Nursing Diagnosis PDF

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nursing diagnosis for severe anxiety...

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NURSING DIAGNOSIS Akira Allen NURS 250s – Psych and Mental Health Professor Glaubia Weaver

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Identify 3 Highest Priority Nursing Diagnosis: #1 Nursing Diagnosis Risk for self-mutilation as evidence by history of self-harm in response to anxiety (Townsend, 2011).

#2 Nursing Diagnosis Risk for injury as evidence by extreme hyperactivity.

#3 Nursing Diagnosis Self-care deficit related to poor attention span as evidence by poor personal hygiene.

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NURSING DIAGNOSIS #1 include stem, related to, as evidenced by: Predicted Behavioral Outcome: The patient will… Patient will establish alternative behavior in response to anxiety during admission. Nursing Strategies: 1. Provide frequent rest periods.

Evidence based Rationale for Strategies: 1. Prevents exhaustion.

Patient’s Actual Responses (Evaluation): 1. The patient has admitted to feeling well rested.

2. Maintain low level of stimuli in client’s environment

2. Minimizes escalation of anxiety.

2. The patient has remained free of stress in environments free of stimulation but has become anxious during meals and groups

3. Redirect violent behavior.

3. Physical exercise can decrease tension and provide focus.

3. Patient utilizes mediation techniques and guided imagery when starting to feel anxious.

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Evaluation: The patient has remained calm during hospitalizations and has complied to medication treatment. The patient shows improvement in coping skills and represents with a decrease in her anxious behaviors.

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NURSING DIAGNOSIS #2 include stem, related to, as evidenced by:

Predicted Behavioral Outcome The patient will… Patient will remain free of falls and abrasions during hospitalization. Nursing Strategies: 1. Provide structure with the help from a nurse or mental health worker

Evidence based Rationale for Strategies: 1. Structure provides focus and security (Varcarolis, 2016).

Patient’s Actual Responses (Evaluation): 1. The patient has remained focus on her care and has participated in the activities without disruption

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Protect client from giving away money and possessions.

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“Generosity” is a manic defense that is consistent with irrational, grandiose thinking.

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Patient asked that valuables be given to parents during her admission.

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Provide an environment for task efforts that is as free of distractions as possible.

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Client is highly distractible and is unable to perform in the presence of even minimal stimulation.

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Patient was able to concentrate and complete provided task at hand.

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Evaluation: The patient has remained under control and has remained within normal limits of anxious behaviors. The patient has remained free of falls and injury.

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NURSING DIAGNOSIS #3 include stem, related to, as evidenced by:

Predicted Behavioral Outcome: The patient will… Patient will maintain good hygiene daily and maintain a clean environment. Nursing Strategies: 1. Use visual cues such as a towel to prompt attention to hygiene task.

Evidence based Rationale for Strategies: 1. Visual cues can help a patient remember to perform necessary hygiene tasks.

Patient’s Actual Responses (Evaluation): 1. Patient showers and brushes teeth each morning.

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Identify expected level of hygiene and provide positive reinforcement for each task completed.

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Setting achievable expectations can help patient maintain good hygiene.

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Patient learns how to maintain good hygiene.

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Offer simple step-by-step reminders for hygiene and dress.

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Distractibility and poor concentration are countered by simple, concrete instructions (Varcarolis, 2016).

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Patient has begun bathing every other day and has dressed self in appropriate clothing.

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Evaluation: Patient has reported decrease in racing thoughts and ability to somewhat focus on one task at hand. Patient showers daily and remembers to put on clean clothes when necessary.

References: Varcarolis, E. M. (2016). Foundations of psychiatric mental health nursing. Elsevier. Townsend, M. C. (2011). Nursing diagnosis in psychiatric nursing: Care plans and psychotropic medications (8th ed.). F. A. Davis....