RLE 002

Cebu Normal University

College of Nursing
Cebu City

Mission-Vision: “Care Using Knowledge and Compassion”

Theory-based (Betty Neuman)

NURSING CARE PLAN

Assessment 3 points Goals 2 points Interventions 4 points Bibliography

Diagnosis 3 points Theoretical Basis 2 points Evaluation 1 point 15 points

Name of Student:__________________________________________
Client’s Initials:___________________________________________ Stressor Classification: (Please check)
Age:______Gender: _____Civil Status:________Religion:_______ ______ Physiological (body structure and functions)
Allergies: ________________________________________________ ______ Psychological (mental processes and emotion)
Diet:_____________________________________________________ ______ Socio-cultural (relationships, social expectations)
Date of Admission:________________________________________ ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression:_____________________________________ ______ Developmental (developmental processes over the lifespan)

NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME

Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
 (Goal attainable within the shift) (with Rationale & Source)

Subjective: PRIMARY INTERVENTIONS

“Wa. Wa. Ako? Oo, ambot.” By the end of the shift: Promotive:
I: Maintain consistent scheduling with allowances
 Patient will have for patient’s specific needs, and avoid frustrating
Chronic confusion r/t minimal confusion, situations and overstimulation.
Alzheimer’s disease cognitive impairment, and
Objective: R: Prevents patient agitation, erratic behaviors,
other dementia and combative reactions.
manifestations.
 Decreased ability to S:Doenges, Murr & Moorhouse (2015)
 Patient will have stable,
interpret one’s environment
safe environment with I:Provide time for reminiscing if patient so desires.
 Decreased capacity for
routine scheduling of
thought R: Allows for memory of past pleasant events.
activities to decrease Patient may be reliving events in the past and the
 Memory impairment
anxiety and confusion. caregiver should identify this behavior and respect
 Disorientation it.
 Patient will exhibit
 Behavioral changes
minimal or reduced S:Doenges, Murr & Moorhouse (2015)
 Personality changes
confusion, memory loss,
 Altered interpretation
and cognitive disturbances,
 Response to stimuli
depending upon stage of
AD.
Preventive:
 Patient will be able to
tolerate stimuli when I: Utilize cognitive function testing.

Theoretical basis: introduced slowly in R: Identifies current level of dementia.

nonthreatening manner,
with one item at a time. S: Doenges, Murr & Moorhouse (2015)
Chronic Confusion is an  Patient will be able to
rreversible, long-standing, I: Assess patient for reversible or irreversible
be distracted or use other dementia, causes, ability to interpret environment,
and/or progressive deterioration
of intellect and personality techniques to avoid intellectual thought processes, memory loss,
characterized by a decreased stressful situations that disturbances with orientation, behavior, and
ability to interpret environmental may cause aggressive, socialization.
stimuli and a decreased hostile behaviors or
capacity for intellectual thought R: Determines type and extent of dementia to
frustration. establish a plan of care to enhance cognition and
processes, which manifest as
disturbances of memory,  Family will be able to
orientation, and behavior. utilize information emotional functioning at optimal levels.
Alzheimer’s disease (AD) is a
effectively in dealing with S: Doenges, Murr & Moorhouse (2015)
progressive and irreversible,
degenerative, fatal disease and patient with confusion with
is the most common form of regard to limitations of
dementia among older stimulation and validation
people. Dementia is of patient’s thoughts.
a braindisorder that seriously SECONDARY INTERVENTIONS
 Family will be able to
affects a person’s ability to
carry out daily activities. utilize information to begin Curative
Progression of the disease is making decisions for long-
done in phases until all term plans for patient. I: Limit sensory stimuli and independent decision-
cognitive function is destroyed. making.
Pathologic consequences
R: Decreases frustration and distractions from
include the loss of neurons in
multiple areas within the brain, environment. Decreasing stress of making a
atrophy with wide sulci and choice helps to promote security.
dilated ventricles of the brain,
S: Doenges, Murr & Moorhouse (2015)
the presence of plaques
composed of I: Assist with establishing cues and reminders for
neurites, astrocytes, and glial
patient’s assistance.
cells that surround an amyloid
center, and neurofibrillary R: Assists patients with early AD to remember
tangles. location of articles and facilitates some orientation.

S: Doenges, Murr & Moorhouse (2015)

I: Identify family members and/or support systems

for the patient.

R: Helps to determine appropriate person to notify

for changes, to assist with care, and someone
familiar to patient to help deal with his confusion

S: Doenges, Murr & Moorhouse (2015)

TERTIARY INTERVENTIONS
 Rehabilitative
I: Ask family members about their ability to provide
care for patient.

R: Identifies family’s need for assistance.

S: Doenges, Murr & Moorhouse (2015)

I: Instruct family to utilize distraction techniques,

such as soothing music, going for a walk, or
looking at picture albums if patient has delusions.

R: Distraction may be effective to calm patient if

stressful situations occur.

S: Doenges, Murr & Moorhouse (2015)

Bibliography:
Doenges, Murr & Moorhouse. 2015. Nursing Diagnosis & Interventions (NANDA).