Week 10 I human
Primary Diagnosis: Alzheimer’s Dementia (AD)
Status/Condition: Stable
Code Status: Full
Allergies: NKDA
Admit to Unit: Plan based on daughter taking mother with her.
Will discharge home with dau
...
Week 10 I human
Primary Diagnosis: Alzheimer’s Dementia (AD)
Status/Condition: Stable
Code Status: Full
Allergies: NKDA
Admit to Unit: Plan based on daughter taking mother with her.
Will discharge home with daughter if she is willing to take mother. Hypothetically speaking, if daughter unable or unwilling to take care of her mother, would plan to admit the patient for inpatient AD workup and for placement to SNF or dementia facility.
Activity Level: Pt is a fall risk. Activity as tolerated.
Diet: Cardiac, Low Na diet
IVF (if ordered, include type and rate ): N/A
Critical Drips (If ordered, include type and rate. Do not defer to ICU Protocol): N/A
Respiratory: 0xygen (if ordered, include type and rate), pulmonary toilet needs, ventilator settings: N/A
Medications: (include ALL, tx of primary condition, underlying conditions, pain, comfort needs etc. dose and route)
Continue home medications except Ambien
Discontinue Ambien
Donepezil 5 mg PO QHS for AD
Sertraline 50 mg PO QD for depression
Trazadone 25 mg PO QHS insomnia
Vitamin B12 500mcg 2 tabs PO QD supplementation
Tylenol 500 mg PO Q6H PRN for pain
Will start bowel regimen for constipation prevention
Senna 8.6 mg PO QHS
Docusate 100 mg PO QD
Nursing Orders: Monitor blood pressure at least once a week and as needed for blood pressure control
Follow Up Lab tests: Baseline and repeat in 4 weeks CBC, CMP, UA, TSH/T4, LFTs.
Monitor Vitamin B12/folate levels
Will obtain RPR, HIV, homocysteine, level, ESR, CRP, coags, blood and urine drug and toxicology screen
Diagnostic testing (CXR, US, 2D Echo, etc…) Include indication for test, for example CXR to evaluate pneumonia):
EKG-pre-medication to determine rhythm and repeat in 4 weeks (this medication can cause AV block, bradycardia, syncope.)
EEG- the only clinical diagnostic instrument that directly reflects cortical neuronal functioning. AD and evaluate disease progression
Initial MRI brain-AD and evaluate disease progression
MMSE, GDS, Mini-Cog-AD and depression
LP-for collection of CSF to r/o other infectious process such as meningitis
CT scan-r/o SAH
Baseline chest x-ray-r/o any infectious process i.e. pneumonia
Consults: [Do not defer management to a specialist. As an ACNP you must manage the patient’s acute needs for at least a 24 hour period]. Include indication for consult, for example “Cardiology consult for evaluation of new-onset atrial fibrillation., or Nutrition consult for TPN recommendations.”
Neurologist-new diagnosis of AD for evaluation and further treatment
PT/OT-assess function status and recommendations for treatment
Social work consult-initial comprehensive assessment, recommendations for available resources for patient and family, Advance directive and power of attorney information, information for adult daycare
Case management- will need home health evaluation pending current work-up
Nutritional consult-assess nutritional status, weight loss of 8-10 lbs
Patient Education and Health Promotion (address age appropriate patient education if applicable):
• The family/caregiver should be educated about AD and the disease process including it is not curable. Interventions are done to slow the progression of the disease only.
• Teach the caregiver about the importance of compliance to the treatment regimen
• Educate on the side and adverse effects of the medications
• Educate the caregiver to give the Donepezil at bedtime since it can cause bradycardia and/or syncope
• Teach the caregiver the signs and symptoms of pain and provide adequate pain control since the patients with AD may not be able to verbalize the pain.
• They need to be educated about the signs and symptoms of moderate to severe AD
o where the patient becomes a total care
o incontinence of bowel and bladder
o wanders and gets lost
o problems with speech and stops following commands
o may start conversation and forget to complete sentences
o loses ability to read and write
o Develops problems recognizing familial people (agnosia)
o Severe AD
may stop walking
may use wheelchair or become bedridden,
change in behavior such as be more aggressive, and then become incoherent and mute, and apathetic.
• The patient will be monitored in every 3 months and she may need to be placed in SNF or dementia facility for the farther management of care.
• Work with nutritionist regarding dietary compliance and recommendations for supplementation to decrease further weight loss
• Hospitalization and/or respite care may be necessary if the behavior poses significant dangers to herself and others, is refractory to other interventions, or is causing considerable caregiver stress.
• Monitor blood pressure. Maintain blood pressure less than 150/90.
• Sleep hygiene measures, including daytime activity, avoidance of naps, daily walking, and bright light therapy, have been shown to improve sleep quality
Discharge planning and required follow-up care:
• Follow up with PCP no later than 2 days. Please take discharge instructions to appointment along with all new medications.
• Will make an appointment with neurologist. Will received a phone call from them in the next 2 days.
• Take all medications as prescribed.
• Notify provider if symptoms worsen before neurologist appointment.
• Return to ED for chest pain or SOB.
• Follow PT/OT/Nutrition recommendations, if home health is not available.
References (minimum of 3, timely, that prove this plan follows current standard of care).
Creavin, S. (2016). Mini-Mental State Examination (MMSE) for the detection of dementia in people aged over 65. Cochrane Database of Systematic Reviews. Retrieved from https://www.cochrane.org/CD011145/DEMENTIA_mini-mental-state-examination-mmse-detection-dementia-people-aged-over-65.
Fage, B. (2015). A brief cognitive screening test (Mini-Cog) for the assessment of possible dementia. Cochrane Database of Systematic Reviews. Retrieved from https://www.cochrane.org/CD010860/DEMENTIA_a-brief-cogntive-screening-test-mini-cog-for-the-assessment-of-possible-dementia.
Neugrolschl, J. (2018). Alzheimer Dementia. Epocrates. Retrieved from https://online.epocrates.com/diseases/31711/Alzheimer-dementia/Key-Highlights.
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