Defining Characteristics
Identification Interventions
Subjective:
“Indi ko kapanumdom mayad” as
verbalized by the client
Objective:
Disorientation to time, place,
person, and circumstance
Inability to cooperate
Easy distractibility
Agitated
Disturbance in judgement and
abstract thoughts
Vital signs taken:
BP – 152/76mmHg
RR – 17cpm
PR – 85bpm
T – 98.7 degrees Fahrenheit
Nursing Diagnosis Outcome Nursing Rationale Evaluation
Long term: Independent:
Disturbed thought process related to After 24 hours of Assess and monitor To have a baseline
Alzheimer’s disease as evidenced by nursing intervention vital signs. data. Goal completely met.
Disorientation to time, place, person, patient will have
Patient have appropriate
and circumstance, inability to appropriate Assess patient’s ability Changes in status may
maintenance of mental
cooperate, easy distractibility, maintenance of mental for thought processing indicate progression of
and psychological
agitated, and disturbance in and psychological every shift. Observe deterioration or
function and reversal of
judgement and abstract thoughts function as long as patient for cognitive improvement in
behaviors.
possible, and reversal functioning, memory condition.
of behaviors when changes,
Patient achieve functional
Rationale: possible. disorientation,
ability at her optimum
The diagnosis Disturbed Thought difficulty with
level with modifications
Processes describes an individual Patient will achieve communication, or
and alterations within her
with altered perception and functional ability at changes in thinking
environment to
cognition that interferes with daily his optimum level patterns.
compensate for deficits.
living. Causes are biochemical or with modifications and
psychological disturbances like alterations within his Assess level May indicate
Patient is aware and
depression and personality disorders. environment to of confusion and effectiveness of
oriented, and reality
The focus of nursing is to compensate for disorientation. treatment or decline in
maintained at an optimal
reduce disturbed thinking and deficits. condition.
level.
promote reality orientation.
Patient will be aware Assess patient’s ability Patient may exhibit
Note: Nursing Diagnosis should be and oriented if to cope with events, assertiveness or
base from (NANDA- Approved possible, and reality interests in aggressiveness to
Nursing Diagnosis) will be maintained at surroundings and compensate for
an optimal level. activity, motivation, feelings of insecurity,
and changes in or develop more
memory pattern. narrowed interests and
have difficulty
accepting changes in
lifestyle.
Short term: Orient patient to Reality orientation
After 4 hours of environment as techniques help
nursing intervention needed, if patient’s improve patient’s
the family member short-term memory is awareness of self and
will be able to exhibits intact.  environment 
understanding of
required care and will Allow patient the Respect for the
demonstrate freedom to sit in a patient’s personal
appropriate coping chair near the window, space allows patient to
skills and ability to utilize books and exert some control.
utilize community magazines as desired.
resources.
Label drawers, use Assists patient’s
Patient’s family will written memory by use of
be able to access reminders notes, reminders of what to
community resources pictures, or color- do and location of
and make informed coding articles to articles.
choices regarding assist patients.
patient’s care, both
currently and for Allow hoarding and Increases patient’s
future care. wandering in a security and decreases
controlled hostility and agitation
environment, as by permitting
appropriate or within behaviors that are
acceptable limitations. difficulty to prevent,
to be allowed within
the confines of a safe
supervised
environment.

Provide positive Promotes patient

reinforcement and confidence and
feedback for positive reinforces progress.
behaviors.

Dependent:
Administer medication
as ordered:

Donepezil Donepezil increase the

hydrochloride/Aricept availability of
10 mg once daily at acetylcholine at the
bedtime: synapses, enhancing
cholinergic
 transmission. Is
approved to treat all
stages of the disease.
It's taken once a day as
a pill. 

FeSo4 (Iberet) 500mg To treat or prevent

1 tablet OD @ HS vitamin deficiency due
to poor diet, certain
illnesses

Defining Characteristics Nursing Diagnosis Outcome Nursing Rationale Evaluation

Identification Interventions
Risk for injury related to Long term: Independent:
Subjective: Alzheimer’s disease as evidenced by After 4 hours of Assess and monitor To have a baseline Goal completely met.
confusion, disorientation, and nursing intervention vital signs. data. Patient remain safe from
agitation. patient will remain environmental hazards
Objective: safe from Assess the degree of Impairment of visual resulting from cognitive
Confusion Rationale: environmental hazards impaired ability of perception increase the impairment.
Disorientation Falls are a leading cause of broken resulting from competence, risk of falling. Identify
Agitation. hips and other serious injuries in the cognitive impairment. emergence of potential risks in the Patient remain in a safe
Vital signs taken: elderly, and those impulsive behavior, environment and environment with no
BP – 140/ 90mmHg with Alzheimer's are at particularly Patient will remain in and a decrease in heighten awareness so complications or injuries
RR – 12cpm high risk of falling. Problems with a safe environment visual perception. that caregivers more obtained.
PR – 78bpm vision, perception and balance with no complications aware of the danger.
increase as Alzheimer's advances, or injuries obtained.
making the risk of a fall more likely Assess patient’s AD decreases
surroundings for awareness of potential
Note: Nursing Diagnosis should be hazards and remove dangers, and disease
base from (NANDA- Approved Short term: them. progression coupled
Nursing Diagnosis) After 2 hours of with hazardous
nursing intervention environment that
the family will ensure could lead to
safety precautions are accidents.
instituted and
followed. Help the people To prevent future
closest to identify the injury to occur.
Family will be able to risk of hazards that
identify and eliminate may arise.
hazards in the patient’s
environment Eliminate or minimize Maintain security by
sources of hazards in avoiding a
the environment. confrontation that
could improve the
behavior or increase
the risk for injury.

Maintain adequate Allows patient to be

lighting and clear able to see and find
pathways. the way around room
without danger of
tripping or falling.

Instruct family Prevents physical

regarding removal or injury from
locking up knives and ingestion, burns,
sharp objects away overdoses, or
from the patient. accidents.
Instruct family to
apply protective guard Prevents accident
over electrical outlets, injury.
thermostats, and stove
knobs.

Instruct family to keep

pathways clear, move Prevents risk of falls.
furniture against the
wall, remove throw
rugs, remove wheels
on beds and chairs or
set lock them in place,
and keep rooms and
hallways well lighted.

Instruct patient to Noise, crowds, the

maintain a nice quiet crowds are usually the
neighborhood. excessive sensory
neurons and can
increase interference.

Dependent:
Administer medication
as ordered:

Donepezil
hydrochloride/Aricept Donepezil increase the
10 mg once daily at availability of
bedtime: acetylcholine at the
synapses, enhancing
cholinergic
transmission. Is
approved to treat all
stages of the disease.
It's taken once a day as
a pill. 
FeSo4 (Iberet) 500mg
1 tablet OD @ HS
To treat or prevent
vitamin deficiency due
to poor diet, certain
illnesses