PART IV: PSYCHIATRIC NURSING CARE PLANS
Anxiety Disorders
Copyright © 2015. Elsevier. All rights reserved.
OVERVIEW/PATHOPHYSIOLOGY
Anxiety is a diffuse response to a vague threat, as opposed to
fear, which is an acute response to a clear-cut external threat.
Anxiety often precedes significant changes, for example,
beginning new employment. When it is prolonged or excessive, crippling physical and psychologic symptoms may
develop. The anxiety disorders are a group of conditions characterized by anxiety symptoms and behavioral efforts to avoid
these symptoms. They are the most common psychiatric disorders in the United States, affecting more than 40 million
people or about 18.1% of American adults aged 18 and older.
Comorbidity with depression is common. Acute anxiety
creates physical sensations of arousal (fight or flight), an emotional state of panic, decreased cognitive problem-solving
ability, and altered spiritual state with hopelessness and/or
helplessness. Anxiety is considered abnormal when reasons for
it are not evident or when manifestations are excessive in
intensity and duration. Psychologic stress refers to the response
of an individual appraising the environment and concluding
that it exceeds his or her resources and jeopardizes well-being.
Some stressors are universal, whereas others are person specific
because of highly individual interpretations of events.
Anxiety is always part of the stress response and has four
levels, ranging from mild to panic. Normally, a person experiencing mild-to-moderate anxiety uses voluntary behaviors
called coping skills, that is, distraction, deliberate avoidance,
and information seeking. Another common response is use of
unconscious defense mechanisms, including repression, suppression, projection, introjection, reaction formation, undoing,
displacement, denial, and regression. If stress continues at an
unbearable level or if the individual lacks sufficient biologic
mechanisms for coping, an anxiety disorder may develop.
There are eight major categories.
Generalized anxiety disorder: Characterized by excessive,
uncontrollable worrying over a period of at least 6 months.
Symptoms include motor tension (trembling; shakiness;
muscle tension, aches, soreness; easy fatigue), autonomic
hyperactivity (shortness of breath, palpitations, sweating, dry
mouth, dizziness, nausea, diarrhea, frequent urination), and
scanning behavior (feeling on edge, having an exaggerated
startle response, difficulty concentrating, sleep disturbance,
irritability).
95
Panic disorder: Characterized by a specific period of intense
fear or discomfort with at least four of the following symptoms:
palpitations or pounding heart, sweating, trembling or shaking,
sensations of smothering or difficulty breathing, feeling of
choking, chest pain, nausea, feeling dizzy or faint, feeling of
unreality or losing control, numbness, and chills or flushes.
Phobias: Characterized by a persistent and severe fear of a
clearly identifiable object or situation despite awareness that
the fear is unreasonable. There are two types, specific and
social. Specific phobias are subdivided into five types: animals,
natural environment (e.g., lightning), blood-injection-injury
type, situational (e.g., flying), and other (situations that could
lead to choking or contracting an illness). Social phobia
relates to profound fear of social or performance situations in
which embarrassment could occur.
Agoraphobia is characterized by feelings of intense fear of
being alone in open or public places where escape might be
difficult. Individuals with agoraphobia become immobilized
with anxiety and may find it impossible to leave their homes.
Acute stress disorder: Like posttraumatic stress disorder
(PTSD), the problem begins with exposure to a traumatic
event, with a response of intense fear, helplessness, or horror.
In addition, the person shows dissociative symptoms, that is,
subjective sense of numbing, feeling “in a daze,” depersonalization, or amnesia and clearly tries to avoid stimuli that arouse
recollection of the trauma. But just like PTSD, the victim
reexperiences the trauma and shows functional impairment in
social, occupational, and problem-solving skills. The key difference is that this syndrome occurs within 4 wk of the traumatic event and only lasts 2 days to 4 wk.
Anxiety disorder caused by a general medical condition: May be characterized by severe anxiety, panic attacks, or
obsessions or compulsions, but the cause is clearly related to
a medical problem, excluding delirium. History, physical
examination, and laboratory findings support a specific diagnosis, for example, hypoglycemia, pheochromocytoma, or
thyroid disease.
Anxiety disorder not otherwise specified: Describes individuals with significant anxiety or phobic avoidance but not
enough symptoms to meet the criteria for a particular anxiety
or adjustment disorder diagnosis. The patient may show a
mixed anxiety-depressive picture or demonstrate social phobic
symptoms related to having another medical problem, for
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701
PART IV: Psychiatric Nursing Care Plans
702
PART IV
PSYCHIATRIC NURSING CARE PLANS
example, Parkinson’s disease, or present with insufficient data
to rule out a general medical condition or substance abuse.
HEALTH CARE SETTING
Depends on the type of anxiety disorder. Primary (outpatient)
care is likely for most categories, and possibly emergency
department care for panic disorders. If the patient has developed agoraphobia, psychiatric home care may be the best care
option. Some patients may be hospitalized for physiologic
problems or to treat psychiatric needs.
ASSESSMENT
Physical indicators: Dry mouth, elevated vital signs, diarrhea, increased urination, nausea, diaphoresis, hyperventilation, fatigue, insomnia, sexual dysfunction, irritability,
tenseness.
Emotional indicators: Fear, sense of impending doom, helplessness, insecurity, low self-confidence, anger, guilt.
Cognitive indicators: Mild anxiety produces increased
awareness and problem-solving skills. Higher levels produce
narrowed perceptual field; missed details; diminished problemsolving skills; and catastrophic, dichotomous thoughts resulting in deteriorated logical thinking.
Social indicators: Occupational, social, and familial role,
e.g., marital and parental functioning may be adversely
affected by anxiety and therefore should be assessed.
Spiritual indicators: Hopelessness/helplessness, feeling of
being cut off from God, and anger at God for allowing anxiety
may be experienced.
Suicidality: Suicide assessment is critical with anxious
patients, especially those with panic disorder. For patients
suffering dual diagnoses of depression and substance abuse or
other anxiety disorders, risk of self-injury is even greater. Suicidal assessment includes questions to determine presence of
suicidal ideation, intent, presence, and lethality of any plan.
Essential questions to ask include:
• Have you thought of hurting yourself?
• Are you presently thinking about hurting yourself?
• If you have been thinking about suicide, do you have a
plan?
• What is the plan?
• Have you thought about what life would be like for others
if you were no longer a part of it?
A previous history of suicide attempts combined with
depression places the patient at higher risk in the present. A
patient whose depression is lifting is at higher risk for suicide
than a severely depressed individual. The improvement may
result in an increase in energy. This increased energy is not
enough to make the patient feel well or hopeful, but it is
enough to carry out a suicidal plan.
DIAGNOSTIC TESTS
There is no specific diagnostic test for anxiety disorders. The
diagnosis of anxiety is made through history, interview of the
patient and family, and observation of verbal and nonverbal
behaviors. A number of effective scales are available to quantify the degree of anxiety, such as the Hamilton Rating Scale
for Anxiety, Panic Attack Cognitions Questionnaire, StateTrait Anxiety Inventory, Sheehan Patient Rated Anxiety
Inventory, and the Beck Anxiety Inventory.
Nursing Diagnosis:
Deficient Knowledge
Copyright © 2015. Elsevier. All rights reserved.
related to unfamiliarity with the causes, signs and symptoms, and treatment
of anxiety or specific anxiety disorder
Desired Outcome: By discharge (if inpatient) or after 2 wk of outpatient treatment, the
patient and/or significant other verbalize accurate information about at least two of the possible causes of anxiety, four of the signs and symptoms of the specific anxiety disorder, and
the available treatment options.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s understanding of anxiety, its signs and symptoms,
and its treatment.
This assessment helps the nurse reinforce, as needed, information about
anxiety and correct any misunderstanding. Many people lack
understanding about the physiologic basis for anxiety and that
feeling a little worry is different from the overwhelming anxiety
experienced by those who have an anxiety disorder.
Inform the patient and significant other that anxiety disorders are
physiologic disorders caused by the interplay of many factors, such
as stress, imbalance in brain chemistry, psychodynamic factors,
faulty learning, and genetics.
Many people who suffer from anxiety disorders accept that they are just
“nervous worriers” and lack the knowledge that anxiety disorders
represent a complex interplay of treatable biologic, genetic, and
environmental factors.
Swearingen, P. L. (2015). All-in-one care planning resource. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank')
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Anxiety Disorders
Anxiety (Recurring Panic Attacks)
703
RATIONALES
Inform the patient and significant other about the holistic nature of
anxiety, which produces physical, emotional, cognitive, social, and
spiritual symptoms.
Many people believe that anxiety equates with nervousness and fail to
recognize the many other signs and symptoms that make this a
holistic disorder.
Inform the patient and significant other that anxiety disorders are
treatable.
Medications are usually indicated for the treatment of these disorders
and may include antidepressants and anxiolytics or a combination of
medications. In addition, other interventions are useful, including
dietary interventions (e.g., elimination of caffeinated products), and
behavioral therapy, which may include breathing control, exercise,
relaxation techniques, and psychological interventions (i.e.,
distraction, positive self-talk, psychoeducation, exposure therapy,
systematic desensitization, implosive therapy, social interventions,
cognitive therapy, and stress and time management interventions).
For more information about medications, see Deficient Knowledge
related to unfamiliarity with prescribed medications, their purpose,
and their potential side effects, later.
Nursing Diagnosis:
Anxiety (Recurring Panic Attacks)
related to lack of knowledge regarding cause and treatment
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: Within 48 hr of treatment/intervention the patient verbalizes methods
for dealing with panic attacks and the understanding that panic attacks are not life threatening and that they are time limited and demonstrates this knowledge accordingly.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s current understanding of the nature and cause
of and treatments for panic disorders as well as current coping
strategies employed by the patient.
Most patients who experience panic attacks have experienced several
attacks before obtaining an accurate diagnosis. Patients sometimes adopt
unhealthy coping strategies, such as restricting their movement (i.e.,
avoiding bridges if they have experienced a panic attack on a bridge or
avoiding shopping in stores if this is where a panic attack occurred). It is
important to provide information that the patient can understand and use
to make appropriate lifestyle changes.
Administer medication as prescribed for panic attacks.
Panic attacks are neurobiologic events that respond to medications. See
Deficient Knowledge related to unfamiliarity with prescribed
medications, their purpose, and their potential side effects, later.
Teach the patient to reduce or eliminate dietary substances that
may promote anxiety and panic, such as caffeine, food coloring,
and monosodium glutamate (MSG).
Caffeine increases feelings of anxiety. However, caffeine withdrawal
symptoms also can stimulate panic. Therefore, the plan should include
focus on reducing consumption first, followed by elimination from the
diet. Some individuals are sensitive to food colorings and MSG. This
sensitivity is experienced as increased anxiety.
Teach relaxation techniques; assist with practicing imagery, deep
breathing, progressive relaxation, and use of relaxation tapes.
Relaxation is effective in reducing anxiety. The patient’s ability to master
relaxation techniques provides a sense of control and enhances self-care
ability.
Stay with the patient during panic attacks. Use short, simple
directions. Encourage the patient to use relaxation, remind the
patient that the attack is time limited, and reduce environmental
stimulation. Remain calm.
During a panic attack, the ability to refocus is limited. The patient needs
reassurance that he or she is not dying and that this will pass. Therefore,
it is important that the nurse remain calm and not respond to the
patient’s anxiety with anxiety.
Teach the patient to self-administer anxiolytic medication when the
first signs and symptoms of a panic attack start and initiate
coping strategies to ward off the most severe symptoms.
This information empowers the patient by providing a strategy to deal with
panic attacks. As patients become aware of early signs of oncoming
panic, taking the prescribed anxiolytics and initiating relaxation and
cognitive strategies to reduce the magnitude of the event will increase a
sense of mastery over panic anxiety.
Swearingen, P. L. (2015). All-in-one care planning resource. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank')
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
PART IV: Psychiatric Nursing Care Plans
704
PART IV
PSYCHIATRIC NURSING CARE PLANS
Nursing Diagnosis:
Social Isolation
related to agoraphobia
Desired Outcome: By discharge (if inpatient) or after 4 wk of outpatient treatment, the
patient demonstrates behavior consistent with increased social interaction.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the degree of social isolation experienced by the patient in
response to agoraphobia.
It is critical to know how isolated the patient has become secondary
to agoraphobia. If the patient no longer leaves her or his home
and has no contact with anyone except those who either live in
the home or those who come to visit, the social phobia is very
severe and will require more intense work to overcome it,
including home visits.
Assist the patient in a graded exposure plan to gradually increase
independent functions and interactions with others.
Gradual exposure is effective in treating agoraphobia.
Assist the patient with practicing relaxation techniques.
Relaxation helps mitigate impending panic attacks.
Discuss alternatives for social interaction.
Patients may need assistance with developing activity plans.
Appropriate alternatives for social interaction may be volunteer
work in small groups and taking a friend to a social event to
increase comfort.
Nursing Diagnosis:
Ineffective Coping
related to perceived inadequate level of control or support/resources in dealing
with situational crises
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: Within 24-48 hr of intervention/treatment, the patient begins to identify
ineffective coping behaviors and consequences, expresses feelings appropriately, identifies
options, uses resources effectively, and uses effective problem-solving techniques.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s previous methods of coping with life problems.
How individuals have handled problems in the past is a reliable predictor
of how current problems will be handled.
Determine use of substances (alcohol, other drugs, smoking and eating
patterns).
The patient may have used substances as coping mechanisms to control
anxiety. This pattern can interfere with the ability to deal with the
current situation.
Provide information regarding different ways to deal with situations that
promote anxious feelings, for example, identification and appropriate
expression of feelings and problem-solving skills.
This information provides patients with an opportunity to learn new
coping skills.
Role-play and rehearse new skills.
Role-playing promotes skill acquisition in a nonthreatening environment.
Encourage and support patients in evaluating their lifestyle and
identifying activities and stresses of family, work, and social
situations.
These measures enable patients to examine areas of life that may
contribute to anxiety and make decisions about how to engender
changes gradually without adding undue anxiety.
Assist with identifying some short- and long-term goals focused on
making life changes and decreasing anxiety.
Goals help provide direction in making necessary changes.
Teach the patient how to break responsibilities into manageable units.
Small steps enhance success and avoid the anxiety that comes from
facing a huge task and feeling overwhelmed.
Suggest incorporating stress management techniques (e.g., relaxation)
into a normal day.
This encourages the patient to take care of self, take control, and
decrease stress.
Swearingen, P. L. (2015). All-in-one care planning resource. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank')
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Anxiety Disorders
Deficient Knowledge
705
RATIONALES
Teach the importance of balance in life.
A life out of balance adds tremendously to stress and anxiety. Changes
such as getting adequate sleep, nutrition, exercise, quiet time, work
time, family time, and spiritual time enhance quality of life, decrease
anxiety, and increase a sense of power and control.
Refer to outside resources, including support groups, psychotherapy,
religious resources, and community recreation resources.
Many people benefit from the support of other people and resources to
help keep life in balance and monitor stress level.
Nursing Diagnosis:
Compromised Family Coping
related to family disorganization and role changes
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: Within 24 hr of this diagnosis, family members begin to identify resources
within themselves to deal with the situation; interact appropriately with the patient, providing support and assistance as needed; recognize own needs for support; seek assistance; and
use resources effectively.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the level of information available to and understood by the family.
Lack of understanding about the patient’s anxiety disorder can lead
to unhealthy interaction patterns and contribute to anxiety felt
by family members.
Identify role of the patient and current family roles, and discuss how illness
has changed the family organization.
Patients’ disabilities (e.g., resulting in inability to go to work or
maintain the household) interfere with their usual role in the
family structure and can substantially contribute to family stress
and disorganization.
Help the family identify other factors besides the patient’s illness that affect
their ability to provide support to one another.
This takes the focus off of the patient as “the problem” and helps
family members examine each of their individual responsibilities
and behaviors.
Discuss the psychoneurologic basis of anxiety to reduce stigmatizing the
patient with having an anxiety disorder.
This helps the family understand and accept behaviors that may
be very difficult and reduces labeling the patient as weak or
“crazy,” which can aggravate the stigma of having an anxiety
disorder.
Help the family to be supportive of the patient but to recognize to whom the
disorder belongs and who is responsible for resolution of the disorder.
This recognition promotes self-responsibility. The individual with
the disorder can seek support and ask for help, but it is not the
responsibility of the family to seek treatment.
Teach the family constructive problem-solving skills.
These skills help the family learn new ways to deal with conflicts
and reduce anxiety-provoking situations.
Refer the family to appropriate community resources.
The family may need additional assistance (e.g., from
counselors, psychotherapy, Social Services, financial advisors,
and spiritual advisor) to work through family issues and remain
intact.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the prescribed medications, their purpose, and
their potential side effects
Desired Outcome: By discharge (if inpatient) or after 4 wk of outpatient treatment, the
patient verbalizes accurate information about the prescribed medications and their side
effects.
Swearingen, P. L. (2015). All-in-one care planning resource. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank')
href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a>
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
PART IV: Psychiatric Nursing Care Plans
706
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s knowledge about the prescribed medications and
her or his understanding of the importance of taking medications as
prescribed.
This assessment helps the nurse to reinforce, as needed, information
about the medications and correct any misunderstanding.
Teach the physiologic action of anxiolytics and/or antidepressants and
how they alleviate symptoms of the patient’s anxiety disorder.
Anxiety disorders are neurobiologic occurrences that respond to both
anxiolytics and antidepressants. Many people who suffer from
anxiety are fearful of taking medications because they fear drug
dependence and view taking it as a sign of weakness.
Explain the importance of taking antidepressant medications as
prescribed.
These medications require certain blood levels to be therapeutic;
therefore, patients need to take them daily at the dose and time
interval prescribed.
Teach the side effect profile and its management of the patient’s
prescribed medications that follow:
The anxiolytic medications, as well as each class of antidepressants,
carry specific side-effect profiles. Knowledge about expected side
effects, ways to manage these side effects, and how long these
side effects last is important for ensuring therapy adherence.
Tricyclic antidepressants: amitriptyline (Elavil), desipramine
(Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline
(Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil)
Imipramine and desipramine are very effective in anxiety disorders due
to their sedating properties to promote sleep restoration.
Copyright © 2015. Elsevier. All rights reserved.
For patients taking tricyclic antidepressants, teach the following:
- Drink at least 8 glasses of water a day and add high-fiber foods to
the diet.
Water and high-fiber foods combat constipation, a potential
anticholinergic effect.
- Rise from a sitting position slowly. Discuss risks of falling related to
dizziness associated with hypotension.
Orthostatic hypotension is a potential side effect.
- Suck on sugar-free candy or mints or use sugar-free chewing gum.
These products combat dry mouth, a potential anticholinergic effect.
- Establish a sleep routine and regular exercise.
Regular sleep and exercise combat feelings of fatigue associated with
these medications.
- Limit intake of refined sugars and carbohydrates.
