CONDUCT DISORDER

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. !here is a total disregard for age-
appropriate social norms as the child purposely engages in criminals acts truancy
from school and brea"ing curfew. !he DSM-IV criteria rates the level of severity as
mild, moderate, to severe. !he greater the level of delin#uency and fre#uency in
early childhood the greater the ris" for chronic o$ending into adulthood. %ther
prognostic factors leading to the continuation of the disorder include age of onset
and the variation in problem behaviors displayed in multiple settings. Co-morbid
diagnoses often associated with this condition are hyperactivity depression and
chemical abuse and dependence.
ETIOLOGICAL THEORIES
Psychodynamics
According to psychoanalytical theory these children are &'ated in the
separation-individuation phase of development. !he mother &gure pro(ects her view
of the child)s needs as an unrealistic demand on her. !he child cannot solidify
attachment with the maternal ob(ect and compensates for the mother)s narcissistic
need for grati&cation by overidealizing the image of the mother. !he child fails to
build up identi&cation and di$erentiation between self and others to support
su*cient superego development. !he id behavior is prominent.
Bioloical
!emperamental abnormalities have been observed in infants at birth in terms of
e'citability attention span and adaptability. +eredity in,uences such traits as the
tendency to see" ris"s and obey authority. %ne possibility is the biological in,uence
of heightened arousal in the C-. and abnormally high levels of testosterone leading
to aggression. /i$erences in the lac" of su*cient serotonin transmission is
evidenced.
Current research suggests that negative e'periences in infancy cause biological and
neurological damage to the brain tissue. 0hen persistent stress results in an internal
perception of a constant state of danger the 1fght-or-fight2 hormones 3adrenaline and
cortisol4 are released reaching dangerously high levels that can cause neurological
impairment. !hese damaged brain cells react in unusual ways to the stimuli possibly
resulting in epileptic sei5ures or depression.
!amily Dynamics
Certain family patterns contribute to the disruptive behavior. A high correlation
e'ists between chronic con,ict and neglect in the parent6child relationship. 7oor
parental management s"ills inconsistent or rigid and harsh discipline practices
increase the ris" for acting out by the child. Changes in careta"ers unstable spousal
relationships and parental re(ection are all contributing8causal factors. !hese children
lac" strong emotional bonds or reliable role models to promote prosocial behavior.
.ocioeconomic conditions may also play a part with poverty being a ris" factor.
CLIENT ASSESSMENT DATA BASE
Eo In"#$i"y
9eelings of re(ection powerlessness
:lames others for what happens to self
/isplays maladaptive coping behaviors; uses manipulation to get needs met
<ngages in unacceptable behaviors in response to stressors 3e.g. staying out at
night running away4
=ay have had fre#uent8recurrent life changes 3e.g. multiple moves change of
schools lifestyle changes placement in foster homes4
!ood%!l&id
."ips meals eats e'cessive amounts of (un" foods
<ats in response to e'ternal cues8stressors
>eports of nausea
=ay have e'cessive weight for height; recent weight gain may be noted
Hyi#n#
7oor hygiene8personal habits
.tyle of dress may re,ect fashion trends or be atypical 3antisocial8gang attire4
N#&$os#nso$y
-ervousness worry and (itteriness8e'cessive psychomotor activity
=ay be depressed angry or react with ambivalence or hostility; poor impulse control
A$ect may be labile
7hysical characteristics8development may not be normal for age range
Sa'#"y
<ngages in ris"-ta"ing behavior 3e.g. gang involvement e'posure to .!/s drug use4
%vert aggressive acts
.uicidal ideation; may have plan8means previous suicide attempts
S#(&ali"y
<arly onset of se'ual behavior may have forced others into se'ual activity
Social In"#$ac"ions
.ymptoms most often appear during prepubertal to pubertal period and may
predispose the child to conduct or ad(ustment disorders in adolescence
9amily disharmony8disruption little contact with absent parent8separation from
e'tended family may be reported
?ndividual may have history of poor school8wor" performance
7arents may report client isolates self plays stereo loudly does not participate in
family activities; shows little empathy or concern for others
/isplays hostility toward authority &gures; intimidates others
7articipation in social activities may be none'istent or sporadic or gang-related
Client may be involved with legal system8(uvenile court have record of antisocial
behavior 3e.g. &re-setting cruelty to people8animals stealing use of a weapon4
T#achin%L#a$nin
%nset usually between age @ to early adolescence; rare after age 1A
=ay be involved in drug use8abuse 3e.g. alcohol inhalants cigarettes8chewing
tobacco4
=ay have had previous psychiatric hospitali5ation for same or other problems
DIAGNOSTIC STUDIES
D$& Sc$##n) !o identify substance use8abuse.
