ASSESSMENT NURSING RATIONALE PLANNING NURSING INTERVENTIONS
DIAGNOSIS
Subjective: Disturbed thought Increased After 6 hours of Independent:
• Verbalized, processes r/t dopamine levels nursing -Monitor client’s vital signs.
“anim anak ko, memory deficit as (dopamine interventions,
nagtrabaho ako, manifested by hypothesis) the patient will -Assess for signs and symptoms of physica
sapatero, binaril confabulation causes disturbed be able to illness.
kamay ko ng hapon.” thought establish contact
Client kept asking of processes. The with reality as -Reorient the client to person, place and
the time, “alas singko dopamine neuro evidenced by: time.
na ba?” transmitter’s
function is for • Responding to -Encourage the patient to perform ADLs
Objective: motor simple (as tolerated) and to participate in
• Client sitting movements, questions decisions about self-care, independence.
on bed, hands sensory • Being able to Provide assistance as appropriate.
clasped together integration and provide self –
• Hands shake emotional care such as -Provide emotional support, positive
when moved behaviors. urinating, reinforcement.
• Inactivity defecating and
• Disorientatio bathing with
n or without -Develop a therapeutic nurse-client
• Mute when supervision relationship through frequent, brief contacts
not asked • Eating food and an accepting attitude. Show
• Reduced from trays and unconditional positive regard.
emotional takes
expression, medications -Spend time with client; sit in silence for a
• In a stare without while.
• Blank facial evidence of
expression mistrust. -Encourage client to verbalize feelings.
• No eye • Continuing
contact when compliance
conversed with with
• Social medication -Help the client reestablish what is real
isolation regimen and unreal. Validate the client’s real
perceptions, and correct the client’s
misperceptions.
Dependent:
-Administer antipsychotic (such as
Risperidone) and other drugs as ordered.
ASSESSMENT NURSING DIAGNOSIS RATIONALE OBJECTIVES NURSING INTERVENTIONS
Subjective: Impaired motor The patient is After 6 hours of Independent:
• “Nandyan activity r/t catalepsy unable to do nursing -Assess degree of immobility produced by
lang yan si tatay di secondary to ADLs or any interventions, the injury/treatment and note patient’s
gumagalaw, catatonic activity due patient will be perception of immobility.
tumatayo lang schezophrenia as alteration in the able to manifest
pagkakain,” as manifested by connections of an optimum
verbalized by the immobility neurons. mobility level as -Monitor vital signs.
staff who takes care Impaired motor evidenced by:
of the client activity is not a -Encourage participation in recreational
disease in itself • Demonstrating activities. Maintain stimulating
Objective: but may be a techniques that environment, e.g., radio, TV, newspapers
• Client sitting characteristic of a enable personal possessions/pictures, clock,
on bed, hands catholic resumption of calendar, and visits from family/friends.
clasped together catatonic. activities
• Hands shake Slowed, limited • Maintaining -Assist with/encourage self-care activities
when moved movement and position of (e.g., bathing, grooming).
• Inactivity report of function
• Disorientatio discomfort • performing
n activities of -Encourage the patient to perform ADLs
• Mute when daily living (as tolerated) and to participate in
not asked (ADLs) and decisions about self-care.
• Reduced desired
emotional activities -Reposition periodically and encourage
expression, • maintaining coughing/deep- breathing exercises.
• In a stare skin integrity
• Blank facial
expression
• No eye
contact when -Encourage the patient to socialize by
conversed with ambulating (assistance is necessary).
• Social
isolation
• Prolonged
sitting position
-Provide the patient with age-appropriate
activities, such as television and reading
materials, other recreational activities
possible.
Dependent:
-Administer antipsychotic (such as
Risperidone) and other drugs as ordered.
.
ASSESSMENT NURSING DIAGNOSIS RATIONALE OBJECTIVES NURSING INTERVENTIONS
Subjective: Social isolation r/t The client After 6 hours of Independent:
• Client did altered mental status experiences nursing -Monitor vital signs.
not want to join any as evidenced by aloneness. He interventions, the
activity that was inability to engage in states that his patient will be -Provide emotional support, positive
provided. Client did personal family is gone able to develop reinforcement.
not want to go relationships, and he doesn’t basic social skills
outside. The staff uncommunicativeness know where they as evidenced by:
mentioned that the and inadequate are anymore.
client just goes out emotional responses. • Answering -Spend time with client; sit in silence for a
for food. When the questions with while.
client was asked appropriate
about his family, answers
client did not
respond and became -Develop a therapeutic nurse-client
teary eyed. “Wala relationship through frequent, brief contacts
na,” as verbalized by and an accepting attitude. Show
the client when unconditional positive regard.
asked about his
family. -Encourage client to verbalize feelings.
Objective:
• Client sitting
on bed, hands Dependent:
clasped together -Administer antipsychotic (such as
• Hands shake Risperidone) and other drugs as ordered.
when moved
• Inactivity
• Disorientatio
n
• Mute when
not asked
• Reduced
emotional
expression,
• In a stare
• Blank facial
expression
• No eye
contact when
conversed with
• Social
isolation
