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THE CONCEPT OF STRESS ADAPTATION
CHAPTER FOCUS The focus of this chapter is to describe the concept of stress using various definitions that have been identified in the literature. The relationship between stress and illness is discussed. OBJECTIVES After reading this chapter, the student will be able to: 1. Define adaptation and maladaptation. 2. Identify physiological responses to stress. 3. Explain the relationship between stress and “diseases of adaptation.” 4. Describe the concept of stress as an environmental event. 5. Explain the concept of stress as a transaction between the individual and the environment. 6. Discuss adaptive coping strategies in the management of stress. KEY TERMS “fight-or-flight syndrome” general adaptation syndrome precipitating event predisposing factors CORE CONCEPTS adaptation maladaptation stressor
CHAPTER OUTLINE/LECTURE NOTES I. Introduction A. The word stress lacks a definitive definition. B. Adaptation as a healthy response to stress has been defined as restoration of homeostasis to the internal environmental system. This includes responses directed at stabilizing internal biological processes and psychological preservation of self-identity and self-esteem. C. Maladaptive responses are perceived as negative or unhealthy and occur when the integrity of the individual is disrupted. Stress as a Biological Response A. This definition of stress is a result of research by Hans Selye. He defined stress as “the state manifested by a specific syndrome, which consists of all the nonspecifically induced changes within a biologic system.” This syndrome of physical symptoms has come to be known as the “fight-orflight syndrome.” B. Selye called this general reaction of the body to stress the general adaptation syndrome (GAS). He described the reaction in three distinct stages:
2 1. Alarm reaction stage. During this stage, the physiological responses of the “fight-or-flight” syndrome are initiated. 2. Stage of resistance. The individual uses the physiological responses of the first stage as a defense in the attempt to adapt to the stressor. If adaptation occurs, the third stage is prevented or delayed. Physiological symptoms may disappear. 3. Stage of exhaustion. Occurs when there is a prolonged exposure to the stressor to which the body has become adjusted. The adaptive energy is depleted, and the individual can no longer draw from the resources for adaptation described in the first two stages. Diseases of adaptation may occur, and, without intervention for reversal, exhaustion and even death can ensue. C. The “Fight-or-Flight Syndrome” 1. The initial stress response a. The hypothalamus stimulates the sympathetic nervous system, which in turn stimulates the adrenal medulla b. The adrenal medulla releases epinephrine and norepinephrine into the bloodstream c. Changes in the eyes include pupil dilation and increased secretion from the lacrimal glands d. In the respiratory system, the bronchioles and pulmonary blood vessels are dilated and the respiration rate is increased e. Changes in the cardiovascular system result in increases in force of contraction, cardiac output, heart rate, and blood pressure f. The gastrointestinal (GI) system undergoes decreases in motility and secretions. Sphincters contract. g. Effects on the liver result in increased glycogenolysis and gluconeogenesis and decreased glycogen synthesis h. Ureter motility increases. In the bladder, the muscle itself contracts, while the sphincter relaxes. i. There is increased secretion from the sweat glands j. The fat cells undergo lipolysis 2. The sustained stress response a. The hypothalamus stimulates the pituitary gland b. The pituitary gland releases adrenocorticotopic hormone (ACTH), which stimulates the adrenal cortex (1) The adrenal cortex releases glucocorticoids, resulting in increased gluconeogenesis, immunosuppression, and an anti-inflammatory response (2) The adrenal cortex also releases mineralocorticoids, resulting in increased retention of sodium and water
3 c. The pituitary gland releases vasopressin (antidiuretic hormone) [ADH]), which results in increases in blood pressure and fluid retention d. The pituitary gland releases growth hormone, which produces a direct effect on protein, carbohydrate, and lipid metabolism, resulting in increased serum glucose and free fatty acids e. The pituitary gland releases thyrotropic hormone (TTH), which stimulates the thyroid gland, resulting in an increase in the basal metabolic rate f. The pituitary gland releases gonadotropins, the initial response of which is an increase in secretion of sex hormones. Later, with sustained stress, secretion is suppressed, resulting in decreased libido or impotence. Stress as an Environmental Event A. This concept defines stress as a “thing” or “event” that triggers the adaptive physiological and psychological responses in an individual. The event is one that creates change in the life pattern of the individual, requires significant adjustment in lifestyle, and taxes available personal resources. The change can be either positive or negative. B. Easily measured by the Miller and Rahe Recent Life Changes Questionnaire. C. It is not known for certain whether stress overload merely predisposes a person to illness or actually precipitates it, but there does appear to be a clear causal link. D. A weakness in the Miller and Rahe tool is that it does not take into consideration the individual’s personal perception of the event or his or her coping strategies and available support systems at the time of the life change. Stress as a Transaction Between the Individual and the Environment A. This definition of stress emphasizes the relationship between the individual and the environment that is appraised by the individual as taxing or exceeding his or her resources and endangering his or her wellbeing. B. Precipitating Event. A stimulus arising from the internal or external environment and perceived by the individual in a specific manner. C. Individual’s Perception of the Event. When an event occurs, an individual undergoes a primary appraisal and a secondary appraisal of the situation. 1. Primary appraisal. The individual makes a judgment about the situation in one of the following ways: a. Irrelevant. When an event is judged irrelevant, the outcome holds no significance for the person. b. Benign-positive. This type of event is perceived as producing pleasure for the individual. c. Stress appraisal. These types of events include harm/loss, threat, and challenge.
4 (1) Harm/loss. Refers to damage or loss already experienced by the individual. (2) Threatening. These types of events are perceived as anticipated harms or losses. (3) Challenges. With these types of events, the individual focuses on potential for gain or growth, rather than on risks associated with the event. 2. Secondary appraisal. This type of appraisal is an assessment of skills, resources, and knowledge that the person possesses to deal with the situation. 3. The interaction between the primary appraisal of the event that has occurred and the secondary appraisal of available coping strategies determines the individual’s quality of adaptation response to stress. D. Predisposing Factors. Elements that influence how an individual perceives and responds to a stressful event. They include genetic influences, past experiences, and existing conditions. 1. Genetic influences. Circumstances of an individual’s life that are acquired by heredity (e.g., family history of physical and psychological conditions). 2. Past experiences. Occurrences that result in learned patterns that can influence an individual’s adaptation response (e.g., previous exposure to the stressor, learned coping responses, and degree of adaptation to previous stressors). 3. Existing conditions. Vulnerabilities that influence the adequacy of the individual’s physical, psychological, and social resources for dealing with adaptive demands (e.g., current health status, motivation, developmental maturity, severity and duration of the stressor, financial and educational resources, age, existing coping strategies, and a support system of caring others). Stress Management A. Stress management is the utilization of coping strategies in the response to stressful situations. B. Adaptive coping strategies protect the individual from harm and restore physical and psychological homeostasis. C. Coping strategies are considered maladaptive when the conflict being experienced goes unresolved or intensifies. D. Some adaptive coping strategies include awareness, relaxation, meditation, interpersonal communication with caring other, problem solving, pets, music, and many others. Summary and Key Points Review Questions
the student will be able to: 1.5 CHAPTER 2. The history of psychiatric care is explored. 2. OBJECTIVES After reading this chapter. various psychological responses to stress are discussed. Define mental health and mental illness. 4. Discuss cultural elements that influence attitudes toward mental health and mental illness. 5. 3. MENTAL HEALTH /MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS CHAPTER FOCUS The focus of this chapter is to differentiate between mental health and mental illness. Discuss the history of psychiatric care. Describe psychological adaptation responses to stress. Identify correlation of adaptive/maladaptive behaviors to the mental health/mental illness continuum. KEY TERMS anticipatory grieving bereavement overload defense mechanisms compensation rationalization denial reaction formation displacement regression identification repression intellectualization sublimation introjection suppression isolation undoing projection humors mental health mental illness neurosis psychosis “ship of fools” CORE CONCEPTS anxiety grief . and cultural components that influence individual attitudes and behaviors toward mental illness are identified.
and otherwise tortured to “purge” the body of these “evil spirits. and psychiatric nurses.” C. . L. black bile. Dorothea Dix was successful in her lobbying for the establishment of state hospitals for the mentally ill. J. Graduate-level psychiatric nursing was also established during this period.D. Individuals with mental illness were beaten. the mentally ill were sent out to sea on sailing boats with little guidance and in search of their lost rationality. Psychiatric nursing was not included in the curricula of schools of nursing until 1955. but the population grew faster than the system of hospitals. Individuals who did not have family or other resources became the responsibility of the communities in which they lived and were incarcerated in places where they could do no harm to themselves or others. B. mental illness was equated with witchcraft. This practice originated the term “ship of fools. starved. Linda Richards is considered to be the first American psychiatric nurse. E.C. The first hospital in America to admit mentally ill clients was established in Philadelphia in the mid 18th century. II. The concepts of mental health and mental illness are culturally defined. N. During the Middle Ages (500 to 1500 A. Introduction A. Her goal was to ensure humane treatment for these patients. Some correlated mental illness with witchcraft.” F. K. and phlegm.6 CHAPTER OUTLINE/LECTURE NOTES I. In the 19th century. I. yellow bile. During this same time period the Middle Eastern Islamic countries began to establish special units in general hospitals for the mentally ill—creating what were likely the first asylums for the mentally ill. G. The National Mental Health Act was passed by the government in 1946. Deinstitutionalization and the community health movement began in the 1960s (see Chapter 37).). psychologists. D. It provided funds for the education of psychiatrists. and the institutions became overcrowded and understaffed. M. She graduated from the New England Hospital for Women and Children in Boston. Early beliefs centered on mental illness in terms of evil spirits or supernatural or magical powers that had entered the body. In colonial America. Historical Overview of Psychiatric Care A. social workers. H. Benjamin Rush. Individuals experience both physical and psychological responses to stress. often called the father of American psychiatry. was a physician at this hospital and initiated the first humane treatment for mentally ill individuals in the United States.) associated mental illness with an irregularity in the interaction among the four humors: blood. B. She helped to establish the first school of psychiatric nursing at the McLean Asylum in Waverly. Massachusetts in 1882. Hippocrates (about 400 B. and mentally ill individuals were burned at the stake.
d. feelings. 4. Defined as: “The successful adaptation to stressors from the internal or external environment. and behaviors interfere with an individual’s functioning. A few of these include eating. primary psychological response patterns to stress. 2. and that interfere with the individual’s social. sleeping.” B. Moderate: Perceptual field diminishes. Peplau identified four levels of anxiety: a. Horwitz describes cultural influences that affect how individuals view mental illness. Misperceptions of the environment are common. feelings. Mental Illness A. and awareness of the environment is heightened.” IV. c. These include incomprehensibility (the inability of the general population to understand the motivation behind the behavior) and cultural relativity (the “normality” of behavior is determined by the culture). and there may be a loss of contact with reality. Senses are sharp. A variety of thoughts. Individual is unable to focus on even one detail. Learning is enhanced. Attention span and ability to concentrate decrease. Human function and communication with others are ineffective. B. 3. Adaptation is determined by the degree to which the thoughts. Psychological Adaptation to Stress A. feelings. Anxiety and grief have been described as two major. Anxiety is extremely common in our society. evidenced by thoughts. b. Prolonged panic anxiety can lead to physical and emotional exhaustion and can be a life-threatening situation. Less alert to environmental stimuli. Anxiety 1. Defined: A diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. Defined as: “Maladaptive responses to stressors from the internal or external environment. Severe: Perceptual field is so diminished that concentration centers on one detail only or on many extraneous details. Virtually all behavior is aimed at relieving the anxiety. occupational. feelings. and behaviors that are ageappropriate and congruent with local and cultural norms. evidenced by thoughts. Physical symptoms may be evident. Mental Health A. Mild: Seldom a problem. although some learning can still occur. individuals employ various coping mechanisms to deal with stress. Mild anxiety is adaptive and can provide motivation for survival. drinking. At the mild level. V. Panic: The most intense state. Associated with the tension of day-to-day living. and behaviors are associated with each of these response patterns. Very limited attention span. and/or physical functioning. Muscular tension and restlessness may be evident. Behavior may be characterized by wild and desperate actions or by extreme withdrawal. . motivation is increased. and behaviors that are incongruent with the local and cultural norms.7 III. Behavioral adaptation responses to anxiety: a.
8 physical exercise, smoking, crying, laughing, and talking to someone with whom they feel comfortable. b. At the mild to moderate level, the ego calls on defense mechanisms for protection, such as: (1) Compensation—covering up a real or perceived weakness by emphasizing a trait one considers more desirable (2) Denial—refusal to acknowledge the existence of a real situation or the feelings associated with it (3) Displacement—feelings are transferred from one target to another that is considered less threatening or neutral (4) Identification—an attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires (5) Intellectualization—an attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis (6) Introjection—the beliefs and values of another individual are internalized and symbolically become a part of the self, to the extent that the feeling of separateness or distinctness is lost (7) Isolation—the separation of a thought or a memory from the feeling, tone, or emotions associated with it (8) Projection—feelings or impulses unacceptable to one’s self are attributed to another person (9) Rationalization—attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors (10) Reaction formation—preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors (11) Regression—a retreat to an earlier level of development and the comfort measures associated with that level of functioning (12) Repression—the involuntary blocking of unpleasant feelings and experiences from one’s awareness (13) Sublimation—the rechanneling of drives or impulses that are personally or socially unacceptable into activities that are more tolerable and constructive (14) Suppression—the voluntary blocking of unpleasant feelings and experiences from one’s awareness (15) Undoing—a mechanism that is used to symbolically negate or cancel out a previous action or experience that one finds intolerable c. Anxiety at the moderate to severe level that remains unresolved over an extended period of time can contribute to a number of physiological disorders. These may include, but are not limited to, tension and migraine headaches, angina pectoris, obesity, anorexia nervosa, bulimia nervosa, rheumatoid arthritis, ulcerative colitis, gastric and duodenal ulcers, asthma, irritable bowel syndrome, nausea and vomiting, gastritis, cardiac arrhythmias, premenstrual syndrome, muscle spasms, sexual dysfunction, and cancer.
9 d. Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving. Neuroses are psychiatric disturbances characterized by excessive anxiety or depression, disrupted bodily functions, unsatisfying interpersonal relationships, and behaviors that interfere with routine functioning. Examples of psychoneurotic disorders that are described in the DSM-IV-TR include anxiety disorders, somatoform disorders, and dissociative disorders (discussed in Chapters 29 and 30). e. Extended periods of functioning at the panic level of anxiety may result in psychotic behavior. Psychoses are serious psychiatric disturbances characterized by the presence of delusions and/or hallucinations and the impairment of interpersonal functioning and relationship to the external world. Examples of psychotic responses to anxiety include the schizophrenic, schizoaffective, and delusional disorders (discussed in Chapter 26). C. Grief 1. Defined: The subjective state of emotional, physical, and social responses to the loss of a valued entity. The loss may be real or perceived. 2. Kubler-Ross identified five stages of the grief process through which individuals pass as a normal response to loss: a. Denial—a stage of shock and disbelief b. Anger—anger felt for experiencing the loss is displaced upon the environment or turned inward on the self c. Bargaining—promises made to God for delaying the loss d. Depression—the full impact of the loss is felt. Disengagement from all association with the lost entity is initiated. e. Acceptance—resignation that the loss has occurred. A feeling of peace regarding the loss is experienced. 3. Anticipatory grief. The experiencing of the grief process prior to the actual loss. 4. Resolution. Length of the grief process is entirely individual. It can last from a few weeks to years. It is influenced by a number of factors: a. The experience of guilt for having had a “love-hate” relationship with the lost entity. Guilt often lengthens the grieving process. b. Anticipatory grieving is thought to shorten the grief response when the loss actually occurs. c. The length of the grief response is often extended when an individual has experienced a number of recent losses and when he or she is unable to complete one grieving process before another one begins. d. Resolution of the grief response is thought to have occurred when an individual can look back on the relationship with the lost entity and accept both the pleasures and the disappointments (both the positive and the negative aspects) of the association. 5. Maladaptive grief responses a. Prolonged response. Intense preoccupation with memories of the lost entity for many years after the loss has occurred. Behavior is
10 characterized by disorganization of functioning and intense emotional pain related to the lost entity. b. Delayed/inhibited response. Fixation in the denial stage of the grieving process. The loss is not experienced, but there may be evidence of psychophysiological or psychoneurotic disorders. c. Distorted response. Fixation in the anger stage of the grieving process. All the normal behaviors associated with grieving are exaggerated out of proportion to the situation. The individual turns the anger inward on the self and is consumed with overwhelming despair. Pathological depression is a distorted grief response (discussed in Chapter 27). VI. Mental Health/Mental Illness Continuum A. In Figure 2-3 of the text, anxiety and grief are presented on a continuum according to degree of symptom severity. Disorders as they appear in the DSMIV-TR are identified at their appropriate placement along the continuum. VII. The DSM-IV-TR Multiaxial Evaluation System A. From the psychiatric diagnostic manual, individuals are evaluated on five axes: 1. Axis I—Clinical disorders and other conditions that may be a focus of clinical attention 2. Axis II—Personality disorders and mental retardation 3. Axis III—General medical conditions 4. Axis IV—Psychosocial and environmental problems 5. Axis V—Global assessment of functioning rated on the Global Assessment of Functioning (GAF) Scale that measures an individual’s psychological, social, and occupational functioning VIII. Summary and Key Points IX. Review Questions
CHAPTER 3. THEORETICAL MODELS OF PERSONALITY DEVELOPMENT
CHAPTER FOCUS The focus of this chapter is to provide background information for understanding the development of the personality. Major components of seven leading theories are presented.
OBJECTIVES After reading this chapter, the student will be able to: 1. Define personality. 2. Identify the relevance of knowledge associated with personality development to nursing in the psychiatric/mental health setting. 3. Discuss the major components of the following developmental theories: a. Psychoanalytic theory—Freud b. Interpersonal theory—Sullivan c. Theory of psychosocial development—Erikson d. Theory of object relations development—Mahler e. Cognitive development theory—Piaget f. Theory of moral development—Kohlberg g. A nursing model of interpersonal development—Peplau
KEY TERMS cognitive development cognitive maturity counselor ego id libido psychodynamic nursing superego surrogate symbiosis technical expert temperament
CORE CONCEPT personality
12 CHAPTER OUTLINE/LECTURE NOTES I. It has been called the “pleasure principle. Present at birth.” C. Development begins at age 4 to 6 months. Ego. F. Dynamics of the Personality 1. Oral stage (birth to 18 months). thereby suggesting the possibility for renewal and growth in adults. Stages are identified by age. C. Individuals may become fixed in a certain stage and remain developmentally delayed. Freud believed basic character was formed by age five. Psychoanalytic Theory—S. Stages overlap. Freud A. It is transferred through all three components of the personality as the individual matures. Introduction A. Id. Also called the “reality principle. II. Relief from anxiety through oral gratification of needs. The DSM-IV-TR states that personality disorders occur when personality traits become inflexible and maladaptive. and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Anticathexis is the use of psychic energy by the ego and the superego to control id impulses. D. Development of the Personality 1. Life-cycle developmentalists believe that people continue to develop and change throughout life.” 2. Superego. Development begins at about 3 to 6 years. B. If an excess of psychic energy is stored in one part of the personality. and individuals may be working on tasks from more than one stage at a time. It is possible for behaviors from an unsuccessfully completed stage to be modified and corrected in a later stage.” 3. It may be referred to as the “perfection principle. the id. relating to. Freud termed the process by which the id invests energy into an object in an attempt to achieve gratification cathexis. the id serves to satisfy needs and achieve immediate gratification.” B. D. Freud identified five stages of development and the major developmental tasks of each: a. G. and the superego. It is composed of the ego-ideal (the self-esteem that is developed in response to positive feedback) and the conscience (the culturally influenced sense of right and wrong). . E. He organized the structure of the personality into three major components: 1. 2. It serves as the rational part of the personality and works to maintain harmony between the external world. Personality traits are defined by the DSM-IV-TR as “enduring patterns of perceiving. personality is influenced by temperament (inborn personality characteristics) and the environment. However. the behavior reflects that part of the personality. Freud termed the force required for mental functioning psychic energy. and cause either significant functional impairment or subjective distress.
the initiation of feelings of affection for another person. focus is on relationships with members of the opposite sex. Fulfillment of all requirements associated with an individual’s physiochemical environment. 3. Phallic stage (3 to 6 years). Relief from anxiety through oral gratification of needs. d. Learning to form satisfactory peer relationships. Understanding the use of ego defense mechanisms is important in making determinations about maladaptive behaviors and in planning care for clients to assist in creating change. focus is on genital organs.13 b. Anal stage (18 months to 3 years). Interpersonal Theory—H. The “not me”—the part of the personality that develops in response to situations that produce intense anxiety in the child B. Learning independence and control. Identification with parent of same sex. Libido is reawakened as genital organs mature. Interpersonal security. The major components of this theory include: 1. 4. Learning to experience a delay in personal gratification without undue anxiety. Learning to form satisfactory relationships with persons of same sex. d. Self-system. adopted by the individual to protect against anxiety. Learning to form satisfactory relationships with persons of the opposite sex. Sexuality is repressed. Childhood (18 months to 6 years). with focus on the excretory function. or security measures. focus is on relationships with same-sex peers. E. c. Stages of Development 1. e. Satisfaction of needs. Genital stage (13 to 20 years). b. Based on the belief that individual behavior and personality development are the direct result of interpersonal relationships. Sullivan identified six developmental stages and the major tasks associated with each: a. and superego will assist in the assessment of developmental level in clients. Juvenile (6 to 9 years). A collection of experiences. ego. development of sexual identity. Anxiety. c. The “good me”—the part of the personality that develops in response to positive feedback b. Latency stage (6 to 12 years). S. Early adolescence (12 to 14 years). e. developing a sense of identity. Being able to recognize behaviors associated with the id. A feeling of emotional discomfort. Preadolescence (9 to 12 years). Relevance of Psychoanalytic Theory to Nursing Practice. Sullivan A. 2. . III. The “bad me”—the part of the personality that develops in response to negative feedback c. The feeling associated with relief from anxiety. toward the relief or prevention of which all behavior is aimed. Consists of three components: a. Infancy (birth to 18 months).
To develop a sense of purpose and the ability to initiate and direct own activities. B. suspiciousness. Initiative versus guilt. Failure results in difficulty in interpersonal relationships due to feelings of inadequacy. Theory of Psychosocial Development—E. doubt. To review one’s life and derive meaning from both positive and negative events. Early childhood (18 months to 3 years). performing successfully. intimate opposite-sex relationship. Failure results in feelings of inadequacy and guilt and the accepting of liability in situations for which he or she is not responsible. Ego integrity versus despair. Intimacy versus isolation. a lack of pride in the ability to perform. Infancy (birth to 18 months). c. and receiving recognition from significant others. lasting relationship or a commitment to another person. Establishing self-identity. Failure results in emotional dissatisfaction with self and others. School age (6 to 12 years). experiencing satisfying relationships. Trust versus mistrust. a cause. and difficulty with interpersonal relationships. To integrate the tasks mastered in the previous stages into a secure sense of self. and a rage against the self. To form an intense. Relationship development is a major psychiatric nursing intervention. b. Late childhood (3 to 6 years). Failure results in a sense of self-consciousness. and the inability to form lasting. Based on the influence of social processes on the development of the personality. Failure results in withdrawal. social isolation. To develop a trust in the mothering figure and be able to generalize it to others. h. competing. f. To achieve a sense of self-confidence by learning. Identity versus role confusion. e. Erikson identified eight stages of development and the major tasks associated with each: a. Erikson A. To gain some self-control and independence within the environment. Stages of Development 1. Generativity versus stagnation. Autonomy versus shame and doubt.14 f. and acquaintances. aloneness. Late adolescence (14 to 21 years). Young adulthood (20 to 30 years). peers. an institution. C. . working to develop a lasting. d. IV. Old age (65 years to death). Failure results in lack of concern for the welfare of others and total preoccupation with the self. Adulthood (30 to 65 years). Relevance to Nursing Practice. and confusion about one’s role in life. intimate relationships. Adolescence (12 to 20 years). while also considering the welfare of future generations. To achieve the life goals established for oneself. Industry versus inferiority. or a creative effort. a sense of being controlled by others. Failure results in a lack of self-confidence. g. Knowledge about the behaviors associated with all levels of anxiety and methods for alleviating anxiety helps nurses to assist clients to achieve interpersonal security and a sense of well-being.
(4) Subphase 4. Developing awareness of external source of need fulfillment. Piaget identified four stages of development that are related to age. Phase II. b. Differentiation (5 to 10 months). (3) Subphase 3. Rapprochement (16 to 24 months). Fulfillment of basic needs for survival and comfort is the focus and is merely accepted as it occurs. VI. Acute awareness of separateness of self. Phase I. Mahler identified six phases and subphases through which the individual progresses on the way to object constancy. (2) Subphase 2. c. increased sense of separateness of self. The emotional problems of many individuals can be traced to lack of fulfillment of the tasks of separation/individuation. on-the-way-to object constancy—able to internalize a sustained image of loved object/person when object/person is out of sight. Cognitive Development Theory—J. Sense of separateness established. The process of separating from mothering figure and the strengthening of the sense of self. Stages of Development 1. learning to seek “emotional refueling” from mothering figure to maintain feeling of security. Divided into four subphases: (1) Subphase 1. Lack of expected nurturing in this phase may lead to symbiotic psychosis. resolution of separation anxiety. Relevance to Nursing Practice. Mahler A. demonstrating at each successive stage a higher level of logical . Many individuals with mental health problems are still struggling to achieve tasks from a number of developmental stages. Major developmental tasks are also described. Phase III. Based on the premise that human intelligence is an extension of biological adaptation. Understanding the concepts of Mahler’s theory of object relations assists the nurse to assess the client’s level of individuation from primary caregivers. The autistic phase (birth to 1 month). B. C. a. Practicing (10 to 16 months). Consolidation (24 to 36 months). Nurses can plan care to assist these individuals to fulfill these tasks and move on to a higher developmental level. Theory of Object Relations—M. B. Failure results in a sense of self-contempt and disgust with how life has progressed. Increased independence through locomotor functioning. A primary recognition of separateness from the mother begins. C. Stages of Development 1. V. Separation-Individuation. or one’s ability for psychological adaptation to the environment.15 while achieving a positive sense of self-worth. Relevance to Nursing Practice. Based on the separation-individuation process of the infant from the maternal figure (primary caregiver). Symbiosis (1 to 5 months). Piaget A.
Behavior is motivated by respect for authority. strong desire for approval and acceptance. Learning to think and reason in abstract terms. Preoperational (2 to 6 years). a. VII. Learning to apply logic to thinking. develops understanding of reversibility and spatiality. Behavior is motivated by egocentrism and concern for self. Preconventional level (prominent from ages 4 to 10 years) (1) Stage 1. Behavior is motivated by fear of punishment. Nurses must have knowledge of cognitive development in order to help clients identify the distorted thought patterns and make the changes required for improvement in affective functioning. each of which is further subdivided into two stages: a. Formal operations (12 to 15+ years). b. Kohlberg A. Interpersonal concordance orientation. Law and order orientation. 2. makes and tests hypotheses. c. Concrete operations (6 to 12 years). Postconventional level (can occur from adolescence on) (1) Stage 5. Major developmental tasks are also described. Theory of Moral Development—L.16 organization than at the previous stages. Relevance to Nursing Practice. increased socialization and application of rules. Sensorimotor (birth to 2 years). C. achievement of object permanence. c. . Punishment and obedience orientation. learning to differentiate and classify. Instrumental relativist orientation. Conventional level (prominent from ages 10 to 13 years and into adulthood) (1) Stage 3. Kohlberg identified three major levels of moral development. b. the concept of object permanence emerges as the ability to form mental images evolves. d. Nurses who work in psychiatry may use techniques of cognitive therapy to help clients. Not closely tied to specific age groups. Learning to express self with language. (2) Stage 4. Social contract legalistic orientation. Behavior is motivated by the expectations of others. (2) Stage 2. develops understanding of symbolic gestures. Stages of Development 1. logical thinking and reasoning ability expand and are refined. Cognitive therapy focuses on changing “automatic thoughts” that occur spontaneously and contribute to negative thinking. With increased mobility and awareness develops a sense of self as separate from the external environment. Behavior is motivated by respect for universal laws and moral principles and guided by an internal set of values. cognitive maturity achieved. More accurately determined by the individual’s motivation behind the behavior.
Learning the satisfaction of pleasing others by delaying selfgratification in small ways. C. 4. Universal ethical principle orientation. Stage 4. Relevance to Nursing Practice. Psychiatric nurses must be able to assess the level of moral development of their clients in order to be able to help them in their effort to advance in their progression toward a higher level of developmental maturity. Learning to delay gratification. establishment of more realistic view of the world and a feeling of one’s place in it. Stage 3. Peplau identifies four stages of personality development: 1. 3. B. competition. Moral development has relevance to psychiatric nursing in that it affects critical thinking about how individuals ought to behave and treat others. Counselor—one who listens while the client relates difficulties he or she is experiencing in any aspect of life 3. Using nursing roles . Peplau identifies six nursing roles in which nurses function to assist individuals in need of health services: 1. an earlier level of development.17 (2) Stage 6. Relevance to Nursing Practice. Interpersonal experiences are seen as learning situations for nurses to facilitate forward movement in the development of personality. Learning to communicate in various ways with the primary caregiver in order to have comfort needs fulfilled. Peplau A. Teacher—one who identifies learning needs and provides information to client or family to fulfill those needs 4. Stage 2. Technical expert—one who possesses the skills necessary to perform the interventions directed at improvement in the client’s condition 6. many of whom are fixed in. The early childhood stage of development. Resource person—one who provides specific information 2. The infant stage of development. Learning to count on others. Learning appropriate roles and behaviors by acquiring the ability to perceive the expectations of others. and respect for human dignity and guided by the conscience. Developing skills in participation. 2. Peplau’s model provides nurses with a framework to interact with clients. Stage 1. D. Peplau correlates the stages of personality development in childhood to stages through which clients advance during the progression of an illness. Behavior is motivated by internalized principles of honor. and cooperation with others. The late childhood stage of development. Application of the interpersonal theory to nurse-client relationship development. Surrogate—one who serves as a substitute figure for another E. Learning the skills of compromise. VIII. A Nursing Model of Interpersonal Development—H. Leader—one who guides the interpersonal interactions and ensures the fulfillment of goals 5. B. or because of illness have regressed to. justice. The toddlerhood stage of development. F. Identifying oneself.
Summary and Key Points Review Questions IX. X. . nurses may facilitate client learning of what has not been learned in earlier experiences.18 suggested by Peplau.
the student will be able to: 1. 10. CONCEPTS OF PSYCHOBIOLOGY CHAPTER FOCUS The focus of this chapter is to explore the role of neurophysiological. and the implications to psychiatric/mental health nursing are discussed. 6. 4. Discuss the association of endocrine functioning to the development of psychiatric disorders. Describe the physiological mechanism by which various psychotropic medications exert their effects. 9. 2. Describe the role of genetics in the development of psychiatric disorders. and endocrine influences on psychiatric illness. neurochemical. 5. genetic.19 CHAPTER 4. Discuss the correlation of alteration in brain functioning to various psychiatric disorders. Identify various diagnostic procedures used to detect alteration in biological functioning that may be contributing to psychiatric disorders. 7. OBJECTIVES After reading this chapter. 3. 11. Identify gross anatomical structures of the brain and describe their functions. Discuss the influence of psychological factors on the immune system. Describe the role of neurotransmitters in human behavior. KEY TERMS axon cell body circadian rhythms dendrites genotype limbic system neuron neurotransmitter phenotype receptor sites synapse CORE CONCEPTS genetics neuroendocrinology psychobiology psychoimmunology psychotropic medication . Various diagnostic procedures used to detect alteration in biological function that may contribute to psychiatric illness are identified. 8. Discuss historical perspectives related to psychopharmacology. Discuss the physiology of neurotransmission in the central nervous system. Discuss the implications of psychobiological concepts to the practice of psychiatric/mental health nursing.
thinking and judgment formation. each named for the overlying bones in the cranium: the frontal lobe. It is sometimes called the “emotional brain” and is associated with feelings of fear and anxiety. hypothalamus. and body position). and hope. parietal lobe. The Brain 1. b. (d) Occipital lobes. taste. The Nervous System: An Anatomical Review A. (3) The limbic system consists of medially placed cortical and subcortical structures and the fiber tracts connecting them with one another and with the hypothalamus. Responsible for visual reception and interpretation. also has some involvement with emotions and mood. and with sexuality and social behavior. love. . and sense of smell. short-term memory. temporal lobe. and occipital lobe (a) Frontal lobes. and limbic system. thus permitting the presence of millions more neurons than would be possible otherwise (3) Each hemisphere is divided into four lobes. Introduction: In recent years. (c) Temporal lobes. (b) Parietal lobes. including movements that permit speaking. Responsible for voluntary body movement. The forebrain a.20 CHAPTER OUTLINE/LECTURE NOTES I. (2) The hypothalamus regulates anterior and posterior lobes of the pituitary gland and exerts control over actions of the autonomic nervous system. joy. anger and aggression. Responsible for hearing. pain. Responsible for perception and interpretation of most sensory information (including touch. The diencephalon. and expression of feelings. The cerebrum (1) Consists of a right and left hemisphere connected by a deep groove of neurons (nerve cells) called the corpus callosum (2) The cerebral cortex is identified by numerous folds (called gyri) and deep grooves (called sulci) that extend the surface area of the cortex. (1) The thalamus integrates all sensory input (except smell) on the way to the cortex. II. expression of emotions through connection with the limbic system. Connects the cerebrum with lower brain structures and consists of the thalamus. a greater emphasis has been placed on the study of the organic basis for psychiatric illness. Also regulates appetite and temperature.
Charged with regulation of respiration and skeletal muscle tone. The sympathetic division is dominant in stressful situations and prepares the body for “fight-or-flight” (see Chapter 1) b. Interneurons exist entirely within the CNS. An electrical impulse causes its release into the synaptic cleft. reflex centers for swallowing. B. a. b. The autonomic nervous system (ANS) has two divisions: the sympathetic and the parasympathetic. Efferent neurons carry impulses from the CNS to muscles (which respond by contracting) and glands (that respond by secreting). Responsible for visual. Neurons conducting impulses toward the synapse are called presynaptic neurons and those conducting impulses away are called postsynaptic neurons. Afferent neurons carry impulses from receptors in the internal and external periphery to the CNS. sneezing. Cerebellum. and vomiting. The junction between two neurons is called a synapse and the small space between the two neurons is called a synaptic cleft. The cell body contains the nucleus and is essential for the life of the neuron b. c. Nerve Tissue 1. a. C. The midbrain: The mesencephalon. Three classes of neurons exist within the CNS: afferent (sensory). Synapses. blood pressure. and balance (“righting”) reflexes. an axon. 3. and dendrites. The hindbrain a. 4. auditory. where it combines with receptor sites on the postsynaptic neuron and determines whether another electrical impulse will be generated. ascending and descending tracts connect brainstem with cerebellum and cortex. and interneurons. The nerve cells of CNS tissue are called neurons and are composed of three parts: a cell body. Pons. or they may serve as integrators in the pathways between afferent and efferent neurons. Medulla. b. c. coughing.21 2. a. A pathway for all ascending and descending fiber tracts. where they are interpreted into various sensations. nonstressful condition . It contains vital centers that regulate heart rate. The parasympathetic division dominates when an individual is in a relaxed. A chemical neurotransmitter is stored in the axon terminals of the presynaptic neuron. 3. The axon transmits impulses away from the cell body c. and respiration. Regulates muscle tone and coordination and maintains posture and equilibrium. The dendrites are processes that transmit impulses toward the cell body 2. They may carry only sensory or motor impulses. efferent (motor). Autonomic Nervous System 1.
They are involved in . and release of prolactin. It causes recurrent inhibition of motor neurons. When an electrical impulse reaches this point. also the hippocampus. Neurotransmitters are stored in terminal vesicles of neuronal axons. and retina. 2. and cerebral cortex. and the primary sensory afferent systems. arousal. basal ganglia. (3) Serotonin is found in the hypothalamus. locomotion. perception. and neuropeptides. and brainstem. (3) Glutamate and aspartate are found in pyramidal cells of the cortex. posterior pituitary. and spinal cord. hypothalamus. cerebral cortex. a. basal ganglia. cardiovascular functioning. 3. limbic system. voluntary judgment. Monoamines (1) Norepinephrine is found in the thalamus. spinal cord. monoamines. c. (2) Dopamine is found in the frontal cortex. and pain perception.22 D. and spinal cord. thalamus. thalamus. and memory. Cholinergics (1) Acetylcholine is found in the cerebral cortex. It is involved in movement and coordination. and sleep and arousal. emotions. It is involved in the slowdown of body activity. cerebellum. the neurotransmitter is released from the vesicles into the synaptic cleft. and spinal cord. b. Amino acids (1) Gamma aminobutyric acid (GABA) is found in the hypothalamus. where it binds with receptor sites on the postsynaptic neuron to determine whether another electrical impulse will be generated. movement. cortex. d. Its exact function is unclear but may have some influence on mood. limbic system. thalamus. hippocampus. pain perception. Neuropeptides (1) Endorphins and enkephalins are found in the hypothalamus. (2) Glycine is found in the spinal cord and brainstem. it is either inactivated and dissolved by enzymes or returned to the vesicles to be stored and used again. cognition. mood. limbic structures. (4) Histamine is found in the hypothalamus. limbic structures. It influences sleep and arousal. amino acids. It is involved in sleep. cerebellum. limbic system. hippocampus. Enkephalins are also found in the GI tract. midbrain. Neurotransmitters play an important role in human emotions and behavior and are the target for the mechanism of action in many psychotropic medications. hippocampus. cerebellum. libido. thalamus. hypothalamus. After the neurotransmitter has accomplished this task. They are involved in the relay of sensory information and in the regulation of various motor and spinal reflexes. Neurotransmitters 1. Major categories of neurotransmitters include cholinergics. aggression. cerebellum. It influences mood. appetite. and basal ganglia.
The pituitary gland has two major lobes. which plays a role in the response to stress. and lipid metabolism. limbic structures. thalamus. III. (3) Somatostatin is found in the cerebral cortex. which has direct control over the pituitary gland. midbrain. are produced in the hypothalamus and stored in the posterior pituitary. basal ganglia. thalamus. Their release is mediated by neural impulses from the hypothalamus. The posterior lobe is under neural control of the hypothalamus. the posterior lobe (also called the neurohypophysis) and the anterior lobe (also called the adenohypophysis). increased plasma concentration. and inhibitory effects on norepinephrine. histamine. (2) Thyroid-stimulating hormone stimulates the thyroid gland to secrete thyroid hormones necessary for metabolism of food and regulation of temperature. vasopressin (or antidiuretic hormone) and oxytocin. It also acts as a neuromodulator for serotonin. brainstem.” 1. norepinephrine. it has stimulatory effects on dopamine. . It is involved in the regulation of pain. Two hormones. brainstem. (1) Growth hormone is responsible for growth in children and for continued protein synthesis throughout life. and glutamate. and possibly other neurotransmitters.23 the modulation of pain and the reduction of peristalsis (enkephalins). Its release is stimulated by pain. serotonin. and spinal cord. Endocrine functioning in the CNS is under the influence of the hypothalamus. a. (2) Oxytocin stimulates contraction of the uterus at the end of pregnancy and stimulates release of milk from the mammary glands. dehydration. it has both inhibitory and stimulatory properties. and acetylcholine. Its role in behavioral functioning is unclear. The anterior lobe produces a number of hormones whose release is under the control of releasing hormones that are produced by the hypothalamus. When these pituitary hormones are required by the body. basal ganglia. (2) Substance P is found in the hypothalamus. Neuroendocrinology A. emotional stress. During prolonged stress. (1) Vasopressin (antidiuretic hormone) conserves body water and maintains normal blood pressure. hippocampus. (3) Adrenocorticotropic hormone (ACTH) stimulates the adrenal cortex to secrete cortisol. the releasing hormones from the hypothalamus pass through the capillaries and veins of the hypophyseal portal system to capillaries in the anterior pituitary. sometimes called the “master gland. and spinal cord. resulting in increased serum glucose and free fatty acids to be used for increased energy. In its function as a neurotransmitter. carbohydrate. and decreases in blood volume. Depending on the part of the brain. b. where they stimulate secretion of these specialized hormones. it has a direct effect on protein.
Sleep is measured by the type of brain wave activity during various stages of sleep. Rhythms associated with the menstrual cycle show monthly cycles of progression. Serotonin and its precursor. Period of rapid eye movement. Vital signs increase. Circadian Rhythms 1. drift in and out of sleep. Norepinephrine and serotonin appear to be most active during non-REM sleep c. Transition into sleep. Minimal eye movement and muscular activity. have been shown to induce sleep b. Decreased vital signs. 3. 5. Minimal eye movement and muscular activity occur. Deep. (6) Melanocyte-stimulating hormone stimulates the pineal gland to secrete melatonin. restful sleep. Neurochemical influences. b. a hormone that may be implicated in the etiology of seasonal affective disorder (SAD). and testosterone. (5) Gonadotropic hormones stimulate the ovaries and testes to secrete estrogen. The dream cycle. About half of sleep is spent in this stage. patterns of activity such as eating and drinking. progesterone. 4. and testosterone. The stage of deepest sleep. 7. (4) Stage 3—Delta rhythm. no eye movement. Sleep disturbances are common in many individuals. B. Relaxed. The sleep-wake cycle is one of the most common biological rhythms that demonstrates circadian influence.24 (4) Prolactin stimulates the breasts to produce milk. (5) Stage 4—Delta rhythm. A number of neurochemicals have been shown to influence the sleep-wake cycle. Acetylcholine may induce and prolong REM sleep. including the sleep-wake cycle. dozing. The role of circadian rhythms in psychopathology is being studied. (6) REM sleep—Beta rhythm. (2) Stage 1—Beta rhythm. GABA probably plays a role in sleep and arousal d. Circadian rhythms follow a near-24-hour cycle in humans and may influence a variety of regulatory functions. Genetics . in sperm production. (3) Stage 2—Theta rhythm. and hormone secretion. Estrogen and progesterone also play a role in ovulation. whereas histamine may inhibit the effect IV. L-tryptophan. waking state with eyes closed. The sleep-wake cycle is genetically determined and demonstrates an approximate 24-hour rhythm. 2. Sleep-wake cycle a. (1) Stage 0—Alpha rhythm. body temperature regulation. 6. Some mood disorders have been linked to increased secretions of melatonin during darkness hours. a.
Certain neurochemicals may influence the immune system. VI. Studies have been conducted with adopted children whose biological parent(s) or relatives had the illness. . resulting in the suppression of lymphocyte proliferation and function. The term phenotype refers to the physical manifestations of a particular genotype. those whose adoptive parent(s) or relatives had the illness. Various types of studies are conducted to determine etiological factors associated with psychiatric illness. coded in the DNA. Serotonin has demonstrated both enhancing and inhibiting effects. Immunological abnormalities have also been associated with alcoholism. The role of neuroimmunology remains unclear in the relationship to onset and course of schizophrenia. 3. 2. Implications for Psychiatric Illness 1. the T4 lymphocytes become sensitized to and specific for the foreign antigen. The antibodies prevent the foreign antigen from invading body cells. 1. 2. blood type. Example of a genetic illness: Down’s syndrome. The humoral response is activated when antigen-specific T4 cells communicate with the B cells in the spleen and lymph nodes. Familial—compare the percentages of family members with the illness to those in the general population or a specific control group. autism. B. Decreased immunity has been associated with grief. Intended to be used as an adjunct to individual or group psychotherapy. C. language. 3. bereavement. and depression. 3. Genetic—search for a specific gene that is responsible for the individual having the illness. 4. The B cells in turn produce the antibodies specific to the foreign antigen. such as eye color. Normal Immune Response 1. V. Studies have shown that during times of stress. Neuroleptics were introduced into the United States in the 1950s. In the cellular immune response. Psychoimmunology A. Phenotypes are a combination of genetic and environmental characteristics. The term genotype refers to the total set of genes present in an individual at the time of conception. Twin studies—examine the frequency of a disorder in monozygotic and dizygotic twins.25 A. 2. height. the immune system is suppressed. Growth hormone may enhance immunity. Historical Perspectives 1. D. and with monozygotic twins reared apart by different adoptive parents. 2. Example of a familial illness: schizophrenia. Adoption studies—allow comparisons to be made of the influences of genetics versus environment on the development of a psychiatric disorder. 4. Psychopharmacology A. and dementia. The goal of behavioral genetics is to clarify the role that genetic factors play in the determination of behavior. whereas testosterone and increased production of norepinephrine and epinephrine may decrease immunity. B. and hair type.
histaminergic. VII. and what to expect in terms of side effects and possible adverse reactions. 3. Genetic influences 6. 2. and dopamine release. b. Assessment: A thorough baseline assessment must be conducted before a client is placed on a regimen of psychopharmacological therapy. Neuroendocrinology 4. 4. Nurses must understand the ethical and legal implications associated with the administration of psychotropic medications. nurses must have a clear understanding of the following: 1. C. Psychopharmacology 8. Most psychotropics have their effects at the neuronal synapse. b. Antipsychotic medications block dopamine receptors. 3. and α-adrenergic receptors. Neuronal processes 3. Ethical and legal implications a. Implications for Nursing A. c. Diagnostic technology . b. The psychostimulants work by increasing norepinephrine. 2. The “atypical” antipsychotics block a specific serotonin receptor. how and when it should be taken. serotonin. The nurse must translate complex information into terms that can be easily understood by the client. To ensure a smooth transition from a psychosocial focus to one of biopsychosocial emphasis. Role of the Nurse 1. Most states adhere to the client’s right to refuse treatment. Psychiatric nurses must integrate knowledge of the biological sciences into their practices if they are to ensure safe and effective care to people with mental illness. producing changes in neurotransmitter release and the receptors they bind to. Psychoimmunology 7. B. Benzodiazepines facilitate the transmission of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Most antidepressants work by blocking the reuptake of serotonin and norepinephrine. A thorough knowledge of psychotropic medications is essential.26 B. Circadian rhythms 5. 4. How Do Psychotropics Work? 1. except in emergency situations when client may be likely to harm self or others. The nurse is the key professional in direct contact with the individual receiving the psychotropic medication. Neuroanatomy and neurophysiology 2. Client education a. The nurse must evaluate for therapeutic effectiveness of the medication and for side effects and adverse reactions. and some affect cholinergic. Medication administration and evaluation a. 5. Clients must understand why the medication was prescribed.
