Group 8:

1) BAGUS ADI U.
2) DEVITA DWI F
3) DWI DAMAYANTI
4) NITA HABIBA

NURSING CARE PLAN PATIENT

WITH INEFFECTIVE COPING

Ineffective Coping
 change in usual communication
NANDA-I Definition patterns; risk taking
Inability to form a valid appraisal of the
stressors, inadequate choices
of practiced responses, and/or inability to Related Factors:
use available resources  Gender differences in coping
strategies;
 inadequate level of confidence in
Defining Characteristics: ability to cope;
 uncertainty;
 Lack of goal-directed
 inadequate social support created by
behavior/resolution of problem,
characteristics of relationships;
including inability to attend,
 inadequate level of perception of
difficulty with organized
control;
information, sleep disturbance, abuse
of chemical agents;  inadequate resources available;
 decreased use of social support;  high degree of threat;
 use of forms of coping that impede  situational crises;
adaptive behavior;  maturational crises;
 poor concentration;  disturbance in pattern of tension
 fatigue; release;
 inadequate problem solving;  inadequate opportunity to prepare for
stressor;
 verbalized inability to cope or ask for
help;  inability to conserve adaptive
energies;
 inability to meet basic needs;
 disturbance in pattern of appraisal of
 destructive behavior toward self or
threat
others;
 inability to meet role expectations;
 high illness rate;
 NOC Outcomes (Nursing Outcomes
Classification)
Suggested NOC Labels
 Coping
 Decision Making
 Impulse Control
 Information Processing
Client Outcomes
 Verbalizes ability to cope and asks
for help when needed
 Demonstrates ability to solve
problems and participates at usual
level in society
 Remains free of destructive behavior
toward self or others
 Communicates needs and negotiates
with others to meet needs
 Discusses how recent life stressors
have overwhelmed normal coping
strategies
 Has illness and accident rates not
excessive for age and developmental
level
NIC Interventions (Nursing Interventions
Classification)
Suggested NIC Labels
 Decision-Making Support
Nursing Interventions and Rationales
1. Observe for causes of ineffective coping
such as poor self-concept, grief, lack of
problem-solving skills, lack of support, or
recent change in life situation.
Situational factors must be identified to gain
an understanding of the client's current
situation and to aid client with coping
effectively (Norris, 1992).
2. Observe for strengths such as the ability
to relate the facts and to recognize the
source of stressors.
Family members who are coping with
critical injuries often feel defeated, hopeless,
and like a failure; therefore it is imperative
to verbally commend them for their
strengths and use those strengths to aid
functioning (Leske, 1998).
3. Monitor risk of harming self or others and
intervene appropriately. See care plan for
Risk for Suicide.
Situational factors can lead to depression or
risk for suicide. Identification of such
factors leads to appropriate referral or help
(Norris, 1992). A client with hopelessness
and an inability to problem solve often runs
the risk of suicide (Buchanan, 1991). In
these cases immediate referral for mental
health care is essential (Norris, 1992).
4. Help client set realistic goals and identify
personal skills and knowledge.
Involving clients in decision making helps
them move toward independence (Connelly
et al, 1993).
5. Use empathetic communication, and
encourage client/family to verbalize fears,
express emotions, and set goals.
Acknowledging and empathizing creates a
supportive environment that enhances
coping (Feeley, Gottlieb, 1998). Clients
report increased satisfaction and
empowerment, greater compliance with
mutually agreed-upon goals, and less
anxiety and depression when
communication is empathic (Wells-
Federman et al, 1995). Acknowledgment of
feelings communicates support and conveys
that clients are understood (Leske, 1998).
6. Encourage client to make choices and
participate in planning of care and scheduled
activities.
Participation gives a feeling of control and
increases self-esteem.
7. Provide mental and physical activities
within the client's ability (e.g., reading,
television, radio, crafts, outings, movies,
dinners out, social gatherings, exercise,
sports, games).
Interventions that enhance body awareness
such as exercise, proper nutrition, and
muscular relaxation may be effective for
treating anxiety and depression (Wells-
Federman et al, 1995).
8. If the client is physically able, encourage
moderate aerobic exercise.
Aerobic exercise increases one’s ability to
cope with acute stress (Anshel, 1996).
9. Use touch with permission. Give client a
back massage using slow, rhythmic stroking
with hands. Use a rate of 60 strokes a minute
for 3 minutes on 2-inch wide areas on both
sides of the spinous process from the crown
to the sacral area.
A gentle touch can display acceptance and
empathy (Hopkins, 1994). Slow stroke back
massage decreased heart rate, decreased
systolic and diastolic blood pressure, and
increased skin temperature at significant
levels. The conclusion is that relaxation is
induced by slow stroke back massage
(Meek, 1993).
10. Provide information regarding care
before care is given.
In traumatic situations, families have a need
for information and explanations (Hopkins,
1994). Providing information prepares the
family for understanding the situation and
possible outcomes (Leske, 1998). Adequate
information and training before and after
treatment reduces anxiety and fear (Herranz,
Gavilan, 1999).
11. Discuss changes with client before
making them.
Communication with the medical staff
provides patients and families with
understanding of the medical condition
(Grootenhuis, Last, 1997).
12. Discuss client’s/family’s power to
change a situation or the need to accept a
situation.
Such a discussion helps the client maintain
self-esteem and look at the situation
realistically with the aid of a trusted
individual (Norris, 1992). In threatening
situations, people search for reasons for the
event(s). This search is an effort to make
sense of the event, gain control, and cope
(Grootenhuis, Last, 1997).
13. Use active listening and acceptance to
help client express emotions such as crying,
guilt, and anger (within appropriate limits).
Active listening provides the client and/or
family a nonjudgmental person to listen to
them and relieve their guilt feelings
(Hopkins, 1994). Acknowledgment of
feelings communicates support and conveys
that they are understood (Leske, 1998).