NURSING PRIORITIES
1. 7rovide a safe environment and protect client from self-harm.
2. 7romote development of strategies that regulate impulse control regain sense of
self-worth and security.
3. 9acilitate learning of appropriate and satisfying methods of dealing with
stressors8feelings.
B. 7romote client)s ability to engage in satisfying relationships with family members
and peer group.
@. ?ncrease the client)s behavioral response repertoire.
DISCHARGE GOALS
1. <'hibits e$ective coping s"ills in dealing with problems.
2. Cnderstands need and strategies for controlling negative impulses8acting-out
behaviors.
3. <'presses anger in appropriate8nonviolent ways.
B. 9amily involved in group therapy; participating in treatment program.
@. 7lan in place to meet needs after discharge.
NURSING DI*AGNOSIS VIOLENCE+ $is, 'o$+ di$#c"#d a" s#l'%o"h#$s
Ris, !ac"o$s May Incl&d#) >etarded ego development; loss of self-esteem;
antisocial character
/ysfunctional family system and loss of
signi&cant relationships; feelings of re(ection
sense of powerlessness
7oor impulse control
+istory of suicidal8acting-out behavior
-Possi.l# Indica"o$s)/ :ehavior changes 3e.g. absenteeism poor
grades hostility toward authority &gures
stealing4
?ncreased motor activity increasing an'iety level
anger
%vert aggressive acts directed at the
environment
.elf-destructive behavior active suicidal
threat8gestures
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 Derbali5e understanding of behavior and factors
Cli#n" 2ill) that precipitate violent actions.
<'press anger in appropriate ways avoiding
hostile or suicidal gestures8statements or harm to
self or others.
/emonstrate self-initiated intervention strategies
that facilitate more e$ective coping s"ills.
?dentify and use resources and support systems
in an e$ective manner.
ACTIONS%INTERVENTIONS RATIONALE
Ind#3#nd#n"
<stablish trusting relationship with client. <ncourage Client)s e'pression of internal con,icts in
words
e'ploration and verbali5ation of feelings. rather than action will more li"ely be made to
"nowledgeable and accepting sta$.
.tri"e a balance in the intimacy of the therapeutic Children who are more disturbed respond
best to
relationship. a less-intrusive relationship in the beginning.
=onitor stressors and warning signals such as ?mpulsive reactions to stressful situations
directed
behavior changes anger an'iety and recently toward harm to self or others may be a cry for
disrupted family. help.
%bserve8assist client to recogni5e mood 3e.g. anger ?dentifying own feelings is the &rst step in
the
sadness an'iety4. change process. .igns and symptoms of an'iety
need to be identi&ed before client can begin to
ma"e constructive changes.
?dentify antecedents to violent behavior. Correct assessment and interpretation of
premonitory conditions provide for timely
intervention to reduce ris" of violent8acting-out
behavior.
.upport client)s e'ploration to identify behaviors or Connecting feelings with behaviors that
a$ord
interventions that o$er relief. relief will encourage the development of more
productive behaviors.
/etermine seriousness of suicidal tendency gestures Enowledge of past and present behavior in
threats or previous attempts. 3Cse scale of 161F and reference to suicidal ideation will assist in
prioriti5e according to severity of threat availability assessing client)s tolerance for stress
degree of
of means.4 concern. No"#) !his may be &rst-priority nursing
diagnosis if suicide ris" is rated in the 861F range.
7rovide information regarding suicidal ideation8 Client may be unaware or8ignorant of meaning of
warnings. ?nclude signi&cant other3s4 in discussions. warning signals when suicidal ideation
e'ists.
=aintain a therapeutic milieu that includes a safe ?nternal controls may be inade#uate re#uiring
environment 3e.g. suicide precautions behavioral some e'ternal controls and interventions
until
contract4. internal control is learned.
