Louise Margaret Tomas
SCR200.4710
03/20/2008
LAGUARDIA COMMUNITY COLLEGE
Nursing Program
NURSING CARE PLAN
SCR200
Nursing Diagnosis
(Number
nursing
diagnoses in
order of
priority.)
1-Social isolation
r/t Disease
process
(Schizophrenia)
as evidenced by
client does not
attend group
activities and
client does not
interact with
staff.
Expected Outcomes
1-The client will identify
feelings of isolation within 34 weeks.
Nursing Actions/
Implementation
Rationale
(Cite Specific Sources)
1-The nurse should establish
a therapeutic relationship
with client by being present
and showing a caring attitude.
1-Being emotionally present and
authentic fosters growth in
relationships and decreases isolation.
(Ackley 1126)
2-The client will practice
social and communication
skills needed to interact with
others during hospital stay.
2-Provide positive
reinforcement when client
seeks out others.
2-Receiving instrumental social
support such as feedback contributes
to a positive self being,
3-The client will initiate
interaction with others within
3-4 weeks.
3-Establish trust one to one
then gradually introduce the
client to others.
3-This is individualization of care.
4-The client will participate
4-Put client into groups or
Evaluation
4-Positive social interaction is
enhanced when you provide
opportunities or assist in making
1
2-Risk for
loneliness r/t client
refusal to
participate in
group activities,
and client’s family
not visiting often
as evidenced by
client not
attending group
activities, staying
in her room, and
the client stating
that her family
does not visit.
in one of the group activities
for 20 minutes by the end of
the week.
allow client to select which
group according to
preference, abilities, age.
decisions.
(All above from Ackley & Ladwig,
p. 1127-1129)
1. Client will participate in
ongoing positive and relevant
social activities that are
personally meaningful in one
week.
1-Encourage the client to be
involved in meaningful social
relationship that are
characteristics of both giving
and receiving support.
1-It is important to recognize that
the positive relevance of social
relationships is related to the content
and quality relationship.( Mosby
782)
2. Client will maintain one or
more meaningful
relationships allowing selfdisclosure and demonstrate a
balance between emotional
dependence and
independence before
discharge.
2-Explore ways to increase
the client’s support system
and participation in groups
and organization.
2-Satisfaction with support networks
was a potent predictor of selfesteem, emotional health. (Mosby
782)
3-Encourage the client to
develop closeness in at least
one relationship.
3-Dependence and independence
should be balanced in healthy
relationship, which will reduce risk
for loneliness. ( Mosby 782)
2
3-Risk for
constipation r/t
medications side
effects as
evidenced by
client is taking
Abilify.
1-Maintains passage of soft,
formed stool every 1 to 3
days without straining.
1-Observe usual pattern of
defecation including time and
day, amount and frequency of
stool, consistency of stool.
2-Identifies measure that
prevents or treats constipation 2-Encourage fiber intake of
by discharge.
25g per day for adults.
3-Encourage client to respond 3-Encourage fluid in take of
promptly to defecation reflex. 1.5 to 2 liters per day.
4-Encourage client to eat
fiber in his daily meals and to
increase intake of fluids to
reduce constipation.
1-There are often multiple reasons
for constipation; the first step is
assessment.
2-Fiber helps prevent constipation
by giving stool bulk.
3-Adequate fluid intake is necessary
to prevent hard dry stools.
(All above form Ackley & Ladwig,
p. 692-695)
4-The reflex that cause the urge to
defecate diminishes after a few
minutes and may remain quite for
several hours, as a result the stool
becomes hardened and more
difficult to expel. (Ackley 302)
3
4-Disturbed sleep
pattern r/t
inadequate
Day time activity
and
uncomfortable
sleep
environment as
evidenced by
client yawning
and stating “I
feel tired; I want
to take a nap for
a little bit.’
1. Pt will verbalize
satisfaction with sleep-rest
pattern as evidenced by
stating, “I slept well” within 1
week.
5. Self-esteem
disturbance
related to
feelings of
inferiority and
sense of
Client will:
1. Make one positive
statement about self within 48
hours.
1. Observe the client’s
medication, diet and caffeine
intake.
2. Eliminate or reduce sleep
interruptions by closing the
door or pulling the curtains
1. Schedule meetings with
client that ensure privacy and
communicate her importance
as an individual.
2. Examine with client
specific feelings regarding
herself.
1. Difficulty sleeping can be a side
effect of medication. Also, caffeine
can interfere with sleep. (Mosby pg
886)
2. Excessive noise or changes in the
environment can cause poor quality
sleep. (Mosby pg 887)
1. Facilitate feelings of acceptance
and belonging and validate client’s
worth. (Johnson, p 556)
2. Client’s view of himself is a vital
aspect of his personality.
(Johnson, p. 555)
4
inadequacy, as
evidenced by
client stating,
“No one loves
me. I want to
have a family but
no one marry
me.”
6. Self- esteem
disturbance r/t
personal identity
as evidenced by
poor hygiene,
uncombed hair
and soiled attire.
3. Encourage client to
express emotions, fears,
feelings of inferiority, and
sadness.
4. Identify with client
achievements that would
make the client feel better
about herself and focus on
one of these.
Client will:
1. state accurate selfappraisal.
2. take bath and comb
hair within 48 hours.
1. Treat client with
respect and as an
equal to maintain
positive self esteem.
2. Encourage the client
to create a sense of
competence through
short term goal setting
and goal achievement.
3. Expression will provide catharsis.
(Johnson, p. 555)
4. To foster client’s sense of
accomplishment. (Johnson, p. 558)
1.Clients with Schizophrenia may
have significant self-care deficits.
Inattention to hygiene and grooming
needs is common, especially during
psychotic episodes. (Videbeck pg
290)
5
7. Social
Client will:
Isolation r/t
1. Identify barriers that
failure to
cause impaired social
establish trust as
interactions.
evidenced by
2. Participate in activites
client was in her
and programs at level
room lying
of ability and desire
down, avoidance
within 72 hours.
of social
3. Describe feelings of
activities with
self-worth before
other residents
discharge.
and she has
never been
married before
and she doesn’t
have a boyfriend.
1. Establish a therapeutic
relationship by being
emotionally present
and authentic.
2. Establish trust one on
one and then
gradually introduce
the client to others.
Allow the client
oppurtunities to
introduce issues and
to describe his or her
daily life.
1. Relating to others is difficult
when one’s self-concept is
not clear. Clients have
problems with trust and
intimacy, which interfere
with the ability to establish
satisfactory relationships
with others and the
environment. These clients
lack confidence, feel strange
or different from other
people and don’t believe they
are worthwhile. The result is
avoidance of other people.
(Videbeck 290)
6