Impaired Social Interaction related to Fear of being scrutinized and embarrassed by others

EXPLANATION OF EVALUATION
ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE
THE PROBLEM
SUBJECTIVE: Identify with client
STO: within 8 hours of Increased anxiety can STO: within 8 hours of
Nangangatog ang aking mga
The state in which Therapeutic Therapeutic
binti gayundin nanlalamig ang an individual communication symptoms he intensify agitation,
communication Client
aking pakiramdam sa tuwing ako ay Client will be able experiences when aggressiveness, and
maatasan na makipag usap participates in an was able to
sa iba to enumerate signs he or she begins to suspiciousness.
enumerate signs and
insufficient or
and symptoms of feel anxious around
OBJECTIVE excessive quantity symptoms of
increasing anxiety others.
Nail picking were noted while increasing anxiety
client was talking. or ineffective and healthy ways such as nail picking
to maintain anxiety Keep client in an Client might respond
Avoids eye contacts during
quality of social
conversations. and stammering thus
at manageable environment as to noises and
Stammering speech noted exchange. she was able to
Spends time alone by self level free of stimuli (loud crowding with
demonstrate
noises, crowding) as agitation, anxiety,
techniques to
LTO: Patient will possible and increased
maintain anxiety at
maintain an inability to
manageable level
interaction with concentrate on
such as deep
another client Ensure that the outside events
breathing and
while doing an goals set are rhythmic exercise
Avoids pressure on
activity (e.g., simple realistic;  whether
the client 
board game, in the hospital or LTO: Patient was able
drawing. community. to maintain an
interactions with
Structure times
other clients while
each day to include
Helps client to doing an activity of
planned times for
develop a sense of simple board game,
brief interactions
safety in a non- and drawing.
and activities with
the client on one- threatening
environment.
on-one basis
Teach client to
remove himself Teach client skills in
briefly when feeling dealing with anxiety
agitated and work and increasing a
on some anxiety sense of control.
relief exercise such
as rhytmic exercise
and deep breathing
exercise.

Provide
opportunities for
Social skills training
the client to learn
helps the client adapt
adaptive social
and function at a
skills in a non-
higher level in
threatening
society, and
environment. Initial
increases the client’s
social skills training
quality of life.
could include basic
social behaviors
(e.g., appropriate
distance, maintain
good eye contact,
calm
manner/behavior,
moderate voice
tone
Recognition and
Give appreciation go a
 acknowledgment long way to
and recognition for sustaining and
positive steps client increasing a specific
takes in increasing behavior.
social skills and
appropriate

interactions with
others.

Defensive Coping related to Perceived vulnerability

EXPLANATION OF THE EVALUATION
ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE
PROBLEM
SUBJECTIVE: Repeated projection STO: Assess and observe Intervene before STO:
Hindi ako natatakot sa
of falsely positive Patient will interact clients regularly for client loses control. Patient was able
inyo at sa mga hawak
self-evaluation based with others signs of increasing interact with others
nyong injection kahit
turukan nyo ako hindi on a self-protective appropriately. anxiety and hostility. appropriately.
ako papalag ang LTO: LTO:
pattern that defends
problema ko hindi nyo Patient will state that Patient was able to
alam ang ginagawa against underlying Explain to client what Prepares the client
feels safe and more determine causes of
ninyo kasi mga bobo perceived threats you are going to do beforehand and
in control with hostility such as fear
kayo as stated by patient before you do it. minimizes
directed towards the environment of needles and state
misinterpreting your
doctor that he feels safe and
intent as hostile or
more in control with
OBJECTIVE aggressive.
Hostility and environment with use
aggression towards Use a non There is less chance of oral medications
medical staff judgemental, for a suspicious client
Fearful respectful, and to misinterpret intent
Grandiosity neutral approach or meaning if
 with the client. approach is neutral
Be honest and Honesty and
consistent with client consistency provide
regarding an atmosphere in
expectations and which trust can grow.
enforcing rules.
Injections might be
Maintain low level of perceived as
stimuli avoid giving threatening.
medications in a
form of injection use
alternative route as
prescribed by doctor

