ADAMSON UNIVERSITYCollege of Nursing900 San Marcelino Street, Ermita, 1000 Manila

In Partial Fulfillment of Requirements in NCM 325:Hospice Palliative Care

A CASE STUDY ON DEMENTIA

Submitted By:

1

John Michael R. OpolintoBSN 301

Submitted To:Mrs. Teresita Flores Merin, MPH, RNProfessor

March 26, 2015

TABLE OF CONTENTS

I.OBJECTIVES OF THE STUDY2II.INTRODUCTION2a.Definition of Case2b.Etiology2c.Incidence3d.Theoretical Framework3III.CLIENTS PROFILE3a.Client Data3b.Nursing History41.Chief Complaint42.Present Medical History43.Past Medical History44.Family History55.Developmental History56.Physical Examination10IV. ANATOMY AND PHYSIOLOGY30V. PATHOPHYSIOLOGY45VI. THE ACTIVITIES-SPECIFIC BALANCE CONFIDENCE (ABC) SCALE46VII. DRUG STUDY48VIII. NURSING CARE PLAN49IX. IMPLICATIONS OF THE CASE STUDY50X. BIBLIOGRAPHY51

I. OBJECTIVES OF THE STUDYThe student nurse will be able to: Participate in the course of care of client. Provide health teachings to the client about certain interventions in the maintenance ofhealthcare. Establish rapport and therapeutic interaction with the client and significant others to obtain necessary information and positive compliance to care being provided. Provide health teachings necessary forthe palliative care of theclient from the condition. Share the learning acquired to co-student nurses to increase awareness and helpthem if ever they will encounter a client with the same condition.

II. INTRODUCTION

a. Definition of CaseAccording to PubHealth, dementia is a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. It is a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.

b. EtiologyDementia is caused by damage to brain cells.This damage interferes with the ability of brain cells to communicate with each other. When brain cells cannot communicate normally, thinking, behavior and feelings can be affected.

The brain has many distinct regions, each of which is responsible for different functions (for example, memory, judgment and movement). When cells in a particular region are damaged, that region cannot carry out its functions normally.

c. IncidenceThe numbers and statistics surrounding dementia are staggering. Worldwide, there are now an estimated 24 million people living with some form of dementia. Without a major medical breakthrough in the fight against dementia, this number could jump to as many as 84 million who have age-related memory loss by the year 2040 (DisabledWorld). Most people with dementia live in developing countries: 60% in 2001 rising to 71% by 2040 (Alzheimers Disease International). In a research done in 2004, there were an estimated 116,781 cases of dementia over 86,241,697 of the total population in the Philippines.

d. Theoretical FrameworkPerson-centered care focuses on the individualneeds of a person rather than on efficienciesof the care provider; builds upon the strengthsof a person; and honors their values, choices,and preferences (McCance, McCormack, andDewing, 2011; Edvardsson, Fetherstonhaugh, andNay, 2010; Brooker, 2007; McCormack andMcCance, 2006; McCormack, 2003; Kitwood,1992). A person-centered model of care reorientsthe medical diseasedominated model of carethat can be impersonal for those oriented toholistic well-being that encompasses all fourhuman dimensions: bio-psycho-social-spiritual.

III. CLIENTS PROFILEa. Client Data1. Clients Initials: I.T. 10. Date of Interview: March 20,20152. Address: Malate, Manila 11. Primary Informant: Client I.T.3. Age: 78 years old 12. Secondary Informant: Daughter4. Birth Date: June 29, 1936 5. Birth Place: Aklan 6. Gender: Female 7. Civil Status: Widowed 8. Religion: Roman Catholic9. Highest Educational Attainment: College undergraduate

b. Nursing History1. Chief ComplaintAccording to client I.T.s daughter, she has a chief complaint of being forgetful and does not remember recent activities.

2. Present Medical HistoryAccording to clients daughter, client I.T. started to be forgetful a year ago. They did not consult a doctor about it because they thought it was because client I.T. is already old. There was once an incident that client I.T. took a jeepney but passed by her destination. She is not allowed to go out alone. During the interview, client I.T. gave relevant answers but there were information given by her that are not true as the interviewer confirmed to her daughter.

3. Past Medical HistoryShe cannot remember if she had completed her immunization during childhood. Client I.T. had chicken pox and measles. However, she cannot remember when it was. There were times that she fell and her head bled.

The client also verbalized that she takes over the counter drugs for fever, cough and cold; she directly consults her doctor for serious illness and comply with her doctors order. She prefers to go to professional doctors than quack doctors. She also takes herbal medicine like lagundi.

According to client I.T., she has never been hospitalized. Client I.T. has no vices. She is hypertensive. According to her, she takes Losartan daily. She takes it in the morning after eating breakfast. She also has increased uric acid, so she does not usually eat meat and legumes. According to client I.T., she has medicine whenever she experiences pain on her joints especially on her knee though she cannot remember the name of the medicine.

Halos isa at gulay gaya ng kangkong lang ang pwede sakin, kasi pag kumain ako sasakit ang tuhod ko. as verbalized by client I.T.

4. Family History

Died during the World War

Heart AttackHypertension

Kidney failure; DM

Interpretation:As illustrated in the diagram, clients parents are both dead. They have history of hypertension and diabetes mellitus. Her mother died but the client cannot remember the reason of her death. The client is the only child. She has eight children. Her first son died because of diabetes mellitus and kidney failure as complication. Other children are well and alive.

5. Developmental History

Jean Piagets Cognitive Theory of DevelopmentJean Piaget is a Swiss psychologist who introduced concepts of cognitive development that are similar to Freud and Erikson and yet separate from each. Piaget defined four stages of cognitive development. Each period is an advance over the previous one. To progress from one period to the next, the child recognizes his or her thinking process to bring them closer to reality.

Life StageCharacteristics/ DescriptionAnalysis/Justification

1. Sensorimotor

Simple Reflexes Birth-6weeks Coordination of sensation and action through reflexive behaviors. Three primary reflexes are described by Piaget: sucking of objects in the mouth, following moving or interesting objects with the eyes, and closing of the hand when an object makes contact with the palm (palmar grasp). Over the first six weeks of life, these reflexes begin to become voluntary actions; for example, the palmar reflex becomes intentional grasping.)The client was not observed to have difficulty in terms of hand and eyes coordination. She can easily grab the objects that were asked her to get and also was able to eat and shallow without difficulty. Due to her age, she seldom has hand tremors but it does not hinder her to still perform house chores.

First habits and primary circular reactions phase 6weeks-4months

Coordination of sensation and two types of schemes: habits (reflex) and primary circular reactions (reproduction of an event that initially occurred by chance). Main focus is still on the infant's body. As an example of this type of reaction, an infant might repeat the motion of passing their hand before their face.

The client was not observed having habitual actions. During the interview, the client was simply sitting with her hands in her knees.

Secondary circular reactions phase 48months Infants become more object-oriented, moving beyond self-preoccupation; repeat actions that bring interesting or pleasurable results. This stage is associated primarily with the development of coordination between vision and pretensions. Three new abilities occur at this stage: intentional grasping for a desired object, secondary circular reactions, and differentiations between ends and means. At this stage, infants will intentionally grasp the air in the direction of a desired object, often to the amusement of friends and family. Secondary circular reactions or the repetition of an action involving an external object begin; for example, moving a switch to turn on a light repeatedly. The differentiation between means and ends also occurs. This is perhaps one of the most important stages of a child's growth as it signifies the dawn of logic.During the interview, the client stated that she usually sweep their street every morning, she verbalized that it gives her pleasure when doing this. She does not miss a day without doing the chores.

Coordination of secondary circular reactions stages 812months Coordination of vision and touch--hand-eye coordination; coordination of schemes and intentionality. This stage is associated primarily with the development of logic and the coordination between means and ends. This is an extremely important stage of development, holding what Piaget calls the "first proper intelligence." Also, this stage marks the beginning of goal orientation, the deliberate planning of steps to meet an objective.

Despite of her age, the client was still active as the head of BHW or Barangay Health Workers in their neighborhood. According to client, she still attends to meetings and was able to participate in the activities of their organization. As observed during the interview, although the she does not remember some of the events that were asked to her and disoriented in date, she was rational in some of her answers.

Tertiary circular reactions, novelty, and curiosity 1218months Infants become intrigued by the many properties of objects and by the many things they can make happen to objects; they experiment with new behavior. This stage is associated primarily with the discovery of new means to meet goals. Piaget describes the child at this juncture as the "young scientist," conducting pseudo-experiments to discover new methods of meeting challenges.During the interview, the client was able to ask questions to the student and seems a little intrigued since it was the first time she was able to meet the student.

Internalization of Schemes 1824months Infants develop the ability to use primitive symbols and form enduring mental representations. This stage is associated primarily with the beginnings of insight, or true creativity. This marks the passage into the preoperational stage.During interview, the student has not noticed any rituals or symbolic presentation of her thoughts.

2. Preoperational Thought (2-7 years old) The hallmark of the preoperational stage is sparse and logically inadequate mental operations. During this stage, the child learns to use and to represent objects by images, words, and drawings. The child is able to form stable concepts as well as mental reasoning and magical beliefs. The child however is still not able to perform operations; tasks that the child can do mentally rather than physically. Thinking is still egocentric: The child has difficulty taking the viewpoint of others.The client can identify the objects that are presented to her. She also knows where and how to use them. As part of the interview, the client was able to describe certain objects that were asked her to visualize.

3.Concrete Operational Thought (7-12 years old) Concrete operations include systematic reasoning. Classifications involve sorting objects according to attributes such as color; seriation, in which objects are ordered according to increasing or decreasing measures such as weight; multiplication, in which objects are simultaneously classified and seriated using weight. Child is aware of reversibility, an opposite operation or continuation of reasoning back to a starting point.The client was able to determine the colors and sizes from larger to smaller during the interview. She was able to reason out her answers whenever her children contradict her responses.

4.Formal Operational Thought (12 yrs. old) Can solve hypothetical problems with scientific reasoning; understands causality and can deal with the past, present, and future. The client was a college undergraduate. She was also the current president of the BHW or Barangay Health Workers in their neighborhood. According to her, she still participates in discussions and planning of activities in their organization.

6. Physical Examinationi. Anthropometric DataHeight: 172.7 cm Weight: 63 kgBody Mass Index: 21.1 cm/kg *(normal weight)

*According to World Health Organization, Body Mass Index normal standard is 18.5-24.9.

ii. General Appearance

Client I.T. is a 78 year old female. She has a mesomorph type of the body and has light body built. She has a good posture and can stand still unless she feels dizzy. She can walk without the assistance. Client I.T. looks clean and neat. She has no any foul odor. Client I.T. does not look pale and weak. She was cooperative in answering what was asking to her thought. The client was easily to have a conversation with the interviewer. The clients quality of speech is comprehensible. The arrangements of conversation are that precise. Client I.T.s vital signs were taken and recorded during the assessment. Her vital signs were as follows. Blood pressure of 140/70 mmHg, temperature was 36.5C, her respiratory rate was 21 cycles/minute and pulse rate of 83 beats/ minute.

iii. Review of Systems

Body Part ExaminedReview of SystemActual FindingNormal FindingClinical Significance

INTEGUMENTARY SYSTEM

Syempre hindi na gaya ng dati, laylay na ang balat ko lalo na ditto sa may braso. As stated by the client.Inspection:-dryness of the skin-decreased elasticity of the skin especially in the face and arms-presence of moles on face-with wrinkles-no rashes

Palpation:-Rough and dry skin on both upper and lower extremities-temperature: 36.5 C*Dry skin is common.*Decreased elasticity of the skin.*Facial wrinkles are prominent. *Hyperpigmentation occurs in skin exposed to sunlight, manifests as brown pigmented areas called lentigenes (age spots)*Dermatologic lesions are common in the elderly but many are benign.

*Decrease in eccrine, sebaceous and apocrine glands function causes the common complaint of dryness.*Gradual replacement of elastic collagen with more fibrous tissue and loss of subcutaneous tissue.*Because of subcutaneous fat decreases with age, wrinkles are visible.*Hypothermia is due to decreased vascularity and loss of subcutaneous tissue.

HairPuro puti na nga ang buhok ko eh. As stated by the client.Inspection:-grayish to white in color-no signs of infestation-short hair-fine dry hair-Dry scalp*Loss of hair pigment is the cause of graying.* Scalp, axillary and pubic hair gradually becomes thinner and coarser.*Somewhat transparent, pale, skin with an overall decrease in body hair on lower extremities.*Hair color begins to gray with age, initially appearing during the third decade of life, when the loss of melanin begins to become apparent.

NailWala naman akong problema sa mga kuko ko. as stated by the client.Inspection:-hard and fine in texture-nails are short and clean-Pale color of nail bed*Toenails usually thicken, but fingernails may become thin and split. They may also appear yellowish and dull.

Paleness of the nail bed or skin can also be caused by environmental and dietary factors, such as cold temperatures and dehydration.

Eyes and Vision

Eyebrows

Eyelashes

Eyelids

Lacrimal gland sac, nasolacrimal duct

PupilHindi pa malabo ang mga mata ko. As stated by the client.Inspection:-Pupil size: 3mm-20/20 vision-dry

Palpations:- no nodules- no masses

Inspection:-few hair in the eyebrows-limited movements-Symmetrical-grayish to white in color

-eyelashes are black in color-Turned outward.

-loss of skin elasticity-decreased muscle tone with wrinkles-with eye bags

Inspection/Palpation-pale-no tearing

Inspection:- 3mm in size-minimal response in light-Pupil dilation*Dryness of the eyes is common among elderly clients.

* Upper lid may limit peripheral field of vision and may produce a feeling of heaviness and tired appearance.

*Loss of hair pigment is the cause of graying.

*Decreased elasticity and tone of the eyelids tend to drop the lids and cover the eyes.

*Lower eyelid forms bags.

*Decreased tear production by the lacrimal gland often results in dry eyes.

*Decreased in size and its ability to dilate in the dark.

*Decreased tear production by the lacrimal gland often results in dry eye

*Hair color begins to gray with age, initially appearing during the third decade of life, when the loss of melanin begins to become apparent.

The finding is normal.

*Eyelid skin is the thinnest skin of the body; it tends to stretch over time.

*With age, the overall size decrease in the size of the pupil and its ability to dilate in the dark

Ears and HearingExternal canal

Internal canalMahina na ang pandinig ko. As stated by the client.Inspection:-Earlobes are elongated in shape-presence of mole on left earlobe-no lesions, nodules, discharges-dry ears-decreased ability to hear sounds in both ears

Palpation:- no tenderness-soft

Inspection:-No found cerumen-no discharge or lesions*Elongated earlobes. Pinna increases in length and width.*Common type of hearing loss associated with aging is called presbycusis.

*Decreased cerumen production

*Cerumen production decreases leading to dryness.*Diminished ability to hear high-frequency sounds due to degeneration in the hair cells of the inner ear.

The finding is normal.

Nose and Sinuses

Nasal Mucosa

Maxillary and frontal sinusesWala naman akong problema sa pang-amoy. As stated by the client.Inspection:-slightly moist-no swollen sinuses-no masses or tenderness-symmetric

Inspection:-no redness in nasal mucosa-no discharge or swelling

Palpation:- no masses- no tenderness

- no tenderness in palpating*Olfactory function gradually decreases with aging and may lead to a decreased ability to detect odors.

*Diminished smell, however may lead to a decline appetite.

*Nasal hairs are coarser and may not filter air well.

The finding is normal.

The finding is normal.

Mouth/Oropharynx /Lips

Gums

Tongue

Palate

UvulaOkay naman ang paglunok ko. as stated by the client.Inspection-symmetric-lips are pale in color-Dry mouth and lips-with dentures-no nodules or masses-no mouth sore-with positive gag reflex

-pale brown in color (gums)-no bleeding - no retraction- no swelling

-no lesions-no mass

-no presence of bony prominence-no lesion

-in the midline *Decrease in saliva production with aging.*Tooth loss may be observed*Dry mouth (xerostomia)*Esophageal motility is slower and more disorganized.

*The gums recede; become ischemic

*hard palate is concave

*Use of Anticholinergic can cause dry mouth

*Tooth surfaces may be worn from prolonged use. These changes make the older client more susceptible to periodontal disease and tooth loss.

*The gums recede, become ischemic and undergo fibrotic changes as a person ages.

*The finding is normal.

Neck

ThyroidInspection:-symmetrical-no mass-no nodules

-symmetrical*Cervical curvature may increase because of kyphosis of the spine.

*The finding is normal.

RESPIRATORY SYSTEMThorax and Lungs

Anterior Thorax

Hindi naman ako nahihirapan huminga. As stated by the client.Inspection:-effortless in respiration-3 dark spots on cervical area approx. 0.5cm-RR 21cpm-Diaphragmatic excursion: 3cm

Palpation:-Symmetric excursion-equal expand-no tenderness-no masses-no pulsation

Auscultations:-no abnormal breath sound-no auscultated crackles

*Use of accessory muscle when breathing.*Barrel chest

*The finding is normal.

CARDIOVASCULAR SYSTEMHeartBasta ang sakit ko lang, hilo. Umiinom ako ng losartan tuwing umaga.As stated by the client.Inspection-Pulse rate 83 bpm: -BP 140/70 mmHg-regular rhythm

Auscultation:-no murmur*Pulse rate: 80bpm (60~100bpm)*Blood pressure in elderly may have possible higher diastolic.

*The heart undergoes an increase fibrotic tissue and a decrease in elastic tissue.

*Both systolic and diastolic pressures rise with age due to a loss of elasticity of the aorta and arteries. There are generally increase in the systolic pressure, resulting in a widening of the pulse pressure.

GASTROINTESTINAL SYSTEMAbdomen

Wala naman akong problema sa tiyan ko. as stated by the client.Inspection:-natural brown color of skin-no lesions-no rashes-rough skin

Palpation:-no mass

*The occurrence of lactose intolerance increases with age and may result bloating, abdominal discomfort and increased flatus.

*Rough skin might due to dehydration

Musculoskeletal SystemUpper ExtremitiesFeatures

Range of Motion

Lower ExtremitiesFeatures

Range of Motion

Kayang kaya ko pa. Nakakapagwalis pa nga ako ng buong paligid namin. as stated by the client.Inspection:-symmetric structure and development of muscles-no masses-decreased muscle tone-decreased muscle strength on both arms

-hyperextension, 30; adduction 20; flexion 160; extension 180

Palpation:-arm has a cold temperature

Inspection:-no lesions-no ulcer-decreased muscle tone and strength-hip flexion with knee flexed 80; hip flexion with knee straight 75; hyperextension 5*Decreased muscle tone*Decreased muscle strength*Tendons shrink and sclerose that causes muscle cramping

*Poor range of motion may be related to muscle atrophy and weakness

*Poor range of motion may be related to muscle atrophy and weakness

*Decrease in type II muscle fibers accompanied by an increase in small type I fibers also contributes to muscle atrophy with aging.*Loss of muscle strength attributable to aging should be the same on both left and right sides.*Muscle atrophy and weakness are accompanied by limited range of motion.

*Hypothermia is due to decreased vascularity and loss of subcutaneous tissue.

*Muscle atrophy and weakness are accompanied by limited range of motion.*Hypothermia is due to decreased vascularity and loss of subcutaneous tissue.

*Swollen joints may indicate arthritis or inflammation of the joints.

iv. Gordons Functional Health Patterns

a) Health Perception- Health Management PatternClient I.T. has a great view in life. She considers herself as healthy individual in terms of physical condition. She added that she can do anything such as household chores. She also admitted that she is experiencing some cognitive impairment and hypertension. She tends to forget things as she verbalized nakakalimutan ko na ang ibang bagay lalo na kung saan ko naiilagay.

She uses any herbal medications such as lagundi for cough and currently taking her maintenance, Losartan once a day after breakfast for her Hypertension. According to her second informant, her daughter R.E., client I.T. has monthly check up with the Barangay Health Center and sometimes in the hospital. She prefers to go to professional doctors than quack doctors because she is a volunteer in the Barangay Health Center and current president of the organization.

b) Nutritional-Metabolic Pattern3-Day Diet RecallMEALSMarch 18, 2015(Wednesday)KilocalorieMarch 19, 2015(Thursday)KilocalorieMarch 20, 2015(Friday)Kilocalorie

Breakfast (6am)1 serving of rice2 ham1 glass of milk2 glasses of water100 kcal172 kcal110 kcal1 serving of rice1 hardboiled egg1 hotdog3 glass of water100 kcal86 kcal122 kcal1 serving of rice1 longganisa 3 glass of water1 pc banana and 4 slices pakwan100 kcal

100 kcal45kcal

Snacks1 biscuit 1 glass of juice140 kcal30 kcal

1 pc of puto1 glass of juice 180 kcal30 kcal1 serving of Arroz caldo with chicken and 1 hardboiled egg1 glass of soft drinks 386 kcal200kcal

Lunch (12 nn)1 serving of rice 1cup gulay (leafy)3 glass of water100 kcal60kcal1 serving of rice Sinagang na Isda 2 glass of water 100 kcal

247 kcal

1 serving of rice,Ginisang mais and 1 Fried chicken leg with 2 glass of water100 kcal35kcal185 kcal

Dinner (5 pm)1 serving of ricefish (paksiw)1 glass of water100 kcal140 kcal1 serving of rice 1 cup gulay1 glass of water 100 kcal1 serving of rice Tuyo Toge 1 glass of water100 kcal45kcal80 kcal

Total :Fluid Intake1760 mlKilocalorie9521760 mlKilocalorie9651760 mlKilocalorie1381

According to her, clients appetite was good. She likes vegetables and fruits. She prefers to eat fish than meat. She also mentioned that she eats biscuits for snack. She drinks eight glasses of water a day and 1 glass of milk every morning. Client I.T.s fluid intake in her 3-day diet recall is 1760 ml of water daily. Client I.T.s fluid intake is normal. Her caloric intake ranges from 952 to 1381, is balanced to her daily needs. Upon taking client I.T.s BMI, it was found out that she is in normal weight.

c) Elimination PatternShe eliminates depending on the food she eats. Usually, if it is vegetables and fruits, its twice but if she eats meaty foods, she defecates only once a day. In terms of voiding, she approximately urinates 800 to 1000 mL of urine in a day. She also mentioned that she can urinate three times a day. She has a soft, formed brown to dark stool. She defecates approximately 1-2 times/day and does not feel any discomfort in defecating.

According to Weber and Kelly, the normal defecation pattern of an adult is (3) or lessen times/day and a urine amount of 30 cc per hour.

d) Activity- Exercise PatternClient I.T. is currently a barangay health worker for almost thirty years and president of the organization for almost thirty two years. She assists in taking blood pressure and calling for the clients. She also helps in general barangay survey about maternal and child health conditions.

7-Day Activity TableTimeDays of the week & date

Mar 13Mar 14Mar 15Mar 16Mar 17Mar 18Mar 19

1am2 am

3 am

4 am

5 am

6 am

7am

8 am9 am

10 am 11 am

12 nn

1 pm 4 pm

5 pm

6 pm 7 pm

8 pm12 mn

Waking upEating Bathing Boiling water and helping in cookingSleepingRelaxingResting

Transporting to mallWatching movieAssisting in health centerChatting with friendsCleaning the streetGoing to churchWatching TV

Legend:

She wakes up at 5am to eat breakfast and drinks coffee and does some morning rituals like walking in their backyard and cleaning their street and takes a rest and sleeps at about 8 in the evening. She still has active way of living.

