ASSESSMENT Subjective: may bumubulong sakin, papatayin daw ako as verbalized by the patient.

Objective:

DIAGNOSIS Disturbed thought process related to mental disorder.

PLANNING Short term goal: After the nursepatient interaction, patient will identify interventions to deal effectively with the situation. Long term goal: After 4 days of nurse patient interaction, patient will demonstrate behavior to minimize changes in mentation.

INTERVENTION INDEPENDENT: Determine clients anxiety level in relation to situation Reorient to time/ place/ person as needed. R: inability to maintain orientation is a sign of deterioration Provide safety measure as needed Schedule structured activities and rest periods R: provides stimulation while reducing fatigue Give simple directions using short words and simple sentences Listen with regard R: to convey interest and worth to individual Allow ample time for client to respond to questions/ comments and make simple decision Present reality concisely and briefly and do not challenge logical thinking. R: Defensive reaction may result Encourage participation in socialization.

EVALUATION Short term goal: After the nursepatient interaction, patient identified interventions that dealed effectively with the situation. Long term goal: After 4 days of nurse- patient interaction, patient demonstrated behavior that minimized changes in mentation.