XII.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for injury Within 4 hours Assess the In order to The client was
related to of nursing patient’s ability to provide able to
“Hindi ko po blurred vision intervention, see and perform appropriate perform the
alam, hindi ko secondary to the client will activities. assistance and activity well
po masyado old age as not have injury support in and safely.
makita. Kayo na evidenced by while performance of Goal met.
lang po the patient's maintaining the activity.
gumawa”, as report of not the ability to
stated by the seeing clearly. perform Provide sufficient Elderly patients Assisted by
patient during activities and lighting for the need twice as the student
the start of the increase the patient to carry much light as nurses the
activity. likelihood of a out activities. younger patient was
safe people. able to
Moreover, when environment. visualize with
the student Read and To inform the good lighting
nurse asked explain the patient about and complete
what was wrong specific activity the activity. the activity
with his eyes he to the patient. given namely
stated that picture puzzle.
“malabo po”. Assist the patient Goal met.
as necessary To ensure
Objective: when client’s safety.
walking/moving
*Cloudy eyes around the area.
due to aging

*Lost of After 4 hours

sharpness of The client may of nursing
Remove intervention
eyesight hazardous be at risk to
harm the client has
objects from the no evidence of
*Trouble area that may inadvertently.
focusing on injury.
contribute to the
objects risk of injury. Goal met.
*Dizziness

*The patient
somehow
doesn't pay
attention to his
path.
Vital Signs:

BP: 90/60
mmHg
HR:63 bpm
RR: 24 bpm
Temp: 36.5 °C
SpO2: 98%

Date of Admission: July 12, 2022

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Disturbed Within the 4 Use simple and Improve the The Goal Met.
sensory hours of short sentences client’s ability
“Hindi ko po perception nursing while speaking. to After the 4
marinig”, as related to intervention, comprehend hours of
stated by the diminished the client will Lean forward the uttered nursing
patient. hearing be able to near the client’s sentences. intervention,
secondary to experience ears and speak the client was
Objective: old age as improvement clearly with a The client will able to
evidenced by in hearing by normal tone or be able to understand the
*The client leans lack of proper body pitching voice hear clearly uttered
forward when response and positioning, low. and better sentences and
listening inability to gestures and and increase was able to
hear volume of Establish eye the likelihood respond better.
*Observes lack voice. contact, and use of being
of response concrete understood
gestures in
*Inability to hear giving Simple
spoken words instructions. directions will
allow the
patient to
Vital Signs: process the
information
BP: 90/60 mmHg and adhere to
HR:66 bpm the
RR: 20 bpm instructions.
Temp: 36.5
SpO2: 99%
 Date of Admission: July 12, 2022

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Established
Subjective: Impaired social The client therapeutic The first stepAt the end of
interaction will show communication/ in dealing nurse-patient
“Mahiyain po related to comfort relationship with emotions interaction, the
ako”, as stated difficulty on during using positive is to express client was able
by the client. communication communicati regard to the them. to
and social on/social client such as communicate
“Ayoko po interpersonal interaction active listening Encourage better to the
sumali”, client interaction as and and providing a the student nurse,
also added. evidenced by decrease safe continuation show positive
observed anxiety by environment for of desired change such
discomfort in participating self-disclosure. behaviors as smiling and
Objective: social situation in the and efforts for was able to
and anxiety activities. This is to change. participate in
*Dysfunctional provide positive the activities.
social The client interaction for To improve But the patient
interaction with will achieve improvement in the client’s was not totally
others due to positive social behavior social able to hold
discomfort and changes and interactions interaction eye-to-eye
hesitation, such as such as giving deficit. contact, still
anxiety smiling, in encouragement scratches his
social and providing hand and back
behaviors information of his neck.
and Therefore, the
*Emotional interpersonal about a specific goal is partially
blandness (flat relationships activity. met.
affect) in a
structured
*Self- environment
preoccupation, by
especially with interacting
physical with the
functioning student
nurse for 20
*Slouching and minutes
close posture within 4
hours of
*No to the interaction.
moderate eye to
eye contact

*Scratches
hand and neck

Vital Signs:

BP: 100/80
mmHg
HR:68 bpm
RR: 22 bpm
Temp: 36.7
SpO2: 97%

Date of Admission: July 12, 2022

XIII. RECOMMENDATION

● Antipsychotic medications- the patient needs medication to lessen and ease

symptoms such as social anxiety. Monitor side effects of medication especially

for those medications with underlying adverse effects that can worsen the

patient’s condition.
● When communicating with the patient, use simple words and lean forward to

ensure that they can hear and understand what is being said.

● Undergo comprehensive eye exams, especially that the patient is experiencing

blurred vision. Provide assistance when the patient is walking, standing, playing

and doing some activities as necessary to keep the patient's safety in the

environment.

● Maintain a pleasant and quiet environment and approach the client in a

non-threatening manner which is a slow and calm manner.

● Establish and maintain a trusting relationship by listening to the client; displaying

warmth, answering questions directly, offering unconditional acceptance; being

available, and respecting the client’s use of personal space.

● Social Skills Training: the therapeutic approach used to improve interpersonal

relations. The therapy focuses on verbal and nonverbal behaviors common in

social relationships. 

● Psychotherapy: One of the most effective forms of psychotherapy is

cognitive-behavioral therapy. It is a structured, goal-oriented, and didactic form of

therapy that focuses on helping individuals identify and modify characteristic

maladaptive thinking patterns and beliefs that trigger and maintain symptoms.

This form of therapy focuses on building behavioral skills so that patients can

behave and react more adaptively to anxiety-producing situations.

● Cognitive behavioral therapy is defined as "psychotherapy that combines

cognitive therapy with behavior therapy by identifying faulty or maladaptive

patterns of thinking, emotional response, or behavior and substituting them with

desirable patterns of thinking, emotional response, or behavior." It provides a

supportive, non-judgmental, and safe environment that allows you to talk openly

with a mental health professional whose objective and specially trained to help

you with the issues you’re having.