NURSING CARE PLAN

PRIORITIZATION OF THE PROBLEM (PROBLEM LIST):

NO. NURSING DIAGNOSIS DATE IDENTIFIED DATE EVALUATED

1. Risk for injury secondary to sensory integration February 22, 2024 February 29, 2024
dysfunction related to hypersensitivity to certain stimuli.

2. Sensory Integration Dysfunction related to neurological February 22, 2024 February 29, 2024
impairement
3. Cognitive Impairment related to autism February 22, 2024 February 29, 2024
4. Speech Impairment related to impaired verbal February 22, 2024 February 29, 2024
communication.
5. Impaired verbal communication related to autism February 22, 2024 February 29, 2024
6. Disturbed sensory perception related to autism February 22, 2024 February 29, 2024
7. Impaired social interaction related to autism February 22, 2024 February 29, 2024

Problem #1:

ASSESSMENT NURSING PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS INTERVENTIONS RATIONALE

Independent:
Subjective Data: Risk for Injury Independent: After 2 hours of nursing
related to After 2 hours 1. Affects intervention client’s
“mahadlok siya sensory of nursing 1. Note client’s age, client’s ability to environment are:
maka dungog ug integration intervention gender, developmental protect self
tingog sa razor” dysfunction client’s stage, decision making and/or others, · Modified as
as verbalized by related to environment ability, level of and influences indicated to enhance
the teacher. hypersensitivity cognition/competence. choice of safety
 to certain will: 2. Assess mood, interventions and · Episode of head
stimuli in the coping abilities, teaching. banging behavior still
environment · personalities styles(e.g. noted.
temperament, 2. Because this
Objective Data: Modify
may result in Goal partially met.
head- environment aggression, impulsive
carelessness or
banging behavior as indicated behavior).
increase risk
to enhance
3. Assess client’s taking without
Easily agitated safety
muscle strength, gross considerations of
Be free of and fine motor consequences.
injury coordination.
3. To identify
4. Monitor risk for falls.
environment for
potentially unsafe 4. To prevent
conditions and modify the risk for injury
as needed, and Orient
or reorient client to 5. To inform and
environment, as for them to
needed. understand their
child.

6. To prevent
5. Educated parent’s child risk from fall.
about their child’s
disorder/problem. 7. To prevent
stumbled and risk
6. Encourage the for injury
parents to Maintain
bed or chair in lowest 8. To prevent
position with wheels stimulate
 locked. tantrums that will
lead to self harm.
7. Ensure that floors
are clear of hazards and 9. Because this
that pathway to can cause injury
bathroom is when not
unobstructed and monitored.
properly lighted.
Collaborative:
8. Provide a calm and
quiet environment. 1. To identify
high-risk tasks,
9. Encourage parents conduct site visits;
to create a safe select, create,
environment by modify equipment
removing sharp objects, or assistive
cover sharp corners. devices; and
provide education
Collaborative: about body
mechanics and
1. Refer to physical or musculoskeletal
occupational therapist, injuries, in
as appropriate. addition to
providing
therapies as
indicated.

