eNursing Care Plan 59-1
Patient with Alzheimer’s Disease
Nursing Diagnosis*
Confusion
Etiology: Effects of dementia
Supporting data: Loss of memory, distractibility, inappropriate thinking
Patient Goal
Functions at highest level of cognitive ability
Outcomes (NOC)
Cognition
 Communication clear and
appropriate for age _____
 Comprehension of the
meaning of situations _____
 Attentiveness _____
 Cognitive orientation _____
 Immediate memory _____
 Recent memory _____
 Remote memory _____
 Information processing _____
 Appropriate decision-making
_____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
*Nursing diagnoses listed in order of priority.
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Interventions (NIC) and Rationales
Dementia Management
 Determine type and extent of cognitive deficit(s),
using standardized assessment tool, to establish
baseline function.
 Include caregiver(s) and family members in
planning, providing, and evaluating care to the extent
desired to plan appropriate and consistent
interventions.
 Discuss with caregiver(s), family members, and
friends how best to interact with patient to maintain
consistency.
 Identify usual patterns of behavior for activities such
as sleep, medication use, elimination, food intake,
and self-care to maintain familiar routines.
 Give one simple direction at a time to decrease
confusion and frustration.
 Use distraction, rather than confrontation, to manage
behavior, which will decrease anxiety.
 Avoid unfamiliar situations when possible (e.g.,
room changes and appointments without familiar
people present) to avoid anxiety and confusion.
 Limit number of choices patient has to make so not
to cause anxiety.
Reality Orientation
 Repeat patient’s last expressed thought to stimulate
memory and affirm patient’s expression.
 Inform patient of person, place, and time as needed
to promote memory and reduce confusion.
 Avoid frustrating patient with demands that exceed
capacity (e.g., repeated orientation questions that
eNursing Care Plan 59-2

Outcomes (NOC) Interventions (NIC) and Rationales

cannot be answered, abstract thinking when patient
can think only in concrete terms, activities that
cannot be performed, decision making beyond
preference or capacity).
 Use environmental cues (e.g., signs, pictures, clocks,
calendars, color coding of environment) to stimulate
memory, reorient, and promote appropriate
behavior.

Nursing Diagnosis
Self-Care Deficit
Etiology: Memory deficit, cognitive impairment, and neuromuscular impairment
Supporting data: Inability to independently and appropriately bathe, dress, toilet, or feed
self

Patient Goal
Performs basic personal care activities of daily living (ADL)s including bathing,
dressing, feeding, and toileting by self or with assistance as needed

Outcomes (NOC) Interventions (NIC) and Rationales

Self-Care: Activities of Self-Care Assistance
Daily Living (ADL)
 Eating _____  Monitor patient’s ability for independent self-care to plan
 Dressing _____ appropriate interventions specific to patient’s unique
 Toileting _____ problems.
 Bathing _____  Use consistent repetition of health routines as a means of
 Grooming _____ establishing them as memory loss impairs patient’s ability to
 Hygiene _____ plan and complete specific sequential activities.
 Oral hygiene _____  Assist patient in accepting dependency needs to ensure all
 Walking _____ needs are met.
 Wheelchair mobility  Teach patient and caregiver(s) to encourage independence
_____ and to intervene only when patient is unable to perform to
 Transfer performance promote independence.
_____
Self-Care Assistance: Bathing/Hygiene
 Positions self_____
 Provide desired personal articles (e.g., deodorant,
Measurement Scale toothbrush, bath soap, shampoo, lotion) to enhance memory
1 = Severely compromised and provide care.
2 = Substantially  Facilitate patient’s bathing self to promote independence
compromised and provide appropriate help in hygiene.
3 = Moderately
compromised Self-Care Assistance: Dressing/Grooming
4 = Mildly compromised  Provide patient’s clothes in accessible area (e.g., at bedside)
5 = Not compromised to enhance memory and independence.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 59-3

Outcomes (NOC) Interventions (NIC) and Rationales

 Be available for assistance in dressing to facilitate
independence and provide appropriate help in dressing.

Self-Care Assistance: Feeding

 Fix food on tray, as necessary, such as cutting meat or
peeling an egg, to facilitate handling of food.
 Provide adaptive devices (e.g., long handles, handle with
large circumference, or small strap on utensils) to facilitate
patient self-feeding.
 Provide frequent cueing and close supervision as patient
may forget to eat.

