DEMENTIA CASE MANAGEMENT

 MARKING KEY FOR MENTAL HEALTH & PSYCHIATRY NURSING

DEMENTIA

COMPULSORY QUESTION

 

1.     Mr. Mutokofita aged 30 years is brought to Chainama Hospital Ward X with history of wondering about and self -neglect for the past 3 months. On admission, the Doctor conduct a Mental State Examination and a diagnosis of Dementia is made

a)      Define Dementia                                                                                                 5 marks

b)     Explain five (5) causes/predisposing factors of Dementia                                  25 marks

c)     State five (5) cardinal signs of Dementia                                                             20 marks

d)     Discuss how you are going to nurse Mr. Mutokofita during his stay in hospital

                                                                                                                             50 marks

KEY

a)     Def:

ü  Dementia is a syndrome characterized by progressive, usually irreversible, global cognitive (mental activity) deficits such as memory, language, emotion and personality which is of sufficient severity to interfere with one’s normal & occupational functioning.

ü  This is a syndrome where the patient has multiple cognitive deficits and memory loss sufficient to impair occupational or social functioning.

b)     Five (5) causes/predisposing factors of Dementia

ü  Picks disease due to frontotemporal lobar degeneration

ü  Alzheimer’s disease due to neurodegerative changes

ü  Vascular dementia due to impaired blood flow to the brain

ü  General medical condition eg. HIV/AIDS

ü  Substance induced due to increased toxins to the brain

ü  Huntington disease due to breakdown of the nerve cells

ü  Head trauma

ü  Creutzfeldt-Jakob Disease

ü  Parkinsons disease

 

c)     Five (5) cardinal signs of Dementia                                                            

ü  Memory impairment (starts with short-term and progresses to long-term) which is impaired ability to learn new information or to recall previously learned information

ü  Impairment in abstract thinking, judgment, & impulse control.

ü  Aphasia – difficulties in naming objects, or in speaking

ü  Apraxia – loss of ability to carry out purposeful, complex movement and to use objects properly.

ü  Impaired executive functioning

ü  Personality disintegration: History of personality change, forgetfulness, social withdrawal, lability of affect, disinhibition, diminished self care, apathy, fatigue, deteriorating executive functioning.

ü  Significant impairment of normal functioning

ü  Hallucinations and delusions often paranoid

ü  Anxiety or/and depression in some

ü  Neurological features (eg. Seizures, focal deficits)

ü  Disorientation

ü  Wandering

 

d)     NURSING CARE

              AIMS:                         2%

ü  To rehabilitate patient

ü  To relief the signs and symptoms

ü  To prevent injuries

 

SPECIFIC NURSING CARE- 5%

ü  Maintain calm manner with pt

ü  Interrupt periods of unreality & reorient

ü  Teach relaxation exercises to be used when anxious

ü  Provide simple & structured environment to minimize confusion:

ü  Identify self care deficit & provide assistance as required

ü  Allow plenty of time for pt to perform task

ü  Orient to reality (time, place, person) frequently.

ü  Teach caregiver successful methods of preventing harm to pt and orientation of pt.

ü  Maintain low levels of stimulation eg. Sounds, light, too many visitors etc as these lead to increased anxiety.

ü  Sufficient staff to restrain pt when necessary

 

 

Ø  Environment                 2%

ü  The room should be clean, well lit, well ventilated and patient maybe isolated if being danger to others or him/herself.

ü  The furniture should be removed from the ward where this patient is being nursed from in order to prevent injuries and it should be stimuli free.

ü   The environment should support both mental and physical rest, therefore, nurse patient in a quiet environment to promote rest as patient with mental illness experience.

ü  Environment should be well ventilated to promote comfort.

ü  Ensure that environment is free from stressful stimuli as stress increases vagal activity which worsens the condition

Ø  Observation                 2%

ü  Observe for general condition of the patient, changes in mood and suicidal idealation

ü  Observe also their sleeping and feeding pattern

ü  Observe their levels of activities and their general behavior noting the signs and symptoms of depression.

Ø  Medical – psycho pharmacology                        3%

ü  This is a field of science which analyses the impact of different drugs effects on the mental health of patients.

ü  This is widely used in personality disorders, although no specific medication has been shown to treat any specific disorder.

ü  Instead, medications are targeted at the various associated symptoms of personality disorders.

ü  For example, mood stabilizers may be used for mood instability and impulsiveness.

Ø  Milieu therapy                        3%

ü  During their stay in hospital, patients are encouraged to take responsibilities for themselves and others.

ü  Milieu therapy is a type of psychotherapy that seeks to control your environment to keep you safe, improve your ability to learn new mental skills and encourage attitudes like respect and positivity.

ü  This is a form of psychotherapy that involves the use of communities. Patients join a group of about 30 for between 9 to 18 months

ü  Most are patients treated in the community because it is difficult and takes a long time to change maladaptive social responses.

ü  However, in case of self destructive or danger to others hospitalization in a structured environment with limit setting may

Ø  Psychosocial rehabilitation                 2%

ü  It promotes personal recovery, successful community integration and satisfactory quality of life for persons who have a mental illness or mental health concern.