KATZ indexActivitiesIndependence = 1 pt.Dependence = 0 pt.

Bathing1

Dressing1

Toileting1

Transferring1

Continence1

Feeding1

Total Points:6

Client I.T. was able to do her activities of daily living such as bathing, dressing, toileting, transferring, continence and feeding without the assistance of any health care provider. Using the Katz Index of Independence in activities of daily living, it shows that client I.T. is basically independent.

e) Sleep-Rest Pattern Client I.T. used to have 6 to 8 hours of sleep. She does not have difficulty in falling asleep. She does not use any medication to fall asleep and she does not even have any bed time rituals. According to her she feels rested upon waking up and she has enough rest periods during the day.

According to Weber and Kelley, the optimal sleep duration for adults is approximately 6-8 hours.

f) Cognitive-Perceptual PatternAccording to client I.T., she has no problems in his vision with grade of 20/20 and her daughter also added that kaya pa ni nanay magpasok ng sinulid sa karayom at malinaw pa ang mata ni nanay. Her hearing ability is not in good condition because her both ears have a negative result in whisper test (1-2 feet distance). During the conversation, the student should speak louder for her to respond. However, her smell and taste preferences have not been changed.

She was able to express her feelings and thoughts verbally and through body language but there are times that she forgets some words and cannot complete the sentence. She also forgets some of her short and long term memory. When she asked about her children, she was not able to answer the names in chronological order. She also forgets some special occasions in their family like wedding anniversary, exact date of death of her husband, etc.

In assessing her short term memory, she got five errors in Short Portable Mental Status Questionnaire by Pfeiffer which means she has moderate intellectual impairment. Her family is not permitting her to go far places alone because there are circumstances that she was not able to reach her destination properly. And they are not giving her money because the client was not able to recall where she placed it.

Client reported headaches occuring every morning. Using a Verbal Descriptor Scale (VDS) to gauge it as Severe Pain. May panahon na sobrang sakit ng ulo ko as stated by the client.

g) Self-Perception- Self- Concept PatternMalakas naman ako, makakalimutin lang at sakit ng ulo. Kaya ko pa, kaya ko pa! as stated by the client. She was aware of her condition but shes trying to be physically powerful than she is. The client was self-conscious especially when the student has performed the physical assessment. She depicts simplicity on her looks and actions.

h) Role Relationship PatternClient lives with her family in their house. Client I.T. is a mother of 5 men and 3 women; 4 have their own family, 1 is working abroad, 1 died and 2 is living with her. According to her daughter her mother is a responsible and caring person because she does everything for the sake of her family.

Currently, her daughter is the one who is taking care of to her. According to her, she is happy because she had raised her family well and they were in a good condition. She also has six grandchildren who are always visiting her every day. May apo narin ako sa tuhod. as stated by the client and she seems contented. But because of her age and her health condition she tends to forget some of her family members names which lead to misunderstanding.

The client I.T. is a barangay health worker and current president of the organization. She was called nanay by her co-workers and treats them as a family. She gives pieces of advice to them and corrects their wrong doing. She was very supportive and helpful to them. She also attends to church every weekend and she has a good relationship with the community.

i) Sexuality- Reproductive PatternClient I.T. is 78 years old and her husband died last 1987. She said that she is satisfied with her sexual relationship with her loving husband back then. The client had her postmenopausal period when she was 45 years old. The client had her first menstruation at the age of 12 when she was at her first year high school level. She stated that she was able to use at least 2 napkins per day and it is always on a regular blood flow. Moreover, she has a twenty eight (28) up to thirty (30) day cycle.

She has an OB score of G8 P8- T8 P0 A0 L8. She had her delivery on her eight kids on Normal Spontaneous Delivery (NSD) in term and had no abortion.

j) Coping Stress PatternShe seeks help from greatest Almighty Father for every problem in her life and feels relieved. Nanonood din ako ng telebisyon para mawili, as stated by the client. Aside from watching TV, the client has other way of relieving her stress by sharing it to her daughter. She does not take medications to relieve her stress.

k) Value-Belief PatternThe client believes first and foremost to God which He exists, He guides us and for every struggle in life that came, He is just testing our faith. Client always attends the mass every Sunday and seeks for guidance as she verbalized lagi ako nagsisimba tuwing Linggo ng umaga. For her, God and her family are the most important persons in her life that she wont trade for anything in this world.

She does not believe in any superstitions. As a health care provider in their barangay, she practices proper caring for ill family members. She also follows the doctors advice and properly drinks her medication. She also believes in hilot and herbal medicine as one of their primary health care access.

Client I.T. also practices the values such as respect for the people around her most especially in elderly age and she teaches the young generation to behave properly. She also practices hospitality and gratitude. During the interaction with the client, she offers anything to the visitor.

IV. ANATOMY AND PHYSIOLOGYThe human brain serves many important functions ranging from imagination, memory, speech, and limb movements to secretion hormones and control of various organs within the body. These functions are controlled by many distinct parts that serve specific and important tasks. These components and their functions are listed below.

Brain Cells: The brain is made up of two types of cells: neurons (yellow cells in the image below) and glial cells (pink and purple cells in the image below). Neurons are responsible for all of the functions that are attributed to the brain while the glial cells are non-neuronal cells that provide support for neurons. In an adult brain, the predominant cell type is glial cells, which outnumber neurons by about 50 to 1. Neurons communicate with one another through connections called synapses.

Meninges: The bony covering around the brain is called the cranium, which combines with the facial bones to create the skull. The brain and spinal cord are covered by a tissue known as the meninges, which are made up of three layers: dura mater, arachnoid layer, and pia mater. The dura mater is a whitish and nonelastic membrane which, on its outer surface, is attached to the inside of the cranium. This layer completely covers the brain and the spinal cord and has two major folds in the brain that are called the falx and thetentorium. The falx separates the right and left halves of the brain while the tentorium separates the upper and lower parts of the brain. The arachnoid layer is a thin membrane that covers the entire brain and is positioned between the dura mater and the pia mater, and for the most part does not follow the folds of the brain. The pia mater, which is attached to the surface of the entire brain, follows the folds of the brain and has many blood vessels that reach deep into the brain. The space between the arachnoid layer and the pia mater is called the subarachnoid space and it contains thecerebrospinal fluid.

