Docstoc

Dementia Nursing Care Plan - Self Care Deficit

Document Sample
Dementia Nursing Care Plan - Self Care Deficit Powered By Docstoc
					   Nursing Diagnosis                   Objectives             Nursing Interventions              Rationale                  Evaluation
                                 Short term goal:            1. Assess if how is the   - It will provide important   Client is able to groom
    Self- Care Deficit                                       client able to meet her   information as to how         and dress herself with
 (Grooming and dressing)         Client will be able to      basic needs, who is she   the client functions at       minimal assistance or
                                 maintain physical care      residing with, presence   home and indicate the         with assistance as
Possible Etiologies:             with less assistance        of visual or hearing      need for the degree of        necessary.
(Related to)                     and on the level of her     disabilities, and her     assistance required by
                                 ability, after 2 weeks of   usual daily routine.      the client.                   Client is participative in
Difficulty in completing         intervention.                                                                       activities like fixing and
tasks/ loss of previous                                      2. Observe and assess     - Clients with cognitive      feeding self at her own
capabilities                     Long term goal:             for her appearance i.e.   impairment often have         level of ability,
                                                             appropriate dressing,     some changes in               reminiscing previous
Defining characteristics:        Client will be able to      disturbances in gait or   appearance because of         roles and capabilities,
(Evidenced by)                   participate in activities   movement, presence of     inability to assume           and learning or
                                 that would promote her      injuries.                 previous role or              relearning tasks
Subjective:                      level of functioning and                              functioning.                  (enhancing memory)
“Mama seems to forget            learn and recall            3. Check her judgement, -These are indicators to        needed for her to
herself nowadays. So, I          previous capabilities, at   orientation, memory and the proper functioning of       accomplish her ADLs.
help her clean herself and       the end of nurse-           cognitive abilities.      a person as client with
wear her clothes every           patient social                                        dementia usually would
day.” As verbalized by           interaction.                4. Build rapport with     require prompting to
daughter.                                                    client through a calm,    complete tasks.
                                                             supportive approach in    - Trust is the main key
Objective:                                                   interaction.              point in establishing
   -   Inability to maintain                                                           relationship with the
       her appearance unlike                                 5. Organize a             client. It would prevent
       before                                                structured, routine       the client from becoming
   -   Forgetfulness (time                                   schedule of activities    suspicious or delinquent
       and place where she                                   considering client’s      from asking assistance.
       is)
                                                             abilities while           - It would help client
   -   Inability to recall
       previous tasks                                        maximizing her            resume her ADLs
   -    Presence of urinary                                  independence.             without overstimulation.
       incontinence as                                       6. Reorient client
       claimed by daughter                                   frequently by putting her - This would help her
   -   Difficulty articulating                               name in bold big letters enhance her memory
       needs                                                 in her door or by calling and it would create a
   -   Poor judgement when                                   her by name always,       comfortable environment
assessed   putting a clock and          for her.
           some familiar pictures in
           her room and even            -This would ensure her
           putting the schedule of      safety and would help
           activities for a given       prevent harm/ injury
           day.                         since client may be
           7. Provide a safe, non-      disoriented and
           restrictive environment      confused at times.
           for the client through       -This will help client
           proper and adequate          regain strength and
           lighting, etc.               energy and would
                                        minimize mood changes
                                        like irritability and some
           8. Encourage enough          agitation.
           resting periods and          - This will promote
           adequate sleep.              positive self- concept
                                        and her ability to solve
           9. Encourage client to       or accomplish simple
           engage in activities like    tasks.
           music therapy and
           dancing; involve client in   -By doing this, client will
           simple decision making.      be able to lessen
           10. Assist client in her     dependency and be able
           ADLs but as much as          to function with integrity.
           possible let her regain
           independence
           depending on her
           abilities.