Adjustment Disorders: A Case Study
ADJUSTMENT DISORDERS
DSM-IV
ADJUSTMENT DISORDERs (SPECIFY if ACUTE/CHRONIC)
309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood
The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement.) The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder.
The response is considered maladaptive because social …show more content…
or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e.g., a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist.
ETIOLOGICAL THEORIES
Psychodynamics
Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego.
The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change. The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur.
Biological
The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.
The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.
Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.
Family Dynamics
The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life.
Individuals with adjustment difficulties have experienced negative learning through inadequate role-modeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment responses.
CLIENT ASSESSMENT DATA BASE
(Symptoms of affective, depressive, and anxiety disorders are manifested dependent on the individual’s specific response to a stressful situation.)
Activity/Rest
Fatigue
Insomnia
Ego Integrity
Reports occurrence of personal stressor/loss (e.g., job, financial, relationship) within past 3 months
May appear depressed and tearful and/or nervous and jittery
Feelings of hopelessness
Neurosensory
Mental Status: Depressed mood, tearful, anxious, nervous, jittery
Attention and memory span may be impaired (depends on presence of depression, level of anxiety, and/or substance use)
Communication and thought patterns may reveal negative ruminations of depressed mood or flight of ideas/loose associations of severely anxious condition
Pain/Discomfort
Various physical symptoms such as headache, backache, other aches and pains (maladaptive response to a stressful situation)
Safety
Anger expressed inappropriately
Involvement in high-risk behaviors (e.g., fighting, reckless driving)
Suicidal ideations may be present
Social Interactions
Difficulties with performance in work/social setting, when no difficulties had been experienced prior to the occurrence of the stressor
Socially withdrawn/refuses to interact with others (e.g., isolates self in own room)
Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities, violation of the rights of others or age-appropriate norms and rules
May display manipulative behavior (e.g., testing limits, playing individuals/family members against each other)
Teaching/Learning
Academic difficulties, failure to attend class/complete course work
Substance use/abuse possibly present
DIAGNOSTIC STUDIES
Diagnostic studies and psychological testing as indicated to rule out conditions that may mimic or coexist (e.g., endocrine imbalance, cardiac involvement, epilepsy, or a differential diagnosis with affective, anxiety, conduct, or antisocial personality disorders).
Drug Screen: Determine substance use.
NURSING PRIORITIES
1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.
DISCHARGE GOALS
1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS ANXIETY [moderate to severe]
May Be Related to: Situational/maturational crisis
Threat to self-concept; threat (or perceived threat) to physical integrity
Unmet needs; fear of failure
Dysfunctional family system; unsatisfactory parent/child relationship resulting in feelings of insecurity
Fixation in earlier level of development
Possibly Evidenced by: Overexcitement/restlessness; increased tension; insomnia
Feelings of inadequacy; fear of unspecified consequences
Poor eye contact, focus on self; difficulty concentrating
Continuous attention-seeking behaviors; selective inattention
Sympathetic stimulation; numerous physical complaints
Desired Outcomes/Evaluation Criteria— Verbalize awareness of feelings of/indicators of
Client Will: increasing anxiety.
Demonstrate/use appropriate techniques to interrupt escalation of anxiety.
Appear relaxed and report anxiety is reduced to a manageable level.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Establish a therapeutic nurse/client relationship. Be Honesty, availability, and unconditional honest, consistent in responses, and available. Show acceptance promote trust, which is necessary for genuine positive regard. the development of a therapeutic relationship.
Provide activities geared toward reduction of Tension and anxiety can be released safely, and tension and decreasing anxiety (e.g., walking or physical activity may provide emotional benefit to jogging, musical exercises, housekeeping chores, the client through release in the brain of morphine- group games/activities). like substances (endorphins) that promote sense of well-being.
Encourage client to identify true feelings and to Anxious clients often deny a relationship between acknowledge ownership of those feelings. emotional problems and their anxiety. Use of the defense mechanisms of projection and displacement are exaggerated.
Maintain a calm atmosphere and approach to client. Can help to limit transmission of anxiety to/from client.
Assist client to recognize specific events that precede Recognition of precipitating stressors and a plan of onset of elevation in anxiety. Provide information action to follow should they recur provides client about signs and symptoms of increasing anxiety with feelings of security and control over similar and ways to intervene before behaviors become situations in the future. This in itself may help to disabling. control anxiety response.
Offer support during times of elevated anxiety. Presence of a trusted individual may provide
Provide physical and psychological safety. (Refer to needed security/client safety.
ND: Violence, risk for, directed at self/others.)
Collaborative
Administer medications as necessary, e.g., benzo- Antianxiety medications induce a calming effect diazepines: alprazolam (Xanax). and work to maintain anxiety at a manageable level while providing the opportunity for client to develop other ways to manage stress.
NURSING DIAGNOSIS VIOLENCE, risk for, directed at self/others
Risk Factors May Include: Depressed mood, hopelessness, powerlessness; inability to tolerate frustration; rage reactions
Low self-esteem; unmet needs
Negative role modeling; lack of support systems
Substance use/abuse; history of previous suicide attempts
[Possible Indicators:] Increased motor activity (pacing, excitement, irritability, agitation)
Muscle tension (e.g., clenched fists, tense facial expressions, rigid posture, tautness)
Hostile, threatening verbalizations; provocative behavior (argumentative, dissatisfied, overreactive, hypersensitive)
Suicide ideation
Desired Outcomes/Evaluation Criteria— Verbalize understanding of behavior and
Client Will: precipitating factors.
Participate in care and meet own needs in an assertive manner.
Rechannel anger/hostile feelings into socially acceptable behaviors.
Demonstrate self-control as evidenced by relaxed posture, absence of violent behavior, etc.
Use resources/support systems in an effective manner.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Observe client’s behavior frequently during routine Close observation is required so that intervention activities and interactions; avoid appearing watchful can occur if required to ensure the safety of others. and suspicious. Instilling suspicion may provoke aggressive behaviors.
Ask client direct questions regarding intent, plan, Direct questions, if presented in a caring, and availability of the means for self-harm. Evaluate concerned manner, provide the necessary and prioritize on a scale of 1–10 according to information to assist the nurse in formulating an severity of threat, availability of means. appropriate plan of care for the suicidal client.
