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Depressed Moods
Intervention
Identification of the level of risk for potential suicide will be done through asking of direct questions such as, Do you still think about killing yourself? The potential for suicide will be assessed at regular intervals and at key points in the course of treatment such as during mood changes, during initiation and change of medication, in preparation for discharge, and when discharging Janet from the program. This will be done alongside careful assessment of body language through gestures, threats, previous attempts to commit suicide and delusions. The nurse will put in place suicide precautions. This may involve the nurse assuring the patient that the nurse is genuinely concerned for her well being and will be involve in keeping the patient free of danger. Highlight the positive as well as the negative attributes of the Janets experiences in life.
The nurse will help the patient to rephrase her frustrations. The patient will be encouraged and helped in participating in recreational/ occupational therapy. The nurse will also ensure that the patient is adhering to the mood stabilization prescriptions by being physically present to observe that the patient has swallowed their medication every time. A contract that is time bound will be created to outline the responsibilities of the patient and of the nurse in the provision of safety for the patient. This will be renewed when necessary, kept in the patients folder. Another copy will be given to Janet.
Rationale
The extent to which the Janet is experiencing hopelessness is an indicator of how likely she is to commit suicide (Hally 2008). It is also an indicator of the severity of depression in the patient. 80% of patients that consider and communicate that they have intentions of committing suicide actually do it (Ivanov & Blue 2008). The risk factors for suicide in this patient include: a past attempt(s) at suicide, family history of suicide, and presence of depression. The risk is compounded in patients that suffer from psychotic thinking, hallucinations and delusions that encourage self harm (Hally 2008). These precautions will show the Janet that the nurse cares and thus the patient experiences a sense of protection (Kent & McCormack 2010).
Research has shown that the risk for suicide is greatest in the weeks following a patients admission for treatment (Cutcliffe & Ward 2006). This normally takes place outside the hospital premises, and at the time that the patient has actually started feeling better. Risk is significantly higher among patients with suicide intentions as well as the energy to do it (Fry & Johnstone 2008). This contract will consist of activities and actions that are aimed to prevent suicide and aid the response of the patient (Evans & Elder 2004). It encourages communication from the client and thus Janet may come to the realization that other people care about her. Short term contracts of this kind provide a patient with the ways and means of dealing with the situation at hand immediately (Cutcliffe & Ward 2006).
Evaluation
Janet will be able to identify and utilize socially accepted methods of solving crises in her life. Disappearance of her delusions will be an indicator of the success of the intervention. Janet will have the ability to participate in individual and group activities for leisure. She will display high self esteem and personal power. Janets family will be involved with her care outside the health care setting. Janet will have stopped thinking about suicide. The effectiveness of this plan will be assessed through observation of: voluntary compliance of Janet to the suicide precautions, her willingness to sign the no harm contract, a reduction or the disappearance of the suicidal thoughts in the conversations with nurse, ability of the patient to outline at least two reasons for not harming herself, and for the patient to not commit acts of violence towards herself.
Social Isolation
Intervention
The nurse will deliberately and frequently spend time with Janet; even in silence and display an accepting attitude towards her. The nurse will explore all areas of Janets life to identify the sources of these feelings of loneliness. The nurse will encourage Janet to participate in activities involving groups of people. If she feels uncomfortable, she will be allowed to withdraw from the groups activities. The nurse will in addition talk to her about these absences. The nurse will help Janet build her assertiveness besides giving her feedback concerning her interactions with other people. This includes teaching the client how to approach other people, and how to respond to others who approach the client. These skills will be practiced through role playing with client. Janet will also receive feedback concerning her in the social setting from a trusted individual. The nurse will also provide Janet with positive reinforcement when she goes out of her way to look for company. This feedback will be delivered in positive, non-judgmental and non threatening way.
Her nutrition will be assessed and efforts will be made to ensure she feeds well. Complications arising out of social isolation such as risk of suicide and alcoholism will be assessed and treated separately.
Rationale
This will help boost the patients self perceptions as a worthwhile person. Janets realization that her absences were noticed from these group activities will reinforce her feelings of self worth (Burkhardt & Nathaniel 2007). Janets feelings of self worth, guilt and hate may be keeping others from interacting with her properly. Knowledge of these techniques will enable Janet to build better relationships with other people. It will also enhance her self esteem (Roy & Jones 2006).
It has been found out that people that suffer from social isolation may have nutritional problems, alcoholism and suicidal thoughts as complications. It is therefore useful to treat the problem itself as well as the complications arising out of it.
Evaluation
Janet will be able to communicate to the nurse freely and openly without fear. She will indicate through talking positive feelings for herself. She will attend events and activities at the health care centre which involve interaction with other people. Janet will be able to spend time with her family members without overly feeling guilty or blaming herself for the loss of her daughter. Evaluation of the plan will be done on the basis of: the Janets willingness and desire to interact with other people socially, voluntary attendance of group activities, appropriate behaviour when approaching others and when being approached by others, and by lack of self condemnation which discourages relationships with others. It will also be judged on her ability to make eye contact, shake hands, remember names, and sit side by side with the nurse. The ability of Janet to talk about her feelings after interacting with other people and family identify the reasons for withdrawal and use of medication prescribed well.
