Caring for Patients with Cognitive Impairment and Related Conditions

The term cognitive impairment is used to describe changes in mental function caused by
injury or disease. Persons who are cognitively impaired may have difficulty learning,
processing, and remembering information.

Caring for Patients with Mental Retardation or Developmental Disability

Ensuring a safe environment and teaching safety
Providing information in a slow, simple manner
Promoting self-esteem
Being patient and repeating simple instructions
Assisting and supervising the patient with activities of daily living
Using praise and rewards liberally
Smiling and showing support and affection


Person with delirium develop confusion and decrease awareness of the environment



Alzheimers Disease - can begin during middle age, but is more common in older
persons. It has been called a slow death of the mind. The cause is not known. It is
progressive and cannot be cured.
Despite having a healthy appearance, persons with Alzheimers have changes in the
structure and function of the brain, which shrinks and becomes smaller.

Alzheimers disease generally has three main stages:

Stage I: Mild Dementia
They are usually physically capable and can attend to the activities of daily living with
supervision.
Characteristics of stage I include:


Personality changes, with indifference and loss of spontaneity
Short-term memory loss
Decreased ability to concentrate; shortened attention span
Disorientation as to time and space
Poor judgment
Lack of safety awareness
Carelessness in actions and appearance
Anxiety, depression, and agitation
Delusions of persecutionthe person thinks that others are conspiring to do him harm

Stage II: Moderate Dementia
Symptoms of this stage are:
Increased short-term memory loss and deterioration of memory for remote events.
Complete disorientation.
Wandering and pacing.
Sundowning (confusion and restlessness).
Sensory/perceptual changes. (The person becomes unable to recognize and use
common objects, such as eating utensils, combs, and pencils. He or she cannot
distinguish between right and left, up and down, hot and cold)
Perseveration phenomena. (repeat an action, Examples are repeating the same word or
phrase, lip-licking, chewing, or finger-tapping)
Problems with walking.
Problems with speech, reading, writing.
Incontinence of bowel and bladder.
Catastrophic reactions, hallucinations, delusions.

Stage III: Severe Dementia
The person in Stage III:
Is totally dependent
Is verbally unresponsive
May have seizures
May refuse to eat and drink
Biting, scratching, and kicking may be the only way the person can express displeasure.
They lose the ability to control their impulses.

Activities of Daily Living for Patients with Dementia

Allow the patient to do as much as possible.
Observe the patients physical condition. People with dementia are usually unaware.


Assist the patient to maintain a dignified, attractive appearance

Monitor food and fluid intake.


Check food temperatures.

Prepare foods for eating as needed.
Weigh patients regularly to identify patterns of weight gain or loss.
Patients with dementia eventually lose bowel and bladder continence. Taking them to
the bathroom regularly helps them remain dry and maintains dignity.
In later stages, use sensory stimulation with quiet music, soft touching, and calm talk.
Holding puppies or kittens (pet therapy) often brings pleasure to severely impaired
patients.


Provide daily exercise according to the care plan and the patients habits and abilities.

Wandering and Pacing


Patients with Alzheimers disease wander continually
The patient may not know where he is, but knows he does not want to be there. He is
seeking a state of mind, not a physical location.

Ask the patient the intended destination. A man may tell you he is going to work. A woman
may say she is going home to cook dinner for the children. Avoid arguing or providing
reality orientation, which will agitate the patient. Instead, talk about the patients activities,
work, meal preparation, or cooking. Make comments.
Walk with the patient and subtly guide her to circle back.
Thinking is a very complex process. If someone tells you not to think of a purple dog, you
will think of it, then avoid saying, Dont go outside or Dont go in that room. A better
approach is to say, Stay inside or Stay here.


Avoid forcing your own agenda on the patient, which will cause agitation and worsen the
behavior. Instead, use gentle persuasion.


Try distraction


Take the patient to activities that he or she enjoys


Patients who wander may become physically exhausted. Seating enables him to rest.