27 VIII. Summary and Key Points IX. Review Questions .
Differentiate among ethics. and principles are explored as a foundation for decision making. and situations for which nurses may be held liable are discussed. Identify behaviors relevant to the psychiatric/mental health setting for which specific malpractice action could be taken. 4. beneficence. Discuss legal issues relevant to psychiatric/mental health nursing. natural law theories. and justice. and rights. 3.28 CHAPTER 5. ETHICAL AND LEGAL ISSUES IN PSYCHIATRIC/MENTAL HEALTH NURSING CHAPTER FOCUS The focus of this chapter is on ethical and legal issues that affect psychiatric/mental health nursing. Discuss ethical theories including utilitarianism. 10. 8. and ethical egoism. KEY TERMS assault autonomy battery beneficence Christian ethics civil law common law criminal law defamation of character ethical dilemma ethical egoism false imprisonment informed consent justice Kantianism libel malpractice natural law negligence nonmaleficence privileged communication slander statutory law tort utilitarianism veracity CORE CONCEPTS bioethics ethics moral behavior right values values clarification . OBJECTIVES After reading this chapter. 9. Ethical theories. morals. Various types of law are defined. Describe ethical issues relevant to psychiatric/mental health nursing. Discuss the ethical principles of autonomy. Differentiate between malpractice and negligence. values. the student will be able to: 1. dilemmas. 2. Christian ethics. Kantianism. 11. 6. 7. 5. Define statutory law and common law. Use an ethical decision-making model to make an ethical decision. nonmaleficence. Define ethical dilemma. Differentiate between civil law and criminal law. veracity.
B. Humans have inherent knowledge of the difference between good and evil. Autonomy. Legislation determines what is “right” or “good” within a society. Conduct that results from serious critical thinking about how individuals ought to treat others. Values clarification. G. Absolute right. Bioethics. 5. Abstaining from negative acts toward another. Applies to ethics when they refer to concepts within the scope of medicine. Definitions of Core Concepts A. nursing. Ethical Dilemmas 1. Do good and avoid evil. and this knowledge directs our decision making. Refers to one’s duty to benefit or promote the good of others. Values. and allied health. Kantianism. Ethical Considerations A. D. The concept of justice reflects a duty to treat all individuals equally and fairly. legally recognized claim or entitlement. A valid. Moral behavior. Nonmaleficence. H. 3. 2. 4. A process of self-exploration by which people identify and rank their own personal values. Ethics. Right. 4. Also called deontology. Ethical dilemmas occur when moral appeals can be made for taking each of two opposing courses of action. 2. Principle based on the notion of a hypothetical social contract between free. Suggests that decisions and actions are bound by a sense of duty. Natural law theories. B.29 CHAPTER OUTLINE/LECTURE NOTES I. B. Beneficence. F. Ethical egoism. Utilitarianism. Justice. C. E. Introduction A. When there is no restriction whatsoever on the individual’s entitlement. II. Personal beliefs about what is important and desirable. Do unto others as you would have them do unto you. encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or service. Theoretical Perspectives 1. and rational persons. III. An ethical theory that promotes action based on the end results that produce the most good (happiness) for the most people. 3. Taking no action is considered an action taken. . 2. C. Emphasizes the status of persons as autonomous moral agents whose right to determine their destinies should always be respected. A branch of philosophy that deals with distinguishing right from wrong. Ethical Principles 1. Legal right. including acting carefully to avoid harm. Nurses are constantly faced with the challenge of making difficult decisions regarding good and evil or life and death. A right on which the society has agreed and formalized into law. equal. Decisions are based on what is best for the individual making the decision. Christian ethics.
Compensation or performance of the obligation set forth in the contract is sought. a. Statutory law. Act on the decision made and communicate the decision to others. 2. 5. Exception: A duty to warn (protection of a third party) 2. Classifications within Statutory and Common Law 1. or the Congress of the United States. Select an alternative 4. Types of Law 1. Laws that have been enacted by legislative bodies. Ethical Issues in Psychiatric/Mental Health Nursing 1. D. Laws that provide protection from conduct deemed injurious to the public welfare. b. Restraints and seclusion a. False imprisonment 4. state legislature. The Nurse Practice Act defines the legal parameters of professional and practical nursing B. Confidentiality and right to privacy a. Health Insurance Portability and Accountability Act (HIPAA) (1) Protected health information (2) Pertinent medical information may be released without consent only in a life-threatening situation b. Commitment issues a. Veracity. Consider principles of ethical theories c. D. Evaluate outcomes. 2. Principle that refers to one’s duty to always be truthful. Explore the benefits and consequences of each alternative b.30 5. Legal Issues in Psychiatric/Mental Health Nursing 1. C. Common law. Legal Considerations A. Assessment 2. Tort. Informed consent 3. Involuntary commitment (1) Emergency commitments (2) The mentally ill person in need of treatment . Contracts. Laws derived from decisions made in previous cases. The right to refuse medication 2. Criminal law. Torts may be intentional or unintentional. Implementation. Laws that protect the private and property rights of individuals and businesses. Plan a. The right to the least restrictive treatment alternative IV. Voluntary admission b. A violation of a civil law in which an individual has been wronged. Doctrine of privileged communication c. Problem identification 3. such as a county or city council. Civil law. A Model for Making Ethical Decisions 1. Evaluation. E.
False imprisonment F. Respond to the client 2. Comply with the standard of care 4. Educate the client 3. Breach of confidentiality b. Invasion of privacy d. Summary and Key Points VI. Develop and maintain a good interpersonal relationship with client and family V.31 (3) Involuntary outpatient commitment (4) The gravely disabled client E. Document carefully 7. Review Questions . Defamation of character (1) Libel (2) Slander c. Supervise care 5. Adhere to the nursing process 6. Malpractice and negligence 2. Assault and battery e. Types of lawsuits that occur in psychiatric nursing a. Follow-up as required 8. Nursing Liability 1. Avoiding Liability 1.
Identify clients’ spiritual and religious needs. African Americans c. KEY TERMS culture-bound syndromes curandera curandero density distance folk medicine shaman stereotyping territoriality yin and yang CORE CONCEPTS culture ethnicity religion spirituality . The concepts of human spirituality and religion as they relate to client needs are addressed. 3. 6. Asian/Pacific Islander Americans. Emphasis is given to Northern European Americans.32 CHAPTER 6. the student will be able to: 1. Apply the nursing process in the care of individuals from various cultural groups. Western European Americans g. Define and differentiate between spirituality and religion. Describe cultural variances. Arab Americans h. CULTURAL AND SPIRITUAL CONCEPTS RELEVANT TO PSYCHIATRIC/MENTAL HEALTH NURSING CHAPTER FOCUS The focus of this chapter is the study of various sociocultural concepts that have an impact on the way individuals interact with each other. Apply the six steps of the nursing process to individuals with spiritual and religious needs. Native Americans. Latino Americans. Native Americans d. 2. Jewish Americans 4. Identify cultural differences based on six characteristic phenomena. Latino Americans f. based on the six phenomena. 5. Northern European Americans b. Western European Americans. and Jewish Americans. Define and differentiate between culture and ethnicity. Arab Americans. African Americans. 7. OBJECTIVES After reading this chapter. Asian/Pacific Islander Americans e. for a.
II. D. Social organizations are the groups within which individuals are acculturated. acquiring knowledge. Territoriality refers to the innate tendency to own space 2. Distance is the means by which various cultures use space to communicate a. . and gestures B. Time 1. All individuals must be appreciated for their uniqueness. How Do Cultures Differ? A. Intimate distance: 0 to 18 inches b. Differences among people in various racial groups include body structure. and ethnic groups D. and the response to human behavior. Environmental Control 1. and internalizing values 2. Personal distance: 18 inches to 3 feet c. paralanguage. feeling. and knowledge that guide people’s conduct and are passed down from generation to generation. Biological Variations 1. Ethnicity relates to people who identify with each other because of a shared heritage. the interpretation of human behavior. encompassing shared patterns of belief. Is expressed through language. Examples of social organizations are families. Social Organization 1. Culture describes a particular society’s entire way of living. Density refers to the number of people within a given environmental space 3. religious groups. Social distance: 3 to 6 feet C. Caution must be taken not to assume that all individuals who share a culture or ethnic group are identical or exhibit behaviors perceived as characteristic of the group. Cultural Concepts A. Has to do with the degree to which individuals perceive that they have control over their environment 2. Space (the place where the communication occurs) 1. physiological responses to medication. skin color. Has its roots in culture 2. Cultural beliefs and practices influence how individuals respond to their environment during periods of wellness and illness F. Some cultures place great importance on values that are measured by time. This constitutes stereotyping and must be avoided. B.33 CHAPTER OUTLINE/LECTURE NOTES I. Whether individuals perceive time in the present orientation or future orientation influences many aspects of their lives E. C. whereas others are actually scornful of clock time 2. Communication 1. Nurses must understand these cultural concepts because cultural influences affect human behavior.
. h. May work closely with traditional medicine to heal the sick. heart disease. Large group in the U. and nutritional deficiencies 4. Punctuality and efficiency highly valued f. alcoholism. African Americans a.” “old lady. at the time of its settlement b. Some are completely assimilated into the dominant culture. Health problems include diabetes. Language has roots in the first English settlers b. comprising about 4 percent of the U. They value territory. Children are taught to respect tradition.S. today. Descendants of these immigrants make up what is considered the dominant cultural group in the U. Present-time oriented g. Touch is not highly regarded by Native Americans and a handshake may be viewed as aggressive c. Forty-five percent of African-American households are headed by a woman d. Less value is placed on marriage and religion as once was e. but still enjoy fast food 2. Hypertension and sickle cell anemia have genetic tendencies within the African-American culture 3. Future-oriented g. Sometimes appear silent and reserved d. personal space is about 18 inches to 3 feet d. today c. Most value a healthy lifestyle. Primary social organization is the family and tribe.S. Native Americans a. Less than half live on reservations b. and uses a variety of methods in practice. Medicine man is called a shaman.S. Application of the Nursing Process A. Northern European Americans a. population. Some (particularly from the rural South) practice folk medicine and receive their care from a “granny. Large support groups of families and friends e. Asian/Pacific Islander Americans a.S.34 electrocardiographic patterns. Background Assessment Data 1. Uncomfortable expressing emotions e. f. Language dialect thought to be a combination of various African languages and the languages of other cultural groups present in the U. while others find it too difficult and prefer to remain in their own social organization c. and nutritional preferences and deficiencies III.” or “spiritualist” f. tuberculosis. susceptibility to disease.
Confucianism.S. Alcohol consumption is low due to a possible genetic intolerance of the substance 5. Time orientation is on both past and present k. and the primary social organization is a large extended family e. and other countries of Central and South America b. Education is highly valued. Vietnam. Latino Americans a. Western European Americans a. beliefs. and the Pacific Islands c. Touching is not considered totally appropriate by some Asian Americans g. Ancestry traced to Mexico.-born Latinos than it is for immigrants from the same cultural group 6. and language. Spain. Laos. Italy. Many of the younger generation Asian Americans have become almost totally acculturated into the dominant cultural group f. Asian Americans are quiet spoken. i. They are viewed as one (Asian) culture. and loyalty to family is emphasized above all else h. Common language is Spanish c. values. Cuba. but in fact constitute a multiplicity of differences regarding attitudes. Puerto Rico. Touch is a common form of communication d.35 b. Folk medicine combines elements of Roman Catholicism and Indian and Spanish ancestries h. India. Religious practices and beliefs are very diverse and exhibit influences of Taoism. for to raise the voice indicates a loss of control e. Origin is from France. The prevalence for psychiatric illness is higher among U. the Philippines. Thailand. Islam. Tend to be present-oriented f. and Christianity j. Roman Catholicism is the predominant religion g. Korea. d. Psychiatric illness is viewed as behavior that is out of control and brings great shame to the family n. Cambodia. religious practices. The folk healer is called a curandero (male) or curandera (female). Buddhism. Latinos are very group oriented. and fish are main staple foods m. vegetables. Hinduism. although many remain undereducated i. Restoring the balance of yin and yang is the fundamental concept of Asian health practices l. Rice. Includes immigrants and their descendants from Japan. and Greece . The family is the ultimate social organization in the Asian American culture. China. Many still subscribe to the “hot and cold” theory of disease (a concept similar to the Asian perception of yin and yang).
Time is present-oriented. Children are prized and cherished. Arabic is the official language of the Arab world c. Very family-oriented. Roman Catholicism is the predominant religion for the French and Italians. and symptoms are likely to be presented as physical complaints . Muslims are prohibited from eating pork and pork products. Interact in large groups. Spiritual medicine is combined with conventional medical treatment. Each has unique language with unique dialects within each language c. including hugging and kissing d. Women value modesty and many observe the custom of hijab— covering the body except for one’s face and hands i. maintain steady eye contact. but some folk beliefs and superstitions still endure j. k. e. The man is the head of the household and women are subordinate to men g. Mental illness is a major social stigma. and elderly are respected for their age and wisdom. Sickle cell disease and thalassemias are common in the eastern Mediterranean. Conversants stand close together. Western European Americans are present-oriented and view whatever happens in the future as God’s will i. Greek Orthodox for the Greeks h. A strong allegiance to the cultural heritage is common f. and punctuality is not taken seriously except in case of business or professional meetings f. l. and children are loved and indulged h. Bread is served at every meal and is viewed as a gift from God. The family is the primary social organization. Wine is the beverage of choice. Father is head of household. and touch (only between members of the same sex) the other’s hand or shoulder d. and there is no separation of church and state.36 b. very physically expressive. and use a lot of body language. g. Islam is the religion of most Arab countries. Arab Americans a. Sedentary lifestyle and high fat intake create a high risk for cardiovascular diseases. Ancestry and traditions are traced to the nomadic desert tribes of the Arabian Peninsula b. Many spices and herbs are used in cooking. but alcoholism rate is low 7. Speech is loud and expressive. Warm and affectionate. j. with lots of gesturing e. Traditional Western European women view their role as mother and homemaker. Lamb and chicken are the most popular meats. Most follow health beliefs and practices of the dominant American culture.
Jewish Americans a. Diagnosis/Outcome Identification 1. more flexibility and adaptation of those laws to absorb aspects of the culture. They do not believe that Jews are God’s chosen people. and most are located in the larger urban areas c. Symptoms associated with specific cultures that may be expressed differently from the dominant American culture. (3) Conservative Jews believe the code of laws come from God.. (2) Reform Judaism is the largest group. d. and familial dysautonomia j. and consumed k. The primary language is English. and there is general acceptance of interreligious marriage.S. Religious laws dictate how food is prepared. Jewish people believe that maintenance of one’s mental health is considered just as important as the maintenance of one’s physical health B. but accept a more liberal interpretation. Hebrew is used for prayers and is taught in Jewish religious education. Time orientation is simultaneously to the past. Impaired verbal communication . Jewish Americans are very health conscious i. reform. Gaucher’s disease. they reject the notion of divine intervention. conservative. They believe in the autonomy of the individual in interpreting the Jewish code of law.37 8. Four main Jewish religious groups exist today: Orthodox. and the future g. Formal education is highly respected value among the Jewish people. and Eastern Europe b. There are more than 5 million Jewish Americans living in the U. served. Nursing diagnoses for individuals with varied cultural influences may include: a. Culture-Bound Syndromes 1. Most are considered to be “illnesses. f. 2. e. The Jewish people came to the U. (4) Reconstructionists have modern views that generally override traditional Jewish laws. Many hold advanced degrees and are employed as professionals. Children are highly valued and are expected to be forever grateful to their parents for giving them the gift of life h.S. and reconstructionist (1) Orthodox Jews adhere to strict interpretation and application of Jewish laws and ethics. predominantly from Spain. while remaining true to Judaism’s values. the present. Portugal. Genetic diseases common in the Jewish population include TaySachs disease. The Torah is considered divine law. and a more liberal interpretation is followed.” and most have local names C. Germany.
less than body requirements d. can be a very powerful element in the healing process 3. facilitate coping. Hope may promote healing. May be life’s most powerful force and the greatest spiritual need b. Evaluation. Forgiveness . IV. 1. Based on accomplishment of previously established outcome criteria. loving relationship 5. A special kind of positive expectation—an energizing force b. Studies have shown that individuals can overcome the effects of a deleterious lifestyle if they have the benefit of a strong. Anxiety (moderate to severe) c. Refers to the human quality that gives meaning and sense of purpose to an individual’s existence 2. and enhance quality of life 4. Spiritual Concepts A. the environment. Studies show that faith. and a higher power B. Faith a. Planning/Implementation 1. Hope a. Imbalanced nutrition. Spiritual distress 2. and that any barriers to communication are eliminated E. Love a. Outcome criteria are identified for measuring the effectiveness of nursing care D. Spirituality 1. The acceptance of a belief in the absence of physical or empirical evidence b. Having a purpose in life gives one a sense of control and the feeling that life is worth living 2.38 b. combined with conventional treatment and an optimistic attitude. Emphasis is also placed on developing a trusting relationship with the client and his or her family. Spiritual Needs. May be an important key in the healing process by having a positive effect on the immune system c. Nurses must be able to assess the spiritual needs of their clients. Nursing intervention with clients whose beliefs are culturally influenced are aimed at insuring that those beliefs are not misunderstood and that nursing care includes elements that are important to the individual within his or her culture 2. Exists within each individual regardless of belief system and serves as a force for interconnectedness between the self and others. Meaning and purpose in life a.
Increased chance of survival following serious illness b. 1. A set of beliefs. values. Spiritual assessment tools may be used to gather needed information Diagnoses/Outcome Identification/Evaluation Nursing Diagnoses. Risk for impaired religiosity 5. Less juvenile delinquency d. . Spiritual distress 3. The following may be used when addressing spiritual and religious needs of clients: 1. There are more than 6. Risk for spiritual distress 2. Overall better physical and mental health 5. Long-held feelings of bitterness and resentment can have a detrimental effect on an individual’s health c. Improved mental illness outcomes 6. Less depression and other mental illness c.39 a.500 religions in the world 3. Readiness for enhanced religiosity Planning/Implementation 1. Lower drug use and abuse c. Readiness for enhanced spiritual well-being 4. and self-satisfaction C. contentment. E. Nurses must consider spiritual and religious needs when planning care for their clients 2. The practices are usually grounded in the teachings of a spiritual leader 2. Lower divorce rates e. D. Studies indicate that individuals who have a religious faith or attend church regularly experience: a. Impaired religiosity 6. This positive health and well-being may be related to the strong social support network found among members of a religious organization Assessment of Spiritual and Religious Needs 1. rites. Forgiveness offers freedom and peace of mind and enables a person to begin the pathway to healing Religion. Affiliation with a religious group has been shown to be a healthenhancing endeavor 4. F. and rituals adopted by a group of people. Longer life d. Lower suicide rates b. all sense of guilt and loss b. A religious commitment has been correlated with: a. G. peace. Nursing intervention with clients who have spiritual and religious needs is aimed at helping the client achieve meaning and purpose in life that reinforce hope. The ability to release from the mind all the past hurts and failures.
Evaluation. Review Questions . Based on accomplishment of previously established outcome criteria. Summary and Key Points VI.40 H. V.
the student will be able to: 1. 5. growth promotion. Identify goals of the nurse-client relationship. The nurse-client relationship is the foundation upon which psychiatric nursing is established. 6. RELATIONSHIP DEVELOPMENT CHAPTER FOCUS The focus of this chapter is to describe the role of the psychiatric nurse and the importance of a therapeutic relationship between client and nurse. Describe the relevance of a therapeutic nurse-client relationship. and/or illness prevention. OBJECTIVES After reading this chapter. Describe the phases of relationship development and the tasks associated with each phase. Discuss the importance of self-awareness in the nurse-client relationship. Identify and discuss essential conditions for a therapeutic relationship to occur. Introduction A. Steps in the development of a therapeutic relationship are discussed. 3. A therapeutic relationship is an interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing. Discuss the dynamics of a therapeutic nurse-client relationship. 2. B.41 CHAPTER 7. 4. . KEY TERMS attitude belief concrete thinking confidentiality countertransference empathy genuineness rapport sympathy transference unconditional positive regard values CORE CONCEPT therapeutic relationship CHAPTER OUTLINE/LECTURE NOTES I.
The nurse fulfills for the client basic needs associated with mothering. 2. both participants have needs met by the relationship. When this occurs. III. D. Therapeutic Use of Self A. Peplau believed that the emphasis in psychiatric nursing is on the counseling subrole. and directed at learning and growth promotion. C. Promote discussion of desired changes 3. and the overall human condition. The nurse uses “interpersonal techniques” to assist clients to learn to adapt to difficulties or changes in life experiences. Goals are often achieved through use of the problem-solving model: 1. Identify realistic changes 4. death. The teacher. independent member of the professional health-care team. 4. and ways to more adaptively cope with them 5. Assist client to evaluate outcomes of the change and make modifications as required IV. Discuss alternative strategies for creating changes the client desires to make 6. Identify the client’s problem 2. In the beginning.42 II. and a philosophical belief about life. The stranger. Provide positive feedback for client’s attempts to create change 10. V. Nurse must possess self-awareness. Peplau and Sullivan. 5. Hildegard Peplau identified six subroles within the role of the nurse: 1. The nurse identifies learning needs and provides information required by the client and/or family to improve the health situation. 6. Gaining Self-Awareness . The counselor. Weigh benefits and consequences of each alternative 7. emphasize the importance of relationship development in the provision of emotional care. Nursing has evolved through various roles as custodial caregiver and physician’s handmaiden to being recognized as a unique. self-understanding. Defined: The ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions. B. The resource person. 3. both interpersonal therapists. The leader. Democratic leadership allows the client to be an active participant in planning his or her care. Therapeutic relationships are goal oriented. C. nurse and client are strangers to each other. A therapeutic nurse-client relationship can only occur when each views the other as a unique human being. B. The nurse provides information related to the client’s health care. B. Assist client to select an alternative 8. Dynamics of a Therapeutic Nurse-Client Relationship A. Encourage client to implement the change 9. The surrogate. Role of the Psychiatric Nurse A. Discuss aspects that cannot be realistically changed.
and sincere desire to provide assistance when requested. Trust. VI. The part of the self that is unknown to both the individual and to others. to accept differences in others. Rapport. They may be judgmental. aspects of the self about which both the individual and others are aware. Values clarification is one process by which an individual may gain selfawareness. c. and to observe each person’s right to respect and dignity. The goal of increasing self-awareness by using the Johari Window is to increase the size of the quadrant that represents the open or public self. a. common interest. and a nonjudgmental attitude. Implies a feeling of confidence in another person’s presence. a sense of trust. The part of the self that is known to the individual. The Johari Window is a representation of the self and a tool that can be used to increase self-awareness. Increased self-awareness allows an individual to interact with others comfortably. b. integrity. d. a. contradictory evidence. selective. Abstract standards. The open or public self.43 A. Values differ from attitudes and beliefs in that they are action-oriented or action producing. b. The private self. . 1. veracity. B. Values. but which the individual deliberately and consciously conceals from others. b. Frames of reference around which an individual organizes knowledge about his or her world. Conditions Essential to Development of a Therapeutic Relationship A. The unknowing self. positive or negative. and biased. Beliefs may be: a. Rational—objective evidence exists to substantiate its truth. d. B. 2. The unknown self. but remains hidden from the awareness of the individual. Irrational—an individual holds the idea as true despite the existence of objective. Attitudes and beliefs flow out of one’s set of values. Attitudes have an emotional component. 3. The Johari Window 1. b. The part of the self that is known to others. c. reliability. 3. Held on faith—ideas that an individual holds as true for which no objective evidence exists. Attitudes and beliefs become values only when they have been acted upon. 2. Trust is the basis of a therapeutic relationship. friendliness. c. Beliefs. warmth. Stereotypical—the belief describes a concept in an oversimplified or undifferentiated manner. Attitudes. Ideas that one holds to be true. that is. The part of the self that is public. Implies special feelings on the part of both the client and the nurse based on acceptance. that represent an individual’s ideal mode of conduct and ideal goals. It is divided into four quadrants: a. Attitudes may be positive or negative.
B. Gather assessment data 4. Boundaries in the Nurse-Client Relationship A. Feelings about termination of the relationship are recognized and explored VIII. Formulate nursing diagnoses 6. Explore feelings of both client and nurse C. with sympathy. Maintain trust and rapport 2. Carl Rogers called this unconditional positive regard. fears. Examine one’s own feelings. Overcome resistance behaviors 5. Professional boundary concerns commonly include issues such as the following: . Set mutually agreeable goals 7. Create environment for trust and rapport 2. Genuineness. Progress has been made toward attainment of the goals b. and experiences a need to alleviate distress. Implies the dignity and worth of an individual regardless of his or her unacceptable behavior. or other health-team members. The Preinteraction Phase 1. It differs from sympathy in that. Empathy. 2. A plan of action for more adaptive coping with future stressful situations has been established c. A process wherein an individual is able to see beyond outward behavior and sense accurately another’s inner experience at a given time. B. Respect. The Working Phase 1. Professional boundaries limit and outline expectations for appropriate professional relationships with clients. Genuineness implies congruence between what is felt and what is being expressed. and anxieties about working with a particular client. Continuously evaluate progress toward goal attainment 6. significant others. Transference and countertransference a. Transference occurs when the client unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person from the past b. D. Identify client’s strengths and weaknesses 5. Use problem-solving model to work toward achievement of established goals 4. Promote client’s insight and perception of reality 3. and “real” in interactions with the client.44 C. Establish contract for intervention 3. The Orientation (Introductory) Phase 1. honest. Refers to the nurse’s ability to be open. the nurse actually shares what the client is feeling. The Termination Phase 1. Therapeutic conclusion of the relationship occurs when a. Countertransference refers to the nurse’s behavioral and emotional response to the client D. Obtain information about the client from chart. Develop a realistic plan of action 8. VII. With empathy the nurse’s feelings remain on an objective level. E. Phases of a Therapeutic Nurse-Client Relationship A.
or similar personal relationships are never appropriate between nurse and client. Friendship or romantic association. Self-disclosure (on the part of the nurse) can be appropriate if is it judged to be therapeutic for the client. Receiving of gifts or continued contact/communication with the client after discharge IX. Keeping secrets with a client 3. Sharing personal information or work concerns with the client 9. 3. Caring touch is the touching of clients when there is no physical need. Frequently thinking about the client when away from work 8. Accepting a financial gift is never appropriate. Cultural issues must be taken into consideration. Changing dress style for working with a particular client 4. 2. Touch.45 1. Spending free time with a client 7. Romantic. sexual. C. Highly anxious or suspicious clients may interpret touch as threatening. 4. Favoring a client’s care over another’s 2. Gifts may also be shared among all staff members. Cultural issues must enter into the decision. Giving special attention or treatment to one client over others 6. Swapping client assignments to care for a particular client 5. Individuals often feel the need to present the nurse with tangible evidence of their appreciation. It often provides comfort and encouragement and can have a therapeutic effect on the client. Warning signs that indicate that professional boundaries of the nurse-client relationship may be in jeopardy: 1. Gift-giving. Review Questions . Summary and Key Points X.
4. and a description of therapeutic and nontherapeutic techniques is given. and distance as components of the environment. Discuss the transactional model of communication. Describe active listening. THERAPEUTIC COMMUNICATION CHAPTER FOCUS The focus of this chapter is to introduce the student to the concept of communication. Discuss therapeutic feedback. II. and simultaneously engage in the process of creating meaning in a relationship. B. Both verbal and nonverbal components of expression are discussed. listen to each other. Define territoriality. . density. 7. 5. In the transactional model. Both persons participate simultaneously. Interpersonal communication is a transaction between the sender and the receiver. for they are the “tools” of psychosocial intervention. 6. 3. 2. KEY TERMS density distance intimate distance paralanguage personal distance public distance social distance territoriality CORE CONCEPTS communication therapeutic communication CHAPTER OUTLINE/LECTURE NOTES I. Identify components of nonverbal expression. OBJECTIVES After reading this chapter. the student will be able to: 1. Introduction: The nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client. What Is Communication? A. Describe therapeutic and nontherapeutic verbal communication techniques. both participants perceive each other. Identify types of preexisting conditions that influence the outcome of the communication process.46 CHAPTER 8.
IV. 3. (1) Intimate distance—the closest distance that individuals will allow between themselves and others. attitudes. norms. Example: Unkempt . Examples: Attitudes of prejudice are expressed through negative stereotyping.. 2. Age or developmental level. a. Nonverbal Communication A. (3) Social distance—conversations with strangers or acquaintances (e. Examples: Territoriality. The Impact of Preexisting Conditions A. c. it is 18 to 40 inches. more frequent use of hands on hips. Social status. Gender. it is 4 to 12 feet. and distance are aspects of environment that communicate messages. 1. The influence of developmental level on communication is especially evident during adolescence. it is 0 to 18 inches. 4. power dressing. In the U. Territoriality—the innate tendency to own space. A person who values youth may dress and behave in a manner that is characteristic of one who is much younger. Examples: Less eye contact. High status persons often convey their high-power position with gestures. b. All individuals lay claim to certain areas as their own. Distance—the means by which various cultures use space to communicate.S. criminal activity. Environment in which the transaction takes place. such as aggression. Ways in which individuals dress or wear their hair conveys a message to all who observe their appearance. and customs provide the basis for our way of thinking.47 III. such as close conversations with friends.. (2) Personal distance—interactions that are personal in nature. In the U. Values. and hostility. 5. ideas. 6. Some messages about religion are conveyed by wearing crosses around one’s neck or hanging crucifixes on the wall. and feel safer in their own area. and more distance when communicating with individuals considered to be of lower social status. Physical Appearance and Dress.S. Cultural mores.. Example: Sign language is a unique system of gestures used by individuals who are deaf or hearing impaired. stress. Culture or religion. the distance exceeds 12 feet. Masculine and feminine gestures influence messages conveyed in communication with others. at a cocktail party). In the U. greater height. and beliefs...g. Both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted. Prolonged exposure to high-density situations elicits certain behaviors. density. Examples: Men who hug each other on the street give a different message in the Italian culture than they would in the American culture. Density—the number of people within a given environmental space. louder voice pitch.S. Examples: Differences in posture and gender roles within various cultures. In the U. (4) Public distance—speaking in public or yelling to someone some distance away. more relaxed posture.S.
2. D. Staring or gazing can make another feel very uncomfortable. head and eyes pointed downward conveys a message of low self-esteem. It consists of pitch. and emphasis assigned to certain words. and keeping the hands still. the rate of speaking. Standing tall with head high and hands on hips indicates a superior status over the person being addressed. F. Vocal Cues or Paralanguage. The way in which an individual positions his or her body communicates messages regarding self-esteem. Functional-professional—impersonal. fear. Encourages the client to continue. Allows the client to take control of the discussion. such as happiness. indicating awareness. expressively placed pauses. . Example: A handshake. V. Acknowledging. G. 3. 5. 4. The face can give multiple messages. Eye contact conveys a personal interest in the other person. Sitting with legs crossed at the thighs sometimes depicts feminine identity. doubt. F. surprise. Giving Recognition. Next to human speech.” Social and cultural rules dictate where we can look. C. E. Example: Touching another in the genital region. and at whom we can look. Therapeutic Communication Techniques A.48 appearance may give an impression to some people that the individual is sloppy and irresponsible. tone. Love-intimacy—conveys an emotional attachment or attraction for another person. Giving Broad Openings. gender identity. facial expression is the primary source of communication. Accepting. Making oneself available. sadness. anger. Types of touch: 1. when we can look. 4. mutual embrace. Making Observations. Clarifies the relationship of events in time. Example: A tailor fitting a suit for a customer. B. direct eye contact. businesslike touch. Friendship-warmth—indicates a strong liking for another person. Example: To engage in a strong. for how long we can look. and loudness of spoken messages. and disgust. D. status. Allows the client to select the topic. Facial Expressions. E. Warmth is conveyed by a smile. How a message is verbalized can be as important as what is verbalized. Slumped posture. Example: Laying one’s hand upon the shoulder of another. 3. Offering Self. and interpersonal warmth or coldness. Examples: 1. Offering General Leads. Paralanguage is the gestural component of the spoken word. depending on cultural interpretation. Placing the Event in Time or Sequence. Sexual arousal—an expression of physical attraction. H. if they so desire B. Eye Behavior. 2. Using Silence. Social-polite—impersonal. but affirming. C. Body Movement and Posture. Conveys positive regard. Eyes have been called the “windows of the soul. Touch. Can elicit both negative and positive reactions. Verbalizing what is observed or perceived.
To defend what the client has criticized implies that he or she has no right to express ideas. Encourages the client to project blame for his or her thoughts or behaviors upon others. Putting into words what the client has only implied. M. S. These are meaningless in a nurse-client relationship. Giving Approval or Disapproval. and that the client is incapable of any self-direction. P. Putting into words the feelings that client has expressed only indirectly. J.” E. Focusing. Asking the client to verbalize what is being perceived. Using Denial. or feelings. Giving Advice. T. Verbalizing the Implied. Rejecting. Requesting an explanation. Attempting to Translate Words into Feelings.49 I. J. opinions. Asking “Why?” implies that the client must defend his or her behavior or feelings. Encouraging Description of Perceptions. K. G. Questions or feelings are referred back to the client so that they may be recognized and accepted. Exploring. Expressing uncertainty as to the reality of the client’s perceptions. Implies that the nurse knows what is best for the client. F. Belittling Feelings Expressed. Agreeing/Disagreeing. Voicing Doubt. Striving to explain that which is vague and searching for mutual understanding. Causes the client to feel insignificant or unimportant. Q. Nontherapeutic Communication Techniques A. L. D. Delving further into a subject. L. Encouraging Comparison. Formulating a Plan of Action. experiences. Presenting Reality. K. Asking the client to compare similarities and differences in ideas. experience. Probing. I. May discourage the client from further expression of feelings if he or she believes they will only be belittled. Defending. Blocks discussion with the client and avoids helping the client identify and explore areas of difficulty. Pushing for answers to issues the client does not wish to discuss causes the client to feel used and valued only for what is shared with the nurse. M. Seeking Clarification and Validation. Implies that the nurse has the right to pass judgment on the “goodness” or “badness” of the client’s behavior. B. VI. N. Restating. Clichés. Interpreting. Indicating the Existence of an External Source of Power. Results in the therapist telling the client the meaning of his or her experience. C. Implies that the nurse has the right to pass judgment on whether the client’s ideas or opinions are “right” or “wrong. or interpersonal relationships. Refusing to consider the client’s ideas or behavior. Lets the client know whether an expressed statement has been understood or not. . or relationship. Clarifying misperceptions that the client may be expressing. Reflecting. idea. Strives to prevent anger or anxiety from escalating to an unmanageable level the next time the stressor occurs. O. Taking notice of a single idea or even a single word. H. Giving Reassurance. and Trite Expressions. R. Making Stereotyped Comments.
Feedback is descriptive rather than evaluative and focuses on the behavior rather than on the client. 5. VII. 2. Introducing an Unrelated Topic. Feedback should be specific rather than general. To listen actively is to be attentive to what the client is saying. both verbally and nonverbally. Review Questions . They can be identified by the acronym SOLER: 1. Summary and Key Points XI. Feedback is useful when it is conveyed in the following manner: 1. They are written by the nurse or student as a tool for improving communication techniques. Feedback should be well timed. Feedback should impart information rather than offer advice. Several nonverbal behaviors have been designed as facilitative skills for attentive listening. 4. L—Lean forward toward the client 4. E—Establish eye contact 5. IX. Feedback should be directed toward behavior that the client has the capacity to modify. R—Relax VIII. B. 3. S—Sit squarely facing the client 2. Causes the nurse to take over the direction of the discussion. X. Active Listening A. Process Recordings A. O—Observe an open posture 3.50 N. Feedback A. Process recordings are written reports of verbal interactions with clients.
Define and discuss the use of case management and critical pathways of care in the clinical setting. 3. Describe the benefits of using nursing diagnosis. and the concept of case management is described. Document client care that validates use of the nursing process. Documentation to the nursing process is discussed. Discuss the list of nursing diagnoses approved by NANDA International for clinical use and testing. 7. the student will be able to: 1. KEY TERMS case management case manager concept mapping critical pathways of care Focus Charting interdisciplinary managed care nursing interventions classification (NIC) nursing outcomes classification (NOC) nursing process PIE charting problem-oriented recording CORE CONCEPTS assessment evaluation nursing diagnosis outcomes . THE NURSING PROCESS IN PSYCHIATRIC/MENTAL HEALTH NURSING CHAPTER FOCUS The focus of this chapter is to introduce the reader to each of the six steps of the nursing process and identify its use in psychiatric nursing. Identify six steps of the nursing process and describe nursing actions associated with each. Define nursing process. 4. Apply the six steps of the nursing process in the care of a client within the psychiatric setting. 5.51 CHAPTER 9. 2. OBJECTIVES After reading this chapter. 6.
standardized classification of patient outcomes developed to evaluate the effects of nursing interventions. Planning. and complementary intervention with applied clinical skills to restore the patient’s health and prevent further disability. Implementation. enhance the abilities of other clinicians to provide services for patients. a. 2. biological. using evidence-based psychotherapeutic frameworks and nurse-patient therapeutic relationships. Data from the assessment are analyzed. Health teaching and health promotion c. Standards of Practice. couples. Incorporating knowledge of pharmacological. (3) Consultation—to influence the identified plan. Milieu therapy—providing and maintaining a therapeutic environment for the client d. Pharmacological. groups. NIC interventions are based on research and reflect current clinical practice. not static B. The collection of health data pertinent to the patient’s health or situation. b. Uses a problem-solving approach 3. They must be measurable and estimate a time for attainment. standardized language describing treatments that nurses perform in all settings and in all specialties. Nursing Interventions Classification (NIC)—a comprehensive. (2) Psychotherapy—with individuals. Nursing Outcomes Classification (NOC)—a comprehensive. Assessment. Interventions selected during the planning stage are executed. . 5. Dynamic. Expected outcomes of care are identified. Definition 1. Outcomes identification.52 CHAPTER OUTLINE/LECTURE NOTES I. Advanced practice interventions also include: (1) Prescriptive authority and treatment—in accordance with state and federal laws and regulations. The standards of practice for psychiatric nursing are written around the six steps of the nursing process: 1. Goal-directed toward the delivery of quality client care 4. e. and effect change. The Nursing Process A. Specific interventions include: a. 3. Evidence-based interventions for achieving the outcome criteria are selected. a. Diagnoses and potential problem statements are formulated and prioritized. and families. Coordination of care b. 4. Diagnosis. biological. and integrative therapies. A systematic framework for the delivery of nursing care 2.
Both general and specialty standards are written around the six steps of the nursing process. decrease fragmentation. Evaluation. CPCs are used by the entire interdisciplinary team. It is defined in most state nursing practice acts as a legal responsibility of nursing. Applying Nursing Process in the Psychiatric Setting A. D. Concept Mapping A. Measures progress toward attainment of expected outcomes. nursing diagnoses. Identification and classification of nursing phenomena began in 1973 with the first task force to name and classify nursing diagnoses. Why Nursing Diagnosis? A. It is an abbreviated plan of care on which outcome-based guidelines for goal achievement within a designated length of time have been established. 4. who determines what categories of care are to be performed. III. scope of practice. and treatments. and by whom. Managed Care. feelings. assessment data. 3. C. V. Individuals receive care based on need. CPCs may be standardized. To assist the client to successfully adapt to stressors within the environment. Role of the Nurse in Psychiatry 1. 2. 3. enhance the client’s quality of life. Case Manager. 2. B. Critical Pathways of Care (CPCs) 1. . and contain costs. CPCs are the tools for provision of care in a case management system. by what date. and behaviors that are age-appropriate and congruent with local and cultural norms. of which nursing diagnosis is an inherent part. B. Goals are directed toward change in thoughts. Nursing Case Management A. providing a service that is unique and based on sound knowledge of psychopathology. C. A diagrammatic teaching and learning strategy that allows students and faculty to visualize interrelationships between medical diagnoses. IV. Nurses may be identified as case managers and will be ultimately responsible for ensuring that goals on the CPC are achieved within the designated time dimension. II. and legal implications of the role.53 6. D. Defined: A health delivery process whose goals are to provide quality health care. The individual responsible for negotiating with multiple health-care providers to obtain a variety of services for the client. It promotes research in nursing. A CPC can be viewed as protocol for the client with problems for which a designated outcome can be predicted. The nurse is a valuable member of the interdisciplinary team. which is determined by coordinators of the providership. because they are intended to be used with uncomplicated cases. A concept designed to control the balance between cost and quality of care.
Has a list of problems as its basis b. Problem-oriented recording (POR) a. Based on the components of the nursing process. A focus may be: (1) A nursing diagnosis (2) A current client concern or behavior (3) A significant change in the client’s status or behavior (4) A significant event in the client’s therapy b. Helps students develop a holistic view of their clients. and self-monitoring. objective. It utilizes flow sheets as accompanying documentation c. VI. assessment. Improvement in control of chronic illnesses through computer-based client education. Easier access to computerized test results. and response (DAR) format 3. . B. Computer-based order entries are safer and more efficient. intervention. Documentation of the steps of the nursing process is often considered as evidence in determining certain cases of negligence by nurses. Efficiency of health-care organizations is increased through electronic scheduling systems. 7. and evaluation (SOAPIE) format 2. C. The “A PIE” method a. Focus charting a. It is also required by some health-care organization accrediting agencies. 2. Improved communication among health-care providers enhances client safety and quality of care. Results management. action. It uses an assessment. Administrative processes. Health information and data. Documentation of the Nursing Process A. B. intervention. Main perspective is to choose a “focus” for documentation. C. Most health-care facilities have implemented—or are in the process of implementing—some type of electronic health records (EHRs) or electronic documentation system. plan. Electronic Documentation A. More rapid access to patient information. 3. self-testing. Patient support. The focus cannot be a medical diagnosis c. It uses a data. C. and evaluation (A PIE) format VII. 6. 4. Electronic communication and connectivity. Examples of documentation that reflect use of the nursing process: 1.54 B. Order entry/order management. Decision support. problem. Uses subjective. Eight core functions that EHR systems should perform in the delivery of more efficient health care include: 1. 5. A problem-oriented system b. EHRs have been shown to improve both the quality of client care and the efficiency of the health-care system. Information support systems enhance clinical performance for many aspects of health care.
55 8. Computer-assisted reporting increases speed and accuracy. Summary and Key Points IX. Review Questions . Reporting and population health management. VIII.
Defined A. B. Describe the phases of group development. Discuss psychodrama as a specialized form of group therapy. Identify various types of groups. Describe physical conditions that influence groups. Identify various roles that members assume within a group. . Discuss “curative factors” that occur in groups. Clients learn from each other in a group setting. 2. 5. OBJECTIVES After reading this chapter. 4. Define a group. II. 7. Identify various leadership styles in groups. the student will be able to: 1. values. Introduction A. THERAPEUTIC GROUPS CHAPTER FOCUS The focus of this chapter is on the dynamics and functions of therapeutic groups. 3. 6. or purpose. The role of the nurse in this type of intervention is explored. Health-care professionals not only share their personal lives with groups of people but also encounter multiple group situations in their professional operations. A collection of individuals whose association is founded on shared commonalities of interest. 10. KEY TERMS altruism autocratic catharsis democratic laissez-faire psychodrama universality CORE CONCEPTS group group therapy CHAPTER OUTLINE/LECTURE NOTES I. 9. Describe the role of the nurse in group therapy. norms. Discuss eight functions of a group. The Group. 8.56 CHAPTER 10.
or medicine. Camaraderie. as well as group content (the topic or issue being discussed in the group). A group formed to accomplish a specific outcome. Empowerment. by choice (voluntary affiliation). Individuals receive joy and pleasure from interactions with significant others. Types of Groups A. a circle of chairs is better than chairs set around a table. Teaching Groups. Groups provide assistance in endeavors that result in more effective outcomes than can be achieved by an individual alone. For example. Focus is to convey knowledge and information to a number of individuals. Functions of a Group A. Different groups enforce the established norms in various ways. Composed of individuals with a similar problem. D. B. Focus is on group relations. and leadership often rotates from member to member. interactions between group members. The concern of these groups is to prevent possible future upsets by educating the participants in effective ways of dealing with emotional stress arising from situational or developmental crises. Fellow members are available in time of need. H. 1. Membership in a group is generally by chance (born into a group). Therapeutic groups are based to a lesser degree in theory. Size. social work. group therapy a. V. F. nursing. III. Group therapy has a sound theoretical base and the leaders generally have advanced degrees in psychology. Informational. Support. Run by members. May or may not have a professional leader. Leaders of both types of groups must be knowledgeable about group process (the way in which group members interact with each other). or by circumstance (the result of life-cycle events over which an individual may or may not have control). E. It is best when there is no barrier between the members. Size of the group makes a difference in the interaction among . G. C. Task Completion. Socialization. Learning takes place when group members share their knowledge with the others in the group. Governance.57 B. and the consideration of a selected issue. b. Normative. C. Self-help groups. The teaching of social norms. Task Groups. IV. Seating. Therapeutic groups vs. Groups often can bring about change at times when individuals alone are ineffective. B. Serve to reduce the possibilities of further emotional distress leading to pathology and necessary treatment. Supportive/Therapeutic Groups. c. Large organizations often have leadership that is provided by groups rather than by a single individual. B. Physical Conditions That Influence Group Dynamics A. D.
