2013

Psychiatric Mental Health Nursing

Elma Pierre, Krishna Henry, Fiona Amsterdam

[MOOD DISORDERS]

Depressive Disorder

Predisposing Factors .`

Presenting signs and symptoms

Risk for violence: self-directed or other directed at risk for behaviors in which an individual demonstrates that he/she can be physically , emotionally, and / or sexually harmful to self and others Nursing Diagnosis Defining characteristics Risk for violence: Suicidal behavior (attempts, talk, self-directed ideation, plan, available means) Suicide plan (clear, specific, lethal method and available means) Previous attempts When depression begins to lift, clients may have energy to carry out suicide plan Related factors Severe depression/ psychosis/ severe personality, substance abuse Hopelessness, helplessness, anhedonia Social isolation loneliness

Expected outcomes Behavioral manifestation of depression are absent Satisfaction and social circumstances and achievement of life goals

Long term goals client will: Demonstrate alternative ways of dealing with negative feelings and emotional stress by (date) Identify supports and support groups with whom he/she is in contact within 1 month State that he or she wants to live Start working on constructive plans for the future

Demonstrate compliance with any medication or treatment plan within 2 weeks.

Short term goals client will: Not harm self or others Identify at least two persons he /she can call for support and emotional guidance when he/she is feeling self-destructive before discharge

Nursing interventions Nursing Interventions Rationale Determine level of suicide precautions needs. If A high client will need constant supervision high, does client need hospitalization? If low, and a safe environment. will client be safe to go home with supervision from a friend or family member? Does client have more than one week medication? Encourage clients to talk freely about feelings (anger, disappointments), and help client plan alternative ways to handle anger and frustration Implement a written no-suicide contract if appropriate. Contact family, arrange for crisis counseling. Activate links to self-help groups. If hospitalized, follow unit protocols Usually when a client is suicidal, medication supply should be limited to 3 to 5 days. Client can learn alternative ways of dealing with overwhelming emotions and gain a sense of control over his/ her life

Reinforce action the client can take when feeling suicidal Clients need a network of resources to help diminish personal feelings of worthlessness. Hospitals have their unique protocols for hospitalized patients

Disturbed thought processes a state in which an individual experiences a disruption in cognitive operations and activities. Nursing Diagnosis Defining characteristics Related factors Disturbed thought Memory deficit/ problems Severe anxiety or depressed mood processes Inaccurate interpretation of the Biochemical/ neurophysical imbalances environment Overwhelming life circumstances Hypo vigilance Persistent feelings of extreme anxiety , Impaired perception, judgment, guilty or fear decision making Biologic / medical factors Impaired attention span / easily Prolonged grief reaction distracted

 Expected outcome

Impaired ability to grasp ideas or order thoughts Negative ruminations Impaired insight Decreased problem- solving abilities

Recalls and remote information accurately Processes information and makes appropriate decisions

Long term goals client will: Give example showing that short-term memory and concentration have improved to usual levels by (date) Demonstrate an increased ability to make appropriate decisions when planning with nurse by (date) Identify negative thoughts and rationally counter them and / or reframe them in a positive manner within 2 weeks Show improved mood as demonstrated by the Beck Depression Inventory

Short term goals client will Remember to keep appointments, attend activities and attend to grooming with minimal reminders from others within 1 3 weeks. Identify 2 goals he/she wants to achieve from treatments, with aide of nursing intervention within 1-2 days Discuss with nurse 2 irrational thoughts about self and others by end of the first day Reframe 3 irrational thoughts with nurse by (date)

Nursing interventions Nursing Intervention Rationale Identify clients previous level of cognitive Establishing a baseline ability allows for functioning (from client, family, friends, and evaluation of clients progress previous medical records.) Help the client postpone important major life Making rational major the decisions requires decision making optimal psychophysiologic functioning Minimize clients responsibilities whiles he/she is severely depressed Allow client plenty of time to think and frame responses Decreases feelings of pressure and anxiety, and minimizes feelings of guilt Slow thinking necessitate time to formulate a response.

