Dementia: Optimal Goal? Help pls!

  1. I need help w/ a realistic overall "goal" for this pt. My book says that the goal would be, "Will have no s/s of ineffective tissue perfusion by {date} (w/in 2 days). However, this is an unrealistic goal. My instructor told me last time that a realistic goal for an elderly pt, as in this case s/b
    " Will exhibit s/s optimal to pt condition".
    I'm having a hard time trying to figure out how a pt can improve with s/s of dementia (irreversible brain damage!!) How can they improve? The only thing I can think of is BP w/in normal range. But that seems more like an outcome than an overall "GOAL" to me. What else? Please help, I am so confused! Thanx! Angela

    My nursing dx is this: (yes I know, VERY long but my instructor wants ALL s/s included!)
    Ineffective Tissue Perfusion: Cerebral & Peripheral r/t Interruption of arterial/venous flow aeb CT results: Enlarged ventricles cortical sulci enlarged. No scull fracture. Small hypodense area in R. cerebellum and in L basal ganglia, R. putamen, centrum semiovale-corona radiata, probably chronic lacunar infarcts. Low attenuation in bilat periventricular and deep white matter. ECG results: Normal sinus rhythm w/frequent ventricular complexes, L. atrial enlargement, L. axis deviation, R. bundle branch block abnormal, pt report of frequent falls, dizziness, headaches, altered mental status, behavioral changes, confusion, forgetfulness, evening agitation, unsteady gait, skin cool to touch & pale, high blood pressure of 161/95, pt report of leg weakness.
  2. 6 Comments

  3. by   ktwlpn
    don't forget quality of life issues-maintaining comfort and maintianing their current level of function as long as possible.....
  4. by   suzy253
    Safety would be a big from injury....etc. etc.
  5. by   discobunni
    I agree w/maintaining comfort. Pain is my second DX (the pt has a occipital lesion from syncope) But this is my #1 DX according to NANDA, following the ABC's. I have to maintain circulation. I agree as well that safety is an issue...the only NANDA DX's I see for that is "Risk for" and we've been taught that these fall below all other actual DX. (It is marked wrong if we use "Risk" DX over an actual DX. So I guess to rephrase my question:
    How can I measure improvement on ineffective cerebral tissue perfusion when there is irreversible damage? On my last careplan, I put "pt will not show increase in ineffective tissue perfusion" and my instructor responded with this: " Will exhibit s/s optimal to pt condition". So what would the s/s be for this problem that are optimal to this condition? Normal BP? How do you measure confusion? AO to self only? UGH I'm very frustrated w/this. Sorry for the vent.
  6. by   discobunni
    Do you think this s/b Chronic confusion secondary to Ineffective Cerebral Tissue Perfusion?
  7. by   Daytonite
    hi, discobunni. . .i just saw your post now. let me work on this a little and i will post an answer back for you. the first major problem that i see you have is that you have lumped all your data into one diagnosis and i can see that there are at least two, possible three nursing diagnoses that would be appropriate for this patient. let me ask you to be patient as i work through the data you have given. my telephone line is acting up and dumping me off frequently here again this afternoon, so i ask you be patient in waiting for a reply. . .daytonite
  8. by   Daytonite
    first of all, the diagnosis ineffective tissue perfusion is defined as a decrease in oxygen resulting in a failure to nourish tissues at a capillary level. you don't have any evidence of that in your assessment data, including what you have from the ct scan. so, you need to trash that diagnosis. what your ct scan does suggest, however is that she has evidence of lacunar infarcts which means she has had a series of old strokes. lacunar infarcts is a doctor's fancy language of saying she has physical evidence in her brain of old strokes. therefore, you need a careplan tailored more toward a patient who is long-term survivor of cva, or stroke. dementia is a broad medical term that refers to cognitive deficits of memory that may be caused by many different things, stroke among them. therefore, your diagnosis connected with this would be:

    chronic confusion r/t clinical evidence of organic impairment and long-standing cognitive impairment aeb
    • enlarged ventricles
    • cortical sulci enlarged
    • small hypodense area in r. cerebellum and in l basal ganglia, r. putamen, centrum semiovale-corona radiata
    • probably chronic lacunar infarcts
    • low attenuation in bilat periventricular and deep white matter
    • altered mental status
    • behavioral changes (this needs more clarification, what are the specific behavioral changes?)
    • confusion
    • forgetfulness
    • headaches
    • evening agitation
    • unsteady gait
    • pt report of leg weakness
    your goals will be (and i am pretty much copying this right out of my care plan book):
    • remain content and free from harm
    • to function at the patient's maximum cognitive level
    • to perform adls (activities of daily living) appropriate to their maximum functional ability
    • have minimal episodes of agitation (i'd make this evening agitation since this is one of your data items)
    now, you have some left over data assessment items to deal with. and, these are the nursing diagnoses i would put with them:

    decreased cardiac output r/t altered heart rhythm aeb
    • ecg results: normal sinus rhythm w/frequent ventricular complexes, l. atrial enlargement, l. axis deviation, r. bundle branch block abnormal
    • high blood pressure of 161/95
    • skin cool to touch & pale
    • dizziness
    • add any medications the patient is on that relate to this (antihypertentives, antiarythmics)
    risk for falls r/t history of falls (no aeb needed since this is an anticipated problem)
    • pt report of frequent falls
    an important point. . .your assessment data must form the basis for the nursing diagnosis you use. if your signs and symptoms don't fit the nursing diagnosis as in the case of your attempt to use ineffective tissue perfusion, you can't use that diagnosis. it is the same as trying to say a person who has a runny nose, cough and a fever has a sore toe. you know that's not right. every one of the nanda nursing diagnosis has signs and symptoms that must meet it's criteria.

    if you are writing a complete careplan on this patient, you would write your nursing interactions for each one of your aebs. if you need more assistance with these, post another message to this thread.
    Last edit by Daytonite on Aug 14, '06