NURSING 432 FA Chuck Roberts Questions/Answers (Rationale)

Chuck Roberts 1. Your wife says she has noticed changes over the past year. Have you noticed any of the changes she mentioned? Rationale Relevancy Your Answer It is important to assess the client’s perspective about his own health. Even though he may not be aware of his cognitive decline with the same specificity or accuracy of his spouse, it is critical to gain his input and insight into the chief complaint. Relevant Relevant Client: You know, there’s really nothing wrong with me other than getting older. Sometimes it’s hard to remember where I put something or where we are going that day, but that’s the only thing…and I know that comes from old age! 2. When you are feeling confused, have you been running a fever? Rationale Relevancy Your Answer Fever is associated with episodes of delirium, not dementia. Irrelevant Irrelevant Client: I haven’t had any fevers. 3. Have you noticed that one side of your body is weaker than the other? Rationale Relevancy Your Answer Unilateral weakness is association with cerebrovascular accident (CVA) and transient ischemic attacks (TIA), not dementia. Irrelevant Irrelevant Client: No. Both sides seem the same. 4. You said that sometimes you forget where you are going or where you put something. Are you able to remember things from long ago, such as your wedding to Mrs. Roberts? Rationale Relevancy Your Answer Alzheimer’s disease is characterized by memory impairment or the impaired ability to learn new information or recall previously learned information. Most clients in the early stages of Alzheimer’s disease will still have clear recollection of events long Relevant Relevant past. Client: Of course. It was in the middle of February of 1958 with snow up to my knees. How could I forget that? 5. Are the hand tremors that you experience while at rest worsening as your memory declines? Rationale Relevancy Your Answer Hand tremors are associated with Parkinson’s disease, which can also cause a progressive deficit in memory and cognition. However, Mr. Roberts’ diagnosis has already been established as early Alzheimer’s disease, and there are no other issues in the chief complaint to indicate that this is a new concern. Irrelevant Relevant Client: I don’t have those. 6. Do you find that you get upset or frustrated more easily now than you did last year when we saw you? Rationale Relevancy Your Answer An increase in a clinically significant behavioral disturbance, such as wandering or agitation, can accompany a progression in Alzheimer’s disease. Therefore, it is important to know if Mr. Roberts has developed further accompanying symptoms as his wife stated. Relevant Relevant Client: Well, of course I get more frustrated than normal. Mrs. Roberts here is on me all the time about forgetting things and it just gets on my nerves. I guess I just get irritated and then say things that maybe I shouldn’t. It just ticks me off when she keeps asking me about forgetting things, and then I let her know what I think. 7. Have you noticed any difficulty speaking over the past 12 months? Rationale Relevancy Your Answer Although language disturbance (aphasia) can be associated with a number of cognitive disorders (e.g., stroke), it is also one of the potential diagnostic criteria associated with later stages of dementia of the Alzheimer’s type. In addition to memory Relevant Relevant impairment or the impaired ability to learn new information or to recall previously learned information, Alzheimer’s clients will exhibit at least one additional symptom such as aphasia, apraxia, agnosia, and/or disturbance in executive functioning (planning, organizing, sequencing, abstracting). With this in mind, it is important to understand if Mr. Roberts has any of these additional symptoms associated with dementia of the Alzheimer’s type. Client: Nope. I speak just fine. I never have trouble finding words to say. I always know what I want to say. 8. Have you had any difficulty doing things with your hands, like holding a fork or working with small objects? Rationale Relevancy Your Answer Although an inability to carry out motor activities despite intact motor function (apraxia) can be associated with a number of cognitive disorders, it is also one of the potential diagnostic criteria associated with dementia of the Alzheimer’s type. In addition to memory impairment or the impaired ability to learn new information or recall previously learned information, Alzheimer’s clients will exhibit at least one additional symptom such as