Psychiatric Nursing Care Plans

by Fortinash

• ISBN13: 9780323039819
• ISBN10: 0323039812
• Edition: 5th
• Format: Paperback
• Copyright: 2006-04-28
• Publisher: Mosby

Summary

The most comprehensive psychiatric nursing care planning text available assists students and practitioners in providing effective care in a variety of settings. Clear presentation of information, consistent use of the nursing process, correlation of nursing and medical diagnoses, and prioritization of interventions make this text an invaluable resource. Grounded in the latest classification of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the most current list of NANDA-approved nursing diagnoses, this text covers a wide range of disorders, their psychopathology, and appropriate nursing interventions with rationales. Care plans use real clinical situations and include therapeutic and nontherapeutic dialogue examples to familiarize nurses with likely scenarios and equip them with the tools they need to feel confident in any clinical setting. The first chapter, The Nursing Process, effectively describes the central principles of psychiatric nursing practice in detailing the ANAs six-step nursing process along with additional information on therapeutic nurse-client communication skills, client history and assessment tools, NIC and NOC, and more. The six-step nursing process format is maintained throughout to emphasize a practice-oriented, problem-solving approach to psychiatric care. Major psychiatric disorders are reviewed consistently and completely with sections including Etiology, Epidemiology, Assessment and Diagnostic Criteria, Interventions, and Prognosis and Discharge Criteria. With this basis of knowledge, relevant care plans are offered in the second section of each chapter. Care plans based on DSM-IV-TR medical and NANDA nursing diagnoses are logically and consistently organized with Assessment Data, Outcome Criteria, Planning and Implementation, and Evaluation sections. Assessment Data sections include detailed related factors (etiology) and defining characteristics or risk factors as appropriate for the specific diagnosis. Outcome Criteria sections give the reader clear indications of the desired end state. Planning and Implementation sections list specific, relevant, and practical nursing interventions with rationales in a clear, comprehensible two-column format. UNIQUE! Therapeutic and non-therapeutic dialogue examples are presented throughout to promote more effective client communication. Evaluation sections state the role of outcome evaluation as a critical and ongoing step in the nursing process. Client and Family Teaching boxes include Nurse Needs to Know and Teach Client and Family sections covering all aspects of post-treatment instructions for clients and caregivers. DSM-IV-TR boxes list all related DSM-IV-TR diagnoses for quick reference. Helpful appendices contain information and strategies that are timely and useful in the care of clients with mental and emotional disorders including such topics as psychiatric and psychosocial therapies, grief and loss, spirituality, and many more. New care plans, many that focus on the family, join completely updated and revised care plans to make this text the most comprehensive psychiatric nursing care planning text available. Dynamic internal design emphasizes the care plans as the focus of the text; tabbed pages noting the relevant disorder and a complete list of care plans with page number references make finding a specific care plan easier than ever before. Appropriate Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) labels are presented with each care plan in order that students become familiar with these emerging classifications and practicing nurses can easily identify them for use in their care setting if applicable. A comprehensive pharmacotherapy appendix includes the most recent psychotropic drug information and appropriate related client care. O

