NURSING CARE PLAN NURSING CONCEPT

Date: November 10, 2021 Client Initials: MX PRIORITY

COGNITION MOOD & AFFECT
NURSING DIAGNOSIS: anxiety (primary diagnosis) AIRWAY COMMUNICATION PAIN
BREATHING COMFORT SAFETY
RT: change in role status/ new living situation GRIEF SEXUALITY
CIRCULATION
SAFETY INTERPERSONAL SPIRITUALITY
AEB: irritability, angry outbursts, dizziness, palpations,
OTHER: ______________ VIOLENCE STRESS & COPING
insomnia, chest pain

ASSESSMENT PLANNING GOAL IMPLEMENTATION RATIONALE EVALUATION GOAL

Desired Outcome Reason for the interventions MET
Specific &
Measurable
Patient Data Patient Will Nurse will: Why? What happened? Y/N
Subjective: Patient• Short-term goal: By 1. The nurse will assist the patient in 1. The patient needs to be able to 1. The patient was able to meet this Yes
stated there was a the end of a week the identifying signs of anxiety and acknowledge their diagnosis to be able short-term goal. MX was able to
recent life change patient will be able to causes. If the patient is ready to learn, to continue with the learning process. acknowledge the diagnosis of anxiety and
when his wife describe own anxiety the nurse can help determine their Asking MX what usually makes him identified events that trigger his anxiety.
moved back in and identify one usual coping mechanisms and ask, upset will help him learn what is He acknowledged that his wife moving
after living “what do you usually do when you get triggering the anxiety. Encouraging the back in was when his anxiety started
strategy to reduce
separately for most upset?” Nurse can ask the patient to patient to focus on things they can because they lived apart for most of their
anxiety.
of their life. describe what is experienced change. The nurse’s availability to the marriage. He stated that symptoms of
Patient states he immediately before feeling anxious. patient promotes expression of anger anxiety worsened when he and his
has had difficulty Allow patient to express emotions and feelings. This can help the patient and wife would start to argue. MX
sleeping and be available to the patient for listening significant other look at the reality of acknowledged the need to focus on things
irritability for 6 or talking. Nurse will help the patient the issues. By helping the patient within his control when feelings of anger
months. Patient develop self-awareness of their become aware the nurse is helping MX arise towards his wife to help redirect
states they behaviors (Aprn-Cns & Pmhcns-Bc- control these behaviors and begin to thoughts.
experienced Retired, 2020). deal with the issues that are causing the
frequent chest anxiety. 2. MX identifies helpful activities that he
tightness. 2. Nurse can promote wellness by has used successfully and will try to
helping the patient identify new 2. The nurse helps the patient realize implement them into daily life. Patient
Objective: Several methods of coping with anxiety. Nurse positive coping mechanisms that have reports that anxiety has reduced to a
incidences of chest can ask MX of any coping strategies been successful in the past. The patient manageable level when implementing
pain 3 weeks ago that have been successfully used in the then is taught a new technique to use in deep breathing techniques. MX reports
and called 911 past with his anxiety. The nurse can a stressful situation with his spouse. that deep breathing exercises help
each time. teach the patient new techniques such MX might find deep breathing helpful promote relaxation and decrease stress
as deep breathing, when confronted to deal with anxiety-provoking when feelings of anger arise during a
with stress (Aprn Bc et al., 2019). situations; especially during disagreement with spouse.
confrontations with SO.

Name: Alexandra Coakley Page: 1

 NURSING CARE PLAN NURSING CONCEPT
Date: November 10, 2021 Client Initials: MX PRIORITY
COGNITION MOOD & AFFECT
NURSING DIAGNOSIS: Ineffective Role performance AIRWAY COMMUNICATION PAIN
(long-term diagnosis) BREATHING COMFORT SAFETY
CIRCULATION GRIEF SEXUALITY
RT: inadequate role preparation/ role transition & conflict INTERPERSONAL SPIRITUALITY
SAFETY
OTHER: ______________ VIOLENCE STRESS & COPING
AEB: Angry altercations with spouse

ASSESSMENT PLANNING GOAL IMPLEMENTATION RATIONALE EVALUATION GOAL

Desired Outcome Reason for the interventions MET
Specific & Measurable
Patient Data Patient Will Nurse will: Why? What happened? Y/N
Subjective: MX reports Long-term goal: 1. The nurse will help 1. The nurse continues optimism while 1. Mr. X met this goal because he was Yes
feelings of anxiousness and Before discharge MX deal with the giving MX a realistic assessment, but able to evaluate his feelings with the
nervous all day. Patient patient will verbalize existing situation by still instilling feelings of. Once MX nurse and discuss the situation with his
states there was a recent realistic perception of discussing the perception gives his perception of the situation the wife in a safe space. Patient was able to
change when wife moved self in changed role of the situation with the nurse can then help the patient with evaluate their own feelings of anger
in 6 months ago. Patient and develop a realistic patient and acknowledge decision making. Changes in role due towards spouse due to his recent
stated he and wife lived plan for adapting to the reality of situation. to changes in family structure change in role due to his wife moving
apart for several years. new role changes. The nurse will continue accompany a sense of loss. The nurse is home. Mr. X was able to openly grieve
Reports becoming easily to maintain a positive allowing the patient to deal with the for the loss of his old life, when he and
agitated by things and attitude and Give MX feelings of loss that come with his wife SO lived separately. MX stated that he
reports frequent arguing the opportunity to be in being back home. By letting the patient wants to try to make it work with his
with his wife. MX states control over as many exercise control over decisions, it wife but is apprehensive due to
his symptoms become decisions as possible enhances the patient’s self-concept and skepticism of spouse. MX stated he
worse when aggravated by (Aprn Bc et al., 2019). promotes MX commitment to his goals. would like to try and improve situation
his wife. with spouse but does not know how.
2. Give patient 2. By giving MX information about
Objective: Ineffective information to learn role changes, it helps the patient be pre- 2. MX arrived at the conclusion that he
coping strategies and about role expectations. emptive about dealing with the life would like to try therapy with his wife.
ineffective coping The nurse will provide change of his wife moving back home. The nurse talked with patient and SO
strategies and ineffective positive feedback for The nurse will encourage the patient’s which helped mediate the differences
adaptation to change. MX changes and goals the acceptance of the situation to between the two individuals until they
became increasingly patient achieves. The encourage hope and optimism. By mutually decided to try therapy. The
agitated when speaking of nurse will refer MX and referring the patient and SO to support nurse referred them to several providers
his wife. MX declined SO to support groups or groups/ therapy, the nurse is providing and patient and spouse plan to start
Sertraline 25 mg daily. counseling (EdS Rn et ongoing support for the patient after marriage counseling next week.
al., 2016). discharge.

