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Nursing Case Study: Evident From He Symptoms

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Nursing Case Study: Evident From He Symptoms

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Nursing Case Study: Evident From He Symptoms

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Alzheimer’s Disease
Alzheimer’s Disease (AD) is a form of dementia that results in the problems with behavior, thinking and memory. The symptoms of the disease develop gradually and tend to worsen over the time that gets severe enough to end up with interfering with the daily life activities (Alzheimer’s Association, 2013). It is the commonest form of dementia that affects the intellectual abilities and holds up to 60 to 80 percent of the cases of dementia which is expected expand largely by 2050 (Appendix 1). Although it is not a normal part of increasing age, however, the biggest risk factor for the pathogenesis of the disease is increasing age and majority of the patients suffering from the disease are found in the age 65 years or older (Healthdirect.gov.au, 2016). It is a progressive disease that worsens gradually worsens over the time and becomes evident from the symptoms. The early stages of the disease are marked with mild memory loss and the later stage is characterized by the loss of ability of the individual to carry out the conversation in response to their environment (Aihw.gov.au, 2016). The prevalence of AD in Australia is 353,800 which is expected to reach 400,000 in five years. It has been identified as the second leading cause of the death of the people in Australia and three out of ten people who are above the age of 85 are suffering from AD and dementia (Fightdementia.org.au, 2016).
The pathophysiology of the disease begins with the fact that the brain of the patient exhibits marked atrophy with a shrinkage of the gyri and widening of the sulci. It involves the entire cerebral cortex sparing the occipital pole. Ventricular dilation becomes apparent with thinning of the cortical ribbon in the temporal horn because of the atrophy of the hippocampus and amygdala (Jack et al., 2013). On the microscopic level, the large cortical neurons shrink resulting in a significant loss of neurons. The critical pathological substrate of the disease is shrinkage of the dendritic arbor of the bigger neurons with neurofibrillary tangles and neuritic plaques. These tangles and plaques act by damaging the healthy brain cells surrounding them causing the brain to shrink and death of the damaged cells. This death and destruction of the nerve cells result in problems in performing the daily life activities, changes in personality and memory failure (Burnham et al., 2016).
There are a number of risk factors that results in the development of the disease in the individual and this includes lifestyle, environment, genetics and age. These factors have a different effect on different people and some of them can be controlled or changed while others are not. Age is the most prominent risk factor responsible for the development of AD and the risk is known to double every five years after the attainment of the age of 65 (Jack, 2013). The fastest growing age group has been found among the aged population above 85 years. Genes have a crucial role to play in the development of AD as it controls the early and late onset of the disease. While the early onset of the disease is less common, late onset constitutes the major portion of the occurrence of the disease (Reitz & Mayeux, 2014). Air pollution has a link with the occurrence of AD as the analyzed amyloid plaques have revealed many environmental pollutants like nickel and aluminum. Lifestyle factors including obesity, hypertension, diet lacking in vegetables and fruits and lack of exercise act as risk factors for the development of AD. Apart from these factors, the other factors include head injury, Down syndrome and family history that promote the development of the disease (Burnham et al., 2016).
Assessment of Alzheimer’s Disease
AD can be diagnosed by examination of the brain of the patient by an autopsy and therefore, it is difficult to carry out the diagnosis in the condition. However, brain imaging techniques can be helpful in this regard for tracing the amyloid plaques present in the living brain and is rapidly becoming a practice in Australia as AD is predicted to take an enormous shape in near future (Appendix 2). Specific assessment data based on history, physical exam and investigation has to be collected and the details have been presented below.
Table 1: Specific assessment data for Alzheimer’s disease


Physical Examination


Focused history: Cognitive problems, onset of memory, safety concerns, current functioning, behavioral issues and patterns of losses.

Orthostatic blood pressure, vision and hearing screens

Laboratory tests: Glucose, serum electrolytes, drug levels, CBC, TSH and BUN/creatinine

Past medical history: Neurological conditions, head trauma and risk factors.

Neurologic exam: Pathologic reflexes, deep tendon, localized findings, tremor, muscle tone and strength and cranial nerves

Diagnostic tests: Treatment of  depression, removal of offending medications

Family and social history



Medication history



Source: (Loewenstein, 2013)
Assessment tests for AD are essential as some of the pathological conditions tend to mimic AD that includes brain tumors and strokes, depression, drug reactions and thyroid problems. Therefore, early diagnosis and detection are recommended for AD. 
Three major problems associated with AD are disturbed thought process, chronic confusion and impaired verbal communication. The disturbed thought process is characterized by disorientation to circumstance, person, place and time, inability to reason, decreased ability to conceptualize or reason and memory loss. Chronic confusion is characterized by decreased ability for the interpretation of the environment, decreased thought capacity, disorientation and memory impairment. Impaired verbal communication is characterized by disorientation to person, anxiety, flight of ideas and repetitive speech. These signs and symptoms begin in the early stage of the disease, progresses over the middle stage and worsen over the later stage of the disease (Karantzoulis & Galvin, 2014).
Nursing diagnoses for AD are vital for the management of the disease as it worsens over the time. Patients need total care as not only them but also their family members fall under stress with the behavior of the patient. The nursing diagnoses for AD begin with bowel and urinary elimination as it is related to the loss of neurological function and muscle tone. Failure to determine the location of the bathroom and identification of their needs forms the essential diagnoses of AD. Sensory changes are also responsible for the disturbed sleep patterns that the patients face due to AD. Reduced muscle strength or tone and neuromuscular damage cause impaired physical mobility (Howard et al., 2015). Physical limitations and cognitive decline cause self-care deficit and it is another crucial nursing diagnosis for AD. Changes in the integration, transmission and reception results in disturbed sensory perception and is responsible for AD. Altered thought process is a result of irreversible neuronal degeneration and ineffective coping of the individuals is the result of incapability of the individual to resolve the intellectual changes and issues. Impaired verbal communication is related to the intellectual changes that includes disorientation and dementia. The ability of the individual to cope with the problems of life decreases. Emotional changes like lack of confidence and irritability is a result of impaired social interaction. Inability to identify and recognize the environmental hazards and weakness increases the risk for injury. Easy to forget and sensory changes cause imbalanced nutrition that reduces the intake of necessary nutrients required for the normal functioning of the body (Farina, Rusted & Tabet, 2014). The exact cause of AD is yet not understood however, the nursing diagnoses help identify the disease and provide the required intervention as immediate treatment is a must for AD or it starts to worsen over the period.
Goal of Nursing Care
Since AD is incurable, therefore, the chief goals of the nursing care process are maintenance of the quality of life, maximizing the functions in the daily activities, fostering a safe environment and promotion of the social engagement. Based on the clinical reasoning cycle, the three discussed problems needs the description of the proposed action plan, the desired outcome and a time frame for the establishment of a goal. The proposed action plan has been discussed as the nursing intervention and since AD has no treatment, therefore, no time frame can be fixed for the duration of nursing care (Hartley et al., 2015). For disturbed thought process, the desired outcome is appropriate maintenance of the psychological and mental functioning of the patient for the maximum possible duration and reversal of the behavior as evident. After the nursing intervention, the patient is expected to have improved thought processing and its maintenance at the baseline level. Since AD is associated with behavioral problems, therefore the goal will include identification and control of the problem. Chronic confusion has the desired outcome of minimal dementia manifestations of reduced cognitive impairment and confusion. The patient will have a safe and stable environment for routine scheduling of the activities for reducing confusion and anxiety. The family of the patient has to be involved in the process of care as a part of the goal and they have to be enabled to utilize the patient information effectively for dealing with the patient confusion in regard to the limitations of the validation and stimulation of the patient’s thoughts (Hardy et al., 2014). In case of impaired verbal communication, the desired outcome is that the patient will be having effective understanding of communication and speech or should be enabled to use alternative communication methods. The goal of the nursing care is to promote the coordinated speech breathing.
Nursing Care Strategies
Nurse’s care strategies play a crucial role in the recognition of AD among the patients by assessment of the signs during the admission assessment procedure for achieving the goals. The nursing interventions aim at promoting the independence and function of the patient for the maximum possible duration (Aihw.gov.au, 2016). Other nursing objectives include promoting the safety of the patients, reduction of agitation and anxiety, improvement in communication and providing for intimacy and socialization. For disturbed thought process, the nursing intervention includes assessment of the ability of the patient for thought processing and observation of the memory changes, cognitive functioning, communication difficulty and disorientation. The rationale for this intervention is the assessment of the changes in status of the patient that may indicate progression of the deterioration or improvement of the condition (Laver et al., 2016). Assessment of the level of the cognitive disorders by the nurses includes the changes to orientation to the times, places, thinking skills and attention. The rationale for this intervention is to provide the basis for comparison or evaluation and influence the intervention choice. For chronic confusion, the nursing intervention includes assessment of the irreversible or reversible dementia, ability for interpretation of the environment, disturbances with orientation and intellectual thought processes. The rationale for this intervention includes determination of the extent and type of dementia for establishment of a care plan to enhance the emotional and cognitive functioning at the optimal levels. Terminating or avoiding the conversations or situations that are emotionally charged by the nurses is another form of nursing intervention. Anger should be avoided and expectations from the patient should be kept low according to their capability. The rationale for this is that catastrophic emotional responses are a result of the task failure when the patients feel that they are expected to perform beyond their ability and it results in anger and frustration (Jack et al., 2013).
Impaired verbal communications include the nursing intervention of assessment of the ability of the patient to speak, sensory or cognitive impairment, neurologic disorders that affect the speech and presence of psychosis. Rationale for these nursing interventions includes identification of the speech patterns and problem areas for establishing a plan of care for the patient. Another intervention includes monitoring the patient for their nonverbal communication procedures that includes crying, pointing and smiling and they should be encouraged for the use of speech as possible. The rationale behind is that needs and feelings are expressed in case the process of speech is impaired. In such a situation, the patient can express his discomfort only by non-verbalization clues, striking out and excess mumbling (Smyth et al., 2013). Apart from these three major problems, the patient of AD suffers from the self-care deficit for hygiene and bathing. The nursing intervention for this problem includes provision of assistance to the patients for the maximum amount of activities while bathing and hygiene process. They should be provided with a hand towel and wash cloth for holding on. The rationale for this intervention is to promote self-esteem and independence for enabling them to control the situation. The patients like to grasp the hands of the nurse for support while bathing and using a washcloth will help them to provide a hold on as the means of support (Fightdementia.org.au, 2016). For patient care and management of AD, both pharmacologic and non-pharmacologic interventions are essential for optimal treatment of the psychological, behavioral and cognitive symptoms of the disease.
(2016). Businessinsider.com.au. Retrieved 21 August 2016, from https://www.businessinsider.com.au/the-scale-of-the-growing-tragedy-of-alzheimers-disease-has-been-reforecast-2014-11
{{meta.og.title}}. (2016). Healthdirect.gov.au. Retrieved 21 August 2016, from https://www.healthdirect.gov.au/alzheimers-disease
Alzheimer’s Association. (2013). 2013 Alzheimer’s disease facts and figures.Alzheimer’s & dementia, 9(2), 208-245.
Alzheimer’s Australia | Statistics. (2016). Fightdementia.org.au. Retrieved 21 August 2016, from https://www.fightdementia.org.au/about-dementia/statistics
Burnham, S. C., Bourgeat, P., Doré, V., Savage, G., Brown, B., Laws, S., … & Masters, C. L. (2016). Clinical and cognitive trajectories in cognitively healthy elderly individuals with suspected non-Alzheimer’s disease pathophysiology (SNAP) or Alzheimer’s disease pathology: a longitudinal study. The Lancet Neurology, 15(10), 1044-1053.
Dementia (AIHW). (2016). Aihw.gov.au. Retrieved 21 August 2016, from https://www.aihw.gov.au/dementia/
Farina, N., Rusted, J., & Tabet, N. (2014). The effect of exercise interventions on cognitive outcome in Alzheimer’s disease: a systematic review. International Psychogeriatrics, 26(01), 9-18.
Hardy, J., Bogdanovic, N., Winblad, B., Portelius, E., Andreasen, N., Cedazo‐Minguez, A., & Zetterberg, H. (2014). Pathways to Alzheimer’s disease. Journal of internal medicine, 275(3), 296-303.
Hartley, D., Blumenthal, T., Carrillo, M., DiPaolo, G., Esralew, L., Gardiner, K., … & Lott, I. (2015). Down syndrome and Alzheimer’s disease: Common pathways, common goals. Alzheimer’s & Dementia, 11(6), 700-709.
Howard, R., McShane, R., Lindesay, J., Ritchie, C., Baldwin, A., Barber, R., … & Jones, R. (2015). Nursing home placement in the Donepezil and Memantine in Moderate to Severe Alzheimer’s Disease (DOMINO-AD) trial: secondary and post-hoc analyses. The Lancet Neurology, 14(12), 1171-1181.
Jack, C. (2013). How do heart disease and stroke become risk factors for Alzheimer’s disease?. Neurological research.
Jack, C. R., Knopman, D. S., Jagust, W. J., Petersen, R. C., Weiner, M. W., Aisen, P. S., … & Lesnick, T. G. (2013). Tracking pathophysiological processes in Alzheimer’s disease: an updated hypothetical model of dynamic biomarkers. The Lancet Neurology, 12(2), 207-216.
Karantzoulis, S., & Galvin, J. E. (2014). Distinguishing Alzheimer’s disease from other major forms of dementia. Expert review of neurotherapeutics.
Laver, K., Cumming, R. G., Dyer, S. M., Agar, M. R., Anstey, K. J., Beattie, E., … & Dietz, M. (2016). Clinical practice guidelines for dementia in Australia. Med J Aust, 204(5), 191-193.
Loewenstein, D., 2013. Assessment of Alzheimer’s Disease. In Handbook on the Neuropsychology of Aging and Dementia (pp. 271-280). Springer New York.
Reitz, C., & Mayeux, R. (2014). Alzheimer disease: epidemiology, diagnostic criteria, risk factors and biomarkers. Biochemical pharmacology, 88(4), 640-651.
Smyth, W., Fielding, E., Beattie, E., Gardner, A., Moyle, W., Franklin, S., … & MacAndrew, M. (2013). A survey-based study of knowledge of Alzheimer’s disease among health care staff. BMC geriatrics, 13(1), 1.
Sounding the Alarm on a Looming Public Health Threat | Jonathan and Karin Fielding School of Public Health. (2016). Ph.ucla.edu. Retrieved 21 August 2016, from https://ph.ucla.edu/news/magazine/2015/autumnwinter/article/sounding-alarm-looming-public-health-threat

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