Safety First: Which Goal Would the Nurse Add to the Plan of Care for a Forgetful, Disoriented Client Who Has Dementia?

Over 6 million Americans live with Alzheimer's, a primary cause of dementia. When considering this, which goal would the nurse add to the plan of care for a forgetful, disoriented client who has dementia? The unwavering priority must always be client safety.

Quick Summary

For a forgetful, disoriented client with dementia, the priority nursing goal is to ensure safety and prevent injury. Care plans are built around maintaining a hazard-free environment and constant risk assessment.

Key Points

• Priority Goal: The primary nursing goal for a disoriented dementia client is to prevent injury and maintain physical safety at all times.

• SMART Framework: Effective goals are Specific, Measurable, Achievable, Relevant, and Time-bound, such as 'Client will remain free from falls for 24 hours.'

• Environmental Safety: Key interventions include removing hazards like throw rugs, improving lighting, and securing the environment to prevent falls and wandering.

• Supportive Goals: Secondary goals that contribute to overall well-being include maintaining Activities of Daily Living (ADLs), ensuring proper nutrition, and managing behavioral symptoms.

• Safety Over Orientation: While gentle reorientation can be used, it should never take priority over ensuring the client's immediate physical safety or be used if it causes distress.

The Core Challenge: Forgetfulness and Disorientation in Dementia

Dementia is a progressive neurological condition that impairs memory, thinking, and the ability to perform everyday activities. Two of the most common and challenging symptoms are forgetfulness (amnesia) and disorientation. Forgetfulness can range from misplacing items to forgetting names, recent events, or even one's own personal history. Disorientation refers to a client's confusion about time (the date, day of the week, or season), place (where they are), and person (who they are and who others are). Together, these symptoms create a significant risk for injury, making safety the cornerstone of any effective nursing care plan.

A client who is disoriented may not recognize their own home, leading them to wander in search of a familiar place. They might forget how to use household appliances safely, increasing the risk of burns or other accidents. Forgetfulness can cause them to miss medications or forget that they've already taken them, leading to under- or overdosing. This cognitive decline necessitates a proactive, safety-focused approach from the entire healthcare team.

The Primary Nursing Goal: Ensuring Client Safety

When asked, which goal would the nurse add to the plan of care for a forgetful, disoriented client who has dementia?, the most critical and immediate answer is centered on safety. The formal nursing goal is often stated as:

"The client will remain free from injury during their hospital stay / throughout the shift / for the next 7 days."

This goal directly addresses the highest risk associated with the client's symptoms. It is a broad objective that encompasses the prevention of falls, burns, wandering-related incidents, medication errors, and any other potential harm. All nursing interventions for a client with these symptoms should, in some way, support this primary goal.

To make this goal actionable, nurses use the SMART framework:

• Specific: The goal is clearly defined—prevent all forms of physical injury.
• Measurable: It can be measured by the absence of incidents. An injury, fall, or adverse event indicates the goal was not met, prompting a reassessment of interventions.
• Achievable: While challenging, it is an achievable goal with proper interventions and a dedicated care team.
• Relevant: It is highly relevant to the client's primary diagnoses and symptoms of dementia, forgetfulness, and disorientation.
• Time-bound: The goal is set for a specific timeframe (e.g., per shift, per day, per week), allowing for regular evaluation and adjustment of the care plan.

Specific Interventions to Support the Safety Goal

Achieving the goal of client safety requires a multi-faceted approach involving environmental changes, direct supervision, and therapeutic communication.

1. Environmental Modifications

Creating a safe, predictable environment is the first line of defense.

• Fall Prevention: Remove throw rugs, clear clutter from walkways, ensure adequate, non-glare lighting (especially at night), and install grab bars in bathrooms and hallways.
• Wandering Prevention: Install alarms on doors that alert staff when opened. Use stop signs or camouflage on doorknobs to discourage exit-seeking. Ensure the client has an identification bracelet.
• Hazard Removal: Lock away medications, cleaning supplies, and sharp objects. Lower the water heater temperature to prevent scalds. Ensure appliances are unplugged when not in use.

2. Direct Patient Monitoring and Support

• Frequent Checks: Perform regular checks on the client, especially during times of high risk like shift changes or sundowning.
• Alarms: Use bed or chair alarms that sound when the client attempts to get up without assistance.
• Routine: Establish a consistent daily routine for waking, meals, activities, and bedtime. This predictability can reduce anxiety and confusion.

3. Communication and Reorientation

• Calm Approach: Always approach the client in a calm, reassuring manner. Avoid arguing or correcting them forcefully if they are disoriented.
• Simple Instructions: Use clear, simple, one-step instructions.
• Gentle Reorientation: If the client is distressed by their disorientation, gently provide reminders of time and place. A large-print clock and calendar can be helpful visual aids.

Secondary Goals in the Dementia Care Plan

While safety is paramount, other goals are essential for holistic care and quality of life. These goals often support the primary safety objective.

• Maintain Activities of Daily Living (ADLs): The client will perform ADLs (bathing, dressing, eating) with assistance as needed. This preserves dignity and function.
• Promote Nutrition and Hydration: The client will consume adequate calories and fluids. Dehydration can worsen confusion.
• Manage Behavioral Symptoms: The client will exhibit reduced agitation or restlessness. Identifying and addressing triggers for anxiety can prevent unsafe behaviors.
• Enhance Communication: The client will be able to make their needs known, either verbally or non-verbally.

Comparison: Safety Goal vs. Reality Orientation Goal

A common point of confusion is whether to prioritize keeping the client safe or trying to force them back to reality. Safety always wins. Constantly correcting a disoriented client can lead to increased agitation, frustration, and mistrust, which can paradoxically increase safety risks.

Feature	Primary Goal: Patient Safety	Secondary Goal: Reality Orientation
Priority	High (Immediate & Continuous)	Moderate to Low (As tolerated by the client)
Focus	Preventing physical harm, falls, and accidents.	Correcting the client's perception of time and place.
Intervention	Environmental modifications, supervision, alarms.	Using clocks, calendars, and gentle verbal reminders.
Potential Outcome	Client remains physically unharmed.	May increase client agitation or distress if forced.
Best Practice	This is always the top priority for disoriented clients.	Use gently and therapeutically; abandon if it causes distress.

Conclusion: A Proactive and Compassionate Approach

For a nurse caring for a forgetful, disoriented client with dementia, the plan of care must be anchored by the goal of maintaining client safety. This objective guides the selection of interventions, from modifying the environment to providing compassionate, routine-based care. While other goals related to function, nutrition, and orientation are important, they are secondary to the non-negotiable need to protect the client from harm. By prioritizing safety, nurses create a secure foundation upon which all other aspects of care can be built. Learn more about dementia safety from the Alzheimer's Association.

Frequently Asked Questions

What is the number one priority when caring for a patient with dementia?

The absolute number one priority when caring for a patient with dementia, especially one who is forgetful and disoriented, is ensuring their safety. This includes preventing falls, wandering, and other potential injuries.

Why is 'Risk for Injury' a common nursing diagnosis for dementia?

'Risk for Injury' is a primary nursing diagnosis because cognitive impairments like poor judgment, memory loss, and disorientation directly increase a person's chances of accidents. They may not recognize dangers in their environment.

How do you write a measurable nursing goal for a dementia patient?

A measurable goal must have a clear, observable outcome. For safety, a good goal is: 'The client will remain free from falls during each 12-hour shift.' This is measurable because any fall indicates the goal was not met, prompting care plan reassessment.

Is it always necessary to reorient a disoriented client?

No. While gentle reorientation can be helpful, it should not be forced. If correcting the client causes them to become agitated or distressed, it is better to use validation therapy and enter their reality, while still maintaining a safe environment.

What are some examples of simple safety interventions for dementia at home?

Simple but effective interventions include removing throw rugs, adding nightlights in hallways and bathrooms, locking up chemicals and medications, and placing alarms on exterior doors to be alerted if the person wanders.

How can a nurse help a dementia client who is wandering?

Instead of stopping them, a nurse should walk with them to ensure safety, gently try to redirect them back to a safe area, and check for unmet needs. Wandering can be a sign of pain, hunger, or a need to use the restroom.

What role does the family play in the safety care plan?

The family is crucial. They provide valuable information about the client's baseline behaviors, potential triggers for agitation, and past history. They are also key partners in implementing and reinforcing safety measures, both in a facility and at home.