DATE

TIME CUES NEED NSG. GOAL OF NSG. INTERVENTIONS EVALUATION

SHIFT DIAGNOSIS CARE

Septem S: “Wala S That within my  Offer a limited amount of September 27,

Sleep pattern
ber mana L rotation, patient milk as a substitute for 2004
disturbance:
siya’y tulog E will be able to other bedtime beverages 12:00 PM
r/t inability to
20, kay nag- E establish regular “GOAL MET”
sleep as
sige mana P hours of sleep, ® Milk products contain L- Patient has
evidenced by
2004 siyag as evidenced by trytophan is a natural sedative established regular
dark eyebags
singgit / a. Verbaliz hours of sleep as
and irritability.
@ gabii.” ation of  Avoid full meals at least 3 evidence by

Objective: R patient hours prior to bedtime. a. verbalization

Rationale:
7-12 E that she Foods that cause gastric of “Ok man
The inability to
Wearing S had distress for the client also akong tulog”
rest and sleep
shift red daster T sleep should be avoided. b. able to sleep
 has been well; after eating

Had taken P described as and ® After 3 hours the stomach her snacks.

a bath A “one of the b. Sleep has emptied, and the client

T causes, as undistur will not feel full or

Hair tied T well as one of bed for uncomfortable. Any foods

E the at least known to cause distress will

Droopy R accompanime 4 hours. interfere with the ability to

eyes noted N nts of a maximize relaxation.

disease” this

Frequent can result  Limit fluid intake for 4 to 5

yawning from hours before bedtime.

noted physiologic,

psychological, ® Limiting fluid intake can

Euphoric social, eliminate awakening due to a

mood and environmental, full bladder.

inappropria and

te affect maturational  Encourage client to

with changes or increase physical activity

quality problems. during waking hours,

noted Bibliography: event though he or she

Carpenito, may feel fatigued.

Over Lynda Juall.

talkative NURSING ® Physical activity is

noted DIAGNOSIS frequently avoided because

APPLICATIO the client may experience a

Word salad N TO lack of energy. Activity during

noted CLINICAL the day will promote a healthy

PRACTICE. feeling of physical “tiredness”,

Flight of 4th ed. J. B. which can facilitate sleep.

Ideas Lippincott Co.

noted Philadelphia.  Limit vigorous physical

1992. p. 777. activity for 2 hours prior to

Incoherent bedtime

noted
 ® The stimulating effects of

Incompreh physical activity last for

ensible several hours and interfere

noted. with efforts to relax prior to

bedtime.

 Assist the client to

determine the desired

number of sleep hours

each night, then designate

a time to retire and a

regular time to rise to

obtain that amount of

sleep.

® Regular hours help

establish a routine. If the

client awaits until he or she

“feels sleepy”, sleep patterns

may be erratic.

 Encourage the client to

avoid naps, unless

indicated by age or

physical condition.

® Daytime napping may

interfere with the ability to

sleep an adequate number of

hours at night, unless there is

a physiologic need for

additional sleep.

 Provide an atmosphere
 conducive for sleeping

® External stimuli or

disturbances interfere with

sleep

 Assist the client to identify

factors that induce

relaxation. These may be

former habits that were

effective, or the client may

have to initiate new

behaviors.

® The client may be

neglected to things that have

been purposefully relaxing or

may never have had a need

to purposefully relax before

retiring.

 If the client is unable to

feel drowsy in 20 minutes

after retiring, suggest that

he or she get up and

engage in 15 – 20 minutes

of a quiet activity that is

boring for the client.

(reading, sorting) then

return to bed. This should

be repeated until the

client begins to feel ready

for sleep.
 ® Lying in bed fir extended

periods can increase the

client’s focus on and

frustration with sleeping

difficulties. Monotonous

activities can facilitate

drowsiness.

DATE/ CUES NEED NSG. OBJECTIVE NURSING EVALUATION

TIME DIAGNOSIS S OF CARE INTERVENTIONS

Septem S: C Disturbed That within my 1. Assess mental and September 29,

ber 20, “ Yes O thought rotation my neurological status using 2004 at 12 pm

2004@ Sir,Yes G process R/T patient will be appropriate tools. GOAL PARTIALLY

7;30 Sir… N non-reality able to: ® Establishes functional level at MET

Student I based thinking a.) interact time of admission and provides Patient was not
nurse mo? T ® Non reality on reality baseline for future comparison. able to participate

O: I based thinking based 2. Consider effects of emotional in all the activities.

