Psych Nursing Diagnosis Flashcards

Nursing Diagnoses

• Risk for suicide includes suicidal ideation and self-directed violence.
• Risk for injury encompasses homicidal ideation and other-directed violence.
• Self-mutilation is linked to cutting and at risk for self-harm.
• Imbalanced nutrition indicates less than body requirements due to lack of appetite or refusal to eat.
• Anxiety constitutes a nursing diagnosis in its own right.
• Confusion and memory loss are addressed through impaired memory and disturbed thought processes.
• Self-care deficit arises from poor activities of daily living (ADLs).
• Insomnia is characterized by disturbed sleep patterns.
• Hallucinations relate to disturbed sensory perceptions.
• Delusions are associated with disturbed thought processes.
• Flight of ideas and loose associations indicate impaired verbal communication.
• Paranoia and suspiciousness indicate disturbed thought processes and ineffective coping.
• Withdrawal and seclusiveness result in social isolation and impaired social interaction.
• Selectively mute individuals experience impaired verbal communication.
• Hyperverbal or loquacious patients reflect impaired verbal communication and risk for injury.
• Manipulation denotes ineffective coping and may lead to noncompliance.

Nursing Interventions

• For risk of suicide: frequently observe the client, assess intent and means, remove dangerous objects, and encourage socialization.
• For risk of injury: reduce environmental stimuli, monitor client behavior, remove dangerous items, and utilize physical redirection.
• For self-mutilation: observe client actions, address sounds factually, listen to feelings, and remove hazardous objects.
• For imbalanced nutrition: support during meals, observe for one hour post-eating, document intake and outputs, and encourage exercise.
• For anxiety: build a trusting relationship, help clients identify anxiety triggers, encourage coping mechanisms, and engage in tension-reducing activities.
• For confusion/memory loss: assess disorientation safety, eliminate harmful items, regularly reorient the client, and utilize reminiscence therapy.
• For self-care deficits: promote independence in ADLs, monitor engagements, and assist with grooming when necessary.
• For insomnia: track sleep patterns, discourage daytime sleeping, limit caffeine intake, and promote exercise.
• For disturbed sensory perceptions: monitor for hallucinations, provide gentle warning before touching, distract client, and avoid reinforcing hallucinations.
• For disturbed thought processes: reorient clients, allow personal item access, minimize stimuli, and include distraction exercises.
• For impaired verbal communication during flight of ideas: anticipate needs, decode communication, reinforce positive interactions, and encourage nonverbal communication.
• For paranoid thought processes: offer sealed food, explain medication side effects, address disorder-related questions, and promote the verbalization of feelings and fears.
• For social isolation: reorient clients regularly, maintain honesty and trust, provide unconditional positive regard, and accompany clients on walks.
• For selective mutism: provide positive reinforcement for participation, orient to reality, avoid abstraction, and decode communication patterns.
• For hyperverbal communication: frequently orient to reality, assist with mobility, monitor behavior, and assess disorientation levels.
• For ineffective coping via manipulation: ensure consistent staff interactions, build trust, teach consequences of behavior, and maintain assertive communication.
• Noncompliance may require tailored interventions.