Louise Margaret Tomas

SCR200.4710
03/20/2008
LAGUARDIA COMMUNITY COLLEGE
Nursing Program
NURSING CARE PLAN
SCR200

Nursing Actions/ Rationale

Nursing Diagnosis Expected Outcomes Implementation (Cite Specific Sources) Evaluation
(Number
nursing
diagnoses in
order of
priority.)

1-Social isolation 1-The client will identify 1-The nurse should establish 1-Being emotionally present and
r/t Disease feelings of isolation within 3- a therapeutic relationship authentic fosters growth in
process 4 weeks. with client by being present relationships and decreases isolation.
(Schizophrenia) and showing a caring attitude. (Ackley 1126)
as evidenced by 2-The client will practice
client does not social and communication 2-Provide positive 2-Receiving instrumental social
attend group skills needed to interact with reinforcement when client support such as feedback contributes
activities and others during hospital stay. seeks out others. to a positive self being,
client does not
interact with 3-The client will initiate 3-Establish trust one to one 3-This is individualization of care.
staff. interaction with others within then gradually introduce the
3-4 weeks. client to others. 4-Positive social interaction is
enhanced when you provide
4-The client will participate 4-Put client into groups or opportunities or assist in making

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 in one of the group activities allow client to select which decisions.
for 20 minutes by the end of group according to (All above from Ackley & Ladwig,
the week. preference, abilities, age. p. 1127-1129)

2-Risk for 1. Client will participate in 1-Encourage the client to be 1-It is important to recognize that
loneliness r/t client ongoing positive and relevant involved in meaningful social the positive relevance of social
refusal to social activities that are relationship that are relationships is related to the content
participate in personally meaningful in one characteristics of both giving and quality relationship.( Mosby
group activities, week. and receiving support. 782)
and client’s family
not visiting often 2. Client will maintain one or 2-Explore ways to increase 2-Satisfaction with support networks
as evidenced by more meaningful the client’s support system was a potent predictor of self-
client not relationships allowing self- and participation in groups esteem, emotional health. (Mosby
attending group disclosure and demonstrate a and organization. 782)
activities, staying balance between emotional
in her room, and dependence and 3-Encourage the client to 3-Dependence and independence
the client stating independence before develop closeness in at least should be balanced in healthy
that her family discharge. one relationship. relationship, which will reduce risk
does not visit. for loneliness. ( Mosby 782)

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3-Risk for 1-Maintains passage of soft, 1-Observe usual pattern of 1-There are often multiple reasons
constipation r/t formed stool every 1 to 3 defecation including time and for constipation; the first step is
medications side days without straining. day, amount and frequency of assessment.
effects as stool, consistency of stool.
evidenced by 2-Identifies measure that 2-Fiber helps prevent constipation
client is taking prevents or treats constipation 2-Encourage fiber intake of by giving stool bulk.
Abilify. by discharge. 25g per day for adults.
3-Adequate fluid intake is necessary
3-Encourage client to respond 3-Encourage fluid in take of to prevent hard dry stools.
promptly to defecation reflex. 1.5 to 2 liters per day. (All above form Ackley & Ladwig,
p. 692-695)
4-Encourage client to eat
fiber in his daily meals and to 4-The reflex that cause the urge to
increase intake of fluids to defecate diminishes after a few
reduce constipation. minutes and may remain quite for
several hours, as a result the stool
becomes hardened and more
difficult to expel. (Ackley 302)

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4-Disturbed sleep 1. Pt will verbalize 1. Observe the client’s 1. Difficulty sleeping can be a side
pattern r/t satisfaction with sleep-rest medication, diet and caffeine effect of medication. Also, caffeine
inadequate pattern as evidenced by intake. can interfere with sleep. (Mosby pg
Day time activity stating, “I slept well” within 1 886)
and week. 2. Eliminate or reduce sleep
uncomfortable interruptions by closing the 2. Excessive noise or changes in the
sleep door or pulling the curtains environment can cause poor quality
environment as sleep. (Mosby pg 887)
evidenced by
client yawning
and stating “I
feel tired; I want
to take a nap for
a little bit.’

1. Schedule meetings with 1. Facilitate feelings of acceptance

5. Self-esteem Client will: client that ensure privacy and and belonging and validate client’s
disturbance 1. Make one positive communicate her importance worth. (Johnson, p 556)
related to statement about self within 48 as an individual.
feelings of hours. 2. Examine with client 2. Client’s view of himself is a vital
inferiority and specific feelings regarding aspect of his personality.
sense of herself. (Johnson, p. 555)

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inadequacy, as 3. Encourage client to 3. Expression will provide catharsis.
evidenced by express emotions, fears, (Johnson, p. 555)
client stating, feelings of inferiority, and
“No one loves sadness. 4. To foster client’s sense of
me. I want to 4. Identify with client accomplishment. (Johnson, p. 558)
have a family but achievements that would
no one marry make the client feel better
me.” about herself and focus on
one of these.

6. Self- esteem Client will: 1. Treat client with 1.Clients with Schizophrenia may
disturbance r/t 1. state accurate self- respect and as an have significant self-care deficits.
personal identity appraisal. equal to maintain Inattention to hygiene and grooming
as evidenced by 2. take bath and comb positive self esteem. needs is common, especially during
poor hygiene, hair within 48 hours. 2. Encourage the client psychotic episodes. (Videbeck pg
uncombed hair to create a sense of 290)
and soiled attire. competence through
short term goal setting
and goal achievement.

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7. Social Client will: 1. Establish a therapeutic 1. Relating to others is difficult
Isolation r/t 1. Identify barriers that relationship by being when one’s self-concept is
failure to cause impaired social emotionally present not clear. Clients have
establish trust as interactions. and authentic. problems with trust and
evidenced by 2. Participate in activites 2. Establish trust one on intimacy, which interfere
client was in her and programs at level one and then with the ability to establish
room lying of ability and desire gradually introduce satisfactory relationships
down, avoidance within 72 hours. the client to others. with others and the
of social 3. Describe feelings of Allow the client environment. These clients
activities with self-worth before oppurtunities to lack confidence, feel strange
other residents discharge. introduce issues and or different from other
and she has to describe his or her people and don’t believe they
never been daily life. are worthwhile. The result is
married before avoidance of other people.
and she doesn’t (Videbeck 290)
have a boyfriend.