demencia - Nursing Case Study

Pathophysiology

• Primary mechanism: Neuronal damage - Chronic degeneration of neurons in the brain leads to loss of cognitive function. In Alzheimer's, the most common type of dementia, amyloid plaques and neurofibrillary tangles cause neuron and synapse loss.

• Secondary mechanism: Neurotransmitter disruption - The loss of neurons leads to a shortage of key neurotransmitters, especially acetylcholine, disrupting communication between neurons. This affects memory, learning, and other cognitive functions.

• Key complication: Progressive brain atrophy - As the disease progresses, the brain shrinks, especially in areas responsible for memory and learning, leading to a broad range of cognitive and functional impairments.

Patient Profile

Demographics:

78, Female, Retired School Teacher

History:

• Key past medical history: Diagnosed with Mild Cognitive Impairment (MCI) 3 years ago, Hypertension for 10 years

• Current medications: Donepezil for dementia, Lisinopril for hypertension

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing forgetfulness, confusion, and difficulty performing daily activities

• Key symptoms: Memory loss, disorientation, difficulty in speaking and understanding language, decreased judgment, difficulty in swallowing, frequent mood changes

• Vital signs: Blood Pressure: 145/90 mmHg, Pulse: 78 beats per minute, Respiratory rate: 16 breaths per minute, Temperature: 98.6 °F, Oxygen Saturation: 94%

Section 1

Change in Patient Status:

Over the next week, the patient's cognitive decline continues to accelerate. She frequently forgets the names of close family members and can no longer complete basic tasks such as dressing or using the bathroom independently. Her mood has become increasingly unpredictable; she alternates between periods of apathy and unexplained frustration or agitation. She has also been having trouble sleeping, often waking up in the middle of the night disoriented and confused.

The patient's vitals remain largely unchanged, with a blood pressure of 148/92 mmHg, pulse of 80 beats per minute, respiratory rate of 15 breaths per minute, and oxygen saturation of 93%. However, during these episodes of agitation, her pulse can spike to 95 beats per minute. The patient's difficulty in swallowing has led to a decreased intake of food and water, resulting in a weight loss of 4 pounds in the last week and signs of mild dehydration, including dry mouth and decreased urine output. The patient's confusion and disorientation, combined with her poor nutritional status and dehydration, indicate the need for immediate medical intervention and possibly a reassessment of her current treatment plan.

Section 2

New Diagnostic Results:

The patient's primary care physician recommended a thorough re-evaluation of her condition. Lab tests were ordered to determine if there were any underlying conditions or infections contributing to her rapid cognitive decline. The complete blood count (CBC) showed a slightly elevated white blood cell count of 12,000 cells/mcL, indicating a possible infection. Serum electrolytes revealed mild hyponatremia with a sodium level of 132 mEq/L, likely due to her decreased fluid intake. Liver and kidney function tests were within normal limits, suggesting that the patient's organs were still functioning correctly despite her deteriorating condition.

The physician also ordered a brain MRI to identify any structural abnormalities that could be contributing to her cognitive impairment. The MRI showed moderate atrophy in the frontal and temporal lobes, consistent with advanced dementia. However, the presence of multiple small infarcts also suggested a vascular component to her cognitive decline. This new information necessitated a reevaluation of her treatment plan and a more comprehensive approach to addressing her cognitive symptoms, potential infection, and hydration status. These results provide a basis for further clinical reasoning and planning of appropriate interventions.

Section 3

Change in Patient Status:

Following the new diagnostic results, the patient's status began to exhibit some changes. Despite the constant monitoring and efforts of the healthcare team, the patient's cognitive symptoms continued to deteriorate. She frequently appeared confused, had difficulty recognizing family members, and often had trouble finding the right words during conversations. These changes were indicative of the progressive nature of dementia and the possible vascular contribution to her cognitive decline.

In addition to this, the patient also began to show signs of physical discomfort. She complained of a throbbing headache, persistent fatigue, and general weakness. Her body temperature spiked to 100.8°F, further supporting the suspicion of an ongoing infection. The patient's blood pressure also fluctuated, averaging at 140/90 mmHg, which could be attributed to her hyponatremia and potential vascular issues. These changes in her status necessitate immediate interventions to manage her symptoms, prevent further complications, and improve her quality of life. The healthcare team will need to use clinical reasoning to prioritize care and determine the most effective interventions based on her rapidly evolving condition.

Section 4

New Diagnostic Results:

The healthcare team performed a series of diagnostic tests to identify the source of the infection causing the fever. A urine culture was conducted and revealed the presence of Escherichia coli (E. coli), indicating a urinary tract infection (UTI). This could potentially explain the patient's symptoms of headache and general weakness, as UTIs can often cause systemic symptoms, especially in elderly patients.

The patient's blood tests also showed a raised white blood cell count of 15,000 cells/mcL, indicating an active infection. Her sodium levels continued to be low at 130 mEq/L, which could potentially contribute to her confusion and hypertension. Her cholesterol level was also high at 240 mg/dL, suggesting a risk for further vascular conditions. The healthcare team had to consider these results and decide on a course of action considering her dementia and the newly diagnosed UTI. The complexity of her condition required a careful balance of interventions to treat her infection, manage her dementia symptoms, and address her hyponatremia and hypertension.

Section 5

Change in patient status:

Over the next few days, the patient's condition started to worsen. Despite being started on antibiotics for her UTI, her fever spiked to 38.5°C and she complained of lower abdominal pain, suggestive of pyelonephritis. Additionally, the patient's confusion seemed to be intensifying, which was possibly due to her unresolved hyponatremia. Her blood pressure measurements remained erratic, fluctuating between hypertensive and normotensive levels.

The healthcare team noted that the patient was becoming increasingly agitated and disoriented, even failing to recognize her own family members. She also showed signs of increased restlessness during the night, indicative of 'sundowning' - a common phenomenon in dementia patients. As a result, she was not eating or drinking adequately which could exacerbate her hyponatremia and potentially lead to dehydration. The team decided to closely monitor her fluid and electrolyte balance, and consider the need for a more aggressive approach in managing her hyponatremia and hypertension. The patient's deteriorating cognitive and physical state, coupled with her persistent fever, signaled a possible escalation of her UTI into a full-blown urosepsis which needed to be addressed immediately.