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42 years old Black female, retail clerk, single - Coggle Diagram
42 years old Black female, retail clerk, single
Major depressive disorder
S & Sx: feeling of powerlessness, oversleeping, decrease in affect, chronic pain, report of losses
Nsg Dx: hopelessness
Nsg actions/ interventions: 1. assess for hopelessness with Beck Hopelessness Scale, 2. assess for pain and respond with appropriate measures for pain relief, 3. assist patient in looking at alternatives and setting long-term and short-term goals that are important to her, 4. assist patient to explore the meaning of life, satisfaction with her life and life goals
Outcomes: 1. verbalizes feelings, 2. make positive statements, 3. set goals, 4. sleep appropriate length of time for age and physical health
S&Sx: alcohol abuse, narcotics abuse, alteration in concentration, insomnia
Nsg Dx: ineffective coping
Nsg actions/ interventions: 1. use therapeutic communication to encourage patient to express emotions, verbalize fears, and set goals; 2. collaborate with patient to identify strengths such as ability to relate the facts and to recognize the source of stressors; 3. provide mental and physical activities within patient's ability
Outcomes: 1. remain free of destructive behavior toward self, 2. demonstrates adaptive coping strategies, 3. reports return to a pre-illness level of functioning
S &Sx: scars on wrists, reports of current suicidal thoughts, history of suicide attempts
Nsg Dx: risk for suicide
Nsg actions/ interventions: 1. complete initial suicide assessment using SAD PERSONS suicide risk assessment scale, 2.monitor continually, 3. limit medication supplies, 4. encourage patient to talk about feelings, 5. develop safety plan
Outcomes: 1. not harm self, 2. disclose suicidal ideas if present, 3. expresses feelings,4. plans for the future, 5. obtain no access to harmful objects
Medical Rx: 1. Duloxetine 30 mg bid, 2. Quetiapine 300 mg qhs, 3. Diphenhydramine 30 mg q4h, 4. Meloxicam 7.5 mg qd
S&Sx: delusion( being watched and followed), scanning behavior, insomnia
Nsg Dx: anxiety
Nsg actions/ interventions: 1. provide a safe, calm environment by decreasing environmental stimuli; 2. encourage the patient to use positive self-talk, 3. offer patient accurate information, and encourage her to talk about the meaning of the events contributing to the anxiety
Outcomes: 1. experiences elimination of maladaptive anxiety, 2. demonstrates some ability to reassure self, 3. demonstrates increased external focus, 4. demonstrates the accuracy of thoughts
Source: Ackley, B. J., & Ladwig, G. B. (2020). Nursing diagnosis handbook: an evidence-based guide to planning care. Twelfth edition. Maryland Heights, Missouri: Mosby Elsevier.