Nursing Client Nursing Interventions/Actions/Orders I Evaluation

DX/Clinical Goals/Desired Goals Interventions

Problem Outcomes/Object
ives
Risk for self Long-Term Goal: Long-Term Interventions: Long-Term: 1.) The client stated that
or Client will 1.) Assist clients to identify precipitants Evaluation by knowing the way his
other- direct identify impulse of dysfunctional mood, differentiating of this goal body feels when he gets
ed violence behaviors and what can and cannot be changed. Help is set for in aggressive moods, he
r/t demonstrate them identify available resources and [date]. The can to stop and think
impulsivity appropriate self- personal strengths. Teach new problem- client has about what his next move
and control behaviors solving and coping skills. (Foley, 2010). demonstrat is going to be instead of
impaired to refrain from Rationale: Knowledge of precipitants ed progress acting out on impulse. He
judgment harming self and helps clients develop strategies to toward this also said that he knows
and others by [date]. prevent mood changes. Using personal goal by that instead of punching
persuasive strengths and abilities enhances feels of identifying or pushing a peer, he can
disregard control. that he now go to the staff to talk
for the Short-Term Goal: 2.) Develop a behavioral management knows when about the situation.
rights of Client will plan that is implemented consistently he is 2.) The client discussed a
others AEB displace anger to among all healthcare providers. becoming time when he did not
risk-taking meaningful Communication of rules, expectations, angry and follow the rules during
behaviors, activities, refrain and consequences should be addressed what usually gym time and
irritability, from verbal as well as limitations on intrusive, results when consequentially he lost
anger and outbursts, and interruptive behaviors. Provide he does not gym privileges for the
aggressiven display no consistent consequences for both control his rest of the week and did
ess, conflict aggressive desired and undesired behaviors and impulses. not receive his points for
with activity [date] praise the desired behaviors (Foley, He has also the day. He stated that he
authority, 2010). demonstrat knows he deserves the
history of Rationale: Consistency about rules and ed less punishment, and from
previous expectations reduce power struggles and aggressive now on he will be patient
violence, promote feelings of security for clients. behaviors and follow the rules.
and Positive feedback for desired behaviors towards his 3.) The client had just
impulsive, helps reinforce them. peers during found out about a death
explosive 3.) Have client keep an anger diary and conflicts. in his family, and shortly
behavior discuss alternative responses together. following had an
Teach cognitive behavioral techniques Short-term: altercation with a peer
for self- evaluation from the client Evaluation where he was shoved. He
(Ackley, & Ladwig, 2008). of this goal demonstrated self-control
Rationale: Clients with anger was set for behaviors by putting his
management difficulties may not be [date]. The hands up, taking a few
aware of changes and cues that they are client has steps backward, and
becoming angry or of a time delay in the accomplishe explaining to the peer
stimulus to their angry response. By d this goal why he was upset and
using cognitive behavior techniques and by using that he did not want to
reviewing the diary with staff, the client meaningful fight. They both
can identify though processes leading u physical apologized and moved
to anger and the space between the activities on.
stimulus and response. whenever
he gets
angry,
Short-Term Interventions: refraining
1.) Identify stimuli that initiate violence from verbal
and the means of dealing with the outbursts by
stimuli, such as walking away. (Ackley, & explaining
Ladwig, 2008). his feelings
Rationale: Assisting the client to identify first, and
situations and people that upset him not getting
provides information needed for problem into
solving. The client can then identify aggressive
alternative responses: leaving the activity. 1.) The client verbally
stimulus, initiating a distracting activity, expressed stimuli that
or responding assertively rather than triggered his violence: not
aggressively. being able to get his way,
being wrong, having
2.) Emphasize that the client is everyone tell him what to
responsible for his choices and behavior. do.
Introduce descriptions of possible effects 2.) The client expressed
of a client’s aggressive/violent behavior that he wants to be able
 on others (Ackley, & Ladwig, 2008). to control his temper and
Rationale: In many cases clients operate that he knows all of the
from a worldview that perceives others clients in the facility are
as instruments of the clients’ under stress. He stated
gratification. Clients must gain that they that some people clash so
are dealing with other human beings it is best to avoid them or
who experience pain. Clients’ behaviors try to decrease their
influence how others respond to them. triggers as well as his
own to promote a better
3.) Redirect possible violent behaviors environment.
into physical activities such as doing 3.) The client has gone to
pushups and sit-ups (Ackley, & Ladwig, his room to do pushups
2008). and sit-ups whenever his
Rationale: Activities that distract while temperament has
draining excess energy help to build a escalated.
repertoire of alternative behaviors for
stress reduction.

