X.

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: At the end of 8 hour-  Accepted the fact that  Validate that your GOAL MET
shift, after effective the voices are real to the reality does not
nursing interventions, client, but explain you do include voices can a. The patient learned
the patient will be not hear the voices. help client to not ways to refrain
able to: doubt on the reality from responding to
Objective: of the voices she hallucinations.
  hears.
b. The patient
 Explored how the  Exploring the demonstrated
hallucinations are hallucinations and techniques that
experienced by the sharing the help distract her
client. experience can help from the voices.
give her sense of
power that she c. The patient was
might be able to compliant in taking
manage those her antipsychotic
voices. medications and
follows doctor’s
 Helps both nurse order when asked
 Helped client identify and client identify to go for follow-up
times that the situations and times check-up.
hallucinations are most that might be
prevalent and frightening mood, anxiety The patient stated:
producing and
threatening to the “Hindi ko nalang
client papansinin yung mga
naririnig ko ma’am.
 Notified others,  Clients often obey Saka sasali nalang ako
physician and hallucinatory palagi sa mga OT
administration according commands to kill ma’am kung meron lalo
to unit protocol. Clearly self or others. Early na kapag naboboring
documented what the assessment and na ako ma’am.”
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 client said. interventions might
save lives.

 Client thinking
 Kept simple basic, reality might be confused/
based topics on disorganized, this
conversation. intervention helps
client and
comprehend
reality- based
issues.

 Redirecting client’s
 Engaged client in reality energies to
based activities such as acceptable
painting, dancing and activities can
singing. decreases the
possibility of acting
on hallucinations
and help distract
from voices.

 Ensured that the patient  In order to prevent

is compliant to her relapse of the
medication especially positive and
antipsychotic drugs. negative symptoms
of the disorder.

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 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Disturbed sleep At the end of 3 days,  Observed and obtained  To determine usual GOAL MET
“Hindi ako makatulog pattern related to after effective nursing feedback from client sleep patterns and
ng maayos araw-araw sustained interventions, the regarding usual sleeping provide a a. The patient
ma’am kasi mabaho environmental patient will be able to: routines, number of comparative identified factors
dun sa room kaya dun stimulation sleep. baseline. that can help her
ako sa may tabi ng  Identify factors promote effective
nurse station natutulog that can help her  Assessed client’s sleep  Data collected sleeping pattern.
paminsan-minsan saka promote effective patterns and usual through a
maingay din ma’am sleeping pattern bedtime rituals and comprehensive and b. The patient
kapag may  Achieve optimal incorporate them into holistic assessment achieved optimal
sinusumpong.” as amount of sleep the plan of care. are needed to amount of sleep
verbalized by the as evidenced by determine the as evidenced by
patient rested etiology of the rested
appearance and disturbance. appearance and
Objective: verbalization of verbalization of
 Appears tired improved sleeping  Observed client’s  Difficulty sleeping improved sleeping
 Noisy environment pattern. medication, diet, caffeine can be a mood pattern.
in the ward intake. effect of
 Dirty surroundings medication, The patient stated:
 Foul smelling caffeine can also
environment interfere with sleep.
“Sasabihan ko po yung
mga kasama ko na
 Provided measures to  Excessive noises maglilinis kami ng
take before bedtime with cause sleep kwarto palagi para po
sleep quiet time to allow deprivation. mabilis akong
mind to slow down. makatulog ma’am kasi
wala na po yung amoy
 Advised patient to avoid  Daytime naps may saka malinis na.”
daytime naps unless lengthen ability to
necessitated by achieve nighttime
condition. sleep or may reduce
hours of sleep at
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 night.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

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Subjective: Deficient diversional At the end of 8 hour-  Assessed client’s  Validates reality of GOAL MET
 “Wala ngang activity related to shift, after effective physical, cognitive, environmental
magawa sa loob long term nursing interventions, emotional and deprivation when it a. The patient coped
ma’am eh. Boring hospitalization the patient will be environmental status. exists or considers with personal
po ma’am. Kaya able to: potential for loss of circumstance by
gustung- gusto desired diversional communicating
kong mag-OT.  Recognize own activities in order to with others.
Manonood saka psychological plan for prevention
maglalaro po kasi response (e.g., or early b. The patient
ma’am.”as hopelessness, intervention. adapted to other
verbalized by the depression) and diversional
patient. initiate  Provide activities readily
appropriate  Noted impact of comparative available.
Objective: coping actions disability or illness on baseline for
 Usual hobbies and  Engage in lifestyle. assessments and
activities cannot satisfying interventions. The patient stated:
be undertaken in activities within
the current personal  Presence of acute, “Hindi ko nalang
setting limitations. illness, depression, papansinin yung mga
 Determined client’s problems of naririnig ko ma’am.
actual ability to mobility, protective Saka sasali nalang ako
participate and interest isolation, or palagi sa mga OT
in available activities, sensory deprivation ma’am kung meron lalo
noting attention span, may interfere with na kapag naboboring
physical limitations and desired activity. na ako ma’am.”
tolerance, level of
interest or desire and
safety needs.  These interfere
with the
 Instituted and continued individual’s ability
appropriate actions to to engage in
deal with concomitant meaningful
conditions such as diversional
anxiety, depression, activities.
grief, dementia, physical
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 injury, isolation and
immobility, malnutrition,
or acute or chronic pain.
 To establish
 Acknowledged reality of therapeutic
situation and feelings of relationship and
the client. support hopeful
relations.