Eventually, Janet will be able to recognize when she feels lonely, identify the source of these feelings and deal with them appropriately.
Alcohol Withdrawal
Intervention
The nurse will build a trusting relationship with the patient that enables the patient to communicate clearly and honestly concerning her fears, anxieties, and feelings concerning the stress in her life and her drinking. The nurse will find out if Janet is willing to stop overindulging in alcohol by asking relevant questions. The nurse will explain the dangers of abusing alcohol and then enable her to realize that the decision to change is hers. The nurse will show Janet that she is responsible for her choice to overindulge in alcohol and would be equally responsible for the decision to quit. The nurse will counsel the patient in a non judgmental way concerning the dangers of overindulging in alcohol. The nurse will advice her to stop overindulging in alcohol. This will go hand in hand with the signing of a contract.
Within this contract are the drinking goals that the patient and the nurse have made. Measures will be implemented to prevent injuries from falls and the patient will be encouraged to rest well. Hypertension, dysrhythmia, gastrointestinal bleeding, alterations in liver function, blood values and nutrition will all be assessed. The nurse will ensure that Janet receives tests to assess the extent of damage by alcohol on her internal organs and see to it that Janet receives and takes appropriate medication to manage any disturbances in the bodys physiological processes that have arisen out of alcohol abuse. This will also be done to mitigate withdrawal symptoms of Janet from alcohol. While at the hospital, the nurse will avoid exposing the patient to television and some activities that may cause hallucinations. In addition, the nurse will ensure that Janet is well fed with a balanced diet. She will also be provided with fluids such as nutritious drinks and water and encouraged to drink plentifully. The nurse will provide the Janet with manuals that contain strategies and guides for quitting alcohol.
These may include self help materials and drinking diaries that may monitor the abstinent days as well as the days when she drinks in addition to how much she drinks during those times. The nurse will encourage Janet to be self reliant and optimistic in her pursue of sobriety. Janets family will be contacted by the nurse and included in the care plan for the patient especially after hospital. The nurse will initiate talks with the family and the patient in a non threatening environment. The family is encouraged to explore all options that may promote the health of the withdrawing alcoholic as well as therapeutic interventions. The nurse will continue to contact the Janet and assist with her health needs.
Rationale
Pharmaceutical drugs, such as benzodiazepines are administered to patients with alcohol withdrawal symptoms to reduce the severity of the withdrawal symptoms and to prevent progression of these symptoms into their more dangerous forms. Assessment of hypertension, dysrhythmia, gastrointestinal bleeding, alterations in liver function, blood values and nutrition will enable the nurse assess the damage to the central nervous system, cardiovascular, hematopoietic, gastrointestinal and musculoskeletal damage as well as response to the interventions. Research has found out that the most successful patients that have been through alcohol withdrawal intervention are those that have made the decision to change all on their own. Research has show that individuals are more likely to stop overindulging when they realize the risks that this poses to their health (Schober & Affara 2006).
When the patient knows that the biggest responsibility for her health and the discontinuance of overindulging in alcohol lies with her, she will feel like she has more control over the issues and thus the probability of her intervention being successful are even higher (Cutcliffe & Ward 2006). Patients expressing alcohol withdrawal symptoms are at risk for malnutrition and dehydration. Fluid retention occurs as a result of inhibition of production of vasopressin which increases in blood alcohol levels. Research has shown that patients that are shown warmth, compassion and understanding have a 77% chance of recovering in contrast to patients that receive confrontational attitudes from the nurses whose chances of recovery are 55% (Fry & Johnstone 2008). This will encourage the patient to develop, implement, and commit to plans to stop drinking (Webb and Roe 2007).
An environment without threats and devoid of judgment will enable the family and the patient to engage in honest communication concerning their fears, anxieties, needs and struggles that are associated with having a relative that has been involved with alcoholism (Burkhardt & Nathaniel 2007). The family, together with the withdrawing alcoholic is able to acknowledge each others feelings as well as the roles that every member played in the deterioration of the patients health (Evans & Elder 2004). For the patient to fully recover, it is necessary to combine intervention from outside the health care setting which may be in the form of social support, alcoholics anonymous, and family therapy among others (Fry & Johnstone 2008).
Evaluation
Complications that are likely to arise in Janets body due to her past drinking are identified and managed. Her physiological processes will be at equilibrium during her stay at the health care institution. She will be sober for more days in a week. Janet will be able to enlist in a rehabilitation program outside the health care centre. Janet will be able to open up to the nurse and honestly discuss her feelings while being able to listen to the nurse. She will adhere to the prescriptions that are given to her. Janet will be able to identify ways and means and alternatives to alcohol in response to various stressors in her life. The client should be able to identify the negative effects associated with alcohol and show willingness to seek professional help in reigning in the drinking habit.
The family is enlightened on their role in the patients illness which is their dysfunctional roles. Individuals in the family are able to express their feelings, both positive and negative such as love and resentment respectively. This is seen when the family, including the patient are able to enjoy more liaisons and trust amongst each other. Evaluation from outside the hospital and sometimes family setting promotes healing for both the alcoholic and for the family members that have been hurt by the habit indirectly. It prevents relapse. Families, when present to give support to the recovering alcoholic enable her to avoid periods of relapse.
Suicidal
Intervention
The nurse will build a relationship of trust with the Janet. The nurse will closely observe the Janets behaviour and will in addition use the nurses global assessment of suicide risk (NGASR) to help evaluate the extent of risk for Janet committing suicide. The nurse will pay attention to what she says and note any verbal or non verbal pointers of harm. The nurse will talk patiently with her in a bid to establish if suicidal intents are still present, alongside plans and means to accomplish suicide. The nurse will make effort to remove any potentially dangerous material from the patients room and ensure the patient is under close observation to ensure that Janet does not have the means or the opportunity to commit suicide while under hospitalization.
She will encourage and teach the patient new life skills such as coping in a safe and therapeutic setting. The nurse will give positive feedback to Janet for every little step she manages to accomplish during the treatment process. The nurse will help the Janet overcome he drug abuse problem by encouraging her to express he feelings verbally, teaching alternative coping strategies. The nurse will also educate the patient on the dangers of drug abuse and provide a plan to help her quit drug abuse.
Rationale
The establishment of a relationship built on trust will enable the patient to rely on the nurse and to be open concerning the events in her life that are causing her to view suicide as an option. It will also accord the nurse an opening through which she can help the patient stop thinking about committing suicide. It will also help the nurse to determine the degree of planning, the lethality of the suicide method that Janet has in mind, time when Janet thinks is best for commission of suicide, as well as the availability of the preferred means of death for Janet. Close observation of the patient as well as removal of items that can aid Janet in commission of suicide are done for the purpose of ensuring that the patient remains safe and free of harm (Burkhardt & Nathaniel 2007). Non verbal clues are critical for indicating the probability of the patient to harm herself (Evans & Elder 2004).
The NGASR evaluation tool is highly accurate even when used by inexperienced nurses. Overestimation or underestimation of the risk of suicide is dangerous to the patients outcome during an intervention as it leads to unjustifiable restriction of the patients rights and wastage of hospital resources; and adoption of a dismissive attitude towards the patient by the nurse which may lead to suicide respectively. The probability of a patient committing suicide is higher if the means and plans are present alongside the intentions (Ivanov & Blue 2008). Positive feedback encourages the patient to keep practicing effective coping methods (Cutcliffe & Ward 2006). This will enable the Janet to avoid abuse of drugs as a coping mechanism that may be a factor behind her feelings of lack of control in her life leading to thoughts of suicide.
Evaluation
Janet will be able to talk openly to the nurse concerning the issues in her life that may have caused her to attempt suicide. She will be free of harm while at the health care institution and after discharge. Janet will be able to seek help when harmful thoughts or thoughts of suicide occur. She will be able to outline the dangers of abuse of drugs. Instead, she will utilize alternative coping methods. She will deny wanting to harm herself or others. She will be able believe in and rely on the trust that the nurse will have created. Janet stayed free of harm and was safe. She no longer exhibits verbal or non verbal clues of intentions to commit suicide. Janet should show and say that she has no intentions to commit suicide. She will identify positive skills for coping with life such as leisure. Janet will be able to express and practice a combination of past coping methods as well as the newly learned coping skills.
References
Burkhardt, M & Nathaniel, A 2007, Ethics and Issues in Contemporary Nursing, 3rd Edition, Sydney, Delmar Cengage Learning.
Cutcliffe, J & Ward, M 2006, Key Debates in Psychiatric/Mental Health Nursing, Armidale, Churchill Livingstone.
Evans, K & Elder, R 2004, Psychiatric and Mental Health Nursing, Albury, Mosby Australia.
Fry, S & Johnstone, M 2008, Ethics in Nursing Practice, Liverpool, Wiley-Blackwell.
Hally, B 2008, A Guide for International Nursing Students in Australia and New Zealand, Albury, Churchill Livingstone.
Ivanov, L & Blue, C 2008, Public Health Nursing, Policy, Politics and Practice, Sydney, Delmar Cengage Learning.
Kent, B & McCormack, B 2010, Clinical Context for Evidence-based Nursing Practice, Goulburn, Wiley-Blackwell.
Roy, C & Jones, D 2006, Nursing Knowledge Development and Clinical Practice, Opportunities and Directions, Lithgow, Springer Publishing Company.
Schober, D & Affara, F 2006, International Council of Nurses: Advanced Nursing Practice, Parramatta, Wiley-Blackwell.
Webb, C & Roe, B 2007, Reviewing Research Evidence for Nursing Practice, Systematic Reviews, Newcastle, Wiley-Blackwell.
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