Cerebrospinal Fluid(CSF): CSF is a clear fluid that surrounds the brain and spinal cord, and helps to cushion these structures from injury. This fluid is constantly made by structures deep within the brain called the choroid plexus which is housed inside spaces within the brain called ventricles, after which it circulates through channels around the spinal cord and brain where is it finally reabsorbed. If the delicate balance between production and absorption of CSF is disrupted, then backup of this fluid within the system of ventricles can causehydrocephalus.

Ventricles: Brain ventricles are a system of four cavities, which are connected by a series of tubes and holes and direct the flow ofCSFwithin the brain. These cavities are the lateral ventricles (right and left), which communicate with the third ventricle in the center of the brain through an opening called the interventricular foramen. This ventricle is connected to the fourth ventricle through a long tube called the Cerebral Aqueduct.CSFthen exits the ventricular system through several holes in the wall of the fourth ventricle (median and lateral apertures) after which it flow around the brain and spinal cord.

Brainstem: The brainstem is the lower extension of the brain which connects the brain to the spinal cord, and acts mainly as a relay station between the body and the brain. It also controls various other functions, such as wakefulness, sleep patterns, and attention; and is the source for ten of the twelvecranial nerves. It is made up of three structures: the midbrain, pons and medulla oblongata. The midbrain is inovolved in eye motion while the pons coordinates eye and facial movements, facial sensation, hearing, and balance. The medulla oblongata controls vegetative functions such as breathing, blood pressure, and heart rate as well as swallowing.

Thalamus: The thalamus is a structure that is located above the brainstem and it serves as a relay station for nearly all messages that travel from the cerebral cortex to the rest of the body/brain and vice versa. As such, problems within the thalamus can cause significant symptoms with regard to a variety of functions, including movement, sensation, and coordination. The thalamus also functions as an important component of the pathways within the brain that control pain sensation, attention, and wakefulness.

Cerebellum: The cerebellum is located at the lower back of the brain beneath theoccipital lobesand is separated from them by thetentorium. This part of the brain is responsible for maintaining balance and coordinating movements. Abnormalities in either side of the cerebellum produce symptoms on the same side of the body.

Cerebrum: The cerebrum forms the major portion of the brain, and is divided into the right and left cerebral hemispheres. These hemispheres are separated by a groove called the great longitudinal fissure and are joined at the bottom of this fissure by a struture called the corpus callosum which allows communication between the two sides of the brain. The surface of the cerebrum contains billions ofneuronsandgliathat together form the cerebral cortex (brain surface), also known as "gray matter." The surface of the cerebral cortex appears wrinkled with small grooves that are called sulci and bulges between the grooves that are called gyri. Beneath the cerebral cortex are connecting fibers that interconnect the neurons and form a white-colored area called the "white matter."

Lobes: Several large grooves (fissures) separate each side of the brain into four distinct regions called lobes: frontal, temporal, parietal, and occipital. Each hemisphere has one of each of these lobes, which generally control function on the opposite side of the body. The different portions of each lobe and the four different lobes communicate and function together through very complex relationships, but each one also has its own unique characteristics. The frontal lobes are responsible for voluntary movement, speech, intellectual and behavioral functions, memory, intelligence, concentration, temper and personality. The parietal lobe processes signals received from other areas of the brain (such as vision, hearing, motor, sensory and memory) and uses it to give meaning to objects. The occipital lobe is responsible for processing visual information. The temporal lobe is involved in visual memory and allows for recognition of objects and peoples' faces, as well as verbal memory which allows for remembering and understanding language.

Hypothalamus: The hypothalamus is a structure that communicates with the pituitary gland in order to manage hormone secretions as well as controlling functions such as eating, drinking, sexual behavior, sleep, body temperature, and emotions.

Pituitary Gland: The pituitary gland is a small structure that is attached to the base of the brain in an area called the sella turcica. This gland controls the secretion of several hormones which regulate growth and development, function of various organs (kidneys, breasts, and uterus), and the function of other glands (thyroid gland, gonads, and the adrenal glands).

Basal Ganglia: The basal ganglia are clusters of nerve cells around the thalamus which are heavily connected to the cells of the cerebral cortex. The basal ganglia are associated with a variety of functions, including voluntary movement, procedural learning, eye movements, and cognitive/emotional functions. The various components of the basal ganglia include caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nucleus. Diseases affecting these parts can cause a number of neurological conditions, including Parkinson's disease and Huntington's disease.

Cranial Nerves: There are 12 pairs of nerves that originate from the brain itself, as compared to spinal nerves that initiate in the spinal cord. These nerves are responsible for specific activities and are named and numbered as follows:Cranial nerve I (Olfactory nerve): SmellCranial nerve II (Optic nerve): VisionCranial nerve III (Oculomotor nerve): Eye movements and opening of the eyelidCranial nerve IV (Trochlear nerve): Eye movementsCranial nerve V (Trigeminal nerve): Facial sensation and jaw movementCranial nerve VI (Abducens nerve): Eye movementsCranial nerve VII (Facial nerve): Eyelid closing, facial expression and taste sensationCranial nerve VIII (Vestibulocochlear nerve): Hearing and sense of balanceCranial nerve IX (Glossopharyngeal nerve): Taste sensation and swallowingCranial nerve X (Vagus nerve): Heart rate, swallowing, and taste sensationCranial nerve XI (Spinal accessory nerve): Control of neck and shoulder musclesCranial nerve XII (Hypoglossal nerve): Tongue movement

Pineal Gland: The pineal gland is an outgrowth from the back portion of thethird ventricle, and has some role in sexual maturation, although the exact function of the pineal gland in humans is unclear.

