Nursing Care Plan-Mental Health

NURSING ASSESSMENT/MENTAL HEALTH CARE PLANCOMMENTS ARE IN PURPLE. PLEASE CORRECT WHERE YOU SEE THE *. USE A DIFFERENT COLOR INK THAN MAROON OR PURPLE OR BLACK FOR YOUR CORRECTIONS. DO NOT ERASE MY COMMENTS OR YOUR ORIGINAL WORK. SUBMIT YOUR CORRECTED CARE PLAN IN THE CORRECTED CARE PLAN SUBMISSION LINK.
STUDENT:
DATE OF CARE: 9/18/2018 GENDER: Female AGE: 58
MARITAL STATUS: W NATIONALITY: Caucasian RELIGION: Non-Denomination ADMISSION DATE: 9/13/2018
HOW MANY DAYS IN THE HOSPITAL: 5 days
PSYCHIATRIC HISTORY: Include chief complaint in the patient’s words and reason for hospitalization
Patient states that she is depressed, anxious, and wasn’t able to sleep for several days after her father passed away a week ago. Patient also stated that she voluntarily went to the ER seeking help, and she was feeling sick. *Here, instead of telling what she said, give a quote. What did she tell you when you asked what brought her to the hospital?
“I went voluntarily to the ER Friday night because I wasn’t feeling well at all. I was irritated and anxious. My father just passed away several days ago. (patient sobbing) I couldn’t sleep at night because every time I closed my eyes, I saw my father’s image. I also ran out of medications several months ago and I am diabetic.”
SIGNS AND SYMPTOMS: The patient displayed prior to and during this hospitalization:
Lack of sleep, non-compliant about her medications about what, insomnia, restless, angry, crying outburst, low self-esteem, hopelessness, lack of interest, grieving about the death of her father, and short-term memory loss, and sometimes long-term memory loss
Past psychiatric history
History of depression, Bipolar disorder, Suicide Attempts, and previous psychiatric admissions.

*What about the memory loss? Does she have some kind of dementia?
Short term and long term memory loss and Dementia
The patient after losing her father suffered depression. Though she had no suicidal thoughts, she experienced memory loss and a decline in her thought process making her forget even simple tasks. However, she had no previous psychiatric admissions and any related bipolar disorders.
Home Medications: Add more lines if you need to.
GENERIC NAME BRAND NAME DOSE/TIME CLASS/WHY DO THEY TAKE IT?
Escitalopram Lexapro 10mg BID Antidepressant/SSRIs
*Tell me why she takes each of these medications.
Treatment and maintenance therapy for patients with major depressive disorder
Haloperidol Haldol 6mg q am Antipsychotic
For chronic psychosis requiring prolonged therapy
Gabapentin Neurontin 600mg TID Anticonvulsants
Adjunctive treatment of partial seizures with or without secondary generalization in patients with epilepsy
Metformin Glucophage 1000mg BID Antidiabetics
Adjunct to diet to lower glucose level in patients with type 2 diabetes mellitus
Humulin Regular Insulin 12 units sliding scale of <140 Antidiabetics
An insulin that is used to control high blood sugar in adults and children with diabetes mellitus
Hospital Medications: Haldol, Lexapro, Neurontin, Glucophage, Humulin
Are home meds continued? _____NO__?????????__YES_______ . Update any changes and add all new medications including all PRN medications below. Add more lines if you need to.
*This doesn’t make any sense, and I know it is not correct. Why do you say they are not continuing ANY of her home medications? Yet you have a little list labeled Hospital Medications that are the same as the home medications. Did they continue her home medications exactly as she took them at home? If not was there any change in dosage or any added medication? Did she have any PRN medications available at the hospital, like Tylenol or sleep medication? If yes, then you need to list them below.
I didn’t see any additional medications on the list.
