ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Short Term Goal: Independent Independent Short Term Goal:

3 year history of gradual Disturbed thought 1. Assess patient’s ability for thought processing 1. Changes in status may indicate progression
social withdraw process related to After 8 hours of every shift. Observe patient for cognitive of deterioration or improvement in After 8 hours of nursing
alteration in cognitive nursing intervention, functioning, memory changes, disorientation, condition. intervention, the patient
difficulty with communication, or changes in 2. Reality orientation techniques help
Objective: abilities as manifested the patient will be able wasable to verbalize
thinking patterns. improve patient’s awareness of self and
Mental Status by social withdrawal, to verbalize 2. Orient patient to environment as needed, if environment only for patients with
understanding of the disease.
Examination: deterioration in understanding of the patient’s short term memory is intact. Using of confusion related to cognitive problesms The patient was also able to
Tomas could name the personal care, disease. The patient calendars, radio, newspapers, television and so 3. Client may respond with anxious or be aware and oriented with
year but not the month or disorientation to will also be able to be forth, are also appropriate. aggressive behaviors if startled or reality be maintained at an
day of the week for his date/time and memory aware and oriented if 3. Reduce environmental stimulation. Maintain a overstimulated. optimal level.
appointment. deficit possible, and reality pleasant, quiet environment and approach client 4. Maintain security by avoiding a
will be maintain at an in a slow, calm manner. confrontation that could improve the
He remembered one of optimal level. 4. Eliminate or minimize sources of hazards in the behavior or increase the risk for injury. Long Term Goal:
three objects in two environment 5. Sleep deprivation may further impair
minutes 5. Promote adequate rest and undisturbed periods cognitive abilities. After 2 weeks of nursing
of sleep. 6. May aid in reducing confusion, and
Long Term Goal: interventions the patient was
6. Give simple instructions, using short words and increases possibility that communications
Performed three of five simple sentences. will be understood and remembered. able to achieve functional
subtractions correctly, After 2 weeks of 7. Provide positive reinforcement and feedback 7. Promotes patient confidence and reinforces ability at his optimum level
nursing interventions for positive behaviors. progress. with modifications and
Named four common the patient will be able 8. Inform patient of care to be done, with one 8. Patients with AD require extended time for alterations within his
objects correctly, to achieve functional instruction at a time. processing information. Removal of environment to compensate
ability at his optimum 9. Instruct family in methods to use with decision making may facilitate improved for deficits. The Family
He was able to draw the level with communication with patient: listen carefully, compliance and feelings of security. members was able to
fact of a clock and place modifications and listen to stories even if they’ve heard them 9. Comments from the patients may involve exhibits understanding of
the numbers correctly, but alterations within his many times previously, and to avoid asking reliving experiences from previous years required care and will
questions that the patient may not be able to and may be totally appropriate within that
he was not able to environment to demonstrate appropriate
answer. context.
correctly place the hands compensate for deficits. 10. Instruct family members in the disease process, 10. Once diagnosis of AD is made, the family
coping skills and ability to
at 10 minutes after two. The Family members what can be expected, and assist with providing should be prepared to make long-term utilize community resources.
will be able to exhibits a list of community resources for support. plans in order to discuss problems before
understanding of they arise.
required care and will 11. Call patient by name. 11. The name is a form of self-identity and
demonstrate 12. Use a rather low voice and spoke slowly in lead to recognition of reality and the
appropriate coping patients. individual.
skills and ability to 13. Divert attention to a client when agitated or 12. Increasing the possibility of understanding.
utilize community dangerous behaviors like getting out of bed by 13. To promote safety and prevent risk for
resources. climbing the fence bed. injury.
Dependent
14. Administer medications as ordered 14. Helps to temporarily manage memory loss,
thinking and reasoning problems, and day-
to-day function.