ASSESSMENT` Subjective— “ kasi yung babaeng gusto ko, hindi ako gusto, si Jackylou. Eh kasi pauwi na kami noon, tapos ihahatid ko sana sya gamit ang motor ko, eh sabi nya may sundo daw sya” “kaya ayun, nalungkot ako ng sobra, nag inom ako, tapos nagwala ako sa bahay dahil sa pag-ibig ko kay Jackylou” Objective: Mood and facial expression : happy and smiling face VS T-35.6 Bp-120/80 Pr-76 RR-18
DIAGNOSIS DISTURBED THOUGHT PROCESSES related to Unresolved grief-denial of depression evidenced by Impaired ability to make decisions, problem solve, reason.
INFERENCE Grief affects all aspects of one's life. Most often, it is the response to loss of a loved one through death or separation. It may also follow the loss of something that is highly valued, such as a job, an object, or status. People often have emotional, physical, and behavioral reactions to an irrevocable loss. Grief usually lessens over time.
PLANNING Short-Term Goal : Within 1 week, client will be able to recognize and verbalize when thinking is non--reality based Long-Term Goal Client will experience no delusional thinking by discharge from treatment. Objectives: 1.Let the client express or verbalized what he/she feels.
IMPLEMENTATION 1.Do not argue or deny the belief. Use reasonable doubt as a therapeutic technique: "I find that hard to believe."
RATIONALE Arguing with the client or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded.
EVALUATION The client was able to experience no delusional thinking by discharge from treatment.
SAMPLE LANG
ASSESSMENT` Subjective: Objective:
DIAGNOSIS RISK FOR INJURY as a result of internal environmental conditions interacting with the individual's adaptive and defensive resources. OR Risk for injury directed at others.
INFERENCE Bipolar disorder involves periods of excitability (mania) alternating with periods of depression. The “mood swings” between mania and depression can be very abrupt. Mania is the signature characteristic of bipolar disorder and, depending on its severity, is how the disorder is classified. People commonly experience an increase in energy and a decreased need for sleep.
PLANNING Short-Term Goal Client's condition will stabilize within 5 days. Long-Term Goal Client will not experience physical injury.
IMPLEMENTATION Assess client's level of disorientation to determine specific requirements for safety. Place client in quiet, private room.
RATIONALE Knowledge of client's level of functioning is necessary to formulate appropriate plan of care Excessive increase agitation. stimuli client
EVALUATION After 5 days of nursing intervention the client’s condition was stabilized.
Institute necessary safety precautions: a. Observe client behaviors frequently; assign staff on one-toone basis if condition is warranted; accompany and assist client when ambulating; use wheelchair for transporting long distances. b.Be sure that side rails are up when client is in bed. c.Pad headboard and side rails of bed with thick towels to protect client in case of seizure. d.Use mechanical restraints as necessary to protect client if excessive hyperactivity accompanies the disorientation. Ensure that smoking materials and other potentially harmful objects are stored outside client's access.
Client safety is nursing priority.
a
Client may harm self or others in disoriented, confused state.
Frequently orient client to reality and surroundings.
Disorientation may endanger client safety if he or she unknowingly wanders away from safe environment.
ASSESSMENT SUBJECTIVE: “Hindi na siya makatulog ilang gabi na.” as verbalized by the nurse.
DIAGNOSIS Disturbed Sleep Pattern related to hyperactivity.
OBJECTIVE: Restlessness noted Dark Circles under eyes Irritability noted Frequent change of mood noted Vital signs T: 36.5 P: 54 R: 12 BP: 110/80
INFERENCE Bipolar disorder involves periods of excitability (mania) alternating with periods of depression. The “mood swings” between mania and depression can be very abrupt. Mania is the signature characteristic of bipolar disorder and, depending on its severity, is how the disorder is classified. People commonly experience an increase in energy and a decreased need for sleep.
PLANNING After 8 hours, patient will be able to report feeling rested and show improvement in sleep / rest pattern.
IMPLEMENTATION INDEPENDENT: Assess past patterns of sleep in normal environment: amount, bedtime, rituals, depth, length, positions, aids, and interfering agents. Documents nursing or caregiver observations of sleeping and wakeful behaviors. Record number of sleep hours. Instruct patient to follow as consistent daily schedule for retiring and arising as possible. Avoid including in the meal alcohol or caffeine as well as heavy meal. Increase daytime physical activities as indicated. Recommend an environment conducive to sleep or rest. COLLABORATIVE Administer sedative as ordered.
RATIONALE Sleep patterns are unique to each individual.
EVALUATION After 8 hours, patient was able to report feeling rested and showed improvement in sleep / rest pattern.
Often, the patients perception of the problem may differ from objective evaluation. This promotes regulation of cardiac rhythm, and reduces the energy required for adaptation changes. Gastric digestion and stimulation from caffeine and nicotine can disturb sleep. This reduces stress and promotes sleep. To promote sleep.
Different drugs are prescribed depending on whether the patient has trouble falling asleep or staying asleep.