NORTH VALLEY COLLEGE FOUNDATION INC.

LANAO KIDAPAPAWAN CITY

NURSING CARE PLAN

Date and Cues Need Diagnosis Planning Intervention Evaluation

Time
September SUBJECTIVE: S Situational At the end of 1. Encourage client GOAL UNMET
27, 2010 “Maulaw man E low 2 to · The patient
@ gyud ko mag pa L self-esteem hours of express honest Was unable to
2:30Pm interview” as F related to nursing feelings in relation verbalize
verbalized by the - cognitive care, the to loss of prior level understanding
patient. P impairment patient of functioning. of things that
E It is the state will: Acknowledge pain lead to current
R in · Verbalize of loss. Support situation
OBJECTIVE: C which an understandin client through · The patient
· Lacking eye E individual g process of grieving. Was unable to
contact P who of things ® Client may be demonstrate
· Lack social T previously that fixed in anger stage behaviors that
interaction I had precipitate of grieving process, Show positive
· Has little interest O positive self- current which is turned self-esteem as
in activities N esteem situation; inward on the self, evidenced by
· Talks only when experience a and resulting in Inability to
asked negative · diminished self- have
feeling Demonstrate esteem. an eye contact
towards self behaviors 2. Devise methods as well as
due that show for Looking down
to a certain positive assisting client to at during
situation self-esteem express feelings the
Handbook of properly.. Activity.
Nursing ® To explore the
Diagnosis by feelings of the
Lynda Juall client thereby
Carpenito- allowing him to
Muyet acknowledge his
own strength and
weakness.
3. Encourage
client's
attempts to
communicate. If
verbalizations are
not
understandable,
express to client
what you think he
or she intended to
say. It may be
necessary to
reorient client
frequently.
® The ability to
communicate
effectively with
others may
enhance self-
esteem.
4. Encourage
reminiscence and
discussion of life
review. Also
discuss present-day
events. Sharing
picture albums, if
possible, is
especially good. ®
Reminiscence and
life review help the
client resume
progression
through
the grief process
associated with
disappointing life
events and
increase
self-esteem as
successes are
reviewed.
5. Encourage
participation in
group activities.
Caregiver may
need to accompany
client
at first, until he or
she feels secure
that
the group members
will be accepting,
regardless of
limitations in verbal
communication.
® Positive
feedback from
group members will
increase
selfesteem.
6. Offer support
and
empathy when
client expresses
embarrassment at
inability to
remember people,
events, and places.
® Focus on
accomplishments
to
lift self-esteem.
7. Encourage client
to be as
independent
as possible in
selfcare
activities.
® The ability to
perform
independently
preserves
selfesteem.
8. Listen to
patient’s
concerns and
verbalizations
without comment
or judgment.
®It enables the
client to develop
trust and thereby
establish
communication
9. Provide feedback
to
client’s negative
feelings.
®To allow the
 client experience a
different view.

NORTH VALLEY COLLEGE FOUNDATION INC.

LANAO KIDAPAPAWAN CITY

NURSING CARE PLAN

Time and Cues Need Diagnosis Planning Intervention Evaluation

Date
Septemb SUBJECTIVE: A Self care After 2 hours 1. Establish rapport. GOAL
er 29, “Makatamad C deficit: of R: to gain client’s trust PARTIALLY
2010 usahay T bathing / nursing care, and facilitate a MET
@ maligo. Wala pa I hygiene the good working After 2 hours
2:30 pm gani ko V related client will be relationship. of
ligo ron. Kapoy I to lack of able 2. Identify reason for nursing care,
pud T motivation to: difficulty in self-care. the
manlimpyo ug Y ® The a) verbaliz R: underlying cause client was able
kuko”, as - patient e self affects choice of to:
verbalized by the E has an care interventions/ a) verbalize
patient. X impaired need strategies. self care
OBJECTIVE: E ability to b) Demon 3. Determine hygienic need
Unkempt hair R provide self strate needs and provide b) but was
noted C care techniq assistance as needed unable to
food stains visible I requisites ues to with activities like demonstrate
on S due to meet care of nails and techniques to
clothing E environment selfcare brushing teeth. meet self-care
untrimmed P al needs R: basic hygienic needs needs.
fingernails A and may be forgotten.
and toenails with T psychological 4. Discuss on importance
visible T factors. of hygiene.
dirt noted E R: makes client aware
R of how hygiene is
N vital in caring for
oneself.
5. Orient client to
different equipment for
self-care like
various toiletries.
R: increases the client’s
awareness of
different materials
for self-care.
6. Let the patient
enumerate his ideas on
the importance of
hygiene.
R: Encourages the
patient to
understand the need
for hygiene.
7. Discuss the possible
negative implications
of not taking a bath
such as infections and
odor.
R: Broadens the
patient’s idea about
the problem and
encourages him to
meet the need.
8. Encourage client to
perform self-care to
the maximum of

ability as defined by
the client. Do not rush
client.
R: promotes
independence and
sense of control,
may decrease
feelings of
helplessness.
9. Allot plenty of time to
perform tasks.
R: cognitive
impairment may
interfere with
ability to manage
even simple
activities.
10. Assist with dressing
neatly or provide
colorful clothes.
R: Enhances esteem
and convey
aliveness.
 NORTH VALLEY COLLEGE FOUNDATION INC.
LANAO KIDAPAPAWAN CITY

NURSING CARE PLAN

Date Cues Need Diagnosis Planning Interventions Evaluation
and s
Time
SUBJECTIVE C Disturbed At the end of 2 1. Be sincere and GOAL
“Magpatambal ko. O thought hours of honest when PARTIALLY
Kani G process nursing communicating MET
man gud akong N related to care, the with the client. · The client
utok, naa I disintegration patient ®Clients are was able to
niy grasa.” as T thinking. will be able to extremely maintain
verbalized I · Maintain sensitive reality
by the patient V ® It is the reality about others and orientation.
E disruption in orientation; can recognize He is
OBJECTIVE - cognitive · Demonstrate insincerity. Evasive oriented to
· Delusion of P operations reality based remarks reinforce time when
persecution E and thinking in mistrust. asked what
· Delusion of R activities. verbal and 2. Assess client’s day it is.
paranoia C Cognitive nonverbal nonverbal But he is
· Thought insertion E processes behavior. behavior, still
· Incoherent P include those · Demonstrate such as gestures, preoccupie
speech T mental the ability to facial expression d with his
· Demonstrates a U processes by abstract, and posture. delusions
disturbance in A which conceptualize, ®This assessment about his
sleep pattern L knowledge is reason and may help to meet being
· Presence of acquired. calculate the client’s needs jealous to
auditory These consistent with that cannot be him
hallucinations mental ability to conveyed through The client
processes perform. speech. was not
include reality 3. Encourage the able to
orientation, client to express demonstrat
comprehensio feelings and do not e
n, pry cross examine realitybased
awareness, for information thinking in
and ®Probing verbal and
judgment. A increases nonverbal
disruption in client’s suspicion responses.
these mental and interferes with His
processes the therapeutic mannerism
may relationship is largely
lead to 4. Show empathy observed
inaccurate to and he
interpretation the client’s wasn’t able
s feelings, reassure to establish
of the the client of your eye contact
environment presence and with any of
and may acceptance the
result ®The client’s interviewer.
in an inability experiences can
to be
evaluate distressing.
reality
accurately.
Alterations in
thought
processes are
not limited to
any one age
group,
gender,
or clinical
problem.
(http://www1.
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.
elsevierhealth
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