Gonzales John Angelo Rusvelt S.

BSN 3-1

Nursing Diagnosis (1) e.g. Risk For Self-Directed Violence

Nursing Diagnosis (2) e.g. Risk for disturbed personal identity related to lows elf-esteem. 

Nursing Diagnosis (3) e.g. Disturbed thought processes r/t degenerative process as manifested by memory deficit.

Nursing Care Plan

Assessment Nursing Diagnosis Outcome Nursing Actions Rationale Evaluation

Identification
Subjective Disturbed thought Short Term: Independent  Determines Short Term:
‘’I have been processes  After 8 hours  Assess attention ability to  After 8 hours
sleeping 12 hours a degenerative of nursing span/distractibility participate in of nursing
day and I can’t process as intervention, and ability to make planning and intervention,
function at work. I manifested by not the patient decisions or executing the patient
am so depressed functioning well. will be able to problem solve. care. will be able to
and feel like giving verbalize the verbalize the
up.’’ As verbalized feeling that  Test ability to  To assess feeling that
by the patient leads to receive, send, and degree of leads to
depressed and appropriately impairment. depressed and
Method: Interview can’t function interpret can’t function
at work. communications. at work.
 Reorient to time,  Inability to  Goal was
Long Term: place, and person as maintain partially met.
 After 5 days needed orientation is Long Term:
of nursing a sign of  After 5 days
intervention deterioration. of nursing
the client will  Provide safety  To prevent intervention
voluntarily measures such as further the client will
spend time siderails, padding as deterioration. voluntarily
with other necessary and close spend time
clients and supervision as with other
nurse or indicated. clients and
therapist in nurse or
group therapist in
activities. group
Dependent activities.

 Assist in identifying  This measure

ongoing treatment is important to
needs/rehabilitatio maintain gains
n program for the and continue
individual progress if
able.
 Refer to community  These
resources (e.g., day- measures are
care programs, necessary to
support groups, promote
drug/alcohol wellness.
rehabilitation,
mental health
treatment
programs).

 Assist with  This is to

testing/review assess the
results evaluating degree of
mental status impairment.
according to age
and developmental
capacity.

Collaborative
 Review laboratory  Monitoring
values for laboratory
abnormalities such values aids in
as metabolic identifying
alkalosis, contributing
hypokalemia, factors.
anemia, elevated
ammonia levels, and
signs of infection.

 Refer to physician
for furthermore test  To diagnose
and possible the patient
rehabilitation more and to
treat the
patient.