Sample Nursing Diagnosis

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Axis I: Schizoaffective, Bipolar, Paranoid type

Nursing DX: Ineffective coping R/T inadequate levels of/or perception of control AEB increased dependency on others and drug/alcohol use Ineffective Coping as evidenced by excessive ETOH, homelessness, loss of friends, jobs, etc. will be relevant for this client. His grief issue is not established or described in the nursing assessment? How is this connected? Can you clarify or revise?

Subjective Data: Client states “I used marijuana daily because I liked how it made me feel.” When engaged in conversations with nurses.

Objective Data: lab test results positive for THC, withdrawal symptoms of not smoking and positive signs of taking prescribed medication daily.

Supporting Diagnostic Studies: Patients verbal expressions that related to drug use, comprehensive nursing assessment and patients response to interventions.
Reference: page 89-91, Spark’s and Taylor Nursing Diagnosis Reference Manual. Manual of Psychiatric nursing care planning, pages 341-345. Expected OutcomesPlanRationalesEvaluation
1.Participate weekly in drug-free activities in groups with drug free peers and demonstrate coping behaviors.

2.By discharge from treatment, client will identify, develop, and use socially acceptable coping skills.

Each Outcome needs 5 interventions or plans which is supported by a specific rationale with a reference and page #. I do see your reference - can you add the page # to the rationales?

Outcome #1 focuses on rules and manipulating behaviors – but the ND targets ineffective coping – it is not clear how these are related. You may want to change this one – see Chap. 10 pg. 341 Varcarolis Psych Nursing manual? 1.Discuss with client the rules of therapy and the consequences of noncompliance.

2.Do not argue or bargain with the client regarding limit setting.

3.Encourage discussion of repressed feelings. Encourage patient to try coping behaviors.

4.Take care not to...
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