ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for injury At the end of the nursing Assess the degree of Assessing the degree of Goal met as
related to loss intervention the patient impaired ability of impaired ability will help in evidenced by:
“Gusto namon siya of memory, and the folks would be competence, emergence of planning care for the
mabuligan nga language, able to: impulsive behavior and a patient and Impairment of -Folks were able
mangabuhi sang normal problem-solving decrease in visual visual perception increase to identify and
nga malayo sa disgrasya and other -Folks of the patient perception. the risk of falling. remove hazards
kay indi siya makaintindi thinking would be able to Identify with in their
sa amon badlong sa abilities. and remove potential risk Promoting and ensuring home making
iya” as verbalized by in the environment and safety by : Identifying potential risks in the patient free
folks. provide a safe and free of -Assisting the folks of the the environment heightens of injury.
injury environment. patient in identifying the awareness of folks
potential risk/hazards in the about the possible risks. -Folks were able
Objective data -Patient would be able to environment. And Visual-perceptual to provide a
- Disorientation perform ADLs without deficits increase the risk of responsible
acquiring any possible -Eliminating and minimizing falls. person in
-inability to recognize
injuries. identified hazards. (covering supervision and
objects of sharp edges, removing support making
sharp objects nearby, Preventive measures can ADLs less risky.
- inability to identify
providing non- slippery contain patient without
danger in the floors/ minimizing elevated constant supervision. Patient was
ones making room and able to perform
environment
amenities easy to locate) ADLs without
-weakness injury.
- Maintain adequate lighting It allows patient to see and
-balancing difficulties
and clear pathways. find the way around the
room without danger of
-Providing one responsible tripping or falling and even
folks to accompany patient getting lost around the
at all times. area.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

“Indi siya kaintindi Chronic At the end of the nursing -Assess degree of Provides baseline for Goal partially met
sang amon confusion intervention the patient cognitive impairment future evaluation and as evidenced by
instruction, irritable related to and the folks of the patient including changes in comparison and increase in
siya kag kis’a irreversible would be able to: orientation to person, influences choice of cooperation of
nahadlok man siya sa neuronal place, and time and interventions the patient during
amon kag wala gd ga degeneration -Patient Experience a attention span and ADLs and
kooperar” as decrease in level of thinking ability. therapies.
verbalized by folks. frustration, especially when -Note behavioral changes
participating in daily and length of time
activities. problem has existed and
Objective data inform the psychiatrist
-irritablity (short -Patient would be able to upon check- ups (if
tempered) tolerate stimuli when behavior worsens the
- Decreased ability to introduced slowly in need to refer immediately
interpret one’s nonthreatening manner, may arise).
environment with one item at a time. Reduces distorted input,
-Provide a rest conducive whereas crowds, clutter,
-Decreased capacity
Folks of the patient would environment and noise generate
for thought be able to: (free from noise and sensory overload that
- impaired Short term -Verbalize understanding crowd). stresses the impaired
memory about disease process and neurons.
-Disturbed client’s needs.
personality; impaired -Identify and participate in Any provocation
socialization interventions to deal -Reduce provocative decreases self-esteem and
effectively with situation. stimuli, such as negative may be interpreted
-Disturbed
criticism, arguments, and as a threat, which may
interpretation / confrontations. trigger agitation or
response to stimuli increase inappropriate
behavior

-Give simple directions, The communication

one at a time, or step-by- centers in the brain
step instructions, using become impaired,
short words and simple hindering the individual’s
sentences. ability to process and
comprehend complex
messages.

-Health education to the

family/folks of the patient It allows the family to fully
about: understand the client’s
condition.
1. Disease Process
/information and what to
expect.

2. Instruct family to utilize

distraction techniques, -Distraction (divert
such as soothing music, attention) may be
going for a walk, or effective to calm patient if
looking at picture albums stressful situations occur.
if patient has delusions.

