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.


DSM-IV ADJUSTMENT DISORDERS (SPECIFY IF ACUTE/CHRONIC)
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

ETIOLOGICAL THEORIES
Psychodynamics
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.

Biological
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
responses.

NURSING PRIORITIES
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.

DISCHARGE GOALS
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