Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

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.

Problem

Chronic sorrow

Long Term:

Client will attend Our Lady of Peace two times a week to engage in self-fulfilling activities.

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.

R/T

Unrelieved grief

Short Term:

Client will make a list of 10 things she likes about herself before the end of the visit.

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.

AEB

Client’s claim to be lonely after losing close friend and husband.