Weight gain is a common occurrence with these medications, and
eating sugar and carbohydrates can cause added weight gain and
carbohydrate cravings.
- Caution is needed for patients with epilepsy or other seizure disorder.
Tricyclic antidepressants lower the seizure threshold.
- Be alert for and report signs of cardiac toxicity. Explain that patients
older than 40 yr need an electrocardiogram evaluation before
treatment and periodically thereafter.
These medications may decrease the vagal influence on the heart
secondary to muscarinic blockade and by acting directly on the
bundle of His to slow conduction. Both effects increase risk of
dysrhythmias.
- Discuss possible drug interactions.
The combination of tricyclics with monoamine oxidase (MAO) inhibitors
can cause severe hypertension. The combination of tricyclics with
central nervous system (CNS) depressants, such as alcohol,
antihistamines, opioids, and barbiturates, can cause severe CNS
depression. Because of the anticholinergic effects of tricyclics, any
other anticholinergic drug, including over-the-counter antihistamines
and sleeping aids, should be avoided.
Selective Serotonin Reuptake Inhibitors (SSRIs): fluoxetine (Prozac),
fluvoxamine maleate (Luvox), sertraline (Zoloft), paroxetine (Paxil),
citalopram (Celexa), and escitalopram (Lexapro)
SSRIs are helpful not only for patients with depression and obsessivecompulsive symptoms but for patients with panic and anxiety
disorders as well.
Teach the patient that the following can occur: nausea, headache,
nervousness, insomnia, anxiety, agitation, sexual dysfunction,
dizziness, fatigue, rash, diarrhea, excessive sweating, and anorexia
with weight loss.
These are reported side effects. Because these medications can
increase anxiety, it is recommended that treatment be started at
very low doses and increased gradually.
Discuss possible drug interactions.
Interaction with MAO inhibitors can cause serotonin syndrome, a potentially
life-threatening event. Symptoms include anxiety, diaphoresis, rigidity,
hyperthermia, autonomic hyperactivity, and coma. Because of this
possibility, MAO inhibitors should be withdrawn at least 14 days before
starting an SSRI, and when an SSRI is discontinued, at least 5 wk should
elapse before an MAO inhibitor is given.
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Anxiety Disorders
Deficient Knowledge
707
RATIONALES
Other Antidepressant Medications: bupropion (Wellbutrin); mirtazapine
(Remeron); nefazodone (Serzone); trazadone (Desyrel); duloxetine
(Cymbalta); venlafaxine (Effexor); and desvenlafaxine (PRISTIQ)
Antidepressants are frequently prescribed for treatment of anxiety
disorders because of their effectiveness and low side effect profile.
Remind the patient to take the medication as prescribed daily and not to
abruptly discontinue the medication. Explain that a gradual tapering is
necessary when being taken off the medication.
Effexor in particular, when abruptly withdrawn, causes an
uncomfortable discontinuation syndrome including dizziness,
nausea, blurred vision, headache, and general malaise. Patients
must be monitored carefully during the tapering period to avoid
serious withdrawal symptoms.
Benzodiazepines: diazepam (Valium), chlordiazepoxide (Librium),
clorazepate (Tranxene), lorazepam (Ativan), oxazepam (Serax),
alprazolam (Xanax), halazepam (Paxipam), and clonazepam (Klonopin)
These benzodiazepines are used for generalized anxiety disorder.
Alprazolam also can be used for panic disorder.
Teach the patient the following about benzodiazepines:
- Drowsiness, impairment of intellectual function, impairment of
memory, ataxia, and reduced motor coordination can occur.
These are common side effects that subside as tolerance to the drug
develops.
- For patients who use these medications for sleep, there may be
daytime fatigue, drowsiness, and cognitive impairments that can
continue while awake.
These are common side effects that subside as tolerance to the
medication develops.
- A gradual tapering is necessary when being taken off the medication.
Abrupt discontinuation of the benzodiazepines can result in a
recurrence of target symptoms such as anxiety. Gradual tapering is
also necessary to prevent occurrence of seizures.
- Nausea, vomiting, impaired appetite, dry mouth, and constipation may
occur.
These are gastrointestinal (GI) symptoms associated with this
medication.
- Take the medication with food.
Taking the medication with food may ease GI distress.
- Report worsening of depression symptoms.
This effect may occur in patients who are both depressed and anxious.
- Older adults should take the smallest possible therapeutic dose.
Older adults taking this drug are at increased risk for incontinence,
memory disturbances, dizziness, and falls.
- Pregnant women and nursing mothers should avoid using
benzodiazepines.
Benzodiazepines are excreted in breast milk of nursing mothers. They
also cross the placenta and are associated with increased risk of
certain birth defects.
- Decrease or stop smoking altogether.
Nicotine decreases effectiveness of benzodiazepines.
Nonbenzodiazepines: buspirone
Buspirone is indicated in treatment of generalized anxiety disorder. It
does not increase depression, so it is a good choice when anxiety
and depression coexist. It is not effective in treating other anxiety
disorders.
Copyright © 2015. Elsevier. All rights reserved.
Teach patients taking buspirone the following:
- Be alert for dizziness, drowsiness, nausea, excitement, and headache.
These are common side effects.
- Take buspirone on a continual dosing schedule bid or tid.
Buspirone has a short half-life.
- Caution should be used with patients on digoxin.
In vitro, buspirone may displace less firmly protein-bound medications
such as digoxin. However, the clinical significance of this property
is unknown.
- This medication can cause liver and kidney toxicity. Patients with
kidney or liver impairment must be monitored for this adverse effect.
Buspirone is metabolized in the liver and excreted predominantly by the
kidneys.
Noradrenargic Medications: clonidine (Catapres), propranolol (Inderal),
and pregabalin (Lyrica)
These medications are used for off-label treatment of anxiety.
Propranolol is used in the treatment of performance anxiety found in
some forms of social phobia and in panic disorder. Clonidine is
used to block physiologic symptoms of opioid withdrawal.
Pregabalin, an anticonvulsant medication, is showing positive
results in the treatment of anxiety disorders.
Swearingen, P. L. (2015). All-in-one care planning resource. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank')
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
PART IV: Psychiatric Nursing Care Plans
708
PART IV
PSYCHIATRIC NURSING CARE PLANS
ADDITIONAL NURSING
DIAGNOSES/PROBLEMS:
“Major Depression” for:
Hopelessness
p. 727
Risk for Suicide
p. 727
Self-Esteem: Chronic Low
p. 729
PATIENT-FAMILY TEACHING AND
DISCHARGE PLANNING
Copyright © 2015. Elsevier. All rights reserved.
The patient with an anxiety disorder experiences a wide
variety of symptoms that affect ability to learn and retain
information. Teaching must be geared to a time when medication has begun to calm the person and improve abilities to
concentrate and learn. Verbal teaching should be simple and
supplemented with written materials to which the patient and
family can refer at a later time. Demonstrate and practice with
the patient self-calming strategies, e.g., relaxation techniques,
deep breathing, and “5 senses” exercise, and teach the patient
to practice daily even when not anxious. Ensure that follow-up
treatment is scheduled and that patient and family understand
the need to take medication as prescribed. Psychiatric home
care might be a valuable part of the discharge planning to
facilitate compliance with the discharge plan. In addition,
provide verbal and written information about the following
issues:
✓ Medications, including drug name; purpose; dosage; frequency; precautions; drug-drug, food-drug, and herbdrug interactions; and potential side effects.
✓ Thought-stopping techniques to deal with negativism.
✓ Reducing catastrophic, dichotomous thinking to
promote realistic appraisal of anxiety-provoking event.
✓ Importance of maintaining a healthy lifestyle—balanced
diet, minimal to no caffeine, decrease or stop smoking,
exercise, and regular adequate sleep patterns—for
remaining in remission.
✓ Importance of continuing medication use long after
symptoms have gone.
✓ Importance of social support and strategies to obtain it.
✓ Importance of using constructive coping skills to deal
with stress.
✓ Importance of using relaxation techniques to minimize
stress.
✓ Importance of maintaining or achieving spiritual
well-being.
✓ Importance of follow-up care, including day treatment programs, appointments with psychiatrist and
therapists, and vocational rehabilitation program if
indicated.
✓ Referrals to community resources for support and education. Additional information can be obtained by contacting the following organizations:
• Anxiety Disorders Association of America (ADAA)
at www.adaa.org
• The Anxiety Disorders Association of Canada at
www.anxietycanada.ca
• National Alliance for the Mentally Ill (NAMI) for
information on all of the anxiety disorders.
• National Institute of Mental Health (NIMH) for
information on anxiety disorders at www.nimh.nih.gov
• The Canadian Mental Health Association at
www.cmha.ca
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Bipolar Disorder
(Manic Component)
Copyright © 2015. Elsevier. All rights reserved.
OVERVIEW/PATHOPHYSIOLOGY
Bipolar disorder is a mood disorder characterized by episodes
of major depression and mania or hypomania. (For the
purpose of this chapter we will focus on the assessment and
treatment of mania; see the care plan on “Major Depression,”
p. 725, for specifics regarding depression.) Mania is characterized by a period in which there is a dramatic change in mood;
the individual is either elated and expansive or irritable. For
the diagnosis to be made, this change in mood must last 1 wk
(or any duration if hospitalization is required). At least three
other symptoms from the following list must be present:
inflated self-esteem or grandiosity; decreased need for sleep;
pressured speech; flight of ideas; distractibility; increased
involvement in goal-directed activities or psychomotor agitation; and overinvolvement in pleasurable activities with
potentially damaging consequences. Examples of this behavior
include hypersexuality, impulsive spending, and other reckless
and dangerous behaviors.
Hypomania is characterized by at least 4 days of abnormally
and persistently elevated, expansive, or irritable mood accompanied by at least three additional symptoms seen in a manic
episode.
About 25% of the first episodes of bipolar disorder occur
before age 20. In women, hormonal factors may account for a
greater rate of rapid cycling (meaning highs and lows in a
short period), but in general, women and men are equally
affected with this disorder. There is no difference in prevalence rates by race or ethnicity. Bipolar disorder is a chronic,
relapsing, and episodic disease. In individuals 40 yr of age or
older who experience a first episode of mania, it is most likely
related to medical conditions such as substance abuse or a
cerebrovascular disorder. About 50% of bipolar patients have
concurrent substance abuse disorders. Cigarette smoking is
significantly more prevalent among individuals with bipolar
disorder than among those without the disorder. Theories that
explain causation of bipolar disorder include disorders in brain
function or structure and genetic factors. Sleep deprivation
may trigger manic/hypomanic episodes.
HEALTH CARE SETTING
Most patients may be treated outpatient except those who
are at high risk for suicide, represent a danger to others, or
are experiencing a psychotic mania. Acute care (inpatient
96
psychiatric unit) stays are brief and focus on restabilization.
Patients with bipolar disorder require long-term medication
management; intensive psychosocial support to function
within the community; and possibly individual, group, and
family therapy.
ASSESSMENT
Similar to depression, the assessment of mania involves much
more than an assessment of mood. This is a holistic disorder
that results in changes in self-attitude (feelings of self-worth),
as well as vital sense (sense of physical well-being) and spiritual sense. Depression diminishes self-worth, self-attitude, and
vital sense, whereas mania may increase these perceptions.
Feelings, attitudes, and knowledge: During manic episodes, patients express inflated views of themselves. Many
manic patients state that they enjoyed being high and because
of this refused medications. After the mania has subsided, the
patient is confronted with the consequences of behaviors and
actions engaged in while manic. Being faced with the reality
of those behaviors and their consequences produces negative
feelings expressed as shame, humiliation, denial, anger, fear of
experiencing a relapse, fear of passing the disorder onto children, and fear of cycling into an episode of depression.
Elevated mood or irritability: Patients may be excessively
cheerful and unusually elated or display irritability over the
smallest matters. This irritability increases when others
attempt to reason with them. A manic person may display a
haughty or superior attitude toward others. He or she may
display overt anger, particularly if his or her requests or behaviors are curtailed.
Increased self-attitude: Patients may express and act in
unusually optimistic fashion, engaging in behaviors that
reflect poor judgment, and may act in inappropriate, dangerous, or indiscreet ways. For example, a normally conservative
person may engage in sexual indiscretions or speak in overly
critical or judgmental terms, often at inappropriate times and
about sensitive subjects.
Increased vital sense: The person with mania has increased
energy and may appear tireless in the face of physical and
mental efforts that would greatly tax unaffected individuals.
He or she may feel completely refreshed after only a few
minutes or hours of sleep.
Spiritual issues: Bipolar disorder mania carries with it
many negative experiences—such as marital and family
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709
PART IV: Psychiatric Nursing Care Plans
710
PART IV
PSYCHIATRIC NURSING CARE PLANS
problems, divorce, legal difficulties, financial ruin, and
unemployment—that contribute to the downward spiral of
self-appraisals. Spirituality is an important, though often a
neglected, aspect of assessment, especially during the acute
episode. Bipolar disorder can lead to a crisis in faith, in self,
others, life, and ultimately God. This loss of faith and hope
contributes significantly to the risk of suicide.
Additional sign: Manic individuals may experience a voracious appetite or may be too busy to eat.
Suicidality: Suicide assessment is critical with manic
patients. The presence of psychotic thinking, hyperactivity,
impulsiveness, and possible substance abuse increases suicide
risk significantly. It is important to ask questions to determine
the presence of suicidal ideation and the lethality of any plan.
Essential questions to ask include:
• Have you thought of hurting yourself?
• Are you presently thinking about hurting yourself?
• If you have been thinking about suicide, do you have a
plan? What is the plan?
• Have you thought about what life would be like if you were
no longer a part of it?
A previous history of suicide attempts places the patient at
high risk for attempting suicide.
DIAGNOSTIC TESTS
There are no diagnostic tests to diagnose bipolar disorder
mania. Diagnosis is made through history, interview of the
patient and family, and observation of verbal and nonverbal
behaviors. To be diagnosed with bipolar disorder, the individual must meet the criteria spelled out in the Diagnostic and
Statistical Manual of Mental Disorders (DSM). The Young
Mania Rating Scale (YMRS) is an effective instrument to
quantify the degree of mania.
Nursing Diagnosis:
Risk for Other-Directed Violence
related to impulsivity/agitation occurring with manic excitement
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: By the time of discharge from an inpatient psychiatric unit, the patient
demonstrates increased self-control and decreased hyperactivity.
ASSESSMENT/INTERVENTIONS
RATIONALES
Continually assess the patient’s response to frustrations or difficult
situations.
This enables early intervention and helps patients manage situations
independently, if possible.
Continually assess to ensure that the patient’s environment is safe.
Remove objects that could be dangerous and rearrange the room to
decrease environmental risks to prevent accidental/purposeful injury
to self or others.
Hyperactive behavior and grandiose thinking can lead to destructive
actions with possible harm to self or others.
Decrease environmental stimuli, assign a private room (if possible),
avoid exposure to situations of predictable high stimulation, and
remove the patient from the area if he or she becomes agitated.
Patients may be unable to focus attention on relevant stimuli and will be
reacting/responding to all environmental stimuli.
Intervene at the earliest signs of agitation. Use direct verbal
interventions prompting appropriate behavior, redirect or remove the
patient from the difficult situation, establish voluntary time-out or
move to a quiet room, use physical control (e.g., hold the patient).
Offer PRN medications.
Early intervention assists patients in regaining control, defuses a difficult
situation, prevents violence, and enables treatment to continue in the
least-restrictive manner.
Note: Physical hold/restraints are used only as a last resort.
Until the patient is calm, avoid analyzing or problem solving regarding
prevention of violence or collecting information about precipitating
events or provoking stimuli.
Any questioning will only add to agitation. Analyze and problem solve
when the patient is calm.
Communicate the rationale for taking action using a concrete, direct,
and simple approach.
People are unable to process complicated communication when they are
agitated or upset.
When the patient is ready to leave the quiet area or time-out location,
allow gradual reentry to the area of greater stimulation.
The patient has diminished tolerance for environmental stimuli; gradual
reentry fosters coping skills.
Do not argue with the patient if he or she verbalizes put-downs or
unrealistic or grandiose ideas.
Arguing only increases agitation and reinforces undesirable behavior.
Ignore and minimize attention given to bizarre dress or use of profanity,
while placing clear limits on destructive behavior.
This avoids reinforcing negative behavior while providing controls for
potentially dangerous behavior.
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Deficient Knowledge
711
Bipolar Disorder (Manic Component)
RATIONALES
Avoid unnecessary delay of gratification when the patient makes a
request. If refusal is necessary, make sure the rationale is given in
nonjudgmental and concrete manner.
Patients in a hyperactive state do not tolerate waiting or delays, which
add to frustration or agitation level. Any unnecessary delays could
trigger aggressive behavior.
Offer alternatives when available.
This uses the patient’s distractibility to decrease the frustration of
having a request refused. For example, “I don’t have any soda.
Would you like a glass of juice?”
When the patient is less agitated and labile, provide information about
alternative problem-solving strategies.
When calm, patients are able to hear and retain information.
When the patient is calm, help to examine the antecedents/precipitants
to agitation.
This promotes early recognition of the developing problem, enabling
patients to plan for alternative responses and intervene in a timely
fashion.
Collaborate with the patient to identify alternative behaviors that are
acceptable to both the patient and staff. Role-play how to use these
behaviors if appropriate.
Patients are more apt to follow through if the alternatives are mutually
agreed on. This practice enables patients to “try on” new behaviors
while calm and ready to learn.
Give positive reinforcement when the patient attempts to deal with
difficult situations without violence.
Praise increases patients’ sense of success and increases likelihood that
desired behaviors will be repeated.
Administer the following medications as prescribed:
Antimanic medications: lithium carbonate (Lithobid, Eskalith),
divalproex sodium (Depakote), valproic acid (Depakene), valproate
(Depacon), carbamazepine (Tegretol), topiramate (Topamax),
oxcarbazepine (Trileptal), tiagabine (Gabitril), and lamotrigine
(Lamictal).
Lithium is the drug of choice for mania and is indicated for alleviation of
hyperactive symptoms. Some patients do not respond to or are
intolerant of lithium and may need alternative medications, which
may include divalproex, carbamazepine, topiramate, valproic acid,
valproate, tiagabine, or lamotrigine.
Atypical antipsychotics with mood-stabilizing effects: olanzapine
(Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), clozapine
(Clozaril), paliperidone (Invega), risperidone (Risperdal Consta,
M-tabs), ziprasidone (Geodon)
Atypicals have been found to be helpful as adjuncts to mood stabilizers.
Olanzapine is well-tolerated and is also helpful in treating the anxiety
symptoms in bipolar depression. Each of the atypical antipsychotics
is effective in managing mania.
Provide restraint or seclusion per agency policy.
These measures may be necessary for brief periods to protect the
patient, staff, and others.
Prepare the patient for electroconvulsive therapy (ECT) if indicated.
