Personality Disorders Nursing

Care Plans
Personality is defined as the differences in the characteristic patterns of
behaving, feeling and thinking of an individual.

A personality disorder is a type of mental illness in which a person’s

personality traits have become rigid, inflexible, maladaptive and can hinder the
person’s perception and association to situations and people. This can cause
significant problems and restriction in the family, social activities, school,
employment and other functional roles.

Nursing Care Plans

The nursing care plan varies according to the kind of personality disorder, its
severity, and life situation. A collaborative intervention is needed to make sure
all of the clients social, medical and psychiatric needs are met.

The goals of the nurse for clients with personality disorders focus on
establishing trust, providing safety and comfort, teaching basic living skills
and promoting a responsible behavior.

Here are four (4) nursing care plans (NCP) for personality disorders:

Risk For Self-Mutilation

Risk For Self-Mutilation: At risk for deliberate self-injurious behavior causing

tissue damage with the intent of causing nonfatal injury to attain.

Risk factors
  Desperate need for attention.
 Emotionally disturbed or battered children.
 Feelings of depression, rejection, self-hatred, separation anxiety, guilt,
and depersonalization.
 History of self-injury.
 History of physical, emotional, or sexual abuse.
 High-risk populations (BPD, psychotic states).
 Impulsive behavior.
 Inability to verbally express feelings.
 Ineffective coping skills.
 Mentally retarded and autistic children.

Possibly evidenced by

 Fresh superficial slashes on wrists or other parts of the body.

 Intense rage focused inward.
 Signs of old scars on wrists and other parts of the body
(cigarette burns, superficial knife/razor marks).
 Statements as to self-mutilation behaviors.

Desired Outcomes

 Patient will be free of self-inflicted injury.

 Patient will participate in impulse control training.
 Patient will participate in coping skills training.
 Patient will seek help when experiencing self-destructive impulses.
 Patient will discuss alternative ways a client can meet demands of
current situation.
 Patient will express feelings related to stress and tension instead of
acting-out behaviors.
 Patient will sign a “no-harm” contract that identifies steps he or she
will take when urges return.
 Patient will respond to external limits.
  Patient will participate in the therapeutic regimen.
 Patient will demonstrate a decrease in frequency and intensity of self-
inflicted injury.
 Patient will demonstrate two new coping skills that work for the client
for when tension mounts and impulse returns.

Nursing Interventions Rationale

Assess client’s history of self-mutilation:

Identifying patterns and circumstances surrounding

1. Types of mutilating behaviors. self-injury can help the nurse plan interventions and
2. Frequency of behaviors. teaching strategies suitable to the client.
3. Stressors preceding behavior.

Identify feelings experienced before and around the Feelings are a guideline for future intervention (e.g.,
act of self-mutilation. rage at feeling left out or abandoned).

Self-mutilation might also be:

Explore with the client what these feelings might 1. A way to gain control over others.
mean.
2. A way to feel alive through pain.
3. An expression of self-hate or guilt.

Client is encouraged to take responsibility for

Secure a written or verbal no-harm contract with
healthier behavior. Talking to others and learning
the client. Identify specific steps (e.g., persons to call
alternative coping skills can reduce frequency and
upon when prompted to self-mutilate).
severity until such behavior ceases.

Set and maintain limits on acceptable behavior and

make clear client’s responsibilities. If the client is Clear and nonpunitive limit setting is essential for
hospitalized at the time, be clear regarding the unit decreasing negative behaviors.
rules.

Be consistent in maintaining and enforcing the

Consistency can establish a sense of security.
limits, using a nonpunitive approach.

Use a matter-of-fact approach when self-mutilation A neutral approach prevents blaming, which
occurs. Avoid criticizing or giving sympathy. increases anxiety, giving special attention that
 encourages acting out.

After the treatment of the wound, discuss what

identify dynamics for both client and clinician. Allows
happened right before, and the thoughts and
the identification of less harmful responses to help
feelings that the client had immediately before self-
relieve intense tensions.
mutilating.

Work out a plan identifying alternatives to self-

mutilating behaviors.

1. Anticipate certain situations that might

lead to increased stress (e.g., tension or
rage).
Plan is periodically reviewed and evaluated. Offers a
2. Identify actions that might modify the chance to deal with feelings and struggles that a
intensity of such situations.
3. Identify two or three people whom the
client can contact to discuss and
examine intense feelings (rage,self
hate) when ther arise.

Chronic Low Self-Esteem

Chronic Low Self-Esteem: Long standing negative self-evaluation/feelings

about self or self-capabilities.

May be related to

 Avoidant and dependent patterns.

 Childhood physical, sexual, psychological abuse and/ or neglect.
 Dysfunctional family of origin.
 Lack of realistic ego boundaries.
 Persistent lack of integrated self-view, with splitting as a defense.
 Shame and guilt.
  Substance abuse.

Possibly evidenced by

 Evaluates self as unable to deal with events.

 Excessively seeks reassurance.
 Expresses longstanding shame/guilt.
 Hesitant to try new things/situations.
 Longstanding or chronic self-negting verbalizations; expressions of
shame and guilt.
 Overly conforming, dependent on others’ opinions, indecisive.
 Rationalizes away/ rejects positive feedback and exaggerates negative
feedback about self.

Desired Outcomes

 Patient will identify one skill he or she will work on to meet future
goals.
 Patient will identify two cognitive distortions that affect self-image.
 Patient will identify three strengths in work/school life.
 Patient will reframe and dispute one cognitive distortion with nurse.
 Patient will set one realistic goal with nurse that he or she wishes to
pursue.
 Patient will state a willingness to work on two realistic future goals.
 Patient will identify one new skills he or she has learned to help meet
personal goals.
 Patient will demonstrate ability to reframe and dispute cognitive
distortions with assistance of a nurse/clinician.

Nursing Interventions Rationale

Assess with clients their self perception. Target Identify with client with realistic areas of strength and
different areas of the client’s life: weaknesses. Client and nurse can work on the realities
of the self-appraisal, and target those areas of

1. Strengths and weaknesses in
performance at work/school.daily-life
tasks.
2. Strengths and weaknesses as to
physical appearance, sexuality,
personality.
Maintain a neutral, calm, and respectful manner,
although with some clients this is easier said than
done.
Review with the client the types of cognitive
distortions that affect self-esteem (e.g., self-blame,
mind reading, overgeneralization, selective
inattention, all-or-none thinking).
Teach client to reframe and dispute cognitive
distortions. Disputes need to be strong, specific,
and nonjudgmental.
Work with client to recognize cognitive distortions.
Encourage client to keep a log.
Keep in mind clients with personality disorders
might defend against feeling of low-self-esteem
through blaming, projection, anger, passivity, and
demanding behaviors.
Discourage client from making repetitive self-
blaming and negative remarks.
Discourage client from dwelling on and “relieving”
past mistakes.
Discuss with client his or her plans for the future.
Work with client to set realistic short-term goals.
Identify skills to be learned to help client reach his
or her goals.
assessment that do not appear accurate.
Helps client see himself or herself as respected as a
person even when behavior might not be appropriate.
These are the most common cognitive distortions
people use. Identifying them is the first step to
correcting distortions that form one’s self-view.
Practice and belief in the disputes over time help
clients gain a more realistic appraisal of events, the
world, and themselves.
Cognitive distortions are automatic. Keeping a log
helps make automatic, unconscious thinking clear.
Many behaviors seen in PD clients cover a fragile
sense of self. Often these behaviors are the crux of
clients’ interpersonal difficulties in all their
relationships.
Unacceptable behavior does not make the client a bad
person, it means that the client made some poor
choices in the past.
The past cannot be changed. Dwelling on past
mistakes prevents the client from appraising the
present and planning for the future.
Looking toward the future minimizes dwelling on the
past and negative self-rumination. When realistic
short-term goals are met, client can gain a sense of
accomplishment, direction, and purpose in life.
Accomplishing goals can bolster a sense of control and
 enhance self-perception.

Focus questions in a positive and active light; helps

Allows client to look at past behaviors differently, and
client refocus on the present and look to the future.
gives the client a sense that he or she has choices in
For example. “What can you do differently now?”
the future.
or “What have you learned from that experience?”.

Give the client honest and genuine feedback

Feedback helps give clients a more accurate view of
regarding your observations as to his or her
self, strengths, areas to work on, as well as a sense that
strengths, and areas that could use additional
someone is trying to understand them.
skills.

Dishonesty and insincerity undermine trust and

Do not flatter or be dishonest in your appraisals.
negatively affect any therapeutic alliance.

Set goals realistically, and renegotiate goals Unrealistic goals can set up hopelessnessin clients and
frequently. Remember that client’s negative self- frustrations in nurse clinicians. Clients might blame
view and distrust of the world took years to the nurse for not “helping them,” and nurses might
develop. blame the client for not “getting better”.

Impaired Social Interaction

Impaired Social Interaction: Insufficient or excessive quantity or ineffective

quality of social exchange.

May be related to

 Biochemical changes in the brain.

 Disruptive or abusive early family background.
 Genetic factors.
 Immature interests.
 Unacceptavle social behavior or values.

Possibly evidenced by
  Alienating others through angry, clinging, demeaning, and/or
manipulative behavior or ridicule toward others.
 Destructive behavior toward self or others.
 Dysfunctional interaction with peers, family, and/or others.
 Observed use of unsuccessful social interaction behaviors.

Desired Outcomes

 Patient will identify and express feelings as they occur with nurse.
 Patient will identify two personal behaviors that are responsible for
relationship difficulties within two weeks.
 Patient will identify one specific area that requires change.
 Patient will verbalize decreased suspicions and increased security.
 Patient will begin to demonstrate an increase in nonviolent behaviors
as evidenced by a reduction in reported outbursts.
 Patient will begin to demonstrate a reduction in manipulative behaviors
as evidenced by nurse/staff.
 Patient will state that he or shes is willing to continue in follow up
therapy.
 Patient will keep follow-up appointments.
 Patient will demonstrate, with the aid of the nurse/clinician, the ability
to identify at least two unacceptable social behavior (manipulation,
splitting, demeaning attitudes, angry acting out) that client is willing to
change.
 Patient will work with the nurse/clinician on substituting positive
behaviors for those unacceptable behaviors identified earlier on an
ongoing basis.

Nursing Interventions Rationale

Set limits on any manipulative behaviors: From the beginning, limits need to be clear. It will be
necessary to refer to these limits frequently, because
1. Arguing or begging. it is to be expected that the client will test these limits
 repeatedly.
2. Flattery or seductiveness.
3. Instilling guilt, clinging.
4. Constantly seeking attention.
5. Pitting one person, staff, group against
another.
6. Frequently disregarding the rules.
7. Constant engagement in power
struggles.
8. Angry, demanding behaviors.

When time is taken in initial meetings to clarify

Expand limits by clarifying expectations for clients
expectations, confrontations, and power struggles
in a number of settings.
with clients can be minimized and even avoided.

In a respectful, neutral manner, explain expected
client behaviors, limits, and responsibilities during
sessions with nurse clinician. Clearly state the rules
and regulations of the institution, and the
consequences when these rules are not adhered to.
From the beginning, clients need to have explicit
guidelines and boundaries for expected behaviors on
their part, as well as what client can expect from the
nurse. Clients need to be fully aware that they will be
held responsible for their behaviors.

Strong and intense countertransference reactions to

Monitor own thoughts and feelings constantly
PD clients are bound to occur. When the nurse is
regarding your response to the PD client.
enmeshed in his or her own strong reactions toward
Supervision is strongly recommended for new and
the client (either positive or negative), nurse
seasoned clinicians alike when working with PD
effectivess suffers, and the therapeutic alliance might
clients.
be threatened.

Collaborate with the client, as well as the

multidisciplinary team, to establish a reward Tangible reinforcement for meeting expectations can
system for compliance with clearly defined strenthen the client’s positive behaviors.
expectations.

Skils training workshops offer the client wats to

increase social skills through role play and
Assess need for and encourage skills training interactions with others who are learning similar
workshop. skills. This often acts as a motivating factor where
positive feedback and helpful suggestions are readily
available.

Problem solve and role play with client acceptable Over time, alternative ways of experiencing
social skills that will help obtain needs effectively interpersonal relationships might emerge. Take one
and appropriately. small skill that client is willing to work on, break it
down into small parts, and work on it with the client.

Responding to client’s resistance and seeming lack of

Understand that PD clients in particular will be
resistant to change and that this is symptomatic of
PDs. This is particularly true in the beginning
phases of therapy.
change in a neutral manner is part of the foundation
for trust. In other words, the nurse does not have a
vested interest in the client “getting better.”. The
nurse remains focused on the client’s needs and
issues in any event.

Intervene in manipulative behavior.

1. All limits should be adhered to by all

staff involved.
2. Objective physical signs in managing Client will test limits, and, once they understand that
clinical problems should be carefully the limits are solid, this understanding can motivate
documented. them to work on other ways to get their needs met.
Hopefully, this will be done with the nurse clinician
3. Behaviors should be documented throughout problem-solving alternative behaviors
objectively (give times, dates, and learning new effective communication skills.
circumstances).
4. Provide clear boundaries and
consequences.
5. Enforce the consequences.

Ineffective Coping

Ineffective Coping: Inability to form a valid appraisal of the stressors,

inadequate choices of practiced responses, and/or inability to use available
resources.

May be related to

 Failure to intend to change behavior.

  Intense emotional state.
 Lack of motivation to change behaviors.
 Negative attitudes toward health behavior.
 Neurologic factors.
 Trauma early in life (physical, emotional, or sexual abuse).

Possibly evidenced by

 Anger or hostility.
 Demonstration of nonacceptance of health status.
 Dependency.
 Dishonesty.
 Extreme distrust to others.
 Failure to learn or change behavior based on past experience or
punishment.
 Failure to achieve an optimal sense of control.
 Intense emotional dysregulation.
 Manipulation of others.
 Poor judgment.
 Superficial relationship with others.

Desired Outcomes

 Patient will identify behaviors leading to hospitalization.

 Patient will have an increased in frequency of expressing needs directly
without ulterior motives.
 Patient will learn and master skills that facilitate functional behavior.
 Patient will demonstrate an increase in impulse control.
 Patient will demonstrate a use of a newly learned coping skill to modify
anxiety and frustration.
 Patient will demonstrate decreased manipulative, attention speaking
behaviors.
 Patient will not act out anger toward others while hospitalized.
  Patient will remain safe while hospitalized.
 Patient will spend time with the nurse and focus on one thing he or she
would like to change.
 Patient will state that he/she will continue the treatment on an
outpatient basis.
 Patient will talk about feelings and perceptions and not act on them at
least twice.
 Patient will focus on one problem and work through the problem-
solving process with the nurse.
 Patient will practice the substitution of functional skills for times of
increased anxiety with the nurse.

Nursing Interventions Rationale

General Interventions for All Personality Disorders:

All clients are individuals, even within the same

Review intervention guidelines for each personality
diagnostic category. However, guidelines for
disorder in this chapter.
specific categories are helpful for planning.

Client needs clear structure. Expect frequent

Identify behavioral limits and behaviors that are
testing of limits initially. Maintaining limits can
expected.
enhance feelings of safety in the client.

Identify what the client sees as the behaviors and Ascertain client’s understanding of behaviors
circumstances that lead to the hospitalization. and responsibility for own action.

Ascertain from family/friends how the person interacts

Identifying baseline behaviors helps with
with significant people. Is the client always withdrawn,
setting goals.
distrustful, hostile, have continuous physical complaints?

Enhances feelings of security and provides

Approach the client in a consistent manner in all
structure. Exceptions encourage a manipulative
interactions.
behavior.

Refrain from sharing personal information with the client.

Open up areas for manipulation and
 undermines professional boundaries.

Giving into client’s thinking that you are “the

Be aware of flattery as an attempt to feed into your needs
best” or “the only one” can pit you against other
to feel special.
staff and undermine client’s need for limits.

Again, clouds the boundaries and can give the

Do not receive any gift from the client. client the idea that he or she is due special
consideration.

The client is in the hospital/clinic for a reason.

If the client becomes seductive, reiterate the therapeutic
Being taken in by seductive behavior
goals and boundaries of treatment.
undermines effectiveness of the treatment.

Be clear with the client as to the unit/hospital/clinic

Institutional policies provide structure and
policies. Give brief concrete reasons for the rules, if asked,
safety.
and then move on.

Be very clear about the consequences if policies/limits Client needs to understand the consequences of
are not adhered to. breaking the rules.

When limit or policies are not followed, enforce the Enforces that the client is responsible for his or
consequences in a matter-of-fact, nonjudgmental manner. her own actions.

Make a clear and concrete written plan of care so other Helps minimize manipulations and might help
staff can follow. encourage cooperation.

If goals and interventions are agreed upon,

If feasible, devise a care plan with the client.
cooperation with the plan is optimized.

If the client becomes hostile or projects blame onto you or

Defuses tension and opens up productive
staff, project a neutral, calm demeanor, and avoid power
interaction.
struggles. Focus on the client’s underlying feelings.

Often acting out behaviors stem from

underlying feelings of anger, fear, shame,
When appropriate, try to understand underlying feelings
insecurity, loneliness, etc. Talking about feeling
prompting inappropriate behaviors.
can lead to problem solving and growth for the
client.
 Nurses often want to be seen as “nice”
Some clients might attempt to instill guilt when they do
However, being professional and maintaining
not get what they want. Remain neutral but firm.
limits is the better therapeutic approach.

Keep goals very realistic and go in small steps. There are It can take a long time to positively change
no overnight successes with people with personality ingrained, life-long, maladaptive habits;
disorders. however, change is always possible.

Work with the client on problem-solving skills using a

situation that is bothering the client. Go step by step: Client might not know how to articulate the
problem. Helping identify alternatives gives the
1. Define the problem. client a sense of control. Evaluating the pros
and cons of the alternatives facilitates choosing
2. Explore alternatives. potential solutions.
3. Make decisions.

When the client is ready and interested, teach client

Increasing skills helps the client use healthier
coping skills to help defuse tension and trouble feelings
ways to defuse tensions and get needs met.
(e.g., anxiety reduction, assertiveness skills).

Change if often very slow and may seem to take

longer than it actually is. Nurture yourself
Guard against personal feelings of frustration and lack of
outside the job. Keep your “bucket” full of
progress.
laughter and high regard from family and
friends.

