Ms. Mcgyver, 58 years old, retired teacher, sells flowers as a hobby, diagnosed with Alzheimer’s disease. Ms. Mcgyver was a valedictorian with honors in her grade school time. She was also a salutatorian in her high school and again, a valedictorian in college with a lot of medals and honors from different quiz bees and competitions. She was top 3 in her licensure exam and immediately hired from two different prestigious schools. Below is a sample of nursing care plan for chronic confusion of Ms. Mcgyver.
Assessment:
Subjective:
"I had forgotten what happen yesterday," as verbalize by the patient.
Objectives:
- Loss of memory
- Loss of time sense
- Altered perceptions
- Poor judgment
- Loss of affect
- Loss of recognition to others and environment
- Increasing self-preoccupation
- Purposeful wandering
- Incontinence
Diagnosis:
Chronic confusion
related to progressive degeneration of the cerebral cortex secondary to Alzheimer’s disease.
Check the related
diagnosis Acute Confusion.
Planning:
After 8 hours of nursing
intervention, the patient will participate to the maximum level of
independence in a therapeutic milieu as evidenced by the decreased frustration,
diminished episodes of combativeness, increased hours of sleep at night,
stabilized or increased weight.
Interventions:
- Assess who the person
was before the onset of confusion. Ask her educational level, her career,
her hobbies and lifestyle styles.
- Observe Ms. Mcgyver to determine baseline of her behaviors by
checking the response time to a simple question. Amount of distraction
tolerated, judgment, insight into disability, signs and symptoms of depression,
and routine.
- Adapt communication
to Ms. Mcgyver’s level. Avoid “baby talk” and a condescending tone of
voice. Use simple sentences and present one idea at a time. If Ms.
Mcgyver does not understand, repeat the sentence using the same words. Use
positive statements; avoid “don’ts.” Unless a safety issue is involved, do not
argue. Avoid general questions, such as, “What would you like to do?” Instead,
ask, “Do you want to go for a walk or work on your rug?” Be sensitive to the
feelings of Ms. Mcgyver is trying to express. Avoid questions you
know the she cannot answer. If possible, demonstrate to reinforce verbal
communication. Use touch to gain her attention or show her concern unless a
negative response is elicited. Maintain good eye contact to her and pleasant
facial expressions. Determine which sense dominates Ms. Mcgyver’s
perception of the world. Communicate through her preferred sense.
- Promote Ms. Mcgyver’s safety. Ensure that she carries identification.
Adapt the environment so that Ms. Mcgyver can pace or walk if she
desired. Keep the environment uncluttered. Reevaluate whether treatment is
needed. If needed, provide the following to promote safety.
- Camouflage tubing with loose gauze. Consider an intermittent access device
instead of continuous IV therapy. If dehydration is a problem, institute a
regular schedule for offering oral fluids. Use the least restrictive sites.
- Evaluate causes of incontinence. Institute a specific treatment depending on
type. Place urinary collection bag at the end of her bed with catheter between
rather than draped over her legs. Velcro bands can hold the catheter against
her leg.
- Enlist the aid of her family or her friends to watch Ms.
Mcgyver during confused periods. Give her something to hold like her
favorite stuffed animals.
If Combative, determine the source of the fear and frustration, check for her
fatigue, misleading or inappropriate stimuli, change in routine, environment,
caregiver, pressure to exceed functional capacity, and physical stress.
Evaluation:
After 8 hours of nursing
intervention, the patient was participated to the maximum level of
independence in a therapeutic milieu as evidenced by the decreased frustration,
diminished episodes of combativeness, increased hours of sleep at night,
stabilized or increased weight.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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