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Care Plans
Personality is defined as the differences in the characteristic patterns of
behaving, feeling and thinking of an individual.
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 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
Desired Outcomes
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).
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.
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.
May be related to
Possibly evidenced by
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.
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
assessment that do not appear accurate.
1. Strengths and weaknesses in
performance at work/school.daily-life
tasks.
2. Strengths and weaknesses as to
physical appearance, sexuality,
personality.
Teach client to reframe and dispute cognitive Practice and belief in the disputes over time help
distortions. Disputes need to be strong, specific, clients gain a more realistic appraisal of events, the
and nonjudgmental. world, and themselves.
Work with client to recognize cognitive distortions. Cognitive distortions are automatic. Keeping a log
Encourage client to keep a log. helps make automatic, unconscious thinking clear.
Keep in mind clients with personality disorders Many behaviors seen in PD clients cover a fragile
might defend against feeling of low-self-esteem sense of self. Often these behaviors are the crux of
through blaming, projection, anger, passivity, and clients’ interpersonal difficulties in all their
demanding behaviors. relationships.
Discuss with client his or her plans for the future. Looking toward the future minimizes dwelling on the
Work with client to set realistic short-term goals. past and negative self-rumination. When realistic
Identify skills to be learned to help client reach his short-term goals are met, client can gain a sense of
or her goals. accomplishment, direction, and purpose in life.
Accomplishing goals can bolster a sense of control and
enhance self-perception.
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”.
May be related to
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.
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.
In a respectful, neutral manner, explain expected From the beginning, clients need to have explicit
client behaviors, limits, and responsibilities during guidelines and boundaries for expected behaviors on
sessions with nurse clinician. Clearly state the rules their part, as well as what client can expect from the
and regulations of the institution, and the nurse. Clients need to be fully aware that they will be
consequences when these rules are not adhered to. held responsible for their behaviors.
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.
Ineffective Coping
May be related to
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
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.
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.
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.
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.
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.
Use assertiveness when setting limits on client’s Firm, clear, nonjudgmental limits give client
unreasonable demands for attention and time. structure.
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.
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
May be related to
Desired Outcomes
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.
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.
Fear
May be related to
Phobic stimulus
Physiological symptoms, mental/cognitive behaviors indicative of panic
Possibly evidenced by
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 Rationale
Present and discuss reality of the situation with client in Client must accept the reality of the situation
order to recognize aspects that can be changed and those before the work of reducing the fear can
that cannot. progress.
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
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
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.
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.
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
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.
Social Isolation
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
Convey an accepting and positive attitude by making brief, An accepting attitude increases feeling of
frequent contacts. self-worth and facilitates trust.
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.
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.
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.
Self-Care Deficit
May be related to
Possibly evidenced by
Desired Outcomes
Urge client to perform normal ADLs to Successful performance of independent activities enhances self-
his level of ability. esteem.
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
May be related to
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
Explain the physiologic action of SSRI in Anxiety disorders are caused by neuropsychiatric disorder that
relieving anxiety. responds to medication.
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 factors
Possibly evidenced by
Desired Outcomes
May be related to
Possibly evidenced by
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.
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).
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
May be related to
Possibly evidenced by
Desired Outcomes
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.
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.
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
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
Desired Outcomes
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.
Self-Care Deficit
May be related to
Possibly evidenced by
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.
Encourage the use of soap, washcloth, Being clean and well groomed can
toothbrush, shaving equipment, make-up etc. temporarily increase self-esteem.
Constipation
Provide rest periods after activities. Fatigue can intensify feelings of depression.
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.
quiet activities.
Imbalanced Nutrition
Weight the client weekly and observe the Give the information needed for revising the
eating patterns of the client. intervention.
Serve foods or drinks the client likes. Clients are more likely to eat foods they like.
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
Desired Outcomes
Use clear or simple words, and keep directions simple as Client might have difficulty processing even
well. simple sentences.
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.
May be related to
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.
Identify with client symptoms he experiences when he or she Increased anxiety can intensify agitation,
begins to feel anxious around others. aggressiveness, and suspiciousness.
If client is unable to respond verbally or in a coherent An interested presence can provide a sense
manner, spend frequent, short period with clients. of being worthwhile.
If client is delusional/hallucinating or is having trouble Even simple activities help draw client away
concentrating at this time, provide very simple concrete from delusional thinking into reality in the
activities with client (e.g., looking at a picture or do a environment.
painting).
Try to incorporate the strengths and interests the client had Increase likelihood of client’s participation
when not as impaired into the activities planned. and enjoyment.
Remember to give acknowledgment and recognition for Recognition and appreciation go a long way
positive steps client takes in increasing social skills and to sustaining and increasing a specific
appropriate interactions with others. behavior.
May be related to
Possibly evidenced by
Desired Outcomes
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.
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.
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.
May be related to
Possibly evidenced by
Delusions.
Inaccurate interpretation of environment.
Inappropriate non-reality-based thinking.
Memory deficit/problems.
Self-centeredness.
Desired Outcomes
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.
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.
Defensive Coping
May be related to
Possibly evidenced by
Desired Outcomes
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.
