Diagnosis Goal Intervention Rationale Implementation Evaluation

1. Thought Processes, 1. Mrs. Rodriguez will 1.1 Provide Mrs. 1.1 People in the 1.1 Helped the client 1. S: “my mother
Altered, related to remain calm and will Rodrigues with clues early stages of with ADLs at 7:00 am. becomes calmer.”
progressive dementia not experience for orientation: Alzheimer’s disease - Kristina Devinta, SN O: the client does not
as evidenced by agitation and anxiety “Good morning Mrs. may become agitated (Student Nurse) experience agitation
disorientation to time as a result of her Rodrigues. My name because their world is and anxiety’
and place, loss of disorientation and is Devi, and I will help always unfamiliar to A: goal met
short-term memory, memory loss. you today.” Avoid them. The issue is not P: continue
inability to putting her on the whether individuals interventions
concentrate, and spot by asking with a dementia are Mrs. Rodriguez
periods of agitation. questions she may oriented, but remained calm and
not answer, such as whether they can showed no signs of
DS= her daughter “Do you know what cope with their agitation or anxiety.
reported that her day this is?” environment.
mother disappeared; 1.2 Place a large sign 1.2 Short-term
Mrs. Rodriguez was on Mrs. Rodriguez’s memory loss makes it 1.2 Posted a large
agitated and door with her name impossible for Mrs. print on the client’s
disoriented printed in large letter Rodriguez to door of her name at
to help her find the remember where her 7:00 am
DO=loss of short- room. room is or where the -Kristina Devinta,SN
term memory, bathroom is. If she
inability to still recognizes her
concentrate name, posting it on
the door will help her
find her way.
1.3 Have family bring 1.3 Reminiscing can 1.3 Put up a pictures
in snapshots and be a satisfying given by daughter
photos to stimulate activity. It is near her bed at 7:30
reminiscence. especially helpful if am
the photos are from -Kristina Devinta, SN
an earlier, happier
time such as when
her children were
young. Long-term
 memory may still be
intact, allowing her to
recall these happier
times.
1.4 Avoid changing 1.4 Consistency in the 1.4 Cleaned room 305
Mrs. Rodriguez’s environment (as well and prepared it for
room. Put items back as in routine and Mrs Rodriguez at 9:00
in the same place all staff) reduces am
the time. frustration. -Kristina Devinta, SN
1.5 Consult with 1.5 Appropriate 1.5 Sign up the client
activities staff in activities prevent for the seminar on
planning self- boredom, which can May 6, 2011
expensive, non-fail lead to irritation. It is -Kristina Devinta, SN
activities that require important to plan
little concentration non-stressful, non-
(e.g., painting with competitive, failure-
non-toxic paints, proof activities in
modeling with non- order to prevent
toxic clay). frustration.
1.6 If Mrs. Rodriguez 1.6 Persons with 1.6 Successfully
is resistant to care, cognitive deficits taught and aided her
provide clear, simple, often vary between through the seminar
nonthreatening combativeness and at 4:00 pm
instructions and delay cooperation. Often, -Kristina Devinta, SN
care as needed until delaying care for even
she is calmer. 10 to 15 minutes
when resistance is
encountered
improves client
outcomes.
2. Injury, risk for, 2. Mrs. Rodriguez will 2.1 Look up tools, 2.1 Persons with 2.1 Prepared room 2.
related to risk factors remain free injury medicines, and Alzheimer’s disease for client at 6:00 am S – “Thank you for
of mode of while retaining as chemicals. Keep only do not recognize -Samuel Rumahorbo, helping me, nurse”
transportation and much independence nonpoisonous plants unsafe acts or Student Nurse client is delighted in
cognitive and and freedom as of the unit. Arrange conditions due to loss the nursing home.
affective factors as possible. furniture so that of judgment. They do O – Mrs. Rodriguez
evidenced by walkways are open. not comprehend has experienced no
wandering behavior, Pad sharp corners of cause and effect. injury
impaired judgment, Tables and chests. A – Goal met;
and disorientation Cover electrical P – Continue
DS – “Where am I? outlets and radiators. intervention.
Why am I here?” Place electrical cords
DO – client has risk and telephone wires
for injury due to out of reach.
wandering off 2.2 Provide assurance 2.2 Unusual activity 2.2 Help client during
during free drills. of any sort increases free drill at 8:00 am.
agitation, especially Samuel Rumahorbo,
when noise level is SN
increased.