3. Instruct family
regarding avoidance of Client may have delusions
arguing with patient and hallucinations, that
about what he thinks, are real to the patient,
 sees, or hears. and no amount of
(Educate folks to assess persuasion will convince
where the need of him or her otherwise. The
medical help is needed patient may become
such as violent or agitated or violent if
aggressive behaviors contradicted.
where sedative or calming
medications are needed).
Hand in active contact
numbers of nearest
medical unit or attending
psychiatrist) .
Dependent:
Memantine 5 mg PO as
prescribed by the
pyschiatrist.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Self Care At the end of the -Identify reason for -Underlying cause affects Goal met as
“nabudlayan siya sa iya deficit related nursing intervention the difficulty in self-care helps in deciding choice evidenced by:
pang adlaw-adlaw nga to cognitive patient and the folks of related to physical of interventions and
pang tatap sa decline and the patient would be limitations in motion, strategies. -Patient was
kaugalingon, kay kis’a physical able to: depression, cognitive able to
natak an siya kag kis’a limitations decline, or environment. perform ADLs
nalipat na siya kung -The patient would be and self care
paano, depende sa able to perform self-care -Basic hygienic needs with minimal
madumduman niya” as activities within level of -Determine hygienic may be forgotten. assistance.
verbalized by folks. own ability with minimal needs and provide Infection, gum disease,
assistance form assistance as needed disheveled appearance, -Folks showed
Objective data folks/caregiver. With activities, including or harm may occur when understanding
-Inability to perform care of hair, nails, and client or caregivers of the client’s
Activities of daily -The folks of the patient skin; brushing teeth, and become frustrated, current
Living(ADL) would be able to cleaning of glasses. irritated, or intimidated condition and
promote feasible Provide reminders for by degree of care the need for
specifically
independence and be elimination need required. Tasks that were assistance by
Bathing/Hygiene
able to assist and guide once easy, such as responsible
eating the patient in performing dressing or bathing, are family
Toileting self care and ADLs when now complicated by member.
Dressing needed. decreased motor skills or
. cognitive and physical
Forgetfulness/Memory changes
loss
-Supervise activities but -Loss of control and
allow as much autonomy independence in this
- Disorientation as possible. self-care activity can
have a great impact on
- Weakness self-esteem and may
limit socialization.

- Provide one responsible This will lessen the risk

folks/caregiver to assist for injury during ADLs
patient during ADLs. and promote proper
understanding and
assistance in performing
ADLs decreasing
confusion and
forgetfulness in the
patient’s perspective.
Assessment Nursing Diagnoses Planning Intervention Rationale Evaluation
Compromised Family After the nursing Assess family’s Knowledge will After the nursing
Subjective: Coping related to intervention the knowledge of enhance family’s intervention the
“busy abi kami tanan Progressive Family members patient’s disease and understanding of family members
permi sa amon will achieve the dementia achieved
dependence of the erratic behaviors, and
trabaho kag wala increased coping associated with increased coping
patient on the family possible violent
permi tawo ang ability concerning the disease and ability concerning
amon balay” as as evidenced by patient’s reactions. development. patient’s dementia
verbalize by the folks withdrawal from dementia and and care needs.
patient at his time of care needs.
need.
Objective:
Assess for level of
Social isolation family’s fatigue,
reduced social -
exposure of family,
feelings about role
reversal in caring for
patient and increasing
demands of patient.

Provide for It promotes

opportunity for family venting of feelings
and reduces
to express concerns
anxiety.
 and lack of control of
situation.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Impaired Verbal After the nursing Monitor the patient for Indicates that After the nursing
Subjective Communication intervention patient nonverbal feelings or needs intervention, the
‘Nabudlayan kami related to will be able to have communication, such are being patient was able
mag intindi sang expressed when to have an
Dementia. effective speech as facial grimacing,
iya gina hambal speech is effective
and understanding smiling, pointing and impaired. communication
kun siya of communication, crying; encourage use as evidenced the
maghala’as or will be able to of speech when patient didn’t
verbalized by the use another possible. stutter and have
folks of the patient. method of Helps to prevent a repetitive
communication and Anticipate patient’s frustration and speech.
Objective: anxiety.
make needs known. needs.
Stuttering Promotes self-
confidence of the
Repetitive speech Use simple, direct patient and will
questions requiring be able to
Difficulty in one-word answers. achieve some
comprehending Repeat and reword degree of speech
communication. or
questions if
communication.
misunderstanding
occurs.
 Promotes
coordinated
breathing pattern
Encourage patient to
breath prior to
speaking, pause
between words.

Avoid rushing the

patient when
struggling to express Helps reduce
feelings and thoughts. feelings of
isolation, which
Encourage patient to then result in
take part in social further
activities. depression and
unwillingness to
communicate.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Disturbed Sleep After the nursing Ensure External stimuli After the nursing
Pattern related to intervention the environment is can interfere with intervention the
“Ganereklamo siya na di siya
environment patient would be quiet, well- sleeping pattern patient have
katulog mayad kun gabi” as stimuli able to achieve ventilated, absence and with frequent achieve and
and maintain of odor, and has awakenings. maintain a
verbalized by the family.
restful sleep comfortable restful sleep
temperature. pattern
Objective:
Provide ritualistic Prevents
Difficulty of falling to sleep procedures of disruption of
warm drink, extra established
Irritability
covers, clean pattern and
linens, or warm promotes comfort
baths prior to and relaxation
bedtime. before sleep.