Table of Contents

The Nursing Process	p. 1
Assessment	p. 2
Assessment of Mental Status	p. 3
The Interview	p. 3
Essential Qualities for a Therapeutic Relationship	p. 3
Principles of a Therapeutic Nurse-Client Relationship	p. 6
The Nurse-Client Relationship	p. 7
Impasses That Obstruct a Therapeutic Relationship	p. 9
Interpersonal Techniques	p. 9
Nursing Diagnosis	p. 9
Nursing Diagnoses and Medical Diagnoses	p. 9
Components of the Nursing Diagnosis Statement	p. 9
Risk Nursing Diagnosis	p. 13
Outcome Identification	p. 14
Planning	p. 15
Clinical Pathways	p. 15
Implementation	p. 16
Impact of Interventions on Etiology	p. 20
Interventions and Medical Actions	p. 20
Rationale Statements	p. 20
Evaluation	p. 20
Legal and Ethical Issues	p. 21
Confidentiality	p. 21
Duty to Warn	p. 21
Clients Rights	p. 21
Voluntary and Involuntary Treatment	p. 21
Forensic Evaluations	p. 21
Malpractice	p. 21
Documentation	p. 22
The Nursing Process in Community and Home Settings	p. 22
Psychiatric Home Health Care Case Management System	p. 22
Nursing Outcomes Classification and Nursing Interventions Classification	p. 22
Application of the Nursing Process	p. 23
Case Study: The Client with Anxiety	p. 23
Anxiety and Related Disorders	p. 27
Anxiety	p. 27
Responses to Anxiety	p. 29
Anxiety Escalation	p. 30
Anxiety Transmission	p. 30
Etiology	p. 31
Biologic Factors	p. 31
Mind-Body Connection	p. 31
Other Factors	p. 32
Epidemiology	p. 32
Anxiety Disorders	p. 32
Assessment and Diagnostic Criteria	p. 33
Panic Disorder	p. 33
Panic Disorder with Agoraphobia and Agoraphobia without History of Panic Disorder	p. 33
Specific Phobia	p. 34
Social Phobia	p. 34
Obsessive-Compulsive Disorder	p. 34
Posttraumatic Stress Disorder	p. 34
Acute Stress Disorder	p. 35
Generalized Anxiety Disorder	p. 35
Somatoform Disorders	p. 35
Somatization Disorder	p. 35
Conversion Disorder	p. 35
Pain Disorder	p. 35
Hypochondriasis	p. 35
Body Dysmorphic Disorder	p. 36
Factitious Disorders	p. 36
Dissociative Disorders	p. 36
Dissociative Identity Disorder	p. 36
Dissociative Fugue	p. 36
Dissociative Amnesia	p. 36
Depersonalization Disorder	p. 37
Interventions	p. 37
Treatment Settings	p. 37
Medications	p. 37
Therapies	p. 37
Prognosis and Discharge Criteria	p. 38
Care Plan: Anxiety Disorders (All Types)
Anxiety	p. 40
Compromised Family Coping	p. 46
Care Plan: Phobia
Ineffective Coping	p. 50
Care Plan: Obsessive-Compulsive Disorder
Impaired Social Interaction	p. 56
Care Plan: Posttraumatic Stress Disorder/Acute Stress Disorder
Posttrauma Syndrome	p. 62
Care Plan: Somatoform Disorders
Ineffective Coping	p. 67
Care Plans: Dissociative Disorders
Ineffective Coping	p. 73
Risk for Self-Directed Violence/Risk for Other-Directed Violence	p. 78
Mood Disorders	p. 81
Etiology	p. 82
Epidemiology	p. 83
Depression	p. 83
Bipolar Disorder	p. 83
Assessment and Diagnostic Criteria	p. 84
Episodes of Mood Disorders	p. 84
Additional Criteria for Episodes	p. 85
Major Depressive Disorder	p. 86
Dysthymic Disorder	p. 86
Bipolar I and II Disorders	p. 86
Cyclothymic Disorder	p. 87
Mood Disorder due to Medical Condition	p. 87
Substance-Induced Mood Disorder	p. 87
Complications	p. 87
Interventions	p. 89
Treatment Settings	p. 89
Medications	p. 89
Electroconvulsive Therapy	p. 90
Therapies	p. 90
Neuromodulation Devices	p. 91
Prognosis and Discharge Criteria	p. 91
Care Plans: Depression (All Types)
