IX.

NURSING CARE PLAN Assessment Data Nursing Diagnosis Ineffective coping related to substance addiction and episodic compulsive indulgence as evidenced by cravings to take prohibited drugs especially at night, thoughts about prohibited drugs and constant thinking on how to obtain prohibited drugs. Rationale Predisposing factors: Gender (Male) Precipitating factors: History of alcoholism and chronic cigarette smoking Substance abuse Psychoactive substance dependence Impaired ability to control use Increase presence of pleasurable effect of drugs cravings to take prohibited Expected Outcome After 32 hours of nurse-client interaction, the client will be able to: 1. Admit inability to control drug habit and to surrender to powerlessne ss over addiction. Nursing Intervention Justification Evaluation After 32 hours of nurse-client interaction, the client was be able to: 1.1 Use crisis intervention techniques behavior changes. 1.2 Assist patient to recognize problem exists. Discuss caring, nonjudgment al manner how drug has interfered with life. 1.1 Patient is more amendable to 1. Goal met. acceptance of Verbalize, need for may oras treatment. gid na nga daw indi ko 1.2 In the mapunggan precontemplati ang akun on phase, kaugalingon patient has not nga indi yet identified magusar that drug use lalo na sng is problematic. wala pa ko While patient di na is hurting, it is nakasulod. easier to admit Kay daw substance use indi ko has created mapakali negative kung indi consequences. ko ka usar, pamatyagan 1.3 During the ko daw ara contemplation na gid sa phase, patient akun

Actual/Abnormal Cues: Verbalization of cravings to take prohibited drugs especially at night Thoughts about prohibited drugs Constant thinking on how to obtain prohibited drugs Caught taking cigarettes by the nurse on duty Risk Factors: History of substance abuse History of chronic

Definition: Powerlessness is a perceived lack of control over a current

1.3 Involve patient in

cigarette smoking History of alcoholism Admission to the institution

situation or immediate happening.

Strengths: Strong spiritual belief Good family support Disciplined Compliance to treatment regimen Willingness to change Cooperation

Source: Nursing Care Plan6th Ed by Doenges, et al pp 800-801

drugs, thoughts about prohibited drugs and constant thinking on how to obtain prohibited drugs Difficulty to discontinue drugs Ineffective Coping

development al treatment plan, using problemsolving process in which patient identifies goals for change and agrees to desired outcome.

Source: Nursing Care Plan 6th Ed by Doenges, et al pp 800-801

2. Verbalize acceptance of need for treatment and awareness 2.1 Discuss that alternative willpower solutions. alone cannot control abstinence. 2.2 Support decision and implementati on of selective alternative/s

realizes a problem exists and is thinking about a change of behavior. Patient is committed to the outcomes when the decisionmaking process involve solutions that promulgated by the individual. 2.1 Brainstorming helps creatively identify possibilities and provides sense of control 2.2 Helps patient persevere in process of change. During the action phase,

sistema ang druga nga daw indi ko na ba untatan. Amo na ang rason nga ikatatlo ko na ni nga balik sa rehab.

2. Goal met. State, Amo na nga nagkusa na lng gid ko nga magpa rehab kay daw ka damo na gid

3. Engage in peer support.

3.1Explore support in peer group. 3.1 Patient may Encourage need sharing about assistance in drug hunger, expressing situations that self, speaking increase the about desire to powerlessness indulge, ways , admitting that need for help substance has in order to influenced face up to life. problem and begin 3.2 Assist patient resolution. in selfexamination of 3.2 Although not spirituality, mandatory for faith recovery, surrendering to and faith in

patient engages in a sustained effort to maintain sobriety, and mechanisms are put in place to support abstinence.

sang malain nga epekto sa lawas ko kag ga damu ang problema namon tungod sa akun ni nga pag-usar.

3. Goal met. Engage actively in every peer group session such as the morning exercise and morning worship. He also stated thathe

4. Regain and maintain healthy state with a drugfree lifestyle.

3.3 Instruct in and role-play assertive communicati on skills.

a power greater than oneself has been found to be effective for many individuals in substance recovery; may decrease sense of powerlessness . 3.3 Effective in helping refrain from use, to stop contact with users and dealers, to build healthy relationships, regain control of own life.

always mingle and talks with his friends at the institution.

