RLE 002

Cebu Normal University

College of Nursing
Cebu City

Mission-Vision: “Care Using Knowledge and Compassion”

Theory-based (Betty Neuman)

NURSING CARE PLAN

Assessment 3 points Goals 2 points Interventions 4 points Bibliography

Diagnosis 3 points Theoretical Basis 2 points Evaluation 1 point 15 points

Name of Student:__________________________________________
Client’s Initials:___________________________________________
Age:______Gender: _____Civil Status:________Religion:_______
Allergies: ________________________________________________
Diet:_____________________________________________________
Date of Admission:________________________________________
Diagnosis/Impression:_____________________________________
Stressor Classification: (Please check)
______ Physiological (body structure and functions)
______ Psychological (mental processes and emotion)
______ Socio-cultural (relationships, social expectations)
______ Spiritual (influence of spiritual beliefs)
______ Developmental (developmental processes over the lifespan)

NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME

Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
 (Goal attainable within the shift) (with Rationale & Source)

Subjective: PRIMARY INTERVENTIONS

“Wa. Wa. Ako? Oo, ambot.” By the end of the shift: Promotive:
I: Maintain consistent scheduling with allowances
 Patient will have for patient’s specific needs, and avoid frustrating
Chronic confusion r/t minimal confusion, situations and overstimulation.
Alzheimer’s disease cognitive impairment, and
Objective: R: Prevents patient agitation, erratic behaviors,
other dementia and combative reactions.
manifestations.
 Decreased ability to S:Doenges, Murr & Moorhouse (2015)
 Patient will have stable,
interpret one’s environment
safe environment with I:Provide time for reminiscing if patient so desires.
 Decreased capacity for
routine scheduling of
thought R: Allows for memory of past pleasant events.
activities to decrease Patient may be reliving events in the past and the
 Memory impairment
anxiety and confusion. caregiver should identify this behavior and respect
 Disorientation it.
 Patient will exhibit
 Behavioral changes
minimal or reduced S:Doenges, Murr & Moorhouse (2015)
 Personality changes
confusion, memory loss,
 Altered interpretation
and cognitive disturbances,
 Response to stimuli
depending upon stage of
AD.
Preventive:
 Patient will be able to
tolerate stimuli when I: Utilize cognitive function testing.

Theoretical basis: introduced slowly in R: Identifies current level of dementia.

Chronic Confusion is an
rreversible, long-standing,
and/or progressive deterioration
of intellect and personality
characterized by a decreased
ability to interpret environmental
stimuli and a decreased
capacity for intellectual thought
processes, which manifest as
disturbances of memory,
nonthreatening manner,
with one item at a time.
 Patient will be able to
be distracted or use other
techniques to avoid
stressful situations that
may cause aggressive,
hostile behaviors or
frustration.
 Family will be able to
S: Doenges, Murr & Moorhouse (2015)
I: Assess patient for reversible or irreversible
dementia, causes, ability to interpret environment,
intellectual thought processes, memory loss,
disturbances with orientation, behavior, and
socialization.
R: Determines type and extent of dementia to
establish a plan of care to enhance cognition and
orientation, and behavior.
Alzheimer’s disease (AD) is a
progressive and irreversible,
degenerative, fatal disease and
is the most common form of
dementia among older
people. Dementia is
a braindisorder that seriously
 Family will be able to
affects a person’s ability to
carry out daily activities.
Progression of the disease is
done in phases until all
cognitive function is destroyed.
Pathologic consequences
include the loss of neurons in
multiple areas within the brain,
atrophy with wide sulci and
dilated ventricles of the brain,
the presence of plaques
composed of
neurites, astrocytes, and glial
cells that surround an amyloid
center, and neurofibrillary
tangles.
utilize information
effectively in dealing with
patient with confusion with
regard to limitations of
stimulation and validation
of patient’s thoughts.
utilize information to begin
making decisions for long-
term plans for patient.
emotional functioning at optimal levels.
S: Doenges, Murr & Moorhouse (2015)
SECONDARY INTERVENTIONS
Curative
I: Limit sensory stimuli and independent decision-
making.
R: Decreases frustration and distractions from
environment. Decreasing stress of making a
choice helps to promote security.
S: Doenges, Murr & Moorhouse (2015)
I: Assist with establishing cues and reminders for
patient’s assistance.
R: Assists patients with early AD to remember
location of articles and facilitates some orientation.
S: Doenges, Murr & Moorhouse (2015)
I: Identify family members and/or support systems
for the patient.
R: Helps to determine appropriate person to notify
for changes, to assist with care, and someone
familiar to patient to help deal with his confusion
S: Doenges, Murr & Moorhouse (2015)
TERTIARY INTERVENTIONS
 Rehabilitative
I: Ask family members about their ability to provide
care for patient.

R: Identifies family’s need for assistance.

S: Doenges, Murr & Moorhouse (2015)

I: Instruct family to utilize distraction techniques,

such as soothing music, going for a walk, or
looking at picture albums if patient has delusions.

R: Distraction may be effective to calm patient if

stressful situations occur.

S: Doenges, Murr & Moorhouse (2015)

Bibliography:
Doenges, Murr & Moorhouse. 2015. Nursing Diagnosis & Interventions (NANDA).