SAS 22

DISCUSSION QUESTIONS

1. What pathophysiologic changes are associated with AD?

 The pathophysiology of AD includes cellular changes with neurofibrillary tangles with altered tau proteins and neuritic plaques containing β-
amyloid protein in the cerebral cortex and hippocampus. There is also a loss of the connections between neurons.
2. How is a diagnosis of AD made?
 AD is diagnosed by exclusion. When all other possible causes of mental impairment and persistence of dementia are ruled out, the
diagnosis of AD remains. Brain atrophy and enlarged ventricles seen in some patients with AD are also seen in normal people and in other
conditions. Positron emission tomography (PET) can be used to differentiate AD from other forms of dementia. Neuroimaging techniques
detect changes earlier in the disease and can be used to monitor the response to therapy. Only on autopsy can AD be confirmed by the
presence of amyloid plaques and neurofibrillary tangles in brain tissue.
3. What progression of symptoms should G.D.’s wife be told to expect over the course of the disease?
 All functions of mental capacity and ability to care for oneself are lost as the disease progresses. There will be deterioration of personal
hygiene and all ADLs, progression of psychotic symptoms now evidenced by his hallucinations, loss of long-term memory and recognition of
his family, and loss of communication.
4. What suggestions can the nurse make to relieve some of the stress on the wife?
 All functions of mental capacity and ability to care for oneself are lost as the disease progresses. There will be deterioration of personal
hygiene and The nurse should assess what the wife is doing now to manage his care, teach her about the expected progression of the
disease, assist her in planning respite care or arranging for home health assistants, help her to identify problem areas, encourage her to
keep G.D. awake and busy during the day so that he will sleep better at night and so will she, and refer her to community resources. ADLs,
progression of psychotic symptoms now evidenced by his hallucinations, loss of long-term memory and recognition of his family, and loss of
communication.
5. What community resources might be available to G.D. and his wife?
 Community resources may include Alzheimer’s support groups, adult day care, home health assistants and home nursing, and various forms
of assisted living and long-term care facilities.
6. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses for G.D.? Are there any collaborative
problems?
 Nursing diagnoses:
• Risk for injury related to impaired judgment (night time wandering) and sensory/perceptual alteration (hallucinations)
• Risk for other-directed violence related to misinterpretation of environmental stimuli
 • Impaired memory related to effects of dementia
• Wandering related to cognitive impairment
• Disturbed sleep pattern related to circadian asynchrony
• Self-neglect related to cognitive impairment
Collaborative problems: Potential complication: depression, psychosis
7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses for G.D.’s wife? Are there any collaborative
problems?
 Nursing diagnoses:
• Anxiety related to erratic behavioral patterns and cognitive decline of husband
• Ineffective health maintenance related to fatigue and chronic stress
• Caregiver role strain related to grieving over the family member’s illness
• Risk for other-directed violence (patient abuse) related to ineffective coping Collaborative problems: Potential complication: depression,
illness
NCP 1

