CASE STUDY OF DEMENTIA.

Introduction
Dementia is not a specific disease but is rather a general term for the impaired ability
to remember, think, or make decisions that interferes with doing everyday activities.
Alzheimer's disease is the most common type of dementia. Though dementia mostly
affects older adults, it is not a part of normal aging.
B.HISTORY COLLECTION
HISTORY COLLECTION

I. IDENTIFICATION
Name: T.R
Sex: Female
Age: 48yrs
Marital status: married
Place of birth: Western Province, Nyabihu District

Occupation
Religion: ADVENTIST
Nationality: Rwandese
Medical diagnosis: Dementia
Admission date:
CHIEF COMPLAINTS
My bclient complaints are: Hallucinations, Delusions, Thought disorders (unusual or dysfunctional ways of
thinking),Movement disorders (agitated body movements)

PRESENT HISTORY
The patient is having agitation, thought disorder and delusions.
PAST HISTORY
Past medical history
No history of chronic illness like diabetes, cancer, hypertension and others
Past surgical history
No surgical history.
FAMILY HISTORY
The patient is coming from the family of 5 persons: he has Father, 2 sisters and 2 brothers. They are no chronic
diseases in the family
Family tree
This client is the lastborn of the family and is having only mother as parent.
LIFESTYLEHISTORY
He has history of drinking alcohol, using tobacco or drug abuse.
SOCIO ECONOMICHISTORY
This single client coming from the family of 7 persons. They have their own house with one toilet outside. They have also
medical insurance.
ALLERGIC HISTORY
Noknown allergic reaction either to medication, dust,food,or animal hair.
PHYSICAL EXAMINATION
Vital signs

SNO PARAMETER BOOK PICTURE (normal PATIENT REMARKS

ranges ) PICTURE
TEMPERATURE (‘c/) 36.5- 37.5oc 37oc normal
PULSE RATE (/MIN) 60-100beats/min 86beats/min normal
RESPIRATION 12-20movement/min 20movement/min normal
RATE /MIN
BLOOD PRESSURE Systolic 140-90mmhg 120/90mmhg Normal
mmHg Diastolic 90-60mmhg

 General appearance of the patient: weak

 Level of consciousness: is oriented to time place and people Gsc scale15/15
 Head : size and shape are normal
Hair
- Color: normal
- Texture: normal
- Distribution: well distributed
- Ring worms: no ring worms
- Lice : no lice
- Dandruff: no dandruff
- Scalp: no wound ,lesion or scars

Face
 Size: normal
 Shape :long
 Edema : absent
 Skin color : dark
 No Lesions
 Scars: absent
Eye
 Is Symmetry
 No Eyelid presence edema /sunken
 Eyelashes; presence distribution is normal
 No Eyeball-protruded/jaundice
 No Pupils-presence of cataracts
  Eyebrows- distribution is normal
 Conjunctiva –color is normal /no discharge
 Visual acuity-normal
Nose
 Is Symmetry
 No discharge
 No polyps
 sense of smell is present
Mouth
Lips
 size normal
 shape round
 no cracked
 no dryness
 no cleft lip / palate
Mucus membranes
 no Lesions /bleeding/
 Gingival/gums –color pale red /bleeding present
Teeth
 color –yellow –poor hygiene

 Number of teeth 32
 Distribution is disorganised
Tongue
 Size normal
 Shape normal
 Color pink
 Range of motion normal range in all direction
 No Lesions
No Tonsils –swelling
Sense of testing present
EAR
 Size normal
 shape normal
 no discharge
 no wounds
 sense of hearing present
 Neck
 no Scars / lesion.
 Range of motion –normal
 No Palpate for swollen lymph node /tonsils

 Chest
 Is Symmetry
 Lung sound is clear no wheezing or crackles
 Heart sounds s1 and s2 is audible
 Size normal
  Shape normal

 Abdomen
 Size normal
 Shape long
 Skin –color black
 No Striae /linear nigra
 No Organomegaly
 Bowel movement (peristalsis) is present
 No Edema
 No Swelling
 No Pains
 Scar present
 No Wound
 Back
 Shape normal
 Is Symmetry
 No Deformities
- no clubbing
- capillary refilling normal
- no presence of jiggers
- athlete foot present
ix. Vital signs: Blood pressure: 118/75mmhg

Pulse: 88 bpm

Temperature: 36.70c

Respiration rate: 18 bpm

Memory loss and other symptoms of dementia

Signs of dementia can vary greatly. Examples include:

 Problems with short-term memory.

 Keeping track of a purse or wallet.
 Paying bills.
 Planning and preparing meals.
 Remembering appointments.
 Traveling out of the neighborhood.

Causes

Dementia is caused by damage to brain cells. This damage interferes with the ability
of brain cells to communicate with each other. When brain cells cannot communicate
normally, thinking, behavior and feelings can be affected.

The brain has many distinct regions, each of which is responsible for different
functions (for example, memory, judgment and movement). When cells in a
particular region are damaged, that region cannot carry out its functions normally.

 Depression.
 Medication side effects.
 Excess use of alcohol.
 Thyroid problems.
 Vitamin deficiencies.
Assessment Nursing Objectives Planning Rationale Evaluation
diagnosis
S:“Whenever I’m Risk for trauma After 3 hours A person with ➢ To gain After 5 hours of nursing
surrounded with related to of nursing later stage client’s intervention the client w
too many people disorientation or intervention the dementia often to acknowledge and dis
cooperation
confusion. Risk for
either I know client will deteriorates and recognized healthy
self-directed or
them or not I still acknowledge and slowly over ➢ Promote unhealthy fears as mani
other-directed
feel scared and discuss fears, many months. atmosphere of 1.Stated5/5example of f
violence related to
restless” as recognizing They gradually caring and 2.Summarized the whol
delusional thinking
verbalized by the healthy versus become more permits discussion Goal partiall
patient  Risk for unhealthy fears as frail, and will explanation/c to lack of time
self-directed or manifested by need more help orrection
other-directed
Objective data: violence related State at least 3/5 with everyday of mispercepti
•Diminished to delusional example of fears activities such on
thinking.
activity Understanding as eating,
 Chronic ➢ Facilitates
•Avoidance confusion due to of what have dressing,
understanding
•Narrowed focus alteration in the discussed by washing and
function of the and retention
on the source of brain tissue. summarization using the toilet.
of information
fear  Self-care People may
deficit due to ➢ Enhances
experience weig
cognitive sense of trust
impairment ht loss, as
and nurse-
swallowing and
client
chewing
relationship
become more
difficult.
Provide
information in
verbal and
written form.
Speak in
simplest
sentences.
4 . Provideoppo
rtunity for
questions and
answer honestly