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NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Disturbed Sensory At the end of 8 hour-  Accepted the fact that  Validate that your GOAL MET
 “tatanga-tanga” as Perception: Auditory shift, after effective the voices are real to the reality does not
verbalized by the related to altered nursing interventions, client, but explain you do include voices can a. The patient learned
patient (auditory sensory perception the patient will be able not hear the voices. help client to not ways to refrain from
hallucination to: doubt on the reality responding to
perceived by the of the voices she hallucinations.
patient)  Learn ways to hears.
refrain from b. The patient
Objective: responding to  Explored how the  Exploring the demonstrated
 Looks frightened hallucinations hallucinations are hallucinations and techniques that
 Confused about  Demonstrate experienced by the client. sharing the help distract her
heard voices techniques that experience can help from the voices.
help distract her give her sense of
from the voices. power that she c. The patient was
might be able to compliant in taking
manage those her antipsychotic
voices. medications and
follows doctor’s
 Helped client identify  Helps both nurse order when asked
times that the and client identify to go for follow-up
hallucinations are most situations and times check-up.
prevalent and frightening that might be mood,
anxiety producing The patient stated:
and threatening to
the client “Hindi ko nalang
papansinin yung mga
 Notified others, physician  Clients often obey naririnig ko ma’am.
and administration hallucinatory Saka sasali nalang ako
according to unit commands to kill palagi sa mga OT ma’am
protocol. Clearly self or others. Early kung meron lalo na
documented what the assessment and kapag naboboring na
client said. ako ma’am.”
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 interventions might
save lives.

 Kept simple basic, reality  Client thinking

based topics on might be confused/
conversation. disorganized, this
intervention helps
client and
comprehend
reality- based
issues.

 Engaged client in reality  Redirecting client’s

based activities such as energies to
painting, dancing and acceptable activities
singing. can decreases the
possibility of acting
on hallucinations
and help distract
from voices.

 Ensured that the patient  In order to prevent

is compliant to her relapse of the
medication especially positive and
antipsychotic drugs. negative symptoms
of the disorder.

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 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Disturbed sleep At the end of 3 days,  Observed and obtained  To determine usual GOAL MET
“Hindi ako makatulog pattern related to after effective nursing feedback from client sleep patterns and
ng maayos araw-araw sustained interventions, the regarding usual sleeping provide a a. The patient
ma’am kasi mabaho environmental patient will be able to: routines, number of comparative identified factors
dun sa room kaya dun stimulation sleep. baseline. that can help her
ako sa may tabi ng  Identify factors promote effective
nurse station natutulog that can help her  Assessed client’s sleep  Data collected sleeping pattern.
paminsan-minsan saka promote effective patterns and usual through a
maingay din ma’am sleeping pattern bedtime rituals and comprehensive and b. The patient
kapag may  Achieve optimal incorporate them into the holistic assessment achieved optimal
sinusumpong.” as amount of sleep as plan of care. are needed to amount of sleep as
verbalized by the evidenced by determine the evidenced by
patient rested appearance etiology of the rested appearance
and verbalization disturbance. and verbalization
Objective: of improved of improved
 Appears tired sleeping pattern.  Observed client’s  Difficulty sleeping sleeping pattern.
 Noisy environment medication, diet, caffeine can be a mood
in the ward intake. effect of The patient stated:
 Dirty surroundings medication,
 Foul smelling caffeine can also “Sasabihan ko po yung
environment interfere with sleep. mga kasama ko na
maglilinis kami ng
 Provided measures to  Excessive noises kwarto palagi para po
take before bedtime with cause sleep mabilis akong
sleep quiet time to allow deprivation. makatulog ma’am kasi
mind to slow down. wala na po yung amoy
saka malinis na.”
 Advised patient to avoid  Daytime naps may
daytime naps unless lengthen ability to
necessitated by condition. achieve nighttime
sleep or may reduce
hours of sleep at
night.

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 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Deficient diversional At the end of 8 hour-  Assessed client’s physical,  Validates reality of GOAL MET
 “Wala ngang activity related to shift, after effective cognitive, emotional and environmental
magawa sa loob long term nursing interventions, environmental status. deprivation when it a. The patient coped
ma’am eh. Boring hospitalization the patient will be exists or considers with personal
po ma’am. Kaya able to: potential for loss of circumstance by
gustung- gusto desired diversional communicating
kong mag-OT.  Recognize own activities in order to with others.
Manonood saka psychological plan for prevention
maglalaro po kasi response (e.g., or early b. The patient
ma’am.”as hopelessness, intervention. adapted to other
verbalized by the depression) and diversional
patient. initiate  Noted impact of disability  Provide activities readily
appropriate or illness on lifestyle. comparative available.
Objective: coping actions baseline for
 Usual hobbies and  Engage in assessments and
activities cannot satisfying interventions. The patient stated:
be undertaken in activities within
the current setting personal  Determined client’s  Presence of acute, “Hindi ko nalang
limitations. actual ability to illness, depression, papansinin yung mga
participate and interest in problems of naririnig ko ma’am.
available activities, mobility, protective Saka sasali nalang ako
noting attention span, isolation, or sensory palagi sa mga OT ma’am
physical limitations and deprivation may kung meron lalo na
tolerance, level of interfere with kapag naboboring na
interest or desire and desired activity. ako ma’am.”
safety needs.

