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ASSESSME NT Objective: Disorientati on to person, place and time -Memory deficit, altered attention span, and decreased ability

to grasp ideas -Impaired ability to make decisions and problem solve -Disordered thought sequencing

DIAGNOS IS Disturbed thought processes r/t degenerat ive process as manifeste d by memory deficit

RATIONA LE Dementia is a chronic disturbanc e involving multiple cognitive deficits, including memory impairmen t. Dementia is characteri zed by chronicity and deteriorati on of selective mental functions therefore giving the client a disturbed thought processes.

PLANNING Goal: After 2 days of nursing intervention, the patient will maintain usual reality orientation. Objectives: After 8 hours of nursing intervention, the patient will: -Identify ways to compensate for cognitive impairment and memory deficits -Demonstrate behaviors to minimize changes in mentation

INTERVENTION Assess attention span/distractibility and ability to make decisions or problem solve. Test ability to receive, send, and appropriately interpret communications. Perform periodic neurologic assessment, as indicated.

EVALUATIO N Determines ability to After 2 days participate in of nursing planning and intervention, executing care. the patient was able to maintain To assess degree of usual reality impairment. orientation. After 8 hours Early recognition of of nursing changes promotes intervention, proactive the patient modifications to plan was able to: of care. -Identify ways to Inability to maintain compensate orientation is a sign for cognitive of deterioration. impairment and memory To prevent further deficits deterioration. -Demonstrate behaviors to minimize changes in Provides stimulation mentation while reducing fatigue. Client may respond with anxious or aggressive behaviors if startled or overstimulated. May aid in reducing


Reorient to time, place, and person as needed. Provide safety measures such as side rails, padding as necessary and close supervision as indicated. Schedule structured activity and rest periods. Maintain a pleasant, quiet environment and approach client in a slow, calm manner.

Give simple directions, using short words and simple sentences.

confusion, and increases possibility that communications will be understood and remembered. To convey interest and worth to individual. To assist client in developing coping strategies.

Listen with regard. Allow ample time for client to respond to questions and comments and make simple decisions.

Provides clues to aid in recognition of Maintain reality oriented reality. relationship and environment (clocks, calendar, personal items). Confrontation potentiates Present reality concisely defensive reactions and briefly and do not and may lead to challenge illogical patient mistrust and thinking. heightened denial of reality. To avoid triggering fight and flight responses. Client may feel threatened and may withdraw or rebel.

Reduce provocative stimuli, negative criticism, arguments and confrontations. Refrain from forcing

activities and communications. Respect individuality and personal space. Provide for nutritionally well balanced diet, incorporating clients preferences as able. Promote adequate rest and undisturbed periods of sleep. Establish a regular schedule for expected activities.

To create therapeutic milieu. Enhances intake and general well being. Sleep deprivation may further impair cognitive abilities. Aids in maintaining reality orientation and may reduce fear and confusion.