6.8 Spotlight Application

Client Scenario

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 caring for this client.

1. What assessment data should the nurse collect?

• 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)
• Use of coping strategies
• Ability to care for self

2. Based on the assessments, what NANDA nursing diagnosis applies?

• Maladaptive Coping

3. What is an appropriate 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 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

Client Teaching

• Teach client coping strategies
• Reinforce teaching to client and family about condition and treatments
• Identify symptoms of relapse and people to contact for help

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

• Identified Outcome: The client will develop a plan for self-care in treating alcohol use disorder by discharge from the facility.
  • Evaluation: The client plans to attend one Alcoholics Anonymous meeting each day on discharge. The client has a list of meetings. The client will start therapy and continue medication for depression.

• Evaluation of Interventions: 
  • Client set a daily goal to stay sober this day. 
  • Client needed chlordiazepoxide on the first day but not after that.
  • Client using fluoxetine and mood is stable.
  • Client states they would like to listen to music and practice mindfulness as coping strategies. 
  • Client states it is difficult to identify feelings because they were not allowed to while growing up. 
  • Client states they would like more information on healthy communication.

Based on the evaluation process, the nurse keeps the outcome and interventions in the nursing care plan but removes chlordiazepoxide because it is no longer needed. The nurse plans on reinforce the outcome and interventions until discharge.