Nursing Care Plan
Nursing DX/Clinical Problem
Client Goals/Desired Outcomes/Objectives
Ineffective coping r/t disturbance in pattern
of tension release, uncertainty and inadequate resources available
as evidenced by client report of consuming a quart of alcohol a day, client
report of smoking a pack of cigarettes a day, report of sleep disturbance and verbalization
of avoiding others in the community out of fear and verbalization of lack of friends
and lack of communication with family members.
Short term goals:
will identify personal strengths as measured by the verbalization of two characteristics
that aid in problem solving by 15:00, [Month] 14, [Year].
will describe previous stressors and coping mechanisms used as measured by verbalization
of at least two stressful circumstances and how she coped with them by 15:00, [Month]
will express feelings about using substances as a method of coping with stress as
measured by verbalization of those emotions by 15:00, [Month] 14, [Year].
Long term goals:
will demonstrate ability to cope effectively to stressors measured by utilization
of two new stress-reducing skills by 15:00, August 1, [Year]
will verbalize use of adaptive coping mechanisms utilized instead of substance use
in response to stress as measured by verbalization of coping mechanisms by 15:00,
August 1, [Year].
Monitor client for risk of harming self
or others and intervene as warranted. Substance use is a risk factor for suicide
and homicide (Hauenstein & Boyd, [Year]).
Use verbal and nonverbal therapeutic communication
approaches including active listening, empathy, and acceptance to encourage the
client to express negative emotions and verbalize fears and concerns. Psychological
manifestations of ineffective coping can only be understood through the client’s
framework of appraisal (Dudley-Brown, 2002).
Collaborate with the client to identify
personal strengths. Recognition of personal strengths identifies a person’s values
and beliefs as well as allowing for coordination of interventions to fit the client’s
perception of threat (Raak, Hurtig, & Wahren, 2003).
Increase and mobilize support available
by encouraging participation at Oak and Acorn facility and enrollment in the Senior
Companion program through Elderserve. Relationships are pivotal in supporting coping
in older adults (Ho, [Year]).
Offer instruction regarding alternative
coping strategies including using physical activity as a distraction, deep breathing
exercises, and reminiscence. Alternate
methods of coping should be introduced and offered to a client as a possible choice
of a new coping strategy (Wassem, Beckham, & Dudley,
Engage the client in reminiscence. Life
review as an intervention had a significant effect of lowering depression and evokes
positive memories and well-being (Puentes, 2002).
Goal met. Client identified personal strengths as
being observant and knowledgeable about when to call her social worker for assistance
on at 10:45 on June 30, [Year].
Goal met. Client reported situations where she called
her social worker for guidance and her older brother C. for financial assistance.
She also reported maintaining a positive attitude and attending church as sources
met. Client wasn’t forthcoming regarding
emotions associated with substance use as a coping tool.
Development of a deeper trust is still necessary.
met. Evaluation of this goal is set for August 1, [Year], 15:00. The client has made
no progress toward this goal.
met. Evaluation of this goal is set for August 1, [Year], 15:00.
The client has made no progress towards this goal.
Client stated no desire to commit suicide
Utilized verbal and nonverbal therapeutic
communication approaches. Client verbalized
fear of others within the community, including hesitancy to develop relationships
due to concerns of being taken advantage of, robbed, or assaulted. Client provided
noncommittal responses to questions regarding substance use as a coping mechanisms.
Continued development of a therapeutic relationship is required.
Collaborated with client to identify personal
strengths and coping mechanisms that were successful in the past during periods
of stress. She identified that she is observant and knows to call her social worker
if she needs help. Continued strength
identification is warranted.
Oak and Acorn was suggested as a community
resource and the client expressed interest in going there.
Referral will be in place [Month] 21, [Year]. Discussion regarding the Senior
Companion program to be performed [Month] 21, [Year].
Provided instruction regarding the benefits
of regular exercise on stress and suggested it as an alternative to drinking or
smoking. Demonstrated 4-square deep
breathing and client return demonstrated it.
She has breathing problems related to asthma causing some difficulty; however, she
indicated she would like to keep practicing.
Conducted a scrapbooking activity to facilitate
reminiscence. The client enjoyed the
activity and expressed a desire to do it again.
Continuation of activity recommended as well as creation of a reminiscence
program to foster socialization and support network development.
Client report of consuming approximately
one quart of alcohol daily. Client report of smoking approximately 1 pack of cigarettes
daily. Client report of infrequent
contact with immediate family members. Client’s verbalization of fear of developing
relationships with others in her community because “they’re trouble.” Client’s report
of sleep disturbances.
Client was observed drinking at 10:30 AM
with her live-in boyfriend.
Client demonstrates lack of goal-directed
behavior in problem solving (i.e. finding something to do when bored).
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