NURSING CARE PLAN CUES Subjective: “ I have sine! that s"n in #e$te%the&e is a st&ane 'an%(e is a )itch* as ve&ba#i+e! b$ the ,atient-
Objective: D"esn.t &ec"ni+e! ,&esent i##ness N"t "&iente! t" ti'e In"&es SN !u&in inte&acti"n ($iene an! &""'in ne#ecte! S"cia# Is"#ati"n n"te! B#unte! a/e
NURSING DIAGNOSIS Distu&be! th"uht ,&"cesses &e#ate! t" !is&u,ti"n in c"nitive ",e&ati"n an! activities
OBJECTIVES 0ithin "u& ca&e% ,atient )i## be ab#e t" 'aintain usua# &ea#it$ "&ientati"n
INTERVENTION
RATIONALE
Dete&'ine !&u use
Assess !ieta&$ inta1e2nut&iti"na# status Assess Assess the attenti"n attenti"n s,an2!ist&actibi#it$ an! abi#it$ abi#it$ t" 'a1e 'a1e !ecisi"ns N"te behavi"& behavi"& such as unti unti!$ !$ habi habits ts%% s#u& s#u&&i &in n "& s#") s#")e! e! s,eech Re"&i e"&ien entt t" ti'e ti'e%% ,#ace an! ,e&s"n as nee!e! (ave (ave c#ie c#ient nt )&it )&ite e na'e Enc"u&a Enc"u&ae e 3a'i#$ 3a'i#$ t" ,a&tici,ate in &e"&ientati"n Give si',#e !i& !i&ecti ecti"n "ns% s% usin usin sh"&t )"&!s
Listen )ith &ea&!
EVALUATION
D&u D&us s 'a$ 'a$ have have si!e si!e 0ithin "u& ca&e% e/ects that a#te& ,atient )i## be ab#e t" 'aintain usua# th"uht ,&"cess T" T" assess causative &ea#it$ "&ientati"n 3act"&s
T" T" !ete&'ine !ete&'ine the abi#it$ t" ,a&tici,ate in ,#annin "3 ca&e
T" T" assess i',ai&'ent
T" T" ,&event !ete&i"&ati"n
T" T" have a &ec"&! 3"& c"',a&is"n
T" T" 'a4i'i+e #eve# 3uncti"n
T" T" !eve#", st&ateies
T" T" c"nve$ inte&est an! )"&th t" in!ivi!ua#
!e&ee
"3
3u&the&
"3
c",in
55 6 7 a e
Re3&ain 3&"' 3"&cin activities an! c"''unicati"n
T" av"i! the c#ient 3ee#in "3 bein th&eatene! an! t" av"i! ,atient bein )ith!&a) an! &ebe#
NURSING CARE PLAN CUES Subjective: “ Gust" na na1" 'uu#i* as ve&ba#i+e! b$ the ,atient 8,atient )as c&$in )hi#e s,ea1in9
Objective: Sta$e! "n be! '"st "3 the ti'e A#)a$s sta&e b#an1#$ A#)a$s #""1 3"&
NURSING DIAGNOSIS Ine/ective c",in &e#ate! t" ,e&ce,tua#2sens"&$ i',ai&'ent
OBJECTIVES 0ithin "u& ca&e% ,atient )i## be ab#e t" ve&ba#i+e 3ee#ins c"n&uent )ith behavi"&
INTERVENTION Estab#ish the&a,eutic nu&se,atient &e#ati"nshi, Dete&'ine !&u use% a#c"h"# use% s'"1in habits% s#ee,in an! eatin ,atte&ns Assess c#ient.s un!e&stan!in "3 cu&&ent situati"n Use &ea#it$ "&ientati"n an! 'a1e a 3&e;uent
RATIONALE T" ain t&ust an! estab#ish &a,,"&t
T" !ete&'ine !e&ee "3 i',ai&'ent
T" assess c",in s1i##s
T" assist ,atient t" !ea# )ith cu&&ent situati"n
EVALUATION 0ithin "u& ca&e% ,atient )i## be ab#e t" ve&ba#i+e 3ee#ins c"n&uent )ith behavi"&
5< 6 7 a e
he& '"the& D"esn.t inte&act )ith "the& ,atients (as ,""& c",in 'echanis' Lac1 "3 s"cia# s1i##s
&e3e&&a#s "3 ti'e% ,#ace an! ,e&s"n Ca## c#ient b$ na'eAsce&tain h") c#ient ,&e3e&s t" be a!!&esse! A##") c#ient t" &eact in ")n )a$
T" enhance sense "3 se#3 an! ,&"'"te se#3estee' T" ,&"vi!e 3"& 'eetin ,s$ch"#"$ nee!s T" e4,&ess the 3ee#ins "3 the ,atient
Enc"u&ae ve&ba#i+ati"n "3 3ea&s% an4ieties an! 3ee#ins "3 !enia#% !e,&essi"n an! ane&
NURSING CARE PLAN CUES Subjective: “)a#a ,a 1" 1a#i"% )a#a$ aas* as ve&ba#i+e! b$ the ,atient
NURSING DIAGNOSIS Se#3ca&e !e=cit &e#ate! t" ,e&ce,tua# i',ai&'ent
OBJECTIVES 0ithin "u& ca&e% ,atient )i## be ab#e t" ,e&3"&' se#3ca&e activities )ithin #eve# "3 ")n abi#it$
INTERVENTIONS Dete&'ine e4istin c"n!iti"ns2e4t&e' es "3 ae2 !eve#",'enta# abi#it$ t" ca&e 3"& ")n nee!s I!entit$ !e&ee "3
RATIONALE T" i!enti3$ causative 3act"&s
EVALUATION 0ithin "u& ca&e% ,atient )i## be ab#e t" ,e&3"&' se#3ca&e activities )ithin #eve# "3 ")n abi#it$
5> 6 7 a e
Objective:
L"n an! unt&i''e! =ne&nai#s Unc"'be! hai& (as n"t ta1en a bath 0ea&s !i&t$ c#"thes (as !&$ b&itt#e hai&
in!ivi!ua# i',ai&'ent2 3uncti"na# #eve# Dete&'ine in!ivi!ua# st&enths an! s1i##s "3 c#ient 7&"'"te c#ient2SO ,a&tici,ati"n in ,&"b#e' i!enti=cati"n 7#an ti'e 3"& #istenin t" the c#ient2SO 7&"vi!e c"''unicati"n 3"& th"se )h" an inv"#ve in ca&in ,atient 7&"vi!e ,&ivac$ !u&in ,e&s"na# ca&e activities Revie) sa3et$ c"nce&ns- ?"!i3$ activities
T" assess !e&ee "3 !isabi#it$
T" assess the !e&ee "3 the ,atient can !"