Even short encounters with therapeutic

Understand that many people with personality disorders
persons can make a difference when a client is
do not stay with the treatment and often come to facilities
ready to learn more adaptive ways of living his
because of crisis or court order.
or her life.

Give the client positive attention when behaviors are Reinforcing positive behaviors might increase
appropriate and productive. Avoid giving any attention the likelihood of repetition. Ignoring negative
(when possible and not dangerous to self or others) when behaviors (when feasible) robs client of even
client’s behaviors are inappropriate. negative attention.

Borderline Personality Disorder (BPD):

Assess for self-mutilating or suicidethoughts or Self-mutilating and suicide threats are common
behaviors. behaviors for clients with BPD.

Clients with BPD can be manipulative. Consistent limit setting helps provide structure
 and decrease negative behaviors.

Encourage the client to explore feelings and concerns

Client is used to acting out feelings.
(e.g., identify fears, loneliness, self-hate).

Be nonjudgmental and respectful when listening to

Clients have an intense fear of rejection.
client’s feelings, thoughts, or complaints.

Use assertiveness when setting limits on client’s Firm, clear, nonjudgmental limits give client
unreasonable demands for attention and time. structure.

Many of the dysfunctional behaviors of BPD

Interventions often call for responses to client’s intense
clients (e.g., parasuicidal, anger, manipulation,
and labile mood swings, irritability, depression, and
substance abuse) are used as “behavioral
anxiety:
solutions” to intense pain.

Clients with BPD are extremely uncomfortable

 Irritability, anger: Use interventions early and want immediate relief from painful feelings.
before anxiety and anger escalate. Anger is a response to this pain. Intervening
early can help avoid escalation.

 Depression: Client might need medications

Most clients with BPD suffer profound
to help curb depression. Observe for side depression.
effects and mood level.

 Anxiety: Teach stress-reduction techniques Clients experience intense anxiety and fear of
such as deep breathing relaxation, abandonment. Stress reduction techniques help
the client focus more clearly.
meditation, and exercise.

Provide and encourage the client to use professionals in Clients with BPD often have multiple social
other in other disciplines such as social services, problems. Often they do not know how to
vocational rehabilitation, social work, or the law. obtain these services.

Clients with BPD benefit from coping skills training (e.g., Client learns to refine skills in changing
anger management skills, emotional regulation skills, behaviors, emotions, and thinking patterns
interpersonal skills). Provide referrals and/or involve associated with problems in living that are
professional experts. causing distress and misery.

Clients with BPD often drop out of treatment Clients might become impatient and leave, then
prematurely. However, when they return, they can still return in a crisis situation. It is a good thing
draw upon what they have learned from previous when they are able to tolerate longer periods of
encounters with health care personnel. learning.

Treatment of substance abuse is best handled by well- Keeping detailed records and having a team
organized treatment systems, not by an individual involved with each client can minimize
nurse/clinician. manipulation.

Anxiety and Panic Disorders

Nursing Care Plans
Anxiety is a vague feeling of dread or apprehension (uneasiness); it is the
activation of the autonomic nervous system in response to an external or
internal stimuli that can have behavioral, emotional, cognitive, and physical
symptoms. In contrast, fear is the feeling of apprehension over a specific threat
or danger to the person.

Anxiety disorders comprise a group of conditions that share a key feature of

excessive anxiety with ensuing behavioral, emotional, cognitive, and physiologic
responses. People suffering from anxiety disorders can demonstrate unusual
behaviors such as panic without reason, unwarranted fear of objects, or
unexplainable or unwavering worry. They experience significant distress over
time, and the disorder significantly impairs their daily routines, social lives, and
occupational functioning.

Anxiety disorders are diagnosed when anxiety no longer function as a signal of

danger or a motivation for needed change but becomes chronic and permeates
major portions of the person’s life, resulting in maladaptive behaviors and
emotional disability.

Panic disorder is composed of discrete episodes of panic attacks usually of 15

to 30 minutes of rapid, intense, escalating anxiety in which the person
experiences great emotional fear as well as physiologic discomfort. It is
diagnosed when the person has recurrent, unexpected panic attacks followed by
at least one month of persistent concern or worry about future attacks or their
meaning or significant behavioral change related to them.

Nursing Care Plans

Nurses encounter anxious clients and families in a variety of situations. The

nurse must first assess the person’s anxiety level because this determines what
interventions are likely to be effective. Treatment of anxiety disorders usually
involves medication and therapy. A combination of both produces better results
than either one alone.

When working with an anxious person, the nurse must be aware of her own
anxiety level. It is easy for the nurse to become easily anxious – remaining
calm and in control is essential if the nurse is going to work effectively with the
client.

The following are seven (7) nursing care plans for patients with anxiety
and panic disorders:

Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an

autonomic response.

May be related to

 lack of knowledge regarding symptoms, progression of condition, and

treatment regimen.
 actual or perceived threat to biologic integrity.
 unconscious conflict about essential values and goals of life.
 Situational and maturational crises.
Possibly evidenced by

 Decreased attention span

 Restlessness
 Poor impulse control
 Hyperactivity, pacing
 Feelings of discomfort, apprehension or helplessness
 Delusions
 Disorganized thought process
 Inability to discriminate harmful stimuli or situations

Desired Outcomes

 Be free from injury

 Discuss feelings of dread, anxiety, and so forth
 Respond to relaxation techniques with a decreased anxiety level.
 Reduce own anxiety level.
 Be free from anxiety attacks.

Nursing Interventions Rationale

Anxiety is contagious and may be transferred

Maintain a calm, non threatening manner while working from health care provider to client or vice
with the client. versa. Client develops feeling of security in
presence of calm staff person.

Establish and maintain a trusting relationship by listening Therapeutic skills need to be directed toward
to the client; displaying warmth, answering questions putting the client at ease, because the nurse
directly, offering unconditional acceptance; being available who is a stranger may pose a threat to the
and respecting the client’s use of personal space. highly anxious client.

Remain with the client at all times when levels of anxiety The client’s safety is utmost priority. A highly
are high (severe or panic); reassure client of his or her anxious client should not be left alone as his
safety and security. anxiety will escalate.

Move the client to a quiet area with minimal stimuli such Anxious behavior escalates by external stimuli.
as a small room or seclusion area (dim lighting, few people, A smaller or secluded area enhances a sense of
and so on.) security as compared to a large area which can
make the client feel lost and panicked.

The client will feel more secure if you are calm

Maintain calmness in your approach to the client. and inf the client feels you are in control of the
situation.

Provide reassurance and comfort measures. Helps relieve anxiety.

Pharmacological therapy is an effective

Educate the patient and/or SO that anxiety disorders are treatment for anxiety disorders; treatment
treatable. regimen may include antidepressants and
anxiolytics.

The client uses defenses in an attempt to deal

with an unconscious conflict, and giving up
Support the client’s defenses initially.
these defenses prematurely may cause
increased anxiety.

Anxiety is communicated interpersonally.

Being with an anxious client can raise your
Maintain awareness of your own feelingsand level of
own anxiety level. Discussion of these feelings
discomfort.
can provide a role model for the client and
show a different way of dealing with them.

During a panic attack, the patient needs

reassurance that he is not dying and the
Stay with the patient during panic attacks. Use short,
symptoms will resolve spontaneously. In
simple directions.
anxiety, the client’s ability to deal with
abstractions or complexity is impaired.

The client may not make sound and

Avoid asking or forcing the client to make choices. appropriate decisions or may unable to make
decisions at all.

Observe for increasing anxiety. Assume a calm manner,

Early detection and intervention facilitate
decrease environmental stimulation, and provide
modifying client’s behavior by changing the
temporary isolation as indicated.
environment and the client’s interaction with
 it, to minimize the spread of anxiety.

Medication may be necessary to decrease

PRN medications may be indicated for high levels of
anxiety to a level at which the client can feel
anxiety. Watch out for adverse side effects.
safe.

Encourage the client’s participation in relaxation exercises

Relaxation exercises are effective nonchemical
such as deep breathing, progressive muscle relaxation,
ways to reduce anxiety.
guided imagery, meditation and so forth.

Teach signs and symptoms of escalating anxiety, and ways

So the client can start using relaxation
to interrupt its progression (e.g., relaxation techniques,
techniques; gives the client confidence in
deep- breathing exercises, physical exercises, brisk walks,
having control over his anxiety.
jogging, meditation).

Panic attacks are caused by neuropsychiatric

Administer SSRIs as ordered. disorder that responds to SSRI
antidepressants.

Help the client see that mild anxiety can be a positive The client may feel that all anxiety is bad and
catalyst for change and does not need to be avoided. not useful.

Cognitive-behavioral therapy (further discussed here)

Positive reframing Turning negative messages into positive ones.

It involves the therapist’s use of questions to

more realistically appraise the situation. It is
Decatastrophizing also called the “what if” technique because the
worst case scenario is confronted by asking a
“what if” question.

Helps the person take more control over life

situations. These techniques help the person
Assertiveness training
negotiate interpersonal situations and foster
self-assurance.

When level of anxiety has been reduced, explore with the

Recognition of precipitating factors is the first
client the possible reasons for occurrence.
step in teaching client to interrupt escalation
 of anxiety.

Encourage client to talk about traumatic experience under

nonthreatening conditions. Help client work through
Verbalization of feelings in a nonthreatening
feelings of guilt related to the traumatic event. Help client
environment may help client come to terms
understand that this was an event to which most people
with unresolved issues.
would have responded in like manner. Support client
during flashbacks of the experience.

Fear

Fear: Response to perceived threat that is consciously recognized as a danger.

May be related to

 Phobic stimulus
 Physiological symptoms, mental/cognitive behaviors indicative of panic

Possibly evidenced by

 Acknowledge and discuss fears.

 Demonstrate understanding through use of effective coping behaviors
and active participation in treatment regimen.
 Resume normal life activities.

Desired Outcomes

 Client will be able to discuss phobic object or situation with the nurse.
 Client will be able to function in presence of phobic object or situation
without experiencing panic anxiety by time of discharge from
treatment.
 Nursing Interventions
Reassure client of his safety and security.
Explore client’s perception of threat to physical integrity
or threat to self-concept.
Present and discuss reality of the situation with client in
order to recognize aspects that can be changed and those
that cannot.
Suggest that the client substitute positive thoughts for
negative ones.
Include client in making decisions related to selection of
alternative coping strategies.
Encourage client to explore underlying feelings that may
be contributing to irrational fears. Help client to
understand how facing these feelings, rather than
suppressing them, can result in more adaptive coping
abilities.
Discuss the process of thinking about the feared
object/situation before it occurs.
Encourage client to share the seemingly unnatural fears
and feelings with others, especially the nurse therapist.
Rationale
At panic level anxiety, client may fear for own
life.
It is important to understand the client’s
perception of the phobic object or situation in
order to assist with the desensitization process.
Client must accept the reality of the situation
before the work of reducing the fear can
progress.
Emotion connected to thought, and changing to
a more positive thought can decrease the level
of anxiety experienced. This also gives the client
an alternative way of looking at the problem.
Allowing the client choices provides a measure
of control and serves to increase feelings of self-
worth.
Verbalization of feelings in a nonthreatening
environment may help client come to terms
with unresolved issues.
Anticipation of a future phobic reaction allows
client to deal with the physical manifestations
of fear.
Clients are often reluctant to share feelings for
fear of ridicule and may have repeatedly been
told to ignore feelings. Once the client begins to
acknowledge and talk about these fears, it
becomes apparent that the feelings are
manageable.

Encourage to stop, wait, and not rush out of
feared situation as soon as experienced. Support use
of relaxation exercises.
Explore things that may lower fear level and keep
it manageable (e.g. singing while dressing, repeating a
mantra, practicing positive self-talk while in a
fearful situation).
Use desensitization approach:
 Systematic desensitization
 Expose client to a predetermined list of
anxiety-provoking stimuli rated in hierarchy
from the least frightening to the most
frightening.
 Pair each anxiety-producing stimulus (e.g.
standing in an elevator) with arousal of
another affect of an opposite quality (e.g.
relaxation, exercise,biofeedback) strong
enough to suppress anxiety.
Client fears disorganization and loss of control
of body and mind when exposed to the fear
producing stimulus.This fear leads to an
avoidance response, and reality is never tested.
If client waits out the beginnings of anxiety and
decreases it with relaxation exercises, then she
or he may be ready to continue confronting the
fear.
Provides the client with a sense of control over
the fear. Distracts the client so that fear is not
totally focused on and allowed to escalate.
Systematic desensitization (gradual systematic
exposure of the client to the feared situation
under controlled conditions) allows the client
to begin to overcome the fear, become
desensitized to the fear. Note: Implosion or
flooding (continuous, rapid presentation of the
phobic stimulus) may show quicker results
than systematic desensitization, but relapse is
more common or client may become terrified
and withdraw from therapy.
Experiencing fear in progressively more
challenging but attainable steps allows client to
realize that dangerous consequences will not
occur. Helps extinguish conditioned avoidance
response
Helps client to achieve physical and mental
relaxation as the anxiety becomes less
uncomfortable.
  Help client to learn how to use these
techniques when confronting an actual
anxiety-provoking situation. Provide for
practice sessions (e.g.role-play), deal with
phobic reactions in real- life situations.
Client needs continued confrontation to gain
control over fear. Practice helps the body
become accustomed to the feeling of relaxation,
enabling the individual to handle feared
object/situation.

Develops confidence and movement toward

Encourage client to set increasingly more difficult goals.
improved functioning and independence.

Administer antianxiety medications as indicated; watch out for any adverse side effects

Benzodiazepines:
Biological factors may be involved in
 Alprazolam (Xanax), phobic/panic reactions, and these medications
(particularly Xanax) produce a rapid calming
 Clonazepam (Klonopin), effect and may help client change behavior by
 diazepam (Valium), keeping anxiety low during learning and
 lorazepam (Ativan) desensitization sessions. Addictive tendencies
of CNS depressants need to be weighed against
 chlordiazepoxide (Librium),
benefit from the medication.
 oxazepam (Serax)

Ineffective Coping

Ineffective Coping: Inability to form a valid appraisal of the stressors,

inadequate choices of practiced responses, and/or inability to use available
resources.

May be related to

 Situational crises
 Maturational crises
 Fear of failure

Possibly evidenced by
  Ritualistic behavior or obsessive thoughts
 Inability to meet basic needs
 Inability to meet role expectations
 Inadequate problem solving

Desired Outcomes

 Client will decrease participation in ritualistic behavior.

 Client will demonstrate ability to cope effectively.
 Client will verbalize signs and symptoms of increasing anxiety and
intervene to maintain anxiety at manageable level.
 Client will demonstrate ability to interrupt obsessive thoughts and
refrain from ritualistic behaviors.

Nursing Interventions Rationale

Assess client’s level of anxiety. Investigate the Helping the client recognize the precipitating factors is the
types of situations that increase anxiety and first step in teaching the client to interrupt the escalating
result in ritualistic behaviors. anxiety.

Sudden and complete elimination of avenues for

Initially meet the client’s dependency needs
dependency would create anxiety and will burden the client
as necessary.
more.

Encourage independence and give positive Positive reinforcement enhances self-esteem and
reinforcement for independent behaviors. encourages repetition of desired behaviors.
During the beginning of treatment, allow
plenty of time for rituals. Do not be To deny client this activity can precipitate panic level of
judgmental or verbalize disapproval of the anxiety.
behavior.

Client may be unaware of the relationship between

Support and encourage client’s efforts to
emotional problems and compulsive behaviors. Recognition
explore the meaning and purpose of the
and acceptance of problems is important before change can
behavior.
occur.

Gradually limit the amount of time allotted for

Anxiety is minimized when client is able to replace
ritualistic behavior as client becomes more
ritualistic behaviors with more adaptive ones.
involved in unit activities.

Encourage the recognition of situations that

Recognition of precipitating factors is the first step in
provoke obsessive thoughts or ritualistic
teaching client to interrupt escalation of anxiety.
behaviors.

Provide positive reinforcement for Positive reinforcement enhances self-esteem and

nonritualistic behaviors. encourages repetition of desired behaviors.

Powerlessness

Powerlessness: The perception that one’s own action will not significantly
affect an outcome; a perceived lack of control over a current situation or
immediate happening.

May be related to
  Lifestyle of helplessness
 Fear of disapproval from others
 Consistent negative feedback

Possibly evidenced by

 Apathy
 Dependence on others that may result in irritability, resentment,
anger, and/or guilt.
 Verbal expressions of having no control
 Nonparticipation in care or decision making when opportunities are
provided.
 Reluctance to express true feelings.

Desired Outcomes

 Client will participate in decision making regarding own care.

 Client will be able to effectively problem-solve ways to take control of
his or her life situation.

Nursing Interventions Rationale

Have client take as much responsibility for own self- Providing client with choices and responsibility
care practices. will increase his or her feelings of control.

Unrealistic goals set the client up for failure and

Help client set realistic goals.
reinforce feelings of powerlessness.
 Client’s emotional condition prevents his ability to
Help identify areas of life situation that client can solve problems. Support is required to perceive the
control. benefits and consequences of available
alternatives.

Help the client identify areas of life situation that are

To deal with unresolved issues and accept what
not with his ability to control; encourage verbalization
cannot be changed.
of these feelings.

Identify ways and instances in which the client can

Positive reinforcement enhances self-esteem and
achieve and encourage participation in these activities;
encourages repetition of positive behaviors.
provide positive reinforcement for participation.

Social Isolation

Social Isolation: Aloneness experienced by the individual and perceived as

imposed by others and as a negative or threatening state.

May be related to

 Maturational crisis.
 Panic level of anxiety.
 Past experiences of difficulty in interaction with others.
 Repressed fears.

Possibly evidenced by
  Uncommunicative
 Withdrawn
 No eye contact
 Insecurity in public
 Expression of feelings of rejection
 Preoccupation with own thoughts; repetitive meaningless actions

Desired Outcomes

 Client will willingly attend therapy activities accompanied by trusted

support person.
 Client will voluntarily spend time with other clients and staff members
in group activities.

Nursing Interventions Rationale

Convey an accepting and positive attitude by making brief, An accepting attitude increases feeling of
frequent contacts. self-worth and facilitates trust.

To convey your belief in the client as a

Show unconditional positive regard.
worthwhile individual.