Self-Care Assistance: Toileting

 Assist patient to toilet/commode/bedpan/fracture pan/urinal
at specified intervals to promote regularity.
 Facilitate toilet hygiene after completion of elimination to
prevent discomfort and skin excoriation.
 Begin a toileting schedule to promote regular toileting and
avoid elimination accidents.

Nursing Diagnosis
Risk for Injury
Risk factors: Impaired judgment, gait instability, muscle weakness, sensory/perceptual
alteration

Patient Goals
1. Has no injury
2. Uses assistive devices appropriately for ambulation support

Outcomes (NOC) Interventions (NIC) and Rationales

Fall Prevention Behavior Fall Prevention
(Caregiver)
 Places barriers to prevent falls  Identify cognitive or physical deficits of the patient
_____ that may increase potential of falling in a particular
 Eliminates clutter, spills, glare environment to decrease or prevent occurrence of
from floors _____ injury.
 Uses assistive devices  Provide assistive devices (e.g., cane, walker) to
correctly _____ steady gait and provide ambulation support.
 Uses safe transfer  Identify characteristics of environment that may
procedure_____ increase potential for falls (e.g., slippery floors and
 Provides assistance with open stairways) to reduce risk of injury.
mobility _____  Ensure that patient wears shoes that fit properly,
fasten securely, and have nonskid soles to provide

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 59-4

Outcomes (NOC) Interventions (NIC) and Rationales

Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
support during ambulation.
 Teach patient to wear prescription glasses when out
of bed to allow for proper vision.
 Use a bed alarm to alert caregiver(s) that individual
is getting out of bed to ensure assistance as needed.

Nursing Diagnosis
Risk for Injury
Etiology: cognitive impairment
Supporting data: Getting lost numerous times a day, frequent movement from place to
place, locomotion into unauthorized or private spaces, unintended leaving of premises,
and patient’s statement of “I don’t know where I am”

Patient Goal
Remains in restricted area during ambulation and activity

Outcomes (NOC) Interventions (NIC) and Rationales

Safe Wandering
 Moves about without
harming self _____
 Moves about without
harming others _____
 Remains in secure area when
unaccompanied _____
 Moves about only in own and
public space _____
 Can be redirected from
unsafe activities _____
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
Dementia Management
 Provide space for safe pacing and wandering to
prevent injury and getting lost.
 Use symbols, other than written signs, to assist
patient to locate room, bathroom, or other areas to
orient patient to environment.
 Provide boundaries, such as red or yellow tape on the
floor, when low-stimulus units are not available.
Elopement Precautions
 Familiarize patient with environment and routine to
decrease anxiety.
 Limit patient to a physically secure environment
(e.g., locked or alarmed doors at exits and locked
windows) as needed to prevent elopement.
 Provide patient with identification band to enable
identification if patient becomes lost.
 Provide appropriate level of supervision/surveillance
to monitor patient and to allow for therapeutic
actions.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 59-5

eNursing Care Plan 59-2

Family Caregivers

Nursing Diagnosis*
Difficulty Coping
Etiology: Grieving the family member’s illness, change in role, pressure from unrelieved
caregiving
Supporting data: Statements about stress, inadequate resources to provide care, concern
about having to put the family member in a long-term care facility

Patient Goals
1. Seeks appropriate assistance and support to maintain caregiver role
2. Expresses satisfaction with ability to fulfill caregiver role
3. Receives periodic respite from caregiving role

Outcomes (NOC) Interventions (NIC) and Rationales

Caregiver Stressors
 Reported stressors of
caregiving _____
 Physical limitations for
caregiving _____
 Psychological limitations
for caregiving _____
 Role conflict _____
 Perceived lack of social
support _____
 Perceived lack of health
professional support _____
 Loss of personal time _____
 Conflict between work and
caregiver responsibilities
_____
 Perceived burden of care
recipient’s progressing
health problems _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Caregiver Support
 Monitor for indicators of stress to plan interventions
and support.
 Act for caregiver if overburdening becomes apparent.
 Acknowledge difficulties of caregiving role.
 Accept expressions of negative emotion to enable open
discussion of needs.
 Encourage the acceptance of interdependency among
family members.
 Inform caregiver of health care and community
resources to provide support and relief to caregiver as
needed.
 Acknowledge dependency of patient on caregiver to
demonstrate empathy.
 Teach caregiver strategies to access and maximize
health care and community resources to assist
caregiver with planning for long-term care.
 Provide support for decisions made by caregiver (e.g.,
placing patient in long-term care) to allay guilt and
reinforce services the patient now requires.
Respite Care
 Monitor endurance of caregiver to identify the need for
respite care.
 Coordinate volunteers for in-home services to provide
respite for caregiver).

*Nursing diagnoses listed in order of priority.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 59-6

Outcomes (NOC) Interventions (NIC) and Rationales

 Arrange for substitute caregiver to allow caregiver
relief from role.

Nursing Diagnosis
Impaired Socialization
Etiology: Diminishing social relationships, behavioral problems of patient with disease,
underdeveloped social support system
Supporting data: Feelings of abandonment and uselessness, behavior changes, inability to
make decisions or concentrate

Patient Goals
1. Expresses satisfaction with social relationships with others
2. Uses family and community support systems to relieve feelings of isolation

Outcomes (NOC) Interventions (NIC) and Rationales

Caregiver Lifestyle
Disruption
 Role flexibility _____
 Relationships with family
members _____
 Social interactions _____
 Social support _____
 Diversional activities
_____
 Relationships with friends
_____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Socialization Enhancement
 Encourage caregiver to change environment, such as
going outside for walks or out to movies.
 Encourage enhanced involvement in already established
relationships to develop care alternatives.
 Encourage social and community activities to decrease
social isolation.
Family Support
 Arrange for ongoing respite care to enable caregiver to
continue with important activities and social contacts.
 Provide opportunities for peer group support (e.g.,
Alzheimer’s Association, American Heart Association)
because these groups can meet socialization,
recreational, and educational needs of caregiver.
Support System Enhancement
 Determine adequacy of existing social networks to
evaluate need for change.
 Involve family/significant others/friends in care and
planning to decrease isolation of caregiver.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 59-7

Nursing Diagnosis
Anxiety
Etiology: Uncertain outcome, perceived powerlessness, possible change in role
functioning, behavioral problems of the person with disease, financial insecurity
Supporting data: Apprehension, helplessness, fear, irritability, forgetfulness, inability to
concentrate

Patient Goals
1. States decreased anxiety
2. Reports sense of control of situation

Outcomes (NOC) Interventions (NIC) and Rationales

Caregiver Emotional Health Coping Enhancement
 Anger _____  Assess the impact of the patient’s life situation on
 Resentfulness _____ roles and relationships to determine the extent of
 Guilt _____ role changes required of caregiver.
 Depression _____  Assist caregiver in developing an objective
 Frustration _____ assessment of the event so that appropriate
 Perceived burden _____ decisions can be made.
 Provide the caregiver with realistic choices about
Measurement Scale certain aspects of care.
1 = Severe  Assist the caregiver to solve problems in a
2 = Substantial constructive manner to ensure that caregiver has
3 = Moderate skills to manage changing roles and patient status.
4 = Mild
5 = None Caregiver Support
 Inform caregiver of health care and community
 Certainty about future _____ resources to relieve anxiety related to financial
 Sense of control _____ insecurity.
 Satisfaction with life _____  Teach caregiver stress management techniques to
 Perceived adequacy of resources control anxiety.
_____

Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

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eNursing Care Plan 59-8

Nursing Diagnosis
Impaired Health Maintenance
Etiology: Unrelieved caregiving responsibilities, fatigue, chronic stress
Supporting data: Failure to care for self

Patient Goals
1. Demonstrates appropriate health behaviors for age and gender
2. Uses health care resources to maintain health

Outcomes (NOC) Interventions (NIC) and Rationales

Caregiver Physical Health
 Physical fitness _____
 Sleep/rest pattern _____
 Blood pressure _____
 Energy level _____
 Physical comfort _____
 Resistance to infection
_____
 Perceived general health
_____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Risk Identification
 Review data derived from routine risk assessment
measures to predict need for intervention.
 Review past health history and documents for evidence
of existing or previous medical and nursing diagnoses
and treatments to determine if the problem is present
and to plan appropriate interventions.
 Initiate referrals to health care personnel and/or
agencies for access to long-term support.
Caregiver Support
 Teach caregiver strategies to access and maximize
health care and community resources for personal
health and well-being.
 Teach caregiver health care maintenance strategies to
sustain own physical and mental health and support
caregiver in setting limits and taking care of self to
avoid increasing the complexity of the caregiving
situation.

Copyright © 2020 by Elsevier, Inc. All rights reserved.