FON Care Plan

Student: Abigail Rodriguez Date: November 4, 2019

Course: NSG 300 CC Instructor: Professor Aspell

Clincial Site: Suntree Adult Day Center Client Identifier: J.G. Age: 79

Reason for Admission: Respite care/ lacking socialization

Client was admitted to Suntree Adult day center by his caregiver, due to J.G. needing constant attention. He is also lacking socialization.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Dementia and Alzheimer’s Disease:
Dementia is a vascuar disease that clinically reflects
predominantly deterioration of function in the association cortex.
The damage to the brain cells that are associated with Dementia
interferes with the ability of the brain to communicate with itself.
Therefore, depending on the region of the brain, individauls can
experience issues with memory, judgment, and movement
(Alzheimer’s Association, 2019a). The utmost cause/connection
with Dementia is atherosclerosis, which is hardening of the
arteries due to thickening of the artery from fatty deposits or
plaques. Individuals who have diabetes, are overweight, unhealthy
diet, and lack physical activity are at risk for developing
atherosclerosis. Dementia contains a collection of symptomes that
affect memory, thinking, and social abilities (OMICS
International, 2016).
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
The clinical manifistations associated with demenita include both
cognitive and psychological changes. Cognitive changes involve
memory loss, difficulty with communication and making words,
difficulty reasoning and problem-solving, and confusion and
disorientation. In addition, the psychological changes include
personality changes, depression, anxiety, inappropriate behavior,
agitation, and hallucinations. Dementia is commonly progressive,
therefore patients may experience different symptoms at different
times, some more worsening compared to others. Early diagnosis of
Dementia allows individuals to to get maximum benefit from the
treatments that are available which are mostly symptomatic (Mayo
Clinic, 2019).
The clinical manifestations associated with Alzheimer’s disease
most generally revolve around memory loss. As it is a developing
diseases, memory impairments worsen and other symptoms
 Alzheimer’s disease is the most common form of Dementia. develop. The memory issues seen with this disease include
Alzheimer’s is a progressive neurodegenerative disorder, resulting repetition when communicating with others, forgetfulness with
in gradual, irreversible loss of memory and cognitive function. It is conversations and events, get lost in familiar places, and eventually
most commonly believed that Alzheimer’s is caused by a forgetting the names of family members and everyday objects.
combination of genetic, lifestyle, and environmental factors that Personality changes also occur, issues like depression, apathy,
affect the brain overtime, as the exact cause is not yet fully social withdrawal, mood swings, and wandering. There are many
understood. There are also two proteins, beta-amyloid, and skills that are preserved for longer periods even though the
neurofibrillary tangles, Tau proteins, that are focused on when condition continues to progress. Therefore, some patients continue
discussing Alzheimer’s disease. As Beta-amyloid is a leftover to read, tell stories, sing, and dance while their symptoms continue
fragment of a larger protein, these numerous fragments cluster to worsen (Mayo Clinic, 2019).
together- causing a toxic effects on neurons as they are causing a
disrupt to cell-to-cell communication. Secondly, Tau proteins,
which are normally in charge of carrying nutrients and other
essential minerals, change shape and organize themselves into
neurofibrillary tanges. These tangles are also toxic to the cells in
the brain and negatively affect the cell-to-cell communication
(Mayo Clinic 2018).

Assessment Data

Subjective Data: Patient stated he felt no pain. J.G. was very cooperative, as he shared family stories and old memories while being assessed.
Patient stated, “Do whatever you need, when you pull on my ear it reminds me of my Greek mother that tugged on my ears everytime I did
something I knew I was not supposed to.” He laughed continuously throughout the assessment.
VS: T : 97.8 F Labs: Although the client does not have any labs Diagnostics: Although the client does not have any
in his chart, the labs I would recommend diagnostics in his chart, I would recommend:
BP: 146/81 mmHg
include:
- Brain imaging: standard imaging, like an MRI or
HR: 70
- Psychometric testing: this test is a CT, are primarily used to rule out other
RR: 14 intended to diagnose all dementias, as it conditions that may cause symptoms similar to
O2 Sat: 94% on RA measures an individual’s mental Alzheimer’s disease (Alzheimer’s Association
capabilites and behavioural styles. I 2019). J. G. would benefit from brain imaging
No pain noted. Scoring a recommend this lab because J. G.’s because in some circumstances, health care
0 on the Wong-Baker faces
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pain rating scale. condition will continue to worsen, providers may use this as a tool to find out if the
therefore his caregivers will be well individual ahs high levels of beta-amyloid, which
informed (Alzheimer’s Association as stated before has toxic affects on brain cells.
2019b).
- Vitamin B12: This would be a routinely
test, that will help identify cognitive
imparments. Due to him being diagnosed
with two diseases resembling cell
degeneration, this would be an important
test for him to take routinely
(Alzheimer’s Association 2019).

