Ass N Rati Evaluatio

Date/ Time essment Diagnosis Planning ursing Interventions onale n

Subjective: Social Within 8º  Establish  Promotes trust. GOAL PARTIALLY MET

“Usahay gusto span of
D siya na siya lang
isolation r’t
alterations nursing
therapeutic
nurse- After 8º span of nursing
isa, mag sigeg care, the care, the patient was
E kanta kanta” as
in physical
appearance/ patient will
patient
relationship.  To know when able to:
verbalized by be able to:
C father of patient.
mental
status as
 Note onset
of
the patient
needs medical  Responded to

E evidenced
by patient Participate
physical/me
ntal illness
assistance or
aid.
interventions/tea
ching and actions
M having
difficulty in
in
activities/
and where
recovery is
performed.
 Attainment/
B Objective: interacting
with people
programs
at level of
anticipated
or condition  For easy
progress toward
desired
E  avoiding eye even family ability/
desire.
is chronic /
progressive.
building of
rapport and full
outcomes.
 Modifications to
members.
R contact and
facial expression 
 Spend time
visiting with
trust building
from patient.
plan of care.
 Eye contact
 Indifferent to Express patient, and improved but not
affection and increased identify  To fast and maintained.
11 physical contact
 Becomes
sense of
self worth.
other
resources
easy
improvement of
 Participated in
activities
rigid or flaccid available. patient. performed.
when held, cries  Have  Develop  Responded to
2010 when touched,
and shows little
eye
plan of
action with
calling of name.
 Performed
contact
or no interest in patient: sweeping and
improve Look at
human contact and washing of plates
8:00am  His smiling respond to
available
resources;
appropriately,
and following
response is calling of
delayed or support risk- instructions being
name. taking
absent told to him.
behaviors,
 Failure to  financial
form Perform planning,
activities appropriate
interpersonal medical
necessary
relationships. care/self-
in
 Impairment in everyday care, and so
communication living. forth.
verbal and  Provide  Encourages
positive continuation of
nonverbal,
reinforceme efforts.
nonverbal nt when
expressions patient
may be makes
inappropriate or moves
absent. towards
others.
 Bizarre
 Provide  For
responses to the environment appreciation of
environment. al stimuli other people
 Extreme (e.g. open and knowledge
fascination for curtains, of the current
photos, TV, situation in the
objects that
radio) community.
move.  Promote  To have
 participation entertainment
Unreasonable in while
insistence on recreational/ interacting with
following special others in a way
interest that he thinks is
routines in activities in not a danger
precise detail. setting that for him.
 Marked patient
distress over views as
changes in trivial safe.
 Assist  It is necessary
aspects of
patient to for him to know
environment. learn skills. skills important
 Stereotyped  Refer to in everyday
body therapists as living, such as
movements. appropriate. cleaning, and
 Expresses  Involve washing plates.
interests children and  To facilitate
inappropriate to adolescents grief work,
in programs/ relationship
developmental
activities. building, and
age/stage
so on.
 Hostility
 To promote
projected in
socialization
voice/ behavior
skills and peer
 contact.
Preoccupation
with own
thoughts ;
repetitive
meaningless
actions