; Nursing Care Plan Student NameDate ____Astrid Anderson_____
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Nursing Care Plan Student NameDate ____Astrid Anderson_____

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									Nursing Care Plan
Student Name/Date: ____Astrid Anderson_____

Nursing Diagnosis
(Dx, related to, & as evidenced by)

Expected Outcomes
(Short term (8-48 hr.) reasonable expectations stated in measurable, behavioral terms, i.e., action verbs)

Nursing Interventions/Rationale
List all interventions for each nsg. dx (include patient/family teaching)

Outcome Evaluation
(Patient outcome noted as met or unmet/responses described)

Impaired Memory r/t Dementia Alzheimer type as evidenced by forgetfulness and inability to retain new information

Client will remain calm and free from harm.

-Begin each interaction with the client by identifying myself and calling the client by name to reorient client to me and my role as it relates to the client. -Determine the client’s blood sugar levels as elevated levels have been associated with impaired memory. - Place call light in front of client and within easy reach to remind client to request assistance.

Goal partially met: client remained free from harm, but was anxious during bed bath and when using BSC.

Impaired Environmental interpretation syndrome r/t Dementia Alzheimer type as evidenced by impaired short-term memory, confusion, and clinical evidence of organic impairment.

Client will participate in ADLs at maximum of functional ability

-Begin each interaction with the client by identifying myself and calling the client by name to reorient client to me and my role as it relates to the client. -Give one simple direction at a time and repeat as necessary so as not to confuse the client. -Avoid the use of anticholinergic medications which have high side effect profile that includes disorientation, urinary retention, and excessive drowsiness.

Goal partially met: client performed self-care activities with instruction and assistance. However, client was prescribed and administered an anticholinergic medication.

Nursing Diagnosis
(Dx, related to, & as evidenced by)

Expected Outcomes
(Short term (8-48 hr.) reasonable expectations stated in measurable, behavioral terms, i.e., action verbs)

Nursing Interventions/Rationale
List all interventions for each nsg. dx (include patient/family teaching)

Outcome Evaluation
(Patient outcome noted as met or unmet/responses described)

Impaired physical mobility r/t neuromuscular impairment as evidenced by postural instability.

Client will sit up in chair for lunch and transfer to BSC every 3 hours

-Assist client to use footwear that facilitates walking and prevents injury, which increases confidence in ability to walk and decreases risk of falls. -Refer client to physical therapy for exercise and ambulation assistance to increase client’s strength and increase confidence in ability to walk. --Encourage client’s highest degree of independence by refraining from routine performance of transfers and bathing activities. Always doing activities for the client may contribute to impaired mobility.

Goal partially met: Client sat up in chair for 3 hours during lunch and visit with family. Client went to commode only 2 times during 8 hr shift.


								
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