NURSING CARE PLAN – FRONTO-ORBITAL MASS

Cues Nursing Analysis Goal and Nursing Rationale Evaluation

Diagnosis Objectives Intervention
Subjective: Disturbed Thought GOAL: After 8 After 8 hours of
Processes is the state in hours of nursing nursing intervention,
- Client stated which an individual intervention, the was the client able
that, “Opo experiences a disruption in client will be able to to maintain or
ngayon nga such mental activities as maintain or regain regain reality
pong na- conscious thought, reality reality orientation orientation and
ospital ako, orientation, problem-solving, and communicate communicate
talagang judgment, and clearly with others. clearly with others?
minsan comprehension. Acceptability
nagiging __ Yes
makakalimutin A person with traumatic brain __ No
na rin ako.” DISTURBED injuries may be unable to Effectiveness
THOUGHT focus, pay attention, or attend __ Yes
- He also said PROCESSES to more than one thing at a __ No
that, “Minsan related to time and this may result in Adequacy
naman din po head injuries restlessness and being easily __ Yes
kapag may distracted. __ No
mga Efficiency
nagtatanong REFERENCES: Wayne, G., RN. __ Yes
sa akin, gaya (2017, November 10). Disturbed __ No
po niyang Thought Processes. Retrieved Appropriateness
iniinterview from __ Yes
https://nurseslabs.com/disturbed-
niyo po ako, thought-processes/
__ No
minsanpo
hindi ko Neumann, D., PhD, & Lequerica, After 45 minutes of
masundan OBJECTIVES: After nursing
A., PhD. (n.d.). Cognitive
yung tanong.” 45 minutes of interventions, was
Problems after Traumatic Brain
nursing the client able to:
 Injury. Retrieved from interventions, the
https://msktc.org/tbi/factsheets/ client will be able to:
Cognitive-Problems-After-
Objective: Traumatic-Brain-Injury
- Understand the  Provide  Loss of internal structure - Understand the
- The client injury process information (changes in memory, injury process
gets easily in relationship about injury reasoning, and ability to in relationship
distracted to symptoms. process in conceptualize) and fear to symptoms?
then focuses relationship of the unknow affect the Acceptability
attention to to processing and retention __ Yes
other things symptoms. of information and can __ No
during the compound anxiety, Effectiveness
interview. confusion and __ Yes
disorientation. __ No
- The client Adequacy
can’t think REF: Doenges, M. E., __ Yes
straight or Moorhouse, M., & Murr, A. C. __ No
concentrate (2010). Disturbed Thought Efficiency
Processes. In Nursing Care Plans.
when being Guidelines for Individualizing
__ Yes
asked. Client Care Across the Life __ No
Span(8th ed., p. 232). Appropriateness
- The client Philadelphia: F.A. Davis Company. __ Yes
takes too __ No
much time to
respond when
he asked.
- Have safety  Provide  It is always necessary to - Have safety
measures safety consider the safety of the measures?
measures patient. Acceptability
(e.g. side __ Yes
rails, Ref: Wayne, G., RN. (2017, __ No
padding, as November 10). Disturbed Effectiveness
necessary; Thought Processes. Retrieved __ Yes
from
 close https://nurseslabs.com/disturbed- __ No
supervision, thought-processes/ Adequacy
seizure __ Yes
precautions), __ No
as indicated. Efficiency
__ Yes
__ No
Appropriateness
__ Yes
__ No

- Have a  Maintain a  Patient may respond with - Have a

pleasant and pleasant and anxious or aggressive pleasant and
quiet quiet behaviors if startled or quiet
environment. environment overstimulated. environment?
and Acceptability
approach Ref: Wayne, G., RN. (2017, __ Yes
patient in a November 10). Disturbed __ No
Thought Processes. Retrieved
slow and Effectiveness
from
calm https://nurseslabs.com/disturbed- __ Yes
manner. thought-processes/ __ No
Adequacy
__ Yes
__ No
Efficiency
__ Yes
__ No
Appropriateness
__ Yes
__ No
- Maintain  Assist in  This measure is - Maintain
ongoing identifying important to maintain ongoing
treatment ongoing gains and continue treatment
needs. treatment progress if able. needs?
needs/ Acceptability
rehabilitation Ref: Wayne, G., RN. (2017, __ Yes
program for November 10). Disturbed __ No
the Thought Processes. Retrieved Effectiveness
individual. from __ Yes
https://nurseslabs.com/disturbed- __ No
thought-processes/
Adequacy
__ Yes
__ No
Efficiency
__ Yes
__ No
Appropriateness
__ Yes
__ No

- Participate in  Promote  Reinforcement of - Participate in

resocialization socialization positive behaviors, such resocialization
activities/groups within as appropriate activities/groups
when available. individual interaction with others, when
limitations. may be helpful in available?
relearning internal Acceptability
structure. __ Yes
__ No
REF: Doenges, M. E., Effectiveness
Moorhouse, M., & Murr, A. C. __ Yes
(2010). Disturbed Thought __ No
Processes. In Nursing Care Plans. Adequacy
Guidelines for Individualizing
 Client Care Across the Life __ Yes
Span(8th ed., p. 232). __ No
Philadelphia: F.A. Davis Company.
Efficiency
__ Yes
__ No
Appropriateness
__ Yes
__ No

- Understand the
 Verbalization of feelings
- Understand the  Encourage importance of
in a non-threatening
importance of patient to voicing out his
environment may help
voicing out his verbalize true feelings?
client come to terms with
true feelings. true feelings. Acceptability
long-unresolved issues.
__ Yes
__ No
Ref: Wayne, G., RN. (2017,
Effectiveness
November 10). Disturbed
Thought Processes. Retrieved __ Yes
from __ No
https://nurseslabs.com/disturbed- Adequacy
thought-processes/ __ Yes
__ No
Efficiency
__ Yes
__ No
Appropriateness
__ Yes
__ No