c
Subjective: PATIENT C/O PAIN LEFT
FOREARM, LEFT LOWER LEG, IRRIABILTY
Objective: Difficulty recalling events or
information, consistently forgets to perform a
behavior at the scheduled time.
Implement safety and fall precautions. To
prevent injury to client and others
Assess level of confusion to determine presence
and or severity of impairment.
Frequent reorient client to reality.
Instruct family/caregivers in memory involvement
task such as reminiscence and memory exercises.
Patient functional ability will improve.
Medications
Malnutrition
Difficulty communicating
Inability to interact with others.
Disorientation
Reduced lifespan
Personality changes
Increased infections within the body
Hallucinations
Wandering
Insomnia
Nursing Interventions and Outcomes
Subjective /Objective data
Laboratory and Diagnostic
Testing
Etiology/HPI (History of Present Illness
Complications
Disease/Condition: mood disturbances, with altered personality changes a condition
characterized by progressive or persistent loss of intellectual functioning especially
with impairment of memory.
Medical Diagnosis: Dementia
Risk Factors
Age, smoking, sleep apnea, heavy alcohol use,
depression, diabetes, diet and exercise, high
blood pressure, obesity, down syndrome and
lack of physical activity
Donepezil (ARICEPT)
Galantamine (RAZADYNE)
Rivastigmine (EXELON)
Choline inhibitors
MRI, CT scan, PET scan, neurological
exams, cognitive and functional
assessments, cerebrospinal fluid or blood
tests to make an accurate diagnosis.
CHRONIC CONFUSION related to impaired memory loss evidence by mood disturbance.
Self-care deficit related to cognitive impairment.
Disturbed thought process related to impaired memory.
Nursing Diagnoses
Nursing Considerations
and Client education
Avoid the cultivation of false ideas. Do not permit the
rumination of false ideas. Observe the client closely.
Close observation of the client’s behavior is indicated
if delusional thinking reveals an intention for violence.
Discourage suspiciousness of others. Express
reasonable doubt if the client relays suspicious beliefs
in response to delusional thinking. Explain simply. Use
simple explanations and face-to-face interaction when
communicating with clients. Do not shout messages
into the client’s ear.
Refer to social services and case managers for long-
term/home management, Alzheimer's Association,
community outreach programs, and support groups.
Educate family/ caregivers about illness, methods of
care, medications, and adaptation of the home
environment. Provide information about care for
seizures that can happen late in the disease. Provide
strategies to reduce caregiver stress.