Spinal CordThe spinal cord is a long, thin, tubular bundle of neurons and support cells that extends from the bottom of the brain down to the space between the first and second lumbar vertebrae, and is housed and protected by the bony vertebral column. The spinal cord functions primarily in the transmission of signals between the brain and the rest of the body, allowing movement and sensation, but it also contains neural circuits that can control numerous reflexes independent of the brain.

General Structure: The length of the spinal cord is much shorter than the length of the bony spinal column, extending about 45 cm (18 inches). It is ovoid in shape and is enlarged in the cervical (neck) and lumbar (lower back) regions. Similar to the brain, the spinal cord is protected by three layers of tissue, called spinal meninges. The dura mater is the outermost layer, and it forms a tough protective coating. Between the dura mater and the surrounding bone of the vertebrae is a space called the epidural space, which is filled with fatty tissue and a network of blood vessels. The arachnoid mater is the middle protective layer. The space between the arachnoid and the underlyng pia mater is called the subarachnoid space which containscerebrospinal fluid(CSF). The medical procedure known as alumbar puncture(or spinal tap) involves use of a needle to withdraw cerebrospinal fluid from the subarachnoid space, usually from the lumbar (lower back) region of the spine. The pia mater is the innermost protective layer. It is very delicate and it is tightly associated with the surface of the spinal cord.

In the upper part of the vertebral column, spinal nerves exit directly from the spinal cord, whereas in the lower part of the vertebral column nerves pass further down the column before exiting. The terminal portion of the spinal cord is called the conus medullaris. A collection of nerves, called the cauda equina, continues to travel in the spinal column below the level of the conus medullaris. The cauda equina forms as a result of the fact that the spinal cord stops growing in length at about age four, even though the vertebral column continues to lengthen until adulthood.Three arteries provide blood supply to the spinal cord by running along its length. These are the two Posterior Spinal Arteries and the one Anterior Spinal Artery. These travel in the subarachnoid space and send branches into the spinal cord that communicate with branches from arteries on the other side.

Function: The spinal cord is divided into 33 different segments. At every segment, a pair of spinal nerves (right and left) exit the spinal cord and carry motor (movement) and sensory information. There are 8 pairs of cervical (neck) nerves named C1 through C8, 12 pairs of thoracic (upper back) nerves termed T1 through T12, 5 pairs of lumbar (lower back) nerves named L1 through L5, 5 pairs of sacral (pelvis) nerves numbered S1 through S5, and 3-4 pairs of coccygeal (tailbone) nerves. These nerves combine to supply strength to various muscles throughout the body as follows:C1-C6: Neck flexionC1-T1: Neck extensionC3-C5: DiaphragmC5-C6: Shoulder movement and elbow flexionC6-C8: Elbow and wrist extensionC7-T1: Wrist flexionC8-T1: Hand movementT1-T6: Trunk muscles above the waistT7-L1: Abdominal musclesL1-L4: Thigh flexionL2-L4: Thigh adduction (movement toward the body)L4-S1: Thigh abduction (movement away from the body)L2-L4: Leg extension at the kneeL5-S2: Leg extension at the hipL4-S2: Leg flexion at the kneeL4-S1: Foot dorsiflexion (move upward) and toe extensionL5-S2: Foot plantarflexion (move downward) and toe flexionThe spinal nerves also provide sensation to the skin in an organized manner as depicted below.

Vertebral ColumnGeneral Structure: The vertebral column is made up of 33 vertebrae that fit together to form a flexible, yet extraordinarily tough, column that serves to support the back through a full range of motion. There are seven cervical vertebrae (C1-C7), 12 thoracic vertebrae (T1-T12), five lumbar vertebrae (L1-L5), five fused sacral vertebrae (S1- S5), and four coccygeal vertebrae in this column, each separated by intervertebral disks.

The first two cervical vertebrae have very distinct anatomy as compared to the ramaining vertebrae. The first cervical vertebra, known as the atlas, supports the head; and pivots on the second cervical vertebra, the axis. The seventh cervical vertebra joins the first thoracic vertebra. The thoracic vertebrae provide an attachment site for the ribs, and make up part of the back of the chest (thorax). The thoracic vertebrae join the lumbar vertebrae, which are particularly study and large, as they support the entire upper body weight. At the top of the pelvis, the lumbar vertebrae join the sacral vertebrae. By adulthood these five bones have usually fused to form a triangular bone called the sacrum. At the tip of the sacrum, the final part of the vertebral column projects slightly outward. This is the coccyx, better known as the tailbone. It is made up of three to five coccygeal vertebrae.

A typical vertebra consists of two essential parts: the vertebral body in front and the vertebral arch in the back. The vertebral arch consists of a pair of pedicles, a pair of lamina, a spinous process, and four articular processes (joints) that connect the vertebra to one another, as depicted below.The vertebral bodies, stacked on top of each other, form a strong pillar for the support of the head and trunk. Between each two vertebral bodies exists a hole, called the intervertebral foramina, which allows for the transmission of the spinal nerves on either side.

Anatomical Changes in the Brain with Alzheimers DiseaseAlzheimer's disease is characterized by anatomical changes, including the development ofamyloid plaquesandneurofibrillary tangles.

Amyloid plaquesare sticky buildup which accumulates outside the nerve cells in the brain. Amyloid is a protein which is normally found throughout the body. In AD this protein begins to divide improperly, creating a substance called beta amyloid which is toxic to brain cells. As the beta amyloid builds up, the brain cells begin to die.

Neurofibrillary tanglesare the second anatomical hallmark of AD. Normally, every brain cell contains long fibers made of protein which act as scaffolds, holding the brain cell in its proper shape and also helping transport of nutrients within the cell. In AD, these fibers begin to twist and tangle. The brain cell loses its shape and also becomes unable to transport nutrients properly; it eventually dies.

