Spiritual Distress

Spiritual
Distress

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_) Pain
(_) Trauma
(_) Loss of body part/function

(_) Terminal illness
(_) Death of s/o
(_) Unable to practice religious rituals
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
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