Nursing Prioritization Date Identified January 24, 2013 Subjective Cues Minsan wala akong ganang kumain.

Problem/Nursing Diagnosis Nutrition less than body requirement as manifested by below the average BMI. Social Isolation related to traumatic incidents causing emotional pain. Justification This is the 1st to be prioritized because according to Maslow, because food is one of the basic needs of man, so the patient should satisfy this first. This is the 2rd to be prioritized because according to Maslow, the hierarchy explains that before you attain the higher level, you must surpass the lowest level which is the physiologic needs. This is the 3rd to be prioritized because according to Maslow, esteem need should be satisfy, because if the client cannot express his feelings he cannot socialize with other people. This is the 4th to be prioritized because you need to surpass all the four levels before attaining the highest level which is self-actualization.

January 29, 2013

Ayaw ko ng umuwi sa barrio namin dahil nalaman nilang nagkasakit ako sa isip at pinagtsitsismisan ako.

January 24, 2013

Pano ba sabihin yun? AhmBasta ang hirap ipaliwanag kasi.

Impaired Verbal Communication as manifested by flight of ideas.

January 24 & 25, 2013

January 24, 2013

Jan. 24: Patay na yung tatay ko. Hindi man lang ako pinayagan na makalabas para makapunta sa libing niya. Jan. 25:Gusto kong umuwi para makita yung tatay ko. Nakaratay kasi siya dahil may sakit siya. Nangangati ako dahil sa sugat sugat ko.

Disturbed thought process related to mental disorder (undifferentiated schizophrenia).

Risk for impaired skin integrity related to broken skin.

This is the 5th to be prioritized because according to the rule risk problem should prioritized least, because actual problem should be solve first.

Nursing Care Plan Diagnosis Planning Intervention Rationale Evaluation Nutrition less than body Long term: Independent: Goal met Subjective cues: After 1 day of nursing Helps to determine After 1 day of nursing Provide information requirement as evidenced intervention the client nutritional needs. intervention the client Minsan wala akong by 18.3 BMI. regarding specific will be able to: has increase appetite. nutritional needs. ganang kumain, as a. Demonstrate To impart knowledge Emphasize verbalized by the client. behaviors, lifestyle and to maintain the importance of well changes to regain adequacy of intake of Goal met balance, nutritious and/or maintain nutrients needed. After 30 minutes of intake of foods. appropriate weight. nursing intervention the Provide information client can verbalize food regarding individual that the patient can take nutritional needs and Objective cues: and avoid to help him for ways to meet these Weight: 110 lbs. fast recovery. Short term: needs within BMI:18.3 After 30 minutes of financial constraints. (underweight) nursing intervention the Weigh at regular To monitor clients weight. client will be able to: intervals and a) verbalize specific document result. foods that the client can eat to help him for fast recovery and foods that he will avoid. Assessment

Assessment Diagnosis Subjective Cues: Social Isolation related to Ayaw ko ng umuwi sa traumatic incidents barrio namin dahil causing emotional pain. nalaman nilang nagkasakit ako sa isip at pinagtsitsismisan ako, as verbalized by the client.

Planning Long term: After 2 days of nursing intervention the client will be able to: a. express increase sense of self worth.

Intervention Provide attention in a sincere, interested manner. Support any successes or responsibilities fulfilled, projects, interactions with staff members and other clients, and so forth. Avoid trying to convince the client verbally of his or her own worth.

Rationale Flattery can be interpreted as belittling by the client. Sincere and genuine praise that the client has earned can improve self-esteem.

Evaluation Goal met After 2 days of nursing intervention the client expresses increase sense of self worth.

Objective Cues: Poor eye contact Not that cooperative

Short term: After 30 minutes of nursing intervention the client will be able to: a. verbalize willingness to be involve with others. b. participate in activities.

The client will respond to genuine recognition of a concrete behavior rather than to unfounded praise or flattery. The client may have little or no knowledge of social interaction skills. Modeling provides a concrete example of the desired skills

Goal met After 30 minutes of nursing intervention the client verbalize willingness to be involved with others and participate in activities.

Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, and so forth. Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth.

Help the client improve his or her grooming.

Good physical grooming can enhance confidence in social situations.

Assessment Subjective Cues: Pano ba sabihin yun? AhmBasta ang hirap ipaliwanag kasi, as verbalized by the client.

Diagnosis Impaired Verbal Communication as manifested by flight of ideas.

Objective Cues: Speaks/verbalizes with difficulty; stuttering; slurring. Difficulty expressing thoughts verbally. Inappropriate verbalization [incessant, loose association of ideas; flight of ideas].

Planning Long term: After 1 day of nursing intervention the client will be able to: a. Verbalize or indicate an understanding of the communication difficulty and plans for ways of handling. b. Establish method of communication in which needs can be expressed.

Short term: After 30 minutes of nursing intervention the client will be able to: a. Participate well in therapeutic communication.

Intervention Rationale Listen attentively Decreases frustration and when the patient demonstrates caring. attempts to communicate. Clarify your understanding of the patients communication. Maintain eye contact Eye contact lets the patient know that with the patient when they have your speaking. Stand attention when trying close, within the to communicate. patients line of Patients with vision. artificial airways may need to lip words and standing in front of the patient will allow the nurse a better view to understand the patient. Give the patient t may be difficult for ample time to patients to respond respond. under pressure, they may need extra time to convey thoughts. Avoid finishing This may lead to frustration and sentences for the decrease the patients patient. Be calm and trust in you. accepting during communication attempts. Do not say

Evaluation Goal met After 1 day of nursing intervention the client Verbalize or indicate an understanding of the communication difficulty and plans for ways of handling and establish method of communication in which needs can be expressed. Goal met After 30 minutes of nursing intervention the client participate well in therapeutic communication.

you understand if you dont. Orient the patient to Not knowing who is providing care or surroundings. State where they are can be procedural and task a stressor to the intentions when patient. Patient may providing care. prefer that the nurse give them some indication of what they will be experiencing, especially if it will cause discomfort.