aphasia, apraxia, agnosia, and/or disturbance in executive functioning (planning, organizing, sequencing, abstracting). With this in mind, it is important to understand if Mr. Roberts has any of these additional symptoms associated with dementia of the Alzheimer’s type. Relevant Relevant Client: Yes, somewhat I guess. I like to work with wristwatches, replacing glass and batteries, and sometimes that isn’t so easy. 9. Do you always recognize objects that you see, such as the wristwatches you work with? Rationale Relevancy Your Answer Although agnosia, or the failure to recognize or identify objects despite intact sensory function, can be associated with a number of cognitive disorders, it is also one of the potential diagnostic criteria associated with dementia of the Alzheimer’s type. In addition to memory impairment or the impaired ability to learn new information or recall previously learned information, Relevant Relevant Alzheimer’s clients will exhibit at least one additional symptom such as aphasia, apraxia, agnosia, and/or disturbance in executive functioning (planning, organizing, sequencing, abstracting). With this in mind, it is important to understand if Mr. Roberts has any of these additional symptoms associated with dementia of the Alzheimer’s type. Client: Of course. I haven’t had any problem figuring out what things are. 10. Do you seem to have any challenges organizing yourself to do work or hobbies? Rationale Relevancy Your Answer In addition to memory impairment or the impaired ability to learn new information or recall previously learned information, Alzheimer’s clients will exhibit at least one additional symptom such as aphasia, apraxia, agnosia, and/or disturbance in executive functioning (planning, organizing, sequencing, abstracting). With this in mind, it is important to understand if Mr. Roberts has any of these additional symptoms associated with dementia of the Alzheimer’s type. Relevant Relevant Client: No, I don’t seem to have any problems like that. Client’s Wife: Actually, sometimes he does. He will sit down to work with his wristwatches and forget if he’s worked on that one before or not. It’s like he knows what he wants to do but can’t organize himself enough to remember if he’s done it or not. 11. Do you seem to forget how to do simple, daily tasks such as buttoning a shirt? Rationale Relevancy Your Answer In addition to memory impairment or the impaired ability to learn new information or recall previously learned information, Alzheimer’s clients will exhibit at least one additional symptom such as aphasia, apraxia, agnosia, and/or disturbance in executive functioning (planning, organizing, sequencing, abstracting). With this in mind, it is important to understand if Mr. Roberts has any of these additional symptoms associated with dementia of the Alzheimer’s type. Forgetting how to perform simple, daily tasks, such as buttoning a shirt, would generally be seen in later stages of the disease process. Asking this type of question also helps Relevant Relevant determine where in this process Mr. Roberts might be. Client: No, I don’t have any problems like that. I can dress myself just fine. Client’s Wife: Sometimes he does need a few reminders or a little assistance. He gets upset and sometimes angry when I try to help him or when he can’t figure things out. 12. Do you notice that you have symptoms of illusions or hallucinations that fluctuate during the day? Rationale Relevancy Your Answer Illusions, hallucinations, and misinterpretations are generally associated with delirium rather than with Alzheimer’s disease. Irrelevant Irrelevant Client: No, nothing like that. 13. Do you have problems falling asleep at night because you are disturbed, or are you excessively sleepy during the day? Rationale Relevancy Your Answer Delirium is associated with sleep–wake cycle variations and not with Alzheimer’s disease. Irrelevant Relevant Client: No, not at all. Assessment Assess Mr. Robert’s current level of distress and anxiety. It is important to maintain the client’s comfort level during the interview. When the client is in distress or is overly apprehensive or anxious, the examiner will want to make the exam as short as possible while still gathering necessary data. This is especially important when working with a client who has concerns that are possibly related to Alzheimer’s disease. Relevant Relevant 2. Ask Mr. Roberts what day of the week it is, what his wife’s name is, and where he is. This question assesses orientation to time, person, and place in the immediate setting. It provides