EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH DEPRESSION

NURSING DIAGNOSIS: Complicated Grieving

RELATED TO: Real or perceived loss, bereavement overload
EVIDENCED BY: Denial of loss, inappropriate expression of anger, idealization of or
obsession with lost object, inability
to carry out activities of daily living
OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1. Determine the stage of grief in which

 Client will express anger about the loss. the client is fixed. Identify behaviors
 Client will verbalize behaviors associated with this stage.
associated with normal grieving 2. Develop a trusting relationship with the
Long-Term Goal client. Show empathy, concern, and
 Client will be able to recognize his or unconditional positive regard.
her position in the grief process, while 3. Convey an accepting attitude, and enable
progressing at own pace toward the client to express feelings openly.
resolution 4. Encourage the client to express anger.
Do not become defensive if the initial
expression of anger is displaced on the
nurse or therapist.
5. Help the client to discharge pent-up
anger through participation in large
motor activities (e.g., brisk walks,
jogging, physical exercises, volleyball,
punching bag, exercise bike).
6. Teach the normal stages of grief and
behaviors associated with each stage.
7. Encourage the client to review the
relationship with the lost concept. With
support and sensitivity, point out the
reality of the situation in areas where
 misrepresentations are expressed

EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH SCHIZOPHRENIA

NURSING DIAGNOSIS: DISTURBED SENSORY PERCEPTION: AUDITORY/VISUAL
RELATED TO: Panic anxiety, extreme loneliness, and withdrawal into the self
EVIDENCED BY: Inappropriate responses, disordered thought sequencing, rapid mood swings,
poor concentration, disorientation
OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1. Observe client for signs of hallucinations

Client will discuss content of hallucinations (listening pose, laughing or
with nurse or therapist within 1 week talking to self, stopping in midsentence). Ask,
Long-Term Goal “Are you hearing the
 Client will verbalize understanding that voices again?”
the voices are a result of his or her 2. Avoid touching the client without
illness and demonstrate ways to warning him or her that you are
interrupt the hallucination about to do so.
 Client will be able to define and test 3. An attitude of acceptance will encourage the
reality, reducing or eliminating the client to share the content of the hallucination
occurrence of hallucinations with you. Ask, “What do you hear the
voices saying to you? “misrepresentations are
expressed
4. Do not reinforce the hallucination. Use “the
voices” instead of words like “they” that
imply validation. Let client know
that you do not share the perception.
5. Help the client understand the
connection between increased
anxiety and the presence of
hallucinations
6. Try to distract the client from the
 hallucination

EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH SCHIZOPHRENIA

NURSING DIAGNOSIS: DISTURBED THOUGHT PROCESS
RELATED TO: Inability to trust, Panic level of anxiety, Repressed fears
EVIDENCED BY: presence of delusional thinking, suspiciousness, and inaccurate
interpretation of the environment.
OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1. Convey your acceptance of client’s need

 By the end of 2 weeks, client will for the false belief, while letting him or her
recognize and verbalize those false know that you do not share the belief.
ideas occur at times of increased 2. Do not argue or deny the belief
anxiety 3. Help client trye to connect the false beliefs
Long-Term Goal to times of increased anxiety
 By time of discharge from treatment, 4. Reinforce and focus on reality
client’s verbalizations will reflect 5. Assist and support client in his or her
reality-based thinking with no evidence attempt to verbalize feelings of anxiety,
of delusional ideation. fear, or insecurity.
 By time of discharge from treatment,
the client will
be able to differentiate between
delusional thinking and reality
EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH BIPOLAR DISORDER

NURSING DIAGNOSIS: IMPAIRED SOCIAL INTERACTION

RELATED TO: Delusional thought processes (grandeur and/or persecution); underdeveloped

ego

EVIDENCED BY: Inability to develop satisfying relationships and manipulation of others for
own desires

OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1. Recognize the purpose manipulative

behaviors serve for the client: to reduce
 Client will verbalize which of his or her
feelings of insecurity by increasing feelings of
interaction behaviors are appropriate
power and control.
and which are inappropriate within 1
2. Set limits on manipulative behaviors.
week
Explain to the client what is expected and what
Long-Term Goal
the consequences are if the limits are violated.
 Client will demonstrate use of
3. Do not argue, bargain, or try to
appropriate interaction skills as
reason with the client. Merely state
evidenced by lack of, or marked
the limits and expectations.
decrease in, manipulation of others to
4. Provide positive reinforcement
fulfill own desires.
for nonmanipulative behaviors

5. Help the client recognize that

he or she must accept the consequences of own
behaviors and refrain from attributing them to
others.
EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH ANXIETY

NURSING DIAGNOSIS: PANIC ANXIETY

RELATED TO: Real or perceived threat to biological integrity or self-concept

EVIDENCED BY: Inability to develop satisfying relationships and manipulation of others for
own desires

OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1. Recognize the purpose manipulative

behaviors serve for the client: to reduce
 Client will verbalize which of his or her
feelings of insecurity by increasing feelings of
interaction behaviors are appropriate
power and control.
and which are inappropriate within 1
2. Set limits on manipulative behaviors.
week
Explain to the client what is expected and what
Long-Term Goal
the consequences are if the limits are violated.
 Client will demonstrate use of
3. Do not argue, bargain, or try to
appropriate interaction skills as
reason with the client. Merely state
evidenced by lack of, or marked
the limits and expectations.
decrease in, manipulation of others to
4. Provide positive reinforcement
fulfill own desires.
for nonmanipulative behaviors

5. Help the client recognize that

he or she must accept the consequences of own
behaviors and refrain from attributing them to
others.
EXAMPLE OF NURSING CARE PLAN FOR A CLIENT WITH SUBSTANCE USE

NURSING DIAGNOSIS: INEFFECTIVE DENIAL

RELATED TO: Weak, underdeveloped ego

EVIDENCED BY: Statements indicating no problem with substance use

OUTCOME CRITERIA NURSING INTERVENTION

Short-Term Goals 1. Begin by working to develop a trusting

nurse-client relationship. Be honest. Keep all
 Client will divert attention away from
promises.
external issues and focus on behavioral
2. Convey an attitude of acceptance to the
outcomes associated with substance
client. Ensure that he or she understands “It is
use.
not you but your behavior that is
Long-Term Goal
unacceptable.”
 Client will verbalize acceptance of
3.Provide information to correct
responsibility for own behavior and
misconceptions about substance abuse.
acknowledge association between
4. Identify recent maladaptive behaviors or
substance use and personal problems
situations that have occurred in the client’s life,
and discuss how use of substances may have
been a contributing factor.
5. Use confrontation with caring. Do not allow
client to fantasize about his or her lifestyle