NURSING CARE PLAN CLUES/CUES NURSING DIAGNOSIS Risk for loneliness related to chaotic family relationship secondary to prolonged

hospitalization NURSING GOAL NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ayaw ko na dito, gusto ko na talagang umuwi. As verbalized by the patient. Objective: no visitors since admission Admitted since year 2002

At the end of the nursing interventions, the patient will be able to identify means to lessen loneliness

Assess the following: a. General condition b. Appetite disturbances and ability to concentrate Determine the degree of distress, tension and anxiety Discuss individual concerns about feelings of loneliness

For data

baseline

To identify contributing factors To identify clients feelings in situations in which she experience loneliness

Seen patient verbalizing feelings Seen patient enjoying the activities Seen patient interacting with others Loneliness felt was decreased

Establish NursePatient relationship Encourage client verbalize feelings to

Client may feel free to express her feelings To help release inner feelings

 Identify individual strengths and interest Encourage to have a support group Provide opportunities for interactions in a supportive environment during initial attempts to socialize

To provide opportunity to be involved To have good relationship Helps reduce stress, provides positive reinforcement and facilitates successful outcome.

CLUES/CUES

NURSING DIAGNOSIS

NURSING GOAL

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Altered thought Subjective: Di ko na alam kung process related to anong petsa mental disorder ngayon, miyerkules yata eh, as verbalized by the patient Objective: With Episodes of disorientation With inconsistent answers Cannot focus well With poor judgment With poor thought process

At the time the Evaluated mental status patient will be accordingly to age and discharged, she will mental capacity be able to Assessed attention span, demonstrate and distractibility and ability to improve ability to make decision. participate in therapy Oriented and reoriented to three spheres; time, place and person Provided opportunities to ask question

To assess the Patient is oriented clients condition to time, place and person To assess the Patient is seen in a clients current calm environment mental status Inability to maintain orientation is a sign of deterioration To allow expression of feelings Maintained a pleasant Patient may act approach in a slow and anxiously if over calm manner estimated Maintained a reality Serves as a bridge oriented environment to reality Refrained from activities communication forcing Patient may and threatened withdrawn. feel and

CLUES/CUES

NURSING DIAGNOSIS Impaired skin integrity related to prolonged intake of medications as manifested by dry skin and presence of scratches on both extremities

NURSING GOAL

NURSING INTERVENTIONS Assessed contributing factors to present condition Encouraged on proper personal hygiene

RATIONALE

EVALUATION

Objectives: with fair skin turgor with dry skin Seen scratching at times

At the end of nursing interventions, patient will determine and demonstrate ways on how to prevent occurrence of bruises in the skin

To identify the underlying cause of the disease To help reduce the multiplication of microorganisms

Observed taking a bath during the morning Seen washing her hands

Instructed on frequent hand washing especially before and after eating Instructed to take a bath during the morning Advised not to touch dirty objects

To prevent crosscontamination

To provide comfort and maintain cleanliness To decrease the possibility of microorganisms in entering the body

CLUES/CUES

NURSING DIAGNOSIS Self care deficit; Poor oral hygiene related infrequent oral care secondary to disease process

NURSING GOAL

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Objectives: With poor oral hygiene With foul odor of breath With dental cavities

At the end of nursing interventions, patient will improve hygienic habits of oral health

Assessed contributing factors to present condition Encouraged on personal hygiene proper

To identify the underlying cause of the disease To help reduce the multiplication of microorganisms To know the level of self care To know importance cleanliness the of

Observe d taking a bath during the morning Seen washing her hands

Identified changes of self awareness Prevent client from being messy Assisted client on performance of oral health Provided health education of oral hygiene such as; Proper way of tooth brushing, having dental floss and avoid foods that lead to dental carries

To promote health and cleanliness to patients body To stress the importance of hygiene

CLUES/CUES Subjective: Hindi ko na naala yung iba kong anak eh, as verbalized by the patient

NURSING DIAGNOSIS Impaired Memory related to disturbances in the environmental stimuli secondary to disease condition

NURSING GOAL

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Objectives: With episodes of confabulation during conversation

At the end of nursing interventions, patient will be able to demonstrate ways and techniques on how to tolerate/ verbalize awareness of memory problems

Assessed physical, biochemical, and environmental factors that may be related with memory loss Note clients age and potential for depression Ascertain how client view the problem Assist with treatment of underlying conditions such as electrolyte imbalances Reorient client as needed Assist client in associate learning skills such as practice sessions recalling personal information, reminiscing Refocus attention of control and progress

To identify the underlying cause of the disease To help reduce the multiplication of microorganisms To know the level of self care To know importance cleanliness the of

Observe d taking a bath during the morning Seen washing her hands

To promote health and cleanliness to patients body To stress the importance of hygiene

 Monitor clients behavior and assist in use of stree management techniques Assist client to deal with functional limitations and identify resources