Problem #2:
ASSESSMENT NURSING PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS INTERVENTIONS RATIONALE
Subjective: Sensory After 2 hours of Independent: Independent: Goal met.
Integration nursing 1. Assess sensory 1. To identify After 2 hours of
Dysfunction intervention sensitivities and specific nursing
Objective: related to patient will preferences, sensory intervention
hypersensitivity to hypersensitivity improve the including preferences patient
sensory stimuli to certain patient's ability responses to and improve the
difficulty stimuli. to cope with stimuli such as aversions. patient's ability to
processing sensory sensory stimuli 2. Identifying cope with sensory
light, sound, touch,
input and parents will sensory stimuli and
and taste.
impaired ability to learn about challenges is parents will learn
participate in daily sensory 2. Identify any vital for about sensory
activities. integration sensory challenges improving integration
strategies. that may impact comfort, strategies.
the individual’s enabling
comfort and participation,
engagement in reducing
daily activities. stress,
3. Integrate sensory- supporting
friendly learning,
environments and enhancing
social
activities into daily
interactions.
routines.
3. To address
techniques to
sensory
address sensory
sensitivities
sensitivities and
and promote
promote comfort.
comfort.
4. Provide a calm and
4. It supports
structured
 environment sensory
conducive to regulation,
sensory regulation. self-
5. Minimize sensory regulation,
overload by comfort,
reducing well-being.
unnecessary 5. Because it is
stimuli such as essential for
noise, bright lights, promoting
or strong odors. comfort,
6. Incorporate well-being,
sensory activities sensory
that provide input processing,
in a controlled attention.
manner, such as 6. To the
deep pressure, individual's
vestibular sensory
stimulation, tactile needs is
experiences, and essential for
proprioceptive addressing
activities. Sensory
7. Educate the Integration
patient's family Dysfunction
and caregivers related to
about sensory Autism
integration Spectrum
dysfunction and its Disorder
impact on daily 7. To provide
functioning. meaningful
 8. Teach strategies support and
and techniques to create a
support the supportive
patient's sensory environment
regulation at that
home, school, and promotes the
other individual's
environments. overall
health, well-
being, and
participation
in daily
activities.
8. To support
the patient's
sensory
regulation at
home,
school, and
other
environments

Problem #3:

ASSESSMENT NURSING PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS INTERVENTIONS RATIONALE
Subjective Data: Cognitive After 2 hours of Independent: Independent: Goal met.
Impairment nursing 1. Assess the client 1. To identify After 2 hours of
related to intervention we strength and strengths and nursing
Autism will be able to areas of areas of intervention we
Objective Data: Spectrum Provide support impairment impairment, able to Provide
deficits in Disorder (ASD) and education to including including support and
executive the patient, executive executive education to the
functioning, family, and functioning, functioning, patient, family, and
social cognition, caregivers about attention, attention, caregivers about
communication managing memory, and memory, and managing
skills, cognitive problem-solving problem- cognitive
and adaptive impairment skills. solving skills. impairment
behaviors. associated with 2. Evaluate social 2. To identify associated with
ASD. communication deficits, guiding ASD.
Improve social and interaction intervention Improve social
communication abilities, planning, communication
and interaction including verbal supporting and interaction
abilities. and nonverbal social abilities.
communication, integration,
perspective- facilitating
taking, and effective
understanding of communication
social cues. .
3. Provide 3. To improve
structured social social cognition
skills training and interaction
sessions to abilities.
improve social 4. It is an effective
cognition and and evidence-
interaction based approach
abilities. to teach
4. Use role-playing, appropriate
social stories, and social
video modeling behaviors,
to teach perspective-
appropriate taking, and
social behaviors, conversation
perspective- skills to
taking, and individuals with
conversation autism
skills. spectrum
5. Implement disorder.
augmentative 5. To facilitate
and alternative communication
communication for nonverbal
(AAC) strategies, or minimally
such as picture verbal
exchange individuals.
communication 6. To support
system (PECS) or cognitive
communication functioning and
boards. reduce anxiety.
6. Create a 7. to provide
structured and structure and
predictable organization.
environment. 8. For the family
7. Minimize sensory to know about
distractions, autism and
maintain understand
consistent how to deal
routines, and use with it every
visual schedules day.
 or calendars.
8. Educate the
family and
caregivers about
cognitive
impairment
associated with
ASD and its
impact on daily
functioning.

Problem #4:

