Nursing Assessment, Diagnosis, Intervention for Dementia

Tuesday, August 23, 2011 ·

Nursing Assessment Nursing Care Plans For Dementia

  • Assess the onset and characteristics of symptoms (determine type and stage of disorder).
  • Establish cognitive status using standard measurement tools.
  • Determine self-care abilities.
  • Assess threats to physical safety (eg, wandering, poor reality testing).
  • Assess affect and emotional responsiveness.
  • Assess ability and level of support available to caregivers.

  • Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding
  • Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs
  • Risk for Injury related to cognitive impairment and wandering behavior
  • Impaired Social Interaction related to cognitive impairment
  • Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places

Interventions and Evaluation Nursing Care Plans For Dementia

NO

DIAGNOSIS

OUTCOME

INTERVENTION

EVALUATION

1Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word findingDemonstrate congruent verbal and nonverbal communication.
  • Speak slowly and use short, simple words and phrases.
  • Consistently identify yourself, and address the person by name at each meeting.
  • Focus on one piece of information at a time. Review what has been discussed with patient.
  • If patient has vision or hearing disturbances, have him wear prescription eyeglasses and/or a hearing device.
  • Keep environment well lit.
  • Use clocks, calendars, and familiar personal effects in the patient’s view.
  • If patient becomes verbally aggressive, identify and acknowledge feelings.
  • If patient becomes aggressive, shift the topic to a safer, more familiar one.
  • If patient becomes delusional, acknowledge feelings and reinforce reality. Do not attempt to challenge the content of the delusion.
  • Demonstrates decreased anxiety and increased feelings of security in supportive environment
2Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLsIndependence in Self-Care
  • Assess and monitor patient’s ability to perform ADLs.
  • Encourage decision making regarding ADLs as much as possible.
  • Label clothes with patient’s name, address, and telephone number.
  • Use clothing with elastic and Velcro for fastenings rather than buttons or zippers, which may be too difficult for patient to manipulate.
  • Monitor food and fluid intake.
  • Weigh patient weekly.
  • Provide food that patient can eat while moving.
  • Sit with patient during meals and assist by cueing.
  • Initiate a bowel and bladder program early in the disease process to maintain continence and prevent constipation or urine retention
Maintains maximum degree of orientation and self-care within level of ability
3Risk for Injury related to cognitive impairment and wandering behaviorSafety appears
  • Discuss restriction of driving when recommended.
  • Assess patient’s home for safety: remove throw rugs, label rooms, and keep the house well lit.
  • Assess community for safety.
  • Alert neighbors about the patient’s wandering behavior.
  • Alert police and have current pictures taken.
  • Provide patient with a MedicAlert bracelet.
  • Install complex safety locks on doors to outside or basement.
  • Install safety bars in bathroom.
  • Closely observe patient while he is smoking.
  • Encourage physical activity during the daytime.
  • Give patient a card with simple instructions (address and phone number) should the patient get lost.
  • Use night-lights.
  • Install alarm and sensor devices on doors.
Safety precautions and close surveillance maintained; no injury
4Impaired Social Interaction related to cognitive impairmentSocialization increase
  • Provide magazines with pictures as reading and language abilities diminish.
  • Encourage participation in simple, familiar group activities, such as singing, reminiscing, doing puzzles, and painting.
  • Encourage participation in simple activities that promote the exercise of large muscle groups.
Attends group activities; sings, exercises with group
5Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or placesRisk for violence is not appears
  • Respond calmly and do not raise your voice.
  • Remove objects that might be used to harm self or others.
  • Identify stressors that increase agitation.
  • Distract patient when an upsetting situation develops.

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