Alzheimer’s Nursing Care Plan-Risk for Injury by RNspeakcom

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									                                                           Nursing Care Plan for Alzheimer’s disease

    NURSING DIAGNOSIS                    OBJECTIVES                  NURSING INTERVENTIONS                      RATIONALE                         EVALUATION

                                Short term goal:                   1. Evaluate client’s level of      - This is to assess the degree      Within the whole duration of
      RISK FOR INJURY                                              competence and ability to          of risk for injury of client and    nursing care, client should be
                                Within the whole duration of       participate in preventive          aids in detecting what              free from any sorts of injury.
Possible Etiologies: (Related   nursing care, the client will      measures.                          appropriate measures you will
to)                             be free from injury.                                                  include in the plan of care.        After 2 weeks of nursing care,
                                                                   2. Adapt communication to          -Communicating with the             client should have
Disorientation to time and      Long term goal:                    the level of client and speak      client in this way promotes         demonstrated behaviours like
place                                                              with the client using slow pace    positive atmosphere and a           enhanced memory and
Confusion (wandering at         After 2 weeks of nursing           and simple words while             relaxed pace for learning.          orientation to time, place and
night)                          care, the client will be able to   maintaining a firm volume and                                          significant person, and ability
Forgetfulness and increased     demonstrate behaviors that         low pitch.                         -Some personality changes           to participate in doing self-
memory loss                     protect self from injury and                                          may occur in client’s with          care and other activities of
Presence of motor               will have reality orientation      3. Observe for nonverbal           Alzheimer’s such as irritability,   daily living with minimal
disturbance i.e. apraxia        necessary in learning/             behaviours and intervene if        suspiciousness, and                 assistance in a safe
                                retaining essential aspects in     client becomes angry or            indifference. This would also       environment.
Defining characteristics:       daily living.                                                         aid in reducing demands on
                                                                   hostile by decreasing stressful
(Evidenced by)                                                                                        client.
                                                                   stimuli and approaching client
    *Not Applicable                                                in calm, reassuring manner.
                                                                                                      -These measures are
                                                                   4. Frequently reorient of time,    necessary in enhancing
                                                                   place, date, and person; place     client’s memory.
                                                                   a clock and a calendar in his
                                                                   room; allow him to reminisce;
                                                                   and repeat instructions as

                                                                   4. Assess environment for          -This will provide information
                                                                                                      on what safety devices are
                                                                   potential factors indicating
                                                                                                      necessary to be instituted.
                                                                   risk for injury like dim lighted
                                                                   room, absence of hand rails,
                                                                   slippery floor, and high bed.
                                                                                                      -These measures minimize
5. Provide adequate lighting,    client’s misperception of his
reduce client’s bed to lower     environment and his risk for
position, put necessary          injury.
devices in aiding client’s
mobility around the house
and remove harmful objects       - Client’s with Alzheimer’s
                                 disease are sometimes
like slippery rug etc.
                                 confused making them
6. Ensure that client cannot     wanders without valid reason
                                 (especially during night time);
leave the premises without
                                 this will avoid the client from
being noticed; provide an        being missing or face
identification bracelet or tag   accidents outside the
for the client to wear at all    institution.
                                 - Providing health teachings
7. Educate family members        regarding client’s condition
and care giver of client’s       could assist family members
                                 in understanding the
condition and how to deal and
                                 manifestations elicited by the
care the client; the need for    client and would reassure
safe environment; how to         them that peculiar personality
communicate with the client;     changes and increasing
and measures that enhance        memory loss is part of this
memory.                          condition; it would aid them
                                 cope and take care with the
                                 client at home upon

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