%bserve client unobtrusively for signs of potential ?ntervention before the onset of violence can
violence toward others. prevent in(ury to the client and others. %vert
monitoring may be interpreted negatively and
potentiate acting-out behavior.
<'plore and o$er more satisfying alternatives to ?ncreased ability to discover satisfying
alternatives
aggressive behavior 3e.g. physical outlets for in coping with stressors will decrease need for
redirection of angry feelings; use of #uiet room or aggressive behavior. 7hysical outlets help
relieve
1.oft .pot2 with soft balls8pillows to pound4. pent-up tension and an'iety.
<ngage in action-oriented recreational therapy >ecreational therapy helps discharge nervous
3e.g. e'ercise activities G(ogging in the gym etc.H pent-up energy releasing tension and
reducing
outdoor program wall climbing noncompetitive an'iety. .ustained activity stimulates release of
games8supervised sports4. endorphins enhancing sense of well-being.
9ormal
e'ercise therapy programs are an ad(unct to
psychotherapy decreasing symptoms related to
an'iety depression and thought disturbances.
<'ercise does not need to be aerobic or intensive
to
achieve desired e$ect. No"#) Competitive games
may increase an'iety.
<stablish hierarchy of responses to aggressive !his conveys to client evidence of control over
the
behaviors 3e.g. !ime out4. +ave su*cient sta$ situation and provides some sense of security for
available to indicate a show of strength to the client and sta$.
client if it becomes necessary.
<ncourage client to as" for time with sta$ give <arly interventions can interrupt the pattern prior
permission to e'press angry feelings. :e alert to to seriously escalating behavior. >ecogni5ing
1acting out2 to please peers or nursing sta$. feelings and ta"ing responsibility by as"ing for
time to discuss them helps the adolescent learn
more e$ective ways of dealing with problems that
can lead to anger and acting-out behaviors.
Assess how unit functioning a$ects adolescent =ilieu stressors li"e vacations personnel
changes
behaviors. and sta$ con,ict can a$ect client)s own issues
3e.g. abandonment4. ?t is important to loo" at the
psychodynamics as well as the uni#ue meaning
of
individual behavior.
+ave sta$ member stay with client when necessary. .ta$ member can help client to e'press
feelings
<ncourage client to choose own 1!ime out2 going to and begin to recogni5e value of
appropriate
room for alone time ta"ing medications; or choosing handling of anger. Adolescent may see
1!ime out2
room schedules use of seclusion and8or restraints. as punishment if sta$ imposes but begins
to ta"e
responsibility for self by recogni5ing and choosing
own #uiet8alone time.
?nclude whole community8classroom in reinforcing 7eer interaction is e$ective in this age
group to
positive behaviors. Cse daily goal-setting group or help client control own behavior.
problem-solving group.
Colla.o$a"i0#
7lace in seclusion or apply restraints as necessary. <'ternal restraints may be needed until
client
regains control of own behavior.
Administer8supervise medications and monitor +elps client to maintain impulse control.
e$ects of therapy. -euroleptic medications decrease aggressive
outbursts and improve impulse control.
NURSING DIAGNOSIS THOUGHT PROCESSES+ al"#$#d
May B# R#la"#d "o) 7hysiological changesIdamage to brain tissues
Jac" of psychological con,icts
:iochemical changesIsubstance use8abuse
Possi.ly E0id#nc#d .y) Inacc&$a"# in"#$3$#"a"ion o' s"im&li4
"#nd#ncy "o in"#$3$#" the intentions and
actions of others as blaming and hostile
/e&cits in problem-solving s"ills perceptions and
self-statements; demonstrating fewer solutions to
interpersonal problemsIphysical aggression is
the solution most often chosen
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 /escribe how thoughts and emotions relate to
Cli#n" 2ill) own behavior.
Jist characteristics of the antisocial personality
that client sees in self.
<'plain the concept of thin"ing error how it leads
to antisocial behavior and name those that
personally apply.
7ractice new cognitive problem-solving s"ills that
will lead to social competence and ad(ustment.
ACTIONS%INTERVENTIONS RATIONALE
Ind#3#nd#n"
Assign primary nurse to develop a therapeutic Continuity of care for client builds trust and
relationship. clari&es e'pectation.
