PSYCHIATRIC NURSING CRITICAL THINKING/CAREPLAN BASICS FOR FINAL NURSING DIAGNOSIS to be used in Critical Thinking/ Care Plan

exercises: • • • • Risk For Self-Directed Violence (=Risk for Suicide) Risk For Violence directed toward self and others Risk for Injury towards self and others Disturbed thought Process GUIDELINES FOR CRITICAL THINKING EXERCISES Use this table to help you identify the problems from the scenario: 1. Identify EGO FUNCTIONS
• • • • • • • • • • • Reality Testing Judgment Sense of Reality of the world and Self (=Self Esteem) Impulse Control Thought Processes Object Relations A.R.I.S.E (Creativity) Defensive Functioning Stimulus Barrier Autonomous Functioning Mastery-Competence

3. Identify STAGE OF DEVELOPMENT
• • • • • • • • Trust vs. Mistrust Autonomy vs. Shame and Doubt Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion Intimacy vs. Isolation Generativity vs. Stagnation Integrity vs. Despair

4. Identify ANXIETY LEVELS
• • • Mild Moderate Severe

2. Identify DEFENSE MECHANISMS
• • • • • • • • • • • • • • • • • • Sublimation Rationalization Intellectualization Suppression Repression Displacement Reaction Formation Somatization (=Conversion) Undoing Passive-Aggression Acting-Out Behavior Idealization Splitting Devaluation Projection Denial Introjection Compensation

5. Identify PSYCHOPATHOLOGY (S&S OF
DISEASE)

Refers to signs and symptoms of specific mental illnesses (e.g. Schizophrenia, Depression, Anxiety Disorders, Personality Disorders, etc) (See the list that follows next page)

PSYCHOPATHOLOGY OF THE DISEASE: (These terms must be used –in addition to the previous table terms) when referring to identified signs and symptoms. For example, instead of writing “Risk for violence towards self or others AEB pt throwing objects at staff, and verbalizes “I think you want to kill me” it should say “AEB Poor Impulse control, Poor judgment, and aggressive behavior toward staff”) • • • • • • • • • • • • • • • • • • • • • • • Type of Crisis (Maturational/Developmental, Situational, Adventitious) Phobia (specify type) Obsessions Compulsions Persistent intrusive thoughts Restlessness Sleep Disturbances Fatigue Amnesia Dissociative Amnesia Depersonalization Derealization Suicidal Ideations/Thoughts Hopelessness Helplessness Inability to perform ADLs Poor Self-Care (=Poor grooming and Hygiene) Increased/Decreased/Inadequate Appetite Increased/Decrease/Inadequate Fluid Intake Inappropriate Affect Blunted/Flat) Hallucinations (specify: auditory, visual…) Delusions (specify: of persecution, of reference…) Bizarre behavior (=Inappropriate behavior) (extreme motor agitation, stereotyped movements, automatic obedience, waxy flexibility, stupor) Aggressive behavior Impulsive behavior • • • • • • • • • • • • • • • • • • • • • Disorganized speech –specify the presence of: (associative looseness, neologisms, echolalia, clang association, word salad) Hypervigilance (instead of saying “paranoia”) Alterations in perception Disorganized thinking Labile mood Anergia Avolition Alogia Apathy Anhedonia Non adherence to medication regimen (=Non-compliance) Withdrawal symptoms Substance abuse (if obvious, specify) Altered level of conscience (LOC) Altered mental status Decreased LOC (=Acute confusion) Dysphasia Aphasia Apraxia Agnosia Comorbidities (Identify any current medical problems: Hyper/Hypoglycemia, High BP etc)

