Nursing Care Plan (NCP) for Dissociative Disorders

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Outline

Pathophysiology

Dissociative disorders are the common result of many traumatic or stressful situations and often develop as a way of avoiding difficult memories.  Some clients report a feeling of being outside of the body, or watching their life from a distance. Others experience a memory gap and present with various identities.

Etiology

People who have experienced physical, sexual, or emotional abuse during childhood are at a higher risk of developing dissociative disorders. These clients may also be more likely to attempt suicide or self-destructive behaviors.

Desired Outcome

Client will remain safe; client will  have optimal functioning during social and daily routine activities; client will identify stressors and triggers for dissociative behaviors or reactions

Subjective Data

  • Memory loss
  • Feeling of being detached
  • Feeling of surroundings being foggy or dreamlike
  • Inability to cope with emotional or social stress
  • Suicidal thoughts
  • Depression

Objective Data

  • Anxiety
  • Distant or reclusive behavior
  • Erratic or chaotic behavior
  • Unresponsiveness to environmental stimuli (sound, smell, temperature, etc.)

Nursing Interventions

Intervention

Rationale

Perform complete nursing and neurological assessment. Note any signs of self-mutilation or previous suicide attempts

Get a baseline of data and help determine neurological status. Also rules out underlying physiological cause of symptoms.

Assess for any suicidal or homicidal ideations

Provide teaching to family members and encourage their support in dealing with client’s symptoms.

Clients often feel isolated in regards to their past experiences. Incorporating a family support system helps the progression and effectiveness of treatment

Monitor skin integrity when using restraints or for clients with suicidal ideations.

Clients may develop self-destructive behaviors during treatment. Improper or extended use of restraints can cause skin breakdown.

Administer medications as needed appropriately.

While there are no medications for these specific disorders, many clients have other mental illnesses or conditions that exacerbate symptoms such as depression and anxiety. Some medications may be used for chaotic or  erratic behaviors and are given on a PRN basis.

Provide support and encouragement during recollection of past traumatic experiences

Build rapport and trust to help the client work through the difficult emotions and circumstances that they may have been avoiding

Lesson Details

Pathophysiology

Dissociative disorders are the common result of many traumatic or stressful situations and often develop as a way of avoiding difficult memories.  Some clients report a feeling of being outside of the body, or watching their life from a distance. Others experience a memory gap and present with various identities. People who have experienced physical, sexual, or emotional abuse during childhood are at a higher risk of developing dissociative disorders. These clients may also be more likely to attempt suicide or self-destructive behaviors.

Etiology

 

Diagnostic Criteria:

 

See chart below for specific diagnostic criteria for each disorder according to the DSM-V. These symptoms are not due to substance use / abuse or another medical condition and cannot be better explained by another mental disorder.

Dissociative Amnesia Dissociative Identity Disorder Depersonalization – Derealization Disorder Other Specified Dissociative Disorder (formerly DD-NOS)
  • Localized/selective amnesia
  • Significant distress or functional impairment
  • Bewildered wandering
  • Two or more distinct identities
  • Recurrent gaps in memory
  • Behaviors are outside “normal” cultural or religious practices
  • “Out of body experience”
  • Surroundings may seem foggy or dreamlike.
  • Reality testing remains intact
  • Recurrent episodes
  • Client experienced traumatic coercive persuasion (brainwashing, torture, long-term imprisonment)
  • Symptoms are brief
  • Trance-like state or unresponsive to stimuli

Desired Outcome

Client will remain safe; client will have optimal functioning during social and daily routine activities; client will identify stressors and triggers for dissociative behaviors or reactions

Dissociative Disorders Nursing Care Plan

Subjective Data:

  • Memory loss
  • Feeling of being detached
  • Feeling of surroundings being foggy or dreamlike
  • Inability to cope with emotional or social stress
  • Suicidal thoughts
  • Depression

Objective Data:

  • Anxiety
  • Distant or reclusive behavior
  • Erratic or chaotic behavior
  • Unresponsiveness to environmental stimuli (sound, smell, temperature, etc.)

Nursing Interventions and Rationales

  • Perform complete nursing and neurological assessment. Note any signs of self-mutilation or previous suicide attempts

 

Get a baseline of data and help determine neurological status. Also rules out underlying physiological cause of symptoms.

 

  • Assess for any suicidal or homicidal ideations

 

To provide for client safety and the safety of others

 

  • Set limits for inappropriate behaviors

 

Clients may act chaotic or erratic. Setting limits and consistently maintaining boundaries reinforces routine and reality.

 

  • Provide care with calm and positive, respectful attitude

 

Negativity or hostility can trigger hostile reactions or manipulative behaviors.

Gaining the client’s respect and trust helps facilitate care.

 

  • Encourage client to talk about their life, their past and their interests

 

Helps identify specific areas of avoidance or infatuation that may pose as stress triggers for behaviors

 

  • Provide support and encouragement during recollection of past traumatic experiences

 

Build rapport and trust to help the client work through the difficult emotions and circumstances that they may have been avoiding

 

  • Administer medications as needed appropriately

 

While there are no medications for these specific disorders, many clients have other mental illnesses or conditions that exacerbate symptoms such as depression and anxiety. Some medications may be used for chaotic or erratic behaviors and are given on a PRN basis.

