Acute hospitalization & Alzheimer's disease: a special kind of care.North Carolina Department of Health and Human Services The North Carolina Department of Health and Human Services (DHHS) is a large government agency in the U.S. state of North Carolina, somewhat analogous to the United States Department of Health and Human Services. DHHS has more than 19,000 employees. Division of Aging [ILLUSTRATION OMITTED] A new environment filled with strange sights, odors Odors anosmia Medicine. the absence of the sense of smell; olfactory anesthesia. Also called anosphrasia. — anosmic, adj. halitosis bad breath; an unpleasant odor emanating from the mouth. and sounds, a change in the daily routine, medications and tests, and the disease process itself can all be factors that increase confusion, anxiety and agitation in a hospitalized individual with Alzheimer's disease Alzheimer's disease (ăls`hī'mərz, ôls–), degenerative disease of nerve cells in the cerebral cortex that leads to atrophy of the brain and senile dementia. . This booklet will help you to meet the needs of these patients. In it you will find facts about Alzheimer's disease, communication tips, personal care techniques, suggestions for working with behaviors and environmental factors to consider in the ER and in the hospital room. When hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. occurs, the best option for the individual with Alzheimer's disease is the constant presence of a family member or a trusted friend. Because this may not always be possible, this booklet hopes to serve as a guide in helping you understand and practice the many facets of care for your patient with memory disorder There are several different types of memory disorders which occur in the human mind. Among these are less severe disorders including minor short term memory loss, and the eventually incapacitating Alzheimer's Disease. . Remember, family members are your most valuable resource for information about the individual and the caregiving techniques that work best. Alzheimer's Disease: Just The Facts * Alzheimer's disease attacks the brain and causes problems with memory, thinking and behavior. * Most people diagnosed with Alzheimer's are over age 65, but it can occur in people in their 40s and 50s. * Symptoms include gradual memory loss, decreased ability to perform routine tasks, disorientation disorientation /dis·or·i·en·ta·tion/ (-or?e-en-ta´shun) the loss of proper bearings, or a state of mental confusion as to time, place, or identity. , problems with language skills, poor judgment and personality changes. * The time from the beginning of symptoms until death ranges from 3 to 20 years; the average is 8 years. * There is no single test to identify Alzheimer's disease. A complete medical evaluation for diagnosis is essential. * A thorough evaluation will provide a correct diagnosis of possible or probable Alzheimer's 90-percent of the time. * There is no cure for Alzheimer's disease at present. There are FDA-approved drug treatments, designed specifically for memory symptoms occurring in mild to moderate stages of Alzheimer's disease. * The causes of Alzheimer's disease are not known. Suspected causes include genes and environmental exposure. More Than Just Words: Effective Communication Techniques Communicating with an Alzheimer's patient can be challenging, but remember, decreased verbal communication does not mean decreased awareness. Most patients are very aware and feel a great deal of distress about their increased loss of ability. General Rules of Thumb: Reality orientation does not work. Instead, use memory aids such as labeling objects (i.e. closet, bathroom). Be aware that as Alzheimer's disease progresses, an individual's ability to name objects and use words decreases. Simplify the environment for Alzheimer's patients. Eliminate distracting noises such as the radio or TV, or loud conversation. Do not use the in-room intercom to communicate. The patient may be frightened fright·en v. fright·ened, fright·en·ing, fright·ens v.tr. 1. To fill with fear; alarm. 2. or confused by hearing a voice only. Communication Tips * Always begin by identifying yourself and calling the patient's name. * Always approach from the front. * Maintain good eye contact. * Use short, simple sentences. * Speak slowly. * Be specific. Use the name of the person or object instead of "this" or "they". * Keep tone of voice low and pleasant. * Keep facial expression facial expression, n the use of the facial muscles to communicate or to convey mood. warm and friendly. * Use non-verbal cues: a reassuring touch, a smile, a demonstration stating the emotion. * Give the person plenty of time to respond to your question (20 seconds). * Always repeat your question exactly the same way. * Use concrete language. * State in positive terms. Constant use of "no" or commands increases resistance. * Don't test the patient's memory. Erase the words, "Don't you remember?" from your vocabulary. * Give directions simply and one at a time. * When helping with personal care, tell the patient what you are doing each step of the way. Add occasional social or reassuring comments to avoid "task-focused talk" only. * Do not appear rushed or tense. The patient will become tense and agitated ag·i·tate v. ag·i·tat·ed, ag·i·tat·ing, ag·i·tates v.tr. 1. To cause to move with violence or sudden force. 