DEMENTIA

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Impaired memory Short term Independent: Short term
related to dementia as After 8 hours of nursing Assessed patient’s ability for - Changes in status After 8 hours of nursing
evidenced by memory intervention the client thought processing every shift. may indicate intervention the client will
loss or inability to recall will verbalize awareness progression of verbalize awareness of
S: “Di ko alam anu na nangyare simula her life events, of memory problems Observed patient for cognitive deterioration or memory problems
nagkakilala kame ni Roger, asawa ko disoriented about functioning, memory changes, improvement in
pala siya, ano pa ba mga nangyare person and disorientation, difficulty with condition.
saken sa buhay ko ?” as verbalized by circumstance, wandering communication, or changes in
the client and inappropriate thinking patterns.
behavior
O: Assessed level of confusion and - To indicate
-memory loss disorientation. effectiveness of
-forgetfulness treatment or decline Long term
-disoriented about person and Long term in condition. After 3 weeks of nursing
circumstance After 3 weeks of nursing Assessed patient’s ability to cope - The elderly may intervention, the client was
-wandering intervention, the client with events, interests in have a decrease in able to have appropriate
-inappropriate behavior( agitation and will have appropriate surroundings and activity, memory for more maintenance of mental and
anxiety) maintenance of mental motivation, and changes in recent events and psychological function as long
and psychological memory pattern. more active memory as possible, and reversal of
function as long as for past events and behaviors when possible, as
possible, and reversal of more active memory evidenced by the client
behaviors when possible. for past events and remained calm and showed no
reminisce about the signs of agitation and anxiety
pleasant ones.
Called patient by her name - to recognize of
reality and the
individual.

Dependent:
 Determined client’s response to - Medication for
and effects of medications cognitive
prescribed to improve attention, enhancement can be
concentration and memory effective but, but
processes. benefits need to be
weighed against
whether quality of
life is improved after
side effects and cost
of drugs are
considered
Collaboration: - To determine
Collaborated with medical and presence and
psychiatric providers in evaluating severity of
orientation, attention span, ability impairment.
to follow directions, send or
receive communication,
appropriateness of response.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

S: “takot ako mamatay sabi ng doctor
mamatay nako sa sakit ko diba,?
Please wag sana marami pako pede
gawin diba” as verbalized by the client
O:
-feels like threatened
-hysterical
-attack behaviors
Fear related to death as Short term Independent: Short term
evidenced by After 6 hours of nursing Monitored Vital signs - To provide baseline After 6 hours of nursing
inappropriate behavior intervention the client data intervention the client was
shown, panic, and will acknowledge and Determined the type of the - Patients who find it able to acknowledge and
increased VS. discuss fears, recognizing patient’s fear by thorough, rational unacceptable to discuss fears, recognizing
healthy versus unhealthy questioning and active listening. expose fear may find healthy versus unhealthy fears
fears it convenient to as evidenced by the client
know that someone remained calm and showed no
is willing to listen if sign of hysterical.
Long term they choose to share
After 2 weeks of nursing their feelings at Long term
intervention, the client some time in the After 2 weeks of nursing
will demonstrate future. intervention, the client was
- increased PR (93) understanding through Assessed the behavioral and verbal - This information able to demonstrate
- increased BP (150/90) use of effective coping expression of fear. provides a understanding through use of
-increased RR (21) behaviors and resources foundation for effective coping behaviors and
planning resources
interventions to
support the patient’s
coping strategies.
Opened up about your awareness - This approach
of the patient’s fear. validates the feelings
the patient is holding
and demonstrates
recognition of those
feelings.
Discussed the situation with the - This approach helps
patient and help differentiate the patient deal with
between real and imagined threats fear.
to well-being.

Be with the patient to promote - The physical

safety especially during frightening connection with a
procedures or treatment. trusted person helps
the patient feel
secure and safe
during a period of
fear.
Maintained a relaxed and - The physical
accepting demeanor while connection with a
communicating with the patient. trusted person helps
the patient feel
secure and safe
during a period of
fear.
Encouraged contact with a pear - To provide a role
who has successfully dealt with a model, and the

Assessment
S: “ano ba dapat gawin sa sarili ko
hayaan niyo nalang ako di naman ako
mabaho” as verbalized by the client
O:
-inability to access bathroom, gather
bathing supplies, regulated bath water
and wash or dry body
-unable to brush her teeth
-inability to comb her hair
similar fearful situation client is more likely
to believe others
who have had
similar experiences
Dependent:
Reviewed the use of anti anxiety
medications and reinforced use as
prescribed
Collaboration:
Encouraged regular physical - This provides a
activity within limits of ability, refer healthy outlet for
to a physical therapist to develop energy generated by
an exercise program to meet fearful feelings and
individual needs promotes relaxation
Nursing Diagnosis Planning Intervention Rationale Evaluation
Self- care deficit in Short term Independent Short term
bathing related to After 8 hours of nursing Assessed patient’s appearance, - Identifies specific After 8 hours of nursing
alteration in cognitive intervention the client body odors, ability to recognize needs and the intervention the client was
functioning such as will verbalize knowledge and user articles for washing and amount of assistance able to verbalize knowledge of
decrease in motivation of healthcare practices grooming, and any other self-care that the patient will healthcare practices as
deficits. require in order to evidenced by coping step by
establish a plan of step in understanding her
care. health care hygiene through
Long term bathing.
After 3 weeks of nursing
intervention the client Assessed and identify patient’s - Promotes familiarity Long term
will perform self -care previous history of grooming and with routine bathing After 3 weeks of nursing
activities within level of bathing, and attempt to maintain time and type of intervention the client was
own ability similar care. bath or shower, and able to perform self -care
lessens further activities within level of own
 confusion and ability
agitation.
Ensure all needed items are - Prevents the need to
present in bathroom prior to the leave the patient
patient’s arrival. Ensure that water unattended, which
temperature in tube is appropriate. may result in injury.
Elderly are easily
child and have
fragile skin that is
susceptible to
scalding.
Allow patient to perform as much - Fosters
of the task as able. independence and
promotes self-care
as long as possible.
Assist with as much activity as - Promotes
needed. Give patient a washcloth independence and
or hand towel to hold on to. self-esteem when
patient is allowed to
control situation.
Instruct patient in activity with - Promotes self-
short step-by-step method; do not esteem and feelings
rush patient. of accomplishment;
rushing the patient
causes frustration.
Instruct family members in bathing - To provide
technique and what to observe for knowledge and
during bath. decreases anxiety.

PTSD
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
 Post trauma syndrome Short term Independent: After 2-3 days of nursing
related to history of After 2-3 days of nursing Identify client who survived or - To recognize intervention, the patient was
physical and intervention, the client witnessed traumatic event individual at high risk able to report absence of
psychological abuse and will report absence of for post trauma anxiety or reduced anxiety or
S: “sa tuwing naaalala ko yung exposure to violent anxiety or reduced syndrome fear when memories occur as
nangyari na pagmaltrato saken parang death anxiety or fear when Assessed client’s knowledge of and - To assess causative evidenced by reduced anxiety
wala nako Karapatan sumaya at memories occur. anxiety related to potential for individual reaction or remained calm.
mamuhay ng payapa ngayon, di ko na work related trauma
alam gagawin ko” Long term Long term
After 2 weeks of nursing Observed for elicit information - Anxiety is viewed as After 2 weeks of nursing
O: intervention, the client about physical and psychological a normal reaction to intervention, the client was
-anxiety will verbalize a positive logical injury and note associated a realistic danger or able to verbalize a positive
-inability to sleep self- image stress-related symptoms like threat, and noting self- image
-hypervigilance headache, tightness in chest, these factors can
-panic attacks nausea and pounding heart identify severity of
-dependence on others the anxiety the client
is experiencing.
Identified psychological responses - Indicators of severe
like anger, acute anxiety and response to trauma
hysterical behavior that client has
experienced and
need for specific
interventions
Assessed client’s knowledge of and - Client may be aware
anxiety related to the situation. but speak as though
Noted ongoing threat the incident is
related to someone
else, flashbacks may
occur with the
individual reliving
the incident o event
Dependent:
Administered anti-anxiety with
caution
 Collaboration:
Provided for sensitive, trained - To provide an
counselors and therapists and effective
engage in therapies such as improvement of
psychotherapy, relaxation and clients psychological
implosive therapy status

