Professional Documents
Culture Documents
Basic Concepts of Psychiatric PDF
Basic Concepts of Psychiatric PDF
Editor
Louise Rebraca Shives MSN, ARNP, CNS
PsychiatricMental Health Nurse Practitioner and Clinical
Nurse Specialist
Consultant in Long-Term Care, Legal Nurse Consultant, Orlando,
Florida
Secondary
Margaret
Senior
Editors
Zuccarini
Acquisitions
Editor
Joseph Morita
Managing Editor
Danielle DiPalma
Developmental
Editor
Carol DeVault
Editorial Assistant
Danielle Michaely
Production Editor
Helen Ewan
Director of Nursing Production
Erika Kors
Managing
Editor/Production
Brett MacNaughton
Design Coordinator
Anthony Groves
Cover Designer
Bill Donnelly
Interior Designer
Annelisa Ochoa
Interior
Illustration
William Alberti
Senior Manufacturing
Manager
Angela Holt
Indexer
Compositor:
Printer:
R.R.
TechBooks
DonnelleyWillard
Dedication
This book is dedicated to my daughters, Terri Spence, Lorrie
Shives, and Debbie Moore; to my grandchildren, Jeffray,
Jennifer, and Zachary; and to the memory of my parents, Pete
and Christine Rebraca.
Preface
Although the fifth edition of this textbook underwent a major
revision, the development of the sixth edition has been quite a
challenge due to the recent proliferation of research knowledge
and the advancements made in the treatment of psychiatric
mental illness. Since its inception, the goal has been to produce
a textbook that addresses the current concepts used in
psychiatricmental health nursing to foster competency in
practicing nurses and other mental health professionals.
Conversations with various nurse educators and comments by
reviewers of the fifth edition helped this author to identify
specific content that should be included in this sixth edition of
Basic Concepts of PsychiatricMental Health Nursing.
Consideration was given to the limited amount of time in which
nurse educators are able to present psychiatricmental health
nursing content. They recommended:
incorporating the following threads throughout the text:
psychobiological and developmental theories related to
specific disorders; economic, spiritual, and religious factors
affecting mental health; cultural and ethnic diversity; loss
and grief; the nurse's role in clinical psychopharmacology;
management of pain; and the utilization of behavior therapy
as a nursing intervention when appropriate
adding a discussion about student issues and concerns
regarding psychiatricmental health nursing clinical
experience
Text
Organization
Issues
Related
to
PsychiatricMental
three
of various
available at
as well as
with
Psychiatric
Disorders, contains
10
chapters (Chapters
focusing on:
Schizophrenia
18, 1 9, 2 0, 2 1, 2 2, 2 3, 2 4, 2 5, 2 6, 2 7)
and
Schizophrenic-like
disorders
disorders
Anxiety
disorders
Anxiety-related
Personality
Cognitive
Eating
disorders
development
and
personality
disorders
disorders
disorders
Substance-related
disorders
diagnosis
AIDS
Ineffective coping with the psychosocial aspects of aging
Serious and persistent mental illness
New
or
Expanded
Pedagogic
Features
including
describing
premenstrual
dysphoric
34 identifying special
persistently mentally ill clients,
crimes, and exploring the more
of clients who are
selected
references,
and
Ancillary
Package
The
Back-of-Book
CD-ROM
Acknowledgments
The inception of the first edition of this textbook began in the
early 1980s. At that time, many nursing programs followed the
medical model of psychiatricmental health nursing. The
emergence of the biopsychosocial model or paradigm of
psychiatricmental health nursing has challenged authors
such as myself to reevaluate the format in which
psychiatricmental health nursing content should be
presented. The sixth edition of this textbook would not have
materialized without the guidance and support of the staff at
Lippincott Williams and Wilkins. I would like to express my
sincere appreciation to the following individuals who were
readily accessible throughout this project: Margaret Belcher
Zuccarini, Senior Acquisitions Editor; Carol DeVault, Editorial
Assistant; Danielle DiPalma, Senior Developmental Editor; and
Danielle Michaely, Production Editor. Special recognition is given
to Maryann Foley, Developmental Editor, whose expertise and
guidance inspired me to explore all available resources to obtain
current, pertinent, and factual information during this project.
Her comments and suggestions are reflected throughout this
text.
Two other individuals who were supportive both professionally
and personally were Dr. Sardar Aziz, board-certified psychiatrist
and geropsychiatrist with whom I have shared a private practice
for 10 years, and his wife, Dr. Shahedra Akhtar, board-certified
child, adolescent, and adult psychiatrist who specializes in the
treatment of children and adolescents. Both were readily
Chapter 1
Student Issues and Concerns
It takes so much more skill to understand the
human mind and emotions than it does to give
a shot.
--Funderburk,
Learning
2001
Objectives
Key
Terms
Extrovert
Facilitate
Introspection
Introvert
Judgmental
Personality
traits
Prejudice
Self-awareness
Sensors
Stereotyped
Thinkers
P.2
Student nurses have described psychiatricmental health
nursing as a challenging experience, providing an opportunity
for personal and professional growth. Working with clients who
exhibit wide-ranging clinical symptoms of different
psychiatricmental health disorders can elicit a variety of
emotional or behavioral responses. Psychiatric clients are often
stereotyped or categorized by the public as being poor,
violent, confused, or unable to care for themselves. Consider
these questions as you prepare for your psychiatricmental
health nursing experience:
Do you have any fears?
Do you feel nervous knowing that you will be interacting
with clients in a psychiatricmental health clinical setting?
Do you feel adequately prepared to provide interventions for
clients with clinical symptoms of a mental illness?
Do you have any concerns that have not been answered by
your instructor or peers?
Do you have any prejudice or feelings of intolerance about
persons who are hospitalized in psychiatricmental health
facilities?
In 1957, a paper entitled Facilitating Student Learning
Through the Teacher's Use of Self
was presented at the
curriculum conference of the National League for Nursing (NLN).
The paper's author, Catherine Norris, stated that one of the
greatest contributions a teacher can make is to help students
discover who they are, what they can do, and where they want
to go. She also noted that students need someone to listen to
them, someone to be concerned about how they feel, and
someone to help them obtain satisfaction during their nursing
experience (Norris, 1957) .
This chapter addresses some of the common issues and
concerns you may have as you prepare for this unique
experience.
Frequently Asked
Student
Nurses
Questions
by
What Do I Wear?
Street clothes are generally worn in the clinical setting unless
uniforms including scrubs
and laboratory coats are
required in areas where both medical and psychiatricmental
health nursing care are provided. The student nurse may feel
uncomfortable at first because he or she has lost the
props
(uniform and stethoscope) that assist in
Recommendations
by
Student
Nurses
Self-awareness
Self-awareness refers to the ability to recognize the nature of
one's own attitude, emotions, and behavior. It can be an
effective tool when interacting with clients who are exhibiting
anxiety (Chapter 21), depression (Chapter 20), confusion
(Chapter 24), or psychosis (Chapter 18). Have you ever taken a
test such as the Myers-Briggs Type Indicator to identify your
personality traits or distinguishing characteristics of your
personality? The Myers-Briggs Type Indicator is one example.
This test identifies whether you are an extrovert or introvert. An
extrovert is an outgoing person who relates more easily to
people and things in the environment, while an introvert is a
quiet individual who relates better to the inner world of ideas,
thoughts, and feelings. Do you prefer to work with known facts
rather than look for possibilities and relationships? According to
Self-Awareness
Prompt
uncomfortable
offering
constructive
criticism
Hesitate to disagree
Evade topics that are uncomfortable
Have difficulty responding to negative comments
Am embarrassed when given a compliment
Enjoy giving directions or explaining a task
Am a good listener but will also initiate conversation
Accept criticism as a learning experience
Avoid
making
judgemental
statements
Key
Concepts
Chapter
Worksheet
CRITICAL
THINKING
QUESTIONS
were told that part of
a psychiatric nursing
Who told you? What was
feel? How did you resolve
Reflection
Review the chapter opening quote by Funderburk. Explain its
significance to psychiatricmental health nursing and your
role as a student nurse.
Multiple
Choice
Questions
View
1. D
Answer
Answer
View
3. B
a.
Introvert
b.
Judgmental
c.
Extrovert
d.
Prejudice
attitude
Answer
Stereotyping
b.
Prejudice
c.
Introspection
d.
Censorship
View
4. A
Answer
Answer
Internet
Resources
for
Nursesstudent
Association:
nursing:
http://www.nurse.com/student_nursing
Selected
References
Suggested
Readings
Medicine,
learning
in
nursing. Malden,
Chapter 2
History and Trends in
PsychiatricMental
Health
Nursing
The twenty years in this era (19151935)
brought an awakening of interest in raising
standards of care in psychiatric work, a
growing realization of the role of nurses and
the nursing profession in the needed
improvements, and gradual inclusion in basic
nursing curricula of the dominant psychiatric
concepts available at this time.
Peplau,
Learning
1956
Objectives
interacts
with
Define ego
others.
defense
mechanism.
health
nursing.
Key
Ego
Terms
defense
Forensic
mechanisms
nursing
Mental
disorder
Mental
health
Mental
illness
Nursing
Parish
informatics
nursing
Privileging
process
Psychiatricmental
Self-actualization
health
nursing
Significant
others
Standards of practice
Telehealth
Psychiatricmental health nursing involves the diagnosis
and treatment of human responses to actual or potential mental
health problems. It is a specialized area of nursing practice that
uses theories of human behavior as its scientific framework and
requires the purposeful use of self as its art of expression. It is
concerned with promoting optimum health for society.
Comprehensive services focus on prevention of mental illness,
health maintenance, management of and referral for mental and
physical health problems, diagnosis and treatment
P.8
of mental disorders, and rehabilitation (Haber & Billings, 1993) .
According to the American Nurses Association's A Statement on
PsychiatricMental Health Clinical Nursing Practice (1994, p.
7), psychiatric nurses must be able to make rapid
comprehensive assessments; use effective problem-solving
skills in making complex clinical decisions; act autonomously as
well as collaboratively with other professionals; be sensitive to
issues such as ethical dilemmas, cultural diversity, and access
to psychiatric care for underserved populations; be comfortable
working in decentralized settings; and be sophisticated about
the costs and benefits of providing care within fiscal constraints.
This chapter serves two major purposes: to introduce the
concepts of mental health and mental illness and to describe the
historical development of the role of the psychiatricmental
health nurse.
Concept
of
Mental
Health
Factors
Influencing
Mental
Health
Inherited
Characteristics
Nurturing
During
Childhood
Life
Circumstances
Characteristics
of
Mental
Health
their
environment.
P.9
SUPPORTING
PRACTICE
The
EVIDENCE
FOR
2.1
Relationship
Environment
and
Between
Mental
Health
Footnote
Source: Diffendal, J. (2003). Better homes, gardens.and
mental health? Advance for Nurse Practitioners. [Online].
Retrieved January 30, 2003, from
http://www.advancefornp.com/npfeature2.html
Factors
Affecting
Mental
Health
Maintenance
Factors that influence the ability to achieve and maintain mental
health include engaging in interpersonal communication and
resorting to the use of ego defense mechanisms (Powell, 1969) .
The presence of significant others, or support people, also plays
a role in maintaining mental health.
Interpersonal
Communication
BOX 2.1
Five
Levels
of
Communication
Ego
Defense
Mechanisms
Self-Awareness
Prompt
Significant
Others
or
Support
People
Personal Strategies
Maintenance
for
Mental
Health
Self-Awareness
with them.
Prompt
EGO DEFENSE
MECHANISMS
DEFINITION
EXAMPLE
Compensation
Use of a specific
behavior to
make up for a
real or imagined
inability or
deficiency, thus
maintaining
self-respect or
self-esteem
Unattractive
man selects
expensive,
stylish clothes
to draw
attention to
himself.
Conversion
Unconscious
expression of a
Woman
experiences
mental conflict
as a physical
symptom to
relieve tension
blindness after
witnessing a
robbery.
or anxiety
Denial
Unconscious
Woman
denies
refusal to face
thoughts,
feelings,
wishes, needs,
or reality
factors that are
intolerable
that her
marriage is
failing by telling
her estranged
husband that all
couples go
through marital
slumps and
things will
be better
tomorrow.
Displacement
Unconscious
shifting of
feelings such as
hostility or
anxiety from
one idea,
person, or
object to
another
Teen-aged son
slams door when
told he can't
attend a
concert.
Dissociation
Separation and
detachment of a
strong,
emotionally
charged conflict
from one's
Male victim of
car-jacking
exhibits
symptoms of
traumatic
amnesia the
consciousness
next day.
Unconscious
Teenager
attempt to
identify with
personality
traits or actions
dresses, walks,
and talks like
his favorite
basketball
of another to
player.
Identification
preserve one's
self-esteem or
to reach a
specific goal
Introjection
Application of
the philosophy,
ideas, customs,
and attitudes of
another person
to one's self
Psychiatric client
who claimed to
be Moses grew a
beard and long
hair, wore a
blanket and
sandals, and
read his Bible
daily.
Projection
Unconscious
assignment of
unacceptable
thoughts or
characteristics
of self to others
Rationalization
Justification of
one's ideas,
actions, or
feelings to
maintain self-
Student states
he didn't make
the golf team
because he was
sick.
respect, prevent
guilt feelings, or
obtain social
approval
Reactionformation
Demonstration
of the opposite
behavior,
attitude,
polite and
or
feeling of what
one would
normally show
in a given
situation
courteous
toward her.
Regression
Retreat to past
developmental
stages to meet
basic needs
Restitution
Negation of a
previous
consciously
Man sends
flowers to
fiance
after
intolerable
action or
experience
embarrassing
her at a cocktail
party.
Rechanneling of
intolerable or
socially
unacceptable
impulses or
behaviors into
activities that
are personally
College student
with hostile
feelings joins
the debate
team.
Sublimation
or socially
acceptable
Substitution
Replacement
of
A student
nurse
unacceptable
impulses,
attitudes,
needs, or
decides to be a
teacher because
he or she is
unable to
emotions
master
with
clinical
competencies.
Suppression
Voluntary
rejection of
unacceptable
thoughts or
feelings from
conscious
awareness
Student who
failed a test
states she isn't
ready to talk
about her grade.
Symbolization
Use of external
objects to
become an
outward
An engagement
ring symbolizes
love and a
commitment to
representation
of an internal
idea, attitude,
or feeling
another
person.
BOX 2.2
Examples of Situations Involving
Use of a Support Person
the
Concept
of
Mental
Illness
BOX 2.3
Personal Strategies for Reducing
Stress and Enhancing Well-Being
Aerobic
exercise
Aromatherapy
Martial
techniques
arts
Massage
Meditation
Progressive
relaxation
Self-hypnosis
Walking
Yoga
Misconceptions
Altrocchi
About
Mental
Illness
P.13
MENTAL
HEALTH
MENTAL
ILLNESS
Feels inadequate
Has poor self-concept
Is unable to cope
Exhibits
maladaptive
behavior
Is unable to establish a
meaningful
relationship
Displays
Accepts
Is irresponsible or unable
responsibility
for
poor
judgment
actions
Is
Is
optimistic
Recognizes
limitations
(abilities and deficiencies)
pessimistic
and
Can
and
function effectively
independently
Is able to distinguish
imagined
circumstances
from reality
Is unable to perceive
reality
Is able to develop
potential and talents to
fullest extent
Can
Desires or demands
immediate
gratification
delay
gratification
displaying a sense of
humor, and coping
successfully with
emotional
conflict.
Historical
Development
PsychiatricMental
(PMHN)
of
Health
Nursing
Superstition,
patients were
or subjected to
at the stake were
in some
TABLE 2.3
Development
of
PsychiatricMental
Health
Nursing
Phase 1: The
Emergence of
PsychiatricMental
Health Nursing
(17731881)
Phase 2: Development
of the Work Role of
the Psychiatric Nurse
(18821914)
Phase 3: Development
of Undergraduate
Psychiatric
Nursing
Education
(19151935)
Phase 4: Development
Clinical
experiences
in
of Graduate
Psychiatric
Nursing
Education
(19361945)
for
nursing
Phase 5: Development
of Consultation and
Research in
Psychiatric
Nursing
Practice
(19461956)
should be stimulated to
facilitate research focusing
on the prevention and cure
of mental illness.
P.15
1773 to 1956
In contrast, the 18th century is regarded as an era of reason
and observation. According to Peplau (1956), the historical
development of psychiatric nursing began in 1773. Peplau
identified five eras, or phases in the establishment of
psychiatric nursing, both as an aspect of all nursing and as a
specialty in nursing. Table 2-3 summarizes these eras.
Phenothiazines and other major tranquilizers were introduced in
the United States in the early 1950s to treat the major
symptoms of psychoses, enabling clients to be more responsive
to therapeutic care. During this same time period, open-door
policies were implemented in large mental institutions, allowing
clients to leave the units or wards under supervision.
Other
Developments
Since
the
1950s
BOX 2.4
Results of Research on Biologic
Aspects of Mental Illness
Molecular targets have been identified in the treatment of
bipolar disorder.
Panic attacks appear to induce a long-lasting rise in LDI and
total cholesterol in men, placing them at increased risk of
cardiovascular
disease.
High dose electroconvulsive therapy on the right brain
maximizes therapy efficacy while minimizing adverse effects
on memory.
Schizophrenia may be caused by a virus, autoimmune
phenomena or frontal lobe dysfunction.
Approximately 60% of chronic alcoholics may experience
cerebral atrophy, cortical shrinkage, and ventricular
dilatation in the frontal lobe. Electroencephalograms are
poorly
synchronized.
Increased episodes of depression and mania cause changes
in brain structure and function, which lead to treatmentresistant
depression.
Self-Awareness
Prompt
P.16
TABLE 2.4
Events
Influencing PsychiatricMental
Health Nursing
1856
to
1929
1856
to
1939
1857
to
1939
1870
to
1937
1875
to
1961
organ
1940
to
1945
1946
to
1971
1947
1949
1952
1955
1961
1963
to
1979
1980s
1990s
exam.
Standards
of
PsychiatricMental
Health Nursing Practice (PMHNP)
Standards of practice are authoritative statements used by
the nursing profession to describe the responsibilities for which
nurses are accountable. They provide direction for professional
nursing practice and a framework for the evaluation of practice.
They also define the nursing profession's accountability to the
public and the client outcomes for which nurses are responsible.
In 1967, the American Nurses Association (ANA) published the
Statement on Psychiatric and Mental Health Nursing Practice. A
revision followed in 1976. Belief that the
P.17
scope of practice is linked to practice standards resulted in the
publication of Standards of Psychiatric and Mental Health
Nursing Practice in 1982. Broader general standards of nursing
practice are delineated in the Standards of Clinical Nursing
Practice (ANA, 1991) .
In May 1999, a workgroup convened to review and revise, if
necessary, the A Statement on PsychiatricMental Health
Clinical Nursing Practice and Standards of PsychiatricMental
Health Clinical Nursing Practice published in 1994. The current
revision, Scope and Standards of PsychiatricMental Health
Nursing Practice (ANA, 2000), is divided into two sections,
Standards of Care and Standards of Professional Performance,
as described in Boxes 2-5 and 2-6.
BOX 2.5
Standards
Standard
I.
of
Care
Assessment:
The
psychiatricmental
health
outcomes
Practice
Intervention
VhVj:
VI.
Evaluation:
The
psychiatricmental
health
Footnote
APRNPMH, advanced
mental health.
practice
registered
nursepsychiatric
nursing
practice. Washington,
DC:
American
Nurses
Publishing.
P.18
BOX 2.6
Standards of
Performance
Professional
Footnote
Reprinted with permission from American Nurses Association
(2000). Scope and standards of psychiatricmental health
nursing practice. Washington, DC; American Nurses Publishing.
PsychiatricMental
Today
Health
Nursing
Education
A paradigm shift is taking place in education, moving from the
Licensed Practical
Programs
or
Vocational
Nursing
Associate's
Degree
Nursing
Programs
Baccalaureate
Degree
Nursing
Programs
Master's
Degree
Nursing
Programs
Continuing
Education
the American
various levels of
specialist, and
prior to taking
the test.
Career
Opportunities
USE
CAREER
OPPORTUNITIES
Obstetric
nursing
OF
PSYCHIATRICMENTAL
HEALTH
NURSING SKILLS
Helping the mother in labor and
support person cope with anxiety
or stress during labor and delivery
Providing support to bereaved
parents in the event of fetal
demise, inevitable abortion, or the
birth of an infant with congenital
anomalies
Providing support to a mother
Forensic
Oncologic
nursing
nursing
Industrial
(occupational
health) nursing
Implementing or participating in
industrial substance abuse
programs for employees and their
families
Providing crisis intervention during
an industrial accident or the acute
onset of a physical or mental
illness (eg, heart attack or anxiety
attack)
Teaching stress management
Public health
nursing
Office
nursing
Emergency
nursing
room
Finally, forensic
Key
Concepts
maturity.
psychiatric
nursing
education
was
developed
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
Review the quote at the beginning of the chapter. According to
Peplau (1956), several trends occurred in psychiatricmental
health nursing between 1915 and 1935. Explain the impact of
these trends on the delivery of care to clients during the 21st
century.
MULTIPLE
CHOICE
QUESTIONS
Answer
Answer
Answer
Answer
Psychotherapy
and
prescribing
medications
Answer
Internet
Resources
Psychiatric
Nurses
Association:
http://www.apna.org
iTelehealth, Inc.: http://www.itelehealthinc.com
National League for Nursing: http://www.nln.org
Selected
References
of
clinical
DC:
of
Kennedy, J. L., Pato, J., Bauer, A., Carvalho, C., & Pato, O.
(1999). Genetics of schizophrenia. Current findings and
issues. CNS Spectrum, 4 (5), 1721.
Kolb, L. C. (1977). Modern
W. B. Saunders.
clinical
and
psychiatry.
Philadelphia:
about
Texas:
Argus
Communication.
Suggested
Readings
City,
MO: Author.
American Nurses Association. (1992). Working
definition:
for
of
for
Chapter 3
Development of
PsychiatricMental
Nursing Theory
Health
Learning
1997
Objectives
framework.
Key
approach.
Terms
Behavioral
Nursing
theory
Cognator
Conceptual
Eclectic
framework
approach
Interaction-oriented
Interpersonal
approach
theory
Needs-oriented
Outcome-oriented
approach
approach
Regulator
Systems-oriented
theory
Theory
Theory of Adaptation
Theory of Human Becoming
Prior to the 1950s, the medical model dominated
psychiatricmental health nursing practice. Physicians
and
Theory
Theory is considered a branch of science dealing with
conceptual principles that describe, explain, and predict a class
of phenomena. Meleis (1997) defines theory as an organized,
coherent, and systematic articulation of a set of statements
related to significant questions in a discipline that is
communicated in a meaningful whole. It is a symbolic depiction
of aspects of reality that are discovered or invented to describe,
explain, predict, or prescribe responses, events, situations,
conditions, or relationships.
Theories can be tested, challenged, modified, or replaced, or
they can become obsolete. For example, Rosemarie Parse's
theory of human becoming was initially called the Man-LivingHealth Theory when it was first published in 1981. Parse
synthesized her theory from works by European philosophers
and the American theorist Martha Rogers. The name was
officially changed to the Theory of Human Becoming in 1992 to
remove the word man
from its title.
Nursing
Theories
Peplau's
Interpersonal
Theory
THEORIST
THEORY
IMPACT ON NURSING
THEORY
Sigmund
Freud
Psychoanalytic
theory
Harry
Stack
Sullivan
Interpersonal
theory
B.F.
Skinner
Behavior
theory
behavior.
Murray
Bowen
Family
Systems
theory
Nurses developed an
understanding of
individual and family
behaviors and their
relationship to each
other.
Eric
Erikson
Developmental
theory
(2001), Johnson
(2001).
(1997), Meleis
P.26
YEAR
1952
THEORIST
Hildegard
Peplau
THEORY
Interpersonal
theory
1955
Virginia
1960
Faye
Henderson
Abdellah
Needs
theory
Patient-centered
theory
1961
Josephine Patterson
Loretta Zderad
1961
Ida
1964
Ernestine
1964
Joyce
1966
Myra
1970
Martha
1971
and
Orlando
Weidenbach
Travelbee
Levine
Interaction
theory
Interaction
theory
Interaction
theory
Interaction
theory
Conservation
theory
Rogers
Unitary Human
Being theory
Imogene
King
Systems theory
Updated
1971
Dorothea
Orem
Self-care Deficit
theory Updated
1971
Adaptation
1972
Betty
Systems
1973
Madeleine
1978
Joyce
1979
Jean
Neuman
Leininger
Fitzpatrick
Watson
theory
theory
Cultural Care
Diversity theory
Rhythm
Human
theory
theory
Caring
1981
Rosemarie
Parse
Human
theory
1983
Becoming
Orem's
Behavioral
Nursing
Theory
Roy's
Theory
of
Adaptation
Parse's
Theory
of
Human
Becoming
P.27
path for oneself in the midst of ambiguity and continuous
change.
Parse's theory is considered by some advanced practitioners to
be an excellent framework for community psychiatric nursing in
which the nurse focuses on the client's experiences, not
problems; bears witness to the client's experiences; respects
the individual's capacity for self-knowing; and assists the client
in cocreating a valuable space for the client to voice the lived
experience of health (Norris, 1999; also available at:
http://www.humanbecoming.org). Humanly lived experiences
such as loss and grief are believed to respond well to
interventions based on Parse's theory. Clients with mood
disorders and psychotic disorders also have benefited from
interventions promoting independence and empowerment.
Application
to
Practice
Needs-Oriented
Approach
With a needs-oriented
approach nurses are actively doing and
functioning. They problem-solve, perform physiologic and
psychosocial activities for the client, supplement knowledge,
and may become temporary self-care agents for clients with
self-care
deficits.
Interaction-Oriented
The interaction-oriented
Approach
actions.
evaluate
counsel,
in their
Outcome-Oriented
Approach
The outcome-oriented
approach is used by nurses who are
viewed as goal setters. They are referred to as controllers,
conservators, and healers without touch. They focus on
maintaining and promoting energy and harmony with the
environment. They do not view themselves as therapeutic
agents as they focus on enhancing the development of health
environments.
Self-Awareness
Prompt
Eclectic
Approach
Agreement
Among
Nursing
Theorists
Key
Concepts
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
Reflect on the development of psychiatric nursing and nursing
theories by Peplau, Roy, and Parse. Do they remain appropriate
or should modifications be considered to meet the multifaceted
needs of clients in the 21st century?
MULTIPLE
CHOICE
QUESTIONS
Leininger
b. Orem
c. Peplau
d. Roy
View
1. B
Answer
spouse
to a grief support group. The nurse's
recommendation emphasizes coping mechanisms in
adaptation, illustrating which of the following nursing
theories?
a. Levine
b.
Henderson
c. Peplau
d. Roy
View
2. D
Answer
Interaction
oriented
d. Research based
View
Answer
3. A
The eclectic approach refers to an individualized approach that
incorporates the client's own resources as a unique person with
the most suitable theoretical model or models. This approach is
not limited because the nurse therapist realizes that there is no
one way to deal with all of life's stresses or problems.
Interaction-oriented approach incorporates the use of the nurse
as a therapeutic tool. Although all theories are considered to be
Interaction
b.
Eclectic
oriented
c. Needs oriented
d. Outcome oriented
View
4. A
Answer
View
a.
Biologic
b.
Holistic
c.
Psychological
d.
Sociological
Answer
5. B
Although nursing theorists may differ in their beliefs and
concepts, they all do believe in the need to view the client
holistically, not as a biologic, psychologic, or sociologic being.
Internet
Resources
Theories:
http://www.nurses.info/nursing_theory.htm
Nursing Theory page:
http://www.sandiego.edu/nursing/theory/
Parse's Theory of Human Becoming:
http://www.humanbecoming.org/
Selected
References
of
the
and
Suggested
health
nursing.
Readings
16aaa16bbb.
Chapter 4
Cultural and Ethnic Issues
And since human beings are born, live,
become ill, survive, experience life rituals, and
die within a cultural care frame of reference,
these life experiences have meanings and
significance to them in any given culture and
subculture.
Leininger,
Learning
1991
Objectives
to
Leininger.
Key
Terms
Acculturation
Culture
Culture-bound
syndrome
Cultural
care
accommodation/negotiation
Cultural
care
preservation/maintenance
Cultural
care
repatterning/restructuring
Ethnic
group
Ethnicity
Ethnocentrism
Ethnopharmacology
Stereotyping
Subculture
Yin-yang
Psychiatricmental health nursing provides client care that
maintains mental health, prevents potential problems, and
treats human response to actual problems of mental illness.
Although Abraham Maslow's theory states that all human
behavior is motivated by basic human needs, the expression of
Culture
and
Nursing
Self-Awareness
Prompt
Think about the rituals surrounding death with which you are
familiar. Consider rituals such as the wake, funeral, religious
service, burial, and family gatherings. Discuss with someone
from a different ethnic background and compare and contrast
similarities and differences in customs and rituals.
Ethnicity, or ethnic group, refers to people in a larger social
system whose members have common ancestral, racial,
physical, or national characteristics, and who share cultural
symbols such as language, lifestyles, and religion (Andrews &
Boyle, 2002). For example, hundreds of different Native
American and Alaskan tribes and many different Asian and
Pacific Island ethnic groups exist. There are also different ethnic
groups of African Americans, including individuals from Africa,
the Caribbean, and other parts of the world. Other examples of
ethnic groups include people who share membership in
American culture, but trace their ethnic identity to Western and
Eastern Europe. Thus, ethnicity differs from culture in that
ethnic identity is often defined by specific geographic origins as
well as other unique characteristics that differ from the larger
cultural group.
The tendency to believe that one's own way of thinking,
believing, and behaving is superior to that of others is called
ethnocentrism. Hunt and Zurek (1997) present an example of
an ethnocentric response by a nurse as follows: Ms. Wang is
noncompliant with her treatment. She won't take her real
medicine and only takes the teas given her by the community
herbalist.
The belief that only prescribed medication is
useful or helpful to the client leads the nurse to conclude that
the client is noncompliant. A nurse who respects another's belief
system would discuss with this client the reasons she does not
want to take the prescribed medication.
Culturally
Congruent
Nursing
Care
care
preservation/maintenance
Cultural
care
accommodation/negotiation
Cultural
care
repatterning/restructuring
In cultural
care
preservation/maintenance, the nurse
assists the client in maintaining health practices that are
derived from membership in a certain ethnic
P.34
group. For example, a client with a Chinese background may
want foods that are considered hot
to counteract an
illness that is considered cold.
The nurse helps the
client select and obtain foods congruent with these beliefs.
Self-Awareness
Prompt
care
Population
Groups
Groups
Socioeconomic
Groups
Status
of
Ethnic
The Surgeon General's 1999 report stated that many racial and
ethnic groups have limited financial resources (U.S. DHHS,
1999). There is an association between lower socioeconomic
status (in terms of income, education, and occupation) and
mental illness; however, no one is certain whether one
influences the other. Certainly, substandard housing,
unemployment or underemployment, poor nutrition, lack of
preventive care, and limited access to medical care create
severe stressors for affected families. Statistics from the 1990
Self-Awareness
Prompt
Cultural Perceptions:
as Spiritual Concern
Mental
Illness
CLINICAL
EXAMPLE
4.1
the
Cultural
Expressions
of
Mental
Illness
and
Nursing
Implications
Psychiatric
Nursing
Ethnopharmacologic
of
Ethnic
Groups
Considerations
TABLE 4.1
SYNDROME
CultureBound
Syndromes
ASSOCIATED
CULTURE(S)
DESCRIPTION OF
SYMPTOMS
Amok
Malaysia, Laos,
Philippines,
Polynesia
Dissociative
episode followed
by outburst of
violent behavior
directed at people
or objects
Ataque de
Latin-American
Uncontrollable
nervios
and LatinMediterranean
groups
shouting, crying,
trembling, and
verbal or physical
aggression.
Occurs frequently
as direct result of
stressful family
event
Latin-American
and LatinMediterranean
groups
Acute nervous
tension,
headache,
trembling,
screaming,
stomach
disturbance, and
even loss of
consciousness.
Cause is thought
to be strong anger
or rage
Boufe
delirante
Sudden outburst
of agitated and
aggressive
behavior,
confusion, and
psychomotor
excitement
Brain fag
West
Africa
Difficulty
concentrating,
remembering, and
thinking.
Associated with
challenge of
schooling
Nervios
Latin
America
General state of
vulnerability to
stressful life
experiences. Wide
range of
symptoms of
emotional
distress
Dhat
India
Severe
and
anxiety
hypochondrical
concerns
Falling-out or
blacking out
Southern U.S.
and Caribbean
groups
Sudden collapse;
may occur without
warning, but
sometimes
preceded by
feelings of
dizziness. Person
claims inability to
see and may feel
powerless to
move.
Ghost
American
Indian tribes
Preoccupation
with death and
the deceased. Bad
dreams,
weakness, feelings
of danger,
anxiety, and
sickness
hallucinations
occur.
Hwa-byung
(wool-hwabyung),
anger
Korea
syndrome
Pibloktog
may
Insomnia, fatigue,
panic, fear of
impending death,
indigestion, and
anorexia
Eskimo
Abrupt
cultures
dissociative
episode
accompanied
extreme
excitement
by
Rootwork
African
American,
European
American, and
Caribbean
groups
Illness ascribed to
hexing, witchcraft,
sorcery, or evil
influence of
another person
Shenjing
shuairo
(neurasthenia)
China
Physical and
mental fatigue,
dizziness,
headaches, sleep
disturbance, and
memory loss
Susto,
fright
or soul
loss
Latin American,
Mexican,
Central, and
South
American
cultures
Illness attributed
to frightening
event that causes
the soul to leave
the body and
results in
unhappiness and
sickness
Nursing
Implications
DRUG
CLINICAL
FINDING
Antianxiety drugs
Benzodiazepines
Diazepan
Alprazolam
Antidepressants
Antipsychotics
Haloperidol
Antimanics
Lithium
Role of Family
Families play an important role in providing support for
individuals with psychiatric problems. However, the definition of
what constitutes a family differs by ethnic group, as do the
roles assumed by different family members. In some ethnic
groups, the family may include the nuclear family, the extended
family, and community members. Often, members of diverse
ethnic groups will not seek psychiatric treatment until supports
provided by family and community have been exhausted.
Nursing
Implications
Role of Healers
Most ethnic cultures have traditional healers who speak the
client's native tongue, usually make house calls, and may cost
Nursing
Implications
CULTURE
SCOPE OF PRACTICE
Hispanic
Curandero
Espiritualista
spiritualist
Black
or
(African
American)
Spiritualist
Voodoo priest or
priestess or
Hougan
Chinese
Herbalist
Knowledgeable in diagnosis of
illness and herbal remedies
Acupuncturist
Native
American
Shaman
Crystal
gazer,
hand trembler
(Navajo)
illnesses
Role
of
Translators
Nursing
Implications
The
Nursing
Process
Assessment
Cultural nursing assessment has been described as a systematic
appraisal or examination of individuals, groups, and
communities as to their cultural beliefs, values, and practices to
determine nursing needs and intervention practices within the
cultural context of the individuals being evaluated (Andrews &
Boyle, 1997) .
Cultural assessment of a mentally ill client can be part of the
initial data collection for a nursing history. The first essential
question to ask is With what culture or ethnic group(s) do
you identify?
Many clients from multiracial or ethnic
backgrounds identify with the group that was most influential in
their early family life. Bloch's Assessment Guide for
Ethnic/Cultural
Variation is useful from a clinical practice
perspective
P.41
because it addresses psychological data categories such as selfconcept, mental and behavioral processes, and psychological
and cultural responses to the stress and discomfort of illness
(Andrews & Boyle, 1997). The nurse may conclude this
assessment by asking the client, Is there anything else that
need to know that will help me to provide care for you?
Additional cultural assessment information includes inquiries
related to the composition and frequency of contact with the
family or social network. Determining the nature of these
relationships aids in identifying support persons to be included
in the plan of care. Information about religious and spiritual
practices and the use of healers also is important to help the
client maintain practices that are congruent with his or her
ethnic group. The explanation by the client and family as to the
cause of the illness and beliefs about treatment provide
relevant data with which to ensure culturally relevant
treatment. The client's use of any alternative therapies,
including herbal or other dietary substances or remedies, can
affect prescribed psychotropic medications, and therefore
should be included in the nurse's assessment. Box 4-1
illustrates
sample
cultural
assessment
Nursing Diagnoses
Identification
and
questions.
Outcome
Implementation
Nursing interventions are selected to enable the client to
accomplish the stated outcome. Interventions specific to
cultural considerations include those that enable the nurse to
establish a trusting relationship; to communicate with the
ethnically diverse client, including the family or social network
in the care plan; and to incorporate the cultural beliefs of the
client and family in treatment.
Establishing
Trusting
Relationship
Communicating
With
Client
and
Family
DIAGNOSIS
OUTCOME
Impaired Verbal
Communication related to
difficulty speaking and
understanding the English
language
Noncompliance
related
to
nonacceptance of psychiatric
treatment secondary to
cultural beliefs
Incorporating
Cultural
Beliefs
Evaluation
As part of the evaluation process, the nurse determines if the
nursing care provided enabled the client to accomplish the
stated outcomes. Nursing care is also evaluated to ensure that
respect and understanding of the ethnically diverse client and
family have been demonstrated. The use of appropriate nursing
interventions, including communication strategies congruent
with the client's culture, is also evaluated. Client and family
expression of satisfaction with nursing care is important and is
the final measure of the success of incorporating cultural
considerations in the nursing process. Nursing Plan of Care 4-1
provides an example of the nursing process for a client from a
diverse ethnic group.
BOX 4.1
for
Key
Concepts
Planning/Implementation
Rationale
Individuals at high
risk for suicide
need constant
supervision and
limitation of
opportunities to
harm self
Client needs to
identify and
express the
feelings that
underlie the
suicidal behavior or
thoughts
Increasing
client's
support system
may help decrease
future suicidal
behavior
Administer ordered
antidepressant
medication,
Chemical control
can help the client
regain self-control
while exploring
feelings and
problems
Planning/Implementation
Respect client's beliefs about
meaning of symptoms
Rationale
Showing respect
demonstrates
interest and caring
yang
respect of her
cultural beliefs and
can help to increase
remedies
a sense of
responsibility
control
and
Relaxation
techniques are used
to reduce stress and
minimize somatic
symptoms
P.44
The nurse provides culturally congruent nursing care so that
the client's cultural perspective is preserved or maintained
and negotiates with the client when changing the client's
practices is necessary for health.
Many diverse ethnic groups in the United States do not use
the services of the mental health system because of factors
such as differences in language, values, and beliefs between
providers
and
clients.
ethnic
spiritual
illness, and
the client
incorporating
cultural
beliefs.
Chapter
Critical
Worksheet
Thinking
Questions
Reflection
Reread the quote at the beginning of the chapter and then
research the plan of care of a culturally diverse client. Do the
nursing interventions facilitate effective transcultural mental
health care? If not, what changes can be made to implement
culture-specific
Multiple
care?
Choice
Questions
Answer
1. C
The nurse's priority is to respect the client's belief, thereby
providing culturally competent care. Questioning the validity of
the belief would interfere with the development of trust and
undermine the nurseclient relationship. There is no reason
to expect that the client's response to treatment would be poor.
Seeking assistance from family members would not be the
priority. Additionally, they too may have the same belief.
2. The client from a diverse culture who is admitted to the
inpatient psychiatric unit has difficulty speaking English.
Which of the following interventions would be best?
a. Communicating with gestures and pictures
P.47
b. Evaluating client's understanding of written English
c. Planning to assign the client to a private room
d. Using the services of a translator
View
2. D
Answer
View
3. A
a.
Accommodation/negotiation
b.
Preservation/maintenance
c.
Repatterning/restructuring
d.
Supporting/providing
Answer
Answer
View
5. B
b.
Indirect
questioning
c.
Confrontational
d.
Family-provided
strategies
information
Answer
Internet
Resources
(CRECH): http://www.sph.umich.edu/crech/
Journal of Transcultural Nursing:
http://www.tcns.org/journal/
Leininger's Transcultural Nursing:
http://www.healthsci.clayton.edu/eichelberger/nursing.htm
Minority Culture and Health:
http://www.healthri.org/chic/minority/culture.htm
Social Action, Culture, and Health:
http://www.earthrenewal.org/soccult.htm
Selected
References
6365.
community-
and
Mendyka, B. (2000). Exploring culture in nursing: A theorydriven practice. Holistic Nursing Practice, 15(10), 3241.
Mitchell, H. B. (1999). Roots of wisdom (2nd ed.). Belmont,
California:
Wadsworth.
Community
Mental
Health
Silk-Walker, P. (1993).
and Alaska Natives. In
mental illness (pp.
Psychiatric Press.
Suggested
Readings
Chapter 5
Ethical and Legal Issues
Nurses,
workers
effective
utilizing
ROSS,
Learning
2001
Objectives
psychiatric
facilities.
care
facilities.
Key
Terms
Assault
Battery
Bill of Rights for Registered Nurses
Civil
commitment
Client
Client
confidentiality
privacy
capacity
imprisonment
Forensic
psychiatry
consent
Intentional
tort
Involuntary
admission
Libel
Malpractice
Miranda
warning
Negligence
Not guilty by reason of insanity
Nurse Practice Act
Omnibus
Reconciliation
Act
Paternalism
Slander
Tarasoff
decision
Voluntariness
hearing
of
Charitable
Immunity, or the Good Samaritan Act. This doctrine
provided immunity from prosecution for hospitals, churches, and
schools. If a client was harmed by the negligence of another, the
doctrine prevented the client from suing to recover damage. By
the mid-1970s, however, most states had revoked the doctrine,
leading to the malpractice crisis.
Health care risk
management developed, preventive law in medicine was
Ethics
In
Nursing
additional
BOX 5.1
Code of Ethics for
NursesProvisions
The nurse, in all professional relationships, practices with
compassion and respect for the inherent dignity, worth, and
uniqueness of every individual, unrestricted by
considerations of social or economic status, personal
attributes, or the nature of health problems.
The nurse's primary commitment is to the patient, whether
an individual, family, group, or community.
The nurse promotes, advocates for, and strives to protect the
health, safety, and rights of the patient.
Footnotes
Voted on and accepted by the ANA House of Delegates on June
30, 2001.
The Code of Ethics for Nurses is available for sale from American
Nurses Publishing at (800) 637-0323 or
http://www.nursesbooks.org
Reprinted with permission from American Nurses Association
(2001). Code of Ethics for Nurses with Interpretive
Statements. Washington,
DC:
American
Nurses
Publishing,
American
Nurses
Association.
BOX 5.2
Examples
Ethics
of
Nursing
Resources
on
education
discusses
Hospital-based
committees
Ethics
in
Pain
Management
BOX 5.3
Examples of Ethical Dilemmas
Associated With Pain Management
A 23-year-old male client with a suspected history of
substance abuse (narcotics) is hospitalized with a back
injury. He requests a stronger pain pill
because he
feels that the prescribed muscle relaxant and nonsteroidal
anti-inflammatory agent are not effective.
A 31-year-old woman, married and mother of two small
(Sanders,
2001).
Malpractice
Conduct that falls below the standard of care established by law
for the protection of others and involves an unreasonable risk of
harm to a client is referred to as negligence.
Malpractice is a
type of negligence that applies only to professionals, such as
licensed nurses (Schipske, 2002; Calloway, 1986a). Nursing
malpractice law is generally based on fault. Before a nurse can
be held legally liable, it must be shown that the nurse's conduct
fell below the professional standard of other professionals with
the same education and training. The following four elements
must be present to constitute nursing malpractice (Schipske,
2002; Calloway, 1986a):
Failure to act in an acceptable way
renewal.
P.53
BOX 5.4
THE AMERICAN NURSES
ASSOCIATION'S Bill of Rights
Registered
Nurses
for
Footnotes
Disclaimer: The American Nurses Association (ANA) is a national
professional association. ANA policies reflect the thinking of the
nursing profession on various issues and should be reviewed in
conjunction with state association policies and state board of
nursing policies and practices. State law, rules, and regulations
govern the practice of nursing. The ANA's Bill of Rights for
Registered Nurses
contains policy statements and does not
necessarily reflect rights embodied in state and federal law. ANA
judgment.
In the psychiatricmental health clinical setting, knowledge of
the law and of the bill of rights for psychiatricmental health
clients (discussed below) in addition to the provision of quality
care greatly reduces the risk of
P.54
malpractice litigation. Legal issues could arise in various practice
settings involving situations such as child abuse, breach of
confidentiality, failure to provide for informed consent, family
violence, mental retardation, prenatal substance abuse, rape,
sexual assault, spouse or significant-other abuse, and suicide.
Box 5-5 lists potential legal issues the psychiatricmental
health nurse could face.
Breaches
Privacy
of
Client
Confidentiality
and
BOX 5.5
Potential
Legal
Issues
PsychiatricMental
in
Health
Nursing*
Footnote
*The issues of assault, battery, defamation of character, false
imprisonment, and nursing malpractice are discussed in detail
within the text.
BOX 5.6
HIPAA
Privacy
Provisions
Rule
Footnote
Sources: Standards for Privacy of Individually Identifiable Health
P.55
Self-Awareness
Prompt
Bill of
Health
Rights for
Clients
PsychiatricMental
informed
choice.
Psychiatric
Hospitalization
institution.
or initiate civil
after an involuntary
the client is located,
the mental health
Hospitalization
of
Minors
State laws regarding the age and legal rights of minors vary.
Such rights include the right to purchase cigarettes or alcoholic
beverages, obtain an abortion, or obtain medical treatment
without consent. In the past, parents or guardians made
decisions regarding admission to psychiatric facilities and
commitment for treatment. Now, in most states, a
minorconsidered anyone under 18 years of age who has not
been court-ordered to receive treatmenthas a right to a
voluntariness
hearing at the time of admission to a facility.
During a private interview, an objective professional, such as the
registered nurse, asks the minor if he or she has voluntarily
P.57
agreed to obtain psychiatric care or if coercion has occurred. The
U.S. Supreme Court has stated that such a neutral fact finder
has the authority to refuse admission of a minor if a parent has
erred in the decision to have the minor institutionalized or to
seek treatment for psychiatric care.
In most states, minors under the age of 18 years but at least 14
years of age have the opportunity to petition the court for full
rights as an adult if factors make it inappropriate for the minor's
parents to retain control over the minor (eg, the minor is
married or on active duty with the armed forces). A minor who
becomes emancipated is granted adult rights and has the
privilege of consenting to medical, dental, and psychiatric care
without parental consent, knowledge, or liability (Harbet, 2003).
Long-Term
Care
Facilities
Forensic
Psychiatry
BOX 5.7
Elements of
Stand Trial
The
Mental
Competency
to
client:
has mental capabilities to appreciate his or her presence in
relation to time, place, and things.
has elementary processes enabling him or her to comprehend
that he or she is in a Court of Justice, charged with a
criminal offense.
comprehends that there is a judge on the bench.
comprehends that a prosecutor will try to convict him or her
of a criminal charge.
comprehends that he or she has a lawyer who will undertake
to defend him or her against the charge.
comprehends that he or she will be expected to tell his or her
lawyer the circumstances, to the best of his or her mental
ability, and the facts surrounding him or her at the time and
place of the alleged law violation.
comprehends that there is or will be a jury present to pass
upon evidence adduced as to his or her guilt or innocence of
such charges.
has memory sufficient to relate those things in his or her own
personal
manner.
Whatever his or her function, the nurse must be familiar with the
BOX 5.8
Practice
Areas
of
Forensic
Nurses
educators/consultants
coroners
Death
Legal
nursing
investigators
nurse
Nurse
consultants
attorneys
Correctional
nurses
pediatric
nurses
Forensic
gerontology
Forensic
psychiatric
nurses
nurses
Self-Awareness
Prompt
Key
Concepts
Chapter
Critical
Worksheet
Thinking
Questions
For several days you have been caring for a 15-year-old girl
who was admitted for episodes described by her parents as
outbursts of rage.
She confides in you that her
parents forced her to come to the hospital and she feels like
a prisoner. What do you need to consider before taking
action?
Reflection
Review the quote presented at the beginning of the chapter and
then imagine the following: you are providing care for a client
undergoing a clinical research drug study. The client informs you
that she suspects that she is pregnant but has not seen a doctor
to confirm the pregnancy. What informed and effective care
decisions do you need to make before taking action?
Multiple
Choice
Questions
Answer
View
c.
Defamation
d.
Negligence
Answer
2. A
Continuing to restrain a client by failing to adhere to policies
regarding frequency of assessment suggests false imprisonment,
the intentional and unjustifiable detention of a person against his
or her will. If policies were followed, assessment findings may
have indicated that the client's restraints were no longer needed.
Breach of client privacy involves invasion of the person's life and
sharing of client information with others without the client's
consent. Defamation involves injury to the person's reputation or
character through oral or written communications. Negligence
refers to conduct that falls below the standard of care
established by law, placing the client at an unreasonable risk of
harm.
3. Which of the following represents inappropriate
maintenance of client confidentiality by the psychiatric
nurse?
a. Discussing client's current problems and past history in
treatment team meeting
b. Explaining to client's visitor that it is inappropriate to
discuss client's care
c. Sending copy of client records to referring agency
without client's written consent
d. Telling a coworker that it is inappropriate to discuss
client's problems in the cafeteria
View
3. C
Answer
Answer
4. B
The key element or criteria for involuntary admission is that the
client is considered to be a threat to himself or others. Refusing
admission, a long history of mental illness, and a family's
request for admission are not considered appropriate criteria.
5. A client on a day pass from a psychiatric in-patient unit
runs a red light while driving and is involved in an accident
resulting in the death of another. The client's lawyer
subpoenas the nurse to testify at the trial that the client
was delusional when released for the day pass. The nurse
understands that the lawyer is attempting to establish the
legal defense of which of the following?
a.
Diminished
capacity
Answer
Internet
Resources
Selected
References
5254.
Journal
http://www.chhd.csun.edu/shelia/436/lecture0405.html
Johnson, B. S. (1997). Psychiatricmental
health
nursing:
1819.
Suggested
Readings
Journal
1722.
Chapter 6
Loss, Grief, and End-of-Life
Care
In this sad world of ours, sorrow comes to
all It comes with bittersweet agony
(Perfect) relief is not possible, except with
time. You cannot now realize that you will
ever feel better And yet this is a mistake.
You are sure to be happy again.
To know this, which is certainly true, will
make you feel less miserable now.
--Abraham
Learning
Lincoln
Objectives
care.
Differentiate between
dysfunctional
grief.
Define advance
planning.
care
Key
stages.
Terms
Advance
care
Advance
planning
directive
Bereavement
Durable health care power of attorney
Dying declaration exception to hearsay
Dying Person's Bill of Rights
Dysfunctional
End-of-life
grief
care
Grief
Grief
process
Health
care
directive
care
will
Loss
Mourning
Palliative
Patient
care
Self-Determination
Act
Suffering
Unresolved
grief
Loss
The concept of loss can be defined in several ways. The
following definitions have been selected to familiarize the
student with the concept of loss:
Change in status of a significant object
Any change in an individual's situation that reduces the
probability of achieving implicit or explicit goals
An actual or potential situation in which a valued object,
person, or other aspect is inaccessible or changed so that it
is no longer perceived as valuable
A condition whereby an individual experiences deprivation
of, or complete lack of, something that was previously
present
Everyone has experienced some type of major loss at one time
or another. Clients with psychiatric disorders, such as
Types of Loss
A loss may occur suddenly (eg, death of a child due to an auto
accident) or gradually (eg, loss of a leg due to the progression
of peripheral vascular disease). It may be predictable or occur
unexpectedly. Loss has been referred to as actual (the loss has
occurred or is occurring), perceived (the loss is recognized only
by the client and usually involves an ideal or fantasy),
anticipatory (the client is aware that a loss will occur),
temporary, or permanent. For example, a 65-year-old married
woman with the history of end stage renal disease is told by her
physician that she has approximately 12 months to live. She
may experience several losses that affect not only her, but also
her husband and family members, as her illness gradually
progresses. The losses may include a predictable decline in her
physical condition, a perceived alteration in her relationship
with her husband and family, and a permanent role change
within the family unit as she anticipates the progression of her
illness and actual loss of life. Whether the loss is traumatic or
temperate to the client and her family depends on their past
experience with loss; the value the family members place on the
loss of their mother/wife; and the cultural, psychosocial,
economic, and family supports that are available to each of
them. Box 6-1 describes losses identified by student nurses
during their clinical experiences.
Grief
Grief is a normal, appropriate emotional response to an
external and consciously recognized loss. It is usually timelimited and subsides gradually. Staudacher (1987, p. 4) refers
to grief as a stranger who has come to stay in both the
heart and mind.
Mourning is a term used to describe an
individual's outward expression of grief regarding the loss of a
love object or person. The individual experiences emotional
BOX 6.1
Examples
Student
of
Losses
Identified
by
Nurses
Loss of spouse, friend, and companion. The client was a 67year-old woman admitted to the psychiatric hospital for
treatment of depression following the death of her husband.
During a group discussion that focused on losses, the client
stated that she had been married for 47 years and had
never been alone. She described her deceased husband as
her best friend and constant companion. The client told the
student and group that she felt better after expressing her
feelings about her losses.
loss of body image and social role as the result of a belowthe-knee amputation. The client was a 19-year-old girl who
was involved in a motorcycle accident. She had shared her
feelings with the student nurse about her new
image and dating after hospitalization.
body
Grief
Theory
BOX 6.2
Five Stages of Grief Identified by
Kubler-Ross
Denial: During this stage the person displays a disbelief in
the prognosis of inevitable death. This stage serves as a
temporary escape from reality. Fewer than 1% of all dying
clients remain in this stage. Typical responses include:
No, it can't be true,
It isn't possible,
and
No, not me.
Denial usually subsides when the client
realizes that someone will help him or her to express
feelings while facing reality.
