ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Disturb though SHORT TERM  Instructed SO  To secure that  After 5hrs of
N/A process related to GOAL: After 4-5hrs not to leave the pt. will be nursing
accumulation of of nursing the pt. safe. intervention
Objective: toxin intervention  Raised side pt. was free
 Disorientation patient will be free rails. from any
to place and from any injury. injuries.
situation  Ascertain  To provide
LONG TERM GOAL: from SO pt. comparison to  After 4 days
 Altered After 3-4 days of usual level of evaluate of nursing
attention effective nursing mentation. progression of intervention
span intervention pt. impairment. pt. was need
would regain more further
optimal level of  Minimizes evaluation.
mentation.  Provide quiet environmental
and calm stimuli to
environment. reduce sensory
overload.

 To aid in
 Reorient recognition of
surrounding reality.
and person.
 Aid in reducing
 Communicate confusion, and
in simple and increases
short possibility that
sentences. communication
will be
understood.

 Promote  Sleep
adequate rest deprivation
and may further
undisturbed impair
period of cognitive
sleep. abilities.