In a severely manic episode, ECT may be recommended. ECT is one of
the most effective treatment options and is especially useful for
individuals who are in need of a rapid treatment response, cannot
take or are refusing medications, or do not respond to other
treatment modalities.
Nursing Diagnosis:
Copyright © 2015. Elsevier. All rights reserved.
Deficient Knowledge
related to unfamiliarity with causes, signs and symptoms, and treatment of
bipolar disorder mania
Desired Outcome: Within 24 hr of teaching, the patient and/or significant other verbalize
accurate information about at least two possible causes of bipolar disorder, four signs and
symptoms of the disorder, and available treatment options.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess level of knowledge of the patient and significant other(s)
regarding the causes of bipolar disorder, signs and symptoms of the
disorder, and the available treatment options.
Initially it is difficult to diagnose bipolar disorder. Patients as well as
their significant other(s) may have faulty perceptions about it. Unless
corrected, these faulty perceptions may interfere with treatment
adherence on the part of the patient and weaken support for
treatment adherence from the significant other(s).
continued
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
PART IV: Psychiatric Nursing Care Plans
712
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Inform the patient and significant other that bipolar disorder is a
physiologic disorder caused by the interplay of many factors, such
as imbalance in brain function and structure, psychodynamic
factors, and genetics.
Providing education about the physical basis for the disorder increases
understanding and acceptance and decreases blaming behavior.
Inform the patient and significant other that there are treatments
available for bipolar disorder.
Medications are essential to stabilize and maintain mood. However, they
are not enough. Comprehensive treatment involves intensive
outpatient programs, frequent office visits, crisis telephone calls,
family involvement, and psychosocial interventions including
psychoeducation, suicide prevention, psychotherapy for depression,
and limit setting in mania and hypomania. Management of bipolar
disorder is a lifelong commitment.
Nursing Diagnosis:
Imbalanced Nutrition: Less Than Body Requirements
related to inadequate intake in relation to metabolic expenditures
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: Immediately following interventions, the patient displays increased attention to eating behaviors.
ASSESSMENT/INTERVENTIONS
RATIONALES
Establish a baseline regarding nutritional and fluid intake, as well as
activity level.
This assessment is necessary to quantify deficits, needs, and progress
toward goals.
Weigh the patient daily.
This is another form of quantification that provides information about
therapeutic needs and effectiveness of interventions.
Serve meals in a setting with minimal distractions.
This encourages patients to focus on eating and prevents other
distractions from interfering with food intake.
Stay with the patient during mealtime, even if this means walking with
the patient.
This provides support and encouragement for patients to take in
adequate nutrition and does not set the unrealistic expectation that
patients must sit during mealtime.
Provide finger foods, snacks, and juices.
Patients will most likely eat small frequent meals on the move and this
allows a reasonable accommodation for this behavior.
Enable the patient to choose food when he or she is able to make
choices.
Encouraging choices before patients are ready may add to confusion.
However, if patients are able to handle choices, this increases a
sense of control.
Refer to a dietitian as indicated.
It may be useful to involve an expert in determining patients’ nutritional
needs and the most appropriate options for meeting these needs.
Administer vitamins and mineral supplements as prescribed.
Supplements correct dietary deficiencies and improve nutritional status.
Nursing Diagnosis:
Dressing/Bathing Self-Care Deficit
related to impulsivity and lack of concern
Desired Outcome: Immediately following interventions, the patient performs self-care activities within his or her level of ability.
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713
Bipolar Disorder (Manic Component)
Deficient Knowledge
RATIONALES
Assess the patient’s current level of functioning; reevaluate daily.
Patients’ abilities for self-care may change daily. This information is
needed to plan or modify care.
Provide physical assistance, supervision, simple directions, reminders,
encouragement, and support as needed.
This helps patients focus on the task. Providing only required assistance
fosters independence.
If possible, use the patient’s clothing and toiletries.
Patients may have been disorganized entering the hospital or
hospitalized as an emergency measure, so their own belongings
were left at home. Having personal clothing and supplies supports
autonomy and self-esteem.
As appropriate, limit choices regarding clothing.
During periods of extreme hyperactivity and distractibility, patients may
be unable to make appropriate choices or to care for personal
belongings.
As the patient’s condition improves, set goals to establish minimum
standards for self-care (e.g., taking a bath every other day).
Setting goals promotes the idea that patients are responsible for
themselves and enhances a sense of self-worth.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with medication use, including purpose and potential
side effects of prescribed medications
Desired Outcome: Immediately following teaching interventions, the patient verbalizes accurate information about the prescribed medications.
ASSESSMENT/INTERVENTIONS
RATIONALES
It is vital that the nurse assess the patient’s level of knowledge regarding the
prescribed medications.
Education should be directed to assessed deficits in knowledge
regarding the expected benefits of taking the prescribed drug,
potential side effects, and how to deal with them. Knowledge
increases adherence to taking the prescribed medications.
In simple terms teach the physiologic action of mood stabilizers.
Patients may have little or no understating regarding the purpose
and actions of these medications.
Teach the importance of taking the medication as prescribed and the need
for follow-up blood tests to monitor medication serum level.
The medication requires certain blood levels to be therapeutic, and
therefore patients need to take it at the dose and time interval
prescribed. The scheduled serum evaluations ensure that the
medication level remains within therapeutic range.
Antimanic medications for adults: lithium carbonate (Lithobid, Eskalith,
Duralith) or lithium citrate (Cibalith)
Lithium provides mood stability and prevents dangerous highs and
despairing lows experienced in bipolar disorder.
Copyright © 2015. Elsevier. All rights reserved.
Teach the patient the following:
- How to monitor for swelling of feet or hands, fine hand tremor, mild
diarrhea, muscle weakness, fatigue, memory and concentration difficulties,
metallic taste, nausea or abdominal discomfort, polydipsia, polyuria.
These are common side effects.
- The importance of monitoring intake and output, sodium intake, and
weight and how to elevate legs when sitting or lying down.
These are interventions for the prevention of edema of the feet and
hands.
- The importance of notifying the health care provider if urinary output
decreases.
This may be a sign of increasing serum level of lithium.
- When to notify the prescriber if tremors interfere with work.
A medication that interferes with work may result in compliance
issues. Smaller, more frequent doses may help. In addition,
tremors worsen when patients are anxious.
- The need to take lithium with meals, replace fluids lost secondary to
diarrhea, and notify the prescriber if diarrhea becomes severe.
Some people can have nausea from lithium. At higher doses, loose
stools or even diarrhea are frequently noted. The prescriber
may need to change the medication.
continued
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
Copyright © 2015. Elsevier. All rights reserved.
PART IV: Psychiatric Nursing Care Plans
714
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Caution the patient that if any of the following symptoms occur while taking
lithium—muscle weakness, fatigue, memory problems, or concentration
difficulties—the patient should avoid driving or operating hazardous
equipment during this period, use reminders and cues for memory
deficits, and notify the prescriber if these symptoms become severe.
These are interventions to prevent harm to self and others. The
prescriber may change to another medication.
Encourage the patient to use sugarless candies or throat lozenges and
engage in frequent oral hygiene.
These are interventions for metallic taste and the dry mouth that
can be associated with some medications.
Explain that drinking large amounts of fluids is a normal mechanism for
coping with the side effect of increased urine.
This information provides reassurance for polydipsia.
Explain in simple terms the importance of having laboratory work done as
prescribed as well as being alert to signs and symptoms of lithium
toxicity.
This helps ensure that the serum lithium level is maintained
between 0.6 and 1.2 mEq/L. Mild toxic lithium effects, including
impaired concentration, lethargy, tremor, slurred speech, and
nausea, may be seen at plasma levels of 1.0 to 1.5 mEq/L.
Moderate toxic lithium effects, including confusion,
disorientation, drowsiness, unsteady gait, dysarthria, and
muscle fasciculations, may be seen at plasma levels of 1.6 to
2.5 mEq/L. Severe toxic lithium effects, including impaired
consciousness with progression to coma, delirium, ataxia,
impaired renal function, and convulsions, may be seen at
plasma levels greater than 2.5 mEq/L. Laboratories have
established critically high lithium values that are used for
clinician notification. Usually, these concentrations are greater
than 2.0 mEq/L, although some facilities may consider lithium
concentrations greater than 1.5 mEq/L as their critically high
lithium level (Lum, 2007). Usually, once stabilization is
achieved, laboratory work is done q1-2 wk during the first 2 mo
and q3-6 mo during long-term maintenance.
Caution the patient to avoid alcohol or other central nervous system (CNS)
depressant medications.
These substances may increase serum lithium level. Risk of injury
may increase due to the combination secondary to sedation
and/or dizziness.
Advise the patient to notify the prescriber if pregnant or planning to become
pregnant and to avoid breastfeeding while taking this medication.
Safe use during pregnancy and breastfeeding has not been
established.
Advise the patient to notify the prescriber before taking any other prescription
or over-the-counter (OTC) medication.
Many other medications interact with lithium to either increase or
decrease the serum level. For example, when combined with
lithium, NSAIDs can increase lithium levels in the blood,
resulting in an increased risk for serious adverse effects.
Caution the patient not to discontinue this medication abruptly.
This could lead to exacerbation of manic symptoms.
Antiseizure medications with mood-stabilizing effects: divalproex sodium
or valproic acid (Depakote or Depakene), carbamazepine (Tegretol),
topiramate (Topamax), lamotrigine (Lamictal), oxcarbazepine (Trileptal),
and tiagabine (Gabitril).
These medications are generally used when lithium does not work
or when side effects from lithium are intolerable to the patient.
Atypical antipsychotics with mood-stabilizing effects: olanzapine
(Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), clozapine (Clozaril),
paliperidone (Invega), risperidone (Risperdal Consta, M-tabs), ziprasidone
(Geodon)
Olanzapine is often better tolerated than lithium. Quetiapine is also
effective in treating the anxiety symptoms in bipolar depression.
Each of the atypical antipsychotics is effective in managing
mania.
Teach the patient to be alert for anorexia, nausea, vomiting, drowsiness
(most common), and tremor.
These are common side effects.
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Bipolar Disorder (Manic Component)
Deficient Knowledge
“Major Depression” for:
Hopelessness
p. 727
Risk for Suicide
p. 727
Self-Esteem: Chronic Low
p. 729
PATIENT-FAMILY TEACHING AND
DISCHARGE PLANNING
Copyright © 2015. Elsevier. All rights reserved.
The patient with a bipolar disorder mania experiences a wide
variety of symptoms that affect the ability to learn and retain
information. Patient teaching must be geared to a time when
medication has begun to decrease hyperactive symptoms and
improve abilities to concentrate and learn; otherwise, it is a
wasted effort. Verbal teaching should be simple and supplemented with reading materials the patient and/or significant
other and family can refer to at a later time. Ensure that
follow-up treatment is scheduled and that the patient and/or
significant other and family understand the need to get prescriptions filled and the importance of taking the medication
as prescribed. Consider whether or not the patient has transportation available to get to follow-up treatment. Psychiatric
home care might be a valuable part of the discharge planning
to facilitate adherence to the discharge plan. In addition,
provide the patient and/or significant other/family with verbal
and written information about the following issues:
✓ Medications, including drug name; purpose; dosage; frequency; precautions; drug-drug, food-drug, and herbdrug interactions; and potential side effects.
✓ Importance of laboratory follow-up tests for serum
lithium levels.
✓ Importance of maintaining a healthy lifestyle—balanced
diet, minimal to no caffeine or alcohol, exercise, and
regular adequate sleep patterns—to ensure remaining in
remission.
✓ Importance of continuing medication use for life.
✓ Importance of social support and strategies for obtaining it.
✓ Importance of using community follow-up resources; for
example, psychiatrist, psychiatric nurse, intensive outpatient, support groups, family counseling.
✓ Importance of maintaining or achieving spiritual
well-being.
✓ Referrals to community resources for support and education. Additional information can be obtained by contacting the following organizations:
• Depression and Related Affective Disorders Association (DRADA) at www.drada.org. This nonprofit
organization is composed of individuals with mood
disorders, family members, and mental health professionals. It offers information, education, referral, and
support services to people nationwide. DRADA
sponsors a nationally renowned training program for
group leaders.
• Depression Awareness, Recognition, and Treatment
Program (D/ART), 5600 Fishers Lane, Suite 10-85,
Rockville, MD 20857, (301) 443-4140, Fax: (301)
443-4045. D/ART is a national self-help clearinghouse. It provides a list of resources throughout the
United States that can help in networking and providing consultative assistance.
• Depression and Bipolar Support Alliance (DBSA) at
www.dbsalliance.org. The DBSA provides education
as well as support to individuals and families affected
by depression and bipolar illnesses.
• NAMI is the National Alliance on Mental Illness,
the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. NAMI
advocates for access to services, treatment, support
services, and research. They are steadfast in their
commitment to raise awareness and building a community of hope for all of those in need (www.nami.org).
• The Mood Disorders Society of Canada provides
links to support groups as well as patient education
materials (www.mooddisorderscanada.ca).
• The Canadian Mental Health Society’s website
(www.cmha.ca) provides patient education information and allows the user to search for patient support
services available in the patient’s community.
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PART IV: Psychiatric Nursing Care Plans
ADDITIONAL NURSING
DIAGNOSES/PROBLEMS:
715
Dementia—Alzheimer’s Type
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OVERVIEW/PATHOPHYSIOLOGY
Dementia is a chronic cognitive disorder that is part of a category of psychiatric disorders classified as Neurocognitive Disorders in the 5th edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5; American Psychiatric Association,
2013). Delirium is characterized by an acute change in cognition and consciousness that occurs over a short period of time.
Dementia is characterized by multiple cognitive deficits that
include impairment in memory. The dementias are also classified according to etiology: dementia of the Alzheimer’s type;
vascular dementia; Lewy body disease; frontotemporal degeneration; and neurocognitive disorder due to other general
medical conditions, such as human immunodeficiency virus
(HIV) disease, head trauma, Parkinson’s disease, Huntington’s
disease, Pick’s disease, and Creutzfeldt-Jakob disease; substanceinduced persisting dementia; dementia due to multiple etiologies; and dementia not otherwise specified.
The most common form is Alzheimer’s disease (AD), a
primary dementia accounting for approximately 60%-80% of
dementia cases (Alzheimer’s Association, 2012), and it is the
focus of this care plan. Although AD is age related, it does
not represent the normal process of aging. It occurs with distinctive brain lesions without any certain physiologic basis.
The brain lesions are neurofibrillary tangles and neuritic
plaques that take up space in the brain, replacing normal
tissue in the cell body of the neuron. There are multiple theories to explain the occurrence of AD, including genetic transmission, a decrease in acetylcholine, beta-amyloid activity,
impact of a head injury, mini strokes, lack of estrogen, immunologic factors, effects of a slow-acting virus, and environmental factors.
AD affects more than 5.1 million Americans, making it the
most common neuropsychiatric illness in older adults. Its diagnosis covers deficits in memory, problem solving, attention,
and cognition. The actual course of the disorder follows a
predictable pattern of early, middle, and late stages of progression, each displaying characteristic behaviors and requiring a
different focus of treatment. The early stage is frequently
referred to as the amnestic stage, the middle stage as the dementia stage, and the late stage as the vegetative stage. As the
disease progresses, patients lose control over their bladder and
bowel functions and develop apraxia (incoordination of
movements), and later they lose control over speech and swallowing. Seizures and psychotic symptoms are common in late
stages. Death inevitably occurs as a result of neurologic complications imposed by the brain lesions.
AD represents the clinical prototype for chronic cognitive
disorders. The care required by the Alzheimer’s patient, especially in the middle and late stages of the disorder, is essentially the same care required by all dementia patients regardless
of type. The cognitive symptoms of dementia involve serious
memory impairment, as well as significant alterations in language and perceptual acuity and abilities to abstract, problem
solve, and make appropriate judgments. Patients ultimately
experience loss of all memory (amnesia), agnosia (inability
to recognize objects, people, places), and aphasia (loss of
meaningful verbal communication). Noncognitive behavioral
symptoms can be just as profound. These include significant
personality changes, purposeless movements, agitation and
aggression, overreaction to situations, irritable and repetitive
behavior, and emotional disinhibition.
HEALTH CARE SETTING
In the early stage of AD, care takes place in the home and
primary care setting. By the end of the early stage of the
disease, additional services such as home care and use of adult
day care are needed to safely maintain the patient at home.
At the end of the early stage and moving into the middle
stage, the decision regarding where to place the patient begins.
The patient is generally moved into residential care in the
middle stage, and during the late stage, care is frequently
provided in a skilled nursing facility and sometimes a specialized, locked dementia unit for safety.
ASSESSMENT
Psychiatric assessment
Involves assessment of primary and secondary psychiatric
manifestations of AD and differential diagnosis from psychosis, depression, anxiety, and phobias.
Family history: Dementing illness, psychiatric disease, neurologic disease, substance-use disorders.
Social history: Education, past level of functioning per
occupational history, close relationships and children, current
living situation, and history and present substance use.
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716
97

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Physical assessment
Psychomotor functioning: Difficulty carrying out new or
complex motor tasks is apparent in the early stages; difficulty
carrying out activities such as dressing, eating, and walking
becomes apparent in the middle stages. Unsteadiness of gait
coupled with confusion pose a significant risk for falls during
the middle stages. In addition, marked psychomotor agitation
is common. Restlessness, agitation, and aimless pacing replace
normal motion.
Nutrition and elimination: Eating difficulties may present in
the early stages. The patient may forget that he or she has just
eaten, exhibit lax table manners, fail to know it is mealtime
without prompting, experience changes in taste and appetite,
express denial of hunger or need to eat, and experience weight
loss. As the disease progresses, the patient does not respond
to the need for elimination, which necessitates the caregiver
to plan regular bathroom breaks. Constipation and incontinence of urine and feces become problems. Additionally,
patients may forget to swallow food, which increases risk for
choking and/or aspiration.
Activity and rest: Fatigue increases severity of symptoms,
especially as evening approaches. Patients may reverse days
and nights, with wakefulness and aimless wandering at night
indicative of disturbance of sleep rhythms. Patients may be
content to sit and watch others. The main activity may be
hoarding inanimate objects, hiding articles, wandering, or
engaging in repetitive motions.
717
Hygiene: As the disease progresses, so does dependence on
the caregiver to meet basic hygiene needs. Appearance may
be disheveled, and patients may have body odor. Clothing
may be inappropriate for the situation or weather conditions.
Patients may forget to go to the bathroom and the steps
involved in toileting.
Social assessment: Patients may ignore rules of social
conduct and exhibit inappropriate behavior and disinhibition.
Speech may be fragmented; family roles may be altered/
reversed as patients become more dependent.
