COLLEGE OF NURSING

Silliman University Dumaguete City

NURSING CARE PLAN
CUE/EVIDENCES SUBJECTIVE DATA: - Patient verbalized: ³Anha ra panutana sa akong asawa.´ Kamo ra sa akong asawa pagsabot.´ To wife,´Ayaw sige isturyakay daghan unya kag sayop ma sulti.´ NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS EVALUATION Impaired social interaction At the end of our care, the related to altered thought patient will« process. - Patient will demonstrate stable vital signs: T: 37.4 P: 104 bpm strong and bounding R: 22 cpm strong, regular, with no use of accessory muscles BP: 120/90 mmHg

Monitor and record V/S every 15 mins for 1 hour, then every shift until discharge.

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OBJECTIVE DATA: - T: 37.4 - P: 104 bpm strong and bounding - R: 22 cpm strong, regular, with no use of accessory muscles - BP: 120/90 mmHg - Hospitalized for severe head trauma - Patient was irritable and Patient and family members will report concerns about difficulties in social interaction. Assess neurologic function and mental status every shift to monitor changes in patient¶s status; reorient as often as necessary. Assist patient and family members in progressive participation in care and -

Goal met as evidenced by patient demonstrating stable vital signs: T: 37.4 P: 104 bpm strong and bounding R: 22 cpm strong, regular, with no use of accessory muscles BP: 120/90 mmHg Goal not met as evidenced by neither patient nor family members reporting difficulties in social interaction. Goal not met as evidenced by neither patient nor family members participating

Patient and family will members will participate in care and prescribed therapies. -

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. noncare-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. Patient will demonstrate effective social interaction skills in one-on-one and group settings Provide specific. - in ambulation therapy.Patient does not comply with recommended therapies: has not ambulated since admission therapies. Goal not met as evidenced by patient still demonstrating abrasive and indifferent attitude toward healthcare workers and family members.uncooperative .

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