care plan for battered woman, need experienced nurses help!!

Daytonite, BSN, RN · Jun 8, 2009

a care plan is about determining a patient's nursing needs and developing interventions to help them. a nursing diagnosis is merely a label that describes in shorthand what a nursing problem is. its definition gives a more specific description of what it is. all actual nursing problems (nursing diagnoses) are based upon signs and symptoms that the patient has that are found during the assessment of the patient. this is very similar to what detectives do in looking for clues to the crimes that people commit except we don't always know what diagnosis we are looking for. there is a method to doing this called the nursing process. what a care plan book does for you is eliminate having to go through the nursing process. however, care plan books only cover the common medical diseases and conditions. when less common problems arise, the nursing process needs to be used in solving these nursing problems. follow the steps of the nursing process to do this. i demonstrate how this is done all the time in this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. nursing diagnoses that begin with the words "risk for" are potential nursing problems that do not exist yet and, therefore, do not have any signs or symptoms.

step #1 assessment - collect as much information as you can before you even begin thinking about what the nursing problems (nursing diagnoses) are. assessment consists of:

a health history (review of systems) - this is historical information about the patient. there is a history of physical abuse and a concussion and the patient is stating she now has headaches since the concussion.
performing a physical exam - you really have provided none. since the patient states she is having headaches a neuro exam should have been done. the degree of the headaches should have been assessed since a headache is pain and pain is a symptom. the body should have been inspected for evidence of bruising and any other injuries. rom of the extremities should have been done to assess for fractures, sprains and dislocations.
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - after a beating there is tissue damage and pain making the ability to perform adls difficult. this should be assessed. there are basic adls and instrumental adls. if the patient contemplates leaving the situation, instrumental adls may be a problem for her to accomplish. (see post #4 at https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html for information about adl assessments).
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - websites that have information about domestic violence and injuries include:
- http://www.mayoclinic.com/health/domestic-violence/wo00044 - domestic violence
- http://www.medicinenet.com/domestic_violence/article.htm - domestic violence
- http://www.merck.com/mmpe/sec21/ch310/ch310a.html - traumatic brain injury
- http://www.merck.com/mmpe/sec21/ch312/ch312a.html - facial trauma
- http://www.merck.com/mmpe/sec21/ch309/ch309a.html - fractures, dislocations and sprains

for the area you live in you should do a survey of the services available to battered women because this information would be needed for your nursing interventions.

reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - pain medication?

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - all diagnoses are based upon abnormal data. now you have a better base of information from which to put a list of symptoms together. up to this point the only abnormal data that you had was:

husband beat her
started having headaches
she feels unsafe

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - every nursing diagnosis has a definition, set of defining characteristics (signs and symptoms) and includes some related factors (causes or reasons they happen). a nursing diagnosis reference should be consulted to make sure you are using a nursing diagnosis correctly. more recently published care plan books will include this information in them if all the nursing diagnoses have been used. the appendix of current editions of taber's cyclopedic medical dictionary will have the information, and about 80 of the most commonly used nursing diagnoses are included with that information on these 2 websites:

based on the data you have provided i would diagnose in this priority:

acute pain r/t trauma aeb headache
fear r/t stressful domestic relationship aeb patient's report that she feels unsafe
ineffective coping r/t inadequate social support and low self-esteem aeb inability to appropriately solve current problems with spouse or ask for help in solving these problems
risk for self-directed violence r/t history of physical abuse (she is harmful to herself by remaining in a proven harmful situation where she will likely get beaten up again)

step #3 planning (write measurable goals/outcomes and nursing interventions) - nursing interventions are based upon the aeb items for each diagnosis. the goals are what you predict will happen when the nursing interventions are performed. . .

acute pain r/t trauma aeb headache

(this headache needs better description)

assessment:

where the pain is located
how long it lasts
how often it occurs
a description of it (sharp, dull, stabbing, aching, burning, throbbing)
- have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain (this is needed for later assessment and goal development)
[*]what triggers the pain
[*]what relieves the pain
[*]observe their physical responses
- behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
- sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
- parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness

goal:

the patient will report improvement of the headache.

nursing interventions:

assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
assess and document where on the head the pain is located and what, if anything, makes it worse or better
observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
assess for any declining level of consciousness and report changes to the physician.
give pain medication as ordered
provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
use short, simple relaxation exercises to distract the patient's attention
dim the lights in the room and keep noise down
play soft, soothing music
reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
teach the patient about prescriptions they will be taking including the dosage, how they should be taken and any side effects
instruct the patient to report any worsening of the headache to her physician.

