DEPRESSION Nursing Diagnosis Risk for suicide related to feeling of worthlessness Background Knowledge Depression is a state of low mood

and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless. They may lose interest in activities that once were pleasurable, experience loss of appetite or overeating, or problems concentrating, remembering details or making decisions; and may contemplate or attempt suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains or digestive problems that are resistant to treatment may be present. Planning Goal: After 3 days of nursing intervention, the patient will not harm his/her self. Objectives: After rendering nursing interventions patient will: >seek out staff when feeling urge to harm self >make short-term contract with the nurse not to harm self Intervention 1 Ask client directly, have you ever thought about killing yourself>, If so, what do you plan to do?, during therapeutic communication. 2 Create a safe environment for the client. Remove all potentially harmful objects from clients access. 3 formulate a short term verbal contract with the client that he or she will not harm self during specific time period. 4 secure promise from client that he/she will seek out a staff member or support person if thoughts of suicide emerge. 5 Encourage client to express angry feelings within appropriate limits. Rationale >the risk of suicide is greatly increased if the client has developed a plan and particularly if means exist for the client to execute plan. >client safety is a nursing priority. Evaluation >Client verbalizes no thoughts of suicide. >Client commits no acts of self harm. >Client is able to verbalize names of resources outside the hospital from which she may request help in feeling of suicidal.

>this will provide some relief to the client.

>this may provide assistance before the client experiences a crisi situation.

>If the anger was verbalized in a nonthreatening environment, the client may be able to resolve these feelings, regardless of the discomfort involved.

MANIC DISORDER Nursing Diagnosis Risk for injury related to extreme hyperactivity Background Knowledge Mania can be experienced at the same time as depression, in a mixed episode. Dysphoric mania is primarily manic and agitated depression is primarily depressed. This has caused speculation amongst doctors that mania and depression are two independent axes in a bipolar spectrum, rather than opposites. Planning Goal: After 3 days of nursing intervention, the patient will experience no physical injury. Objectives: After rendering nursing interventions patient will: >no longer exhibit potentially injurious movements Intervention 1 Reduce environmental stimuli. Rationale >In hyperactive state, client is extremely distractible, responses even the slightest stimuli are exaggerated. >Milieu unit may be too distracting. >Client feels more secure in one-two relationship. Evaluation >Client is no longer exhibiting signs of physical agitation. >Client exhibits no evidence of physical injury obtained while experiencing hyperactive behavior.

2 Assign to quiet unit, if possible. 3 Limit group activities. Help client try to establish one or two close relationships. 4 Remove hazardous objects and substances from clients environment. 5 Stay with the client and provide rest periods throughout the day. 6 Provide physical activities as a substitute for purposeless hyperactivity.

>Clients rationality is impaired, so client may harm self inadvertently.

>to offer support and provide feeling of security. >Provide a safe and effective means of relieving pent-up tension.

SCHIZOPHRENIA Nursing Diagnosis Impaired Social Interaction related to absence of available significant others or peers as evidenced by dysfunctional interaction with peers, family, and others Background Knowledge Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood. Planning Goal: After 3 days of nursing intervention, the patient will be able to demonstrate attempts to communicate. Objectives: After rendering nursing interventions patient will: >verbalize to express honest feelings in relation to loss of prior level of functioning Intervention 1 Spend time with client. This may mean just sitting in silence for a while. 2 Develop a therapeutic nurse-client relationship through frequent, brief contacts and an accepting attitude. Show unconditional positive regard. 3 Provide positive reinforcement for client's voluntary interactions with others. 4 Teach assertiveness techniques. Interactions with others may be negatively affected by client's use of passive or aggressive behaviors. Rationale >Your presence may help improve client's perception of self as a worthwhile person. Evaluation > Client demonstrates willingness and desire to socialize with others. >Client voluntarily attends group activities. >Your presence, acceptance, and conveyance of positive regard enhance the client's feelings of self-worth. >Client approaches others in appropriate manner for oneto-one interaction

>Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. >Knowledge of assertive techniques could improve client's relationships with others

ANTISOCIAL Nursing Diagnosis Impaired social interaction related to disturbed brain development Background Knowledge Antisocial Personality Disorder is a condition characterized by persistent disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. Deceit and manipulation are central features of this disorder. For this diagnosis to be given, the individual must be at least 18, and must have had some symptoms of Conduct Disorder (i.e., delinquency) before age 15. This disorder is only diagnosed when these behaviors become persistent and very disabling or distressing. Planning Long term goal: After 6 days of nursing intervention client will be able to demonstrate successful interactions with family members and staffs in educational setting. Objectives: After rendering nursing care client will: >Successfully complete tasks or assignments with assistance >Demonstrate acceptable social skills while interacting with staff or family Intervention 1 Identify the factors that aggravate and alleviate the clients performance. Rationale >The external stimuli that exacerbate the clients problems can be identified and minimized. >The clients ability to deal with external stimulation is impaired >The client must hear instructions as a first step toward compliance. Evaluation >The client was able to demonstrate willingness and desire to socialize with some educational staff but not with all staff.

2 Provide an environment as free from distractions as possible. 3 Engage the clients attention before giving instructions. (calling his/her name, having an eye contact) 4 Give instructions slowly, using simple language and concrete directions. 5 Provide positive feedback for completion of each step or task.

>The clients ability to comprehend instruction is impaired. >The clients opportunity for successful experiences is increased by treating each step/task as an opportunity for success. >The clients restless energy can be given an acceptable outlet, so that he/she can attend to future task more effectively. >This approach called shaping is a behavioral procedure in which

6 Allow breaks during which the client can move around.

7 Give the client positive

feedback for performing behaviors that comes close to task achievement.

successive approximations of a desired behavior are positively reinforced. >Increase logical thought and decrease tangentiality.

8 Assist the client to verbalize by asking sequencing questions to keep on the topic (what happens next?).

OCPD Nursing Diagnosis Background Knowledge Planning Intervention Rationale Evaluation