As enough plaques and tangles accumulate in the brain, widespread cell death occurs throughout the brain. At this point, it is unclear exactly why plaques and tangles begin to form in the brain of a person with AD. Many researchers are studying this question and trying to develop ways to halt or reverse the degeneration.

The plaques and tangles characteristic of Alzheimer's can be observed only through biopsy, which is usually done during an autopsy. This means that a doctor can only diagnose "probable" Alzheimer's in a living client based on the pattern of behavioral symptoms, and by ruling out other possible causes. The firm diagnosis of Alzheimer's is made or ruled out after death.

A recent report announced the discovery of a vaccine that may hold promise for preventing or treating AD. The study considered mice which had been specifically bred to develop AD-like plaques in their brains. Young mice given the vaccine showed little or no development of plaques as they aged. The older mice, which had already developed plaques, were given the vaccine. The plaques appeared to dissolve.This vaccine is causing tremendous excitement among those who study AD, since it suggests it might be possible to develop a way to immunize people against AD or reduce AD in those who already suffer the disease. However, it is important to remember that the rats in this study did not have AD: they were bred to develop plaques, but they did not develop neurofibrillary tangles. Some researchers suspect that the tangles, rather than the plaques, are the culprits that cause most of the damage in AD. Worse, not every person who dies of AD has plaques in his brain. Thus, a vaccine that fights plaques may not be enough to prevent or cure AD. It will take years of further study in animals to answer some of these questions, and years more before a human treatment becomes available. Nonetheless, this study is an example of the progress that is being made in understanding the various components of AD.

Possible Causes of Alzheimer's diseaseSeveral possible causes have been implicated in the development of AD. About 10% of clients with AD have the early-onset form of the disease, in which symptoms can appear as early as the 30s and 40s. Scientists have discovered that many people with this form of the disease have a specific genetic abnormality: mutation in genes located on chromosomes 1, 14, and 21. However, the correlation isn't perfect; people with these genetic abnormalities account for only 50% of all known cases of early-onset AD.

The more common form of AD is late-onset AD, in which symptoms begin to appear only late in life. This form of AD is also linked to a genetic abnormality. Chromosome 19 contains a gene called apoE which helps carry cholesterol in the blood and also helps nerves to recover after injury. Each of us has two copies of apoE - one inherited from each parent - and each copy can come in one of several forms: apoE2, apoE3, and apoE4. ApoE3 is the most common in the general population. But people who inherit one apoE4 gene have an increased risk of developing AD, and people who inherit two copies of apoE4 are about eight times as likely to develop AD as people with two copies of the "normal" apoE3 variant. Interestingly, the rarest apoE2 form of the gene may lower an individual's risk of AD.

A simple blood test is available to determine which forms of apoE a person has. However, this test cannot tell you whether or not you will develop AD, or when. Over half of the people who develop late-onset AD do not have the apoE4 gene, and not everyone with apoE4 does develop the disease. Right now, the blood test is most useful as a research tool, helping scientists study AD risk factors in large groups of people. Most scientists and health professionals do not recommend routine apoE4 tests for predicting AD risk in individuals, although it may be useful as part of a medical evaluation of a client who already shows AD symptoms.

In addition to genetic factors, many biological factors have been implicated in AD. One of the best-studied is overproduction offree radicals, substances formed when the body metabolizes oxygen. Normally,free radicalsserve important functions, such as helping the immune system fight off disease. However, too many free radicals can start to cause problems. Brain cells producing the mutated form of amyloid protein - the beta amyloid that forms the plaques in AD - seem to produce more free radicals. At this point, it's unclear whether free radicals boost beta amyloid production or vice versa.

There are also several environmental factors which have been suspected of contributing to AD risk. One of the earliest suspects was aluminum, which is a common contaminant in drinking water. Both the plaques and tangles in AD contain illuminum, and early studies linked AD with aluminum ingested through drinking water or even by using aluminum cooking utensils. However, most researchers are currently not convinced that there is a strong link between aluminum and AD.

Other environmental suspects which have been suggested to promote AD include zinc (normally found in shellfish, beans and dark turkey meat), smoking, high exposure to paint solvents, and exposure to electromagnetic fields (EMFs), the high-electricity areas around power lines and electrical machinery. People who have experienced head injuries orstrokesmay also be more prone to develop AD. Viral infections, such as HIV (the virus that causes AIDS), may also leave the brain vulnerable to AD.

Neither toxin ingestion, nor brain injury, nor viral infection alone is enough to cause AD. However, in people genetically predisposed to AD, these environmental factors may help trigger the disease or cause symptoms to appear earlier. Currently, much more research is needed to identify other triggering factors, to determine just how much they increase risk, and to learn what can be done to offset this risk.

V. PATHOPHYSIOLOGY

Signs and symptoms:-unable to perform ADLs without assistance-immobility (terminal stage)Signs and symptoms:-anxiety and agitation-decrease attention spanSigns and symptoms:Forgetfulness, disorientation to person, places, things, and environmentDecrease functional ability (fine movements)Emotional and attention deficitDecrease production of dopamineCognitive deteriorationDecrease production of acetylcholineAlteration of normal activity of neurotransmitterDecrease in brain sizeTangled masses of non-functioning neurons (neurofibrillary tangles)Formation of neuritic plaques(deposits of amyloid protein, which is found in brain)Neural damagePrimarily in cerebral cortexNeurodegenerationAdvanced age (early onset 30-65 y/o)Late onset (65 y/o and above)Genetics

VI. THE ACTIVITIES-SPECIFIC BALANCE CONFIDENCE (ABC) SCALEInstructions for ScoringThe ABC is an 11point scale and ratings should consist of whole numbers (0-100) for each item. Total the ratings (possible range = 0-1600) and divide by 16 to get each subjects ABC score. If a subject qualifies his/her response to items #2, #9, #11, #14 or #15 (different ratings for up vs. down or onto vs. off), solicit separate ratings and use the lowest confidence of the two (as this will limit the entire activity, for instance the likelihood of using the stairs. )

80% = high level of physical functioning50-80% moderate level of functioning