- Chronic Low Self-esteem related to disturbed body image, Low self-efficacy and Abandonment as evidenced by constant seeking of reassurance and Hopelessness
- Disturbed Thought Processes related to cognitive dysfunction, Low self-esteem and Social Isolation as evidenced by decreased willingness to participate in social interactions and speech abnormalities
- Ineffective Coping related to inadequate confidence in the ability to deal with a situation and Ineffective tension release strategies as evidenced by altered communication pattern and difficulty organizing information
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalizes Inadequate social support from friends and family Objective Data: -Insomnia -Loneliness -Passive behavior -Overly conforming behaviors -Reduced eye contact -Rejects positive feedback -Reports repeated failures -Self-negating verbalizations | Chronic Low Self-esteem related to disturbed body image, Low self-efficacy and Abandonment as evidenced by constant seeking of reassurance and Hopelessness | The patient will verbalize an increased sense of self-worth The patient will demonstrate behaviors of improved self-esteem such as eye contact, appropriate physical appearance, posture, and participation in conversations | 1. Focus on what can be controlled. A chronic sense of failure may need to be overcome. The patient may feel that their every action or entire life is a failure. Attempt to have the patient focus only on what can be controlled, and that what may be deemed a “failure” does not have to be tied with one’s sense of self. 2. Apply active listening and open-ended questions. Therapeutic communication is an important aspect of providing care and support to patients suffering from mental health problems. Communication methods like active listening and using open-ended questions enable the patient to verbalize interests, worries, concerns, and thoughts without interruption. 3. Provide positive feedback and reinforcement. Continuous positive feedback and support promote the patient’s self-esteem and self-worth. In time, the patient will hopefully begin to believe and be a source of their own positive feedback. 4. Teach the patient to recognize and shut down negative self-talk. Recognition of negative thoughts enables the patient to develop new ways of coping. The patient can be taught to replace negative ideas and beliefs with positive affirmations. | The patient verbalized an increased sense of self-worth The patient demonstrated behaviors of improved self-esteem such as eye contact, appropriate physical appearance, posture, and participation in conversations |
| Subjective Data: -Altered self-concept -Low self-esteem -Psychological barriers -Anxiety -Fear -Stressors -Unaddressed trauma Objective Data: -Difficulty comprehending communication -Inappropriate social behavior -Cognitive dissonance -Inappropriate verbalization -Hallucinations/delusions -Distractibility -Suspiciousness | Disturbed Thought Processes related to cognitive dysfunction, Low self-esteem and Social Isolation as evidenced by decreased willingness to participate in social interactions and speech abnormalities | The patient will maintain reality orientation and communicate and interact with other people according to social norms The patient will recognize and implement strategies to manage hallucinations/delusions | 1. Reorient the patient to person, place, and time as necessary. When a patient is unable to maintain reality orientation, it can cause anxiety or worsening confusion. Consistent reorientation allows the patient to develop a sense of control and builds a trusting relationship with the healthcare provider. 2. Provide safety measures as needed. It is always important to consider the patient’s safety at all times since mental health problems can affect the patient’s reactions to external stimuli. Safety measures include side rails, close supervision, or seizure precautions as indicated. 3. Schedule structured tasks with adequate rest periods. This will help provide adequate stimulation and appropriate treatment interventions while allowing the patient to rest to reduce fatigue. 4. Maintain a quiet and calm environment and approach the patient slowly and calmly. Patients with disturbed thought processes may respond with exaggerated or aggressive behaviors if overstimulated. 5. Do not challenge or accept illogical thinking. Patients who express delusions should not have their reality challenged, but the nurse can offer understanding of what the patient is experiencing while maintaining reality. | The patient-maintained reality orientation and communicated and interact with other people according to social norms The patient recognized and implement strategies to manage hallucinations/delusions |
| Subjective Data: -Verbalizes an inability to cope and handle stressors -Complaints of secondary concerns from lack of coping (sleep disturbances, fatigue, lack of appetite) Objective Data: -Insufficient skills to meet goals, problem-solve or reach resolutions -Behaviors that impede progress -Inability to handle life responsibilities and activities of daily living -Multiple acute illnesses or chronic pain -Depression | Ineffective Coping related to inadequate confidence in the ability to deal with a situation and Ineffective tension release strategies as evidenced by altered communication pattern and difficulty organizing information | The patient will demonstrate effective coping when faced with unfavorable situations The patient will verbalize confidence in dealing with psychosocial issues | 1. Establish trust and a therapeutic relationship with the patient. An unbiased attitude establishes trust. An open and patient tone will reduce feelings of isolation and ultimately facilitate coping. 2. Assist the patient in setting realistic goals. Patients may feel helpless in goal setting especially if they never reach goals. Instruct the patient on how to set short, manageable goals. 3. Allow the patient to express their fears, feelings, concerns, and expectations. Verbalization of perceived or actual threats can help reduce anxiety and promote open communication with the patient. These should be met without judgment from the healthcare team. 4. Support relaxation and leisure activities. Coping with stress, grief, or other mental health issues requires time for hobbies, exercise, and distraction. Remind the patient to take time to read, write, walk, and enjoy activities. 5. Encourage therapy and counseling. Mental health professionals can help the patient learn and implement healthy coping mechanisms. | Patient identified their disruptive behaviors and how they prevent them from coping effectively. Patient verbalized appropriate coping strategies and resources to prevent ineffective coping. Patient expressed confidence in handling their stressors and when to ask for help. |