Primary Nursing Diagnosis

Self-care deficit related to impaired cognitive and motor function

OUTCOMES. Self-care: Activities of daily living—Bathing, Hygiene, Eating, Toileting; Cognitive ability; Comfort level; Role performance; Social interaction skills; Hope

INTERVENTIONS. Self-care assistance: Bathing and Hygiene; Oral health management; Behavior management; Body image enhancement; Emotional support; Mutual goal setting; Exercise therapy; Discharge planning

U PLANNING AND IMPLEMENTATION Collaborative

The initial management of the patient begins with education of the family and caregivers regarding the disease, the prognosis, and changes in lifestyle that are necessary as the disease progresses. Basic collaborative principles include:

• Keep requests for the patient simple

• Avoid confrontation and requests that might lead to frustration

• Remain calm and supportive if the patient becomes upset

• Maintain a consistent environment

• Provide frequent cues and reminders to reorient the patient

• Adjust expectations for the patient as he or she declines in capacity

Pharmacologic Highlights

Generally, therapy Is focused on symptoms with an attempt to maintain cognition.

Medication or Drug Class

Dosage

Description

Rationale

Donepezil Antidepressants

5-10 mg PO qd Varies with drug

Cholinesterase Inhibitor; elevates acetylcholine concentration In cerebral cortex by slowing degradation of acetylcholine released by intact neurons

Selective serotonin reuptake inhibitors; increases activity of serotonin in the brain

Improves cognitive symptoms; Improves cognitive function in the early stages of the disease only; drug effects diminish as the disease progresses

Treats depression, anxiety, and irritability

Other Therapies: Secondary treatments are aimed at treating depression, psychosis, and agitation. To control night wandering and behavioral outbursts, physicians prescribe mild sedatives such as diphenhydramine. Barbiturates are avoided because they can precipitate confusion. Depression is treated with antidepressants (trazodone), and agitation is controlled by anxiolytics (oxazepam or diazepam). Psychotic behaviors are treated with antipsychotics (chlorpromazine or haloperidol).

Independent

Promote patient activities of daily living to the fullest, considering the patient's functional ability. Give the patient variable assistance or simple directions to perform those activities. Anticipate and assess the patient's needs mainly through nonverbal communication because of the patient's inability to communicate meaningfully through speech. Many times emotional outbursts or changes in behavior are a signal of the patient's toileting needs, discomfort, hunger, or infection.

To maximize orientation and memory, provide a calendar and clock for the patient. Encourage the patient to reminisce, since loss of short-term memory triggers anxiety in the patient. Emotional outbursts usually occur when the patient is fatigued, so it is best to plan for frequent rest periods throughout the day.

Maintain physical safety of the patient by securing loose rugs, supervising electrical devices, and locking doors and windows. Lock up toxic substances and medications. Supervise cooking, bathing, and outdoor recreation. Be sure that the patient wears appropriate identification in case he or she gets lost. Terminate driving by removing the car keys or the car. Provide a safe area for

62 Amputation wandering. Encourage and anticipate toileting at 2- to 3-hour intervals. Change incontinence pads as needed, but use them only as a last resort. Bowel and bladder programs can be beneficial in the early stage of the disease.

Provide structured activity during the day to prevent night wandering. If confusion and agitated wandering occur at night, provide toileting, fluids, orientation, nightlights, and familiar objects within a patient's view. Some patients respond calmly when given the security of a stuffed animal or a familiar blanket.

Encourage family members to verbalize their emotional concerns, coping strategies, and other aspects of caregiver role strain. Discuss appropriate referrals to local support groups, clergy, social workers, respite care, day care, and attorneys. Provide information about advanced directives (living wills and durable power of attorney for healthcare).

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