ASSESSMENT:

● Monitored vital signs

● Assessed patient capability to cooperate and participate in the activities.
● Assessed client’s level of disorientation and confusion to determine specific
requirements for safety. Knowledge of the client's level of functioning is necessary to
formulate an appropriate plan of care.
● Assessed client's level of anxiety and behaviors and factors contributing to it and
determine the types of situations that increase her anxiety
● Assessed the client’s mood and level of energy.
● Assessed and documented moistness and color of oral mucous membranes since
dry, pale mucous membranes may be indicative of malnutrition or dehydration.
● Assessed the client’s level of knowledge regarding positive self care practices and
ability to perform ADL.
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