2. . * Listen to the patient. Try to find the key thought and take note of the feeling or emotion being expressed along with the spoken word. * Reassure through words. Remind the patient who you are and that you will take care of him. * Sometimes asking a "Why" question can get to the reason behind a repetitive question and decrease its occurrence. (i.e. "Why are you concerned about what time it is?") In The Emergency Room: Assessment Tips * Do not leave the patient alone. A family member, trusted caregiver or friend should be present at all times. * Continuous cueing to the environment (place) and activity may be necessary. A family member can assist with this and offer reassurance as well. * Obtain patient's history from a close relative or caregiver. * Pay close attention to the caregiver's description of the patient's usual level of consciousness. Increased dementia or the onset of delirium delirium Condition of disorientation, confused thinking, and rapid alternation between mental states. The patient is restless, cannot concentrate, and undergoes emotional changes (e.g., anxiety, apathy, euphoria), sometimes with hallucinations. can be a sign of acute physical illness or metabolic distress. * Perform a complete head to toe assessment. The patient may not be able to automatically identify painful or affected areas to you. * Before every communication with the patient, make sure you have his attention by calling his name and making direct eye contact with him. Your eyes should be level with the patient's eyes. * Ask simple "yes" and "no" questions. Allow ample response time (at least 20 seconds). * Watch for non-verbal communication of pain or discomfort such as grimacing, guarding or anger. * Apologize each time you cause pain and avoid repeating painful exams. * In short, simple statements, tell the patient what you are doing, why and that you will be finished soon. Repeat this throughout the examination. * Never talk about the patient to others as if he is not in the room. My Patient Has Alzheimer's: General Guidelines For an Alzheimer's patient, the trauma or ailment ail·ment n. A physical or mental disorder, especially a mild illness. that preceded hospitalization, the strange new environment, the disrupted daily routine and the influence of medications can all be factors for increased confusion and decreased ability. There are a number of things you can do to reassure your patient. You should: * Provide a consistent, predictable routine. Ask the primary caregiver for the patient's usual routine and follow it as closely as possible. * Encourage the use of security objects from home (i.e. favorite pillow or quilt). * Provide care by the same nurses and nursing assistants as much as possible. * Avoid surrounding the patient with several doctors and medical students at one time. General Guidelines continued * Evaluate the patient for sources of potential pain and discomfort. Even though he may be experiencing pain, the patient will probably not verbally complain. * When possible, schedule tests at a time of day when the patient is at his best and not fatigued. * Discontinue asking orientation questions once the patient's level of comprehension is established. * Use good communication techniques. (See Communication Section). * Schedule at least two rest periods: A half hour after morning care and an hour in early afternoon. Rest is important! * Post rest period times on the patient's door. Use a big "Resting" or "Do Not Disturb Do not disturb usually referes to a status where the subject prefers to be left in solitary. It can also mean the following:
* Limit visitors to one or two at a time. * Cue the patient for sleep by darkening dark·en v. dark·ened, dark·en·ing, dark·ens v.tr. 1. a. To make dark or darker. b. To give a darker hue to. 2. To fill with sadness; make gloomy. 3. and quieting the room. * Avoid using physical restraints Physical restraint refers to the practice of rendering people helpless or keeping them in captivity by means such as handcuffs, shackles, straitjackets, ropes, straps, or other forms of physical restraint. . They do not prevent falls. Injuries from falls while the patient is restrained are often more serious. Room Service: Assessing the Environment * Avoid numerous room changes. Change increases confusion and anxiety. * Avoid placing the patient in a room located in a high noise, high traffic area. * Keep the television off until the patient turns it on or requests it. * Remove artwork containing people or animals if the patient interprets them as real-life intruders. * Keep lighting as free of shadows and glare as possible. * Avoid clutter. It can increase confusion, agitation and the risk of falls. * If the patient can understand written words, then large, bold lettered signs can serve as cues to the bathroom, closet and personal items. Providing the Essentials: Comfort and Safety Comfort * Always communicate a sense