Memoir of a Schizo

Dysthymic Disorder Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Fri, 27 Jan 2012 20:30:00 +0000

A disturbance of mood, characterized by a full or partial depressive syndrome, or loss of interest or pleasure in usual activities and pastimes with evidence of interference in social/occupational functioning.

DSM-IV
DEPRESSIVE DISORDERS
296.xx Major depressive disorder
296.2x Single episode
296.3x Recurrent
300.4 Dysthymic disorder
311 Depressive disorder NOS

ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory focuses on an early unsatisfactory parent/child relationship, with an unresolved grieving process. This results in the individual remaining fixed in the anger stage of the grieving process and turning it inward on the self. The ego remains weak, while the superego expands and becomes punitive.

Cognitive theory projects a belief that depression occurs as a result of impaired cognition, fostering a negative evaluation of self through disturbed thought processes. The individual is pessimistic and views self as inadequate and worthless and life as hopeless.

Learning theorists propose that depressive illness arises out of the individual’s having experienced numerous failures (either real or perceived). A feeling of inability to succeed at any endeavor ensues. This “learned helplessness” is viewed as a predisposition to depressive illness. The behavioral model states that the cause of depression is in the person-behavior-environment interaction. Although people are seen as capable of exercising control over their behavior, they are not totally free of environmental influence.

Biological
A family history of major affective disorders may exist in individuals with depressive disorders. Recently it has been found that the disease has a genetic marker, as shown by numerous studies that support the involvement of heredity in depressive illness.

Biochemical factors (e.g., electrolyte imbalances) appear to play a role in depressive illness. An error in metabolism results in the transposition of sodium and potassium within the neuron. Another theory implicates the biogenic amines norepinephrine, dopamine, and serotonin. The levels of these chemicals are deficient in individuals with depressive disorders. Controversy remains as to whether these biochemical changes cause the depression or whether they are caused by the illness. In recent years, a common form of major depression called seasonal affective disorder (SAD) has been identified. Recurring each year, starting in fall or winter and ending in spring, the symptoms are largely typical of depression, with some atypical symptoms (excessive sleep, increased appetite, and weight gain). This disorder is believed to be caused by the decreased availability of sunlight and is related to circadian cycles, which are set by each individual’s internal biological clock. Circadian cycles are more precisely adjusted and coordinated by the alternation of darkness and light.

Impaired seratonergic transmission has also been investigated as a cause of depression (indolamine hypothesis). It has been shown that multiple regions of the brain in depressed clients lack metabolic responsivity, suggesting a generalized subresponsivity of the serotonergic system. Additionally, current research suggests that infection with the Borna disease virus (BDV) may be linked to some cases of major depression and other severe mood disorders.

Family Dynamics
Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is thereby interrupted, and the child withdraws from people and the environment.

NURSING PRIORITIES
1. Promote physical safety with special focus on suicide prevention.
2. Provide for client’s basic needs, promoting highest possible level of independent functioning.

3. Provide experience/interactions that enhance self-esteem, sense of personal power.
4. Support client/family participation in follow-up care/community treatment.
5. Provide information about condition, prognosis, and treatment needs.

DISCHARGE GOALS
1. Suicidal ideation/self-violent behaviors absent.
2. Physiological stability achieved with responsibility for self demonstrated.
3. Client expressing feelings appropriately with some optimism and hope for the future.
4. Client/family participating in follow-up care/community treatment.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for Dysthymic Disorder: Risk for Violence, Directed to Self may be related to Depressed mood; and Feelings of worthlessness and hopelessness possibly evidenced by Verbalization of suicidal ideation/plan or futility of trying (e.g., “What’s the use?”); Giving possessions away/making a will; Sudden mood elevation/appearing more energized or displaying calmer, more peaceful manner; and Refusal/reluctance to sign a “no harm” contract.

Desired Outcomes:
1. Voluntarily comply with suicide precautions, sign “no harm” contract.
2. Verbalize a decrease/absence of suicidal ideas.
3. State 2 reasons for not harming self.
4. Commit no acts of self-violence.

Nursing intervention with rationale:
1. Identify degree of risk/potential for suicide through direct questions (e.g., “Have you thought about killing yourself?”). Assess seriousness of suicidal tendency, noting behaviors such as gestures, threats, giving away possessions, previous attempts, presence of hallucinations or delusions. (Use scale of 1–10 and prioritize care according to severity of threat, availability of means.)
Rationale: Degree of hopelessness expressed by client is important indicator of severity of depression and suicide risk. Eight of 10 clients who state an intention to commit suicide do so. The more thought-out the plan, the higher the chances of completing it. The chances of suicide increase if there was a previous suicide attempt or if a family history of suicide and depression is present. Impulsive clients are more likely to attempt suicide without giving clues, including those with psychotic thinking who are especially at risk when hallucinations or delusions encourage self-harm. Note: Individuals with untreated depression have a suicide rate of 15%.

2. Reevaluate potential for suicide periodically at key times (e.g., during mood changes, at initiation of/ changes in medication regimen, when increasing withdrawal occurs, when discharge planning becomes active, before sending out on pass, before discharge from program).
Rationale: Suicide risk is the greatest during the first few weeks following admission to treatment. More than half of suicides by hospitalized clients occur out of the hospital, while they are on leave or during an unauthorized absence. The highest risk is when the client has both suicidal ideation and sufficient energy with which to act (e.g., at the point when the client begins to feel better).

3. Implement suicide precautions. For example, explain to client that you are concerned for his or her safety and that you will be helping client to stay “safe.”
Rationale: Communicates caring and provides sense of protection.

4. Create a time-specific contract with client on what client and nurse will do to provide for client’s safety. Renew contract as appropriate. Place a copy of the “contract,” signed by client and staff, in the chart/ file and give a copy to the client to keep.
Rationale: Documents actions taken to prevent suicide and client response. It also promotes communication and can help client realize that others care what happens. Short-term contracts encourage client to deal with the here-and-now and provide opportunity to reassess situation.

When patient is hospitalized
1. Provide close observation (1:1 or random checks every 10 to 15 minutes for most acute risk). Place in room close to nurse’s station; do not assign to a single room. Accompany to off-ward activities if attendance is indicated. Ask client to stay in view of staff member at all times.
Rationale: Being alert for suicidal and escape attempts facilitates being able to prevent or interrupt harmful behavior.

2. Be alert to use of hazardous equipment; remove hazardous personal items (e.g., scarves, belts, razor blades, scissors).
Rationale: Provides environmental safety; removes objects that may prompt suicidal thoughts/attempts.

3. Check all items brought in to or by the client as indicated. Ask family and other visitors to avoid bringing hazardous items.
Rationale: Suicidal clients may bring harmful items back from a pass or may ask family for items, with a suicide plan in mind.

4. Routinely check environment for hazards. Provide for environmental safety (e.g., lock doors/windows when not supervised; block access to stairways, roof, and construction areas; monitor cleaning chemicals /repair supplies).
Rationale: Minimizing opportunities for self-harm is an ongoing issue requiring constant attention and consideration of the unusual.

5. Administer medications as indicated, e.g.: SSRIs: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft); tricyclics, e.g., amitriptyline (Elavil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil); heterocyclics, e.g., amoxapine (Asendin), bupropion (Wellbutrin), maprotiline (Ludiomil), trazodone (Desyrel); monoamine oxidase inhibitors (MAOIs), e.g., phenelzine (Nardil), isocarboxazid (Marplan), tranylcypromine (Parnate).
Rationale: Selective serotonic reuptake inhibitors and cyclic antidepressants are generally considered the safest and easiest to manage of the antidepressants and so are started first. If response is not noted in 4 to 6 weeks, an MAOI may be the drug of choice. These drugs act by blocking enzyme degradation of neurotransmitters (norepinephrine, serotonin). Note: Medications inhibiting reuptake of serotonin, or heterocyclic drugs (e.g., Wellbutrin), are usually preferred for treating depression in bipolar disorders, whereas tricyclics and MAOIs may increase possibility of switch to manic behavior. (Tricyclics use a “shotgun approach,” whereas newer generations of drugs usually target a specific neurotransmitter. TCAs also can cause toxicity before therapeutic levels are achieved, and MAOIs can cause fatal central serotonin syndrome if administered within 2 weeks of SSRI therapy).

6. Prepare for/assist with ECT as indicated.
Rationale: ECT becomes essential and in some cases life saving when depression does not respond to other treatments and suicide is a major risk. (Of clients with major depression, 80% to 90% show marked improvement after ECT.)

Hallucinogen, Phencyclidine, and Cannabis Related Disorders Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Fri, 27 Jan 2012 09:30:00 +0000

Hallucinogenic substances can distort an individual’s perception of reality, altering sensory perception, and inducing hallucinations. For this reason, these substances are referred to as “mind expanding.” They are highly unpredictable in the effects they may induce each time they are used, and adverse reactions, including “flashbacks,” can recur at any time, even without current use of the drug. Hallucinogens have been used as part of religious ceremonies and at social gatherings by Native Americans for more than 2000 years. Therapeutic uses for LSD have been proposed; however, more research is required. At this time, no real evidence speaks to the safety and efficacy of LSD in humans.

Of the drugs that produce mood and perceptual changes varying from sensory illusions to hallucinations, the most popular and well-known are ergot and related compounds (LSD, morning glory seeds), phenyl alkylamines (mescaline, “STP,” and MDMA or “Ecstasy”), and indole alkaloids (DMT).

A separate classification of drugs includes phencyclidine (PCP, “angel dust,” HOG) and similarly acting compounds such as ketamine (Ketalar) and the thiophene analogue of phencyclidine (TCP). Although these drugs have an entirely different chemical structure, they can have similar hallucinogenic effects and therefore are included here.

Additionally, cannabis (marijuana, hashish, synthetic THC) also produces an altered state of awareness accompanied by feelings of relaxation and mild euphoria and is often used in conjunction with other substances.

This plan of care addresses acute intoxication/withdrawal and is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.

DSM-IV
HALLUCINOGEN-RELATED/INDUCED DISORDERS
292.89 Hallucinogen intoxication
292.81 Intoxication delirium
292.89 Hallucinogen persisting perception disorder (flashbacks)
292.89 Hallucinogen-induced anxiety disorder
292.84 Hallucinogen-induced mood disorder

PHENCYCLIDINE (OR PHENCYCLIDINE-LIKE)/INDUCED DISORDERS
292.89 Phencyclidine intoxication
292.81 Intoxication delirium
292.11 Induced psychotic disorder with delusions
292.12 Induced psychotic disorder with hallucinations

CANNABIS-RELATED/INDUCED DISORDERS
292.89 Cannabis intoxication
292.81 Intoxication delirium
292.89 Cannabis-induced anxiety disorder

ETIOLOGICAL THEORIES
Psychodynamics
Individuals who abuse substances fail to complete tasks of separation-individuation, resulting in underdeveloped egos. The person is thought to have a highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem. The superego is weak, resulting in absence of guilt feelings for behavior.

Certain personality traits may play an important part in the development and maintenance of dependence. Characteristics that have been identified include impulsivity, negative self-concept, weak ego, low social conformity, neuroticism, and introversion. Substance abuse has also been associated with antisocial personality and depressive response styles.

Biological
A genetic link is thought to be involved in the development of substance abuse disorders. Although statistics are currently inconclusive, hereditary factors are generally accepted to be a factor in the abuse of substances. Research is currently being done into the role biochemical factors play in the problems of substance abuse.

Family Dynamics
A predisposition to substance use disorders is found in the dysfunctional family system. Often one parent is absent or is an overpowering tyrant, and/or another parent is weak and ineffectual. Substance abuse may be evident as the primary method of relieving stress. The child has negative role models and learns to respond to stressful situations in like manner. However, parents may be average, normal individuals with children who succumb to overwhelming peer pressure and become involved with drugs.

In the family the effects of modeling, imitation, and identification on behavior can be observed from early childhood onward. Peer influence may exert a great deal of influence also. Cultural factors may help to establish patterns of substance use by attitudes of acceptance of such use as a part of daily or recreational life.

NURSING PRIORITIES
1. Protect client/others from injury.
2. Promote physiological/psychological stability.
3. Provide appropriate referral and follow-up.
4. Support client/family in Intervention (confrontation) process for decision to stop using drugs.

DISCHARGE GOALS
1. Homeostasis achieved.
2. Complications prevented/resolved.
3. Abstinence from drug(s) maintained on a day-to-day basis.
4. Participation in drug rehabilitation program.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for Hallucinogen, Phencyclidine, and Cannabis Related Disorders: Risk for Violence, directed at self/others may be related to Chemical alteration, exogenous (CNS stimulants/mind-altering drug), toxic reactions to drug(s); Organic brain syndrome (drug anesthetizes mind and body); and Psychological state (narrowed perceptual field) possibly evidenced by Synesthesias, hallucinations, illusions, visual/auditory distortions; panic state; suspiciousness of others, paranoid ideation, delusions; Hostile, threatening verbalizations; exaggerated emotional response; increased motor activity, pacing, excitement, irritability, agitation; Change in behavior pattern; unpredictable behavior; increasing anxiety, fear, and feelings of loss of control; Overt and aggressive acts; self-destructive behavior; and Decreased response to pain.

Desired Outcomes:

1. Demonstrate self-control, as evidenced by relaxed posture, free of violent behavior.
2. Acknowledge reality of situation and understanding of relationship of behavior to drug use.
3. Participate in treatment program.

Nursing intervention with rationale:
1. Place in darkened, quiet, nonthreatening environment with a nonintrusive observer.
Rationale: Lowered stimulation decreases the likelihood of confusion and fear; thus, there is less chance of violent behavior. Use of an observer promotes safety. Note: PCP users seek help only after the situation has gotten out of hand, and it is therefore important to take safe action immediately.

2. Speak in a soft, nonthreatening voice. Use “Talk- downs” when LSD has been taken. If technique is tried with other drugs (particularly PCP) and agitation increases, stop immediately.
Rationale: Nonthreatening communication may have a calming effect. However, “Talk-downs” (the use of orientation, support, and reassuring words/touch) may be deleterious in the presence of PCP intoxication, resulting in an increase in the client’s agitation level.

3. Observe for escalating anxiety, fear, irritability, and agitation.
Rationale: May indicate potential for progression to violent behavior. Note: Client is not in complete control of self because of drug use.

4. Accept and deal with client’s anger without reacting on an emotional basis.
Rationale: Responding emotionally on a personal level is not constructive and may escalate reactions.

5. Provide protection within the environment via constant observation and removal of objects that may be used to hurt self or others.
Rationale: Reduces risk of injury to client and/or staff. Client may not feel pain and may not be able to follow directions because of use of the drug.

6. Observe behavior without administering medications.
Rationale: A period of drug-free observation should precede any decision to administer medications (e.g., antianxiety agents), so that a clear clinical picture can develop. In addition, because it is not known what other drugs may also have been taken, it is not generally advisable to add another drug.

7. Administer medications as necessary, e.g.: diazepam (Valium)
Rationale: Used to reduce muscle spasms and/or restlessness in PCP user.

8. Administer haloperidol (Haldol).
Rationale: Preferred to control psychosis and assaultive behavior.

9. Avoid use of phenothiazine neuroleptics.
Rationale: Drugs such as chlorpromazine (Thorazine) are generally avoided because of the possibility of potentiating PCP anticholinergic effects.

10. Apply restraints, if needed, and document reason(s) for use.
Rationale: Restraints should be avoided in a frightened, hallucinating client but may be necessary because of potential injury to self or others, or when other dangerous drugs have been taken. PCP users are
unpredictable, so it is best to err on the side of safety (using restraints with sufficient documentation) rather than to risk injury.

Generalized Anxiety Disorder Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Thu, 26 Jan 2012 23:06:00 +0000

Although some degree of anxiety is normal in life’s stresses, anxiety can be adaptive or maladaptive. Problems arise when the client has coping mechanisms that are inadequate to deal with the danger, which may be recognized or unrecognized. The essential feature of this inadequacy is unrealistic or excessive anxiety and worries about life circumstances. Anxiety disorders are the most common of all major groups of mental disorders in the United States, sharing comorbidity with major depression and substance abuse, increasing the client’s risk of suicide.

DSM-IV
300.02 Generalized anxiety disorder

ETIOLOGICAL THEORIES
Psychodynamics
The Freudian view involves conflict between demands of the id and superego, with the ego serving as mediator. Anxiety occurs when the ego is not strong enough to resolve the conflict. Sullivanian theory states that fear of disapproval from the mothering figure is the basis for anxiety. Conditional love results in a fragile ego and lack of self-confidence. The individual with anxiety disorder has low self-esteem, fears failure, and is easily threatened.

Dollard and Miller (1950) believe anxiety is a learned response based on an innate drive to avoid pain. Anxiety results from being faced with two competing drives or goals.

Cognitive theory suggests that there is a disturbance in the central mechanism of cognition or information processing with the consequent disturbance in feeling and behavior. Anxiety is maintained by this distorted thinking with mistaken or dysfunctional appraisal of a situation. The individual feels vulnerable, and the distorted thinking results in a negative outcome.

Biological
Although biological and neurophysiological influences in the etiology of anxiety disorders have been investigated, no relationship has yet been established. However, there does seem to be a genetic influence with a high family incidence.

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 exhibiting dysfunctional behavior is seen as the representation of family system problems. The “identified patient” (IP) is carrying the problems of the other members of the family, which are seen as the result of the interrelationships (disequilibrium) between family members rather than as isolated individual problems.

It is recognized that multiple factors contribute to anxiety disorders.

NURSING PRIORITIES
1. Assist client to recognize own anxiety.
2. Promote insight into anxiety and related factors.
3. Provide opportunity for learning new, adaptive coping responses.
4. Involve client and family in educational/support activities.

DISCHARGE GOALS
1. Feelings of anxiety recognized and handled appropriately.
2. Coping skills developed to manage anxiety-provoking situations.
3. Resources identified and used effectively.
4. Client/family participating in ongoing therapy program.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for generalized anxiety disorder: Severe Anxiety may be related to Real or perceived threat to physical integrity or self-concept (may or may not be able to identify the threat); Unconscious conflict about essential values (beliefs) and goals of life; unmet needs; Negative self-talk possibly evidenced by Persistent feelings of apprehension and uneasiness (related to unidentified stressor or stimulus) that client has difficulty alleviating; Sympathetic stimulation; restlessness; extraneous movements (foot shuffling, hand/arm fidgeting, rocking movements); Poor eye contact; focus on self; Impaired functioning; verbal expressions of having no control or influence over situation, outcome, or self-care; Free-floating anxiety; Nonparticipation in care or decision-making when opportunities are provided.

Desired Outcomes:
1. Verbalize awareness of feelings of anxiety.
2. Identify effective coping mechanisms to successfully deal with stress.
3. Report anxiety is reduced to a manageable level.
4. Demonstrate problem-solving skills/lifestyle changes as indicated for individual situation.

Nursing intervention with rationale:
1. Establish and maintain a trusting relationship through the use of warmth, empathy, and respect. Provide adequate time for response. Communicate support of the client’s self-expression.
Rationale: The client may perceive the nurse as a threat, which may increase the client’s anxiety. Attending behaviors can increase the degree of comfort the client experiences with the nurse.

2. Be aware of any negative or anxious feelings nurse may have because of client’s conscious or unconscious resistance of nurse’s helpful efforts.
Rationale: Negative reactions to the client will block future progress. Anxiety is “contagious,” and nurse needs to recognize and control own anxiety.

3. Identify behaviors of the client that produce anxiety in the nurse. Explore these behaviors with the client once relationship is established.
Rationale: Promotes growth and change and helps client realize how own behavior affects others.

4. Use supportive confrontation as indicated.
Rationale: Confrontation can be useful when client’s progress is blocked but may heighten anxiety to a level that is detrimental to the therapy process. Therefore, it should be used with caution.

5. Have client identify and describe the sensations of emotional and physical feelings. Assist the client to link behavior and feelings. Validate all inferences and assumptions with the client.
Rationale: To adopt new coping responses, the “5 R’s” of anxiety reduction are used. The client first needs to RECOGNIZE anxiety and be aware of feelings, how they link to certain maladaptive coping responses, and own responsibility in learning to control behavior.

6. Help to explore conflictual issues by beginning with nonthreatening topics and progressing to more conflict-laden ones.
Rationale: Anxious client does not think clearly, and beginning with simple topics promotes comfort level, increasing sense of success and progress.

7. Monitor the anxiety level of the nurse/client interaction on an ongoing basis.
Rationale: Moderate anxiety may be productive for/motivate client, but too high a level of anxiety can interfere with the interaction and ability to attend to information.

8. Assist the client to identify the situations and interactions that immediately precede the anxiety. Suggest that the client keep an “anxiety notebook” that focuses on feelings and what is going on in the environment when anxious feelings begin.
Rationale: After the client recognizes feelings of anxiety, examination of the development of the anxiety (e.g., what precipitates it, the strength of the stressor[s]) and what resources are available can help the client develop new coping skills. Therapeutic writing serves to decrease the anxiety while the client is learning about it, making it more tangible/controllable.

9. Encourage client to use relaxation techniques (e.g., meditation, massage, breathing techniques, exercises, guided imagery, and biofeedback).
Rationale: RELAXATION is the ultimate stress management technique because it brings about a decreased heart rate, lowers metabolism, and decreases respiration rate. The relaxation response is the physiological opposite of the anxiety response.

10. Administer medication as indicated, e.g., buspirone (BuSpar), benzodiazepines, e.g., alprazolam (Xanax), clonazepam (Klonopin), clorazepate (Tranxene), chloridiazepoxide (Librium), diazepam (Valium), oxazepam (Serax).
Rationale: Anxiolytics provide relief from the immobilizing effects of anxiety. BZDs have few side effects, are generally well tolerated, have a fairly rapid rate of onset, and do not impair sleep. Note: When anxiety is associated with depression, antidepressant agents alone may provide relief of symptoms. Unlike BZDs, BuSpar is nonaddicting, has a delayed onset of action (10 days–2 weeks), and must be taken on a regular basis (not PRN).

Gender Identity Disorder Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Thu, 26 Jan 2012 09:22:00 +0000

Sexuality is a product of one’s genetic identity, gender identity, gender role and sexual orientation. As all of these are independent components, there is a 4 3 4 interaction that can result in 16 distinct possibilities of sexual identity. In a society in which clear differences between the sexes is the expected norm, any individual challenging this dichotomy is deemed problematic. However, in the mental health arena, sexual orientation is a concern only when the individual experiences persistent and marked distress regarding uncertainty about issues relating to personal identity—in this case, sexual orientation and behavior.

Consensual homosexuality in adults is no longer viewed as a mental disturbance. Homosexual individuals in general have no more psychopathology than heterosexuals, and when they do seek treatment it is for the same reasons as heterosexuals—psychiatric disorders (e.g., bipolar disorder, borderline personality), relationship problems, and stress. Therefore, it is important to avoid mistakenly attributing psychiatric symptoms to the individual’s sexual orientation.

In gender identity disorder, the individual does not view himself or herself as homosexual; rather, there is a strong and persistent cross-gender identification and discomfort with one’s gender or a sense of inappropriateness in the assigned gender role exists (e.g., a male “trapped” in a female’s body). This perception results in clinically significant distress/functional impairments (e.g., social, occupational).

In addition, this plan of care also addresses the diagnosis of Identity Problem for homosexuals who are uncertain about multiple issues relating to their identity, such as sexual orientation and behavior, moral values, friendship patterns, and group loyalties.

to fully understand about gender identity disorder you may read my previous post: http://www.enurse-careplan.com/2012/01/sexual-and-gender-identity-disorders.html

DSM-IV
GENDER IDENTITY DISORDERS
302.6 Gender identity disorder in children
302.85 Gender identity disorder in adolescents and adults (specify: sexually attracted to males/females/both/neither)
302.6 Gender identity disorder not otherwise specified (intersex conditions, androgen insensitivity syndrome, or congenital adrenal hyperplasia and gender dysphoria)
313.82 Identity problem (specific to sexual orientation and behavior)

ETIOLOGICAL THEORIES
Psychodynamics
The libido is seen as the force that expresses sexual instinct and develops gradually during the oral stage, which focuses on the mouth and lips. The central concern of the anal stage is the anus and the elimination/retention of feces. During the phallic stage, the male is concerned with love of his mother, is jealous of his father, and has castration anxiety (Oedipus complex). The female has penis envy, loves her father, and rejects her mother (Electra complex). This theory focuses on the biological inferiority of women because they do not have penises, with subsequent envy of the male.

Developmental theories suggest that sexuality develops throughout life and especially during the formative years. Confusion about one’s individual personality and sexual identity affects the ability to be intimate, interfering with sexual development.

Biological
Although adult endocrine levels are usually normal in individuals who are homosexual, a “hormonal wash” may have occurred at a critical time of embryonic development, sensitizing brain cells in as yet immeasurable ways. Androgen is necessary for masculinization in the fetal male, with the fetus developing as female without the addition of this hormone. When androgenic influences in the fetal hypothalamus are decreased in the male or increased in the female, homosexuality may occur. Some research sources report that there is a neuroendocrine factor (e.g., that the fetus was exposed to large amounts of androgenic hormones or that the mother may have received synthetic hormones at a crucial fetal developmental period, preventing adequate stimulation for neural differentiation).

Current research allows monitoring of normal fetal exposure to testosterone in utero. When subsequent behavior is linked to this information, we will understand more than has been previously available from studies of abnormal exposure of the fetus to high levels of androgen, overdoses due to drugs, or adrenal malfunction. Research continues into the effect of prenatal brain-sexing on homosexual development. We know that lack of male hormone at a crucial state of male fetal development can lead to a feminine brain in a male body. It is clear that, as with other aspects of behavior, sexual orientation is crucially mediated by
hormonal influences on the developing brain in utero. It is believed that abnormal hormones interact with
neurotransmitters, the chemicals that direct the construction of the brain, affecting the sex centers, mating
centers, and the so-called gender-role centers, which assume their structure at different times of brain
development (Moir & Jessel, 1991).

Family Dynamics
Role-modeling of gender-specific behaviors is believed to play a part in the development of these disorders as well as the negative effect of a disturbed relationship with one or both parents. Imprinting and classic conditioning may affect the development of gender identity.

In males with gender identity disorders, a symbiotic relationship appears to exist between mother and child. The father is usually absent, ineffectual, or hostile and is perceived as weak and distant, with the mother seen as strong and protective.

In females with these disorders, the child may not be valued as a girl, or the mother may be absent, depressed, or suffer from other illness, resulting in inadequate mothering. The father may treat the daughter as his little boy, expecting “masculine” behavior.

NURSING PRIORITIES
1. Help client reduce level of anxiety.
2. Promote sense of self-worth.
3. Encourage development of social skills /comfort level with own sexual identity/preference.
4. Provide opportunities for client/family to participate in group therapy/other support systems.

DISCHARGE GOALS
1. Anxiety reduced/managed effectively.
2. Self-esteem/image enhanced.
3. Accepts and is comfortable with identity as established.
4. Client/family are participating in ongoing treatment/support programs.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for gender identity disorder: Severe Anxiety may be related to Ego-dystonic gender identification; Unconscious conflicts about essential values/beliefs; Threat to self-concept; unmet needs possibly evidenced by Increased tension/helplessness (hopelessness); Feelings of inadequacy, apprehension, uncertainty; Increased wariness; insomnia; and Focus on self; impaired daily functioning.

Desired Outcome:
1. Verbalize awareness of feelings of anxiety and healthy ways to deal with them.
2. Appear relaxed and report anxiety is reduced to a manageable level.
3. Demonstrate problem-solving skills and use resources effectively.

Nursing intervention with rationale:
1. Assess level of anxiety and degree of interference with daily activities/life.
Rationale: Necessary information to identify the extent of problem for the individual and plan appropriate interventions.

2. Review drug/substance use history (e.g., prescription/illicit), familial/physiological factors (e.g., mental/physical illness, family disorganization).
Rationale: Drugs (including alcohol) may have been used to handle anxious feelings in the past. Other factors contribute to anxiety and may affect individual’s ability to handle stress of dealing with own identity problems.

3. Help client identify feelings, conveying empathy and unconditional positive regard. Encourage free expression of feelings in appropriate ways.
Rationale: Identification of feelings within a safe, therapeutic environment can help the client begin to explore causes of anxiety and begin to move toward acceptance of self as a worthwhile person.

4. Acknowledge reality of anxiety/fear. (Do not deny or reassure client that everything will be all right.)
Rationale: Helps client accept own feeling(s) and learn trust in self. Denial of these feelings contributes to increased anxiety. Platitudes lack factual basis, and providing false reassurance can damage trust and may increase client’s anxiety.

5. Provide accurate information to assist client to clarify reality base, reframe sexuality, and delineate boundaries.
Rationale: Anxiety may be the result of misinterpretation or lack of knowledge about sexuality/gender identity, and client may fantasize unrealistic ideation.

6. Accept the client as he or she is.
Rationale:Lack of self-acceptance is the basis of much anxiety, and other’s unacceptance increases anxiety.

7. Identify things client has done previously when feeling nervous/anxious.
Rationale: Helps client see which previous actions have been beneficial and can be used in this situation, increasing sense of control/capability and allaying anxiety.

8. Assist with developing program of exercise (e.g., brisk walking, aerobic class).
Rationlae: Strenuous activity releases opiate-like endorphins, which create sense of well-being and decrease anxiety. However, exercise therapy need not be aerobic or intensive to achieve the desired effect.

Elimination Disorders: Enuresis/Encopresis Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Wed, 25 Jan 2012 22:34:00 +0000

The DSM-IV defines enuresis/encopresis as repeated involuntary (or, much more rarely, intentional) voiding/passage of feces into places not appropriate for that purpose, after attaining the developmental level at which continence is expected. If continence has not been achieved, the condition can be termed “functional” or “primary.” The period of continence necessary to differentiate between primary and secondary enuresis/encopresis is now considered to be 1 year. There does seem to be a significant relationship between enuresis and encopresis, although neither condition can be the direct effect of a general medical condition (e.g., diabetes, spina bifida, seizure activity) to be included in this category.

DSM-IV
307.6 Enuresis (not due to a general medical condition)
307.7 Encopresis without constipation and overflow incontinence
787.6 Encopresis with constipation and overflow incontinence

ETIOLOGICAL FACTORS
Psychodynamics
Numerous psychological interpretations exist speculating on the dynamics of toilet training and the significance of flushing bodily fluids down the toilet. Freudian theory places the fixation at the anal stage of development whereby the child fails to neutralize libidinal urges, and the aggressive impulses are fused with the pleasure of controlling bodily functions. Expulsion of feces or urination and untimed feces or urination or intentionally placing the feces in inappropriate places elicits hostility from parents. Loss of bodily functions leads to loss of self-respect, loss of friends, and feelings of shame and isolation.

Biological
Learning to control urination/defecation is a developmental task most likely achieved by age 4 or 5 and requires a mechanically effective anatomy. In some enuretic children, abnormalities in regulation of vasopressor/antidiuretic hormone (ADH) have been evidenced, with ADH regulation being linked to both the dopaminergic and serotonergic systems. A theory of developmental delay suggests there is a common underlying maturational factor that predisposes children to manifest both enuresis and behavioral disturbances. Enuresis and encopresis are normal responses to environmental stresses that occur in certain situations (e.g., when a child is separated from his or her family or is abused). In either case, as the child matures and the environmental stressors are alleviated, normal bodily control is resumed. Children who are hyperactive may have occasional accidents, as they do not attend to the sensory stimuli until it is too late.

Enuresis and its relationship to bladder capacity and urinary tract infections has been explored, as has nocturnal enuresis occurring during deep sleep with no response to arousal signals. In addition, research has been conducted to investigate the physiological basis for encopresis. These studies indicate that the act of bearing down led to decreased anal sphincter control in almost all cases.

Soiling may result from excessive fluid buildup caused by diarrhea, anxiety, or the retention overflow process, whereby leakage occurs around a retentive fecal mass. This mechanism is responsible for 75% of encopretic children.

Genetically, a child is at risk for enuresis if the parent has a history of enuresis after the age of 4. Recent research suggests a genetic mutation on chromosome 13.

Family Dynamics
As mentioned previously, the parental attitude toward cleanliness and the rigidity with which this behavior is controlled may perpetuate the fear associated with loss of bodily control. Parents often get caught up in the volitional aspects, blaming the child for “acting like a baby.” Further social embarrassment ensues when school personnel target the problem in terms of “the dirty child from a dirty family.” Attempts to deny the problem lead to covert behaviors such as hiding soiled clothing in lockers, under the bed, or in the trash. The child may in fact be using the only weapon available, as in the case of severe neglect and/or sexual assault.

NURSING PRIORITIES
1. Promote understanding of condition.
2. Identify and support change in parent/child patterns of interaction.
3. Enhance self-esteem.
4. Assist client in achieving continence.

DISCHARGE GOALS
1. Condition/therapy needs are understood.
2. All parties are participating in therapeutic regimen.
3. Achieves as near a normal pattern of bowel/bladder functioning as individually possible.
4. Plan in place to meet needs after discharge.

