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Mary Holmes

Nursing Care Plan

Medical History: A.H. is a 70 year old widowed Hispanic female with a history of

moderate Alzheimers disease who is admitted to the hospital for loss of language

skills and inability to care for self. Rehabilitation is schedules with PT, ST, and OT.

She is to undergo 5 hours of therapy a day 5 days a week.

Medical Diagnosis: Alzheimers Disease

Nursing Assessment: Patient is Alert at present, able to state his name and where

he is, but not able to communicate the date. While speaking to patient she showed

signs of aphasia. Patient lives at home with a daughter. Daughter states that

patient at times gets lost, clumsy, and roams around pacing frequently in the

house Daughter also states that the patient is at times restless in the middle of

the night and the clients speech is at times slow or absent Daughter also states

that she has to help the patient get dressed and wash up, the patient gets agitated

or frustrated at times because she forgets a lot.

Nursing Diagnosis:Self-care deflect(bathing/hygiene, dressing/grooming,

feeding, toileting) related to altered thought processes secondary to Alzheimers

disease evidence by daughters statement about difficulty with dressing and

washing.

Planning:

Short-Term Goals:

Expected within 1 to 2 weeks the patient goal is to: Self-care maintained within

limitations do to AD, as evidence by personal appearance and care being adequate

and appropriate.

Long- Term Goals:

Expected within 1 month the patient goal is to: appropriate pattern of ADL

achieved, as evidence by cleanliness and adequate hygiene, grooming, dressing,

eating, and toileting with or without assistance and minimal frustration.

Implementation:

Nursing Action: Maintain a routine of similar care that is experienced at the

patients home. Encourage the daughter to bring in personal care items from home.

Nursing Action: Label articles for the clients use.

Nursing Action: have one nurse assigned to the patient consistently.

Evaluation: per usual routine at home patients hygiene activities are scheduled in

the morning. Patients toothbrush, hair brush, and pictures where brought from

home and where labeled. Client participates in hygiene activities with verbal

guidance.

Nursing Action: Speaking clearly and calmly explain all procedures, test, and

treatments in simple terms.

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Nursing Action: Encouraged patient to verbalize feelings of fear frustration and

anger when they occur

Evaluation: Patient continues to participate in hygiene activities with verbal

guidance. When asked to wash legs patient became frustrated and threw

washcloth. Continued work needed for long term goal.