. Septum not deviated.

Mouth. Lips are normal red color, light moisture, with no cracking or lesions. No sores, lesions, nodules in mouth or tongue. Buccal mucosa is pink and moist with no lesions. There is one small lesion in the front, upper gum, about 0.25 cm in diameter, white in color. Client has dysphagia with no pain, feels like food stops at certain points when swallowing. Client has never smoked and does not use alcohol. Client has full upper and partial lower dentures. She performs oral hygiene twice daily. Tongue has no ulcerations with some fissures present. Ventral surface looks smooth, glistening, and shows veins, saliva is present. No lesions are present on the ventral surface. Tonsils are graded at 1+. No unusual breath odor. Uvula does not rise when client says "ahhh" (cranial nerve X) but hangs midline. Tongue protrudes midline with only a slight tremor (cranial nerve XII). Tonsils graded at 1+. No abnormal breath odor.

Lymph Nodes. Not palpable.

Sinuses. Not tender or swollen.

Chest

Respiratory. Thin chest wall (Chart). Occasionally congested with lose cough, crackles in upper lungs (chart). Left lung wheeze/rattle heard with exhale, at 4th intercostal space, posterior, mid-clavicular line. No areas of tenderness or increased skin temperature. No increase in skin moisture. No superficial lumps or masses, no skin lesions. No evidence of tactile fremitus.

Cardiac. Regular rhythm with no murmurs. Crisp heart tones.

Abdomen

Gastrointestinal. Constipation. Anemia which is improving. Body Mass Index outside parameters. Calorie intake does not meet estimated fluid requirements (chart)

Genito urinary. Wears depends. Needs stand-by assistance when toileting.

Reproductive system

Post menopausal

Extremities. ROM in arms, hands, shoulders reveal decrease in ROM of approximately 10% overall. Venous lake structures present in hands and arms. No clubbing of nails. Fingernails have 2 second capillary refill. Feet, knees, toes reveal approximately 30% decrease in ROM. Pain with rotation of left hip (chart). Feet and lower legs are purple due to decreased circulation. Edema is present in the ankles, with pitting graded at 3+. Lower legs each have a 1.5 cm lesion which is white and scaly. Popliteal, posterior tibial, and dorsalis pedis pulses are weak and are graded at 2+, and are regular, rhythmic, and springy and resilient. The radial, brachial pulse are also graded at 2+, rhythmic, with arteries feeling springy and resilient. Pulse at 84 beats per minute.

Neurological

Client is alert, but not oriented to place, or time. She is unable to name people in photographs. She does not know what time of year it is, or even what year it is. She often forgets how to get back to her room, or what her room number is. However, she knows what town she is in and she knows she is in a nursing home. No history of unusual headaches. Occasional dizziness. No tremors in hands or face. Incoordination as evidenced by fall (hip fracture). No numbness or tingling. Difficulty swallowing, no pain. No difficulty speaking. No significant past history of stroke, spinal cord injury, meningitis or encephalitis, congenital defect, or alcoholism. However, some history may be omitted due to clients inability to recall factual information. This would include history of dizziness with no specific time frame (how often it occurs). Client does notice decrease in memory, and feelings of confusion.

Cranial Nerves:

1. Not done
2. Optic nerve test not done due to client's inability to comply.
3. Pupils constricted even in dim light, and do not constrict further as a result of test.
4. Intact. Down and inward movement of eye observed.
5. Intact. Muscles of mastication feel equally strong, bilaterally.
6. Intact. Lateral movement of eye observed.
7. Intact. Mobility and symmetry observed with movement of facial muscles with facial expressions observed.
8. Could not hear whispered word test, tuning fork in Weber test, or tuning fork in Rinne test until tuning fork placed next to external auditory meatus, bilaterally.
9. Uvula does not rise when client says "ahhh."
10. Sternomastoid and trapezius muscles are equal in size bilaterally, with equal resistance to force applied to side of chin. Shoulders move equally in strength against resistance.
11. Tongue protrudes midline with no tremors.

Cerebral function test, Romberg test, heel-to-shin test not done due to client's mobility status. Client is able to perceive pin prick, and light touch. Client can feel vibrations of tuning fork over bony prominences. Deep tendon reflexes not present, responses graded at 0.

