Patient With Chronic Disease Case Study 2 Assessment Answer
43-year-old Sandy has been diagnosed with Alzheimer’s disease for the last 14 months and has been visiting the St. Jones rehabilitation centre in Queensland ever since. He had been smoking for nearly ten years and had symptoms of high blood pressure levels (Health Navigator, 2020). His family claimed that he started getting sensitive over many trivial matters, began to yell at his children if he found them playing around him, and sometimes he would even beat them up for doing so. They also said he started getting insecure about them and began to hide his possessions, calling them all "robbers" who wanted to steal his "property" (NIA, 2020). Apart from that unusual behaviour of constant irritation, when his family started noticing how Sandy began to forget the most recent happenings, sometimes events that were not even as old as a day, they got anxious. Upon their visit to a neurologist, they discovered that Sandy had been diagnosed at the early stages of the chronic disease Alzheimer's. The purpose of this paper is to describe the pathophysiology of the disease, discuss its care priorities using the Levitt Jones' Clinical Reasoning Cycle and plan a proper health education for the same, and lastly explain pharmacokinetics of Sandy's medication.
Alzheimer's disease is chronic and incurable because of which the patient starts facing neurodegenerative disorders which causes him to go through behavioural and cognitive changes (Medscape, 2019). Although the patient goes through some prolonged clinical treatment for this disease, there is no permanent cure for it, and it only helps to keep the current situation of the patient consistent at most (MSD, 2020). Alzheimer's has different effects on different individuals as it depends on the two factors: extracellular beta-amyloid deposits which happen in senile plaques and the intracellular neurofibrillary tangles which occur in paired helical filaments (MSD, 2020). Out of the two, plaques are denser because of their insoluble protein deposits and cellular material around the neutrons, and they are made up beta-amyloid which are fragments of larger proteins – APP (amyloid precursor protein) (Medscape, 2019). [Please refer to Appendices A and B].
On the other hand, tangles are twisted fibres, insoluble as well, which build up inside the nerve cells that indicate symptoms of this dementia (MSD, 2020). Both these beta-amyloid depositions and neurofibrillary tangles cause damage to the temporal lobe of the brain, which further develops into the disease. However, the exact cause of this phenomenon is still unknown to humanity, and there are just some hypothetical theories to support the justifications (MSD, 2020). Out of all the theories, the most common theory that has been used to support a majority of the work on the pathophysiology of Alzheimer's disease is the amyloid hypothesis. This hypothesis has mainly laid out five predictions to support its statement which is: all the causes of the disease relate to the amyloid production and clearance; the amyloid/Aβ is toxic; the amyloid/Aβ causes the tangle dysfunction; the tangle dysfunction is associated with the cause of neuronal cell death and; reducing the amyloid/Aβ and plaques will help in improving the symptoms of the disease (Hardy, 2009). [Please refer to Appendix C].
While dealing with Alzheimer patients, there are several care priorities that the nurses need to follow, the first and the most essential importance being to keep the patient under supervision at all times. The caregivers must check if the patient is not delusional, is putting on the appropriate behaviour, if the surroundings around him or the actions he is doing are safe for him as his well-being is the primary concern of a caregiver (Nurselabs, 2019). The second priority is orienting the patient in which they have to continually orient the patient to reality and keep familiar objects around them for assistance. It is essential to orient the patient with the time frequently, the place they are in, and the people around as it will help keep the patient grounded to reality (Nurselabs, 2019).
