PHINMA UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES

Nursing Department

NURSING CARE PLAN

NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective:  Chronic Short-term: Independent: Short-term:
“my mom would confusion After 1-2 weeks of nursing  Establish rapport with the  To build a trusting relationship After 1-2 weeks of nursing
always ask why is related to intervention the client will be patient. between the nurse and the patient. intervention, goal met. The
she in the house Alzheimer’s able to:  Assess patient for reversible or  Determines type and extent of patient was able to:
and said it’s not her disease as  Exhibit minimal or irreversible dementia, causes, dementia to establish a plan of care  Exhibited minimal or
house, and she evidenced by reduced confusion, ability to interpret environment, to enhance cognition and emotional reduced confusion,
sometimes doesn’t decrease ability memory loss, and intellectual thought processes, functioning at optimal levels. memory loss, and
know the use of to recognize cognitive disturbances, memory loss, disturbances with cognitive disturbances,
kitchen utensils”, as things and depending upon stage of orientation, behavior, and depending upon stage
stated by the interpret one’s ad. socialization. of ad.
patient’s daughter. environment,  Be distracted or use  Maintain consistent scheduling  Prevents patient agitation, erratic  Able to be distracted or
decreased other techniques to with allowances for patient’s behaviors, and combative reactions. used other techniques
capacity for avoid stressful situations specific needs, and avoid Scheduling may need revision to to avoid stressful
Objective: thought, that may cause frustrating situations and show respect for the patient’s sense situations that may
 Decrease ability memory aggressive, hostile overstimulation. of worth and to facilitate completion cause aggressive,
to recognize impairment, behaviors or frustration. of tasks. hostile behaviors or
things and disorientation,  Remain safe and free  Avoid or terminate emotionally  Catastrophic emotional response is frustration.
interpret one’s and behavioral from harm. charged situations or prompted by task failure when the  Remained safe and
environment. changes.  Maintain usual level conversations. Avoid anger and patient feels expected to perform free from harm.
 Decreased orientation. expectation of patient to beyond ability and becomes  Maintained usual level
capacity for remember or follow instructions. frustrated and angry. Responding orientation.
thought Long-term: Do not expect more than the calmly to the patient validates
 Memory After 1-3 months of nursing patient is capable of doing. feeling and causes less stress. Long-term:
impairment intervention the client will be  Provide time for reminiscing if  Allows for memory of past pleasant After 1-3 months of nursing
 Disorientation able to: patient so desires. events. Patient may be reliving intervention, goal met. The
 Behavioral  Maintain usual level of events in the past and the caregiver patient was able to:
changes orientation should identify this behavior and  Maintained usual level
 Use appropriate support respect it. of orientation
systems.  Limit sensory stimuli and  Decreases frustration and  Used appropriate
 Remains safe and harm independent decision-making. distractions from environment. support systems.
free. Decreasing stress of making a  Remained safe and
 Maintain minimal or choice helps to promote security. harm free.
reduce confusion,  Assist with establishing cues and  Assists patients with early AD to  Maintained minimal or
memory loss, and reminders for patient’s remember location of articles and reduce confusion,
cognitive disturbances if assistance. facilitates some orientation. memory loss, and
not improved.  Identify family members and/or  Helps to determine appropriate cognitive disturbances
support systems for the patient. person to notify for changes, to if not improved.

 Ask family members about their
ability to provide care for patient.
 Instruct family and provide them
with information regarding
community services and long-
term health care facilities.
 Instruct family regarding
avoidance of arguing with patient
about what he thinks, sees, or
hears.
 Instruct family to consider if what
patient believes has some basis
in reality.
 Instruct family to avoid having
patient watch violent TV shows.
 Instruct family to utilize
distraction techniques, such as
soothing music, going for a walk,
or looking at picture albums if
patient has delusions.
Dependent:
 Assist in treating contributing
conditions.
 Administer medications, as
ordered.
Collaborative:
 Identify appropriate
community resources.
 Provide appropriate
referrals.
PREPARED BY: BEATRICE MANINGAS, UICN-SN
assist with care, and someone
familiar to patient to help deal with
his confusion.
 Identifies family’s need for
assistance.
 Patient may require ongoing skilled
nursing care that the patient’s family
is unable or unwilling to provide.
 Patient may have delusions and
hallucinations, that are real to the
patient, and no amount of
persuasion will convince him or her
otherwise. The patient may become
agitated or violent if contradicted.
 Sometimes portions of
conversations can be heard and
misinterpreted by the patient.
 Patient cannot make distinction of
reality from fiction, and witnessing
violent acts on the screen may be
frightening to the patient.
 Distraction may be effective to calm
patient if stressful situations occur.
 The patient may have an underlying
condition that can contribute
to/exacerbate confusion, discomfort
and agitation.
 To managed symptoms of
psychosis, depression, or
aggressive behavior.
 To provide patient with support and
assist with problem-solving.
 To promote wellness and to provide
appropriate assistance for the
patient.