Assessment: Orders:
Patient was alert x1, to person. Patient is responsive to questions but has
an attention span of approximately 10 minutes.
Past medical history: Heart surgery (2001), Appendectomy,
hypertension, hypothyroidism, and hypercholesterolemia.
Skin:
- The individual’s skin is warm, dry, and intact. No lesions noted
on the exposed skin.
- The skin turgor is appropriate with no apparent tenting,
bilaterally.
- Upon assessment, no upper body edema was noted bilaterally.
- The radial pulses are strong, equal and palpable bilaterally,
approximately 2+.
- Capillary refill is less than 2 seconds bilaterally on fingers and
toes.
- DNR
- Regular Diet.
- Water and soap to wash skin tear.
- Approximate wound margin. Steri strip/nonadhering dressing
for wounds.
- Pulse oximeter to obtain the Oxygen Saturation level as
needed (PRN).
- Blood glucose test to rule out hypoglycemia or
hyperglycemia.
- Activities of Daily Living (ADL): dependent on caregiver
- Bathing: 1 person assisst supervision
- Hydration: drink 8-12oz fluids each day.

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Head, Face, and Neck:
- The head is a normocephalic shape, face is symmetrical, and
neck is proportionate to the head and face; hair distribution is
normal.
- Temporal and carotid arteries are palpable bilaterally.
- The patient denied pain or tenderness on the maxillary and
frontal sinuses, bilaterally.
- After assessing TMJ, the client denies pain; no popping or
clicking noted bilaterally.
- Cranial nerve V, Trigeminal is intact. Although, sluggish
reaction to the cotton ball stimulus.
- Cranial nerve VII, Facial, is intact.
- CN XII, Hypoglossal, is intact.
- Lymph nodes are non-palpable and non-tender bilaterally.
- Trachea is midline.
Eyes:
- The eyes are symmetrical, conjunctiva is pink, sclera is white,
and no drainage or jaundice were noted bilaterally.
- For PERRLA assessment, pupils are equal and round bilaterally,
pupils are sluggish reactive to light ( both direct and consensual)
and accommodation showed sluggish pupil constriction, and
dilation bilaterally. Convergence is noted. Pupil size is noted at
approximately 3 mm bilaterally.
Ears:
- External ears are intact and symmetrical. The color is consistent
with his exposed skin, and the pinna and tragus are nontender
and moveable, bilaterally.

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Nose, Mouth, Throat:
- The nose is midline. Nares are symmetrical and patent
bilaterally.
- Tongue is pink, moist, and without lesions. The buccal mucosa
is pink, moist, and without lesions bilaterally. He has an upper
denture, however, dentition is intact.
- Uvula rises with pronation; CN XII, Glossopharyngeal is intact.
Thorax:
- The client is sitting upright and respirations are regular, even,
and non-labored.
- The rise/fall of posterior chest is symmetrical.
- Bilateral breath sounds are clear to auscultation throughout
posterior chest in all lobes. Good inspiratory effort, no
adventitious sounds noted.
- No carotid bruits auscultated bilaterally.
- Bilateral breath sounds are clear to auscultation throughout
anterior chest in all lobes. Good inspiratory effort, no
adventitious sounds noted.
- S1 and S2 heart sounds auscultated with regular rate and
rhythm; no S3 and S4 sounds or murmurs auscultated.
Extremities:
- There was no swelling, tenderness, redness or nodules noted in
the shoulder, elbow, wrist, knee, or ankle joints bilaterally.
Client denies pain with palpation. No spinal abnormalites noted.
- Client has equal range of motion in all joints, bilaterally.
Strength, with and without resistance is equal in the shoulder,
elbow, wrist, knee, and ankle bilaterally.
- No lower body edema was noted, bilaterally.

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 - The posterior tibial and dorsalis pedis pulse sites were strong,
equal, and palpable bilaterally, approximately 2+.
- The capillary refill of the toes was sluggish and took
approximately 5 seconds to refill bilaterally.
Neurological:
- The barefoot and heel-to-toe gait is steady, and patient
ambulates independently.
- Negative Romberg test; no swaying noted.
- Deep tendon reflexes of brachioradialis and patellar reflex are
present bilaterally.
- Rapid Alternating Movements are noted and intact, bilaterally.

