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Assessment Diagnosis Planning Implementation Rationale Evaluation

The document summarizes a nursing care plan for a patient with Alzheimer's disease. It notes the patient's symptoms of memory deficits, disorientation, and confabulation. The diagnosis is disturbances in thought processes related to Alzheimer's. The goal is for the patient to regain optimal mental status within 2-3 days through nursing interventions. Interventions include frequent assessment of orientation, speaking slowly and clearly to the patient, and encouraging use of personal belongings and a calendar. The plan was successfully evaluated, with the patient's mental state improving after 2-3 days.

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2K views3 pages

Assessment Diagnosis Planning Implementation Rationale Evaluation

The document summarizes a nursing care plan for a patient with Alzheimer's disease. It notes the patient's symptoms of memory deficits, disorientation, and confabulation. The diagnosis is disturbances in thought processes related to Alzheimer's. The goal is for the patient to regain optimal mental status within 2-3 days through nursing interventions. Interventions include frequent assessment of orientation, speaking slowly and clearly to the patient, and encouraging use of personal belongings and a calendar. The plan was successfully evaluated, with the patient's mental state improving after 2-3 days.

Uploaded by

ria_soriano_2
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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ASSESSMENT

Subjective Cues: Filipino speaks better English than American as verbalized by the client repeatedly Objective Cues: Memory deficit Impaired ability to make decisions and problem solving Disorientation Confabulation Perseveration

DIAGNOSIS
Disturb Thought Processes related to primary degenerative disease ( Alzheimers Disease) as manifested by memory deficit and disorientation.

PLANNING
Goal: After 2 to 3 days of effective nursing interventions, patient would regain optimal level of mental state. Objective: After 4 to 8 hrs of effective nursing interventions, patient would identify ways to compensate for the cognitive impairment/memory deficits

IMPLEMENTATION
Independent: Assess degree of disorientation to time, place, person, and situation regularly and frequently.

RATIONALE
This will determine the amount of reorientation and intervention the patient will need to evaluate reality accurately. This decreases chances for misinterpretation. Present information in a matter-of-fact manner. To get oriented to time.

EVALUATION
The goal was met. After 2-3 days of effective nursing intervention, the patient regained optimal level of mental state.

Use patients name when speaking to him or her.

Speak slowly and clearly.

Refer to the time of day, date, and recent events in your interactions with the patient. Encourage patient to check calendar and clock often. Encourage patient to have familiar personal belongings in his or her environment. Be matter-of-fact and respectful when correcting patients misperceptions of

This decrease the sense of alienation patient may feel in an environment that is strange. Orientation to ones environment increases ones ability to trust others.

reality. Use the words "you" and "I," instead of "we." This increases orientation and encourages patient to maintain his sense of separateness and personal boundary.

Dependent: Administer medications as ordered by the physician.

To aid in the treatment and reduce signs and symptoms

Nursing Care Plan and Drug Study


Submitted to: Mam Lenie Agpalasin Submitted by: Ria Janine A. Soriano

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