ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM
Subjective: Self-Care Deficit is the inability After providing nursing Recognize choice for food, The patient will be eager to submit After providing
“I tend to overthink about of an individual to perform self- interventions personal care items, and other himself or herself to the treatment nursing interventions
my future that sometimes I care. The deficit may be the things. regimen that supports his or her
tend to question where will effect of temporary limitations, Patient will sleep individual preferences. Patient sleep between 6
it lead me. I am insecure such as those one might between 6 to 8 hours to 8 hours per night
about my friend for experience while recovering per night This may imply the demand for
becoming an overachiever” from surgery, or the result of Monitor impulsive behavior or supplementary interventions and Patient partially return
gradual deterioration that erodes actions indicative of altered management to guarantee safety or to weight consistent for
Patient will gradually
Objective: the individual’s ability or judgment. security. height and age or
return to weight
changes in appetite, willingness to perform the baseline before illness.
consistent for height
anxiety/anxiousness, sleep activities required to care for and age or baseline Fatigue can intensify feelings of
problems, stress vomiting himself or herself. Also, patients before illness. Provide rest periods after activities. depression.
and having a hard time to eat who are suffering
or digest his foods. from depression may not have Encourage relaxation measures in These measures induce sleep and
the interest to engage in self- the evening (e.g., drinking warm relaxation.
Nursing Diagnosis: care activities. milk, back rub, or tepid bath).

Self-care deficit related to Encourage the client to get up and

severe anxiety possible dress and to stay out of bed during Minimize sleep during the day
evidenced by Persistent the day. increases the likelihood of sleep at
insomnia and Weight loss. night.
https://nurseslabs.com/self-care- Reduce environmental and physical
deficit/ stimulants in the evening; Provide Decreasing caffeine and
decaffeinated coffee, soft music, epinephrine levels increases the
soft lights and quiet activities. possibility of sleep.

Weight the client weekly and

observe the eating patterns of the
client.
Give the information needed for
Encourage eating with others. revising the intervention.

Serve foods or drinks the client Increases socialization, decrease

likes. focus on the food.

Encourage small, high-calorie, and

high-protein snacks and fluids Clients are more likely to eat foods
frequently throughout the day and they like.
evening if weight loss is noted.
 Minimize weight loss, constipation,
Educate family and significant and dehydration.
others to promote autonomy and to
intervene if the patient becomes
tired, not capable of carrying out
task, or become extremely This displays caring and concern
aggravated. but does not hinder with patient’s
efforts to attain autonomy.
Inform family members to allow
the patient perform self-care
measures as much as possible.

Reinstitutes feeling of independence

https://nurseslabs.com/major- and promotes self-esteem and
depression-nursing-care-plans/6/ improves rehabilitation process.

Subjective: Depression was associated After 5 days of nursing After 5 days of nursing

“I have suicidal thoughts. I with increased risk of engaging intervention, the -Identify the level of suicide -A client with a high-risk will intervention, the
tend to overthink about my in self-directed violence as well as client’s suicidal precautions needed. require a constant supervision and a client’s suicidal
future that sometimes I tend intimate partner physical and ideation will be safe environment. ideation is lessened
to question where will it lead psychological violence. lessened or will be
me. I am insecure about my Self-direct violence a variety of absent -Normally, a suicidal client’s
friend for becoming an stressful events or circumstances -Check for the availability of medical supply should be limited to
overachiever” can put people at increased risk of required supply of medications 3-5 days.
harming themselves including the needed.
loss of loved ones, interpersonal
Objective: conflicts with family or friends
changes in appetite, -monitor client’s weight -dramatic and extreme changes in
and legal or work-
anxiety/anxiousness, sleep the client’s weight helps identify the
related problems.
problems, stress vomiting degree of depression the client
and having a hard time to eat
or digest his foods. https://pubmed.ncbi.nlm.nih.gov/29294777/ -monitor environment for potential -to prevent client from access of
https://www.who.int › safety hazards possible tools for self-harm
Nursing Diagnosis: selfdirectedviolfacts
-remove dangerous items from the -to prevent client for further
Risk For Self-Directed
client’s environment ideation of inflicting self-harm
Violence related to
depression evidenced by -provide appropriate level of -to monitor patient and to allow
Suicidal plan/thoughts supervision/surveillance by placing therapeutic actions as needed
patient in a least restrictive
environment
-refer to psychiatrist as needed -for further effective management, a
specialty physician is needed

-Implement a written no-suicide

contract. -Reinforces action the client can
take when feeling suicidal.

-Encourage clients to express

feelings (anger, sadness, guilt) and -Clients can learn alternative ways
come up with alternative ways to of dealing with overwhelming
handle feelings of anger and emotions and gain a sense of
frustration. control over his/her life.

-Contact the family, arrange for -Clients need a network of

crisis counseling. Activate links to resources to help diminish personal
self-help groups. feelings of helplessness,
worthlessness, and isolation.

-There are different measures for

-If, hospitalized, follow unit the suicidal client in either the
protocols. hospital, clinic, and community.

https://nurseslabs.com/major-
depression-nursing-care-plans/