2nd GROUP DISCUSSION RESULT NERVOUS SYSTEM ALZHEIMERS DISEASE

Arpidho Prasetya Lalatul Purwasih Awaliya Ramadhan Hadiyan Raditya Dannial Bagus S. Fatimatuzzahroh Vina Nur Puspitasari Nurul Kamajaya C A Muhammad Hafidl H Titik Tri Ardiani Resti Lovita

105070200131012 105070200131013 105070207131005 105070201131013 105070203131006 105070204131001 105070201131004 105070201131014 105070201131016 105070207131001 105070200131011

NURSING DEPARTMENT (K3LN) MEDICAL FACULTY UNIVERSITY OF BRAWIJAYA 2011

Trigger 3:

Eyang kung dan eyang uti sudah menikah selama 47 tahun. Keduanya berusia 66 tahun. Kedua anaknya sudah menikah dan tinggal terpisah. Selama Sembilan bulan terakhir, Eyang Uti tidak dapat mengingat nama anak-ananknya dan juga nomor telepon mereka. Kesehariannya, semua aktifitas di rumah di bantu oleh Eyang Kung, bahkan untuk memilih bajunya pun tidak bisa. Suatu sore, Eyang Kung meminta Eyang Uti untuk membelikan roti di warung. Namun setelah ditunggu satu jam, Eyang Uti tidak kunjung pulang. Tetangga menemukan Eyang Uti terlihat gemetar, bingung, dan berjalan tanpa tujuan yang jelas. Saat diperiksa oleh perawat, kesadaran baik, afebril, skor MMSE 20/30, mempunyai riwayat DM tipe 2, TD 160/100 mmHg, N=80x/menit, RR=18x/menit, S=37 o C. Eyang Kung mengatakan kesulitan merawat Eyang Uti dengan kondisi seperti ini. Dokter menginstruksikan pemberian anti-kholinesterase dan anti-hipertensi.

1st Group Discussion: A. Keyword Cant remember her sons/ daughters name Eyang Kung and Eyang Uti are 66 y.o Afebril Given anti-cholinesterase and anti-hypertensi as treatment Eyang Uti was helped by Eyang Kung to do her daily activity Eyang Uti is female They live separately from their sons/ daughters MMSE score: 20/30 Tremble, confuse, walk without destination Has DM type 2 TTV ( BP = 160/100 mmHg, Pulse = 80/ mnt, RR = 18/ mnt, T = 37,5o C) Eyang Kung get difficulty for giving care to Eyang Uti Consciousness = compos mentis, GCS 15

B. Questions Is there a relation between DM type 2 with this disease? Is there a relation between high blood pressure with this disease? Do age and gender influence this disease? What is causes this disease? What is the mean of MMSE score 20/30? Is there a relation between keyword no. 2 and 9? What is the indication of giving anti-cholinosterase? Is this disease acquired or genetic? What is the nurses role? What is the disease? Is there a time to be forgetting something? Does marriage status influence this disease? : Alzheimers disease : Age, gender, past history, genetic, etc.

C. Hypothesis Definition Etiology

Pathway

:DM Type 2/ other factor nerve impairment

Alzheimers wandering/ trembling. D. SLO Definition Etiology Pathophysiology Epidemiology Clinical manifestation Diagnostic test Implementation Nursing care Chronic confusion f.r Alzheimers Wandering f.r cognitive impairment Self care deficit f.r cognitive impairement Caregiver role strain f.r receiver cognitive impairment

E. Diagnosa (Nursing Care) -

2nd Group Discussion:

1. Definition Alzheimers disease is a disease of the brain cause problems with memory, thinking, and behavior. It is not a normal part of aging. Alzheimer's disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects a person's ability to carry out daily activities. 2. Epidemiology Alzheimer's disease can occur at any age, 96% of cases found after 40 years of age or older. Schoenburg and Coleangus (1987) reported incidence by age: 4.4 / 1000.000 at the age of 30-50 years, 95.8 / 100,000 at age> 80 years. The revalence of this disease per 100,000 population about 300 in the age group 60-69 years, 3200 in the age group 70-79 years, and 10 800 at age 80. It is estimated that in 2000 there were 2 million people with Alzheimer's disease. While in Indonesia estimated the number of old age range, 18.5 million people with the incidence and prevalence of Alzheimer's disease is not known with certainty. Based on gender, the prevalence of three times more women than men. This may be a reflection of women's life expectancy longer than men. From some studies no differences for gender. The World Health Organization estimated that in 2005, 0.379% of people worldwide had dementia, and that the prevalence would increase to 0.441% in 2015 and to 0.556% in 2030. Other studies have reached similar conclusions. Another study estimated that in 2006, 0.40% of the world population (range 0.170.89%; absolute number 26.6 million, range 11.459.4 million) were afflicted by AD, and that the prevalence rate would triple and the absolute number would quadruple by 2050. 3. Etiology

