Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: After 8 hours of  Establish rapport  To establish an

“wala po kasi yung Risk for self- nursing intervention  Orient patient to effective nurse After 8 hours of
bantay ko, siya po care deficit the patient will time, date and patient nursing intervention
nagaayos niyan related to consistently person interaction. the patient was able to
e”((referring to the performs self-care  Monitor continually  To assess if the understand the
bedside table) as activities and the extent to which patient is lucid to importance of good
verbalized by the consistent with self care deficits process health hygiene and a clean
patient. developmental interfere with the teaching that will environment which
stage as evidenced client’s function. be rendered. she could od
by being dependent  Establish routine  For goal independently as
Objective: in providing self- goals for self-care. orientation evidenced by
 Disorganized care  Encourage client in  This is to verbalization and fixing
bedside wearing slippers or promote good of bedside table and
table any kind of hygiene and bed.
 Do not wear footwear. prevent any
slippers or  Reinforced the further viral
any kind of importance of a infection
foot wear clean and safe  To promote
when environment. healing and
walking  Assist patient in comfort
around the fixing bedside  To clean
ward table. environment and
 Untidy hair  Encourage client to promote comfort
remove 
unnecessary things
on bed.