Unresolved
or
Dysfunctional
Grief
Unresolved or dysfunctional
grief could occur if the
individual is unable to work through the grief process after a
reasonable time. The cause of dysfunctional grief is usually an
actual or perceived loss of someone or something of great value
to a person. Clinical features or characteristics include
expressions of distress or denial of the loss; changes in eating
and sleeping habits; mood disturbances, such as anger,
hostility, or crying; and alterations in activity levels, including
libido (sex drive). The person experiencing dysfunctional grief
idealizes the lost person or object, relives past experiences,
loses the ability to concentrate, and is unable to work
purposefully because of developmental regression. The grieving
person may exhibit symptoms of anxiety (Chapter 21) ,
depression (Chapter 20), or psychosis (Chapter 18) .
Self-Awareness
Prompt
End-of-Life
Care
Self-Determination
Advance
Care
Planning
Ethnic Considerations
Sensitivity
and
Cultural
Palliative
Care
and
Hospice
Care
Manifestations
of
Suffering
BOX 6.3
Common Responses Associated
Suffering at End of Life
Behavioral:
Avoidance,
controlling,
With
distancing
Footnote
Adapted from: Kearney, M. (1996). Mortally
wounded. New
Pain
The Agency for Health Care Policy and Research (AHCPR; 1994,
p. 12) defined pain as an unpleasant sensory and emotional
experience associated with actual or potential tissue damage or
described in terms of such damage.
Box 6-4 lists the ABCDE
mnemonic of pain assessment and management as stated by
AHCPR.
BOX 6.4
ABCDE
Mnemonic
of
Pain
Management
A : Ask about the client's pain regularly and assess the pain
systematically.
B: Believe the client, family, and/or significant other in their
reports of pain and what relieves it.
C : Choose pain-control options that are appropriate for the
client, family, or significant other. Consider the setting in which
the client is receiving care.
D : Deliver nursing interventions in a timely, logical, and
coordinated
fashion.
E : Empower the client, family, and/or significant other. Enable
client to control his or her course to the greatest extent
possible.
Footnote
Source: Agency for Health Care Policy and Research. (1994).
Management of cancer pain, clinical practice guideline mumber
6. Rockville, MD: Department of Health and Human Services, p.
24.
P.68
In 1996, the World Health Organization (WHO; 1996) developed
an Analgesic Ladder that outlines the principles of analgesic
selection and titration as well as the use of adjunctive drug
therapy to ease pain or to counteract adverse effects
treatment of clients with cancer. For example, control
pain may be achieved with the use of a non-narcotic
As the severity of pain increases, a narcotic analgesic
in the
of mild
analgesic.
would be
SURVIVOR'S
NEEDS
Be available to offer
comfort and care even
though the survivor feels
like running away to
escape the pain of death
Remain as independent as
possible, fearing he or
she will become unlovable
Supporting
Evidence
for
Practice
6.1
Providing
Interventions
for
End-of-Life
Ethical Concerns of Clients in the
PsychiatricMental
Setting
Health
Clinical
ethical
Spiritual
Needs
BOX 6.5
The Dying Person's Bill of Rights*
I have the right to:
Be treated as a living human being until I die.
Maintain a sense of hopefulness however changing its focus may
be.
Be cared for by those who can maintain a sense of hopefulness,
however changing this might be.
Express my feelings and emotions about my approaching death
in my own way.
Participate in decisions concerning my care.
Expect continuing medical and nursing attention even though
cure
goals must be changed to comfort
goals.
Not die alone.
Be free from pain.
Have my questions answered honestly.
Not be deceived.
Have help from and for my family in accepting my death.
Die in peace and with dignity.
Retain my individuality and not be judged for my decisions,
which may be contrary to beliefs of others.
Discuss and enlarge my religious and/or spiritual experiences,
whatever these may mean to others.
Expect that the sanctity of the human body will be respected
after death.
Be cared for by caring, sensitive, knowledgeable people who will
attempt to understand my needs and will be able to gain some
satisfaction in helping me face my death.
Footnotes
(Taken from the American Journal of Nursing, January, 1975, p.
99)
*The Dying Person's Bill of Rights was created at a workshop on
The Terminally Ill Patient and the Helping Person
in
Lansing, Michigan, sponsored by the Southwestern Michigan
P.70
Self-Awareness
Prompt
Children
and
Death
AGE
GROUP
Age
35
years
DEVELOPMENTAL
RESPONSES, AND
CONCEPTIONS,
INTERVENTIONS
Ages
68
years
Ages
911
years
included
compartmentalization
of
Ages
1214
years
Ages
1517
years
Key
Concepts
end-of-life
care.
Chapter
Critical
Worksheet
Thinking
Questions
Your best friend hasn't been herself lately; in fact, you are
becoming increasingly worried about her. It has been 18
months since her father died of lung cancer. She is smoking
more, missing class, and reacting angrily when questioned.
Reflection
A new neighbor tells you that his wife of 30 years was killed in
an automobile accident 3 months ago and he is having difficulty
adjusting to living alone. Reflect on the chapter opening quote
by Abraham Lincoln. How would you interpret the meaning of
this quote? What significance does it have in relation to the
neighbor's disclosure about the loss of his wife?
Multiple
Choice
Questions
View
1. D
c.
Acceptance
d.
Bereavement
Answer
Answer
Answer
3. D
Preschool children, between the ages of 3 to 5 years, do not
view death as permanent and irreversible. Rather they view it
as a temporary trip in which the person still functions actively.
Therefore, they expect the person to come back. Children
between the ages of 5 to 6 see death as a reversible process
that others experience, whereas children between the ages of 6
to 9 begin to accept death as a final state, conceptualized as a
destructive force.
4. Palliative care differs from hospice care because
palliative care:
a. may be provided in the early stages of a chronic disease
b. requires that a client is a Medicare recipient
c. does not provide care for hospitalized clients
d. does not provide spiritual support for family members
View
4. A
Answer
Answer
5. C
In 1991, the American Nurses Association issued a position
statement that stated that promotion of comfort and aggressive
efforts to relieve pain and other symptoms in dying patients are
the obligations of the nurse. The Agency for Health Care Policy
and Research provided a definition of pain and specific
components of a pain assessment. The Joint Commission on
Accreditation of Healthcare Organizations issued pain treatment
standards that mandated pain assessment in all hospitalized
clients. The World Health Association developed an
analgesic ladder
to outline the principles of analgesic
selection and titration and adjunctive therapy for pain relief.
Internet
Resources
Selected
References
1213.
Lutheran
Fortress
Suggested
Readings
7577.
Frascogna, L. (2002). Legal Issues: Nurse testimony in
criminal court. American Journal of Nursing, 102(5),
6566.
Jarr, S. L., & Pierce, S. F. (2001). Nurses speak out to
improve end-of-life care. Advance for Nurses, 2(7), 2223,
36.
Kessler, D. (2001). The needs of the dying. Geriatric
2(3), 3942.
Times,
Chapter 7
Continuum of Care
Many patients leave the hospital with ongoing
medical (or mental health) needs, and they need a
health care continuum that workstreating the
whole person from wellness to illness to recovery,
within the community.
--Green & Lydon, 1998
Learning
Objectives
manager.
Key
Case
Terms
management
Community
mental
health
care
review
nurse
Inpatient
Care
BOX 7.1
Trends
Affecting
Delivery
of
Care
Administration's
website
at
http://www.hcfa.gov .
Acute
Care
Facilities
Subacute
Care
Units
units.
Clinical nurse specialists, nurse practitioners, or psychiatric liaison
nurses have been used in the subacute setting to ensure continuum
of care while medical needs are addressed and to assist with
discharge planning. Length of stay and services provided are
generally dictated by criteria developed by insurance providers or
Medicare.
Nurses may be confronted with culture shock as they apply subacute
care skills to clients. Endless paperwork, such as long assessment
forms and documentation necessary to comply with various
guidelines, rules, and regulations, can result in frustration. The
psychiatric needs of clients may go unnoticed or unmet if taskoriented procedures take precedence.
Long-Term
Care
(LTC)
Facilities
Over the past decade, the long-term care environment has changed
rapidly due to the establishment of subacute and rehabilitation units
within long-term care (LTC) facilities. The average client can be
admitted to the LTC facility for short-term rehabilitation, behavioral
problems, some chronic care issues, or respite care. Today, most
clients go home for services that were once provided in LTC facilities.
As a result, the clients that are admitted to LTC facilities have more
complex conditions or multiple problems. The prevalence of admitted
clients with a dual medical and psychiatric disorder has increased as
a result of these changes. Frequently seen comorbid psychiatric
diagnoses include dementia, delirium, organic anxiety disorder, mood
disorder,
and
adjustment
disorder.
P.79
Community
Mental
Health
continuity
of
care
Historical Development
Mental Health
of
Community
TYPE OF PROGRAM
DESCRIPTION
PROGRAM
NurseFamily
Located in 270
OF
GOAL OF
PROGRAM
Teach
positive
Partnership
communities in 23
states; nurses visit
high-risk pregnant
women
parenting and
coping skills
Schoolbased
mental health
Located in Dallas;
formed by a school
principal and
physician; nurses
and counselors
visit students
Identify mental
health problems
of students
Tailor classroom
activities to
meet specific
needs
IMPACT (Improving
Mood & Providing
Located in
California;
Identify
depression
Access to
Collaborative
Treatment)
of a mental health
professional and
medical team
older
Located in
California
Identify the
homeless
Provide safe
housing
Engage them in
care
Suicide
Encourages
Air Force
personnel to
seek help for
emotional pain
and trauma
prevention
consists
in
adults
Provides
education
training
regarding
and
stress
management
Concepts
of
Community
Mental
Health
multifaceted
treatment
program
Continuity of care
Group and family therapy
Environmental and social support and intervention
Community
participation,
support,
and
control
family and friends, and could strengthen the psychiatric client's need
for independence and self-care. Crosby further promoted the theory
that all community mental health should be based on the concepts of
structure, support, and conceptual awareness for adaptation to
societal norms and expectations.
The fundamental concepts and beliefs expressed in the 1980s about
the need for community mental health services still hold true today.
Unfortunately, an adequate financial budget from state and federal
governments to develop community mental health services to meet
these needs remains lacking. The hope is that the results of the New
Freedom Commission on Mental Health will inspire government
officials to revisit this issue.
Types of
Services
Community
Psychiatric
Emergency
Mental
Health
Care
business
hours.
care have included the use of mobile crisis units and crisis residence
units. Crisis residence units provide short-term (usually fewer than
15 days) crisis intervention and treatment. Clients receive 24-hourper-day
supervision.
Because of the psychiatric client's increasing reliance on these
emergency services in the past decade, hospitals have assumed a
key role in providing and managing crisis intervention and psychiatric
emergency care. Nurius (19831984) notes that hospitals often
functioned as the revolving door
between clients and the
mental health services network, focusing on crisis stabilization
services. The research that Nurius and others have conducted
indicates that the people who use community-based emergency
services most commonly tend to be young, unemployed veterans of
the mental health system and either chronically mentally ill or
chronic substance abusers.
The psychiatric emergency room is often located in a separate room
or a specially allocated section of the hospital emergency
department. The triage staff may include members of several
psychiatric disciplines: psychiatric nurses, social workers, mental
health counselors, and marriage and family therapists. The primary
focus is on crisis stabilization through the therapeutic interview and
immediate mobilization of available community- and client-centered
resources and support systems. A nurse practitioner or clinical nurse
specialist may supervise the triage area. The nurse may have a
collaborative agreement with a consulting psychiatrist to prescribe
necessary psychotropic medication or to support admission to a
psychiatric inpatient unit. The staff who provide these critical
services must be knowledgeable and skillful in the areas of
psychiatric assessment, including the administration of a complete
mental status examination; application of crisis intervention theories;
individual and family counseling; and use of resources in the specific
community that can provide emergency housing, financial aid, and
medical and psychiatric hospitalization.
Day-Treatment
Programs
hospital or partial
hospitalization
programs . The first day-treatment program in North
America was established in Montreal, Canada shortly after the end of
World War II. Day-treatment programs are usually located in or near
the community mental health center or in an inpatient treatment
facility such as a psychiatric hospital. The programs usually provide
treatment for 30 to 90 days, operating for 6 to 8 hours per day, 5
days a week. Most of these programs can accommodate up to 25
persons. These persons are not dysfunctional enough to require
psychiatric hospitalization, but need more structured and intensive
treatment than traditional outpatient services alone can provide.
These programs generally provide all the treatment services of a
psychiatric hospital, but the clients are able to go home each
evening.
Day-treatment programs are usually supervised by a psychiatrist and
staffed by psychologists, social workers, psychiatric nurses, family
therapists, activity therapists, and mental health counselors.
Multidisciplinary assessments usually include a physical examination;
a complete psychiatric evaluation; psychological, educational, and
nursing assessments; a substance abuse assessment; and a
psychosocial history. A treatment plan, which is usually formulated
within 10 days of admission to the program, is reviewed weekly by
the multidisciplinary treatment team. Examples of day-treatment
program interventions are listed in Box 7-2 .
Research shows that day-treatment programs have been successful,
as evidenced by the increase in the number of programs in
communities. Clients participating in day-treatment programs have
fewer hospitalizations, a decrease in psychiatric symptoms, more
successful work experiences, and better overall social functioning in
the community (National Alliance for the Mentally Ill [NAMI], 1999 ).
BOX 7.2
Examples
of
Day-Treatment
Interventions
Family
therapy
multifamily
groups
Program
therapy
therapy
Therapeutic
education
or
vocational
training
therapy
therapies
(eg,
art,
movement,
psychodrama)
P.82
Residential
Treatment
Programs
BOX 7.3
Examples of
Programs
Group
Residential
Treatment
housing:
Apartment
clusters,
transitional
residences,
Psychiatric
Home
Care
Aftercare
and
Rehabilitation
BOX 7.4
Therapeutic
Services
Provided
by
CMHCs
Self-Awareness
Prompt
Key
can provide
and evaluation
medical setting.
nonthreatening
Concepts
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
live.
Visit the Web site of a mental health support group on the
Internet. What information is available? How would the nurse be
able to use this information to benefit his or her client?
REFLECTION
Review the quote at the beginning of the chapter. Interview a client
in your present clinical practice setting. Assess the client's medical
and mental health needs. What health care service(s) should be used
to ensure an effective continuum of care for the client? Are such
services available in the community? If not, what alternative
interventions could be employed?
MULTIPLE
CHOICE
QUESTIONS
Utilization
reviewer
c. Primary nurse
d. Community mental health nurse
View
Answer
1. B
The utilization reviewer determines whether a client's clinical
symptoms meet the appropriate psychiatric or medical necessity
criteria or clinical guidelines. A case manager acts as a coordinator
of a client's care and determines the providers of care for a client
with a specific condition. The primary nurse is the nurse responsible
for the client's care 24 hours a day. The community mental health
nurse provides services to the psychiatric client in the community.
P.88
2. Which of the following reflects most accurately the direct
impact of managed care on psychiatric nursing care planning?
a. Assessing and planning for client care must occur in a short
period of time.
b. Family members need to be involved in planning care.
c. Clients require follow-up or provision for continuum of care.
d. All treatment team members should be involved with
planning.
View
2. A
Answer
Answer
Crisis
intervention
b.
Partial
c.
Residential
hospitalization
treatment
program
program
Answer
Answer
5. A
One of the key concepts of community mental health centers is
community participation, support, and control. By participating in a
parentteacher group, the nurse is providing information that
includes the total community. This discussion on discipline issues
would have no impact on preventing mental illness, providing
continuity of care, or addressing social and environmental
interventions.
Internet
Resources
Continuum of Care:
http://www.aacap.org/publications/factsfam/continum.htm
Managed
Nursing
Care
Case
Selected
Nursing:
http://www.aamcn.org
Management:
http://www.nursingcenter.com
References
fact
Suggested
Readings
Chapter 8
Assessment of
PsychiatricMental
Clients
Health
Learning
Objectives
assessment
process.
Key
Acute
Terms
insomnia
Affect
Blocking
Circumstantiality
Compulsions
Delusions
Depersonalization
Flight of ideas
Hallucinations
Insight
Insomnia
Memory
Mutism
Neologism
Neurovegetative
changes
Obsessions
Perseveration
Primary
insomnia
Secondary
insomnia
Verbigeration
The nursing process is a six-step problem-solving approach to
nursing that also serves as an organizational framework for the
practice of nursing (Fig. 8-1 ). It sets the practice of nursing in
motion and serves as a monitor of quality nursing care. Nurses in all
specialties practice the first step, assessment. This chapter focuses
specifically on the assessment of clients with psychiatric disorders,
including those clients who may have a coexisting medical diagnosis.
P.91
Client
Assessment
P.92
Two types of data are collected: objective and subjective. Objective
data include information to determine the client's physical
alterations, limits, and assets (Nettina, 2001 ). Objective data are
tangible and measurable data collected during a physical examination
by inspection, palpation, percussion, and auscultation. Laboratory
results and vital signs also are examples of objective data.
Subjective data are obtained as the client, family members, or
significant others provide information spontaneously during direct
questioning or during the health history. Subjective data also are
collected during the review of past medical and psychiatric records.
This type of data collection involves interpretation of information by
the nurse.
Types
of
Assessment
Cultural
Competence
During
Assessment
approaches
are:
Collection
of
Data
Appearance
General appearance includes physical characteristics, apparent age,
peculiarity of dress, cleanliness, and use of cosmetics. A client's
general appearance, including facial expressions, is a manner of
nonverbal communication in which emotions, feelings, and moods are
related. For example, people who are depressed often neglect their
personal appearance, appear disheveled, and wear drab-looking
clothes that are generally dark in color, reflecting a depressed mood.
The facial expression may appear sad, worried, tense, frightened, or
distraught. Clients with mania may dress in bizarre or overly colorful
outfits, wear heavy layers of cosmetics, and don several pieces of
jewelry.
Affect,
or
Emotional
State
may elicit
Ask
BOX 8.1
Types
of
Affective
Responses
Behavior,
Attitude,
and
Coping
Patterns
Communication
and
Social
Skills
disturbances
(Small,
1980 , p. 8).
Impaired
interaction
Communication
Blocking
Blocking refers to a sudden stoppage in the spontaneous flow or
stream of thinking or speaking for no apparent external or
environmental reason. Blocking may be due to preoccupation,
delusional thoughts, or hallucinations. For example, while talking to
the nurse, a client states, My favorite restaurant is Chi-Chi's. I
like it because the atmosphere is so nice and the food is
Blocking is most often found in clients with schizophrenia
experiencing auditory hallucinations.
Circumstantiality
With circumstantiality , the person gives much unnecessary detail
that delays meeting a goal or stating a point. For example, when
asked to state her occupation, a client may give a very detailed
description of the type of work she did. This impairment is commonly
found in clients with mania and those with some cognitive
impairment disorders, such as the early stage of dementia or mild
delirium. Individuals who use substances may also exhibit this
pattern of speech.
Flight
of
Ideas
Perseveration
DELUSION
DESCRIPTION
Delusion of
reference or
persecution
Delusion of
alien control
Nihilistic
delusion
Delusion
of
selfdeprecation
Delusion
grandeur
of
Napoleon!
Somatic
delusion
Verbigeration
Verbigeration describes the meaningless repetition of specific words
or phrases (for example, bad dog ). It is observed in clients
with certain psychotic reactions or clients with cognitive impairment
disorders.
Neologism
Neologism describes the use of a new word or combination of
several words coined or self-invented by a person and not readily
understood by others; for example, His phenologs are in the
dryer.
This impairment is found in clients with certain
schizophrenic
disorders.
Mutism
Mutism refers to the refusal to speak even though the person may
give indications of being aware of the environment. Mutism may
occur due to conscious or unconscious reasons and is observed in
clients with catatonic schizophrenic disorders, profound depressive
disorders, and stupors of organic or psychogenic origin.
Content
of
Thought
Delusions
Delusions are fixed false beliefs not true to fact and not ordinarily
accepted by other members of the person's culture. They cannot be
corrected by an appeal to the reason of the person experiencing
them. Delusions occur in clients with various types of psychotic
disorders, such as cognitive impairment disorder and schizophrenic
disorder, and in clients with some affective disorders. Table 8-1
describes several types of delusions.
HALLUCINATION
EXAMPLE
Auditory
hallucination
Visual
hallucination
rounds.
Olfactory
hallucination
Gustatory (taste)
hallucination
Tactile
hallucination
P.96
Hallucinations
Hallucinations are sensory perceptions that occur in the absence of
an actual external stimulus. They may be auditory, visual, olfactory,
gustatory, or tactile in nature (Table 8-2 ). Hallucinations occur in
clients with substance-related disorders, schizophrenia, and manic
disorders.
Depersonalization
Depersonalization refers to a feeling of unreality or strangeness
concerning self, the environment, or both. For example, clients have
described out-of-body sensations in which they view themselves from
a few feet overhead. These people may feel they are going
crazy.
Causes of depersonalization include prolonged stress and
psychological fatigue, as well as substance abuse. Clients with
schizophrenia, bipolar disorders, and depersonalization disorders
have described this feeling.
Obsessions
Obsessions are insistent thoughts, recognized as arising from the
self. The client usually regards the obsessions as absurd and
relatively meaningless. However, they persist despite his or her
endeavors to be rid of them. Persons who experience obsessions
generally describe them as thoughts I can't get rid of or by
saying I can't stop thinking of things they keep going on in
Compulsions
Compulsions are insistent, repetitive, intrusive, and unwanted urges
to perform an act contrary to one's ordinary wishes or standards. For
example, a client expresses the repetitive urge to gamble although
his wife has threatened to divorce him if he does not stop playing
poker. If the person does not engage in the repetitive act, he or she
usually experiences feelings of tension and anxiety. Compulsions are
frequently seen in clients with obsessivecompulsive disorders.
Orientation
During the assessment, clients are asked questions about their ability
to grasp the significance of their environment, an existing situation,
or the clearness of conscious processes. In other words, are they
oriented to person, place, and time? Do they know who they are,
where they are, or what the date is? Levels of orientation and
consciousness are subdivided as follows: confusion, clouding of
consciousness, stupor, delirium, and coma (Table 8-3 ).
Memory
Memory is the ability to recall past experiences. Typically, memory
is categorized as recent and long-term memory. Recent memory is
the ability to recall events in the immediate past and for up to 2
weeks previously. Long-term memory is the ability to recall remote
past experiences such as the date and place of birth, names of
schools attended, occupational history, and chronologic data relating
to previous illnesses. Loss of recent memory may be seen in clients
with dementia, delirium, or depression. Long-term memory loss
usually is due to a physiologic disorder resulting in brain dysfunction.
Memory defects may result from lack of attention, difficulty with
retention, difficulty with recall, or any combination of these factors.
Three disorders of memory include:
LEVEL
DESCRIPTION
Confusion
Clouding of
consciousness
Stupor
Delirium
Coma
Loss of consciousness
P.97
Intellectual
Ability
P.98
Insight
Regarding
Illness
or
Condition
Spirituality
Spirituality involves the client's beliefs, values, and religious culture.
Ability to obtain a spiritual history enables nurses to be better
equipped in evaluating whether these beliefs and values are helping
or hindering the client. For example, does the hospitalized client
exhibit spiritual anxiety and verbalize a need to connect with his or
her own spiritual support system? Is the terminally ill client
exhibiting a spiritual dilemma regarding the meaning of life and
death or the presence of a higher power? Questions asked in a
matter-of-fact fashion can focus on the religious background of
parents, spouse, or significant other; the client's current religious
affiliation or important spiritual beliefs; whether the client is
currently active in a religious community; whether religious beliefs
serve as a coping mechanism; and to what extent religious or
spiritual issues are pertinent to the client's current situation (Larson,
Larson, & Puchalski, 2000 ). A sample spiritual needs assessment is
shown in Figure 8-3 .
Sexuality
Sexuality may be a factor with a client for a number of reasons. For
example, a client may be impotent, may have lost a sexual partner,
or may have been a victim of sexual abuse. The following questions
may be helpful in initiating a discussion on the topic of sexuality:
Does the client express any concerns about sexual identity,
activity, and function?
When did these concerns begin?
Does the client prefer a male or female clinician to discuss these
concerns?
The age and sex of the clinician may affect the responses given. For
example, a 50-year-old male client may feel uncomfortable
discussing issues related to sexuality with a nurse who appears to be
the same age as his daughter. A female client with the clinical
symptoms of
P.99
depression may be reluctant to discuss sexual abuse with a male
nurse. Obtaining a sexual history is discussed in detail in Chapter 27
, Sexuality and Sexual Disorders.
SUPPORTING
EVIDENCE
FOR
PRACTICE
8.1
Nursing
Assessment
for Clients in
Health Setting
Insomnia
and
Interventions
the PsychiatricMental
Who Experience
Footnote
Source: Nowell, P. D., et al. (1997, Oct.) Clinical factors
contributing to the differential diagnosis of primary insomnia and
insomnia related to mental disorders. American Journal of Psychiatry
154
Neurovegetative
Changes
Neurovegetative
changes involve changes in psychophysiologic
functions such as sleep patterns, eating patterns, energy levels,
sexual functioning, or bowel functioning. Persons with depression
(see Chapter 20 ) usually complain of insomnia or hypersomnia, loss
of appetite or increased appetite, loss of energy, decreased libido,
and constipation, all signs of neurovegetative changes. Persons who
are diagnosed as psychotic may neglect their nutritional intake,
appear fatigued, sleep excessively, and ignore elimination habits
(sometimes to the point of developing a fecal impaction).
During the collection of data, specific questions are asked about the
client's appetite and eating pattern, energy level and ability to
Sleep
Pattern
BOX 8.2
Common
Sleep
Disorders
Medical
Issues
Pain
Pain, a major yet largely avoidable health problem, is considered a
multidimensional experience that potentially affects the individual
physically, emotionally, spiritually, and socially. The Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)
has developed standards that create new expectations for the
assessment and management of pain in accredited hospitals and
other health care settings, including behavioral health facilities.
Clinicians are now expected to assess, record, and treat pain as
routinely as they would the other four vital signs.
Initially, pain is assessed using a pain intensity rating scale
appropriate to the client's age and ability to communicate. This
baseline pain assessment is used for comparison with all future
assessments.
Self-report of pain is the most reliable and valid pain assessment
tool. If the client is unable to communicate, data are obtained by
observing behavior, obtaining proxy reports from family or significant
others, or by the documentation of physiological parameters
(Dempsey, 2001).
Physiological
Responses
to
Medication
Documentation
of
Assessment
Data
Examples
of
Documentation
Self-Awareness
Prompt
BOX 8.3
Example of DAP Nursing Progress Notes
DATE
AND
PROBLEM
NUMBER
TIME
2/7/00
9:00
AM
NAME
AND
TITLE
#1
J
Smith,
ARNP
MULTIDISCIPLINARY
TREATMENT TEAM
PROGRESS
NOTES
2/7/00
2:00
PM
#1
M
Smith,
D: RK attended group
therapy from 1:00 PM to
LCSW
2:00 PM
A: Informed members of
group of incident that
occured at 9 AM today.
Appeared calm. Good eye
contact. Did not express
fears.
P: Focus on present coping
skills. Encourage attendance
and participation in group
therapy on M-W-F.
P.102
Key
Concepts
psychologically,
and
spiritually.
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
Review the quote at the beginning of the chapter, then complete an
assessment of a client in your clinical practice setting. What
information did you obtain? How was that information crucial to the
client's care?
MULTIPLE
CHOICE
QUESTIONS
Answer
Blocking
b.
Circumstantiality
c.
Perseveration
d.
View
2. B
Neologism
Answer
Answer
3. D
A person exhibiting flight of ideas continuously shifts from one idea
to another and these ideas are fragmentary. Sudden stops in the
flow of conversation indicate blocking. Coining new words or
combinations of several words indicates neologism. Providing
excessive detail that delays starting a point indicates
circumstantiality.
4. A client tells the nurse that his body is made of wood and is
quite heavy. The nurse interprets this as which of the
following?
a.
Compulsion
b.
Hallucination
c.
Depersonalization
d.
View
Obsession
Answer
4. C
The client's description suggests depersonalization, a feeling of
unreality or strangeness about one's self, the environment, or both.
A compulsion is an insistent, repetitive, intrusive, and unwanted urge
to act contrary to one's ordinary wishes or standards. Hallucination
refers to sensory perceptions that occur without an actual external
stimulus. Obsession is an insistent thought from within one's self.
5. Which finding would lead the nurse to suspect that a female
client has insight into the mental disorder she is experiencing?
a. Demonstration of self-understanding related to the origin of
behavior
b. Verbalization of acceptance of her mental illness
c. Placement of responsibility for problems on dysfunctional
family
d. Suggestion that problems are related to bad nerves
View
5. A
Answer
Internet
Resources
American
Journal
of
Nursing:
http://www.ajnonline.com/
Net,
http://www.medscape.com/druginfo
Inc.:
http://www.painnet.com/
Sleepnet:
http://www.sleepnet.com
Selected
References
17 (1),
Suggested
examination . East
Readings
for
Philadelphia:
Lippincott
Williams
&
Wilkins.
Journal
Geriatrics,
8 (9),
standards.
Chapter 9
Nursing Diagnosis, Outcome
Identification,
Planning,
Implementation, and Evaluation
Making accurate nursing diagnoses takes
knowledge and practice. If the nurse uses a
systematic approach to nursing diagnosis
validation, the accuracy will increase. The
process of making nursing diagnoses is difficult
because nurses are attempting to diagnose
human responses. Humans are unique, complex,
and ever-changing.
--Carpenito,
Learning
2002
Objectives
health
setting.
nursing
diagnosis.
health
setting.
Key
Actual
Terms
nursing
diagnosis
Clinical
pathways
Critical
pathways
Cues
Decision
trees
DSM-IV-TR
Expected
outcomes
Inferences
Nursing
Risk
diagnosis
nursing
diagnosis
nursing
nursing
diagnosis
diagnosis
diagnosis
identification
Nursing
Diagnosis
2002) .
2002) .
Diagnostic
Systems
CLASSIFICATION
EXAMPLES
Actual Nursing
Diagnoses
Risk Nursing
Diagnoses
Wellness
Readiness
Diagnoses
Nursing
for
Enhanced
Community
Syndrome Nursing
Diagnoses
Impaired
Environmental
Interpretation Syndrome related to
disorientation and confusion
Rape-Trauma Syndrome related to
sexual assault as evidenced by
Relocation Stress Syndrome related
to high degree of environmental
change secondary to frequent
moves
P.107
BOX 9.1
Nursing Diagnoses in
PsychiatricMental
Health
Acute
Confusion
Anticipatory
Grieving
Anxiety
Bathing/Hygiene
Decisional
Self-Care
Deficit
Conflict
Deficient
Diversional
Deficient
Knowledge
Activity
Sleep
Pattern
Dressing/Grooming
Dysfunctional
Fear
Self-Care
Grieving
Deficit
Nursing
Feeding
Self-Care
Deficit
Hopelessness
Imbalanced
Nutrition:
Adjustment
Impaired
Memory
Impaired
Parenting
Impaired
Social
Impaired
Verbal
Interaction
Communication
Ineffective
Coping
Ineffective
Health
Ineffective
Role
Ineffective
Sexuality
Interrupted
Maintenance
Performance
Family
Patterns
Processes
Noncompliance
Post-Trauma
Syndrome
Powerlessness
Relocation
Stress
Syndrome
for
Other-Directed
Violence
Isolation
Spiritual
Distress
Toileting
Self-Care
Deficit
were made:
Anticipatory Grieving related to terminal condition as
evidenced by denial, anger, and the statement I don't
have long to live
P.108
Situational Low Self-Esteem due to alterations of body
image as evidenced by negative statements about self
Defensive Coping demonstrated by the increased use of
suppression, projection, dissociation, and denial
Anxiety, acute, related to illness, hospitalization, and
separation from spouse as evidenced by increased
restlessness, rapid pulse, and increased questioning about
illness
BOX 9.2
DSM-IV-TR
Multiaxial
System
code)
Footnote
With permission from The American Psychiatric Association.
(2000). Diagnostic and statistical manual of mental disorders (4th
ed., Text Revision). Washington, DC.
Just as the ANA and PMHN have formed a task force to develop a
single nursing classification system, the APA has worked closely
with the World Health Organization (WHO), developers of the
International Statistical Classification of Diseases and Related
Health Problems (ICD-9-CM and ICD-10), to ensure that both
systems are compatible and correspond more closely. For
example, ICD codes are used for selected medical conditions and
medication-induced disorders included in Axis III (General Medical
Decision
Trees
for
Differential
Diagnoses
Outcome
Identification
Self-Awareness
Prompt
Planning
The next phase of the nursing process is planning. This phase
involves developing a plan of care to guide therapeutic
intervention and achieve expected outcomes (Figure 9-1) .
Plan of Care
The plan of care, or nursing care plan, is individualized and
identifies priorities of care and proposed effective interventions. It
includes client education to achieve the
P.110
stated outcomes. Stating the rationale for the planning and
implementation of each nursing intervention is an effective way to
help students understand the development of the plan of care. The
responsibilities of the psychiatricmental health nurse, client,
and multidisciplinary team members are indicated. Team members
are allowed access to the plan of care when it is documented,
modifying the plan as necessary (American Nurses Association,
2000).
Implementation
During implementation, the nurse uses various skills to put the
plan of care into action. Standard V of the Standards of Care
describes interventions planned by the psychiatricmental
health nurse. These interventions are categorized based on the
nurse's level of education and certification. The following is a list
of interventions used by all nurses in the psychiatricmental
health clinical setting:
Counseling interventions to help the client improve or regain
coping abilities
Maintenance of a therapeutic environment or milieu
Structured interventions to foster self-care and mental and
physical well-being
Psychobiologic interventions to restore the client's health and
prevent
Health
Case
future
disability
education
management
health
nurse
P.111
provides
agent
prescription
Evaluation
The evaluation phase of the nursing process focuses on the
client's status, progress toward goal achievement, and ongoing
reevaluation of the care plan. Four possible outcomes may occur:
(1) the client may respond favorably or as expected to nursing
interventions; (2) short-term outcomes (goals) may be met but
long-term goals may remain unmet; (3) the client may be unable
to meet or achieve any outcomes (goals); or (4) new problems or
needs may be identified, requiring the
the plan of care. All members of the
team, as well as the client, should be
feedback regarding the effectiveness of
Key
Concepts
Self-Awareness
Prompt
psychiatricmental
health
nursing
diagnoses.
Clinical nurse specialists and nurse practitioners use the DSMIV-TR to make a psychiatric diagnosis when a psychiatric
problem exists.
Outcomes are measurable client-oriented goals that are the
expected consequences of a treatment or intervention.
The plan of care must be individualized to meet the needs of
the client; the client's needs are prioritized according to
urgency or seriousness of identified problems.
None
identified
PLANNING/IMPLEMENTATION
RATIONALE
Establishing a
routine sleep
pattern promotes
sleep hygiene
and deters
erratic sleep
habits
so forth
facilitate
effective
pattern
Keeping a sleep
an
sleep
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
The chapter opening quote states that making accurate nursing
diagnoses takes knowledge and practice. As you developed the
care plan for the client listed in question number 4 of the Critical
Thinking Questions, did you have any difficulty arriving at a
nursing diagnosis or diagnoses? How did you validate data? How
did you classify your nursing diagnoses (eg, actual, risk, wellness,
or syndrome diagnosis)?
P.114
MULTIPLE
CHOICE
QUESTIONS
priority?
a.
Ineffective
Denial
Answer
improved.
d. The client will spend time with peers and staff members in
unit activities.
View
Answer
2. D
The most appropriate outcome would be the client spending time
with peers and staff members in unit activities. By participating in
unit activities with others, the client is no longer socially isolated.
In addition, this participation helps to foster a beginning sense of
Self-esteem
Self-actualization
d. Physical safety
View
3. D
Answer
View
4. B
Answer
Answer
or
Internet
appearance.
Resources
Selected
References
practice
11(10),
7578.
Suggested
Readings
of
Chapter
10
Therapeutic Communication
Relationships
and
Listen
When I ask you to listen to me and you start giving
advice, you have not done what I asked.
When I ask you to listen to me and you begin to tell
me why I shouldn't feel that way, you are trampling
on my feelings.
When I ask you to listen to me and you feel you
have to do something to solve my problem, you
have failed me, strange as that may seem.
Listen! All I asked was that you listen, not talk or
dojust hear me.
And I can do for myself; I'm not helpless. Maybe
discouraged and faltering, but not helpless.
When you do something for me that I can and need
to do for myself, you contribute to my fear and
weakness.
But, when you accept as a simple fact that I do feel
what I feel, no matter how irrational, then I can
Learning
Objectives
the
factors
that
influence
communication.
during
Key
therapeutic
relationship.
Terms
Comfort
zones
Communication
Countertransference
Nonverbal
communication
Parataxic
Process
distortion
recording
Professional
Social
boundaries
communication
Therapeutic
communication
Therapeutic
relationship
Transference
Verbal
communication
Communication
Factors
Influencing
Communication
Attitude
Attitudes are developed in various ways. They may be the result of
interaction with the environment; assimilation of others' attitudes;
life experiences; intellectual
P.117
processes; or a traumatic experience. Attitudes can be described as
accepting, caring, prejudiced, judgmental, and open or closed
minded. An individual with a negative or closed-minded attitude may
respond with It won't work
or It's no use trying.
Conversely, the individual with a positive or open-minded attitude
may state Why not try it? We have nothing to lose.
Sociocultural
or
Ethnic
Background
often are quiet and reserved, may appear stoic and reluctant to
discuss personal feelings with persons outside their families.
Past
Experiences
Knowledge
of
Subject
Matter
Interpersonal
Perceptions
Environmental
Factors
Types
of
Communication
Verbal
Communication
Nonverbal
Communication
Vocal
health
clinical
setting.
Cues
explored.
Gestures
Pointing, finger tapping, winking, hand clapping, eyebrow raising,
palm rubbing, hand wringing, and beard stroking are examples of
nonverbal gestures that communicate various thoughts and feelings.
They may betray feelings of insecurity, anxiety, apprehension,
power, enthusiasm, eagerness, or genuine interest.
Physical
Appearance
Distance
or
Spatial
Territory
BOX
10.1
Territory
Position
or
Posture
Touch
Reactions to touch depend on age, sex, cultural background,
interpretation of the gesture, and appropriateness of the touch. The
nurse should exercise caution when touching people. For example,
hand shaking, hugging, holding hands, and kissing typically denote
positive feelings for another person. The client with depression or
who is grieving may respond to touch as a gesture of concern,
whereas the client who is sexually promiscuous may consider
touching an invitation to sexual advances. A child suffering from
abuse may recoil from the nurse's attempt to comfort, whereas a
person who is dying may be comforted by the presence of a nurse
sitting by the bedside silently holding his or her hand.
FIGURE
P.119
Facial
Expression
Effective
Therapeutic
Communication
Self-Awareness
Prompt
Ineffective
Therapeutic
Communication
BOX
10.2
Social
and
Therapeutic
Communication
with
clients.
interaction:
Exercise
effective
listening.
Confidentiality
During
Communication
SOCIAL
THERAPEUTIC
Therapeutic
communication
promotes the functional use of
one's latent inner resources.
Encouraging verbalization of
feelings after the death of
one's child or exploring ways
to cope with increased stress
are examples of therapeutic
helping.
A personal or intimate
relationship
occurs.
not be discussed.
client.
Constructive or destructive
dependency may occur.
Constructive
dependency,
interdependency,
and
independence, are promoted.
socialization.
nursing
interventions.
Saunders.
P.122
TABLE 10.2
Therapeutic
Communication
TECHNIQUES
Using
silence
EXAMPLES
Yes. That must have been
Accepting
Giving recognition
acknowledging
Offering
Techniques
or
self
Offering
Go on.
or
general
leads
door-openers
Encouraging
of
description
perceptions
Encouraging
comparison
Restating
Reflecting
Focusing on specifics
Exploring
Giving information
informing
or
Seeking clarification
clarifying
Presenting reality
confronting
Voicing
or
doubt
Encouraging
or
or
evaluating
His name is
I'm going with you to the beauty
shop.
evaluation
Attempting to translate
into feelings or
verbalizing the implied
Suggesting
collaboration
Summarizing
Encouraging
formulation
of a plan of action
Asking
direct
questions
The
One-to-One
NurseClient
Therapeutic
Relationship
A therapeutic
relationship is a planned and goal-directed
communication process between a nurse and a client for the purpose
of providing care to the client and the client's family or significant
others. An understanding of the factors influencing communication,
realization of the importance of nonverbal communication,
development of effective communication skills, recognition of the
causes of ineffective communication, and ability to participate in a
therapeutic communication process provide the foundation for
developing a therapeutic relationship with a client.
Conditions Essential
Relationship
for
Therapeutic
of
feelings when he or she believes the client will benefit from such
a discussion.
Client
Boundaries
of
Therapeutic
Relationships
BOX
10.3
Examples of
Violations
Professional
Boundary
Roles of
Nurse in
Self-Awareness
Prompt
agent.
Phases
of
Therapeutic
Relationship
Initiating
or
Orienting
Phase
therapeutic
environment,
including
privacy
Working
Phase
available
a
Encouraging
positive
support
systems
self-concept
verbalization
of
feelings
client
Terminating
independence
Phase
independence
and
work
interdependently
with
emotional
stability
Process
Recording
BOX
10.4
Process
Client's
Recording
Format
initials:
Age:
Nursing
diagnosis:
changes in eye contact, voice quality, and voice tone by the client or
yourself.
Evaluation
of
Key
Concepts
BOX
10.5
Example
Client's
of
Process
Recording
initials: JW
Age: 33
Nursing diagnosis: Anxiety related to hospitalization, limited
mobility, and pain
Goal of interaction: To explore coping skills to reduce anxiety
Description
of
STUDENT
CLIENT
INTERPRETATION
Good morning.
My name is. I will
be your nurse for this
morning.
(Smiling; speaking
softly; gazing directly
at JW while walking
to the side of the
bed.)
Oh. How
long will you
be here?
(Turns over
in bed and
briefly gazes
at me with a
blank facial
expression;
speaks in a
low voice.)
It
started as I
moved a
chair in my
living
room.
Client appears to
have difficulty with
mobility.
Client may not
wish to interact at
this time.
a . Giving recognition
b . Giving
information
c . Offering self
(Maintains
eye contact
and grimaces
as he
moves.)
It's a
sharp,
Client is
responding
(Maintaining eye
contact while sitting
in chair beside his
bed.)
stabbing pain
that occurs
whenever I
move from
individual
attention.
a.
b.
to
Client is beginning
a . Exploring
b . Active listening
side to side
or try to get
up and
walk.
(Facial
expression is
more relaxed
with less
grimacing.)
It also
bothers me
when I have
a lot on my
mind, like
problems at
home.
I've
never had a
back
injury.
My
doctor told
me I should
see a
counselor
because it
could be due
to my
to disclose his
feelings.
nerves.
I guess
he knows
Client is becoming
uncomfortable with
recommendation?
(Maintaining eye
contact; sitting.)
what he is
doing.
(Breaks eye
contact;
the
a . Encouraging
conversation.
a . Encouraging
description of
perceptions
fingers
sheets
nervously.)
I hope
so. I can't
afford to
miss any
more
work.
(Became
more
relaxed. Eye
contact
improved.)
Client appears to
be relieved that he
will be able to
discuss his feeings
with a counselor
and possibly avoid
hospitalization in
the future.
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
Imagine that you enter a client's room and find her crying
quietly. She looks up and tells you that her doctor has just
announced that she needs surgery. Construct an imaginary
conversation in which you encourage her to explore her fears,
REFLECTION
Reflect on the quote at the beginning of the chapter. Do any of the
statements apply to you? If so, which ones? What actions can you
take to improve your listening skills?
MULTIPLE
CHOICE
QUESTIONS
Answer
Answer
Telling the client that she will do the right thing provides the client
with false reassurance. Such a response blocks communication and is
ineffective, possibly leading to mistrust if the statement turns out to
be incorrect. False reassurance does not foster client independence,
provide time for the nurse to think about the situation, or provide
the client with support and encouragement.
3. The client states, I'm not sure what to do. What do you
think would be best?
The nurse refrains from giving advice
for which of the following reasons?
a. Advice may be more appropriate if it comes from the
physician.
Answer
Establishing
c.
Exploring
therapeutic
alternate
contract
behaviors
Answer
Counselor
b. Socializing agent
c. Surrogate parent
d. Teacher
View
5. B
Answer
Internet
Resources
NursePatient
Therapeutic
Relationships:
http://www.southalabama.edu/nursing/psynp/nursepat.pdf
Therapeutic communication techniques:
sioux.org/dcli/dcli_tips09.pdf
Selected
http://www.alz-
References
therapeutic
communication . Bowie,
for
therapeutic
relations
in
Suggested
Readings
Chapter
The
11
Therapeutic
Milieu
Learning
Objectives
therapy .
spiritual
needs.
Key
Terms
training
Aversion
therapy
Behavior
therapy
Cognitive
behavior
therapy
Flooding
Implosive
therapy
Limit-setting
Milieu
therapy
nursing
care
Religion
Skinner's Theory of Operant Conditioning
Sleep
pattern
disturbance
Spiritual
distress
Spirituality
Systematic
desensitization
Therapeutic
milieu
Ward
Atmosphere
Scale
Development
of
the
Therapeutic
Milieu
Components
of
Therapeutic
Milieu
mental
Participants
health
in
settings.
the
Therapeutic
Milieu
BOX
11.1
Criteria
Milieu
for
Establishing
Therapeutic
regulations,
and
a socially
acceptable
manner.
TABLE 11.1
Multidisciplinary
DISCIPLINE
Treatment
Team
DESCRIPTION
Psychiatric
A registered
nurse
specializing
in
psychiatric
nurse
Psychiatric
nurse
assistant or
technician
High school graduate who receives inservice education pertaining to the job
description. Assists the mental health team
in maintaining a therapeutic environment,
providing care, and supervising client
activities.
Psychiatrist
Clinical
psychologist
Psychiatric
social
worker
environment.
Conducts
the
intake
interview;
Occupational
therapist
Educational
therapist
Art
therapist
settings.
Musical
therapist
Psychodrama
therapist
Recreational
or activity
therapist
Play
Pet
therapist
therapist
Speech
therapist
Chaplain
Dietitian or
clinical
nutritionist
Auxiliary
personnel
clients.
P.133
The multidisciplinary treatment team participates in regularly
scheduled meetings to allow team members to discuss the client's
progress and to review the client's individualized plan of care.
Clients, family members, significant others, and support persons are
invited to participate in these meetings (Figure 11-1 ). Their input is
encouraged as clients develop positive coping skills and are
empowered to demonstrate accountability and responsibility in
interdependent
relationships.
Interventions
Milieu
Used
in
the
Therapeutic
Client
Education
P.134
According to the 1992 National Adult Literacy Survey conducted by
the Department of Education's National Center for Education
Statistics, approximately 40 million adults in the United States can't
understand written materials due to limited or low literacy. Older
adults and members of inner-city minority groups are twice as likely
to have poor reading abilities compared with the general population.
However, despite these statistics, written patient education materials
provided by health care facilities continue to be a primary source of
information for many clients. Therefore, educational material should
contain familiar words and short sentences, and define any essential
medical or psychiatric terminology in simple language (Winslow,
2001 ).
FIGURE
information:
Prioritize the client's needs and focus on everyday issues (eg,
safety versus nutritional needs).
Present specific information (eg, Let's discuss what you
should do when you experience what you describe as panic
attacks.
).
Use simple language and avoid speaking in a monotone.
Utilize different educational approaches depending on the client's
ability to relate to the written word, video or audio presentations,
or ability to use the Internet.
Involve family members and support persons in the educational
process.
Educate and reinforce information while providing care.
Spiritual
Interventions
(eg,
dietary,
clothing,
activities).
Personal
and
Sleep
Hygiene
Management
FIGURE
Pain
Management
Protective
Care
1999 ).
Self-Awareness
Prompt
Behavior
Therapy
(1989)
P.139
Faulty learning can result in psychiatric disorders.
Behavior is modified through the application of principles of
learning.
Maladaptive behavior is considered to be deficient or excessive;
thus, behavior therapy seeks to promote appropriate behavior or
Behavior
Modification
Aversion
Aversion
Therapy
Cognitive
Cognitive
Behavior
behavior
Therapy
Assertiveness
During assertiveness
Training
training , clients are taught how to relate
Implosive
Therapy
Limit-Setting
Limit-setting is an important aspect of the therapeutic milieu.
Limits reduce anxiety, minimize manipulation, provide a framework
Adjunctive
or
Management
Therapy
Self-Awareness
Prompt
What behaviors do you find, or do you think you will find, disturbing
or difficult to deal with in the psychiatric setting? Why? How can you
overcome these responses to provide professional, competent, and
therapeutic care?
Evaluation
of
the
Therapeutic
Milieu
as
Key
Concepts
Chapter
Critical
Worksheet
Thinking
Questions
Reflection
Review the quote at the beginning of the chapter and then interview
three members of the staff who work with clients in your current
clinical area (the staff members may represent different disciplines
such as nursing, social services, or occupational therapy). Ask each
of them to describe their perceptions of a therapeutic milieu. Do they
have similar perceptions? If not, how do their perceptions differ?
Multiple
Choice
Questions
Answer
Answer
Answer
3. B
When acting as the mother surrogate, the nurse assists the client to
perform activities of daily living. Here, this would be assisting the
client to bathe and change her clothes. Rather than allowing the
Answer
Assertiveness
training
b. Aversion therapy
c. Implosive therapy
d.
View
5. C
Behavior
Answer
modification
Internet
Resources
Recovery
Center:
Selected
http://www.advanceforsleep.com
&
Health:
http://www.spiritualityhealth.com
References
psychiatric
Psychiatric
IL:
Author.
Suggested
Readings
5660.
Jasovsky, D. A., & Webb, E. M. (1998). Where are your patient
education resources? American Journal of Nursing, 98 (4),
16aaaa16bbbb.
Jensen, B., Hess-Zak, A., Johnston, S. K., Otto, D. C., Tebbe, L.,
Russell, C. L., et al. (1991). Psychiatricmental health nursing.
Application of the nursing process . Philadelphia: J. B. Lippincott.
Larson, D. B., Larson, S. S., & Puchalski, C. M. (2000). The onceforgotten factor in psychiatry, Part 1: Residency training
addresses religious and spiritual issues. Psychiatric Times, 17 (1),
1823.
Moos, R. H. (1974). Evaluating treatment
ecological
approach . London: Wiley.
environments:
social-
Chapter
12
Crisis
Intervention
Learning
Objectives
Define crisis
intervention .
intervention.
Key
Terms
Crisis
Crisis
forensics
Crisis
intervention
Crisis
situations
Maturational
crisis
crisis
P.146
On September 11, 2001, the hijacking of commercial airplanes and
subsequent terrorist attacks on the World Trade Centers and
Pentagon left many Americans feeling numb, frightened, angry, and
profoundly sad. The number of individuals classified as missing or
dead was high, businesses were destroyed, and many individuals
stated that they would never fly again.
In October 2002, the beltway sniper
killed several
individuals in Maryland, Virginia, and Washington, DC. Residents of
these areas responded to this stressful situation by discontinuing
their daily routines such as grocery shopping, going to gas stations,
eating at restaurants, attending outdoor activities, and taking their
children to school. Numerous outdoor events were cancelled. Public
schools maintained a lock-down mode and later cancelled classes.
The news media often calls such crimes against the public crisis
Crises
Most people exist in a state of equilibrium, despite the occurrence of
crisis situations. That is, their everyday lives contain some degree of
harmony in their thoughts, wishes, feelings, and physical needs. This
existence generally remains intact unless there is a serious
interruption or disturbance of one's biologic, psychological, spiritual,
or social integrity. As undue stress occurs, one's equilibrium can be
affected and one may lose control of feelings and thoughts, thus
experiencing an extreme state of emotional turmoil. When this
occurs, one may be experiencing a crisis. Individuals respond to
crisis in different ways. Table 12-1 summarizes two types of common
responses to a crisis, high anxietyemotional shock or
stunnedinactive
response.
TYPE OF RESPONSE
High-anxietyemotional
shock
CLINICAL
SYMPTOMS
Hyperactivity
Loud screaming or crying
Wringing of the hands
Rapid speech
Increased
respirations
Flushed face
Nausea/vomiting
Emotionally out of control
Stunnedinactive
response
Inactivity
Aimless wandering
Pale appearance
Rapid pulse, low blood
pressure
Cold, clammy skin
Diaphoresis
Nausea/vomiting
Syncope (fainting)
Types of Crises
A crisis can be situational or maturational. A situational crisis
refers to an extraordinarily stressful event such as the terrorist
attacks or beltway sniper
incidents that affects an individual
or a family regardless of age group, socioeconomic status, or
sociocultural status. Examples of other events that can precipitate a
situational crisis include economic difficulty, medical or psychiatric
illness, rape, workplace or school violence, marital discord, divorce,
or death of a loved one due to a terminal illness.
A maturational
crisis , on the other hand, is an experiencesuch
as puberty, adolescence, young adulthood, marriage, or the aging
processin which one's lifestyle is continually subject to change.
These are the normal processes of growth and development that
evolve over an extended period and require the person to make some
type of change. Another example of a maturational crisis is
retirement, in which a person faces the loss of a peer group as well
as loss of a status identity.
Classification
According
to
Severity
Characteristics
of
Crisis
Phases of a Crisis
Research involving crisis has led to the identification of specific
stages or phases associated with it. Most individuals consider Eric
Lindemann (1965) to be the father of crisis theory. His theory
evolved from the study of grief responses in families of victims of the
Coconut Grove nightclub fire in Boston in 1943. After World War II,
Gerald Caplan (1964) contributed to the concept of crisis theory
while working with immigrant mothers and children. Each described
stages or phases of a crisis. Generally, theorists describe five stages
or phases of a crisis:
Precrisis
Impact
Crisis
Resolution
Postcrisis
The general state of equilibrium in which a person is able to cope
with everyday stress is called the precrisis phase . When a stressful
event occurs, the person is said to be experiencing the impact phase
. This phase occurs when, for example, a pediatrician tells a young
couple that their 5-year-old son has inoperable cancer. After the
shock is over, the young parents become acutely aware of their son's
critical illness and poor prognosis. This is an extraordinarily stressful
event, threatening their child's life and their integrity as a family.