Provide a safe environment: reduce stimuli (e.g., A stimulating environment may increase agitation low lighting, few people, simple decor, low noise and provoke aggressive behavior. level). Remove potentially dangerous objects, such as External control of environment aids in preventing straps, belts, ties, sharp objects, glass items, and impulsive actions at a time when client lacks own drugs, as indicated. internal controls.
Secure contract from client that she or he will not A contract encourages the client to share in the harm self and will seek out staff member if suicidal responsibility of own safety. A degree of control is ideations emerge. experienced, and the attitude of acceptance of the client as a worthwhile individual is conveyed.
Promote verbalizations of honest feelings. Through May be difficult for client to express negative exploration and discussion, help client identify feelings. Verbalization of these feelings in a symbols of hope in own life. nonthreatening environment may help client come to terms with unresolved issues and identify reasons for wanting to change life/continue living.
Help client identify true source of anger/hostility Because of weak ego development, client may be and underlying feelings. using the defense mechanism of displacement. Helping the client to recognize this in a nonthreatening environment may help reveal unresolved issues so that they may be confronted, regardless of the discomfort involved.
Convey an attitude of acceptance toward the client.
Promotes feelings of self-worth. These feelings are
Impart a message that it is not the client but the further enhanced as person and behavior are behavior that is unacceptable. viewed separately, communicating unconditional positive regard.
Explore with client alternative ways of handling Physically demanding activities help to relieve frustration/pent-up anger that channel hostile pent-up tension. Note: Exercise need not be energy into socially acceptable behavior (e.g., brisk aerobic or intensive to achieve therapeutic effect. walks, jogging, physical exercises, volleyball, punching bag, exercise bike).
Maintain a calm attitude toward the client if Anxiety is contagious and can be transferred from behavior escalates. Have sufficient staff available to person to person. A calm attitude provides client convey a show of strength to the client if it becomes with a feeling of safety and security. A display of necessary. strength provides reassurance for the client that the staff is in control of the situation and will provide physical security for the client, staff, and others.
Be alert to increased potential for suicidal action as Client may mobilize self for suicidal attempt
as mood elevates. decrease in depression results in increased energy and motivation.
Collaborative
Administer medication as indicated, e.g.:
Tricyclic drugs: amitriptyline (Elavil), desipramine Antidepressant medication may elevate the mood, (Norpramin), doxepin (Sinequan), imipramine as it increases level of energy and decreases (Tofranil); selective serotonin reuptake feelings of fatigue. inhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil); monoamine-oxidase inhibitors: isocarboxazid (Marplan), phenelzine (Nardil);
Benzodiazepines: diazepam (Valium), Antianxiety medication may provide needed relief chlordiazepoxide (Librium), alprazolam from anxious feelings, inducing a calming effect (Xanax). and inhibiting aggressive behavior.
NURSING DIAGNOSIS COPING, INDIVIDUAL, ineffective
May Be Related to: Situational/maturational crises
Dysfunctional family system; negative role modeling; inadequate support systems
Unmet dependency needs; low self-esteem; retarded ego development
Possibly Evidenced by: Inability to cope/problem-solve
Chronic worry, depressed/anxious mood
Alteration in societal participation; manipulation of others
Inability to meet role expectations; increased dependency; refusal to follow rules of the unit
Numerous physical complaints
Destructive behavior, substance abuse
Desired Outcomes/Evaluation Criteria— Assess the current situation accurately.
Client Will: Identify ineffective coping behaviors and consequences.
Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
Refrain from manipulating others for own gratification.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Explain rules of the unit/therapeutic relationship Negative reinforcement may work to decrease and consequences of lack of cooperation. Set limits undesirable behaviors. Consistency among all staff on manipulative behavior. Be consistent in enforcing members is vital if intervention is to be successful. the consequences when rules are broken and limits tested. Ignore negative behaviors when possible and Negative behaviors diminish when they provide provide feedback when positive behaviors are noted, no reward of attention. When client gives self encouraging client to acknowledge own success. positive feedback, inner rewards are enhanced.
Encourage client to discuss angry feelings. Help Verbalization of feelings with a trusted individual client identify the true object of the hostility. Provide may help client work through unresolved issues. physical outlets for healthy release of the hostile Physical exercise provides a safe and effective feelings (e.g., punching bags, pounding boards). means of releasing pent-up tension, as well as of
Involve in outdoor recreation program, if available. developing self-confidence and trust in others.
Take care not to reinforce dependent behaviors. Independent accomplishment and positive reinforcement enhance self-esteem and encourage repetition of desirable behaviors.
Allow client to perform as independently as possible Recognition of personal control, however, and provide feedback. Help client recognize aspects minimal diminishes the feeling of powerlessness of life over which a measure of control is maintained/ and decreases the need to manipulate possible. (Refer to ND: Powerlessness.) others.
Give minimal attention to the physical condition if Organic pathology must always be considered. client is coping through numerous somatic Failure to do so may place the client in physical complaints and organic pathology has been ruled jeopardy. Lack of attention to maladaptive out. Increase attention when client is not focusing behaviors may decrease their repetition. Positive on physical complaints. reinforcement encourages desirable behaviors.
Discuss the negative aspects of substance abuse as Denial of problems related to substance use is a response to stress. Help client recognize difficult common. Client needs to recognize relationship life situations that may be contributing to use of between substance use and personal problems substances. before rehabilitation can begin.
Assist with problem-solving process. Suggest Because of level of anxiety and delayed alternatives, and help client to select more adaptive development, client may require assistance in strategies for coping with stress. determining which methods of coping are most individually appropriate. Increased anxiety interferes with client’s problem-solving ability.
Encourage client to learn relaxation techniques, use These skills can be helpful in developing new of imagery. coping methods to deal with/reduce stress.
Collaborative
Refer client to substance rehabilitation program if A greater likelihood of success can be expected if problem is identified. client seeks professional assistance with this problem.
NURSING DIAGNOSIS ADJUSTMENT, impaired [when stressor is a change in health status]
May Be Related to: Change in health status requiring modification in lifestyle (e.g., development of chronic disease/disability, changes associated with aging process)
Assault to self-esteem
Inadequate support systems
Possibly Evidenced by: Verbalization of nonacceptance of health status change
Difficulty in problem-solving, decision-making, or goal-setting; lack of future-oriented thinking
Lack of movement toward independence
Desired Outcomes/Evaluation Criteria— Recognize reality of situation and individual
Client Will: needs/options.
Assume personal responsibility for care, problem-solve needs.
Initiate necessary lifestyle changes.
