LOS ANGELES HARBOR COLLEGE ASSOCIATE DEGREE NURSING PROGRAM
Nursing 333
STUDENTNAME: Elizabeth Rojas
Client’s Secondary Roles: Student, son, sibling
(Role assumed in order to complete primary roles; stable, achieved & long term)
NURSING PROCESS
Primary Role: Child
Maturation Stage: Early Childhood (Initiative vs. Guilt)
Developmental Tasks: 1. Establish autonomy and emotional
regulation 2. Develop trust in caregivers and routine 3. Begin
socialization and peer interaction
______________________________________________________
Tertiary Roles: Patient
Psychosocial
Nursing Care Plan (5)
Date(s): 05/06/2025
(Roles that meet the obligations of the secondary roles; roles more apt to change)
______________________________________________________
Stage of Illness: Acute
(Continue the plan of care on the back of this page, if needed)
1st Level Assessment
Behavior
(10)
Subjective Data:
1.“ I don’t like the noises, it
hurts my ears” (patient)
2.Patient yells “No! Don’t
touch me” whenever there’s
an assessment
3.Parent states, “he
complained that the bed
sheets felt too scratchy.”
4.Patient states “I hate it
here!”
Objective Data:
5.Covers ears when exposed
To normal sounds (monitors,
IV pump)
6.Repetitive behaviors such
as rocking or hand flapping
when overstimulated
7.Refuses and physically
resists vital sign checks;
screams and attempts to flee
during assessments."
8.Hides under blankets when
approached
9. Only wants to eat cereal
because everything else is too
“squishy”
2nd Level Assessment
Stimuli
(10)
Nursing
Diagnosis
Autism spectrum disorder
(2)
Disturbed sensory
Perception related to
Autism Spectrum
Disorder secondary to
acute hospitalization
Change in
routine/environment
(4,7,8)
THERAPEUTIC NURSING INTERVENTIONS
Goal Outcome
(5)
Auditory stimulation
(1,5)
As manifested by
Tactile hypersensitivity
(7)
Tactile hypersensitivity
Texture aversion
(3,9)
Physical resistance
during assessments
(5)
The Patient Will:
The patient will
demonstrate improved
sensory regulation
As Evidenced By:
Accepts one new or
previously refused
sensory stimulus
Evaluation (5)
(Nursing activities to achieve outcomes and
(Check Outcomes)
Rationales for interventions)
(10) State Behaviors. Goal met? F/U
I: Maintain a calm, low stimulus environment by dimming
Goal met: Patient
lights, reducing noise, and limiting unnecessary staff in the
tolerated one focus
room.
R: Reduces sensory overload and supports the child’s ability assessment within 6
to self-regulate in a hospital setting.
hours with minimal
I: Use visual communication aids such as pictures when
offering choices or explaining procedures.
R: Enhances understanding and decreases anxiety in children
with limited verbal communication due to ASD.
1.Tolerates at least one
I: Encourage the child to use a preferred comfort object
nursing assessment
during assessments or transitions.
within 6 hours with
R: Familiar objects provide emotional security and help
minimal resistance.
resistance after being
given choices and
shown visual cards
to explain the
procedure.
Goal met: Patient
accepted one
reduce distress during sensory challenges.
previously refused
sensory stimulus by
I: Allow the caregiver to remain at the bedside and
the end of the shift
2. Accepts one new or participate in care activities.
following gradual
previously refused
R: Caregiver presence reduces fear, promotes trust, and
introduction of the
sensory stimulus by the improves cooperation with nursing care.
stimulus using firm,
end of the shift
brief touch and
I: Offer choices when performing care
verbal preparation.
R:
Giving
choices
promotes
autonomy
and
reduces
resistance
3. Engages in one
by
increasing
the
child’s
sense
of
control.
calming coping strategy
Goal met: Patient
during overstimulation I: Gradually introduce tactile stimuli by starting with firm,
used his favorite
within 4 hours.
brief touch and explaining each step before physical contact. elephant toy and
R: Gradual desensitization reduces tactile defensiveness and earmuffs to selfhelps build tolerance to necessary touch-based care.
soothe during
overstimulation
I: Use consistent, predictable handling techniques during
within 4 hours in a
assessments such as assessing in the same sequence, and
quiet, low stimulus
same nurse when possible.
environment.
