Name : Jose Ralph Christopher C. Fernandez Instructor: Mr. Ernest Darwin Esguerra R.N.

Section: BSN-30 Clinical Area of Assignment: SPMC Psychiatric Unit

NURSING CARE PLAN

Patients name: Anabelle C. Quiamco

Date:April 7, 2010 Cues: Objective  Anhedonia (Inability to express pleasure  Disorientation  Slowed Mental process  Hallucinational  Delusion  Diminished interest in any activity Nursing Diagnosis : Ineffective Coping r/t cognitive perceptual alteration Objectives : Within 3 hours of nursing interventions the patient will be able to :  Verbalize awareness of own coping abilities  Verbalize feelings of congruent with behavior  Nursing Interventions 1. Provide a safe environment for the client by making sure that any harmful objects are taken out of reach. R- Physical safety of the client is a priority. Many common items may be used in a self destructive manner. 2. Reorient the clien to person, place and time as indicated R- repeated presentation of reality is concrete reinforcement with the pt. 3. Spend time with the client R- Your physical presence is comforting and therapeutic 4. When approaching the client, use a moderate, level tone of voice. Avoid being cheerful. R- Being overly cheerful is the goal and that other feelings are not acceptable 5. Use silence and active listening when interactin with the client. Let the client know you are concerned. R- the client may not communicate if you are talking too much. Your prescence and use of active listening wii communicate your interest and concern. 6. Avoid asking the client many questions especially questions that only require brief answers. R- Asking questions and requiring only brief answers may discourage the client expressing feelings. 7. Be comfortable sitting with the client in silence. Let the client know you are available to converse, but do not require the client to talk. R-Your silence will only convey your expectation that the clients difficulty with communication. 8. Encourage client to ventilate feelings in whatever way is comfortable. R- Expressing feelings may help relieve despair, hopelessness and so foth. 9. Interact with the client on topics with which he or she is comfortable. Do not probe for information. R- topics hat are uncomfortable for the client and probing may be threatening and discourage commmunication 10. Provide positive feedback at each step of the process. R- positive feedback at each step will ive the client many opportunities for success.

Evaluation: Goal partially met. After three hours of nursing interventions the patient was able to verbalize Maayo man when asked about what she felt after the activities.

Name : Jose Ralph Christopher C. Fernandez Instructor: Mr. Ernest Darwin Esguerra R.N.

Section: BSN-30 Clinical Area of Assignment: SPMC Psychiatric Unit

NURSING CARE PLAN

Patients name: Anabelle C. Quiamco

Date: March 31, 2010 Cues: Objective  Disorientation to time and date and person whom she interacts with  Answers are way off from the questions asked  Inability to concentrate  Unable to recall recent past events an activities. Nursing Diagnosis : Disturbed though processes r/t mental disorder Objectives: Within 3 hous of nursing interventions the patient will be able to maintain usual reality orientation such as the date, time Nursing Interventions: 1. Provide a safe environment for the client by making sure that any harmful objects are taken out of reach. R2. Be sincere and honest when communication with client. Avoid vague or evasive remarks. R- Clear, consistent limits provide a secure structure for the client 3. Be consistent in setting expectations enforcing R-Broken promises reinforce the clients mistrust for others. 4. Encourage the client to talk and do pry information. R- Probing increases the clients suspicion and interferes with the therapeutic relationship. 5. Explain procedures and be sure the client understands them before client understands them before carrying them out. R-When the client has full knowledge o procedures he or she is less likely to feel tricked by the staff 6. Give positive feedback to the client. R- Positive feedback for genuine success enhances the clients well being. 7. Interact with the client on the basis of real things. R-Interaction with the client about reality is healthy for the client. 8. Do not make any promises to the client that you cannot keep. R-Empathy conveys your caring, interest and acceptance of the client. 9. Show empathy on the client on the clients feelings. R- provides stimulantion without undue fatigue. 10. Schedule structured activity and rest periods R-inability to maintain orientation is a sign of deterioration. 11. Maintain a pleasant, quit environment and approach in a slow, calm manner R-Client may respond with anxios or aggressive behaviors if startled. 12. Listen with regard R- To convey interest and self worth to individual 13. Stress importance of cooperation with therapeutic regimen. R- to promote wellness and socialization. Evaluation : Goal met. After 2 hours of nursing interventions.

Name : Jose Ralph Christopher C. Fernandez Instructor: Mr. Ernest Darwin Esguerra R.N.