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 Medications
ALLERGIES:
Sulfonamide

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect
Buspirone 5mg PO BID for 30 - Management of anxiety. Bind
days to serotonin and dopamine
receptors in the brain,
increasing norepinephrine
metabolism in the brain. Reliefs
anxiety.
Memantine 10mg PO BID - - For moderate to severe
AM/ PM dementia/neurocognitive
disorder associated with
Alzheimer’s disease.
- Binds to CNS N-methyy-D-
aspartate receptor sites,
preventing binding of
glutamate, an excitatory
neurotransmitter. Does not cure
disease, but does decrease
symtpoms of cognitive decline.
CNS: dizziness, drowsiness,
excitement, fatigue, headache,
insomnia, nervousness,
weakness, personality changes.
EENT: blurred vision, nasal
congestion, sore throat, tinnitus,
comjuctivitis.
CV: chest pain, palpitations,
tachycardia, hypertension,
syncope.
GI: nausea, abdominal pain,
constipation, dry mouth.
Neuro: incoordination,
numbness, paresthesia.
CNS: dizziness, fatigue,
headache, sedation
CV: hypertension
GI: diarrhea, weight gain
Hemat: anemia
Considerations
1. The degree and
manifistations of
anxiety need to be
assessed before and
periodically during
therapy.
2. Beware of substance
dependence or tolerance
if patient has a history
of substance use
disorder.
3. If patient has history
of substance abuse,
assess the patient’s
tolerance as well as
impaired control
(Vallerand, Sanoski, &
Deglin J. 2017).
1. Cognitive function
(memory, attention,
reasoning, language,
ability to perform
simple tasks) must be
assessed before, during,
and after medication
therapy.
2. Teach patient about
postural hypotension,
because the patient may
experience dizziness.
3. Teach patient that the
medication may take
7
 months to reach
therapeutic level.
(Vallerand, Sanoski, &
Deglin, 2017).
Escitaloprám 10mg PO Once per - Management of depressive CNS: insomnia, dizziness, 1. Monitor mood
day - AM disorder and generalized drowsiness, fatigue, neuroleptic changes and level of
anxiety disorder. malignant syndrome, suicidal anxiety during therapy.
- selectively inhibits the ideation 2. Assess for suicidal
reuptake of serotonin in the GI: diarrhea, nausea, abdominal tendencies, especially
CNS. Antidepressent action. pain, constipation, dry mouth. during early therapy.
Metabolism: increased appetite 3. Assess for sexual
dysfunction- erectile
dysfunction, and
decreased libido
(Vallerand, Sanoski, &
Deglin, 2017).
Levothyroxine 50mg PO Once per - Thyroid supplementation in CNS: headache, insomnia, 1. Assess apical pulse
day - AM hypothyroidism. irritability. and BP prior to and
- Replaces or supplements the CV: angina pectoris, arrhythmia, periodically during
endogenous thyroid hormones. tachycardia. therapy. Assess for
Principal effect is increasing GI: abdominal cramps, diarrhea, tachyarrythmias and
metabolic rate of body tissues. vomiting. chest pain.
Aids in the development of the Endo: hyperthyroidism 2. Overdose is
brain and CNS. manifested as
hyperthyroidism
(Vallerand, Sanoski, &
Deglin, 2017).
Losartan 100mg PO Once per - Management of hypertension CNS: dizziness, anxiety, 1. Assess BP (laying,
day - AM depression, fatigue, insomnia. sitting, standing) and
EENT: nasal congestion, pulse frequently during
pharyngitis. initial dose adjustment
CV: hypotension, chest pain, and periodically during
edema. therapy.
GI: abdominal pain, diarrhea, 2. Monitor frequency of
nausea. perscription refills to
determine compliance
(Vallerand, Sanoski, &
Deglin, 2017).
Atorvastatin 20mg PO Once per - Management of CNS: amnesia, confusion, 1. Obtain a diet history,
day - PM hypercholesterolemia and dizziness, memory loss, especially with regard
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 mixed dyslipidemia. Primary
prevention of coronary heart
disease.
- Inhibits 3-hydroxy-3-
methylglutaryl-coenzyme A
reductase, an enzyme which is
responsible for catalyzing an
early step in the synthesis of
cholesterol.
- Lowers total and LDL
cholesterol and triglycerides.
Quetiapine 25mg PO Once per - Decreases manifestation of
day - PM depression
- Acts by serving as an
antagonist of dopamine and
serotonin. Antagonizes
Histamine receptors and alpha
1 adrenergic receptors.
Rivastigmine 95mg PO Once per - Decreases dementia
day - PM symptoms and enhances
congitive function.
- Enhances cholinergic function
by reversible inhibiton of
cholinesterase. Does not cure
the disease.
Melatonin 3mg PO Once per - Used for sleep disorders,
day - pM including insomnia, jet lag, and
circadian rhythm disorder.
-Supplements the hormone
melatonin, which regulates the
normal sleep/wake cycle.
weakness.
EENT: rhinitis, blurred vision
CV: chest pain, peripheral
edema
GI: abdomnial cramps,
constipation, diarrhea, flatus,
heartburn
CNS: neuroleptic malignant
syndrome, seizures, dizziness,
cognitive impairment.
EENT: ear pain, rhinitis,
pharyngitis.
CV: increased blood pressure,
palpitations, postural
hypotension.
GI: pancreatitis, anorexia,
constipation.
CNS: weakness, dizziness,
unusual sedation.
CV: edema, heart failure,
hypotension.
GI: anorexia, nausea, vomiting,
diarrhea.
CNS: headache, dizziness,
drowsiness.
GI: abdominal cramps, nausea.
to fat consumption.
2. Evaluate serum
cholesterol and
triglyceride levels
before initiating, and
periodically after
(Vallerand, Sanoski, &
Deglin, 2017).
1. Monitor mental
status (mood,
orientation, behavior)
before and periodically
during therapy
2. Assess for suicidal
tendencies, especially
during early therapy
(Vallerand, Sanoski, &
Deglin, 2017).
1. Assess congitive
function (memory,
attention, reasoning,
language, ability to
perform simple tasks)
periodically throughout
therapy.
2. Monitor patient for
nausea, vomiting,
anorexia, and weight
loss (Vallerand,
Sanoski, & Deglin,
2017).
1. Assess sleep patterns
before and periodically
throughout therapy.
2. Monitor blood
glucose, coagulation
panel, hormone panel,
9

