Assessment Nursing Diagnosis Nursing Goal Nursing Intervention Rationale Outcome Criteria

Subjective: Risk for suicidal After 4-8 hours of Determine history of If present, suicide risk is (Goal met)
“everyone would be tendency related to nursing intervention, suicide attempts. increased.
better off without depression patient will be Client
me” as verbalized by involved in planning Observe for suicidal Clients who are demonstrates use
the patient. course of action to behaviors: verbal contemplating suicide of adaptive
correct existing statements. often give clues coping strategies
Objective: problems and regarding their potential when feelings of
-verbal dictation of Scientific basis: verbalize control of behavior. hostility or
taking one’s own life Behaviors in which an impulses. Develop therapeutic suicide occur.
-hopelessness individual nurse-patient Promotes sense of trust
-disrupted family life demonstrates that he relationship. allowing patient to
or she can be discuss feelings openly.
physically, Encourage expression
emotionally, and/or of feelings and make Helps individual sort out
sexually harmful to time to listen for thinking and begin to
self . concerns. develop understanding
of situation.
Determine suicidal
intent and available The risk of suicide is
means. Ask direct greatly increased if the
questions. client has developed a
plan and particularly if
the client has means to
execute the plan.
Obtain verbal or
written contract from  A contract gets the
client agreeing not to subject out in the open
harm self and to seek and places some of the
out staff if suicidal responsibility for his or
ideation occurs. her safety with the
client.
Discuss losses client
has experienced and Unresolved issues may
 meaning of those be contributing to
losses. thoughts of
hopelessness.
Monitor environment
for potential safety To increase client
hazards. safety/reduce risk of
impulsive behavior.

Engage in physical
activity programs. Promote feelings of self-
worth and improves
Involve family/SO in sense of well being.
planning/patient care.
To improve
understanding and
Administer support.
medications as
prescribed. To manage mood
changes and prevent
aggressive behavior.

Subjective: Ineffective coping Goal: After 4 hours of -Assess specific -Accurate appraisal can After 4 hours of
“My children are related to difficulty nursing intervention, stressors. facilitate development nursing
currently home alone adapting in stress the client will be able of appropriate coping intervention, the
and that she fears to describe and -Assess level of strategies. client able to
losing them since I Scientific basis: initiates alternative understanding and -Appropriate problem describe and
have no family to Inability to form a coping strategies in readiness to learn solving requires initiates
help her” valid appraisal of the adapting stress needed lifestyle accurate information alternative coping
stressors, inadequate changes. and understanding of strategies in
choices of practiced options. adapting stress.
Objective: used responses, and/or -Assess decision
negative forms of inability to use making and problem - Patients may feel that
coping like arguing available resources. solving abilities. the threat is greater
than their resources to
 handle it and feel a loss
of control over solving
-Determine alcohol the threat or problem.
intake, drug use,
smoking habits, -These mechanisms are
sleeping and eating often used when
patterns. individual’s is not coping
-Establish a working effectively with
relationship with stressors.
patient through -An ongoing relationship
continuity of care. establishes trust,
reduces the feeling of
-Provide opportunities isolation, and may
to express concerns, facilitate coping.
fears, feelings, and
expectations. -Verbalization of actual
-Encourage patient to or perceived stress can
identify own strengths help reduce anxiety.
and abilities.
-During crises, may not
be able to recognize
-Provide information their strengths.
the patient wants and Fostering awareness can
needs. Do not provide expedite use of these
more than patient can strengths.
handle. -Patients who are
coping ineffectively have
-Encourage patient to reduced ability to
communicate feelings assimilate information.
with significant others.
- Instruct in need for -Unexpressed feelings
adequate rest and can increase stress.
prescribed diet.
 -Teach use of -These facilitate coping
relaxation, exercise, strengths. Inadequate
and diversional diet and fatigue can
activities. themselves be stressors.
-Determine previous -Methods to cope with
methods of dealing stress.
with life problems.
-Converse at client’s
level, providing -To identify successful
meaningful techniques that can be
conversation while used in current
performing care. situation.
-Encourage and -Enhances therapeutic
support client in relationship.
evaluating lifestyle,
occupation, and leisure
activities. -Promotes long term
-Provide for gradual development that deals
implementation and with current situation.
continuation of
necessary -Enhances commitment
behavior/lifestyle. to plan.