ASSESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION

THE PROBLEM

Subjective Data: Patient experience STO: Independent: -Acute phase of withdrawal may STO:
alcohol withdrawal this Within 4 hours of nursing -Identify caused of anxiety, be unable to identify and/or Within 4 hours of nursing
-“Nahihirapan ako occur when a heavy intervention, the patient will involving patient in the process. accept what is happening. intervention, the patient
tumigil sa pag iinom drinker patient verbalize reduction fear Explain that alcohol withdrawal Anxiety may be physiologically verbalize reduction fear
pnakakapanghina” suddenly stops or and anxiety to an increases anxiety and or environmentally caused. and anxiety to an
reduces alcohol intake, acceptable and uneasiness. -Provides patient with a sense of acceptable and
this may experience a manageable level. humanness, helping to decrease manageable level.
Objective Data: combination of physical -Develop a trusting relationship paranoia and distrust. Patient
and emotional LTO: through frequent contact being will be able to decrease biased LTO:
-Appears anxious symptoms from mild After 4 to 5 days of nursing honest and non-judgemental. or condescending attitude of After 2 to 3 days of nursing
anxiety. intervention, the patient will Project an accepting attitude caregivers. intervention, the patient
-Slight tremors in express sense of regaining about alcoholism. -Enhances sense of trust, and express sense of regaining
his hand some control of -Inform patient about what you explanation may increase some control of
situation/life. plan to and why. Include patient cooperation/reduce anxiety. situation/life.
-Heart rate of in planning process and provide Provides sense of control over
110bpm choices when possible. self in circumstance where loss
of control is a significant factor.
-Appears flushed -Patient may experience periods
-Reorient frequently. of confusion, resulting in
-Tension increased anxiety.

Nursing Collaborative:
Diagnosis: Administer medications as
Anxiety related to indicated:
cessation of alcohol -Benzodiazepines, e.g.
intake withdrawal chlordiazepoxide (Librium),
diazepam (Valium).
-Barbiturates, e.g.
phenobarbital, or possibly
secobarbital (Seconal),
pentobarbital (Nembutal).
-Antianxiety agents are given
during acute withdrawal to help
patient relax, be less
hyperactive, and feel more in
control.
-These drugs suppress alcohol
withdrawal but need to be used
with caution because they are
respiratory depressants and
 -Provide consultation for referral
to detoxification/ crisis center for
ongoing treatment program as
soon as medically stable.
REM sleep cycle inhibitors.
-Patient is more likely to contract
for treatment while still hurting
and experiencing fear and
anxiety from last drinking
episode. Motivation decreases
as well-being increases and
person again feels able to
control the problem.

https://popularquotesimg.blogspot.com/2020/03/nursing-diagnosis-for-alcoholism-and.html

ASSESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION

THE PROBLEM
 SUBJECTIVE: The patient is risk for self- STO: Nursing Assessment STO:
-“Parang masarap na lang directed violence because Within 8 hours of shift Pt -A client with a high-risk At the end of the shift the
mamatay kesa mabuhay of her severe depression. will verbalize 3 techniques -Identify the level of suicide will require a constant patient verbalized the 3
ng walang katuturan” on developing copings precautions needed. supervision and a safe techniques on developing
skills to help her handle environment. coping skills to help her
stressful situations. handle stressful situations.
OBJECTIVE: -a suicidal client’s medical
-Check for the availability supply should be limited to
-Feelings of despair, LTO: of required supply of 3-5 days. LTO:
hopelessness, and Pt will remain free from medications needed. The patient remained free
worthlessness any self-harm during from any self-harm during
hospitalization. Therapeutic Interventions her stay in the hospital.
-Generalized restlessness -Encourage clients to -Clients can learn
or agitation express feelings (anger, alternative ways of dealing
sadness, guilt) with overwhelming
-Sleep disturbances: emotions and gain a sense
insomnia of control over his/her life.

-threatening verbalization -Reinforce reality: -To decrease false sensory

Correct client’s description
NURSING DIAGNOSIS: of inaccurate perception
Risk for self-directed -Reorient and let client
violence related to focus on real situations
depression and people
-Remove dangerous
objects (sharps and
breakable things) from the
client’s environment
perception and enhance
client’s sense of self-worth
and dignity.
-To provide safety to the
client, other patients and
personnel

https://www.registerednursern.com/nursing-care-plan-and-diagnosis-for-risk-for-self-harm-related-to-suicide-depression-nanda-nursing-interventions-and-outcomes/