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Risk for other directed Short term Independent: Short term
violence related to After 3 days of nursing Ascertained client’s perception of After 3 days of nursing
aggressive acts and intervention, the client self and situation - To determine intervention, the client
manic excitement as will refrain from contributing factors refrained from threatening,
S: “mas okay siguro kung pinatay ko manifested by shouting threatening, loud Observed for signs of homicidal - To determine signs loud language towards others
nalang yun” as verbalized by the client and clenching of fist. language towards others intent of violent intention and identified calming
and identifies calming strategies.
O: strategies Asked directly the client if he is - To determine violent
- Clenching of fist thinking of acting on thoughts or intent
- Facial flaring Long term feelings Long term
- Shouting After 3 weeks of nursing After 3 weeks of nursing
- Flaring eyes intervention, the client Identified risk factors and assessed - To identify the intervention, the client was
- Grunting of teeth will participate in care for indicators of child abuse or causative factors able to participate in care and
and meet own needs in neglect; unexplained or frequent meet own needs in an
an assertive manner injuries, failure to thrive and so assertive manner
forth

Developed therapeutic nurse client

relationship - This promotes sense
of trust, allowing
client to discuss
 feelings openly

Maintained straightforward
communication - To avoid reinforcing
manipulative
Discussed motivation for change behavior
- crisis situation can
provide impetus for
Dependent: change
Administered prescribed
medications - to lower the
aggressive behavior
Collaboration: of the client
Referred to formal resources as
indicated such as individual or - to promote wellness
group psychotherapy, social and teaching
services and parenting classes considerations

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

S: “pano kopa magagawa yung mga
dati kong ginagawa dahil lang wala
nakong isang kamay para san pa
mabuhay” as verbalized by the client
O:
- Anxious
Ineffective coping Short term Independent: Short term
related to changes in After 2 days of nursing Establish rapport or nursing- - to provide After 2 days of nursing
body integrity secondary intervention, the client patient relationship with the client supportive intervention, the patient was
to loss of body part will identify response companionship able to identify response
disfigurement secondary patterns and the Determine the onset of the client’s - to assist client to patterns and the
to trauma. consequences of feelings and symptoms and their deal with current consequences of resulting
resulting behavior. correlation with events and his life situation behavior.
changes.
Long term Long term
After 2 weeks of nursing Explained disease process, - this may help the After 2 weeks of nursing
intervention, the client procedures and events in a simple client to express intervention, the client was

- Fatigue
- Rejecting social support
- Impaired social participation
- Alcohol dependent
- Lack of goal-directed behavior
- Destructive behavior toward self
will meet psychological
needs as evidenced by
appropriate expression
of feelings, identification
of options, and use of
resources.
concise manner. Devoted time for
listening
Emphasized positive body
responses to medical conditions,
but do not negate the seriousness
of the situation
emotions, grasp the able to meet psychological
situation, and feel needs as evidenced by
more in control appropriate expression of
- to provide the feelings, identification of
client’s options, and use of resources.
understanding with
current situation

Encouraged the client to try new - for an effective

coping behaviors and gradually coping mechanism
master the situation of the client

Confronted the client when - this provides an

behavior is inappropriate, pointing external locus of
out the difference between words control, enhancing
and actions safety