Integumentary

Skin is thin. Temperature is warm bilaterally. Skin is clean and free of body odor. hair is fine, thin, gray. Nail thickness is uniform. Poor skin turgor, pinched skin recedes slowly. Feet and lower legs are purple due to decreased circulation. Edema is present in the ankles, with pitting graded at 3+. Lower legs each have a 1.5 cm lesion which is white and scaly.

Endocrine

No history of diabetes. Thyroid is not palpable.

Allergies

No known allergies.

Medical and Surgical History

Previous surgical history unknown. Was unable to obtain information due to client's inability to remember. Past medical diagnoses include dysphagia, constipation, dementia, left hip fx, pain from fx, depression, sleeplessness, nausea with stomach irritation, allergies, dry eyes, and post-menopausal (chart).

Social Habits

E.S. does not use alcohol or drugs, and has never smoked. Alcoholism may be a contributing factor in dementia, but it is not known for sure if alcoholism leads to dementia. However, this information does not apply to E.S. since she was never an alcoholic.

E.S. is more of an extrovert than an introvert. She enjoys having others around and expresses interest in joining in group activities such as playing bingo at the nursing facility. She prefers to be around others as opposed to staying in her room alone. Hobbies include watching television, playing bingo, cards, crossword puzzles, listening to music, and animals.

Family Composition/Family Health Problems

There is no doubt after speaking with E.S. that her son and grandson are very important to her. She speaks of them often, and when she does talk about them, her mood changes to happy and cheerful, she will smile and laugh. She has expressed many times how much she misses her husband who is deceased, and becomes teary eyed. Staff at the nursing facility informed me that her son comes to visit E.S. almost every day, however, he has been on vacation. E.S. forgets that he is on vacation and is often confused and disappointed as to why he hasn't been coming to see her lately. There are no familial/hereditary health problems listed in her chart, and E.S. does not remember this information.

Diet Therapy

E.S. is on a mechanical soft diet, with pureed meats, and nectar thick fluids (chart). This diet is a common diet for clients who have dysphagia because the food and fluid is formed more easily into a bolus and is more easily swallowed. This diet enhances swallowing ability to meet fluid and caloric body requirements (Doenges et. al., 2001).

Physical and Cognitive Ability

Physical impairments include being confined to a wheelchair for ambulation. E.S. will need assistance with any ADL's that cannot be done from her wheelchair. Examples include assistance with transfers to and from her wheelchair, assistance with bathing and toileting, and help with dressing. Client is able to perform ADL's such as cleaning her teeth and combing her hair. E.S. also suffers from hearing loss, and has loss of peripheral vision and night blindness. Reducing background noise as much as possible, speaking clear, loud, and slow, and making sure she can see your mouth while speaking improves communication. Mental impairments include dementia and depression. Since client cannot recall recent information, charting information such as medication given, ADL's performed, I & O's are crucial to client's health and safety.

Nursing Diagnosis/Problems/Need

Nutrition: imbalanced, less than body requirements, related to dysphagia secondary to dementia, as evidenced by reported inadequate food intake less than recommended daily allowances.

Short-Term Goal

Short-Term Goals: Increase caloric intake by 5% by December 15, 2002.

Long-Term Goal

Long-Term Goals: Progressive weight gain. Client will gain 5 lbs. by February 25, 2003.

Interventions

Referral for proper denture fit (Doenges et. al., 2001). The lesion on her gum causes her some pain when biting, and could have been caused by an improper fit. Rationale: An improper fit and pain discourages eating.

Provided snacks as requested by client after meals, but not less than one hour before meals (Doenges et. al., 2001). Rationale: To increase daily calorie intake (Doenges et. al., 2001).

Stay with her during meal time to reduce anxiety, promote a pleasant, relaxing environment, including socialization. Rationale: To enhance intake. (Doenges et. al., 2001).

Ask her son (Ron) if he would be willing to bring in a dish once a week that she has been accustomed to eating (related to her cultural background). She has stated that she misses certain dishes that she used to have at home (Doenges et. al., 2001). The dishes would have to be appropriate for diet.

Face her away from near wall in dining area (have client face towards tv. area). There are clients who are placed next to the wall area to eat that E.S. has stated several times it upsets her to see them in "their condition," and has stated she believes she will end up in the same condition. This intervention minimizes sights that are unpleasant to E.S., and may have a negative effect on eating (Doenges et. al., 2001).