Individuals provide assistance and support to each other. I. members are able to express both positive and negative feelings. Universality. and feelings they are experiencing. D. Two types of groups exist: open-ended groups (those in which members leave and others join at any time during the existence of the group) and closed-ended groups (those in which all members join at the time the group is organized and terminate at the end of the designated length of time). B. Curative Factors A. The Development of Socializing Techniques. C. H. Group members are able to reexperience early family conflicts that remain unresolved. Existential Factors. Members develop a sense of belonging that separates the individual (“I am”) from the group (“we are”). The Instillation of Hope. individuals are able to correct maladaptive social behaviors and learn and develop new social skills. Within the group. Group members share their knowledge with each other. C. Group members who have mastered a particular psychosocial skill or developmental task serve as valuable role models for others.58 members. The group is able to help individual members take direction of their own lives and to accept responsibility for the quality of their existence. Membership. By observing the progress of others in the group with similar problems. thereby helping to create a positive self-image and promote self-growth. The Imparting of Information. Individuals come to realize that they are not alone in the problems. 2. The group offers many and varied opportunities for interacting with other people. E. Initial or Orientation Phase 1. Trust has not yet been established. J. a group member garners hope that his or her problems can also be resolved. The Corrective Recapitulation of the Primary Family Group. Leader and members work together to establish rules and goals for the group. Middle or Working Phase . B. VI. Interpersonal Learning. The leader promotes trust and ensures that the rules do not interfere with the fulfillment of the goals. Altruism. Seven or eight members provides a favorable climate for optimal group interaction and relationship development. Group Cohesiveness. Imitative Behavior. Leaders of teaching groups also provide information to group members. G. F. K. Phases of Group Development A. Members are superficial and overly polite. thoughts. VII. Through interaction with and feedback from other members within the group. Catharsis. 3.
support groups for clients with similar problems. B. Other members of the group play the roles of people with whom the protagonist has unresolved issues. B. Nurses who work as psychodramatists require specialized training beyond the master’s degree. and the group leader is called the director. assertiveness training. Production is somewhat lower than it is with autocratic leadership. Defined as a type of therapeutic group that employs a dramatic approach in which clients become “actors” in life-situation scenarios. IX. transition to discharge groups. XI. Group members who do not participate in the drama act as the audience. 2. Psychodrama A. The focus is on the leader. Roles that serve to fulfill personal or individual needs. The Role of the Nurse in Group Therapy A. Maintenance roles. on whom the members are dependent for problem solving. Grief for previous losses may be triggered. Goals are undefined. decision making. Nurses who work in psychiatry may lead various types of therapeutic groups. precipitating the grief process. There is no focus in this type of leadership. Members play one of three types of roles within a group: 1. Roles that serve to maintain or enhance group processes. 3. Democratic. The purpose is to provide the client with a safe place in which to confront unresolved conflicts. A sense of loss. and permission to perform. including taking action to effect change. Individual (personal) roles. 2. The focus is on the members. Trust has been established between the members and cohesiveness exists. and to reminisce about the accomplishments of the group. but morale is much higher. The leader encourages the group members to discuss these feelings of loss. C. Task roles. such as client education groups. C. Production is high. Productivity and morale are low. . Member Roles A. Final or Termination Phase 1. may be experienced by group members. but morale is low. and members do as they please. Productive work toward completion of the task is undertaken. Feelings of abandonment may be experienced by some members. who are encouraged to participate fully in problem solving of issues that relate to the group. and hopefully progress toward resolution. 2. VIII. 3. and others. Leader role diminishes and becomes more one of facilitator. Roles that serve to complete the task of the group. Laissez-faire. An identified client (called the protagonist) is selected to portray a life situation. 3. D. Leadership Styles A.59 1. C. Conflict is managed by the group members themselves. Autocratic. X. parent groups.
60 B. Guidelines set forth by the American Nurses’ Association specify that nurses who serve as group psychotherapists should have a minimum of a master’s degree in psychiatric nursing. Summary and Key Points XIII. Review Questions . XII.
KEY TERMS boundaries disengagement double-bind communication enmeshment family structure family system genogram marital schism marital skew paradoxical intervention pseudohostility pseudomutuality reframing scapegoating subsystems triangles CORE CONCEPTS family family therapy CHAPTER OUTLINE/LECTURE NOTES I.61 CHAPTER 11. 8. Discuss the essential components of family systems. Discuss characteristics of adaptive family functioning. Describe major variations to the American middle-class family life cycle. INTERVENTION WITH FAMILIES CHAPTER FOCUS The focus of this chapter is to introduce the student to the concept of psychotherapy with the family as a unit. Define the term family. Types of families: 1. 4. Apply the steps of the nursing process in therapeutic intervention with families. B. 3. 7. 6. Theoretical components of selected therapeutic approaches are described. 2. Identify stages of family development. and strategic therapies. Construct a family genogram. OBJECTIVES After reading this chapter. the student will be able to: 1. Biological family of procreation 2. Describe behaviors that interfere with adaptive family functioning. structural. Stages of family development and the characteristics of adaptive and maladaptive family functioning are discussed. Introduction A. Family defined: A family is who they say they are. Nuclear family (that incorporates one or more members of the extended family) . 5.
repetitive relationship patterns. D. Nurse generalists provide support and referrals to families of ill clients. Advancing toward financial independence 3. 1. Establishing intimate peer relationships c. Tasks: a. and larger community 3.62 3. 2. Goal: Accepting separation from parents and responsibility for self. B. The homosexual couple or family C. Realigning relationships with members of the extended family. Stage 4. The stepfamily 5. Goal: Commitment to the new system. Problems arise when either the young adult or the parents have difficulty separating from the previous interdependent relationship. E. Stage 1. Integrating the roles of extended family members into the family 3. Goal: Accepting a new generation of members into the system. Tasks: a. 1. Nurse specialists may perform family therapy. Forming an identity separate from the parents b. maladaptive. Goal: Increasing the flexibility of family boundaries to include children’s independence and grandparents’ frailties. The single young adult. Problems arise when either partner has difficulty separating from family of origin or when the couple cuts itself off completely from extended family. The sole-parent family 4. Stages of Family Development A. a sense of belonging. Establishing a new identity as a couple b. The communal family 6. Adjusting the couple system to make space for children b. Tasks: a. C. 1. 2. F. The family with young children. II. The family with adolescents. friends. 2. Tasks: a. The family joined through marriage/union. D. Problems arise when the parents’ lack of knowledge about normal childhood development interferes with satisfactory childrearing. Sharing equally in the tasks of childrearing c. 1. strong emotional ties. They should be familiar with the tasks of adaptive family functioning. Stage 2. Family therapy defined: A form of intervention in which members of a family are assisted in identifying and changing problematic. Stage 3. as well as self-defeating or self-limiting belief systems. 2. Families may be more appropriately determined based on attributes of affection. and durability of membership. Shifting of parent-child relationships to permit adolescents to move in and out of the system .
Separation d. Realigning relationships with extended family . Divorce 1. Tasks: a. Problems arise when older adults have failed to fulfill the tasks of earlier stages and are dissatisfied with the way their lives have gone. Divorce 4. Major Variations A. disabilities. or the death of their own parents. Refocusing on midlife couple and career issues c. Deciding to divorce b. life review and integration d. Stage 5. Stage 6. Beginning a shift toward concerns for the older generation 3. Currently in the United States. F. Problems arise when parents are unable to relinquish control and allow the adolescent increasing autonomy or when the parents cannot agree and support each other in this effort. and death of parents (grandparents) 3. 2. 1. 3. Development of adult-to-adult relationships between grown children and parents c. Support for a more central role for the middle generation c. Managing reversed roles in caretaking between middle and older generations 3. or when the couple bond has deteriorated. approximately one-third of all first marriages end in separation or divorce within 10 years. 2. Planning the break-up of the system c. and preparation for own death. The family in later life. Problems arise when parents are unable to accept the departure of their children from the home and their status as adults. Goal: Accepting a multitude of exits from and entries into the family system. Goal: Accepting the shifting of generational roles and the realities of limitations and death. Tasks: a. Dealing with loss of spouse. Stages in the family life cycle of divorce: a. Accepting one’s own part in the failure of the marriage b. Realignment of relationships to include in-laws and grandchildren d. 1. Dealing with care needs. Maintaining own and/or couple functioning and interests in face of physiological decline b. Tasks: a.63 b. Some indication that this trend may be declining. Renegotiation of couple system as a dyad b. III. siblings. 2. and other peers. Working cooperatively on problems related to custody and visitation of children and finances c. E. The family launching children and moving on in midlife.
Stages in the remarried family life cycle: a. b. Encouraging healthy relationships with biological (noncustodial) parents and grandparents 5. Cultural Variations 1. having children is seen as a scriptural and social obligation. In traditional Asian American cultures. Attitudes toward marriage are strongly influenced by Roman Catholicism in many Italian American and Latino American families. Realigning relationships with extended family to include new spouse and children e. d. 3. the father is considered the authority figure and head of the household and the mother assumes the role of homemaker and caretaker. sons are more highly valued than are daughters. Remarriage 1. In the traditional Jewish community. 3. Entering the new relationship b. In many ethnic subcultures. strong family influence on mate selection still exists. Children a. Planning the new marriage and family c. Marriage a. Extended family a. b. 4. Latino. C. Problems arise when there is a blurring of boundaries between custodial and noncustodial families. . Maintaining open communication c. Italian. Tasks: a. 2. The rate of redivorce for remarried couples is even higher than the divorce rate following first marriages. Older family members are valued for their wisdom in Asian. c. and Iranian subcultures. Jewish American families are as diverse as the mainstream culture. Facing fears d. and the most important child is the oldest son. In Asian American families. and large numbers of children are encouraged. c.64 d. Making a firm commitment to confronting the complexities of combining two families b. Roman Catholicism promotes marital relations for procreation. 2. Caution must be taken in generalizing about variations in family life cycle development according to culture. although marriages are no longer arranged. Remarriage and reestablishment of family 4. Mourning the loss of the marriage relationship and the intact family B. About three-fourths of those who divorce will eventually remarry.
65 b. Family members’ expectations a. Functional families strive to reinforce and strengthen each member’s self-concept. flexible. b. Several generations within these subcultures may live together and share tasks of childrearing. with the positive results being that family members feel loved and valued. Six elements on which families are assessed to be either functional or dysfunctional 1. and individualized. a low rate of divorce has existed among those cultures that are largely Catholic. Family members are encouraged to express honest feelings and opinions. Family Functioning A. Behaviors that interfere with functional communication include the following: (1) Making assumptions—assuming to know what another person is thinking or feeling without checking to make certain (2) Belittling feelings—ignoring or minimizing another’s feelings when they are expressed (3) Failing to listen—one does not hear what the other individual is saying (4) Communicating indirectly—seeking to communicate to another through a third person (5) Presenting double-bind messages—sending conflicting messages to another (verbal communication may not be congruent with nonverbal communication) 2. and all members participate in decisions that affect the family system. Behaviors that interfere with adaptive functioning in terms of member expectations include the following: . divorce is often seen as a violation of family togetherness. 5. b. b. IV. Communication a. In the Jewish community. In functional families. Self-concept reinforcement a. Because of the opposition to divorce by Roman Catholicism. Divorce a. b. expectations are realistic. Behaviors that interfere with self-concept reinforcement include: (1) Expressing denigrating remarks—“put-downs” that send messages that the individual is worthless or unloved (2) Withholding supportive messages—individuals who were not supported and reinforced by significant others are often unable to provide this type of support to others (3) Taking over—doing things for another and thereby failing to permit that person to develop a sense of responsibility and selfworth 3.
A dysfunctional family climate is evidenced by tension. guilt. and a general feeling of well-being. A positive family climate is founded on trust and is reflected in openness. and destructive. but in practice may destroy healthy interactional patterns 6. b. selfdefeating. and promote the needs of all family members. Family interactional patterns a. expressions of caring. They are dysfunctional when they become contradictory. b. Functional families understand that it is acceptable to disagree and deal with differences in an open. and making statements that devalue the worth of others (2) Patterns that perpetuate or intensify problems rather than solve them—occurs when unresolved problems are ignored. pain. parent-child subsystems. Family climate a. frustration. V. and then ignoring similar problems becomes the pattern of interaction (3) Patterns that are in conflict with each other—family rules that appear to be functional on the surface.66 (1) Ignoring individuality—expecting others to do things or behave in ways that do not fit with the latter’s individuality or current life situation (2) Demanding proof of love—placing conditions on an individual’s behavior as proof of love 4. and feelings of hopelessness. . physical disabilities. Family interactional patterns are functional when they are workable. and sibling subsystems. persistent anger. The Family as a System 1. Therapeutic Modalities With Families A. appropriate humor and laughter. The family can be viewed as a system composed of various subsystems. such as the marital subsystem. b. constructive. nonattacking manner. Examples include: (1) Patterns that cause emotional discomfort—behaviors such as never admitting making a mistake. rigidity in life situations. a valuing of the quality of each individual. Behaviors that interfere with successful family negotiations are: (1) Attacking—when differences of opinion become a personal attack by one individual on another (2) Avoiding—differences are not discussed by an individual who fears that the other person will withdraw love or approval or become angry in response to the disagreement (3) Surrendering—an individual avoids expressing a difference of opinion for fear of angering another person or losing approval and support 5. mutual respect. Handling differences a.
Major concepts: a. They provide an overall picture of the life of the family over several generations. when anxiety occurs because of lack of differentiation on the part of one of the marital partners (called scapegoating) e. b. Techniques: (1) Defining and clarifying the relationship between the family members (2) Helping family members develop one-to-one relationships with each other and minimizing triangles within the system (3) Teaching family members about the functioning of emotional systems (4) Promoting differentiation by encouraging members to speak as individuals rather than as a family unit B. Systems—the structure of the family system is founded on a set of invisible principles that influence the interaction among family members . Societal emotional process—compares society’s response to stress to the same type of response seen in individuals and families in response to emotional crisis 3. independent of others b. Goal and techniques of therapy a. Emotional cutoff—the degree to which individuals cut themselves off from the family of origin (often related to unresolved emotional attachment) h. while remaining in touch with the family system.67 2. A major contributor to this theory is Murray Bowen. Family projection process—the process of blaming a third person. Goal: To increase the level of differentiation of self. usually a child. He has identified the following major concepts: a. 2. Differentiation of self—the ability to define oneself as a separate being. Nuclear family emotional process—the patterns of emotional functioning in a single generation d. The family is viewed as a social system within which the individual lives and to which the individual must adapt. Triangles—a three-person emotional configuration that is considered the basic building block of the family system c. Multigenerational transmission process—the manner in which interactional patterns are transferred from one generation to another (1) Genograms—a useful tool to plot a multigenerational assessment. f. Sibling position profiles—the position one holds in a family influences the development of predictable personality characteristics g. The Structural Model 1.
68 b. Transactional patterns—the “laws” that have been established over time that organize the ways in which family members relate to one another c. Subsystems—smaller elements that make up the larger family system. Individual subsystems can be united by gender, relationship, generation, interest, or purpose d. Boundaries—the level of participation and interaction among subsystems. Boundaries may be rigid or diffuse. Rigid boundaries promote disengagement, or extreme separateness, among family members. Diffuse boundaries promote enmeshment, or exaggerated connectedness, among family members. 3. Goal and techniques of therapy a. Goal: To facilitate change in the family structure. b. Techniques: (1) Joining the family—the therapist becomes a part of the family system during therapy (2) Evaluating the family structure—assessment is made of the family transactional patterns, system flexibility and potential for change, boundaries, family developmental stage, and role of the identified patient within the system (3) Restructuring the family—the therapist manipulates the system and facilitates the circumstances and experiences that can lead to structural change C. The Strategic Model 1. The strategic model uses the interactional or communications approach. 2. Communication theory is viewed as the foundation for this model. 3. Functional families are open systems with clear, precise messages that are congruent with the situation. 4. Dysfunctional families are viewed as closed or partially closed, communication is vague, and messages are often inconsistent and incongruent with the situation. 5. Major concepts: a. Double-bind communication—a pattern of communication that occurs when a statement is made and succeeded by a contradictory statement or nonverbal behavior that is inconsistent with the verbal communication b. Pseudomutuality—a facade of mutual regard that allows family members to deny underlying fears of hostility and separation c. Pseudohostility—a facade of chronic conflict that allows family members to deny underlying fears of tenderness and intimacy
69 d. Marital schism—a state of severe chronic disequilibrium and discord, with recurrent threats of separation e. Marital skew—a relationship in which one partner dominates the relationship and the other partner 6. Goal and techniques of therapy a. Goal: To create change in destructive behavior and communication patterns among family members. The identified problem is the focus of therapy. b. Techniques: (1) Paradoxical intervention—requesting that the family continue to engage in the behavior they are trying to change (2) Reframing—relabeling problematic behavior by viewing it in a new, more positive light that emphasizes its good intention D. The Evolution of Family Therapy 1. Contemporary family therapists a. Narrative therapy. Emphasizes the role of the stories people construct about their experience. b. Feminist family therapy. A form of collaborative, egalitarian, nonsexist intervention, applicable to both men and women, addressing family gender roles, patriarchal attitudes, and social and economic inequalities in male-female relationships. c. Social constructionist therapy. Concerned with the assumptions or premises different family members hold about the problem. Focuses on engaging families in conversations to solicit everyone’s views. d. Psychoeducational family therapy. Emphasizes educating family members to help them understand and cope with a seriously disturbed family member. VI. The Nursing Process A. A Case Study: The Marino Family 1. Assessment a. The Calgary Family Assessment Model (CFAM) (1) Structural assessment (a) Internal structure (b) External structure (c) Context (2) Developmental assessment (3) Functional assessment (a) Instrumental functioning (b) Expressive functioning 2. Diagnosis a. Interrupted family processes b. Disabled family coping 3. Outcome identification
70 4. Planning/implementation 5. Evaluation Summary and Key Points Review Questions
CHAPTER 12. MILIEU THERAPY—THE THERAPEUTIC COMMUNITY
CHAPTER FOCUS The focus of this chapter is to introduce the student to the concept of milieu therapy. The role of the nurse in this therapeutic setting is emphasized. OBJECTIVES After reading this chapter, the student will be able to: 1. Define milieu therapy. 2. Explain the goal of therapeutic community/milieu therapy. 3. Identify seven basic assumptions of a therapeutic community. 4. Discuss conditions that characterize a therapeutic community. 5. Identify the various therapies that may be included within the program of therapeutic community and the health-care workers that make up the interdisciplinary treatment team. 6. Describe the role of the nurse on the interdisciplinary treatment team. KEY TERMS milieu therapeutic community CORE CONCEPT milieu therapy
CHAPTER OUTLINE/LECTURE NOTES I. Introduction: Standard 5c of the ANA Standards of Psychiatric-Mental Health Nursing Practice states that, “The psychiatric-mental health nurse provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other health-care clinicians.” II. Milieu, Defined A. Milieu therapy is defined as a scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual. B. Within the therapeutic community setting the client is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life. III. Current Status of the Therapeutic Community A. Milieu therapy came into its own during the time when hospital stays for psychiatric clients were extended. B. The current focus of care is on short stays and is often more biologically based.
72 Strategies of milieu therapy have been modified to conform to the shortterm approach to care or to outpatient treatment programs. D. Some programs (e.g., those for children and adolescents, clients with substance addictions, and geriatric clients) have successfully adapted the concepts of milieu treatment to their specialty needs. IV. Basic Assumptions A. The health in each individual is to be realized and encouraged to grow. B. Every interaction is an opportunity for therapeutic intervention. C. The client owns his or her own environment. D. Each client owns his or her own behavior. E. Peer pressure is a useful and powerful tool. F. Inappropriate behaviors are dealt with as they occur. G. Restrictions and punishment are to be avoided. IV. Conditions That Promote a Therapeutic Community A. Basic physiological needs are fulfilled. B. The physical facilities are conducive to achievement of the goals of therapy. C. A democratic form of self-government exists. D. Responsibilities are assigned according to client capabilities. E. A structured program of social and work-related activities is scheduled as part of the treatment program. F. Community and family are included in the program of therapy in an effort to facilitate discharge from treatment. V. The Program of Therapeutic Community A. Directed by an interdisciplinary team. B. A treatment plan is formulated by the team. C. All disciplines sign the treatment plan and meet regularly to update the plan as needed. D. Disciplines may include psychiatry, psychology, nursing, social work, occupational therapy, recreational therapy, art therapy, music therapy, dietetics, and chaplain’s service. VI. Role of the Nurse A. Through use of the nursing process, nurses manage the therapeutic environment on a 24-hour basis. B. Nurses have the responsibility for ensuring that clients’ physiological and psychological needs are met. C. Nurses also are responsible for: 1. Medication administration 2. Development of a one-to-one relationship 3. Setting limits on unacceptable behavior 4. Client education VII. Summary and Key Points VIII. Review Questions C.
CHAPTER 13. CRISIS INTERVENTION
CHAPTER FOCUS The focus of this chapter is to introduce the student to the concept of crisis and the therapy of crisis intervention. The role of the nurse in crisis intervention is emphasized.
OBJECTIVES After reading this chapter, the student will be able to: 1. Define crisis. 2. Describe four phases in the development of a crisis. 3. Identify types of crises that occur in people’s lives. 4. Discuss the goal of crisis intervention. 5. Describe the steps in crisis intervention. 6. Identify the role of the nurse in crisis intervention. 7. Apply the nursing process to care of victims of disaster. KEY TERMS disaster crisis intervention CORE CONCEPT crisis
CHAPTER OUTLINE/LECTURE NOTES I. Introduction A. Any stressful situation can precipitate a crisis. B. Assistance with problem solving during the crisis period preserves selfesteem and promotes growth with resolution. II. Crisis, Defined A. Crisis is defined as a sudden event in one’s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. B. Characteristics of a Crisis 1. Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology. 2. Crises are precipitated by specific identifiable events. 3. Crises are personal by nature. 4. Crises are acute, not chronic, and will be resolved in one way or another within a brief period. 5. A crisis situation contains the potential for psychological growth or deterioration. III. Phases in the Development of a Crisis
74 A. The individual is exposed to a precipitating stressor. B. When previous problem-solving techniques do not relieve the stressor, anxiety increases further. C. All possible resources, both internal and external, are called upon to resolve the problem and relieve the discomfort. D. If resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual with drastic results often occurs. IV. Whether or not individuals experience a crisis in response to a stressful situation depends upon: A. The individual’s perception of the event. B. The availability of situational supports. C. The availability of adequate coping mechanisms. V. Types of Crises A. Dispositional Crisis. An acute response to an external situational stressor. B. Crisis of Anticipated Life Transition. Normal life-cycle transitions that may be anticipated, but over which the individual may feel a lack of control. C. Crisis Resulting From Traumatic Stress. A crisis that is precipitated by an unexpected, external stressor over which the individual has little or no control, and from which he or she feels emotionally overwhelmed and defeated. D. Maturational/Developmental Crisis. Crisis that occurs in response to situations that trigger emotions related to unresolved conflicts in one’s life. E. Crisis Reflecting Psychopathology. Emotional crisis in which preexisting psychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution. F. Psychiatric Emergencies. Crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility. VI. Crisis Intervention A. The minimum therapeutic goal of crisis intervention is psychological resolution of the individual’s immediate crisis and restoration to at least the level of functioning that existed before the crisis period. B. A maximum goal is improvement in functioning above the precrisis level. C. The therapist’s role is direct, supportive, and that of an active participant. VII. Phases of Crisis Intervention: The Role of the Nurse A. Nurses may be called upon to function as crisis helpers in virtually any setting committed to the practice of nursing. 1. Phase 1. Assessment. Information is gathered regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help. Relevant nursing diagnoses are selected.
Evaluation IX. Assessment a. A reality-oriented approach is used. Desired outcome criteria are established. Appropriate nursing actions are selected taking into consideration the type of crisis. B. as well as the individual’s strengths and available resources for support. nightmares. 4.75 2. Common behavioral responses include anger. Risk for posttrauma syndrome g. Risk for injury b. The actions identified in the planning phase are implemented. Phase 4. 3. Application of the Nursing Process 1. and problems with concentrating 2. and tobacco use c. Grieving is a natural response b. and by attending to immediate needs. Fear e. Phase 3. by active listening. Disaster Nursing A. VIII. disbelief. Children may experience separation anxiety. Intervention. Ineffective community coping 3. A problemsolving model becomes the basis for change. Phase 2. Risk for infection c. Planning/implementation 4. A plan of action is developed for the individual to deal with the stressor should it recur. Nursing diagnoses/outcome identification a. Review Questions . A rapid working relationship is established by showing unconditional acceptance. Evaluation of crisis resolution and anticipatory planning. anxiety. sadness. Anxiety (panic) d. fear. Spiritual distress f. C. Disasters leave victims with a damaged sense of safety and well-being. the nurse selects appropriate nursing diagnoses that reflect the immediacy of the crisis situation. caffeine. Planning of therapeutic intervention. A common feature of disasters is that they overwhelm local resources and threaten the function and safety of the community. and varying degrees of emotional trauma. A reassessment is conducted to determine if the stated objectives were achieved. From the assessment data. and increases in alcohol. Summary and Key Points X. sleep disturbances.
Discuss various methods of achieving relaxation. . and metabolism. The Stress Epidemic A. E. D. the student will be able to: 1. lung ailments. 3. II. OBJECTIVES After reading this chapter. B. Stress is known to be a major contributor. RELAXATION THERAPY CHAPTER FOCUS The focus of this chapter is to introduce the student to the benefits of relaxation therapy. and Behavioral Manifestations of Relaxation A. Various methods of achieving relaxation are presented. either directly or indirectly. 2. 4. Identify conditions for which relaxation is appropriate therapy. and suicide—six of the leading causes of death in the United States. cirrhosis of the liver. to coronary heart disease. blood sugar. past experiences. KEY TERMS biofeedback meditation mental imagery progressive relaxation stress management CORE CONCEPTS stress relaxation CHAPTER OUTLINE/LECTURE NOTES I. Describe the role of the nurse in relaxation therapy. Physiological. Physiological manifestations of stress include increases in heart rate.76 CHAPTER 14. blood pressure. respirations. and existing conditions) influence the degree of severity to which an individual perceives and responds to stress. Individuals experience the “fight-or. accidental injuries.flight” response on a regular basis. Cognitive. C. cancer. An individual’s predisposing factors (genetic influences. Describe physiological and behavioral manifestations of relaxation. The “fight-or-flight” emergency response is inappropriate to today’s psychosocial stresses that persist over long periods of time. Stress is rapidly permeating our society. and the role of the nurse in relaxation therapy is emphasized.
muscle tension. E. Behavioral manifestations of stress include restlessness. D. 4. depression. skin surface temperature. An advantage of this type of exercise is that it may be accomplished anywhere at any time. It has been used successfully in the treatment of cardiovascular disease. F.” 3. anxiety. irritability. Mental Imagery 1. Cognitive manifestations of stress include confusion. and hostility. C. and anorexia. depression. muscular tension.000 years. The goal of meditation is to gain “mastery over attention. muscle spasms. Modified (or Passive) Progressive Relaxation: Relaxation is achieved with this method by passively concentrating on the feeling of relaxation within the muscle groups. 3. Methods of Achieving Relaxation A. and to help bring them under voluntary control. Each muscle group is tensed for 5 to 7 seconds. obsessive thinking. Excellent results have been observed with this method in the treatment of muscular tension. 2. Biofeedback 1. irritability. during which time the individual concentrates on the difference in sensations between the two conditions. held for a few seconds. blood pressure. insomnia. Air is breathed in slowly through the nose. insomnia.77 B. Biofeedback is the use of instrumentation to become aware of processes in the body that usually go unnoticed. . D. Meditation 1. Relaxation is accomplished by allowing the lungs to breathe in as much oxygen as possible. Breathing exercises have been found to be effective in reducing anxiety. and difficulty with concentration. high blood pressure. Meditation has been practiced for more than 2. 4. Some of these processes include blood pressure. neck and back pain. III. Relaxation can counteract these symptoms. depression. 3. This method of relaxation employs the imagination in an effort to reduce the body’s response to stress. and learning. irritable bowel. Deep Breathing Exercises 1. 2. The individual then concentrates on this relaxing image in an effort to achieve relaxation. Progressive Relaxation 1. Soft background music enhances the effect. 2. B. and then relaxed for 20 to 30 seconds. Relaxation is achieved through fulfillment of a special state of consciousness brought about by extreme concentration solely on one thought or object. and fatigue. C. and heart rate. and then exhaled slowly through the mouth. 2. and stuttering. anxiety. The individual follows his or her imagination in selecting an environment considered to be relaxing. mild phobias. problem solving. fatigue.
anxiety. and increase flexibility. physiological equilibrium is restored. relieve muscular tension. stuttering. hypertension. resulting in a feeling of relaxation and revitalization. The Role of the Nurse in Relaxation Therapy A. Nurses can help individuals recognize the source of stress in their lives and identify methods of adaptive coping.78 2.” 2. muscle spasms/pain. D. 4. phobias. IV. maladaptive methods of coping with stress. Nurses can help individuals analyze the usefulness of various relaxation techniques in the management of stress in their daily lives. Nurses can serve as educators to increase clients’ knowledge regarding methods for achieving relaxation. 3. prevent muscle spasms. Physical exertion provides a natural outlet for the tension produced by the body in its state of arousal for “fight-or-flight. Physical exercise can also be effective in reducing general anxiety and depression. 5. Following exercise. Summary and Key Points VI. Aerobic exercises have been shown to be successful in strengthening the cardiovascular system. and teeth grinding. C. Review Questions . B. Low intensity physical exercise can help prevent obesity. tension and migraine headaches. V. Physical Exercise 1. Biofeedback has been used successfully in the treatment of spastic colon. G. Relaxation therapy provides alternatives to old.
ASSERTIVENESS TRAINING CHAPTER FOCUS The focus of this chapter is to introduce the student to the concepts of assertiveness training. Discuss the role of the nurse in assertiveness training. B. The right to express feelings. 6. opinions. Assertive Communication A. OBJECTIVES After reading this chapter. KEY TERMS aggressive assertive nonassertive passive-aggressive thought stopping CORE CONCEPT assertive behavior CHAPTER OUTLINE/LECTURE NOTES I. The right to be treated with respect 2. 5. Discuss basic human rights. the student will be able to: 1. or to exercise their own rights without denying the rights of others. II. aggressive. assertive. The right to say “no” without feeling guilty 4. to express their honest feelings comfortably.79 CHAPTER 15. 3. Assertiveness is behavior that enables individuals to act in their own best interests. Differentiate among nonassertive. Various techniques to promote assertive behavior are discussed. 4. The right to make mistakes and accept the responsibility for them . to stand up for themselves without undue anxiety. Describe techniques that promote assertive behavior. and the role of the nurse in assertiveness training is emphasized. Demonstrate thought-stopping techniques. and passive-aggressive behaviors. Honesty is basic to assertive behavior and is expressed in a manner that promotes self-respect and respect for others. Define assertive behavior 2. Basic human rights include: 1. and beliefs 3. Basic Human Rights A.
Aggressive behavior hinders interpersonal relationships. Intermittent Eye Contact B. . Fluency. These individuals stand up for their own rights while protecting the rights of others. Sitting and leaning slightly toward the other person in a conversation. By inventing a response 4. these individuals seek to please others at the expense of denying their own basic human rights. Assertive behavior. Appropriate physical distance is culturally determined. patterns of responding to others. he or she must also accept the responsibilities that accompany them. D. Invasion of personal space may be interpreted by some individuals as aggressive. Aggressive behavior. Gestures can add meaning to the spoken word. IV. Voice. The right to refuse justification for your feelings or behavior B. Facial Expression. These individuals use actions instead of words to convey their message. Feelings are expressed openly and honestly. F. Various facial expressions convey different messages. and the actions express covert aggression. The right to ask for what you want 8. These individuals defend their own basic rights by violating the basic rights of others. Gestures. and taken seriously 6. Self-respect and respect for others are maintained. Body Posture. and evidence of emotional tone. Behavioral Components of Assertive Behavior A. These ways include: 1. in certain ways. Individuals develop. nonconfrontational action. 4. Nonassertive behavior. C. The right to be listened to. By not thinking of a better way to respond 5. If one is to accept these rights. III. softness. this behavior takes the form of passive. 2. sometimes 9. 3. Being able to discuss a subject with ease and with obvious knowledge conveys assertiveness and self-confidence. G. Four common response patterns: 1. E. Response Patterns A. May also be culturally related. By being positively reinforced or punished for a certain response 3. Passive-aggressive behavior. The right to set your own priorities 10. By not developing the proper skills for a better response 6. Sometimes called indirect aggression. degree and placement of emphasis. By consciously choosing a response style B. By watching other people (role modeling) 2.80 5. The voice conveys a message by its loudness. These individuals defend their own rights by expressing resistance to social and occupational demands. Sometimes called passive. The right to put yourself first. Distance/Physical Contact. The right to change your mind 7.
B. C. Responding assertively with irony. This element of assertive behavior speaks to not giving up. Seeking additional information about critical statements. One’s attitudes about the appropriateness of assertive behavior influences one’s responses. D. Delaying assertively. J. Inquiring assertively. Shifting from content to process. Agreeing assertively. Clouding/fogging. H. Techniques That Promote Assertive Behavior A.81 H. Nurses must understand and use assertive skills to effect change that will improve the status of nursing and the system of health care provision in our country. Assertively accepting negative aspects about oneself. Standing up for one’s basic human rights.” and shifting his or her thoughts to one that is considered pleasant and desirable. G. A technique that was developed to eliminate intrusive. C. Nurses can teach clients assertive skills on a one-to-one basis or in a group situation. VII. Using “I” statements. Assertive responses are most effective when they are spontaneous and immediate. L. to refrain from concluding that the individual is not worth whatever it is he or she is pursuing. Assertive listening means giving the other individual full attention. that is. Content. unwanted thoughts. I. K. Responding as a “broken record. Thoughts. Putting off further discussion with an angry individual until he or she is calmer. Persistence. The individual practices interrupting negative thought processes with the word “stop. E. B. K. Role of the Nurse A. Many times it is not what is being said that is as important as how it is said. . Defusing. Changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction. Timing. Admitting when an error has been made. VI. Concurring with the critic’s argument without becoming defensive and without agreeing to change. F. Assuming responsibility for own statements. Putting off further discussion with another individual until one is calmer. V. Listening. B. I. Taking ownership of one’s feelings rather than saying they are caused by another person. J. Nurses who understand and use assertiveness skills themselves can in turn assist clients who wish to effect behavioral change in an effort to increase self-esteem and improve interpersonal relationships. Thought-Stopping Techniques A.” Persistently repeating in a calm voice what is wanted.
E. Information should include examples of various behavioral responses (assertive. aggressive. Summary and Key Points IX. VIII. as well as techniques that can be used to promote assertive behavior. and passive-aggressive). Review Questions .82 D. nonassertive. Clients should be given the opportunity to practice their newly learned skills through role play in order to facilitate the behavior when the actual situation arises.
Components of Self-Concept A. 5. 3. Introduction A. Self-concept is defined as the cognitive or thinking component of the self and generally refers to the totality of a complex. the student will be able to: 1. PROMOTING SELF-ESTEEM CHAPTER FOCUS The focus of this chapter is on the developmental progression of self-esteem. KEY TERMS body image boundaries contextual stimuli enmeshed boundaries flexible boundaries focal stimuli moral-ethical self physical self residual stimuli rigid boundaries self-consistency self-expectancy self-ideal CORE CONCEPTS self-concept self-esteem CHAPTER OUTLINE/LECTURE NOTES I.83 CHAPTER 16. An awareness of self is an important differentiating factor between humans and other animals. Identify and define components of the self-concept. Discuss the concept of boundaries and its relationship to self-esteem. and the concept of boundaries and its relationship to self-esteem is explored. Nursing care of clients with disturbances in self-esteem is described in the context of the nursing process. II. and dynamic system of learned beliefs. Verbal and behavioral manifestations of self-esteem are described. organized. 2. OBJECTIVES After reading this chapter. attitudes. B. Describe the verbal and nonverbal manifestations of low self-esteem. 4. Discuss influencing factors in the development of self-esteem and its progression through the life span. Apply the nursing process with clients who are experiencing disturbances in selfesteem. Healthy self-esteem has been described as essential for psychological survival. . and opinions that each person holds to be true about his or her personal existence.
and appearance. or to become. Expectations to complete tasks that they perceive are valued by others. Disturbances in body image may occur when individuals undergo alterations in structure or function. wellness-illness state. A sense of survival. A sense of responsibility. 6. Virtue. whether it be positive or negative. Competence. Warren lists the following as important for parents and others who work with children to emphasize and encourage healthy self-esteem: 1. 2. 2. III. and provides a feeling of security. Realistic goals. The self-consistency strives to maintain a stable self-image. The ability to perform successfully or achieve selfexpectations and the expectations of others. 3. respected. moral. A feeling of being loved. 5. The following antecedent conditions of positive self-esteem have been identified by Coopersmith: 1. Personal identity consists of three parts: a. functioning. Self-esteem—the degree of regard or respect that individuals have for themselves that is a measure of worth that they place on their abilities and judgments. Consistently set limits. The ability to learn and grow from having experienced failure. Demonstrates acceptance and caring. Unconditional love.84 B. These include conditions such as amputations. Power. The moral-ethical self functions as observer. Knowledge that actions reflect a set of personal. The physical self or body image—a personal appraisal by an individual of his or her physical being that includes physical attributes. to do. 4. Having expectations that are attainable by the child. and may be perceived as losses. 3. The knowledge that they are loved regardless of success or failure. Significance. b. b. dreamer. 5. and cared for by significant others. The Development of Self-Esteem A. Achieving a healthy balance between what they can possess and achieve. 4. standard setter. c. sexuality. and most of all evaluator of who the individual says he or she is. A sense of competence. The self-ideal/self-expectancy relates to an individual’s perception of what he or she wants to be. C. A feeling of control over own life situation. 2. Personal body image may not necessarily coincide with actual physical appearance. colostomy. and impotence. Self-concept consists of the following three components: 1. comparer. Other factors that are influential in the development of self-esteem: . and what is beyond their capability or control. paralysis. and ethical values. a. 3. B. Reality orientation. The feeling that they are skilled at something.
and concern for others remain unfulfilled. . 4. 3. Initiative versus guilt. he or she has difficulty with this task and social isolation occurs. Generativity promotes positive selfesteem through gratification from personal and professional achievements and from meaningful contributions to others. the individual lacks self-worth and becomes withdrawn and isolated. self-identity. Developmental Progression of Self-Esteem Through the Life Span A. When previous tasks go unfulfilled. Focal stimuli. Ego integrity results in a sense of selfworth and self-acceptance as one reviews life goals. Environmental conditions IV. Behaviors that reflect low self-esteem manifest themselves according to three types of stimuli: 1. 6. whereas dissatisfaction with the self and suspiciousness of others promotes negative self-esteem. When earlier developmental tasks of self-confidence. V. Ego integrity versus despair. whereas negative self-esteem is promoted by failure to achieve this task and a lack of pride in the ability to perform and a sense of being controlled by others. Failure to develop a new selfdefinition results in a sense of self-consciousness. and confusion about one’s role in life. Industry versus inferiority. Positive self-esteem is gained through initiative when creativity is encouraged and performance is recognized and positively reinforced. Trust versus mistrust. accepting that some were achieved and some were not. particularly significant others 2. Autonomy versus shame and doubt. Generativity versus stagnation. When one has been deprived of unconditional love in the younger years. 1. 2. Intimacy versus isolation. Positive self-esteem is gained at this stage by performing and receiving recognition from others. 8. 7. a sense of despair and negative self-esteem prevail. Achievement of autonomy results in a feeling of self-confidence in one’s ability to perform.85 1. Guidance and discipline that relies heavily on shaming the child creates guilt and results in a decrease in self-esteem. Hereditary factors 3. Identity versus role confusion. Erikson’s theory of personality development provides a useful framework for illustration of self-esteem development. Positive self-esteem is promoted through the capacity for giving of oneself to another. Positive self-esteem occurs when individuals are allowed to experience independence by making decisions that influence their lives. The immediate concern that is causing the threat to selfesteem and the stimulus that is engendering the current behavior. Achievement of trust results in positive selfesteem. 5. The Manifestations of Low Self-Esteem A. Negative selfesteem is the result of nonachievement or when accomplishments are met with negative feedback. doubt. The responses of others.
Boundaries A. Residual Stimuli. Being criticized for doing something differently than others is an example of an invasion of a psychological boundary. Chronic low self-esteem b.86 2. sexual behavior. Boundaries can be rigid. The Nursing Process A. c. privacy. Occur when people are able to let go of their boundaries when appropriate. Negative role modeling b. or enmeshed a. needs. Boundaries are established in childhood 2. Boundary Pliancy 1. Factors that may influence one’s maladaptive behavior in response to focal and contextual stimuli. interests. Boundaries are the personal space. touching. They perceive that things must be one way and refuse to change for any reason. b. Establishing Boundaries 1. Occur when two people’s boundaries are so blended together that neither can be sure where one stops and the other begins. Healthy boundaries are flexible. B. E. VI. Flexible boundaries. and pollution. flexible. Symptoms of low self-esteem are many. Touching someone who does not want to be touched is an example of an invasion of a physical boundary. Nursing diagnoses a. Sometimes referred to as “limits. F. 3. or dysfunctional families a. Enmeshed boundaries. individual differences. G. Diagnosis/Outcome Identification 1. choices. feelings. Unhealthy boundaries are the products of unhealthy. Rigid boundaries. Contextual stimuli. Types of psychological boundaries include beliefs. All of the other stimuli present in the person’s environment that contribute to the behavior being caused by the focal stimulus. that individuals identify as their own. eye contact. D. Types of physical boundaries include physical closeness. The Self-Esteem Inventory B. confidences. Risk for situational low self-esteem 2. and spirituality. Abuse or neglect VII. troubled. both physical and psychological. and appear in Box 16-1 of the text. Outcome criteria . B. Situational low self-esteem c. Individuals who are aware of their boundaries have a healthy self-esteem because they must know and accept their inner selves. time alone. An individual with an enmeshed boundary is unable to differentiate his or her wants and needs from the other person’s.” C. Assessment 1. Occur when people have a very narrow perspective on life.
87 C. Evaluation VIII. Planning/Implementation D. Review Questions . Summary and Key Points IX.
the student will be able to: 1. OBJECTIVES After reading this chapter. Diagnosis/Outcome Identification: Formulate nursing diagnoses and outcome criteria for clients expressing anger and aggression. Assessment: Describe physical and psychological responses to anger.88 CHAPTER 17. d. Apply the nursing process to clients expressing anger or aggression. a. Identify when the expression of anger becomes a problem. Define and differentiate between anger and aggression. Anger need not be a negative expression. C. Predisposing factors to the maladaptive expression of anger are discussed. Introduction A. Discuss predisposing factors to the maladaptive expression of anger. Anger . Anger and Aggression. KEY TERMS modeling operant conditioning prodromal syndrome CORE CONCEPTS aggression anger anger management CHAPTER OUTLINE/LECTURE NOTES I. ANGER/AGGRESSION MANAGEMENT CHAPTER FOCUS The focus of this chapter is on the concepts of anger and aggression. Defined A. b. Evaluation: Evaluate achievement of the projected outcomes in the intervention with clients demonstrating maladaptive expression of anger. Anger becomes a problem when it is not expressed and when it is expressed aggressively. 2. c. can provide an individual with a positive force to solve problems and make decisions concerning life situations. Planning/Intervention: Describe nursing interventions for clients demonstrating maladaptive expressions of anger. and the nursing process as a vehicle for delivery of care to assist clients in the management of anger and aggression is described. 3. B. when handled appropriately and expressed assertively. 4. II. Anger is a normal human emotion that.
Earliest role models are the primary caregivers. 2. 4. Significantly different from aggression e. It is accompanied by physiological and biological changes. Brain trauma d. or weapons.89 1. Aggressive behavior may have some correlation to alterations in brain chemicals. frustration. a. blood pressure. Several disorders of or conditions within the brain have been implicated in episodic aggression and violent behavior. Hormonal dysfunction associated with hyperthyroidism . B. They include: a. A physiological arousal. role models can be celebrities or any other influential individual in the child’s life. 2. Role models can be positive or negative. C. Biochemical Factors 1. 2. Neurophysiological Disorders 1. Not a primary emotion b. Capable of being under personal control 2. Aggression can cause damage with words. Modeling 1. As the child matures. A negative reinforcement is a response to the specific behavior that prevents an undesirable result from occurring. Aggression is one way that individuals express anger. Learned f. Predisposing Factors to Anger and Aggression A. Typically experienced as an automatic inner response to hurt. such as increases in heart rate. Operant Conditioning 1. and levels of the hormones epinephrine and norepinephrine. 3. Anger is an emotional state that varies in intensity from mild irritation to intense fury and rage. B. b. Aggression is a behavior that is intended to threaten or injure the victim’s security or self-esteem. 3. Aggression 1. or fear c. fists. Temporal or frontal lobe epilepsy b. Anger has both positive and negative functions (see Table 17-1 in the text). These include: a. Operant conditioning occurs when a specific behavior is positively or negatively reinforced. instilling feelings of power and generating preparedness d. III. Role modeling is one of the strongest forms of learning. Anger and aggression can be learned through operant conditioning. Brain tumors c. Anger is: a. Encephalitis D. but it is virtually always designed to inflict punishment or pain. A positive reinforcement is a response to the specific behavior that is pleasurable or produces the desired results.