- - - - - - - - - - - - - - -

is it risk for violence or just plain violence?

these are the official nanda diagnoses and their definitions. they are patient based because the patient is always the focus of the diagnosis:

risk for other-directed violence
:
at risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to
others
.
risk for self-directed violence
:
at risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to
self
.

i was thinking perhaps you help her make a plan to escape if (but of course she feels unsafe all the time perhaps have her form a codeword and the number she can reach you and you call 911? but would you give out your number to a client? in class we talked all about having a client that was in a violent situation have a code word but who is she calling? perhaps a family member? i am at a loss for the nursing actions and goals.

there are several problems here that have to be addressed. she has a physical problem, a headache, and physical problems always take priority over other things. see maslow's hierarchy of needs (

http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs

).then you can get to the safety issues. read the domestic violence articles first. she states she feels unsafe. deal with that. then teach her how to cope with her problem. if she did, she would have done something about it a long time ago (your hypothetical patient). the reason people stay in abusive relationships is because they don't know what they can do about it. she's not going anywhere until her self-esteem is boosted and someone shows her how to help herself. often there is a knowledge deficit as well going on (i didn't include that with the related factor) so teaching nursing interventions can be included. or, you can just add a

deficient knowledge

diagnosis which goes to the bottom of the actual diagnoses list. a plan for escape would come under the

risk for self-directed violence

because the goal for any potential problem is for that problem

not

to occur. your nursing interventions for that are specifically:

strategies to prevent the problem from happening in the first place
monitoring for the specific signs and symptoms of this problem
reporting any symptoms that do occur to the doctor or other concerned professional (in this case the police or social professional)

Daytonite, BSN, RN · Jun 8, 2009

now that i came back and actually read what you put into this post which was a tad different from what you posted on the nursing student discussion forum, where i also posted the above reply which took me approximately 2 hours to put together for you, i am going to tell you to read the weblinks on domestic violence that i found for you and not rely on others to give you this information. a big part of this assignment is to learn about the patient's condition. you are not learning well if you are depending on second hand information.

please read what i posted for you. there is a great deal of information i put in there for you. your interventions for any diagnosis are based upon the symptoms that you have to support it. what diagnosis are you asking about and what symptoms do you have to support it? based on the 3 symptoms you gave in the nursing student discussion forum i was able to come up with 4 nursing diagnoses for you. the 4th diagnosis is the one that supports strategies to get the patient away from her abusive spouse. the goal for it (and i gave you that as well) is to prevent the violence. again, please read what i posted. i covered everything, but i wasn't going to write the entire care plan for you--there are some things you have to do yourself. please go to the websites i posted on domestic violence to get information on what is done for it.

anangelsmommy, ADN, BSN, RN · Jun 8, 2009

thank you, I did read it and I will read the articles. I certainly dont want anyone to do the work for me...I just have no experience with violence and we only covered it in my lpn classes in a little blip in fundamentals. I feel like the headaches part I can do, it is something that I have dealth with, have had myself and seems fairly straight forward. I wanted to add the violence because it is something i havent experienced so obviously learning is needed there. I appreciate your help!

angels mommy!

JP

anangelsmommy, ADN, BSN, RN · Jun 8, 2009

oh, now another thought...if she hasnt complained about the situation...except to say that is how she obtained the head injury....I didnt really get details on her situation other than she lives with him and her two children. and he has a violent temper. No violence geared towards kids.

I guess I should have asked more questions about the home situation? I didnt really know what to ask so I realize now, I just didnt.

I will read the articles before further comments.

angels mommy.

