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Risk of injury
Risk of suicide
Impaired function
Knowledge deficit
Nursing Interventions
Injury risk: monitor the patient closely and create and environment to reduce risk
Knowledge deficit: educate the patient on the disease process, treatment, and
management
Rationale: The patient will benefit from learning new ways to manage stress
Assist the patient in developing approaches that work the best for current issues
Rationale: The patient needs support to develop new social skills and test new
social situations to promote engagement
Suicide risk: place on suicide watch. Ensure that a qualified staff member is no
more than an arms length away from the patient at all times. Remove any
potentially hazardous items from the room, such as blind cords, wires, and tubing,
and restrict access to objects such as silverware, pens and pencils
Coping skills: identify currently used coping skills. Assist the patient in developing
new skills
Nursing Outcomes
The patient will remain free of injury for the duration of the visit
The patient will experience resolution of suicidal ideation by the end of the day
The patient will experience restoration of sleeping patterns by 2200 hours tonight
The patient will verbalize at least two new effective coping skill by discharge