FINALS

TOPIC: SUBSTANCE RELATED DISORDERS

Substance use or abuse and related disorders are a national health problem. It is estimated that over
15 million people in the Philippines are dependent on alcohol and other drugs and 500,000 are
between the ages of 9 and 12 years. However the actual prevalence of substance abuse is difficult to
determine precisely because many people meeting the criteria for diagnosis do not seek treatment.
This IG focuses on the different classifications of substance related disorders, its causes, managements
and nursing process in the care of client who experiences substance related disorders.
At the end of the session the student will be able to:
1. Discuss the characteristics, risk factors, and family dynamics prevalent with substance abuse
2. Apply the nursing process to the care of client with substance abuse issues
3. Explain the trends in substance abuse and discuss the need for related prevention programs.
4. Provide education to clients, families, caregivers, and community members to increase knowledge
and understanding of substance use and abuse
5. Discuss the nurse’s role in dealing with the chemically impaired professional
6. Evaluate your own feelings, beliefs and attitude regarding clients with eating disorders, and sexual
deviations and dysfunctions.
1. Explain the concept of tapering medications during detoxification.
2. Discuss your role in dealing with the chemically impaired professional
3. Describe the classifications of substances that are abused
4. Discuss nursing interventions for client during alcohol detoxification or withdrawal.
5. Identify diagnostic criteria for client who abused substance
CRITICAL THINKING CHALLENGES
CASE 1: Normal adolescent behavior is often similar to that associated with substance abuse. How
would you differentiate this normal behavior from possible substance abuse or dependence ?
CASE 2: Sylvia Garcia has been abusing heroin intravenously heavily for 2 years. She has come into
the hospital with an abscess on her leg. What symptoms would you expect to observe as she
experiences withdrawal from opiates? What medications would likely be used to ease these
symptoms?
CASE 2. You are working in an orthopedic unit, and Mary L. has been admitted for treatment for a
fractured femur. She has been drinking recently and has a blood alcohol level of 0.08%. What further
information in the following areas would you need to plan for her care?
a. Medical
b. Alcohol and drug use related
SUBSTANCE RELATED DISORDERS
Substance abuse is the use of chemicals or material for non-medical purposes with the intention of
producing an altered state of consciousness sensorium, heightened sensory perception, or change in
self-image. It is manifested by repeated use of the substance and/or cognitive, behavioral, and
psychological symptoms of intoxication, withdrawal, anxiety and delirium.
Substance abuse and substance dependence are related to the use of alcohol, CNS depressant, CNS
stimulants, opiods, hallucinogens, and cannabinoids.

DSM –IV SUBSTANCE RELATED DISORDERS

A. SUBSTANCE DEPENDENCE
1. Alcohol dependence
2. Amphetamine dependence
3. Cannabis dependence
4. Cocaine dependence
5. Hallucinogen dependence
6. Inhalant dependence
7. Nicotine dependence
8. Opioid dependence
9. Phencyclidine dependence
10. Sedative, hypnotic, or anxiolytic dependence
11. Polysubstance dependence

DIAGNOSTIC CRITERIA
- Maladaptive pattern of substance use leading to clinically significant impairment or distress
- Impairment manifested by three or more of the following: tolerance; withdrawal; substance
often taken in large amounts or over a longer period than was intended; persistent desire or
unsuccessful efforts to cut down or control use; much time spent in activities necessary to
obtain the substance or use it; reduction or cessation of important social, occupational, or
recreational activities; use continued despite knowledge of having persistent or recurrent
physical or psychological problem likely to have been caused or exacerbated by the substance
B. SUBSTANCE ABUSE
1. Alcohol abuse
2. Amphetamine abuse
3. Cannabis abuse
4. Cocaine abuse
5. Hallucinogen abuse
6. Inhalant abuse
7. Opioid abuse
8. Phencyclidine abuse
9. Sedative, hypnotic, or anxiolytic abuse
DIAGNOSTIC CRITERIA
- Maladaptive pattern of substance use leading to clinically significant impairment or distress
- Impairment manifested by three or more of the following occurring within a 12-month period:
Recurrent use, resulting in failure to fulfill major role
 obligations at work, school, or home
 Recurrent use in situations that are physically hazardous
 Recurrent substance related legal problems
 Continued use despite feeling persistent or recurrent effects of the substance

C. SUBSTANCE INTOXICATION
1. Alcohol intoxication
2. Alcohol intoxication delirium
3. Amphetamine intoxication
4. Amphetamine intoxication delirium
5. Caffeine intoxication
6. Cannabis intoxication
7. Cannabis intoxication delirium
8. Cocaine intoxication
9. Cocaine intoxication delirium
10. Hallucinogen intoxication
11. Hallucinogen intoxication delirium
12. Opioid intoxication
13. Opioid intoxication delirium
14. Inhalant intoxication
15. Inhalant intoxication delirium
16. Phencyclidine intoxication delirium
17. Sedative, hypnotic, or anxiolytic intoxication

DIAGNOSTIC CRITERIA
- Symptoms never met criteria for substance dependence Reversible substance-specific
syndrome due to the recent ingestion or exposure to a substance
- Clinically significant maladaptive behavioral or psychological changes due to effect of
substance on central nervous system, developing during or shortly after use of substance
- Symptoms not due to general medical condition, nor better accounted for by another mental
disorder

D. SUBSTANCE WITHDRAWAL
1. Alcohol withdrawal
2. Amphetamine withdrawal
3. Cocaine withdrawal
4. Opioid withdrawal
5. Sedative, hypnotic, or anxiolytic withdrawal

DIAGNOSTIC CRITERIA
- Development of substance-specific syndrome due to cessation or reduction in substance use,
previously heavy and prolonged
- Syndrome causing significant distress or impairment in social, occupational, or other important areas of function

SUBSTANCE-INDUCED DISORDERS
1. Mood and anxiety disorders
2. Amnesia and psychosis
3. Intoxication and withdrawal
4. Delirium and dementia
5. Sexual dysfunction and sleep disorders
RISK FACTORS
1. BIOLOGIC FACTORS
a. Genetics: Heredity factors play a role especially in alcohol abuse
b. Biochemical.- Alcohol may produce morphine like substances in the brain leading to alcohol
addiction.
2. PSYCHOLOGICAL FACTORS
a. Development influence: Certain personality traits have been suggested to play a part In both the
development and maintenance of dependence. They include impulsivity negative self-concept,
weak ego, social conformity issues, and introversion.
3. SOCIOCULTURAL FACTORS
a. Social learning- Children is more likely to use substances if their parents do so, modeling their
behavior. Peer pressure also promotes substance abuse
b. Conditioning: Pleasurable effects from substance use act as a positive reinforcement for their
continued use.
c. Culture in ethnic influences: Some ethnic groups are more susceptible to substance abuse, due
to cultural acceptance.
4. MENTAL ILLNESS: Clients with certain mental illnesses (e.g- bipolar disorder, schizopherenia) are
vulnerable to substance abuse.

NURSING DIAGNOSIS COMMON IN CLIENT WITH SUBSTANCE RELATED DISORDERS

1. Powerlessness
2. Risk to self or others
3. Altered thought processes
4. Anxiety
5. Ineffective denial
6. Ineffective individual coping
7. Spiritual distress
8. Disturbances in self-esteem
9. Altered role performance
10. Ineffective family coping

