ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING THEORIST EVALUATION

DIAGNOSIS COMPETENC
Y
Subjective: Independent:
 “Alam mo ba Disturbed After 4 hours of  Developed a  Presence, Safe and Ernestine GOAL MET
na nanggaling thought nursing therapeutic acceptance Quality Weidenbach’s
ako sa royal processes r/t interventions, nurse-client and Nursing Care “The Helping After 4 hours of
family? memory the client will be relationship conveyance of Art of nursing
Parang sa deficit as able to establish through positive regard Nursing” interventions,
hierarchy manifested contact with frequent, brief enhance the the client was
kami yung by reality AEB: contacts and an client’s feelings This includes able to establish
nandito at confabulatio accepting of self-worth. understandin contact with
kayo yung sa n  Responding attitude. g a patient’s reality AEB:
ilalim” as to simple Showed needs and
claimed by questions unconditional concerns,  Responded
the client positive regard. developing to simple
 Take goals and questions
Objective: medication  Spent time  Presence may Safe and actions
 Non–reality- s without with client; sit help improve Quality intended to  taken
based evidence of in silence for a client's Nursing Care enhance a medication
thinking mistrust. while. perception of patient’s well- s without
self as a being and evidence of
 With delusion  Continuing worthwhile directing the mistrust.
of grandeur compliance person. activities
with Physical related to the  Continuing
 Blank facial medication presence is medical plan compliance
expression regimen reality. to improve with
patient’s medication
 Blunted affect  Oriented the  Repeated Safe and condition. regimen
client to presentation of Quality
 Short person, place reality is Nursing Care

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 attention span and time. concrete
reinforcement
 Displays for the client.
argumentativ
e behavior  Encouraged  Verbalization Safe and
client to of feelings in a Quality
 Seen glaring verbalize nonthreatenin Nursing Care
at others at feelings g environment
times may help client
come to terms
with long
unresolved
issues.

 Decrease  Helps lower Safe and

environmental escalation of Quality
stimuli and anxiety and Nursing Care
provided a manic
calming symptoms.
atmosphere.

 Help client  Reality must be Safe and

reestablish reinforced. Quality
what is real and Reinforced Nursing Care
unreal. Validate reality and
the client’s real behavior will
perceptions, recur more
and correct the frequently.
client’s
misperceptions

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 .

Dependent:  It blocks post- Legal

 Administered synaptic D2 responsibility
Chlorpromazin dopamine
e 200 mg 1 tab receptors. It is
BID considered
that dopamine
receptor
blockade in the
mesolimbic
area accounts
for the
antipsychotic
effect,
Legal
 It acts by responsibility
 Administered increasing
Divalproex Na gamma-
500 Mg 1 tab aminobutyric
BID acid levels in
the brain or by
altering the
properties of
voltage
dependent
sodium
channels. Legal
responsibility
 It blocks the
 Administered effects of

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 Haloperidol 20 dopamine and
mg ¼ tab OD increases its
turnover rate

 It is an anti- Legal
 Administered psychotic drug responsibility
Fluphenazine that works by
1 cc IM blocking the
action of
dopamine in
the brain.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING THEORIST EVALUATION

DIAGNOSIS COMPETENCY

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

Subjective: Independent:
 “Ang ganda Disturbed Within 4 hours  Develop  Promotes Safe and Ernestine GOAL PARTIALLY
niya parang Sensory of Nursing therapeutic sense of Quality Weidenbach’s MET
siyang Miss Perception: Interventions, nurse-client trust, Nursing Care “The Helping Art
earth” as Auditory the client will relationship. allowing of Nursing” Within 4 hours
claimed by Hallucinations be able to Use a calm and client to of Nursing
the client related to recognize firm approach. discuss This includes Interventions,
alteration in present reality feelings understanding a the client was
 “Pupugutan the function of via activities openly. patient’s needs able to recognize
ko yan ng brain as prepared by and concerns, present reality
Ulo” as manifested by the student  Observe client  Early Safe and developing goals by actively
verbalized by inappropriate nurse and for signs of intervention Quality and actions participated in
the client response eliminate or hallucinations may prevent Nursing Care intended to all the activities
reduce the (listening pose, aggressive enhance a conducted by
 “My occurrence of laughing or response to patient’s well- the student
nababatian hallucination talking to self, command being and nurses and
ina siya nga stopping in hallucination directing the partially able to
mga midsentence) activities related reduce the
malingaw to the medical occurrence of
nga tunog”  Avoided  Client may Safe and plan to improve hallucination.
as claimed touching the perceive Quality patient’s
by his client without touch as Nursing Care condition.
mother permission threatening
and may
Objective: respond in
 Verbalized an aggressive
depiction of manner
decapitation
of a woman.
 Non–reality-  An attitude of  This is Safe and
based acceptance will important to Quality