4.1 Assist patient to learn ways to enhance health and structure healthy diversion 4.1 Learning to from drug empower self use (e.g., in constructive maintaining a areas can balanced diet, strengthen getting ability to adequate rest, continue

4. Goal met.

exercise [e.g., walking]; and biofeedback

recovery. These activities help restore natural biochemical balance, aid detoxification, and manage stress, anxiety, use of free time. These diversions can increase selfconfidence, thereby improving self-esteem.

Sources: Nursing Care Plan 6th Ed by Doenges, et al pp 800-801

Eat adequately and did exercise through play such as basketball and billiards with his friends using the available sport equipments. He also makes sure that he will get enough sleep during the daytime since he cannot sleep well at night.

NURSING CARE PLAN # 2 Assessment Data Actual/Abnorm al Cues: Difficulty falling asleep at night Clients verbalizatio n hambal sang doctor side effect na kuno sang bulong ko Long hours of sleep at daytime (average of 3-5 hours) Fatigue on awakening Nursing Diagnosis Disturbed sleep pattern related to excessive daytime sleeping secondary to medicatio ns as evidenced by difficulty falling asleep at night, long hours of sleep at daytime and fatigue on awakening. Rationale Predisposing factors: History of substance abuse Expected Nursing Intervention Justification Outcome After 32 hours of nurse-client interaction, the client will be able to: 1.1 Obtain a sleep1.1 Assessmen wake history t of sleep 1. Identify including history behavior personal of sleep and habits problems, patterns that changes in sleep are an disrupt patterns, and use important sleep of medications part of any pattern. and stimulants. health status 1.2 Assess for use of examinatio alcohol or n. cigarettes prior to use of sleep medication or 1.2 Alcohol retiring for the and evening. nicotine should be avoided for several hours prior to sleep. Evaluation After 32 hours of nurse-client interaction, the client was able to:

Precipitating factors: History of alcoholism History of chronic cigarette smoking Environment Health care intervention Administration of medications Therapeuti Nonc effects therapeuti c effects Drowsiness and sleepiness during daytime Risk Factors: Side effects Difficulty sleeping at of night time medications Environmen Fatigue upon awakening Definition: t Disturbed in the morning History of

1. Goal met.Recognize that before he was admitted, prohibited drugs used to relax him; but now that he is under treatment, the medication he is taking causes him to have sleep disturbance. He verbalized that according to the doctor, what he is experiencing is one of the side effects of his medications. He also added that his cravings

alcoholism History of chronic cigarette smoking

Strengths: Strong spiritual belief Disciplined Good interpersona l relationship Compliance to treatment regime Willingness to change to improve his health

sleep patternis the state in which an individual experience s or is at risk of experiencin g a change in the quantity or quality of his or her rest pattern that causes discomfort or interferes with desired lifestyle.

Disturbed sleep pattern Source: Handbook of Nursing Diagnosis 13 Ed by Moyet pp 446-449 2.1 Initiate nonpharmacologic interventions for 2. Verbali improved sleep ze ways including: that can Sleep help restriction promote Increasing his sunlight sleeping exposure pattern. Educational interventions to promote beneficial sleep hygiene (Including the impact of substance use on sleep quality, keeping regular waking and sleeping times, avoiding naps, refraining from

2.1 Nonpharmacologic interventions have been found to improve sleep efficiency and increase satisfaction with sleep pattern while decreasing use of hypnotics.

Source: Handbook of Nursing Diagnosis 13 Ed by Moyet Pp 446-449

for drugs especially at night contribute to his sleep disturbance. 2. Goal met. State that he usually watches television or have a chit-chat with his roommates to help him fall asleep and lessen the cravings of taking drugs. He added that he would sometimes write anything or read magazines and play with his friends so that he could divert his attention and he will not get sleepy during the day.

caffeine, impact of exercise on sleep and environment al adjustments to promote sleep) Provide diversional activities to provide stimulation (social interaction, watching television or radio, play with a guitar)

3. Achieve optimal amounts of sleep as evidenc ed by verbaliz ation of feeling rested

3.1 Evaluate learning outcomes using patient verbalizations of following the treatment recommendations and experiencing enhanced sleep.

