Assessment Diagnosis Planning Intervention Evaluation

Name: Iris Murdoch Self-care deficit :Bathing or -The patient will have his self- -observe, document, and report -patient meets self-care needs
Age: 75 years old hygiene: related to perceptual care needs met. patient’s functional and with help of staff nurses.
or cognitive impairment -Patient and family members perceptual cognitive ability -patient and family members
Subjective: will carry out self-care program daily. become more active in carrying
-verbalizes feelings of anger, daily. Rationale: A careful interaction out self-care program.
disbelief, and detachment from helps you adjust nursing actions
others. to meet patient’s needs.
-allow patient to ample time for
The patient manifested the patient to perform bathing and
following: hygiene.
Objective: Rationale: Rushing creates
- unable to carry out bathing unnecessary stress and
rituals promotes failure.
-unable to nourish herself -assist with bathing and hygiene
-unable to communicate with daily only when patient has
other individuals difficulty
-lacking ability to look and Rationale: to encourage
protect herself independence and self-reliance.
-disorientation to time and place
-difficulty performing familiar Self-care deficit: feeding: related -Patient and family members -observe patients functional -patient maintains weight at
task to perceptual or cognitive will demonstrate the correct use level every shift; document and designated level
-patient always misplace things impairment of assistive devices report changes
- patient changes her mood and - Patient and family members Rationale: careful observation
behavior will carry out feeding program helps you adjust nursing action
-Restless and Irritable daily. to meet patient needs
-preoccupation with thoughts of -weight patient weekly and
the deceased. record the results; report if two
pounds or more is loss
Rationale: ensure adequate
nutrition and balance
-Perform the prescribed
treatment for the underlying
 condition. Monitor patients
progress and report favorable
and adverse responses
Rationale: applying therapy
consistently aids patient’s
independence.

Impaired verbal communication -patients will communicate -observe the patient -patient consistently
related to psychological barriers needs and desires to staff, consistently communicates her needs to
family, or friends. Rationale: to anticipate its staff, family members, or
-patient’s communication ability needs. friends.
will return to base line ability. -minimize environmental stimuli -patient demonstrates return to
and maintain a quiet non- base line communication by
threatening environment stating name, place, and time.
Rationale: to reduce anxiety
- encourage communication
attempts and allow the patient’s
time to say or write words in
response.
Rationale: to decrease
frustration.
Risk for injury related to lack of -Patient and family will -help patient identify situations -patient and family indentify and
awareness of environmental acknowledge presence of and hazards that can cause eliminate safety hazards in their
hazard. environmental hazards in the accidents. surroundings.
everyday surroundings Rationale: to increase patient’s -patient and family members
-Patients and family will practice awareness of potential dangers demonstrate prevention and
safety and take safety -encourage patient to make safety measures.
precaution and harm. repairs and remove potential
safety hazards from
environments.
Rationale: to decrease
possibility of injury
-maintain lighting so that
patient can find her way around
 room and to bathroom.
Rationale: arranging patient’s
environment helps prevent
injury.

Risk for complicated grieving. -Acknowledge presence or -identify loss that is present. -The patient demonstrate
impact of dysfunctional Note circumstances of death Progress in dealing with stages
situation. such as sudden or traumatic. of grief at own pace.
-the patient will demonstrate Rationale: to determine -verbalize a sense of progress
progress in dealing with stages causative factors. toward grief resolution.
of grief at own pace. -listen towards indicative of
renewed intense grief.
Rationale: to determine degree
of impairment or dysfunction.
-permit verbalization of anger
with acknowledgement of
feelings and setting of limits
regarding destructive behavior.
Rationale: enhances clients
safety and promotes resolution
of grief process

Ineffective coping related to -Patient will verbalize increase -Assist the patient in becoming -Patient states understanding of
inability to solve problems or ability to cope. involved in informal community strategies to improve coping
adapt to demands of daily living. -Patient will report increase programs. ability.
ability to meet demands of daily Rationale: to provide peer and -Patient identifies lifestyle
living. social contact and decrease the changes that will improve her
patient’s loneliness. ability to cope or states that she
-encourage the patient to understands and accepts needs
reminisce the about the past. to meet the demands of daily
Rationale: to help her recall the living.
past challenges and successful
coping strategies.
 -provide the patient with
information about the aging
process, methods of coping to
stress and techniques used by
other older adults to meet the
demands of daily living.
Rationale: to assist the patient
in implementing coping
strategies.

Impaired memory related to -The patient will verbalize -Call patient by name and tell -The patient expresses feelings
neurological disturbances. awareness of memory her your name. Provide about memory impairment.
problems. background information -The patient describes for coping
-Patient will acknowledge need frequently throughout the day. with memory loss.
to take measure to cope with Rationale: to provide reality -The patient and family
memory impairment. information. members set realistic goals to
-Inform the patient that you are cope with further memory loss.
aware of her memory loss and
that you will help her with her
condition.
Rationale: to bring the issue into
the open and help patient
understand that your goal is to
help her.
-Be clear, concise, and direct in
establishing goals.
Rationale: so that the patient
can maximize the use of her
remaining cognitive skills.
Nursing Care Plan for Alzheimer’s Disease
Iris: Memoirs of Iris Murdoch

Submitted by:

Bianchi A. Sarmenta
Kim Louelle G. Ong
Mylean F. Florentino
Rafael Sandino F. Espiritu
Erickson J. Tecson
BSN-3 E
Submitted to:
Ma. Fatima San Juan,RN