| Assessment of Data | Nursing Diagnosis | Planning | Nursing Implementation | Evaluation |
S: Kate started abusing alcohol, reported changes in communication patterns and adopted destructive behaviours towards others and self. He also reports fatigue and afraid to ask for help. She inappropriately uses defence mechanism and unable to meet what is expected of her. Kate avoids travelling and other activities like walking along the road. She no longer drives and records a significant decline in the interest of some of the activities she liked. She feels detached and unable to maintain strong relationships with friends and family. O: A closer assessment shows that Kate has guilt dissociation, challenges with affect regulations, unable to concentrate, alteration in personality, detachment, upsetting thoughts, distress, and flashbacks. She was not exposed to another traumatic, even in her life. Hyperarousal symptoms include difficulty in concentrating sleep disturbance, anxiety, irritability, and self-destructive behaviors like drinking (Gulanick & Myers, 2012; Mabey & van Servellen, 2013) | Physiological: Ineffective Coping r/t car accident AEB Destructive behavior toward self and sleep disturbances | STG1: Kate will describe and instigate appropriate coping strategies LTG1: Kate will make decisions and takes appropriate actions to address provocative circumstances in her environment (Shalev, Liberzon, & Marmar, 2017). | The nurse established working relationship with Kate by handling her case and continuing to care for her base on her progress The nurse facilitated a conducive environment for Kate to open up and share her experiences and concerns about the care process. The nurse was friendly to enhance her ability to express fear and her feelings. The nurse and her aid encouraged Kate to decide what she wanted including contributing to the care process and draw a schedule that she can stick to. The social worker and nurse aid helped Kate to realize her goals and identify her strength, skill and knowledge boosting her morale and self esteem The Nurse, aid and social worker avoided giving Kate false reassurance that will only affect her recovery. On the contrary, they conveyed a sense of understanding and acceptance which built her morale and self esteem The nurse provided all the information that Kate needed to make a decision on her care and before starting the process to ensure that she understood everything (Gulanick & Myers, 2012; Mabey & van Servellen, 2013). | STG: Goal Met. Kate appropriately describes and understands coping strategies that will reduce her current situation including addressing sleep disturbance and self destructive behaviour LTG1 Partially met. Kate makes decisions but fails to take some of the necessary actions to deal with provocative issues. Some of the additional interventions include being supportive and engaging her in developing the care plan Interventions The first intervention was successfully implemented and Kate developed a working relationship with the care provider. Nurse established an environment for Kate to express her feelings, concerns and fear. However, the subject did not open up about everything. On the third intervention, Kate was slow in decision making and the Nurse and aid supported her especially on the care process and schedule. On the fourth intervention, Kate was able to identify her goals, strengths skill and knowledge. On intervention 5, the nurse, aid and social worker succeeded in creating a sense of acceptance which enhanced Kate’s self esteem The nurse provided relevant information to help Kate make decisions on the care process. |
Rationale Kate is unable to cope with the current situation Her situation affects physical and mental health Her behavior can have adverse effects in the long term. | Interventions Establish a working relationship with Kate by continuing with her care Create opportunities for Kate to express her fear, concern, expectations and feelings Encourage Kate to make decisions and participate in the care process and other scheduled activities Help Kate set realistic goals and identify her skills and knowledge Avoiding false reassurance but conveying a sense of understanding and acceptance Offer appropriate information and clarification to Kate on the proposed care before giving the care (Gulanick & Myers, 2012) | Implementation and RationaleAn ongoing relationship with Kate will help to address feelings of isolation and build trust allowing her to open up facilitating her coping with the situation. The ability to verbalize threats, actual or perceived can reduce anxiety and facilitate open communication between her and care providers enhancing her recovery Kate’s participation in the planning of care and decision making creates a sense of control and boost self esteem. Active participation in decision making will help Kate to be independent and avoid the self destructive behaviour Establishing honest relationship helps in solving the challenges facing Kate and speeds her coping. False reassurance on the other hand will not help her to recover. They can only serve to alleviate the discomfort of the care professional. Information is critical to the patient and family following a traumatic incident. Providing the information prepares Kate and her family members and enables them to understand the situation and its outcomes (Shalev, Liberzon, & Marmar, 2017). |
References
Gulanick, M., & Myers, J. (2012). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. (7th ed.). Elsevier Health Sciences.
Delegate your assignment to our experts and they will do the rest.
Mabey, L., & van Servellen, G. (2013). Treatment of post-traumatic stress disorder in patients with severe mental illness: A review. International Journal Of Mental Health Nursing , 23 (1), 42-50. https://doi.org/10.1111/inm.12007
Shalev, A., Liberzon, I., &Marmar, C. (2017). Post-Traumatic Stress Disorder. New England Journal Of Medicine , 376 (25), 2459-2469. https://doi.org/10.1056/nejmra1612499