Be with the client to offer support during group activities that The presence of a trusted individual
may be frightening or difficult for him or her. provides emotional security for the client.

Honesty and dependability promote a

Be honest and keep all promises.
trusting relationship.

Be cautious with touch. Allow client extra space and avenue A person in panic level anxiety may
for exit if he becomes too anxious. perceive touch as a threatening gesture.

Short-term use of antianxiety

Administer tranquilizing medications as ordered; monitor
medications helps to reduce the level of
adverse side effects.
anxiety in most individuals.

Discuss with the client the signs of increasing anxiety and Maladaptive behaviors are manifested
techniques for interrupting the response such as breathing during times of increased anxiety.
exercises, thought stopping, relaxation, meditation.

Positive reinforcement enhances self-

Give recognition and positive reinforcement for client’s
esteem and encourages repetition of
voluntary interaction with others.
acceptable behaviors.

Self-Care Deficit

Self-Care Deficit: Impaired ability to perform or complete activities of daily

living (ADL) independently.

May be related to

 Excessive ritualistic behavior

 Disabling anxiety
 Withdrawal
 Unmet dependency needs

Possibly evidenced by

 Unwillingness to perform self-hygiene.

 Uncombed hair, dirty clothes, offensive body odor
 Lack of interest in selecting appropriate clothing to wear
 Incontinence

Desired Outcomes

 Client will verbalize desire to take control of self-care activities.

 Client will be able to take care of own ADLs and demonstrate a
willingness to do so.
 Nursing Interventions Rationale

Urge client to perform normal ADLs to Successful performance of independent activities enhances self-
his level of ability. esteem.

Encourage independence. Intervene

Safety and comfort of the client are nursing priorities.
when client is unable to perform.

Offer recognition and positive

Positive reinforcement enhances self-esteem and encourages
reinforcement for independent
repetition of desired behaviors.
accomplishments.

During high levels of anxiety, client may require simple, concrete

Show client how to perform activities
demonstrations of activities that would be performed without
with which he is having difficulty with.
difficulty under normal conditions.

Keep strict records of food and fluid

For an accurate nutritional assessment.
intake.

Offer nutritious snacks and fluids Client may be unable to tolerate large amounts of foods and
between meals. mealtimes and may therefore require additional nourishment.

Deficient Knowledge

Deficient Knowledge: The state in which an individual or group experiences a

deficiency in cognitive knowledge or psychomotor skills concerning the condition
or treatment plan.

May be related to

 Unfamiliarity with medications used and potential adverse effects.

Possibly evidenced by
  Verbalizes a deficiency in knowledge or skill or requests information.
 Expresses an inaccurate perception of health status.
 Does not corretly perform desired or prescribed health behavior.

Desired Outcomes

 Client states correct information about medications and adverse side

effects.

Nursing Interventions Rationale

Explain the physiologic action of SSRI in Anxiety disorders are caused by neuropsychiatric disorder that
relieving anxiety. responds to medication.

These are the common adverse effects of SSRIs. Treatment

Assess for nausea, headache, nervousness,
should be started at low doses and increased gradually as
insomnia, agitation, sexual dysfunction.
patient tolerates.

Assess for fatigue, drowsiness, and

Common side effects of benzodiazepines.
cognitive impairments.

A gradual tapering is necessary when a

Abrupt discontinuation can cause recurrence of anxiety.
benzodiazepine is discontinued.

Major Depression Nursing Care

Plans
Major depression is classified under mood disorders which are characterized
by disturbances in the regulation of mood, behavior, and affect that go beyond
the normal fluctuations that most people experience.
Nursing Care Plans

The nurse’s plan of care for patients with major depression should be to
determine degree of impairment, assess coping abilities, assist client to deal
with current situation, provide for meeting psychological needs, and promote
health and wellness.

Here are six (6) nursing care plans for major depression:

Risk For Self-Directed Violence

Risk for self-directed violence: At risk for behaviors in which an individual

demonstrates that he/she can be physically, emotionally, and/or sexually
harmful to self.

Risk factors

 Anhedonia, helplessness, hopelessness

 Loneliness
 Social isolation
 Severe personality disorder/ depression/ psychosis, substance abuse

Possibly evidenced by

 Previous attempts of violence.

 Suicidal plan (clear, specific, lethal method and available means).
 Suicidal behavior (attempts, ideation, plan and available means).
 When depression begins to lift, clients may have energy to carry out
suicidal plan.

Desired Outcomes

 Patient will seek help when experiencing self-destructive impulses.

  Patient will have a behavioral manifestation of absent depression.
 Patient will have satisfaction with social circumstances and
achievements of life goals.
 Patient will identify at least two-three people he/she can seek out for
support and emotional guidance when he/she is feeling self-destructive
before discharge.
 Patient will not inflict any harm to self or others.
 Patient will identify support and support groups with he/she is in
contact within one month.
 Patient will state that he/she wants to live.
 Patient will start working on constructive plans for the future.
 Patient will demonstrate compliance with any medication or treatment
plan within the next two weeks.
 Patient will demonstrate alternative ways of dealing with negative
feelings and emotional stress.

Nursing Interventions Rationale

Identify the level of suicide precautions needed. If there is a high-

risk, does a hospitalization requires? Or if there is a low risk, will the
client be safe to go home with supervision from a family member or a
friend? For example, does client:
A client with a high-risk will require
a constant supervision and a safe
 Admit previous suicide attempts. environment.
 Abuse any substances.
 Have no peers/friends.
 Have any suicide plan.

Clients need a network of resources

Contact the family, arrange for crisis counseling. Activate links to to help diminish personal feelings of
self-help groups. helplessness, worthlessness, and
isolation.

Normally, a suicidal client’s medical

Check for the availability of required supply of medications needed.
supply should be limited to 3-5 days.
 Clients can learn alternative ways of
Encourage clients to express feelings (anger, sadness, guilt) and
dealing with overwhelming
come up with alternative ways to handle feelings of anger and
emotions and gain a sense of control
frustration.
over his/her life.

There are different measures for

If, hospitalized, follow unit protocols. the suicidal client in either the
hospital, clinic, and community.

Reinforces action the client can take

Implement a written no-suicide contract.
when feeling suicidal.

Impaired Social Interaction

Impaired Social Interaction: Insufficient or excessive quantity or ineffective

quality of social exchange.

May be related to

 Altered thought processes.

 Anergia (lack of energy and motivation).
 Feelings of worthlessness.
 Fear of rejection.
 Lack of support system.
 Self-concept disturbance.

Possibly evidenced by

 Dysfunctional interaction with family, peers, and/or others.

 Family reports change of style or patterns of interaction.
 Verbalized discomfort in social situations.
 Remains feelings of seclusion, avoids contact with others and
lacks eye contact.
Desired Outcomes

 Patient will identify feelings that lead to poor social interactions.

 Patient will interact with family/friends/peers.
 Patient will participate in certain community social activities
(e.g.,leisure activity, church member).
 Patient will participate in one activity by the end of the day.
 Patient will discuss two-three alternative ways to take when feeling the
need to withdraw.
 Patient will identify two-three personal behaviors that might discourage
others from seeking contact.
 Patient will eventually voluntarily attend individual/group therapeutic
meetings within a therapeutic milieu (community or hospital).
 Patient will verbalize that he/she enjoys interacting with others in
activities and one-on-one interactions to the extent they did before
becoming depressed.
 Patient will state and demonstrate progress in the resumption of
sustaining relationships with friends and family members within one
month.

Nursing Interventions Rationale

Initially, provide activities that require Depressed people lack concentration and memory. Activities that
minimal concentration (e.g., drawing, have no “right or wrong” or “winner or loser” minimizes
playing simple board games). opportunities for the client to put himself/herself down.

Involve the client in gross motor

Such activities will aid in relieving tensions and might help in
activities that call for very little
elevating the mood.
concentration (e.g.,walking).

When the client is at the most

Maximizes the potential for interactions while
depressed state, Involve the client in
minimizing anxiety levels.
one-to-one activity.

Eventually involve the client in group Socialization minimizes feelings of isolation. Genuine regard for
activities (e.g., group discussions, art others can increase feelings of self-worth.
therapy, dance therapy).

Eventually maximize the client’s

contacts with others (first one other, Contact with others distracts the client from self-preoccupation.
then two others, etc.).

Refer the client and family to self-help The client and the family can gain tremendous support and insight
groups in the community. from people sharing their experiences.

Spiritual Distress

Spiritual Distress: Impaired ability to experience and integrate meaning and

purpose in life through a person’s connectedness with self, others, art,
literature, music, nature, or a power greater than oneself.

May be related to

 Chronic illness of self or others.

 Death or dying of self or others.
 Lack of purpose in life.
 Life changes.
 Pain.
 Self-alienation.
 Sociocultural deprivation.

Possibly evidenced by

 Expresses intense feelings of guilt.

 Expresses feelings of hopelessness and helplessness.
 Expresses being abandoned by or having anger towards God.
 Expresses concern with meaning of life/death or belief systems.
  Expresses lack of hope, meaning, or purpose in life, forgiveness of self,
peace, serenity, acceptance.
 Inability to pray.
 Inability to express previous state of creativity (e.g., writing, drawing,
singing).
 Inability to participate in religious activities
 Lack of interest in art.
 Questions meaning of own existence.
 Refuses interaction with families, friends or religious leaders.
 Searching for a spiritual source of strength.

Desired Outcomes

 Patient will feel the connectedness with others to share thoughts,

feelings, and beliefs.
 Patient will feel the connectedness with the inner self.
 Patient will participates in spiritual rites and passages.
 Patient will discuss with nurse two things that gave his or her life
meaning in the past within 3 days.
 Patient will talk to a nurse or a spiritual leader about spiritual conflicts
and concern within 3 days.
 Patient will keep a journal tracking thoughts and feelings for one week.
 Patient will state that he/she feels a sense of forgiveness.
 Patient will state that he/she wants to participate in former creative
activities.
 Patient will state that he/she gained comfort from previous spiritual
practices.

Nursing Interventions Rationale

Assess what spiritual practices have offered Evaluates neglected areas in the person’s life that, if
comfort and meaning to the client’s life when not reactivated, might add comfort and meaning during
ill. a painful depression.
 This will help in identifying important personal issues
Encourage client to write a journal expressing and one’s thought and feelings surrounding spiritual
thoughts and reflections daily. issues. Writing a journal is a good way to explore deeper
meanings in life.

If the client is unable to write, provide a tape Often speaking aloud helps a person clarify thinking and
recorder. explore issues.

When depressed, clients usually are having a hard time

Discuss with the client what has given comfort
searching for meaning in life and reasons to go on when
and meaning to the person in the past.
feeling hopelessness and despondent.

Suggest that the spiritual leader affiliated with Spiritual leaders are familiar in dealing spiritual distress
the facility contact the client. and can offer comfort to the client.

Provide information on referrals, when needed,

When hospitalized, spiritual tapes and readings can be
for religious or spiritual information (e.g.,
useful; when the client is in the community, client might
readings, programs, tapes, community
express other needs.
resources).

Chronic Low Self-Esteem

Chronic Low Self-Esteem: Long standing negative self-evaluation/feelings

about self or self-capabilities.

May be related to

 Biochemical/neurophysiological imbalances.
 Feelings of shame and guilt.
 Impaired cognitive self-appraisal.
 Repeated past failure.
 Unrealistic expectation of self.

Possibly evidenced by
  Evaluates self as unable to deal with events.
 Inability to recognize own achievement.
 Negative view of self and abilities.
 Repeated expression of worthlessness.
 Rejection of a positive feedback.
 Self-negating verbalizations.

Desired Outcomes

 Patient will express belief in self.

 Patient will maintain self-esteem.
 Patient will demonstrate a zest for life and ability to enjoy the present.
 Patient will identify one or two strengths by the end of the day.
 Patient will identify two unrealistic self-expectations and reformulate
more realistic life goals with nurse by the end of the day.
 Patient will identify three judgemental terms (e.g., “I am lazy”) client
uses to describe self and identify objective terms to replace them (e.g.,
” I do not feel motivated to).
 Patient will keep a daily load and identify on a scale of 1 to 10 (1 being
the lowest, 10 being the highest) feelings of guilt, shame, self-hate.
 Patient will report decreased feelings of guilt, shame and self-hate by
using a scale of 1 to 10 (1 being the lowest, 10 being the highest).
 Patient will demonstrate the ability to modify unrealistic self-
expectations.
 Patient will give an accurate and nonjudgmental account of four
positive qualities as well as identify two areas he or she wishes to
improve.

Nursing Interventions Rationale

To promote a healthier and more realistic

Teach visualization techniques that can help the client replace
self-image by helping the client choose
negative self-images with more positive images and thought.
more positive thoughts and actions.
 To minimize the feelings of isolation and
Encourage the client to participate in a group therapy where
provide an atmosphere where positive
the members share the same situations/feelings that they
feedback and a more realistic appraisal of
have.
self are available.

Evaluate client’s need for assertiveness training tools to

Low self-esteem individuals often have
pursue things he or she wants or needs in life. Arrange for
feelings of unworthiness and have difficulty
training through community-based programs, personal
determining their needs and wants.
counseling, literature etc.

Role model assertiveness. Clients can follow examples/role models.

Involve the client in activities that he or she wants to improve

Feelings of low self-esteem can interfere
by using problem-solving skills. Assess and evaluate the need
with usual problem-solving abilities.
for more teaching in this area.

Cognitive distortions reinforce negative,

inaccurate perception of self and the world.

1. Focus on negative qualities.

Work with the client to identify cognitive distortions that 2. Assuming others “do not like
encourage negative self-appraisal. For example:
me”. for example, without any
real evidence that assumptions
1. Discounting positive attributes.
are correct.
2. Mind reading.
3. Taking one fact or event and
3. Overgeneralizations.
making a general rule out of it.
4. Self-blame.
(“He always”, I never”).
4. Consistent self-blame for
everything perceived as
negative.

Disturbed Thought Processes

Disturbed Thought Processes: A state in which individual experiences a

disruption in cognitive operations and activities.
May be related to

 Biologic/medical factors.
 Biochemical/neurophysical imbalances.
 Persistent feelings of extreme guilt, fear or anxiety.
 Prolong grief reaction.
 Overwhelming life circumstances.
 Severe anxiety or depressed mood.

Possibly evidenced by

 Decreased problem-solving abilities.

 Hypovigilance.
 Impaired ability to grasp ideas or orders thoughts.
 Impaired attention span/easily distracted.
 Impaired insight.
 Impaired judgment, perception, decision making.
 Inaccurate interpretation of the environment.
 Memory problems/deficits.
 Negative ruminations.

Desired Outcomes

 Patient will process information and makes appropriate decisions.

 Patient will accurately recall recent and remote information.
 Patient will exhibit organized thought process.
 Patient will identify two goals he or she wants to achieve from
treatment, with aid of nursing intervention, within 1 to 2 days.
 Patient will discuss with nurse two irrational thoughts about self and
others by the end of the first day.
 Patient will reframe three irrational thoughts with the nurse.
  Patient will remember to keep appointments, attend activities, and
attend to grooming with minimal reminders from others within 1 to 3
weeks.
 Patient will identify negative thoughts and rationally counter them
and/or reframe them in a positive manner within 2 weeks.
 Patient will show improved mood as demonstrated by the Beck
Depression Inventory.
 Patient will give examples showing that short-term memory and
concentration have improved to usual levels.
 Patient will demonstrate an increased ability to make appropriate
decisions when planning with the nurse.

Nursing Interventions Rationale

Determine the client’s previous level of

Establishing a baseline data allows for evaluation of
cognitive functioning (from client, family, past
client’s progress.
medical records).

Slowed thinking and difficulty concentrating impair

Use simple, concrete words.
comprehension.

Allow the client to have plenty of time to think

Slowed thinking necessitates time to formulate a response.
and frame responses.

Allow more time than usual for the client to Usual tasks might take long periods of time; demands that
finish usual activities of daily living (ADL) the client hurry only increase anxiety and slow down
(e.g.,eating, dressing). ability to think clearly.

Help the client to postpone important major Making rational major life decision requires optimal
life decision making. psychophysiological functioning.

While the client is severely depressed,

Decreases feelings of guilt, anxiety and pressure.
minimize client’s responsibility.

Negative ruminations add to feelings of hopelessness and

Help the client identify negative
are part of a depressed person’s faulty thought processes.
thinking/thoughts. Teach the client to reframe
Intervening in this process helps in healthier and more
and/or refute negative thoughts. useful outlook in life.

Help client and family structure an

environment that can help re-establish set A fairly and non-demanding repetitive routine is easier to
schedules and predictable routines during both follow and remember.
severe depressions.

Self-Care Deficit

Self-Care Deficit: Impaired ability to perform or complete bathing/hygiene,

dressing/grooming, feeding or toileting activities for oneself.

May be related to

 Anergia (Decreased or lack of motivation).

 Perceptual or cognitive impairment.
 Severe anxiety.
 Severe preoccupation.

Possibly evidenced by

 Awakening earlier or later than desired.

 Body odor/hair unwashed and unkempt.
 Constipation related to lack of exercise, roughage in diet, and poor
fluid intake.
 Consuming insufficient food or nutrients to meet minimum daily
requirements.
 Decreased ability to function secondary to sleep deprivation.
 Inability to organize simple steps in hygiene and grooming.
 Persistent insomnia or hypersomnia.
 Weight loss.

Desired Outcomes
  Patient will groom and dress appropriately with help from a nursing
staff and/ or family.
 Patient will regain more normal elimination pattern with aid of foods
high in roughage, increased fluid intake, and exercise daily (also with
the aid of medications).
 Patient will sleep between 4 to 6 hours with aid of nursing measures
and/or medications.
 Patient will gain 1 pound a week with encouragement from family,
significant others, and/or staff if significant weight loss is noted.
 Patient will demonstrate progress in the maintenance of adequate
hygiene and be appropriately groomed and dressed (shave/makeup,
clothes clean and neat).
 Patient will experience normal elimination with the aid of diet, fluids,
and exercise within 3 weeks.
 Patient will sleep between 6 to 8 hours per night within one month.
 Patient will gradually return to weight consistent for height and age or
baseline before illness.

Nursing Interventions Rationale

Bathing and/or Hygiene Self-Care Deficit:

 Encourage the use of soap, washcloth, Being clean and well groomed can
toothbrush, shaving equipment, make-up etc. temporarily increase self-esteem.

