ASSESSMENT NURSING GOALS AND INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES
Subjective: Impaired Verbal Within 8 hours of Independent: Within 8 hours of
“Nalilito ako lagi tapos Communication nursing interventions, 1) Establish rapport and therapeutic 1) To make the patient nursing interventions,
parang wala naman related to the client will participate environment more comfortable the client participated
akong naiisip.” altered with the treatment by with the treatment with the treatment by
” as verbalized by the perception as being able to: being able to:
client evidenced by • Cooperate with 2) Use relaxed manner when 2) to decrease and make • Cooperate
Difficulty the activities talking to the client client feel less with the
“Ang nangyari sakin, communication (Playing bingo anxious, which may activities
nagkaroon ng thoughts in the activity reduce the intensity (Playing bingo
disarrangement ang verbally area, Eating of the ritualistic in the activity
brain ko kaya andito with other behaviors.
area, Eating
ako.” as verbalized by patients)
with other
the client • Show interest 3) Encourage client to verbalize 3) To have a better
thoughts, feeling, meaning of patients)
with the understanding of the
“Ako ang kapatid ni treatment and her behaviors and when it condition and can be • Show interest
Jesus, Savior din ako at verbalize its occurs and intensify. a basis for with the
tapos na ang mission ko importance interventions. treatment and
dito.” as verbalized by • Have a talk with verbalize its
the client the student 4) Acknowledge behavior without 4) Lack of attention to importance
nurse for at focusing attention on it. ritualistic behaviors • Have a talk
least 10 mins Verbalize empathy toward can diminish them. with the
Objective: client’s experience rather than student nurse
• Hypoactive disapproval or criticism. for 15 mins
• Difficulty
communication
thoughts Within 3 days of nursing 5) Encourage client to participate 5) To divert her After 3 days of nursing
interventions, the client in activities such as: attention from interventions, the client
verbally
will show an • Playing in the activity area thinking about her will show an
• Altered
improvement with her (BINGO and Charades) condition and make improvement with her
Perception
condition as manifested • Singing her favorite song her concentrate in condition as
• Grandiose and
by: doing other activities manifested by:
Religious that can help her feel Discussing her
• Discussing her •
Delusions thoughts and better. thoughts and
• Soft Voice feelings about feelings about
• Speaks slowly her condition 6) Give positive reinforcement for 6) To help her feel that her condition
• Slow and signs of improvement such as she can do more and Being able to
• Being able to •
minimal participating voluntarily and can feel better talk more than
talk more than
movements her usual daily her usual daily
• Trembling minimal talking being able to accomplish the 7) This serves as a part of minimal
• Staring blankly (one on one activities. her daily exercise as talking (one on
• Laughs interaction with she is a hypoactive one interaction
suddenly at a the student 7) Let the client finish her daily person and wants wo with the
serious topic nurse that can routine according to her time just sleep all day long student nurse
• Prefers to lay in last up to 30 for 30 mins or
the bed and mins or more) more)
sleep most of • Having to speak 8) Encourage client to talk or have • Having to
8) To help reduce feeling
the time louder than interaction with the other speak louder
before female patients. of loneliness
than before
• Engage more • Engage more
with the 9) Nurse patient interaction which with the
activities includes discussing about their 9) To help the client feel
activities
prepared for condition, feelings and better and get to
prepared for
them such as anything that they want to talk know more about her
them such as
singing, playing about. condition and assess
charades and singing,
her current situation
eating together playing
with other charades and
patients. Dependent: eating
1) Administer medications as together with
ordered by the doctor such as: 1) To treat the client’s other patients.
• Clozapine mental health
• Fluphenazine Decanoate condition and helps
control schizophrenia

Collaborative:
1) Collaborate with a Psychiatrist
for further assessment. 1) To provide
comprehensive
2) Collaborate with the nursing assessment and
aids for the other needs of the interventions
client. appropriate for the
patient

2) To make sure that the

DRUG USES ACTION DOSAGE SIDE EFFECTS | PRECAUTION NURSING CONSIDERATIONS

Clozapine Management of Interferes with 100 mg Side Effects: • Contraindicated to 1. Assess for therapeutic
severely ill binding of HS • Drowsiness, patients with response (interest in
schizophrenic pts Dopamine and Per Dizziness, Hypersensitivity to surroundings,
who have failed to serotonin Orem • Hypotension Clozapine. improvement in self-
respond to other receptor sites. • Decreased • History of care, increased ability to
antipsychotic Appetite. Clozapine-induced concentrate, relaxed
therapy. Therapeutic • Confusion, agranulocytosis or facial expression)
Effect: • Diaphoresis, severe 2. Supervise suicidal-risk
Diminishes • Facial granulocytopenia pt closely during early
schizophrenic Flushing, therapy (as depression
behavior • Urinary lessens, energy level
Retention, improves, increasing
• Constipation, suicide potential)
• Dry Mouth, 3. Avoid tasks that require
• Nausea, alertness/motor skills
• Vomiting, until response to the
• Headache, drug is established.
4. Do not abruptly
Adverse Effects: discontinue long-term
• Seizures drug therapy.
• CNS
Depression