Caring for the Bariatric Patient

Body Mass Index


Overweight is a condition in which a person weighs more than he or she should, according
to standards.
Obesity is being overweight by 20% to 30% of the ideal body weight.
Morbid obesity have a BMI of 40 or higher. It usually qualifies a patient for surgical
treatment.



Nursing assistant must know how to care for them correctly.
Providing quality care for the bariatric patient presents many challenges and risks, both
physical and emotional.


Daily living activities are difficult or painful.

Apathy or signs of depression
Excessive thirst
Complaints of heartburn or esophageal reflux
Increased urination
Unexplained weakness
Signs of fatigue, becoming quieter, lethargy, progressive sleepiness


Weight of the chest makes breathing difficult, so supplemental oxygen is often
necessary.


Change in leg color, sensation, swelling, and temperature. Change in patients ability to
move legs.

COMORBIDITIES
Being overweight or obese increases the risk for many health conditions. These conditions
are called comorbidities.



Specialized Equipment and Supplies
The obese patient may be unable to fit into regular hospital furniture. Regular furnishings
may be unsafe and break under the patients weight.

-Large, extra-large, or thigh-size cuff may be necessary.


Bed


Bedside Chairs


Mechanical Lift. To move patient from one location to another.


Gowns


Toileting and Bathing


Wheelchair

Assisting with ADLs
Protect the patients dignity at all costs. Some patients may refuse an offer of help with
personal care because they are embarrassed by their inabilities or ashamed of their
bodies.
However, some patients are so large that they cannot complete their own personal
hygiene.

Patient Transport
When you must transport a patient evaluate the route you will take to make sure that
doors, elevators, and other areas are wide enough for the patient and extra equipment.

Moving the Bariatric Patient


Many different devices are available to make moving the patient easier for staff and less
traumatic

The HoverMatt


Lateral Transfer and Repositioning System is commonly used for lifting, moving, and
transferring bariatric patients. It seems as you are moving only about 10% of patient
weight. The device is comfortable and reduces the risk of injury.


The HoverMatt cradles the patient when it is inflated, so he or she feels secure and is
less likely to roll off. Nevertheless, reassure the patient and never leave him or her alone
when the mattress is inflated.

Moving the Patient: Bed Mobility
Moving procedures present a high risk of injury to the patient and the nursing assistant.
Bedfast patients must be turned every 2 hours or more often, even if a special bed or
mattress is used. If the patient turns herself, check to ensure that she is turning often
enough and that pressure is relieved from all high-risk areas.
Make sure that all tubes are firmly secured, and monitor them for proper placement each
time you are in the room. Because the patient uses the arms for bed mobility, try to avoid
devices that limit movement of the hands and arms. For example, having an IV in the left
arm and an electronic blood pressure monitor on the right arm acts as a method of
restraint and will restrict the patients ability to move about in bed.


Accessories such as the bed ladder will help facilitate movement.


Fowlers position relieves pressure on the chest and eases breathing.


If the patient complains of back pain when the head is elevated, elevating the knee of the
bed will not provide sufficient relief. A commercial knee elevator will relieve pressure on
the back.


The TLC Pad and other similar patient handling devices can be used for moving patients
up in the bed or chair, and from side to side in bed.

Moving the patient by tugging on his or her body increases the risk of injury to patient and
staff. Use a lifting device for moving the patient in bed. Supporting the patients body
reduces the effects of gravity, making the move easier for both patient and staff. Four to
six people may be needed to reposition a total-care patient safely. One person lifts the
head. A second and third are positioned on each side, and a lift sheet or other device is
also used. Another assistant positioned at the foot of the bed lifts the heels to eliminate
friction and shearing.
When the patient is on the side, support the upper leg on pillows. The extra support
reduces the risk of skin problems caused by the legs rubbing together, as well as
preventing pressure on the bony prominence at the knee. Supporting the upper leg helps
relieve pain in the hip joint and lumbar area of the spine. Unsupported, the weight of the
leg exerts a downward pull on both the hip and the
spine, which can be very painful.
The patients skin and extremities are heavy and will not move on their own. You must
move his or her body parts manually.