a baseline for further questioning about previously learned material in which a deficiency can indicate further progression of Alzheimer’s disease. Relevant Relevant 3. Tell Mr. Roberts to remember a ball, a mouse, and a glass. Ask him to immediately repeat these objects. As part of the Mini Mental Status Exam, this task provides useful information regarding whether a client can recall previously learned material, even if that material was introduced only in the very recent past. Asking him to immediately repeat these objects is a form of active learning with immediacy and, later in the examination, recall of these objects will be tests. A deficiency in immediate ability to repeat the objects or in subsequent recollection can indicate further progression of Alzheimer’s disease. Relevant Relevant 4. Ask Mr. Roberts to count backwards from 100 in increments of 7. As part of the Mini Mental Status Exam, this task involves calculation, organization, and sequencing of numerical data. Results should be compared against Mr. Roberts’ first performance with this task at his initial assessment 16 months ago. Relevant Relevant 5. Ask Mr. Roberts to draw the face of a clock. The Clock Drawing Test is a simple test that can be used as a part of a neurological test or as a screening tool for Alzheimer's disease and other types of dementia. Relevant Relevant 6. Ask Mr. Roberts to repeat the names of the objects you recited earlier (a ball, a mouse, and a glass). As part of the Mini Mental Status Exam, this task provides useful information regarding whether a client can recall previously learned material, even if that material was introduced only in the very recent past. A deficiency found in recollection can indicate further progression of Alzheimer’s disease. Relevant Relevant 7. Assess Mr. Roberts’ vital signs. Measuring vital signs provides baseline data. Based on the information gathered from the assessment questions, Mr. Roberts is here only because his wife thinks he is experiencing more cognitive changes. Measuring vital signs assists in ruling out the suspicion of a physiological problem more than a cognitive one. Therefore, although the nurse may not anticipate abnormalities within the vital signs, they should be taken to help discern if Mr. Roberts has any physiological concerns that will need to be addressed in addition to, or as a causative agent of, the chief complaint. Relevant Relevant 8. Perform an abdominal assessment. Rationale Relevancy Your Answer Assessing Mr. Roberts’ abdomen will provide no useful data associated with Alzheimer’s disease. Irrelevant Irrelevant Assessment Data/Patient Results: Mr. Roberts’ abdomen is soft with normal bowel sounds. 9. Assess Mr. Roberts for presence of hallucinations. Rationale Relevancy Your Answer Hallucinations are associated with delirium, not with Alzheimer’s disease. Irrelevant Irrelevant Labs BC and Diff (complete blood count and differential) Rationale Relevancy Your Answer Establishing a baseline would be important in order to assess for physiological conditions that might affect the client’s health status. Relevant Relevant 2. Serum electrolytes Rationale Relevancy Your Answer Establishing baseline values are important in the event that the client presents with a fluid and electrolyte imbalance in the future. Relevant Relevant 3. Urinalysis Rationale Relevancy Your Answer This test is part of a routine diagnostic and screening evaluation. It can provide preliminary information about renal function and other metabolic processes. Relevant Irrelevant 4. CXR (chest x-ray) Rationale Relevancy Your Answer A chest x-ray is not of value when diagnosing or treating Alzheimer’s dementia. Irrelevant Irrelevant 5. ECG (electrocardiogram) Rationale Relevancy Your Answer There is no indication that Mr. Roberts has cardiac abnormalities. Irrelevant Irrelevant 6. Ethanol (blood ETOH) Rationale Relevancy Your Answer This test measures alcohol in the blood. There is no indication that Mr. Roberts consumes or abuses alcohol. Irrelevant Relevant 7. Positron emission tomography (PET) Rationale Relevancy Your Answer Used to reveal the metabolic activity of the brain—an assessment important in the diagnosis as well as for tracking the progression of the disease. Relevant Relevant Clustering 1. Cluster A Rationale Correct Answer Your Answer Rationale: This is a primary Mr. Roberts’ cognitive Mr. and Mrs. Roberts characteristic of progression of abilities have clearly may not understand all Alzheimer’s disease. Therefore, the declined since his visit 16 options that