 Give step-by-step reminders such as “Brush

Slowed thinking and difficulty concentrating
the teeth “Clean the outer surfaces of your make organizing simple tasks difficult.
upper teeth, then your lower teeth. . .”

Constipation

Most of the depressed clients are constipated.

 Monitor intake and output, especially the
If this problem is not addressed, it can lead to
bowel movements. fecal impaction.
  Encourage the intake of nonalcoholic and
Fluids can help prevent constipation.
noncaffeinated fluids, 6 to 8 glasses a day.

Roughage and exercise

 Offer fiber-rich foods and periods of exercise. stimulate peristalsis and help evacuation of
fecal material.

These prevent the occurrence of fecal

 Evaluate the need for laxatives and enemas. impaction.

Disturbed Sleep Pattern

 Provide rest periods after activities. Fatigue can intensify feelings of depression.

 Encourage relaxation measures in the evening

(e.g., drinking warm milk, back rub, or tepid These measures induce sleep and relaxation.
bath).

 Encourage the client to get up and dress and Minimize sleep during the day increases the
to stay out of bed during the day. likelihood of sleep at night.

 Reduce environmental and physical

stimulants in the evening; Provide Decreasing caffeine and epinephrine levels
decaffeinated coffee, soft music, soft lights and increases the possibility of sleep.

quiet activities.

Imbalanced Nutrition

 Weight the client weekly and observe the Give the information needed for revising the
eating patterns of the client. intervention.

Increases socialization, decrease focus on the

 Encourage eating with others. food.

 Serve foods or drinks the client likes. Clients are more likely to eat foods they like.

 Encourage small, high-calorie, and high- Minimize weight loss, constipation,

 and dehydration.
protein snacks and fluids frequently
throughout the day and evening if weight loss
is noted.

Schizophrenia Nursing Care

Plans
Schizophrenia refers to a group of severe, disabling psychiatric disorders
marked by withdrawal from reality, illogical thinking, possible delusions and
hallucinations, and emotional, behavioral, or intellectual disturbance.

Nursing Care Plans

Nursing management of schizophrenia involves recognizing schizophrenia,

establishing trust and rapport, maximizing level of functioning, assessing
positive and negative symptoms, assessing medical history and evaluating
support system.

Here are six (6) nursing care plans for schizophrenia:

Impaired Verbal Communication

Impaired Verbal Communication: decreased, reduced, delayed, or absent

ability to receive, process, transmit, or use a system of symbols.

May be related to

 Altered perceptions.
 Biochemical alterations in the brain of certain neurotransmitters.
 Psychological barriers (lack of stimuli).
  Side effects of medication.

Possibly evidenced by

 Difficulty communicating thoughts verbally.

 Difficulty in discerning and maintaining the usual communication
pattern.
 Disturbances in cognitive associations (e.g., perseveration, derailment,
poverty of speech, tangentiality, illogicality, neologism, and thought
blocking).
 Inappropriate verbalization.

Desired Outcomes

 Patient will express thoughts and feelings in a coherent, logical, goal-

directed manner.
 Patient will demonstrate reality-based thought processes in verbal
communication.
 Patient will spend time with one or two other people in structured
activity neutral topics.
 Patient will spend two to three 5-minute sessions with nurse sharing
observations in the environment within 3 days.
 Patient will be able to communicate in a manner that can be
understood by others with the help of medication and attentive
listening by the time of discharge.
 Patient will learn one or two diversionary tactics that work for him/her
to decrease anxiety, hence improving the ability to think clearly and
speak more logically.

Nursing Interventions Rationale

Assess if incoherence in speech is chronic or if it is more

Establishing a baseline facilitates the
sudden, as in an exacerbation of symptoms.
establishment of realistic goals, the foundation
 for planning effective care.

Therapeutic levels of an antipsychotic aids clear

Identify the duration of the psychotic medication of the
thinking and diminishes derailment or looseness
client.
of association.

High-pitched/loud tone of voice can elevate

Keep voice in a low manner and speak slowly as much as
anxiety levels while slow speaking aids
possible.
understanding.

Keep anxiety from escalating and

Keep environment calm, quiet and as free of stimuli as
increasing confusion and
possible.
hallucinations/delusions.

Short periods are less stressful, and periodic

Plan short, frequent periods with a client throughout the
meetings give a client a chance to develop
day.
familiarity and safety.

Use clear or simple words, and keep directions simple as Client might have difficulty processing even
well. simple sentences.

Minimizes misunderstanding and/or

Use simple, concrete, and literal explanations. incorporating those misunderstandings into
delusional systems.

Focus on and direct client’s attention to concrete things Helps draw focus away from delusions and focus
in the environment. on reality-based things.

Look for themes in what is said, even though spoken Often client’s choice of words is symbolic of
words appear incoherent (e.g., fearful, sadness, guilt). feelings.

Pretending to understand limits your credibility

When you do not understand a client, let him/her know
in the eyes of your client and lessens the
you are having difficulty understanding.
potential for trust.

When client is ready, introduce strategies that can

minimize anxiety and lower voices and “worrying” Helping client to use tactics to lower anxiety can
thoughts, teach client to do the following: help enhance functional speech.
  Focus on meaningful activities.
 Learn to replace negative thoughts with
constructive thoughts.
 Learn to replace irrational thoughts with
rational statements.
 Perform deep breathing exercise.
 Read aloud to self.
 Seek support from a staff, family, or other
supportive people.
 Use a calming visualization or listen to
music.

Use therapeutic techniques (clarifying feelings when

Even if the words are hard to understand,
speech and thoughts are disorganized) to try to
try getting to the feelings behind them.
understand client’s concerns.

Impaired Social Interaction

Impaired Social Interaction: The state in which an individual participates in an

insufficient or excessive quantity or ineffective quality of social exchange.

May be related to

 Difficulty with communication.

 Difficulty with concentration.
 Exaggerated response to alerting stimuli.
 Feeling threatened in social situations.
 Impaired thought processes (delusions or hallucinations).
 Inadequate emotional responses.
 Self concept disturbance (verbalization of negative feelings about self).
Possibly evidenced by

 Appears upset, agitated, or anxious when others come too close in

contact or try to engage him/her in an activity.
 Dysfunctional interaction with others/peers.
 Inappropriate emotional response.
 Observed use of unsuccessful social interactions behaviors.
 Spends time alone by self.
 Unable to make eye contact, or initiate or respond to social advances
of others.
 Verbalized or observed discomfort in social situations.

Desired Outcomes

 Patient will attend one structured group activity within 5-7 days.
 Patient will seek out supportive social contacts.
 Patient will improve social interaction with family, friends, and
neighbors.
 Patient will use appropriate social skills in interactions.
 Patient will engage in one activity with a nurse by the end of the day.
 Patient will maintain an interaction with another client while doing an
activity (e.g., simple board game, drawing).
 Patient will demonstrate interest to start coping skills training when
ready for learning.
 Patient will engage in one or two activities with minimal
encouragement from nurse or family members.
 Patient will state that he or she is comfortable in at least three
structured activities that are goal directed.
 Patient will use appropriate skills to initiate and maintain an
interaction.

Nursing Interventions Rationale


Assess if the medication has reached therapeutic levels.
Identify with client symptoms he experiences when he or she
begins to feel anxious around others.
Keep client in an environment as free of stimuli (loud noises,
crowding) as possible.
Avoid touching the client.
Ensure that the goals set are realistic; whether in the
hospital or community.
Structure activities that work at the client’s pace and activity.
Structure times each day to include planned times for brief
interactions and activities with the client on one-on-one
basis
If client is unable to respond verbally or in a coherent
manner, spend frequent, short period with clients.
If client is found to be very paranoid, solitary or one-on-one
activities that require concentration are appropriate.
If client is delusional/hallucinating or is having trouble
concentrating at this time, provide very simple concrete
Many of the positive symptoms of
schizophrenia (hallucinations, delusions,
racing thoughts) will subside with
medications, which will facilitate
interactions.
Increased anxiety can intensify agitation,
aggressiveness, and suspiciousness.
Client might respond to noises and crowding
with agitation, anxiety, and increased
inability to concentrate on outside events.
Touch by an unknown person can be
misinterpreted as a sexual or threatening
gesture. This particularly true for a paranoid
client.
Avoids pressure on the client and sense of
failure on part of nurse/family. This sense of
failure can lead to mutual withdrawal
Client can lose interest in activities that are
too ambitious, which can increase a sense of
failure.
Helps client to develop a sense of safety in a
non-threatening environment.
An interested presence can provide a sense
of being worthwhile.
Client is free to choose his level of
interaction; however, the concentration can
help minimize distressing paranoid thoughts
or voice.
Even simple activities help draw client away
from delusional thinking into reality in the
activities with client (e.g., looking at a picture or do a
painting).
If client is very withdrawn, one-on-one activities with a
“safe” person initially should be planned.
Try to incorporate the strengths and interests the client had
when not as impaired into the activities planned.
Teach client to remove himself briefly when feeling agitated
and work on some anxiety relief exercise (e.g.,
meditations,rhytmic exercise, deep breathing exercise).
Useful coping skills that client will need include
conversational and assertiveness skills.
Remember to give acknowledgment and recognition for
positive steps client takes in increasing social skills and
appropriate interactions with others.
Provide opportunities for the client to learn adaptive social
skills in a non-threatening environment. Initial social skills
training could include basic social behaviors (e.g.,
appropriate distance, maintain good eye contact, calm
manner/behavior, moderate voice tone).
As client progresses, provide the client with graded activities
according to level of tolerance e.g., (1) simple games with
one “safe” person; (2) slowly add a third person into “safe”.
As client progresses, Coping Skills Training should be
available to him/her (nurse, staff or others). Basically the
process:
1. Define the skill to be learned.
2. Model the skill.
3. Rehearse skills in a safe environment, then in
environment.
Learn to feel safe with one person, then
gradually might participate in a structured
group activity.
Increase likelihood of client’s participation
and enjoyment.
Teach client skills in dealing with anxiety
and increasing a sense of control.
These are fundamental skills for dealing
with the world, which everyone uses daily
with more or less skill.
Recognition and appreciation go a long way
to sustaining and increasing a specific
behavior.
Social skills training helps client adapt and
function at a higher level in society, and
increases client’s quality of life.
Gradually the client learns to feel safe and
competent with increased social demands.
Increases client’s ability to derive social
support and decrease loneliness. Clients will
not give up substance of abuse unless they
have alternative means to facilitate
socialization they belong.
 the community.
4. Give corrective feedback on the implementation
of skills.

Eventually engage other clients and significant others in

social interactions and activities with the client (card games, Client continues to feel safe and competent
ping pong, sing-a-songs, group sharing activities) at client’s in a graduated hierarchy of interactions.
level.

Disturbed Sensory Perception: Auditory/Visual

Disturbed Sensory Perception: Change in the amount or patterning of incoming

stimuli accompanied by a diminished, exaggerated, distorted or impaired
response to such stimuli.

May be related to

 Altered sensory perception.

 Altered sensory reception; transmission or integration.
 Biochemical factors such as manifested by inability to concentrate.
 Chemical alterations (e.g., medications, electrolyte imbalances).
 Neurologic/biochemical changes.
 Psychologic stress.

Possibly evidenced by

 Altered communication pattern.

 Auditory distortions.
 Change in a problem-solving pattern.
 Disorientation to person/place/time.
 Frequent blinking of the eyes and grimacing.
 Hallucinations.
  Inappropriate responses.
 Mumbling to self, talking or laughing to self.
 Reported or measured change in sensory acuity.
 Tilting the head as if listening to someone.

Desired Outcomes

 Patient will learn ways to refrain from responding to hallucinations.

 Patient will state three symptoms they recognize when their stress
levels are high.
 Patient will state that the voices are no longer threatening, nor do they
interfere with his or her life.
 Patient will state, using a scale from 1 to 10, that “the voices” are less
frequent and threatening when aided by medication and nursing
intervention.
 Patient will maintain role performance.
 Patient will maintain social relationships.
 Patient will monitor intensity of anxiety.
 Patient will identify two stressful events that trigger hallucinations..
 Patient will identify to personal interventions that decrease or lower the
intensity or frequency of hallucinations (e.g, listening to music, wearing
headphones, reading out loud, jogging, socializing).
 Patient will demonstrate one stress reduction technique.
 Patient will demonstrate techniques that help distract him or her from
the voices.

Nursing Interventions Rationale

Accept the fact that the voices are real to the client, Validating that your reality does not include voices
but explain that you do not hear the voices. Refer to can help client cast “doubt” on the validity of his or
the voices as “your voices” or “voices that you hear”. her voices.

Might herald hallucinatory activity, which can be

Be alert for signs of increasing fear, anxiety or
very frightening to client, and client might act upon
agitation. command hallucinations (harm self or others).

Exploring the hallucinations and sharing the

Explore how the hallucinations are experienced by experience can help give the person a sense of
the client. power that he or she might be able to manage the
hallucinatory voices.

Hallucinations might reflect needs for:

Help the client to identify the needs that might

 Anger.
underlie the hallucination. What other ways can
these needs be met?  Power.
 Self-esteem.
 Sexuality.

Helps both nurse and client identify situations and

Help client to identify times that times that the
times that might be most anxiety producing and
hallucinations are most prevalent and frightening.
threatening to the client.

If voices are telling the client to harm self or others,

take necessary environmental precautions.

 Notify others and police, physician, and

administration according to unit
protocol.
 If in the hospital, use unit protocols for
suicidal or threats of violence if client People often obey hallucinatory commands to kill
plans to act on commands. self or others. Early assessment and intervention
might save lives.
 If in the community, evaluate the need
for hospitalization.

Clearly document what client says and if

he/she is a threat to others, document
who was contacted and notified (use
agency protocol as a guide).

Stay with clients when they are starting to Client can sometimes learn to push voices aside
hallucinate, and direct them to tell the “voices they when given repeated instructions. especially within
hear” to go away. Repeat often in a matter-of-fact the framework of a trusting relationship.
manner.

Decrease environmental stimuli when possible (low Decrease potential for anxiety that might trigger
noise, minimal activity). hallucinations. Helps calm client.

Intervene before anxiety begins to escalate. If the

Intervene with one-on-one, seclusion, or PRN
client is already out of control, use chemical or
medication (As ordered) when appropriate.
physical restraints following unit protocols.

Client’ thinking might be confused and disorganized;

Keep to simple, basic, reality-based topics of
this intervention helps client focus and comprehend
conversation. Help client focus on one idea at a time.
reality-based issues.

Work with the client to find which activities help If clients’ stress triggers hallucinatory activity, they
reduce anxiety and distract the client from might be more motivated to find ways to remove
a hallucinatory material. Practice new skills with themselves from a stressful environment or try
the client. distraction techniques.

Engage client in reality-based activities such as card Redirecting client’s energies to acceptable activities
playing, writing, drawing, doing simple arts and can decrease the possibility of acting on
crafts or listening to music. hallucinations and help distract from voices.

Disturbed Thought Process

Disturbed Thought Process: Disruption in cognitive operations and activities.

May be related to

 Chemical alterations (e.g., medications, electrolyte imbalances).

 Inadequate support systems.
 Overwhelming stressful life events.
 Possibility of a hereditary factor.
 Panic level of anxiety.
 Repressed fears.

Possibly evidenced by
  Delusions.
 Inaccurate interpretation of environment.
 Inappropriate non-reality-based thinking.
 Memory deficit/problems.
 Self-centeredness.

Desired Outcomes

 Patient will verbalize recognition of delusional thoughts if they persist.

 Patient will perceive environment correctly.
 Patient will demonstrate satisfying relationships with real people.
 Patient will demonstrate decrease anxiety level.
 Patient will refrain from acting on delusional thinking.
 Patient will develop trust in at least one staff member within 1 week.
 Patient will sustain attention and concentration to complete task or
activities.
 Patient will state that the “thoughts” are less intense and less frequent
with the help of the medications and nursing interventions.
 Patient will talk about concrete happenings in the environment without
talking about delusions for 5 minutes.
 Patient will demonstrate two effective coping skills that minimize
delusional thoughts.
 Patient will be free from delusions or demonstrate the ability to
function without responding to persistent delusional thoughts.

Nursing Interventions Rationale

Important clues to underlying fears and issues

Attempt to understand the significance of these beliefs to
can be found in the client’s seemingly illogical
the client at the time of their presentation.
fantasies.

Recognizes the client’s delusions as the client’s

Recognizing the client’s perception can help you
perception of the environment.
understand the feelings he or she is
 experiencing.

Identify feelings related to delusions. For example:

 If client believes someone is going to harm

him/her, client is experiencing fear. When people believe that they are understood,
anxiety might lessen.
 If client believes someone or something is
controlling his/her thoughts, client is
experiencing helplessness.

When the client has full knowledge of

Explain the procedures and try to be sure the client
procedures, he or she is less likely to feel
understand the procedures before carrying them out.
tricked by the staff.

Interact with clients on the basis of things in the When thinking is focused on reality-based
environment. Try to distract client from their delusions activities, the client is free of delusional thinking
by engaging in reality-based activities (e.g., card games, during that time. Helps focus attention
simple arts and crafts projects etc). externally.

Suspicious clients might misinterpret touch as

either aggressive or sexual in nature and might
Do not touch the client; use gestures carefully.
interpret it as threatening gesture. People who
are psychotic need a lot of personal space.

Arguing will only increase client’s defensive

Initially do not argue with the client’s beliefs or try to
position, thereby reinforcing false beliefs. This
convince the client that the delusions are false and
will result in the client feeling even more
unreal.
isolated and misunderstood.

Encourage healthy habits to optimize functioning:

 Maintain medication regimen.

All are vital to help keep the client in remission.
 Maintain regular sleep pattern.
 Maintain self-care.
 Reduce alcohol and drug intake.

The client’s delusion can be distressing.

Show empathy regarding the client’s feelings; reassure
Empathy conveys your caring, interest and
the client of your presence and acceptance.
acceptance of the client.
Teach client coping skills that minimize “worrying”
thoughts. Coping skills include:

 Going to a gym.
When client is ready, teach strategies client can
 Phoning a helpline. do alone.
 Singing or Listening to a song.
 Talking to a trusted friend.
 Thought-stopping techniques.

