Nursing Care Plan 2

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective data: Disturbed sensory Short term: -Assessing the -To have a baseline Short term:
perception related After three weeks hearing capabilities assessment of After three weeks
As observed on the to altered sensory of virtual duty, the of the patient hearing capacity. of virtual duty, the
virtual duty, the perception as client will be able to client was able to
patient was evidenced by display focus -Present reality -Delusional patients display focus
distracted and covering his ears without getting concisely and are extremely without getting
displayed an act of as if avoiding to distracted from an briefly and do not sensitive about distracted from an
covering his ears. hear something unknown sound. challenge illogical others and can unknown sound.
thinking. Avoid recognize
Subjective data: Long term: vague or evasive insincerity. This can Long term:
The client will be remarks. lead to evasive The client was able
The client able to assess comments or to identify the
verbalized: himself and to hesitation sound and can
“Parang may perceive if its real reinforces mistrust distinguish if it is
bulong, pinabayaan or not sounds he is or delusions. real or not.
ko lang, Mahina hearing.
lang, pero nawala
na din siya, Wala -Inform the carer or - To promote good
naman, parang family to speak communication
may mabilis lang.” slowly and clearly between the patient
to the patient. and the carer.
Encourage them to
face the patient
while speaking.