Nursing Care Plan for Alzheimer’s disease

NURSING DIAGNOSIS

OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

RISK FOR INJURY

Possible Etiologies: (Related to) Disorientation to time and place Confusion (wandering at night) Forgetfulness and increased memory loss Presence of motor disturbance i.e. apraxia Defining characteristics: (Evidenced by)

*Not Applicable

Short term goal: Within the whole duration of nursing care, the client will be free from injury. Long term goal: After 2 weeks of nursing care, the client will be able to demonstrate behaviors that protect self from injury and will have reality orientation necessary in learning/ retaining essential aspects in daily living.

1. Evaluate client’s level of competence and ability to participate in preventive measures. 2. Adapt communication to the level of client and speak with the client using slow pace and simple words while maintaining a firm volume and low pitch. 3. Observe for nonverbal

behaviours and intervene if

client becomes angry or

hostile by decreasing stressful

stimuli and approaching client

in calm, reassuring manner.

4. Frequently reorient of time,

place, date, and person; place

a clock and a calendar in his

room; allow him to reminisce;

and repeat instructions as

necessary.

4. Assess environment for

potential factors indicating

risk for injury like dim lighted

room, absence of hand rails,

slippery floor, and high bed.

- This is to assess the degree of risk for injury of client and aids in detecting what appropriate measures you will include in the plan of care. -Communicating with the client in this way promotes positive atmosphere and a relaxed pace for learning. -Some personality changes may occur in client’s with Alzheimer’s such as irritability, suspiciousness, and indifference. This would also aid in reducing demands on client. -These measures are necessary in enhancing client’s memory. -This will provide information on what safety devices are necessary to be instituted.

-These measures minimize

Within the whole duration of nursing care, client should be free from any sorts of injury. After 2 weeks of nursing care, client should have demonstrated behaviours like enhanced memory and orientation to time, place and significant person, and ability to participate in doing self- care and other activities of daily living with minimal assistance in a safe environment.

5. Provide adequate lighting,

reduce client’s bed to lower

position, put necessary

devices in aiding client’s

mobility around the house

and remove harmful objects

like slippery rug etc.

6. Ensure that client cannot

leave the premises without

being noticed; provide an

identification bracelet or tag

for the client to wear at all

times.

7. Educate family members

and care giver of client’s

condition and how to deal and

care the client; the need for

safe environment; how to

communicate with the client;

and measures that enhance

memory.

client’s misperception of his environment and his risk for injury.

- Client’s with Alzheimer’s disease are sometimes confused making them wanders without valid reason (especially during night time); this will avoid the client from being missing or face accidents outside the institution.

- Providing health teachings regarding client’s condition could assist family members in understanding the manifestations elicited by the client and would reassure them that peculiar personality changes and increasing memory loss is part of this condition; it would aid them cope and take care with the client at home upon discharge.