/iscuss characteristics of the antisocial personality .ome common beliefs of the person with
an
with the client. antisocial personality are as followsK does not
have
to conform to society)s rules or norms believes
the
world revolves around self and believes that
others should meet client)s needs rather than
client
meeting society)s e'pectations.
7rovide written handout and allow time for client to Allows client to internali5e information and
review information as" #uestions and clarify prepares for restructuring activities to change
understanding behavior.
/iscuss the concept of thin"ing errors. A thin"ing error occurs when a person has a
thought that is e'tremely di$erent from the way
most people under the same circumstances
would
thin". ?f the person acts on the thought the
behavior will be outside of societal norms.
>elate concept to client)s own thin"ing errors and Common thin"ing errors are as followsK
victim
behavior. stance 31+e started it8? couldn)t help it24; doesn)t
stop to thin" how actions will hurt others; lac" of
e$ort; unwillingness to do anything perceived as
boring or disagreeable; refusal to accept
obligation
31? forgot8? don)t have to24; gaining power
through anger; refusal to ac"nowledge fear;
blaming others when critici5ed; 1? can)t2
attitudeIstatement of refusal not inability.
+ave client "eep a 1thin"ing log2 emphasi5ing the 7rovides opportunity for client to 1see2
thoughts
importance of writing actual thoughts and not trying and compare with reality connect
outcomes8
to 1con2 the sta$ with what the client thin"s they conse#uences with speci&c behaviors and begin
to
want to hear. <'plain responsibility for daily entry ta"e responsibility for change process.
and attendant conse#uence.
7romote client responsibility for the review process. +elps client begin to assume inner-
directed self-
+elp client identify the thin"ing errors and relate control. 7romotes attention to content and
them to the client)s pattern of thin"ing in everyday conformity to process allowing client to
begin to
life. >einforce that the thin"ing errors are only the identify ine$ective methods of getting
needs met.
1tip of the iceberg.2
%bserve for shame reactions. <'plain that the process !hin"ing log is a tool for client to identify
thin"ing
is not (udgmental and discuss behavioral responses. errors and choose not to act on them.
>e#uire attendance at !hin"ing <rror Lroup. .haring information from the log promotes
9acilitate honest noncritical feedbac" from group awareness and opportunities to change behavior
members. Continuously evaluate the group process in safe environment of the group.
and identify thin"ing errors as they occur in the
group.
>eview entire log with client before discharge. !his provides opportunity for client to identify
7rovide feedbac" regarding improved behavioral predominant pattern of thin"ing errors and
responses and areas in which continued wor" is recogni5e new ways to respond that have been
needed. <ncourage client to continue thin"ing log learned in treatment.
after discharge.
NURSING DIAGNOSIS SOCIAL INTERACTION+ im3ai$#d
May B# R#la"#d "o) Jac" of social s"ills
/evelopmental state 3adolescence4
Possi.ly E0id#nc#d .y) Derbali5ed or observed discomfort in social
situations and use of unsuccessful social
interaction behaviors
/ysfunctional interactions with peers family
and8or others
9amily report of change of style or pattern of
interaction
.elf-concept disturbance
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 Derbali5e awareness of factors and identify
Cli#n" 2ill) feelings related to impaired social interactions.
:e involved in achieving positive changes in
social behaviors and interpersonal relationships.
/evelop e$ective social support systems.
ACTIONS%INTERVENTIONS RATIONALE
Ind#3#nd#n"
Assess individual causes and contributing factors Although learning social s"ills is one of the
3e.g. disruption of the family fre#uent moves during maturational tas"s many factors can
interfere with
child)s8adolescent)s life individual)s poor coping and the client)s ability to interact satisfactorily
with
ad(ustment to developmental stage4. others in social situations.
>eview medical history. Jong-term illness8accident may have interfered
with development of social s"ills at earlier stages.
%bserve family patterns of relating and social 9amily may not have e$ective patterns of relating
behaviors. <'plore possible family scripting of to others and the child learns these s"ills in this
e'pectations of the child8adolescent. -ote setting. %ften child re,ects family e'pectations
prevalent patterns. rather than own desires. ?denti&cation of patterns
will help with plan for change.
<ncourage client to verbali5e feelings about Client identi&es areas of concern and suggests
discomfort in social settings noting recurring ways to learn new s"ills.
factors or precipitating patterns.
