Judith M. Schultz, - uswr.ac.ir

1 Judith M. schultz , MS, RNSenior Account ManagerHealthways, Francisco, CaliforniaSheila L. Videbeck, PhD, RNProfessor, NursingDes Moines Area Community CollegeAnkeny, IowaNINTH EDITIONLIPPINCOTT S MANUAL OF Psychiatric Nursing Care PlansVice President, Publishing: Julie K. StegmanSupervising Product Manager: Betsy GentzlerEditorial Assistant: Jacalyn ClayDesign Coordinator: Joan WendtArt Coordinator: Brett MacNaughtonManufacturing Coordinator: Karin Duf!eldPrepress Vendor: S4 Carlisle Publishing Services9th editionCopyright 2013 Wolters Kluwer Health | Lippincott Williams & 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright 2005, 2002 Lippincott Williams & Wilkins. Copyright 1998 Lippincott-Raven Publishers. Copyright 1994 by Judith M. schultz and Sheila Dark Vide-beck. Copyright 1990, 1986, 1982 by Judith M. schultz and Sheila L. Dark. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews.

2 Materials appearing in this book prepared by individuals as part of their of!cial duties as government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at or via our website at (products and services).9 8 7 6 5 4 3 2 1 Printed in of Congress Cataloging-in-Publication DataSchultz, Judith s manual of psychiatric nursing care plans / Judith M. schultz , Sheila L. Videbeck. 9th ed. p. ; cm. Manual of psychiatric nursing care plans Includes bibliographical references and index. ISBN 978-1-60913-694-9 (alk. paper) I. Videbeck, Sheila L. II. Title. III. Title: Manual of psychiatric nursing care plans. [DNLM: 1. Mental Disorders nursing Handbooks. 2. Patient Care Planning Handbooks. 3. Psychiatric Nursing methods Handbooks. WY 49] '0231 dc232011051681 Care has been taken to con!

3 Rm the accuracy of the information presented and to describe generally accepted practices. How-ever, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant "ow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions.

4 This is particularly important when the recommended agent is a new or infrequently employed drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical Kusick, MSN, BSN, RNInstructor, NursingButler County Community CollegeButler, PennsylvaniaAnn MichalskiAssociate ProfessorBakers!eld CollegeBakers!eld, CaliforniaAlita Sellers, PhD, RN, CNEP rofessor, Coordinator RN to BSN ProgramWest Virginia University, ParkersburgParkersburg, West VirginiaKaren Gahan Tarnow, PhD, RNClinical Associate ProfessorUniversity of Kansas School of NursingKansas City, KansasREVIEWERSD olores Bradley, MSN, BSN, RN, CNEN ursing Faculty, Associate ProfessorFarmingdale State CollegeState University of New YorkFarmingdale, New YorkKay Foland, PhD, RN, CNP, CNS-BC, PMHNP-BCProfessorCollege of NursingSouth Dakota State UniversityRapid City, South DakotaJennifer Graber, EdD(c)

5 , APRN, BC, CSNursing InstructorStanton CampusDelaware Technical Community CollegeNewark, DelawareMary Lou Hamilton, MS, RNNursing Faculty in Psychiatric Mental Health NursingDelaware Technical Community CollegeNewark, DelawareiiiPREFACEThe ninth edition of Lippincott s Manual of Psychiatric Nursing Care Plans continues to be an outstanding resource for nursing students and practicing psychiatric mental health nurses. The Manual is a learning tool and a reference presenting information, concepts, and principles in a simple and clear format that can be used in a variety of settings. The Manual complements theory-based general psychiatric nursing textbooks and provides a solid clinical orientation for students learning to use the nursing process in the clinical psychiatric setting. Its straight-forward presentation and effective use of the nursing process provide students with easily used tools to enhance understanding and support often, students feel ill-prepared for their clinical psychiatric experience, and their anxiety interferes with both their learning and appreciation of psychiatric nursing.

6 The Man-ual can help to diminish this anxiety by its demonstration of the use of the nursing process in psychiatric nursing and its suggestions for speci!c interventions addressing particular behaviors, together with rationale, giving the student a sound basis on which to build clinical continued, widespread, international use of this Manual supports our belief in the enduring need for a practical guide to nursing care planning for clients with emotional or psychiatric problems. However, the care plans in this Manual do not replace the nurse s skills in assessment, formulation of speci!c nursing diagnoses, expected outcomes, nursing inter-ventions, and evaluation of nursing care. Because each client is an individual, he or she needs a plan of nursing care speci!cally tailored to his or her own needs, problems, and circum-stances. The plans in the Manual cover a range of problems and a variety of approaches that may be employed in providing nursing care.

