Cues and clues Nursing Diagnosis
Objective:
• •
Restlessness, Weak
• Irritable
• Poor communication
• In denial stage (use of
substance)
• Does not involved to
activities
• (+) Delusion
• Manifest Projection
• Withdrawal from
environmental stimuli
• Stays on bed all the
time.
Subjective:
• Verbalization of “ Sana
nga UST na lang ako
nag-aral. Sa FB nga
UST school ko”.
• Verbalization of “Wala
akong bisyo ”
• Verbalization of “”
• Verbalization of
mother “Nagsasalita at
tumatawa syang
magisa”
Rationale
Ineffective Coping related to
weak/impaired ego as
manifested by suppression and
withdrawal.
Objectives
Inability to form Short term:
a valid appraisal Identify effective and
ineffective coping
of the stressors, patterns.
inadequate • Establish rapport
choices of • Establish trust
practiced • Demonstrate effective
coping mechanism
responses,
and/or inability
to use available
resources Long term
• Verbalized sense of
control
• Report decrease in
negative feelings
• Able to cope effectively.
Nursing Intervention
Establish a working relationship with patient
through continuity of care.  the feeling of isolation, and may facilitate coping
Provide opportunities to express concerns,
fears, feelings, and expectations.  reduce anxiety.
Provide information the patient wants and
needs. Do not provide more than patient can
handle. 
Encourage patient to set realistic goals.  parts may make the problem more manageable.
Encourage verbalization of feelings,
perceptions, and fears
Encourage Patient to identify his own
strengths and abilities
Foster constructive outlets for anger and
hostility
Encourage patient to communicate feelings
with significant others.
Instruct in need for adequate rest and
balanced diet. 
Rationale
An ongoing relationship establishes trust, reduces
Verbalization of actual or perceived threats can h
Patients who are coping ineffectively have reduce
ability to assimilate information.
This helps patient gain control over the situation.
Guiding the patient to view the situation in smalle
Open, nonthreatening discussions facilitate the
identification ofcausative and contributing factor
Assists Patient to develop appropriate strategies
coping based on personal strengths and previous
experiences. Improves self-concept and sense of
ability to manage stress
Assists the individual in channeling potentially
harmful emotionsand physical energy into
constructive behaviour
Unexpressed feelings can increase stress.
These facilitate coping strengths. Inadequate di
and fatigue can themselves be stressors. 
 Cues and clues
Objective: Impaired Social Interaction
• Restlessness, Weak related to inability to trust
• Irritable
• Poor communication
skills
• Isolate self from others
• Doutful to others
• In denial stage (use of
substance) lead to
suppression
• Observed to be in
constant fear
• Does not involved self
to activities
• Self care/hygiene is
poor or neglected
• Does not established
eye contact
• Talks to itself
• Disorganized
• Inappropriate affect
Subjective:
• Verbalized “Minsan
mabigat yung
pakiramdam ko ,
ayoko lang
makipagusap nun o
kinakausap ako”.
• Verbalized “Bored lang
ako nun kaya
kinakausap ko sarili
ko”
• Verbalized”doutful ako
sa iba”
• Verbalized
“Manahimik kayo
nagshooshoot ako”
• Verbalized mother “
kinakausa niya sarili
niya at di ako
Nursing Diagnosis Rationale
Social isolation is the Short-Term Goal
condition of aloneness
experienced by the
individual and
perceived as imposed
by others and as a
negative or threatened
Long-Term Goals
state; impaired social
interaction is the state
in which an individual
participates in an
insufficient or
excessive quantity or
ineffective quality of
social exchange.
Objectives Nursing Intervention Rationale
Spend time with client. This may mean just Your presence may help improve client's percepti
sitting in silence for a while. of self as a worthwhile person
• Client will gradually
develop trusting Develop a therapeutic nurse-client relationship
relationship with nurse. through frequent, brief contacts and an Your presence, acceptance, and conveyance of
accepting attitude. Show unconditional positive regard enhance the client's feelings of se
positive regard.  worth.
After client feels comfortable in a one-to-one
• Client will voluntarily The presence of a trusted individual provides
relationship, encourage attendance in group
spend time with other emotional security for the client
activities
clients and nurse in
group activities. Verbally acknowledge client's absence from Knowledge that his or her absence was noticed m
• Client will effectively any group activities. reinforce the client's feelings of self-worth.
interact with other
clients Teach assertiveness techniques. Interactions Knowledge of assertive techniques could improve
• Client will be able to with others may be negatively affected by client's relationships with others.
verbalized feeling, fears client's use of passive or aggressive behaviors.
and emotions.
• Client will refrain from
using egocentric Provide direct feedback about client's
behaviors that offend interactions with others. Do this in a Client may not realize how he or she is being
others and discourage nonjudgmental manner. Help client learn how perceived by others. Direct feedback from a trust
relationships. to respond more appropriately in interactions individual may help alter these behaviors in a
with others. Teach client skills that may be positive manner. Practicing these skills in role pla
used to approach others in a more socially facilitates their use in real situations.
acceptable manner. Practice these skills
through role play
Provide positive reinforcement for client's Positive reinforcement enhances self-esteem and
voluntary interactions with others encourages repetition of desirable behaviors.
 pinapansin”