Active-listen verbali5ations indicating hopelessness Client may believe that nothing can be
done to
powerlessness fear an'iety grief anger feeling change the way things are and that own actions
do
unloved or unlovable problems with se'ual identity not ma"e a di$erence. Active-listening
client)s
and8or hate 3directed or not4. words and feelings conveys a message of
con&dence in the individual)s own abilities.
Assess client)s coping s"ills and defense mechanisms. Although s"ills may have helped client to
1survive2 in the past their use was often based
on
thin"ing errors8misinterpretation of the situation.
!hese s"ills may be e$ective for dealing with
restructured reality and8or provide a base for
learning new s"ills.
+ave client identify behaviors that cause discomfort Jisting speci&c behaviors will help the
client "now
and review negative behaviors others have identi&ed. where change is possible. Enowing what
others
see can help the client accept and e$ect change.
<'plore with client and role-play new ways of Active involvement is the most e$ective way to
handling identi&ed behaviors8situations. create change.
7rovide reinforcement for positive social behaviors 7romotes feelings of self-worth and helps
reinforce
and interactions. desired behaviors.
0or" with client to correct basic negative -egative self-concepts may be a ma(or factor
self-concept 3>efer to -/K .elf <steem chronic low4. impeding positive social interactions.
+elp client identify responsibility for own behavior. <nhances self-esteem and provides
feedbac" to
<ncourage "eeping a daily (ournal of social interactions improve s"ills. Mournaling can provide an
ongoing
and feelings. record to note improvement and8or areas of need
for change.
Colla.o$a"i0#
?nvolve in group therapy as indicated. +elpful arena to practice new social s"ills and to
receive feedbac" with support for e$orts to
improve.
<ncourage reading attendance at classes 3e.g. Assists in alleviating negative self-concepts
positive image self-help assertiveness4 and that lead to impaired social interactions.
community support groups.
NURSING DIAGNOSIS COPING+ d#'#nsi0#
May B# R#la"#d "o) ?nade#uate coping strategies; maturational crisis;
multiple life changes8losses
Jac" of control of impulsive actions; personal
vulnerability
Possi.ly E0id#nc#d .y) /enial of obvious problems8wea"nesses;
pro(ection of blame8responsibility; rationali5ing
failures
/i*culty in reality-testing perceptions;
grandiosity
?nappropriate use of defense mechanisms 3e.g.
stealing and other acting-out behaviors
e'cessive smo"ing8drin"ing4
?nability to meet role e'pectations
/i*culty establishing8maintaining relationships;
hostile laughter at or ridicule of others; superior
attitude toward others; hypersensitivity to slight
or criticism
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 Derbali5e and recogni5e signi&cance of losses in
Cli#n" 2ill) life.
Derbali5e understanding of the relationship
between emotional needs and acting-out
impulsive behaviors and the conse#uences
thereof.
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 /evelop ego strength su*cient to cope with inner
Cli#n" 2ill 5con"*6) impulses.
?dentify and demonstrate ways to meet own
needs.
7articipate in treatment program8therapy.
ACTIONS%INTERVENTIONS RATIONALE
Ind#3#nd#n"
<stablish level of authority of primary nurse; Consistent 1parent &gure2 can uniformly reinforce
monitor the need for nurturance and limit-setting. conse#uences of behaviors of the client.
7rovide e'planation of the rules of the treatment Clear e'planation of the rules allows the client to
setting and develop conse#uences with the client ma"e choices about participating.
?nvolvement in
for his or her lac" of cooperation. setting of the conse#uences promotes an
investment in which the client is more apt to
comply.
<ncourage client to e'press fears and concerns. .elf-understanding and further e'ploration are
enhanced when verbali5ations of concern and
an'iety are received in a non(udgmental manner.
Jisten to client)s perception of inability to adapt to 7rovides clues to reality of these
perceptions and
situations occurring at present. avenues to assist in dealing with them.
+elp client to recogni5e signi&cance of losses and Lrief wor" cannot begin until losses are
e'press feelings regarding these. ac"nowledged 3e.g. divorce relocation loss of
friends8e'tended family8support systems4.
<ncourage e'ploration of the relationship of behavior Enowledge regarding possible
psychological and
an'iety and somatic symptoms to the grief process. physiological manifestations of the grief
process
helps identify etiology of e'isting symptoms and
to alleviate denial.
