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Chapter five: CONFUSION, DEMENTIA and ALZHEIMER’S DISEASE • Changes in the nervous system with aging: • Nerve cells are lost • Nerve conduction slows • Responses and reactions slow • Reflexes slow • Taste and smell decrease • Hearing and vision decrease • Touch and sensitivity to pain decrease • Sleep patterns change • Memory is shorter • Forgetfulness occurs
Dementia • Dementia is impaired cognition • Memory, thinking, reasoning, ability to understand, judgment and behavior are effected • Dementia is impaired cognition • Memory, thinking, reasoning, ability to understand, judgment and behavior are effected • An be caused by drugs. ETOH (alcohol), tumors depression, CV (heart) problems, infection, head injuries, • No.1 cause of dementia is Alzheimer’s Disease (AD)
Delirium & Depression • State of sudden, severe confusion and rapid brain changes • Occurs with a mental or physical illness and is considered a medical ER • It is temporary and reversible • Causes include an acute illness (sudden onset), heart or lung diseases • Look for changes in alertness, sensation, awareness, movement and memory, problems concentrating, speech is silly and emotional changes • Depression characterized by 2-4 weeks of helpless, hopeless feelings, tearful, change in sleep and appetite, thoughts of death, withdrawal • DO NOT TRY TO CHEER UP…LISTEN AND REPORT TO RN
Alzheimer’s Disease (AD) • Progressive • Fatal, familial, avg life expectancy 8-10 years • Early onset is inherited • Affects more women than men • Includes dementia, depression and delirium • Gradual loss of short-term memory may be first symptom
Warning signs of AD • Perseveration (MOVEMENT OVER AND OVER OR WORDS OVER AND OVER) • Repeating same story over and over • Forgetting how to cook, play cards, pay bills, dress self, balance checkbook • Getting lost in familiar places • Losing household items • Neglecting to bathe, wearing same clothes
Stages of AD • Mild: memory loss, poor judgment, disoriented to place and time, moodiness, difficulty with everyday tasks • Moderate: restlessness,> memory loss, wandering, dulled senses, incontinence, needing help with ADLS, loses impulse control, perseveration, agitation, violence, communication problems (dysphasia) • Severe: seizures, aphasia (NO SPEECH) , total care, dysphagia (CANT SWALLOW), bedbound, coma, death
Hooray For Hollywood!! • Still Alice** • Away From Her • Savages • Iris • The Notebook • Aurora Borealis • Cocoon 2
Strategies for working with AD • Follow a routine • Promote self-care • Explain procedures • Call by name throughout conversation • Know triggers • Don’t tease • Don’t tire out
Behaviors common in AD • Delusions- false, fixed beliefs- “I CAN FLY” • Hallucinations- false sensory peRceptions “I SEE DEAD PEOPLE” • Sundowning- restlessness and agitation in PM hours • Pacing • Hoarding (COLLECTING USELESS THINGS) • Pillaging (TAKING THINGS THAT BELONG TO ANOTHER) • Inappropriate sexual behaviors • Catastrophic reactions (MAKING A BIG DEAL OUT OF NOTHING) • Perseveration- repetitive words or behaviors • Elopement- leaving the building or wandering off
Managing behaviors • Don’t argue- distract or let person discuss feelings • Allow pacing in safe area with regular breaks • Place stop signs outside rooms to prevent pillaging • Ankle bracelets for wanderers
“I want to go home!” • Redirect • Talk about home • Gently remind him that he will be staying ‘here’ for awhile • Don’t argue, don’t play along
Reality Orientation • Keeping residents who suffer from dementia aware of who, what and why is important • Call by name each time you address them • ID yourself each day • Use phrases like “good morning”, tell them where you are taking them, what you are doing to them • The facility should post large calendars, clocks and orientation boards throughout the facility
Validation Therapy • Therapy based on these principles: • All behavior has meaning • A person may return to the past to resolve issues and emotions • Caregivers need to listen and provide empathy • Attempts are NOT made to correct the person’s thoughts or bring back to reality Be sure to read about communicating, feeding, performing ADLS and dressing the person with AD
Why do it??? • Promotes comfort • Prevents infection • Improves self esteem • Prevents body odor
To promote dignity and respect….. • Encourage independence • Knock, wait to enter room • Don’t interrupt when resident in bathroom • Leave room when resident on the phone • Respect residents’ private time and personal things • Keep residents covered whenever possible when helping with care
