COLLEGE OF NURSING

Silliman University
Dumaguete City

NURSING CARE PLAN

CUE/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS EVALUATION

SUBJECTIVE DATA: Impaired social interaction At the end of our care, the
related to altered thought patient will…
- Patient verbalized: process.
“Anha ra panutana sa - Patient will - Monitor and record V/S - Goal met as evidenced
akong asawa.” demonstrate stable every 15 mins for 1 by patient
Kamo ra sa akong vital signs: hour, then every shift demonstrating stable
asawa pagsabot.” T: 37.4℃ until discharge. vital signs:
To wife,”Ayaw sige P: 104 bpm strong and T: 37.4℃
isturyakay daghan unya bounding P: 104 bpm strong and
kag sayop ma sulti.” R: 22 cpm strong, bounding
regular, with no use of R: 22 cpm strong,
accessory muscles regular, with no use of
BP: 120/90 mmHg accessory muscles
OBJECTIVE DATA: BP: 120/90 mmHg

- T: 37.4℃ - Assess neurologic - Goal not met as

- P: 104 bpm strong and - Patient and family function and mental evidenced by neither
bounding members will report status every shift to patient nor family
- R: 22 cpm strong, concerns about monitor changes in members reporting
regular, with no use of difficulties in social patient’s status; difficulties in social
accessory muscles interaction. reorient as often as interaction.
- BP: 120/90 mmHg - necessary.
- Hospitalized for severe - Goal not met as
head trauma - Patient and family will - Assist patient and evidenced by neither
- Patient was irritable members will family members in patient nor family
and uncooperative participate in care and progressive members participating
- Patient does not comply prescribed therapies.
with recommended
therapies: has not
ambulated since - Patient will
admission demonstrate effective
social interaction skills
in one-on-one and
group settings
participation in care
and therapies.
- Goal not met as
- Provide specific, non-
care-related time with
patien each shift to
encourage social
interaction beginning
with one-on-one
interaction and increase
to group interaction as
patient’s skill indicates.
in ambulation therapy.
evidenced by patient
still demonstrating
abrasive and
indifferent attitude
toward healthcare
workers and family
members.