With this realization, they are now in the crisis phase . They may
experience continuing confusion, anxiety, and disorganization
because they feel helpless and are unable to cope with their son's
physical condition. When the young parents are able to regain control
of their emotions, handle the situation, and work toward a solution
concerning their son's illness with or without intervention from
others, they are in the resolution phase of a crisis. If they are able to
resume normal activities while living through their son's
hospitalization and illness, they are in the postcrisis phase . The
Paradigm
of
Balancing
Factors
Realistic
Perception
A realistic
perception occurs when a person is able to distinguish the
relationship between an event and feelings of stress. For example, a
45-year-old executive recognizes the fact that her company is on the
verge of bankruptcy because of inefficient projected financial
planning by the board of trustees. Although she realizes the
seriousness of the situation and feels stress, she does not place the
blame on herself and view herself as a failure. Her perception ,
rather than the actual event, determines her reaction to the
situation.
P.148
PHASES
DESCRIPTION
1.
Precrisis
2.
Initial impact or
shock occurs (may
last a few hours to a
few days)
3.
4.
Recoil,
acknowledgment, or
beginning of
resolution occurs
5.
Resolution,
adaptation, and
change continues
Postcrisis begins
Situational
Situational
may
Supports
Defense
Mechanisms
FIGURE
Crisis
Intervention
Crisis
intervention is an active but temporary entry into the life
situation of an individual, a family, or a group during a period of
stress (Mitchell & Resnik, 1981 ). It is an attempt to resolve an
immediate crisis when a person's life goals are obstructed and usual
problem-solving methods fail. The client is called on to be active in
all steps of the crisis intervention process, including clarifying the
problem, verbalizing feelings, identifying goals and options for
reaching goals, and deciding on a plan.
Crisis intervention can occur in many settingsthe home,
emergency department, industrial dispensary, classroom, surgical
intensive care unit, or psychiatric unit. The generic approach focuses
on a particular kind of crisis by directly encouraging adaptive
behavior and providing general support, environmental manipulation,
and anticipatory guidance. The individual approach focuses on the
present, shows little or no concern for the developmental past, and
places an emphasis on the immediate causes of disequilibrium. It can
be used as secondary or tertiary prevention and can be effective in
preventing
future
crises.
Steps
in
and
effective
Crisis
crisis
intervention.
Intervention
Assessment
Assessment of a client during crisis intervention depends on several
factors, such as the severity of the crisis, the client's perception of
the crisis, and the accurate interpretation of data to formulate a
nursing diagnosis.
Determining
Crisis
Severity
Assessing
Client's
Perception.
Formulating
Nursing
Diagnoses.
Coping
Verbal
Communication
Planning
Grieving
Family
of
Coping
Therapeutic
Intervention
support.
Implementation
Interventions
of
Therapeutic
Resolution
During resolution, anticipatory planning and evaluation occur.
Reassessment is crucial to ascertain that the intervention is reducing
tension and anxiety successfully rather than producing negative
effects. Reinforcement is provided whenever necessary while the
crisis work is reviewed and accomplishments of the client are
emphasized. Assistance is given to formulate realistic plans for the
future, and the client is given the opportunity to discuss how present
experiences may help in coping with future crises.
BOX
12.1
Commonly
Crisis
Used
Therapeutic
Techniques
in
Intervention
false
reassurance
Self-Awareness
Prompt
Have you ever experienced a crisis situation? If so, describe how you
reacted. What effects did you experience? Was the crisis resolved
within a short period of time? How was it resolved? What did you
learn from this personal experience?
Crisis
Intervention
Modes
Legal
Aspects
of
Crisis
Intervention*
BOX
12.2
Protective
Services
Center
Center
Crisis
Center
Crisis
Center
Self-Awareness
Prompt
Reflect on your ability to interact with clients in a crisis. Are you able
to present a mature, nonjudgmental attitude? Are you able to
maintain a calm approach? Do you have a need to rescue others?
What preparation do you feel would improve your ability to be a
crisis
clinician?
Crisis
Intervention
for
Children
When children are in crisis, the entire family is affected. Trauma can
change the way
Children view their world. Assumptions about safety and security are
challenged. Their reactions will depend upon the severity of the
trauma, their personality, the way they cope with stress, and the
availability of support. It is not uncommon for children to regress
both behaviorally and academically following a trauma.
disturbances
or
nightmares
or
restlessness
regression
or
aggression
Key
Concepts
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
Crisis can be a turning point for better or for worse in a person's life.
Review the quote at the beginning of the chapter and applying this
quote, cite at least three ways divorce can be a turning point in the
life of a middle-aged woman who has been physically and
emotionally abused by her husband for several years. State the
rationale for your answers.
MULTIPLE
CHOICE
QUESTIONS
1. A client who informs the nurse that she has recently filed
for divorce complains of feeling confused, helpless, and
disorganized for the past 2 days. The nurse identifies that the
client is in which crisis phase?
a.
Precrisis
b. Initial impact
c.
Postcrisis
d.
Resolution
View
1. B
Answer
Answer
Although all of the factors listed may be playing a role, the couple's
recent move to a new state and being away from their children is a
critical change. This loss of environmental support is the major
factor. Often situational supports (persons in the environment) may
prevent a state of disequilibrium and crisis from occurring. The less
readily available emotional or environmental supports systems are,
the more overwhelming a person will define an event.
3. An older adult client is admitted to the nursing home for
Answer
View
4. C
Answer
Postcrisis
Precrisis
Answer
Internet
Resources
http://www.mentalhealth.org/cmhs/emergencyservices/after.htm
Helping Older Americans Cope with Crisis:
http://www.aagponline.org/p_c/holiday.asp
Suicide Crisis Center:
http://www.suicidecrisiscenter.com/whattodo.html
Selected
References
of
preventive
from
http://www.lifeskills.com/crisis-services.htm
response
to
Selected
Readings
Times,
17 (3), 21.
Lippincott
Williams
&
Wilkins.
http://www.fortnet.org/crossroads/service.html
Chapter
13
Individual Psychotherapy
Group Therapy
and
1960
Learning
Objectives
countertransference, and
groups.
Key
Terms
Autocratic
Behavior
Brief
Brief
Closed
group
leader
therapy
cognitive
therapy
interpersonal
psychotherapy
groups
Counseling
Countertransference
Democratic
group
leader
E-therapy
Group
therapy
Individual
psychotherapy
Laissez-faire
Open
group
groups
Parataxis
Psychotherapy
leader
Split-treatment
psychotherapy
Transference
Psychotherapy has been referred to as the treatment of
emotional and personality problems and disorders by
psychological means. Many different techniques may be used to
treat problems and disorders and to help the client become a
mature, satisfied, and independent person. However, an
important factor common to all of the techniques is the
clienttherapist relationship with its interpersonal experiences
(Kolb, 1982) .
Sigmund Freud (18561939) was the first to understand and
describe the psychotherapeutic process as an interpersonal
experience between client and therapist. He thought that our
relationships with other people, including clients, are patterned
by early infant and childhood relationships with significant
people in our environment. These patterns of relationships are
repeated later in our lives and may interfere with
clienttherapist relationships because of transference, or the
client's unconscious assignment to the therapist of feelings and
attitudes originally associated with important figures in his or
her early life. Transference can be positive
P.160
(affectionate) or negative (hostile). The therapist may exhibit
countertransference, or an emotional reaction to the client
based on the therapist's unconscious needs and conflicts. Such
a response could interfere with therapeutic interventions during
the course of treatment (Edgerton & Campbell, 1994) .
Harry Stack Sullivan introduced the term parataxis. It refers to
the presence of distorted perception or judgment exhibited by
the client during therapy. Parataxis is thought to be the result
of earlier experiences in interpersonal relationships (Edgerton &
Campbell, 1994; Fromm-Reichmann,
1960) .
Although psychotherapy may be performed only by the certified
specialist in psychiatricmental health nursing (American
Nurses Association [ANA], 2000), the psychiatricmental
Individual
Psychotherapy
Modes
consistent
of
emotional
Individual
support
Psychotherapy
In the past, individual psychotherapy typically involved longterm therapy. However, the advent of managed care has
BOX
13.1
Schools
of
Psychotherapy
on
emotional
and
life
Footnote
Edgerton, J. E. & Campbell, R. J. (Eds.). (1994). American
psychiatric
glossary (7th ed.). Washington, DC: American
Psychiatric Press, Inc: Kolb, L. C. (1982). Modern clinical
psychiatry (10th ed.). Philadelphia: W. B. Saunders; Lego, S.
(1996). Psychiatric nursing: A comprehensive reference (2nd
ed.). Philadelphia: Lippincott-Raven Publishers; Yalom, I. E.
(1995). The theory and practice of group psychotherapy (4th
ed.). New York: Basic Books.
Brief
Cognitive
Therapy
Behavior
Therapy
Brief
Interpersonal
Psychotherapy
MODE
Psychoanalysis
SUMMARY
ROLE OF
THERAPIST
Lengthy, 3 to 5
years; client
talks in an
uncontrolled,
spontaneous
manner of
free
association
Explores
repressed
feelings by
interpreting
dreams,
emotions, and
behavior
Encourages a
about anxieties,
fears, and
childhood
images
reliving
experience to
deal with
once-fearful
experiences
Uncovering
therapy
Uncovering
conflicts,
of
mainly
Assists
in
client
exploring
unconscious
insight to
work through
conflict
Hypnotherapy
Adjunct to
therapy to
effect
behavioral
change and
relaxation,
control
attitudes, and
uncover
repressed
feelings or
thoughts
Hypnotizes
client
Encourages
discussion of
emotional
conflicts
Reality
Based on
premise that
persons who
are mentally
unhealthy are
irresponsible,
cannot meet all
of their basic
needs, and
refuse to face
reality
Rejects
unrealistic
behavior
displayed by
client
Assists the
client in
assuming
responsibility
for actions
and in making
therapy
value
judgments
Cognitive
therapy
Emphasis
placed on
cognition and
attitude, as
Utilizes seven
techniques to
assist the
client in
cognition
abandoning
Rationalemotive
therapy
affects
emotional state
and subsequent
behavioral
patterns
maladaptive
behavior and
thus
demonstrate
adaptive
behavior
Techniques:
collaborative
emphasis,
agendasetting,
summarizing,
hypothesistesting,
guided
discovery,
feedback, and
homework
A form of
experiential
therapy based
on the premise
that behavior is
Applies
learning
principles
question
illogical
controlled by
values and
beliefs
thinking
Promotes
problemsolving
to
abilities,
social skills,
and
assertiveness
Techniques:
visual
imagery, role
playing,
modeling,
behavior
reversal,
thought
stopping, selfassessment,
selfmonitoring,
and
assertiveness
training
BOX
13.2
Basic Principles
Therapy
of
Brief
Cognitive
organisms,
taking
in
harnesses
the
client's
problem-solving
skills.
Footnote
Schuyler, D. (1991). A practical guide to cognitive therapy. New
York: W. W. Norton.
Split-Treatment
Psychotherapy
Split-treatment
psychotherapy, also referred to as dual
treatment, triangulated treatment, or medication backup,
involves a protocol between a nursetherapist who provides
psychotherapy and a psychiatrist or nurse practitioner who
provides pharmacotherapy for the client. Clients with the
diagnosis of a mood disorder, dual diagnosis, psychotic
disorder, or mental retardation are often seen in split-treatment
psychotherapy. Therapists who specialize in certain treatment
approaches such as cognitive or behavioral therapy often
request that medication be prescribed by another clinician. This
type of therapy is deeply rooted and widely practiced in places
such as community mental health centers due to the increasing
pressure from managed care organizations and third-party
payers (Balon & Riba, 2001).
P.163
SUPPORTING
13.1
Managing
Clients
in
EVIDENCE
Disruptive
Long-Term
FOR
PRACTICE
Behaviors
Care
of
Facilities
Footnote
Source: Burgio, L. D., Stevens, A., Burgio, K. L., Roth, D. L.,
Paul, P., & Gerstle, J. (2002). Teaching and maintaining
behavior management skills in the nursing home. The
Gerontologist, 42, 487496.
Group
Therapy
experience.
isolation
and
dependence
Characteristics
of
Group
Therapy
of
settings
(Lego,
1996).
emphasize
leaders while working
members' cognitive
problems.
Establishment
of
Group
Stages
of
Group
Development
Group
Leadership
Styles
Self-Awareness
Prompt
in
reading,
formal
Counseling
The psychiatric nurse uses counseling interventions to assist
clients in improving or regaining their previous coping abilities,
fostering mental health, and preventing mental illness and
disability (ANA, 2000). Counseling interventions may occur in a
variety of settings and may include the following:
Communication
Problem-solving
Crisis
Stress
and
interviewing
skills
intervention
management
techniques
Relaxation
techniques
Assertiveness
Conflict
Behavior
training
resolution
modification
P.167
MAINTENANCE ROLE
FUNCTIONS
direction in pursuit of
task.
Act as a support and
resource person.
Promote
termination.
length of group.
Alternate
Approaches
to
Psychotherapy
Online psychotherapy or e-therapy is a viable alternative
source for help when traditional psychotherapy is not
accessible. It is effective and private and conducted by skilled,
qualified, ethical professionals. For some individuals, it may be
the only way they are willing to obtain help from a professional
therapist. One online service, Therapy 4 Life
(http://www.therapy4life.com/), provides therapists for
individual therapy, couples therapy, metaphysical or spiritual
therapy, and holistic healing.
Self-Awareness
Prompt
Key
Concepts
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
Reflect on the chapter opening quote about the goal of
individual therapy. Articulate how split-treatment psychotherapy
achieves this goal. Identify clients who might benefit from splittreatment psychotherapy. Explain the rationale for your
selection.
MULTIPLE
CHOICE
QUESTIONS
a.
Transference
b.
Parataxis
c.
Psychoanalysis
d.
View
1. D
Countertransference
Answer
Answer
Answer
Uncovering
therapy
Answer
View
a.
altruism.
b.
catharsis.
c.
transference.
d.
universality.
Answer
5. D
The client is describing universality, a sense of realizing that
one is not completely alone in any situation. Altruism is an
element of group therapy in which the group benefits members
Internet
Resources
Selected
References
practice. Washington,
Bacon.
Burgio, L. D., Stevens, A., Burgio, K. L., Roth, D. L., Paul,
P., & Gerstle, J. (2002). Teaching and maintaining behavior
management skills in the nursing home. The
4 2, 487496.
Gerontologist,
Clinics
with
groups.
Essentials
Mosby.
of
psychiatric
Times,
19(2),
7576.
supported. Nursing
Times.
Suggested
Readings
Times,
16(10), 1,
Chapter
14
1996
Learning
1980
Objectives
Key
Brief
Terms
couples
Contextual
Couple
therapy
therapy
therapy
Dysfunctional
families
Families
Family
Healthy
therapy
functioning
family
Marital-relations
therapy
Object-relations
therapy
Overview
of
Families
Healthy
when
conflict
arises.
Functioning
Families
family is difficult,
family
In addition, the healthy family expects interactions among its
members to be unreserved, honest, attentive, and protective,
whereas interactions in the unhealthy family tend to be reserved,
guarded, or antagonistic (Goldenberg & Goldenberg, 1995).
In the healthy functioning family , no single member dominates or
controls another. Instead, there is a respect for the individuation of
other family members and their points of view and opinions, even if
the differences lead to confrontation or altercation. Family members
participate in activities together, unlike members of dysfunctional
families, who tend to be isolated from one another, possibly trying to
control others in the family. Although power is found in healthy
families in the parent coalition (union or alliance), it is not used in an
authoritarian manner. Children are allowed to express opinions,
negotiations are worked out, and power struggles do not ensue.
Good communication patterns are paramount (Goldenberg &
Goldenberg, 1995).
A healthy and functioning family encourages personal autonomy and
independence among its members, but individuality is not obscured.
Family members are able to adapt to the changes that occur with
normal growth and development and to cope with separation and
loss.
In a healthy functioning family, each family member typically
progresses through specific stages of development, which include
bonding, independence, separation, and individuation. Ego
boundaries are clearly developed. By
adolescence, they begin to function
independence requires an adjustment
members. However, family members
STAGE
DESCRIPTION OF
FAMILY TASKS
I.
Establishing a mutually
satisfying marriage by
learning to live together
and to provide for each
other's personality needs
Relating harmoniously to
three families: each
respective family and the
one being created by
marriage
Family planning: whether
to have children and
when
Developing a satisfactory
sexual and marital role
adjustment
II.
Early
Developing a stable
childbearing
III.
Exploring of environment
by children
Establishing
privacy,
housing, and adequate
space
Having
husbandfather
become more involved in
household
responsibilities
Developing of preschooler
to a more mature role
and assuming
responsibilities for selfcare
Socializing of children
such as attending school,
church, sports
Integrating of new family
members (second or third
child)
Separating from children
as they enter school
IV.
Promoting school
achievement of children
Maintaining a satisfying
marital
relationship,
because this is a period
when it diminishes
Promoting open
communication in the
family
Accepting
adolescence
V.
Families
with
teenagers
Maintaining a satisfying
marital relationship while
handling parental
responsibilities
Maintaining open
communication
between
generations
Maintaining family ethical
and moral standards by
the parents while the
teenagers search for
their own beliefs and
values
Allowing children to
experiment with
independence
VI.
Launching-center
families (covers the first
child through last child
leaving home)
VII.
Maintaining a sense of
VIII.
(empty nest
period through
retirement)
well-being
psychologically
and physiologically by
living in a healthy
environment
Attaining and enjoying a
career or other creative
accomplishments by
cultivating
leisure-time
activities and interests
Sustaining satisfying and
meaningful
relationships
with aging parents and
children
Strengthening the marital
relationship
Families in retirement
and old age (begins with
retirement of one or
both spouses, continues
through loss of one
spouse, and terminates
with death of the other
spouse)
Maintaining
satisfying
living arrangements
Maintaining marital
relationships
Adjusting to a reduced
income
Adjusting to the loss of a
spouse
Dysfunctional
Families
role and who fulfills the child's role. This confusion encourages
dependency, not autonomy, and individuation is not enhanced. In
contrast, the sharing of similar thoughts and feelings among all
family members is viewed as family closeness rather than a loss of
autonomy (Goldenberg & Goldenberg, 1995).
P.175
SUPPORTING
14.1
EVIDENCE
FOR
PRACTICE
Footnote
Source: Van Horn, E., Fleury, J., & Moore, S. (2002). Family
interventions during the trajectory of recovery from cardiac event:
An integrative literature review. Heart & Lung, 31 , 18698.
In dysfunctional
families , communication is not open, direct, or
honest; usually, it is confusing to other family members. Little
warmth is demonstrated. All these experiences tend to undermine
each member's individual thoughts, feelings, needs, and emotions so
that they are regarded as unimportant or unacceptable. Also, in
dysfunctional families, children and adults may perform roles that are
inappropriate to their age, sex, or personality. For example, the
mother of a 7-year-old daughter and a 3-year-old son may expect
the daughter to take care of the son and help prepare meals. This
expectation can create distress in the daughter because of the
amount of responsibility being placed on her, and because she is
being forced to fulfill the role of a mother. If such expectations
persist, it could result in a dysfunctional family system.
Culturally
Diverse
Families
Couple
Therapy
behavior.
object-relations
therapy . Marital-relations therapy is a form of
psychotherapy designed to modify the interactions of two individuals
who are in conflict with each other over social, emotional, sexual, or
economic issues. Contextual therapy is a nondirective form of
therapy that, through promotion of mutual understanding and trust,
fosters a dialogue between couples, thus making change possible.
Object-relations therapy is a psychodynamic approach to resolve
self-destructive patterns of relationships with people or objects such
as food or alcohol. Table 14-2 describes the issues or indications for
and the therapist's role in each type of couple therapy (Helm,
Wynne, & Simon, 1985; Klee, 2002; Sadock & Sadock, 2003).
Another type of couple therapy is brief couples therapy as
described by Papp (1997). This therapy is based on understanding
each partner's belief systems and how these systems interlock to
govern their lives and relationships. Beliefs determine the nature and
quality of relationships, the kind of problems a couple will have, and
how the couple will resolve problems.
When beliefs are acted on over time, they form themes, or highly
charged emotional issues, that dominate a relationship. Recurring
conflicts may occur as a result of such issues. Techniques that can be
used to understand and change dysfunctional relationships of couples
include:
Understand what each person wants changed and in what way he
or she would like to change it.
Understand each person's perception of solutions and how he or
she intends to bring this about.
Look for the constraints that stand in the way of bringing about a
desired solution.
Explore three-generational and cultural sources of the beliefs and
constraints, and place them in their context by tracing them to
their source in family of origin or culture.
Challenge the constraints by introducing an alternate way of
perceiving or reacting to a specific situation.
Explore the motivating force that would help the couple work
toward their desired goal.
Identify hidden qualities or values that can be defined as
positive, and expand on them.
Identify a negative central theme that can be changed into one
that is more constructive.
Ask future-oriented questions, such as How would you like
your relationship to be different?
P.177
THERAPY
Maritalrelations
therapy
ISSUES
Negative
interactions
Conflicts in
problem solving
Inability to
communicate
Sexual
dysfunction
ROLE OF THERAPIST
Encourages partners to
identify their own
behavior
Provides
communication
and problem-solving
training
Encourages imaging
and fantasy exercises
related to sexual
dysfunction
Contextual
Power
struggles
Directs
concern
toward
therapy
Abuse of child or
spouse
Infidelity
Impaired
development as a
couple
Parental conflict
Object-
Complaint by child
Reflects position of
relations
therapy
or adolescent
Poor self-esteem
Recurrent
dissatisfaction
with partner or
spouse
Escalating
interactions and
emotional
patterns
partners
Focuses on empathy,
anger control,
vulnerability, and
misperceptions
Couple
Assessment
Family
Therapy
BOX
14.1
Examples
Couples
of
Nursing
Diagnoses
for
Footnote
Adapted from Carpenito, L. J. (2002). Handbook of nursing diagnosis
(9th ed.). Philadelphia: Lippincott Williams & Wilkins.
Approaches
to
Family
Therapy
Integrative
Approach
Psychoanalytic
Approach
Bowen
Approach
Structural
Approach
Interactional
or
Strategic
Approach
Social
Network
or
Systemic
Approach
Behaviorist
Approach
members).
Initially, the therapist determines which family members need to
participate or continue in family therapy and how the problems of the
identified client(s) interlock
members. This interlocking
Finally, the therapist helps
their relationships with one
behavior on each other.
Stages
of
Family
Therapy
The three main stages of family therapy are the initial interview, the
intervention or working phase, and the termination phase.
The
Initial
Interview
Self-Awareness
Prompt
BOX
14.2
Family
Assessment
Guide
are
expressed
BOX
14.3
Examples
of
Nursing
Diagnoses
for
Families
Family
Family
Processes:
Footnote
Adapted from Carpenito, L. J. (2002). Handbook of nursing diagnosis
(9th ed.). Philadelphia: Lippincott Williams & Wilkins.
P.182
The
Intervention
or
Working
Phase
The goal of the intervention phase is to help the family accept and
adjust to change (Goldenberg & Goldenberg, 1995). During this
phase,
family.
present
helping
of the
are
useful in
seem
member.
feelings,
emotions,
beliefs,
and
values
effectively.
Self-Awareness
Prompt
The
Termination
Phase
The NurseTherapist's
Therapy
Role
in
Family
Key
Concepts
The term couple is used to describe two adults who have a close
or intimate relationship. They may be heterosexual or
homosexual, married or single.
Families may consist of married or nonmarried, homosexual or
heterosexual couples with or without children. They are an
integral part of society in which members learn how to relate to
and communicate with others.
Duvall's theory of the family life cycle describes the family as a
system that experiences developmental tasks as it progresses
through eight predictable, successive stages of growth.
Like mental health and mental illness, family functioning occurs
on a continuum. Healthy families encourage personal autonomy
and independence. Healthy families can become dysfunctional
under stress when issues of power persist and are not resolved.
Couple therapy is used to resolve tension or conflict in a
relationship by changing troublesome behavior and dysfunctional
patterns in the couple.
Family therapy is a method of treatment in which family members
gain insight into problems, improve communication, and improve
functioning of individual members and the family as a whole.
Several approaches to family therapy have been identified,
including the integrative approach, psychoanalytic
P.184
approach, Bowen approach, structural approach, interactional or
strategic approach, social network or systematic approach, and
behavioral
approach.
The three main stages of family therapy include the initial
interview, the intervention or working phase, and the termination
phase.
The nursefamily therapist obtains a detailed family history of
at least three generations to provide information regarding the
family's current and past levels of functioning. A genogram may
be used as an assessment and teaching tool to convey
FIGURE
14.1
Sample
three-generation
genogram.
P.185
P.186
Chapter
Worksheet
CRITICAL
THINKING
QUESTIONS
REFLECTION
Reflect on the opening chapter quote by Jones. Do you agree with
the current conceptual focus of family therapy? Explain the reason
for your response. If you do not agree with the conceptual focus,
what changes would you make in your approach as a family
therapist?
MULTIPLE
CHOICE
QUESTIONS
encourages
adolescent
rebellion.
Answer
1. B
The family belief that disagreement represents betrayal interferes
with development of autonomy in the child. This causes confusion
and encourages dependency, not adolescent rebellion. This belief
does not provide a united front but rather a control over others that
inhibits growth and development. It is not limit-setting that is too
strict, but rather an authoritarian approach that leads to power
struggles.
2. Which characteristic would the nurse expect to assess in a
family that is considered dysfunctional?
a. Individual autonomy is encouraged.
b. Family problems are identified.
c. Disagreement between spouses is present.
d. The parent and child exhibit role reversal.
View
Answer
2. D
Role reversal is common in dysfunctional families because of the lack
of leadership in the family unit. Encouragement of individual
autonomy, identification of family problems, and disagreements
between spouses are characteristics of healthy families.
P.187
3. The parents of a young adult recently diagnosed with
schizophrenia express feelings of being overwhelmed and
powerless in coping with the client at home. Which nursing
diagnosis would be most appropriate?
a. Compromised Family Coping
b. Impaired Social Interaction
c. Ineffective Family Therapeutic Regimen Management
d.
View
Deficient
Answer
Knowledge
3. A
The parents feeling overwhelmed and powerless with the care of
their son indicates that they are having difficulty coping as a family.
Thus, compromised family coping is most appropriate. Although
impaired social interaction and deficient knowledge may be problems
that occur, they are not reflected in the parents' statement.
Ineffective therapeutic regimen management would be reflected in
statements involving problems with their son's care routine, such as
maintaining appointments or giving medications.
4. The community health nurse visits the family of a client
with Alzheimer's disease and discusses issues of increasing
stress related to the worsening of the client's symptoms. The
nurse suggests appropriate referrals to the community agency
on aging and the local Alzheimer's Association based on the
knowledge that these referrals primarily would:
a. help the client with Alzheimer's disease improve functioning.
b. allow the family to vent thoughts and feelings to others.
c. enhance family's problem-solving ability with help of outside
resources.
d. provide direction to a dysfunctional system.
View
4. C
Answer
Answer
Internet
Alternative
Resources
Family
Institute:
http://www.altfamily.org/
Selected
References
Aronson.
solving
Suggested
and
Readings
therapy
techniques
family
Chapter
15
Psychopharmacology
1996
Learning
Objectives
antiparkinsonism
agents.
antiparkinsonism
agents.
Key
Terms
Acute
dyskinesia
Akathisia
Atypical
antipsychotics
Clearance
Clinical
Clinical
efficacy
psychopharmacology
Conventional
antipsychotics
Discontinuation
(withdrawal)
Drug
half-life
Drug
polymorphism
Extrapyramidal
adverse
syndrome
effects
(EPS)
effective
dose
malignant
syndrome
Neuroleptics
Parkinsonism
Peak
plasma
concentration
(NMS)
Pharmacodynamics
Pharmacokinetics
Potency
Primary
effects
Psychopharmacology
Secondary
Serotonin
Tardive
Tertiary
effects
syndrome
dyskinesia
(TD)
effects
Therapeutic
index
Therapeutic
window
Tolerance
Typical
antipsychotics
P.190
Psychopharmacology is the study of the regulation and stabilization of em
through the interactions of endogenous signaling substances or chemicals su
serotonin and drugs (Wilcox & Gonzales, 1998). Clinical
psychopharmacol
clients and the expert use of drugs in the treatment of psychiatric condition
behavior, and cognition are assumed to be caused by biochemical alterations
functions in the brain. Clinical symptoms are generally lessened when the b
by pharmacotherapy or the administration of specific psychotropic agents.
The introduction of new psychotropic agents is perhaps the most rapidly grow
psychiatry and clinical pharmacology. In recent years, important new drugs
revolutionizing the treatment of various psychiatric disorders. This progress
advances in neuroscience and clinical research during the past few decades
agents
Antidepressants
Antimanic
agents
Anticonvulsants
The
Science
of
Psychopharmacology
and an effector organ) via the aid of specific substances called neurotransmi
seen an explosion in the amount of data concerning the molecular biology o
on the surface of the next neuron (post-synaptic response; see Figure 15-1
These steps include synthesis, vesicular uptake, transmitter release, receptor
transmitter metabolism. Each of these steps offers a potential target for the
For example, certain drugs can enhance the release of neurotransmitters, b
inhibit the cellular uptake of neurotransmitters (Wilcox & Gonzales, 1998).
with the serotonin transporter and inhibit reuptake of serotonin into the pre
drugs such as lorazepam enhance -aminobutyric acid (GABA) neurotransm
2001; Sadock & Sadock, 2003).
Pharmacodynamics
P.192
FIGURE
The psychiatricmental health nurse must be familiar with these terms beca
clinical settings such as substance abuse units; during clinical research stud
and when agents are prescribed for special populations, such as older adults
Pharmacokinetics
P.193
Most psychotropic drugs are metabolized by the cytochrome P-450 (CYP) he
contains over 30 isoenzymes. The phase 1 enzymatic process of metabolism
phase, a specific drug is reduced to form a more water-soluble compound. D
process, a compound (such as glucuronide) is added to the parent drug or t
enhance water solubility and promote excretion. Some drugs induce or stimu
Four quantities are important regarding the metabolism and excretion of psy
concentration, drug half-life, first pass effects, and clearance (Sadock & Sado
concentration (the greatest accumulation of the drug in the plasma) of a d
route of administration and rate of absorption of the drug. Parenteral admini
achieves peak plasma concentration more rapidly than oral administration. D
of time it takes for metabolism and excretion to reduce the plasma concentra
liver is the principal site of metabolism and bile, feces, and urine are the pri
pass effects describes the initial metabolism of an orally administered drug
the fraction of the absorbed drug that reaches systemic circulation unmetabo
amount of a drug excreted from the body in a specific period of time. Figure
and pharmacodynamics of psychotropic drug therapy.
FIGURE
P.194
Factors
Affecting
Pharmacodynamics
and
Drug
Polymorphism
Cultural factors that affect drug response include a client's values and beliefs
herbal and homeopathic remedies in some cultures can alter the body's resp
clients at risk for drugdrug interactions. Also, clients may not inform clin
adverse effects due to a certain drug because it is not acceptable to report
discontinue taking the prescribed medication.
Discontinuation
(Withdrawal)
Syndrome
Medicating
the
PsychiatricMental
Health
P.195
consideration of several guidelines (Bernstein, 1998). These guidelines are h
treatment considerations are given to children, older adult clients, pregnant
hepatic or renal insufficiency, and persons with comorbid medical illnesses. H
situations, psychopharmacology can result in adverse effects affecting the cl
summarizes common adverse effects of psychotropic medications and appro
Antipsychotic
Agents
(eg,
haloperidol).
BOX
15.1
Psychopharmacologic
Guidelines:
Medicating
Failure to medicate properly may prolong the client's illness and sufering
Lack of desired response may indicate that the client is not taking medic
antipsychotics , ha
activity of serotonin and dopamine. Thus they are used to treat both the pos
disorders such as schizophrenia (see Chapter 18 for discussion of symptoms
produce fewer motor adverse effects than the neuroleptic agents do. Examp
include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), q
ariprazole
(Abilify).
SIDE
Blurred
EFFECT
vision
Constipation
INTERVENTION
contraindicated).
Promote dietary intake of fresh fruits, vegeta
Provide stool softeners or bulk-forming agen
Drowsiness
Dry mouth
Gastrointestinal
disturbances
Hypo-
or
hyperglycemia
Hypotension,
orthostatic
Insomnia
Libido
changes
(sexual
dysfunction)
Tachycardia
Urinary
retention
Weight gain
Contraindications
and
Precautions
P.197
depression, bone marrow depression, blood dyscrasias, and brain damage. Cl
liver function; cardiovascular disease; hypertension; glaucoma; diabetes; Pa
disease; seizure disorder; or pregnancy require close observation when tak
Although most atypical antipsychotics have not been associated with prolonga
evidenced on electrocardiogram (ECG), caution is needed if these agents are
known to increase the QT interval. Antipsychotic agents are used cautious
General
Adverse
Effects
Adverse effects may occur due to the use of antipsychotic medication or due
client is taking other medication to treat a medical problem. For example, d
if a client is taking medications such as haloperidol (Haldol) and diphenhyd
Clozapine (Clozaril) may cause agranulocytosis. The newer-generation antips
with new-onset type 2 diabetes, changes in lipid metabolism and blood con
Neuromuscular
or
Neurologic
Adverse
Effects
Extrapyramidal adverse effects may occur during the early phase of drug th
occur after short-term use of moderate doses, although it generally occurs a
therapy. Neuroleptic malignant syndrome can occur suddenly from 1 to 7 da
initiated, or can occur as late as 2 months into therapy. It has also occurred
(dopaminergic) agonists, such as the combination of carbidopa and levodopa
disease, are discontinued (Marder & Van Putten, 1995; Herman, 1998). Cloz
antipsychotic, does not cause these neuromuscular or neurologic adverse effe
who exhibit psychotic symptoms who also have neurologic disorders such as
BOX
Major
15.2
Adverse
Effects
of
Antipsychotic
Drugs
or
phototoxicity
in laboratory
cholesterol
values:
agranulocytosis,
Nursing
Implications
neutropenia,
hyperglycem
If antacids are needed, give them either 2 hours prior to or 1 hour afte
medication.
Know that antipsychotic agents may provoke seizures in clients with sei
Closely observe the client receiving antipsychotic drugs for the following
Anticholinergic
effects,
respiratory
depression,
and
hypersensitivity
endocrine-related
changes
such
as
menstrual
irregula
2003)
TABLE 15.2
SIDE
EFFECT
Neuromuscular/Neurologic
Adverse
Effects
of
DEFINITION/SYMPTOMS
ONSET/PREVALENCE
Parkinsonism
Motor retardation or
akinesia, characterized by
masklike
appearance,
rigidity, tremors, pill
rolling,
salivation
Generally occurs
after first week of
treatment or before
second month
(2%90%)
A
A
a
m
Akathisia
(motor
restlessness)
Constant state of
movement,
characterized
by restlessness, difficulty
sitting still, or strong urge
Generally occurs 2
weeks after
treatment begins
(35%)
A
c
b
to move about
Acute
dystonic
Irregular,
involuntary
spastic muscle movement,
A
c
reactions
(disturbance
of movement
involving the
wryneck or torticollis,
facial grimacing, abnormal
eye movements, backward
rolling of eyes in the
a
b
d
muscles of
thehead,
neck, trunk,
sockets
(oculogyric
crisis)
or limbs)
Tardive
dyskinesia
(abnormal
movements)
Occurs in
approximately 3% to
5% of clients taking
antipsychotics in first
10 years
Cumulative
prevalence over
1020 years is
about 40%55%
R
a
i
G
b
o
Neuroleptic
malignant
syndrome
(NMS)
Idiosyncratic, rare
syndrome
characterized
by hyperpyrexia, severe
muscle rigidity, altered
consciousness,
alterations
in blood pressure,
elevated
creatinine
phosphokinase,
elevated
white blood cell count
D
a
a
a
r
c
r
b
K
b
e
b
N
b
trunk are rated on a scale from 0 (no adverse effects) to 4 (severe effects).
extremity movements, trunk movements, global movements, and denture sta
takes usually 5 to 10 minutes; the total score may range from 0 to 42. A lo
Client
Education
Nurses need to inform clients about the planned drug therapy, drug dosage,
therapeutic results, and possible adverse effects of drug therapy. Table 15-3
common antipsychotic agents. Clients are instructed to report any physical i
and to avoid taking over-the-counter (OTC) drugs or medications prescribed
Include the following instructions about antipsychotic drug therapy when teac
Avoid alcohol and sleeping pills, which can cause drowsiness and decreas
environmental hazards, and other medication during drug therapy.
BOX
Med
15.3
Alert:
Antipsychotics/Neuroleptics
drugs,
antacids,
and
anticholinergic
agents.
P.200
GENERIC
NAME
TRADE NAME
acetophenazine
Tindal
601
chlorpromazine
Thorazine
252
chlorprothixene
Taractan
306
clozapine
Clozaril
757
Prolixin
140
(atypical)
fluphenazine
fluphenazine
decanoate
haloperidol
haloperidol
Prolixin
Decanoate
Haldol
decanoate
Haldol
12.5
110
Decanoate
12.5
loxapine
Loxitane
105
mesoridazine
Serentil
304
molindone
Moban
152
Zyprexa
520
olanzapine
(atypical)
perphenazine
Trilafon
464
pimozide
Orap
120
prochlorperazine
Compazine
515
quetiapine
Seroquel
258
Risperdal
0.5
thioridazine
Mellaril
108
thiothixene
Navane
160
trifluoperazine
Stelazine
280
ziprasidone
Geodon
201
risperidone
(atypical)
(atypical)
Dosages listed are for tablet or capsule form. Several of the above-listed
available in liquid and injectible form.
Avoid exposure to direct sunlight for any extended time to prevent sunb
skin.
Do not increase, decrease, or cease taking drugs without discussing this
be taken off the drug slowly to avoid nausea or seizures.
or
injuries.
Practice good oral hygiene to minimize the risk of mouth infections, den
Follow up with the dentist yearly.
Keep the drugs in a safe place especially if children are in the home bec
capsules for candy.
Antianxiety
Agents
and
Hypnotics
Antianxiety agents and hypnotics share many characteristics, often being ref
hypnosedatives . However, antianxiety agents are used primarily to treat da
used primarily to relieve insomnia. Antianxiety agents, also referred to as an
manage withdrawal symptoms associated with chronic alcoholism, to control
skeletal muscle relaxation. Antianxiety agents can be classified as follows:
nonbenzodiazepines, antihistamines, beta blockers, hypnotics, certain SSRIs,
Hypnotics are used to induce a state of natural sleep, reduce periods of inv
night, and increase total sleep time. Hypnotic medications have seen a dram
barbiturates and non-barbiturates were the major hypnotic drugs of choice. I
P.201
for 2 or 4 months. The need for continued use is reevaluated at 2- to 4-mo
Benzodiazepines
When used in combination with alcohol, the interactive effects can be lethal.
benzodiazepines increase, resulting in respiratory distress or other medical
interfere with normal coping mechanisms; increase irritability, aggressiveness
an extended period of time; and increase the risk for depression. Long-term
recommended because these drugs can produce dependency. Additionally, b
the phenomenon of tolerance (ie, needing increasing amounts of the drug to
occurrence of withdrawal symptoms if it is abruptly discontinued).
Nonbenzodiazepines
Antihistamines
Beta
Blockers
Selective Serotonin
Antidepressant
Reuptake
Inhibitors
and
P.202
section of this chapter. Their use is also discussed in the chapters related to
21, and 22).
Nursing
Implications
Give the daily dose at bedtime to promote sleep, minimize adverse effec
activities to occur.
to tissues and can cause pain at the site of injection. The Z-track method
irritation of tissue.
Observe for therapeutic effects.
Be alert for possible drugdrug interactions. (See Box 15-4 : Med Ale
Hypnotics; Abrams, 2003; Karch, 2003.)
Client
Education
Tell clients the name of the drug they have been prescribed, the dosage, and
treatment. Table 15-4 lists daily dosages of common antianxiety agents and
In addition, include the following information in client and family teaching:
Review the adverse effects of the prescribed medication and instruct the
adverse effects as well as symptoms such as fever, malaise, sore throat,
bleeding, and skin rash.
Instruct the client to avoid the use of alcoholic beverages with antianxie
increase the depressant effects of these agents, possibly causing death.
Instruct the client not to alter the dose of medication and not to drive o
equipment.
it can decrease the effects of hypnotic agents and increase the effects o
BOX
15.4
Med
Alert
Antianxiety
Agents
and
Hypnotics
Displacement of digoxin from serum proteins can occur when taken con
Hypertension can occur when buspirone and MAOIs are combined during
Prothrombin times may vary during anticoagulant therapy.
Beta blockers may decrease the effects of insulin and oral antidiabetic a
GENERIC
Antianxiety
NAME
TRADE NAME
Agents
atenolol
Tenormin
50
alprazolam
Xanax
0.5
buspirone2
BuSpar
15
chlordiazepoxide
Librium
10
clomiprimaine
Anafranil
25
Klonopin
0.5
Tranxene
7.5
Valium
Benadryl
25
hydrochloride
clonazepam
clorazepate
dipotassium
diazepam
diphenhydramine
hydrochloride
fluvoxamine
maleate3
Luvox
50
hydroxyzine
hydrochloride
Atarax
10
Vistaril
25
lorazepam
Ativan
1.0
meprobamate
Miltown/Equanil
200
oxazepam
Serax
30
prazepam
Centrax
10
propanolol
Inderal
40
hydroxyzine
Hypnotic
pamoate
Agents
amobarbital
sodium
Amytal
50
aprobarbital
Alurate
40
estazolam
ProSom
Benadryl
25
Dalmane
15
Atarax
10
Vistaril
25
quazepam
Doral
7.5
secobarbital
Seconal
100
temazepam
Restoril
15
trazodone1
Desyrel
25
zaleplon
Sonata
zolpidem
Ambien
diphenhydramine
hydrochloride
flurazepam
hydroxyzine
hydroxyzine
hydrochloride
pamoate
.
2
Instruct the client to avoid excessive use of these drugs to prevent the o
addiction.
Explain that hypnotics are ineffective as analgesics.
Instruct clients who take hypnotics to keep a sleep diary (see Chapter 11
prescribed
hypnotic.
Explain rebound insomnia, which is the worsening of insomnia that may
medication.
Antidepressants
Atypical antidepressants do not readily fit into the familiar categories of TCA
the following atypical antidepressants have been identified: trazodone (Des
venlafaxine (Effexor), mirtazapine (Remeron), maprotiline (Ludiomil), nefazo
P.204
enhance central noradrenergic and serotonergic activity. Nefazodone blocks s
5-HT2 receptor antagonist. Reboxetine is a noradrenaline reuptake inhibitor
MAOIs prevent the metabolism of neurotransmitters, but are used less freque
are less effective, must be given for longer periods before they are beneficia
duration of action, and may cause severe adverse reactions if taken with ty
Selective
Serotonin
Reuptake
Inhibitors
Contraindications,
Precautions,
and
Adverse
Eff
If a client has been taking MAOIs, a 14-day drug clearance is required befor
an accumulation of serotonin and subsequent serotonin syndrome . This p
Nursing
Implications
Because certain drugs should not be given concurrently with SSRI therapy, e
medication administration record are marked clearly to avoid any adverse
Client
Education
Instruct clients who are receiving SSRI drug therapy to do the following:
Take the drugs exactly as prescribed. Never attempt to alter the dosage.
daily dosages for SSRI therapy.)
Avoid altering the dosage of the medication. Contact the physician before
GENERIC
NAME
citalopram
TRADE NAME
DOSAGE
RANGE(
Celexa
1060 mg
Lexapro
1020 mg
fluoxetine
Prozac
1080 mg
fluvoxamine
Luvox
paroxetine
Paxil
1060 mg
sertraline
Zoloft
25200
escitalopram
oxalate
mg
Have your blood pressure and pulse monitored initially and after each do
hypotension, hypertension, and irregular heart rates.
Tricyclic
Antidepressants
alertness and physical activity with mood elevation within a few days after
clients receiving antidepressant drug therapy continue taking the medication
neurotransmitters to return to normal levels and to achieve a reversal of th
disorders that usually respond to TCAs include agoraphobia, borderline pers
Contraindications,
Precautions,
and
Adverse
Eff
Several drugs increase the effects of TCAs; they include antihistamines, atr
benzodiazepines, and urinary alkalizers (eg, sodium bicarbonate). Barbiturate
decrease the effects of TCAs (Abrams, 2003; Karch, 2003).
Nursing
Implications
Within 2 or 3 weeks after the initial dose, tricyclic drugs should reach a seru
response occurs (therapeutic window). Therefore, if no therapeutic response i
another drug usually is prescribed.
Because these agents may cause urinary retention and constipation, assess
Also, assess the client's vital signs and cardiac status closely. Orthostatic h
arrhythmias may occur. Report any significant changes immediately and expe
adjusted accordingly. Monitor clients receiving high doses for signs of seizur
Client
Education.
Take drugs exactly as prescribed. Never attempt to alter the dosage. (Se
commonly
used
tricyclic
antidepressants.)
Be aware that the therapeutic effects may not occur for 2 to 3 weeks af
physician about the need for follow-up laboratory testing for drug levels
Avoid taking OTC cold remedies or other drugs without the physician's k
P.206
GENERIC
Tricyclic
NAME
TRADE NAME
DOSAGE
RANGE(m
Antidepressants
amitriptyline
Amitril,
amoxapine
50300
mg
Asendin
50400
mg
clomipramine
Anafranil
25300
mg
desipramine
Norpramin
75300
mg
doxepin
Sinequan,
75300
mg
imipramine
Tofranil
75300
mg
nortriptyline
Aventyl,
50150
mg
protriptyline
Vivactil
1560 mg
trimipramine
Surmontil
75300
Wellbutrin
200450
Atypical
bupropion
Elavil,
Endep
Pertofrane
Adapin
Pamelor
mg
Antidepressants
mg
maprotiline
Ludiomil
25225
mirtazapine
Remeron
1545 mg
Serzone
100600
nefazodone
hydrochloride
Vestro
mg
mg
reboxetine
Edronax,
412 mg
trazodone
Desyrel
25600
mg
venlafaxine
Effexor
75375
mg
Know that these drugs are not addictive, but some clients may have a c
neurotransmitters, requiring them to take these agents over an extended
Atypical
Antidepressants
Contraindications,
Precautions,
and
Adverse
Eff
Adverse effects vary depending upon which atypical drug is used (Karch, 200
Sadock, 2003). Common adverse effects include drowsiness or somnolence, d
upset. Trazodone may cause CNS overstimulation; mirtazapine causes weight
EPS; bupropion may precipitate symptoms of mania or psychosis; nefazodon
and venlaxafine and trazodone may cause sexual dysfunction.
Nursing
Implications
Providing care for clients who take atypical antidepressants can be challengin
contraindications and potential adverse effects associated with each drug. Th
client has an existing comorbid medical disorder. The client may need to und
laboratory tests, ECG, and electroencephalogram (EEG) to rule out the prese
disorder, neurologic disorder, liver disease, or renal impairment. When adm
adhere to the following:
Ensure that clients who are depressed and potentially suicidal have acces
prescribed drug.
Monitor liver and hepatic function tests in clients with a history of liver
Peterson,
2001).
Client
Education
Instruct the client receiving atypical antidepressant drug therapy and the fam
Take medication exactly as prescribed. Do not combine doses or attempt
abruptly discontinue taking the drug. (See Table 15-6 for daily dosages
antidepressants.)
Report any adverse effects or changes in medical condition.
Avoid the use of alcohol, sleep-inducing drugs, and OTC drugs while tak
Use contraceptives to prevent pregnancy. Consult with your health care
Monoamine
Oxidase
Inhibitors
(MAOIs)
Monoamine oxidase inhibitors may be prescribed for clients with treatmenthave depression associated with anxiety attacks, phobic attacks, or many so
to respond to tricyclic agents or who cannot tolerate SSRIs; and clients who
bipolar disorder. MAOIs may be superior to TCAs in treating atypical depress
2002).
Contraindications,
Precautions,
and
Adverse
Eff
The list of conditions that prohibit the use of MAOIs is lengthy. Box 15-5 list
the need for caution when prescribing or administering these drugs. Serious
BOX
adrenergic
agents,
alcohol,
levodopa,
and
meperidine
15.5
(Abra
Asthma
Cerebral
vascular
Congestive
disease
heart
failure
Hypertension
Hypernatremia
Impaired
Cardiac
kidney
function
arrhythmias
Pheochromocytoma
Hyperthyroidism
Liver
disease
headaches
Alcoholism
Glaucoma
Atonic
colitis
Paranoid
Debilitated
schizophrenia
clients
As stated earlier, MAOIs are antidepressants that are well known for their m
because they inhibit the enzyme that breaks down the amino acids tyramine
of these substances triggers the release of norepinephrine, and a hypertensiv
symptoms include elevation of diastolic and systolic blood pressure, headach
rapid heart rate or arrhythmias, and intracerebral hemorrhage (Ahmed & Fec
beverages to be avoided are found in Box 15-6 .
P.208
BOX
15.6
Foods
and
Beverages
That
Contain
Tyramine
Hypertensive crisis may occur if MAOIs are taken with the following:
Aged
cheese
Avocados
Bananas
Beer
Caffeine
Canned
figs
Chicken
livers
Chocolate
Fava bean pods
Guacamole
Meat
dip
tenderizers
Pickled
herring
Raisins
Sauerkraut
Sour cream
Soy sauce
Wine
Yeast
Yogurt
supplements
and
Nursing
Implications
MAOIs are nonaddictive and are considered safe and effective if taken as dir
client for signs of therapeutic effects, adverse effects, and drug or food inte
To reach a maximum therapeutic effect, MAOIs may
should be evident within 3 to 4 weeks. Monitor the
readily available should signs and symptoms occur.
excessive pressor response (dilation of blood vessels
excessive
agitation.
Client
require 2 to 6 weeks of
client closely for possible
Medication for overdose
and lowering of arterial
Education
Have vision checked periodically because optic toxicity may occur if thera
period.
GENERIC
NAME
TRADE NAME
DOSAGE
RANGE(mg/day)
isocarboxazid
Marplan
1070 mg
phenelzine
Nardil
1590 mg
tranylcypromine
Parnate
2060 mg
Carry a Medic Alert card to inform emergency room staff about therapy
Box 15-7 : Med Alert: Antidepressants lists some important adverse reactions
antidepressants.
BOX
Med
15.7
Alert:
Antidepressants
Assume that there is a potential for drug interactions when treating for dep
are reduced when given to children, adolescents, or the elderly. Nortriptyline
available in liquid form. Fluoxetine is now available in a once-a-week dose.
are available for intramuscular injection. Uncommon, but potentially serious,
the administration of antidepressants. They include:
Sustained-Release,
Parenteral,
and
Transder
Europe, only amitriptyline has been approved for use parenterally in the Un
indicate that the parenteral route is well tolerated, with no greater incidence
medication.
Stimulants
to enhance their therapeutic effects. They are also used in the treatment of
Daily dosages, included in Table 15-8 , may vary depending upon the age o
adult, or geriatric client) and the rationale for treatment (eg, narcolepsy, de
Contraindications,
Precautions,
and
Adverse
P.210
Tourette's syndrome. Pemoline is contraindicated in the presence of hepatic
GENERIC
NAME
dexmethylphenidate
HCL
TRADE NAME
DOSAGE
RAN
Focalin
2.520
Dexedrine
560 mg
Adderall
2.540
Ritalin
1060 mg
Concerta
1854 mg
Metadate CD
2060 mg
modafinil
Provigil
100200
pemoline
Cylert
37.5112.5
dextroamphetamine
dextroamphetamine
and
amphetamine
methylphenidate
methylphenidate
HCL
methylphenidate
HCL,
USP
mg
mg
mg
Potential adverse effects are too numerous to list in detail; however, the mo
appetite suppression and sleep disturbances (drowsiness or insomnia). Occa
increases in pulse and blood pressure, and CNS overstimulation have been
with the use of amphetamine stimulants. Stimulant-associated toxic psychosi
Nursing
Implications
Assess the client's blood pressure, pulse, weight, height, and sleep habit
each visit.
Monitor liver enzyme levels and weight of clients taking pemoline.
Client
Education
Avoid the use of alcohol or OTC drugs including nose drops and cold rem
interactions.
Avoid pregnancy while taking stimulants because they may cause harm t
Antimanic
Agents:
Mood
Stabilizers
syndrome
disorder
depressive
Sadock,
Contraindications,
Precautions,
and
Adverse
P.211
who have heart disease; perspire profusely; are on a sodium-restricted diet;
parkinsonism, or other CNS disorders; or are dehydrated. Serum lithium con
presence of extreme vomiting, diarrhea, or perspiration, resulting in lithium
Nursing
Implications
Before beginning therapy with lithium, the client undergoes a complete phy
laboratory tests and an ECG to obtain baseline information and to rule out a
renal abnormalities. When administering lithium therapy, be sure to include
Give the prescribed drug during or after meals to decrease gastric irritat
Monitor serum lithium levels at least twice a week during the initiation o
Observe clients for decreases in manic behavior and mood swings; adve
Client
Education
Take the drug exactly as directed. (See Table 15-9 for daily dosage of li
Do not alter the dosage or cease taking the prescribed drug. Be aware th
weeks to be effective.
GENERIC
NAME
TRADE
NAME
DOSAGE RANGE
lithium
carbonate
Eskalith
Lithonate
Lithobid
Lithotabs
Eskalith CR
lithium
Cibalith-S
citrate
P.212
Avoid taking other medications without a physician's knowledge because
the effects of lithium.
Report any unusual symptoms, illnesses, or loss of appetite immediately
Notify a doctor whenever a change in diet occurs because this may affec
Do not breast-feed while taking lithium.
Schedule an annual physical examination.
Carry a Medic Alert card or wear a Medic Alert bracelet.