ü  This involves assisting the person with mental illness to regain skills and maximize functioning in the community.

ü  It also involves treating patients with mental or emotional disorders by teaching them to function within their community.

ü  The process of restoration of community functioning and well- being of an individual diagnosed in mental health or emotional disorder.

Ø  Individual psychotherapy                        3%

ü  This is a process through which clients work one –on- one with a trained therapist in a safe, caring and confidential environment to explore their feelings, beliefs or behaviours, work through challenging or influential memories.

ü  This therapy helps patients overcome obstacles to their well-being.

ü  It can also increase positive feelings, such as compassion and self-esteem.

 

Ø  Establish a therapeutic relationship                             1%

ü  If nurse -patient relationship is enhanced, patient can learn how to find satisfaction in other human relationships.

ü  Nurse patient closely physically and psychologically (nurse to provide emotional sounding board).

Ø  Group therapy                                  3%

ü  This is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group.

ü  It helps individuals develop communication skills  and socialization skills and allows clients to learn how to express their issues and accept criticism from others

ü  It also allows individuals to develop self- awareness by listening to others with similar issues

Ø  Family therapy                    2%

ü  Family members should be educated on the patient’s condition so as to accept her or him as being part of the family in order to avoid stigma and rejection by members of the family.

ü  Significant others must always be involved in the plan of care since intimate relationships are always affected by maladaptive responses especially for manipulative patients who can turn relatives against staff & vise- versa to distract attention from self.

 

Ø  Behavior therapy                              3%

ü  Limit setting on all interactions and behaviours. Eg. Realistic limits about what can /cannot be done for the client.

ü  Use reinforcing techniques and consequences to achieve desired goals.

ü  Reinforce with something concrete that is readily available because material rather than    emotional rewards are preferred.

ü  Discourage bad behaviours in patients at all cost, you may use re-enforcement when patient does something good and withdraw reward when they do something bad.

ü   A physically aggressive patient may be told the need to tighten up restrictions & also issue an ultimatum.

Ø  Occupational Therapy                           3%

ü  This treatment focuses on helping people with a physical, sensory or cognitive disability be as independent as possible in all areas of their lives.

ü  Train patients on their survival skills because they may not continue with their current employment.

ü  Help patients of all ages to improve their ability to perform tasks in their daily living and working environments.

ü  Occupation includes all the activities or tasks that a person performs each day such as getting dressed, playing a sport, cooking a meal, getting together with friends and working at a job.

Ø   Recreational therapy                       2%

ü  This is a systematic process that utilizes recreation and other activity-based interventions to address the assessed needs of individuals with illnesses or disabling conditions as a means to psychological and physical health recovery and well-being.

ü  Use a variety of modalities including arts, crafts, drama, music, dance, sports and games as well as community outings to help patients maintain or improve on their physical, social and emotional well-being.

Ø  Psychological  care                             2%

ü  Explain condition to patient in simple terms and in language patient can understand.

ü  Involve patient and family in the care.

ü  Explain procedures to patient before carrying them out.

ü  Allow patient to ask questions and answer them appropriately

Ø  Supportive therapy                     2%

ü  The communities should incorporate mentally ill patients in available support systems

ü  It seeks to reduce psychological conflict and strengthen patient’s defenses through the use of various techniques, as reassurance, suggestion, counseling and reeducation.  

ü  This is the treatment designed to improve, reinforce or sustain a patients psychological care well-being or psychological self-esteem and self-reliance.

ü  The goal of supportive care is to prevent or treat as early as possible the symptoms of the disease, side effects, psychological, social and spiritual problems related to a disease.

ü  It also involves comfort care, palliative care and symptom management

Ø  Peer therapy                   2%

ü  In this therapy, involve the friends in the care of the patient and those of his or her age group especially those that suffered from the same illness so that they may share experiences.

 

Ø  Hygiene                           2%

ü  Assist patient with bathing to promote comfort, promote blood circulation and to remove dirty.

ü  Do oral care to promote appetite and prevent halitosis. Change linen whenever necessary.

ü  Encourage patients to be changing clothing after bathing or whenever they are dirty

Ø  Nutrition                            2%

ü  Monitor patients feeding pattern as patients with psychotic disorders tend be more suspicious

ü  Patients to be fed on normal diets in order to maintain their nutritional status.

ü  Encourage them also to be taking fluids and foods high in roughage in order to maintain the fluid volume and prevent constipation.

Ø  Rest                                  2%

ü  Ensure adequate rest for these patients by keeping the environment free from stimuli.

ü  Sedation may also help them rest

ü  The environment should support both mental and physical rest, therefore, nurse patient in a quiet environment to promote rest as patient with mental illness experience.

 

Ø  Injury prevention                     3%

ü  Monitor aggressive patients closely  because they maybe danger to others and themselves

ü  Furniture, equipments and other instruments should be away from the patients environment in order to prevent injuries.

Ø  Medical advice                             2%

ü  If the patient is to be discharged home, the family needs clear understanding of the residual deficits. The family and patient need to have realistic expectations about the patient’s abilities.

ü  Emphasis on the need of physiotherapy if there’s residue disability as rehabilitative measures.