AssessmentDiagnosisPlanningInterventionRationaleEvaluation

S: Nakakahiya naman, mabaho na yata kili kili ko, wala kasing deodorant eh. Tapos wala ring shampoo ang kati tuloy ng ulo ko. As verbalized by the patient.

O:-sad facial expression -armpits guarding-head scratching-(+) dandruff flakes-self conscious

Disturbed body image related to unrealistic perception of appearance as evidenced by verbalization of perception and feeling towards ones own appearance.Within 8 hours, the client will be able to have a clean and good appearance.Determine whether condition is permanent with no suspection for resolution.

Recognize behaviour indicative of overconcern with body and its process.

Have a client describe self, noting what is negative. Be aware of how client believes others see self.

Health teaching.

After 8 hours, the client was able to perform good hygiene and will cooperate to the procedure of proper grooming.

AssessmentDiagnosisPlanningInterventionRationaleEvaluation

S: Disturbed thought process related to increased dopaminergic as manifested by disorganized thoughts.Within 2-3 weeks of nursing intervention the client will have maintain reality orientation and identify intervention to deal effectively with the situation.Tested abilityto receive,send and appropriately interpret communications.

Maintain reality oriented relationship and environment.

Present reality concisely and briefly and do not challenge logical thinking.

Encouraged participation in resocialization activities.Determine ability to participate in planning and executing care.

Client may respond with anxious or aggressive behaviours if started or over stimulated

Client may feel threatened and may withdraw or rebel.

To maintain gains and continue progress if tablesAfter 2-3 weeks of nursing interventions, the client identifies and understands interventions to improve behaviors and maikntains reality orientation.

Assessment DiagnosisPlanningInterventionRationaleEvaluation

S: As per by informant patient is restlessness, continuous on shouting, talking to herself.

O:-not continuous eye contact-social isolation-disorientation-inactivityImpaired social interaction related to mental health condition as manifested by por interpersonal action.Within 4-6 ours of nursing intervention patient will regain her social functioning.Assess the patients ability to carry out activities of daily living.

Provide a safe , relaxing environment.

Engage the patient in reality oriented activities that involve human contact with her co-client.

Avoid promoting dependence.

Giving rewards or recognition.To know how patient response to the plan of care

To minimize stimuli thatwill trigger symptoms of disease of anxiety.

To gain confidence of the patient in interacting with other people.

To meet the patients needs but only do for the patient what she cant do.

This will help to improve his level of functioning.After 4-6 hours of nursing intervention patient increased social functioning and interaction.