Terry Ross, RN, MSN, Winter 2012, OHSU School of Nursing, Klamath Falls

DEMENTIA CONCEPT BASED LEARNING ACTIVITY

COURSE: NRS 321 Nursing in Chronic Illness II and End of Life: Junior level baccalaureate nursing course at Oregon Health and Science University, Klamath Falls Campus.

Location: Pelican Point Memory Care which is a 48 bed facility located in Klamath Falls, Oregon which specializes in providing 24 hour care for people with Alzheimer’s and related dementia.

Time Allotted: 8 hours of clinical over a four week period (2 hours per week) and four 1 ½ hour seminars.

Supervision: A two hour orientation and tour was given by both the faculty of record and the memory care nurse. Over the next four weeks the student went independently to the facility and at times of their own choosing. The instructor was available by phone. Memory care nurse available Monday-Friday. No invasive procedures or medications given with this learning activity.

Purpose of Activity: To provide the student with an opportunity to experience a therapeutic relationship with a resident who has dementia and as a result gain a deeper appreciation of the complexity and challenging aspects in promoting safety and quality of life care for the resident.. The student will also have the opportunity to use a variety of assessment tools in order to develop a plan of care that will be individualized to the resident; evidenced based; and shared with the facility, faculty and peers.

Objectives: The following objectives provide the student with learning outcomes specific to the concept based learning activity and the NRS 321 course objectives:

  • Become more knowledgeable in dementia by observing the various types of dementia, methods of diagnosis, and recognition of the vast variations in the signs and symptoms of dementia.
  • Challenge one’s own myths, biases and fears regarding dementia and the complexity of care that is required.
  • Have the opportunity to obtain the story of a resident’s life (past and present) in order to appreciate their attributes, contributions, character and individuality as they live with their dementia.
  • Observe and interact with the staff of a memory care unit with the goal of understanding their roles; the significant contributions of the care they give; the complexity of their jobs; and potential educational needs that would enhance their care of residents with dementia.
  • Observe for changes and challenges in the resident‘s behavior during the following times and activities and suggest interventions as indicated:
  • Shower and hygiene
  • In the morning
  • In the evening close to bedtime
  • Eating a meal
  • Taking medications
  • Doing an activity
  • Perform a variety of assessments that will identify strengths, problems and concerns regarding the physical, emotional, mental, social and environmental needs of a resident with dementia.
  • Be able to identify the limitations that occur when using standardized assessment tools with this population.
  • Evaluate the resident’s current plan of care designated by the memory care staff in relationship to their assessments in order to ensure that the resident has a current and effective plan of care.
  • Identify one major problem for the resident.Develop a plan of care by performing a thorough literature search in order to provide interventions and rationale that are best practices and evidenced based.
  • Share findings of the research and interventions with the staff, resident, family, facutlyand peers as indicated and appropriate.

Flow of Learning Activity:Students are expected to make a minimum of 4 visits to the facility over the four week rotation.Below is the criteria used for each visit as well as the prep and topics for seminar.

  • Week One:“Who is this Resident”

o Before going through the chart or talking with staff about the resident, observe the resident’s appearance, interactions and behavior for about 15-30 minutes.Be sure to look at how resident responds to other residents and staff. What are they doing when staff is not present? What is the quality and nature of the staff/resident communication?

o Walk around the unit to familiarize yourself with the environment.Look at the Shadow box that is outside the room of your resident as well as other residents.Go into the room and observe the personal items and other effects that might give you a “snapshot” about who the resident is.

o Orient yourself to the facility in general.As you walk around use the Oregon Regulations for Memory Care Units pp. 11-18to evaluate how well Pelican Pointe conforms to the state standards and regulations.

o Introduce yourself to staff and let them know what resident you have.Find out from a variety of health care providers (resident aides, resident manager, RN, and Activity Director) their knowledge and impressions of the resident. Make sure to identify the status of the resident’s family involvement and support..

o Fill out the Resident Personal History form.Do this by exploring the chart, asking the resident as well as staff the questions and information suggested in this form.

o Make sure to go through the chart to determine what type of dementia the resident has, identify other co-morbidities/chronic conditions, and any other problems and concerns that are significant to the health and quality of life of the resident. Identify how the care for this resident is being financed.

o Identify what times the resident eats; days and times for showers; types and times of activities that the resident participates in; medication times etc., This will be essential in order to plan the times that you can come to accomplish the objectives for this concept based learning activity.

  • Spend some time interacting with your resident.
  • Seminar: Prep prior involved readings from text and articles related to causes and pathophysiology of dementia. Seminar took place at the Memory Care Unit with an extensive tour, discussion of CBLA and dementia facts learned from prep. The resident was assigned.

Week Two:“Cognitive/Behavioral Assessments”

  • Perform the following assessments on the resident
  • Mini Cog
  • Mini Mental (PRSQ)
  • Geriatric Depression Scale
  • Fall Risk
  • Functional Assessment/Mobility
  • Social Interaction

***The tools can be found by going to the CBLA for Dementia and clicking on Assessment Tools for CBLA.

  • Evaluate the chart and plan of care for any changes that have occurred in the past week.
  • Continue to work on Activity Observations:(meal, hygiene, medication, bedtime behaviors.)
  • Seminar: Prep was reading articles related to behavior, agitation and communications skills as it relates to dementia. Discussion was based on articles and how to assist caregivers with strategies when working with these challenging behaviors. Shared first week’s visits with their residents.
  • Week Three:“Medication and Physical /Health Assessments”
  • Perform the following assessments on the resident
  • Vital Signs
  • Brief head to toe, focusing on patients current chronic conditions
  • Skin assessment and the Braden Scale
  • Oral assessment and use the Kayser-Jones Brief Oral Assessment Tool
  • Pain (PAINAD)
  • Elimination Assessment
  • Nutritional and hydration assessments
  • List of both prn and scheduled medication. In addition perform a medication assessment using the Beers Tool

**The tools can be found by going to the CBLA for Dementia and clicking on Assessment Tools for CBLA.

  • Evaluate the chart and plan of care for any changes that have occurred in the past week.
  • Continue to work on Activity Observations:(meal, hygiene, medication, bedtime behaviors).
  • Seminar: Prep assigned were articles on medication use in older adults and dementia medications. Students brought their resident’s medication list to seminar and the group analyzed each resident’s medications using the following criteria about the actions of the medications: used to decrease progression of dementia, used to control symptoms of dementia, used in treating symptoms of dementia medications; used to treat the resident’s co-morbidities; and specific implications for nursing practice.
  • Week Four:“Resident’s Plan of Care and Wrap Up”
  • Spend time with staff:medication aide, resident assistant, resident case manager, RN and activity director in order to get a sense of their job regarding their roles and responsibilities, challenges, and limitations in caring for residents with dementia.
  • Observe and interact with other residents in the unit.
  • Evaluate the plan of care with the assessments that you have made over the last three weeks and note similarities and differences.
  • Identify one major problem for the resident. Through research provide a plan of care using best practices and evidence for your proposed interventions. Make sure that you take into consideration that the interventions are realistic and individualized to the resident.Present a written document for the staff.
  • Evaluate the chart and plan of care for any changes that have occurred in the past week.
  • Continue to work on Activity Observations:(meal, hygiene, medication, bedtime behaviors)
  • One last time do a 15 minute observation of your resident. Be sure to look at their appearance, interactions and behaviors. Note the similarities and/or differences in the resident from this observation in comparison to the first week. Identify how your perspective has changed regarding dementia and the relationship you have developed with the resident.
  • Initiate closure with the resident and the staff.
  • Seminar: Each student brought in their plan of care for the resident and one of the evidenced based articles used to develop their plan of care. Each student shared their plan of care and time was spent receiving feedback and collaboration regarding the potential effectiveness of the plan from the student group. Lastly a plan was discussed on how to share this information with the facility. Wrap up and reflections shared about the experience.

Evaluation: 2 written assignments were turned in: one at the end of week two and the other at the end of the CBLA. The written assignments consist of journaling/reflection; assessments that were done with analysis; and the plan of care with supporting evidence.