Name: Kim Kristine Dee D.

Guillen Section: BSN Psychiatric Nursing Lecture

Clinical Example:
Martha Smith, a 79-year-old widow with Alzheimer disease, was admitted to a nursing home.
The disease has progressed during the past 4 years to the point that she can no longer live
alone in her own house. Martha has poor judgment and no short-term memory. She had
stopped paying bills, preparing meals, and cleaning her home. She had become increasingly
suspicious of her visiting nurse and home health aide, finally refusing to allow them in the
house. After her arrival at the facility, Martha has been sleeping poorly and frequently wanders
from her room in the middle of the night. She seems agitated and afraid in the dining room at
mealtimes, is eating very little, and has lost weight. If left alone, Martha would wear the same
clothing day and night and would not attend to her personal hygiene.

Guide Questions:

1. What additional assessments would the nurse want to make to plan care for this
client?
➢ The nurse would want to make additional assessments for the plan of care of the
client that would be comprising a diagnostic work-up that includes test that
involves the client’s reflexes, muscle tone and strength, ability to get up from a
chair and walk across the room, the sense of sight and hearing, coordination,
and balance. A blood test may help to rule out other potential causes of memory
loss and a mental statis exam to assess memory and other thinking
skills. neuropsychological testing may provide additional details about mental
function compared with people of a similar age and education level. These tests
can help establish a diagnosis and serve as a starting point to track the
progression of symptoms in the future.
2. What nursing diagnoses would the nurse identify for this client?
➢ Disturbed thought process related to Alzheimer’s disease as evidenced by poor
judgment, poor sleeping habits, agitation, frequently wandering, and disheveled
general appearance.
➢ Self-Care deficit related to Alzheimer’s disease as evidenced by poor judgment,
poor sleeping habits, and disheveled general appearance.
➢ Disturbed sleep pattern to Alzheimer’s disease as evidenced by poor judgment,
poor sleeping habits, agitation, frequently wandering, and disheveled general
appearance.
3. Write an expected outcome and at least two interventions for each nursing diagnosis?
 ➢ Disturbed thought process related to Alzheimer’s disease as evidenced by poor
judgment, poor sleeping habits, agitation, frequently wandering, and disheveled
general appearance.
o Client will have improved thought processing or will be maintained at a
baseline level.
o Observe client for cognitive functioning, memory changes, disorientation,
difficulty with communication, or changes in thinking patterns.
o Assess client’s ability to cope with events, interests in surroundings and
activity, motivation, and changes in memory pattern.
➢ Self-Care deficit related to Alzheimer’s disease as evidenced by poor judgment,
poor sleeping habits, and disheveled general appearance.
o Client will be appropriately groomed and dressed independently with or
with minimal assistance.
o Assess client’s functional and cognitive ability to provide self-care.
o Allow client to perform as much care as able, giving simple instructions,
step-by-step.
➢ Disturbed sleep pattern to Alzheimer’s disease as evidenced by poor judgment,
poor sleeping habits, agitation, frequently wandering, and disheveled general
appearance.
o Client will achieve and maintain restorative restful sleep.
o Assess client’s sleep patterns and changes, naps, and frequency, amount
of activity, sedentary status, number and time of awakenings during night,
and patient’s complaints of fatigue apathy, lethargy, and impotence.
o Provide ritualistic procedures of warm drink, extra covers, clean linens, or
warm baths prior to bedtime.
4. What is/are the appropriate nursing interventions for Martha?

➢ Observe client for cognitive functioning, memory changes, disorientation, difficulty

with communication, or changes in thinking patterns.
➢ Assess client’s ability to cope with events, interests in surroundings and activity,
motivation, and changes in memory pattern.
➢ Orient client to environment as needed, if patient’s short term memory is intact.
Using of calendars, radio, newspapers, television and so forth, are also appropriate.
➢ Maintain a regular daily schedule routine to prevent problems that may result from
thirst, hunger, lack of sleep, or inadequate exercise.
➢ Allow patient the freedom to sit in a chair near the window, utilize books and
magazines as desired.
➢ Allow hoarding and wandering in a controlled environment, as appropriate or within
acceptable limitations.
➢ Be supportive and convey warmth and concern when communicating with the
patient.