Fear related to Phobic stimulus

EXPLANATION OF THE EVALUATION
ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE
PROBLEM
SUBJECTIVE: Response to STO: within 3 hours of Reassure client of his At panic level anxiety, STO: within 3 hours of
Nurse dito ka lang therapeutic safety and security. client may fear for own therapeutic
perceived threat that
huwag mo ko iiwan baka communication client life. communication client
bigla akong patayin ng is consciously will be able to discuss was able to discuss
mga kasama ko sa recognized as a phobia with the Explore client’s It is important to
her fear of being
kwarto plss dito ka lang danger perception of threat to understand the client’s
nurse. physical integrity or perception of the phobic alone in public places
OBJECTIVE LTO:Client will be threat to self-concept. object or situation in such as psychiatric
Fearful able to function alone order to assist with the ward were escape
Holding tightly to nurse desensitization process.
Self-centerdness in public places Present and discuss would be difficult this
without experiencing reality of the situation Client must accept the causes her to have
panic with client in order to reality of the situation increases anxiety
recognize aspects that before the work of
level
can be changed and reducing the fear can
those that cannot progress.
 LTO: Client was able
Include client in making Allowing the client choices
to function alone in
decisions related to provides a measure of
selection of alternative control and serves to public places without
coping strategies. experiencing panic as
increase feelings of self-
worth. evidenced by
Encourage client to explore
underlying feelings that Verbalization of feelings in resumption of normal
may be contributing to a nonthreatening life activities
irrational fears. Help client environment may help
to understand how facing client come to terms with
these feelings, rather than unresolved issues.
suppressing them, can
result in more adaptive
coping abilities.

Use desensitization Systematic desensitization

approach such as (gradual systematic
Systematic exposure of the client to
the feared situation under
desensitization
controlled conditions)
allows the client to begin to
overcome the fear, become
desensitized to the fear.
Note: Implosion or
flooding (continuous, rapid
presentation of the phobic
stimulus) may show
quicker results than
systematic desensitization,
but relapse is more
common or client may
become terrified and
withdraw from therapy.
Situational Low Self-Esteem related to Feelings of shame and guilt

EXPLANATION OF THE EVALUATION

ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE
PROBLEM
SUBJECTIVE: “Ang negative self- STO: Patient will be Assess the self-esteem Signs of a low self-esteem STO: Patient was able
bobo ko simpleng mga level of the patient. includes withdrawal from
evaluation/feelings able to identify one to identify two
problema lang di ko pa social relationships, feeling
magawahan ng solusyon or two strengths by of inadequacy, neglect of strengths such as:
about self or self-
kailangan ko pang iaasa the end of the day. personal hygiene and dress, Able to perform hygiene
sa iba napaka walang capabilities. LTO: Patient will keep a and rejecting self which all care alone
kwenta kong tao ” as daily load and identify on may indicate a negative Able to maintain a
stated by patient a scale of 1 to 10 (1 thought pattern. conversation with other
OBJECTIVES: being the lowest, 10 client without feelings of
Hostility towards others being the highest) Allow the patient to Paying attention to shame .
Demotivation to perform feelings of guilt, shame, perform personal care grooming serves as a first
daily activities such as self-hate. activities step towards achieving LTO: on the second day
bathing and positive self-image. of nursing intervention
toothbrushing patient rated feeling of
Rated feeling of guilt shame and self
shame ,guilt and self Give positive feedback Positive reinforcement has hate to 4/10
hate 7/10 after a task is achieved a big part in building self-
esteem.

