Mary Holmes Nursing Care Plan Medical History: A.H.

is a 70 year old widowed Hispanic female with a history of moderate Alzheimers disease who is admitted to the hospital for loss of language skills and inability to care for self. Rehabilitation is schedules with PT, ST, and OT. She is to undergo 5 hours of therapy a day 5 days a week. Medical Diagnosis: Alzheimers Disease Nursing Assessment: Patient is Alert at present, able to state his name and where he is, but not able to communicate the date. While speaking to patient she showed signs of aphasia. Patient lives at home with a daughter. Daughter states that patient at times gets lost, clumsy, and roams around pacing frequently in the house Daughter also states that the patient is at times restless in the middle of the night and the clients speech is at times slow or absent Daughter also states that she has to help the patient get dressed and wash up, the patient gets agitated or frustrated at times because she forgets a lot. Nursing Diagnosis: Self-care deflect(bathing/hygiene, dressing/grooming, feeding, toileting) related to altered thought processes secondary to Alzheimers disease evidence by daughters statement about difficulty with dressing and washing. Planning: Short-Term Goals: Expected within 1 to 2 weeks the patient goal is to: Self-care maintained within limitations do to AD, as evidence by personal appearance and care being adequate and appropriate. Long- Term Goals: Expected within 1 month the patient goal is to: appropriate pattern of ADL achieved, as evidence by cleanliness and adequate hygiene, grooming, dressing, eating, and toileting with or without assistance and minimal frustration. Implementation: Nursing Action: Maintain a routine of similar care that is experienced at the patients home. Encourage the daughter to bring in personal care items from home. Nursing Action: Label articles for the clients use. Nursing Action: have one nurse assigned to the patient consistently. Evaluation: per usual routine at home patients hygiene activities are scheduled in the morning. Patients toothbrush, hair brush, and pictures where brought from home and where labeled. Client participates in hygiene activities with verbal guidance. Nursing Action: Speaking clearly and calmly explain all procedures, test, and treatments in simple terms.

Nursing Action: Encouraged patient to verbalize feelings of fear frustration and anger when they occur Evaluation: Patient continues to participate in hygiene activities with verbal guidance. When asked to wash legs patient became frustrated and threw washcloth. Continued work needed for long term goal.