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 thinking encourage the prevent Nursing Care
client to share possible
 With the content of injury to the
delusion of the client or
grandeur hallucination others from
with you command
 Blank facial hallucination
expression
 Conducted  Involvement Safe and
therapeutic in Quality
activity such as interpersonal Nursing Care
Remotivation activities and
Therapy, Music explanation
and Arts of the actual
therapy, Food situation will
Preparation, help bring
Craft Making the client
and Health back to
education reality
activity

 Decrease  Helps lower Safe and

environmental escalation of Quality
stimuli and anxiety and Nursing Care
provided a manic
calming symptoms.
atmosphere.

Dependent:
 Administered  It blocks Legal

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 Chlorpromazine post-synaptic responsibility
200 mg 1 tab D2 dopamine
BID receptors. It
is considered
that
dopamine
receptor
blockade in
the
mesolimbic
area
accounts for
the
antipsychotic
effect,

 Administered  It acts by Legal

Divalproex Na increasing responsibility
500 Mg 1 tab gamma-
BID aminobutyric
acid levels in
the brain or
by altering
the
properties of
voltage
dependent
sodium
channels.

 Administered  It blocks the Legal

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 Haloperidol 20 effects of responsibility
mg ¼ tab OD dopamine
and
increases its
turnover rate

 It is an anti-
 Administered psychotic Legal
Fluphenazine drug that responsibility
1 cc IM works by
blocking the
action of
dopamine in
the brain.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING THEORIST EVALUATION

DIAGNOSIS COMPETENCY

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

Subjective: Independent:
 Patient Risk for After 3 days of  Develop  Promotes Safe and Ernestine GOAL MET
verbalized Violence: nursing therapeutic sense of Quality Weidenbach’s
hatred for Other Directed interventions, nurse-client trust, Nursing Care “The Helping Art AEB client being
homosexual Client will be relationship. allowing of Nursing” able to display
people “Mga able to display Use a calm and client to non—violent
walang non-violent firm approach. discuss This includes behavior
kwenta yan, behavior feelings understanding a towards others
ang mga towards openly. patient’s needs and being free of
bastos” others and be and concerns, injury.
free of injury.  Regularly  Early Safe and developing goals
Objective: monitored detection Quality and actions
 History of client’s and Nursing Care intended to
killing behavior for intervention enhance a
someone signs of of escalating patient’s well
using a knife agitation mania will being and
and/or prevent the directing the
 Threw a hyperactivity. possibility of activities related
plastic bottle harm to self to the medical
to his co- or others plan to improve
patient patient’s
condition.
 Shoved co-  Decrease  Helps lower Safe and
patient environmental escalation of Quality
towards the stimuli and anxiety and Nursing Care
ground . provided a manic
calming symptoms.
 Verbalized atmosphere.
depiction of
decapitation  Remain neutral  Client may Safe and
of a woman. and avoid value Quality

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 Displays arguing with judgments as Nursing Care
argumentative the client. justification
behavior for arguing
and
 Seen glaring escalating
at others at mania.
times

Dependent:  It blocks
 Administered post-synaptic Legal
Chlorpromazine D2 responsibility
200 mg 1 tab dopamine
BID receptors. It
is considered
that
dopamine
receptor
blockade in
the
mesolimbic
area
accounts for
the
antipsychotic
effect,

 It acts by
 Administered increasing Legal
Divalproex Na gamma- responsibility
500 Mg 1 tab aminobutyric

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7

 BID acid levels in
the brain or
by altering
the
properties of
voltage
dependent
sodium
channels.

 It blocks the
 Administered effects of Legal
Haloperidol 20 dopamine responsibility
mg ¼ tab OD and
increases its
turnover rate

 It is an anti-
psychotic
 Administered drug that Legal
Fluphenazine works by responsibility
1 cc IM blocking the
action of
dopamine in
the brain.

Nursing Care Plan Submitted by: Kristian Dave Diva Page 7