Nursing Care Plan Sample: Patient Living With Dementia

Model Answer

Patient Scenario

Mr F, an 79-year-old man with a four-year history of moderate Alzheimer’s disease, was admitted to an acute medical ward via the emergency department after his daughter found him unusually agitated, unsteady and reluctant to eat over a 48-hour period. He normally lives with his daughter, who provides prompting for medication and personal care, and he is usually orientated to person and familiar surroundings, though he requires cueing for time and place. On admission he was disorientated, restless, picking at his bedclothes, and intermittently calling out for his late wife. Observations recorded a temperature of 38.1°C, pulse 102 beats per minute, blood pressure 138/84 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 96% on room air. Urinalysis was strongly positive for leucocytes and nitrites, consistent with a urinary tract infection precipitating delirium superimposed on his underlying dementia. He has a background of hypertension and mild osteoarthritis, no known drug allergies, and normally mobilises independently around the home with a stick, though his daughter reports several near-falls in the fortnight before admission.

A collateral history from his daughter, obtained with Mr F’s assent, indicated that his baseline cognitive function had been relatively stable on donepezil, with good appetite and continence during the day, though he experiences some sundowning in the early evening. The acute deterioration in orientation, agitation and reduced oral intake represented a clear change from his usual presentation, meeting the clinical threshold for delirium rather than progression of his dementia alone (NICE CG103, 2019). This distinction matters for care planning: delirium is frequently reversible with prompt treatment of the underlying cause, whereas dementia itself is progressive, so the plan below is built around treating the infection, minimising distress and risk during the acute episode, and preserving Mr F’s dignity and function rather than assuming permanent decline.

On the general medical ward, staff unfamiliar with his usual communication style initially found it difficult to reassure him, and he was noted to attempt to climb out of bed twice during the first evening, prompting a one-to-one observation decision by the nurse in charge pending a fuller risk assessment. His wedding ring and a small photograph of his late wife, brought in by his daughter, were kept at his bedside as familiar, reassuring objects, reflecting an early recognition by the admitting team that environmental and relational continuity would be central to managing his distress safely, alongside medical treatment of the underlying infection.

Assessment

Assessment combined a structured Airway, Breathing, Circulation, Disability, Exposure (A–E) survey with the Activities of Living framework of Roper, Logan and Tierney (2000), supplemented by dementia-specific tools, in line with the Nursing and Midwifery Council Code (2018).

Airway/Breathing: patent airway, respiratory rate mildly elevated at 20 breaths per minute, no distress, saturations 96%. Circulation: tachycardic at 102 bpm, blood pressure within acceptable limits, capillary refill under two seconds, dry mucous membranes suggesting mild dehydration. Disability: the 4AT rapid delirium screening tool was completed, scoring 6, indicating probable delirium; blood glucose was within normal limits, excluding hypoglycaemia as a contributing factor. Exposure: skin intact, no pressure damage, though his daughter reports reduced oral intake over recent days.

Further assessment covered eating and drinking (reduced appetite, at risk of dehydration), elimination (urinary symptoms consistent with infection, no incontinence at baseline), mobility (usually independent with a stick, currently unsteady and at heightened falls risk), communication (able to express basic needs when calm, more difficult to engage when agitated), and maintaining a safe environment (disorientation increasing risk of wandering or line/tube interference). A falls risk assessment scored him as high risk given the combination of acute confusion, unsteadiness and an unfamiliar environment. A Malnutrition Universal Screening Tool (MUST) score of 1 was recorded, reflecting reduced recent intake, prompting food and fluid chart monitoring. Pain was assessed using the Abbey Pain Scale, appropriate for patients with cognitive impairment who cannot reliably self-report, and scored mild, attributable to his osteoarthritis rather than an acute cause. This is care not a diagnosis of exclusion made lightly, and the multidisciplinary team, including the ward’s dementia specialist nurse, was involved from admission to ensure his care plan reflected his usual preferences, communication style and routine wherever possible, informed by a “This is Me” document completed with his daughter.

Nursing Diagnoses

Three prioritised nursing diagnoses were identified, ranked by immediacy of risk:

1. Acute confusion related to delirium secondary to urinary tract infection, evidenced by a 4AT score of 6, disorientation and agitation representing an acute change from baseline (actual problem, high priority).

2. Risk of falls related to unsteady gait, acute confusion and an unfamiliar environment, evidenced by reported near-falls and current disorientation (risk problem, high priority).

3. Risk of impaired nutrition and hydration related to reduced oral intake and cognitive impairment, evidenced by a MUST score of 1 and dry mucous membranes (risk problem, medium priority).

Prioritisation reflects immediate physiological and safety risk ahead of the longer-term nutritional concern, while recognising that all three are interlinked: untreated delirium worsens falls risk and reduces safe oral intake, so treating the infection and reducing agitation is expected to have a beneficial knock-on effect across all three diagnoses (NICE CG103, 2019; Roper, Logan and Tierney, 2000).

The Care Plan

Evaluation and Review

Evaluation was undertaken at each nursing handover and formally reviewed at 72 hours, using the 4AT score, falls incident log, food and fluid charts and documented agitation episodes as objective markers of progress, alongside Mr F’s daughter’s observations of his presentation compared with his usual baseline. Where goals were only partially met, for example if confusion persisted beyond the expected timeframe, the plan specified escalation for medical review to exclude a co-existing cause and closer liaison with the dementia specialist nurse rather than continuing an unchanged approach. Discharge planning began early, involving the multidisciplinary team, the community dementia support service and, with Mr F’s assent and his daughter’s involvement, a review of his home care package to ensure it reflected any change in his needs (NMC, 2018).

By day four, Mr F’s 4AT score had fallen to 0, he was correctly orientated to his daughter and the ward routine, his oral intake had returned to an adequate level with fluid balance charts showing a positive trend, and no falls had occurred throughout the admission. The one-to-one observation initiated on the first evening had been safely stepped down by day two once his agitation reduced, an outcome attributed by the team to a combination of resolving delirium and the consistent use of his personal reassurance items alongside familiar staff wherever possible. His antibiotic course was completed with clinical and biochemical improvement confirmed by repeat urinalysis. A discharge planning meeting was held with the ward team, the dementia specialist nurse, his daughter and the community team, at which it was agreed that his existing care package would be temporarily increased for two weeks to support recovery, with a follow-up review by the community dementia nurse within one week of discharge. This evaluation illustrates the cyclical nature of the nursing process: assessment findings shaped diagnoses, diagnoses shaped goals and interventions, and evaluation against those goals informed both the ongoing plan and a safe, person-centred discharge (Roper, Logan and Tierney, 2000; NMC, 2018).

References

Alzheimer’s Society (2021) Dementia and Delirium: Guidance for Care in Hospital. London: Alzheimer’s Society.
National Institute for Health and Care Excellence (2013) Falls in Older People: Assessing Risk and Prevention (CG161). London: NICE.
National Institute for Health and Care Excellence (2018) Dementia: Assessment, Management and Support for People Living With Dementia and Their Carers (NG97). London: NICE.
National Institute for Health and Care Excellence (2019) Delirium: Prevention, Diagnosis and Management (CG103). London: NICE.
National Institute for Health and Care Excellence (2022) Dementia Quality Standard (QS1). London: NICE.
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
Roper, N., Logan, W.W. and Tierney, A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Churchill Livingstone.