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

1. Risk For Injury 4. Ineffective Individual Coping

2. Risk For Violence: Self-Directed or Other Directed 5. Interrupted Family Processes
3. Impaired Social Interaction 6. 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.  Extreme hyperactivity/physical agitation.
 Biochemical/neurologic imbalances.  Rage reaction.
 Exhaustion and dehydration.
Possibly evidenced by
 Abrasions, bruises, cuts from running/falling into objects.  Lack of fluid ingestion.
 Extreme hyperactivity.  Lack of control over purposeless and potentially injurious
 Impaired judgment (reality-testing, risk behavior). movements.
Desired Outcomes
 Patient will respond to the medication within the therapeutic  Patient will be free of dangerous levels of hyperactive motor
levels. behavior with the aid of medications and nursing
 Patient will sustain optimum health through medication interventions within the first 24 hours.
management and therapeutic regimen.  Patient will spend time with the nurse in a quiet environment
 Patient will have stable cardiac status while in the hospital. three to four times a day between 7 am and 11 pm with the
aid of nursing guidance.
 Patient will drink 8 oz of fluid every hour throughout the day
while on acutely manic stage.  Patient will take short voluntary rest periods during the day.
 Patient will remain free from falls and abrasions every day  Patient will be free of excessive physical agitation and
while in the hospital. purposeless motor activity within 2 weeks.
 Patient will be free of injury within 2 to 3 weeks:
o Stable cardiac status.
o Skin free of abrasions and scrapes.
o 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-
Helps minimize escalation of anxiety.
temperature ventilation).
Acute mania might warrant the use of phenothiazines and seclusions to decrease any Exhaustion and death result from dehydration, lack of sleep,
physical harm. and constant physical activity.
Observe for signs of lithium toxicity (e.g., nausea, vomiting, diarrhea,
There is a small margin of safety between therapeutic and toxic
drowsiness, muscle weakness, tremor, lack of coordination, blurred vision, or ringing in
doses.
your ears).
Protect client from giving away money and possessions. Hold valuables in a hospital Client’s “generosity” is a manic defense that is consistent with
safe until rational judgment returns. irrational, grandiose thinking.
Redirect violent behavior. 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.  Psychotic symptomatology.
 Impulsivity.  Rage reaction.
 Manic excitement.  Restlessness.
Possibly evidenced by
 Agitated behaviors (e.g., slamming doors, increased muscle  Poor impulse control.
tension, throwing things over).  Provocative behaviors (e.g., argumentative).
 Delusional thinking.  Verbal threats against others.
 Hallucinations.  Verbal threats against self (suicidal threats/attempts, hitting
 Loud, threatening, profane speech. or injuring self, banging head against the wall).
Desired Outcome
 Patient will verbalize control of feelings.  Patient will seek help when experiencing aggressive
 Patient will respond to external controls (medications, impulses.
seclusion, nursing interventions) when potential or actual  Patient will refrain from verbal threats and loud, profane
loss of control occurs. language toward others.
 Patient will refrain from provoking others to physical harm,  Patient will be safe and free from injury.
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.
Nursing Interventions Rationale

Frequently assess client’s behavior for signs of increased agitation and
hyperactivity.
Use a calm and firm approach.
Use short, simple and brief explanations or statements.
Remain neutral as possible; Do not argue with the client;
Maintain a consistent approach, employ consistent expectations, and provide
a structured environment.
Redirect agitation and potentially violent behaviors with physical outlets in
an area of low stimulation (e.g., punching bag).
Decrease environmental stimuli (e.g., by providing a calming environment or
assigning a private room)
Early detection and intervention of escalating mania will prevent the
possibility of harm to self or others, and decrease the need for seclusions.
Provides structure and control for a client who is out of control.
Short attention span limits understanding to small pieces of information.
Client can use inconsistencies and value judgments as justification for
arguing and escalating mania.
Clear and consistent limits and expectations minimize potential for client’s
manipulation of staff.
Can help to relieve pent-up hostility and relieve muscle tension.
Helps decrease escalation of anxiety and manic symptoms.
 Alert staff if a potential for seclusion appears imminent. Usual priority of
interventions would be:
 Firmly setting limits.
 Chemical restraints (tranquilizers).
 Seclusions.
Chart, in nurse’s notes, behaviors; interventions; what seemed to escalate
agitation; what helped to calm agitation; when as-needed (PRN) medications
were given and their effect; and what proved most helpful.
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.
Staff will begin to recognize potential signals for escalating manic
behaviors and have a guideline for what might work best for the individual
client.

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

When less manic, the client might join one or two other clients in quiet,
contact becomes more appropriate. Competitive games can stimulate
nonstimulating activities (e.g., drawing, board games, cards).
aggression and can increase psychomotor activity.
When possible, provide an environment with minimum stimuli (e.g., quiet,
Reduction in stimuli lessens distractability.
soft music, dim lighting).
Solitary activities requiring short attention spans with mild physical exertion Solitary activities minimize stimuli; mild physical activities release tension
are best initially (e.g., writing, taking photos, painting, or walks with staff). constructively.

