Mental Health Promotion Plan (Individual)

Cues Nursing Rationale to Nursing Goals and Nursing Interventions Rationale to Nursing Measures of
Diagnosis Diagnosis Objectives Interventions Evaluation
Subjective Risk for After nursing Independent Intervention
Cues: Ineffective intervention 1. Determine the client’s functional abilities -Cognitive abilities can -The results of
>Suicidal ideas Coping will: and developmental level for the impact the client’s ability this
or behavor related adaptation of all future interventions. to develop appropriate assessment
“Mas maupay perceived Short term: coping behaviors. should be
atakehon nala threat of 1. Identifies 2. Discuss with the client his or her -Promotes the noted here.
ako” exposure to [number] of perception of the current crisis and development of a trusting -Assessment
>Feelings of Covid-19 support stressors. This should include information relationship by data on her
despair, systems by about the coping strategies that the client communicating respect perception
hopelessness, [date]. has attempted and his or her assessment for the client about current
and 2. Identify of what has made them ineffective in crisis and
worthlessness strategies to resolving this stressor or crisis. stressors,
“I dont think help in coping strategies
makakaya ko through 3. Assist the client in developing an -“De-catastrophizes” the -Time Table
it verbalization appropriate time frame for the resolution client’s perceptions of the for resolving
discrimination of 3-4 of the situation. (Often when experiencing situation. crisis
kun maging intervention a crisis, the individual has the perception
swabber ako” that resolution must take place
>Doesnt eat Long Term: immediately.) This could include, as
>Expresses 1. Ineffective appropriate to the client’s situation:
anger on small Coping Will • Informing the client that any difficulty
things return- that has taxed his or her resources as
demonstrate at much as this one has will take an
least [number] extended time to resolve because it must
Objective new coping be complex.
Cues: strategies by • Informing the client that a situation that
[date]. is as important as this one is to the
individual’s future deserves a well
thought-out answer and that a decision
VS: should not be made hastily.
T – 36.9˚C • Assisting the client in determining the
P – 71 bpm source of the time pressure and the
R – 19 cpm appropriateness of this time frame.
BP – 110/80 • Assisting the client in developing an
mmHg appropriate perspective on the time
 frame. (One question that could be useful
is “What would be the worst that could
happen if this problem is not resolved by
[put client’s stated time frame here]?”)
• Assist the client in understanding that Provides an opportunity
goals should be modest. Complex change for client success in
should be taken slowly. achieving change while
enhancing self-esteem

