Nursing Care Plan for Adjustment Disorders

The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement.) The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder. The response is considered maladaptive because social or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e.g., a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist.

309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood

Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego.

The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change. The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur.

The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.

The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.

Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.

Family Dynamics
The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life.

Individuals with adjustment difficulties have experienced negative learning through inadequate role-modeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment

1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.

1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for Adjustment Disorder: Anxiety may be related to situational/maturational crisis; threat to self-concept; threat (or perceived threat) to physical integrity; unmet needs; fear of failure; dysfunctional family system; unsatisfactory parent/child relationship resulting in feelings of insecurity; fixation in earlier level of development possibly evidenced by overexcitement/restlessness; increased tension; insomnia; feelings of inadequacy; fear of unspecified consequences; poor eye contact, focus on self; difficulty concentrating; continuous attention-seeking behaviors; selective inattention; sympathetic stimulation; numerous physical complaints.

Desired Outcomes:

1. Verbalize awareness of feelings of/indicators of increasing anxiety.
2. Demonstrate/use appropriate techniques to interrupt escalation of anxiety.
3. Appear relaxed and report anxiety is reduced to a manageable level.

Nursing intervention with rationale:
1. Establish a therapeutic nurse/client relationship. Be honest, consistent in responses, and available. Show genuine positive regard.
Rationale: Honesty, availability, and unconditional acceptance promote trust, which is necessary for the development of a therapeutic relationship.

2. Provide activities geared toward reduction of tension and decreasing anxiety (e.g., walking or jogging, musical exercises, housekeeping chores, group games/activities).
Rationale: Tension and anxiety can be released safely, and physical activity may provide emotional benefit to the client through release in the brain of morphine like substances (endorphins) that promote sense of well-being.

3. Encourage client to identify true feelings and to acknowledge ownership of those feelings.
Rationale: Anxious clients often deny a relationship between emotional problems and their anxiety. Use of the defense mechanisms of projection and displacement are exaggerated.

4. Maintain a calm atmosphere and approach to client.
Rationale: Can help to limit transmission of anxiety to/from client.

5. Assist client to recognize specific events that precede onset of elevation in anxiety. Provide information about signs and symptoms of increasing anxiety and ways to intervene before behaviors become disabling.
Rationale: Recognition of precipitating stressors and a plan of action to follow should they recur provides client with feelings of security and control over similar situations in the future. This in itself may help to control anxiety response.

6. Offer support during times of elevated anxiety. Provide physical and psychological safety.
Presence of a trusted individual may provide needed security/client safety.

7. Administer medications as necessary, e.g., benzodiazepines: alprazolam (Xanax).
Rationale: Antianxiety medications induce a calming effect and work to maintain anxiety at a manageable level while providing the opportunity for client to develop other ways to manage stress.

Other NANDA diagnosis of Adjustment Disorder: VIOLENCE, risk for, directed at self/others; COPING, INDIVIDUAL, ineffective; ADJUSTMENT, impaired [when stressor is a change in health status]; GRIEVING, dysfunctional; HOPELESSNESS; SELF ESTEEM disturbance; SOCIAL INTERACTION, impaired; FAMILY PROCESSES, altered

Nursing Care Plan for Deviations in Growth Patterns

Deviations in intrauterine growth patterns not only increase the risk of morbidity and mortality in the early newborn period, but may also have long-term implications for altered growth and development and for altered CNS function and learning disabilities in childhood.

This general plan of care is designed to facilitate optimal nursing management of the infant with deviations in intrauterine growth and is to be used in conjunction with the CPs: The Neonate at Two Hours to Two Days of Age, and The Preterm Infant, as appropriate. Growth deviations are classified as SGA, intrauterine growth retardation/restriction (IUGR), and LGA.

SGA/IUGR: Any newborn whose birth weight falls at or below the 10th percentile on classification charts, considering local factors (e.g., ethnicity, altitude).

LGA/Macrosomic: Any newborn whose birth weight is at or above the 90th percentile on classification charts, considering local population at any week in gestation (with special attention to determining appropriate gestational age), or who at birth weighs more than 4000 g (8 lb 13 oz).

1. Maintain physiological homeostasis.
2. Prevent and/or treat complications.
3. Identify/minimize effects of birth trauma.
4. Provide family with appropriate information/strategies for meeting short- and long-term needs associated with
growth deviation.

