NURSING CARE PLAN

CUES NURSING SCIENTIFIC ANALYSIS OBJECTIVES NURSING RATIONALE EVALUAT

DIAGNOSIS INTERVENTIONS ION

Subjective Complicated Complicated grieving is Mrs. C will 1. Assess Mrs. Cs 1. Accurate

Cues: grieving related to a maladaptive process demonstrate position in the baseline data are
Report of loss of death of husband, that occurs when grief is adaptive grief process. required to plan
20 pounds since evidenced by intensified to the degree grieving accurate care for
the death of her symptoms of that the person is behaviors and 2. Develop a Mrs. C.
husband and depression such as overwhelmed, becomes evidence of trusting 2. These
difficulty of withdrawal, stuck in one phase of progression relationship by interventions
sleeping. anorexia, weight grieving an demonstrate toward showing provide the basis
loss, difficulty excessive prolonged resolution. empathy and for a therapeutic
Objective sleeping, and emotional responses to caring. Be relationship
Cues: dysphoric / tearful a significant loss. Mrs. C will honest and keep
Mood is mood. discuss any all promises.
dysphoric Source: angry feelings Show genuine
and Medical surgical she has about positive regard.
tearful at Nursing, Brunner and the loss of her
3. Explore feelings 3. Knowledge of
times, but Suddarths, Volume 1, husband.
of anger and acceptability of
client is page 987, 10th edition.
help Mrs. C the feelings
cooperati
direct them associated with
ve.
toward the normal grieving
Height
source. Help her may help to
55; relieve some of
understand it is
weight
appropriate and the guilt that
102 lb. these responses
acceptable to
Flat affect generate.
have feelings of
anger and guilt
about her
husbands
4. Mrs. C must give
death.
up an idealized
4. Encourage Mrs. perception of her
C to review husband. Only
honestly the when she is able
relationship she to see both
 had with her positive and
husband. With negative aspects
support and about the
sensitivity, point relationship will
out reality of the the grieving
situation in process be
areas where complete.
misrepresentatio
ns may be 5. Recovery may be
expressed. blocked if
spiritual distress
5. Determine if is present and
Mrs. C has care is not
spiritual needs provided.
that are going
unfulfilled. If so,
contact spiritual
leader for
intervention with 6. Antidepressant
Mrs. C. therapy may help
Mrs. C to function
6. Refer Mrs. C to while confronting
physician for the dynamics of
medication her depression
evaluation.
 CUES NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATI
DIAGNOSIS ANALYSIS INTERVENTION ON

Subjective Risk for injury Dizziness, weakness Mrs. C will not 1. Assess vital signs 1. Client safety is a
Cues: related to dizziness from lack of activity, experience at every visit. nursing priority.
Report of and weakness from low blood pressure, physical harm Report to
occasional lack and poor nutritional or injury. physician should
dizziness. of activity, low status which may they fall below
blood pressure, affect the clients Mrs. C will use baseline. 2. The walker will assist
Objective and poor loss of balance, in walker when Mrs. C from falling.
Cues: nutritional status relation to limitation ambulating. 2. Encourage Mrs. C
Blood of movements the to use walker until
pressure client is unstable to Mrs. C will not strength has 3. She is more likely to
90/60 gain her balance and experience returned. eat what is
mmHg protect herself that physical harm convenient and what
Poor skin leads to possible or injury 3. Visit Mrs. C during she enjoys.
injury. mealtimes and sit
turgor,
with her while she
dehydrati
eats. Encourage
on
Source: her niece to do
Height
Medical surgical the same. Ensure
55;
Nursing, Brunner and that easy to
weight
Suddarths, Volume prepare, nutritious
102 lb.
1, page 789, 10th foods for meals
edition. and snacks are
available in the 4. This would ensure
house and that that she receives at
they are items least one complete
that Mrs. C. likes. and nutritious meal
each day.
4. Contact local meal
 delivery service 5. Weight gain is a
(e.g., Meals on measurable,
Wheels) to deliver objective means of
some of Mrs. Cs assessing whether
meals Mrs. C is eating.

5. Weigh Mrs. C each 6. Adequate dietary fl

week. uid and fiber will
help to alleviate
constipation. She
6. Ensure that diet may also benefi t
contains sufficient. from a daily stool
Fluid and fiber. softener.

CUES NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATI

DIAGNOSIS ANALYSIS INTERVENTIONS ON

Subjective Social isolation Social isolation is a Mrs. C will 1. As nutritional status 1. Increased activity
Cues: related to state where an discuss with is improving and enhances both
I feel so alone; depressed mood individual has nurse feelings strength is gained, physical and
so useless as and feelings of decreased or even about past encourage Mrs. C to mental status.
verbalized by worthlessness, not at all able to social become more
Mrs. C. evidenced by interact with others relationships active. Take walks
staying home around them. and those she with her; help her
Objective alone, refusing to Patients may feel may like to perform simple
Cues: leave her rejected, not tasks around her 2. Basic personality
renew.
Memory apartment accepted, lonely, and house. characteristics
unable to foster Mrs. C will will not change.
(remote
meaningful 2. Assess lifelong Mrs. C will very
and renew contact
relationships with patterns of likely keep the
recent) with friends
others. relationships. same style of
intact and
relationship
Oriented participate in
Social isolation is a development that
to time, social
lonely condition is she had in the
place, activities.
expressed by the past.
person,
individual and
 and perceived as being 3. She is the person
situation. caused by others and who truly knows
Denies as a negative 3. Help her identify what she likes,
thought situation that present and these
to harm threatens. With relationships that personal
self characteristics: living are satisfying and preferences will
alone in the room, activities that she facilitate success
inability to considers in reversing social
communicate, interesting. isolation.
withdrawal, lack of
eye contact. 4. There are many
Discrepancies or documented
immaturity interests 4. Consider the studies of the
and activities with feasibility of a pet. benefi ts to
the development or elderly individuals
the age. of companion
Preoccupation with pets.
his own thoughts,
5. Suggest possible 5. She is more likely
repetition, no
alternatives that to attend and
meaningful action.
Mrs. C may consider participate if she
Expressing feelings
as she seeks to does not have to
of rejection or
participate in social do so alone.
loneliness caused by
activities. These
others. Experience
may include foster
different feelings
grandparent
with others, feel
programs, senior
uncomfortable with
citizens centers,
people.
church activities,
craft groups, and
volunteer activities.
Source:
Help her to locate
Medical surgical
individuals with
Nursing, Brunner and
whom she may
Suddarths, Volume
attend some of
1, page 885, 10th
these activities.
edition.