Impaired Home MaintenanceInability to independently maintain a safe growth-promoting immediate environment.Assessment Data• Lack of skills with which to function independently outside the hospital• Lack of confidence• Dependence on hospital• Perceived helplessness• Nonexistent or unrealistic goals and plans• Lack of knowledge• Inadequate support system• Inadequate financial resources• Disorganized or dysfunctional living environmentExpected OutcomesImmediateThe client will:• Verbalize concrete realistic plans regarding:• Meeting essential physical needs (housing, employment, financial resources, necessary transportation, and physical care, if needed)• Meeting emotional needs through significant relationships, social activities...
Impaired Social Interaction
Insufficient or excessive quantity or ineffective quality of social exchange.
Assessment Data
• Difficulty trusting others
• Difficulties in relationships with significant others
• Difficulties with others in school or work environment
• Discomfort in social or interactive situations
• Poor social skills
• Feelings of anxiety, fear, hostility, sadness, guilt, or inadequacy
Expected Outcomes
Immediate
The client will:
• Participate in the trust relationship
• Demonstrate ability to interact with staff and other clients within the therapeutic milieu
Stabilization
The client will:
• Assume increasing responsibility within the context of the therapeutic relationship
• Identify relationships outside the hospital environment to be used as support system
• Terminate the nurse–client relationship successfully
Community
The client will:
• Use community support system successfully
• Participate in follow-up or outpatient therapy...
Behavior problem related to Dx. SDAT as evidenced by: Combative behavior toward family Name:---------------------------------------------------------------------------Problem / Need / StrengthBehavior problem related to Dx. SDAT as evidenced by: Combative behavior toward family---------------------------------------------------------------------------Goal(s)Will have fewer episodes of _________ behavior daily/weekly by review date.Will have no evidence of behavior problems by review date.---------------------------------------------------------------------------Intervention(s)Administer medications as ordered and monitor for side effects, effectiveness.Anticipate and meet needs.Assist in developing more appropriate methods of coping and interacting.Encourage to express feelings appropriate...
CHF (Congestive Heart Failure), Fluid Volume ExcessName:---------------------------------------------------------------------------Problem / Need / StrengthCHF (Congestive Heart Failure), Fluid Volume Excess---------------------------------------------------------------------------Goal(s)Body weight will remain within normal limitsElectrolyte levels will be within normal limitsWill demonstrate adequate knowledge concerning medical condition.Will maintain optimal fluid balanceWill verbalize less dyspnea and be more comfortable.---------------------------------------------------------------------------Intervention(s)Administer Oxygen as orderedAsess for symptoms such as dizziness, weaknes/fatigue, nausea/vomiting, confusion, sweatiness, cyanosis. Notify physician as appropriate.Assess for pr...
Abusive verbal attacks on staff and others.Name:---------------------------------------------------------------------------Problem / Need / StrengthAbusive verbal attacks on staff and others.---------------------------------------------------------------------------Goal(s)will converse with others without swearing by ____.---------------------------------------------------------------------------Intervention(s)Administer medications as ordered and monitor for side effects, effectiveness.Approach resident in low, calm voice.Document behavior as to type, duration, and precipitating causes.Inform physician of resident's behavior.Praise all appropriate behavior and interactions with others.Remind resident that verbal abuse is unacceptable and redirect.Talk with resident in calm voice when beha...
Angina Pectoris- Nursing Diagnoses/Collaborative ProblemsAngina pectoris is transient chest pain or discomfort that is caused by an imbalance between myocardial oxygen supply and demand. The discomfort typically occurs in the retrosternal area; may or may not radiate; and is described as a tight, heavy, squeezing, burning, or choking sensation. The most common cause of angina pectoris is decreased coronary blood supply due to atherosclerosis of a major coronary artery. The atherosclerosis causes narrowing of the vessel lumen and an inability of the vessel to dilate and supply sufficient blood to the myocardium at times when myocardial oxygen needs are increased. Other conditions that can compromise coronary blood flow (e.g., spasm and/or thrombosis of a coronary artery, hypovolemia) and co...
Ulrich & Canale: Nursing Care Planning Guides: For Adults in Acute, Extended, and Home Care Settings, 6th EditionAbdominal Aortic Aneurysm Repair- Nursing Diagnoses/Collaborative ProblemsAn abdominal aortic aneurysm is an abnormal dilation of the wall of the abdominal aorta. The aneurysm usually develops in the segment of the vessel that is between the renal arteries and the iliac branches of the aorta. The most common cause of an abdominal aortic aneurysm is atherosclerosis. The plaque that forms on the wall of the artery causes degenerative changes in the medial layer of the vessel. These changes lead to loss of elasticity, weakening, and eventual dilation of the affected segment. Some other causes of abdominal aortic aneurysm include inflammation (arteritis), trauma, infection, cong...
DSM-IV Premenstrual dysphoric disorder (provided for further study) Recommended for further systematic clinical study and research, Premenstrual Dysphoric Disorder (popularly called PMS) is characterized by multiple symptom clusters occurring during the menstrual cycle, becoming progressively disabling. Some research suggests these symptoms may be a delayed effect of hormonal changes earlier in the menstrual cycle, or the result of an independent cyclical mood disorder that is synchronized with the menstrual cycle. Although the physical symptoms produce discomfort, the mood change or premenstrual negative affect symptoms are often more distressing, interfering with familial, social, and work-related activities. The condition usually improves after the ...
DSM-IV 316 (Psychologicalfactors) affecting medical condition Choose name based on nature of/most prominent factor: Mental disorder affecting medical condition Psychological symptoms affecting medical condition Personality traits or coping style affecting medical condition Maladaptive health behaviors affecting medical condition Stress-related physiological response affecting medical condition Unspecified psychological factors affecting medical condition (Refer to DSM-IV listing for specific definitions.) These disorders represent a group of ailments in which emotional stress is a contributing factor to physical problems (coded on Axis III) involving an orga...
DSM-IV 301.9 Personalitydisorder NOS Passive-Aggressive personality disorder (negativistic personality disorder)—provided for further study. This disorder is characterized by a pervasive pattern of passive resistance, expressed indirectly rather than directly, to demands for adequate social/occupational performance, with the individual viewing the future as negatively as they view the present. ETIOLOGICAL THEORIES Psychodynamics These clients are unaware that ongoing difficulties are the result of their own behaviors. They experience conscious hostility toward authority figures but do not connect their ownpassive-resistant behaviors with hostility or resentment. They do not trust others, are not assert...
DSM-IV 301.7 Antisocialpersonalitydisorder “Sociopath†and “psychopath†are terms often used to describe the individual with antisocial personality. As deceit and manipulation are central features of the disorder, it is extremely difficult to treat. Imprisonment has been society’s major method for controlling the most dangerous behaviors. ETIOLOGICAL THEORIES Psychodynamics Psychodynamically, this individual remains fixed in an earlier level of development. Because of parental rejection or indifference, needs for satisfaction and security remain unmet, and the ego is underdeveloped. Because of a lack of ego strength, behavior is id directed and ...
DSM-IV 307.1 Anoxexia nervosa 307.51 Bulimia nervosa 307.50 Eating disorders NOS Binge-eating disorder (proposed, requiring further study) Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity. Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating, followed by self-induced vomiting. It may include abuse of laxatives and diuretics. Binge-eating is defined as recurrent episodes of overeating associated with subjective and behavioral indicators of impaired control over and significant distress about the eating behavior but without the use of inappropriate compensatory behaviors (e.g., purging, fasting, exce...
DSM-IV GENDERIDENTITYDISORDERS 302.6 Gender identity disorder in children 302.85 Gender identity disorder in adolescents and adults (specify: sexually attracted to males/females/both/neither) 302.6 Gender identity disorder not otherwise specified (intersex conditions, androgen insensitivity syndrome, or congenital adrenal hyperplasia and gender dysphoria) 313.82 Identity problem (specific to sexual orientation and behavior) Sexuality is a product of one’s genetic identity, gender identity, gender role and sexual orientation. As all of these are independent components, there is a 4 3 4 interaction that can result in 16 distinct possibilities of sex...
DSM-IV 309.81 Posttraumaticstressdisorder (specify acute, chronic, or delayed onset) 308.3 Acute stress disorder An anxiety disorder resulting from exposure to a traumatic event in which the individual has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death/serious injury or a threat to the physical integrity of the self or others. The individual’s response involved intense fear, helplessness, or horror. (A thorough physical examination should be done to rule out neurological organic problems.) Additionally, a newly recognized phenomenon is the development of PTSD-like symptoms in some individuals who have been involve...
DSM-IV 300.3 Obsessive-compulsive disorder An obsession is an intrusive/inappropriate repetitive thought, impulse, or image that the individual recognizes as a product of his or her own mind but is unable to control. A compulsion is a repetitive urge that the individual feels driven to perform and cannot resist without great difficulty (severe anxiety). Most common obsessions are repetitive thoughts about contamination, repeated doubts, a need to have things in a specific order, aggressive or horrific impulses, or sexual imagery. The individual usually attempts to ignore or suppress such thoughts or to neutralize them with some other thought or action (compulsion). ETIOLOGICAL THEORIES Psychodynamics Freud placed origin for obsessive-compulsive char...
DSM-IV 300.02 Generalized anxietydisorder Although some degree of anxiety is normal in life’s stresses, anxiety can be adaptive or maladaptive. Problems arise when the client has coping mechanisms that are inadequate to deal with the danger, which may be recognized or unrecognized. The essential feature of this inadequacy is unrealistic or excessive anxiety and worries about life circumstances. Anxiety disorders are the most common of all major groups of mental disorders in the United States, sharing comorbidity with major depression and substance abuse, increasing the client’s risk of suicide. ETIOLOGICAL THEORIES Psychodynamics The Freudian view involves conflict between demands of the id and super...
DSM-IV 296.xx Bipolar I disorder 296.0x Single manic episode 296.40 Most recent episode hypomanic 296.4x Most recent episode manic 296.6x Most recent episode mixed 296.7 Most recent episode unspecified 296.5x Most recent episode depressed 296.89 Bipolar II disorder (recurrent major depressive episodes with hypomania) 301.13 Cyclothymic disorder 296.80 Bipolar disorder NOS Bipolar disorders are characterized by recurrent mood swings of varying degree from depression to elation with intervening periods of normalcy. Milder mood swings such as cyclothymia may be manifested or viewed as everyday creativity rather than an illness requiring treatment. Hypomania can actually enhance artistic creativity and creative thinking/ problem-solving. This pl...
DSM-IV 297.1 Delusional disorder Specific type: Erotomanic (delusions that another person of higher status is in love with the individual) Grandiose (delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person) Jealous (delusions that one’s sexual partner is unfaithful) Persecutory (delusions that one, or someone to whom one is close, is being malevolently treated in some way) Somatic (delusions that one has some physical defect or general medical condition) Mixed (delusions characteristic of more than one of the above types, but no one theme predominates) ETIOLOGICAL THEORIES Psychodynamics Emotional development is delayed because of a lack of maternal stimulation/attention. The infant i...
DSM-IV 295.70 Schizoaffective disorder This disorder emphasizes the temporal relationship of schizophrenic and mood symptoms and is used for conditions that meet the criteria for both schizophrenia and a mood disorder with psychotic symptoms lasting a minimum of 1 month. The clinical features must occur within a single uninterrupted period of illness (for some, this may be years or even decades) that is judged to last until the individual is completely recovered for a significant period of time, free of any significant symptoms of the disorder. In comparison with schizophrenia, schizoaffective disorder occurs more commonly in women than in men. ETIOLOGICAL THEORIES Psychodynamics Refer to CPs: Schizophrenia, Major Depression, and Bipolar Disorder. ...
DSM-IV SEDATIVE-, HYPNOTIC-, OR ANXIOLYTIC-INDUCED DISORDERS 292,89 Sedative, hypnotic, or anxiolytic intoxication 292.0 Sedative, hypnotic, or anxiolytic withdrawal 292.81 Intoxication delirium 292. 84 Induced mood disorder OPIOID-RELATED DISORDERS 292.89 Opioid intoxication 292.81 Intoxication delirium 292.0 Opioid withdrawal (For further listings, consult DSM-IV.) CNS depressants are drugs that slow down the central nervous system. They are usually divided into four types: barbiturates, antianxiety agents, sedative-hypnotics, and narcotics (opioids such as morphine, heroin). CNS depressants prescribed for symptoms of anxiety, depression, and sleep disturbances are among the most widely used and abused drugs. These drugs are very likely to be abused when the underlying condit...
DSM-IV DEMENTIAS DUE TO OTHER MEDICAL CONDITIONS 294.1 Dementia due to HIV disease (Code 042 On Axis III) Dementia is impairment of short- and long-term memory, abstract thinking, and judgment with personality changes, severe enough to interfere with work, normal social activities, and relationships. Human immunodeficiency virus (HIV) has been shown to affect the brain directly by crossing the blood-brain barrier on two types of immune cells—monocytes and macrophages. Cells within the central nervous system (CNS) have been found to have express CD4 receptor sites for HIV entry into cells. Although several hypotheses have been proposed, it is not known exactly by what mechanism neurological dysfunction occurs. Neuropsychiatric symptoms may range...
DSM-IV V61.20 Parent-child relational problem Many parents are concerned about how to raise responsible children who have high self-esteem, demonstrate self-control, and display skills of cooperation and consideration of others. Most people believe that we somehow know how to “parent†instinctively. Usually, this attitude results in parenting the same way we were parented. However, it is clear that the traditional authoritarian or permissive methods of parenting create inner conflict for most parents, and praise, punishment, and rewards do not have the desired effects of positive relationships with children. Conflicts in the parent/child relationship can lead to dysfunctional/abusive relationship pat...
DSM-IV 307.6 Enuresis (not due to a general medical condition) 307.7 Encopresis without constipation and overflow incontinence 787.6 Encopresis with constipation and overflow incontinence The DSM-IV defines enuresis/encopresis as repeated involuntary (or, much more rarely, intentional) voiding/passage of feces into places not appropriate for that purpose, after attaining the developmental level at which continence is expected. If continence has not been achieved, the condition can be termed “functional†or “primary.†The period of continence necessary to differentiate between primary and secondary enuresis/encopresis is now considered to be 1 year. There does seem to be a significant relationship between enuresis and encopresis, although neither condition can be...
DSM-IV 313.81 Oppositional defiant disorder 312.9 Disruptive behavior disorder NOS A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, in which the child loses temper, argues with adults, often actively defies or refuses adult requests or rules, blames others, deliberately does annoying things, and swears or uses obscene language. This behavior creates significant impairment in academic/social functioning but does not meet the criteria for conduct disorder. (Disruptive behavior disorder NOS reflects clinical features that constitute the subthreshold for both oppositional defiant and conduct disorders.) ETIOLOGICAL THEORIES Psychodynamics The oppositional youth is fixed in the separation-individuation stage of develo...
DSM-IV 312.XX Conduct disorder 312.81 Childhood-onset type 312.82 Adolescent-onset type Conduct disorder is most distinguishable by the degree of repetitive and persistent violation of the basic rights of others. Common antisocial behaviors acted out in the home and school setting include physical aggression toward people and animals, destruction of property, lying, and theft. There is a total disregard for age-appropriate social norms as the child purposely engages in criminals acts, truancy from school, and breaking curfew. The DSM-IV criteria rates the level of severity as mild, moderate, to severe. The greater the level of delinquency and frequency in early childhood, the greater the risk for chronic offending into adulthood. Other prognostic fac...
DSM-IV 314.00 ADHD predominantly inattentive type 314.01 ADHD predominantly hyperactive-impulsive type 314.01 ADHD combined type 314.9 ADHD NOS This disorder is associated with inattentive, impulsive, and hyperactive behavior that is maladaptive and inconsistent with developmental level. This behavior creates clinically significant impairment in social/academic functioning. Accurate diagnosis is difficult, as symptoms resemble depression, learning disabilities, or emotional problems. The diagnosis is made through extensive observation of the child’s behavior; however, contact with health professionals is limited and the child’s activity may be misleading during short office visits. Reports from parents ...
