Client / Caregiver Education -

Dementia is a decline of reasoning, memory, and other mental abilities (the cognitive functions). This decline eventually impairs the ability to carry out everyday activities such as driving; household chores; and even personal care such as bathing, dressing, and feeding (often called activities of daily living, or ADLs).

Dementia is most common in elderly people; it used to be called senility and was considered a normal part of aging.
We now know that dementia is not a normal part of aging but is caused by a number of underlying medical conditions that can occur in both elderly and younger persons.
In some cases, dementia can be reversed with proper medical treatment. In others, it is permanent and usually gets worse over time.

Manifestations	Behavioural Interventions
Impaired recall of recent events	Use reminders (notes, single-day calendars, cues) Talk with the client about recent events
Impaired functioning, especially complex tasks Gradual withdrawal from activities Lowered tolerance of new ideas and changes in routine	Avoid stressful situations Do not ask for more than the client can do Keep the environment, schedule, routine the same Maintain normal mealtime routine Have items in the same place and in view
Difficulty finding words	Anticipate what the client is trying to say Provide word or respond to thought/feeling
Repetitive statements	Be tolerant and respond like it is the first time stated or heard
Decreased judgment and reasoning	Assess safety of driving and other desired activities Allow performance of skills as long as safe
Becoming lost	Accompany on walks Provide safe and secure walking area
Inconsistency in ordinary tasks of daily living Increasing tendency to misplace things Narrowing of interest Self-centred thoughts; restlessness or apathy	Ignore inconsistencies Help to maintain consistency by keeping needed items in view and maintaining routines Keep items in the same place and in view Find things and replace or hand to the client without focusing on the forgetfulness Maintain familiar social, physical, mental, and work activities Focus on the client and listen Allow pacing or sleeping
Preoccupation with physical functions Increased forgetfulness (meals, medications, people, self)	Assist in maintaining normal physical functions (basic and instrumental activities of daily living) Place food where client can see and reach it Hand medications to client Remove mirrors
Untidiness, hoarding, rummaging	Put things away as desired; do not expect client to put them away Provide a chest of drawers for hoarding
Difficulty with basic activities of daily living	Keep needed objects in sight/reach Do for the client what he or she cannot, but allow the client to do as much as possible Provide assistive equipment: shower stool, elevated seat
Wandering, becoming lost Uncoordinated motor skills, poor balance	Close and perhaps lock doors on stairways and rooms that the client should not access Fence the yard Place cues to help recognize rooms or objects Have non-shiny floors without contrasting colours or patterns. Provide soft environment.
Repetition of words or activities Reversed sleep-wake cycles	Provide environment where repetitive activities can safely be done Provide activities in daytime Provide room where the client can safely be up alone for a time. Put back to bed with usual bedtime routine
Loss of contact with reality; hallucinations, confusion Withdrawal	Make available materials for activities that the client enjoyed throughout life Keep the client's room location and layout unchanged Remove confusing stimuli Ignore hallucinations unless they are distressing to the client; remain calm; act normally Provide meaningful stimuli Provide place for quiet time
Agitation	Remove objects that could be damaging Provide space
Impaired judgment	Provide safe environment Have unsafe objects out of sight
Altered sensory-perceptual functioning	Provide good lighting Have non-shiny floors without contrasting colours or patterns

Most people often feel uncomfortable when they feel like the demands or pressures on them are more than what they can cope with. This includes its share of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. Everybody feels stressed at times. However, the way one responds to such stressors depends in part on the person's coping resources.