Nursing diagnosis for elimination disorders: Altered Urinary Elimination/Bowel Incontinence may be related to Situational/maturational crisis; Psychogenic factors: predisposing vulnerability; threat to physical integrity (child/sexual abuse); Constipation possibly evidenced by Nocturnal and/or diurnal enuresis; Involuntary passage of stool at least once monthly; Strong odor of urine/feces on client; Hiding fecal material/soiled clothing in inappropriate places.

Desired Outcome:
1. Verbalize understanding of contributing factors and appropriate interventions.
2. Participate in appropriate toileting program.
3. Achieve continence.

Nursing intervention with rationale:
1. Identify times of occurrence, preceding/precipitating events, amounts of oral fluids, and family/client response to incontinence.
Rationale: Baseline data will help identify patterns and document improvement after treatment begins

2. Check for fecal impaction.
Rationale: This may be a contributing factor.

3. Discuss measures client/family have tried and successes/failures to date.
Rationale: Typically, parents/caregivers have tried various methods, usually getting child up periodically at night, limiting fluids before bedtime, and having older children change soiled bed linens. These methods are not very effective and usually lead to frustration, power struggles/battles.

4. Suggest use of bladder-stretching exercises (e.g., ask child to drink favorite beverage and wait to urinate until the urge becomes very strong, then measure the amount of urine voided). Gradually increase amount of liquid and waiting period.
Rationale: Although this method can have good results, the length of time needed may be discouraging and result in the family discontinuing the program.

5. Active-listen and involve client in developing the plan for remaining dry/clean. Institute a system of positive reinforcement. Use rewards that the child would like or agrees to. Use the previously determined baseline data to determine parameters of the reward system and when to increase schedule.
Rationale: Establishing a plan to which the client agrees has more chance of success than using aversive operant behavioral interventions (e.g., bell alarm) alone. Behavioral therapy may be useful when client is included in the planning, with rewards, such as tokens having value, if client agrees to their use. Note: If client is not involved in planning/vested in behavioral program, then therapy becomes an external control manipulating the client rather than promoting internal control and growth.

6. Establish toileting routine with positive reinforcement for “sitting time” and depositing urine/feces in lavatory appropriately.
Rationale: Client may begin to establish bowel/bladder habits often missing prior to treatment.

7. Treat occasional relapses with matter-of-fact attitude and follow through with procedures for self-hygiene.
Rationale: Relapse (whether intentional or not) is to be expected but may be minimized when the client does not feel pressured/blamed for lack of cooperation.

8. Discuss length of treatment with parents/client and make plans for maintaining dry/clean status.
Rationale: Knowing that treatment is ongoing prevents becoming discouraged and giving up treatment.

9. Administer medications as appropriate, e.g: Imipramine (Tofranil).
Rationale: May be used after age 7 for enuresis. However, drug therapy is only a temporary treatment, not a cure, as condition recurs within 3 months after medication is discontinued. Pharmacological studies indicate improvement in encopresis with relatively low doses over 2-week period. Note: Factors such as child’s age, duration of problem, and child’s motivation to change are factors that affect decision to include pharmacological agents in combination with behavioral interventions.

10. Refer for evaluation of other therapies (e.g., hypnotherapy).
Rationale: Used alone or in conjunction with conditioning, the use of hypnosis can help the child access the subconscious mind allowing the child to work through emotional conflicts and develop positive suggestions t hat he or she has good muscle control and will be dry in the morning. Note: This technique is contraindicated in the presence of child abuse.

Dissociative Disorders Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Wed, 25 Jan 2012 08:31:00 +0000

In these disorders a disturbance or alteration exists in the normally integrative functions of identity, memory, or consciousness. The individual blocks off part of his or her life from consciousness during periods of intolerable stress. The stressful emotion becomes a separate entity, as the individual “splits” from it and mentally drifts into a fantasy state.

DSM-IV
300.12 Dissociative amnesia
300.13 Dissociative fugue
300.14 Dissociative identity disorder
300.15 Dissociative disorder NOS
300.6 Depersonalization disorder

ETIOLOGICAL THEORIES
Psychodynamics
Selective repression of distressing mental contents from conscious awareness is used as a mechanism for protecting the individual from emotional pain or expressing self in dangerous ways. The stressor(s) may arise from external circumstances or internal sources with onset of symptoms sudden or gradual and of transient or chronic nature. Intrapsychic conflict thus uses denial and “ego splitting” to decrease anxiety.

Physical sensations seen in these disorders may represent forbidden wishes that have been somatized. The use of the defense mechanism of displacement allows the feeling(s) to be directed away from the egothreatening object toward one less threatening. In psychoanalytic terms, dissociation is a form of denial in which the object denied is part of the self or ego.

Biological
Research on the biological basis of these disorders is increasing as more recognition of the mind-body connection is accepted. It is difficult to determine whether the biological changes (fight-or-flight mechanism) that accompany severe anxiety precede or precipitate the emotional state. Biochemical, physiological, and endocrine systems have an intimate connection with actual physical changes occurring in all body systems via the autonomic nervous system. Some studies have shown EEG abnormalities associated with cerebral mechanisms in the temporal and limbic regions of the brain, which mediate identity formation and a sense of personal boundaries and may affect development of gender and generation boundaries.

Organic causes of pathological dissociative experiences that are known or suspected include temporal lobe epilepsy, sensory deprivation, sleep loss, strokes, encephalitis, and Alzheimer’s disease. Drugs may also induce amnesia or depersonalization directly or indirectly in some incidences. However, most dissociative states are not associated with any obvious organic conditions and the diagnosis of dissociative disorder requires that the condition is not due to the direct effects of a substance or a general medical condition.

Family Dynamics
In Systems theory, the family is viewed as a system in which the process (interactions between/among family members) is the prime determinant. Level of differentiation and level of anxiety determine the degree of pathology.

Psychosocial theory states that individuals who develop dissociative disorders have often experienced severe physical, sexual, and/or emotional abuse early in life—stress so severe that the only way to cope with the painful emotions is to detach from them. The child learns to respond to stressful situations in this manner. One parent may be abusive, with the other being a passive participant, not taking care of or protecting the child. Psychiatric diagnoses (especially alcoholism) in close relatives are common, although multiple personality diagnosis is not.

Certain behaviors observed in childhood, though considered normal, may be identified as dissociative, including construction of imaginary playmates, use of different names or ages for themselves, taking on the role of an animal, imagining self as having been adopted or coming from another family, separation from the past, gender confusion, and regressive behavior. Responding to stressful situations with dissociative behaviors then becomes a method of coping for some individuals into adulthood, when there is less control over the dissociative states. The response becomes maladaptive in that the individual escapes from the stressful situation rather than facing it.

NURSING PRIORITIES
1. Provide safe environment; protect client/others from injury.
2. Assist client to recognize anxiety.
3. Promote insight into relationship between anxiety and development of dissociative state/other personalities.
4. Support client/family in developing effective coping skills and participating in therapeutic activities.

DISCHARGE GOALS
1. Recognizes potentially dangerous behaviors/personalities and contracts for safety.
2. Client/family are participating in therapeutic regimen.
3. Effective coping skills, understanding of underlying dynamics of condition are demonstrated.
4. Recovers deficits in memory.
5. Major/emerging personality has been chosen and accepted (dissociative identity disorder) or client is managing stress without resorting to dissociation.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for dissociative disorders: Anxiety may be related to Maladaptation of ineffective coping continuing from early life; Unconscious conflict(s); threat to self-concept, threat of death (perceived or actual); Unmet needs and Phobic stimulus possibly evidenced by Increased tension; apprehension, fright; restlessness; Feelings of inadequacy; focus on self or projection of personal perceptions onto the environment; Verbalized focus of fear, e.g., fear of “going crazy”; Maladaptive response to stress (dissociating self/fragmentation of the personality); Sympathetic stimulation: cardiovascular excitation, superficial vasoconstriction, pupil dilation.

Desired Outcome:
1. Acknowledge and discuss feelings of anxiety and fear.
2. Identify ways to manage anxiety/fear effectively.
3. Demonstrate problem-solving skills.
4. Use resources effectively.

Nursing intervention with rationale:
1. Develop rapport and trust; accept client’s verbal expression of feelings/anxieties.
Rationale: A trusting alliance facilitates early identification of the underlying sources of anxiety and development of an appropriate treatment approach. Learning to turn to trusted others for support helps the client develop healthy methods of dealing with anxiety.

2. Discuss with the client the availability of assistance in maintaining safety.
Rationale: Prevents a false assurance of safety, particularly when internal threats to safety may not be readily apparent. Lack of awareness of need/failure to use resources increases the likelihood of isolation and destructive behaviors. Note: Expressions of anxiety may represent a very real threat to or from alternate personalities and/or others.

3. Identify stressor(s) that precipitate severe anxiety.
Rationale: Helps client recognize individual factors precipitating dissociative symptoms (e.g., splitting, fugue, amnesia), which interfere with developments/use of adequate coping skills.

4. Maintain a neutral approach when confronted by an alternate personality or dissociative state.
Rationale: Allows essential observation and documentation and promotes a trusting relationship. Also helps the therapist/care provider to avoid consciously or unconsciously promo ting fragmentation of the personality. Because dissociative identity disorder has been sensationalized, personnel may be intrigued by manifestations and respond to the client in ways that reinforce the behaviors manifesting the disorder.

5. Provide support and encouragement during times of depersonalization.
Rationale: Client experiences fear and anxiety at these times and may fear “going crazy.” Acknowledging these feelings will help client deal appropriately with them.

6. Reduce alterable sources of stress. Provide calm environment; minimize external stimuli. Identify individual causes/precipitators of stress.
Rationale: Manipulation of the environment to reduce extraneous sources of stress allows the client to recognize and develop skills in managing internal sources of conflict.

7. Observe for/review with client untoward effects/ adverse reaction to medication regimen. Monitor level of alertness, vital signs; note urinary retention, dry mouth, blurred vision, parkinson-like symptoms, rigidity, or atypical response (excitability, restlessness, agitation).
Rationale: Psychoactive medications (sedatives, antianxiety/ antipsychotic agents, and antidepressants) frequently produce hypotension and anticholinergic and extrapyramidal symptoms, in addition to the desired effect. Early intervention will alleviate prolonged difficulties and/or serious physical complications and may prevent/lessen anxiety about their presence.

8. Coordinate and develop a combined treatment plan. Facilitate communication among team members.
Rationale: These clients do better when dealing with one primary provider supported by a cohesive treatment team. Therefore, it is essential that all members of the treatment team work together in planning care to ensure that goals and objectives are in agreement and continuity of care exists. Because these clients are prone to manipulative behaviors and may be resistant to therapy, a coordinated treatment plan prevents dissension between disciplines.

9. Administer antianxiety medications as indicated, e.g., alprazolam (Xanax), diazepam (Valium).
Rationale: Antianxiety medications are given with caution for brief periods to allay panic states or disabling anxiety. Caution is essential, as substance abuse is a common complication and also because of the potential for self-destructive behavior.

10. Explore past experiences and painful situations (e.g., trauma, abuse) that may be repressed.
Rationale: Traumatic experiences/patterns of behavior may predispose individuals to dissociative disorders.

Depressants (Barbiturates, Nonbarbiturates, Hypnotics and Anxiolytics, Opioids) Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Tue, 24 Jan 2012 08:12:00 +0000

CNS depressants are drugs that slow down the central nervous system. They are usually divided into four types: barbiturates, antianxiety agents, sedative-hypnotics, and narcotics (opioids such as morphine, heroin).

CNS depressants prescribed for symptoms of anxiety, depression, and sleep disturbances are among the most widely used and abused drugs. These drugs are very likely to be abused when the underlying conditions remain untreated. Sometimes these drugs are used in conjunction with stimulants, with the user developing a pattern of taking a stimulant to be “up,” then needing the depressant drug to “come down.”

Several principles apply to all CNS depressants: (1) The effects are interactive and cumulative with one another and with the behavioral state of the user; (2) there is no specific antagonist that will block the action of these drugs; (3) low doses produce an initial excitatory response; (4) they are capable of producing physiological and psychological dependency; and (5) cross-tolerance and cross-dependence may exist between various CNS depressants. Although the margin of safety of these drugs is great, they have a characteristic syndrome of withdrawal that can be very severe.

This plan of care addresses acute intoxication/withdrawal and is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.

DSM-IV
SEDATIVE-, HYPNOTIC-, OR ANXIOLYTIC-INDUCED DISORDERS
292,89 Sedative, hypnotic, or anxiolytic intoxication
292.0 Sedative, hypnotic, or anxiolytic withdrawal
292.81 Intoxication delirium
292. 84 Induced mood disorder

OPIOID-RELATED DISORDERS
292.89 Opioid intoxication
292.81 Intoxication delirium
292.0 Opioid withdrawal

ETIOLOGICAL THEORIES
Psychodynamics
Individuals who abuse substances fail to complete tasks of separation-individuation, resulting in underdeveloped egos. The person has a highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem. The superego is weak, resulting in absence of guilt feelings. Underlying psychiatric status must be assessed, as these individuals may use stimulants for varying self-medication reasons.

Psychostructural factors (e.g., personality) are seen as significant. The defect is believed to precede the addiction, with the ego structure breaking down and the substance being used as a maladaptive coping mechanism. Characteristics that have been identified include impulsivity, negative self-concept, weak ego, low social conformity, neuroticism, and introversion.

Biological
A genetic link is thought to be involved in the development of substance use disorders. Although statistics are currently inconclusive, hereditary factors are generally accepted to be a factor in the abuse of substances.

Family Dynamics
There is an apparent predisposition to substance abuse disorders in the dysfunctional family system. Factors such as the absence of a parent or a parent who is an overpowering tyrant or weak and ineffectual, and the use of substances as the primary method of relieving stress, appear to contribute to this dysfunction. These role models have a negative influence, and the child learns to handle stress in like manner. However, parents may be average, normal individuals with children who succumb to overwhelming peer pressure and become involved with drugs. Cultural factors such as acceptance of the use of alcohol and other drugs may also influence the individual’s choice.

NURSING PRIORITIES
1. Achieve physiological stability.
2. Protect client from injury.
3. Provide appropriate referral and follow-up.
4. Promote family involvement in the withdrawal/rehabilitation process.

DISCHARGE GOALS
1. Homeostasis achieved.
2. Complications prevented/resolved.
3. Abstinence from drug(s) initiated/maintained on a day-to-day basis.
4. Attends rehabilitation program, group therapy (e.g., Narcotics Anonymous).
5. Plan in place to meet needs after discharge.

Nursing diagnosis: Risk for Trauma/Suffoation/Poisoning may be related to CNS depression (effect of overdose); CNS agitation (effect of abrupt withdrawal); Hypersensitivity to the drug(s); Psychological stress (narrowed perceptual fields seen with anxiety).

Desired Outcomes:
1. Verbalize understanding of risks of taking drugs.
2. Refrain from acting on hallucinations/impaired judgment.
3. Complete withdrawal without injury to self/development of complications.

Nursing intervention with rationale:
1. Talk with client/SO regarding when person was last seen well; noting history/duration of health problems, sleep patterns, and prescriptions used.
Rationale: Determines degree and approximate time frame for impairment, with sleep disruption often the first observable sign of problem. Ongoing health problems (e.g., chronic pain conditions) potentiate substance use. Prescription information provides clues to identify drug(s) and amount taken.

2. Identify drug(s) taken, when taken, and route used, if possible.
Rationale: Helpful to identify interventions for specific drug. Determining drug(s) taken may be difficult without blood/urine testing as the client may not feel free to tell because of embarrassment or for legal reasons, or may not know what has been ingested.

3. Assess level of consciousness (e.g., agitated, stuporous, lethargic, confused, or comatose). Note pinpoint pupils.
Rationale: May indicate degree of intoxication and level of intervention required. Constricted pupils are a classic sign of opioid (heroin) use.

4. Evaluate for evidence of head trauma.
Rationale: This is important to note for differential diagnosis, to prevent inappropriate treatment/interventions.

5. Determine when food was last eaten. Note reports of nausea.
Rationale: Presence of food in stomach may slow absorption of drug(s) into the bloodstream; however, if level of consciousness is depressed, presence of food in stomach increases the risk of vomiting and aspiration.

6. Provide quiet, lighted room (e.g., an isolation room with simple furniture).
Rationale: Reduces internal or external stimuli, which may lead to injury as depressant effect lessens.

7. Note presence of tremors.
Rationale: Involuntary movements of one or more parts of the body may result from abrupt removal of drug.

8. Provide seizure precautions (e.g., padded side rails, bed in low position, airway adjunct/ suction at bedside).
Rationale: These precautions can prevent injury if convulsions occur during withdrawal.

9. Assess emotional state, noting psychiatric history and suicide gestures/attempts. Note use/abuse of other substances.
Rationale: Patterns of drug use will indicate likelihood of intentional or accidental overdose. Substance abuse/suicidal attempts may be symptom of, or response to, underlying psychiatric illness or to hallucinations caused by sensitivity to drug.

10. Assist with barbiturate detoxification program.
Rationale: Reintoxication should be done before drug withdrawal is attempted. This establishes an
independent estimate of prior drug use and provides a baseline on which to begin the detox schedule. Reintoxication is done so the drug can be withdrawn on a strict schedule and should begin as soon as there are signs of intoxication (e.g., nystagmus, slurred speech, ataxia on backward and forward tandem gait).

Dementia Due to HIV Disease Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Mon, 23 Jan 2012 23:09:00 +0000

Dementia is impairment of short- and long-term memory, abstract thinking, and judgment with personality changes, severe enough to interfere with work, normal social activities, and relationships.

Human immunodeficiency virus (HIV) has been shown to affect the brain directly by crossing the blood-brain barrier on two types of immune cells—monocytes and macrophages. Cells within the central nervous system (CNS) have been found to have express CD4 receptor sites for HIV entry into cells. Although several hypotheses have been proposed, it is not known exactly by what mechanism neurological dysfunction occurs. Neuropsychiatric symptoms may range from barely perceptible changes in a person’s normal psychological presentation to acute delirium to profound dementia. Because of the associated immune dysfunction, secondary brain infections may cause further damage.

Studies have shown CNS abnormalities in a large percentage of clients, with 3 people in 10 who are HIV-symptomatic exhibiting symptoms of dementia. Recent studies suggest symptoms can occur prior to an acquired immunodeficiency syndrome (AIDS) diagnosis, as they are the first clinical symptoms of progression.

DSM-IV
DEMENTIAS DUE TO OTHER MEDICAL CONDITIONS
294.1 DEMENTIA DUE TO HIV DISEASE (CODE 042 ON AXIS III)

NURSING PRIORITIES
1. Promote socially acceptable responses, limit inappropriate behavior.
2. Prevent injury/complications.
3. Support SO/family involvement in care.
4. Provide information about condition, prognosis, and treatment.

DISCHARGE GOALS
1. Maximal level of independent functioning achieved.
2. Injury prevented/minimized, complications resolved.
3. SO/family effectively participating in care.
4. Condition, prognosis, and therapeutic regimen understood at level of ability.
5. Plan in place to meet needs after discharge.

Primary Nursing Diagnosis for Dementia Due to HIV Diseases: Acute/Chronic Confusion may be related to Direct CNS infection by HIV, disseminated systemic opportunistic infection, hypoxemia, brain malignancies, and/or; CVA/hemorrhage; vasculitis, Alteration of drug metabolism/excretion, accumulation of toxic elements; severe electrolyte imbalance and Sleep deprivation.

Possibly evidenced by:

Fluctuation in cognition; progressive/long-standing cognitive impairment
Fluctuation or no change in level of consciousness
Increased agitation, restlessness
Altered interpretation/response to stimuli; misperceptions
Changes in sleep/wake cycle
Clinical evidence of organic impairment

Desired Outcomes and Goal
1. Regain usual/maintain optimum reality orientation and cognitive function.
2. Demonstrate a decrease in undesired behaviors, threats, and confusion.
3. Verbalize understanding of causative/contributing factors.
4. Initiate lifestyle/behavior changes to minimize recurrence.

Nursing intervention with rationale:
1. Assess mental and neurological status using appropriate tools (e.g., Neurobehavioral Rating Scale [Freeman]). Note changes in orientation, response to stimuli, ability to problem-solve, anxiety, altered sleep patterns, hallucinations, paranoid ideation. Repeat serial/periodic evaluation at least every 2 to 4 months.
Rationale: Establishes functional level at time of admission. Serial evaluations alert the nurse to changes in status that may be associated with failure of prophylaxis, progression of HIV dementia, exacerbation of CNS infection/opportunistic disease, environmental/psychological stressors, or side effects of drug therapy.

2. Consider effects of emotional distress (e.g., anxiety, grief, anger, depression).
Rationale: May contribute to reduced alertness, confusion, withdrawal, hypoactivity and require further evaluation and intervention.

3. Monitor medication regimen and usage.
Rationale: Actions and interactions of various medications and prolonged drug half-life/altered excretion
results in cumulative effects, potentiating risk of toxic reactions. Some drugs may have adverse side effects (e.g., Haldol can seriously impair motor function in clients with AIDS dementia complex) necessitating a change in therapy.

4. Note signs of acute CNS infection (e.g., headache, nuchal rigidity, vomiting, fever, changes in motor function).
Rationale: CNS symptoms associated with disseminated meningitis/encephalitis may range from subtle personality changes to confusion, irritability, drowsiness, stupor, seizures, and dementia. Sudden onset of motor changes may indicate polyradiculopathy and need for immediate medical response.

5. Approach client in a slow, calm manner.
Rationale: Hurried approaches can startle/threaten the confused client who misinterprets or feels threatened by imaginary people and/or situations.

6. Maintain a pleasant environment, with appropriate auditory, visual, and cognitive stimuli.
Rationale: Providing normal environmental stimuli can help in maintaining some sense of reality orientation.

7. Decrease noise, especially at night.
Rationale: Promotes sleep, reducing cognitive symptoms and sleep deprivation.

8. Maintain safe environment: e.g., excess furniture out of the way, call bell within client’s reach, bed in low position/rails up or bed against wall and padding on floor, restriction of smoking (unless monitored by caregiver/SO), seizure precautions, soft restraints if indicated.
Rationale: Decreases the possibility of client injury.

9. Provide controlled environment/behavioral management.
Rationale: Team approach may be required to protect client when mental impairment (e.g., delusions, loss of cognition) threatens client safety.

10. Refer to counseling as indicated.
Rationale: May help client gain control in presence of thought disturbances or psychotic symptomatology.

Dementia of the Alzheimer’s Type Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Mon, 23 Jan 2012 08:48:00 +0000

Dementia of the Alzheimer’s type is a specific degenerative process occurring primarily in the cells located at the base of the forebrain that send information to the cerebral cortex and hippocampus. It is the most common form of dementia and is characterized by a steady and global decline. In comparison, vascular dementia reflects a pattern of intermittent deterioration related to multiple infarcts to various areas of the brain. Although the etiologies differ, these two forms of dementia share a common symptom presentation and therapeutic intervention.

DSM-IV
DEMENTIA OF THE ALZHEIMER’S TYPE (DAT)
Early Onset (At or Below Age 65)
290.10 Uncomplicated
290.11 With delirium
290.12 With delusions
290.13 With depressed mood

Late Onset (After Age 65)
290.0 Uncomplicated
290.3 With delirium
290.20 With delusions
290.21 With depressed mood
(Note: DAT should also be coded on Axis III, 331.0.)

VASCULAR DEMENTIA
290.40 Uncomplicated
290.41 With delirium
290.42 With delusions
290.43 With depressed mood
Note: In the presence of vascular dementia, the specific underlying medical cause, such as stroke, should be coded on Axis III. (For dementias due to other general medical conditions, refer to DSM-IV for specific code listing.)

ETIOLOGICAL THEORIES
Psychodynamics
These forms of dementia reflect a chronic organic mental disorder with progressive cognitive losses caused by damage to various areas of the brain, depending on underlying pathology. Personality change is common and may be manifested by either an alteration or accentuation of premorbid characteristics with primary deficits in memory and planning and a predisposition to confusion.

Biological Theories
Vascular dementia reflects a pattern of intermittent deterioration in the brain. Symptoms fluctuate and are determined by the area of the brain that is affected. Deterioration is thought to occur in response to repeated infarcts of the brain. Predisposing factors include cerebral and systemic vascular disease, hypertension, cerebral hypoxia, hypoglycemia, cerebral embolism, and severe head injury.

Several studies have shown that antibodies are produced in the brains of individuals with Alzheimer’s disease. Although the triggering mechanism is not known, the reactions are actually autoantibody production, suggesting a possible alteration in the body’s immune system. Although the exact cause of Alzheimer’s disease is unknown, several hypotheses have been supported by varying amounts and quality of research data. The exception is research on environmental causes, such as the ingestion of aluminum, which to date have not been supported by research findings. Research has revealed that, in DAT, the enzyme required to produce acetylcholine is dramatically reduced, especially in the areas of the brain where the senile plaques and neurofibrillary tangles occur in the greatest numbers. This decrease in acetylcholine production reduces the amount of neurotransmitter that is released to cells in the cortex, hippocampus, and nucleus basalis, resulting in a disruption of memory processes. Additionally, the neuritic plaques that accumulate are composed of beta-amyloid, an insoluble protein that is an abnormal breakdown product of the cell membrane constituent amyloid precursor protein (APP). Furthermore, the formation of the customary plaques and tangles appears to be related to the cholesterol-transporting protein, apolipoprotein-E (ApoE), which has been associated with an earlier-than-average age of onset for the common form of Alzheimer’s disease for individuals who carry the ApoE4 genetic variant.

Thus, genetics appears to play a role. Studies suggest a familial pattern of transmission that is four times greater than in the general population. Familial, or early-onset Alzheimer’s, has been linked to defects of genes on chromosomes 1, 14, or 21, with some families exhibiting a pattern of inheritance that suggests possible autosomal-dominant gene transmission. Furthermore, Down syndrome (extra chromosome 21) may have some relationship to Alzheimer’s disease. At autopsy, both have many of the same pathophysiological changes, and a high percentage of individuals with Down syndrome who survive to adulthood develop Alzheimer’s lesions by age 50. (Incidentally, these individuals carry two copies of the gene for APP.)

Current research suggests that Alzheimer’s disease may actually be a lifelong process, with changes in the brain developing decades before the onset of dementia. Other researchers theorize that a rich education may increase a person’s reserve of brain cells or connections between nerve cells, either of which could reduce the risk of dementia.

NURSING PRIORITIES
1. Provide safe environment; prevent injury.
2. Promote socially acceptable responses; limit inappropriate behavior.
3. Maintain reality orientation/prevent sensory deprivation/overload.
4. Encourage participation in self-care within individual abilities.
5. Promote coping mechanisms of client/significant other(s).
6. Support client/family in grieving process.
7. Provide information about disease process, prognosis, and resources available for assistance.

DISCHARGE GOALS
1. Adequate supervision/support systems available.
2. Maximal level of independent functioning achieved.
3. Coping skills developed/strengthened and SOs using available resources.
4. Disease process/prognosis and client expectations/needs understood by SO.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for Dementia of the Alzheimer’s Type: Risk for Violence may be related to Inability to recognize/identify danger in environment, impaired judgment; Disorientation, confusion, agitation, irritability, excitability; Weakness, muscular incoordination, balancing difficulties, altered perception (missing chairs, steps, etc.) and Seizure activity.

Desired Outcome:
1. Recognize potential risks in the environment
2. Identify and implement steps to correct/compensate for individual factors.
3. Be free of injury.

Nursing intervention with rationale:
1. Assess degree of impairment in ability/competence, presence of impulsive behavior. Assist SO to identify any risks/potential hazards and visual-perceptual deficits that may be present.
Rationale: Identifies potential risks in the environment and heightens awareness of risks so caregivers are
more alert to dangers. Clients demonstrating impulsive behavior are at increased risk of injury because they are less able to control their own behavior/actions. Visual-perceptual deficits increase the risk of falls.

2. Eliminate/minimize identified hazards in the environment.
Rationale: A person with cognitive impairment and perceptual disturbances is prone to accidental injury because of the inability to take responsibility for basic safety needs or to evaluate the unforeseen consequences (e.g., may light a stove/cigarette and forget about it, mistake plastic fruit for the real thing and eat it, misjudge distance involving chairs and stairs).

3. Monitor behavior routinely, note timing of behavioral changes, increasing confusion, hyperactivity. Initiate least restrictive interventions before behavior escalates.
Rationale: Early identification of negative behaviors with appropriate action can prevent need for more stringent measures. Note: “Sundown syndrome” (increased restlessness, wandering, aggression) may develop in late afternoon/early evening, requiring programmed interventions and closer monitoring at this time to redirect and protect client.

4. Distract/redirect client’s attention when behavior is agitated or dangerous (e.g., climbing out of bed).
Rationale: Maintains safety while avoiding a confrontation that could escalate behavior/increase risk of injury.

5. Obtain identification jewelry (bracelet/necklace) showing name, phone number, and diagnosis.
Rationale: Facilitates safe return of client if lost. Because of poor verbal ability and confusion, these persons may be unable to state address, phone number, etc. Client may wander, exhibit poor judgment, and be detained by police, appearing confused, irritable, or having violent outbursts.

6. Dress according to physical environment/individual need.
Rationale: The general slowing of metabolic processes results in lowered body heat. The hypothalamic gland is affected by the disease process, causing person to feel cold. Client may have seasonal disorientation and may wander out in the cold. Note: Leading causes of death in these clients are pneumonia and accidents.

7. Be attentive to nonverbal physiological symptoms.
Rationale: Because of sensory loss and language dysfunction, may express needs nonverbally (e.g., thirst by panting; pain by sweating, doubling over). Note: Wandering may be a coping mechanism as client seeks a change in environment (too hot/cold, bored/overstimulated), searches for food/bathroom, or relief from discomfort (pain/adverse drug reaction).

8. Provide quiet room/activity.
Rationale: Overstimulation increases irritability/agitation, which can escalate to violent outbursts.

9. Avoid continuous use of restraints. Have SO/ others stay with client during periods of acute agitation.
Rationale: Endangers the individual who succeeds in partial removal of restraints. May increase agitation and potentiate fractures in the elderly (owing to reduced calcium in the bones).

10. Administer medications as appropriate, e.g., thioridazine hydrochloride (Mellaril).
Rationale: Short-term use of low-dose neuroleptics may moderate “sundowning” behaviors. Note:
Condition may be related to deterioration of the suprachiasmatic nucleus of the hypothalamus (controls the sleep-wake cycle) with disturbance of circadian rhythms.

NCP Delusional Disorder | Nursing Care Plan

schizo_me86@yahoo.com — Mon, 23 Jan 2012 00:31:00 +0000

SPECIFIC TYPE:
Erotomanic (delusions that another person of higher status is in love with the individual)
Grandiose (delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person)
Jealous (delusions that one’s sexual partner is unfaithful)
Persecutory (delusions that one, or someone to whom one is close, is being malevolently treated in some way)
Somatic (delusions that one has some physical defect or general medical condition)
Mixed (delusions characteristic of more than one of the above types, but no one theme predominates)

DSM-IV
297.1 Delusional disorder

ETIOLOGICAL THEORIES
Psychodynamics
Emotional development is delayed because of a lack of maternal stimulation/attention. The infant is deprived of a sense of security and fails to establish basic trust. A fragile ego results in severely impaired self-esteem, a sense of loss of control, fear, and severe anxiety. A suspicious attitude toward others is manifested and may continue throughout life. Projection is the most common mechanism used as a defense against feelings.

Biological
A relatively strong familial pattern of involvement appears to be associated with these disorders. Individuals whose family members manifest symptoms of these disorders are at greater risk for development than the general population. Twin studies have also suggested genetic involvement.

Family Dynamics
Some theorists believe that paranoid persons had parents who were distant, rigid, demanding, and perfectionistic, engendering rage, a sense of exaggerated self-importance, and mistrust in the individual. The clients become vulnerable as adults because of this early experience.

NURSING PRIORITIES
1. Promote safe environment, safety of client/others.
2. Provide open, honest atmosphere in which client can begin to trust self/others.
3. Encourage client/family to focus on defining methods for coping with anxieties and life stressors.
4. Promote a sense of self-worth and increased self-esteem.

DISCHARGE GOALS
1. Copes with anxiety without the use of threats or assaultive behavior.
2. Recognizes reality; agrees to give up or live with the delusional system.
3. Client/family/SOs participate in therapy (e.g., behavioral, group).
4. Family/SO(s) provide emotional support for the client.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for delusional disorder: Risk for Violence, directed to self and others may be related to perceived threats of danger and increased feelings of anxiety possibly evidenced by Acting out in an irrational manner and Becoming threatening or assaultive in the face of perceived threat.

Desired Outcomes:
1. Verbalize awareness of delusional system.
2. Resolve conflicts, coping with anxiety without the use of threats or assaultive behavior.

Nursing intervention and rationale:
1. Note prior history of violent behavior when under stress.
Rationale: Indicator of increased risk for recurrence of aggression/violent behavior.

2. Assist client to identify situations that trigger anxiety and aggressive behaviors.
Rationale: Understanding relationship between severe anxiety and aggressive feelings can help client identify options to avoid violent behavior.

