Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Patient states he is “upset” and voices concern about “dying like my father did.”

Objective

Fatigue, has not moved out of bed since beginning of shift, apprehension, identify fears and avoidance behaviors

Problem

fear

Long Term:

1.     Patient will verbalize and demonstrate effective coping mechanism by the time of discharge.

2.     Patient will demonstrate fear self control by the time of discharge

Explore coping skills and previously used to help deal with previous fear, reinforce these skills and explore other outlets (Ackley & Ladwig,2008, p 364).

*

Goal met- patient verbalized ways to cope with the fear and then demonstrated how to show fear self control.

Continue to help reduce fear, cope, and show self control over fear.

R/T

Diagnosis of cancer and possible terminal illness

Short Term:

Patient will verbalize known fears at the end of this shift.

Assess source of fear with the patient (Ackley & Ladwig, 2008, p 364).

*

Goal met- patient was able to verbalize fear of dying and not being able to marry current fiancé.

Continue to identify fear by listening to subjective comments and objective assessment signs.

AEB

Apprehension, decreased movement and verbalization of fears