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Date/time
Cues Need
Nursing Diagnosis Objectives of Care Interventions Evaluation
Jan.24,
2012@
2pm
Subjective:N: Ano sa tinginnyo ang dapatnyong gawinkapag may lalapitna negro sa iyomaam?R: Wala, aalislang ako. Takotkasi ako sa kanilaeh.N: May naiisip poba kayo natechnique paramaovercome nyoang takot nyo sakanila?J: Wala eh. Di nalang ako lalapit sakanila.
Objectives:Inability to makedecisionsInability to ask for
helpFair appetite
Ineffectiveindividual copingrelated toinadequate copingmethod.
R:Inability to form avalid appraisal ofthe stressors,inadequatechoices ofpracticedresponses, and/orinability to useavailableresourcesFor mostpersons, everydaylife includes itsshare of stressorsand demands,ranging fromfamily, work, andprofessional roleresponsibilities to
major life eventssuch as divorce,illness, and thedeath of lovedones. How one
Within my 4 days spanof care , the client willbe able to identify ownmaladaptive copingbehaviors asevidenced by:
.a. Patient identifiesavailable resourcesand supportsystems such asthe staff nurses,student nurses andfriends and herfamily; andb. Patient describesand initiatesalternative copingstrategies such asPhysical Exercise;e.g., aerobic,strength, stretching,dance, yoga,martial arts, tai-chi,
etc.,Creative/artisticself-expression;e.g., creativewriting, painting,
1.Determine thepresence/degree ofimpairment of clientscoping abilities.
R: Provides information
about perceived and actualcoping ability, life changeunits, anxiety level,
2. Assist client toidentify/discuss thoughts,perceptions,and feelings.
R:Client is able to viewhow perceptions/thinking/affect is processed and tostrengthen reality
3.Encourage client toexpress areas ofconcern. Supportformulation of realisticgoals and learning ofappropriate problem-solving techniques.R: This disorder firstmanifests itself at an
early age before theclient has had anopportunity to learneffective coping skills.In a trustingrelationship (a climate
February 01, 2012@
6pm
goal metThat at the end of my 4days span of care , theclient was able toidentify own maladaptivecoping behaviors asevidenced by:
.a. Patient identified
available resources andsupport systems such asthe staff nurses, studentnurses and friends and
her family; andb. Patient described and
initiates alternativecoping strategies suchas Physical Exercise;e.g., aerobic, strength,
stretching, dance, yoga,
martial arts, tai-chi, etc.,Creative/artistic self-
expression; e.g.,creative writing, painting,
drawing
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as elderly patients,those in adversesocioeconomicsituations, those
with complexmedical problemssuch as substanceabuse, or thosewho findthemselvessuddenlyphysicallychallenged maynot have the
resources or skillsto cope with theiracute or chronicstressors.
activities as methods tocope with stress.
R: to divert the attention.
8. Encourage patient to
seek information thatincreases coping skills.
Patients who are notcoping well may need
more guidance initially.
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