Dementia: the case of Alex

Dementia: the case of Alex

Dementia: the case of Alex
Mary Jo has been contacted by her maternal grandmother and asked to
come and visit so that they can talk about her grandmother’s concerns
about her second husband, Alex.
Mary Jo is a little apprehensive as Grandma has asked her at this stage not
to mention anything to her mother or to her two older brothers and their
wives.
[David, 33 years old, is the elder of Mary Jo’s two brothers; his wife is
Maria; they have two children: Jimmy, six years old, and Thomas, four
years old. Barry, the younger brother, is married to Anna; both are 30 and
they have only one child, Leah, three years old. Sadly Anna miscarried last
year but they are optimistic about having more children.]
Mary Jo is also aware that her own mother has not really accepted her
mother’s (Grandma’s) decision to marry Alex, a Mediterranean man, 12
years ago now, and eight years after her grandfather had died suddenly due
to an aortic aneurism. Mary Jo has always liked Alex as he is a jovial person
who clearly loves and respects her grandmother, often buying her jewellery
and other presents and very often fresh flowers. Mary Jo assumed that her
mum was grieving for her own father and that that got in the way of her
accepting her mother’s second marriage. Mary Jo’s mother had emphasised
how different the personalities of the two men were and explained that as
an only child she had always been her father’s ‘princess’. These thoughts
and more were going through Mary Jo’s mind as she travelled by train to
her grandmother’s home to stay overnight. She knew something was wrong
because Grandma had said, ‘You will understand because you are a nurse.’
Mary Jo was concerned that Alex’s ‘memory problems’ were getting worse
and was worried about how she could best help her grandmother.
Grandma met Mary Jo at the door; she was wearing a brace on her left arm
and clearly sporting a healing right ‘black eye’. Mary Jo couldn’t contain
herself and started quizzing her grandmother about what had happened.
Had Alex hit her? This was no good; how could she live with domestic
violence? Something had to be done! Mary Jo stopped when she realised
that her grandmother was just sitting softly weeping while she had gone on
and on.
Mary Jo suddenly saw herself as attacking and criticising the woman she
had come to help. She drew her breath and said, ‘Oh Grandma, I am so
sorry for how I have just behaved! I can see that you’ve been hurt, and
that has upset me because I love you. I’ll put my bag in the spare room,
check on Alex and we’ll meet in the kitchen and have a cuppa. Is that OK?’
Mary Jo’s grandmother nodded and took a few breaths to steady her crying.
Mary Jo was cross with herself for being so… She couldn’t find the words
but knew she would not have behaved that way if she had been at work.
Prompting questions, set 1
• Can you record a genogram for Mary Jo from the above information?
If you have been able to do this, share its elements with your fellow
students in the discussion forum.
page 1
What other information would be informative? What are the benefits of a
genogram in aged care?
• What significance can be placed on the family dynamics?
• If Mary Jo wants to let her mother know about her concerns, how should
she deal with the fact that she has promised not to talk to other family
members?
• What might account for Mary Jo’s response to seeing her grandmother’s
injuries?
• How prevalent is aggressive behaviour between people with dementia and
their carers?
• What advice can be provided to help prevent and minimise aggressive
behaviour?
In the kitchen
Mary Jo informed her grandmother (Matilda) that Alex was asleep in his
recliner.
Mary Jo and Matilda did have a cuppa, with Mary Jo listening to what
Matilda said and allowing her to tell the story as she had experienced it.
Mary Jo also learnt that Matilda had put off approaching her granddaughter,
as she was still embarrassed that Alex had hit her and twisted her arm. It
was so out of character for him but it really had scared her, and she still
felt a bit on edge because it might happen again. She thought that it
related to his wanting a cigarette and her saying no because she didn’t
want to bother at the time. She was not able to distract him from the idea.
Her grandmother continued, ‘He got up to look for his smokes and spotted
them and then went to light one. But in his agitation, he tried to put the
match in his pyjama pocket when it was still alight. I was trying to stop him
from burning himself—thank God they were good cotton and not synthetic—
and God knows what he thought but he hit out at me and grabbed my arm.
Then when he saw me crying he was all ‘lovey dovey’ and not aware of
what had just happened!’
Mary Jo thought about the number of smokers who are admitted to hospital
but don’t get to smoke while they are there. She quietly wondered how
much crankiness and worse could be attributed to nicotine withdrawal.
Prompting questions, set 2
• How might you as a health professional respond to this story?
• Why is Alex’s wife feeling guilty and embarrassed?
• What problem-solving techniques could be employed to assist with the
issue of unsafe smoking?
• If one of the options selected were for Alex to undertake a quit smoking
program what would be required?
Further disclosure
Mary Jo and Matilda got into the flow of interacting and maintaining the
routine that had been pretty well established between Matilda and her
husband. Mary Jo was pleased to be able to prepare the meal her
grandmother had planned and observed her grandparents holding hands
while watching the TV together. Although Mary Jo offered, Matilda did not
accept any assistance with toileting or caring for Alex. Mary Jo was
page 2
mpressed with her grandmother’s ability to help Alex maintain the skills he
did have; she seemed to wind into her conversation with him the
suggestions and cues about what needed to be done or focused on. There
wasn’t that babying approach that Mary Jo had so often seen and
sometimes knew she resorted to at the hospital just to get the task done.
Later that evening Mary Jo and Matilda were able to spend time together
again.
At this time Matilda revealed that their GP had suggested that she needed
to start thinking about putting Alex into residential care. This was her worst
fear as they had in fact made part of their marriage vows to care for each
other in their latter years. She did not deny that he had hit her but felt that
with more help and information she could do better.
The doctor had given Alex a definite diagnosis of dementia, and probably
Alzheimer’s disease. Matilda wanted to know whether the type of dementia
made any difference to what she should do. The doctor was also reluctant
to discuss how long this might go on for. Matilda understood that no one
had a crystal ball but felt that it would help her if she knew some of what
was in store and had some timeframe to work from. She was thinking of
visiting relatives in Holland before she got too old to manage such a trip but
didn’t know what was best to do.
Matilda said that she hadn’t properly answered the doctor’s questions about
Alex‘s incontinence because that would have just made things worse. She
explained that Alex had had some urinary incontinence for a year or more
but this had been mostly at night or he had just used the wrong place or
thing to urinate in. But over the past month he had been wetting himself
and was now occasionally incontinent of faeces as well.
Again Mary Jo disciplined herself from jumping in and answering the parts
of the questions she could answer. She was feeling that her grandmother
had a new level of trust in her and she wanted to live up to that trust.
Somehow it also really mattered to understand what her grandmother was
experiencing.
Their conversation extended beyond ‘Alex’s problems’ to Mary Jo’s learning
more about her own (and Alex’s) extended family in Europe and some
catching up about what Mary Jo was up to at work and in her rather inactive
social life.
Towards the end of the evening Mary Jo said that she felt that the
Alzheimer’s Association was the best source of information for her
grandmother and that she would be happy to go along with her and support
any steps or stages she chose along the way. When her grandma was ready
Mary Jo was also willing to approach the social worker and get the full
information about nursing home assessment and admission and what that
entailed.
Prompting questions, set 3
• What influence does the type of dementia have on the onset, progression
and prognosis of the condition?
• What factors contribute to the likelihood of aggressive behaviour in people
experiencing dementia?
• Identify what community resources are available in your community to
answer Matilda’s questions.
• What could account for the changes in Alex’s continence issues?
page 3
What resources and advice could be made available to Alex in his own
home?
• How would you as a health professional support Matilda’s plans to travel to
Europe?
Epilogue
Matilda did explore the information and community resources available to
her and Alex. She found that the carers’ support group was very welcoming
and good at sharing helpful information.
The continence nurse specialist did an assessment and Alex was found to be
constipated, with some faecal overflow, and his dietary habits and exercise
regime were adjusted under her supervision.
Mary Jo became a regular visitor and support to her grandmother. The
range of topics that they discussed together expanded and sometimes even
surprised Mary Jo.

What you need to do to meet your learning outcomes
? Explore these websites
Explore the following websites, which provide information about dementia.
Australian Government Department of Health and Ageing 2007, Dementia,
http://www.health.gov.au/dementia.

AIHW 2007, Dementia in Australia: national data analysis and development,
AIHW Cat. No. AGE 53, AIHW, Canberra,
http://www.aihw.gov.au/publications/index.cfm/title/10368.

Dementia Training Study Centres: http://www.dtsc.com.au/

Bridges-Webb, C & Wolk, J 2003, Care of patients with dementia in general
practice: guidelines, NSW Department of Health, Sydney,
http://www.health.nsw.gov.au/pubs/2003/pdf/care_dementia_guide.pdf.

Dementia Care Australia: http://www.dementiacareaustralia.com

Alzheimer’s Australia: http://www.alzheimers.org.au
Simons, LA, Simons, J, McCallum, J & Friedland, Y 2006, ‘Lifestyle factors and
risk of dementia: Dubbo study of elderly’, Medical Journal of Australia,
vol. 184, no. 2, January, pp. 68-70,
http://www.mja.com.au/public/issues/184_02_160106/sim10682_fm.pdf

Department of Human Services, Victorian Government Health Information 2004,
A guide for assessing older people in hospitals, developed by the Centre for
Applied Gerontology, Bundoora Extended Care Centre, Northern Health,
http://www.health.vic.gov.au/acute-agedcare/assessing-older-people.pdf.