Maintain low level of stimuli and enhance a non- Noisy environments might be perceived as
threatening environment (avoid groups). threatening.
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.
May be related to
Possibly evidenced by
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.
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.
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.
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Nursing Care Plans
Paul Martin, RN
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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.
Rape-Trauma Syndrome
May be related to
Sexual assault.
Possibly evidenced by
Desired Outcomes
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.
Many clinics offer prophylaxis to pregnancy Approximately 3% to 5% of women who are raped become
with norgestrel (Ovral). pregnant.
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.
Denial
May be related to
Possibly evidenced by
Desired Outcomes
Ascertain by what name patient would like to be Shows courtesy and respect, giving patient a sense of
addressed. orientation and control.
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.
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 Rationale
activated by environment; compulsive desire.) may relieve patient’s guilt and blame and may help
awareness of recurring addictive characteristics.
Provide information regarding effects of addiction Individuals often mistake effects of addiction and
on mood and personality. use this to justify or excuse drug use.
Remain nonjudgmental. Be alert to changes in Confrontation can lead to increased agitation, which
behavior, (restlessness, increased tension). may compromise safety of patient and staff.
Provide positive feedback for expressing awareness Necessary to enhance self-esteem and to reinforce
of denial in self and others. insight into behavior.
Encourage family members to seek help whether or To assist the patient deal appropriately with the
not the abuser seeks it. situation.
Ineffective Individual Coping
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
Desired Outcomes
Review program rules, philosophy expectations. Having information provides opportunity for patient
to cooperate and function as a member of the group
Nursing Interventions Rationale
Encourage verbalization of feelings, fears, and May help patient begin to come to terms with long-
anxiety. unresolved issues.
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.
Encourage involvement with self-help associations ( Puts patient in direct contact with support system
Alcoholics, NarcoticsAnonymous). necessary for managing sobriety and drug-free life.
Remove harmful objects from the patient’s room. To prevent the patient from harm
Powerlessness
May be related to
Possibly evidenced by
Desired Outcomes
Use crisis intervention techniques to initiate Patient is more amenable to acceptance of need for
behavior changes: treatment at this time.
Explore support in peer group. Encourage sharing Patient may need assistance in expressing self,
about drug hunger, situations that increase the speaking about powerlessness, admitting need for
desire to indulge, ways that substance has influenced help in order to face up to problem and begin
life. resolution.
May be related to
Possibly evidenced by
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.
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.
Low Self-Esteem
May be related to
Possibly evidenced by
Desired Outcomes
changes.
May be related to
Possibly evidenced by
Desired Outcomes
Determine understanding of current situation and Provides information on which to base present plan
previous methods of coping with life’s problems. of care.
(secondary gain).
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.
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.
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
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
May be related to
Possibly evidenced by
Desired Outcomes
Ascertain patient’s beliefs and expectations. Have Determines level of knowledge, identifies
patient describe problem in own words. misperceptions and specific learning needs.
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.
Assess drinking and drug history of pregnant Awareness of the negative effects of alcohol and
patient. Provide information about effects of other drugs on reproduction may motivate patient to
substance abuse on the reproductive system and stop using drug(s). When patient is pregnant,
fetus ( increased risk of premature identification of potential problems aids in planning
birth, brain damage, and fetal malformation). for future fetal needs and concerns.
Nursing Interventions Rationale
Deficient Knowledge
May be related to
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
Be aware of and deal with anxiety of patient and Anxiety can interfere with ability to hear and
family members. assimilate information.
Review condition and prognosis and future Provides knowledge base from which patient can
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.
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 Factors
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
In the Community:
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.
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:
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.
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.
Ineffective Coping
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
Desired Outcomes
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.
Hopelessness
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
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.
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.
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 factors
Possibly evidenced by
Desired Outcomes
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.
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
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.
May be related to
Biochemical imbalances.
Disturbed thought processes.
Excessive hyperactivity and agitation.
Possibly evidenced by
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.
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: 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
Possibly evidenced by
Desired Outcomes
1. Arguing with the client. These behaviors by the staff can escalate
environmental stimulation and, consequently,
2. Getting involved in power struggles. manic activity. Once the manic client is out of
3. Joking or “clever” repartee in control, seclusion might be required, which can be
response and other clients. to traumatic to the manic individual as well as the
staff.
client’s “cheerful and humorous”
mood.
Have valuables, credit cards, and large sums During manic episodes, people give away valuables
of money sent home with family or put in and money indiscriminately to strangers, often
hospital safe until the client is discharged. leaving themselves broke and in debt.
Provide hospital legal service when and if Judgement and reality testing are both impaired
the client is involved in making or signing during acute mania. Client might need legal advice
important legal documents during an acute and protection against making important decisions
manic phase. that are not in their best interest.
Bipolar disorder is caused by
Administer an antimanic medication and biochemical/neurologic imbalances in the brain.
PRN tranquilizers, as ordered, and evaluate Appropriate antimanic medications allow
for efficacy, and side and toxic effects. psychosocial and nursing interventions to be
effective.
May be related to
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
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.
May be related to
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
Keep client in areas of low stimulation. Promotes relaxation and minimizes manic behavior.
Imbalanced Nutrition:
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:
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.