Socioeconomic Factors 1. and unemployment. Aggression can be identified by a cluster of characteristics that include: a. These chemicals may play a role in either the facilitation or inhibition of aggression. restlessness b. amphetamines. with overreaction to environmental stimuli g. suspiciousness i. Threats of homicide or suicide f. Assessment 1. and serotonin. Anger can be identified by a cluster of characteristics that include: a. F. Alterations in the neurotransmitters epinephrine. b. use of obscenities. Angry mood. continuous state of tension 2. Loud voice. Prevention is the key issue in the management of aggressive or violent behavior. The Nursing Process A. E. Discomfort associated with a moderate increase in environmental temperature. Physical crowding of people. Intense eye contact or avoidance of eye contact f. Three factors are important considerations in identifying degree of risk: . often disproportionate to the situation 3. Assessing risk factors a. shouting. Yelling and shouting e. Poverty is thought to encourage aggression because of the associated deprivation. argumentative e. Frowning facial expression b. c. acetylcholine. Environmental Factors 1. Use of alcohol and some other drugs. Easily offended g. Panic anxiety. High rates of violence exist within the subculture of poverty in the United States. Clenched fists c. leading to misinterpretation of the environment h. Emotional overcontrol with flushing of the face j. hallucinogens. norepinephrine. Intense discomfort.90 b. particularly cocaine. Increase in agitation. Passive-aggressive behaviors i. Defensive response to criticism h. Tense facial expression and body language c. and anabolic steroids. b. They include: a. 2. Several environmental factors have been associated with an increase in aggressive behavior. Pacing. IV. Verbal or physical threats d. dopamine. disruption of families. Disturbed thought processes. Low-pitched verbalizations forced through clenched teeth d.
g.” The prodromal syndrome is characterized by anxiety and tension. raised voice (5) Arguing and demanding (6) Using profanity and threatening verbalizations (7) Agitation and pacing (8) Pounding and slamming B. The most common diagnoses associated with violence include: (a) Substance use disorders (b) Psychotic disorders (e. bipolar disorder) (c) Personality disorders (e.g. Diagnosis/Outcome Identification 1. Certain behaviors are predictive of impending violence and have been termed the “prodromal syndrome.91 (1) Past history of violence is widely recognized as a major risk factor for violence in a treatment setting. Review Questions . antisocial and borderline personality disorders) (d) Major depression (e) Intermittent explosive disorder (f) Organic mental disorders (e. defiant affect (4) Talking in a rapid. schizophrenia. C. verbal abuse and profanity. Nursing diagnoses for inappropriate expression of anger or for aggressive behavior include: a.. Behaviors associated with the prodromal syndrome include: (1) Rigid posture (2) Clenched fists and jaws (3) Grim. Summary and Key Points VI. Risk for self-directed or other-directed violence 2. (2) Client diagnosis. Ineffective coping b.. dementia and delirium) (3) Current behavior c.. and increasing hyperactivity. Planning/Implementation D.g. Outcome behaviors are identified as criteria for evaluation. Evaluation V.
3. but some individuals began to associate suicide with mental illness. Suicide was illegal in England until 1961. OBJECTIVES After reading this chapter. Discuss epidemiological statistics and risk factors related to suicide. 2. B. Differentiate between facts and fables regarding suicide. it is a behavior. Apply the nursing process to individuals exhibiting suicidal behavior. Epidemiological and etiological aspects of suicide are also explored. In the Middle Ages. F. individuals sometimes resorted to suicide to escape humiliation or abuse. Most philosophers of the 17th and 18th centuries condemned suicide. C. B. I. G. suicide was an offense against the state. the student will be able to: 1. Historical Perspectives A. KEY TERMS altruistic suicide anomic suicide egoistic suicide CHAPTER OUTLINE/LECTURE NOTES Introduction A. E. Approximately 95 percent of all persons who commit or attempt suicide have a diagnosed mental disorder. suicide was viewed as a selfish or criminal act. In the culture of the imperial Roman army.92 CHAPTER 18. and individuals who committed suicide were denied burial in community sites. the view became more philosophical. THE SUICIDAL CLIENT CHAPTER FOCUS The focus of this chapter is on the care of the suicidal client. During the Renaissance. Describe predisposing factors implicated in the etiology of suicide. Suicide is not a diagnosis or a disorder. 4. and intellectuals could discuss suicide more freely. In ancient Greece. D. Most religions consider suicide a sin against God. . and only in 1993 was it decriminalized in Ireland. II.
Having attempted suicide previously increases the risk of a subsequent attempt. personality disorders. 4. F. Risk of suicide increases with age. and Asian Americans. 2. particularly a same-sex parent. C. Predisposing Factors: Theories of Suicide A. Suicide is the third leading cause of death among young Americans ages 15 to 24 years. Risk Factors A. B. Socioeconomic Status. Women attempt suicide more. The suicide rate for single persons is twice that of married persons. . Other Risk Factors 1. but more men succeed. Religion. Marital Status. Epidemiological Factors A. Mood disorders are the most common psychiatric illnesses that precede suicide. Family history of suicide. Loss of a loved one through death or separation is a risk factor. particularly for men. Anger turned inward. E.000 persons in the United States end their lives each year by suicide. D. and anxiety disorders. followed by Native Americans. 2.93 III. Affliction with a chronic painful or disabling illness increases the risk of suicide. Freud believed that suicide was a result of an earlier repressed desire to kill someone else. B. Anger that was previously directed to another person was turned inward on the self. 5. 8. and the eighth leading cause of death for individuals 45 to 64 years of age. 3. Hispanic Americans. Psychiatric illness. More than 34. Lack of employment or increased financial burden increases the risk of suicide. G. Homosexual individuals have a higher risk of suicide than their heterosexual counterparts. V. IV. Whites are at highest risk for suicide. Severe insomnia is associated with increased risk of suicide. 7. 2. White males over the age of 80 are at the greatest risk of all age/gender/race groups. Gender 1. African Americans. Age 1. Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle classes. increases the risk of suicide. Other psychiatric disorders that account for suicidal behavior include substance-related disorders. About half of those who ultimately commit suicide have a history of a previous attempt. Men commonly choose more lethal methods than women. Psychological Theories 1. the fourth leading cause of death for ages 25 to 44. Roman Catholics have lower rates of suicide than Jews and Protestants. Ethnicity. 6. schizophrenia.
b. Biological Theories 1. Rage and violent behavior have been identified as important psychological factors underlying suicidal behavior. Studies indicate a high correlation between feelings of hopelessness and suicide. Anomic suicide. Durkheim believed that suicide was correlated to the cohesiveness of a society in which the individual lived. Desperation and guilt. Shame and humiliation. Some studies have revealed decreased levels of serotonin (measured by decreased levels of 5-HIAA in cerebrospinal fluid) in depressed clients who attempted suicide. Demographics (1) Age (2) Gender (3) Ethnicity (4) Marital status (5) Socioeconomic status (6) Occupation (7) Method . History of aggression and violence. 4. Genetics. Twin studies have indicated a possible genetic predisposition toward suicidal behavior. The response of the individual who feels separate and apart from the mainstream of society. Altruistic suicide. Application of the Nursing Process with the Suicidal Client A. Certain life stressors that occur during various developmental levels have been identified as precipitating factors to suicide. Desperate feelings occur when an individual feels the need for change. c. Sociological Theory 1. The opposite of egoistic suicide. 3. Developmental stressors. such as a sudden loss of status or income. Individuals are excessively integrated into the group and allegiance to the group is so strong that they will sacrifice their own life for the group. Occurs in response to changes in the individual’s life that disrupt feelings of relatedness to the group. He described three social categories of suicide: a. Some individuals view suicide as a “facesaving” mechanism following a social defeat. Hopelessness. VI. C. Assessment 1. The interruption in the customary norms of behavior instills feelings of “separateness” and fears of being without support from the formerly cohesive group. Integration is lacking.94 2. 6. but helpless to bring about that change. The aspects of information that are gathered during a suicidal assessment include: a. 2. B. Egoistic suicide. Guilt and self-recrimination are other aspects of desperation. Neurochemical factors. 5.
Be a good listener . Discuss the current crisis situation in the client’s life h. Nursing diagnoses for the suicidal client may include the following: a. Antidepressant medication j. Planning/Implementation 1. Be direct and talk matter-of-factly about suicide g. Identify areas of self-control i. Analysis of the suicidal crisis (1) The precipitating stressor (2) Relevant history (3) Life-stage issues f. Presenting symptoms/medical-psychiatric diagnosis c. Interpersonal support system e. Do not leave the person alone b. Schedule frequent appointments e. Risk for suicide b. A care plan for the hospitalized suicidal client is presented. status. Diagnosis/Outcome Identification 1. Introduce alternatives to suicide. Crisis counseling with the suicidal client: (1) Focus on the current crisis and how it can be alleviated (2) Note client’s reactivity to the crisis and how it can be changed (3) Work toward restoration of the client’s self-worth. Establish a no-suicide contract with the client c. morale.95 (8) Religion (9) Family history of suicide b. Establish rapport and promote a trusting relationship f. Psychiatric/medical/family history g. Coping strategies B. Guidelines for treatment of the suicidal client on an outpatient basis: a. Suicidal ideas or acts (1) Seriousness of intent (2) Plan (3) Means (4) Verbal or behavioral clues d. Hopelessness C. Information for family and friends of the suicidal client: a. 2. (4) Rehearse cognitive reconstruction—more positive ways of thinking (5) Identify experiences and actions that affirm self-worth and selfefficacy (6) Encourage movement toward the new reality (7) Be available for ongoing therapeutic support and growth 3. Do not keep secrets c. Take any hint of suicide seriously b. Enlist the help of family or friends d. and control.
or provoke guilt in them 4. Discourage blaming and scapegoating c. l. h. Review Questions d. . g. Encourage them to talk about the suicide b. Identify resources that provide support D. Recognize differences in styles of grieving f.96 Express to the client feelings of personal worth Know about suicide intervention resources Restrict access to firearms or other means of self-harm Acknowledge and accept their feelings Provide a feeling of hopefulness Do not leave them alone Show love and encouragement Seek professional help Remove children from the home Do not judge the person. j. Summary and Key Points VIII. m. Assist with development of adaptive coping strategies g. Listen to feelings of guilt and self-persecution d. i. show anger toward them. Evaluation VII. e. Talk about personal relationships with the victim e. f. k. Interventions with family and friends of suicide victims: a.
The role of the nurse in behavior therapy is emphasized. Discuss the principles of classical and operant conditioning as foundations for behavior therapy. Is age-inappropriate 2. Introduction A. 3. 2. OBJECTIVES After reading this chapter. BEHAVIOR THERAPY CHAPTER FOCUS The focus of this chapter is on various concepts associated with learning. Identify various techniques used in the modification of client behavior. Interferes with adaptive functioning . the student will be able to: 1. A behavior is considered to be maladaptive when it: 1.97 CHAPTER 19. and on techniques for modification of learned behaviors. Implement the principles of behavior therapy using the steps of the nursing process. KEY TERMS aversive stimulus classical conditioning conditioned response conditioned stimulus contingency contracting covert sensitization discriminative stimulus extinction flooding modeling negative reinforcement operant conditioning overt sensitization positive reinforcement Premack principle reciprocal inhibition shaping stimulus generalization systematic desensitization time out token economy unconditioned response unconditioned stimulus CORE CONCEPTS behavior therapy stimuli CHAPTER OUTLINE/LECTURE NOTES I.
it is called stimulus generalization. He learned that the dogs soon began salivating (conditioned response) at the sound of the bell alone (conditioned stimulus). The behavioral approach to therapy is that people have become what they are through learning processes. D.98 3. or through the interaction of the environment with their genetic endowment. it is called a negative reinforcer. Modeling refers to the learning of new behaviors by imitating the behavior of others. Premack Principle. C. it is called a positive reinforcer. . Techniques for Modifying Client Behavior A. D. Introduced by Russian physiologist Pavlov in his experiments with dogs. II. E. Positive and negative reinforcers for performing the desired behaviors. IV. Contingency Contracting. F. This principle states that a frequently occurring response can serve as a positive reinforcement for a response. B. He introduced an unrelated stimulus (the sound of a bell) with presentation of food. as well as aversive reinforcers for failure to perform. reinforcements are given for increasingly closer approximations to the desired response. Pavlov related that the dogs salivated when presented with food (unconditioned response). Is misunderstood by others in terms of cultural inappropriateness B. C. He soon learned that dogs salivated when food came into view (conditioned response). C. Skinner. F. In shaping the behavior of another. Operant Conditioning A. D. A stimulus that follows a behavior (or response) is called a reinforcer. F. Extinction. A contract for behavioral change is developed. A stimulus that follows a behavioral response and decreases the probability that the behavior will recur is called an aversive stimulus or punisher. The basic assumption is that problematic behaviors occur when there has been inadequate learning. When the reinforcing stimulus increases the probability that a behavior will recur by removal of an undesirable reinforcing stimulus. E. E. are stated explicitly in the contract. When the reinforcing stimulus increases the probability that the behavior will recur. III. Introduced by American psychologist B. Modeling. C. When a similar response is elicited from similar stimuli. Basic assumption: That the connection between a stimulus and a response is strengthened or weakened by the consequences of the response. B. Shaping. B. The gradual decrease in frequency or disappearance of a response when the positive reinforcement is withheld. and therefore can be corrected through the provision of appropriate learning experiences. Classical Conditioning A.
The nursing process is the vehicle for delivery of nursing care with clients requiring assistance with behavior modification. J. the physician alone. Flooding. C. A type of contingency contracting in which the reinforcers for desired behaviors are presented in the form of tokens. K. D. but one that is incompatible with the unacceptable behavior. this technique is used to desensitize individuals to a phobic stimulus. An aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited. A systematic hierarchy of events associated with the phobic stimulus is used to gradually desensitize the individual. the nurse and physician together. The plan may be devised by the nurse alone. Reciprocal Inhibition. Nursing diagnoses are formulated and outcome criteria are established. The tokens may then be exchanged for designated privileges. Role of the Nurse in Behavior Therapy A. Token Economy. Time Out. Sometimes called implosive therapy.99 F. this technique serves to decrease or eliminate a behavior by introducing a more adaptive behavior. or with input from the client and various members of the treatment team. This aversion technique relies on the individual’s imagination to produce unpleasant symptoms as consequences for undesirable behavior. Also called counter-conditioning. G. Covert Sensitization. Review Questions . VI. The client is usually isolated so that reinforcement from the attention of others is absent. Evaluation of care is based on achievement of the outcome criteria. Assessment of behaviors that are unacceptable for age and cultural inappropriateness is conducted. Systematic Desensitization. Summary and Key Points VII. It differs from systematic desensitization in that. V. instead of working through a hierarchy of anxiety producing stimuli. H. All members of the treatment team must be made aware of the behavior modification plan. A technique to assist individuals to overcome their fear of a phobic stimulus. E. B. Overt Sensitization. I. An aversion therapy that produces unpleasant consequences for undesirable behavior. F. L. A plan for behavior modification is devised utilizing techniques thought to be most appropriate for the client. the individual is “flooded” with a continuous presentation of the phobic stimulus until it no longer elicits anxiety. Consistency among all staff is required for implementation to be successful.
but by the views which they take of them. Apply techniques of cognitive therapy within the context of the nursing process.100 CHAPTER 20. “Men are disturbed not by things. Discuss historical perspectives associated with cognitive therapy. the student will be able to: 1. Various techniques of therapy are discussed.” II. COGNITIVE THERAPY CHAPTER FOCUS The focus of this chapter is to introduce the student to the concepts of cognitive therapy. Describe goals. and the role of the nurse in cognitive therapy is highlighted. Introduction A. 5. and basic concepts of cognitive therapy. . 4. 2. The foundation on which cognitive therapy is established can be identified by the statement. principles. Cognitive therapy has its roots in the early 1960s’ research on depression conducted by Aaron Beck. KEY TERMS arbitrary inference automatic thoughts catastrophic thinking decatastrophizing dichotomous thinking distraction magnification minimization overgeneralization personalization schemas selective abstraction Socratic questioning CORE CONCEPTS cognitive cognitive therapy CHAPTER OUTLINE/LECTURE NOTES I. Discuss a variety of cognitive therapy techniques. OBJECTIVES After reading this chapter. 3. Identify various indications for cognitive therapy. Historical Background A.
B. Cognitive therapy teaches clients to identify. Cognitive therapy aims to be time limited. social phobias. 4. Beck’s concepts have been expanded to include active. In this type of error. The goal of cognitive therapy is for the client to learn to identify and alter the dysfunctional beliefs that predispose him or her to distort experiences. C. Cognitive therapy initially emphasizes the present. Cognitive therapy was originally developed for use with depression. Indications for Cognitive Therapy A. 10. Cognitive therapy is based on an ever-evolving formulation of the client and his or her problems in cognitive terms. Basic Concepts. Examples include: a. eating disorders. Automatic thoughts. substance abuse. hypochondriasis. 2. aims to teach the client to be his or her own therapist. and somatoform disorder. 5. The following principles underlie cognitive therapy for all clients: 1. and behavior. D. 8. B. generalized anxiety disorder. Sweeping conclusions are made based on one incident—a type of “all or nothing” kind of thinking. and without rational analysis. Arbitrary inference. D. III. direct dialogues with clients and behavioral techniques such as reinforcement and modeling. Cognitive therapy uses a variety of techniques to change thinking. The general thrust of cognitive therapy is that emotional responses are largely dependent on cognitive appraisals of the significance of environmental cues. C. Basic concepts include: 1. schizophrenia. 9. evaluate. Thoughts that occur rapidly in response to a situation. bipolar disorder. Cognitive therapy is goal oriented and problem focused. posttraumatic stress disorder. Overgeneralization (absolutistic thinking). Cognitive therapy is educative. lasting from 12 to 16 weeks. b. it is also used with panic disorder. Today. 6. Cognitive therapy requires a sound therapeutic alliance. Lazarus and Folkman’s concept of personal appraisal by an individual of an event has also contributed to the cognitive therapy approach. IV. the individual automatically comes to a conclusion about an incident without the facts to support it.101 B. Cognitive therapy is highly structured and short-term. 7. . or even sometimes despite contradictory evidence to support it. mood. obsessive-compulsive disorder. Sometimes called cognitive errors. Cognitive therapy emphasizes collaboration and active participation. couples’ problems. Cognitive therapy sessions are structured. and emphasizes relapse prevention. 3. and respond to their dysfunctional thoughts and beliefs. Goals and Principles of Therapy A. personality disorders. Cognitive therapy is aimed at modifying distorted cognitions about a situation.
Schemas (core beliefs). Techniques include: a. a. The client is asked to describe feelings associated with specific situations. . influence the formation of other beliefs. Helping the client see a broader range of possibilities than had originally been considered. Situations are viewed in all-or-nothing. good-or-bad terms. With role play. Taking complete responsibility for situations without considering that other circumstances may have contributed to the outcome. general or specific. c. h. the therapist assumes the role of an individual within a situation that produces a maladaptive response in the client. b. Thought recording. Generating alternatives. In thought recording. Cognitive Techniques 1. V. Through guided imagery. Undervaluing the positive significance of an event. Catastrophic thinking. A full explanation about correlation between distorted thinking and the client’s mental illness is provided. black-or-white. the client is asked to keep a written record of situations that occur and the automatic thoughts that are elicited by the situation. Cognitive structures that consist of the individual’s fundamental beliefs and assumptions. 2. Always thinking that the worst will occur without considering the possibility of more likely positive outcomes. Selective abstraction (sometimes referred to as mental filter). Magnification. the client is asked to “relive” the stressful situation through his or her imagination. Dichotomous thinking.102 c. f. Modifying automatic thoughts and schemas. Minimization. which develop early in life from personal experiences and identification with significant others. A conclusion is drawn based on only a selected portion of the evidence. 2. Didactic (Educational) Aspects 1. These concepts are reinforced by further learning experiences and. g. Imagery. Therapist provides information about cognitive therapy and provides assignments to reinforce learning. Recognizing automatic thoughts and schemas. values. Techniques of Therapy A. Questions are stated in such a way that may stimulate recognition of possible dysfunctional thinking and produce a dissonance about the validity of the thoughts. e. 2. Personalization. and positive or negative. B. Schemas may be adaptive or maladaptive. Socratic questioning (also called guided discovery). The situation is played out in an effort to elicit recognition of automatic thinking on the part of the client. d. and attitudes. Client must be prepared to become own therapist. Role play. in turn. Exaggerating the negative significance of an event. 3. d.
It is important for nurses to understand the basic concepts of cognitive therapy. VII. Behavioral rehearsal. 5. Cognitive therapy techniques are within the scope of nursing practice. Role of the Nurse: Application of the Nursing Process A. Daily record of dysfunctional thoughts (DRDT). . Behavioral Interventions A. B. Use of activities to distract the client and divert him or her from the intrusive thoughts or depressive ruminations that are contributing to the client’s maladaptive responses. With the DRDT. This technique is aimed at helping clients decrease the tendency of attributing adverse life events to themselves. Distraction. 2. This helps to make the client feel less powerless. role modeling. C. Graded task assignments. assertiveness training. f. as the scope of nursing practice continues to expand. B. A technique that uses mental imagery to uncover potential automatic thoughts in advance of their occurrence in a stressful situation. A common tool used in cognitive therapy to identify and modify automatic thoughts. Often used in conjunction with cognitive rehearsal. with a goal and time interval attached to each. The following procedures are directed toward helping the client learn more adaptive behavioral strategies that will in turn have a more positive effect on cognitions. Decatastrophizing. and thought-stopping techniques may also be used to modify dysfunctional cognitions. The therapist assists the client to examine the validity of a negative automatic thought. 3. Reattribution. 1. c. e. Activity scheduling. When a client perceives a task to be overwhelming. Relaxation exercises. An extended thought-recording instrument in which the client is asked to record more rational cognitions than the automatic thoughts that occurred. Changes in emotional responses are also recorded. The client is asked to keep a daily log of activities on an hourly basis and rate each activity for mastery and pleasure. Cognitive rehearsal. Others.103 b. the client is able to modify automatic thoughts by identifying them and actually formulating a more rational alternative. it is broken down into smaller subtasks. this technique uses role play to “rehearse” a modification of maladaptive behaviors that may be contributing to dysfunctional cognitions. social skills training. These concepts are often not a part of basic nursing education. d. 4. Examining the evidence. The client and therapist set forth the automatic thought as the hypothesis and study the evidence both for and against the hypothesis. It is believed that cognitions affect behavior and behavior influences cognitions. The schedule is then used to determine important areas needing concentration during therapy. VI.
Review Questions . A case study presented the role of the nurse in cognitive therapy in the context of the nursing process. VIII. Summary and Key Points IX.104 D.
Electroconvulsive Therapy (ECT). Dose of stimulation is based on the client’s seizure threshold. OBJECTIVES After reading this chapter. 3. 2. which was believed to alleviate the symptoms of . Other types of somatic therapies had been tried prior to that time: insulin coma therapy and pharmacoconvulsive therapy. 4. Identify risks associated with electroconvulsive therapy. II. mechanism of action. KEY TERMS insulin coma therapy pharmacoconvulsive therapy CORE CONCEPT electroconvulsive therapy CHAPTER OUTLINE/LECTURE NOTES I. Discuss historical perspectives related to electroconvulsive therapy. The role of the nurse in the administration of electroconvulsive therapy is described. D. B. C. 5. B. an injection of insulin produced a hypoglycemic coma. ECT is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain. the student will be able to: 1. Define electroconvulsive therapy. C. which is highly variable among individuals. and side effects of electroconvulsive therapy. Discuss indications. Defined A. The duration of the seizure should be at least 15 to 25 seconds. Describe the role of the nurse in the administration of electroconvulsive therapy.105 CHAPTER 21. E. The first treatment was performed in 1938 in Rome. Historical Perspectives A. Applied through electrodes placed bilaterally in the frontotemporal region. contraindications. or unilaterally on the same side as the dominant hand. Usually administered every other day. but some may require up to 20 treatments. ELECTROCONVULSIVE THERAPY CHAPTER FOCUS The focus of this chapter is to introduce the student to the use of electroconvulsive therapy in psychiatry. for three times per week. Most clients require an average of 6 to 12 treatments. With insulin coma therapy.
A second peak of acceptance began around 1980 and has been increasing to the present. VII. III. E. It seems to be of little value in the treatment of chronic schizophrenia. V. Schizophrenia. ECT can induce a remission in some clients who present with acute schizophrenia.S. B. C. IV. and congestive heart failure. other neuroses. He switched to the use of pentylenetetrazol when camphor was found to be unreliable. Mania. and dopamine. Individuals at high risk with ECT include those with myocardial infarction or cerebrovascular accident within the preceding 3 to 6 months. Some successes were reported in terms of reduction of psychotic symptoms.106 schizophrenia.000 people in the U. Risks Associated with Electroconvulsive Therapy . The only absolute contraindication for ECT is increased intracranial pressure (from brain tumor. Pharmacoconvulsive therapy involved induction of convulsions with intramuscular injections of camphor in oil. Side Effects A. norepinephrine. This period was followed by a 20-year span during which ECT was considered objectionable by both the psychiatric profession and the lay public. or other cerebrovascular lesion). A number of fatalities occurred with insulin therapy. The exact mechanism of action by which ECT affects a therapeutic response is unknown. ECT is also indicated in the treatment of acute manic episodes of bipolar affective disorder. D. recent CVA. Little evidence exists to support the efficacy of ECT in the treatment of these conditions. and personality disorders. VI. severe underlying hypertension. F. but may be administered following a trial of therapy with antidepressant medication. and 2 million people worldwide receive ECT treatments each year. It is usually not considered the treatment of choice for depression. ECT has been used with obsessive-compulsive disorders. and its use has been discontinued in the treatment of mental illness. ECT has been shown to be effective in the treatment of severe depression. Some credibility has been given to the biochemical theory that ECT results in significant increases in the circulating levels of serotonin. Most common side effects: temporary memory loss and confusion. aortic or cerebral aneurysm. Major Depression. Mechanism of Action A. B. An estimated 100. and this method was used until the advent of ECT. Indications A. D. It has been shown to be effective in treating manic clients who are refractory to antimanic drug therapy. The originator of this therapy believed this treatment also alleviated schizophrenic symptoms. Contraindications A. ECT was widely accepted from around 1940 to 1960. Other Conditions.
Nurses prepare the client for the treatment by having him or her void. when it does occur. however. thought and communication patterns. G. no current data to substantiate that ECT produces any permanent changes in brain structure or functioning.000 treatments. A skeletal history and x-ray assessment should also be considered. eyeglasses or contact lenses. as well as providing support to the client. I. Most individuals report no problems with memory aside from the time immediately surrounding the ECT treatments. VIII. as well as laboratory blood and urine studies. Vital signs are taken every 15 minutes for the first hour.107 A. F. C. however. Permanent Memory Loss 1. . the nurse remains with the client until he or she is fully awake. The client receives oxygen during and after the treatment. Evaluation of changes in client behavior is made to determine improvement and provide assistance in deciding the number of treatments that will be administered. 2. The nurse must ensure that informed consent has been granted. Critics of ECT remain adamant in their belief that the procedure always results in some degree of immediate brain damage. The client must receive a thorough physical exam prior to initiation of therapy. and hairpins. B. Brain Damage. and given an explanation of what has occurred. B. The client is oriented to time and place. Appropriate nursing diagnoses are formulated based on assessment data. Following the treatment. This exam should include assessment of cardiovascular and pulmonary status. both physically and emotionally. There are. The nurse must also assess mood. it is usually related to cardiovascular complications. Role of the Nurse in Electroconvulsive Therapy A. An airway/bite block is used to facilitate the client’s airway patency. E. jewelry. and vital signs. In the treatment room. Mortality. Although death is rare. The mortality rate from ECT is about 2 per 100. C. D. although the potential for these effects appears to be minimal. removing dentures. The nursing process is the method of delivery of care for the client receiving ECT. H. the anesthesiologist administers a muscle relaxant (usually succinylcholine) and a short-acting anesthetic (such as thiopental sodium or methohexital sodium). Electrodes are placed on the temples to deliver the electrical stimulation. level of anxiety. The nurse assists the psychiatrist and the anesthesiologist as required. some clients have reported retrograde amnesia extending back to months before treatment. The pretreatment medication (usually atropine sulfate or glycopyrrolate) is administered according to physician’s orders approximately 30 minutes prior to the treatment. All clients receiving ECT should be informed of the possibility for some degree of permanent memory loss.
Summary and Key Points X.108 IX. Review Questions .
acupressure and acupuncture. Discuss the historical background of various complementary therapies. C. including herbal medicine. 3. therapeutic touch and massage. diet and nutrition. conventional medical treatment. and pet therapy. D.109 CHAPTER 22. the student will be able to: 1. chiropractic medicine. The historical background and techniques of each are presented. KEY TERMS acupoints acupressure acupuncture allopathic medicine chiropractic medicine meridians qi subluxation yoga CORE CONCEPTS alternative medicine complementary medicine CHAPTER OUTLINE/LECTURE NOTES I. B. . Describe the techniques used in various complementary therapies. 4. 2. yoga. The connection between mind and body is well recognized. rather than alternative ones. COMPLEMENTARY THERAPIES CHAPTER FOCUS The focus of this chapter is to introduce the student to various alternatives to allopathic medicine. Some individuals elect to choose “complementary” therapies. Describe the philosophies behind various complementary therapies. Conventional medicine practiced in the United States today is based on scientific methodology and is known as allopathic medicine. Practices that differ from the usual conventional practices are known as alternative medicine. Complementary interventions are different from. “Alternative” refers to an intervention that is used instead of conventional treatment. Compare and contrast various types of conventional and alternative therapies. OBJECTIVES After reading this chapter. but used in conjunction with. Introduction A.
The Office of Alternative Medicine was established by the National Institutes of Health in 1991 to study nontraditional therapies and to evaluate their usefulness and their effectiveness. All herbal medicines must be approached with caution. 6. rather than combined herbal preparations. 5. Acupressure and acupuncture are healing techniques based on the ancient philosophies of traditional Chinese medicine dating back to 3000 B. and safety profile are included. Because of lack of regulation and standardization. II. The U. Examples of herbal medicines. Some plants from which even prescription drugs are derived are highly toxic in their natural state. Since that time. c. It is safer to use preparations that contain a single herb. 2. Increasing numbers of third-party payers are bowing to public pressure and including alternative and complementary therapies in their coverage. F.110 E. their uses. their labels cannot indicate medicinal uses. b. Acupressure and Acupuncture 1. The method of manufacture may alter potency. 4. Therefore. Herbal Medicine 1. which deals not only with the physical perspective. It is important to remember: a. I. Types of Complementary Therapies A. B. Food and Drug Administration (FDA) classifies herbal remedies as dietary supplements or food additives. H. but they have been shown to be effective in the treatment of certain disorders. Just because a substance is called “natural” does not mean that it is necessarily completely safe. and they are not subjected to FDA approval. the name has been changed to the National Center for Complementary and Alternative Medicine (NCCAM). 3. 2. and merit further examination as a viable component of holistic health care. G.S. . Virtually every culture in the world has relied on herbs and plants to treat illness. All of the Commission E monographs of herbal medicines have been translated into English. Complementary medicine is viewed as holistic health care. Commonalities and Contrasts III. ingredients may be adulterated. The meridians connect a series of acupoints to which the clinician applies pressure. d.C. but also the emotional and spiritual components of the individual. action. The Commission E of the German Federal Health Agency has been researching and regulating the safety and efficacy of herbs and plant medicines in Germany. Most complementary therapies are not founded in scientific principle. The main concept is that healing energy (qi) flows through the body along specific pathways called meridians.
6. In acupuncture. Food groups to encourage. Half the daily servings of grains should come from whole grains. hair-thin. tennis elbow. e. disposable. added sugars. Essential Vitamins and Minerals (Table 22-5 in the textbook). Weight management. psychological well-being. make small decreases in food and beverage calories and increase physical activity. Daily requirements d. The U. Chiropractic Medicine . dysmenorrhea. Maintain body weight in a healthy range. Consume alcoholic beverages in moderation: one drink per day for women and two drinks per day for men. The treatment has been found to be effective in the treatment of asthma. Pressure to these acupoints is thought to dissolve any obstructions in the flow of healing energy (qi) and to restore the body to a healthier functioning. and many other conditions. C. Keep total fat intake between 20 to 35 percent of calories. c. To prevent gradual weight gain. sterile. Many diseases today are linked to poor nutritional habits. Diet and Nutrition 1. with most fats coming from sources of polyunsaturated and monounsaturated fatty acids. cervical pain. Carbohydrates should comprise 45 to 64 percent of total calories. Physical activity. 5. postoperative and chemotherapy-induced nausea and vomiting. Consume less than 1 teaspoon of salt per day. cholesterol. b. low back pain. salt. Choose a variety of fruits and vegetables each day. with the majority coming from fiber-rich foods. Examples b. Limit fat. The Western medical philosophy regarding acupressure and acupuncture is that they stimulate the body’s own painkilling chemicals. Food sources D. Functions c.111 3. Make daily choices of fat-free or low-fat milk. stroke rehabilitation. stainless-steel needles are inserted into acupoints to dissolve the obstructions along the meridians. carpal tunnel syndrome. anxiety. the morphine-line substances known as endorphins. and alcohol. and a healthy body weight. Engage in regular physical activity and reduce sedentary activities to promote health. fibromyalgia. a. Consume nutrient-dense foods and beverages from among the basic food groups. nausea of pregnancy. Food groups to moderate. Adequate nutrients within calorie needs. substance abuse. depression. 3. insomnia. 4. They include: a. 2. Departments of Agriculture and Health and Human Services have collaborated on a set of guidelines to help individuals understand what types of foods to eat in order to promote health and prevent disease. d.S.
” To restore normal function. Developed in the late 1800s. rhythmic hand motions are swept over the entire body while the hands remain 2 to 4 inches from the skin. smoothing it out. and thus correcting the obstruction. Therapeutic Touch and Massage 1. Theory behind this type of healing is that energy flows from the brain to all parts of the body through the spinal cord and spinal nerves. Displacements of vertebrae are called “subluxations. . When vertebrae of the spinal column become displaced. 2. Muscle relaxation may be achieved with massage. they may press on a nerve and interfere with the normal nerve transmission. allergies. 2. 4. 3. Heat should be felt where the energy is blocked. The therapist “massages” the energy field in that area. Therapeutic touch is used to correct the blockages and relieve the discomfort. 5. Adjustments are made by hand or facilitated by the use of special treatment tables.112 1. the vertebrae are manipulated back into their normal positions. 7. the practitioner need not actually touch the client’s skin. It has been useful in the treatment of chronic health conditions. menstrual difficulties. Because therapeutic touch is based on the premise that the energy field extends beyond the surface of the body. Chiropractors are licensed to practice in all 50 states. carpal tunnel syndrome. Therapeutic touch is thought to reduce pain and anxiety and promote relaxation and health maintenance. Probably the most widely used form of alternative healing in the United States. 6. neck injuries. scoliosis. Massage 1. F. Slow.000 years. The technique of therapeutic touch was developed in the 1970s by Dolores Krieger. 7. sinusitis. which when blocked. Massage is the technique of manipulating the muscles and soft tissues of the body.” 5. 3. a nurse associated with the New York University School of Nursing. 4. and certain sports injuries. the application of heat or cold. Others include headaches. 6. 3. E. The Eastern style focuses on balancing the body’s vital energy (qi) as it flows through pathways called meridians. 8. This therapy is based on the philosophy that the human body projects a field of energy around it. pain or illness occurs. 2. It has been used by Chinese physicians for the treatment of disease for more than 5. and through the use of ultrasound treatments. respiratory and gastrointestinal disorders. The manipulations are called “adjustments. The most common type of ailment for which individuals seek chiropractic treatment is back pain.
2. migraine headaches. pain of labor and delivery. stress-related disorders. 4. Yoga 1. 2. b. arthritis. osteoporosis. Summary and Key Points V. d. G. 5. and energizes the mind. Pets have been shown to: a. varicose veins. 6. or burn.. bruise. used to achieve a profound feeling of relaxation. The Western style of massage affects muscles. Yoga is helpful in relieving stress and in improving overall physical and psychological wellness. and the cardiovascular system. The objective of yoga is to integrate the physical. and increase mobility. tones the internal organs. Some researchers believe that animals actually may retard the aging process among those who live alone. or over the site of a recent injury. 3. along with deep circular movements and vibrations. so that natural healing can occur. Massage is contraindicated in high blood pressure. 3.000 years ago. thereby easing stress and fatigue. Yoga breathing is a deep. Enhance mood and improve social interaction among nursing home clients. skin conditions. Evidence has shown that animals can directly influence a person’s mental and physical well-being. Reduce the death rate from recurrence of heart attack. A variety of gliding and kneading strokes. Review Questions . 7. are used to relax the muscles. phlebitis.113 4. along with meditation and breathing exercises. acute infection. mental. 6. Another component of yoga is meditation. to achieve a balanced. tendons and ligaments). Decrease the probably of depression in AIDS clients. muscle spasms. Yoga is thought to have been developed in India some 5. sciatica. 5. connective tissues. and boosting energy. (e. insomnia. which can occur simply by petting a dog or cat. body. Western yoga uses body postures. c. H. and whiplash.g. Pet Therapy 1. disciplined workout that releases muscle tension. Lower blood pressure. improve circulation. IV. diaphragmatic breathing that increases oxygen to brain and body tissues. and spiritual energies that enhance health and well-being. Massage is helpful in reducing anxiety and in relieving chronic back and neck pain. and spirit.
and adolescent psychiatric disorders. Tourette’s disorder. Introduction A. Identify symptomatology and use the information in the assessment of clients with the aforementioned disorders. CHILDHOOD. 2.114 CHAPTER 23. DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY. KEY TERMS aggression autistic disorder clinging echolalia impulsivity negativism palilalia CORE CONCEPTS autism spectrum disorders disruptive behavior disorders hyperactivity impulsiveness temperament CHAPTER OUTLINE/LECTURE NOTES I. childhood. Identify psychiatric disorders usually first diagnosed in infancy. conduct disorder. It is often difficult to determine if a child’s behavior is indicative of emotional problems. Describe treatment modalities relevant to selected disorders of infancy. 4. and adolescence. autistic disorder. OBJECTIVES After reading this chapter. Symptomatology and predisposing factors are described. childhood. OR ADOLESCENCE CHAPTER FOCUS The focus of this chapter is on psychiatric disorders usually first evident in infancy. childhood. . oppositional defiant disorder. the student will be able to: 1. or adolescence. 5. Discuss relevant criteria for evaluating nursing care of clients with selected infant. The role of the nurse in the care of these clients is emphasized. Discuss predisposing factors implicated in the etiology of mental retardation. and separation anxiety disorder. 3. childhood. Identify nursing diagnoses common to clients with these disorders and select appropriate nursing interventions for each. 6. or adolescence. attention-deficit/hyperactivity disorder.
Pregnancy and perinatal factors a. such as Down syndrome and Klinefelter syndrome (3) Single gene abnormalities. such as Tay-Sachs disease.115 B. linguistic. Deviate from cultural norms 3. Account for approximately 5 percent of cases of MR b. such as head injuries. such as toxemia and uncontrolled diabetes 3. viral or other infections during pregnancy (2) Trauma or complications of the birth process that result in deprivation of oxygen to the infant (3) Premature birth 4. Environmental influences and other mental disorders a. Defined by deficits in general intellectual functioning (as measured by intelligence quotient exams) and adaptive functioning (the ability to adapt to the requirements of daily living and the expectations of age and cultural group). B. Account for 30 percent of MR cases b. Can be caused by: (1) Infections. such as from insecticides. and hyperglycinemia (2) Chromosomal disorders. Early alterations in embryonic development a. Includes: (1) Inborn errors of metabolism. and hyperpyrexia 5. medications. Create deficits or impairments in adaptive functioning II. such as tuberous sclerosis and neurofibromatosis 2. The DSM-IV-TR suggests that an emotional problem exists if the behavioral manifestations: 1. May be attributed to: (1) Deprivation of nurturance and social. Predisposing Factors 1. Implicated in approximately 5 percent of cases. Account for approximately 10 percent of cases of MR b. Damages may occur in response to: (1) Toxicity associated with maternal ingestion of alcohol or other drugs (2) Maternal illnesses and infections during pregnancy (3) Complications of pregnancy. Are not age appropriate 2. Can be caused by: (1) Fetal malnutrition. asphyxiation. Hereditary factors a. and other stimulation . General medical conditions acquired in infancy or childhood a. and lead (3) Physical traumas. Accounts for between 15 and 20 percent of cases of MR b. Mental Retardation A. phenylketonuria. such as meningitis and encephalitis (2) Poisonings.
5. 7. 2. Onset occurs prior to age 3 and in most cases runs a chronic course with symptoms persisting into adulthood. Application of the Nursing Process to Mental Retardation 1. Abnormalities in brain structures or functions. Research findings have suggested involvement with chromosomes 2. maternal rubella. Predisposing Factors 1. 16. Background assessment data (symptomatology) a. severe. Impairment in social interaction b. Application of the Nursing Process to Autistic Disorder 1. Characterized by a withdrawal of the child into the self and into a fantasy world of his or her own creation. 4. realistic expectations and client potentials. fragile X syndrome. 4. methods for modifying behavior as required. dopamine.116 (2) Severe mental disorders. Neurological implications. moderate. cerebral cortex. congenital hypothyroidism. and epinephrine. in the areas of the cerebellum. Medical conditions that may be implicated in the etiology of autistic disorder include tuberous sclerosis. and profound. The role of neurotransmitters. and brainstem. 6. Women who suffered from asthma and/or allergies around the time of pregnancy are at increased risk of having a child affected by autism. Down syndrome neurofibromatosis. such as serotonin. have been implicated. Perinatal influences. is currently under investigation 2.000 and occurs about four times more often in boys than in girls. 15. 3. Genetics. C. D. and Angelman’s syndrome. limbic system. Degree of severity of mental retardation is identified by level of IQ. B. Family members should receive information regarding the scope of the condition. and 17. such as autistic disorder C. It is important to include family members in the planning and implementation of care. Sibling and twin studies have revealed strong evidence that genetic factors play a significant role. Four levels have been delineated: mild. 3. Evaluation of care given to the client with MR should reflect positive behavioral change. Nurses must access strengths as well as limitations in order to encourage the client to be as independent as possible. III. Physiological implications. basal ganglia. A study conducted by the NIH has implicated a region on chromosome 11 and aberrations in a brain-development gene called neurexin 1. Autistic Disorder A. Prevalence of the disorder is about 9 per 1. phenylketonuira. community resources from whom they may seek assistance and support. Restricted activities and interests . corpus callosum. Impairment in communication and imaginative activity c.
perinatal. Biochemical theory. fatigue. constipation. Deliberate self-injury c. IV. Genetics (1) Frequency among family members has been noted (2) Variations on certain chromosomes have been implicated b. Predominantly Inattentive Type 3. Nursing intervention is aimed at protection of the child from self-harm and improvement in social functioning. The disorder is further categorized into three subtypes: 1. and personal identity E. d. 4. prolonged labor. Common side effects of risperidone: drowsiness. and weight gain. and tremor. increased appetite. Diet factors. nasal congestion. weight gain. Pharmacological Intervention for Autistic Disorder 1. and CNS trauma or infections 2. and perinatal asphyxia (3) Postnatal factors include cerebral palsy. and hyperactivity. Prenatal. drooling. Common side effects of aripiprazole: sedation. Quickly changing moods 3. including food dyes and additives (further study is needed) . and postnatal factors (1) Prenatal factors include maternal smoking and alcohol intake during pregnancy (2) Perinatal factors include prematurity. Attention-Deficit/Hyperactivity Disorder (ADHD) A. Environmental influences a. and possibly serotonin have been implicated. ADHD. 2. verbal communication.S. basal ganglia. impulsiveness. fatigue. Predisposing Factors 1. ADHD. Anatomical influences. Abnormal levels of dopamine. Essential features include developmentally inappropriate degrees of inattention. Combined Type 2. seizures. globus pallidus. Predominantly Hyperactive-Impulsive Type C. c. Environmental lead b. vomiting. ADHD. signs of fetal distress. Temper tantrums d. Biological influences a. Brain alterations in the regions of the prefrontal lobes. Aggression b. Dosage is based on weight of the child and the clinical response. norepinephrine. The U.117 2. B. somnolence. dizziness. caudate nucleus. 5. Food and Drug Administration (FDA) has approved two medications for the treatment of irritability associated with autistic disorder: risperidone and aripiprazole. and cerebellum have been suggested. These medications are targeted for the following symptoms: a.
The prevalence of comorbid psychiatric disorders with ADHD may be as high as 84 percent. Comorbid conditions must also be treated a. tachycardia. Application of the Nursing Process to ADHD 1. Unstable foster care D. Psychiatric symptoms may worsen. CNS stimulants (controlled category CII) (1) Examples: dextroamphetamine (Dexadrine). Excessive levels of activity. High degree of psychosocial stress c. Anxiety and depression may be treated concurrently with symptoms of ADHD b. Low socioeconomic status f. Highly distractible with extremely limited attention span b. Growing up in an institution h. anorexia. Anxiety d. Common ones include: a. Comorbidity. Bipolar symptoms must be controlled with a mood stabilizer before stimulants are prescribed for ADHD 5. Dexmethylphenidate (Focalin). restlessness. Conduct disorder c. 4. selfesteem. Oppositional defiant disorder b. Low frustration tolerance and outbursts of temper d. Paternal criminality e. Bipolar disorder f. Living in poverty g. Nursing intervention is aimed at protection from injury due to excessive hyperactivity. weight loss. Substance use disorders 3. and fidgeting 2. Background assessment data (symptomatology) a. methamphetamine (Desoxyn). (3) Side effects: insomnia. Disorganized or chaotic environments b. Depression e. Tolerance can occur. and a dextroamphetamine/amphetamine composite (Adderall). Difficulty forming satisfactory interpersonal relationships c. and temporary decrease in rate of growth and development. Substance addiction must be stabilized before treating the ADHD c. control of hyperactive behavior. Psychosocial influences a. (4) Warning: Careful monitoring of cardiovascular function during treatment is necessary. and compliance with task expectations. Psychopharmacological intervention for ADHD a. methylphenidate (Ritalin). Maternal mental disorder d. improvement in social interaction. . lisdexamfetamine (Vyvanse). and improvement in learning ability.118 3. (2) Effects on children with ADHD: increased attention span.
insomnia. Adolescent-onset type. sedation. rebound syndrome if discontinued abruptly. c. 2. c. Psychiatric symptoms may worsen. upper abdominal pain. b. (3) Side effects: headache. nausea and vomiting. Individuals with history of seizures or eating disorders should not take this medication. Clonidine (Catapres). and sexual dysfunction. tachycardia or bradycardia. (2) Exact mechanism in treatment of ADHD is unknown. d. Alterations in levels of norepinephrine and serotonin have been implicated. nausea. Childhood-onset type. anorexia. dizziness. dry mouth. Atomoxatine (Strattera) (1) A selective norepinephrine reuptake inhibitor. shakiness. constipation. weight loss. decreased appetite. Biochemical. V. Biological influences a. constipation. dry mouth. 2. constipation. Twins and non-twin sibling studies indicate a higher incidence among those who have family members with the disorder. (3) Side effects: palpitations. Two subtypes based on age at onset: 1. increased blood pressure and heart rate. Predisposing Factors 1. (2) Exact mechanism in treatment of ADHD is unknown (3) Side effects: tachycardia. Conduct Disorder A. guanfacine (Tenex. Bupropion (Wellbutrin) (1) A nonselective reuptake inhibitor. Defined by the absence of any criteria characteristic of conduct disorder prior to age 10. and weight loss. Intuniv) (1) Centrally acting alpha-agonists. (2) Exact mechanism in treatment of ADHD is unknown. insomnia. Temperament. Genetics. Defined by the onset of at least one criterion characteristic of conduct disorder prior to age 10. A persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated.119 (5) A drug “holiday” should be attempted periodically under direction of the physician to determine effectiveness of the medication and need for continuation. Children who are born with “difficult” temperaments were found to have a significantly higher degree of aggressive behavior later in life. Reports of the involvement of elevated levels of testosterone are inconsistent. (4) Warning: Careful monitoring of cardiovascular and liver function during treatment is necessary. Psychosocial influences . B. b.
