NURSING CARE PLAN
Name of the Patient: Mr. Macario
Civil Status: Religion:
Address:
Date of Admission: _____________________ Diagnosis: Alzheimer’s Disease
CUES
Subjective/ Objective
NOTE: A risk diagnosis is
not evidenced by signs and Alzheimer’s disease process. Intervention the client will
symptoms, as the problem
has not occurred; rather,
nursing interventions are
directed at prevention.
Age: 72 years old Sex: Male Name of Student: Casilao, Mike Arone H.
Rm/Bed No. _________________ Area: Level/ Block: BSNIII-B
Date Submitted: March 28, 2022
Rating: ___________________________________________________
Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Expected Outcomes
Risk for injury r/t disorientation After 4 hours of Independent Independent After 4 hours of
and confusion secondary to Independent Nursing Independent Nursing
 Establish rapport  To obtain trust on the client Intervention the goal was
be able to: and guardian to allow them met as evidenced by:
Definition: be more comfortable
Risk for injury: discussing or raising any  The patient was able
Susceptible to physical  Patient will remain in issues. to remain in a safe
damage due to environmental a safe environment environment with no
conditions interacting with the with no complications  Perform thorough  Failure to accurately complication or
individual’s adaptive and or injuries obtained assessments regarding assess and intervene or injuries are presented
defensive resources, which safety issues when refer these issues can  The patient was able
may compromise health planning for client care place the client at needless to remain in a safe
 Remain safe from and/or preparing for risk and creates environment whereas
environmental discharge from care. negligence issues for the there was no hazard
hazards resulting from healthcare practitioner. noted with regards to
Nurse’s pocket guide: cognitive impairment.  Assess client’s muscle  To identify risk for falls cognitive impairment
diagnoses, prioritized strength and gross and  The family was able
interventions, and rationales /  The family will ensure fine motor coordination to ensure safety
Doenges Marilynn E., safety precautions are precautions that helps
Moorhouse Mary Frances, instituted and patient to be safe
Murr Alice C.—Ed. 13 followed. from hazard, and
have a safety
measures followed.
 Use simple explanations  Speaking slowly and in a
and face-to-face face-to-face position is
 interaction when
communicating with client
 Assess client’s level of
disorientation to determine
specific requirements for
safety.
 Assess the patient’s
surroundings for hazards
and remove them.
 Instruct family to apply
protective guard over
electrical outlets,
thermostats, and stove
knobs
 Observe for behavioral
responses such as
hyperactivity,
disorientation, confusion,
sleeplessness, irritability
 Place client in a safe and
quiet room.
 Instruct family to keep
pathways clear, move
furniture against the wall,
remove small rugs,
most effective when
communicating with an
elderly individual
experiencing a hearing
loss. Visual cues facilitate
understanding.
 Knowledge of client’s level
of functioning is necessary
to formulate appropriate
plan of care.
 Persons with AD have
decreased awareness of
potential dangers. All
potential and obvious
hazards should be
removed to allow the
patient to move about as
freely as possible.
 Prevents accident injury
and electrocution.
 Hyperactivity related to
CNS disturbances may
escalate rapidly. Sleep
deprivation may aggravate
disorientation or confusion.
Progression of symptoms
may indicate impending
delirium
 Excessive stimuli increase
client agitation
 Prevents the risk of falls.
 remove wheels on beds
and chairs or lock them in
place.
 Instruct the family to  Helps to prevent tripping
provide non-slip shoes and and falls.
shoes without laces when
possible.
 Do make the patient wear  Identification can help in
some form of identification case of separation from the
when doing activities caregiver. All activities
outside. done outside the home
must be supervised to
protect the patient.