During acute phase, client’s delusional thinking

Utilize safety measures to protect clients or others, if the
might dictate to them that they might have to
client believe they need to protect themselves against a
hurt others or self in order to be safe. External
specific person. Precautions are needed.
controls might be needed.

Defensive Coping

Defensive Coping: Repeated projection of falsely positive self-evaluation based

on a self-protective pattern that defends against underlying perceived threats to
positive self-regard.

May be related to

 Perceived lack of self-efficacy/vulnerability.

 Perceived threat to self.
 Suspicions of the motives of others.

Possibly evidenced by

 Denial of obvious problems.

 Difficulty in reality testing of perceptions.
 Difficulty establishing/maintaining relationships.
 False beliefs about the intention of others.
 Fearful.
  Grandiosity.
 Hostile laughter or ridicule of others.
 Hostility, aggression, or homicidal ideation.
 Projection of blame/responsibility.
 Rationalization of failures.
 Superior attitude towards others.

Desired Outcomes

 Patient will avoid high-risk environments and situations.

 Patient will interact with others appropriately.
 Patient will maintain medical compliance.
 Patient will identify one action that helps client feel more in control of
his or her life.
 Patient will demonstrate two newly learned constructive ways to deal
with stress and feeling of powerlessness.
 Patient will demonstrate learn the ability to remove himself or herself
from situations when anxiety begins to increase with the aid of
medications and nursing interventions.
 Patient will demonstrate decreased suspicious behaviors regarding with
the interaction with others.
 Patient will be able to apply a variety of stress/anxiety-reducing
techniques on their own.
 Patient will acknowledge that medications will lower suspiciousness.
 Patient will state that he/she feels safe and more in control with
interactions with environment/family/work/social gatherings.

Nursing Interventions Rationale

Prepares the client beforehand and minimizes

Explain to client what you are going to do before you do
misinterpreting your intent as hostile or
it.
aggressive.
Assess and observe clients regularly for signs of
Intervene before client loses control.
increasing anxiety and hostility.

There is less chance for a suspicious client to

Use a nonjudgemental, respectful, and neutral approach misinterpret intent or meaning if content is
with the client. neutral and approach is respectful and non-
judgemental.

Minimize the opportunity for

Use clear and simple language when communicating with
miscommunication and misconstruing the
a suspicious client.
meaning of the message.

When staff become defensive, anger escalates

for both client and staff. a non-defensive and
Diffuse angry verbal attacks with a non defensive stand. non-judgemental attitude provides an
atmosphere in which feelings can be explored
more easily.

Set limits in a clear matter-of-fact way, using a calm Calm and neutral approach may diffuse
tone. Giving threatening remarks to Jeremy is escalation of anger. Offer an alternative to
unacceptable. We can talk more about the proper ways verbal abuse by finding appropriate ways to
in dealing with your feelings. deal with feelings.

Suspicious people are quick to discern honesty.

Be honest and consistent with client regarding
Honesty and consistency provide an atmosphere
expectations and enforcing rules.
in which trust can grow.

Maintain low level of stimuli and enhance a non- Noisy environments might be perceived as
threatening environment (avoid groups). threatening.

Be aware of client’s tendency to have ideas of reference;

do not do things in front of client that can be
misinterpreted: Suspicious clients will automatically think that
they are the target of the interaction and
 Laughing or whispering. interpret it in a negative manner (e.g., you are
laughing or whispering about them).
 Talking quitely when client can see but not
hear what is being said.

Initially, provide solitary, noncompetitive activities that If a client is suspicious of others, solitary
take some concentration. Later a game with one or more activities are the best. Concentrating on
client that takes concentration (e.g., chess checkers, environmental stimuli minimizes paranoid
thoughtful card games such as ridge or rummy). rumination.

Provide verbal/physical limits when client’s hostile

behavior escalates: We cannot allow you to verbally Often verbal limits are effective in helping a
attack someone here. If you cant held/control yourself, we client gain self control.
are here in order to help you.

Interrupted Family Process

Interrupted Family Process: Change in family relationships and/or functioning.

May be related to

 Developmental crisis or transition.

 Family role shift.
 Physical or mental disorder of a family member.
 Shift in health status of a family member.
 Situational crisis or transistion.

Possibly evidenced by

 Changes in expression of conflict in family.

 Changes in communication patterns.
 Changes in mutual support.
 Changes in participation in decision making.
 Changes in participation in problem solving.
 Changes in stress reduction behavior.
 Knowledge deficit regarding community and health care support.
 Knowledge deficit regarding the disease and what is happening with ill
family member (might believe client is more capable than they are).
  Inability to meet the needs of family and significant others (physical,
emotional, spiritual).

Desired Outcomes

 Family and/or significant others will recount in some detail the early
signs and symptoms of relapse in their ill family member, and know
whom to contact in case.
 Family and/or significant others will state and have written information
identifying the signs of potential relapse and whom to contact before
discharge.
 Family and/or significant others will state that they have received
needed support from community and agency resources that offer
education, support, coping skills training, and/or social network
development (psychoeducational approach).
 Family and/or significant others will state what medications can do for
their ill family member, the side effects and toxic effects of the drugs,
and the need for adherence to medication at least 2 to 3 days before
discharge.
 Family and/or significant others will name and have a complete list of
community supports for ill family members and supports for all
members of the family at least 2 days before the discharge.
 Family and/or significant others will attend at least one family support
group (single family, multiple family) within 4 days from onset of acute
episode.
 Family and/or significant others will be included in the discharge
planning along with the client.
 Family and/or significant others will meet with nurse/physician/social
worker the first day of hospitalization and begin to learn about
neurologic/biochemical disease, treatment, and community resources.
 Family and/or significant others will problem-solve, with the nurse, two
concrete situations within the family that all would like to discharge.
  Family and/or significant others will recount in some detail the early
signs and symptoms of relapse in their ill family member, and know
whom to contact.
 Family and/or significant others will demonstrate problem-solving skills
for handling tensions and misunderstanding within the family member.
 Family and/or significant others will have access to family/multiple
family support groups and psychoeducational training.
 Family and/or significant others will know of at least two contact
people when they suspect potential relapse.
 Family and/or significant others will discuss the disease (schizophrenia)
knowledgeably:
o Know about community resources (e.g., help with self care
activities, private respite).
o Support the ill family member in maintaining optimum health.
o Understand the need for medical adherence.

Nursing Interventions Rationale

Family might have misconceptions and

Assess the family members’ current level of knowledge misinformation about schizophrenia and
about the disease and medications used to treat the treatment, or no knowledge at all. Teach
disease. client’s and family’s level of understanding and
readiness to learn.

Inform the client family in clear, simple terms about

Understanding of the disease and the
psychopharmacologic therapy: dose, duration, indication,
treatment of the disease encourages greater
side effects, and toxic effects. Written information should
family support and client adherence.
be given to client and family members as well.

Identify family’s ability to cope (e.g., experience of loss, Family’s need must be addressed to stabilize
caregiver burden, needed supports). family unit.

Rapid recognition of early warning symptoms

Teach the client and family the warning symptoms of
can help ward off potential relapse when
relapse.
immediate medical attention is sought.
Provide information on disease and treatment strategies
Meet family members’ needs for information.
at family’s level of understanding.

Provide an opportunity for the family to discuss feelings

Nurses and staff can best intervene when they
related to ill family member and identify their immediate
understand the family’s experience and needs.
concerns.

Schizophrenia is an overwhelming disease for

both the client and the family. Groups, support
groups, and psychoeducational centers can
help:

Provide information on client and family community

resources for the client and family after discharge: day  Access caring.
hospitals, support groups,  Access resources.
organizations,psychoeducational programs, community
 Access support.
respite centers (small homes), etc.
 Develop family skills.
 Improve quality of life for all
family members.
 Minimizes isolation.

Sexual Assault Nursing Care Plan

Sexual assault is defined as a sexual contact or behavior that occurs against
the will of the person. It is a form of a sexual violence that includes rape (a
non-consensual vaginal, anal, oral penetration, done by force or threat of bodily
harm), forced kissing, groping, child sexual abuse, or drug-facilitated sex.

Nursing Care Plans

The nursing care plan for clients experiencing sexual assault should include
assisting the victim to seek medical attention, encouraging verbalization of the
assault, informing the significant others in the victim’s life, providing safety,
providing support at certain times of stress, especially during police
 investigations or court proceedings, and planning for follow-up contact with a
crisis counselor.

Here’s a nursing care plan for Sexual Assault:

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 Nursing Care Plans

 Mental Health and Psychiatric Care Plans

Sexual Assault Nursing Care Plan

By

Paul Martin, RN

October 11, 2016

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Sexual assault is defined as a sexual contact or behavior that occurs against

the will of the person. It is a form of a sexual violence that includes rape (a
non-consensual vaginal, anal, oral penetration, done by force or threat of bodily
harm), forced kissing, groping, child sexual abuse, or drug-facilitated sex.

Nursing Care Plans

The nursing care plan for clients experiencing sexual assault should include
assisting the victim to seek medical attention, encouraging verbalization of the
assault, informing the significant others in the victim’s life, providing safety,
 providing support at certain times of stress, especially during police
investigations or court proceedings, and planning for follow-up contact with a
crisis counselor.

Here’s a nursing care plan for Sexual Assault:

 1 Nursing Care Plans

o 1.1 Rape-Trauma Syndrome
 2 See Also
 3 Further Reading

Rape-Trauma Syndrome

Rape-Trauma Syndrome: Sustained maladaptive response to a forced,

violent, sexual penetration against the victim’s will and consent.

May be related to

 Sexual assault.

Possibly evidenced by

 Aggression; muscle tension.

 Change in relationships.
 Denial.
 Depression, anxiety.
 Disorganization.
 Dissociative disorders.
 Feelings of revenge.
 Guilt, humiliation, embarrassment.
 Hyperalertness.
 Inability to make decisions.
  Loss of self-esteem.
 Mood swings.
 Nightmare and sleep disturbances.
 Phobias.
 Physical trauma (e.g., bruising, tissue irritation).
 Self-blame.
 Sexual dysfunction.
 Shame, shock, fear.
 Substance abuse.
 Suicide attempts.
 Vulnerability, helplessness.

Desired Outcomes

 Survivor will experience hopefulness and confidence in going ahead

with life plans.
 Survivor will have a resolution of anger, guilt, fear, depression, low
self-esteem.
 Survivor will acknowledge the right do disclose and discuss abusive
situations.
 Survivor will list common physical, emotional, and social reactions that
often follow a sexual assault before leaving the emergency department
or crisis center.
 Survivor will state the results of the physical examination completed in
the emergency department or crisis center.
 Survivor will speak to a community-based rape victim advocate in
the emergency department or crisis center.
 Survivor will have an access to information on obtaining competent
legal council.
 Survivor will begin to express reactions and feelings about the assault
before leaving the emergency department or crisis center.
 Survivor will have a short-term plan for handling immediate situational
needs before leaving the emergency department or crisis center.
  Survivor will verbalize the details of abuse.
 Survivor will state that the physical symptoms (e.g., sleep
disturbances, poor appetite, and physical trauma) have subsided within
3 to 5 months.
 Survivor will state that the acuteness of the memory of the rape
subsides with time and is less vivid and less frightening within 3 to 5
months.
 Survivor will discuss the need for follow-up crisis counseling and other
supports.

Nursing Interventions Rationale

Since the victim may misinterpret any statements unrelated

to her immediate situation as blaming or rejecting, the nurse
Establish trust and rapport.
should delay asking questions until the therapeutic nature is
established.

The client’s situation is not to be talked over with anyone

Provide strict confidentiality. other than medical staff involved unless the client gives
consent to it.

Nurses’ attitudes can have an important therapeutic impact.

Approach the client in a nonjudgmental
Displays of shock, horror, disgust, or disbelief are not
manner.
appropriate.

Use the following:

Never use judgmental language.  Reported not alleged.

 Declined not refused.
 Penetration not intercourse.

Have someone stay with the client (friend, People in high levels of anxiety needs to feel physical safety
neighbor, or staff member) while he or she by providing someone by his/her side until anxiety level is
waiting to be treated. down to moderate.

Rape victims might feel guilt and shame. Reinforcing that

Stress that they did the right thing to save
they did what they had to do to stay alive can reduce guilt
their life. and maintain self-esteem.

When people feel understood, they feel more in control of

Encourage verbalization.
their situations.

Explain to the client signs and symptoms

that many people experience during the
long-term phase, for example:

Many individuals think they are going crazy as time goes on

1. Anxiety, depression.
and are not aware that this is a process that many people in
2. Insomnia. their situation have experienced.
3. Nightmares.
4. Phobias.
5. Somatic symptoms.

Forensic Examination and Issues:

Assess the signs and symptoms of physical

More common injuries are to face, head, neck extremities.
trauma.

Make a body map to identify size, color, and

Accurate records and photos that can be used as medicolegal
location of injuries. Ask permission to take
evidence for the future.
photos.

Carefully explain all procedures before doing

them (e.g., “I will perform a vaginal
The individual is experiencing high levels of anxiety. Matter-
examination and do a swab. Have you had a
of-fact explaining what you plan to do and why you are doing
vaginal examination before?” [rectal
it can help reduce fear and anxiety.
examination in case of a male who has been
raped]).

Explain the forensic specimens you plan to

collect; inform client that they can be used
for identification and prosecution of the
rapist, for example: Collecting body fluids and swabs is essential (DNA) for
identifying the rapist.
1. Blood.
2. Combing pubic hairs.
3. Semen samples.
 4. Skin from underneath nails.

Encourage the client to consider treatment

Many survivors are lost to follow-up after being seen in the
and evaluation for sexually transmitted
emergency department or crisis center and will not
diseases before leaving the emergency
otherwise get protection.
department.

Many clinics offer prophylaxis to pregnancy Approximately 3% to 5% of women who are raped become
with norgestrel (Ovral). pregnant.

All data must be carefully documented:

1. All lab tests should be noted.

2. Detailed observations of
physical trauma. Accurate and detailed communication is crucial legal
3. Detailed observations of evidence.
emotional status.
4. Results from the physical
examination.
5. Verbatim statements.

Arrange for support follow-up:

1. Crisis counseling. Many individuals carry with them constant emotional

2. Group therapy. distress and trauma. Depression and suicidal ideation are
frequent sequelae of rape. As soon as the intervention is
3. Individual therapy.
carried out, the less complicated the recovery may be.
4. Rape counselor.
5. Support group.

Substance Dependence and

Abuse Nursing Care Plans
Drug abuse and drug dependence represent different ends of the same
disease process.
Drug abuse is an intense desire to use increasing amounts of a particular
substance or substances to the exclusion of other activities.

Drug dependence is the body’s physical need, or addiction, to a specific agent.

There is therefore virtually no difference between dependency and addiction.
Over the long term, this dependence results in physical harm, behavior
problems, and association with people who also abuse drugs. Stopping the use
of the drug can result in a specific withdrawal syndrome.

Nursing Care Plans

Nursing care plan goals for patients who abuse substances includes providing
support for decision to stop substance use, strengthen individual coping skills,
facilitate learning of new ways to reduce anxiety, promote family involvement in
rehabilitation program, facilitate family growth and development, and provide
information about the prognosis and treatment needs.

Below are 8 substance dependence and abuse nursing care plans:

Denial

May be related to

 Personal vulnerability; difficulty handling new situations

 Previous ineffective/inadequate coping skills with substitution of
drug(s)
 Learned response patterns; cultural factors, personal/family value
systems

Possibly evidenced by

 Delay in seeking, or refusal of healthcare attention to the detriment of

health/life
  Does not perceive personal relevance of symptoms or danger, or admit
impact of condition on life pattern; projection of blame/responsibility
for problems
 Use of manipulation to avoid responsibility for self

Desired Outcomes

 Verbalize awareness of relationship of substance abuse to current

situation.
 Engage in therapeutic program.
 Verbalize acceptance of responsibility for own behavior.

Nursing Interventions Rationale

Ascertain by what name patient would like to be Shows courtesy and respect, giving patient a sense of
addressed. orientation and control.

Convey attitude of acceptance, separating individual

Promotes feelings of dignity and self-worth.
from unacceptable behavior.

Provides insight into patient’s willingness to commit

to long-term behavioral change, and whether patient
Ascertain reason for beginning abstinence,
even believes that he or she can change. (Denial is
involvement in therapy.
one of the strongest and most resistant symptoms of
substance abuse.)

Review definition of drug dependence and This information helps patient make decisions
categories of symptoms (patterns of use, impairment regarding acceptance of problem and treatment
caused by use, tolerance to substance). choices.

Answer questions honestly and provide factual

Creates trust, which is the basis of the therapeutic
information. Keep your word when agreements are
relationship.
made.

Provide information about addictive use versus Progression of use continuum is from experimental
experimental, occasional use; biochemical or genetic or recreational to addictive use. Comprehending this
disorder theory (genetic predisposition; use process is important in combating denial. Education
 Nursing Interventions
activated by environment; compulsive desire.)
Discuss current life situation and impact of
substance use.
Confront and examine denial and rationalization in
peer group. Use confrontation with caring.
Provide information regarding effects of addiction
on mood and personality.
Remain nonjudgmental. Be alert to changes in
behavior, (restlessness, increased tension).
Provide positive feedback for expressing awareness
of denial in self and others.
Maintain firm expectation that patient attend
recovery support and therapy groups regularly.
Encourage and support patient’s taking
responsibility for own recovery (development of
alternative behaviors to drug urge and use). Assist
patient to learn own responsibility for recovering.
Encourage family members to seek help whether or
not the abuser seeks it.
Rationale
may relieve patient’s guilt and blame and may help
awareness of recurring addictive characteristics.
First step in decreasing use of denial is for patient to
see the relationship between substance use and
personal problems.
Because denial is the major defense mechanism in
addictive disease, confrontation by peers can help
the patient accept the reality of adverse
consequences of behaviors and that drug use is a
major problem. Caring attitude preserves self-
concept and helps decrease defensive response.
Individuals often mistake effects of addiction and
use this to justify or excuse drug use.
Confrontation can lead to increased agitation, which
may compromise safety of patient and staff.
Necessary to enhance self-esteem and to reinforce
insight into behavior.
Attendance is related to admitting need for help, to
working with denial, and for maintenance of a long-
term drug-free existence.
Denial can be replaced with positive action when
patient accepts the reality of own responsibility.
To assist the patient deal appropriately with the
situation.
Ineffective Individual Coping

Ineffective Individual Coping: Inability to form a valid appraisal of the

stressors, inadequate choices of practiced responses, and/or inability to use
available resources.

