Sample of Nursing Care Plan for Wandering

Wandering Definitions:

Moving from place to place without a fixed plan; roaming; rambling: wandering tourists.

Related factors:

• Cognitive impairment (disorientation, difficulty remembering and memory).
• Emotional (depression).
• Excessive stimuli from the environment.
• Lasts all day.

Objective data:
A woman, 62-year-old was found wandering, not be able to remember the people (neighbors, saleswoman) and the events that happened in the previous weeks.

Subjective data:
The patient reported that the stress because she was arguing with her husband. She said that she did not plan wandering. Only instinctively move from one place to another.


NOC

1. Safe Wandering
Definition: Safe, socially acceptable with no visible that cognitively impaired.

Indicators:

• The patient is able to move without hurting themselves (1-5).
• The Patient were able to demonstrate that the activity has a goal (1-5).
• The patient wants to go home (1-5).

2. Acute confusion level
Definition: The severity of disturbances in consciousness and cognition that develops in a short period of time.

Indicators:

• Patients did not experience disorientation place (1-5)
• Patients did not experience disorientation people (1-5)
• Patients experienced a decline in memory impairment (1-5)

3. Memory
Definition:
The ability to restore cognitive function and reported previously stored information.

Indicators:

• Given the close information accurately (1-5)
• Given the information just accurately (1-5)
• Given the information that the information is accurate (1-5)

NIC

1. Reality Orientation
Definition: introduce / increase patient awareness regarding personal identity, time and the environment.

Activities:

• Using a consistent approach when interacting with patients.
• Inform patients about the people, places and times as needed.
• Preventing patients frustrated by giving questions related to orientation can not afford missed.
• Provide a physical environment that remains and planned daily routine.
• Approach the patient with slowly and from the front.
• Using a calm approach and not rush when interacting with patients.
• Speak slowly, clearly and corresponding volume in patients.

2. Medication Management
Definition: Facilitation of safe and effective use of prescription and over the counter drugs.

Activities:

• Determine and regulate the drug is needed in accordance with the protocol.
• Monitor the effectiveness of treatment modalities.
• Monitor patient adherence to treatment regimens.

3. Family Involvement Promotion
Definition: Facilitating family participation in the emotional and physical care of patients.

Activities:

• Identification with family members about the patient's difficulty coping.
• Inform family members about the factors that may increase the patient's condition.
• Encourage family members to keep or maintain a good relationship with the family.

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NANDA Wandering Nursing Diagnosis

NANDA Definition:
Meandering; aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles

Defining Characteristics:

• Frequent or continuous movement from place to place, often revisiting the same destinations; 
• persistent locomotion in search of "missing" or unattainable people or places; 
• haphazard locomotion; 
• locomotion in unauthorized or private spaces; 
• locomotion resulting in unintended leaving of a premise; 
• long periods of locomotion without an apparent destination; 
• fretful locomotion or pacing;
• inability to locate significant landmarks in a familiar setting; 
• locomotion that cannot be easily dissuaded or redirected; 
• following behind or shadowing a caregiver's locomotion; 
• trespassing; 
• hyperactivity; 
• scanning, seeking, or searching behaviors; 
• periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping); 
• getting lost

Related Factors:

• Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, and language (primarily expressive) defects; 
• cortical atrophy; 
• premorbid behavior (e.g., outgoing, sociable personality); 
• premorbid dementia; 
• separation from familiar people and places; 
• sedation; 
• emotional state, especially frustration, anxiety, boredom, or depression (agitation); 
• overstimulating/understimulating social or physical environment; 
• physiological state or need (e.g., hunger/thirst, pain, urination, constipation); 
• time of day

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Safety Status: Falls Occurrence
• Safety Behavior: Fall Prevention
• Caregiver Home Care Readiness

Client Outcomes

• Decreased incidence of falls (preferably free of falls)
• Decreased incidence of elopements
• Appropriate body weight maintained
• Caregiver able to explain interventions can use to provide a safe environment for care receiver who displays wandering behavior

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Dementia Management

Read More : http://nanda-nic-noc.blogspot.com/2013/04/wandering-nursing-diagnosis.html

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