Nursing Diagnosis: Ineffective Coping Application of NANDA, NOC, NIC

Nursing Diagnosis: Ineffective Coping
Gail B. Ladwig and Jill M. Barnes

NANDA Definition: Inability to form a valid appraisal of stressors, inadequate choices of practiced responses, and/or inability to use available resources

Defining Characteristics: Lack of goal-directed behavior/resolution of problem, including inability to attend, difficulty with organized information, sleep disturbance, abuse of chemical agents; decreased use of social support; use of forms of coping that impede adaptive behavior; poor concentration; fatigue; inadequate problem solving; verbalized inability to cope or ask for help; inability to meet basic needs; destructive behavior toward self or others; inability to meet role expectations; high illness rate; change in usual communication patterns; risk taking

Related Factors: Gender differences in coping strategies; inadequate level of confidence in ability to cope; uncertainty; inadequate social support created by characteristics of relationships; inadequate level of perception of control; inadequate resources available; high degree of threat; situational crises; maturational crises; disturbance in pattern of tension release; inadequate opportunity to prepare for stressor; inability to conserve adaptive energies; disturbance in pattern of appraisal of threat

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
·         Coping
·         Decision Making
·         Impulse Control
·         Information Processing
Client Outcomes
·         Verbalizes ability to cope and asks for help when needed
·         Demonstrates ability to solve problems and participates at usual level in society
·         Remains free of destructive behavior toward self or others
·         Communicates needs and negotiates with others to meet needs
·         Discusses how recent life stressors have overwhelmed normal coping strategies
·         Has illness and accident rates not excessive for age and developmental level
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Decision-Making Support
Nursing Interventions and Rationales
·         Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation. Situational factors must be identified to gain an understanding of the client's current situation and to aid client with coping effectively (Norris, 1992).
·         Observe for strengths such as the ability to relate the facts and to recognize the source of stressors. Family members who are coping with critical injuries often feel defeated, hopeless, and like a failure; therefore it is imperative to verbally commend them for their strengths and use those strengths to aid functioning (Leske, 1998).
·         Monitor risk of harming self or others and intervene appropriately. See care plan for Risk for Suicide. Situational factors can lead to depression or risk for suicide. Identification of such factors leads to appropriate referral or help (Norris, 1992). A client with hopelessness and an inability to problem solve often runs the risk of suicide (Buchanan, 1991). In these cases immediate referral for mental health care is essential (Norris, 1992).
·         Help client set realistic goals and identify personal skills and knowledge. Involving clients in decision making helps them move toward independence (Connelly et al, 1993).
·         Use empathetic communication, and encourage client/family to verbalize fears, express emotions, and set goals. Acknowledging and empathizing creates a supportive environment that enhances coping (Feeley, Gottlieb, 1998). Clients report increased satisfaction and empowerment, greater compliance with mutually agreed-upon goals, and less anxiety and depression when communication is empathic (Wells-Federman et al, 1995). Acknowledgment of feelings communicates support and conveys that clients are understood (Leske, 1998).
·         Encourage client to make choices and participate in planning of care and scheduled activities. Participation gives a feeling of control and increases self-esteem.
·         Provide mental and physical activities within the client's ability (e.g., reading, television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports, games). Interventions that enhance body awareness such as exercise, proper nutrition, and muscular relaxation may be effective for treating anxiety and depression (Wells- Federman et al, 1995).
·         If the client is physically able, encourage moderate aerobic exercise. Aerobic exercise increases one’s ability to cope with acute stress (Anshel, 1996).
·         Use touch with permission. Give client a back massage using slow, rhythmic stroking with hands. Use a rate of 60 strokes a minute for 3 minutes on 2-inch wide areas on both sides of the spinous process from the crown to the sacral area. A gentle touch can display acceptance and empathy (Hopkins, 1994). Slow stroke back massage decreased heart rate, decreased systolic and diastolic blood pressure, and increased skin temperature at significant levels. The conclusion is that relaxation is induced by slow stroke back massage (Meek, 1993).
·         Provide information regarding care before care is given. In traumatic situations, families have a need for information and explanations (Hopkins, 1994). Providing information prepares the family for understanding the situation and possible outcomes (Leske, 1998). Adequate information and training before and after treatment reduces anxiety and fear (Herranz, Gavilan, 1999).
·         Discuss changes with client before making them. Communication with the medical staff provides patients and families with understanding of the medical condition (Grootenhuis, Last, 1997).