Pressure Ulcers • AKA decubitus ulcers or bedsores • Pressure points- areas of the body that bear weight-mainly at bony prominences • Bony prominences are areas where the bone lies close to the skin- elbows, ankles, wrists, hips, shoulders, knees, etc. • Causes: immobility, incontinence, poor hydration and nutrition, friction and shearing • Friction is the rubbing together of 2 surfaces (skin)- use powder, drawsheet, never pull anything from under the skin, pad areas where skin touches skin with pillows • Shearing is when skin sticks to a surface as muscle moves in other direction- keep in low fowler’s except at meal time
Prevention • Turn and reposition every 2 hours; if sitting in chair reposition every hour • Use pressure relieving devices as ordered (page 203) • Encourage adequate nutrition and fluids • Keep skin clean and dry • Moisture barrier to areas where urine touches • Apply lotion to bony prominences: elbows, shoulders, wrists, back, hips, knees, ankles, heels
Massage skin lightly in circular strokes to increase circulation, but never over a discolored area • Be gentle during transfers • Pay special attention in overwt residents with folds of fat • Keep plastic/rubber away from the skin (increase sweat) • Make a wrinkle free bed • Never put a resident across sheets causes shearing • Bedcradle to keep linen from rubbing on skin
Orthotic devices • A device that helps support and align a limb and improve its functioning • Examples include splints, hand rolls, trochanter rolls, footboards
Stages • 1: Skin is intact: red or discolored area- report to nurse • 2: Partial-thickness skin loss of outer and/or inner layers of skin; appears like a blister • 3: Full thickness skin loss in which fat is seen; epidermis and dermis are gone • 4. Full thickness skin loss down all layers to bone, fat, muscle • See page 201
EARLY AM CARE • WAKE UP • ASSIST WITH TOILETING • WASH HANDS AND FACE • RINSE MOUTH/DENTURES • LEAVE IN UPRIGHT POSITION • NEEDS TO BE COMPLETED BEFORE BREAKFAST ARRIVES
PM Care • Undress • Toilet • Brush teeth or dentures • Wash hands and face • Give back rub • Change into night clothes
Partial bath • Given on days when a complete bath or tub/shower not given • Wash the eyes, hands, axillae (underarms), perineum • Only use products approved by the facility • Be sure room is warm and draft free before starting bath • Gather supplies before giving a bath so that resident is not left alone • If possible, allow resident to choose a comfortable water temp • Remove all soap from skin
Bathing Guidelines • Water temp between 105-115 degrees when you start because it will cool • No soap on the face • Change water if too soapy, cold or dirty • Bath from clean to dirty areas • Rinse soap well • Pat skin dry • Allow resident to do as much as possible for self • Privacy, only expose area being bathed, reduce drafts in room • Clean the eyes from inner to outer canthus using separate part of washcloth for each eye
Perineal Care • For female- clean from front to back using a separate part of washcloth for each side of labia, rinse well • For male, push back foreskin if uncircumcised; clean in circular motion from urinary meatus (opening) towards scrotum, using a separate part of washcloth for each stroke • Done during AM/PM care and incontinent care • Pages 208-209
Word Alert • Incontinent is the medical term for loss of bowel or bladder control • Never considered a normal part of aging • We are always expected to assist residents in regaining control (B & B training) • Never shame a resident for incontinence
A word about Showers…. • Never leave a resident unaccompanied in the shower area Use a shower chair, brakes on to transfer in/out
Mouthcare • Oral hygiene prevents infection, improves appetite, improves self-esteem and reduces halitosis (bad breath) • Done at least BID- after breakfast and HS • Wear gloves! • Equipment: brush, paste, emesis basin, swabs • Report bleeding, odor, sores
Routine Mouthcare • Resident placed in Fowler’s position • Resident must be able to expectorate (spit) • Note and report any problems with oral cavity or teeth • Clean all surfaces, including tongue from gumline using gentle short, strokes, going back and forth • Edntulous means no teeth
Special Mouthcare • Done for people who cannot expectorate such as someone in a coma, very weak, very confused, or NPO (nothing by mouth) • Head is turned to the side! • Use mouth swabs or toothettes • Never put your hand/fingers inside a resident’s mouth- keep mouth open with tongue depressor • Performed Q2h • Goal is prevent aspiration: breathing fluid, food vomitus into lungs- keep head turned to side!
