NURSING CARE PLAN

CUES
Subjective:
I have singed that
song in leyte,there is
a strange man,He is a
witch as verbalized
by the patient.

Objective:
Doesnt
recognized
present illness
Not oriented to
time
Ignores SN
during
interaction
Hygiene and
grooming
neglected
Social Isolation
noted
Blunted affe

NURSING
DIAGNOSIS
Disturbed
thought
processes
related to
disruption in
cognitive
operation and
activities

OBJECTIVES
Within our care,
patient will be able
to maintain usual
reality orientation

INTERVENTION
Determine drug use
Assess
dietary
intake/nutritional
status
Assess the attention
span/distractibility
and ability to make
decisions
Note behavior such
as
untidy
habits,
slurring or slowed
speech
Reorient
to
time,
place and person as
needed
Have
client
write
name
Encourage family to
participate
in
reorientation
Give
simple
directions,
using
short words
Listen with regard

RATIONALE

EVALUATION

Drugs may have side

effects
that
alter
thought process
To
assess
causative
factors

Within our care,

patient will be able
to maintain usual
reality orientation

To determine the ability

to
participate
in
planning of care
To assess
impairment

degree

To
prevent
deterioration

of

further

To have a record for

comparison
To maximize
function
To
develop
strategies

level

of

coping

To convey interest and

worth to individual
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 Refrain from forcing

activities
and
communication

To avoid the client

feeling
of
being
threatened and to avoid
patient being withdraw
and rebel

NURSING CARE PLAN

CUES
Subjective:
Gusto na nako
muuli as verbalized
by the patient
(patient was crying
while speaking)

Objective:
Stayed on bed
most of the
time
Always stare
blankly
Always look for

NURSING DIAGNOSIS
Ineffective coping
related to
perceptual/sensory
impairment

OBJECTIVES
Within our care,
patient will be able to
verbalize feelings
congruent with
behavior

INTERVENTION
Establish
therapeutic
nurse-patient
relationship
Determine
drug use,
alcohol use,
smoking
habits,
sleeping and
eating patterns
Assess clients
understanding
of current
situation
Use reality
orientation and
make a
frequent

RATIONALE
To gain trust
and
establish
rapport
To
determine
degree
of
impairment

EVALUATION
Within our care,
patient will be able to
verbalize feelings
congruent with
behavior

To
assess
coping skills
To
assist
patient to deal
with
current
situation

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her mother
Doesnt
interact with
other patients
Has poor
coping
mechanism
Lack of social
skills

referrals of
time, place and
person
Call client by
name.
Ascertain how
client prefers
to be
addressed
Allow client to
react in own
way

To
enhance
sense of self
and
promote
self-esteem
To provide for
meeting
psychology
needs
To express the
feelings of the
patient

Encourage
verbalization of
fears, anxieties
and feelings of
denial,
depression and
anger

NURSING CARE PLAN

CUES
Subjective:
wala pa ko kaligo,
walay agas as
verbalized by the
patient

NURSING DIAGNOSIS
Self-care deficit
related to perceptual
impairment

OBJECTIVES
Within our care,
patient will be able
to perform self-care
activities within
level of own ability

INTERVENTIONS
Determine existing
conditions/extrem
es
of
age/
developmental
ability to care for
own needs
Identity degree of

RATIONALE
To
identify
causative
factors

EVALUATION
Within our care, patient
will be able to perform
self-care activities
within level of own
ability

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individual
impairment/
functional level
Determine
individual
strengths
and
skills of client
Promote client/SO
participation
in
problem
identification

Objective:
Long and
untrimmed
fingernails
Uncombed hair
Has not taken
a bath
Wears dirty
clothes
Has dry brittle
hair

Plan
time
for
listening to the
client/SO
Provide
communication for
those
who
an
involve in caring
patient
Provide
privacy
during
personal
care activities
Review
safety
concerns. Modify
activities

To
assess
degree
of
disability

To assess the
degree of the
patient can do
To
enhance
commitment to
plan,
optimizing
outcomes
To
discover
barriers
in
regimen
participation
To
respect
patients
dignity
To reduce risk
of injury

NURSING CARE PLAN

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION
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No Subjective cues

Objective:
Sitting alone
Not interacting
with other
patients
Appears lonely
Lack of self
esteem
Speak only few
words

Impaired social
interaction related to
disturbed thought
processes and
communication
barriers (neurological
condition affecting
the ability to
communicate)

Within our care,

patient will be
able to verbalize
factors causing
impaired social
interaction with
the SNs and find
or develop
effective social
support system
(family, relatives)
to help promote
and enhance
social interacting
skills

Review
history
client/SO

social
with

Establish
NursePatient
therapeutic
relationship
Identify blocks to
social contacts

Listen with regard

Provide
positive
reinforcement
when
client
approach
to
interact with the
SNs
Provide
for
occasional follow
up
Encourage family
to involve patient
in
activities
beneficial to her
like
constant
verbal

To note when
changes
in
social behavior
or patterns of
relating
occurred/began
To
gain
the
trust

Patient may be
unable to go
out,
embarrassed to
be with others,
and
reluctant
to solve these
problems
To
convey
interest
To
boost
clients urge to
interact

Within our care, patient

will be able to verbalize
factors causing
impaired social
interaction with the
SNs and find or
develop effective social
support system (family,
relatives) to help
promote and enhance
social interacting skills

To
check
if
client
continuously
interact
with
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communication, or
participating
in
doing
the
household chores

others
To
let
the
family help the
patient
overcome
seclusion and
be the clients
agent to cope
up

NURSING CARE PLAN

CUES
S: no verbal cues

O:
-restlessness noted

NURSING
DIAGNOSIS
Deficient diversional
activity related to
medication regimen
management

OBJECTIVES
Within my 4 hours of
duty, patient will be
able to engage in
satisfying activities
within personal
limitation.

INTERVENTIONS

Determine ability
to participate/
interest in
activities that are
available.

To assess
precipitating
factor.

Acknowledge
reality of
situation and
feelings of the
client.

To establish
therapeutic
relationship.

To motivate and
stimulate client
involvement in
solution.

To motivate and

-drowsiness noted
-lack of interest
noted
-flat affect noted
-slowed reaction

RATIONALE

Review history of
activity/hobby
preferences.

EVALUATION
After my 4 hours of
duty, patient will be
able to engage in
satisfying activities
within personal
limitation.

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noted

Provide for
physical as well
as mental
diversional
activities.
Explore options
for useful
activities using
the persons
strength/abilities.

stimulate client
involvement in
solution.

To promote
wellness.

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