ASESSMENT NURSING DIAGNOSIS SCIENTICFIC ANALYSIS PLANNING INTERVENTION RATIONALE

SUBJECTIVE: Risk for injury related Alzheimer disease SHORT TERM INDEPENDENT Impairment of visual
• Wanders out of the to impaired judgment causes progressive After an hour of Assess the degree of perception increase the risk
house at night (night time wandering) cognitive deterioration nursing interventions, impaired ability of of falling. Identify potential
• States that he “sees and and is characterized by Patient will remain in a competence, risks in the environment and
things that aren’t sensory/perceptual beta-amyloid deposits safe environment with emergence of heighten awareness so that
there” alteration and neurofibrillary no complications or impulsive behavior, caregivers more aware of
• His wife is distressed (hallucinations) tangles in the cerebral injuries obtained. and a decrease in the danger.
about his cognitive cortex and subcortical visual perception.
decline gray matter. The beta- LONG TERM
• His wife says that she amyloid deposition and After 8hrs of Assess patient’s AD decreases awareness of
is depressed and neurofibrillary tangles intervention, family surroundings for potential dangers, and
cannot watch him at lead to loss of synapses will be able to identify hazards and remove disease progression coupled
night and get rest and neurons, which and eliminate hazards them. with hazardous environment
herself results in gross atrophy in the patient’s that could lead to accidents.
of the affected areas of environment.
OBJECTIVE: the brain, typically
• CT scan: Moderate starting at the mesial
cerebral atrophy temporal lobe. COLLABORATIVE An impaired cognitive and
Alzheimer's disease is a Help the people closest perceptual disorders are
progressive neurologic to identify the risk of beginning to experience the
disorder that causes hazards that may arise. trauma as a result of the
the brain to shrink inability to take
(atrophy) and brain responsibility for basic
cells to die. Alzheimer's security capabilities, or
disease is the most evaluating a particular
common cause of situation.
dementia — a
continuous decline in
thinking, behavioral
and social skills that Eliminate or minimize Maintain security by
affects a person's sources of hazards in avoiding a confrontation that
ability to function the environment could improve the behavior
independently. or increase the risk for
injury.

Maintain adequate Allows patient to be able to

lighting and clear see and find the way around
pathways. room without danger of
tripping or falling.

Instruct family Prevents physical injury from

regarding removal or ingestion, burns, overdoses,
locking up knives and or accidents.
sharp objects away
from the patient, these
includes cleaning
supplies, insecticides,
other household
chemicals, all
medications, aerosol
sprays, weapons,
power tools, small
appliances, smoking
materials, and
breakable items.

Instruct family to apply Prevents accident injury.

protective guard over
electrical outlets,
thermostats, and stove
knobs.

Instruct family to keep Prevents risk of falls.

 pathways clear, move
furniture against the
wall, remove throw
rugs, remove wheels
on beds and chairs or
set lock them in place,
and keep rooms and
hallways well lighted.

NCP 2
ASESSMENT NURSING DIAGNOSIS SCIENTICFIC ANALYSIS PLANNING INTERVENTION RATIONALE
SUBJECTIVE: Impaired memory Alzheimer disease SHORT TERM INDEPENDENT Provide the basis for the
• Wanders out of the related to effects of causes progressive After 4 hrs of nursing Assess the level of evaluation or comparison that
house at night dementia cognitive deterioration interventions, patient cognitive disorders will come, and influencing the
• States that he “sees and is characterized by will have behavioral such as change to choice of intervention.
things that aren’t beta-amyloid deposits problems identified orientation to people,
there” and neurofibrillary and controlled. places and times,
• Is able to dress, tangles in the cerebral range, attention,
bathe, and feed cortex and subcortical LONG TERM thinking skills.
himself gray matter. The beta- After 8hrs of
• Has trouble figuring amyloid deposition and intervention, family Assess level of Confusion may range from
out how to use his neurofibrillary tangles members will be able confusion and slight disorientation to agitation
electric razor lead to loss of synapses to exhibit disorientation. and may develop over a short
• His wife is distressed and neurons, which understanding of period of time or slowly over
about his cognitive results in gross atrophy required care and will several months. May indicate
decline of the affected areas of demonstrate effectiveness of treatment or
• His wife says that she the brain, typically appropriate coping decline in condition.
is depressed and starting at the mesial skills and ability to
cannot watch him at temporal lobe. utilize community Orient patient to Reality orientation techniques
night and get rest Alzheimer’s is a resources. environment as help improve patient’s
herself degenerative brain needed, if patient’s awareness of self and
disease that is caused short term memory is environment only for patients
OBJECTIVE: by complex brain intact. Using of with confusion related to
• CT scan: Moderate changes following cell calendars, radio, delirium or with depression.
cerebral atrophy damage. It leads to newspapers, television Depending on the stage of AD, it
dementia symptoms and so forth, are also may be reassuring for patients
that gradually worsen appropriate. in the very early states who are
over time. The most aware that they are losing their
common early sense of reality, but it does not
symptom of work when dementia becomes
Alzheimer’s is trouble irreversible because the patient
remembering new can no longer understand
information because reality. Television and radio
the disease typically programs may be
impacts the part of the overstimulating and may
brain associated with increase agitation, and can be
learning first. disorientating to patients who
cannot make a distinction
between reality and fantasy or
what they may view on
television.