of security, caring and respect. * Each staff/patient interaction should include: touch, eye contact, orienting information and an activity the patient can successfully perform. * Eyeglasses eyeglasses or spectacles, instrument or device for aiding and correcting defective sight. Eyeglasses usually consist of a pair of lenses mounted in a frame to hold them in position before the eyes. , dentures and hearing aids Hearing Aids Definition A hearing aid is a device that can amplify sound waves in order to help a deaf or hard-of-hearing person hear sounds more clearly. can enhance the patient's communication. Offer to assist the patient with placement of these devices. Be aware in some instances the patient is more comfortable without them. * If the patient has a comfort item, something that makes him feel secure, make sure it is within reach. Safety * Provide a safe, structured environment. * Provide consistent staff to attend the patient. * Place the patient in a room that allows easy and careful observation. * Place bed in low position. * Don't leave anything at the bedside that might harm the patient. * Elopement Elopement Carker, James with Dombey’s wife. [Br. Lit.: Dombey and Son] Leonora with Alvaro, rejected as suitor by her father. [Ital. precautions: Place the patient in a room where he has to pass the nursing station in order to reach an exit. Have a photo of the patient on file. Positive Approaches To Personal Care: Activities Of Daily Living Eating * Do not ask the patient to fill out a menu. Ask the family about food preferences. * Simplify the food tray. Keep small, colored dishes on the unit to allow for smaller portions and the ability to offer one or two food items at a time. * Smaller, more frequent meals may work better for the patient than the standard three large meals. * Cueing the patient to eat by using verbal reminders along with a light touch to the forearm forearm /fore·arm/ (for´ahrm) antebrachium; the part of the arm between elbow and wrist. fore·arm n. The part of the arm between the wrist and the elbow. increases food intake. * Finger foods, cups with lids and broad-handled utensils may make mealtime easier for the patient. * Late stage patients may chew, but need frequent reminders to swallow. * Plate guards and bibs with pockets catch spills and protect the patient's clothing. * Offer the patient fluids frequently throughout the day. Ask the caregiver what the patient prefers to drink and the type of drinking container used at home. Oral Hygiene Oral Hygiene Definition Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease. * Brush the patient's teeth at least twice a day. * For less impaired patients, apples and other fresh fruits aid with oral hygiene. Bathing * Bathe the patient at his "best" time of day. * If possible, bathe the patient at the time he normally bathes at home. * Avoid using the shower. A hand-held showerhead provides better control of the water. * Allow the patient to do as much as possible. Break down the task into simple steps using verbal and visual cues. * When assisting the patient, give the bath slowly. To avoid agitation, tell the patient what you are going to do one step at a time. * Use soft music, talking or snacks as pleasant distractions. * Keep the patient warm! During a bed bath, cover body parts except the parts that are being washed. * Sounds amplify off tile walls. Running water can sound frightening. * Be flexible. A "bird bath" may be more acceptable to the patient. Toileting * Clear a path to the toilet or commode commode Piece of furniture resembling the English chest of drawers, used in France from the late 17th century. Most had marble tops, and some were fitted with pairs of doors. . * Place bed in view of toilet. * To help cue the patient, place a picture of a toilet or a written sign on bathroom door. * Place your patient on a two-hour toileting schedule. * Use a nightlight to make it easier for the patient to find the toilet in the middle of the night. * Observe your patient for constipation constipation, infrequent or difficult passage of feces. Constipation may be caused by the lack of adequate roughage or fluid in the diet, prolonged physical inactivity, certain drugs, or emotional disturbance. . Ask questions about abdominal discomfort. Watch for non-verbal signs of discomfort such as grimacing or clutching. Do not ask the patient if he has had a bowel movement. [ILLUSTRATION OMITTED] The Art of Camouflage camouflage (kăm`əfläzh), in warfare, the disguising of objects with artificial aids, especially for the purpose of making them blend into their surroundings or of deceiving the observer as to the location of strategic points. : Protecting Tubes and Dressings Reduce the number of tubes as quickly as possible while considering patient safety. Make remaining tubes as unobtrusive as possible. * Nasogastric Tubes nasogastric tube n. A tube that is passed through the nasal passages and into the stomach. Nasogastric tube A tube placed through the nose into the stomach. Mentioned in: Life Support (of small diameter): Tape to the side of the face, place tube behind patient's ear and fasten to shoulder area of the gown with a safety pin. * Central Venous Pressure central venous pressure n. Abbr. CVP The pressure of the blood within the superior and inferior vena cava, depressed in circulatory shock and deficiencies of circulating blood volume, and increased with cardiac failure and congestion of lines: Can remain under the gown with a point of departure through the sleeve. * Peripheral Intravenous Line: 1. Can be wrapped in bandage bandage /ban·dage/ (ban´daj) 1. a strip or roll of gauze or other material for wrapping or binding a body part. 2. to cover by wrapping with such material. gauze gauze (gawz) a light, open-meshed fabric of muslin or similar material. absorbable gauze gauze made from oxidized cellulose. to prevent access or, 2. Can be placed high on dominant arm. Dress patient in long sleeve gown with cuff (like an O.R. gown), run tubing up the arm and out of the neck of the gown. * Foley Catheters Fo·ley catheter n. A catheter held in the bladder by an inflatable balloon. Foley catheter A two-channel catheter with a balloon on the bladder end of one channel. : Should be run directly from the area of insertion to the end of the bed to prevent accidental pulling by the patient. Patient should wear undergarments to minimize access to the catheter. * Foley Catheter in Men: Should be taped to the abdomen. * Picks at Dressing: Consult with your occupational therapist occupational therapist A person trained to help people manage daily activities of living–dressing, cooking, etc, and other activities that promote recovery and regaining vocational skills Salary $51K + 4% bonus. See ADL. to develop hand splints splints inflammation of the interosseous ligament between the small and large metacarpal bones of horses and an accompanying periostitis and exostosis production on the small metacarpal bone. The metatarsal bones are similarly but less frequently involved. (like those used for patients with burns or rheumatoid arthritis rheumatoid arthritis Chronic, progressive autoimmune disease causing connective-tissue inflammation, mostly in synovial joints. It can occur at any age, is more common in women, and has an unpredictable course. ) that maintain alignment and mobility but eliminate the pincer grasp, thus eliminating the ability to pick at the dressing. [ILLUSTRATION OMITTED] What Do I Do When ... ? Tips For Working With Behaviors General Guidelines * Think of behaviors (no matter how unusual) as communication signals from the patient that there is a problem or unmet need. Try to figure out that signal. * Remain calm. * Protect the patient both physically and from embarrassment. * Offer reassurance and appropriate assistance. Changes In Sleep Patterns Possible Causes: * Medications * Pain * Not enough activity during the day * Can't find the bathroom * Too hot or too cold * May be hungry Possible Strategies: * Review medications for possible side effect of restlessness. * Evaluate your patient for pain and treat if needed. * Provide nightlights to aid the patient in finding the bathroom. Make sure the pathway is clear and well lit. * Attend to toilet needs right before bedtime bedtime Sleep disorders The time when one attempts to fall asleep–as distinguished from the time when one gets into bed . * Continue the patient's at-home bedtime routine as much as possible. * Limit beverages containing caffeine caffeine (kăfēn`), odorless, slightly bitter alkaloid found in coffee, tea, kola nuts (see cola), ilex plants (the source of the Latin American drink maté), and, in small amounts, in cocoa (see cacao). in the afternoon and evening. * If the patient wakes up at night, let him walk around (in sight) or sit at the nursing station until he is tired. Confusion Possible Causes: * Unfamiliar environment * Medications * Environment too noisy * Unfamiliar or difficult task * Unable to understand directions Possible Strategies: * Identify any potential dangers in the environment. * Use pictures (symbols) instead of written signs to assist the patient with locating his room and bathroom. * Decrease noise level if possible by avoiding paging systems and buzzing call lights. * Place the patient's name in large block letters block letters npl → letras fpl de molde block letters block npl → majuscules fpl block letters npl on the door to his room. * Review medications for side effect of confusion. * Simplify tasks. Break them down into smaller steps. * Simplify communication. Use short sentences and avoid lengthy explanations. * Ask the family member/caregiver about the comfort strategies used at home. [ILLUSTRATION OMITTED] Wandering Possible Causes: * Patient is stressed and anxious * Lifestyle related-previous work role or habits * Looking for Looking for In the context of general equities, this describing a buy interest in which a dealer is asked to offer stock, often involving a capital commitment. Antithesis of in touch with. security * Pain * Searching for something familiar Possible Strategies: * Ask the caregiver where and when the patient usually wanders. Find out what strategies have worked at home. * Place the patient in a room that is convenient for you to keep a watchful watch·ful adj. 1. Closely observant or alert; vigilant: kept a watchful eye on the clock. See Synonyms at aware, careful. 