 Assesmen Diagnosis Goal Intervention Implementation Evaluation

Subjective data High risk for Short-Term To observe client’s behavior Observed client’s behavior Risk for
Client said that I injury related Goal: frequently. frequently. violence- self-
want to hit my to extreme Client will directed or
family members. hyperactivity recognize signs To remove all dangerous Removed all dangerous objects other-directed is
and impulsive of increasing objects from client’s from client’s environment like reduced to some
Objective behaviour as anxiety and environment. sharp items and rop. extent .
Data evidenced by agitation and
I observed that lack of control report to staff (or To maintain a calm attitude Maintained a calm attitude
client is having over purpose other care toward the client. toward the client.
violent behavior. and potentially provider) for
injurious assistance with Client on restraints should be Observed client restraint at least
movements. intervention. observed at least every 15 every 15 minutes to ensure that
minutes to ensure that circulation to extremities is not
Long-Term circulation to extremities is compromised.
Goal: not compromised.
Client will not
harm self or To assist the client with needs Encouraged the family members
others. related to nutrition, hydration, to considered client’s likes and
and limitation; and to dislikes regarding the choice of
position the client so that food and to provide adequate
comfort is facilitated and fluid
aspiration is prevented.
Assesment Diagnosis Goal Intervention Implementation Evaluation
Subjective  Insomnia Short-Term Goal: To Encourage activities that Encouraged activities that Client’s
data related to • Client’s sleeping prepare one for sleep . prepare one for sleep i.e., soft sleeping pattern
Client said thought pattern is improved. music, relaxation exercises, warm is improved to
that I am disturban Long-Term Goals: bath. some extent.
unable to ce as • Client will be able to
sleep evidence achieve To Control intake of tea Controlled intake of tea
d by adequate, containing substances containing substances by told
Objective verbalizat uninterrupted sleep. client to avoid tea within 4 hours
data ion with • Client will report of bedtime.
On patient feeling
observation To Provide the comfort devices Provide the comfort devices to
and rested and demonstrate
client look to client client e.g pillow, blanket as now
family a sensation of well-
tired and member. being is winter season
dull. To Discourage daytime Discouraged daytime napping by
napping. Increasing program of activities
to keep the person busy.
Assesment Diagnosis Goal Intervention Implementation Evaluation
Subjective data Short-Term To Identify self-care deficits Identified self-care deficits i.e Client is able to
Client said that Self-care deficit Goal: bad oral and hair hygiene performed
I am unable to related to Client will To provide motivation as Provided motivation to do oral activities of daily
do activity. withdrawal, participate in required related to hygiene care and hair care by telling living at some
regression, panic Activities of maintenance. advantages of hygiene to client extent
Objective data anxiety, daily living
On observe perceptual or with assistance To allow plenty of time for Allowed the client to have
client is unable cognitive from caregiver. client to perform tasks. plenty of time for client to
to fulfill impairment, Long-Term perform tasks by observing
activities of inability to trust Goals: patient with patience
daily living by evidenced by Client will
inadequate difficulty accomplish To provide guidance and support Provided guidance and support
hygiene level as carrying out Activities of for independent actions for independent actions by
assesed from tasks associated daily living to talking the client through the
physical with hygiene, the best of her task one step at a time.
To provide a structured schedule Provided a structured schedule
examination of dressing, ability. of activities that does not change of activities that does not change
client. grooming, eating Unfulfilled from day to day. from day to day by telling
needs will be
met by activities of daily living should
caregivers. be followed as much as
possible.

To provide information to Provided information to

caregivers about responsibility
to fulfill client’s need.
caregivers about responsibility to
fulfill client’s need by making
them aware of available
community support systems
from which they may seek
assistance when required.