Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders
and Rationale
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*I
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Evaluation
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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.
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Problem
Social isolation
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Long Term:
Client will attend
at least two social activities at Nursing Home by [date].
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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).
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R/T
Altered state of wellness, inability to see
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Short Term:
Client will describe
feelings of self-worth to nursing student during shift today.
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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).
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X
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Through conversation with Patient, it appears as if her poor eyesight is the main
barrier to socialization with other residents. Goal was met.
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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.
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