Nursing Management of Dementia

Sreeja V, RN, RPN*, Jyoti Beck, RN, RPN**

* staff Nurse, Central Institute of Psychiatry, Ranchi, India

** Dep. Nur. Superintendent. Central Institute of Psychiatry, Ranchi, India

	Introduction
	Prevalence & Epidemiology
	Etiology
	Signs & Symptoms
	Types of dementia
	Assessment & Management
	Nursing management
	Nursing care plan
	Problems of the carer
	Conclusion
	Bibliography

VIII. NURSING MANAGEMENT OF PATIENTS WITH DEMENTIA

 The Nursing care should be given according to its cause, onset of illness and severity. The main aim of nursing care is to make the patients life easier and pleasant. There is no effective treatment of cerebral pathology but we can help the patient in adjustment to life and coping with stress.

1. Maintenance of optimal cognitive functions.

a). Reduce environmental confusion

- Approach patient in a pleasant, calm way.

-Introduce yourself to the patient and greet him/her

-Keep the environment simple and pleasing, remove all unwanted utensils from the room.

-Maintain a regular daily living schedule, so that the patient will get touch with the daily living activities.

-Provide memory device like, lists of activities, reminding notes, labels on items; pictures, diagrams etc. will assist the patient to remember.

b). Increased environmental cues.

(It will enhance orientation to time place and person by filling memory gaps and serving as reminders)

-Identify yourself when interacting with the patient

-Address patient by name facilitate orientation to self.

-Offer environmental cues for orientation to time, place and person.

-Bring the patient near the window and shows him the surroundings.

-Interpret environmental stimulation as part of the conversation.

E.g. : Prior to switch on the light late in the evening, tell the patient that the day is going to be over and we need light, hence switch on the light. 

2. 2). Maintenance of Physical Safety

a). Control of environment

-Remove obvious hazards – knife, iron bars, drugs etc.,

-Reduce injury potential from bed time falls.

-Use of half bed rails.

-Keep bed in low position

-Use night lights

-Have accessible calling bell / light 

b). Monitor medication regimen

Administer drug at appropriate time and dose, should not leave the medicine by the patient. 

c). Monitor the temperature of food.

-Patient is protected from burning his mouth with warm food.

d)        Permit maximum independence and freedom.

-Allow freedom to move around in the safe environment will give a sense of autonomy and relaxation

-Avoid use of restraints (restraints may increase agitation)

-Keep identification tag on patient will facilitate a safe return to the ward. 

3. Maintenance of an optimal level of psychological functioning.

a). Reduce anxiety provoking situations in daily routine.

-Keep reality orientation, non-threatening but acceptable to the patient – repeat the answer if the patient asks again and again.

-Be patience with forgetfulness.

-Maintain a daily, regular routine so that the client is able to recall the daily activities.

-Simple structured stimuli are easiest to interpret, for example call the patient by name just before lunch, tell him the exact time and about the lunch. 

-Be with the patient and listen to him what he/she actually wish to communicate with you.

-Avoid situation that have upset patient in the past.

-Do not try to reason with the patient (Patient is unable to conduct abstract thinking)

b). Enhance the quality of life.

-Offer multiple opportunities for fulfillment like light music , walks , exercises, old hobbies watching TV etc. if the patient is able to perform such activities.

c). Encourage positive feeling of self.

-Treat the person as an individual with feelings (acceptance is the great inner support)

-Should not under estimate the patient.

-Openly discuss his feelings of anxiety and encourage him for further emotional ventilation when ever he needs and teach him relaxation methods , to reduce anxiety.

- Praise appropriately for expected behaviour.

-When skills are lost do not try to restrain deterioration of the cognitive process makes loss of skills inevitable.

4. Attainment of an optimal exchange of ideas between the patient and others.

a). Implement strategies to promote the patient’s interpretation of messages.

-Be calm , pleasant , and unhurried.

-Keep verbal message short and simple.

-Use non-verbal messages along with words .

-Be consistent in conversation.

-Simple message are easiest to interpret .

-Write down simple instructions and lists.

-Observe patient’s expression for signs that he understands.

-Talk to the patient even if he givens little or no response.

b). Develop strategies to improve the patient’s ability to express messages.

-Supply forgotten words when possible. This will allow to express his needs and feelings.

-Guess the message and confirm with the patient (Active listening will minimize frustration)

-Ignore mistakes

-Allow adequate time for conversation

-Encourage short, simple sentences.

