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
identiable psychosocial stressor that occurs !ithin 3 months of the onset of the
stressor. "The reaction to the death of a loved one is not included here# as it is
$enerally dia$nosed as bereavement.% The stressor also does not meet the criteria
for any specic &xis ' disorder or represent an exacerbation of a preexistin$ &xis ' or
&xis '' disorder.
The response is considered maladaptive because social or occupational
functionin$ is impaired or because the behaviors are exa$$erated beyond the usual
expected response to such a stressor. (uration of the symptoms for more than )
months indicates a chronic state. *y denition# an adjustment disorder must resolve
!ithin ) months of the termination of the stressor or its conse+uences. 'f the
stressor/conse+uences persist "e.$.# a chronic disablin$ medical condition# emotional
di,culties follo!in$ a divorce# nancial reversals resultin$ from termination of
employment# or a developmental event such as leavin$ one-s parental home#
retirement%# the adjustment disorder may also persist.
ETIOLOGICAL THEORIES
Psychody!"#cs
.actors implicated in the predisposition to this disorder include unmet
dependency needs# xation in an earlier level of development# and underdeveloped
e$o.
The client !ith predisposition to adjustment disorder is seen as havin$ an
inability to complete the $rievin$ process in response to a painful life chan$e. The
presumed cause of this inability to adapt is believed to be psychic overload/a level
of intrapsychic strain exceedin$ the individual-s ability to cope. 0ormal functionin$ is
disrupted# and psycholo$ical or somatic symptoms occur.
$#o%o&#c!%
The presence of chronic disorders is thou$ht to limit an individual-s $eneral
adaptive capacity. The normal process of adaptation to stressful life experiences is
impaired# causin$ increased vulnerability to adjustment disorders. & hi$h family
incidence su$$ests a possible hereditary in1uence.
The autonomic nervous system dischar$e that occurs in response to a fri$htenin$
impulse and/or emotion is mediated by the limbic system# resultin$ in the peripheral
e2ects of the autonomic nervous system seen in the presence of anxiety.
3ome medical conditions have been associated !ith anxiety and panic disorders#
such as abnormalities in the hypothalamic4pituitary4adrenal and hypothalamic4
pituitary4thyroid axes5 acute myocardial infarction5 pheochromocytomas5 substance
intoxication and !ithdra!al5 hypo$lycemia5 ca2eine intoxication5 mitral valve
prolapse5 and complex partial sei6ures.
F!"#%y Dy!"#cs
The individual-s ability to respond to stress is in1uenced by the role of the
primary care$iver "her or his ability to adapt to the infant-s needs% and the child4
rearin$ environment "allo!in$ the child $radually to $ain independence and control
over o!n life%. (i,culty allo!in$ the child to become independent leads to the child
havin$ adjustment problems in later life.
'ndividuals !ith adjustment di,culties have experienced ne$ative learnin$
throu$h
inade+uate role4modelin$ in dysfunctional family systems. These dysfunctional
patterns impede the development of self4esteem and ade+uate copin$ s7ills# !hich
also contribute to maladaptive adjustment responses.
CLIENT ASSESSMENT DATA $ASE
"3ymptoms of a2ective# depressive# and anxiety disorders are manifested
dependent on the individual-s specic response to a stressful situation.%
Ac'#(#'y/R)s'
.ati$ue
'nsomnia
E&o I')&*#'y
8eports occurrence of personal stressor/loss "e.$.# job# nancial# relationship% !ithin
past 3 months
9ay appear depressed and tearful and/or nervous and jittery
.eelin$s of hopelessness
N)+*os)so*y
M)'!% S'!'+s, (epressed mood# tearful# anxious# nervous# jittery
&ttention and memory span may be impaired "depends on presence of
depression# level of anxiety# and/or substance use%
:ommunication and thou$ht patterns may reveal ne$ative ruminations of
depressed mood or 1i$ht of ideas/loose associations of severely anxious condition
P!#/D#sco"-o*'
;arious physical symptoms such as headache# bac7ache# other aches and pains
"maladaptive response to a stressful situation%
S!-)'y
&n$er expressed inappropriately
'nvolvement in hi$h4ris7 behaviors "e.$.# $htin$# rec7less drivin$%
3uicidal ideations may be present
Soc#!% I')*!c'#os
(i,culties !ith performance in !or7/social settin$# !hen no di,culties had been
experienced prior to the occurrence of the stressor
3ocially !ithdra!n/refuses to interact !ith others "e.$.# isolates self in o!n room%
8eports of vandalism# rec7less drivin$# $htin$# defaultin$ on le$al responsibilities#
violation of the ri$hts of others or a$e4appropriate norms and rules
9ay display manipulative behavior "e.$.# testin$ limits# playin$ individuals/family
members a$ainst each other%
T)!ch#&/L)!*#&
&cademic di,culties# failure to attend class/complete course !or7
3ubstance use/abuse possibly present
DIAGNOSTIC STUDIES
(ia$nostic studies and psycholo$ical testin$ as indicated to rule out conditions
that may mimic or coexist "e.$.# endocrine imbalance# cardiac involvement# epilepsy#
or a di2erential dia$nosis !ith a2ective# anxiety# conduct# or antisocial personality
disorders%.
D*+& Sc*)), (etermine substance use.
NURSING PRIORITIES
<. =rovide safe environment/protect client from self4harm.
2. &ssist client to identify precipitatin$ stressor.
3. =romote development of e2ective problem4solvin$ techni+ues.
4. =rovide information and support for necessary lifestyle chan$es.
>. =romote involvement of client/family in therapy process/plannin$ for the future.
DISCHARGE GOALS
<. 8elief from feelin$s of depression and/or anxiety noted# !ith suicidal ideation
reduced.
2. &n$er expressed in an appropriate manner.
3. 9aladaptive behaviors reco$ni6ed and rechanneled into socially accepted
actions.
4. :lient involved in social situations/interactin$ !ith others.
>. &bility and !illin$ness to mana$e life situations displayed.
). =lan in place to meet needs after dischar$e.
NURSING DIAGNOSIS AN.IETY /"od)*!') 'o s)()*)0
M!y $) R)%!')d 'o, 3ituational?maturational crisis
Threat to self4concept5 threat "or perceived
threat% to physical inte$rity
@nmet needs5 fear of failure
(ysfunctional family system5 unsatisfactory
parent?child relationship resultin$ in feelin$s of
insecurity
.ixation in earlier level of development
Poss#1%y E(#d)c)d 1y, Averexcitement?restlessness5 increased tension5
insomnia
.eelin$s of inade+uacy5 fear of unspecied
conse+uences
=oor eye contact# focus on self5 di,culty
concentratin$
:ontinuous attention4see7in$ behaviors5 selective
inattention
3ympathetic stimulation5 numerous physical
complaints
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 ;erbali6e a!areness of feelin$s of?indicators of
C%#)' 3#%%, increasin$ anxiety.
(emonstrate?use appropriate techni+ues to
interrupt escalation of anxiety.
&ppear relaxed and report anxiety is reduced to a
mana$eable level.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
Bstablish a therapeutic nurse/client relationship. *e Conesty# availability# and unconditional
honest# consistent in responses# and available. 3ho! acceptance promote trust# !hich is
necessary for
$enuine positive re$ard. the development of a therapeutic relationship.
=rovide activities $eared to!ard reduction of Tension and anxiety can be released safely# and
tension and decreasin$ anxiety "e.$.# !al7in$ or physical activity may provide emotional benet to
jo$$in$# musical exercises# house7eepin$ chores# the client throu$h release in the brain of
morphine4
$roup $ames/activities%. li7e substances "endorphins% that promote sense
of
!ell4bein$.
Bncoura$e client to identify true feelin$s and to &nxious clients often deny a relationship bet!een
ac7no!led$e o!nership of those feelin$s. emotional problems and their anxiety. @se of the
defense mechanisms of projection and
displacement are exa$$erated.
9aintain a calm atmosphere and approach to client. :an help to limit transmission of anxiety
to/from
client.
&ssist client to reco$ni6e specic events that precede 8eco$nition of precipitatin$ stressors and
a plan of
onset of elevation in anxiety. =rovide information action to follo! should they recur provides client
about si$ns and symptoms of increasin$ anxiety !ith feelin$s of security and control over similar
and !ays to intervene before behaviors become situations in the future. This in itself may help to
disablin$. control anxiety response.
A2er support durin$ times of elevated anxiety. =resence of a trusted individual may provide
=rovide physical and psycholo$ical safety. "8efer to needed security/client safety.
0(D ;iolence# ris7 for# directed at self/others.%
Co%%!1o*!'#()
&dminister medications as necessary# e.$.# ben6o4 &ntianxiety medications induce a calmin$
e2ect
dia6epinesD alpra6olam "Eanax%. and !or7 to maintain anxiety at a mana$eable
level !hile providin$ the opportunity for client to
develop other !ays to mana$e stress.
NURSING DIAGNOSIS VIOLENCE5 *#s6 -o*5 d#*)c')d !' s)%-/o'h)*s
R#s6 F!c'o*s M!y Ic%+d), (epressed mood# hopelessness# po!erlessness5
inability to tolerate frustration5 ra$e reactions
Fo! self4esteem5 unmet needs
0e$ative role modelin$5 lac7 of support systems
3ubstance use?abuse5 history of previous suicide
attempts
/Poss#1%) Id#c!'o*s,0 'ncreased motor activity "pacin$# excitement#
irritability# a$itation%
9uscle tension "e.$.# clenched sts# tense facial
expressions# ri$id posture# tautness%
Costile# threatenin$ verbali6ations5 provocative
behavior "ar$umentative# dissatised#
overreactive# hypersensitive%
3uicide ideation
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 ;erbali6e understandin$ of behavior and
C%#)' 3#%%, precipitatin$ factors.
=articipate in care and meet o!n needs in an
assertive manner.
8echannel an$er?hostile feelin$s into socially
acceptable behaviors.
(emonstrate self4control as evidenced by relaxed
posture# absence of violent behavior# etc.
@se resources?support systems in an e2ective
manner.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
Abserve client-s behavior fre+uently durin$ routine :lose observation is re+uired so that
intervention
activities and interactions5 avoid appearin$ !atchful can occur if re+uired to ensure the safety
of others.
and suspicious. 'nstillin$ suspicion may provo7e a$$ressive
behaviors.
&s7 client direct +uestions re$ardin$ intent# plan# (irect +uestions# if presented in a carin$#
and availability of the means for self4harm. Bvaluate concerned manner# provide the necessary
and prioriti6e on a scale of <G<0 accordin$ to information to assist the nurse in formulatin$ an
severity of threat# availability of means. appropriate plan of care for the suicidal client.
=rovide a safe environmentD reduce stimuli "e.$.# & stimulatin$ environment may increase a$itation
lo! li$htin$# fe! people# simple decor# lo! noise and provo7e a$$ressive behavior.
level%.
8emove potentially dan$erous objects# such as Bxternal control of environment aids in
preventin$
straps# belts# ties# sharp objects# $lass items# and impulsive actions at a time !hen client lac7s o!n
dru$s# as indicated. internal controls.
3ecure contract from client that she or he !ill not & contract encoura$es the client to share in the
harm self and !ill see7 out sta2 member if suicidal responsibility of o!n safety. & de$ree of
control is
ideations emer$e. experienced# and the attitude of acceptance of
the
client as a !orth!hile individual is conveyed.
=romote verbali6ations of honest feelin$s. Throu$h 9ay be di,cult for client to express
ne$ative
exploration and discussion# help client identify feelin$s. ;erbali6ation of these feelin$s in a
symbols of hope in o!n life. nonthreatenin$ environment may help client
come
to terms !ith unresolved issues and identify
reasons for !antin$ to chan$e life/continue
livin$.
Celp client identify true source of an$er/hostility *ecause of !ea7 e$o development# client may be
and underlyin$ feelin$s. usin$ the defense mechanism of displacement.
Celpin$ the client to reco$ni6e this in a
nonthreatenin$ environment may help reveal
unresolved issues so that they may be
confronted# re$ardless of the discomfort
involved.
:onvey an attitude of acceptance to!ard the client. =romotes feelin$s of self4!orth. These
feelin$s are
'mpart a messa$e that it is not the client but the further enhanced as person and behavior are
behavior that is unacceptable. vie!ed separately# communicatin$ unconditional
positive re$ard.
Bxplore !ith client alternative !ays of handlin$ =hysically demandin$ activities help to relieve
frustration/pent4up an$er that channel hostile pent4up tension. No'), Bxercise need not be
ener$y into socially acceptable behavior "e.$.# bris7 aerobic or intensive to achieve therapeutic
e2ect.
!al7s# jo$$in$# physical exercises# volleyball#
punchin$ ba$# exercise bi7e%.
9aintain a calm attitude to!ard the client if &nxiety is conta$ious and can be transferred from
behavior escalates. Cave su,cient sta2 available to person to person. & calm attitude provides
client
convey a sho! of stren$th to the client if it becomes !ith a feelin$ of safety and security. &
display of
necessary. stren$th provides reassurance for the client that
the sta2 is in control of the situation and !ill
provide physical security for the client# sta2#
and others.
*e alert to increased potential for suicidal action as :lient may mobili6e self for suicidal
attempt as
mood elevates. decrease in depression results in increased
ener$y
and motivation.
Co%%!1o*!'#()
&dminister medication as indicated# e.$.D
Tricyclic dru$sD amitriptyline "Blavil%# desipramine &ntidepressant medication may elevate
the mood#
"0orpramin%# doxepin "3ine+uan%# imipramine as it increases level of ener$y and decreases
"Tofranil%5 selective serotonin reupta7e feelin$s of fati$ue.
inhibitors "338's%D 1uoxetine "=ro6ac%# sertraline
"Holoft%# paroxetine "=axil%5 monoamine4oxidase
inhibitorsD isocarboxa6id "9arplan%# phenel6ine
"0ardil%5
*en6odia6epinesD dia6epam ";alium%# &ntianxiety medication may provide needed relief
chlordia6epoxide "Fibrium%# alpra6olam from anxious feelin$s# inducin$ a calmin$ e2ect
"Eanax%. and inhibitin$ a$$ressive behavior.
NURSING DIAGNOSIS COPING5 INDIVIDUAL5 #)7)c'#()
M!y $) R)%!')d 'o, 3ituational?maturational crises
(ysfunctional family system5 ne$ative role
modelin$5 inade+uate support systems
@nmet dependency needs5 lo! self4esteem5
retarded e$o development
Poss#1%y E(#d)c)d 1y, 'nability to cope?problem4solve
:hronic !orry# depressed?anxious mood
&lteration in societal participation5 manipulation
of others
'nability to meet role expectations5 increased
dependency5 refusal to follo! rules of the unit
0umerous physical complaints
(estructive behavior# substance abuse
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 &ssess the current situation accurately.
C%#)' 3#%%, 'dentify ine2ective copin$ behaviors and
conse+uences.
9eet psycholo$ical needs as evidenced by
appropriate expression of feelin$s# identication
of options# and use of resources.
8efrain from manipulatin$ others for o!n
$ratication.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
Bxplain rules of the unit/therapeutic relationship 0e$ative reinforcement may !or7 to decrease
and conse+uences of lac7 of cooperation. 3et limits undesirable behaviors. :onsistency amon$
all sta2
on manipulative behavior. *e consistent in enforcin$ members is vital if intervention is to be
successful.
the conse+uences !hen rules are bro7en and limits
tested.
'$nore ne$ative behaviors !hen possible and 0e$ative behaviors diminish !hen they provide
provide feedbac7 !hen positive behaviors are noted# no re!ard of attention. When client $ives
self
encoura$in$ client to ac7no!led$e o!n success. positive feedbac7# inner re!ards are enhanced.
Bncoura$e client to discuss an$ry feelin$s. Celp ;erbali6ation of feelin$s !ith a trusted individual
client identify the true object of the hostility. =rovide may help client !or7 throu$h unresolved
issues.
physical outlets for healthy release of the hostile =hysical exercise provides a safe and e2ective
feelin$s "e.$.# punchin$ ba$s# poundin$ boards%. means of releasin$ pent4up tension# as !ell as of
'nvolve in outdoor recreation pro$ram# if available. developin$ self4condence and trust in
others.
Ta7e care not to reinforce dependent behaviors. 'ndependent accomplishment and positive
reinforcement enhance self4esteem and
encoura$e
repetition of desirable behaviors.
&llo! client to perform as independently as possible 8eco$nition of personal control# ho!ever#
and provide feedbac7. Celp client reco$ni6e aspects minimal diminishes the feelin$ of
po!erlessness
of life over !hich a measure of control is maintained/ and decreases the need to manipulate
possible. "8efer to 0(D =o!erlessness.% others.
Iive minimal attention to the physical condition if Ar$anic patholo$y must al!ays be considered.
client is copin$ throu$h numerous somatic .ailure to do so may place the client in physical
complaints and or$anic patholo$y has been ruled jeopardy. Fac7 of attention to maladaptive
out. 'ncrease attention !hen client is not focusin$behaviors may decrease their repetition. =ositive
on physical complaints. reinforcement encoura$es desirable behaviors.
(iscuss the ne$ative aspects of substance abuse as (enial of problems related to substance
use is
a response to stress. Celp client reco$ni6e di,cult common. :lient needs to reco$ni6e
relationship
life situations that may be contributin$ to use of bet!een substance use and personal problems
substances. before rehabilitation can be$in.
&ssist !ith problem4solvin$ process. 3u$$est *ecause of level of anxiety and delayed
alternatives# and help client to select more adaptive development# client may re+uire
assistance in
strate$ies for copin$ !ith stress. determinin$ !hich methods of copin$ are most
individually appropriate. 'ncreased anxiety
interferes !ith client-s problem4solvin$ ability.
Bncoura$e client to learn relaxation techni+ues# use These s7ills can be helpful in developin$
ne!
of ima$ery. copin$ methods to deal !ith/reduce stress.
Co%%!1o*!'#()
8efer client to substance rehabilitation pro$ram if & $reater li7elihood of success can be expected if
problem is identied. client see7s professional assistance !ith this
problem.
NURSING DIAGNOSIS ADJUSTMENT5 #"4!#*)d /8h) s'*)sso* #s !
ch!&) # h)!%'h s'!'+s0
M!y $) R)%!')d 'o, :han$e in health status re+uirin$ modication in
lifestyle "e.$.# development of chronic
disease?disability# chan$es associated !ith a$in$
process%
&ssault to self4esteem
'nade+uate support systems
Poss#1%y E(#d)c)d 1y, ;erbali6ation of nonacceptance of health status
chan$e
(i,culty in problem4solvin$# decision4ma7in$# or
$oal4settin$5 lac7 of future4oriented thin7in$
Fac7 of movement to!ard independence
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 8eco$ni6e reality of situation and individual
C%#)' 3#%%, needs?options.
&ssume personal responsibility for care# problem4
solve needs.
'nitiate necessary lifestyle chan$es.
=lan for future needs?chan$es.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
Bncoura$e client to tal7 about lifestyle before the 't is important to identify the client-s stren$ths so
chan$e in health status. that they may be used to facilitate adaptation to
chan$e or loss that has occurred.
(iscuss copin$ mechanisms that !ere used at 3ome individuals may not reali6e that an$er is a
stressful times in the past. Celp client to discuss the normal sta$e in the $rievin$ process. 'f it
is not
chan$e/loss and particularly to express an$er released appropriately# it may be turned in!ard
associated !ith it. on the self# leadin$ to patholo$ical depression.
Cave client express fears associated !ith the :han$e often creates a feelin$ of dise+uilibrium#
chan$e/loss or the resultin$ alteration in lifestyle and the individual may respond !ith fears that
are
that has occurred. irrational or unfounded. :lient may benet from
feedbac7 that corrects misperceptions about ho!
life !ill be !ith the chan$e in health status.
&ssist !ith activities of daily livin$ as re+uired# but 'ndependent accomplishments and
positive feed4
encoura$e independence to the limit that client-s bac7 enhance self4esteem and encoura$e
repetition
ability !ill allo!. Iive positive feedbac7 for of desired behaviors. 3uccesses also provide
hope
activities accomplished independently. that adaptive functionin$ is possible and
decrease
feelin$s of po!erlessness.
Celp client !ith decision4ma7in$ re$ardin$ The hi$h de$ree of anxiety that usually
incorporation of chan$e or loss into lifestyle. 'dentify accompanies a major lifestyle chan$e
often
an individual-s ability to solve problems and ma7einterferes !ith problems created by the chan$e
or
appropriate decisions. loss.
(iscuss alternative solutions# !ei$hin$ potential :lient may need help !ith this process to
pro$ress
benets and conse+uences of each alternative. to!ard successful adaptation.
3upport client-s decisions.
8ole4play stressful situations that mi$ht occur (ecreases anxiety and provides a feelin$ of
in relation to the health status chan$e. security for the client by preparin$ a plan of
action
!ith !hich to respond appropriately !hen a
stressful situation occurs.
=rovide information re$ardin$ the physiolo$y of Celps client and family understand !hat has
the chan$e in health status and necessity for happened# claries information# and provides
optimal !ellness. Bncoura$e client and family to opportunity to revie! information at individual-s
as7 +uestions. =rovide printed material explainin$leisure.
the chan$e.
Co%%!1o*!'#()
8efer to resources !ithin the community "e.$.# =rovides assistance in adaptin$ to the chan$e in
self4help/support $roups# public health nurse# health status.
counselor# or social !or7er%.
NURSING DIAGNOSIS GRIEVING5 dys-+c'#o!%
M!y $) R)%!')d 'o, 8eal or perceived loss of any concept of value to
the individual5 bereavement overload "cumulative
$rief from multiple unresolved losses# excludin$
the death of a loved one%
&bsence of anticipatory $rievin$5 th!arted
$rievin$ response to loss
.eelin$s of $uilt $enerated by ambivalent
relationship !ith the lost concept?person
Poss#1%y E(#d)c)d 1y, 'deali6ation of the lost concept5 di,culty in
expressin$ loss5 denial of loss
Bxcessive an$er# expressed inappropriately5 labile
a2ect
(evelopmental re$ression
&lterations in concentration and?or pursuit of
tas7s
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 Bxpress emotions appropriately.
C%#)' 3#%%, (emonstrate pro$ress in dealin$ !ith sta$es of
$rief at o!n pace.
:arry out activities of daily livin$ independently.
Bxpress feelin$ of hope for the future.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
(etermine sta$e of $rief in !hich client is xed. &ccurate baseline assessment data are necessary
to
'dentify behaviors associated !ith this sta$e. choose appropriate interventions/provide
e2ective care and evaluate pro$ress. "9ost
depressed people are xed in the an$er sta$e#
!ith
the an$er directed in!ard on the self.%
:onvey an acceptin$ attitude5 encoura$e client to&n acceptin$ attitude enhances trust and
express self openly. communicates to the client that you believe the
client is a !orth!hile person# re$ardless of !hat
may be expressed.
Bncoura$e client to express an$er. &void defensive ;erbali6ation of feelin$s in a
nonthreatenin$
response if initial expression of an$er is displaced environment may help client come to terms !ith
on nurse/therapist. &ssist client to explore an$ry unresolved issues related to the loss.
feelin$s and direct them to!ard the intended object/
person or other loss.
Bncoura$e participation in lar$e motor activities. =hysical activity provides a safe and e2ective
method for dischar$in$ pent4up tension/an$er.
=rovide information about the sta$es of $rief and the Jno!led$e of the acceptability of the
feelin$s
behaviors associated !ith each sta$e. Celp client associated !ith normal $rievin$ may help relieve
understand that feelin$s# such as an$er directed some of the $uilt that these responses $enerate.
to!ard the loss# are appropriate durin$ the $rief
process.
Bncoura$e client to revie! relationship !ith loss. :lient needs to $ive up ideali6ed perception and
With support and sensitivity# point out reality of accept both positive and ne$ative aspects about
the situation in areas !here misrepresentations are the loss before resolution of $rief can
occur.
expressed.
Celp client determine methods for more adaptive .eelin$s of depression may interfere !ith client-s
copin$ !ith the experienced loss. =rovide positiveproblem4solvin$ ability# resultin$ in need for
feedbac7 for strate$ies identied and decisions made. assistance. =ositive feedbac7 enhances
self4esteem
and encoura$es repetition of desirable behaviors.
Co%%!1o*!'#()
(etermine client-s perception of spiritual needs as 3ome individuals derive $reat stren$th
from
support in the $rievin$ process. 'nvolve chaplain or spiritual support. This stren$th may be
used by
appropriate spiritual leader as indicated. the client in the tas7 of $rief resolution.
NURSING DIAGNOSIS HOPELESSNESS
M!y $) R)%!')d 'o, Fifestyle of helplessness "repeated failures#
dependency%
'ncomplete $rief !or7 of losses in life
Fost belief in transcendent values?Iod
Poss#1%y E(#d)c)d 1y, ;erbal cues?despondent content "e.$.# K' can-t#L
si$hin$%
&pathy?passivity# decreased response to stimuli
Fac7 of initiative# nonparticipation in care or
decision4ma7in$ !hen opportunities are provided
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 8eco$ni6e and verbali6e feelin$s.
C%#)' 3#%%, (emonstrate independent problem4solvin$
techni+ues to ta7e control over life.
;erbali6e acceptance of life situations over !hich
one does not have control.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
'dentify use of maladaptive behaviors/defense =ersonal attempts to overcome feelin$s of
mechanisms "e.$.# !ithdra!al# substance use# hopelessness may have resulted in ine2ective/
re$ression%. harmful behaviors. 8eco$ni6in$ the behaviors
provides opportunity for chan$e.
Bncoura$e client to explore and verbali6e feelin$s'dentication of feelin$s underlyin$ behaviors
and perceptions. helps client to be$in process of ta7in$ control of
o!n life.
'dentify individual si$ns of hopelessness# "e.$.# Celps to individuali6e interventions# focus
decreased physical activity# social !ithdra!al%. attention on areas of need.
Bxpress hope to client in positive# lo!47ey manner. Bven thou$h client feels hopeless# it can
be helpful
to hear positive expressions from others.
Celp client identify areas of life situation that are :lient-s emotional condition may interfere !ith
under o!n control. ability to problem4solve. &ssistance may be
re+uired to perceive the benets and
conse+uences of available alternatives accurately.
Bncoura$e client to assume responsibility for o!n =rovidin$ the client !ith choices increases
feelin$s
self4care "e.$.# settin$ realistic $oals# schedulin$ of control. No'), @nrealistic $oals set the client
up
activities# ma7in$ independent decisions%. for failure and reinforce feelin$s of hopelessness.
Celp client identify areas of life situation that are :lient needs to identify and resolve feelin$s
not !ithin ability to control. (iscuss feelin$s associated !ith inability to control certain life
associated !ith this lac7 of control. situations before level of acceptance can be
achieved.
NURSING DIAGNOSIS SELF ESTEEM d#s'+*1!c) /s4)c#-y0
M!y $) R)%!')d 'o, 9aturational transitions
@nmet dependency needs5 retarded e$o
development
8epeated ne$ative feedbac7# diminished self4
!orth
(ysfunctional family system
Poss#1%y E(#d)c)d 1y, 3elf4ne$atin$ verbali6ation# inability to deal !ith
events5 di,culty acceptin$ positive feedbac7
Fac7 of eye contact5 nonassertive?passive
behaviors5 indecision# di,culty ma7in$ decisions
Cesitancy to underta7e ne! tas7s5 fear of failure
3ocial isolation5 nonparticipation in therapy
9anipulation of one sta2 member a$ainst
another
3elf4destructive ideas?behavior
D)s#*)d O+'co")s/E(!%+'#o C*#')*#!2 'dentify feelin$s and underlyin$ dynamics for
C%#)' 3#%%, ne$ative perception of self.
(emonstrate behaviors?lifestyle chan$es to
promote positive self4esteem.
&ccept reco$nition for personal
accomplishments?abilities.
;erbali6e increased sense of self4!orth.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
(iscuss $oals# ma7in$ sure they are realistic. =lan&chievement/success enhance self4concept.
activities in !hich success is li7ely.
:onvey unconditional positive re$ard for the client. @nconditional acceptance of an individual
serves
=romote understandin$ of acceptance for client as a to counteract feelin$s of !orthlessness by
!orth!hile human bein$. reinforcin$ that individual is !orthy of another
person-s respect.
3pend time !ith client both on a <D< basis and in :onveys that the nurse sees the client as
someone
$roup activities. !orth spendin$ time !ith.
&ssist client to identify positive aspects of self and 'ndividuals !ith lo! self4esteem often
have
develop plans for chan$in$ the characteristics di,culty reco$ni6in$ positive attributes. They
vie!ed as ne$ative. may also lac7 problem4solvin$ s7ills and re+uire
assistance to formulate a plan for implementin$
the desired chan$es.
Bncoura$e and support client in confrontin$ the 8eco$nition and positive reinforcement enhance
fear of failure by attendin$ therapy activities and self4esteem and encoura$e repetition of desirable
underta7in$ ne! tas7s. A2er reco$nition of behaviors.
successful endeavors and positive reinforcement
for attempts made.
Celp client avoid ruminatin$ about past failures. Fac7 of attention to these undesirable behaviors
Withdra! attention if client persists. may discoura$e their repetition. :lient needs to
focus on positive attributes if self4esteem is to be
enhanced.
9inimi6e ne$ative feedbac7 to client. Bnforce limit 0e$ative feedbac7 can be extremely
threatenin$ to
settin$ in matter4of4fact manner# imposin$ a person !ith lo! self4esteem# possibly
previously established conse+uences for a$$ravatin$ the problem. :onse+uences need to
unacceptable behavior. convey unacceptability of the behavior but not
the
person.
Bncoura$e independence in the performance of The ability to perform self4care activities
personal responsibilities# as !ell as in decision4 independently enhances self4concept. =ositive
ma7in$ related to o!n self4care. A2er reco$nition reinforcement encoura$es repetition of desirable
and praise for accomplishments. behaviors.
3upport client in critical examination of feelin$s# The need for jud$in$ the behavior of others
attitudes# and behaviors. Celp client understand diminishes as client increases self4esteem
throu$h
that it is acceptable for attitudes and behaviors to$reater self4a!areness and the achievement of
di2er from those of others# as lon$ as they do not self4acceptance.
become intrusive.
NURSING DIAGNOSIS SOCIAL INTERACTION5 #"4!#*)d
M!y $) R)%!')d 'o, @nmet dependency needs5 retarded e$o
development
0e$ative role4modelin$
Fo! self4concept
Poss#1%y E(#d)c)d 1y, ;erbali6ed?observed discomfort in social
situations5 use of unsuccessful?dysfunctional
social interaction behaviors
;erbali6ed or observed inability to receive or
communicate a satisfyin$ sense of belon$in$#
carin$# interest
Bxhibits behaviors unacceptable for a$e# as
dened by dominant cultural $roup
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 ;erbali6e a!areness of factors resultin$ in
C%#)' 3#%%, di,culty in formin$ satisfactory relationships !ith
others.
'dentify feelin$s that lead to poor social
interactions.
'nteract !ith sta2 and peers !ith little?no
indication of discomfort.
=articipate in $roup activities appropriately and
!illin$ly.
'dentify?develop e2ective social support system.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
Bstablish <D< relationship !ith client# !hich serves :lient needs to learn to interact
appropriately !ith
as role model for testin$ ne! behaviors. nurse# so that behaviors may then be $enerali6ed
to others.
Bncoura$e client to en$a$e in activities out of (ecreases opportunity for client to isolate self.
room/home.
A2er to attend initial $roup interactions !ith client. =resence of a trusted individual may
provide a
=rovide feedbac7 for appropriate interactions. feelin$ of security and decrease the anxiety
$enerated by di,cult social situation. =ositive
reinforcement enhances self esteem and
encoura$es repetition of desirable behaviors.
&ct as role model for client throu$h appropriate *ecause of !ea7 e$o development# client is
interactions !ith client and others. inclined to imitate the actions of those individuals
admired or trusted.
Bstablish schedule of $roup activities for client. 't is throu$h these $roup interactions# !ith
positive and ne$ative feedbac7 from peers# that
client learns socially acceptable behavior.
NURSING DIAGNOSIS FAMILY PROCESSES5 !%')*)d
M!y $) R)%!')d 'o, 3ituational?maturational crisis
Poss#1%y E(#d)c)d 1y, 0eeds of family members not bein$ met5
confusion !ithin family system re$ardin$ ho!
needs should be met
'mpaired family communication5 dissonance
amon$ family members
'mpairment of family decision4ma7in$ process5
family developmental tas7s not bein$ fullled
8educed?restricted social involvement
D)s#*)d O+'co")s/E(!%+!'#o C*#')*#!2 Bxpress feelin$s freely and appropriately.
F!"#%y 3#%%, (evelop e2ective patterns of communication#
encoura$in$ honest input from all members.
'dentify source"s% of dysfunction and e2ectively
problem4solve to achieve desired resolution.
(emonstrate pattern of functionin$ improved
from premorbid state# havin$ $ained 7no!led$e
and achieved $ro!th from crisis situation.
ACTIONS/INTERVENTIONS RATIONALE
Id)4)d)'
&ssess family developmental sta$e# communication 'denties specic needs and provides
direction for
patterns# and extent of dysfunction. care.
9eet !ith the total family $roup as often as possible. The family as a system operates as a
sin$le unit.
Bach member a2ects# and is a2ected by# all other
members. Therapy is most e2ective !hen
directed
to!ard the functionin$ of the family system.
:onstruct a client/family $eno$ram. Ieno$rams help identify emotional closeness
amon$ family members over several $enerations.
.amily process is claried# and con$uration and
dynamics are clearly illustrated.
&ssist family to identify true source of con1ict. Celp :on1ict creates hi$h levels of anxiety
!ithin the
them reco$ni6e that Kidentied patient-sL family system. :ommon defense mechanisms
such
adjustment disorder may be a !ay to avoid as denial# displacement# projection# and
confrontin$ the real problem. rationali6ation are used by the family to decrease
anxiety and avoid con1ict.
Bncoura$e family members to set $oals and identify Fife crises interfere !ith family decision4
ma7in$
alternatives. 3upport e2orts directed to!ard and problem4solvin$ abilities. &ssistance !ith this
positive chan$e. &ssist !ith necessary modications process may be re+uired to promote
adaptation
of ori$inal plan. and $ro!th.
=romote separation and individuation and clear# Bmotional connectedness amon$ family members
functional boundaries bet!een/amon$ members. "enmeshment% discoura$es individual $ro!th and
ability to function autonomously.
Celp client4family identify actions/problem4solve &nticipatory $uidance/7no!in$ !hat to expect
for potential life crises. and havin$ a plan of action for mana$ement of
situations may help to avert a crisis in the future.
Co%%!1o*!'#()
'nvolve family in $roup therapy. 'nteractin$ !ith others in family/multifamily
$roups can help identify dysfunctional patterns
and assist in learnin$ ne! s7ills and solutions for
family problems.
8efer family to other resources# such as support 3harin$ !ith others !ho have had similar
$roups# classes "e.$.# parentin$/assertiveness experiences can provide support and assist family
trainin$%. members to learn ne! !ays to deal !ith
situation.