Help client and significant others structure an environment that can help re-establish set schedules and predictable routines during severe depression Allow more than usual for client to finish usual activities of daily living e.g. dressing eating Work with client to recognize negative thinking and thoughts. Teach the client to reframe and / or refute negative thoughts

A routine that is fairly repetitive and nondemanding is easier to both follow and remember

Usual tasks might take long periods of time; demands that the client hurry only increases anxiety and slow down ability to think clearly. Negative ruminations add to feelings of hopelessness and are parts of a depressed persons faulty thought processes. Intervening in this process aids in healthier and more useful outlooks

Chronic low self-esteem long standing negative self evaluation/feeling about self or self-capabilities Nursing Diagnosis Defining characteristics Chronic low self- Negative feedback about self esteem Self-negating verbalizations Rejection of positive feedback Repeated expressions of worthlessness Inability to recognize own achievements Negative view of abilities Expected outcome Expresses belief in self Demonstrates a zest for life and ability to enjoy the present Related factors Biochemical / neurophysical imbalances Impaired cognitive self-appraisal Unrealistic expectations of self Shame and guilt Repeated past failures

Long term goals client will: Give an accurate and nonjudgmental account of four positive qualities as well as identify two areas he or she wishes to improve by (date) Demonstrate the ability to modify un realistic self-expectations by (date) Report decreased feelings of shame , guilt and self-hate by using a scale of 1- 10 (1 lowest 10 highest)

Short term goals client will Identify one or two strengths by the end of the day

Identify two unrealistic two self-expectations and reformulate more realistic life goals with nurse by the end of the day Keep a daily log and identify on a scale of 1 to 10 (1 lowest 10 highest) feelings of shame , guilt and self-hate Identify three judgmental terms client(e.g. I am lazy) use to describe self and identify objective terms to replace them (e.g. I do not feel motivated today) to date

Nursing interventions Nursing Intervention Work with the client to identify cognitive distortions that encourage negative selfappraisal e.g. Overgeneralizations Self-blame Mind reading Discounting positive attributes Teach visualization techniques that help client replace negative self-image with more positive thoughts and images Rationale Cognitive distortions reinforce negative inaccurate perception of self and the world Taking one fact or event and making a general rule out of it (he always, I never) Consistent self-blame for everything perceived as wrong Assume others do not like me e.g. without any real evidence that assumptions are correct Focusing on negative qualities Promotes a healthier and more realistic selfimage by helping the client choose more positive actions and thoughts. Feelings of low self-esteem can interfere with usual problem solving abilities People with low self-esteem often feel unworthy and have difficulty asking appropriately for what they need and want Clients can follow examples Decrease feelings of isolation and provide an atmosphere where positive feedback and a more realistic appraisal of self are available

Work with client on areas that he or she would like to improve using problem-solving skills. Evaluate need for more teaching in this area. Evaluate clients need for assertiveness training tools to pursue things he or she wants or needs in life. Arrange for training through community based programs, personal counseling, literature etc. Role model assertiveness Encourage participation in a support group where others are experiencing similar thoughts feelings and situation

Spiritual distress- impaired ability to express and integrate meaning and purpose in life through a persons connectedness with self , others art, music, literature , nature , or a power greater than oneself

Nursing Diagnosis Spiritual distress Expected outcome

Defining characteristics

Related factors

Long term goals client will: Short term goals client will Nursing Diagnosis Rationale

Impaired social interaction insufficient or excessive quality of social exchange Nursing Diagnosis Defining characteristics Impaired social interaction Expected out come Long term goals client will: Short term goals client will Nursing interventions Nursing Intervention Rationale Related factors

Self-care deficit impaired ability to perform or complete bathing/ hygiene dressing/grooming, feeding or toileting activities for one self Nursing Diagnosis Self-care deficit Defining characteristics Consuming insufficient food or nutrients to meet minimum daily requirements Decreased abilityto function secondary to sleep deprivation Weight loss Persistent insomnia or hypersomnia Body odor/ hair unkempt Inability to organize simple steps in hygiene and grooming Constipation related to lack of exercise , roughage in diet and poor fluid intake Related factors Perceived or cognitive impairment Decreased or lack of motivation (anergia) Severe anxiety Severe preoccupation

