Mental Health - Nursing Care Plan for Janet Gray - Assignment Example

Arlene Bible No 200516 Unit Assignment No 2 Assignment Mental Health: Nursing Care plan for Janet Gray Problem/ Issue Expected Outcome Intervention Rationale Evaluation Risk for Suicide r/t feelings of helplessness as evidenced by previous suicide attempts. Short term: Client will not commit any self- inflicted harm. Client will sign “no suicide” contract. Client will verbalize feelings, perceptions and fears. Long term: Client will have no suicidal ideation and will gain conviction to live life. Client will use community resources and crisis centers on a long term basis. Client will independently submit to individual psychotherapy and counseling as necessary. Client will develop insight to her situation. Determine the lethality of the suicide plan by direct questioning—the ideation, plan, method, access, place, time and timing (Videbect, p.162). Implement appropriate suicide precautions especially when the client is having recurrent and intensifying suicidal ideation. Remove potentially harmful objects from the client’s environment and ensure adequate supervision as necessary. Discuss with client the importance of “no suicide” contract and obtain mutual approval. Renew contract as necessary. Continue assessment with the client, taking note of the suicidal ideations, sudden or unusual cheerfulness, giving of possessions, among others. If the client is taking antidepressants, continue to monitor risk for suicide even if the client feels well. Document overt and covert cues relating to suicide on the client’s record. Overt cues may be client statements as “I am going to kill myself.” Covert cues may be client statements as “Nothing seems helpful, I want to have a good rest” (Videbect, p.121). Communicate with the client constantly at your agreed schedule. Be accepting with the client’s feelings, including anger and fear. Encourage ventilation of feelings. Use active listening and silence and let the client know that you are concerned. Encourage the client to be engaged in individual psychotherapy and counseling. Work with the client to identify community resources and crisis centers, including phone numbers. Encourage the client to have an “emotion notebook” for the recording of feelings of anger, shame and guilt. Discuss with the client the entries in the notebook and teach alternative responses to maladaptive behaviors. Direct questioning is useful for most suicidal clients who are generally ambivalent whether to live or die (Videbect, pp.121). Health care agency policies on suicidal precautions vary with each unique case. This ensures safety of the client (Videbect, p.344). Clients agree with the contract especially when they feel that their safety is valued (Videbect, p. 365). Constant assessment determines the status and suicidal risk of the client (Townsend 2003). Antidepressants make the client feel more energized. If suicidal thoughts are still present, the client will have high chances to commit suicide (Videbect, p.363). Accurate documentation alerts the entire health team & ensures that the client will have no chance to commit suicide (Townsend 2003). Constant communication upholds trust and promotes a therapeutic relationship between the client and the nurse (Videbect 2004). Ventilation of feelings provides a release of emotional tension. It will also facilitate the exploration of underlying reasons of committing suicide. Active listening and silence allows the client to verbalize feelings, anger and fear (Townsend 2003). Individual psychotherapy promotes resolution of the problem on a long term basis since it aims to teach the client to understand self and make necessary changes (Videbeck, p. 62). Community resources and crisis centers provide adequate social support. Phone numbers of these agencies are helpful for the client especially when there is a sudden impulse to commit suicide (Videbect, p.365). Letting the client record her feelings gives insight of the situation and helps her cope with negative feelings in an acceptable way (Townsend 2004). Goal met. Client did not commit any self- inflicted harm. She approved to sign a “no suicide” contract. Nevertheless, the client also agreed to verbalize her feelings, perceptions and fears. Furthermore, client reported “having no suicidal ideation” and “desire to live life and correct mistakes”. She identified community resources and phone numbers to call at the first instance of impulse to harm self. The client gained independence in deciding to engage in individual psychotherapy and counseling. In addition, client kept a record of her emotions and developed insights as to the situations that cause her to think about committing suicide. Problem/ Issue Expected