May be related to

 Personal vulnerability
 Negative role modeling; inadequate support systems
 Previous ineffective/inadequate coping skills with substitution of
drug(s)

Possibly evidenced by

 Impaired adaptive behavior and problem-solving skills

 Decreased ability to handle stress of illness/hospitalization
 Financial affairs in disarray, employment difficulties (e.g., losing time
on job/not maintaining steady employment; poor work performances,
on-the-job injuries)
 Verbalization of inability to cope/ask for help

Desired Outcomes

 Identify ineffective coping behaviors/consequences, including use of

substances as a method of coping.
 Use effective coping skills/problem solving.
 Initiate necessary lifestyle changes.

Nursing Interventions Rationale

Review program rules, philosophy expectations. Having information provides opportunity for patient
to cooperate and function as a member of the group
 Nursing Interventions Rationale

or milieu, enhancing sense of control and sense of

success.

Provides information about degree of denial,

Determine understanding of current situation,
acceptance of personal responsibility and
previous, and other methods of coping with life’s
commitment to change; identifies coping skills that
problems.
may be used in present situation.

Patient has learned manipulative behavior

Set limits and confront efforts to get caregiver to
throughout life and needs to learn a new way of
grant special privileges, making excuses for not
getting needs met. Following through on
following through on behaviors agreed on, and
consequences of failure to maintain limits can help
attempting to continue drug use.
the patient to change ineffective behaviors.

Lack of understanding, judgmental or enabling

Be aware of staff attitudes, feelings, and enabling
behaviors can result in inaccurate data collection
behaviors.
and non-therapeutic approaches.

Encourage verbalization of feelings, fears, and May help patient begin to come to terms with long-
anxiety. unresolved issues.

Based on standard hospital policy, institute

To avoid suicide attempts
appropriate measures.

Patient may have little or no knowledge of adaptive

responses to stress and needs to learn other options
Explore alternative coping strategies.
for managing time, feelings, and relationships
without drugs.

Assist patient to learn and encourage use of Helps patient relax, develop new ways to deal with
relaxation skills, guided imagery, visualizations. stress, problem-solve.

Discovery of alternative methods of coping with

Structure diversional activity that relates to recovery
drug hunger can remind patient that addiction is a
(social activity within support group), wherein
lifelong process and opportunity for changing
issues of being chemically free are examined.
patterns is available.
 Nursing Interventions
Use peer support to examine ways of coping with
drug hunger.
Use peer support to examine ways of coping with
drug binges.
Encourage involvement in therapeutic writing. Have
patient begin journaling or writing autobiography.
Discuss patient’s plans for living without drugs
Administer medications as indicated:
 Disulfiram (Antabuse)
 Acamprosate
Rationale
Self-help groups are valuable for learning and
promoting abstinence in each member, using
understanding and support as well as peer pressure.
Self-help groups are valuable for learning and
promoting abstinence in each member, using
understanding, support, and peer pressure.
Therapeutic writing or journaling can enhance
participation in treatment; serves as a release for
grief, anger, and stress; provides a useful tool for
monitoring patient’s safety; and can be used to
evaluate patient’s progress. Autobiographical
activity provides an opportunity for patient to
remember and identify sequence of events in his or
her life that relate to current situation.
Provide opportunity to develop and refine plans.
Devising a comprehensive strategy for avoiding
relapses helps patient into maintenance phase of
behavioral change.
This drug can be helpful in maintaining abstinence
from alcohol while other therapy is undertaken. By
inhibiting alcohol oxidation, the drug leads to an
accumulation of acetaldehyde with a highly
unpleasant reaction if alcohol is consumed.
Helps prevent relapses in alcoholism by lowering
receptors for the excitatory neurotransmitter
glutamate. This agent may become drug of choice
because it does not make the user sick if alcohol is
consumed; it has no sedative,
antianxiety, muscle relaxant, or antidepressant
properties and produces no withdrawal symptoms.
 Nursing Interventions Rationale

This drug is thought to blunt the craving or diminish

the effects of opioids and is used to assist in
Methadone (Dolophine); withdrawal and long-term maintenance programs. It
can allow the individual to maintain daily activities
and ultimately withdraw from drug use.

Used to suppress craving for opioids and may help

prevent relapse in the patient abusing alcohol.
 Naltrexone (Trexan), nalmefene
Current research suggests that naltrexone
(Revex). suppresses urge to continue drinking by interfering
with alcohol-induced release of endorphins.

Encourage involvement with self-help associations ( Puts patient in direct contact with support system
Alcoholics, NarcoticsAnonymous). necessary for managing sobriety and drug-free life.

Maintain a quiet, safe environment during

Excessive noise may agitate the patient.
withdrawal from any drug.

Remove harmful objects from the patient’s room. To prevent the patient from harm

Use restraints ONLY if you think the patient may

To promote safety
harm himself or herself and others.

Encourages patient to talk freely without fear of

Provide safe, non threatening environment.
judgment.

Powerlessness

Powerlessness: The lived experience of lack of control over a situation,

including a perception that one’s actions do not significantly affect an outcome.

May be related to

 Substance addiction with/without periods of abstinence

 Episodic compulsive indulgence; attempts at recovery
  Lifestyle of helplessness

Possibly evidenced by

 Ineffective recovery attempts; statements of inability to stop

behavior/requests for help
 Continuous/constant thinking about drug and/or obtaining drug
 Alteration in personal, occupational, and social life

Desired Outcomes

 Admit inability to control drug habit, surrender to powerlessness over

addiction.
 Verbalize acceptance of need for treatment and awareness that
willpower alone cannot control abstinence.
 Engage in peer support.
 Demonstrate active participation in program.
 Regain and maintain healthy state with a drug-free lifestyle.

Nursing Interventions Rationale

Use crisis intervention techniques to initiate Patient is more amenable to acceptance of need for
behavior changes: treatment at this time.

In the precontemplation phase, the patient has not

Assist patient to recognize problem exists. Discuss in
yet identified that drug use is problematic. While
a caring, nonjudgmental manner how drug has
patient is hurting, it is easier to admit substance use
interfered with life;
has created negative consequences.

During the contemplation phase, the patient realizes

Involve patient in development of treatment plan,
a problem exists and is thinking about a change of
using problem-solving process in which patient
behavior. The patient is committed to the outcomes
identifies goals for change and agrees to desired
when the decision-making process involves
outcomes;
solutions that are promulgated by the individual.
 Nursing Interventions
Discuss alternative solutions;
Assist in selecting most appropriate alternative;
Support decision and implementation of selected
alternative(s).
Explore support in peer group. Encourage sharing
about drug hunger, situations that increase the
desire to indulge, ways that substance has influenced
life.
Assist patient to learn ways to enhance health and
structure healthy diversion from drug use
(maintaining a balanced diet, getting adequate rest,
exercise [walking, slow or long distance running];
and acupuncture, biofeedback, deep meditative
techniques).
Provide information regarding understanding of
human behavior and interactions with others
(transactional analysis).
Assist patient in self-examination of spirituality,
faith.
Rationale
Brainstorming helps creatively identify possibilities
and provides sense of control. During the
preparation phase, minor action may be taken as
individual organizes resources for definitive change.
As possibilities are discussed, the most useful
solution becomes clear.
Helps the patient persevere in process of change.
During the action phase, the patient engages in a
sustained effort to maintain sobriety, and
mechanisms are put in place to support abstinence.
Patient may need assistance in expressing self,
speaking about powerlessness, admitting need for
help in order to face up to problem and begin
resolution.
Learning to empower self in constructive areas can
strengthen ability to continue recovery. These
activities help restore natural biochemical balance,
aid detoxification, and manage stress, anxiety, use of
free time. These diversions can increase self-
confidence, thereby improving self-
esteem.Note: Exercise promotes release of
endorphins, creating a feeling of well-being.
Understanding these concepts can help the patient to
begin to deal with past problems or losses and
prevent repeating ineffective coping behaviors and
self-fulfilling prophecies.
Although not mandatory for recovery, surrendering
to and faith in a power greater than oneself has been
found to be effective for many individuals in
substance recovery; may decrease sense of
powerlessness.
 Nursing Interventions Rationale

Effective in helping refrain from use, to stop contact

Instruct in and role-play assertive communication
with users and dealers, to build healthy
skills.
relationships, regain control of own life.

Helps patient know what to expect, and creates

opportunity for patient to be a part of what is
Provide treatment information on an ongoing basis.
happening and make informed choices about
participation and outcomes.

Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients

insufficient to meet metabolic needs.

May be related to

 Insufficient dietary intake to meet metabolic needs for psychological,

physiological, or economic reasons

Possibly evidenced by

 Weight loss; weight below norm for height/body build; decreased

subcutaneous fat/muscle mass
 Reported altered taste sensation; lack of interest in food
 Poor muscle tone
 Sore, inflamed buccal cavity
 Laboratory evidence of protein/vitamin deficiencies

Desired Outcomes
  Demonstrate progressive weight gain toward goal with normalization of
laboratory values and absence of signs of malnutrition.
 Verbalize understanding of effects of substance abuse, reduced dietary
intake on nutritional status.
 Demonstrate behaviors, lifestyle changes to regain and maintain
appropriate weight.

Nursing Interventions Rationale

Monitor the patient’s nutritional intake. To promote adequate nutrition

Provides information about individual on which to

Assess height and weight, age, body build, strength, base caloric needs and dietary plan. Type of diet or
activity and rest level. Note condition of oral cavity. foods may be affected by condition of mucous
membranes and teeth.

Take anthropometric Calculates subcutaneous fat and muscle mass to aid

measurements (triceps skinfold, when available). in determining dietary needs.

Note total daily calorie intake; maintain a diary of Information will help identify nutritional needs and
intake, as well as times and patterns of eating. deficiencies.

Evaluate energy expenditure (pacing or sedentary), Activity level affects nutritional needs. Exercise
and establish an individualized exercise program. enhances muscle tone, may stimulate appetite.

Enhances participation or sense of control, may

Provide opportunity to choose foods and snacks to promote resolution of nutritional deficiencies, and
meet dietary plan. helps evaluate patient’s understanding of dietary
teaching.

Provides information regarding effectiveness of

Recommend monitoring weight weekly.
dietary plan.

Useful in establishing individual dietary needs and

Consult with dietitian.
plan and provides additional resource for learning.

Identifies anemias, electrolyte imbalances, and other

Review laboratory studies as indicated, (glucose,
abnormalities that may be present, requiring specific
Nursing Interventions Rationale

serum albumin and prealbumin, electrolytes). therapy.

Teeth are essential to good nutritional intake and

Refer for dental consultation as necessary. dental hygiene and care is often a neglected area in
this population.

Low Self-Esteem

Situational Low Self-Esteem: Development of a negative perception of self-

worth in response to current situation.

May be related to

 Social stigma attached to substance abuse, expectation that one

controls behavior
 Negative role models; abuse/neglect, dysfunctional family system
 Life choices perpetuating failure; situational crisis with loss of control
over life events
 Biochemical body change (e.g., withdrawal from alcohol/other drugs)

Possibly evidenced by

 Self-negating verbalization, expressions of shame/guilt

 Evaluation of self as unable to deal with events, confusion about self,
purpose or direction in life
 Rationalizing away/rejecting positive feedback about self

Desired Outcomes

 Identify feelings and underlying dynamics for negative perception of

self.
  Verbalize acceptance of self as is and an increased sense of self-worth.
 Set goals and participate in realistic planning for lifestyle changes
necessary to live without drugs.

Nursing Interventions Rationale

Patient often has difficulty expressing self, even

Provide opportunity for and encourage verbalization more difficulty accepting the degree of importance
and discussion of individual situation. substance has assumed in life and its relationship to
present situation.

Many patients use substances in an attempt to

obtain relief from depression or anxiety, which may
predate use and be the result of substance use.
Assess mental status. Note presence of other
Approximately 60% of substance-dependent
psychiatric disorders (dual diagnosis).
patients have underlying psychological problems,
and treatment for both is imperative to achieve and
maintain abstinence.

The nurse’s presence conveys acceptance of the

Spend time with patient. Discuss patient’s behavior individual as a worthwhile person. Discussion
and use of substance in a nonjudgmental way. provides opportunity for insight into the problems
abuse has created for the patient.

Failure and lack of self-esteem have been problems

Provide reinforcement for positive actions and
for this patient, who needs to learn to accept self as
encourage patient to accept this input.
an individual with positive attributes.

Substance abuse is a family disease, and how the

members act and react to the patient’s behavior
affects the course of the disease and how patient
Observe family interactions and SO dynamics and
sees self. Many unconsciously become “enablers,”
level of support.
helping the individual to cover up the consequences
of the abuse. (Refer to ND: Family Processes, altered:
alcoholism, following.)

The patient often has lost respect for self and

Encourage expression of feelings of guilt, shame, and
believes that the situation is hopeless. Expression of
anger.
these feelings helps the patient begin to accept
responsibility for self and take steps to make
 Nursing Interventions
Help the patient acknowledge that substance use is
the problem and that problems can be dealt with
without the use of drugs. Confront the use of
defenses (denial, projection, rationalization).
Ask the patient to list and review past
accomplishments and positive happenings.
Use techniques of role rehearsal.
Involve patient in group therapy.
Formulate plan to treat other mental illness
problems.
Administer antipsychotic medications as necessary.
Rationale
changes.
When drugs can no longer be blamed for the
problems that exist, the patient can begin to deal
with the problems and live without substance use.
Confrontation helps the patient accept the reality of
the problems as they exist.
There are things in everyone’s life that have been
successful. Often when self-esteem is low, it is
difficult to remember these successes or to view
them as successes.
Assists patient to practice developing skills to cope
with new role as a person who no longer uses or
needs drugs to handle life’s problems.
Group sharing helps encourage verbalization
because other members of group are in various
stages of abstinence from drugs and can address the
patient’s concerns and denial. The patient can gain
new skills, hope, and a sense of family and
community from group participation.
Patients who seek relief for other mental health
problems through drugs will continue to do so once
discharged. Both the substance use and the mental
health problems need to be treated together to
maximize abstinence potential.
Prolonged and profound psychosis following LSD or
PCP use can be treated with these drugs because it is
probably the result of an underlying functional
psychosis that has now emerged. Note: Avoid the use
of phenothiazines because they may
decrease seizure threshold and cause hypotension in
the presence of LSD or PCP use.
Altered Family Process

Altered Family Processes/Role Performance: A change in family

relationships and/or functioning.

May be related to

 Abuse of substance(s); resistance to treatment

 Family history of substance abuse
 Addictive personality
 Inadequate coping skills, lack of problem-solving skills

Possibly evidenced by

 Anxiety; anger/suppressed rage; shame and embarrassment

 Emotional isolation/loneliness; vulnerability; repressed emotions
 Disturbed family dynamics; closed communication systems, ineffective
spousal communication and marital problems
 Altered role function/disruption of family roles
 Manipulation; dependency; criticizing; rationalization/denial of
problems
 Enabling to maintain drinking (substance abuse); refusal to get
help/inability to accept and receive help appropriately

Desired Outcomes

 Verbalize understanding of dynamics of enabling behaviors.

 Participate in individual family programs.
 Identify ineffective coping behaviors and consequences.
 Initiate and plan for necessary lifestyle changes.
  Take action to change self-destructive behaviors/alter behaviors that
contribute to partner’s/SO’s addiction.
Nursing Interventions
Review family history; explore roles of family
members, circumstances involving drug use,
strengths, areas for growth.
Explore how the SO has coped with the patient’s
habit, (denial, repression, rationalization, hurt,
loneliness, projection).
Determine understanding of current situation and
previous methods of coping with life’s problems.
Assess current level of functioning of family
members.
Determine extent of enabling behaviors being
evidenced by family members; explore with each
individual and patient.
Provide information about enabling behavior,
addictive disease characteristics for both user and
nonuser.
Identify and discuss sabotage behaviors of family
members.
Rationale
Determines areas for focus, potential for change.
The person who enables also suffers from the same
feelings as the patient and uses ineffective methods
for dealing with the situation, necessitating help in
learning new and effective coping skills.
Provides information on which to base present plan
of care.
Affects individual’s ability to cope with situation.
Enabling is doing for the patient what he or she
needs to do for self (rescuing). People want to be
helpful and do not want to feel powerless to help
their loved one stop substance use and change the
behavior that is so destructive. However, the
substance abuser often relies on others to cover up
own inability to cope with daily responsibilities.
Awareness and knowledge of behaviors (avoiding
and shielding, taking over responsibilities,
rationalizing, and subserving) provide opportunity
for individuals to begin the process of change.
Even though family member(s) may verbalize a
desire for the individual to become substance-free,
the reality of interactive dynamics is that they may
unconsciously not want the individual to recover
because this would affect the family member(s)’ own
role in the relationship. Additionally, they may
receive sympathy and attention from others
 Nursing Interventions Rationale

(secondary gain).

Serves as a release for feelings (anger, grief, stress);

Encourage participation in therapeutic writing such
helps move individuals forward in treatment
as journaling (narrative), guided or focused.
process.

Provide factual information to patient and family Many patients and SOs are not aware of the nature of
about the effects of addictive behaviors on the family addiction. If patient is using legally obtained drugs,
and what to expect after discharge. he or she may believe this does not constitute abuse.

When the enabling family members become aware

Encourage family members to be aware of their own
of their own actions that perpetuate the addict’s
feelings, look at the situation with perspective and
problems, they need to decide to change themselves.
objectivity. They can ask themselves: “Am I being
If they change, the patient can then face the
conned? Am I acting out of fear, shame, guilt, or
consequences of his or her own actions and may
anger? Do I have a need to control?”
choose to get well.

Provide support for enabling partner(s). Encourage Families and SOs need support to produce change as
group work. much as the person who is addicted.

Assist the patient’s partner to become aware that Partners need to learn that user’s habit may or may
patient’s abstinence and drug use are not the not change despite partner’s involvement in
partner’s responsibility. treatment.

Help the recovering (former user) partner who is

Enabling behavior can be partner’s attempts at
enabling to distinguish between destructive aspects
personal survival.
of behavior and genuine motivation to aid the user.