T" enhance c"''it'ent t" ,#an% ",ti'i+in "utc"'es
T" !isc"ve& ba&&ie&s in &ei'en ,a&tici,ati"n
T" &es,ect ,atient.s !init$
T" &e!uce &is1 "3 inju&$
NURSING CARE PLAN CUES
NURSING DIAGNOSIS
OBJECTIVES
INTERVENTIONS
RATIONALE
EVALUATION 5@ 6 7 a e
N" Subjective cues
Objective:
Sittin a#"ne N"t inte&actin )ith "the& ,atients A,,ea&s #"ne#$ Lac1 "3 se#3 estee' S,ea1 "n#$ 3e) )"&!s
I',ai&e! s"cia# inte&acti"n &e#ate! t" !istu&be! th"uht ,&"cesses an! c"''unicati"n ba&&ie&s 8neu&"#"ica# c"n!iti"n a/ectin the abi#it$ t" c"''unicate9
0ithin "u& ca&e% ,atient )i## be ab#e t" ve&ba#i+e 3act"&s causin i',ai&e! s"cia# inte&acti"n )ith the SNs an! =n! "& !eve#", e/ective s"cia# su,,"&t s$ste' 83a'i#$% &e#atives9 t" he#, ,&"'"te an! enhance s"cia# inte&actin s1i##s
Revie) hist"&$ c#ient2SO
Estab#ish Nu&se 7atient the&a,eutic &e#ati"nshi, I!enti3$ b#"c1s t" s"cia# c"ntacts
s"cia# )ith
Listen )ith &ea&! 7&"vi!e ,"sitive &ein3"&ce'ent )hen c#ient a,,&"ach t" inte&act )ith the SNs 7&"vi!e 3"& "ccasi"na# 3"##") u, Enc"u&ae 3a'i#$ t" inv"#ve ,atient in activities bene=cia# t" he& #i1e c"nstant ve&ba#
T" n"te )hen chanes in s"cia# behavi"& "& ,atte&ns "3 &e#atin "ccu&&e!2bean T" ain the t&ust
0ithin "u& ca&e% ,atient )i## be ab#e t" ve&ba#i+e 3act"&s causin i',ai&e! s"cia# inte&acti"n )ith the SNs an! =n! "& !eve#", e/ective s"cia# su,,"&t s$ste' 83a'i#$% &e#atives9 t" he#, ,&"'"te an! enhance 7atient 'a$ be s"cia# inte&actin s1i##s unab#e t" " "ut% e'ba&&asse! t" be )ith "the&s% an! &e#uctant t" s"#ve these ,&"b#e's T" c"nve$ inte&est T" b""st c#ient.s u&e t" inte&act
T" chec1 i3 c#ient c"ntinu"us#$ inte&act )ith 5 6 7 a e
c"''unicati"n% "& ,a&tici,atin in !"in the h"useh"#! ch"&es
"the&s T" #et the 3a'i#$ he#, the ,atient "ve&c"'e sec#usi"n an! be the c#ient.s aent t" c",e u,
NURSING CARE PLAN CUES
S: n" ve&ba# cues
O: &est#essness n"te!
NURSING DIAGNOSIS
De=cient !ive&si"na# activit$ &e#ate! t" 'e!icati"n &ei'en 'anae'ent
OBJECTIVES
0ithin '$ > h"u&s "3 !ut$% ,atient )i## be ab#e t" enae in satis3$in activities )ithin ,e&s"na# #i'itati"n-
INTERVENTIONS
•
•
!&")siness n"te! #ac1 "3 inte&est n"te! at a/ect n"te! s#")e! &eacti"n
Dete&'ine abi#it$ t" ,a&tici,ate2 inte&est in activities that a&e avai#ab#eAc1n")#e!e &ea#it$ "3 situati"n an! 3ee#ins "3 the c#ient-
RATIONALE
•
•
• •
Revie) hist"&$ "3 activit$2h"bb$ ,&e3e&ences•
T" assess ,&eci,itatin 3act"&-
EVALUATION
A3te& '$ > h"u&s "3 !ut$% ,atient )i## be ab#e t" enae in satis3$in activities )ithin ,e&s"na# #i'itati"n-
T" estab#ish the&a,eutic &e#ati"nshi,-
T" '"tivate an! sti'u#ate c#ient inv"#ve'ent in s"#uti"n T" '"tivate an! 5 6 7 a e
n"te!
•
7&"vi!e 3"& ,h$sica# as )e## as 'enta# !ive&si"na# activitiesE4,#"&e ",ti"ns 3"& use3u# activities usin the ,e&s"n.s st&enth2abi#ities-
sti'u#ate c#ient inv"#ve'ent in s"#uti"n-
•
T" ,&"'"te )e##ness-
5 6 7 a e