GENERIC NAME BRAND NAME DOSE/TIME CLASS/WHY THEY TAKE IT
Escitalopram Lexapro 10mg BID Antidepressants/SSRIs
Treatment and maintenance therapy for patients with major depressive disorder
Haloperidol Haldol 6mg Q am Antipsychotic
For chronic psychosis requiring prolonged therapy
Gabapentin Neurontin 600mg TID Anticonvulsants
Adjunctive treatment of partial seizures with or without secondary generalization in patients with epilepsy
Metformin Glucophage 1000mg BID Antidiabetics
Adjunct to diet to lower glucose level in patients with type 2 diabetes mellitus
Humulin Rapid Insulin 12 units sliding scale of <140 Antidiabetics
An insulin that is used to control high blood sugar in adults and children with diabetes mellitus
Diet: Regular Allergies: Levaquin
Patient Activity: Normal/ Up and about Independently Nursing Alert: Falls Precaution
Hygiene: Neat and clean PT/OT: Daily group exercise with OT
Last Vital Signs: 136/80, P-62, RR-18, T-97.6, O2-98% RT: None
NARRATIVE DOCUMENTATION
(Remember to document where you got the information if it is not your direct observation – pt. says, from chart, nursing report, HCP report, etc.)
Mood: stable, talkative
Euthymic
OK, what does stable mood mean? Better: happy or euthymic. You do not have to say direct observation. In a nursing assessment it is assumed to be direct observation unless you say otherwise. Wounds (describe): No open wounds noted or complained by the patient.
No open wounds present
Good way to document this!
Neurological: PERRLA, A&O, no history of stroke (Pt chart)
PERRLA, Alert & Oriented x3 to person, place, and time. No history of CVA. Intact cranial nerves and sensation. Coordinated movements.
You should describe if she is alert and oriented from your own observation. AND remember to tell HOW well she is oriented: to person, place, time, and situation (AOX4 would mean that the person is fully alert and oriented) Skin: clean and dry, warm to touch, no rash, no edema (Pt chart). Again, you should be able to assess her skin condition yourself without the chart.
Clean and dry, warm to touch, no edema and lesions
Pain (remember your pain scale): no pain 0/10 (Pt. chart) OK better if you had asked her yourself.
Patient shows no sign of distress. Patient’s pain level is 0 out of 10.
If there was pain what did you do about it?
NA
Pulmonary: Chest rise and fall symmetrical, clear lung sounds, no history of pneumonia (Pt. chart) Remember when you document lung sounds to say that they were auscultated, otherwise it means they are clear to your ear. You can use CTA for clear to ausculatation. Equipment Pt. Uses: none
All areas of lung sounds are CTA, chest rise and fall symmetrical, no history of pneumonia Cardiovascular: Normal heart sounds in all 4 areas, rate and rhythm normal, no history of MI (Pt. chart) Notes (anything you think is important that doesn’t quite fit anywhere else:
Better: remember how normal heart sounds should be described S1S2 ausc with no murmurs noted. I know you are using the chart, but you can use the information and then chart it the way you learned in health assessment. And how many areas should you listen to the heart? 4?
You also left out cap refill. Your statement about edema goes here.
Normal heart sounds in all 5 areas, S1-S2 auscultated with no heart murmurs noted. No edema in all extremities. Capillary refill < 3 seconds. GI: No diarrhea or constipation, Normal bowel sounds in all 4 quadrants, no NV (Pt. chart) What is normal? Avoid using normal in charting assessments. I know it is from the chart, but you should know better. Active is a much better word. Abdomen round and soft. Active bowel sounds present in all 4 quadrants. No diarrhea or constipation. Nontender. No organomegaly. Urinary: No symptoms of burning or pain during urination, urine clear and no odor (Pt. chart) Musculoskeletal: Normal ROM, no recent injuries, no pain (Pt. chart) Normal again. Full ROM is better. And what about her ability to move and control her arms and legs? Better: Full ROM. Moves all extremities without difficulty on command. Full ROM noted. Moves all extremities without difficulty and moves according to commands. Muscle strength +4. Negative Romberg test. FUNCTIONAL HEALTH PATTERNS
What does the person believe about his own health? Does he have cognitive deficit?
Patient states that her memory is worsening and that she struggles with her bipolar disorder and depression. Patient states that she has short term and sometimes long-term memory loss
Good way to describe this. *But what did you observe about her memory?
The patient had trouble in remembering simple details like the day and date of the month and the time to take her medication.
Who helps him/her manage his health? How far did he/she go in school?
Pt states she has a sister that helps her and checks on her once in a while and that her sister lives about 20 mins away. Patient states received GED
Does he/she have perceptual problems? Hallucinations/Delusions/Bizarre Behavior?