The exact cause of AD is inknown. Several causes which have been (dihipotesa) is metal intoxication, impaired immune function, infection viruses, air pollution/industrial, trauma, heriditer predispotition, etc. Theres some risk factor: Age The greatest known risk factor for Alzheimers is increasing age. Most individuals with the illness are 65 and older. The likelihood of developing Alzheimers approximately doubles every five years after age 65. After age 85, the risk reaches nearly 50 percent. Family history Risk of Alzheimer's that appears slightly higher if first-degree relatives - parents and siblings - have Alzheimer's. In additional to aging and genetic factors, all the following have been documented as risk factors for Alzheimers disease: DM type 2 Head injury Stroke and mini-stroke High cholesterol level High blood pressure Down syndrome Chronic inflammatory condition History of depression Stress Lack of physical exercise Inadequate brain exercise Unhealthy consumption Obesity Gender

Women are more susceptible than men, this is because women generally live longer than men. Mild cognitive impairment (MIC) People who have mild cognitive impairment have memory problems that get worse than what might be expected at his age and has not been bad enough to classify as dementia. Many of those who are in this condition continues to have Alzheimer's disease. Lifestyle Same factors that made you are at the same risk of heart disease also increases the likelihood you will get Alzheimer's disease. Level of education Some scientists theorize, the more often you use your brain synapses will be more that you create will be available where a lot of reserves in the old days. It would be difficult to find the Alzheimer's brain in people who train regularly, or those who have higher education levels.

4. Pathophysiology

5. Clinical Manifestation There are 10 warning signs of Alzheimers disease: a. Memory loss that disrupts daily life One of the most common signs of Alzheimers disease, especially in the early stages, is forgetting recently learned information. Others include forgetting important dates or events; asking for the same information over and over; and relying on memory aides (e.g., reminder notes or electronic devices) or family members for things they used to handle on their own. b. Challenges in planning or solving problems Some people may experience changes in their ability to develop and follow a plan or work with numbers. They may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty concentrating and take much longer to do things than they did before. c. Difficulty of completing familiar tasks at home People with Alzheimers disease often find it hard to complete daily tasks. Sometimes, people have trouble driving to a familiar location, managing a budget at work or remembering the rules of a favorite game. d. Disorientation time and place People with Alzheimers can lose track of dates, seasons and the passage of time. They may have trouble understanding something if it is not happening immediately. Sometimes they may forget where they are or how they got there. e. Trouble understanding visual images and spatial relationships For some people, having vision problems is a sign of Alzheimers. They may have difficulty reading, judging distance and determining color or contrast. In terms of perception, they may pass a mirror and think someone else is in the room. They may not realize they are the person in the mirror. f. Have problem with words in speaking or writing

People with Alzheimers may have trouble following or joining a conversation. They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves. They may struggle with vocabulary, have problems finding the right word or call things by the wrong name (e.g: calling a watch a hand clock). g. Misplacing things and losing the ability to retrace steps A person with Alzheimers disease may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. Sometimes, they may accuse others of stealing. This may occur more frequently over time. h. Decreased or poor judgement People with Alzheimers may experience changes in judgment or decision making. For example, they may use poor judgment when dealing with money, giving large amounts to telemarketers. They may pay less attention to grooming or keeping themselves clean. i. Withdrawal from work or social activities A person with Alzheimers may start to remove themselves from hobbies, social activities, work projects or sports. They may have trouble keeping up with a favorite sports team or remembering how to complete a favorite hobby. They may also avoid being social because of the changes they have experienced. j. Changes in mood and personality The mood and personality of people with Alzheimers can change. They can become confused, suspicious, depressed, fearful or anxious. They may be easily upset at home, at work, with friends or in places where they are out of their comfort zone. Stage of Alzheimers disease According to National Alzheimers Association (2011), there are 7 stages of AD:

Stage 1: No impairment (normal function) The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms of dementia.

Stage 2: Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease) The person may feel as if he or she is having memory lapses forgetting familiar words or the location of everyday objects. But no symptoms of dementia can be detected during a medical examination or by friends, family or co-workers.

