Social Isolation
Social Isolation
(_)Actual (_) Potential
| (_)
Death of s/o (_) Divorce (_) Substance abuse (_) Illness:____________________________ ____________________________________ (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major:
(Must be present) |
(_)
Expressed feelings of unexplained dread or abandonment (_) Desire for more contact with people |
| Minor:
(May be present) |
(_) Time
passing slowly (_) Inability to concentrate and make
decisions (_) Feelings of uselessness (_) Doubts about ability to survive |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Identify the reasons for his/her feelings of isolation. (_) Identify ways of increasing meaningful relationships. (_) Identify appropriate diversional activities. (_) Other: |
(_)
Encourage patient to verbalize feelings. (_) Assist to identify causative and contributing factors. (_) Assist to reduce
or eliminate causative and contributing factors: (_) Assist to identify diversional activities. (See Diversional Activity Deficit) (_) Initiate referrals
as needed or increase social relationships: (_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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