3. Explore implications and consequences of handling these situations with aggression.
Rationale: Emphasizes importance of thinking through situations before acting.

4. Encourage to engage in solitary activity instead of group activities to being with.
Rationale: Anxiety, fear, and suspiciousness may escalate if client is involved in competitive/group activities.

5. Assist client to define alternatives to aggressive behaviors. Engage in physical activities such as Ping-Pong, foosball. (Monitor competitive activities; use with caution.)
Rationale: Enables client to learn to handle situations in a socially acceptable manner. Appropriate outlets will allow for release of hostility. Note: Competition can trigger violent behavior.

6. Encourage verbalizations of feelings and promote outlet for expression.
Rationale: Ventilation of feelings reduces need for physical action.

7. Be alert to signs of impending violent behavior (e.g., increase in psychomotor activity, intensity of affect, verbalization of delusional thinking, especially threatening expressions).
Rationale: Therapeutic interventions are more effective before behavior becomes violent.

8. Accept verbal hostility without retaliation or defense. Nurse (caregiver) needs to be aware of own response to client behavior (e.g., anger/fear).
Rationale: Behavior is not usually directed at nurse personally, and responding defensively may exacerbate situation. Concentrating on meaning behind the words is more productive. Awareness of own response allows nurse to confront/deal with those feelings.

9. Isolate promptly in nonpunitive manner, using adequate help if violent behavior occurs. Hold client if necessary. Tell client to STOP behavior.
Rationale: Removal to a quiet environment can help calm client. Sufficient help will prevent injury to client/staff. Usually the individual is being selfcritical and afraid of hostility and does not need external criticisms. Saying “Stop” may be enough to allow client to regain control.

10. Administer medications, as indicated.
Rationale: Antipsychotic/antianxiety drugs may decrease anxiety and delusional thinking, decreasing suspicious thoughts/aggressive behaviors and aiding client in maintaining control.

NCP Conduct Disorder | Nursing Care Plan

schizo_me86@yahoo.com — Sat, 21 Jan 2012 09:51:00 +0000

Conduct disorder is most distinguishable by the degree of repetitive and persistent violation of the basic rights of others. Common antisocial behaviors acted out in the home and school setting include physical aggression toward people and animals, destruction of property, lying, and theft. There is a total disregard for age-appropriate social norms as the child purposely engages in criminals acts, truancy from school, and breaking curfew. The DSM-IV criteria rates the level of severity as mild, moderate, to severe. The greater the level of delinquency and frequency in early childhood, the greater the risk for chronic offending into adulthood. Other prognostic factors leading to the continuation of the disorder include age of onset and the variation in problem behaviors displayed in multiple settings. Co-morbid diagnoses often associated with this condition are hyperactivity, depression, and chemical abuse and dependence.

DSM-IV
312.XX Conduct disorder
312.81 Childhood-onset type
312.82 Adolescent-onset type

ETIOLOGICAL THEORIES
Psychodynamics
According to psychoanalytical theory, these children are fixated in the separation-individuation phase of development. The mother figure projects her view of the child’s needs as an unrealistic demand on her. The child cannot solidify attachment with the maternal object and compensates for the mother’s narcissistic need for gratification by overidealizing the image of the mother. The child fails to build up identification and differentiation between self and others to support sufficient superego development. The id behavior is prominent.

Biological
Temperamental abnormalities have been observed in infants at birth in terms of excitability, attention span, and adaptability. Heredity influences such traits as the tendency to seek risks and obey authority. One possibility is the biological influence of heightened arousal in the CNS and abnormally high levels of testosterone, leading to aggression. Differences in the lack of sufficient serotonin transmission is evidenced.

Current research suggests that negative experiences in infancy cause biological and neurological damage to the brain tissue. When persistent stress results in an internal perception of a constant state of danger, the “fight-or-flight” hormones (adrenaline and cortisol) are released, reaching dangerously high levels that can cause neurological impairment. These damaged brain cells react in unusual ways to the stimuli, possibly resulting in epileptic seizures or depression.

Family Dynamics
Certain family patterns contribute to the disruptive behavior. A high correlation exists between chronic conflict and neglect in the parent–child relationship. Poor parental management skills, inconsistent or rigid and harsh discipline practices increase the risk for acting out by the child. Changes in caretakers, unstable spousal relationships, and parental rejection are all contributing/causal factors. These children lack strong emotional bonds or reliable role models to promote prosocial behavior. Socioeconomic conditions may also play a part, with poverty being a risk factor.

NURSING PRIORITIES
1. Provide a safe environment and protect client from self-harm.
2. Promote development of strategies that regulate impulse control, regain sense of self-worth and security.
3. Facilitate learning of appropriate and satisfying methods of dealing with stressors/feelings.
4. Promote client’s ability to engage in satisfying relationships with family members and peer group.
5. Increase the client’s behavioral response repertoire.

DISCHARGE GOALS
1. Exhibits effective coping skills in dealing with problems.
2. Understands need and strategies for controlling negative impulses/acting-out behaviors.
3. Expresses anger in appropriate/nonviolent ways.
4. Family involved in group therapy; participating in treatment program.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for Conduct Disorder: Risk for VIOLENCE, directed at self/others may be related to Retarded ego development; loss of self-esteem; antisocial character; Dysfunctional family system and loss of significant relationships; feelings of rejection, sense of powerlessness; Poor impulse control; History of suicidal/acting-out behavior possibly evidenced by Behavior changes (e.g., absenteeism, poor grades, hostility toward authority figures, stealing); Increased motor activity, increasing anxiety level, anger; Overt aggressive acts directed at the environment; Self-destructive behavior, active suicidal threat/gestures.

Desired Outcomes and Goal:
1. Verbalize understanding of behavior and factors that precipitate violent actions.
2. Express anger in appropriate ways, avoiding hostile or suicidal gestures/statements or harm to self or others.
3. Demonstrate self-initiated intervention strategies that facilitate more effective coping skills.
4. Identify and use resources and support systems in an effective manner.

Nursing intervention with rationale:
1. Establish trusting relationship with client. Encourage exploration and verbalization of feelings.
Rationale: Client’s expression of internal conflicts, in words rather than action, will more likely be made to knowledgeable and accepting staff.

2. Strike a balance in the intimacy of the therapeutic relationship.
Rationale: Children who are more disturbed respond best to a less-intrusive relationship in the beginning.

3. Monitor stressors and warning signals such as behavior changes, anger, anxiety, and recently disrupted family.
Rationale: Impulsive reactions to stressful situations, directed toward harm to self or others, may be a cry for help.

4. Observe/assist client to recognize mood (e.g., anger, sadness, anxiety).
Rationale: Identifying own feelings is the first step in the change process. Signs and symptoms of anxiety need to be identified before client can begin to make constructive changes.

5. Identify antecedents to violent behavior.
Rationale: Correct assessment and interpretation of premonitory conditions provide for timely intervention to reduce risk of violent/acting-out behavior.

6. Determine seriousness of suicidal tendency, gestures, threats, or previous attempts. (Use scale of 1–10 and prioritize according to severity of threat, availability of means.)
Rationale: Knowledge of past and present behavior in reference to suicidal ideation will assist in assessing client’s tolerance for stress, degree of concern. Note: This may be first-priority nursing diagnosis if suicide risk is rated in the 8–10 range.

7. Explore and offer more satisfying alternatives to aggressive behavior (e.g., physical outlets for redirection of angry feelings; use of quiet room, or “Soft Spot” with soft balls/pillows to pound).
Rationale: Increased ability to discover satisfying alternatives in coping with stressors will decrease need for aggressive behavior. Physical outlets help relieve pent-up tension and anxiety.

8. Engage in action-oriented recreational therapy (e.g., exercise activities [jogging in the gym, etc.], outdoor program, wall climbing, noncompetitive games/supervised sports).
Rationale: Recreational therapy helps discharge nervous, pent-up energy, releasing tension and reducing anxiety. Sustained activity stimulates release of endorphins, enhancing sense of well-being. Formal exercise therapy programs are an adjunct to psychotherapy, decreasing symptoms related to anxiety, depression, and thought disturbances. Exercise does not need to be aerobic or intensive to achieve desired effect. Note: Competitive games may increase anxiety.

9. Place in seclusion or apply restraints as necessary.
Rationale: External restraints may be needed until client regains control of own behavior.

10. Administer/supervise medications and monitor effects of therapy.
Rationale: Helps client to maintain impulse control. Neuroleptic medications decrease aggressive outbursts and improve impulse control.

NCP Borderline Personality Disorder | Nursing Care Plan

schizo_me86@yahoo.com — Sat, 21 Jan 2012 08:30:00 +0000

“Borderline” has been used to identify clients who seem to fall on the border between the standard categories of neuroses or psychoses. The term has been refined to indicate a client with a pervasive pattern of instability of interpersonal relationships, self-image, affect, and control over impulses beginning in early adulthood, and includes such factors as feelings of abandonment, impulsivity, reactivity of mood, chronic feelings of emptiness, and problems with anger.

DSM-IV
301.83 Borderline personality disorder

ETIOLOGICAL THEORIES
Psychodynamics
Unconscious processes that are believed to shape personality are set in motion by drives or instincts that are then influenced by conflicts among them as well as instinctual wishes and demands of reality. Defensive maneuvers are unconsciously developed to protect against anxiety arising from this conflict. This personality is seen as a painstaking but poorly constructed defense.

It is also seen as resulting from a fixation of libido at stages of psychosexual development associated with certain body parts. Although it is difficult to agree on how personality is formed, severe personality disorders are believed to begin early in childhood and milder forms are thought to be influenced by factors during later development.

Biological
Personality is believed to have a hereditary basis known as “temperament” and biological dispositions that affect mood and level of activity (e.g., cranky, placid, self-contained, outgoing, impulsive, cautious). There is little agreement about how this affects the development of personality disorders.

Family Dynamics
The child’s social environment, particularly that within the family, is assumed to be the main force that shapes personality. The theory of object relations provides a basis for personality development and an explanation of the dynamics that manifest the borderline characteristics. The individual with borderline personality may be fixed in the rapprochement phase of development (18–25 months of age). In this phase, the child is experiencing increasing autonomy, while still requiring “emotional refueling” from the mothering figure. Because the mother feels threatened by the child’s efforts at independence, she strives to keep the child dependent. Nurturing and emotional support become bargaining tools. They are withheld when the child exhibits independent behaviors and are used as rewards for clinging, dependent behaviors. This engenders a deep fear of abandonment in the child that persists into adulthood as the child continues to view objects (people) as parts—either good or bad. This is called “splitting,” which is the primary dynamic of borderline personality.

Current studies suggest that borderline personality disorders are strongly associated with a history of physical or sexual abuse by family members, and incest may be a major reason for the disproportionate ratio (2:1) of female clients.

NURSING PRIORITIES
1. Limit aggressive behavior; promote socially acceptable responses.
2. Encourage assertive behaviors to attain sense of control.
3. Assist client to learn healthy ways of controlling anxiety/developing positive self-concept.
4. Promote development of effective coping skills.
5. Help client learn alternate, constructive methods of interacting with others.

DISCHARGE GOALS
1. Impulsive behavior(s) recognized and controlled.
2. Establishes goals and asserts control over own life.
3. Problem-solving techniques used constructively to resolve conflicts.
4. Interacts with others in socially appropriate manner.
5. Client/family involved in behavioral therapy/support programs.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for Borderline Personality Disorder: Risk for VIOLENCE, directed at self or others and Risk for SELF MUTILATION may be related to Use of projection as a major defense mechanism; Pervasive problem with negative transference; Feelings of guilt/need to “punish” self, distorted sense of self
Inability to cope with increased psychological/physiological tension in a healthy manner possibly evidenced by Vulnerable self-esteem; Easily agitated, angry when frustrated (may become assaultive); Provocative behavior: argumentative, dissatisfied, overreactive, hypersensitive; use of unprovoked anger, hostility toward others; Choice of maladjusted ways of getting needs met (e.g., splitting, projection, provocation, depression); Self-mutilative acts; substance abuse.

Desired Outcomes and Goal:
1. Verbalize understanding of why behavior occurs.
2. Recognize precipitating factors.
3. Demonstrate self-control, using appropriate, assertive coping skills.
4. Clarify feelings of negative transference and eliminate the use of projection.

Nursing intervention with rationale:
1. Establish therapeutic nurse/client relationship. Maintain a firm, consistent approach.
Rationale: Building rapport and trust is imperative, although

2. Determine negative transference feelings and clarify the actual source of anger, hostility.
Rationale: Heightens self-awareness of these feelings to assist with resolution.

3. Help identify how much anger is “elicited” by significant other(s) and how much results from own unresolved feelings.
Rationale: Becoming aware of the use of projection helps break this maladjusted pattern. Note: Feelings of anger and hostility, not depression, are more often the basis for destructive behaviors/suicidal acts.

4. Intervene immediately in a nondefensive manner when acting-out occurs. Set firm, consistent limits.
Rationale: Intervention is critical to prevent dangerous situation for client or others. Therapeutic milieu helps client manage self and develop self-control. Environmental safety provides external control until internal control is regained.

5. Make an agreement or “no harm” contract to discuss angry or hurt feelings when they begin, instead of “internalizing” and displacing anger/ hurt onto others and acting on the feelings.
Rationale: Agreeing not to engage in violent behaviors involving self, others, or property promotes safety and enhances feelings of self-worth by having client assume control of own behavior. Helps client learn to work through feelings as they occur, to prevent intensification and promote resolution.

6. Determine prior suicidal gestures/attempts. Evaluate seriousness of suicidal expressions/ideation. Use scale of 1–10 and prioritize according to seriousness of threat, availability of means, timing of previous attempts, current age.
Rationale: It is important to take suicidal threats seriously, listening carefully to underlying messages and providing a safe environment to prevent client from following through on plan, especially when scale is in upper range. Note: Risk of suicide completion is highest during first few years after initial presentation, declining as client ages.

7. Provide close supervision, as indicated.
Rationale: Allows for early recognition of escalating behavior and timely intervention.

8. Provide care for client’s wounds, if self-mutilation occurs, in a matter-of-fact manner. Do not offer sympathy or provide additional attention.
Rationale: Additional attention and sympathy can provide positive reinforcement for the maladaptive behavior and may encourage its repetition. A matter-of-fact attitude can convey empathy/concern.

9. Have client participate in group therapy sessions with feedback given by peers.
Rationale: Group setting aids in promoting diffusion of anger; provides insight as to how negative, aggressive behaviors affect others, making feedback easier to digest.

10. Administer medication as indicated, e.g., carbamazepine (Tegretol), tranylcypromine (Parnate).
Rationale: May reduce frequency of impulsive/self destructive acts while other therapeutic interventions are initiated.

Bipolar Disorders Care Plan Nursing Care Plan (NCP)

schizo_me86@yahoo.com — Fri, 20 Jan 2012 09:00:00 +0000

Bipolar disorders are characterized by recurrent mood swings of varying degree from depression to elation with intervening periods of normalcy. Milder mood swings such as cyclothymia may be manifested or viewed as everyday creativity rather than an illness requiring treatment. Hypomania can actually enhance artistic creativity and creative thinking/ problem-solving.

This plan of care focuses on treatment of the manic phase. (Note: Bipolar II disorder is characterized by periods of depression and hypomania, but without manic episodes.)

DSM-IV
296.xx Bipolar I disorder
296.0x Single manic episode
296.40 Most recent episode hypomanic
296.4x Most recent episode manic
296.6x Most recent episode mixed
296.7 Most recent episode unspecified
296.5x Most recent episode depressed
296.89 Bipolar II disorder (recurrent major depressive episodes with hypomania)
301.13 Cyclothymic disorder
296.80 Bipolar disorder NOS

ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory explains the cyclic behaviors of mania and depression as a response to conditional love from the primary caregiver. The child is maintained in a dependent position, and ego development is disrupted. This gives way to the development of a punitive superego (anger turned inward or depression) or a strong id (uncontrollable impulsive behavior or mania). In the psychoanalytical model, mania is viewed as the mirror image of depression, a “denial of depression.”

Biological
There is increasing evidence to indicate that genetics plays a strong role in the predisposition to bipolar disorder. Research suggests a combination of genes may create this predisposition. Incidence among relatives of affected individuals is higher than in the general population. Biochemically there appear to be increased levels of the biogenic amine norepinephrine in the brain, which may account for the increased activity of the manic individual.

Family Dynamics
Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is interrupted and the child withdraws from people and the environment. Rejection by parents in childhood or spending formative years with a family that sees life as hopeless and has a chronic expectation of failure makes it difficult for the individual to be optimistic. The mother may be distant and unloving, the father a less powerful person, and the child expected to achieve high social and academic success.

