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

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