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.  Inadequate level of perception of control.
 Disturbance in tension release.  Ineffective problem-solving strategies/skills
 .
Possibly evidenced by
 Changes in usual communication patterns.  Inability to meet basic needs.
 Destructive behavior toward self or others.  Inability to ask for help.
 Giving away valuables and financial savings  Presence of delusions (grandeur, persecution).
indiscriminately, often to strangers.  Using extremely poor judgment in business and financial
 Inability to problem-solve. 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 intervention of bipolar clients,
2. Pitting one staff member against another (“You are more
especially when intervening in manipulative behaviors. Staff agreement on
appreciative than Nurse Paul Martin, do you know what she
limits set and consistency is imperative if the limits are to be carried out
said to me?”) or pitting one group against another
effectively.
(morning shiftversus 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 Hostile verbal behaviors, poor impulse control, provocative behaviors, and
early phases of escalation of manic behavior. violent acting out against others or property are some of the symptoms of

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.
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.

Interrupted Family Processes

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

May be related to
 Erratic and out-of-control behavior of one family member  Nonadherence to antimanic and other medications.
with the potential for dangerous behavior affecting all family  Shift in the health status of family member.
members (violence, leaving family in debt, risky behaviors in
relationships and business, fragrant infidelities, unprotected
 Situational crisis or transistion (e.g., illness, manic episode
of one member).
and promiscuous sex).
 Family role shift.
Possibly evidenced by
 Changes in communication patterns.  Deficient knowledge regarding disorder, need for medication
 Changes in participation in decision making. adherence, and available support systems.
 Changes in participation in problem solving.  Family in crisis.
 Changes in effectiveness in completing assigned tasks.  Inability to deal with traumatic or crisis experiences
constructive
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 lithium or other antimanic medications (e.g.,
need for adherence, side effects, toxic effects).
3. Knowledge about bipolar support groups in the family’s community and
how they can help families going through crises.
This is a disease that can devastate and destroy some families.
During an acute manic attack, families experience a great deal
of disruption and confusion when their family members begins to
act bizarre, out of control and at times aggressive. Families
need to understand about the disease what can and cannot be
done to help control the disease, and where to go for help for
their individual issues.

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

Disturbed Sleep Pattern:

