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Nursing Care Plan: NCP Alzheimer's Disease

Nursing Care Plan for Alzheimer's Disease with a primary nursing diagnosis of Self-care deficit related to impaired cognitive and motor function. Other possible nursing diagnoses included: Constipation, Disturbed thought processes, Dressing or grooming self-care deficit, Feeding self-care deficit, Imbalanced nutrition: Less than body requirements, Impaired verbal communication, Ineffective coping, Risk for infection, Toileting self-care deficit, Disabled family coping, Interrupted family processes, and Risk for injury.

Alzheimer’s disease (AD) is a degenerative disorder of the brain that is manifested by dementia and progressive physiological impairment. It is the most common cause of dementia in the elderly but is not a normal part of aging. More than 4 million Americans suffer from AD. Dementia involves progressive decline in two or more of the following areas of cognition: memory, language, calculation, visual-spatial perception, judgment, abstraction, and behavior. Dementia of the Alzheimer’s type (DAT) accounts for approximately half of all dementias. The average time from onset of symptoms to death is 8 to 10 years. The pathophysiological changes that occur in DAT include the following: (1)Presence of neurofibrillary tangles, neuritic plaques, and amyloid angiopathy; (2) Accumulation of lipofuscin granules and granulovacuolar organelles in the cytoplasm of the neurons; (3) Structural changes in the dendrites of the neurons and in the cell bodies; (4) Predominant neuronal degeneration in the cortical association areas of the basal ganglia; (5) Gross cortical atrophy and widening of the sulci; (6) Enlargement of the ventricles; and (7) Decrease in neurotransmitters (acetylcholine, dopamine, norepinephrine, serotonin), somatostatin, and neuropeptide substance P.

The cause of Alzheimer's Disease is unknown but knowledge about the hereditary links is growing. Patients with Down syndrome eventually develop DAT if they live long enough. There is a higher-than-normal concentration of aluminum in the brain of a person with DAT, but the effect is unknown. A distinct protein, AZ-50, has been identified at autopsy in the brains of DAT patients. This protein has been isolated from neurons that were not yet damaged, suggesting that its presence early in the degenerative process might cause the neuronal damage. The life expectancy of a DAT patient is reduced 30% to 60%.

Alzheimer's Disease is not caused by a single gene. The genetic contributions to the disease are complex because more than one gene mutation can cause AD, and genes on multiple chromosomes are involved. There are two basic types of AD from a genetic standpoint: familial and sporadic (associated with late-onset disease). Familial AD (FAD) is a rare form of AD that has an early onset before age 65 and affects less than 10% of AD patients. FAD is caused by gene mutations on chromosomes 1, 14, and 21 and has an autosomal dominant inheritance pattern. Therefore, if one of these mutated genes is inherited from a parent, the person will almost always develop early-onset AD.

Nursing care plan physical assessment and examination
Dementia of the Alzheimer’s type is a slowly progressing disease, and secondary sources are used for diagnosis because the patient is often unaware of a thought-processing problem. Past medical history should be evaluated for previous head injury, surgery, recent falls, headache, and family history of DAT.

The history will help determine which stage the disease
process has reached at the time of patient assessment. The following four-stage scale reflects the
progressive symptoms of Dementia of the Alzheimer’s type :

Stage 1 is characterized by recent memory loss, increased irritability, impaired judgment, loss
of interest in life, decline of problem-solving ability, and reduction in abstract thinking. Remote memory and neurological exam remain unchanged from baseline.

Stage 2 lasts 2 to 4 years and reveals a decline in the patient’s ability to manage personal and business affairs, an inability to remember shapes of objects, continued repetition of a meaningless word or phrase (perseveration), wandering or circular speech patterns (circumlocution dysphasia), wandering at night, restlessness, depression, anxiety, and intensification of cognitive and emotional changes of stage 1.

Stage 3 is characterized by impaired ability to speak (aphasia), inability to recognize familiar objects (agnosia), inability to use objects properly (apraxia), inattention, distractibility, involuntary emotional outbursts, urinary or fecal incontinence, lint-picking motion, and chewing movements. Progression through stages 2 and 3 varies from 2 to 12 years.

Stage 4, which lasts approximately 1 year, reveals a patient with a masklike facial expression, no communication, apathy, withdrawal, eventual immobility, assumed fetal position, no appetite, and emaciation.

The neurological examination remains almost normal except for increased deep tendon reflexes and the presence of snout, root, and grasp reflexes that appear in stage 3. In stage 4, there may be generalized seizures and immobility, which precipitate flexion contractures.

Appearance may range from manifesting normal patient hygiene in the early stage to a total lack of interest in hygiene in the later stages. Some patients also demonstrate abusive language, inappropriate sexual behaviors, and paranoia. The Folstein-mini-mental exam is a quick evaluation tool that can assist in diagnosis and monitoring of the disease’s progression.

The nurse needs to assess the family for its ability to cope with this progressive disease, to provide physical and emotional care for the patient, and to meet financial responsibilities. A multidisciplinary team assessment approach is recommended for the patient and family.

Nursing care plan intervention and treatment
The initial management of the patient begins with education of the family and caregivers regarding the disease, the prognosis, and changes in lifestyle that are necessary as the disease progresses.

Basic collaborative principles include:
• Keep requests for the patient simple
• Avoid confrontation and requests that might lead to frustration
• Remain calm and supportive if the patient becomes upset
• Maintain a consistent environment
• Provide frequent cues and reminders to reorient the patient
• Adjust expectations for the patient as he or she declines in capacity

Promote patient activities of daily living to the fullest, considering the patient’s functional ability. Give the patient variable assistance or simple directions to perform those activities. Anticipate and assess the patient’s needs mainly through nonverbal communication because of the patient’s inability to communicate meaningfully through speech. Many times emotional outbursts or changes in behavior are a signal of the patient’s toileting needs, discomfort, hunger, or infection.

To maximize orientation and memory, provide a calendar and clock for the patient. Encourage the patient to reminisce, since loss of short-term memory triggers anxiety in the patient. Emotional outbursts usually occur when the patient is fatigued, so it is best to plan for frequent rest periods throughout the day.

Maintain physical safety of the patient by securing loose rugs, supervising electrical devices, and locking doors and windows. Lock up toxic substances and medications. Supervise cooking, bathing, and outdoor recreation. Be sure that the patient wears appropriate identification in case he or she gets lost. Terminate driving by removing the car keys or the car. Provide a safe area for wandering. Encourage and anticipate toileting at 2- to 3-hour intervals. Change incontinence pads as needed, but use them only as a last resort. Bowel and bladder programs can be beneficial in the early stage of the disease.

Provide structured activity during the day to prevent night wandering. If confusion and agitated wandering occur at night, provide toileting, fluids, orientation, nightlights, and familiar objects within a patient’s view. Some patients respond calmly when given the security of a stuffed animal or a familiar blanket.

Encourage family members to verbalize their emotional concerns, coping strategies, and other aspects of caregiver role strain. Discuss appropriate referrals to local support groups, clergy, social workers, respite care, day care, and attorneys. Provide information about advanced
directives.

Discharge and home health care guidelines
Explain the need to supervise outdoor activity, cooking, and bathing. Lock doors and windows, and lock up medications and toxic chemicals. Make sure the patient wears identification to provide a safe return if she or he becomes lost. Commercially made products are available that trigger an alarm if the patient wanders out of safe territory.
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