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Friday, November 26, 2010

Ineffective Coping

 Ineffective Coping

NANDA Definition
It is the inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.


Discussion of the Problem
Stress is a universal phenomenon. All people experience it. The concept of stress is important because it provides a way of understanding the person as a being who responds in totality to a variety of changes that take place. Stress is a condition in which a person experiences changes in the normal balanced state. A stressor is any event or stimulus that causes an individual to experience stress. When a person faces stressors, responses are referred to as coping strategies, coping resources, or coping mechanism. Coping may be described as dealing with change—successfully or unsuccessfully. A coping strategy (coping mechanism) is a natural or learned way of responding to a changing environment or specific problem or situation. How one responds to such stressors depends on the person’s coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources. Sociocultural and religious factors may influence how people view and handle their problems. Coping can be adaptive or maladaptive. Adaptive coping helps the person to deal effectively with stressful events and minimizes distress associated with them. As resources become limited and problems become more acute, this strategy may prove ineffective. Maladaptive coping can result in unnecessary distress for the person and others associated with the person or stressful event. In nursing literature, effective and ineffective coping are often differentiated. Effective coping results in adaptation, while ineffective coping results in maladaptation. Medical condition that could contribute to ineffective coping are as follows: cerebrovascular accident (CVA), stroke, herniated nucleus pulposus, severe hypertension, inflammatory bowel disease, ulcerative colitis, regional enteritis, multiple sclerosis, and those who are in substance dependence. The overall patient goals for persons experiencing stress related responses are to decrease or resolve anxiety, to increase ability to manage or cope with stressful events or circumstances, and to improve role performance.

Nursing Interventions Classification (NIC)
  • Coping Enhancement
  • Substance Use Treatment

Nursing Outcomes Classification (NOC)
  • Anxiety Control
  • Coping
  • Decision Making
  • Information Processing

Goal and Objectives
  • Patient will articulate acceptance of self in situation.
  • Patient will converse with Significant Other about condition and alterations that has occurred precisely.
  • Patient will develop plan and show essential lifestyle changes to prevent or limit repeated episodes.
  • Patient will express and begin efficient coping skills or techniques and problem-solving skills
  •  Patient will express positive results from new behaviors.
·         Patient will formulate decisions and articulate satisfaction with choices.
  • Patient will identify own maladaptive coping behaviors and consequences.
  • Patient will meet psychological requirements as manifested by appropriate verbalization of feelings, formulation of options, and utilization of resources.
  • Patient will recognize existing resources and support systems.
·         Patient will recognize potential stressful conditions and steps to keep away from or change them.
·         Patient will show relaxed and report anxiety is lowered to a controllable level.

Subjective and Objective Data
·         Alteration in social participation; change in usual communication patterns; verbal manipulation
·         Apprehension, uncertainty, helplessness
  • Chronic depression and dependency
  • Destructive behavior toward self
·         Difficulty problem solving
  • Emotional tension
·         Expressed concerns regarding changes in life events
·         Financial affairs in disarray, employment difficulties (e.g., losing time on job/not maintaining steady employment; poor work performances, on-the-job injuries)
·         Frequent head/neck aches
·         High illness/accident rate
  • Inability to ask for help
  • Inability to make decisions
·         Inability to meet basic needs/role expectations, basic needs
·         Inability to meet role expectations
  • Inappropriate use of defense mechanisms
  • Insomnia
  • Irritable bowel
·         Muscular tension, general irritability, restlessness
  • Physical symptoms such as the following:
Ø  Chronic fatigue
Ø  Excessive smoking and drinking
Ø  Overeating or lack of appetite
Ø  Overuse of tranquilizers
Ø  Alcohol abuse
·                   Preoccupation with physical self, chronic worry, anxiety, poor concentration
·         Uncertainty about choices; vacillation between alternative actions

Related Factors
  • Change in or loss of body part
·         Cognitive perceptual changes, high degree of threat
  • Diagnosis of serious illness
·         Impairment of nervous system; memory loss; impaired adaptive behaviors
  • Inadequate coping method
  • Inadequate psychological resources (poor self-esteem, lack of motivation)
·         Inadequate relaxation, little or no exercise, work overload
·         Lack of sleep, rest
·         Maturational crisis; multiple life changes, age/developmental stage
·         Multiple stressors, repeated over period of time
·         Negative role modeling; inadequate support systems
·         No vacations/inadequate relaxation
  • Personal vulnerability
·         Poor nutrition
·         Recurrent disorder with continuing pain/overwhelming threat to self
  • Situational crises
·         Threat to/change in health status, socioeconomic status, role functioning
·         Unclear personal values/beliefs; perceived threat to value system; lack of information
·         Unmet expectations
·         Unpredictable nature of disease process