Cues and clues Nursing Diagnosis Rationale Objectives Interventions Rationale

Objective: Altered health Short Term: Assess the client’s feelings, values, and Assessment of an individual’s preferences f
Ineffective health
• Restlessness, Weak maintenance reasons for not following the prescribed participation in decision-making will allow
• Irritable maintenance related to reflects a change in • Patient will discuss plan of care.  enlisting involvement in decision-making at
• Disorganized
Inability to focus and lack of an individual’s fear of implementing the preferred level
• Poor communication
self care needs. ability to perform health care as
skills
• Isolate self from others the functions measured by
• In denial stage (use of necessary to identification of fears -Assess for family patterns, economic The family’s reaction to the diagnosis has a
substance) lead to maintain health or or things that blocks issues, and cultural patterns that significant influence on adherence to the
suppression wellness. That to implementation of influence compliance with a given treatment regimen.   There are marked
• Does not established individual may health maintenance. medical regimen.   differences in use of healthcare services
eye contact already manifest among different cultural groups 
• Neglect hygiene symptoms of Long Term:
• Anorexia (+) existing or
• Insomnia
impending physical • Patient will follow -Help the client to choose a healthy Healthy lifestyle measures, such as exercisi
• Possible For substance
abused ailment or display mutually agreed on lifestyle and to have appropriate regularly, maintaining a healthy weight, no
• Poor insights (meds, behaviors that are healthcare diagnostic screening tests completed.    smoking, and limiting alcohol intake, help
nahihilo daw sya) strongly or certainly maintenance plan as reduce the risk of cancer and other chronic
• Lab results linked to disease. measured by one illnesses
Subjective: week of
• Verbalized “ ayoko documentation of -Discuss with the client and support
maligo, is this your participation in person realistic goals for changes in The importance of personalized goals and
house? Bahay ng healthcare health maintenance.   social support in designing health
prinsesa to eh”
maintenance interventions for older adults is a unique
• Verbalized “Hindi ako
natulog for 1 week activities. predictor of health goal attainment 
dahil sa computer
games at dahil sa
katext ko”
• Verbalized “less na
lang kinakain ko para
matipid”
• According to the
mother the patient
shifted to an
unrecalled foor
supplement because
 he thought that it can
substitute for his
medications.
Cues and Clues Nursing Diagnosis rationale Objectives Interventions Rationale
Objective: Low self-esteem related to Development of a Short-Term Goal Establish a working relationship with patient An ongoing relationship establishes trust, reduces
• Restlessness, Weak Impaired ego as manifested by negative perception of through continuity of care.  the feeling of isolation, and may facilitate coping
• Irritable suppression and mistrust. self-worth in response • Client will voluntarily
• Poor communication to a current situation spend time with nurse Provide opportunities to express concerns, Verbalization of actual or perceived threats can h
skills and other patients in fears, feelings, and expectations.  reduce anxiety.
• Isolate self from others activities.
• In denial stage (use of Patients who are coping ineffectively have reduce
Provide information the patient wants and
substance) lead to ability to assimilate information.
Long-Term Goal needs. Do not provide more than patient can
suppression
handle. 
• Does not established This helps patient gain control over the situation.
eye contact • Client will exhibit Guiding the patient to view the situation in smalle
• Lack of Motivation increased feelings of Encourage patient to set realistic goals.  parts may make the problem more manageable.
• (+) Delusion self-worth, as evidenced
Subjective: by voluntary Encourage verbalization of feelings, Open, nonthreatening discussions facilitate the
• Verbalization of “ Sana participation in own perceptions, and fears identification ofcausative and contributing factor
nga UST na lang ako self-care and interaction
nag-aral. Sa FB nga with others. Assists Patient to develop appropriate strategies
UST school ko”. coping based on personal strengths and previous
• Verbalization of “Wala . experiences. Improves self-concept and sense of
akong bisyo ” Encourage Patient to identify his own ability to manage stress
• Verbalized strengths and abilities
“Nahihirapan akong Assists the individual in channeling potentially
magtiwala sa ibang harmful emotionsand physical energy into
tao” Foster constructive outlets for anger and constructive behaviour
• Verbalized by mother hostility
“Nagseselos sya sa
kapatid niya kasi akala Encourage patient to communicate feelings Unexpressed feelings can increase stress.
niya favorite sya ng with significant others.
daddy niya” These facilitate coping strengths. Inadequate di
and fatigue can themselves be stressors. 
Instruct in need for adequate rest and
balanced diet. 