Interventions	Rationales
Set a working relationship with the patient through continuity of care.	An ongoing relationship establishes trust, reduces the feeling of isolation, and may facilitate coping.
Assist patient set realistic goals and identify personal skills and knowledge.	Involving patients in decision making helps them move toward independence.
Provide chances to express concerns, fears, feeling, and expectations.	Verbalization of actual or perceived threats can help reduce anxiety and open doors for ongoing communication.
Use empathetic communication.	Acknowledging and empathizing creates a supportive environment that enhances coping.
Convey feelings of acceptance and understanding. Avoid false reassurances.	An honest relationship facilitates problem-solving and successful coping. False reassurances are never helpful to the patient and only may serve to relieve the discomfort of the care provider.
Encourage patient to make choices and participate in planning of care and scheduled activities.	Participation gives a feeling of control and increases self-esteem.
Encourage the patient to recognize his or her own strengths and abilities.	During crises, patients may not be able to recognize their strengths. Fostering awareness can expedite use of these strengths.
Consider mental and physical activities within the patient's ability (e.g., reading, television, outings, movies, radio, crafts, exercise, sports, games, dinners out, and social gatherings).	Interventions that improve body awareness such as exercise, proper nutrition, and muscular relaxation may be helpful for treating anxiety and depression.
Assist patients with accurately evaluating the situation and their own accomplishments.	It can be helpful for the patient to recognize that he or she has the skills and reserves of strength to effectively manage the situation. The patient need help coming to a realistic perspective of the situation.
If the patient is physically capable, encourage moderate aerobic exercise.	Aerobic exercise improves one's ability to cope with acute stress.
Provide information the patient wants and needs. Do not give more than the patient can handle.	Patients who are coping ineffectively have reduced ability to absorb information and may need more guidance initially.
Provide touch therapy with permission. Give patient a back massage using slow, rhythmic stroking with hands. Use a rate of 60 strokes a minute for 3 minutes on 2-inch wide areas on both sides of the spinous process from the crown to the sacral area.	A soothing touch can reveal acceptance and empathy. Slow stroke back massage decreased heart rate, decreased systolic and diastolic blood pressure, and increased skin temperature at significant levels. The conclusion is that relaxation is induced by slow stroke back massage.
Assist the patient with problem-solving in a constructive manner.	Constructive problem solving can promote independence and sense of autonomy.
Provide information and explanation regarding care before care is given.	In traumatic situations, families have a need for information and explanations. Providing information prepares the patient and family for understanding the situation and possible outcomes.
Eliminate stimuli in an environment that could be misinterpreted as threatening.	The presence of noise associated with medical equipment can increase anxiety and make coping more challenging.
Discuss changes with patient before making them.	Communication with the medical staff provides patients and families with understanding of the medical condition.
Provide outlets that foster feelings of personal achievement and self-esteem.	Opportunities to role-play or rehearse appropriate actions can increase confidence for behaviour in actual situations.
Point out signs of positive progress or change.	Patients who are coping ineffectively may not be able to assess their progress toward effective coping.
Encourage use of cognitive behavioral relaxation (e.g., music therapy, guided imagery).	Relaxation techniques, desensitization, and guided imagery can help patients cope, increase their sense of control, and allay anxiety.
Be supportive of coping behaviors; give patient time to relax.	A supportive presence creates a supportive environment to enhance coping.
Discuss with patient about his or her previous stressors and the coping mechanisms used.	Describing previous experiences strengthens effective coping and helps eliminate ineffective coping mechanisms.
Use distraction techniques during procedures that cause patient to be fearful.	Distraction is used to direct attention toward a pleasurable experience and block the attention of the feared procedure.
Apply systematic desensitization when introducing new people, places, or procedures that may cause fear and altered coping.	Fear of new things diminishes with repeated exposure.
Refer for counseling as necessary.	Arranging for referral assists the patient in working with the system, and resource use helps to develop problem-solving and coping skills.
Refer to medical social services for evaluation and counseling.	This will promote adequate coping as part of the medical plan of care.
If the patient is associated with the mental health system, actively engage in mental health team planning.	Based on knowledge of the home and family, home care nurses can often advocate for patients. These nurses are often requested to monitor medications and therefore need to know the plan of care.

Shortness of breath (respiratory rate > 26-28/min)

Usual cause:

Excess fluid in the lungs.
Left ventricular failure or pump failure.

