17.7 Putting It All Together
Client Scenario
Mr. Yun is a 34-year-old man presenting to his physician’s office for a follow-up visit. The client recently experienced the loss of his wife in a motor vehicle accident and reports, “I have problems concentrating and I can’t sleep at night.” The client’s chart indicates he has lost 15 pounds since his previous visit last month. He reports, “I have a hard time getting out of bed in the morning.” On further questioning, he admits drinking five to six alcoholic beverages every night to “numb myself.”
Applying the Nursing Process
Assessment: The nurse notes that Mr. Yun is experiencing difficulty concentrating, difficulty sleeping, and unintentional weight loss of greater than 15 pounds since his wife passed away. He self-reports drinking five to six alcoholic beverages every night to “numb myself.”
Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Yun:
Nursing Diagnosis: Ineffective Coping related to inability to deal with a situation as manifested by unintended weight loss, difficulty concentrating, difficulty sleeping, and drinking five to six alcoholic beverages daily to “numb myself.”
Overall Goal: The client will demonstrate improved coping.
SMART Expected Outcome: Mr. Yun will verbalize three positive coping behaviors by the end of the teaching session.
Planning and Implementing Nursing Interventions:
The nurse will identify the client’s personal resources and relationships. The nurse will use empathetic communication to establish a relationship with the client. The nurse will encourage the client to participate in activities that bring personal satisfaction to the client. The nurse will provide education regarding the value of exercise, meditation, prayer, etc., to enhance individual coping. The nurse will provide health teaching about support resources available within the client’s community.
Sample Documentation:
Mr. Yun exhibits signs of ineffective coping in relation to his inability to deal with the loss of his wife. He reports difficulty concentrating, difficulty sleeping, and drinking five to six alcoholic beverages nightly to “numb myself.” He has had unintended weight loss of 15 pounds in the past month. Health teaching was provided regarding positive coping skills. Mr. Yun verbalized three positive coping behaviors he plans to implement this month.
Evaluation:
At the end of the teaching session, the nurse asks Mr. Yun what healthy coping strategies he plans to implement. Mr. Yun states he plans to go for daily walks, limit his alcohol intake to two servings a day, and listen to a meditation app that he enjoys every evening before bed. He plans to contact a local church to attend a support group for widowers. The SMART outcome was “met.”