Determines enabling style. A parallel exists between

Note how partner relates to the treatment team and
how partner relates to user and to staff, based on
staff.
partner’s feelings about self and situation.

Explore conflicting feelings the enabling partner may Useful in establishing the need for therapy for the
have about treatment including the feelings similar partner. This individual’s own identity may have
to those of abuser (blend of anger, guilt, fear, been lost, she or he may fear self-disclosure to staff,
exhaustion, embarrassment, loneliness, distrust, and may have difficulty giving up the dependent
 Nursing Interventions Rationale

grief, and possibly relief). relationship.

Drug abuse is a family illness. Because the family has

been so involved in dealing with the substance abuse
behavior, family members need help adjusting to the
Involve family in discharge referral plans.
new behavior of sobriety and abstinence. Incidence
of recovery is almost doubled when the family is
treated along with the patient.

Lack of understanding of enabling can result in non-

Be aware of staff’s enabling behaviors and feelings
therapeutic approaches to patients and their
about patient and enabling partners.
families.

Encourage involvement with self-help associations, Puts patient and family in direct contact with
Alcoholics and Narcotics Anonymous, Al-Anon, support systems necessary for continued sobriety
Alateen, and professional family therapy. and to assist with problem resolution.

Sexual Dysfunction

Sexual Dysfunction: The state in which an individual experiences, or is at risk

of experiencing, a change in sexual function that is viewed as unrewarding or
inadequate.

May be related to

 Altered body function: Neurological damage and debilitating effects of

drug use (particularly alcohol and opiates)

Possibly evidenced by

 Progressive interference with sexual functioning

  In men: a significant degree of testicular atrophy is noted (testes are
smaller and softer than normal); gynecomastia (breast enlargement);
impotence/decreased sperm counts
 In women: loss of body hair, thin soft skin, and spider angioma
(elevated estrogen); amenorrhea/increase in miscarriages

Desired Outcomes

 Verbally acknowledge effects of drug use on sexual

functioning/reproduction.
 Identify interventions to correct/overcome individual situation.

Nursing Interventions Rationale

Ascertain patient’s beliefs and expectations. Have Determines level of knowledge, identifies
patient describe problem in own words. misperceptions and specific learning needs.

Most people find it difficult to talk about this

Encourage and accept individual expressions of
sensitive subject and may not ask directly for
concern.
information.

Provide education opportunity (pamphlets, Much of denial and hesitancy to seek treatment may
consultation with appropriate persons) for patient to be reduced as a result of sufficient and appropriate
learn effects of drug on sexual functioning. information.

Sexual functioning may have been affected by drug

(alcohol) itself or psychological factors (such as
Provide information about individual’s condition. stress or depression). Information can assist patient
to understand own situation and identify actions to
be taken.

Assess drinking and drug history of pregnant
patient. Provide information about effects of
substance abuse on the reproductive system and
fetus ( increased risk of premature
birth, brain damage, and fetal malformation).
Awareness of the negative effects of alcohol and
other drugs on reproduction may motivate patient to
stop using drug(s). When patient is pregnant,
identification of potential problems aids in planning
for future fetal needs and concerns.
 Nursing Interventions Rationale

In about 50% of cases, impotence is reversed with

Discuss prognosis for sexual abstinence from drug(s); in 25% the return to
dysfunction (impotence, low sexual desire). normal functioning is delayed; and approximately
25% remain impotent.

Couple may need additional assistance to resolve

Refer for sexual counseling, if indicated.
more severe problems and situations. Patient may
have difficulty adjusting if drug has improved sexual
experience (heroin decreases dyspareunia in
women, premature ejaculation in men).
Furthermore, the patient may have engaged
enjoyably in bizarre, erotic sexual behavior under
influence of the stimulant drug; patient may have
found no substitute for the drug, may have driven a
partner away, and may have no motivation to adjust
to sexual experience without drugs.

Assesses fetal growth and development to identify

Review results of sonogram if pregnant. possibility of fetal alcohol syndrome and future
needs.

Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related

to specific topic.

May be related to

 Lack of information; information misinterpretation

 Cognitive limitations/interference with learning (other mental illness
problems/organic brain syndrome); lack of recall

Possibly evidenced by
  Statements of concern; questions/misconceptions
 Inaccurate follow-through of instructions/development of preventable
complications
 Continued use in spite of complications/adverse consequences

Desired Outcomes

 Verbalize understanding of own condition/disease process, prognosis,

and potential complications.
 Verbalize understanding of therapeutic needs.
 Identify/initiate necessary lifestyle changes to remain drug-free.
 Participate in treatment program including plan for follow-up/long-term
care.

Nursing Interventions Rationale

Be aware of and deal with anxiety of patient and Anxiety can interfere with ability to hear and
family members. assimilate information.

Provide an active role for the patient and SO in the

Learning is enhanced when persons are actively
learning process (discussions, group participation,
involved.
role playing).

Provide written and verbal information as indicated.

Helps patient and SO make informed choices about
Include list of articles and books related to patient
future. Bibliotherapy can be a useful addition to
and family needs and encourage reading and
other therapeutic approaches.
discussing what they learn.

Assists in planning for long-range changes necessary

Assess patient’s knowledge of own situation
for maintaining sobriety and drug-free status.
(disease, complications, and needed changes in
Patient may have street knowledge of the drug but
lifestyle).
be ignorant of medical facts.

Facilitates learning because information is more

Pace learning activities to individual needs.
readily assimilated when timing is considered.

Review condition and prognosis and future Provides knowledge base from which patient can
 Nursing Interventions
expectations.
Discuss relationship of drug use to current situation.
Educate about effects of specific drug(s) used [PCP is
deposited in body fat and may reactivate
(flashbacks) even after long interval of abstinence;
alcohol use may result in mental
deterioration, liverinvolvement/damage; cocaine can
damage postcapillary vessels and increase platelet
aggregation, promoting thromboses and infarction of
skin and internal organs, causing localized atrophie
blanche or sclerodermatous lesions].
Discuss potential for re-emergence of withdrawal
symptoms in stimulant abuse as early as 3 mo or as
late as 9–12 mo after discontinuing use.
Inform patient of effects of disulfiram (Antabuse) in
combination with alcohol intake and importance of
avoiding use of alcohol-containing products
(cough syrups, foods and candy, mouthwash,
aftershave, cologne).
Review specific aftercare needs (PCP user should
drink cranberry juice and continue use of ascorbic
acid; alcohol abuser with liver damage should refrain
from drugs and anesthetics or use of household
cleaning products that are detoxified in the liver).
Rationale
make informed choices.
Often patient has misperception (denial) of real
reason for admission to the medical (psychiatric)
setting.
Information will help patient understand possible
long-term effects of drug use.
Even though intoxication may have passed, patient
may manifest denial, drug hunger, and periods of
“flare-up,” wherein there is a delayed recurrence of
withdrawal symptoms (anxiety; depression;
irritability; sleep disturbance; compulsiveness with
food, especially sugars).
Interaction of alcohol and Antabuse results in
nausea and hypotension, which may produce fatal
shock. Individuals on Antabuse are sensitive to
alcohol on a continuum, with some being able to
drink while taking the drug and others having a
reaction with only slight exposure. Reactions also
appear to be dose-related.
Promotes individualized care related to specific
situation. Cranberry juice and ascorbic acid enhance
clearance of PCP from the system. Substances that
have the potential for liver damage are more
dangerous in the presence of an already damaged
liver.
 Nursing Interventions Rationale

Discuss variety of helpful organizations and Long-term support is necessary to maintain optimal
programs that are available for assistance and recovery. Psychosocial needs and other issues may
referral. need to be addressed.

Other Possible Nursing Care Plans

Nursing diagnoses you can use to make your own care plan for substance
abuse:

 Therapeutic Regimen: Individual/Families, ineffective

management—decisional conflicts, excessive demands made on
individual or family, family conflict, perceived seriousness/benefits.
 Coping, Individual, ineffective—vulnerability, situational crises,
multiple life changes, inadequate relaxation, inadequate/loss of support
systems.
 Family Coping: potential for growth—needs sufficiently gratified
and adaptive tasks effectively addressed to enable goals of self-
actualization to surface.
 (Physical needs depend on substance effect on organ systems—refer to
appropriate medical plans of care for additional considerations.)

Suicide Behaviors Nursing Care

Plans
Suicide is the intentional act of killing oneself. Suicidal thoughts are common in
people with depression, schizophrenia, alcohol/substance abuse and personality
disorders(antisocial, borderline, and paranoid). Physical illness (chronic illness
such as HIV, AIDS, recent surgery, pain) and environmental factors
(unemployment, family history of depression, isolation, recent loss) can play a
role in the suicide behavior.

Nursing Care Plans

The nursing care plan for suicidal patients involves providing a safe
environment, initiating a no-suicide contract, creating a support system and
ensuring close supervision.

Here are three (3) nursing care plans (NCP) for suicide behaviors:

Risk For Suicide

Risk For Suicide: At risk for self-inflicted, life-threatening injury.

Risk Factors

 Alcohol and substance abuse/use.

 Abuse in childhood.
 Family history of suicide.
 Fits demographic (children, adolescent, young adult male, elderly
male, Native American, Caucasian).
 Grief, bereavement/loss of an important relationship.
 History of prior suicide attempt.
 Hopelessness/helplessness.
 Legal or disciplinary problems.
 Physical illness, chronic pain, terminal illness.
 Psychiatric illness (e.g., bipolar disorder, depression, schizophrenia).
 Poor support system, loneliness.

Possibly evidenced by
  Statements of despair, helplessness, hopelessness and nothing left to
live for.
 Suicide plan (clear and specific, lethal method and available means).
 Suicide behavior (attempt, ideation, talk, plan, available means).
 Suicide cues
o Covert: Making out a will, giving valuables away, writing
forlorn love notes, taking out large life insurance policy.
o Overt: “No one will miss me”; “No reason to live for”; “I’d be
better off dead”.

Desired Outcomes

 Patient will refrain from attempting suicide.

 Patient will make a no-suicide contract with the nurse covering the
next 24 hours, then renegotiate the terms at that time (If in hospital
and accepted at your institution).
 Patient will remain safe while in the hospital, with the aid of nursing
intervention and support (if in the hospital).
 Patient will stay with a friend or family if the person still has the
potential for suicide (if in the community).
 Patient will join family in crisis family counseling.
 Patient will have links to self-help groups in the community.
 Patient will keep an appointment for the next day with a crisis
counselor (if in the community).
 Patient will identify at least one goal for the future.
 Patient will uphold a suicide contract.
 Patient will state that he or she wants to live.
 Patient will name at least one acceptable alternative to his or her
situation.
 Patient will name two people he/she can call if thoughts of suicide
recur before discharge.
 Nursing Interventions Rationale

In the Community:

Arrange for the client to stay with family or friends.

A hospitalization is considered if there is no one is Relieve isolation and provide safety and comfort.
available especially if the person is highly suicidal.

Encourage the client to avoid decisions during the During crisis situations, people are unable to think
time of crisis until alternatives can be considered. clearly or evaluate their options readily.

Encourage the client to talk freely about feelings and Gives client other ways of dealing with strong
help plan alternative ways of handling emotions and gaining a sense of control over their
disappointment, anger, and frustration. lives.

Weapons and pills are removed by friends, relatives, To provide a safe environment, free from things that
or the nurse. may harm the client.

If anxiety is extremely high, or client has not slept in

days, a tranquilizer might be prescribed. Only a 1 to 3 Relief of anxiety and restoration of sleep loss can
day supply of medication should be given. Family help the client think more clearly and might help
member or significant other should monitor pills for restore some sense of well-being.
safety.

Contact family members, arrange for individual and/ Reestablishes social ties. Diminishes sense of
or family crisis counseling. Activate links to self-help isolation, and provides contact from individuals who
groups. care about the suicidal person.

In the Hospital:

During the crisis period, health care workers will

continue to emphasize the following four points:
Because of “tunnel vision“, clients do not have
1. The crisis is temporary. perspective on their lives. These statements give
perspective to the client and help offer hope for the
2. Unbearable pain can be survived.
future.
3. Help is available.
4. You are not alone.
Forensic Issues:

Provide safe environment during time client is

Follow unit protocol for suicide regarding creating a
actively suicidal and impulsive; self-destructive acts
safe environment (taking away potential weapons–
are perceived as ties, the only way out of an
belts, sharp objects, items, and so on).
intolerable situation.

Keep accurate and thorough records of client’s These might become court documents. If client
behaviors (verbal and physical) and all checks and attention to client’s needs or request are
nursing/physician actions. not documented, they do not exist in a court of law.

Put on either suicide precaution (one-on-one

monitoring at one arm’s length away) or suicide Protection and preservation of the client’s life at all
observation (15-minute visual check of mood, costs during crisis is part of medical and nursing
behavior, and verbatim statements), depending on staff responsibility. Follow unit protocol.
level of suicide potential.

Keep accurate and timely records, document client’s Accurate documentation is vital. The chart is a legal
activity, usually every 15 minutes (what client is document as to client’s “ongoing status,”
doing, with whom, and so on). Follow unit protocol. intervention taken, and by whom.

Encourage the client to talk about their feelings and Talking about feelings and looking at alternatives
problem solve alternatives. can minimize suicidal acting out.

The no-suicide contract helps client know what to do

Construct a no-suicide contract between the suicidal
when they begin to feel overwhelmed by pain (e.g., “I
client and nurse. Use clear, simple language. When
will speak to my nurse/counselor/support
the contract is up, it is renegotiated (If this is
group/family member when I first begin to feel the
accepted procedure at your institution).
need to end my life”).

Ineffective Coping

Ineffective Individual Coping: Inability to form a valid appraisal of the

stressors, inadequate choices of practiced responses, and/or inability to use
available resources.

May be related to
  Disturbance in pattern of tension release.
 Impulsive use of extreme solutions.
 Inadequate coping skills.
 Inadequate social support created by characteristics of relationship.
 Inadequate resources available.
 Inadequate opportunity to prepare for a stressor.
 Personal loss or threat of rejection.
 Poorly developed social skills.
 Situational or maturational crises.

Possibly evidenced by

 Abuse of chemical agents.

 Change in usual communication pattern.
 Decreased use of social supports.
 Destructive behavior toward self or others.
 Expression of anxiety, depression, fear, impatience, frustration, and/or
discouragement.
 Inability to meet basic needs.
 Inability to meet role expectations.
 Inability to problem solve.
 Lack of goal-directed behavior.
 Poor problem solving.
 Use of forms of coping that might impede adaptive behavior.
 Verbalization of inability to cope or inability to ask for help.

Desired Outcomes

 Patient will refrain from using or abusing chemical agents.

 Patient will reports adequate supportive social contacts.
 Patient will state that he or she feels comfortable with one new coping
technique after three sessions of role playing.
  Patient will discuss with the nurse/counselor at least three situations
that trigger suicidal thoughts, as well as feelings about these situation.
 Patient will name two effective ways to handle difficult situations in the
future.
 Patient will state willingness to learn new coping strategies (through
group, individual, therapy, coping skills training, cognitive-behavior
skills and so on).
 Patient will name two persons to whom he/she can talk if suicidal
thoughts recur in the future.
 Patient will state that she or he believes his/her life has value and that
they have an important role to play (mother, son, huband, father,
provider, friend, job-related position, etc).
 Patient will demonstrate two behaviors in dealing with emotional pain.
 Patient will demonstrate a reduction of self-destructive behaviors.

Nursing Interventions Rationale

Assess client’s strengths and positive coping skills

Use these to build upon and draw from in planning
(talking to others, creative outlets, social activities,
alternatives to self-defeating behaviors.
problem-solving abilities).

Assess client’s coping behaviors that are not effective

and that result in negative sequelae:

 Angry outbursts. Identify areas to target teaching and planning

 Denial. strategies for supplanting more effective and self-
enhancing behaviors.
 Drinking.
 Procrastination.
 Withdrawal.

When people have difficulty getting their needs

Assess need for assertiveness training. Assertiveness
met or asking for what they need, frustration and
skills can help client develop a sense of balance and
anger can build up, leading to, in some cases,
control.
ineffective outlet for stress.
 Identify targets for learning more adaptive coping
Identify situations that trigger suicidal thoughts.
skills.

Clarify those things that are not under the person’s Recognizing one’s limitations in controlling other
control. One cannot control another’s actions, likes, is, paradoxically, a beginning to finding one’s
choices, or health status. strength.

Have client experiment with attending at least two

Assess client’s social supports.
chosen possibilities.

Hopelessness

Hopelessness: Subjective state in which an individual sees limited or no

alternatives or personal choices available and is unable to mobilize energy on
his/her own behalf.

May be related to

 Abandonement.
 Chronic pain.
 Failing or deteriorating physiologic conditions (Cancer, AIDS).
 Long-term stress.
 Lost belief in transcendent values/God.
 Loss of significant support systems.
 Perceived hopelessness, helplessness.
 Perceiving the future as bleak and wasted.
 Prolonged isolation.
 Severe stressful events (financial reversals, relationship turmoil, loss of
job).

Possibly evidenced by

 Decreased affect.
 Decreased judgment.
  Decreased problem solving.
 Impaired decision making.
 Lack of initiative.
 Lack of involvement in care.
 Lack of motivation.
 Loss of interest in life.
 Passivity, decreased verbalization.
 Turning away from speaker.

Desired Outcomes

 Patient will express the will to live.

 Patient will have an expression of positive future orientation.
 Patient will have an expression of meaning in life.
 Patient will make two decisions related to his/her care.
 Patient will identify three things that he/she is doing right.
 Patient will reframe two problem areas in his/her life that encourage
problem-solving alternative solutions.
 Patient will identify two alternatives for one life problem area.
 Patient will name one community resource (support group, counseling,
social service, family counseling) that he/she has attented at least
twice.
 Patient will state three optimistic expectations for the future.
 Patient will describe and plan for at least two future-oriented goals.
 Patient will demonstrate two new problem-solving skills that client
finds effective in making life decisions.
 Patient will demonstrate reframing skills when viewing aspects of
client’s life that appear all negative.

Nursing Interventions Rationale

Encourage clients to look into their negative thinking, Cognitive reframing helps people look at
and reframe negative thinking into neutral objective situations in ways that allow for alternative
 thinking. approaches.

When people are feeling overwhelmed, they no

Work with client to identify areas of strengths.
longer view their lives or behavior objectively.