Nutritional Status( include BMI): Normal weight, BMI 18.5
Avoid using the word normal. Either give her actual weight or leave it out. However, what you could say (not knowing her weight, but knowing her BMI) is weight is appropriate to her height
(Pt chart)-Patient had hallucinations and delusions. Agitated and angry when she missed her diabetes medications. (Pt. reported)
*Did you see any while you were with her?
The patient became agitated when she realized she had missed her pills and when questions became personal.
Appetite: Eats about 70% of her meal (Pt chart) Metabolic Problems: Diabetes Mellitus Type 2 (Pt chart) Elimination include last BM: Normal Daily (Pt chart)
OK, the chart says normal, but you know better. Better: Pt. has no complaint of elimination problems, Pt. states normal (for her) BM this morning. What is his/her self-perception?
Continent? No (Pt chart)
*Does she wear incontinence pants or is it stress incontinence – wear a panty liner? Of bowel and bladder?
The patient has no panty liners neither does she seem without control of her bladder or bowel.
Why is this important to know other than in helping maintain her hygiene? Why in a Mental Health sense? It has to do with self-esteem. Incontinence is often what lands people in nursing homes when they can no longer care for themselves in keeping clean. “I am willing to change my diet and if someone can help me plan it.” Patient states she is willing to help her self to seek a Doctor or Therapist that can help and accept her, since her last doctor fired her. Patient states she is willing to get back to normal life.
So, what does this tell you about her self-perception? With her memory loss, will she be able to care for herself successfully as a diabetic, or does she just need a little help? Will she be able to follow up with her other medication regimen?
Baring in mind she still experiences episodes of memory loss, a little help is necessary to keep her condition in check
Patient Activity/Exercise: No regular exercise, but patient states she is willing to start to walk 3x a week with her sister at the park. How about his/her self-esteem:
Patient states she wants to get back home and start all over again.
*What does this tell you about her self-esteem?
The patient is determined to recover and resume her normal life. She is also eager to get help.
Role-Relationships: Sister, Aunt, Grand Aunt (Pt chart)
Sleep/Rest: Patient complains of lack of sleep or troubled sleeping at night. Patient states “I see my father’s image every time I close my eyes to sleep.” How many hours did he/she sleep last night? Patient states not able to sleep for several days until she started her medications to help her sleep.
*This doesn’t answer my question.
After receiving medication, the patient was able to get some sleep last night. She recorded 5 hours of sleep. Was it disturbed/undisturbed? Patients states X4 getting up at night and stay awake. Sexual/Reproductive: Widowed with no partner. (Pt chart) What are his/her sources of stress: (Pt chart)
Recent death of father, availability of medications, financial, family support, uncontrolled diabetes
Value/Beliefs/Cultural Issues: What are his/her coping strategies (remember to give negative as well as positive strategies):
Patient states she is a Christian but not attending any church that she likes and fit in.
So, you can use this also to help her with coping. Christians believe in prayer and communion with God. She likes to read, so Bible reading might be an option. Reading the Bible, passages of hope and comfort are helpful to many.
Remember that people are mind, body, and spirit. As nurses we can’t ignore the spirit of people. Patient states she loves board games, sudoku, reading books, watching TV, loves solving math or anything that involve numbers
So any coping skills you teach will me more effective if you include her love of math.
Drug/Alcohol Use: Alcohol use as young woman. Stopped 10 years ago. Drug used in the past. (Pt chart) PROBLEM LISTLIST ALL MENTAL HEALTH RELATED PROBLEMS AND PRIORITIZE THESEAdd more lines if you need them.
I am not wanting medical or nursing diagnosis here. I want what problems you see the problems the patient is having with those diagnoses. Then prioritize them in order of importance. Two mental health ND and one Knowledge Deficit problem.
1 Grieving
2 Insomnia
3 Knowledge Deficit (about what?) importance of medications, disease process, mental disorders, and grieving process
4 Depression * Look at my note above here. I want problems. Tell me the problems she is having with depression other than grieving, insomnia, irritability, poor social support, poor self-care, and weight loss (which you have already listed):
Eating disorder
Anxiety.
5 Lack of Support
6 Irritability
7 Poor self-care
8 Weight loss/malnutrition
CARE PLANNING SECTION
Create your nursing diagnosis from the problem list. Use problem one for ND #1, etc.
