AssignmentIdea: Change in Cognition – Elderly
Overview
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A normal part of the aging process includes a mild decline in some areas of cognition. Many older adults experience changes in immediate memory or the ability to name objects but not all cognitive changes are considered a normal part of the aging process. Individuals with cognitive decline diagnosed with dementia often experience unmet needs that include hunger, pain, and toileting. This activity will provide students the opportunity to gain an understanding of normal versus abnormal changes in cognition and identify nursing and collaborative interventions to minimize the impact of cognitive impairment, including safety concerns, and to optimize resources and services.
Objectives
· Recognize normal versus abnormal changes in cognition in relation to the aging process.
· Develop a comprehensive care plan for an individual experiencing a decline in cognition.
· Identify risk assessments and cognition screening tools for an individual experiencing a decline in cognition.
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Discuss interventions used to address agitation, distress, and challenging behaviors in an individual with a decline in cognition.
· Describe resources and services that are available to providers, families, and caregivers for the patient with experiencing a decline in cognition or dementia.
2020 NCLEX-RN® Test Plan
· Client Needs Category: Psychosocial Integrity
· Provide care and education for acute and chronic psychosocial health issues (e.g., addictions/dependencies, depression, dementia, eating disorders)
· Client Needs Category: Health Promotion and Maintenance
· Subcategory: Health Screening
· Perform targeted screening assessments
· Subcategory: Coping Mechanisms
· Assess client’s support systems and available resources
· Integrated Processes:
· Nursing Process & Teaching/Learning
AACN BSN Essentials
This assignment addresses the following AACN BSN Essentials:
· Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health
· Communication and collaboration among healthcare professionals are critical to delivering high quality and safe patient care
· Essential VII: Clinical Prevention and Population Health for Optimizing Health
· Practice evidence-based public health nursing to promote the health of individuals, families, and groups
AACN Public Health Essentials
This assignment addresses the following AACN Public Health Essentials:
· Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes
· Communicates effectively in writing, orally, and electronically as a member of interprofessional teams.
· Essential VII: Clinical Prevention and Population Health for Optimizing Health
· Practice evidence-based public health nursing to promote the health of individuals, families, and groups.
Student Instructions
1. Review the following resources:
· Assigned Readings
· Optional:
https://www.cdc.gov/steadi/pdf/Steadi-Coordinated-Care-Final-4_24_19
2. Enter Sentinel City® Simulation and click the map to locate the assigned citizen
· Anna Jordan
3. Next review the home health visit notes below to differentiate normal versus abnormal age-related changes. Record pertinent observations and subjective and objective signs of a decline in cognition or dementia.
4. Suggest risk assessments and cognition screening tools for an individual experiencing a decline in cognition, such as a mini mental status exam and fall risk assessment.
Home Health Visit
No
tes
After reviewing the baseline information on Anna in Sentinel City®, read the notes below of the RN home health visits with Anna for wound care following a fall. Identify subjective and objective data and observations of normal and abnormal changes observed with geriatric or dementia patients.
Notes from Visit One
Anna welcomed the nurse into the living room where there was a pile of unfolded laundry on the couch. Anna ambulated around the room, without the use an ambulatory device. Home hazards noted include loose rug, low toilets, step over shower, shower without a bench, and stairs. Anna often wears shoes in the house supporting her feet. Anna’s last eye exam was within the last 6 months and her eyeglasses were updated. Wound care supplies are available near her chair. Anna’s glasses are sitting on the table, alongside a birthday card and holiday cards. Anna mentions how it was wonderful to see her family for her birthday. Anna offered the nurse some coffee. Anna is dressed in clean yet wrinkled clothing with her hair styled and earrings on. When asked about nutrition, she was excited to share that she had leftovers from the holidays.
Anna was confused to the month, while orientated to the day, time, and year. She laughed and said that she meant that that she had been pulling leftovers out of the freezer from the holidays for their meals. Anna mentioned that it has been too cold for her to go out like she enjoys, so she and her partner have been staying home. There are a few unwashed dishes and open soup cans on the counter, near several medication bottles. Anna reported that she has been trying to drink enough water and drinks coffee in the morning. Anna asked the nurse if she would like some coffee.
