how to format a nursing care plan
Janet Pedi 
DementiaCarePlan-MolitaMclean.docST. PAUL’S SCHOOL OF NURSING
NURSING CARE PLAN
ST. PAUL’S SCHOOL OF NURSING
NURSING CARE PLAN
Student Name: Molita Mclean Course/Section # NUR201-EVE
Clinical Facility: Richmond University Medical Center
Clinical Instructor: Prof. Daphne Duran, RN
Client Initial (Last Name Initial only) Mr. Aponi
Date of Care: ______________________________________
Date Care Study Due: ______________________________________
Date Submitted: March 30, 2023
Two nursing diagnoses: Nursing Diagnosis #1 and Nursing Diagnosis #2
Nursing Care Planning Books should be used.
Note significant results of Lab results and/or medical testing. Include EKG sheet or telemetry strip if on monitoring.
Medical History: Benign Prostatic Hyperplasia , Dementia
Surgical History: N/A
Admitting Diagnosis: Impaired Memory related to changes in cognitive abilities and dementia.
Subjective Data
Patient states that he seen a little boy in his room. No presence of a child in patient’s room. Patient refuse to take medications. When given medication patient is spitting them out. When turning patient, he grips the beside rail.
Objective Data
Vital Signs: Temp 98.1 // Bp 123/65 // RR 16 // HR 74
|
ASSESS |
PLAN: EXPECTED OUTCOME |
NURSING INTERVENTION |
RATIONALE FOR INTERVENTION (CITE SOURCES) |
EVALUATE (Progress toward outcome)
|
|
NURSING DIAGNOSIS 1 Risk for Injury Related to: Dementia
|
SHORT TERM: 1) Patient will remain safe in long term facility. 2) Patient will call for help when needed. LONG TERM: 1) Patient will remain safe from environmental hazards resulting from cognitive impairment.
|
1)Distract or redirect client’s attention when behavior is agitated or dangerous. 2)Assess degree of impairment in ability and competence and presence of impulsive behavior. 3)Monitor behavior routinely; Document when patient behavior has increased or decreased. 1). Divert attention to a client when agitated or dangerous behaviors like getting out of bed. 2)Assists caregiver to identify any risks or potential hazards and visual-perceptual deficits that may be present.
|
1) Maintains safety while avoiding a confrontation that could escalate behavior or increase risk of injury. 2)Identifies risks in the environment. 3) Determine what triggered or caused the disruptive behaviors and try to prevent it from reoccurring. 1) The patient may have a short attention span and be forgetful. Repeat instructions as necessary to promote safety and prevent injury. 2)Visual-perceptual deficits increase the risk of falls.
|
SHORT TERM: 1) Patient able to comply with staff redirection. 2) Patient did not acquire any injury. LONG TERM: 1) Patient doesn’t try to get out of bed without help. 2) Patient no has visual perceptions. |
|
ASSESS |
PLAN: EXPECTED OUTCOME |
NURSING INTERVENTION |
RATIONALE FOR INTERVENTION (CITE SOURCES) |
EVALUATE (Progress toward outcome)
|
|
NURSING DIAGNOSIS 2 Noncompliance to taking medication related to developmental abilities. Related to Psychological factors such as agitation and impaired judgement
|
SHORT TERM: 1) Patient will access resources in order to improve compliance 2)Patient will improved thought processing. LONG TERM: 1) Patient will demonstrate a commitment to improving health status by implementing positive behaviors (not missing doses of medications,
|
1.Maintain regularly daily routine to prevent problems. 2.Use written reminders such as notes & pictures to assess the patient 3.Provide positive reinforcement & feedback 1) Educate the patient and the family members on the treatment regimen that the patient will undergo. 2) Provide specific instructions as indicated.
|
1) may cause the patient to become agitated and anxious. Predictable behavior is less threatening to the patient and does not tax limited ability to function with ADLs. 2) Label drawers, use written reminders notes, pictures, or color-coding articles to assist patients. 3.Assists the patient’s memory by using reminders of what to do and the location of articles. 3) Promotes patient confidence and reinforces progress. 1) This increases awareness about the importance of completing the prescribed treatment. It provides increased compliance with such treatment. 2) The information allows the patient to better take control in selecting and implementing required changes in behavior.
|
SHORT TERM: 1)patient take & understand reason for medications. 2)patient adapts to routine. LONG TERM: 1) Unable to meet. Not present at discharge. 2) Unable to meet. Not present at discharge. |
MEDICATIONS
List all medications prescribed for your patient and do drug cards (5) on the most relevant medications.
Drug cards should be completed for at least 5 of the patient’s medications. List all of the medications and how they relate to the patients Diagnosis[s]. Consult your clinical instructor if you need further instructions on proper format for drug cards.
1. ARICEPT – Given to the patient for his Dementia/Alzheimer’s Disease.
2. SERORUEL – For the patient’s agitation behavior.
3. FLOMAX – Decreases patient’s symptoms of BPH (urinary urgency or nocturia)
4. VITAMIN D 2000 UNITS daily – For resolution of prevention of Vitamin D deficiency.
5. MULTIVITAMINS – To make sure that patient has supplemental nutrition due to poor intake or poor diet intake.
PAGE
2
