NURSING CARE PLAN

CUES NURSING DEFINITIO GOAL AND NURSING RATIONALE EVALUATI

DIAGNOSIS N OBJECTIVES INTERVENTIONS ON

• The client was not  Diturebe  Disru GOAL: T he client

able to answer d ption After 1 month of improve
questions being Thought in nursing thought
asked completely Process cognt intervention, the process,
ive client will be able decrease
• The client has oper improve thought agitation,
reduced Level of ation process, cooperation
Consciousness s and decrease with
activi agitation, interventio
ties. cooperation with ns and
(Nurs interventions and appropriate
e’s appropriate response to
Pock response to questions
et questions about about
Guid recent and past recent and
e events. past
10th events.
ed. OBJECTIVES:
696) After 2 weeks of a. Assess a. Determines Goal met _
nursing attention ability to Goal
intervention, the span and participate partially
client will be ability to in planning met_
able: make care. Goal
decisions or (Nurse’s unmet_
1. To assess problem Pocket
degree of solving Guide 10th
impairmen ed. 697)
t
b. To provide
baseline
b. Interview data
caregiver to (Nurse’s
determine Pocket
client’s usual Guide 10th
thinking ed. 697)
ability,
changes in
behavior,
length of
time
problem has
existed and
other a. Cognitive
pertinent often
information improves
with
a. Assist in treatment
2. To prevent underlying of medical
further problems problems.
deteriorati (Nurse’s
on, Pocket
maximize Guide 10th
level of ed. 697)
function.
b. Early
recognitio
n of
b. Perform changes
periodic promotes
neurologic proactive
assessment modificatio
ns of plan
of care.
(Nurse’s
Pocket
Guide 10th
ed. 698)
c. Inability to
c. Reorient to maintain
time/ orientation
place/person is a sign of
as needed. deteriorati
on
(Nurse’s
Pocket
Guide 10th
ed. 698)
d. Schedule
structured d. Provides
activity and stimulation
rest periods. while
reducing
fatigue
(Nurse’s
Pocket
Guide 10th
a. Maintain ed. 698)
pleasant,
3. To create quiet a. Client may
therapeutic environment respond
milieu and and with
assist approach anxious or
client to client in a aggressive
develop slow, calm behaviors
coping manner. if started
strategies or
– overstimul
especially ated.
when (Nurse’s
condition is Pocket
irreversible Guide 10th
b. Listen ed. 699)
b. To convey
interest
and worth
to
individual
(Nurse’s
c. Present Pocket
reality Guide 10th
concisely ed. 699)
and briefly
and do not c. Defensive
challenge reactions
illogical may result
thinking. (Nurse’s
Pocket
d. Reduce Guide 10th
provocative ed. 699)
stimuli,
negative d. To avoid
criticism, triggering
arguments fight/flight
and result
confrontatio (Nurse’s
ns Pocket
Guide 10th
ed. 699)
e. Refrain from
forcing e. Client may
activities and feel
communicati threatened
ons and may
withdraw
or rebel.
(Nurse’s
Pocket
Guide 10th
f. Provide a ed. 699)
nutritionally
well f. Enhances
balanced intake and
diet. general
Encourage well-being.
client to eat. (Nurse’s
Provide Pocket
pleasant Guide 10th
environment ed. 699)
and allow
sufficient
time to eat.