College of Health Sciences Education

3rd Floor, DPT Building

Matina Campus, Davao City
Telefax: (082)
Phone No.: (082)300-5456/300-0647 Local 117

Nursing Care Plan

Name of Patient: Umyong

Age: 46 years’ old
Gender: Male
Admitting Diagnosis: Depression

Potential or Risk Nursing Diagnosis

Cues Nursing Diagnosis Objective of Care Nursing Intervention Rationale Evaluation

Subjective cue: - Risk for Self- - Assisting the client - Identify the amount of - A high-risk patient will - Dysfunctional contact
he wished he were Directed Violence to deal with the precautions required for need continuous monitoring with relatives, friends,
dead. current situation, suicide. When a high risk and a secure atmosphere. and/or others. Changes
occurs, if there is a low chance, in style or patterns of
He states that he - Providing for with supervision by a family - Normally, a suicidal contact in family
stopped seeing his meeting member or a friend, will the client’s medical supply accounts. In social
friends on month psychological needs. client be able to go home? For should be limited to 3-5 contexts, verbalized
ago and does not starters, clients do: days. discomfort. It maintains
want to do anything Admit previous suicide feelings of confinement,
anymore. attempts. inhibits contact with
Have any suicide plan. others and lacks eye
He admits to -> Check for the availability of contact.
staying in bed "all required supply of medications
the time" but needed.
sleeping only 3 to 4 Therapeutic Intervention: - Patient can learn to cope
hours a night. - Encourage consumers to with conflicting feelings in
convey emotions (pain, alternative ways to develop
He admits to feeling disappointment, guilt) and a sense of control over their
suicidal but denies discover alternative forms of lives.
having any suicide coping with feelings of
plans. dissatisfaction and indignation. - To help diminish personal
feelings of helplessness,
- Keep in contact with the worthlessness, and
family, plan trauma therapy. loneliness, clients need a
Activate self-help groups' ties. network of support..
Actual Nursing Diagnosis:

Cues Diagnosis Objective Cues Nursing Intervention Rationale Evaluation

Objective cue: - Impaired Social - Determining a - Eventually involve the client in - Socialization minimizes - Patients will monitor
Interaction degree of group activities (e.g., group lonely emotions. Genuine and show success in the
he had not been impairment, discussions, art therapy, dance care of others will raise restoration of sustained
getting out of bed to - Disturbed Thought therapy). feelings of self-worth. relationships after one
shower or eat. Processes - Assessing the month with friends and
client’s coping - Give the customer more time - Usual activities can take family members.
His hair is greasy abilities, than average to complete long periods of time;
and uncombed and habitual daily life tasks (ADL) pressures only raise anxiety
his clothes smell of (e.g. Eating, dressing). and slow down the ability to
body odor. think clearly for the client to
hurry.
- Involve the client in one-to-one - Maximizes engagement
He is not close with interaction while the client is in potential thus minimizing
his parents, who live the most stressed situation. levels of anxiety.
out of the state.
- Determine the prior level of - The development of a
He called the school cognitive functioning of the benchmark data enables
in which he teaches customer (from client, family, client success to be
four days ago and past medical records). measured.
said he was sick.

References:
Keltner, N. L. (2013). Psychiatric nursing. Elsevier Health Sciences.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.

Submitted by: Rheynel Nietes BSN 1

Code: NCM 103n\L Code: 9228