Risk for Suicide	p. 95
Impaired Social Interaction	p. 100
Chronic Low Self-Esteem	p. 103
Ineffective Coping	p. 106
Hopelessness	p. 109
Powerlessness	p. 111
Self-Care Deficit	p. 114
Interrupted Family Processes	p. 115
Care Plans: Mania (All Types)
Risk for Self-Directed Violence/Risk for Other-Directed Violence	p. 119
Risk for Injury	p. 122
Impaired Social Interaction	p. 123
Disturbed Thought Processes	p. 126
Defensive Coping	p. 130
Imbalanced Nutrition: Less than Body Requirements	p. 133
Compromised Family Coping	p. 135
Schizophrenia and Other Psychotic Disorders	p. 139
Etiology	p. 140
Epidemiology	p. 140
Onset of Schizophrenia	p. 140
Course of Schizophrenia	p. 141
Drug Use	p. 141
Mortality and Suicide	p. 142
Assessment and Diagnostic Criteria	p. 142
Symptoms of Schizophrenia	p. 142
Acute Phase of Schizophrenia	p. 142
DSM-IV-TR Criteria	p. 145
Types of Schizophrenia	p. 145
Paranoid Type	p. 145
Disorganized Type	p. 145
Catatonic Type	p. 145
Undifferentiated Type	p. 145
Residual Type	p. 145
Associated Types	p. 146
Other Psychotic Disorders	p. 146
Delusional Disorder	p. 146
Brief Psychotic Disorder	p. 146
Shared Psychotic Disorder	p. 146
Psychotic Disorder due to Medical Condition	p. 146
Substance-Induced Psychotic Disorder	p. 146
Interventions	p. 146
Medications	p. 147
Therapies	p. 147
Community-Based Treatment	p. 148
Prognosis and Discharge Criteria	p. 149
Care Plans: Schizophrenia (All Types)
Disturbed Sensory Perception	p. 152
Disturbed Thought Processes	p. 157
Risk for Self-Directed Violence/Risk for Other-Directed Violence	p. 163
Social Isolation	p. 168
Impaired Verbal Communication	p. 171
Defensive Coping	p. 175
Disabled Family Coping	p. 179
Self-Care Deficit	p. 181
Adjustment Disorders	p. 185
Etiology	p. 185
Epidemiology	p. 185
Assessment and Diagnostic Criteria	p. 186
DSM-IV-TR Criteria	p. 186
Interventions	p. 187
Treatment Settings	p. 187
Medications	p. 187
Psychosocial Therapies	p. 187
Prognosis and Discharge Criteria	p. 188
Care Plans: Adjustment Disorders (All Types)
Ineffective Coping	p. 190
Dysfunctional Grieving	p. 195
Interrupted Family Processes	p. 197
Personality Disorders	p. 203
Etiology	p. 203
Epidemiology	p. 204
Assessment and Diagnostic Criteria	p. 205
DSM-IV-TR Criteria	p. 205
Interventions	p. 208
Medications	p. 208
Therapeutic Nurse-Client Relationship	p. 208
Prognosis and Discharge Criteria	p. 208
Care Plans: Personality Disorders (All Types)
Defensive Coping	p. 211
Chronic Low Self-Esteem	p. 234
Ineffective Coping	p. 258
Interrupted Family Processes	p. 272
Disorders of Infancy, Childhood, and Adolescence	p. 278
Etiology	p. 278
Epidemiology	p. 279
Prevalence	p. 279
Suicides	p. 279
Assessment and Diagnostic Criteria	p. 280
DSM-IV-TR Criteria	p. 280
Mental Retardation	p. 280
Etiology	p. 280
Epidemiology	p. 281
Mild Mental Retardation	p. 281
Moderate Mental Retardation	p. 281
Severe Mental Retardation	p. 282
Profound Mental Retardation	p. 282
Learning Disorders	p. 282
Reading Disorder	p. 282
Mathematics Disorder	p. 282
Disorder of Written Expression	p. 282
Motor Skills Disorder	p. 282
Developmental Coordination Disorder	p. 282
Communication Disorders	p. 282
Expressive and Receptive Language Disorders	p. 282
Phonologic Disorder	p. 282
Stuttering	p. 283
Pervasive Developmental Disorders	p. 283
Autistic Disorder	p. 283
Rett's Disorder	p. 284
Childhood Disintegrative Disorder	p. 284
Asperger's Disorder	p. 284
Attention Deficit and Disruptive Behavior Disorders	p. 284
Attention-Deficit/Hyperactivity Disorder	p. 284
Conduct Disorder (Solitary Aggressive Type)	p. 285
Oppositional Defiant Disorder	p. 285
Feeding and Eating Disorders of Infancy or Early Childhood	p. 285
