Help please with care plans

Daytonite, BSN, RN · Feb 28, 2009

you've got major problems with the construction of your diagnoses. until you correct them you can't even begin to work on your goals and nursing interventions.

social isolation r/t depression aeb client does not socialize nor participate in activities. the physician had to d/c her arom due to non-participation.

depression

is not a related factor (cause) of social isolation but a result, or symptom, of it. the reason for the isolation needs to be because the client misbehaves in groups, is so hideous to look at that others shun them, is too ill to attend groups, doesn't act their age, or doesn't act appropriately.

client does not socialize nor participate in activities

is merely a restatement of the diagnosis and really has not elaborated, or given any evidence, of the client's symptoms. why, specifically, is it that the client doesn't participate in activities? are activities offered but the resident

refuses

to go or is taken but

asks to leave

?

the physician had to d/c her arom due to non-participation

indicates that the physician evaluated the patient's response to a treatment he had ordered and changed his plan of care when she failed to meet a goal he had set for her.

goal: resident will participate in group activities for 30 minutes on my 7am- 2:30 pm shift

the goal lies in how you approach the problem. since the problem hasn't really been identified, a goal can't really be formulated yet either.

ineffective coping r/t anxiety aeb trembling of one or both upper extremities during physical assessments causing interference with independent management of adl.

if anxiety is at play here, then use the nursing diagnosis of

anxiety

. anxiety cannot be a related factor for

ineffective coping

. trembling is a symptom of the nursing diagnosis of

anxiety

which addresses the physical symptoms of stress and coping, but not of

ineffective coping

which addresses the psychosocial and behavior symptoms of stress and coping. the related factors for

ineffective coping

need to be thing(s) that is(are) a threat or impediment to coping. trembling is

not

a symptom of

ineffective coping

.

goal: resident will be relaxed & free from tremors for 30 minutes while i perform my physical assessments.

since tremors are not a symptom of

ineffective coping

, then this goal is not appropriate to this diagnosis.