NURSING PRIORITIES
1. Protect client/others from the consequences of hyperactive behavior.
2. Provide for client’s basic needs.
3. Promote reality orientation, realistic problem-solving, and foster autonomy.
4. Support client/family participation in follow-up care/community treatment.

DISCHARGE GOALS
1. Remains free of injury with decreased occurrence of manic behavior(s).
2. Balance between activity and rest restored.
3. Meeting basic self-care needs.
4. Communicating logically and clearly.
5. Client/family participating in ongoing treatment and understands importance of drug
therapy/monitoring.
6. Plan in place to meet needs after discharge.

Nursing diagnosis of Bipolar Disorders: TRAUMA, risk for/VIOLENCE, risk for directed at others may be related to Emotional difficulties; irritability and impulsive behavior; delusional thinking; angry response when ideas are refuted/wishes denied; Manic excitement; History of assaultive behavior possibly evidenced by Body language, increased motor activity; Difficulty evaluating the consequences of own actions; Overt and aggressive acts; hostile, threatening verbalizations.

Desired Outcome:

1. Demonstrate self-control with decreased hyperactivity.
2. Acknowledge why behavior occurs.
3. Verbalize feelings (anger, etc.) in an appropriate manner.
4. Use problem-solving techniques instead of violent behavior/threats or intimidation.

Nursing intervention and rationale:
1. Decrease environmental stimuli, avoiding exposure to areas or situations of predictable high stimulation and removing stimulation from area if client becomes agitated.
Rationale: Client may be unable to focus attention on only relevant stimuli and will be reacting/responding to all environmental stimuli.

2. Continually reevaluate client’s ability to tolerate frustration and/or individual situations.
Rationale: Facilitates early intervention and assists client to manage situation independently, if possible.

3. Provide safe environment, removing objects and rearranging room to prevent accidental/purposeful injury to self or others.
Rationale: Grandiose thinking (e.g., “I am Superman”) and hyperactive behavior can lead to destructive actions such as trying to run through the wall/into others.

4. Intervene when agitation begins to develop, with strategies such as being verbally direct, prompting more effective behavior, redirecting or removing from the provoking situation, voluntary “Time out” in room or a quiet place, physical control (e.g.,holding).
Rationale: Intervention at earliest sign of agitation can assist client in regaining control, preventing escalation to violence and allowing treatment in least restrictive manner.

5. Defer problem-solving regarding prevention of violence and information collection about precipitating or provoking stimuli until agitation/ irritability is diminished (e.g., no “why,” analytical questions).
Rationale: Questions regarding prevention increase frustration because agitation decreases ability to analyze situation.

6. Communicate rationale for staff action in a concrete manner.
Rationale: Agitated persons are unable to process complicated communication.

7. Provide information regarding more independent and alternative problem-solving strategies when client is not labile or irritable.
Rationale: Improves retention, as agitated person will not be able to recall or use strategies discussed.

8. Analyze any violent incidents with involved staff/ observers, identifying antecedents or provoking situations, client indicators of increasing agitation, client response(s) to intervention attempted, etc.
Rationale: Information is used to develop individualized and proactive interventions based on experience.

9. Provide seclusion and/or restraint (according to agency policy).
Rationale: May be required for brief period when other measures fail to protect client, staff, or others.

10. Prepare for electroconvulsive therapy as indicated.
Rationale: ECT may be required in presence of severe manic decompensation, when client does not tolerate/fails to respond to lithium or other drug treatments.

NCP ADHD | Nursing Care Plan

schizo_me86@yahoo.com — Fri, 20 Jan 2012 08:30:00 +0000

Attention deficit hyperactivity disorder is associated with inattentive, impulsive, and hyperactive behavior that is maladaptive and inconsistent with developmental level. This behavior creates clinically significant impairment in social/academic functioning. Accurate diagnosis is difficult, as symptoms resemble depression, learning disabilities, or emotional problems. The diagnosis is made through extensive observation of the child’s behavior; however, contact with health professionals is limited and the child’s activity may be misleading during short office visits. Reports from parents and teachers are often used to make the diagnosis, and their observations may be distorted, as they assume a problem exists and often predetermine the diagnosis themselves.

DSM-IV
314.00 ADHD predominantly inattentive type
314.01 ADHD predominantly hyperactive-impulsive type
314.01 ADHD combined type
314.9 ADHD NOS

ETIOLOGICAL THEORIES
Psychodynamics
The child with this disorder has impaired ego development. Ego development is retarded and manifested impulsive behavior represents unchecked id impulses, as in severe temper tantrums. Repeated performance failure, failure to attend to social cues, and limited impulse control reinforce low self-esteem. Some theories suggest that the child is fixed in the symbiotic phase of development and has not differentiated self from mother.

Genetic/Biological
The disorder may be gender-linked as the incidence is higher in boys than in girls (3:1). ADHD is also more prevalent among children whose siblings have been diagnosed with the same disorder. Recent studies have established that the fathers of hyperactive children are more likely to be alcoholic or to have antisocial personality disorders. Affected children have shown the presence of subtle chromosomal changes and mild neurological deficits with irregular brain function including too little activity in the area that inhibits impulsiveness. Hyperactivity may result from fetal alcohol syndrome, congenital infections, and brain damage resulting from birth trauma or hypoxia. Cognitive distractibility and impulsivity are associated with other disorders involving brain damage or dysfunction, such as mental retardation, seizure disorder, and brain lesions.

Physiological conditions that can mimic the symptoms include constipation, hypoglycemia, lead toxicity, and thyroid and other metabolic diseases.

Family Dynamics
This theory suggests that disruptive behavior is learned as a means for a child to gain adult attention. It is likely that whether or not the impulsive irritability seen in individuals with ADHD was present from birth, some parental reactions tend to reinforce and thus maintain or increase its intensity. Anxiety generated by a dysfunctional family system, marital problems, and so forth, could also contribute to symptoms of this disorder. Parents become frustrated with the child’s poor response to limit-setting. Parents may become overly sensitive or may give up and provide no external structure.

NURSING PRIORITIES
1. Facilitate child’s achievement of more consistent behavioral self-control and improvement in selfesteem.
2. Promote parents’ development of effective means of coping with and interventions for their child’s behavioral symptoms.
3. Participate in the development of a comprehensive, ongoing treatment approach using family and community resources.

Nursing diagnosis for attention deficit hyperactivity disorder (ADHD): SOCIAL INTERACTION, impaired may be related to retarded ego development; low self-esteem; dysfunctional family system, negative role models; abuse/neglect; neurological impairment; mental retardation possibly evidenced by discomfort in social situations; Difficulty waiting turn in games or group situations; interrupts or intrudes on others; Does not seem to listen to what is being said; Difficulty playing quietly, maintaining attention to task or play activity; often shifts from one activity to another.

Desired Outcome:
1. Identify feelings that lead to poor social interactions.
2. Participate appropriately in interactive play with another child or group of children.
3. Develop a mutual relationship with another child or adult.

Nursing intervention with rationale:
1. Develop trust relationship with child, show of child separate from unacceptable behavior.
Rationale: Acceptance and trust encourage feelings of self acceptance worth.

2. Encourage client to verbalize feelings of inadequacy and need for acceptance from others. Discuss how these feelings affect relationships by provoking defensive behaviors such as blaming and manipulating others.
Rationale: Recognition of problem is first step toward resolution.

3. Offer positive reinforcement for appropriate social interaction. Ignore ineffective methods of relating to others; teach competing behaviors.
Rationale: Behavior modification can be an effective method of reducing disruptive behaviors in children by encouraging repetition of desirable behaviors. Attention to unacceptable behavior may actually reinforce it.

4. Identify situations that provoke defensiveness and role-play more appropriate responses.
Rationale: Provides confidence to deal with difficult situations when they occur.

5. Provide opportunities for group interaction and encourage a positive and negative peer feedback system.
Rationale: Appropriate social behavior is often learned from age-mates.

6. Arrange staffings with other professionals (e.g., social workers, teachers). Include parents and child when possible.
Rationale: Cooperation and coordination among those working with these children enhance treatment program. Including child and parents provides them with understanding of the total problem and proposed treatment program.

NCP Antisocial Personality Disorder | Nursing Care Plan

schizo_me86@yahoo.com — Thu, 19 Jan 2012 23:37:00 +0000

“Sociopath” and “psychopath” are terms often used to describe the individual with antisocial personality. As deceit and manipulation are central features of the disorder, it is extremely difficult to treat. Imprisonment has been society’s major method for controlling the most dangerous behaviors.

DSM-IV
301.7 Antisocial personality disorder

ETIOLOGICAL THEORIES
Psychodynamics
Psychodynamically, this individual remains fixed in an earlier level of development. Because of parental rejection or indifference, needs for satisfaction and security remain unmet, and the ego is underdeveloped. Because of a lack of ego strength, behavior is id directed and results in the need for immediate gratification. An immature superego allows this individual to pursue gratification, regardless of means and without experiencing feelings of guilt.

Biological
Genetic involvement has been implicated in studies that showed that individuals with antisocial personality, and their parents, showed excessive EEG abnormalities when these examinations were conducted on both groups. Some research suggests that a variant of the D4 dopamine receptor gene (D4DR) appears more frequently in individuals who report high levels of “novelty seeking.” People scoring high on this characteristic are often judged to be excitable, quick-tempered, and seek out thrilling sensations/situations—features associated with antisocial personality disorder. However, no clear effect on personality has been demonstrated at this time. (Despite genetic or environmental factors, sociopaths choose their lifestyle; therefore, it is up to them to choose to change it.)

Family Dynamics
Family functioning has been implicated as an important factor in determining whether or not an individual develops this disorder. The following circumstances may predispose to the disorder: absence of parental discipline (teaching/guidance), extreme poverty, removal from the home, growing up without parental figures of both sexes, erratic and inconsistent limit-setting, being “rescued” each time the person is in trouble (never having to suffer the consequences of own behavior), and maternal deprivation.

NURSING PRIORITIES
1. Limit aggressive behavior; promote socially acceptable responses.
2. Develop a trusting relationship.
3. Assist client to learn healthy ways to deal with anxiety.
4. Increase sense of self-worth.
5. Promote development of alternate, constructive methods of interacting with others.

DISCHARGE GOALS
1. Self-control maintained.
2. Assertive behaviors used to gain desired responses.
3. A trusting relationship initiated.
4. Anxiety recognized and diminished/managed.
5. Client/family involved in ongoing therapy/support groups.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for Antisocial Personality Disorder: VIOLENCE, risk for, directed at others may be related to contempt for authority/rights of others (antisocial character), inability to tolerate frustration; need for immediate gratification; easy agitation, vulnerable self-esteem; inability to verbalize feelings, use of maladjusted coping mechanisms including substance, and negative role modeling; suspiciousness of others use possibly evidenced by body language (muscle tension, facial expression, rigid posture); increased motor activity, irritability, agitation; hostile, threatening verbalizations (boasting of prior abuse of others); possession of destructive means; becoming assaultive when angry; choice of aggression to meet needs; overt and aggressive acts; substance abuse.

Desired Outcome
1. Verbalize understanding of why behavior occurs, its consequences, and how it affects outcome(s).
2. Develop and use assertive/nonaggressive, socially acceptable behaviors to gratify needs and interact with others.
3. Demonstrate self-control as evidenced by relaxed posture and manner.

Nursing intervention with rationale:
1. Convey accepting attitude toward client. Work on development of trust. Be honest, keep all promises, and convey message that the behavior, not the client, is unacceptable.
Rationale: Feelings of rejection are undoubtedly familiar to client. An attitude of acceptance promotes feelings of self-worth. Trust is the basis of a therapeutic relationship. Note: Major obstacles in working with this client lie in an inherent inability to form a trusting, open relationship with a therapist.

2. Maintain low level of stimuli in client’s environment (low lighting, few people, simple decor, low noise level).
Rationale: A stimulating environment may increase agitation and promote aggressive behavior.

3. Provide structured environment, set firm limits (e.g., consistent schedule, ward rules, expectations of the client for cooperating. Involve client in process and follow through with consequences).
Rationale: Individuals with antisocial personality disorder often function better in a controlled setting. Structure discourages escalation of aggressive behaviors and facilitates therapeutic intervention by reducing the anxiety caused by ambiguity.

4. Encourage verbalization of feelings and provide outlet for expression.
Rationale: Increases client’s self-awareness of feelings and stressors.

5. Note distortions of the truth, manipulation. Confront client with these behaviors in a calm but firm manner, pointing out discrepancies in statements and behaviors.
Rationale: Confronting unacceptable behaviors helps to increase client’s awareness of own feelings and the effect these feelings and behaviors have on others.

6. Monitor escalating behaviors (e.g., increased psychomotor activity, threats, attempts to intimidate). Isolate if observed to be losing control.
Rationale: Client can become dangerous very quickly with or without provocation. Early detection provides opportunity to alter behavior before violence occurs.

7. Be aware of prior history of violent behavior, seriousness of homicidal tendency, gestures, threats. (Use scale 1–10 and prioritize according to severity of threat, availability of means.)
Rationale: Therapist needs to be aware of client’s style of acting and behaviors to provide a safe environment and protect client and others.

8. Remain calm and non-aggressive in communicating with client. Avoid responding to client’s verbal hostility with anger.
Rationale: Anger is released through others. Not responding to client’s anger breaks cycle, providing opportunity for change.

9. Review with client the benefits of using assertive behaviors and the consequences of aggression. Ask client to identify situations when aggression was used and discuss/role-play alternate methods for handling those situations.
Rationale: Consequences serve as the best motivation for changing behavior. Client needs a rehearsed plan of action to aid in handling situations differently.

10. Encourage client to engage in healthy outlets for anger (e.g., telling other person in an assertive manner, use of large motor skill activities/relaxation techniques).
Rationale: Developing new ways of reacting is essential to breaking the maladaptive pattern of responding.

Anorexia Nervosa | Bulimia Nervosa Nursing Care Plan

schizo_me86@yahoo.com — Thu, 19 Jan 2012 23:19:00 +0000

Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a
morbid fear of obesity. Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating, followed by self-induced vomiting. It may include abuse of laxatives and diuretics. Binge-eating is defined as recurrent episodes of overeating associated with subjective and behavioral indicators of impaired control over and significant distress about the eating behavior but without the use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise).

DSM-IV
307.1 Anoxexia nervosa
307.51 Bulimia nervosa
307.50 Eating disorders NOS
Binge-eating disorder (proposed, requiring further study)

ETIOLOGICAL THEORIES
Psychodynamics
The individual reflects a developmental arrest in the very early childhood years. The tasks of trust, autonomy, and separation-individuation are unfulfilled, and the individual remains in the dependent position. Ego development is retarded. Symptoms are often associated with a perceived loss of control in some aspect of life and may center on fears of sexual maturity/intimacy. Although these disorders affect women primarily, approximately 5% to 10% of those afflicted are men. Additionally, eating disorders are often associated with depression, anxiety, phobias, and cognitive problems.

Biological
These disorders may be caused by neuroendocrine abnormalities within the hypothalamus. Symptoms are linked to various chemical disturbances normally regulated by the hypothalamus. Furthermore, a physiological defect may make it difficult for the individual to interpret sensations of hunger and fullness.

Family Dynamics
Issues of control become the overriding factors in the family of the client with an eating disorder. These families often consist of a passive father, a domineering mother, and an overly dependent child. There is a high value placed on perfectionism in this family, and the child believes she or he must please others and satisfy these standards.

NURSING PRIORITIES
1. Reestablish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist client to develop realistic body image/improve self-esteem.
4. Provide support/involve SO, if available, in treatment program to client/SO.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment.

DISCHARGE GOALS
1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.

Nursing diagnosis of Anorexia Nervosa and Bulimia Nervosa: NUTRITION: altered, less than body requirements may be related to inadequate food intake; self-induced vomiting and chronic/excessive laxative use possibly evidenced by body weight 15% (or more) below expected (anorexia), or may be within normal range (bulimia, binge-eating), pale conjunctiva and mucous membranes; poor skin turgor/muscle tone, edema, excessive loss of hair; increased growth of body hair (lanugo), amenorrhea, hypothermia, bradycardia, cardiac irregularities, hypotension, electrolyte imbalances.

Desired Outcome:
1. Verbalize understanding of nutritional needs.
2. Establish a dietary pattern with caloric intake adequate to regain/maintain appropriate weight.
3. Demonstrate weight gain toward expected goal range.

Nursing intervention with rationale:
1. Establish a minimum weight goal and daily nutritional requirements.
Rationale: Malnutrition is a mood-altering condition leading to depression and agitation and affecting cognitive functioning/decision-making. Improved nutritional status enhances thinking ability, and psychological work can begin.