For the next part, we will use the Levitt-Jones’ Clinical Reasoning Cycle to justify the first two care priorities of Sandy. This comprehensive concept is not a stepwise or phase-wise moving concept but something that is interdependent on all the phases unless equilibrium is reached in assessing the patient's health conditions (European Heart Association, 2020). The first phase of this cycle is considering the facts from the patient’s situation (European Heart Association, 2020). Sandy is a 43-year-old man who lives with his wife, younger sister, and two children who have been diagnosed with the disease for the last 14 months and has been visiting the rehab centre ever since. The second phase is the collection of information (European Heart Association, 2020). Sandy has been a rigorous smoker for the last ten years and has had high blood pressure problems. His vital signs have normalized than before; however, due to his newly developed short temper, his blood pressure rises very quickly because of which he feels fatigued now and then sometimes. The third phase is processing the gathered information (European Heart Association, 2020). For this phase, Sandy’s medical information has been assessed by an expert physician who checked his pathophysiological and pharmacological patterns to identify the necessary and relevant details about Sandy, which will be the major factors of consideration for any decisions that need to be made. The fourth phase is identifying the problem (European Heart Association, 2020). After many clinical tests were conducted, Sandy's leading cause of his current state has been identified. The fifth phase is establishing goals; the sixth is taking action, the seventh is evaluation, and the last and eighth phase is a reflection which is all associated with making a nursing care plan for Sandy. [Please refer to Appendix D].
The caregivers need to keep Sandy under supervision at all times as Sandy doesn't like staying at one place for too long and keeps off wandering now and then. Sandy had been an avid traveller and loved travelling, and ever since he has been forced to stay at the rehab centre regularly, he tries to force his wife or sister who accompanies him sometimes, to give him the car so he can drive away. Once, he even crashed into some street lamp. However, he wasn't injured. Therefore, it is essential to see that Sandy doesn't wander off on his own and is looked after as much possible. It is also necessary to constantly orient Sandy with real-time, place, and surroundings. Sandy's condition has worsened a bit over the months, and sometimes he forgets where he is in less than 10 hours which makes him insecure and violent around his caregivers sometimes.
For the selected care priorities, the following table depicts the recommended health education plan for Sandy (Alzheimer’s Association, 2020):
|Time sense||Sandy will sleep at night and eat his meals at the appropriate times.||The lights will be kept off at night. Frequent snacking will be avoided for Sandy, and he will be fed healthy meals at proper times.|
|Communication||Sandy will communicate with everyone without feeling insecure or aggressive.||Sandy will be made to practice to read, write, and communicate both verbally as well as with gestures. He will also be made to spend more time with his family under supervision so he can communicate with them.|
|Weight loss||Sandy will maintain a healthy weight and body||Sandy will be indulged in peaceful yet physically labouring activities such as gardening, walking, simple cardio exercises and will be made to eat healthy meals on time.|
|Loss of fear||Sandy will be more fearless around people he knows and will stop suspecting them||Sandy will be made to participate in self-validation activities with positive feedback. He will also frequently encounter people he is familiar with, so he can be himself around them and not feel insecure.|
Sandy primarily takes the two prescribed medications, which are galantamine and memantine. Galantamine is a selective acetylcholinesterase inhibitor whose pharmacokinetics are different from that of memantine as it modulates the presynaptic nicotinic receptors of the brain and has at(1/2) of 6-8 h. It specifically works with the isoenzymes CYP2D6 and CYP3A4 to help stabilize cognitive behaviour (Farlow, 2003). Memantine, on the other hand, is more of an antagonist of the N-methyl-D-aspartate (NMDA) receptor with at(1/2) of 70, which is a glutamate receptor, with low affinity and does not compete with other enzymes. Its route of elimination is via kidneys (Noetzli & Eap, 2013) which is the primary mechanism of blocking the current flow through the NMDA receptor channels (Johnson & Kotermanski, 2006). This modulation of the NMDA receptors alters the excitation of the neuronal circuits, which will enormously help in improving Sandy's memory, attentiveness, and performance of simple tasks (Alzheimer's Association, 2020).
On a concluding note, Sandy's caregiver should be holistic with their approach as he is well below the age to be diagnosed with such a painful disease. Therefore, there should be all efforts to help him enjoy life and live as normally as he can. The caregiver should follow proper ethics and be attentive towards Sandy’s rehabilitation.