Assessment (Dx)
  • Review particular stressors such as family, work, social, future nursing or healthcare requirements. Precise assessment can enable development of proper coping strategies. For the reason that a patient has a distorted health status does not mean the coping difficulties he or she displays are only (if at all) associated to that. Helps out recognize specific needs, gives chance to offer information or assistance and start problem-solving. Taking consideration of social factors, as well as functional status, is significant in determining proper discharge destination.

GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL
COPING-STRESS TOLERANCE PATTERN ASSESSMENT
SUBJECTIVE
1.         Have you experienced any stressful or traumatic events in the past year in addition to             this       admission? No__ Yes__ Describe:___________________
2.         How would you rate your usual handling of stress? Good__ Average__ Poor__
3.         What is the primary way you deal with stress or problems? ____________
4.         Have you or your family used any support or counseling groups in the past year? No__             Yes__ Group name: ________________________________
            Was the support group helpful? Yes__ No__ Additional comments: _____
5.         What do you believe is the primary reason behind a need for this admission? 6.  How             soon, after first noting the symptoms, did you seek health care assistance? 7.    Are you             satisfied with the care you have been receiving at home? No__ Yes __ Comments: 8.            Ask primary caregiver: What is your understanding of the care that will be needed when             the        patient goes home? ____________________________

OBJECTIVE
1.         Observe behavior: Are there any overt signs of stress (crying, wringing of hands,             clenched fists, etc)? Describe: ____________________________



  • Establish presence or quality of resources and support systems accessible to patient. Patients may have support in one setting, for instance during hospitalization, yet be discharged home without adequate support for effective coping. Resources may comprise significant others, health care providers such as home health nurses, community resources, and spiritual counseling.

  • Recognize available methods of dealing with life problems or helpful past and present coping mechanisms. Successful adjustment is affected by prior coping accomplishments. Offers chance to use behaviors formerly effective, build on past successes, and gather together resources. Patients with history of maladaptive coping may require additional resources. Similarly, previously successful coping skills may be insufficient in the at hand situation.

·         Assess pathophysiology affecting the patient; degree of sense of hopelessness/helplessness/loss of control over life;  level of anxiety; and awareness of situation. Markers of amount of disequilibrium and necessitate for intervention to avoid or resolve the crisis. Studies propose that up to 85% of all physically ill people are depressed to some degree. Alterations of normal functioning for more than 2 weeks, particularly in incidence of chronic condition, may echo depression, requiring additional assessment.

·         Check for sleep interruption, increased difficulty concentrating, statements of incapability to cope, lethargy, withdrawal. May signify beginning of depression which may need additional assessment and intervention.

  • Evaluate decision-making and problem-solving abilities. Patients may sense that the threat is superior to their resources to handle it and sense a loss of control over solving the threat or problem.

  • Evaluate level of understanding and willingness to learn required lifestyle changes. Proper problem solving needs precise information and understanding of options. Frequently, patients who are unsuccessfully coping are not capable to hear or incorporate required information.

·         Take note of articulation of incapability to find meaning in life or reason for living, feelings of futility or alienation from God. Crisis situation may evoke questioning of spiritual beliefs, affecting capability to cope with present situation and plan for the future.

·         Take note the actions and  behaviors of Significant Other that encourages “sick role” for patient. Sinificant Other may deliberately allow patient to remain dependent by doing things that patient supposed to do for self.

Therapeutic Interventions (Tx)
  • Express feelings of acceptance and understanding. Avoid false reassurances.

  • Give opportunities to articulate worries, fears, feelings, and expectations. Recognize verbal expressions of anger, setting restrictions on maladaptive behavior. Articulation of actual or perceived threats can help decrease anxiety. Communicating angry feelings is a significant process for resolution of grief and loss. Nevertheless, avoiding destructive actions preserves patient’s self-esteem.

  • Give precise information to the patient and honest answers. Do not give more than patient can handle. Useful in clarifying misconceptions, recognizing actual risk. Permits patient to create decisions based on knowledge. Patients who are coping unsuccessfully have decreased capability to incorporate information.