Cues and Clues Nursing Diagnosis Rationale Objectives Nursing Interventions Rationale
Objective:
 Ineffective role
• Restlessness, Weak
• Irritable
• Poor communication
skills
• Isolate self from others
• In denial stage (use of
substance) lead to
suppression
• Does not established
eye contact
• Neglect hygiene
• Lack of motivation
Subjective:
 Frustration to mother
verbalized “Nagagalit
ako sa nanay ko kasi
pinepressure niya ako”
 Verbalization of
“doutful ako sa iba”
 Verbalized by mother
“Nagseselos sya sa
kapatid niya kasi akala
niya favorite sya ng
daddy niya”
 Verbalized by mother
“binuhusan niya ako
ng tubig”
 Verbalized by mother
“Hindi nya ako
pinapansin”
 of a positive outcome.
Patterns of behavior Short-Term Goal
and self-expression
performance related that do not match
• Client is able to
the environmental
to Mood disorder and verbalize realistic
context, norms, and
expectations. perception of role
disturbed family expectations.
relations.
Long-Term Goal
• Client will be able to
assume role-related
responsibilities.
• Client and family are
able to verbalize plan
for attempt at resolving
conflict.
Determine client's usual role within the An accurate database is required in order to
family system. Identify roles of other formulate appropriate plan of care for the client.
family members. 
It is important to determine the realism of the
Assess specific disabilities related to role
expectations. Assess relationship of client's role expectations.
disability to physical condition. 
Encourage client to discuss conflicts
.  It is necessary to identify specific stressors, as w
evident within the family system. Identify
as adaptive and maladaptive responses within t
how client and other family members
system, before assistance can be provided in an
have responded to this conflict
effort to create change.
Help client identify the feelings associated
with family conflict, the subsequent Client may be unaware of the relationship betw
exacerbation of physical symptoms, and physical symptoms and emotional problems. An
the accompanying disabilities.  awareness of the correlation is the first step tow
creating change.
Help client identify changes he or she
would like to see within the family
system.
Input from the individuals who will be directly
Encourage family participation in the involved in the change will increase the likelihoo
development of plans to effect positive of a positive outcome.
change, and work to resolve the conflict
for which the client's sick role provides
relief. 
Input from the individuals who will be directly
Allow all family members’ input into the involved in the change will increase the likelihoo
plan for change: knowledge of benefits
and consequences for each alternative,
selection of appropriate alternatives,
methods for implementation of
alternatives, formation of alternate plan
in the event initial change is unsuccessful
.  Family may require assistance with this proble
Ensure that client has accurate perception solving process.
of role expectations within the family
system. Use role playing to practice areas
associated with client’s role that he or she
perceives as painful. 

Repetition through practice may help desensitiz

As client is able to see the relationship
client to the anticipated distress.
between exacerbation of physical
symptoms and existing conflict, discuss
more adaptive coping strategies that may
be used to prevent interference with role
performance during times of stress.