Tylenol/Acetaminophen 1000mg PO Every 6 - Treat mild pain, fever.
hours/PRN - Inhibits the synthesis of
prostaglandins that may serve
as mediators of pain and fever,
primarily the CNS.
Tylenol/Acetaminophen 500mg PO Every 6 - Treat mild pain, fever.
hours/PRN - Inhibits the synthesis of
prostaglandins that may serve
as mediators of pain and fever,
primarily the CNS.
Imodium/Loperamide Per label PO Per label - Relief of acute diarrhea.
- inhibits peristalis and
prolongs transit time by a direct
effect on nerves in the intestinal
muscle wall. Reduces fecal
volume and increases viscosity.
CNS: agitation, anxiety,
headache
CV: hypertension, hypotension
GI: hepatotoxicity, constipation,
increased liver enzymes, nausea,
vomiting
CNS: agitation, anxiety,
headache
CV: hypertension, hypotension
GI: hepatotoxicity, constipation,
increased liver enzymes, nausea,
vomiting
CNS: drowsiness, dizziness
GI: constipation, abdominal
pain, distention/discomfort,
nausea.
and lipid panel
periodically during
therapy (Vallerand,
Sanoski, & Deglin,
2017).
1. Assess the overall
health status and
alcohol usage before
administering.
2. Patients who are
malnourished or
chronically abuse
alcohol are at higher
risk of developing
hepatotoxicity.
(Vallerand, Sanoski, &
Deglin, 2017).
1. Assess the overall
health status and
alcohol usage before
administering.
2. Patients who are
malnourished or
chronically abuse
alcohol are at higher
risk of developing
hepatotoxicity.
(Vallerand, Sanoski, &
Deglin, 2017).
1. Assess the frequency
and consistency of
stools and bowel sounds
proior to and during
therapy.
2. Assess fluid and
electrolyte balance and
skin turgor for
dehydration (Vallerand,
Sanoski, & Deglin,
2017).
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Ibuprofen 400mg PO Per label
Hydrocortisone Cream 1% Per label Topical Per label
Nursing Diagnoses and Plan of Care
Goal Expected Outcome
Client or family focused. Measurable, time-specific,
reasonable, and attainable.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Anxiety
Anxiety, related to cognitive impairment, as evidence by constant pacing and agitation.
- Client will have posture, facial - Client will demonstrate
expressions, gestures, and increased external focus by the
activity levels that reflect end of the day.
decreased distress throughout his - Client will remain distracted
day at Suntree day center. with caregivers, keeping him
- Decrease pain, inflammation,
and fever.
- Inhibits prostaglandin
synthesis.
- Suppress normal immune
system response and
inflammation.
- Suppression of dermatologic
inflammation and immune
processes.
Intervention(s)
Nursing or interprofessional
interventions.
- Recognize awareness of the
patient’s anxiety.
- Use presence, touch,
verbalization, and demeanor to
remind patient that they are not
CNS: headache, dizziness,
drowsiness, intraventricular
hemorrhage.
EENT: amblyopia, blurred
vision, tinnitus.
CV: heart failure, edema,
hypertension.
GI: GI bleeding, hepatitis,
constipation, dyspepsia, nausea.
DERM: allergic contact
dermatitis, atrophy, burning,
dryness, edema, hypersensitivity
reactions, irritation, secondary
infection.
Rationale
Provide reason why intervention
is indicated/therapeutic.
Provide references.
- Since a cause of anxiety cannot
always be identified, the patient
may feel as though the feelings
being experienced are
counterfeit. Acknowledgment of
1. Assess for signs and
symptoms of GI
bleeding, renal failure,
and hepatic impairment.
2. Assess patient for
skin rash frequently
during therapy.
Discontinue after first
sign of rash (Vallerand,
Sanoski, & Deglin,
2017).
1. Assess affected skin
before and daily during
therapy. Note
inflammation and
pruritus.