Pica	p. 285
Rumination Disorder	p. 285
Feeding Disorder of Infancy or Early Childhood	p. 285
Tic Disorder	p. 285
Tourette's Disorder	p. 285
Elimination Disorders	p. 286
Enuresis	p. 286
Encopresis	p. 286
Other Disorders of Infancy, Childhood, or Adolescence	p. 286
Separation Anxiety Disorder	p. 286
Selective Mutism	p. 287
Reactive Attachment Disorder of Infancy or Early Childhood	p. 287
Stereotypic Movement Disorder	p. 287
Interventions	p. 287
Prevention Programs	p. 287
Medications	p. 287
Therapies	p. 288
Prognosis and Discharge Criteria	p. 290
Care Plan: Attention Deficit and Disruptive Behavior Disorders
Risk for Self-Directed Violence/Risk for Other-Directed Violence	p. 293
Care Plan: Mental Retardation or Pervasive Development Disorders
Delayed Growth and Development	p. 301
Care Plan: Disorders of Infancy, Childhood, and Adolescence (All Types)
Chronic Low Self-Esteem	p. 313
Compromised Family Coping	p. 320
Cognitive Disorders: Delirium, Dementia, and Amnestic Disorders	p. 325
Etiology	p. 325
Epidemiology	p. 326
Delirium	p. 326
Dementia	p. 327
Amnestic and Other Cognitive Disorders	p. 327
Assessment and Diagnostic Criteria	p. 328
Delirium	p. 328
Dementia	p. 329
Amnestic and Other Cognitive Disorders	p. 331
Interventions	p. 331
Treatment Settings	p. 331
Medications	p. 332
Other Treatments	p. 332
Therapies	p. 332
Prognosis and Discharge Criteria	p. 332
Care Plans: Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Acute Confusion	p. 335
Disturbed Thought Processes	p. 347
Impaired Social Interaction	p. 356
Substance-Related Disorders	p. 362
Drugs of Abuse	p. 362
Etiology	p. 362
Epidemiology	p. 363
Raves	p. 364
Comorbidity	p. 364
Assessment and Diagnostic Criteria	p. 364
Substance Intoxication	p. 364
Substance Abuse	p. 364
Substance Dependence	p. 366
The Substances of Abuse	p. 366
Alcohol	p. 366
Amphetamines	p. 366
Caffeine	p. 366
Cannabis	p. 367
Cocaine	p. 367
Hallucinogens	p. 367
Inhalants	p. 367
Nicotine	p. 368
Opiates	p. 368
Phencyclidine	p. 368
Sedatives, Hypnotics, and Anxiolytics	p. 368
Polysubstance Dependence	p. 368
Interventions	p. 369
Treatment Settings	p. 369
Medications	p. 370
Therapies	p. 371
Prognosis and Discharge Criteria	p. 372
Care Plans: Substance-Related Disorders
Ineffective Denial	p. 376
Disabled Family Coping	p. 383
Risk for Injury	p. 388
Risk for Self-Directed Violence/Risk for Other-Directed Violence	p. 396
Eating Disorders	p. 399
Etiology	p. 399
Epidemiology	p. 399
Comorbidity	p. 399
Assessment and Diagnostic Criteria	p. 399
Anorexia Nervosa	p. 399
Bulimia Nervosa	p. 400
DSM-IV-TR Categories	p. 401
Interventions	p. 401
Therapies	p. 401
Medications	p. 402
Prognosis and Discharge Criteria	p. 402
Care Plans: Anorexia Nervosa/Bulimia Nervosa
Imbalanced Nutrition: Less than Body Requirements	p. 405
Disturbed Body Image	p. 417
Interrupted Family Processes	p. 421
Sexual and Gender Identity Disorders	p. 427
Etiology	p. 427
Epidemiology	p. 427
Assessment and Diagnostic Criteria	p. 428
Sexual Dysfunctions	p. 428
Paraphilias	p. 431
Gender Identity Disorder	p. 432
Interventions	p. 432
Treatment Settings	p. 432
Therapies	p. 432
Medications	p. 433
Prognosis and Discharge Criteria	p. 433
Care Plan: Sexual Dysfunctions
Sexual Dysfunction	p. 436
Care Plan: Sexual and Gender Identity Disorders
Interrupted Family Processes	p. 440
Appendixes
Suicide Assessment and Intervention Guidelines	p. 446
Principles	p. 446
Nursing Interventions	p. 446
Crisis and Crisis Intervention	p. 448
Types of Crisis	p. 448
Developmental Crisis	p. 448
Situational Crisis	p. 448
Influencing Factors	p. 448
Crisis Intervention	p. 449
Therapist's Role	p. 449
Active Intervention Process	p. 449
Client Rights	p. 450
