care plan help for violence, other directed

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)

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

thank you!! we havent done the physical assessment but i got the the entire health history and i did ask her to rate the pain and the location and exacerbating symptoms etc. she had an abnormal ct scan - she is trying to find the actual results to tell me how they graded it, i think i have the pain issue under control, however i dont like that the doctor only gave her prescription strength ibuprofen? she was already taking ibuprofen and it wasnt helping. but i think i can handle the pain with the headaches -i can think of several things her to help, massage, stretching because she says she has a very tense neck at the end of the day when she has these headaches, relaxing things such as dim lights, music, positive imagery, cold cloth on her head, heat pack on her neck. i also believe anxiety plays a big role here and i can discuss ways to reduce anxiety etc.

thanks for the input, it gave me a lot of food for thought!

"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." oh yeah, i never even thought about this, we have a battered womens shelter that has some resources - i had a friend that had gone there for a lawyer for her divorce and counseling services.

"

acute pain r/t trauma aeb headache yup this one i had no problem with but i have to have more than one diagnosis and that is where the violence comes in i believed.
fear r/t stressful domestic relationship aeb patient's report that she feels unsafe i had fear as a possible dx but wasnt sure how to rate it and i felt that the violence seemed more important on maslows heirarchy - but i guess if it is a "risk" than it isnt.
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 ok, this sounds good but how do you improve someones self esteem? (can you tell i just graduated two weeks ago and am now starting the next phase?)
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)" i like this one! and i guess the escape planning etc goes along with this one but i need to read those articles first before i decide on this.

thank you for your help!!

jp

thank you!

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

Daytonite!

the one website is for the careplanning book that i just bought for this course! but it doesnt list this website, funny! thanks

angels mommy!

Daytonite, BSN, RN · Jun 8, 2009

Daytonite!
the one website is for the careplanning book that i just bought for this course! but it doesnt list this website, funny! thanks
angels mommy!

Try looking on the back cover or in the Preface.

Daytonite, BSN, RN · Jun 8, 2009

i just read your post on the general nursing discussion forum. this case gets better and better, doesn't it? sarcasm intended. ok. take a photo of a point in time that you want to base this care plan on because i'm getting confused. first, i thought you said that for purposes of this care plan you were going to "pretend" that this person hadn't left her spouse. then, on the other thread you talk about how the spouse has left and she has a new boyfriend that takes advantage of her. you can't get all this stuff into one care plan or this care plan will run pages and pages. my longest care plan was 45 pages in my bsn program and i don't think you want to go with something like that!

can we go back to your original idea that for the sake of the care plan we have a wife who has been beaten, has not left her husband, has a concussion and comes in a week later with a headache? i will be less confused, can give you the information i found, eat my breakfast and go to the store to get cat food for my cats before my soap operas come on. ha! ha! hang with me here because i think you're gonna like what i found.

i went through my psych care plan book and came up with a few ideas. first of all, i think the diagnosis of risk for self-directed violence r/t history of physical abuse should be changed to simply risk for injury r/t history of physical violence.

risk for injury r/t history of physical violence

long term goal: within 3 weeks the patient will state that her living conditions are now safe from potential abuse.
short term goal: after an initial interview with the patient, she will be able to describe a safety plan and two community resources that she can contact in the event of a future violent situation.
nursing interventions:
- make sure that the physician does a complete physical assessment of the patient to assess for physical injuries.
- in all interactions with the patient the nurse will remain nonjudgmental and understand that the patient may want to remain loyal to her spouse.
- always speak to the patient where there is privacy and their confidentiality is ensured.
- encourage the patient to talk about the battering incident and listen without interrupting them
- document accurately any verbatim statements made by the patients regarding violence and when it occurred.
- ask and assess if the patient has a safe place to go when violence escalates.
- know your state requirement for reporting suspected spousal abuse: contact the appropriate agency or facility supervisor/social worker as per facility policy and procedure regarding reporting of domestic abuse.
- discuss an escape plan to be put into effect when violence escalates:
  - keep important phone numbers available.
  - know who they can call and tell about the violence and ask them to call the police if they hear any suspicious noises coming from the home.
  - write down 4 places they can go to in an emergency.
  - write down the place where they can/have left extra money, car keys. clothes and copies of important documents
  - if i leave i will bring:
    - identification
    - birth certificates for me and my children
    - social security cards
    - school and medical records
    - money, bankbooks, credit cards
    - keys (house/car/office)
    - driver's license and registration
    - medications
    - change of clothes
    - welfare identification
    - passports, green cards, work permits
    - divorce papers
    - lease,/rental agreement, house deed
    - mortgage payment book, current unpaid bills
    - insurance papers
    - address book
    - pictures, jewelry, items of sentimental value
    - children's favorite toys and/or blankets
    [*]to ensure safety and independence i can open my own bank account, reheorifice my escape plan with a support person and review my safety plan periodically.
  [*]tell the patient that "no one deserves to be beaten.", "you cannot make anyone hurt you.", and "it is not your fault."
  [*]encourage the patient to contact friends and family that they have been avoiding in order to make them allies.
  [*]provide a list of psychotherapists in the area who are experienced working with battered spouses and provide it to the patient.
  [*]provide a list of community resources available to patient that she can take advantage of at any time she is ready to do so:
  - hotlines
  - shelters
  - battered women's groups
  - battered women's advocates
  - social services
  - afdc (aid to families with dependent children)

gotta eat breakfast now. let me know how you're coming along with the other diagnoses.

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

Wow that is great information, thank you!! I have searched for that kind of detail! Sorry about the boyfriend stuff, yes for the purpose of the care plan she is still with the abuser - thus I can learn about this. I just happen to have too much info- as I am a friend also. thank you for this!! I have to get back to class, will update as I finish more on the care plan.

angels mommy