ASSESSMENT DIAGNOSIS IMPLIMENTATION EVALUATION

Identification Exploitation Resolution

Orientation

Interventions are planned

The nurses collects a Altered thought The client responds
to relieve anxiety. Positive
detailed history and process to the treatment and
feedback is emphasized.
conducts a through Self care deficit nursing management
Improved communication
physical and mental and socialized more
Impaired social and socializing skills.
status examination to interaction and involved in
taught her importance of
reveal the problems the group activity
Self esteem taking medications and
client faces. disturbance maintenance of hygiene
Knowledge deficit and requested family
Risk for violence, support to improve his
impaired family self esteem.
coping
NURSING PROCESS
Sl ASSESSMENT NURSING GOAL NURSING INTERVENTIONS IMPLEMENTATION EVALUATION
No DIAGNOSIS
1.
Subjective data 1.Establish positive relationship , 1. Established Positive
Patient says “I help the patient develop trust in relationship with the patient by
Developed trust in the
know everything nurse talk.
nurse & others in
and other people Disturbed Patient maintains 2. Provided a planned
community as evident
always tell about thought normal thoughts 2.Provide a planned opportunity for opportunity for interaction in the
by patient experienced
me” process interaction ward.
her feeling
Objective Data related to 3.Planned to identify the
 On MSE presence of 3.Plan to identify the relationship of relationship of reality &
thought block delusions reality and delusion delusion by conversation with
present relative and patient
 Delusion of
Reference and 4. Ignored the delusion
reference present . 4.Ignore the delusion expressed by expressed by the patient.
the patient
5.Talked to patient in simple
5.Talk the patient about her problem understandable voice
Make conversion Simple
Sl ASSESSMENT NURSING GOAL NURSING INTERVENTIONS IMPLEMENTATION EVALUATION
No DIAGNOSIS
2.
Subjective data 1. Develop good IPR with the patient 1. Developed good IPR to the
Patient says “I patient by conversation.
can hear people 2. Assess the sensory perception of 2.Assessed the sensory
Patient could identify
talking about me” Disturbed Help the patient patient perception patient has third
hallucinatory voice from
Objective data sensory to identify person auditory hallucination
reality as evident by
Patient is always perception hallucination
reduced talk &
Whispering hallucination voice from reality 3.Do a thorough MSE 3.MSE done delusion of
hyperactivity
Talking to self related to reference and auditory
Laughing, altered mental hallucination present
listening actively status
& responding 4.Encourage the patient to express 4.Encourage the patient to
his feelings express his feelings
5.Provide calm & quiet environment 5.Provided calm & quite
environment
6.Assess the precipitating factors 6.Assessed the participating
which can cause violence feeling which can cause
violence
7.Provide nursing measures to induce 7.Provided nursing measures to
sleep induce sleep

NURSING NURSING INTERVENTIONS IMPLEMENTATION

ASSESSMENT
 DIAGNOSIS GOAL EVALUATION
.
Subjective data
3 Patient’s father Disturbed 1.Assess the activity level of patient 1.Assessed the patient .patient Helped the patient to
tells “he is not motor activity Help the patient had hyperactivity avoid harm to self and
sitting and lying related to to avoid harm to 2.Develop good IPR with the patient 2. Developed good IPR with others as evidenced
in bed” hyperactivity self and others patient by conversation. from his decreased
Objective Data 3.Encourage to take rest in between 3.Encouraged to take rest in activity level.
hyperactivity activity between activity
always walking
talking 4.Explain about importance of 4.Explained about importance of
herself energy conservation energy conservation
5.Provide calm & quiet environment 5. Provided calm & quiet
environment which induce sleep
and rest.
6.Explain about importance of rest 6. Explained about importance
periods of rest periods.
Sl ASSESSMENT NURSING GOAL NURSING INTERVENTIONS IMPLEMENTATION EVALUATION
No DIAGNOSIS

Subjective data Imbalanced Client maintains 1.Assess the 1.Patient is

4.
Patient says “I am nutrition less normal nutritional intake of patient having poor intake of food Client increased his oral
having thirst. I than body nutritional status 2.Consult with 2.Consulted intake as evident by
need water give requirement dietitian to determine daily calorie dietitian to determine daily eating three meals per
me it” related to requirement calorie requirement day
decreased 3.Encourage client 3.Encouraged
Objective Data intake to eat meals and others client to eat meals & other
Patient is very secondary to foods
restless and weak. over activity. 4.Obtain daily 4.checked daily weight and
weight until weight is stable patients weight is 44kg
5.Consider clients 5.Considered
likes and dislikes Patient’s likes & dislikes.
Patient likes vegetable food.
6.Encourage to 6.Encouraged to
take meal for three times take meals for three times.
7. Provide health education to the 7. Provided health education to
patient and family members the patient and family members
regarding importance of nutritious regarding importance of
food. nutritious food.
5
Subjective data 1.Assess the communication ability 1.Patient is not
Patients father Impaired Patient maintains of patient interested in communication Verbal communication
says “he gets verbal normal verbal and he is hyperactive improved by making an
angry communicatio communication 2.Accept the patient exactly as he is 2.Accepted the attempt to listen the
Very easily and n related to patient exactly as he was patient.
not talk in a thought 3.Use simple and 3.Used simple & brief sentences
normal way” disturbance as brief sentences
Objective Data evidenced by 4.Avoid arguments 4.Avoid arguments
Patient is thought block. 5.Focus on a small topic for 5.Focused on a small topic for
talking but it is discussion discussion
not 6.Help the patient to identify the 6. Helped the patient to find out
understandable remarks which were appreciated by remarks which are appreciated
and not interested others by others.
in communication 7. Encourage him to speak slowly 7. Encouraged him to speak
and with pauses. slowly and with pauses.