Anna is observed walking independently with occasional loss of balance. Anna was opening curtains and moving small items around the room, trying to locate her glasses. Anna reported that she has been changing her dressing whenever it needs it and there has not been too much pain. Anna stated that she had not had any other falls since her injury. Upon assessment, the wound measurements have not improved in the last two weeks. Several layers of gauze were added, without removing the old dressing. Anna was asked to demonstrate wound care for the nurse and missed several steps. The nurse demonstrated correct wound care and provided visual instructions for Anna. Anna asked four repetitive questions to clarify process. Plan for home health aide to visit three times weekly. Nurse to visit weekly.
VS: T 98.4/tympanic; HR regular 84 bpm; Resting Respiratory rate 18. BP 112/64.
Notes from Visit Two:
Three weeks later, the nurse was alerted that Anna would not open the door to allow the home health aide in. Anna answered the door and allowed the nurse to enter. Anna walked independently to the living room and sat down in her chair. Anna knew that she was in her home, the name of her city and state. Anna did not have any medical equipment attached to her. The curtains were closed, the kitchen and living area was cluttered and unkempt and Anna appeared to have been sitting alone in the dark room. Anna was picking at her lap blanket, appeared disheveled and ungroomed. The living room smelled of urine. Adult diapers were viewed in the bathroom garbage can. The nurse identified that Anna is having urgency, frequency, and incontinence.
The birthday and holiday cards remained on the table alongside several pieces of unopened mail. Anna stated that it was wonderful to have her family come by for the holidays and take such good care of her. Anna was unable to recall the names of all her grandchildren in a photo, while naming her partner. Anna was able to state the year, season, day of the week and the date. Anna was again confused to the month.
When asked about her home health aide, she said it was nice to have more company and extra help around the house this week. Anna laughed when the nurse inquired about letting the aide in her home. Anna paused and thought about it in silence. After a minute she said there was someone handing out political papers and she told them to not come back. Anna then asked the nurse why she was there today. The nurse explained she wanted to check on her, including her bandage. Anna said that things had been fine, and she was glad to get rested after the holidays. Anna mentioned that they have not been getting together with friends in the last few weeks. It was evident that Anna is forgetting some words and is demonstrating less initiative to conversate.
The microwave kept beeping every few seconds. The nurse went to the microwave and found an uneaten breakfast plate. Anna laughed and said that she meant to put the leftovers in the refrigerator. The nurse reminded Anna of the importance of nutrition, hydration, and hygiene for her body to heal. Anna became irritable and again asked the nurse why she was there. The nurse reminded Anna that she was there to check on the bandage on her leg. Anna pulled up both of her pant legs, revealing a soiled bandage on her wound. Anna became tearful and said she changed the bandage several times. The bandage was dated three days ago by the home health aide. Anna reached down and tore off the bandage. Anna became anxious and agitated while looking at the supply table. The nurse offered to assist her with the wound care and Anna declined assistance. Anna began to cry and then allowed the nurse to provide wound care.
VS: T 97.8/ty; HR regular 94 bpm; Resting Respiratory rate 22. BP 116/66 lying flat; BP 92/ 58 standing
Notes: Review medication list, history for comorbidities and risks listed in Anna’s profile that increase her risk for falls. Does the patient take vitamin D?
Care Plan Sample
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Nursing Diagnosis
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Patient Goals
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Intervention: Rationale
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Implementation
(
Yes
or No)
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Evaluation
Outcome
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Example
Nursing Diagnosis
Patient Goals
Intervention: Rationale
Implementation (Yes or No)
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Evaluation Outcome
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Diagnosis:
High risk for falls related to confusion as evidenced by disorientation to place, time, situation, unsteady gait, generalized
weakness
Subjective Data:
Patient asking, “who are you again?”
Multiple family stated, “he doesn’t seem right”
Patient stated, “I feel weak when I get up”
Objective Data: History of dementia Set off bed alarm
continually during night Requires walker for ambulation
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Patient will remain free from injury during this admission.
Patient will remain free from falls during this admission.
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Patient will wear non-skid socks when out of bed: to provide stability during ambulation
Patient’s bed alarm will be on at all times: to alert staff if patient is attempting to get out of bed independently
Patient will be relocated to a room closer to the RN station: to enable staff to visualize patient on a more frequent basis
Nurse will increase frequency of rounding: to assess needs more frequently, toilet more often, reorient.
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Yes
Yes
No
Yes
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Patient utilized non-skid socks during all periods of ambulation, did need to be continually reminded, as he does not like socks, per his report. Will continue to promote.
Patient’s bed alarm was on consistently throughout shift and patient did set alarm off approximately 4-6 times. Will continue to have bed alarm on.
Another confused patient occupied the room closest to RN station; will move if room becomes available.
Patient rounded on q 30 min or q 1 hour. Noted that patient became agitated when he had to use the bathroom during first rounding, therefore offered toileting with each visit and noted decrease in agitation. Will continue to round frequently.
Patient remained injury and fall free during this shift. Goals progressing.
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Sample Draft Assignment Rubric
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Assignment
Competencies
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Point Scale
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Student Earned Points & Faculty Comments
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Assessment includes observations and objective and subjective data from background and home health visit notes.
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Identifies related risk assessments and cognition screening tools for an individual experiencing a decline in cognition, such as a mini mental status exam and fall risk assessment.
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Develop care plan for patient experiencing a decline in cognition.
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Discuss interventions used to address agitation, distress, and challenging behaviors in an individual with a decline in cognition.
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Describes resources and services that are available to providers, families, and caregivers in Sentinel City®. List resources in your community that could benefit Anna.
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Uses textbooks to provide evidence-based plan of care.
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Faculty Feedback:
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Assignment Grade
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Note: Faculty should determine point scale based on their institution guidelines. This assignment was developed to be used with the family support assessment form, however suggested table above per faculty discretion, other families in Sentinel City® may be used for this assignment. Faculty may elect to use the family support care plan or require students to address each competency listed on the rubric in a three- to five-page written paper or presentation. Create a digital care plan.
Home Safety and Elderly Assignment
· What did you learn about the role of the community public health nurse in completing a home safety assessment?
· How did the public health nurse use a strengths based approach to make assessments of the client, his family and the home environment?
· Reflect on how you feel about working with a client whose home is in disarray. What might be the same or different than working with a client who lives in a home that is neat and clean?
Application Questions:
How would you apply this virtual experience to clients in other home visiting situations?
What did you learn about the complexity of working with a client who is having a difficult time maintaining a safe home environment? How would you involve the client, the family, or outside agencies in the assessment and plan?
Using principle of motivational interviewing, what are some options for discussing with the client an disseminating a plan for making the home a safe environment?
As a public health nurse working with an elderly client, you may encounter some resistance to change. What are some options you could use to decrease the resistance?
Mrs. Anna Jordan is a 76 year-old woman who lives independently in her own home. She has come in to your primary care clinic for a wellness visit.
Self-Risk Assessment
Mrs. Anna completes the Stay Independent brochure in the waiting room. She circles “Yes” to the questions, “I have fallen in the last 6 months” and “I take medicine to help me sleep or improve my mood.” Her risk score is 3.
Gait, Strength & Balance Assessment (Completed and documented by medical assistant)
Timed Up and Go: 12 seconds. Gait: decreased arm swing but otherwise normal.
30-Second Chair Able to rise from the chair without using Stand Test: her arms to push herself up. Score of 14 stands.
4-Stage Able to hold a full tandem stance for 10 seconds Balance Test: unsupported without postural
History
When asked, Mrs. Anna Jordan reports she fell the previous week but wasn’t hurt and so didn’t seek medical attention. She says she was out walking with a friend, they were talking and she wasn’t looking where she was going, and she tripped over a crack in the sidewalk. This was her first fall.
Anna reports that she usually walks about 2 miles each day around her neighborhood. She feels steady when walking at all times, even when out of doors. She tries to avoid potholes and usually watches out for cracks in the sidewalk so she won’t trip. She’s not afraid of falling. Walking is her only form of exercise.
Medical Problem list
· Seizure disorder
· Schizoaffective disorder
· Chronic kidney disease stage 3
· Hypothyroidism
Medications
1. Depakote 250 mg twice daily
2. Zyprexa 12.5 mg daily
3. Ativan 0.5 mg twice daily
4. Levothyroxine 750 mcg daily
5. Colace 250 mg daily
6. Tylenol 500 mg 4 times daily as needed for pain
Review of Systems
Positive for poor eyesight, urinary incontinence, and nocturia >2 times a night.