Nursing Diagnosis – Priority #1: Complicated grieving related to death of father, as evidenced by symptoms of depression such as withdrawal, difficulty sleeping, crying outburst, weight loss, isolation and dysphoric/tearful mood.
This is just beautiful!
Outcome #1 – The patient will:
The patient will demonstrate adaptive grieving behaviors and evidence of progression toward resolution by the end of my 9-hour shift.
The patient demonstrated adaptive grieving behaviors and showed signs of progression toward resolution.
Her sleep disorder was improving because she had a 6-hour sleep last night and she never complained of seeing her dad’s image every time she closed her eyes.
Her memory is improving. She can recall dates and remember the time to take her medication.
*You need to rewrite this here is what needs fixing:
1. It is not measurable
a. how will she demonstrate adaptive grieving? What does adaptive grieving look like? Who says when it is adaptive or maladaptive?
b. How can you measure that? How many times must she do it today?
c. What evidence of progression are you looking for? How will you measure that?
2. It is not reasonable or attainable, I think, to expect her to do this in one shift (if you could measure it)
So, choose something smaller (reasonable, attainable), more measurable and write a better outcome. THEN, rewrite your interventions, rationale and evaluation so they all match the new outcome. I’ll look at the whole thing in your corrected care plan.
I am going to look at what you’ve written below. So, if you have mistakes you can learn from them.
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
Assess the patient position in the grief process. This works, it is a focused assessment Accurate baseline data are is required to plan accurate care for the patient.
Develop a trusting relationship by showing empathy and caring. Be honest and keep all promises. Show genuine positive regard.
The patient enjoys math tests. Give her some mathematical problem to solve.
This does not go in your care plan. This is a part of your everyday job and is not special to this patient. These provide the basis for a therapeutic relationship.
These keep her occupied to enable her mind to focus on something different.
Explore feelings of anger and help the patient direct her toward the source. Help her understand it is appropriate and acceptable to have feelings of anger and guilt about her father’s death.
This is more like therapy. As a nurse you don’t do therapy. You can listen to her talk about her feelings of anger, you can teach her about anger, you can use therapeutic communication in which you ask her questions using Exploration when you are talking with her, but don’t go over the line into therapy.
Engage the patient in a conversation. Encourage her to talk about her loss and how she is feeling Talking helps patients cope with grief and acquire a sense of social activity.
Refer the patient to physician for medication evaluation.
This doesn’t go in the care plan. Why should you need to do this referral? Medication evaluation is part of his/her job. Trust me, doctors do not like you to tell them how to do their job. If you have a question about the patient’s medication regimen you ask face to face or on the phone, you do not put it in the care plan. Antidepressant therapy will help the patient to function and decrease anxiety and depression.
Enquire how the patient is responding to medication and whether she is experiencing change. Response and change or absence of change will determine progress.
EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?) circle or underline as applies
31667451828802661920173355 Outcome Criteria # 1 Did not meet Met Continue
Evidence of success/failure:
Level of depression and grief decreases and showed improvement by showing positive signs like talking to nurses and other patients. Patient improved interacting with others and stated, “I am getting to understand why I am feeling this way, and this is just a normal process of grieving.”
*Redo this to match your new outcome.
It is clear that her level of depression decreased based on her current cognitive ability and the ability to get through sleeping patterns without suffering insomnia.
Ideas what to do next if they met this goal and you don’t want to continue:

Outcome #2 -The patient will:
The patient will discuss her sorrow, her past experiences, and any angry feelings she has about the loss of her father by the end of my shift.
*Rewrite this. Make it measurable. And instead of 3 things to measure, just make it one (why, you ask me. It will be more measurable, and this is too much for one session on one shift) Leave yourself out of the chart whenever possible.
THEN redo/adjust your interventions/rationale and evaluation to match.
The patient can now discuss the pain of losing her father without getting emotional to an extent of grieving. She can now face her grief and is determined to get through the loss.
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
1.Introduce self and intention during the first phase of interaction.
You do not need to tell the nurses to introduce themselves, that is a routine nursing practice. However, the second part of this is useful. Let’s look at it another way:
Explain the purpose of this meeting with the patient.
Access the level of improvement in social activities and the patient’s determination to move on with her life normally. This will help patient build her trust with the nurse; ensuring that it is a professional type of interaction and that will ensure the confidentiality of interaction.
Explaining the purpose of your meeting let’s the patient prepare for the rest of this/these interactions.