This guide provides one of the major discussions in the field regarding the
pros and cons of assessments and other tools that are available.
Tameside Council, The single assessment process for older people, frequently
asked questions, http://www.tameside.gov.uk/sap.

This web resource about the single assessment process (SAP) was developed
by the Department of Health in the UK. It discusses different types of
assessment scales and social problems facing the older person.
Ministry of Health [NZ] and New Zealand Guidelines Group 2003, Best practice
evidence-based guideline summary, ‘Assessment of older people with complex
needs’, New Zealand Government,
http://www.nzgg.org.nz/guidelines/0030/Specialist_summary.pdf.

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NUR2800 Simulated Practice

NUR2800 Simulated Practice

[1]    Reasons for end-to-end anastomosis                    /5 marks

[2]    Subjective and Objective assessment data.                /10 marks

[3]    Specific pre-operative nursing cares.                    /10 marks

[4]    Observations and nursing cares.                        /10 marks

[5]    Observations between 1300hrs to 1500hrs.                /5 marks

[6]    Priorities of care according to 5 Rights of Clinical Reasoning.        /15 marks

[7]    Complete SBAR.                                /5 marks

[8]    Medication orders.                                /10 marks

[9]    Post-operative care over next 24hrs.                    /10 marks

[10]    Post-operative complications.                        /15 marks

[11]    Planning discharge                                /5 marks

Total Marks                                        /100

NUR2800 SIMULATED PRACTICE
CASE SCENARIO
Assignment Task
Discuss what would be expected of the RN (you) in looking after Mrs Catherine
Windsor from the day of her admission for an abdominal surgical procedure. Utilise
the principles of clinical reasoning to assist in determining what the nurse should
assess, monitor, and plan including why/what/how and when to intervene and the
rationales associated with these during the evolving situation.
Student’s instructions
You are advised to read Levett-Jones’ et al. article on ‘The five rights of clinical
reasoning’ and Banning’s article on ‘Clinical reasoning and its application to nursing’
(on DiReCt). There are other articles on DiReCt and in various journals and text
books that would assist you in completing this assignment.
As the nurse is the first point of patient contact in patient care, there is an
expectation that the nurse will be in a prime position to identify when a patient is at
risk of experiencing a critical event through the presentation of warning signs. As
these warning signs may be “missed or not always identified or managed
appropriately” (Levett-Jones et.al. 2010), it is likely that the patient may deteriorate to
a stage where/when suitable rescue (management) may not be possible.
The nurse who “collects cues, processes the information, come to an understanding
of a patient problem or situation, plan and implement interventions, evaluate
outcomes, and reflect on and learn from the process” (Levett-Jones et.al. 2010) is
said to undertake the process of clinical reasoning. Clinical reasoning “focuses on
the assimilation and analysis of health care evidence” …. which is viewed “as the
hallmark of the expert nurse” (Banning 2008).
Case Study:
Mrs Catherine Windsor, 61yrs old, has Type 2 diabetes treated with medication,
exercise and dietary control. She lives alone and her children live out of state. Over
the past six months Mrs Windsor has noticed that she was losing weight, has had
repeated urinary tract infections, having a poor appetite, is lethargic and doesn’t
have as much strength as she used to have. Her weight is 54kgs and her height is
174cms. She used to be a keen gardener. She is quite anxious about the surgery.
She also admits to taking Dandelion and St John’s Wort for the last year.
With various tests performed over the last fortnight, Mrs Windsor was diagnosed as
having prolonged intestinal obstruction. She was admitted for surgery to remove a
cancerous growth in her transverse colon. She went to theatre at 1000hrs. She had
an end-to-end anastomosis performed over a stent. The operation progressed as
expected with no unexpected events.
Question 1 5 marks
Discuss the various health conditions and the reasons why an end-to-end
anastomosis may need to be performed on a patient diagnosed with prolonged
intestinal obstruction.
Question 2 10 marks
Describe, with appropriate rationale, the subjective and objective assessment data
that would need to be collected during the pre-operative phase?
Question 3 10 marks
Discuss the specific pre-operative nursing cares that would be provided to Mrs
Windsor?
Upon returning from theatre at 1300hrs, Mrs Windsor has an NG tube insitu and she
has an IDC on hourly drainage. Prior to returning to the ward, Mrs Windsor was
administered 25mgs Metoclopramide. She has also returned to the ward with a PCA
insitu for pain control. A unit of whole blood (350mL) is running over 4hrs.
Medications have been prescribed as per chart.
Question 4 10 marks
Identify what observations and nursing cares would the nurse commence for Mrs
Windsor following her return to the ward at 1300hrs? How often should these
observations be monitored? Include your rationale.
It is now two hours since Mrs Windsor returned from theatre. The frequency of
observations is continued at half hourly intervals. As the RN looking after her, you
are going over the observations and updating the charts.
Question 5 5 marks
Between 1300hrs to 1500hrs, the following observations have been recorded for Mrs
Windsor (see charts). Include in your discussion on the observations the following
areas:
a) Would any of the observations cause the RN to be concerned? WHY?
b) What actions should the RN undertake in relation to their concerns?
The following observations were then recorded over the next hour (see ADDS chart
for 1600hrs and 1630hrs). As the RN looking after the patient, there seems to be
some concern in relation to the Mrs Windsor’s present condition.
At 1640hrs, the nurse-call bell is activated within the four bed area where Mrs
Windsor is situated. When the RN answers this, another patient informs you that Mrs
Windsor has slumped her head to one side.
As the RN looking after Mrs Windsor, you assess the overall and immediate
situation. Upon pulling down the sheets, it is noted that there is a pool of blood
around the waist of Mrs Windsor. The emergency call bell is activated. The following
observations are noted (at 1645hrs) (see chart).
Question 6 15 marks
Using the 5 Rights of Clinical Reasoning, discuss the priorities of care, and its
rationale that would be appropriate at this time considering Mrs Windsor’s history
and the procedure that was performed.
Question 7 5 marks
Complete, and attach, an SBAR that the RN would utilise when calling the doctor to
explain the essence of the emergency.
Over the next 15 minutes, the surgical team have assessed the presenting situation
and it is concluded that Mrs Windsor will be taken to theatre for an exploration of the
anastomosis and the effects of the bleed into the abdominal cavity. Mrs Windsor is
intubated and wheeled to theatre. Her children are informed of the presenting crisis.
Question 8 10 marks
Discuss the clinical indications and provide a rationale (WHY) for each of the
medication orders which has been written up for Mrs Windsor. Include the nursing
responsibilities that would be associated with the medication orders.
Mrs Windsor is returned to the ward after having an oversewing of a leak at the site
of the anastomosis. A blood transfusion is in progress for 2 units of whole blood.
Question 9 10 marks
List the post-operative care that Mrs Windsor would require during the next 24 hours
and WHY.
Question 10 15 marks
List possible postoperative complications of (the procedure that Mrs Windsor
underwent.) OR (following general surgery).
Over the next few hours, Mrs Windsor’s condition improves. By the next morning she
is sitting up in the bed at 350. Her observations are now being taken 2hrly. Following
the ward round, the doctors are pleased with her progress and a plan for the next
24hrs is being discussed.
Question 11 5 marks
List the areas that would need to be considered in the discharge planning for Mrs
Windsor.