·         Discuss client’s/family’s power to change a situation or the need to accept a situation. Such a discussion helps the client maintain self-esteem and look at the situation realistically with the aid of a trusted individual (Norris, 1992). In threatening situations, people search for reasons for the event(s). This search is an effort to make sense of the event, gain control, and cope (Grootenhuis, Last, 1997).
·         Use active listening and acceptance to help client express emotions such as crying, guilt, and anger (within appropriate limits). Active listening provides the client and/or family a nonjudgmental person to listen to them and relieve their guilt feelings (Hopkins, 1994). Acknowledgment of feelings communicates support and conveys that they are understood (Leske, 1998).
·         Avoid false reassurance; give honest answers and provide only the information requested. Identification of previously used effective coping mechanisms allow the nurse to focus attention on necessary education and referral (Norris, 1992).
·         Encourage client to describe previous stressors and the coping mechanisms used. Describing previous experiences strengthens effective coping and helps eliminate ineffective coping mechanisms.
·         Be supportive of coping behaviors; allow client time to relax. A supportive presence creates a supportive environment to enhance coping (Feeley, Gottlieb, 1998).
·         Help clients to define what meaning their symptoms might have for them. In one study, the importance of helping clients find meaning in their suffering experiences was identified as a strategy perceived as helpful with a group of patients who had the diagnosis of multiple sclerosis (Pollock, Sands, 1997).
·         Encourage use of cognitive behavioral relaxation (e.g., music therapy, guided imagery). Relaxation techniques, desensitization, and guided imagery can help clients cope, increase their sense of control, and allay anxiety (Narsavage, 1997). Relaxation with guided imagery is a technique used with increasing frequency to help individuals improve their performance and control their responses to stressful situations (Rees, 1993). Music is not a cure, but it can lift the human spirit, comfort the heart, and inspire the soul. Imagery is useful for relaxation and distraction (Fontaine, 1994). The provision of information and general mastery may play a role in decreasing helplessness and dysfunctional coping (Nicassio et al, 1997).
·         Use distraction techniques during procedures that cause client to be fearful. Distraction is used to direct attention toward a pleasurable experience and block the attention of the feared procedure (DuHamel, Redd, Johnson-Vickberg, 1999).
·         Use systematic desensitization when introducing new people, places, or procedures that may cause fear and altered coping. Fear of new things diminishes with repeated exposure (DuHamel, Redd, Johnson- Vickberg, 1999).
·         Provide the client/family with a video of any feared procedure to view before the procedure. Ensure that the video shows a patient of similar age and background. Videos provide the client/family with the information necessary to eliminate fear of the unknown (DuHamel, Redd, Johnson-Vickberg, 1999).
·         Refer for counseling as needed. Arranging for referral assists the client in working with the system, and resource use helps to develop problem-solving and coping skills (Feeley, Gottlieb, 1998).
·         Engage client in reminiscence. Reminiscence can activate past sources of self-esteem and aid in coping (Nugent, 1995).
·         Be aware of client's fear of illness. Identify and reinforce patterns the elderly client has previously used to respond to stress. Allow client time to reminisce about past successes. The elderly client has had a lifetime of experience dealing with stressful events. A standard reminiscence interview and one that focused on successfully met challenges reduced state anxiety and enhanced coping self-efficacy when measured against both attention-placebo and no-intervention control groups (Rybarczyk, Auerbach, 1990).
·         Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects). Such alterations may be contributing to confusion and must be corrected (Matthiesen et al, 1994). Medications are considered the most common cause of delirium in the ICU (Harvey, 1996).
·         Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping. An older individual's responses to age-related stress will depend on the balance of personality strengths and weaknesses. Severe or multiple stresses in late life may overwhelm an individual's coping skills and lead to personality change (Agronin, 1998).
·         Increase and mobilize support available to the elderly client. Encourage interaction with family and friends. Friends and relatives have shared many of the older person's life experiences. Such mutual interests and overlapping memories can serve to stimulate and focus conversation and contribute effectively to the client's self-esteem (Erber, 1994). Support from family, friends, and the medical community aids coping ability (Grootenhuis, Last, 1997).
·         Maintain continuity of care by keeping the number of caregivers to a minimum. Consistency in caregivers helps decrease anxiety and fosters trust by providing the client and family with familiar faces (Hopkins, 1994).
·         Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of effective coping. The client’s coping behavior may be based on cultural perceptions of normal and abnormal coping behavior (Leininger, 1996).
·         Assess for intergenerational family problems that can overwhelm coping abilities. Intergenerational family problems put families at risk of dysfunction (Seiderman et al, 1996).
·         Encourage spirituality as a source of support for coping. Many African-Americans and Latinos identify spirituality, religiousness, prayer, and church-based approaches as coping resources (Samuel-Hodge et al, 2000; Bourjolly, 1998; Mapp, Hudson, 1997).
·         Negotiate with the client with regard to the aspects of coping behavior that will need to be modified. Give and take with the client will lead to culturally congruent care (Leininger, 1996).
·         Identify which family members the client can rely on for support. Many Latinos, Native Americans, and African-Americans rely on family members to cope with stress (Abraido-Lanza, Guier, Revenson, 1996; Seiderman et al, 1996).
·         Assess the influence of fatalism on the client’s coping behavior. Fatalistic perspectives involve the belief in some African-American and Latino populations that you cannot control your own fate and influence health behaviors (Phillips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).
Home Care Interventions
·         Observe family for coping behavior patterns. Obtain family and client history as able. Obtaining a family assessment provides a wealth of information regarding current family functions and can guide interventions (Leske, 1998).
·         Assess for suicidal tendencies. Refer for mental health care immediately if indicated. Identify an emergency plan should the client become suicidal. A suicidal client is not safe in the home environment unless supported by professional help.
·         Refer to medical social services for evaluation and counseling, which will promote adequate coping as part of the medical plan of care. If no primary medical diagnosis has been made, request medical social services to assist with community support contacts.
·         If the client is involved with the mental health system, actively participate in mental health team planning. Based on knowledge of the home and family, home care nurses can often advocate for clients. These nurses are often requested to monitor medications and therefore need to know the plan of care.
·         Refer patient/family to support groups. Support groups foster the sharing of common experiences and help to build mutual support. They are particularly helpful when others within the family are unable to provide support because of their own grieving or coping needs (Leske, 1998).
·         If monitoring medications, contract with client or solicit assistance from a responsible caregiver. Pre-pouring of medications may be helpful with some clients. Successful contracting provides the client with control of care and promotes self- esteem while establishing responsibility for desired actions.
NOTE: All of the previously mentioned interventions may be applied in the home setting. Home care may offer psychiatric nursing or the services of a licensed clinical social worker under special programs. Traditionally, insurance does not reimburse for counseling that is not related to a medical plan of care unless it falls under one of the programs just described. Public health agencies generally do not have the clinical support needed to offer psychiatric nursing services to clients. Clients are usually treated in the ambulatory mental health system.
Client/Family Teaching
·         Teach clients to problem solve. Have them define the problem and cause and list the advantages and disadvantages of their options.
·         Provide seriously ill clients and their families with needed information regarding their condition and treatment. Information is an important need of families of critically ill patients (Henneman, Cardin, 1992). In one study, information structured to meet individual needs reduced anxiety and increased satisfaction with the information provided (McGaughey, Harrisson, 1994).
·         Teach relaxation techniques. Problem-solving skills promote the client's sense of control. Relaxation decreases stress and enhances coping (Fontaine, 1994).
·         Suggest listening to music. Listening to music has been found to decrease total mood disturbances scores (profile of mood states [POMS] scores). A decrease in POMS scores is indicative of decreased distress and a mood improvement (McNair, Lorr, Droppleman, 1992).
·         Teach process imagery (purposely evoking a mental image of a desired effect). Using process imagery, a person can look at an old problem in a totally different way, making new connections and freeing the problem from the original memory. Imagery engenders a feeling of control and gives the client an effective tool for self-care (Stephens, 1993).
·         Work closely with the client to develop appropriate educational tools that address individualized coping strategies. Collaboration between client and staff in the production of client information can improve client understanding and empower the client and family to take an active part in treatment (Willock, Grogan, 1998).
·         Teach client about available community resources (e.g., therapists, ministers, counselors, self-help groups). Resource use helps to develop problem-solving and coping skills (Feeley, Gottlieb, 1998). Client and family teaching that promotes the ability to understand and carry out any necessary medical, rehabilitative, or daily living activities contributes to a sense of mastery, competency, and control and is vital to discharge planning and community- based assessments (Norris, 1992). Praying and religion are frequently used effective coping strategies (Grootenhuis, Last, 1998).

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