Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications

3. Client demonstrates use of adaptive coping strategies when 14. Observe the client in restraints every 15 minutes (or ac- 1. Anxiety is maintained at a level at which client feels no need Outcome Criteria 15. As agitation decreases, assess client’s readiness for restraint 2. Client denies any ideas of self-destruction.for aggression.licensed independent practitioner responsible for the care of the patient) be conducted within 1 hour of initiating restraint or seclusion (The Joint Commission, 2010). The physician must reevaluate and issue a new order for re-straints every 4 hours for adults and every 1 to 2 hours for children and adolescents.pulses). Assist client with needs related to nutrition, hy-cording to institutional policy). Ensure that circulation to extremities is not compromised (check temperature, color, (formerly the Joint Commission on Accreditation of Health-dration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. care Organizations [ JCAHO]) requires that an in-person a nursing priority.evaluation (by a physician, clinical psychologist, or other removal or reduction. Remove one restraint at a time, while assessing client’s response. the client and staff.^ This minimizes risk of injury to Adjustment Disorder Client safety is ●^241

2 2506_Ch13_236-255.indd Sec1:241 506 Ch 13 236 - 255 .indd ipation of danger. It is an alerting signal that warns of impending dan-unknown to the individual); a feeling of apprehension caused by antic-S[Feelings of powerlessness and lack of control in life situation][Retarded ego development]Defi[Fixation in earlier level of development] 4. Client verbalizes community support systems from which as-[Dysfunctional family system]●[Low self-esteem]Situational and maturational crisesPossible Etiologies (“related to”)ger and enables the individual to take measures to deal with threat.panied by an autonomic response (the source often nonspecifie^ c 1 ANXIETY (MODERATE TO SEVERE)are not successful. feelings of hostility or suicide occur.sistance may be requested when personal coping strategies : nition: 241 Vague uneasy feeling of discomfort or dread accom- c or 1 10/1/10 9:36:15 AM 0 / 1 / 10 9 : 36 : 15 AM