PATIENT CARE PLAN

STUDENT DATE Sunday

Patient Initials W.J. AGE 75 SEX Male ADMITTING DX Alzheimer’s Disease
OTHER MEDICAL DX Residual Delirium, UTI,
Sepsis, Hyperension
Diabetes
Mellitus

NURSING DIAGNOSIS PATIENT-CENTERED NURSING RATIONALE EVALUATION

(in priority order) GOALS INTERVENTION

Nursing Diagnosis: Short term goal: 1. Provide W.J. with clues for 1. This will assit W.J. with At the end of 2 weeks the
Disturbed Thought orientation: “Good morning Mr. W.J. learning to build his trust nurse will take anther look at
After 2 weeks of My name is Tommie Waiters, and I with the nurse; ensuring that the care plan and the
1) As evidence by: nursing interaction, will assist you today.” I will Avoid it is a professional type of interaction, the client can
Alzheimer’s Disease W.J. will be able to putting him on the spot by asking interaction and that will verbalize positive concept of
Changes in cognitive view his progress in a questions he may not answer, such as ensure the confidentiality of self, know his strengths and
abilities-Impaired positive manner by “Do you know what Month we are in interaction. limits as a person.
memory-Disorientation working through some or what color is the American Flag.
Chemical imbalances in of his memory
the brain-Dementia challenges and the W.J. is able to participate in
Neuronal destruction in realization that he has all his normal daily activities
the brain-Memory loss2) the strength and with safety measures in
family support to push place, he will be able to show
As evidence by: High forward. 2. I will place a large sign on his door 2. -This will promote a an eagerness to socialize
Fever Nausea with his name printed in Bold letters positive and trusting with family and other people,
W.J. will remain calm to assist his with finding his room. environment with the client he has learned to deal well
High WBC High and will not considering that Alzheimer's with the problems by
hematocrit count experience agitation patients often times require working on his negative
Escherichia coli culture and anxiety as a result and little assistance in omission and have a more
of his disorientation finding there way. positive though process, he
3) As evidence by: and memory loss. will have a more open
Mental confusion Fever appraisal, and express
Cognitive concerns Long term goal: 3. Ask the family bring in large print 3. -Sometimes clients who emotional productivity
Delirium photos to stimulate his mind. are suffering from associated with having
At the end of nursing Alzheimer's and depressed Alzheimer's.
4) As evidence by: High interaction, the client may have some emotional
Blood Pressure test will be able to outbursts, crying spells or
Family History Past demonstrate behaviors hesitancy in sharing their
medical history that show optimism of thoughts. The photos are a
self and his ability to reminder that there are
5) As evidence by: Need work with the people that love them, and
to urinate High blood challenges associates there are people that care
sugar with Alzheimer's and only want their best
Disease. He can start interest. But, we have to
Subjective: Wife reports to understand the keep in mind that nonverbal
client has Alzheimer's world that he lives in, cues from W.J. could tell a
disease, diabetes, he will be able to better story this would allow
hypertension and thoroughly learn to for a better outcome and
arthritis. accept the of limits, assist in taking care of his
interacting with other exaggerated emotions.
Objective: Labs: people, performing
tasks, learning to do
Sodium 160 his ADL's and have an 4. Ensure the W.J. takes all of his 4. -These will help in
Potassium 3.6 improved ability to required medication and receives all knowing which medication
Chloride 104 express self and solve of his treat and ordered by the is best for the patient. This
BUN 21 concerns properly. physician. will be reinforce during the
plan of care. It may also
help client understand of his
Creatinine 1.6 Glucose limits as person.
206
Carbon dioxide 24

(WBC) 9.8
(RBC) 4.2
(Hgb) 12 5. Avoid changing W.J. sleeping 5. -Knowing these will help
(Hct) 42% area, replace items back where they you pinpoint with the client
Platelets 220,000 mm3 came from. if he can cope with his
challenges effectively or
Vitals: not; they will guide him to
Temp: 100.6 avoid negative coping
Pulse: 94 measures.
RR: 20
BP: 140/76
O2: 96%