/iscuss appropriateness and desirability of the grief Lrief wor" is necessary and a natural
reaction to
process as it relates to the loss3es4. /iscuss stages of loss. !ime is re#uired 3at least A612
months4 to
the grief process and behaviors associated with each wor" through grief. !he process gives the
client
stage. permission to grieve and o$ers hope for eventual
acclimation to the loss.
/etermine coping mechanisms used 3e.g. pro(ection 7rovides a beginning point for client to see
how
rationali5ation4 and how these a$ect current situation. use of ine$ective coping methods causes
problems
in life8relationships.
Assist client to recogni5e the reality and %ld patterns of behavior tend to recur under
nonproductivity of maladaptive behaviors 3e.g. stress. Continuous monitoring of behavior is
failing grades trouble with the law running away4. necessary to avoid old nonproductive
methods of
%$er support and confront client when appropriate. coping and problem-solving. !herapeutic
confrontation can help client to loo" at
incongruencies of behavior and own responsibility
for actions.
/escribe all aspects of the problems using !his clari&es problems and promotes
therapeutic communication s"ills 3e.g. understanding by the client and nurse.
Active-listening4.
9ocus on speci&c behaviors 3e.g. poor academic <nergy is best used when focus is on those areas
performance antisocial behavior4 that are amenable that can be altered.
to change.
.et limits on manipulative behavior by telling client :eing clear and confronting these
behaviors in a
what will be tolerated; be consistent in enforcing consistent manner will help client begin to
change
conse#uences when rules are bro"en and limits tested. ways of getting needs met.
>einforce client positively when change in Adolescence is a time of stress and
vulnerability
behaviors indicates e$ective coping through because of a lac" of well-
developed coping s"ills.
behavior-modi&cation system. Anticipate and 7ositive reinforcement
encourages continuing
accept occasional regressive behavior. personal growth. +ospitali5ation may
precipitate
periodic regression.
?dentify past and present support systems. >einforces availability of resources to aid the
client
to develop new coping s"ills.
<'plore religious beliefs8a*liations. <ncourage 0hen these ties have been previously
established
client to draw again on spiritual resources that had they may be helpful in providing resources
for the
been useful in the past. adolescent to enhance inner controls.
<'plore possible ways to re"indle relationships with Attaining peer acceptance is of primary
positive peer8role models in,uential adults importance during adolescence. 7eer groups that
organi5ations8church youth group as appropriate. share common values promote the formation of
belonging and identity.
<ncourage the development of a positive relationship A #uality relationship with an adult
3preferably a
with an adult. parent4 reinforces the strength and supportive
function of the relationship 3family4 and is a positive
factor when setting limits with the adolescent.
NURSING DIAGNOSIS !AMIL7 COPING+ in#8#c"i0#)
com3$omis#d%disa.lin
May B# R#la"#d "o) Joss of signi&cant relationship 3parent8child4; lac"
of e$ective parent management s"ills
+ighly ambivalent family relationships; family
disorgani5ation8role changes
7resence of other situational8developmental
crises a$ecting family members
Possi.ly E0id#nc#d .y) Client states feelings of abandonment re(ection
and guilt about parent)s response to adolescent)s
problems
Client e'presses sense of powerlessness and lac"
of control
7arents describe preoccupation with own
reactions 3e.g. fear guilt an'iety4
7arents withdraw or have limited communication
with adolescent or display protective behavior
disproportionate 3too little or too much4 to client)s
abilities or need for autonomy
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 <'press feelings openly and honestly.
!amily 2ill) <valuate individual role in family problems.
?nitiate positive8amicable relationship with one
another.
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 7romote prosocial behaviors by role-modeling
!amily 2ill 5con"*6) appropriate behaviors in the home.
?dentify need for8see" outside support as
appropriate.
ACTIONS%INTERVENTIONS RATIONALE
Ind#3#nd#n"
9oster trust through 1K1 family8nurse relationship. :asic trust and stability can be established
through
continuity and consistency of care.
?dentify underlying family dynamics and determine <stablished family patterns a$ect how
current
how they are operating in the present. situation has arisen as well as how problems
need
to be resolved and changed now.
<ncourage open communication between client and Communication patterns a$ect the
functional level
family. of each family member.