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A description of a current topic or development in your field and an explanation of its significance to those outside of the field.

A description of a current topic or development in your field and an explanation of its significance to those outside of the field.

Order Description

Paper #1: A description of a current topic or development in your field (nursing) and an explanation of its significance to those outside of the field.
Audience: Students new to your major who have a curiosity or research interest in this particular topic but no prior specialized knowledge of the topic; your English 3311 teacher Length: at least 1,400 words, not counting references page There are two basic tasks to fulfill in this paper: – to describe this topic or development as clearly and concisely as possible for the specified audience; in other words, to educate your audience about this topic as thoroughly as possible given the space constraints. – to make a compelling, specific, and explicit case explaining obvious and not-so-obvious reasons this development is important to the world outside your major. It may help you to think in terms of a little role-playing to imagine how this assignment might match real-world expectations: You are doing research or making something closely related to this topic. Your company, department, or division needs funds to begin your research or project. To be awarded these funds, you need to go in front of a group of people and provide them some necessary background as they make their decision. This could be an internal or external group: a board of directors, a grant committee, a government agency, a venture capital firm, among other possibilities. You can’t assume (ever!) that every member of the group making the funding decision is familiar with your topic. We need to understand and be responsible for the terminology we use given the audience for whom we write. This means that you need to decide for yourself how much members of the specified audience already know about the topic and its terminology, and how much those student doesn’t know. This will help you in turn decide what kind of vocabulary, detail, and tone will be appropriate for your writing. You’ll also need to decide what kind of research is appropriate for the paper. I will require in-text citations and a references page in the citation style of your choice. That references page should include a variety of source material, so that your reader will understand that you are not simply repeating one or two sources without considering audience and purpose.

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