NURSING CARE PLAN

Patient’s Initials: L.D Chief Complaint: Poor Coordination and Slurred Speech Name of Student Nurse:
Age & Gender: 39 yrs. Old/Male

Birthdate: August 23, 1983 Admitting Diagnosis: Denial r/t personal vulnerability Level/Block/Group:
AEB delay in refusal of healthcare attention to the
detriment of health/life
Address: Lucao District, Dagupan City, Hospital/Area:
Pangasinan, Philippines Patient’s Home
Date of Confinement: 03/17/2022 Clinical Instructor:
Date: 03/17/2022

ASSESSMENT NURSING GOAL/PLAN OF CARE NURSING INTERVENTIONS

DIAGNOSIS

Subjective Data: • Denial r/t After nursing interventions, the patient is INDEPENDENT:
 “Hindi ako lasing, personal expected to: - Determine how the patient like to be
okay lang talaga ako vulnerability AEB addressed.
ano ba kayo“ as delay in refusal of Short – Term:
verbalized by the healthcare - Verbalize awareness of relationship of - Demonstrate a positive attitude by
patient. attention to the alcohol abuse to current situation. isolating the individual from unwanted
detriment of behavior.
Objective Data: health/life - Can engage in therapeutic program
 Restlessness - Answer questions truthfully and provide
 Fatigue - Verbalize acceptance of responsibility for accurate data. When you make a
 Weakness own behavior. commitment, keep it.
 Loss of conscious
Long – Term: - Provide information regarding effects of
 Facial Grimace addiction on mood and personality.
Vital Signs taken: - Can regain and maintain healthy state with
 BP- 160/90 mmHg an alcohol-free lifestyle. - Provide positive feedback for expressing
awareness of denial in self and others.
 HR- 68 bpm
- Can demonstrate behaviors, lifestyle
 RR- 16 cpm changes to regain and maintain appropriate COLLABORATIVE:
 Temp- 37.5 degrees weight. - Review definition of drug dependence
Celsius and categories of symptoms (patterns of
- Set goals and participate in realistic planning use, impairment caused by use, tolerance
for lifestyle changes necessary to live without to substance).
drugs.
- Provide information about addictive use
versus experimental, occasional use;
biochemical or genetic disorder theory

- Encourage and support patient’s taking

responsibility for own recovery

- Encourage family members to seek help

whether or not the abuser seeks it.

- Maintain firm expectation that patient

attend recovery support and therapy
groups regularly.

- Administer medications such as

Disulfiram (Antabuse) since the drug can
be helpful in maintaining abstinence from
alcohol while other therapy is undertaken.

SOURCE:
https://nurseslabs.com/substance-abuse-
nursing-diagnosis-care-plan