Constructive interpretations of events and

Point out unrealistic and perfectionistic thinking. behavior open up more realistic and satisfying
option for the future.

Identify things that have given meaning and joy to life in

Reawakens in client abilities and experiences that
the past. Discuss how these things can be
tapped areas of strength and creativity. Creative
reincorporated into their present lifestyle (e.g., religious
activities give people intrinsic pleasure and joy,
or spiritual beliefs, group activities, creative
and a great deal of life satisfaction.
endeavors).

Spend time discussing client’s dreams and wishes for

Renewing realistic dreams and hopes can give
the future. Identify short-term goals they can set for the
promise to the future and meaning to life.
future.

Encourage contact with religious or spiritual persons or During times of hopelessness people might feel
groups that have supplied comfort and support in abandoned and too paralyzed to reach out to
client’s past. caring people or groups.

Stress that it is not so much people are

Teach client steps in the problem-solving process. ineffective, but rather it is often the coping
strategies they are using that are not effective.

Bipolar Disorders Nursing Care Plans

Bipolar disorders are mood disorders that comprise of one or more manic or hypomanic episode
and usually one or more depressive episodes with periods of relatively normal functioning in
between. They are said to be linked to biochemical imbalances in the brain and it is said that the
disease is genetically transferred.

Nursing Care Plans

Clients with bipolar disorders are at a high risk for suicide. Although clients in the manic phase are
briefly agitated, energized and elated, their underlying depression makes them likely to inflict self-
injury.
Essential responsibilities of nurses are to provide a safe environment, to improve the self-esteem,
to meet the physiologic needs and to guide patients toward socially appropriate behavior.

Here are six (6) nursing care plans (NCP) for bipolar disorders:

 Risk For Injury

 Risk For Violence: Self-Directed or Other Directed
 Impaired Social Interaction
 Ineffective Individual Coping
 Interrupted Family Processes
 Total Self-Care Deficit

Risk For Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the
individual’s adaptive and defensive resources, which may compromise health.

Risk factors

 Affective, cognitive, and psychomotor factors.

 Biochemical/neurologic imbalances.
 Exhaustion and dehydration.
 Extreme hyperactivity/physical agitation.
 Rage reaction.

Possibly evidenced by

 Abrasions, bruises, cuts from running/falling into objects.

 Extreme hyperactivity.
 Impaired judgment (reality-testing, risk behavior).
 Lack of fluid ingestion.
 Lack of control over purposeless and potentially injurious movements.

Desired Outcomes

 Patient will respond to the medication within the therapeutic levels.

  Patient will sustain optimum health through medication management and therapeutic
regimen.
 Patient will have stable cardiac status while in the hospital.
 Patient will drink 8 oz of fluid every hour throughout the day while on acutely manic stage.
 Patient will remain free from falls and abrasions every day while in the hospital.
 Patient will be free of dangerous levels of hyperactive motor behavior with the aid of
medications and nursing interventions within the first 24 hours.
 Patient will spend time with the nurse in a quiet environment three to four times a day
between 7 am and 11 pm with the aid of nursing guidance.
 Patient will take short voluntary rest periods during the day.
 Patient will be free of excessive physical agitation and purposeless motor activity within 2
weeks.
 Patient will be free of injury within 2 to 3 weeks:
 Stable cardiac status.
 Skin free of abrasions and scrapes.
 Well dehydrated.

Nursing Interventions Rationale

Provide structured solitary activities with the
assistance of a nurse or aide. Structure provides focus and security.
Provide frequent rest periods. Prevents exhaustion.
Provide frequent high-calorie fluids (e.g., fruit shake,
milk). Prevents the risk of serious dehydration.
Maintain a low level of stimuli in client’s environment
(e.g., loud noises, bright light, low-temperature
ventilation). Helps minimize escalation of anxiety.

Acute mania might warrant the use of phenothiazines Exhaustion and death result from dehydration, lack
and seclusions to decrease any physical harm. of sleep, and constant physical activity.

Observe for signs of lithium toxicity (e.g., nausea,

vomiting, diarrhea, drowsiness, muscle weakness,
tremor, lack of coordination, blurred vision, or ringing
in your ears).
Protect client from giving away money and
possessions. Hold valuables in a hospital safe until
rational judgment returns.
Redirect violent behavior.
There is a small margin of safety between
therapeutic and toxic doses.
Client’s “generosity” is a manic defense that is
consistent with irrational, grandiose thinking.
Physical exercise can decrease tension and provide
focus.

Risk For Violence: Self-Directed or Other Directed

Risk for self-directed violence: At risk for behaviors in which an individual demonstrates that
he/she can be physically, emotionally, and/or sexually harmful to self.

Risk factors

 Biochemical/neurologic imbalances.
 Impulsivity.
 Manic excitement.
 Psychotic symptomatology.
 Rage reaction.
 Restlessness.

Possibly evidenced by

 Agitated behaviors (e.g., slamming doors, increased muscle tension, throwing things over).
 Delusional thinking.
 Hallucinations.
 Loud, threatening, profane speech.
 Poor impulse control.
 Provocative behaviors (e.g., argumentative).
 Verbal threats against others.
 Verbal threats against self (suicidal threats/attempts, hitting or injuring self, banging head
against the wall).

Desired Outcomes

 Patient will verbalize control of feelings.

 Patient will respond to external controls (medications, seclusion, nursing interventions)
when potential or actual loss of control occurs.
 Patient will refrain from provoking others to physical harm, with the aid of seclusion or
nursing interventions.
 Patient will display nonviolent behavior toward others in the hospital, with the aid of
medications and nursing interventions.
 Patient will seek help when experiencing aggressive impulses.
 Patient will refrain from verbal threats and loud, profane language toward others.
 Patient will be safe and free from injury.

Nursing Interventions Rationale

Early detection and intervention of escalating

Frequently assess client’s behavior for signs of
mania will prevent the possibility of harm to self or
increased agitation and hyperactivity.
others, and decrease the need for seclusions.
 Provides structure and control for a client who is
Use a calm and firm approach.
out of control.

Use short, simple and brief explanations or Short attention span limits understanding to small
statements. pieces of information.

Remain neutral as possible; Do not argue with the Client can use inconsistencies and value judgments
client; as justification for arguing and escalating mania.

Maintain a consistent approach, employ Clear and consistent limits and expectations
consistent expectations, and provide a structured minimize potential for client’s manipulation of
environment. staff.

Redirect agitation and potentially violent

Can help to relieve pent-up hostility and relieve
behaviors with physical outlets in an area of low
muscle tension.
stimulation (e.g., punching bag).

Decrease environmental stimuli (e.g., by

Helps decrease escalation of anxiety and manic
providing a calming environment or assigning a
symptoms.
private room)

Alert staff if a potential for seclusion appears

imminent. Usual priority of interventions would
be:
 Firmly setting limits.
 Chemical restraints (tranquilizers).
 Seclusions.
If nursing interventions (quiet environment and
firm limit setting) and chemical restraints
(tranquilizers–e.g., haloperidol[Haldol]) have not
helped dampen escalating manic behaviors, then
seclusion might be warranted.

Chart, in nurse’s notes, behaviors; interventions;

what seemed to escalate agitation; what helped to Staff will begin to recognize potential signals for
calm agitation; when as-needed (PRN) escalating manic behaviors and have a guideline
medications were given and their effect; and what for what might work best for the individual client.
proved most helpful.

Impaired Social Interaction

Impaired Social Interaction: The state in which an individual participates in an insufficient or
excessive quantity or ineffective quality of social exchange.

May be related to
  Biochemical imbalances.
 Disturbed thought processes.
 Excessive hyperactivity and agitation.

Possibly evidenced by

 Dysfunctional interaction with family, peers, and/or others.

 Family reports a change of style or patterns of interaction.
 Inability to develop satisfying relationships
 Increase of manic behaviors when the client is in a highly stimulating environment (e.g.,
with groups of people, bright lights, loud music).
 Intrusive and manipulative behaviors antagonizing others.
 Loud, obscene, or threatening verbal behavior.
 Observed use of unsuccessful social interaction behaviors.
 Poor attention span and difficulty focusing on one thing at a time.

Desired Outcomes

 Patient will initiate and maintains goal-directed and mutually satisfying activities/verbal
exchanges with others.
 Patient will find one or two solitary activities that can help relieve tensions and minimize
escalation of anxiety with aid of nurse or occupational/activity therapist.
 Patient will focus on one activity requiring a short attention span for 5 minutes three times
a day with nursing assistance.
 Patient will sit through a short, small group meeting free from disruptive outbursts.
 Patient will demonstrate an ability to remove self from a stimulating environment in order
to “cool down” by discharge.
 Patient will participate in unit activities without disruption or demonstrating inappropriate
behavior by discharge.
 Patient will put feelings into words instead of actions when experiencing anxiety or loss of
control before discharge.

Nursing Interventions Rationale

As mania subsides, involvement in activities that

When less manic, the client might join one or
provide a focus and social contact becomes more
two other clients in quiet, nonstimulating
appropriate. Competitive games can stimulate
activities (e.g., drawing, board games, cards).
aggression and can increase psychomotor activity.

When possible, provide an environment with

minimum stimuli (e.g., quiet, soft music, dim Reduction in stimuli lessens distractability.
lighting).

Solitary activities requiring short attention Solitary activities minimize stimuli; mild physical
spans with mild physical exertion are best activities release tension constructively.
initially (e.g., writing, taking photos, painting,
or walks with staff).

Ineffective Individual Coping

Ineffective Individual Coping: Inability to form a valid appraisal of the stressors, inadequate
choices of practiced responses, and/or inability to use available resources.

May be related to

 Biochemical/neurologic changes in the brain.

 Disturbance in tension release.
 Inadequate level of perception of control.
 Ineffective problem-solving strategies/skills.

Possibly evidenced by

 Changes in usual communication patterns.

 Destructive behavior toward self or others.
 Giving away valuables and financial savings indiscriminately, often to strangers.
 Inability to problem-solve.
 Inability to meet basic needs.
 Inability to ask for help.
 Presence of delusions (grandeur, persecution).
 Using extremely poor judgment in business and financial negotiations.

Desired Outcomes

 Patient will report an absence of delusions, racing thoughts, and irresponsible

actions as a result of medications adherence and environmental structures.
  Patient will return to pre-crisis level of functioning after acute/severe manic phase is
past.
 Patient will cease use of manipulation to obtain needs and control others.
 Patient will demonstrate an absence of destructive behavior toward self or others.
 Patient will be protected from making any major life decisions (legal, business,
marital) during an acute or severe manic phase.
 Patient will respond to limit-setting techniques with aid of medication during acute
and severe manic phase.
 Patient will respond to external controls (medication, seclusion, nursing
intervention) when potential or actual loss of control occurs.
 Patient will retain valuables or other possessions while in the hospital.
 Patient will demonstrate a decrease in manipulative behavior.
 Patient will demonstrate a decrease in demanding and provocative behavior.
 Patient will seek competent medical assistance and legal protection when signing
any legal documents regarding personal or financial matters during manic phase of
illness.

Nursing Interventions Rationale

Assess and recognize early signs of

manipulative behavior, and intervene
appropriately: For example:

1. Taunting staff by pointing out faults

or oversights.
Setting limits is an important step in the
2. Pitting one staff member against intervention of bipolar clients, especially when
another (“You are more intervening in manipulative behaviors. Staff
appreciative than Nurse Paul agreement on limits set and consistency is
imperative if the limits are to be carried out
Martin, do you know what she said effectively.
to me?”) or pitting one group
against another (morning shift
versus night shift).
3. Aggressively demanding behaviors
that can trigger exasperation and
 frustration in staff.
Observe for destructive behavior toward self
or others. Intervene in the early phases of
escalation of manic behavior.
Maintain a firm, calm, and neutral approach
at all times. Avoid:
1. Arguing with the client.
2. Getting involved in power struggles.
3. Joking or “clever” repartee in
response and other clients. to
client’s “cheerful and humorous”
mood.
Have valuables, credit cards, and large sums
of money sent home with family or put in
hospital safe until the client is discharged.
Provide hospital legal service when and if
the client is involved in making or signing
important legal documents during an acute
manic phase.
Administer an antimanic medication and
PRN tranquilizers, as ordered, and evaluate
for efficacy, and side and toxic effects.
Interrupted Family Processes
Interrupted Family Processes: Change in family relationships and/or functioning.
May be related to
Hostile verbal behaviors, poor impulse control,
provocative behaviors, and violent acting out
against others or property are some of the
symptoms of this disease and are seen in extreme
and/or acute mania. Early detection and
intervention can prevent harm to client or others in
the environment.
These behaviors by the staff can escalate
environmental stimulation and, consequently,
manic activity. Once the manic client is out of
control, seclusion might be required, which can be
traumatic to the manic individual as well as the
staff.
During manic episodes, people give away valuables
and money indiscriminately to strangers, often
leaving themselves broke and in debt.
Judgement and reality testing are both impaired
during acute mania. Client might need legal advice
and protection against making important decisions
that are not in their best interest.
Bipolar disorder is caused by
biochemical/neurologic imbalances in the brain.
Appropriate antimanic medications allow
psychosocial and nursing interventions to be
effective.
  Erratic and out-of-control behavior of one family member with the potential for
dangerous behavior affecting all family members (violence, leaving family in debt,
risky behaviors in relationships and business, fragrant infidelities, unprotected and
promiscuous sex).
 Family role shift.
 Nonadherence to antimanic and other medications.
 Shift in the health status of family member.
 Situational crisis or transistion (e.g., illness, manic episode of one member).

Possibly evidenced by

 Changes in communication patterns.

 Changes in participation in decision making.
 Changes in participation in problem solving.
 Changes in effectiveness in completing assigned tasks.
 Deficient knowledge regarding disorder, need for medication adherence, and
available support systems.
 Family in crisis.
 Inability to deal with traumatic or crisis experiences constructively.

Desired Outcomes

 Family members and/or significant others will discuss with nuse/counselor three
areas of family life that are most disruptive and seek alternative options with aid of
nursing/counseling interventions.
 Family members and/or significant others will state and have in writing the names
and telephone numbers of at least two bipolar support groups.
 Family members and/or significant others will state that they have gained support
from at least one support group on how to work with family member when he or she
is manic.
 Family members and/or significant others will state their understand the need for
medication adherence, and be able to identify three signs that indicate possible need
for intervention when their family member’s mood escalates.
  Family members and/or significant others will briefly discuss and have in writing,
the names and addresses of two bipolar organizations, two Internet site addresses,
and medication information regarding bipolar disorder.
 Family members and/or significant others will state that they find needed support
and information in a support group (s).
 Family members and/or significant others will identify the signs of increase manic
behavior in their family member.
 Family members and/or significant others will state what they will do (whom to call,
where to go) when client’s mood begins to escalate to dangerous levels.
 Family members and/or significant others will demonstrate an understanding of
what a bipolar disorder is, the medications, the need for adherence to medication
and treatment.

Nursing Interventions Rationale

During the first or second day of

hospitalization, spend time with
family identifying their needs during
this time; for example:

1. Need for information about

the disease.
2. Need for information about This is a disease that can devastate and destroy some
families. During an acute manic attack, families experience
lithium or other antimanic a great deal of disruption and confusion when their family
medications (e.g., need for members begins to act bizarre, out of control and at times
aggressive. Families need to understand about the disease
adherence, side effects, toxic
what can and cannot be done to help control the disease,
effects). and where to go for help for their individual issues.
3. Knowledge about bipolar
support groups in the
family’s community and how
they can help families going
through crises.
Total Self-Care Deficit

Self-Care Deficit: Impaired ability to perform or complete bathing/hygiene,

dressing/grooming, feeding, or toileting activities for oneself.

May be related to

 Inability to concentrate on one thing at a time.

 Manic excitement.
 Perceptual or cognitive impairment.
 Racing thoughts and poor attention span.
 Severe anxiety.

Possibly evidenced by

 Observation or valid report of inability to eat, bathe, toilet, dress, and/or groom self
independently.

Desired Outcomes

 Patient will sleep 6 hours out of 24 with aid of medication and nursing measures
within 3 days.
 Patient will eat half to one third of each meal plus one snack between meals with aid
of nursing intervention.
 Patient will have normal bowel movements within 2 days with the aid of high-fiber
foods, fluids, and, if needed, medication.
 Patient will wear appropriate attire each day while in the hospital.
 Patient will bathe at least every other day while in hospital.
 Patient will sleep 6 to 8 hours per night.
 Patient will have a weight within normal limits for age and height.
 Patient will have bowel habits within normal limits.
 Patient will dress and groom self in appropriate manner consistent with pre-crisis
level of dress and grooming.
 Nursing Interventions Rationale

Disturbed Sleep Pattern:

Keep client in areas of low stimulation. Promotes relaxation and minimizes manic behavior.

Encourage frequent rest periods during

Lack of sleep can lead to exhaustion and death.
the day.

At night, encourage warm baths,

soothing music, and medication when
Promotes relaxation, rest, and sleep.
indicated. Avoid giving the client
caffeine.

Imbalanced Nutrition:

Ensures adequate fluid and caloric intake; minimizes

Monitor intake, output, and vital signs.
dehydration and cardiac collapse.

Frequently remind the client to eat

The manic client is unaware of bodily needs and is easily
(e.g.,Rob, finish your pancake”, “Sandra,
distracted. Needs supervision to eat.
drink this apple juice.”).

Encourage frequent high-calorie Constant fluid and calorie replacement are needed.
protein drinks and finger foods (e.g., Client might be too active to sit at meals. Fingers foods
sandwiches, fruit, milkshakes). allow “eating on the run”.

Constipation:

Monitor bowel habits; offer fluids and

foods rich in fiber. Evaluate the need for Prevents fecal impaction resulting from dehydration and
a laxative. Encourage client to go to the decreased peristalsis.
bathroom.

Dressing/Grooming Self-Care Deficit:

If warranted, supervise choice of Lessens the potential for inappropriate attention, which
clothes; minimize flamboyant and can increase the level of mania, or ridicule, which lowers
bizarre dress, and sexually suggestive self-esteem and increases the need for manic defense.
dress, such as bikini tops and bottoms. Assists client in maintaining dignity.

Give simple step-by-step reminders for

hygiene and dress (e.g.,”Here is your Distractability and poor concentration are countered by
toothbrush. Put the toothpaste on the simple, concrete instructions.
brush”).