NURSING CARE PLAN FOR DEMENTIA

A Nursing Care Plan Presented to:

Lendell Kelly B. Ytac, RN
Faculty, INAHS BSN-Program
Davao Oriental State University

_____________________________________________

In Partial Fulfillment of the Requirements for

NCM 117
Care of Clients with Maladaptive Patterns of Behavior

Russel Faye I. Sabillo

Student Nurse, BSN-3A

March 27, 2023

ASSESSMENT HEALTH GORDON’S LEVEL PLAN OF CARE NURSING EVALUATION
PROBLEM/ FUNCTIONAL OF INTERVENTIONS/
NURSING HEALTH CARE ACTIVITIES
DIAGNOSIS PATTERN/
NEED
Subjective Self-Care Deficit Cognitive- S After 2 weeks of NURSE INITIATED: The outcome
cues: may be related Perceptual E nursing criteria for a
“Mama seems to cognitive C intervention, the 1. Assess if how is the client patient with
to forget herself decline, physical O patient will be able able to meet her basic needs, dementia
nowadays. So, I limitations, N to: who is she residing with, include:
help her clean frustration over D  Client will be presence of visual or hearing
herself and loss of A able to disabilities, and her usual  Client is
wear her clothes independence, R maintain daily routine. able to
every day.” as depression, Y physical care Rationale: It will provide groom and
verbalized by possibly with less important information as to dress
daughter. evidenced by assistance and how the client functions at herself with
impaired ability on the level of home and indicate the need minimal
to perform her ability. for the degree of assistance assistance
Objective ADLs.  Client will be required by the client. or with
cues: able to 2. Observe and assess for assistance
 Inability to Definition: participate in her appearance i.e. as
maintain her Inability to activities that appropriate dressing, necessary.
appearance independently would promote disturbances in gait or  Client is
unlike before perform or her level of movement, presence of participative
 Forgetfulness complete functioning and injuries. in activities
(time and cleansing learn and recall Rationale: Clients with like fixing
place where activities; to put previous cognitive impairment often and feeding
she is) on or remove capabilities, at have some changes in self at her
 Inability to rec clothing,; to eat; the end of appearance because of own level of
all previous or to perform nurse-patient inability to assume previous ability,
tasks tasks social role or functioning. reminiscing
 Presence of u associated with interaction. 3. Check her judgement, previous
rinary bowel and orientation, memory and roles and
incontinence bladder cognitive abilities. capabilities,
as claimed by elimination Rationale: These are and learning
daughter indicators to the proper or
 Difficulty articul Reference: functioning of a person as relearning
ating needs NANDA 16TH client with dementia usually tasks
EDITION F.A. would require prompting to
 Poor judgeme DAVIS ISBN complete tasks. (enhancing
nt when 978-974-652- 4. Build rapport with client memory)
assessed 351-6 through a calm, supportive needed for
approach in interaction. her to
Rationale: Trust is the main accomplish
key point in establishing her ADLs.
relationship with the client. It
would prevent the client from DOCUMENTA
becoming suspicious or TION:
delinquent from asking 1. Established
assistance. positive
5. Organize a structured, approach to
routine schedule of activities the patient
considering client’s abilities 2. Build
while maximizing her rapport with
independence. client
Rationale: It would help client through a
resume her ADLs without calm,
overstimulation. supportive
6. Reorient client frequently approach in
by putting her name in bold interaction.
big letters in her door or by 3. Take steps
calling her by name always, that avoid
putting a clock and some agitation,
familiar pictures in her room stress and
and even putting the conflict
schedule of activities for a 4. Recognized
given day. dangerous
Rationale: This would situations
help her enhance her and
memory and it would create a implemente
comfortable environment for d
her. precautions.
7. Provide a safe, non- 5. Patient was
restrictive environment for the able to
client through proper and respond to
adequate lighting, etc. the memory
Rationale: This would ensure cues
her safety and would help 6. Provide
prevent harm/injury since health
client may be disoriented and teachings to
confused at times. the client
8. Encourage enough resting and family.
periods and adequate sleep.
Rationale: This will help client
regain strength and energy
and would minimize mood
changes like irritability and
some agitation.
9. Encourage client to
engage in activities like music
therapy and dancing; involve
client in simple decision
making.
Rationale: This will promote
positive self-concept and her
ability to solve or accomplish
simple tasks.
10. Assist client in her ADLs
but as much as possible let
her regain independence
depending on her abilities.
Rationale: By doing this,
client will be able to lessen
dependency and be able to
function with integrity.

PSYCHIATRIST INITIATED:

1. The Psychiatrist will

provide prescription in
response to client medical
diagnosis
Rationale: to help manage
symptoms that affects
thinking and memory, as well
as mood and behavior.
COLLABORATIVE:

2. Assist the client to become

aware of rights and
responsibilities in health and
healthcare to assess own
health strengths- physical,
emotional, and intellectual.
Rationale: To promote
wellness
(Teaching/Discharge
Considerations);.
3. Review and modify
program periodically to
accommodate changes in
client's abilities.
Rationale: Assists client to
adhere to plan of care to
fullest extent.
4. Encourage keeping a
journal of progress and
practicing of independent
living skills.
Rationale: to foster self-care
and to accommodate self-
determination.
5. Give family information
about respite or other care
options.
Rationale: Allows them free
time away from the care
situation to renew
themselves. (Refer to ND
caregiver Role Strain for
additional interventions.)
6. Collaborate with medical
and psychiatric providers in
evaluating orientation,
attention span, ability to
 follow directions, send/
receive communication, and
appropriateness of response.
Rationale: to determine
presence and/ or severity of
impairment.

Nursing Theory:

Florence Nightingale:
Environmental Theory

Jean Watson:
Theory of Human Caring

Dorothea Orem:
Self-Care Deficit Theory

REFERENCE
https://www.scribd.com/document/279089337/Dementia-Nursing-Care-Plan