|
Assessment
|
Nursing DX/Clinical Problem
|
Client Goals/Desired Outcomes/Objectives
|
Nursing Interventions/Actions/Orders
and Rationale
|
*I
|
Evaluation
|
|
Subjective
Unable to obtain
any information from client
Objective
Client unable to answer
simple questions regarding past events
Client repeats questions
and unable to retain information
Extreme of age (93)
Disoriented to place and
time
|
Problem
Chronic confusion
|
Long Term:
Function at maximum
cognitive level
|
1.Engage client in individualized communication to
maximize client interaction and response
1. communication that involve clients interests improves
communication abilities in those with dementia above the level that would normally
be expected
|
*
|
Client able to engage in
simple conversation relating to present time
|
|
|
R/T
Diminished mental capacity secondary to dementia
|
Short Term:
1.
participate
in activities of daily living at the
maximum of functional ability
2.
remain
content and free of harm until discharge
|
1.break down self care tasks into simple steps
1. simple verbal prompts can help those with dementia be more independent
2. decrease stimuli in the environment and institute activities associated with
pleasant emotions
2. a decrease in stimuli decreases agitation
|
*
*
|
1.Goal met: client able to assist during bath time and participated in dressing
self
2.goal met: client showed no signs of agitation
|
|