Dementia
UNFOLDING Case Study
Morgan Adams, 72 years old
Primary Concept
Cognition
Interrelated Concepts (In order of emphasis)
• Pain
• Mood and Affect
• Psychosis
• Clinical Judgment
• Patient Education
• Communication
• Collaboration
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory 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% ✓
,History of Present Problem:
Morgan Adams 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 Healthcare Center, 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 Morgan this morning, she reports to the nurse that he is more
confused and is concerned because Morgan is easily angered. Morgan 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 Morgan to act like this! Please do something to help him!”
Personal/Social History:
Morgan has been married to Rita for 51 years. They have three adult children who visit him weekly. Rita comes to visit
Morgan every day after work. Morgan was a salesman for 35 years before he retired seven years ago. Morgan believes
he is at Pineville Healthcare Center 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 Data
RELEVANT fromfrom
thePresent
histories are Clinical
Problem: nd have clinical significance to the nurse?
Significance:
RELEVANT
72 yo male w/ HF, COPD, HTN, DMII and dementia. (Reduction
The clinical of Risk Potential)
significance of the patient’s behavior is that he is experiencing
Hospitalization Hx for HF x3 in past 3 mos. Resides confusion and could be experiencing some confusion related to his heart failure or
in long term care of dementia. LOC change today w/ COPD Where he is not receiving enough oxygen/blood (hypoxia or hypoxemia)
hallucinations. flow to his brain. Also, medication SE can be contributing to this, too. Does he
have a UTI or other infection?
RELEVANT Data from Social History: Clinical Significance:
Patient and wife have been married for 51 years Patient is no longer able to make his own decisions. His confusion may also be
have 3 children. Rita is now pt’s guardian. Pt does attributable to unfamiliar surroundings and not understanding why he is there. He
not understand why he is at SNF. is well loved by his family who make sure to visit him. They are worried that he is
not “himself”.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current
meds?
(Which medication treats which condition? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• COPD 1. Fluticasone/salmeterol 1. Long Acting Beta-2 1. Chronic treatment and
• Hypertension diskus 1 puff every 12 hours agonist/Corticosteroid maintenance of COPD & asthma
2. Albuterol MDI 2 puffs combination inhaler; anti- producing decreased
• Heart failure
every 4 hours PRN shortness asthmatic; anti-inflammatory inflammation and histamine
• Diabetes type II 2. Selective Beta-2 adrenergic response in lung tissues thereby
• Dementia of breath
agonist; bronchodilator increasing ability to exchange
3. Lisinopril 10 mg PO daily
3. Long-acting angiotensin gases.
4. Atenolol 25 mg PO BID
Color coded match of drugs converting enzyme inhibitor; 2. Acute treatment for COPD &
5. Furosemide 20 mg PO Asthma relaxing bronchial
with the corresponding antihypertensive
daily 4. Cardio Selective-Beta smooth muscles in order to
indication for use.
6. Hydrochlorothiazide 25 blocker; antihypertensive exchange gases during an acute
Please know that some of the exacerbation of COPD.
mg 1 tab PO daily 5. Sulfonamide;
green and dark blue boxes can 3. Decrease of hypertension
7. Metformin 1000 mg PO antihypertensive; diuretic
be interchangeable, as
BID 6. Benzothiadiazide; diuretic; and heart failure as a result of
medications such as lisinopril, suppression of the renin-
8. Glyburide 10 mg PO BID antihypertensive.
atenolol, and 7. Antihyperglycemic; angiotensin-aldosterone
9. Memantine 5 mg PO daily
hydrochlorothiazide can be biguanide system.
used to treat both 8. Second generation 4. Management of hypertension
hypertension and heart failure. sulfonylurea; antihyperglycemic alone or in combination with
9. N-methyl-D-aspartate other anti-hypertensives by
(NMDA) receptor giving rise in intracellular
antagonist/antidementia calcium and triggering the
ryanodine receptors to release
calcium stored in the
sarcoplasmic reticulum (SR),
thus increasing cardiac
contractility. And, also off
label- management of HF.
, 5. To decrease edema caused by
HF and also to decrease
hypertension via inhibition of
sodium-potassium-chloride
cotransporters in the loop of
Henle which results in
increased excretion of water
along with sodium, chloride,
magnesium, calcium, hydrogen,
and potassium ions.
6. HCTZ acts on the proximal
region of the distal convoluted
tubule, reducing reabsorption of
water. This both reduces blood
pressure and water retention
which can cause edema.
7. Serum glucose is reduced by
metformin’s action of
decreasing hepatic glucose
production (gluconeogenesis),
decreasing the intestinal
absorption of glucose, and
increasing insulin sensitivity by
increasing peripheral glucose
uptake and utilization.
8. Glyburide acts by closing
ATP-sensitive potassium
channels on pancreatic beta cells
stimulating release of insulin
thereby reducing blood glucose.
9. Memantine is an
uncompetitive (open-channel)
NMDA receptor antagonist,
preventing glutamate action on
this receptor. This action helps
to decrease glutamate
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in
Morgan’s life?
COPD likely occurred first…
COPD, when it becomes severe, can affect the heart by causing a development in right-sided heart failure. This happens because
chronic lower oxygen levels create increased blood pressure in the lung’s arteries. This is known as pulmonary hypertension
where the lung’s blood vessels narrow or become blocked or even destroyed. All of this leads to the heart becoming weaker and
blood is harder to distribute throughout the body. Body tissues and organs do not perfuse as efficiently, thus decreasing
oxygenation. Oxygen deficits to the brain’s tissues doubly increase the chances of developing dementia. Therefore, Morgan’s
diseases are a cascade of one disease setting off the next, and so on.
