NURSING CARE PLAN

Patient’s Initials: G.D Chief Complaint: Increasingly forgetful Name of Student Nurse: Arjay G. Venezuela
Age & Gender: ___79-year-old/ Female___ Birthdate: _Jan 8, 1955_ Admitting Diagnosis: _Alzheimer’s Disease ____
Level/Block/Group: ____3BSN-08 _____ Address: ___Poblacion, Manaoag Pangasinan__________
Hospital/Area: _____Geriatric Ward _______ Date of Confinement: ______11/05/21_________
Clinical Instructor: _Sir Ronnie N. De Vera, RN, MAN_ Date: ___11/05/21______

ASSESSMENT NURSING DIAGNOSIS NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:  Impaired Alzheimer’s disease (AD) is Short Term Goals: Independent: Independent: Short Term Goals:
 The patient Memory a progressive and  The Patient will  Orient the patient to  Reality orientation  The Patient was
states that he related to irreversible, degenerative, remain safe from the environment as techniques help able to remain safe
wanders out of changes in fatal disease and is the environmental needed if the improve patients’ from
the house. cognitive most common form hazards resulting patient’s short-term awareness of self environmental
 The patient abilities as of dementia among older from cognitive memory is intact. and environment. hazards resulting
states that he evidenced people. Dementia is a brain impairment.  Eliminate or from cognitive
“sees thing
that aren’t
by
Wandering.
disorder that seriously
affects a person’s ability to
 The Family will
ensure safety
minimize sources of
hazards in the  Maintain security
impairment.
 The Family was able
there”. carry out daily activities. It precautions are environment. by avoiding a to ensure safety
 He is able to usually begins after age 60, instituted and  Instruct family confrontation that precautions are
dress, bathe, and the risk goes up as you followed. regarding could improve the instituted and
and feed get older. Risk is also higher  Family members the removal or behavior or increase followed.
himself but he if a family member has the will exhibit an locking up knives the risk for injury.  Family members
has trouble disease. understanding of and sharp objects was able to exhibit
figuring out Progression of the disease
is done in phases until all
required care and
demonstrate
away from the
patient. 
 Prevents physical an understanding
of required care
how to use his injury from
electric razor. cognitive function is appropriate  Instruct family to and demonstrate
ingestion, burns,
 His wife is destroyed. Pathologic coping skills and apply protective appropriate coping
overdoses, or
distressed consequences include the utilize community guard over electrical skills and utilize
accidents.
loss of neurons in multiple resources. outlets, community
 about his
cognitive
areas of the brain, atrophy
with wide sulci and dilated
decline. brain ventricles, and
 His wife says plaques composed of
that she is
depressed and
neurites, astrocytes, and
glial cells surrounding an
cannot watch amyloid center, and
him at night neurofibrillary tangles.
and get rest Symptoms of Alzheimer’s
herself. Disease result from the
destruction of numerous
Objective: neurons in the
 CT scan: hippocampus and the
Moderate cerebral cortex. The
cerebral enzyme choline
atrophy acetyltransferase has a
decreased action with AD
patients, which results in
impaired conduction of
impulses between the
nerve cells caused by a lack
of acetylcholine
production.
 Patient will
achieve functional
thermostats, and
stove knobs.  Prevents accident resources.
 Patient was able to
ability at his  Instruct family to injury and achieve functional
optimum level double lock doors electrocution.  ability at his
with
modifications and
and windows,
swimming pool  Helps reduce the optimum level with
modifications and
alterations within areas, and install risk of injury to alterations within
his environment pressure-sensitive patients who his environment to
to compensate buzzers on doors. wander. compensate for
for deficits.  Instruct the family
to ensure that the  Reduces the risk for deficits.
patient has hearing patients who need
Long Term Goals: aids, glasses, and supplemental Long Term Goals:
 The client will be others if they have a assistance with  The client was able
able to sensory deficit. sensory status. to participate in
participate in
activities that
 Have the patient
wear some form of  Identification can activities that
would promote her
would promote identification when help in case of level of functioning
her level of doing activities separation from the and learn and recall
functioning and outside. caregiver. All previous
learn and recall  Maintain adequate activities done capabilities, at the
previous lighting and clear outside the home end of nurse
capabilities, at pathways. must be supervised patient social
the end of nurse  Divert attention to a to protect the interaction.
patient social client when agitated patient.
interaction. or dangerous
behaviors like  Adequate lighting
getting out of bed by in halls, stairways,
climbing the fence bathrooms is
bed. necessary to prevent
 During the middle injury.
 and later stages of
AD, the patient must  The patient may
not be left have a short
unattended. attention span and
be forgetful. Repeat
instructions as
necessary to promote
safety and prevent
injury. 

 Patients with AD
have impaired
thinking and cannot
rationalize cause and
effect.

Within 30 minutes-1
hour of effective
nursing
interventions, the
patient will be able
to:
- Achieved
maximum lung
expansion with
adequate
ventilation.
- Return O2
saturation to
normal
- Demonstrate
appropriate
breathing
technique.
Within 30 minutes-1
hour of effective
nursing
interventions, the
patient will be able
to:
- Achieved
maximum lung
expansion with
adequate
ventilation.
- Return O2
saturation to
normal
- Demonstrate
appropriate
breathing
technique.