Plan for future needs/changes.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Encourage client to talk about lifestyle before the It is important to identify the client’s strengths so change in health status. that they may be used to facilitate adaptation to change or loss that has occurred.
Discuss coping mechanisms that were used at Some individuals may not realize that anger is a stressful times in the past. Help client to discuss the normal stage in the grieving process. If it is not change/loss and particularly to express anger released appropriately, it may be turned inward associated with it. on the self, leading to pathological depression.
Have client express fears associated with the Change often creates a feeling of disequilibrium, change/loss or the resulting alteration in lifestyle and the individual may respond with fears that are that has occurred. irrational or unfounded. Client may benefit from feedback that corrects misperceptions about how life will be with the change in health status.
Assist with activities of daily living as required, but Independent accomplishments and positive feed- encourage independence to the limit that client’s back enhance self-esteem and encourage repetition ability will allow. Give positive feedback for of desired behaviors. Successes also provide hope activities accomplished independently. that adaptive functioning is possible and decrease feelings of powerlessness.
Help client with decision-making regarding The high degree of anxiety that usually incorporation of change or loss into lifestyle. Identify accompanies a major lifestyle change often an individual’s ability to solve problems and make interferes with problems created by the change or appropriate decisions. loss.
Discuss alternative solutions, weighing potential Client may need help with this process to progress benefits and consequences of each alternative. toward successful adaptation.
Support client’s decisions.
Role-play stressful situations that might occur Decreases anxiety and provides a feeling of in relation to the health status change. security for the client by preparing a plan of action with which to respond appropriately when a stressful situation occurs.
Provide information regarding the physiology of Helps client and family understand what has the change in health status and necessity for happened, clarifies information, and provides optimal wellness. Encourage client and family to opportunity to review information at individual’s ask questions. Provide printed material explaining leisure. the change.
Collaborative
Refer to resources within the community (e.g., Provides assistance in adapting to the change in self-help/support groups, public health nurse, health status. counselor, or social worker).
NURSING DIAGNOSIS GRIEVING, dysfunctional
May Be Related to: Real or perceived loss of any concept of value to the individual; bereavement overload (cumulative grief from multiple unresolved losses, excluding the death of a loved one)
Absence of anticipatory grieving; thwarted grieving response to loss
Feelings of guilt generated by ambivalent relationship with the lost concept/person
Possibly Evidenced by: Idealization of the lost concept; difficulty in expressing loss; denial of loss
Excessive anger, expressed inappropriately; labile affect
Developmental regression
Alterations in concentration and/or pursuit of tasks
Desired Outcomes/Evaluation Criteria— Express emotions appropriately.
Client Will: Demonstrate progress in dealing with stages of grief at own pace.
Carry out activities of daily living independently.
Express feeling of hope for the future.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine stage of grief in which client is fixed. Accurate baseline assessment data are necessary to
Identify behaviors associated with this stage. choose appropriate interventions/provide effective care and evaluate progress. (Most depressed people are fixed in the anger stage, with the anger directed inward on the self.)
Convey an accepting attitude; encourage client to An accepting attitude enhances trust and express self openly. communicates to the client that you believe the client is a worthwhile person, regardless of what may be expressed.
Encourage client to express anger. Avoid defensive Verbalization of feelings in a nonthreatening response if initial expression of anger is displaced environment may help client come to terms with on nurse/therapist. Assist client to explore angry unresolved issues related to the loss. feelings and direct them toward the intended object/ person or other loss.
Encourage participation in large motor activities. Physical activity provides a safe and effective method for discharging pent-up tension/anger.
Provide information about the stages of grief and the Knowledge of the acceptability of the feelings behaviors associated with each stage. Help client associated with normal grieving may help relieve understand that feelings, such as anger directed some of the guilt that these responses generate. toward the loss, are appropriate during the grief process. Encourage client to review relationship with loss. Client needs to give up idealized perception and
With support and sensitivity, point out reality of accept both positive and negative aspects about the situation in areas where misrepresentations are the loss before resolution of grief can occur. expressed. Help client determine methods for more adaptive Feelings of depression may interfere with client’s coping with the experienced loss. Provide positive problem-solving ability, resulting in need for feedback for strategies identified and decisions made. assistance. Positive feedback enhances self-esteem and encourages repetition of desirable behaviors.
Collaborative
Determine client’s perception of spiritual needs as Some individuals derive great strength from support in the grieving process. Involve chaplain or spiritual support. This strength may be used by appropriate spiritual leader as indicated. the client in the task of grief resolution.
NURSING DIAGNOSIS HOPELESSNESS
May Be Related to: Lifestyle of helplessness (repeated failures, dependency)
Incomplete grief work of losses in life
Lost belief in transcendent values/God
Possibly Evidenced by: Verbal cues/despondent content (e.g., “I can’t,” sighing)
Apathy/passivity, decreased response to stimuli
Lack of initiative, nonparticipation in care or decision-making when opportunities are provided
Desired Outcomes/Evaluation Criteria— Recognize and verbalize feelings.
Client Will: Demonstrate independent problem-solving techniques to take control over life.
Verbalize acceptance of life situations over which one does not have control.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Identify use of maladaptive behaviors/defense Personal attempts to overcome feelings of mechanisms (e.g., withdrawal, substance use, hopelessness may have resulted in ineffective/ regression). harmful behaviors. Recognizing the behaviors provides opportunity for change.
Encourage client to explore and verbalize feelings Identification of feelings underlying behaviors and perceptions. helps client to begin process of taking control of own life.
Identify individual signs of hopelessness, (e.g., Helps to individualize interventions, focus decreased physical activity, social withdrawal). attention on areas of need.
Express hope to client in positive, low-key manner. Even though client feels hopeless, it can be helpful to hear positive expressions from others.
Help client identify areas of life situation that are Client’s emotional condition may interfere with under own control. ability to problem-solve. Assistance may be required to perceive the benefits and consequences of available alternatives accurately.
Encourage client to assume responsibility for own Providing the client with choices increases feelings self-care (e.g., setting realistic goals, scheduling of control. Note: Unrealistic goals set the client up activities, making independent decisions). for failure and reinforce feelings of hopelessness.
Help client identify areas of life situation that are Client needs to identify and resolve feelings not within ability to control. Discuss feelings associated with inability to control certain life associated with this lack of control. situations before level of acceptance can be achieved.
