Date/Time Focus / Focus Data Action Response

Nursing
Diagnosis

February 03, Maladaptive Subjective Cues: 1. Used therapeutic Was able to understand on how
2023 Grieving Patient verbalized: communication to use relaxation technique and
@ 3:00pm “Alam mo Nurse nung buhay pa asawa ko 2. Encouraged patient to physical exercise to promote
lagi akong kinakausap nun, lalo na pag verbalized her feeling and sleep
malungot ako. Nug nawala sya, wala na work through about her
akong makausap kasi yung anak ko hindi situation at her own space The patient mood had improved
naman ako maintindihan kasi ako mismo 3. Administered slightly after administering the
hindi ko maintindihan ang sarili ko.” prescribed medicine medication
(Maria started crying) A. Carbamazepine
Objective Cues: B. Prozac Goal Met
1. Gloomy 4. Advised or taught
2. Dark Circles calming
3. Avoids eye contact measure/relaxation
4. Tired and lays on the bed most of
techniques, soft music,
the time unless instructed to
deep breathing,
get up and do some activities
meditation, and physical
exercises.

Patient Name: Maria Katie Keri Date of admission: 2/16/23

Age: 42 Sex: Female CC: Attempted suicide
Religion: Roman Catholic Attending Physician: Lorreina Eyna