6.5 Putting It All Together

Client Scenario

Mrs. Vang is an 83-year-old resident who was recently admitted to a long-term memory care facility. She was diagnosed with Alzheimer’s disease last year. She is alert to self but often has periods where she is uncooperative and is unable to follow commands. She has experienced a decline in the ability to provide self-care and wanders and paces at night. She recently fell when wandering outside of her room at night.

Applying the Nursing Process

Assessment: Mrs. Vang is alert to self only and does not follow commands during the assessment. She is unable to provide self-care despite cueing.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Vang:

Nursing Diagnosis: Risk for physical injury as manifested by oriented to self, wandering and pacing at night, recent fall, Alzheimer’s disease, and inability to follow commands

Overall Goal: Client will be free from injury.

SMART Expected Outcome: Mrs. Vang will be free from physical injury throughout their stay at the long-term memory care facility.

Planning and Implementing Nursing Interventions:

The nurse will provide orientation cues, such as family pictures in the client room, as appropriate. The nurse will encourage a daily routine by all caregivers to prevent discomfort issues related to thirst, hunger, or lack of sleep. The nurse will encourage client autonomy and provide choices in decisions as appropriate. The nurse will provide opportunities for reminiscence and cultivate therapeutic communication using touch and validation of emotional communication. The nurse will place a bed alarm to alert staff at night when the client is getting out of bed. The nurse will implement a wander guard ankle bracelet to notify staff if the client wanders near an exit door.

Sample Documentation:

Mrs. Vang has impaired thought processes as a result of her Alzheimer’s disease. A care routine has been established that includes visual cues and reorientation to the environment. Reminiscence therapy provided today regarding how she met her husband. Wander guard ankle bracelet was applied during the day and bed alarm in place this evening.

Evaluation:

Mrs. Vang has remained safe within the care environment and demonstrated no additional decline in thought processes. Her wandering at night has decreased, and the bed alarm alerts staff when she gets out of bed. SMART outcome “met.”