See attached
Iyiobaara@123
conceptmappresentationCVA.pptxMr. T.M.
T.W.
Client Concept Map
AACC Nursing
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Mr. T.M.
71-year-old African American male.
Admitted after a left-sided cerebral infarction that effected his right, dominant, side, and vascular dementia.
Significant medical history includes malignant neoplasm of cecum, hypertension, hyperlipidemia, hemiparesis of right-side extremities, major depressive disorder and generalized anxiety disorder.
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TM: 71 year old A.A. male that loves the baseball, football and the Minnesota Vikings. He also enjoys the winter and the cooler weather season more than the summer months. Mr.. TM has one daughter, that calls often, visits occasionally.
Admitted after a left-sided Cerebral infarction that effected his R dominant side. And has vascular dementia.
Mr.. TM has been at Waugh Chapel since 2016 and is considered a long-termer at the facility.
TM is alert but lethargic at times, needing a gentle rub to wake, and oriented only to self and possibly situation. TM knows name and DOB and that he is in a “hospital” but does not know the date, or why he is at the facility.
Due to Mr.. TM’s medical history and current medical diagnoses, I could not collect much subjective data on his past (outside of his pt. chart).
Significant Medical history: Malignant neoplasm of cecum removed via hemicolectomy (cecal adenocarcinoma) in May 2016.
Mr.. TM’s original admittance record reported right side hemiplegia but he now has active but limited range of motion of all his extremities, including the affected side.
Mr.. TM is mostly calm and compliant pt. but is socially withdrawn. During data collection, Mr. .TM began to weep when he could not answer some of the questions due to lack of memory and inability to find the words.
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Pathophysiology of Vascular Dementia
A dementia syndrome likely to be the consequence of lesions of the brain. It is vascular in origin and irrespective of ischemic, hemorrhagic or hypoxic nature of occurrence.
Vascular dementia is the 2nd most common type of dementia after Alzheimer’s.
Stroke-related: blood vessels narrow and become blocked by a clot, causing an interruption of blood supply to an area of the brain (Huether, McCance, Brashers, & Rote, 2012).
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Etiology
Follows stroke (CVA) or transient ischemic attack (TIA)
Diabetes
Atherosclerosis
Hypercholesteremia
Hypertension
Heart disease
Vascular abnormalities
Head trauma
Presence of seizure disorders
Neurotransmitter changes
Cerebrovascular disease
Stress hormones
Circadian changes
Age (common in males ages 50—70 yrs. old)
Inflammatory factors
Genetic factors (family health history)
Environmental factors (smoking)
Obesity
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(Huether, McCance, Brashers, & Rote, 2012)
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Images from https://radiopaedia.org/cases/normal-brain-mri-6?lang=us; https://www.nhlbi.nih.gov/news/2017/vascular-dementia-exercise-blood-flow-and-aging-brain
Signs & Symptoms
Cognitive Impairment
Neurobehavioral problems
Confusion
Agitation
Depression
Unsteady Gait
Problems with memory
Night Wandering
Poor Attention/Concentration
Urinary Frequency, Urgency, Incontinence
Decline in ability to organize thoughts and actions
Speech Issues
Loss of perception of objects in 3D
(Huether, McCance, Brashers, & Rote, 2012)
Can anyone tell me one of Mr. TM’s interests?
Top image is a normal brain MRI. https://radiopaedia.org/cases/normal-brain-mri-6?lang=us
Bottom image is an MRI image of the blood vessels of the brain. Courtesy of Dr. Kejal Kantarci from the Department of Radiology at Mayo Clinic. https://www.nhlbi.nih.gov/news/2017/vascular-dementia-exercise-blood-flow-and-aging-brain
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Complications
Altered blood supply to brain
Neurofibrillary tangles
Neuron degeneration
Brain atrophy
Decrease in brain size
Changes in motor functions
Continued progression of the disease
Shortened lifespan
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Image Credit: National Institute of Neurological Disorders and Stroke
MEDICAL TREATMENT
There is no known cure for vascular dementia.
Treatment of the underlying disease
Brain imaging
Psychiatric evaluations
According to the Alzheimer’s Association, “The U.S. Food and Drug Administration (FDA) has not approved any drugs specifically to treat symptoms of vascular dementia, but there is evidence from clinical trials that drugs approved to treat Alzheimer’s symptoms may also offer a modest benefit in people with vascular dementia.”
