Diagnosis

1. Thought Processes,
Altered, related to
progressive dementia
as evidenced by
disorientation to time
and place, loss of
short-term memory,
inability to
concentrate, and
periods of agitation.
DS= her daughter
reported that her
mother disappeared;
Mrs. Rodriguez was
agitated and
disoriented
DO=loss of shortterm memory,
inability to
concentrate

Goal
1. Mrs. Rodriguez will
remain calm and will
not experience
agitation and anxiety
as a result of her
disorientation and
memory loss.

Intervention
1.1 Provide Mrs.
Rodrigues with clues
for orientation:
Good morning Mrs.
Rodrigues. My name
is Devi, and I will help
you today. Avoid
putting her on the
spot by asking
questions she may
not answer, such as
Do you know what
day this is?
1.2 Place a large sign
on Mrs. Rodriguezs
door with her name
printed in large letter
to help her find the
room.

1.3 Have family bring

in snapshots and
photos to stimulate
reminiscence.

Rationale
1.1 People in the
early stages of
Alzheimers disease
may become agitated
because their world is
always unfamiliar to
them. The issue is not
whether individuals
with a dementia are
oriented, but
whether they can
cope with their
environment.
1.2 Short-term
memory loss makes it
impossible for Mrs.
Rodriguez to
remember where her
room is or where the
bathroom is. If she
still recognizes her
name, posting it on
the door will help her
find her way.
1.3 Reminiscing can
be a satisfying
activity. It is
especially helpful if
the photos are from
an earlier, happier
time such as when
her children were
young. Long-term

Implementation
1.1 Helped the client
with ADLs at 7:00 am.
- Kristina Devinta, SN
(Student Nurse)

1.2 Posted a large

print on the clients
door of her name at
7:00 am
-Kristina Devinta,SN

1.3 Put up a pictures

given by daughter
near her bed at 7:30
am
-Kristina Devinta, SN

Evaluation
1. S: my mother
becomes calmer.
O: the client does not
experience agitation
and anxiety
A: goal met
P: continue
interventions
Mrs. Rodriguez
remained calm and
showed no signs of
agitation or anxiety.

1.4 Avoid changing

Mrs. Rodriguezs
room. Put items back
in the same place all
the time.
1.5 Consult with
activities staff in
planning selfexpensive, non-fail
activities that require
little concentration
(e.g., painting with
non-toxic paints,
modeling with nontoxic clay).
1.6 If Mrs. Rodriguez
is resistant to care,
provide clear, simple,
nonthreatening
instructions and delay
care as needed until
she is calmer.

memory may still be

intact, allowing her to
recall these happier
times.
1.4 Consistency in the
environment (as well
as in routine and
staff) reduces
frustration.
1.5 Appropriate
activities prevent
boredom, which can
lead to irritation. It is
important to plan
non-stressful, noncompetitive, failureproof activities in
order to prevent
frustration.
1.6 Persons with
cognitive deficits
often vary between
combativeness and
cooperation. Often,
delaying care for even
10 to 15 minutes
when resistance is
encountered
improves client
outcomes.

1.4 Cleaned room 305

and prepared it for
Mrs Rodriguez at 9:00
am
-Kristina Devinta, SN
1.5 Sign up the client
for the seminar on
May 6, 2011
-Kristina Devinta, SN

1.6 Successfully
taught and aided her
through the seminar
at 4:00 pm
-Kristina Devinta, SN

2. Injury, risk for,

related to risk factors
of mode of
transportation and
cognitive and
affective factors as
evidenced by
wandering behavior,
impaired judgment,
and disorientation
DS Where am I?
Why am I here?
DO client has risk
for injury due to
wandering off

2. Mrs. Rodriguez will

remain free injury
while retaining as
much independence
and freedom as
possible.

3. Self-care deficit
related to perceptual
or cognitive
impairment (memory
loss and sensoryperceptual deficits) as
evidenced by needing
a reminder to shower
and change clothes.
DS client looks
anxious
DO client unable to
complete ADL

3. Mrs. Rodriguez will

complete ADL with
minimal assistance
now and with
increasing assistance
as the disease
progresses.

2.1 Look up tools,

medicines, and
chemicals. Keep only
nonpoisonous plants
of the unit. Arrange
furniture so that
walkways are open.
Pad sharp corners of
Tables and chests.
Cover electrical
outlets and radiators.
Place electrical cords
and telephone wires
out of reach.
2.2 Provide assurance
during free drills.

2.1 Persons with

Alzheimers disease
do not recognize
unsafe acts or
conditions due to loss
of judgment. They do
not comprehend
cause and effect.

