Nursing

Date Cues Need Objective/Goal Nursing Intervention Evaluation

Diagnosis
J S: A Self-care deficit: By the end of • Maintain privacy during bathing Goal Met
U “hindi ako C bathing/hygiene the interview: as appropriate.
L komportabl T related to lack of The patient
Y e maligo I motivation The patient will ® The need for privacy is verbalized
dito.” As V verbalize the fundamental for most patients. “maliligo na
1 verbalized I importance of ako
5 by the T bathing/hygien • Ensure that needed utensils are mamaya
, client. Y e close by. kasi ang
- baho ko na
2 E ® This conserves energy and ata
0 O: X optimizes safety. (laughed).
1 •Oily hair E Pasensya
0 •Dirty R • Instruct patient to select bath na ha.”
fingernails C time when he or she is rested and
•Oily skin I unhurried.
S
E ® Hurrying may result in
accidents and the energy required
P for these activities may be
A substantial.
T
T • Encourage patient to comb own
E hair (a one-handed task). Suggest
R hairstyles that are low-maintenance.
N
® This enables the patient to
maintain autonomy for as long as
possible.

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• Encourage patient to perform
minimal oral-facial hygiene as soon
after rising as possible. Assist with
brushing teeth and shaving, as
needed.

• Assist patient with care of

fingernails and toenails as required.

® Patients may require

podiatric care to prevent injury to
feet during nail trimming or because
special implements are required to
cut nails.

• Offer frequent encouragement.

® Patients often have difficulty

seeing progress.

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 Nursing
Date Cues Need Objective/Goal Nursing Intervention Evaluation
Diagnosis
J S: C Disturbed Regain/maintain • Use touch and eye Goal Met
U “ano yun? O sensory usual level of contact.
L Pakilakasan G perception: cognition. “siguro dahil
Y ang boses N auditory related ® These gain patient’s to sa sounds
mo. Hindi ko I to excessive Recognize and attention. ko na
1 naiintindihan T environmental correct/compensat pinapalaksan
5 tanong mo I stimuli e for sensory • Reduce or minimize ko sa bahay
, kasi. V impairments. environmental noise. namin.
Pasensya na E Gusto ko
2 ha.” As – Identify external ® Reduce noise so that kasi mag
0 verbalized by P factors that speaker does not have to soundtrip.
1 the client. E contribute to compete to be heard. Sasusunod
0 R alterations in hindi ko na
C sensory perceptual • Face patient in good light lalakasan
O: E abilities and keep hands away from ang volume
• Chang P mouth. para hindi na
e in T rin
sensory U ® This enhances patient’s magreklamo
acuity A use of lip-reading, facial ung ibang
• Impaire L expressions, and gesturing. kapitbahay.”
d As
communica P • Speak close to patient’s verbalized by
tion A "better" ear, as appropriate. the patient
T
T • Avoid shouting or yelling.
E
R ® This prevents
N
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humiliation.

• Use simple language and

short sentences.

• Speak slowly.

• Use grease boards,

computers, or other writing
tools.

® These help
communicate with profoundly
hearing-impaired individuals.

• Provide encouragement
to use hearing aid(s).

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 Nursing
Date Cues Need Objective/Goal Nursing Intervention Evaluation
Diagnosis
J S: S Disturbed sleep After the • Identify specific related factors Goal Met
U “Hirap ako L pattern related to interview the that can contribute to insomnia.
L makatulog. E environmental patient will: “hindi
Y Hindi ako E changes • Evaluate use of caffeine or talaga ako
sanay.” As P Verbalize the alcoholic beverages. sanay
1 verbalized - understanding matulog
5 by the R of sleep ® over indulgence interferes dito.
, client. E impairment with REM sleep Magbabasa
S nalang ako
2 O: T Identify • Identify circumstances that ng
0 • Lac individually interrupt sleep and the frequency at newspaper
1 k of P appropriate which they occur. mamaya
0 energy A interventions to para
• Cha T promote sleep • Determine client’s expectation of makatulog
nges in T adequate sleep ako.” As
affect E said by the
R ® provides opportunity to patient.
N address misconceptions/unrealistic
expectations

• Observe physical signs of

fatigue

• Recommend limiting intake of

chocolate and caffeine/alcoholic
beverages, especially prior to
bedtime.

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 • Limit fluid intake in evening if
nocturia is a problem

® to reduce need for night time

elimination

• Assure client that occasional

sleeplessness should not threaten
health

® worrying about not sleeping

can perpetuate the problem.

• Assist client to develop

individual program of relaxation.
Demonstrate techniques such as
self-hypnosis, visualization,
progressive muscle relaxation.

• Encourage participation in
regular exercise program during day
to aid in stress control/release of
energy.

® Exercise at bedtime may

stimulate rather than relax client and
actually interfere with sleep.

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 • Recommend inclusion of
bedtime snack such as milk or mild
juice, crackers in dietary program.

® This is to reduce sleep

interference from hunger/hypoglycemia

• Suggest that bedroom is to be

used only for sleep, not for working,
watching TV.