The patient has been involved in board games with other patients and she has participated in group sessions sharing her grief.
2 Interact with the patient in a slow pace, using a low firm tone.
Unless there is some special reason for the nurses to use a certain tone and pace, there is no reason to include it in the care plan. You shouldn’t have to explain therapeutic communication to nurses unless there is a SPECIAL reason with THIS patient.
*Rewrite a better intervention that matches you new outcome.
The patient requires extra care. She suffered a heavy loss, which resulted in her depression and therefore she needs support to overcome her grief. This will promote a positive and trusting environment with the patient considering that depressed patient sometimes communicates with some gaps or may be unresponsive for some reasons.
This does not really explain why THIS patient needs special tone of voice and pace. WHY is this going to work better for HER?
This shows that her condition has improved and her response to medication is positive.
3 Do not hurry client into an interaction, instead maintain a therapeutic and reassuring atmosphere that you are available if she is already ready to talk or share her thoughts with you.
Same problem here. You don’t need to teach the nursing staff therapeutic communication.
*Write a new intervention.
A continued therapeutic intervention necessary for this particular patient and she needs continued interaction to air out her grief to enable her to move on. Sometimes patients who are depressed may have some emotional outburst, crying spells, or hesitancy in sharing their thoughts. Be wary of these nonverbal cues and provide some comforting gestures or allow patient cry as it would lessen her exaggerated emotions.
Discontinuing intervention may draw the patient back to depression.
4 Assess the factors contributing to low self-esteem like previous educational failures, family relationships and interactions, availability of support system, and the ability to express own self.
*Write another intervention. This does not DIRECTLY help her reach this goal. Your outcome was not about self-esteem. This is an assessment that should be done in nursing interview or social work interview, not really in the care plan. It is too big. Care plans are GOAL-DIRECTED. If you do an assessment in a care plan it is a focused assessment about the problem you are addressing. Example: you might do a grieving assessment or level of grieving or some other kind of focused assessment that helps her discover more about her own grieving (I am not suggesting this as an intervention, just talking to you.)
After losing her father, the patient lacked emotional and psychological support to assist her get through her grief, which led her to depression. Therefore, she needs emotional support and love to enable her recover from the loss.
These will help in knowing which aspects you should reinforce with during the plan of care. It may also help patient understand of her limits as person.
Determining the success achieved provides an opportunity to take her through another coping skill.
EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?): circle or underline as applies
30714951962152566670215265 Outcome Criteria # 1 Did not meet Met Continue
Evidence of success/failure:
At the end of my nursing interaction, the patient is participative in daily activities, shows eagerness to socialize with other patients and nurses, verbalizing problems through omission of negative thinking, acceptance of honest appraisal, and express emotions productively.
*Redo this to match your new outcome. And leave yourself out of the chart as much as possible.
With time, the patient shows signs of improvement by engaging in social activities and she gets more positive on her perception. She can now identify with her loss and aims to get through and move on with life.

Ideas what to do next if they met this goal and you don’t want to continue:
Involve her in simpler interactions and check on her regularly to ensure she does not fall back into low self-esteem.

Nursing Diagnosis #2: This is not what you gave as your second priority problem What your #2 problem is is Insomnia. So your #2 ND should be Insomnia rather than ineffective coping. However, I’ll grade it as it is. Remember, you should work on the patient’s problems in the order of importance.
Ineffective coping related to alteration in sleep pattern or insomnia as evidenced by patient states “I can’t sleep at night because every time I close my eyes, my father’s image appears.”
Although she has been able to cope with her loss, the patient still suffer insomnia, which indicates her lack of total control in getting over her loss. She still thinks about her father, which leads to her lack of sleep. Therefore, the patient needs therapy to enable her get over her loss.
*You need to rewrite this. Here is why: Her sleep disturbance is not what is causing her ineffective coping. What did? Your evidence is not evidence of ineffective coping, it is evidence of insomnia.
Outcome #1 -The patient will:
The patient will verbalize awareness of own coping abilities by the end of my shift.
The patient will show signs of improvement in recovering from her loss.
*Rewrite: this is not measurable. And leave yourself out of the chart.
*I am curious. How is this going to look? Are you expecting her to say “I have trouble coping?” Why do you need this outcome? You have already assessed that she has problems coping. Is it that she does not realize she is having trouble coping and having her say that will make it real to her? What is your thinking here?