2.1 Prepared room

for client at 6:00 am
-Samuel Rumahorbo,
Student Nurse

2.2 Unusual activity

of any sort increases
agitation, especially
when noise level is
increased.

2.2 Help client during

free drill at 8:00 am.
Samuel Rumahorbo,
SN

3.1 Use verbal clues

and hand-over-hand
assistance with ADL.
Instruct staff to avoid
doing tasks that Mrs.
Rodriguez can do by
herself. Watch for
signs of frustration
and irritation and
intervene when
appropriate.
3.2 Ask family to
bring in clothing that
is easy to manipulate.

3.1 Using these

simple techniques
can minimize the
need for assistance,
thereby increasing
feelings of selfesteem.

3.1 Help client with

breakfast and
morning walk at
8:15am
Samuel Rumahorbo,
SN

3.2 Dressing is one of

the more difficult
tasks to accomplish.

3.2 Aided client in

changing clothes at
9:00 am

2.
S Thank you for
helping me, nurse
client is delighted in
the nursing home.
O Mrs. Rodriguez
has experienced no
injury
A Goal met;
P Continue
intervention.

3. S - Mrs. Rodriguez
participates in ADL
with no anxiety
O ADLs are
completed
A - Goal met;
P - Continue
intervention

4. Sleep Pattern
Disturbance related
to disorientation as
evidenced by
wakefulness at night.
DS client is grouchy
in the morning,
wakes at night and
anxious
DO Client have
heavy eye bags and
looks drowsy in the
morning

4. Mrs. Rodriguez will

experience fever
periods of
wakefulness during
the night if she
awakens, she will
remain calm and free
of agitation.

Set clothing out in

order it is to be put
on.
3.3 Consider tub
baths rather than
showers. Put privacy
and do not leave the
client alone.

Appropriate clothing
can simplify the
activity.
3.3 Showers are
frequently
threatening or
confusing to person
with Alzheimers
disease. Tub baths
are also more
relaxing.

Samuel Rumahorbo,
SN

4.1 Avoid stimulating

activities prior to
bedtime. Establish a
consistent bedtime
routine. Take Mrs.
Rodriguez to the
bathroom and allow
sufficient time for
complete bladder
emptying.

4.1 Overstimulation
prior to bedtime may
increase anxiety,
preventing sleep.
Having the client
participate in
relaxation activities
and repeating the
clients long-practiced
bedtime routine prior
to bed may also be
helpful.
These activities are
relaxing.
4.2Hunger or
overeating can
interfere with sleep.

4.1 Prepared for

bedtime at 8:45pm,
brought the client to
the bathroom at
8:50pm.
-E J Solaiman, SN

4.2 Help Mrs.

Rodriguez with a
sponge bath and with
oral care; give her a
back rub using warm
lotion and slow,
smooth strokes.

3.3 Client took a bath

at 8:50 am safely
without accident
-Samuel Rumahorbo,
SN

4.2 Aided the client

for a sponge bath,
provided oral care,
back rub with lotion
at 8:55pm
-Kristina Devinta, SN

4. S- I had a
wonderful sleep
O - Mrs. Rodriguez
sleeps through the
night several times a
week;
A- Goal met;
P - Continue
intervention.

4.3 Provide a light

snack of a warm,
noncaffeinated
beverage and a plain,
easily digested
cracker, cookie, or a
piece of toast. Be
patient and do not
rush her.
4.4 Question family
concerning previous
bed-time routines
and sleeping habits.
Repeat bedtime
routine when Mrs.
Rodriguez awakens
during night.
4.5 Encourage a short
nap early in the
afternoon.
4.6 Avoid the use of
sleeping medications.

4.3 Individuals may

have used specific
sleep routines
throughout their
lifetimes, such as
sleeping with a night
light, having a
window open, playing
a radio, or wearing
socks to bed.
4.4 Mrs. Rodriguez
will think it is time to
go to the bed

4.3 Gave client a

whole wheat cracker
and a warm glass of
water at 9:15pm.
-E J Solaiman, SN

4.5 Sleep pattern

disturbances may
result from over
fatigue.
4.6 Sleeping
medications are
seldom effective and
may increase
confusion,
disorientation, and
restlessness.

4.5 Client took a nap

at 2:00pm
-Samuel Rumahorbo,
SN
4.6 Client fell asleep
at 9:35pm without
the use of
medications.
-E J Solaman, SN

4.4 Brought client to

the bed and prepare
for sleep at 9:25pm.
-E J Solaiman, SN