Daytonite, BSN, RN · Jun 8, 2009

The focus is always on her, the patient, and what she tells you. Deal with the evidence that you get.

anangelsmommy, ADN, BSN, RN · Jun 8, 2009

ok, so i read both articles, I think it gives me a better understanding not only of the situation but of what kind of questions to ask. I think what you ask and what answers you get seem to depend on the level of trust or intimacy you have established with the patient.

I realize that I need to talk more with my patient - although we know each other on a personal level, I dont know a lot about this relationship except that when he beat her this time, she made him leave. And now I want to know, what did she do to actually get him to leave the house and not come back! of course he stalked her afterwards and still does in some ways. He still tries to control her. I know for a fact that the police did not make him leave, the neighbor called the police and they told my friend that her husband would lose his job if she went to the hospital, because then they would have to arrest him (he is a police officer). She didnt go to the hospital til the next day.

And here is the next issue - she has another boyfriend now. He is not physically abusive but he takes advantage of her monetarily - basically lives with her and pays no money toward anything - she is constantly worried about her financial situation with her two kids and he has a good job and pays $0 toward food, rent, household bills. So I ask, how do you get a person like this to change their mindset? And they fight all the time. I talk to her almost weekly about even HOW to talk to him! I worked out the monthly bills with her and showed her that if he was paying her 1/4 of the bills, she would be able to save $800 a month and at the end of a year, she would have the down payment on a small house! I know she wants to buy a house. But I can see she still has the low self esteem even though she has completed lpn school, with good grades! she will doubt that she will get into the rn program, she will doubt herself on tests constantly! I can see how she got into the relationship, but I can't change it for her and I dont know how to help her change her way of thinking....or can I?

I did have her go to counseling but I guess the counselor told her to chuck the new boyfriend and she hasnt so she hasnt gone back to the counselor.

anyway, it gave me a lot of food for thought but I still feel like my hands are tied as far as doing anything! I imagine if I feel this way when she isnt being beaten (anymore), I would feel this way even more if she was!

JP

Daytonite, BSN, RN · Jun 8, 2009

a lot of what you are posting is assessment (data collection) information that is part of step #1 of the nursing process. some of it is useful for the care plan and some isn't. you also have to focus on what you originally said you were going to do with this care plan which was assume that she had not left her husband. i figured you wanted to do that because you wanted to include this escape plan business in a care plan. it's a good teaching idea to incorporate into a care plan. how can you introduce a boyfriend if you are going to have this patient still living with her husband? make sure you keep focused on what you are doing. a care plan is like a photograph. it is interventions for problems that a patient has for a frozen moment in time. it will eventually change, but for the purpose of writing the care plan (and turning it in for a grade) freeze the picture and events in time and be clear about what problems (and the data that goes into them) you will address.

i just posted an escape plan on the other thread: https://allnurses.com/general-nursing-student/care-plan-help-398523.html. it is based on information from a psych book.

how do you get a person like this to change their mindset?

can you get anyone to change their mind? you give them the best information you have, let them know you are there to help and if and when they are ready, they will change.

i can see she still has the low self esteem

what are the cues (signs and symptoms). maybe this care plan needs a diagnosis adjustment and

chronic low self-esteem

would be a more appropriate diagnosis to include on this care plan. defining characteristics (signs and symptoms) are:

dependent on others' opinions
evaluates self as unable to deal with events
exaggerates negative feedback about self
excessively seeks reassurance
expressions of guilt
expressions of shame
frequent lack of success in life events
hesitant to try new things/situations
indecisive
lack of eye contact
nonassertive
overly conforming
passive
rejects positive feedback about self
self-negating verbalization

there is also

situational low self-esteem

that has to do specifically with self worth in response to a situation they are in assuming that their self-esteem is otherwise ok in all other situations.

anangelsmommy, ADN, BSN, RN · Jun 8, 2009

Yes, i have a disadvantage because i know her outside of a simple care plan. The chronic low self esteem - BINGO! oh my gosh that is so her!! now....I didnt put information to support this in my history. I guess I can add it now that I know more about what questions to ask - as this IS supposed to be a learning experience. would you NOTE on your history if someone didnt look you in the eyes? would you note, self negating verbalizations, indecisiveness, and excessively seeks reassurance or would you put it on the care plan under assessment? I feel like I never did a care plan before, LOL! I guess they were so simple that now that I am trying to do something I have no experience with, I feel like I am feeling around blind!

angels mommy

Morning-glory · Jun 8, 2009

Daytonite,

That was awesome work. I wish I had had you around when I was in school. I understood your idea of a care plan better in 10 minutes of reading than I did with 3 years of school. The school I went to used Sister Calista Roy's model. At first I was thrown off by a "philosophy" of nursing. I now understand the point of having a way to sort out all the information gathered, no matter what system in used. At work, the system in use is the Tidal Model as we are a mental health facility and this was designed with that in mind. I'm not entirely "with the program" but I will have another look and see what I can use to be better at what I do. Thank you for spending all that time explaining what a care plan is for and how to build it up into something that makes sense in the real world. Leaning all of this stuff in school was my biggest challenge. First, I wasn't expecting it, second, it made no sense. And third, it was so much work to put it all together. One student in my class (the genius one) had a list of close to 500 behaviours that she sorted all out into 20 goals. It was a master piece, but the rest of us in the class just about stroked out looking at it. There was no way that any of us would be able to get that done in the time that we had. I could do it now that I have been a nurse for 10 years, but would I want to?

Anyway, I wanted to let you know that I did read all of your stuff in this post and I am really impressed with the way you organized it all. Kudos!!

Daytonite, BSN, RN · Jun 8, 2009

Would you NOTE on your history if someone didnt look you in the eyes? would you note, self negating verbalizations, indecisiveness, and excessively seeks reassurance or would you put it on the care plan under assessment?

Simply note exactly what you observe on your history. If the patient doesn't look you in the eyes when you are talking with them, then state that on the care plan under the assessment along with self negating verbalizations, indecisiveness, and excessively seeks reassurance. Then, because these are abnormal things they also are signs and symptoms that fit in and match with your evidence supporting the problem of Chronic Low Self-Esteem. You can then diagnose Chronic Low Self-Esteem R/T unrealistic expectations of self AEB not looking you in the eyes during speaking with others, self negating verbalizations, indecisiveness, and excessively seeking reassurance. Are you beginning to see how diagnosis works? It starts with assessment of the patient and finding the clues to the problem first, every problem has evidence that supports it, then attaching a name to the problem. Once the problem is identified (that's the nursing diagnosis), you develop a plan of action: goals and nursing interventions. The nursing interventions are specifically aimed at the evidence you have that supports the diagnostic problem--that's why the diagnostic statement says "as evidenced by" for the proof. The goals predict what will happen as a result of those interventions.

Daytonite, BSN, RN · Jun 9, 2009

daytonite,
that was awesome work. i wish i had had you around when i was in school. i understood your idea of a care plan better in 10 minutes of reading than i did with 3 years of school. the school i went to used sister calista roy's model. at first i was thrown off by a "philosophy" of nursing. i now understand the point of having a way to sort out all the information gathered, no matter what system in used. at work, the system in use is the tidal model as we are a mental health facility and this was designed with that in mind. i'm not entirely "with the program" but i will have another look and see what i can use to be better at what i do. thank you for spending all that time explaining what a care plan is for and how to build it up into something that makes sense in the real world. leaning all of this stuff in school was my biggest challenge. first, i wasn't expecting it, second, it made no sense. and third, it was so much work to put it all together. one student in my class (the genius one) had a list of close to 500 behaviours that she sorted all out into 20 goals. it was a master piece, but the rest of us in the class just about stroked out looking at it. there was no way that any of us would be able to get that done in the time that we had. i could do it now that i have been a nurse for 10 years, but would i want to?
anyway, i wanted to let you know that i did read all of your stuff in this post and i am really impressed with the way you organized it all. kudos!!

i am glad my explanations are helpful for you. i have a number of others that explain the nursing process and how to construct a nursing diagnostic statement that i think are posted on the help with care plans thread (https://allnurses.com/forums/f50/help-care-plans-286986.html)

i really didn't start understanding care plans and the nursing process until i was several years out of nursing school and had started doing care plans at work. it is because of having a few years of clinical experience under my belt. i was a slow learner. however, once the light bulbs get turned on in my brain there is no getting them turned off!