 Weari V can affect how topics distress, e.g. anxiety and anger. Environment was

ng a E a persons b.) participat ® May contribute to reduced free from injury

violet / think which e in alertness, confusion, withdrawal,

duste P maybe activities and hyperactivity, requiring

r E sometimes c.) be free further evaluation and

 Lying R evidenced by from intervention.

on C restlessness, injury 3. Monitor medication regimen

the E hostility, and and usage.

floor P may lead to ® Actions and interactions of

 Hostil T hurting one’s various medications prolonged

e U self. This is drug half-life/ altered excretion

 Assist A because they rates results on cumulative

ed on L cant control effects, potentiating risk of toxic

her anymore there reactions.

ADL P behavior. 4. Investigate changes in

 Restl A personality, response to stimuli,

essne T Bibliography: orientation/ level of

ss T Videbeck, consciousness; or development

noted E Sheila. of headache, nuchal rigidity,

 (+) R Psychiatric vomiting, fever, seizure activity.

negat N Mental Health ® Changes may occur for

ivistic Nursing 2nd numerous reasons, including

beha Edition. development/ exacubation of

vior Copyright© opportunistic diseases/ CNS

 (+) 2004. infection. Note: Early detection

word Lippincott and treatment of CNS infection

salad Williams & may limit permanent impairment

 (+) Wilkins. of cognitive ability.

assoc 5. Maintain a pleasant

iative environment with appropriate

loose auditory, visual, and cognitive

ness stimuli.
 disori ® Providing normal

ented environmental stimuli can help in

 agitati maintaining some sense of reality

on orientation.

noted 6. Provide cues for reorientation,

 shouti e.g., radio, television, calendars,

ng clock, room with an outside view.

Use patient’s name; identify

yourself. Maintain consistent

personnel and structured

schedules as appropriate.

® Frequent orientation to place

and time may be necessary,

especially during acute CNS

involvement. Sense of continuity

may reduce associated anxiety.

7. Encourage patient to do as
much as possible, e.g., dress

and groom daily, make friends

and so forth.

® Can help maintain mental

abilities for longer period.

8. Reduce provocative/ noxious

stimuli. Maintain bedrest in quiet,

darkened room if indicated.

® If patient is prone to agitation,

violent behavior, or seizures,

reducing external stimuli maybe

helpful.

9. Set limits on maladaptive/

abusive behavior; avoid open-

ended choices.

® Provide sense of security/

stability in an otherwise
 confusing situation.

10. Maintain safe environment.

® Decreases the possibility of

patient injury.

DATE CUES NEED NURSING OBJECTIVE NURSING EVALUATION

AND DIAGNOSIS OF CARE INTERVENTIONS

TIME

Septem Subjective: C Ineffective At the end of 1.) Establish a therapeutic September 29, 2004

ber 27, Objective: O Individual our rotation, my communication @

2004 - received P Coping, client will: ® To gain trust and the client’s 12:00 pm

@ wearing I related to a.) Express participation to avoid suspicions. “GOAL NOT MET”

8:00 white shirt N Denial to feelings 2.) Provide a safe environment My patient was not able

am and khaki G present such as fear for the client. to:

pants; able / condition and anxiety ® Physical safety of the client is a.) express her

to take a S ® Clients with b.) Participate a priority. Many feelings regarding

bath T depression in the common items and fear and anxiety

- with R may describe activities environmental situations may be b.) participate in

blunted E themselves as c.) Learn used by the client in a self- games because

affect S hopeless, problem destructive manner. she complained of

- able to S helpless, solving skills 3.) Observe the client closely. body weakness

answer down, or ® You must be aware of the c.) learn problem

questions T anxious. They client’s activity at all times when solving skills

asked O also may say there is a potential for suicidal or

-has short L they are a self injury.

span of E burden on 4.) Interact with the client on

attention R others, a topics with which he/she is

- A failure at life, comfortable. Do not probe for

complaine or may make information.

d body N other similar ® Topics that are uncomfortable

weakness C statements. for the client and probing may be

- E They are threatening and initially may

drowsiness easily discourage communication.

noted P frustrated, are When trust has been established,

- A angry with the client may be encouraged to

hallucinatio T themselves, discuss more difficult topics.

n/ delusion T and be angry 5.) Encourage the client to talk

not noted E at others. about what she feels.

