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MORAL DISTRESS Nursing Care Plan

Patient's Data
Mr. Ines is a 74 year old nursing home patient who has co-occurrence of two or more medical and psychiatric conditions including significant dementia. He is combative and often bites those who attempt to care him. Four nurses have been treated for injuries
caused by Mr. Ines. Unfortunately the doctors don't know the severity of the problem and the patients wife don't want medications to sedate Mr. Ines because of the possible side effects. Nurses are now morally distressed because they feel forced to endure physical violence without any power to change the situation. The feeling of powerlessness, they know caring Mr. Ines requires to sedate him, but they are constrained because the doctors, who must write the prescription do not know the severity of the situation and the wife who refuses any means to sedate Mr. Ines.

Diagnosis:

Moral distress related to powerlessness of the nurses as evidenced by being constrained to sedate the patient in order to prevent his physical violence.

Planning:

After 4 hours of nursing intervention, the nurses will relate strategies to address moral distress such as to be able to identify sources of moral distress, will share their distress with a colleague. The nurses must able to identify at least two strategies to enhance decision-making with clients and family. The nurses must able to identify two strategies to enhance discussion of the situation with the physician.

Interventions:

- Identify sources of Mr. Ines moral distress. There are lots of factors and sources of moral stress, most common are staffing, competency of nurses or the doctor, futile care, needless pain and suffering, end-of-life conflicts, incomplete information, inadequate symptom management, disrespectful interactions. In this situation, nurse-physician communication and violence in the workplace are the two sources of Mr. Ines' moral distress.

- Evaluate the risks and benefits of options of taking care Mr. Ines and consider the worse possible outcome to your action, also consider the risks of doing nothing. Avoid rationalization. Do not try to avoid moral distress instead acknowledge it and affirm your professional obligation to act, if better, you can ask for help and clarification about the moral distress. Use the chain of command to share and discuss issues that have escalated beyond the problem solving ability. 

- Educate yourself about moral distress initiate dialogue with Mr. Ines which is the patient, family and the doctor. Explore what the perception of the situation is. Encourage the doctor to enlighten the situation, if possible, pose questions. Elicit feelings about the present situation, stay in the room to promote sharing and encourage Mr. Ines and the family to write down questions for the doctor. Start with an approach to address an unsatisfactory moral. Engage in open communication with involved doctor. Start the conversation with the patient, wife, and doctor, like start saying “Mr. Ines, I’m not comfortable with...” If possible, have a conversation with other professionals especially ethics committee or social workers.

Evaluation:

After 4 hours of nursing intervention, the nurses related strategies to address moral distress such as was able to identify sources of moral distress, shared their distress with a colleague. The nurses was able to identify at least two strategies to enhance decision-making with clients and family. The nurses was able to identify two strategies to enhance discussion of the situation with the physician.
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