THERAPEUTIC NURSING INTERVENTIONS

1. ENVIRONMENT TREATMENT (Milieu Therapy)
Some clients may seek an impatient treatment program for substance abuse and dependence. These
are highly structured, intensive programs which often the most successful methods of treatment
Insurance support may play a role in the availability type and duration of treatment.
2. PSYCHOLOGICAL TREATMENT
a. Group therapy: Substance abusers are forced to confront their usage and recognize the serious
consequences that their use has on their body
system family and friends,
b. Behavioral therapy includes avoidance of the abused substance. Stress management and
behavioral modification using positive and negative reinforcement are commonly employed
techniques.
c. Counseling: The goal of counseling or individual therapy is to alleviate or reduce a client's
aversive life situation and to assist the client in putting the pieces of his/her life back together.
Regression or relapse is a frequent problem because often the underlying problem is not resolved.
3. SOCIAL TREATMENT
a. Support group: The goal of this type of social treatment is
to decrease co-dependent behavior and reinforce
appropriate behavior for the client and family- Clients attend support groups such as alcoholic
Anonymous (AA) or Narcotics Anonymous (NA) and family members may participate in the A1-
Anon group. These are other support groups available in many communities. Members of these
groups are asked to share their experiences as I give support without advice/ judgment to
other members during times of crisis or relapse.
4. PSYCHOPHARMACOLOGIC TREATMENT:
May approaches to substance abuse treatment do not recommend the use of any drugs, even if
prescribed. There are times, however, when they are prescribed.
a. Benzodiazepine agents to manage withdrawal symptoms.
b. Multivitamins, folic acid thiamine and narcotic antagonist agents.
c. Narcan for acute narcotic depression.
d. Disulfiram is used to discourage impulsive alcohol use. While taking antabuse client should not
ingest substance containing alcohol including cough syrup, fruitcake, or cooking wine or they will
feel very ill.
 e. If the symptoms of narcotic withdrawal are severe methadone hydrochloride (Dolophine) is used
to achieve narcotic abstinence. Treatment is usually 10-40 mg. in a single daily dose- Restricted
use of methadone during pregnancy and lactation is key consideration.
f. Anxiolytic agents such as Chlordiazepoxide (Librium) are the drugs of choice for alcohol
withdrawal.
g. Anticonvulsant drugs, particularly Phenytoin (Dilantin) or Phenobarbital (Luminal) are given for
alcohol and sedative-hypnotic drug withdrawal seizures.
5. Therapeutic Nursing Interventions
a. Conduct a comprehensive health history with physical assessment.
b. Monitor vital signs during the withdrawal period. For example in the client with alcohol
withdrawal monitor blood pressure every two hours for the first 12 hours, then every four
hours for the next 24 hours, followed by every six hours unless it is unstable. Early signs of
withdrawal are anxiety, anorexia, tremors and insomnia and may begin up to eight hours after
last intake of alcohol.
c. Protect the clients from injury
d. Assess for seizure and hallucination approach client calmly, using soft voice keep light dim,
allow a family member or friend stay with the client. Reduce environmental stimulation and
noise,
e. Assist the client with new learning problem solving methods.
f. Educate the client about stress reduction techniques and alternative coping mechanisms.

ALCOHOLISM
ALCOHOLISM – chronic disorder characterized by excessive alcohol intake and interferes in the
individual’s health, economic and interpersonal relationships.
- first episode of intoxication is between 12 and 17 years of age

LEVELS OF INTOXICATION
– can be determined by blood alcohol level
A. 0.1% – 0.2% - Mild Intoxication (SLUM)
S – Slurred speech and talkativeness
L – Loss of inhibition
U – Unsteady gait
M - Motor incoordination
B. 0.2% - 0.3% - Moderate (BAIT)
B – Blackouts
A – Ataxia
I – Impaired memory (confabulation)
T – Tremors
C. 0.3% and above – Severe (CAReS)
C – Coma
A – altered level of consciousness
Re – Respiratory depression
S – Stupor

PHASES OF PROGRESSION OF ALCOHOLISM

1. PRE-ALCOHOLIC PHASE
– starts with social drinking until tolerance begins to develop
2. PRODROMAL PHASE
B - blackout occurs
A - alcohol becomes a need
D - denial begins to develop
3. CRUCIAL PHASE
- cardinal signs of alcoholism develops
- loss of control over drinking
4. CHRONIC PHASE
- the person becomes intoxicated all day to prevent symptoms of withdrawal

EFFECTS OF ALCOHOL USE:

A. IMMEDIATE EFFECTS
ACUTE INTOXICATION (HILUS)
H - high dose may cause stupor or coma
I - impaired attention and memory
L - lack of motor coordination
U - unsteady gait
S - slurred speech
B. CHRONIC EFFECTS
1. Gastrointestinal effects
gastritis pancreatitis cirrhosis
ascites esophagitis hepatitis
2. CNS effects
a. WERNICKE’S SYNDROME
- acute confusional state char by:
P - peripheral neuropathy
A - ataxia
D - delirium due to thiamine deficiency
b. KORSAKOFF’ SYNDROME
- chronic cognitive impairment (dementia) characterized
by cerebral atrophy and memory loss related to Vit. B
deficiencies
3. Cardiovascular problems
Ex: anemia, alcoholic cardiac myopathy, thrombocytopenia
4. Reproductive problems
- Fetal Alcohol Syndrome in infants of alcoholic mother
C – cardiac and genital abnormalities
L – low birth weight
A – abnormal facial features
M – microcephaly/ mental retardation
P – problems in vision, and hearing

WITHDRAWAL SYMPTOMS OF ALCOHOLISM

- Withdrawal may take 1 -2 weeks
- Safe withdrawal includes:
a. Benzodiazepine to suppress the withdrawal symptoms
V - Valium (Diazepam)
A - Ativan (Lorazepam)
L - Librium (Chlordiazepoxide)
A. 3 – 24 hrs after the last drink – called “The SHAKES” or “Mild Tremors”
S – sweating
A – anxiety /agitation
I – increased pulse and blood pressure
N – nausea / vomiting
T - tremors
B. 36 – 72 hrs after the last drink – results to “DELIRIUM TREMENS”
C - confusion
I – increase body temperature
S – seizures
H – hallucination (48 hours)
A – agitation is extreme
D – diaphoresis
BEHAVIORAL PROBLEMS COMMON BEHAVIORAL PROBLEMS
SEEN IN ALCOHOLICS
D – destructive and rebellious behavior
D – dominant and critical behavior
D – difficulty with intimate relationships and tendency toward narcissism
D – decreased self-esteem

DEFENSE MECHANISM COMMON DEFENSE MECHANISM

USED BY ALCOHOLIC
1. Denial
Ex: “ I don’t have a problem, I can quit anytime I want”
2. Rationalization
Ex: “If you have the problems I have, you’d drink too
3. Projection
Ex: “ Tom is the one who can’t hold his liquor”
4. Minimization
Ex: “I only have a couple of beers”
TREATMENT FOR ALCOHOLISM
A. PHARMACOLOGY
1. Folic acid (Folate) 1 – 2 mg/day – treat nutritional deficiency
2. Thiamine (Vit. B1) 100 mg/day
– prevent or treat Korsakoff-Wernicke’s Syndrome
 3. Cyanocobalamin (Vit. B12) 25 – 50 mg/day
– prevent or treat nutritional deficiencies
4. Benzodiazepine – 50-100 mg repeat in 2-4 hrs if necessary but should not exceed 300 mg/day
– suppress the symptoms of abstinence
V - Valium (Diazepam)
A - Ativan (Lorazepam)
L - Librium (Chlordiazepoxide)
5. Naltrexone (Revia, Trexan)
- use to reduce alcohol craving > 50 mg / day for 12 weeks
- use for treatment of opioid abuse (blocks the effects of
opiates) >350 mg/week given in 3 divided doses for
opiate-blocking effect
6. Dizulfiram (Antabuse)
- 250-500mg/day for 1-2 weeks then 125-250mg/day as maintenance
- help client to maintain abstinence from alcohol
- adverse reactions:
a. Mild: - flushing - throbbing headache
- N/V - sweating
b. Severe: - hypotension - confusion
- coma - death

WHAT TO AVOID when in ANTABUSE therapy? (FASt MOVE)

F – food sauces made of wine
A – after shave lotion
St – skin products
M – mouth wash
O – over the counter drugs
V – vinegar
E – extract fruit flavored
B. ALCOHOLIC ANONYMOUS
EVALUATION
1. Formulate a nursing care plan for Sylvia Garcia. See Case 1.
2. Describe management for alcohol intoxication

