Laguardia Community College

Louise Margaret Tomas

SCR200.4710

03/20/2008

LAGUARDIA COMMUNITY COLLEGE

Nursing Program

NURSING CARE PLAN

SCR200

Nursing Actions/ Rationale

Nursing Diagnosis Expected Outcomes Implementation (Cite Specific Sources) Evaluation

(Number nursing diagnoses in order of priority.)
1-Social isolation r/t Disease process (Schizophrenia) as evidenced by client does not attend group activities and client does not interact with staff.
2-Risk for loneliness r/t client refusal to participate in group activities, and client’s family not visiting often
as evidenced by
client not attending group activities, staying in her room, and the client stating that her family does not visit.
3-Risk for constipation r/t medications side effects as evidenced by client is taking Abilify.
4-Disturbed sleep pattern r/t inadequate
Day time activity and uncomfortable sleep environment as evidenced by client yawning and stating “I feel tired; I want to take a nap for a little bit.’
5. Self-esteem disturbance related to feelings of inferiority and sense of inadequacy, as evidenced by client stating, “No one loves me. I want to have a family but no one marry me.”
6. Self- esteem disturbance r/t personal identity as evidenced by poor hygiene, uncombed hair and soiled attire.
7. Social Isolation r/t failure to establish trust as evidenced by client was in her room lying down, avoidance of social activities with other residents and she has never been married before and she doesn’t have a boyfriend. / 1-The client will identify feelings of isolation within 3-4 weeks.
2-The client will practice social and communication skills needed to interact with others during hospital stay.
3-The client will initiate interaction with others within 3-4 weeks.
4-The client will participate in one of the group activities for 20 minutes by the end of the week.
1. Client will participate in ongoing positive and relevant social activities that are personally meaningful in one week.
2. Client will maintain one or more meaningful relationships allowing self-disclosure and demonstrate a balance between emotional dependence and independence before discharge.
1-Maintains passage of soft, formed stool every 1 to 3 days without straining.
2-Identifies measure that prevents or treats constipation by discharge.
3-Encourage client to respond promptly to defecation reflex.
4-Encourage client to eat fiber in his daily meals and to increase intake of fluids to reduce constipation.
1. Pt will verbalize satisfaction with sleep-rest pattern as evidenced by stating, “I slept well” within 1 week.
Client will:
1. Make one positive statement about self within 48 hours.
Client will:
1.  state accurate self-appraisal.
2.  take bath and comb hair within 48 hours.
Client will:
1.  Identify barriers that cause impaired social interactions.
2.  Participate in activites and programs at level of ability and desire within 72 hours.
3.  Describe feelings of self-worth before discharge. / 1-The nurse should establish a therapeutic relationship with client by being present and showing a caring attitude.
2-Provide positive reinforcement when client seeks out others.
3-Establish trust one to one then gradually introduce the client to others.
4-Put client into groups or allow client to select which group according to preference, abilities, age.
1-Encourage the client to be involved in meaningful social relationship that are characteristics of both giving and receiving support.
2-Explore ways to increase the client’s support system and participation in groups and organization.
3-Encourage the client to develop closeness in at least one relationship.
1-Observe usual pattern of defecation including time and day, amount and frequency of stool, consistency of stool.
2-Encourage fiber intake of 25g per day for adults.
3-Encourage fluid in take of 1.5 to 2 liters per day.
1. Observe the client’s medication, diet and caffeine intake.
2. Eliminate or reduce sleep interruptions by closing the door or pulling the curtains
1. Schedule meetings with client that ensure privacy and communicate her importance as an individual.
2. Examine with client specific feelings regarding herself.
3. Encourage client to express emotions, fears, feelings of inferiority, and sadness.
4. Identify with client achievements that would make the client feel better about herself and focus on one of these.
1.  Treat client with respect and as an equal to maintain positive self esteem.
2.  Encourage the client to create a sense of competence through short term goal setting and goal achievement.
1.  Establish a therapeutic relationship by being emotionally present and authentic.
2.  Establish trust one on one and then gradually introduce the client to others. Allow the client oppurtunities to introduce issues and to describe his or her daily life. / 1-Being emotionally present and authentic fosters growth in relationships and decreases isolation. (Ackley 1126)
2-Receiving instrumental social support such as feedback contributes to a positive self being,
3-This is individualization of care.
4-Positive social interaction is enhanced when you provide opportunities or assist in making decisions.
(All above from Ackley & Ladwig, p. 1127-1129)
1-It is important to recognize that the positive relevance of social relationships is related to the content and quality relationship.( Mosby 782)
2-Satisfaction with support networks was a potent predictor of self-esteem, emotional health. (Mosby 782)
3-Dependence and independence should be balanced in healthy relationship, which will reduce risk for loneliness. ( Mosby 782)
1-There are often multiple reasons for constipation; the first step is assessment.
2-Fiber helps prevent constipation by giving stool bulk.
3-Adequate fluid intake is necessary to prevent hard dry stools.
(All above form Ackley & Ladwig, p. 692-695)
4-The reflex that cause the urge to defecate diminishes after a few minutes and may remain quite for several hours, as a result the stool becomes hardened and more difficult to expel. (Ackley 302)
1. Difficulty sleeping can be a side effect of medication. Also, caffeine can interfere with sleep. (Mosby pg 886)
2. Excessive noise or changes in the environment can cause poor quality sleep. (Mosby pg 887)
1. Facilitate feelings of acceptance
and belonging and validate client’s worth. (Johnson, p 556)
2. Client’s view of himself is a vital aspect of his personality.
(Johnson, p. 555)
3. Expression will provide catharsis. (Johnson, p. 555)
4. To foster client’s sense of accomplishment. (Johnson, p. 558)
1.Clients with Schizophrenia may have significant self-care deficits. Inattention to hygiene and grooming needs is common, especially during psychotic episodes. (Videbeck pg 290)
1.  Relating to others is difficult when one’s self-concept is not clear. Clients have problems with trust and intimacy, which interfere with the ability to establish satisfactory relationships with others and the environment. These clients lack confidence, feel strange or different from other people and don’t believe they are worthwhile. The result is avoidance of other people. (Videbeck 290)

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