Careplan
NURSING DIAGNOSES
Impaired Memory r/t
neurological impairment
(dementia) AEB pt frequently
forgetting to void, pts delayed
ability to recall recent factual
information like my name, and
pt history of dementia.
Impaired physical mobility R/T
alteration in cognitive
functioning (dementia); body
mass index >75th percentile for
age (morbid obesity); reluctance
to initiate movement AEB use of
WC and RW; history of morbid
obesity
Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based guide to
planning care (11th ed.). St. Louis, MO: Elsevier.
Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and
management of clinical problems(10th ed.). St. Louis, MO: Elsevier, Inc.
EXPECTED PATIENT
OUTCOMES
Pt will strengthen recent
memory capacity by playing
a memory game like Go
Fish twice a day while
awake for 7 days ending on
10/25/2017.
Pt will build up muscle
strength to be able to
transfer independently by
standing on both feet while
holding onto Rolling Walker
for a minimum of 2 minutes
three times a day at 0730,
1100, and 2030 for 5 days
ending on 10/23/2017.
References
ASSESSMENT ACTION TEACHING
interventions: interventions: interventions:
-Assess for any signs -Nurse will encourage -Teach pt to eat a
that pt may be pt to perform the healthy diet with
depressed. memory games twice a adequate intake of
day for 7 days to whole grains, fruits,
-Evaluate all the ensure pt is attempting and vegetables to
medications pt is to improve short-term decrease
taking in order to memory. cerebrovascular
determine if one could deficits.
have adverse effect of -Encourage pt to use
impairing memory. cues, alarms, -Teach pt to use
calendars, and lists to memory techniques
-Perform a nutritional promote memory and such as concentrating
assessment to ensure trigger actions at and attending,
pt does not need designated times. repeating information,
supplementation with making mental
foods/vitamins because associations, and
may contribute to placing items in
cognitive deficits. strategic places so they
will not be forgotten.
-Do complete pain -Nurse will administer -Encourage pt to
assessment every shift. pain medications PRN. verbalize any pain felt
with movement
-Monitor pts ability to -Nurse will monitor especially during
tolerate activity and the pt while he stands transfers.
use all 4 extremities for 2 minutes three
noting pulse, skin times a day to ensure -Teach pt to do deep
color, and B/P before pt performs task. breathing exercises to
and after transfers and Nurse will execute help with lung
PT sessions. passive and active expansion and use an
ROM exercises on pts incentive spirometer to
legs to avoid muscle promote better
fatigue and cramping.
breathing when
exercising.
-Nurse will watch for
orthostatic -Teach pt to stand up
hypotension while pt is slowly by dangling feet
moving and
from side of bed,
transferring.
flexing and extending
legs several times after
sitting up, and standing
up slowly using the RW
for support to avoid
lightheadedness and
dizziness.