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 Nursing
Date Cues Need Objective/Goal Nursing Intervention Evaluation
Diagnosis
J S: C Disturbed At the end of • Encourage patient to Goal Met
U “ikaw ata O thought process the interview communicate own thoughts and
L yung nurse G related to sleep the client will : perceptions with significant others The patient
Y na lumapit N deprivation in the environment. said,
sakin I Recognize “nagkaganito
1 kanina. T changes in ® Validation of patient’s siguro ako
5 Parang I thinking. needs, thoughts, and perceptions dahil hindi
, kamukha V will encourage trust and openness. masiyado
kasi kayo.” E Verbalize ako
2 - understanding • Clarify patient’s nakatulog
0 O: P of causative misperceptions of events and kagabi.
1 Experiencing E factors when situations that may result from Mawawala
0 delusion R known memory impairment. lang din to.
C Itutulog ko
E Identify ® Clarification is necessary nalang to
P interventions to and more easily accepted when mamaya.”
T deal effectively offered in a respectful manner.
U with the
A situation • Orient to time, place, person,
L and situation as needed.

P ® The patient’s ability to orient

A himself or herself may be impaired
T by memory loss.
T
E • Minimize situations that
R provoke anxiety.
N
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 ® Anxiety may impair patient’s
ability to communicate, problem
solve, and reason.

• If patient is experiencing
delusional thinking, assist him or
her in recognizing the delusions.
Acknowledge the delusions without
agreeing to the content of the
delusions.

® Delusions can be anxiety-

provoking and distressing for
patient. It is important to
acknowledge this distress but to
convey that one does not accept
the delusions as real.

• Communicate verbally with

patient by using concrete and
direct words and avoiding gesturing
so the patient is not threatened by
the care provider.

• Encourage patient to inform

staff when experiencing
hallucinations.

® Contact from care provider

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can often distract the patient from
the hallucination.

• Discuss content of the

hallucinations to determine
appropriate interventions.

® The nurse may be able to

take measures that will reduce the
frequency of the
hallucination/delusion (e.g., leaving
the lights on, or the door open).

• Determine whether the

hallucinations are resulting in
thoughts and/or plans to harm
himself or herself or others.

® This enables the nurse to

take protective measures for the
safety of the patient and others.

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 Nursing
Date Cues Need Objective/Goal Nursing Intervention Evaluation
Diagnosis
J S: S Disturbed sleep After the • Identify specific related factors Goal Met
U “Hirap ako L pattern related to interview the that can contribute to insomnia.
L makatulog. E environmental patient will: “hindi
Y Hindi ako E changes • Evaluate use of caffeine or talaga ako
sanay.” As P Verbalize the alcoholic beverages. sanay
1 verbalized - understanding matulog
6 by the R of sleep ® over indulgence interferes dito.
, client. E impairment with REM sleep Magbabasa
S nalang ako
2 O: T Identify • Identify circumstances that ng
0 • Lac individually interrupt sleep and the frequency at newspaper
1 k of P appropriate which they occur. mamaya
0 energy A interventions to para
• Cha T promote sleep • Determine client’s expectation of makatulog
nges in T adequate sleep ako.” As
affect E said by the
R ® provides opportunity to patient.
N address misconceptions/unrealistic
expectations

• Observe physical signs of

fatigue

• Recommend limiting intake of

chocolate and caffeine/alcoholic
beverages, especially prior to
bedtime.

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 • Limit fluid intake in evening if
nocturia is a problem

® to reduce need for night time

elimination

• Assure client that occasional

sleeplessness should not threaten
health

® worrying about not sleeping

can perpetuate the problem.

• Assist client to develop

individual program of relaxation.
Demonstrate techniques such as
self-hypnosis, visualization,
progressive muscle relaxation.

• Encourage participation in
regular exercise program during day
to aid in stress control/release of
energy.

® Exercise at bedtime may

12 | P a g e
 stimulate rather than relax client and
actually interfere with sleep.

• Recommend inclusion of
bedtime snack such as milk or mild
juice, crackers in dietary program.

® This is to reduce sleep

interference from hunger/hypoglycemia

• Suggest that bedroom is to be

used only for sleep, not for working,
watching TV.

13 | P a g e
 Nursing
Date Cues Need Objective/Goal Nursing Intervention Evaluation
Diagnosis
J O: “ayaw H Noncompliance By the end of Determine client’s Goal
U ko uminon E related to health the visit the perception/understanding of the Partially
L kasi iba A beliefs client will: situation. Met
Y ang ipekto L
nito sa T Verbalize Listen to client’s complaints, “o sige,
2 katawan H accurate comments. iinom ako
1 ko.” As knowledge of nang
, verbalized P condition and ® helps to identify client’s gamot
by the E understanding thinking about the treatment regimen mamaya
2 client R of treatment (e.g., may be concerned about side kaso ayaw
0 C regimen. effects of medications or success of ko talaga
1 S: E procedures) ng epekto
0 P Make choices at sa akin.
T level of Identify the factors that interfere with Hindi ko
I readiness the taking medications or lead to lack itutuloy
O based on adherence kung hindi
N accurate ko na
- information. ® Forgetfulness is the most kaya.”
H common reason given for not
E Verbalize complying with the treatment plan.
A commitment to
L mutually agree Note length of illness.
T upon goals and
H treatment plan. ® Individuals tend to become
passive and dependent in long-term,
M Access debilitating illness.
A resources
N appropriately.
A

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G
E Demonstrate Develop therapeutic nurse-client
M progress toward relationship
E desired
N outcomes/goals. ® promotes trust, provides
T atmosphere in which client can freely
express views/concerns.
P
A Provide contract with the client for
T participation in care.
T
E ® enhances commitment to
R follow-through
N

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