PAIN DISORDER

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Chronic pain related After 8 hours of Assess and document - Patient’s self-report After 8 hours of
to severe level of nursing interventions, pain characteristics is the most reliable nursing interventions,
Ø anxiety, repressed. the client will information about the client was able to
demonstrate the chronic pain demonstrate
OBJECTIVE: alternative ways to experience. alternative ways to
deal with pain related deal with pain related
-unrelieved by to stress, anxiety, and Assess the patient’s - Patients with to stress, anxiety, and
analgesics other feelings. perception of the chronic pain have a other feelings.
-negative and effectiveness of long history of using
distorted cognition After 24 hours of techniques used for various After 24 hours of
-has insomnia and nursing interventions, pain relief in the past. pharmacological and nursing interventions,
fatigue Patient will verbalize nonpharmacological Patient verbalizes
-disrupted social acceptable level of means to control and acceptable level of
relationsip pain relief and ability alleviate their pain. pain relief and ability
to engage in desired to engage in desired
activities. Evaluate factors such - Recognizing the activities.
as gender, cultural, variables that
societal, and religious influence the
features that may patient’s pain
influence the experience can be
patient’s pain instrumental in
experience and developing a plan of
reaction to pain care that is
relief. acceptable to the
patient.

Validate the patient’s - Validation lets the

feelings and emotions patient know the
regarding current nurse has heard and
health status. understands what
 was said, and it
promotes the nurse-
client relationship.

Dependent: -the psychiatrist will

Refer to psychiatrist determine the cause
of the pain and/or
severity of the pain.

BODY DYSMORPHIC DISORDER

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Disturbed body image After 8 hours of Acknowledge and - Acceptance of these After 8 hours of
related to low self- nursing interventions, accept expression of feelings as a normal nursing interventions,
“Nagparetoke na ko esteem, severe level patient will feelings of response to what has patient was able to
ng ilong pero di pa rin of anxiety incorporate changes frustration, occurred facilitates incorporate changes
ako masaya sa mukha into self-concept dependency, anger, resolution. It is not into self-concept
ko” without negating self- grief, and hostility. helpful or possible to without negating self-
esteem. Note withdrawn push patient before esteem
OBJECTIVE: behavior and use of ready to deal with
After 24 hours of denial. situation. Denial may After 24 hours of
-high level of anxiety nursing interventions, be prolonged and be nursing interventions,
present Patient will verbalize an adaptive Patient verbalizes
-patient always blame acceptance of self in mechanism because acceptance of self in
her appearance situation. patient is not ready to situation.
fornot having a cope with personal
significant others problems.

Support verbalization - Expression of

of positive or feelings can enhance
negative feelings the patient’s coping
about the actual or strategies.
perceived loss.

Be realistic and - This enhances trust

positive during and rapport between
treatments, in health patient and nurse.
teaching, and in
setting goals within
limitations.

Provide hope within - This promotes

parameters of positive attitude and
individual situation; provides opportunity
do not give false to set goals and plan
reassurance. for future based on
reality.

Refer to physical and - These are helpful in

occupational therapy, identifying
vocational counselor, ways/devices to
psychiatric regain and maintain
counseling, clinical independence.
specialist psychiatric Patient may need
nurse, social services, further assistance to
and psychologist, as resolve persistent
needed. emotional problems.
DISSOCIATIVE DISORDER

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION PLANNING EVALUATION

SUBJECTIVE: Disturbed thought After 8 hours of Identify factors - Identifying factors After 8 hours of
processes related to nursing interventions, present present is important nursing interventions,
“minsan hindi ko psychological patient will maintain [acute/chronic brain to know the patient was able to
maintindihan sarili conflicts reality orientation syndrome (recent causative/contributing maintain reality
ko, naguguluhan isip characterized by and communicate stroke, Alzheimer’s factors. orientation and
ko at hindi ko alam cognitive deficits clearly with others disease), brain injury communicate clearly
kung bakit” or increased with others
After 24 hours of intracranial pressure,
OBJECTIVE: nursing interventions, anoxic event, acute After 24 hours of
Patient will be able to infections, nursing interventions,
-patient is feeling recognize and clarify malnutrition, sleep or Patient was able to
disconnected from possible sensory deprivation, recognize and clarify
himself misinterpretations of chronic mental illness possible
-sudden and the behaviors and (schizophrenia)]. misinterpretations of
unexpected change in verbalization of the behaviors and
moods others. Determine - Drugs can have verbalization of
-depression alcohol/other drug direct effects on the others.
characterized by use. brain, or have side
insomnia effects, dose-related
- effects, and/or
cumulative effects
that alter thought
patterns and sensory
perception.

- Assist with - This is to assess the

testing/review results degree of impairment
evaluating mental
status according to
age and
 developmental
capacity.

This is to assess the -This is to assess the

degree of degree of impairment.
impairment.

Schedule structured - This provides

activity and rest stimulation while
periods. reducing fatigue

Maintain a pleasant - Patient may respond

and quiet with anxious or
environment and aggressive behaviors if
approach patient in a startled or
slow and calm overstimulated.
manner.

DEPERSONALIZATION

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION PLANNING EVALUATION

SUBJECTIVE: Chronic low self- After 8 hours fo Assess with clients - Identify with client After 8 hours fo
esteem related to nursing interventions, their self perception. with realistic areas of nursing interventions,
Ø lack of realistic ego patient will be able to strength and patient was able to
boundaries. demonstrate ability weaknesses. Client demonstrate ability
OBJECTIVE: to reframe and and nurse can work to reframe and
dispute cognitive on the realities of the dispute cognitive
distortions with self-appraisal, and distortions with
assistance of a target those areas of assistance of a
nurse/clinician. assessment that do nurse/clinician
not appear accurate.
 Maintain a neutral, - Helps client see
After 3 days of calm, and respectful himself or herself as After 3 days of
nursing interventions, manner, although respected as a person nursing interventions,
patient will be able to with some clients this even when behavior patient was able to
set one realistic goal is easier said than might not be set one realistic goal
with nurse that he or done. appropriate. with nurse that he or
she wishes to pursue. she wishes to pursue.
Review with the - These are the most
client the types of common cognitive
cognitive distortions distortions people
that affect self- use. Identifying them
esteem (e.g., self- is the first step to
blame, mind reading, correcting distortions
overgeneralization, that form one’s self-
selective inattention, view.
all-or-none thinking).

Teach client to - Practice and belief

reframe and dispute in the disputes over
cognitive distortions. time help clients gain
Disputes need to be a more realistic
strong, specific, and appraisal of events,
nonjudgmental. the world, and
themselves.

Discuss with client his Looking toward the

or her plans for the future minimizes
future. Work with dwelling on the past
client to set realistic and negative self-
short-term goals. rumination. When
Identify skills to be realistic short-term
learned to help client goals are met, client
reach his or her goals. can gain a sense of
accomplishment,
direction, and
purpose in life.
Accomplishing goals
can bolster a sense of
control and enhance
self-perception.