JH CERILLES STATE COLLEGE

in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

PATIENT INITIALS : __________________________

- DATE March 14, 2020
: __________________________
STUDENT NURSE Group 1
: __________________________ AREA of ROTATION ZDSMC – Pediatrics Ward
: __________________________
BSN-II, Batch Merakia
YEAR LEVEL and BATCH : __________________________ Dominador P. Apale Jr., MN
CLINICAL INSTRUCTOR : __________________________
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired After nursing Independent: After nursing intervention, the

"My 3 year old Verbal intervention, the patient  Assess the patient’s  Speech patient was able to:
son is not talking Communicatio will be able to: ability to speak, disorders are
unlike his 3 year n language deficit, present in most  Patient was able to
old cousin “ as  Patient will be able cognitive or sensory patients with have effective speech
verbalized by the to have effective impairment. Klinefelter and understanding of
mother speech and syndrome, this communication
understanding of  Monitor the patient helps identify
Objective: communication for nonverbal problem areas  Patient was able to
 Not paying communication, and speech speak in an
attention  Patient will be able such as facial patterns to help understandable way
to speak in an grimacing, smiling, establish a plan possible when
 Shy understandable way pointing, crying, and of care necessary.
possible when so forth; encourage
 Inability to necessary. use of speech when  Indicates that
possible. feelings or  Patient was able make
talk
 Patient will be able needs are being needs known utilizing
to make needs  When expressed when nonverbal methods if

known utilizing communicating with speech is required
nonverbal methods patient, face patient impaired.
if required and maintain eye
 Patient will be able contact, speaking  Clarity, brevity,  Patient was able to
to exhibit minimal slowly and and time exhibit minimal
frustration and enunciating clearly provided for frustration and anxiety
anxiety with speech in a moderate or responses with speech attempts.
attempts. low-pitched tone. promotes the
opportunity for
 Refer to speech and successful
language therapist. speech by
allowing patient
time to receive
and process the
information.

 Speech
therapist helps
people with
speech problem.