7 This information is meant to be adapted and used appropriately in planning nursing care for each ORGANIZATIONThe Manual is organized into three One, Using the Manual, provides support for nursing students, instructors, and clini-cal nursing staff in developing psychiatric nursing skills; provides guidelines for developing interaction skills through the use of case studies, role play, and videotaped interaction; and provides strategies for developing written nursing care Two, Key Considerations in Mental Health Nursing, covers concepts that are con-sidered important underpinnings of psychiatric nursing practice. These include the therapeutic milieu, sexuality, spirituality, culture, complementary and alternative medicine, aging, lone-liness, homelessness, stress, crisis intervention, community violence, community grief and disaster response, the nursing process, evidence-based practice, best practices, the interdis-ciplinary treatment team, nurse client interactions, and the roles of the psychiatric nurse and of the Three, Care Plans, includes 52 care plans organized into 13 sections.

8 The section titles are General Care Plans; Community-Based Care; Disorders Diagnosed in Childhood or Adolescence; Delirium, Dementia, and Head Injury; Substance-Related Disorders; Schizo-phrenia and Psychotic Disorders/Symptoms; Mood Disorders and Related Behaviors; Anxi-ety Disorders; Somatoform and Dissociative Disorders; Eating Disorders; Sleep Disorders and Adjustment Disorders; Personality Disorders; and Behavioral and Problem-Based Care vNURSING PROCESS FRAMEWORKThe Manual continues to use the nursing process as a framework for care, and each care plan is organized by nursing diagnoses. The care plans provide an outcomes-focused approach, and therapeutic goals content is included in the basic concepts section and the introductory paragraphs of the care TO THIS EDITIONr /FX JOGPSNBUJPO PO $PNQMFNFOUBSZ BOE "MUFSOBUJWF .FEJDJOF JOGPSNBUJPO BOE Using the Internetr "MM DBSF QMBOT SFWJTFE BOE VQEBUFEr &YQBOEFE PVUDPNFT TUBUFNFOUT XJUI TQFDJ D UJNJOH FYBNQMFTr 6 QEBUFE 3 FDPNNFOEFE 3 FBEJOHT JO FBDI TFDUJPOr 6 QEBUFE 3 FTPVSDFT GPS "EEJUJPOBM *OGPSNBUJPO GPS FBDI TFDUJPO BEEJUJPOBM JOGPSNBUJPO is also available on thePointr 6 QEBUFE SFGFSFODFT UISPVHIPVU UIF Manualr 3 BUJPOBMF GPS DPSSFDU SFTQPOTFT PG UIF TFDUJPO SFWJFX RVFTUJPOTr 6 QEBUFE /"/%" *OUFSOBUJPOBM m OVSTJOH EJBHOPTFT JODMVEFE*r /FX BQQFOEJY PO &MFDUSPDPOWVMTJWF 5 IFSBQZr &YQBOEFE VQEBUFE BOE SFGPSNBUUFE 1 TZDIPQIBSNBDPMPHZ "QQFOEJYr /FX BQQFOEJY PO 4 JEF &GGFDUT PG.

9 FEJDBUJPOT BOE 3 FMBUFE /VSTJOH *OUFSWFOUJPOTr /FX BQQFOEJY PO 4 DIJ[PJE )JTUSJPOJD /BSDJTTJTUJD "WPJEBOU BOE 0 CTFTTJWF $PNQVMTJWF Personality DisordersUSING THE MANUALThe Manual is an ideal text and reference for mental health and general clinical settings, including community and home care nursing, in addition to its use as a text for students. The Manual offers sound guidance to those professionals who have less con!dence in dealing with clients who are experiencing emotional dif!culties and offers new staff members guidelines for clear and speci!c approaches to various problems. The Manual can be especially helpful in the general medical or continuing care facility, where staff members may encounter a variety of challenging patient believe that effective care must begin with a holistic view of each client, whose life is composed of a particular complex of physical, emotional, spiritual, interpersonal, cultural, socioeconomic, and environmental factors.]

10 We sincerely hope that Lippincott s Manual of Psychiatric Nursing Care Plans, in its ninth edition, continues to contribute to the delivery of nonjudgmental, holistic care and to the development of sound psychiatric nursing knowledge and skills, solidly based in a sound nursing FOR STUDENTS, INSTRUCTORS, AND PRACTICING NURSESV isit at for materials to assist students and QSBDUJDJOH OVSTFT UP XSJUF JOEJWJEVBMJ[FE DBSF QMBOT RVJDLMZ BOE FG DJFOUMZ TFF 1 BSU 0OF 6T-ing the Manual). Resources on thePoint include all 52 care plans, the Sample Psychosocial *From Nursing Diagnoses: De!nitions and Classi!cation 2012 2014. Copyright 2012, 1994-2012 by NANDA International. Used by arrangement with Blackwell Publishing Limited, a company of John Wiley & Sons, Preface Assessment Tool, and lists of resources for additional information. Individual care plan !les can be downloaded onto a personal computer to streamline the student s or nurse s efforts, enhance the care planning process, and facilitate the consistent use of care plans in any setting where mental health clients are encountered.]