-Ask “Yes/No” questions unhurried attitude will enhance communication.

-Provide alternative methods for communication pointing, describing with pictures etc.

-Acknowledge frustration in conversation that the patient is experiencing. It facilitate confidence.

5. Maintenance of maximum independence in activities of daily living.

a). Develop plan to facilitate daily performance of activities.

-Maintain a regular daily schedule at a time convening with the patient.

-Provide adaptive devices like lengthy brush for bath. Keep the instruction simple and divide the tasks in to small parts and do it first then ask the patient to do if further as much as he can. Stay with the patient till the task is over. Remind him if he stops in between because of confusion or short attention span.

-Monitor functions of body system supervision will promote optimal function and help to detect early problems.

b). Provide specific safe guards of safety in bathing.

-Monitor bath water temperature

-Help the patient to take his bath completely and safely

-If we leave the patient alone for bath he may pour few mugs of water and come off

-he may loose connection with what is being done ?

why he is in the bath room?

-Encourage use of safety measures in the bathroom like hand rails , rubber mats to prevent bath room falls.

c). Provide specific measures to remember places.

-Provide accessibility to bath room. Indicate bathroom with coloured pictures , visual stimuli reinforces recognition.

-Remind the patient about toilet, where it is , it is in the north/south? Confused or disoriented patient may pass motion in an odd place thinking that is toilet.

-Use clothing that open easily .

-Maintain toileting  schedule every two hourly (This help to maintain normal elimination)

-Encourage adequate fluid and fiber rich food and activity for regular bowel movement.

-Restrict fluid in evening hours . (This may interfere  with sleep)

6. Maintenance of optimal level of nutrition

a) Monitor food intake and observe food habits.

-Note weight loss or gain

-Provide regular mealtime schedule.

-Encourage adequate fluid intake.

-Provide balanced diet. If the client is unable to feed himself, feed the patient; during feeding narrate short stories which stimulate appetite as well as concentration.

-Maintain a calm and pleasant atmosphere.

-Offer a menu choice if possible.

-Offer familiar food. (Pleasant mealtime C favorite and familiar food, the client will eat well with enjoyment). 

b). Promote regular mouth care.

-Encourage care of gums and teeth after meals.

-Assist and encourage the patient to maintain clean mouth  

7. Maintain optimum personal hygiene

a). Promote healthy skin

-Keep the skin clean and dry.

-Massage the extremities and back it will helps to improve muscle tone and circulation.

-Lubricate the skin it is dry.

-Assist with back, buttock and foot, care to prevent bedsore.

-Provide clean and dry under clothing’s. 

b). Promote healthy hair and scalp.

-Wash hair weekly twice.

-Comb the hair daily , apply oil if needed and massage the scalp.

-Prevent pediculosis.

c). Encourage nail care.

-Maintain clean and short nails of both extremities.

-Provide soap and water to wash hands after each toiler visit. 

D). Maintenance of a balance of sleep and activity. 

-Reduce nighttime distractions such as noise, nursing procedures or for mid – night medications etc.

-Take measurement to increase safety.

Provide adequate night-lights.

Enhance comfort if awake at night.

Avoid use of restraints

Design a balanced schedule of activity / sleep

Increase daytime wakefulness and encourage short rests than long time rest.

Encourage regular exercise and activity programs to mobilize joints (Daily activity and exercise reduce agitation and produce soothening and a calming effect.

8. Enhancement of socialization and fulfillment of intimacy needs.

-Encourage visits from family and friends.

-Use touching to maintain contact with patient. Tactile stimulation is easiest to interpret.

-Introduce the family members and friends using names which is familiar to the patient.

-Address the patient with his designation e.g.: Daddy, Uncle, and Granny etc.

-Share feelings honestly and openly with patient simultaneously holding his/her hands or touching on his/her shoulder. (He client continuous to need love and affection from his own people)

-Limit numbers of visitors one or two at a time, to avoid confusion and to maintain single stimuli.

-Accept the patient despite negative interactions. 

9. 8). Provide Rehabilitation

-Provide Physiotherapy if the client has difficulty in walking.

-Support and retrain the existing skills.

-Provide hearing aids, if the hearing is impaired.

-Speech therapy and cognitive retraining in the case of aphasia (expressive aphasia)

-Impaired vision, provide big lettered books/schedule

-Reading glass if necessary

-Bladder and bowel training if incontinence is present