Oppositional Defiant Disorder (ODD) A. disobedience. C. and unwillingness to compromise. impulsiveness. procrastination. Background assessment data (symptomatology) a. Biological influences. carelessness.120 a. Inability to control anger g. Characterized by a pattern of negativistic. resistance to directions. . Nursing intervention is aimed at protection of others from client’s physical aggression. Application of the Nursing Process to Conduct Disorder 1. improvement in social interaction and self-esteem. Background assessment data (symptomatology) a. and interferes with social. B. or if they exercise authority for their own needs. Problems with inattentiveness. Peer relationships. 2. defiant. Use of drugs and alcohol c. Application of the Nursing Process to ODD 1. or occupational functioning. Low academic achievement h. Role not established. and acceptance of responsibility for own behavior VI. negativism. Family influences (1) The following family dynamics may contribute to the development of conduct disorder: (a) Parental rejection (b) Inconsistent management with harsh discipline (c) Early institutional living (d) Frequent shifting of parental figures (e) Large family size (f) Absent father (g) Parents with antisocial personality disorder or alcohol dependence (h) Marital conflict and divorce (i) Inadequate communication patterns (j) Parental permissiveness C. Symptoms include passive-aggression exhibited by stubbornness. disobedient. academic. and hostile behavior toward authority figures that occurs more frequently than is typically observed in individuals of comparable age and developmental level. deliberately ignoring the communication of others. Sexual permissiveness d. Family influences. b. Physical aggression in the violation of the rights of others b. testing of limits. a power struggle can be established between the parents and the child that sets the stage for the development of ODD. Use of projection as a defense mechanism e. Low self-esteem manifested by “tough-guy” image f. If power and control are issues for parents. Predisposing Factors 1. Having poor peer relations during childhood has been implicated in the etiology of later deviance. and hyperactivity 2.
and coughing. improvement in social interaction. or repeating the words of others (called echolalia).121 b. gamma-aminobutyric acid. increase in self-esteem. and in about 10 percent of cases. dynorphin. and argumentativeness. and improvement in self-esteem. yelps. Biological factors a. The essential feature is the presence of multiple motor tics and one or more vocal tics. Nursing intervention is aimed at protection of the client and others. c. Complex motor tics include touching. d. Vocal tics may also include repeating one’s own sounds or words (called palilalia). b. Carbon monoxide poisoning e. Tourette’s Disorder A. Other symptoms may include running away. The familial predisposition to tic disorders appears to be governed by a single gene with an autosomal pattern intermediate between dominant and recessive transmission. Encephalitis f. Possible autoimmune response to strep infection D. hopping. temper tantrums. and twirling when walking. school avoidance. b. Head trauma d. Abnormalities in levels of dopamine. Genetics. acetylcholine. and improvement in social interaction. barks. and it is more common in boys than in girls. Brain studies in Tourette’s disorder have found dysfunction in the area of the basal ganglia. deep knee bends. Structural factors. Simple motor tics include eye blinking. B. . Twin studies suggest an inheritable component. Severe nausea and vomiting or excessive stress during pregnancy b. retracing steps. skipping. Application of the Nursing Process to Tourette’s Disorder 1. c. Background assessment data (symptomatology) a. Predisposing Factors 1. Environmental factors a. and norepinephrine have been associated with Tourette’s disorder. Interpersonal relationships are impaired and school performance is often unsatisfactory. facial grimacing. snorts. fighting. 2. c. neck jerking. serotonin. squatting. 2. C. school underachievement. sniffs. coughs. One recent study found a correlation between smaller size of corpus callosum and Tourette’s disorder in children. 2. shoulder shrugging. acceptance of responsibility for own behavior. Biochemical factors. Vocal tics include words or sounds such as clicks. Nursing intervention is aimed at compliance with therapy. Low birthweight c. the uttering of obscenities. VII. Onset of the disorder most commonly occurs during childhood. grunts.
It is believed that certain individuals inherit a “disposition” toward developing anxiety disorders. Not recommended for children younger than age 12 years. Separation Anxiety Disorder A. and family therapy. Family influences a. agitation. Because of the severe side effects. Intuniv). headaches. Predisposing Factors 1. The most common medications used are: a. socially. Common side effects include weight gain. fatigue. 3. and a rapid rise in blood pressure. such as behavioral therapy. (3) Atypical antipsychotics: risperidone (Risperdal). ziprasidone (Geodon). olanzapine (Zyprexa). tremor. Used only with severe cases. Alpha agonists: clonidine (Catapres) and guanfacine (Tenex. (2) Pimozide (Orap). and dizziness or postural hypotension. b. To do so could result in symptoms of nervousness. (1) Should not be prescribed for children and adolescents with preexisting cardiac or vascular disease. Biological influences a. Pharmacological intervention with Tourette’s disorder is most effective when it is combined with other forms of therapy. Common side effects include dry mouth. Possible overattachment to the mother b. Environmental influences a. sedation. Separation conflicts between parent and child c. sedation. Similar in response rate and side effect profile to haloperidol. b. this medication should be reserved for children with severe symptoms or with symptoms that impede their ability to function in school. or within their family setting. QTc prolongation with ziprasidone. Families that are very close-knit d. Genetics. Essential feature of this disorder is excessive anxiety concerning separation from the home or from those to whom the person is attached. individual counseling or psychotherapy. 2. VIII. B. Studies show that a greater number of children with relatives who manifest anxiety problems develop anxiety disorders themselves than do children with no such family patterns. Temperament. Stressful life events. and hyperglycemia. (2) Should not be discontinued abruptly. Transfer of fears and anxieties from parents to child through role modeling . Overprotection by parents e.122 3. It is thought that children who are already predisposed to developing anxiety disorders may be affected significantly by stressful life events. Antipsychotics (1) Haloperidol (Haldol).
screaming. 6. Family dynamics has an impact on disruptive behavior and disruptive behavior affects family dynamics. or craft therapy groups. rarely as late as adolescence b. Onset of separation anxiety disorder may occur as early as preschool age. May also learn to accept differences in others. complaints of physical problems. Common and effective treatment for disruptive behavior disorders (ADHD. Play therapy groups are effective treatment for children between the ages of 3 and 9. B. C. IX. Principle: Positive reinforcements encourage repetition of desirable behaviors and aversive reinforcements (punishments) discourage repetition of undesirable behaviors. 3. and development of adaptive coping strategies that prevent maladaptive symptoms of anxiety in response to separation from attachment figure. improvement in social interaction. art or activity groups. Family Therapy 1. and to practice these new skills in a safe environment. Genograms are helpful (see Chapter 11 of the text). to learn to offer and receive support from others. 3. 5. Based on the concepts of classical conditioning and operant conditioning (see Chapter 19 of the text). Behavior Therapy 1. Separation results in tantrums. Group therapy provides children and adolescents with the opportunity to interact within an association of their peers. and “clinging” behaviors d. Nightmares may occur h. conduct disorder. Group Therapy 1. crying. May learn appropriate social behaviors from the positive and negative feedback of peers. The treatment plan must be instituted within the context of family-centered care. Phobias and depressed mood are not uncommon 2. Background assessment data (symptomatology) a. and ODD). Nursing intervention is aimed at maintaining anxiety at moderate level or below. 2. Application of the Nursing Process to Separation Anxiety Disorder 1. Psychoeducational groups are very beneficial for adolescents. 3. Fear of sleeping away from home f. Child has difficulty separating from mother c. 2. 2. General Therapeutic Approaches A. . 4. School reluctance or refusal e. May take the form of music therapy groups. Fear of harm to self or attachment figure g. Therapy for children and adolescents must involve the entire family if problems are to be resolved.123 C.
. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. can’t sit still. Summary and Key Points XI. Psychopharmacology: Research has indicated that medication alone is not as effective as a combination of medication and psychosocial therapy. Noncompliance and defensive coping. Assessment data: behavior unmanageable. Critical Thinking Exercise XII. is physically aggressive. interrupts. 2.124 D. Risk for other-directed violence. jumps from topic to topic. yells. no insight into his own behavior. refusing to cooperate. 3. X.
dementia. Discuss criteria for evaluating nursing care of clients with delirium. dementia. and amnestic disorders. These disorders were identified in previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as organic mental syndromes and disorders. DEMENTIA. dementia. 5. 2. dementia. OBJECTIVES After reading this chapter. and select appropriate nursing interventions for each. dementia. dementia. AND AMNESTIC DISORDERS CHAPTER FOCUS The focus of this chapter is on predisposing factors. and amnestic disorders. and amnestic disorders. Identify symptomatology and use the information to assess clients with delirium. 6. 3. symptomatology. Identify nursing diagnoses common to clients with delirium. and amnestic disorders. DELIRIUM. Describe various treatment modalities relevant to care of clients with delirium. and amnestic disorders. and nursing interventions for the care of clients with delirium.125 CHAPTER 24. KEY TERMS aphasia apraxia ataxia confabulation primary dementia pseudodementia secondary dementia sundowning CORE CONCEPTS amnesia delirium dementia . Discuss predisposing factors implicated in the etiology of delirium. 7. and amnestic disorders. and amnestic disorders. dementia. 4. the student will be able to: 1. Define and differentiate among delirium. Identify topics for client and family teaching relevant to cognitive disorders.
Misperceptions of the environment. . Symptoms include: 1. representing a significant change from a previous level of functioning. Symptoms are attributed to side effects of anesthetics. Speech that is rambling. anticonvulsants. hypoxia. Disturbance in level of consciousness. Disorganized thinking 4. Substance-induced delirium. and elevated blood pressure C. Toxins reported to cause delirium include organophosphate insecticides. Impairment of recent memory 8. Delirium usually begins abruptly. psychotropic medications. sweating. Delirium due to a general medical condition. antihistamines. Emotional instability 12. including illusions and hallucinations 9. Characterized by a disturbance of consciousness and a change in cognition that develop rapidly over a short period. and incoherent 5. pressured. Difficulty sustaining and shifting attention 2. Psychomotor activity that fluctuates between agitation and restlessness and a vegetative state 11.. carbon monoxide. antihypertensive and cardiovascular medications. irrelevant. metabolic disorders (e. postictal states. D. B. This chapter discusses disorders in which a clinically significant deficit in cognition or memory exists. and hypoglycemia).g. rarely more than 1 month) and subsides completely upon recovery from the underlying determinant. hypercarbia. Introduction A. with interruption of the sleepwake cycle 10. E. The name was changed to prevent the implication that nonorganic mental disorders do not have a biological basis. fluid or electrolyte imbalances. Predisposing Factors 1. Delirium A.g. B. hypertensive encephalopathy. and others. dilated pupils. Autonomic manifestations. Previously known as organic mental syndromes and disorders. Duration is usually brief (e. Disorientation to time and place 7. 2.. analgesics. such as following a head injury or seizure. thiamine deficiency. such as systemic infections. hepatic or renal disease.126 CHAPTER OUTLINE/LECTURE NOTES I. It can have a slower onset if the underlying etiology is systemic illness or metabolic imbalance. postoperative states. and sequelae of head trauma. and volatile substances such as fuel or organic solvents. 1 week. Impaired reasoning ability and goal-directed behavior 6. flushed face. Extreme distractibility 3. antiasthmatic agents. II. such as tachycardia.
Disregard for the conventional rules of social conduct 3. or anxiolytics. 2. and memory function in a state of full alertness. Dementia A. As the disease progresses. Delirium due to multiple etiologies. C. Reversible dementia can occur as the result of cerebral lesions. Wandering away from the home may become a problem 6. judgment. Personality change is common G. such as HIV disease or a cerebral trauma. Defined by a loss of previous levels of cognitive. symptoms may include: 1. . Primary: The dementia itself is the major sign of some organic brain disease. sedatives. vitamin or nutritional deficiencies. usually high-dose use of certain substances such as alcohol. 1. Impairment in abstract thinking. executive. Substance-withdrawal delirium. or narcotics. Withdrawal delirium symptoms develop after reduction or termination of sustained. Alzheimer’s disease (AD) is the most common form of dementia. Alzheimer’s disease (AD) accounts for 50 to 60 percent of all cases of dementia. No apparent symptoms. F. Stage 1. III. AD affects 5 percent of people from ages 71 to 79. H. Neglect of personal appearance and hygiene 4. hallucinogens. Apraxia (inability to carry out motor activities despite intact motor functioning) 3. and impulse control 2. 5. Dementia can be classified as either primary or secondary. anxiolytics. CNS infections. The delirium symptoms may be related to more than one general medical condition or to the combined effects of a general medical condition and substance use. such as Alzheimer’s disease. depression. cocaine.127 3. which is middle age and beyond. AD progresses according to stages: 1. Symptoms may occur following ingestion of high doses of cannabis. and 37 percent of those ages 90 and older. Incontinence I. Symptoms include: 1. alcohol. Reversible dementia occurs in a small percentage of cases and might be more appropriately termed temporary dementias. Secondary: Dementia caused by or related to another disease or condition. normal pressure hydrocephalus. B. E. Language may or may not be affected 5. D. Substance-intoxication delirium. Aphasia (absence of speech) 2. with sudden outbursts over trivial issues 4. and metabolic disorders. Irritability and moodiness. 4. hypnotics. side effects of certain medications. 24 percent of people ages 80 to 89. Inability to care for personal needs independently 5. The numbers of individuals with this disorder is growing because more people now survive into the high-risk period for dementia.
Mild cognitive decline. Onset is slow and insidious and the course of the disorder is generally progressive and deteriorating b. early dementia. agitated. J. Stage 5. and course is more variable c. 7. Predisposing Factors 1. May use confabulation.128 2. Symptoms may range from barely perceptible changes to acute delirium to profound dementia 4. Dementia is due to brain infections by opportunistic organisms or by the HIV-1 virus directly b. Stage 3. Institutional care is usually required at this stage. Mild-to-moderate cognitive decline. 3. Refinement of diagnostic criteria now enables clinicians to use specific clinical features to identify the disease with considerable accuracy c. Dementia due to HIV disease a. or even name of spouse. Requires assistance to manage on an ongoing basis. middle dementia. 5. Disoriented to time and place. Unable to perform ADLs independently. Etiologies may include: (1) Hypertension (2) Cerebral emboli (3) Cerebral thrombosis 3. Wandering is common. Individual may become lost while driving. Dementia due to significant cerebrovascular disease (significant number of small strokes) b. Moderate-to-severe cognitive decline. 6. Etiologies may include: (1) Acetylcholine alterations (2) Plaques and tangles (3) Head trauma (4) Genetic factors 2. Anxiety and depression common. May be unable to recall recent major life events. Moderate cognitive decline. More abrupt onset than Alzheimer’s disease. Unable to perform tasks or understand current events. Stage 6. Symptoms worsen in late afternoon and evening—a phenomenon called sundowning. May forget names of close relatives. Commonly bedfast and aphasic. Loss of short-term memory. and sleeping may be a problem. late dementia. Forgets important dates. Incontinent. Stage 2. 4. confusion. Dementia due to head trauma . Unable to recognize family. Severe cognitive decline. Vascular dementia a. Forgetfulness. Stage 4. Difficulty concentrating. Dementia of the Alzheimer’s type a.
dysarthria. can result in dementia pugilistica. characterized by emotional lability. May account for 25 percent of all dementia cases 6. Dementia due to Parkinson’s disease a. Amnesia is the most common neurobehavioral symptom. A genetic factor may be involved 9. but progresses more rapidly b. Pathology results from atrophy in the frontal and temporal lobes of the brain b. Patients are highly sensitive to EPS with antipsychotic medications d. Etiology is thought to be a transmissible agent known as a “slow virus.129 a.” Five to 15 percent have a genetic component. A profound state of dementia and ataxia eventually occur d. Onset of symptoms occurs between ages 40 and 60 and course is extremely rapid. and a degree of permanent disturbance may persist b. Dementia due to Pick’s disease a. 10. Transmitted as a Mendelian dominant gene b. Other medical conditions that can cause dementia include: (1) Endocrine conditions (2) Pulmonary disease (3) Hepatic or renal failure (4) Cardiopulmonary insufficiency (5) Fluid and electrolyte imbalances (6) Nutritional deficiencies (7) Frontal or temporal lobe lesions (8) CNS or systemic infections (9) Uncontrolled epilepsy (10) Other neurological conditions. Similar to AD. Dementia due to Huntington’s disease a. ataxia. Appearance of Lewy bodies in the cerebral cortex and brainstem c. Clinical picture is very similar to that of Alzheimer’s disease c. with progression from diagnosis to death in less than 2 years. Dementia due to Lewy body disease a. Caused by a loss of nerve cells located in the substantia nigra. and a decrease in dopamine activity b. b. Average course of the disease is based on age at onset. Dementia due to other general medical conditions a. and impulsivity 5. such as multiple sclerosis . Dementia due to Creutzfeldt-Jakob disease a. with juvenile-onset and late-onset having the shortest duration 8. Damage from this disease occurs in the areas of the basal ganglia and the cerebral cortex c. such as the type experienced by boxers. Cerebral changes in dementia of Parkinson’s sometimes resemble those of Alzheimer’s disease 7. Repeated head trauma.
Poorly controlled insulin-dependent diabetes g. such as anticonvulsants and intrathecal methotrexate (5) Toxins. the creation of imaginary events to fill in memory gaps 3. Cerebral anoxia e. Amnestic disorders are characterized by an inability to learn new information (short-term memory deficit) despite normal attention. Predisposing Factors 1. Transient amnestic syndromes can occur from: (1) Cerebrovascular disease (2) Cardiac arrhythmias (3) Migraine (4) Thyroid disorders (5) Epilepsy 2. Confabulation. mercury. hypnotics. Cerebral neoplastic disease d. Duration and course may be quite variable and are also correlated with extent and severity of the cause. Herpes simplex encephalitis f. Other symptoms include: 1. such as lead. Denial that a problem exists. D. Apathy. Substance-induced persisting amnestic disorder. Amnestic Disorders A. and anxiolytics (4) Medications. Dementia due to multiple etiologies: This diagnosis is used when the symptoms of dementia are attributed to more than one etiology. Medical conditions that may be associated with amnestic disorder include: a. Head trauma b. Cerebrovascular disease c. Substance-induced persisting dementia a. Amnestic disorder due to a general medical condition. and an inability to recall previously learned information (long-term memory deficit). and emotional blandness C. IV. depending on the underlying pathological process. but with a lack of concern 4. Dementia is related to the persisting effects of use of substances such as: (1) Alcohol (2) Inhalants (3) Sedatives. and industrial solvents 12. B. or acknowledgment that a problem exists. lack of initiative. Disorientation to place and time (rarely to self) 2. Onset may be acute or insidious.130 11. E. carbon monoxide. Surgical intervention to the brain h. organophosphate insecticides. The amnestic symptoms are related to the persisting effects of the use of the following substances: .
Physical Assessment 1. Client/family history of specific illnesses B. Cognitive changes e. Neurological examination to assess mental status. including alcohol and drugs 2.131 Alcohol Sedatives. Language difficulties f. The Client History 1. Application of the Nursing Process A. Possible exposure to toxins k. Hepatic and renal dysfunction c. and industrial solvents V. Presence of toxic substances. Positron emission tomography (PET) d. Electroencephalogram (EEG) b. . Personality and behavioral changes c. Possible laboratory evaluations include blood and urine evaluations to test for: a. Diagnostic Laboratory Evaluations 1. and behavioral changes. Psychological tests to differentiate between dementia and pseudodementia (depression). Current and past use of drugs and alcohol j. Catastrophic emotional reactions d. b. c. place. d. Current and past use of medications i. language skills. and severity of mood swings b. The following areas of concern should be addressed: a. muscle strength. Electrolyte imbalances e. Lumbar puncture to examine cerebrospinal fluid B. Orientation to person. hypnotics. carbon monoxide. Common nursing diagnoses for the client with cognitive dysfunction include: a. Other diagnostic evaluations may include: a. sensory perception. Diabetes or hypoglycemia d. and coordination. 2. time. Magnetic resonance imaging (MRI) e. organophosphate insecticides. Various infections b. frequency. such as anticonvulsants and intrathecal methotrexate Toxins. loss of memory. and anxiolytics Medications. mercury. Appropriateness of social behavior h. Type. and situation g. such as lead. alertness. Computerized tomography (CT) scan c. 3. Assessment for diseases of various organ systems that can induce confusion. reflexes. Metabolic and endocrine disorders f. Nutritional deficiencies g. C. Diagnosis/Outcome Identification 1.
Benzodiazepines are commonly used when the etiology is substance withdrawal. 2. Low-dose neuroleptics may be administered to relieve agitation and aggression. 3. aggression. thought disturbances. They include: a. with focus on identification and resolution of potentially reversible processes. Medical Treatment Modalities A. Disturbed sensory-perception e. A number of pharmaceutical agents have been tried with varying degrees of success in the treatment of dementia. and wandering: (1) Risperidone (Risperdal) (2) Olanzapine (Zyprexa) (3) Quetiapine (Seroquel) (a) These drugs cause fewer anticholinergic and EPS than older antipsychotics. B. Planning/Implementation D. Self-care deficit h. 5. Room with low level of stimuli. 4. 2. Situational low self-esteem i. (b) They carry a black-box warning that all antipsychotics are associated with an increased risk of death in elderly patients with dementia.132 a. Determination and correction of the underlying causes. Primary consideration is given to etiology. Dementia 1. Client/Family Education E. Grieving C. Risk for trauma b. Delirium 1. Risk for other-directed violence f. For agitation. (4) Haloperidol (Haldol) (a) Still commonly used because of its proven efficacy. Impaired memory d. Disturbed thought processes c. Evaluation VI. Impaired verbal communication g. Staff should remain with client at all times to monitor behavior and provide reorientation and assurance. hallucinations. For cognitive impairment: (1) Physostigmine (Antilirium) (2) Tacrine (Cognex) (3) Donepezil (Aricept) (4) Rivastigmine (Exelon) (5) Galantamine (Razadyne) (6) Memantine (Namenda) b. .
is a good choice for individuals also experiencing insomnia. are particularly sensitive to anticholinergic side effects of medications. VII. Critical Thinking Exercise IX. amantadine. methylphenidate. (4) Dopaminergic agents (e. (2) Tricyclic antidepressants (a) Although still sometimes used. For sleep disturbances: (1) Flurazepam (Dalmane) (2) Temazepam (Restoril) (3) Triazolam (Halcion) (4) Zolpidem (Ambien) (5) Zaleplon (Sonata) (6) Eszopiclone (Lunesta) (7) Ramelteon (Rozerem) (8) Trazodone (Desyrel) (9) Mirtazapine (Remeron 3. they are often avoided because of cardiac and anticholinergic side effects.133 (b) Higher potential for anticholinergic. Review Questions . bromocriptine. Dosage adjustments with regards to physiological changes in aging clients must be made with all medications. (3) Trazodone (Desyrel) (a) Because of strong sedative effect. For anxiety (these medications should not be used routinely or for prolonged periods): (1) Diazepam (Valium) (2) Chlordiazepoxide (Librium) (3) Alprazolam (Xanax) (4) Lorazepam (Ativan) (5) Oxazepam (Serax) e. and sedative side effects than with the atypical antipsychotics. d. older people. Summary and Key Points VIII.. For depression: (1) SSRIs (a) Often considered first-line treatment because of their favorable side effect profile. EPS. bupropion) (a) May be helpful in the treatment of severe apathy. c.g. and especially those with dementia. (c) Because of decreased production of acetylcholine. (d) Carries a black-box warning that all antipsychotics are associated with an increased risk of death in elderly patients with dementia.
so a series of step-objectives would be used. Since the disease is progressive. 2. Joe is allowed to wander in a safe. 3. Anxiety. . suspiciousness. Joe dresses himself with step-instructions from the nurse. Outcome criteria: 1. confusion. Risk for trauma related to confusion and disorientation. Goal: Joe will be able to perform self-care needs with assistance. disorientation. 2. 2. Joe is able to find his room with the aid of a large sign on the door that identified it by name. enclosed area. 3. it would be unrealistic to expect resolution.134 ANSWERS TO CRITICAL THINKING EXERCISE 1. Joe washes his face with supplies provided by the nurse. Outcomes would be based on short-term goals. physically abusive. Outcome criteria: 1. For example: Goal: Joe will not harm himself in his confused state. Joe straightens up his room with direction from the nurse.
2. and the role of the nurse in the care of these clients is emphasized. Define abuse. 4. Describe various modalities relevant to treatment of individuals with substance-use disorders and substance-induced disorders. 7. and select appropriate nursing interventions for each. dependence. Discuss the issue of substance-related disorders within the profession of nursing. Define codependency and identify behavioral characteristics associated with the disorder. Discuss predisposing factors implicated in the etiology of substance-related disorders.135 CHAPTER 25. 10. and withdrawal. OBJECTIVES After reading this chapter. Describe relevant outcome criteria for evaluating nursing care of clients with substance-use disorders and substance-induced disorders. Identify nursing diagnoses common to clients with substance-use disorders and substance-induced disorders. Identify topics for client and family teaching relevant to substance-use disorders and substance-induced disorders. Predisposing factors are discussed. 8. Discuss treatment of codependency. 5. KEY TERMS Alcoholics Anonymous amphetamine ascites cannabis codependence detoxification disulfiram dual diagnosis esophageal varices hepatic encephalopathy Korsakoff’s psychosis opioids peer assistance programs phencyclidine substitution therapy Wernicke’s encephalopathy CORE CONCEPTS abuse dependence intoxication withdrawal . 9. SUBSTANCE-RELATED DISORDERS CHAPTER FOCUS The focus of this chapter is on the physical and behavioral manifestations and personal and social consequences for the individual who abuses or is dependent on substances. 6. intoxication. the student will be able to: 1. Identify symptomatology and use the information in assessment of clients with various substance-use disorders and substance-induced disorders. 3.
Recurrent substance use in situations in which it is physically hazardous 3. Some illegal substances have achieved a degree of social acceptance by various subcultural groups within our society. Psychosis g. Abuse b. Dementia e. Sleep disorders B.136 CHAPTER OUTLINE/LECTURE NOTES I. Substance Dependence 1. Evidence of withdrawal symptoms. Recurrent substance-related legal problems 4. Amnesia f. Substance-related disorders are composed of two groups: 1. school. Withdrawal c. Substance-induced disorders (only intoxication and withdrawal are discussed in this chapter) a. Physical dependence is manifested by the need for increasing amounts to produce the desired effects and a syndrome of withdrawal upon cessation 2. Dependence 2. Recurrent substance use resulting in a failure to fulfill major role obligations at work. Evidence of tolerance. Substance-use disorders a. as defined by either of the following: (1) A need for markedly increased amounts of the substance to achieve intoxication or desired effects (2) Markedly diminished effect with continued use of the same amount of the substance b. Sexual dysfunction j. as manifested by either of the following: (1) The characteristic withdrawal syndrome for the substance . Substance abuse. Substance-Use Disorders A. Anxiety disorder i. Psychological dependence exists when there is an overwhelming desire to repeat the use of a particular drug to produce pleasure or avoid discomfort 3. Intoxication b. Mood disorder h. Introduction A. DSM-IV-TR criteria for substance abuse: 1. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance B. DSM-IV-TR criteria for substance dependence include: a. II. Delirium d. or home 2.
Classes of Psychoactive Substances A. A great deal of time is spent in activities necessary to obtain the substance. or Anxiolytics V. or other important areas of functioning. Cocaine F. Amphetamines and related substances C. or recreational activities are given up or reduced because of substance use. use the substance. IV. III. Opioids J. d. occupational. Substance Intoxication. Predisposing Factors A. There is a persistent desire or unsuccessful efforts to cut down or control substance use. DSM-IV-TR criteria include: 1. g. The substance is often taken in larger amounts or over a longer period than was intended. Apparent hereditary factor. 2. Genetics. Biological Factors 1. Inhalants H. Cannabis E. Clinically significant maladaptive behavior or psychological changes that are due to the effect of the substance on the CNS and develop during or shortly after use of the substance. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Hallucinogens G. Sedatives. The substance-specific syndrome causes clinically significant distress or impairment in social. occupational. 2. DSM-IV-TR criteria include: 1. f. B. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. e. Caffeine D.137 (2) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms c. or recover from its effects. Phencyclidine (PCP) and related substances K. Alcohol B. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. The development of a reversible substance-specific syndrome caused by recent ingestion of (or exposure to) a substance. Nicotine I. . Substance-Induced Disorders A. Important social. 3. particularly with alcoholism. The development of a substance-specific syndrome caused by the cessation of (or reduction in) heavy and prolonged substance use. Substance Withdrawal. Hypnotics. 3.
Certain personality traits have been suggested to play a part in the tendency toward addictive behavior. frequent depression. Effects on the body (1) Peripheral neuropathy (2) Alcoholic myopathy (3) Wernicke’s encephalopathy (4) Korsakoff’s psychosis (5) Alcoholic cardiomyopathy (6) Esophagitis (7) Gastritis (8) Pancreatitis (9) Alcoholic hepatitis (10) Cirrhosis of the liver (a) Portal hypertension (b) Ascites (c) Esophageal varices (d) Hepatic encephalopathy (11) Leukopenia (12) Thrombocytopenia (13) Sexual dysfunction . Focus is on a punitive superego and fixation at the oral stage of psychosexual development. Conditioning. Biochemical.138 2. The Early Alcoholic Phase (3) Phase III. the inability to relax or to defer gratification. The Dynamics of Substance-Related Disorders A. B. C. Children and adolescents are more likely to use substances if they have parents who provide a model for substance use. Use of substances may also be promoted within one’s peer group. The Crucial Phase (4) Phase IV. and the inability to communicate effectively. Pleasurable effects from substance use act as a positive reinforcement for their continued use. Patterns of use/abuse (1) Phase I. Cultural and ethnic influences. Social learning. 3. Psychological Factors 1. Personality factors. They include: low self-esteem. 2. Developmental influences. passivity. Historical aspects c. Alcohol 1. Some cultures are more prone to use of substances than others. The Prealcoholic Phase (2) Phase II. Alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction. The Chronic Phase d. Abuse and dependence a. Sociocultural Factors 1. 2. VI. A profile of the substance b.
Abuse and dependence a. and drug and alcohol dependence) 2. Historical aspects c. memory. ADHD.139 e. Intoxication. B. 3. Characteristics of FAS include the following: (1) Small size for gestational age or small stature in relation to peers (2) Facial abnormalities (3) Poor coordination or delays in psychomotor development (4) Hyperactive behavior (5) Learning disabilities (6) Mental retardation or low IQ (7) Problems with daily living (8) Vision or hearing problems (9) Poor reasoning and judgment skills (10) Sleep and sucking disturbances in infancy (11) Heart and kidney defects (12) Abnormalities in size and shape of brain (13) Risk for psychiatric disorders (e. vision. and hearing. Sedative. Effects on the body (1) Effects on sleep and dreaming (2) Respiratory depression (3) Cardiovascular effects (4) Renal function (5) Hepatic effects (6) Body temperature . Hypnotic. attention span. communication. Occurs at blood alcohol levels between 100 and 200 mg/dl. or Anxiolytics 1. No amount of alcohol during pregnancy is considered safe g. (2) Alcohol-related neurodevelopmental disorder (3) Alcohol-related birth defects f. Alcohol can damage a fetus at any stage of pregnancy h.g. eating disorders. A profile of the substance (1) Barbiturates (2) Non-barbiturate hypnotics (3) Antianxiety agents (4) Club drugs b. Effects of alcohol on the fetus can result in problems with learning.. mood and anxiety disorders. Use during pregnancy can result in fetal alcohol spectrum disorders (FASDs) (1) Fetal alcohol syndrome (FAS). Patterns of use/abuse d. Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use. Withdrawal.
D. nausea or vomiting. impaired judgment. Abuse and dependence a. Withdrawal a. Restlessness and insomnia are the most common symptoms. Inhalants 1. confusion. Amphetamine and cocaine intoxication produces euphoria. respiratory depression. Intoxication with these CNS depressants can range from disinhibition and aggressiveness to coma and death (with increasing dosages of the drug). Onset of symptoms depends on the half-life of the drug from which the individual is withdrawing b. irritability. Historical aspects c. anxiety. A profile of the substance (1) Amphetamines (2) Non-amphetamine stimulants (3) Cocaine (4) Caffeine (5) Nicotine b. restlessness. b. 3. Withdrawal a. Effects on the body (1) CNS effects (2) Cardiovascular/pulmonary effects (3) Gastrointestinal and renal effects (4) Sexual functioning 2. Withdrawal from caffeine may include headache. irritability. A profile of the substance (1) Aliphatic and aromatic hydrocarbons . fatigue. muscular weakness. sleep disturbances. impaired psychomotor performance. and increased appetite. psychomotor agitation. Withdrawal from nicotine may include dysphoria. 3. difficulty concentrating. Abuse and dependence a. b. c. or coma. fatigue. Withdrawal from amphetamines and cocaine may include dysphoria. depression. seizures. dystonias. and nausea and vomiting. changes in vital signs. Intoxication a. and increased appetite. anxiety.140 (7) Sexual functioning 2. Intoxication from caffeine usually occurs following consumption in excess of 250 mg. muscle pain and stiffness. dyskinesias. CNS Stimulants 1. cardiac arrhythmias. anxiety. Patterns of use/abuse d. Intoxication. Severe withdrawal from CNS depressants can be life threatening C.
and are complete in 10 to 14 days. and typewriter correction fluid b. stupor or coma. 3. and usually last for several hours. use of or exposure to volatile inhalants. (3) With longer-acting drugs such as methadone. nystagmus.141 (2) Examples include: gasoline. blurred vision or diplopia. lethargy. varnish remover. or shortly after. tremor. rubber cement. Withdrawal a. E. unsteady gait. Severe opioid intoxication can lead to respiratory depression. and subside in 4 to 5 days. lighter fluid. generalized muscle weakness. (2) With short-acting drugs such as heroin. and death. Historical aspects c. Effects on the body (1) CNS effects (2) Respiratory effects (3) Gastrointestinal effects (4) Renal system effects 2. Patterns of use/abuse c. Intoxication a. peak within 1 to 3 days. Abuse and dependence a. symptoms begin within 1 to 3 days. coma. peak in 8 to 12 hours. symptoms being quickly. (1) With ultra-short-acting meperidine. psychomotor retardation. A profile of the substance (1) Opioids of natural origin (2) Opioid derivatives (3) Synthetic opiate-like drugs b. or euphoria. incoordination. slurred speech. Intoxication a. airplane glue. shoe conditioner. Patterns of use/abuse d. depressed reflexes. Symptoms may include: dizziness. and gradually subside over a period of 5 to 7 days. cleaning fluid. symptoms occur within 6 to 12 hours after last dose. The DSM-IV-TR defines inhalant intoxication as “clinically significant maladaptive behavioral or psychological changes that developed during. Symptoms are consistent with the half-life of most opioid drugs. spray paint. Appearance of withdrawal symptoms differ according to drug halflife.” b. Effects on the body (1) Central nervous system (2) Gastrointestinal effects (3) Cardiovascular effects (4) Sexual functioning 2. b. . Opioids 1.
Patterns of use/abuse d. conjunctival injection. Intoxication a. DOM (d) Phencyclidine (e) Ketamine (f) Designer drugs b. yawning. lacrimation or rhinorrhea. F. increased appetite. Abuse and dependence a. and insomnia. Symptoms include dysphoric mood. Symptoms include perceptual alteration. G. muscle aches. impaired judgment. and tachycardia. Historical aspects c. b.142 b. sweating. Occurs within minutes to a few hours after using the drug. dry mouth. Abuse and dependence a. Historical aspects c. and may proceed to seizures or coma. piloerection. Effects on the body (1) Cardiovascular effects (2) Respiratory effects (3) Reproductive effects (4) Central nervous system effects (5) Sexual functioning 2. pupillary dilation. Symptoms of PCP intoxication also include belligerence. derealization. Hallucinogens 1. a sensation of slowed time. diarrhea. euphoria. abdominal cramping. and palpitations. nausea or vomiting. Patterns of use/abuse d. . depersonalization. A profile of the substance (1) Naturally occurring hallucinogens (a) Mescaline (b) Psilocybin and psilocin (c) Ololiuqui (2) Synthetic compounds (a) LSD (b) Dimethyltryptamine (c) STP. fever. A profile of the substance (1) Marijuana (2) Hashish b. Intoxication a. Symptoms include impaired motor coordination. Effects on the body (1) Physiological effects (2) Psychological effects 2. Cannabis 1. tachycardia. anxiety. assaultiveness.
The Chemically Impaired Nurse A. C. acceptance of personal responsibility for use of substances. identification of more adaptive coping strategies. Application of the Nursing Process A. Nurse must begin relationship development with a person who abuses substances by examining own attitudes and personal experiences with substances. Evaluation of care is based on achievement of the outcome criteria. Alcohol is the most widely abused drug. To regain accountability within their profession 4. Client/Family Education G. Nursing diagnoses are formulated from the data gathered during the assessment phase. D. Clinical Institute Withdrawal Assessment of Alcohol Scale. Revised 2. acceptance of use of substances as a problem. F. Treatment for clients who abuse substances is a long-term process. Contract is drawn up: . E. Client is assigned to a special program that targets both problems. Tendency to isolate 6. Elaborate excuses for behavior 7. Problems with relationships 4. Irritability 5. B. CAGE Questionnaire C. followed closely by narcotics. Michigan Alcoholism Screening Test (MAST) 3. Impairment of motor skills lasts for 8 to 12 hours. To obtain necessary treatment 3. Impaired motor coordination. VIII. Patient complaints of inadequate pain control 11. To assist impaired nurses to recognize their impairment 2. Determination is made that the client has a co-existing substance disorder and mental illness. Frequent trips to the bathroom 10. 2. B. It is estimated that 10 to 15 percent of nurses suffer from the disease of chemical dependency. 1. Clues that may identify an impaired nurse: 1. VII.143 b. Unkempt appearance 8. slurred speech 9. High absenteeism (if substance source is outside the work area) 2. Outcome criteria are established for each. Dual Diagnosis 1. Peer Assistance Program developed by the American Nurses’ Association in 1982. Various assessment tools are available for determining extent of problem with substances a client has: 1. and restoration of nutritional status. Nursing intervention for the client with substance use disorder is aimed at safe withdrawal. often beginning with detoxification and progressing to total abstinence/rehabilitation. Rarely misses work (if substance source is at work) 3. Discrepancies in documentation D.
Pharmacotherapy D. Strong need to be in control. 3. or among family members who harbor secrets of physical or emotional abuse. A codependent person derives self-worth from others. Stage II. A refusal to acknowledge that any personal problems or painful issues exist. Stage IV. F. Counseling E. To detail method of treatment b. b. The Codependent Nurse 1. Treatment Modalities for Substance-Related Disorders A. Psychopharmacology for Substance Intoxication and Substance Withdrawal XI. a. B. 4. Various support groups patterned after Alcoholics Anonymous. Stage III. C. who often have a tendency to fulfill everyone’s needs but their own. Facing the fact that relationships cannot be managed by force of will. Caretaking. Perfectionism. The Reintegration Stage. Codependent nurses rarely express their true feelings. D. other cruelties. The Reidentification Stage. G. or pathological conditions. Certain characteristics associated with codependency seem to apply to some nurses. spending. Accepting self and willingness to change. Letting go of the denial that problems exist. Alcoholics Anonymous B. Stage I. Codependency A.144 a. Self-worth is derived from a feeling of being needed by others and maintaining control over their environment. Feels responsible for the happiness of others. and anxiety may be released in the form of stress-related illnesses or compulsive behaviors such as eating. The Survival Stage. Taking responsibility for own dysfunctional behavior. Summary and Key Points . but for individuals with problems with other substances C. working. X. Poor communication. c. d. Feelings are kept in control. Treating Codependence 1. or use of substances. Denial that problems exist is common. Meeting the needs of others to the point of neglecting their own. The Core Issues Stage. Denial. Defined by dysfunctional behaviors that are evident among members of the family of a chemically dependent person. They often strive for an unrealistic level of achievement. E. To establish guidelines for monitoring course of treatment 5. 2. Group Therapy F. Usually lasts for a period of 2 years IX. May be manifested by compulsive and addictive behaviors.
.145 XII. 2. Suicide precautions. Decrease environmental stimuli. Critical Thinking Exercise XIII. 3. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. Risk for suicide. Let her sleep as much as she wants. Provide adequate diet to restore nutrition. To help her recognize the correlation between taking the drugs and the problems she is having in her life.
Formulate nursing diagnoses and goals of care for clients with schizophrenia and other psychotic disorders. 6. Describe relevant criteria for evaluating nursing care of clients with schizophrenia and related psychotic disorders. the student will be able to: 1.146 CHAPTER 26. and nursing care is presented in the context of the six steps of the nursing process. Describe appropriate nursing interventions for behaviors associated with these disorders. Describe various types of schizophrenia and related psychotic disorders. 4. Identify symptomatology associated with these disorders and use this information in client assessment. SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS CHAPTER FOCUS The focus of this chapter is on nursing care of the client with psychotic disorders. 5. 7. OBJECTIVES After reading this chapter. Predisposing factors and symptomatology are explored. Medical treatment modalities are also discussed. Identify predisposing factors in the development of these disorders. Identify topics for client and family teaching relevant to schizophrenia and other psychotic disorders. 8. Discuss the concepts of schizophrenia and related psychotic disorders. 3. 9. KEY TERMS agranulocytosis akathisia akinesia amenorrhea anhedonia associative looseness autism catatonic circumstantiality clang association delusions dystonia echolalia echopraxia extrapyramidal symptoms gynecomastia hallucinations illusion magical thinking neologism neuroleptic malignant syndrome neuroleptics oculogyric crisis paranoia perseveration pseudoparkinsonism religiosity retrograde ejaculation social skills training tangentiality tardive dyskinesia waxy flexibility word salad CORE CONCEPT psychosis . Discuss various modalities relevant to treatment of schizophrenia and related psychotic disorders. 2.
and suspiciousness develop late in this phase. B. Later age at onset c. and more fears than any other mental illness. Symptoms similar to the prodromal phase. In the active phase of the disorder. Schizophrenia. biochemical dysfunction. including genetic predisposition. 2. Schizophrenia results in disturbances in thought processes. Prognosis 1. B. 1. irritability. Introduction A. D. depressed mood. and self-care. and affect. 3. Residual Phase. Good premorbid adjustment b. E. and demonstrating antisocial behavior. and may herald the imminent onset of psychosis. and psychosocial stress. Phase II. Schizophrenia requires treatment that is comprehensive and is presented in a multidisciplinary effort. physiological factors. D.147 CHAPTER OUTLINE/LECTURE NOTES I. Nature of the Disorder A. psychotic symptoms are prominent. Substantial functional impairment can occur. 4. II. Phase IV. although events can occur that contribute to the development of the subsequent illness. having poor peer relationships. 2. social relations. C. Personality and behavioral measurements include being very shy and withdrawn. poor concentration. more exorbitant costs to individuals and governments. Schizophrenia probably causes more lengthy hospitalizations. These include delusions. with flat affect and impairment in role functioning being prominent. Phase I. hallucinations. Phase III. Being female . C. The word schizophrenia is derived from the Greek words “skhizo” (split) and “phren” (mind). The Prodromal Phase. The Premorbid Phase. ideas of reference. anxiety. Schizophrenia is probably caused by a combination of factors. perception. There is severe deterioration of social and occupational functioning. About 1 percent of the population will develop schizophrenia over the course of a lifetime. there is deterioration in role functioning and social withdrawal. In this phase. Marked by normal functioning. with nonspecific symptoms such as sleep disturbance. more chaos in family life. A return to full premorbid functioning is not common. doing poorly in school. The premorbid behavior of an individual with schizophrenia can be viewed in four phases. and impairment in work. which lasts from a few weeks to a few years. Factors associated with a more positive prognosis include: a. Perceptual abnormalities. and fatigue.
systemic lupus erythematosus. the onset of which is influenced by factors within the environment (either internal or external).148 d. Minimal residual symptoms i. cerebrovascular accidents. Huntington’s disease. A growing body of knowledge indicates that genetics plays an important role in the development of schizophrenia. Behavior is bizarre. Biochemical influences. Stressful life events have been associated with the onset of schizophrenic symptoms. alcohol abuse. Disorganized Schizophrenia. One theory suggests that schizophrenia may be caused by an excess of dopamine-dependent neuronal activity in the brain. Characterized by extreme psychomotor retardation. Types of Schizophrenia and Other Psychotic Disorders A. brain abnormalities. Researchers now focus their studies in terms of schizophrenia as a brain disorder. and Wilson’s disease. Schizophrenia is most likely a biologically based disease. 3. C. 2. Normal neurological functioning k. IV. Physiological influences. The Transactional Model. . Abnormalities in the neurotransmitters norepinephrine. have also been implicated. serotonin. Stress may contribute to the severity and course of the illness. Sociocultural factors. Brief duration of active-phase symptoms g. No family history of schizophrenia III. birth trauma. Catatonic stupor. and histological changes in the brain. Chronic variety with flat or inappropriate affect. Psychological Influences. cerebral tumor. and social interaction is impaired. B. Associated mood disturbance f. B. Genetics. including viral infection. parkinsonism. Posturing is common. and gamma-aminobutyric acid have also been suggested. Family history of mood disorder l. Lower socioeconomic status has been linked to the development of schizophrenia. Abrupt onset of symptoms precipitated by a stressful event e. myxedema. acetylcholine. Catatonic Schizophrenia 1. These theories no longer hold credibility. Psychosocial theories probably developed early on out of a lack of information related to a biological connection. D. Several physiological factors have been implicated. such as epilepsy. The individual is usually mute. head injury in adulthood. Silliness and incongruous giggling is common. 2. Predisposing Factors A. Good inter-episode functioning h. Environmental Influences 1. Absence of structural brain abnormalities j. Various physical conditions. Biological Influences 1.
