Assessment Nursing Dx.

Planning Intervention Rationale Evaluation

Subjective Disturbed After 1 day of Independent: Identify factors After 1 day of
Data: thought nursing Identify factors present (e.g., present that is nursing
“I’ve been processes intervention, the acute/chronic brain important to know intervention, the
forgetting related to patient will syndrome, stroke, the patient
things. physiologic maintain reality Alzheimer’s disease), brain causative/contributi maintained
Yesterday, I al changes orientation and injury or increased ng factor. reality orientation
couldn’t such as recognizes intracranial pressure, anoxic and recognizes
remember aging (66 changes in changes in
event, acute infections,
my dog’s y/o), and thinking/behavio thinking/behavio
malnutrition, sleep or
name. I was disorientatio ur. ur.
trying to n AEB sensory deprivation, chronic
call her to patient mental illness.
come in and reported
I just stood that she Review laboratory values for Monitoring
there sometimes abnormalities such as laboratory values
staring at has metabolic aids in identifying
her for a difficulty alkalosis, hypokalemia, ane contributing
good long thinking of mia, elevated ammonia factors.
time. It was the words levels, and signs of infection.
very scary.” she needs to
As express Assess attention
verbalized herself and span/distractibility and This determines the
by the concerned ability to make decisions or
patient. of being ability of the
problem solve. patient to
forgetful,
Objective frequently participate in
Data: misplacing planning/executing
Mini objects or Assist with testing/review care.
Mental forgetting results evaluating mental
State Exam what she status according to age and This is to assess the
score: was doing.  developmental capacity. degree of
24/30 impairment.
Age: 66 y/o Interview SO or caregiver to
Temperatur determine patient’s usual
e: 37.2 ̊C thinking ability, changes in
HR: 85 behavior, length of time This is to provide
bpm problem has existed, and baseline for
BP: 142/76 other pertinent information. comparison.
Respiratory
rate: 17, Reorient to
unlabored
time/place/persin, as
needed. Have patient write Inability to
name periodically; keep this maintain
record for comparison and orientation is a sign
report differences. of deterioration.
These are
important
measures to
 prevent further
deterioration and
maximize level of
function.

Assessment Nursing Dx. Planning Intervention Rationale Evaluation

Subjective Data: Disturbed After 1 day of Independent: Cognitive After 1 day of
“I just seem to sensory nursing Assess for dysfunction nursing
get frustrated or perception intervention, the confusional behavior changes intervention, the
irritated easily.” related to Patient will have state, may result from Patient had
As verbalized by inability to preservation of disorientation, sensory preservation of
the patient. communicate, sensory/perceptual difficulty and deficits/deprivation sensory/perceptual
understand, and function and slowing of caused by function and
Objective Data: speak/respond controlled effects mental ability, physiologic, controlled effects of
Mini Mental AEB rapid mood of deficits within changes in psychological, deficits within limits
State Exam swings and limits of disease behavior and and/or of disease process,
score: 24/30 irritability. process, and emotional environmental and patient is now
Age: 66 y/o patient will be able responses factors. able to respond and
Temperature: to respond and communicate to
37.2 ̊C communicate to the discussion
HR: 85 bpm the discussion Assess visual Presbyopia is appropriately.
BP: 142/76
appropriately. acuity, visual common among
Respiratory rate:
difficulties or elderly, other
17, unlabored
loss and its visual changes
effect from these caused by
changes; physiologic
presence changes require
of cataract, correction
glaucoma, and by surgery or with
status of eye glasses. Visual
remaining vision. deficits create
mobility and
socialization
changes.

Assess auditory Presbycusis is

acuity, cerumen common in the
in ears, elderly. Conductive
responses to hearing loss results
noises and effect in false
on hearing, interpretation of
ability to words and creates
communicate, poor
amount of loss communication,
and effect, and isolation and
difficulty in depression.
locating and
identifying
sounds. Enhances
Face the patient, communication if
use eye contact hearing is impaired
and speak loud and promotes
enough to be feeling of warmth
heard, speak and caring.
slowly and
clearly with
proper pitch, use
short clear
sentences and
gestures,
maintain
position even
with patient to
allow view of
lips, and use
touch to hold
attention.
Provides for
Instruct family in patient safety by
environmental preventing injury in
modifications to the presence of
enhance vision, sensory
hearing, taste, impairment.
smell, and touch
as appropriate.