UNFOLDING Case Study
Morgan Adams, 72 years old
Primary Concept
Cognition
Interrelated Concepts (In order of emphasis)
• Pain
• Mood and Affect
• Psychosis
• Clinical Judgment
• Patient Education
• Communication
• Collaboration
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory 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% ✓
,History of Present Problem:
Morgan Adams 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 Healthcare Center, 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 Morgan this morning, she reports to the nurse that he is more
confused and is concerned because Morgan is easily angered. Morgan 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 Morgan to act like this! Please do something to help him!”
Personal/Social History:
Morgan has been married to Rita for 51 years. They have three adult children who visit him weekly. Rita comes to visit
Morgan every day after work. Morgan was a salesman for 35 years before he retired seven years ago. Morgan believes
he is at Pineville Healthcare Center 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 Data
RELEVANT fromfrom
thePresent
histories are Clinical
Problem: nd have clinical significance to the nurse?
Significance:
RELEVANT
72 yo male w/ HF, COPD, HTN, DMII and dementia. (Reduction
The clinical of Risk Potential)
significance of the patient’s behavior is that he is experiencing
Hospitalization Hx for HF x3 in past 3 mos. Resides confusion and could be experiencing some confusion related to his heart failure or
in long term care of dementia. LOC change today w/ COPD Where he is not receiving enough oxygen/blood (hypoxia or hypoxemia)
hallucinations. flow to his brain. Also, medication SE can be contributing to this, too. Does he
have a UTI or other infection?
RELEVANT Data from Social History: Clinical Significance:
Patient and wife have been married for 51 years Patient is no longer able to make his own decisions. His confusion may also be
have 3 children. Rita is now pt’s guardian. Pt does attributable to unfamiliar surroundings and not understanding why he is there. He
not understand why he is at SNF. is well loved by his family who make sure to visit him. They are worried that he is
not “himself”.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current
meds?
(Which medication treats which condition? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• COPD 1. Fluticasone/salmeterol 1. Long Acting Beta-2 1. Chronic treatment and
• Hypertension diskus 1 puff every 12 hours agonist/Corticosteroid maintenance of COPD & asthma
2. Albuterol MDI 2 puffs combination inhaler; anti- producing decreased
• Heart failure
every 4 hours PRN shortness asthmatic; anti-inflammatory inflammation and histamine
• Diabetes type II 2. Selective Beta-2 adrenergic response in lung tissues thereby
• Dementia of breath
agonist; bronchodilator increasing ability to exchange
3. Lisinopril 10 mg PO daily
3. Long-acting angiotensin gases.
4. Atenolol 25 mg PO BID
Color coded match of drugs converting enzyme inhibitor; 2. Acute treatment for COPD &
5. Furosemide 20 mg PO Asthma relaxing bronchial
with the corresponding antihypertensive
daily 4. Cardio Selective-Beta smooth muscles in order to
indication for use.
6. Hydrochlorothiazide 25 blocker; antihypertensive exchange gases during an acute
Please know that some of the exacerbation of COPD.
mg 1 tab PO daily 5. Sulfonamide;
green and dark blue boxes can 3. Decrease of hypertension
7. Metformin 1000 mg PO antihypertensive; diuretic
be interchangeable, as
BID 6. Benzothiadiazide; diuretic; and heart failure as a result of
medications such as lisinopril, suppression of the renin-
8. Glyburide 10 mg PO BID antihypertensive.
atenolol, and 7. Antihyperglycemic; angiotensin-aldosterone
9. Memantine 5 mg PO daily
hydrochlorothiazide can be biguanide system.
used to treat both 8. Second generation 4. Management of hypertension
hypertension and heart failure. sulfonylurea; antihyperglycemic alone or in combination with
9. N-methyl-D-aspartate other anti-hypertensives by
(NMDA) receptor giving rise in intracellular
antagonist/antidementia calcium and triggering the
ryanodine receptors to release
calcium stored in the
sarcoplasmic reticulum (SR),
thus increasing cardiac
contractility. And, also off
label- management of HF.
, 5. To decrease edema caused by
HF and also to decrease
hypertension via inhibition of
sodium-potassium-chloride
cotransporters in the loop of
Henle which results in
increased excretion of water
along with sodium, chloride,
magnesium, calcium, hydrogen,
and potassium ions.
6. HCTZ acts on the proximal
region of the distal convoluted
tubule, reducing reabsorption of
water. This both reduces blood
pressure and water retention
which can cause edema.
7. Serum glucose is reduced by
metformin’s action of
decreasing hepatic glucose
production (gluconeogenesis),
decreasing the intestinal
absorption of glucose, and
increasing insulin sensitivity by
increasing peripheral glucose
uptake and utilization.
8. Glyburide acts by closing
ATP-sensitive potassium
channels on pancreatic beta cells
stimulating release of insulin
thereby reducing blood glucose.
9. Memantine is an
uncompetitive (open-channel)
NMDA receptor antagonist,
preventing glutamate action on
this receptor. This action helps
to decrease glutamate
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in
Morgan’s life?
COPD likely occurred first…
COPD, when it becomes severe, can affect the heart by causing a development in right-sided heart failure. This happens because
chronic lower oxygen levels create increased blood pressure in the lung’s arteries. This is known as pulmonary hypertension
where the lung’s blood vessels narrow or become blocked or even destroyed. All of this leads to the heart becoming weaker and
blood is harder to distribute throughout the body. Body tissues and organs do not perfuse as efficiently, thus decreasing
oxygenation. Oxygen deficits to the brain’s tissues doubly increase the chances of developing dementia. Therefore, Morgan’s
diseases are a cascade of one disease setting off the next, and so on.
