Assessme

nt
S:
Nakakahiy
a naman,
mabaho na
yata kili kili
ko, wala
kasing
deodorant
eh. Tapos
wala ring
shampoo
ang kati
tuloy ng ulo
ko. As
verbalized
by the
patient.
O:
-sad facial
expression
-armpits
guarding
-head
scratching
-(+)
dandruff
flakes
-self
conscious

Diagnosis

Planning

Disturbed
body image
related to
unrealistic
perception
of
appearance
as
evidenced
by
verbalizatio
n of
perception
and feeling
towards
ones own
appearance
.

Within 8
hours, the
client will
be able to
have a
clean and
good
appearance
.

Interventi
on
Determine
whether
condition is
permanent
with no
suspection
for
resolution.
Recognize
behaviour
indicative of
overconcern
with body
and its
process.
Have a
client
describe
self, noting
what is
negative.
Be aware of
how client
believes
others see
self.
Health
teaching.

Rationale

Evaluation
After 8
hours, the
client was
able to
perform
good
hygiene and
will
cooperate
to the
procedure
of proper
grooming.

Assessme
nt
S:

Diagnosis

Planning

Interventio
n

Rationale

Evaluation

Disturbed
thought
process
related to
increased
dopaminerg
ic as
manifested
by
disorganize
d thoughts.

Within 2-3
weeks of
nursing
interventio
n the client
will have
maintain
reality
orientation
and identify
interventio
n to deal
effectively
with the
situation.

Tested
abilityto
receive,send
and
appropriately
interpret
communicati
ons.

Determine
ability to
participate
in planning
and
executing
care.

After 2-3
weeks of
nursing
intervention
s, the client
identifies
and
understand
s
intervention
s to
improve
behaviors
and
maikntains
reality
orientation.

Maintain
reality
oriented
relationship
and
environment.

Present
reality
concisely and
briefly and do
not challenge
logical
thinking.
Encouraged
participation
in
resocializatio
n activities.

Client may
respond
with
anxious or
aggressive
behaviours
if started or
over
stimulated
Client may
feel
threatened
and may
withdraw or
rebel.
To maintain
gains and
continue
progress if
tables

Assessme
nt
S: As per
by
informant
patient is
restlessness
, continuous
on shouting,
talking to
herself.
O:
-not
continuous
eye contact
-social
isolation
disorientati
on
-inactivity

Diagnosis

Impaired
social
interaction
related to
mental
health
condition as
manifested
by por
interperson
al action.

Planning

Interventi
on

Rationale

Evaluation

Within 4-6
ours of
nursing
intervention
patient will
regain her
social
functioning.

Assess the
patients
ability to
carry out
activities of
daily living.

To know
how patient
response to
the plan of
care

After 4-6
hours of
nursing
intervention
patient
increased
social
functioning
and
interaction.

Provide a
safe ,
relaxing
environmen
t.

Engage the
patient in
reality
oriented
activities
that involve
human
contact with
her coclient.
Avoid
promoting
dependence
.

Giving
rewards or
recognition.

To minimize
stimuli
thatwill
trigger
symptoms
of disease
of anxiety.

To gain
confidence
of the
patient in
interacting
with other
people.

To meet the
patients
needs but
only do for
the patient
what she
cant do.

This will
help to
improve his
level of
functioning.