NURSING DIAGNOSIS SELF ESTEEM disturbance [specify]
May Be Related to: Maturational transitions
Unmet dependency needs; retarded ego development
Repeated negative feedback, diminished self-worth
Dysfunctional family system
Possibly Evidenced by: Self-negating verbalization, inability to deal with events; difficulty accepting positive feedback
Lack of eye contact; nonassertive/passive behaviors; indecision, difficulty making decisions
Hesitancy to undertake new tasks; fear of failure
Social isolation; nonparticipation in therapy
Manipulation of one staff member against another
Self-destructive ideas/behavior
Desired Outcomes/Evalution Criteria— Identify feelings and underlying dynamics for
Client Will: negative perception of self.
Demonstrate behaviors/lifestyle changes to promote positive self-esteem.
Accept recognition for personal accomplishments/abilities.
Verbalize increased sense of self-worth.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Discuss goals, making sure they are realistic. Plan Achievement/success enhance self-concept. activities in which success is likely.
Convey unconditional positive regard for the client. Unconditional acceptance of an individual serves
Promote understanding of acceptance for client as a to counteract feelings of worthlessness by worthwhile human being. reinforcing that individual is worthy of another person’s respect.
Spend time with client both on a 1:1 basis and in Conveys that the nurse sees the client as someone group activities. worth spending time with.
Assist client to identify positive aspects of self and Individuals with low self-esteem often have develop plans for changing the characteristics difficulty recognizing positive attributes. They viewed as negative. may also lack problem-solving skills and require assistance to formulate a plan for implementing the desired changes.
Encourage and support client in confronting the Recognition and positive reinforcement enhance fear of failure by attending therapy activities and self-esteem and encourage repetition of desirable undertaking new tasks. Offer recognition of behaviors. successful endeavors and positive reinforcement for attempts made.
Help client avoid ruminating about past failures. Lack of attention to these undesirable behaviors
Withdraw attention if client persists. may discourage their repetition. Client needs to focus on positive attributes if self-esteem is to be enhanced.
Minimize negative feedback to client. Enforce limit Negative feedback can be extremely threatening to setting in matter-of-fact manner, imposing a person with low self-esteem, possibly previously established consequences for aggravating the problem. Consequences need to unacceptable behavior. convey unacceptability of the behavior but not the person.
Encourage independence in the performance of The ability to perform self-care activities personal responsibilities, as well as in decision- independently enhances self-concept. Positive making related to own self-care. Offer recognition reinforcement encourages repetition of desirable and praise for accomplishments. behaviors.
Support client in critical examination of feelings, The need for judging the behavior of others attitudes, and behaviors. Help client understand diminishes as client increases self-esteem through that it is acceptable for attitudes and behaviors to greater self-awareness and the achievement of differ from those of others, as long as they do not self-acceptance. become intrusive.
NURSING DIAGNOSIS SOCIAL INTERACTION, impaired
May Be Related to: Unmet dependency needs; retarded ego development
Negative role-modeling
Low self-concept
Possibly Evidenced by: Verbalized/observed discomfort in social situations; use of unsuccessful/dysfunctional social interaction behaviors
Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest
Exhibits behaviors unacceptable for age, as defined by dominant cultural group
Desired Outcomes/Evaluation Criteria— Verbalize awareness of factors resulting in
Client Will: difficulty in forming satisfactory relationships with others.
Identify feelings that lead to poor social interactions.
Interact with staff and peers with little/no indication of discomfort.
Participate in group activities appropriately and willingly.
Identify/develop effective social support system.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Establish 1:1 relationship with client, which serves Client needs to learn to interact appropriately with as role model for testing new behaviors. nurse, so that behaviors may then be generalized to others.
Encourage client to engage in activities out of Decreases opportunity for client to isolate self. room/home. Offer to attend initial group interactions with client. Presence of a trusted individual may provide a
Provide feedback for appropriate interactions. feeling of security and decrease the anxiety generated by difficult social situation. Positive reinforcement enhances self esteem and encourages repetition of desirable behaviors.
Act as role model for client through appropriate Because of weak ego development, client is interactions with client and others. inclined to imitate the actions of those individuals admired or trusted.
Establish schedule of group activities for client. It is through these group interactions, with positive and negative feedback from peers, that client learns socially acceptable behavior.
NURSING DIAGNOSIS FAMILY PROCESSES, altered
May Be Related to: Situational/maturational crisis
Possibly Evidenced by: Needs of family members not being met; confusion within family system regarding how needs should be met
Impaired family communication; dissonance among family members
Impairment of family decision-making process; family developmental tasks not being fulfilled
Reduced/restricted social involvement
Desired Outcomes/Evaluation Criteria— Express feelings freely and appropriately.
Family Will: Develop effective patterns of communication, encouraging honest input from all members.
Identify source(s) of dysfunction and effectively problem-solve to achieve desired resolution.
Demonstrate pattern of functioning improved from premorbid state, having gained knowledge and achieved growth from crisis situation.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Assess family developmental stage, communication Identifies specific needs and provides direction for patterns, and extent of dysfunction. care.
Meet with the total family group as often as possible. The family as a system operates as a single unit. Each member affects, and is affected by, all other members. Therapy is most effective when directed toward the functioning of the family system.
Construct a client/family genogram. Genograms help identify emotional closeness among family members over several generations. Family process is clarified, and configuration and dynamics are clearly illustrated.
Assist family to identify true source of conflict. Help Conflict creates high levels of anxiety within the them recognize that “identified patient’s” family system. Common defense mechanisms such adjustment disorder may be a way to avoid as denial, displacement, projection, and confronting the real problem. rationalization are used by the family to decrease anxiety and avoid conflict.
Encourage family members to set goals and identify Life crises interfere with family decision-making alternatives. Support efforts directed toward and problem-solving abilities. Assistance with this positive change. Assist with necessary modifications process may be required to promote adaptation of original plan. and growth.
Promote separation and individuation and clear, Emotional connectedness among family members functional boundaries between/among members. (enmeshment) discourages individual growth and ability to function autonomously.
Help client-family identify actions/problem-solve Anticipatory guidance/knowing what to expect for potential life crises. and having a plan of action for management of situations may help to avert a crisis in the future.
Collaborative
Involve family in group therapy. Interacting with others in family/multifamily groups can help identify dysfunctional patterns and assist in learning new skills and solutions for family problems.
Refer family to other resources, such as support Sharing with others who have had similar groups, classes (e.g., parenting/assertiveness experiences can provide support and assist family training). members to learn new ways to deal with situation.
