Professional Documents
Culture Documents
Nursing Diagnosis
Objective
Nursing Intervention
Rationale Accurate baseline data are important in planning care to assist client with this problem
Evaluation
Subjective: Sleep hindi talaga ako Disturbance makatulog sa gabi. to agitation As verbalized by the client
Objective:
Pattern Short term: 1. 1. Keep strict records related With the aid of of sleeping patterns Antipsychotic medication, within 2 home visits, client will be able to exhibit a well-rested feeling 2. 2. Discourage sleep during the day Long term: At the end of 5 home 3. 3. Administer visits client will antidepressant verbalize continuous medication at sleep of at least 6- bedtime 8hrs 4. 4. Perform relaxation techniques to soft music
At the end of 5 home visits objectives were not met but client was sleeping during the final visit so we cannot determine if To promote more interventions were restful sleep at night effective So client may not become drowsy during the day
5. 5. Assist clients with To help client get to measures that may sleep promote sleep, such as warm, nonstimulating drinks, light snacks, warm bath, back rubs 6. 6. Limit intake of caffeinated drinks, such as tea, coffee, and colas Caffeine is a CNS stimulant that may interfere with the clients achievement of rest and sleep
Cues
Nursing Diagnosis
Objective Short term: 7. At the end of 3 home visits client will be able to verbalize understanding reality against delusion Long term: 8. At the end 6 days client will be able to define and test reality, eliminating the occurrence of 9. sensory misperception
Nursing Intervention 1. Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping in midsentence) 2. Avoid touching the client before warning her that you are about to do so 3. An attitude of acceptance will encourage the client to share content of the hallucination with you
Rationale
Evaluation
Subjective: Sensory perceptual ayokong mag lakad alteration related to mag isa kasi sleep deprivation sumusunod sa akin si God, pinaparemind niya ako sa mga kasalanan ko. As verbalized by the client Objective:
Early intervention At the end of may prevent aggressive responses to command hallucinations
Client may perceive touch as threatening and respond in an aggressive manner This is important in order to prevent possible injury to the client or others from command hallucination
10. 11. 4. Do not reinforce Words like they the hallucination. Use may validate that the words as the voices voices are real instead of they when reffering to the hallucinations 12. 5. Try to connect the times of misperception to times of increased anxiety. Help client to If client can learn to interrupt the escalating anxiety, reality orientation may be maintained
understand connection
this
13. 6. Try to distract the Involvement in client away from the interpersonal misperception activities explanation of actual situation bring the client to reality
Cues Subjective:
Nursing Diagnosis Dysfunctional grieving related to feelings of guilt generated by ambivalent relationship with lost concept
Objective Short term: 14. At the end of 3 home visits client will express anger toward lost concept Long term: At the end of 5 visits 15. client will be able to verbalize behaviors associated with the normal stages of grief
Nursing Intervention 1. Determine stage of grief in which client is fixed. Identify behaviors associated with this stage
Rationale Accurate baseline assessment data are necessary to effectively plan care for the grieving client
Evaluation At the end of 5 visits objectives were not met because client was unable to resolve ambivalent feelings towards mother.
Objective:
2. Develop trusting Trust is the basis for relationship with the therapeutic client. Show empathy communication and be caring. Be honest and keep promises An accepting attitude conveys to the client that you believe she is a worthwhile person. Trust is enhanced Verbalization of feeling is nonthreatening environment may help client come to terms with unresolved issues
16. 3. Convey an accepting attitude, and enable the client to express feelings, openly
17. 4. Encourage client to express anger. Do not become defensive if initial expression of anger is displaced on nurse or therapist. Assist client to explore angry feelings so that they may be directed toward the intended object or
person 18. 19. 5. Assist client to discharge pent-up anger through participation in large motor activities (e.g., brisk walks, jogging, physical exercise, volleyball, punching bag, exercise bike) 20. 6. Teach normal stages of grief and behaviors associated with each stage. Help client to understand that feeling such as guilt and anger toward the lost entity are appropriate and acceptable during the grief process Physical exercise provide a safe and effective method for discharging pent-up tension
Knowledge of acceptability of the feelings associated with the normal grieving may help to relieve some of the guilt that these responses generate