Krishelle Anne U.

Teofilo BSN III B MVH NS2 Group 5

ASSESSMENT NURSING SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS BACKGROUND
Subjective Risk factors: Short-term goals: Independent: Short-term goals:
“May mga times, Chronic Aging After 6-10 hours of  Assess the  Determines the After 6-10 hours
hindi na siya
sumasagot ng
confusion
related to
↓ nursing
interventions,
patient for
reversible or
type and extent
of dementia to
of nursing
interventions,
Damage to or
maayos, di na din dementia as  Patient will irreversible establish a plan  Patient
loss of nerve cells
siya nakakaalala, evidenced by have minimal dementia, of care to shows signs
and minsan kahit
lalabas lang siya ng
Decreased
ability to
↓ confusion,
cognitive
causes, ability to
interpret the
enhance
cognition and
of confusion
as he cannot
neuronal cell
bahay papunta sa interpret impairment, environment, emotional comprehend
death
veranda, ang akala one’s and other intellectual functioning at with the
na niya nawawala na environment, ↓ dementia thought optimal levels. situation
siya,kaya ako na din decreased manifestations processes, (Goal not
lahat capacity for Disruption of memory loss, met)
nagdedesisyon,” as thought and nerve-brain disturbances  Patient is
verbalized by memory connection  Patient will be with orientation, distracted
patient’s son. impairment able to be behavior, and that he
↓ distracted or socialization. cannot tell
“Kinakantahan ako progressive use other  Utilize cognitive  Determines the that he has
ng mga anghel neurotransmitter techniques to function testing. extent of an
tuwing gabi at deficits avoid stressful dementia. underlying
nagpapakita dina ang  
↓
situations that Maintain Prevents condition
aking asawa, miss may cause consistent patient (Goal met)
niya na daw ako,” Dementia aggressive, scheduling with agitation,

↓
verbalized by the hostile allowances for erratic
patient as we ask behaviors or patients’ specific behaviors, and
who is he talking to Declined frustration. needs, and combative
at night. cognitive skills avoid frustrating reactions. Long-term goals:

Objective: ↓ Long-term goals:

After a month of
situations and
overstimulation.
Scheduling may
need revision to
After a month of
nursing
 Confused Changed in nursing show respect interventions:
 Repetitive thought interventions: for the  Patient have
asking processes patient’s sense stable, safe
 
Lack of
motivation to ↓ Patient will
have stable,
of worth and
facilitate
environment
with routine
initiate and/or Confusion safe completing scheduling
follow through environment tasks. of activities
with goal- with routine  Avoid or  Catastrophic to decrease
directed or scheduling of terminate emotional anxiety and
purposeful activities to emotionally responses are confusion
behavior decrease charged prompted by with the help
 Fluctuation in anxiety and situations or task failure of his
psychomotor confusion. conversations. when the relatives
activity Avoid anger and patient feels (Goal met)
(tremors, body expectation of expected to  Patient still
movement) the patient to perform shows that
 Misperceptions  Patient will remember or beyond ability his mental
 Fluctuation in exhibit follow and becomes status is
cognition minimal or instructions. Do frustrated and altered as he
 Increased reduced not expect more angry. is still
agitation or confusion, than the patient Responding confused,
restlessness memory loss, is capable of calmly to the and barely
 Fluctuation in and cognitive doing. patient remembers
level of disturbances, validates (Goal not
consciousness depending feelings and met)
 Fluctuation in upon stage of causes less
sleep-wake AD. stress.
cycle  Limit sensory  Decreases
 Hallucinations stimuli by frustration and
(visual/auditory) decreasing distractions
Vital signs: noise, keeping from the
 BP- 130/80 stimuli to a environment.
 Pulse- 96 minimum, Decreasing the
 RR- 22 speaking in a stress of
calm, low voice, making a
 Temp-36.9
and take an choice helps to
 O2Sat- 97%
 unhurried promote
approach. security.
 Assist with  Assists patients
establishing with early AD
cues and to remember
reminders for the location of
patient’s articles and
assistance. facilitates some
orientation.
 Ask family  Identifies
members about family’s need
their ability to for assistance.
provide care for
the patient.
 Instruct family  Distraction may
to utilize be effective in
distraction calming the
techniques, such patient if
as soothing stressful
music, walking, situations
or looking at occur.
picture albums if
the patient has
delusions.
 Provide for  This is to
safety needs prevent
(e.g., untoward
supervision, incidents and
siderails, seizure to promote
precautions, safety.
placing call bell
within reach,
positioning
needed items
 within
reach/clearing
traffic paths,
ambulating with
devices).

Dependent:
 Closely monitor  To treat the
lab results. underlying
Monitor causes
laboratory
values, noting
hypoxemia,
electrolyte
imbalances,
BUN/Cr,
ammonia levels,
serum glucose,
signs of
infection, and
drug levels
(including
peak/trough as
appropriate).
 Administer  Antidementia
medications to drugs are
treat dementia pharmaceutical
to avoid agents that
confusion may slow the
progression or
otherwise
benefit patients
with dementia
of the
 Alzheimer's
type.
 Collaborate with  Rehabilitation
psychiatrists aids in client to
and physical atleast improve
therapists for his ADLs
rehabilitation