Medical Diagnoses: Anxiety, Change in environment, situational crisis, and stress

Subjectiv Problem Long Term: ∙ Assess the ∙A ∙ If the client’s
e Anxiety By a week client's level of successfully level of anxiety
∙ Client from the anxiety and met goal decreases
states date of care, physical would be throughout the
the XXXXXX, the reactions to evident by week this
XXXXX client will anxiety the client intervention
family identify, (tachycardia, being able has been
lived verbalize, tachypnea, to identify, successfully
through and nonverbal verbalize, used. If it does
a demonstrate expressions of and not decrease
hurrican techniques anxiety). demonstrat throughout the
e and to control Consider using e4 week this
lost anxiety (Ackl The Face techniques intervention
their ey & Ladwig, Anxiety Scale. to control has not been
home 2008). (It is important anxiety. An successfully
as a to assess the unsuccessfu used.
result client’s lly met goal ∙ If the client
∙ Family baseline would occur verbalizes
relocate anxiety level to if the client having used
d to determine if can not do positive self
xxxxx 6 any progress this by talk throughout
months has been made xxxx4, the week to
ago to control 2xxxx. control anxiety
anxiety) this
Objective (Ackley & intervention
∙ Could Ladwig, 2008). has been
include ∙ Encourage the successfully
increas client to use used. If the
ed positive self- client does not
urinatio talk such as, “I use positive
n or can do this one self talk or does
diarrhe step at a time,” not feel the self
a, “Right now I talk is
shortne need to decreasing
ss of breathing” anxiety levels
breath, (Cognitive then the
increas therapy intervention
ed HR, changes was not
sweatin behaviors by successful.
g, etc. changing ∙ If the client
thoughts. It is verbalizes
important to feeling
use positive additional
self talk support and a
instead of further
negative self decrease in
talk) (Ackley & anxiety levels
Ladwig, 2008). as the result of
∙ Provide back rubs or
backrubs or aromatherapy
aromatherapy the
for the client to intervention
decrease has been
anxiety successful. If
(Massage and the touch is not
aromatherapy therapeutic to
can help to the client or
decrease aromatherapy
tension in the does not
body, thus decrease
decreasing anxiety levels,
anxiety) the
(Ackley & intervention
Ladwig, 2008). has not been
successful.
R/T Short Term: ∙ If the ∙A ∙ If the client
Change in By the end situational successfully verbalizes an
environme of the date response is met goal is increase in self
nt, of care, rational, use shown when esteem as a
situational xxxxx, the empathy to the client result of
crisis, and client will encourage the can therapeutic
stress identify and client to verbalize validation and
verbalize interpret the her conversation
AEB symptoms of anxiety symptoms this
Concerns anxiety (Ackl symptoms as of anxiety. intervention
due to ey & Ladwig, normal An has been
change in 2008). (Validating unsuccessfu successful. If
life events, client feelings lly met goal the client does
living promotes self is if the not feel an
through a esteem, which client can increase in self
natural can increase not identify esteem this
disaster, quality of life) her intervention
and (Ackley & symptoms has not been
relocating Ladwig, 2008). of anxiety successful.
(Ackley & ∙ Guided by the end ∙ If the client
Ladwig, imagery can be of the date verbalizes a
2008). used to of care. decrease in
decrease anxiety
anxiety following
(Guided guided imagery
imagery can this
help to intervention
decrease has been
tension in the successful. If
body and mind, the client does
thus not feel a
decreasing decrease in
anxiety) anxiety after
(Ackley & guided imagery
 Ladwig, 2008). this
∙ Use intervention
therapeutic has not been
touch and successful.
healing touch
techniques
(Touch can be
therapeutic
and further
encourage
open
discussion)
(Ackley &
Ladwig, 2008).

