Need help with care plan please!

[momof3iniowa]

I have a care plan to write for a substance abuse patient and was just given a small amount of information. Here is the scenario:

Mark is a 43 year old male who is attending a drug treatment program after he was hospitalized for multiple burns when he passed out with his cigarette burning. He does not hide the fact that he has no intention of giving up his alcohol and will start using "as soon as I get out". He has demonstrated minimal cooperation in the program. His diagnosis given is: Substance abuse.

So I have to write 2 psychosocial nursing dx, 2 goals for each dx, and 2 interventions for each. Here are the nursing dx I have come up with:

Risk-prone health behavior r/t excessive alcohol consumption m/b patient passed out with cigarette burning and sustained multiple burns.

Ineffective denial r/t refusal to acknowledge substance abuse problem m/b patient states he will use "as soon as I get out" and has shown minimal cooperation in the program.

Do you think those look ok with the little bit of information I have? Also I am having trouble coming up with goals that relate to the dx. This is my first time doing one on substance abuse so your ideas and help would be great! Thanks!!

[DayDreamin ER CRNP]

Risk-prone health behavior r/t excessive alcohol consumption m/b patient passed out with cigarette burning and sustained multiple burns.

Ineffective denial r/t refusal to acknowledge substance abuse problem m/b patient states he will use "as soon as I get out" and has shown minimal cooperation in the program.

Are these NANDA approved NDs? I would start with some approved diagnoses and go from there. If you have to come up with the goals and interventions I would make sure my DXs can yield some good goals too.

[classicdame, MSN, EdD]

goals will support your projected outcomes and reflect what the NURSE can do. So if a patient has ineffective gas exchange secondary to pneumonia, then the nurse could certainly monitor O2 sats, provide O2 as ordered, minimize exertion, monitor VS--- and the goal could be that at least one of these interventions shows an improvement. State what improvement you are looking for and be specific. "improved sats" is not specific. "O2 sats of 98% or better without oxygen by 5/27/11" is specific. Good luck