Keep client in areas of low stimulation. Promotes relaxation and minimizes manic behavior.
Encourage frequent rest periods during the day. Lack of sleep can lead to exhaustion and death.
At night, encourage warm baths, soothing music, and medication when indicated. Avoid
Promotes relaxation, rest, and sleep.
giving the client caffeine.
Imbalanced Nutrition:
 Ensures adequate fluid and caloric intake; minimizes dehydration
Monitor intake, output, and vital signs.
and cardiac collapse.
Frequently remind the client to eat (e.g.,Rob, finish your pancake”, “Sandra, drink this The manic client is unaware of bodily needs and is easily
apple juice.”). distracted. Needs supervision to eat.
Constant fluid and calorie replacement are needed. Client might
Encourage frequent high-calorie protein drinks and finger foods (e.g., sandwiches, fruit,
be too active to sit at meals. Fingers foods allow “eating on the
milkshakes).
run”.
Constipation:
Monitor bowel habits; offer fluids and foods rich in fiber. Evaluate the need for a laxative. Prevents fecal impaction resulting from dehydration and
Encourage client to go to the bathroom. decreased peristalsis.
Dressing/Grooming Self-Care Deficit:
Lessens the potential for inappropriate attention, which can
If warranted, supervise choice of clothes; minimize flamboyant and bizarre dress, and increase the level of mania, or ridicule, which lowers self-esteem
sexually suggestive dress, such as bikini tops and bottoms. and increases the need for manic defense. 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 simple,
toothbrush. Put the toothpaste on the brush”). concrete instructions.
Here are four (4) nursing care plans (NCP) for personality disorders:
1. Risk For Self-Mutilation 3. Impaired Social Interaction
2. Chronic Low Self-Esteem 4. Ineffective Coping
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.  High-risk populations (BPD, psychotic states).
 Emotionally disturbed or battered children.  Impulsive behavior.
 Feelings of depression, rejection, self-hatred,  Inability to verbally express feelings.
separation anxiety, guilt, and depersonalization.  Ineffective coping skills.
 History of self-injury.  Mentally retarded and autistic childr
 History of physical, emotional, or sexual abuse.
Possibly evidenced by
 Fresh superficial slashes on wrists or other parts of the  Signs of old scars on wrists and other parts of the body
body. (cigarette burns, superficial knife/razor marks).
 Intense rage focused inward.  Statements as to self-mutilation behaviors.
Desired Outcomes
 Patient will be free of self-inflicted injury.  Patient will sign a “no-harm” contract that identifies steps he or
 Patient will participate in impulse control training. she will take when urges return.
 Patient will participate in coping skills training.  Patient will respond to external limits.
 Patient will seek help when experiencing self-destructive  Patient will participate in the therapeutic regimen.
impulses.  Patient will demonstrate a decrease in frequency and intensity
 Patient will discuss alternative ways a client can meet demands of self-inflicted injury.
of current situation.  Patient will demonstrate two new coping skills that work for
 Patient will express feelings related to stress and tension the client for when tension mounts and impulse returns.
instead of acting-out behaviors.
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.
Feelings are a guideline for future intervention (e.g.,
Identify feelings experienced before and around the act of self-mutilation.
rage at feeling left out or abandoned).
Self-mutilation might also be:
1. A way to gain control over others.
Explore with the client what these feelings might 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 the client. Identify specific steps (e.g., persons to healthier behavior. Talking to others and learning
call upon when prompted to self-mutilate). alternative coping skills can reduce frequency and
severity until such behavior ceases.
Set and maintain limits on acceptable behavior and make clear client’s responsibilities. If Clear and nonpunitive limit setting is essential for
the client is hospitalized at the time, be clear regarding the unit rules. decreasing negative behaviors.
Be consistent in maintaining and enforcing the limits, using a nonpunitive approach. Consistency can establish a sense of security.
A neutral approach prevents blaming, which
Use a matter-of-fact approach when self-mutilation occurs. Avoid criticizing or giving sympathy. increases anxiety, giving special attention that
encourages acting out.
identify dynamics for both client and clinician. Allows
After the treatment of the wound, discuss what happened right before, and the thoughts and
the identification of less harmful responses to help
feelings that the client had immediately before self-mutilating.
relieve intense tensions.
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).
2. Identify actions that might modify the 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.  Persistent lack of integrated self-view, with splitting as a
 Childhood physical, sexual, psychological abuse and/ defense.
or neglect.  Shame and guilt.
 Dysfunctional family of origin.  Substance abuse.
 Lack of realistic ego boundaries.
Possibly evidenced by
 Evaluates self as unable to deal with events.
 Excessively seeks reassurance.
 Expresses longstanding shame/guilt.
 Hesitant to try new things/situations.
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.
Nursing Interventions
Assess with clients their self perception. Target different areas of
the client’s life:
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.
Focus questions in a positive and active light; helps client refocus
on the present and look to the future. For example. “What can you
do differently now?” or “What have you learned from that
experience?”.
Give the client honest and genuine feedback regarding your
observations as to his or her strengths, and areas that could use
additional skills.
Do not flatter or be dishonest in your appraisals.
Set goals realistically, and renegotiate goals frequently.
Remember that client’s negative self-view and distrust of the
world took years to develop.
Here are three (3) nursing care plans (NCP) for suicide behaviors:
1. Risk For Suicide
2. Ineffective Coping
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.
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).
 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.
 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.
Rationale
Identify with client with realistic areas of strength and weaknesses. Client
and nurse can work on the realities of the self-appraisal, and target those
areas of 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.
Allows client to look at past behaviors differently, and gives the client a
sense that he or she has choices in the future.
Feedback helps give clients a more accurate view of self, strengths, areas
to work on, as well as a sense that someone is trying to understand them.
Dishonesty and insincerity undermine trust and negatively affect any
therapeutic alliance.
Unrealistic goals can set up hopelessnessin clients and frustrations in
nurse clinicians. Clients might blame the nurse for not “helping them,” and
nurses might blame the client for not “getting better”.
3. Hopelessness
 Hopelessness/helplessness.
 Legal or disciplinary problems.
 Physical illness, chronic pain, terminal illness.
 Psychiatric illness (e.g., bipolar disorder,
depression, schizophrenia).
 Poor support system, loneliness.
 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 name at least one acceptable alternative to his or
 Patient will state that he or she wants to live. 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 available especially if the person is Relieve isolation and provide safety and comfort.
highly suicidal.
Encourage the client to avoid decisions during the time of crisis until During crisis situations, people are unable to think clearly or
alternatives can be considered. evaluate their options readily.
Encourage the client to talk freely about feelings and help plan Gives client other ways of dealing with strong emotions and gaining
alternative ways of handling disappointment, anger, and frustration. a sense of control over their lives.
To provide a safe environment, free from things that may harm the
Weapons and pills are removed by friends, relatives, or the nurse.
client.
If anxiety is extremely high, or client has not slept in days, a tranquilizer
Relief of anxiety and restoration of sleeploss can help the client
might be prescribed. Only a 1 to 3 day supply ofmedication should be
think more clearly and might help restore some sense of well-being.
given. Family member or significant other should monitor pills for safety.
Reestablishes social ties. Diminishes sense of isolation, and
Contact family members, arrange for individual and/ or family crisis
provides contact from individuals who care about the suicidal
counseling. Activate links to self-help groups.
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 perspective on their
1. The crisis is temporary.
lives. These statements give perspective to the client and help offer
2. Unbearable pain can be survived.
hope for the future.
3. Help is available.
4. You are not alone.
Forensic Issues:
Provide safe environment during time client is actively suicidal and
Follow unit protocol for suicide regarding creating a safe environment
impulsive; self-destructive acts are perceived as ties, the only way
(taking away potential weapons– belts, sharp objects, items, and so on).
out of an intolerable situation.
These might become court documents. If client checks and
Keep accurate and thorough records of client’s behaviors (verbal and
attention to client’s needs or request are not documented, they do
physical) and all nursing/physician actions.
not exist in a court of law.
Put on either suicide precaution (one-on-one monitoring at one arm’s
Protection and preservation of the client’s life at all costs during
length away) or suicide observation (15-minute visual check of mood,
crisis is part of medical and nursing staffresponsibility. Follow unit
behavior, and verbatim statements), depending on level of suicide
protocol.
potential.
Keep accurate and timely records, document client’s activity, usually
Accurate documentation is vital. The chart is a legal document as to
every 15 minutes (what client is doing, with whom, and so on). Follow
client’s “ongoing status,” intervention taken, and by whom.
unit protocol.
Encourage the client to talk about their feelings and problem solve Talking about feelings and looking at alternatives can minimize
alternatives. suicidal acting out.
The no-suicide contract helps client know what to do when they
Construct a no-suicide contract between the suicidal client and nurse.
begin to feel overwhelmed by pain (e.g., “I will speak to my
Use clear, simple language. When the contract is up, it is renegotiated
nurse/counselor/support group/family member when I first begin to
(If this is accepted procedure at your institution).
feel the need to end my life”).
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.  Perceived hopelessness, helplessness.
 Chronic pain.  Perceiving the future as bleak and wasted.
 Failing or deteriorating physiologic conditions (Cancer, AIDS).  Prolonged isolation.
 Long-term stress.  Severe stressful events (financial reversals, relationship turmoil,
 Lost belief in transcendent values/God. loss of job).
 Loss of significant support systems.
Possibly evidenced by
 Decreased affect.  Lack of involvement in care.
 Decreased judgment.  Lack of motivation.
 Decreased problem solving.  Loss of interest in life.
 Impaired decision making.  Passivity, decreased verbalization.
 Lack of initiative.  Turning away from speaker.
Desired Outcomes
 Patient will express the will to live.  Patient will name one community resource (support group,
 Patient will have an expression of positive future orientation. counseling, social service, family counseling) that he/she has
attented at least twice.
 Patient will have an expression of meaning in life.
 Patient will state three optimistic expectations for the future.
 Patient will make two decisions related to his/her care.
 Patient will describe and plan for at least two future-oriented
 Patient will identify three things that he/she is doing right. goals.
 Patient will reframe two problem areas in his/her life that  Patient will demonstrate two new problem-solving skills that
encourage problem-solving alternative solutions.
client finds effective in making life decisions.
 Patient will identify two alternatives for one life problem area.  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, and reframe negative
thinking into neutral objective thinking.
Work with client to identify areas of strengths.
Cognitive reframing helps people look at situations in ways that
allow for alternative approaches.
When people are feeling overwhelmed, they no longer view their
lives or behavior objectively.