Spiritual assessment
An assessment of the patient’s faith tradition, practices, level
of commitment, and connection to a faith community is critical. In the early stage of AD, the patient may have full awareness of the journey that lies ahead, and spirituality may offer
support and comfort in ways that nothing else can. As the
disease progresses and deficits become greater, it is difficult to
assess the patient’s spiritual needs. However, because longterm memory remains intact long after the short-term memory
is gone, patients may still be comforted by spiritual traditions
such as worship services, prayers, and hymns that are a vivid
part of his or her history. Moreover, care of the Alzheimer’s
patient is so demanding that spiritual needs of the caregiver
must be assessed and support provided. A faith community
may provide invaluable assistance in the actual care of the
patient, providing the caregiver with respite and help with
day-to-day activities.
DIAGNOSTIC TESTS
Obtaining an accurate differential diagnosis of dementia is
essential. AD is basically a rule-out disorder; that is, the diagnosis is made after family history, laboratory tests, and brain
imaging eliminate other disorders with similar cognitive deficits. Sources of information needed to make a differential
diagnosis of dementia include a full neurologic assessment,
laboratory tests to rule out metabolic factors, and family
history of the patient’s past behavior and symptom progression. Mini-Cog (or other cognitive screening) and functional
assessment of ADLs provide necessary information. A computed tomography (CT) scan identifies structural deficits.
Brain imaging with positron emission tomography (PET) provides the clinician with information about changes in the
metabolic activity and neurochemical characteristics associated with dementia. Typically, testing of patients in the early
stage of AD reveals a normal electroencephalogram, CT scan,
and magnetic resonance imaging (MRI) study, and generally
laboratory tests are within normal range. A comprehensive
psychiatric assessment provides additional information. Use of
the Functional Assessment Staging Tool (FAST) allows for
staging the disease, recognizing cognitive and functional abilities and deficits of each stage of AD, and enables planning for
the appropriate adjustments to care.
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PART IV: Psychiatric Nursing Care Plans
Medical history: All past and present medical illnesses,
especially cardiovascular; past surgeries; past trauma especially
to the head; allergies; and medications.
Psychiatric history: Psychotic illness; depressive illness;
other psychiatric illnesses; psychiatric symptoms, especially
mood lability and psychotic symptoms; past and current treatments; hospitalizations; suicidal ideation; and violence or
aggression.
Present illness: Length of cognitive loss and degree of
memory loss:
• Is short-term memory loss so significant that the patient is
no longer able to remember and perform activities of daily
living (ADLs)?
• Other presenting problems, physical symptoms and injuries, functional deficits, psychiatric symptoms.
• Personality changes, including low tolerance for normal
frustrations, oversensitivity to remarks of others, lack of
initiative, decreased attention span, diminished emotional
presence, emotional lability, restlessness.
• Difficulty with word finding and comprehension; thought
blocking.
Mental status examination: Appearance, behavior, speech,
mood, hallucinations, delusions, paranoid ideation, anxiety,
phobias, cognition, insight and judgment, behavioral disturbances such as agitation, combativeness, screaming, catastrophic reactions.
Dementia—Alzheimer’s Type
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PART IV: Psychiatric Nursing Care Plans
718
PART IV
PSYCHIATRIC NURSING CARE PLANS
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the disease progression and care of the dementia
patient
Desired Outcome: By the time the diagnosis of AD is confirmed, significant other/family
relay accurate information and expectations about the course of the disease and the role they
will play in the care of their loved one.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the significant other’s/family’s understanding about the disease
process and expected care that will be needed for their loved one.
This assessment enables the nurse to reinforce, as needed, information
about AD and correct any misunderstandings.
Provide information about the staging of the disease and changes to
expect in their loved one.
The family plays an integral role in the care of their loved one. Initially,
they are the informants, providing information that facilitates
diagnosis; they move into role of advocate, then primary caregivers,
and finally the patient supporter. Staging is discussed in the
introductory data.
Provide written information regarding educational resources, such as
The Thirty-Six Hour Day (2012) by Mace and Rabins and
identification of appropriate support groups.
The cited book presents a compilation of family experiences with the
disorder at different stages. Although there are other helpful books,
this one remains the definitive resource for family caregivers.
Support groups for family members offer an ongoing, practical
socioeducational source, even in the early stage. They provide a safe
place to explore issues such as whether or not the patient should
stop driving; whether other people should be told about the
diagnosis; whether the patient should wear an ID bracelet or carry a
card indicating a dementia diagnosis; what the healthy spouse
should do to handle the sexual desires of the affected spouse when
the unaffected spouse no longer feels as though he or she has an
adult relationship.
Coach the family to recall past memories in talking with their loved one.
Families feel more comfortable and are more likely to continue to
interact with the patient if they know that reduced animation in the
patient’s face is part of the disease. Conversation may have
noticeable pauses with less spontaneous speech; conversations
should be short and simple. Reassuring the patient decreases
overconcern about minor matters; touch continues to be important;
and sharing important memories from the past helps maintain links
to the patient even if the response is minimal.
Teach about safety issues.
Safety issues become the responsibility of the caregiver early in the
disorder. The patient with Alzheimer’s needs room to pace and may
fail to notice scatter rugs, spills on the floor, and changes in floor
elevations, which increase the risk for falls. Other safety concerns
deal with wandering, unsteady gait, forgetting the stove is turned on,
and using toxic substances inappropriately.
Provide information about legal matters.
Decisions about durable and health care power of attorney need to be
decided in the early stage of the disease, when the patient is still
competent. Legal counsel may be desirable for decisions regarding
financial matters.
Provide information about health care resources.
The job of the family caregiver is overwhelming. Family members need
to consider use of adult day care centers and varieties of respite
care, even in the early stage of the illness. Use of home health
services also may be of valuable assistance.
Teach strategies to deal with behavioral issues such as wandering,
rummaging, incontinence, difficulty following directions, and
profound memory loss.
The more knowledge the family has regarding strategies to deal with
these various behaviors, the better they will be able to care for the
patient.
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Dementia—Alzheimer’s Type
Impaired Environmental Interpretation Syndrome
719
Risk for Trauma
related to impaired judgment and inability to recognize danger in the
environment
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: The patient remains free of signs and symptoms of trauma/injury.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the degree of impairment in the patient’s abilities. Assist the
caregiver to identify risks and potential hazards that may cause
harm in the patient’s environment and the necessary interventions
that must be made to ensure safety.
Patients with impulsive behavior are at increased risk for harm because
they are less able to control their own behaviors. Patients may have
visual/perceptual deficits that increase risk of falls. Caregivers need
heightened awareness of potential risks in the environment and need
to take appropriate action.
Eliminate or minimize identified environmental risks.
Because a person with a cognitive deficit is unable to take responsibility
for basic safety needs, the caregiver must eliminate as many risks
as possible: take knobs off of stove, remove scatter rugs, place a
safety gate at the top and bottom of stairs, and make sure doors to
the outside are locked.
Routinely monitor the patient’s behavior. Initiate interventions to prevent
negative behaviors from escalating.
Close observation of the patient’s behavior allows early identification of
problematic behaviors (e.g., increasing agitation) and enables early
intervention.
Use distraction or redirection of the patient’s attention when agitated or
dangerous behavior such as climbing out of bed occurs.
Using the patient’s distractibility avoids confrontation or behavioral
escalation and helps maintain safety.
Ensure that the patient wears an ID bracelet providing name, phone
number, and diagnosis. Do not allow the patient to have access to
stairways or exits.
Because of memory deficits and confusion, these patients may not be
able to provide this basic identifying information. The ID bracelet
facilitates the patient’s safe return.
Ensure that doors to the outside are locked. Make sure there is
supervision and/or activities if the patient is regularly awake at night.
Taking appropriate preventive measures facilitates safety without
constant supervision. Activities keep the patient occupied and limit
wandering.
Ensure that the patient is dressed appropriately for weather/physical
environment and individual need.
Patients with cognitive disorders many times experience seasonal
disorientation. In addition, AD affects the hypothalamic gland,
making the person feel cold. The patient is not able to make
appropriate choices regarding dress.
Inspect the patient’s skin during care activities.
Identification of rashes, lacerations, and areas of ecchymosis enables
necessary treatment and signals need for closer monitoring and
protective interventions.
Attend to nonverbal expressions of physiologic discomfort.
The patient may lack the ability to express needs clearly but may give
clues to a problem by grimacing, sweating, doubling over, or
panting.
Monitor for medication side effects; signs of overmedication, for
example, gastrointestinal (GI) upset; extrapyramidal symptoms; and
orthostatic hypotension.
Drugs easily build up to toxic levels in older adults, and the patient may
not be able to report any signs or symptoms that would indicate
drug toxicity.
Nursing Diagnoses:
Chronic Confusion/
Impaired Environmental Interpretation Syndrome
related to physiologic changes/dementia occurring with the progressive course
of AD
Desired Outcome: The patient remains calm and displays fewer undesirable behaviors.
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PART IV: Psychiatric Nursing Care Plans
Nursing Diagnosis:
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PART IV: Psychiatric Nursing Care Plans
720
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the degree of confusion experienced by the patient with AD
and how much short-term memory the patient still retains.
In the middle stage of AD individuals have only about 5 min of short-term
memory and no longer can learn. This fact carries with it significant
environmental safety issues that must be confronted. For instance, a
person could exit from the home or facility where he/she resides and
may become lost.
Provide a predictable environment with orientation cues.
A calm environment with scheduled activities, adequate lighting, low noise
level, calendars, clocks, and frequent verbal orientation helps maintain
the patient’s sense of calm and security.
Always address the patient by name.
Patients may respond to their own name long after they no longer recognize
their significant others. Names are an integral part of self-identity; using
the person’s name is a part of reality orientation.
Communicate with the patient using a low voice, slow speech, and
eye contact.
Deliberate communication techniques such as these increase the patient’s
attention and chance for comprehension. Calm begets calm.
Break directions into a simple step-by-step process, giving one
direction at a time and using simple and clear words.
As the disease progresses, the patient’s ability to comprehend complex
directions and interactions diminishes greatly. Direct simplicity is the key
to effective communication.
Encourage the patient’s response, allow pauses in interaction, and
use open-ended comments and phrases.
These interventions invite a verbal response.
Listen carefully to the content of the patient’s speech even if it is
incomprehensible.
The patient may be having difficulty processing and decoding messages.
However, listeners need to continue to show interest and encouragement
to keep communication going.
Offer interpretations regarding the patient’s statements, meanings,
and words. If the patient struggles to find a word, supply the
word if possible.
Assisting patients in processing words promotes continuing communication
efforts and decreases frustration.
Avoid negative comments, taking argumentative stands,
confrontations, and criticism.
These aggressive responses only serve to increase frustration, agitation, and
inappropriate behaviors. Cognitively impaired patients have no internal
controls over their thinking and communications.
Listen carefully to the patient’s stories.
As memory continues to fail, patients are unable to reenter the reality of
their caregivers. To argue or reason with the patient only causes more
anxiety. It is more important to provide an emotional connection with the
patient than to correct the details of his or her stories.
Monitor for hallucinations. Observe the patient for verbal and
nonverbal cues of responding to hallucinations. Validate the
presence of the patient’s hallucinatory experiences.
Validating that the patient is hearing voices allows some discussion of fears
associated with the experience and permits assurance that the
experience is part of the illness.
Allow the patient to hoard safe objects within reason.
This provides patients with a sense of security.
Provide musical stimulation using selections that would have been
popular during the patient’s adolescent and early adult years.
Music is a powerful intervention. People who no longer can speak can many
times sing. Music can calm an agitated mood and encourage
socialization and movement.
Provide useful and productive outlets for the patient to engage in
repetitive activities, for example, folding and unfolding laundry,
collecting junk mail, dusting, and sweeping floors.
This measure acknowledges that repetitive activities are a normal expression
of illness but channels these activities in a way that increases the
patient’s self-esteem and may decrease restlessness.
Ensure that the environment is quiet, calm, and visually
nondistracting.
These qualities help to avoid visual/auditory overload.
Provide touch to the patient in a caring way.
Touch enhances perception of self and body boundaries, as well as
communicates caring.
Use reminiscence therapy with props such as photo albums, old
music, historic events, and mementos. Encourage the patient to
talk about memories and feelings attached to these items.
This measure aids in preservation of self by recalling past accomplishments
and events, increases the patient’s sense of security, and encourages
sharing that keeps the patient linked to others socially.
Encourage intellectual activity such as word games, discussion of
current events, and story telling.
This provides patients with normalcy and connection to others and the world
and stimulates remaining cognitive abilities.
Suggest that the caregiver accompany the patient on short outings
in the car, taking walks, and going shopping.
This decreases sense of isolation, increases physical stamina, and provides
sensory pleasure.
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721
Dementia—Alzheimer’s Type
Risk for Caregiver Role Strain
PART IV: Psychiatric Nursing Care Plans
Nursing Diagnosis:
Grieving
related to awareness on the part of the patient and significant other/family
that something is seriously wrong as changes in memory and behaviors are
increasingly evident
Desired Outcome: The patient and family discuss loss and participate in planning for the
future.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess for and encourage the patient and family to discuss feelings
associated with anticipated losses.
This conveys the message that grief is a normal and expected
reaction to the diagnosis of AD, with which progression and
decline are certain.
Acknowledge expressions of anger and statements of despair and
hopelessness, such as, “I and my family would be better off if I were
dead.”
Feelings of anger may be the patient’s way of dealing with
underlying feelings of despair. Despairing and hopeless
statements may be indicative of suicidal ideation. These should
be explored and appropriate action taken to protect the patient
from self-directed violence (see Risk for Suicide, p. 727, in
“Major Depression”).
Provide honest answers and do not give false reassurances or gloomy
predictions.
Honesty promotes a trusting relationship and open communication.
False reassurances or predictions of gloom are not helpful.
Discuss with the patient and significant other/family ways they can plan for
the future. Recognize and respect generational and cultural differences.
Participation in problem solving increases a sense of control.
Effective communication, respect, and compassion are
strengthening (Donald W. Reynolds Foundation, 2013).
Emphasize that this is a disease in which research is active and ongoing, as
well as the possibility the disease will progress slowly.
Real hope may exist for the future.
Assist the patient, significant other, and family to identify strengths they see
in themselves, each other, and in available support systems.
This emphasizes that there are supports and resources to help
work through grief.
Encourage the family to participate in a support group for caregivers of
Alzheimer’s patients.
Support groups not only provide valuable information but also
communicate to caregivers that they are not alone as they
struggle to manage the illness.
Nursing Diagnosis:
Risk for Caregiver Role Strain
Copyright © 2015. Elsevier. All rights reserved.
related to severity of the patient’s illness, duration of care required, and complexity and number of care-giving tasks required
Desired Outcome: The caregiver exhibits behaviors consistent with a healthy lifestyle.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the caregiver’s physical/emotional/spiritual condition and the
care-giving demands that are present.
This assessment helps to determine individual care needs of the
caregiver.
Determine the caregiver’s level of responsibility, involvement in, and
anticipated duration of care involved.
This helps the caregiver realistically assess what is involved in a
commitment to providing care.
Identify strengths of the caregiver and the patient.
This identifies positive aspects of each so that they may be incorporated
into daily activities.
Encourage the caregiver to discuss personal perspectives and views
about the situation.
This allows venting of concerns and provides opportunities for validation
and acceptance of the caregiver’s issues.
continued
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PART IV: Psychiatric Nursing Care Plans
722
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Explore available supports and resources. Facilitate decision-making
regarding the least restrictive, safe living environments.
This enables evaluation of adequacy of current resources. For example,
“What is currently used? Is it effective? What else is needed?” This
allows patients to maintain a level of personal independence (Donald
W. Reynolds Foundation, 2013).
Encourage and offer to facilitate family conferences to develop a plan for
family involvement in care activities.
The more people involved in care, the less risk that one person will
become overwhelmed.
Identify additional resources, including financial, legal, and respite care.
These issues of concern can add to the burden of caregiving if not
resolved.
Identify equipment needs/resources and other environmental
adaptations.
Appropriate equipment and environmental modifications promote patient
safety and ease the care burden on the primary caregiver. An
Occupational Therapy consult may be helpful.
Teach caregiver/family techniques and strategies to deal with acting out
and disoriented behaviors, as well as incontinence and other
physical challenges.
This increases a sense of control and competency of the caregiver and
family.
Teach the caregiver the importance of continuing own activities.
Risk of caregiver burden, burnout, and stress is greatly diminished if the
caregiver takes time for self, for example, continuing a hobby,
pursuing social activities, and taking care of personal needs.
Encourage and help the caregiver/family to plan for changes that may
be necessary, such as home care services, use of adult day care,
and eventual placement in a long-term facility.
Planning is essential for these eventualities. As the disease progresses,
the burden of care outstrips the resources of the caregiver.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the rationale, potential side effects, and interventions for side effects of the prescribed medications
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: Immediately following teaching, the caregiver and/or family verbalize
accurate information about the rationale for use of certain medications, their common side
effects, and methods for dealing with those side effects.
ASSESSMENT/INTERVENTIONS
RATIONALES
In the early stages of AD for the patient, as well as ongoing for the
caregivers and/or family, assess their knowledge level regarding the
use of cholinesterase inhibitors and/or memantine as part of the
treatment plan for AD.
As the disease progresses and the patient’s memory continues to
deteriorate, the caregiver’s and/or family’s role in administering and
monitoring the effects of the prescribed medications becomes
increasingly important.
Describe the physiologic action of cholinesterase inhibitors and how
they improve cognition.
There are four cholinesterase inhibitors. Tacrine (Cognex) was the first
to be developed and is no longer prescribed. The three others in this
category, including donepezil (Aricept), rivastigmine tartrate (Exelon),
and galantine (Razadyne, formerly Reminyl) do not cure AD. Instead,
they slow cognitive decline by slowing the breakdown of
acetylcholine released by intact cholinergic neurons.
Describe the physiologic action of memantine and the rationale for
including it in the medication regimen along with a cholinesterase
inhibitor.
Memantine (Namenda) is an NMDA receptor antagonist that targets
glutamate, the main excitatory neurotransmitter, and blocks the
glutamate from attaching to nerve cells. Specifically, memantine
targets the N-methyl-D-aspartate receptors, another chemical and
structural system involved in memory. Researchers believe that too
much stimulation of nerve cells by glutamate may be responsible for
the degeneration of nerves that occurs in some neurologic disorders
such as AD. It is the first medication to be developed that targets
symptoms during the moderate to severe stages of AD. It is taken in
conjunction with a cholinesterase inhibitor.
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Dementia—Alzheimer’s Type
Deficient Knowledge
RATIONALES
Advise the patient, caregiver, and family that these medications ideally
will return the patient’s function to the level that was present
6-12 mo before the medication was started.
This is a significant improvement and may delay nursing home
placement for as much as a year.
Teach the side effect profile of the specific prescribed medication and
methods for dealing with those effects as follows:
Knowledge about expected side effects and adverse effects is important
for promoting adherence to the therapeutic regimen.
