Cebu Normal University College of Nursing
NURSING CARE PLAN IN PSYCHIATRY AS A NURSING SPECIALTY Name of student: student: _____________ _______________________ ___________________ __________________ _______________ ______ Date Date of Exposure: Exposure: ___March 4-8, 2013________ 2013________ Yr. & Section: __________III-A_____________________________________ Area of exposure: ___Seven Sisters Servants of Mary Home of Elderly___ Client Initials: __________________________________________________ Date of Submission: ___March 8, 2013________ Diagnosis: _________________________________________________________________________________________________________________________ Doctor: ___________________________________________________________________________________________________________________________ PHASE OF NURSE-CLIENT RELATIONSHIP: Working Phase PROBLEM/CUES:
NURSING DIAGNOSIS
SUBJECTIVE: - “Naai puti2x sa ako Disturbed Body Image mata dong. Wa pa related to significance of man unta ni sauna." as body part or functioning with verbalized regard to age. - "Naai burot ako tiil. Arthirits daw ni." as verbalized - “ Naay bugon-bugon akng dunggan” as verbalized
OUTCOME CRITERIA SHORT TERM GOAL: After 8 hours of nursing intervention, client will be able to: -Verbalize understanding of body changes - Seek information and actively pursue growth
EVALUATION
INDEPENDENT NURSING FUNCTION (10):
Day 1: Orientation Phase
Physical I: Discuss pathophysiology present and/or affecting the members of the community R: Allows understanding of the current situation S: Doenges, 2010
After 8 hours of nursing intervention, client was able to: - Verbalize understanding of body changes -“Paita aning maniguwang na ta” as verbalized
situation
I: Assist in correc ting underlying problems R: To promote optimal adaptation S: Doenges, 2010 I: Determine ethnic background and cultural and religious perceptions or considerations R: May influence how individual deals with the situation S: Doenges, 2010
OBJECTIVE: - Change in ability to estimate spatial relationship of body to the environment noted - Change in social involvement noted -Low frustration tolerance noted - Constant monitoring of the affected body part noted
NURSING STRATEGIES
LONG GOAL:
TERM
After 40 hours of nursing intervention, client will be able to: - Verbalize relief of anxiety and adaptation to actual/altered body
I: Encourage to look at/touch affected part R: To begin to incorporate changes into body image S: Doenges, 2010 Psychological I: Determine whether condition is permanent with no expectation for resolution. R: There is always something that can be done to enhance acceptance, and it is important to hold out the possibility of living a good life
Day 2: Working Phase After 8 hours of nursing intervention, client was able to: - Seek information “Unsay naa sa pagkatiguwang nganong naingani ni siya?” siya ?” as verbalized.
Day 3: Working Phase After 8 hours of nursing intervention, client was able to: - Verbalize acceptance of situation -“Dawaton na lang ta ni kay
THEORETICAL BASIS:
“The image of physical self, or body image, is how a person perceives the size appearance, and functioning of the body and its parts. Body image has both cognitive and affective aspects. The cognitive is the knowledge of the material body; the affective includes the sensations of the body such as pain, pleasure, fatigue, and physical movement. Body image is the sum of these attitudes, conscious and conscious, that a person has toward his or her body. The person who has a disturbance in body image may hide or not look at or touch a body part that has significant changes in structure. Some individuals may also express feelings of helplessness, hopelessness, and vulnerability, and may exhibit self-destructive behaviors such as over- or under-eating or suicide attempts.” (Kozier, et. al., 2007)
image - Verbalize acceptance of situation -Acknowledge self as an individual who has responsibility for self.
S: Doenges, 2010 I: Evaluate client’s level of knowledge of and anxiety related to situation. Observe emotional changes. R: May indicate acceptance or non-acceptance of the situation S: Doenges, 2010 I: Note signs of grieving or indicators of severe or prolonged depression R: To evaluate need for counseling and/or medications S: Doenges, 2010 I: Note withdrawn behavior or use of denial. R: May be normal response to situation or may be indicative of mental illness (e.g. schizophrenia) S: Doenges, 2010 Therapeutic Communication I: Visit client frequently and acknowledge the individual as someone who is worthwhile R: Provides opportunities for listening to concerns and questions. S: Doenges, 2010 I: Encourage verbalization and of role-play of anticipated conflicts R: To enhance handling of potential situations S: Doenges, 2010 I: Listen to client’s comments and responses to the situation R: Different situations are upsetting to different people, depending on individual coping skills and past experiences. S: Doenges, 2010 Spiritual I: Encourage client to continue spiritual/religious activities like praying. R: Promote spiritual wellness S: Doenges, 2010
DEPENDENT NURSING FUNCTION (1): I: Monitor drug regimen if prescribed. R: Anti-depressants may be prescribed if signs of severe depression are present S: Doenges, 2010
mao man ning gihatag sa ginoo” as verbalized
Day 4: Phase
Terminating
After 8 hours of nursing intervention, client was able to: - Acknowledge self as an individual who has responsibility for self. - “Ako lay kuha ana” as verbalized.
COLLABORATIVE NURSING FUNCTION(1): I: Refer client to counseling for help adjusting to body image. R: Counseling is important for a client who is trying to create a new body ideal or work through a grief process S: Doenges, 2010
BIBIOGRAPHY:
* Doenges,M.E; Moorshouse,M.M; Murr.A.C. 2010. Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales .10th edition. F.A. Davis Company. Philadelphia, Pennsylvania page 625 – 647. * Kozier, B.; Erb, G. L.;Berman, A.; Snyder, S.J..2007. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice. 8th edition. Pearson Education South Asia Pte Ltd. Page 808. * Seeley, R,R,; Stephens, T.D.; Philip, T. 2007. Essential’s of Anatomy and Physiology. 6th edition. McGraw Hill(Singapore) page. 150 * Smeltzer, S.C.; Bare, B.G.; Hinkle, J.L.; Cheever, K.H.2010. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 12th edition. Lippincott Williams and Wilkins. Page 1309. * Varcarolis, E.M.2007.Manual of Psychiatric Nursing Care Palns: Diagnoses, Clinical Tools and Psyschopharmacology.3rd edition.Elsevier(Singapore) Pte Ltd. Pages 109-112
