Nursing Client Goals/Desired Nursing Interventions/Actions/Orders I Evaluation

DX/Clinical Outcomes/Objectives Goals Interventions

Problem
Risk for self or Long-Term Goal: Long-Term Interventions: Long-Term: 1.) The client stated that by
other- directed Client will identify 1.) Assist clients to identify precipitants of Evaluation of knowing the way his body feels
violence r/t impulse behaviors dysfunctional mood, differentiating what can and this goal is set when he gets in aggressive
impulsivity and and demonstrate cannot be changed. Help them identify available for [date]. The moods, he can to stop and think
impaired appropriate self- resources and personal strengths. Teach new client has about what his next move is
judgment and control behaviors to problem-solving and coping skills. (Foley, 2010). demonstrated going to be instead of acting out
persuasive refrain from harming Rationale: Knowledge of precipitants helps clients progress toward on impulse. He also said that he
disregard for self and others by develop strategies to prevent mood changes. Using this goal by knows that instead of punching
the rights of [date]. personal strengths and abilities enhances feels of identifying that or pushing a peer, he can go to
others AEB control. he now knows the staff to talk about the
risk-taking 2.) Develop a behavioral management plan that is when he is situation.
behaviors, Short-Term Goal: implemented consistently among all healthcare becoming 2.) The client discussed a time
irritability, Client will displace providers. Communication of rules, expectations, angry and what when he did not follow the rules
anger and anger to meaningful and consequences should be addressed as well as usually results during gym time and
aggressiveness, activities, refrain limitations on intrusive, interruptive behaviors. when he does consequentially he lost gym
conflict with from verbal Provide consistent consequences for both desired not control his privileges for the rest of the
authority, outbursts, and and undesired behaviors and praise the desired impulses. He week and did not receive his
history of display no aggressive behaviors (Foley, 2010). has also points for the day. He stated that
previous activity [date] Rationale: Consistency about rules and expectations demonstrated he knows he deserves the
violence, and reduce power struggles and promote feelings of less aggressive punishment, and from now on he
impulsive, security for clients. Positive feedback for desired behaviors will be patient and follow the
explosive behaviors helps reinforce them. towards his rules.
behavior 3.) Have client keep an anger diary and discuss peers during 3.) The client had just found out
alternative responses together. Teach cognitive conflicts. about a death in his family, and
behavioral techniques for self- evaluation from the shortly following had an
client (Ackley, & Ladwig, 2008). Short-term: altercation with a peer where he
Rationale: Clients with anger management Evaluation of was shoved. He demonstrated
difficulties may not be aware of changes and cues this goal was self-control behaviors by putting
that they are becoming angry or of a time delay in set for [date]. his hands up, taking a few steps
the stimulus to their angry response. By using The client has backward, and explaining to the
cognitive behavior techniques and reviewing the accomplished peer why he was upset and that
diary with staff, the client can identify though this goal by he did not want to fight. They
processes leading u to anger and the space between using both apologized and moved on.
the stimulus and response. meaningful
physical
activities
Short-Term Interventions: whenever he
1.) Identify stimuli that initiate violence and the gets angry,
means of dealing with the stimuli, such as walking refraining from
away. (Ackley, & Ladwig, 2008). verbal outbursts
Rationale: Assisting the client to identify situations by explaining
and people that upset him provides information his feelings
needed for problem solving. The client can then first, and not
identify alternative responses: leaving the stimulus, getting into
initiating a distracting activity, or responding aggressive
assertively rather than aggressively. activity. 1.) The client verbally expressed
stimuli that triggered his
2.) Emphasize that the client is responsible for his violence: not being able to get
choices and behavior. Introduce descriptions of his way, being wrong, having
possible effects of a client’s aggressive/violent everyone tell him what to do.
behavior on others (Ackley, & Ladwig, 2008). 2.) The client expressed that he
Rationale: In many cases clients operate from a wants to be able to control his
