Nursing Diagnosis: Powerlessness related to failure to communicate effectively

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE: Within 8 hours or providing 1. Identify situational circumstances that  To assess causative factor GOAL MET
 Feeling of guilt proper nursing made her feel powerless that leads and affects the At the end of 6 hours span of
 Seen to be always in deep interventions, pt. will be problem nursing care, the patient was
thought able to: 2. Encourage patient to rest  To promote adequate rest able to:
 Express sense of control and sleep  Express sense of control
over the present 3. Determine client’s perception and  Perception and knowledge of over the present situation
situation and future knowledge of condition the condition serves as the and future
outcome; basis for appropriate nursing  Acknowledge reality that
 Acknowledge reality interventions some areas are beyond
that some areas are individual’s control
4. Listen to verbalization of feelings and
beyond individual’s  To determine degree of  Make choices related to
note for negative expressions like
control powerlessness and be involved in care
“giving up” and “I’m tired”.
5. Note nonverbal behavioral responses
Within 2 days of providing  Gestures and nonverbal cues
proper nursing are significant in looking
interventions, pt. will be deeper into what a person
able to: feels. It is one important way
 Make choices related to of expressing one’s feelings
6. Show concern for client as a person.
and be involved in care.  To make the client feel that
she is not alone and gives
7. Express hope for the client increases her self-esteem
 There is always hope in
8. Identify the area that she can do everything
and areas beyond her control.  This helps the client
9. Encourage client to maintain a recognize her own ability
sense of perspective about the situation.  To promote optimism and
10. Encourage use of anxiety and stress- positive outlook towards life
reduction techniques such as thinking of  To promote wellness.
happy thoughts and positive self-recitation
Nursing Diagnosis: Ineffective coping related to situational crisis

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE: After 4 weeks of nursing
 Inappropriate use of intervention client will:
defense mechanisms  Talk/communicate with
 Inability to SO about situation and
cope/difficulty asking for changes that have
help occurred.
 Change in usual  Verbalize awareness of
communication patterns own coping abilities.
 Inability to meet basic  Meet psychological
needs/role expectations needs as evidenced by
appropriate expression
of feelings,
identification of options,
and use of resources.
1. Assess extent of altered perception 1. Determination of GOAL MET
and related degree of disability. individual factors aids in After 4 weeks of nursing
Determine Functional Independence developing plan of intervention client was:
Measure score. care/choice of  Talk/communicate with SO
2. Identify meaning of the dysfunction interventions and about situation and changes
and change to patient. Note ability to discharge expectations. that have occurred.
understand events, provide realistic 2. Some patients accept and  Verbalize awareness of
appraisal of the situation. manage altered function own coping abilities.
3. Determine outside stressors: family, effectively with little  Meet psychological needs
work, future healthcare needs. adjustment, whereas as evidenced by appropriate
4. Provide psychological support and others may have expression of feelings,
set realistic short-term goals. Involve considerable difficulty identification of options,
the patient’s SO in plan of care when recognizing and adjust to and use of resources.
possible and explain his deficits and deficits. In order to
strengths. provide meaningful
5. Encourage patient to express support and appropriate
feelings, including hostility or anger, problem-solving,
denial, depression, sense of healthcare providers need
disconnectedness. to understand the
6. Acknowledge statement of feelings meaning of the
about betrayal of body; remain stroke/limitations to
matter-of-fact about reality that patient.
patient can still use unaffected side 3. Helps identify specific
and learn to control affected side. needs, provides
Use words (weak, affected, right- opportunity to offer
left) that incorporate that side as part information and begin
of the whole body. problem-solving.
Consideration of social
 factors, in addition to
functional status, is
important in determining
appropriate discharge
destination.
4. To increase the patient’s
sense of confidence and
can help in compliance to
therapeutic regimen.
5. Demonstrates acceptance
of patient in recognizing
and beginning to deal
with these feelings.
6. Helps patient see that the
nurse accepts both sides
as part of the whole
individual. Allows
patient to feel hopeful
and begin to accept
current situation.
Nursing Diagnosis: Anxiety related to stress

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE: After 2 hours of nursing 1. Observe client’s behavior. 1. Helps client to identify GOAL MET
 Fear may be seen in some intervention, the client will 2. Review coping skills the client used in what is reality-based. At the end of 6 hours span of
facial expression. be able to appear relax and past. 2. To determine those that nursing care, the patient was
report anxiety is reduced to
 Regret 3. Establish therapeutic relationship might be helpful in current able to:
a manageable level.
 Insomnia conveying empathy and unconditional circumstances  Express sense of control
positive regard. 3. To avoid contagious over the present situation
4. Be available to client for listening and effect/transmission of and future
talking. anxiety.  Acknowledge reality that
5. Provide comfort measures such as calm 4. Knowing that someone some areas are beyond
and quiet environment and Provide understands what he feels
individual’s control
privacy for the patient and relatives. it can help to at least
 Make choices related to
lessen the burden and
and be involved in care
show support.
5. To avoid the occurrence of
precipitating factor that
may increase the anxiety.