Name: Alexandra Coakley Page: 2

 NURSING CARE PLAN NURSING CONCEPT
Date: November 10, 2021 Client Initials: MX PRIORITY
COGNITION MOOD & AFFECT
NURSING DIAGNOSIS: Dysfunctional family process AIRWAY COMMUNICATION PAIN
(Educational diagnosis) BREATHING COMFORT SAFETY
CIRCULATION GRIEF SEXUALITY
RT: ineffective coping strategies INTERPERSONAL SPIRITUALITY
SAFETY
OTHER: ______________ VIOLENCE STRESS & COPING
AEB: insufficient relationship skills and disturbance in
family dynamics

ASSESSMENT PLANNING GOAL IMPLEMENTATION RATIONALE EVALUATION GOAL

Desired Outcome Reason for the interventions MET
Specific & Measurable
Patient Data Patient Will Nurse will: Why? What happened? Y/N
Subjective: Patient Long-term goal: The 1. The nurse will establish 1.By understanding from both 1. Mr. X reached his long-term goal because he and Yes
states he gets angry patient will verbalize that the patient and parties what has brought about his spouse both stated that they fight frequently and
at spouse. Patient feelings to spouse and significant other understand the current situation can help state that since Mr. X’s spouse recently moved back
states that there has plan for necessary the situation. Nurse will take determine a start for treatment into the home. Both came to the agreement that they
been a change since lifestyle changes. a family history and explore planning. Although Mr. X is the have a desire to enhance their relationship. Mr. X
wife moved home 6 roles of family members as patient, the nurse knows that explained his anger and frustration towards his wife
months ago after well as situations that involve MX and SO are both part of the is due to miscommunication between the two. The
living apart most of communication patterns problem and both need to be a patient states since they lived apart for a long time,
their marriage. (Aprn-Cns & Pmhcns-Bc- part of the solution as well. most of her actions disrupt the daily life he has
Patient states he Retired, 2020). become used to. Mr. X’s spouse, via a translator,
fights with spouse 2. by acknowledging the stated that she does not know what her new role is
and that he becomes 2. The nurse will realities and difficulties of the since retiring and moving home. She states she
angry with her and acknowledge the realities and situation the nurse is doesn’t know where she fits in at home. Both parties
describes her as a difficulties of the situation. reinforcing the fact that there want to try to make the relationship work, but state
“headstrong woman The nurse will find interests will be some degree of conflict that neither knows how.
who likes to do the patient and spouse enjoy and the nurse can use this
things her own doing together on a regular conflict to promote growth. The 2. While talking about the realities of the situation,
way.” and frequent basis. The nurse nurse is promoting feelings of both parties began to argue, and the nurse found the
will encourage the use of warmth and caring when opportunity to pause and have them reflect on where
Objective: Patient stress management having the couple discuss an the conversation escalated. She taught them a
becomes agitated techniques (relaxation/ deep activity they will enjoy doing relaxion technique of deep breathing, which helped
when discussing his breathing exercise, or on a frequent basis. By calm both parties. They then continued to reflect on
significant other. appropriate expression of referring the patient and SO to current situation (as stated above). Both parties
Noticeable, feelings). Refer the patient to counseling the nurse is agreed to seek counseling and made their first
inadequate respect support services such as promoting commitment to appointment. The couple also agreed they both
for spouse. marital counseling (Aprn Bc goals/ continuation. enjoy walking in the park and agreed to do that
et al., 2019). daily.

Name: Alexandra Coakley Page: 3

 References

Aprn Bc, M. D. E., Crrn, M. M. R. M. F., & Bsn Rn, A. M. C. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
(Fifteenth ed.). F.A. Davis Company.

Aprn-Cns, M. K. R. M., I., & Pmhcns-Bc-Retired, D. M. T. C. (2020). Davis Advantage for Psychiatric Mental Health Nursing (Tenth ed.). F.A.
Davis Company.

EdS Rn, M. B. A. J., Msn Rn, G. L. B., & Fcns, F. M. M. P. R. C. F. F. B. (2016). Nursing Diagnosis Handbook: An Evidence-Based Guide to
Planning Care (11th ed.). Mosby.

Name: Alexandra Coakley Page: 4