Outcome Intervention Rationale Evaluation Social Isolation r/t perceived inadequacy of social support as evidenced by insecurity in public and verbalization of lack of communication with family members. Short term: Client will verbalize feelings affecting her social relationship with other people. Client will identify her strengths and weaknesses in initiating and sustaining a conversation. Client will use techniques to improve positive thought patterns. Long term: Client will eventually learn to reintegrate with the society. Start with short but frequent interaction and establish a therapeutic nurse- client relationship. Use positive reinforcement as necessary, especially when the client initiates a conversation with other people. Involve the client in formulating a schedule and choice of daily activities, as appropriate. Encourage verbalization of feelings and emotions. Teach effective communication skills like eye contact, active listening and taking turns to talk by role playing. When the client is ready, encourage to be involved in group activities. Recognize the client’s absence in each activity. Encourage the client to be involved in an assertiveness training, using the word “I” in communication. Point out the differences between assertiveness from aggressiveness. With a non- judgmental attitude, provide feedback for each client attempts to interact with other people. Help the client identify her negative behaviors and practice by role- playing on alternative ways on communicating effectively. Work out with the client to reshape the thinking pattern using the techniques like cognitive restructuring, thought- stopping, positive self- talk and decatastrophizing. Encourage the client to join active and productive social groups in the society like joining in an art club, learning a new sport or volunteer for civic action. Clients who have been socially isolated may not be able to sustain long conversations (Videbect 2004). Positive reinforcements encourage the client to repeat the positive behavior and convey the idea that the client is a worthwhile person. It promotes well- being (Ackley & Ladwig, p. 769). Involvement with decision- making advocates client’s autonomy with their health. It also conveys the genuine interest and care (Videbect 2004). Verbalization helps create a therapeutic relationship by implying that the client’s feelings and emotions are considered (Videbect 2004). Role playing involves the client participation. Communication skills help the client to reintegrate with the society. (Townsend 2003). After learning to interact with the nurse, the client can be ready to engage in group interaction. Recognizing the client’s absence in each group activity reinforces the idea that the client is valued and her feelings are being considered (Townsend 2003). Assertiveness training develops the client’s control of the situation. It fosters self- assurance and develops the client’s interpersonal relations (Videbeck, p. 278). Client attempts of interaction need to be corrected as necessary to ensure that the client develops effective techniques of communication. Role- playing facilitates learning and strengthens therapeutic nurse- client relationship (Townsend 2003). Cognitive restructuring aims to replace negative thoughts with positive ones. Thought- stopping intends to halt the negative patterns of self- thought by actually saying “stop”. Positive self- talk reframes negative thoughts into positive ones. Decatastrophizing helps to assess the situation realistically and not always assume that negative effects will happen (Videbect, p. 393). Joining social groups promote a sense of belongingness and enhance interaction with other people. Identifying trusted people in the community enhances the client’s social support in a productive way (Videbect 2004). Goal met. Client verbalized feelings of “insecurity” and states “worried about children”. Furthermore, she learned how to initiate and sustain a conversation with other people using active listening, eye contact and taking turns to talk. She verbalized her feelings and perceptions openly and learned to be assertive in conversations. She identified her own weaknesses in conversation like being too shy and mumbled. Thus, she used the techniques of cognitive restructuring, thought- stopping, positive self- talk and decatastrophizing in improving her thought patterns. She volunteered in a community civic action and stated “it feels so good being productive”. Consequently, client decided to commit herself to a productive and socially meaningful life. Problem/ Issue Expected Outcome Intervention Rationale Evaluation Ineffective individual coping r/t disturbance in pattern of tension- release as evidenced by substance abuse (alcoholism) and