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Name of patient: K. P.

Name of Student: Joseph Ray Inocencio

Age: 17 Section: BN3-I
Sex: Male Group 3
Chief Complaint: Irritable and withdrawn
Medical Diagnosis: Schizo-affective disorder
Nursing Care Plan
Assessment Nursing Diagnosis Rationale Desired Nursing Intervention Justification Evaluation

Actual and Social isolation Predisposing Precipitating After 40 hours of Independent: Independent: After 40 hours of
Abnormal cues: related to Factor Factor Nursing Nursing
alterations in Intervention, the Intervention:
-client stated mental status as (+) Family Fell from a client will be
“maulaw ko ninyo, evidenced by History 15-20ft tree able to:
gwapa ug gwapo being withdrawn
kayo mo unya ako and no eye ●Identify feelings ●Establish therapeutic ●To promote trust, ●
maot”. contact. that lead to poor nurse-client allowing client to
social interaction. relationship. feel free to discuss
-“Dili ko kasabot Abnormal Brain Activity sensitive matters.
sa mga tao diri kay Definition:
dili ko kasabot ug Aloneness
Ilonggo.” experienced by the Alteration in mental status
individual and ●Verbalize ●Encourage to join ●To promote ●
-Low toned voice perceived as Abnormal brain activity willingness to be programs and socialization skills
and No eye contact imposed by others involved with activities. and peer contact.
when interacting. and as a negative or Withdrawn and No eye others.
threatened state. contact
Risk related
factors: Source: NANDA Social Isolation
-Alterations in 11th Edition
physical Source: ●Participate in ●Teach client some ●To interact with ●
appearance/mental Contemporary Psychiatric activities/program common Ilonggo other persons in
status Mental Health Nursing 2nd s at level of words. the area.
Edition ability/desire.
-Unaccepted social Collaborative: Collaborative:
behaviors ●Refer to therapists, ●To facilitate grief
-Inability to as appropriate. work, relationship
engage in building and so
satisfying personal forth.
-Inadequate ●Assist in treatment of ●To reduce
personal resources. underlying medical complications.
conditions and
Strength: management of risk
-Faith in God factors.

●Monitoring of ●To determine

medication regimen. potential adverse

●Conduct Therapeutic ●To assess the

Activities thinking process of
the patients.

Source: Source:
NANDA 11th NANDA 11th
Edition Edition