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Nursing Resource Guide


Dementia Care Best Practice

From the Texas Health Care Association
word .doc link

Dementia is a syndrome in which progressive deterioration in intellectual abilities is so severe that it interferes with the person's usual social and occupational functioning. An estimated 5 to 10 percent of the U.S. adult population ages 65 and older is affected by a dementia disorder, and the incidence doubles every 5 years among people in this age group. Despite its prevalence, dementia often goes unrecognized or is misdiagnosed in its early stages. Many health care professionals, as well as patients and family members, mistakenly view the early symptoms of dementia as inevitable consequences of aging. Dementia symptoms include: anxiety, paranoia, personality changes, lack of initiative and difficulty acquiring new skills.

Alzheimer/Dementia care requires a commitment to providing quality care. It focuses on the person and always recognizes the individual with respect and dignity.

The following dementia best practices focus on early recognition of symptoms and what care providers, routines, activities and environments must do, to change and not the resident who is doing their best with diminished capacity.

Does the person have increased difficulty with any of the activities listed below?
Knowledge of the resident's previous levels is invaluable in assessing symptoms and interpreting results. Positive findings in any of these areas generally indicate the need for further assessment for the presence of dementia.
Report results to the attending physician.

Learning and retaining new information.
For example: Is more repetitive; has more trouble remembering recent conversations, events, and appointments; more frequently misplaces objects.

Handling complex tasks.
For example: Has more trouble following a complex train of thought, performing tasks that require many steps such as balancing a checkbook or cooking a meal.

Reasoning ability.
For example: Is unable to respond with a reasonable plan to problems at work or home, such as knowing what to do if the bathroom flooded; shows uncharacteristic disregard for rules of social conduct.

Spatial ability and orientation.
For example: Has trouble driving, organizing objects around the house, and finding his or her way around familiar places.

For example: Has increasing difficulty with finding the words to express what he or she wants to say and with following conversations.

For example: Appears more passive and less responsive; is more irritable than usual; is more suspicious than usual; misinterprets visual or auditory stimuli. In addition to failure to arrive at the right time for appointments; the clinician can look for difficulty discussing current events in an area on interest and changes in behavior and dress. It might also be helpful to follow up on areas of concern by asking the patient or family members relevant questions.

Resident Name: Room#:____________________________________
Focused Dementia Care____________________________________

Focus I. Assessment and Care Plans

Assessment is crucial to the development of a useful care plan. The abilities and needs of the resident with dementia change throughout the disorder at a rate and in a course that is highly individual to that person. Families can provide information regarding the resident's prior life, customary routines, preferences, behavior triggers, and results of attempted interventions. They can help interpret language, nonverbal interactions and the meaning behind the behaviors affected by major life events and traditions. Include caregivers in the assessment process, as they are an integral part as they notice subtle, individual cues they've come to understand.

Ask questions in a systematic way, write down the answers, and observe. Also, describe a situation and then ask why the situation exists.

Occasions For Assessment
? How long might this person stay at this level of need and ability?
? What is this person's history and current status?
? What are this person's preferences, habits, and daily routines?
? How will this person fit in socially with other residents?
?I s this person and our program a good fit?
Care Plan Development
? What does this person need from us to meet his/her own life goals?
? Who needs to help residents with efforts to meet those goals?
? How can we operationalize goals into concrete, measurable objectives?
? How can we adapt our care and services to the resident's schedules and needs rather than expecting that the resident adapt to ours?
? How can staff caregivers be flexible and adapt care to the changes this resident may go through?
? How can we compensate for deficits and build on the abilities a resident has retained?
Ongoing Documentation
? What is the "baseline" level of ability, functioning, and behavior for this resident?
? How can we measure the overt and subtle changes occurring daily?
? As the resident's abilities and needs change, how should our care plan change?
? What is the impact of the initiation of an intervention?
? What is working and what isn't?
? What differentiates good from bad days?
Problem Analysis and Resolution
? Why is this behavior occurring in this resident at this time?
? Is this behavior consistent with the past?
? What needs or desires are evident in the behavior?
? What is occurring in the environment, in interactions with this resident, and within this resident at the time of the behavior?
? Does the behavior reflect changes in the resident's physical/medical status or the effects of medications?
Situational Decision Making
? What is the most urgent at this time?
? Why is the resident doing this?
? What is triggering this in the environment, the interactions with this resident, within this resident at this time?
? How is the resident experiencing this event right now?
? What are the response options?

Focus II. Ongoing Resident Care

Day to day care should be individualized based on the resident's capabilities, physical health, behavioral status, and personal preferences. Goals should include: maintaining maximum independence in ADL's, safety and security, minimizing discomfort, special attention to medical conditions, special attention to skin, feet, teeth, gums, the perineal area and bowels; promotion of nutrition and hydration, provision of physical conditioning and fresh air; appropriate level of stimulation, achievement and maintenance of a good mood, maintenance of dignity, family involvement/satisfaction and promotion and support of functional skills of bowel and bladder continence.