3. Self-care deficit 3. Mrs. Rodriguez will 3.1 Use verbal clues 3.1 Using these 3.1 Help client with 3. S - Mrs. Rodriguez
related to perceptual complete ADL with and hand-over-hand simple techniques breakfast and participates in ADL
or cognitive minimal assistance assistance with ADL. can minimize the morning walk at with no anxiety
impairment (memory now and with Instruct staff to avoid need for assistance, 8:15am O – ADLs are
loss and sensory- increasing assistance doing tasks that Mrs. thereby increasing Samuel Rumahorbo, completed
perceptual deficits) as as the disease Rodriguez can do by feelings of self- SN A - Goal met;
evidenced by needing progresses. herself. Watch for esteem. P - Continue
a reminder to shower signs of frustration intervention
and change clothes. and irritation and
DS – client looks intervene when
anxious appropriate.
DO – client unable to 3.2 Ask family to 3.2 Dressing is one of 3.2 Aided client in
complete ADL bring in clothing that the more difficult changing clothes at
is easy to manipulate. tasks to accomplish. 9:00 am
 Set clothing out in Appropriate clothing Samuel Rumahorbo,
order it is to be put can simplify the SN
on. activity.
3.3 Consider tub 3.3 Showers are 3.3 Client took a bath
baths rather than frequently at 8:50 am safely
showers. Put privacy threatening or without accident
and do not leave the confusing to person -Samuel Rumahorbo,
client alone. with Alzheimer’s SN
disease. Tub baths
are also more
relaxing.
4. Sleep Pattern
Disturbance related 4. Mrs. Rodriguez will 4.1 Avoid stimulating 4.1 Overstimulation 4.1 Prepared for 4. S- “I had a
to disorientation as experience fever activities prior to prior to bedtime may bedtime at 8:45pm, wonderful sleep…”
evidenced by periods of bedtime. Establish a increase anxiety, brought the client to O - Mrs. Rodriguez
wakefulness at night. wakefulness during consistent bedtime preventing sleep. the bathroom at sleeps through the
DS – client is grouchy the night if she routine. Take Mrs. Having the client 8:50pm. night several times a
in the morning, awakens, she will Rodriguez to the participate in -E J Solaiman, SN week;
wakes at night and remain calm and free bathroom and allow relaxation activities A- Goal met;
anxious of agitation. sufficient time for and repeating the P - Continue
DO – Client have complete bladder client’s long-practiced intervention.
heavy eye bags and emptying. bedtime routine prior
looks drowsy in the to bed may also be
morning helpful.
These activities are
relaxing.
4.2 Help Mrs. 4.2Hunger or 4.2 Aided the client
Rodriguez with a overeating can for a sponge bath,
sponge bath and with interfere with sleep. provided oral care,
oral care; give her a back rub with lotion
back rub using warm at 8:55pm
lotion and slow, -Kristina Devinta, SN
smooth strokes.
4.3 Provide a light 4.3 Individuals may 4.3 Gave client a
snack of a warm, have used specific whole wheat cracker
noncaffeinated sleep routines and a warm glass of
beverage and a plain, throughout their water at 9:15pm.
easily digested lifetimes, such as -E J Solaiman, SN
cracker, cookie, or a sleeping with a night
piece of toast. Be light, having a
patient and do not window open, playing
rush her. a radio, or wearing
socks to bed.
4.4 Question family 4.4 Mrs. Rodriguez 4.4 Brought client to
concerning previous will think it is time to the bed and prepare
bed-time routines go to the bed for sleep at 9:25pm.
and sleeping habits. -E J Solaiman, SN
Repeat bedtime
routine when Mrs.
Rodriguez awakens
during night.
4.5 Encourage a short 4.5 Sleep pattern 4.5 Client took a nap
nap early in the disturbances may at 2:00pm
afternoon. result from over -Samuel Rumahorbo,
fatigue. SN
4.6 Avoid the use of 4.6 Sleeping 4.6 Client fell asleep
sleeping medications. medications are at 9:35pm without
seldom effective and the use of
may increase medications.
confusion, -E J Solaman, SN
disorientation, and
restlessness.