ASSESSMENT NURSING PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS INTERVENTIONS RATIONALE
Subjective Data: Speech After 2 hours of Independent: Independent: Goal met.
Impairment nursing 1. Assess the 1. To identify After 2 hours of
related to interventions: patient's verbal deficits, guiding nursing
impaired verbal The child will communication intervention interventions:
Objecive Data: communication. demonstrate abilities, including planning, The child
difficulty in improved verbal speech clarity, monitoring demonstrate
speech clarity, communication articulation, progress, improved verbal
limited expressive and atleast say 2 expressive informing communication
language skills words. language skills, collaborative and atleast say 2
and receptive care, facilitating words.
language skills. communication
2. Evaluate the support, and
patient's ability to enhancing
produce sounds, patient-
form words, and centered care.
convey messages 2. To help identify
effectively. specific
3. Determine problems of
primary language speech.
spoken. 3. Knowing the
4. Interview parent client’s primary
to determine language and
child’s fluency in other
developmental languages is
level of speech important to
and language communication.
comprehension. 4. To check if
5. Note parental parents knows
speech patterns how to teach
and manner of their child how
communicating to speak.
 with child, 5. To determine if
including it is effective or
gestures. appropriate for
6. Establish rapport child to speak in
with client, that way.
initiate eye 6. Helps establish
contact, shake a trusting
hands, address by relationship
preferred name. with
7. Reduce client/family,
environmental demonstrating
noise that can caring about
interfere with the client as a
comprehension. person.
Provide adequate 7. To have a
lighting, especially proper learning
if client is reading environment.
lips or attempting 8. To facilitate
to write. calm learning
8. Teach child about and
basic letters and productivity.
words without in 9. Because it
hurry. enhance the
9. Implement the learning
use of visual aids process.
like picture or 10. Reduces stress
things like fruits of difficult
and animals. situation and
10. Encourage family promotes
to involve client in earlier return to
family activities more normal
 using enhanced life patterns.
communication 11. To maintain
techniques. contact with
11. Discuss to parents reality or
and caregiver reduce
ways to provide environmental
environmental stimuli or noise.
stimuli as 12. To reduce
appropriate. caregiver role
12. Teach the strains knows
caregiver about how to manage
coping strategies the child’s
and relaxation behavior at
techniques to home.
help manage 13. For child to be
anxiety and used to know
frustration. and do not
13. Make sure that forget about
child’s learning is the words that
contiuous at he learned.
home.

Problem #5:

ASSESSMENT NURSING PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS INTERVENTIONS RATIONALE
Subjective data: Impaired verbal After 4 days of INDEPENDENT : Independent: Goal Partially Met
communication Nursing
1. 1. It helps the
related to intervention the
child
“Dili siya dali cognitive client will be able After 4 days of
2. Use simple, clear,
makastorya, ug limitation to demonstrate and concise understand Nursing
dali ra pud siya secondary to improved eye language when and respond intervention the
madistract sa autism contact during communicating more client was able to
ubang butang”, communication with the child. effectively. demonstrate
as verbalized by and use two new 3. Encourage the 2. Encouraging improved eye
the therapist. words during the child to express this can help contact during
rotation , as their feelings and the child feel communication
observed by the needs, either understood but unable to use
Objective data: caregiver or verbally or through and validated, two new words
therapist. non-verbal cues. which can during the
4. Provide a quiet foster a sense rotation, as
-Difficulty and calm of security and observed by the
forming words or environment to improve their caregiver or
sentences reduce sensory overall therapist.
overload, which communicatio
can hinder n skills.
-Limited communication 3. A calm
vocabulary 5. Use visual aids, environment
such as pictures or can help them
symbols, to focus better
-Inconsistent or facilitate on the task at
inappropriate use understanding and hand, in this
of verbal expression. case,
language 6. Implement a communicatio
routine to provide n
structure and 4. They can aid in
predictability, understanding
which can reduce complex
 anxiety and concepts and
improve expressing
communication thoughts and
7. Use social stories feelings.
and role-playing to 5. Routines can
teach appropriate provide a
social and sense of
communication security and
skills. predictability
8. Encourage the for children,
child to engage in reducing
play activities that anxiety. When
promote children are
interaction and less anxious,
communication they are
9. Provide positive generally
reinforcement more open to
when the child communicatio
attempts to n
communicate or 6. This can help
successfully children
communicates. understand
and practice
10. Collaboration: these skills in
11. Collaborate with a safe and
occupational controlled
therapist environment
7. Engaging in
 play activities
that promote
interaction
can provide
opportunities
for the child to
practice and
improve their
communicatio
n skills.
8. Positive
reinforcement
can motivate
the child to
continue
practicing
their
communicatio
n skills. It can
also boost
their
confidence
and self-
esteem, which
are important
factors in
effective
communicatio
 n
9. Collaboration:
10. To Improve
communicatio
n and enhance
child verbal
abilities.