Nursing diagnosis: Impaired gas exchange may be related to Alveolar capillary membrane changes (decreased surfactant levels, retained pulmonary fluid, meconium aspiration), altered oxygen supply (diaphragmatic paralysis/phrenic nerve paralysis, increased intracranial pressure) possibly evidenced by restlessness/irritability; inability to move secretions, tachypnea, cyanosis, hypoxia.

Desired Outcome
1. Display spontaneous, unassisted regular respiratory effort with rate of 30–50/min; and ABGs WNL.
2. Be free of apnea and complications of hypoxia/lung disease.

Nursing intervention with rationale:
1. Review history for abnormal prenatal growth patterns and/or reduced amounts of amniotic fluid, as detected by ultrasonography/fundal changes.
Rationale: Low-birth-weight infant or infant with IUGR suffers chronic intrauterine asphyxia, resulting in hypoxia/malnutrition. Fetal contribution to the amniotic pool is reduced in the stressed infant. Macrosomia can be related to maternal diabetes, prolonged pregnancy, heredity, and inappropriate nutrition. Macrosomia in IDM results from excess release of growth hormone (thyroid stimulation), increasing the number of cells and/or organ size throughout the body.

2. Note type of delivery and intrapartal events indicative of hypoxia.
Rationale: Infant with chronic hypoxia will be more susceptible to acidosis/respiratory depression/persistent fetal circulation (PFC) after delivery. Cesarean birth increases risk of excess mucus because thoracic compression by the birth canal does not occur as in a vaginal delivery.

3. Note time/onset of breathing and Apgar scores. Observe ensuing respiratory patterns.
Rationale: The infant with intrapartal asphyxia may present with a delayed onset of respirations and altered respiratory pattern. Apgar scores aid in evaluation of the degree of depression or asphyxia of the newborn at birth and are directly correlated with serum pH/degree of infant acidosis.

4. Assess respiratory rate, depth, effort. Observe and report signs and symptoms of respiratory distress, distinguishing from symptoms associated with polycythemia.
Rationale: Infant with altered growth is more susceptible to respiratory distress associated with chronic asphyxia in SGA infant, inadequate surfactant levels in IDM,

5. Auscultate breath sounds regularly.
Rationale: Presence of crackles/rhonchi reflect respiratory congestion and need for intervention.

6. Suction nasopharynx/endotracheal tube as needed, after first providing supplemental oxygen.
Rationale: Ensures patency of airway, removes excess mucus. Supplemental oxygen reduces hypoxic effect of procedure.

7. Auscultate apical pulse; note presence of cyanosis.
Rationale: Tachypnea, bradycardia, and cyanosis may occur in response to altered oxygen levels.

8. Prevent iatrogenic complications associated with cold stress, metabolic imbalance, and caloric insufficiency.
Rationale: Such complications increase metabolic demands and oxygen needs.

9. Ensure availability of resources in the event complications occur.
Equipment for oxygenation, suction, intubation, assisted ventilation, resuscitation, and chest tube placement must be readily available in the event of severe/prolonged respiratory distress.

10. Monitor transcutaneous oxygen/pulse oximeter readings.
Rationale: Identifies therapy needs/effectiveness.

Nursing Care Plan for Hysterectomy/TAHBSO

Hysterectomy is the surgical removal of the uterus through an abdominal incision. It may be a total hysterectomy (removal of the uterus and cervix) or panhysterectomy (removal of the uterus, cervix, fallopian tubes and ovaries). It is done to treat endometriosis, tumors (benign and malignant of the cervix, endometrium, or muscle of the uterus), severe abnormal bleeding, and prolapse of the uterus.

Nursing diagnosis for hysterectomy: Body image disturbance related to biophysical factor of hormonal imbalance and loss of body part resulting in loss of childbearing ability and possible sexual dysfunction.

Expected Outcomes: Improved body image evidenced by verbalization of more positive feelings about loss of childbearing function and self-worth; adaptation to hormonal changes with treatment.

Nursing intervention with rationale:
I. Assess for:
1. Knowledge of effect of surgery on sexuality and physiology.
Rationale: Provides information about feeling of loss and meaning to patient.

2. Feelings about changes and effect on femininity, relationships, self-worth.
Rationale: Provides information about impact on personal life.

II. Administer:
1. Hormone (estrogen)
Rationale: Acts to provide estrogen replacement in bilateral oophorectomy

III. Perform or Provide
1. Encouragement to express feelings about changes in life and acceptance by others.
Rationale: Facilitates communication about impact surgery has on lifestyle.

2. Opportunity for makeup and hair grooming.
Rationale: Provides active interest in personal appearance, which enhances self-image.

3. Support and opportunity for interaction with partner and others.
Rationale: Improves and maintains relationships with partner.