are nurse’s focus should be on giving months ago. Although he available to help slow attention to the disturbed thought can recall distant events, the progression of processes and how to best care for he has more trouble Alzheimer’s disease Mr. Roberts based on this change focusing on current while maintaining in status. Personality changes often activities. quality of life. become apparent as the disorder Mrs. Roberts identifies Mr. Roberts believes that progresses. Information about that Mr. Roberts’ his symptoms are related effective coping strategies can forgetfulness has begun to to the normal aging assist the couple in dealing with interfere with his ability to process. the behavioral effects of the enjoy his hobbies and Mr. and Mrs. Roberts disorder. leisure activities. identify that, based upon Mrs. Roberts states that his symptoms, they are Mr. Roberts’ personality uncertain about what to has been changing over do when he becomes the past 12 months. He disoriented. alternates between being Mrs. Roberts is acutely aware of the changes in “normal” as she states, Mr. Roberts and, upon and “not right in the head, taking a history, it is like he can’t remember apparent that Mr. what he’s doing.” Roberts also recognizes Mrs. Roberts explains that that there are changes, he periodically seems although he attributes disoriented and can’t these changes to “getting remember recent events; old.” at other times, he is Mr. Roberts denies verbally aggressive and needing assistance with episodically becomes self-care; however, Mrs. agitated, alternating Roberts identifies that between periods of calm occasionally he does and normalcy. require prompting. 2. Cluster B Rationale Correct Answer Your Answer Rationale: Education can help Mr. Mr. and Mrs. Roberts Mr. Roberts’ cognitive Roberts understand the stages of may not understand all abilities have clearly Alzheimer’s disease and what to expect options that are declined since his visit as his cognitive function changes. available to help slow 16 months ago. Education can also assist Mr. and Mrs. the progression of Although he can recall Roberts with minimizing complications Alzheimer’s disease distant events, he has associated with Alzheimer’s disease in while maintaining more trouble focusing order to maintain the highest quality of quality of life. on current activities. life possible. Mr. Roberts believes Mrs. Roberts identifies that his symptoms are that Mr. Roberts’ related to the normal forgetfulness has aging process. begun to interfere with Mr. and Mrs. Roberts his ability to enjoy his identify that, based hobbies and leisure upon his symptoms, activities. they are uncertain about what to do when he becomes disoriented. Mrs. Roberts is acutely aware of the changes in Mr. Roberts and, upon taking a history, it is apparent that Mr. Roberts also recognizes that there are changes, although he attributes these changes to “getting old.” 3. Cluster C Rationale Correct Answer Your Answer Mrs. Roberts states that Mr. Roberts’ personality has been changing over the past 12 months. He alternates between being “normal” as she states, and “not right in the head, like he can’t remember what Mr. Roberts denies he’s doing.” needing assistance Mrs. Roberts explains that Rationale: The nurse should consider with self-care; he periodically seems that Mr. Roberts could have the risk however, Mrs. disoriented and can’t for eventual self-care deficit based on Roberts identifies remember recent events; at his cognitive changes. If he is unable that occasionally he other times, he is verbally to remember how to perform basic does require aggressive and episodically ADLs, he could indeed be prompting. becomes agitated, progressively unable to care for Mrs. Roberts alternating between himself as a result of his cognitive identified that periods of calm and decline. It is important that the nurse sometimes Mr. normalcy. provide information to minimize the Roberts gets upset Mrs. Roberts identified that effects of cognitive decline in self-care and angry when he is sometimes Mr. Roberts gets and provide information that will unable to perform upset and angry when he is keep Mr. Roberts independent in his activities of daily unable to perform activities self-care for as long as safely possible. living (ADLs). of daily living (ADLs). Diagnoses 1. Cluster A Rationale Correct Answer Your Answer True Disturbed Thought Processes Disturbed Thought Processes 2. Cluster B Rationale Correct Answer Your Answer True Risk for Deficient Knowledge Risk for Deficient Knowledge 3. Cluster