Patient's Initials: R Gender: F Student Name: AaLona Robinson, SN

Date(s) Cared For (Month & Day only): Nursing Care Plan Form Instructor's Name:

Course Number: NRSG 220 Care Plan #: 2

Nursing Diagnosis ***Clinical Reasoning *** Client Expected Nursing Interventions Rationale Evaluation of
(Actual- 3 parts; Risk For Explain your rationale for Outcomes (with sources) Expected Outcomes
2 parts: Readiness for 2 choosing this nursing (short & long term) (Be clear: Start with (include date/time)
parts; include secondary diagnosis. Include With Expected Outcome Nursing will)
to as appropriate.) connections/relationships Criteria
between the parts of the n. Start with Patient will
dx. EX: how the R/T
caused the problem.
Patient expressed feelings Patient will make 1. Facilitate development 1. Trust is necessary 1S: Patient verbalized
Anxiety/Death Anxiety of anxiety and stress. decisions and follow of a trusting relationship before patient and/or understanding of the
Patient has a history of through with appropriate with patient and/or family family can feel free to open stages of grief and loss,
Related to anxiety prior to diagnosis actions to change 2. Assess patient and personal lines of ventilated conflicts and
that has been increased reactions to situations in significant other for stage communication with the feelings related to illness
Patient being newly because of the new her personal environment of grief currently being health care team and and death.
diagnosed with Acute diagnosis. as evidenced by the experienced. Explain address sensitive issues. MET
Myeloid Leukemia (AML). following indicators: process as appropriate. 2. Knowledge about the
Perceived death of patient. 3. Provide open, grieving process 2S: Patient explained
Anticipated loss of Short Term: nonjudgmental reinforces the normality of information learned
physiological well-being. 1S: Verbalizes known environment. Use feelings and/or reactions from educational
fears and anxiety therapeutic being experienced and can pamphlets on AML,
As Evidenced By communication skills of help patient deal more including treatments and
2S: States accurate active listening and effectively with them. statistics of prognosis.
O: Patient information about the affirmation. 3. Promotes and MET
crying and agitated situation 4. Encourage encourages realistic Short Term Goals Met by
S: Patient reports nausea, verbalization of thoughts dialogue about feelings end of shift
fatigue, and/or concerns and and concerns. 05/ 24 /2017 3pm
apprehension, COMPLETE EVERY SHIFT accept expressions of 4. The patients coping
and jitteriness. sadness, anger, rejection. behavior may be based on 1L: Patient stated that she
Patient also reports Long Term: Acknowledge normality of cultural perceptions of will take it one minute
feelings of fear of 1L: Identifies, verbalizes, these feelings. normal and abnormal at a time to stay
death and stress and demonstrates those 5. Reinforce teaching coping behavior. positive. Patient also
Worrying about impact of coping behaviors that regarding disease process 5. Patient and significant states that she will
ones own death reduce own anxiety and treatments and other will benefit from adhere to anxiety
on SOs 2L: Reports and provide information as factual information. medication regimen.
Powerlessness over issues demonstrates reduced requested or Patient may ask direct MET
related to dying anxiety appropriate about dying. questions about death,

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 3L: Patient uses coping Be honest; do not give
strategies to deal with false hope while providing
feelings of being emotional support.
overwhelmed 6. Review past life
4L: Identify personal experiences, role changes,
strengths and accept sexuality concerns, and
support through the coping skills. Promote an
health care teams environment conducive to
relationships. talking about things that
5L: Continue normal life interest patient.
activities, looking 7. Encourage
toward/planning for the participation in care and
future, one day at a time. treatment decisions.
8. Visit frequently and
provide physical contact
as appropriate or desired,
or provide frequent phone
support as appropriate for
setting. Arrange for care
provider and/or support
person to stay with
patient as needed.
9. Determine spiritual
needs or conflicts and
refer to appropriate team
members including clergy
and/or spiritual advisor
10. If the patient is
physically capable,
encourage moderate
aerobic exercise.
11. Refer to visiting nurse,
home health agency as
needed, or hospice team,
when appropriate.
12. Use active listening
and acceptance to help
client express emotions
such as crying, guilt, and
anger (within appropriate
limits).
13. Identify need for and
appropriate timing
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and honest answers 2L: Patient reports
promote trust and provide decreased anxiety, but
reassurance that correct still has episodes of
information will be given. crying bouts.
PARTIALLY MET
6. Opportunity to identify (continue POC)
skills that may have as of end of shift
helped individuals cope 05/24/2017 3pm
with grief in the past may
establish source of
confidence to work 3L: Patient listed positive
through current situation attributes that she
more effectively. possesses right now along
7. Allows patient to retain with strengths to build
some control over life. confidence to handle
8. Helps reduce feelings of negative situations.
isolation and
abandonment. 4L: Patient listed positive
9. Providing for spiritual attributes that she
needs, forgiveness, prayer, possesses right now and
devotional materials, or plans to participate in
sacraments as requested Cancer support group
can relieve sessions discussed with
spiritual pain and provide the nurse.
a sense of peace. Praying
and religion are frequently 5L: Patient expressed how
used effective coping planning for the future
strategies was a trigger for anxiety
10. Aerobic exercise and wants to take it
improves ones ability to minute by minute
cope with acute stress. UNMET
11. Provides support in (continue POC)
meeting physical and
emotional needs of patient LONG TERM GOALS MET
and/or SO, and can BY 05/ 24/2017 3pm
supplement the care
family and friends are able
to give.
12. Active listening
provides the client and/or
family a nonjudgmental
person to listen to them
and relieve their guilt
 of antidepressants
and anxiety medications.
14. Identify which family
members the client can
rely on for support.
15. Encourage the clients
appropriate expression of
feelings regarding
treatment or discharge
plans. Support any
realistic plans the patient
proposes.
16. Provide time for a rest
period during the clients
daily schedule.
17. Encourage the client
to follow a routine of
sleeping at night rather
than during the day; limit
interaction with the client
at night and allow only a
short nap during the day.
18. Teach client about
available community
resources (e.g., therapists,
ministers, counselors, self-
help groups).
These interventions are
reinforced Q Shift
appropriately.
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feelings (Hopkins, 1994).
Acknowledgment of
feelings communicates
support and conveys that
they are understood
(Leske, 1998).
13. May alleviate
distress, enhance coping,
especially for patients not
requiring analgesics.
14. Many Latinos, Native
Americans, and African-
Americans rely on family
members to cope with
stress (Abraido-Lanza,
Guier, Revenson, 1996;
Seiderman et al, 1996).
15. Positive support can
reinforce the clients
healthy expression of
feelings, realistic plans,
and responsible behavior
after discharge.
16. The clients increased
activity increases his or
her need for rest.
17. Talking with the client
during night hours will
interfere with sleep by
stimulating the client and
giving attention for not
sleeping. Sleeping
excessively during the day
may decrease the clients
ability to sleep at night.
18. Resource use helps to
develop problem-solving
and coping skills (Feeley,
Gottlieb, 1998). Client and
family teaching that
promotes the ability to
understand and carry out
any necessary medical,
 rehabilitative, or daily
living activities
contributes to a sense of
mastery, competency, and
control and is vital to
discharge planning and
community- based
assessments (Norris,
1992).

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