PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: AJPM
Age & Gender: 21y/o Female
Birthday: 06/11/2000
Address: Dagupan City,
Pangasinan
Chief Complaint: Feeling inadequate Name of Student Nurse: Maynigo,
Admitting Diagnosis: Defensive Ann Jel
coping Level/block/group: 3BSN4
Hospital/area: Psychiatric Ward Clinical Instructor: Ma’am Mary
Date of Confinement: 03/14/2022 Mar N. Espital
Date: 03/14/2022

ASSESSMENT NURSING DIAGNOSIS GOAL/PLAN OF CARE NURSING INTERVENTIONS

Subjective: Defensive coping related to Short-Term: Independent:

“I feel like nobody feelings of inadequacy and ● Encourage ventilation of ● Accept the patient or individual as what she
acknowledges my need for acceptance from feelings of frustration, is.
achievements or others. helplessness, and so forth. ● Approach the patient at her current level of
anything I do. That is Refocus attention to areas functioning.
why I'm not giving my of control and progress. ● Use simple and direct instructions.
best anymore and just ● Monitor client’s behavior ● Implement a scheduled routine every day.
going with the flow” as and assist in using stress ● Avoid stimulating or distracting settings.
verbalized by the management techniques. ● Give positive reinforcements.
patient. Long-Term: ● Encourage physical activity.
● Provide for / emphasize the Collaborative:
Objective: importance of pacing ● Help the patient build self-esteem.
Vital Signs learning activities and ● Help the patient get the most out of school.
BP: 120/80 mmHg having appropriate rest. ● Help the patient get things done.
RR: 18 bpm Source:
PR: 85 bpm https://nurseslabs.com/attention-deficit-hyperactivit
TEMP.: 36.3 ‘C y-disorder/#nursing_management

Patient wanders off,

lacks persistence and
has difficulty sustaining
focus.