6.8 Spotlight Application

A nurse is caring for a client who was admitted to the medical-surgical unit with a diagnosis of pancreatitis, depression, and alcohol withdrawal. The nurse plans to apply principles of maladaptive coping when developing a nursing care plan for this client.

1. What assessment data should the nurse collect related to coping?

• Pain, including onset, location, duration, character, aggravating and relieving factors, and treatment
• Mood, affect, and cognitive function
• Usual intake of alcohol and other substances
• Symptoms of alcohol withdrawal using the CIWA-Ar (nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and level of orientation)
• Current use of coping strategies
• Ability to care for self

2. Based on the assessment data, what NANDA nursing diagnosis applies to this client?

• Maladaptive Coping

3. What is an example of a SMART outcome for this client?

• The client will develop a plan for self-care in treating alcohol use disorder by discharge from the facility.

4. What nursing interventions can the nurse plan to implement?

Nursing Actions

• Assist client in setting daily goals for coping
• Assist client in creating a self-care plan
• Refer client and family to health care and community resources
• Administer benzodiazepines according to CIWA-Ar score
• Administer psychotropic medications as prescribed
• Assist client in identifying and using coping strategies
• Assist client to identify feelings
• Assist client in healthy communication

Teaching Topics

• Positive coping strategies
• Stress management techniques
• Information about the physical causes of substance use disorders and available treatments
• Symptoms of relapse 
• Community resources available, such as Alcoholics Anonymous (AA) 

5. Give an example of the nurse evaluating if the outcome and interventions were effective?

The identified outcome was, “The client will develop a plan for self-care in treating alcohol use disorder by discharge from the facility.”

The nurse assesses the client to evaluate the effectiveness of the planned interventions: 

• • The client set a daily goal to stay sober this day. 
  • The client required administration of chlordiazepoxide on the first day but not after that.
  •  The client is taking the prescribed fluoxetine and their mood is stable.
  • The client states they would like to listen to music and practice mindfulness as coping strategies. 
  • The client states it is difficult to identify feelings because they were not allowed to verbalize their feelings while growing up. 
  • The client states they would like more information on healthy communication.
  • The client states, “I am interested in attending AA meetings but I don’t know how to get started.” 

The nurse evaluates the data related to the identified outcome criteria and determines it is “partially met.” The nurse keeps the identified outcome criteria and planned interventions in the nursing care plan but removes chlordiazepoxide because it is no longer needed. The nurse provides the client a list of AA meetings available in their community and reinforces the importance of scheduling a meeting on their calendar before discharge.