Problem #6:

ASSESSMENT NURSING PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS INTERVENTIONS RATIONALE

Subjective data: Disturbed After 2 hours of Independent: Independent: Goal partially

Sensory nursing met.
“Pag makadungog 1. Identify client with 1. Identifying a
Perception intervention child
na siya og tingog condition that can client with a
related to will be able to
sa pangpagupit affect sensing, condition such
overreactivity to Nursing
mag tantrum na Regain or interpreting, and as autism
sensory stimuli Evaluation:
siya mao sab sa maintain usual communicating spectrum
Monitor and
tingog sa timer.” level of stimuli. disorder (ASD)
document the
As verbalized by cognition. 2. that can
client's responses
the Teacher significantly
to sensory stimuli,
impact their
noting any
Recognize and ability to
overreactivity or
Objective data: correct or sense,
hypersensitivity,
compensate for interpret, and
- Looks confused sensory communicate and collaborate
impairments. stimuli is with the
- Screeching
3. Review results of essential for interdisciplinary
- Slaps the face sensory and motor providing team to
forcefully Verbalize neurological appropriate implement
awareness of testing support and sensory
sensory needs 4. interventions modulation
and presence of tailored to techniques and
overload and/or their sensory environmental
deprivation. needs. modifications to
minimize distress
and promote
2. Reviewing the optimal sensory
results of processing and
sensory and perception.
motor
neurological
testing allows
healthcare
professionals
5. Determine to assess the
response to client's sensory
painful stimuli to processing
note whether abilities, motor
response is function, and
appropriate to neurological
stimulus and is status, guiding
immediate or treatment
delayed.
 planning and
interventions
to address any
identified
deficits or
abnormalities.

3. Assessing the
client's
response to
painful stimuli
helps
determine if
the reaction is
appropriate to
the stimulus
and whether it
occurs
immediately or
is delayed,
aiding in
evaluating
sensory
processing,
neurological
function, and
pain
 perception.

Problem #7:

ASSESSMENT NURSING PLANNING NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION

DIAGNOSIS

Subjective data: Impaired Social After 4 hours of Independent: Independent: Goal Partially
Interaction nursing Met
“Dili kaayo tig 1. Review social 1. Reviewing social
related to intervention child
halubilo ang history with history with the
underdevelope will be able to After 4 days of
akong anak sa client/SO(s) going client and
d conscience Nursing
uban bata kay To develop back far enough in significant
secondary to Intervention,
mura gyud na siya interpersonal time to note when others is
autism the client will
og naay lain social skills. changes in social essential to
iimplement
kalibutan.” As behavior or pinpoint when
structured
verbalized by the patterns of relating changes in social
social skills
father. - To gain an occurred or began. behavior or
training and
adequate level of 2. relational
behavioral
concentration. patterns
interventions
emerged,
tailored to the
Objective data: enabling tailored
client's level of
- Identify feelings interventions
Elopes randomly understanding
that lead to poor and support
and
Minimal eye social 3. Determine family strategies to
communication
contact interactions. patterns of relating address
abilities to
and social underlying
Self-inflicts injury behaviors. Explore factors promote social
when easily possible family effectively. interaction and
- Develop
overwhelmed scripting of 2. By examining development,
effective social
behavioral family patterns considering the
support system;
expectations in the of relating and unique
use available
children and how social behaviors, challenges
resources
the client was we can uncover posed by their
appropriately.
affected. potential underdevelope
4. scripting of d conscience
behavioral secondary to
expectations in autism.
children and
5. Observe client assess their
while relating to impact on the
family/SO(s) to note client's
prevalent development
interaction and social
patterns. functioning.

3. Observing the
client's
interactions with
family or
significant
others allows us
to identify
prevalent
patterns in their
social behavior
and
communication
dynamics,
providing insight
into their
relational
dynamics and
areas for
intervention.