Collaboration:
Stressed the importance of follow
up care
ANXIETY
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Anxiety, mild related to Short term Independent: Short term
threat to current status After 8 hours of nursing Observed behaviors that can point - to determine level of After 8 hours of nursing
and unconscious conflict intervention the client to the client’s level of anxiety anxiety intervention the patient was
S: “sobrang takot ko baka makuha ng about essential values will appear relaxed and which is mild anxiety that includes relaxed and reported that
mga anak ko ang sakit kong to” and goals of life as report that anxiety is insomnia, restless and motivated anxiety is reduced to a
evidenced by insomnia, reduced to a manageable to deal with existing problems manageable level
O: fear, shakiness, level
-insomnia weakness, fidgeting and Long term
-fear decrease in productivity Long term Maintained a calm, non After 2 weeks of nursing
-shakiness After 2 weeks of nursing -threatening manner while working - Client develops intervention, the client was
-weakness intervention, the client with the client. feeling of security able to use resources and
-restless will use resources and in presence of support systems effectively
-decrease in productivity support systems
calm staff person.
effectively
Established and maintain a trusting
- Therapeutic skills
relationship by listening to the
need to be directed
client; displaying warmth,
toward putting the
answering questions directly,
client at ease,
offering unconditional acceptance;
because the nurse
being available and respecting the
who is a stranger
client’s use of personal space.
may pose a threat to
the highly anxious
client.
Maintained calmness in your
approach to the client.
- The client will feel
more secure if you
are calm and inf the
client feels you are
in control of the
 Provide reassurance and comfort situation.
measures.
- Helps relieve
Stayed with the patient during anxiety.
panic attacks. Use short, simple
directions. - During a panic
attack, the patient
needs reassurance
that he is not dying
and the symptoms
Dependent: will resolve
Referred to the physician for drug spontaneously.
management alteration of the
prescription regimen - Drugs that often
cause symptoms of
anxiety include
aminophylline,
Collaboration: dopamine, levodopa,
Referred to individual and or group salicylates and
therapy, as appropriate steroids.

- To deal with chronic

anxiety states

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

S: “ayaw na ayaw ko sa may mga tao,
Social isolation related Short term Independent: - An accepting Short term
to repressed fears as After 8 hours of nursing Conveyed an accepting and attitude increases Short term
evidenced by history of intervention the client positive attitude by making brief, feeling of self-worth After 8 hours of nursing
rejection, withdrawn will identify causes and frequent contacts. and facilitates trust. intervention the client was
and poor eye contact. actions to correct able to identify causes and
di ako mapakali kase lahat ng
sasabihin ko mali, ayoko nalang
makipaghalubilo di rin ako mapakali”
O:
-history of rejection
-withdrawn
-poor eye contact
-disabling condition
isolation
Long term
After 2 weeks of nursing
intervention, the client
will participate in
activities or programs at
level of ability and desire
Showed unconditional positive - To convey your
regard. belief in the client as
a worthwhile
individual.
Be honest and keep all promises. - Honesty and
dependability
promote a trusting
relationship.
Discussed with the client the signs - Maladaptive
of increasing anxiety and behaviors are
techniques for interrupting the manifested during
response such as breathing times of increased
exercises, thought stopping, anxiety.
relaxation, meditation.
actions to correct isolation as
evidenced by actively
participating in therapeutic
relationship with healthcare
staff.
Long term
After 2 weeks of nursing
intervention, the client was
able to participate in activities
or programs at level of ability
and desire

Gave recognition and positive - Positive

reinforcement for client’s voluntary reinforcement
interaction with others. enhances self-
esteem and
encourages
repetition of
acceptable
behaviors.

Dependent:
Discussed use of medication when - Client may benefit
depression is interfering with from the short- term
ability to manage life use of an
antidepressant
medication to help
with dealing
situation.