Diagnosis of dementia is confirmed by neurocognitive testing, which involves several hours of written or computerized tests that provide detailed evaluation of specific thinking skills such as judgment, planning, problem-solving, reasoning and memory.
The second diagnostic test is brain imaging evidence, usually with magnetic resonance imaging (MRI), to confirm stroke and/or vascular changes to the brain tissues.
The primary treatment is to treat the underlying disease processes that may have contributed to the stroke and ultimately dementia.
Can anyone tell me/remember an underlying disease that attributes to vascular dementia?
This image (MRI) shows the impact on the brain after a major stroke. The top image shows the brain starved of nutrients one hour after symptom onset. The bottom image shows the flow of blood and nutrients restores after successful use of clot-busting drug.
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Nursing Treatments
Monitor vitals, LOC, neurological decline
Administer or aid in ADLs
Implement teaching of communication skills
Encourage exercise
Teaching healthy lifestyle choices
Report any abnormalities
Document everything!
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ADL skill training can promote independence in personal care tasks (for example, dressing, feeding and washing) and maximize the use of skills and participation in their own care.
Teaching and using communication skills: Verbal, body language, written or pictorial form, such as memory books.
Exercise: can help with overall health and physical functioning of the pt., ranging from improved continence to slowing loss of mobility and improving or slowing loss in strength, balance and endurance levels.
Adopt a healthy lifestyle, particularly to take regular physical exercise, quit smoking, eat a diet with plenty of fruit, vegetables and oily fish but not too much fat or salt. Maintain a healthy weight and keeping to recommended levels of alcohol.
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Nursing Diagnosis #3
Constipation
r/t sedentary lifestyle
aeb: infrequent passage of stool
aeb: usage of laxative for bowel movements
aeb: malnutrition
Pt is unable to ambulate independently.
Pt prescribed 3 different laxative medications (milk of magnesia, Senna, Dulcolax supp)
Pt chart notes abnormal weight loss and prescription for protein supplement b.i.d. with med pass.
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Nursing Diagnosis #2
Impaired Physical Mobility
r/t neuromuscular impairment
s/t cerebral infarction
aeb: inability to use dominant side (R) extremities
aeb: depression and anxiety disorders
aeb: inability to perform ADLs without assistance
Pt has R side musculoskeletal impairment s/t cerebral infarction
Pt’s dominant side (extremities) is the affected side
Pt has been diagnosed with Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD)
Pt requires assistance and is dependent for toileting, oral care, ambulating, and dressing.
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Nursing Diagnosis #1
Impaired Swallowing
r/t decreased gag reflex
As evidenced by:
abnormality in swallow study
difficulty swallowing whole foods
prolonged mastication due to no dentition
TOP!
Pt has had a swallow study done to find mild pharyngeal dysphagia.
Pt is on soft foods/thing liquids.
Pt takes meds crushed with applesauce.
#1 diagnosis because pt. is at risk for aspiration when eating, drinking and taking meds. This diagnosis could lead to lack of oxygen or death of pt..
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Broad Goal
Patient will not aspirate while at Waugh Chapel facility.
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Does Mr. TM have any family and how long has he been at Waugh Chapel?
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Outcomes
Patient will demonstrate ability to swallow without difficulty while under my care 11/13/19 – 11/14/19.
Patient will verbalize emergency measures to be enacted should choking occur within 1 month.
Patient will verbalize appropriate eating position and types of foods tolerated to prevent choking by within 2 weeks.
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Assess
Assess results of swallow study and recommended diet prescribed.
Rationale: Swallow study can determine nature and extent of any oropharyngeal swallowing abnormality (Gulanick & Myers, 2014, p. 189).
Assess for coughing or choking during eating and drinking.
Rationale: These signs indicate aspiration risk (Gulanick & Myers, 2014, p. 189).
Assess patient’s presence of cough and gag reflex.
Rationale: The lungs are normally protected against aspiration by reflexes such as cough and gag. When these reflexes are absent or reduced, the patient is at increased risk (Gulanick & Myers, 2014, p. 20).