ASSESSMENT NURSING GOAL INTERVENTIONS IMPLIMENTATION EVALUATION

DIAGNOSIS

6 . 1. Assess the self care abilities of 1. Assessed self care abilities of

Subjective data Client was demonstrated
the patient. patient. Patient is able to take
Self care
Patient says “I an increased interest in
deficit Client will bath but he is not taking bath.
 didn’t take bath dressing & demonstrate an 2.Encouraged to take daily bath personal hygiene &
for one week” grooming increased interest appearance as evident
2.Encourage to take daily bath
related to
in personal 3.Removed unwanted hairs from by taken bath every day
altered mood
Objective Data and fatigue, hygiene and 3.Remove unwanted hairs from face & shaved of all
Patient wears evidenced by appearance unwanted hairs from
mandible
bad smell
two shirts & one 4.Encourage to wear only one set of 4.Encouraged to wear only one face.
sweat and long
pant hairs are long hairs. dress with thorough cleaning set of clean cloth
& without cut 5.Explained about the
Bad smell of 5.Explain the importance of daily importance of daily bath to he
sweat present, bath patient and family members

6.Provided feedback about

6.Provides feedback about appearance
appearance

NURSING
ASSESSMENT DIAGNOSIS EVALUATION
7 GOAL IMPLIMENTATION
INTERVENTIONS

Subjective data Ineffective

1. Patient had poor individual
Patients parents individual 1.Identify the alteration in Client was identified
Client learns coping. He will always irritable
says “all the time coping related proper coping individual coping coping measures as
 he is angry and not to poor mechanisms and shows anger towards evident by watching TV,
talking properly” impulse parents interact with other
Objective data control 2.Explore way to release stress 2.Encouraged to verbalize his patients etc.
Client is not secondary to feelings & fears
accepting the schizophrenia 3. Discuss the events that lead to 3. Discussed the events that lead
presence of health irritability and anger outbursts. to irritability and anger
workers and he is outbursts.
very angry. 4.Explore the need for medication 4.Explored the need for
& or supportive therapy to improve medication and or supportive
coping skills therapy to improve coping skills
5. Instruct the family members to 5. Instructed the family
show love and affection and be members to show love and
friendly with the client. affection and be friendly with
the client.
6. Involve patient in group 6.involved patient in group
activities. activities like yoga, playing
cricket etc

Sl ASSESSMENT NURSING GOAL NURSING INTERVENTIONS IMPLEMENTATION EVALUATION

No DIAGNOSIS
8.
Subjective Data
Patient says “ I 1.Assess for the non compliance 1.Assessed the client Sometimes
Within 24 hours
don’t want any kind of patient client refused to take
patient took
of medication” Non compliance Within 24 medication
prescribed
related to refusal hours client 2.Instruct the 2. Instructed about the
medication.
Objective Data to take will resume client & family members that importance of taking medication
Patient refused to prescribed taking medication restores bio & its effect
take medication psychotropic prescribed chemical imbalances & reduces
and easily become medication. medication psychotic symptoms
angry 3. Educate client & Family 3. Educated client & family
members about residues about residues secondary the
secondary to noncompliance. non compliance.
Sl ASSESSMENT NURSING GOAL NURSING INTERVENTIONS IMPLEMENTATION EVALUATION
No DIAGNOSIS
9.
Subjective Data 1. Assess for the violence 1. Assessed the patient.
Patients father says” behavior of patient Patient remained nonviolent.
Patient remained non
he is very angry and 2.Remove all sharp objects from 2.Removed all sharp objects
violent
beat every one and Risk for Reduce the the ward from the ward
through everything” violence related risk for 3.Continuously observe the 3.Continuously observed the
to hyperactivity violence & patient patient
Objective Data loosening of keep all 4.Instruct other patients that not 4.Instructed other patients that
Patient is association & patients in to disturb him not to disturb him
Hyperactive, manic episode the ward 5.Assess precipitating talking 5. Verbal communication make
Easily become safely factors of violence him violent
Angry and 6.Provide diversion activities 6. Provided diversion activities
Walking two & fro 7. Administer sedative if needed. like yoga, playing cricket.
in the ward 7.no sedatives administered