6.5: Putting It All Together

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Page ID: 52436

Ernstmeyer & Christman (Eds.)
Chippewa Valley Technical College via OpenRN

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Patient Scenario

Mrs. Vang is an 83-year-old resident that 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: Wandering related to separation from familiar environment as manifested by frequent movement from place to place and pacing.

Overall Goal: The patient will remain safe and free from falls.

SMART Expected Outcome: Mrs. Vang will experience reduced episodes of wandering within 72 hours.

Planning and Implementing Nursing Interventions:

The nurse will provide orientation cues, such as family pictures in the patient 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 patient 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 patient is getting out of bed. The nurse will implement a wander guard ankle bracelet to notify staff if the patient 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. The patient receives appropriate visual cues and reorientation to the environment. Safety interventions have been implemented, and the patient is being monitored for signs of increasing confusion or mental decline.

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.”