Nursing Care Plan


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Medical Diagnoses: Chronic Confusion, Diminished mental capacity secondary to dementia

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Unable to obtain any information from client

   

   

   

   

   

Objective

Client unable to answer simple questions regarding past events

   

Client repeats questions and unable to retain information

   

Extreme of age (93)

   

Disoriented to place and time

   


Problem

   

Chronic confusion

   

   

   

   

Long Term:

Function at maximum cognitive level

  


1.Engage client in individualized communication to maximize client interaction and response

1. communication that involve clients interests improves communication abilities in those with dementia above the level that would normally be expected

*

Client able to engage in simple conversation relating to present time

   

R/T

   

Diminished mental capacity secondary to dementia

   

   

   

   

   

Short Term: 

1.       participate in activities of daily living at the  maximum of functional ability

2.       remain content and free of harm until discharge

1.break down self care tasks into simple steps

1. simple verbal prompts can help those with dementia be more independent

2. decrease stimuli in the environment and institute activities associated with pleasant emotions

2. a decrease in stimuli decreases agitation

*

   

   

   

   

   

*

1.Goal met: client able to assist during bath time and participated in dressing self

2.goal met: client showed no signs of agitation


   

AEB

Impaired long term and short term memory

 

 

  

   

   

   

   

   

 

 

 

 

 


   

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



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