NURSING CARE PLAN 1

Date identified: July 16, 2021

Date evaluated: July 18, 2021

CUES NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective cue: Anxiety related to Short Term Goal: Independent: Short Term Goal:
cessation of alcohol
Objective cues: intake, physiological Within 4 hours of Identify cause of anxiety, Persons in acute phase of Goal met. Within 4 hours of
withdrawal as evidenced nursing interventions, involving client in the withdrawal may be nursing interventions,
-fear by increased the patient will be able process. Explain that unable to identify and/or patient was able to
helplessness, fear, to verbalize reduction of alcohol withdrawal accept what is demonstrate participation
-helplessness tension, hopelessness fear and anxiety to an increases anxiety and happening. Anxiety may in interaction with the
with loss of control of acceptable and uneasiness. Reassess be physiologically or student nurse in a calmer
-tension own life. manageable level. level of anxiety on an environmentally caused. manner and was able to
ongoing basis. verbalize acceptance of
- nausea and vomiting Long Term Goal: need for treatment and
Develop a trusting Provides client with a awareness that willpower
-loss of appetite Within 3 days of nursing relationship through sense of humanness, alone cannot control
interventions, the frequent contact and helping to decrease abstinence.
-insomnia patient will be able to being honest and paranoia and distrust.
regain and maintain nonjudgmental. Project Client will be able to Long Term Goal:
healthy state with a drug an accepting attitude detect biased or
and alcohol-free lifestyle. about alcoholism. condescending attitude Goal met. Within 3 days of
of caregivers. nursing interventions,
patient was able to engage
Inform client about what Enhances sense of trust, in peer support and
you plan to do and why. and explanation may demonstrate active
Include client in planning increase cooperation and participation in program.
process and provide reduce anxiety. Provides “With the support I have
choices when possible sense of control over self now I feel like I’m regaining
in circumstance where my healthy living. Though
loss of control is a I’m still working on to be a
significant factor. drug and alcohol-free
person,” as verbalized by
Assist patient to In the precontemplation the patient…………………….....
recognize problem exists. phase, the patient has K.P.Josol,FSUU/SN(7/16/21)
Discuss in a caring, non- not yet identified that
judgmental manner how drug use is problematic.
drug has interfered with While patient is hurting,
life; it is easier to admit
 substance use has
created negative
consequences.

Encourage verbalization May help patient begin

of feelings, fears, and to come to terms with
anxiety. long-unresolved issues.

Reorient frequently Client may experience

periods of confusion,
resulting in increased
anxiety

Guide and assist patient Although not mandatory

in self-examination of for recovery,
spirituality, faith. surrendering to and faith
in a power greater than
oneself has been found
to be effective for many
individuals in substance
recovery; may decrease
sense of powerlessness.
This also helps client to
meditate and achieve
Dependent: better sleep.

Administer medications, Anti-anxiety agents are

as indicated, for given during acute
example: withdrawal to help client
Benzodiazepines, such as relax, be less
chlordiazepoxide hyperactive, and feel
(Librium), and diazepam more in control.
(Valium).

Administer Barbiturates, These drugs are

such as phenobarbital, or sometimes used to treat
possibly secobarbital or prevent alcohol
(Seconal) or withdrawal seizures, but
pentobarbital need to be used with
(Nembutal) caution because they are
respiratory depressants.
 Collaborative:

Provide consultation or Client is more likely to

referral to detoxification contract for treatment
or crisis center for while still hurting and
ongoing treatment experiencing fear and
program as soon as anxiety from last drinking
medically stable episode. Motivation
decreases as well-being
increases and person
again feels able to
control the problem.

Explore support in peer Patient may need

group. Encourage sharing assistance in expressing
about drug hunger, self, speaking about
situations that increase powerlessness, admitting
the desire to indulge, need for help in order to
ways that substance has face up to problem and
influenced life. begin resolution.

NURSING CARE PLAN 2

Date identified: July 16, 2021
Date evaluated: July 18, 2021

CUES NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective cue: Ineffective individual Short Term Goal: Independent: Short Term Goal:
coping related to
Objective cues: personal vulnerability as Within 2 hours of nursing Complete an initial client This information can Goal not met. After 2 hours
evidenced by decreased interventions, the patient assessment; ask what help you anticipate the of nursing interventions,
- Impaired nutrition ability to handle will be able to identify and how much the client onset and severity of patient was still believing
pressure/stress ineffective coping usually drinks, as well as withdrawal symptoms. that only in alcohol and
- Physical exhaustion behaviors/consequences, the time and amount of The client’s memory may drugs she can feel
including use of alcohol the last drink of alcohol. be impaired or he or she contented. “Alcohol and
- Sleep disturbances and substances as a may not reveal the drugs are my only saviors
method of coping. actual extent of alcohol when I’m pressured,” as
- Dependence on intake. verbalized by the patient.
alcohol/drugs Long Term Goal:
Long Term Goal:
Within 3 days of nursing
interventions, the patient
will be able to establish a
balance of rest, sleep,
and activity
Provide food or Many clients who use
nourishing fluids as soon alcohol heavily Goal partially met. After 3
as the client can tolerate experience gastritis or days of nursing
eating; have something anorexia. It is important interventions, patient was
available at night. (Bland to reestablish nutritional able to verbalize having
food usually is tolerated intake as soon as the enough sleep but still
more easily at first.) client tolerates food. experiencing the urge to go
back to the dependency of
Determine Provides information alcohol and drugs. “I’m still
understanding of current about degree of denial, working on it,” as
situation, previous, and acceptance of personal verbalized by the
other methods of coping responsibility and patient………………………………
with life’s problems. commitment to change; K.P.Josol,FSUU/SN(7/16/21)
identifies coping skills
that may be used in
present situation.
Encourage verbalization May help patient begin
of feelings, fears, and to come to terms with
anxiety. long-unresolved issues.
Assist patient to learn Helps patient relax,
and encourage use of develop new ways to
relaxation skills, guided deal with stress,
imagery, visualizations. problem-solve.
Encourage involvement Therapeutic writing or
in therapeutic writing. journaling can enhance
Have patient begin participation in
journaling or writing treatment; serves as a
autobiography. release for grief, anger,
and stress; provides a
useful tool for
monitoring patient’s
safety; and can be used
to evaluate patient’s
progress.
Autobiographical activity
provides an opportunity
for patient to remember
and identify sequence of
events in his or her life
 that relate to current
situation.

Maintain a quiet, safe Helps patient to have a

environment during relaxing rest and sleep.
withdrawal from any Excessive noise may
drug. agitate the patient.

Dependent:

Administer medications Used to suppress craving

as indicated: such as for opioids and may help
Naltrexone (Trexan), prevent relapse in the
nalmefene (Revex). patient abusing alcohol.
Current research
suggests that naltrexone
suppresses urge to
continue drinking by
interfering with alcohol-
induced release of
Collaborative: endorphins.

Structure diversional Discovery of alternative

activity that relates to methods of coping with
recovery (social activity drug hunger can remind
within support group), patient that addiction is
wherein issues of being a lifelong process and
chemically free are opportunity for changing
examined. patterns is available.

Use peer support to Self-help groups are

examine ways of coping valuable for learning and
with drug hunger. promoting abstinence in
each member, using
understanding and
support as well as peer
pressure.