R: Predictability lowers anxiety and minimizes sensoryCritical Time: 1200
related distress in children with tactile hypersensitivity.
Nsgcp: JS4/03
LOS ANGELES HARBOR COLLEGE ASSOCIATE DEGREE NURSING PROGRAM
STUDENTNAME:_____________________________________
Nursing 333
Client’s Secondary Roles:__________________________________
Primary Role:________________________________________
NURSING PROCESS
______________________________________________________
Psychosocial
Tertiary Roles:___________________________________________
(Role assumed in order to complete primary roles; stable, achieved & long term)
Maturation Stage:_____________________________________
Developmental Tasks: 1._______________________________
2.________________________ 3._______________________
(Roles that meet the obligations of the secondary roles; roles more apt to change)
Nursing Care Plan
______________________________________________________
Date(s):_________________
Stage of Illness:__________________________________________
(Continue the plan of care on the back of this page, if needed)
1st Level Assessment
Behavior
(10)
2nd Level Assessment
Stimuli
(10)
THERAPEUTIC NURSING INTERVENTIONS
Nursing
Diagnosis
Goal Outcome
(5)
(5)
Evaluation (5)
(Nursing activities to achieve outcomes and
(Check Outcomes)
Rationales for interventions)
(10) State Behaviors. Goal met? F/U
Subjective Data:
The Patient Will:
As Evidenced By:
1.
Objective Data:
2.
3.
Critical Time:__________
Nsgcp: JS4/03
LOS ANGELES HARBOR COLLEGE ASSOCIATE DEGREE NURSING PROGRAM
STUDENTNAME:_____________________________________
Nursing 333
Client’s Secondary Roles:__________________________________
Primary Role:________________________________________
NURSING PROCESS
______________________________________________________
Physiological
Tertiary Roles:___________________________________________
(Role assumed in order to complete primary roles; stable, achieved & long term)
Maturation Stage:_____________________________________
Nursing Care Plan (5)
Developmental Tasks: 1._______________________________
2.________________________ 3._______________________
Date(s):_________________
(Roles that meet the obligations of the secondary roles; roles more apt to change)
______________________________________________________
Stage of Illness:__________________________________________
(Continue the plan of care on the back of this page, if needed)
1st Level Assessment
Behavior
(10)
2nd Level Assessment
Stimuli
(10)
THERAPEUTIC NURSING INTERVENTIONS
Nursing
Diagnosis
Goal Outcome
(5)
(5)
Evaluation (5)
(Nursing activities to achieve outcomes and
(Check Outcomes)
Rationales for interventions)
(10) State Behaviors. Goal met? F/U
Subjective Data:
The Patient Will:
As Evidenced By:
1.
Objective Data:
2.
3.
Critical Time:__________
Nsgcp: JS4/03
LOS ANGELES HARBOR COLLEGE ASSOCIATE DEGREE NURSING PROGRAM
STUDENTNAME:_____________________________________
Nursing 333
Client’s Secondary Roles:__________________________________
Primary Role:________________________________________
NURSING PROCESS
______________________________________________________
Maturation Stage:_____________________________________
Psychosocial
Tertiary Roles:___________________________________________
(Role assumed in order to complete primary roles; stable, achieved & long term)
2.________________________ 3._______________________
(Roles that meet the obligations of the secondary roles; roles more apt to change)
Nursing Care Plan
Developmental Tasks: 1._______________________________
______________________________________________________
Date(s):_________________
Stage of Illness:__________________________________________
(Continue the plan of care on the back of this page, if needed)
1st Level Assessment
Behavior
(10)
2nd Level Assessment
Stimuli
(10)
THERAPEUTIC NURSING INTERVENTIONS
Nursing
Diagnosis
Goal Outcome
(5)
(5)
Evaluation (5)
(Nursing activities to achieve outcomes and
(Check Outcomes)
Rationales for interventions)
(10) State Behaviors. Goal met? F/U
Subjective Data:
The Patient Will:
As Evidenced By:
Objective Data:
1.
2.
3.
Critical Time:__________
Nsgcp: JS4/03