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NURSING CARE PLAN CUES SUBJECTIVE DATA: molayas ko, diha ko agi atop as verbalized by the patient OBJECTIVE

DATA: Pr esence of 3 inches scar at the frontal parietal lobe noted P oor judgme NURSING DIAGNOSIS OBJECTIVES NURSING INTERVENTIONS INDEPENDENT Monitor, record and report changes in clients neurological status (level of consciousness ) , mental status (memory, cognitive, judgement, concentration), vital sign, laboratory results, and ability to follow commands Adjust communication style to client. Speak slowly and calmly; use short phrase and concrete, nontechnical wordy; listen RATIONALE INDEPENDENT Assessing cognitive, physical and behavioral symptoms help to determine the relationship between brain anatomy, neurochemica l systems and symptoms Basic interactions provide the nurse with opportunity to assess patient agitation and response. EVALUATION At the end of 2 weeks the patient was able to: Show remain oriented in time, place, person and circumstance and demonstrate d improvement in cognitive fucntion

Disturbed At the end of thought the whole process duration of related to nurse-client CNS insult therapeutic (head sessions the trauma) as patient will evidenced manifest by 3 inches improve mental scar at the condition like: frontal parietal Takes lobe. initiative Develop insight Improve short term memory Improve intellectu al functioni ng

These steps

nt noted P oor insight noted S hort attentio n span noted P oor short term memory noted L ack initiative noted U nable to think abstract ly noted

carefully, and seek clarification. Orient client and call client by name; introduce self on each contact; frequently mention time, date and place. Predominantly displays clock and calendars that are easy to read in a room and refer to them.

help reinforcing reality and provide cues that maintain orientation.

UES SUBJECTIVE DATA: ah! Di ko maligo! (as verbalized by the patient)

NURSING DIAGNOSIS Self care deficit: bathing / hygiene related to lack of initiative.

OBJECTIVES SHORT TERM: At the end of 1 week of nursing care, the patient will be able to: Perform ADL with indepen dence Understa nd the reason why ADL is importan t

NURSING INTERVENTIONS INDEPENDENT: Determine hygienic needs provide assistance as needed activities and with like and

RATIONALE INDEPENDENT: Makes client aware of how hygiene is vital in caring for oneself.

EVALUATION After 1 week, the patient was able to: Met the goal partially and patient appeared to be neat and well dressed when going to the activity area. Performed bathing all by himself but still with supervision. Patient was taught how to perform it the right way and verbalizes

care of nails brushing teeth.

To gain independenc e and confidence

OBJECTIVE DATA: dirty dishev eled Rough skin Scabie s noted Untidy Foul

Instruct to


client on how properly ADL Positive reinforcement increases self worth Assist the patient in performing activities of daily living and promotes continuity of functional perform


smellin g Dental carries Sleepi ng on the dirty wet floor near the door

Praise the client for attempts at self care and each successfully completed task. Provide clothing/ toilet needed.

behaviour. Patient feels more comfortable and less confused if personal supplies

understanding of the need.

clean are available. groomin/ as Depressed client.s have more energy and brighter affect later in the day


Initiate grooming and hygiene when Supporting ongoing patient is best able therapies to comply. encourage the client to maintain Continue to support self care routines. and monitor prescribed medication psychosocial treatment plans. and task


NURSING DIAGNOSI S Impaired social interaction related to developme ntal lag


NURSING INTERVENTI ON INDEPENDENT Observe for cause of discomfort in social situations; ask the client to explain when discomfort began. Encourage the client to express feeling to others Use humors as appropriate during interaction with the



SUBJECTIVE DATA: dili ko ganahan moapil as verbalized by the patient. OBJECTIVE DATA: Poo r eye contact or cannot maintain eye contact Slo w speech and soft tone An

SHORT TERM: At the end of 1 week patientnurse interaction, the patient will be able to: Communica te and demonstrat e interest in social interaction with other people

INDEPENDENT Individual assessmen t indicates specific interaction s. To demonstrat e care and reflection Humors is important for helping clients cope mentally Group settings are necessary for the

After 2 weeks the patient was able to: The patient show demonstrated interest in interacting other people Demonstrated increased comfort in social situations

LONGTERM: At the end of 2 weeks the patient will be able to:

hedonic Blu nt affect Hes itant

Demonstrat e increased comfort in social situations

client Encourage group interactions and activities for the client

client to practice new skills


NURSING DIAGNOSI S Interrupted family process r/t lack of family support


NURSING INTERVENTION establish the degree to which the family function an integrity are interrupted as a result of the family members mental illness. -


EVALUATI ON The goal of this NCP was met.

Subjective pabug-at lang na siya diri sa balay, ky bisan asa lang siya malibang, sigi ug laag ug lisud napud siya atimanun as verbalized by

At the end one week patient will be able to begin to express feelings freely and appropriately and to be able to gain self-esteem.

-establishing family function is the first step in identifying areas in need of help.

Helps the nurse to focus on specific behaviours that would benefit from identify therapeutic

the SO

Objective -low selfesteem noted -social withdrawal -blank stare noted -social isolation -

dysfunctional and interventions. harmful patterns of communication within the family. Therpautic modailities are useful in promoting - involve the family more functional and in therapeutic effective communication modailities relevant and behavioural patterns to its needs, in among family members. collaboration with the interdisciplinary mental health care Accepting help will team. provide family members more time to meet there Encourage the own needs and other family to accept family members. assistance from trusted significance Recognizing the familys persons. selfless behaviour, demonstrates respect and appreciation for the Acknowledge the family as a caring and family sacrifice and cohesive unit. team work in caring the mentally ill Education and member. supportive resources help family members learn new strategies and Educate the family begin to make necessary with information changes to promote a knowledge and stronger, more effective

available resources.

family system.