Expected out comes Performs all tasks of self-care consistently Experiences normal elimination Sleeps6-8 hours a night without medication

Long term goals client will: Gradually return to weight consistent for height and age baseline before illness(date) Sleeps between 6-8 hours per night within 1 month Demonstrate progress in the maintenance of adequate hygiene and be appropriately groom and dressed Experience normal elimination with the aid of diet, fluids and exercise within 3 weeks

Short term goals patient will Gain 1 pound a week with encouragement from S/O family members or staff if significant weight loss exist Sleep between 4-6 hours with aid of medications or nursing measures Groom and dress appropriately with help from nursing staff and/or family members

Regain more normal elimination pattern with aid of foods high in roughage increased fluids and exercise daily (also with aid of medication)

Nursing interventions Nursing Interventions Bipolar Disorder Rationale

Predisposing Factors .`

Presenting signs and symptoms

Risk for injury a state in which the individual is at risk of injury as a result of environmental condition interacting with the individual adaptive and defensive resources Nursing Diagnosis Risk for injury Expected out come Defining characteristics Related factors

 Long term goals client will: Short term goals client will Nursing interventions Nursing Intervention Rationale

Risk for violence: self-directed or other directed at risk for behaviors in which an individual demonstrates that he/she can be physically , emotionally, and / or sexually harmful to self and others Nursing Diagnosis Defining characteristics Risk for violence: self-directed Expected outcomes Long term goals client will: Short term goals client will: Related factors

 Nursing interventions Nursing Interventions Rationale

Ineffective coping inability to form a valid apprasial of stressors, inadequate choice of practice responses, and /or inability to use available resources Nursing Diagnosis Ineffective coping Defining characteristics Related factors

Expected outcome Long term goals client will: Give example showing that short-term memory and concentration have improved to usual levels by (date) Demonstrate an increased ability to make appropriate decisions when planning with nurse by (date) Identify negative thoughts and rationally counter them and / or reframe them in a positive manner within 2 weeks Show improved mood as demonstrated by the Beck Depression Inventory

Short term goals client will

Nursing interventions Nursing Intervention Rationale

Chronic low self-esteem long standing negative self evaluation/feeling about self or self-capabilities Nursing Diagnosis Defining characteristics Chronic low self- Negative feedback about self esteem Self-negating verbalizations Rejection of positive feedback Repeated expressions of worthlessness Inability to recognize own achievements Negative view of abilities Expected outcome Expresses belief in self Demonstrates a zest for life and ability to enjoy the present Related factors Biochemical / neurophysical imbalances Impaired cognitive self-appraisal Unrealistic expectations of self Shame and guilt Repeated past failures

Long term goals client will: Give an accurate and nonjudgmental account of four positive qualities as well as identify two areas he or she wishes to improve by (date) Demonstrate the ability to modify un realistic self-expectations by (date) Report decreased feelings of shame , guilt and self-hate by using a scale of 1- 10 (1 lowest 10 highest)

Short term goals client will

Identify one or two strengths by the end of the day Identify two unrealistic two self-expectations and reformulate more realistic life goals with nurse by the end of the day Keep a daily log and identify on a scale of 1 to 10 (1 lowest 10 highest) feelings of shame , guilt and self-hate Identify three judgmental terms client(e.g. I am lazy) use to describe self and identify objective terms to replace them (e.g. I do not feel motivated today) to date

Nursing interventions Nursing Intervention Work with the client to identify cognitive distortions that encourage negative selfappraisal e.g. Overgeneralizations Self-blame Mind reading Discounting positive attributes Teach visualization techniques that help client replace negative self-image with more positive thoughts and images Rationale Cognitive distortions reinforce negative inaccurate perception of self and the world Taking one fact or event and making a general rule out of it (he always, I never) Consistent self-blame for everything perceived as wrong Assume others do not like me e.g. without any real evidence that assumptions are correct Focusing on negative qualities Promotes a healthier and more realistic selfimage by helping the client choose more positive actions and thoughts. Feelings of low self-esteem can interfere with usual problem solving abilities People with low self-esteem often feel unworthy and have difficulty asking appropriately for what they need and want Clients can follow examples Decrease feelings of isolation and provide an atmosphere where positive feedback and a more realistic appraisal of self are available

Work with client on areas that he or she would like to improve using problem-solving skills. Evaluate need for more teaching in this area. Evaluate clients need for assertiveness training tools to pursue things he or she wants or needs in life. Arrange for training through community based programs, personal counseling, literature etc. Role model assertiveness Encourage participation in a support group where others are experiencing similar thoughts feelings and situation

Impaired social interaction insufficient or excessive quality of social exchange Nursing Diagnosis Impaired social interaction Defining characteristics Related factors

Expected out come Long term goals client will: Short term goals client will Nursing interventions Nursing Intervention Rationale

Self-care deficit impaired ability to perform or complete bathing/ hygiene dressing/grooming, feeding or toileting activities for one self Nursing Diagnosis Self-care deficit Defining characteristics Consuming insufficient food or nutrients to meet minimum daily requirements Decreased abilityto function secondary to sleep deprivation Weight loss Persistent insomnia or hypersomnia Body odor/ hair unkempt Inability to organize simple steps in hygiene and grooming Constipation related to lack of exercise , roughage in diet and poor fluid intake Related factors Perceived or cognitive impairment Decreased or lack of motivation (anergia) Severe anxiety Severe preoccupation

Expected out comes Performs all tasks of self-care consistently Experiences normal elimination Sleeps6-8 hours a night without medication

Long term goals client will: Gradually return to weight consistent for height and age baseline before illness(date) Sleeps between 6-8 hours per night within 1 month Demonstrate progress in the maintenance of adequate hygiene and be appropriately groom and dressed Experience normal elimination with the aid of diet, fluids and exercise within 3 weeks

Short term goals patient will Gain 1 pound a week with encouragement from S/O family members or staff if significant weight loss exist Sleep between 4-6 hours with aid of medications or nursing measures Groom and dress appropriately with help from nursing staff and/or family members Regain more normal elimination pattern with aid of foods high in roughage increased fluids and exercise daily (also with aid of medication)

Nursing interventions Nursing Interventions Rationale

Interrupted family processes change in family relationship and/or functioning Nursing Diagnosis Interrupted family processes Defining characteristics Changes in effectiveness in completing assigned tasks Change in participation in problem Related factors Shift in health status of family member Situational crisis or transition(e.g.

Expected outcome All members

solving Change in participation in decision making Change in communication patterns inability to deal with traumatic or crisis experiences constructively Deficient knowledge regarding disorder need for medication adherence and available support systems for both family members and client Family in crisis

illness manic episodes to one member)family role shift Erratic and out of- control behavior of one family member with the potential for dangerous behavior affecting all family members(violence, leaving family in debt risky behaviors in relationships and business, flagrant infidelities unprotected and promiscuous sex Nonadherance to antimanic and other medication

Perform expected roles Adapt to unexpected crises Use stress reduction techniques

Long term goals family member/significant other will: State that they find needed support and information in support groups Can identify the signs of increase manic behavior in their family member State what that they will do (whom to call , where to go ) when client s mood begins to escalate to dangerous level Demonstrate an understanding of what a bipolar disorder is , the medication the need for adherence to medication and treatment

Short term goals family member/significant other will: Discuss with nurse/counselor three area of the family life that are most disruptive and seek alternative options with aid of nursing / counselor interventions by (date) State and have in writing the names and telephone number of at least two biplor support group by (date) State that they have gained support by at one support group to on how to work of with family member when he she is manic by (date) State their need for medication adherences and be able to identify three signs that indicate possible need for intervention when the family member moods escalate by (date) Briefly discuss and have in writing the names and addresses of two bipolar organization , two internet site and medication information regarding bipolar by (date) Rationale This is a disease than can devastate and destroy some families, during a manic episode.

Nursing Diagnosis During the first or second day of hospitalization remain with the client and

families identifying their needs during this time e.g.

Families experience a great deal of disruption and confusion when a family member begins to act bizarre, out of control and at times aggressive. Families need to understand the disease. What can be done or not done to help control the disease and where to go for help for their individual issues.

Medical treatments Psychopharmacology

Bibliography