Some hospitals have an arrangement of slings and pulleys for moving the arms and legs.

Moving the Patient: Transfers and Ambulation
Some bariatric patients can walk for short distances.


Some will use a walker for support. Others use mobility scooters. Some will need help or
use a mechanical device to come to a standing position and others will require assistance
with transfers.

Some patients will be able to ambulate in their rooms with minimal assistance and support.


A gait/transfer belt may be used for transfers and ambulation if you have a long belt. A 72-
inch belt will probably be necessary, in addition to two or three assistants to help. Avoid
doubling a gait belt, if possible.

If a long belt is not available and you must join two regular belts, make sure to lock the
buckles down securely.

Caring for the Patient Who Is Dying

FIVE STAGES OF GRIEF
Dr. Elisabeth Kbler-Ross (19262004) identified five stages of grief that can occur in a
dying person. Family members, friends, and caregivers also experience the grieving
process.
The grief stages are denial, anger, bargaining, depression, and acceptance. If there is
adequate time and support, some patients may be able to move through each stage to a
point of acceptance of their illness and death.

Denial begins when the person is made aware that he is going to die. He may deny that
the information is true. Making long-range plans suggests that the patient is in the denial
stage.

Anger

Patient can no longer deny the fact that she is going to die. The patient may blame others
for her illness. She is angry about her diagnosis, not with you personally.

Bargaining is the stage in which the patient attempts to bargain for more time to live.
Trying to make private deals with God or a higher power is also common. For example,
If you will let me live another two months, I promise I will try to be a better person.
The patient is basically saying, I know Im going to die and Im ready to die, but not just
yet.

Depression

The patient comes to the realization that he will die soon. He is saddened by the thought of
separation from family and friends, and that he could not do everything he wanted to do.

Acceptance

The patient understands and accepts the fact that he is going to die. He may try to
complete unfinished business. Having accepted his eventual death, he may also try to help
those around him to deal with it.

Not all patients progress through these stages in sequential order. Movement from one
level to the next does not mean that the previous level will be completely left behind.
Patients sometimes move back and forth between stages several times before completely
resolving one stage and moving ahead.


The family and staff also go through the grieving process. Seeing the patient in one stage
and the family in another stage is difficult.

THE ROLE OF THE NURSING ASSISTANT
As a nursing assistant, you spend much time with the patient. You have a unique
opportunity to be a source of strength and comfort. You must behave in a way that instills
confidence in both the patient and the patients family.
Developing the proper attitude and approach for this type of situation is not easy. It will
come with experience.
There are some things to keep in mind:
You must be open and receptive, because the terminal patients attitude, feelings, and
wishes may change from day to day.
Your own feelings about death and dying influence your ability to care for dying patients.
Your acceptance of death as a natural occurrence will enable you to meet patient needs in
a realistic manner.
Give your best and most careful nursing care, with special attention to comfort measures
such as mouth care and fluid intake.
Be quietly empathetic and carry out your duties in a calm, efficient way.

HOSPICE CARE
A program designed to meet many needs of the dying person and his or her family
Provided to terminally ill people with a life expectancy of six months or less
Involved with direct physical care when needed
Available 24 hours a day, if needed. Provided care facilities, and at home
A program in which volunteers play an important role, making regular personal visits to
the patient and family

The goals of hospice care include:
Control of pain
Coordination of psychological, spiritual, and social support services for the patient and
the family

Because hospice care is a philosophy, it becomes part of the guide for your actions when
caring for patients who are terminally ill. Give these patients the same care you would
provide if a terminal diagnosis had not been made. Carry out all activities with dignity and
respect.
Hospice care may seem to go against everything you have been taught. For example, a
patient has bone cancer that is very painful, and is expected to die within a few days.
Despite high doses of drugs, she remains in severe pain. Moving the patient worsens the
pain, so the care plan instructs you to leave the patient on her back, rather than turning her
every 2 hours. You know the patient has skin breakdown that will worsen if she is not
turned. However, you must follow the care plan and not turn the patient. This shows
respect for the patients needs and supports the quality of her final hours of life.

