Nursing Care Plan: Ellen Adarna, Borikat Na Siya. Ga Igat Igat Lang Na Siya"

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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Subjective: Kana si Risk for other Independent:
Ellen Adarna, borikat directed violence Short term goal: 1.Built a trust 1.Trust will help Short term goal:
na siya. Ga igat igat related to command After 1 hour of relationship with the decrease clients fears Goal met. The patient
lang na siya" auditory nursing intervention client as soon as and facilitate was able to
verbalized by the hallucinations, the client will be possible communication understand that her
patient in an angry secondary to bipolar aware that the 2. Established 2. To avoid any actions are
tone II disorder actions are respected space and unconventional considered aggressive
"Ginawa mo naman considered aggressive territory for both happenings, such as and may cause harm
akong boang” as and may cause harm sides to work on. harming the SN or to others, and have
responded by the to others. 3. Aware of the other residents and considered changing
patient after being factors that might provide safe space for or improving as
presented the reality Long term goal: increase the client evidence by the
After 4 days of likelihood or 3. For the awareness patient’s
Objective cues: nursing intervention aggressive behavior of the SN, and a acknowledgement of
Aggressively grabs the the client will including traumatic period of building the action and stating
student nurse’s wrist demonstrate the experiences, unmet tension often not to do it again.
aiming for the watch ability to exercise physical and precedes acting out
to identify the time. internal control over emotional needs and 4. To give patient an Long term goal: Goal
Patient seems to be her behavior frustration expression of met. The patient was
angry when companion approach able to demonstrate
studentcontraindicate, 4. Utilized the usage 5. So that the client breathing exercise
present reality and of therapeutic can try and exercise guided by the student
doesn't know what communication. control of feelings, nurse as a part of the
the patient was trying without expressing in internal exercise to
to say. Patient has a 5. Helped and teach a destructive way. control her behavior
history of violence of patient express their 6. To increase safety
hitting a student. feelings in non- and effectiveness
destructive ways, 7. So that the patient
such as breathing will not be anxious
exercise and happy about her behavior,
thoughts. and be open to the
6. Developed SN.
instruction patient 8. Giving client
technique for carrying assurance that
patient someone is ready to
7. Provided listen to her problem,
assurance to the will make her
patient that you’ll not comfortable sharing
judge or be scared by her emotions and
her actions thoughts.
8. Encouraged the
patient express 9. To have a track of
feelings verbally or the clients day to day
share anything she mood.
feels 10. Valproate is a
9. Advised patient to mood stabilizer
document or write in a
journal the episode of 11. This therapeutic
disruptive behavior or approach aims the
day to day
clients to express
documentation of
moods or tell the their suppressed
student nurse about thoughts and
any episodes. emotions 12. To
Dependent: ensure the safety of
10. Encouraged patient both client, student
to participate in nurse and other
psychotherapy such as residents.
(Art and Occupational )
Collaboration:
11. Collaborate with the
staff member for any possible
outburst of attitude.

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