- Be alert for headache, fatigue, dizziness, confusion, nausea,
vomiting, diarrhea, upset stomach, poor appetite, abdominal pain,
rhinitis, and skin rash.
These are common side effects, which, if severe, should be reported to
the prescriber for possible decrease in dosage or gradual
discontinuation.
- Take the medication exactly as prescribed around the clock and on
an empty stomach.
This helps ensure medication effectiveness.
- However, if GI upset occurs, administer with meals.
A full stomach may decrease gastric upset.
- Maintain appointments for regular blood work and medical follow-up
while adjusting to the medication.
This is especially important if the patient has preexisting medical
conditions, such as renal, liver, or cardiac disease, because these
medications may affect these organs.
- Caution is necessary for patients with renal and hepatic disease,
seizures, sick sinus syndrome, and GI bleeding.
These medications can worsen these conditions.
- Avoid concomitant use with nonsteroidal antiinflammatory drugs.
Explore any herbs or supplements taken in conjunction with
prescriptions.
Concomitant use may increase effects and risk of toxicity. Potential
drug-herb interactions should be examined.
See care plans for “Anxiety Disorders,” p. 705, “Major Depression,” 
p. 730, and “Schizophrenia,” p. 735, for a review of antidepressants,
anxiolytics, and antipsychotic medications.
Patients with AD may also suffer from depression, anxiety, and
psychosis at a clinically significant severity. If depression or anxiety
symptoms are severe, psychotropic medications may be indicated
and can significantly decrease distress.
“Psychosocial Support for the Patient’s Family and
Significant Other” for nursing diagnoses as
appropriate
p. 84
“Anxiety Disorders” for Compromised Family Coping
p. 705
“Bipolar Disorder” for Imbalanced Nutrition: Less
Than Body Requirements
p. 712
PATIENT-FAMILY TEACHING AND
DISCHARGE PLANNING
The patient with dementia—Alzheimer’s type—progresses
through predictable stages, each with characteristic symptoms
and behaviors that directly affect the ability to effectively
process and use new information. As the disease progresses,
the patient requires increasing amounts of physical care, and
the caregiver/family require information and support. Dementia is a family disease.
As soon as the diagnosis is made, education and support of
the family begins. They need information on the nature and
expected progress of the disease and use of memory triggers;
establishment of a schedule for basic activities, such as bathing,
toileting, meals, and naps; monitoring for intake and output,
weight, and skin status; recognition of nonverbal indications
of needs and problems; use of redirection and distraction to
reduce difficult behaviors; identification of new symptoms or
changes; physical and mental activities; necessary environmental modifications, safety measures, and legal issues; sources
of information and support; and community resources for caregiving assistance and respite.
Teaching must be geared to a time when medication has
begun to lift mood and clear thinking processes; otherwise, it
is a wasted effort. Verbal teaching should be simple and supplemented with reading materials the patient and family can
refer to at a later time. Ensure that follow-up treatment is
scheduled and that the patient and/or significant other and
family understand the need to get prescriptions filled and to
consistently take medication as prescribed. Consider whether
or not the patient has transportation available to get to
follow-up treatment. Psychiatric home care might be a valuable part of the discharge planning to facilitate compliance
with the discharge plan and for caregiver support. In addition,
provide the patient and/or significant other and family with
verbal and written information about the following issues:
✓ Nature and expected course of AD.
✓ Medications, including drug name; purpose; dosage; frequency; precautions; drug-drug, food-drug, and herbdrug interactions; and potential side effects.
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
ADDITIONAL NURSING
DIAGNOSES/PROBLEMS:
Copyright © 2015. Elsevier. All rights reserved.
723
✓
✓
✓
✓
✓
✓
✓
✓
PART IV
PSYCHIATRIC NURSING CARE PLANS
Strategies to deal with difficult behaviors.
Strategies to maintain patient safety.
Importance of self-care for the caregiver.
Importance of using all available supports to aid in
caregiving.
Importance of caregiver and family engaging in honest
expression of feelings and confronting negative
emotions.
Importance of caregiver using relaxation techniques to
minimize stress.
Importance of maintaining or achieving spiritual wellbeing for the patient and caregiver.
Referrals to community resources for support and education. Additional information can be obtained by contacting the following organizations:
• Alzheimer’s Association at www.alz.org. It provides
a 24-hour hotline, free publications, and information
for local chapters. Worship Services for People with
Alzheimer’s Disease and Their Families: A Handbook is
also available through this organization.
• American Association of Retired Persons (AARP) at
www.aarp.org. This is an advocacy group for elderly;
it also provides (for a reasonable fee) training materials associated with reminiscence therapy.
• National Institute on Aging (NIA) at www.nia.nih.gov.
Alzheimer’s Disease Education and Reference
Center (ADEAR) is available through NIA, which
provides electronic newsletters and evidence-based
resources.
• The Alzheimer Society of Canada at www.alzheimer.ca
Copyright © 2015. Elsevier. All rights reserved.
PART IV: Psychiatric Nursing Care Plans
724
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Major Depression
Copyright © 2015. Elsevier. All rights reserved.
OVERVIEW/PATHOPHYSIOLOGY
Major depression is one of the mood disorders, a category
of disorders characterized by profound sadness or apathy,
irritability, or elation. These disorders rank among the
most serious and poorly diagnosed and treated of the health
problems in the United States. Major depression is defined
as an illness characterized by either depression or the loss
of interest in nearly all activities. The symptoms must be
present for at least 2 wk. At least four other symptoms must
be present from the following list: changes in appetite or
weight, sleep, and psychomotor activity; feelings of worthlessness and guilt; difficulty concentrating or making decisions;
and recurrent thoughts of death or suicidal ideation, plans, or
attempts.
Major depression affects emotional, cognitive, behavioral,
and spiritual dimensions. Depression may range from mild-tomoderate states to severe states with or without psychotic
features. Major depression can begin at any age, although it
usually begins in the mid-20s and 30s. The risk factors for
depression include prior history of depression, family history
of depression, prior suicide attempts, female gender, age of
onset younger than 40 yr, postpartum period, medical comorbidity, lack of social support, stressful life events, personal
history of sexual abuse, and current substance abuse. There
are many theories to explain causation of depression. Research
supports influence of the following factors: sleep disturbance;
effects of pharmacologic substances, including many of the
antihypertensive, steroidal, cardiovascular, and antipsychotic
medications; neuronal factors that involve injury or malfunction of the brain, such as stroke, Parkinson’s disease, and
deficiencies in neurotransmitters; thyroid dysfunction; genetic
factors; and psychodynamic factors.
HEALTH CARE SETTING
Primary care provider, psychiatrist, psychologist, or psychiatric
nurse practitioner with occasional brief acute care hospitalization in a psychiatric unit for severe depression, especially if
there is a serious suicide threat.
ASSESSMENT
The assessment of major depression involves much more than
an assessment of mood. It is a disorder that results in changes
in the following:
98
Feelings, attitudes, and knowledge: Sadness, lack of joy
and happiness about anything, shame, humiliation, fear of
stigma if others find out about depression, denial, anger, fear
of experiencing a relapse, and fear of passing the disorder on
to children.
Signs of low mood: Withdrawal from activities that once
provided pleasure, as well as from social interactions; negativism and unhappiness expressed in persistent sadness or frequent crying.
Signs of lowered self-worth: Self-deprecating, guilty, or
self-blaming comments are common; hopelessness.
Signs of decreased physical well-being: A depressed person
may neglect personal appearance or let assignments, tasks, and
projects slide. Decreased energy is common, with the depressed
person complaining of fatigue and inanition (exhaustion; lack
of vigor or enthusiasm). A decreased ability to concentrate
makes problem solving difficult. Decision making also may be
difficult.
Spiritual issues: Depression carries with it many negative
experiences, such as marital and family problems, divorce, and
unemployment, which contribute to the downward spiral of
self-appraisals. Depression can lead to a crisis in faith in self,
others, life, and ultimately God. This loss of faith and hope
contributes significantly to the risk of suicide.
Additional signs: Some depressed individuals experience
decreased appetite leading to weight loss. Others experience
an increase in appetite and weight gain. A change in sleep
pattern is characteristic of depression, with difficulty falling
asleep, middle of the night awakening, and/or awakening in
the early morning hours being common. Others may experience a need for excessive sleep and have difficulty awakening.
A decline in sexual interest and activity is characteristic of
depressed individuals.
Suicidality: Suicide assessment is critical with depressed
patients and includes questions to determine the presence of
suicidal ideation and the lethality of any plan. Essential questions to ask include:
• Have you thought of hurting yourself?
• Are you presently thinking about hurting yourself?
• If you have been thinking about suicide, do you have a
plan?
• What is the plan?
• Have you thought about what life would be like for others,
if you were no longer a part of it?
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725
PART IV: Psychiatric Nursing Care Plans
726
PART IV
PSYCHIATRIC NURSING CARE PLANS
A previous history of suicide attempts combined with
depression places the patient at higher risk in the present for
attempting suicide. A patient whose depression is lifting is at
higher risk for suicide than a severely depressed individual,
because increased energy usually is manifested before improved
mood. This increased energy is not enough to make the
patient feel good or hopeful, but it is enough to carry out a
suicidal plan.
nonverbal behaviors. Laboratory tests that can rule out a
medical basis for depression symptoms include thyroid and
liver function tests. A number of effective scales are available
to quantify the degree of depression, such as the Zung SelfRating Depression Scale, the Beck Depression Inventory, the
Hamilton Depression Scale, and the Geriatric Depression
Scale. The SAD PERSONS scale for suicide assessment is also
useful and easy to use.
DIAGNOSTIC TESTS
The diagnosis of depression is made through history, interview
of the patient and family, and observation of verbal and
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the causes, signs and symptoms, and treatment
of depression
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: By discharge (if inpatient) or after 4 wk of outpatient treatment, the
patient and significant other verbalize accurate information about at least two of the possible
causes of depression, four of the signs and symptoms of depression, and use of medications,
psychotherapy, and/or electroconvulsive therapy (ECT) as treatment.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s and significant other’s knowledge about
depression and its causes.
Depression is a physiologic disorder caused by the interplay of many
factors such as stress, loss, imbalance in brain chemistry, and
genetics. Many people believe that depression is caused by character
weakness. This belief contributes to the stigma experienced by the
person suffering with depression and interferes with seeking
treatment.
Inform the patient and significant other about the major symptoms of
depression.
Many people believe depression equates with sadness and fail to
recognize the many other signs and symptoms that make this a
holistic disorder. These include sadness and loss of interest in normal
activities, plus at least four of the following: changes in appetite or
weight, sleep, interest in sex, or psychomotor activity; feelings of
worthlessness and guilt; difficulty concentrating or making decisions;
recurrent thoughts of death or suicidal ideation, plans, or attempts. If
the depressed individual displays sadness through irritability, the
conclusion that depression is present may be missed and,
consequently, necessary treatment may be delayed or avoided
entirely.
Explain that depression is treatable.
Medications are usually indicated for treatment. They do not solve the
stressors or problems that may have precipitated or resulted from the
depression, but they provide the energy to deal with these issues. A
combination of antidepressants and psychotherapy generally helps to
relieve the symptoms of depression in weeks. Psychotherapy alone
may be indicated for mild depression related to situational causes.
Explain about the use of ECT if this is appropriate.
ECT may be used to treat patients who do not respond to antidepressant
medications after several trials and psychotherapy. It is generally well
tolerated and is given as a series of treatments, usually between 6
and 12 on a 3×/week basis under brief anesthesia. The patient and
significant other/family may fear ECT due to misinformation in media
portrayals; thus if it is recommended, it provides an opportunity for
education that presents ECT as a positive treatment alternative.
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Major Depression
Risk for Suicide
727
Hopelessness
related to losses, stressors, and the burdensome symptoms of depression
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: By discharge (if inpatient) or by the end of 4 wk of outpatient treatment,
the patient verbalizes feelings and acceptance of life situations over which he or she has no
control, demonstrates independent problem-solving techniques to take control over life, and
does not demonstrate or verbalize suicidality.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess individual signs of hopelessness.
This helps focus attention on areas of individual need. These signs may
include decreased physical activity, social withdrawal, and
comments made by patients that indicate hopelessness and despair.
Assess unhealthy behaviors used to cope with feelings.
The patient may have tried to overcome feelings of hopelessness with
harmful and ineffective behaviors (e.g., withdrawal, substance
abuse, avoidance). Recognizing these behaviors provides an
opportunity for change.
Encourage the patient to identify and verbalize feelings and perceptions.
The process of identifying feelings that underlie and drive behaviors
enables patients to begin taking control of their lives.
Express hope to the patient with realistic comments about the patient’s
strengths and resources.
Patients may feel hopeless, but it is helpful to hear positive expressions
from others.
Help the patient identify areas of life that are under his or her control.
A patient’s emotional state may interfere with problem solving.
Assistance may be required to identify areas that are under his or
her control and to have clarity about options for taking control.
Encourage the patient to assume responsibility for self-care, for
example, setting realistic goals, scheduling activities, and making
independent decisions.
Helping patients set realistic goals increases feelings of control and
provides satisfaction when goals are achieved, thereby decreasing
feelings of hopelessness.
Help the patient identify areas of life situations that are not within his or
her ability to control. Discuss feelings associated with this lack of
control.
The patient needs to recognize and resolve feelings associated with
inability to control certain life situations before acceptance can be
achieved and hopefulness becomes possible.
Encourage the patient to examine spiritual supports that may provide
hope.
Many people find that spiritual beliefs and practices are a great source
of hope.
Conduct a suicide assessment to determine the level of suicide risk.
High risk will necessitate hospitalization.
Teach the patient about crisis intervention services such as suicide
hotlines and other resources.
It is vital to provide patients with resources for support and safety when
thoughts and feelings about suicide become difficult to manage.
Administer antidepressant medication or teach the importance of taking
medication as prescribed (see Deficient Knowledge related to
unfamiliarity with medication use in depression, including potential
side effects), later.
For additional interventions, see Risk for Suicide, which follows.
Suicidal thinking is a symptom of depression that is ameliorated through
appropriate medication.
Nursing Diagnosis:
Risk for Suicide
related to depressed mood and feelings of hopelessness
Desired Outcome: By discharge (if inpatient) or by the end of 4 wk (if outpatient), the
patient expresses and demonstrates that he or she is free of suicidal thinking.
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PART IV: Psychiatric Nursing Care Plans
Nursing Diagnosis:
PART IV: Psychiatric Nursing Care Plans
728
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Complete an initial suicide assessment (see specific questions under
“Assessment”). Consider using a standardized assessment tool
such as SAD PERSONS suicide risk assessment scale.
The degree of hopelessness expressed by the patient is important in
assessing risk for suicide. The more the patient has thought out the
plan, the greater the risk. Risk for suicide is increased if the patient has
a history of a previous attempt or there is family history of suicide and
depression. Patients who display impulsive behaviors are more likely to
attempt suicide without giving clues. Patients who are experiencing
psychotic thinking, especially when there are “voices” that encourage
self-harm, are at great risk. Use of alcohol/substance abuse in the
presence of any of the above risk factors increases the overall risk for
a suicide attempt. A high risk for suicide should prompt hospitalization.
Reassess for suicidality, especially during times of change.
Changes such as the patient’s mood improving, medication regimen being
altered, discharge planning being initiated, and increasing withdrawal
are all signals to reassess suicidality. Suicide risk is greatest in the first
few weeks after treatment is begun. The patient may be feeling a little
better but not well enough to feel hopeful and may have regained
enough energy to actually act on suicidal thoughts.
Administer antidepressant medication or instruct the patient regarding
the importance of taking medication as prescribed.
Suicidal thinking is a symptom of depression, which is ameliorated through
appropriate medication.
Teach the significant other safety precautions and to be alert for
changes in the patient’s behavior and/or verbalization that would
indicate an increase in suicidal thinking.
Using available support provides a safety net for the patient and
communicates that he or she is not alone but that others are concerned
and involved in care.
Copyright © 2015. Elsevier. All rights reserved.
If the patient is hospitalized, implement the following:
- Monitor at least q15min for moderate risk, preferably staggering
monitoring times so that the patient does not take advantage of a
guaranteed window of time to engage in suicidal behavior. Provide
constant one-on-one observation for serious risk. Place the patient
in a room close to the nurses’ station. Do not assign to a single
room. Accompany the patient to all off-unit activities or restrict
him or her to the unit. Ask the patient to remain in view of the
staff at all times.
Providing close observation may prevent suicidal attempts.
- Remove items such as belts, scarves, razor blades, shoelaces,
scissors—anything that could be used for self-harm. Check all
items brought into the unit by patients. Instruct family members to
avoid bringing into the unit any hazardous items.
This provides environmental safety and removes potential suicide weapons.
- Provide supervision when the patient is in the bathroom—the
door must remain open with a staff member outside.
It is important to remove all opportunities to engage in self-harmful
behaviors.
- Perform a mouth check to make sure the patient swallows
medications that are administered.
This prevents saving up medications to overdose or discarding and not
taking.
- Ensure that nursing rounds are made at frequent but irregular
intervals, especially at times that are predictably busy for the staff
such as a change of shift.
It is important that staff surveillance not be predictable; otherwise, patients
would be able to identify a possible suicide time. In addition, it is
essential to maintain awareness of the patient’s location at all times.
- Routinely check the environment for hazards and ensure
environmental safety.
Minimizing opportunities for self-harm (e.g., keeping doors, windows, and
access to stairways and the roof locked and monitoring cleaning,
chemical, and repair supplies) is an ongoing concern requiring constant
vigilance.
- Initiate a safety plan with the patient.
Involving the patient in creating a safety plan advances trust between the
patient and nurse while promoting self-care and monitoring.
The safety plan may include a set of actions the patient agrees to initiate
when suicidal feelings increase, e.g., approaching the nurse for
one-on-one interactions, requesting a prn medication to reduce anxiety,
and creating a list of friends or support persons the patient can call.
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729
Major Depression
Chronic Low Self-Esteem
Grieving
related to actual, perceived, or anticipated loss
Desired Outcome: By discharge (if inpatient) or by the end of 4 wk of outpatient treatment,
the patient demonstrates progress in dealing with stages of grief at his or her own pace,
participates in work/self-care activities at his or her own pace, and verbalizes a sense of
progress toward resolution of grief and hope for the future.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess losses that have occurred in the patient’s life. Discuss the
meaning these losses have had for the patient.
Many people deny the importance/impact of a loss. They fail to
recognize, acknowledge, or talk about their pain and act as if
everything is fine. This has a cumulative effect on the individual.
Denial requires physical and psychic energy. When individuals
become clinically depressed, they likely do so in a physically and
emotionally depleted state.
Discuss cultural practices and religious beliefs and ways in which the
patient has dealt with past losses.
Cultural practices and religious beliefs influence how people express
and accept the grieving process.
Encourage the patient to identify and verbalize feelings and examine the
relationship between feelings and the event/stressor.
