Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Disturbed Thought After the nursing ● Assess the level of ● Provide the basis After the nursing
States that he “sees Process related to intervention, the cognitive disorders for the evaluation or intervention, the
things that aren’t Alzheimer’s Disease client will be aware such as change to comparison that will client is aware and
there” as evidence by and oriented if orientation to people, come, and influencing oriented, and reality is
Hallucination. possible, and reality places and times, the choice of maintained at an
will be maintain at an range, attention, intervention. optimal level.
optimal level. thinking skills.

● Assess level of  ● Confusion may

confusion and range from slight
disorientation. disorientation to
agitation and may
develop over a short
period of time or
slowly over several
months. May indicate
effectiveness of
treatment or decline
in condition.
● Orient patient to
environment as ● Reality orientation
needed, if patient’s techniques help
short term memory is improve patient’s
intact. Using of awareness of self and
calendars, radio, environment
newspapers,
television and so
forth, are also
appropriate.

● Maintain a regular ● If the needs of a

daily schedule routine patient with AD are
to prevent problems not met, it may cause
that may result from the patient to become
thirst, hunger, lack of agitated and anxious.
sleep, or inadequate Predictable behavior
exercise. is less threatening to
the patient and does
not tax limited ability
to function with
ADLs.
● Label drawers, use