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 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Deficient knowledge At the end of 3 hours,  Determined client’s  Individual may not GOAL MET
 “Nadengue na din related to after effective nursing ability or readiness and be physically,
po ako Ma’am. information interventions, the patient barriers to learning. emotionally, or a. The patient
Mga 2010 po ata misinterpretation will be able to: mentally capable at verbalized
yung una, this time. understanding of
dalawang beses na  Verbalize condition/ disease
po akong understanding of  Provided environment  A calm process and
nadengue. Basta condition, disease that is conducive to environment allows treatment.
ang naalala ko process, and learning. the patient to
lang nung treatment. concentrate and b. The patient
pangalawang  Exhibit increased and focus more exhibited increase
beses na assume responsibility completely. interest assume
nadengue na po for own learning by  Begun information that responsibility for
ako, nabaliw na beginning to look for the client already knows  Can arouse interest own learning.
din po ako.” As information and ask and move to what the or limits sense of
verbalized by the questions. client doesn’t know, being c. The patient
patient.  Initiate necessary progressing from simple overwhelmed. initiated
 “Kinulam ata ako lifestyle changes and to complex. necessary lifestyle
nung dalawang participate treatment changes and
taga Kalinga na regimen.  Provided active role for participated
kaboardmate ko  Participate in client in learning  Promotes sense of treatment
nung college. learning process process. control over regimen.
Naiinggit kasi sila situation and is
sakin ma’am. Kasi means for d. The patient
nung kinuha nila determining that participated in
yung gamit ko, client is assimilating learning process.
kinuha ko naman or using new
yung electric fan information.
nila. Nagpa
albularyo kami  Encouraged questions.  Questions facilitate
tapos sabi nung open
albularyo babae communication
daw yung between patient
kumulam sakin and the nurse and

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 tapos mahaba allow verification of
yung buhok na understanding of
maputi. Eh ganun given information.
yung kaboardmate
ko nun sa Caritan
ma’am. Pinasakit  Provided clear thorough  Patients are better
nila ako tapos yun and understandable able to ask
nabaliw na ako. explanations and questions when
Tapos yung demonstrations. they have basic
pinakita sakin information about
nung albularyo na what to expect.
galing sa
nangkulam daw
sakin, buhok ng  Considered what was  Allowing the
babae na may important to the patient. patient to identify
kulay ma’am.”as the most significant
verbalized by the content to be
patient. presented first is
the most effective.
Objective:
 Asks for  Explored reactions and  Assist the nurse in
clarification of feelings about changes. understanding how
disease definition the learner may
respond to the
information and
possibly how
successful the
patient may be with
expected changes.

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 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for Suicide At the end of the entire  Established a therapeutic  Promotes sense of GOAL MET
 “Dalawang beses hospitalization, after relationship with the trust, allowing
na po ma’am. effective nursing client. individual to a. The patient did
Naalala mo ma’am interventions, the patient discuss feelings not harm herself.
will be able to: openly.
nung binugbog
a. Not harm self b. The patient talked
ako ni kuya? b. Express  Asked directly if person is  Determines intent. about her feelings
Umakyat ako ng decreased thinking of acting on Most suicidal and expressed
bubong namin anxiety and thoughts or feelings. people will answer anger
ma’am at nagbalak control honestly because appropriately.
akong hallucinations they actually want
magpakamatay c. Talk about help. c. The patient
feelings and obtained no
pero hindi po ako
express anger  Assessed coping  Client may believe access to harmful
tumalon. May appropriately behaviors presently used. there is no objects.
naririnig kasi ako d. Obtain no access alternative except
na gawin ko daw to harmful suicide.
yun. Nung objects
pangalawa ma’am  Maintained straight  To avoid
forward communication. reinforcing
uminom ako ng
manipulative
lason pero naging
behavior.
okay naman ako
kasi naospital ako  Encouraged expression  Acknowledges
ma’am.”, as and make time to listen to reality of feelings
verbalized by concerns. and that they are
patient DR. okay. Helps
individual sort out
 “Ilang beses na
thinking and begin
yan na nagbalak
to develop
magpakamatay.
understanding of
Umakyat sa
situation and look
bubong tapos
at other
hindi siya tumalon.  Had given permission to alternatives.
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 Alam mo yung express angry feelings in  Promotes
binugbog siya ng acceptable ways and let acceptance and
kuya niya? Yun. client know someone will sense of safety.
Ginawa niya nun. be able to assist in
Saka uminom siya maintaining control.
ng lason. Nagawa
niya daw yun dahil  Discussed consequences
sa problema. of actions if they follow  Helps focus on
Nakita nalang through on intent. Ask consequences of
namin siya na how it will help individual actions and
nakahiga tapos to resolve problems. possibility of other
may hawak siyang options.
sprayer na may  Maintained observation
laman na and eliminated hazards  To increase client’s
solignum. Kaunti that could be used to safety or reduce
nalang yun ma’am commit suicide. risk of impulsive
pero tinakbo na behavior.
namin kaagad sa
Peoples General
hospital.” as
verbalized by her
grandmother.

Risk factors:
 History of prior
suicide attempts

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