14. Avoid false reassurance; give honest
answers and provide only the information
requested.
Identification of previously used effective
coping mechanisms allow the nurse to focus
attention on necessary education and referral
(Norris, 1992).
15. Encourage client to describe previous
stressors and the coping mechanisms used.
Describing previous experiences strengthens
effective coping and helps eliminate
ineffective coping mechanisms.
16. Be supportive of coping behaviors;
allow client time to relax.
A supportive presence creates a supportive
environment to enhance coping (Feeley,
Gottlieb, 1998).
17. Help clients to define what meaning
their symptoms might have for them.
In one study, the importance of helping
clients find meaning in their suffering
experiences was identified as a strategy
perceived as helpful with a group of patients
who had the diagnosis of multiple sclerosis
(Pollock, Sands, 1997).
18. Encourage use of cognitive behavioral
relaxation (e.g., music therapy, guided
imagery).
Relaxation techniques, desensitization, and
guided imagery can help clients cope,
increase their sense of control, and allay
anxiety (Narsavage, 1997). Relaxation with
guided imagery is a technique used with
increasing frequency to help individuals
improve their performance and control their
responses to stressful situations (Rees,
1993). Music is not a cure, but it can lift the
human spirit, comfort the heart, and inspire
the soul. Imagery is useful for relaxation and
distraction (Fontaine, 1994). The provision
of information and general mastery may
play a role in decreasing helplessness and
dysfunctional coping (Nicassio et al, 1997).
19. Use distraction techniques during
procedures that cause client to be fearful.
Distraction is used to direct attention toward
a pleasurable experience and block the
attention of the feared procedure (DuHamel,
Redd, Johnson-Vickberg, 1999).
20. Use systematic desensitization when
introducing new people, places, or
procedures that may cause fear and altered
coping.
Fear of new things diminishes with repeated
exposure (DuHamel, Redd, Johnson-
Vickberg, 1999).
21. Provide the client/family with a video of
any feared procedure to view before the
procedure. Ensure that the video shows a
patient of similar age and background.
Videos provide the client/family with the
information necessary to eliminate fear of
the unknown (DuHamel, Redd, Johnson-
Vickberg, 1999).
22. Refer for counseling as needed.
Arranging for referral assists the client in
working with the system, and resource use
helps to develop problem-solving and
coping skills (Feeley, Gottlieb, 1998).
Geriatric

1. Engage client in reminiscence.
Reminiscence can activate past sources of
self-esteem and aid in coping (Nugent,
1995).
2. Be aware of client's fear of illness.
Identify and reinforce patterns the elderly
client has previously used to respond to
stress. Allow client time to reminisce about
past successes. The elderly client has had a
lifetime of experience dealing with stressful
events.
A standard reminiscence interview and one
that focused on successfully met challenges
reduced state anxiety and enhanced coping
self-efficacy when measured against both
attention-placebo and no-intervention
control groups (Rybarczyk, Auerbach,
1990).
3. Assess and report possible physiological
alterations (e.g., sepsis, hypoglycemia,
hypotension, infection, changes in
temperature, fluid and electrolyte
imbalances, medications with known
cognitive and psychotropic side effects).
Such alterations may be contributing to
confusion and must be corrected
(Matthiesen et al, 1994). Medications are
considered the most common cause of
delirium in the ICU (Harvey, 1996).
4. Determine if the individual is displaying a
change in personality as a manifestation of
difficulty with coping. An older individual's
responses to age-related stress will depend
on the balance of personality strengths and
weaknesses.
Severe or multiple stresses in late life may
overwhelm an individual's coping skills and
lead to personality change (Agronin, 1998).
5. Increase and mobilize support available to
the elderly client. Encourage interaction
with family and friends.
Friends and relatives have shared many of
the older person's life experiences. Such
mutual interests and overlapping memories
can serve to stimulate and focus
conversation and contribute effectively to
the client's self-esteem (Erber, 1994).
Support from family, friends, and the
medical community aids coping ability
(Grootenhuis, Last, 1997).
6. Maintain continuity of care by keeping
the number of caregivers to a minimum.
Consistency in caregivers helps decrease
anxiety and fosters trust by providing the
client and family with familiar faces
(Hopkins, 1994).
Multicultural
1. Assess for the influence of cultural
beliefs, norms, and values on the client’s
perceptions of effective coping.
The client’s coping behavior may be based
on cultural perceptions of normal and
abnormal coping behavior (Leininger,
1996).
2. Assess for intergenerational family
problems that can overwhelm coping
abilities.
Intergenerational family problems put
families at risk of dysfunction (Seiderman et
al, 1996).
3. Encourage spirituality as a source of
support for coping.
Many African-Americans and Latinos
identify spirituality, religiousness, prayer,
and church-based approaches as coping
resources (Samuel-Hodge et al, 2000;
Bourjolly, 1998; Mapp, Hudson, 1997).
4. Negotiate with the client with regard to
the aspects of coping behavior that will need
to be modified.
Give and take with the client will lead to
culturally congruent care (Leininger, 1996).
5. Identify which family members the client
can rely on for support.
Many Latinos, Native Americans, and
African-Americans rely on family members
to cope with stress (Abraido-Lanza, Guier,
Revenson, 1996; Seiderman et al, 1996).
6. Assess the influence of fatalism on the
client’s coping behavior.
Fatalistic perspectives involve the belief in
some African-American and Latino
populations that you cannot control your
own fate and influence health behaviors
(Phillips, Cohen, Moses, 1999; Harmon,
Castro, Coe, 1996).
Home Care Interventions
1. Observe family for coping behavior
patterns. Obtain family and client history as
able.
Obtaining a family assessment provides a
wealth of information regarding current
family functions and can guide interventions
(Leske, 1998).
2. Assess for suicidal tendencies. Refer for
mental health care immediately if indicated.
Identify an emergency plan should the client
become suicidal.
A suicidal client is not safe in the home
environment unless supported by
professional help.
3. Refer to medical social services for
evaluation and counseling, which will
promote adequate coping as part of the
medical plan of care. If no primary medical
diagnosis has been made, request medical
social services to assist with community
support contacts.
4. If the client is involved with the mental
health system, actively participate in mental
health team planning.
Based on knowledge of the home and
family, home care nurses can often advocate
for clients. These nurses are often requested
to monitor medications and therefore need to
know the plan of care.
5. Refer patient/family to support groups.
Support groups foster the sharing of
common experiences and help to build
mutual support. They are particularly helpful
when others within the family are unable to
provide support because of their own
grieving or coping needs (Leske, 1998).
6. If monitoring medications, contract with
client or solicit assistance from a responsible
caregiver. Pre-pouring of medications may
be helpful with some clients.
Successful contracting provides the client
with control of care and promotes self-
esteem while establishing responsibility for
desired actions.
NOTE: All of the previously mentioned
interventions may be applied in the home
setting. Home care may offer psychiatric
nursing or the services of a licensed clinical
social worker under special programs.
Traditionally, insurance does not reimburse
for counseling that is not related to a
medical plan of care unless it falls under one
of the programs just described. Public health
agencies generally do not have the clinical
support needed to offer psychiatric nursing
services to clients. Clients are usually
treated in the ambulatory mental health
system.
Client/Family Teaching
1. Teach clients to problem solve. Have
them define the problem and cause and list
the advantages and disadvantages of their
options.
2. Provide seriously ill clients and their
families with needed information regarding
their condition and treatment.
Information is an important need of families
of critically ill patients (Henneman,
Cardin,1992). In one study, information
structured to meet individual needs reduced
anxiety and increased satisfaction with the
information provided (McGaughey,
Harrisson, 1994).
3. Teach relaxation techniques.
Problem-solving skills promote the client's
sense of control. Relaxation decreases stress
and enhances coping (Fontaine, 1994).
4. Suggest listening to music.
Listening to music has been found to
decrease total mood disturbances scores
(profile of mood states [POMS] scores). A
decrease in POMS scores is indicative of
decreased distress and a mood improvement
(McNair, Lorr, Droppleman, 1992).
5. Teach process imagery (purposely
evoking a mental image of a desired effect).
Using process imagery, a person can look at
an old problem in a totally different way,
making new connections and freeing the
problem from the original memory. Imagery
engenders a feeling of control and gives the
client an effective tool for self-care
(Stephens, 1993).
6. Work closely with the client to develop
appropriate educational tools that address
individualized coping strategies.
Collaboration between client and staff in the
production of client information can
improve client understanding and empower
the client and family to take an active part in
treatment (Willock, Grogan, 1998).
7. Teach client about available community
resources (e.g., therapists, ministers,
counselors, self-help groups).
Resource use helps to develop problem-
solving and coping skills (Feeley, Gottlieb,
1998). Client and family teaching that
promotes the ability to understand and carry
out any necessary medical, rehabilitative, or
daily living activities contributes to a sense
of mastery, competency, and control and is
vital to discharge planning and community-
based assessments (Norris, 1992).