NURSING CARE PLAN CUES/CLUES Subjective: She said that her usual mood is calm but in times of difficulty her mood is mostly irritable. The client described herself as "maraminganak at nahihirapan". "Nahihirapanako, yunyungnafefeelko..parang gusto konangbumigay" . When asked if how she handled big problems in her life she answered “ Inaawaykonalangasawako”. Objective: - used negative forms of coping like arguing - inability to meet basic needs including no time for
NURSING DIAGNOSIS Ineffective coping related to difficulty adapting in stress
ANALYSIS
GOALS/ OBJECTIVES Inability to form a Goal: valid appraisal of After 4 hours the stressors, of nursing inadequate choices intervention, of practiced the client will responses, be able to and/or inability describe and to use available initiates resources. alternative coping Reference: strategies in Doenges, adapting Moorhouse&Murr’s stress. Nurse’s Pocket Guide edition 12, Objective: p. 257 1. After 1 hour of nursing intervention, the client will be able to determine degree of impairment
NURSING INTERVENTION
RATIONALE
EVALUATION After 4 hours of nursing intervention, the client able to describe and initiates alternative coping strategies in adapting stress.
-Assess specific stressors.
-Accurate appraisal can facilitate development of appropriate coping strategies.
-Assess level of understanding and readiness to learn needed lifestyle changes.
-Appropriate problem solving requires accurate information and understanding of
self hygiene - high illness rate as evidenced by high blood pressure Measurement: Date & Time: Feb. 24, 2014/4PM VS Temp: 36 C PR: 95 bpm RR: 21 breaths/min BP: 140/100 mmHg Date & Time: Feb. 24, 2014/8PM VS Temp: 36.1 C PR: 90 bpm RR: 22 breaths/min BP: 140/100 mmHg
options. -Assess decisionmaking and problem-solving abilities.
-Determine alcohol intake, drug use, smoking habits, sleeping and eating patterns.
2. After 1 hour of nursing intervention, the client will be able to assess coping abilities and skills.
-Establish a working relationship with patient through continuity of care.
-Provide opportunities to express concerns, fears, feelings, and expectations.
- Patients may feel that the threat is greater thantheir resources to handle it and feel a loss ofcontrol over solving the threat or problem. -These mechanisms are often used when individual’s is not coping effectively with stressors. -An ongoing relationship establishes trust, reduces the feeling of isolation, and may facilitate coping. -Verbalization of actual or perceived stress can help
reduce anxiety. -Encourage patient to identify own strengths and abilities.
3. After 1 hour of nursing intervention, the client will be able to deal with current situation.
-During crises, may not be able to recognize their strengths. Fostering -Provide information awareness can the patient wants expedite use of these and needs. Do not strengths. provide more than patient can handle. -Patients who are coping ineffectively -Encourage patient have reduced ability to communicate to assimilate feelings with information. significant others. - Instruct in need for adequate rest and prescribed diet.
-Unexpressed feelings can increase stress.
-Teach use of relaxation, exercise,
-These facilitate coping strengths.
and diversionalactivities.
4. After 30 minutes of nursing intervention, the client will be able to provide for meeting psychological needs. 5. After 30 minutes of nursing intervention, the client will be able to promote wellness.
-Determine previous methods of dealing with life problems.
-Converse at client’s level, providing meaningful conversation while performing care. -Encourage and support client in evaluating lifestyle, occupation, and leisure activities. -Provide for gradual implementation and continuation of necessary behavior/lifestyle.
Inadequate diet and fatigue can themselves be stressors. -Methods to cope with stress.
-To identify successful techniques that can be used in current situation. -Enhances therapeutic relationship.
-Promotes long term development that deals with current situation.
-Enhances commitment to plan. Reference: Doenges, Moorhouse&Murr’s Nurse’s Pocket Guide edition 12, p. 257-261