Signs of Death
After death, changes continue to take place in the body.
These changes are called moribund (dying) changes:
Pupils become permanently dilated.
There is no pulse or respiration.
Heat is gradually lost from the body.
The patient may urinate, defecate, or release flatus.
Within 2 to 4 hours, body rigidity, called rigor mortis, develops.
Unless the body is embalmed within 24 hours, there is progressive protein breakdown.
When circulation stops, blood moves into the lowest areas of the body. This process can
begin within 20 minutes of death. Over time, this will result in a stained appearance on the
back of the body if the patient is in the supine position. To reduce the risk of staining about
the head and neck, elevate the head of the bed. Keep the head upright and not turned to
the side. Some facilities do not use ties in the morgue pack to position the body. If used,
tie them loosely.

GIVING POSTMORTEM CARE
1. Carry out initial procedure actions.
2. Assemble equipment:
Shroud, morgue pack, or clean sheet
Basin with warm water
Washcloth
Towels
Disposable gloves
Identification tags
Cotton
Bandages
Pads as needed
3. Put on disposable gloves.
4. Remove all appliances, tubing, and used articles,if permitted.
5. Work quickly and quietly; maintain an attitude of respect.
6. Position the body on the back, with head and shoulders elevated on a pillow. Straighten
the arms and legs and place the arms at the sides.
a. Close the eyes by grasping the eyelashes, gently pulling the eyelids down, and holding
shut for a few seconds.
b. Replace dentures in the patients mouth, if used, or clean the dentures and place them
in a denture cup. Make sure they are sent to the funeral home with the body. Send other
artificial body parts to the funeral home, if used.
c. Close the mouth.
7. Bathe as necessary. Remove any soiled dressings and replace with clean ones. Groom
hair.
8. Place a disposable pad underneath the buttocks.
If the family is to view the body:
a. Put a clean hospital gown on the patient.
b. Cover the body to the shoulders with a sheet.
c. Remove disposable gloves and wash your hands.
d. Make sure the room is neat.
e. Adjust the lights to a subdued level.
f. Provide chairs for the family.
g. Allow the family to visit in private.
9. Return to the patients room after the family leaves. Wash your hands and put on
disposable gloves.
10. Collect all belongings and make a list. Wrap properly and label. Valuables remain in
the hospital safe until they are signed for by a relative.
11. Fill out the identification cards or tags in the morgue kit and attach them as follows:
a. Place one card on the right ankle or right great toe.
b. Attach one card to the bag with the patients valuables.
12. Put the shroud on the patient and attach an identification card or tag to the outside.
13. Transport the body to the morgue, or leave in the room with the privacy curtain and
door closed until the funeral home arrives. When it is time to move the body:
a. Call an elevator to the floor, lock it off, and keep it empty.
b. Close doors to other patients rooms.
c. Empty the corridor.
d. With an assistant, transfer the body to a gurney or the mortuary cart.
e. Keep the patient supine, with the head elevated.
f. Cover the body with a sheet.
g. Remove disposable gloves and discard according to facility policy. Wash your hands.
h. Take the body to the morgue or assist the funeral home as directed.

The Nursing Assistant in Home Care

CHARACTERISTICS OF THE HOME CARE NURSING ASSISTANT AND HOMEMAKER
ASSISTANT

As a home care nursing assistant or homemaker assistant, you must demonstrate:
Honesty in managing the clients possessions and shopping money, and in reporting
time.
Self-starter ability in carrying out your assignment promptly and efficiently without
reminders.
Accuracy and attention to details, so that each task is performed correctly.
Organization, so that you plan your activities around the clients schedule, not your own,
and make the best use of your time.
Observational skills and the ability to recognize and report changes and abnormal signs
and symptoms.
Adaptability in modifying nursing assistant skills to the home situation.
Acceptance of clients and their home environments.
Ability to perform independently, making decisions within the limits of your
responsibilities and the scope of the assignment.

