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Assessment Subjective Data:

Nursing Diagnosis

Rationale

Desired Outcome At the end of 8 hours of nursing interventions, the patient will be able to:

Nursing Intervention
Independent: Dependent:

Justification

Evaluation Goal partially met, the client was able to maintain usual LOC, cognition, and sensory-motor functions, but 8 hour shift was not enough to evaluate further deterioration or reoccurrence of deficits.

Definition:

Objective Data:
Source: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, et. al.

Administer medication

Collaborative: Engage the family in taking


care of the patient.

To create a feeling of being taken cared, express emotions, accept the present condition, and feel a sense of well-being.

Assessment Subjective Data:

Nursing Diagnosis

Rationale

Desired Outcome At the end of 8 hours of nursing intervention, the patient will be able to: Verbalize understanding of situation and individual treatment regimen and safety measures.
.

Nursing Intervention
Independent:
Encourage participation in self-care; occupational, diversional, or recreational activities.

Justification

Evaluation Goal partially met, the client was able to

Definition:
Objective Data:

Enhances self-concept and sense of independence.

verbalize understanding of situation, individual treatment regimen and safety measures. She is also participative when it comes to ADLs and other activities but 8 hours was not enough to evaluate if there is increase strength and if there is development with the function of the affected or compensatory body part.

Source: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, et. al.

Dependent: Collaborative: Consult with physical


therapies regarding active, resistive exercises and client ambulation

Individualized program can


be developed to meet particular needs and deal with deficits in balance, coordination and strength.

Assessment Subjective Data: Wala akong kausap sa loob ng ward Objective Data:
The client will

Nursing Diagnosis Impaired Social Interaction related to absence of available significant others or peers as evidenced by dysfunctional interaction with peers, family, and others.

Rationale

Desired Outcome At the end of 8 hours of nursing intervention, the patient will be able to: Demonstrate techniques and behaviour that enable resumption of activities.

Nursing Intervention
Independent:

Justification

Evaluation Goal partially met, the client was able to verbalize understanding of situation, individual treatment regimen and safety measures.
Client

develop trusting relationship with nurse with in reason able period of time.

Definition:

Source: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, et. al.

Encourage client to express honest feelings in relation to loss of prior level of functioning. Acknowledge pain of loss. Support client through process of grieving.

Spend time with client. This may mean just sitting in silence for a while. Develop a therapeutic nurse-client relationship through frequent, brief contacts and an accepting attitude. Show unconditional positive regard. Provide positive reinforcement for client's voluntary interactions with others.

Your presence may

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

Te ach assertiveness techniques. Interactions with others may be negatively. Your presence may help improve client's perception of self as a worth while person

help improve client's perception of self as a worthwhile person. Your presence, acceptance, and conveyance of positive regard enhance the client's feelings of self-worth. Positive reinforcement enhances selfesteem and encourages repetition of desirable behaviours. Knowledge of assertive techniques could improve clients relationships with others.

demonstrates willingness and desire to socialize with others. Client voluntarily attends group activities. Client approaches others inappropriate manner for one-to-one interaction.

frequently.
Dependent: Give the clients medication. Individualized program can be
developed to meet particular needs and deal with deficits in balance, coordination and strength.

Collaborative: Consult with physician

and therapies regarding to her pass recovery.

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