NURSING CARE PLAN

DATE: 6/27/19
Cues Nursing Diagnosis Rationale to Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Nursing Interventions
Diagnosis
Subjective Cues: Ineffective Coping Loss of love After 3 weeks of my Provide a safe environment Physical safety of the client is a After 3 weeks of my
“ gikan sa related to sleep ones nursing intervention client for the client. priority. Many common items nursing intervention
pagkamatay sa disturbances(inso will be able to: may be used in a self-destructive client was able to:
aq brother dili ko mnia) and manner.
makatulog, anxiety. -Demonstrate an Continually assess the •Demonstrate an
sobrahan siguro Anxiety/depr increased ability to cope client’s potential for suicide. Clients with depression may have increased ability to
ni sige huna ession with anxiety, stress, or Remain aware of this suicide a potential for suicide that may or cope with anxiety,
huna sa iyaha” frustration potential at all times. may not be expressed and that stress, or frustration
As verbalized by -Verbalize/demonstrate may change with time. Such as:
the patient. acceptance of loss or
Spend time with the client.
change, if any Your physical presence is reality. -performed physical
Inability to -Identify a support system activities and exercise
form a valid in the family & Use silence and active to release energy
appraisal of community. listening when interacting The client may not communicate -used relaxation
the stressors with the client. Let the client if you are talking too much. Your techniques such as
References: know that you are concerned presence and use of active listening to music
and that you consider the listening will communicate your , taking showers,
inadequate client a worthwhile person interest and concern. meditating,
From Schultz, J. choices of performing imagery
M. & Videbeck, S. practiced or visualization
responses, Avoid asking the client many Asking questions and requiring
L. (2013). only brief answers may experiences.
Objective Cues: Lippincott’s and/or questions, especially •Verbalize/demonstra
inability to questions that require only discourage the client from
VS taken as Manual of expressing feelings. te acceptance of loss
follows: Psychiatric use available brief answers. or change, if any.
BP:110/80mmHg Nursing Care resources You may be uncomfortable with -patient accepted the
T: 37. 2 °C Plans, 9th edition. certain feelings the client death of her brother
Do not belittle the client’s expresses. If so, it is important
PR: 85 bpm © Wolters Kluwer feelings. Accept the client’s as normal in our life.
RR:19cpm Health | for you to recognize this and •Identify a support
Ineffective verbalizations of feelings as discuss it with another staff
Lippincott real, and give support for system in the family
coping member rather than directly or
Williams & expressions of emotions, & community as
Wilkins. indirectly communicating your evidenced by think
especially those that may be discomfort to the client.
difficult for the client (like through one’s options
Proclaiming the client’s feelings and use of problem
anger).
solving techniques.

Encourage the client to
ventilate feelings in
whatever way is
comfortable—verbal and
nonverbal. Let the client
know you will listen and
accept what is being
expressed.
Talk with the client about
coping strategies he or she
has used in the past. Explore
which strategies have been
successful and which may
have led to negative
consequences.
Teach the client about
positive coping strategies
and stress management
skills, such as increasing
physical exercise, expressing
feelings verbally or in a
journal, or meditation
techniques. Encourage the
client to practice this type of
technique while in the
hospital.
Provide positive feedback at
each step of the process. If
the client is not satisfied with
the chosen alternative, assist
the client to select another
alternative.
to be inappropriate or belittling
them is detrimental
Expressing feelings may help
relieve despair, hopelessness,
and so forth. Feelings are not
inherently good or bad. You must
remain nonjudgmental about the
client’s feelings and express this
to the client.
The client may have had success
using coping strategies in the
past but may have lost
confidence in himself or herself
or in his or her ability to cope
with stressors and feelings. Some
coping strategies can be self-
destructive (e.g., self-medication
with drugs or alcohol).
The client may have limited or no
knowledge of stress management
techniques or may not have used
positive techniques in the past. If
the client tries to build skills in
the treatment setting, he or she
can experience success and
receive positive feedback for his
or her efforts.
Positive feedback at each
step will give the client many
opportunities for success,
encourage him or her to persist
in problem-solving, and enhance
confidence. The client also can
learn to “survive” making a
mistake.
 NURSING CARE PLAN

Cues Nursing Rationale to Goals and Nursing Interventions Rationale to Nursing Evaluation
Diagnosis Nursing Diagnosis Objectives Interventions
Subjective Cues: Impaired Social Loss of love ones -After 1 week of my -Collaborative Your social behavior -After 1 week of my nursing
“ nawad-an ko gana interaction nursing intervention interventions provides a role model for the intervention client was able
makig-istorya sa related to client will be able client. to:
ako mga amiga Social isolation to: Initially, interact with the
sugod namatay ako and poor Anxiety/depression -Re-establish or client on a one-to-one
pinaka close nga hygiene and maintain basis. Awareness of interpersonal  Re-establish or
igsoon” withdrawn relationships and a Talk with the client about and group dynamics is an maintain
As verbalized by the behavior. social life his or her interactions and important part of building relationships and a
patient Ineffective quality -Establish a support observations of social skills. Sharing social life such as:
of social exchange system in the interpersonal dynamics. observations provides an -performing social skills by
 Verbalization and social isolation community, for opportunity for the client to approaching another person
diminished example, initiate express his or her feelings for an interaction,
in quantity, contacts with and receive feedback about appropriate conversation
Teach the client social his or her progress.
quality, or others by topics and active listening.
Impaired Social skills, such as approaching
spontaneity cellphone/telephone - involve in achieving
interaction another person for an
References: positive changes and
interaction, appropriate The client may lack social
interpersonal relationship.
conversation topics, and skills and confidence in
 Establish a support
active listening. social interactions; this may
Objective Cues: From Schultz, J. system in the
Encourage him or her to contribute to the client’s
M. & Videbeck, community
practice these skills with depression and social
VS taken as follows: S. L. (2013). - initiate contacts with
staff members and other isolation
BP:110/80mmHg Lippincott’s others by
clients, and give the client
T: 37. 2 °C Manual of cellphone/telephone
feedback regarding
PR: 85 bpm Psychiatric - Participate/involve in social
interactions.
RR:19cpm Nursing Care gatherings with her family
Plans, 9th and friends.
-poor hygiene edition. © Encourage the client to
-observed Wolters Kluwer identify relationships,
discomfort in social Health | social, or recreational
situaTION Lippincott situations that have been
Williams & positive in the past.
Wilkins. The client may have been
depressed and withdrawn
 for some time and have lost
*Encourage client to interest in people or
identify supportive people activities that provided
in her life and to develop pleasure in the past.
these relationships. In addition to re-establishing
past relationships or in their
absence, increasing the
client’s support system by
establishing new
relationships may help
decrease future depressive
behavior and social isolation
 NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Goals and Objectives Nursing Interventions Rationale to Nursing Evaluation
Nursing Diagnosis Interventions
Subjective Cues: Feeding Self-Care Loss of love ones After 1 week of my nursing Closely observe the client’s The client may not be After 1 week of my
“ wala koy gana Deficit as related to intervention client will be food and fluid intake. Record aware of or interested in nursing intervention
mokaon sugod disturbances of able to: intake, output, and daily meeting physical needs, client was able to:
namatay ako appetite or regular Anxiety/depression weight if necessary. but these needs must be -Establish adequate
pinaka close nga eating patterns -Establish adequate met. nutrition, hydration,
igsoon” nutrition, hydration, and and elimination such
As verbalized by elimination. Offer the client foods that as eat meals at right
the patient. are easily chewed, fortified If the client lacks time, develop
Disturbances of -Establish an adequate liquids such as nutritional interest in eating, highly interest in eating,
appetite(anorexia) balance of rest, sleep, and supplements, and high- nutritious foods that normal elimination
References: activity. protein malts. require little effort to eat pattern
may help meet -Establish an
From Schultz, J. M. Impaired ability to nutritional needs. adequate balance of
perform or Try to find out what foods
& Videbeck, S. L. The client may be more rest, sleep, and
complete self- the client likes, including
(2013). Lippincott’s apt to eat foods he or activity e.g. verbalize
feeding activities culturally based or foods
Manual of she likes or has been of her normal sleep
(feeding self-care from family members, and
Objective Cues: Psychiatric Nursing accustomed to eating. pattern (8 hrs.)
deficit) make them available at
Care Plans, 9th perform ADL’s and
meals and for snacks. Severe constipation may
edition. © Wolters physical exercise.
Observe and record the result from the
VS taken as Kluwer Health |
client’s pattern of bowel depression; inadequate
follows: Lippincott Williams
elimination. exercise, food, or fluid
BP:110/80mmHg & Wilkins.
intake; or the effects of
T: 37. 2 °C Provide a quiet, peaceful some medications.
PR: 85 bpm time for resting. Decrease
RR:19cpm environmental stimuli
(conversation, lights) in the Limiting noise and other
evening. stimuli will encourage
rest and sleep..