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expression offeelings,

identificationof options,

and use ofresources.

Collaborative:

Stress

importanceof follow up

care.

Refer to

outsideresources

and/orprofessional

therapy asindicated/ord

ered.

To promote

wellness.

To

Source:

NANDA

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ASSESSMENT DIAGNOSIS RATIONALE DESIRED

OUTCOME

NURSING

INTERVENTION

JUSTIFICATION EVALUATION

Actual/Abnormal

Findings:

Subjective:Client verbalizes

hindi ko katulogkung kis-a.

Objective:

-fatigue-sleep disturbances

-sleep maintenanceinsomnia

Risk:

-loneliness

-inadequate sleephygiene

-thinking abouthome

Strengths:

-compliance with

medications-financially stable

-good familysupport

Disturbed sleep

pattern r/tpsychological stress

AEB difficulty infalling

asleep/awakeningearlier or later than

desired.

Definition:Disturbed sleep

pattern- timelimited disruption

of sleep (natural,periodic suspension

of consciousness)amount and quality.

Sources:

NANDA

Separation of family

Psychological andemotional stress

Suppression offeelings

Depression

Disturbed sleep

pattern

Source:Medical Surgical

Nursing 7th Edition

After four days of

nursing interventionthe client will be able

to:

Verbalize

understandingof sleep

disturbance.

Identifyindividually

appropriateinterventions

to promotesleep

Adjust

lifestyle to

accommodatechronobiological rhythms

Report

improvementin sleep/rest

pattern

Reportincreased

sense of well

being andfeeling rested.

Independent:

Explainnecessity of

sleepdisturbances for

monitoring vitalsigns.

Provide quietenvironment

and comfortmeasures in

preparation forsleep.

Encourage

participation in

regular exerciseprogram duringday.

Collaborative:

Refer to outsideresources

and/orprofessional

therapy asindicated/order

ed.

To assistclient to

establishoptimal

sleep/restpatterns.

To assistclient to deal

with currentsituation.

To promote

wellness

To

Source:

NANDA

After four days of

nursinginterventions the

client was able to:

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ASSESSMENT DIAGNOSIS RATIONALE DESIRED

OUTCOME

NURSING

INTERVENTION

JUSTIFICATION EVALUATION

Actual/Abnormal

Findings:

Subjective:Client verbalizes

sang una ga las lasko kung depressed

ko

Objective:-fatigue

-sleep disturbances

Risk:

-suicidal

Strengths:

-compliance withmedications

-financially stable-good family

support

Risk for selfdirected violence r/t

altered thought

processes

Definition:

Risk for selfdirected violence-

at risk for behaviorsin which an

individualdemonstrates that

he or she can bephysically or

emotionally and/orsexually harmful to

self.

Sources:

NANDA

Separation of

family

Psychological and

emotional stress

Suppression offeelings

Depression

Risk for self

directed violence

Source:

Medical SurgicalNursing 7th Edition

After four days ofnursing intervention the

client will be able to:

Acknowledgerealities of the

situation.

Express realisticself evaluation

and increasedsense of self

esteem.

Participate incare and meet

own needs in anassertive

manner. Demonstrate

self control as

evidence byrelax posture,

non-violentbehavior.

Use resources

and supportsystems in an

effectivemanner.

Independent:

Observe orlisten for early

cues of distressor increasing

anxiety such asirritability, lack

of cooperation,demanding

behavior, bodyposture or

expression.

Develop

therapeuticnurse-client

relationship.

Maintainstraight forward

communications.

To detectearly signs

of recurrenceof self-

directedviolence and

to implementactions to

avoid it.

Promote

sense oftrust,

allowingclient to

discussfeelings

openly.

To avoidreinforcing

manipulativebehavior.

After four days ofnursing

interventions the

client was able to:

GOAL MET-Patient was able to

verbalizeunderstanding of

why behavioroccurs. The patient

stated that he isaware of why he is

confined in theinstitution that is

sick and needs to becured.

GOAL MET-

Patient was able toexpress realistic self

evaluation andincrease sense of

self esteem becausehe participated in

activities conductedlike art, music and

occupationaltherapy where he

shared a pat of his

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Collaborative:

Regular check-up with

psychologist.

To

encouragepatient to

talk aboutconcerns and

feelings.

Source:NANDA

self.

GOAL MET-Patient was able to

demonstrate selfcontrol because

during the wholeexposure, he

maintained a goodposture, steady gait,

good eye contactand does not use

any hand gesturesduring interactions.