Question

Ms. T, a 28 year old runway model has just been admitted to the rehab unit following an extensive stay at the burn unit in a local hospital. She was set on fire by her vengeful estranged husband 8 months ago and has spent many of those months in the hospital. She was burned about 54% of her body, including part of her face; the burn ranged from partial tissue loss to deep tissue loss. She also had contractures of her elbows, hands, and knees, which is why she was admitted to the rehab today. Some skin grafting has been done to part of her body. During admission data gathering, Ms. T. admitted to feeling worthless, guilty because she had been cheating on her husband before they broke up and he'd heard her tell her boyfriend on the phone that she'd married him for his money. She stated that she feels responsible for him killing himself after he burned her, that she should have done things differently. She stated that her famous "so-called friends" have abandoned her, that they don't even pick up her calls anymore. She said she'd heard that some people blame her for everything that happened. She expressed sadness that she'd lost her beauty, her friends, her job, her popularity, her good reputation, money, and even some of her family members. She says she doesn't see any point in continuing to live, that the health care professionals have done their best for her, but she'll still continue to look like a monster.

1. Write a SOAPIE note for this patient; 2 nursing diagnosis needed & address them separately, 1 goal, at least 6 interventions, evaluation.

Answer 1

1. SOPIE ; SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN, IMPLEMENTATION, EVALUATION

S- Patient states that she in generally doing good in her fast life but due to her one mistake everything chaged. She expressed that she lost her beauty, job, friends, reputationeven some of family members & their is no point to continuing to live.

O: Disturbed thought process, Low self esteem, Hopelessness, Impaired social interaction.

A: Patient had guilty, shamefull, negative thoughts about herself, depression.

P: Counselling of the patient. Group therapy to the patient so that she can express her feelings. Follow up if the condition not improved.

I: The plan which we discussed below implemented to the patient so that the desired outcome will achieved. Couselling, group therapy, self enforcement provided to the patient.

E:- Patient feel overwhelmed, have reliastic self image & positive thoughts about herself

2. Nursing Diagnosis:-

- 1. Impaired Social interaction related to fear of rejection as evidence by patient Verbalization.

2. Low self esteem related to shame & guilt as evidence by nagative views of self.

Goal:

-To maintain the social interaction.

-To maintain self esteem.

1. Impaired Social interaction related to fear of rejection as evidence by patient Verbalization.

Goal: To maintain self esteem

Intervention:

1. Assess the general condition of the patient.

2.Encourage her to maximize the contacts with others which help her to distract from self oreoccupation.

3. Involved her in group activities e.g. art therapy, group discussion etc that help her to socialization and minimize the feeling of loneliness.

4. Ask the client to do the gross motor activities which help her to relieving from tension.

5. Also refer the client to self help group in the community that help her to gain support.

6. encourage the client to ventilate her feelings.

2. Low self esteem related to shame & guilt as evidence by nagative views of self

Goal: To maintain self esteem.

Intervention:

1. Assess the self esteem level of the patient.

2. Ask the patient to engage herself in simple recreational activities to a more complex activities in a group.

3. Encourage the patient to participate in group therapy where she can share her feelings & also help her to minimize her isolation.

4. Set a role model to the patient, so that she can follow example.

5. Engage her in a problem solving activities which help to increase her self esteem

6. Allow her to do her all activities that she can able to do.

Evaluation:- Patient feel overwhelmed, have reliastic self image & positive thoughts about herself