  • Help the patient to recognize own strengths and aptitudes. Throughout crises, patients may not be able to identify their strengths. Nurturing consciousness can speed up use of these strengths.

  • Incorporate patient in planning of care, and persuade utmost involvement in treatment plan. Help patient to set practical goals. This helps out patient to gain control over the condition. Directing the patient to view the condition in smaller parts may make the problem more controllable. Participation offers patient with a continuing sense of control, enhances coping skills, and can improve cooperation with therapeutic regimen.

  • Institute a therapeutic nurse-patient relationship through continuity of care. A continuing relationship creates trust, decreases the feeling of isolation, and may enable coping. Patient may feel freer in the framework of this relationship to express feelings of helplessness/powerlessness and to talk about changes that may be essential in the patient’s life.

·         Maintain behaviors or efforts, for instance, increased concern/partaking in rehabilitation activities. Propose potential adaptation to changes and awareness about own role in future lifestyle.

  • Help patient to problem solve in a constructive manner.

  • Offer emotional support:
1)     Active-Listen in a accommodating manner. Helps in communication and understanding patient’s point of view. Contributes to patient’s feelings of sense of worth.
2)     Keep accommodating body language when caring for patient. Avoids reinforcing patient’s feelings of being a burden.
3)     Allocate same staff as much as possible. Offers a more therapeutic atmosphere and reduces the stress of constant adjustments

  • Discourage decision making when under severe stress.

  • Give tranquilizer, sedative as ordered. These make possible ability to cope.

  • Indicate maladaptive behaviors. This helps patient focus on more fitting strategies.

  • Indicate signs of positive progress or change. Strengthen positive adaptation or new coping behaviors. Patients who are coping unsuccessfully may not be able to evaluate progress.

·         Let patient to be dependent in the initial stages, with slow recommencement of independence in Activities of Daily Living, self-care, and other activities. Formulate opportunities for patient to make simple choices about care or other activities when possible, accommodating choice not to do so. Enhances feelings of security (patient will know nurse will provide safety). As control is recovered, patient has the chance to build up adaptive coping or problem-solving skills.

  • Offer calm, nonstimulating milieu in environment. Settle on what patient needs, and offer if possible. This is particularly common in the acute hospital setting where patients are exposed to new equipment and surroundings. Reduces anxiety and gives control for the patient throughout crisis state.

·         Offer for gradual implementation and maintenance of needed behavior or lifestyle changes.. Decreases anxiety of abrupt change and permits for formulating new and creative solutions.

  • Offer outlets that promote feelings of personal accomplishment and self-worth. Chances to role play or practice appropriate actions can augment confidence for behavior in actual circumstances.

  • Submit to community support groups, social services, financial or vocational counselor, and marital therapy or psychotherapy, as fitting. Offers assistance for adapting to changes and gives resources to deal with problems.

  • Support in development of alternative support system. Persuade partaking in self-help groups as obtainable. Relationships with persons with common interests and goals can be helpful.

  • Support to grieve and work through the losses of chronic illness and alterations in body function if appropriate.


Educative (Edx)
  • Educate in necessitate for sufficient rest and balanced diet. These enable coping strengths. Insufficient diet and fatigue can themselves be stressors.

  • Engage social services, psychiatric liaison, and pastoral care for further and continuing support resources.

·         Persuade participation in therapeutic writing. Have patient commence journaling or writing autobiography. Therapeutic writing or journaling can improve involvement in management; serves as a liberation for grief, anger, and stress; offers a helpful tool for supervising patient’s safety; and can be utilized to assess patient’s progress. Autobiographical activity offerss an opportunity for patient to recall and recognize sequence of events in his or her life that relate to present situation.

  • Persuade patient to articulate feelings, as well as hostility or anger, denial, depression, sense of disconnectedness. Contained feelings can add to stress. Shows acceptance of or helps patient in identifying and initiation to deal with these feelings.

·         Persuade patient to assess life priorities orgoals. Give inquiring statements, for instance, “Is what you are doing getting you what you want?” Focuses patient’s attention on reality of current condition relative to patient’s view of what is required. Strong work ethic, require for “control,” and outward focus may have led to lack of attention to personal needs.

  • Persuade patient to look for information that enhances coping skills. Patients who are not coping well may require more guidance at the start.

·         Persuade use of stress management skills, for example, relaxation techniques, visualization, guided imagery, deep-breathing exercises. Refocuses attention, gives relaxation, and improves coping abilities.

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