TOPIC: COGNITIVE DISORDERS

Cognition is the brains ability to process, retain and use information. Cognitive abilities include
reasoning, judgment, perception, attention, comprehension and memory. These cognitive abilities are
essential for many important tasks, including making decisions, solving problems, interpreting the
environment and learning new information. This IG focuses on the different classifications of cognitive
disorders, causes, and managements.
At the end of the session the student will be able to:
1. Describes the characteristics of and risk factors for cognitive disorders.
2. Apply the nursing process to the care of client with cognitive disorders.
3. Distinguish between delirium and dementia in terms of symptoms, course, treatment and prognosis
4. Identify methods for meeting the needs of people who provide care to clients with dementia
5. Provide education to clients, families, caregivers, and community members to increase knowledge
and understanding of cognitive disorders
6. Evaluate your own feelings, beliefs and attitude regarding clients with cognitive disorders
1.Define Alzheimer’s disease and differentiate it from other cognitive disorders
2.Enumerate the theories of etiology of cognitive disorders
3.Discuss assessment of client with Alzheimer’s disease
4.Identify appropriate diagnoses for the patient with Alzheimer’s disease
5.Write an expected outcome and more than two interventions for each nursing diagnosis CASE 1:
Maria Mercedes, a 79 year old widow with Alzheimer’s disease, was admitted to a nursing home. The
disease has progressed during the past 4 years to the point that she can no longer live alone in her
own house. Maria Mercedes has poor judgment and no short term memory. She had stopped paying
bills, preparing meals, and cleaning her home. She had become increasingly suspicious of her visiting
nurse and home health aide, finally refusing to allow them in the house.
After her arrival in the facility, Maria Mercedes has been sleeping poorly and frequently
wanders from her room in the middle of the night. She seems agitated and afraid in the dining room at
meal times, is eating very little, and has lost weight. If left alone, Maria Mercedes would wear the same
clothing day and night and would not attend to her personal hygiene. Formulate a nursing care plan for
Maria Mercedes.
COGNITIVE DISORDER is a disruption or impairment in the higher level functions of the brain.
Cognitive disorders can have devastating effects on the ability to functions in daily life. They can cause
people to forget the names of immediate family members, to be unable to perform daily household
tasks and to neglect personal hygiene.

TYPES OF COGNITIVE DISORDERS

A. DELIRIUM
- is characterized by a disturbance of consciousness and a change in cognition that develops rapidly
over a short period
- is usually begins abruptly following head trauma or a seizure; however, the onset may be slower if
the etiology is metabolic. Duration is usually brief and subsides upon recovery condition.

RISK FACTORS
1. MEDICAL CONDITION
- Delirium may be due to a general medical condition such as systematic infection, metabolic disorder,
fluid and electrolyte imbalance, hepatic or renal disease, etc.
2. SUBSTANCE INDUCED
- Symptoms may be attributed to side effects of medication or drug abuse
3. SUBSTANCE INTOXICATION
- Symptoms may occur following high doses of cannabis, cocaine, hallucinogens, alcohol, anxiolytics.
or narcotics.
4. SUBSTANCE WITHDRAWAL may occur after the reduction or termination of a substance.
5) Delirium is a common post-anesthesia event

DIAGNOSTIC CRITERIA
1. Speech that is rambling, irrelevant, pressured, and Incoherent.
2. Impaired reasoning and goal-directed behavior.
3. Disorientation of time and place.
4. Extreme distractibility
5. Psychomotor activity that fluctuates between agitation and vegetative state,
6. Interruption of sleep-wake cycle
7. Emotional instability

NURSING DIAGNOSIS & INTERVENTIONS

A. Risk for injury
- Promote client’s safety
1. Teach client to request assistance for activities (getting out of bed, going to the bathroom)
2. Provide close supervision to ensure safety during performance of ADL
3. Respond promptly to client’s call for assistance

B. Acute confusion
C. Disturbed sensory perception
D. Disturbed thought processes
- Manage client’s confusion, disturbed thought process and misconceptions
1. Approach client calmly and speak in a clear low voice and use simple words
2. Allow adequate time for client to comprehend and respond
3. Allow client to make decision when able
4. Provide orienting cues when talking to client such as calling client by name, placing calendar and
clock in the client’s room, introducing self when talking
5. Use supportive touch if appropriate
6. Reduce environmental stimulation such as noises, tv, radio, visitors, etc. to reduce client’s confusion
7. Provide well lighted environment to minimize environmental misperceptions (illusions)

E. Disturbed sleep pattern

F. Risk for deficient fluid volume
G. Risk for imbalanced nutrition: less than body requirement
- Promote sleep, proper nutrition, hydration and elimination, and activities
1. Monitor sleep pattern.
- Discourage daytime napping to help sleep at night
2. Monitor elimination pattern.
- Provide periodic assistance to bathroom if client does not make requests
3. Monitor fluid and food intake.
- Provide prompts assistance to eat and drink adequate amounts of food and fluids
4. Encourage some exercise during day like sitting, walking in hall, or other activities client can
manage

EVALUATION
- Client will return to previous levels of functioning
 - Client and caregivers or family must understand health care practices to avoid recurrence
Ex: Monitor chronic health condition, use medications carefully, or abstain from alcohol or
other drugs.

TREATMENT
The primary treatment for delirium is to identify and to treat any casual or contributing medical
conditions
1. Antipsychotic drug
- Haloperidol (Haldol) 0.5-1 mg to decrease agitation
- Sedatives and benzodiazepines should be avoided because they may worsen delirium

B: DEMENTIA
- Dementia is a syndrome of acquired, persistent intellectual impairment with compromised
function in multiple spheres of mental activity, such as memory, language, emotion,
personality, and cognition. Dementia may also occur with many other medical illnesses, such
as pulmonary, hepatic, cardiopulmonary, and nutritional as well as substance induced.

TYPES OF DEMENTIA
1. Dementia of the Alzheimer’s type - insidious are progressive deterioration in function due to
neurotransmitter deficiency
2. Vascular dementia - due to significant cerebrovascular disease, caused by multiple infracts in the
cortex.
3. Dementia due to HIV - related to brain infections with a range of symptoms from acute delirium to
profound dementia.
4. Dementia due to head trauma - Intellectual and memory difficulties due to post-trauma.
5. Dementia due to Parkinson's disease caused by a loss of nerve cells and decreased in dopamine
activity
6. Dementia due to Huntington’s disease - damage from disease occurs in the areas of the basal
ganglia and cerebral cortex. A profound state of dementia and ataxia occurs within 5-10 years onset.
7. Dementia due to Pick’s disease - atrophy in the frontal and temporal lobes of the brain.
8. Dementia due to general medical disease:
a. Endocrine disorders
b. Pulmonary disease
c. Hepatic or renal failure
d. Cardiopulmonary insufficiency
e. Fluid and electrolyte imbalances
9. Substance-induced dementia - dementia related to the persistent use of :
a. Alcohol
b. Inhalants
c. Sedatives, hypnotics and anxiolytics
d. Medication such as anticonvulsants. Toxin such as lead, mercury, carbon monoxide, insecticides.,
and industrial solvents.

DIAGNOSTIC CRITERIA
1. Impairment of abstract thinking judgment and impulsive control
2. Disregard for rules of social conduct
3. Neglect or personal appearance and hygiene
4. Altered language pattern
5. Personality change

STAGES OF DEMENTIA
A. STAGE I (Mild) (FOLD)
– last 2 – 4 years
F – forgetfulness
O – occupational & social setting is less enjoyable
L – Losses objects frequently
D – difficulty finding words
B. STAGE II (Moderate) (COPRA) - may last several years
C – confusion is apparent
O – oriented to person, time & place
P – progressive memory loss
R – requires assistance to perform tasks because the client
losses ability to live independently
A – ability to recall information is loss (address, numbers)
C. STAGE III (Severe) - nursing home care or hospital facility
 P – Personality changes
- anger, irritability, loss of inhibitions, hypersexualities,
vulgarities
O– obvious loss of memory as manifested by aphasia,
anomia, agnosia, etc
W – wanders at night and difficulty to go back home (get lost)
due to memory loss and confusion
E – Even name of spouse and children can’t recall
R – requires assistance for ADL

NURSING DIAGNOSIS & INTERVENTIONS:

A. Risk for injury
- Promote client’s safety
1. Protect client against injury, meet physiologic needs and manage risk posed by the environment
because they can’t exercise normal caution in daily life.
2. Avoid environmental triggers such as strangers, or changes in daily routine to prevent anxiety and
suspicion which may lead to agitation or erratic behavior that compromise safety
3. Offer self and support in performance of ADL and preserve client’s dignity