4. Provide a quiet, non-stimulating Inappropriate levels of -Potential

environment or an environment that does sensory stimuli can environmental
not add additional stress to an already increase confusion and stressors for
overwhelmed coping ability. disorganization. this client
should be
listed here
with the plan
for reducing
them in this
environment.
5. Sit with the client [number] minutes Communication of -Schedule of
[number] times per day at [specify times concerns in a supportive Counsel Visits
here] to discuss current concerns and environment can facilitate
feelings. the development of
adaptive coping
behaviors. Continues the
development of a trusting
relationship.
6. Assist the client with setting appropriate Inappropriate levels of -Verbalization
limits on aggressive behavior. environmental stimuli can of agreement
increase disorganization to set limits
and confusion, increasing and
the risk for acting-out demonstrate
behavior. effective
coping.
7. Provide the client with appropriate Physical activity decreases Verbalization
alternative outlets for physical tension. the tension that is related and
(This should be stated specifically and to anxiety. Appropriate demonstration
could include walking, running, talking control of behavior of effective
 with a staff member, using a punching promotes the client’s coping
bag, listening to music, or doing a deep sense of control and strategies
muscle relaxation sequence.) Strategies enhances self-esteem.
should be used [number] times per day at
[times] or when increased tension is
observed. These outlets should be
selected with the client’s input.
8. Orient the client to date, time, and place. Orientation enhances the -Client shows
Provide clocks, calendars, and bulletin client’s coping abilities. the clock,
boards. Make references to this calendar or
information in daily interactions with the bulletin board.
client. The frequency needed for this
client should be noted here (e.g., every 2
hours, every day, or three times a day).
9. Provide the client with familiar or needed Promotes the client’s -Notes about
objects. These should be noted here. sense of control, while familiar or
meeting security needs. needed
objects.
10. Provide the client with an environment Inappropriate levels of -Notes about
that will optimize sensory input. This sensory stimuli can intervention
could include hearing aids, eyeglasses, increase confusion and and time
pencil and paper, decreased noise in disorganization. accomplished.
conversation areas, or appropriate
lighting. (These interventions should
indicate an awareness of sensory deficit
as well as sensory overload.) The specific
interventions for this client should be
noted here, for example, place hearing aid
in when client awakens and remove
before bedtime (9:00 P.M.).
11. Provide the client with achievable tasks, Accomplishment of these List of
activities, and goals (these should be goals provides accomplished
listed here). These activities should be reinforcement and tasked and
provided with increasing complexity to encourages positive activities
give the client an increasing sense of behavior, while enhancing
accomplishment and mastery. self-esteem.
12. Communicate to the client an Assists the client to
understanding that all coping behavior to maintain self-esteem,
 this point has been his or her best effort diminishes feelings of
and that asking for assistance at this time failure, and promotes a
is not failure. A complex problem often positive orientation.
requires some outside assistance to
resolve.
13. Provide the client with opportunities to Notes
make appropriate decisions related to conversation
care at his or her level of ability. This may done during
begin as a choice between two options Counsel Visits
and then evolve into more complex
decision making. Notes
14. It is important that decision making be at Promotes the client’s conversation
the client’s level of functioning so that sense of control done during
confidence can be built with successful Counsel Visits
decision-making experience.
15. When a relationship has been developed Promotes development of Number of
with primary care nurse, this person will a trusting relationship. accomplished
sit with the client [number] minutes per counsel visits
shift to discuss concerns about sexual
issues, fears, and anxieties (begin with 30
minutes and increase as the client’s ability
to concentrate improves).
16. Provide constructive confrontation for the Assists the client in reality -List of
client about problematic coping behavior. testing of coping problematic
behaviors. behavior
identified by
the treatment
team
17. Provide the client with information about Promotes the client’s -Notes
care and treatment. Give information in sense of control. conversation
concise terms appropriate to the client’s Inappropriate levels of done during
level of understanding. sensory stimuli increase Counsel Visits
confusion and
disorganization.
18. Identify with the client methods for High levels of anxiety -List of client’s
anxiety reduction. Those specific methods decrease the client’s specific
selected should be listed here. coping abilities and methods ro
interfere with the reduce anxiety
 learning of new
behaviors.
19. Assist the client with practice of anxiety Repeated practice of a
reduction techniques, and remind him or behavior internalizes and Verbalization
her to implement these techniques when personalizes the behavior. and
level of anxiety is increasing demonstration
of effective
20. Provide the client with opportunities to Behavioral rehearsal helps coping
test problem solutions either by role- facilitate the client’s strategies
playing or by applying them to graded learning new skills
real-life experiences. through the use of
feedback and modeling by
the nurse.
21. Assist the client to revise problem Promotes positive
solutions if they are not effective. (This orientation and enhances
will assist the patient to learn that no the client’s self-esteem by Verbalization
solution is perfect or final and that turning disadvantages and
problem solving is a process of applying into advantages. demonstration
various alternatives and revising them, as of effective
necessary.) coping
22. Allow the client to discover and develop Promotes the client’s strategies
solutions that best fit his or her concerns. sense of control, and
The nurse’s role is to provide assistance development of new
and feedback and to encourage creative behaviors enhances the
approaches to problem behavior client’s problem-solving
behaviors and improves
self-esteem.
23. Teach the client skills that facilitate Increases repertoire of Verbalization
problem solving, such as assertive coping behaviors, and
behavior, goal setting, relaxation, decreasing allor-none demonstration
evaluation, information gathering, thinking. of effective
requesting assistance, and early coping
identification of problem behavior. Those strategies
skills that are identified by the treatment
team as being necessary should be listed
here with the teaching plan. This should
include a schedule of the information to
be provided and identification of the
 person responsible for providing the
information.
24. Spend [number] minutes two times per Repeated practice of a Number of
day at [times] with the client role-playing behavior internalizes and accomplished
and practicing problem solving and personalizes the behavior. counsel visits
implementation of developed solutions.
This will be the responsibility of the
primary care nurse.
25. Assist the client in identifying those Increases the client’s Verbalization
problems he or she cannot control or opportunities for success and
resolve and in developing coping in early problem-solving demonstration
strategies for these situations. This may attempts. This success of effective
involve alteration of the client’s provides reinforcement, coping
perception of the problem. which motivates positive strategies
behavior and enhances
self-esteem
26. Monitor the client’s desire for spiritual Increases the resources Progress notes
counseling, and refer to appropriate available to the client.
resources.
27. Provide positive social reinforcement and Reinforcement Verbalization
other behavioral rewards for encourages positive and
demonstration of adaptive problem behavior and enhances demonstration
solving self-esteem of effective
coping
strategies
28. Assist the client in identifying support Decreases the client’s -Health
systems and in developing a plan for their sense of social isolation. Promotion
use Plan

Collaborative Interention
1. Involve the client and family in Family involvement - Verbalization
planning and implementing strategies enhances effectiveness of and
to improve individual coping: interventions. demonstration
• Family conference: Identification of of effective
problem and role each family member coping
plays. strategies by
• Mutual goal setting: Set realistic goals. the family
Specify activities for each family member.
Establish evaluation criteria.
• Communication: Use accurate and
honest feedback in a positive manner.
Assist the family and client in lifestyle
adjustments that may be required:
• Stress management
• Development and use of support
networks
• Alteration of past ineffective coping
strategies
• Treatment for substance abuse
• Treatment for physical illness
• Activities to increase self-esteem:
Exercise or stress management
• Temporary assistance: Babysitter,
housekeeper, or secretarial support
2. Consult with and refer the patient to
assistive resources as appropriate.
Utilization of existing Referral Forms
services is efficient use of
resources. Resources such
as a psychiatric nurse
clinician, a family
therapist, and support
groups can enhance the
treatment plan.