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: ✔ 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
frequently mention time. and seek clarification. ✔ Orient client and call client by name. 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. introduce self on each contact. date and place.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. .
OBJECTIVES SHORT TERM: At the end of 1 week of nursing care. ✔ Performed bathing all by himself but still with supervision. the patient was able to: ✔ Met the goal partially and patient appeared to be neat and well dressed when going to the activity area. ✔ To gain independenc e and confidence OBJECTIVE DATA: ✔ dirty ✔ dishev eled ✔ Rough skin ✔ Scabie s noted ✔ Untidy ✔ Foul ✔ Instruct to the 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 independently . EVALUATION After 1 week.UES SUBJECTIVE DATA: “ah! Di ko maligo!” (as verbalized by the patient) NURSING DIAGNOSIS Self care deficit: bathing / hygiene related to lack of initiative. Patient was taught how to perform it the right way and verbalizes care of nails brushing teeth. 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.
behaviour. clean are available.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. and task . and monitor prescribed medication psychosocial treatment plans.s have more energy and brighter affect later in the day supplies 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. Patient feels more comfortable and less confused if personal supplies understanding of the need. Provide clothing/ toilet needed. groomin/ as Depressed client.
ask the client to explain when discomfort began. 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. ✔ Encourage the client to express feeling to others ✔ Use humors as appropriate during interaction with the RATIONALE EVALUATION SUBJECTIVE DATA: “dili ko ganahan moapil” as verbalized by the patient.CUES NURSING DIAGNOSI S Impaired social interaction related to developme ntal lag OBJECTIVES NURSING INTERVENTI ON INDEPENDENT ✔ Observe for cause of discomfort in social situations. ✔ 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: . 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.
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.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 CUES NURSING DIAGNOSI S Interrupted family process r/t lack of family support OBJECTIVES NURSING INTERVENTION establish the degree to which the family function an integrity are interrupted as a result of the family member’s mental illness. Helps the nurse to focus on specific behaviours that would benefit from identify therapeutic . ky bisan asa lang siya malibang. - RATIONALE EVALUATI ON The goal of this NCP was met. Subjective “pabug-at lang na siya diri sa balay.
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.the SO Objective -low selfesteem noted -social withdrawal -blank stare noted -social isolation - dysfunctional and interventions. provide family members more time to meet there Encourage the own needs and other family to accept family members. collaboration with the interdisciplinary mental health care Accepting help will team. harmful patterns of communication within the family.involve the family more functional and in therapeutic effective communication modailities relevant and behavioural patterns to its needs. Therpautic modailities are useful in promoting . team work in caring the mentally ill Education and member. selfless behaviour. assistance from trusted significance Recognizing the family’s persons. more effective . demonstrates respect and appreciation for the Acknowledge the family as a caring and family sacrifice and cohesive unit. in among family members.
available resources. . family system.