IX.

Nursing Care Plan

Assessment
Subjective Nakikita ko si Kristo at nakikita ko ang mga aninong santo. as verbalized by the patient. kinakausap ako ng santisima trinidad. As verbalize by the patient. Mabigat ang paa ko kasi pumapasok ang panginoon sa katawan ko. as verbalized by the patient Objective Frequently putting one of his hand over his head

Diagnosis
Disturbed sensory perception related to alteration in function of brain tissue.

Planning
At the end of 2hours of nursing care, the patient will be able to: 1.)Maintain reality orientation

Intervention
1.) Be sincere and honest when communicating with the patient.

Rationale
1.) Patient are extremely sensitive about others and can recognize insincerity. Evasive remarks may reinforce mistrust. 2.)This assessment may help to meet the patients needs That cannot be conveyed through speech

Evaluation
Goal was partially met. At the end of 2hours of nursing care: 1.) The patient was able to maintain reality orientation. He was oriented to time when asked what day it is. As well as the place and the person he was talking to.

2.)Demonstrate reality based thinking in verbal and nonverbal behavior

2.) Assess patient s nonverbal behavior, such as gestures, facial expression and posture.

3.) Give positive feedback for the patients accomplishments.

3.)Positive feedback for success enhances the patients sense of well-being &helps to make nondelusional reality

2.)The patient was still preoccupied with his delusions about religious things and his mannerism of putting one of his hand over his head was largely

 Shows difficulty when walking Frequently tells religious stories and characters 4.) Been consistent in setting expectations and enforcing rules 3.) Encourage the patient to express feelings but do not pry cross examine for information 4. Show empathy to the patients feelings, and acceptance. 4.) Clear, consistent limits provide a secure structure for the patient. Probing increases patients suspicion and interferes with the therapeutic relationship The clients experiences can be distressing. Empathy conveys

observed

Assessment
Subjective Ayokong nakikipag usap sa iba dahil baka saktan lang nila ako as verbalized by the patient Objective Had a scar on his head Lack of social interaction

Diagnosis
Impaired social interaction related to fear of being hurt by other people

Planning
Within three weeks of nursing intervention, the patient will be able to: 1.) Learn to trust other people 2.) Demonstrate effective social interaction skills in both one-on-one and group settings 3.) Will maintain a good relationship with other patients. 4.) Demonstrate appropriate social interactions

Intervention
1.) Establish a trusting relationship with the patient

Rationale
1.) Familiarity with the person and trust can facilitate good communication 2.) Makes the patient feel that you are interested and listening to what he is saying 3.) To increase the patient s abilities and confidence in socializing.

Evaluation
Goal was partially met. After three weeks of nursing interventions and interactions, patient was able to: 1.) Respond to social contacts in the environment such as interacting with his student nurse for a specific period of time. 2.) Interact with other patients during therapy However, he still doesnt want to have conversations with his copatients

2.)Maintain an eye contact when the patient is talking

3.) Provide opportunities for socialization and encourage participation in group activities.

Assessment
Objective Poor hand hygiene practice Dirty nails

Diagnosis
Risk for infection related to poor practice of hand hygiene

Planning
At the end of 2hours of nursing care, the patient will be able to: 1.) Learn and demonstrate proper hand hygiene 2.) Be free from infection

Intervention
1.) Teach the patient how to perform proper hand hygiene

Rationale
1.) It is our first line of defense against infection

Evaluation
Goal was partially met. At the end of 2hours of nursing care, the patient was be able to: 1.) Learn and demonstrate proper hand hygiene but there are some certain steps that he missed 2.) Be free from infection