WORKING PLAN OF CARE

Subjective Findings________Hopelessness, feeling fatigue

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Legal Status: _____________ Age__________ Sex______ Employment Status_________________

DSM-5 Diagnosis Current Stressors/Reason for Hospitalization

Adjustment disorder with Anxiety and Depression
 Made a statement regarding suicide while seeing PCP
 Avoided using technology now must use it
 Sold home now unsure of living arrangements
 Does not have much family support beside
grandchildren that live out of state

Assessment Tools Utilized Relevant Medications Cultural Needs

1. PHQ-9 1. Celexa Jehovah Witness
2. 2.
3. 3.
4. 4.
5. 5.
6

1. Risk for suicide related to hopelessness AEB stating not having much to live for and not having family support

INTERVENTIONS RATIONALES
1. Create a safe environment for the client 1. Prevent client from doing self-harm while in care
2. Helps the client feel safe and secure and feel
2.Spend time with the client important
3. Allow client to talk about feelings 3. Client feels like they are being listened to and
assess for causes of suicidal ideation.

EVALUATION/CLIENT RESPONSE/PROGRESS -The client progress continues to improve while in treatment and
stated did not feel like committing self-harm during conversation.

2. Ineffective coping related to emotion disturbance aeb having to sale her home and adjust to using new technology due
to the pandemic
INTERVENTIONS RATIONALES
1. Encourage discussion of angry feelings 1. Helps the client work through unresolved issues.

2. Help client to identify where control is 2. Decreases feelings of powerlessness.

maintained in life.
3. Increases self-esteem and desirable behaviors.
3. Provide positive feedback on adaptive coping skills

EVALUATION/CLIENT RESPONSE/PROGRESS Client is actively working on developing good coping habits by

participating in treatment plan and therapies.

3. Anxiety related to adjustment disorder aeb stating uncertainty of living arrangements after discharge

INTERVENTIONS RATIONALES
1. Use empathy to encourage the client to interpret the 1. The way a nurse interacts with a client influences his/her
anxiety symptoms as normal. quality of life. Providing psychological and social support
can reduce the symptoms and problems associated with
2. Assess the client's level of anxiety and physical reactions anxiety (Wagner & Bear, 2009).
to anxiety
 2. Generalized anxiety disorder (GAD) is the most common
3. If irrational thoughts or fears are present, offer the anxiety with a 12-month prevalence of 3.1% in population-
client accurate information and encourage him or her to based survey and between 5.3% and 7.6% among patients
talk about the meaning of the events contributing to the who visit primary care offices.
anxiety
3. In one study providing cancer patients with accurate
information about their disease, prognosis and outcomes
significantly reduced their anxiety and increased
empowerment (Lauzier et al, 2014).
EVALUATION/CLIENT RESPONSE/PROGRESS – Client reported always being a planner and working with case
management to find assisted living and is becoming okay with that plan.

Source:

EdS Rn, M. B. A. J., Msn Rn, G. L. B., & Fnap, M. M. P. R. C. F. B. (2016). Nursing

Diagnosis Handbook: An Evidence-Based Guide to Planning Care (11th ed.).

Mosby.

Townsend, M. C., & Townsend, M. C. (2014). Psychiatric Nursing (9th ed.). F.A. Davis

Company.