Sunday, February 8, 2009

Nursing Care Plans For Delusional Disorders

Nursing Care Plans For Patient With Delusional Disorders

According to the DSM-IV-TR, delusional disorders are characterized by false beliefs with a plausible basis in reality. Formerly referred to as paranoid disorders, delusional disorders are known to involve erotomanic, grandiose, jealous, or somatic themes as well as persecutory delusions. Some patients experience several types of delusions; other patients experience unspecified delusions that have no dominant theme.
Delusional disorders commonly begin in middle or late adulthood, usually between ages 40 and 55, but they can occur at a younger age. These uncommon illnesses affect less than 1% of the population; the incidence is about equal in males and women. Typically chronic, these disorders often interfere with social and marital relationships but seldom impair intellectual or occupational functioning significantly.

Delusional disorders of later life strongly suggest a hereditary predisposition. At least one study has linked the development of delusional disorders to inferiority feelings in the family. Some researchers suggest that delusional disorders are the product of specific early childhood experiences with an authoritarian family structure. Others hold that anyone with a sensitive personality is particularly vulnerable to developing a delusional disorder.
Certain medical conditions are known to exaggerate the risks of delusional disorders: head injury, chronic alcoholism, deafness, and aging. Predisposing factors linked to aging include isolation, lack of stimulating interpersonal relationships, physical illness, and diminished hearing and vision. In addition, severe stress (such as a move to a foreign country) may precipitate a delusional disorder.

Assessment Nursing Care Plans For Delusional Disorders
The psychiatric history of a delusional patient may be unremarkable, aside from behavior related to his delusions. He's likely to report problems with social and marital relationships, including depressive symptoms or sexual dysfunction. In fact, about one-third of delusional patients are widowed, divorced, or separated at the time of first admission. Others describe a life marked by social isolation or hostility. Such patients may deny feeling lonely, relentlessly criticizing or placing unreasonable demands on others.
Also watch for nonverbal cues, indicating suspiciousness or mistrust, such as excessive vigilance or obvious apprehension on entering the room. During questions, the patient may listen intently, reacting defensively to imagined slights or insults. He may sit at the edge of his seat or fold his arms as if to shield himself. If he carries papers or money, he may clutch them firmly.

Diagnostic Nursing Care Plans For Delusional Disorders
Psychiatric examination confirms the presence of the following diagnostic criteria in the DSM-IV-TR:
  1. Nonbizarre delusions of at least 1 month's duration are present, involving real-life situations, such as being followed, poisoned, infected, loved at a distance, or deceived by one's spouse or lover.
  2.  Auditory or visual hallucinations, if present, aren't prominent.
  3. Apart from the delusion or its ramifications, behavior isn't obviously odd or bizarre, and the patient isn't markedly impaired functionally. 
  4. If a major depressive or manic syndrome has been present during the delusional disturbance, the total duration of all episodes of the mood syndrome has been brief relative to the total duration of the delusional disturbance.
  5. The patient has never met diagnostic criteria for schizophrenia (presence of characteristic psychotic symptoms in the active phase for at least 1 week), and it can't be established that an organic factor initiated and maintained the disturbance.
  6. In addition, blood and urine tests, psychological tests, and a neurologic evaluation rule out organic causes of the delusions, such as amphetamine-induced psychoses and Alzheimer's disease. Endocrine function tests are performed to rule out hyperadrenalism, pernicious anemia, and thyroid disorders such as “myxedemic madness

Effective treatment of delusional disorders, consisting of a combination of drug therapy and psychotherapy, must correct the behavior and mood disturbances that result from the patient's mistaken belief system. Treatment may also include mobilizing a support system for the isolated, aged patient.
Drug treatment with antipsychotic agents is similar to that used in schizophrenic disorders. Antipsychotics appear to work by blocking postsynaptic dopamine receptors. These drugs reduce the incidence of psychotic symptoms, such as hallucinations and delusions, and relieve anxiety and agitation. Other psychiatric drugs, such as antidepressants and anxiolytics, may be prescribed to control associated symptoms.
High-potency antipsychotics include fluphenazine, haloperidol, thiothixene, and trifluoperazine. Loxapine, molindone, and perphenazine are intermediate in potency, and chlorpromazine and thioridazine are low-potency agents. Haloperidol and fluphenazine are depot formulations that are implanted I.M. to release the drug gradually over a 30-day period, improving compliance.
Clozapine, which differs chemically from other antipsychotic drugs, may be prescribed for severely ill patients who fail to respond to standard neuroleptic treatment. This agent effectively controls a wider range of psychotic symptoms without the usual adverse effects.
However, clozapine can cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, and seizures, as well as agranulocytosis, a potentially fatal blood disorder characterized by a low white blood cell count and pronounced neutropenia. Routine blood monitoring is essential to detect the estimated 1% to 2% of all patients taking clozapine who develop agranulocytosis. If caught in the early stages, the disorder is reversible.

Diagnoses that may occur in Nursing Care Plans For Delusional Disorders
  1. Anxiety
  2. Disabled family coping
  3. Disturbed personal identity
  4. Disturbed sensory perception (visual, auditory)
  5. Disturbed thought processes
  6. Fear
  7. Imbalanced nutrition: Less than body requirements
  8. Impaired home maintenance
  9. Impaired social interaction
  10. Ineffective coping
  11. Powerlessness
  12. Risk for injury
  13. Risk for other-directed violence
  14. Risk for self-directed violence
  15. Social isolation

Key outcomes Nursing Care Plans For Delusional Disorders
  • The patient will consider alternative interpretations of a situation without becoming hostile or anxious.
  • The patient and his family will participate in care and prescribed therapies.
  • The patient will identify internal and external factors that trigger delusional episodes.
  • The patient will maintain functioning to the fullest extent possible within the limitations of his visual or auditory impairment.
  • The patient will remain oriented to person, place, time, and situation.
  • The patient will express all fears and concerns.
  • The patient will show no signs of malnutrition.
  • The patient will recognize symptoms and comply with medication regimen.
  • The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
  • The patient will demonstrate adaptive coping behaviors.
  • The patient will identify and perform activities that decrease delusions.
  • The patient will remain free from injury.
  • The patient won't harm others.
  • The patient won't harm self.
  • The patient will maintain family and peer relationships.
Interventions Nursing Care Plans For Delusional Disorders
  • In dealing with the patient, be direct, straightforward, and dependable. Whenever possible, elicit his feedback. Move slowly, with a matter-of-fact manner, and respond without anger or defensiveness to his hostile remarks.
  • Accept the patient's delusional system. Don't attempt to argue with him about what's real.
  • Respect the patient's privacy and space needs. Avoid touching him unnecessarily.
  • Take steps to reduce social isolation, if the patient allows. Gradually increase social contacts after he has become comfortable with the staff.
  • Watch for refusal of medication or food, resulting from the patient's irrational fear of poisoning.
  • Monitor the patient carefully for adverse effects of neuroleptic drugs: drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome.

Patient teaching Nursing Care Plans For  Delusional Disorders
  • If the patient is taking clozapine, stress the importance of returning weekly to the hospital or outpatient setting to have his blood monitored.
  • Emphasize the importance of complying with the prescribed medication treatment. Instruct the patient to report any adverse effects instead of stopping the drug. If he's taking a slow-release formulation, be sure he understands when to return to the physician for his next dose.
  • Involve family members in treatment. Teach them how to recognize an impending relapse, and suggest ways to manage symptoms. These include tension, nervousness, insomnia, decreased concentration ability, and loss of interest.
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