ADJUSTMENT DISORDERS DSM-IV ADJUSTMENT DISORDERs (SPECIFY if ACUTE/CHRONIC) 309. 24 With anxiety 309. 0 With depressed mood 309. 3 With disturbance of conduct 309. 4 With mixed disturbance of emotions and conduct 309. 28 With mixed anxiety and depressed mood The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement. The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder. The response is considered maladaptive because social or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e. g. a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist. ETIOLOGICAL THEORIES Psychodynamics Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego. The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change.
The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur. Biological The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.
The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety. Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.
Family Dynamics The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life. Individuals with adjustment difficulties have experienced negative learning through inadequate role-modeling in dysfunctional family systems.
These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment responses. CLIENT ASSESSMENT DATA BASE (Symptoms of affective, depressive, and anxiety disorders are manifested dependent on the individual’s specific response to a stressful situation. ) Activity/Rest Fatigue Insomnia Ego Integrity Reports occurrence of personal stressor/loss (e. g. , job, financial, relationship) within past 3 months May appear depressed and tearful and/or nervous and jittery Feelings of hopelessness
Neurosensory Mental Status: Depressed mood, tearful, anxious, nervous, jittery Attention and memory span may be impaired (depends on presence of depression, level of anxiety, and/or substance use) Communication and thought patterns may reveal negative ruminations of depressed mood or flight of ideas/loose associations of severely anxious condition Pain/Discomfort Various physical symptoms such as headache, backache, other aches and pains (maladaptive response to a stressful situation) Safety Anger expressed inappropriately Involvement in high-risk behaviors (e. g. fighting, reckless driving) Suicidal ideations may be present Social Interactions Difficulties with performance in work/social setting, when no difficulties had been experienced prior to the occurrence of the stressor Socially withdrawn/refuses to interact with others (e. g. , isolates self in own room) Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities, violation of the rights of others or age-appropriate norms and rules May display manipulative behavior (e. g. , testing limits, playing individuals/family members against each other) Teaching/Learning
Academic difficulties, failure to attend class/complete course work Substance use/abuse possibly present DIAGNOSTIC STUDIES Diagnostic studies and psychological testing as indicated to rule out conditions that may mimic or coexist (e. g. , endocrine imbalance, cardiac involvement, epilepsy, or a differential diagnosis with affective, anxiety, conduct, or antisocial personality disorders). Drug Screen: Determine substance use. NURSING PRIORITIES 1. Provide safe environment/protect client from self-harm. 2. Assist client to identify precipitating stressor. 3. Promote development of effective problem-solving techniques. . Provide information and support for necessary lifestyle changes. 5. Promote involvement of client/family in therapy process/planning for the future. DISCHARGE GOALS 1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced. 2. Anger expressed in an appropriate manner. 3. Maladaptive behaviors recognized and rechanneled into socially accepted actions. 4. Client involved in social situations/interacting with others. 5. Ability and willingness to manage life situations displayed. 6. Plan in place to meet needs after discharge. NURSING DIAGNOSISANXIETY [moderate to severe]
May Be Related to:Situational/maturational crisis Threat to self-concept; threat (or perceived threat) to physical integrity Unmet needs; fear of failure Dysfunctional family system; unsatisfactory parent/child relationship resulting in feelings of insecurity Fixation in earlier level of development Possibly Evidenced by:Overexcitement/restlessness; increased tension; insomnia Feelings of inadequacy; fear of unspecified consequences Poor eye contact, focus on self; difficulty concentrating Continuous attention-seeking behaviors; selective inattention Sympathetic stimulation; numerous physical complaints
Desired Outcomes/Evaluation Criteria—Verbalize awareness of feelings of/indicators of Client Will:increasing anxiety. Demonstrate/use appropriate techniques to interrupt escalation of anxiety. Appear relaxed and report anxiety is reduced to a manageable level. ACTIONS/INTERVENTIONSRATIONALE Independent Establish a therapeutic nurse/client relationship. BeHonesty, availability, and unconditional honest, consistent in responses, and available. Showacceptance promote trust, which is necessary for genuine positive regard. the development of a therapeutic relationship.
Provide activities geared toward reduction ofTension and anxiety can be released safely, and tension and decreasing anxiety (e. g. , walking orphysical activity may provide emotional benefit to jogging, musical exercises, housekeeping chores,the client through release in the brain of morphine- group games/activities). like substances (endorphins) that promote sense of well-being. Encourage client to identify true feelings and toAnxious clients often deny a relationship between acknowledge ownership of those feelings. emotional problems and their anxiety.