Image from https://www.pinterest.it/pin/224265256429777942/?lp=true
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Do
Supervise patient at mealtime or during med pass with oral fluids and whole foods.
Rationale: Supervision helps detect abnormalities early and enables implementation of strategies for safe swallowing (Gulanick & Myers, 2014, p. 21).
Place suction equipment at bedside.
Rationale: Suction may be necessary to maintain a patent airway (Gulanick & Myers, 2014, p. 21).
Encourage patient to eat slowly, swallowing frequently.
Rationale: Well-masticated food is easier to swallow; food cut into small pieces may also be easier to swallow (Gulanick & Myers, 2014, p. 21).
Image from https://www.memesmonkey.com/topic/i+m+watching+you
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Teach
Exercises to enhance muscular strength of face and tongue to enhance swallowing.
Rationale: Coordinated muscle function innervated by CN VII, IX, X, XII, necessary to move food bolus from front of mouth to posterior pharynx for controlled swallowing (Gulanick & Myers, 2014, p. 189).
Teach patient what should be done if aspiration occurs (CPR, suction, abdominal thrusts).
Rationale: Aspiration requires immediate action to maintain the airway and promote effective breathing and gas exchange. Being prepared for an emergency helps prevent further complications (Gulanick & Myers, 2014, p. 191).
Teach upright position and allowance of sufficient time during eating.
Rationale: The upright position facilitates gravitational flow of food or fluid through the alimentary tract (Gulanick & Myers, 2014, p.190).
Image from https://me.me/i/cpr-monkey-everyone-should-have-one-in-their-first-aid-kit-fbbe9d839cb3463797327bf5e3b8cb98
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Evaluation
Patient will demonstrate ability to swallow without difficulty while under my care from 11/13/19 – 11/14/19.
MET
Patient will verbalize emergency measures to be enacted should choking occur by within 1 month.
NOT MET
Patient will verbalize appropriate eating position and types of foods tolerated to prevent choking within 2 weeks.
NOT MET
MET: Pt safely consumed food and drink without any s/s of aspiration or choking, during the time in my care 11/13/19-11/14/19.
Pt had emotional outbursts that limited teaching of both outcome 2 and 3. Pt was also resistant to help during meals. Pt displayed independent eating techniques without swallowing issues and asked to be left alone during meal-time on both days (11/13/19 – 11/14/19) of care.
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Modifications
Continue to monitor patient’s eating and drinking techniques during meal-times. Request follow up swallow study for advanced diet based on evidence of independent eating without incident during days of provided care.
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What is one nursing treatment that can be given for pt. with vascular dementia?
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Conclusion
Mr. TM is a long-termer a Waugh Chapel, so he is not expected to be discharged from the facility in the future. Despite his original admittance diagnoses, Mr. TM has made significant progress in regaining use of his affected dominant side extremities and ability to eat and drink independently.
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References:
CPR Monkey. (n.d.). Retrieved from https://me.me/i/cpr-monkey-everyone-should-have-one-in-their-first-aid-kit-
fbbe9d839cb3463797327bf5e3b8cb98
Gag Reflex. (2019). Retrieved from https://www.pinterest.it/pin/224265256429777942/?lp=true
Galliard, F. (n.d.). Retrieved from https://radiopaedia.org/cases/normal-brain-mri-6?lang=us
Gulanick, M., & Myers, J. L. (2014). Nursing Care Plans: Diagnoses, Interventions, and Outcomes (8th ed). Philadelphia, PA: Elsevier Mosby.
Huether, S. E., McCance, K. L., Brashers, V. L., & Rote, N. S. (2012). Chapter 14: Alterations in Cognitive Systems, Cerebral Hemodynamics.
In Understand Pathophysiology (3rd ed., pp. 357–359). St. Louis, MO: Elsevier Mosby.
Kantarci, K. (2017). Retrieved from https://www.nhlbi.nih.gov/news/2017/vascular-dementia-exercise-blood-flow-and-aging-brain
Memes Monkey. (2019). Retrieved from https://www.memesmonkey.com/topic/i m watching you
Vascular Dementia. (2019). Retrieved from https://www.alz.org/alzheimers-dementia/what-is-dementia/types-of-dementia/vascular-dementia.
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