ASSESSMENT DIAGNOSIS
Identification Exploitation
Orientation
The nurses collects a
detailed history and
conducts a through
physical and mental
status examination to
reveal the problems the
client faces.
IMPLIMENTATION EVALUATION
Resolution
Interventions are planned
Moderate anxiety The client responds
to relieve anxiety. Positive
to the treatment and
Altered thought feedback is emphasized.
process nursing management
Improved communication
and socialized more
Self care deficit and socializing skills.
and involved in
Impaired social taught her importance of
group activity
interaction taking medications and
Self esteem maintenance of hygiene
disturbance and requested family
support to improve his
self esteem.
NURSING PROCESS
Sl ASSESSMENT NURSING GOAL NURSING INTERVENTIONS IMPLEMENTATION EVALUATION
No DIAGNOSIS
1. SUBJECTIVE 1. Assess the level of anxiety, 1. Assessed the anxiety level.
DATA gives basic data for further Mr. Johnson Babu was very
Patient says that he assessment. anxious and depressed.
is very anxious Provided reassurance and
because no one is 2.Provide reasonable and comfort by, Patient
helping him and comfort by a) Stay with person. verbalized that
accepting him and Anxiety related Person a) Stay with person. b) Speak slowly and calmly. he gained self
worried about his to irrational feels b) Speak slowly and calmly. c) Be aware of your own confidence and
future. thoughts reduced c) Be aware of your own concern and avoid reciprocal showed a sense
secondary to anxiety concern and avoid reciprocal anxiety. of recovery.
OBJECTIVE absence of anxiety. d) Convey a sense of empathetic
DATA support system. d) Convey a sense of empathetic understanding.
Patient looks understanding. Eg, Touch,
anxious. He feels allowing talking. 3. Encouraged the person to
sad while talking recall and analyze similar
but not expressing 3. Encourage the person to instances of anxiety.
it. He is a case of recall and analyze similar
alcoholic instances of anxiety to minimize
dependence. the exposure of similar 4. Advised to develop behavior
stimulation in future. modification strategies which
reduce anger.
4. Develop behavior
modification strategies, helps to 5. Provided yoga, play therapy,
modify the behavior which will group therapy as diversion
provoke anger. therapy.
5. Provide activities that can
reduce tension, to divert the 6.allowed visitors and
mind. approached in a calm and
6. Arrange for visitors, to the
nurturing manner, without
patient. Approach in calm,
nurturing manner helps to provoking to reduce anxiety
minimize anxiety.
Sl ASSESSMENT NURSING GOAL NURSING PLANNING,RATIONALE IMPLEMENTATION EVALUATION
No DIAGNOSIS
2. SUBJECTIVE DATA Altered thought Patient 1. Avoid making promises that 1. Avoided making
Patient says that he is process related maintains cannot be fulfilled, minimizes promises that cannot be
treated badly by his to unmet normal trust. fulfilled. Patient
relatives because of dependency thought maintained
his alcoholic habit needs. process 2. Verify your interpretation of 2. Patient was first calm normal thought
and they showed what the person is experiencing and showed dislike but process as
hatred towards him. helps to understand things later slowly showed evidenced by his
correctly. interest. happy mood and
OBJECTIVE DATA verbalization.
Patient looks sad and 3.Observe for verbal and non 3. Observe for hallucination
he is a case of verbal hallucination,, and abnormal behavior.
alcoholic inappropriate laughs, delayed Mr. Johnson Babu has no
dependence. verbal response, eye movements, abnormal behavior and
moves lips without sound, hallucinations.
increased motor movements

4. Direct the focus from delusion 4. Directed the focus form

expression to discussion of reality delusion expression to
centered situation helps to divert discussion of reality. Mr.
the mind. Johnson Babu did not have
any delusion expression.

