Zachary Clark
Submitted to:
Care Plan 2
Medical Diagnosis: Substance Induced Mood Disorder/Anxiety
1. Nursing Diagnosis: Anxiety as evidenced by subjective complaints of being
overwhelmed, observable restlessness, patient’s need to leave the room at times.
Intervention 1: Provide calm and quiet environment – a “quiet room” no
distractions (television, bright lights, loud music) soft music, if any,
Rationale: Decreasing additional stimuli promotes relaxation
Intervention 2: Ensure therapeutic communication within the nurse-patient
relationship by spending 30 minutes with the patient, one on one/twice per shift
Rationale: Gain patient’s trust and opens lines of communication for
patient
Intervention 3: Supply medications as needed for symptom managementAdminister Alprazolam 0.5mg po prn
Rationale: GABA receptors are affected by the benzodiazepine, therefore
decreasing symptoms
2. Nursing Diagnosis: Ineffective coping as evidenced by inability to attend work, lack of
support, and maladaptive coping mechanisms (i.e. alcohol and heroin dependency)
Intervention 1: Begin cognitive behavioral therapy three times per week
Rationale: Teach positive coping skills
Intervention 2: Encourage patient’s family to attend group therapy in a
supportive role one session per week with patient.
Rationale: Increase support for patient, increase understanding for family
Intervention 3: Refer to AA, encourage relationship with sponsor, encouraged
enrollment in work program
Rationale: By building patient’s positive coping skills, increasing support
systems, patient will be able to join work force and further increase selfworth.
3. Nursing Diagnosis: Ineffective Role Performance related to substance abuse as
evidenced by patient stating “The last time I saw my daughter was 8 years ago. I won’t
allow myself to see her like this.”
Intervention 1: Encourage patient to empathize with family members affected by
his lack of role performance and substance abuse.
Rationale: Allows an understanding of others’ feelings and may lead to
greater mutual respect and familial support.
Intervention 2: Give patient opportunities, throughout the day, to make decisions
i.e. what groups he would like to attend.
Rationale: The patient will be able to utilize decision-making skills –
which will be important in future roles pertaining to family and workplace.
Intervention 3: Allow time, on a one to one basis, for the patient to express any
concerns, fears, or questions about role performance on a daily basis.
Rationale: The patient will be able to gain feedback on expected role
performance and will have an insight as to what caused the impaired role
performance.