COLLABORATIVE
Instruct family in Comments from the patients
methods to use with may involve reliving experiences
communication with from previous years and may be
patient: listen totally appropriate within that
carefully, listen to context. In early stages of AD,
stories even if they’ve questions may cause
heard them many embarrassment and frustration
times previously, and when the patient is presented
to avoid asking with another reminder that
questions that the abilities are decreasing.
patient may not be
able to answer.
 Instruct family
members in the Once diagnosis of AD is made,
disease process, what the family should be prepared
can be expected, and to make long-term plans in
assist with providing a order to discuss problems
list of community before they arise. Choices for
resources for support. resuscitation, legal competency
and guardianship including
financial responsibility needed
to be addressed The care of a
person with AD is expensive and
time-consuming, as well as
energy-draining and
emotionally devastating for the
family. Community resources
can help delay the need for
placement in a long-term care
facility and may help defray
some costs.

NCP3
ASESSMENT NURSING DIAGNOSIS SCIENTICFIC ANALYSIS PLANNING INTERVENTION RATIONALE
SUBJECTIVE: Disturbed sleep Alzheimer disease SHORT TERM INDEPENDENT Provide information on
• Wanders out of the pattern related to causes progressive After an hour of Assess patient’s sleep which to establish a plan of
house at night circadian asynchrony cognitive deterioration nursing interventions, patterns and changes, care for correction of sleep
• States that he “sees and is characterized by Patient will achieve naps, and frequency, deprivation. If patient is
things that aren’t beta-amyloid deposits and maintain amount of activity, sleeping during the day,
there” and neurofibrillary restorative restful sedentary status, Sundowning syndrome may
• His wife is distressed tangles in the cerebral sleep. number and time of be the problem, with the
about his cognitive cortex and subcortical awakenings during patient’s day and night
decline gray matter. The beta- LONG TERM night, and patient’s mixed up. By keeping the
• His wife says that she amyloid deposition and After 8hrs of complaints of fatigue patient up during the day,
is depressed and neurofibrillary tangles intervention, Patient apathy, lethargy, and sleeping at night may return.
cannot watch him at lead to loss of synapses will exhibit no impotence.
night and get rest and neurons, which behavioral symptoms,
herself results in gross atrophy such as restlessness, Ensure environment is External stimuli can interfere
of the affected areas of irritability, or lethargy. quiet, well-ventilated, with going to sleep with
OBJECTIVE: the brain, typically absence of odor, and frequent awakenings.
• CT scan: Moderate starting at the mesial has comfortable
cerebral atrophy temporal lobe. temperature.
Alzheimer's disease is a
progressive neurologic Provide ritualistic Prevents disruption of
disorder that causes procedures of warm established pattern and
the brain to shrink drink, extra covers, promotes comfort and
(atrophy) and brain clean linens, or warm relaxation before sleep.
cells to die. Alzheimer's baths prior to bedtime.
disease is the most
common cause of Provide backrubs, Helps in relaxation before
dementia — a music other relaxation sleep and reduces anxiety
continuous decline in techniques. and tension. AD patients
thinking, behavioral respond well to therapeutic
and social skills that touch.
affects a person's
ability to function COLLABORATIVE
independently. Instruct family The patient may not be able
Circadian dysfunction regarding Sundowning to revert back to a “normal”
is a common symptom syndrome, methods of day-night cycle, and either
of Alzheimer disease. coping, and possibility the caregiver will have to
Behavioral circadian of changing their change his own sleeping
rhythms decline in sleeping cycle to match pattern, hire a sitter during
aged mice and that of the patient’s night time, or placement in a
humans,57, 58 and once discharged. long-term facility.
dysregulation of
systemic circadian
 rhythms, such as those Instruct family to avoid Patient may assume she is
seen in sleep–wake putting out patient’s supposed to get dressed and
cycle, activity, and clothes for the next go somewhere.
melatonin secretion, is day if the patient
a common symptom of exhibits a sleep
AD dementia. disorder.

