NURSING IN PATIENTS WITH DEMENTIA

Case:

Tn. B age of 79 years, live in home Werdha Budi Luhur since two years ago, the

family leave Tn. B is because the family is busy with their own affairs. Tn. B

formerly worked at the aluminum plant, the physical condition of Tn. B is currently

impaired memory and orientation. In addition the client is not able to perform nursing

devisit themselves independently but require assistance. Tn. B often forget what way

home when traveling, hard bathing, dressing, and toileting, Tn. B also often irritable

and easily upset. Previous clients have ever taken medication to PKM and diagnosed

by doctors that Mr. B suffering from dementia is a normal part of aging preses.

When study found that TD: 140/80 mmHg, S: 370C, RR: 24 x / min, N: 75 x / min.

The client looks dirty nails, body odor client, less attractive appearance, dirty and

smelly scalp, mouth odor client, the client looks incomplete teeth and dental caries

appears their clients as well as clients looked confused. Client appetite decreased, the

number of clients entering eat less than one serving, clients often eat foods that

contain lots of protein, carbohydrates, and contains calcium to maintain the health of

the client and to improve the client's nutritional status, poor chewing function. The

number of clients taking a 1000 cc / day with mineral water. The nurse said that

muscle strength declines client so that the client runs slowly, clients appear to have

stiff joints, clients seemed to use a cane, the client looks to walk carefully and muscle

strength client 4 (can be against the motion and light barriers) and lab tests.

RESULTS Hb: 9 g / dl, leukosit: 12000 mm3, trombosit 340,000 / mm3, and MMSE

examination: Clients experiencing severe dementia that is 11 with a normal range of

0-15 by weight.

A. ASSESSMENT

a. Identity Of Clients

Name : Tn. B

Gender : Man

Age : 79 year

Work : Entrepreneur

Religion : Islam

Tribe : Melayu

Address : Jambi

b. Medical History

Disease hidtory now

The client's family said that Tan. And impaired memory and

orientation, and Mr. B also often forget what way home when

traveling, hard bathing, dressing, and toileting, Tn. B also often

irritable and easily upset.

Disease history ago

Families clients said once the client had worked in the aluminum

factory. Clients never treated in hospital, never operated, never

allergy medication, eating, and clients do not have the habit of

smoking, alcohol and drugs.

Family history of disease

Client's family members did not suffer from the same disease as

clients and never suffer from other diseases.

c. Physical Examination

Sickness

client is unwell because clients impaired memory and orientation. In

addition the client is not able to do devisit nursing themselves

independently but require assistance.

Vital sign

Awareness composmentis client, the client is still in full awareness.

Blood pressure of 140/80 mm Hg, pulse 75 x / min, 37 ° C using axila,

RR: 24x / minute, the client looks irregular breathing patterns.

Head

Symmetrical head shape, hair color white / graying, hair loss situation,

scalp dirty and smelly.

Eye / vision

Blurred vision acuity client, white sclera and clear, isocor size, dark in

color, reaction to light miosis. Pupillary equal, and react to light,

conjunctival pallor, less clear field of vision, client vision blur when not

using the glasses.

Nose / olfactory

Symmetrical shape, the inner structure of pink, client olfactory function

less well.

Ear / hearing

Outer skin color dark brown outer ear, there are no lesions, reduced ear

skin elasticity. hearing is not good, no pain, do not use hearing aids.

d. Data Analysis

Name : Tn. B

Age : 79 year

No Data Cause Problem

1. DS

Nursing officer

said clients often

irritable and easily

upset

The nurse said

that clients often

Physiological

changes

(degeneration of

neurons is

irreversible)

Thought process

changes

forget their way

home when

traveling is

DO

Clients seem

impaired memory

and orientation

The client looked

confused

Examination

MMSE: the value

of 11 (weight)2. DS

Officers said a

difficult client

parlors bathing,

dressing and

toileting

DO

Nails client looks

dirty

Body Odor client

Look less attractive

The scalp is dirty

and smelly

Mouth odor and

Looks their clients

caries

A decline in

the ability of

taking care

of

themselves

self-care deficit

B. NURSING DIAGNOSES

a. Changes in thought processes associated with the physiological changes

(irreversible neuronal degeneration) is characterized by loss of memory or

memory, loss of concentration, inability to interpret the stimulation and

assess reality accurately

b. Risks to changes in nutrition less than body requirements related to

forgetfulness, setbacks hobby, sensory changes.

c. Risks to injury associated with difficulty with balance, weakness, muscle

uncoordinated, seizure activity.

