Video Case Study - Caring for Patients With Alzheimer Disease

Nurse Darian works in a long-term care facility and is caring for Rosemary, an 84-year-old female with a history of Alzheimer disease who was admitted following an open reduction and internal fixation, or ORIF, for a hip fracture a few weeks ago.

In collaboration with the registered nurse, RN Piper, Nurse Darian goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Rosemary’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Darian recognizes important cues, including Rosemary’s inability to recall her daughter’s name, her disorientation to date and time, and that she becomes agitated when asked several questions in a row.

Nurse Darian also notes that as the evening progresses, Rosemary becomes more impulsive, and tries to get out of bed on her own.

Next, Nurse Darian analyzes these cues. He understands that dementia is a neurological condition, caused by structural changes in the brain, and is characterized by a progressive decline in mental functions, including memory, thinking, language, behavior, mood, and personality.

He knows that Rosemary’s dementia can be exacerbated by illness, such as the surgery for her hip fracture, and changes to her familiar environment.

Nurse Darian re-enters Rosemary’s room to gather additional information. Nurse Darian: Hi Rosemary.

How are you feeling? Rosemary: I've never met you.

Nurse Darian: That’s okay, Rosemary. I’m your nurse, Darian.

I met you earlier today. Are you having any pain right now?

Rosemary: Why does everyone have so many questions all the time? Nurse Darian notes that Rosemary begins to sit up in bed and tries to swing her legs to the side of the bed to stand up.

The two siderails by Rosemary’s head are up, as well as one siderail by her feet. She then moves towards the open space in the bed to exit, so Nurse Darian moves to prevent her from getting up on her own.

Nurse Darian: Careful there. Let’s get you comfortable and back in bed safely, Rosemary.

We can put your favorite show on the television. Rosemary: Okay.

As Nurse Darian assists Rosemary back into bed, he notices that she groans and tenses up with movement. Since Rosemary is unable to verbalize her pain, he uses the Pain Assessment in Advanced Dementia Scale, also known as PAINAD, to assess her pain which he determines is 5 out of 10.

Then, before leaving the room, he ensures her bed alarm is turned on. He also notes that Rosemary’s room is at the end of the hallway near the stairwell, making it difficult for nursing staff to get to her quickly if her bed alarm goes off.

Nurse Darian realizes Rosemary needs effective safety management. Now, using the information he's gathered, Nurse Darian reports his findings to RN Piper, and together they choose a priority hypothesis of risk for injury.

Then, they generate solutions to address Rosemary’s risk for injury including pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Rosemary will not fall or injure herself during the shift.

Nurse Darian then takes action to implement these solutions. He recognizes that Rosemary’s pain can cause increased agitation, so he administers her prescribed pain medication using safe medication administration principles.

He also knows that moving Rosemary’s room closer to the nurse’s station can help staff accommodate her needs and account for her safety more effectively.

So, Nurse Darian collaborates with the unit charge nurse to move Rosemary’s room closer to the nurse’s station. The charge nurse approves the room change and, during Rosemary’s evening walk with the physical therapist, they move Rosemary’s belongings to her new room.

Once she’s settled in the new room, Nurse Darian ensures that Rosemary’s bed alarm is on and turns the television on to her favorite show while she eats her dinner.

At the end of the shift, Nurse Darian hears Rosemary’s bed alarm go off. He re-enters the room to find her trying to get out of bed.

Rosemary: I don’t want to be cooped up in there anymore! I want to be near other people.

Nurse Darian then assists Rosemary to a reclining chair and moves it to the hallway directly outside the nurse's station.

Nurse Darian also recalls from her progress notes that Rosemary used to work as an artist, so he asks if she’d like to do some drawing.

Rosemary eagerly agrees and spends the remaining time of Darian’s shift safely drawing in her chair. Alright, as a quick recap...Nurse Darian recognized and analyzed cues related to Rosemary’s risk for injury and, in collaboration with RN Piper, prioritized hypotheses and generated solutions to address this problem.

Nurse Darian and RN Piper then took action by implementing pharmacologic and nonpharmacologic measures to address Rosemary’s risk for injury and evaluated her outcomes, comparing them to the expected outcomes.

Since Rosemary remained safe during the shift, they determined that the plan of care was successful.