Stage 3: Mild cognitive decline (early-stage Alzheimer's can be diagnosed in some, but not all, individuals with these symptoms) Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration. Common stage 3 difficulties include: - Noticeable problems coming up with the right word or name - Trouble remembering names when introduced to new people - Having noticeably greater difficulty performing tasks in social or work settings Forgetting material that one has just read - Losing or misplacing a valuable object - Increasing trouble with planning or organizing Stage 4: Moderate cognitive decline (Mild or early-stage

Alzheimer's disease) At this point, a careful medical interview should be able to detect clearcut symptoms in several areas: Forgetfulness of recent events Impaired ability to perform challenging mental arithmetic for example, counting backward from 100 by 7s

Greater difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances Forgetfulness about one's own personal history Becoming moody or withdrawn, especially in socially or mentally challenging situations

Stage 5: Moderately severe cognitive decline (Moderate or midstage Alzheimer's disease) Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. At this stage, those with Alzheimer's may: Be unable to recall their own address or telephone number or the high school or college from which they graduated Become confused about where they are or what day it is Have trouble with less challenging mental arithmetic; such as counting backward from 40 by subtracting 4s or from 20 by 2s Need help choosing proper clothing for the season or the occasion Still remember significant details about themselves and their family Still require no assistance with eating or using the toilet

Stage 6: Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease) Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. At this stage, individuals may: Lose awareness of recent experiences as well as of their surroundings Remember their own name but have difficulty with their personal history

Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet Experience major changes in sleep patterns sleeping during the day and becoming restless at night

Need help handling details of toileting (for example, flushing the toilet, wiping or disposing of tissue properly) Have increasingly frequent trouble controlling their bladder or bowels Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding

Tend to wander or become lost

Stage 7: Very severe cognitive decline (Severe or late-stage Alzheimer's disease) In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases.

At this stage, individuals need help with much of their daily personal care, including eating or using the toilet. They may also lose the ability to smile, to sit without support and to hold their heads up. Reflexes become abnormal. Muscles grow rigid. Swallowing impaired.

6. Diagnostic Test a. Neuropathology Its generally obtained a bilateral atrophy, symmetrical, often heary brain revolves about 1000 gr. b. Neuropsychology

To assess the presence of dysfunction of general cognitive and to know the detail of pattern of deficit. Also aims to assess the function of some parts of the brain such as memory, loss of expression, calculation, attention, and understanding language. c. CT Scan, MRI, EEG, PET, SPECT d. CBC, urinalysis, electrolyte serum, Ca2+, liver function. e. Lumbal punction f. Genetic screening

7. Implementation FDA-approved treatments: Two types of drugs are currently approved by the U.S Food and Drug Administration (FDA) to treat cognitive symptoms of Alzheimers disease. 1) Cholinesterase inhibitors, are designed to prevent the

breakdown of acetylcholine, a chemical messenger important for memory and learning. By keeping levels of acetylcholine high, these drugs support communication among nerve cells. They delay worsening of symptoms for six to 12 months for about half of those who take them. Three cholinesterase inhibitors are commonly prescribed: - Donepezil (Aricept), approved in 1996 to treat mild-tomoderate Alzheimers, and in 2006 for the severe stage - Rivastigmine (Exelon), approved in 2000 for mild-tomoderate Alzheimers - Galantamine (Razadyne), approved in 2001 for mild-tomoderate stages 2) Regulating the activity of glutamate, a different messenger chemical involved in information processing: - Memantine (Namenda), approved in 2003 Memantine is the only currently available drug in this class. Approved for treatment of moderate-to-severe Alzheimers

disease,

memantine

may also

temporarily delay

the

worsening of symptoms for some people. 3) Vitamin E Doctors sometimes prescribe vitamin E for cognitive symptoms of Alzheimers disease. One large federally funded study showed that vitamin E slightly delayed loss of ability to carry out daily activities and placement in residential care. Scientists think that vitamin E may work because it is an antioxidant (an-tee-OX-uh-dent), a substance that may protect cells from certain kinds of chemical wear and tear. No one should use vitamin E to treat Alzheimers disease except under the supervision of a physician. The doses used in the federal study were relatively high, and vitamin E can negatively interact with other medications, including those prescribed to prevent blood from clotting.

8. Nursing Care A. Assessment Name Age Sex Race Religion : Eyang Uti : 66 y.o : Female ::-

Marriage status : Married Address Main problem :: wandering, Eyang Uti trembling, cant confuse, remember cant her

remember sons/daughters name and phone number. Current problem : sons/daughters name and phone number for 9 months. She was helped by Eyang Kung to do her daily activities even to choose her clothes. Eyang uti wandered and found in trembling condition, confused, and walk without destination.