Assessment
S: “di talaga ako makatulog kakaisip,
di ko mapigilan kahit anong gawin ko”
O:
-altered concentration
-general tiredness
-awakes earlier
-increased absenteeism
Collaboration:
Referred to other sources such as - Provides additional
counseling, psychotherapy and help when needed
support groups to resolve situation,
continue grief work
Nursing Diagnosis Planning Intervention Rationale Evaluation
Insomnia related to After 2-3 days of nursing Independent: After 2-3 days of nursing
anxiety as evidenced by intervention, the client Determined patterns of sleep in - Information about intervention, the client was
altered concentration, will identify individually the past in a normal environment: this topic provides able to identify individually
tiredness, awakes earlier appropriate amount, bedtime routines, depth, baseline data for appropriate interventions to
and increased interventions to promote length, positions, aids, and other evaluating means to promote sleep as evidenced
absenteeism. sleep. interfering factors. improve the by involved in daily activities
patient’s sleep. and practiced relaxation
Take note observations of sleep- techniques before bedtime.
Long term wake behaviors. Take down notes - This provides
After 3 weeks of nursing on the number of hours the patient baseline data for the Long term
intervention, the client is asleep. evaluation of After 3 weeks of nursing
will report improvement insomnia. intervention, the client was
in sleep-rest pattern Note psychological circumstances able to report improvement in
such as anxiety that hinder sleep. - The patient’s sleep-rest pattern
perception of the
insomnia may differ
from objective
evaluation.
Encouraged daytime physical - In insomnia, stress
activities but instruct the patient to may be reduced by
avoid strenuous activities before therapeutic activities
bedtime. and may promote
sleep.
Instruct the patient to follow a
consistent daily schedule for rest - Consistent schedules
and sleep. facilitate regulation
of the circadian
rhythm and decrease
the energy needed
for adaptation to
changes.
Introduced relaxing activities such
as warm bath, calm music, reading - These activities
a book, and relaxation exercises provide relaxation
before bedtime. and distraction to
prepare mind and
body for sleep.

Dependent:
Used barbiturates and or other - To induce sleep
sleeping medications disturbances

Collaboration:
Referred to sleep specialist as - Follow- up
indicated or desired evaluation or
intervention may be
needed when
insomnia is seriously
impacting the
client’s quality of
life, productivity and
safety.
MENTAL RETARDATION
Assessment
S: “nahihirapan talga ako magsalita
kaya sorry di ko ren alam pano kopa
sasabihin iba ko pa gusto sabihin” as
verbalized by the client in slurred
speech
O:
- verbalizing; slurred speech,
Or dysarthria,
-worried
-absence of eye contact
Nursing Diagnosis Planning Intervention Rationale Evaluation
Impaired verbal Short term Independent: Short term
communication related After 4 days of nursing Learned patient needs and pay - The nurse should set After 4 days of nursing
to cognitive dysfunction intervention the client attention to nonverbal cues. aside enough time to intervention the client was
as evidenced by difficulty will establish method of attend to all of the able to establish method of
in verbalizing; slurred communication in which details of patient communication in which
speech or dysarthria, needs can be expressed. care. needs can be expressed.
and absence of eye
contact. Long term Provided an alternative means of - An alternative Long term
After 2 weeks of nursing communication for times when means of After 2 weeks of nursing
intervention, the client interpreters are not available (e.g., communication (e.g., intervention, the client was
will participate in a phone contact who can interpret flash cards, symbol able to participate in
therapeutic the patient’s needs). boards, electronic therapeutic communication
communication using messaging) can help using silence, accepting,
silence, accepting, the patient express restating, reflecting, active-
restating, reflecting, ideas and listening
active- listening communicate needs.
Clarify your understanding of the
patient’s communication with the - Feedback promotes
patient or an interpreter. effective
communication.
Maintain eye contact with patient
when speaking. Stand close, within - Patients may have
patient’s line of vision (generally defect in field of
 midline). vision or they may
need to see the
nurses’ face or lips
to enhance their
understanding of
what is being
communicated.

- Individuals with
Maintained a calm, unhurried expressive aphasia
manner. Provide sufficient time for may talk more easily
patient to respond. when they are
rested and relaxed
and when they are
talking to one
person at a time.

