Social
Isolation
(_)Actual (_)
Potential
(_) Death of s/o (_) Divorce (_) Substance abuse (_) Illness:____________________________ |
Major: ( Must bepresent) |
(_) Expressed feelings of unexplained dread or abandonment (_) Desire for more contact with people |
Minor:
( May bepresent) |
(_) 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 ways of (_) Identify (_) Other: |
(_) Encourage patient to verbalize feelings. (_) Assist to identify (_) Assist to reduce ________________________ (_) Assist to identify (_) Initiate referrals (_) |
__________________________
Patient/Significant other signature
__________________________
RN signature