Psychosocial Problems and Care Plans

[Daytonite, BSN, RN]

Diagnosing is based upon the symptoms the patient has that will support a diagnosis. (A diagnosis is a label for a problem and the symptoms are evidence of the problem.) Expressive aphasia, only responding to loud auditory stimuli and the inability of client to express himself are evidence of a communication problem which is generally considered a safety issue although nanda places communication in a psychosocial category. That does not mean your instructors agree with that.

In order to diagnose a psychosocial problem you need evidence of what might be considered abnormal behavior. Look at the defining characteristics for powerlessness. It has to do with self-perception and a physical inability to speak is not exactly the kind of symptom that defines what powerlessness means. Since this diagnosis is about a psychological problem your symptoms need to be of a psychological nature. The assessment data you collected in a head to toes assessment isn't going to work here. How does he behave as a result of being unable to express himself?

A long time ago, I listed the Nanda breakdown of the psychosocial diagnoses from the taxonomy and posted them at Desperately Need Help With Care Plans.

Class: Behavior

• ineffective health maintenance
• health-seeking behaviors
• noncompliance
• effective therapeutic regimen management
• ineffective therapeutic regimen management
• ineffective community therapeutic regimen management
• ineffective family therapeutic regimen management
• readiness for enhanced therapeutic regimen management

Class: Communication

• impaired verbal communication
• readiness for enhanced communication

Class: Coping

• risk-prone health behavior
• decisional conflict
• ineffective coping
• ineffective community coping
• readiness for enhanced community coping
• defensive coping
• compromised family coping
• disabled family coping
• readiness for enhanced family coping
• ineffective denial
• grieving
• complicated grieving
• risk for complicated grieving
• post-trauma syndrome
• risk for post-trauma syndrome
• rape-trauma syndrome
• rape-trauma syndrome: compound reaction
• rape-trauma syndrome: silent reaction
• relocation stress syndrome
• risk for relocation stress syndrome
• self-mutilation
• risk for self-mutilation
• risk for suicide
• risk for self-directed violence
• readiness for enhanced coping
• stress overload
• readiness for enhanced decision making

Class: Emotional

• anxiety
• death anxiety
• fear
• hopelessness
• chronic sorrow
• readiness for enhanced hope

Class: Knowledge

• deficient knowledge (specify)
• readiness for enhanced knowledge (specify)

Class: Roles/Relationships

• risk for impaired parent/child attachment
• caregiver role strain
• risk for caregiver role strain
• parental role conflict
• dysfunctional family processes: alcoholism
• interrupted family processes
• impaired parenting
• risk for impaired parenting
• ineffective role performance
• impaired social interaction
• social isolation
• risk for other-directed violence
• readiness for enhanced family processes
• readiness for enhanced parenting

Class: Self-Perception

• disturbed body image
• disturbed personal identity
• risk for loneliness
• powerlessness
• risk for powerlessness
• chronic low self-esteem
• situational low self-esteem
• risk for situational low self-esteem
• readiness for enhanced self-concept
• readiness for enhanced power
• risk for compromised human dignity

If you have a copy of Taber's Medical Dictionary all the diagnoses, their taxonomy information and a medical diagnosis cross reference is included in its appendix.

Use the defining characteristics that are listed under some of these diagnoses as a guideline for what you need to look for in this patient.

[Daytonite, BSN, RN]

Goldenatom said:

He doesn't really react at all, that's part of the problem I'm having trying to work through this. My patient doesn't respond to much at all.

So, what is that in terms of assessment? How does the patient make their needs known to you? (I'm trying to help you get to a diagnosis.)

[Daytonite, BSN, RN]

A.E.B. for what? The diagnosis or the short term goal? Goals are not usually written with the wording "a.e.b." included in them although they can be if you are assessing for the same symptoms you used to diagnose the patient. However, you generally want to predict a positive response or action you want the patient to have as a result of the nursing interventions you plan to order. The goal and nursing interventions is our equivalent of doctor's orders.

This is our chance to order treatment within our scope of practice for the patient. Think about all the possible things you are able, as a licensed nurse, to order to help someone who has Impaired Verbal Communication and why. Why do you hope this patient will achieve as a result of your orders? That is your goal.

Goal statements have four components:

1. A behavior
   • This is the desired patient response/action you expect to see/hear as a direct result of your nursing interventions.
   • You must be able to observe (perhaps in this case, hear) the behavior
2. It is measurable. Criteria that identifies exactly what you are measuring in terms of
   • how much
   • how long
   • how far
   • on what scale you are using
3. Sets the conditions under which the behavior should occur. Such conditions as
   • When
   • How frequently
   • Take into account the patient's overall state of health (this requires knowing the pathophysiology of their disease process)
   • Take into account the patient's ability to meet the goals you are recommending
   • It is a good idea to get the patient's agreement to meet the intended goal so both the nurse and the patient are working toward the same goal
4. Have a realistic time frame for completing the goal
   • Long-term goals usually take weeks or months
   • Short-term goals can take as little time as a day
   • It all depends on knowing what your nursing interventions are designed to do and what you believe your patient is capable of doing.

In general, problems either

• Improve or cure
• Stabilize
• Deteriorate

You may use pictorial drawings or other nonverbal language with this patient. You may need to discover ways of determining how the patient acknowledges receiving, interpreting and understanding what he hears.

[nurseswearpink]

Impaired communication, ineffective family/individual coping, self care deficit,

[Goldenatom]

Ahhh, right communication...duh! Is self care deficit considered psychosocial?

[Goldenatom]

Do these work?

1. Disturbed thought processes- Impaired ability to perform activities of daily living r/t dementia a.e.b. impaired ability to perform activities of grooming/hygiene.

2. Powerlessness r/t chronic illness and dependence on others for activities of daily living a.e.b. inability of client to express himself.

[Goldenatom]

He doesn't really react at all, that's part of the problem I'm having trying to work through this. My patient doesn't respond to much at all.

[Goldenatom]

Well, the patient doesn't really let his needs be known. He's totally dependent for his ADLs. He needs loud auditory stimuli to be roused and falls asleep constantly, even during feedings.

[Daytonite, BSN, RN]

Well, the patient doesn't really let his needs be known. He's totally dependent for his ADLs. He needs loud auditory stimuli to be roused and falls asleep constantly, even during feedings.

So, what is that behaviorally? Look at the list I posted for you. Look, specifically at diagnoses listed under Roles & Relationships and Self-Perception. It's there.

[Goldenatom]

Social isolation? Risk for compromised human dignity?

[Goldenatom]

I discussed some of my assessment findings with my preceptor and we came up with "Impaired verbal communication." Now I'm trying to come up with a short term goal. What would be suitable? Patient will demonstrate improved ability to express himself? I'm not sure he will ever really be able to do that, but does that matter? Could the a.e.b. be something like "increased facial expressions"?