ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

 Subjective Self-care deficit related to Short Term: 1. 1. Monitor continually the Short Term:
1. “Pwede ikaw disorientation extent to which self-care
maglagay sakin ng After 1- 2 hours of nursing deficits interfere with the After 2 hours of nursing
polbo?” as intervention the patient intervention, the patient
client’s function
verbalized by the will verbalized ways how to improved hygienic care
improve hygienic care/ self- R: Monitor the client’s with a verbalization of “Ako
patient
2. “Hindi kasi sya care functional abilities in an na lang… Ako na lang ang
laging naliligo kaya ongoing way to help maghahawak…”
sya kinalbo,” as determine the client’s GOAL MET.
verbalized by the Long Term: strength and areas needing
staff assistance
After 1 week of nursing Long Term:
 Objective intervention the patient
will consistently perform 2. Establish routine goals for After 1 week of nursing
1. Repeatedly use of
clothing self-care activities and self-care. intervention the patient
2. Demonstrate consistent with R: Routine and structure was able to perform self-
infrequent bathing developmental stage as organize the client’s care activities.
3. Displays inadequate evidenced by being chaotic world and promote GOAL PARTIALLY MET.
personal hygiene: dependent in providing success
Unkempt hair self-care

3. Initiate grooming and

hygiene tasks when the
client is best able to
comply
R: Depressed clients have
brighter affect later in the
day; and client with anxiety
and hyperactive behaviors
are more attentive to self-
care after taking
medication
4. Give simple step-by-step
reminders for hygiene and
dress
R: Distractibility and poor
concentration are
countered by simple,
concrete instructions.

5. Praise the client for

attempts at self-care and
each successfully
completed task
R: Positive reinforcement
increases feelings of self-
worth and promotes
continuity of functional
behavior
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

 Subjective Disturbed Sleep Pattern Short Term:  Independent Short Term:

1. “Natatakot ako dito sa related to Episodes of 1. Arrange care to provide for
loob… baka saktan nila Delusion Secondary to After 1- 2 hours of nursing uninterrupted periods of After 2 days of nursing
ako,” as verbalized by Bipolar Disorder intervention the patient rest, especially allowing for intervention, the patient
the patient will verbalized ways how to had identified individually
longer periods of sleep at
2. “Pakiramdam ko may improve hygienic care/ self- appropriate interventions
gustong manakit sa care night when possible. to promote sleep.
anak ko,” as verbalized R: A silent and calm GOAL MET
by the patient environment during sleep
Long Term: will help to lengthen the
 Objective range of sleep. Long Term:
1. Restlessness After 1 week of nursing
2. Dissatisfaction with intervention the patient After 1 week of nursing
2. Encourage client to
sleep will consistently performs intervention, the patient
3. Frequent yawning self-care activities and establish a bedtime reported improvements in
consistent with routine to facilitate quality of sleep pattern as
developmental stage as transition from evidenced by:
evidenced by being wakefulness to sleep  No feeling of
dependent in providing R: Rituals and routines fatigue after waking up.
self-care
induce comfort, relaxation,  Not restless and
weak, no frequent yawning
and sleep.
and dark eyes.
GOAL PARTIALLY MET
3. Encourage client to
eliminate stressful
situations before bedtime.
R: Stress interferes with a
person’s ability to relax,
rest, and sleep.

 Dependent
1. Prescribe medication;
Benadryl
(Diphenhydramine)
R: Nighttime sleep aid
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

 Subjective Impaired Social Interaction After 1 week of nursing  Independent After 1 week of nursing
1. “Wala naman po,” as related to Disturbed intervention the client will - Develop a therapeutic intervention the client
claimed by the patient thought process be able to: nurse client relationship showed improvement in
every after the question through frequent, brief spending time with the
“Ano ang gusto mong - Voluntarily spend other clients and nurse or
contacts and an accepting
pag usapan?” time with other therapist in group activities
clients and nurse or attitude and was able to put feelings
2. “Wala akong kaibigan therapist in group R: Therapeutic into words instead of
dito sa loob,” as activities relationship promotes actions when experiencing
verbalized by the understanding and can anxiety or loss of control.
patient - Put feelings into help establish a GOAL PARTIALLY MET
words instead of constructive relationship
 Objective actions when
between the nurse and the
1. Do not ask question experiencing
2. Family reports a change anxiety or loss of client.
of style or patterns of control
interaction - Provide an environment
3. Inability to maintain with minimum stimuli
interaction with other R: Reduction in stimuli
patients lessens distractibility

- Encourage patient to
participate in solitary
activities requiring short
attention spans with mild
physical exertion are best
initially
R: Solitary activities
minimize stimuli; mild
physical activities release
tension constructively
 Collaborative
1. Encourage the patient to
join the therapeutic
therapies together with the
other patients and nurses
 ASSESSMENT
 Subjective
1. “Nagwawala siya noon
kapag kinukulong
naming sa loob ng
bahay,” as verbalized by
the patient’s relative
 Objective
1. Agitated behaviors
2. Delusional thinking
Doctor ordered restraints
with strict aspiration
precaution
DIAGNOSIS PLANNING
Risk for violence Short Term:
After 2-3 hours of nursing
interventions, the patient
will respond to external
controls (medications,
seclusion, nursing
interventions) when
potential or actual loss of
control occurs
Long Term:
After 1 week of nursing
intervention, the patient
will be able to:
1. Refrain from verbal
threats and loud,
profane language
toward others.
2. Be safe and free from
injury.
INTERVENTION
1. Restraints with strict
aspiration precaution as per
doctor’s order
R: To prevent injury to self
and/or others
2. Provide health education
on understanding the signs
and symptoms of violent
behavior occurrence of
violent behavior.
3. Teach and practice how to
involve the family in caring
for patients with violent
behavior directly in hospital
(constructive manner,
Follow-up)
4. Discuss family perceived
problems in patient care
violent behavior.
R: To positively influence
the health behavior of
individuals and
communities as well as the
living and working
conditions that influence
their health.
EVALUATION
Short Term:
After 2-3 hours of nursing
interventions, the patient
was able to respond to
external controls
(medications, seclusion,
nursing interventions)
when potential or actual
loss of control occurs.
GOAL MET
Long Term:
After 1 week of nursing
intervention, the patient
was able to refrain from
verbal threats and loud,
profane language toward
others and patient was safe
and free from injury.
GOAL PARTIALLY MET