History

: DM type 2

Physical assessment: General condition: consciousness = compos mentis, GCS = 15, tremble, confuse. Sense: Eye Mouth Ear Tongue Nose Respiration (N) (N) (N) (N) (N) : RR = 18/mnt

Cardiovascular : BP = 160/100 mmHg, pulse = 18/mnt Digestion Urogenital Integument Musculoscetal Endokrin : (N) : (N) : (N) : (N) : (N)

B. Analytical dates Data DO: DS: Helped Etiology Predispotition factor by decreasing of metabolism Problem Self care deficit

eyang Kung to do and bloodstream her activities, degeneration of even choose her neuronkoligenik difuse clothes neurofiblar damaged / loss of koligenic nerve cells plac sentis / decreasing of koligenic nerve cells neurotransmitter impairment antikolin decrease alzheimers decreasing of self care ability self care deficit DO: DS: Alzheimers weird trembled, behaviour, like to wander Wandering

confused, walked Wandered w/o destination DO: Alzheimers forgetful Chronic confusion DS: confuse, walk convulsive chronic w/o destination, cant remember her sons/ daughters name and their phone number. DS: DO: Eyang Alzheimers Self care deficit/ lost abilities to solve Uti problem/ wandering/ etc. Caregiver strain role confusion

must be helped 66 y.o caregiver

by Eyang Kung, caregiver role strain Eyang Kung is 66 y.o, Eyang Kung said that have

difficulty to give care to Eyang Uti

C. Diganosis 1) Chronic confusion r.f Alzheimers disease 2) Wandering r.f cognitive impairment 3) Self care deficit r.f cognitive disorder 4) Caregiver role strain r.f cognitive problem of receiver

D. Intervention 1) Chronic confusion r.f Alzheimers disease Aims: Maintain or improve concentration, memory, and thought control. Expected Outcomes: - Client will responds to the visual cue and hearing cue. - Client can have interaction to other people Intervention and rational: a. Determine the underlying cause for chronic confusion, as noted in Related Factors.

Helps to sort out possible causes and likelihood for

improvement, as well as helping to identify potentially useful interventions and therapies. b. Review and evaluate responses on diagnostic examinations (e.g., cognitive, functional capacity, behavior, memory

impairments, reality orientation, attention span, quality of life).

A combinationof tests (e.g., Confusion Assessment

Method [CAM], Mini-Mental State Examination [MMSE], Alzheimers Disease Assessment Scale [ADAS-cog], Brief

Dementia

Severity

RatingScale

[BDSRS],

Neuropsychiatric Inventory [NPI], Functional Assessment Questionnaire [FAQ], Clinical Global Impression of Change [CGIC]) is often needed to complete an evaluationof clients overall condition relating to chronic or irreversible condition. c. Monitor for treatable condition

That may contribute to or execrable distress, discomfort,

and agitation 2) Wandering r.f cognitive impairment a. Review responses of collaborative diagnostic examinations

A combination is often needed to complete an evaluation

of clients overall. b. Determine presence of depression

Research support the idea that wandering develops more

often in depression client with AD. c. Identify clients reason for wandering if possible d. Determine bowel and bladder elimination pattern, timing of incontinence

For possible colleration to wandering behaviour.

e. Monitor activity when hospitalized or admitted to facility 3) Self care deficit r.f cognitive disorder a. Allow sufficient time for dressing and undressing

Because tasks may be tiring, painful, and difficult to

complete.

To allow for easier manipulation of clothing.

b. Teach to dress affected side first, then unaffected side 4) Caregiver role strain r.f cognitive problem of receiver a. Inqure about and observe physical condition of care receiver and surroundings as appropriate.

Important to determine factors that may indicate problems

that can interfere with ability to continue caregiving.

b. Assess caregivers current state of function

Provides basis for determining needs that indicate

caregiver is having difficulty dealing with role. c. Note presence of high situations

Elderly client with total self care dependence due to

physical condition or developmental delays may necessitate role reversal resulting in addedstress or placing excessive demands on parenting skills

References:

Dongoes, Marylin E. 2000. Rencana Asuhan Keperawatan. Jakarta, EGC. Muttaqin, Arif. Buku Ajar Asuhan Keperawatan dengan Gangguan System Persyarafan. Jakarta, Salemba. National Alzheimers Association. 2011. 7 Stages of Alzheimers. http://www.alz.org accessed 6-12-2011. http://zulliesiskawati.staff.ugm.ac.id accessed 6-12-2011. Alzheimers Disease Education and Referral Center. 2010. Alzheimers Disease Medications, US Department of Health and Human Service: National Institute on Aging. http://www.nia.nih.gov accessed 5-122011. Corwin, Elizabeth J. 2008. Buku Saku Patofisiologi. Jakarta. EGC. NANDA International 2009-2011