2. Involve client with team in setting up/carrying out program of behavior modification. Provide reward for weight gain as individually determined; ignore loss.
Rationale: Provides structured eating stimulation while allowing client some control in choices. Behavior modification may be effective only in mild cases or for short-term weight gain. Note: Combination of cognitive-behavioral approach is preferred for treating bulimia.

3. Use a consistent approach. Sit with client while eating; present and remove food without persuasion and/or comment. Promote pleasant environment and record intake.
Rationale: Client detects urgency and reacts to pressure. Any comment that might be seen as coercion provides focus on food. When staff member responds consistently, client can begin to trust her or his responses. The single area in which client has exercised power and control is food/eating, and she or he may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games.

4. Provide smaller meals and supplemental snacks, as appropriate.
Rationale: Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: Client may feel bloated for 3–6 weeks while body readjusts to food intake.

5. Make selective menu available and allow client to control choices, as much as possible.
Rationale: Client who gains self-confidence and feels in control of environment is more likely to eat preferred foods.

6. Be alert to choices of low-calorie foods/beverages; hoarding food; disposing of food in various places such as pockets or wastebaskets.
Rationale: Client will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.

7. Maintain a regular weighing schedule, such as Monday/Friday before breakfast in same attire, on same scale, and graph results.
Rationale: Provides accurate ongoing record of weight loss/gain. Also diminishes obsessing about changes in weight.

8. Weigh with back to scale (depending on program protocols).
Rationale: Although some programs prefer client to see the results of weighing, this approach can force the issue of trust in client who usually does not trust others.

9. Consult with dietitian/nutritional therapy team.
Rationale: Helpful in determining individual dietary needs and appropriate sources. Note: Insufficient calorie and protein intake can lower resistance to infection and cause constipation, hallucinations, and liver damage.

10. Transfer to acute medical setting for nutritional therapy, when condition is life-threatening.
Rationale: The underlying problem cannot be cured without improved nutritional status. Hospitalization provides a controlled environment in which food intake, vomiting/elimination, medications, and activities can be monitored. It also separates the client from SO(s) and provides exposure to others with the same problem, creating an atmosphere for sharing.

Nursing Care Plan | NCP Adjustment Disorders

schizo_me86@yahoo.com — Wed, 18 Jan 2012 23:27:00 +0000

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 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.

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

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.

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 for Adjustment Disorder: Anxiety 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:

1. Verbalize awareness of feelings of/indicators of increasing anxiety.
2. Demonstrate/use appropriate techniques to interrupt escalation of anxiety.
3. Appear relaxed and report anxiety is reduced to a manageable level.

Nursing intervention with rationale:
1. Establish a therapeutic nurse/client relationship. Be honest, consistent in responses, and available. Show genuine positive regard.
Rationale: Honesty, availability, and unconditional acceptance promote trust, which is necessary for the development of a therapeutic relationship.

2. Provide activities geared toward reduction of tension and decreasing anxiety (e.g., walking or jogging, musical exercises, housekeeping chores, group games/activities).
Rationale: Tension and anxiety can be released safely, and physical activity may provide emotional benefit to the client through release in the brain of morphine like substances (endorphins) that promote sense of well-being.

3. Encourage client to identify true feelings and to acknowledge ownership of those feelings.
Rationale: Anxious clients often deny a relationship between emotional problems and their anxiety. Use of the defense mechanisms of projection and displacement are exaggerated.

4. Maintain a calm atmosphere and approach to client.
Rationale: Can help to limit transmission of anxiety to/from client.

5. Assist client to recognize specific events that precede onset of elevation in anxiety. Provide information about signs and symptoms of increasing anxiety and ways to intervene before behaviors become disabling.
Rationale: Recognition of precipitating stressors and a plan of action to follow should they recur provides client with feelings of security and control over similar situations in the future. This in itself may help to control anxiety response.

6. Offer support during times of elevated anxiety. Provide physical and psychological safety.
Presence of a trusted individual may provide needed security/client safety.

7. Administer medications as necessary, e.g., benzodiazepines: alprazolam (Xanax).
Rationale: Antianxiety medications induce a calming effect and work to maintain anxiety at a manageable level while providing the opportunity for client to develop other ways to manage stress.

Other NANDA diagnosis of Adjustment Disorder: VIOLENCE, risk for, directed at self/others; COPING, INDIVIDUAL, ineffective; ADJUSTMENT, impaired [when stressor is a change in health status]; GRIEVING, dysfunctional; HOPELESSNESS; SELF ESTEEM disturbance; SOCIAL INTERACTION, impaired; FAMILY PROCESSES, altered

Nursing Care Plan | NCP Stage III of Labor Placental Expulsion

schizo_me86@yahoo.com — Wed, 18 Jan 2012 13:00:00 +0000

Stage III of labor begins with the birth of the baby and is completed with placental separation and expulsion. Lasting anywhere from 1–30 min, with an average length of 3–4 min in the nullipara, and 4–5 min in the multipara, this stage is the shortest. Careful management and monitoring are necessary, however, to prevent short- and long term negative outcomes.

NURSING PRIORITIES
1. Promote uterine contractility.
2. Maintain circulating fluid volume.
3. Promote maternal and newborn safety.
4. Support parental-infant interaction.

Nursing diagnosis of Placental Expulsion: Risk for Fluid Volume Deficit may be related to lack/restriction of oral intake, vomiting, diaphoresis, increased insensible water loss, uterine atony, lacerations of the birth canal, retained placental fragments

Desired Outcomes:
1. Display BP and heart rate WNL, palpable pulses.
2. Demonstrate adequate contraction of the uterus with blood loss WNL.

Nursing intervention with rationale:
1. Instruct the client to push with contractions; help direct her attention toward bearing down.
Rationale: Client attention is naturally on the newborn; in addition, fatigue may affect individual efforts, and she may need help in directing her efforts toward assisting with placental separation. Bearing down helps promote separation and expulsion, reduces blood loss, and enhances uterine contraction.

2. Assess vital signs before and after administering oxytocin.
Rationale: Hypertension is a frequent side effect of oxytocin.

3. Palpate uterus; note “ballooning.”
Rationale: Suggests uterine relaxation with bleeding into uterine cavity.

4. Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature). (Refer to CP: Postpartal Hemorrhage.)
Rationale: Hemorrhage associated with fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability,

5. Place infant at client’s breast if she plans to breastfeed.
Rationale: Suckling stimulates release of oxytocin from the posterior pituitary, promoting myometrial contraction and reducing blood loss.

6. Massage uterus gently after placental explusion.
Rationale: Myometrium contracts in response to gentle tactile stimulation, thereby reducing lochial flow and expressing blood clots.

7. Record time and mechanism of placental separation; i.e., Duncan’s mechanism (placenta separates from the inside to outer margins) versus Schulze’s mechanism (placenta separates from outer margins inward).
Rationale: Separation should occur within 5 min after birth. The Duncan’s mechanism of separation carries increased risk of retained fragments, necessitating close inspection of the placenta. Failure to separate may require manual removal. The more time it takes for the placenta to separate, and the more time in which the myometrium remains relaxed, the greater the blood loss.

8. Inspect maternal and fetal surfaces of placenta. Note size, cord insertion, intactness, vascular changes associated with aging, and calcification (which possibly contributes to abruption).
Rationale: Helps detect abnormalities that may have an impact on maternal or newborn status.

9. Administer oxytocin (Pitocin) through IM route, or dilute IV drip in electrolyte solution, as indicated. IM methylergonovine maleate (Methergine) or prostaglandins may be given at the same time.
Rationale: Promotes vasoconstrictive effect within the uterus to control postpartal bleeding after placental explusion. IV bolus may result in maternal hypertension. Water intoxication may occur if electrolyte-free solution is used. Note: Methergine is contraindicated in presence of hypertension/ hypotension.

10. Elevate fundus by dipping fingers down behind and moving uterine body up away from symphysis pubis.
Rationale: May be requested by practitioner to facilitate internal examination.

Nursing Care Plan | NCP Preterm Infant

schizo_me86@yahoo.com — Wed, 18 Jan 2012 10:04:00 +0000

Any infant born prior to completing 37 weeks’ gestation is identified as premature. Thus, the level of
development and maturity, and often the degree of complications, varies within this group, dependent on the length of gestation.

NURSING PRIORITIES
1. Promote optimal respiratory functioning.
2. Maintain neutral thermal environment.
3. Prevent or reduce risk of potential complications.
4. Maintain homeostasis.
5. Foster development of healthy family unit.

DISCHARGE GOALS
1. Maintaining physiological and behavioral homeostasis with minimal external support.
2. Weight 41/2 lb or greater appropriate to age/condition.
3. Complications prevented/resolving or independently managed.
4. Family identifying and using resources appropriately.
5. Family demonstrates ability to manage infant care.
6. Plan in place to meet needs after discharge.

Nursing diagnosis of preterm infant: Impaired Gas Exchange may be related to ventilation perfusion imbalances, inadequate surfactant levels, immaturity of pulmonary arteriole musculature, immaturity of CNS and neuromuscular system, airway congestion, anemia, and cold stress possibly evidenced by hypercapnia, hypoxia, tachypnea, cyanosis.

Nursing desired outcome

1. Maintain PO2/PCO2 levels WNL.
2. Suffer minimal RDS, with reduced work of breathing and no morbidity.
3. Be free of bronchopulmonary dysplasia.

Nursing intervention with rationale:
1. Review information related to infant’s condition, such as length of labor, type of delivery, Apgar score, need for resuscitative measures at delivery, and maternal medications taken during pregnancy or delivery, including betamethasone.
Rationale: Prolonged labor increases risk of hypoxia, and respiratory depression may follow maternal drug administration or usage. In addition, infants who required resuscitative measures at birth, or those with low Apgar scores, may require more intense interventions to stabilize blood gases and may have suffered CNS injury with damage to the hypothalamus, which controls respiratory functioning. Note: Administration of corticosteroids to mother within 1 wk of delivery fosters the infant’s lung maturity and surfactant production.

2. Note gestational age, weight, and sex.
Rationale: Neonates born before 30 weeks’ gestation and/or weighing less than 1500 g are at higher risk for developing RDS. In addition, males are twice as susceptible as females. Note: The majority of deaths related to RDS occur in infants weighing less than 1500 g.

3. Assess respiratory status, noting signs of respiratory distress (e.g., tachypnea, nasal flaring, grunting, retractions, rhonchi, or crackles).
Rationale: Tachypnea indicates respiratory distress, especially when respirations are >75/min after the first 5 hr of life. Expiratory grunting represents an attempt to maintain alveolar expansion; nasal flaring is a compensatory mechanism to increase diameter of nares and increase oxygen intake. Crackles/rhonchi may indicate pulmonary vasocongestion associated with PDA, hypoxemia, acidemia, or immaturity of muscles in arterioles, which fail to constrict in response to increased oxygen levels.

4. Apply transcutaneous oxygen monitor or pulse oximeter. Record levels hourly. Change site of probe every 3–4 hr.
Rationale: Provides constant noninvasive monitoring of oxygen levels. Note: Pulmonary insufficiency usually worsens during the first 24–48 hr, then reaches a plateau.

5. Suction nares and oropharynx carefully, as needed. Limit time of airway obstruction by catheter to 5–10 sec. Observe transcutaneous oxygen monitor or pulse oximeter before and during suctioning. Provide “bag” ventilation following suctioning.
Rationale: May be necessary to maintain airway patency, especially in infant receiving controlled ventilation. Preterm infant does not develop the coordinated reflex for sucking, swallowing, and breathing until 32–34 weeks’ gestation. Cilia may not be fully developed or may be damaged from use of endotracheal tube. Exudate phase associated with RDS at about 48 hr postpartum may contribute to infant’s difficulty in handling secretions. Suctioning may stimulate vagus nerve, causing bradycardia, hypoxemia, or bronchospasm. Bag ventilation promotes rapid restoration of oxygen levels.

6. Maintain thermal neutrality with body temperature at 97.7°F (± 0.5°F).
Rationale: Cold stress increases infant’s oxygen consumption, may promote acidosis, and may further impair surfactant production.

7. Monitor fluid intake and output; weigh infant as indicated by protocol.
Rationale: Dehydration impairs ability to clear airways because mucus becomes thickened. Overhydration
may contribute to alveolar infiltrates/pulmonary edema. Weight loss and increased urine output may indicate diuretic phase of RDS, usually beginning at 72–96 hr and preceding resolution of condition.

8. Promote rest; minimize stimulation and energy expenditure.
Rationale: Reduces metabolic rate and oxygen consumption.

9. Observe for evidence and location of cyanosis.
Rationale: Cyanosis is a late sign of low PaO2 and does not appear until there are slightly more than 3 g/dl of reduced Hb in central arterial blood, or 4–6 g/dl in capillary blood, or until oxygen saturation is only 75%–85%, with PO2 levels of 32–41 mm Hg. Therefore, prompt intervention is crucial.

10. Administer supplemental oxygen, as needed, by mask, hood, endotracheal tube, or mechanical ventilation using constant positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV), or intermittent positive-pressure breathing (IPPB) and positive end-expiratory pressure (PEEP).
Rationale: Hypoxemia and acidemia may further decrease surfactant production, increase pulmonary vascular resistance and vasoconstriction, and cause ductus arteriosus to remain open. Immaturity of the hypothalamus may necessitate ventilatory assistance to maintain respirations. Use of PEEP may reduce airway collapse, enhancing gas exchange and reducing the need for high levels of oxygen.

Nursing Board Exam Results December 2011 | PRC NLE Result

schizo_me86@yahoo.com — Tue, 17 Jan 2012 23:14:00 +0000

The Nurses Licensure Examination (NLE) results for December 2011, Nursing Board Exam results December 2011 or Dec. 2011 NLE Results, top 10 passers, top performing schools, and performance of schools will be posted here in alphabetical order once officially released by the Professional Regulations Commission (PRC).

The December 2011 NLE Results, also referred to as the December 2011 Nurses Licensure Examination or Nursing Board Exam Results December 2011, will be posted on this page minutes after the Professional Regulation Commission (PRC) officially released the list of passers, top 10 passers, and other information.

To keep updated with the Nursing Board Exam Results December 2011, visit our website or submit your email address so we can notify when the official results come out.

Good luck to all nursing examinees!

Nursing Care Plan | NCP LABOR Stage II (Expulsion)

schizo_me86@yahoo.com — Tue, 17 Jan 2012 12:36:00 +0000

Stage II of labor, the stage of expulsion, begins with full cervical dilation (10 cm) and ends with the birth of the newborn. Maternal efforts to bear down occur involuntarily during contractions that are 1.5–2 min apart, lasting 60–90 sec. The average rate of fetal descent is 1 cm/hr for nulliparas, 2 cm or more per hr for multiparas.

NURSING PRIORITIES
1. Facilitate normal progression of labor and fetal descent.
2. Promote maternal and fetal well-being.
3. Support client’s/couple’s wishes regarding delivery experience, maintaining safety as a priority.

Nursing diagnosis for Stage 2 of Labor - Expulsion Stage: Pain may be related to mechanical pressure of presenting part, tissue dilation/stretching, nerve compression, muscle hypoxia, intensified contractile pattern possibly evidenced by verbalizations, distraction behavior (e.g., restlessness), facial mask of pain, narrowed focus, autonomic responses.

Nursing intervention with rationale:
1. Identify degree of discomfort and its sources.
Rationale: Clarifies needs; allows for appropriate intervention.

2. Provide comfort measures, such as mouth care; perineal care/massage; clean, dry linen and underpads; cool environment (68°F–72°F [20°C–22.1°C]), cool, moist cloths to face and neck; or hot compresses to perineum, abdomen, or back, as desired.
Rationale: Promotes psychological and physical comfort, allowing client to focus on labor, and may reduce the need for analgesia or anesthesia.

3. Review information with client/couple about type of regional analgesia/anesthesia available at this stage specific to the delivery setting (e.g., local, pudendal block, lumbar epidural reinforcement) or use of transcutaneous electrical nerve stimulation (TENS), acupressure/acupuncture. Review advantages/disadvantages, as appropriate.
Rationale: Although client is under the stress of labor and discomfort levels may interfere with normal decision-making skills, she still needs to be in control and make her own informed decisions regarding anesthesia. Note: The option of a nerve root block should be restricted to a hospital setting where emergency equipment is available.

4. Monitor and record uterine activity with each contraction.
Rationale: Provides information/legal documentation about continued progress; helps identify abnormal contractile pattern, allowing prompt assessment and intervention.

5. Provide information and support related to progress of labor.
Rationale: Keeps couple informed of proximity of delivery; reinforces that efforts are worthwhile and the “end is in sight.”

