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Cues and Clues 1. Client cannot settle in one place 2. Client verbalizes discomfort in the area Clues 3.

Client asks the nurse when he will be able to get out

Nursing diagnosis Disturbed energy field related to disruption of the aura of the person and the environment

Scientific analysis Due to disturbed energy field the client is always tired and sleepy and the client cannot talk to the health personnel that clear cannot also settle in one place and follow commands from the nurse.

Objectives To be able to restore the clients energy field in 1 day To be able to maintain the clients normal energy filed throughout her lifetime To be able to let the patient to have appropriate rest and sleep during the days that he is in the hospital

Interventions 1. Develop therapeutic nurse-client relationship 2. Place client in sitting position without arms or legs crossed 3. Center self physically and psychologic ally 4. Explain the process of answer and question

Rationale 1. To reduce stress 2. To enhance relaxation 3. To promote relaxation 4. To reduce stress when interviewing the client

Evaluation The patient is able to be relaxed in the hospital The patient is now responding well to the with the nurse The patient can now have appropriate rest and sleep

Cues and clues 1. Cclient verbalizes that he wants to recover and get out of the hospital Clues kelan ba ako makakalabas ditto gusto ko nang gumaling at mkauwi na sa pamilya ko

Diagnosis Readiness for enhanced Self care due to the willingness of the patient to obtain optimum health status.

Scientific Rationale The client is eager to be independent when it comes to taking care of himself. Leading to good competence in taking care of himself

Objectives To be able to let the obtain client optimum health status throughout her lifetime. To be able for the patient to be independent when it comes to self care.

Interventions 1. Discuss clients understanding about her situation. 2. Provide accurate/relevant information about current/future needs. 3. Assess for the potential barriers to enhanced participation in self care. 4. Identify individual strengths and skill of the client. 5. Active listening for the clients concern.

Rationale 1. For the nurse to be able to visualize the awareness of the client about her situation. 2. For the client to be able to incorporate self care plans while minimizing problems associated with change. 3. For the nurse and the client to be able to be ready for the possible barriers to optimum health care. 4. For the nurse to be able to know the areas where the client is weak and to be able focus on those better.

Evaluation Client continues to show signs for readiness to enhanced self care

5. To support positive responses by the client and to address concerns.

Cues and Clues


Scientific Rationale





1.client verbalized that he is hearing voices Clues may nagsasabi saaakin na panget daw ako

Impaired thought process related to auditory delusions that seasonally heard by the client

Due to voices that the client seasonally hear, the voices that are not real but he perceives as real, the client is trying to please that voice by acting or doing what the voice is telling him.

To be able to eliminate what the client is hearing To be able to let client understand that what he is hearing is not real To be able to let the client understand that he should not always follow what the voices say

1.determine alcohol or drug use 2. not schedule of drug administration 3. assess attention span/ distractibility and ability to make decisions 4. have a thorough interview 5.reorient to time, place person as needed 6. schedule time for rest and activity 7. maintain a pleasant calm environment and approach the client in slow and calm manner

1. drugs can have direct effect in the CNS 2.may be significant when evaluating cumulative effect/drug interactions 3. determines ability to participate in planning/executive care 4. to provide basis of comparison 5. inability to maintain orientation is sign of deterioration 6. provide stimulation while lessening fatigue 7.client may respond with anxious or aggressive behavior if startled or overstimulated

The client verbalizes that he is not hearing voices anymore The client no longer follow the voices and considers them unreal