Nursing Care Plan
Describe pathophysiology of primary illnesses
(acute and chronic)
The exact etiology of Alzheimer’s Disease
is unknown. Similar to other forms of dementia, age is the most important risk factor
for developing AD. However, AD destroys brain cells by altering the connection between
cells, eventually leading to their death. Alzheimer’s also involves the formation
of amyloid plaques and nuerofibrillary tangles that first occur in the brain areas
for memory and cognition. The plaques and tangles eventually attack the cerebral
cortex, including the areas for language and reasoning.
Nursing DX/Clinical Problem
Client Goals/Desired Outcomes/Objectives
“Momma, I’m coming;
I just have to say good-bye to JJ.”
Patient oriented only to
Disturbed thought processes
Patient will demonstrate
orientation to person and place by 1500 [date].
Patient has shown no signs of cognitive improvement;
still oriented to only person. Family believes condition to be declining and has
been emotionally and spirituality preparing for a loss. Goal not met.
Nursing student spoke to MRL upon each round,
introducing herself and orienting MRL to her environment. Nursing student started
each conversation by telling MRL the date and any news of that day. Nursing student
has kept family updated on patient status and has made herself available for education
organic mental disorder secondary to Alzheimer’s disease
Patient will remain
oriented to person and remain free from actual and potential harm by self or others
by 1500 on [date].
Patient ordered by physician to be in soft wrist restraints to prevent patient from
harming herself or others. At end-of-shift on [date], patient still easily agitated
and oriented only to person. Goal not met.
The gospel music seemed to soothe MRL. Friend helped nursing student try to orient
MRL to environment frequently with no signs of cognitive improvement.
Inaccurate interpretation of environment.
*I = Implementation. Check those interventions/actions/orders
that were implemented.
Your Assessment of Patient
History of present illness:
VS: BP: 168/70 P: 85
Neuro / Musculoskeletal Activity (Movement, Strength, Sensation): Patient oriented
to person only; does not respond to simple commands. Very combative, screaming obscenities.
Pt talks to people whom have been dead for many years. Patient told her deceased
mother “I’ll be there shortly; I just have to say goodbye to Janet.”
Skin (Integrity, Color, Temperature, Moisture, Turgor): Skin dry, cool to touch
with leathery texture. Face gaunt and pale. Poor skin turgor in hands; tenting noted.
No signs of breakdown.
Cardiac (Heart Sounds, Rate & Rhythm, Capillary Refill, Radial & Pedal Pulses):
Pedal pulses 1+ weak, uneven. Radial pulses 2+ at an even bilateral rate of 82 bpm.
Pulmonary (Lung sounds, Rate, Rhythm, Effort): No adventitious lung sounds noted
upon auscultation. Breaths even and unlabored at a rate of 12 breaths/min.
GI / Nutritional Status (Diet, Weight, Bowel Sounds, Abdomen-Flat/Distended &
Soft/Firm, Last BM): Pt ordered regular diet but friend reported pt refusing food
for over two days prior to assessment. Normative bowel sounds.
GU/Reproductive (Urine Color and Amount, Menses for Women): Pt has F/C with clear,
dark yellow urine.
Psychosocial: Friend of pt reported that pt had been “soothed” with gospel music.
A portable CD sat at bedside for use when pt had aggressive fits. Friends and family
visited throughout the day. Pt had been living with daughter and son-in-law before
admission to the GeroPscyh unit prior to transfer to Hospital.
Needs: No learning needs necessary. Pt is receiving only palliative care. Family
and friends will need to be educated on what to expect in the end-of-life.