In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills in order of support systems to:

  • Assist the family to plan care for client with impaired cognition (e.g., Alzheimer's disease)
  • Encourage the client's involvement in the health care decision-making process
  • Evaluate the client's feelings about the diagnosis/treatment plan

Assisting the Family to Plan Care for the Client with Impaired Cognition

Impaired cognition is associated with a number of different etiologies including trauma, electrolyte disorders, Alzheimer's disease and a number of other causes. Some clients may be affected with a temporary decrease in their level of cognition, as often occurs among clients affected with delirium, and other clients may be affected with a permanent cognitive impairment such as occurs with closed head injuries and cerebral tumors, and still more can be affected with progressive impairments of their cognition as occurs with Alzheimer's disease, the most commonly occurring form of dementia.

Regardless of the etiology of the cognitive impairment, it is often quite difficult for the family to adapt and cope with these changes. Nurses support and assist these family members, and the client, in terms of their coping and adaptation. When a cognitive deficit is temporary, the family members may need nothing more than assurances that the medical problem that is causing this change is being treated and to, at the present time, support the client. Family members who are affected with a permanent impairment of cognition may need the assistance of the nurse, and other members of the health care team, to cope with this loss and adjust to the future and all of the changes associated with it. The changes and the stressors associated with a permanent impairment of cognition vary according to the severity of the impairment. At times the client and the family members may have only minor, but permanent, changes to cope with and, at other times, the severity of the cognitive impairment may be so severe that the family is no longer able to care for the person in the home.

Progressive cognitive disorders, although they can progress to a severe and incapacitating level, its slow progression often give the client and family members an opportunity to adjust and cope in a gradual way as the disease progresses. This is often the case for clients and family members affected with irreversible, progressive Alzheimer's disease.

The stages of Alzheimer's disease are the:

  • Early Stage: This stage of Alzheimer's disease is characterized with mild symptoms; however, the affected client is still able to function relatively independently. Some of the mild symptoms associated with this stage of Alzheimer's disease include some difficulties in remembering things like the names of others, forgetfulness, the losing and misplacing items, and having some troubles in terms of organizing things and task performance. It is often a family member or close friend, rather than the client themselves, that notices these changes.
  • The Middle Stage: This stage, also referred to as moderate Alzheimer's disease, is the longest of all the stages of this progressive disease in terms of its duration. Some of the signs and symptoms associated with this stage include all of the signs and symptoms associated with the early stage of Alzheimer's disease in addition to more confusion, a failure to remember basic things like one's age or address, a lack of orientation to the day or date, moodiness, sleep disturbances, withdrawal from others, evening and nighttime restlessness and wandering which is referred to as Sundowner's Syndrome, short term memory loss, suspiciousness, delusions, and some loss of control over bladder and/or bowel functioning.
  • The Late Stage: This stage, also referred to as severe Alzheimer's disease, is characterized with the client's having the signs and symptoms of the earlier two stages of this devastating disorder, in addition to both long term and short term memory losses, an inability to effectively and appropriately communicate with others, an inability to recognize even highly familiar faces such as those of a spouse and/or a loved child, and an inability to perform any self care including controlling basic elimination functions such as bladder and bowel control. The client is wholly compensatory, according to Dorothea Orem's Self Care theory, and, as such, in need of all care from the health care providers and/or family members.

According to the Global Deterioration Scale, also referred to as the Reisberg Scale, Alzheimer's disease is staged according to seven stages. These stages include:

  • Stage 1: Cognitive abilities are intact.
  • Stage 2: Minimal and hardly noticeable forgetfulness occurs.
  • Stage 3: Mild changes in terms of cognition occur. The client may have difficulty in terms of their memory, which at times the client may "cover up" to avoid the detection by others. The signs and symptoms of this stage are similar to those of the Early Stage of Alzheimer's disease, as discussed immediately above.
  • Stage 4: This stage is characterized with increasing confusion about recent events and conversations, mild problems with math and some rather routinized sequential tasks such as cooking. The client may withdraw from others and debate the fact that they are having some cognitive issues.
  • Stage 5: Early Dementia occurs. Short and long term memory losses, a lack of orientation to place and time, poor judgment, and some of the client's self care in terms of the activities of daily living become progressively more problematic. The client may need the assistance and supervision of others to promote the client's highest possible level of independence in the performance of their basic activities of daily living.
  • Stage 6: This stage is referred to a Middle Dementia and moderately severe Alzheimer's disease. There is almost complete short term and long term memory loss, communication is highly limited and it may only consist of nonverbal behavioral responses, and the client needs complete care to manage their activities of daily living. Sundowner's syndrome is present and hallucinations as well as agitation may occur.
  • Stage 7: This stage is referred to as Late or Severe Dementia and Failure to Thrive. The client is in need of complete care; and immobilization, in addition to the hazards of immobility, may affect the client and the family members at this stage.

Nurses assist affected family members by emotionally supporting them and their needs. They also assist the family in terms of their caring for the loved one affected with a cognitive disorder, such as Alzheimer's disease, when the family member is willing as well as cognately and physically able to do so.

Some of the content that should be included in the family's education are:

  • The nature of the disease and its progression
  • The signs and symptoms of the disorder
  • How to recognize the client's and the caregiver's strengths and weaknesses
  • The importance of maintaining the client's level of optimal independence
  • The importance of garnering and utilizing support systems such as other family members, home health services, and respite
  • Symptom related interventions

Some of the symptom related interventions relating to cognitive disorders include:

  • Memory loss: Facilitate the client's memory with reminders and other things like a notebook to keep notes or a list of things that the client will do the next day.
  • Communication problems: Encourage the caregiver to be patient when communicating with their loved one. Allow the person enough time to process input and then enough time to process and respond to verbal messages. The caregiver should speak slowly, in an understandable manner, and also repeat and clarify messages as often as necessary.
  • Depression: The caregiver should be instructed to provide a caring, calm, safe and honest environment. They should also be instructed to speak with the client's doctor for medications and other treatments which can possibly treat the depression.
  • Confusion and the lack of orientation: Provide as many reminders as necessary. Reorient the client to person, time and place as often as necessary.
  • Impaired self care abilities: Provide the person with as much coaching, instruction, and assistance as necessary but allow as much independence as possible.

Encouraging the Client's Involvement in the Health Care Decision-Making Process

Clients are the center of care. Clients, therefore, must be encouraged by the nurse to fully participate in and be totally involved in the entire nursing process and all health care decision making.

As fully detailed in the previous section entitled "Informed Consent", the client must be fully knowledgeable about all treatments, all alternatives, and the benefits and risks associated with these treatments and all possible alternatives in order to make knowledgeable decisions relating to their health care decision.

Evaluating the Client's Feelings About the Diagnosis/Treatment Plan

Nurses assess and evaluate the client feelings and opinions about all diagnoses and treatment plans.

In terms of all diagnoses, the nurse must assess and evaluate their feelings about their diagnosis. For example, a client may feel anger when they are diagnosed with a terminal physical disease diagnosis; they may experience depression, grief and loss when they are faced with the loss of a limb; they may experience feelings of guilt and remorse when they are affected with a substance related diagnosis, particularly when this abuse or addiction has destroyed the family unit and other relationships; and they may experience shame when they are diagnosed with a psychiatric mental health disorder because of the social stigma attached to it.

Clients also have feelings and opinions about their treatment plans. Some may be very accepting and cooperative with the plan because they believe that they can solve their health related problem and concern by following it, other clients may not adhere to their treatment plan because they believe that it will not be helpful, and still more may be apathetic about it.

All of these feelings and beliefs must be identified by the nurse and then the nurse must intervene to assist the client in terms of their feelings about their diagnosis and their treatment plan.

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