B. Disturbed sleep pattern

C. Risk for deficient fluid volume
D. Risk for imbalance nutrition: less than body requirements
- Promote adequate sleep, proper nutrition, hydration, elimination and hygiene , and activity
1. Daily physical activity helps client to sleep at night
2. Monitor food and fluid intake, bowel elimination patterns
3. Prepare desirable foods and foods client can self-feed; include fiber foods; sit with client while eating
4. Remind client to urinate; provide pads or diapers as needed; checking and changing them
frequently to avoid infection
5. Encourage mild physical activities such as walking

E. Ineffective role performance

F. Impaired social interaction
G. Impaired verbal communication
H. Impaired memory
1. Provide structured environment and routine
- Provide familiar surrounding and routine to help eliminate confusion
2. Provide emotional support
- show acceptance, be kind and respectful
- convey reassurance by approaching client in a calm and supportive manner

- use supportive touch when appropriate and frustration from memory loss
3. Promote interaction and involvement
- Plan activities according to client’s interest and abilities
- Reminisce with client about the past
- If client is nonverbal, remain alert to nonverbal cues
- Employ techniques of distraction, time away, going along and reframing to calm clients who are
agitated, suspicious or
confused
DISTRACTION – rechannelling client’s attention and energy to a more neutral topic.
TIME AWAY – involves leaving the client for a short period and then returning to them to re-engage in
interaction
GOING ALONG – means providing emotional reassurance to clients without correcting their
misperception or delusion
Ex: “There’s no need to worry; the children are just fine”
REFRAMING - offering explanations for events or situations
Ex: “The lady has many problems, and she yells sometimes because she’s frustrated

TREATMENT
1. Identify underlying cause and treat
Ex: Vascular dementia – change diet, exercise, control of
hypertension or diabetes
2. PSYCHOPHARMACOLOGY
a. Antidepressants – for depressive Sx
b. Antipsychotics – to manage Sx of hallucinations, delusion & paranoia
HALOPERIDOL (Haldol) OLANZAPINE (Zyprexia) RISPERIDONE (Risperdal) QUETIAPINE
(Seroquel)
c. Mood stabilizer to stabilize affective lability and to diminish aggressive outburst
LITHIUM CARBONATE
VALPROIC ACID (Depakote)
CARBAMAZEPINE (Tegretol)
d. CHOLINESTIRASE INHIBITOR – to slow the progression of dementia
ARICEPT (Donepezil)
- 5 -10 mg orally/day
- monitor for nausea, diarrhea and insomnia
- Test stole periodically for GI bleeding

COGNEX (Tacrine)
- 40-160 mg orally/day divided into 4 doses
- monitor liver enymes for hepatotoxic effects
- monitor for flu-like symptoms
EXELON (Rivastigmine)
- 3 – 12 mg orally/day divided into 2 doses
- monitor for nausea, vomiting, abdominal pain and loss of
appetite
REMINYL (Galantamine)
- 16-32 mg orally/day divided into 2 doses
- monitor for nausea, vomiting, loss of appetite, dizziness
and syncope

C. AMNESTIC DISORDER
- Amnestic disorder is a cognitive disorder characterized by disturbance in memory due to
general medical conditions’ physiological and substance effects
- Signs and Symptoms
C - Confusions
A – Attention deficit
M – Memory deficit
Ex: Korsakoff Syndrome – alcohol induced amnestic disorder that results from a chronic
thiamine or Vit. B deficiency

ALZHEIMER’S DISEASE
Alzheimer's disease is the most prevalent form of dementia characterized by memory loss,
deficit in thought processes, and behavioral changes. The onset is insidious and course of disease
progressive, Physiological studies indicate pathological degeneration of cholinergic neurons and
biochemical deficiency in the neurotransmitter system,

RISK FACTORS
1. Advanced age: one in twenty-six at age 65, two out of five after age 85
2. Female
3. Head trauma
4. Family history of Alzheimer's and/or Down's Syndrome

DIAGNOSTIC CRITERIA
1. Stage 1: lasts 1-3 years
a. Short-term memory loss
b. Decreased attention span
c. Subtle personality changes
d. Mild cognitive deficits
e. Difficulty with depth perception
2. Stage II: lasts 2-10 years
a. Obvious memory loss
b. Confusion
c. Wandering behavior
d. "Sundowning": behavior changes as sun goes down, more confused.
e. Irritability and agitation
f. Poor spatial orientation
g. Impaired motor skills
h. Impaired judgment
i. Covers up memory loss through confabulation
3. Stage III: lasts 5-15 years
a. Increasing loss of expressive language
b. Loss of ability to care for self in ADLs
 c. Becomes more withdrawn
d. Loss of reasoning ability
4) Stage IV: lasts 8-10+years
a. Absent cognitive abilities
b. Disoriented to time and place
c. Absent communication skills
d. Impaired or absent motor skills,
e. Bower and bladder, incontinence
f. Does not recognize family members or self in mirror

FACTS TO REMEMBER
- The client in the later stages of the disease will probably require long-term, protective care and
assistance with ADI-s and other activities.
Families or caregivers also require support during this time.
CASE: The physical environment is particularly important to the patient with dementia. Every effort
should be made to modify the physical environment to compensate for the cognitive and functional
impairment associated with AD and related disorders, including safety measures and the avoidance of
misleading stimuli. Visualize your last experience in a health setting. Identify environmental factors
that could be misleading or stress producing to a person with dementia, and identify ways to modify
this environment to alleviate some of the stressors or stimuli.

TOPIC: EMOTIONAL DISORDERS IN CHILDREN AND ADOLESCENCE

This session focuses on Emotional Disorders in children and adolescents, causes,

approaches and nursing management for patient with the said problem
At the end of the session the student will be able to:
- The students will be able to identify the difference of emotional disorders in children from other
type of psychiatric problems
- Students will identify the presenting clinical manifestation and signs and symptoms of the said
disorder
Autism

- Disorder characterized by impairment in communication skills or the presence of a stereotype

behavior, interest and activities with associated impairment in social interaction
- The main problem is impaired interpersonal functioning
- Possible cause: biological- brain anoxia, intake of drugs by the mother during pregnancy.
- Common problems tantrums and head banging
- Communication all vowels
- Routines
- Priority nursing diagnosis THE RISK FOR INJURY

Mental Retardation

- Inadequate mental functioning

- Significantly sub average intellectual functioning resulting in, impairment in adaptive behavior
manifested before the age of 18.
- IQ: Less than 70
- This is not a mental illness
- Causes include maternal infection, premature

delivery, nutritional deficit, anoxia, lead poisoning to mention few

Level of Mental Learning

IQ Level
Retardation Capabilities
Mild/Moron 50/55-70 Educable
Moderate/Imbecil 35/40-50-55 Trainable
e
Severe/Idiot 20/25-35-40 Needs close
supervision
Profound Below 20-25 Needs custodial
care
Attention Deficit Hyperactivity

- It is disorder characterized by persistent pattern of attention, hyperactive and impulsive

behavior.
- Occurs below the age of 7
- More common in boys
- The main problem are the inattentiveness and hyperactivity
- Factors that may lead to are neurological impairment, prenatal trauma, early malnutrition,
frontal lobe hypo perfusion and mother’s use of drugs during pregnancy
- Priority diagnosis is the risk for injury
- Priority needs are nutrition and safety

EVALUATION
- Observe students learning and participation throughout lesson proper. Including the active
participation in the discussion to clarify/verify points that was not clear.