Nursing Client Nursing *I Evaluation

Assessment DX/Clinical Goals/Desired Interventions/Actions/Orde Goals Intervention
Problem Outcomes/Objectiv rs and Rationale s
es
Subjective Problem Long Term: 1.Engage client in * Client able to
Unable to Function at individualized engage in simple
obtain any Chronic maximum communication to conversation
information confusion cognitive level maximize client interaction relating to
from client and response present time
1. communication that
involve clients interests
improves communication
abilities in those with
dementia above the level
Objective that would normally be
Client unable expected
to answer R/T Short Term: 1.break down self care * 1.Goal met:
simple 1. tasks into simple steps client able to
questions Diminished participat 1. simple verbal prompts assist during
regarding past mental e in can help those with bath time and
events capacity activities of dementia be more participated in
secondary daily living independent dressing self
Client repeats to dementia at 2. decrease stimuli in the * 2.goal met:
questions and the maxim environment and institute client showed no
unable to um of activities associated with signs of agitation
retain functional pleasant emotions
information ability 2. a decrease in stimuli
2. remain decreases agitation
Extreme of AEB content
age (93) Impaired and free of
long term harm until
Disoriented to and short discharge
place and term
time memory
 Medical Diagnoses: Chronic Confusion, Diminished mental capacity secondary to dementia

Medical Diagnoses: Post-trauma Syndrome, Disaster, sudden destruction of one’s home and community
Assessment Nursing DX/ Client Goals/ Nursing *I Evaluation
Clinical Problem Desired Interventions/Actions/Or Goals Interventions
Outcomes ders and Rationale
Subjective Problem Long Term: ∙ Explore and enhance ∙ A successfully ∙ If the client can
∙ Client Post-trauma Client will available support met goal would identify support
states the syndrome return to pre- systems and resources. be evident by systems and
xxxx trauma level (Support systems and the client community
family of community resources returning to her resources, the
lived functioning can encourage level of intervention is
through a as quickly as communication and functioning successful. If the
hurricane possible (Ack can reduce before the client can not, the
and lost ley & Ladwig, isolation) (Ackley & traumatic intervention has
their home 2008). Ladwig, 2008). event. An not been
as a result ∙ Help the client regain unsuccessfully successful.
∙ Family previous sleep and met goal would ∙ If the client’s sleep
relocated eating habit. (Post- be if the client and eating habits
to xxxxx 6 trauma syndrome can does not return return to what
months impact sleeping and to pretrauma they were before
ago eating habits, working functioning the traumatic
to get these areas back level. event the
Objective to pretrauma levels is intervention is
∙ Could key) (Ackley & Ladwig, successful, if these
include 2008). areas to not return
sleep ∙ Help the client use to normal, the
disturbanc positive cognitive intervention was
es, vivid restructuring to not successful.
flashbacks, reestablish feelings of ∙ The intervention
depression self-worth. would be
, etc. (Fluctuations and successful if the
feelings of decreased client verbalizes
well-being can occur increased feelings
due to post-trauma of self-worth. If the
syndrome) (Ackley & client can not do
Ladwig, 2008). this, the
intervention has
not been
successful.
R/T Short Term: ∙ Observe for a reaction ∙ A successfully ∙ A successfully
Disaster, Client will to a traumatic event in met goal would carried out
sudden acknowledge all clients regardless of be evident by intervention would
destruction of traumatic age or sex. (Post- the client using be if the client can
one’s home and event and trauma syndrome can open be identified as
community begin to impact anyone, at any communication either having post-
work with age) (Ackley & Ladwig, to discuss trauma syndrome
the trauma 2008). feelings about or not having post-
by talking ∙ Provide a safe and the hurricane trauma syndrome.
AEB about the therapeutic that occurred. ∙ If the client
Anxiety, experience environment. (A safe, An verbalizes feeling
flashbacks, and and therapeutic unsuccessfully safe in the
fear (Ackley & expressing environment will allow met goal would environment the
 Ladwig, 2008). feelings of the client to feel more be shown if the intervention has
fear, anger, at ease talking through client does not been successful. If
anxiety, the traumatic openly the client does not
guilt, and experience) (Ackley & communicate feel safe, the
helplessness Ladwig, 2008). feelings related intervention has
a week from ∙ Remain with the client to the traumatic not been
the date of and provide support event. successful.
care, during periods of ∙ If the client
xxxxx(Ackley overwhelming verbalizes feeling
& Ladwig, emotions. (Support will supported during
2008). allow the client to feel intense emotional
at ease discussing the periods the
traumatic intervention has
event) (Ackley & been successful. If
Ladwig, 2008). the client does not
∙ Use touch with the feel supported the
client's permission intervention has
(e.g., a hand on the not been
shoulder, holding a successful.
hand). (Touch can be ∙ If the client
therapeutic to a client, verbalizes feeling
and can further additional support
encourage open as the result of
discussion) (Ackley & physical touch the
Ladwig, 2008). intervention has
been successful. If
the touch is not
therapeutic to the
client, the
intervention has
not been
successful.
I