Verbalizing feelings in a nonthreatening environment can help patients
deal with unrecognized/unresolved issues that may be contributing
to depression. It also helps patients connect the response (feeling) to
the stressor or precipitating event.
Discuss healthy ways to identify and cope with underlying feelings of
hurt, rejection, and anger.
This helps expand the patient’s repertoire of coping strategies.
If indicated, tell stories of how others have coped with similar situations.
This not only provides possible solutions but also suggests that the
problem is manageable.
Teach the normal stages of grief and acknowledge the reality of
associated feelings, such as guilt, anger, and powerlessness.
This information helps the patient realize the normalcy of feelings and
may alleviate some of the guilt generated by these feelings.
Help the patient name the problem, identify the need to address the
problem differently, and fully describe all aspects of the problem.
Before patients can agree to change, they need clarity about what the
problem is.
Help the patient identify and recognize early signs of depression and
plan ways to alleviate these signs. Assist with formulating a plan that
recognizes the need for outside support if symptoms continue and/or
worsen.
This actively involves the patient and conveys the message that the
patient is not powerless but rather that options are available.
Nursing Diagnosis:
Copyright © 2015. Elsevier. All rights reserved.
Chronic Low Self-Esteem
related to repeated negative reinforcement of self-appraisal, which is symptomatic of depression
Desired Outcome: By discharge (if inpatient) or after 4 wk of outpatient treatment, the
patient demonstrates behaviors consistent with increased self-esteem.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s level of self-esteem.
It is essential to identify the manifestations of low self-esteem, including
neglect of personal hygiene and dress, withdrawal from social activities,
and self-deprecatory comments, any of which signals a negative thought
pattern.
Encourage the patient to engage in self-care grooming activities.
Attending to grooming is often an initial step in feeling better about oneself.
continued
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PART IV: Psychiatric Nursing Care Plans
Nursing Diagnosis:
PART IV: Psychiatric Nursing Care Plans
730
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Provide positive reinforcement for all observable accomplishments.
Patients with low self-esteem do not benefit from flattery or insincere
praise. Honest, positive feedback enhances self-esteem.
Encourage the patient to participate in simple recreational activities
or art projects, proceeding to more complex activities in a group
setting.
Initially patients may be too overwhelmed to engage in activities that involve
more than one person.
If the patient persists in negativism about self, place a limit on the
length of time you will listen to negativity.
Time limits allow patients a safe time and place to vent negative feelings
and demonstrate thought stopping, the conscious interruption of negative
thoughts. For example, agree to 10 min of negativity followed by 10 min
of positive comments.
Teach thought-stopping techniques and positive reframing.
Many depressed people engage in self-critical thinking and need to be
taught to consciously stop that type of thinking and substitute positive
thinking in its place.
Explore the patient’s personal strengths and suggest making a list to
use as a reminder when negative thoughts return.
Having a written list to review can help patients during difficult times.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with medication use in depression, including potential
side effects
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: By discharge (if inpatient) or after 4 wk of outpatient treatment, the
patient verbalizes accurate information about the prescribed medications and their potential
side effects.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s knowledge level regarding the use of medication to
improve depressive symptoms.
It is essential to ascertain what patients know and do not know
about the medications prescribed to treat their depression.
Frequently patients hold faulty and inaccurate views about
medications, which interfere with adherence to a prescribed
medication regimen.
Teach the physiologic action of the prescribed antidepressant and how it
alleviates symptoms of depression.
Many depressed patients resist taking medications because they fear
becoming “addicted”; however, antidepressants are not addictive
drugs. Providing the patient with information about the medication’s
physiologic action helps with adherence.
Caution about the importance of taking the medication at the prescribed
dose and time interval.
Some medications require certain blood levels to be therapeutic;
therefore, patients need to take them at the dose and time prescribed.
Teach the side-effect profile of the specific prescribed medication,
including interventions to combat these effects, for the following:
Each class of antidepressants carries with it a specific side-effect
profile. Knowledge about expected side effects, ways to manage
these side effects, and the length of time these side effects last is
important in ensuring adherence.
Tricyclic antidepressants: amitriptyline (Elavil), desipramine
(Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline
(Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil). For
more information, see this nursing diagnosis in “Anxiety Disorders,”
p. 705.
These older antidepressant medications are effective in decreasing signs
and symptoms of depression but can produce some troublesome
anticholinergic side effects, including urinary hesitancy or retention,
dry mouth, blurred vision, fatigue, weight gain, and orthostatic
changes, some of which are transient in nature. Additionally, they
can cause cardiac QT prolongation (heart block); therefore, ECGs
must be monitored intermittently.
Selective Serotonin Reuptake Inhibitors (SSRIs): fluoxetine (Prozac),
fluvoxamine maleate (Luvox), sertraline HCl (Zoloft), paroxetine (Paxil),
citalopram (Celexa), and escitalopram (Lexapro). For more information,
see this nursing diagnosis in “Anxiety Disorders,” p. 705.
SSRIs are as effective as tricyclic antidepressants but have a better
safety profile and are generally better tolerated. These agents
enhance serotonergic function by inhibiting serotonin uptake, which
increases bioavailability, thus promoting an antidepressant effect.
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Major Depression
Deficient Knowledge
731
RATIONALES
Dual-mechanism agents: venlafaxine (Effexor), nefazodone HCl
(Serzone), mirtazapine (Remeron), duloxetine (Cymbalta), and
desvenlafaxine (PRISTIQ).
These medications inhibit both norepinephrine and serotonin uptake and
are used when tricyclics and SSRIs fail to improve symptoms.
- Teach the importance of frequent blood pressure (BP) measurements
for patients taking venlafaxine. For more information, see this
nursing diagnosis in “Anxiety Disorders,” p. 705.
At doses greater than 200 mg/day, venlafaxine causes an increase in
BP.
Selective Norepinephrine Reuptake Inhibitor: reboxetine (Vestra)
This medication blocks reuptake of norepinephrine.
Norepinephrine-Dopamine Reuptake Inhibitor: bupropion (Wellbutrin)
This medication blocks reuptake of both norepinephrine and dopamine.
- Teach the patient to be alert for anticholinergic side effects,
decreased libido, and the potential for drug interactions.
These are common side effects.
- Be aware of the risk for seizures.
Risk increases with bupropion although seizures have been reported
with reboxetine use as well.
Miscellaneous antidepressants: trazodone (Desyrel), amoxapine
(Asendin), and maprotiline (Ludiomil)
Copyright © 2015. Elsevier. All rights reserved.
Teach the patient the following:
- Watch for anticholinergic effects (except trazodone) such as urinary
hesitancy or retention, dry mouth, blurred vision, sedation,
hypotension, and risks of falling related to dizziness associated with
hypotension.
These are common side effects and can be managed by encouraging
patients to drink sufficient water and avoid exertion in high
temperatures and activities that require mental alertness while
adjusting to the medication.
- Be aware of the risk for seizures.
Risk is moderate with trazodone and increases with amoxapine and
maprotiline.
- Be aware of the risk of cardiac toxicity. Patients older than 40 yr
need an ECG evaluation before treatment and periodically thereafter.
Risk is minimal with amoxapine and trazodone. There is significant risk
with maprotiline.
MAO inhibitors: isocarboxazid (Marplan), phenelzine (Nardil),
tranylcypromine (Parnate), selegiline transdermal
MAO inhibitors are used when patients have not responded to other
antidepressants. When MAO activity is reduced in the CNS, there is
increased dopamine, serotonin, norepinephrine, and epinephrine at
the receptor sites, thereby promoting an antidepressant effect.
- Teach the patient to be alert to the potential for mild sedation and
hypotension.
These are common side effects.
- Teach the patient about MAO inhibitor restrictions.
MAO inhibitors combined with dietary tyramine can cause a lifethreatening hypertensive crisis. Dietary restrictions include avocados;
fermented bean curd; fermented soybean; soybean paste; figs;
bananas; fermented, smoked, or aged meats; liver; bologna,
pepperoni, and salami; dried, cured, fermented, or smoked fish;
practically all cheeses; yeast extract; some imported beers; Chianti
wine; protein dietary supplements; soups that contain protein extract;
shrimp paste; and soy sauce. Large amounts of chocolate, fava
beans, ginseng, and caffeine may also cause a reaction. The
transdermal form of the MAO inhibitor selegiline does not require
dietary restrictions.
- Teach the patient to watch for possible drug interactions and the
need to avoid all prescription and over-the-counter drugs unless they
have been specifically approved by the provider.
MAO inhibitors can interact with many medications to cause potentially
serious results. Use of ephedrine or amphetamines can lead to
hypertensive crisis. The interaction of tricyclic antidepressants with
MAO inhibitors can cause severe hypertension. Selective serotonin
reuptake inhibitors (SSRIs) should not be used with MAO inhibitors
because together they can cause serotonin syndrome, a potentially
life-threatening event. Symptoms include anxiety, diaphoresis, rigidity,
hyperthermia, autonomic hyperactivity, and coma. Because of this
possibility, MAO inhibitors should be withdrawn at least 14 days before
starting an SSRI, and when an SSRI is discontinued, at least 5 wk
should elapse before an MAO inhibitor is given. Antihypertensive drugs
combined with MAO inhibitors may result in excessive lowering of
blood pressure. MAO inhibitors with meperidine (Demerol) can cause
hyperpyrexia (excessive elevation of temperature).
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
PART IV: Psychiatric Nursing Care Plans
732
PART IV
PSYCHIATRIC NURSING CARE PLANS
ADDITIONAL NURSING
DIAGNOSES/PROBLEMS:
“Anxiety” for Social Isolation
p. 704
“Bipolar Disorder” for:
Imbalanced Nutrition: Less Than Body Requirements
p. 712
Dressing/Bathing Self-Care Deficit
p. 712
“Substance-Related and Addictive Disorders” for
Dysfunctional Family Processes
p. 741
PATIENT-FAMILY TEACHING AND
DISCHARGE PLANNING
Copyright © 2015. Elsevier. All rights reserved.
Patients with major depression experience a wide variety of
symptoms that affect their ability to learn and retain information. Teaching must be geared to a time when medication has
begun to lift their mood and clear thinking processes; otherwise, it is a wasted effort. Verbal teaching should be simple
and supplemented with reading materials the patient and/or
significant other and family can refer to at a later time. Ensure
that follow-up treatment is scheduled and that the patient
and/or significant other and family understand the need to get
prescriptions filled and the importance of taking medication
as prescribed. Consider whether or not the patient has transportation available to get to follow-up treatment. Psychiatric
home care might be a valuable part of the discharge planning
to facilitate adherence to the discharge plan. In addition,
provide the patient and/or significant other/family verbal and
written information about the following issues:
✓ Remission/exacerbation aspects of depression.
✓ Medications, including drug name; purpose; dosage; frequency; precautions; drug-drug, food-drug, and herbdrug interactions; and potential side effects.
✓ Thought-stopping techniques for dealing with
negativism.
✓ Importance of maintaining a healthy lifestyle—balanced
diet, exercise, and regular adequate sleep patterns—to
facilitate remaining in remission.
✓ Importance of continuing medication use long after
depressive symptoms have gone.
✓ Importance of social support and strategies for obtaining it.
✓ Importance of using constructive coping skills to deal
with stress.
✓ Importance of honest expression of feelings and confronting of negative emotions.
✓ Importance of using relaxation techniques to minimize
stress.
✓ Importance of maintaining or achieving spiritual
well-being.
✓ Importance of follow-up care, including day treatment
programs, appointments with psychiatrist and therapists, and vocational rehabilitation program if
indicated.
✓ Referrals to community resources for support and education. Additional information can be obtained by contacting the following organizations:
• Depression and Related Affective Disorders Association (DRADA) at www.drada.org. This nonprofit
organization is composed of individuals with mood
disorders, family members, and mental health professionals. It offers information, education, referral, and
support services to people nationwide. DRADA
sponsors a nationally renowned training program for
group leaders.
• Depression Awareness, Recognition, and Treatment
Program (D/ART) at (301) 443-4140. D/ART is a
national self-help clearinghouse. It provides a list
of resources throughout the United States that
can help in networking and providing consultative
assistance.
• Depression and Bipolar Support Alliance (DBSA) at
www.dbsalliance.org. The DBSA provides education
as well as support to individuals and families impacted
by depression and bipolar illnesses.
• The Canadian Mental Health Association at www
.cmha.ca
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Schizophrenia
OVERVIEW/PATHOPHYSIOLOGY
Schizophrenia is a neurobiologic disorder of the brain categorized as a thought disorder with disturbances in thinking,
feeling, perceiving, and relating to others and the environment. Schizophrenia is a mixture of both positive and negative symptoms that are present for a significant part of a 1-mo
period but with continuous signs of disturbances persisting for
at least 6 mo. It is characterized by delusions, hallucinations,
disorganized speech and behavior, and other symptoms that
cause social or occupational dysfunction.
Schizophrenia is considered one of the most disabling of
the major mental disorders, with an estimated 2.4 million or
about 1.1 percent of Americans afflicted. It can occur at any
age, but it tends to first develop (or at least become evident)
between adolescence and young adulthood. Risk factors
include maternal starvation and infections during fetal development, complications during childbirth, childbirth that
occurs in late winter or early spring, and living in an urban
environment. Theories of causation include genetics, autoimmune factors, neuroanatomic changes, the dopamine hypothesis (people with schizophrenia appear to have excessive
dopamine levels), and psychologic factors. There are several
subtypes of schizophrenia, including paranoid, disorganized,
catatonic, undifferentiated, and residual.
Copyright © 2015. Elsevier. All rights reserved.
HEALTH CARE SETTING
Most patients with schizophrenia receive treatment across a
variety of settings, including inpatient and partial hospitalization (day treatment), psychiatric home care, and crisis
stabilization units. Community services include assertive community treatment, outpatient therapy, case management, and
psychosocial rehabilitation.
ASSESSMENT
Schizophrenia affects many aspects of a person’s being. How
the individual looks, feels, thinks, interacts with others, and
moves in the world are all drastically affected by this disorder.
A thorough assessment focuses not only on the bizarre behaviors characteristic of the disease but on the whole person—his
or her physical, emotional, social, and spiritual dimensions.
Biologic: A thorough history and physical are essential to
rule out a medical illness or substance abuse that could cause
the psychiatric symptoms. It is essential to screen for comorbid
99
treatable medical illnesses. People with schizophrenia have a
higher mortality rate from physical illness and often have
smoking-related illnesses such as emphysema and other
pulmonary and cardiac disorders. The patient may appear
awkward and uncoordinated, with poor motor skills and
abnormalities in eye tracking.
Psychologic: Many patients report prodromal symptoms of
tension and nervousness, lack of interest in eating, difficulty
concentrating, difficulty in making choices, disturbed sleep,
decreased enjoyment and loss of interest, poor hygiene, restlessness, forgetfulness, depression, social withdrawal from
friends, feeling that others are laughing at them, feeling bad
for no reason, thinking about religion more, hearing voices or
seeing things, and feeling too excited. These symptoms are
often ignored and may result in treatment delays.
Appearance: Patients may appear in bizarre and eccentric
dress, be disheveled, and have poor hygiene.
Objective behaviors: Patients may display stereotypy (idiosyncratic, repetitive, purposeless movements), echopraxia
(involuntary imitation of another’s movements), and waxy
flexibility (posture held in odd or unusual fixed position for
extended periods). Patients may display altered mood states
ranging from heightened emotional activity to severely limited
emotional responses. Affect, the outward expression of mood,
may be described as flat, blunted, or full range, or it may be
described as inappropriate. Other common emotional symptoms include affective lability, ambivalence, and apathy.
Delusions: Delusions are beliefs that are held despite clear
contradictory evidence. Sometimes they are plausible; at other
times the delusions expressed are bizarre, implausible, and not
derived from ordinary life experiences. Delusions of persecution are the most common type. Delusions of grandeur are also
commonly expressed. Ideas of reference are delusional ideas
in which patients believe actions of others are directed toward
them. Two other forms of delusional thinking include thought
broadcasting—the belief that one’s thoughts can be heard by
others—and thought insertion—the belief that thoughts of
others can be inserted into one’s mind. It is important to assess
content of the delusion; the degree of conviction with which
the delusion is held; how extensively other aspects of the
patient’s life are incorporated into the delusion; the degree of
internal consistency, organization, and logic evidenced in the
delusion; and the impact exerted on the patient’s life by this
delusion.
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733
Copyright © 2015. Elsevier. All rights reserved.
PART IV: Psychiatric Nursing Care Plans
734
PART IV
PSYCHIATRIC NURSING CARE PLANS
Hallucinations: A hallucination is an alteration in sensory
perception. Although hallucinations can be experienced in
all sensory modalities, auditory hallucinations are the most
common in schizophrenia. Patients may not spontaneously
share their hallucinations, and in order to assess for them,
nurses may need to rely on observations of the patient’s behavior, including pauses in a conversation during which the
patient seems to be preoccupied or appears to be listening to
someone other than the interviewer, looking toward the perceived source of a voice, or responding to the voices in some
manner.
Disorganized communication: Both speech content and
patterns are important to assess. Abrupt shifts in conversational focus are typical of disorganized communication and are
referred to as loose association. The most severe shifts may
occur after only one or two words, referred to as word salad—a
jumble of unrelated words. A less severe shift may occur after
one or two phrases, referred to as flight of ideas. The least severe
shift in the focus occurs when a new topic is repeatedly suggested and pursued from the current topic, referred to as tangentiality. In addition to abrupt shifts from one topic to another,
the person with schizophrenia experiences thought blocking,
in which thoughts and psychic activity unexpectedly cease.
Language may be difficult to understand and may begin to
serve as a tool of self-expression rather than a tool of communication. Sometimes the person creates completely new
words, referred to as neologisms.
Cognitive impairments: Although cognitive impairments
vary widely from patient to patient, several problems are consistent across most patients; these include hypervigilance
(increased and sustained attention to external stimuli over an
extended time), a diminished ability to distinguish relevant
from irrelevant stimuli, familiar cues going unrecognized or
being improperly interpreted, and diminished information
processing leading to inappropriate or illogical conclusions
from available observations and information.
• Memory and orientation: Individuals with schizophrenia
display impairments in memory and abstract thinking.
Although orientation to time, place, and person remains
relatively intact unless the person is preoccupied with delusions and hallucinations, all aspects of memory are affected
in schizophrenia. Patients may experience a diminished
ability to recall within seconds newly learned information.
Both short- and long-term memories are often affected.
• Insight and judgment: Insight and judgment depend on cognitive functions that are frequently impaired in people with
schizophrenia.
Social issues: As the disorder progresses, individuals
become increasingly socially isolated. People with
schizophrenia have difficulty connecting with others on a
one-to-one basis. Emotional blunting, inability to form emotional attachments, problems with face and affect recognition,
inability to recall past interactions, problems making decisions
or using appropriate judgment in difficult situations, and
poverty of speech and language all serve to separate and isolate
the individual.