Use of the defense mechanisms of projection and displacement are exaggerated. Maintain a calm atmosphere and approach to client. Can help to limit transmission of anxiety to/from client. Assist client to recognize specific events that precedeRecognition of precipitating stressors and a plan of onset of elevation in anxiety. Provide informationaction to follow should they recur provides client about signs and symptoms of increasing anxietywith feelings of security and control over similar and ways to intervene before behaviors becomesituations in the future.
This in itself may help to disabling. control anxiety response. Offer support during times of elevated anxiety. Presence of a trusted individual may provide Provide physical and psychological safety. (Refer toneeded security/client safety. ND: Violence, risk for, directed at self/others. ) Collaborative Administer medications as necessary, e. g. , benzo-Antianxiety medications induce a calming effect diazepines: alprazolam (Xanax). and work to maintain anxiety at a manageable level while providing the opportunity for client to develop other ways to manage stress.
NURSING DIAGNOSISVIOLENCE, risk for, directed at self/others Risk Factors May Include:Depressed mood, hopelessness, powerlessness; inability to tolerate frustration; rage reactions Low self-esteem; unmet needs Negative role modeling; lack of support systems Substance use/abuse; history of previous suicide attempts [Possible Indicators:]Increased motor activity (pacing, excitement, irritability, agitation) Muscle tension (e. g. , clenched fists, tense facial expressions, rigid posture, tautness) Hostile, threatening verbalizations; provocative behavior (argumentative, dissatisfied, overreactive, hypersensitive) Suicide ideation
Desired Outcomes/Evaluation Criteria—Verbalize understanding of behavior and Client Will:precipitating factors. Participate in care and meet own needs in an assertive manner. Rechannel anger/hostile feelings into socially acceptable behaviors. Demonstrate self-control as evidenced by relaxed posture, absence of violent behavior, etc. Use resources/support systems in an effective manner. ACTIONS/INTERVENTIONSRATIONALE Independent Observe client’s behavior frequently during routineClose observation is required so that intervention activities and interactions; avoid appearing watchfulcan occur if required to ensure the safety of others. nd suspicious. Instilling suspicion may provoke aggressive behaviors. Ask client direct questions regarding intent, plan,Direct questions, if presented in a caring, and availability of the means for self-harm. Evaluateconcerned manner, provide the necessary and prioritize on a scale of 1–10 according toinformation to assist the nurse in formulating an severity of threat, availability of means. appropriate plan of care for the suicidal client. Provide a safe environment: reduce stimuli (e. g. ,A stimulating environment may increase agitation low lighting, few people, simple decor, low noiseand provoke aggressive behavior. evel). Remove potentially dangerous objects, such asExternal control of environment aids in preventing straps, belts, ties, sharp objects, glass items, andimpulsive actions at a time when client lacks own drugs, as indicated. internal controls. Secure contract from client that she or he will notA contract encourages the client to share in the harm self and will seek out staff member if suicidalresponsibility of own safety. A degree of control is ideations emerge. experienced, and the attitude of acceptance of the client as a worthwhile individual is conveyed. Promote verbalizations of honest feelings.
ThroughMay be difficult for client to express negative exploration and discussion, help client identifyfeelings. Verbalization of these feelings in a symbols of hope in own life. nonthreatening environment may help client come to terms with unresolved issues and identify reasons for wanting to change life/continue living. Help client identify true source of anger/hostilityBecause of weak ego development, client may be and underlying feelings. using the defense mechanism of displacement. Helping the client to recognize this in a nonthreatening environment may help reveal unresolved issues so that they may be onfronted, regardless of the discomfort involved. Convey an attitude of acceptance toward the client. Promotes feelings of self-worth. These feelings are Impart a message that it is not the client but thefurther enhanced as person and behavior are behavior that is unacceptable. viewed separately, communicating unconditional positive regard. Explore with client alternative ways of handlingPhysically demanding activities help to relieve frustration/pent-up anger that channel hostilepent-up tension. Note: Exercise need not be energy into socially acceptable behavior (e. g. briskaerobic or intensive to achieve therapeutic effect. walks, jogging, physical exercises, volleyball, punching bag, exercise bike). Maintain a calm attitude toward the client ifAnxiety is contagious and can be transferred from behavior escalates. Have sufficient staff available toperson to person. A calm attitude provides client convey a show of strength to the client if it becomeswith a feeling of safety and security. A display of necessary. strength provides reassurance for the client that the staff is in control of the situation and will provide physical security for the client, staff, nd others. Be alert to increased potential for suicidal action asClient may mobilize self for suicidal attempt as mood elevates. decrease in depression results in increased energy and motivation. Collaborative Administer medication as indicated, e. g. : Tricyclic drugs: amitriptyline (Elavil), desipramineAntidepressant medication may elevate the mood, (Norpramin), doxepin (Sinequan), imipramineas it increases level of energy and decreases (Tofranil); selective serotonin reuptakefeelings of fatigue. inhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil); monoamine-oxidase nhibitors: isocarboxazid (Marplan), phenelzine (Nardil); Benzodiazepines: diazepam (Valium), Antianxiety medication may provide needed relief chlordiazepoxide (Librium), alprazolam from anxious feelings, inducing a calming effect (Xanax). and inhibiting aggressive behavior. NURSING DIAGNOSISCOPING, INDIVIDUAL, ineffective May Be Related to:Situational/maturational crises Dysfunctional family system; negative role modeling; inadequate support systems Unmet dependency needs; low self-esteem; retarded ego development Possibly Evidenced by:Inability to cope/problem-solve Chronic worry, depressed/anxious mood
Alteration in societal participation; manipulation of others Inability to meet role expectations; increased dependency; refusal to follow rules of the unit Numerous physical complaints Destructive behavior, substance abuse Desired Outcomes/Evaluation Criteria—Assess the current situation accurately. Client Will:Identify ineffective coping behaviors and consequences. Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources. Refrain from manipulating others for own gratification. ACTIONS/INTERVENTIONSRATIONALE Independent
Explain rules of the unit/therapeutic relationshipNegative reinforcement may work to decrease and consequences of lack of cooperation. Set limitsundesirable behaviors. Consistency among all staff on manipulative behavior. Be consistent in enforcingmembers is vital if intervention is to be successful. the consequences when rules are broken and limits tested. Ignore negative behaviors when possible andNegative behaviors diminish when they provide provide feedback when positive behaviors are noted,no reward of attention. When client gives self encouraging client to acknowledge own success. positive feedback, inner rewards are enhanced.
Encourage client to discuss angry feelings. HelpVerbalization of feelings with a trusted individual client identify the true object of the hostility. Providemay help client work through unresolved issues. physical outlets for healthy release of the hostilePhysical exercise provides a safe and effective feelings (e. g. , punching bags, pounding boards). means of releasing pent-up tension, as well as of Involve in outdoor recreation program, if available. developing self-confidence and trust in others. Take care not to reinforce dependent behaviors. Independent accomplishment and positive reinforcement enhance self-esteem and encourage epetition of desirable behaviors. Allow client to perform as independently as possibleRecognition of personal control, however, and provide feedback. Help client recognize aspectsminimal diminishes the feeling of powerlessness of life over which a measure of control is maintained/and decreases the need to manipulate possible. (Refer to ND: Powerlessness. )others. Give minimal attention to the physical condition ifOrganic pathology must always be considered. client is coping through numerous somaticFailure to do so may place the client in physical complaints and organic pathology has been ruledjeopardy.
Lack of attention to maladaptive out. Increase attention when client is not focusingbehaviors may decrease their repetition. Positive on physical complaints. reinforcement encourages desirable behaviors. Discuss the negative aspects of substance abuse asDenial of problems related to substance use is a response to stress. Help client recognize difficultcommon. Client needs to recognize relationship life situations that may be contributing to use ofbetween substance use and personal problems substances. before rehabilitation can begin. Assist with problem-solving process.
SuggestBecause of level of anxiety and delayed alternatives, and help client to select more adaptivedevelopment, client may require assistance in strategies for coping with stress. determining which methods of coping are most individually appropriate. Increased anxiety interferes with client’s problem-solving ability. Encourage client to learn relaxation techniques, useThese skills can be helpful in developing new of imagery. coping methods to deal with/reduce stress. Collaborative Refer client to substance rehabilitation program ifA greater likelihood of success can be expected if problem is identified. lient seeks professional assistance with this problem. NURSING DIAGNOSISADJUSTMENT, impaired [when stressor is a change in health status] May Be Related to:Change in health status requiring modification in lifestyle (e. g. , development of chronic disease/disability, changes associated with aging process) Assault to self-esteem Inadequate support systems Possibly Evidenced by:Verbalization of nonacceptance of health status change Difficulty in problem-solving, decision-making, or goal-setting; lack of future-oriented thinking Lack of movement toward independence
Desired Outcomes/Evaluation Criteria—Recognize reality of situation and individual Client Will:needs/options. Assume personal responsibility for care, problem-solve needs. Initiate necessary lifestyle changes. Plan for future needs/changes. ACTIONS/INTERVENTIONSRATIONALE Independent Encourage client to talk about lifestyle before theIt is important to identify the client’s strengths so change in health status. that they may be used to facilitate adaptation to change or loss that has occurred. Discuss coping mechanisms that were used atSome individuals may not realize that anger is a stressful times in the past.
Help client to discuss thenormal stage in the grieving process. If it is not change/loss and particularly to express angerreleased appropriately, it may be turned inward associated with it. on the self, leading to pathological depression. Have client express fears associated with theChange often creates a feeling of disequilibrium, change/loss or the resulting alteration in lifestyleand the individual may respond with fears that are that has occurred. irrational or unfounded. Client may benefit from feedback that corrects misperceptions about how ife will be with the change in health status. Assist with activities of daily living as required, butIndependent accomplishments and positive feed- encourage independence to the limit that client’sback enhance self-esteem and encourage repetition ability will allow. Give positive feedback forof desired behaviors. Successes also provide hope activities accomplished independently. that adaptive functioning is possible and decrease feelings of powerlessness. Help client with decision-making regardingThe high degree of anxiety that usually incorporation of change or loss into lifestyle.
Identifyaccompanies a major lifestyle change often an individual’s ability to solve problems and makeinterferes with problems created by the change or appropriate decisions. loss. Discuss alternative solutions, weighing potentialClient may need help with this process to progress benefits and consequences of each alternative. toward successful adaptation. Support client’s decisions. Role-play stressful situations that might occurDecreases anxiety and provides a feeling of in relation to the health status change. security for the client by preparing a plan of action ith which to respond appropriately when a stressful situation occurs. Provide information regarding the physiology ofHelps client and family understand what has the change in health status and necessity forhappened, clarifies information, and provides optimal wellness. Encourage client and family toopportunity to review information at individual’s ask questions. Provide printed material explainingleisure. the change. Collaborative Refer to resources within the community (e. g. , Provides assistance in adapting to the change in self-help/support groups, public health nurse,health status. ounselor, or social worker). NURSING DIAGNOSISGRIEVING, dysfunctional May Be Related to:Real or perceived loss of any concept of value to the individual; bereavement overload (cumulative grief from multiple unresolved losses, excluding the death of a loved one) Absence of anticipatory grieving; thwarted grieving response to loss Feelings of guilt generated by ambivalent relationship with the lost concept/person Possibly Evidenced by:Idealization of the lost concept; difficulty in expressing loss; denial of loss Excessive anger, expressed inappropriately; labile affect Developmental regression
Alterations in concentration and/or pursuit of tasks Desired Outcomes/Evaluation Criteria—Express emotions appropriately. Client Will:Demonstrate progress in dealing with stages of grief at own pace. Carry out activities of daily living independently. Express feeling of hope for the future. ACTIONS/INTERVENTIONSRATIONALE Independent Determine stage of grief in which client is fixed. Accurate baseline assessment data are necessary to Identify behaviors associated with this stage. choose appropriate interventions/provide effective care and evaluate progress. (Most depressed people are fixed in the anger stage, with he anger directed inward on the self. ) Convey an accepting attitude; encourage client toAn accepting attitude enhances trust and express self openly. communicates to the client that you believe the client is a worthwhile person, regardless of what may be expressed. Encourage client to express anger. Avoid defensiveVerbalization of feelings in a nonthreatening response if initial expression of anger is displacedenvironment may help client come to terms with on nurse/therapist. Assist client to explore angryunresolved issues related to the loss. feelings and direct them toward the intended object/ erson or other loss. Encourage participation in large motor activities. Physical activity provides a safe and effective method for discharging pent-up tension/anger. Provide information about the stages of grief and theKnowledge of the acceptability of the feelings behaviors associated with each stage. Help clientassociated with normal grieving may help relieve understand that feelings, such as anger directedsome of the guilt that these responses generate. toward the loss, are appropriate during the grief process. Encourage client to review relationship with loss.
Client needs to give up idealized perception and With support and sensitivity, point out reality ofaccept both positive and negative aspects about the situation in areas where misrepresentations arethe loss before resolution of grief can occur. expressed. Help client determine methods for more adaptiveFeelings of depression may interfere with client’s coping with the experienced loss. Provide positiveproblem-solving ability, resulting in need for feedback for strategies identified and decisions made. assistance. Positive feedback enhances self-esteem and encourages repetition of desirable behaviors.
Collaborative Determine client’s perception of spiritual needs asSome individuals derive great strength from support in the grieving process. Involve chaplain orspiritual support. This strength may be used by appropriate spiritual leader as indicated. the client in the task of grief resolution. NURSING DIAGNOSISHOPELESSNESS May Be Related to:Lifestyle of helplessness (repeated failures, dependency) Incomplete grief work of losses in life Lost belief in transcendent values/God Possibly Evidenced by:Verbal cues/despondent content (e. g. , “I can’t,” sighing) Apathy/passivity, decreased response to stimuli
Lack of initiative, nonparticipation in care or decision-making when opportunities are provided Desired Outcomes/Evaluation Criteria—Recognize and verbalize feelings. Client Will:Demonstrate independent problem-solving techniques to take control over life. Verbalize acceptance of life situations over which one does not have control. ACTIONS/INTERVENTIONSRATIONALE Independent Identify use of maladaptive behaviors/defensePersonal attempts to overcome feelings of mechanisms (e. g. , withdrawal, substance use,hopelessness may have resulted in ineffective/ regression). harmful behaviors. Recognizing the behaviors provides opportunity for change.
Encourage client to explore and verbalize feelingsIdentification of feelings underlying behaviors and perceptions. helps client to begin process of taking control of own life. Identify individual signs of hopelessness, (e. g. ,Helps to individualize interventions, focus decreased physical activity, social withdrawal). attention on areas of need. Express hope to client in positive, low-key manner. Even though client feels hopeless, it can be helpful to hear positive expressions from others. Help client identify areas of life situation that areClient’s emotional condition may interfere with under own control. bility to problem-solve. Assistance may be required to perceive the benefits and consequences of available alternatives accurately. Encourage client to assume responsibility for ownProviding the client with choices increases feelings self-care (e. g. , setting realistic goals, schedulingof control. Note: Unrealistic goals set the client up activities, making independent decisions). for failure and reinforce feelings of hopelessness. Help client identify areas of life situation that areClient needs to identify and resolve feelings not within ability to control. Discuss feelingsassociated with inability to control ertain life associated with this lack of control. situations before level of acceptance can be achieved. NURSING DIAGNOSISSELF ESTEEM disturbance [specify] May Be Related to:Maturational transitions Unmet dependency needs; retarded ego development Repeated negative feedback, diminished self-worth Dysfunctional family system Possibly Evidenced by:Self-negating verbalization, inability to deal with events; difficulty accepting positive feedback Lack of eye contact; nonassertive/passive behaviors; indecision, difficulty making decisions Hesitancy to undertake new tasks; fear of failure Social isolation; nonparticipation in therapy
Manipulation of one staff member against another Self-destructive ideas/behavior Desired Outcomes/Evalution Criteria—Identify feelings and underlying dynamics for Client Will:negative perception of self. Demonstrate behaviors/lifestyle changes to promote positive self-esteem. Accept recognition for personal accomplishments/abilities. Verbalize increased sense of self-worth. ACTIONS/INTERVENTIONSRATIONALE Independent Discuss goals, making sure they are realistic. PlanAchievement/success enhance self-concept. activities in which success is likely. Convey unconditional positive regard for the client.
Unconditional acceptance of an individual serves Promote understanding of acceptance for client as ato counteract feelings of worthlessness by worthwhile human being. reinforcing that individual is worthy of another person’s respect. Spend time with client both on a 1:1 basis and inConveys that the nurse sees the client as someone group activities. worth spending time with. Assist client to identify positive aspects of self andIndividuals with low self-esteem often have develop plans for changing the characteristicsdifficulty recognizing positive attributes. They viewed as negative. ay also lack problem-solving skills and require assistance to formulate a plan for implementing the desired changes. Encourage and support client in confronting theRecognition and positive reinforcement enhance fear of failure by attending therapy activities andself-esteem and encourage repetition of desirable undertaking new tasks. Offer recognition ofbehaviors. successful endeavors and positive reinforcement for attempts made. Help client avoid ruminating about past failures. Lack of attention to these undesirable behaviors Withdraw attention if client persists. may discourage their repetition. Client needs to ocus on positive attributes if self-esteem is to be enhanced. Minimize negative feedback to client. Enforce limitNegative feedback can be extremely threatening to setting in matter-of-fact manner, imposinga person with low self-esteem, possibly previously established consequences foraggravating the problem. Consequences need to unacceptable behavior. convey unacceptability of the behavior but not the person. Encourage independence in the performance ofThe ability to perform self-care activities personal responsibilities, as well as in decision-independently enhances self-concept. Positive making related to own self-care.
Offer recognitionreinforcement encourages repetition of desirable and praise for accomplishments. behaviors. Support client in critical examination of feelings,The need for judging the behavior of others attitudes, and behaviors. Help client understanddiminishes as client increases self-esteem through that it is acceptable for attitudes and behaviors togreater self-awareness and the achievement of differ from those of others, as long as they do notself-acceptance. become intrusive. NURSING DIAGNOSISSOCIAL INTERACTION, impaired May Be Related to:Unmet dependency needs; retarded ego development Negative role-modeling
Low self-concept Possibly Evidenced by:Verbalized/observed discomfort in social situations; use of unsuccessful/dysfunctional social interaction behaviors Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest Exhibits behaviors unacceptable for age, as defined by dominant cultural group Desired Outcomes/Evaluation Criteria—Verbalize awareness of factors resulting in Client Will:difficulty in forming satisfactory relationships with others. Identify feelings that lead to poor social interactions. Interact with staff and peers with little/no indication of discomfort.
Participate in group activities appropriately and willingly. Identify/develop effective social support system. ACTIONS/INTERVENTIONSRATIONALE Independent Establish 1:1 relationship with client, which servesClient needs to learn to interact appropriately with as role model for testing new behaviors. nurse, so that behaviors may then be generalized to others. Encourage client to engage in activities out of Decreases opportunity for client to isolate self. room/home. Offer to attend initial group interactions with client. Presence of a trusted individual may provide a Provide feedback for appropriate interactions. eeling of security and decrease the anxiety generated by difficult social situation. Positive reinforcement enhances self esteem and encourages repetition of desirable behaviors. Act as role model for client through appropriateBecause of weak ego development, client is interactions with client and others. inclined to imitate the actions of those individuals admired or trusted. Establish schedule of group activities for client. It is through these group interactions, with positive and negative feedback from peers, that client learns socially acceptable behavior. NURSING DIAGNOSISFAMILY PROCESSES, altered
May Be Related to:Situational/maturational crisis Possibly Evidenced by:Needs of family members not being met; confusion within family system regarding how needs should be met Impaired family communication; dissonance among family members Impairment of family decision-making process; family developmental tasks not being fulfilled Reduced/restricted social involvement Desired Outcomes/Evaluation Criteria—Express feelings freely and appropriately. Family Will:Develop effective patterns of communication, encouraging honest input from all members. Identify source(s) of dysfunction and effectively problem-solve to achieve desired resolution.
Demonstrate pattern of functioning improved from premorbid state, having gained knowledge and achieved growth from crisis situation. ACTIONS/INTERVENTIONSRATIONALE Independent Assess family developmental stage, communicationIdentifies specific needs and provides direction for patterns, and extent of dysfunction. care. Meet with the total family group as often as possible. The family as a system operates as a single unit. Each member affects, and is affected by, all other members. Therapy is most effective when directed toward the functioning of the family system. Construct a client/family genogram. Genograms help identify emotional closeness mong family members over several generations. Family process is clarified, and configuration and dynamics are clearly illustrated. Assist family to identify true source of conflict. HelpConflict creates high levels of anxiety within the them recognize that “identified patient’s”family system. Common defense mechanisms such adjustment disorder may be a way to avoidas denial, displacement, projection, and confronting the real problem. rationalization are used by the family to decrease anxiety and avoid conflict. Encourage family members to set goals and identifyLife crises interfere with family decision-making alternatives.
Support efforts directed towardand problem-solving abilities. Assistance with this positive change. Assist with necessary modificationsprocess may be required to promote adaptation of original plan. and growth. Promote separation and individuation and clear,Emotional connectedness among family members functional boundaries between/among members. (enmeshment) discourages individual growth and ability to function autonomously. Help client-family identify actions/problem-solveAnticipatory guidance/knowing what to expect for potential life crises. nd having a plan of action for management of situations may help to avert a crisis in the future. Collaborative Involve family in group therapy. Interacting with others in family/multifamily groups can help identify dysfunctional patterns and assist in learning new skills and solutions for family problems. Refer family to other resources, such as supportSharing with others who have had similar groups, classes (e. g. , parenting/assertivenessexperiences can provide support and assist family training). members to learn new ways to deal with situation.
