ALZHEIMERS

Nursing Assessment

Activity / rest
Signs: anxiety, helplessness, sleep pattern disturbance, lethargy and impaired motor
skills.
Symptoms: feeling melting

Circulation
Symptoms: History of cerebral vascular disease / systemic, hypertension, embolic
episodes
Ego integrity
Signs: hide incompetence, sit down and watch the other, the first activity might
accumulate objects are not moving and emotional stability
Symptoms: suspicious or afraid of the situation / person fantasies, misperceptions of the
environment, loss of multiple.

Elimination
Signs: Incontinence of urine / feces
Symptoms: The urge to urinate

Nursing Diagnosis
Change the thought process related to:

Irreversible neuronal degeneration

Memory Loss

Psychological Conflict

Sleep deprivation

Changes in sensory perception related to:

Changes in perception, transmission and / or sensory integration

Limitations related to the social environment

Changes in sleep patterns related to:

Changes in sensory

Psychological pressure

Changes in activity patterns

The risk of trauma related to:

The inability to recognize / identify hazards in the environment

Disorientation, confusion, impaired decision making

Weakness, the muscles are not coordinated, the presence of seizure activity.

Nursing Care Plans

Risk for Injury
Related to:

Unable to recognize / identify hazards in the environment.

Disorientation, confusion, impaired decision making.

Weakness, the muscles are not coordinated, the presence of seizure activity.

Interventions
1. Assess the degree of impaired ability of competence emergence of impulsive behavior
and a decrease in visual perception.
2. Help the people closest to identify the risk of hazards that may arise.
3. Eliminate / minimize sources of hazards in the environment
4. Divert attention to a client when agitated or dangerous behaviors like getting out of bed
by climbing the fence bed.
Rationale:
1. Impairment of visual perception increase the risk of falling. Identify potential risks in the
environment and heighten awareness so that caregivers more aware of the danger.
2. An impaired cognitive and perceptual disorders are beginning to experience the trauma as
a result of the inability to take responsibility for basic security capabilities, or evaluating
a particular situation.

3. Maintain security by avoiding a confrontation that could improve the behavior / increase
the risk for injury.
Disturbed Thought Process
Related to

Irreversible neurodegeneration

Memory Loss

Psychological Conflict

Deprivation lie

Nursing Interventions
1. Assess the level of cognitive disorders such as change to orientation to people, places and
times, range, attention, thinking skills.
2. Talk with the people closest to the usual behavior change / length of the existing
problems.
3. Maintain a nice quiet neighborhood.
4. Face-to-face when talking with patients.
5. Call patient by name.
6. Use a rather low voice and spoke slowly in patients.
Rationale
1. Provide the basis for the evaluation / comparison that will come, and influencing the
choice of intervention.
2. Noise, crowds, the crowds are usually the excessive sensory neurons and can increase
interference.
3. Cause concern, especially in people with perceptual disorders.
4. The name is a form of self-identity and lead to recognition of reality and the individual.
5. Increasing the possibility of understanding.