NURSING IN PATIENTS WITH DEMENTIA

Case:
Tn. B age of 79 years, live in home Werdha Budi Luhur since two years ago, the
family leave Tn. B is because the family is busy with their own affairs. Tn. B
formerly worked at the aluminum plant, the physical condition of Tn. B is currently
impaired memory and orientation. In addition the client is not able to perform nursing
devisit themselves independently but require assistance. Tn. B often forget what way
home when traveling, hard bathing, dressing, and toileting, Tn. B also often irritable
and easily upset. Previous clients have ever taken medication to PKM and diagnosed
by doctors that Mr. B suffering from dementia is a normal part of aging preses.
When study found that TD: 140/80 mmHg, S: 370C, RR: 24 x / min, N: 75 x / min.
The client looks dirty nails, body odor client, less attractive appearance, dirty and
smelly scalp, mouth odor client, the client looks incomplete teeth and dental caries
appears their clients as well as clients looked confused. Client appetite decreased, the
number of clients entering eat less than one serving, clients often eat foods that
contain lots of protein, carbohydrates, and contains calcium to maintain the health of
the client and to improve the client's nutritional status, poor chewing function. The
number of clients taking a 1000 cc / day with mineral water. The nurse said that
muscle strength declines client so that the client runs slowly, clients appear to have
stiff joints, clients seemed to use a cane, the client looks to walk carefully and muscle
strength client 4 (can be against the motion and light barriers) and lab tests.
RESULTS Hb: 9 g / dl, leukosit: 12000 mm3, trombosit 340,000 / mm3, and MMSE
examination: Clients experiencing severe dementia that is 11 with a normal range of
0-15 by weight.
A. ASSESSMENT
a. Identity Of Clients

Name
: Tn. B
Gender : Man
Age
: 79 year
Work
: Entrepreneur
Religion : Islam
Tribe
: Melayu
Address : Jambi
b. Medical History
Disease hidtory now
The client's family said that Tan. And impaired memory and
orientation, and Mr. B also often forget what way home when
traveling, hard bathing, dressing, and toileting, Tn. B also often

irritable and easily upset.

Disease history ago
Families clients said once the client had worked in the aluminum
factory. Clients never treated in hospital, never operated, never allergy
medication, eating, and clients do not have the habit of smoking,

alcohol and drugs.

Family history of disease
Client's family members did not suffer from the same disease as

clients and never suffer from other diseases.

c. Physical Examination
Sickness
client is unwell because clients impaired memory and orientation. In
addition the client is not able to do devisit nursing themselves
independently but require assistance.

Vital sign
Awareness composmentis client, the client is still in full awareness.
Blood pressure of 140/80 mm Hg, pulse 75 x / min, 37 C using axila,

RR: 24x / minute, the client looks irregular breathing patterns.

Head
Symmetrical head shape, hair color white / graying, hair loss situation,
scalp dirty and smelly.
Eye / vision

Blurred vision acuity client, white sclera and clear, isocor size, dark in
color, reaction to light miosis. Pupillary equal, and react to light,
conjunctival pallor, less clear field of vision, client vision blur when not

using the glasses.

Nose / olfactory
Symmetrical shape, the inner structure of pink, client olfactory function

less well.
Ear / hearing
Outer skin color dark brown outer ear, there are no lesions, reduced ear

skin elasticity. hearing is not good, no pain, do not use hearing aids.
d. Data Analysis
Name
: Tn. B
Age
: 79 year

No
1.

Data
DS

Cause
Physiological

officer changes
said clients often (degeneration

Nursing

irritable and easily neurons

upset
irreversible)
The nurse said
that clients often
forget their way
home

when

traveling is
DO

Problem
Thought process

Clients
impaired

seem
memory

and orientation
The client looked

confused
Examination
MMSE: the value

changes
of
is

of 11 (weight)
2.

DS

A decline in self-care deficit

Officers

said

difficult
parlors

client
bathing,

dressing

and

the ability of
taking

care

of
themselves

toileting
DO

Nails client looks

dirty
Body Odor client
Look less attractive
The scalp is dirty

and smelly
Mouth odor

and

Looks their clients

caries
B. NURSING DIAGNOSES
a. Changes in thought processes associated with the physiological changes
(irreversible neuronal degeneration) is characterized by loss of memory or
memory, loss of concentration, inability to interpret the stimulation and
assess reality accurately
b. Risks to changes in nutrition less than body requirements related to
forgetfulness, setbacks hobby, sensory changes.
c. Risks to injury associated with difficulty with balance, weakness, muscle
uncoordinated, seizure activity.

C. NURSING INTERVENTIONS
n
o
1.

Nursing diagnoses
Changes

in

Purpose

Interventions

thought After nursing actions are Independently

a. Develop a
processes associated with expected given the
supportive
the physiological changes client
is
able
to

(irreversible

neuronal recognize a change in

environmen

is thinking by KH:
Able
to
characterized by loss of
demonstrate the
memory or memory, loss

t and nurse-

degeneration)

client
relationship

of concentration, inability

cognitive ability

is

to

the

to undergo the

therapeutic

assess

consequences of

interpret

stimulation

and

reality accurately

the

stressful

events

of

emotions

the
and

thoughts of self
Ability
to
develop

strategies

to

overcome

the

presumption

of

negative self
Being able

to

the

degree

of

cognitive
impairment,

recognize

b. Assess

changes

in

such

as

thinking

or

changes in

behavior and the

orientation,

factors causing
Able to show a

attention

decline

to

in

span, ability
think.

unwanted

Talk

with

behavior, threats,

your family

and confusion

about
changes in
behavior
c. Maintain a

pleasant
and

quiet

environmen
t
d. Approach
by

way

slowly and
quietly

Risks

to

changes

in After nursing actions are Independently

a. Assess
nutrition less than body expected given the
knowledge
requirements related to client
is
able
to
of client /
forgetfulness,
setbacks recognize a change in
family
hobby, sensory changes.
thinking by KH:
about
the
Change
the
intake

need
food

patterns
Got a balanced

nutritional diet
Maintain / regain

correct

the

weight

accordingly.
Participate
activities

in
that

b. Try

for

provide
help

in

choosing
the menu

facilitate
adaptive coping.

c. Give small
meals every
hour

as

needed
d. Avoid foods
that are too
hot

Risks to injury associated After nursing actions are Independently

a. Assess the
with
difficulty
with expected given the
degree
balance,
weakness, client
is
able
to
gngguan
muscle
uncoordinated, recognize a change in
ability,
seizure activity.
thinking by KH:
impulsive
Increasing
the

level of activity
Able to adapt to

behavior

the environment

decrease in

to reduce the risk

visual

of

perception.

trauma

injury
No trauma

injury
Families identify
environmental
identify

steps to improve
it

Help
families
identify the
risk of the

potential
and

and

occurrence
of

hazards

that

may

arise
b. Eliminate
sources

of

environmen
tal hazards

c. Divert
attention
when
agitated
behavior

```D. EVALUATION

No
1

Nursing diagnoses
Changes in thought processes

Evaluation
Able to demonstrate the

associated with the physiological

cognitive ability to undergo

changes (irreversible neuronal

the consequences of the

degeneration) is characterized by

stressful

loss of memory or memory, loss

emotions and thoughts of

of concentration, inability to
interpret the stimulation and

of

the

self
Ability to develop strategies
to

assess reality accurately

events

overcome

the

presumption of negative self

Being able to recognize
changes

in

thinking

or

behavior and the factors

2

Risks to changes in nutrition less

causing
Change the correct intake

than body requirements related

to forgetfulness, setbacks hobby,
sensory changes.

Risks to injury associated with

difficulty
weakness,

with

patterns.
Got a balanced nutritional

diet.
Maintain

appropriate weight.
Participate in activities that

facilitate adaptive coping

Increasing the level of

activity
Can
adapt

balance,
muscle

recover

to

the

environment to reduce the

uncoordinated, seizure activity.

risk of trauma / injury

Do not experiencing trauma

/ injury
Families identify potential
environmental and identify
steps to improve it