Point out unrealistic and perfectionistic thinking.
Identify things that have given meaning and joy to life in the past. Discuss
how these things can be reincorporated into their present lifestyle (e.g.,
religious or spiritual beliefs, group activities, creative endeavors).
Spend time discussing client’s dreams and wishes for the future. Identify
short-term goals they can set for the future.
Encourage contact with religious or spiritual persons or groups that have
supplied comfort and support in client’s past.
Teach client steps in the problem-solving process.
Here’s a nursing care plan for Sexual Assault:
 1 Nursing Care Plans
o 1.1 Rape-Trauma Syndrome
 2 See Also
Rape-Trauma Syndrome
Constructive interpretations of events and behavior open up more
realistic and satisfying option for the future.
Reawakens in client abilities and experiences that tapped areas
of strength and creativity. Creative activities give people intrinsic
pleasure and joy, and a great deal of life satisfaction.
Renewing realistic dreams and hopes can give promise to the
future and meaning to life.
During times of hopelessness people might feel abandoned and
too paralyzed to reach out to caring people or groups.
Stress that it is not so much people are ineffective, but rather it is
often the coping strategies they are using that are not effective.

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.  Mood swings.
 Denial.  Nightmare and sleep disturbances.
 Depression, anxiety.  Phobias.
 Disorganization.  Physical trauma (e.g., bruising, tissue irritation).
 Dissociative disorders.  Self-blame.
 Feelings of revenge.  Sexual dysfunction.
 Guilt, humiliation, embarrassment.  Shame, shock, fear.
 Hyperalertness.  Substance abuse.
 Inability to make decisions.  Suicide attempts.
 Loss of self-esteem.  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
Establish trust and rapport. as blaming or rejecting, the nurse should delay asking questions until the therapeutic
nature is established.
The client’s situation is not to be talked over with anyone other than medical staff
Provide strict confidentiality.
involved unless the client gives consent to it.
Nurses’ attitudes can have an important therapeutic impact. Displays of shock, horror,
Approach the client in a nonjudgmental manner.
disgust, or disbelief are not appropriate.
Use the following:
 Reported not alleged.
Never use judgmental language.
 Declined not refused.
 Penetration not intercourse.
Have someone stay with the client (friend, neighbor, or staff People in high levels of anxiety needs to feel physical safety by providing someone by
member) while he or she waiting to be treated. his/her side until anxiety level is down to moderate.
Rape victims might feel guilt and shame. Reinforcing that they did what they had to do
Stress that they did the right thing to save their life.
to stay alive can reduce guilt and maintain self-esteem.
Encourage verbalization. When people feel understood, they feel more in control of their situations.
Explain to the client signs and symptoms that many people
experience during the long-term phase, for example:
1. Anxiety, depression.
Many individuals think they are going crazy as time goes on and are not aware that
2. Insomnia.
this is a process that many people in their situation have experienced.
3. Nightmares.
4. Phobias.
5. Somatic symptoms.
Forensic Examination and Issues:
Assess the signs and symptoms of physical trauma. More common injuries are to face, head, neck extremities.
Make a body map to identify size, color, and location of injuries. Ask Accurate records and photos that can be used as medicolegal evidence for the
permission to take photos. future.
Carefully explain all procedures before doing them (e.g., “I will perform
a vaginal examination and do a swab. Have you had a vaginal The individual is experiencing high levels of anxiety. Matter-of-fact explaining
examination before?” [rectal examination in case of a male who has what you plan to do and why you are doing it can help reduce fear and anxiety.
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:
1. Blood. Collecting body fluids and swabs is essential (DNA) for identifying the rapist.
2. Combing pubic hairs.
3. Semen samples.
4. Skin from underneath nails.
Encourage the client to consider treatment and evaluation for sexually Many survivors are lost to follow-up after being seen in the emergency
transmitted diseases before leaving the emergency department. department or crisis center and will not otherwise get protection.
Many clinics offer prophylaxis to pregnancy with norgestrel (Ovral). Approximately 3% to 5% of women who are raped become 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 evidence.
3. Detailed observations of 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 distress and trauma.
2. Group therapy.
Depression and suicidal ideation are frequent sequelae of rape. As soon as the
3. Individual therapy.
intervention is carried out, the less complicated the recovery may be.
4. Rape counselor.
5. Support group.
Here are six (6) nursing care plans for major depression:
1. Risk For Self-Directed Violence 5. Disturbed Thought Processes
2. Impaired Social Interaction 6. Self-Care Deficit
3. Spiritual Distress Spiritual Distress
4. Chronic Low Self-Esteem

