ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

-began to build a Readiness for After a series Active listen and Can provide a After a series of
life with friends enhanced of nursing clarify clients forum for nursing
-sleeping well coping interventions perceptions of understanding interventions the
without the client will current status. perceptions. client was able to:
medication be able to:
-performance Review previous Enables the Identify effective
returned to normal Identify methods of dealing client to identify coping behavior
effective with life problems. successful and meet
coping techniques. psychological
behaviors, needs as
Help the client Promote evidenced by
Meet develop problem successful appropriate
psychological solving skills. resolution of expression of
needs. potentially feelings
stressful identification of
situations that options, and use of
arise. resources.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

-avoidance of Impaired social After a series Observe and describe Helps identify After a series of
social situations interaction of nursing social and the kinds and nursing
-deteriorating related to interventions interpersonal extent of interventions the
academic disturbance in the client will behavior in the problems client client was able to:
performance thought be able to: therapeutic setting. is exhibiting.
-avoidance of processes. Identify feelings
communication Identify Determine client’s Affects ability that lead to poor
feelings that use of coping skills to be involved in social interactions
lead to poor and defense social situations. and develop
social mechanisms. effective social
interactions, support system as
Have family list Family needs to evidenced by
Develop client’s behaviors understand that trying to interact
effective social that are causing the client is with others and
support system discomfort for them. unable to use given self-positive
social skills that reinforcement for
have not been changes that are
learned. achieved.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

-inconsistent Disturbed After a series Make time to listen Conveys a sense After a series of
behavior personality of nursing to the client, of confidence in nursing
-ineffective identity related interventions encouraging clients ability to interventions the
relationships to the client will appropriate identify extent client was able to:
-violent dysfunctional be able to: expression of of threat.
-aggressive family feelings including Acknowledged
processes and Acknowledge anger and hostility. perceived or
current disorder perceived or actual threat to
actual threat to Discuss client’s Irrational beliefs personal identity
personal concerns without may interfere and verbalized
identity, confronting unreal with ability to acceptance of
idea. manage changes that have
Verbalize situation and occurred as
acceptance of maintain reality evidenced by able
changes that based perception to control anger
have occurred of self. and able to have a
good relationship
Provide calm Helps client to to others.
environment. remain calm.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

-unhappiness Low self- After a series Develop therapeutic Promotes After a series of
-hesitant to try esteem related of nursing relationship. Be trusting situation nursing
new experiences to inadequate interventions attentive, validate in which client interventions the
-feeling like a belonging the client will client’s is free to be client was able to:
loser be able to: communication. open and honest
-chronic with self and Verbalized
insecurity Verbalize therapist. understanding of
understanding negative
of negative Be aware that people To have respect evaluation of elf,
evaluation of are not programmed for self, facts, participated in
self and to be rational. honesty, and to treatment
reasons for her develop positive program, and
problem self-esteem, one demonstrated
must seek behaviors and
Participate in information, lifestyle changes
treatment choosing to to promote
program and, learn, and to positive self-
think, rather image as
Demonstrate than merely evidenced by
behaviors and accepting. feeling of
lifestyle enjoyment, have
changes to Discuss clients Addressing consulted for a
promote perceptions of self- these issues treatment and
positive self- related to what is openly provides absence of
image. happening; confront opportunity for insecurity.
misconceptions and change.
negative-self talk.

Have client review May help the

past successes and client see that
strengths. they can
develop an
internal locus of
control (a belief
that one’s
successes and
failures are the
result of one’s
effort.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

-hallucination Acute confusion After a series of Assess mental status Typical After a series of
-paranoia related to nursing symptoms of nursing
-agitated psychiatric interventions delirium include interventions the
-alteration in disorder the client will anxiety, client was able to:
psychomotor be able to: disorientation,
functioning tremors, Maintain usual
Regain and hallucinations, reality orientation
maintain usual delusions and and level of
reality incoherence. consciousness, as
orientation and Onset is usually evidenced by
level of sudden . changing in good
consciousness behavior and
Talk into significant To understand lessen
Initiate lifestyle others to determine and clarify hallucinations.
or behavior historic baseline, current situation.
changes to observed changes
reduce risk of and onset or
problem recurrence of
changes.

Note occurrence and “Sundown

timing of agitation, Syndrome” may
hallucination, and occur, with
violent behavior. client oriented
during daylight
hours but
confused during
nighttime.

Determine threat to Delirium can

safety of clients or cause the client
others. to become
verbally and
physically
aggressive,
resulting in
behavior
threatening to
safety of self and
others.