verbalization of lack of communication with family members. Short term: Client will verbalize the negative effect of substance abuse in solving problems and coping stress. Client will verbalize negative feelings, perceptions and fears openly. Long term: Client will develop alternative coping strategy without the use of substances, to deal with stressful situations. Client will gain a sense of self- control in handling her situation. Client will join in community social support groups to ensure rehabilitation in a long term basis. Assist the client in identifying the problem area and determine the effect of substance abuse on it. Help the client realize the negative effect of substance abuse on her life. Assess the client’s suicide risk by directly confirming if she has plans to commit suicide, including the manner, time, and place. Help the client establish realistic goals of rehabilitation and encourage her to identify the problems that cannot be controlled. Provide opportunity for the client to verbalize negative feelings, perceptions and fears. Use therapeutic techniques of communication like active listening and silence. Allow the client to cry, if necessary. Assist the client in identifying her strengths and limitations by exploring her previous coping strategies and the ways it alleviated or aggravated her problems. Involve the client in planning her schedule of activities. Collaborate with the client on managing the effects of medications prescribed for withdrawal. Encourage the client to report any disturbing symptoms. Initiate one- to- one interaction with the client by short but frequent visits. When the client is ready, involve her in group therapy sessions appropriate for the case. Teach the client about various community support groups like Alcoholics Anonymous. Teach the client and encourage performance of distraction techniques when feeling stressed like deep- breathing, guided imagery, progressive muscle relaxation and laughter. Help the client identify support systems available like family, crisis centers, or other agencies. Realizing that substance abuse does not solve the problem, or even makes it worse, can be a good turning point to develop alternative coping strategies. Substance abuse causes maladaptive coping mechanism (Pendersen, p.64). Clients with history of substance abuse are at higher risk of suicide. Safety is always a nursing priority (Townsend 2003). Complete abstinence from alcohol is a difficult task. Establishing realistic goals prevent unnecessary discouragement and frustration (Townsend 2003). Expressing negative feelings, perceptions and fears can be helpful to release tension and stress. Crying can be a good way to cope with stresses (Videbect 2004). Identifying the client’s strengths can help her believe that she is capable of handling her problems in a socially acceptable way. On the other hand, identifying her weaknesses enables her to promptly seek for assistance from support groups and significant others (Townsend 2003). Involvement of the client increases adherence to schedule and encourages her to be independent and gain sense of control (Videbect 2004). Effective management of withdrawal symptoms involves careful assessment and cooperation with the client. Some side- effects of medications can be very disturbing, like insomnia and increasing anxiety. However, these should be managed promptly since the client may stop taking prescribed medications (Videbect 2004). Clients need time to develop trust to other people. Group therapy helps the client develop new ways of looking at the problem and learn new coping strategies (Videbeck, p. 64). Support groups are helpful for the client to develop healthier coping strategies and eventually rehabilitate from the effects of substance abuse. However, the initiative to join Alcoholic Anonymous should come from the client. Introducing the topic can let her decide whether or not join the group (Videbect 2004). Alternative methods like distraction techniques are excellent ways to cope with stress (Townsend 2003). Community support is vital in helping the client learn to cope in a positive way for a long term basis (Videbect, p.230). Goal met. Client verbalized “alcohol only worsens my problem”. She learned to verbalize her feelings, perceptions and fears openly. Also, she realized its effectiveness in tension- release. She stated “there is nothing wrong with crying it out”. Side- effects of medications prescribed for alcohol withdrawal were reported and promptly managed. In addition, the client gained sense of self- control in handling her problems. The client decided to join Alcoholics Anonymous to ensure her life- long conviction to avoid alcohol abuse. As alternative methods to cope with everyday stress