Assessment Nursing

diagnosis
Planning Intervention Rationale Expected outcome
Subjective cues:
May maingay kasi
sir as stated by
the patient when
asked why he is
clutching his head
down.

Objective cues:
Patient is
clutching
is head
down and
holding
his ears
while
looking on
the floor
Disturbed
thought
process related
to
undifferentiate
d schizophrenia
as manifested
my auditory
hallucinations
After series of nursing
intervention the client
will be able to:
Recognize
changes in
thinking/beha
viour
Verbalize
understanding
of causative
factors when
known
Identify
intervention
to deal
effectively
with situation
Maintain
usual reality
orientation
Establish NPI
Assess
causative/contrib
uting factors
Assess attention
span/distractibilit
y and ability to
make decisions or
problem solve.
Re orient to
time/places/pers
on, as needed
Schedule
structured
activity and rest
period
Maintain a
pleasant, quiet
environment and
approach client in
a slow, calm
manner
Present reality
concisely and
briefly and do not
challenge illogical
thinking.
Reduced
provocative
stimuli, negative
criticism,
arguments and
To build trust and
cooperation.
For the nurse
know which
factors contribute
to the condition
Determines
ability to
participate in
planning/executin
g care
Inability to
maintain
orientation is a
sign of
deterioration
Provides
stimulation while
reducing fatigue
Client may
respond with
anxious or
aggressive
behaviour if
startled or
overstimulated
Defensive
reaction may
result
Pharmacologic
intervention
After series of nursing
intervention the client
is able to:
Recognize
changes in
thinking/beha
viour
Verbalize
understanding
of causative
factors when
known
Identify
intervention
to deal
effectively
with situation
Maintain
usual reality
orientation
confrontation.
Give medications
as ordered
















Assessment Nursing
diagnosis
Planning Intervention Rationale Expected outcome
Subjective cues:

Objective cues:
Patient is
deprive of
family
interaction
for 3 years
Risk for
loneliness
related to
affectional
deprivation
as
manifested
by no family
visit since
admission
for the last
3 years
After series of nursing
intervention the client will
be able to:
Identify individual
difficulties and
ways to address
them.
Engage in social
activities
Report
involvement in
interaction/relation
ship client views as
meaningful.
Establish NPI
Note clients
age and
duration of
problem: that
is, situational
or chronic

Discuss
individual
concerns
about
feelings pf
loneliness
and
desire/willing
ness beween
loneliness
and lack of
SO.

Involve in
activities,
such as
assertiveness,
language,
communicati
To build trust
and
cooperation.
Elderly
individuals
incur multiple
losses
associated
with aging,
loss of spouse,
decline in
physical health
and changes in
roles
intensifying
feelings of
loneliness.
Motivation
can impede or
facilitate
achieving
desired
outcomes.
Dres individual
needs/enhanc
After series of nursing
intervention the client is
able to:
Identify individual
difficulties and
ways to address
them.
Engage in social
activities
Report
involvement in
interaction/relation
ship client views as
meaningful.
on, social
skills.

Identify
individual
strength,
areas of
interest.

Provide
opportunities
for
interactions
in supportive
environment
during initial
attempt to
socialize
e socialization.
Provide
opportunities
for
involvement
with others.
Help reduce
stress,
provides
positive
reinforcement
and facilitates
successful
outcome.






Assessment Nursing
diagnosis
Planning Intervention Rationale Expected outcome
Subjective cues:

Objective cues:
Defective
left eye
Old age
Risk for injury
related to
decrease
eyesight and
developmenta
l age as
manifested by
defective left
eye.
After series of nursing
intervention the client
will be able to:
Verbalize
understanding
of individual
factors that
contribute to
possibility of
injury.
Demonstrate
behaviours,
lifestyle changes
to reduce risk
factors and
protect self from
injury.
Modify
environment as
indicated to
enhance safety.
Be free of injury
Establish NPI
Perform thorough
assessments
regarding safety
issues when
planning for client
care and/or
preparing for
discharge from
care.
Ascertain
knowledge of
safety
needs/injury
prevention and
motivation
Not clients age,
gender,
developmental
age, decision
making ability,
level of
cognition/compet
ence.
Asses clients
muscle strength,
gross and fine
motor
coordination
Provide health
To build
trust and
cooperatio
n.
Failure to
accurately
asses and
intervene
or refer
these
issues can
place the
client at
needless
risk and
creates
negligence
issues for
the health
care
practitione
rs
To prevent
injury in
home
,communit
After series of nursing
intervention the client is
able to:
Verbalize
understanding
of individual
factors that
contribute to
possibility of
injury.
Demonstrate
behaviours,
lifestyle changes
to reduce risk
factors and
protect self from
injury.
Modify
environment as
indicated to
enhance safety.
Be free of injury
care within a
culture of safety


y and work
setting
Affects
clients
ability to
protect self
and/or
others, and
influence
choice of
interventio
n and/or
teaching.
Identify
risk for
walls
Prevent
errors
resulting in
client
injury,
promote
client
safety and
model
safety
behaviors
for client