Ncp.docx

NURSING CARE PLAN Cues Subjective Cues: “ gikan sa pagkamatay sa aq brother dili ko makatulog, sobrahan siguro ni sige huna huna sa iyaha” As verbalized by the patient.

Nursing Diagnosis

Rationale to Nursing Diagnosis Ineffective Coping Loss of love related to sleep ones disturbances(inso mnia) and anxiety. Anxiety/depr ession

Inability to form a valid appraisal of the stressors References:

Objective Cues: VS taken as follows: BP:110/80mmHg T: 37. 2 °C PR: 85 bpm RR:19cpm

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition. © Wolters Kluwer Health | Lippincott Williams & Wilkins.

inadequate choices of practiced responses, and/or inability to use available resources

Ineffective coping

Goals and Objectives

Nursing Interventions

After 3 weeks of my nursing intervention client will be able to:

Provide a safe environment for the client.

-Demonstrate an increased ability to cope with anxiety, stress, or frustration -Verbalize/demonstrate acceptance of loss or change, if any -Identify a support system in the family & community.

Continually assess the client’s potential for suicide. Remain aware of this suicide potential at all times. Spend time with the client.

DATE: 6/27/19 Rationale to Nursing Interventions Physical safety of the client is a priority. Many common items may be used in a self-destructive manner. Clients with depression may have a potential for suicide that may or may not be expressed and that may change with time. Your physical presence is reality.

Use silence and active listening when interacting with the client. Let the client know that you are concerned and that you consider the client a worthwhile person

The client may not communicate if you are talking too much. Your presence and use of active listening will communicate your interest and concern.

Avoid asking the client many questions, especially questions that require only brief answers.

Asking questions and requiring only brief answers may discourage the client from expressing feelings.

Do not belittle the client’s feelings. Accept the client’s verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger).

You may be uncomfortable with certain feelings the client expresses. If so, it is important for you to recognize this and discuss it with another staff member rather than directly or indirectly communicating your discomfort to the client. Proclaiming the client’s feelings

Evaluation After 3 weeks of my nursing intervention client was able to: •Demonstrate an increased ability to cope with anxiety, stress, or frustration Such as: -performed physical activities and exercise to release energy -used relaxation techniques such as listening to music , taking showers, meditating, performing imagery or visualization experiences. •Verbalize/demonstra te acceptance of loss or change, if any. -patient accepted the death of her brother as normal in our life. •Identify a support system in the family & community as evidenced by think through one’s options and use of problem 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 selfdestructive (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 Diagnosis Subjective Cues: Impaired Social “ nawad-an ko gana interaction makig-istorya sa related to ako mga amiga Social isolation sugod namatay ako and poor pinaka close nga hygiene and igsoon” withdrawn As verbalized by the behavior. patient 

Verbalization diminished in quantity, quality, or spontaneity

Objective Cues:

References:

From Schultz, J. M. & Videbeck, VS taken as follows: S. L. (2013). BP:110/80mmHg Lippincott’s Manual of T: 37. 2 °C PR: 85 bpm Psychiatric RR:19cpm Nursing Care Plans, 9th -poor hygiene edition. © -observed Wolters Kluwer discomfort in social Health | situaTION Lippincott Williams & Wilkins.

Rationale to Nursing Diagnosis Loss of love ones

Goals and Objectives -After 1 week of my nursing intervention client will be able to: Anxiety/depression -Re-establish or maintain relationships and a social life Ineffective quality -Establish a support of social exchange system in the and social isolation community, for example, initiate contacts with others by Impaired Social cellphone/telephone interaction

Nursing Interventions

Rationale to Nursing Interventions

Evaluation

-Collaborative interventions

Your social behavior provides a role model for the client.

-After 1 week of my nursing intervention client was able to:

Initially, interact with the client on a one-to-one basis. Talk with the client about his or her interactions and observations of interpersonal dynamics.

Teach the client social skills, such as approaching another person for an interaction, appropriate conversation topics, and active listening. Encourage him or her to practice these skills with staff members and other clients, and give the client feedback regarding interactions. Encourage the client to identify relationships, social, or recreational situations that have been positive in the past.

Awareness of interpersonal and group dynamics is an important part of building social skills. Sharing observations provides an opportunity for the client to express his or her feelings and receive feedback about his or her progress. The client may lack social skills and confidence in social interactions; this may contribute to the client’s depression and social isolation

The client may have been depressed and withdrawn



Re-establish or maintain relationships and a social life such as: -performing social skills by approaching another person for an interaction, appropriate conversation topics and active listening. - involve in achieving positive changes and interpersonal relationship.  Establish a support system in the community - initiate contacts with others by cellphone/telephone - Participate/involve in social gatherings with her family and friends.

*Encourage client to identify supportive people in her life and to develop these relationships.

for some time and have lost interest in people or activities that provided pleasure in the past. 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

Subjective Cues: “ wala koy gana mokaon sugod namatay ako pinaka close nga igsoon” As verbalized by the patient.

Feeding Self-Care Deficit as related to disturbances of appetite or regular eating patterns

Rationale to Nursing Diagnosis Loss of love ones Anxiety/depression

Disturbances of appetite(anorexia) References:

Objective Cues: VS taken as follows: BP:110/80mmHg T: 37. 2 °C PR: 85 bpm RR:19cpm

From Schultz, J. M. & Videbeck, S. L. (2013). Lippincott’s Manual of Psychiatric Nursing Care Plans, 9th edition. © Wolters Kluwer Health | Lippincott Williams & Wilkins.

Impaired ability to perform or complete selffeeding activities (feeding self-care deficit)

Goals and Objectives

Nursing Interventions

Rationale to Nursing Interventions

Evaluation

After 1 week of my nursing intervention client will be able to:

Closely observe the client’s food and fluid intake. Record intake, output, and daily weight if necessary.

The client may not be aware of or interested in meeting physical needs, but these needs must be met.

After 1 week of my nursing intervention client was able to: -Establish adequate nutrition, hydration, and elimination such as eat meals at right time, develop interest in eating, normal elimination pattern -Establish an adequate balance of rest, sleep, and activity e.g. verbalize of her normal sleep pattern (8 hrs.) perform ADL’s and physical exercise.

-Establish adequate nutrition, hydration, and elimination. -Establish an adequate balance of rest, sleep, and activity.

Offer the client foods that are easily chewed, fortified liquids such as nutritional supplements, and highprotein malts. Try to find out what foods the client likes, including culturally based or foods from family members, and make them available at meals and for snacks. Observe and record the client’s pattern of bowel elimination. Provide a quiet, peaceful time for resting. Decrease environmental stimuli (conversation, lights) in the evening.

If the client lacks interest in eating, highly nutritious foods that require little effort to eat may help meet nutritional needs. The client may be more apt to eat foods he or she likes or has been accustomed to eating. Severe constipation may result from the depression; inadequate exercise, food, or fluid intake; or the effects of some medications. Limiting noise and other stimuli will encourage rest and sleep..