Care Map Monday!

Happy Monday Nurses and Nursing Students! Every Monday  I am planning on dedicating a blog post to a care plan. This week was my last week in Psych and I wanted to share with you a care plan from Psych.

Desired Population Outcomes (2 -3): The Population (Middle Age) will:

• Acknowledge a substance abuse problem.
• Identify positive coping mechanisms and resources to use during alcohol abstinence
• Demonstrate generativity instead of stagnation.
• Demonstrate developing identity.
• Demonstrate self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth.
• Cooperate with a proposed treatment plan
•  

Relevant Nursing Diagnoses:

• Ineffective Health maintenance
• Ineffective denial
• Disturbed thought process
• Risk for infection
• Imbalanced nutrition
• Risk for other directed violence
• Disabled family coping
• Ineffective protection
• Ineffective Coping
• Powerlessness
• Fear

 

Nursing Diagnosis #1 P: Ineffective health maintenance E: related to inadequate coping mechanisms and resources S: AEB abuse of alcohol, drug abuse, smoking, lack of exercise, risk-taking behaviors, lack of support systems, chronic health problems.

Individualized Patient ‘SMART’ (SPECIFIC, MEASURABLE, ACHIEVABLE, REALISTIC, TIME-SENSITIVE) Outcomes Prioritized (2-3): The patient will: During the next two weeks the patient will: Identify personal consequences associated with alcohol misuse Recognize changes in her general health status by learning to check blood pressure and weight Develop effective and personal alcohol use control strategies Commit to alcohol use control strategies by identifying support groups in the community and attending one meeting Learn about nutrition and a healthy diet

Individualized Assessments (HEALTH, DIAGNOSTIC TESTS, VALUES, FUNCTIONAL, SOCIAL SUPPORT, ENVIRONMENTAL, RESOURCES) related to ND (w/Rationales and Citations in parentheses) Monitor Vitals Signs (looking for any changes to her health) (Lewis, Heitkemper, Dirksen, O’Brien, &Bucher, 2007). Monitor anxiety with the Anxiety Scale (Likert 1-5) (associated with withdrawal) (Lewis, Heitkemper, Dirksen, O’Brien, &Bucher, 2007). Assess her social support (She will need this when she finishes the program) (Lewis, Heitkemper, Dirksen, O’Brien, &Bucher, 2007).

Priority Interventions (SYMPTOM MANAGEMENT, MEDICATION MANAGEMENT, SKILLS AND TECHNOLOGIES, SOCIAL/BEHAVIORAL, COUNSELING, REFERRALS, COMMUNITY SUPPORT AND EDUCATION) related to ND (w/Rationales and Citations in parentheses) Encourage patient to take control over own behavior- (to change undesired behaviors) (Kneisl &Trigoboff, 2009). Discuss with the patient the impact of substance abuse on medical condition or general health- (to promote acknowledgement of consequences of use.) (Kneisl &Trigoboff, 2009). Identify constructive goals with the patient (to provide alternatives to the use of substances to reduce stress.) (Kneisl &Trigoboff, 2009). Assist patient to learn alternative methods of coping with stress or emotional distress (to reduce substance abuse) (Kneisl &Trigoboff, 2009). Identify support groups in the community for long-term substance abuse treatment (to promote continued abstinence) (Kneisl &Trigoboff, 2009). Provide opportunities in 1:1 to provide active listening, empathy, and support. (Sometimes clients will open up more to a student and so I will be there to listen and encourage) (Kneisl &Trigoboff, 2009).

Patient/Caregiver Teaching Needs/Plans related to ND: Teach about signs and symptoms related to relapse, teach family that this is a disease and needs to be treated as one. Teach about smoking cessation