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
Assess current functional capacity and note how it is affecting the patient’s coping ability.
*You have already assessed her functional capacity in the assessment above. So, write another intervention.
Write interventions that will DIRECTLY help the person to reach the goal you set, your outcome. How will you help her to verbalize her ability to cope???? What steps do you need to take? Think about it. Put yourself in that place. Think of her sitting across from you. Now, write those steps down so any nurse can understand them and follow your directions.
The patient needs more interaction and social involvement. Involve her in more group activities and utilize her hobbies in coping activities.
A change of living condition preferable with a close relative will help her get over the grief.
She needs an activity to keep her busy and productive. Patient tend to regress to a lower developmental stage during illness or major crisis.
Patient needs time to grieve over her dad. She therefore is at risk of suffering depression again if not active.
Determine alcohol intake, drug use, smoking habits, sleeping and eating patterns. *Same deal, you have already assessed this. Write another intervention.
Determine her daily activities to establish what keeps her away from getting over her lost dad. These mechanisms are often used when individual is not coping effectively with stressors.
This information helps address the stressor.
Devote time for listening especially providing for continuity of care with the same nurse taking care of the patient as often as possible. This is better, but let’s write it so it doesn’t insult the nursing staff by telling them to do their job.
Set an appointment with the patient to teach her new coping skills.
Ask the patient what time of her convenience you can visit her and build on social skills together.
This may help the patient to express emotions, grasp the situation, and feel more in control.
By setting an appointment, the nurse is telling the patient that this is an important task.
This keeps the patient anxious and offers her something to think about to prove how she is improving.
Determine previous methods of dealing with life problems. *You have already done this assessment. Write another intervention. You can’t just assess people, you need to help them in other ways. You can teach, listen, intervene, demonstrate, model. Assessment is just one part of nursing. In the care plan, unless you need a focused assessment to address the problem, you don’t put it in there.
Determine how the effective the patient was dealing with previous losses and whether her intervention measures were effective or not. In case she still bear the pain of her previous grief, recommend a new strategy to help her overcome and lead life normally. To identify successful techniques that can be used in the current situation and individualized program of relaxation, meditation, and enhance coping abilities.
Addressing her past achievements and trials will help the patient improve her self-esteem.
EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?): circle or underline as applies
30524452108202642870201295 Outcome Criteria # 1 Did not meet Met Continue
Evidence of success/failure:
Patient verbalizes feelings congruent with behavior. Patient report a measurable increase in ability to deal with problems and stressors by patient states “I was able to sleep 6-8 hours last night without seeing my father’s face when I closed my eyes at night.” I see where you are going with this, if she is coping better, she will sleep better, but it is not what you asked her to do.
This does not match what you asked her to do in your outcome. Your outcome wasn’t about sleeping, it was that she would state her awareness of her own coping ability. *Make this match your rewritten outcome.
The patient feels that she is coping with her grief. She can now sleep comfortably for 6-8 hours without episodes of seeing her father’s face. Her eating habits improved and she remembers to take her medication in time. Her emotional coping has improved and she feels positive to go on with life.
Ideas what to do next if they met this goal and you don’t want to continue:

Outcome #2 -The patient will:
The patient will meet psychological needs by appropriate expression of feelings, perform relaxation technique exercise, formulate a plan dealing with individual concerns, identification of options, and use of resources by the end of my shift.
*TOO BIG!!!! Not measurable, not reasonable or attainable by this person on one shift. Rewrite, make it smaller, and choose something about ineffective coping to write an outcome she can achieve in one shift. Tell me how to measure:
The patient will start facing life with positivity. She will think more about her life and try to overcome past challenges like improving her eating habits and involving herself in social activities.
1. She will meet her psychological needs by appropriate expression of feelings? What does this mean? How do you do this. Who judges which expression of feelings is appropriate? When is it too much crying? When is it too much sadness or not enough joy? How do you measure this?
2. Perform relaxation technique exercise. Which one, how many times, does she know any? She didn’t mention them in your assessment.
3. Formulate a plan dealing with individual concerns? In one shift???
Identification of options? About what, how many? Use of resources? About what? In one shift? For mental health, for diabetes??? What
I will look at this again after you have rewritten the outcome and made the interventions, rationale, and evaluation match. I’m going to look at the ones you have now, maybe you can learn from my comments.