worldview that perceives others as instruments of temper and that he knows all of
the clients’ gratification. Clients must gain that they the clients in the facility are
are dealing with other human beings who under stress. He stated that some
experience pain. Clients’ behaviors influence how people clash so it is best to avoid
others respond to them. them or try to decrease their
triggers as well as his own to
3.) Redirect possible violent behaviors into physical promote a better environment.
activities such as doing pushups and sit-ups 3.) The client has gone to his
(Ackley, & Ladwig, 2008). room to do pushups and sit-ups
Rationale: Activities that distract while draining whenever his temperament has
excess energy help to build a repertoire of escalated.
alternative behaviors for stress reduction.
Medical Diagnoses: Anxiety, Change in environment, situational crisis, and stress
Subjective Problem Long Term: ∙ Assess the client's ∙ A successfully ∙ If the client’s level
∙ Client Anxiety By a week from level of anxiety met goal would of anxiety
states the the date of care, and physical be evident by decreases
XXXXX XXXXXX, the reactions to anxiety the client being throughout the
family lived client will (tachycardia, able to week this
through a identify, tachypnea, identify, intervention has
hurricane verbalize, and nonverbal verbalize, and been successfully
and lost demonstrate expressions of demonstrate 4 used. If it does not
their techniques to anxiety). Consider techniques to decrease
home as a control using The Face control throughout the
result anxiety (Ackley Anxiety Scale. (It anxiety. An week this
∙ Family & Ladwig, is important to unsuccessfully intervention has not
relocated 2008). assess the client’s met goal would been successfully
to xxxxx baseline anxiety occur if the used.
6 months level to determine client can not ∙ If the client
ago if any progress has do this by verbalizes having
been made to xxxx4, 2xxxx. used positive self
Objective control anxiety) talk throughout the
∙ Could (Ackley & Ladwig, week to control
include 2008). anxiety this
increased ∙ Encourage the intervention has
urination client to use been successfully
or positive self-talk used. If the client
diarrhea, such as, “I can do does not use
shortness this one step at a positive self talk or
of breath, time,” “Right now does not feel the
increased I need to self talk is
HR, breathing” decreasing anxiety
sweating, (Cognitive therapy levels then the
etc. changes behaviors intervention was
by changing not successful.
thoughts. It is ∙ If the client
important to use verbalizes feeling
positive self talk additional support
instead of negative and a further
self talk) (Ackley decrease in anxiety
& Ladwig, 2008). levels as the result
∙ Provide backrubs or of back rubs or
aromatherapy for aromatherapy the
the client to intervention has
decrease anxiety been successful. If
(Massage and the touch is not
aromatherapy can therapeutic to the
help to decrease client or
tension in the body, aromatherapy does
thus decreasing not decrease
anxiety) (Ackley & anxiety levels, the
Ladwig, 2008). intervention has not
been successful.
R/T Short Term: ∙ If the situational ∙ A successfully ∙ If the client
Change in By the end of response is met goal is verbalizes an
environment, the date of care, rational, use shown when increase in self
situational xxxxx, the empathy to the client can esteem as a result
crisis, and client will encourage the verbalize her of therapeutic
stress identify and client to interpret symptoms of validation and
verbalize the anxiety anxiety. An conversation this
AEB symptoms of symptoms as unsuccessfully intervention has
Concerns due anxiety (Ackley normal (Validating met goal is if been successful. If
to change in & Ladwig, client feelings the client can the client does not
life events, 2008). promotes self not identify her feel an increase in
living through esteem, which can symptoms of self esteem this
a natural increase quality of anxiety by the intervention has not
disaster, and life) (Ackley & end of the date been successful.
relocating Ladwig, 2008). of care. ∙ If the client
(Ackley & ∙ Guided imagery can verbalizes a
Ladwig, be used to decrease decrease in anxiety
 2008). anxiety (Guided following guided
imagery can help imagery this
to decrease tension intervention has
in the body and been successful. If
mind, thus the client does not
decreasing anxiety) feel a decrease in
(Ackley & Ladwig, anxiety after guided
2008). imagery this
∙ Use therapeutic intervention has not
touch and healing been successful.
touch techniques
(Touch can be
therapeutic and
further encourage
open discussion)
(Ackley & Ladwig,
2008).

