Social Isolation

Social
Isolation

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Death of s/o
(_) Divorce
(_) Substance abuse

(_) Illness:____________________________
____________________________________
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
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