Cues Nursing Analysis Goals and Nursing Rationale Evaluation

Diagnosis Objectives Intervention

Subjective: Deficient A person Goal: After 2 hours

Knowledge diagnosed After 2 hours of nursing
“Kasi napaaway related to with of nursing intervention,
ako noon eh, information schizophrenia intervention did the client
nakainom kasi misinterpretati may the client will able to
yung mga on as experience be able to verbalize
kabarkada ko manifested by hallucinations verbalize understanding
tapos inaway delusion (most understanding of his
nila ako kaya commonly of his condition and
dinala ako dito hearing condition and treatment?
para makaiwas voices), treatment.
sa away.” delusions YES ____
(often bizarre Objectives: Ascertain level NO ____
“Nanunuod ng or persecutory of knowledge,
TV, in nature), and The client will including
nakikipagkwent disorganized assume anticipatory
uhan sa mga thinking and responsibility need.
nandito, yung speech. A for own
ibang nandito delusion is a learning by Determine
kasi may mga fixed belief beginning to client’s ability
problema sa that is either look for and barriers to
pag-iisip, o yung false, fanciful, information learning.
iba dahil sa or derived and ask Client may
drugs.” from questions. Be alert to need to suffer
deception. In signs of sequences of
“Pero ako kasi psychiatry, it avoidance. lack of
nandito ako is defined to knowledge
dahil be a belief before he is
pinapalamig pa that is ready to
ako ng Kuya ko pathological accept
dahil nga (the result of information.
napaaway ako an illness or
dati.” illness
 process) and
is held despite Determine
evidence to blocks to
Objective: the contrary. learning:
As a language
height of 5’7 pathology, it is barriers;
weighs 130lbs distinct from a physical May need of
belief based factors; caregivers to
slouched on false or learn.
posture incomplete Assess the
information, level of the
dogma, client’s
stupidity, capabilities Motivation
apperception, and the may be a
illusion, or The client will possibilities of negative or
other effects be able the situation. positive
of perception. participate in stimulus,
learning Identify
http://en.wikip process. motivating
e factors for the Prevent
dia.org/wiki/ individual. overload
Delusion
Provide Can
information encourage
relevant only continuaton of
efforts.
Provide
positive
reinforcement
s

Discuss one
topic at a Can arouse
time, avoid interest/ limit
giving too sense of being
 much overwhelmed.
information in
one session.

Begin with
information
the client
already knows Client
The client will and move to feels
initiate what the competent
necessary client does not and
lifestyle know, respected.
changes and progressing
participate in from simple to
treatment complex.
regimen
Discuss
client’s
perception of
need. Relate
information to
client’s
personal Clarifies
desires or expectations
needs and of teacher and
values. learner.

Identify To answer
information questions or
that needs to validate
be information
remembered. post-
discharge.
Provide
mutual goal
setting and
learning
contracts.

Provide
access
information
for contact
person