NURSING CARE PLAN

ASSESSMENT Actual/Abnormal Findings: Subjective: Client verbalizes Gatambok na gid ko subong Objective: -fatigue -overweight -sleep disturbances DIAGNOSIS Ineffective individual coping related to inadequate support system as evidenced by disturbances on REM sleep RATIONALE Separation of family Psychological and emotional stress Suppression of feelings Definition: Depression Ineffective individual copinginability to form a Ineffective coping valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. Source: Medical Surgical Sources: Nursing 7th Edition NANDA DESIRED NURSING OUTCOME INTERVENTION After four days of Independent: nursing intervention Evaluate the client will be ability to able to: understand Assess the events, current provide situation realistic accurately. appraisal of situation. Identify ineffective coping Identify behaviors development and al level of consequences functioning. . Verbalize feelings congruent Provide for with quiet behavior. environment/ position Verbalize equipment awareness of out of view own coping as much as abilities possible Meet when anxiety psychologica is increased l needs as by noisy evidenced by surroundings. appropriate JUSTIFICATION To determine degree of impairment. EVALUATION

Risk related factors: -suicidal

To regress to a lower development al stage during illness. To assist client to deal with current situation.

Strengths: -compliance with medications -financially stable -good family support

expression of feelings, identification of options, and use of resources.

Collaborative: Stress importance of follow up care. Refer to outside resources and/or professional therapy as indicated/ord ered.

To promote wellness.

To

Source: NANDA

ASSESSMENT Actual/Abnormal Findings: Subjective: Client verbalizes hindi ko katulog kung kis-a.

DIAGNOSIS Disturbed sleep pattern r/t psychological stress AEB difficulty in falling asleep/awakening earlier or later than desired.

DESIRED OUTCOME After four days of Separation of family nursing intervention the client will be able to: Verbalize Psychological and understanding emotional stress of sleep disturbance. Suppression of feelings Identify individually appropriate interventions to promote sleep Adjust lifestyle to accommodate chronobiologic al rhythms Report improvement in sleep/rest pattern Report increased sense of well being and feeling rested.

RATIONALE

NURSING INTERVENTION Independent: Explain necessity of sleep disturbances for monitoring vital signs. Provide quiet environment and comfort measures in preparation for sleep. Encourage participation in regular exercise program during day.

JUSTIFICATION To assist client to establish optimal sleep/rest patterns. To assist client to deal with current situation.

EVALUATION After four days of nursing interventions the client was able to:

Objective: -fatigue -sleep disturbances -sleep maintenance insomnia Risk: -loneliness -inadequate sleep hygiene -thinking about home Strengths: -compliance with medications -financially stable -good family support Definition: Disturbed sleep pattern- time limited disruption of sleep (natural, periodic suspension of consciousness) amount and quality.

Depression Disturbed sleep pattern Source: Medical Surgical Nursing 7th Edition Sources: NANDA

To promote wellness

Collaborative: Refer to outside To resources and/or professional therapy as indicated/order ed. Source: NANDA

ASSESSMENT Actual/Abnormal Findings: Subjective: Client verbalizes sang una ga las las ko kung depressed ko

DIAGNOSIS Risk for self directed violence r/t altered thought processes

RATIONALE Separation of family

Psychological and emotional stress Definition: Risk for self directed violenceat risk for behaviors in which an individual demonstrates that he or she can be physically or emotionally and/or sexually harmful to self.

Objective: -fatigue -sleep disturbances

Suppression of feelings

Depression

Risk: -suicidal

Risk for self directed violence Source: Medical Surgical Nursing 7th Edition

Strengths: -compliance with medications -financially stable -good family support

Sources: NANDA

DESIRED OUTCOME After four days of nursing intervention the client will be able to: Acknowledge realities of the situation. Express realistic self evaluation and increased sense of self esteem. Participate in care and meet own needs in an assertive manner. Demonstrate self control as evidence by relax posture, non-violent behavior. Use resources and support systems in an effective manner.

NURSING INTERVENTION Independent: Observe or listen for early cues of distress or increasing anxiety such as irritability, lack of cooperation, demanding behavior, body posture or expression. Develop therapeutic nurse-client relationship.

JUSTIFICATION

EVALUATION

Maintain straight forward communication s.

After four days of nursing To detect interventions the early signs of recurrence client was able to: of selfGOAL METdirected violence and Patient was able to to implement verbalize understanding of actions to why behavior avoid it. occurs. The patient stated that he is aware of why he is confined in the institution that is Promote sick and needs to be sense of cured. trust, allowing GOAL METclient to Patient was able to discuss express realistic self feelings evaluation and openly. increase sense of self esteem because To avoid he participated in reinforcing manipulative activities conducted like art, music and behavior. occupational therapy where he shared a pat of his

Collaborative: Regular checkup with psychologist.

self. To encourage patient to talk about concerns and GOAL METPatient was able to feelings. demonstrate self control because during the whole exposure, he Source: maintained a good NANDA posture, steady gait, good eye contact and does not use any hand gestures during interactions.