ACTUAL NURSING CARE PLAN

CUES Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Expected Outcomes

Subjective/ Objective

Subjective: Impaired social interaction Short Term: Independent Nursing GOAL MET. After 8 hours of
related to disturbance in Interventions: independent, dependent,
- “the depression was thought process as After 8 hours of independent, and collaborative nursing
back” she reported evidenced by dysfunctional dependent, and collaborative interventions, the patient
because of crying nursing interventions, the ● It provides a secure
interaction with family and ● Establish rapport and comfortable was able to understand her
many time through colleagues client will be able to: condition and how to
the week is a “sign” with the client. environment in
which the patient manage it as evidenced by:
- she said that may express her
psychotherapy Scientific Explanation: ● verbalize her thoughts, feelings,
“worked okay” until feelings and and concerns.
● verbalizing current
another depressive Impaired Social Interaction- concerns on how to
episode a state in which an individual feelings and
participates in either an cope with her concerns;
- stated that she is insufficient or an excessive condition; ● It ensures that the
“not at all like them” quantity of social exchange, patient has the
● identifying a present
because her aunt or with an ineffective quality ● identify one support information and
knowledge she support system;
and grandfather who of social exchange. system;
were hospitalized for ● Assess the patient's needs to manage
her condition ● using a social
mania ● use at least one level of insight and
understanding of her effectively. activity to manage
Reference recreational or social
condition, and negative emotions
activity to manage with social
Nurse’s Pocket Guide, providing education
Objective: negative emotions
Interventions, and and resources as ● This will help the interactions; and
with social
- long history of Rationales 15th Ed, needed. healthcare team in
interactions; and
(Doenges, Moorhouse, and creating a treatment ● taking all
 depression Murr). plan that addresses medications and
● take medications
the patient's specific stating how they
- depressed for a and verbalize their goals and needs. help her well-being
month since her new importance in her
job regimen

- concerned of boss ● A calm and less LONG TERM GOAL MET.

and colleagues’ stimulating Within 3 days of
thoughts of her Long Term: environment can independent, dependent,
After 3 days of independent, help her relax and and collaborative nursing
- no energy or focus on the task of interventions, the client
enthusiasm at home dependent, and collaborative
nursing interventions, the social interaction, successfully decreased
- watches TV instead client will be able to: ● Assess the patient's increasing the negative emotions on social
of playing with her current level of chances of a interactions as evidenced by:
children or talking to social interaction successful
husband and identify specific interaction.
● demonstrate an
areas of difficulty. ● initiating and
- overeating improvement in
initiating and maintaining social
- oversleeping maintaining social ● This can help intercations; and
intercations; and improve her ability to
- gained 6 lbs in 3 manage negative ● verbalizing decrease
weeks which made ● verbalize decrease emotions associated in negative emotions
her feeling worse in negative emotions with social associated and
● Provide an increased positive
associated with interactions.
- crying many times a environment with emotions toward
social interactions
week minimum stimuli, social interactions
and increase
such as a quiet
- often thought of positive emotions
room with soft music
death but never and dim lighting.
attempted suicide

- fuzzy memory about

history of depression
- had at least 5
different periods of
depression as an
adult involving ● Social activities
depressed mood, provide
lack of energy, deep opportunities for her
feelings of guilt, loss to interact with
● Provide the patient
of interest in sex and others, which can
with coping
some thoughts that help to build and
strategies and
life wasn’t worth maintain social
stress-management
living connections and
techniques to
- periods of “too improve their ability relationships, while
much” energy, to manage negative recreational
irritability and racing emotions associated activities can help to
thoughts that last for with social improve physical
hours, days or a interactions. health, which can
couple of weeks also have a positive
impact on mental
- perceived “like a health.
different person” by
her husband when ● Encourage the
she seemed excited, patient to participate
happy, and self- in recreational and
confident social activities to ● This can enhance
promote the patient's ability
- had help from to form and maintain
socialization and
mental health care healthy
improve overall well-
providers since mid- relationships.
being.
teens but could not
attend sessions and
would just quit

- Lithium salts and

 antidepressant gave ● Expressing feelings
her short-term relief and concerns can
from depression help her identify and
followed by relapse understand the
specific issues that
- family history (aunt are impacting her
and grandfather) of social interactions.
mania This can help her to
feel heard and
validated, which can
improve self-esteem
and self-confidence.

● Assess the patient's

support system and
provide appropriate
referrals as needed. ● Addressing the
triggers can help her
develop a sense of
control over the
situation, which can
● Encourage the help to reduce
patient to express feelings of
her feelings and helplessness and
concerns and hopelessness.
provide emotional
support to help her
cope with the impact
of the disorder on
her social ● This can help
interactions. adjusting
interventions as
 needed to promote
improvement in
social interaction
● Assist the patient to and overall
identify and address functioning.
any triggers that
may lead to negative
social interactions.

● It helps in ensuring
that the patient is
receiving safe and
effective care.

● Document and
report the patient's
progress to her
physician.

● Medications help to
improve the patient's
symptoms, and
promote overall well-
being. Educating the
patient about
medications give her
knowledge and a
sense of control for
her own regimen.
● Monitor any side
effects and adverse
 reactions to
medicine.
● It provides
comprehensive care
and support for the
patient, ensuring
that the she receives
a coordinated,
holistic approach to
her care, which can
Dependent Nursing
improve overall
Interventions:
health outcomes
and recovery.

● Administer
medications
● This can teach the
(Vortioxetine &
patient specific skills
Diazepam) as
such as initiating
prescribed and
conversations,
educate the patient
maintaining eye
how they can help
contact, and
her condition.
understanding
nonverbal cues.

Collaborative Nursing
Intervention:

● Collaborate with
 other healthcare
providers as needed
to provide
comprehensive care
and support for the
patient.

● Implement a
communication plan
to improve the
patient's ability to
initiate and maintain
social interactions,
including the use of
social skills training
and communication
techniques.

References:
Herdman, T. H., Kamitsura, S. & Lopes, C. (2023). NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
Martin, P. (2022). 6 Bipolar Disorders Nursing Care Plans. https://nurseslabs.com/bipolar-disorders-nursing-care-plans/
Steger, M. F. & Kashdan, T. B. (2010). Depression and Everyday Social Activity, Belonging, and Well-Being. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860146/