<ncourage client to identify and appropriately Derbali5ing feelings tends to alleviate tensions
that
verbali5e feelings of re(ection abandonment and may be internali5ed or somati5ed 3e.g.
reports of
ambivalence related to individual situation. nausea4. Client lac"s emotional attachment to
others
and may be charming and engaging which is a
pretense to deceive others8facilitate e'ploitation.
/iscuss reasons for client behaviors including theCnderstanding of childhood8adolescent tas"s
relationship between di$erences in the client)s ambivalent feelings etc. can help individual3s4
thoughts8beliefs and how others in the family thin" accept and deal more appropriately with
di*cult
and behave. behaviors. As a rule client is easily bored and has
a low frustration tolerance when desires are not
immediately grati&ed. <motional reactions can be
erratic and demonstrate a lac" of concern for
others. 0hen the client acts on his or her
thoughts
behavior will be outside of societal norms.
<'plore feelings of self-blame and guilt related to Change or disruption in the family system a$ects
problems8changes in the family system. Assist all other parts of the system. Children may
individuals in realistic appraisal and verbali5ation incorrectly assume that they were instrumental in
of own role in situation. family problems8marital disruption.
Luide client8family in correlating anger and feelings Cnderstanding internal dynamics of anger
leads to
that are centered around lac" of in,uence in family acceptance of locus of control within self.
behavior.
<ncourage client8family to ma"e as many decisions An increase in autonomy and decision-
ma"ing
as are possible within the milieu. E(am3l#) Client enhances feeling of self-worth and
competency.
decision to participate in choice of evening activity.
9ocus on speci&c behaviors that are amenable to Changing some behaviors can enhance feelings
of
change. self-esteem and encourage willingness to ma"e
other changes.
+elp family recogni5e and set limits on manipulative .tating rules clearly and being consistent
in
behavior. maintaining them helps establish family
boundaries and allows the client to recogni5e
when they are violated.
<'plore ways client and family can be mutually .ecurity and trust provide a climate for growth
supportive without fostering overdependence on and ris"-ta"ing.
each other.
Live immediate consistent and positive Consistent reinforcement of appropriate
behaviors
reinforcement when desired behaviors are observed. fosters continuation of those behaviors.
Conversely withhold reinforcement8ignore negative Conse#uences for inappropriate behaviors
and no
behaviors. reinforcement 3ignoring4 tend to e'tinguish
undesired behaviors.
Colla.o$a"i0#
<'plore potential sources of assistance available to Enowledge of resources available if they
are
meet needs. >efer to social services and other agencies needed tends to decrease fears regarding
as indicated. postdischarge functioning.
<ncourage family to participate in family therapy. <nables family to wor" on issues that a$ect all of
the family system. No"#) 9amily rift may be so
severe that the most that can be e'pected is a
neutral relationship in which parties agree to
disagree. 3>efer to C7K 7arenting.4
NURSING DIAGNOSIS SEL! ESTEEM+ ch$onic lo9
May B# R#la"#d "o) Jife choices perpetuating failure 3e.g. runaway
behavior4
7ersonal vulnerability 3loss of family member8
friends; poor school performance relocation4
9i'ation in earlier level of development 3lac" of
movement toward independence4
Possi.ly E0id#nc#d .y) .elf-negating verbali5ations self-blame anger
>ationali5ing away8re(ecting of positive feedbac"
and e'aggeration of negative feedbac" about
self feelings of re(ection
9re#uent lac" of success in school8other life
events
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 Derbali5e beginning understanding of negative
Cli#n" 2ill) evaluation of self and reasons for problems.
7articipate in treatment program to promote
change in self-evaluation.
/emonstrate behaviors8lifestyle changes to
promote positive self-esteem.
Derbali5e increased sense of self-esteem in
relation to current situation.
ACTIONS%INTERVENTIONS RATIONALE
Ind#3#nd#n"
Continue the trust relationship that is reliable Communication growth and insight ,ourish in an
supportive and reassuring. atmosphere of acceptance and trust.
.chedule time for 1K1 client8nurse interaction ?ndividual attention conveys the importance of
the
and communication. individual. Communication s"ills are re&ned with
fre#uent interaction.
<'plore and discuss feelings of re(ection and anger >ecognition and e'pression of feelings
eliminate
related to individual situation. need for displacement and denial. !his directs
focus of energy to problems and alternative
solutions.
