Castro, Alona

Galleon, Danica Kate

Date / Time Focus Data Action Response

2-26-2021 Ineffective D: Received patient looking hopeless with rugged clothes and disheveled hair;
3pm individual coping with visible dark circles on both eyes; "I feel weak and wanted to die, I feel
hopeless" as verbalized by the patient.
A: Assessed client’s strengths and positive coping skills; Assessed need for
assertiveness training; Identified situations that trigger suicidal thoughts;
Evaluated resources and support systems available to the patient;
Administered prescribed medications; Encouraged patient to join group
therapy; Encouraged patient to join programs like art and crafts, games or
singing
R: patient acknowledged the teaching by stating that he believes his/her life
has value and that they have an important role to play and started to open up
with his thoughts
 Assessment Nursing Diagnosis Goals and Objective Nursing Interventions Rationale Evaluation

Subjective: Ineffective individual After 8 hours of nursing Assessed client’s strengths Use these to build upon and draw from in Goal met. After 8 hours of
coping related to interventions, the and positive coping skills; planning alternatives to self-defeating nursing intervention, the
"I feel weak and difficulty adapting in patient will have behaviors. patient acknowledged the
wanted to die, I feel stress and anxiety acknowledged the teaching by stating that he
hopeless" teaching by stating believes his/her life has
that he believes When people have difficulty getting their value and that they have an
Assessed need for needs met or asking for what they need,
his/her life has value important role to play and
assertiveness training; frustration and anger can build up, leading to,
and that they have an started to open up with his
in some cases, ineffective outlet for stress.
important role to play thoughts
and started to open
up with his thoughts
Identify targets for learning more adaptive
coping skills.
Identified situations that
trigger suicidal thoughts;
Patients may have support in a single setting,
such as during hospitalization, yet lack
Evaluated resources and sufficient support in the home setting.
support systems available to
the patient;

To treat mental illness

Administered prescribed
medications;
Encouraged patient to join
group therapy;
Relaxation techniques, desensitization, and
guided imagery can help patients cope,
increase their sense of control, and allay
anxiety.

Interventions that improve body awareness

such as exercise, proper nutrition, and
muscular relaxation may be helpful for
Encouraged patient to join
programs like art and crafts, treating anxiety and depression
games or singing