Nursing Process - Nursing Care Plans For Dementia

Nursing Assessment Nursing Care Plans For Dementia

  • Assess the onset and characteristics of symptoms (determine type and stage of disorder).
  • Establish cognitive status using standard measurement tools.
  • Determine self-care abilities.
  • Assess threats to physical safety (eg, wandering, poor reality testing).
  • Assess affect and emotional responsiveness.
  • Assess ability and level of support available to caregivers.

Nursing Diagnosis Nursing Care Plans for Dementia

  • Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding
  • Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs
  • Risk for Injury related to cognitive impairment and wandering behavior
  • Impaired Social Interaction related to cognitive impairment
  • Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places

Interventions and Evaluation Nursing Care Plans For Dementia

NO

DIAGNOSIS

OUTCOME

INTERVENTION

EVALUATION
1 Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding Demonstrate congruent verbal and nonverbal communication.
  • Speak slowly and use short, simple words and phrases.
  • Consistently identify yourself, and address the person by name at each meeting.
  • Focus on one piece of information at a time. Review what has been discussed with patient.
  • If patient has vision or hearing disturbances, have him wear prescription eyeglasses and/or a hearing device.
  • Keep environment well lit.
  • Use clocks, calendars, and familiar personal effects in the patient’s view.
  • If patient becomes verbally aggressive, identify and acknowledge feelings.
  • If patient becomes aggressive, shift the topic to a safer, more familiar one.
  • If patient becomes delusional, acknowledge feelings and reinforce reality. Do not attempt to challenge the content of the delusion.
  • Demonstrates decreased anxiety and increased feelings of security in supportive environment
2 Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs Independence in Self-Care
  • Assess and monitor patient’s ability to perform ADLs.
  • Encourage decision making regarding ADLs as much as possible.
  • Label clothes with patient’s name, address, and telephone number.
  • Use clothing with elastic and Velcro for fastenings rather than buttons or zippers, which may be too difficult for patient to manipulate.
  • Monitor food and fluid intake.
  • Weigh patient weekly.
  • Provide food that patient can eat while moving.
  • Sit with patient during meals and assist by cueing.
  • Initiate a bowel and bladder program early in the disease process to maintain continence and prevent constipation or urine retention
 Maintains maximum degree of orientation and self-care within level of ability
3 Risk for Injury related to cognitive impairment and wandering behavior Safety appears
  • Discuss restriction of driving when recommended.
  • Assess patient’s home for safety: remove throw rugs, label rooms, and keep the house well lit.
  • Assess community for safety.
  • Alert neighbors about the patient’s wandering behavior.
  • Alert police and have current pictures taken.
  • Provide patient with a MedicAlert bracelet.
  • Install complex safety locks on doors to outside or basement.
  • Install safety bars in bathroom.
  • Closely observe patient while he is smoking.
  • Encourage physical activity during the daytime.
  • Give patient a card with simple instructions (address and phone number) should the patient get lost.
  • Use night-lights.
  • Install alarm and sensor devices on doors.
 Safety precautions and close surveillance maintained; no injury
4 Impaired Social Interaction related to cognitive impairment Socialization increase
  • Provide magazines with pictures as reading and language abilities diminish.
  • Encourage participation in simple, familiar group activities, such as singing, reminiscing, doing puzzles, and painting.
  • Encourage participation in simple activities that promote the exercise of large muscle groups.
 Attends group activities; sings, exercises with group
5 Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places Risk for violence is not appears
  • Respond calmly and do not raise your voice.
  • Remove objects that might be used to harm self or others.
  • Identify stressors that increase agitation.
  • Distract patient when an upsetting situation develops.