2. Archaic Not sleeping; awake. eye on and that is away from stairs or elevator. * Keep the the patient's suitcase, street shoes and street clothes out of sight. * Assess the patient for pain and treat if needed. * Plan walks with the patient. * Use distractions such as a snack or music. * Take time to talk with the patient. * Offer a simple, meaningful activity. Catastrophic Reactions cat·a·stroph·ic reaction n. Disorganized behavior due to a severe shock or threatening situation with which the person cannot cope. : Patient feels overwhelmed o·ver·whelm tr.v. o·ver·whelmed, o·ver·whelm·ing, o·ver·whelms 1. To surge over and submerge; engulf: waves overwhelming the rocky shoreline. 2. a. and overreacts to a situation. Possible Causes: * Fatigue * Environment is too stimulating * Patient is asked too many questions at a time * Too many strangers in a noisy, crowded atmosphere * Patient is asked to perform a task beyond his abilities * Fails at a simple task * Encounters irritable irritable /ir·ri·ta·ble/ (ir´i-tah-b'l) 1. capable of reacting to a stimulus. 2. abnormally sensitive to stimuli. 3. prone to excessive anger, annoyance, or impatience. , impatient staff Possible Strategies: * Remain calm. * Use a low tone of voice. * Do not argue with the patient. * Try the activity or task again later. * Refrain from forcing or restraining the patient. * Offer reassurance and try distraction. * Move the patient to a quieter area. * Simplify the task for the patient. * Build in rest periods. * Simplify communication. * Be aware of your own body language and what it is saying. Preventing Catastrophic Reactions * Maintain a simple, structured, secure environment. * Follow routines and schedules. * Limit choices--choose between two items instead of five or six. * Introduce new treatments slowly. * Give step by step directions. Disruptive Vocalizations: Calling out or screaming Possible Causes: * Fear * Pain * Loneliness * Self-stimulation Possible Strategies: * Offer the patient reassurance. * Place the patient where he can see a nurse. * Spend time with the patient. * Assess the patient for pain. * Provide a range of textures in the environment for stimulation. Sources Alzheimer's Disease Fact Sheet, National Alzheimer's Association The Alzheimer's Association, incorportated on April 10, 1980 as the Alzheimer’s Disease and Related Disorders Association, Inc., is a non-profit American voluntary health organization which focuses on care, support and research for Alzheimer's disease. , Chicago, IL, 1994. Effective Communication with Patients with Dementia, Zimmermann, Polly G., RN, MS, MBA MBA abbr. Master of Business Administration Noun 1. MBA - a master's degree in business Master in Business, Master in Business Administration , CEN CEN - Conseil Européen pour la Normalisation. A body coordinating standardisation activities in the EEC and EFTA countries. , Journal of Emergency Nursing, Vol. 24, Number 5, October, 1998, pp. 412-415. Managing the Care of Patients with Irreversible Dementia During Hospitalization for Comorbidities, Stolley, Jacqueline M., Hall, Geri R., MA, RN, CS, Collins, Judith, RN, CS, et al, Nursing Clinics of America, Vol. 28, Number 4, December, 1993, pp. 774 -775. Nursing the Hospitalized Dementia Patient, Evans, Lois K., DNSc, RN, Journal of Advanced Medical-Surgical Nursing, March, 1989, pp. 22, 24- 26, 28-29 The Person With Dementia: ED Assessment Tips for This At-Risk Patient, Royer, Mark, RN, MSW (MicroSoft Word) See Microsoft Word. , CSW CSW Commission on the Status of Women CSW Christian Solidarity Worldwide CSW Clinical Social Worker CSW College of the Southwest (New Mexico) CSW Cambridge SoundWorks (audio manufacturer) , Journal of Emergency Nursing, Volume 24, Number 4, August, 1998, pp. 331-332. This Hospital Patient Has Alzheimer's, Hall, Geri R., MA, RN, CS, American Journal of Nursing, October, 1991, pp. 45-50. When Your Patient Has Alzheimer's Disease, Stolley, Jacqueline M., RN,C RN,C Registered Nurse, Certified , MA, American Journal of Nursing, August, 1994, p.38. * Information on The Art of Camouflage: Protecting Tubes and Dressings from Managing the Care of Patients with Irreversible Dementia During Hospitalization for CoMorbidities, Stolley, Jacqueline M., Hall, Geri R., MA, RN, CS, Collins, Judith, MA, RN, et al, Nursing Clinics of America, Vol. 28, Number 4, December, 1993, pp.774-775. This booklet was originally produced by the North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures Area, 52,586 sq mi (136,198 sq km). Pop. Division of Aging in conjunction with the Joseph and Kathleen Bryan Alzheimer's Disease Research Center through the Administration on Aging The Administration on Aging (AoA) is an agency of the United States Department of Health and Human Services. AoA awards annual grants (computed by formulas) to State government agencies on aging and Native American tribal organizations to support programs mandated by the Congress grant # 90AZ2246 |
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