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
Client reported
being depressed, and having been hospitalized for depression on more than one occasion
in past.
Objective
Client does not make much
eye contact throughout interview. Client
is quick to respond to questions about weaknesses and disparities in health but
has difficult time responding to questions of strengths.
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Problem
Chronic sorrow
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Long Term:
Client will attend
Our Lady of Peace two times a week to engage in self-fulfilling activities.
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Nursing student will ask client each week if client has been attending OLP. Nursing student will ask for an account
of activities and how they made client feel.
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R/T
Unrelieved grief
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Short Term:
Client will make
a list of 10 things she likes about herself before the end of the visit.
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Nursing student will provide verbal prompts to assist client in coming up with 10
things she likes about herself. Nursing
student will post the list in client’s room to be referred to at any point in the
day the client feels down about self.
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