Nursing Care Plan

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Medical Diagnoses: Disturbed thought processes, organic mental disorder secondary to Alzheimer’s disease

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.


Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

“Momma, I’m coming; I just have to say good-bye to JJ.”

         

         

Objective

Patient oriented only to person.


Problem

Disturbed thought processes

      

Long Term:

Patient will demonstrate orientation to person and place by 1500 [date].

         

  1. Engage client in conversation, reminding her where she is and about any current events.
  2. Continue to orient client to environment and introduce self on each encounter.
  3. Educate family on client’s cognitive changes.

      

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 and support.

R/T

organic mental disorder secondary to Alzheimer’s disease

      

Short Term:

Patient will remain oriented to person and remain free from actual and potential harm by self or others by 1500 on [date].


  1. Evaluate patient’s current mental status using Mini Mental Status Exam.
  2. Frequently orient patient to environment using soothing voice and patient’s name.
  3. Check on patient every hour to assess comfort needs to help reduce anxiety.
  4. Play patient’s gospel music when feeling agitated.

X

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. 

AEB

Inaccurate interpretation of environment.

      

      

      

*I = Implementation.  Check those interventions/actions/orders that were implemented.

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Your Assessment of Patient

History of present illness:

         

VS: BP: 168/70  P: 85  RR:12   

         

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.

         

         

Learning 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.




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