Section: BSN-30 Clinical Area of Assignment: SPMC Psychiatric Unit

NURSING CARE PLAN

Patients name: Anabelle C. Quiamco
Date:April 7, 2010 Cues: Objective  Inappropriate or inadequate emotional response  Poor interpersonal relationship  Difficulty with verbal ommunications  Preoccupation with own thoughts

Nursing Diagnosis : Social Isolation r/t alteration in mental status Objectives : Within 3 hours of nursing interventions, the patient will be able to: participate in activities at level of ability/desire.

Nursing Interventions 1. Note onset of physical illness whether recovery is anticipated or condition is chronic/progressive R-May affect clients desire to isolate self. 2. Identify blocks to social contracts R-Client may be unable to go out, embarrassed to be with others 3. Establish therapeutic nurse-client relationship R-Promotes trust, allowing client to feel free to discuss sensitive maters 4. Provide positive reinforcement when client make moves toward others R-Encourage continuation of efforts 5. Identify behavior or response of isolation R- Which may also potentiate isolation 6. Provide attention in a sincere, interested manner. R-Flattery can be interpreted as belittling by the client. 7. Support any success, responsibilities fulfilled, interaction with others R- Sincere and genuine praise that the client has earned can improve self esteem 8. Avoid trying to convince the client R- The client will respond to genuine recognition of a concrete behavior rather than unfounded praise or flattery. 9. Teach the client social skills. Describe and demonstrate specific skills such as eye. R- The client may have little or no knowledge of social interaction skills. 10. Help the client improve her grooming R- Good personal grooming can enhance confidence in social situations. 11. Help the client accept as much responsibility as possible R-The client must be encouraged to be as independent as possible to foster self-esteem and continued self care practices. Evaluation: Goal Met. After 2 hours of nursing interventions he client was able to verbalize nalingaw ko sa activity gaina .

Name : Jose Ralph Christopher C. Fernandez Instructor: Mr. Ernest Darwin Esguerra R.N.

Section: BSN-30 Clinical Area of Assignment: SPMC Psychiatric Unit

NURSING CARE PLAN

Patients name: Anabelle C. Quiamco
Date: April 5, 2010 Cues: Objective      Inability to recall recent or past events Inability to learn or retain new skills or information Observe experience of forgetting Disorientation to, date and person whom she interacts with Short attention span during interaction

Nursing Diagnosis : Impaired memory r/t neurological disturbances Objectives/Evaluation Criteria: Within 3 hours of nursing interventions the patient will be able to: a). Maintain attention and respond appropriately to environmental cues with limits of disease. b). be oriented to time, person, place and self within limits of disease. Nursing Interventions 1. Assess the pt. for behavioral changes such as anxiety, combativeness or withdrawal. R- The patient with memory loss or diminished orientation may exhibit restlessness, anxiety, aggressiveness and combatativeness 2. Assess the impact of memory loss on the pt. give special attention to assessing safety issues in the patients living situation. R-Memory loss can limit the patients day to day functioning. The Patient may be unable to effectively manage safety and responsibilities 3. Assess quality of sleep R- Normal sleep plays a role in consolidation of memories. Inadequate sleep can limit cognitive functioning. 4. Point reality orientation for the patient at every contact. R-The patient with impaired memory will have difficulty maintaining orientation to the immediate environment. Reality orientation helps the patient remain mentally integrated with the immediate environment 5. Provide a low stimulation environment R- Excessive auditory and visual stimulation can add to disorientation and confusion. The pt. needs a setting with limited distraction. 6. Ask patient about recent events R- Review of events in response to questions assists the patient in encoding information for retrieval at a later time. 7. Encouraged patient to reminisce about past experiences. R-The mental stimulation that occurs with recall and review of life events can enhance information on each time it is needed. 8. Plan daily activities so the pt. is rested before activity. R- A plan that balances periods of activity with periods of rest can help the pt. complete the desired activity without undue fatigue and frustration. 9. Encourage pt to bathe self as much as he or she is capable of. Assisst with completion of bath. Brushing teeth only as needed. R- hospital workers are often in a hurry and do more for patients than needed, thereby slowing the pt s efforts at regaining independence. 10. Administer medications as prescribed. R- Some medications have been seen improvement in memory function to some patients. Evaluation Goal not met. After 3 hours of nursing interventions the patient was unable to demonstrate and attain evaluation criteria.

Name : Jose Ralph Christopher C. Fernandez Instructor: Mr. Ernest Darwin Esguerra R.N.