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.  Pain.
 Death or dying of self or others.  Self-alienation.
 Lack of purpose in life.  Sociocultural deprivation.
 Life changes.
Possibly evidenced by
 Expresses intense feelings of guilt.  Inability to express previous state of creativity (e.g., writing,
 Expresses feelings of hopelessness and helplessness. drawing, singing).
 Expresses being abandoned by or having anger towards  Inability to participate in religious activities
God.  Lack of interest in art.
 Expresses concern with meaning of life/death or belief  Questions meaning of own existence.
systems.  Refuses interaction with families, friends or
 Expresses lack of hope, meaning, or purpose in life, religious leaders.
forgiveness of self, peace, serenity, acceptance.  Searching for a spiritual source of strength.
 Inability to pray.
Desired Outcomes
 Patient will feel the connectedness with others to share  Patient will keep a journal tracking thoughts and feelings for one
thoughts, feelings, and beliefs. week.
 Patient will feel the connectedness with the inner self.  Patient will state that he/she feels a sense of forgiveness.
 Patient will participates in spiritual rites and passages.  Patient will state that he/she wants to participate in former
 Patient will discuss with nurse two things that gave his or her life creative activities.
meaning in the past within 3 days.  Patient will state that he/she gained comfort from previous
 Patient will talk to a nurse or a spiritual leader about spiritual spiritual practices.
conflicts and concern within 3 days.
Nursing Interventions Rationale

Assess what spiritual practices have offered comfort and
meaning to the client’s life when not ill.
Encourage client to write a journal expressing thoughts and
reflections daily.
If the client is unable to write, provide a tape recorder.
Discuss with the client what has given comfort and meaning to
the person in the past.
Suggest that the spiritual leader affiliated with the facility
contact the client.
Provide information on referrals, when needed, for religious or
spiritual information (e.g., readings, programs, tapes,
community resources).
Disturbed Thought Processes
Evaluates neglected areas in the person’s life that, if reactivated, might add comfort and
meaning during a painful depression.
This will help in identifying important personal issues and one’s thought and feelings
surrounding spiritual issues. Writing a journal is a good way to explore deeper meanings
in life.
Often speaking aloud helps a person clarify thinking and explore issues.
When depressed, clients usually are having a hard time searching for meaning in life
and reasons to go on when feeling hopelessness and despondent.
Spiritual leaders are familiar in dealing spiritual distress and can offer comfort to the
client.
When hospitalized, spiritual tapes and readings can be useful; when the client is in the
community, client might express other needs.

Disturbed Thought Processes: A state in which individual experiences a disruption in cognitive operations and activities.
May be related to
 Biologic/medical factors.  Prolong grief reaction.
 Biochemical/neurophysical imbalances.  Overwhelming life circumstances.
 Persistent feelings of extreme guilt, fear or anxiety.  Severe anxiety or depressed mood.
Possibly evidenced by
 Decreased problem-solving abilities.  Impaired judgment, perception, decision making.
 Hypovigilance.  Inaccurate interpretation of the environment.
 Impaired ability to grasp ideas or orders thoughts.  Memory problems/deficits.
 Impaired attention span/easily distracted.  Negative ruminations.
 Impaired insight.
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 cognitive