Anticonvulsants
Anticonvulsant drugs are used to treat seizure disorders, which are not unco
psychiatric disorders. They may be used to control seizure activity, such as
(absence), grand mal (tonicclonic), psychomotor, akinetic and myoclonic,
seizures associated with neurosurgery (Bristol-Myers Squibb, 1996). Individu
tremens. Other examples include clients with delirium and dementia associat
or conditions such as brain tumor, history of head injury, explosive persona
Anticonvulsants may also be used to treat clinical symptoms of bipolar diso
anxiety disorder, pain, and substance abuse (Maxmen, Dubovsky, & Ward, 2
Self-Awareness
Prompt
Examine your attitude about the use of psychotropic drugs to stabilize clinic
disorders. How would you feel about medicating a child or an older adult? W
play? How would you feel about medicating a client in your age group? If yo
questions reveals discomfort on your part, what measures can be taken to c
Contraindications,
Precautions,
and
Adverse
should
not
take
anticonvulsants.
Nursing
Implications
Monitor for adverse effects including CNS changes (eg, drowsiness, seda
disorders, blood dyscrasias, respiratory depression, liver damage, gingiv
lymphadenopathy.
P.213
hepatotoxicity with
ace
Arrange for laboratory testing to monitor the client's liver function, blood
serum drug levels (Karch, 2001; Abrams, 2003).
Client
Education
Inform the health care provider of any known physical illnesses or pregn
OTC drugs presently being used.
Avoid the use of antacids because they reduce the serum level of antico
Ask for the same brand and form of drug when renewing prescriptions.
Follow directions when taking a liquid preparation of phenytoin.
Report any unusual or adverse effects to the health care provider.
Refrain from driving or operating heavy machinery if drowsiness occurs.
Wear a Medic Alert bracelet stating the use of anticonvulsants.
Antiparkinsonism
Agents
TABLE
GENERIC
NAME
TRADE NAME
DOSAGE
RANGE(mg/day)
carbamazepine
Tegretol
6001200
mg
clonazepam
Klonopin
1.520
ethosuximide
Zarontin
5001500
mg
gabapentin
Neurontin
3002400
mg
lamotrigine
Lamictal
25500
oxcarbazepine
Trileptal
3001200
phenytoin
Dilantin
300625
primidone
Mysoline
5002000
topiramate
Topamax
25400
valproate
Depakote
5001500
mg
mg
mg
mg
mg
mg
mg
valproic
acid
Depakene
5001500
mg
relieve their symptoms (Karch, 2003; Sadock & Sadock, 2003; Stanilla & Sim
with other agents such as propranolol (Inderal), clonidine (Catapres), clonaz
(Ativan), are the drugs of choice for treating extrapyramidal disorders and
Parkinson's
disease.
Contraindications,
Precautions,
and
Adverse
Nursing
Implications
Give the agent (except levodopa) with or immediately after food intake t
Client
Education
As is true with other types of drug therapy, the client receiving medication to
psychotropic drugs needs instructions about following the physician's prescrib
Additional instructions for the client and family members include the followin
Report any adverse effects or unusual symptoms to the health care prov
TABLE
GENERIC
NAME
TRADE NAME
DOSAGE
RANGE(mg/day)
amantadine
Symmetrel
100300
mg
benztropine
Cogentin
0.56 mg
biperiden
Akineton
216 mg
bromocriptine
Parlodel
2.5100
mg
diphenhydramine
Benadryl
25200
mg
entacapone
Comtan
2001600
levodopa
Larodopa or Dopar
10008000
pergolide
Permax
0.055
pramipexole
Mirapex
0.3754.5
procyclidine
Kemadrin
1020 mg
ropinirole
Requip
0.7524
selegiline
Eldepryl
510 mg
tolcapone
Tasmar
300600
trihexyphenidyl
Artane
215 mg
mg
mg
mg
mg
mg
mg
Key
Concepts
The past few decades have seen an explosion in the amount of data con
neurotransmission, broadening our understanding of the science of psy
The importance of drug polymorphism has been researched as clinicians
competent in the treatment of psychiatric disorders.
Self-Awareness
Prompt
Now that you have read the chapter and learned about psychopharmacology,
biases about the use of psychotropic drugs changed? Please explain why or w
P.215
Hypnotic agents are used to induce a state of natural sleep, reduce peri
during the night, and increase total sleep time.
Antidepressants
include
antidepressants,
and
selective
monoamine
serotonin
oxidase
reuptake
inhibitors,
tricyclic
inhibitors.
Although lithium has long been considered the treatment of choice for th
research has shown that certain anticonvulsants and atypical antipsychot
alternative drugs are valuable in the treatment of clients who cannot tol
For additional study materials, please refer to the Student Resource CD-ROM
textbook.
P.216
P.217
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
Research and create a lesson plan to teach clients and families about a
with a pharmacy student, and team-teach this material to an appropriate
student's focus differ from yours? What are the strengths you bring to th
pharmacy
student's?
MAOIs present unique problems for the clients taking them. What membe
be of great assistance to you as you prepare client education materials f
REFLECTION
Reflect on the chapter opening quote by Sadock and Sadock. Explain how the
foundation for a successful treatment approach for a specific disorder, such
could you provide to a client who is resistant to trying a psychotropic drug?
information? Would you include any other staff members in the presentation?
MULTIPLE
CHOICE
QUESTIONS
Acetylcholine
b. Dopamine
View
1. B
c.
Serotonin
d.
Histamine
Answer
Haloperidol acts on dopamine, blocking its action. It does not affect other n
acetylcholine, serotonin, or histamine.
P.218
2. For the client receiving the antipsychotic medication clozapine (Cl
would be most important for the nurse to monitor?
a. Complete blood count
b. Liver function study
c. Thyroid profile
d. Renal function study
View
2. A
Answer
client's condition. Liver and renal functions studies are commonly done for m
metabolized by the liver and excreted by the kidneys.
drooling and fine hand tremors. Which medication would the nurse ex
a.
Benztropine
(Cogentin)
b.
Acetaminophen
(Tylenol)
c.
Lorazepam
(Ativan)
d. Naproxen (Aleve)
View
Answer
3. A
Gastrointestinal
b.
Hypertensive
c.
Neuromuscular
upset
crisis
effects
d. Urinary retention
View
4. B
Answer
Ingestion of foods high in tyramine while receiving MAOI therapy can lead t
Gastrointestinal upset is an adverse effect commonly seen with many pharm
adverse effects are associated with antipsychotic agents. Urinary retention i
agents.
Answer
To prevent the possibility of lithium toxicity, the nurse would instruct the cli
of sodium and water. Foods high in tyramine are to be avoided when a clien
Establishing a regular sleep schedule would be helpful for clients receiving h
increased temperature suggestive of infection would be important for clients
possible
agranulocytosis).
Internet
Resources
http://www.medscape.com/druginfo/search?search
Selected
References
Ahmed, D. S., & Fecik, S. (2000). MAOIs: Still here, still dangerous. Americ
2930.
Bowes, M. (2002, Jul/Aug). Advances in medicine: New sustained-release
medications. Geriatric Times, 3 (4) (Suppl.).
Boyd, M. A. (2002). Psychiatric
& Wilkins.
nursing:
Contemporary
Psychiatric
Adviso
comprehensive
Pincus, H. A., Zarin, D. A., Tanielian, T. L., Johnson, J. L., West, J. C., Pett
Sadock, B. J., & Sadock, V. A. (2003). Kaplan & Sadock's synopsis of psyc
sciences/clinical
psychiatry (9th ed.). Philadelphia: Lippincott Williams & W
Suggested
Readings
Ayd, F. J., Jr. (2000). Evaluating interactions between herbal and psychoac
Times, 17 (12), 4547.
practitioners'
prescribing
Tim
refe
Chapter
16
Electroconvulsive
Therapy
1999
Learning
Objectives
therapy (ECT).
Key
Terms
Clitoridectomy
Electroconvulsive
therapy
(ECT)
Electronarcosis
Insulin
shock
therapy
Lobotomy
Physiotherapy
Postictal
agitation
Psychosurgery
Somatic
therapy
Sterilization
Although the potential for major physiological complications and death exist
physicians performed these techniques in an attempt to minimize disordered
behavior by locating their perceived origins in the body (Ginther, 1998).
in 1936. This invasive surgery severs fibers connecting one part of the brain
another, or removes or destroys brain tissue. It is designed to affect the clie
psychological state, including modification of disturbed behavior, thought co
or mood. Currently, prefrontal lobotomy and transorbital lobotomy are two t
of psychosurgery still used in research and treatment centers for chronic cli
and those who have not responded to other recommended approaches.
psychopharmacology
and
psychotherapy
(Kolb,
1982).
(see disc
focuses o
of the
during it
adverse effects, advances in the technique, guidelines for ECT, and nursing
interventions.
Electroconvulsive
Therapy
(ECT)
With ECT, electrodes are applied to the client's scalp. Two types of electrode
P.221
A third type of placement, bifrontal (BF), has been studied recently, in which
electrodes are placed on the forehead immediately above each eye. Ongoing
studies of BF placement find equal efficacy to BL placement. BF may be a us
alternative to BL placement (Fink, 1999; Fink, Abrams, Bailine, & Jaffe, 199
Box 16-1 gives a step-by-step description of the ECT procedure.
ECT delivered to the right side of the brain appears to maximize ECT efficacy
minimizing adverse effects on memory. It is postulated that electrode placem
may affect memory more than ECT dosage does (Moon, 1999).
Indications
for
Use
Initially, ECT was used to treat clients with depression, schizophrenia, or the
depressive phase of bipolar disorder, and clients at risk for suicide. Such use
been broadened to include clients who exhibit therapy-resistant depression,
BOX
16.1
ECT
Procedure
NPO 8 hours prior to ECT. Also, elderly clients do not metabolize medica
as readily as younger clients.
The client should not eat or drink at least 8 hours before treatment.
Vital signs are taken 30 minutes before treatment.
Instruct the client to empty the bladder just before or after vital signs ar
taken.
electrocardiogram
electrodes.
Insert IV line.
A sedative may be given to decrease anxiety.
Vital signs are taken during the recovery stage. The nurse stays with the
client until the client is oriented and able to care for him-or herself.
Electroconvulsive therapy, initially used to treat adults, has been proven eff
in the treatment of special populations, such as pregnant women who are un
to take psychotropic medication; children or adolescents who are depressed,
delusional, or exhibit manic episodes of bipolar disorder; elderly clients with
severe depression; and persons with mental retardation who have an underl
mental health condition such as depression, mania, psychosis, or catatonia
(DeMott, 1999; Fink & Foley, 1999; Sherman, 1999). Box 16-2 lists indicatio
ECT in children and adolescents.
Conditions
During
Associated
With
Increased
Risk
ECT
BOX
16.2
Children
mania
Adolescents
Catatonia
or
neuroleptic
Delirious
mania
malignant
syndrome
Severe depressive mood disorder with prominent weight loss and/or sui
Adverse
Effects
The most common adverse effects reported by clients during ECT include
headache, disorientation, and memory disturbance. Rare skeletal complicati
such as vertebral compressions or fractures, have occurred. Although the cli
The effects of ECT are cumulative. Marked confusion may occur in up to 10%
clients during treatment. As the client progresses through a course of
treatmentfor example, one treatment two to three times a week for a tot
six to twelve treatmentscognition may show signs of increased disturban
Although memory impairment during a course of treatment is common and m
cumulative, follow-up data indicate that almost all clients regain their cognit
baseline function after 6 months. Some clients, however, complain of persis
memory difficulties after the discontinuation of ECT (Sadock & Sadock, 2003
Postictal
(Seizure)
Agitation
Hyperactive delirium may occur as the client emerges from the anesthesia.
symptoms include marked motor restlessness, agitation, incoherence,
disorientation, and a fluctuating level of consciousness. This phenomenon,
referred to as postictal
agitation , may last from a few minutes to an hour
client may require intravenous
P.223
diazepam (Valium) to stabilize the symptoms (Fitzsimons & Ramos, 1996; S
& Sadock, 2003).
BOX
16.3
Considerations
Cardiac
Aortic
Conditions
ECT
decompensation
aneurysm
Tuberculosis
Recent
fractures
myocardial
disease
infarction
Associate
Pregnancy
Space-occupying
Recent
Retinal
cerebral
lesion
vascular
accident
detachment
Pheochromocytoma
Bleeding or clotting problem
Advances in ECT
In the past, any seizure was thought to be effective in restoring mental heal
minimizing clinical symptoms. Research has proven that electrode location an
form and dosage of the electrical stimulus contribute to the clinical efficacy
cognitive effects of seizures (Fink, 1999; Fink & Abrams, 1998). The
characteristics of seizures are best seen in the seizure electroencephalogram
(EEG). The EEG is examined for duration, characteristics, and endpoint. Seiz
as noted on the EEG, should be longer than 25 seconds for ECT to be effecti
Seizures fewer than 25 seconds in duration, without defined periods of EEG
activity, and without a sharp endpoint, are considered inefficient treatments
When effective treatments are not elicited despite attention to EEG details,
augmentation strategies are considered. They include changing the placemen
electrodes; selecting an alternate anesthesia; using intravenous caffeine; re
the impact of benzodiazepines by administering the antagonist flumazenil
(Anexate); or adding pindolol (Visken), which blocks serotonin uptake and a
levels of serotonin to rise rapidly to increase response to ECT (Fink, 1999;
Finkelstein, 1999). Continuation ECT (ie, episodes of ECT treatment) has bee
used to prevent relapse in clients who were treatment resistant prior to the
ECT.
Guidelines
for
ECT
Nursing
Interventions
for
the
Client
Receivin
ECT
decisions for a few weeks after the course of treatment is completed. The cl
and significant others are given an opportunity to ask questions about the
procedure and the nurse clarifies any misunderstanding they may have.
Supporting Evidence for Practice 16-1 highlights information about the need
client education about ECT.
Informed
Consent
After the client and/or family have been educated about the ECT procedure,
Client
Preparation
for
Treatment
SUPPORTING
Student
ECT
EVIDENCE
Nurses'
PROBLEM UNDER
depression
and
FOR
Clients'
PRACTICE
16.1
Attitudes
About
ECT was significantly more effective than simulated ECT. In 18 trials enrollin
1,144 subjects, ECT was significantly more effective than pharmacotherapy.
Bitemporal ECT was more effective than unitemporal ECT in 22 trials involvin
1,408 subjects.
Footnote
Source: Barclay, L. (2003). Electroconvulsive therapy more effective than
medication in depression. Lancet , 361, 799808.
Resources
for
Client
Education
Several Web sites provide education and seek to dispel fears about ECT.
Wikipedia, The Free Encyclopedia (http://www.en.wikipedia.org/wiki/ect )
discusses the historical use of ECT; how it works; indications for use, includ
psychiatric diagnoses; efficacy of treatment; risks and benefits; adverse eff
controversy and fears; and alternative treatment. Other Web sites that prov
educational material are Depression ECT, http://www.HealthyPlace.com , Inc
Self-Awareness
Prompt
Examine your feelings and attitude about the use of ECT. Do you have any b
Key
Concepts
pseudodementia,
and
neuroleptic
malignant
syndrome.
Research has focused on improving the clinical efficacy and cognitive effe
ECT-induced seizures. It has proven that depressed children, the elderly,
persons with mental retardation can benefit from ECT. Although clients w
movement disorders secondary to Parkinson's disease are also treated w
ECT, the efficacy has not been established.
P.225
Postictal agitation or hyperactive delirium may occur as the client emerg
from anesthesia and may last from a few minutes to an hour.
Prior to ECT, expected benefits, possible risks, and the likelihood of mor
or mortality are discussed with the client and/or family members.
For additional study materials, please refer to the Student Resource CD-ROM
located in the back of this textbook.
P.226
Chapter
Worksheet
CRITICAL
THINKING
QUESTIONS
Interview a psychiatric nurse about the use of ECT. Has the nurse provid
care for clients who received ECT? Why did the clients undergo ECT? How
many treatments did the clients receive? What responses, both physiolo
and emotionally, did the clients exhibit posttherapy?
REFLECTION
The chapter
that provide
con,
your answer
MULTIPLE
CHOICE
QUESTIONS
Answer
effect of the treatment, not the reason for its use. It does not enhance drug
therapy; rather it is commonly used in clients who have not responded to dr
therapy. It does not affect the thyroid gland.
2. The nurse in the outpatient ECT clinic reviews the client's history f
which of the following that might increase the client's risk during ECT
a. Degenerative joint disease
b.
Insulin-dependent
diabetes
mellitus
Answer
The client's risk for injury or complications with ECT is increased with a histo
a recent myocardial infarction or other cardiac disease. Degenerative joint
disease, diabetes, and multiple medication use are not conditions associated
an increased risk to the client.
3. The nurse teaches the client scheduled for ECT treatment that
preparation includes which of the following?
a. Eating a light breakfast at least 3 hours before treatment
P.227
b. Limiting intake of carbohydrates at least 3 days before treatment
c. Refraining from food and fluids for at least 8 hours before treatment
d. Washing hair the morning of treatment
View
Answer
3. C
Prior to ECT, food and fluids are withheld from the client for at least 8 hours
does not need to be washed before treatment.
Answer
4. D
During the ECT procedure, the priority is protecting the client from injury th
may result from the motor seizures secondary to the procedure. Assessing t
EEG and seizure activity is the responsibility of the anesthesiologist and phy
Assisting the client, not the physician, is the priority.
5. In the post-ECT recovery period, which finding would alert the nur
a possible problem?
a.
Sleepiness
Urinary
incontinence
Answer
Internet
Depression
Resources
ECT:
http://www.familydoctor.org/handouts/058.html
TherapyECT:
http://www.psycom.net/depression.central.ect.html
Journal
of
ECT:
http://www.ECTjournal.com/
Selected
the
Free
Encyclopedia:
http://www.en.wikipedia.org/wiki/ect
References
Fink, M., & Abrams, R. (1998). EEG monitoring in ECT: A guide to treatmen
efficacy. Psychiatric Times, 15 (5), 7072.
Fink, M., Abrams, R., Bailine, S., & Jaffe, R. (1996). Ambulatory
electroconvulsive
therapy .
Task Force Report No. 1 of the Association for Convulsive Therapy, (12),
4255.
Fink, M., & Foley, C. A. (1999). Pediatric ECT: An update. Psychiatric
(9), 6365.
Times
(EC
clinical
Sherman, C. (1999). ECT often a good choice for depressed elderly. Clinica
Psychiatry News, 27 (6), 19.
Suggested
Readings
University
Press.
Kellner, C. H., Pritchett, J. T., Beale, M. D., & Coffey, C. E. (1997). Handbo
of ECT . Washington, DC: American Psychiatric Press.
Chapter
17
Alternative
Therapies
and
Complementary
Learning
2000
Objectives
Discuss the roles assumed by the client and the holistic nurse during
the nursing process.
Identify the importance of client education during holistic nursing
and
alternative
therapy.
Key
Terms
Alternative
therapy
Aromatherapy
Cellopathy
Complementary
therapy
Curing
Essential
oils
Healing
Holism
Holistic
nursing
Homeopathic
remedies
Homeopathy
Alternative
therapy , also referred to as complementary
therapy or
medicine, refers to practices that are not considered to be conventional
medicine taught in medical schools, not typically used in hospitals, and
not generally reimbursed by insurance companies (National Center for
Complementary and Alternative Medicine [NCCAM], 2002). It is clearly
gaining popularity. Public interest is at an all-time high, and usage,
according to national surveys, jumped 43% between 1990 and 1997
(Jancin, 2000). It has been estimated that one person in three uses
these therapies for clinical symptoms of anxiety, depression, back
problems, and headaches, for example (Sadock & Sadock, 2003).
Reasons for this dramatic change include dissatisfaction with increasing
health
clients.
Holistic
Nursing
CLASSIFICATION
EXAMPLES OF THERAPIES
Alternative systems
of medical practice
Biobehavioral
interventions
Biofeedback, hypnosis,
meditation, imagery
Bioelectronics
yoga,
disease
Herbal
medicine
Manual healing
modalities
Pharmacologic and
biologic treatments
Summary
of
Holistic
Nursing
Process
interactions.
P.230
BOX
17.1
health.
Homeopathy: Based on the law of similars, this system of
healing, developed in the 18th century, states that a much-diluted
preparation of a substance that can cause symptoms in a healthy person
can cure those same symptoms in a sick person. Homeopathic medicines
(remedies) are made from plant, animal, and mineral substances and are
approved by the Food and Drug Administration.
Hypnosis: Hypnosis is used to achieve a relaxed, yet heightened, state
of awareness during which clients are more open to suggestion.
Massage therapy: Massage therapy is considered to be a science of
muscle relaxation and stress reduction and includes techniques such as
healing touch, Rolfing, and Trager therapy.
Meditation: During this therapy, clients sit quietly with eyes closed and
focus the mind on a single thought. Chanting or controlled breathing may
be used.
Spiritual healing: Spiritual healing addresses the spirit, which is the
unifying force of an individual, and may occur as the direct influence of
one or more persons on another living system without using known
physical means of intervention.
Therapeutic or healing humor: Based on the belief that laughter allows
one to experience joy when faced with adversity, therapeutic humor is
positive, loving, and uplifting. It connects the usual with the unusual and
conveys compassion and understanding. Humor may be found in movies,
stories, pantomime, mime, cartoons, and the like.
Therapeutic touch: This therapy is based on the premise that disease
reflects a blockage in the flow of energy that surrounds and permeates
the body. A four-step process of center, healing intent, unruffling, and
energy transfer occurs as a practitioner attempts to detect and free the
blockages.
After the client completes self-assessment, problems (diagnoses) are
identified and guidelines are provided to assist the client with problemsolving skills. The client and nurse discuss mutually agreed-on goals and
outcomes. For example, suppose the client identifies the problem of
BOX
17.2
Summary
of
the
American
Holistic
Nurses'
1.
Holistic
Philosophy
and
1.1 Holistic
Philosophy: Holistic nurses develop and expand their
conceptual framework and overall philosophy in the art and science of
holistic nursing to model, practice, teach, and conduct research in the
most effective manner possible.
1.2 Holistic
Education: Holistic nurses acquire and maintain current
knowledge and competency in holistic nursing practice.
CORE Value
Research
2.1 Holistic
2.
Holistic
Ethics,
Theories,
and
CORE
Value
3.
Holistic
Nurse
Self-Care
CORE
Value
5.
Holistic
Caring
Process
specified.
Footnote
Reprinted with permission from the American Holistic Nurses' Association.
Homeopathy
Homeopathy , also called vitalism , is classified by the NCCAM as an
alternative medical system that evolved independently of and prior to the
conventional biomedical approach. (Other examples of alternative
medical systems include Traditional Oriental medicine, Ayurvedic
medicine, non-Western cultural medical traditions, and naturopathy.)
Homeopathy is a specific healing therapy started in the late 1700s to
early 1800s by Samuel Hahnemann, a German physician and chemist. He
formulated the theory that the body possesses the power to heal itself.
Therefore a substance creating certain symptoms in a healthy person
would cure an ill person exhibiting the same particular set of symptoms.
For example, the symptoms of arsenic poisoning include abdominal
discomfort, such as stomach cramping with burning pain, nausea, and
vomiting. Arsenicum album is a homeopathic remedy used to treat people
with symptoms of food poisoning, such as nausea, vomiting, and
abdominal discomfort. The remedy cancels out
(O'Brien, 2002).
Aromatherapy
Therapy)
(Biologically
the illness
Based
MindBody
Interventions
Manipulative
or
Body-Based
Treatments
Energy
Therapies
Insomnia
Psychologic stress commonly causes clients to experience problems
sleeping. Clients often rely on homeopathic remedies or aromatherapy.
Homeopathy
Two herbal or homeopathic
remedies (herbal medicines used in
homeopathy) helpful in treating insomnia and jet lag are melatonin and
valerian (Valeriana
officinalis ). In 1995 alone, there were 20 million new
melatonin users in the United States. Melatonin is secreted by the pineal
gland and helps set the body's circadian cycle, thus triggering the onset
of sleep. This hormone is available in powder, capsules, or tablets.
Therapeutic dosage range is 0.2 to 5 milligrams at bedtime (Sadock &
Sadock, 2003). The usual dose for jet lag is 0.5 milligrams, and it is
generally taken the day before travel starts. Although adverse reactions
are rarely reported, and until further information becomes available,
clients
P.233
taking steroids, pregnant women and lactating mothers, and clients with
autoimmune diseases should not use melatonin (Stimmel, 1999).
Aromatherapy
Some clients find that aromatherapy relaxes them and induces sleep.
Essential oils may be applied directly on the skin with a compress where
they are absorbed into the bloodstream; diluted with water or alcohol for
massage; or released into the air for inhalation. Lavender, orange
blossom, and marjoram stimulate the release of serotonin and the
Pain
Clients may have numerous somatic complaints, may be hypochondriacal,
or may have pain disorders associated with psychological or general
medical conditions. Several forms of complementary or alternative
therapies are used to reduce pain. Some of them (eg, acupressure,
aromatherapy, homeopathy, imagery, or therapeutic touch) can be
learned quickly and have little or no risk to their use. Other
unconventional therapies (eg, acupuncture, nutritional supplements, or
osteopathic manipulations) require extensive training and have some
risks associated with their use (Milton, 2001). Examples of alternative
and complementary therapies used to control pain may include:
Homeopathic remedies consisting of herbs or minerals, such as
Arniflora Arnica Gel or Traumed Cream, may relieve pain, swelling,
and stiffness in clients who exhibit chronic pain syndrome secondary
to arthritis, fibromyalgia, or neuropathy.
Hypnosis, an excellent way to mobilize a client's resources to alter
physical sensations such as pain, allows clients to concentrate on
competing sensations or simply to detach themselves.
Relaxation therapy, guided imagery, biofeedback, and meditation also
use the client's ability to concentrate on focal points, thus reducing
painful sensations.
P.234
Aromatherapy stimulates the brain to release endorphins for pain
control.
Acupuncture or acupressure relieves pain by correcting imbalances of
q i (vital energy) and improving the flow of energy (see Box 17-1 for
a complete definition); massage therapy relieves pain through
manipulation of soft tissue and surfaces of the body, increasing blood
and lymph flow and improving musculoskeletal tone; therapeutic
touch and healing touch involve the transfer of energy over specific
body parts to relieve pain and promote healing. All have been used in
the psychiatricmental health clinical setting to minimize pain
(Evans, 1999; Hilton, 2000; Hutchinson, 1999).
Stress
and
Anxiety
Homeopathy
According to a survey in 1998, two in five Americans use homeopathic
remedies (herbal medicines) such as kava-kava (Piper methysticum ),
passion flower (Passiflora
incarnata ), and valerian to treat clinical
symptoms of anxiety and stress (Astin, 1998).
Kava-kava, a green, leafy member of the pepper family, is considered to
be the most potent anxiolytic available without a prescription. It is
nonaddictive, and clients who use it rarely develop tolerance. It does not
alter mental clarity or interfere with reaction time, alertness, or other
cognitive abilities. It is particularly useful in the management of daytime
anxiety. The average daily dosage for general
200 milligrams per day in divided doses. It is
bedtime for treatment of insomnia secondary
effects have been noted including dermatitis,
Massage
Therapy
Therapeutic
Humor
Depression
Herbal remedies such as St. John's wort and SAM-e; therapeutic touch or
massage therapy; acupuncture; and aromatherapy are frequently used to
minimize the clinical symptoms of depression. Meditation also may be
used.
Homeopathy
The herbal medicine St. John's wort (Hypericum
perforatum ) is the most
popular antidepressant in Germany. The mechanisms of action in the
treatment of depression remain unclear. However, pharmacologically, St.
John's wort has been shown to affect neurotransmitters. It is an option
for clients who exhibit low levels of depression; it also may be used for
clients who are more seriously depressed but have not experienced
success with conventional antidepressant therapy. It appears to be a
safe, effective treatment for depression in children,
P.235
adolescents, and adults (Bilger, 1997a; Sherman, 1999). Dosages range
from 500 to 2000 milligrams per day. For children, the usual dose is 300
milligrams per day; for adolescents and adults, the usual dose is 300
milligrams three times a day. Adverse effects include nausea and
vomiting, dry mouth, fatigue, skin rash, phototoxicity, and acute
neuropathy, which generally subside after the herb is discontinued. Its
use is limited by the negative interactions that have resulted when it is
coadministered with certain medications. St. John's wort is
contraindicated during pregnancy or concurrent therapy with other
antidepressants (Assemi, 2000; Ayd, 2001; Baker, 2000; Bilger, 1997a;
Cuccinelli, 1999b, Waddell, Hummel, & Sumners, 2001).
SAM-e (S -adenosyl-L-methionine) is a naturally occurring compound in
the human body formed from methionine and adenosine triphosphate.
SAM-e is found in many mammalian tissues, especially the liver and
brain. It regulates the secretion of neurotransmitters, such as serotonin
and dopamine, but it has not been compared directly with selective
serotonin reuptake inhibitors (SSRIs). SAM-e has been approved as a
prescription drug in Italy, Germany, Spain, and Russia and must be taken
with folic acid and Vitamin B12 daily to be effective. It is available as a
stable, enteric-coated tablet. Starting daily dosage is 400 milligrams, but
research indicates therapeutic dosages range from 800 to 2000
milligrams per day for severe depression. No apparent adverse effects
have been noted, except for gastric distress. SAM-e may precipitate
manic episodes in clients prone to bipolar disorder (Baker, 2000;
Boschert, 1999; Keller, 2001; Knowlton & Staff, 2001; Pies, 2000).
Meditation
Meditation is particularly indicated for clients with stress-related
disorders or any condition exacerbated by stress such as depression,
chronic illness or pain, or terminal illness. Clients who practice
meditation state that they experience positive physical, emotional,
cognitive, behavioral, attitudinal, and spiritual changes, a state of
open stillness
(Edwards, 2003).
Cognitive
Decline
Implications
for
Nursing
Self-Awareness
Prompt
How informed are you about alternative therapies? Do you know anyone
who has used this type of therapy? Do you believe clients with
psychiatric disorders would benefit from this type of treatment? Would
you feel comfortable providing supportive care to a client who requested
herbal remedies instead of antidepressant medication? Explore your
reasons for your answers to these questions .
P.236
REMEDY
Ginkgobiloba or
USE
Herb used to
increase memory
POTENTIAL DRUG
INTERACTIONS
Aspirin,
ergotamine,
warfarin, thiazide diuretics,
Gingkobiloba
in
dementia
phenobarbital,
Kava-kava
Herb used to
decrease anxiety
Levodopa,
dopamine,
alprazolam,
ethanol
Ma huang
Herb used to
Oxytocin,
increase energy
and to lose
weight
guanethidine
Melatonin
Hormone used to
treat insomnia
and jet lag
Verapamil,
steroids,
immunosuppressant
drugs
Passion
flower
Herb used as a
sedative,
hypnotic, or
antispasmodic
SAM-e
Amino acid
supplement
to treat
depression
used
NSAIDs
halothane,
St. John's
Herb used to
Cyclosporine,
warfarin,
wort
treat depression
and anxiety
Valerian
Herb used as a
sedative and
hypnotic
Adverse
Reactions
Psychiatric
Manifestations
The use of herbal remedies has been associated with the development of
psychiatric problems. Sherman (2002) discusses the potential for serious
Client
Education
and
Resources
Findings reinforce the idea that the use of natural herbal medicine may
not be without risk. With these concerns in mind, the nurse should
instruct the client to:
P.237
Inform health care providers of all therapies being used, whether
self-prescribed or prescribed by a practitioner.
Follow directions regarding storage of remedies or supplements.
Follow instructions regarding prescribed dosages and type of
preparation (eg, powder, oil, or tincture).
Report any unusual symptoms, allergic reactions, or concerns while
undergoing
therapy.
Maintain
all
scheduled
appointments.
Key
Concepts
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
According to the quote at the beginning of the chapter, one in every
three persons in the United States uses some form of alternative or
complementary therapy. Does your nursing program include a course on
this topic? If so, does it address the application of alternative and
complementary
therapies
in
the
psychiatricmental
health
clinical
setting? If not, do you feel that the clients are receiving adequate care
to help them access their greatest healing potential? Please explain your
answer.
MULTIPLE
CHOICE
QUESTIONS
Answer
Answer
2. B
Guided imagery and relaxation therapy relieve pain by having the client
concentrate on sensations other than pain. Hypnosis allows a client to
detach from the pain. Aromatherapy stimulates the brain to release
endorphins for pain control. Acupuncture or acupressure relieves pain by
correcting imbalances of vital energy.
P.240
3. The client tells the nurse about her regular use of the remedy
kava-kava. Further assessment would reveal that this remedy is
used to relieve which of the following?
a. Anxiety
b.
Depression
c. Fatigue
d. Pain
View
3. A
Answer
Kava-kava
b.
Lavender
View
4. C
Answer
View
5. A
a.
Anticoagulant
agents
b.
Antidepressant
c.
Antihypertensive
d.
Antidiarrheal
medications
agents
medications
Answer
Internet
Advance
Alternative
Resources
for
Nurse
&
Practitioners:
Complementary
http://www.advancefornp.com
Therapies
Research:
http://www.internethealthlibrary.com/
Alternative
American
Medicine:
Holistic
http://www.altmed.net/
Nurses'
Association:
http://www.ahna.org
of
Alternative-Medicine
Methods:
http://www.acsh.org/dictionary/index.html/
International
(IBIDS):
Natural
Selected
Pharmacist:
International:
http://www.tnp.com
References
for
medicine:
Saint-John's-Wort.
Orlando
for
adolescents.
Suggested
Readings
Medical
Economics.
for
Chapter
18
Schizophrenia
Disorders
and
Schizophrenic-Like
Learning
Objectives
treatment
team
meetings.
Key
Terms
Affective
disturbance
Ambivalence
Autistic
thinking
Awakening
phenomena
Awareness
syndrome
Dementia
praecox
Disorganized
Dopamine
symptoms
hypothesis
Double-bind
situation
Echolalia
Echopraxia
Looseness
Negative
of
association
symptoms
Pica
Positive
symptoms
Psychogenic
polydipsia
Schizophrenia
P.242
Schizophrenia is considered the most common and disabling of the psychot
disorders. Although it is a psychiatric disorder, it stems from a physiologic
malfunctioning of the brain. This disorder affects all races, and is more prev
in men than in women. No cultural group is immune and persons with intelli
quotients of the genius level are not spared. Schizophrenia occurs twice as o
in people who are unmarried and divorced people as in those who are marrie
widowed. People with schizophrenia are more likely to be members of lower
socioeconomic groups (Well-Connected, 1999b).
Clinical symptoms can be draining on both the person with schizophrenia and
or her family because it is considered a chronic syndrome that typically follo
deteriorating course over time. Clients experience difficulty functioning in so
in school, and at work. Family members often provide the financial support,
possibly assuming the responsibility for monitoring medication compliance.
individuals with psychotic disorders have been relocated into nursing homes,
general hospitals, or prisons, or have been forced to live in the streets or
homeless shelters (see Chapter 34 ).
Etiology
of
Schizophrenia
Genetic
Predisposition
Theory
identical twin. About 60% of people with schizophrenia have no close relativ
with the illness (Sherman, 1999a).
The first true etiologic subtype of schizophrenia, the consequence of a
chromosome deletion referred to as the 22q1 deletion syndrome , has been
identified. Persons with this syndrome have a distinct facial appearance,
abnormalities of the palate, heart defects, and immunologic deficits. The risk
developing schizophrenia in the presence of this syndrome appears to be
approximately 25%, according to Dr. A. Bassett of the University of Toronto
(Baker, 1999; Kennedy, et al., 1999; Sherman, 1999d).
Biochemical
and
Neurostructural
Theory
The cause of the release of high levels of dopamine has not yet been found,
the administration of neuroleptic medication supposedly blocks the excessive
release. Other neurotransmitters or chemicals in the brain, such as the amin
acids glycine and glutamate, and proteins called SNAP-25 and a-fodrin, are
being studied (Kennedy et al., 1999).
Abnormalities of brain shape and brain circuitry are being researched as wel
Supposedly, a circuit filters information entering the brain and sends the rel
information to other parts of the brain for determining action. A defective ci
can result in the bombardment of unfiltered information,
negative and positive symptoms. Overwhelmed, the mind
perception and hallucinates, draws incorrect conclusions,
To compensate for this barrage, the mind withdraws and
possibly causing bo
makes errors in
and becomes delu
negative symptoms
FIGURE
Organic
or
Psychophysiologic
Theory
Those who suggest the organic or psychophysiologic theory offer hope that
Environmental
or
Cultural
Theory
Proponents of the environmental or cultural theory state that the person who
develops schizophrenia has a faulty reaction to the environment, being unab
respond selectively to numerous social stimuli. Theorists also believe that p
who come from low socioeconomic areas or single-parent homes in deprived
are not exposed to situations in which they can achieve or become successfu
life. Thus they are at risk for developing schizophrenia. Statistics are likely t
reflect the alienating effects of this disease rather than any causal relationsh
risk factor associated with poverty or lifestyle (Kolb, 1977).
Perinatal
Theory
Experts suggest that the risk of schizophrenia exists if the developing fetus
newborn is deprived of oxygen during pregnancy or if the mother suffers fro
malnutrition or starvation during the first trimester of pregnancy. The
development of schizophrenia may occur during fetal life at critical points in
development, generally the 34th or 35th week of gestation. The incidence of
trauma and injury during the second trimester and birth has also been cons
in the development of schizophrenia (Well-Connected, 1999a).
Psychological
or
Experiential
Theory
Although genetic and neurologic factors are believed to play major roles in t
development of schizophrenia, researchers also have found that the prefront
Vitamin
Deficiency
Theory
The vitamin deficiency theory suggests that persons who are deficient in vita
B, namely B1, B6, and B12, as well as in vitamin C, may become schizophre
a result of a severe vitamin deficiency. As stated earlier, extensive research
be done to prove this theory.
Clinical
Symptoms
and
Diagnostic
Characteristics
attitudes, ideas, or desires for the same person, thing, or situation. Loosene
association is the inability to think logically. Ideas expressed have little, if
connection and shift from one subject to another.
Clinical symptoms fall into three broad categories: positive symptoms, nega
symptoms, and disorganized symptoms. Positive symptoms reflect the pre
of overt psychotic or distorted behavior, such as hallucinations, delusions, o
suspiciousness, possibly due to an increased amount of dopamine affecting t
cortical areas of the brain. Negative symptoms reflect a diminution or loss
normal functions, such as affect, motivation, or the ability to enjoy activities
these symptoms are thought to be due to cerebral atrophy, an inadequate a
of dopamine, or other organic functional changes in the brain. The category
disorganized
symptoms was recently added. This category refers to the
presence of confused thinking, incoherent or disorganized speech, and
disorganized behavior such as the repetition of rhythmic gestures. These
symptoms
P.245
and diagnostic characteristics are listed in the accompanying Clinical Sympto
and Diagnostic Characteristics box.
Two categories have been developed to describe the etiology and onset of
schizophrenia: type I and type II. In type I schizophrenia , the onset of pos
symptoms is generally acute. Type I symptoms generally respond to typical
neuroleptic medication. Theorists believe that an increased number of dopam
receptors in the brain, normal brain structure, and the absence of intellectua
deficits contribute to a better prognosis than for those identified with type II
schizophrenia.
medication
(Sherman,
1999c).
Paranoid
Type
Symptoms
POSITIVE
SYMPTOMS
(persecutory
Conceptual
or
grandiose)
disorganization
or
or
aggressive
Suspiciousness,
Pressurized
agitation
ideas
behavior
of
speech
reference
Possible
suicidal
NEGATIVE
tendencies
SYMPTOMS
withdrawal
(passive,
apathetic,
social
withdrawal)
relationship
DISORGANIZED
with
others
SYMPTOMS
Cognitive
defects/confusion
Incoherent
speech
Disorganized
speech
deficits
Diagnostic
Characteristics
speech
disorganized
or
catatonic
behavior
Negative
symptoms
Above symptoms present for a major portion of the time during a 1-mon
period
BOX
18.1
Classification
of
Subtypes
of
Schizophrenia
Paranoid:
Disorganized: All of the following are prominent and criteria are not met fo
catatonic type:
Disorganized
speech
Disorganized
behavior
disorganized,
or
catatonic
subtypes
Residual:
Footnote
Reprinted with permission from the Diagnostic and Statistical Manual of Men
Disorders, 4th Edition, Text Revision . Copyright 2000 American Psychiatric
Association.
Catatonic
Type
Example
The student nurse may feel challenged when the client with catatonic
schizophrenia is unresponsive to interventions and continues to exhibit selec
mutism or refuses nursing care, food, and medication. Purposeless movemen
hands and feet or extreme catatonic excitement that could result in harm to
caretakers may elicit fear in the student.
Disorganized
Type
Example
CLINICAL
The
Client
EXAMPLE
With
18.1
Schizophrenia,
Paranoid
Type
CLINICAL
The
Client
EXAMPLE
With
18.2
Schizophrenia,
Catatonic
Typ
Because most clients who are diagnosed with schizophrenic disorder, disorg
type, are of a young age, student nurses' reactions may vary from shock to
disbelief. Students may identify with the client who is close to their age or
resembles someone they know. This reaction could interfere with the develo
of a therapeutic relationship. Such feelings need to be shared and explored
the clinical instructor.
Undifferentiated
Type
schizophrenia. The client may exhibit both positive and negative symptoms.
behavior, delusions, hallucinations, and incoherence may occur. Prognosis is
favorable if the onset of symptoms is acute or sudden.
CLINICAL
EXAMPLE
The Client
Type
With
18.3
Schizophrenia,
Disorganized
The student nurse may feel uncomfortable or fearful in the presence of a clie
diagnosed with undifferentiated schizophrenia. The presence of atypical,
disorganized clinical symptoms may prevent the student from attempting to
communicate with the client.
Residual
Type
Schizophrenic-Like
Disorders
disorders are discussed briefly here. See Chapter 19 for discussion of shared
psychotic
disorder.
Schizoaffective
disorder is characterized by an uninterrupted period of illnes
during which, at some time, the client experiences a major depressive, mani
P.248
hallucinations or delusions determined as due to the direct physiologic effects
specific medical condition. For example, olfactory hallucinations may be
experienced in the presence of temporal lobe epilepsy. A right parietal brain
may cause an individual to develop delusions. Evidence from history, physica
examination, or laboratory findings is necessary to confirm the diagnosis.
Self-Awareness
Prompt
Identify the clinical symptoms of schizophrenia that you feel would be the m
challenging to you. Why do you consider these symptoms to be challenging?
would you prepare yourself to meet these challenges?
The
Nursing
Process
Assessment
History
and
Physical
Examination
Another key area of assessment is the client's fluid intake. Ask the client ho
Document the client's physical condition noted during the assessment. Como
medical problems that are commonly seen in older clients with psychotic dis
include hypertension, type II diabetes, and hepatitis. Also note the presence
any abnormal body movements, disturbance of gait, or unusual behavior.
Additionally, document any hallucinations or delusions and other disorders su
anxiety, substance abuse, or depression that are assessed.
Transcultural
Considerations
presence of strong family systems and social structures that place lower dem
on sick individuals. In the Hispanic culture, hallucinations take the form of g
spirits, or animals. Individuals with the diagnosis of schizophrenia in German
exhibit delusions related to sexual, homosexual, or technical content.
P.249
Always consider cultural differences when assessing clinical symptoms in clie
with suspected psychotic disorders. Ideas that appear delusional in one cultu
may be acceptable in another. For example, speaking in tongues or the pres
of visual or auditory hallucinations with religious content may be considered
normal religious experience or a special sign to some individuals. (See Chapt
for a more complete discussion.)
Nursing
Diagnoses
After data have been collected and prioritized, the nursing diagnoses are ma
Outcome
Identification
Expected outcomes are stated for each nursing diagnosis. The statement of
outcomes is influenced by several factors, such as the client's present coping
strategies and level of cognitive function, the presence or absence of suppor
systems and adequate income, and the clinical setting in which each treatme
occurs. Examples of Stated Outcomes are highlighted in the accompanying b
Example
of
NANDA
Nursing
Diagnoses:
Schizophrenia
EXAMPLES OF STATED
SCHIZOPHRENIA
OUTCOMES:
Planning
Interventions
treatment efficacy (2001), the acute treatment success rate for schizophrenia
months was 65%. Relapse rate at 2 years in clients who received antipsycho
medication plus psychosocial therapy specific to schizophrenia was 25%,
compared to 63% in clients given medication alone (Jancin, 1998). The failu
provide comprehensive treatment for clients with a dual diagnosis has also b
cited as a cause of recidivism. (See Chapter 30 , Clients With a Dual Diagno
Implementation
Remember that all behavior is meaningful to the client, if not to anyone else
Clients may refuse to communicate or may communicate ineffectively as a r
of self-contradictory or conflicting statements, frequent changes in subject,
inconsistency in verbalization, the use of incomplete sentences or fragmente
phrases, or the presence of delusions or hallucinations. Encouragement such
Help me to understand how you feel
has been therapeutic when
communicating with clients. Communicate in simple, easy-to-understand ter
directed at the client's present level of functioning. See Chapter 10 for addi
information regarding therapeutic interactions.
Providing a safe, structured environment is important to maintain biologic
integrity and to protect the client from potential self-harm due to command
hallucinations, irrational behavior, disorientation, or poor safety awareness.
setting, time-out, or physical restraints may be necessary during the acute
of schizophrenia to decrease agitation or aggressive behavior, or to prevent
physical injury to self or others. Box 18-2 lists specific nursing interventions
clients exhibiting agitation, hallucinations, and delusions. See Chapter 11 fo
additional discussion of the therapeutic milieu.
Medication management focuses on stabilizing acute symptoms and then
new agents efficacious; they are safer and better tolerated, thus more effec
Table 18-1 lists the characteristics of second-generation antipsychotics.
BOX
18.2
Interventions
Delusions
for
Agitation,
Hallucinations,
Agitation
Remove clients from, or avoid, situations known to cause agitation.
prescribed
medication
as
ordered.
Hallucinations
prescribed
medication
as
ordered.
DRUG
Drugs
SUMMARY
Used for
GENERIC
(TRADE)
NAME
DAILY
DOSAGE
RANGE
IMPLEMENTATION
aripiprazole
1030
(Abilify)
mg
clozapine
75700
Follow
(Clozaril)
mg
Clozaril
Client
Management
haloperidol
(Haldol)
416 mg
olanzapine
(Zyprexa)
520 mg
quetiapine
(Seroquel)
25800
mg
risperidone
(Risperdal)
0.516
mg
Mix oral solution with water, juice, lowfat milk, or coffee; monitor for
galactorrhea, weight gain, and adverse
effects* listed below.
ziprasidone
(Geodon)
20160
mg
TABLE 18.1
Characteristics
of
Second-Generation
Antipsychotics
DRUG
(YEAR OF
BEGINNING
USE)
TRADE
NAME
DAILY
DOSAGE
THERAPEUTIC
PLASMA
LEVEL
COMPARISO
OF ADVERS
EFFECTS
haloperidol
(1970s)
Haldol
416
mg/day
416
mg/mL
Increased
motor activit
No weight ga
clozapine
(1988)
Clozaril
75700
mg/day
350500
mg/mL
No increased
motor activit
Weight gain
Multiple
adverse effec
Effect on
cholesterol
metabolism
leading to
decreased
serum
cholesterol
levels
risperidone
(1992)
Risperdal
0.516
mg/day
530
mg/mL
Minimal
increase in
motor activit
Minimal weig
gain
Galactorrhea
olanzapine
(1994)
Zyprexa
520
mg/day
2154
mg/mL
Minimal
increase in
motor activit
Weight gain
Effect on
cholesterol
metabolism
leading to
decreased
serum
cholesterol
levels
quetiapine
(Mid 1990s)
Seroquel
25800
mg/day
45100
mg/mL
No increase i
motor activit
Minimal
adverse effec
even with
higher doses
ziprasidone
Geodon
20160
Not
Minimal
mg/day
established
increase in
motor activit
No weight ga
Changes in Q
segment of
EKG
(prolongation
1030
mg/day
Not
established
Anxiety
Headache
Insomnia
Considered
(Late
1990s)
aripiprazole
(2002,
Dec.)
Abilify
to
cause minima
adverse effec
P.252
The earlier schizophrenia is treated, the better the outcome is. The use of
neuroleptic medication during the first episode is thought to decrease the
After symptoms are stabilized, clients may exhibit what has been referred to
the awareness syndrome or awakening phenomena . For example, after
clinical symptoms such as hallucinations, confusion, and ideas of reference a
stabilized, the client may begin to experience inner emotions such as anxiety
fear as he or she regains an awareness of reality. Ineffective or dysfunction
coping mechanisms no longer shield the client from environmental stress.
Conversely, therapeutic levels of medication may enable clients to assume
responsibility for themselves and to participate in various treatment modalit
such as individual, group, cognitive, behavioral, supportive, or family therap
Over time, treatment resistance may occur due to several factors such as in
biologic factors; inadequate dose or plasma level of the prescribed drug; mi
diagnosis of a comorbid medical or psychiatric disorder; or inappropriate
psychosocial treatment. The following interventions have been used as an
Using clozapine if the client has not responded favorably to the use of tw
different
neuroleptics
SUPPORTING
EVIDENCE
FOR
PRACTICE
With
18.1
the
and 21.8% denied being ill. In addition, 25% of the clients expected their m
health to improve; 25% expected some relapses; and another 25% expected
condition to stabilize or possibly get worse. At time of discharge and after 3
months, 33% of the clients had not been taking medication as prescribed an
Footnote
Source: Holzinger, A., Loffler, W., Muller, P., et al. (2002). Subjective illnes
theory and antipsychotic medication compliance by patients with schizophre
Journal of Nervous and Mental Disease, 190 , 597603.
P.253
ADVERSE
EFFECT
Allergic
reaction
NURSING
INTERVENTIONS
Dry mouth
Menstrual
irregularity
Somnolence
lethargy
or
Sexual
dysfunction
Provide
Weight gain
emotional
support.
The client, family members, or significant others are all involved in the plan
Evaluation
Key
Concepts
CLIENT
WITH
UNDIFFERENTIATED
SCHIZOPHRENIA,
TYPE
Janet, a 47-year-old white female, was brought to the mental health center
sister, who expressed concern about recent behavioral changes exhibited by
Janet. She stated that Janet was diagnosed with schizophrenia, undifferentia
type at age 40 and was placed on Risperdal 1.0 mg bid.
Janet lived with her sister. She was unemployed but received Social Security
Disability compensation. Janet was able to perform activities of daily living
independently until recently, when she discontinued taking her medication. A
result of medication noncompliance, Janet became overly concerned about i
and bugs that she believed were in her room. She began to wear gloves to
her hands as she sprayed insect repellant on all the furniture. She also turne
water on in her bathroom sink because she believed the bugs contaminated
sink. Unfortunately, she neglected to turn the water off and flooded the
bathroom.
Although she was oriented to person, place, and time, Janet's speech had be
incoherent at times. Janet stated that she felt better while taking medication
therefore, believed that she was cured of her illness. Consequently, she stop
taking the medication. When Janet's sister confronted her about her recent
behavioral changes, Janet was insightful enough to tell her sister that she n
help and agreed to see the nurse at the center where she received follow-up
DSM-IV-TR
DIAGNOSIS:
Schizophrenia,
undifferentiated
type
DIAGNOSIS:
Noncompliance
regarding
noncompliance
medication
reg
management
Planning/Implementation
Rationale
recidivism
secondary
to
noncompliance.
Planning/Implementation
Explore stressors contributing
psychotic symptoms.
to
Rationale
Planning/Implementation
Rationale
pointing
to visual hallucinations or
fears.
or
gesturing.
Repetitive
communication
approaches are less stressf
to cognitively impaired
clients.
P.255
to
decrease
recidivism.
For additional study materials, please refer to the Student Resource CD-ROM
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
As you take the first bite of your burger in a fast-food restaurant, you n
a disheveled, dirty man in the booth across from you. He is talking to h
and gesturing wildly. Describe your thought processes as you assess this
What interventions, if any, would be appropriate?
Observe a psychiatric treatment milieu and analyze how the unit is
therapeutic for a client with schizophrenia.
REFLECTION
Reread the chapter opening quote. In what manner does active
schizophrenia produce disability equal to quadriplegia? Cite two
to substantiate your explanation. How would these examples of
the family of a client with schizophrenia? Identify what support
family and client could use.
MULTIPLE
CHOICE
psychosis in
or three exa
disability af
systems the
QUESTIONS
Answer
1. B
Anger,
auditory
hallucinations,
persecutory
delusions
Answer
a. Client will talk about concrete events in the environment without tal
about delusions.
b. Client will state three symptoms that occur when feeling stressed.
c. Client will identify two personal interventions that decrease intensity
delusional
thinking.
d. Client will use distracting techniques when having delusions.
View
3. A
Answer
The most appropriate outcome for a client with disturbed thought processes
delusions would be the client's ability to talk about concrete events without
talking about delusions. This would indicate that the client is in touch with r
Stating three symptoms of stress is unrelated to the problem involving thou
processes. Identifying two personal interventions to decrease delusions woul
more appropriate for a nursing diagnosis of deficient knowledge associated w
controlling delusions. Using distracting techniques would be appropriate for
nursing diagnosis of ineffective coping.
4. Which nursing response would be most appropriate when a client
about hearing voices?
a. I do not hear the voices that you say you hear.
b. Those voices will disappear as soon as the medicine works.
c. Try to think about positive things instead of voices.
d. Voices are only in your imagination.
View
4. A
Answer
When a client reports hearing voices it is important for the nurse to underst
that the voices have meaning to the client, yet acknowledge to the client tha
nurse does not hear the voices. Telling the client that the voices will disappe
with medication, telling the client to think about positive things, or stating t
the voices are the client's imagination ignores the importance or significance
the voices for the client.
Answer
In any situation, but especially one in which a client begins to show anger a
possible loss of control, the nurse is responsible for maintaining the safety o
client and others first. Once safety is addressed and the situation is stabilize
then the nurse can address the other areas such as reasons, group behavior
group process.