Spiritual issues: Persons with schizophrenia may experience delusions and hallucinations with religious content, and
some health care providers tend to dismiss religious verbalizations as psychotic expressions. However, the contrary is true.
Religion and spirituality can be a source of comfort to patients
dealing with a terrible disease. It is important to assess religious commitment, religious practices, and spiritual issues
such as the meaning of the illness to the individual, the role
of God, and sources of hope and support.
Suicidality: Suicide assessment is critical in schizophrenia.
The presence of psychotic thinking and command hallucinations, coupled with possible substance abuse, increases the
suicide risk significantly. It is important to ask questions to
determine the presence of suicidal ideation and the lethality
of any plan. Essential questions to ask include:
• Have you thought of hurting/killing yourself?
• Are you presently thinking about hurting/killing yourself?
• If you have been thinking about suicide, do you have a
plan? What is the plan?
• Have you thought about what the life of others would be
like if you were no longer a part of it?
• Consider using the SAD PERSONS suicide assessment
tool to quantify the risk of suicide.
DIAGNOSTIC TESTS
There are no specific tests to diagnose schizophrenia. Diagnosis is made using the diagnostic criteria put forth in The
Diagnostic and Statistical Manual-5 (American Psychiatric
Association, 2013). Diagnosis is made through history,
interview of the patient and family, and observation of
verbal and nonverbal behaviors. There are several reliable
rating scales that are useful in the assessment of schizophrenia.
These include the Scale for the Assessment of Negative
Symptoms (SANS), Scale for the Assessment of Positive
Symptoms (SAPS), Positive and Negative Syndrome
Scale (PANSS), and the Brief Psychiatric Rating Scale
(BPRS).
The Abnormal Involuntary Movement Scale (AIMS), and
Simpson-Angus Rating Scale are tools used to evaluate movement abnormalities related to medications. These tools are
beneficial in assessing severity of extrapyramidal symptoms or
tardive dyskinesia.
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735
Schizophrenia
Deficient Knowledge
PART IV: Psychiatric Nursing Care Plans
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the causes, signs and symptoms, and treatment
of schizophrenia
Desired Outcome: Before discharge from the care facility or after 4 wk of outpatient treatment, the patient and/or significant other verbalize accurate information about at least two
of the possible causes of schizophrenia, four of the signs and symptoms of the disorder, and
the available treatment options.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s and significant other’s understanding of
schizophrenia.
Schizophrenia is a physiologic disorder caused by the interplay of many
factors such as stress, genetics, infectious-autoimmune factors,
neuroanatomic changes, the dopamine hypothesis, and psychologic
factors. Providing education about the physical basis for the disorder
increases understanding and acceptance and decreases blaming
behavior.
Explain that there are treatments available for schizophrenia.
Medications are essential to stabilize and maintain patients with
schizophrenia. They decrease psychotic thinking, hallucinations, and
delusions. Some, but not all, drugs target negative symptoms.
However, medications are not enough. Comprehensive treatment
involves inpatient and partial hospitalization, day treatment,
psychiatric home care, and crisis stabilization. Community services
include assertive community treatment, outpatient therapy, case
management, and psychosocial rehabilitation.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the medications used in schizophrenia, including
their purpose and potential side effects
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: Before discharge from the care facility or after 4 wk of outpatient treatment, the patient verbalizes accurate information about the prescribed medications.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s knowledge about the physiologic action of
antipsychotic medications.
Education should be directed to assess deficits in knowledge regarding
the expected benefits of taking the prescribed drug, potential side
effects, and how to deal with them. Knowledge increases adherence
to taking the prescribed medications.
Teach the following side-effect profiles of the specific prescribed
medication, as well as interventions to mitigate the effects.
A knowledgeable patient is likely to report adverse symptoms and know
how to intervene properly for others, which optimally will promote
adherence.
Typical (1st-generation) antipsychotic agents: chlorpromazine
(Thorazine), thioridazine (Mellaril), mesoridazine (Serentil), loxapine
(Loxitane), perphenazine (Trilafon), trifluoperazine (Stelazine),
thiothixene (Navane), fluphenazine (Prolixin), haloperidol (Haldol), and
pimozide (Orap)
Typical antipsychotics block all dopamine receptors in the central
nervous system (CNS) and can produce serious movement disorders,
referred to as extrapyramidal side effects (EPS).
Explain that sedation, orthostatic hypotension, and anticholinergic effects
can occur.
These are common side effects of traditional antipsychotic agents.
continued
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PART IV: Psychiatric Nursing Care Plans
736
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Teach the patient to be alert for EPS, including acute dystonia (impaired
muscle tone), parkinsonism, akathisia (restlessness, agitation), and
tardive dyskinesia (involuntary movements of the face, trunk, and
limbs) using the AIMS.
These are adverse effects of traditional antipsychotic drugs, with tardive
dyskinesia being the most serious. Use of AIMS enables objective
quantification of changes in movements and permits early
intervention before the appearance of tardive dyskinesia. AIMS shall
be assessed at least once every 6 months or more frequently as
necessary by symptom assessment or as determined by the
prescribing practitioner.
Explain the potential for neuroleptic malignant syndrome (NMS).
This is an idiosyncratic hypersensitivity to antipsychotics that is believed
to affect the body’s thermoregulatory mechanism. It is a rare but
serious reaction that carries with it a 4% risk of mortality. Symptoms
include high fever, sweating, unstable blood pressure, stupor,
muscular rigidity, and autonomic dysfunction. Early identification of
and treatment for individuals with neuroleptic malignant syndrome
improve outcome.
Caution the patient that there is a risk for seizures.
Antipsychotics can reduce the seizure threshold and should be used
with caution for patients with epilepsy or other seizure disorder.
Teach the importance of avoiding all products with anticholinergic
actions, including antihistamines and specific over-the-counter
sleeping aids.
Products with anticholinergic properties intensify the anticholinergic
responses to antipsychotic drugs, including dry mouth, constipation,
blurred vision, urinary hesitancy, and tachycardia.
Explain the importance of avoiding alcohol and other medications with
CNS-depressant actions, for example, antihistamines, opioids, and
barbiturates.
Antipsychotics can intensify CNS depression caused by alcohol and
other medications.
For patients taking Thorazine, Mellaril, Prolixin, Trilafon, or Stelazine,
teach the importance of avoiding excessive exposure to sunlight,
using sunscreen, and wearing protective clothing.
These medications belong to the phenothiazine class, which causes
sensitization of the skin to ultraviolet light, thus increasing the
chance of severe sunburn.
Teach the patient that sexual dysfunction is a possible side effect and
should be reported to the prescriber rather than stop the medication.
It is important that the patient not discontinue the medication abruptly,
but rather report it so that the prescriber can intervene accordingly.
Atypical (2nd-generation) antipsychotic agents: clozapine (Clozaril),
risperidone (Risperdal Consta, M-tabs), olanzapine (Zyprexa),
quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify),
lurasidone (Latuda), asenapine (Saphris), iloperidone (Fanapt), and
Paliperidone (Invega)
Atypical antipsychotics are more selective in blocking specific dopamine
receptors. Because of this, they have less risk of EPS.
Explain that patients taking clozapine should be watchful for drowsiness
and sedation, hypersalivation, tachycardia, constipation, and postural
hypotension.
These are common side effects.
Explain that patients taking clozapine need weekly hematologic
monitoring for the first 6 mo of treatment, and after 6 mo,
monitoring is monthly. Advise the patient that clozapine will not be
dispensed if a blood test is not done.
Agranulocytosis occurs in 1%-2% of patients, with an overall risk of
death of about 1 in 5000. Agranulocytosis usually occurs in the first
6 mo.
Caution that patients taking clozapine, especially those with seizure
disorder, are at risk for seizures.
Generalized tonic-clonic seizures occur in 3% of patients, and the risk is
dose related, with higher incidence in patients receiving doses
greater than 600 mg. Patients who have experienced a seizure
should be warned not to drive a car or participate in other potentially
hazardous activities while on this medication.
Explain that patients taking clozapine should avoid medications that can
suppress bone marrow function, such as carbamazepine (Tegretol)
and many cancer drugs. Cimetidine and erythromycin increase levels
of clozapine, leading to toxicity. Smoking, Tegretol, and phenytoin
can decrease levels of clozapine, diminishing its efficacy.
These are drug-to-drug interactions that can occur when they are
combined with clozapine.
Advise patients taking risperidone that there is a risk for insomnia,
agitation, anxiety, constipation, nausea, dyspepsia, vomiting,
dizziness, and sedation.
These are common side effects.
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Schizophrenia
Deficient Knowledge
RATIONALES
Advise patients taking risperidone to be watchful for EPS.
This is an adverse effect that is dose related (reported in doses greater
than 10 mg/day).
Explain that patients taking olanzapine should be watchful for headache,
insomnia, constipation, weight gain, akathisia, and tremor.
These are common side effects.
Explain that patients taking quetiapine should be watchful for headache,
somnolence, constipation, and weight gain.
These are common side effects.
Caution patients taking ziprasidone (Geodon) who have a history of
cardiac disease, low electrolyte levels, or family history of QT
prolongation that they are at risk for electrocardiogram changes,
specifically QT prolongation.
This is a common side effect.
“Anxiety Disorders” for Ineffective Coping
p. 704
Compromised Family Coping
p. 705
“Bipolar Disorder” for Dressing/Bathing Self-Care
Deficit
p. 712
Imbalanced Nutrition: Less than body requirements
p. 712
Risk for other-directed violence
p. 710
“Major Depression” for:
Hopelessness
p. 727
Risk for Suicide
p. 727
Self-Esteem: Chronic Low
p. 729
PATIENT-FAMILY TEACHING AND
DISCHARGE PLANNING
Patients with schizophrenia experience a wide variety of
symptoms that affect their ability to learn and retain information. Teaching must be geared to a time when medication has
begun to decrease the psychotic symptoms, thoughts are more
organized, and communication is more effective. Verbal teaching should be simple and supplemented with reading materials
that the patient and/or significant other and family can refer
to at a later time.
Most patients with schizophrenia experience memory deficits, so retention of new information does not come easily.
Repetition and attention to clarity and simplicity of teaching
approaches and materials facilitate learning. Ensure that
follow-up treatment is scheduled and that the patient and/or
significant other and family understand the need to get prescriptions filled and to take medications as prescribed. Consider whether or not the patient has transportation available
to get to follow-up treatment. Psychiatric home care might be
a valuable part of the discharge planning to facilitate adherence to the discharge plan. In addition, provide the patient
and/or significant other/family with verbal and written information about the following issues:
✓ Medications, including drug name; purpose; dosage; frequency; precautions; drug-drug, food-drug, and herbdrug interactions; and potential side effects.
✓ Importance of laboratory follow-up tests if the patient is
taking Clozaril.
✓ Importance of maintaining a healthy lifestyle—balanced
diet, minimal to no caffeine or alcohol, exercise, limit
the amount of smoking, and regular adequate sleep
patterns—to facilitate remaining in remission.
✓ Importance of continuing medication use, probably for
a lifetime.
✓ Importance of social support and strategies to obtain it.
✓ Importance of using community resources, for example,
psychiatrist, psychiatric nurse, intensive outpatient
support groups, family counseling, psychosocial programs including club houses, and other patient-run
support groups.
✓ Importance of following up with medical care, as well
as psychiatric care.
✓ Importance of maintaining or achieving spiritual
well-being.
✓ Referrals to community resources for support and education. Additional information can be obtained by contacting the following organizations:
• Johnson & Johnson Patient Assistance Foundation,
Inc. (JJPAF) provides access to medicines for uninsured individuals who lack the financial resources to
pay for them (1-800-652-6227).
• Lilly Cares Patient Assistance Program, at Eli Lilly
and Company, Lilly Corporate Center, Indianapolis,
IN 46285, (800) 545-6962. This program was
designed to assist providers, patients, and the patient
caregivers through reimbursement support and temporary provision of Zyprexa and other drugs at no
charge to eligible patients.
• National Alliance for the Mentally Ill (NAMI)
at www.nami.org. Contact NAMI chapter in
local state for information and schedule or contact
national office of NAMI. The NAMI Family to
Family Education Program is a 12-session
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
ADDITIONAL NURSING
DIAGNOSES/PROBLEMS:
Copyright © 2015. Elsevier. All rights reserved.
737
PART IV
PSYCHIATRIC NURSING CARE PLANS
comprehensive course for families of people with
serious mental illnesses.
• Mental Illness Education Project, Inc., at
www.miepvideos.org, has a videotape for families
and mental health professionals entitled, “Families
Coping with Mental Illness.”
• MedicAlert Foundation at www.medicalert.org provides a simple tool to ensure that people with schizophrenia receive proper care in an emergency
department or to help family members find a loved
one who has stopped taking medication and is experiencing behavioral problems in public. MedicAlert
has a program for people who cannot afford the membership fees.
• National Institute of Mental Health (NIMH) Public
Inquiries at www.nimh.nih.gov has a booklet prepared
by the Schizophrenia Research Branch titled,
“Schizophrenia: Questions and Answers” (DHHS
Publication No. ADM 90-1457).
• National Alliance for Research on Schizophrenia
and Depression (NARSAD) at www.narsad.org
• Schizophrenia Society of Canada at www
.schizophrenia.ca
• American Psychiatric Association: Healthy
Minds TV—Living with Schizophrenia, at http://
www.psychiatry.org/mental-health/more-topics/healthyminds-tv
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PART IV: Psychiatric Nursing Care Plans
738
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Substance-Related and
Addictive Disorders
Copyright © 2015. Elsevier. All rights reserved.
OVERVIEW/PATHOPHYSIOLOGY
Substance use disorders are a major health issue in the United
States. The connection between substance use and social and
health problems is well documented and includes such issues
as an increase in illegal and violent activities associated with
the sale and distribution of illegal drugs, major health problems including the spread of human immunodeficiency virus
(HIV) and other communicable diseases among intravenous
(IV) drug users, developmental issues of “crack babies” born
to addicted mothers, fetal alcohol syndrome babies, low-birthweight babies, and domestic violence and child abuse and
neglect. Deaths caused by motor vehicular accidents are
directly linked to alcohol consumption. In addition, there are
a full range of medical complications that are a direct result
of alcohol use disorders, including cardiovascular, respiratory,
hematologic, nervous, digestive, endocrine, metabolic, skin,
musculoskeletal, and genitourinary problems, as well as nutritional deficiencies.
According to the Diagnostic and Statistical Manual of Mental
Disorders-5 (DSM-5; American Psychiatric Association
[APA], 2013), the essential feature of a substance use disorder
is a cluster of cognitive, behavioral, social, and physiologic
symptoms indicating that the individual continues using a
substance despite significant substance-related problems and
dangers. There is an underlying change in brain circuits
that may persist beyond detoxification. The distinction
between substance abuse and substance dependence made in
DSM-IV-TR has moved toward a DSM-5 diagnosis for each
substance based on a continuum from mild to severe:
mild (2-3 symptoms), moderate (4-5 symptoms), and severe
(6 or more symptoms). Each substance the person uses will
receive its own diagnosis in relation to its severity on this
spectrum, e.g., Alcohol Use Disorder—Severe; Stimulant Use
Disorder—Moderate.
Identifying the specific drug(s) used is essential for individualized treatment of toxicity and withdrawal. However, it
is the outcome of psychoactive drug use, shared in common
by all drug classifications, that is most likely to account for
the problems associated with the disorder. These properties
include acute and chronic structural and functional changes
in the brain associated with drug intake; variable effects
on the person taking the drugs; tolerance and reinforcing
properties that are unique characteristics of most psychoactive
100
substances and are not found in other pharmacologic classifications; and the treatment concepts of recovery and relapse
prevention after cessation of drug intake.
HEALTH CARE SETTINGS
Treatment of substance use disorders occurs over the full range
of the health care continuum. Acute detoxification usually
takes place in an acute care/hospital facility. However, longterm care takes place in various community settings: outpatient or partial hospitalization therapy, vocational supports,
family therapy, residential programs, and employee assistance
programs. Treatment adjuncts include support group programming such as Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA).
ASSESSMENT (ALCOHOL USE DISORDER)
Assessment focuses on alcohol use disorder (or alcoholism) as
a prototype for the category of Substance Use Disorders because
it constitutes the most frequently used and misused psychoactive substance in the United States.
Major symptoms supportive of a diagnosis of alcohol use
disorder:
• Withdrawal symptoms
• Tolerance, as evidenced by needing more alcohol to get the
same effect or consuming the same amount with less effect.
• Indiscriminate or regular drinking (or cravings) despite
social or medical contraindications.
• Significant interference with psychosocial functioning in
family and job relationships.
• Drinking in hazardous situations or arrests for driving while
under the influence of alcohol.
Assessment interview: This should include family history,
history of drug use, and a description of behavior patterns
described above. It is important to ask about preexisting
mental disorders, metabolic conditions, cardiac and gas
exchange problems, prescribed medications, and head injuries,
all of which have symptoms that sometimes mimic acute
intoxication or withdrawal symptoms.
Psychologic symptoms, behavior patterns, and defense
mechanisms: The patient uses denial to insist that she or he
does not have a problem despite concrete evidence to the
contrary. Rationalization appears in the form of self-imposed
rules that explain the person’s drinking habits as legitimate.
Statements may be made such as, “I only drink on weekends”
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739
Copyright © 2015. Elsevier. All rights reserved.
PART IV: Psychiatric Nursing Care Plans
740
PART IV
PSYCHIATRIC NURSING CARE PLANS
or “I limit myself to a beer, none of the hard stuff for me.”
Projection is evidenced in the blaming of external forces for
stimulating the need to drink, for example, a nagging spouse
or a stressful job. Blackouts occur when there is a neuronal
irritability that erases the memory of behaviors while under
the influence.
Physical indicators/examination:
• Activity/rest: Difficulty sleeping, not feeling well rested.
• Cardiovascular: Peripheral pulses weak, irregular, or rapid;
hypertension common in early withdrawal stage from
alcohol but may become labile and progress to hypotension
as withdrawal progresses; tachycardia common in early
withdrawal; dysrhythmias may be identified; other abnormalities depending on underlying heart disease/concurrent
drug use.
• Elimination: Diarrhea, varied bowel sounds resulting from
gastric complications such as gastric hemorrhage or
distention.
• Nutrition and fluid intake: Nausea, vomiting, and food
intolerance; difficulty chewing and swallowing food; muscle
wasting; dry, dull hair; swollen salivary glands, inflamed
buccal cavity, capillary fragility (malnutrition); possible
generalized tissue edema resulting from protein deficiency;
gastric distention, ascites, liver enlargement (seen in cirrhosis with long-term use).
• Pain/discomfort: Possible constant upper abdominal
pain and tenderness radiating to the back (pancreatic
inflammation).
• Respiratory: History of smoking; recurrent/chronic respiratory problems; tachypnea (with hyperactive state of
alcohol withdrawal); diminished breath sounds.