- did not R They ® The client may have difficulty

participate N experience identifying and expressing

in the anhedonia, feelings directly. Your

activities using any encouragement and support may

- sense of help the client to develop these

verbalized pleasure from skills.

the desire activities they 6.) Give positive feedback by

to sleep formerly giving

-with good enjoyed. recognition.

appetite; Clients may ® Positive feedback will

consumed be apathetic, encourage the client to continue

2 banana that is, not socialization attempts and

cakes and caring about enhance self-esteem.

2 glasses self, activities, 7.) When first communicating

of juice and much of with the client, use

- denial to anything. simple, direct sentences; avoid

present Affect is sad complex sentences or directions.

condition or depressed ® The client’s ability to perceive

noted or may be flat and response to complex stimuli

- with poor with no is impaired.

insight emotional 8.) Avoid asking the client many

expressions. questions, especially which

Typically require only brief answers.

depressed ® Asking questions and

clients sit requiring only brief answers may

alone staring discourage the client from

into space or communicating or taking

lost in thought. responsibility for expressing

When his/her feelings.

addressed, 9.) Be comfortable sitting with the

they interact client in silence. Let the client

minimally with know you are available to

a few words or converse, but do not require the

a gesture. client to talk.

Noise and ® Your silence will convey your

people who expectation that the client will

might make communicate and your

demands on acceptance of the client’s

them, so they difficulty with communication.

withdraw from 10.) Encourage client to comply

the stimulation with the treatment regimen.

of interaction ® To facilitate the treatment

with others process.

overwhelm

them.
Bibliography:

Videbeck,

Sheila.

Psychiatric

Mental

Health

Nursing

2nd Edition.

©2004 by

Lippincott

Williams and

Wilkins. Page

342.
DATE/ NURSING

TIME CUES NEED DIAGNOSIS GOAL OF INTERVENTION EVALUATION

CARE

Septem O: S Anxiety r/t That within my  Encourage the patient’s September 29, 2004

ber anxiety E daughter’s rotation, my discussion of feelings. 12:00 PM

scale: L incoming client will be ® Reduce the threat that the “GOAL UNMET”

20, none-0 F wedding. able to lessen nurse poses to the highly At the end of our rotation

Mild-1 C ® Anxiety the anxiety from anxious patient. patient was not able to

2004 Moderate – O occurs when 3-2 as lessen the anxiety from

2 N something evidenced by:  Remain with the client at 3-2 as evidenced by:

@ Severe – 3 C central to a. identify all times when levels of a. inability to identify

(accdg. To E one’s healthy anxiety are high. healthy ways to to

7-12 Hamilton) P personality, ways to ® The client’s safety is a deal with and

Anxiety T essential to deal with priority. A highly anxious express anxiety;

shift scale of 3 / one’s and client should not be left alone- and

S existence and express his or her anxiety will b. inability to

 Rest E security, is anxiety; escalate. verbalize

less L being b. verbalize awareness of

nes F threatened. It awarenes  Move the client to a quiet feelings of

s P may be s of area with minimal or anxiety.

note E connected feelings decreased stimuli. Using

d R with the fear of of a small room or seclusion

 Irrita C punishment anxiety. area may be indicated.

bility E and ® The client’s ability to deal

note P disapproval, with excessive stimuli is

d T withdrawal of impaired. Anxious behavior

 Poo I love, can be escalated by external

r O disruption of a stimuli. A smaller room can

atte N relationship, enhance the client’s sense of

ntio P isolation, or security. The larger the area,

n A loss of body the more lost and panicked

spa T functioning. the client can become.

n T
 Hyp E Bibliography:  Remain calm in your

erac R Stuart, G. approach to the client.

tive N W.,PhD, RN, ® The client will feel more

 Inco CS, Sundeen, secure if you are calm and if

here S. RN, MS. the client feels you are in

nt & PRINCIPLES control of the situation.

inco & PRACTICE

mpr OF  Use short, simple, and

ehe PSYCHIATRI clear statements.

nsibl C NURSING. ® The client’s ability to deal

e C. V. Mosby with abstractions or

 Co. Canada. complexity is impaired.

