ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Disturbed Short Term Independent Independent Short Term

- “Nung nasa Sensory - After 3 days of - Address client by - To preserve client's - After 3 days of
Mapua ako pag Perception nursing name and have sense of identity and nursing intervention
naglalaro kami ng related to intervention the personnel wear name orientation the client was able
basketball dun altered client will tags and reintroduce to maintain reality
pinapatay ko sensory maintain reality self, as needed orientation. Goal
yung mga kalaro perception as orientation was met
ko e, sinasaksak evidenced by - Consider the patient’s - The patient should feel
ko sa mukha” as Delusion Long Term willingness and ability comfortable and for it Long Term
verbalized by the - After 6 days of to participate, to be an effective - After 6 days of
client nursing preference, past strategy, the patient mustnursing intervention
intervention the experiences, and be involved in the the client
Objective client will contraindications planning demonstrated
- Delusion demonstrate before selecting a coping strategies,
- Bizarre Thinking coping strategies specific relaxation expressed delusion
to deal with strategy less frequently,
stressors, interacted and was
expresses - Avoid isolating - To show that patient is able to cooperate
delusional less patient, physically and not alone and is with healthcare
frequently, emotionally supported, and to avoid providers. Goal was
interact and any risk of met.
cooperates with falls/complication
healthcare
providers
- Promote a stable - Patients who receive
environment with continuity have better
continuity of care by healthcare outcomes &
same personnel as to aid in sensory
much as possible perception of the patient
 - To provide the
- Provide safety patient’s safety and
measures as needed; security, comfort
side rails up, adequate
lighting, assistance with
walking
Collaborative
Collaborative - To achieve maximal
- Collaborate with gains in function and
other health team psychosocial well-being
members in providings
rehabilitative therapies
and stimulating
modalities such as
music