Nursing Client Nursing Evaluation

DX/Clinical Goals/Desired Interventions/Acti
Problem Outcomes/Objecti ons/Orders
ves

Goals Interventions
Chronic Long Term Long Term Long Term Long Term
low self-
esteem r/t Client will verbally 1: Work with client on areas that he Evaluation set for Client states
impaired give an accurate or she would like to improve using * [Month] 8, [Year] at that he doesn’t
cognitive and problem-solving skills. Evaluate 1400. Client has know of areas
self- nonjudgmental need for more teaching in this area. made some progress that he could
appraisal account of three toward goal; on improve on. He
AEB positive qualities Rationale: Feelings of low self- [Month] 14, [Year] he thinks that he
negative as well as identify esteem can interfere with usual was able to identify 2 has reached his
feedback two areas that he problem-solving abilities (Varcarolis, strengths and did not maximum
about self wishes to improve pg 171). reject positive self potential.
through by [Month] 8, feedback. Nursing student
client’s [Year] at 1400. 2: Work with client to identify worked with
statement cognitive distortions that encourage Short Term client to
of, “I don’t Short Term negative self-appraisal. identify that he
have any Goal met. As of focuses on
good Client will identify Rationale: Cognitive [Month] 14, [Year] at negative
qualities” one or two 1400 client was able qualities while
and client strengths by to identify two discounting his
seeking [Month] 14, [Year] strengths: being a positive
validation. at 1400. * good listener and attributes.
having good Client states
communication skills. that he would
like to work on
distortions reinforce negative, being able to
inaccurate perception of the world accept positive
(Varcarolis, pg. 170). feedback.
Developing both self-acceptance Short Term
and self-esteem have been
identified as ways to enhance Assessment of
cognitive interventions (Macinnes, client’s
pg 483).

Short term:

1: Assess existing strengths and

coping abilities, and provide
opportunities for their expression
and recognition. strengths
shows that he
Rationale: Supporting a client’s is very
beliefs and self-rejection and helping intelligent and
them cope can affect self-esteem can hold a good
(Ackley & Ladwig, pg. 716). conversation.
The nursing
2: Reinforce the personal strengths student worked
and positive perceptions that the with the client
client identifies. to identify his
*
strength in
Rationale: Clients with low self- communication.
esteem need to have their existence
and value confirmed (Ackley &
Ladwig, pg. 717).

*
Medical Diagnoses: Chronic low self-esteem r/t impaired cognitive self-appraisal