5. Helped correct false

5. Helps correct false beliefs with beliefs with increased level
increased level of anxiety to of anxiety.
prevent further dependency to
alcohol.
Sl ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
No DIAGNOSIS PLANNING,RATIONALE

3. SUBJECTIVE DATA 1. Build a good rapport with the 1. Built a good rapport Patient verbal
Patient says that Impaired Verbal patient to improve with the patient by talk communication
he cannot verbal communication communication with the improved and he
establish good communication will be improved as patient. expressed out his
rapport with related to evidenced by 2. Do not ignore the patient, 2. Patient is not ignored. problems clearly.
neighbors and incoherent patient verbalizes promotes anxiety.
other relatives speech pattern his problems
due to incoherent and side clearly. 3. Initiate the conversation 3. Initiated conversation
speech. effects of while the patient is in good while the patient is in
medication. mood, in order to get full happy mood,ie during the
OBJECTIVE DATA alteration of patient. play therapy.
Patient suddenly
starts to speak
incoherently and 4. Use an active friendly 4. Used an active friendly
he is unable to approach to have the approach to have the
verbalize all his therapeutic communication and therapeutic
problems. eliminate the fear of medical communication.
persons.

5. Provided comfortable and 5. Provided comfortable

trust worthy environment to and trust worthy
promote comfort to the patient. environment.
6. Use various communication 6. Used various
techniques like talking, communication
interviewing to improve verbal techniques like talking.
communication.
7. Provided a separate
7. Provide a separate place for place for talking and
talking and see that there is any collected his history and
disturbance while talking. reassured him.
Sl ASSESSMENT NURSING GOAL NURSING PLANNING,RATIONALE IMPLEMENTATION EVALUATION
No DIAGNOSIS

4. SUBJECTIVE Impaired Patient’s 1. Assessed for attention and 1. Assessed for attention
DATA concentration concentration and judgment of the patient for and judgment of the Patient’s
Patient says that and attention attention improved planning, nursing care. patient. Patient has less concentration
he is not able to related to as evidenced by attention and patience. and attention
concentrate in a alcohol intake. the works improved and he
particular thing, effectively and worked
for example in prays well. 2. Activities of such kind where 2. Observed activities of effectively as
his work and attention is required for a such kind where attention evidenced by his
prayer. longtime, to know about the is required for long time proper judgment
OBJECTIVE DATA concentration of the patient. and provided safety. and interest.
Patient is Provide new activities to hold the
irritable and did attention of the patient, it gives
not sitting at a new ideas and interest in doing
place and activities.
restless
3. Ask the patient to tell the 3. Asked the patient to tell
counting numbers backward and the counting numbers
also forward the attention of the backward and also
patient. forward.

4. Provide new activities to hold 4. Provided new activities

the attention of the patient, gives to hold the attention of the
new ideas and interest in doing patient like chess playing
activities. caroms play etc

5. Ask the patient to tell a story 5. Asked the patient to tell

and judge a moral and do not a story and he judges a
encourage wrong judgment and moral which was very
 teach correct judgment. appropriate.

5 ASSESSMENT NURSING GOAL NURSING PLANNING,RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSIS

SUBJECTIVE 1. Accept the patient with 1. Accept the patient with

DATA whatever feeling to improve the whatever feeling he has.
Patient says that Ineffective realization.
everyone looks family coping Patient feels 2. Encouraged the family
upon him with related to improved family 2.Encourage the family members members to socialize with Family coping
pity and he is depression coping to socialize with the patient the patient. improved as
separated from secondary to evidenced b y the
his parents, so alcohol 3. Instruct the family members to 3. Instructed the family patient’s
lacks his family dependence. show love and affection and be members to show love and verbalization and
coping. friendly with the client. affection and be friendly interactions with
with the client. family members.
0BJECTIVE DATA
Patient looks 4. Establish a trusting nurse – 4. Establish a trusting
depressed and patient relationship helps to nurse-patient relationship.
he needs maintain a good relationship.
dependable for
5. Involve patient in group 5.involved patient in group
his family and
activities. activities like yoga, playing
financial cricket etc
facilities. 6.provide health education to the
family members regarding the 6. Health education given
importance of providing self regarding the importance
of providing confidence
confidence to the patient and
and improving family
need for improved family relationships in recovery.
relationship in his recovery
Sl ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
No DIAGNOSIS PLANNING,RATIONALE