 Instituted and continued  These interfere with

appropriate actions to the individual’s
deal with concomitant ability to engage in
conditions such as meaningful
anxiety, depression, grief, diversional
dementia, physical injury, activities.
isolation and immobility,
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 malnutrition, or acute or
chronic pain.

 Acknowledged reality of  To establish

situation and feelings of therapeutic
the client. relationship and
support hopeful
relations.

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 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Deficient knowledge At the end of 3 hours,  Determined client’s  Individual may not GOAL MET
 “Nadengue na din related to after effective nursing ability or readiness and be physically,
po ako Ma’am. information interventions, the patient barriers to learning. emotionally, or a. The patient
Mga 2010 po ata misinterpretation will be able to: mentally capable at verbalized
yung una, this time. understanding of
dalawang beses na  Verbalize condition/ disease
po akong understanding of  Provided environment  A calm environment process and
nadengue. Basta condition, disease that is conducive to allows the patient treatment.
ang naalala ko lang process, and learning. to concentrate and
nung pangalawang treatment. focus more b. The patient
beses na nadengue  Exhibit increased and completely. exhibited increase
na po ako, nabaliw assume responsibility interest assume
na din po ako.” As for own learning by  Begun information that  Can arouse interest responsibility for
verbalized by the beginning to look for the client already knows or limits sense of own learning.
patient. information and ask and move to what the being
 “Kinulam ata ako questions. client doesn’t know, overwhelmed. c. The patient
nung dalawang  Initiate necessary progressing from simple initiated
taga Kalinga na lifestyle changes and to complex. necessary lifestyle
kaboardmate ko participate treatment changes and
nung college. regimen.  Provided active role for  Promotes sense of participated
Naiinggit kasi sila  Participate in learning client in learning process. control over treatment
sakin ma’am. Kasi process situation and is regimen.
nung kinuha nila means for
yung gamit ko, determining that d. The patient
kinuha ko naman client is assimilating participated in
yung electric fan or using new learning process.
nila. Nagpa information.
albularyo kami
tapos sabi nung  Encouraged questions.  Questions facilitate
albularyo babae open
daw yung communication
kumulam sakin between patient
tapos mahaba and the nurse and
yung buhok na allow verification of

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 maputi. Eh ganun understanding of
yung kaboardmate given information.
ko nun sa Caritan
ma’am. Pinasakit
nila ako tapos yun  Provided clear thorough  Patients are better
nabaliw na ako. and understandable able to ask
Tapos yung explanations and questions when
pinakita sakin nung demonstrations. they have basic
albularyo na galing information about
sa nangkulam daw what to expect.
sakin, buhok ng
babae na may
kulay ma’am.”as  Considered what was  Allowing the patient
verbalized by the important to the patient. to identify the most
patient. significant content
to be presented first
Objective: is the most
 Asks for effective.
clarification of
disease definition  Explored reactions and  Assist the nurse in
feelings about changes. understanding how
the learner may
respond to the
information and
possibly how
successful the
patient may be with
expected changes.

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 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for Suicide At the end of the entire  Established a therapeutic  Promotes sense of GOAL MET
 “Dalawang beses hospitalization, after relationship with the trust, allowing
na po ma’am. effective nursing client. individual to a. The patient did
Naalala mo ma’am interventions, the patient discuss feelings not harm herself.
will be able to: openly.
nung binugbog ako
a. Not harm self b. The patient talked
ni kuya? Umakyat b. Express  Asked directly if person is  Determines intent. about her feelings
ako ng bubong decreased thinking of acting on Most suicidal and expressed
namin ma’am at anxiety and thoughts or feelings. people will answer anger
nagbalak akong control honestly because appropriately.
magpakamatay hallucinations they actually want
pero hindi po ako c. Talk about help. c. The patient
feelings and obtained no
tumalon. May
express anger  Assessed coping behaviors  Client may believe access to harmful
naririnig kasi ako appropriately presently used. there is no objects.
na gawin ko daw d. Obtain no access alternative except
yun. Nung to harmful suicide.
pangalawa ma’am objects
uminom ako ng  Maintained straight  To avoid
forward communication. reinforcing
lason pero naging
manipulative
okay naman ako
behavior.
kasi naospital ako
ma’am.”, as  Encouraged expression  Acknowledges
verbalized by and make time to listen to reality of feelings
patient DR. concerns. and that they are
 “Ilang beses na yan okay. Helps
na nagbalak individual sort out
magpakamatay. thinking and begin
Umakyat sa to develop
bubong tapos hindi understanding of
siya tumalon. Alam situation and look
mo yung binugbog at other
alternatives.
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 siya ng kuya niya?  Had given permission to  Promotes
Yun. Ginawa niya express angry feelings in acceptance and
nun. Saka uminom acceptable ways and let sense of safety.
siya ng lason. client know someone will
Nagawa niya daw be able to assist in
yun dahil sa maintaining control.
problema. Nakita
nalang namin siya  Discussed consequences  Helps focus on
na nakahiga tapos of actions if they follow consequences of
may hawak siyang through on intent. Ask actions and
sprayer na may how it will help individual possibility of other
laman na to resolve problems. options.
solignum. Kaunti
nalang yun ma’am  Maintained observation  To increase client’s
pero tinakbo na and eliminated hazards safety or reduce
namin kaagad sa that could be used to risk of impulsive
Peoples General commit suicide. behavior.
hospital.” as
verbalized by her
grandmother.

Risk factors:
 History of prior
suicide attempts

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