DSM-IV
ADJUSTMENT DISORDERs (SPECIFY if ACUTE/CHRONIC)
309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood
The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement.) The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder.
The response is considered maladaptive because social …show more content…
or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e.g., a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist.
ETIOLOGICAL THEORIES
Psychodynamics
Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego.
The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change. The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur.
Biological
The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.
The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.
Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.
Family Dynamics
The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life.
Individuals with adjustment difficulties have experienced negative learning through inadequate role-modeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment responses.
CLIENT ASSESSMENT DATA BASE
(Symptoms of affective, depressive, and anxiety disorders are manifested dependent on the individual’s specific response to a stressful situation.)
Activity/Rest
Fatigue
Insomnia
Ego Integrity
Reports occurrence of personal stressor/loss (e.g., job, financial, relationship) within past 3 months
May appear depressed and tearful and/or nervous and jittery
Feelings of hopelessness
Neurosensory
Mental Status: Depressed mood, tearful, anxious, nervous, jittery
Attention and memory span may be impaired (depends on presence of depression, level of anxiety, and/or substance use)
Communication and thought patterns may reveal negative ruminations of depressed mood or flight of ideas/loose associations of severely anxious condition
Pain/Discomfort
Various physical symptoms such as headache, backache, other aches and pains (maladaptive response to a stressful situation)
Safety
Anger expressed inappropriately
Involvement in high-risk behaviors (e.g., fighting, reckless driving)
Suicidal ideations may be present
Social Interactions
Difficulties with performance in work/social setting, when no difficulties had been experienced prior to the occurrence of the stressor
Socially withdrawn/refuses to interact with others (e.g., isolates self in own room)
Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities, violation of the rights of others or age-appropriate norms and rules
May display manipulative behavior (e.g., testing limits, playing individuals/family members against each other)
Teaching/Learning
Academic difficulties, failure to attend class/complete course work
Substance use/abuse possibly present
DIAGNOSTIC STUDIES
Diagnostic studies and psychological testing as indicated to rule out conditions that may mimic or coexist (e.g., endocrine imbalance, cardiac involvement, epilepsy, or a differential diagnosis with affective, anxiety, conduct, or antisocial personality disorders).
Drug Screen: Determine substance use.
NURSING PRIORITIES
1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.
DISCHARGE GOALS
1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS ANXIETY [moderate to severe]
May Be Related to: Situational/maturational crisis
Threat to self-concept; threat (or perceived threat) to physical integrity
Unmet needs; fear of failure
Dysfunctional family system; unsatisfactory parent/child relationship resulting in feelings of insecurity
Fixation in earlier level of development
Possibly Evidenced by: Overexcitement/restlessness; increased tension; insomnia
Feelings of inadequacy; fear of unspecified consequences
Poor eye contact, focus on self; difficulty concentrating
Continuous attention-seeking behaviors; selective inattention
Sympathetic stimulation; numerous physical complaints
Desired Outcomes/Evaluation Criteria— Verbalize awareness of feelings of/indicators of
Client Will: increasing anxiety.
Demonstrate/use appropriate techniques to interrupt escalation of anxiety.
Appear relaxed and report anxiety is reduced to a manageable level.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Establish a therapeutic nurse/client relationship. Be Honesty, availability, and unconditional honest, consistent in responses, and available. Show acceptance promote trust, which is necessary for genuine positive regard. the development of a therapeutic relationship.
Provide activities geared toward reduction of Tension and anxiety can be released safely, and tension and decreasing anxiety (e.g., walking or physical activity may provide emotional benefit to jogging, musical exercises, housekeeping chores, the client through release in the brain of morphine- group games/activities). like substances (endorphins) that promote sense of well-being.
Encourage client to identify true feelings and to Anxious clients often deny a relationship between acknowledge ownership of those feelings. emotional problems and their anxiety. Use of the defense mechanisms of projection and displacement are exaggerated.
Maintain a calm atmosphere and approach to client. Can help to limit transmission of anxiety to/from client.
Assist client to recognize specific events that precede Recognition of precipitating stressors and a plan of onset of elevation in anxiety. Provide information action to follow should they recur provides client about signs and symptoms of increasing anxiety with feelings of security and control over similar and ways to intervene before behaviors become situations in the future. This in itself may help to disabling. control anxiety response.
Offer support during times of elevated anxiety. Presence of a trusted individual may provide
Provide physical and psychological safety. (Refer to needed security/client safety.
ND: Violence, risk for, directed at self/others.)
Collaborative
Administer medications as necessary, e.g., benzo- Antianxiety medications induce a calming effect diazepines: alprazolam (Xanax). and work to maintain anxiety at a manageable level while providing the opportunity for client to develop other ways to manage stress.
NURSING DIAGNOSIS VIOLENCE, risk for, directed at self/others
Risk Factors May Include: Depressed mood, hopelessness, powerlessness; inability to tolerate frustration; rage reactions
Low self-esteem; unmet needs
Negative role modeling; lack of support systems
Substance use/abuse; history of previous suicide attempts
[Possible Indicators:] Increased motor activity (pacing, excitement, irritability, agitation)
Muscle tension (e.g., clenched fists, tense facial expressions, rigid posture, tautness)
Hostile, threatening verbalizations; provocative behavior (argumentative, dissatisfied, overreactive, hypersensitive)
Suicide ideation
Desired Outcomes/Evaluation Criteria— Verbalize understanding of behavior and
Client Will: precipitating factors.
Participate in care and meet own needs in an assertive manner.
Rechannel anger/hostile feelings into socially acceptable behaviors.
Demonstrate self-control as evidenced by relaxed posture, absence of violent behavior, etc.
Use resources/support systems in an effective manner.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Observe client’s behavior frequently during routine Close observation is required so that intervention activities and interactions; avoid appearing watchful can occur if required to ensure the safety of others. and suspicious. Instilling suspicion may provoke aggressive behaviors.
Ask client direct questions regarding intent, plan, Direct questions, if presented in a caring, and availability of the means for self-harm. Evaluate concerned manner, provide the necessary and prioritize on a scale of 1–10 according to information to assist the nurse in formulating an severity of threat, availability of means. appropriate plan of care for the suicidal client.
Provide a safe environment: reduce stimuli (e.g., A stimulating environment may increase agitation low lighting, few people, simple decor, low noise and provoke aggressive behavior. level). Remove potentially dangerous objects, such as External control of environment aids in preventing straps, belts, ties, sharp objects, glass items, and impulsive actions at a time when client lacks own drugs, as indicated. internal controls.