Internet
Mental
Resources
Health
InfoSource
National
Institute
National
Mental
of
Mental
Health
Directory:
Health:
Awareness
http://www.mhsource.com/schizophre
http://www.nimh.nih.gov/
Campaign:
http://www.nostigma.com
Selected
References
treatm
Holzinger, A., Loffler, W., Muller, P., Priebe, S., & Angermeyer, M. C. (200
Subjective illness theory and antipsychotic medication compliance by patie
with schizophrenia. Journal of Nervous and Mental Disease, 190 , 59760
Jancin, B. (1998). Schizophrenic outcomes. Not doing too bad. Clinical
Psychiatry News, 26 (10), 31.
Kennedy, J. L., Pato, J., Bauer, A., Carvalho, C., & Pato, D. (1999). Geneti
schizophrenia: Current findings and issues. CNS Spectrum, 4 (5), 1721
Kolb, L. C. (1977). Modern
clinical
fact
sheet.
Me
Psych
Suggested
Readings
Chapter
19
Delusional
Psychotic
and Shared
Disorders
Learning
Objectives
disorder.
Key
Terms
Conjugal
paranoia
Content-specific
delusions
(CSDs)
Delusion
Erotomanic
delusions
Folie deux
Grandiose
delusions
Ideas of reference
Nonbizarre
delusions
Paradoxical
conduct
Paranoid
Persecutory
Somatic
delusions
delusions
Etiology
of
Delusional
Disorders
isolation
stress
conflicts
Clinical Symptoms
Characteristics
and
Diagnostic
CLINICAL
EXAMPLE
19.1
Disorder,
Persecutory
Subtype
2003).
Conjugal
(Jealous)
Subtype
Erotomanic
Subtype
Grandiose
Subtype
Somatic
Subtype
Etiology
of
Shared
Psychotic
Disorder
Clinical Symptoms
Characteristics
and
Diagnostic
19-2.
Self-Awareness
Prompt
CLINICAL
EXAMPLE
The Clients
Disorder
With
19.2
Shared
Psychotic
The
Nursing
Process
Assessment
Assessment of clients with delusional disorders or shared
psychotic disorder is challenging because the clients typically
deny any pathology. This challenge is further compounded by
the presence of suspiciousness or ideas of reference, their
inability to trust others, and their resistance to therapy.
History
and
Physical
Examination
Transcultural
Considerations
Nursing
Diagnoses
Outcome
Identification
delusional
material
Planning
Interventions
Implementation
Caring for clients with delusional disorders and shared psychotic
disorder focuses on assisting the client in the activities of daily
living; providing a safe environment to observe for suicidal
ideation; stabilizing behavior such as hostility and aggression;
establishing rapport; enhancing self-esteem; and decreasing
fears, suspicions, ideas of reference, and delusions. Box 19-1
lists some examples of nursing interventions for delusional and
shared psychotic disorders.
Assistance
in
Meeting
Basic
Needs
Medication
Management
Interactive
Therapies
Client
Education
Evaluation
Thought
Processes
related
to
suspiciousness
behavior.
BOX
19.1
Nursing Interventions
and Shared Psychotic
for Delusional
Disorders
delusion.
If the client asks you if you believe the delusion, inform the
client that you do not share the perception or delusional
belief.
Acknowledge the plausible elements of the delusion.
Identify the purpose or needs the delusion serves.
If possible, meet the needs the delusion fulfills (ie,
dependence, low self-esteem).
Identify ways to help the client control thoughts, such as
distracting oneself from thinking the same thought
repeatedly; using thought-switching techniques; identifying
signs, such as staring, that indicate thoughts are becoming
disorganized; and anticipating new situations that may
increase anxiety or enhance delusional thoughts.
GENERIC
(TRADE)
NAME
DAILY
DOSAGE
RANGE
IMPLEMENTATION
pimozide
(Orap)
110 mg
quetiapine
(Seroquel)
25800
mg
ziprasidone
(Geodon)
20160
mg
information.
behavior;
Weaknessess:
socialization
NURSING
physically
Delusional
healthy
thoughts,
persecutory
type;
limited
Planning/Implementation
Encourage verbalization
feelings and thoughts.
of
Rationale
The client will identify
with the nurse as
someone who will not
censure his feelings or
thoughts, even if they
are unusual or bizarre.
of the environment.
Planning/Implementation
Investigate whether there is a
precipitating stressor that
triggered the delusional
thoughts.
Rationale
If the client can
identify the
relationship
between
his delusions and
life events, he may
be able to make
behavioral changes
and develop more
positive coping
skills.
If the client is
willing to explore
alternative coping
measures and
problem-solving
skills, behavioral
changes may occur
without focusing on
the validity of the
delusions.
socialization.
Planning/Implementation
Rationale
P.267
Key
Concepts
Delusional
disorders,
generally
characterized
by
extreme
interventions.
Individual psychotherapy is the treatment of choice because
clients with delusional thoughts do not respond well to
insight-oriented, problem-oriented, or group therapy in
which delusions are confronted by peers or therapists.
Long-term management may be required, as clients may
exhibit periods of remission followed by relapses or may
have a chronic delusional disorder.
For additional study materials, please refer to the Student
Resource CD-ROM located in the back of this textbook.
P.268
P.269
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
According to the chapter opening quote, delusional disorder is
considered to be relatively uncommon. Given the numerous
precipitating factors that are believed to cause delusional
MULTIPLE
CHOICE
QUESTIONS
View
1. A
a.
Projection
b.
Regression
c.
Suppression
d.
Sublimation
Answer
Encouraging
activities
c. Presenting reality
d. Reducing anxiety
View
2. C
Answer
View
3. C
b.
Conjugal
c.
Erotomanic
d.
Grandiose
Answer
Answer
Antidepressants
Depot
neuroleptics
Sedative-hypnotics
Antiparkinsonism
agents
Answer
Internet
Resources
http://www.emedicine.com/med/topic3352.htm
Selected
References
of
psychiatry:
Behavioral
sciences/clinical
Suggested
Readings
Chapter
Mood
20
Disorders
Learning
Horizons,
1993
Objectives
Key
Terms
Affective
disorders
Anaclitic
depression
Anergia
Anhedonia
Apathy
Asthenia
Dysthymia
Elation
Endogenous
Euphoria
Hypomania
Mania
depression
agitation
Psychomotor
retardation
Residual
symptoms
Etiology
of
Mood
Disorders
Genetic
Theory
BOX
20.1
suicide
Female
attempts
gender
period
life
events
Biochemical
Theory
FIGURE
Neuroendocrine
Regulation
Psychodynamic
Theory
Behavioral
Theory:
Learned
Helplessness
Behavioral theorists regard mood disorders as a form of acquired or
learned behavior. For one reason or another, people who receive
little positive reinforcement for their activity become withdrawn,
overwhelmed, and passive, giving up hope and shunning
responsibility. This, in turn, leads to a perception that things are
beyond their control. This perception promotes feelings of
helplessness and hopelessness, both hallmarks of depressed states.
Behaviorists who subscribe to this theory believe that a client's
depressed mood could improve if the client develops a sense of
control and mastery of the environment (Sadock & Sadock, 2003).
P.275
Cognitive
Cognitive
or
Theory
cognitivebehavioral
theorists
believe
that
thoughts
Life
2003).
Events
and
Environmental
Theory
Clinical
Symptoms
Characteristics
of
and
Diagnostic
Depressive
Disorders
person
person
chosen
hoped
usually
may become
as a
to attend.
Major
Depressive
Disorder
Disorder
Clinical
Symptoms
Depressed
mood
or
Psychomotor
hypersomnia
agitation
or
retardation
Characteristics
CLINICAL
The
Client
EXAMPLE
With
20.1
Major
Depressive
Disorder
AS, a 25-year-old professional basketball player, complained of
fatigue during practice. He had a few episodes of vertigo the
previous week and also stated he could not remember the different
plays the coach recently designed. The team physician examined AS.
During the examination, AS revealed that he did not enjoy playing
basketball anymore, had no interest in socializing with his peers or
fiance, and felt as if he didn't belong or fit in with other
members of the team. The physician noted that despite no
physiologic reason for a weight loss, AS had lost 15 pounds since his
last physical examination. AS described a lack of appetite for
approximately 2 weeks. The team physician was able to determine
that AS was exhibiting clinical symptoms of major depressive
disorder without psychotic features or suicidal ideation and
subsequently prescribed an antidepressant medication and
supportive
psychotherapy.
Major depressive disorder may be coded as mild, moderate, or
severe; with or without psychotic features; and as in partial or full
remission. Reference also is made to identify it as a single or
recurrent episode. The specifier with seasonal pattern
can be
applied to the pattern of major depressive episodes if the clinical
symptoms occur at characteristic times of the year. For example,
most episodes begin in fall or winter and remit in the spring,
although some clients experience it during the summer. Clinicians
often refer to this type of mood disorder with seasonal pattern as
seasonal affective disorder (SAD) . According to DSM-IV-TR,
approximately 4% to 6% of the U.S. population experiences SAD.
This disorder occurs more frequently in women who are between the
ages of 20 and 40 years and in individuals living in areas where
seasonal changes are more extreme.
Dysthymic
Disorder
Depressive Disorder,
Specified
(NOS)
Not
Otherwise
FIGURE
criteria for any specific BPD. Bipolar I, bipolar II, and cyclothymic
disorders are discussed below.
Bipolar
Disorder
Bipolar
II
Disorder
CLINICAL
EXAMPLE
20.2
Symptoms
self-esteem
or
grandiosity
distractible
Increased
goal-directed
activity
Excessive
overinvolvement
in
or
psychomotor
pleasurable
agitation
activities
usually
Characteristics
Cyclothymic
Disorder
P.279
the criteria for
at least 2
2 months at a
condition or
Clinical
Symptoms
Characteristics
of
and
Other
Diagnostic
Mood
Disorders
CLINICAL
The
Client
EXAMPLE
With
20.3
Cyclothymic
Disorder
BOX
20.2
Medications and
Correlated With
Medical Illnesses
Depression
Medications
Analgesics,
ibuprofen,
nonsteroidal
and
Antimicrobials:
anti-inflammatory
drugs:
indomethacin
sulfonamides
and
isoniazide
Antineoplastic
agents:
asparaginase
Antiparkinson
agents:
levodopa
and
and
tamoxifen
amantadine
narcotics,
blockers:
Hormonal
agents:
Medical
cimetidine
and
corticosteroids,
ranitidine
estrogen,
and
progesterone
Illnesses
deficiency
heart
failure
and
disturbances:
hypercalcemia,
hypokalemia,
rheumatoid
arthritis,
cancer
(particularly
of
the
P.280
physical examination, or laboratory findings confirm the diagnosis of
depression in the absence of delirium. Symptoms cause clinically
significant impairment in areas of functioning. See Clinical Example
20-4 .
Premenstrual
(PMDD)
Dysphoric
Disorder
CLINICAL
EXAMPLE
20.4
The
Nursing
Process
Assessment
When conducting an assessment of a client with a mood disorder,
maintain eye contact, display empathic listening, and communicate
interest and concern in an unhurried manner. Focus the assessment
on the client's general description or appearance; ability to
communicate; mood, affect, and feelings; and behavior.
Screening
Tools
and
Assessment
Scales
General
Description
or
Appearance
are often very friendly and invasive of the territorial space of others
(Sadock & Sadock, 2003). Assessment data must reflect which phase
of BPD the client is presently exhibiting and describe the frequency
with which the symptoms cycle from depressed mood to manic
episode (eg, hours, days, or months). Remember that rapid cyclers
have four or more episodes per year.
Communication
In clients with mood disorders, body language may replace
communication skills because the client is unable to convey feelings
or thoughts. For example, clients with depression may respond to
questions with single words, and exhibit delayed responses to
questions requiring the nurse to wait 2 or 3 minutes for a response.
Conversely, clients with manic features generally exhibit
hyperactivity, in which speech is pressured and considered a
nuisance to those around them. They cannot be interrupted while
they are speaking.
The inability of clients to relate to the nurse may hinder the
development of a therapeutic relationship and the formulation of
accurate nursing diagnoses. Consequently, it may be necessary to
obtain additional information from family members or employees who
bring or send clients for treatment, due to clients' social withdrawal
as evidenced by decreased communication or verbalization of suicidal
or homicidal thoughts.
Mood,
Affect,
and
Feelings
Behavior
The client's behavior is influenced by thought content, level of
cognition, judgment and insight, impulse control (eg, presence of
aggressive, destructive, suicidal, or homicidal behavior), and the
presence of perceptual disturbances (eg, delusions or hallucinations).
Nursing assessment focuses on the client's ability to meet daily
needs, follow directions, and remain compliant with the plan of care.
Ask questions to provide information related to attention span,
concentration, sleep pattern, appetite, and the presence of psychotic
or suicidal thoughts (see Chapter 29 ).
Also assess for the presence of risk factors such as medical
comorbidity or the use of medication associated with behavioral
changes and a high risk of a mood disorder (see Box 20-2 earlier in
this chapter). Prepare the client for a physical examination if a
medical doctor has not seen the client within the past year.
Because the client may have a history of a mood disorder, obtain
information about prior treatment, including the use of and response
to antidepressant medication or other psychotropic medication and
any alternative therapies. Obtain a family history to rule out the
presence of genetic or biologic predisposition to depression.
Transcultural
Considerations
Nursing
Diagnoses
Outcome
Identification
Planning
Interventions
demanding.
Implementation
Implementing appropriate nursing interventions can occur in a
variety of settings. Typically, hospitalization is recommended for
clients who are severely depressed, display suicidal ideation, or
require medical care secondary to depression. Clients displaying
symptoms of acute manic behavior require hospitalization as well.
Providing a safe environment is of the utmost importance.
Assistance
in
Meeting
Basic
Needs
Medication
Management
Somatic
Therapies
Interactive
Therapies
Alternative
and
Complementary
Therapies
Client
Education
Evaluation
The client's response to interventions is evaluated based on the
attainment of desired outcomes. The nurse compares the client's
clinical symptoms as initially seen when entering treatment with
symptoms exhibited following completion of a plan of care. Input by
family members and members of the treatment team is important.
P.288
An important aspect of evaluation involves determining the
resolution of clinical symptoms. Not all clinical symptoms improve at
the same time. Residual symptoms (the phase of an illness that
occurs after the remission of the initial clinical symptoms) have been
identified in some clients on antidepressant therapy. These
symptoms include anergia (sluggishness or listlessness), apathy
(indifference), asthenia (profound fatigue with loss of motivation
and short-term memory problems), excessive daytime somnolence,
fatigue, and hypersomnia.
Although SSRIs are employed to treat an array of mood disorders
because they generally produce fewer adverse effects and are
usually tolerated well, clients have been known to develop movement
disorders similar to those produced by neuroleptics; serotonin
syndrome; and serotonin withdrawal syndrome (see Chapter 15 ). Be
Self-Awareness
Prompt
BOX
20.3
Screening
Tools
and
Assessment
Scales
Numerous tools and scales can be used to assess a client for a mood
disorder. These tools and scales provide qualitative and quantitative
evidence of the client's severity of symptoms. Commonly used
assessment tools or scales include:
Hamilton Rating Scale for Depression: A 17- to 21-item observerrated scale that assesses depressive symptoms; one of the most
widely used instruments for the clinical assessment of depressive
states
Global Assessment Scale: A single-item rating scale for
evaluating the overall functioning of a client during a specific
period on a continuum from psychiatric illness to health
Zung Self-Assessment Scale: A 20-item self-rating scale that
Questionnaire:
12-item
self-reporting
questionnaire
non-psychiatric
clinical
settings
Examples Of NANDA
Mood Disorder
Nursing
Diagnoses:
disorder
Fatigue related to hyperactivity secondary to manic state of
bipolar disorder
Hopelessness related to poor self-concept secondary to
depression
Impaired Verbal Communication related to inability to
concentrate secondary to depression
Ineffective Coping related to delusions of grandeur secondary to
manic state of bipolar disorder
Situational Low Self-Esteem related to feelings of failure
secondary to depression
Disturbed Sleep Pattern related to hyperactivity secondary to
manic state of bipolar disorder
Social Isolation related to fear of rejection secondary to low selfconcept
EXAMPLES
OF
STATED
OUTCOMES:
MOOD
DISORDERS
The client will identity factors that reduce activity tolerance.
The client will report a reduction of symptoms of activity
intolerance.
The client will describe causative factors of anorexia when
known.
The client will describe rationale for the use of an appetite
stimulant.
The client will discuss the causes of fatigue.
The client will demonstrate improved ability to express self.
The client will identify personal coping patterns and the
consequences of the behavior that results.
DAILY
(TRADE)
NAME
DOSAGE
RANGE
Drug
Class:
IMPLEMENTATION
Antidepressants
bupropion
(Wellbutrin)
150450
mg
fluoxetine
(Prozac)
1080 mg
as for headache,
nervousness, abnormal sleep
pattern, GI disturbances, and
weight loss.
mirtazapine
(Remeron)
1545 mg
Contraindicated during or
within 14 days of MAOI
therapy; can be given at
night to induce sleep; avoid
use of alcohol; monitor for
drowsiness,
increased
appetite and weight gain,
dizziness, dry mouth, and
constipation.
nefazodone
(Serzone)
100600
mg
Contraindicated during or
within 14 days of MAOI
therapy and during
pregnancy; given in divided
doses; use with caution in
clients with a history of
cardiovascular or cerebral
vascular disorders, liver
disease, mania, hypomania,
or suicidal ideation; monitor
liver function, monitor for
CNS agitation, orthostatic
hypotension, and skin rash.
paroxetine
(Paxil)
1050 mg
Contraindicated during or
within 14 days of MAOI
therapy; limit amount of drug
given to potentially suicidal
clients; administer in the
morning; use cautiously in
the presence of renal or
sertraline
(Zoloft)
50200
mg
Contraindicated during or
within 14 days of MAOI
therapy, or with pimozide
(Orap) or disulfiram
(Antabuse); if given in
concentrated form, dilute just
before giving in 4 oz. water,
ginger ale, orange juice, etc.;
monitor for increase in uric
acid and hyponatremia, GI
disturbances, tremor, weight
loss, and anxiety.
venlafaxine
(Effexor)
75375
mg
Contraindicated
during
pregnancy; should not be
taken concurrently with
MAOIs; monitor BP and
reduce dose or discontinue if
hypertension occurs; monitor
for dreams, tremor,
dizziness, somnolence, GI
disturbance, and dry mouth.
divalproex
(Depakene)
5001500
mg
gabapentin
(Neurontin)
3003600
mg
Lamotrigine
(Lamictal)
25500
mg
topiramate
25400
(Topamax)
mg
disturbances
occur;
maintain
and olanzapine
manic phase of
of benzodiazepines
to stabilize clinical
lithium
carbonate
(Eskalith)
9001800
mg
SUPPORTING
EVIDENCE
FOR
PRACTICE
20.1
The Use of Psychoeducation as an
Intervention in the Treatment of Bipolar
Disorder
PROBLEM UNDER INVESTIGATION: Recurrence of clinical
symptoms in bipolar disorder
SUMMARY : The study consisted of 120 outpatient subjects with the
diagnosis of Bipolar Disorder who had been in remission for at least
6 months and who scored less than 6 on the Young Mania Rating
Scale and less than 8 on the Hamilton Depression Rating Scale.
Subjects, after matching for age and sex, were randomized to
receive 21 sessions of group psychoeducation (experimental group)
or 21 sessions of nonstructured group meetings (control group), in
addition to standard psychiatric care. Group psychoeducation focused
on the early detection of symptoms, enhancement of treatment
compliance, and lifestyle. Researchers concluded that 23 subjects
(38%) in the psychoeducation group had significantly fewer relapses
and recurrences per subject and demonstrated an increased time
span between recurrences of depression, manic, hypomanic, or
mixed episodes than 36 subjects (60%) in the control group. At 2year follow-up, 55 subjects (92%) in the control group met criteria
for recurrence of bipolar disorder, compared with 40 subjects (67%)
in the psychoeducation group. The number of hospitalizations and
days of hospitalization per subject were significantly lower in the
psychoeducational group compared with the control group.
SUPPORT FOR PRACTICE : Group psychoeducation, when used as a
nursing intervention for clients with the diagnosis of bipolar disorder
being treated with psychopharmacologic agents, may facilitate early
detection of a recurrence of symptoms and thereby decrease the
severity of the episode.
Footnote
Source: Colon, F., et al. (2003). A random trial on the efficacy of
Key
Concepts
Planning/Implementation
Rationale
Verbalization of feelings
may help relieve stress.
Identification of
precipitating events may
prepare the client to
avoid similar
circumstances in the
future.
improve
understanding and
acceptance of
responsibility to stabilize
his behavior.
coping
skills.
Rationale
behavior
Rationale
Rationale
Identify
community
support
P.290
For additional study materials, please refer to the Student Resource
CD-ROM located in the back of this textbook.
P.291
P.292
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
Reflect on the chapter opening quote by Sadock and Sadock. In your
own words, explain what is meant by the phrase, not merely the
external or affective expression of a transitory emotional state.
During the assessment of a client with the diagnosis of major
depressive disorder, what sustained emotional responses would you
expect to observe? Please explain.
MULTIPLE
CHOICE
QUESTIONS
affecting
mood
Answer
Answer
Answer
Answer
View
5. A
Answer
To preserve the client's self-esteem, the nurse would help the client
change into more appropriate attire. Clients with mania often have
difficulty making decisions, even ones as simple as what to wear.
Explaining to the peer group would do nothing to foster the client's
self-esteem. Discussing the issues of good grooming at a community
meeting may be helpful later on, once the client's symptoms have
stabilized. Telling the client that she must select less flamboyant
clothing would be inappropriate. Such a statement is accusatory and
would most likely lead to decreased self-esteem. Additionally, the
client typically loses interest in self-care and has difficulty
concentrating; therefore, telling her to wear something different
probably would have no effect.
Internet
Resources
Depression:
http://www.biopsychiatry.com/psychoticdepress
Selected
References
DC:
Author.
Times,
12
Harvard
Harvard
for
Suggested
Readings
18
Harvard
Chapter
Anxiety
21
Disorders
Learning
1999
Objectives
biologic,
genetic,
and
socialcultural
Key
Terms
Agoraphobia
Anxiety
Anxiety
state
Anxiety
trait
Compulsion
Fear
Free-floating
Ideational
anxiety
compulsion
Obsession
Phobia
Secondary
Signal
traumatization
anxiety
Overview
Historical
of
Anxiety
Perspectives
Related
Terminology
out after dark because she fears coming back to a dark, empty
home.
Etiology
of
Anxiety
Genetic
Theory
Biologic
Theory
FIGURE
Psychoanalytic
Theory
Cognitive
Behavior
Theory
SocialCultural
Theory)
Socialcultural
theorists
Theory
believe
integrated
(Integrated
social
or
cultural
CLINICAL
EXAMPLE
21.1
to
Clinical
Symptoms
and
Diagnostic
Characteristics
The clinical symptoms of anxiety are numerous. They are
generally classified as physiologic, psychological or emotional,
behavioral, and intellectual or cognitive responses to stress. (See
the accompanying Clinical Symptoms and Diagnostic
Characteristics box). The clinical symptoms may vary according to
the level of anxiety exhibited by the client.
Anxiety occurs on a continuum, ranging from normal to panic.
This range is often referred to as the levels of anxiety.
Normal: The client may experience periodic warnings of a
threatsuch as uneasiness or apprehensionthat prompt
the client to take necessary steps to prevent a threat or
lessen its consequences (Sadock & Sadock, 2003).
Euphoria: The client experiences an exaggerated feeling of
well-being that is not directly proportional to a specific
circumstance or situation. Euphoria usually precedes the onset
of mild anxiety. However, many individuals experience
episodic euphoria without transitioning to mild anxiety.
Mild anxiety: The client has an increased alertness to inner
or Why bother?
may be
Symptoms
PHYSIOLOGIC
SYMPTOMS
or
hyperventilation
Diaphoresis
Vertigo
or
lightheadedness
Blurred
vision
of
urination
Headache
Insomnia or sleep disturbance
Weakness or muscle tension
Tightness in the chest
Sweaty
palms
Dilated
pupils
PSYCHOLOGICAL
OR
EMOTIONAL
Withdrawal
Depression
Irritability
Crying
Lack of interest or apathy
SYMPTOMS
Hypercriticism
Anger
Feelings
of
BEHAVIORAL
worthlessness,
apprehension,
or
helplessness
SYMPTOMS
Pacing
Inability to sit still
Fingering hair continuously or other nervous habits
Hypervigilance
INTELLECTUAL
Decreased
Inability
OR
COGNITIVE
SYMPTOMS
interest
to
concentrate
Nonresponsiveness
Decreased
to
external
stimuli
productivity
Preoccupation
Forgetfulness
Orientation to past rather than present or future
Rumination
Diagnostic
Characteristics
substance-abuse
disorders.
Symptoms
Diaphoresis
Tremors
Shortness of breath or smothering sensation
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Vertigo
Feelings of unreality or of being detached from oneself
Fear of losing control or of going crazy
Fear of dying
Numbness or tingling sensations
Chills or hot flashes
Diagnostic
Characteristics
CLINICAL
EXAMPLE
21.2
her fianc but was reluctant to leave her job, friends, and
family to move to California. MJ was able to relate the onset of
her symptoms to the time of her engagement. The family
physician helped MJ to explore feelings of ambivalence about her
engagement and suggested that she seek the help of a therapist.
After several weeks of counseling, the panic attacks subsided and
she was able to discuss her feelings with her fianc.
Phobias
Phobias are the most common form of mental disorders among
women and second among men, affecting 8% (11.5 million) of
adult Americans (ADAA, 2003; Sadock & Sadock, 2003). A phobia
is described as an irrational fear of an object, activity, or
situation that is out of proportion to the stimulus and results in
avoidance of the identified object, activity, or situation. The
person unconsciously displaces the original internal source of fear
or anxiety, such as an unpleasant childhood experience, to an
external source. Avoidance of the object or situation allows the
person to remain free of anxiety.
A phobic reaction can be so mild that it hardly affects a person's
life. The feared object or situation may enter the person's life so
rarely that the phobia does not interfere with daily functioning.
Other phobias, such as fear of water, may prohibit common
activities such as taking a shower or brushing one's teeth. Three
major types of phobias are described here.
Agoraphobia
Recognized as the most common phobic disorder, agoraphobia is
the fear of being alone in public places from which the person
thinks escape would be difficult or help would be unavailable if he
or she were incapacitated. Normal activities become restricted
and individuals refuse to leave their homes.
Two thirds of those exhibiting clinical symptoms are women, in
whom symptoms develop between the ages of 18 and 35 years.
Social
Phobia
anxiety
disorder, is a
SUPPORTING
21.1
EVIDENCE
Identifying Social
Care Setting
Phobia
FOR
in
PRACTICE
the
Primary
Specific
Phobia
BOX
21.1
Common
Phobias
CLINICAL
EXAMPLE
21.3
Generalized
Anxiety
Disorder
ObsessiveCompulsive
Disorder
CLINICAL
The
Client
EXAMPLE
With
21.4
Generalized
Anxiety
Disorder
RP, a 50-year-old man, was admitted to the psychiatric hospital
for treatment of a generalized anxiety disorder. As the student
nurse completed the initial assessment form, she noted that RP
was quite restless, sitting on the edge of his bed and fidgeting
with his gown. He constantly rearranged his personal items on the
bedside stand. Complaints of dizziness, an upset stomach,
insomnia, and frequency of uination were noted. RP appeared to
be easily distracted as
care for another client
nurse as she took the
were cold and clammy
Post-Traumatic
Stress
Disorder
CLINICAL
EXAMPLE
21.5
Disorder
Symptoms:
Recurrent
and
intrusive
Recurrent
distressing
distressing
recollection
dreams
affect
Insomnia
Labile
emotion
Decreased
concentration
Hypervigilance
Exaggerated
Diagnostic
startle
response
Characteristics
re-experience
of
trauma
heightened
feelings
of
arousal
Acute
Stress
Disorder
Atypical
Anxiety
Disorder
The
Nursing
Assessment
Process
Screening
Tools
and
Assessment
Scales
General
Description
and
Appearance
Communication
and
Cognitive
Ability
Mood,
Affect,
or
demonstrate
and
nonresponsiveness
Feelings
to
Behavior
Common behavioral symptoms of anxiety include pacing, the
inability to sit still, hypervigilance, and sleep disturbances. Sleep
disturbances may include sleep-onset insomnia, sleepmaintenance insomnia, re-experiencing symptoms (eg,
nightmares related to trauma), or a hyperarousal state (eg,
difficulty initiating and maintaining sleep). Also assess the client
for the presence of nervous habits (eg, nail biting or finger
tapping), an exaggerated startle response, avoidance behavior
due to a phobia or associated with a traumatic event, or
compulsive behavior. Occupational functioning and social or
family relationships may be impaired. Ask the client how long the
symptoms have persisted and what he or she has done to
minimize them. For example, does the client self-medicate with
over-the-counter drugs, take prescription drugs, or use alcohol or
other substances that have a potential for abuse? Be sure to
obtain a list of all medications the client takes for the
management of clinical symptoms of medical and/or psychiatric
disorders.
Transcultural
Considerations
Nursing
Diagnoses
Outcome
Identification
Planning
Interventions
Implementation
Maintain a calm, nonjudgmental approach to convey acceptance
toward the client. Initially, during interactions, use short, simple
sentences to reduce the client's heightened response to
Assistance
in
Meeting
Basic
Needs
Medication
Management
Interactive
Therapies
Alternative
and
Behavioral
Therapies
Client
Education
Evaluation
Whether the client required hospitalization or participated in
outpatient treatment, evaluation focuses on the client's response
to treatment. Clients who respond to treatment generally self-
Self-Awareness
Prompt
BOX
21.2
personal
relationships?
BOX
21.3
related
to
obsessivecompulsive
behavior
EXAMPLES OF STATED
ANXIETY
DISORDERS
OUTCOMES:
GENERIC
(TRADE) NAME
DAILY
DOSAGE
RANGE
IMPLEMENTATION
Drug Class:
Benzodiazepines
alprazolam
(Xanax)
0.58
mg
clonazepam
0.520
Monitor
(Klonopin)
mg
liver
function
diazepam
(Valium)
240
mg
lorazepam
(Ativan)
1.010
mg
Inform client of
increased CNS
depression when taken
with alcohol; monitor for
transient mild
drowsiness or sedation,
mild paradoxical
excitement during first 2
weeks of therapy;
instruct client to report
constipation, dry mouth,
or nausea; discuss
potential for drug
dependence
and
withdrawal syndrome
with client.
buspirone
1560
Provide
(BuSpar)1
sugarless
mg
citalopram
(Celexa)
1060
mg
fluoxetine
2050
(Prozac)
mg
doses if taking
>20mg/day; not to be
given concurrently with
or until after 2 weeks of
discontinuation of an
MAOI; avoid use of
alcohol; monitor client's
response closely in the
presence of hepatic or
renal impairment or
diabetes as well as for
headache,
nervousness,
abnormal sleep pattern,
GI disturbances, and
weight loss
fluvoxamine
(Luvox)
50300
mg
venlafaxine
(Effexor)2
75375
mg
mouth.
atenolol
(Tenormin)
50200
mg
propranolol
(Inderal)
Drug
Class:
40120
mg
Antihistamines
diphenhydramine
(Benadryl)
25300
mg
monitor
for
thickening of bronchial
secretions,
hallucinations, and
impaired
coordination.
hydroxyzine
(Atarax)
10100
mg
hydroxyzine
25100
pamoate
(Vistaril)
mg
(Atarax).
Atypical
SNRI
Key
HCL
agent
Concepts
Planning/Implementation
Rationale
Addressing feelings
directly may help
diminish the client's
anxiety.
Identifying
positive
coping skills may
help reduce the
client's anxiety and
promote selfconfidence.
Relaxation
exercises are
effective ways to
reduce anxiety.
NURSING
related to resentment
Rationale
her present
situation.
Supportive therapy
may help the client
resolve anger and
resentment toward
her mother.
Rationale
her
relationship
between emotional
issues and low selfesteem.
mother.
Planning/Implementation
Rationale
Reflecting on
interactions gives
the client an
opportunity to
explore factors
contributing to her
situational low selfesteem.
Positive feedback
enhances the
client's
self-worth.
interventions.
P.313
P.314
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
REFLECTION
According to the chapter opening quote, clients with anxiety
disorders often present with various vague physical complaints.
Develop a self-reporting assessment checklist for a client to
complete to rule out the possibility of an anxiety disorder. If the
client identified several clinical symptoms of anxiety, what
interventions would you propose?
MULTIPLE
CHOICE
QUESTIONS
Answer
1. D
Clinical symptoms of generalized anxiety disorder include
unrealistic or excessive anxiety and worry about several events in
one's life. Fear and avoidance of specific situations or places
characterizes phobias. Persistent obsessive thoughts are
associated with obsessivecompulsive disorder. Re-experiencing
feelings associated with traumatic events typically is noted with
post-traumatic stress disorder.
2. The nurse understands that which of the following
Disability
payments
Answer
Answer
The nurse would accept the client's rituals during the initial phase
of treatment for the client with OCD. Once treatment has been
initiated and the client's symptoms have stabilized, then the
nurse can assist the client with measures to limit the rituals and
to teach methods for preventing the ritualistic behavior.
Challenging the client's rituals at any time would increase the
client's anxiety and should be avoided.
Answer
Biofeedback
b. Imaging
c.
Relaxation
d.
Systematic
techniques
desensitization
View
5. D
Answer
Internet
Resources
Selected
Alliance:
References
Diagnostic
and
1046.
Beecham
Pharmaceuticals.
for
Nurse
Practitioners,
ed.,
pp.
195200).
Philadelphia:
Lippincott-Raven.
Suggested
Advisor,
Readings
Post-traumatic
1718
stress
disorders.
Times,
Chapter
22
Anxiety-Related
Learning
Disorders
Objectives
between
dissociative
amnesia
and
dissociative
fugue.
Relate the importance of addressing medical issues and
cultural differences when assessing a client with an anxietyrelated disorder.
Articulate at least five common nursing diagnoses appropriate
for
clients
exhibiting
anxiety-related
disorders.
Key
Terms
Dissociative
amnesia
Dissociative
fugue
Dysmorphobia
General
Adaptation
Syndrome
(GAS)
La belle indifference
Primary
gain
Pseudoneurologic
Secondary
manifestation
gain
Type A personality
Type B personality
Anxiety can occur under many guises that are not readily
recognized by the nurse or practicing clinician. For example,
clients may experience anxiety as the result of a specific medical
condition (eg, hyperparathyroidism), as a result of treatment for a
specific medical condition (eg, thyroid medication), or as a result
of changes in employment or lifestyle due to a medical condition
(eg, myocardial infarct). Anxiety can interfere with a client's
response to treatment for a medical condition (eg, anxious client
refuses to undergo a magnetic resonance imaging [MRI] scan due
to fear of closed spaces). Anxiety can also precipitate somatic
complaints without a physical basis (eg, back pain or
gastrointestinal symptoms). Moreover, the emotional dimensions
of medical conditions are often overlooked when medical care is
given.
Chapter 21 described the more commonly seen anxiety disorders.
This chapter provides an overview of the relationship between
anxiety and real or perceived medical conditions and dissociative
reactions such as amnesia, fugue, identity disorder, and
Etiology
of
Anxiety-Related
Disorders
Theories Involving
Genetic
Factors
Biological
and
Organ
Specificity
Theory
Selye's
General
Adaptation
Syndrome
Emotional
Specificity
Theory
theory include Shapiro and Crider (1969), who found anger and
hostility to be underlying factors for the development of essential
hypertension.
Later researchers, Friedman and Rosenman (1981), investigated
the type A personality, which is characterized by an excessive
competitive drive, impatience, aggressiveness, and a sense of
urgency. Type A individuals were found to have higher levels of
serum triglycerides, cholesterol, adrenaline, and steroids than the
more relaxed individuals with a type B personality. Because
these substances have an adverse effect on the heart, causing the
person to be at risk, the researchers concluded that a person with
a type A personality is more susceptible to the development of
coronary heart disease. Box 22-1 lists characteristics of type A
personality.
Familial
or
Psychosocial
Theory
BOX
22.1
Characteristics
of
Type
Personality
Often
feeling
trapped
in regard to time
commitments
Being
overly
competitive
relaxing
quickly
during
conversations
Learning
dealing
with
deadlines
Theory
experienced
specific
physiologic
symptoms.
receives attention from his mother as she reads to him, fixes his
favorite meals, and monitors his vital signs. As a result of this
experience, he unconsciously learns to produce physiologic
symptoms of a migraine headache or an upset stomach as he feels
the need for attention. This behavior may continue throughout his
life as he attempts to satisfy unmet needs.
Clinical Symptoms
Characteristics
and
Diagnostic
Psychological
Affecting
Factors
Medical
(Anxiety)
Condition
BOX
22.2
Selected Medical
Cause Anxiety
Problems
That
Can
Cardiovascular:
pulmonary
embolism
Endocrine:
Hematologic:
Anemia,
Neurologic:
Cerebrovascular
encephalopathy,
Nutritional:
Respiratory:
cancer,
pheochromocytoma
accident (CVA),
neoplasms,
encephalitis
Somatoform
Disorders
BOX
22.3
Possible
Medical
Problems
Conditions Caused
Factors
(Anxiety)
by
and
Psychological
Colitis,
diarrhea,
Menstrual
Rheumatoid
Backaches,
problems,
nausea,
sexual
ulcers
dysfunction
arthritis
headaches,
migraines
CLINICAL
EXAMPLE
22.1
dysmorphic
Somatization
Conversion
Pain
disorder
disorder
disorder
disorder
Hypochondriasis
Undifferentiated
Somatoform
Body
somatoform
disorder,
Dysmorphic
not
disorder
otherwise
Disorder
specified
(BDD)
Somatization
Disorder
Conversion
Disorder
BOX
22.4
Subtypes
of
Conversion
Disorders
gain)
Pain
Disorder
CLINICAL
The
Client
EXAMPLE
22.2
Exhibiting
Conversion
Disorder
Hypochondriasis
Hypochondriasis is a somatoform disorder in which a client
presents with unrealistic or exaggerated physical complaints.
Minor clinical symptoms are of great concern to the person and
often result in an impairment of social or occupational functioning.
Preoccupations usually focus on bodily functions or minor physical
abnormalities. Such persons are commonly referred to as
professional patients
who shop for doctors because they
feel they do not get proper medical attention. Such clients often
elicit feelings of frustration and anger from health care providers.
This disorder usually is accompanied by anxiety, depression, and
compulsive personality traits. It generally occurs in early
adulthood and usually becomes chronic, causing impaired social or
occupational functioning. The person may adopt an invalid's
lifestyle, possibly becoming actually bedridden. This disorder is
found equally in men and women (APA, 2000).
BOX
22.5
Subtypes
of
Pain
Disorder
Undifferentiated
Somatoform
Disorder
Somatoform
Specified
Disorder,
Not
Otherwise
Dissociative
Disorders
Dissociative
Dissociative
Amnesia
amnesia)
CLINICAL
The
Client
EXAMPLE
With
22.3
Dissociative
Amnesia
Dissociative
Fugue
Dissociative
Identity
Disorder
Depersonalization
Disorder
The
Nursing
Process
Assessment
Chapters 8 and 2 1 discussed the importance of assessing the
client's general appearance, communication skills, and observable
behavior, as well as obtaining a thorough biopsychosocial and
cultural history, and validating data obtained from the client. The
assessment of clients with anxiety-related disorders can be
difficult and complex because of the presence of a comorbid
medical condition, somatic complaints that cannot be validated,
amnesia or fugue, an identity disorder, or depersonalization.
Assessment of Clients
Medical
Diagnosis
With
Comorbid
Self-Awareness
Prompt
Assessment
of
Clients
With
Somatoform
Disorders
Assessing clients with somatoform disorders is challenging. Be
sure to obtain a history of the following regarding somatic
complaints:
Repeated visits to physicians or emergency rooms
Admissions
Any
to
surgical
hospitals
interventions
Assessment
Disorders
of
Clients
With
Dissociative
Nursing
Diagnoses
Outcome
Identification
Diagnoses:
mobility.
Planning
Interventions
Implementation
A variety of levels of care can be provided for clients with the
diagnosis of anxiety-related disorders depending upon the degree
of disability the client exhibits, the presence of any comorbid
medical or psychiatric disorders, the client's motivation for
treatment, the availability of community resources, and insurance
and managed care considerations. Interventions focus on
managing symptoms and improving lifestyles. As always, client
education is extremely important and included when appropriate in
the
following
interventions.
Assistance
in
Meeting
Basic
Needs
Medication
Management
Medication
Disorders
Management
for
Somatoform
Medication
Disorders
Management
for
Dissociative
GENERIC
(TRADE)
NAME
DAILY
DOSAGE
RANGE
Disorders
IMPLEMENTATION
citalopram
(Celexa)
1060
mg
fluoxetine
(Prozac)
2050
mg
fluvoxamine
(Luvox)
50300
mg
loss.
loss.
paroxetine
(Paxil)
1050
mg
Is contraindicated during or
within 14 days of MAOI
therapy; limit amount of drug
given to potentially suicidal
clients; administer in the
morning; use cautiously in
the presence of hepatic or
renal impairment; monitor
for drowsiness, tremor,
somnolence, GI disturbances,
and sexual dysfunction in
males.
sertraline
(Zoloft)
50200
mg
Is contraindicated during or
within 14 days of MAOI
therapy, or with pimozide
(Orap) or disulfiram
(Antabuse); if given in
concentrated form, dilute
just before giving in 4 oz,
water, ginger ale, orange
juice, etc.; monitor for
increase in uric acid and
hyponatremia, GI
disturbances, tremor,
loss, and anxiety.
weight
Interactive Therapies
Interventions
and
Behavioral
Holistic
Approach
Project
SMART
Evaluation
Evaluation begins with a review of the client's role in the
individualized, holistic approach to care. The client is given an
opportunity to compare pretreatment clinical symptoms, including
those related to a comorbid medical condition, with changes that
have occurred as a result of nursing interventions employed
during treatment. Clients who respond to treatment are able to
identify anxiety-producing stressors and demonstrate insight into
their specific anxiety-related disorder. Effective coping skills are
exhibited.
Posttreatment continuum of care is discussed. The client is
strongly encouraged to maintain contact with an attending
physician who manages medical problems as well as a support
person or group. See Nursing Plan of Care 22-1: The Client With
Anxiety Due to a Medical Condition.
Key
Concepts
None
identified
Planning/Implementation
Rationale
Verbalization of
feelings can help
identify symptoms of
anger, fear, or
anxiety.
and
effectively.
Planning/Implementation
Rationale
Recognizing the
manifestations of
anxiety gives the
client confidence in
feeling
having an
understanding
anxiety.
).
of
These
interventions
are effective, nonchemical ways for
the client to
independently
control her anxiety.
regarding
anxiety.
P.331
P.332
Chapter
Worksheet
Critical
Thinking
Questions
Reflection
Reflect on the chapter opening quote by Sadock and Sadock.
Explain the phrase stating that the brain sends various signals
that impinge on the patient's awareness, indicating a serious
problem in the body.
Cite at least three examples of possible
stress-or anxiety-induced medical problems. What interventions
would you provide for each of these medical problems to minimize
the effect of further stress or anxiety?
Multiple
Choice
Questions
Answer
1. B
Hypochondriasis is a somatoform disorder in which a client
presents with unrealistic or exaggerated physical complaints.
Minor clinical symptoms are of great concern to the person. The
symptoms are not used to avoid situations; however, they often
result in an impairment of social or occupational functioning.
Preoccupations usually focus on bodily functions or minor physical
abnormalities. The diagnosis of pain disorder is given when an
individual experiences significant pain without a physical basis for
pain or with pain that greatly exceeds what is expected based on
the extent of injury. Conversion disorder is a somatoform disorder
that involves motor or sensory problems suggesting a neurological
condition. Malingering is the production of false or grossly
exaggerated physical or psychological symptoms that are
consciously motivated by external incentives to avoid an
unpleasant situation, eg, to avoid work.
2. The nurse establishes which nursing diagnosis for a client
with conversion disorder characterized by pain and the
inability to move his left leg?
a. Fatigue related to difficulty moving left leg secondary to
pain
b. Ineffective Health Maintenance related to chronic disability
P.333
c. Impaired Physical Mobility related to leg pain secondary to
conversion
disorder
d. Chronic Low Self-Esteem related to the presence of
conversion
View
2. C
Answer
disorder
Answer
a. Anxiety attacks
b. Excessive fatigue
c. Preoccupation with body defect
d. Symptoms of mild depression
View
4. C
Answer
View
5. B
a.
Confrontation
b.
Limit-setting
c.
Reflection
d.
Reality
orientation
Answer
Internet
Resources
Dissociative
Disorders:
http://www.athealth.com/Consumer/disorders/Dissociative.html
Dissociative
Disorders:
http://www.nami.org/helpline/dissoc.htm
Somatoform
Disorders:
http://www.psychological.com/somatofom_disorders.htm
Somatoform
Disorders:
http://www.allpsych.com/disorders/somatoform/
Selected
References
manual
of
Suggested
Readings
of
Psychosomatic
Research, (11),
of
without
Chapter
23
Personality
Disorders
Learning
Development
and
Persona
Objectives
health
setting.
clinical
symptoms
of
antisocial
personality
disorder.
Construct a nursing plan of care for a client with the diagnosis of histrio
disorder.
Key
Terms
Ego
Egocentrism
Id
Personality
Projective
identification
Schemata
Splitting
Superego
P.335
Personality is the total of a person's internal and external patterns of adju
determined in part by the individual's genetic make-up and by life experienc
of personality development become increasingly complex throughout the lifes
that are the results of learning and adaptation; and one's mental health statu
developmental stage. Thus, a newborn or infant reacts differently to a given
than does an adolescent, a young adult, or an elderly person.
This chapter focuses on the theories of personality development and the etio
disorders. It also addresses the effects of a personality disorder on the clien
health care providers. The chapter uses the nursing process to provide infor
care to clients diagnosed with a specific personality disorder.
Theories
of
Personality
Development
Freud's
Psychoanalytic
Theory
of
Personality
amount of psychic energy to cope with the problems of everyday living. The
reduce tension and may be exhibited, for example, by frequency of urination
eating. The ego's energy controls the impulsive actions of the id and the mo
In his psychosexual theory, Freud also describes five phases of the psychob
have a great impact on personality development: oral, anal, phallic or oedip
During the anal phase (18 mos to 3 years), attention focuses on the exc
foundation is laid for the development of the superego.
P.336
During the latency phase (7 years to adolescence), the person learns to
reality, has a limited sexual image, develops an inner control over aggre
impulses, and experiences intellectual and social growth.
In the genital phase (puberty or adolescence into adult life), the final st
development, the individual develops the capacity for object love and m
establishes identity and independence.
Erikson's
Psychosocial
Theory
of
Personality
Piaget's
Cognitive
Developmental
Theory
thought,
concrete
operational,
and
formal
operational.
During the sensorimotor stage (0 to 2 years), the infant uses the senses to
environment by exploring objects and events and by imitating. The infant als
or methods of assimilating and accommodating incoming information; these
hearing schema, and sucking schema.
The concrete operational stage begins at about 8 years of age and lasts unti
child is able to think more logically as the concepts of moral judgment, num
relationships are developed.
The formal operational stage begins at age 12 years and lasts to adulthood.
adult logic and is able to reason, form conclusions, plan for the future, think
ideals.
Etiology
of
Personality
Disorders
him or her to observe, interact with, and think about the environment and o
develops a positive self-concept, body image, and sense of self-worth, and is
Personality disorders exist on a continuum. They can range from mild to mor
pervasive the symptoms of a particular personality disorder are, and to what
exhibits these symptoms. Although most individuals can live fairly normal liv
of personality disorders, during times of increased stress or external pressure
family, or a new relationship), the symptoms will be exacerbated and begin
with the individual's emotional and psychological functioning.
The potential causes of personality disorders are as numerous as the people
Positive
Developmental
Space
Area of
Conflict And
Resolution
Virtues or
Qualities
Behavior or
Resolution of
Conflict
Sensoryoral or
early infancy (birth
to 18 mos)
Trust vs
mistrust
Drive and
hope
Displays
affection,
confidence,
gratification,
recognition,
and the ability
to trust others
Muscularanal or
later infancy (18
mos3 yrs)
Autonomy
vs shame
and doubt
Self-control
and
willpower
Cooperative,
expresses
oneself,
displays selfcontrol, views
self apart from
parents
Locomotorgenital
or early childhood
(35 yrs)
Initiative
guilt
vs
Direction
and purpose
Tests reality.
Shows
imagination,
displays some
ability to
evaluate own
behavior,
exerts positive
controls over
self
Latency or middle
childhood (611
yrs)
Industry vs
inferiority
Method and
competence
Develops a
sense of duty,
and scholastic
and social
competencies.
Displays
perseverance
and interacts
with peers in a
less infantile
manner
Puberty and
adolescence
(1218 yrs)
Identity vs
role
confusion
Devotion
and fidelity
Displays selfcertainty,
experiments
with role,
expresses
ideologic
commitments,
chooses a
career or
vocation, and
develops
interpersonal
relationships
Young adulthood
(1940 yrs)
Intimacy vs
isolation
Affiliation
and love
Establishes
mature
relationship
with a member
of the opposite
sex, chooses a
suitable
marital
partner,
performs work
and social
roles in
socially
acceptable
manner
Middle adulthood
(4164 yrs)
Generativity
vs
stagnation
Productivity
and ability
to care for
others
Spends time
wisely by
engaging in
helpful
activities such
as teaching,
counseling,
community
activities and
volunteer
work; displays
creativity
Late adulthood or
maturity (65 yrs to
death)
Ego
integrity
despair
Renunciation
or
letting
Reviews life
realistically,
accepts past
go,
and
wisdom
failures and
limitations,
helps members
vs
of younger
generations
view life
positively and
realistically,
accepts death
with dignity
Genetic
Factors
Although research has not isolated the cause of any specific factor at this ti
15,000 pairs of twins in the United States revealed that monozygotic
P.338
twins, living together or apart, develop personality disorders much more fre
twins do. Cluster A personality disorders occur more frequently in biologic re
schizophrenia than in control groups. Cluster B personality disorders apparen
basis. Antisocial personality disorder is associated with alcohol use disorder.
in the family backgrounds of clients with borderline personality disorders. C
disorders also may have a genetic basis. Clients with avoidant personality d
clinical symptoms of anxiety and depression (Sadock & Sadock, 2003).
Biologic
Factors
Research has also indicated that individuals with high levels of hormones su
estradiol, and estrone are thought to be biologically predisposed to the deve
personality disorder. Studies of dopaminergic and serotonergic systems indic
many persons dopamine and serotonin reduce depression and produce a sens
Psychoanalytic
Factors
they can abolish anxiety and depression. Therefore, individuals with persona
reluctant to abandon them.
According to Freud's theory, socially deviant persons have defective egos thr
unable to control their impulsive behavior. Additionally, a weak superego res
Childhood
Experiences
Creativity is not encouraged in the child; therefore, the child does not h
express self or learn to relate to others. The ability to be creative could
the opportunity to develop a positive self-concept and sense of self-wort
Characteristics
of
Personality
Disorders
behavior, which the person uses to fulfill his or her needs and bring satisfact
behaviors begin during childhood or adolescence as a way of coping and rem
adulthood, becoming less obvious during middle or old age. As a result of his
relate to the environment, the person acts out his or her conflicts socially.
P.339
Individuals with personality disorders have many common characteristics. Th
Inflexible,
socially
maladaptive
behaviors
Self-centeredness
Manipulative
and
exploitative
behavior
Diagnostic
Characteris
The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text
Specified (NOS) is reserved for those disorders that do not fit into any of th
the accompanying Clinical Symptoms and Diagnostic Characteristics box.
Diagnostic
Character
Symptoms
responses
Interpersonal
Impulse
Diagnostic
(affect)
functioning
control
Characteristics
Cluster
Paranoid
Disorders:
Personality
Odd,
Eccentric
Behavior
Disorder
result, the person who has experienced much loneliness becomes unwarrant
mistrusts people. The person may suspect attempts to trick or harm him or
CLINICAL
The
EXAMPLE
Client
With
23.1
Paranoid
Personality
Disorder
JV, a 43-year-old Cuban immigrant who worked for a local utility company, w
hospital for surgery due to a work-related knee injury. During the assessmen
JV was hesitant to answer personal questions related to his medical history
to provide information about his family. JV's oldest daughter, who had accom
hospital, offered to provide the necessary information. She also informed the
frequently warned the members of the family to lock the doors and windows
trust his neighbors. He refused to allow his wife to leave the house while he
insisted that his children notify him of their activities when they left home. T
JV had emigrated from Cuba when he was 20 years old to get away from
regime. According to JV's daughter, he was a good father who provided w
attended church regularly. Although JV did not verbalize any fixed delusional
suspicious of strangers or new neighbors.
Schizoid
Personality
Disorder
Schizotypal
Personality
Disorder
Cluster B
Behavior
Disorders:
Emotional,
Erratic,
or
Individuals with Cluster B personality disorders have the greatest risk for su
with individuals with Cluster A or Cluster C disorders. The risk is similar for
mood disorder but without a personality disorder. Factors contributing to an
Antisocial
Personality
Disorder
psychopath
The child may become self-indulgent and expect special favors from othe
display appreciation or reciprocal behavior.
SUPPORTING
EVIDENCE
FOR
PRACTICE
23.1
were 807 mothers of 910 children aged 6 to 9 years. The mothers were inte
and 1990 regarding the frequency of spanking of their children as a form of
antisocial behavior (eg, disobedience, cheating, lying, and lack of remorse).
spanking continued between 1988 and 1990, so did the antisocial behavior s
more likely to be related to increased scores in boys and in European-Americ
Footnote
conduct disorder is given to clients who exhibit clinical symptoms before age
of conduct disorder usually include truancy, misbehavior at school resulting
expulsion, delinquency, substance abuse, vandalism, cruelty, and disobedienc
and 3 1 for additional information.