Allow the patient to engage Patient may feel

in simple recreational overwhelmed at the start
activities, advancing to a when participating in a
more complex activities in group setting.
a group environment

Role model assertiveness. Clients can follow

examples/role models.
Teach visualization
techniques that can help To promote a healthier and
the client replace negative more realistic self-image
self-images with more by helping the client
 positive images and choose more positive
thought. thoughts and actions

Fear related to behaviors indicative of panic

EXPLANATION OF THE EVALUATION

ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE
PROBLEM
SUBJECTIVE Response to STO: Within 2 hrs of Reassure client of his At panic level anxiety, STO: Within 2 hrs of
nurse! pakiramdam ko nursing intervention safety and security. client may fear for own nursing intervention
perceived threat that
bumibilis ang pintig ng patient will be able to life. patient was able to
puso ko naninikip din ito is consciously calm down maintain manageable
at nahihirapan na akong recognized as a Explore client’s It is important to anxiety level and keep
huminga as stated by danger LTO: perception of threat to understand the client’s calm in presence of
patient Client will be able to physical integrity or perception of the phobic external stimuli
OBJECTIVE threat to self-concept. object or situation in
function without
Trembling order to assist with the LTO:
Excessive sweating experiencing panic desensitization process. Client was able to
(Diaphoresis) anxiety by time of Present and discuss
function without
BP 150/90 mmhg discharge from reality of the situation Client must accept the
HR 120 bpm with client in order to reality of the situation experiencing panic
RR 22 cpm treatment recognize aspects that before the work of anxiety by time of
can be changed and reducing the fear can discharge from
those that cannot progress.
treatment
Include client in making Allowing the client choices
decisions related to provides a measure of
selection of alternative control and serves to
coping strategies. increase feelings of self-
worth.
Encourage client to explore
underlying feelings that Verbalization of feelings in
may be contributing to a nonthreatening
irrational fears. Help client environment may help
to understand how facing client come to terms with
these feelings, rather than unresolved issues.
suppressing them, can
result in more adaptive
 coping abilities.

Expose client to a
predetermined list of Experiencing fear in
anxiety-provoking stimuli progressively more
rated in hierarchy from challenging but attainable
the least frightening to steps allows client to
the most frightening realize that dangerous
consequences will not
occur. Helps extinguish
conditioned avoidance
response
Administer antianxiety
medications as ordered Biological factors may be
such as Alprazolam involved in phobic/panic
(Xanax), reactions, and these
medications (particularly
Xanax) produce a rapid
calming effect and may
help client change behavior
by keeping anxiety low
during learning and
desensitization sessions.
Addictive tendencies of
CNS depressants need to
be weighed against benefit
from the medication.

Powerlessness related to Lifestyle of helplessness

EXPLANATION OF THE EVALUATION
ASSESSMENT OBJECTIVE INTERVENTIONS RATIONALE
PROBLEM
SUBJECTIVE The perception that STO: Within 2 days of Have client take as Providing client with STO: Within 2 days of
I cannot control what is much responsibility for choices and responsibility
happening around me one’s own action will constant nurse -client own self-care practices. will increase his or her
constant nurse -client
for It seems that when I interaction she will be feelings of control. interaction she was
not significantly affect
try to think my mind able to participate in able to do ADL s such
goes blank and I feel so an outcome; a Help client set realistic Unrealistic goals set the
tired maybe because I perceived lack of decision making goals. client up for failure and as bathing and
can not sleep well at reinforce feelings of
night so I need to control over a current regarding own care. powerlessness.
dressing alone.
depend too much on situation or Help identify areas of life Client’s emotional LTO: Client was able
others to help me get LTO: Client will be situation that client can condition prevents his
immediate to effectively take
through the day as able to effectively control. ability to solve problems.
stated by patient happening. Support is required to control of her life
take control of her
OBJECTIVE: perceive the benefits and situation as
life situation
Increase dependence consequences of available evidenced by active
alternatives.
on others to do ADL participation in care
Irritability Help the client identify To deal with unresolved and decision making
Anger areas of life situation that issues and accept what thus patient exhibit
Guilt are not with his ability to cannot be changed.
control; encourage limited moments of
Nonparticipation in verbalization of these irritability
care or decision feelings.
making
Identify ways and instances Positive reinforcement
Reluctance to express
in which the client can enhances self-esteem and
true feelings. achieve and encourage encourages repetition of
participation in these positive behaviors.
activities; provide positive
reinforcement for
participation