ASSESSMENT Subjective/ Objective

Nurse: Ano nga ulit pangalan ko? Patient: Carla Nurse: Ilang taon ka na? Patient: 19 Nurse: Saan po kayo nakatira? Patient: Sabang Beach, Mandaluyong City. Sensory &Cognition: *Conscious but disoriented to person *Impaired memory on personal information *Poor focus regarding specific topic Attitude: *Withdrawn Thought Process: *blocking *perseveration *inability to recall familiar words, phrases, or names of known persons.

Nursing Diagnosis
Impaired Verbal Communication related to impaired cognitive abilities

Nursing Objectives
Short term outcome: After 8 hours of nursing intervention, the pt will be able to: *Use a form of communication to get needs met and to relate effectively with persons on her environment. * Demonstrate congruent verbal and non-verbal communication *Participate in social activities and group therapies.

Nursing interventions
INDEPENDENT: 1. Assess degree of disorientation to time, place, person, and situation regularly and frequently. 2.Giving information a. Offer the client clear, simple explanations of environmental events, activities and the behaviors of other clients as necessary. 3. Anticipate patient needs and pay attention to non-verbal cues. 4. Give the patient ample time to respond. 5. Face the patient when communicating And maintain eye contact.

Rationale
This will determine the amount of reorientation and intervention the patient will need to evaluate reality accurately. Clear direct explanations of environment events help to lessen the clients suspiciousness and fear or mistrust of the surroundings and other. This can prevent aggressive behavior. The nurse should set aside enough time to attend to all of the details of patient care. Care measures may take longer to complete in the presence of a communication deficit. It may be difficult for patients to respond under pressure; they may need extra time to organize responses, find the correct word, or make necessary language translations. Trust, self-disclosure and feedback, to the degree that dehumanizing communication attitudes are expressed by another to that degree one tend to use assertiveness as a pattern of interaction.

Expected Outcome
Goal met. *The patient used a form of communication to get needs met and to relate effectively with persons on her environment. *The patient demonstrated congruent verbal and nonverbal communication *The patient participated in social activities and group therapies.

6. Encouragement and reassurance to the patient at all times when they are attempting to communicate with you.