Establishing a baseline data allows for evaluation of client’s progress.
functioning (from client, family, past medical records).
Use simple, concrete words. Slowed thinking and difficulty concentrating impair comprehension.
Allow the client to have plenty of time to think and frame
Slowed thinking necessitates time to formulate a response.
responses.
Allow more time than usual for the client to finish usual Usual tasks might take long periods of time; demands that the client hurry only increase
activities of daily living (ADL) (e.g.,eating, dressing). anxiety and slow down ability to think clearly.
Help the client to postpone important major life decision
Making rational major life decision requires optimal psychophysiological functioning.
making.
While the client is severely depressed, minimize client’s
Decreases feelings of guilt, anxiety and pressure.
responsibility.
Negative ruminations add to feelings of hopelessness and are part of a depressed person’s
Help the client identify negative thinking/thoughts. Teach
faulty thought processes. Intervening in this process helps in healthier and more useful
the client to reframe and/or refute negative thoughts.
outlook in life.
Help client and family structure an environment that can
help re-establish set schedules and predictable routines A fairly and non-demanding repetitive routine is easier to both follow and remember.
during severe depressions.
Here are six (6) nursing care plans for schizophrenia:
1. Impaired Verbal Communication 4. Disturbed Thought Process
2. Impaired Social Interaction 5. Defensive Coping
3. Disturbed Sensory Perception: Auditory/Visual 6. Interrupted Family Process
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.  Psychological barriers (lack of stimuli).
 Biochemical alterations in the brain of certain neurotransmitters.  Side effects of medication.
Possibly evidenced by
 Difficulty communicating thoughts verbally.  Disturbances in cognitive associations (e.g., perseveration,
 Difficulty in discerning and maintaining the usual communication derailment, poverty of speech, tangentiality, illogicality,
pattern. 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 sudden, as in an Establishing a baseline facilitates the establishment of realistic goals, the
exacerbation of symptoms. foundation for planning effective care.
Therapeutic levels of an antipsychotic aids clear thinking and diminishes
Identify the duration of the psychotic medication of the client.
derailment or looseness of association.
High-pitched/loud tone of voice can elevate anxiety levels while slow
Keep voice in a low manner and speak slowly as much as possible.
speaking aids understanding.
Keep anxiety from escalating and increasing confusion and
Keep environment calm, quiet and as free of stimuli as possible.
hallucinations/delusions.
Short periods are less stressful, and periodic meetings give a client a
Plan short, frequent periods with a client throughout the day.
chance to develop familiarity and safety.
Use clear or simple words, and keep directions simple as well. Client might have difficulty processing even simple sentences.
Minimizes misunderstanding and/or incorporating those
Use simple, concrete, and literal explanations.
misunderstandings into delusional systems.
Focus on and direct client’s attention to concrete things in the environment. Helps draw focus away from delusions and focus on reality-based things.
Look for themes in what is said, even though spoken words appear
Often client’s choice of words is symbolic of feelings.
incoherent (e.g., fearful, sadness, guilt).
When you do not understand a client, let him/her know you are having Pretending to understand limits your credibility in the eyes of your client
difficulty understanding. and lessens the potential for trust.
When client is ready, introduce strategies that can minimize anxiety and
lower voices and “worrying” thoughts, teach client to do the following:
 Focus on meaningful activities.
 Learn to replace negative thoughts with constructive thoughts.
 Learn to replace irrational thoughts with rational statements. Helping client to use tactics to lower anxiety can help enhance functional
speech.
 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 speech and thoughts Even if the words are hard to understand, try getting to the feelings behind
are disorganized) to try to understand client’s concerns. them.
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.  Neurologic/biochemical changes.
 Biochemical factors such as manifested by inability to  Psychologic stress.
concentrate.
 Chemical alterations (e.g., medications, electrolyte imbalances).
Possibly evidenced by
 Altered communication pattern.  Hallucinations.
 Auditory distortions.  Inappropriate responses.
 Change in a problem-solving pattern.  Mumbling to self, talking or laughing to self.
 Disorientation to person/place/time.  Reported or measured change in sensory acuity.
 Frequent blinking of the eyes and grimacing.  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, but explain that you do
not hear the voices. Refer to the voices as “your voices” or “voices that you
hear”.
Be alert for signs of increasing fear, anxiety or agitation.
Explore how the hallucinations are experienced by the client.
Help the client to identify the needs that might underlie the hallucination.
What other ways can these needs be met?
Help client to identify times that times that the hallucinations are most
prevalent and frightening.
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 plans to act on commands.
 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 hallucinate, and direct them to tell
the “voices they hear” to go away. Repeat often in a matter-of-fact manner.
Decrease environmental stimuli when possible (low noise, minimal activity).
Intervene with one-on-one, seclusion, or PRN medication (As ordered) when
appropriate.
Keep to simple, basic, reality-based topics of conversation. Help client focus
on one idea at a time.
Work with the client to find which activities help reduce anxiety and distract
the client from a hallucinatory material. Practice new skills with the client.
Engage client in reality-based activities such as card playing, writing, Redirecting client’s energies to acceptable activities can decrease the
drawing, doing simple arts and crafts or listening to music. possibility of acting on hallucinations and help distract from voices.
The following are seven (7) nursing care plans for patients with anxiety and panic disorders:
1. Anxiety
2. Fear
3. Ineffective Coping
4. Powerlessness
Validating that your reality does not include voices can help client cast
“doubt” on the validity of his or her voices.
