Risk for Injury related to Dementia

Risk for injury related to dementia 1

Nursing Care Plan for Dementia

Dementia is a decline in intellectual function obtained which leads to loss of social independence. (William F. Ganong, 2010)


1. Infection

  • Neurosyphilis
  • Tuberculosis
  • Disease virus

2. Metabolic disorders

  • Hypothyroidism
  • Electrolyte balance

3. Deficiency of nutrients

  • Deficiency of vitamin B12
  • Niamin deficiency
  • Korsakoff deficiency (thiamine)

4. Lesion persisted space

  • Subdural hematoma
  • Tumor
  • Abscess

5. Brain infarction
6. Toxic substances

  • Drugs
  • Alcohol
  • Arsenic

7. Vascular disorders

  • Cerebral embolus
  • Cerebral vasculitis

8. Others

  • Parkinson’s disease
  • Wilson’s disease
  • Huntington’s disease
  • Depression
  • Previous head injury

Signs and Symptoms

  1. Loss of memory (the early stages of memory loss such as forgetting recently was cooking food on the stove, the next stage memory loss of the past such as forgetting names of children, work).
  2. Decreased function of language (forget the name of common objects such as a chair or table, palilalia [repeating sound], and repeat the words heard [ekolalia]).
  3. Lose the ability to think abstractly and to plan, initiate, sequence, monitor, or stop complex behavior (loss of executive function): client loses the ability to perform self-care activities.

Nursing Diagnosis for Dementia : Risk for Injury related to the difficulty of balance, weakness, uncoordinated muscle, seizure activity.

Goal: Risk of injury does not occur


  • Increasing activity levels.
  • Can adapt to the environment to reduce the risk of trauma / injury.
  • Not injured.


  1. Assess the degree of hearing ability, impulsive behavior and a decrease in visual perception. Help families identify the risk of hazards that may arise.
  2. Eliminate sources of environmental hazards.
  3. Divert attention when agitated behavior / dangerous, climbing fences bed.
  4. Assess for medication side effects, signs of poisoning (extrapyramidal signs, orthostatic hypotension, visual disturbances, gastrointestinal disorders).
  5. Avoid continuous use of restrain. Give the family a chance to live with the client during the period of acute agitation.


  1. Identifying risks in the environment and raising awareness of the dangers. Clients with trauma risky behavior impulsion as less able to control the behavior. Decrease in visual perception at risk of falling.
  2. Clients with cognitive impairment, perceptual disturbances are due to the initial trauma is not responsible for the basic security needs.
  3. Maintaining security by avoiding confrontation that increase the risk of trauma.
  4. Clients who are not able to report signs / symptoms of drug can cause toxicity levels in the elderly. The size of the dose / drug reimbursement is necessary to reduce interference.
  5. Endanger the client, increasing the agitation and raised the risk of fracture in the elderly client (associated with decreased bone calcium).


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Risk for injury related to dementia 2

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