• Neurosensory: Internal shakes or tremors, headache, dizziness, blurred vision, blackouts.
• Psychiatric: Possible dual diagnoses of mental illness, for
example, schizophrenia, bipolar disorder, and major depressive disorder.
• Level of consciousness/orientation: Confusion, stupor,
hyperactivity, distorted thought processes, slurred/
incoherent speech.
• Affect/mood/behavior: May be fearful, anxious, easily
startled, inappropriate, irritable, labile, physically/verbally
abusive, depressed, or paranoid.
Withdrawal assessment: Monitor the patient q4-6h with
Clinical Institute Withdrawal Assessment—Alcohol, Revised
(CIWA-Ar) until the score is less than 10 for 24 hr, when
medication for withdrawal is usually no longer necessary.
• Early symptoms (6-12 hr after alcohol use cessation):
temperature, pulse, respirations (TPR) and systolic blood
pressure (SBP) elevated; palpitations; slight diaphoresis;
oriented × 3; mild anxiety and restlessness; restless sleep;
tremulousness; decreased appetite; nausea.
• 12-24 hr after alcohol use cessation: increased diaphoresis; intermittent confusion; transient visual and auditory
hallucinations, primarily at night; increased anxiety and
motor restlessness; insomnia; nightmares; nausea, vomiting, anorexia.
• 24-48 hr after alcohol use cessation: additional symptoms
may include generalized tonic-clonic seizures.
• Later (48-72 hr after alcohol use cessation): severe additional symptoms. Pulse 120-140 bpm; increased temperature; increased diastolic blood pressure (DBP) and SBP;
marked diaphoresis; marked disorientation and confusion;
frightening visual, auditory, and tactile hallucinations (predominantly visual); illusions (misinterpretation of objects);
delusions; delirium tremens; disturbances in consciousness;
agitation, panic states; inability to sleep; gross uncontrollable tremors, convulsions; inability to ingest any oral fluids
or foods.
Safety assessment: History of recurrent accidents, such as
falls, fractures, lacerations, burns, bruises, blackouts, or automobile accidents.
Suicidal assessment: Alcoholic suicide attempts may be as
much as 30% higher than the national average, and impulsivity is increased during intoxication.
Social assessment: Dysfunctional family system; problems
in current relationships; frequent sick days off work/
school; history of arrests because of fighting with others or
driving while intoxicated, disorderly conduct, or automobile
accidents.
Spiritual assessment: It is important to assess for spiritual
beliefs, practices, faith traditions, and commitment to those
traditions. Many alcoholics and others addicted to substances
find recovery through the spiritual program models of AA
and NA. Additionally, spiritual beliefs may provide the
anchor that prevents an addicted individual from considering
suicide.
DIAGNOSTIC TESTS
Blood alcohol and drug levels can be obtained. However,
diagnosis of Alcohol Use Disorder is generally made through
interview history and physical and psychiatric examinations.
The diagnosis is made by confirmation of the presence of the
four major symptoms of alcoholism listed above. Two of the
most common assessment screening tools used to establish
problem severity are the Michigan Alcohol Screening Test
(MAST) and the CAGE-AID questionnaires.
Nursing Diagnosis:
Risk for Trauma
related to altered cognitive function occurring with alcohol withdrawal
Desired Outcome: The patient does not exhibit evidence of physical trauma caused by
alcohol withdrawal.
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741
Substance-Related and Addictive Disorders
Dysfunctional Family Processes
Assess the stage of alcohol withdrawal and severity of
symptoms. Monitor vital signs, gait and motor
coordination, presence and severity of tremors, mental
status, and electrolyte status.
The greater the severity of symptoms, the more likely the patient will experience
increasing disorientation, confusion, and restlessness. As the withdrawal
progresses, the risk for a fall or injury increases significantly.
Monitor for seizure activity; institute seizure precautions: bed
in lowest position with side rails padded.
Withdrawal seizures usually occur within 24-48 hr following the last alcoholic
drink.
Keep communication simple.
As withdrawal progresses, the patient’s ability to comprehend complex directions
and interactions diminishes greatly. Simplicity is the key to effective
communication.
Continue to orient the patient to surroundings and call light or
communication system.
As the blood alcohol level drops, disorientation increases and can last several
days.
Maintain a calm, quiet environment.
Controlling the amount of external stimulation and keeping it at a minimal level
promotes calm in the patient.
Administer IV/PO fluids with caution as indicated.
Careful fluid replacement corrects dehydration and facilitates renal clearance of
toxins. Excessive alcohol use damages the cardiac muscle and/or conduction
system. Overhydration poses significant risk to cardiac functioning.
Administer medications as prescribed and be alert for side
effects:
- Benzodiazepines: lorazepam (Ativan), diazepam (Valium),
or chlordiazepoxide (Librium)
These medications are commonly used to control neuronal activity as alcohol is
detoxified from the body. Either IV or PO route is preferred. These agents
produce muscle relaxation, which is effective in controlling the “shakes,”
trembling, and ataxic movements, as well as preventing seizures. They are
usually initiated at a high dose and tapered and discontinued within 96 hr.
They must be used cautiously in patients with hepatic disease because the
liver metabolizes them.
- Benzodiazepine: oxazepam (Serax)
This may be the medication of choice for patients with liver disease. Although it does
not produce quite the dramatic effects of controlling withdrawal symptoms, it has
a shorter half-life, so it is safer in the presence of hepatic disease.
- Phenobarbital or carbamazepine
This medication is highly effective in suppressing withdrawal symptoms and is an
effective anticonvulsant. Use must be monitored to prevent exacerbation of
respiratory depression.
- Haloperidol or olanzapine
Antipsychotic medications may be used with delirium tremens, specifically for
symptoms of psychosis or severe agitation.
Nursing Diagnosis:
Dysfunctional Family Processes
Copyright © 2015. Elsevier. All rights reserved.
related to long-term pattern of the patient’s alcoholism
Desired Outcome: Before the patient is discharged from the care facility or after 4 wk if the
patient is outpatient, family members verbalize the dysfunctional behavioral dynamics
present within the family system, the difference between caring and enabling, and the available services and treatment options that would help the family.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess for and provide family members with an opportunity to discuss
their experiences of living with the disabling effects of alcoholism.
This validates their experience and encourages open discussions of the
problem.
Educate family members about the effects of alcoholism on the family
system.
This information enables recognition that the dynamics in their family,
although dysfunctional, is a predictable response to having a family
member addicted to alcohol. It also encourages engagement in a
realistic appraisal of the family’s dynamics.
continued
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS RATIONALES
PART IV: Psychiatric Nursing Care Plans
742
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Provide family members with a list of services and treatment options
available.
This validates that the dysfunction within the family is serious and
requires and normalizes support of professionals to correct the
patterns.
Define the term enabling for family members. Encourage each of them
to identify at least one time when he or she enabled the patient.
Offer family members alternative choices to enabling behaviors.
Have them practice what they will do and say when a situation
arises.
It is important to reframe helping behavior as enabling behavior in order
for family members to recognize the pattern. It is also important for
them to realize that changing these patterns requires practice and
feedback. During times of anxiety, it is normal to fall back on
previous patterns of behaving.
If in a relationship, encourage the couple to consider couples therapy to
begin to discuss regrets and resentments that have occurred as a
result of alcoholism.
After many years of denial, it is important to begin to talk about feelings
that have been buried. This process should be undertaken with a
professional who can act as a mediator and teach the couple how to
communicate without blaming, a common dynamic in a marriage
affected by alcoholism.
Explain how roles have changed within the family as a result of
alcoholism.
Teaching may have to be repeated frequently based on the family’s
readiness to learn. Alcoholism produces dramatic role shifts that
families are unaware of when they are in the midst of problems such
as codependence. Presenting this emotionally charged information in
a concrete, didactic manner increases their ability to hear.
Encourage family members to tell one another their needs and that
caring about them is different from enabling.
Social and emotional isolation and denial of needs are common in
alcoholic families. Enabling behaviors are frequently intended to be
caring.
Encourage the family to attend Al-Anon meetings.
Significant change will require long-term commitment and support.
Nursing Diagnosis:
Ineffective Denial
related to lack of control of alcoholism resulting in minimization of its symptoms and effects
Copyright © 2015. Elsevier. All rights reserved.
Desired Outcome: Before discharge from the care facility or after 4 wk if outpatient, the
patient acknowledges that his or her drinking is out of control and his or her life has become
unmanageable.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s level of denial vs. acceptance that his/her alcohol
use is a major problem and responsible for disruption in every area
of his or her life.
Denial interferes with the patient’s ability to participate in treatment.
Encourage the patient to self-admit to an alcoholism treatment program.
Self-admittance is preferred because the element of denial has been
addressed to a certain degree.
Assure the patient that alcoholism is a physiologic, chronic illness and
not a moral problem.
This demonstrates a nonjudgmental attitude; it is easier to accept
treatment for an illness than it is for what may be perceived as a
moral weakness or flaw.
Encourage the patient to compile a written list of the deleterious
consequences of excessive alcohol use experienced over the time he
or she has been drinking. Ask the patient to show the list to another
nurse, peer, or member of AA (if the patient is participating in AA
programming).
These interventions help break through the process of denial.
Ask the patient to compile a list of situations that influenced excessive
drinking and discuss ways to respond that do not involve drinking.
To help avoid relapse, it is important to know which situations triggered
excessive drinking in the past.
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Deficient Knowledge
Substance-Related and Addictive Disorders
743
Imbalanced Nutrition: Less Than Body Requirements
related to poor dietary intake
Desired Outcome: Within 1 wk of this diagnosis, the patient verbalizes accurate understanding of the effects of alcohol and reduced dietary intake on nutritional status and demonstrates
nutritional intake adequate for his or her needs.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess for abdominal distention, tenderness, and the presence
and quality of bowel sounds.
Excessive alcohol intake may irritate gastric mucosa and result in epigastric
pain and hyperactive bowel sounds. Other, more serious gastrointestinal
(GI) effects may occur secondary to hepatitis and cirrhosis.
Note the presence of nausea/vomiting and diarrhea.
These signs are frequently among the first indicators of alcohol withdrawal and
may interfere with establishing adequate nutritional intake.
Assess the patient’s ability to feed self.
A number of factors, including tremors, mental status changes, and
hallucinations, may interfere with independent feeding and signal the need
for assistance.
Refer to a dietitian as indicated.
Expert advice may be necessary to coordinate the patient’s nutritional regimen.
Provide small, easily digested, and frequent feedings/snacks as
desired; increase as tolerated.
Small feedings may enhance intake and toleration of nutrients by limiting gastric
distress. As appetite and ability to tolerate food increase, adjustments are
made to the diet to ensure that adequate calories and nutrition are supplied
for tissue repair and healing and restoration of energy and vitality.
Review liver function tests.
Liver function status influences the choice of diet and need for/effectiveness of
supplemental therapy.
Provide a diet high in protein with about 50% of the calories
supplied by carbohydrates.
This diet provides for energy needs and tissue healing while stabilizing blood
sugar levels.
Administer medications as prescribed:
- Antacids, antiemetics, and antidiarrheals
These medications reduce gastric irritation.
- Thiamine and vitamins
All substance users should receive thiamine and vitamins because most have
these deficiencies.
Keep the patient nothing by mouth (NPO) if indicated.
It may be necessary to reduce gastric/pancreatic stimulation in the presence of
GI bleeding or excessive vomiting.
Nursing Diagnosis:
Copyright © 2015. Elsevier. All rights reserved.
Deficient Knowledge
related to unfamiliarity with the prescribed medications, rationale for use, and
potential side effects
Desired Outcome: The patient verbalizes accurate information about the prescribed medication, including rationale for use and common side effects.
ASSESSMENT/INTERVENTIONS
RATIONALES
Assess the patient’s level of knowledge of the medications used in
treatment.
Knowledge increases adherence to a prescribed medication regimen. In
addition, because some of the medications used to treat alcoholism
carry significant and dangerous risks, the patient must be informed
regarding these risks.
Teach the patient about the medications that are sometimes used as
adjuncts to alcohol use disorders treatment:
continued
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PART IV: Psychiatric Nursing Care Plans
Nursing Diagnosis:
PART IV: Psychiatric Nursing Care Plans
744
PART IV
PSYCHIATRIC NURSING CARE PLANS
ASSESSMENT/INTERVENTIONS
RATIONALES
Disulfiram (Antabuse)
This agonist medication is used as a deterrent to impulsive drinking.
Teach the risks of drinking while taking Antabuse.
Response of taking alcohol while on Antabuse includes the following:
severe nausea, vomiting, hypotension, headache, cardiovascular
collapse, heart palpitations, seizures, or death.
Inform the patient both verbally and in writing of the serious side effects
that occur while taking Antabuse when ingesting alcohol or other
substances containing alcohol such as cough syrups or cold remedies.
Potential side effects are so serious that informed consent is essential.
Reinforce the following:
- Do not take any form of alcohol (beer, wine, liquor, vinegars, cough
medicines, sauces, aftershave lotions, liniments, or cologne).
Doing so may cause a severe, even life-threatening reaction.
- Take the medication daily (at bedtime if it produces fatigue or
dizziness). Crush or mix the tablet with liquid if necessary.
- Wear or carry medical identification with you at all times.
This alerts any medical emergency personnel that the patient is taking
Antabuse.
- Keep appointments for follow-up laboratory tests.
Disulfiram may worsen coexisting conditions such as diabetes mellitus,
hypothyroidism, chronic and acute nephritis, and hepatic disease. It
also increases prothrombin time. When these conditions exist, blood
sugar monitoring, kidney and liver function tests, thyroid tests, and
prothrombin times need scheduled follow-up evaluations.
- The metallic aftertaste is temporary and will disappear after the
medication is discontinued.
- Avoid drinking for 14 days after discontinuing disulfiram (Antabuse).
It takes up to 2 weeks for Antabuse to be totally metabolized by the
body. Drinking before the drug is fully metabolized can lead to
unpleasant symptoms such as nausea, vomiting, and sweating.
- Avoid driving or performing tasks that require alertness.
Drowsiness, fatigue, or blurred vision may occur.
Naltrexone (Re-Via); Long-Acting Injectable Formulation (Vivitrol)
This is a narcotic antagonist originally used as a treatment for heroin
abuse but has now been approved for treatment of alcoholism. The
drug reduces the cravings for alcohol and works best when
accompanied by psychosocial treatment.
Teach the patient about adverse effects: difficulty sleeping, anxiety,
nervousness, headache, low energy, abdominal pain, cramps,
nausea, vomiting, delayed ejaculations, decreased potency, skin
rash, chills, increased thirst, and joint and muscle pain.
These common adverse effects should be reported to the prescriber.
Reinforce the following:
Copyright © 2015. Elsevier. All rights reserved.
- This medication will make it easier not to drink and it blocks the
effects of narcotics.
- Wear a medical identification tag. Notify other health professionals
that you are taking this medication.
This alerts emergency medical personnel that the patient is taking this
medication.
- Avoid use of heroin or other opiate drugs.
Small doses may have no effect, but large doses can cause death,
serious injury, or coma.
- Report any signs and symptoms of adverse effects.
- Keep appointments for follow-up blood tests and treatment program.
Ondansetron (Zofran)
Zofran is a serotonin receptor antagonist and is useful in reducing
alcohol consumption and craving in patients with early onset alcohol
use disorders.
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Substance-Related and Addictive Disorders
Deficient Knowledge
RATIONALES
Nalmefene (Revex)
Revex is an opioid antagonist that is similar in structure to naltrexone
and is used often in emergency department treatment. It is less toxic
to the liver and effective in preventing relapse to heavy drinking. It
has few side effects.
Acamprosate (Campral)
Campral is a synthetic compound that is associated with increased
abstinence through decreased alcohol craving.
Medications being Investigated for Treatment of Alcoholism
Topiramate (Topamax)
Topiramate is an antiseizure agent that also helps control impulsivity
and has shown some evidence of decreasing days and amounts of
drinking.
Baclofen (Lioresal)
Baclofen is a muscle relaxant and antispasmodic agent and has shown
some benefit in helping patients maintain abstinence, particularly in
those with alcoholic cirrhosis.
ADDITIONAL NURSING
DIAGNOSES/PROBLEMS:
“Psychosocial Support” for relevant nursing diagnoses
p. 72
“Psychosocial Support for the Patient’s Family and
Significant Other” for relevant nursing diagnoses
p. 84
“Seizures and Epilepsy”
p. 304
“Anxiety Disorders” for:
Anxiety
p. 703
Social Isolation
p. 704
Ineffective Coping
p. 704
Compromised Family Coping
p. 705
Copyright © 2015. Elsevier. All rights reserved.
“Bipolar Disorder” for:
Risk for Other-Directed Violence
p. 710
Dressing and Bathing Self-Care Deficits
p. 712
“Major Depression” for:
Hopelessness
p. 727
Grieving
p. 729
PATIENT-FAMILY TEACHING AND
DISCHARGE PLANNING
The patient with a substance use disorder suffers from a
problem that can and will affect every area of his/her life. To
remain free of the use of substances, the patient will likely
benefit from lifelong adjunctive treatment support through
AA or NA. The patient and family need to recognize that
substance use disorders are family problems necessitating professional counseling and that alcoholism is a relentlessly progressive disease with profound medical, psychologic, social,
and spiritual implications. Provide the patient and family with
verbal and written information about the following issues:
✓ Nature and expected course of alcoholism/alcohol use
disorder/substance use disorder.
✓ Medications, including drug name; purpose; dosage; frequency; precautions; drug-drug, food-drug, and herbdrug interactions; and potential side effects.
✓ Withdrawal process—what to expect.
✓ Nutrition issues.
✓ Emergency measures.
✓ Importance of social support and strategies to obtain it;
importance of changing social support if that support
promotes drug use.
✓ Importance of using relaxation techniques to minimize
stress.
✓ Importance of maintaining or achieving spiritual
well-being.
✓ Importance of lifestyle issues such as benefits of
exercise.
✓ Importance of group support for continued adjunctive
treatment through AA or NA.
✓ Additional information can be obtained by contacting
the following organizations:
• National Clearinghouse for Alcohol and Drug Information (NCADI) at http://www.dhs.state.il.us/page
.aspx?item=4843
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PART IV: Psychiatric Nursing Care Plans
ASSESSMENT/INTERVENTIONS
745
PART IV
PSYCHIATRIC NURSING CARE PLANS
• National Institute on Alcohol Abuse and Alcoholism (NIAAA) at www.niaaa.nih.gov
• National Institute on Drug Abuse (NIDA) at
www.nida.nih.gov
• Online Alcoholics Anonymous (AA) Recovery
Resources at www.recovery.org/aa or at www.aacanada
.com
• Research Institute on Addictions at www.ria.
buffalo.edu
• The Centre for Addiction and Mental Health at
www.camh.ca
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PART IV: Psychiatric Nursing Care Plans
746
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