2. May cause increased
serum and urine glucose
concentration if
significant absorption
occurs (Vallerand,
Sanoski, & Deglin,
2017).
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
- Caregivers and student
nurses were with J.G.
throughout the entire day,
ensuringt that he did not
place himself in an
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 from wandering off throughout alone and to encourage
his stay at Suntree day center. expression or clarification of
needs, concerns, and questions.
- Interact with patient in a
peaceful manner.
Secondary Nursing Diagnosis: Chronic confusion
Chronic confusion, related to cognitive impairment, as evidence by constantly meandering aimlessly and potentially puttng himself in harm.
-Patient will remain content and - Patient participates in activites - Collect information about
free from harm throughout the of daily living at the maxium of patient functioning, including
day at Suntree day center. functional ability. social situation, physical
- Patient functions at a maximal condition, and psychological
cognitive level. functioning.
- Examine the ability to receive confusing.
and send effective
communications.
- Assess the patient for signs of
depression: insomnia, poor
appetite, flat affect, and
withdrawn behavior.
References
Alzheimer’s Association (2019a). What is dementia? Retrieved from https://www.alz.org/alzheimers-dementia/what-is-dementia.
the patient’s feelings validates
the feelings and communicates
acceptance of those feelings.
- Being supportive and
approachable promotes
communication.
- The nurse or health care
provider can transmit his or her
own anxiety to the
hypersensitive patient. The
patient’s feeling of stability
increases in a calm and non-
threatening environment
(Wayne, 2019a).
- The background of the patient
will allow the caregiver, or
student nurse, to understand the
patient’s behavior if the patient
becomes delusional or
- Ability/readiness to reply to
verbal direction/limits may vary
with the degree of orientation.
- Patients with chronic
confusion may have depressive
symptoms ( Wayne, 2019b).
untentional dangerous
situation due to his anxiety
and wandering.
- Caregivers and student
nurses kept J.G. distracted all
day, asking him stories and
for help to ensure that they
knew were he was the entire
time.
- J.G. had several peaceful
interactions with the nursing
students, as he sang with
them and shared fun personal
stories while I assessed him.
- The caregivers and staff at
Suntree made it clear to all of
the student nurses that J.G. has
cognitive impairment that leads
him to wander off and
unintentionally put himself in
dangerous situations. So he was
monitored closely the entire
day.
- Client was able to have many
effective conversations
throughout the day.
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Alzheimer’s Association (2019b). Medical tests. Retrieved from https://www.alz.org/alzheimers-dementia/diagnosis/medical_tests.

Mayo Clinic (2018). Alzheimer's disease. Retrieved from https://www.mayoclinic.org/diseases-conditions/alzheimers-

disease/symptoms-causes/syc-20350447.

Mayo Clinic (2019). Dementia. Retrieved from https://www.mayoclinic.org/diseases-conditions/dementia/symptoms-causes/syc-

20352013.

OMICS International (2016). Dementia Pathophysiology. Retrieved from https://www.omicsonline.org/conferences-list/dementia-

pathophysiology.

Wayne, G. (2019a). Anxiety – nursing diagnosis & care plan. Retrieved from https://nurseslabs.com/anxiety/.

Wayne G. (2019b). Chronic confusion care plan and nursing diagnosis guide. Retrieved from https://nurseslabs.com/chronic-

confusion/.

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