PERSONAL SAFETY
Thousands of nursing personnel make daily home care visits, and incidents of violence are
few. Still, personal safety is always a concern for home care workers. Be alert to
conditions and people around you. Trust your instincts. If something does not feel right, it
probably is not. There are several basic ways to protect your own safety:
Map out the route in advance so you know where you are going.
Inform the client what time you will be arriving.
Lock your purse in the trunk of your car at the beginning of your day. Use pockets or a
belt-type (fanny) pack for essentials such as drivers license and pens.
Wear scrubs or clothing that identifies you as a nursing caregiver. Wear your name
badge.
In potentially dangerous areas, ask your agency if you can make joint visits with a
coworker or use an escort.
Avoid parking on deserted streets or in dark areas.
Attend classes on personal safety and self-defense.
Always carry a cellular telephone, and keep the battery charged.

HOME HEALTH CARE DUTIES
The duties of the home health care assistant are planned around the clients and familys
routine. These duties may include:
Helping with the activities of daily living
Providing hygiene and comfort care
Maintaining a safe environment
Homemaker duties may include:
Light housekeeping
Shopping and preparing meals


You may also have to transport the client to clinic or therapy visits.

The homemaker duties do not include:
Doing heavy housework, such as washing windows or moving heavy furniture
Making decisions about food purchases, unless the client is unable to do so
Becoming involved in family disputes


Some equipment may be rented from equipment rental companies or borrowed from
church groups or other organizations.

Apply the principles of standard precautions if contact with blood, body fluids, mucous
membranes, or non-intact skin is likely.
A pillowcase or plastic bag hung on the back of a chair can serve as a laundry bag.
If you are assigned to do dressing changes on minor skin wounds, use a plastic bag.
Place your hand inside the bag and gently remove the old dressing. Then turn the bag
inside out, with the dressing on the inside. Tie or seal the bag and throw it away. This
method may also be used for handling bio-hazardous or soiled material.
Some clients cannot suck forcefully enough to draw liquids up through a straw. Wash
and dry your bandage scissors, then cut the straw a few inches shorter. Place the cut end
in the bottom of the glass and have the client suck from the smooth end. Removing a few
inches is usually enough to enable them to drink successfully.
Use denture cleaner or dishwasher soap to remove sediment and stains on bedpans
and urinals.

THE HOME ENVIRONMENT
You are responsible for maintaining a safe and comfortable environment for the client. This
means that you must:
Be alert to unsafe situations


Control the spread of infection

Care for and maintain the clients furnishings, supplies, and appliances
Learn the locations of items that may be needed in an emergency

http://www.youtube.com/watch?v=vKzKYAnX7Mc
Dealing With Aggression

http://www.youtube.com/watch?v=3zKADdgcf14
Dementia : End of life care

http://www.youtube.com/watch?v=uSUNMbQz59g
Safe at Home -- A Caregiver's Guide

http://www.youtube.com/watch?v=RKGDzCRZuwM
My Wishes: An End Of Life Care Story (Patient)

http://www.youtube.com/watch?v=ciEPpcubgUg
Four Stages of Dementia: The Final Stage

http://www.youtube.com/watch?v=N7O3vHRuGls
Living with Dementia

http://www.youtube.com/watch?v=Gsw2J2Ur8xo
Bariatric Care - Leading Edge Solutions

http://www.youtube.com/watch?v=O7fbeGCPcjA
NHS Innovations in Health: Advances in Bariatric Care

http://www.youtube.com/watch?v=A4LRFMYNdX8
Healthcare: The Nursing Assistant and Bariatric Care
http://www.youtube.com/watch?v=4o7w3iOV_WM
A Lesson in Dying: A Nurse With Cancer Offers

http://www.youtube.com/watch?v=Fte4l8am8Mo
End of Life Care (excerpt)

http://www.youtube.com/watch?v=5-SQJog_-84
A day in the life of a Care Assistant at Heritage Care