6 SUBJECTIVE DATA 1.Restrict amount and 1.Restricted amount and

Patient says that he is length f day time sleeping length f day time sleeping
sleeping late night Insomnia related Patient Patient maintained
and unable to sleep to emotional maintains normal sleep
as before since disturbances. normal sleep 2. Limit intake of 2. Adviced to limit the pattern as
hospitalization. pattern. caffeinated drinks. intake of caffeinated evidenced by his
drinks. verbalization.
OBJECTIVE DATA
Patient’s facial 3. Advice the patient to 3. Advised the patient to
expression shows avoid plenty of fluids avoid plenty of fluids
sleepy and he is before bedtime and void before bedtime as voiding
inactive. before bed time. will interfere with sleep.

4. Explain the person and 4. Health education given

significant others the regarding causes of sleep
causes of sleep disturbance and ways to
disturbance and possible avoid it.
ways to avoid it

5.Encourage the patient 5. Encouraged patient to

to have a cup of milk take a cup of milk before
before going to bed going to bed.

6. Provide calm and quiet 6. Provided calm and quiet

environment environment
Sl ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
No DIAGNOSIS PLANNING,RATIONALE

7. SUBJECTIVE DATA 1. Assess the level of 1. Assessed the level of

Patient is asking “what knowledge of the patient knowledge. Patient and
my problem is and and his family members family members have less Patient’s
what treatment is Knowledge deficit Patient gains knowledge regarding knowledge level
giving to me?” related to adequate disease condition. increased as
alcoholic knowledge evidenced by his
OBJECTIVE DATA dependence, regarding 2. Explain about the 2. Explained about the correct
Patient is asking the treatments and its disease treatment and home treatment and home answering to the
type of treatment for effects. condition. management. management. questions asked.
his alcoholic
dependence and its 3. Explain the importance of 3. Explained the
effect on his body. His taking medications regularly importance of taking
educational status is BA to prevent relapse. medications regularly.
Economics.
4. Provide health education 4. Provided health
regarding the disease education regarding the
condition and treatment disease condition and
strategies.
treatment strategies.
5. Explain the patient about 5.Explained all hospital
all hospital procedures
procedures
before implementing.
6. Encouraged questioning
6. Encourge questioning
and asking doubts.
and asking doubts.
Sl ASSESSMENT NURSING GOAL NURSING IMPLEMENTATION EVALUATION
No DIAGNOSIS PLANNING,RATIONALE
8. SUBJECTIVE DATA
1. Check for side effects of
Patient says that “I medicine, to prevent
have some shivering Potential for Patient remains complications like extra
in hands and legs.” complications free from pyramidal syndrome.
related to intake complications.
OBJECTIVE DATA of anti-anxiety 2. Assess the side effects of the
Patient is taking anti – drugs. drugs of the patient, to give
anxiety drugs. He is a proper nursing care.
case of alcoholic
dependence. So there 3. Check the side effects of
is a chance for Parkinsonism symptoms like
developing tremors, weakness, and
complications. irritability to do any works, to
prevent or detect it earlier and
care fast.
4. Teach the patient about the
side effects of drug and advice
to report if he is having any
symptoms helps to know about
the side effects of drugs.
5. Explain the importance of
follow-up to identify the
changes and behavior after
treatment.
1. Checked for the side
effects of medicine, no Patient remained
complications identified. free from
complications as
evidenced by
2. Assessed the side improvement in
effects and not identified patient’s
any complications. condition.
3. Check the side effects
of Parkinsonism
symptom, no side effects
identified.
4. Taught the patient
about the side effects of
drug and advice to report
if he is having any side
effects of drugs.
5. Explained the
importance of follow-up
to the patient.