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
Conceptualize goals for recovery together with the patient and involve patient in simple decision making. This is part of routine nursing care. We always allow patients to make decisions about their own care when they are able. The other part may work depending on what your new outcome is. However, instead of Conceptualize, (it is too nebulous for other nurses to understand what you are trying to do), try a different action word such as: Plan, Develop, Write, List,
Create a to-do list with the patient addressing steps you will walk her through to achieve recovery This will help patient know her strengths as a person and would help her resume her autonomy and integrity. Listing her strengths would be a better intervention for this rationale.
The patient wanst to build concrete relationships over time. She needs to improve her social network and be around people who can help her cope through her down moments.
*What is the rationale for creating goals for recovery?
I can think of one as an example: Listing her goals for recovery makes them more real, more attainable. When goals are only a dream they seem less attainable.
Say I want a new car. That is my goal… somewhere off in the unseen future. But, if I write down my goal it makes it more attainable: I will put aside $300 per month toward my new (used) car. I want a small yellow truck – a little Nissan truck. By the end of the year I can buy it.
Involve patient in activities that meets her abilities and her honestly for achievements done.
You don’t need to tell nurses to match the patient’s abilities to the activities. This is routine nursing care. *Write one that matches your new outcome
Involve patient in activities that will enable her to build more relations that can offer her comfort in times of grief. She needs to feel closer to people. This will promote patient’s positive concepts of self but would also enhance her ability to resume functioning like her daily self-care.
This prepares her for life after admission and determines her success in building positive social relationships.
Provide a quiet environment for the patient.
This is not a bad intervention, it just won’t DIRECTLY help her reach THIS goal.
Recommend a hobby to undertake before going to bed. She can play a game or solve a mathematical problem before going to bed.
It helps and promote a relaxing atmosphere and improves sleeping habit.
Solving a math’s problem or reading a book will help her get drowsy.
Assess current support system like family, friends and church group.
You already did this. *Write one that matchesyour new outcome
Enquire on the nature of meals she takes before going to bed. It provides patient access to support group like church, friends, and family member when situation or problem arises
Although she is coping with her loss of sleep, eating habits determine how well one sleeps. A light meal before going to bed would be great.
EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?): circle or underline as applies
31000701708152604770189865 Outcome Criteria # 1 Did not meet Met Continue
Evidence of success/failure: *You left this blank and I can see why. It is not measurable. Write one to match your new outcome.
The patient showed signs of improvement but needed more time to build relations and get over her grief.

Ideas what to do next if they met this goal and you don’t want to continue:

Nursing Diagnosis #3:
Deficient knowledge (about what?) related to alteration in cognitive functioning or memory as evidenced by “Patient stated, I easily forget things and don’t remember when to take my medicine.”
*Rewrite: Tell me what her Knowledge deficit is in the ND. Is it about remembering to take her medication? That is what is in your evidence.
Deficiency in cognitive ability as evidenced from patient, “I easily forget to take my medication”.
Outcome #1 -The patient will:
The patient will verbalize understanding of condition, disease process, treatment about medications and why is essential to take it on a regular scheduled basis by the end of my shift.
The patient will try to remember her prescription period at least once today.
Her teaching today will revolve around helping her manage time by writing a commotion list in relation to her medication.
*Too big. Choose one thing, one smaller thing for her to learn today. If this ND is about her remembering to take her medication, then the outcomes should DIRECTLY help her to do that better. And leave your self out of the chart.
For example: Pt. will present herself to the medication window at the correct time twice today. OR
Pt. will state the time she takes each of her medications at least once today. OR
Pt. will demonstrate how to set up a pill box by end of shift. OR
Pt. will create a medication card with correct times to take her medications by end of shift OR etc……
WHAT DO YOU WANT TO TEACH HER TODAY? (Not shouting, just for emphasis). She has a knowledge deficit, let’s teach her something, not assess her some more.
Then make all the interventions, rationale, and evaluation match your outcome. I’ll look at the whole thing after you correct it. Meanwhile, I’ll look at what is here.
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
Determine the patient’s ability, readiness, and barriers to learning.
This works. It is a focused assessment about her barriers to learning. The patient may not be physically, emotionally, or mentally capable at this time.