4. Encouragement and praise qualities and behaviors that have positive effect on self-image.
Rationale: Supports and reinforces adaptation to loss.

IV. Teach Patient and Family:
1. Inform that may feel depressed and have crying spells following surgery.
Rationale: Response to hormonal changes of vacillation in estrogen and progesterone levels.

2. Inform that menstruation will cease.
Rationale: Effect of total hysterectomy

3. Inform that hot flashes and other menopausal changes may occur.
Rational: Symptoms of surgically induced menopause from bilateral oophorectomy

4. Administration of hormonal therapy.
Rationale: Provides needed and accurate hormone replacement.

Nursing Care Plan for Low Back Pain

Chronic pain in the lumbar region usually caused by the straining of paravertebral muscles, herniation, and degeneration of the nucleus pulposus, osteoarthritis of the lumbosacral spine.

Nursing diagnosis for low back pain: Chronic pain relater to intermittent physical discomfort and disability caused by degenerative processes, strain, poor body mechanics.

Expected Outcomes: Reduced or relief of pain for extended lengths of time evidenced by absence of muscle spasm and verbalizations that able to manage pain effectively.

Nursing intervention with rationale:
I. Assess for:
1. Location, length and severity of pain, posture, body mechanics (sitting, standing, stooping, walking), what relieves or precipitates back pain.
Rationale: Provides data base for control of and prevention of pain.

II. Administer:
1. Analgesic (aspirin, acetaminophen, ibuprofen)
Rationale: Acts to control pain by interfering with CNS pain pathways.

2. Muscle relaxants (dantrolene)
Rationale: Acts to relax muscle spasm.

III. Perform or Provide:
1. Cold or heat application; massage to area every 4 hours.
Rationale: Provides comfort and relaxation of muscles to ease pain.

2. Bedrest with head elevated and knees flexed.
Rationale: Promotes comfort and relieves tension on back.

3. Pelvic traction continuously in proper body alignment.
Relieves pressure on nerves of lumbosacral area.

Nursing Care Plan for Pulmonary Embolus

Pulmonary embolism is a condition in which the pulmonary vasculature is blocked by foreign matter such as blood clot, air, tumor tissue, bone, or by needle or catheter. Usually the result of peripheral venous thrombosis, it may lead to pulmonary infarction and pulmonary hypertension. This plan, which includes intervention specific to this condition, may be used in association with thrombophlebitis/thrombosis.

Nursing Diagnoses: Ineffective breathing pattern related to chest pain, decreased lung expansion caused by emboli with severity depending on size and number of vessels occluded. Impaired gas exchange related to altered blood flow caused by obstruction of circulation to the pulmonary vascular bed.

Expected Outcomes: Adequate ventilation evidenced by reduction in dyspnea, hypoxia, respiration within normal baseline limits for rate depth, and ease, ABGs within normal range.

Nursing Intervention
I. Assess for:
A. Respiratory status including history and physical examination especially thrombus/thrombophlebitis of both peripheral and deep veins.
Rationale: Provides data base and baselines.

B. Respiratory rate, depth, ease, dyspnea, tachypnea, tachycardia, cough, chest pain, hemoptysis; crackles, and accentuated pulmonic heart sound on auscultation.
Rationale: Changes indicate whether emboli are small, medium, or massive-sized.

II. Monitor, descibe, record:
A. Vital signs, chest sounds evey 2 to 4 hours, respiratory rate, quality.
Rationale: Indicates any changes in status leading to possible complications.

B. Chest X-ray.
Rationale: May indicate infarction, pulmonary effusion, consolidation.

C. Perfusion and ventilation scanning.
Rationale: Reflects pulmonary circulation and gas movement through lungs; size of clot.

D. Pulmonary angiography.
Rationale: Determines emboli in pulmonary vascular system; filling defect in pulmonary vessels.

E. Arterial blood gas.
Rationale: Decreasd PaO2 level indicates hypoxemia caused by inadequate oxygen supply.

III. Administer:
A. Oxygen via cannula or mask at rate based on ABGs.
Rationale: Provides oxygen to maintain oxygenation of tissues.

IV. Perform/Provide:
A. Bedrest in semi-Fowlers position.
Rationale: Reduces oxygen demand and facilitates chest expansion.

B. Deep breathing exercises, coughing, postural drainage if needed.
Rationale: Promotes adequate breathing pattern and air intake; prevents atelectasis.

C. Stay with patient, give reassurance and emotional support.
Rationale: Reduces anxiety and fear caused by pain and dyspnea.