• •

NURSING DIAGNOSIS: Lets assume pt is depressed or schizophrenic, and expresses will to kill himself (or makes overt statement) 1. Risk for Suicide (Self-directed violence) R/T Biochemical/ Neurological imbalance in the brain AEB (use available data from problem list) 2. Disturbed Thought Process R/T Biochemical/Neurological Imbalance in the brain AEB POSSIBLE EXPECTED OUTCOMES • Patient will not harm his/herself during hospitalization and will demonstrate absence of suicidal ideations/plans AEB no suicidal intent, pt signs “no suicide” contract every shift, makes no overt/covert statements and verbalizes will to live • Pt will state that “I will not harm myself now and throughout hospitalization” and will verbalize a will to live ASSESS: 1. Vital Signs 2. Safety of patient and in the environment 3. Suicidal Risk (SAD PERSONS scale, overt/covert statements) 4. Previous history of Suicide attempts (patient) or Suicide (family) 5. Psychiatric assessment 6. Past and present psychiatric history 7. Past and present medical history 8. Past and current medication regimen and compliance 9. Past and present history of substance abuse 10. Mental status 11. Level of anxiety 12. Pt’s perception of the event and Coping mechanisms 13. Support system 14. Ego functions (Reality testing, thought process, Impulse control, sense of reality of the world and self, Judgment) 15. Stage of development 16. Psychopathology of specific current disease process 17. Assess any comorbid (medical) condition if present Rationale: 1. To establish a baseline for future treatment and evaluation of pt’s progress 2. To prevent pt from harming self 3. To determine potential for suicide, presence of a plan, and its lethality, and adjust interventions accordingly 4. B/C a history of previous suicide attempts and/or successful family Hx of suicide is an important risk factor 5. To obtain significant data on which to base plan of care 6. To determine risk factors 7. To determine comorbid conditions that may impact outcome and mental health 8. B/C medications play a role at adjusting (or failing to adjust) any present chemical imbalance that may be causing the problems 9. To rule out abuse as the cause of the mental disorder, and adjust treatment accordingly 10. To monitor thought process, cognition, and changes toward expected outcome 11. B/C anxiety level strongly influences behavior 12. B/C pt’s perception may influence pt’s decisions 13. B/C a structured environment and support system is important to mental balance, especially after discharge 14. B/C Ego integrity constitutes the pillar of mental health 15. B/C successful achievement of each developmental stage is essential to mental health 16. B/C identifying specific disease traits may aid in the formulation of a treatment plan 17. To identify current conditions that may need interventions

INTERVENTIONS: 1. Provide Safety for patient and in the environment by: removing unsafe objects, place pt in semiprivate room 2. Implement one-to-one constant observation. Stay with client at all times. 3. Have patient sign “No suicide” contract every shift 4. Maintain MD informed of pt’s condition and progress during hospitalization and obtain orders as needed 5. Decrease anxiety by: firm, calm, consistent approach, use of breathing exercises and relaxation techniques 6. Develop a therapeutic, trusting nurseclient relationship 7. Provide consistent, nurturing environment 8. Set limits 9. Increase Reality Testing by: presenting reality and reorienting patient as needed 10. Increase self-esteem by: giving positive feedback and have pt explore positive features and previous achievements 11. Instill hope 12. Administer medications as prescribed 13. Ensure all basic needs are met (includes: physiological needs, attend to any medical problem if present) 14. Assist pt with ADLs as needed 15. Encourage patient to participate in group therapy 16. Ensure adequate sleep/rest periods 17. Decrease environmental stimuli 18. Educate patient on: a. Disease Process b. Medication Regimen/Side Effects, Interactions, therapeutic effects and importance of compliance c. Adaptive coping skills d. Breathing exercises and relaxation techniques

1. 2. 3. 4.

To minimize access to potential objects to inflict harm To prevent client from acting on suicide behavior To have pt make commitment and take responsibility B/C implementation of treatment requires ongoing teamwork 5. B/C high levels of anxiety may cause impairment of thought process and increase violent behavior 6. B/C this is essential to have pt express feelings and reduce anxiety 7. To reduce anxiety, develop trust, and discourage pt from acting on violent thoughts 8. To establish boundaries and thus prevent violent behavior 9. B/C Reality Testing is paramount to ego integrity 10. B/C self-esteem is also an important part of Ego integrity 11. To increase pt’s motivation to comply with treatment plan 12. To correct any biochemical imbalances in the brain 13. To meet Maslow’s hierarchy of needs 14. To facilitate healing process 15. To help pt develop insight, and improve social interactions 16. To maintain physiological integrity 17. To reduce anxiety 18. B/C an informed pt is more compliant, more motivated, and less likely to relapse

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