C. NURSING INTERVENTIONS

n

o

Nursing diagnoses Purpose Interventions

1. Changes in thought

processes associated with

the physiological changes

(irreversible neuronal

degeneration) is

characterized by loss of

memory or memory, loss

of concentration, inability

to interpret the

stimulation and assess

reality accurately

After nursing actions are

expected given the client

is able to recognize a

change in thinking by

KH:

Able to

demonstrate the

cognitive ability

to undergo the

consequences of

the stressful

events of the

emotions and

thoughts of self

Ability to

develop

strategies to

Independently

a. Develop a

supportive

environmen

t and nurse-

client

relationship

is

therapeutic

overcome the

presumption of

negative self

Being able to

recognize

changes in

thinking or

behavior and the

factors causing

Able to show a

decline in

unwanted

behavior, threats,

and confusion

b. Assess the

degree of

cognitive

impairment,

such as

changes in

orientation,

attention

span, ability

to think.

Talk with

your family

about

changes in

behavior

c. Maintain a

pleasant

and quiet

environmen

t

d. Approach

by way

slowly and

quietly

2 Risks to changes in

nutrition less than body

requirements related to

forgetfulness, setbacks

hobby, sensory changes.

After nursing actions are

expected given the client

is able to recognize a

change in thinking by

KH:

Change the

correct intake

patterns

Got a balanced

nutritional diet

Maintain / regain

the weight

accordingly.

Participate in

activities that

facilitate

adaptive coping.

Independently

a. Assess

knowledge

of client /

family

about the

need for

food

b. Try /

provide

help in

choosing

the menu

c. Give small

meals every

hour as

needed

d. Avoid

foods that

are too hot

3 Risks to injury associated

with difficulty with

balance, weakness,

muscle uncoordinated,

seizure activity.

After nursing actions are

expected given the client

is able to recognize a

change in thinking by

KH:

Increasing the

level of activity

Independently

a. Assess the

degree

gngguan

ability,

impulsive

behavior

Able to adapt to

the environment

to reduce the risk

of trauma /

injury

No trauma /

injury

Families identify

potential

environmental

and identify

steps to improve

it

and a

decrease in

visual

perception.

Help

families

identify the

risk of the

occurrence

of hazards

that may

arise

b. Eliminate

sources of

environmen

tal hazards

c. Divert

attention

when

agitated

behavior

```D. EVALUATION

No Nursing diagnoses Evaluation

1 Changes in thought processes

associated with the physiological

changes (irreversible neuronal

degeneration) is characterized by

loss of memory or memory, loss

of concentration, inability to

interpret the stimulation and

assess reality accurately

Able to demonstrate the

cognitive ability to undergo

the consequences of the

stressful events of the

emotions and thoughts of

self

Ability to develop strategies

to overcome the

presumption of negative self

Being able to recognize

changes in thinking or

behavior and the factors

causing

2 Risks to changes in nutrition less

than body requirements related

to forgetfulness, setbacks hobby,

sensory changes.

Change the correct intake

patterns.

Got a balanced nutritional

diet.

Maintain / recover

appropriate weight.

Participate in activities that

facilitate adaptive coping

3 Risks to injury associated with

difficulty with balance,

weakness, muscle

uncoordinated, seizure activity.

Increasing the level of

activity

Can adapt to the

environment to reduce the

risk of trauma / injury

Do not experiencing trauma

/ injury

Families identify potential

environmental and identify

steps to improve it