18.6 Putting It All Together

Client Scenario

Mr. Yun is a 34-year-old man presenting to his physician’s office with complaints of difficulty concentrating, sadness, and anxiety. The client recently experienced the loss of his wife in a motor vehicle accident and reports difficulty sleeping and weight loss of greater than 15 pounds in the previous month. He reports feeling “hopeless” and “angry at God” for the loss that he has experienced. He states he used to attend religious services with his wife, but “That was really more of ‘her’ thing. I really don’t know what to believe anymore.”

Applying the Nursing Process

Assessment: The nurse notes that the client is experiencing difficulty concentrating, feelings of sadness and hopelessness, and reported anxiety. He self-reports feeling hopeless, feelings of anger toward God, and uncertainty in his belief system.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mr. Yun:

Nursing Diagnosis: Spiritual Distress related to loss of challenged belief system as manifested by self-reported “hopelessness,” being “angry at God,” and general uncertainty in beliefs.

Overall Goal: The client will demonstrate improved spirituality.

SMART Expected Outcome: By the end of the teaching session, Mr. Yun will describe a spiritual practice that provides him comfort.

Planning and Implementing Nursing Interventions:

The nurse will identify the factors that influence the client’s personal belief system. The nurse will provide support to the client and allow the client to express emotions and anger. The nurse will observe and listen empathetically in the communication experience. The nurse will encourage the use of spiritual resources and ask the client permission to contact a chaplain.

Sample Documentation:

Mr. Yun exhibits signs of spiritual distress in relation to the loss of his personal belief system as the result of his wife’s recent death. He verbalizes anger, hopelessness, and uncertainty in his belief system. However, he states he does find comfort in spending time outdoors in nature. A chaplain has been contacted with the client’s permission to address Mr. Yun’s spiritual needs.

Evaluation:

At the end of the teaching session, the nurse explains that with his permission, a chaplain will call Mr. Yun at home to follow up. Mr. Yun grants permission for the referral. The nurse asks what other spiritual resources Mr. Yun plans to use at home. Mr. Yun explains that he will purposefully go for daily walks outdoors to spend time in nature. The SMART outcome was “met.”