CLINICAL
The
Client
EXAMPLE
With
an
23.2
Antisocial
Personality
Disord
MS, a 19-year-old male, was referred to the local community mental health
out of school at the age of 16 years after he obtained his driver's license. M
for driving under the influence of alcohol. He agreed to attend a driver's edu
the points from his driving record. However, he failed to attend the class. W
parents, he lied to them stating that the class had been canceled. The result
psychiatricmental health evaluation revealed the DSM-IV-TR diagnosis of
disorder.
P.342
Borderline
Personality
Disorder
which a person can simultaneously experience feelings of love and hate for
With projective identification, the person is able to protect the self from the
person perceives in the external object by attempting to control it. Example
FIGURE 23.1 The client with a borderline personality disorder who exhib
behavior.
Histrionic
Personality
Disorder
P.343
somatization disorder and alcohol use disorder (APA, 2000; Sadock & Sadock
Narcissistic
Personality
Disorder
Because clients value beauty, strength, and youthful attributes, aging is han
this disorder is prevalent in less than 1% of the general population and occu
men, the number of cases reported is increasing steadily. Offspring of clients
have a higher than usual risk for the development of this disorder themselve
2003).
Cluster
Disorders:
ObsessiveCompulsive
Anxious,
Fearful
Personality
Behavio
Disorder
Many professionals such as nurses, accountants, and bank tellers may exhib
obsessivecompulsive traits as they attempt to avoid errors or mistakes w
The individual is preoccupied with details, lists, and rules to the extent that t
activity is lost. Perfectionism interferes with task completion, as the client
scrupulous, inflexible, and reluctant to delegate duties to others. Leisure ac
are excluded because of the client's excessive devotion to work and product
discard worn-out or worthless objects that have no sentimental value is refle
miserly spending style (APA, 2000; Lebelle, 2003).
Dependent
Personality
Disorder
others. They feel uncomfortable or helpless when alone and urgently seek a
when a close relationship ends. As a result of dependency on others, the cli
preoccupied with fears of being left alone to care for him- or herself. Person
chronic illness in childhood are considered to be most prone to this disorder,
frequently in women than in men. See Clinical Example 23-3 . It is the mos
personality disorder in mental health clinics (APA, 2000; Lebelle, 2003; Sado
Avoidant
Personality
Disorder
P.344
or shame, appearing devastated by the slightest amount of disapproval. Thi
CLINICAL
The
EXAMPLE
Client
With
23.3
Dependent
Personality
Disorde
Personality
Disorder,
Not
Otherwise
Specifie
Two personality disorders are now listed in the category of personality disor
specified. These are passiveaggressive personality disorder and depressiv
PassiveAggressive
Also referred to as negativistic
Personality
personality
Disorder
BOX
23.1
Personality
Antisocial
Avoidant
Disorders:
personality:
Common
Impulsive,
personality:
Shy,
timid
aggressive,
personality:
Impulsive,
Dependent
personality:
Dependent,
Histrionic
personality:
Narcissistic
Emotional,
personality:
Obsessivecompulsive
Paranoid
Schizoid
personality:
personality:
Schizotypal
Boastful,
submissive,
egotistical,
personality:
Suspicious,
Socially
personality:
Odd,
complex
self-destructive,
dramatic,
Beh
manipulative
inferiority
Borderline
Descriptive
unstable
clinging
theatrical
superiority
Perfectionistic,
rigid,
complex
controlling
distrustful
distant,
detached
eccentric
Footnote
Depressive
Personality
Disorder
themselves, and their relationships with others. They exhibit poor posture, ra
flat or blunted affect, and psychomotor retardation. No epidemiologic data ar
(APA, 2000; Sadock & Sadock, 2003).
The
Nursing
Process
Assessment
Disturbance
of
Cognition
Clients with personality disorders are in contact with reality, but may have
stress. Cognitive ability may be difficult to assess if the client
P.345
is suspicious or distrustful; exhibits distorted perceptions of self, other peopl
displays impoverished thoughts. Illusions or feelings of depersonalization (co
strange or unreal) may be exhibited by clients with schizotypal personality d
judgment may be impaired because maladaptive coping behaviors have becom
Anticipate the need to obtain additional data from family or friends, because
denial and minimize clinical symptoms.
Self-Awareness
Prompt
Disturbance
of
Affect
Disturbance
of
Interpersonal
Functioning
Dysfunctional
Behavior:
Lack
of
Impulse
Control
Are any legal charges pending due to illegal activities such as gambling,
in drugs?
Has the client been arrested in the past?
Individuals with histrionic behavior are prone to conflict with the law, given
sexually seductive or provocative behavior. Clients with antisocial behavior
in forensic settings because they fail to comply with social norms when meet
immediate
gratification.
Transcultural
Considerations
Nursing
Diagnoses
Outcome
Identification
Examples
of
NANDA
Nursing
Diagnoses:
Person
related
to
unsatisfactory
interpersonal
relationships
Planning
Interventions
that cure is not realistic. When developing the plan of care, focus on the cl
needs that have not been resolved. Interventions are planned to assist the
identified problems and to anticipate possible future developmental stressor
EXAMPLES
OF
STATED
OUTCOMES:
PERSONALITY
The client will verbalize increased insight into his or her behavior.
The client will demonstrate decreased manipulative behavior.
The client will exhibit increased impulse control.
The client will not harm others or destroy property.
The client will communicate directly and honestly with other clients and
feelings.
The client will use the support system without becoming overly dependen
The client will demonstrate alternate ways to deal with frustration.
The client will be free of self-inflicted harm.
The client will verbally recognize that others do not see his or her belief
The client will establish an adequate balance of rest sleep, and activity.
The client will stop acting on the delusional belief.
Implementation
Establish an environment in which the client, but not the maladaptive behav
Examining one's own feelings about such behavior is crucial to ensure that t
interfere with therapeutic nursing interventions. Personal feelings, beliefs, an
identified, discussed, and accepted before one can work effectively with clien
setting. Also be aware of the potential for transference and countertransferen
neither necessary nor particularly desirable for the client to like you persona
to be the client's friend. Maintaining a professional role with the client provid
Assistance
Clients
display
impulse
plan of
in
Meeting
Basic
Needs
Symptom
Management
Medication
Management
P.348
administered (Doskoch, 2001; Sadock & Sadock, 2003; Sherman, 2001). Va
psychopharmacologic agents facilitate the client's capacity to use psychother
issues of biologic factors such as high levels of neurotransmitters and the pr
disorders or anxiety (Gabbard, 1998). For example, psychotropic drugs, whi
based on the client's needs, may be prescribed for specific clinical symptoms
depression, paranoid thoughts, or aggression. Drug Summary Table 23-1 hig
drugs used for the client's specific symptoms.
BOX
23.2
Managing
the
Symptoms
of
Clients
With
Person
For the client with a disturbance in cognition, helpful interventions may inclu
Assist the client to develop insight regarding the purpose of nursing int
If the client displays a disturbance in affect, try the following:
Give attention and support when the client expresses feelings honestly a
Encourage the client to share his or her feelings with others.
DRUG
SUMMARY
TABLE
23.1
Drugs
Used
for
Per
D i s o r d e r s*
GENERIC
(TRADE)
Drug
DAILY
NAME
Class:
IMPLEMENTATIO
DOSAGE
RANGE
Antipsychotics
haloperidol
(Haldol)
416 mg
olanzapine
(Zyprexa)
520 mg
Drug
Class:
carbamazepine
(Tegretol)
Anticonvulsants
6001200
mg
valproate
(Depakote)
5001500
mg
Drug
Class:
Antidepressants
nefazodone
(Serzone)
100600
mg
venlafaxine
(Effexor)
75375
mg
clomipramine
(Anafranil)
25300
mg
clonazepam
(Klonopin)
0.520
mg
P.349
Interactive
Therapies
(Johnson, 2000). Research has shown that family environment and involveme
outcome of several conditions, including borderline personality disorder. Fam
Cognitive behavioral therapy has been used with elderly clients with person
(Sherman, 1999b). The purpose is not to reconfigure character (this late in
symptoms, foster interdependence, and support healthy narcissism.
Client
Education
Although clients frequently deny responsibility for their actions and tend to
after clinical symptoms are stabilized, clients are encouraged to participate
Information may be provided regarding the impact of comorbid disorders suc
Evaluation
Key
Concepts
P.351
For the category of Personality disorder, not otherwise specified, two new
listed: passiveaggressive personality disorder and depressive persona
Treatment tends to be long term and does not guarantee recovery, beca
CLIENT
WITH
PARANOID
PERSONALITY
feared that the information would be used maliciously against him. He perce
reputation by the accountant and his partners during the last corporate meet
react angrily to their comments. Walter's partners confronted him about the
During the conversation it was obvious that Walter had been harboring unju
their loyalty. They recommended that he be seen by his family physician to
to the stress of his position. Walter was seen by his family physician who ru
problems and referred him to a mental health provider for a psychiatric eva
DSM-IV-TR
without
displaying
anger
OUTCOME: The client will recognize that others do not share his parano
Planning/Implementation
Ration
Discussing concrete or
may redirect the clien
reality.
OUTCOME: The client will demonstrate less defensive behavior when int
peers and employees.
Planning/Implementation
Ration
Verbalizing feelings ma
work through his para
acceptance
of
behavio
OUTCOME: The client will modify behaviors that are problematic when
others.
Planning/Implementation
Ration
Role-playing enables t
feelings and obtain fe
positive behaviors.
For additional study materials, please refer to the Student Resource CD-ROM
this textbook.
P.352
P.353
Chapter
Critical
Worksheet
Thinking
Questions
Reflection
Multiple
Choice
Questions
Answer
A client with borderline personality disorder would most likely exhibit impul
2. The client with a borderline personality disorder tells the nurse tha
nurse in the hospital until the nurse sets limits on client behavior. Th
complains that the nurse is cruel and a poor excuse for a person
View
2. C
Rationalization
c.
Splitting
d.
Projection
Answer
Splitting is the inability to integrate and accept both positive and negative fe
moment. The person can handle only one type of feeling at a time, such as
anger. Denial involves the unconscious refusal to face thoughts, feelings, or
considered intolerable. Rationalization is an attempt to justify actions, ideas,
acceptable reasons. Projection occurs when a client assigns undesired traits
another.
P.354
3. The nurse uses which intervention for the client who expresses fee
depersonalization as one of the manifestations of a personality disor
a.
Challenging
feelings
View
3. C
c.
Reinforcing
reality
d.
Employing
diversional
activities
Answer
Answer
4. A
c. Client will identify accurate and realistic perception of good and bad
d. Client will demonstrate alternate ways to deal with anxiety and frus
View
5. C
Answer
The client's ability to identify good and bad qualities would be an appropriate
nursing diagnosis of chronic low self-esteem. Verbally recognizing that others
belief as real would be an appropriate outcome for a nursing diagnosis invo
processes. Demonstrating appropriate interactions with staff and peers would
nursing diagnosis of impaired social interaction or social isolation. Demonstra
deal with anxiety and frustration would be appropriate for a nursing diagnos
Internet
Behavior
Internet
Resources
Online:
Mental
http://www.behavior.net
Health:
http://www.mentalhealth.com
Journal
of
Personality
cart_id=770655.32670
Mental
Health
Sanctuary:
Personality
Disorders:
Personality
Theories:
Disorders:
http://www.catchword.com/guilford/088
http://www.mhsanctuary.com
http://www.focusas.com/PersonalityDisorders.html
http://www.ship.edu/~cgboeree/perscontents.html
Selected
References
Freud, S. (1960). The ego and the id . (J. Strachey, Ed.; J. Riviere, Trans.)
Norton.
Piaget, J. (1963). The child's conception of the world . Ames, IA: Littlefield
Sadock, B. J., & Sadock, V. A. (2003). Kaplan & Sadock's synopsis of psyc
sciences/clinical
psychiatry (9th ed.). Philadelphia: Lippincott Williams & W
Schultz, J. M., & Videbeck, S. L. (2002). Lippincott's manual of psychiatric
(6th ed.). Philadelphia: Lippincott Williams & Wilkins.
Sherman, C. (1999a). Cognitive therapy's reach extends to Axis II. Clinical
(10),
2425.
Suggested
Readings
Ma, W. F., & Shih, F. (1999). The impact of caring experiences of patients
disorder on psychiatric nurses. Journal of Psychiatric Mental Health Nursing
and
Nels, N. (2000). Being a case manager for persons with borderline person
perspectives of community mental health center clinicians. Archives of Psy
(1),
1218.
Chapter
24
Cognitive
Learning
Disorders
Objectives
Describe the four distinct, yet mutually interacting, memory systems ide
Heindel and Salloway.
Key
Terms
Agnosia
Anterograde
amnesia
Aphasia
Apraxia
Asterixis
Binswanger's
disease
Cognition
Cognitive
disorder
Confabulation
Delirium
Dementia
Disturbances
in
executive
functioning
Dysgraphia
Dysnomia
Perseveration
Retrograde
Sundown
amnesia
syndrome
disorders are the most prevalent psychiatric disorders occurring in later life,
occur at any time. At least 70 known cognitive disorders are due to intracran
primary diseases of the central nervous system (eg, epilepsy, brain trauma,
infection) and extracranial diseases or diseases of other organ systems
P.356
(eg, drug intoxication, poisons, or systemic infections). Cognitive impairmen
from irreversible to fully reversible, depending on the contributing factor. On
the beds in community long-term care facilities contain clients with the diagn
dementia. Other cognitive disorders, such as delirium and amnestic disorders
consume large amounts of public health resources. As the U.S. population in
and ages, more older adults will be diagnosed with cognitive deficits such as
dementia, or amnesia (Peskind & Raskind, 1996; Sadock & Sadock, 2003).
This chapter discusses the major cognitive disorders and their subtypes, whe
applicable, as identified by the Diagnostic and Statistical Manual of Mental D
4th Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association [A
2000). Cognitive disorders secondary to substance-related disorders are incl
the classifications but are discussed fully in Chapters 26 and 3 0 . According
criteria established by the DSM-IV-TR, the differential diagnosis of each diso
based on the type of onset and course of symptoms. Mental processes, spee
behavior, and level of consciousness, as well as presumed or established et
are considered in determining a diagnosis (APA, 2000).
Cognitive
Function
Research has been done to determine the effects of aging on the brain and
function. Figure 24.1 illustrates the major areas of the brain involved in cog
functions. Some findings include the following:
The normal human brain weighs approximately 1350 grams and declines
approximately 7% to 8% in weight as one ages.
Cell loss is not uniform because the frontal lobes degenerate at a faster
the other lobes.
Gray matter is lost at a greater rate initially, but white matter loss
disproportionately increases as one ages.
Ventricular size increases with age.
Results also demonstrate that intellect peaks at age 30, plateaus at ages 50
and then slowly declines until the age of 70. Decline of intellect accelerates
age nears 80 years (Salloway, 1999). According to neuropsychological inves
studies of brain-injured clients by Heindel and Salloway (1999), results dem
convincingly that memory is not a single homogenous entity. Rather it is com
four distinct, yet mutually interacting, memory systems: working memory, e
memory, semantic memory, and procedural memory. Figure 24.2 illustrates
different memory systems and their locations, including examples of the spe
types of memory impairment. Understanding these systems provides a powe
clinical tool for assessing cognitive disorders in clients.
Etiology
of
Cognitive
Disorders
Studies regarding the etiology of delirium and amnestic disorders have focus
almost exclusively on biologic factors. Various theories have been proposed
suggest the etiology of dementia, diseases associated with dementia, and a
disorders.
Etiology
of
Delirium
The three major causes are central nervous system diseases (eg, epilepsy,
meningitis, or encephalitis), systemic illnesses (eg, heart failure or pulmona
insufficiency), and either drug intoxication or withdrawal from pharmacologic
agents. For example, any drug taken by a client has the potential to precipit
delirium secondary to adverse effects.
postoperative states, and traumatic injury to the head or body also are asso
with
P.357
causing delirium (APA, 2000; Peskind & Raskind, 1996; Sadock & Sadock, 2
FIGURE
Etiology
of
Dementia
persistent and stable nature of the impairment distinguishes it from the alte
of consciousness and fluctuating deficits of delirium. Although dementia has
causes, the majority of cases (up to 75%) are of two main types: dementia
Alzheimer's type and vascular dementia (Peskind & Raskind, 1996; Sadock &
2003).
Etiology
of
Dementia
of
the
Alzheimer's
Type
(D
The search for the causes and treatment of dementia of the Alzheimer's type
continues. Several theories exist. A complete discussion of these theories is
the scope of this chapter. However, current theories regarding the causes of
dementia are cited below and include:
The genetic theory proposing a genetic link to DAT focuses on three gene
three separate chromosomes (1, 14, 21).
The immune system theory suggesting that DAT is the result of immune
malfunctions.
The oxidation theory stating that the buildup of damage from oxidative
in neurons results in the loss of various body functions.
The virus and bacteria theory proposing that DAT may be due to a viralbacterial-induced condition secondary to the breakdown of the immune s
(eg, herpesvirus).
The nutritional theory postulating that poor nutrition and lack of mental
stimulation during childhood may predispose one to DAT later in life.
P.358
The metal deposit theory speculating that an accumulation of aluminum
replacing iron ions may contribute to existing dementia.
FIGURE
emission computed tomography (SPECT) scans show atrophy and lowered blo
and energy consumption in the brains of clients with DAT. Deterioration app
in the superior parietal cortex, the temporal lobes, and the hippocampus. In
stages, atrophy is severe (Figure 24.3 ). At present, brain imaging can disti
early DAT fairly well from depression but not always from other brain diseas
Microscopic findings (postmortem) show senile plaques, neurofibrillary tangl
neuronal loss, synaptic loss, and granulovascular degeneration of neurons (H
Devous, 1992; Sadock & Sadock, 2003).
Etiology
of
Vascular
Dementia
P.359
parenchymal lesions to occur over wide areas of the brain. Plaques or throm
from distant organs such as heart valves are presumed to be the cause of th
infarction. Binswanger's
disease is a type of vascular dementia that is
characterized by the presence of many small infarctions affecting the white m
the brain that spare the cortical regions (Peskind & Raskind, 1996; Sadock &
2003).
Etiology
of
Diseases
Associated
With
Dementia
Several diseases are often associated with dementia (APA, 2000; Busse & B
1996; Sadock & Sadock, 2003). They include:
from
DAT.
Etiology
of
Amnestic
Disorders
Diagnostic
Character
compare and contrast clinical symptoms with those of delirium and dementia
P.360
SYMPTOMS
DEMENTIA
DELIRIUM
DEPRESS
Judgment
Impaired
May be impaired
May seem
impaired
Mood
Fluctuates
Apathetic
Fluctuates
Labile
Apathetic
Memory
Impaired
Impaired
May seem
impaired;
selective
Cognition
Disordered
reasoning
Disordered
reasoning
I don
know
responses
Orientation
Disoriented
Disoriented
It do
matter
responses
Thoughts
Confused
Suspicious
Paranoid
Confused
Suspicious
Incoherent
Low selfconcept
Negativist
hopelessn
Death rel
Possible
delusions
Perception
No change
Misinterpretations
Visual
hallucinations
Auditory
hallucinat
Consciousness
Normal
Clouded
Normal
Speech
Sparse
Repetitive
Sparse or fluent
Incoherent
Fluent or
retarded
response)
Soft-spok
selectively
mute
Behavior
Agitation
Wanders
Insomnia
Agitation
May wander
Insomnia
Insomnia
sleeps oft
Changes i
appetite
Complains
fatigue
Mental
Poor testing
Progressively
worsens
Inappropriate
Poor testing
Improves when
medically stable
Improves with
Inconsiste
poor
performan
I don
answers
treatment
know
answers
Activities of
daily living
Deteriorate as
dementia
progresses
Usually remain
stable unless
medically unstable
May
deteriorat
with majo
depression
to apathy
PROGNOSIS
No return to
premorbid
function,
Return to premorbid
function if cause is
correctable and is
Risk of in
or suicide
Return to
chronic,
depends on
cause as is
generally
corrected in time.
Generally acute
onset
premorbid
function o
recovery
Usually
status
insidious
onset
in
requires
treatment
Coincides
major life
changes
Delirium
Delirium is one of the most common and, by far, one of the most life-threat
psychiatric illnesses. Several terms may be used to identify delirium, includin
psychosis, encephalopathy, acute brain failure , and acute confusional state
Thought
processes
ap
Although the client may perform poorly on mental status examinations, cogn
ability generally improves when the client recovers, unless the delirium is
superimposed on moderate to severe dementia. The prognosis includes a ret
premorbid function if the cause is corrected in time.
High-risk populations include the following individuals: those who take nume
medications that may interact and cause adverse reactions; persons who
P.361
Delirium
Due
to
General
Medical
Condition
The diagnosis, delirium due to a general medical condition, is given when fin
indicate that the cognitive disturbance is the direct physiologic consequence
general medical condition such as a urinary tract infection (see Clinical Exam
), respiratory tract infection, septicemia, or end-stage renal disease.
Certain focal lesions of the right parietal lobe and occipital lobe also may ca
delirium. Other causes include metabolic disorders, fluid or electrolyte imba
hepatic disease, thiamine deficiency, postoperative states, hypertensive
encephalopathy, and sequelae of head injury (APA, 2000; Peskind & Raskind
CLINICAL
EXAMPLE
24.1
aware of his surroundings and was able to make his needs known. He had no
the episodic confusion or disorientation he exhibited. The result of a urinalys
culture and sensitivity revealed a urinary tract infection due to Escherichia c
was exhibiting clinical symptoms of delirium that resolved after a 10-day cou
treatment with Bactrim.
Substance-Induced
Delirium
taking relatively high doses of certain drugs. The delirium resolves as the su
is discontinued or eliminated from the body. Substances and medications rep
cause delirium include anesthetics, analgesics, antihistamines, anticonvulsan
antiasthmatic agents, antiparkinsonism drugs, corticosteroids, and muscle r
Antibiotics and nonsteroidal anti-inflammatory agents also have been identifi
causes of delirium in the elderly (Sadock & Sadock, 2003).
Delirium
Due
to
Multiple
Etiologies
delirium has more than one etiology. For example, a 55-year-old male who
coronary artery bypass surgery may exhibit clinical symptoms of delirium se
to anesthesia, pain medication, antibiotics, and environmental stimuli second
high-tech equipment in the recovery room.
Delirium,
Not
Otherwise
Specified
This diagnosis refers to delirium that does not meet criteria for any specific
delirium. There is insufficient evidence to establish a specific etiology.
Dementia
Disorientation to person, place, and time is one of the most common signs o
dysfunction. An individual becomes more disoriented as the impairment beco
more extensive. A person with minimal impairment may misjudge the date b
or months. Moderate impairment generally involves confusion about geograp
location such as city or state as well as time, whereas severe impairment is
demonstrated by disorientation
P.362
with respect to time, place, and person. Short-term memory, attention, and
concentration deficits are observable in this disorder because the person lose
her train of thought, forgets what was said just a few minutes earlier, and m
unable to repeat the information just communicated (Peskind & Raskind, 199
Sadock & Sadock, 2003).
Other
characteristics
or
associated
features
include
confabulation,
persevera
Personality changes are often seen in clients with dementia. The normally a
person may become withdrawn and apathetic when social involvement narro
dementia
persisting
dementia
not
otherwise
specified
Clinical symptoms of DAT and vascular dementia are discussed because these
disorders constitute the majority of all dementias. Definitions of Parkinson's
Huntington's disease, Pick's disease, and Creutzfeldt-Jakob disease appear in
glossary in the back-of-book CD.
Dementia
of
the
Alzheimer's
Type
(DAT)
older than 65 years of age in the United States. It is not a natural course of
Rather, it is a silent epidemic characterized by the development of multiple
deficits including memory impairment, aphasia (language disturbance), apr
(impaired ability to carry out motor activities despite motor function), agnos
P.363
stooping gait, loss of voluntary functions, seizures, and violent behavior may
Death can result from neglect, malnutrition, dehydration, incorrect diagnosis
inappropriate treatment, or suicide.
FIGURE
Risk factors associated with the occurrence of AD include advanced age, fem
gender, head trauma, low educational level, and family history of Down syn
(Cummings, 1995).
Vascular
Vascular
common
females.
generally
Dementia
P.364
impairment. Apathy, unsteady gait, weakness, dizziness, and sensory loss g
occur. Clients with vascular dementia often exhibit the same clinical symptom
CLINICAL
EXAMPLE
24.2
Stage 6
MM, an 80-year-old female client, was admitted to the special care unit of a
term care facility because her family is no longer able to meet her needs. Du
assessment process, MM scored 8 of 30 points on the Mini-Mental State Exam
Deficits were noted in the area of orientation, recall, inability to spell w
backwards, inability to write a complete sentence, and the inability to copy a
diagram. MM also had difficulty performing activities of daily living while res
home. She had become incontinent of bowel and bladder and was resistant t
provided by her family. MM had wandered outside at night and was returned
the police. During the interview process, MM used confabulation during respo
questions about her husband, family, and past employment as an executive
secretary. After the completion of a dementia workup, the diagnosis of Dem
the Alzheimer's Type, Late Onset, Stage 6, was noted.
CLINICAL
The
Client
EXAMPLE
With
24.3
Vascular
Dementia
years. His recovery was uneventful; however, she noted that BW had difficu
expressing himself and would become frustrated because he was unable to r
previously learned information. At that time, he also exhibited apraxia, the
to carry out motor activities despite intact motor function. Approximately 8
ago, BW had another stroke that left him with his current symptoms. During
course of rehabilitation, BW was able to speak but continued to exhibit some
expressive aphasia. He was oriented to person and knew that he was not at
but could not state where he was. He was unable to state the date. Prior to
discharge, a follow-up neurologic evaluation was conducted. BW was able to
complete a modified Mini-Mental State Exam. The results indicated the prese
vascular dementia.
Dementia
Due
to
Other
General
Medical
Conditio
Lewy body dementia have extreme adverse reactions (eg, stiff, rigid moveme
immobility) to drugs commonly used to treat behavioral problems associated
dementia. These adverse reactions can be serious and could jeopardize the
health.
Amnestic
Disorders
P.365
24.2 .) An understanding of these different memory syste
their location in the human brain enables the clinician to effectively evaluate
client's memory functioning and area of pathology.
Cognitive
Disorder,
Not
Otherwise
Specified
Symptoms
Characteristics
BOX
24.1
lobe:
lobe:
lobe:
lobe:
lobe:
in
socialization
The
Nursing
Process
Assessment
The single most important piece of information when assessing a client with
impairment is a careful history from the client's family or another reliable
P.366
observer. To identify a cognitively impaired client's baseline mental status an
characteristics of any change is crucial (Henry, 2002).
Self-Awareness
Prompt
Reflect on your thoughts and nonverbal behavior when faced with clients wh
impaired cognition and behavioral disturbances. Do you feel comfortable? Do
convey acceptance, patience, and a caring attitude? What phase of the nurs
process do you feel would be the most challenging to you? Why?
Clients with impaired cognition, such as those with dementia, may exhibit a
progressive decline in their ability to perform activities of daily living (ADLs)
goes unnoticed over a period of time. Conversely, clients with clinical sympto
Does the client live alone? If not, where does the client reside? With who
the client relocated recently? If so, why?
Is the client able to provide self care? If not, who assists the client? Doe
Does the client have impaired hearing or vision that interferes with his/h
to follow directions to meet basic needs?
Appearance,
Mood,
and
Affect
Does the client present with any signs of physical abuse or self-sustaine
injuries?
Do the client's height and weight appear to be within normal limits?
Cognitive
Abilities
How and when did the symptoms first occur? Do they fluctuate frequentl
Does the client require cues or prompting to complete tasks?
Behavioral
Manifestations
Does the client take any medication such as anticholinergic agents, hist
blocking agents, analgesics, sedative-hypnotics, or cardiovascular drugs
produce adverse effects?
Does the client have any medical conditions that are currently being trea
an attending physician or that the client has refused to have treated?
Has the client been exposed to any chemical toxins?
Does the client have a history of getting lost in familiar territory, inappr
behavior, disinhibition, suspiciousness, delusions, or hallucinations? If so,
involved? Where and when does the behavior occur? What is the duration
frequency of the behavior? What occurs prior to (antecedents) and after
behavior (consequences)? Sensory impairments are often the cause of s
behavior in older adults.
P.367
Is the client's behavior affected by any specific environmental changes o
(eg, temperature, noise levels, or the presence of strangers)?
Has the client ever been evaluated and treated for a psychiatric disorder?
when and where?
Assessment
Tools
Several assessment tools are available to use for interviewing clients to asse
cognitive status and behavioral symptoms. Theses tools include:
Annotated
Mini-Mental
Status
Exam
Mini-Cog
Global
Multi-lingual
Deterioration
Screen
Scale
Scale
Dementia
Screener
The NEECHAM Confusion Scale may be used to assess clients who may exhib
and symptoms of confusion in a variety of ways and differently with each ep
(Allen, 1999). This scale, a nine-item checklist that then can be used during
care, assesses the client's behavior and physiologic control, including vital s
stability, urinary continence, and oxygen saturation levels, as well as the cl
ability to process information.
Also assess the client's social support to determine which resources are need
whether they are available. Family members also may benefit from support
programs or reading or viewing educational material about cognitive impairm
Transcultural
Considerations
Always consider the client's cultural and educational background when evalu
or her cognitive capacity. Individuals from various backgrounds may have d
answering questions in certain tests because they are unfamiliar with the ge
CHARACTERISTICS
The client has difficulty
completing complex tasks
related to finances and
DIAGNOSIS
DURATI
Mild DAT
2 years
Moderate
DAT
Moderately
severe DAT
Approximate
months to
years
shopping.
years
Severe DAT
Approxima
12 months
months
BOX
24.2
Comprehensive Assessment of
and
Behavioral
Manifestations
Impaired
Cogniti
History
Will likely require interview with close family or friend
Examination
rate
Chemistry panel
blood sugar)
(electrolytes,
Thyroid
tests
function
calcium,
albumin,
BUN,
creatinine,
transamin
VDRI or RPR
Urine Alzheim Alert TM Test (a noninvasive urinary test that measures neura
protein and is elevated in DAT)
Urinalysis
Serum B12 and folate levels
Human immunodeficiency virus (HIV), if permission is granted
Imaging
Chest x-ray
Head computed tomography (CT) scan
Electrocardiogram
Additional
(ECG).
Studies
(if
Electroencephalogram
Neuropsychiatric
indicated)
(EEG)
testing
Nursing
Diagnoses
provides time for decision-making. For example, it may allow a client to par
as a candidate for one of the FDA-approved drugs that may slow the progres
some symptoms and delay the need for long-term care placement. Additiona
client can have time to complete advance directives, making his or her wishe
future care known. Moreover, family members may have more time to adjust
needs of the client and consider home-based care as the clinical symptoms
(Douris, 2003).
P.369
in thought processes, impaired communication, behavioral disturbances, sel
deficits, and impaired socialization. In addition, a comorbid medical condition
exist. These commonalities are considered during the formulation of the nur
diagnoses. See the accompanying Examples of North American Nursing Diag
Association (NANDA) Nursing Diagnoses box for examples of nursing diagnos
clients with cognitive disorders.
Outcome
Identification
Stating outcomes for clients with cognitive disorders can be challenging beca
the variety of identified problems. Generally, outcomes for clients with cogn
disorders include: the elimination of organic etiology, if possible; the preven
acceleration of symptoms; and the preservation of the client's dignity (Detw
2003)
When developing outcomes, consider the client's present physical and emot
Examples of
Disorders
NANDA
Nursing
Diagnoses:
Cog
EXAMPLES OF
DISORDERS
STATED
OUTCOMES:
COGNITIV
The client will verbalize beginning of the grieving process related to loss
mobility.
The client will live in the least restrictive environment that is safe.
Planning
Interventions
Nursing interventions planned for a client with a cognitive disorder often var
depending on the client's diagnosis of delirium, dementia, or amnestic disor
However, the focus is on maintaining the client's contact with reality, reduci
agitation, preventing injury, promoting adequate nutritional and fluid intake,
promoting adequate sleep and rest, treating any underlying causes, encoura
expression of feelings, and stimulating the memory through various activitie
Attempts to maximize remaining learning potential are important while makin
client feel comfortable both physically and emotionally.
Implementation
are irreversible and become progressively worse over time. Repeating onese
constantly, knowing that the client is unable to recall information or will soo
is frustrating. Emotional reactions are possible when faced with the inability
control inevitable deterioration in some clients. Feelings of helplessness, im
anger, disgust, overprotectiveness,
result (Husseini, 1996).
chronic
helpfulness,
or
burnout
Establishment
of
Safe
Environment
Assistance
in
Meeting
Basic
Needs
Stabilization
of
Behavior
disorder are overtly aggressive (Rawlings & Verma, 2001). Agitation tends t
increase with the severity of dementia and may predict the need for early
institutionalization.
Many hospitals, rehabilitation centers, and long-term care facilities take prid
having restraint-free
environments. If a client is at risk for injury an
to be restrained, some facilities have committees that review the client's be
determine the least restrictive device to be used. Also, family members or c
sitters are considered an alternate measure to the use of restraints (Bransk
Outreach
Programs
Several outreach programs are available for clients with behavioral problems
to dementia. The Mayo Clinic Internal Medicine outreach program in Rochest
Minnesota, provides a multidisciplinary team approach to the behavioral
manifestations of clients with dementia (Allen, 1999). This program is called
Dementia-Behavioral Assessment and Response Team (D-BART). The target
population of D-BART includes clients whose behavior puts them at risk for
use of physical or pharmacologic restraints, potential abuse of self or others
compromised safety, dismissal from a facility, or institutionalization; or
P.371
clients whose behavior puts their caregivers at risk for extreme physical and
psychological stress. The team consists of geriatric health specialists, includi
geriatric nurse practitioner, who meet with caregivers and families in a clien
or care facility. The team's goal is to educate caregivers about the disease
and its impact on behavior and to develop an individualized plan of care to r
eliminate problem behaviors.
SUPPORTING
EVIDENCE
FOR
PRACTICE
24.1
Footnote
Source: Clark, M. E., Lipe, A. W., & Bilbrey, M. (1998). Use of music to dec
Palliative care and end-of-life care are also provided in the home if requeste
Medication
Management
Client
and
Family
Education
2003).
GENERIC
(TRADE)
NAME
Drug
Class:
DAILY
DOSAGE
RANGE
Cholinesterase
IMPLEMENTATION
Inhibitors *
donepezil
(Aricept)
510 mg
galantamine
(Reminyl)
824 mg
rivastigmine
(Exelon)
312 mg
tacrine
(Cognex)
40160
mg
Continuum
of
Care
The client's physical and psychosocial changes and the availability of caregiv
determine the setting in which continuum of care will occur. Nearly 4 million
residents have DAT and approximately 70% of these people live at home, wi
majority of care being provided by friends and family. To assist families in c
clients, several resources are available, such as the Administration on Aging
Alzheimer's Association, Family Caregiver Alliance Resource Center, and the
Council on Aging (Johnson, 2002). These resources also help family member
providers of continuum-of-care services such as adult day care centers, ass
living facilities, and long-term care facilities that have special units for client
dementia, as well as respite care centers.
Every year about 540,000 terminally ill Americans enter hospice programs to
a wide array of supportive care for themselves and their families. Hospice ca
available to clients with cognitive disorders, including DAT. Hospice workers
medical support; assist clients and family members with emotional support
life closure, grief counseling, and spiritual counseling; and may provide art,
and music therapy when the need is identified. Follow-up contact and berea
counseling continue if family members indicate a need or desire. Although ca
be delivered in a variety of settings, it is usually given in the home setting a
guidelines
P.373
for certification of care (Knowlton, 2000a; Knowlton, 2000b).
Evaluation
Key
Concepts
Research has shown that as the brain ages, the potential for cognitive i
exists.
Neuropsychological
investigative
studies
of
brain-damaged
clients
have
treatments.
Clinical symptoms of more than one cognitive disorder may occur at the
time, which can be challenging to the assessment process.
The basic commonalities that link delirium, dementia, and amnestic diso
include self-care deficits; alteration in appearance, mood, and affect; co
impairment, including alteration in thought processes and the inability to
communicate needs; and behavioral manifestations. Impaired socializatio
occurs due to a decline in the client's cognitive abilities and the presence
behavioral
manifestations.
Continuum of care is based on the client's needs and his or her ability to
For additional study materials, please refer to the Student Resource CD-ROM
in the back of this textbook.
P.374
The
client
with
Delirium
Mike, a 35-year-old real estate broker, was admitted to the emergency room
evaluation of a possible fractured right arm following a rollerblading accident
then admitted to the hospital for surgical intervention. The evening of surge
was given pain medication. A few hours later he was found to be confused a
talking incoherently. His level of consciousness changed as he was no longer
to place and time. He thought that he was trapped on a boat and kept asking
staff for assistance to find the bathroom. The following day, a neurologic ev
was requested. Mike was diagnosed as exhibiting clinical symptoms of deliriu
pain medication, anesthesia, and changes in his environment.
dsm-iv-TR
Disoriented,
confused,
incoherent
speech,
impaired
mobility.
Rationale
fluctuating capabilities
delirium clears.
until
the
NURSING
confusion
Rationale
This approach minimizes the
possibility of environmental
distraction during interactions
the client.
Rationale
Provide
adequate
lighting.
NURSING
Rationale
self-care.
is a priority.
Planning/Implementation
Assist the client daily as needed to
maintain daily functions and
complete ADLs.
Rationale
P.375
P.376
P.377
Chapter
Worksheet
Critical
Thinking
Questions
Attend a local support group for families of people with Alzheimer's disea
did you observe? What techniques did the group leader employ? What ro
nursing play to help these families?
Reflection
Multiple
Choice
Questions
Degeneration
c.
Perseveration
d. Sundown syndrome
View
Answer
1. D
P.378
2. The family of a client with Alzheimer's disease questions the nurse
what to expect as the disease progresses. The nurse bases the answe
which fact associated with this disorder?
a. Improvement depends on what medications are used for treatment.
Answer
Answer
A client with dementia who is upset and agitated needs a quiet environment
provide calm and minimize stimulation. Therefore, the nurse would remain w
client and decrease environmental stimuli. Firmly telling the client that the
is unacceptable or questioning the client about the cause would be too over
for the client who is already overly stimulated. Medication for a calming effe
be appropriate if measures to decrease environmental stimuli were ineffectiv
Answer
is to ask about the onset. Typically delirium has an abrupt onset whereas de
occurs gradually. The other questions would be appropriate to ask once the
stabilized.
b. The client will identify life areas that require alterations due to illnes
c. The client will maintain reality orientation.
d. The client will remain safe in the least restrictive environment.
View
5. D
Answer
For the client in the late stages of Alzheimer's disease, cognitive ability is s
affected; therefore, maintaining safety is a priority. Ability to verbalize may
affected as well, so expecting the client to verbalize feelings of self-worth m
unrealistic and inappropriate. Having the client identify life areas needing ch
Internet
Resources
Cognitive
Disorders:
http://www.psyweb.com/Mdisord/amnd.htm
http://www.dementia.com
Selected
(Delirium):
http://www.medterms.com/script/main/art.
References
of
geriatric
psychiatry (2nd
Clark, M. E., Lipe, A. W., & Bilbrey, M. (1998). Use of music to decrease
aggressive behaviors in people with dementia. Journal of Gerontological N
2 4 (7), 1017.
psychiatric
glo
Foreman, M. D., & Zane, D. (1996). Nursing strategies for acute confusion
elders. American Journal of Nursing, 96 (4), 4452.
Appro
Heindel, W. C., & Salloway, S. (1999). Memory systems in the human brain
Psychiatric Times, 16 (6), 1921.
Henry, M. (2002). Descending into delirium. American Journal of Nursing,
4956.
Holman, L., & Devous, M. D. (1992). Functional brain SPECT: The emergenc
Husseini, M. B. (1996). The client who has dementia. In S. Lego (Ed.), Psy
nursing: A comprehensive reference (2nd ed., pp. 285290). Philadelphi
Lippincott-Raven.
Sadock, B. J., & Sadock, V. A. (2003). Kaplan & Sadock's synopsis of psyc
Behavioral
sciences/clinical
psychiatry (9th ed.). Philadelphia: Lippincott W
& Wilkins.
Suggested
Nursing
of
Re
Gerontolo
Readings
Annerstedt, L., Elmstahl, S., Ingvad, B., & Samuelson, S. M. (2000). Famil
caregiving in dementia An analysis of the caregiver's burden and the break
point when home care becomes inadequate. Scandinavian Journal of Public
2 8 (1), 2331.
Times,
17 (1), 6162.
Fletcher, K., & Damgaard, P. (1998). A glimmer of hope. Advance for Nurs
Practitioners, 6 (6), 4952, 84.
Hashmi, F. H., Drady, A. I., Qayum, F., & Grossberg, G. T. (2000). Sexuall
disinhibited behavior in the cognitively impaired elderly. Clinical Geriatrics,
(11), 6168.
24bbbb24hhhh.
Advisor , 2
of
Gerontolog
Practitioner,
22 (10), 5875.
Medina, J. (2001). Yet another gene for Alzheimer's disease. Geriatric Time
(5), 15, 18.
Simard, M., van Reekum, R., & Suvajac, B. (2000). Improving cognition, b
and function, and slowing disease progression of Alzheimer's disease. Clini
Geriatrics, 8 (11), 3258.
(1), 31.
Chapter
25
Eating
Disorders
1999
The conflicting feelings about food and eating that trouble so many
debilitating form in the eating disorders, anorexia and bulimia.
--Grinspoon,
Learning
1997
Objectives
State the criteria for inpatient treatment of a client with an eating disord
Formulate a plan of care for a client with the diagnosis of bulimia nervos
Key
Binge
Terms
eating
obesity
Obesity
Purging
Reactive
obesity
Russell's
sign
Eating disorders such as anorexia nervosa, bulimia nervosa, and obesity are
81% of 10-year-olds are afraid of being fat (National Eating Disorders Assoc
At the same time, medical experts warn that America's weight problem is re
million people, including nearly three in five adults, are classified as overweig
70 years is 36%, and for men it is 34% (NEDA, 2002).
All three disorders may have serious medical consequences if clients remain
disorder can often learn to stabilize their eating patterns, maintain a healthy
This chapter focuses on the etiology of anorexia, bulimia, and obesity and a
each. Using the nursing process approach, the chapter describes the care of
Etiology
of
Anorexia
Nervosa
and
Bulimia
A mental picture of one's body that the individual develops based on int
woman, who successfully loses 50 pounds and achieves a dress size of 9,
magazine and determines that he must reduce his caloric intake and incr
that of the male model in magazine)
Genetic
or
Biochemical
Theories
A second theory states that eating disorders, including obesity, could be due
stimulating hormone, gonadotropin-releasing hormone, and corticotropin-relea
dopamine, and norepinephrine that preserve the balance between energy out
descending from the hypothalamus control levels of sex hormones, thyroid h
influence appetite, body weight, mood, and responses to stress. Research ha
the tendency to become obese (Sadock & Sadock, 2003; Sharp, 1998). Studie
and 35% to 83% are at risk for bulimia (Discovery Health.Com Disease Cent
Psychological
and
Psychodynamic
Theories
sexual functioning) and fears becoming like her mother. Fasting allows the cl
lose weight is a substitute for independence as well as an avoidance of ackn
Family
Systems
Theories
Parents wield a great deal of influence over children's self-concepts and perce
we are totally dependent as children, is also extremely powerful. Three theo
disorders have emerged: conflict between parentchild expectations, family
enmeshed
families.
According to the second theory, both anorectic and bulimic individuals are in
weight by parents or siblings close to them can inadvertently set into motion
P.382
a chain of feelings and events emphasizing external appearances. Thinking tha
attractive, the individuals assume nurturing or caretaking roles toward siblings
need nurturing. The family may indirectly encourage this behavior by praisin
The enmeshed
family theory states that families with anorectic daug
responsibilities of each person and the boundaries among them are indistinct
of everyone else. Individual needs are not met, feelings are not honestly ack
daughter reaches puberty, the parents are reluctant to make necessary chang
Etiology
of
Obesity
Several theories regarding obesity have also been postulated and described i
or biologic, and behavioral theories.
Genetic
or
Biologic
Theories
A third theory, referred to as the leptin theory , states that an obesity gene
cells), which acts on the hypothalamus and influences hunger and satiety. M
effect (Albu, et al., 1997).
Behavioral
Inactivity has
low metabolic
too much but
or a difficulty
Theories
day associated with eating), individuals eat when they aren't hungry and they
Clinical
Symptoms
and
Diagnostic
Characteris
Clients with eating disorders share similar clinical symptoms or warning sign
food as well as an unhealthy amount of body fat or unhealthy body mass in
identifies whether a person is overweight or underweight based on height in
An individual with a BMI of 25 to 29 is considered to be moderately overweig
BOX
25.1
Determining
BMI
19
20
21
22
23
24
HEIGHT
(inches)
25
26
27
BODY WEIGH
58
91
96
100
105
110
115
119
124
12
59
94
99
104
109
114
119
124
128
13
60
97
102
107
112
118
123
128
133
13
61
100
106
111
116
122
127
132
137
14
62
104
109
115
120
126
131
136
142
14
63
107
113
118
124
130
135
141
146
15
64
110
116
122
128
134
140
145
151
15
65
114
120
126
132
138
144
150
156
16
66
118
124
130
136
142
148
155
161
16
67
121
127
134
140
146
153
159
166
17
68
125
131
138
144
151
158
164
171
17
69
128
135
142
149
155
162
169
176
18
70
132
139
146
153
160
167
174
181
18
71
136
143
150
157
165
172
179
186
19
72
140
147
154
162
169
177
184
191
19
73
144
151
159
166
174
182
189
197
20
74
148
155
163
171
179
186
194
202
21
75
152
160
168
176
184
192
200
208
21
76
156
164
172
180
189
197
205
213
22
Source: National Heart, Lung, and Blood Institute. Body Mass Index Tab
http://wwww.nblbi.nih.gov/guidelines/obesity/bmi.tbl.htm
Clinical symptoms specific to each disorder are discussed within each classi
Anorexia
Nervosa
The client with anorexia nervosa refuses to maintain a normal body weight,
about his or her body. See the accompanying Clinical Symptoms and Diagno
P.384
Clinical
Clinical
Symptoms
and
Diagnostic
Characteri
Symptoms
mood
withdrawal
Irritability
Insomnia
Decreased interest in sex
Inflexible
thinking
Characteristics
Most females with anorexia are teenaged girls or women who usually are br
this disorder has increased. Age has little significance: the diagnosis been ma
to as old as 70 years of age (Tumolo, 2003). Characterized by an aversion t
image, this disorder may result in death due to serious malnutrition. Of diag
are due to suicide (Jancin, 1999).
Various methods are used to lose weight. Methods include purging , or atte
vomiting; abuse of laxatives, enemas, diuretics, diet pills, or stimulants; exc
prevail as the anorectic client disposes of food that he or she is supposed to
disorder progresses (not all persons who are anorectic exhibit all symptoms),
Dry, flaky, or cracked skin
Brittle hair and nails; hair beginning to fall out
Amenorrhea
or
menstrual
irregularity
Constipation
Hypothermia due to loss of subcutaneous fat
caries
Warning signs that should alert parents, teachers, or others to the possibilit
Drastic weight loss in the presence of unusual eating habits, such as fas
mood
FIGURE
25.1 The client with anorexia nervosa. Note the layered, baggy c
(Erikson,
1963,
1968).
With
Anorexia
Nervosa.
CLINICAL
The
EXAMPLE
Client
With
25.1
Anorexia
Nervosa
MJ, 19 years old, was a sophomore in college when her psychology professor
weight loss. When questioned about her behavior, MJ told the professor that
team, although she was unable to give him a specific goal regarding her de
dehydration. The physician also suspected a potassium and protein deficit alt
approximately 15 pounds under the desired weight for her height and body b
experienced amenorrhea for 3 months. The college physician recommended t
weight loss.
P.386
Bulimia
Nervosa
The prevalence of this disorder among adolescent and young adult women is
more common in women than in men (10:1 ratio). The age of onset is usuall
with bulimia varies due to fluctuations in weight: If underweight, the BMI us
Clinical
Clinical
Binge
Symptoms
Symptoms
eating
and
Diagnostic
Characteri
self-esteem
Mood
Possible
Diagnostic
disturbance
stimulant
use
Characteristics
Certain traits are found among individuals with bulimia, who often view them
may develop into a chronic disorder and occur intermittently over several ye
Heart problems, irreversible heart failure, and death due to abuse of ipe
Chronic enlargement of the parotid glands
Dehydration
Irritable bowel syndrome or abnormal dilation of the colon
Rectal prolapse, abscess, or bleeding
Rupture of the diaphragm, with entrance of the abdominal contents into
Dental erosion; gum disease
Chronic
edema
Example
Eating
Disorder,
Not
Otherwise
Specified
This category is for disorders of eating that do not meet the criteria for any
diagnosed with eating disorder, not otherwise specified if the client repeatedly
food. Another example of this diagnosis is a female client who meets all of t
menses.
P.387
CLINICAL
EXAMPLE
25.2
measures to control her appetite. She found herself craving sweets and othe
devour everything in sight that was easily ingested, eating for 1 to 2 hours
$150.00 per week, because of such cravings. After such bingeing episodes, L
she felt out of control and anxious when she binged. Her main fear was of b
herself of guilt feelings due to overeating. Recent publicity about anorexia an
that had been present for several weeks. LR agreed to a complete physical
working with bulimia clients.
Obesity
The prevalence of obesity in America has tripled since the early 1900s. Appro
are significantly overweight. Weight gain is most pronounced in both sexes be
men stabilize and may even decline between the ages of 60 and 74. Women
decline. Clients with a BMI of 30 to 35 are diagnosed as moderately obese. C
obesity. Approximately 8% to 10% of individuals who exhibit obesity are sev
obesity occurs in later life, when compulsive eating is used to cope with s
anxiety, or a psychotic disorder in which an individual develops an abnormal
The social stigma of being overweight can have long-term, devastating effect
rejected by their peers. For example, in August 1996, a 12-year-old-boy in c
start. His parents stated that he had tried all summer to lose weight before
stated that the boy's body frame was large and, genetically, he was predispo
Self-Awareness
Prompt
What was your emotional reaction the last time you looked in a mirror? Wha
concept? Are you comfortable with your present physical appearance? If not,
P.388
The
Nursing
Process
Assessment
Assessment
Tools
Several assessment guides can be used to collect data about the client with
developed assessment guides to use when collecting biopsychosocial data ab
Regardless of the specific tool used, the focus is on the following:
Weight history and what the client thinks an ideal weight would be
Perception of body appearance, including self-concept and sexuality
Lifestyle,
support
including
living
arrangements,
meal
preparation,
financial
reso
A new tool, the SCOFF questionnaire (acronym for Sick, Control, One, Fat, an
(Moore, 2000). The client is asked five questions:
Do you make yourself sick because you feel uncomfortably full?
Do you worry that you have lost control over how much you eat?
Have you recently lost more than 14 pounds in a 3-month period?
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?
Physical
Examination
P.389
and a history of electrolyte or fluid imbalances. Be alert for possible medica
obesity (Table 25-1 )
FIGURE
Laboratory
Tests
(ECG)
Endocrine studies such as growth hormone level, cortisol level, and thyr
Ultrasonography to rule out gallstones
Electroencephalogram
(EEG)
Transcultural
Considerations
As with any assessment, be sure to address the client's cultural and ethnic b
industrialized societies with an abundance of food and where physical attract
United States, Canada, Europe, Australia, Japan, New Zealand, and South A
A report in the Harvard Mental Health Letter (Grinspoon, 1998) suggests that
culture. Fifteen hundred black, white, Asian, and mixed-race social science s
weight, height, and eating habits. Sixty percent of the men and 45% of the
the men and 41% of the women felt they were overweight. Black students w
bulimia or anorexia. Asian students had fewer symptoms; the results for mix
concluded that nothing in their culture or social circumstances seems to pro
Several studies have reported information about obesity in children and adol
Control and Prevention, obesity is more prevalent in Native American schoolc
children of all ages and genders. The National Center for Health Statistics re
subgroups of Latino children (eg, Mexican Americans, Puerto Ricans, and Cub
that in Caucasian children (29%). Baker (1999) also reports an increase in
virtually every racial and ethnic group.
P.390
ORGAN/SYSTEM
Cardiovascular
ANOREXIA
Arrhythmias,
hypotension,
congestive heart failure, mitral
Cardiomyopath
myopathy, hy
electrolyte
Endocrine/metabolic
Gastrointestinal
Salivary and
hypertrophy,
esophageal
gastritis, gas
elevated
rupture, abd
constipation,
steatorrhea,
enzymes, too
liver
enzymes
dental
Genitourinary
Decreased
glomerular
filtration
caries
Reduced
glom
elevated BUN
proteinuria,
infection
Hematologic
Anemia,
leukopenia,
thrombocytopenia,
low
erythrocyte sedimentation rate,
folate and iron deficiency,
clotting factor abnormalities,
hypofibrinogenemia,
impaired
immune response
Vitamin
Integumentary
Russell's sign
abrasions), in
petechiae,
purpura,
edema
Musculoskeletal
Stress
Respiratory
Aspiration
edema
Neurologic
Seizures,
activity,
P.391
Nursing
Diagnoses
fractu
pn
ve
Outcome
Identification
Outcome identification for clients with eating disorders may be stated in the
Short-term outcomes focus on stabilizing any existing medical condition incl
decreasing clinical symptoms of a comorbid psychiatric disorder such as anxi
client develop more constructive coping mechanisms and helping the client a
the eating disorder. See the accompanying box for Examples of Stated Outc
Examples
of
NANDA
Diagnoses:
Eating
Disor
Planning
Interventions
Planning involves the client and family and, in many settings, a multidiscipl
by the nurse include a physician or internist, dietitian, psychotherapist, socia
drama therapy have also been used in planning care for clients with eating
EXAMPLES
OF
STATED
OUTCOMES:
EATING
client
will
demonstrate
decreased
obsessivecompulsive
behavior.
Guidelines
for
Planning
Interventions
conditions. Outpatient interventions for clients with eating disorders are the
problematic because clients often deny the illness, evade therapeutic interve
professionals.
