ASSESSMENT NURSING PLANNING NURSING Rationale EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective . - . -

ASSESSMENT NURSING PLANNING NURSING Rationale EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective Data: Disturbed Thought At the end of the -Orient client, call - External, written Goal met. Client
Pt’s facial Processes related shift, client will client by name, and reminders are more has maintained one
expressions and to remain free from introduce self on each effective than verbal meaningful
body language Neurophysiologica actual or potential contact. Promptly reinforcement for relationship
demonstrate l changes as harm by self or display a clock and memory aids allowing self-
confusion and manifested by other throughout calendar. disclosure and
frustration. client this shift, demonstrates a
  demonstrates Report any new onset or balance between
periods of sudden increase in emotional
Objective Data: confusion confusion dependence and
Pt demonstrates independence.
periods of
orientation and
periods of confusion Stay with the client if they
   are agitated and likely to - “One-on-one
Pt demonstrates be injured. contact from staff to
unusual mood client is the first
swings. step to successful
de-escalation
-