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Name: A. E. F.

Age: 52 years old

Status: Single

Religion: Roman Catholic

Birth Date: December 1, 1958

Birth Place: Kalibo, Aklan

Education: B.S. Agriculture

Admitted By: Nimfa

Weight on admission: 42kgs.

Referred for: Psychological Assessment

Referred by: Dr. Agustin

Date Examined: June 2, 2011

Diagnosis: Bipolar with Psychotic Features

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NURSING CARE PLAN

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Cues Nursing

Diagnosis

Analysis/

Inference

Goals And

Objectives

Intervention plan

Nursing

Intervention

Rationale Evaluation

SUBJECTIVE:

The clientsaid,

Magkasamanga kami ngnanay ko saBaclarannaglalakad salabas ngsimbahantapos maynakita akongball of light.

She also saidthat herparents diedlast 1978 butthey areactually stillalive.

She also saidthat shegraduated inAklan

AgriculturalCollege andshe wastrained to domarketing jobin their familybusiness

JavlonInternational(firefighting

equipment). She said,

tatlo langkaming

Disturbed

thought

process

related to

unresolved

grief

denial of

anxiety and

depression

as

evidenced

by

ineffectivein assuming

adult roles

and

responsibili

ties;

inappropria

te non-

reality-

basedthinking;

reacts to

problems in

a hysterical

and

exaggerate

d way; and

previous

unfavorableexperiences

.

Cognitiveprocessesinclude those

mentalprocesses bywhichknowledge isacquired.These mentalprocessesincluderealityorientation,comprehensi

on,awareness,and judgment. Adisruption inthese mentalprocessesmay lead toinaccurateinterpretatio

ns of theenvironmentand mayresult in aninability toevaluaterealityaccurately.Wherever thepatient is

encountered,the nurse isresponsiblefor giving atreatment

GOAL:After 8 hoursof nursing

intervention,client will beable todemonstratebehaviours tominimizechanges inmentationand maintainusual realityorientation.

OBJECTIVES:After a shift ofinterventions,the client willbe able to:

a. Understand how tocope with

problemsand reflecta thinkingprocessesoriented inreality.

b. Refrainfromrespondingto

delusionalthoughts,shouldthey occur.

- Assessattentionspan andability tomake

decisions orproblemsolve.

- Reorientpatient totime, place,and person.

- Present

- Determineability toparticipate inplanning ofcare.

- Inability tomaintainorientation isa sign of deterioration.

- Defensereactionsmay result.

After 8 hoursof nursingintervention,

the goal wasmet asevidenced bydemonstrationof behavioursto minimizechanges inmentationand maintainusual realityorientation.