diagnosis

kwagner_51 · Dec 18, 2006

I'm a second yr nursing student doing clinical rotations. My problem has never been writing care plans or getting the diagnosis but this one has me stumped. My pt has breast cancer with metasis to the brain. The reason she was admitted to the hospital was paranoia/delusions/behavioral disorder. She thinks her family was trying to kill her. She is enrolled with hospice. My instructor wants me to use a diagnosis of Risk for loneliness r/t visitors prohibited. ( they have advised no visitors beyond hospice personal). I have no idea how to come up with goals and interventions for this. (pt slept entire shift I was there). If anyone could help I would greatly appreicate it . ps .. I need this for tomorrow 12/18/06

Lets' think about this.

1. Why is she lonely? [No visitors]

2. How will this affect her?

3. What kinds of meds will she be on and why?

4. How will the meds help her?

_____________________

In His Grace,

Karen

Failure is NOT an option!!

Crocuta, RN · Dec 18, 2006

Well, I think that Social Isolation would be the more appropriate diagnosis. The NANDA definition of Risk for Loneliness is "At risk for experiencing vauge dysphoria", whereas the definition of Social Isolation is "Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state." (Emphasis mine.) Loneliness is more an internal state which one has the ability to correct - social isolation is more external in nature.

Be that as it may, you have to work with what you've been given.

Goals might be something like, Pt will engage in interpersonal relationships with caregivers and report interactions as meaningful; Pt will maintain orientation to reality allowing additional visitors.

This is a tough diagnosis to work with, since the Risk is directly associated with the imposition of visitor restriction which is something that you have little control over.

You could start your patient off with less threatening interactions such as calling someone on the phone 1x/day, and lead up to more frequent direct contact; allow extra caregiver time during interactions to satisfy pt's need for human contact. Don't forget to establish the ever important nurse-client relationship to allow an environment in which the pt can express her feelings. Consider medications and their timing to maximize control during scheduled social times.

Hope this helps. It's a toughy.

AnnieOaklyRN, BSN, RN, EMT-P · Dec 18, 2006

That is sad she is not allowed visitors

PANurseRN1 · Dec 18, 2006

The pt is delusional and paranoid because she has brain mets. Behavioral measures aren't really going to help, particularly since she's end stage. Interventions should be approached with that in mind, not trying to get the pt to open up/gradually increase interactions. That's just not appropriate in this case.

doingourbest · Dec 18, 2006

I'm a second yr nursing student doing clinical rotations. My problem has never been writing care plans or getting the diagnosis but this one has me stumped. My pt has breast cancer with metasis to the brain. The reason she was admitted to the hospital was paranoia/delusions/behavioral disorder. She thinks her family was trying to kill her. She is enrolled with hospice. My instructor wants me to use a diagnosis of Risk for loneliness r/t visitors prohibited. ( they have advised no visitors beyond hospice personal). I have no idea how to come up with goals and interventions for this. (pt slept entire shift I was there). If anyone could help I would greatly appreicate it . ps .. I need this for tomorrow 12/18/06

Actions/Interventions:

1. Spend time with the patient.

Rationale: Care providers may feel they need a reason to be with the patient or that they need to be performing a clinical task to justify presence in the patient's room. However, the simple act of being available and emotionally present can have profound significance. This presence may involve talk or touching. One may be directly ministering to a physical need, or one may simply sit near the bedside, which is in itself an act of comfort.

2. Reinforce the idea that lonliness is a normal and appropriate response to the situation.

Rationale: This places lonliness within the scope of normal human experiences.

3. Convey feelings of acceptance and understanding.

Rationale: Although the nurse must provide perspective and feedback to the patient, he or she must not negate the patient's experience.

4. Document behavioral and verbal expressions of lonliness.

Rationale: This gives care providers the information they need to provide support to the patient. Physiological symptoms and/or complaints may intensify as the level of lonliness increases.

That is a tough one. Let me know if you need more.

leslie :-D · Dec 18, 2006

- music therapy

rationale: known for ameliorating mood disturbances.

energizing or soothing, depending on type of music.

also known to affect bp, rr, pulse.

- q hr check-ins (more if able)

rationale: avoids undue abandonment by touching base and making self available.

- psyche eval

rationale: mets to brain and subsequent mood disturbance, does not preclude depression, hopelessness and anxieties.

appropriate meds ordered, according to pt presentation, and possible therapy, per pt's cognitive and mental status

- ? pt/ot evals

rationale: address sensory and physical/motor deprivation.

- books, magazines, laptop

rationale: distracting, filling void of aloneness.

add: i hope she's not being medicated to sleep her days away.

there has to be some constructive outlets for this woman.

leslie

Crocuta, RN · Dec 18, 2006

That is sad she is not allowed visitors

And the forced isolation may very well exacerbate the delusions and behavior disorders the pt is experiencing. We frequently provide familiar sitters with delusional patients because it can help keep them oriented to reality. I'm assuming the breast CA with mets pt isn't much of a physical danger to those around her. Excluding those visitors who are familiar to the patient and replacing them with rotating caregivers seems like an unwise solution to me, but there may be factors not mentioned in this case.

Mommy TeleRN, RN · Dec 18, 2006

diversional therapy - as Earle said - could she do some puzzles - is there anyone that could spend a little extra time with her pampering her (ie rubbing her legs with lotion or whatever is allowed with her condition)

How about decorating her room with some stuff from home? Could her family send some special things in? A favorite baked goodie? Some pictures drawn by the children? A book made up with something personal written by various family members? Lots of phone calls. Putting up some picture frames with family photos? Is there any interaction between patients (I'm guessing no) If she is sleeping a lot then providing her the things from her family (the photos, drawings, writings) would provide her at least something visual and familiar when she wakes up.

How sad

Home Health Columnist / Guide · Dec 18, 2006

Potential for injury is also a diagnosis to use if they have threatened to harm family/self.

Behavioral modifications are used with limited success due to the brain metastises. These patients usually are given steroids to decrease intercranial swelling from tumor (often PO decadron).

Ensuring medications admistered timely is part of the goal. Visitor restriction would be lifted after percieved threat to family resolves, often 24-48hr period. Side effect of decadron: hyperglycemia needs to be evaluated; caregiver education regarding disease process, meds etc.

PANurseRN1 · Dec 18, 2006

Since the pt's interaction with her family seem to exacerbate her agitation, it would not be appropriate to have them visit. While we may personally feel that a terminally ill pt should have family present, that is not in this pt's best interests right now.