ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SELECTED IMPLEMENTED
Subjective:  Social  After the  Assess  assessed  to assess  Goal met.
 “Hindi ko Isolation nursing factors in factors in causative The client
related to interventi patients clients’ life or was able
sila
altered ons the lie that that may contributi to
kilala.” As mental client will may contribute ng factors participat
verbalized status as be able to contribute to sense of e in group
by the manifeste participat to sense helplessnes activities
d by poor e in group of s at his
patient eye activities helplessne  established level of
contact at level of ss  To ability
therapeuti
Objective: ability.  Establish promote
c nurse-
 absent therapeuti trust and
patient
significant c nurse- to allow
relationshi
others patient patient to
p
 sad and relationshi feel free
dull affect p to discuss
 poor eye  Note onset sensitive
 Introduced
contact of mental matters.
patient to
 seeking to illness and  To provide
those with
be alone where role
similar or
recovery models
shared
is and to
interests
anticipate encourage
and other
d or problem
supportive
 condition people. solving
is chronic  Provided
or positive
progressiv reinforcem  To
e ent when encourage
 Introduce patient continuati
patient to makes on of
those with moves efforts
similar or toward
shared others
interests  Promote
and other participati
supportive on in  To
people recreation alleviate
 Provide al and conditions
positive special that
reinforce interest contribute
ment activities to
when in setting patients
patient that sense of
makes patient isolation
moves views as
toward safe
 others
 Promote
participati
on in
recreation
al and
special
interest
activities
in setting
that
patient
views as
safe
 Refer to
therapist
as
appropriat
e
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SELECTED IMPLEMENTED
Subjective:  Disturbed  After the  Assess  assessed  to assess  goal met.
 No thought nursing dietary dietary causative The client
process interventi intake and intake and and remained
subjective
related to ons the nutritional nutritional contributi oriented.
cues. psychologi client will status status ng factors
Objective: cal be able to  Monitor  assessed  to
 Decreased conflicts maintain laboratory attention determine
as usual
ability to evidenced reality values for span and the ability
grasp ideas by orientatio abnormalit distractibil to
 Altered disorienta n. ies ity and participat
tion to
attention  Evaluate ability to e in
time,
span place, mental make planning
 Disoriented date and status decisions and
to time, person
according and executing
date, to age and problem- care
place and developme solve
persons ntal  occurrence  to assess
capacity of degree of
 Assess paranoia, impairmen
attention hallucinati t
span ons and
 Note delusions
 occurrence noted
of  re-oriented  to prevent
paranoia, to time, further
delusions place, deteriorat
and date and ion and to
hallucinati person maximize
ons when level of
 Re-orient needed function
to time,  to create
place,  simple therapeuti
date and directions, c milieu
person short and and assist
when simple patient to
needed sentences develop
 Give given coping
simple strategies
directions,  to convey
using short  listened interest
and simple with and worth
sentences regard to
 Listen with individual
regard  to
 Maintain  promoted promote
 reality- socializatio wellness
oriented n within
relationshi individual
p and limitations
environme
nt

DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 ASSESSMENT SELECTED IMPLEMENTED
Subjective:  ineffective  After the  Determine  Determined  Level of  Goal met
 no health nursing level of level of dependence the
maintenanc interventio dependen dependence may range patient
subjective
e related to ns the ce and and presence from identified
cues. lack of patient presence of complete health
Objective: psychosocia will of developmenta dependence maintenan
 lack of l supports. identify developm l disabilities or ce
necessary ental dysfunctional activities.
knowledge health disabilitie to partial or
regarding maintenan s relative
basic ce  Assess independenc
activities e.
health communic
 To note
practices ation
 Evaluated individual
 unable to skills,
environment adaptation
take ability or
needs
responsibil need for
 To assist
ity for interprete
 Provided time patient to
meeting r
to listen to maintain and
basic  Evaluate
concerns of manage
health for
patient desired
practices substance
health
abuse
practices
 Evaluate
 To prevent
environme
 Socialization regression
nt
 Provide and personal
time to involvement
listen to done  To provide
concerns  Communicatio continuation
of patient n and of care
 Encourage coordination
socializati between
on and healthcare
personal facility team
involveme and
nt community
 Provide healthcare
for providers  To promote
communic  Provided wellness
ation and information
coordinati about
on individual
 Provide healthcare
informatio needs  To meet
n about  Identified patients
individual ways to adapt changing
healthcar exercise needs and
e needs program abilities and
 Identify environment
ways to al concerns
adapt
exercise
program