Urine Output: 200 mL 6. Consult with Physical Therapy 6. This will help W.J. know
Pain: 5/10 PO: 160 staff with planning memory his strengths as a person and
activities, make sure at any physical would help him resume his
Charts: Providers activity is a non-fail activity that will autonomy and independence
Notes: Very require very little energy or with integrity and a sense of
disoriented last concentration pride.
evening with some
delusions. Better this
morning, oriented to 7. Work to make sure that W.J. is 7. -This will promote W.J.s
person, place. No able to perform the care, being positive concept of self it
anxious behaviors provided make it clear, easy to will also enhance his ability
reported. Vital signs understand, make it nonthreatening to return to functioning with
stable. Will continue instructions and don't delay care it certain limits.
to monitor blood possible, if he is being resistant hold
pressure every shift. care and continue to work with him
Urinalysis within as needed until he is calmer.
normal limits.
Ambulating better on
own. Blood sugars
slightly elevated from
pre-illness but
improving. Delirium 8. Research different methods, and 8. These researched items
continues to be a medications. Make sure that only and safety measures will
concern. nonpoisonous plants are at his bed allow for W.J. to be able to
side for safety. Spread furniture out move around on his own
Nursing Notes: for clearer move about in the room. and his ability to be safe and
Make sure all trip hazards are out of the family to worry less.
Admitted to Skilled the way (cords, tables, rugs ect.)
Nursing Unit from Wireless phone if possible.
Medical Unit.
Accompanied by wife Make any additional changes as
and son (Ronald). Client required.
oriented to name, time
(morning), and family.
Client and family
oriented to room and to
unit. Client and family
understand that the
client will be expected 9. Use verbal cues with ADL. Teach 9. Maintaining a positive
to dress in comfortable the staff to avoid doing tasks that image of self helps a person
street clothes during W.J. can perform by his self. Look feel good about self and the
stay. Goal of admission for cues of frustration and irritation improvement they are
according to client is to from W.J. and intervene when need making towards returning to
"beef me up" before be. their ADL's.
discharge home.
Nursing assessment
completed, see EMR.
Minimum data set 10. Talk with his family and ask them 10. This will promote
(MDS) form initiated. to bring him cloths that he can easily client’s ability to express
MDS coordinator put on Sweat Suit, gym cloths, ect.). self and allow for his to
notified of admission by Work with W.J. s that he can learn to resume some sort of normal
voicemail. set out his own cloths. way to his life.

Drugs Taken:

Rivastigmine tartrate
Metformin
Rosiglitazone maleate 11. Always use a sit down tub for
Hydrochlorothiazide W.J. in order to prevent falls. Assist
Atenolol Enalapril W.J. with bath only if required and
maleate Ciprofloxacin with tooth brushing.
hydrochloride
See Diatary Chart for
additional instruction.
12. Use an established and consistent
bedtime norm. Allow as much
bathroom time as necessary for W.J.
to be at ease.
13. Provide a light snack of and warm
beverage when possible. Make sure
that his snakes have been cleared by
the Dietician. Be patient with W.J.'s
process.
14. Answer any of the families
concerns to ensure that the best
possible care is being given to W.J.
11. This will enhance
client’s ability to be safe
when performing an ability
of his own.
12. The allows for W.J. to
have a routine, this gives his
something that he can
control and makes for a
better day for everyone
knowing that the client has
this under his control.
13. W.J. will have the
ability t snack when he likes
to, this will also allow for
W.J. to be able to be safe
when eating food. W.J. will
have the ability to perform
one of his ADL's on his
own.
14. The allows you to keep
the family informed as to
any changes in the clients
life, the family members are
also involved in the care
and control of what is going
with his safety, it also give
W.J. the ability to know that
he is also in control.