SAS 23

1. How should the nurse explain the pathophysiology of rheumatoid arthritis to N.M.?
 N.M. needs to know that it is not known what causes RA but that in a genetically susceptible person autoantibodies, or RF, are formed that
react with substances causing inflammation and damage to a variety of organs. Inflammation and fibrosis of the joint capsule and
supporting structures may lead to complete immobilization of the joint and cause deformities similar to those she is developing in her
hands. She should be told that RA is a disease that affects her whole body, even though her joints are primarily affected at this time. She
should be told that the fatigue and low-grade fever she has are part of the disease and that with disease control these symptoms will
improve
2. What manifestations does N.M. have that suggest the diagnosis of RA?
 Manifestations of RA include N.M.’s painful, stiff hands and feet; fatigue; low-grade fever; and ulnar drift deviation.
3. What diagnostic studies will confirm the diagnosis of RA?
 Although diagnosis of RA is often based on history and physical findings, positive RF occurs in approximately 80% of adult patients and titers
rise during active disease. Testing for ACPA is a more specific test for RA than RF. Synovial fluid analysis in early disease will show an
increase in the matrix metalloproteinase (MMP)-3 enzyme and WBC count. ESR and CRP are general indicators of active inflammation. An
increase in antinuclear antibody (ANA) titers is also seen in some RA patients. X-rays are not specifically diagnostic of RA, although they may
reveal soft tissue swelling and possible bone demineralization early in the disease.
4. What results may be expected from methotrexate therapy? What are the nursing responsibilities related to methotrexate therapy?
 Methotrexate is a chemotherapeutic agent that is used as a disease-modifying antirheumatic drug (DMARD) because it has an
antiinflammatory effect, reducing symptoms in days to weeks. However, it causes bone marrow suppression and hepatotoxicity, so
frequent laboratory monitoring, including CBC and chemistry panel must be done. Its dosage in RA is much smaller than that used for
cancer therapy and side effects are not as common. Teaching N.M. about methotrexate is an important nursing responsibility. Along with
periodic laboratory monitoring, N.M could take a daily supplement of folic acid and should report signs of anemia or any infection.
Methotrexate is teratogenic and N.M. should be informed that contraception must be used during and for 3 months after treatment.
5. What are some suggestions that may be offered to N.M. concerning home management and joint protection?
 Protection of N.M.’s joints will be enhanced if she can maintain a normal weight; avoid tasks that cause pain; use assistive devices to
prevent joint stress; avoid forceful, repetitive movements; use good posture and proper body mechanics; seek assistance with tasks that
cause pain; and modify home and work environments to create less stressful ways to perform tasks. To protect small joints N.M. should be
taught to maintain joints in neutral position to minimize deformity, use the strongest joint available for any task, distribute weight over
many joints instead of stressing a few, and change positions frequently (see Table 65-10). She should plan regularly scheduled rest periods
alternated with activity throughout the day and should develop organizing and pacing techniques that spread tasks through the day or the
week. Suggesting that she take a warm shower or bath in the morning to relieve her morning stiffness might be helpful. Exercise regimens
will be prescribed and she should be encouraged to follow the regimens daily
6. How can the nurse help N.M. to recognize ineffective, unproven methods of treatment?
 Because of the chronicity and disability associated with arthritis, patients are often vulnerable to claims of unproven remedies. The nurse
should recognize that the copper bracelet will do no harm but may be a waste of money for N.M. It is important to encourage her to
recognize that regular, proven methods of treatment used on a consistent basis are the best way to control her condition. The more she is
taught about the disease and its management, the more compliant she will be with treatment regimens.
7. What other sources of information regarding arthritis might the nurse suggest to N.M.?
 Additional sources of information and sharing are available from the Arthritis Foundation (www.arthritis.org) and should be suggested to
N.M.
8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
 Nursing diagnoses:
• Acute and chronic pain related to joint inflammation
• Impaired physical mobility related to joint pain, stiffness, and deformity
• Fatigue related to disease activity
• Ineffective self-health management related to use of unproven remedies
• Risk for infection related to altered immune function
• Disturbed body image related to chronic disease activity, long-term treatment, deformities, stiffness, and inability to perform usual
activities
Collaborative problem: Potential complication: bone marrow suppression