G. This category is used with the individual who has a history of at least one previous episode of schizophrenia with prominent psychotic symptoms. Catatonic excitement. Symptoms of this disorder include prominent hallucinations and delusions that can be directly attributed to a general medical condition. is in love with him or her. J. Irrational ideas regarding own worth. K. Purposeless movements that must be curtailed to prevent injury to the client or others. either mania or depression. The individual has an irrational belief that he or she has some physical defect. Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months. knowledge. The existence of prominent. The presence of prominent hallucinations and delusions that are judged to be directly attributable to the physiological effects of a substance. Undifferentiated Schizophrenia. Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders. F. Schizoaffective Disorder. 1. and aggressive. E. L. I. . hostile. or power. Irrational idea that the person’s sexual partner is unfaithful. Extreme psychomotor agitation. 2. Jealous type. 5. 3. A delusional system develops in a second person as a result of a close relationship with another person who already has a psychotic disorder with prominent delusions. usually of a higher status. and the individual returns to the full premorbid level of functioning. Characterized by paranoid delusions. Paranoid Schizophrenia. Residual Schizophrenia. Erotomanic type. Also called folie à deux. Delusional Disorder. 4. Brief Psychotic Disorder. D. Shared Psychotic Disorder. Grandiose type. The individual believes that someone. Symptoms last less than 1 month. Persecutory type. Sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. disorder. Psychotic Disorder Due to a General Medical Condition. Residual schizophrenia occurs in an individual who has a chronic form of the disease and is the stage that follows an acute episode. Substance-Induced Psychotic Disorder. Bizarre behavior that does not meet the criteria outlined for the other types of schizophrenia. Delusions and hallucinations are prominent. Schizophreniform Disorder. nonbizarre delusions. or disease. The individual believes he or she is being malevolently treated in some way. talent. Somatic type.149 2. H. C. Client may be argumentative.
Literal interpretations of the environment. Mutism. Repeating movements that are observed. Background Assessment Data—Positive Symptoms. c. Background Assessment Data—Negative Symptoms. Positive symptoms reflect an excess or distortion of normal functions. Excessive demonstration of obsession with religious ideas and behavior. such as disorganized thinking. . The idea that one’s thoughts or behaviors have control over specific situations or people. The feeling state or emotional tone. The interpretation of stimuli through the senses. Paranoia. Sense of self. A group of words put together randomly. False personal beliefs. Echopraxia. d. 4. Concrete thinking. Affect. f. Perception. 1. Associative looseness. and are thought to have a relatively good response to treatment. B. Depersonalization. Hallucinations. Shift of ideas from one unrelated topic to another. d. Inappropriate affect. 2. Clang associations. Negative symptoms reflect a diminution or loss of normal functions. b. e. Application of the Nursing Process A. d. Persistent repetition of the same word or idea in response to different questions. a. False sensory perceptions not associated with real external stimuli. c. i. b. Perseveration. Form of thought a. g. Emotions are incongruent with the circumstances. Religiosity. Feelings of unreality. b. a. Repeating words that are heard. Circumstantiality. 3. h. Word salad. Tangentiality. Misperceptions or misinterpretations of real external stimuli. Delusions. c. Inability or refusal to speak. A delay in reaching the point of a communication due to unnecessary and tedious details. Inability to get to the point of a communication due to introduction of many new topics. Illusions. Extreme suspiciousness of others. Magical thinking. Neologisms. Identification and imitation. 1. The uniqueness and individuality a person feels. b. Made-up words that have meaning only to the individual who invents them. without any logical connection. Content of thought a. such as diminished emotional expression and apathy. Taking on the form of behavior one observes in another. Choice of words is governed by sound (often rhyming).150 V. and are less likely than the positive symptoms to respond to treatment. a. Echolalia.
Apathy. E. Ineffective health maintenance i. and decoding incomprehensible communication patterns. Treatment Modalities for Schizophrenia and Other Psychotic Disorders A. b. Emotional ambivalence. Psychological Treatments 1. Disinterest in the environment. Personal grooming and self-care activities are impaired. Reassessment data on which to base the effectiveness of nursing actions. The coexistence of opposite emotions toward the same object. Disturbed sensory perception b. Posturing. b. Client/Family Education F. A deficiency of energy. Planning/Implementation. The focus inward on a fantasy world. Retreat to an earlier level of development. 4. VI. .151 b. Pacing back and forth and rocking of the body. Impaired verbal communication f. 3. 2. Evaluation. Nursing Diagnosis/Outcome Identification 1. Pacing and rocking. Associated features a. Self-care deficit g. increasing trust to decrease feelings of suspiciousness. 5. Passive yielding of all moveable parts of the body to any efforts made at placing them in certain positions. difficult because of client’s impairment in interpersonal functioning. Long-term therapeutic approach. Inability to experience pleasure. d. Disturbed thought processes c. Social isolation d. C. Disabled family coping h. Nursing implementation for the client with schizophrenia is aimed at decreasing delusional thinking and misperceptions of the environment. Deteriorated appearance. Impaired interpersonal functioning and relationship to the external world a. c. Outcome criteria D. person. Anergia. while distorting or excluding the external environment. Voluntary assumption of inappropriate or bizarre postures. b. Bland or flat affect. or situation. Impairment in the ability to initiate goal-directed activity. Waxy flexibility. Regression. c. preventing injury to client and others. Impaired home maintenance 2. Volition. Risk for violence: self-directed or other-directed e. Individual psychotherapy. Nursing diagnoses a. Autism. Weak emotional tone. a. Anhedonia. Psychomotor behavior a.
and cultural background. Individualized and person-centered. and community. Individuals gain control of their own destiny and influence the organizational and societal structures in their lives. A case management-team approach that is individually tailored to teach clients basic living skills. Social skills training. Selfacceptance is particularly vital. occasional setbacks. The Recovery Model 1. Individuals provide each other with a sense of belonging. resiliencies. Some success if occurring over the long-term course of the illness. valued roles. Consumers lead. c. and assist clients in developing a social support network.. Components of the recovery model include: a. or wherever assistance by the client is required. experiences. interpersonal skills. stores. in local restaurants. d. f. 3. h. choose. and inherent worth of the individual. and determine their own path of recovery. etc. The use of role play to teach client appropriate eye contact. Aimed at helping family members cope with the longterm effects of the illness. Milieu therapy. spirit. A shift in the paradigm of care of persons with serious mental illness from the traditional medical psychiatric treatment toward the concept of recovery. less successful in acute treatment. 2. control. Best if used in conjunction with psychopharmacology. help them work with community agencies. including mind. Chief drawback has been the inability to generalize to the community setting once the client has been discharged from the treatment. Group therapy. Empowerment. Services are provided in the person’s home. parks. and community. supportive relationships. Recovery builds on the multiple capacities. aimed at improvement in social functioning. 2. talents. and learning from experience. e. posture. 3. Program of assertive community treatment (PACT). B. but one based on continual growth. Recovery is not a step-by-step process. Social Treatment 1. C. and societal acceptance and appreciation of consumers are crucial in achieving recovery. b. needs. preferences. systems. Peer support. Recovery encompasses an individual’s whole life. coping abilities. Strengths-based. Holistic. 4. within the neighborhood. . g. Nonlinear. 3. Recovery is based on an individual’s unique strengths. Respect. Self-direction. voice intonation. Behavior therapy. encouraging consumers to leave stymied life roles behind and engage in new life roles. body. A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential. Family therapy. Community.152 2.
The recovery model integrates services provided by professionals. Recovery provides the essential motivating message of a better future—that people can and do overcome the barriers and obstacles that confront them. . Organic Treatment 1. Used to counteract the extrapyramidal symptoms associated with some antipsychotic medications. Antipsychotics (1) Indications: used to decrease agitation and psychotic symptoms (2) Action (3) Contraindications/precautions (4) Interactions (5) Side effects b. Summary and Key Points VIII. services provided by consumers. D.153 i. Hope. and services provided in collaboration. Possible command hallucinations. Psychopharmacology a. Client/family education related to antipsychotics VII. Disturbed sensory perception: auditory. Antiparkinsonian agents. j. 2. 3. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. c. Consumers have a personal responsibility for their own self-care and journeys of recovery. Decrease Sara’s anxiety and establish trust. 4. Critical Thinking Exercise IX. Responsibility.
C. Describe appropriate nursing interventions for behaviors associated with depression. 9. Formulate nursing diagnoses and goals of care for clients with depression. Identify topics for client and family teaching relevant to depression. Identify predisposing factors in the development of depression. Transient symptoms are normal. 4. 8. 5. Predisposing factors and symptomatology are explored. Depression is likely the oldest and one of the most frequently diagnosed psychiatric illnesses. the student will be able to: 1. Identify symptomatology associated with depression and use this information in client assessment. Medical treatment modalities are also discussed. 3. LEARNING OBJECTIVES After reading this chapter. 6. Discuss various modalities relevant to treatment of depression. 11. Discuss implications of depression related to developmental stage. and nursing care is presented in the context of the six steps of the nursing process. KEY TERMS cognitive therapy dysthymic disorder melancholia postpartum depression premenstrual dysphoric disorder psychomotor retardation tyramine CORE CONCEPTS depression mood CHAPTER OUTLINE/LECTURE NOTES I.154 CHAPTER 27. B. Introduction A. healthy responses to everyday disappointments in life. Discuss epidemiological statistics related to depression. . 2. Describe relevant criteria for evaluating nursing care of clients with depression. Recount historical perspectives of depression. Pathological depression occurs when adaptation is ineffective. Describe various types of depressive disorders. 10. 7. MOOD DISORDERS—DEPRESSION CHAPTER FOCUS The focus of this chapter is on nursing care of the client with depression.
and they are less likely to be treated. Historical Perspective A. about 21 percent of women and 13 percent of men will become clinically depressed. E. G. and pessimism. Epidemiology A. Depression: An alteration in mood that is expressed by feelings of sadness. Evidence of psychomotor retardation or excessive motor activity. No consistent relationship between race and affective disorder has been reported. excessive brooding. Age. Various other theories were espoused regarding the etiology of depression. C. F. It was described as the result of obstruction of vital air circulation. There is an inverse relationship between social class and report of depressive symptoms. Affective disorders are more prevalent in the spring and in the fall. Single episode or recurrent. or helpless situations beyond the client’s control. Mild. These categories are identified by the number and severity of symptoms. One recent study revealed that depression is more prevalent in whites than it is in blacks. Social Class. despair. With psychotic features. persistent. Presence of hallucinations or delusions. Many ancient cultures have believed in the supernatural or divine origin of mood disorders. 4. II.155 D. but after age 65. Hippocrates believed that melancholia was caused by an excess of black bile. Types of Depressive Disorders A. (Differences occur in various age groups. Marital Status. D. Mood is also called affect. women are again more likely to be depressed than men. Seasonality. The perspectives of 20th-century theorists lend support to the notion of multiple causation in the development of mood disorders. During their lifetime. Single episode indicates the individual’s first diagnosis of depression. Gender. Recurrent reveals history of two or more episodes. C.5 million persons reported a depressive episode in 2008. Depression is more prevalent in women than men by about 2 to 1. . moderate. 3. E. B. Mood is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. or severe. Race. which affected the brain. Includes evidence of impairment in reality testing. With catatonic features. D. IV. but that depression tends to be more severe. and disabling in blacks. Major Depressive Disorder 1. The gender difference is less pronounced between ages 44 and 65.) H. Approximately 9. Depression is more common in young women than young men. B. a heavily toxic substance produced in the spleen or intestine. III. 2. Single and divorced persons are more likely to experience depression than married persons or persons with a close interpersonal relationship.
Premenstrual Dysphoric Disorder. Theory that cognitive distortions result in negative. V. With seasonal pattern. Symptoms occur before age 21 years. c. Biochemical influences. B. Psychoanalytical theory. Late onset. A mood disorder with symptoms somewhat milder than those associated with major depression. serotonin. Neuroendocrine disturbances (1) Possible failure within the hypothalamic-pituitaryadrenocortical axis (2) Possible diminished release of thyroid-stimulating hormone d. Chronic. d. Early onset. Episodes of depression are consistent with the fall or winter months. 8. defeatist attitudes that serve as the basis for depression. Learning theory. Freud: A loss is internalized and becomes directed against the ego. D. Genetics. Object loss theory. C. . Current episode of depressed mood has been evident continuously for at least the past 2 years. The depression is considered to be the direct result of physiological effects of a substance. b. Severe form of major depression. Mood disorder (depression) due to a general medical condition. Psychosocial theories a. c. Other Depressive Disorders 1. 6. Predisposing Factors 1. 7. The depression is attributable to the direct physiological effects of a general medical condition. Substance-induced mood disorder (depression). Occurs when an individual is separated from a significant other during the first 6 months of life. b. Learned helplessness: The individual who experiences numerous failures learns to give up trying. Deficiency of norepinephrine. With melancholic features. Symptoms of major depression occur within 4 weeks postpartum. Physiological influences (1) Medication side effects (2) Neurological disorders (3) Electrolyte disturbances (4) Hormonal disturbances (5) Nutritional deficiencies (6) Other physiological conditions 2. 1. With postpartum onset. Affective symptoms occur during the week prior to menses and subside shortly after the onset of menstruation. Dysthymic Disorder. Cognitive theory. Symptoms are exaggerated. Symptoms occur at age 21 years or older. 2. Biological theories a.156 5. and dopamine has been implicated. Hereditary factor may be involved. 2.
Moderate depression: Identified by those symptoms associated with dysthymic disorder 5. Symptoms occur by degree of severity and may be ranked as transient. Nursing diagnoses commonly associated with depression include: 1. acting out behaviors are common 2. 1 or 2 out of 1. The transactional model. Complicated grieving 3. Symptoms of depression manifested differently than adults 2. Outcome criteria are identified for each. Social isolation . or alterations in membrane transport during the early postpartum period VII. or severe 2. tryptophan metabolism. VI. Depression common in the elderly 2. Behavioral change that lasts for several weeks is the best clue for a mood disorder in adolescence 3. Background Assessment Data 1. Adolescence 1. Transient: Life’s everyday disappointments that result in the “blues” 3. Lower tolerance of antidepressant medications D. and psychosocial. Bereavement overload 3. Evidence indicates depression is likely related to multiple factors. Application of the Nursing Process to Depressive Disorders A. Senescence 1. Developmental Implications A. Risk for suicide 2. Severe depression: Identified by those symptoms associated with major depressive disorder and bipolar depression B. Mild “blues” very common following childbirth 2. Postpartum Depression 1. Nursing diagnoses are formulated by analyzing the data gathered during the assessment phase of the nursing process. Low self-esteem 4. 10 to 20 percent experience moderate depression 3. Depression is sometimes misdiagnosed as senile dementia in the elderly 4. Family therapy is common B.000 experience severe or psychotic depression 4. Depression is hard to recognize in adolescence. Mild depression: Identified with those symptoms of normal grieving 4. Childhood 1. including genetic. Spiritual distress 6. Probably related to hormonal changes. biochemical. All antidepressants carry an FDA black box warning for increased risk of suicidality in children and adolescents C. moderate. Powerlessness 5. mild.157 e.
May occur with all classes: (1) Dry mouth (2) Sedation (3) Nausea (4) Discontinuation syndrome b. Group Therapy C. SNRIs: Block reuptake of neurotransmitters norepinephrine. Individual Psychotherapy B. Client/Family Education E. Imbalanced nutrition: Less than body requirements 10. elimination. and/or dopamine b. SSRIs. Psychopharmacology 1. MAOIs inhibit monoamine oxidase. and personal hygiene are met D. Treatment Modalities for Depression A. Disturbed thought processes 9. Protection from harming self 2. rest. serotonin. Impaired social interaction 8. Self-care deficit (hygiene/grooming) C. Action a. heterocyclics. Contraindications/precautions 3. Light Therapy H. Transcranial Magnetic Stimulation G. Enhancing client self-esteem 4.158 7. Most commonly occur with tricyclics and heterocyclics: (1) Blurred vision (2) Constipation (3) Urinary retention (4) Orthostatic hypotension (5) Reduction of seizure threshold . Family Therapy D. Cognitive Therapy E. Ensuring that needs related to nutrition. Electroconvulsive Therapy F. Interactions 4. activity. TCAs. Assistance in confronting anger that has been turned inward on the self 6. serotonin. Side effects a. an enzyme that is known to inactivate norepinephrine. Assisting with progression through the grief process 3. Insomnia 11. Evaluation of the effectiveness of nursing interventions is measured by fulfillment of the outcome criteria VIII. Helping the client determine ways to take control over his or her life 5. Nursing interventions for the depressed client are aimed at: 1. and dopamine 2.
Risk for suicide. There is a risk of suicidality in children and adolescents associated with the use of antidepressant medications. Critical Thinking Exercise XI. Most commonly occur with SSRIs and SNRIs: (1) Insomnia. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. Miscellaneous side effects: (1) Priapism (with trazodone) (2) Hepatic failure (with nefazodone) 5. Ask her directly if she wants to harm herself or take her life. 2. Fluoxetine (Prozac) is the only antidepressant approved to treat depression in children and adolescents. and if she has the means to carry out the plan. Summary and Key Points X. other antidepressants are sometimes prescribed by physicians in “off-label use.159 (6) Tachycardia. 3. . Most commonly occur with MAOIs: (1) Hypertensive crisis (2) Application site reactions (with transdermal system) e. Client/family education related to antidepressants IX. agitation (2) Headache (3) Weight loss (may occur early in therapy) (4) Sexual dysfunction (5) Serotonin syndrome d.” 4. However. arrhythmias (7) Photosensitivity (8) Weight gain c. Ask her if she has a plan.
5. 4. Discuss implications of bipolar disorder related to developmental stage. Mood is defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. 9. Describe relevant criteria for evaluating nursing care of clients with bipolar mania. Medical treatment modalities are also discussed. joy. 3. Examples of mood include: depression. anger. Etiological implications and symptomatology are explored. and nursing care is presented in the context of the six steps of the nursing process. MOOD DISORDERS—BIPOLAR DISORDER CHAPTER FOCUS The focus of this chapter is on nursing care of the client with bipolar disorder. Describe appropriate nursing interventions for behaviors associated with bipolar mania. 6. Introduction A. Recount historical perspectives of bipolar disorder.160 CHAPTER 28. Identify symptomatology associated with bipolar disorder and use this information in client assessment. 8. and accelerated thinking and speaking. . the student will be able to: 1. KEY TERMS bipolar disorder cyclothymic disorder delirious mania hypomania tyramine CORE CONCEPT mania I. LEARNING OBJECTIVES After reading this chapter. Formulate nursing diagnoses and goals of care for clients with bipolar disorder. Identify topics for client and family teaching relevant to bipolar disorder. Describe various types of bipolar disorders. 2. Discuss epidemiological statistics related to bipolar disorder. elation. grandiosity. 7. Affect is described as the emotional reaction associated with an experience. hyperactivity. 10. B. D. and anxiety. 11. agitation. Identify predisposing factors in the development of bipolar disorder. inflated self-esteem. Discuss various modalities relevant to treatment of bipolar disorder. Mania is an alteration in mood that is expressed by feelings of elation. C.
In early writings.7 million American adults. B. Gender: The incidence is roughly equal. a full syndrome of manic or mixed symptoms. Occurs more often in the higher socioeconomic classes. G. A somewhat milder form of mania is called hypomania. Bipolar II Disorder. Predisposing Factors A.” D. III. The client may also have experienced episodes of depression. a drug of abuse. with terms such as “dual-form insanity” and “circular insanity. Strong hereditary implications. or as a response to substance use or a general medical condition.2 to 1. Mixed. Types of Bipolar Disorders A. D. Bipolar I Disorder. Average age of onset is the early twenties.161 E. Bipolar Disorder. Biological Theories 1. C. Cyclothymic Disorder 1.” C. Bipolar Disorder Due to a General Medical Condition. Characterized by mood swings of at least 2-year duration 2. Documentation of the symptoms associated with bipolar disorder dates back to about the second century in ancient Greece. The term manic-depressive was first coined in 1913. D. II. with a ratio of women to men of about 1. C. Epidemiology A. and the American Psychiatric Association adopted the term bipolar disorder in 1980. Bipolar disorder is the sixth leading cause of disability in the middle-age group. a medication. This diagnosis is used when the symptom presentation includes rapidly alternating moods (sadness. or toxin exposure). Historical Perspective A. Numerous episodes of hypomania and depressed mood 3. Substance-Induced Bipolar Disorder. E.. Genetics. More common in unmarried than in married persons. mania was categorized with all forms of “severe madness. Physiological influences . Possible excess of norepinephrine and dopamine. B. Bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania). with intervening periods of normalcy. This diagnosis is used when the individual has experienced recurrent bouts of major depression with episodic occurrence of hypomania. Mania can occur as a biological (organic) or psychological disorder.g. A disturbance of mood (depression or mania) that is considered to be the direct result of physiological effects of a substance (e. Bipolar disorder affects approximately 5. V. B. IV. Characterized by a prominent and persistent disturbance in mood (depression or mania) that is judged to be the result of direct physiological effects of a general medical condition. euphoria) accompanied by symptoms associated with both depression and mania. F. Symptoms are of insufficient severity or duration to meet the criteria for Bipolar I or II disorder E. 3. or has experienced. F. irritability. 2. F. The modern concept of manic-depressive illness began to emerge in the 19th century. Biochemical influences. This diagnosis is given to the person who is experiencing.
a continuous “high” (2) Cognition and perception: Flight of ideas. Symptoms may be categorized by degree of severity. Frequency: Symptoms occur most days in a week b.g. Number: Symptoms occur three or four times a day d. and psychosocial determinants. Stage I. Brain lesions b. Psychopharmacology (1) Mood stabilizers (e. carbamazepine) (2) Atypical antipsychotics (e. (1) Mood: Euphoria and elation. divalproex. Hypomania: Symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization. Treatment strategies a. Psychosocial Theories. pressured speech. inexhaustible energy.g. a. Intensity: Symptoms are severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains c. clinicians use the FIND (frequency. Bipolar disorder most likely results from an interaction between genetic. Delirious mania: A grave form of the disorder characterized by severe clouding of consciousness and representing an intensification of the symptoms associated with acute mania. Family interventions VII. social and sexual inhibition. ziprasidone) b. olanzapine. accelerated. Childhood and Adolescence 1. heightened perception of the environment (3) Activity and behavior: Increased motor activity b. (1) Mood: Cheerful and expansive (2) Cognition and perception: Rapid flow of ideas. quetiapine. 2. and duration) strategy. The condition is rare since the advent of antipsychotic medication.162 a. aripiprazole. C. The Transactional Model. Developmental Implications A. distractibility. hallucinations and delusions (3) Activity and behavior: Excessive psychomotor activity. VI. neglect of hygiene and grooming c. Stage II. lithium... Usually requires hospitalization. Background Assessment Data 1. . Duration: Symptoms occur four or more hours a day 3. a. number. To differentiate between occasional spontaneous behaviors of childhood and behaviors associated with bipolar disorder. Stage III. little need for sleep. biological. risperidone. Children and adolescents difficult to diagnose. Application of the Nursing Process to Bipolar Disorder (Mania) A. Acute mania: Marked impairment in functioning. Credibility has been questioned. intensity. Medication side effects B.
Anticonvulsants (1) Carbamazepine (2) Clonazepam (3) Valproic acid (4) Lamotrigine (5) Gabapentin (6) Topiramate (7) Oxcarbazepine c. Group Therapy C. Disturbed thought processes 5. Antimanics (1) Lithium carbonate b. Impaired social interaction 7. Disturbed sensory-perception 6. Restoration of nutritional status 4. Individual Psychotherapy B. Client/Family Education E. Electroconvulsive Therapy F. Protection from harm to self or others 3. panic anxiety may be evident (2) Cognition and perception: Clouding of consciousness. Risk for violence: Self-directed or other-directed 3.163 (1) Mood: Labile. Family Therapy D. Examples a. incoherence (3) Activity and behavior: Psychomotor activity is frenzied. Treatment Modalities for Bipolar Disorder (Mania) A. exhaustion. Acquiring sufficient rest and sleep D. confusion. Nursing diagnoses are formulated by analyzing the data gathered during the assessment phase of the nursing process. VIII. Cognitive Therapy E. Nursing diagnoses commonly associated with bipolar disorder include: 1. Insomnia C. and eventually death could occur without intervention B. disorientation. Protection from injury due to hyperactivity 2. Outcome criteria are identified for each. Psychopharmacology with Mood-Stabilizing Agents 1. The Recovery Model G. Calcium channel blocker . Evaluation of the effectiveness of the nursing interventions is measured by fulfillment of the outcome criteria. Improvement in interactions with others 6. Risk for injury 2. Nursing interventions for the client experiencing a manic episode are aimed at: 1. injury to self or others. Progression toward resolution of the grief process 5. Imbalanced nutrition: Less than body requirements 4.
thirst (3) GI upset. Side effects a. arrhythmias. With antipsychotics: (1) Drowsiness. dizziness (2) Hypotension. Client/family education related to mood-stabilizing agents IX. dizziness. dehydration (7) Weight gain b. With lithium carbonate: (1) Drowsiness. pulse irregularities (6) Polyuria. Review Questions . Summary and Key Points X. Action. interactions 3. With verapamil: (1) Drowsiness. nausea/vomiting (4) Fine hand tremors (5) Hypotension. December 2008) c. With anticonvulsants: (1) Nausea/vomiting (2) Drowsiness. bradycardia (3) Nausea (4) Constipation d.164 (1) Verapamil d. dizziness (2) Dry mouth. dizziness (3) Blood dyscrasias (4) Prolonged bleeding time (with valproic acid) (5) Risk of severe rash (with lamotrigine) (6) Decreased efficacy with oral contraceptives (with topiramate) (7) Risk of suicide with all antileptic drugs (warning by FDA. Critical Thinking Exercise XI. Antipsychotics (1) Olanzapine (2) Aripiprazole (3) Chlorpromazine (4) Quetiapine (5) Risperidone (6) Ziprasidone (7) Asenapine 2. constipation (3) Increased appetite. contraindications/precautions. headache (2) Dry mouth. weight gain (4) ECG changes (5) Extrapyramidal symptoms (6) Hyperglycemia and diabetes 4.
tinnitus. Ataxia. Lithium does not take effect for 1 to 3 weeks. 3. nausea and vomiting. persistent diarrhea. Evidence of full manic episode.165 ANSWERS TO CRITICAL THINKING EXERCISE 1. 4. blurred vision. The olanzapine was ordered to calm her hyperactivity immediately. Protection from injury and adequate nutrition and rest. 2. .
.166 CHAPTER 29. Identify topics for client and family teaching relevant to anxiety disorders. Introduction A. Predisposing factors and symptomatology are explored. It is not the same as stress. the student will be able to: 1. KEY TERMS agoraphobia flooding generalized anxiety disorder implosion therapy obsessive-compulsive disorder panic disorder posttraumatic stress disorder social phobia specific phobia systematic desensitization CORE CONCEPTS anxiety compulsions obsessions panic phobia CHAPTER OUTLINE/LECTURE NOTES I. Medical treatment modalities are also discussed. anxiety. Identify predisposing factors in the development of anxiety disorders. Evaluate nursing care of clients with anxiety disorders. Anxiety is a necessary force for survival. 5. 3. Describe appropriate nursing interventions for behaviors associated with anxiety disorders. Formulate nursing diagnoses and outcome criteria for clients with anxiety disorders. and nursing care is presented in the context of the six steps of the nursing process. 6. 8. 10. 2. Discuss various modalities relevant to treatment of anxiety disorders. 9. Differentiate between normal anxiety and psychoneurotic anxiety. and fear. 7. ANXIETY DISORDERS CHAPTER FOCUS The focus of this chapter is on nursing care of the client with anxiety disorders. Describe various types of anxiety disorders and identify symptomatology associated with each. 4. Use this information in client assessment. Discus historical aspects and epidemiological statistics related to anxiety disorders. OBJECTIVES After reading this chapter. Differentiate among the terms stress.
(1) Palpitations. or other important areas of functioning. . unsteady. anxiety disorders were viewed as purely psychological or purely biological in nature. For many years. Characterized by recurrent panic attacks. or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (5) Feeling of choking (6) Chest pain or discomfort (7) Nausea or abdominal distress (8) Feeling dizzy. III. Panic Disorder 1. Anxiety is the subjective emotional response to that stressor. but in addition. often associated with feelings of impending doom.167 B. and manifested by intense apprehension. With agoraphobia (1) When panic disorder is accompanied by agoraphobia. Epidemiological Statistics A. lightheaded. Application of the Nursing Process A. experiences a fear of being in places or situations from which escape might be difficult or embarrassing or in II. V. or faint (9) Derealization (feelings of unreality) or depersonalization (being detached from oneself) (10) Fear of losing control or going crazy (11) Fear of dying (12) Paresthesias (numbness or tingling sensations) (13) Chills or hot flashes b. the onset of which are unpredictable. or terror. It is out of proportion to the situation that is creating it. Anxiety is distinguished from fear in that anxiety is an emotional process. the individual experiences the symptoms described above. The anxiety interferes with social. Stress (or stressor) is an external pressure that is brought to bear on the individual. occupational. Anxiety was once identified by its physiological symptoms. Anxiety disorders are the most common of all psychiatric illnesses and result in considerable functional impairment and distress. C. and accompanied by intense physical discomfort. Historical Aspects A. Anxiety is pathological if: 1. Anxiety disorders are more common in women than in men. 2. How Much Is Too Much? A. focusing largely on the cardiovascular system. pounding heart. whereas fear is a cognitive one. B. Freud was the first to associate anxiety with neurotic behaviors. IV. Background assessment data a. fear. C. B.
(2) Neuroanatomical. the diencephalon. An underdeveloped ego is not able to intervene when conflict occurs between the id and the superego. This theory places emphasis on distorted cognition. Psychodynamic theory. mitral valve prolapse. Panic disorder has a strong genetic element. and the reticular formation. c. Cognitive theory. hypoglycemia. Various medical conditions. and complex partial seizures. Phobias 1. Background assessment data a. Panic and generalized anxiety disorders are most likely caused by multiple factors. (3) Biochemical. Biological aspects (1) Genetics. including the limbic system. unrealistic. Background assessment data a. Abnormal elevations of blood lactate have been noted in clients with panic disorder. which results in anxiety that is maintained by mistaken or dysfunctional appraisal of a situation. C.168 which help might not be available in the event of a panic attack. or in which help might not be available in the event of suddenly developing a panic or limited symptom attack. . Generalized Anxiety Disorder 1. such as acute MI. B. d. and excessive anxiety and worry. have been associated to a greater degree with individuals who suffer panic and generalized anxiety disorders than in the general population. Predisposing factors to panic and generalized anxiety disorders a. b. Agoraphobia without history of panic disorder. Characterized by chronic. Pathological involvement has been identified in the temporal lobes of individuals with panic disorder. producing anxiety. Transactional model of stress/adaptation. (4) Neurochemical. (5) Medical conditions. Symptoms include: (1) Excessive anxiety and worry about a number of events that the individual finds difficult to control (2) Restlessness or feeling keyed up or on edge (3) Being easily fatigued (4) Difficulty concentrating or mind “going blank” (5) Irritability (6) Muscle tension (7) Sleep disturbance 2. Physiology of emotional states may be associated with the lower brain centers. A fear of being in places or situations from which escape might be difficult. Evidence exists for the involvement of the neurotransmitter norepinephrine in the etiology of panic disorder.
Psychoanalytical theory. Specific phobia. the child becomes frightened of the aggression he fears the same gender parent feels for him. Transactional model of stress/adaptation. Learning theorists believe that fears are learned. Biological aspects: Temperament. b. a specific object or situation. d. Certain early experiences may set the stage for phobic reactions later in life. Innate fears may represent a part of the overall characteristics or tendencies with which one is born that influence how he or she responds throughout life to specific situations. and become conditioned responses when the individual escapes panic anxiety (a negative reinforcement) by avoiding the phobic stimulus. Life experiences. Individuals with this disorder have weak.169 b. e. and displaced on to something safer. The traumatic event produces anxiety and discomfort. Recurrent obsessions or compulsions that are severe enough to be time consuming or to cause marked distress or significant impairment. Psychoanalytical theory. Obsessive-compulsive behavior is viewed as a conditioned response to a traumatic event. Predisposing factors to obsessive-compulsive disorder a. The etiology of phobic disorders is most likely influenced by multiple factors. Abnormalities in the region of the basal ganglia and orbital-frontal cortex of the brain have been implicated in the neurobiology of obsessive-compulsive disorder. Biological aspects (1) Neuroanatomy. Characterized by an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others. c. Cognitive theorists espouse that anxiety is the product of faulty cognitions or anxiety-inducing self-instructions. c. persistent. D. and excessive or unreasonable fear when in the presence of. Cognitive theory. b. Social phobia. 2. f. Learning theory. 2. Background assessment data. Freud believed that during the Oedipal period. A marked. underdeveloped egos. and the individual learns to engage in behaviors that provide relief from the anxiety and discomfort associated with the traumatic event. c. . Predisposing factors to phobias a. Regression to the pre-Oedipal phase of development during times of anxiety produces the symptoms of obsessions and compulsions. This fear is repressed. which becomes the phobic stimulus. Obsessive-Compulsive Disorder 1. or when anticipating an encounter with. Learning theory.
The development of characteristic symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to the physical integrity of others. Transactional model of stress/adaptation. and which result in increased feelings of comfort and control. d. and the recovery environment. Cognitive theory. Some individuals with obsessive-compulsive disorder exhibit nonspecific EEG changes. (2) Variables include characteristics that relate to the traumatic experience. Background assessment data . The etiology of PTSD is most likely influenced by multiple factors. b. Intrusive recollections or nightmares of the event are common. Symptoms may include a reexperiencing of the traumatic event. Learning theory. Anxiety Disorder Due to a General Medical Condition 1. Predisposing factors to PTSD a. Symptoms may include generalized anxiety symptoms. a sustained high level of anxiety or arousal. Psychosocial theory (1) Seeks to explain why some individuals exposed to massive trauma develop PTSD while others do not. It is suggested that the symptoms related to the trauma are maintained by the production of endogenous opioid peptides that are produced in the face of arousal. E. or general numbing of responsiveness. Background assessment data a. Background assessment data a. Substance-Induced Anxiety Disorder 1. F. d. A decrease in the neurotransmitter serotonin may be influential in the etiology of obsessive-compulsive disorder. The etiology of OCD is most likely influenced by multiple factors. Posttraumatic Stress Disorder (PTSD) 1. panic attacks. b. G. the individual. The symptoms are judged to be the direct physiological consequence of a general medical condition. Takes into consideration the cognitive appraisal of an event and focuses on assumptions that an individual makes about the world. Biological aspects. 2. the symptoms of which bear a strong resemblance to those of PTSD. (3) Biochemical. When the stressor terminates. Transactional model of stress/adaptation. Commonalities in neuroendocrine studies between OCD and depressive disorders have been demonstrated. e.170 (2) Physiology. b. c. the individual may experience opioid withdrawal. The avoidance behaviors and psychic numbing in response to a trauma are mediated by negative reinforcement (behaviors that decrease the emotional pain of the trauma). or obsessions and compulsions.
Social isolation (phobic disorders) e. 3. Nursing diagnoses are formulated from the data gathered during the assessment phase. Based on accomplishment of previously established outcome criteria K. I. or obsessions or compulsions. The focus is on development of more adaptive methods of coping with anxiety.171 a. 4. Diagnosis/Outcome Identification 1. generalized anxiety disorder) b. Systematic desensitization 2. Fear (phobic disorders) d. generalized anxiety disorder) c. Evaluation 1. Nursing interventions for the client with OCD are aimed at helping him or her maintain anxiety at a manageable level without having to resort to use of ritualistic behavior. demonstration of more adaptive coping strategies. panic attacks. Powerlessness (panic disorder. 2. Ineffective role performance (OCD) g. Assessment scales: The Hamilton Anxiety Rating Scale (HAM-A) is included in the textbook. J. b. H. Panic anxiety (panic disorder. and may involve prominent anxiety.g. a. Symptoms may occur during substance intoxication or withdrawal. Individual Psychotherapy B. Implosion therapy (flooding) . Behavior Therapy 1. Topics for Client/Family Education Related to Anxiety Disorders VI. Posttrauma syndrome (PTSD) h. Prominent anxiety symptoms that are judged to be due to the direct physiological effects of a substance. decrease in maladaptive symptoms (e. 2. Nursing interventions for the client with PTSD are aimed at reassurance of safety. Cognitive Therapy C. Nursing interventions for the client with phobias are aimed at decreasing the fear and increasing the ability to function in the presence of the phobic stimulus. Planning/Implementation 1. nightmares). and adaptive progression through the grief process. Complicated grieving (PTSD) 2. flashbacks. Nursing interventions for the client with panic or generalized anxiety disorder are aimed at relief of acute panic symptoms and assisting the client to take control of own life situation and accept situations over which he or she has no control. Treatment Modalities for Anxiety Disorders A. Ineffective coping (OCD) f. Outcome criteria are used as measurement guidelines to evaluate effectiveness of nursing care.. phobias.
or sertraline) and individual psychotherapy. Contraindications/precautions d. paroxetine.. Actions c.. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. Summary and Key Points VIII. For phobic disorders: (1) Anxiolytics (2) Antidepressants (3) Antihypertensive agents c. For OCD: (1) Antidepressants d. Indications b.g. or lorazepam) or an SSRI (e. clonazepam. 2. For panic and generalized anxiety disorders: (1) Anxiolytics (2) Antidepressants (3) Antihypertensive agents b. alprazolam. Critical Thinking Exercise IX. For PTSD: (1) Antidepressants (2) Anxiolytics (3) Antihypertensives (4) Others VII. Psychopharmacology 1. Antianxiety agents a. A benzodiazepine (e. Interactions 2. . Group/Family Therapy E. Stay with her and reassure her of her safety. 3.172 D. fluoxetine. Panic anxiety related to threat to self-concept (fear of failure). Medications for specific disorders a.g.
Describe various types of somatoform and dissociative disorders and identify symptomatology associated with each. 3. OBJECTIVES After reading this chapter. Discuss historical aspects and epidemiological statistics related to somatoform and dissociative disorders. Introduction A. Discuss various modalities relevant to treatment of somatoform and dissociative disorders. Medical treatment modalities are also discussed. the student will be able to: 1. 5. Describe appropriate nursing interventions for behaviors associated with somatoform and dissociative disorders. Evaluate the nursing care of clients with somatoform and dissociative disorders. and nursing care is presented in the context of the six steps of the nursing process. 4. KEY TERMS abreaction anosmia aphonia depersonalization derealization fugue hypochondriasis integration la belle indifference primary gain pseudocyesis secondary gain tertiary gain CORE CONCEPTS amnesia dissociation hysteria somatization CHAPTER OUTLINE/LECTURE NOTES I. Predisposing factors and symptomatology are explored. Identify predisposing factors in the development of somatoform and dissociative disorders. .173 CHAPTER 30. Use this information in client assessment. SOMATOFORM AND DISSOCIATIVE DISORDERS CHAPTER FOCUS The focus of this chapter is on nursing care of individuals experiencing somatoform and dissociative disorders. but without demonstrable organic pathology or known pathophysiological mechanism to account for them. Formulate nursing diagnoses and goals of care for clients with somatoform and dissociative disorders. Somatoform disorders are characterized by physical symptoms suggesting medical disease. 6. 7. 2.
174 B. Dissociative disorders are defined by a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. II. Historical Aspects A. Historically, somatoform disorders have been identified as hysterical neuroses. Somatoform disorders are thought to occur in response to repressed severe anxiety. B. Freud viewed dissociation as a type of repression, an active defense mechanism used to remove threatening or unacceptable mental contents from conscious awareness. III. Epidemiological Statistics A. Somatoform disorders are more common in women than they are in men. They are more common in those who are poorly educated and those from the lower socioeconomic groups. B. Dissociative disorders are statistically quite rare, but when they do occur, they may present very dramatic clinical pictures of severe disturbances in normal personality functioning. Dissociative amnesia and dissociative identity disorder (DID) are more common in women than they are in men. Brief episodes of depersonalization symptoms appear to be common in young adulthood, particularly in times of severe stress. IV. Application of the Nursing Process A. Background Assessment Data: Types of Somatoform Disorders 1. Somatization disorder a. A chronic syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from health-care professionals. b. The disorder is chronic, and anxiety, depression, and suicidal ideation are frequently manifested. c. Drug abuse and dependence are common complications of somatization disorder. d. Personality characteristics: heightened emotionality, strong dependency needs, and a preoccupation with symptoms and oneself. 2. Pain disorder a. The predominant disturbance in pain disorder is severe and prolonged pain that causes clinically significant distress or impairment in social, occupational, or other areas of functioning. b. Even when organic pathology is detected, the pain complaint may be evidenced by the correlation of a stressful situation with the onset of symptoms. c. The disorder may be maintained by: (1) Primary gains: the symptom enables the client to avoid some unpleasant activity. (2) Secondary gains: the symptom promotes emotional support or attention for the client.
175 (3) Tertiary gains: in dysfunctional families, the physical symptom may take such a position that the real issue is disregarded and remains unresolved, even though some of the conflict is relieved. d. Symptoms of depression and substance abuse are common. 3. Hypochondriasis a. Unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease. b. Even in the presence of medical disease, the symptoms are grossly disproportionate to the degree of pathology. c. Anxiety and depression are common, and obsessive-compulsive traits frequently accompany the disorder. 4. Conversion disorder a. A loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism. b. The most obvious and “classic” conversion symptoms are those that suggest neurological disease and occur following a situation that produces extreme psychological stress for the individual. c. The person often expresses a relative lack of concern that is out of keeping with the severity of the impairment. This lack of concern is identified as la belle indifference and may be a clue to the physician that the problem is psychological rather than physical. 5. Body dysmorphic disorder a. Characterized by the exaggerated belief that the body is deformed or defective in some specific way. b. Symptoms of depression and characteristics associated with obsessive-compulsive personality are common. B. Predisposing Factors Associated with Somatoform Disorders 1. Genetic. There are possible hereditary factors associated with somatization disorder, conversion disorder, and hypochondriasis. 2. Biochemical. Decreased levels of serotonin and endorphins may play a role in the etiology of pain disorder. 3. Psychodynamic theory a. This theory suggests that hypochondriasis is an ego defense mechanism. Physical complaints are the expression of low selfesteem and feelings of worthlessness. b. Conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptably “converted” into physical symptoms. 4. Family dynamics. In dysfunctional families, when a child becomes ill, a shift in focus is made from the open conflict to the child’s illness, leaving unresolved the underlying issues that the family is unable to confront openly. Somatization brings some stability to the family and positive reinforcement to the child (called tertiary gain).
