Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

“I’m almost blind and my eyes are getting worse everyday…I don’t like artificial light, and the sun is too bright.”

Objective:

Resident sits in room with shades drawn and no lights on.

Problem

Social isolation

Long Term:

Client will attend at least two social activities at Nursing Home by [date].

Nursing student will help client identify appropriate activities to encourage socialization. Rationale: Active participation by the client is essential for behavioral changes (Ackley & Ladwig, 2008).

R/T

Altered state of wellness, inability to see

Short Term:

Client will describe feelings of self-worth to nursing student during shift today.

Nursing student will observe for barriers to social interaction. Rationale: Causes of social isolation may be different for each individual; adequate information must be gathered so that appropriate interventions can be planned (Ackley & Ladwig, 2008).

X

Through conversation with Patient, it appears as if her poor eyesight is the main barrier to socialization with other residents. Goal was met.

Nursing student took Patient outside to the porch to experience the beautiful day. Resident started conversation with another resident doing the same. The two talked for awhile. Next week, nursing student will suggest attending an activity.

AEB

Resident sits alone in unlit room. Resident reports inability to see visitors and staff.