Professional Documents
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NCP For Adjustment Disorders
NCP For Adjustment Disorders
DSM-IV
ADJUSTMENT DISORDERS (SPECIFY IF ACUTE/CHRONIC)
309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood
ETIOLOGICAL THEORIES
Psychodynamics
Factors implicated in the predisposition to this disorder include unmet
dependency needs, fixation in an earlier level of development, and underdeveloped
ego.
The client with predisposition to adjustment disorder is seen as having an
inability to complete the grieving process in response to a painful life change. The
presumed cause of this inability to adapt is believed to be psychic overload—a level
of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is
disrupted, and psychological or somatic symptoms occur.
Biological
The presence of chronic disorders is thought to limit an individual’s general
adaptive capacity. The normal process of adaptation to stressful life experiences is
impaired, causing increased vulnerability to adjustment disorders. A high family
incidence suggests a possible hereditary influence.
The autonomic nervous system discharge that occurs in response to a frightening
impulse and/or emotion is mediated by the limbic system, resulting in the peripheral
effects of the autonomic nervous system seen in the presence of anxiety.
Some medical conditions have been associated with anxiety and panic disorders,
such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-
pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance
intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve
prolapse; and complex partial seizures.
Family Dynamics
The individual’s ability to respond to stress is influenced by the role of the
primary caregiver (her or his ability to adapt to the infant’s needs) and the child-
rearing environment (allowing the child gradually to gain independence and control
over own life). Difficulty allowing the child to become independent leads to the child
having adjustment problems in later life.
Individuals with adjustment difficulties have experienced negative learning
through
inadequate role-modeling in dysfunctional family systems. These dysfunctional
patterns impede the development of self-esteem and adequate coping skills, which
also contribute to maladaptive adjustment responses.
Activity/Rest
Fatigue
Insomnia
Ego Integrity
Reports occurrence of personal stressor/loss (e.g., job, financial, relationship) within
past 3 months
May appear depressed and tearful and/or nervous and jittery
Feelings of hopelessness
Neurosensory
Mental Status: Depressed mood, tearful, anxious, nervous, jittery
Attention and memory span may be impaired (depends on presence of
depression, level of anxiety, and/or substance use)
Communication and thought patterns may reveal negative ruminations of
depressed mood or flight of ideas/loose associations of severely anxious condition
Pain/Discomfort
Various physical symptoms such as headache, backache, other aches and pains
(maladaptive response to a stressful situation)
Safety
Anger expressed inappropriately
Involvement in high-risk behaviors (e.g., fighting, reckless driving)
Suicidal ideations may be present
Social Interactions
Difficulties with performance in work/social setting, when no difficulties had been
experienced prior to the occurrence of the stressor
Socially withdrawn/refuses to interact with others (e.g., isolates self in own room)
Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities,
violation of the rights of others or age-appropriate norms and rules
May display manipulative behavior (e.g., testing limits, playing individuals/family
members against each other)
Teaching/Learning
Academic difficulties, failure to attend class/complete course work
Substance use/abuse possibly present
DIAGNOSTIC STUDIES
Diagnostic studies and psychological testing as indicated to rule out conditions
that may mimic or coexist (e.g., endocrine imbalance, cardiac involvement, epilepsy,
or a differential diagnosis with affective, anxiety, conduct, or antisocial personality
disorders).
Drug Screen: Determine substance use.
NURSING PRIORITIES
1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.
DISCHARGE GOALS
1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation
reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted
actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Establish a therapeutic nurse/client relationship. Be Honesty, availability, and unconditional
honest, consistent in responses, and available. Show acceptance promote trust, which is
necessary for
genuine positive regard. the development of a therapeutic relationship.
Provide activities geared toward reduction of Tension and anxiety can be released safely, and
tension and decreasing anxiety (e.g., walking or physical activity may provide emotional benefit to
jogging, musical exercises, housekeeping chores, the client through release in the brain of
morphine-
group games/activities). like substances (endorphins) that promote sense
of
well-being.
Encourage client to identify true feelings and to Anxious clients often deny a relationship between
acknowledge ownership of those feelings. emotional problems and their anxiety. Use of the
defense mechanisms of projection and
displacement are exaggerated.
Maintain a calm atmosphere and approach to client. Can help to limit transmission of anxiety
to/from
client.
Assist client to recognize specific events that precede Recognition of precipitating stressors and
a plan of
onset of elevation in anxiety. Provide information action to follow should they recur provides client
about signs and symptoms of increasing anxiety with feelings of security and control over similar
and ways to intervene before behaviors become situations in the future. This in itself may help to
disabling. control anxiety response.