NCP 1
 ASESSMENT NURSING DIAGNOSIS SCIENTICFIC ANALYSIS PLANNING INTERVENTION RATIONALE
SUBJECTIVE: Acute and chronic pain Rheumatoid arthritis SHORT TERM INDEPENDENT Favorable in determining
• Has painful, stiff related to joint (RA) is a chronic After an hour of Consider reports of pain management needs and
hands and feet inflammation systemic inflammatory nursing interventions, pain, noting location effectiveness of the
• Feels tired all of the disease whose Client will report and intensity (scale of program.
time hallmark feature is a relieved/controlled of 0–10). Note
• Reports an persistent symmetric pain. precipitating factors
intermittent low-grade polyarthritis (synovitis) and nonverbal pain
fever that affects the hands LONG TERM cues.
• Takes naproxen and feet. RA is After 8hrs of
(Aleve) 220 mg twice characterized by intervention, Client will Suggest patient In severe disease or acute
daily dysregulated appear relaxed, able to assume a position of exacerbation, total bedrest
• Wears a copper inflammatory sleep/rest and comfort while in bed or may be necessary (until
bracelet on the advice processes in the participate in activities sitting in a chair. objective and subjective
of a neighbor synovium of the joint appropriately. Promote bedrest as improvements are noted) to
that eventually leads to indicated. limit pain or injury to joint.
OBJECTIVE: the destruction of both
• CT scan: Moderate cartilaginous and bony Place and monitor use Rests painful joints and
cerebral atrophy elements of the joint, of pillows, sandbags, maintains a neutral position.
with resulting pain and trochanter rolls, Note: Use of splints can
disability. Systemic splints, braces. decrease pain and may
inflammation reduce damage to joint;
associated with RA is however, prolonged
associated with a inactivity can result in loss of
variety of extra- joint mobility and function.
articular comorbidities,
including Encourage frequent Prevents general fatigue and
cardiovascular disease, changes of position. joint stiffness. Stabilizes
resulting in increased Assist the patient to joint, decreasing joint
mortality in patients move in bed, movement and associated
with RA. supporting affected pain.
joints above and
below, avoiding jerky
 movements.

Recommend that Heat promotes muscle

patient take a warm relaxation and mobility,
bath or shower upon decreases pain, and relieves
arising or at bedtime. morning stiffness. Sensitivity
Apply warm, moist to heat may be diminished
compresses to affected and dermal injury may occur.
joints several times a
day. Monitor water
temperature of
compress, baths, and
so on.

COLLABORATIVE
Administer drugs as These drugs control mild to
indicated. moderate pain and
inflammation.

Apply ice or cold packs Cold may relieve pain and

when indicated. swelling during acute
episodes.