and tension, the client learned and performed deep- breathing exercises, guided imagery, progressive muscle exercise and laughter. On the other hand, the client identified social support in the community like her family, community crisis centers and other psychiatric agencies. She committed to be completely abstinent from alcohol and learned alternative ways of coping with stress. Moreover, client identified that contacting her family and other social agencies are much helpful to cope with the stresses of life. Problem/ Issue Expected Outcome Intervention Rationale Evaluation Sleep pattern disturbance r/t effects of substance abuse, depression and preoccupation with the day’s stresses as evidenced by difficulty remaining asleep. Short term: Client will identify activities causing sleep problems. Client will formulate a structured schedule for a typical day’s activity. Client will modify environment to be conducive for sleeping. Long term: Client will develop good sleeping habit to maintain optimum health on a long term basis. Help the client explore sleep problems and usual sleep patterns. Assess the client’s sleep- wake cycle as part of the overall health assessment. Review with the client the usual intake of food and fluids at night. Avoid alcohol and caffeine especially at bedtime. Also, avoid taking in too much fluid at bedtime. Explain the importance of avoiding a day- time nap as much as possible. Encourage the client not to think about the incoming events and stresses of life when getting to sleep. Assist the client in formulating a typical day’s schedule including the time of retiring at night. Assist the client in modifying the bedroom environment like the amount of light and ventilation, level of noise and temperature. Teach and encourage performance of relaxation technique like deep breathing and guided imagery. Work with the client to identify non- pharmacological measures to promote sleep like massage and listening of music. Encourage the client to perform such methods of promoting sleep. Securing a baseline data of the client’s sleep properly guides the care plan formulation. Sleep- wake cycle can vary greatly among individuals (Hilliker, pp.577-578). Food and fluids with high caffeine content results to difficulty falling asleep. Ingestion of chemical substances increases the internal stimuli (Hilliker, pp.577-578). Limiting day- time nap helps improve ability to sleep at night (Videbect, pp. 517-518). Thinking about the incoming events does not promote good sleep (Gulanick et al. 2010). Following a schedule helps promote a regular sleep and wake pattern (Gulanick et al. 2010). Environmental condition is primarily important to achieve comfort conducive for sleeping (Hilton, p. 272). Relaxation techniques release tension and help the client to sleep. Deep Breathing aids in ventilation and circulation, which in turn promotes sleep (Hilton, p.274). Guided imagery relieves anxiety and promotes comfort (Videbect, p.283). Non- pharmacologic measures increase satisfaction and promotes good sleep pattern (Morin et al, pp. 103-106). Goal met. Client identified that pre-occupation with the day’s stresses; taking a nap in mid-afternoon and having a cup of coffee at night and alcohol abuse all contributed to her sleep problems. Thus, the client decided to sleep at a regular schedule every night. Client identified that her anxiety for incoming events also contributed to her sleep- pattern disturbance. Her room was modified to be conducive for sleeping. The amount of noise, light and ventilation were all considered according to her preferences. Client performed relaxation techniques like deep- breathing and guided imagery, as well as the use of massage and music to promote sleep. References Ackley, BJ & Ladwig GB 2008, Nursing Diagnoses handbook: An Evidence-based Guide to Planning Care, 8th ed, , Mosby Elsevier, St. Louis. Gulanick, Myers, Klopp, Galanes, Gradishar, Puzas 2010, Nursing Care Plans, Mosby- Elsevier Inc, St. Louis. Hilton, PA (ed.) 2004, Fundamental Nursing Skills, Whurr Publishers, London/ Philadelphia. Hilliker, NA 2008, ‘Sleep Disorders’, in MA Boyd, Psychiatric Nursing: Contemporary Practice, Lippincott Williams & Wilkins, Philadelphia, pp.577-578. Morin, CM, Mimeault, V & Gagne, A. 1999, ‘Non-pharmacological Treatment of Late- life Insomnia’, Journal of Psychosomatic Research, vol. 46, no. 2, pp. 103-116. Pendersen, D 2005, Psych Notes, F.A. Davis Company, Philadelphia. Townsend, MC 2003, Psychiatric/Mental Health Nursing: Concepts of Care, F.A. Davis Company, Philadelphia. Townsend, MC 2004, Nursing Diagnosis in Psychiatric Nursing, F.A. Davis Company, Philadelphia. Videbeck, S 2004, Psychiatric Mental Health Nursing, Lippincott Williams & Wilkins, London. Read More