Secure contract from client that she or he will not A contract encourages the client to share in the harm self and will seek out staff member if suicidal responsibility of own safety. A degree of control is ideations emerge. experienced, and the attitude of acceptance of the client as a worthwhile individual is conveyed.
Promote verbalizations of honest feelings. Through May be difficult for client to express negative exploration and discussion, help client identify feelings. Verbalization of these feelings in a symbols of hope in own life. nonthreatening environment may help client come to terms with unresolved issues and identify reasons for wanting to change life/continue living.
Help client identify true source of anger/hostility Because of weak ego development, client may be and underlying feelings. using the defense mechanism of displacement. Helping the client to recognize this in a nonthreatening environment may help reveal unresolved issues so that they may be confronted, regardless of the discomfort involved.
Convey an attitude of acceptance toward the client.
Promotes feelings of self-worth. These feelings are
Impart a message that it is not the client but the further enhanced as person and behavior are behavior that is unacceptable. viewed separately, communicating unconditional positive regard.
Explore with client alternative ways of handling Physically demanding activities help to relieve frustration/pent-up anger that channel hostile pent-up tension. Note: Exercise need not be energy into socially acceptable behavior (e.g., brisk aerobic or intensive to achieve therapeutic effect. walks, jogging, physical exercises, volleyball, punching bag, exercise bike).
Maintain a calm attitude toward the client if Anxiety is contagious and can be transferred from behavior escalates. Have sufficient staff available to person to person. A calm attitude provides client convey a show of strength to the client if it becomes with a feeling of safety and security. A display of necessary. strength provides reassurance for the client that the staff is in control of the situation and will provide physical security for the client, staff, and others.
Be alert to increased potential for suicidal action as Client may mobilize self for suicidal attempt
as mood elevates. decrease in depression results in increased energy and motivation.
Collaborative
Administer medication as indicated, e.g.:
Tricyclic drugs: amitriptyline (Elavil), desipramine Antidepressant medication may elevate the mood, (Norpramin), doxepin (Sinequan), imipramine as it increases level of energy and decreases (Tofranil); selective serotonin reuptake feelings of fatigue. inhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil); monoamine-oxidase inhibitors: isocarboxazid (Marplan), phenelzine (Nardil);
Benzodiazepines: diazepam (Valium), Antianxiety medication may provide needed relief chlordiazepoxide (Librium), alprazolam from anxious feelings, inducing a calming effect (Xanax). and inhibiting aggressive behavior.
NURSING DIAGNOSIS COPING, INDIVIDUAL, ineffective
May Be Related to: Situational/maturational crises
Dysfunctional family system; negative role modeling; inadequate support systems
Unmet dependency needs; low self-esteem; retarded ego development
Possibly Evidenced by: Inability to cope/problem-solve
Chronic worry, depressed/anxious mood
Alteration in societal participation; manipulation of others
Inability to meet role expectations; increased dependency; refusal to follow rules of the unit
Numerous physical complaints
Destructive behavior, substance abuse
Desired Outcomes/Evaluation Criteria— Assess the current situation accurately.
Client Will: Identify ineffective coping behaviors and consequences.
Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
Refrain from manipulating others for own gratification.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Explain rules of the unit/therapeutic relationship Negative reinforcement may work to decrease and consequences of lack of cooperation. Set limits undesirable behaviors. Consistency among all staff on manipulative behavior. Be consistent in enforcing members is vital if intervention is to be successful. the consequences when rules are broken and limits tested. Ignore negative behaviors when possible and Negative behaviors diminish when they provide provide feedback when positive behaviors are noted, no reward of attention. When client gives self encouraging client to acknowledge own success. positive feedback, inner rewards are enhanced.
Encourage client to discuss angry feelings. Help Verbalization of feelings with a trusted individual client identify the true object of the hostility. Provide may help client work through unresolved issues. physical outlets for healthy release of the hostile Physical exercise provides a safe and effective feelings (e.g., punching bags, pounding boards). means of releasing pent-up tension, as well as of
Involve in outdoor recreation program, if available. developing self-confidence and trust in others.
Take care not to reinforce dependent behaviors. Independent accomplishment and positive reinforcement enhance self-esteem and encourage repetition of desirable behaviors.
Allow client to perform as independently as possible Recognition of personal control, however, and provide feedback. Help client recognize aspects minimal diminishes the feeling of powerlessness of life over which a measure of control is maintained/ and decreases the need to manipulate possible. (Refer to ND: Powerlessness.) others.
Give minimal attention to the physical condition if Organic pathology must always be considered. client is coping through numerous somatic Failure to do so may place the client in physical complaints and organic pathology has been ruled jeopardy. Lack of attention to maladaptive out. Increase attention when client is not focusing behaviors may decrease their repetition. Positive on physical complaints. reinforcement encourages desirable behaviors.
Discuss the negative aspects of substance abuse as Denial of problems related to substance use is a response to stress. Help client recognize difficult common. Client needs to recognize relationship life situations that may be contributing to use of between substance use and personal problems substances. before rehabilitation can begin.
Assist with problem-solving process. Suggest Because of level of anxiety and delayed alternatives, and help client to select more adaptive development, client may require assistance in strategies for coping with stress. determining which methods of coping are most individually appropriate. Increased anxiety interferes with client’s problem-solving ability.
Encourage client to learn relaxation techniques, use These skills can be helpful in developing new of imagery. coping methods to deal with/reduce stress.
Collaborative
Refer client to substance rehabilitation program if A greater likelihood of success can be expected if problem is identified. client seeks professional assistance with this problem.
NURSING DIAGNOSIS ADJUSTMENT, impaired [when stressor is a change in health status]
May Be Related to: Change in health status requiring modification in lifestyle (e.g., development of chronic disease/disability, changes associated with aging process)
Assault to self-esteem
Inadequate support systems
Possibly Evidenced by: Verbalization of nonacceptance of health status change
Difficulty in problem-solving, decision-making, or goal-setting; lack of future-oriented thinking
Lack of movement toward independence
Desired Outcomes/Evaluation Criteria— Recognize reality of situation and individual
Client Will: needs/options.
Assume personal responsibility for care, problem-solve needs.
Initiate necessary lifestyle changes.
