Assessment Nursing diagnosis Goal Planning Implementation Evaluation

Subjective data:- High risk for injury Patient will not  To reduce all  All external Patient is free from
related to extreme experience injury external stimuli, stimuli that may injury
Patient is angry and keep lighting and provoke patient
hyperactivity
irritated. low noise level. activity are
evidenced by lack of
removed.
control over
purposeless injurious  To remove
Objective data:- movements. hazardous objects  All sharps objects
Patient talk loudly and substances are kept away
away. from patient.
and run here and
there
 To stay with  Patient is kept
patient. under observation.

 To administer  Ordered
medicines as medicines are
ordered by doctor. given regularly on
time.
family member
 To educate family are educated
member about
about patient
disease
disease condition.

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Subjective data:- Imbalance nutrition, less Patient will exhibit no  To provide small
than body requirement sign or symptoms of frequent meals to
Patient is angry and related to refusal malnutrition. patient.
irritated. evidenced by weight  To maintain patient
intake and output
loss.
record.
 To provide patient
Objective data:- favorite food to him.
Patient talk loudly and  To provide
supplements of
run here and there
proteins and vitamins
to patients.
 To provide food to
patient under family
member observation.
 To educate family
members about
healthy diet.
To provide nutritious
diet (high protein, high
calorie, juices) to patient
 Family members
provide juice, egg,
milk to patient.
 Family member give
snacks to patient in
between meals.
 Family members are
advised to give
favorite food to
patient so that he can
eat something.
 Family member sit
with patient when he
take his meal.
 Family members are
educated about
healthy and balanced
diet.
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Subjective data:- Disturbed sleep Patient will maintain  Patient will avoid  Patient avoids day Patient sleep pattern
pattern related to normal sleep cycle. day time sleeping. time sleeping. improves a little
Patient has insomnia.  To educate patient  patient is involved
hyperactivity as
evidenced by patient to prepare day in preparing day
time activity time activity
drowsiness
Objective data:- schedule. schedule.
 To educate patient  patient fix his
Patient look tired to go to sleep at a daily sleep time.
and drowsy fix time daily.  various relaxation
 To teach patient exercise and yoga
about various is taught to patient
relaxation and instructed to
exercises. do it regularly.
 To educate patient Patient is involved in
to do some physical activity at
physical work at day time.
day time, so that
he get tired and
sleep at night.

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