Dementia SKINNY Reasoning William “Butch” Welka, 72 years old

Dementia SKINNY Reasoning William “Butch” Welka, 72 years old Primary Concept Cognition Interrelated Concepts (In order of emphasis) • Pain • Mood and Affect • Psychosis • Clinical Judgment • Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23%  • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity • Basic Care and Comfort 6-12%  • Pharmacological and Parenteral Therapies 12-18%  • Reduction of Risk Potential 9-15%  • Physiological Adaptation 11-17%  Part I: Recognizing RELEVANT Clinical Data History of Present Problem: William “Butch” Welka is a 72-year-old male with a history of heart failure, COPD, hypertension, diabetes type II and dementia who has been hospitalized for exacerbation of heart failure three times the past six months. He is now a resident of Pineville Estates, a local long-term care facility the past four months because his dementia progressed and his wife Rita was unable to care for him. When Rita visited Butch this morning, she reports to the nurse that he is more confused and is concerned because Butch is easily angered. Butch insists that he sees his friend Roger, who served with him in the Navy, is in the room, but he died ten years ago. Rita approaches the nursing station with tears in her eyes and states, “What is happening to my husband? This just isn’t like Butch to act like this! Please do something to help him!” Personal/Social History: Butch has been married to Rita for 51 years. They have three adult children who visit him weekly. Rita comes to visit Butch every day after work. Butch was a salesman for 35 years before he retired seven years ago. Butch believes he is at Pineville Estates for rehab, but his family is concerned that it is no longer safe at home if he were alone. Rita was just awarded guardianship due to his declining mental status. What data from the histories are RELEVANT and have clinical significance to the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.8 F/37.7 C (oral) Provoking/Palliative: “Standing and moving.” P: 60 (regular) Quality: “Dull” R: 16 (regular) Region/Radiation: “Lower back” BP: 115/72 Severity: “4/10” O2 sat: 96% room air Timing: “It is always there.” What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Mental Status Examination (MSE): APPEARANCE: Dressed in t-shirt and pants. His pants are urine soaked. Wearing a sweater even though it is summer. MOTOR BEHAVIOR: Ambulates with a walker, shuffling gait SPEECH: Clear MOOD/AFFECT: Pleasant, except when talking about being at Pineville Estates, becomes agitated Anxiety increases, and angry affect displayed; emotionally labile – can become easily angered THOUGHT PROCESS: Generally coherent conversation; can make himself understood THOUGHT CONTENT: Preoccupied with not wanting to be at Pine Estates. Talks about how they are not helping him. Wants to go home and get his hunting license so he can go hunting. PERCEPTION: Reports having seen a friend, Roger, from the Navy climbing down the side of the building yesterday. No other current evidence of hallucinations INSIGHT/JUDGMENT: Insight – poor- not understanding why he needs to be at a facility and not at home. (thinks he is here for rehab) Unable to recognize own deficits in functioning Judgment Poor-often asks his wife to bring him take-out food (which she does), then he eats an additional dinner in the cafeteria. COGNITION: Alert and Oriented to person and place. Not oriented to time or purpose. Believes it is 2017. Able to recognize it is spring. Short-term memory impaired: Doesn’t always remember that he has eaten; sometimes forgets when wife visits. Long-term memory seems to be intact. Remembers personal history Attention span is adequate when tested. Able to state months backwards INTERACTIONS: Pleasant when spoken to. Hesitant to initiate conversation. SUICIDAL/HOMICIDAL: “If I don’t get out of here soon, I might just walk into traffic.” What MSE assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably in chair. RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds strong and regular, S1 S2 with no murmurs or abnormal beats, pulses 3+, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill NEURO: Alert & oriented to person, place, but not to time or date and situation/purpose (Oriented x2), difficulty falling asleep and wakes up 1-2 times during the night GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, incontinent of urine. Reported that he just changed himself. SKIN: Skin integrity intact, tenting of the skin