Brenda a 40 year old woman with a history of multiple admission is admitted to a psychiatric

facility. Brenda was found wandering in front of a church, incoherent and disheveled. During
MSE, Brenda is noted to have flat affect and is withdrawn. She reports not seeing her family for
5 years and cannot remember when she last held a job. There is no history of hallucinatory or
delusional thought content in this recent admission. The nurse knows Brenda and knows that
during past admission she responded to a less expensive Haloperidol. After admission, Brenda
says “let us go, onward, forward, backward (pause) Brenda hide and died. When asked where
she lives, Brenda slowly responded overthere, somewhere, anywhere, nowhere”. Brenda’s
boarding housekeeper knows her well and a bed is being kept for her.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSI
S

OBJECTIVE Impaired SHORT TERM 1.Establish a 1. The therapeutic After a series of

DATA: Social GOAL : therapeutic relationship improves nursing
-Withdrawn Interaction By the end of nurse-client understanding and interventions, the
-Disorganized the day, the relationship through can aid in the patient was able to
Speech patient will frequent, quick formation of a be involved in
have rapport interactions and a positive relationship social interaction
with the nurse. positive attitude. between the nurse through the
SUBJECTIVE Show unconditional and the patient. support group and
DATA: positive regard. Your was able to
- “ I haven’t presence, reconnect with
seen my family acceptance, and family.
in 5 years” LONG TERM communication of
GOAL: good regard will help
After a week, the client feel better GOAL MET.
the patient will about herself.
be able to
interact and 2. Encourage the 2.These therapeutic
reconnect with patient to participate strategies are intended
friends, family in social and physical to assist the patient in
and peers activities. overcoming feelings of
isolation as a result of
poor social connection
with people of varied
ages at least once a
week. Furthermore,
 exercise allows
patients to have a
varied routine while
also improving their
mental condition.
Enrolling the patient in
a support group might
be suitable for
long-term intervention.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSI
S

OBJECTIVE Self Care SHORT TERM 1. Initially, assist the 1. The client may have After a series of
DATA: Deficit GOAL : client with personal little awareness of the nursing
- Disheveled After nursing tasks as needed. need for hygiene or interventions, the
appearance interventions Brushing their teeth, other activities of daily patient was able to
the patient will showering, and living or may have little demonstrate
- Inattention to be able to combing their hair are or independence in
grooming and begin in examples of good no interest in these. self care.
Personal performing hygiene.
Hygiene activities
personal 2. Provide supervision 2.The patient's GOAL MET.
hygiene with for each activity until capacity to conduct
nurse the patient self-care measures
assistance successfully may fluctuate over
within demonstrates the time and should be
24 to 48 hours competence and is evaluated on a
placed in independent frequent basis.
LONG TERM care; review on a
GOAL: regular basis to
After nursing ensure that the
interventions patient maintains the
the patient will skill level and is safe
be able to in the setting.
demonstrate
independence
in performing
activities of
daily living,
personal
hygiene, and
meeting other
self-care
needs