Assesment Diagnosis Goal Intervention Implementation Evaluation

Subjective data Disturbed The patient will . Observe the client for signs Patient’s
Client says that I Sensory- demonstrate of hallucinations (listening Observed the client for signs of sensory
can hear the voice perceptual decreased pose, laughing or talking to hallucinations (listening pose, perception has
of my daughter Auditory hallucinations, self,stopping in mid- laughing or talking to improved to an
who is died. /visual, related interact with sentence). self,stopping in mid-sentence). extent.
to panic others, verbalize
Objective anxiety, plan to deal with show an attitude of showed an attitude of acceptance
Data withdrawal hallucination if acceptance encourage the encourage the patient to share the
Client shows into self, they recur patient to share the content of content of the hallucination with
inappropriate evidenced by the hallucination with you. you.
response and inappropriate
selftalk. responses,
disordered Help the client understand Helped the client understand the
thought the connection between connection between anxiety and
process, poor anxiety and hallucinations. hallucinations.
concentration
and
disorientation.
Try to distract the client Tried to distract the client away
away from the hallucinations from the hallucinations and
and involve him in involve him in interpersonal
interpersonal activities and activities and actual situation
actual situation
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.