Nursing Care Plan on Creutzfeldt-Jakob Disease

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An NCP Presented to
the Faculty of Nursing Department
Ms. Karen Eve Mirafuentes, RN

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In Partial Fulfillment of
the Requirements in NCM 214 – RLE
GERIATRIC NURSING ROTATION

BY
Jerome Rex Santos, St. N
BSN 3G – Group 4

October 7, 2020
 RISK FOR INJURY

Date/ Cues Need Nursing Diagnosis Patient Outcome Interventions Impleme Evaluation
ntation
Time

O Subjective cues H Risk for injury related to That within 8 hours 1. Assess the degree of October 2020 @ 3:00
cognitive impairment of nursing impaired ability of pm “Goals
C - as verbalized E (disorientation, halucinations, interventions, the competence, emergence of 1 completely met”
by the patient’s confusion, memory loss, etc.), patient will be able to impulsive behaviour, and a
T daughter “mag A After 8 hours of
inability to recognize hazards remain safe from decrease in visual
sige lang siya ug in the environment, loss of undesirable injuries perception. nursing interventions,
O L
kalimot tapos balance and coordination and as evidenced by: the patient was able
B mawala sa iyang T vision problems. R: Impairment of patient’s to remain safe from
huna-huna.” a. Identification of normal functioning increase undesirable injuries
E H Rationale the potential hazards the risk of acquiring as evidenced by:
Objective cues and risk factors that accidents/injuries.
R — Creutzfeldt-Jakob disease is affect safety. a. Identified the
- disorientation a degenerative brain disorder 2. Assess patient’s potential hazards and
— P that is marked by rapid b. Elimination of the surroundings for potential 2 risk factors that affect
- inability to
mental deterioration potential dangers dangers and safety such as sharp
2 recognize E
(personality changes, and hazards that environemental hazards. objects, slippery
hazards in the
0 R memory loss, impaired increase the floor, breakable
environment R: CJD causes a decrease
thinking, loss of vision, susceptibility to items, etc.
2 C altered mobility, etc). This injury. in awareness of potential
- confusion
condition causes decrease in dangers b. Eliminated the
0 - hallucination E awareness of potential c. Family environmental
verbalization of 3. Instruct family regarding hazards and potential
dangers and inability to
@ - forgetfulness/ P
identify/recognize hazards understanding on the removal or locking up danger that increase
increased within the environment individual factors that knives and sharp objects
7:00 memory loss T making the person contribute to away from the patient, 9 the risk of injury.
am susceptible to undesirable possibility of injury. these includes cleaning
- loss of balance I injuries. supplies, other household c. Family verbalized
and coordination d. Institution of chemicals, all medications, understanding on the
(walking, O Reference various safety individual factors that
weapons, power tools,
standing, etc.) precautionary small appliances, smoking contribute to
N Mayo Clinic (2019). measures. materials and breakable possibility of injury
- loss of vision Creutzfeldt-Jakob Disease. “ahh daghan diay ug
— items.
Mayo Foundation for Medical pwede maka-injury
H Education and Research. R: Prevents physical injury sa akong mama ug
Retrieved September 26, from ingestion, burns, kailangan na siya
E 2020. Retrieved from overdoses, or accidents. tagaan ug pagtagad”.
https://www.mayoclinic.org/di
A seases-conditions/creutzfeldt- 4. Instruct family to apply d. Instituted safety
jakob-disease/symptoms- protective guard over precautions such as
L 8
causes/ electrical outlets, restraints, side rails,
T thermostats and stove wheelchairs, cane,
knobs. walkers, etc.
H
R: Prevent accident injury.
—
5. Instruct family to keep
M pathways clear, eliminate
slippery floors, move
A furniture against the wall,
remove throw rugs, provide
N
restrictions on chairs,
A remove wheels on beds 7
and chairs or set lock them
G in place, and keep rooms
and hallways well lighted.
E
6. Instruct family to double
M lock doors and windows, 6
swimming pool areas, and
E
other places that can cause
N accidents.

T R: Reduce the risks to

undesirable injuries
— especially to patients who
wander.
P
7. Observe for nonverbal
A behaviours and intervene if 3
client becomes angry or
T
hostile by decreasing
T stressful stimuli and
approaching in calm,
E reassuring manner.

R R: Some personality
changes may occur in
N patients with CJD such as
irritability, suspiciousness
and indifference.

8. Apply restraints
whenever necessary and
as prescribed by the 5
physician.

R: To prevent the patient

from causing harm to
himself and as well as to
others.

9. Provide assistive
devices such as cane, 4
crutches and or
wheelchairs.

R: Provide support to the

client.

Health Perception/Health
Management Pattern
1. Inability to recognise hazards in
the environment
2. Loss of intellect and memory
3. Loss of brain function
4. Personality changes
Cognitive-Perceptual Pattern
1. Loss of vision
2. Slurred speech
3. Hallucination
4. Confusion
5. Disorientation
Sexuality-Reproductive Pattern
Gordon’s Functional Health Pattern
Nutritional-Metabolic Pattern
1. Difficulty swallowing
Sleep-Rest Pattern
1. Insomnia
Coping-Stress Tolerance Pattern
Elimination Pattern Activity-Exercise Pattern
2. Loss of bowel and bladder 1. Loss of balance and
control coordination (walking, standing
etc.)
2. Abnormal jerking movements
Self-Perception/Self-Concept Role-Relationship Pattern
Pattern
Value-Belief Pattern
References
Mayo Clinic (2019). Creutzfeldt-Jakob Disease. Mayo Foundation for Medical Education and Research. Retrieved September 26, 2020. Retrieved from
https://www.mayoclinic.org/diseases-conditions/creutzfeldt-jakob-disease/symptoms-causes
NHS (2020). Creutzfeldt-Jakob Diseases Signs and Symptoms. National Health Services. Retrieved October 06, 2020. Retrieved from
https://www.nhs.uk/conditions/creutzfeldt-jakob-disease-cjd/
Serrano, M. (2018). Alzheimer’s Nursing Care Plan-Risk for Injury. RNSpeak. Retrieved Ocotber 06, 2020. Retrieved from https://rnspeak.com/alzheimer’s-
nursing-care-plan-risk-for-injury/