CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective SHORT TERM: 1. Determine make 1. Stressors of family Goal met.
“Akong papa kay relationship related Within 4 hours of up of family, length of relationship within a
ikatulo a sa isa katuig to stressful life nursing intervention relationship- parents, household, difficulties At the end of 4 hours of
muuli dayo hubog events the patient will be other members of the with child rearing, nursing intervention the
pajud. Gibyaan nami sa able to verbalize a childhood. older adult needing patient was able to
akong papa og nihawa desire to improve care, and financial verbalize desire to improve
na pud akong mama” as relationship. difficulties can strain relationship.
verbalized by the relationship between
patient LONG TERM: partners.
Within 8 days of 2. Determine each 2. View of self as a
nursing intervention person’s self-image positive or negative After 2 weeks of nursing
the patient will be and locus of control. individual who is in intervention the patient
Objective: able to participate in control or controlled was able participate in
- does not meet therapy sessions to by others influences therapy sessions to learn
developmental goals learn ways to develop behavior. ways to develop
appropriate for family satisfactory 3. Assess emotional 3.This is the ability to satisfactory relationship.
lifecycle stage relationship. intelligence skills of recognize and control
- does not identify each individual. one’s own emotions
partner as a key person and recognize the
emotions of the
others.
4.Provide information 4. Avoids giving
about active listening advice and
technique. encourages other
person to find own
solution, enhancing
self-esteem.
5. Promote non 5. Not placing blame
blameful self- results in a more
disclosure when considerate and
having a discussion. respectful resolution.
 CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective: Disturbed thought Short term:
“Ako ang sunod nga process Within 4 hours of Interact with the Interacting about At the end of 4 hours
Rizal” nursing intervention client on the basis of reality is healthy for nursing intervention the
“Nahike naku ang the client will be able real things, do not the client. client was able to
Masbate paingon to demonstrate dwell on the demonstrated decreased
Ormoc” decreased push of delusional material. push of speech,
“Naa koy nakita na speech, tangentiality, tangentiality, loose
shadow sa dako na loose associations. Recognize client’s Recognizing client’s associations.
halas nga gasunod nako delusions as the perceptions can help
maam” Long term: client’s perception of you understand the Within 2 weeks of nursing
As verbalized by the Within 2 weeks of the environment. feelings he is intervention the client was
client. nursing intervention experiencing. able to demonstrate
the client will be able adequate cognitive
to demonstrate Show empathy Client’s delusions can functioning.
adequate cognitive regarding the client’s be distressing.
functioning. feelings, reassure the Empathy conveys
client of your your caring, interest
Objective: presence and and acceptance of
-Delusions (Religious) acceptance the client.
-Hallucinations
-Loose Associations Ask the client if he Discussion of the
-Push of speech can see that the problems caused by
-Flight of ideas delusions interfere the delusions is a
with or cause focus on the present
problems with his life. and is reality based.

Maintain reality Client may become

orientation without defensive, blocking
confronting client’s opportunity to look at
irrational beliefs. other possibilities
 CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION
Short term: Identify client with -Specific clinical concerns At the end of 4 hours
Subjective: Disturbed sensory Within 4 hours of condition that can have the potential for nursing intervention
“Naay gasunod na perception (visual) r/t nursing intervention affect sensing, altering one or more of the the client verbalized
shadow sa dako na bipolar I disorder the client will be able interpreting and senses with resultant awareness of sensory
bitin saako maam” to: communicating change in reception, needs. Recognized and
- Verbalize awareness stimuli. sensitivity or compensate for
Objective: of sensory needs and interpretation of sensory sensory impairments
-Hallucinations presence of overload input.
(visual) and/or deprivation.
-irritable -Recognize and Review results of - To note presence or After 2 weeks of
correct or sensory & motor possible cause of changes nursing intervention
compensate for neurological testing in response to sensory the client maintained
sensory impairments. and laboratory stimuli usual level of cognition.
studies Pt verbalized
Long term:
After 2 weeks of Observe for - That may indicate
nursing intervention behavioral responses mental/emotional
the client will be able problems
to regain or maintain
usual level of Interpret stimuli and - To assist client to
cognition offer feedback separate reality from
fantasy