But this is not why you do the assessment. A better rationale: Determining the patient’s barriers to learning and readiness for learning helps the nurse to tailor lessons that fit the patient’s needs.
Identifying barriers assist in developing a contingency plan.
Provide positive reinforcement to the patient.
Good. This could encourage continuation of efforts.
Identify information that needs to be remembered (cognitive).
Recommend a time management plan to enable the patient recall her prescription. *What are you going to teach her? This is a teaching ND. So you should teach her something. You are assessing again when there is no need. To establish a routine for the patient when to take her medications on time. This rationale doesn’t match this intervention.
A time management schedule enables her to plan her tasks and allocate time for each to prevent overindulging in some activities.
Determine the patient’s method of accessing information like visual, auditory, and olfactory and include in teaching plan.
Assessing…..You did that already in step one. *Write an intervention that helps her accomplish what you have asked for in your rewritten outcome.
Recommend a method of improving her cognitive ability. It will help patient facilitate learning or recall important things.
It will assist her remember not only her prescriptions but also important tasks requiring her attention.
EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?): circle or underline as applies
3071495167005259524518605600 Outcome Criteria # 1 Did not meet Met Continue
Evidence of success/failure: Patient exhibit interest and assume responsibility for own learning by beginning to look for information and ask questions. This doesn’t match the outcome. *Rewrite to match the new outcome.
Evidence of success/failure: Patient show signs of improvement and positive attitude towards recommendations to assist her move on.
Ideas what to do next if they met this goal and you don’t want to continue:

Outcome #2 -The patient will:
The patient will identify relationship of signs/symptoms to the disease process, and correlate symptoms with causative factors by the end of my shift.
*Rewrite, too big for this lady to do in one shift. Is this ND about her remembering to take her medication? If so, then the outcomes should directly deal with helping her to do that. Make all the interventions, rationales, and evaluation match.
The patient will remember to write down a list of daily routines to enable her shift between the tasks and taking her medication.
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
Determine blocks to learning like language barriers, physical factors, physical stability, and difficulty of material to be learned.
Check on the list of goals you planned together and motivate her.
Assessing again. You already did this Determine other factors pertinent to the learning process.
The list offers insight on areas that need attention.
Provide patient information relevant only to the situation. Teach her something. Specific.
Assist the patient in preparing a to-do- list To prevent overload to the patient.
Referring to the list will prevent over indulgence
Determine the patient’s most urgent need from both patient’s and nurse’s viewpoints. Teach her something or ask her to demonstrate what you taught her in steps 1 and 2.
Ask the patient the challenges if any she encountered when accomplishing the set goals It may differ and require adjustments in teaching plan.
Establish the success of the interactions and the patients will to recover.
Discuss the client’s perception of need. Relate the information to the client’s personal desires, needs, values, and beliefs. Teach her something. OR tell her she did a good job learning what you taught her in interventions 1-3.
Recommend the patient for the determination to move on and her quest to be better. Will establish priorities in conjunction with the patient, so that the patient feels competent and respected.
Improves self-esteem and helps the patient identify with the stressor
Here are 4 interventions that are all assessing. Teach her something that will help her! EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?): circle or underline as applies
3033395195580259524518605500 Outcome Criteria # 1 Did not meet Met Continue
Evidence of success/failure: The patient verbalizes understanding of the disease process and listed 3 signs and symptoms. Patient stated the importance of promoting health and wellness.
*Rewrite this to match your new outcome.
Evidence of success/failure: patient shows willingness to adapt to new changes and determination to overcome her illness.

Ideas what to do next if they met this goal and you don’t want to continue:

EMERGENCY SECTION (IGNORE UNLESS DIRECTED TO USE THIS)
Nursing Diagnosis:
Outcome #1 – The patient will:
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?): circle or underline as applies
Outcome Criteria # 1 Did not meet Met Continue
Evidence of success/failure:

Ideas what to do next if they met this goal and you don’t want to continue:

Outcome #2 – The patient will:
Extra Notes:
Specific
Nursing Interventions
For This Patient
(Give at least 4 interventions per outcome) Rationale
For Intervention
EVALUATION
Status of Outcome (Did he meet his goal? Do you want to continue?): circle or underline as applies
Outcome Criteria # 2 Did not meet Met Continue
Evidence of success/failure:

Ideas what to do next if they met this goal and you don’t want to continue: