Ron Jackson - Alzheimers_Dementia_2020 | Dementia/Physical Aggression

Dementia/Physical Aggression Ron Jackson, 87 years old Primary Concept COGNITION Interrelated Concepts (In order of emphasis) • Psychosis • Mood and Affect • Coping • Clinical Judgment NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% • Reduction of Risk Potential 9-15% • Physiological Adaptation 11-17% Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Ron Jackson is an 87-year-old Caucasian male with a medical history of hypertension and Alzheimer's disease who was brought to the emergency department (ED) by paramedics for evaluation of hallucinations, increased agitation, and aggressive behavior toward Shirley, his elderly wife. His daughter was visiting and witnessed Ron becoming angry for no apparent reason, telling Shirley she had to leave the house. He then pushed her, causing her to fall to the ground. Ron has become progressively more agitated the past year and was started on quetiapine. Shirley confirms that Ron has been more verbally abusive the past week, believing that she divorced him and that she needs to get out of the house, but no physical aggression took place until today. Ron currently complains of a headache and insists that he got this because “the Koreans beat me up real good in the ambulance!” Personal/Social History: Ron lives at home with Shirley, his wife of 62 years and has three children. Ron is a Korean War veteran who saw active duty and is a retired salesman. Because his wife has been struggling to care for him, his family is in the process of making arrangements for him to reside at a local memory care unit. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: History of Hypertension Alzheimer’s Hallucinations Increased Agitation Medication is Quetiapine Complains of a headache Hypertension medication has side effects He is cognitively impaired Hallucinations can cause agitation and anxiety Need to know what is causing the agitation Is this medication appropriate? What are the side effects? What is causing the headache? (we know it wasn’t the Koreans) RELEVANT Data from Social History: Clinical Significance: War veteran that saw active duty Wife has been struggling to care for him Making arrangements for him to go to a memory care unit Retired salesman Possible PTSD symptoms Shows has been increasingly getting worse Consult social work and start looking for options Useful to know when it comes time for therapeutic communication 1. Identify the relationship between the PMH and home medications. Which medication treats which condition? Draw a line to connect the PMH to the correct medication. Past Medical History (PMH): Home Meds: Hyperlipidemia Hypertension Alzheimer's disease Agitation/Delusions (Color matched) Donepezil 10 mg PO at HS Aspirin 325 mg PO daily Memantine 10 mg PO BID Simvastatin 20 mg PO HS Triamterene-HCTZ 75-50 mg PO daily Quetiapine 50 mg PO BID 2. Is there a relationship between any problem in his past medical history and the present problem? If so, describe. Yes, Alzheimer’s causes alterations in ones perceptions. Agitation/Delusions is what he is experiencing this time. Hypertension and his BP is slightly elevated today. Medication Simvastatin can cause headaches. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.0 F/36.7 C (oral) Provoking/Palliative: “Those Koreans banged my head in the ambulance.” P: 78 (regular) Quality: “That’s a stupid question!” R: 18 (regular) Region/Radiation: “My head hurts all over!” BP: 148/90 Severity: “It just hurts!” O2 sat: 98% room air Timing: “All the time.” What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: BP is slightly elevated “my head hurts all over” Can be due to overstimulation, or it he needs his hypertension meds Headache pain can cause agitation making his episode worse Current Assessment: GENERAL APPEARANCE: Thin elderly male, appears stated age, sitting upright on stretcher, appears tense RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk capillary refill NEURO: Oriented to person only, denies hallucinations GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present Mental Status Examination (MSE): APPEARANCE: Disheveled appearance; cooperative at times, other times irritable MOTOR BEHAVIOR: Variable; at times pacing and agitated; at other times sits quietly SPEECH: Able to understand what the patient is saying MOOD: Variable; quiet and calm with sudden episodes of anger, anxiety, and irritability AFFECT: Variable: looks calm, then may suddenly appear angry THOUGHT PROCESS: Able to understand what the patient is saying THOUGHT CONTENT: Paranoid and persecutory delusions/ideation; “Koreans” are harming him; delusions “believes wife divorced him” PERCEPTION: Denies hallucinations INSIGHT: Grossly impaired; attributes H/A to an attack by “Koreans”; not aware of illness or reason for ER visit JUDGMENT: Grossly impaired COGNITION: Oriented to person only. Significant short- and long-term memory deficits SUICIDAL/HOMICIDAL: High risk for physical aggression toward others; recently assaultive toward wife; unable to assess suicide ideation at this time What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Appears tense Only oriented to person Note that Resp, cardiac, GI, GU, and skin are all standard Know to approach him in a calm, slow manner Be sure to properly introduce yourself No signs of underlying issues in those areas RELEVANT Mental Status Exam Data: Clinical Significance: Disheveled appearance Motor behavior, mood, and affect are all variable Thought content:Paranoid Insight: grossly impaired Suicidal/homicidal: high risk Appearance often displays the patients grasp on reality Patient is not cognitively aware of his actions A detailed MSE is important to determine onset, time course, and progression of symptoms. This is the number one safety issue with mental health patients assess and reassess - - - - - - - -- Continued