8/7/2019 NCP Pineds

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Assessment Planning Intervention Rationale Evaluation

Subjective:

Nagbago si tiya Lucypalagi niya akong

pinagagalitan at sinasaktanat wala rin akong kaibigan

as patient verbalized.

Objective : Discomfort in

sharing about her

life

Doesnt use eye

contact in

communicating

Dysfunctional

interaction withfamily and peers

Diagnosis

Impaired Social InteractionRelated to absence of

significant others

Long Term Goal

Supportive Educative

After eight days of nursing

intervention the patient can

socially interact to her

significant others

Facilitate observing the client

while relating tofamily/significant others

Encourage the client to verbalize

perceptions of problemsand causes

Establish therapeutic relationship

using positive regard forthe client, active-listening

& providing safeenvironment for self-

disclosure

Facilitate providing positive

reinforcement forimprovement in social

behaviors & interactions

Facilitate the client

in seeking

programs for client

involvement that

promote positive

behaviors the

client is striving toachieve

To noteprevalent interaction pattern

To assessdegree of impairment

To assist

client/significant others torecognize/ make positive changes

in impaired social andinterpersonal interactions

Encouragecontinuations of desired

behaviors/efforts for change

To promote

wellness

The patients

conditionimproved

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Assessment Planning Intervention Rationale Evaluation

Subjective:

Objective :

Diagnosis

Ineffective coping related to

inadequate or ineffective

support system.

Long Term Goal

Supportive Educative

After ____of nursing

intervention, the patient willbe able to identify helpfulresources and support

systems available on

discharge such as relativesor friends who replaces

dysfunctional.

Protect the client from

harm or injury during

dissociates episodes

Client may become

confused, disoriented, or

frightened during

dissociative episode and

may require safety

measures

Assure the client that she

is not to blame for

behavior that occur

during dissociative state

This assurance will

reduce the clients fear,

guilt and embarrassment

when client is vulnerable

and unable to cope

effectively with internal

conflict.

Assure the client that

staff will remain with the

client during times of

overwhelming anxiety This assurance will

promote feelings of trust,

support and

psychological safety

during stressful times

when the client is too

frighten and confused to

cope effectively

Structure theenvironment to reduce

stimulation, such as loud

noise, bright lights or

To noteprevalent interaction pattern

To assessdegree of impairment

To assistclient/significant others to

recognize/ make positive changesin impaired social and

interpersonal interactions

Encourage

continuations of desiredbehaviors/efforts for change

To promotewellness

The patients

conditionimproved