TOPIC: ABUSE AND VIOLENCE

Violence manifested in the abuse of women, children and elders is a national health problem that
causes significant impairment in survivors. Abuse of any type permanently changes the survivor’s
construction of reality and the meaning of his or her life. It wounds deeply, endangering core beliefs
about self, others, and the world. It can damage or destroy the survivor’s self esteem. Violent behavior
has been identified as a national health concern and a priority for intervention in the Philippines and
other countries. This unit discusses domestic abuse and rape. Because many survivors of abuse suffer
long term emotional trauma, it also includes disorders associated with abuse and violence.
At the end of the session the student will be able to:
The student will be able to:
1. Classify the different types of abuses and violence to be able to give quality nursing care.
2. Apply the nursing process to the care of clients who have survived abuse and violence
- Provide education to clients, families, and communities to promote prevention and early
intervention of abuse and violence
1. What are your thoughts and feelings about women who will not leave an abusive relationship?
2. What are some reasons that women remain in abusive relationships?
- 3. How do you handle your feelings toward abusive parents or relatives who abuse elders?
Exploitation Use of the victim for selfish purposes and/ or
financial profit
(Haber et al, 1992)
Family Violence Includes physical and emotional abuse of \
children, child neglect,
spouse battering, material rape, and elder
abuse (stuart and
sundeen, 1995)
Physical abuse Deliberate violent actions that inflict pain
and/or nonaccidental
injury, which may cause permanent or
temporary disfigurement or
death (Haber et al, 1992)
Physical Neglect Deliberate deprivation or nonprovision of
necessary and societal-
available resources (Haber et al, 1992)
Psychological Abuse Deliberate and willful destruction or
significant impairment of a
person’s sense of competence through
behaviors that have a
negative impact on and social relationships
(Haber et al/ 1992)
Psychological Neglect Psychosocial unavailability and caretaking
that lacks warmth and
sensitive, personalized attention (Haber et al,
(1992)
Sexual Abuse Use of victim for sexual gratification when
the victim is either unable or unwilling to
Consent.

II
1. Theories related to abuse, neglect, exploitation
A. Instinct theory – innate aggressive tendencies
B. Genetic theory – Y chromosomes connection to aggressive impulses
C. Neurophysiologic theory – increased levels of neurotransmitters (norepinephrine, dopamine, and
serotonin) connected with aggression.
D. Brain lesion theory –
1. Tumors
2. Seizures
E. Psychosis
1. Delusions
2. Hallucinations
F. Intrapsychic theory
1. Victims identify with victimizers in order to survive

2. Victims internalize victimizers and become themselves aggressive

G. Intrapersonal theory
1. Impaired ability to relate to others
2. Impaired superego development
3. Self-entered
4. Impulsive
5. Devalue others
6. Susceptible
H. Family system theory
1. Learned ways of coping with stress and frustration
2. Passive response to abuse
3. Level of differentiation
I. Social learning theory
1. Learned ways of coping with stress and frustration.
2. Passive response to abuse
J. Media influence – glorification of violence in newspapers, advertisements, toys, games, and
Television
K. Alcohol abuse – decreases control over impulsive behavior
L. Cocaine abuse
1. Paranoid thinking
2. Compulsive need for drug
M. Hallucinogen abuse
1. Disorientation
2. Misinterpretation of reality

III. Violence and Aggression

A. Violence
1. Physical force
2. Unjust strength.
Example : husband who is physically stronger beats up his much
Smaller wife.
3. Power
4. Consequence for perpetrators and victims
5. Arouses fear in others
6. Threat to personal safety
7. Trauma remains vivid in dreams and thoughts
8. May be premeditated or spontaneous
9. Intense hatred and rage

B. Aggression
1. Natural drive – Freud believed aggression to be an id impulse
2. Motivating force – impulses and feelings are converted into action
3. If not controlled or sublimated
a. Harmful
b. Destructive
4. Can be constructive or destructive
5. Expression is learned reaction
6. Violence – destructive aggressive drive
A. Feeling of annoyance or displeasure
B. Natural feeling
C. The development of anger
D. May be displaced onto object or person
E. Used to avoid anxiety
F. Anger gives feelings of power in situation in which persons feels out of control
G. result of frustration
H. Characteristic findings of anger
1. Muscle rigidity
2. Flushed face
3. Pacing
4. Pounding
5. Stomping
6. Loud voice
7. Speeded up body movements
8. Glaring
I Assessments findings for violence potential in response to anger.
1. History of violence
2. Poor impulse control
3. History of self-harm
4. Temper tantrums
5. Low tolerance of frustration
6. Increased pacing
7. Increased agitation
8. Verbal threats of violence
9. Defiance
10. Argumentation
J. Nursing interventions for the angry client
1. Set limits on behavior
2. Provide safe outlets for expressing anger
3. Provide safety for client and others
4. Acknowledge anger
5. Model expression of anger
6. Listen actively
7. Help deal with consequences of anger
8. Teach assertiveness
9. Provide positive feedback when client is appropriately expressing
anger
10. Help resolve conflicts and solve problems
11. Apply physical restraints if necessary, Restraint guidelines
a. Physical and verbal threats from client
b. Hypersensitivity of client to environmental stimuli
c. Physical assault to self, others, or environment
d. Help client gain physical control
e. Physician orders required
f. RN supervision required
g. Adequate number of staff required
12. Seclusion
a. Client behaviors that require seclusion (highest priority to lowest priority)
(1). Needs for protection of self or others
(2). Destructiveness to physical environment
(3). Increasing agitation
(4). Hyperactive
b. Care provider actions (in order of sequence)
(1). Use short, simple, direct statements
(2). May give medication to calm client
(3). Remove dangerous articles
(4). Have room prepared in advance
(5). Use seclusion as a last resort
IV
FAMILY VIOLENCE
A. Demographics
1. All socioeconomic levels
2. All educational, racial, occupation, gender, and religious groups
B. Victimizer- Characteristics
1. Impaired self-esteem
2. Strong, unrealistic dependency needs
3. Immaturity
4. Self-absorption
5. Narcissistic
6. Suspicious
7. History of sexual abuse during childhood
8. Perceive victims as property
9. Believe they are entitled to abuse victim
C. Victims – Characteristics
1. Feels like a captive in the system
2. Dependent
3. Helpless
4. Powerless
5. Blame themselves
6. Low self-esteem
7. Depressed
D. Family system (Clinical Example 12-1). Assess for an indication of family dysfunction.
1. Low level of differentiation (see section on family systems theory in chapter 6, pp, 91-93).
2. Unable to meet own or other’s needs
3. Characteristic
a. Impermeable boundaries to outsiders
b. No one is aware what is happening in the family
c. When outsiders try to enter, family feels assaulted.
Example: abusive father convinces daughter to keep the violence a secret.
d. Socially isolated family members
e. Pain and desperation among family members
f. Family members expect other family members to meet their needs, but no one capable of doing this
g. Parents usually married young
h. Lack autonomy among family members
i. Lack of trust among family members
j. Absence of (in the family)
(1) Humor
(2) Flexibility
(3) Caring
(4) Empathy
(5) Excitement
(6) Productivity
(7) Clear communication
(8) Intimacy
4. Family violence
a. May be an attempt for closeness and companionship
b. May provide release of frustration
c. Allows for coping with a problematic world
5. Conflict
a. Expressed through violence, aggression
b. Power struggles
c. Confusion of caring with violence
d. Sexuality aggression become fused-rape
e. Cycle of response to decrease stress
6. Focus on present
a. Minimal awareness of fast or future
b. Long-range goal-directed behaviors not evident
7. Financial Problems
8. Early marriages
9. Lack of parenting skills
10. Lack of underlying normal growth and development
11. Communication characteristics within family
a. Mixed messages
b. Lack of direct communication
c. Decrease communication outside of family secrets
12. Values and beliefs
a. Violence is normal
b. Victim is responsible for abuse
c. Problems are solved through violence
13. Abuse of power
a. Abuser tells others they are worthless
b. Threats of abandonment’s
c. Stereo typing of behaviors
(1) Women’s work is in home
(2) Children are not to be heard
(3) Older sibling may punish younger ones
(4) Elders have little to contribute
14. The cycle of violence (figure 12-2) (in order of occurrence)
a. Tension-building phase
(1) Minor assaults
(2) Verbal Assault
(3) Threats
(4) Victim attempts to comply
(5) Alienation from support systems
b. Explosion
(1) Major trauma
(2) Destructiveness
(3). Lack of control
(4). Victims protect themselves
(5). Victims underplay the severity
c. Honeymoon period
(1). Tenderness
(2). Love
(3). Truce
e. Types of family violence
1. Child abuse or neglect
a. Physical or mental injury
b. Sexual abuse
c. Negligence
d. Maltreatment
e. Under 18 years of age
f. Usually is the person responsible for child’s welfare
g. Mandatory reporting is required by nurses for confirmed or suspected cases
h. Vulnerable population because of victim’s dependence on care provider
i. Cyclical, repetitive acts of abuse are typical
j. Assessment findings
(1). Client report
a) Night terrors
b) Chronic fatigue
c) Somniloguy (talking during sleep)
d) Enuresis (incontinence of urine)
e) Insomnia
f) Increased sleeping
g) Weight loss or gain
(2). Observation by care providers
a) External signs of trauma
b) Scarring
c) Head injuries
d) Immunization and dental care lacking
e) Fear in the presence of parent’s or care provider
(3). Exams/procedures to collect data
a) Ear exams
b) Ophthalmoscopic examinations
c) Gynecological exams
d) Tests for sexually transmitted diseases
e) X-rays
f) Tests for urinary tract infections
k. Nursing diagnoses
(1). Ineffective family coping
(2). Anxiety related to parent’s abusive behaviors
(3). Fear
(4). Self-esteem disturbance
(5). Sleep pattern disturbances
l. Interventions
(1). Protect child from further harm
(2). Move slowly around child
(3). Use light; avoid loud noises
(4). Keep child near center of activity
(5). Keep at eye level of child for communication
(6). Have child participate in decisions about care
(7). Educate family on alternate ways to express feelings of hostility and frustration
 (8). Refer parents to parenting classes
(9). Do not rescue child from parents
(10). Reassure child that he/she is loved and not responsible for parents behaviors
(11). Encourage family to connect with community support systems such as parents anonymous
(12). Give parents numbers of crisis hotlines
(13). Reassure child that he/she is not a bad person
(14). Collaborate with physician and authorities to report suspected or confirmed child abuse cases
2. Elder abuse
a. Family history of dysfunction
(1). Alcohol abuse
(2). Unemployment
(3). Change in living arrangement, such as when a son and family move
into mothers home
(4). Burden of caring for ill older parent
(5). Isolation
(6). Rigid, compulsive, inflexible
(7). History of abusive relationship
b. Types of abuse
(1). Physical – infliction of pain or injury
(2). Sexual
(3). Psychological – infliction of mental anguish by demeaning, name
calling, insulting
(4). Financial/materials – Exploitation using assets, funds for personal
gain.
c. Types of neglect
(1). Passive - Unintentional failure to caretaking of elder person’s
physical, emotional or financial needs.
(2). Active – Abandonment, denial of food, shelter, clothing, medical
assistance, personal needs, isolation; an intentional neglect.
d. Assessment findings
(1). Physical abuse
a) Fractures
b) Welts
c) Lacerations
d) Punctures
e) Burns
f) Bruises
(i). Shape similar to an object (belt marks, fingers)
(ii). Bilateral on upper arms
(iii). Clustered on trunk
(2). Sexual Abuse
a) Torn ,stained, or bloody underclothing
b) Difficulty in walking or sitting
c) Pain, itching, bruising, or bleeding in genital area
d) Unexplained venereal disease or genital infections
(3). Psychological abuse
a) Confusion
b) Excessive fears
c) Sleep disorders
d) Change in appetite
e) Unusual weight gain or loss
f) Loss of interest in self, activities, or environment
g) Ambivalence
h) Withdrawal
i) Agitation
(4). Financial Abuse
a) Inaccurate, confused, or no knowledge of finances
b) Unexplained inability to pay bills
c) Disparity between income/assets and lifestyle
d) Fear when discussing finances
(5). Neglect
a) Dehydration
b) Malnutrition
c) Hypo/hyperthermia
d) Excessive dirt or odor
e) Inadequate or inappropriate clothing
 f) Absence of eyeglasses, hearing aids, dentures
g) Sign of excess drugging
h) Decubitus ulcers
e. Common themes and issues in elder abuse
(1). Suspected victims may attempt to dismiss physical injuries as
accidental.
(2). Abuser may prevent victims from receiving proper medical care to
avoid discovery.
(3). Victims may be care providers for the abusers
(4). Abusers and victims may have unrealistic expectations of each
other
(5). Abusers may resist allowing outsiders to provide service in home
(6). Victims and abusers often live in same household
(7). Abusers may be dependent on victim for living expenses
(8). Victims are often socially isolated
(9). Mistreatment often increases in severity and frequency over time
(10). Several types of mistreatment may occur simultaneously
(11). Denial of mistreatment by victims and abusers is common
f. Interventions with the victim
(1). Document observations and indicators of mistreatment
(2). Provide information related to emergency community resources
(3). Explore alternative living arrangement-begin with least restrictive
and disruptive change
a) Arrange for trusted significant other to stay with patient
b) Utilize police to remove abuser and obtained order of protection
c) Arrange temporary or permanent alternative residence
d) Arrange nursing home placement if appropriate
(4). Assist with financial management protection
(a). Direct bank deposit
(b). Joint bank account
©. Power of attorney
(5). Encourage mistreatment counseling
(a). Issues to explore
(i). Self-blame
(ii). Isolation
(iii). Low self-esteem
(b). Support groups
©. Couple of family counseling

(6). Assist with legal procedures

a) Order of protection
b) Police reports
c) Court-ordered counseling
(7). Refer to Protective services for adults (PSA)
g. Nursing interventions with the abuser
(1). Arrange counseling and treatment
a) Individual or group
b) Couple or family counseling
c) Support groups
d) Drug and alcohol treatment programs
e) Vocational counseling and job placement
f) Coping skills educational groups
(2). Arrange the respite care
a) Adult day care or home respite
b) Help in home
(i). House keeper
(ii). Meals on wheels
(3). Provide education
a) Short term and long term effects of mistreatment
b) Alternatives to violence
(4). Facilitate a change in living arrangements
a) Other living arrangements for abuser
b). limit or cease contact with elder
3. Spouse abuse
a. Often age 18 or older
b. Involves a relationship with spouse or a partner
 c. Commonly an international act of physical violence
d. No uniform laws mandating reporting
e. Often happens first during a pregnancy
f. Abused spouse/partner reluctant to reveal cause of injuries
g. Abused spouse/partner often blamed for not leaving
h. Assessment findings of abused spouse/partner
(1). Eating disorder
(2). Insomnia
(3). Fatigue
(4). Headaches
(5). Hypertension
(6). Palpitation
(7). Hyperventilation
(8). Depression
(9). Suicidal thought
(10). Flat or inappropriate affect
(11). Guilt
(12). Fear
(13). Social isolation
i. Common injuries from abuse
(1). Facial injuries
(2). Head injuries
(3). Fractures of upper extremities
(4). Joint tenderness
(5). Strangulation marks on neck
(6). Cigarette burns
(7). Spontaneous abortion
(8). Human bite marks
(9). Trauma to genitalia
j. Nursing diagnoses for abused individual
(1). Anxiety
(2). Pain
(3). Ineffective coping
(4). Disturbance in self concept
(5). Social isolation
(6). Sleep pattern disturbance
(7). Alteration in nutritional status
k. Nursing interventions for abused spouse/partner
(1). Offer protection
(2). Relieved of child care responsibilities
(3). Facilitate the expression of feelings
(a). Ambivalence
(b). Guilt
(c). Anger
(4). Help victim make own decision regarding whether to stay or leave
(5). Support decisions of client
(6). Refer client to support group
(7). Increase client’s self-esteem
(8). Refer to vocational rehabilitation

V. Rape
a. A legal term
b. Definition – engaging another person in sexual intercourse through the use of force and without
the consent of the sexual partner
c. Statutory rape – The act of sexual intercourse with a person under the age of legal consent. NOTE:
sexual intercourse with a minor is rape, even with consent of the minor.
d. Acquaintance rapes – involves someone known to the victim
e. Victim not required by law to report it
f. Victim often receives no support from significant others
g. Victim often blamed by others
h. Nursing assessment
(1). Physical
a. Last menstrual period
b. Form of birth control used by client
c. Determine last act of coitus before rape
d. Penile penetration
 e. Orifices violated
f.. Duration of intercourse
g. Use of condom by perpetration
h. Has client bathed, showered, douched, urinated, defecated, vomited,
cleansed mouth?
i. Pelvic exam
j. Swabs taken of body cavities for semen
k. Sleep disturbances
l. Sobbing
m. Crying
n. Headaches
o. Oropharyngeal trauma due to oral penetration
p. Gastrointestinal disturbances
2. Emotional
a. Fear
b. Loss of control
c. Guilt for having survive
d. Shame
e. Embarrassment
f. Humiliation
g. Obssessive thoughts – What could have done differently
h. Anger
i. Revenge
j. Change in residence
k. Changes in relationships with men
l. Hesitation to tell others for fear of not being believed
I. Nursing diagnoses
1. Fear
2. Anxiety
3. Social Isolation
4. Body image disturbances
5. Alteration in self concept
6. Alteration in mood
7. Ineffective individual coping
8. Alteration in comport
9. Sleep pattern disturbances
J. Nursing interventions for the victim
1. Encourage not to shower, bathe, douche, or change clothing
2. Preserve all evidence
3. Treat physical injuries
4. Reassure of safety
5. Help victim refrain from self blame
6. Refer to crisis intervention, legal aid
7. refer to support groups

TOPIC: GRIEF AND LOSS

This session focuses on grief and losses, the causes, approaches and nursing
management for patient with the said problem.
At the end of the session the student will be able to:
1. Identify the type of losses for which people may grieve
2. Discuss various theories related to understanding the grief process
3. Describe the 5 dimensions of grieving
4. Discuss universal and culturally specific mourning rituals
5. Identify factors that increase a persons’ susceptibility to complications related to grieving
6. Apply the nursing process to facilitate grieving for clients and
Families
CASE 1: After the death of his mother, a 24 year old single man with schizophrenia moves into
an apartment. He continues to take his medication but feels sad about his mother’s death. He is
not adjusting well to living alone and tells his nurse that he no longer wants to go to work. In
tears, he admits that he is lonely and can no longer cope with the apartment. The nurse
generates the following nursing diagnosis: Ineffective coping related to inadequate support
system. Develop a plan of care for this young man.
 Grief
– a normal response to the experience of loss
A. - refers to the subjective emotions DEFINITION OF GRIEF AND LOSS
 B. Birth, loss and death are universal phenomena and individuality unique events of human
experience. A person experiences loss in the absence of an, person, body part or function, or
emotion that was formerly present.
Losses maybe actual or perceived
5 Categories of loss
1. Loss of external object
2. Loss of known environment
3. Loss of significant others
4. Loss of aspect of self
5. Loss of life
Grief
- is form of sorrow involving thoughts, feelings and behaviors

 MOURNING
- outward expression of grief
 rituals of mourning includes:
> Having a wake
> arranging funerals
> holding religious ceremonies
 GRIEVING/BEREAVEMENT
 Refers to the process by which a person experience the grief.
 All people grieve when they experience life’s changes and losses
 ANTICIPATORY GRIEVING
 When people grieve for an imminent loss or when there is a real possibility of loss or
death in the near future
 DISENFRANCHIZED GRIEF
- Grief over a loss that is not acknowledge openly, mourned publicly or supported socially
1. LOSS ITSELF IS NOT RECOGNIZED
- abortion - death of a pet
- job loss - separation/divorce
- children living home
2. THE GRIEVER IS NOT RECOGNIZED
- same sex relationship
- extramarital relationship
- illegitimate child
 COMPLICATED GRIEVING
- occurs when person grieve for a prolonged period or express feelings that seem out of proportion.
 PEOPLE WHO ARE VULNERABLE TO COMPLICATED GRIEVING
P - Previous psychiatric disorders
- Previous suicide threats or attempts
- Paranoid behavior
A - Absent of support system
- Ambivalent, dependent or insecure attachment to the deceased person
L - Low self-esteem
 RISK FACTORS LEADING TO VULNERABILITY TO COMPLICATED GRIEVING
 Death of a spouse or child
 Death of parent (particularly in early childhood or adolescence)
 Sudden, unexpected and untimely death
 Multiple deaths
 Death by suicide or murder
 TYPES OF LOSSES
 PHYSIOLOGIC LOSS
 Loss of body parts
Ex: Loss of sight/hearing
 SAFETY/ SECURITY LOSS
 Loss of safe environment (domestic or community violence)
 Loss of psychological safety (trust, breach of confidentiality, unfulfilled promises)
 TYPES OF LOSSES
 LOSS OF LOVE and a SENSE OF BELONGINGNESS
 Death of loved one
 Separation from loved one/Rejection
 Illness
 LOSS OF SELF-ESTEEM
  Any change in how the person is valued at work or in relationships.
 TYPES OF LOSSES
 LOSS RELATED TO SELF- ACTUALIZATION
 An internal/external crisis that blocks or inhibits strivings toward fulfillment may
threaten personal goals and individual potential
 Ex: loss of pregnancy, losing the hope of marriage or having a family of one’s own
 STAGES OF GRIEVING (KUBLER)
1. Denial
– shock and disbelief of loss
2. Anger
– may be expressed toward God, relatives, friends or health provider
3. Bargaining
– occurs when the person asks God for more time to delay the inevitable loss
 STAGES OF GRIEVING (KUBLER)
4. Depression
– results when the person becomes aware of the loss
5. Acceptance
– occurs when the person shows evidence of coming to terms with the event Ex: death of
loved one
 STAGES OF GRIEVING (RODEBAUGH, SCHWINDT, & VALENTINE
1. REELING
– person feels, shock, disbelief and denial
2. FEELING
– person experiences anguish, guilt, profound sadness, anger resulting to lack of
concentration, sleep disturbances, appetite changes, fatigue and general discomfort

 STAGES OF GRIEVING (RODEBAUGH, SCHWINDT, & VALENTINE

3. DEALING
– person begins to adapt to the loss by engaging in support groups, grief therapy, reading and
spiritual guidance
4. HEALING
– person integrates the loss as part of life,
however healing does not imply that the person has forgotten or accepted the loss
 RESPONSES OF THE GRIEVING CLIENT
 COGNITIVE RESPONSE
- Questioning and trying to make sense of the loss
- Attempting to keep the lost one present
- Disruption of assumptions and belief
 RESPONSES OF THE GRIEVING CLIENT
 BEHAVIORAL RESPONSE
- Seeking or avoiding places and activities shared with lost one
- Ambivalent feeling (Keeping valuables of lost one while wanting to discard them)
- Poor coping mechanism
 May abuse drugs or alcohol
 May commit suicide or homicide
 RESPONSES OF THE GRIEVING CLIENT
 EMOTIONAL RESPONSE
- Guilt over things not done or said in the lost relationship
- Anger, sadness, and anxiety are the predominant emotional experiences of loss
- Feeling of hatred and revenge can be expected when death has been due to extreme circumstances
such as suicide, murder or war
 RESPONSES OF THE GRIEVING CLIENT
 SPIRITUAL RESPONSE
 Finding explanations and meaning through religious and spiritual beliefs.
 PHYSIOLOGICAL RESPONSE
 Headache - insomnia
 Loss of appetite- indigestion
 Weight loss - Palpitation
 NURSING INTERVENTIONS FOR GRIEVING
 PERCEPTION OF LOSS
 Explore client’s perception and meaning of his/her loss to help alleviate the pain of
what some would call the initial emotional response
 Allow adaptive denial
 > this will help the client gradually adjust to the reality of loss
 SUPPORT SYTEM
 Identify support system and assist client to reach out for and accept support.
 Make self available
 NURSING INTERVENTIONS FOR GRIEVING
 COPING MECHANISM
 Encourage client to examine patterns of coping in the past and present situation of
loss, and helping him/her renew a sense of personal power
 PROMOTE SELF-ESTEEM
 Encourage client to review personal strength and personal power
 Encourage client to care for himself
 NURSING INTERVENTIONS FOR GRIEVING
 USE EFFECTIVE COMMUNICATION
 Offer support and empathy
(Respect for client’s personal belief)
 Use broad opening
 Encourage description of perception
 Share observation
 Provide information
 NURSING INTERVENTIONS FOR GRIEVING
 DEVELOP NURSE - PATIENT RELATIONSHIP
 Maintain trust and interpersonal skills
 Respect client’s unique grieving process
 Be honest, trustworthy, dependable and consistent

C. DEFINITION OF GRIEF AND LOSS

D. Birth, loss and death are universal phenomena and individuality unique events of human
experience. A person experiences loss in the absence of an, person, body part or function, or
emotion that was formerly present.
Losses maybe actual or perceived
5 Categories of loss
6. Loss of external object
7. Loss of known environment
8. Loss of significant others
9. Loss of aspect of self
10. Loss of life
Grief
- is form of sorrow involving thoughts, feelings and behaviors

Concept and theory in grieving process

- of mental health
- Prevention of mental illness
1. Fairbairn’s Object Relation Theory
2. Groves
3. Engle and Kubler Ross

Engle (1964) Process Kubler-Ross (1969)

Oriented Behavior oriented
1. Shock and 1. Denial
disbelief 2. Anger
2. Developing 3. Bargaining
Awareness 4. Depression
3. Reorganization 5. Acceptance
and Restitution

Coping Reaction to Death throughout the life Cycle

Reaction of children to death

o Infant and Toddler

 Live only at present

  Are concern with separation with mother, afraid of being alone/being
abandoned
 Can sense sadness from others and may feel guilty due to magical thinking
 Healthy toddlers may insist on seeing other long after the person’s death

o Pre-school

 See death as temporary type of separation as if it is a sleep separation

 See life as concrete, know the word death but doesn’t know it’s finality
 Fear of separation from parents “wanted to know who will take care of them”
 Dying children may have regress behavior

o School Age

 Have concept of time, causality and irreversibility of death

 They fear of mutilation, pain abandonment
 Interested with death ceremony
 Feel/Interpret death as a punishment
Cultural and spiritual belief
- Values, attitudes, belief and customs are cultural aspect of a person’s life style
- Spiritual or religious belief includes practices, rites and
Rituals directed toward loss experience and grieving
EVALUATION
- Observe students learning and participation through out the
Lesson proper. Including the active participation in the discussion to clarify/verify points that was not
clear.

TOPIC: ANGER, HOSTILITY AND AGGRESSION

This session focuses on grieve and losses, the causes, approaches and nursing
management for patient with the said problem
At the end of the session the student will be able to: 1.Identify the type of losses for which people may
grieve
2. Discuss various theories related to understanding the grief process
3.Describe the 5 dimensions of grieving
4.Discuss universal and culturally specific mourning rituals
5.Identify factors that increase a persons’ susceptibility to complications related to grieving
6.Apply the nursing process to facilitate grieving for clients and families ANGER
- Anger a normal emotional response when a person is frustrated, hurt, afraid, threatened or
provoked.
- Anger can be a normal and healthy reaction when situations or circumstances are unjust or
unfair, personal rights are not respected or realistic expectations are not met
RESPONSES TO ANGER
1. POSITVE RESPONSE When anger is handled appropriately and expressed assertively, it can be a (+)
force that helps a person to:
- Resolve conflicts
- Solve a problem
- Make decisions
2. NEGATIVE RESPONSE
- Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately
- when anger is expressed inappropriately or suppressed, it can cause:
> Emotional problem
- low self-esteem - depression
> Physical problem
- headache - stress ulcers
- palpitations - coronary artery disease

NURSING INTERVENTION OF ANGER

1. Be a role model in expressing anger appropriately
2. Encourage client to use assertive communication
Ex: “I feel angry when you interrupt me”
3. Role playing assertive communication technique
4. Provide activities that are not aggressive such as walking or talking with another person
5. Encourage women to express their anger instead of suppressing them (anger suppression).
This may result to somatic complaints and psychological problems
RELATED DISORDERS WITH AGRESSION AND HOSTILITY
1. Paranoid delusion
2. Auditory hallucination
3. Dementia
4. Delirium
5. Intoxication with alcohol or other substances
6. Borderline personality
7. Antisocial personality
8. ADHD
HOSTILITY
- Hostility is also called verbal aggression
- It is an emotion expressed through:
> Verbal abuse
> Threatening behavior
> Lack cooperation
> Violation of rules or norm
- Hostile behavior is intended to cause emotional harm to other and it can lead to PHYSICAL
AGGRESSION

PHYSICAL AGGRESSION
- Physical aggression is a behavior in which a person
attacks or injures another person and destructs
properties
STAGES OF HOSTILITY AND AGGRESSION
A. TRIGGERING – when an events or circumstances initiates client to hostile or angry response
R – Restlessness and irritability
A – Anxiety or anger
M – Muscle tension, perspiration and rapid breathing
P – Pacing
NURSING INTERVENTION
1. Approach client in a non-threatening, calm manner
2. Convey empathy for the client’s anger or frustration
3. Encourage client express his/her angry feelings verbally, suggesting that the client is in control
and can maintain that control
4. NURSING INTERVENTION
5. Use relaxation techniques
6. Resolve conflicts or problems that may exist
7. Suggest client to retreat to a quiet place to decrease stimulation
8. Offering PRN medication
B. ESCALATION
- client’s angry behavior escalates leading toward loss of control
- physiologic changes: pale or flushed face, agitated
- Verbal aggression: yelling, swearing, threatening, demanding
- cognitive changes:
> inability to solve problem
> inability to think abstractly

NURSING INTERVENTION
1. Provide directions to the client in a calm, firm voice
2. Instruct client to take time-out for cooling off in a quiet area or in his/her room
3. Inform client that aggressive behavior is unacceptable and that the nurse is there to help client
regain control
4. NURSING INTERVENTION
5. The nurse should obtain assistance from other staff members (initially 4-6) if client’s behavior
continues to escalate and should ready within sight but not as close as the primary nurse
(show of force)
C. CRISIS
- client loses physical and emotional control
- verbal abuse
- physical aggression
> throwing objects > kicking
> hitting > scratching
> biting
- impaired judgment
NURSING INTERVENTION
 1. Restrain and seclude client.
2. Inform client that his/her behavior is out of control and that the staff is taking control to
provide safety and prevent injury
3. Administer PRN medication if not taken earlier
4. Perform close assessment of the client in seclusion or restraint and documents the actions
D. RECOVERY – client regain physical and emotional control
- lowering of voice
- decreased muscle tension
- clearer, more rational communication
- physical relaxation
NURSING INTERVENTION
1. Encourage client to talk about the situation that triggered to aggressive behavior
2. Help client to relax, perhaps sleep, and return to a calmer state
3. Help client explore alternatives to aggressive behavior to avoid another aggressive episode
4. NURSING INTERVENTION
5. Assess staff members for any injuries and complete incident reports and flow sheets
6. Encourage other clients to talk about their feelings regarding the incident
7. STAGES OF HOSTILITY AND AGGRESSION
E. POSTCRISIS
- client attempts reconciliation with others and returns to the level of functioning before the aggressive
incident and its antecedents
- remorse - apologizes
-crying - quiet
- withdrawn behavior
NURSING INTERVENTION
1. Remove client from restraint or seclusion as soon as client meets the behavioral criteria
2. Discuss with client the behavior in a calm rational manner. Avoid being judgmental and
advising
3. Resume client’s activities as soon as he/she can participate in milieu therapy

TREATMENT
- Treatment for aggressive clients often focuses or treating the underlying or co-morbid
psychiatric diagnosis
LITHIUM
– effective in treating aggressive clients with bipolar disorder, conduct disorder and mental retardation
TEGRETOL (CARBAMAZEPINE)
DEPAKOTE (VALPROATE)
– use to treat aggression associated with dementia, psychosis and personality disorders
RISPERDAL (RISPERIDONE)
ZYPREXA(OLANZAPINE)
CLOZARIL (CLOZAPINE)
- use to treat aggression associated with dementia, brain injury, mental retardation and personality
disorders
BEZODIAZEPINE
– reduce irritability and agitation in older adults with dementia but they can result in the loss of social
inhibitions for other aggressive clients thereby increasing rather than decreasing their aggression
HALDOL (HALOPERIDOL)
ATIVAN (LORAZEPAM)
– use in combination to decrease agitation/aggression and psychotic symptoms
VERZED (MIDAZOLAM)
– effective to decrease agitation
NOTE: When Olanzapine (Zyprexa) is given by IM, it is effective in:
> decreasing agitation
> providing rapid tranquilization
> in making a smooth transition to maintenance therapy with oral Olanzapine
EVALUATION Discuss the biopsychosocial theories used to explain
anger, aggression and violence