Plan for future needs/changes.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Encourage client to talk about lifestyle before the It is important to identify the client’s strengths so change in health status. that they may be used to facilitate adaptation to change or loss that has occurred.
Discuss coping mechanisms that were used at Some individuals may not realize that anger is a stressful times in the past. Help client to discuss the normal stage in the grieving process. If it is not change/loss and particularly to express anger released appropriately, it may be turned inward associated with it. on the self, leading to pathological depression.
Have client express fears associated with the Change often creates a feeling of disequilibrium, change/loss or the resulting alteration in lifestyle and the individual may respond with fears that are that has occurred. irrational or unfounded. Client may benefit from feedback that corrects misperceptions about how life will be with the change in health status.
Assist with activities of daily living as required, but Independent accomplishments and positive feed- encourage independence to the limit that client’s back enhance self-esteem and encourage repetition ability will allow. Give positive feedback for of desired behaviors. Successes also provide hope activities accomplished independently. that adaptive functioning is possible and decrease feelings of powerlessness.
Help client with decision-making regarding The high degree of anxiety that usually incorporation of change or loss into lifestyle. Identify accompanies a major lifestyle change often an individual’s ability to solve problems and make interferes with problems created by the change or appropriate decisions. loss.
Discuss alternative solutions, weighing potential Client may need help with this process to progress benefits and consequences of each alternative. toward successful adaptation.
Support client’s decisions.
Role-play stressful situations that might occur Decreases anxiety and provides a feeling of in relation to the health status change. security for the client by preparing a plan of action with which to respond appropriately when a stressful situation occurs.
Provide information regarding the physiology of Helps client and family understand what has the change in health status and necessity for happened, clarifies information, and provides optimal wellness. Encourage client and family to opportunity to review information at individual’s ask questions. Provide printed material explaining leisure. the change.
Collaborative
Refer to resources within the community (e.g., Provides assistance in adapting to the change in self-help/support groups, public health nurse, health status. counselor, or social worker).
NURSING DIAGNOSIS GRIEVING, dysfunctional
May Be Related to: Real or perceived loss of any concept of value to the individual; bereavement overload (cumulative grief from multiple unresolved losses, excluding the death of a loved one)
Absence of anticipatory grieving; thwarted grieving response to loss
Feelings of guilt generated by ambivalent relationship with the lost concept/person
Possibly Evidenced by: Idealization of the lost concept; difficulty in expressing loss; denial of loss
Excessive anger, expressed inappropriately; labile affect
Developmental regression
Alterations in concentration and/or pursuit of tasks
Desired Outcomes/Evaluation Criteria— Express emotions appropriately.
Client Will: Demonstrate progress in dealing with stages of grief at own pace.
Carry out activities of daily living independently.
Express feeling of hope for the future.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine stage of grief in which client is fixed. Accurate baseline assessment data are necessary to
Identify behaviors associated with this stage. choose appropriate interventions/provide effective care and evaluate progress. (Most depressed people are fixed in the anger stage, with the anger directed inward on the self.)
Convey an accepting attitude; encourage client to An accepting attitude enhances trust and express self openly. communicates to the client that you believe the client is a worthwhile person, regardless of what may be expressed.
Encourage client to express anger. Avoid defensive Verbalization of feelings in a nonthreatening response if initial expression of anger is displaced environment may help client come to terms with on nurse/therapist. Assist client to explore angry unresolved issues related to the loss. feelings and direct them toward the intended object/ person or other loss.
Encourage participation in large motor activities. Physical activity provides a safe and effective method for discharging pent-up tension/anger.
Provide information about the stages of grief and the Knowledge of the acceptability of the feelings behaviors associated with each stage. Help client associated with normal grieving may help relieve understand that feelings, such as anger directed some of the guilt that these responses generate. toward the loss, are appropriate during the grief process. Encourage client to review relationship with loss. Client needs to give up idealized perception and
With support and sensitivity, point out reality of accept both positive and negative aspects about the situation in areas where misrepresentations are the loss before resolution of grief can occur. expressed. Help client determine methods for more adaptive Feelings of depression may interfere with client’s coping with the experienced loss. Provide positive problem-solving ability, resulting in need for feedback for strategies identified and decisions made. assistance. Positive feedback enhances self-esteem and encourages repetition of desirable behaviors.
Collaborative
Determine client’s perception of spiritual needs as Some individuals derive great strength from support in the grieving process. Involve chaplain or spiritual support. This strength may be used by appropriate spiritual leader as indicated. the client in the task of grief resolution.
NURSING DIAGNOSIS HOPELESSNESS
May Be Related to: Lifestyle of helplessness (repeated failures, dependency)
Incomplete grief work of losses in life
Lost belief in transcendent values/God
Possibly Evidenced by: Verbal cues/despondent content (e.g., “I can’t,” sighing)
Apathy/passivity, decreased response to stimuli
Lack of initiative, nonparticipation in care or decision-making when opportunities are provided
Desired Outcomes/Evaluation Criteria— Recognize and verbalize feelings.
Client Will: Demonstrate independent problem-solving techniques to take control over life.
Verbalize acceptance of life situations over which one does not have control.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Identify use of maladaptive behaviors/defense Personal attempts to overcome feelings of mechanisms (e.g., withdrawal, substance use, hopelessness may have resulted in ineffective/ regression). harmful behaviors. Recognizing the behaviors provides opportunity for change.
Encourage client to explore and verbalize feelings Identification of feelings underlying behaviors and perceptions. helps client to begin process of taking control of own life.
Identify individual signs of hopelessness, (e.g., Helps to individualize interventions, focus decreased physical activity, social withdrawal). attention on areas of need.
Express hope to client in positive, low-key manner. Even though client feels hopeless, it can be helpful to hear positive expressions from others.
Help client identify areas of life situation that are Client’s emotional condition may interfere with under own control. ability to problem-solve. Assistance may be required to perceive the benefits and consequences of available alternatives accurately.
Encourage client to assume responsibility for own Providing the client with choices increases feelings self-care (e.g., setting realistic goals, scheduling of control. Note: Unrealistic goals set the client up activities, making independent decisions). for failure and reinforce feelings of hopelessness.
Help client identify areas of life situation that are Client needs to identify and resolve feelings not within ability to control. Discuss feelings associated with inability to control certain life associated with this lack of control. situations before level of acceptance can be achieved.
