Spiritual Distress
Spiritual Distress
(_)Actual (_) Potential
| (_) Pain (_) Trauma (_) Loss of body part/function (_) Terminal illness (_) Death of s/o (_) Unable to practice religious rituals (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major:
(Must be present) |
(_) Experiences a disturbance in belief system. |
| Minor:
(May be present) |
(_)
Questions credibility of belief system. (_) Demonstrates discouragement or despair. (_) Is unable to practice usual religious rituals. (_) Has ambivalent feelings (doubts) about beliefs. (_) Expresses that he/she has no reason for living. (_) Feels a sense of spiritual emptiness. (_) Shows emotional detachment from self and others. (_) Expresses concern, anger, resentment, fear - over the meaning of life, suffering, death. (_) Requests spiritual assistance for a disturbance in belief system. |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Continue spiritual practices not detrimental to health. (_) Express decreasing feelings of guilt and anxiety. (_) Express satisfaction with spiritual condition. (_) Other: |
(_)
Assess current level of spiritual state: Comfort,
distress, desire for minister, priest, rabbi to visit,
desire to practice religious rituals. (_) Implement patient requests regarding spiritual needs. (_) Contact spiritual/religious advisor of patients choice. (_) Discuss impact of stress on challenging one's spiritual beliefs. (_) As patient desires, allow opportunity to discuss belief system, the meaning of illness/suffering within this system. (_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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