Patient-Centered Nursing Care for Dementia Patients

Foundations of Patient-Centered Nursing

Nursing is best practiced when it follows the intentions of its founder, Florence Nightingale, who urged that nursing should provide for and care for the patient. Nursing, in other words, should be purely patient-centered. This caring extends to all aspects—not just to the illness—so that one treats the patient in a holistic way, considering all components of the patient such as family, social needs, hobbies, desires, spiritual inclinations, and so forth. When done in this way, nursing extends itself from an automatic, robotic procedure to something that can motivate the nurse and uplift the patient (Watson, 1998). Nursing, in other words, extends to caring for the patient as a whole.

An effective nurse will strive to accomplish her best in providing comprehensive care that integrates philosophy with practice. Nursing is far more than simply providing the patient with the necessary treatments. It includes caring for the person as a whole, namely seeing that all his or her needs are met. The person is part of a greater whole, and this includes taking care of the environment and ensuring that the person receives support as well as social and emotional care. The patient should be regarded as a person rather than as a patient per se.

The Four Metaparadigms of Nursing Practice

According to Fawcett, there are four metaparadigms essential to the field of nursing: health, environment, person, and nursing. Health refers to the generalized condition as relevant to that particular individual. Environment is holistic, including social and cultural dynamics such as the patient's family, friends, and community. "Person" refers to the sick individual as a person rather than merely a patient; the nurse must have dignity and respect for the patient. Finally, nursing refers to the root of nursing—caring rather than as a mechanized set of practices. This is the crux and the importance of the therapeutic relationship.

Placing herself within the patient's locus of concern, the nurse works to understand and address all dimensions of care. This framework ensures that nursing interventions go beyond physical treatment to encompass psychological, social, cultural, and spiritual dimensions of health and healing.

Communication and Behavioral Management in Dementia Care

Patients with dementia present unique communication challenges. The nurse should follow these evidence-based communication principles: she will speak slowly and use short, simple words and phrases. She should consistently identify herself and address the client by name at each meeting; she will focus on one piece of information at a time; and she should review medical plans and procedures with the patient until she has affirmed that the patient understands and agrees. With someone with dementia, this may take repetitious attempts and may be frustrating (Norberg, 2012).

Patients with dementia are often frustrated by their incapacity and by living in a confusing, unfamiliar world that has suddenly become overwhelming to them (Norberg, 2012). As a reaction, they may become aggressive. In this case, the nurse is advised to shift the topic to a safer, more familiar one. She is advised to respond calmly at all times and not raise her voice whilst seeking to identify stressors that increase agitation and helping patients respond to them. The nurse can also teach her patient techniques to deal with stressors in a calm way. WebMD recommends that caregivers maintain composure and redirect rather than confront agitated patients.

Fall Prevention and Environmental Safety

Patients with dementia must be protected from falling. Falls are a major problem among the elderly, particularly among the 65+ population, and can lead to many related problems and occasionally to fatal results. Approximately one-third to one-half of elderly individuals fall each year (Downton, 1991), whilst in the United States alone, one in three people over 65 fall at least once a year, and this incidence increases to one in two people for those over 80 (Todd & Skelton, 2004; McClure et al., 2005). The severity of fall complications also increases with age, particularly among females, resulting in more mortality and morbidity related to falls in individuals whose age exceeds 70 than in those who are younger (Rubenstein & Josephson, 2006).

The nurse caring for an elderly patient with dementia can help prevent falls by ensuring that the patient's environment is well lit and free of objects that may cause falls. Safety bars should be installed in the bathroom to prevent slipping. Vitamin D supplementation has also been shown to be helpful; studies indicate it reduces fall risk in nursing home residents (Broe et al., 2007).

Managing Wandering and Maintaining Physical Activity

People who have dementia tend to wander. The nurse should warn the family to alert neighbors about the patient's wandering behavior and, for the same reason, alert the police and have the patient's current picture taken. At the same time, however, the nurse should still encourage the patient to keep moving, encouraging physical activity (Ray et al., 2005). This balance between safety monitoring and maintaining functional capacity is essential to quality of life.

Structuring Daily Routines and Reducing Confusion

Dementia can be frustrating for the patient. Things that were once familiar are now confused, and the patient has to be constantly reminded of her situation and circumstances. Life becomes scary. To mitigate this overwhelming confusion, Mayo Clinic advises that there should be an organized, although flexible schedule in place so that frustrations are reduced while tasks are performed in a quiet, patient way. Distractions should be eliminated while these tasks are performed. Activities should be familiar to the patient; the nurse should confine herself to repeating the same activity various times instead of introducing new ones that would only perplex the patient. To the same end, the nurse should make sure that all clocks, calendars, and familiar personal effects are in the patient's view.

Providing patient-centered care does not mean that the nurse makes the patient dependent on her. On the contrary, the nurse should provide the patient with the skills to enable her to conduct her own life while making sure that the patient is protected and receives the necessary social support and care. To that end, the nurse should assess and monitor the patient's ability to perform activities of daily living and should encourage decision-making regarding activities of daily living as much as possible.

Promoting Patient Independence and Activities of Daily Living

To ensure that the patient is well-protected, the nurse not only teaches her family how to care for her but also helps the patient, to the extent that she possibly can, monitor her own health. The nurse herself engages in tasks that include the following: she monitors food and fluid intake; weighs the patient weekly; sits with the patient during meals and assists by cueing. Moreover, in order to best help the patient, the nurse needs to have knowledge about her illness, since dementia can sometimes display the same symptoms as delirium, depression, and other conditions.

Caregiver Wellness and Family Support

Last but certainly not least is the importance of simultaneously taking care of one's own health and stress level as a health practitioner to ensure that the nurse does not become overwhelmed by the patient's situation (Samson et al., 2004; Hayslip et al., 2008). The nurse should also help the family care for themselves while taking care of the patient. These are just some of the attitudes and practices that derive from client-centered nursing. Research in nursing journals consistently demonstrates that caregiver support and respite care reduce burnout and improve patient outcomes.