176 5. Learning theory a. Somatic complaints are often reinforced when the sick person learns that he or she may avoid stressful obligations or be excused from unwanted duties (primary gains); become the prominent focus of attention because of the illness (secondary gains); or relieve conflict within the family as concern is shifted to the ill person and away from the real issue (tertiary gains). b. Past experience with serious or life-threatening physical illness, either personal or that of close family members, can predispose an individual to hypochondriasis. 6. Transactional model of stress/adaptation. The etiology of somatoform disorders is most likely influenced by multiple factors. C. Background Assessment Data: Types of Dissociative Disorders 1. Dissociative amnesia a. An inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness, and which is not due to the direct effects of substance use or a general medical condition. Onset usually follows severe psychosocial stress. b. Five types of disturbance in recall: (1) Localized amnesia. The inability to recall all incidents associated with the traumatic event for a specific time period following the event (usually a few hours to a few days). (2) Selective amnesia. The inability to recall only certain incidents associated with a traumatic event for a specific time period following the event. (3) Continuous amnesia. The inability to recall events occurring after a specific time up to and including the present. (4) Generalized amnesia. The inability to recall anything that has happened during the individual’s entire lifetime, including personal identity. (5) Systematized amnesia. The individual cannot remember events that relate to a specific category of information (e.g., one’s family) or to one particular person or event. 2. Dissociative fugue a. The characteristic feature of dissociative fugue is a sudden, unexpected travel away from home or customary place of daily activities. b. An individual in a fugue state is unable to recall personal identity, and assumption of a new identity is common. 3. Dissociative identity disorder a. Characterized by the existence of two or more personalities within a single individual. b. The transition from one personality to another is usually sudden, often dramatic, and usually precipitated by stress. 4. Depersonalization disorder
177 a. Characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body. b. Depersonalization is defined as a disturbance in the perception of oneself. c. Derealization is described as an alteration in the perception of the external environment. d. Symptoms of depersonalization disorder are often accompanied by anxiety, depression, fear of going insane, obsessive thoughts, somatic complaints, and a disturbance in the subjective sense of time. D. Predisposing Factors Associated with Dissociative Disorders 1. Genetics. Possible hereditary factors associated with DID. 2. Neurobiological. It is possible that dissociative amnesia and dissociative fugue may be related to neurophysiological dysfunction. EEG abnormalities have been observed in some clients with DID. 3. Psychodynamic theory. Freud described amnesia as the result of repression of distressing mental contents from conscious awareness. Current psychodynamic explanations of dissociation are based on Freud’s concepts—that is, that behaviors such as amnesia, fugue, and depersonalization are defenses against unresolved painful issues. 4. Psychological trauma. A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelms the individual’s capacity to cope by any means other than dissociation. These experiences usually take the form of severe physical, sexual, or psychological abuse by a parent or significant other in the child’s life. DID is thought to serve as a survival strategy for the child in this traumatic environment. E. Diagnosis/Outcome Identification for Somatoform and Dissociative Disorders 1. Nursing diagnoses are formulated from the data gathered during the assessment phase and with background knowledge regarding etiological implications for the illness. 2. Some common nursing diagnoses for clients with somatoform and dissociative disorders include: a. Ineffective coping evidenced by numerous physical complaints (somatization disorder) b. Deficient knowledge [psychological causes for physical symptoms] (all somatoform disorders) c. Chronic pain (pain disorder) d. Social isolation (all somatoform disorders) e. Fear [of having a serious disease] (hypochondriasis) f. Chronic low self-esteem (all somatoform disorders) g. Disturbed sensory perception (conversion disorder) h. Self-care deficit (conversion disorder) i. Disturbed body image (body dysmorphic disorder)
Supportive care 4. Disturbed thought processes. Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than preoccupation with physical symptoms. Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than dissociation from the environment. Reassurance of his safety and security. Risk for suicide (DID) n. Encourage him to discuss the stressful life situation that preceded the fugue state and his feelings associated with his life situation. Disturbed sensory perception (depersonalization disorder) 3. . Group psychotherapy 3. 2. Individual psychotherapy 2. Evaluation 1. Psychopharmacology I. 2. Hypnosis 3. Disturbed personal identity (DID) o. Nursing care of the individual with a dissociative disorder is aimed at restoration of normal thought processes. Psychopharmacology V. F. Behavior therapy 4. impaired memory (dissociative amnesia) k. Critical Thinking Exercise VII. G. Nursing care of the individual with a somatoform disorder is aimed at relief of discomfort from the physical symptom. H. Treatment Modalities for Dissociative Disorders 1. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. To develop more adaptive coping strategies. Ineffective coping evidenced by sudden travel away from home with inability to recall previous identity (dissociative fugue) m. 3. Individual psychotherapy 2. Outcome criteria are identified for measuring the effectiveness of nursing care. Summary and Key Points VI. Cognitive therapy 5. Group/family therapy 6. Treatment Modalities for Somatoform Disorders 1.178 j. Powerlessness (dissociative amnesia) l. Planning/Implementation 1. Based on accomplishment of previously established outcome criteria. Integration therapy (DID) 7.
and gender identity disorders. Conduct a sexual history. and gender identity disorders. ISSUES RELATED TO HUMAN SEXUALITY AND GENDER IDENTITY CHAPTER FOCUS The focus of this chapter is on nursing care of clients with sexual or gender identity disorders. sexual dysfunction disorders. Describe developmental processes associated with human sexuality. 5. 7. Identify topics for client/family education relevant to sexual disorders. 13. Identify various types of paraphilias. Identify appropriate nursing interventions for clients with sexual and gender identity disorders. KEY TERMS anorgasmia dyspareunia exhibitionism fetishism frotteurism homosexuality lesbianism masochism pedophilia premature ejaculation retarded ejaculation sadism sensate focus transgenderism transvestic fetishism vaginismus CORE CONCEPTS gender sexuality . Medical treatment modalities are also discussed. 12. Describe the physiology of the human sexual response. Predisposing factors and symptomatology are explored. and nursing care is presented in the context of the six steps of the nursing process. 2. 9.179 CHAPTER 31. Evaluate nursing care of clients with sexual and gender identity disorders. Identify various types of sexually transmitted diseases and discuss the consequences of each. 4. 11. 3. Formulate nursing diagnoses and goals of care for clients with sexual and gender identity disorders. Discuss historical and epidemiological aspects of paraphilias and sexual dysfunction disorders. Discuss variations in sexual orientation. Discuss predisposing factors associated with the etiology of paraphilias. sexual dysfunction disorders. Describe various medical treatment modalities for clients with sexual disorders. 8. 10. 6. OBJECTIVES After reading this chapter. the student will be able to: 1.
Adolescence 1. repetitive sexual activity with humans involving real or simulated suffering or humiliation. whether to participate in various types of sexual behavior. This period begins at approximately 20 years of age and continues to age 65. therapeutic. how to prevent unwanted pregnancy. and repetitive sexual activity with nonconsenting partners. but some evidence exists to suggest that the incidence for women may be increasing. children know what gender they are.180 orgasm paraphilia voyeurism CHAPTER OUTLINE/LECTURE NOTES I. By age 2 or 2½. C. Marital sex. III. B. Hormonal changes occurring during this period produce changes in sexual activity for both men and women. children engage in heterosexual play. A term used to identify repetitive or preferred sexual fantasies or behaviors that involve the preference for use of a nonhuman object. how to recognize love. and how to define age-appropriate sex roles. 4. 3. Development of Human Sexuality A. B. Sexuality is a basic human need and an innate part of the total personality. Adulthood. Choosing a marital partner or developing a sexual relationship with another individual is one of the major tasks in the early years of this life cycle stage. Some enjoy their freedom and independence while others are desperately seeking an intimate relationship. and educational interventions to assist individuals to attain. Sex and the single person. 2. Paraphilias. regain. Attitudes about sexual intimacy vary greatly from individual to individual. Sexual Disorders A. Adolescents relate to sexual issues. About a third of married men and a fourth of married women have engaged in extramarital sex at some time during their marriages. 4. Ages 10 to 12 are preoccupied with pubertal changes and the beginnings of romantic interest in the opposite gender. Late childhood and preadolescence may be characterized by heterosexual or homosexual play. . such as how to deal with new or more powerful sexual feelings. 1. Extramarital sex. These numbers have remained somewhat constant for men. they can readily integrate information on sexuality in the care they give by focusing on preventive. Although not all nurses need to be educated as sex therapists. The middle years—46 to 65. II. Introduction A. 3. Birth Through Age 12 1. or maintain sexual wellness. 2. By age 4 or 5.
behaviors. peaks between ages 15 and 25.181 1. The behavioral model hypothesizes that whether or not an individual engages in paraphiliac behavior depends on the type of reinforcement he or she receives following the behavior. Historical aspects. behaviors. intense sexual urges. Psychoanalytical theory. Characterized by recurrent. or sexually arousing fantasies involving the use of nonliving objects (e. Recurrent. Abnormal levels of androgens have also been implicated. e. 4. Recurrent.. But once the initial act has been .g. or sexually arousing fantasies involving the act of observing unsuspecting people. The recurrent preoccupation with intense sexual urges or fantasies involving touching or rubbing against a nonconsenting person. or sexually arousing fantasies involving the exposure of one’s genitals to an unsuspecting stranger. Voyeurism. Exhibitionism. not simulated) of being humiliated. intense sexual urges. Fetishism. gloves. stockings). intense sexual urges. or otherwise made to suffer. Most individuals with paraphilias are men. shoes. Biological factors. usually strangers. behaviors. modeling the paraphilic behavior of others. c. beaten. mimicking sexual behavior depicted in the media). bound. Frotteurism. Epidemiological statistics. Types of paraphilias a. who are either naked. Suggests that a paraphiliac is one who has failed the normal developmental process toward heterosexual adjustment. in the process of disrobing. The behavior is usually established in adolescence. f. Sexual masochism. various sexual behaviors have been. not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting. Behavioral theory. This occurs when the individual fails to resolve the Oedipal crisis and either identifies with the parent of the opposite gender or selects an inappropriate object for libido cathexis. behaviors. c. or engaging in sexual activity. Predisposing factors to paraphilias a. b. Recurrent. Pedophilia.g. 3.. intense sexual urges. 2. These include abnormalities in the limbic system and the temporal lobe. b. Involves recurrent. and declines to low incidence by age 50. or sexually arousing fantasies involving acts (real. or sexually arousing fantasies involving the act (real. Sexual sadism. and still are. Recurrent sexual urges. The initial act may be committed for various reasons (e. condemned by certain social and religious sanctions. or sexually arousing fantasies involving sexual activity with a prepubescent child. behaviors. behaviors. Various studies have implicated several organic factors in the etiology of paraphilias. intense sexual urges. g. d. At certain times in history.
Behavioral therapy. With this type of therapy. Persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. Historical and epidemiological aspects related to sexual dysfunction a. c. (2) Sexual aversion disorder. such as the use of electric shock and bad odors. Resolution 2. the client is assisted to identify unresolved conflicts and traumas from early childhood. have been used to modify undesirable paraphilic behavior. Role of the nurse a. Sexual Dysfunctions 1. Nursing may best become involved in the primary prevention process. Psychoanalytical therapy. Concurrent with the cultural changes occurring during the sexual revolution of the 1960s and 1970s came an increase in scientific research into sexual physiology and sexual dysfunctions. d. Aversion techniques. Persistent or recurrent extreme aversion to. The focus of primary prevention in sexual disorders is to intervene in home life or other facets of childhood in an effort to prevent problems from developing. Usually occur as a problem in one of the following phases of the sexual response cycle: a. 3. Transactional model of stress/adaptation. thus resolving the anxiety that prevents him or her from forming appropriate sexual relationships. Sexual arousal disorders . B. Phase II: Excitement c. a conscious evaluation of the behavior occurs. Phase IV. usually in combination with exposure to photographs depicting the undesired behavior. b. 5. c. The focus of this treatment is on blocking or decreasing the level of circulating androgens. b. It is most likely that the etiology of paraphilias is influenced by multiple factors. 6. Orgasm d. An additional concern of primary prevention is to assist in the development of adaptive coping strategies to deal with stressful life situations. Sexual desire disorders (1) Hypoactive sexual desire disorder. Types of sexual dysfunction a. Phase III. Phase I: Desire b. Masters and Johnson pioneered this work with their studies on human sexual response and the treatment of sexual dysfunctions. b.182 committed. and avoidance of all (or almost all) genital sexual contact with a sexual partner. Biological treatment. b. and a choice is made of whether or not to repeat it. Treatment modalities a.
diabetes. anxiolytics. Certain medications (e.g. temporal lobe epilepsy. Persistent or recurrent ejaculation with minimal sexual stimulation before. antidepressants.. an adequate erection. Biological factors (1) Sexual desire disorders. (3) Premature ejaculation. (2) Male erectile disorder. (2) Male orgasmic disorder (retarded ejaculation). (2) Sexual arousal disorders. or experience a subjective sense of sexual excitement and pleasure in a female during sexual activity. 4. Persistent or recurrent inability to attain. and anticonvulsants). orgasm following a normal sexual excitement phase during sexual activity that the clinician. those with antihistaminic and anticholinergic properties) may contribute to decreased ability for arousal in women.g. as well as alcohol and cocaine. and duration. Failure to attain or maintain the lubrication-swelling response. on. Predisposing factors to sexual dysfunctions a. Certain medications (e. Orgasmic disorders (1) Female orgasmic disorder (anorgasmia).. arteriosclerosis. e. Sexual pain disorders (1) Dyspareunia. c. antipsychotics. Decreased levels of serum testosterone may be associated with hypoactive sexual desire disorder in men. have also been implicated in the etiology of hypoactive sexual desire disorder. The recurrent and persistent delay in.. during. Medications that have been implicated in ED . multiple sclerosis) may cause erectile dysfunction (ED) in men. An involuntary constriction of the outer one-third of the vagina that prevents penile insertion and intercourse. or absence of. antihypertensives. taking into account the person’s age. or absence of. d. or after sexual intercourse that is not associated with vaginismus or with lack of lubrication. orgasm following a normal sexual excitement phase. Persistent or recurrent delay in. judges to be adequate in focus. or to maintain until completion of the sexual activity. Recurrent or persistent genital pain in either a male or female before. Various medical conditions (e. intensity. or shortly after penetration and before the person wishes it. Elevated levels of serum prolactin may be associated with diminished libido in both men and women. Sexual dysfunction due to a general medical condition and substance-induced sexual dysfunction (1) With these disorders.183 (1) Female sexual arousal disorder.g. (2) Vaginismus. the sexual dysfunction is judged to be caused by the direct physiological effects of a general medical condition or use of a substance.
Organic contributing factors to female sexual pain disorder include intact hymen. such as diabetes. c. such as depression. marital. clients with infertility problems. family. Psychosocial factors. Nursing intervention for the client with sexual disorders is aimed at assisting the individual to gain or regain the aspect of his or her sexuality that is desired. anxiety. or depression. and anxiolytics. (4) Sexual pain disorders. B. Diagnosis/Outcome Identification 1. antidepressants. C. IV. neurological disorders such as Parkinson’s disease. Some medications (e. episiotomy scar. Chronic use of alcohol may also be a contributing factor.g. The etiology of sexual dysfunction is most likely influenced by multiple factors. and desire or practices different from partner. sexually transmitted disease. or job problems. sexual identity conflicts. A tool for gathering a sexual history is included. Sexual dysfunction b. ligament injuries.. (3) Orgasmic disorders. and diabetes. and individuals in premarital. or sexual abuse. Assessment. SSRIs) may inhibit orgasm in women. b. phimosis.184 include antihypertensives. Outcome criteria are identified for measuring the effectiveness of nursing care. or complaints of sexual inadequacy. Infections. and other diseases. may cause decreased female sexual arousal and orgasm. vaginal or urinary tract infection. current physical. Medical conditions. endometriosis. Certain medications are also implicated. Transactional model of stress/adaptation. financial. Relationship causes include interpersonal conflicts. or ovarian cysts or tumors. fears of pregnancy. Additional information should be gathered for clients who have medical or surgical conditions that may affect their sexuality. past sexual abuse. Planning/Implementation 1. and aging-related concerns. and prostate problems may be contributing factors in men. . A number of psychosocial factors have been associated with sexual disorders in men and women. hypothyroidism. and psychiatric counseling. extramarital affairs. clients who are pregnant or present with gynecological problems. chronic stress. antipsychotics. verbal. Nursing diagnoses for clients experiencing sexual dysfunction include: a. Examples include religious orthodoxy. those seeking information on abortion or family planning. Application of the Nursing Process A. Biological factors associated with inhibited male orgasm include surgery of the GI tract. Ineffective sexuality pattern 2.
Testosterone. Most are biological males desiring reassignment to the female gender. Premature Ejaculation 1. Male Erectile Disorder 1. D. Systematic desensitization H. the awareness of one’s masculinity or femininity. tadalafil (Cialis). The prevalence of GID is estimated at 1 in 30. Education of the woman and her partner regarding the anatomy and physiology of the disorder 2. Behavioral therapy 4. Hypoactive Sexual Desire Disorder 1. Systematic desensitization with dilators of graduated sizes VI. Systematic desensitization 2.000 men and 1 in 100. Sildenafil (Viagra). C. “Squeeze” technique G. Gender identity disorder (GID) occurs when there is incongruence between anatomical sex and gender identity. Physical and gynecological examination 2. . Sensate focus exercises D. Group therapy 3. Sensate Focus Exercises 2. and values have been clarified and do not interfere with acceptance of the client. yohimbine 6. B. Cognitive therapy 3. Course and Epidemiology 1.000 women. Antidepressant medication C. The nurse must remain nonjudgmental and ensure that personal feelings. Gender identity is the sense of knowing whether one is male or female—that is. Dyspareunia 1. Female Sexual Arousal Disorder 1. Evaluation is based on accomplishment of previously established outcome criteria. Sensate focus exercises 2. Relationship therapy B. Sexual Aversion Disorder 1. Hypnotherapy 4. Female and Male Orgasmic Disorder 1. 2.185 2. Vaginismus 1. Testosterone 2. vardenafil (Levitra) 7. attitudes. V. Gender Identity Disorders A. Systematic desensitization 5. Penile implantation E. Treatment Modalities for Sexual Dysfunctions A. Directed masturbation training F. Sensate focus exercises 2.
but not necessarily to extinguish all coexisting opposite-gender behaviors.186 3. B. and ultimately with normal gender identity. which interferes with the child’s loving of the opposite-gender parent and identifying with the same-gender parent. Suggests that gender identity problems begin during the struggle with the Oedipal conflict. VII. d. preference for cross-dressing or simulating female attire. Predisposing Factors 1. Recent suggestion of a possible genetic link 2. Nursing intervention for the client with gender identity disorder is aimed at enhancing culturally appropriate same-gender behaviors. Most individuals with childhood GID will not have the symptoms of adolescent or adult GID. Family dynamics. the opposite gender. Intense desire to participate in the stereotypical games and pastimes of the opposite gender. or the conviction that he or she has the typical feelings and reactions of the opposite gender. 2. D. or insistence that he or she is. Possible link to congenital adrenal hyperplasia b. b. Impaired social interaction c. Strong and persistent preferences for cross-gender roles in makebelieve play or persistent fantasies of being the opposite gender. Psychoanalytical theory. a desire to live or be treated as the opposite gender. Biological influences a. 2. c. Background Assessment Data (Symptomatology) 1. Symptomatic manifestations include a stated desire to be of the opposite gender. Strong preference for playmates of the opposite gender. May be influenced by parents who encourage strong interests in opposite-gender activities and weak reinforcement of normative gender-role behavior. in girls. insistence on wearing only stereotypical masculine clothing. Gender identity disorder in adolescents and adults a. 3. Variations in Sexual Orientation . Application of the Nursing Process A. D. frequent passing as the opposite gender. Diagnosis/Outcome Identification 1. Nursing diagnoses for the client with gender identity disorder include: a. In boys. Gender identity disorder in children a. e. Emphasis is also given to improvement in social interactions and enhancement of positive self-esteem. VIII. Disturbed personal identity b. Evaluation is based on accomplishment of previously established outcome criteria. but most will report a homosexual or bisexual orientation. Planning/Implementation 1. Low self-esteem C. Repeatedly stated desire to be.
They implicate the roles of a dominant. C. This hypothesis lacks definitive evidence. despite having the anatomical characteristics of a given gender. or hostile father. HIV disease b. A disorder of gender identity or gender dysphoria (unhappiness or dissatisfaction with one’s gender) of the most extreme variety. Homosexuality. Predisposing factors a. Refer to section on Gender Identity Disorder for predisposing factors 2. An individual who is not exclusively heterosexual or homosexual. This is only seen by the psychiatric community as a problem when the individual experiences “persistent and marked distress about his or her sexual orientation. supportive mother and a weak. remote. Special concerns a. Both subsequently try to meet their unmet samegender needs through sexual relationships. Psychosocial theories (1) Freud suggested a possible fixation in the stage of development where homosexual tendencies are common. An individual. but engages in sexual activity with members of both genders. Identified in the DSM-IV-TR under the broad category of gender identity disorder b. has the self-perception of being of the opposite gender. (2) Some theories suggest that a dysfunctional family pattern may have an etiological influence in the development of homosexuality. Sexually transmitted diseases. Decreased levels of testosterone and increased levels of estrogen in homosexual men have been implicated. Fear of being rejected by parents and significant others d. Twin studies suggest that a genetic tendency for homosexuality may exist. b. Discovery of their sexual orientation c. Extensive psychological testing prior to surgical intervention b. The expression of a sexual preference for individuals of the same gender. Predisposing factors a. in particular. Predisposing factors a. Both men and women continue to receive maintenance hormone therapy following surgery. Bisexuality. Same-sex marriage B.187 A. Hormonal treatment initiated during this period c. Biological theories. 2. Transgenderism. Special concerns a. 1. 1. (3) These theories of family dynamics have been disputed by some clinicians who believe that parents have very little influence on the outcome of their children’s sexual-partner orientation.” 1. Lesbians may have had a dysfunctional mother-daughter relationship. Little research exists on the etiology of bisexuality . Discrimination within society e.
Hepatitis B 7. STDs refer to infections that are contracted primarily through sexual activities or intimate contact with the genitals. To resume sexual activity with her husband at a level of participation that is satisfactory to both. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. Summary and Key Points XI.. STDs are at epidemic levels in the United States. Genital warts 6. They may be transmitted from one person to another through heterosexual or homosexual contact. Suggest they spend regular time alone (away from the house if necessary). Acquired immunodeficiency syndrome (AIDS) X. Critical Thinking Exercise XII. Sexual dysfunction related to unresolved sexual issues from her teen years evidenced by loss of sexual desire. B.g. and external genital evidence of pathology may or may not be manifested. Help her problem solve ways to overcome these fears (e. the nurse may need to make a referral to a sex therapist who specializes in this type of problem. Help her to understand that she and her husband need not return to the level of sexual interaction in which they participated early in their marriage. Information regarding the following types of STDs is presented: 1. Prevention of STDs is the ideal goal. The nurse’s first responsibility in STD control is to educate clients who may develop or have a sexually transmitted infection. C. If they are unable to resolve their differences. 3. Chlamydial infection 4. Help her problem solve ways to accomplish this. Gonorrhea 2. IX. Encourage her to talk about her relationship with her husband. 2. but early detection and appropriate treatment continue to be considered a realistic objective. Explore her fears of having sex with her husband with the teenagers in the house. Freud believed that all humans are inherently bisexual c. mouth. Syphilis 3. Sexually Transmitted Diseases (STDs) A. Encourage her to talk about the incident from her adolescence. Gender identity (determining whether one is male or female) is usually established by the age of 2 or 3 years. D. Sexual identity (determining whether one is heterosexual or homosexual or both) may continue to evolve throughout one’s lifetime. or rectum of another individual.188 b. (This may mean that her husband will have to compromise his level of sexual desire. Take a medication history to ensure lack of sexual desire is not related to a substance.) . a lock on their bedroom door). Genital herpes 5. E.
189 CHAPTER 32. and use the information in client assessment. Identify predisposing factors in the development of eating disorders. Formulate nursing diagnoses and goals of care for clients with eating disorders. and nursing care is presented in the context of the six steps of the nursing process. 4. 8. 5. 3. It regulates the body’s ability to recognize when it is hungry and when it has been sated. Introduction A. Discuss various modalities relevant to treatment of eating disorders. 9. Medical treatment modalities are also discussed. Identify and differentiate among the various eating disorders. Eating behaviors are influenced by society and culture. 6. Describe symptomatology associated with anorexia nervosa. OBJECTIVES After reading this chapter. society and culture also have influenced what is considered desirable in the female body. Historically. 2. Describe appropriate interventions for behaviors associated with eating disorders. KEY TERMS amenorrhea anorexia nervosa anorexiants binging bulimia nervosa emaciated obesity purging CORE CONCEPTS anorexia body image bulimia CHAPTER OUTLINE/LECTURE NOTES I. The hypothalamus contains the appetite regulation center within the brain. 7. the student will be able to: 1. EATING DISORDERS CHAPTER FOCUS The focus of this chapter is on nursing care of clients with eating disorders. Identify topics for client and family teaching relevant to eating disorders. Predisposing factors and symptomatology are explored. bulimia nervosa. Evaluate the nursing care of clients with eating disorders. and obesity. C. B. . Discuss epidemiological statistics related to eating disorders.
Depression. Predisposing factors to anorexia nervosa and bulimia nervosa a. Bulimia nervosa is more prevalent than anorexia nervosa. and substance abuse are not uncommon. compulsive. Background Assessment Data (Symptomatology) 1. some slightly overweight. (a) Anorexia nervosa is more common among sisters and mothers of those with the disorder than among the general population. preoccupation with food. The individual may weigh less than 85 percent of expected weight. Bulimia nervosa a. c. (b) Possible chromosomal linkage sites have been suggested. F. rapid ingestion of large quantities of food over a short period of time (binging). and refusal to eat. b. d. and 34 percent of these are in the obese range. Feelings of anxiety and depression are common. Anorexia nervosa a. e. C. 68 percent of adult Americans are overweight. f. 2. D. edema. There may be an obsession with food. anxiety. diuretics. Application of the Nursing Process A. Characterized by a morbid fear of obesity.190 II. Bulimia nervosa is the episodic. or enemas). g. and a variety of metabolic changes. B. 3. lanugo. d. Amenorrhea is typical. Symptoms include gross distortion of body image. The prevalence rate of anorexia nervosa among young women in the United States is approximately 1 percent. uncontrolled. b. hypotension. e. A hereditary predisposition to eating disorders has been hypothesized. Biological influences (1) Genetics. Weight loss is extreme. or the misuse of laxatives. Most individuals with bulimia are within a normal weight range. Excessive vomiting and laxative/diuretic abuse may lead to problems with dehydration and electrolyte imbalance. Anorexia nervosa occurs predominantly in females aged 12 to 30 years. Obesity has been defined as a body mass index of 30 or greater. c. bradycardia. and may even precede significant weight loss. Epidemiological Factors A. Other symptoms include hypothermia. III. Onset of bulimia nervosa occurs in late adolescence or early adulthood. . some slightly underweight. followed by inappropriate compensatory behaviors to rid the body of the excess calories (self-induced vomiting. Fasting or excessive exercise may also occur. with estimates up to 4 percent of young women. E.
5. who continues to seek love. approval. Psychosocial influences . and recognition. (2) Physiological factors (a) Lesions in the appetite and satiety centers of the hypothalamus (b) Hypothyroidism (c) Decreased insulin production (d) Increased cortisone production (3) Lifestyle factors (a) Increased caloric intake (b) Sedentary lifestyle b. Twin studies have also supported a hereditary factor. The sick child becomes the problem and focus on the conflict is diverted. At this level. b. Some speculation has occurred regarding a primary hypothalamic dysfunction in anorexia nervosa. Ambivalence toward the parents develops. Obese people are at higher risk for hyperlipidemia.191 (2) Neuroendocrine abnormalities. resulting in retarded ego development and an unfulfilled sense of separation-individuation. Predisposing factors to obesity a. weight alone can contribute to increases in morbidity and mortality. Parental criticism promotes an increase in obsessive and perfectionistic behavior on the part of the child. Eighty percent of children born of two obese parents will also be obese. Power and control may become the overriding elements in the family of the client with an eating disorder. diabetes mellitus. b. Psychodynamic theory suggests that eating disorders result from very early and profound disturbances in mother-infant interactions. Psychodynamic influences. and respiratory insufficiency. osteoarthritis. A body mass index (weight in kilograms divided by height in meters squared) of 30 is considered obesity. Families may promote and maintain psychosomatic symptoms. c. and remain in. control. The neurotransmitters serotonin and norepinephrine may be involved in the predisposition to bulimia nervosa. in an effort to avoid spousal conflict. (3) Neurochemical influences. (2) Elements of power and control. Family influences (1) Conflict avoidance. c. angina. Obesity a. and distorted eating patterns may represent a rebellion against the parents—a way to gain. 4. while high levels of endogenous opioids may be associated with anorexia nervosa. including anorexia nervosa. Biological influences (1) Genetics.
Critical Thinking Exercise VII. Disturbed body image/low self-esteem f. Outcome criteria are identified for measuring the effectiveness of nursing care.192 (1) Unresolved dependency needs (2) Fixation in the oral stage of psychosexual development c. Ineffective denial d. B. C. she will still need to be watched carefully. 3. Restoring her nutritional condition. 2. The etiology of eating disorders is most likely influenced by multiple factors. 3. Imbalanced nutrition: More than body requirements e. Diagnosis/Outcome Identification 1. Anxiety (moderate to severe) 2. Emphasis is also placed on helping the client gain control over life situation in ways other than inappropriate eating behaviors. 2. Behavior Modification B. . Summary and Key Points VI. Imbalanced nutrition: Less than body requirements b. Treatment Modalities A. Client/Family Education E. as she may go into other clients’ bathrooms to purge. Transactional model of stress/adaptation. Nursing care of the client with an eating disorder is aimed at restoring nutritional balance. Deficient fluid volume (risk for or actual) c. Self-esteem and positive self-image are promoted in ways that relate to aspects other than appearance. with privileges based on weight gain. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. The door to her bathroom will need to be kept locked for at least 1 hour following meals. Family Therapy D. Individual Therapy C. D. IV. Psychopharmacology V. Planning/Implementation 1. Nursing diagnoses for the client with eating disorders include: a. A program of behavior modification. Evaluation is based on accomplishment of previously established outcome criteria. However.
Discuss various modalities relevant to treatment of adjustment and impulse control disorders. Medical treatment modalities are also discussed. Discuss historical aspects and epidemiological statistics related to adjustment and impulse control disorders. ADJUSTMENT AND IMPULSE CONTROL DISORDERS CHAPTER FOCUS The focus of this chapter is on nursing care of clients with adjustment and impulse control disorders. Evaluate nursing care of clients with adjustment and impulse control disorders.193 CHAPTER 33. Use this information in client assessment. 8. and nursing care is presented in the context of the six steps of the nursing process. 6. Describe various types of adjustment and impulse control disorders and identify symptomatology associated with each. 2. Identify predisposing factors in the development of adjustment and impulse control disorders. Formulate nursing diagnoses and goals of care for clients with adjustment and impulse control disorders. OBJECTIVES After reading this chapter. 4. Describe appropriate nursing interventions for behaviors associated with adjustment and impulse control disorders. 3. 5. the student will be able to: 1. Identify topics for client and family teaching relevant to adjustment and impulse control disorders. 7. Predisposing factors and symptomatology are explored. KEY TERMS adjustment disorder Gamblers Anonymous kleptomania pathological gambling pyromania trichotillomania CORE CONCEPTS adjustment impulsive .
Categories are distinguished by the predominant features of the maladaptive response. Adjustment and impulse control disorders are precipitated by a type of psychosocial stress. B. b. is thought to limit the general adaptive capacity of an individual. the severity of which may or may not directly affect the individual response. Adjustment disorder with disturbance of conduct. Adjustment disorder with anxiety. An adjustment disorder is characterized by a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months after onset of the stressor and has persisted for no longer than 6 months after onset of the stressor. and kleptomania. The presence of chronic disorders. The original impulse control disorders date back to the 19th century and included alcoholism. such as cognitive disorders or mental retardation. Adjustment disorders are one of the most common psychiatric diagnoses for patients hospitalized for medical and surgical problems. Predominant features of this category include emotional disturbances and conduct disturbances in which there is violation of the rights of others or of major age-appropriate societal norms and rules. This subtype is used when the maladaptive reaction is not consistent with any of the other categories. Impairment in an individual’s usual social and occupational functioning 2. homicide.194 CHAPTER OUTLINE/LECTURE NOTES I. a. Historical and Epidemiological Factors A. although less pronounced than that of major depression. b. Psychosocial theories (1) Some proponents of psychoanalytic theory view adjustment disorder as a maladaptive response to stress that is caused by . Predisposing factors to adjustment disorders a. c. III. Compulsive acts that may be harmful to the person or others II. Application of the Nursing Process A. Introduction A. B. Biological theory. Historically. clients with symptoms identified by adjustment or impulse control disorders were classified as having personality disturbances. Adjustment Disorders: Background Assessment Data 1. C. firesetting. 2. e. Adjustment disorder with depressed mood. This category denotes a maladaptive response to a psychosocial stressor in which the predominant manifestation is anxiety. Adjustment disorder unspecified. This category (the most common) is one of predominant mood disturbance. Characterized by conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules. d. 3. Adjustment disorder with mixed disturbance of emotions and conduct. Behaviors may include: 1.
5. The way in which certain individuals respond to various types of stressors depends on the type of stressor. 2. the disorder is more common in first-degree biological relatives of people with the disorder than in the general population. Impulse Control Disorders: Background Assessment Data 1. Evaluation is based on accomplishment of previously established outcome criteria. B. available support systems. 4. or relief at the time of committing the act. the situational context in which the stressor occurs. Intermittent explosive disorder. 6.195 early childhood trauma. Nursing intervention for the client with adjustment disorder is aimed at assisting the individual to progress toward resolution of grief that has been generated in response to real or perceived losses. and retarded ego development. or temptation to perform some act that is harmful to the person or others. An increasing sense of tension or arousal before committing the act. (2) Other psychosocial theories relate a predisposition to adjustment disorder with lack of developmental maturity. and intrapersonal factors. Transactional model of stress/adaptation. increased dependency. (1) Predisposing factors to intermittent explosive disorder include: (a) Biological influences. b. The essential features of impulse control disorders include: a. or adequate coping strategies to adapt. the nurse assists the client to accept the change and make required lifestyle modifications in order to function as independently as possible. gratification. Failure to resist an impulse. (3) The disorder may also be related to a dysfunctional grieving process. Genetically. drive. Five categories of impulse control disorders are described: a. If the adjustment disorder is in response to a change in health status. The transactional model takes into consideration the interaction between the individual and his or her internal and external environment. c. Outcome criteria are identified for measuring the effectiveness of nursing care. Nursing diagnoses for the client with an adjustment disorder may include: (1) Complicated grieving (2) Risk-prone health behavior (3) Anxiety (moderate to severe) b. c. Discrete episodes of failure to resist aggressive impulses resulting in serious assaultive acts or destruction of property. An experience of pleasure. Diagnosis/outcome identification a. . b. Planning/implementation a.
a high family value placed on material and financial symbols. family. and budgeting. or vocational pursuits. abnormalities may be found in the serotonergic. disrupts. and gambling behavior that compromises. Brain disease and mental retardation are known on occasion to be associated with kleptomania. The behavior may be in response to some personal crisis. (b) Psychosocial influences. Physiologically.196 Physiologically. noradrenergic. The inability to resist the impulse to set fires. or desertion. or damages personal. Possible contributors include: loss of a parent before age 15 to death. and dopaminergic neurotransmitter systems. separation. inappropriate parental discipline. . as well as tendency toward hypoglycemia. have been implicated. c. any central nervous system insult may predispose to the general clinical syndrome. A chronic and progressive failure to resist impulses to gamble. and a lack of family emphasis on saving. exposure to gambling activities as an adolescent. Pathological gambling. (b) Psychosocial influences. (1) Predisposing factors to pathological gambling: (a) Biological influences. Psychoanalytical issues associated with impulsive firesetting include an association between firesetting and sexual gratification. Characterized by recurrent failure to resist impulses to steal items not needed for personal use or their monetary value. Kleptomania. Mild mental retardation and learning disabilities have been associated with firesetting. Physiologically. familial and twin studies show an increased prevalence of pathological gambling in family members of individuals diagnosed with the disorder. (b) Psychosocial influences. d. The psychoanalytical view suggests that a punitive superego fosters the gambler’s inherent need for punishment. b. Pyromania. such as a life-threatening diagnosis or the death of a loved one. (1) Predisposing factors to kleptomania: (a) Biological influences. divorce. Genetically. planning. Individuals with intermittent explosive disorder often have strong identification with assaultive parental figures. which is then achieved through losing. low CSF levels of 5-HIAA and MHPG. (b) Psychosocial influences. (1) Predisposing factors to pyromania: (a) Biological influences.
IV. To establish support systems that maximize adaptation 2. e. fear of abandonment. Nursing intervention for the client with impulse control disorder is aimed at protection of the client and others from harm associated with aggressive impulses and assaultive behavior. (1) Predisposing factors to trichotillomania: (a) Biological influences. To relieve symptoms associated with a stressor b. The etiology of impulse control disorders is most likely influenced by multiple factors. 4. Psychopharmacology . The recurrent pulling out of one’s own hair that results in noticeable hair loss. Other factors that have been considered include disturbances in mother-child relationships. Treatment Modalities A. 6. The nurse also assists the client to learn to delay gratification and to develop more adaptive strategies for coping with stress. Structural brain alterations. Family therapy c. and recent object loss. and poor social skills. Transactional model of stress adaptation. Nursing diagnoses for clients with impulse control disorders include: (1) Risk for other-directed violence (2) Ineffective coping 5. Commonly associated with OCD among first-degree relatives. Types of therapy a. Diagnosis/outcome identification a. Onset of the disorder can be related to stressful situations in more than 25 percent of the cases.197 a feeling of impotence and powerlessness. The major goals of therapy include: a. Evaluation is based on accomplishment of previously established outcome criteria. Self-help groups e. To enhance coping with stressors that cannot be reduced or removed c. Planning/implementation a. b. have also been noted. (b) Psychosocial influences. Individual psychotherapy b. Trichotillomania. as well as alterations in the serotonin and endogenous opioid systems. 3. Adjustment Disorders 1. Behavioral therapy d. Crisis intervention f.
Gamblers Anonymous 4. Cognitive therapy c. STGs: a. Psychopharmacology V. Psychopharmacology d. Encourage exploration of feelings (particularly anger) at the loss working toward progression of the grief process. Psychopharmacology e. 3. Alice will express feelings regarding loss of breast. Behavior therapy b. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. . b. Electroconvulsive therapy 3. c. Intermittent explosive disorder a. LTG: Alice will adjust to the loss of her breast and demonstrate acceptance of her new body image. Behavior therapy b. Trichotillomania a. Group/family therapy b. Psychoanalysis d. Kleptomania a. Impulse Control Disorders 1. Behavior therapy 5. Alice will talk to the Reach to Recovery representative.198 B. 2. Critical Thinking Exercise VII. Risk-prone health behavior related to loss of right breast. Psychopharmacology 2. Pyromania a. Behavior therapy c. Summary and Key Points VI. Individual psychotherapy c. Insight-oriented psychodynamic psychotherapy b. Pathological gambling a. Alice will be able to look at the scar.
10. Erikson. the student will be able to: 1. Medical treatment modalities are also discussed. Define personality. Identify various types of personality disorders. PERSONALITY DISORDERS CHAPTER FOCUS The focus of this chapter is on nursing care of clients with personality disorders. Compare stages of personality development according to Sullivan. Predisposing factors and symptomatology are explored. KEY TERMS histrionic narcissism object constancy passive-aggressive schizoid schizotypal splitting CORE CONCEPT personality . Describe appropriate nursing interventions for behaviors associated with borderline personality disorder and antisocial personality disorder. Evaluate nursing care of clients with borderline personality disorder and antisocial personality disorder. Formulate nursing diagnoses and goals of care for clients with borderline personality disorder and antisocial personality disorder. Discuss historical and epidemiological statistics related to various personality disorders. 5. 3. Identify predisposing factors for borderline personality disorder and antisocial personality disorder. and use these data in client assessment. Discuss various modalities relevant to treatment of personality disorders. 6. OBJECTIVES After reading this chapter. 4. Describe symptomatology associated with borderline personality disorder and antisocial personality disorder. and nursing care is presented in the context of the six steps of the nursing process. 2.199 CHAPTER 34. 9. 7. and Mahler. 8.
Borderline personality disorder c. with the recognition that an individual can behave irrationally even when the powers of intellect are intact. The disorder is more common in men than in women. were cause for their own special concern was in 1801. Types of Personality Disorders A. Clinical picture a. emotional. b. The first recognition that personality disorders. according to the type of behavior observed: 1. Cluster A: behaviors that are described as odd or eccentric a. apart from psychosis. Schizoid personality disorder c. Schizotypal personality disorder 2. beginning by early adulthood and present in a variety of contexts. 2. Personality disorders occur when these traits become inflexible and maladaptive and cause either significant functional impairment or subjective distress. B. Personality can be defined as the totality of emotional and behavioral characteristics that are particular to a specific person and that remain somewhat stable and predictable over time. B. Individuals with paranoid personality disorder are constantly on guard. A pattern of behavior. Cluster B: behaviors that are described as dramatic. Definition and epidemiological statistics a. Historical Aspects A. Narcissistic personality disorder 3. Personality traits are enduring patterns of perceiving. They trust no one and are constantly testing the honesty of others. Personality disorders have been categorized into three clusters. C. Antisocial personality disorder b. Cluster C: behaviors that are described as anxious or fearful a. of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Dependent personality disorder c. b. relating to. Paranoid Personality Disorder 1. Avoidant personality disorder b. Paranoid personality disorder b. Obsessive-compulsive personality disorder III. or erratic a. Introduction A.200 CHAPTER OUTLINE/LECTURE NOTES I. hypervigilant. These individuals are insensitive to the feelings of others but are themselves extremely oversensitive and tend to misinterpret even . II. Histrionic personality disorder d. and ready for any real or imagined threat.
and notably lacking in nurturing. D. Characterized primarily by a profound defect in the ability to form personal relationships or to respond to others in any meaningful. Schizoid Personality Disorder 1. In the presence of others. A graver form of the pathologically less severe schizoid personality pattern. or uneasy.201 minute cues within the environment. c. Schizotypal Personality Disorder 1. Predisposing factors a. illusions. bizarre speech. Antisocial Personality Disorder . hallucinations. and unable to experience pleasure. Possible genetic link b. Early family dynamics characterized by indifference. Definition and epidemiological statistics a. aloof. Individuals with schizoid personality disorder are indifferent to others. Prevalence within the general population has been estimated at between 3 and 7. b. Studies indicate that approximately 3 percent of the population has this disorder. c. Possible physiological influence. Predisposing factors a. Symptoms include magical thinking. They have no close friends and prefer to be alone. and withdrawal into the self. The affect of these individuals is commonly bland and constricted. anxious.5 percent. C. c. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. b. superstitiousness. ideas of reference. b. 2. Childhood has been characterized as bleak. 2. and diagnosis occurs more frequently in men. 3. Possible hereditary factor. emotional way. such as anatomic deficits or neurochemical dysfunctions within certain areas of the brain. magnifying and distorting them into thoughts of trickery and deception. Clinical picture a. or formality. Definition and epidemiological statistics a. They do not accept responsibility for their own behavior and maintain their self-esteem by attributing their shortcomings to others. detached. 3. unempathic. Predisposing factors a. cold. Clinical picture a. they appear shy. 3. leading to a pattern of discomfort with personal affection and closeness. Subject to early parental antagonism and aggression B. b. impassivity. depersonalization. Possible hereditary factor b. b. delusions.
Biogenetically determined temperament. Clinical picture and predisposing factors a. Individuals with histrionic personality disorder are selfdramatizing. have difficulty forming close relationships. Characterized by a pattern of intense and chaotic relationships. are strongly dependent. are easily influenced by others. Clinical picture . 2. More common in women than in men. Presented later in this outline. overly gregarious. Borderline Personality Disorder 1. 2. and guiltless behavior. seductive. to sustain consistent employment. range from 3 percent in men to about 1 percent in women. fluctuating and extreme attitudes regarding other people. E. with affective instability. b.S. directly and indirectly selfdestructive behavior. have difficulty paying attention to detail. b. Prevalence is thought to be about 2 to 3 percent. exploitative. 3. and to fail to develop stable relationships. 2. Prevalence estimates in the U. May be associated with increased noradrenergic activity and/or decreased serotonergic activity. and may complain of physical symptoms. attention-seeking. Definition and epidemiological statistics a. Definition and epidemiological statistics a. evident in the tendency to fail to conform to the law. b. Definition and epidemiological statistics a. Characterized by an exaggerated sense of self-worth. 2. d. Narcissistic Personality Disorder 1. These individuals have a consuming need for approval and feel dejected and anxious if they do not get it. Definition and epidemiological statistics a. manipulative. b. dramatic. b. to exploit and manipulate others for personal gain. b. and it is more common in women than in men. Heredity may be a factor. A pattern of socially irresponsible. The disorder is more common in men than in women. c. and lack of a clear sense of identity. c. Presented later in this outline. and extroverted behavior in excitable. to deceive. Histrionic Personality Disorder 1. G. F. emotional persons. Characterized by colorful. Learned behavior patterns. and exhibitionistic.202 1. Predisposing factors a. They are highly distractible. impulsivity. Prevalence estimates range from 1 to 2 percent of the population. Clinical picture and predisposing factors a. Clinical picture a. c.
. They are typically passive and acquiescent to the desires of others. Parental rejection and criticism. Predisposing factors a. H. and view others as critical. Dependent Personality Disorder 1. The individual may have unfulfilled dependency needs.203 a. These individuals may be perceived by others as timid. cheerful. 3. Definition and epidemiological statistics a. b. and more common in the youngest children of a family than the older ones. Avoidant Personality Disorder 1. Parents may have been narcissistic. voice. Possible hereditary influence. Individuals with narcissistic personality disorder are overly selfcentered and exploit others in an effort to fulfill their own desires. b. Characterized by extreme sensitivity to rejection and social withdrawal. I. but cannot help believing that such will result in pain and disillusionment. It is more common among women than men. Mood can easily change because of fragile self-esteem. and the child models the behavior. is usually optimistic. Mood. perfectionistic. They are often lonely. b. and placed unrealistic expectations on the child. c. which is often grounded in grandiosity. and humiliating. b. Clinical picture a. These individuals avoid positions of responsibility and become anxious when forced into them. Prevalence is between 0. and carefree. express feelings of being unwanted. 3. Definition and epidemiological statistics a. Clinical picture a. Individuals with avoidant personality disorder are awkward and uncomfortable in social situations. Predisposing factors a. They desire to have close relationships. and critical. b. 2. 2.5 percent and 1 percent. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. betraying. withdrawn. b. d. and mannerisms. and is equally common in men and women. Parents may have overindulged their child and failed to set limits on inappropriate behavior. c. b. or perhaps cold and strange. relaxed. The disorder is relatively common within the population. Individuals with dependent personality disorder have a notable lack of self-confidence that is often apparent in their posture. Parents may have been overly demanding.
procrastination. b. 2. irritable. Characterized by inflexibility about the way in which things must be done and a devotion to productivity at the exclusion of personal pleasure. These individuals tend to be complaining. and “forgetting. Possible hereditary influence. conflict. whining. J. Predisposing factors a. argumentative. but quite autocratic and condemnatory with subordinates. b. b. Predisposing factors a. and disgruntled. and hostility. with notable lack of positive reinforcement for acceptable behavior and frequent punishment for undesirable behavior. The disorder is relatively common and occurs more often in men than in women. No statistics are available. A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance in social and occupational situations. Passive-Aggressive Personality Disorder 1. Definition and epidemiological statistics a. these individuals appear to be very calm and controlled. critical. 2.” They can be very ingratiating with authority figures. it appears to be most common in oldest children. demands. and tend to be rigid and unbending about rules and procedures. obligations. Overcontrol by parents. On the surface. and a singular attachment is made by the infant to the exclusion of all others. Stimulation and nurturance are experienced exclusively from one source. Individuals with obsessive-compulsive personality disorder are especially concerned with matters of organization and efficiency. and responsibilities by such behaviors as dawdling. These individuals are very “rank conscious. but it appears to be a relatively common syndrome. 3. Clinical picture a. They have low self-worth and are easily hurt by criticism and disapproval. 3. discontented. while underneath this exterior lies a great deal of ambivalence. Social behavior tends to be polite and formal.” b. disillusioned. c. scornful. Obsessive-Compulsive Personality Disorder 1. Within the family constellation. Clinical picture a. . Definition and epidemiological statistics a. Individuals with passive-aggressive personality disorder are passively resistant to authority.204 c. d. b. K.