3.1 Evaluation 3. Goal partially serves as met. Verbalize an biskan assessment makatulug ko sa of the aga..makatulug effectivene naman ko amatss of care amat kung and allows gabemakapah opportunit uway naman ko y for sang maayo

and improve d sleeping pattern.

adjustment s to the plan of care

kag ga amatamat naman dula ang sakit sa kalawasan ko

Source: http://www. pterrywave. com/nursing/ care%20plans/ 51.aspx

NURSING CARE PLAN # 3 Assessment Data Risk factors: Physical isolation Social isolation Verbalized, kasubo diri sa amon kung kis-a kay kamikami lang dayun talagsa man lng kami mabisita sang amon nga mga pamilya. Kag indi man gid di tanan pwde mo ma istorya ka yang iban daw wala ka man bala kwa-on haw, kag kung kis-a indi Nursing Diagnosis Risk for loneliness related to therapeutic isolation secondary to substance abuse. Rationale Predisposing factors: Gender Precipitating factors: Substance abuse Admission to the institution Physical isolation Social isolation Impaired social interaction Affectional deprivation Risk for loneliness Expected Outcome After 32 hours of nurse-client interaction, the client will be able to: 1. Verbalize feelings of loneliness and express desire to socialize more. Nursing Intervention Justification Evaluation After 32 hours of nurse-client interaction, the client was able to: 1.1 Work with the patient to identify factors and behaviors that have contributed to loneliness. 1.2 Help client identify feelings associated with loneliness. 1.1 To begin 1. Goal met. changing Verbalize,Nasu behaviors that bon ko di kay may have wala kami di alienated others. masyado may ginahimo, lalo na bi kung wala 1.2 This lessens the kamo, subo gid impact of ya eh! Sadya feelings and kung ari kamo di mobilizes kag kung wala na energy to kami himo-on ga counteract lantaw kami tv or them. ga hampang diri sa may polan. 1.3 To establish a trusting relationship.

Definition: Risk for Loneliness The state in which an individual is at risk for experiencing discomfort associated with a desire or need for

1.3 Spend sufficient time with the patient

1.4 By being assertive, client assumes

mo sila ma intindihan. He added, dyutay lang di ang mg amigo ko kag ang pwede ko gid ma istorya sang tadlong. Affectional deprivation Cathectic Deprivation Substance abuse Caught by nurse on duty while taking cigarettes

contact with others. Source: Handbook of Nursing Diagnosis 13 Ed by Moyet Pp 273-277

to allow him to express his feelings. 1.4 Encourage client to address his needs assertively.

responsibility for meeting his needs without anger or guilt. 2.1 To bring issue into open and help client understand that you want to help him. 2. Goal met. State kung daw ka subo na gid, ga isturya na lang ko sa mga upod ko lalo na kay JR kay migo ko na siya di. Dayun ga pasalamat man ko kay ginaduaw ko di kag ginasuportahan ko sang akun amay kag iloy kag kung kis-a upod man nila ang bata ko. Masadyahan naman ko na dayun kay maisturya ko sila kag makamusta man. Ga pasalamat man ko kay ari kamo di para may ma isturya man ko.

Source: Handbook of Nursing Diagnosis 13 Ed by Moyet Pp 273-277

2. Identify people who will likely support and accept him.

Strengths: Extrovert personality Good interpersona l relationship Being

2.1 Inform client that assistance is available to help him express feelings of loneliness and identify ways to increase social activity. 2.2 Help client curb feelings of

2.2 To promote feelings of acceptance and support.

3.1 To promote the

participative and active during group sessions Good family support

loneliness by 3. Formulate plans on how to comfortabl y interact with peers and on how to continue involvemen t with others through recreational activities or social interaction groups. encouraging oneon-one interaction with others who are likely to accept him.

use of social skills.

3.2 To ensure continued care and maintain social involvement.

3. Goal met. Encourage his colleagues to join the morning worship and join the activities lead by the students. Also, he always try to play with his colleagues so as to maintain his good interpersonal relationship with them.

3.1 As clients comfort level improves, encourage him to attend to group activities and social functions. 3.2 Refer client

Source: http://nandanursing diagnosis.org/ nursing-diagnosisrisk-loneliness/

and family to social service agencies, mental health center and appropriate support groups.