Ongoing treatment and management of behavioral symptoms is a major element of the care and in the effective treatment of the disease. Five general modalities are available for the treatment of behaviors are:

Address difficult behaviors analytically. Assess the resident in the situation in which the behaviors are occurring. Analysis of the behavior and its causes should precede any consideration of the use of medication or physical restraints to control the behavior.

Problem Solving Outline For Challenging Behavior
Assess The Behavior To Discern Why The Resident Is Engaging In The Behavior
1. Describe in detail the behavior
? Include what occurs, when it occurs, how often it occurs, and who else tends to be involved in the situation in order to discern the pattern of the behavior. Be very specific and use objective terms (e.g., "Mrs. S struck caregiver's shoulder with open hand when the caregiver was leaning over to tie Mrs. S's shoe," rather than "Mrs. S was combative during her care").
? Describe conditions regarding the behavior. Identify what preceded and what resulted from the behavior.
? Document the occurrence and conditions of the behavior for a period of time to establish a baseline.
2. Examine the extent to which the behavior is a problem
? Identify who is raising the concern about the behavior (family member, caregiving staff, the person with dementia, or other residents).
? Who experiences the behavior as a problem? Is anyone in physical or other danger as a result of the behavior?
? Can the problem be solved by reducing others' exposure to the behavior rather than changing the behavior itself or by changing others' tolerance level for the behavior (such as staff perceptions and tolerance for sexual invitations or swearing)?
3. Try to discern why the resident is engaging in the behavior, by examining 1& 2 above
? To what extent can the behavior be explained by understanding the way the individual with cognitive deficits experiences and reacts to the situation? For example, does hitting or screaming during undressing occur because the resident feels threatened?
? Did something in the environment trigger or cause the behavior? For example, is there too much, too little, or an inappropriate type of stimulation? Is there a change in the environment?
? Is the task too difficult? Are there too many task steps to keep in order?
? Is there something about the resident's preferences, habits or expectations that has been affected? For example, is the resident used to eating breakfast before taking a bath? To what extent is the resident's health or emotional status playing a role?
4. Identify the interventions attempted to date that have and those that haven't worked. Examine the conditions under which interventions are more likely to be effective.

Modalities For Treatment Of Behaviors

1. Prevention of the problem through caregiving staff education (especially about recognizing what happens before a behavioral crisis erupts) and the provision of meaningful activities.
2. Behavioral management through changing the environment, i.e., identification and removal of triggers of disruptive and replacement with more pleasant stimuli. For example: unpleasant stimuli (noise, commotion, or sun glare).
3 Behavior modification directed at discouraging unwanted behavior and/or rewarding desired behavior, but this may not be a useful approach in the late stage of the disease.
4. Distraction (e.g., preventing biting by giving food) or engagement in meaningful activities.
5. Medication

Focus III. Programs

The challenge of designing a program that meets the needs of residents with dementia and fits the interests, habits, values and abilities of these individuals is the responsibility of the caregiving staff. The purpose of programming is to help a resident express herself as the person he/she knows themselves to be in a way that accommodates their disability and honors their abilities, values, habits and familiar roles.

There are activities that help one feel safe, in charge, a part of a group, loved, and loving come from the day-to-day, moment-by-moment events and encounters of life.
A full balanced life depends on successfully performing activities from the following three domains:

? Productive Activities (work) - That make us feel useful and needed

? Leisure Activities - Relaxation and entertainment that are fun

? Self Care Activities - Personal and instrumental activities of daily living through which we express our independence and the intimate personal aspects of our personality.

The amount of satisfaction one gets from doing things that make each day goes a long way to determining our overall satisfaction with life.

To be meaningful, an activity will meet the following criteria:

Activity Programming
1. Have a purpose that the resident can appreciate and endorse. Does the resident know what he is doing and why?
2. Be done voluntarily. Does the resident really want to do this or is she being coerced?
3. Respect the resident's age and social status. Avoid activities that feel or look childish or socially inconsistent with resident's status. The product of any activity must also be appropriate to adults. For example, instead of making figurines with plasticine, use gingerbread dough and bake them into cookies.
4. Take advantage of the resident's retained abilities. Security depends on being in control and control depends on being able.
5. Ensure an opportunity for success.
6. Feel good. When the resident is unable to remember or anticipate, there is no place for "present pain for future gain."

The actual activities that will meet the above criteria differ from individual to individual. Each individual needs and deserves individualized program planning based on the best possible evaluation of his abilities, interest, habits and needs.

When presenting an activity don't ask; direct and inform and phrase it politely. Give strong, concrete cues. Point to the thing or demonstrate the action. Initiate the activity with the resident watching so he/she can see what is expected. Trigger an automatic reaction. For example, it is easier to respond when one is simply handed an article instead of being told to find it and pick it up. Be sure that the activity is within the resident's ability to understand and perform. If the person is truly refusing to participate, respect his/her right to refuse. Minimize distractions, turn off TV's and radios, and avoid "crossfire" conversation, in which staff members are talking to one another over the resident's head.



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