Criteria
for
Hospitalization
Clients are usually hospitalized when the following criteria are met: suicidal
behavior is out of control; psychosis is evident; family is demonstrating cris
outpatient interventions; or any life-threatening condition based on laborator
summarizes the criteria for hospitalization based on data provided by the A
Sadock (2003).
Implementation
The nurse plays an important role in the care of clients with eating disorders
quite challenging. Be cognizant of any transference by the client and use ca
earlier, clients may have difficulty relating to individuals they perceive to be
approaches that have been used successfully to avoid conflict and develop a
Be matter-of-fact, friendly, patient, and casual if the client is withdrawn
Avoid statements that indicate shock, disbelief, or disgust at the eating
Set limits to avoid manipulative behavior.
Remain uninvolved when the client is indecisive or ambivalent.
CRITERIA
ADULTS
Weight
Vital signs
Pulse
<40 bpm
<90/60 mmHg
Blood Pressure
Temperature
Laboratory
<97.0 F (36.1 C)
values
ECG
Abnormal
Suicidal
Ideation or attempt
Creation
Clients
with
of
eating
Safe
disorders
Environment
may
display
impulsive,
unpredictable,
obsessiv
P.393
self-abusive behavior. Living in a safe, structured environment minimizes the
Stabilization
of
Medical
Condition
Also monitor intake and output, vital signs, weight, elimination patterns, and
ordered. Perform or assist with skin care as necessary because the client is a
subcutaneous tissue. Provide adequate clothing and bedding to prevent hypo
in purging are at risk for the development of dental caries or periodontal dis
secondary to the presence of gastric acid in emesis.
Stabilization
of
Behavior
Medication
Management
P.394
has occurred and physiologic and psychological functions are restored. Other
(TCAs), MAOIs, and neuroleptics (Cote, 2001; Grady, 1997; Sadock & Sadock
drugs used for eating disorders.
Clients with anorexia or bulimia often are resistant to taking any medication
They may exhibit behaviors such as palming or cheeking medication and disp
Suicidal clients may save medication to overdose if they feel a loss of contro
nursing interventions and therapy. Administering medication before weight is
a medical crisis such as cardiac arrhythmias or seizures.
DAILY
DOSAGE
RANGE
fluoxetine(Prozac)
1080 mg
Drug
Class:
amitriptyline
Tricyclic
Antidepressants
50300
(Elavil)
mg
desipramine
(Norpramin)
75300
mg
imipramine
75300
(Tofranil)
mg
cyprohepatadine
(Periactin)
420 mg
megestrol
(Megace)
80320
mg
acetate
Drug therapy is considered for clients with obesity who are unable to control
have a BMI of at least 27 and other risk factors such as hypertension, diab
P.395
Dexfenfluramine (Redux) and fenfluramine (FenPhen) have been withdrawn fr
disease. Sibutramine (Meridia) has recently been approved for weight loss fo
Although sibutramine has not been linked to valvular heart disease or pulm
(Xenical), a lipase inhibitor that blocks the absorption of about one third of
treatment of obesity (Hensrud, 1999; Sharp, 1998). Other agents include
(Bontril PDM), benzphetamine hydrochloride (Didrex), and diethylpropion hy
Interactive
Therapies
Based on research findings, the efficacy of CBT and IPT have been compare
sooner, by about week 6. However, both treatments were equally effective in
purging, concerns about shape and weight, and thinking patterns. Cognitive
change after the client overcame binge eating and purging and no longer fel
Clients are expected to eat some meals together under supervision. Cognitiv
shape, and weight; the intense link between self-concept and physical appe
Group participation is used primarily for its supportive qualities.
SUPPORTING
EVIDENCE
FOR
PRACTICE
25-1
Footnote
Source: Thiels, C. M., Schmidt, U, Treasure, J., Garthe, R., & Troop, N. (1
of a self-care manual. American Journal of Psychiatry, 155 (7 ), 947953.
P.396
and autonomy; life events; and the onset or maintenance of the eating prob
disputes, role transitions, and long-standing avoidance of relationships (Dec
FIGURE
SFBT
eating behavior is under control? The clinician's role during SFBT is to lea
occur as a result of treatment (Decker, 2003).
Family
Therapy
lack of conflict resolution are addressed during the sessions. Siblings and me
Self-Help
and
Support
Groups
Self-help groups can give the client information and support during lifelong
times can generally be obtained from local mental health centers, local hos
organizations such as Overeaters Anonymous, the American Dietetic Associat
of Anorexia Nervosa and Associated Disorders.
Client
Education
Psychoeducational groups are generally recommended for all but the most se
that of a classroom. Personal self-disclosure is neither expected nor encourag
discussion about the material being presented and encourages opinions. Fam
information and to begin the correction of erroneous notions about food and
The purpose of self-help and support groups is discussed. The client identifies
without fear of rejection. The client learns that recovery involves coping wit
communicating with others; and rebuilding family and social relationships.
P.397
Evaluation
and 50% achieve partial improvement. Forty percent of those who recover w
rate is 18% to 20%. Recovery and relapse rates are not much better for cli
The prognosis for weight reduction in clients with obesity is poor. Ninety per
weight regain it eventually. The prognosis for juvenile-onset obesity is poor,
emotional disturbance than adult clients (Sadock & Sadock, 2003).
Key
Concepts
Although eating disorders are among the most challenging illnesses conf
individuals do not seek help. Others remain ill or die, even after years o
factors.
For additional study materials, please refer to the Student Resource CD-ROM
P.398
CLIENT
WITH
ANOREXIA
NERVOSA,
BIN
May, a high school senior, voluntarily comes to the high school health clinic
past 3 days. Her vital signs are within normal range, but she appears to be
weighed, but on further questioning she reveals that she is 5 feet 7 inches
relates the following information.
After nearly 4 years of playing competitive high school sports, she has quit t
hope of making the track and cross-country teams. She feels the sports were
keep her weight down as she perceives herself to be fat. She is una
body weight.
May began dieting in 9th grade. During the first month, she lost 25 pounds.
DIAGNOSIS: Anorexia
nervosa
binge-eating/purging
type
OUTCOME: The client will increase nutritional and caloric intake while rest
Planning/Implementation
Establish a contract with client regarding oral intake and
limiting activity to lose weight.
Contra
while
Superv
discard
meal.
concea
The cl
nutrit
The cl
medica
The cl
ineffec
The cl
eating
The a
develo
NURSING
Using
discuss
The cl
her n
clarify
P.399
P.400
P.401
Chapter
Critical
Worksheet
Thinking
Questions
students? Ask the nurse practitioner to discuss her view of her role in c
Reflection
Reflect on the chapter opening quote by Kaye. Why do you think that eating
neurotransmitter pathways? What impact do you think such research data wil
providing care for a client with the diagnosis of an eating disorder? How do
respond to biologic theories of eating disorders?
Multiple
Choice
Questions
View
1. C
b.
Enablement
c.
Enmeshment
d.
Functional
Answer
View
b.
Compliance
c.
Rebellion
d.
Suspicion
Answer
2. B
3. An adolescent client tells the nurse that she frequently feels compe
Overeating
Compulsiveness
View
3. B
Answer
Answer
Answer
For the client with a suspected eating disorder, asking about the use of diet
Internet
Resources
Academy
Eating
National
for
Eating
Disorders
Eating
Selected
Disorders:
Association:
Disorders
http://www.aedweb.org/
http://www.edauk.com/
Association:
http://www.nationaleatingdisorders
References
Association.
Associated Press. (2001, Apr 1). Researchers connect mutated gene to ano
Bensing, K. (2003). Unveiling the mystery of body image. Advance for Nurs
Bruch, H. (2003). Eating disorders: Obesity, anorexia nervosa, and the per
Epstein, L. I. T., Wisniewski, L., & Weng, R. (1994). Child and parent psyc
, 509515.
Foreyt, J. P., & Poston, W. S. C., II. (1997). Diet, genetics, and obesity. Fo
Grady, T. A. (1997, Nov 1315). An update on eating disorders . Paper
Mental Health Congress, Orlando, FL.
Irvine, M. (2001, Jul 17). Younger kids are worried about weight. Florida
James, K. S. (2001). All in the family: Treating obesity in children and ado
Johnson, K. (2000). CBT is quicker than IBT in treating bulimia. Clinical Psy
Moore, A. S. (2000). A new screening tool for eating disorders. RN, 63 (2),
Murphy, J.L. (Ed.). (2003, Summer). Nurse
Practitioners'
Prescribing
Refer
Rohland, P. (1996). The battle of the bulge. Advance for Nurse Practitioners
Sadock, B. J., & Sadock, V. A. (2003). Kaplan & Sadock's synopsis of psy
Philadelphia: Lippincott Williams & Wilkins.
Schilder, P. (1950). The image and appearance of the human body . New
Thiels, C. M., Schmidt, U., Treasure, J., Garthe, R., & Troop, N. (1998). G
self-care manual. American Journal of Psychiatry, 155 (7), 947953.
Tumolo, J. (2003). Not just for women anymore: Eating disorders in men. A
Whitaker, J. A., Pepe, M. S., Seidel, K. D., & Dietz, W. I. T. (1997). Predi
obesity. New England Journal of Medicine, 337 (14), 869873.
White, J. H. (2000). Improving outcomes for obesity. American Journal for
Suggested
Readings
Bates, B. (1999). Eating disorder cases don't always fit profile. Clinical Psy
Conant, M. (1996). The client with an eating disorder. In S. Lego (Ed.), Psy
Philadelphia:
Lippincott-Raven.
Manning, M. (1997). Making peace with the body in the mirror. Hippocrates
Selekman, J. (1998). Sensitivity toward those who are obese. American Jou
Sherman, C. (2000). Eating disorder patients receptive to E-mail therapy.
Tumolo, J. (2001). Slim pickings: The facts about fad diets. Advance for N
Yager, J. (2001). New strategies for the management of anorexia nervosa.
Chapter
26
Substance-Related
Disorders
Learning
Psychiatric
Association,
1989
Objectives
the
and
following
physiologic
terms:
addiction,
psychological
dependence,
dependence.
disorder.
Describe the treatment measures, including nursing interventions, for a
client with a substance-related disorder.
Formulate a list of nursing interventions for a client with clinical
symptoms of acute substance intoxication.
Develop a list of services available to clients who abuse substances.
Key
Terms
Addiction
Addictions
nursing
Addictive
personality
Alcohol
intoxication
Alcohol
withdrawal
Behavioral
Delirium
Drug
dependence
tremens
dependence
Habituation
Intervention
Korsakoff's
psychosis
Physiologic
dependence
Psychological
dependence
Tolerance
Wernicke's
encephalopathy
Substance-related
disorders refers to the use and abuse of alcohol and illicit
drugs or substances. When substance use creates difficulties for the user or
ceases to be entirely volitional, it becomes the concern of all the helping
professions, including nursing. This chapter describes the concepts
associated
with
substance-related
disorders
including
terminology
and
Overview
of
Substance-Related
Terminology Associated
Related
Disorders
With
Disorders
Substance-
Epidemiology
Disorders
of
Substance-Related
According to the statistics, approximately 90% of all U.S. residents have had
an alcohol-containing drink at least once in their lives, and about 51% of all
U.S. adults currently use alcohol. Most people engage in the reasonable and
FIGURE
P.406
SUPPORTING
EVIDENCE
FOR
PRACTICE
Alcoholism
26.1
and
Footnote
Source: Banks, S. M., Pandiani, J. A., Schacht, L. M., & Gauvin, L. M.
(2000). Age and mortality among white male problem drinkers. Addiction,
9 5 (8), 12491254.
Fifty-three percent of the men and women surveyed in the United States
reported that one or more close relatives abuse or are dependent on
alcohol. Alcohol abuse is present in 3% to 15% of the elderly population,
18% of medical inpatients, and 44% of psychiatric patients (NIDA, 2003).
Abuse of alcohol also is a major health problem for older children and
adolescents. Approximately 28% of high school seniors and 41% of persons
in the 21- to 22-year-old age group engage in binge drinking. Heavy
drinking by adolescents is associated with emotional and behavioral
problems. Data show that adolescents who drink heavily skip school, use
illicit drugs, steal from others, feel sad and depressed, run away from home,
and try to injure themselves or commit suicide more often than their
nondrinking counterparts (Clinical Psychiatry News, 2000).
substances in their lifetime, and about 15% have used illicit substances in
the past year (Sadock & Sadock, 2003). According to the 1999 National
Institute of Drug Abuse Sixth Triennial Report to Congress , data from three
major surveys painted a mixed picture of the nation's drug-use problem.
The survey indicated a high rate of drug use among all age groups.
However, there were indications that drug use was leveling off, particularly
among younger age groups (ie, eighth graders), and that the use of certain
drugs among younger age groups appeared to be decreasing. There also
appeared to be a resurgence of antidrug attitudes among all grades (NIDA,
1999, p. 1).
The 2000 National Household Survey on Drug Abuse (NHSDA) supported the
1999 findings by NIDA; however, a follow-up survey in 2001 indicated that
more than 8 million people have used substances referred to as club
drugs
(eg, ecstasy, Rohypnol, ketamine) at least once during their
lifetime. Among students surveyed in 2002, 23% of eighth graders, 41% of
tenth graders, and 59% of twelfth graders reported that club drugs
were fairly easy or very easy to obtain.
Specialty
Practice
Practice:
Addictions
Nursing
In the 1970s and 1980s, the care of clients with substance-related disorders
became recognized as a unique
publication The Care of Clients
Nursing Practice described the
with substance-related disorders
broad range of abuse and addiction patterns (ANA et al., 1987). Addictions
nursing was defined as an area of specialty practice concerned with care
related to dysfunctional patterns of human response that have one or more
Etiology
of
Substance-Related
Disorders
Biologic
Theories
The discovery that all drugs of abuse have one thing in common namely, the
stimulation of dopamine secretion occurred in the 1980s. With scientific
innovations, studies have identified the neural structures and pathways
responsible for pleasure and reinforcement of behavior. Researchers have
discovered that addictive drugs capture these structures and pathways and
subvert normal functions.
1998a;
Smith,
1999).
predisposition
hormones, a
their drug of
of people at
Genetic
Theories
Separate studies of twins, adoptees, and siblings indicate that the cause of
alcohol abuse has a genetic component. According to Grinspoon,
Individual differences in sensitivity to the addictive powers of drugs are
almost certainly strongly influenced by genetics
(1998b, p. 1). Jellinek
(1960, 1977) theorized that some individuals have a predisposition to
alcoholism as a result of the loss of control
over alcohol. His theory
was supported by comparing data from studies of twins living with their
biologic parents to data from studies of twins born to alcoholic parents, but
separated after birth and raised by nonalcoholic foster parents. The data
indicated that children born to alcoholic parents are particularly susceptible
to becoming alcoholic (Goodwin, 1999, 1979). Additional studies with less
conclusive data show that other types of substance-related disorders may be
due to a genetic component (Sadock & Sadock, 2003).
P.408
Behavioral
and
Learning
Theories
Behavioral theorists believe that addiction results from the positive effect of
mood alterations and reduction in feelings of fear and anxiety that one
experiences using drugs or alcohol. Additionally, several types of learning
are thought to be associated with compulsive self-administration of drugs.
Associative learning is exhibited during relapses experienced among clients
addicted to psychostimulants. The brain is specifically designed to absorb
and respond in very powerful ways to environmental cues and contexts.
Nothing could be more specific, or powerful, than large doses of mindaltering drugs. The brain stores discrete patterns of information related to
specific drug usage and produces context-independent sensitization of the
organism to the drug or a general lethargy and unresponsiveness to the
environment. The response depends on the individual's choice of substance
(Medina,
2000).
Sociocultural
Theories
Teenagers who possess more leisure time and money and experience less
parental or community supervision are at risk for substance abuse,
especially when they attend weekend or all-night parties. Drugs are
available everywhere,
according to grade-school children. Over-thecounter drugs, prescriptions readily obtained for insomnia, and pain-relief
medication used by parents all make substance abuse easy for children and
teenagers.
Service
[NCJRS],
Psychodynamic
2003a).
Theories
Disease
Concept
of
Alcoholism
The American Medical Association and the U.S. Public Health Service
consider alcoholism to be a disease. Most authorities in the field of alcohol
abuse base their beliefs on the pioneering work of Jellinek (1960). He
surveyed 2,000 alcoholic men and classified alcoholics into five types. He
also identified four progressive phases that the alcoholic experiences.
Clinical Symptoms
Characteristics
of
Disorders
and Diagnostic
Substance-Related
orientation,
memory,
P.409
affect, cognition, and speech, and mobility and behavioral changes. Specific
clinical symptoms are addressed in the following discussion.
Two categories of alcohol-related disorders are included in this
classification. The first, alcohol use disorders, includes alcohol dependence
and alcohol abuse. The second, alcohol-induced disorders, includes 12
subtypes:
Alcohol
intoxication
Alcohol
withdrawal
Alcohol
intoxication
Alcohol
withdrawal
delirium
delirium
Alcohol-induced
persisting
Alcohol-induced
persisting
amnestic
Alcohol-induced
psychotic
disorder
Alcohol-induced
mood
Alcohol-induced
anxiety
Alcohol-induced
sexual
Alcohol-induced
sleep
Alcohol-related
dementia
disorder
disorder
disorder
dysfunction
disorder
disorder,
not
otherwise
specified
Both alcohol use disorders are discussed in the sections that follow; selected
alcohol-induced disorders are also discussed.
Alcohol
Use
Disorders
Alcohol
health
nursing
Dependence
practice.
Alcohol
Abuse
Disorder
The criteria for alcohol abuse disorder do not include tolerance, withdrawal,
or a pattern of compulsive use. The individual exhibits one or more of the
following symptoms in a 12-month period:
Recurrent drinking of alcohol resulting in a failure to fulfill major role
obligations at work, school, or home
Recurrent drinking in situations in which it is physically hazardous
Recurrent
alcohol-related
legal
problems
Alcohol-Induced
Disorders
Alcohol
Intoxication
Alcohol
intoxication occurs after the recent ingestion of alcohol and is
evidenced by behavioral changes such as
P.410
impaired social or occupational functioning, fighting, or impaired judgment.
The client may exhibit mood changes, increased verbalization, impaired
attention span, or irritability. Other symptoms include slurred speech, lack
of coordination, unsteady gait, nystagmus, impaired memory, and stupor or
coma.
Alcohol
Withdrawal
Alcohol
Withdrawal
Delirium
Alcoholic-Induced
Persisting
Dementia
Alcoholic-Induced
Persisting
Amnestic
Disorder
Other
Alcohol-Induced
Disorders
Clinical
Symptoms
Characteristics
Disorders
of
and
Diagnostic
Other
Substance-Related
Ten classes of substances, other than alcohol, are associated with both
abuse and dependence: amphetamines, caffeine, cannabis, cocaine,
hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), and the
group of sedatives, hypnotics, and anxiolytics.
A diagnosis of multiple-substance or polysubstance abuse occurs when
people mix drugs and alcohol. The severity of psychoactive substance
dependence is classified according to the following criteria: mild, moderate,
severe, in partial remission, or in full remission.
Sedative-,
Disorders
Hypnotic-,
or
Anxiolytic-Related
P.411
Normal effects of these drugs include a decrease in cardiac and respiratory
rate, lowered blood pressure, and a mild depressant action on nerves,
skeletal muscles, and the heart. Overdoses or intoxication may result in
symptoms such as slurred speech, incoordination, drunken appearance,
staggering gait, nystagmus, impaired memory, stupor, or coma (American
Psychiatric Association [APA], 2000; Sadock & Sadock, 2003). Street names
for these drugs include libs,
blues,
rainbows,
yellow-jackets,
and downers.
Opioid-Related
Disorders
Opioids are narcotic drugs that induce sleep, suppress coughing, and
alleviate pain. People abuse opiates by taking them orally, inhaling them, or
injecting them into their veins in an attempt to help relieve withdrawal
symptoms, for kicks,
or to feel good.
The user becomes
passive and listless as the opioids depress the respiratory center of the
brain, causing shallow respirations. The person also experiences reduced
feelings of hunger, thirst, pain, and sexual desire. As the effects of the drug
wear off, the user, who becomes physically and emotionally addicted by
requiring increasingly larger dosages, suffers withdrawal symptoms unless
another dose of the drug is taken.
Amphetamine-Related
Disorders
Cocaine-Related
Disorders
heart attack, or heart failure. Cocaine also can cause sudden heart attack in
healthy young people (APA, 2000; Sadock & Sadock, 2003).
Cannabis-Related
Disorders
sativa .
HallucinogenDisorders
and
Phencyclidine-Related
Hallucinogens and PCP are associated only with abuse because physiologic
dependence has not been demonstrated. They are referred to as mind
benders
or psychedelic drugs, affecting the mind and causing changes in
perception
and
consciousness.
Hallucinogens
Examples of hallucinogens include lysergic acid diethy-lamide (LSD),
mescaline, dimethyl-tryptamine (DMT), 2,5 dimethoxy-4methylamphetamine (STP), and psilocybin.
Phencyclidine
(PCP)
know pain. They may become violent, destructive, and confused after one
dose. Clinical symptoms of PCP intoxication include vomiting, seizures,
tachycardia, muscle rigidity, and extremely high blood pressure (APA, 2000;
Sadock & Sadock, 2003).
Inhalant-Related
Disorders
Inhalants are any chemicals that give off fumes or vapors and, when
inhaled, produce symptoms similar to intoxication. Commonly abused
inhalants include glue, gasoline, lighter fluid, paint thinner, varnish, shellac,
nail polish remover, and aerosol-packaged products. The person who inhales
or sniffs such substances may experience inhalant intoxication. Clinical
symptoms include unsteady gait, slurred speech, dizziness, nystagmus,
tremor, blurred vision, lethargy, depressed reflexes, muscle weakness,
euphoria, stupor, or coma. After such a high,
the person may
experience a loss of coordination, a distorted perception of reality, and
hallucinations and convulsions (APA, 2000; Sadock & Sadock, 2003).
Although withdrawal-like symptoms have occurred in animals exposed to
certain inhalants, no clinically meaningful withdrawal syndrome occurs in
humans.
Caffeine-
and
Nicotine-Related
Disorders
Approximately 28% of adult women and 30% of adult men smoke cigarettes
for stimulation, to relax or feel better, or due to habit. Regular smokers
become psychologically dependent on cigarettes and find it difficult to stop
smoking. Tobacco dependence usually begins in late adolescence or by early
adulthood and may result in tobacco withdrawal when the person attempts
to stop smoking. Symptoms of withdrawal include a craving for tobacco,
irritability, difficulty concentrating, restlessness, anxiety, headache,
drowsiness, and gastrointestinal disturbances.
Designer
Drugs,
Club
Drugs,
and
Anabolic
Steroids
Designer
Drugs
(amphetamine labs) and then made available on the street. They differ from
one another in their potency, speed of onset, duration of action, and their
capacity to modify mood with or without producing overt hallucinations.
P.414
Because they are produced in clandestine laboratories, they are seldom
pure. Thus the amount in a capsule or tablet is likely to vary considerably.
Examples of designer drugs include 4-methyl-2,5-dimethoxyamphetamine
(DOM, also referred to as STP), 3,4-methylenedioxyamphetamine (MDA, also
referred to as ecstasy
or XTC ), and 4-bromo-2,5dimethoxyhenethylamine
(NEXUS).
The use of ecstasy is a global phenomenon. The prevalence of its use in the
United States is increasing among young adults. Ecstasy is being used
Club
Drugs
Anabolic
Steroids
Anabolic steroids are a family of drugs that includes the natural male
hormone testosterone and a group of many synthetic analogues of
testosterone synthesized since the 1940s. They are Schedule III drugs and
are subject to the same regulatory dispensing requirements as narcotics.
Athletes and adolescent men abuse steroids to enhance masculine
appearance; men and women abuse steroids to maximize physical
development. Adverse behavioral effects as well as medical complications
CLUB DRUG
MDMA
(ecstasy)
CLASSIFICATION
Amphetamine
POTENTIAL
ADVERSE
EFFECTS
Critical
elevation
BP, P
in
Severe
hyperthermia
Heart or
kidney failure
Brain damage
gamma
hydroxybutyrate
(GHB)
Increased
muscle
relaxation
Loss of
consciousness
Inability to
recall
information
after ingesting
drug
flunitrazepam
Similar to GHB
(Rohypnol)
ketamine
methamphetamine
rape drug)
Animal anesthetic
(similar to
phencyclidine
[PCP])
Impaired
motor function
Elevated BP
Amnesia
Respiratory
depression
Seizures
Addictive
Dramatic CNS
effects
Increased
energy and
alertness
Decreased
appetite
Convulsions
Hyperthermia
Tremors
Cerebral
vascular
accident
Cardiac
arrhythmia
stimulant
Addictability.
It indicates the degrees of addictability for each substance
(ie, heroin at the top has a high potential for addiction, whereas caffeine at
the bottom has a low potential for addiction).
FIGURE 26.2 Mann's Index of Addictability : list of moodaltering substances arranged according to the potential each has for
causing addiction.
The
Nursing
Process
Assessment
Assessment
of
the
Client
Who
Abuses
Alcohol
General
Description
The nurse uses the interview process to obtain data from the client,
including the client's interpretation of the drinking problem and attitude
toward control of the problem. Data regarding the client's level of
sensorium, mood and affect, ability to communicate needs and follow
instructions, ability to meet basic needs, and general physical condition are
collected. Document whether the client is inebriated, undergoing
withdrawal, dehydrated, malnourished, in any physical distress, or at risk
for injury due to an unsteady gait or the presence of tremors. Also obtain
information regarding available support systems at this time.
Behavior
Several screening tools are frequently used during the assessment process.
They include the Michigan Alcohol Screening Test (MAST; Box 26-1 ) and
the CAGE Screening Test for Alcoholism (Box 26-2 ). The Alcohol Use
Disorders Identification Test (AUDIT) also may be used. The AUDIT contains
10 questions about quantity and frequency of drinking, bingeing, and
drinking consequences. Because of its emphasis on drinking within the past
P.416
year, this self-administered screening tool may not identify clients with
previous drinking problems. Alcoholics Anonymous has also developed a 12question quiz to identify teenagers at risk for alcohol use or abuse. Experts
caution that brief screening tests may be less effective in some populations.
These implications could have a significant importance, given the number of
individuals who abuse alcohol (Lucas, 1998).
Diagnostic
Tests
Diagnostic laboratory tests include liver function tests and mean corpuscular
volume, which when elevated are indicators of heavy alcohol use. Other
tests, such as blood alcohol level or urine screen for alcohol, may be
ordered depending on the physical condition of the client or complaints
verbalized during the assessment process. Table 26-2 summarizes blood
alcohol levels and associated findings, comparing various
P.417
blood alcohol levels, the approximate amount of beverage for each level,
effects of alcohol, and the amount of time it takes alcohol to leave the body
(Altrocchi, 1980; Liska, 2003; Walker, 1982). A neurologic evaluation may
be requested as well as a psychiatric consultation to rule out coexisting
psychiatric disorders such as depression, delirium, dementia, or anxiety.
rationalization,
projection,
and
repression
commonly
are
exhibited.
BLOOD
ALCOHOL
LEVEL (%)
APPROXIMATE
AMOUNT OF
BEVERAGE
EFFECTS OF
ALCOHOL
TIME
NEEDED
FOR
ALCOHOL
TO LEAVE
THE BODY
0.03
1 cocktail, 1
bottle beer, or
5 oz. wine
Slight tension
Euphoria
Feeling of
superiority
2 hrs
0.06
2 cocktails, 3
bottles beer, or
11 oz. wine
Feeling of warmth
and relaxation
Decreased mental
efficiency
Loss of normal
inhibitions
Loss of some
motor
coordination
4 hrs
0.09
3 cocktails, 5
bottles beer, or
16 oz. wine
Talkative
Clumsy
Exaggerated
6 hrs
behavior
0.10
3 to 5 cocktails,
Legally drunk in
6 to 7 bottles
beer, or 20 to 22
oz. wine
most states
Impaired motor,
mental, and
6 hrs
speech activity
Decreased
feelings of guilt
0.15
5 to 7 cocktails
or 26 to 27 oz.
wine
Gross intoxication
Slurred speech
Impaired motor
coordination
10 hrs
0.20
8 cocktails
Angers easily
Motor abilities
severely impaired
Blackout level
Unable to recall
events
At least 10
or more
hours
0.30
10
cocktails
Stupor likely;
possible
aggressive
behavior
Death may occur
due to deep
anesthetic effect
or paralysis of
the respiratory
center
0.40
13
cocktails
Coma leading to
death
0.60
20
cocktails
Severely impaired
breathing and
heart rate
Death will
probably
occur
P.418
General
Description
In addition to using the assessment format described for the client who
abuses alcohol, the nurse must be able to recognize symptoms of drug
overdose or drug withdrawal during the collection of data. Each drug reacts
differently and is identified in part by physical and behavioral
manifestations. Therefore, focus assessment measures on obtaining baseline
data and monitoring vital signs; observing for signs of CNS depression, such
as irregular respirations or hypotension; recognizing signs of impending
seizures or coma; assessing the client for cuts, bruises, infection, or needle
tracks; assessing general nutritional status; determining the client's level of
sensorium; and listening to physiologic complaints.
Behavior
Also monitor the client's behavior. Focus on the client's history of suicidal
ideation or attempts; withdrawal symptoms, including hallucinations,
confusion, tremors, seizures, and the like; longest drug-free period; and
desire for treatment.
Screening
Tools
within the family, employment, and social settings (Riggin, 1996b). Both
tools can be used to assess the client who abuses substances to rule out the
presence of comorbid alcohol and drug abuse.
Diagnostic
Tests
Drug screening via blood or urine specimens (or both) may be ordered.
Additional tests may include liver profile, electrolytes, or testing for the
human immunodeficiency virus (HIV) (see Chapter 32 ). In a crisis, data
Transcultural
Considerations
the
Nursing
client.
Diagnoses
Clients who use or abuse substances may have poor general health and
inadequate nutrition. They are more susceptible to infections and medical
complications. Sensory or perceptual alterations may occur, and there is a
potential for injury due to impaired memory or cognition. Communication
and social interaction may be impaired. Family dynamics may be
dysfunctional. A dual diagnosis may exist (see Chapter 30 ). Examples of
North American Nursing Diagnosis Association (NANDA) Nursing Diagnoses
P.419
for clients with substance-related disorders are presented in the
accompanying box.
Outcome
Identification
Planning
Interventions
The nursing plan of care documents the human response patterns that
will be addressed by nursing interventions; guides each nurse to intervene
in a manner congruent with client needs and goals; and provides outcome
criteria for measurement of client progress. Upon the basis of this plan,
nurses can contribute effectively to formulation of the multidisciplinary
treatment plan and collaborative therapeutic interventions
(ANA &
NNSA,1988, p. 8).
Planning is similar to that used when caring for clients with eating
disorders, because both client populations typically deny their illness and
refuse care. Thus planning must involve the client and family and a
multidisciplinary
approach.
Implementation
Addictions nursing addresses an area of concern extending over the
entire health-care continuum. Addictions nursing interventions consist of all
those nursing actions that are directed toward fostering adaptive human
responses to actual or potential
P.420
health problems stemming from patterns of abuse or addiction
(ANA &
NNSA, 1988, p. 9).
STAGE OF
CHANGE
DESCRIPTION
Precontemplation
Client seems
unaware of problem
NURSING
INTERVENTIONS
Ask client what he or
she considers to be
problematic
abuse
Contemplation
Client is aware of
problem but is not
motivated to change
substance
Offer assistance
Discuss pros and cons
of substance abuse
Discuss possible
solutions that have
been effective for
others
Preparation
Client is getting
ready to change
Determination
Action
Client develops a
plan to seek help
Client actively
engages in change
process and
achieves
abstinence
Offer support
Continue to offer
support
Monitor efficacy of
treatment
Maintenance
Relapse
Client returns to
drinking or
substance abuse
meeting the client's basic needs; monitors the client's medical condition;
uses interventions to stabilize the client's medical condition and behavioral
problems; and assists with medication management, intervention strategies,
interactive therapies, and client education.
Provision
of
Safe
Environment
Client safety is a priority because the client may exhibit clinical symptoms
of overdose, intoxication, or withdrawal. The client also may react to
substance-induced internal stimuli such as hallucinations or delusions,
placing him or her at risk for injury to self or others. It may be necessary to
place the hospitalized client in a room near the nurses' station or where the
staff can observe the client closely. Reduce stimuli by placing the client in a
partially lighted room. Seizures can occur during withdrawal from various
substances. Therefore, institute seizure precautions to minimize chances of
injury. Intravenous (IV) barbiturates may be required to control extreme
agitation. Chapter 29 discusses nursing interventions for clients who exhibit
self-abusive
or
suicidal
Assistance
in
behavior.
Meeting
Basic
Needs
Stabilization
of
Medical
Condition
Several medical problems are associated with substance abuse (Box 26-3 ).
Also assess vital signs frequently for changes and observe for signs of
impending or current delirium tremens (Figure 26-3 ). Due to the
substance's effect on the heart, cardiac status may require monitoring.
Laboratory tests may need to be repeated because of abnormal values. A
computed tomography (CT) scan and electroencephalography (EEG) may be
ordered to rule out metabolic encephalopathy or coexisting neurologic
disorders.
Stabilization
of
Behavior
Clients who abuse substances are often manipulative and prone to staffsplitting. They may continue to exhibit drug-seeking behavior despite
placement in a secure, controlled environment. Clients have been known to
Medication
Management
use of low doses of sedatives may produce discomfort when drug use is
stopped, but detoxification is not generally required (Bernstein, 1995;
Sadock & Sadock, 2003). Table 26-4 lists initial treatment options to
counteract adverse physiologic or behavioral effects of various substances.
Disulfiram
Therapy)
and
Naltrexone
Therapy
(Aversion
Substance use creates a hold on the user by operant conditioning. Each time
a substance is taken, it stimulates the release of endorphins, a morphinelike action that encourages the individual to think about and seek the
substance. However, learning can be reversed through extinction of the
individual's desire to think about or seek the substance (Sherman, 2001).
Aversion therapy, one way of reversing the individual's desire to seek and
use an illicit substance, consists of giving a drug such as emetine (an
extract of the ipecac root) and then following it with alcohol. Nausea and
vomiting are induced by the emetine, causing an aversion to alcohol based
on the reflex association between alcohol and vomiting.
Disulfiram (Antabuse) is another drug that may be used to cause an
aversion to alcohol. This drug interferes with the breakdown of alcohol,
causing an accumulation of acetaldehyde, a by-product of alcohol, in
P.423
the body. The person who takes disulfiram and drinks alcohol experiences
severe nausea and vomiting, hypotension, headaches, rapid pulse and
respirations, flushed face, and bloodshot eyes. This reaction lasts as long as
there is alcohol in the blood. Persons with serious heart disease, diabetes,
epilepsy, liver impairment, or mental illness should not take disulfiram.
SUBSTANCE
Heroin
TREATMENT
OPTIONS
Methadone,
LAAM
(levo-alpha-acetyl-methadol),
naltrexone. Maintenance therapy may be
necessary.
Narcotics
Methadone,
comparable
symptoms,
substitute
Alcohol
Hallucinogens
Sedatives
Inhalants
Haloperidol
Amphetamines
Phencyclidine
for
psychotic
symptoms
Cannabis
Anxiolytic,
antipsychotic,
antidepressant
Pain Management of
Related
Disorders
Clients
With
Substance-
drug, while at the same time ensuring those who need the medication have
access to it. Combating abuse requires a delicate balance of getting to know
a client's needs and treating the client in a way that does not cause harm.
The possibility of undertreated pain is rarely explored (Nichols, 2003; Willis,
2001).
Intervention
Strategy
Interactive
Therapies
Individual
Psychotherapy
Group
Therapy
Group therapy provides the client with an opportunity to identify with peers
and respond to confrontation about ineffective coping or dysfunctional
behavior. The client has an opportunity to improve communication skills as
he or she receives emotional support from the group. Feelings of
hopelessness, discouragement, and demoralization are shared with peers.
The importance of establishing social skills and developing interpersonal
relationships in a drug-free environment is stressed (Riggin, 1996a, 1996b;
Family
Therapy
Family therapy, effective if the family members are supportive of the client
and willing to participate, provides an opportunity for the client and family
members to share personal feelings, to rebuild relationships, and to
reestablish healthy roles in the family. Helping the family gain knowledge
about alcoholism and put the knowledge into effect may also occur during
family therapy, because problem-solving guidance and direction are
available.
The concept of codependency is usually addressed in family or marital
therapy. The codependent becomes so involved with the family member's
drinking problem that the codependent's needs and desires are ignored. As
a result, the codependent may allow abusive behavior to continue even
when it is dangerous. Codependent behavior impedes recovery.
Client
Education
Smoking-Cessation
Programs
Support
and
Self-Help
Groups
treatment.
Alcoholics Anonymous (AA) (founded in 1935 by a surgeon and a
stockbroker who were unable to obtain help for their alcoholism): A
voluntary, nonprofessional, nondenominational fellowship of alcoholics
who help themselves and each other recover from the illness of
alcoholism by following 12 steps (Box 26-4 ); educational materials,
including videos, pamphlets, and books, available online through AA's
Web site
Al-Anon: A fellowship of spouses, relatives, and friends
Evaluation
The nursing process is a dynamic activity that incorporates alternative
strategies at every stage of the process, based on ongoing and systematic
evaluation of client assessment data
(ANA & NNSA, 1988, p. 17).
The nurse evaluates the response of the client to the interventions and
inpatient
program
centers
programs
or
aftercare
programs
or
Self-Awareness
Prompt
Reflect on your thoughts about substance abuse. Do you have any biases or
prejudices about persons who abuse drugs or alcohol? Do you stereotype
people because of their cultural or ethnic background? What experience
influenced
BOX
your
attitude?
26.1
Michigan
Alcohol
Screening
Test
(MAST)
The MAST involves a list of 26 questions, each with a specific point score. A
total of five or more points on the MAST indicates the presence of
alcoholism. A total of four points suggests a potential problem with alcohol.
A total of three or fewer points indicates that the individual does not have a
problem
with
Points
alcohol.
Questions
(0)
(2)
(2)
(1)
(2)
(1)
(2)
(0)
(2)
9. Are you always able to stop drinking when you want to?
*
(4)
(1)
(2)
12. Has drinking ever created problems with you and your
spouse?
(2)
13. Has your spouse (or other family member) ever gone
to anyone for help about your drinking?
(2)
(2)
(2)
(2)
(1)
(2)
19. Have you ever been told you have liver trouble?
Cirrhosis?
(2)
(9)
21. Have you ever gone to anyone for help about your
drinking?
(4)
(0)
(2)*
(0)
(2)
25. Have you ever been arrested, even for a few hours,
because of drunk behavior?
(2)
26. Have you ever been arrested for drunk driving after
drinking?
BOX
CAGE
26.2
Screening
Test
for
Alcoholism
The CAGE tool involves a list of four questions. A positive response to one
question in the CAGE questionnaire indicates the individual has a potential
problem with alcoholism. Two affirmative responses correctly identify 75%
of persons with an alcohol problem.
Have you ever felt you ought to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your
nerves or get rid of a hangover (Eye-opener)?
Footnote
From Ewing, J.A. (1984). Detecting Alcoholism: The CAGE questionnaire.
Journal of the American Medical Association , 252, 19051907.
related
to
addiction
Denial
related
to
rationalization
behavior.
BOX
26.3
Medical
Abuse
Problems
Associated
With
Substance
arrhythmias, cardiomyopathies,
cardiac arrest
Amenorrhea,
adrenergic
effects
mimicking
hyperthyroidism
GENERIC
(TRADE) NAME
Drug
Class:
DAILY
DOSAGE
RANGE
IMPLEMENTATION
Anticonvulsants
carbamazepine
(Tegretol)
6001200
mg
valproate
(Depakote)
5001500
mg
Drug
Class:
Benzodiazepines
chlordiazepoxide
(Librium)
25300
mg
diazepam
(Valium)
240 mg
disulfiram
(Antabuse)
500 mg
Never administer to an
intoxicated client or to a client
without the client's knowledge;
instruct client of seriousness of
disulfiramalcohol
reaction
and the potential consequences
of alcohol use during therapy;
obtain liver function tests, CBC,
and serum electrolytes before
therapy and according to
protocol; give single dose 12
hours after client has abstained
from use of alcohol; crush tablet
and mix with liquid beverages if
necessary; if a sedative effect
occurs, administer next
scheduled dose at h.s.; monitor
for drowsiness, headache,
metallic or garliclike aftertaste,
and skin eruptions.
20 and 2 1 .
BOX
26.4
Twelve
Steps
of
Alcoholics
Anonymous
We admitted we were powerless over alcohol, that our lives had become
unmanageable.
Came to believe that a Power greater than ourselves could restore us to
sanity.
Made a decision to turn our will and our lives over to the care of God as
we understood Him.
Made a searching and fearless moral inventory of ourselves.
Admitted to God, to ourselves, and to another human being the exact
nature of our wrongs.
Were entirely ready to have God remove all these defects of character.
Humbly asked Him to remove our shortcomings
Made a list of all persons we had harmed, and became willing to make
amends to them all.
Made direct amends to such people wherever possible, except when to
do so would injure them or others.
Continued to take personal inventory, and when we were wrong,
promptly admitted it.
Sought through prayer and meditation to improve our conscious contact
with God as we understood Him, praying only for knowledge of His will
for us and the power to carry that out.
Having had a spiritual awakening as the result of these steps, we tried
to carry this message to alcoholics and to practice these principles in all
our affairs.
Footnote
not mean that A.A.W.S. has reviewed or approved the contents of this
publication, or that A.A.W.S. necessarily agrees with the views expressed
herein. A.A. is a program of recovery from alcoholism onlyuse of the
Twelve Steps in connection with programs and activities which are patterned
after A. A., but which address other problems, or in any other non-AA
context, does not imply otherwise.
Key
Concepts
P.428
functions of neural structures and pathways. Some researchers have
also speculated that individuals have a predisposition to or are at risk
for addiction due to a high level of stress hormones; a deficit in
dopamine function that is temporarily corrected by their drug of choice;
or electrical phenomena in the brains of people at risk for alcoholism.
Studies of twins, adoptees, and siblings indicate that the cause of
alcohol abuse has a genetic component.
Behavior and learning theories, sociocultural theories, and
psychodynamic theories have also been described by theorists in an
attempt to understand the etiology of substance dependence and abuse.
In addition, the disease concept of alcoholism has been accepted by the
medical profession.
Alcohol-related disorders include two categories: alcohol use disorders,
including alcohol dependence and alcohol abuse; and alcohol-induced
disorders, including intoxication, withdrawal, delirium, dementia,
amnestic disorder, depression, anxiety, sexual dysfunction, and sleep
disorders.
Ten classes of substances, other than alcohol, are associated with both
abuse and dependence: amphetamines, caffeine, cannabis, cocaine,
hallucinogens, inhalants, nicotine, opioids, PCP, and the group of
sedatives, hypnotics, and anxiolytics.
Designer drugs, club drugs, and anabolic steroids are three popular
categories of illicit substances readily accessible to the public.
CLIENT
WITH
ALCOHOL
DEPENDENCE
Alan's physician informed him that he was anemic and that his weight was
below the ideal body weight range for his height. He recommended that Alan
be seen for an evaluation regarding the possibility of alcoholism before he
developed any medical complications secondary to alcoholism.
DSM-IV-TR
Rationale
with
Rationale
Rationale
For additional study materials, please refer to the Student Resource CD-ROM
located in the back of this textbook.
P.429
P.430
P.431
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
Prepare a genogram of a client with alcohol abuse and his or her family.
What patterns do you find? What conclusions can you make about
alcoholism as a disease?
Attend an AA, Al-Anon, or Alateen meeting in your community. What
kinds of appropriate and inappropriate coping skills did you see? What
kinds of group tasks did you observe?
Professional nurses are not exempt from substance abuse; in fact, many
communities have support groups for recovering nurses. Research the
available services for impaired nurses at your hospital and in the
community. Explore the behaviors and personality traits of the impaired
nurse. What assessment parameters might assist the profession to
quickly identify and help these nurses?
REFLECTION
A client on the substance-abuse unit tells you that he is confused because
he has been told that his addiction to morphine is due to a chemical
imbalance. Using the quote at the beginning of the chapter and your
understanding of the biologic theory of addiction, develop an educational
tool to explain the development of a substance-related disorder to the
client.
P.432
MULTIPLE
CHOICE
QUESTIONS
Acetylcholine
b. Dopamine
View
1. B
c.
Norepinephrine
d.
Serotonin
Answer
c. Niacin
d.
View
2. D
Thiamine
Answer
View
3. B
c.
Marijuana
d.
Steroids
Answer
View
4. B
Answer
abuses
treatment. It also
not assist the
treatment
Answer
Internet
Resources
AllPsych Online:
http://www.allpsych.com/disorders/substance/substancedependence.html
AllPsych Online:
http://www.allpsych.com/disorders/substance/substanceabuse.html
American
Society
of
Pain
Management
Nurses:
http://www.ASPMN.org
Selected
References
Treatment
of
psychiatric
position
in
nursing
Banks, S. M., Pandiani, J. A., Schacht, L. M., & Gauvin, L. M. (2000). Age
and mortality among white male problem drinkers. Addiction, 95 (8),
12491254.
Bernstein, J. G. (1995). Handbook of drug therapy in psychiatry (2nd
ed.). Littleton, CT: PSG Publishing.
Community Epidemiology Work Group (CEWG). (2000, Jun).
Epidemiologic trends in drug abuse: Advance report . Bethesda, MD:
National Institute on Drug Abuse.
Clinical
Psychiatry
psychiatric
alcoholism
Harvard
Grinspoon, L. (Ed.). (1998b). Addiction and the brain Part II. The
Harvard Mental Health Letter, 15 (7), 13.
Internet Alcohol Recovery Center. (2003). Naltrexone: Frequently
questions . Retrieved December 13, 2003, from
http://www.uphs.upenn.edu/recovery/cons/nalfaq.html
asked
and
statistics .
Philadelphia:
Lippincott-Raven.
2632.
13.
Sherman, C. (2001). Targeted
naltrexone: Last call for alcohol.
Clinical Psychiatry News, 29 (11), 27.
Smith, J. (1999). Alcoholism and free will. Psychiatric
5962.
Times,
16 (4),
Times,
Suggested
for
Readings
Banks, S. M., Pandiani, J. A., Schacht, L. M., & Gauvin, L. M. (2000). Age
and mortality among white male problem drinkers. Addiction, 95 (8),
12491254.
Berman, C. W. (2001). Alcohol addiction: A case history. CNS News, 3
(5), 4.
Blume, S. B. (1998). Alcoholism in women. The Harvard Mental Health
Letter, 15 (3), 5.
Graham, J. (2000). Rock bottom: Recognizing alcoholism in your
Journal
Chapter
27
Sexuality
and
Sexual
Disorders
Learning
1994
Objectives
identity .
and
adults.
masochistic
and
sadistic
behavior.
Key
Terms
Ambiguous
genitalia
Chromosomes
Gender
identity
Hermaphrodism
Homosexuality
Klinefelter's
Male
pseudohermaphrodites
Masochistic
Sadistic
syndrome
behavior
behavior
Sex
Sexual
acts
Sexual
addiction
Sexual
identity
Sexuality
Sexual
orientation
Sexual
response
Transgender
Transsexual
Transvestite
Turner's
syndrome
P.434
The terms sex, sexual acts , and sexuality are often used interchangeably.
Trieschmann (1975), though, believes the terms should be differentiated. Se
described as one of four primary drives that also include thirst, hunger, and
avoidance of pain. Sexual acts occur when behaviors involve the genitalia a
erogenous zones. Sexuality is the result of biologic, psychological, social, a
experiential factors that mold an individual's sexual development, self-conce
body image, and behavior. Sexuality depends on four interrelated psychosex
factors. They include:
Sexual
orientation: How one views one's self in terms of being emotio
romantically, sexually, or affectionately attracted to an individual of a
particular
gender
Nurses come into contact with a variety of client concerns regarding sexual
or activity (Box 27-1 ). Sexuality influences how we view ourselves and how
relate to others. It has become an integral part of the nursing process in pla
holistic health care. Nurses who are uncomfortable with or confused about t
own sexuality may have difficulty discussing sexual issues with clients. Sexu
concerns may conflict with the religious beliefs of both clients and staff mem
Having respect for the client, examining your own feelings, and maintaining
nonjudgmental attitude are the standards for working with clients in any asp
human sexuality (Schultz & Videbeck, 2002).
BOX
27.1
Sexuality:
Examples
of
Clients'
Concerns
A mastectomy client verbalizes that her husband no longer finds her sex
attractive.
A cardiac client expresses fear of resuming sexual activity.
A colostomy client fears rejection due to change in body image and stom
odors.
Elderly clients of the opposite sex ask permission to share a room in the
nursing home.
A middle-aged client makes sexual advances while being bathed and atte
to expose his genitals to the nurse.
A young male client asks a nurse for her address and telephone number.
A teenaged client tells a male nurse that she thinks she has a sexually
transmitted
disease.
Self-Awareness
Prompt
Examine your personal feelings about your own sexuality. With which of the
mentioned in the examples in Box 27-1 would you find it difficult to interact
you provide care for all of the clients? What actions could you take to chang
attitude or feelings about those clients?
P.435
Identity is the core of human existence. This reality manifests itself in the h
as an evolutional focal point. No other species contemplates its very nature.
Understanding gender identity encompasses knowledge about sexual develo
Terminology
Sexual
disgusting or that they will disappear as they grow up. They elicit a variety o
social reactions as they reject their own anatomy and demand that others a
their feminine names and female identity (Rekers & Kilgus, 2001). Girls with
gender identity disorders have male companions and an avid interest in spor
rough-and-tough play. They show no interest in dolls or playing house (unles
play the male role). They may refuse to urinate in a sitting position, claim th
they have or will develop a penis, do not want to develop breasts or experie
menses, and state that they will grow up to be a man (Sadock & Sadock, 20
Etiology
of
Gender
Identity
Development
Genetic
and
Biologic
Theories
XXY chromosome grouping (an extra X chromosome). The male appears norm
until adolescence, when low levels of testosterone result in small testes, inf
and a low level of sexual interest. Turner's syndrome , seen in females, oc
as the result of a missing sex chromosome (XO grouping instead of XX
combination). The female appears short in stature and lacks functioning gon
During puberty, breasts do not develop and menstruation does not occur. XY
syndrome, seen in males, contributes to a slightly taller stature, low sperm
and abnormalities of the seminiferous tubules.
P.436
before any conclusions can be drawn. Unfortunately, sexual orientation
enormously difficult to define in a way that would make sense to biochemica
benches
(Medina, 1999, p. 16).
Psychosocial
Theories
Sigmund Freud (1960) theorized that gender identity problems result within
oedipal triangle when conflict is fueled by both real family events and fantas
Whatever interferes with a child loving a parent of the opposite sex and ide
with the same-sex parent interferes with normal gender identity. For exampl
quality of motherchild relationship in the first years of life affects the
development of gender identity as mothers normally facilitate their children'
awareness of and pride in their gender. Devaluing, hostile mothering can res
gender identity problems. The father's role is equally important during the e
years, as his presence generally helps the separationindividuation proces
Without a father, the mother and child may remain overly close and the child
not have the opportunity to develop a sense of maleness or femaleness, or
distinguish between the roles of males and females. The father represents f
love objects for girls and a model of male identification for boys (Sadock &
2003).
According to Zucker, head of the Child and Adolescent Gender Identity Clinic
Clarke Institute of Psychiatry in Toronto, Canada, research in the 1950s sho
that among children with physical intersex conditions (ie, both male and fem
sexual characteristics), sexual assignment and rearing was a better predictor
gender identity than chromosomal, gonadal, and other physical variables (B
1999). Little evidence exists that frank parent-initiated cross-gender rearing
attitudes caused gender identity disorder (eg, dressing a girl in boy's clothin
enrolling a girl in sports with boys). Most often, parents just tolerate signs o
cross-gender
behavior.
Recent theories explore the impact of gender, race, and ethnicity on gender
identity. Gender identity, considered to evolve over time, is thought to be s
by attitudes, values, beliefs, sex roles, religious values, family and ethnic
communities, and degree of acculturation. Ryan, Futterman, and Stine (1998
discuss the psychosocial aspects of gender identity development, including t
average age of coming out
(self-identification as lesbian, gay, or sam
and sharing one's sexual identity with others). They reported that this age h
dropped from the early twenties to age 16.
Clinical
Symptoms
Characteristics
of
and
Diagnostic
Gender
Identity
Disorders
The features of gender identity disorders are twofold. The Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-T
states that there must be evidence of a strong and persistent cross-gender
identification in which one expresses the desire to be, or the insistence to be
the opposite sex (American Psychiatric Association, 2000). The individual als
experiences persistent discomfort about his or her assigned sex or feels
inappropriate in the role of the assigned sex. Impairment occurs in social,
occupational, or other important areas of functioning. For example, boys, wh
outnumber girls more than six to one in diagnosed cases of gender identity
disorder, identify with girls or women and are preoccupied with traditionally
feminine activities (Zucker, Bradley, & Sanikhani, 1997).
Girls with gender identity disorders display intense negative reactions when
parents attempt to feminize them. They polarize to male attire and activities
prefer to associate with boy playmates. Adult men and women who are preo
with their wish to live as the opposite sex may act on their desires by adopt
behavior, dress, and mannerisms of the opposite sex.
P.437
Cross-dressing, hormonal treatments, or sex reassignment in the presence o
genital ambiguity may be attempted to pass convincingly as the other sex.
European statistics cited in the DSM-IV-TR indicate that approximately 1 per
30,000 adult men and 1 per 100,000 adult women seek sex-reassignment s
No statistics are available for the United States.
Overview
of
Sexual
Disorders
Two major factors that impact sexual performance are the presence or absen
normal sexuality (ie, feelings of desire and pleasure to engage in the sexual
and the presence or absence of an adequate sexual response cycle. A discus
these two factors follows.
