THE CLIENT WITH INSOMNIA RELATED TO DEPRESSED MOOD
want to take any medication for insomnia or depression but that he was willing to try alternative measures to sleep better at night.
ASSESSMENT: Personal strengths: employed; college graduate; motivated for treatment; good support system; insightful
WEAKNESSES: None identifi ed Jim, a 58-year-old White male, was seen by the nurse
practitioner 2 weeks after the death of his wife. They had been married for 30 years and never had any children.
Jim’s sister and brother-in-law suggested that he tell his primary clinician that he was having diffi culty adjusting to the death of his wife. During the visit, Jim confi ded in the nurse that he had not been sleeping well. His affect was blunted as he stated that he thought he would be the fi rst to die. He informed the nurse that he did not
NURSING DIAGNOSIS: Disturbed Sleep Pattern related to depression as evidenced by diffi culty remaining asleep and statement by client that he is not sleeping well
OUTCOME: By the next visit, client will report that the time spent in sleeping has improved by 1 to 2 hours.
PLANNING/IMPLEMENTATION RATIONALE
Explore client’s present sleep habits. Clients who are depressed may sleep during the daytime and require less sleep at night.
Assist the client to determine the desired amount of sleep each night including time to retire and time to rise.
Establishing a routine sleep pattern promotes sleep hygiene and deters erratic sleep habits.
Provide client with educational material regarding positive behaviors to promote sleep, such as relax- ation techniques, reading, warm bath, and so forth.
The client has the opportunity to try various techniques to facilitate an effective sleep pattern.
Provide client with a sleep diary and ask the client to return in 7 days to evaluate his progress.
Keeping a sleep diary allows the client to identify any behaviors or stressors that may interfere with his sleep pattern.
EVALUATION: Client kept a sleep diary for 7 days. When he returned in 1 week for a follow-up visit, he stated that he was able to sleep 5 to 6 hours each night. He also stated that he was able to discuss his feelings with his sister and brother-in-law and had decided to attend grief counseling at their church.
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CHAPTER 10 Nursing Diagnosis, Outcome Identifi cation, Planning, Implementation, and Evaluation 125 Clinical nurse specialists, nurse practitioners, psychiatrists,
•
psychologists, and licensed clinical social workers use the DSM-IV-TR to make a psychiatric diagnosis when a psy- chiatric problem exists.
Outcomes are measurable client-oriented short- or long-
•
term goals that are the expected consequences of a treat- ment or intervention.
The plan of care must be individualized to meet the identi-
•
fi ed needs of the client, his/her family, and/or signifi cant other. The needs are prioritized according to urgency or seriousness of identifi ed problems.
Plans of care may be standardized to achieve desired
•
outcomes for medical, surgical, or psychiatric disorders.
Concept mapping enables the nurse to synthesize assess- ment data, develop comprehensive plans of care focus- ing on multiple problems, and effectively apply nursing care. Clinical pathways map the sequence of the stan-
dards of care necessary to achieve desired outcomes for a specifi c disorder or condition within a particular period of time. Critical pathways contain interdisciplinary practice guidelines with predetermined standards of care.
Implementation of the nursing plan of care is guided
•
by nursing theory. Delivery of care can be challenging in the psychiatric clinical setting. The nurse may utilize evidence-based nursing practice to determine which nurs- ing interventions would be the most effective for a specifi c nursing diagnosis.
Four possible outcomes of a plan of care may be identi-
•
fi ed during the evaluation process. Depending on these outcomes, the plan of care may be maintained, modifi ed, or totally revised.
For additional study materials, please refer to the Student Resource DVD-ROM located in this textbook.
Critical Thinking Questions
1. Identify your own level of need attainment according to Maslow’s hierarchy of needs. Develop a care plan for yourself, being sure to include short- and long-term goals to promote your growth and development.
2. Every time you take a report from Susan Fowler, RN, you fi nd that her care plans are incomplete and the nursing actions do not seem appropriate for the clients as you assess them. What actions can you take to help the clients, Susan, and yourself?
3. Using a clinical case with which you are familiar, prepare a 10-minute presentation that will help the members of a multidisciplinary treatment team to see the nursing process in action.
4. Develop a plan of care for the client described in the fol- lowing paragraph, focusing on the client’s emotional or psychosocial needs:
A 50-year-old man complains of chronic low back pain from degenerative disk disease and other somatic symptoms. He alleges that he is disabled and cannot work or pursue his hobbies because of his back pain. This person was divorced approximately 6 years ago at age 44 and described the divorce in great detail during his initial assessment. He refers to himself as a failure, stating, “I never could do anything well enough to please my father and then my marriage ended in divorce.
Things never did go right for me. I don’t have any friends.”
He states that he has diffi culty falling asleep at night, has lost 18 pounds in the last year, and “does not feel like” eating. He has no social or civic involvements and alleges fi nancial problems because he is receiving only Social Security disability benefi ts of $637.00 per month. During the interview, his voice became tremulous as he discussed his divorce. He rubbed the arm of the
chair incessantly, chain-smoked four cigarettes, and complained of headaches, dizziness, restlessness in his legs, and back pain.
Refl ection
The chapter opening quote states that making accurate nursing diagnoses takes knowledge and practice. As you developed the plan of care for the client listed in Question 4 of the Critical Thinking Questions, did you have any diffi culty arriving at a nursing diagnosis or diagnoses? How did you validate data?
How did you classify your nursing diagnoses (eg, actual, risk, wellness, or syndrome diagnosis)?
NCLEX-Style Questions
1. Assessment of a client reveals a long history of alcohol use.
The client tells the nurse in the inpatient alcohol treatment unit, “I really don’t have a problem with drinking because I drink only on weekends.” Which of the following nurs- ing diagnoses classifi cation of alcoholism fi ts best?
a. actual b. risk c. syndrome d. familial
2. Which of the following outcomes is most appropriate for the client with a nursing diagnosis of Social Isolation related to inability to trust as evidenced by withdrawal from others?
a. The client will ask the nurse for permission to be excused from activities.
b. The client will identify positive qualities in self and others.
c. The client will state that his or her level of trust in others is improved.
d. The client will spend time with peers and staff members in unit activities.
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126 UNIT III Components of the Nurse–Client Relationship
3. The multidisciplinary treatment team is developing a plan of care for a client who has been living on the streets for several years. The client has delusions and frequently responds to auditory hallucinations. Which of the following client needs would be the priority?
a. self-preservation
b. feeling of belonging to society c. self-actualization
d. physical safety
4. The nurse reviews the psychiatric history of a client with the DSM-IV-TR diagnosis of Borderline Personal- ity Disorder. This diagnosis is coded on which of the following diagnostic axes?
a. Axis I b. Axis II c. Axis III d. Axis IV
5. A client tells the nurse, “I never could do anything well enough to please my mother, and my wife never thought
I’d amount to anything before she divorced me.” Which of the following would be the priority nursing diagnosis for this client?
a. Disturbed Thought Processes b. Disturbed Body Image c. Anxiety
d. Chronic Low Self-Esteem
6. After presenting a class about nursing interventions applicable to all nurses in psychiatric–mental health clinical settings, which of the following, if stated by the group, would indicate to the presenter that the teaching was successful? Select all that apply.
a. counseling to improve client abilities b. maintaining a therapeutic milieu c. prescribing antipsychotic medications d. providing group therapy
e. performing health education
REFERENCES
American Nurses Association. (2000). Scope and standards of psychiatric–mental health nursing practice. Washington, DC:
American Nurses Publishing.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Boyd, M. A. (2002). Psychiatric nursing: Contemporary practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Bultema, J. K., Milliard, L., Getzfrid, M. K., Lerner, R., & Colone, M.
(1996). Geriatric patients with depression. JONA: Journal of Nursing Administration, 26(1), 31.
Caplan, J. P., & Stern, T. A. (2008). Mnemonics in a nutshell: 32 aids to psychiatric diagnosis. Current Psychiatry, 7(10), 27–33.
Carpenito-Moyet, L. J. (2008). Handbook of nursing diagnosis (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Chamberlain, R. S. (2006). Nursing practice and the nursing process. In S. M. Nettina (Ed.), Lippincott Manual of Nursing Practice (8th ed., pp. 2–11). Philadelphia, PA: Lippincott Williams & Wilkins.
Critical and Clinical Pathways. (2003). Retrieved April 10, 2003, from http://www.nlm.nih.gov/archive/20040829/pubs/cbm/ critpath.
html
Dixon, M. (2003). Assessing psychosocial needs of psychiatric patients and their families. Vital Signs, 12(1), 8.
Glendon, K., & Ulrich, D. (2004). Dear Florence: Tips and strategies for faculty. Nurse Educator, 29(5), 175–178.
Haas, L. J., Sanyer, O. M., & White, G. L. (2001). Caring for the frustrating patient. Clinician, 11(10), 75–78.
North American Nursing Diagnosis Association. (2006). Nursing diag- noses: Defi nitions and classifi cation, 2005–2006. Philadelphia, PA:
Author
Psychodynamic Diagnostic Manual. (2006). Retrieved October 3, 2008, from http://www.pdm1.org/
Schultz, J. M., & Videbeck, S. L. (2009), Lippincott’s manual of psy- chiatric nursing care plans (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Schuster, P. M. (2002). Concept mapping. Philadelphia, PA: F. A. Davis.
Sherman, C. (2006). Manual’s breadth may aid diagnosis. Clinical Psychiatry News, 34(3), 1, 31.
University of Minnesota. (2005). Evidence based nursing. Retrieved August 12, 2005 from http://evidence.ahc.umn.edu/ebn.htm
SUGGESTED READINGS
Ferrario, C. (2004). Developing nurses’ critical thinking skills with concept mapping. Journal for Nurses in Staff Developments, 20(6)261–267.
Hanson, K. (2009). Concept mapping in health care management.
Retrieved January 10, 2009, from http://learn.sdstate.edu/
nursing/ConceptMap.html
Hill, C. M. (2006). Integrating clinical experiences into the concept mapping process. Nurse Educator, 31(1), 36–39.
Meszaros, L. (2004). Focus on mental health. Fine-tuning the role of the PCP. Central Florida M. D. News, 6(4), 11–13.
NANDA International. (2009). NANDA. Retrieved January 10, 2009, from http://www.nanda.org/Development/News and Updates.
aspx
Taylor, J., & Wros, P. (2007). Concept mapping: A nursing model for care planning. Journal of Nursing Education, 46(5), 211–216.
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127
11
Comfort zones Communication Countertransference Nonverbal communication Parataxic distortion Process recording Professional boundaries Social communication Therapeutic communication Therapeutic relationship Transference
Verbal communication Zones of distance awareness
KEY TERMS
LEARNING OBJECTIVES
After studying this chapter, you should be able to:
1. Explain the process of communication.
2. Distinguish the factors that infl uence communication.
3. Describe the importance of assessing nonverbal communication.
4. Articulate the relationship between comfort zones and effective communication skills.
Therapeutic
Communication and Relationships
Listen
When I ask you to listen to me and you start giving advice, you have not done what I asked.
When I ask you to listen to me and you begin to tell me why I shouldn’t feel that way, you are trampling on my feelings.
When I ask you to listen to me and you feel you have to do something to solve my problem, you have failed me, strange as that may seem.
Listen! All I asked was that you listen, not talk or do—just hear me.
And I can do for myself; I’m not helpless. Maybe discouraged and faltering, but not helpless.
When you do something for me that I can and need to do for myself, you contribute to my fear and weakness.
But, when you accept as a simple fact that I do feel what I feel, no matter how irrational, then I can quit trying to convince you and can get about the business of understanding what’s behind this irrational feeling.
And when that’s clear, the answers are obvious and I don’t need advice.
So, please listen and just hear me. And, if you want to talk, wait a minute for your turn; and I’ll listen for you.
—ANONYMOUS
11
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128 UNIT III Components of the Nurse–Client Relationship 5. Recognize factors that contribute to ineffective