Name: Gilbert Paraiso Age: 20 years old Chiefcomplaint: DATE CUES & TIME

N E E D

NURSING DIAGNOSIS

OJECTIVES OF CARE

Rm&Bed#: Attending Physician: Final Dx: NURSING INTERVENTION EVALUATION

J A N U A R Y 21, 2012 @ 7:00 a.m.

Subjective:

Objective: Sad Dull affect Being uncommu nicative Withdraw n Preocupa - tion with own thoughts Performa nce of repetitive meaningl ess actions Seeking to be alone

Impaired Social Interaction At the end of my 2 related to disturbed weeks of nursing thought process intervention, the patient will be able to voluntarily R Being overly spend time with other inhibited as children and clients, student nurse and that they often avoid other therapist in group unfamiliar as evidenced by: situations and people with an intensity beyond a. More participative that expected for b. Less of going out developmental stage. This from the activity inhibition, which may have area continued throughout c. Listen to the upbringing, others say such contributes to low selfas student nurses esteem and social advice to alienation. Apt to be participate in the anxious and may fidget activity in the chair and make poor eye contact with the nurse. And may reluctant to ask questions or to make requests. They may appear sad as well as anxious. They describe being shy, fearful, socially awkward, and easily devastated by

1. Spend time with the client. This may mean just sitting in silence for a while. R Your presence may help improve clients perception of self as a worthwhile person. 2. Develop a therapeautic nurseclient relationship through frequent, brief contacts, an accepting attitude. Show unconditional positive regard. R Your presence, acceptance, and conveyance of positive regard enhance the clients feelings of selfworth 3. After client feels comfortable in a one-to-one relationship, encourage attendance in group activities. May need to attend with client the first few times to offer support. Accept client's decision to remove self from group situation if anxiety becomes too great. R The presence of a trusted individual provides emotional security for the client. 4. Verbally acknowledge client's

At the end of my 2 weeks of nursing intervention, the patient was able to voluntarily spend time with other clients, student nurse and other therapist in group as evidenced by: a. More participative in the activity b. Less of going out from the activity area c. Listen to the others say such as student nurses advice to participate in the activity

Name: Gilbert Paraiso Age: 20 years old Chiefcomplaint:

Rm&Bed#: Attending Physician: Final Dx:

real or perceived criticism. Their usual response to these feelings is to become more reticent and withdrawn (Videbeck, S. (2011). Psychiatric Mental Health Nursing pg. 396)

absence from any group activities. R Knowledge that his or her absence was noticed may reinforce the client's feelings of self-worth 5. Teach assertiveness techniques. Interactions with others may be negatively affected by client's use of passive or aggressive behaviors. R Knowledge of assertive techniques could improve client's relationships with others. 6. Provide direct feedback about client's interactions with others. Do this in a nonjudgmental manner. Help client learn how to respond more appropriately in interactions with others. Teach client skills that may be used to approach others in a more socially acceptable manner. Practice these skills through role play. R Client may not realize how he or she is being perceived by others. Direct feedback from a trusted individual may help alter these behaviors in a positive manner. Practicing these skills in role play facilitates their use in real situations.

Name: Gilbert Paraiso Age: 20 years old Chiefcomplaint:

Rm&Bed#: Attending Physician: Final Dx:

7. The depressed client must have a lot of structure in his or her life because of impairment in decision-making and problemsolving ability. Devise a plan of therapeutic activities and provide client with a written time schedule. Remember: The client who is moderately depressed feels best early in the day, whereas the severely depressed individual feels better later in the day; choose these times for the client to participate in activities. 8. Provide positive reinforcement for client's voluntary interactions with others. R Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors