Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition that affects communication, behavior, and social interaction. This nursing diagnosis focuses on identifying key challenges, implementing appropriate interventions, and supporting individuals with autism to achieve their optimal level of functioning and independence.
Causes (Related to)
Autism’s exact causes are not fully understood, but several factors contribute to its development and presentation:
- Genetic factors and chromosomal abnormalities
- Environmental influences during pregnancy or early development
- Neurological differences in brain structure and function
- Family history of autism or other developmental disorders
- Advanced parental age
- Complications during pregnancy or birth
- Metabolic imbalances
Signs and Symptoms (As evidenced by)
Autism presents with various signs and symptoms that nurses must recognize for proper assessment and care planning.
Subjective: (Patient/Caregiver reports)
- Difficulty with social interactions
- Communication challenges
- Sensory sensitivities
- Anxiety in new situations
- Sleep disturbances
- Gastrointestinal issues
- Difficulty with changes in routine
- Food selectivity or aversions
Objective: (Nurse assesses)
- Limited eye contact
- Repetitive behaviors or movements
- Delayed or absent speech
- Unusual responses to sensory input
- Restricted interests or activities
- Difficulty with transitions
- Impaired social reciprocity
- Stereotypical movements
- Echolalia or unusual speech patterns
Expected Outcomes
The following outcomes indicate successful management of autism-related challenges:
- The patient will demonstrate improved communication skills
- The patient will show increased social interaction
- The patient will maintain safety in their environment
- The patient will demonstrate better adaptation to changes
- The patient will exhibit reduced anxiety levels
- The patient will show improved self-care abilities
- The patient will maintain stable sleep patterns
- The patient will demonstrate appropriate behavioral responses
Nursing Assessment
1. Evaluate Communication Patterns
- Assess verbal and non-verbal communication
- Document communication strengths and challenges
- Evaluate the use of alternative communication methods
- Note social interaction patterns
- Monitor response to communication attempts
2. Assess Behavioral Patterns
- Monitor repetitive behaviors
- Document triggers for behavioral changes
- Evaluate response to interventions
- Assess safety awareness
- Note patterns in daily activities
3. Review Sensory Processing
- Identify sensory sensitivities
- Document environmental triggers
- Assess response to various stimuli
- Monitor coping mechanisms
- Note successful calming techniques
4. Evaluate Daily Living Skills
- Assess self-care abilities
- Document level of independence
- Monitor feeding patterns
- Evaluate sleep habits
- Note hygiene practices
5. Check Support Systems
- Assess family dynamics
- Document available resources
- Evaluate caregiver stress
- Monitor educational support
- Review therapy services
Nursing Care Plans
Nursing Care Plan 1: Impaired Social Interaction
Nursing Diagnosis Statement:
Impaired Social Interaction related to neurodevelopmental differences as evidenced by difficulty maintaining eye contact, limited social reciprocity, and challenges in peer relationships.
Related Factors:
- Neurodevelopmental differences
- Communication challenges
- Sensory processing issues
- Social anxiety
- Limited understanding of social cues
Nursing Interventions and Rationales:
- Establish consistent communication methods
Rationale: Provides predictability and supports successful interactions - Implement social skills training
Rationale: Develops fundamental social interaction abilities - Create structured social opportunities
Rationale: Allows practice of social skills in a controlled environment
Desired Outcomes:
- The patient will demonstrate increased social engagement.
- The patient will show improved eye contact
- The patient will participate in group activities with support
Nursing Care Plan 2: Risk for Injury
Nursing Diagnosis Statement:
Risk for Injury related to impaired sensory perception and decreased safety awareness as evidenced by impulsive behaviors and limited understanding of dangerous situations.
Related Factors:
- Impaired judgment
- Sensory processing differences
- Limited safety awareness
- Impulsive behaviors
- Environmental hazards
Nursing Interventions and Rationales:
- Implement safety precautions
Rationale: Prevents accidents and injuries - Provide consistent supervision
Rationale: Ensures immediate response to unsafe situations - Modify the environment for safety
Rationale: Reduces risk of injury while maintaining independence
Desired Outcomes:
- The patient will remain free from injury
- The patient will demonstrate increased safety awareness
- The patient will follow safety instructions with support
Nursing Care Plan 3: Disturbed Sensory Perception
Nursing Diagnosis Statement:
Disturbed Sensory Perception related to altered sensory processing as evidenced by unusual responses to sensory stimuli and environmental sensitivity.
Related Factors:
- Neurological differences
- Sensory processing challenges
- Environmental stimuli
- Anxiety
- Overwhelm
Nursing Interventions and Rationales:
- Create sensory-friendly environment
Rationale: Reduces sensory overload and promotes comfort - Implement sensory integration activities
Rationale: Improves processing of sensory input - Develop coping strategies
Rationale: Provides tools for managing sensory challenges
Desired Outcomes:
- The patient will show reduced sensory sensitivity
- The patient will demonstrate improved coping with sensory input
- The patient will maintain calm behavior in various environments
Nursing Care Plan 4: Impaired Verbal Communication
Nursing Diagnosis Statement:
Impaired Verbal Communication related to neurodevelopmental differences as evidenced by delayed speech development and difficulty expressing needs.
Related Factors:
- Language processing differences
- Social communication challenges
- Anxiety
- Limited vocabulary
- Echolalia
Nursing Interventions and Rationales:
- Implement alternative communication methods
Rationale: Provides means for expression and understanding - Support speech therapy interventions
Rationale: Develops communication skills systematically - Use visual supports
Rationale: Enhances understanding and expression
Desired Outcomes:
- The patient will demonstrate improved communication abilities.
- The patient will express needs effectively
- The patient will show increased verbal interaction
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to environmental changes and sensory challenges as evidenced by increased stereotypical behaviors and agitation during transitions.
Related Factors:
- Unpredictable changes
- Sensory overload
- Communication difficulties
- Social demands
- Routine disruption
Nursing Interventions and Rationales:
- Maintain consistent routines
Rationale: Reduces anxiety through predictability - Implement calming techniques
Rationale: Provides coping strategies for anxiety management - Use visual schedules
Rationale: Supports understanding of daily activities and transitions
Desired Outcomes:
- The patient will demonstrate reduced anxiety behaviors
- The patient will use coping strategies effectively
- The patient will show improved adaptation to changes
References
- American Psychiatric Association. (2024). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Washington, DC: American Psychiatric Publishing.
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Díaz-Agea, J. L., Macías-Martínez, N., Leal-Costa, C., Girón-Poves, G., García-Méndez, J. A., & Jiménez-Ruiz, I. (2022). What can be improved in learning to care for people with autism? A qualitative study based on clinical nursing simulation. Nurse Education in Practice, 65, 103488. https://doi.org/10.1016/j.nepr.2022.103488
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Hume K, Steinbrenner JR, Odom SL, Morin KL, Nowell SW, Tomaszewski B, Szendrey S, McIntyre NS, Yücesoy-Özkan S, Savage MN. Evidence-Based Practices for Children, Youth, and Young Adults with Autism: Third Generation Review. J Autism Dev Disord. 2021 Nov;51(11):4013-4032. doi: 10.1007/s10803-020-04844-2. Epub 2021 Jan 15. Erratum in: J Autism Dev Disord. 2023 Jan;53(1):514. doi: 10.1007/s10803-022-05438-w. PMID: 33449225; PMCID: PMC8510990.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