NCP 2

ASESSMENT NURSING DIAGNOSIS SCIENTICFIC ANALYSIS PLANNING INTERVENTION RATIONALE

SUBJECTIVE: Impaired physical Rheumatoid arthritis SHORT TERM INDEPENDENT Level of activity and exercise
• Has painful, stiff mobility related to (RA) is a chronic After an hour of nursing Assess and depends on the progression
hands and feet joint pain, stiffness, systemic inflammatory interventions, Client will continuously monitor and resolution of the
• Feels tired all of the and deformity disease whose maintain or increase the degree of joint inflammatory process.
time hallmark feature is a strength and function of inflammation and pain.
• Reports an persistent symmetric the affected and/or
intermittent low-grade polyarthritis (synovitis) compensatory body part. Maintain bedrest or
fever that affects the hands chair rest when Systemic rest is mandatory
• Takes naproxen and feet. RA is LONG TERM indicated. Schedule during acute exacerbations
(Aleve) 220 mg twice characterized by After 8hrs of activities providing and important throughout
daily dysregulated intervention, Client will frequent rest periods all phases of disease to
• Wears a copper inflammatory demonstrate and uninterrupted reduce fatigue, improve
bracelet on the advice processes in the techniques/behaviors nighttime sleep. strength.
of a neighbor synovium of the joint that enable
that eventually leads resumption/continuation Encourage patient to
OBJECTIVE: to the destruction of of activities. maintain upright and Maximizes joint function,
• CT scan: Moderate both cartilaginous and erect posture when maintains mobility.
cerebral atrophy bony elements of the sitting, standing, and
joint, with resulting walking.
pain and disability.
Systemic inflammation Reposition frequently
associated with RA is using adequate Relieves pressure on tissues
associated with a personnel. and promotes circulation.
variety of extra- Demonstrate and Facilitates self-care and
articular comorbidities, assist with transfer patient’s independence.
including techniques and use of Proper transfer techniques
cardiovascular disease, mobility aids such as a prevent shearing abrasions
resulting in increased walker, cane, and of the skin.
mortality in patients trapeze.
with RA.

COLLABORATIVE
Administer drugs as These drugs control mild to
indicated. moderate pain and
inflammation.

Apply ice or cold packs Cold may relieve pain and

when indicated. swelling during acute
episodes.
 NCP 3

ASESSMENT NURSING DIAGNOSIS SCIENTICFIC ANALYSIS PLANNING INTERVENTION RATIONALE

SUBJECTIVE: Disturbed body Rheumatoid arthritis SHORT TERM INDEPENDENT Provides an opportunity to
• Has painful, stiff image related to (RA) is a chronic After 4hrs of nursing Encourage identify fears and
hands and feet chronic disease systemic inflammatory interventions, Client will verbalization about misconceptions and deal
• Feels tired all of the activity, long-term disease whose verbalize increased concerns of disease with them directly.
time treatment, hallmark feature is a confidence in the ability process, future
• Reports an deformities, stiffness, persistent symmetric to deal with illness, expectations.
intermittent low-grade and inability to polyarthritis (synovitis) changes in lifestyle, and
fever perform usual that affects the hands possible limitations. Encouraged a balanced Obesity adds further stress
• Takes naproxen activities and feet. RA is diet, but make sure the to joints.
(Aleve) 220 mg twice characterized by LONG TERM patient understands
daily dysregulated After 8hrs of that special diets won’t
• Wears a copper inflammatory intervention, Client will cure RA. Stress the
bracelet on the advice processes in the formulate realistic need for weight
of a neighbor synovium of the joint goals/plans for the control.
that eventually leads future.
OBJECTIVE: to the destruction of Involve patient in Enhances feelings of
• CT scan: Moderate both cartilaginous and planning care and competency and self-worth,
cerebral atrophy bony elements of the scheduling activities. encourages independence
joint, with resulting and participation in therapy
pain and disability.
Systemic inflammation Give positive Allows patient to feel good
associated with RA is reinforcement for about self. Reinforces
associated with a accomplishments. positive behavior. Enhances
variety of extra- self-confidence.
articular comorbidities,
including
cardiovascular disease, COLLABORATIVE
resulting in increased Administer May be needed in presence
mortality in patients medications as of severe depression until
with RA. indicated (antianxiety the patient develops more
and mood-elevating effective coping skills.
drugs).

Refer to psychiatric Patient and SO may require

counseling like ongoing support to deal
psychiatric clinical with the long-term and
nurse specialist, debilitating process.
psychiatrist or
psychologist, social
worker.