6. Encourage client/couple to manage efforts to bear down with spontaneous, rather than sustained, pushing during contractions. Stress importance of using abdominal muscles and relaxing pelvic floor.
Rationale: Anesthetics may interfere with client’s ability to feel sensations associated with contractions, resulting in ineffective bearing down. Spontaneous, rather than sustained, efforts to bear down avoid negative effects of Valsalva’s maneuver associated with reduced maternal and fetal oxygen levels. Relaxation of the pelvic floor reduces resistance to pushing efforts, maximizing effort to expel the fetus.

7. Observe for perineal and rectal bulging, opening of vaginal introitus, and changes in fetal station.
Rationale: Anal eversion and perineal bulging occur as the fetal vertex descends, indicating need to prepare for delivery.

8. Assist client in assuming optimal position for bearing down; (e.g., squatting or lateral recumbent, semi-Fowler’s position (elevated 30–60 degrees). Assess effectiveness of efforts to bear down.
Rationale: Proper positioning with relaxation of perineal tissue optimizes bearing-down efforts, facilitates labor progress, reduces discomfort, and reduces need for forceps application.

9. Assess bladder fullness. Catheterize between contractions if distension is noted and client is unable to void.
Rationale: Promotes comfort, facilitates fetal descent, and reduces risk of bladder trauma caused by presenting part of fetus.

10. Assist with administration of opiates (e.g., fentanyl [Sublimaze], morphine) into epidural space via indwelling catheter. Have ephedrine, 10 mg, or naloxone (Narcan), 0.4 mg, available as an antidote, depending on agent used.
Rationale: Intraspinal narcotic, acting on opiate receptors within the spinal column, blocks pain for as long as 11 hr. Literature reveals mixed results regarding use of morphine via indwelling catheter in stage II

Nursing Care Plan | NCP Teen Pregnancy

schizo_me86@yahoo.com — Tue, 17 Jan 2012 08:28:00 +0000

Statistics for 1995 reveal that 56.9 babies were born for every 1000 females between the ages of 15 and 19. Although these rates appear to be dropping, pregnant adolescents are at risk physically, emotionally, and socially. The impact of adolescent pregnancy on the individual has far-reaching consequences, which may restrict or limit future opportunities for the adolescent and the child(ren). Educational goals may be altered or eliminated, thus limiting potential for a productive life. The client frequently may be of lower socioeconomic status, with the pregnancy perpetuating financial dependence and lowered self-esteem. Statistically, the obstetric hazards for adolescents and their infants include increased mortality and morbidity rates. Therefore, individualized prenatal nursing care for the adolescent client/family/partner that incorporates developmental needs and health education with prenatal needs has the potential to contribute positively to prenatal, intrapartal, and postpartal outcomes. In addition, neonatal outcomes associated with better Apgar scores, lower incidence of resuscitation, and fewer LBW infants can also be expected.

NURSING PRIORITIES
1. Promote optimal physical/emotional well-being of client.
2. Monitor fetal well-being.
3. Provide information and review the available options.
4. Facilitate positive adaptation to new and changing roles.
5. Encourage family/partner participation in problem-solving.

DISCHARGE GOALS
Inpatient care is not required unless complications develop necessitating hospitalization (refer to appropriate plans of care.)

Nursing diagnosis of teen pregnancy: Body Image disturbance/Role Performance, altered/Personal Identity disturbance/Self Esteem (specify) may be related to situational and maturational crises, fear of failure at life events, biophysical changes, absence of support systems possibly evidenced by self-negating verbalizations, expressions of shame/guilt, hypersensitivity to criticism, fear of rejection, lack of follow-through and/or nonparticipation in care.

Desired Outcomes:
1. Identify feelings and methods for coping with negative perception of self/abilities.
2. Verbalize increased sense of self-esteem in relation to current situation.
3. Demonstrate adaptation to changes/events as evidenced by setting of realistic goals and active participation in meeting own needs.

Nursing intervention with rationale:
1. Establish a therapeutic nurse-client relationship.
Rationale: Adolescent client needs a caring, nonjudgmental adult with whom to talk. Important to establish trust and cooperation so that the client is free to hear the information available.

2. Assess use of terms/language used by the client/significant other(s).
Rationale: Terminology may be specific to the adolescent culture, and words may have different meanings for client and nurse.

3. Determine developmental level and needs relative to age as early, middle, or late adolescence.
Rationale: Cognitive development during this period moves from concrete to abstract thinking (formal operations). The younger client may see control of the situation as external and beyond her grasp, and have little ability to understand the consequences of her behavior. With maturity, the abilities to understand possible consequences and to accept individual responsibility develop.

4. Identify client’s self-perception as positive or negative.
Rationale: Helps client become aware of how she views herself and to begin to increase her self-esteem. Until late adolescence, body image is still formative. The client is dealing with adolescent developmental tasks, establishing an adult identity. Low self-worth may lead to feelings of hopelessness about the future and inability to visualize a successful outcome.

5. Elicit the client’s feelings about sexual identity/roles.
Rationale: May have difficulty seeing herself as a mother. The adolescent must make a role transition from child/daughter to adult/mother, which can create conflicts for the client and significant other(s).

6. Discuss concerns and fears about body image and transitory changes associated with pregnancy; discuss personal value system.
Rationale: Establishes a basis for future learning. Conflicts may exist regarding how client has previously seen herself, what her expectations of pregnancy had been, and what the realities of pregnancy are. By midpregnancy, the enlarging abdomen and the increasing size of breasts and buttocks may prompt the teenager to try to control her appearance by dieting, with adverse consequences for fetal health and her own growth needs.

7. Discuss ways to promote positive self-image (e.g., clothing style, makeup) and recognition of positive aspects of the situation.
Rationale: Assists in coping with changes in appearance and presenting a positive image.

8. Discuss appropriate adaptation techniques and the communication skills to implement these techniques.
Rationale: Role playing and active listening can be used to learn skills of communication and adaptation. Helps client learn information necessary to development of improved self-esteem.

Nursing Care Plan | NCP Child with Special Needs

schizo_me86@yahoo.com — Mon, 16 Jan 2012 23:18:00 +0000

The birth of a child with special needs, regardless of whether the condition is temporary or permanent, creates unique concerns for the family, who mourns the loss of a normal, healthy child. Conditions range from prematurity, growth deviations, and infections to gross anomalies. Although each case is individual and varies in degree of involvement, many similarities are observed in the parents’ responses to their child.

NURSING PRIORITIES
1. Facilitate grieving and positive coping.
2. Provide appropriate information related to short- and long-term implications of child’s illness or anomaly.
3. Facilitate learning of parenting role and participation in infant care tasks.

DISCHARGE CRITERIA
1. Demonstrate progress in dealing with grief at own pace.
2. Display appropriate attachment/bonding behaviors.
3. Participate in infant care; develop mastery of therapeutic regimen.
4. Have plan in place to meet needs after discharge.

Nursing diagnosis: Grieving may be related to perceived loss of the perfect child/ pregnancy/delivery, alterations of future expectations possibly evidenced by expression of distress at loss, sorrow, guilt, anger; choked feelings; reliving of pregnancy events; interference with life activities; crying.

Nursing intervention with rationale:
1. Promote trusting relationship with parents and significant other(s). Encourage verbalization of feelings through listening and an unhurried attitude.
Rationale: Facilitates sharing of feelings, fears, and concerns. Helps parents to focus on reality of the situation and examine their emotional responses. Grieving for the loss of the perfect child must be completed before parents can establish a positive relationship with their offspring. Staff needs to remain available, even if client seems self-sufficient or withdrawn.

2. Facilitate the grief process, even if the newborn’s independent of the severity/permanency of the infant’s problem.
Rationale: The amount of grief the parents experience is problem is temporary or surgically correctable.

3. Determine parents’ religious orientation, and contact appropriate support, if they desire it.
Rationale: Many couples lean heavily on their faith as a source of strength during crisis resolution. Note: Perception of situation/condition and individual’s response will also be affected by religious beliefs.

4. Assess for usual grieving responses (e.g., initial shock, disbelief, and denial, then anger, guilt, sadness, and negative self-evaluation/questioning, followed by acceptance) based on cultural/religious practices. Let parents know that these responses are normal.
Rationale: Grief is the anticipated, healthy emotional response to the profound experience of giving birth to a special needs child, and it involves mourning the loss of the idealized perfect newborn.

5. Note the stage of grief being expressed. Discuss the individual nature of movement through the stages of grief; let parents know that delays in the grief process or relapses of grief are normal.
Rationale: The process of grieving is not usually a fluid progression through the stages to resolution; more often the individual fluctuates between the stages, possibly skipping one or more. Understanding that grieving is individual helps the couple let each other grieve at her or his own pace.

6. Accept use of defense mechanisms (e.g., denial, anger, or silence). Encourage expression of angry feelings, setting limits on unacceptable acting-out behavior.
Rationale: Use of defense mechanisms at this time may be the best way for parents to deal productively with the situation. However, continued use of defense mechanisms may impair resolution of grief. In addition, preventing destructive behavior is important to the maintenance of the client’s selfesteem.

7. Provide information about extreme mood swings, which may be hormonally induced in the postpartal period.
Rationale: Usual hormonal adjustments of postpartal period can trigger labile responses and may require further evaluation/treatment.

8. Ask parents what helps them most in dealing with the affected child. Observe nonverbal signals, such as anguished tone of voice, looking down, or crying.
Rationale: Parents may have a hard time handling the crisis and may have difficulty identifying means of facilitating coping.

9. Evaluate parents for abnormal grief responses, such as inappropriate humor; lack of interest in infant; continued denial of, or failure to recognize, infant’s problem; poor eye contact; continual crying, excessive or vague complaints; inability to carry out self-care activities; or use of distancing in interactions with child (e.g., holding child at arm’s length instead of cuddling).
Rationale: Inappropriate initial responses may result in long term emotional dysfunction and lack of resolution
of grief. Thus, the grief process may be left open ended, and the parents’ unresolved feelings continually resurface. Early identification of problems and prompt intervention facilitates individual growth and coping abilities. Note: Parents may be afraid of becoming emotionally attached if they believe that the child might die.

10. Refer for appropriate individual or family counseling.
Rationale: Counseling may be necessary for resolution of grief and maintenance of family unity.

Nursing Care Plan | NCP Puerperal Infection

schizo_me86@yahoo.com — Mon, 16 Jan 2012 13:21:00 +0000

Puerperal infection is an infection of the reproductive tract occurring within 28 days following childbirth or
abortion. It is one of the major causes of maternal death (ranking second behind postpartal hemorrhage) and includes localized infectious processes as well as more progressive processes that may result in endometritis/metritis (inflammation of endometrium), peritonitis, or parametritis/pelvic cellulitis (infection of connective tissue of broad ligament and possibly connective tissue of all pelvic structures).

NURSING PRIORITIES
1. Control spread of infection.
2. Promote healing.
3. Support ongoing process of family acquaintance.

DISCHARGE GOALS
1. Infection resolving
2. Involution progressing, sense of well-being expressed
3. Attachment/bonding demonstrated and care of infant resumed

Nursing diagnosis for Puerperal Infection: Infection may be related to presence of infection, broken skin and/or traumatized tissues, high vascularity of involved area, invasive procedures and/or increased environmental exposure, chronic disease (e.g., diabetes), anemia, malnutrition, immunosuppression and/or untoward effect of medication (e.g., opportunistic/secondary infections)

Desired Outcomes
1. Verbalize understanding of individual causative risk factors.
2. Initiate behaviors to limit spread of infection, as appropriate, and reduce risk of complications.
3. Achieve timely healing, free of additional complications.

Nursing intervention with rationale
1. Review prenatal, intrapartal, and postpartal record.
Rationale: Identifies factors that place client in high-risk category for development/spread of postpartal infection.

2. Demonstrate and maintain strict hand-washing policy for staff, client, and visitors.
Rationale: Helps prevent cross-contamination.

3. Provide for, and instruct client in, proper disposal of contaminated linens, dressings, chux, and peripads. Initiate/maintain isolation, if indicated.
Rationale: Prevents spread of infection.

4. Demonstrate/encourage correct perineal cleaning after voiding and defecation, and frequent changing of peripads.
Rationale: Cleaning removes urinary/fecal contaminants. Changing pad removes moist medium that favors bacterial growth.

5. Demonstrate proper fundal massage. Review importance and timing of procedure.
Rationale: Enhances uterine contractility; promotes involution and passage of any retained placental fragments.

6. Monitor temperature, pulse, and respirations. Note presence of chills or reports of anorexia or malaise.
Rationale: Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. Note: Persistent fever unresponsive to antibiotic therapy may indicate pelvic thrombophlebitis.

7. Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge and approximation [REEDA scale]). Note subinvolution of uterus, extreme uterine tenderness.
Rationale: Allows early identification and treatment; promotes resolution of infection. Note: Although localized infections are usually not severe, occasional progression to necrotizing fasculitis can be life-threatening.

8. Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day. Note urine output, degree of hydration, and presence of nausea, vomiting, or diarrhea.
Rationale: Increased intake replaces losses and enhances circulating volume, preventing dehydration and aiding in fever reduction.

9. Encourage application of moist heat in the form of sitz baths and of dry heat in the form of perineal lights for 15 min 2–4 times daily.
Rationale: Water promotes cleansing. Heat dilates perineal blood vessels, increasing localized blood flow and promotes healing.

10. Arrange for transfer to intensive care setting as appropriate.
Rationale: May be necessary for client with severe infection (e.g., peritonitis, sepsis) or pulmonary emboli to provide appropriate care leading to optimal recovery.

Nursing Care Plan | NCP Preterm Labor

schizo_me86@yahoo.com — Mon, 16 Jan 2012 07:45:00 +0000

Preterm labor refers to labor that occurs after the fetus has reached the period of viability (at least 20 weeks’ gestation but before the completion of the 37th wk). Carrying the pregnancy to term may be contraindicated if associated client or fetal risks outweigh the risks of delivering a preterm infant.

NURSING PRIORITIES
1. Ascertain maternal condition/presence of labor and fetal well-being.
2. Assist with efforts to maintain pregnancy, if possible.
3. Prevent complications.
4. Provide emotional support.
5. Provide necessary information.

DISCHARGE GOALS
1. Cessation of uterine contractions
2. Free of complications and/or untoward effects
3. Dealing with situation in a positive manner
4. Signs of preterm labor/complications and therapy needs understood

Nursing diagnosis of Preterm Labor: Risk for Fetal Injury may be related to delivery of preterm/immature infant.

Expected Outcome: Maintain the pregnancy at least to the point of fetal maturity.

Nursing intervention with rationale:
1. Assess for maternal conditions that would contraindicate steroid therapy to facilitate fetal lung maturity.
Rationale: In PIH and chorioamnionitis, steroid therapy may aggravate hypertension and mask signs of infection. Steroids may increase serum glucose levels in the patient with diabetes. Drug will not be effective if unable to delay birth for at least 48 hr.

2. Assess FHR; note presence of uterine activity or cervical changes. Prepare for possible preterm delivery.
Rationale: Tocolytics can increase FHR. Delivery may be extremely rapid with small infant if persistent uterine contractions are unresponsive to tocolytics, or if cervical changes continue.

3. Provide information about the actions and side effects of the drug therapy.
Rationale: Important for the client/couple to know the purpose of the drug(s) being administered. Betaagonist
therapy may cause fetal tachycardia, hyperglycemia, acidosis, and hypoxia. Steroid therapy is most effective for increasing lung surfactant when the fetus is between 30 and 32 weeks’ gestation (but may be used between 26 and 34 weeks’ gestation).

4. Review potential side effects of steroid therapy with client/couple.
Rationale: Short-term effects may include hypoglycemia, increased risk of sepsis, and possible suppression of aldosterone for up to 2 wk following delivery. Long term effects on the development of the child will not be known until longitudinal studies have been completed.

5. Stress necessity of follow-up care.
Rationale: If fetus is not delivered within 7 days of administration of steroids, dose should be repeated weekly.

6. Assist as needed with analysis of amniotic fluid from amniocentesis or vaginal pool specimen; test for ferning.
Rationale: L/S ratio, presence of PG, and shake test results indicate fetal lung status. Ferning indicates rupture of membranes with increased risk of infection.

7. Administer betamethasone (Celestone) deep IM.
Rationale: This synthetic cortisol can accelerate fetal lung maturity by stimulating surfactant production and thereby preventing or decreasing the severity of respiratory distress syndrome. Note: Administration into the deltoid muscle may result in local atrophy.

8. Administer antibiotics, as indicated.
Rationale: In the event of PROM and fetal lung immaturity, antibiotics may be used to prevent/reduce risk of infection, while allowing an additional 24–28 hr to elapse after administration of Celestone.

9. Initiate tocolytic therapy, as ordered.
Rationale: Helps reduce myometrial activity to prevent/delay early delivery.