- This approach
Speak slowly. provides the patient
with more channels
through which
information can be
communicated.

Collaboration:
Referred to appropriate resources
such as speech or language therapy
and psychiatric counseling

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Risk for injury related to Short term Independent: Short term
alteration of cognitive After 4 days of nursing Assessed general status of the - This is to determine After 4 days of nursing
 functioning as evidenced intervention, the client patient. the patient’s intervention, the client was
by aggressive behavior will identify or monitor condition that may able to identify or monitor
S: “ayoko nga dito, alisin niyoko dito” imbalance of physical personal risk factors cause injury. personal risk factors
mobility and fatigue
O: Long term Assess mood coping abilities,
-aggressive behavior After 2 weeks of nursing personality style that may result in Long term
-imbalance mobility intervention, the client carelessness. - Mood coping After 2 weeks of nursing
-fatigue will engage in risk control abilities and style of intervention, the client was
strategies personality aid to able to engage in risk control
determine the strategies as evidenced by
Determined whether exposure to patient’s level of lifestyle changes to reduce risk
community violence is contributing cooperation. factors and protect self from
to risk for injury. - Exposure to injury.
community violence
has been associated
with increases in
aggressive behavior
and depression.

Provided medical identification

bracelet for patients at risk for
injury from mental disorders. - Signs are vital for
patients at risk for
injury. Healthcare
providers need to
acknowledge who
has the condition for
they are responsible
for implementing
actions to promote
Asked family or significant others patient safety.
to be with the patient to prevent
him or her from accidentally falling
 or pulling out tubes. - This is to prevent the
patient from
Validate the patient’s feelings and accidentally falling or
concerns related to environmental pulling out tubes.
risks.
- Validation lets the
patient know that
the nurse has heard
and understands
what was said, and it
Collaboration: promotes the nurse-
Coordinate with physical therapist patient relationship.
for strengthening exercises and
gait training to increase mobility.
- Gait training in
physical therapy has
been proven to
effectively prevent
falls.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

S: “wala akong gana makipagusap sa
lahat, pabayaan nyo nalang muna
ako”
O:
- Dysfunctional interaction with
family, peers, and/or others
- Remains feelings of seclusion, avoids
Impaired social Short term Independent: Short term
interaction related to After 8 hours of nursing Reviewed medical history, noting - To determine After 8 hours of nursing
trouble speaking and intervention, the client stressors of illness such as causative factors intervention, the client was
social adaptation will verbalize awareness emotional disabilities able to verbalize awareness of
difficulties as evidenced of factors causing or factors causing or promoting
by Dysfunctional promoting impaired Determined family patterns of - May result in impaired social interactions
interaction with family, social interactions relating and social behavior conforming or
peers, and/or others rebellious behavior
and remains feelings of
seclusion, avoids contact Observed client while relating to - To note prevalent
with others and lacks Long term family or SO interaction patterns
eye contact and After 2 weeks of nursing Long term
contact with others and lacks eye discomfort in social intervention, the client Observed and described social and - Helps identify the After 2 weeks of nursing
contact. situations and will identify feelings that interpersonal behaviors in kinds and extent of intervention, the client will
-restlessness restlessness. lead to poor social objective terms, noting speech problems client is identify feelings that lead to
interaction patterns, body language in the exhibiting poor social interaction
therapeutic setting.
Interviewed family, SO’s, friends - To obtain
observations of
client’s behavioral
changes and effects
on others

Established therapeutic - To recognize positive

relationship using positive regard changes in impaired
for the client. Active listening and interactions.
providing safe environment for
self-disclosure

Have client list behaviors that - Once recognized,

cause discomfort client can choose to
change as he or she
learns to listen and
communicate in
socially acceptable
ways.

Collaboration:
Encouraged ongoing family and - To promote wellness
individual therapy as long as it is and discharge
promoting growth and positive consideration
change.

Provided for occasional follow up, - For reinforcement of

as appropriate positive behaviors
after professional
relationship has
ended