Predisposing factors (1) Biological influences (a) Biochemical. and serious parental psychopathology. Background assessment data a. A pervasive pattern of instability of interpersonal relationships. Double-bind communication. Predisposing factors a. 3. They do not acknowledge or express their anger directly. b. (2) Psychosocial influences (a) Childhood trauma. Designated as “borderline” because of the tendency of these clients to fall on the border between neuroses and psychoses. Borderline Personality Disorder 1. Contradictory parental attitudes and inconsistent training methods. c. The child fails to achieve the task of autonomy. the individual with borderline personality disorder becomes fixed in the rapprochement phase of development (16 to 24 months). Diagnosis/outcome intervention a. preferring instead to express it through resistant and negativistic behavior. Application of the Nursing Process A. IV. May have been reared in a family environment characterized by trauma. Possible defect in the serotonergic system. b. exposure to sexual and physical abuse. 2. neglect. Possible familial connection with depression. and marked impulsivity beginning by early adulthood and present in a variety of contexts. They are most strikingly identified by the intensity and instability of their affect and behavior. Nursing diagnoses for the client with borderline personality disorder may include: (1) Risk for self-mutilation (2) Risk for suicide (3) Risk for other-directed violence (4) Complicated grieving . (b) Genetic. and affects. and/or separation. Common behaviors include: (1) Chronic depression (2) Inability to be alone (3) Clinging and distancing behaviors (4) Splitting (5) Manipulation (6) Self-destructive behaviors (7) Impulsivity e.205 c. (b) According to Margaret Mahler’s Theory of Object Relations. selfimage. d.
Predisposing factors: (1) Possible genetic influence (2) Having a sociopathic or alcoholic father (3) Behavior disordered as a child (4) Parental deprivation during the first 5 years of life (5) Inconsistent parenting (6) History of severe physical abuse (7) Extreme poverty 2. Diagnosis/outcome identification a. Usually only seen in clinical settings when they are admitted by court order for psychological evaluation. Outcome criteria are identified for measuring the effectiveness of nursing care. 4. jails. Nursing diagnoses for the client with antisocial personality disorder may include: (1) Risk for other-directed violence (2) Defensive coping (3) Chronic low self-esteem . and rehabilitation services. Nursing intervention for the client with borderline personality disorder is aimed at protection of the client from self-harm. Planning/implementation a. Common behaviors include: (1) Exploitation and manipulation of others for personal gain (2) Belligerent and argumentative (3) Lacks remorse (4) Unable to delay gratification (5) Low tolerance for frustration (6) Inconsistent work or academic performance (7) Failure to conform to societal norms (8) Impulsive and reckless (9) Inability to function as a responsible parent (10) Inability to form lasting monogamous relationship e. Antisocial Personality Disorder 1. B. Sometimes called sociopathic or psychopathic behavior. Most frequently encountered in prisons. b.206 (5) Impaired social interaction (6) Disturbed personal identity (7) Anxiety (severe to panic) (8) Chronic low self-esteem b. The nurse also seeks to assist the client to advance in the development of personality by confronting his or her true source of internalized anger. d. c. Evaluation is based on accomplishment of previously established outcome criteria. b. 3. Background assessment data a.
Psychopharmacology VI. Milieu or Group Therapy D. that is.207 (4) Impaired social interaction (5) Ineffective health maintenance b. 2. Nursing intervention for the client with antisocial personality disorder is aimed at protection of others from the client’s aggression and hostility. Critical Thinking Exercise VIII. Planning/implementation a. Maintain consistency of care. Lana will undergo institutional procedures for overdose management with Desyrel (usually includes emesis or gastric lavage. 3. 4. Psychoanalytical Psychotherapy C. Summary and Key Points VII. V. Outcome criteria are identified for measuring the effectiveness of nursing care. The nurse also seeks to assist the client to delay gratification by setting limits on unacceptable behavior. Risk for suicide related to fears of abandonment. . activated charcoal. monitoring of vital signs. Dialectical Behavior Therapy F. Ensure that Lana is assigned various nurses to care for her (and not always the same one to which she may “cling”). This is Lana’s way of splitting. 3. Even though the nurse believes Lana’s declaration is untrue. and ECG). b. IV fluids. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. be sure that ALL nurses follow established limits and consequences with Lana and that Lana is not allowed to manipulate some nurses into violating the limits without consequences. Interpersonal Psychotherapy B. Cognitive/Behavioral Therapy E. Evaluation is based on accomplishment of previously established outcome criteria. Treatment Modalities for Clients with Personality Disorders A. she must proceed as though it is.
2. Describe the problem of elder abuse as it exists in today’s society. Discuss societal perspectives on aging. Apply the steps of the nursing process to the care of aging individuals. the student will be able to: 1. Explain personal and sociological perspectives of long-term care of the aging individual. and sexual aspects of the normal aging process. psychological. Discuss retirement as a special concern to the aging individual. 8. Various theories of aging and symptomatology associated with the normal aging process are presented. Describe an epidemiological profile of aging in the United States. 4. 6. Introduction A. 9. . Nursing care is described in the context of the six steps of the nursing process. OBJECTIVES After reading this chapter. Discuss various theories of aging. 5.208 CHAPTER 35. Sixty-six million “baby boomers” will reach their 65th birthdays by the year 2030. B. Growing old is not popular in the youth-oriented American culture. 7. placing more emphasis on the needs of an aging population. Special concerns of the elderly are discussed. sociocultural. Describe biological. THE AGING INDIVIDUAL CHAPTER FOCUS The focus of this chapter is on nursing care of the aging individual. 3. Discuss the implications of the increasing number of suicides among the elderly population. KEY TERMS attachment theory bereavement overload disengagement theory geriatrics gerontology geropsychiatry “granny-bashing” “granny-dumping” long-term memory Medicaid Medicare menopause osteoporosis reminiscence therapy short-term memory CHAPTER OUTLINE/LECTURE NOTES I.
III. Biological Aspects of Aging. B. Changes are observed in: 1. Developmental task theory 3. There were over four times as many widows as widowers. today is 75. 2. Americans 65 years of age or older numbered 39. Genetic theory 2. The average life expectancy for a child born in the U. or with relatives. In 2009.6 million. Health Status 1. The Normal Aging Process A. D. 72 percent of men and 42 percent of women 65 or older were married. C. F. Theories of Aging A.3 percent of the population.3 years for men and 80. By 2030. IV. physical health. with average life span around 18 years. based on variables such attitude. E. B. Emotional and mental illnesses also increase over the life cycle.S. In 2009. Economic Status. Neuroendocrine theory B. representing 12. Marital Status. Employment. Approximately 3. Living Arrangements. Immunity theory 5. Personality theory 2. C. Wear-and-tear theory 3. Continuity theory V.3 years for women. The number of days in which usual activities are restricted because of illness or injury increases with age. Environmental theory 4. or 19. Myths and stereotypes affect the way in which elderly people are treated in our culture. Biological Theories 1. this number is projected to be about 72. Whether one is considered “old” must be self-determined. The majority of individuals age 65 or older live alone. 6.209 II. Psychosocial Theories 1. Skin 2. 2. Epidemiological Statistics A. How Old is Old? A. with a spouse.1 million. Activity theory 5. Our prehistoric ancestors probably had a life span of 40 years.4 million persons age 65 or older were below the poverty level in 2009. In 2008. Disengagement theory 4. D. Cardiovascular system . Population 1. mental health.5 million Americans age 65 and older were in the labor force (working or actively seeking work). and degree of independence.9 percent of the population.
Endocrine system 7. Sexual Aspects of Aging 1. Immune system 9. Americans have grown up in a society that has liberated sexual expression for all other age groups. The elderly in virtually all cultures share some basic needs and interests: a. Cultural stereotypes play a large part in the misperception many people hold regarding sexuality of the aged. D. In some cultures. 2. Psychological Aspects of Aging 1. Loss and grief b. 3. Respiratory system 4. and African Americans. They choose to live the most satisfying life possible until their demise. Physical changes associated with sexuality . but still retains certain Victorian standards regarding sexual expression by the elderly. They want to die with the same respect and dignity. Nervous system 10. They want protection from hazards and release from the weariness of everyday tasks. Intellectual functioning 3. Adaptation to the tasks of aging a. Asian Americans. Memory functioning 2. such as Latino Americans. c. They want to be treated with the respect and dignity that is deserving of individuals who have reached this pinnacle in life. the aged are the most powerful. Sensory systems B. Psychiatric disorders in later life (1) Dementia (2) Delirium (3) Depression (4) Schizophrenia (5) Anxiety disorders (6) Personality disorders (7) Sleep disorders C. Attachment to others c. Gastrointestinal system 6. with the exception of several subcultures. Dealing with death e. d. and the most respected members of the society. Sociocultural Aspects of Aging 1. Learning ability 4. the most engaged. Genitourinary system 8. b. 2.210 3. This has not been the case in the United States. Musculoskeletal system 5. Maintenance of self-identity d.
Stress d. Persons 65 years of age and older represent a disproportionately high percentage of individuals who commit suicide. Factors that contribute to abuse: a. e. Economical implications B. Age. and the informal support network. Learned violence 4. Sixteen percent of all suicides are committed by members of this age group. and suicide is now a leading cause of death among the elderly. The 65+ population is often viewed as one of the important long-term care target groups. 3. Elderly individuals in general are opposed to the use of institutions.211 a. Mental health status. b. Elder Abuse 1. Long-Term Care 1. Sexual behavior in the elderly VI. Longer life b. The potential need for services are predicted by the following factors: a. Special Concerns of the Elderly A. The requirement for ongoing assistance from another person is a consideration. 2. Socioeconomic and demographic factors. Attitudinal factors. financial problems. 2. being Caucasian. Social implications 2.” C. 3. It has been estimated that 10 percent of individuals over age 65 are the victims of abuse or neglect. Changes in men 4. Risk factors for institutionalization. physical illness. Dependency c. Changes in women b. Many view them as “places to go to die. Marital status. and/or depression. Health. Lower socioeconomic status. loss. Retirement 1. . c. Suicide 1. and being female are considered risk factors for long-term care. 2. living arrangement. Identifying elder abuse D. The group at highest risk appears to be white men experiencing loneliness. The abuser is often a relative who lives with the elderly person and may be the assigned caregiver. Living alone without resources for home care and few or no relatives living nearby to provide informal care are factors of high risk for institutionalization. d. Symptoms that would render the individual incapable of meeting the demands of daily living independently place him or her at risk.
2. Assessment. Assessment of the elderly must consider the possible biological. Social isolation k. Risk for aspiration f. sociocultural. Risk for trauma (elder abuse) l. Fear g. Nursing diagnoses that relate to physiological changes in the aging individual may include any or all of the following: a. Complicated grieving c. Self-care deficit o. Disturbed sensory-perception l. Ineffective breathing pattern e. Low self-esteem f. C. Decreased cardiac output d. Imbalanced nutrition. Powerlessness e. Application of the Nursing Process A. Planning/Implementation 1. Risk for suicide d. psychological. Chronic pain n. B. and sexual changes that occur in the normal aging process. Outcome criteria are identified for measuring the effectiveness of nursing care. less than body requirements h. Insomnia m. Sexual dysfunction j. Disturbed thought processes b. . Urinary retention k. Nursing care of the aging individual is aimed at protection from injury due to age-related physical changes or altered thought processes related to cerebral changes. Risk for trauma b. Risk for impaired skin integrity 2. Impaired physical ability g. Disturbed body image h. Stress urinary incontinence j. Hypothermia c. Caregiver role strain 3. Psychosocially related nursing diagnoses that may be a consideration include: a. Diagnosis/Outcome Identification 1. The nurse is also concerned with preservation of dignity and selfesteem in an individual who may have come to be dependent on others for his or her survival. Ineffective sexuality pattern i. Constipation i.212 VII. Age alone does not preclude that these changes have occurred. and each client must be assessed as a unique individual.
Assistance is provided with self-care deficits while encouraging independence to the best of his or her ability. M. Summary and Key Points IX. D. will eat sufficient food to begin gaining weight. Review Questions ANSWERS TO CRITICAL THINKING EXERCISE 1. a. Critical Thinking Exercise X. Reminiscence therapy is encouraged. Her loss of independence. M. Based on accomplishment of previously established outcome criteria. VIII. Complicated grieving related to loss of husband/home/independence. b. Mrs. Evaluation 1. 3.213 3. Mrs. . will begin progression through the grief process by discussing her feelings about her losses. 4. 2.
OBJECTIVES After reading this chapter.214 CHAPTER 36. 3. . Discuss various modalities relevant to treatment of victims of abuse. and sexual assault. and sexual assault. 5. Identify predisposing factors to abusive behaviors. More injuries are attributed to intimate partner violence than to all rapes. An increase in the incidence of child abuse and related fatalities has been documented. and nursing care is presented in the context of the six steps of the nursing process. Introduction A. Identify nursing diagnoses. 4. Discuss characteristics of victims and victimizers. child abuse. child abuse. KEY TERMS child sexual abuse compounded rape reaction controlled response pattern cycle of battering date (acquaintance) rape emotional abuse emotional neglect expressed response pattern marital rape physical neglect safe house or shelter sexual exploitation of a child silent rape reaction statutory rape CORE CONCEPTS abuse battering incest neglect rape CHAPTER OUTLINE/LECTURE NOTES I. and automobile accidents combined. 2. Evaluate nursing care of victims of intimate partner abuse. Various treatment modalities are also discussed. 7. 6. Describe physical and psychological effects on the victims of intimate partner abuse. B. Abuse is the maltreatment of one person by another. and sexual assault. muggings. and sexual assault. child abuse. goals of care. the student will be able to: 1. Predisposing factors and symptomatology are explored. VICTIMS OF ABUSE OR NEGLECT CHAPTER FOCUS The focus of this chapter is on nursing care of clients who are victims of abuse or neglect. Describe epidemiological statistics associated with intimate partner abuse. C. child abuse. and appropriate nursing interventions for care of victims of intimate partner abuse.
brain tumors. Abuse affects all races. Children learn to behave by imitating their role models. Genetic influences. Biochemical influences. Psychodynamic theory. They may be without adequate support systems. B. Psychological Theories 1. 2. Aggressive behavior is primarily a product of one’s culture and social structure. Battering may be defined as a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner. Predisposing Factors A. and the amygdaloid nucleus. Battered women represent all age. Profile of the victim. and educational backgrounds. Many grew up in abusive homes. pathologically jealous. Intimate Partner Abuse 1. Aggressive and violent behavior has been correlated with organic brain syndromes. Biological Theories 1. The spouse is viewed as a personal possession. Societal influences also contribute to violence when individuals realize that their needs and desires are not being met relative to other people. 2. Learning theory. Disorders of the brain. and dopamine. 3. Aggression and violence supply the individual with a dose of power and prestige that increases self-esteem. C. presenting a “dual personality. Unmet needs for satisfaction and security result in an underdeveloped ego and a poor self-concept. E. Individuals who were abused as children or whose parents disciplined with physical punishment are more likely to behave in an abusive manner as adults. religions. They often have low self-esteem. Rape is thought to be vastly underreported. racial.215 D. educational. A possible hereditary factor may be involved. 2. Approximately 83 percent of the victims are women. Areas of the brain that have been implicated in both the facilitation and inhibition of aggressive impulses include the temporal lobe. Sociocultural Theories 1. encephalitis. 2. religious. II. the limbic system. economic classes. 3. brain trauma. Neurophysiological influences.” exhibiting limited coping ability and severe stress reactions. Societal influences. III. cultural. 4. Profile of the victimizer. and temporal lobe epilepsy. . serotonin. ages. Application of the Nursing Process: Background Assessment Data A. have been implicated in the regulation of aggressive impulses. and socioeconomic groups. Certain neurotransmitters. Men who batter usually are characterized as persons with low self-esteem. The American culture was founded on a general acceptance of violence as a means of solving problems. The genetic karyotype XYY has also been implicated. including norepinephrine.
” a. or incest with children. statutory rape. 2. The Calm. and in cases of caretaker or interfamilial relationships. Sexual abuse of a child. The occurrence of sexual contacts or interaction between. maladaptive coping strategies. abandonment.. such as numerous stresses. lack of understanding of child development. b. Indicators of sexual abuse 5. Other reasons given include fear of retaliation. molestation. lack of support systems. or sexual exploitation of. any sexually explicit conduct or any simulation of such conduct for the purpose of producing any visual depiction of such conduct. or other form of sexual exploitation of children. Three distinct phases: a. Phase II.216 4. stepsiblings). Characteristics of the abuser a. Emotional abuse. Physical abuse. B. Indicators of neglect. Loving. use. . or assist any other person to engage in. enticement. A pattern of behavior on the part of the parent or caretaker that results in serious impairment of the child’s social. The Acute Battering Incident c. Child Abuse 1. or coercion of any child to engage in. b. Respite (“Honeymoon”) Phase 5. Physical and behavioral indicators. Physical neglect refers to the parent’s or caregiver’s refusal of or delay in seeking health care. or between participants who are related to each other by a kinship bond that is regarded as a prohibition to sexual relations (e. healthy personality. The cycle of battering. b. 4. inducement. a lack of support network. Any nonaccidental physical injury caused by the parent or caregiver. Defined as: “Employment. 3. and support necessary for the development of a sound. caretakers. and hope that the relationship will improve. Phase III. stepparents. expulsion from the home or refusal to allow a runaway to return home. Why does she stay? The most frequent response to this question is that they fear for their life or the lives of their children. a. Emotional neglect refers to a chronic failure by the parent or caretaker to provide the child with the hope. Incest. and inadequate supervision.g. a. Neglect. or intellectual functioning. Phase I. persuasion. Parents who abuse their children were likely abused as children themselves. Other influences have been identified. for financial reasons. emotional. religious reasons. prostitution. c. love. or the rape. close relatives. a. fear of losing her children. Behavioral indicators. The Tension-Building Phase b. and unrealistic expectations of the child.
Many rapists report growing up in abusive homes. impulsive. c. d. The victim a. The mother of the rapist has been described as “seductive but rejecting” toward her child. Acquaintance rape. Sexual Assault 1. 3. Applied to sexual assault in which the rapist is acquainted with the victim. and physically abusing. Most victims are single women. 2. but simply because they happened to be in that place at that particular time. Profile of the victimizer a. Mother is commonly passive. b. . and denigrates her role of wife and mother. Rape is an act of aggression. c. The adult survivor of incest (1) Common characteristics: (a) A fundamental lack of trust that arises out of an unsatisfactory parent-child relationship (b) Low self-esteem and a poor sense of identity (c) Absence of pleasure with sexual activity (d) Promiscuity C. When the attack is a “stranger rape” victims are not chosen for any reason having to do with their appearance or behavior. although men may also be rape victims. b. Father is often domineering. Marital rape. and the attack often occurs near their own neighborhood. d. a. Often there is an impaired spousal relationship. Her dominance over her son often continues into his adult life. but is quick to withdraw her “love” and attention when he goes against her wishes. the rapist’s anger is directed toward the mother for not providing adequate protection from the father’s abuse. b. The incestuous relationship a. b. She is often aware of (or at least suspects) the incestuous relationship. Sexual violence directed at a marital partner against that person’s will. Even when the abuse was discharged by the father. Unlawful intercourse between a person who is over the age of consent and a person who is under the age of consent. with seductive undertones. most commonly by men over women. but uses denial or keeps quiet out of fear of being abused by her husband.217 6. Term applied to sexual assault that takes place during a social engagement that has been agreed to by the victim. submissive. It is the expression of power and dominance by means of sexual violence. Statutory rape. Rape can occur at any age. Date rape. not passion. She is overbearing. c. The highest risk group appears to be between 16 and 24 years.
smiling. Reporting to authorities when there is “reason to suspect” child abuse or neglect VI. Other nursing concerns include: 1. Outcome criteria are identified for measuring the effectiveness of nursing care. Planning/Implementation A. Treatment Modalities A. Rape-trauma syndrome 2. and even psychotic behaviors may be noted in the victim. e. Nursing intervention for the victim of abuse or neglect is to provide shelter and promote reassurance of his or her safety. IV. substance abuse. Anxiety is suppressed and the emotional burden may become overwhelming. Promoting trust 5. (3) Compounded rape reaction—additional symptoms such as depression and suicide. restlessness. composed. and a calm. Evaluation is based on accomplishment of previously established outcome criteria. (4) Silent rape reaction—the victim tells no one about the assault. B. VII. Assisting the client to recognize options 4.218 d. (2) Controlled response pattern—feelings of the victim are masked or hidden. or subdued affect is seen. Nursing diagnoses for the client who has been abused may include: 1. and tension. Critical Thinking Exercise X. Safe House or Shelter C. Risk for delayed development B. Crisis Intervention B. Staying with the client to provide security 3. sobbing. Family Therapy VIII. anger. Tending to physical injuries 2. Powerlessness 3. Summary and Key Points IX. The presence of a weapon (real or perceived) appears to be the principal measure of the degree to which a woman resists her attacker. V. and anxiety through such behaviors as crying. Review Questions . Victim responses: (1) Expressed response pattern—the victim expresses feelings of fear. Diagnoses/Outcome Identification A.
and it is her decision to choose one of the alternatives or return to her current living situation. The nurse must help Lisa understand that alternatives to her current situation do exist.” 2. . she will be supported in her decision. Powerlessness related to cycle of battering. 3. Either way. “He doesn’t act this way because of anything you do.219 ANSWERS TO CRITICAL THINKING EXERCISE 1.
Emphasis is given to individuals with severe and persistent mental illness and homeless individuals with mental illness. COMMUNITY MENTAL HEALTH NURSING CHAPTER FOCUS The focus of this chapter is on nursing care of psychiatric clients in the community setting. Discuss nursing intervention in primary prevention of mental illness within the community. secondary. Discuss secondary prevention of mental illness within the community. Discuss tertiary prevention of mental illness within the community as it relates to the seriously mentally ill and homeless mentally ill.220 CHAPTER 37. Identify treatment alternatives for care of the seriously mentally ill and homeless mentally ill within the community. 13. 7. Discuss primary prevention of mental illness within the community. Relate historical and epidemiological factors associated with caring for the seriously mentally ill and homeless mentally ill within the community. 8. OBJECTIVES After reading this chapter. Discuss the changing focus of care in the field of mental health. Identify populations at risk for mental illness within the community. 5. KEY TERMS case management case manager deinstitutionalization diagnostically related groups (DRGs) managed care mobile outreach units prospective payment CORE CONCEPTS community primary prevention secondary prevention tertiary prevention . Apply steps of the nursing process to care of the seriously mentally ill and homeless mentally ill within the community. 2. and tertiary prevention. Describe treatment alternatives related to secondary prevention within the community. 10. Define the concepts of care associated with the public health model. 6. using the framework of the model of public health: primary. Differentiate between the roles of basic level and advanced practice psychiatric/mental health registered nurses. 3. 9. the student will be able to: 1. 11. 4. Nursing care is presented in the context of the six steps of the nursing process. Define the concept of case management and identify the role of case management in community mental health nursing. 12.
started a campaign that resulted in the establishment of a number of hospitals for persons with mental illness. there was no known treatment for individuals who were mentally ill.221 shelters storefront clinics CHAPTER OUTLINE/LECTURE NOTES I. Tertiary Prevention 1. The mentally ill population grew faster than the number of hospitals. E. In 1841. F. The Changing Focus of Care A. the Community Mental Health Centers Act was passed. I. Accomplished through early identification of problems and prompt initiation of effective treatment. federal funding was reduced. Outpatient services have become an essential part of the mental health-care system. G. H. In 1963. They were removed from the community to a place where they could do no harm to themselves or others. Nursing in primary prevention is focused on targeting groups at risk and the provision of educational programs. Primary Prevention 1. Reducing the residual defects that are associated with severe and persistent mental illness. Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness. Deinstitutionalization (the closing of state mental hospitals and discharging of individuals with mental illness) had begun. Dorothea Dix. a number of constitutional acts were passed. 2. B. creating overcrowding and poor conditions. II. In the 1940s and 1950s. D. when hospital stays were longer. C. B. C. . drastically affecting the amount of reimbursement for health-care services. a former schoolteacher. Secondary Prevention 1. Clients are being discharged from the hospital with a greater need for aftercare than in the past. and the number of community health centers was diminished. Primary prevention is defined as reducing the incidence of mental disorders within the population. 2. Cost containment by prospective payment was initiated in 1983. The Public Health Model A. It called for the construction of community health centers. attempting to improve the quality of care for individuals with mental illness. Before 1840. However.
Case management is the method used to achieve managed care. Populations at risk a. To identify stressful life events that precipitate crises and target the relevant populations at risk.g. administrator. III. Individuals experiencing maturational crises: (1) Adolescence (2) Marriage (3) Parenthood (4) Midlife (5) Retirement b. Case Management A. supervisor. 2. The case manager is responsible for negotiating with multiple health-care providers to obtain a variety of services for the client. In addition to functions of basic RN. clients with severe and persistent mental illness).) C. May be credentialed by ANCC 2. Nurses who work in psychiatry may work at one of two levels: 1. A way of coordinating health-care services required to meet the needs of the client. Basic RN education b. Individuals experiencing situational crises: .. educator. may serve as consultant. May hold prescriptive authority. Nurses are particularly suited to provide case management for clients with multiple health problems that have a health-related component. Case management is especially beneficial for individuals who require longterm care (e. or researcher. 3. (HMOs and PPOs are examples of managed care. D. B. E. IV. Graduate degree in psychiatric/mental health nursing b.222 2. May be board certified by ANCC as clinical nurse specialist or nurse practitioner d. Demonstrates broad depth and breadth of knowledge and skills related to care of clients with mental health issues and psychiatric disorders c. The Community as Client A. Primary Prevention 1. Managed care is a concept designed to control the balance between cost and quality of care. To intervene with these high-risk populations to prevent or minimize harmful consequences. The psychiatric/mental health advanced practice registered nurse a. V. Accomplished by preventing complications of the illness and promoting achievement of each individual’s maximum level of functioning. The psychiatric/mental health registered nurse a. The Role of the Nurse A. Demonstrates competence in caring for persons with mental health problems c.
posttraumatic stress disorder. autism spectrum disorders. and attention deficit/hyperactivity disorder. (b) Mental health care will be consumer and family driven. Types of illnesses include schizophrenia and related disorders. Individuals with severe and persistent mental illness a. panic disorder and obsessive-compulsive disorder. (c) Disparities in mental health services will be eliminated. Individuals experiencing situational crises: (1) Nursing care at the secondary level of prevention with clients undergoing situational crises occurs only if crisis intervention at the primary level failed and the individual is unable to function socially or occupationally.000 persons with mental illness inhabit public mental hospitals. Populations at risk a. and referral to services will be common practice. (3) The President’s New Freedom Commission on Mental Health has outlined the following goals for mental health reform: (a) Americans will understand that mental health is essential to overall health. Tertiary Prevention 1.223 (1) Poverty (2) High rate of life change events (3) Environmental conditions (4) Trauma B. c. Historical and epidemiological aspects (1) Approximately 100. assessment. b. Early detection and prompt intervention with individuals experiencing mental illness symptoms 2. (2) Deinstitutionalization occurred so rapidly that there was not sufficient time for planning for the needs of these individuals before they reentered the community. borderline personality disorder. and major depressive disorder. Secondary Prevention 1. (d) Early mental health screening. bipolar disorder. (e) Excellent mental health care will be delivered and research will be accelerated. Treatment alternatives (1) Community mental health centers . (f) Technology will be used to access mental health care and information. Individuals experiencing maturational crises: (1) Adolescence (2) Marriage (3) Parenthood (4) Midlife (5) Retirement b. C.
25 percent are between 25 and 34. 45 percent African American. Who are the homeless? (1) Age. 37 percent Caucasian. 6 percent are ages 55 to 64. Community resources for the homeless (1) Interfering factors (a) Residential instability (2) Health issues (a) Alcoholism is common (b) Thermoregulation (c) Tuberculosis (d) Dietary deficiencies (e) Sexually transmitted diseases (f) Special health needs of homeless children (3) Types of resources available (a) Homeless shelters . (3) Families.224 (2) Program of assertive community treatment (PACT) (3) Day-evening treatment/partial hospitalization programs (4) Community residential facilities (5) Psychiatric home health care 2. Families comprise 23 percent of the homeless population. c. 3 percent Native American. (2) Types of mental illness among the homeless: (a) Most common: schizophrenia (b) Bipolar disorder (c) Substance abuse and dependence (d) Depression (e) Personality disorders (f) Organic mental disorders (3) Contributing factors to homelessness among the mentally ill: (a) Deinstitutionalization (b) Poverty (c) A scarcity of affordable housing (d) Lack of affordable health care (e) Domestic violence (f) Addiction disorders d. Mental illness and homelessness (1) It is thought that approximately 26 percent of the homeless population suffers from some form of mental illness. 39 percent are under 18. Historical and epidemiological aspects (1) The number of homeless in the U. More men than women are homeless. 13 percent Hispanic. (4) Ethnicity. 2 percent Asian. (2) Gender. The homeless population a. has been estimated at somewhere between 250.000 and 4 million.S. b.
The homeless client and the nursing process: A case study (1) Assessment (2) Diagnosis/outcome identification (3) Plan/implementation (4) Evaluation VI. Summary and Key Points VII. Review Questions .225 (b) Health-care centers and store-front clinics (c) Mobile outreach units e.
II. The International Association of Forensic Nurses (IAFN) and the American Nurses Association (ANA) define forensic nursing as follows: 1. Forensic is defined as “pertaining to the law.226 CHAPTER 38. The first forensic nurses served in Canada around 1975 as medical examiners’ investigators in the field of death investigation. 3. III. FORENSIC NURSING CHAPTER FOCUS The focus of this chapter is on defining forensic nursing within varied aspects of the role. A discussion of historical perspectives is included. Identify areas of nursing within which forensic nurses may practice. Introduction A. KEY TERMS colposcope forensic nursing sexual assault nurse examiner (SANE) CORE CONCEPT forensic CHAPTER OUTLINE/LECTURE NOTES I. What Is Forensic Nursing? A. 5. The practice of nursing globally when health and legal systems intersect. Define the terms forensic and forensic nursing. Discuss historical perspectives of forensic nursing. Historical Perspectives A. . 6. and care of the client is presented within the context of the nursing process. B. OBJECTIVES After reading this chapter the student will be able to: 1. Describe forensic nursing specialties. Forensic nursing is an example of a nursing role that is rapidly increasing in its scope of practice. legal. 2.” B. The many roles of nurses continue to increase with the ever-expanding health service delivery system. Apply the nursing process within the role of forensic psychiatric nursing in correctional facilities. 4. Apply the nursing process within the role of clinical forensic nursing in trauma care.
Physical and psychosocial examination of victims b. Assessment of victims c. Help perpetrators and victims of crime deal with the criminal justice system e. criminal responsibility. Mass disasters 4. and the community b. Clinical forensic nursing is the management of crime victims from trauma to trial. Collection of evidence b. Testifies as expert legal witness d. With forensic nursing. a. the health-care system and the legal system have joined in an attempt to respond to the increasing needs of crime victims. Death investigation 3. Assessment of inmates for fitness. Registered nurses who integrate psychiatric/mental health nursing philosophy and practice with knowledge of the criminal justice system. The Sexual Assault Nurse Examiner (SANE) 1. Provide mental health treatment for convicted offenders and those who are not found criminally responsible D. Registered nurse who critically evaluates and analyzes health-care issues in medically related lawsuits. The Context of Forensic Nursing Practice A. a. a. Investigation of death that occurs in the clinical setting B. Assessment of sociocultural influences on the individual clients. . Clinical Forensic Nursing 1. C. May offer opinion as to whether a crime occurred C. Work with victims of crime to cope with their emotional wounds d. Forensic mental health 5. A clinical forensic registered nurse who has received specialized training to provide care to the sexual assault victim. The role of forensic nursing has expanded from concerns solely with death investigation to include the living—the survivors of violent crime—as well as the perpetrators of criminal acts. Areas within which a forensic nurse may intervene: 1. IV. Collection and documentation of physical evidence c. Interpersonal violence 2. and early release f. Work with mentally ill offenders in their assessment and care. Correctional nursing 6. Legal Nurse Consultant 1.227 B. Forensic Nursing Specialties A. Emergency/trauma services V. Legal nurse consulting 7. Public health and safety 8. Forensic Psychiatric Nursing 1. disposition. to identify and change behaviors that link criminal offenses to them c. their families.
Application of the Nursing Process in Clinical Forensic Nursing in Trauma Care A. Registered nurse with specialized education who can accurately determine the cause of death. E. Combine medical expertise with legal knowledge to assess compliance with accepted standards of healthcare practice. hairs. glass. Nurse death investigators work with forensic pathologists to collect additional evidence in the lab during autopsy. Nurses in General Practice 1. Defense wounds g. Documentation of the appearance. E. Blunt-force injuries c. May include: a. Preservation of Evidence 1. Assessment 1. 3.228 2. Patterned injuries e. In the emergency department. Crime-related evidence must be safeguarded in a manner consistent with the investigation. and wood C. bullets. and small pieces of material such as fragments of metal. Bite mark injuries f. condition. and behavior of the victim upon arrival at the hospital is critical. and death investigation. Investigation of Wound Characteristics 1. a. Impaired tissue integrity . Deaths in the Emergency Department 1. Forensic Nurse Death Investigator 1. Clothing. Nursing Diagnosis 1. blood stains. The nurse should be able to identify types of undiagnosed trauma injuries and possible weapon involved: a. Victims of sexual assault. documentation of care. 2. 2. B. accidental trauma. gunshot powder on the skin. Forensic applications in the acute care setting. Fast-force injuries D. paint. Assessment. Respond to scenes of deaths or accidents and work in collaboration with law enforcement. particularly in emergency rooms and in critical care units. abuse and neglect. grass. fibers. 2. Sharp injuries b. F. and reporting of information to police or other law enforcement agencies b. All traumatic injuries in which liability is suspected are considered within the scope of forensic nursing. Hesitation wounds h. Dicing injuries d. a determination must be made if the cause of death was natural or unnatural. Collection and preservation of evidence VI.
Medical stabilization b. Preservation of evidence a. Evaluation Application of the Nursing Process in Forensic Psychiatric Nursing in Correctional Facilities A.229 2. . 1. Risk for suicide 7. Overcrowding and violence b. Risk for self-mutilation 6. Deaths in the emergency department a. Risk for complicated grieving F. Preservation of evidence b. Common behaviors observed among the mentally ill incarcerated: (1) Hallucinations (2) Suspiciousness (3) Thought disorders (4) Anger/agitation (5) Impulsivity (6) Denial of problems c. Special concerns a. Assessment. Risk for posttrauma syndrome 3. Anatomical gifts G. Detoxification frequently occurs in jails and prisons 2. Careful preservation of clothing d. SANE may be called in the event of a sexual assault (1) Treatment and documentation of injuries (2) Maintaining the proper chain of evidence (3) Treatment and evaluation of sexually transmitted diseases (4) Pregnancy risk evaluation and prevention (5) Crisis intervention and arrangement for follow-up counseling 2. Protection of the body c. Examination of wounds c. Planning/Implementation 1. Psychiatric diagnoses commonly identified at the time of incarceration: (1) Schizophrenia (2) Bipolar disorder (3) Major depression (4) Personality disorders (5) Substance disorders (6) Dual diagnoses b. Care of the mentally ill offender population is a highly specialized area of nursing practice. Sexual assault VII. Anxiety 5. Fear 4. Assessing mental health needs of the incarcerated a.
HIV infection in the prison population d. Risk for self-directed or other-directed violence 9. Ineffective coping 10. Review Questions . Orientation (introductory) phase (1) The nurse works to establish trust with the client (2) Set limits on manipulative behavior (3) Touch and self-disclosure most commonly unacceptable with the prisoner population c. Nursing Diagnosis 1. Low self-esteem 7.230 c. Rape-trauma syndrome C. Working phase (1) Promoting behavioral change is the primary goal of the working phase (2) Counseling and supportive psychotherapy (3) Crisis intervention (4) Education (a) Health teaching (b) HIV/AIDS education (c) Stress management (d) Substance abuse d. Preinteraction phase (1) The nurse must examine his or her feelings. and anxieties about working with prisoners—violent offenders—perhaps murderers. Risk for self-mutilation 8. fears. Complicated grieving 3. Risk for infection 11. or pedophiles b. rapists. Development of a therapeutic relationship a. nurses may institute assistance for transition to the community setting D. Disturbed thought processes 5. Planning/Implementation 1. Critical Thinking Exercise X. Powerlessness 6. Female offenders B. Anxiety/fear 4. Summary and Key Points IX. Defensive coping 2. Termination phase (1) Closure is difficult in a setting where prisoners may be transferred from one institution to another on short notice (2) When possible. Evaluation VIII.
fibers. hair. Careful documentation.231 ANSWERS TO CRITICAL THINKING EXERCISE 1. clothing. Prophylactic regimen for possible pregnancy. First: Take care of life-threatening injuries (medical stabilization). Lock up evidence or keep under personal observation. Prophylaxis with Hepatitis B immunoglobulin. Second: Protect physical evidence: blood. semen. 2. Prophylactic antibiotics for sexually transmitted diseases (STDs). Risk for posttrauma syndrome. 3. . Take photographs or written descriptions of wounds.
and J. 7. George Engel. 6. 9. 2. Identify relevant criteria for evaluating nursing care of individuals experiencing the grief response. the student will be able to: 1. 8. Describe appropriate nursing interventions for individuals experiencing the grief response. John Bowlby. THE BEREAVED INDIVIDUAL CHAPTER FOCUS The focus of this chapter is on the care of the individual grieving in response to a loss. Describe various types of loss that trigger the grief response in individuals. KEY TERMS advance directive anticipatory grieving bereavement overload delayed grief hospice luto mourning shiva velorio CORE CONCEPTS grief loss . Describe the concept of hospice care for people who are dying and their families. Discuss the use of advance directives for individuals to provide directions about their future medical care. Formulate nursing diagnoses and goals of care for individuals experiencing the grief response. Discuss theoretical perspectives of grieving as proposed by Elisabeth KüblerRoss. 3. Various theoretical perspectives are presented. Discuss grieving behaviors common to individuals at various stages across the life span. 10. 5. Grieving behaviors associated with various cultures and developmental ages are discussed. William Worden. Differentiate between normal and maladaptive responses to loss 4.232 CHAPTER 39. Describe customs associated with grief in individuals of various cultures. Nursing care is presented in the context of the six steps of the nursing process. OBJECTIVES After reading this chapter.
Processing the pain of grief c. Bargaining d. George Engel a. Recovery 4. Task IV. Denial b. Stage II. Task II. Introduction A. A very individual process. Illness or debilitating conditions 3. Reorganization 3. Depression e. Stage I. Stage III. Stage V. The relationship with the lost entity was highly ambivalent. B.233 CHAPTER OUTLINE/LECTURE NOTES I. Stage III. Elisabeth Kubler-Ross a. Stage IV. Accepting the reality of the loss b. Shock and disbelief b. A significant other 2. Stage I. The bereaved person was strongly dependent on the lost concept. The grief response can be more difficult if: 1. Resolution of the loss e. . C. A decrease in self-esteem 5. Loss is the experience of separation from something of personal importance. D. II. Numbness or protest b. Acceptance 2. Adjusting to a world without the lost entity d. Different for every individual. Stages of Grief 1. Stage V. William Worden a. Resolution is thought to occur when a bereaved individual is able to remember comfortably and realistically both the pleasures and disappointments of that which has been lost. Stage II. Developmental/maturational changes or situations 4. Personal possessions that symbolize familiarity and security in a person’s life Theoretical Perspectives on Loss and Bereavement A. Anger c. 2. B. Stage I. Finding an enduring connection with the lost entity in the midst of embarking on a new life Length of the Grief Process A. Restitution d. Developing awareness c. John Bowlby a. J. Disorganization and despair d. III. Task I. Stage IV. Stage III. Stage IV. Acute phase usually lasts 6 to 8 weeks—longer in older adults. Stage II. Disequilibrium c. Task III. Examples: 1.
The loss is that of a young person. 2. 4. All of the symptoms associated with normal grieving are exaggerated. Children a. V. C. Chronic or Prolonged Grieving. in the maladaptive response. 5. The individual has the support of significant others to assist him or her through the mourning process. The grief response may be facilitated if: 1. The individual has the opportunity to prepare for the loss (anticipatory grieving). may believe they are capable of causing someone to die. Anticipatory Grief A. 2. there is a feeling of worthlessness or low self-esteem that is absent in normal grieving. Considered maladaptive when: 1. Believe death is reversible. B. Distorted (Exaggerated) Grief Response 1.234 3. Individual remains fixed in anger stage of grief process. 2. Application of the Nursing Process A. Anticipatory grieving may be positive for some people and less functional for others. C. 3. B. Depressed mood disorder is a type of exaggerated grief reaction. concerned with IV. Background Assessment Data: Concepts of Death—Developmental Issues 1. . 6. Delayed or Inhibited Grief. VI. It is thought that the major difference between normal grieving and a maladaptive grieving response is that. but can experience the feelings of loss and separation. and detachment from the dying person occurs prematurely. The individual has experienced a number of recent losses. The bereaved person perceives some responsibility for the loss. Difficulty arises when family members complete the process of anticipatory grief. D. Grief behaviors are aimed at keeping the lost loved one alive (as though he or she will eventually reenter the life of the bereaved). Disabling behaviors are in evidence that prevent the bereaved from adaptively performing activities of daily living. May react to emotions of grieving adults by becoming more irritable and crying more. The experiencing of the feelings and emotions associated with the normal grief response before the loss actually occurs. Normal versus Maladaptive Grieving 1. Birth to age 2. Maladaptive Responses to Loss A. The absence of evidence of grief when it ordinarily would be expected. The state of the person’s physical or psychological health is unstable at the time of the loss. b. Ages 3 to 5. E. Unable to recognize and understand death.
Elderly adults a. d. Influenced by cultural and religious backgrounds b. Adolescents a. Japanese Americans (1) Predominant religion: Buddhism (2) Funeral ceremonies are held at the Buddhist temple. May withdraw or deny the pain of the loss c. including their own. Asian Americans a. Some blending of cultural practices from the African heritage (e. avoid references to it (3) Do not express emotions openly b. The cumulative grief can lead to bereavement overload c. Adults a. Able to understand the finality of death. Usually able to view death on an adult level b. Background Assessment Data: Concepts of Death—Cultural Issues 1. 2. Behaviors previously discussed in “Theoretical Perspectives” 4. Vietnamese Americans (1) Predominant religion: Buddhism . Similar customs to American cultures of same religion and social class b. difficult to perceive their own death.. Ages 10 to 12.235 safety issues for themselves and loved ones. interested in how the death with affect them. and cremation is common c. Ages 6 to 9. Chinese Americans (1) Death and bereavement are centered on ancestor worship (2) Fear of death. African Americans a. A time of many losses and grief is cumulative b. Bereavement overload has been implicated as a predisposing factor in the development of depressive disorder in the elderly person B. c. regressive and aggressive behaviors may occur. falling out) c. May exhibit acting-out behaviors d. Usually have an attitude of immortality. regressive behaviors may occur.g. Beginning to understand the finality of death. Funeral services may include musical rhythms and patterns of speech and worship unique to African Americans 2. unable to perceive their own death 3. may be afraid that death is contagious. peer relationships and school performance may be disrupted.
. Outcome criteria are identified for measuring the effectiveness of nursing care. Body is wrapped in a shroud and placed in a wooden.236 (2) Belief that birth and death are predestined (3) Emphasis on cyclic continuity and reincarnation (4) Mourning continues for 1 year. Strong belief in an afterlife b. Mexican Americans a. View death as a natural part of life b. Nursing intervention for the bereaved individual is to provide assistance through the grief process in a healthful manner toward resolution. D. Following the death. Filipino Americans a. Nursing diagnoses for the client and family experiencing grief and loss may include: a. Grief is not openly expressed. Mourning lasts for 1 year 4. A cleansing ceremony takes place before burial to prevent the spirit of the dead person from trying to assume control of someone else’s spirit c. Special prayers ask God’s blessing for the deceased c. Planning/Implementation 1. and there is reluctance to touch a dead body C. A seven-day period beginning with the burial is called shiva during which nothing is permitted that diverts attention from thinking about the deceased 5. Nursing Diagnosis/Outcome Identification 1. unadorned casket c. Risk for complicated grieving b. Mourning is called luto and is symbolized by wearing black. Jewish Americans a. a festive watch over the body of the deceased person before burial c. Risk for spiritual distress 2. Emotional outbursts and fainting are common expressions of grief d. Following a death. or dark clothing and by subdued behavior 6. a wake takes place in the home of the deceased and lasts up to a week before the funeral b. A deceased person is not buried for 4 days after death b. black and white. The dead are buried with their shoes on the wrong feet and rings on their index fingers d. Native Americans (Navajo of the Southwest) a. after which a commemoration of the individual’s death occurs 3. large numbers of people gather for a velorio.
237 2. Twenty-four-hour on-call nurse/counselor g. spiritual. Advance Directives 1. Hospice 1. IX. Refers to a living will or a durable power of attorney for health care (also called a health-care proxy) 2. However. Reasons why advance directives are sometimes not honored: a. social workers. past relationships. 2. attendants. The individual is encouraged to participate in usual religious practices from which he or she derives support. 4. The interdisciplinary team b. Evaluation is based on accomplishment of previously established outcome criteria. Hospice is a program that provides palliative and supportive care to meet the special needs of people who are dying and their families. . VIII. health-care professionals are legally bound to honor the client’s wishes. The individual is encouraged to express feelings about the loss and how the loss will affect his or her life. 4. and prospects for the future. 3. psychological. physicians are sometimes unwilling to proceed under a living will’s direction for fear of lawsuits. The client is assisted in identifying positive aspects about his or her life. The health-care proxy is unsure of the client’s wishes. 3. Documents allow an individual to provide directions about his or her future medical care. Bereavement counseling f. Pain and symptom management c. b. Physical. Additional Assistance A. physicians. E. 3. and social care is provided. Emotional support to client and family d. The advance directive is not available at the time the treatment decisions need to be made. 4. The advance directive is not clear. volunteers. c. Focus is on the quality of life. In most states. 5. Hospice is based on seven components: a. Interdisciplinary team includes nurses. Staff support B. and other health-care workers. Pastoral and spiritual care e. Summary and Key Points Review Questions VII.
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