Nursing Care Plan for Dementia

Intervention 

Assess the degree to which skills and competencies are impaired and the presence of impulsive behavior.

Rationale

Identify potential risks in the environment and increase risk awareness so that caregivers are better prepared for hazards. Clients who exhibit impulsive behavior are at increased risk for injury because they are less able to control their own behavior/actions.

Intervention 

Assist caregivers in recognizing risks and potential hazards as well as visual perception deficits that may be present.

Rationale

Visual perception deficits increase the risk of falls.

Intervention  

Eliminate or minimize identified hazards in the environment.

Rationale

A person with cognitive impairments and perceptual deficits is vulnerable to accidents because he or she is unable to take responsibility for basic safety needs or assess unforeseen consequences.

Intervention 

Monitor behavior routinely; watch for timing of behavior changes, increasing confusion, and hyperactivity. If possible, initiate restrictive measures in before behavior escalates.

Rationale

Early identification of negative behaviors with appropriate interventions may prevent the need for more severe interventions.

Intervention 

Divert or redirect client’s attention if behavior is agitated or dangerous, such as climbing out of bed. Place the bed in a low position and the mattress on the floor if necessary.

Rationale

Maintains safety while avoiding confrontation that could escalate behavior or increase risk of injury.

Intervention 

Obtain identification jewelry, such as a bracelet or necklace with name, phone number, and diagnosis, and have client wear it.

Rationale

Facilitate safe return of client if lost. Due to lack of language skills and confusion, these individuals may not be able to provide name, address, and phone number. The client may wander, show poor judgment, and be detained by police because they appear confused and irritable or have violent outbursts.

Intervention 

Dress appropriately for the physical environment and individual needs.

Rationale

General slowing of metabolic processes results in a decrease in body heat.

Intervention

Watch for medication side effects and signs of overmedication – extrapyramidal signs, orthostatic hypotension, visual disturbances, and gastrointestinal (GI) disturbances.

Rationale

The patient may not be able to report signs or symptoms, and the drug can easily reach toxic levels in the elderly. Dosage or drug choice may need to be changed.

Intervention 

Provide a quiet room and reduced activity.

Rationale

Overstimulation increases irritability and agitation, which can lead to violent outbursts.

Intervention 

Avoid the use of restraints. Allow SO or others to remain with client during acute states of agitation.

Rationale

Endangers the person who succeeds in partially removing restraints. May increase agitation and increase risk of falls and fractures in the elderly.

Intervention

Assess caregiver/family members’ understanding of the disease process and the anticipated care that will be required for their loved one.

Rationale

This assessment will allow the caregiver to reinforce information about Alzheimer’s disease and address misconceptions as needed.

Intervention

Guide the family to recall memories from the past when talking with the loved one.

Rationale

Family members feel more comfortable and are more likely to continue talking with the patient if they know that the decreased vividness of the patient’s face is part of the disease. There may be noticeable pauses in conversations and less spontaneous speech; conversations should be brief and simple. Touch is still important, and recounting important memories from the past helps maintain a connection with the patient, even if the response is minimal.

Intervention

Teaching about safety issues.

Rationale

Safety issues become the caregiver’s responsibility early in the course of the disease. The Alzheimer’s patient needs plenty of room to move around and may not realize that scattered rugs, spills on the floor, and height differences on the floor increase the risk of falls. Other safety concerns include wandering, walking unsteadily, forgetting that the stove is on, and improper handling of toxic substances.

Intervention

Provide information on legal issues.

Rationale

Decisions about health care proxies must be made in the early stages of illness, when the patient is still sane. Legal counsel may be desirable for decisions about financial matters.

Intervention

Provide information about health care resources.

Rationale

The task of family caregivers is overwhelming. Family members should consider using adult day care facilities and various forms of respite care, even in the early stages of illness. The use of home care services can also be of valuable assistance.

Intervention

Teaching strategies to manage behavioral problems such as wandering, rumination, incontinence, difficulty following instructions, and profound memory loss.

Rationale

The more the family knows about strategies to manage these various behaviors, the better they can care for the patient.

Risk for Trauma

Associated with impaired judgment and the inability to recognize hazards in the environment.

Desired Outcome: 

The patient remains free of signs and symptoms of trauma/injury.

Intervention

Assess the degree to which the patient’s abilities are impaired. Assist the nurse in identifying risks and potential hazards that may cause harm in the patient’s environment and the necessary actions to be taken to ensure safety.