Guidelines for Seclusion and Restraint Based on JCAHO Standards	p. 451
Nursing Assessment	p. 451
Plan of Action and Rationale	p. 451
Model for Intervention	p. 451
Intervention and Rationale	p. 451
Verbal Interaction	p. 452
Seclusion	p. 452
Procedure	p. 452
Provide Continual Documentation	p. 452
Restraint	p. 452
Policy	p. 452
Documentation (Mandatory for Restraint Order)	p. 453
Procedure (Supervised by Qualified Charge Nurse)	p. 453
Post-Restraint Procedures	p. 453
Grief and Loss: Caregivers, Clients, and Families	p. 455
Grief	p. 455
Phases of Grief	p. 456
Phase I (1 to 3 Weeks): Shock, Numbness, Denial	p. 456
Phase II (3 Weeks to 4 Months): Yearning and Protest, Anger, Confrontation	p. 456
Phase III (4 to 14 Months): Apathy, Aimlessness, Disorganization, Despair	p. 456
Phase IV (14 Months to Throughout Rest of Life): Recovery, Resolution, Acceptance	p. 457
Anticipatory Grief: Premourning, Predeath	p. 457
Interventions in Anticipatory Grief	p. 457
Chronic Sorrow	p. 457
Interventions in Chronic Sorrow	p. 457
Summary of Theories of Grief	p. 457
Lindemann	p. 457
Kubler-Ross	p. 458
Bowlby	p. 458
Engel	p. 459
Shneidman	p. 459
Theory Synthesis	p. 459
Tips for Helping Survivors	p. 459
Spirituality as a Dimension of the Person	p. 460
Descriptions of Terms	p. 460
Spirituality	p. 460
Religion	p. 460
Faith	p. 461
Spirituality in Mental Health	p. 461
Role of the Chaplain in Mental Health	p. 461
Stages of Faith in Spiritual Practice and Interventions	p. 461
Impartial Individual	p. 461
Institutional Individual	p. 461
Individual Seeker	p. 461
Integrated Individuals	p. 462
Summary of Spirituality	p. 462
Care Plan: Spirituality
Spiritual Distress	p. 463
Psychiatric and Psychosocial Therapies	p. 467
Cognitive Behavioral Therapy	p. 467
Thought Stopping	p. 467
Thought Substitution	p. 468
Reframing/Relabeling	p. 468
Rational-Emotive Therapy (RET)	p. 468
Deep-Breathing Exercises	p. 468
Benson's Relaxation Response	p. 468
Progressive Relaxation Technique	p. 469
Visualization (Visual Imagery, Guided Imagery)	p. 469
Strategic Therapy	p. 469
Assertiveness Training	p. 469
Systematic Desensitization	p. 470
Dialectical Behavior Therapy	p. 470
Other Therapies	p. 471
Psychoanalytic Therapy	p. 471
Gestalt Therapy	p. 471
Client-Centered Therapy	p. 471
Family Therapy, Family Systems Therapy	p. 471
Group Therapy	p. 471
Transactional Analysis	p. 472
Psychodrama	p. 472
Eye Movement Desensitization and Reprocessing	p. 472
Virtual Reality Exposure Therapy	p. 472
Psychopharmacology	p. 473
Sedative-Hypnotic Drugs	p. 473
Antianxiety Drugs: Benzodiazepines	p. 474
Antianxiety Drugs: Miscellaneous	p. 477
Antipsychotic Drugs: Typical	p. 478
Antipsychotic Drugs: Atypical	p. 482
Antiparkinson/Anticholinergic Drugs	p. 484
Antidepressant Drugs: Tricyclic (TCAs)	p. 486
Antidepressant Drugs: Selective Serotonin Reuptake Inhibitors (SSRIs)	p. 489
Antidepressant Drugs: Miscellaneous	p. 491
Antidepressant Drugs: Monoamine Oxidase Inhibitors (MAOIs)	p. 494
Antimanic Drugs: Mood Stabilizers	p. 496
Central Nervous System Stimulants and Miscellaneous Drugs for Hyperkinesis	p. 498
Alcohol and Drug Abuse Adjunct Treatment Drugs	p. 499
Cholinesterase Inhibitors (Alzheimer Treatment)	p. 503
Comparison of Developmental Theories	p. 504
Freud's Psychosexual Theory	p. 504
Erikson's Psychosocial Theory	p. 504
Maslow's Theory of Human Need	p. 505
Piaget's Theory of Cognitive Development	p. 505
Kohlberg's Theory of Moral Reasoning	p. 507
Defense Mechanisms and Strategies	p. 508
Standards of Care for Psychiatric-Mental Health Nursing Practice	p. 510
DSM-IV-TR Classification	p. 512
Glossary	p. 522
References	p. 532
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