Might herald hallucinatory activity, which can be very frightening to client,
and client might act upon command hallucinations (harm self or others).
Exploring the hallucinations and sharing the experience can help give the
person a sense of power that he or she might be able to manage the
hallucinatory voices.
Hallucinations might reflect needs for:
 Anger.
 Power.
 Self-esteem.
 Sexuality.
Helps both nurse and client identify situations and times that might be
most anxiety producing and threatening to the client.
People often obey hallucinatory commands to kill self or others. Early
assessment and intervention might save lives.
Client can sometimes learn to push voices aside when given repeated
instructions. especially within the framework of a trusting relationship.
Decrease potential for anxiety that might trigger hallucinations. Helps
calm client.
Intervene before anxiety begins to escalate. If the client is already out of
control, use chemical or physical restraints following unit protocols.
Client’ thinking might be confused and disorganized; this intervention
helps client focus and comprehend reality-based issues.
If clients’ stress triggers hallucinatory activity, they might be more
motivated to find ways to remove themselves from a stressful
environment or try distraction techniques.
5. Social Isolation
6. Self-Care Deficit
7. Deficient Knowledge
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  unconscious conflict about essential values and goals of life.
condition, and treatment regimen.  Situational and maturational crises.
 actual or perceived threat to biologic integrity.
Possibly evidenced by
 Decreased attention span
 Restlessness
 Poor impulse control
 Hyperactivity, pacing
Desired Outcomes
 Be free from injury
 Discuss feelings of dread, anxiety, and so forth
 Respond to relaxation techniques with a decreased anxiety
level.
Nursing Interventions
Maintain a calm, non threatening manner while working with the client.
Establish and maintain a trusting relationship by listening to the client; displaying
warmth, answering questions directly, offering unconditional acceptance; being
available and respecting the client’s use of personal space.
Remain with the client at all times when levels of anxiety are high (severe or
panic); reassure client of his or her safety and security.
Move the client to a quiet area with minimal stimuli such as a small room or
seclusion area (dim lighting, few people, and so on.)
Maintain calmness in your approach to the client.
Provide reassurance and comfort measures.
Educate the patient and/or SO that anxiety disorders are treatable.
Support the client’s defenses initially.
Maintain awareness of your own feelingsand level of discomfort.
Stay with the patient during panic attacks. Use short, simple directions.
Avoid asking or forcing the client to make choices.
Observe for increasing anxiety. Assume a calm manner, decrease
environmental stimulation, and provide temporary isolation as indicated.
PRN medications may be indicated for high levels of anxiety. Watch out for
adverse side effects.
Encourage the client’s participation in relaxation exercises such as deep
breathing, progressive muscle relaxation, guided imagery, meditation and so
forth.
Teach signs and symptoms of escalating anxiety, and ways to interrupt its
progression (e.g., relaxation techniques, deep- breathing exercises, physical
exercises, brisk walks, jogging, meditation).
Administer SSRIs as ordered.
Help the client see that mild anxiety can be a positive catalyst for change and
does not need to be avoided.
Cognitive-behavioral therapy (further discussed here)
Positive reframing
Decatastrophizing
Assertiveness training
When level of anxiety has been reduced, explore with the client the possible
reasons for occurrence.
Encourage client to talk about traumatic experience under nonthreatening
conditions. Help client work through feelings of guilt related to the traumatic
event. Help client understand that this was an event to which most people
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.
 Feelings of discomfort, apprehension or helplessness
 Delusions
 Disorganized thought process
 Inability to discriminate harmful stimuli or situations
 Reduce own anxiety level.
 Be free from anxiety attacks.
Rationale
Anxiety is contagious and may be transferred from health care provider
to client or vice versa. Client develops feeling of security in presence of
calm staff person.
Therapeutic skills need to be directed toward putting the client at ease,
because the nurse who is a stranger may pose a threat to the highly
anxious client.
The client’s safety is utmost priority. A highly anxious client should not
be left alone as his anxiety will escalate.
Anxious behavior escalates by external stimuli. A smaller or
secluded area enhances a sense of 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 and inf the client feels
you are in control of the situation.
Helps relieve anxiety.
Pharmacological therapy is an effective treatment for anxiety disorders;
treatment regimen may include antidepressants and anxiolytics.
The client uses defenses in an attempt to deal with an unconscious
conflict, and giving up these defenses prematurely may cause
increased anxiety.
Anxiety is communicated interpersonally. Being with an anxious client
can raise your own anxiety level. Discussion of these feelings 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 symptoms will resolve spontaneously. In anxiety, the
client’s ability to deal with abstractions or complexity is impaired.
The client may not make sound and appropriate decisions or may
unable to make decisions at all.
Early detection and intervention facilitate modifying client’s behavior by
changing the environment and the client’s interaction with it, to
minimize the spread of anxiety.
Medication may be necessary to decrease anxiety to a level at which
the client can feel safe.
Relaxation exercises are effective nonchemical ways to reduce anxiety.
So the client can start using relaxation techniques; gives the client
confidence in having control over his anxiety.
Panic attacks are caused by neuropsychiatric disorder that responds to
SSRI antidepressants.
The client may feel that all anxiety is bad and not useful.
Turning negative messages into positive ones.
It involves the therapist’s use of questions to more realistically appraise the
situation. It is 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 negotiate interpersonal situations and foster self-
assurance.
Recognition of precipitating factors is the first step in teaching client to
interrupt escalation of anxiety.
Verbalization of feelings in a nonthreatening environment may help client
come to terms with unresolved issues.
 Nursing Interventions Rationale

