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NURSING DIAGNOSIS
OUTCOME NURSING STRATEGIES CRITERIA SHORT TERM INDEPENDENT NURSING FUNCTION (10): Physical GOAL:
After 8 hours of nursing intervention, client will be able to: -Verbalize understanding of body changes - Seek information and actively pursue growth I: Discuss pathophysiology present and/or situation affecting the members of the community R: Allows understanding of the current situation S: Doenges, 2010 I: Assist in correcting 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 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
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
LONG GOAL:
TERM
After 40 hours of nursing intervention, client will be able to: - Verbalize relief of anxiety and adaptation to actual/altered body
image - Verbalize acceptance of situation -Acknowledge self as an individual who has responsibility for self.
S: Doenges, 2010 I: Evaluate clients 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of severe or prolonged depression R: To evaluate need for counseling and/or medications S: Doenges, 2010 I: Note withdrawn behavior or use of denial.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 clients 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
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.
BIBIOGRAPHY:
* Doenges,M.E; Moorshouse,M.M; Murr.A.C. 2010. Nurses 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 Erbs 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. Essentials 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 Suddarths 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