- Disturbed Sensory Perception related to Alzheimer’s disease and excessive stimuli as evidenced by Changes in sensory acuity and confusion
- Impaired Memory related ton Neurological impairment and Mild cognitive impairment as evidenced by Persistent forgetfulness and Persistent inability to recall familiar names or information
- Self-Care Deficit related to Impaired Judgment and Inability to communicate needs as evidenced by Swallowing difficulties and Needing reminders or coaching to complete tasks
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Expresses information’s irrelevantly Objective data: -Changes in sensory acuity -Personality changes -Irritability -Hallucinations -Altered patterns of communication -Confusion | Disturbed Sensory Perception related to Alzheimer’s disease and excessive stimuli as evidenced by Changes in sensory acuity and confusion | Patient will be able to properly identify objects and sounds. Patient will maintain their baseline level of cognition. | 1. Administer treatment for causes that may be exacerbating disturbed sensory perception. Ensure management of high fevers, polypharmacy, or electrolyte imbalances (especially hyponatremia and hypocalcaemia) that may be contributing to sensory disruptions. 2. Encourage the use of visual or auditory aids. Patients with dementia are often of older age and have decreased visual and/or auditory acuity. Corrective glasses, magnifying glasses, brighter lighting, and hearing aids can help stimulate and improve the patient’s sensory perception. 3. Ensure fall precautions are in place. Fall precautions include keeping the bedside rails up, using the bed alarm, ensuring the call light is within reach, and keeping the bed in the lowest position. Maintaining fall precautions can help reduce the risk of falls or injuries in patients with dementia suffering from kinaesthetic alterations and impairment. 4. Instruct the patient to avoid extreme temperatures. Tactile issues are also common in patients with dementia suffering from disturbed sensory perception. Implement strategies to avoid exposure to extreme temperatures to reduce the risk of burns and injuries. 5. Offer reassurance and distraction. Hallucinations and delusions can be frightening. Refrain from trying to convince the patient they are wrong, as this can cause further distress. Instead, reassure them and offer distraction techniques. 6. Balance stimulation with rest. Patients with dementia benefit from social stimulation and should not be isolated. Attempt to balance activities with rest to prevent sensory overload. | Patient properly identified objects and sounds. Patient maintained their baseline level of cognition. |
| Subjective data: Verbalizes unable to recollect information’s Objective data: -Persistent forgetfulness -Persistent inability to recall events -Persistent inability to recall familiar names or information -Persistent inability to learn new information -Persistent inability to learn a new skill | Impaired Memory related ton Neurological impairment and Mild cognitive impairment as evidenced by Persistent forgetfulness and Persistent inability to recall familiar names or information | Patient will demonstrate techniques to help improve memory impairment. Patient will display improved memory through daily activities and interactions. | 1. Orient the patient to the environment as needed. Reality orientation will help promote awareness of self and the environment, decrease anxiety, and promote a trusting relationship. 2. Assist the patient in utilizing cognitive techniques for memory. Cues and external cognitive strategies like calendars or alarms can help patients with dementia remember important appointments and events. 3. Assist the patient in setting up a medication box. A medication box or pill organizer will help remind the patient to take certain medications at their prescribed times. The medication box will also help caregivers to monitor whether the patient is adherent to their medications. 4. Encourage good sleep hygiene techniques. Daily activities like exercise, exposure to light, avoiding large meals before bed, arising at the same time each day, and avoiding long periods of daytime sleep will help with sleep readiness, which can promote cognition. 5. Educate on memory-enhancing techniques and cognitive rehabilitation programs. Encourage the use of techniques such as concentrating and attending, repeating information that is heard, making mental associations, and placing items strategically in places so they will not be forgotten. | Patient demonstrated techniques to help improve memory impairment. Patient displayed improved memory through daily activities and interactions. |
| Subjective data: Verbalizes need for assistance in doing daily needs Objective data: -Swallowing difficulties -Lack of judgment in clothing choices -Difficulty in dressing self -Re-wearing dirty clothing -Inability to safely regulate water temperature for bathing | Self-Care Deficit related to Impaired Judgment and Inability to communicate needs as evidenced by Swallowing difficulties and Needing reminders or coaching to complete tasks | Patient will maintain independence in dressing, bathing, and toileting for as long as possible Patient will prepare meals and feed themselves within their abilities to maintain safety Patient will alert their caregiver to needs | 1. Maintain a schedule and routine. The family or caregiver should encourage a routine each day that includes dressing, bathing, mealtimes, and elimination practices. This prevents confusion and helps the patient maintain organization and independence. 2. Offer simple choices. Patients with dementia can often become overwhelmed when making decisions and cannot translate too much information at once. Regardless, patients should still be respected and given options in their daily lives. When offering decisions, keep it simple: oatmeal or toast for breakfast, black or gray shoes, bathing before or after dinner. 3. Consider resources to improve self-care. Implement equipment to improve safety and assist the patient with accomplishing tasks. Handheld showerheads, grab bars, and benches can make bathing easier and safer. A stairlift, toilet risers, and riser-recliner chairs can help the patient with mobility. Eating equipment such as non-spill cups or easy-grip cutlery can improve eating habits. 4. Make dressing easier. If a patient struggles with choosing appropriate attire or can’t decide between clothing options, but still maintains the motor function to dress themselves, a caregiver can lay out clothing. Increase the ease of dressing by only using clothing that doesn’t have buttons or zippers. Swap out shoes with laces for Velcro or slip-on shoes. 5. Use signage around the house. Labels, post-it notes, whiteboards, clocks, and timers can be used anywhere they are needed. These serve as reminders and can help with memory recall. | Patient maintained independence in dressing, bathing, and toileting for as long as possible Patient alerted their caregiver to needs |