Section: BSN-30 Clinical Area of Assignment: SPMC Psychiatric Unit

NURSING CARE PLAN

Patients name: Anabelle C. Quiamco
Date: April 5, 2010 Cues: Objective     Untrimmed nails Uncombed hair Dirty clothes Plaque noted on teeth

Nursing Diagnosis : Self care deficit r/t cognitive impairment Objectives /Evaluation Criteria: Within 4 hours of nursing interventions the patient will be able to safely perform self-care activities with the assistance of the assigned student nurse. Nursing Interventions

1. Assess ability to carry out activities of Daily living. Determine the aspects of self-care that are problematic to the patient. R- The patient may only require assistance with some self care measures. 2. Assist the patient in accepting necessary amount of dependence. R- If disease, injury or illness resulting in self care deficit is recent, the patient may need to grieve before accepting that dependence is necessary. 3. Set short range goals with the patient R- Assisting the patient to set realistic goals will decrease frustration 4. Implement measures to facilitate independence, but intervene when the patient cannot perform R- An appropriate level of assistive care can prevent injury from activities without causing frustration. 5. Use consistent routines and allow adequate time for the patient to complete tasks. R- This helps the pt. organize and carry out self-care skills. 6. Provide positive reinforcement for all activities attempted, note partial achievements. R- This provides the patient with an external source of positive reinforcement and promotes ongoing efforts. 7. Provide frequent encouragement and assistance with dressing as needed. R- Assistance can reduce energy expenditure and frustration. However, care needs to be taken so the care provider does not rush through tasks, negating the patients attemps. 8. Plan daily activities so the pt. is rested before activity. R- A plan that balances periods of activity with periods of rest can help the pt. complete the desired activity without undue fatigue and frustration. 9. Encourage pt. to bathe self as much as she is capable of assisting with completion of bath, Brushing teeth, only as needed. R- Hospital workers are often in a hurry 10. Encourage pt to comb own hair R- This enables the pt. to maintain autonomy for as long as possible 11. Assist pt with the fingernails and toenails as required R-Patients may require podiatric care to prevent injury to feet during nail trimming or because special implements are required to cut nails. 12. Offer frequent encouragement R- Patients often have difficulty seeing progress

13. Encourage maximum independence R- The goal of rehabilitation is one of achieving the highest level of independence as possible.

Evaluation: Goal met. After 1 hour of nursing interventions the patient was able to perform self care with minimal assistance from the student nurses.

Name : Jose Ralph Christopher C. Fernandez Instructor: Mr. Ernest Darwin Esguerra R.N.

Section: BSN-30 Clinical Area of Assignment: SPMC Psychiatric Unit

NURSING CARE PLAN

Patients name: Anabelle C. Quiamco
Date: April 30, 2010 Cues: Objective      Inability to recognize date and time Absence of eye contact Difficulty in maintaining usual communication pattern Speaks minimally or not at all for long periods Gives little or no information

Nursing Diagnosis : Impaired verbal communication r/t altered perception Objectives /Evaluation Criteria: within 4hours of nursing interventions, the patient will be able to: a. Establish method of communication in which needs can be expressed such as hand and eye signals to indicate approval or refusal. b. Demonstrate reality based thought processes in verbal communication Nursing Interventions. 1. Protect the client and others in the environment from harm and injury.

R- The nurse first priority is to maintain the safety of the client, others and the environment through appropriate therapeutic interventions.
2. Identify the extent to which impaired verbal communication interferes with the clients ability to convey to others.

3.

4.

5.

6.

7. 8.

R- it serves as a guideline for helping the client and peers learn alternative methods of communication Demonstrate a calm, Pt. demeanor rather than attempting to force the client to speak coherently. R- A calm approach helps to decrease the clients fear and anxieties Listen attentively to and observe verbal non-verbal cues and behaviors during the communication process. R- Active listening and keen observation help to understand clients message. Use communication strategies such as restatement, clarification and consensual validation. R- Effective Therapeutic communication strategies help to reveal the intent of the clients message. Assist the client to listen and engage in actual conversations (one to one, group conversations) R- Interaction encourages the client to respond to reality as it distracts the client from his own internally. Monitor the effects of clients cultural and spiritual background. R- Religious spiritual discussions may be appropriate depending on the clients condition Teach the client strategies to use whenever the client initially experiences impaired verbal communication. R- Therapeutic strategies help the client decrease anxiety, which may exacerbate symptoms and promote more functional speech patterns.

9. Praise the clients attempt to speak more coherently and to engage in more meaningful conversations with others. R- Positive reinforcement increases the clients self esteem and promotes continued functional speech pattern. 10. To continue to support and monitor prescribed medical and psychosocial treatment plans. R- Post discharge support helps maintain the ability to understand and epress verbal communication Evaluation: Goal met. After 3 hours of nursing interventions the patient was able to verbalize Uo sir and demonstrate nodding of head as a cue for approval.