Date

Cues

Need

Nursing Diagnosis

Objectives of Care

Nursing Intervention

Evaluation

M A R C H

Subjective: gusto na ko maayo aron makaauli na ko. As verbalized by the client.

H E A L T H

Readiness for enhanced therapeutic management r/t desire to be with family

That within my 1 week span of nursing care, the patient will be able to enhance therapeutic regimen as manifested by:

1. Establish rapport promotes nursepatient cooperation 2. Verify clients knowledge of treatment regimen to provide accuracy

Goal Partially Met!

At March 28, 2012 @ 4:30 pm, client was able to enhance therapeutic regimen as manifested by: a. Verbalization of ways to enhance therapeutic regimen dapat jud magampo ko. dapat pud muistorya jud ko. as verbalized by the client b. Remain free from

24, Objective 2 0 1 2 -smiles more frequently -more open to conversations -no acceleration @ of symptoms P E R C E P T I 10:00 AM O N / H E Distress can be reduced when anxiety and depression are treated with psychoeducational programs, establishment of support systems, and counselling. a. Verbalization of ways to enhance treatment b. Remaining free from progression of condition

and completeness of knowledge 3. Discuss present resources used by the client to note whether changes can be made 4. Identify steps necessary to reach desired health goal To enhance commitment and likelihood of achieving

A L T H

Reference:
Smeltzer, S.C. & Bare, & B.G. Suddarths of

goals. 5. Encourage the client to express herself to relieve anxiety and promote expression of feelings 6. Encourage significant others to always
10th

progression of condition.

(2006). Brunner

M A N A G E M E N T

Textbook MedicalSurgical Nursing. Edition. Lippincott Williams Wilkins. Philadelphia.

converse with the client to enhance clients verbalization of

&

emotions, insights, etc. 7. Acknowledge individual capabilities to reinforce movement toward attainment of desired outcome provides positive reinforcement encouraging continued progress towards desired goals.