Denture Care • Dentures are expensive. Care must be taken to prevent damage to plate or teeth. • Store dentures in a labeled, covered container filled with cool water (never in a paper towel, or glass) • Rinse and brush dentures using cool water to prevent plate from warping (melting) • Line sink with a towel to prevent teeth from accidentally cracking
Back Rub • Performed to increase circulation and for relaxation • Should be offered with PM care or done when back is washed • Use warmed lotion and move in circular motion from buttocks to shoulder • 3 to 5 minutes with resident in lateral position • Never massage or rub over a RED area
Other • Implants/crowns, bridges are permanent and cannot be removed • Implants last a lifetime • Require special care: soft bristled brush, nonabrasive pasts • Flossed, cleaned at least once daily
Hand and foot care • Hands or feet should be soaked for 5-15 minutes • Check with facility before trimming fingernails, never clip toenails • Use an orangewood stick to clean under fingernails • Never apply lotion to palms of hands or in between toes \
Hair Care • Performed as part of daily ADLs • If hair is tangled, comb from ends toward scalp in sections • Never cut the hair • Long hair should be pinned up or pulled back • Note/Report any problems to nurse • Style appropriately and use hair care products as provided- place folded washcloth over eyes or forehead • Shampoo on shower days • Pediculosis- lice, wingless insects that attach their nits (eggs) to hair and cause itching • Hirsutism- excessive body hair growth • Alopecia- baldness
Dressing • If a person has a weak or affected (cast, IV, bandaged, contracted) arm or leg when removing clothes: UNdress Unaffected side 1st • Dress the affected side first • Bob has a cast on his left leg. Which leg is Undressed first? When putting clean pants on Bob which leg is Dressed first????? • If client has an IV, can only change if NOT attached to a pump. If running by gravity, pass IV bag through sleeve (p. 150)
Chapter 6 (pp 162-173) Positioning, Transfers and Ambulation • Gait/transfer belt (page 168) • Place over clothes, around waist, tightened • Held with hands in an upward position • Walk slightly behind to one side • If resident has a WEAK side, you are positioned there • FYI: if resident has a WEAK side, to place in w/c, place chair on strong side!!
For rectal exam, measuring rectal temp and administration of an enema • Always on left side • Top leg sharply flexed, lower arm extended behind • Used for rectal exam, rectal temp and to administer an enema
Chair Positioning • Hips back in seat • Feet flat on floor • Backs of knees and calves slightly away from edge of seat • Arms on armrest or lap • May need postural support- pillows
Ways to move a person in bed: logrolling, in sections, with a drawsheet, trapeze bar • Avoid friction and shearing (when skin sticks to surface while moves in other direction) by using a drawsheet • A drawsheet is a ½ sheet placed from shoulders to mid-thigh • Pp 225-229, 231 • When turning, raise side rail to which person will be turned! • Logrolling keeps the body aligned or straight, place hands on shoulder and hip, move body as one unit; protects neck and spine
If resident able to help • Lower head of bed • Place one hand under resident’s shoulder blades and other under thighs • Ask resident to bend at the knees and push with feet on count of 3 • Page 152
Dangling • Sitting on edge of bed with feet hanging freely, not touching the floor • Prevents orthostatic hypotension, a drop in BP with a sudden position change • If resident dizzy or faint, lie back down and notify RN