C Rationale Correct Answer Your Answer True Risk for Self-Care Deficit Risk for Self-Care Deficit Outcomes The client demonstrates absence of overt anxiety, fear, and confusion. Rationale Relevancy Your Answer Rationale: Anxiety and fear will often contribute to the client’s confusion and aggressiveness. Disturbed Thought Processes Disturbed Thought Processes 2. The client and family members will verbalize an understanding of the disease process, coping strategies, and treatment. Rationale Relevancy Your Answer Rationale: Understanding the dynamics of this diagnosis and the expected progression of the disease, as well as strategies to cope with symptoms, will assist the client and his wife to adapt to changes as they occur. Risk for Deficient Knowledge Risk for Deficient Knowledge 3. The client will accomplish ADLs to the best of his ability and will allow his caregiver to attend to his unfulfilled needs. Rationale Relevancy Your Answer Rationale: It is important that clients be encouraged to continue with self-care activities as long as possible in order to maintain functioning as long as possible. Risk for Self- Care Deficit Risk for Self- Care Deficit 4. The client is able to understand basic communications in interactions with caregivers. Rationale Relevancy Your Answer Rationale: There is no indication that Mr. Roberts is experiencing communication difficulties at this time. None 5. The client and family will participate in and cooperate with the identified treatment plan. Rationale Relevancy Your Answer Rationale: Mr. and Mrs. Roberts have indicated an interest in learning more about his diagnosis and the progression of his disease. Although Mr. Roberts denies that his condition is changing, additional information may be beneficial to assist with adaptive coping to the changes he is experiencing. Risk for Deficient Knowledge 6. The client distinguishes actual from perceived stimuli and interprets his environment accurately. Interventions 1. Educate the family about strategies to decrease stimulation when Mr. Roberts experiences confusion, anxiety, or aggression. Rationale Relevancy Your Answer Rationale: Educating the client and his family will ensure that the family does not become alarmed by the client’s behavior and will encourage the use of effective strategies to address the behaviors. Risk for Deficient Knowledge Risk for Deficient Knowledge 2. Allow Mr. Roberts time to perform tasks while providing support by taking him through tasks one step at a time. Rationale Relevancy Your Answer Rationale: Clients with Alzheimer’s dementia respond best to a calm environment. Rushing the client to complete tasks can result in frustration and confusion. Risk for Self- Care Deficit Risk for Self- Care Deficit 3. Try to keep Mr. Roberts as oriented to reality as possible using clocks and calendars in prominent places. Rationale Relevancy Your Answer Rationale: Clocks, calendars, pictures, etc., can enhance memory function, orientation, and thought processes. Disturbed Thought Processes Disturbed Thought Processes 4. Ensure that the noise level is controlled to prevent excess stimulation. Rationale Relevancy Your Answer Rationale: Too much stimulation results in sensory overload and confuses the client. Disturbed Thought Processes Disturbed Thought Processes 5. Inform the family that Mr. Roberts will respond better to conversations about the past rather than the here and now. Rationale Relevancy Your Answer Rationale: Reminiscing is a positive experience and encourages the client to express his feelings while engaging in social interactions. Risk for Deficient Knowledge Risk for Deficient Knowledge 6. Arrange for Mr. Roberts and his wife to attend a family support group and day treatment program on a regular basis. Rationale Relevancy Your Answer Rationale: Becoming part of a group on a regular basis provides stimulation for the client and ongoing support and education for family members. Risk for Deficient Knowledge Risk for Deficient Knowledge 7. Engage Mr. Roberts in reminiscence sessions by discussing past experiences and individuals who were an integral part of his life. Rationale Relevancy Your Answer Rationale: Reminiscence exercises use functional remote memory and encourage the client to express his feelings. Disturbed Thought Processes Disturbed Thought Processes 8. Ensure that ADLs follow Mr. Roberts’ usual routine as closely as possible. Rationale Relevancy Your Answer Rationale: A regular ADL routine decreases confusion and agitation. Risk for Self-Care Deficit Risk for Self-Care Deficit