Nursing Diagnosis

(Number
nursing
diagnoses in
order of
priority.)
1-Social isolation
r/t Disease
process
(Schizophrenia)
as evidenced by
client does not
attend group
activities and
client does not
interact with
staff.

Expected Outcomes

1-The client will identify

feelings of isolation within 34 weeks.

Nursing Actions/
Implementation

Rationale
(Cite Specific Sources)

1-The nurse should establish

a therapeutic relationship
with client by being present
and showing a caring attitude.

1-Being emotionally present and

authentic fosters growth in
relationships and decreases isolation.
(Ackley 1126)

2-The client will practice

social and communication
skills needed to interact with
others during hospital stay.

2-Provide positive
reinforcement when client
seeks out others.

2-Receiving instrumental social

support such as feedback contributes
to a positive self being,

3-The client will initiate

interaction with others within
3-4 weeks.

3-Establish trust one to one

then gradually introduce the
client to others.

3-This is individualization of care.

4-The client will participate

in one of the group activities
for 20 minutes by the end of
the week.

4-Put client into groups or

allow client to select which
group according to
preference, abilities, age.

Evaluation

4-Positive social interaction is

enhanced when you provide
opportunities or assist in making
decisions.
(All above from Ackley & Ladwig,
p. 1127-1129)

2-Risk for
loneliness r/t client
refusal to
participate in
group activities,
and clients family
not visiting often
as evidenced by
client not
attending group
activities, staying
in her room, and
the client stating
that her family
does not visit.

1. Client will participate in

ongoing positive and relevant
social activities that are
personally meaningful in one
week.

1-Encourage the client to be

involved in meaningful social
relationship that are
characteristics of both giving
and receiving support.

1-It is important to recognize that

the positive relevance of social
relationships is related to the content
and quality relationship.( Mosby
782)

2. Client will maintain one or

more meaningful
relationships allowing selfdisclosure and demonstrate a
balance between emotional
dependence and
independence before
discharge.

2-Explore ways to increase

the clients support system
and participation in groups
and organization.

2-Satisfaction with support networks

was a potent predictor of selfesteem, emotional health. (Mosby
782)

3-Encourage the client to

develop closeness in at least
one relationship.

3-Dependence and independence

should be balanced in healthy
relationship, which will reduce risk
for loneliness. ( Mosby 782)

3-Risk for
constipation r/t

1-Maintains passage of soft,

formed stool every 1 to 3

1-Observe usual pattern of

defecation including time and

1-There are often multiple reasons

for constipation; the first step is

medications side
effects as
evidenced by
client is taking
Abilify.

days without straining.

day, amount and frequency of

stool, consistency of stool.

2-Identifies measure that

prevents or treats constipation 2-Encourage fiber intake of
by discharge.
25g per day for adults.
3-Encourage client to respond 3-Encourage fluid in take of
promptly to defecation reflex. 1.5 to 2 liters per day.
4-Encourage client to eat
fiber in his daily meals and to
increase intake of fluids to
reduce constipation.

4-Disturbed sleep 1. Pt will verbalize

pattern r/t
satisfaction with sleep-rest

assessment.
2-Fiber helps prevent constipation
by giving stool bulk.
3-Adequate fluid intake is necessary
to prevent hard dry stools.
(All above form Ackley & Ladwig,
p. 692-695)
4-The reflex that cause the urge to
defecate diminishes after a few
minutes and may remain quite for
several hours, as a result the stool
becomes hardened and more
difficult to expel. (Ackley 302)

1. Observe the clients

medication, diet and caffeine

1. Difficulty sleeping can be a side

effect of medication. Also, caffeine

inadequate
Day time activity
and
uncomfortable
sleep
environment as
evidenced by
client yawning
and stating I
feel tired; I want
to take a nap for
a little bit.

pattern as evidenced by
intake.
stating, I slept well within 1
week.
2. Eliminate or reduce sleep
interruptions by closing the
door or pulling the curtains

5. Self-esteem
disturbance
related to
feelings of
inferiority and
sense of
inadequacy, as
evidenced by
client stating,
No one loves
me. I want to
have a family but
no one marry

Client will:
1. Make one positive
statement about self within 48
hours.

1. Schedule meetings with

client that ensure privacy and
communicate her importance
as an individual.
2. Examine with client
specific feelings regarding
herself.
3. Encourage client to
express emotions, fears,
feelings of inferiority, and
sadness.
4. Identify with client
achievements that would
make the client feel better

can interfere with sleep. (Mosby pg

886)
2. Excessive noise or changes in the
environment can cause poor quality
sleep. (Mosby pg 887)

1. Facilitate feelings of acceptance

and belonging and validate clients
worth. (Johnson, p 556)
2. Clients view of himself is a vital
aspect of his personality.
(Johnson, p. 555)
3. Expression will provide catharsis.
(Johnson, p. 555)
4. To foster clients sense of
accomplishment. (Johnson, p. 558)

me.

about herself and focus on

one of these.

6. Self- esteem
disturbance r/t
personal identity
as evidenced by
poor hygiene,
uncombed hair
and soiled attire.

Client will:
1. state accurate selfappraisal.
2. take bath and comb
hair within 48 hours.

1. Treat client with

respect and as an
equal to maintain
positive self esteem.
2. Encourage the client
to create a sense of
competence through
short term goal setting
and goal achievement.

1.Clients with Schizophrenia may

have significant self-care deficits.
Inattention to hygiene and grooming
needs is common, especially during
psychotic episodes. (Videbeck pg
290)

7. Social
Isolation r/t
failure to
establish trust as
evidenced by

Client will:
1. Identify barriers that
cause impaired social
interactions.
2. Participate in activites

1. Establish a therapeutic
relationship by being
emotionally present
and authentic.
2. Establish trust one on

1. Relating to others is difficult

when ones self-concept is
not clear. Clients have
problems with trust and
intimacy, which interfere

client was in her

room lying
down, avoidance
of social
activities with
other residents
and she has
never been
married before
and she doesnt
have a boyfriend.

and programs at level

of ability and desire
within 72 hours.
3. Describe feelings of
self-worth before
discharge.

one and then

gradually introduce
the client to others.
Allow the client
oppurtunities to
introduce issues and
to describe his or her
daily life.

with the ability to establish

satisfactory relationships
with others and the
environment. These clients
lack confidence, feel strange
or different from other
people and dont believe they
are worthwhile. The result is
avoidance of other people.
(Videbeck 290)