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.
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.
 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.
Encourage client to set increasingly more difficult goals.
Administer antianxiety medications as indicated; watch out for any adverse side effects
Benzodiazepines:
 Alprazolam (Xanax),
 Clonazepam (Klonopin),
 diazepam (Valium),
 lorazepam (Ativan)
 chlordiazepoxide (Librium),
 oxazepam (Serax)
Powerlessness
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.
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.
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 improved
functioning and independence.
Biological factors may be involved in phobic/panic
reactions, and these medications (particularly Xanax)
produce a rapid calming effect and may help client
change behavior by keeping anxiety low during learning
and desensitization sessions. Addictive tendencies of
CNS depressants need to be weighed against benefit
from the medication.

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

 Providing client with choices and responsibility will increase his or her
Have client take as much responsibility for own self-care practices.
feelings of control.
Unrealistic goals set the client up for failure and reinforce feelings of
Help client set realistic goals.
powerlessness.
Client’s emotional condition prevents his ability to solve problems. Support
Help identify areas of life situation that client can control. is required to perceive the benefits and consequences of available
alternatives.
Help the client identify areas of life situation that are not with his ability to
To deal with unresolved issues and accept what cannot be changed.
control; encourage verbalization of these feelings.
Identify ways and instances in which the client can achieve and encourage
Positive reinforcement enhances self-esteem and encourages repetition of
participation in these activities; provide positive reinforcement for
positive behaviors.
participation.
Here are five (5) alcohol withdrawal nursing care plans (NCP):
1. Anxiety/Fear 3. Risk for Injury
2. Sensory-Perceptual Alterations 4. Risk for Decreased Cardiac Output
5. Risk for Ineffective Breathing Pattern
Below are 8 substance dependence and abuse nursing care plans:
1. Denial 6. Altered Family Process
2. Ineffective Individual Coping 7. Sexual Dysfunction
3. Powerlessness 8. Deficient Knowledge
4. Imbalanced Nutrition: Less Than Body Requirements 9. Other Possible Nursing Care Plans
5. Low Self-Esteem
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 addressed.
Convey attitude of acceptance, separating individual from
unacceptable behavior.
Ascertain reason for beginning abstinence, involvement in therapy.
Review definition of drug dependence and categories of symptoms
(patterns of use, impairment caused by use, tolerance to substance).
Answer questions honestly and provide factual information. Keep your
word when agreements are made.
Provide information about addictive use versus experimental,
occasional use; biochemical or genetic disorder theory (genetic
predisposition; use 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.
Sexual Dysfunction
Shows courtesy and respect, giving patient a sense of orientation and control.
Promotes feelings of dignity and self-worth.
Provides insight into patient’s willingness to commit to long-term behavioral
change, and whether patient even believes that he or she can change. (Denial is
one of the strongest and most resistant symptoms of substance abuse.)
This information helps patient make decisions regarding acceptance of problem
and treatment choices.
Creates trust, which is the basis of the therapeutic relationship.
Progression of use continuum is from experimental or recreational to addictive use.
Comprehending this process is important in combating denial. Education 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.

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 patient describe
problem in own words.
Encourage and accept individual expressions of concern.
Provide education opportunity (pamphlets, consultation with
appropriate persons) for patient to learn effects of drug on sexual
functioning.
Provide information about individual’s condition.
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, braindamage,
and fetal malformation).
Discuss prognosis for sexual dysfunction (impotence, low sexual
desire).
Refer for sexual counseling, if indicated.
Review results of sonogram if pregnant.
Deficient Knowledge
Determines level of knowledge, identifies misperceptions and specific learning
needs.
Most people find it difficult to talk about this sensitive subject and may not ask
directly for information.
Much of denial and hesitancy to seek treatment may be reduced as a result of
sufficient and appropriate information.
Sexual functioning may have been affected by drug (alcohol) itself or psychological
factors (such as stress or depression). Information can assist patient to understand
own situation and identify actions to be taken.
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.
In about 50% of cases, impotence is reversed with abstinence from drug(s); in 25%
the return to normal functioning is delayed; and approximately 25% remain
impotent.
Couple may need additional assistance to resolve 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 possibility of fetal alcohol
syndrome and future needs.

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 family members.
Provide an active role for the patient and SO in the learning
process (discussions, group participation, role playing).
Provide written and verbal information as indicated. Include list of articles
and books related to patient and family needs and encourage reading and
discussing what they learn.
Assess patient’s knowledge of own situation (disease, complications, and
needed changes in lifestyle).
Pace learning activities to individual needs.
Review condition and prognosis and future 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
(coughsyrups, 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).
Discuss variety of helpful organizations and programs that are available for
assistance and referral.
Anxiety can interfere with ability to hear and assimilate information.
Learning is enhanced when persons are actively involved.
Helps patient and SO make informed choices about future. Bibliotherapy can
be a useful addition to other therapeutic approaches.
Assists in planning for long-range changes necessary for maintaining
sobriety and drug-free status. Patient may have street knowledge of the drug
but be ignorant of medical facts.
Facilitates learning because information is more readily assimilated when
timing is considered.
Provides knowledge base from which patient can 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.
Long-term support is necessary to maintain optimal recovery. Psychosocial
needs and other issues may need to be addressed.