Rationale

Patients with impulsive behavior are at increased risk for harm because they are less able to control their own behavior. Patients may have visual/perceptual deficits that increase the risk of falls. Nurses need to have a heightened awareness of potential risks in the environment and take appropriate action.

Intervention

Eliminate or minimize identified environmental risks.

Rationale

Because a person with a cognitive deficit is unable to take responsibility for basic safety needs, caregivers must eliminate as many risks as possible: Remove stove knobs, remove stray rugs, place a safety gate at the top and bottom of the stairs, and make sure doors to the outside are locked.

Intervention

Monitor the patient’s behavior regularly. Initiate interventions to prevent negative behaviors from escalating.

Rationale

Close observation of the patient’s behavior allows for early detection of problematic behaviors (e.g., increasing agitation) and allows for early

Intervention

Distract or redirect the patient’s attention if he or she is acting agitated or exhibiting dangerous behaviors, such as climbing out of bed.

Rationale

Using the patient’s distractibility avoids confrontation or escalation of behavior and ensures safety.

Intervention

Ensure patient wears an ID bracelet with name, phone number, and diagnosis. Do not allow patient access to stairs or exits.

Rationale

Due to memory lapses and confusion, these patients may not be able to provide this basic identifying information. The ID bracelet will facilitate the patient’s safe return.

Intervention

Ensure doors to the outside are locked. Ensure there is supervision and/or activities if the patient is regularly awake at night.

Rationale

Appropriate preventive measures facilitate safety without constant supervision. Activities keep the patient occupied and limit wandering.

Intervention

Ensure patient has dressed appropriately for weather/physical environment and individual needs.

Rationale

Patients with cognitive impairment often suffer from seasonal disorientation. In addition, AD affects the hypothalamus gland, causing the individual to experience cold. The patient is unable to make appropriate clothing choices.

Intervention

Examine the patient’s skin during care activities.

Rationale

Recognition of rashes, lacerations, and ecchymotic areas allows for necessary treatment and signals the need for closer monitoring and protective measures.

Intervention

Watch for nonverbal expressions of physiologic discomfort.

Rationale

Patient may not be able to clearly express needs but may give clues to a problem by grimacing, sweating, rolling over, or gasping.

Intervention

Watch for medication side effects, signs of overmedication, e.g., gastrointestinal distress, extrapyramidal symptoms, and orthostatic hypotension.

Rationale

Medications easily reach toxic levels in the elderly, and the patient may not be able to report signs or symptoms that would indicate drug toxicity.

Intervention 

Assess the degree of confusion of the patient with Alzheimer’s disease and the amount of short-term memory the patient still has

Rationale

In the middle stages of Alzheimer’s disease, patients only have a short-term memory of about 5 minutes and can no longer learn. This fact creates significant environmental safety issues that must be addressed. For example, a person could leave the house or facility where they live and become lost.

Intervention 

Provide a predictable environment with orientation cues.

Rationale

A calm environment with planned activities, appropriate lighting, low noise levels, calendars, clocks, and frequent verbal cues helps maintain the patient’s sense of calm and safety.

Intervention 

Always address the patient by name.

Rationale

Patients may respond to their own name long after they no longer recognize their caregivers. Names are an essential part of self-identity; using one’s name is part of reality orientation.

Intervention 

Communicate with patient using soft voice, slow speech, and eye contact.

Rationale

Deliberate communication techniques such as these increase the patient’s attention and chance of understanding. Quietness begets quietness.

Intervention 

Break down instructions into a simple step-by-step process, giving one instruction at a time and using simple, clear words.

Rationale

As the disease progresses, the patient’s ability to understand complex instructions and interactions greatly diminishes. Direct simplicity is key to effective communication.

Intervention 

Encourage the patient to respond, allow pauses in the interaction, and use open-ended comments and phrasing.

Rationale

These interventions invite a verbal response.

Intervention 

Listen carefully to what the patient says, even if it is incomprehensible.

Rationale

The patient may have difficulty processing and decoding messages. However, the listener must continue to show interest and encouragement to maintain communication.

Intervention 

Offer interpretations of the patient’s statements, meanings, and words. If the patient has difficulty finding a word, provide the word if possible.

Rationale

Helping the patient process words encourages continued communication efforts and reduces frustration.

Intervention 

Avoid negative comments, argumentative statements, confrontation, and criticism.