Treatment:

Rest when needed.
Oxygen if necessary.
Extra pillows to sleep if needed.

Ankle swelling

Usual cause:

Ankle swelling is usually caused by fluid leaking out of the blood vessels into the tissues. This is called oedema.

Treatment:

Inform the GP.
Review fluid intake, diet (especially sodium intake), and medications (e.g., diuretics).
Elevate legs.

Weight gain

Usual cause:

Fluid build-up may cause rapid weight gain. 1 litre fluid = 1 kg weight.

Treatment:

Weigh every morning before breakfast.
Monitor fluid.
Restrict sodium.

Tiredness

Usual cause:

Tiredness can be caused by decreased blood flow to the major organs and muscles.

Treatment:

Adequate rest.
Use energy conservation techniques.

Loss of appetite

Usual cause:

Build-up of fluid in the digestive organs.
Decreased circulation.

Treatment:

Eat smaller meals, more often.

Dizziness

Usual cause:

Decreased blood flow to the brain.
Changes in heart rate and rhythm.

Treatment:

Mobilise slowly.
Sit or lie down when needed.
Inform the GP.
Check pulse. If over 120 or below 40, contact the GP.

Confusion

Usual cause:

Confusion can be caused by decreased blood flow to the brain.

Treatment:

Rest as needed.
Oxygen if required.
Clear communication.

Seizure

First seizure

Consideration:

Could be due to infection, electrolyte imbalance, new medication, stroke, subdural haematoma (SDH), or a brain tumour.

Assessment:

Urinalysis, MSU, routine bloods.
AVPU (Alert, Verbal - patient responds to voice stimulation, Pain - patient responds to pain, Unresponsive). Every 30 minutes for 2 hours, then every hour until reviewed.
Observations (T,P Respiratory rate, BP, O2 sats BGL).
Imaging (CT head or MRI).

Intervention:

Treat underlying cause (e.g., may need antibiotics to treat infection).
Will need specialist referral and review to rule out stroke, SDH, and brain tumour.

Seizure documentation

Consideration:

Need to consider whether it is a partial seizure (with or without secondary generalisation) or a generalised seizure.
Document a detailed description of the seizure, attack, or event and document in residents notes.

Assessment:

If a partial seizure:

Assess patient's ability to speak during a seizure.
Assess patient's ability to obey commands during a seizure.
Assess patient's ability to recall memory after the seizure.

If a generalised seizure:

Assess patient for any lateralising signs such as do they have jerking movements on one side of their body (which side) and which limbs are affected?
Has patient become cyanotic (bluish in colour) or flushed?
Does the patient have any head and/or eye deviation (that is: turned their head and/or eyes to one side only and document which side).
Has patient bitten their tongue or the inside of their mouth (blood noticed in the mouth)?
Has patient been incontinent of urine or faeces?

Intervention:

If the patient does not fully recover because:

The patient has been prolonged to seizure(s) of longer than 5 minutes, or
The patient has had 2 or more complex partial seizures less than 2 hours apart, or
The patient has 2 seizures without any recovery from the post-ictal state.
The patient may be in Status Epilepticus, which is a medical emergency and thus the resident will need to be reviewed by a specialist or transferred to the nearest Emergency Department for further treatment and management.

Post ictal monitoring

Post ictal = The period of time after a seizure that a patient takes to recover to their pre seizure state.

Consideration:

Consider patient's recovery. Is the patient recovering? (Keep in mind some patients can remain post ictally confused or inappropriate for up to 30 to 60 minutes.)
Provide oxygen therapy.

Assessment

Assess patient's AVPU (Alert, Verbal - patient responds to voice stimulation, Pain - patient responds to pain, Unresponsive) every 30 minutes until fully recovered (to patient's pre-seizure state).
Assess routine observations, BP, HR, respiratory rate, and oxygen saturation.

Intervention

Will need GP or specialist referral and review of an anti-epileptic medications (AEDs).
If patient is known to have epilepsy and on AEDs, will need to check the therapeutic drug level of that AED.