1987. p. 343.

 Avoid asking or forcing the

client to make choices.

® The client’s ability to

problem-solve is impaired.
The client may not make

sound decisions or may be

unable to make decisions at

all.

 Be aware of your own

feelings and level of

discomfort or anxiety.

® Anxiety is communicated

interpersonally. Being with

the anxious client can raise

your own anxiety level.

 Encourage the client’s

participation in relaxation

exercises. These include

deep breathing,
 progressive muscle

relaxation, medication,

and guided imagery.

® Relaxation exercises are

effective, nonchemical ways

to reduce anxiety.

 Teach the client to use

relaxation techniques

independently.

® Independent use of the

techniques can give the client

confidence in having some

conscious control over his or

her anxious behavior.

 Support the client and give

 positive feedback when

the client plans for

discharge or talks

positively about discharge.

® Positive support may

reinforce the client’s positive

anticipation of discharge.

 Use of PRN medications

may be indicated if the

client’s level of anxiety is

high or if the client is

experiencing delusions,

disorganized thoughts,

and so forth.

® Medication may be

necessary to decrease the

 client’s anxiety to a level at

which he or she can listen to

you and feel safe.

DATE/ NURSING

TIME CUES NEED DIAGNOSIS GOAL OF INTERVENTION EVALUATION

CARE

September 20, Objective: S Risk for self- After the end of 1.) Establish October 4, 2004

2004  wearing a A directed violence our rotation, the rapport. @ 12:00 pm

@ violent F related to patient will be ® To gain the trust “GOAL

8 AM duster E depressed mood able to: and cooperation of PARTIALLY

 lying on the T as evidenced by a.)be free from the patient. MET”

floor Y suicide attempt.. injury 2.) Introduce self to Patient was:

 assisted on ® A state in b.))participate in client and call by a.) free from

her ADL A which an the activities name harm

 hostile N individual ® Conditions that b.) not able to

 restlessness D experiences make people feel participate in the

noted behaviors that anonymous activities

 (+) S can be facilitate because of her

negativistic E physically aggressive complaint of

behavior C harmful either to behavior. being sleepy

 (+) word U self or others. A 3.) Answer

salad R person who is questions in an

 (+) I not able to open, direct

associative T control his manner.

looseness Y behavior may ® Promotes the

intensify his developing of a

N behavior making trusting relationship

E him combative. and promotes

E Bibliography: consistency in

D Doenges, interventions.

Marilynn, 4.) Observe client’s

Nurse’s Pocket use of physical

Guide: Nursing space, and do not

Diagnosis with invade client’s

Interventions, 3rd personal space.

edition. F.A. ® Encroachment

Davis Company. on the client’s

USA. 1991. pp. personal space

511 may be perceived

as a threat.

5.) If it is necessary

to have physical

contact with the

client, explain this

need to the client in

brief, simple terms

before

approaching.

® Clarifies role of

staff to client so

that the intent of

these interaction

can be framed in a

positive manner.

6.) Talk with the

client in a calm,

reassuring voice.

Do not make

sudden moves. Do

not assume

physical postures
that are perceived

as threatening the

client.

® This can attempt

the client to have

violent behavior.

7.) Maintain eye

contact, but do not

stare; be aware of

the client’s position

and posture.

® The client might

perceive staring as

intrusive or

challenging. If

preparing to strike

out, the client will

glance quickly to

check for a clear

path.

8.) Tell the client

that you will help

him maintain

control that you are

aware of his

concern about

losing control.

® By

acknowledging the

client’s possible

fear of losing

control, the nurse

can help put those

feelings into
perspective.

9.) In an accepting,

nonthreatening

manner, encourage

the client to

verbalize feelings

and perceptions.

® By encouraging

the client to

express

unacceptable

feelings, the nurse

can help put those

feelings into

perspective.

1.)