Assist client to learn - To promote wellness

effective ways of
coping
 CUES NURSING DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
Short term: Evaluate ability to - Provides At the end of 4 hours of
Subjective: Readiness for Within the 4 hours of understand events information about nursing intervention the
“Makaya raman naku enhanced coping nursing intervention and provide realistic client’s perception client identified effective
ni tanan maam kay the client will be able appraisal of situation. and cognitive ability. coping behaviors currently
naa man koy salig sa to: being used and verbalized
Ginoo” - Identify effective Assess level of - Provides feelings congruent with
coping behaviors anxiety and coping on information for behavior.
currently being used. an ongoing basis. baseline to develop
Objective: - Verbalize feelings plan of care to
- patient has positive congruent with improve coping At the end of 2 weeks of
outlook of life behavior. abilities. nursing intervention the
client met psychological
Active listen and - To determine needs as evidenced by
Long term: clarify client’s accuracy of appropriate expression of
At the end of 2 weeks perceptions of interventions needed. feelings, identification of
of nursing current status. options, and use of
intervention the resources.
client will be able to Discuss desire to - To determine what
meet psychological improve ability to is needed to learn
needs as evidenced manage stressors of new skills of coping.
by appropriate life.
expression of
feelings, Help client develop - Learning the process
identification of problem-solving skills. for problem solving
options, and use of will promote
resources. successful resolution
of potentially
stressful situations
that arise.
 CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATiON
Subjective: Disturbed personal Short term: Ascertain client’s - To assess At the end of 4 hours of
“Ako ang sunod nga identity r/t Within the 4 hours of perception of the causative/contributing nursing intervention the
Rizal kay pareho mig psychiatric disorder. nursing intervention, extent of the threat to factors. client acknowledged threat
mga kaagi” as the client will be able self and how client is to personal identity and
verbalized by the to: handling the situation. verbalized acceptance of
patient - Acknowledge threat changes that have occurred.
to personal identity. Assess availability and - Available support
- Verbalize use of support system can provide
Objective: acceptance of systems. client with the ability At the end of 2 weeks of
- contradictory changes that have to handle current nursing intervention the
personal traits occurred. stressful events and client stated ability to
- ineffective often “talking it out” identify ad accept self.
relationships with an empathetic
Long term: listener will help client
At the end of 2 move forward to
weeks of nursing enhance coping skills.
intervention the
client will be able to Make time to - To assist client to
state ability to listen/active listen manage/deal with the
identify and accept client, encouraging threat.
self. appropriate
expression of feelings,
including anger and
hostility.

Allow client to deal - May be unable to

with the situation in cope with larger
small steps. picture when in stress
overload.
Maintain reality - Client may become
orientation without defensive, blocking
confronting client’s opportunity to look at
irrational beliefs. other possibilities
 DISCHARGE PLAN
Patient’s Name: Adelio Sinadjan Date of discharge:

Condition upon discharge: Nature:Home per request ( ) Discharge Against Medical Advice()

1. Medication Take the prescribed medication in the right times and right dose.
Biperiden 20mg/tab 1tab OD
Na valproate + valproic acid 500mg/tab 2 tabs AM 1 tab PM
Clozapine 100mg/tab 1 tab OD q8h

2. Exercise Do exercises such as walking, stretching and jogging

3. Diet Avoid chocolate containing food and high sugar foods.

4. Health Teaching Teach client & SO about the side effects of the drugs.
Teach the SO to present reality if hallucination occurs.

5. Schedule for next visit Visit hospital if symptoms persisted

6. Spiritual Resume church activity such as attending mass.

Strengthen faith by praying to God. Always ask for guidance

7. Lifestyle Get enough sleep

Maintain positive outlook in life.
Eat nutritious food
Avoid stressful situation

8. Referral Refer to a psychiatrist if there are adverse reactions of drugs.

Refer if symptoms of bipolar I disorder persisted.