 

  • Provide teaching to family members and encourage their support in dealing with client’s symptoms

 

Clients often feel isolated in regard to their past experiences. Incorporating a family support system helps the progression and effectiveness of treatment

 

  • Provide appropriate, temporary use of restraints or lock-down facilities as necessary

 

Keep clients safe from harm during gaps or changes in personalities. Prevent clients from wandering into dangerous areas.

 

  • Monitor skin integrity when using restraints or for clients with suicidal ideations

 

Clients may develop self-destructive behaviors during treatment.

Improper or extended use of restraints can cause skin breakdown.

 

  • Provide resource information for continued long-term psychotherapy and counseling

 

Help client with long-term treatment and give information to help client continue managing symptoms.

Writing a Nursing Care Plan (NCP) for Dissociative Disorders

A Nursing Care Plan (NCP) for Dissociative Disorders starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

We are going to work on the nursing care plan for dissociative disorders. So dissociative disorders are a common result of many traumatic or stressful situations, and they develop as a way of avoiding difficult memories. Think of them as an unhealthy coping mechanism. Some clients report feeling outside of their body, or watching their life from a distance. Others tend to experience a memory gap and present with various identities. People who have experienced physical sexual or emotional abuse during childhood or a higher risk of developing dissociative disorder. These our clients will be more likely to attempt suicide or have more self-destructive behaviors. So our nursing considerations, the first thing we want to do with these patients is we want to assess their suicide risk. These patients are at high risk for suicide. So we want to make sure that we’re doing a assessment checking to see if they have a plan and if necessary, make a suicide contract with these patients, we want to encourage self-expression. 

We want to do a skin assessment because sometimes these patients can become very violent and they may need to be placed in restraints. We wanted to do a skin assessment of whether its restraints are applied and each time we go in, we need to reevaluate the need for those restraints. Remember the desired outcome for this patient is that the client is going to remain safe. It’s very important. Safety is number one. We want to make sure that they have optimal functioning during social and daily routine activities. This patient is going to identify stressors and triggers for dissociative behaviors or reactions. So this patient is someone who has dealt with something very traumatic in their life. So they tend to have some subjective things that they will present with a memory loss, maybe a feeling of being detached. Maybe they feel foggy or dreamlike. They have an inability to cope. So coping is very difficult for them. They have an inability to cope. They may have some suicidal thoughts, so suicidal thoughts. 

And then also they also may complain of depression, some things that we’re going to notice as healthcare providers, when we are gathering some of that good objective data we are going to notice that they are distant; some call it reclusive, very, just withdrawn. They may present the other way, and they may be erratic and destructive. They may present with some chaotic behavior, and also there may be just, they may just be unresponsive. They may be what we call flat. They may have an unresponsiveness to any stimuli. So they may be unresponsive to external environmental stimuli. So what can we do as nurses? What are some interventions that we can get into? Well, we want to make sure that we perform a neurological assessment. So we want to make sure that we are doing a neuro assessment. 

We also want to assess for any signs or symptoms of a self-harm or prior suicide attempt. And the reason for this is these patients are at an increased risk of suicide. And so, because they are at an increased risk of suicide, they may have already attempted or are at risk to attempt. Also you want to make sure we check for any homicidal ideations. We just want to make sure that they are safe. Okay. The next thing we want to do is we want to be able to provide teaching. So we want to provide teaching as a lot of mental disorders, or mental illness disorders, are based on family support. So we want to make sure that the family is on board with these patients getting well. So that includes teaching the family and encouraging them to support and deal with the client’s symptoms. Remember, clients feel isolated. 

So in regards to their past experience, the importance of incorporating a family support system is to help the progression and the effectiveness of the treatment. Next, we want to monitor skin integrity. Remember clients may have developed self-destructive behaviors during treatment. So we want to make sure that if we need to apply any restraints, restraints may be necessary. We want to make sure that we are providing restraint care. We want to because it can equal skin breakdown if we’re not careful. Okay, the next thing is, we want to administer any medications as necessary. Now, while these disorders don’t have any specific medications for them, they may have other mental illnesses that may exacerbate their symptoms. So we may want to deal with depression. We may need something for their chaotic behavior, and that may be given on a PRN basis as needed. 

Finally, we want to make sure that we provide support and encouragement. During the recollection of past traumatic events, these patients typically have experienced past trauma and in order to get through it, we want to make sure that they recollect. But in order to do that, we want to build a rapport with these patients. And we want to help them work through all of these difficult emotions and circumstances that they may have been avoiding all this time. So let’s take a look at these key points. Starting with the pathway. Remember dissociative disorders are the result of many traumatic and stressful situations in the past. The subjective data is they may have memory loss, depression, suicidal ideations, their memory be foggy. When you talk to them and you observe them, you may gather insight. It may be erratic, chaotic. They may have that behavior. They may be reclusive. The first thing we want to do is to put them on suicide precautions. These patients may need to be placed in restraints. We also want to do some therapy. We want to make sure that they are seeing a psychiatrist because it’s very important to find out the root cause of these feelings, therapy and encouraging journaling or methods that we could do in order to care for these patients. 

We love you guys; go out and be your best self today. And, as always, happy nursing.

 

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