Nursing Client Goals/Desired Nursing *I Evaluation

Assessment DX/Clinical Outcomes/Objectives Interventions/Actions/Orders Goals Interventions
Problem and Rationale
Subjective Problem Long Term: 1.Engage client in individualized * Client able to engage
Unable to obtain Function at maximum communication to maximize in simple
any information Chronic cognitive level client interaction and response conversation relating
from client confusion 1. communication that involve to present time
clients interests improves
communication abilities in those
with dementia above the level
that would normally be expected

Objective
Client unable to R/T Short Term: 1.break down self care tasks into * 1.Goal met: client
answer simple 1. participate in simple steps able to assist during
questions Diminished activities of 1. simple verbal prompts can help bath time and
regarding past mental daily living at those with dementia be more participated in
events capacity the maximum independent dressing self
secondary to of functional 2. decrease stimuli in the 2.goal met: client
Client repeats dementia ability environment and institute * showed no signs of
questions and 2. remain activities associated with pleasant agitation
unable to retain content and emotions
information free of harm 2. a decrease in stimuli decreases
until agitation
Extreme of age discharge
(93) AEB
Impaired long
Disoriented to term and short
place and time term memory
 Medical Diagnoses: Chronic Confusion, Diminished mental capacity secondary to dementia

Medical Diagnoses: Post-trauma Syndrome, Disaster, sudden destruction of one’s home and community
Assessment Nursing DX/ Client Goals/ Nursing *I Evaluation
Clinical Problem Desired Interventions/Actions/Orders Goals Interventions
Outcomes and Rationale
Subjective Problem Long Term: ∙ Explore and enhance ∙ A successfully met ∙ If the client can identify
∙ Client states Post-trauma Client will available support systems goal would be support systems and
the xxxx syndrome return to pre- and resources. (Support evident by the client community resources,
family lived trauma level of systems and community returning to her the intervention is
through a functioning as resources can encourage level of functioning successful. If the client
hurricane and quickly as communication and can before the traumatic can not, the
lost their possible (Ackley reduce isolation) (Ackley & event. An intervention has not
home as a & Ladwig, Ladwig, 2008). unsuccessfully met been successful.
result 2008). ∙ Help the client regain goal would be if the ∙ If the client’s sleep and
∙ Family previous sleep and eating client does not eating habits return to
relocated to habit. (Post-trauma return to pretrauma what they were before
xxxxx 6 syndrome can impact functioning level. the traumatic event the
months ago sleeping and eating habits, intervention is
working to get these areas successful, if these
Objective back to pretrauma levels is areas to not return to
∙ Could include key) (Ackley & Ladwig, normal, the intervention
sleep 2008). was not successful.
disturbances, ∙ Help the client use positive ∙ The intervention would
vivid cognitive restructuring to be successful if the
flashbacks, reestablish feelings of self- client verbalizes
depression, worth. (Fluctuations and increased feelings of
etc. feelings of decreased well- self-worth. If the client
being can occur due to post- can not do this, the
trauma syndrome) (Ackley intervention has not
& Ladwig, 2008). been successful.
R/T Short Term: ∙ Observe for a reaction to a ∙ A successfully met ∙ A successfully carried
Disaster, sudden Client will traumatic event in all clients goal would be out intervention would
destruction of one’s acknowledge regardless of age or sex. evident by the client be if the client can be
home and traumatic event (Post-trauma syndrome can using open identified as either
community and begin to impact anyone, at any communication to having post-trauma
work with the age) (Ackley & Ladwig, discuss feelings syndrome or not having
trauma by 2008). about the hurricane post-trauma syndrome.
talking about the ∙ Provide a safe and therapeutic that occurred. An ∙ If the client verbalizes
AEB experience and environment. (A safe, unsuccessfully met feeling safe in the
Anxiety, flashbacks, expressing therapeutic environment will goal would be environment the
and fear (Ackley & feelings of fear, allow the client to feel more shown if the client intervention has been
Ladwig, 2008). anger, anxiety, at ease talking through the does not openly successful. If the client
guilt, and traumatic communicate does not feel safe, the
helplessness a experience) (Ackley & feelings related to intervention has not
week from the Ladwig, 2008). the traumatic event. been successful.
date of care, ∙ Remain with the client and ∙ If the client verbalizes
xxxxx(Ackley & provide support during feeling supported
Ladwig, 2008). periods of overwhelming during intense
emotions. (Support will emotional periods the
allow the client to feel at intervention has been
ease discussing the traumatic successful. If the client
event) (Ackley & Ladwig, does not feel supported
2008). the intervention has not
∙ Use touch with the client's been successful.
permission (e.g., a hand on ∙ If the client verbalizes
the shoulder, holding a feeling additional
hand). (Touch can be support as the result of
therapeutic to a client, and physical touch the
 I

Nursing Client Goals/Desired Nursing Interventions/Actions/Orders Evaluation

DX/Clinical Outcomes/Objectives
Problem Goals Interventions
can further encourage open intervention has been
Chronic low Long Term Long Term discussion) (Ackley & Long Term successful.
LongIfTerm
the touch
self-esteem Ladwig, 2008). is not therapeutic to the
r/t impaired Client will verbally 1: Work with client on areas that he or she * client, Client
Evaluation set for [Month] the intervention
states that he
cognitive give an accurate and would like to improve using problem-solving 8, [Year] at 1400. Clienthas notdoesn’t
been successful.
know of
self-appraisal nonjudgmental account skills. Evaluate need for more teaching in this has made some progress areas that he could
AEB of three positive area. toward goal; on [Month] improve on. He
negative qualities as well as 14, [Year] he was able to thinks that he has
feedback identify two areas that Rationale: Feelings of low self-esteem can identify 2 strengths and did reached his
about self he wishes to improve interfere with usual problem-solving abilities not reject positive self maximum potential.
through by [Month] 8, [Year] at (Varcarolis, pg 171). feedback. Nursing student
client’s 1400. worked with client
statement of, 2: Work with client to identify cognitive Short Term to identify that he
“I don’t have Short Term distortions that encourage negative self- focuses on negative
any good appraisal. Goal met. As of [Month] qualities while
qualities” Client will identify one * 14, [Year] at 1400 client discounting his
and client or two strengths by Rationale: Cognitive was able to identify two positive attributes.
seeking [Month] 14, [Year] at strengths: being a good Client states that he
validation. 1400. listener and having good would like to work
communication skills. on being able to
accept positive
feedback.

Short Term
distortions reinforce negative, inaccurate
perception of the world (Varcarolis, pg. 170). Assessment of
client’s
Developing both self-acceptance and self-
esteem have been identified as ways to
enhance cognitive interventions (Macinnes,
pg 483).

Short term:

1: Assess existing strengths and coping strengths shows

abilities, and provide opportunities for their * that he is very
expression and recognition. intelligent and can
hold a good
Rationale: Supporting a client’s beliefs and conversation. The
self-rejection and helping them cope can nursing student
affect self-esteem (Ackley & Ladwig, pg. worked with the
716). client to identify his
strength in
2: Reinforce the personal strengths and communication.
positive perceptions that the client identifies.

Rationale: Clients with low self-esteem need

to have their existence and value confirmed *
(Ackley & Ladwig, pg. 717).