Nursing Diagnosis: Ineffective Coping

NANDA Definition: Inability to form a valid appraisal of internal or external stressors, inadequate choices of practiced responses, and/or inability to access or use available resources

Defining Characteristics: Lack of goal-directed behavior or resolution of problem, including inability to attend; difficulty with organized information; sleep disturbance; abuse of chemical agents; decreased use of social support; use of forms of coping that impede adaptive behavior; poor concentration; fatigue; inadequate problem solving; verbalized inability to cope or ask for help; inability to meet basic needs; destructive behavior toward self or others; inability to meet role expectations; high illness rate; change in usual communication patterns; risk taking

Related Factors: Gender differences in coping strategies; inadequate level of confidence in ability to cope; uncertainty; inadequate social support created by characteristics of relationships; inadequate level of perception of control; inadequate resource availability; high degree of threat; situational crises; maturational crises; disturbance in pattern of tension release; inadequate opportunity to prepare for stressor; inability to conserve adaptive energies; disturbance in pattern of appraisal of threat; chronic conditions; alteration in body integrity; cultural variables

Client Outcomes

1. Verbalize ability to cope and ask for help when needed
2. Demonstrate ability to solve problems related to current needs
3. Remain free of destructive behavior toward self or others
4. Communicate needs and negotiate with others to meet needs
5. Discuss how recent life stressors have overwhelmed normal coping strategies
6. Demonstrate new effective coping strategies
7. Have illness and accident rates not excessive for age and developmental level

Nursing Interventions and Rationales

• 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. 
• Observe for strengths such as the ability to relate the facts and to recognize the source of stressors. 
• Assess the risk of the client's harming self or others and intervene appropriately.
  
• Help the client set realistic goals and identify personal skills and knowledge. 
• Use empathetic communication and encourage the client and family to verbalize fears, express emotions, and set goals. 
• Encourage the client to make choices and participate in the planning of care and scheduled activities. 
• 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). 
• If the client is physically able, encourage moderate aerobic exercise.
• Provide information regarding care before care is given. Adequate information and training before and after treatment reduces anxiety and fear (Herranz and Gavilan, 1999).
• Discuss changes with the client before making them. 
• Discuss the client's and family's power to change a situation or the need to accept a situation. 
• Use active listening and acceptance to help the client express emotions such as sadness, guilt, and anger (within appropriate limits). 
• Encourage the client to describe previous stressors and the coping mechanisms used. 
• Be supportive of coping behaviors; allow the client time to relax. 
• Help the client to define what meaning his or her symptoms might have for the client. 
• Encourage the use of cognitive behavioral relaxation (e.g., music therapy, guided imagery). 
• Use distraction techniques during procedures that cause the client to be fearful. Distraction is used to direct attention toward a pleasurable experience and block the attention to the feared procedure (DuHamel, Redd, and Johnson-Vickberg, 1999).
• 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, and Johnson-Vickberg, 1999).
• Provide the client and/or family with a video of any feared procedure to view before the procedure. Ensure that the video shows a client of similar age and background. Videos provide the client and/or family with the information necessary to eliminate fear of the unknown (DuHamel, Redd, and Johnson-Vickberg, 1999).
• Refer for counseling as needed. 

Geriatric
• Engage the client in reminiscence. Reminiscence activates positive memories and evokes well-being (Puentes, 2002).
• Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and use of medications with known cognitive and psychotropic side effects). 
• 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. 
• Increase and mobilize the support available to the elderly client. Encourage interaction with family and friends.

Multicultural
• Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of effective coping. 
• Assess for intergenerational family problems that can overwhelm coping abilities. 
• Encourage spirituality as a source of support for coping. 
• Negotiate with the client with regard to the aspects of coping behavior that will need to be modified. 
• Identify which family members the client can count on for support. 
• Use an empowerment framework to redefine coping strategies. 
• Assess the influence of fatalism on the client's coping behavior. 
• Assess the influence of cultural conflicts that may affect coping abilities.

  Home Care Interventions

  • The interventions described previously may be adapted for home care use.
  • Observe the family for coping behavior patterns. Obtain family and client history as possible. 
  • Assess for suicidal tendencies. Refer for mental health care immediately if indicated. Identify an emergency plan should the client become suicidal. Ineffective coping can occur in a crisis situation and can lead to suicidal ideation if the client sees no hope for a solution. A suicidal client is not safe in the home environment unless supported by professional help.
  • Encourage the client to use self-care management to increase the experience of personal control. Identify with the client all available supports and sense of attachment to others.
  • 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. 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 frequently requested to monitor medication use and therefore need to know the plan of care.
  • Refer the client and family to support groups. 
  • If monitoring medication use, contract with the client or solicit assistance from a responsible caregiver. Prepouring of medications may be helpful with some clients. Caregivers in the home benefit from interventions that promote self-efficacy and provide a nurse for support (Dibartolo, 2002).
  • Institute case management for frail elderly clients to support continued independent living. Difficulties in coping with changes in health care needs can lead to increasing needs for assistance in using the health care system effectively. Case management combines the nursing activities of client and family assessment, planning and coordination of care among all health care providers, delivery of direct nursing care, and monitoring of care and outcomes. These activities are able to address continuity of care, mutual goal setting, behavior management, and prevention of worsening health problems (Guttman, 1999).
  • If the client is homebound, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. Psychiatric home care nurses can address issues relating to the client's ability to adjust to changes in health status. Behavioral interventions in the home can help the client to participate more effectively in the treatment plan (Patusky, Rodning, and Martinez-Kratz, 1996).
  • 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

• Teach the client to problem solve. Have the client define the problem and cause, and list the advantages and disadvantages of the options. 
• Provide the seriously ill client and his or her family with needed information regarding the condition and treatment. 
• Teach relaxation techniques. 
• Work closely with the client to develop appropriate educational tools that address individualized needs. 
• Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups).