ASSESSMENT EXPLANATION OF THE PROBLEM OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: “I have a hard time coping Ineffective individual coping is the SHORT TERM GOAL: DX: DX: SHORT TERM GOAL:
since my divorce and sometimes I think of inability to from a valid appraisal of the After 8 hours of nursing intervention the 1. Assess for the presence of defining 1. Behavioral and physiological responses After 8 hours of nursing intervention the
committing suicide” stressor, inadequate choices of practiced client will be able to verbalize feeling, characteristics. to stress can be varied and provide clues to client was able to verbalize feelings, fears
responses. Client intoxicate herself with fears and emotions. Client will remain free the level of coping difficulty and emotions. She was able remain free
Objective: alcohol to relieve her stress. of destructive behavior toward self or 2. Situational factors must be identified to from destructive behavior towards self and
 Agitated other. Client will be able to identify own 2. Observe for cause of ineffective coping gain understanding of the patient’s current others. She was able to identify her
 Restlessness maladaptive coping behaviors. situation and to aid patient with coping maladaptive coping behaviors such as
 Anxious SOURCE: Nurse’s Pocket Guide Edition effectively drinking alcohol. Goal met.
 Hand tremors 14 3. Situational factors can lead to
 29 breaths per minute 3. Monitor risk for harming self and depression or risk for suicide.
 Inability to make decision intervene appropriately 4. Successful adjustment is influenced by
 Destructive behavior towards self 4. Analyze past use of coping mechanism previous coping success.
including decision making and problem 5. Patient may have a support in a single
 Inappropriate use of defense and
solving setting, such as during hospitalization, yet LONG TERM GOAL:
coping mechanism
LONG TERM GOAL: 5. Evaluate resources and support system lack sufficient support in the home settings After 3 days of nursing intervention the
After 3 days of nursing intervention the available to the patient client was able to identify different
Nursing Diagnosis:
client will be able to identify effective TX: effective coping strategies, she was able to
Ineffective individual coping related to
coping strategies, report decrease in 1. An ongoing relationship establishes report the decrease of negative feelings.
situational crisis as evidenced by alcohol
negative feelings. Client will be able to trust, reduce feeling of isolation, and may Client was able to initiate positive coping
intoxication
initiate positive coping strategies; and will TX: facilitate coping. strategies such as relaxation technique and
have the ability of decision making. 1. Set a working relationship with the 2. Acknowledging and empathizing exercises, she has the ability to make her
patient through continuity of care creates a supportive environment that own decision. Goal met.
enhances coping.
2. Use empathetic communication and 3. Involving clients in decision making
encourage client to verbalize fears, express helps them move toward independence
emotions and set goals 4. It can be helpful for the patient to
3. Assist client set realistic goals and recognize that she has the skills and
identify personal skills and knowledge. reserves of strength to effectively manage
4. Assist patient with accurately evaluating the situation.
the situation and their own 5. These mechanisms are often when
accomplishment individual’s coping effectively with
stressor
5. Determine alcohol intake, and substance
abuse EDX:
1. Relaxation techniques, desensitization
and guided imagery can help client cope,
EDX: increase their sense of control, and allay
1. Encourage client the use of cognitive anxiety
behavioral relaxation technique 2. Unexpressed feelings can increase
stress.
2. Encourage client to communicate
feelings with significant others 3. These facilitate coping strength.
3. Instruct client to have adequate rest and
balance diet 4. Relationships with persons with
common interest and goals can be
4. Encourage client to participate in self- beneficial.
help groups as available.
5. This well the client to have an option on
5. Educate client about the different choosing ways to relieve stress.
positive coping strategies.