7oint out past academic8personal successes. Assists in preserving self-esteem. 7ast
performance
is a more accurate portrayal of ability than that
indicated by recent evaluations8grades.
Assist client in understanding transient nature of +igh-an'iety levels a$ect motivation attention to
poor academic performance related to current tas" and performance.
stressors.
0or" with client to develop a plan of action to meet 7rovides opportunity for client to learn
sense of
immediate needs 3e.g. physical safety hygiene control and fosters self-esteem.
emotional support4.
=aintain positive attitude toward the client Cooperation can be enhanced when client feels
providing opportunities for client to e'ercise control accepted and included in problem-solving
and
as much as possible. decision-ma"ing.
<ncourage activities in areas of client)s interest tas"s .uccess in accomplishing goals builds
sense of self
that can be completed successfully and reinforce when and diminishes need for disruptive acting-
out
these are accomplished. behaviors.
7rovide opportunities for client to ma"e short-term 7romotes feelings of self-worth which can
lead to
attainable goals 3e.g. crafts activities4. increased appropriate ris"-ta"ing and the
develop-
ment of more elaborate future-oriented goals.
<ncourage participation in activities with peer group .ocial interaction and peer acceptance are
among
3e.g. outings hi"es swimming4. the tas"s of this developmental stage.
7articipation
helps to develop social s"ills.
?nvolve in activities to improve personal appearance +ow an individual loo"s a$ects feelings
about
3e.g. ma"eup hairstyling clothing choices4. inner self and can improve sense of self.
Cse the techni#ue of role rehearsal to help the client Active participation in activity enhances
learning.
develop new s"ills to cope with changes.
Colla.o$a"i0#
Consult with resident educational therapist 3teacher4 Eeeping up with class wor" can help to
lessen
regarding academic pursuits while client is further loss of self-esteem. Can be an opportunity
hospitali5ed 3residential treatment program4. to form a positive relationship with teacher and
e'perience learning successes fostering personal
growth and improved self-worth.
.chedule sta*ngs with 1home2 school counselors !his maintains contact with own
public8private
social wor"er teachers and client8parents as possible. school setting; fosters continuity for return
and
sense of importance for the student.
NURSING DIAGNOSIS NUTRITION+ al"#$#d) l#ss "han%mo$# "han
.ody $#:&i$#m#n"s
May B# R#la"#d "o) ?nade#uate inta"e of balanced nutritional meals
because of lifestyle
Possi.ly E0id#nc#d .y) >eported8observed inade#uate food inta"e and
lac" of weight gain or e'cessive inta"e in relation
to metabolic need with subse#uent weight gain
.atisfaction of hunger through consumption of
e'cessive amounts of (un" food
D#si$#d O&"com#s%E0al&a"ion C$i"#$ia1 Derbali5e understanding of the relationship of
Cli#n" 2ill) food inta"e e'ercise and metabolism.
/emonstrate positive eating habits with
appropriate nutritional inta"e.
Achieve desired weight level.
ACTIONS%INTERVENTIONS RATIONALE
Ind#3#nd#n"
<ncourage client to eat well-balanced meals on a +unger can be satis&ed with nutritous food
inta"e
regular basis. eliminating empty calories.
7rovide information regarding nutritional inta"e and !he correlation of food inta"e and weight
selection of appropriate foods that will encourage gain8loss if understood can lead to food
choices
weight loss8gain as indicated. that result in achieving appropriate weight. 9oods
that are self-selected are more li"ely to be eaten
and en(oyed.
Assist client in developing insight into eating habits as ?ncreased an'iety may lead to anore'ia or
fre#uent
they relate to feelings of an'iety. <ncourage "eeping snac"ing as a response to feelings of
tension.
a diary of food inta"e and related feeling3s4.
>eview daily inta"e diary activity level. !his identi&es reality of ade#uate inta"e in
relation
to energy output and helps child8family to ma"e
decision for change.
?dentify bloc"s to ade#uate nutritional inta"e. 9actors such as substance abuse smo"ing
limited8
inappropriate use of &nancial resources and poor
family patterns may interfere with child
developing healthy eating habits.
Colla.o$a"i0#
>efer to dietitian as needed. +elps determine individual caloric needs while
considering child8adolescent dietary preferences.