NURSING DIAGNOSIS SELF ESTEEM disturbance [specify]
May Be Related to: Maturational transitions
Unmet dependency needs; retarded ego development
Repeated negative feedback, diminished self-worth
Dysfunctional family system
Possibly Evidenced by: Self-negating verbalization, inability to deal with events; difficulty accepting positive feedback
Lack of eye contact; nonassertive/passive behaviors; indecision, difficulty making decisions
Hesitancy to undertake new tasks; fear of failure
Social isolation; nonparticipation in therapy
Manipulation of one staff member against another
Self-destructive ideas/behavior
Desired Outcomes/Evalution Criteria— Identify feelings and underlying dynamics for
Client Will: negative perception of self.
Demonstrate behaviors/lifestyle changes to promote positive self-esteem.
Accept recognition for personal accomplishments/abilities.
Verbalize increased sense of self-worth.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Discuss goals, making sure they are realistic. Plan Achievement/success enhance self-concept. activities in which success is likely.
Convey unconditional positive regard for the client. Unconditional acceptance of an individual serves
Promote understanding of acceptance for client as a to counteract feelings of worthlessness by worthwhile human being. reinforcing that individual is worthy of another person’s respect.
Spend time with client both on a 1:1 basis and in Conveys that the nurse sees the client as someone group activities. worth spending time with.
Assist client to identify positive aspects of self and Individuals with low self-esteem often have develop plans for changing the characteristics difficulty recognizing positive attributes. They viewed as negative. may also lack problem-solving skills and require assistance to formulate a plan for implementing the desired changes.
Encourage and support client in confronting the Recognition and positive reinforcement enhance fear of failure by attending therapy activities and self-esteem and encourage repetition of desirable undertaking new tasks. Offer recognition of behaviors. successful endeavors and positive reinforcement for attempts made.
Help client avoid ruminating about past failures. Lack of attention to these undesirable behaviors
Withdraw attention if client persists. may discourage their repetition. Client needs to focus on positive attributes if self-esteem is to be enhanced.
Minimize negative feedback to client. Enforce limit Negative feedback can be extremely threatening to setting in matter-of-fact manner, imposing a person with low self-esteem, possibly previously established consequences for aggravating the problem. Consequences need to unacceptable behavior. convey unacceptability of the behavior but not the person.
Encourage independence in the performance of The ability to perform self-care activities personal responsibilities, as well as in decision- independently enhances self-concept. Positive making related to own self-care. Offer recognition reinforcement encourages repetition of desirable and praise for accomplishments. behaviors.
Support client in critical examination of feelings, The need for judging the behavior of others attitudes, and behaviors. Help client understand diminishes as client increases self-esteem through that it is acceptable for attitudes and behaviors to greater self-awareness and the achievement of differ from those of others, as long as they do not self-acceptance. become intrusive.
NURSING DIAGNOSIS SOCIAL INTERACTION, impaired
May Be Related to: Unmet dependency needs; retarded ego development
Negative role-modeling
Low self-concept
Possibly Evidenced by: Verbalized/observed discomfort in social situations; use of unsuccessful/dysfunctional social interaction behaviors
Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest
Exhibits behaviors unacceptable for age, as defined by dominant cultural group
Desired Outcomes/Evaluation Criteria— Verbalize awareness of factors resulting in
Client Will: difficulty in forming satisfactory relationships with others.
Identify feelings that lead to poor social interactions.
Interact with staff and peers with little/no indication of discomfort.
Participate in group activities appropriately and willingly.
Identify/develop effective social support system.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Establish 1:1 relationship with client, which serves Client needs to learn to interact appropriately with as role model for testing new behaviors. nurse, so that behaviors may then be generalized to others.
Encourage client to engage in activities out of Decreases opportunity for client to isolate self. room/home. Offer to attend initial group interactions with client. Presence of a trusted individual may provide a
Provide feedback for appropriate interactions. feeling of security and decrease the anxiety generated by difficult social situation. Positive reinforcement enhances self esteem and encourages repetition of desirable behaviors.
Act as role model for client through appropriate Because of weak ego development, client is interactions with client and others. inclined to imitate the actions of those individuals admired or trusted.
Establish schedule of group activities for client. It is through these group interactions, with positive and negative feedback from peers, that client learns socially acceptable behavior.
NURSING DIAGNOSIS FAMILY PROCESSES, altered
May Be Related to: Situational/maturational crisis
Possibly Evidenced by: Needs of family members not being met; confusion within family system regarding how needs should be met
Impaired family communication; dissonance among family members
Impairment of family decision-making process; family developmental tasks not being fulfilled
Reduced/restricted social involvement
Desired Outcomes/Evaluation Criteria— Express feelings freely and appropriately.
Family Will: Develop effective patterns of communication, encouraging honest input from all members.
Identify source(s) of dysfunction and effectively problem-solve to achieve desired resolution.
Demonstrate pattern of functioning improved from premorbid state, having gained knowledge and achieved growth from crisis situation.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Assess family developmental stage, communication Identifies specific needs and provides direction for patterns, and extent of dysfunction. care.
Meet with the total family group as often as possible. The family as a system operates as a single unit. Each member affects, and is affected by, all other members. Therapy is most effective when directed toward the functioning of the family system.
Construct a client/family genogram. Genograms help identify emotional closeness among family members over several generations. Family process is clarified, and configuration and dynamics are clearly illustrated.
Assist family to identify true source of conflict. Help Conflict creates high levels of anxiety within the them recognize that “identified patient’s” family system. Common defense mechanisms such adjustment disorder may be a way to avoid as denial, displacement, projection, and confronting the real problem. rationalization are used by the family to decrease anxiety and avoid conflict.
Encourage family members to set goals and identify Life crises interfere with family decision-making alternatives. Support efforts directed toward and problem-solving abilities. Assistance with this positive change. Assist with necessary modifications process may be required to promote adaptation of original plan. and growth.
Promote separation and individuation and clear, Emotional connectedness among family members functional boundaries between/among members. (enmeshment) discourages individual growth and ability to function autonomously.
Help client-family identify actions/problem-solve Anticipatory guidance/knowing what to expect for potential life crises. and having a plan of action for management of situations may help to avert a crisis in the future.
Collaborative
Involve family in group therapy. Interacting with others in family/multifamily groups can help identify dysfunctional patterns and assist in learning new skills and solutions for family problems.
Refer family to other resources, such as support Sharing with others who have had similar groups, classes (e.g., parenting/assertiveness experiences can provide support and assist family training). members to learn new ways to deal with situation.