Rationale

These aggressive responses only increase frustration, agitation, and inappropriate behaviors. Cognitively impaired patients have no internal control over their thinking and communication.

Intervention 

Listen carefully to the patient’s narratives.

Rationale

As memory loss progresses, patients are unable to relate to the reality of their caregivers. Arguing or reasoning with the patient only causes more anxiety. It is more important to make an emotional connection with the patient than to correct the details of their narratives.

Intervention 

Watch for hallucinations. Observe the patient for verbal and nonverbal signs that he or she is responding to hallucinations. Confirm the presence of the patient’s hallucinatory experiences.

Rationale

Confirmation that the patient is hearing voices allows for discussion of the anxiety associated with the experience and provides reassurance that the experience is part of the illness.

Intervention 

Allow the patient to hoard safe objects in appropriate settings.

Rationale

This gives the patient a sense of security.

Intervention 

Provide musical stimulation with pieces of music that were popular during the patient’s adolescence and early adulthood.

Rationale

Music is an effective intervention. People who can no longer speak can often still sing. Music can calm a troubled mood and promote socialization and movement.

Intervention 

Provide the patient with useful and productive opportunities to engage in repetitive activities, such as folding and unfolding laundry, collecting mail, dusting, and sweeping floors.

Rationale

This intervention recognizes that repetitive activities are a normal expression of illness, but channels these activities in a way that enhances the patient’s self-esteem and reduces agitation.

Intervention 

Ensure that the environment is calm, serene, and visually non-distracting.

Rationale

These characteristics help prevent visual/auditory overload.

Intervention 

Touch the patient in a caring manner.

Rationale

Touch promotes awareness of self and body boundaries and conveys caring.

Intervention

Use reminiscence therapy with props such as photo albums, old music, historical events, and mementos. Encourage the patient to talk about memories and feelings associated with these items.

Rationale

This intervention supports the preservation of self through the recollection of past accomplishments and events, increases the patient’s sense of safety, and promotes interactions that connect the patient socially with others.

Intervention 

Encourage intellectual activities such as word games, discussion of current events, and storytelling.

Rationale

This provides patients with normalcy and connection to others and the world and stimulates remaining cognitive abilities.

Intervention 

Suggest that the caregiver accompany the patient on short car trips, walks, and shopping.

Rationale

This decreases feelings of isolation, increases physical stamina, and provides sensory pleasure.

Intervention

Assess the caregiver’s physical/emotional/mental state and existing nursing requirements.

Rationale

This assessment helps determine the caregiver’s individual care needs.

Intervention 

Determine the caregiver’s level of responsibility, involvement in care, and expected duration of care.

Rationale

This helps the caregiver realistically assess what is involved in a commitment to care.

Intervention 

Identify the strengths of the caregiver and the patient. 

Rationale

This identifies the positive aspects of both individuals so they can be incorporated into daily activities.

Intervention 

Encourage the caregiver to discuss their personal perspectives and views of the situation.

Rationale 

This allows concerns to be expressed and provides an opportunity to validate and accept the caregiver’s issues.

Intervention 

Encourage and offer to facilitate family conferences to develop a plan for family involvement in caregiving activities.

Rationale 

The more people involved in caregiving, the lower the risk that one person will become overwhelmed. 

Intervention 

Identify additional resources, including financial, legal, and respite care.

Rationale 

These issues can increase the burden of caregiving if left unresolved.

Intervention 

Identify the need for equipment/resources and other environmental adaptations.

Rationale 

Appropriate equipment and environmental adaptations promote patient safety and relieve the burden on the primary caregiver. Occupational therapy consultation may be helpful.

Intervention 

Teaching caregiver/family techniques and strategies to manage behavioral challenges and disorientation, as well as incontinence and other physical problems.

Rationale 

This reinforces the caregiver’s and family’s sense of control and competence.

Intervention 

Teach the caregiver the importance of continuing their own activities.

Rationale 

The risk of caregiver strain, burnout, and stress is greatly reduced when caregivers take time for themselves, such as by pursuing a hobby, engaging in social activities, and attending to personal needs.

Intervention 

Encourage the caregiver/family to plan for changes that may become necessary, such as home care services, use of adult daycare, and possible placement in a long-term care facility.

Rationale

Planning is essential for these contingencies. As the disease progresses, the burden of care exceeds the caregiver’s resources.