I'm forming a care plan for a psych patient and I'm having trouble with the "related to". Obviously I can't say "r/t autism". Anyone want to help?
Here's the info pertinent to this dx:
20 yr old male, Bipolar, ADHD, Asperger's Syndrome, Developmentally Delayed Disorder. Has poor sense of personal space/boundaries. Brushes up against staff. Is generally intrusive, interrupting conversations with often strange comments like "I can scratch my nose with my foot" (and then proceeds to do so). Flat affect, wanders away when you're talking to him, generally odd.
I have 2 other dx done, "impaired social interaction" is the 3rd priority. I've been looking through care plan books and I can't find any r/t that really fits. I think his social behaviors are characteristic of autism/aspergers. So how can I say that without mentioning the medical dx?
Here are some things that the care plan books list as r/t: communication barriers, deficit about ways to enhance mutuality (e.g. knowledge, skills), disturbed thought process, self-concept disturbance, lack of social skills, alienation from others, impulse control, difficulty adhering to conventional social behaviors.
Do you think any of those fit? Any other suggestions?
Impaired social interaction r/t ???? AEB brushing up against staff, intrusiveness, and use of unsuccessful social behaviors.
Feb 15, '12
Medscape: Medscape Access
Talks all about autism and behaviors.This requires registration but is a valuable resource.
The Plan Of care depends on what the individuals exhibiting and how severs their impairments are. What is the assessment of the patient?
- After collecting all data, the nurse compares the information and then analyses the data and derives a nursing diagnosis.
- A nursing diagnosis is a statement of the patient’s nursing problem that includes both the adaptive and maladaptive health responses and contributing stressors.
- These nursing problems concern patient’s health aspects that may need to be promoted or with which the patient needs help.
- A nursing diagnosis may be an actual or potential health problem, depending on the situation.
- The most commonly used standard is that of the North American Nursing Diagnosis Association (NANDA).
A nursing diagnostic statement consists of three parts:
Mental Status Examination
- Health problem
- Contributing factors
- Defining characteristics
Components of Assessment
- Dress, grooming, hygiene, cosmetics, apparent age, posture, facial expression.
- Hyperactivity or hyperactivity, rigid, relaxed, restless, or agitated motor movements, gait and coordination, facial grimacing, gestures, mannerisms,, passive , combative, bizarre.
Mood and affect
- Interactions with interviewer: - Cooperative, resistive, friendly, hostile, ingratiating
- Speech-Quantity: - poverty of speech, poverty of content, volume.
- Quality: - articulate, congruent, monotonous, talkative, repetitious, spontaneous, circumstantial, confabulation, tangential and pressured
- Rate:-slowed, rapid
- Mood (Intensity depth duration):- sad, fearful, depressed, angry, anxious, ambivalent, happy, ecstatic, grandiose.
- Affect (Intensity depth duration) :- appropriate, apathetic, constricted, blunted, flat, labile, euphoric.
- Hallucination, illusions, depersonalization, derealization, distortions
Sensorium and Cognition
- Form and content-logical vs. illogical, loose associations, flight of ideas, autistic, blocking., broadcasting, neologisms, word salad, obsessions, ruminations, delusions, abstract vs. concrete
- Level of consciousness, orientation, attention span, , recent and remote memory, concentration, , ability to comprehend and process information, intelligence
- Ability to assess and evaluate situations makes rational decisions, understand consequence of behaviour, and take responsibly for actions
- Ability to perceive and understand the cause and nature of own and other’s situation
- Interviewer’s impression that individual reported information accurately and completely
Nursing Diagnosis: Ineffective individual coping, related to response crisis (retirement), as evidence by isolating behaviour, changes in mood, and decreased sense of well-being.
||Nursing Intervention with Rationale
|Patient will identify positive coping strategies, such as structuring leisure time.
Patient will combine past effective coping methods with newly acquired coping strategies
|Develop trusting relationship with patient to demonstrate caring and, encourage patient to practice new skills in a safe therapeutic setting.
Praise patient for adaptive coping. Positive feedback encourages repetition of effective coping by patient
|Patient expresses trust in nurse-patient relationship.
Patient discusses plans for use of past and newly learned coping methods.
Nursing Process in Psychiatric Nursing
Nursing Resources - Care Plans
Feb 15, '12
here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
- assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans
and the nursing process. . .a care
plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is
a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.
care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.
assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
Feb 16, '12
Thank you for that medscape article - it will be a big help for my outcomes and interventions. I already did all of my assessment -copied everything out of the chart, have had several convos with the patient and did a process recording. I was just having trouble with the r/t but I think I'm going to go with impaired social interaction r/t to poor boundaries. I'm taking a look at the Psych Nursing link now - looks promising as well. Thanks again for your reply.
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