Offer support during times of elevated anxiety. Presence of a trusted individual may provide
Provide physical and psychological safety. (Refer to needed security/client safety.
ND: Violence, risk for, directed at self/others.)
Collaborative
Administer medications as necessary, e.g., benzo- Antianxiety medications induce a calming
effect
diazepines: alprazolam (Xanax). and work to maintain anxiety at a manageable
level while providing the opportunity for client to
ACTIONS/INTERVENTIONS RATIONALE
Independent
Observe client’s behavior frequently during routine Close observation is required so that
intervention
activities and interactions; avoid appearing watchful can occur if required to ensure the safety
of others.
and suspicious. Instilling suspicion may provoke aggressive
behaviors.
Ask client direct questions regarding intent, plan, Direct questions, if presented in a caring,
and availability of the means for self-harm. Evaluate concerned manner, provide the necessary
and prioritize on a scale of 1–10 according to information to assist the nurse in formulating an
severity of threat, availability of means. appropriate plan of care for the suicidal client.
Provide a safe environment: reduce stimuli (e.g., A stimulating environment may increase agitation
low lighting, few people, simple decor, low noise and provoke aggressive behavior.
level).
Remove potentially dangerous objects, such as External control of environment aids in
preventing
straps, belts, ties, sharp objects, glass items, and impulsive actions at a time when client lacks own
drugs, as indicated. internal controls.
Secure contract from client that she or he will not A contract encourages the client to share in the
harm self and will seek out staff member if suicidal responsibility of own safety. A degree of
control is
ideations emerge. experienced, and the attitude of acceptance of
the
client as a worthwhile individual is conveyed.
Promote verbalizations of honest feelings. Through May be difficult for client to express
negative
exploration and discussion, help client identify feelings. Verbalization of these feelings in a
symbols of hope in own life. nonthreatening environment may help client
come
to terms with unresolved issues and identify
reasons for wanting to change life/continue
living.
Help client identify true source of anger/hostility Because of weak ego development, client may be
Convey an attitude of acceptance toward the client. Promotes feelings of self-worth. These
feelings are
Impart a message that it is not the client but the further enhanced as person and behavior are
behavior that is unacceptable. viewed separately, communicating unconditional
positive regard.
Explore with client alternative ways of handling Physically demanding activities help to relieve
frustration/pent-up anger that channel hostile pent-up tension. Note: Exercise need not be
energy into socially acceptable behavior (e.g., brisk aerobic or intensive to achieve therapeutic
effect.
walks, jogging, physical exercises, volleyball,
punching bag, exercise bike).
Maintain a calm attitude toward the client if Anxiety is contagious and can be transferred from
behavior escalates. Have sufficient staff available to person to person. A calm attitude provides
client
convey a show of strength to the client if it becomes with a feeling of safety and security. A
display of
necessary. strength provides reassurance for the client that
the staff is in control of the situation and will
provide physical security for the client, staff,
and others.
Be alert to increased potential for suicidal action as Client may mobilize self for suicidal
attempt as
mood elevates. decrease in depression results in increased
energy
and motivation.
Collaborative
Administer medication as indicated, e.g.:
Tricyclic drugs: amitriptyline (Elavil), desipramine Antidepressant medication may elevate the
mood,
(Norpramin), doxepin (Sinequan), imipramine as it increases level of energy and decreases
(Tofranil); selective serotonin reuptake feelings of fatigue.
inhibitors (SSRIs): fluoxetine (Prozac), sertraline
(Zoloft), paroxetine (Paxil); monoamine-oxidase
inhibitors: isocarboxazid (Marplan), phenelzine
(Nardil);
Benzodiazepines: diazepam (Valium), Antianxiety medication may provide needed
relief
chlordiazepoxide (Librium), alprazolam from anxious feelings, inducing a calming effect
ACTIONS/INTERVENTIONS RATIONALE
Independent
Explain rules of the unit/therapeutic relationship Negative reinforcement may work to decrease
and consequences of lack of cooperation. Set limits undesirable behaviors. Consistency among
all staff
on manipulative behavior. Be consistent in enforcing members is vital if intervention is to be
successful.
the consequences when rules are broken and limits
tested.
Ignore negative behaviors when possible and Negative behaviors diminish when they provide
provide feedback when positive behaviors are noted, no reward of attention. When client gives
self
encouraging client to acknowledge own success. positive feedback, inner rewards are enhanced.
Encourage client to discuss angry feelings. Help Verbalization of feelings with a trusted individual
client identify the true object of the hostility. Provide may help client work through unresolved
issues.
physical outlets for healthy release of the hostile Physical exercise provides a safe and effective
feelings (e.g., punching bags, pounding boards). means of releasing pent-up tension, as well as of
Involve in outdoor recreation program, if available. developing self-confidence and trust in
others.
Take care not to reinforce dependent behaviors. Independent accomplishment and positive
reinforcement enhance self-esteem and
encourage
repetition of desirable behaviors.
Allow client to perform as independently as possible Recognition of personal control, however,
and provide feedback. Help client recognize aspects minimal diminishes the feeling of
powerlessness
of life over which a measure of control is maintained/ and decreases the need to manipulate
possible. (Refer to ND: Powerlessness.) others.
Give minimal attention to the physical condition if Organic pathology must always be considered.
client is coping through numerous somatic Failure to do so may place the client in physical
complaints and organic pathology has been ruled jeopardy. Lack of attention to maladaptive
out. Increase attention when client is not focusing behaviors may decrease their repetition. Positive
on physical complaints. reinforcement encourages desirable behaviors.
Discuss the negative aspects of substance abuse as Denial of problems related to substance
use is
a response to stress. Help client recognize difficult common. Client needs to recognize
relationship
life situations that may be contributing to use of between substance use and personal problems
substances. before rehabilitation can begin.
Assist with problem-solving process. Suggest Because of level of anxiety and delayed
alternatives, and help client to select more adaptive development, client may require
assistance in
strategies for coping with stress. determining which methods of coping are most
individually appropriate. Increased anxiety
interferes with client’s problem-solving ability.
Encourage client to learn relaxation techniques, use These skills can be helpful in developing
new
of imagery. coping methods to deal with/reduce stress.
Collaborative
Refer client to substance rehabilitation program if A greater likelihood of success can be expected if
problem.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Encourage client to talk about lifestyle before the It is important to identify the client’s strengths so
change in health status. that they may be used to facilitate adaptation to
change or loss that has occurred.
Discuss coping mechanisms that were used at Some individuals may not realize that anger is a
stressful times in the past. Help client to discuss the normal stage in the grieving process. If it
is not
change/loss and particularly to express anger released appropriately, it may be turned inward
associated with it. on the self, leading to pathological depression.
Have client express fears associated with the Change often creates a feeling of disequilibrium,
change/loss or the resulting alteration in lifestyle and the individual may respond with fears that
are
that has occurred. irrational or unfounded. Client may benefit from
feedback that corrects misperceptions about how
Collaborative
Refer to resources within the community (e.g., Provides assistance in adapting to the change in
self-help/support groups, public health nurse, health status.
counselor, or social worker).
ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine stage of grief in which client is fixed. Accurate baseline assessment data are necessary
to
Identify behaviors associated with this stage. choose appropriate interventions/provide
effective care and evaluate progress. (Most
depressed people are fixed in the anger stage,
with
the anger directed inward on the self.)
Convey an accepting attitude; encourage client toAn accepting attitude enhances trust and
express self openly. communicates to the client that you believe the
client is a worthwhile person, regardless of what
may be expressed.
Encourage client to express anger. Avoid defensive Verbalization of feelings in a
nonthreatening
response if initial expression of anger is displaced environment may help client come to terms with
on nurse/therapist. Assist client to explore angry unresolved issues related to the loss.
feelings and direct them toward the intended object/
person or other loss.
Encourage participation in large motor activities. Physical activity provides a safe and effective
method for discharging pent-up tension/anger.
Provide information about the stages of grief and the Knowledge of the acceptability of the
feelings
behaviors associated with each stage. Help client associated with normal grieving may help relieve
understand that feelings, such as anger directed some of the guilt that these responses generate.
toward the loss, are appropriate during the grief
process.
Encourage client to review relationship with loss. Client needs to give up idealized perception and
With support and sensitivity, point out reality of accept both positive and negative aspects about
the situation in areas where misrepresentations are the loss before resolution of grief can
occur.
expressed.
Help client determine methods for more adaptive Feelings of depression may interfere with client’s
coping with the experienced loss. Provide positiveproblem-solving ability, resulting in need for
feedback for strategies identified and decisions made. assistance. Positive feedback enhances
self-esteem
and encourages repetition of desirable behaviors.
Collaborative
Determine client’s perception of spiritual needs as Some individuals derive great strength
from
support in the grieving process. Involve chaplain or spiritual support. This strength may be
used by
appropriate spiritual leader as indicated. the client in the task of grief resolution.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Identify use of maladaptive behaviors/defense Personal attempts to overcome feelings of
mechanisms (e.g., withdrawal, substance use, hopelessness may have resulted in ineffective/
regression). harmful behaviors. Recognizing the behaviors
provides opportunity for change.
Encourage client to explore and verbalize feelingsIdentification of feelings underlying behaviors
and perceptions. helps client to begin process of taking control of
own life.
Identify individual signs of hopelessness, (e.g., Helps to individualize interventions, focus
decreased physical activity, social withdrawal). attention on areas of need.
Express hope to client in positive, low-key manner. Even though client feels hopeless, it can
be helpful
to hear positive expressions from others.
Help client identify areas of life situation that are Client’s emotional condition may interfere with
under own control. ability to problem-solve. Assistance may be
required to perceive the benefits and
consequences of available alternatives accurately.
Encourage client to assume responsibility for own Providing the client with choices increases
feelings
self-care (e.g., setting realistic goals, scheduling of control. Note: Unrealistic goals set the client
up
activities, making independent decisions). for failure and reinforce feelings of hopelessness.
Help client identify areas of life situation that are Client needs to identify and resolve feelings
not within ability to control. Discuss feelings associated with inability to control certain life
associated with this lack of control. situations before level of acceptance can be
achieved.
NURSING DIAGNOSIS SELF ESTEEM disturbance [specify]
May Be Related to: Maturational transitions
Unmet dependency needs; retarded ego
development
Repeated negative feedback, diminished self-
worth
Dysfunctional family system
Possibly Evidenced by: Self-negating verbalization, inability to deal with
events; difficulty accepting positive feedback
Lack of eye contact; nonassertive/passive
behaviors; indecision, difficulty making decisions
Hesitancy to undertake new tasks; fear of failure
Social isolation; nonparticipation in therapy
Manipulation of one staff member against
another
Self-destructive ideas/behavior
Desired Outcomes/Evalution Criteria— Identify feelings and underlying dynamics for
Client Will: negative perception of self.
Demonstrate behaviors/lifestyle changes to
promote positive self-esteem.
Accept recognition for personal
accomplishments/abilities.
Verbalize increased sense of self-worth.
ACTIONS/INTERVENTIONS RATIONALE
Independent
Discuss goals, making sure they are realistic. PlanAchievement/success enhance self-concept.
activities in which success is likely.
Convey unconditional positive regard for the client. Unconditional acceptance of an individual
serves
Promote understanding of acceptance for client as a to counteract feelings of worthlessness by
worthwhile human being. reinforcing that individual is worthy of another
person’s respect.
Spend time with client both on a 1:1 basis and in Conveys that the nurse sees the client as
someone
group activities. worth spending time with.
Assist client to identify positive aspects of self and Individuals with low self-esteem often
have
develop plans for changing the characteristics difficulty recognizing positive attributes. They
viewed as negative. may also lack problem-solving skills and require
assistance to formulate a plan for implementing
the desired changes.
Encourage and support client in confronting the Recognition and positive reinforcement enhance
fear of failure by attending therapy activities and self-esteem and encourage repetition of desirable
ACTIONS/INTERVENTIONS RATIONALE
Independent
Establish 1:1 relationship with client, which serves Client needs to learn to interact
appropriately with
as role model for testing new behaviors. nurse, so that behaviors may then be generalized
to others.
Encourage client to engage in activities out of Decreases opportunity for client to isolate self.
room/home.
Offer to attend initial group interactions with client. Presence of a trusted individual may
provide a
Provide feedback for appropriate interactions. feeling of security and decrease the anxiety
generated by difficult social situation. Positive
reinforcement enhances self esteem and
encourages repetition of desirable behaviors.
Act as role model for client through appropriate Because of weak ego development, client is
interactions with client and others. inclined to imitate the actions of those individuals
admired or trusted.
Establish schedule of group activities for client. It is through these group interactions, with
positive and negative feedback from peers, that
ACTIONS/INTERVENTIONS RATIONALE
Independent
Assess family developmental stage, communication Identifies specific needs and provides
direction for
patterns, and extent of dysfunction. care.
Meet with the total family group as often as possible. The family as a system operates as a
single unit.
Each member affects, and is affected by, all other
positive change. Assist with necessary modifications process may be required to promote
adaptation
of original plan. and growth.
Promote separation and individuation and clear, Emotional connectedness among family members
Collaborative
Involve family in group therapy. Interacting with others in family/multifamily
groups can help identify dysfunctional patterns
and assist in learning new skills and solutions for
family problems.
Refer family to other resources, such as support Sharing with others who have had similar
groups, classes (e.g., parenting/assertiveness experiences can provide support and assist
family
training). members to learn new ways to deal with
situation.