Development
of
Sexuality
Family is the most important first source of learning about issues of sexualit
Parental attitudes and behaviors begin to shape feelings about male and fem
gender identity. Developmentally appropriate communication about sex shou
begin at home with young children and continue through adolescence.
Infancy
and
Childhood
confusion in the future. Between the ages of 3 and 6 years, the preschooler
identifies with the same sex, may ask questions about the origin of babies, a
may ask about the anatomic differences between sexes. These are considere
be normal behaviors for children in this age group.
SEXUAL
DYSFUNCTION
Dyspareunia
Incomplete
orgasm
desire
MEN
WOMEN
3%
15%
10%
25%
10%
33%
Hypoactive
sexual
Premature
ejaculation
27%
n/a
Premature
arousal
n/a
20%
As children interact with other children, they may obtain inaccurate informa
that could affect the development of healthy sexuality. Parents may consider
children to be asexual beings and avoid discussing or clarifying information
to sexuality because they feel their children may become preoccupied with s
They also may feel threatened by their child's natural sexual curiosity and r
with hostility or punishment (Finan, 1997; Krozy, 1998). Guidelines are ava
for parents who wish to deal with sexuality issues from infancy through pres
(Finan, 1997). A sexuality values scale is also available to help clinicians ev
parental knowledge about sexuality.
Although child and youth offenders generally are male in the cases known to
more cases of sexual exploitation by girls committing acts of sexualized viol
against younger/weaker children and young people are becoming known (Mo
2001; Theme Paper, Young Offenders and Prevention, 2003).
P.438
Preadolescence
and
Adolescence
Adulthood
peers. Decisions are made regarding career, marriage, and lifestyle. Young
may lack knowledge about relationships with significant others, contraceptiv
measures, sexual trends, sexually transmitted diseases, and alternative lifes
(Krozy, 1998).
Sexual patterns established during early adulthood are the best predictors o
sexual expression in midlife and beyond. However, expressions of sexuality
vary as the individual continues to work through the developmental stages o
middle adulthood (ages 4164) and late adulthood or maturity (65 years t
death) (Baxer, 2001). Although physiologic changes occur and chronic illnes
may begin, interest in sexual activity among the elderly may continue, or in
instances, increase rather than decrease. Frequency of sex acts may decline,
the quality need not change. Also, companionship and physical activities such
touching, hugging, and handholding may replace the individual's earlier
expectations of intimacy.
Krozy (1998) discusses the role of sexuality as a human force throughout life
during the dying process. Individuals generally value intimacy over isolation
express a need for closeness with another person during a terminal illness.
Members of the nursing profession or hospice staff often meet this need whe
individuals are hospitalized, relocated to a long-term care facility, or cared fo
home. Family members may be concerned, surprised, or embarrassed as a f
member or partner expresses an interest in continuing a sexual relationship
his or her husband, wife, or significant other. Nurses should encourage the
and family to discuss sexual issues and needs.
Human
Sexual
Response
Cycle
Desire
Sexual desire is
stimulation. This
functions of the
be controlled by
to receive s
excitatory
Desire appe
personal
Excitement
Orgasm
The third phase of sexual response, orgasm, was formerly termed climax . D
this phase, women experience several strong, rhythmic contractions of the v
which are followed by spastic contractions. The vagina enlarges, the uterus
contracts irregularly, generalized muscle spasm and loss of voluntary muscle
control occurs, and vital signs and the sex flush peak. Men experience emiss
and ejaculation of seminal fluid. Ejaculatory contractions involve the entire
of the penis. They are initially expulsive, followed by several contractions of
intensity. Some women are capable of experiencing multiple orgasms. Men
generally experience a refractory period following orgasm and before resolu
(Byers & Esparza, 1997; Krozy, 1998).
P.439
Resolution
Resolution is the final phase of the sexual response cycle. The organs and b
systems gradually return to the unaroused state. Vital signs return to norma
sex flush disappears. Relaxation and satisfaction are felt.
Sexual
Dysfunctions
Sexual
Desire
Disorders
Two sexual desire disorders are identified: hypoactive sexual desire disorder
sexual aversion disorder. The diagnosis of hypoactive sexual desire disorder
used only if the lack of desire causes distress to the client or the client's pa
Factors such as age, health, frequency of sexual desire (diminished libido), a
lifestyle are considered when one is interviewing the person seeking help. Th
diagnosis of sexual aversion disorder is used if anxiety, fear, or disgust occu
when an individual is confronted with a sexual opportunity.
Sexual
Arousal
Disorders
In males, sexual arousal disorder, also termed male erectile disorder or mor
commonly erectile
dysfunction (ED), refers to the inability to attain or maint
erection adequate for sexual activity. The causes may be organic or psycho
Orgasmic
Disorders
The diagnoses of female orgasmic disorder and male orgasmic disorder are u
describe recurrent, persistent inhibited orgasm following an adequate phase
sexual excitement in the absence of any organic cause.
Sexual
Pain
Disorders
Sexual pain disorders typically include dyspareunia and vaginismus. The dia
FIGURE
had a strict religious upbringing in which sex is associated with sin may exp
vaginismus (Sadock & Sadock, 2003).
Sexual Dysfunction
Condition
Due
to
General
Medical
P.441
medical condition. Marked distress or interpersonal difficulty occurs during s
activity. The subtypes of this disorder include:
Some common physical disorders could cause difficulty with sexual activity.
include chronic pain syndrome, arteriosclerosis, diabetes, liver disease,
hypertension, thyroid disorder, and sexually transmitted diseases. Sexual
dysfunction may also occur as a result of treatments used to manage a gene
medical condition, such as radiation therapy, nerve blocks, or surgical proce
that physically alter the central nervous system (Paice, 2003).
Paraphilias
Mental health professionals generally do not see clients with paraphilias unle
their behavior creates a conflict with society. Nonconsenting partners may r
such activity to legal authorities. Concerned neighbors may suspect that chi
are the object of sadistic sexual behavior and inform the police or the child
bureau of such abuse. Voyeurism, exhibitionism, and pedophilia are three
subclassifications of behavior that usually result in arrest and incarceration.
A description of paraphilias is included in Box 27-2 .
BOX
27.2
Paraphilias
Bestiality or Zoophilia: Sexual contact with animals serves as a preferred
method to produce sexual excitement. It is rarely seen.
Exhibitionism: An adult male obtains sexual gratification from repeatedly
exposing his genitals to unsuspecting strangers, usually women and children
are involuntary observers. He has a strong need to demonstrate masculinity
potency.
person.
needs.
Telephone
Scatologia: Sexual gratification is achieved by telephoning som
and making lewd or obscene remarks.
Transvestic
Fetishism: A heterosexual male achieves sexual gratification t
wearing the clothing of a woman (cross-dressing). It is a learned response d
encouragement by family members. As a child, the person was considered m
attractive when dressed up as a girl.
Characteristics
of
Paraphiliacs
A person may experience more than one paraphiliac disorder at the same tim
may exhibit clinical symptoms of other mental disorders such as a personalit
disorder or
P.442
schizophrenia. Characteristics or associated features of persons who are cla
as paraphiliacs include:
behavior )
Low or poor-self concept
Depression
Not all of the characteristics listed are present in each paraphiliac. The way
paraphiliac expresses him- or herself sexually affords a clue to the paraphili
self-concept. For example, the fetishist who has a very low self-concept cho
inanimate objects to satisfy sexual needs, and therefore does not have to fe
rejection by a partner.
Sexual
Addiction
Sexual addiction , first described by Dr. Patrick Carnes in his book, Out of
Shadows: Understanding Sexual Addiction (1983), is defined as engaging in
obsessivecompulsive sexual behavior that causes severe stress to addicte
individuals and their families. Sexual addicts make sex a more important pr
than family, friends, work, and values. Sex becomes the source of nurturing
trust, and addicts are willing to sacrifice what they cherish most to preserve
behavior. Approximately 6% to 8% of the population is affected by sexual
addiction (Klein, 2003).
Sexual addicts have admitted that their unhealthy use of sex began with an
Addiction to cybersex is a new but growing disorder that often goes undiagn
The explosive growth of the Internet has provided a new outlet for individua
sexual compulsions. For some, the computer has become the primary focus o
sexual or romantic life. Signals that a client is addicted to sex online may be
missed because clinicians may be unaware of the breadth and variety of sex
activities available on the Internet (Macready, 2001).
The
Nursing
do so. The
they suffer: los
a loss of inter
addicts have a
Process
Assessment
In a perfect world, health care providers would be both trained and pro
in all areas of care. In reality, sexual health is often the exception
(War
Rowe, & Whipple, 1999, p. 34). This statement was made regarding the lack
emphasis placed on including a sexual history as part of the assessment pha
the nursing process.
Sexual
History
During the assessment, ask the client's permission to discuss his or her
life,
emphasizing that all client information provided is confidential. Be
professional when approaching the subject about sexuality and provide supp
P.443
sensitive to most sensitive material. Be sure to word the questions in a clos
ended style to elicit a specific response. Examples of questions may include
Are you married?
or Are you living with a partner?
information revealed to guide the discussion.
Allow th
Explore the client's role in sexual relationships, both past and present. Also
information about the client's perception of any sexual issues in the relation
Be especially sensitive with questions regarding the history of any sexual tra
Also explore any history of substance abuse and legal problems and pay par
attention to any cultural and religious influences affecting the client's sexua
(Byers & Esparza, 1997; Warner et al., 1999).
Due to the sensitive nature of the subject, obtaining a sexual history can be
problematic for the client and nurse. Several issues can create barriers to
obtaining the necessary information. Common barriers to taking a client's se
history include: failure to view the client's sexual history as relevant to the p
care; inadequate training of the health care professional; embarrassment to
health care professional; fear of offending the client by asking personal que
and the perception by the health care provider that any sexual concern of th
client will be overly complex and time-consuming for the provider to assess,
less manage (Postlethwaite, Stump, Bielan, & Rudy, 2001).
Another barrier that could interfere with assessment involves legal issues.
Providers may be uncertain about state laws regarding a minor's consent to
treatment or may feel uncomfortable in supporting an adolescent's decisions
may conflict with a parent's wishes. For lesbian and gay youth who haven't
informed their parents of their sexual preference, fear that their confidentia
may not be protected can be a significant barrier to care (Ryan et al., 1998)
or all of these barriers could result in an incomplete sexual health assessmen
Sexual acting-out may occur in the general hospital as the client attempt
test his or her sexuality due to loss of independence, low self-esteem, los
body part, loneliness, fear, anxiety, or loss of control. Behavior frequent
includes flirting, deliberately exposing the genital area, dressing in sedu
attire, touching the caregiver inappropriately, using profanity, or making
provocative comments. Some clients use a shock approach by blatantly
discussing promiscuous sexual activity or telling jokes that center on se
contact.
P.444
or opposite sex, or openly masturbate on the unit. Clients who are confu
delirious may undress or urinate in public. A teenager, admitted because
suicide attempt, may be struggling with an emerging sexual identity. Fam
members express embarrassment to the staff because their loved one is
exhibiting impulsive, uninhibited behavior.
may ask to take their wife or husband home for a few hours or on an ov
leave of absence. Clients with dementia may be sexually attracted to oth
residents and exhibit overt sexual behavior. A referral may be made to a
mental health provider to assess how competent the client is to engage i
Assessment
of
Children
and
Adolescents
master in early development. For example, in our society, only females wear
lipstick or dresses in public. If a boy wears a dress and lipstick to school, ad
react with disapproval and peers react with ridicule (Rekers & Kilgus, 2001).
Children and adolescents who have concerns about body image, sexual ident
attraction to the same sex, or who verbalize sexual fantasies, may experienc
distress and exhibit severe adjustment problems or sexually aggressive beh
that warrants a psychosocial assessment.
Children under the age of 8 often are open to answering questions truthfully
sexual behavior, including sexual fantasies or their attraction to peers of the
sex. Older children and adolescents are more aware of the social significance
their behavior and may conceal their true interests. Lesbian and gay youth w
report significant stress associated with school and related activities need
assessment for evidence of alcohol abuse, depression, and suicidal ideation.
Clinical psychological testing may be necessary to obtain additional data dur
assessment process (Rekers & Kilgus, 1998; Ryan et al., 1998; Zucker & Br
1997).
Transcultural
Considerations
A client's ethnic, cultural, religious, and social back ground influences sexua
attitude, desire, and expectations. Andrews and Boyle (2003) comment abou
cultural norms related to appropriate malefemale and same-sex relations
Nursing
Diagnoses
P.445
sexual assault against his or her will and without his or her consent. The tra
syndrome develops as a result of the attack or attempted attack. Defining
characteristics include a report or evidence of sexual assault (Carpenito, 20
Examples include: (1) Rape-Trauma Syndrome related to fear of sexual inte
due to distrust of men and (2) Rape-Trauma Syndrome related to fear of
intimidation by a sexually abusive husband (see Chapter 31 ).
Other nursing diagnoses that may be used when implementing care for client
sexual problems or concerns include Chronic Low Self-Esteem, Disturbed Bod
Image, Anxiety, Fear, Hopelessness, Social Isolation, and Spiritual Distress.
Outcome
Identification
Planning
Interventions
Implementation
symptoms. The nurse also considers the client's needs, nursing diagnosis or
diagnoses, problem severity, and the nurse's own competence (Krozy, 1998)
knowledge of psychosexual development is imperative. Ensuring the client's
Nurses must examine feelings about their own sexuality before they are able
provide care for clients who present with issues related to sexuality. Feelings
disgust, contempt, anger, or fear need to be identified
P.446
and explored so that they do not interfere with the development of a therap
relationship. If the nurse is unable to be objective while providing care for a
specific client, the nurse should relinquish responsibility to another member
health care team.
Assistance
in
Meeting
Basic
Needs
Adequate rest, exercise, and nutrition, and good general physical health, pr
sexual health. Clients with health problems or who are elderly are assisted in
identifying barriers that interfere with sexual functioning (eg, pain, impaired
mobility, or adverse effects of medication). Techniques are taught to reduce
oxygen consumption and cardiac workload and reduce or eliminate pain duri
sexual activity.
Provision
of
Safe
Environment
pose a threat to the safety of others as well as to themselves. The client who
gender identity conflict may become severely depressed, develop a substanc
abuse disorder, exhibit violent behavior toward others, or be victimized by f
members.
Children who are sexually aggressive may victimize other children. Clients w
Research reveals that many young people who are gay face abuse from fami
members after they disclose their sexual orientation (Worcester, 1999). Les
are most likely to be attacked by mothers, and gay men are most likely to b
attacked by brothers. Such individuals have been known to make suicidal th
which resulted in involuntary admission to a psychiatric facility. See Support
Evidence for Practice 27-1 .
P.447
Medication
Management
Various pharmacologic approaches are used to treat clients with sexual diso
Nurses need to be knowledgeable of and familiar with their application and
potential adverse effects.
touch are used to reduce pain, depression, or anxiety and promote sexual h
Several pharmacologic antidotes are available to treat antidepressant-assoc
sexual dysfunction, which includes decreased sexual desire, and arousal, er
and orgasmic dysfunction (Drug Summary Table 27-1 : Selected Drugs Used
Sexual
Disorders).
Erectile dysfunction has been reported to improve significantly with the use
sildenafil citrate (Viagra). However, the drug is limited in its use. For examp
there is potential cardiac risk for clients with preexisting cardiovascular dise
Also, clients have reported prolonged erection greater than 4 hours and pria
(painful erections greater than 6 hours in duration). If
P.448
priapism is not treated immediately, penile tissue damage and permanent los
potency could result.
Assistance
With
Medical
Management
Is the client being seen in the office primarily for the treatment of impo
secondary to muscular dystrophy?
Is a referral made because a primary care physician suspects alcoholism
client who is infertile?
Does a hospitalized client verbalize concerns about sexuality following a
mastectomy?
Does a hospitalized client exhibit impulsive, sexual acting-out behavior
postoperatively?
Has a client been admitted for a penile implant?
Has the client experienced a decrease in sexual desire since being placed
lithium?
Interactive
Therapies
The true meaning, and indeed, the deep pleasure associated with sexua
cannot be found in a pill Exploring the deeper aspects of sexuality is an
opportunity and a challenge
(Tamerin, 1998, p. 56). Various interactive
therapies are available to clients. The nurse and client discuss which, if any,
interactive therapies would be therapeutic: individual, marital, family, sex,
or behavioral therapy.
Most individuals with a gender identity disorder have fixed ideas and values
Individual
Psychotherapy
Individual therapy is recommended for clients who have had a recent life ch
such as illness, loss, divorce, surgery, and any factors resulting in change in
esteem or body image. A common cause of the cessation of sexual activity is
loss of a partner. Sexual self-confidence may be lost along with the familiar
partner, and new relationships may seem threatening. Individuals who have
experienced a life-threatening illness may fear that sexual behavior will resu
further debilitation. Conformity to cultural taboos about sexuality and aging
play an important part in impotence.
Marital
or
Couples
Therapy
P.449
feelings of sexual inadequacy, infidelity, or incompatibility. It can be effectiv
resolving conflicts, especially if the couple has a difference in opinion regard
what is normal sexual behavior. For example, disclosure, the self-reporting o
marital or partner infidelity during therapy, has been viewed as a positive wa
end an extramarital relationship or a secret life, establish hope for the future
experience the healing value of honesty. The partner or spouse is encourage
reflect and respond to the disclosure and decide if he or she accepts the dis
as a step toward healing the couple or marital relationship (Levin, 1999).
Family
Therapy
As adolescents and young adults struggle with emerging sexual identity, par
and families go through a parallel coming-out process and are affected by th
stigma associated with being gay or lesbian. Family therapy or a referral to
Sex
Therapy
Individuals who are trained and certified generally provide sex therapy. The
which sexual material is experienced and expressed during therapy depends
gender and age of the client or couple, and to some extent, of the therapist
therapists as seen in dual-sex therapy. Specific techniques and exercises to
physiologic problems may be explored. Hypnotherapy may be employed to r
anxiety-producing symptoms and to develop alternative means to deal with
during sexual encounters. Sensitivity to gender aspects of human sexuality
Group
Therapy
and
expressing
personal
identifying
stress
and
managing
anger
appropriately
using
feelings
stress-reduction
techniques
developing a written safety contract and listing activities that can never
allowed in the presence of peers
problem-solving
skills
self-esteem
During the last two sessions, the children review the individual treatment pr
and participate in a graduation ceremony (Moon, 2001).
Behavioral
Therapy
Support
Groups
Client
Education
assist clients in maintaining sexual health through their lifespan (Baxer, 200
Recognize each client's particular cultural, physiologic, and psychological
circumstances when teaching clients. Adapt client teaching by keeping an op
mind and nonjudgmental attitude about human sexual expression.
Evaluation
As noted earlier, not all paraphiliacs want or receive treatment. Those who d
generally participate in individual or group therapy to explore feelings of se
anxiety, depression, and frustration. Behavioral therapy focuses on altering
managing unacceptable or undesirable behaviors. Thus, outcomes are evalua
Clients who exhibit clinical symptoms of sexual addiction may have difficulty
resolving social, marital, and professional issues. Fear of consequences may
them from continuing with treatment. Recidivism for paraphiliacs and sex ad
high.
For example, the nurse and client would discuss whether the client's clinical
symptoms, such as pain, frustration, anxiety performance, depression, or an
have improved. They would also discuss whether the client accepted or tried
suggested interventions and how effective these actions were.
Evaluation focuses on whether the expectations of the client are realistic and
whether the client feels a need to continue with supportive therapy. Some c
may not want to change their behavior or are not ready to change. Partners
be resistant to new suggestions. Evaluation may indicate that the need for a
referral to another therapist with a perspective more consistent with the clie
or to a clinician with more experience, would benefit the client. See Nursing
Care 27-1: The Client Experiencing Hypoactive Sexual Desire Disorder .
BOX
27.3
Basic Principles
Assessment
for
Performing
Sexual
empathetic.
specific,
open-ended
questions.
EXAMPLES OF
DISORDERS
STATED
OUTCOMES:
SEXUAL
The client will verbalize feelings that lead to sexually aggressive behavio
The client will modify behavior to reduce stressors.
SUPPORTING
The
EVIDENCE
Relationship
Sexual
FOR
Between
PRACTICE:
Suicide
Risk
27.1
and
Orientation
PROBLEM UNDER
bisexual/homosexual
RESEARCH SUMMARY: The study consisted of 152 female and 184 male bi
and homosexual groups. Data were obtained from the Adolescent Health Sur
identify the sexual preference of the subjects. Suicide risk was identified fro
questions that were asked about previous attempts, current suicide thoughts
suicide plans. Results indicated that 90% of the subjects answered
regarding suicide and that bisexual/homosexual males (84%) were
complete these questions when compared with their heterosexual
(91%). Economic status was higher among the heterosexual males
compared
with
their
bisexual/homosexual
counterparts
the ques
less likely
counterpa
(69%)
(56%).
Results also indicated that there were more white heterosexual females (86%
compared with bisexual/homosexual females (73%). Suicidal intent was
Source: Remafedi, G., French, S., Story, M. Resnick, S. C., & Blum, R. (199
relationship between suicide risk and sexual orientation: Results of a popula
based study. American Journal of Public Health, 88 (1), 5760.
DAILY
DOSAGE
RANGE
Selected
IMPLEMENTATION
levodopa
(Larodopa)
0.58 g
sildenafil
citrate
25100
mg
(Viagra)
bupropion
(Wellbutrin)
200450
mg
paroxetine
(Paxil)
1050
mg
Note: The following selected drugs are used to treat problems related to
sexual performance.
HYPOACTIVE
Jim, a 36-year-old executive, was admitted to the ICU with the diagnosis of
myocardial infarction. The father of two children, Jim confided in the nurse t
is afraid to resume his duties as husband and father. He also stated that he
afraid to play golf, even though the attending physician assured him he wou
eventually be able to lead a normal life if he adhered to the doctor's orders.
a visit by his wife, Jim appeared withdrawn and apprehensive. As the nurse
evening rounds, Jim complained of chest pain and stated that he thought his
doctor was sending him home too early. Later that evening, Jim's wife called
nurses' station and asked to talk to the head nurse. She expressed concern
her husband's withdrawal, lack of interest in visiting with her, and fear of go
home.
DSM-IV-TR
infarction
Planning/Implementation
Rationale
OUTCOME: The client will verbalize a decrease in fear regarding the resump
activities of daily living.
Planning/Implementation
Encourage client to verbalize feelings.
Rationale
sk
Key
Concepts
The terms sex, sexual acts, and sexuality are often used interchangeably
P.451
Latency-age children who have problems with general aggressiveness ma
a result of anger, family problems, and boredom, exhibit sexual aggress
toward peers.
The human sexual response cycle includes four phases: desire, exciteme
orgasm, and resolution.
Psychological factors, medication, or physical disorders can precipitate a
dysfunction disorder in both male and female clients.
Individuals who participate in unusual or bizarre sexual acts to achieve
excitement are referred to as
P.452
paraphiliacs. They are generally not seen by mental health professionals
their behavior creates a conflict with society.
others, divorce, arrests, low self-esteem, and despair. Many sexual addi
have a dual diagnosis including substance abuse or depression.
include not considering the client's sexual history as relevant to the plan
care, inadequate training of the health care professional, embarrassment
health care professional, fear of offending the client by asking personal
questions, and the perception by the health care provider that any sexua
concern of the client will be overly complex and time-consuming for the
provider to assess, much less manage.
Planning focuses on
respects the client's
assumes the role of
and sexual health in
Although the plan of care is developed with the client's input, the compe
of the nurse has an effect on the outcomes. If the nurse is unable to be
objective while providing care for a specific client, the nurse should relin
responsibility to another member of the health care team.
For additional study materials, please refer to the Student Resource CD-ROM
located in the back of this textbook.
P.453
P.454
Chapter
Critical
Worksheet
Thinking
Questions
you became embarrassed, and what thoughts and feelings you experienc
when evaluating how to answer each question. Could the interviewer tell
these feelings were occurring?
If you and your classmate, who know each other, felt embarrassed, how
a new client feel? How might you make the client more comfortable? How
would you adjust the interview for a client your own age? For a client yo
father's age?
Reflection
Review the chapter quote about the development of sexuality by Sadock & S
In some Middle-Eastern countries, women are not allowed to show their face
public, wear Western-style clothes, or drive a car. They are considered to be
second-class citizens. What influence do you think these cultural practices m
have on the development of a woman's sexual identity? What impact would
cultural practices have on a female American citizen working in such a coun
Explain your answers.
P.455
Multiple
Choice
Questions
Answer
Answer
questions about the origin of babies, and may ask about the anatomic differ
between sexes. These are considered to be normal behaviors for children in
age group. Parents need to be instructed to answer the child's questions ho
and at the level that the child will understand. Sexual aggression has been l
to general aggression in children between the ages of 5 or 6 up until pubert
These children describe a history of neglect and physical abuse; a dysfunctio
relationship with parents who quarrel or abuse alcohol; physical or sexual
aggression against their mother or siblings by their father or another male f
confrontation with adult sexuality at an early age; or exposure to distorted o
deviant sexuality such as pornography.
a. Ignoring the client's behavior, realizing that the client has low self-e
b. Informing client that behavior is unacceptable, knowing limit-setting
appropriate
Answer
The nurse should set appropriate limits for this client, informing the client th
behavior is unacceptable. Ignoring the client's behavior would be inappropri
because the client's behavior is inappropriate. Holding a community meeting
do little to limit the client's inappropriate behavior at the current time. Howe
could be used later on to help educate the client. Requesting the client's do
speak with the client passes the responsibility to another. The nurse needs t
enforce consistent limits.
Answer
The nurse would assess the client's medication history. Medications or subst
can diminish libido or inhibit sexual function by causing changes in the blood
to the genital area or the nervous system control of the area. The age of on
puberty, difficulty with childbirth, and high fat intake have not been associa
with a loss of interest in sexual activity.
5. Which area represents the most significant barrier to the taking of
sexual history by the nurse?
a. Client discomfort and embarrassment
Answer
The most common barrier identified to taking sexual history is the nurse's
discomfort and embarrassment with the topic. Other factors may include fail
view the client's sexual history as relevant to the plan of care; inadequate t
of the health care professional; fear of offending the client by asking person
questions; and the perception by the health care provider that any sexual c
of the client will be overly complex and time-consuming for the provider to
much less manage.
Internet
Resources
Aggression
in
Development:
Children:
http://www.child-hood.com/de/text_p711.h
http://www.ecewebguide.com/sexual_development.h
Selected
References
4344.
American Psychiatric Association. (2000). Diagnostic and statistical manual
mental disorders (4th ed., Text Revision). Washington, DC: Author.
Psychiatry
Ne
psychiatric
glos
Freud, S. (1960). The ego and the id (J. Strachey, Ed., & J. Rivere, Trans).
York: W. W. Norton.
Friedman, R. C., & Downey, J. I. (2000). Discussing sex in the
psychotherapeutic relationship. Psychiatric Times, 17 (7), 5750.
Gender Identity Research and Education Society (GIRES). (2003).
Epidemiological
data . Retrieved August 29, 2003, from
http://www.gires.org.uk/text_assets/etiology_definition.pdf
Spotlight,
Outlook , (1).
Masters, W., & Johnson, V. (1966). Human sexual response . Boston: Little
Brown.
Times,
16 (8),
Postlethwaite, D., Stump, S., Bielan, B., & Rudy, S. J. (2001, Spring). Sex
history and counseling for patients on teratogenic drugs. American Journal
Nurse Practitioners, Special Supplement , 1418.
FL:
Professional
Resource
Press.
Times,
18 (12), 4447.
Remafedi, G., French, S., Story, M., Resnick, S. C., & Blum, R. (1998). The
Ryan, C., Futterman, D., & Stine, K. (1998). Helping our hidden youth.
American Journal of Nursing, 98 (12), 3741.
Sadock, B. J., & Sadock, V. A. (2003). Kaplan & Sadock's synopsis of
psychiatry: Behavioral sciences/clinical psychiatry (9th ed.). Philadelphia:
Lippincott Williams & Wilkins.
Theme Paper, Young Offenders and Prevention . (2003). Retrieved May 28,
2003,
from
http://www.child-hood.com/de/text_p711.html
Warner, P. H., Rowe, T., & Whipple, B. (1999). Shedding light on the sexua
history. American Journal of Nursing, 99 (6), 3441.
Suggested
Readings
Psychiat
Callanan, M. (1996). Sexual assessment & intervention for people with epi
Clinical Nursing Practice in Epilepsy, 3 (1), 79.
Kripke, C. C., & Vaias, L. (1994). The importance of taking a sensitive sex
history. Journal of the American Medical Association, 271 , 713.
sexual
Swaab, D. F., Gooren, L. J., & Hoffman, M. A. (1995). Brain research, gend
and sexual orientation. Journal of Homosexuality, 28 , 283301.
Chapter
28
Learning
UNKNOWN
Objectives
attention-deficit
Distinguish
autistic
disorder
hyperactivity
from
disorder
Asperger's
from
conduct
disorder
disorder.
boy
with
attention-deficit
hyperactivity
disorder
Key
Terms
Asperger's
disorder
Attention-deficit
Autistic
hyperactivity
disorder
disorder
Conduct
disorder
Encopresis
Enuresis
Mental
retardation
Oppositional
Rett's
defiant
disorder
disorder
Scapegoat
Tic
Tourette's
syndrome
P.458
Psychiatric care for children is a growing crisis in America. During the course
of 1 year, almost 21% of U.S. children and adolescents aged 9 to 17 years
are diagnosed with a mental health or addictive disorder associated with at
least minimum impairment. Nearly 4 million (11%) suffer from a major
mental illness that results in significant impairments at home, at school, and
with peers. Of this group, 5% have extreme functional impairment with their
illness. Moreover, approximately 70% of children and adolescents in need of
psychiatric services do not receive treatment (United States Department of
Health and Human Services [USDHHS], 1999). Table 28-1 lists the current
prevalence of mental or addictive disorders exhibited by children and
adolescents.
The Surgeon General's report on children's mental health, National Action
Agenda for Children's Mental Health , draws attention to the crisis in
TYPE OF DISORDER
Anxiety
disorders
Disruptive
Mood
disorders
Substance
Any
disorders
use
PERCENTAGE*
13.0
10.3
6.2
disorders
disorder
2.0
20.9
recognize and manage mental health issues, and educating mental health
providers in scientifically proven prevention and treatment services
Monitoring access to and coordination of quality mental health care
services
Diagnosing childhood and adolescent psychiatric disorders is not an easy
task. The etiology of mental health
P.459
and psychiatric disorders is multifactorial; that is, there is no single cause.
Several risk factors (eg, overprotective or controlling parents, behavior
problems in the toddler or preschool period, lack of resilience, and gay or
bisexual orientation) have been identified as placing children and teens at
risk for mental health disorders. The problem is further compounded by the
scarcity of trained clinicians such as psychiatricmental health clinical
nurse specialists, advanced nurse practitioners, child psychiatrists, clinical
child psychologists, and social workers. Inadequate screening and referral is
a major contributing factor to misdiagnosis, leaving approximately 70% of
children and teens without proper diagnosis and treatment (Kaplan, 2000;
Sadock & Sadock, 2003).
theories.)
Etiology
Several theories have been proposed for the different psychiatricmental
Theories
Mental
Retardation
Pervasive
Developmental
Disorders
Disorder.
Rett's
Researchers have hypothesized that there are two distinct forms of autistic
disorder. The first type is caused by bilateral brain damage early in life. The
second type, which is a more common form, is not associated with
P.460
brain damage, neurologic findings, or biologic markers. Children with the
more common form exhibit very low levels of serotonin on the left side of th
brain in the area responsible for language. Symptoms of autism are thought
to occur when serotonin levels in the left hemisphere of the brain do not
reach a critical level in early childhood (American Psychiatric Association
[APA], 2000; Sadock & Sadock, 2003).
Asperger's Disorder . Although the cause of Asperger's disorder a
disorder similar to autism characterized by impaired behavior and social
interaction but with no impairment in communication is unknown, family
studies suggest a possible relationship to autistic disorder. The similarities
between the two disorders support the presence of genetic, metabolic,
infectious, and perinatal contributing factors. Although definitive data
regarding the prevalence of Asperger's disorder are lacking, the disorder
appears to be diagnosed much more frequently in males (at least 5 times
more) than in females (APA, 2000; Sadock & Sadock, 2003).
Attention-Deficit
Hyperactivity
Disorder
(ADHD)
Attention-deficit
hyperactivity
disorder (ADHD), one of the bestresearched disorders in medicine, is characterized by prominent symptoms o
inattention and/or hyperactivityimpulsivity. Although overall data on the
validity of its existence are far more compelling than for most mental
disorders, a major limitation in the study of the genetics of such disorders in
children has been the overlap of one or more syndromes such as anxiety,
depression, or conduct disorder. The rate of overlap is greatly increased with
ADHD.
Given that any child has a 10% possibility of being diagnosed with ADHD,
overlap with other syndromes can occur merely by chance (Baren, 2000;
Flick, 2002; Myers, Eisenhauer, & Ryan, 2003).
Attention-deficit
hyperactivity
disorder is a heterogeneous behavioral
disorder with multiple etiologies. The symptoms have been attributed to
neuromaturational delay, catecholamine deficits, altered glucose metabolism
in the brain, and frontal lobe dysfunction. For example, genetic influences
such as rare mutations in the human thyroid receptor gene on chromosome
3, dopamine transporter gene on chromosome 5, and D4 receptor gene on
chromosome 11 have been identified in studies of twins and families
(Biederman, 1999). Additionally, severe central nervous system infections
such as Reye's syndrome and meningitis; perinatal insults such as substance
abuse during pregnancy, poor maternal nutrition, premature labor, and
anoxia; and brain injuries during or after birth are also considered to be
causes of ADHD (Baren, 2000).
Disruptive
Behavior
Disorder:
Conduct
Disorder
Childhood
Psychosis
More than 50% of adults with bipolar disorder experience the onset in
childhood or adolescence. Biologic contributions include genetic factors,
neuropathology, and neurotransmitter abnormalities (Hendren, 1997). Box
28-1 summarizes possible causes of psychosis in childhood. Chapters 18 and
2 0 provide additional information regarding theories related to the
development of schizophrenia and bipolar disorder.
Anxiety
Disorders
Children and teens experience anxiety in their lives, just as adults do. The
most common diagnoses include separation anxiety disorder, social phobia,
school phobia, panic disorder in adolescents, and generalized anxiety
disorder. Precipitating factors may include stressful life events such as
starting school, moving, or the loss of a parent. However, a specific stressor
need not be the precursor to the development of an anxiety disorder.
BOX
28.1
Possible
Causes
of
Psychosis
in
Childhood
Metabolic and
Infectious Causes
Adrenal
cortical
Neurologic
Causes
Head
hypofunction
Thyroid and
parathyroid
disease
Porphyria
Endocrinopathies
Wilson's disease
Encephalitis,
meningitis, AIDS
trauma
Multiple
sclerosis
Seizure disorder
Brain tumor
Congenital
malformations
Huntington's
disease
Drug-Induced
Prescription
Causes
drugs,
stimulants,
corticosteroids,
anticholinergics
Drug interactions
Nonprescription
drugs,
cocaine,
phencyclidine
(PCP),
hallucinogens,
solvents
Heavy metals
Depression
Psychosocial
Risk
Factors
Children
in
Families
With
Conflict
or
Divorce
Children
Who
Experience
Poverty
Children who live in poverty are generally denied access to health care, child
care, nutrition, adequate housing, and school and play environments. Social
isolation occurs. Family functioning is compromised because parents in
poverty live under chronic stress, which exposes children to other risk factor
(eg, crime or illicit drug use or abuse) for psychiatricmental health
disorders.
Children
of
Minority
Ethnic
Status
Children aged 18 years and younger from culturally diverse groups were
expected to constitute approximately one third of the U.S. and Canadian
populations. These children live in families in which there is racial, ethnic,
and/or religious diversity. Statistics indicate that nearly 50% of African
American children and more than 40% of young Hispanic children live in
poverty. These children experience adverse effects related to their ethnicity
because of poverty and racism. Learning
P.462
disabilities, deteriorating grades, and lack of developmental assets such as
self-esteem and coping skills often place these children at risk (Andrews &
Boyle, 2003; Li & Bennett, 1994).
Children
Who
Are
Abused
Clinicians who routinely provided care for children saw an average of four to
six victims of abuse and neglect each year (USDHHS, 1999). It is estimated
that more than 2.4 million cases of suspected child abuse and neglect are
reported yearly to state child protective agencies in the United States.
Estimates of abuse continue to rise yearly.
Child abuse can occur in the home, where the abusers are parents or parent
substitutes; in institutional settings, such as daycare centers, child-care
agencies, schools, welfare departments, correctional settings, and residentia
centers; and in society, which allows children to live in poverty or be denied
the basic necessities of life. (Chapter 31 discusses child abuse in more
detail.)
Children of
Parents
Substance-Abusing
and
Mentally
Ill
The terms crack babies and fetal alcohol syndrome are used to describe the
effects of maternal crack addiction and alcoholism on children. Children
exposed to substance abuse in utero or to substances at any early age may
experience altered physical development, decreased intellectual ability,
behavior or conduct disorders, substance abuse, depression, suicide, and
criminality
Children
risk for
disorder
parents
(Johnson,
1997).
and separation from the ill parent who is unable to function as a positive rol
model.
Children
of
Teenaged
Parents
sexual act may occur while the teenager is under the influence of alcohol or
other substances, placing the teenager and infant at risk for a sexually
transmitted disease or acquired immunodeficiency syndrome (AIDS). Infants
born to teenage mothers are likely to be premature and to present with
health problems. The parenting skills of teenagers to deal with stressors of
family life are generally lacking. As a result, the child is at risk for
developmental disorders, behavior or conduct disorders, and emotional
problems.
Children
With
Chronic
Illness
or
Disability
Environmental
Risk
Factors
Two environmental factors that place children at risk for the development of
psychiatricmental health disorders include public schools and the
community, also referred to as neighborhood
or the inner city.
Public
Schools
P.463
services of early identification and timely intervention. When mental health
services are provided within the school system, accessibility and efficiency o
Integration of the intellectually able and less able children provides for a
well-balanced classroom, encouraging normal growth and development.
Acknowledgment and praise by teachers promotes the development of a
positive
self-concept.
Encouragement of participation in running the school fosters
responsibility.
Moderate emphasis on academic achievement permits the child to
participate in a variety of activities and to develop a well-rounded
personality.
Good role-modeling by teachers promotes positive behavior in children.
A comfortable, pleasant, and attractive environment is conducive to the
development of mentally healthy persons.
Neighborhoods
Clinical Symptoms
Characteristics
and
Diagnostic
retardation
disorders
developmental
Attention-deficit
and
disorders
disruptive
behavior
disorders
disorders
Elimination
disorders
chapters.
Many texts present an excellent summary of psychological development,
focusing on the developmental stage, motor and physical development,
Mental
Retardation
The past 2 decades have seen enormous changes in services for children wit
learning and developmental difficulties such as mental retardation, who are
referred to by the general public as mentally or developmentally
challenged.
Although onset occurs before the age of 18 years, the
incidence is difficult to calculate because mental retardation sometimes goes
unrecognized until middle childhood. Its prevalence rate has been estimated
at approximately 1% of the population, with the highest incidence in schoolage children peaking at ages 10 to 14. It occurs about 1 times more
frequently among men than among women. The trend toward
deinstitutionalization has made family and community support a central issu
(Sadock & Sadock, 2003).
Mental retardation is described in the DSM-IV-TR as the presence of
subaverage general intellectual functioning (an IQ of approximately 70 or
below) associated with or resulting in impairments in adaptive behavior.
P.464
Table 28-2 lists the subtypes and associated severity of mental retardation.
Pervasive
Developmental
Disorders
Autistic
Disorder
SUBTYPE
IQ
DEFICITS
COMMENTS
LEVEL
Mild
50 to
70
None in early
childhood
Difficulty
adapting to
school
Sixth-grade level
by late teens
May need
assistance when
experiencing
social or
economic stress
grade
level
Moderate
35 to
55
Poor awareness
of needs of
others
Usually no
progression
beyond secondgrade level
Need moderate
supervision due
to self-care
deficit
Require
supervision and
guidance under
mild social or
economic stress
Severe
20 to
40
Poor motor
development and
minimal speech
Unable to learn
academic skills
but may learn to
3% to 4% of all persons
with mental retardation
May learn to perform
simple work tasks
talk and be
trained in
elementary
hygiene skills or
activities of daily
living
Require complete
supervision in a
controlled
environment
Profound
Below
20 or
25
Minimal capacity
for sensorimotor
functioning
Require total
nursing care and
highly structured
environment with
supervision due
to self-care
deficit
1% to 2% of all persons
with mental retardation
May learn some productive
skills Custodial
P.465
CLINICAL
The
Client
EXAMPLE
With
28.1
Severe
Mental
Retardation
Autism is four to five times more likely to affect males than females.
However, girls with autistic disorder are more likely to have more severe
mental retardation. Autistic disorder knows no racial, ethnic, or social
boundaries. It is incurable and is considered a life-long disability (Johnson &
Dorman, 1998; Sadock & Sadock, 2003).
distractibility,
poor
concentration,
sudden
unprovoked
anger
or
Intellectual functioning varies, because children who are autistic may functio
at a normal, high, or retarded level. Approximately 50% of autistic children
have an IQ below 50 (APA, 2000). Memory may be exceptional, as observed
in the behavior of an autistic child who plays several pieces of complicated
classical music on the piano. See Clinical Example 28-2 .
Asperger's
Disorder
Asperger's disorder, incorporated into the DSM-IV in 1994, has been widely
recognized as part of the mild end of the autistic spectrum. More commonly
seen in boys, the typical child with this syndrome lives in the real world on
his or her terms, has normal or higher intelligence, exhibits pedantic speech
(overemphasis on detail when speaking) by age 5 years, is clumsy, has poor
P.466
handwriting, and exhibits autistic-type behavior such as hand flapping or
pacing when excited or upset.
CLINICAL
The
Client
EXAMPLE
With
28.2
Autistic
Disorder
TJ, age 16, was diagnosed with autistic disorder at age 2. He lives at home
with his parents and attends a school for developmentally disabled children.
His ability to communicate verbally is restricted to making guttural sounds a
times. TJ requires constant supervision because of behavior such as head
banging and biting himself. Custodial care is also necessary to feed and toile
TJ. He has occasional outbursts in which he hits others and attempts to bite
them. TJ responds to music, which seems to have a soothing effect on him
and he will stand on the basketball court for hours shooting baskets.
apparent until preschool or school age when social deficits become apparent
Certain psychiatric disorders occur with unusual frequency in children with
Asperger's disorder, including bipolar disorder, ADHD,
obsessivecompulsive disorder, and Tourette's syndrome (Reed, 2001;
Sherman, 2000).
Attention-Deficit
Disorders
and
Disruptive
Behavior
Attention-Deficit
Hyperactivity
Disorder
Example
Diagnostic
28-3 .
Clinical
Symptoms
tantrums
Obstinacy
Inability
to
tolerate
frustration
Deficit in judgment
Poor
self-image
Aggressiveness
Diagnostic
Characteristics
Inattention
Failure to complete a task, pay attention, or listen
Distractibility
Inability
to
concentrate
Disruptive
Behavior
Disorders
CLINICAL
The Client
Disorder
EXAMPLE
With
28.3
Attention-Deficit,
Hyperactivity
nurses. When BS first entered the room, he jumped up and down several
times, giggled nervously, and then said I'm sorry.
The psychologist
asked BS to sit still as he attempted to time the child's ability to remain
immobile for a period of time.
parentchild
interpersonal
relationship
rejection
children
during
institutional
living
Symptoms may develop first within the family unit when the child attempts t
cope with anxiety or resolve an inner conflict. Involvement in adolescent
gangs also may precipitate the onset of antisocial behavior. In either case,
interpersonal relationships within the family are usually unstable or poor. Se
the accompanying Clinical Symptoms and Diagnostic Characteristics box.
Symptoms
destruction
Deceitfulness
and
theft
Characteristics
Tic
Disorders
Tics are divided into two types: motor tics, involving the rapid movement of
muscle; and vocal tics, which can range from simple throat clearing to more
complex vocalizations involving words or phrases. Tics are relatively commo
in childhood (with onset of motor tics by the age of 7 years and vocal tics by
the age of 11 years), with 5% to 24% of school-age children reporting past
or present tics. Usually, tics are mild and last less than 1 year, generally
referred to as transient tic disorder. Chronic tic disorder refers to the
presence of either motor tics or vocal tics, but not both. The tics occur many
times a day, nearly every day for more than 1 year. Some individuals with ti
disorders can suppress the tics for minutes or hours, but young children
either are not cognizant of their tics or experience their tics as
insuppressible. The frequency of involuntary movement or noise may be
reduced during sleep, relaxation, or absorption in an activity. This disorder
occurs before age 18 years (APA, 2000; Sadock & Sadock, 2003).
Tourette's
syndrome , or Gilles de la Tourette's syndrome, is described as
combination of motor tics and involuntary vocal and verbal utterances that
often are obscene (coprolalia). Repeating one's own sounds or words
(palilalia); repeating the last-heard sound, word, or phrase (echolalia); and
imitating someone else's movements (echokinesis) may be present. The tics
occur many times a day nearly every day, or intermittently for more than 1
year. The onset of this disorder is before age 18 years and it can persist for
lifetime. Approximately 50% of clients with Tourette's syndrome also have
obsessions and compulsions (obsessivecompulsive disorder) (APA, 2000).
Elimination
Disorders
A child must experience encopresis at least once a month for 3 months befo
the diagnosis is given. Age of onset is at least 4 years or the equivalent
developmental level. In the absence of a physical disorder, the main
causative factor is said to be a dysfunctional relationship between the child
and parents, usually the mother. The child may be poorly cared for, under
stress, immature, experiencing increased anxiety or regression, or mentally
retarded (APA, 2000).
Other
Disorders
Separation
Anxiety
Disorder
Separation anxiety disorder may develop after some life stressor, such as th
terrorist attack on the World Trade Center and Pentagon on September 11,
2001. Onset may be as early as preschool age and may occur at any time at
any time before age 18 years. There may be periods of exacerbation and
remission.
P.469
Separation anxiety disorder is characterized by excessive anxiety that is
severe and persistent when the child is separated from the parent (usually
the mother), a significant other, the home, or familiar surroundings. As the
child grows older, he or she may refuse to travel independently from home,
spend the night at a friend's house, attend camp, or go to school (school
phobia). Psychophysiologic symptoms, such as headache, nausea, vomiting,
and stomachache, are seen frequently when the child anticipates separation
or when it actually occurs. The child may show a reluctance or refusal to go
to sleep at night or stay alone in the home, possibly withdrawing socially. Th
child may become housebound or incapacitated in the severe form of
separation anxiety disorder, due to the presence of morbid fears of illness,
injury, danger, or death. Before a diagnosis is made, the symptoms must
have been present for at least 4 weeks. See Clinical Example 28-4 . See
Chapters 21 and 2 2 for additional information on anxiety.
Mood
Disorders
The idea that children can develop conditions that are the same as the
depressive disorders of adults has been controversial. However, children and
adolescents have exhibited clinical symptoms of dysthymic disorder, major
depressive disorder, and bipolar disorder. The use of symptom-oriented,
personal interviews with children has led to widespread recognition that
CLINICAL
The
EXAMPLE
Client
With
28.4
Separation
Anxiety
Disorder
vary
P.470
based on age. See the accompanying Clinical Symptoms and Diagnostic
Characteristics
box.
SUPPORTING
EVIDENCE
FOR
PRACTICE
28.1
The Relationship
Lifestyle Choices
Between Self-esteem
by Adolescents
and
Over 33% did not have a father in the home and 12% received food stamps.
The average self-esteem score among the subjects was 3.0 (slightly above
average) on a 4.0 scale. African American students scored higher than white
students. Although the overall score did not differ between boys and girls,
girls scored higher in the areas of acceptance, popularity, and self-worth.
Boys showed a higher sense of victimization and manipulation.
SUPPORT FOR PRACTICE : Psychiatricmental health nurses who work
with adolescents should consider racial and gender differences when
exploring adolescent self-esteem. Positive self-esteem influences lifestyle
choices and helps promote participation in various activities, whereas low
self-esteem can impair school performance and lead to negative behavior
including self-destructive acts.
Footnote
Source: Hendricks, C. S., Tavakoli, A., Hendricks, D. L., et al. (2001). Selfesteem matters: Racial and gender differences among rural southern
adolescents.
depression.
self-esteem
behavior
between
apathy
and
talkativeness
to
criticism
self-esteem
Loss of confidence
Feelings of helplessness or hopelessness
Intense
ambivalence
between
dependence
and
independence
and
agitation
disturbances
Characteristics
Adjustment
Disorders
or situation and is not the result of or part of a mental disorder. The reactio
usually occurs within 3 months after the onset of the stressor, manifests
itself as impaired social or occupational functioning, and is exaggerated
beyond the normal reaction to an identified stressor. Remission of the
reaction usually occurs within 6 months as the stressor diminishes or
disappears.
The DSM-IV-TR lists six subtypes of adjustment disorders based on the
behavioral
manifestations:
With depressed mood
With
anxiety
The specifiers acute (less than 6 months) and chronic (6 months or longer)
are used to indicate the persistence of symptoms. The criteria listed apply to
children, adolescents, and adults.
Self-Awareness
Prompt
The
Nursing
Process
Assessment
BOX
28.2
Summary of a Comprehensive
Children and Adolescents
Reason for Referral
Why and by whom
History of Current Problem
Assessment
of
Evaluation
Developmental
Current
When
Indicated
History
developmental
level
With
relationships,
Cultural
and
Family
and
religious
communication
styles
observances
NOTE
Assessment of a Child
BOX
28.3
Clinical
Assessment
Tools
for
Children
and
Adolescents
Mental
Status
Behavior
Gilliam Autism Rating Scale (GARS): Assesses ages 3 through 22. Focuses o
stereotyped behaviors, communication, social interaction, and developmenta
disturbances.
Attention
Estimates
severity
of
problem.
Span
Behaviors
Reynolds Adolescent Depression Scale (RADS): For ages 1218 years, this
30-item scale rates severity of current depressive symptoms.
Suicide
Teacher Report Form (TRF): For school-age children, this tool assesses socia
competencies and childhood problems.
HEADSS
Attempt to explore all of the possibilities that could explain a child's behavio
to determine if any additional problems such as learning disabilities, conduct
disorders, or depression may be present. Exploration also helps to provide
information about the family structure and classroom situation and to
determine the child's thinking ability and academic skills.
Assessment, although challenging, can be completed. Additional challenges
are presented when the child is suspected of having an autistic disorder or
ADHD.
Assessment
of
Child
With
Autistic
Disorder
observation
and
P.473
through parent consultation. Functional assessment and play-based
assessment combined with parent interviews may help determine the
diagnosis of an autistic disorder (Mercer, 2002).
Mercer,
2002).
Assessment
of
an
Adolescent
Transcultural
Considerations
Nursing
Diagnoses
Nursing diagnoses for children and adolescents are based on the client's
problems, strengths, and coping abilities; adaptiveness of the symptoms; an
inferences about the etiology of the specific disorder. Developing nursing
diagnoses for a child with a psychiatricmental health disorder often is
difficult because:
Children can be inconsistent and unpredictable in behavior
The relationship and degree of comfort with the examiner affects the
results of data collected
Children
are
constantly
developing
Examples
Disorders
of
of
Adolescence
ADHD
Disturbed Sleep Pattern related to excessive hyperactivity secondary to
ADHD
Interrupted Family Processes related to disruption of family routines due to
Disorder
Disorder
Anxiety
Disorder
nightmares
Footnote
Note. See specific chapters for Nursing Diagnoses related to Depression,
Anxiety, and Psychosis.
Outcome
Identification
Planning
Interventions
Accept the client but discuss any undesirable behavior. Ignoring behavio
such as tics also may be acceptable. Each behavior needs to be evaluate
to decide the appropriate approach.
Be a good role model.
Be aware of body language and nonverbal communication. Children and
adolescents are quite observant of what adults say and how they
Typically, adults are viewed as role models for children and adolescents. The
following rules to live by for adult role models were written by boys in a
reform school for delinquent behavior. Such suggestions can also apply to
nurses who work with children and adolescents in the psychiatric setting:
P.475
Do not lose control in stressful situations because children are great
imitators of parental behavior.
Do not use alcohol or pills as a crutch. Your behavior tells children that i
is okay to do the same.
exploring the client's feelings about being touched (eg, a battered or abused
child would probably withdraw and resist touch).
Activities are planned that are appropriate for the client's developmental
level and age. This activity planning must consider the client's energy level
and need to calm down after an activity.
Implementation
Interventions
for
Mental
Retardation
Assistance
in
Meeting
Basic
Needs
Client
and
Family
Education
Interventions
Disorder
for
Attention-Deficit
Hyperactivity
Assistance
in
Meeting
Basic
Needs
problems are common among children with ADHD (Efron & Pearl, 2003).
Working with the family or teachers also is important to plan a firm,
consistent environment in which limits and standards are set. Behavior
Some children or adolescents with ADHD exhibit anxiety, depression, selfesteem problems, and other emotional difficulties. Therefore, psychotherapy
may be provided by the psychiatricmental health nurse practitioner.
Family therapy also may be helpful to deal with sibling concerns or other
family problems such as divorce or the loss of a loved one (Sadock & Sadock
2003).
Client
and
Family
Education
Medication therapy remains one of the most successful treatments for the
client with ADHD. The child or adolescent, family, and school personnel
(when necessary) are taught about the various types of medication used.
Psychostimulants stimulate the areas of the brain that control attention,
impulses, and self-regulation of behavior. Other medications may be given t
stabilize clinical symptoms of comorbid disorders such as depression, tic
disorders, psychosis, anxiety, and obsessivecompulsive traits. Drug
Summary Table 28-1 highlights selected drugs used for childhood and
adolescent disorders. The parents and teachers are then asked to complete a
form to evaluate the client's response to medication. These observations
enable the nurse to determine which medication and dose are most
efficacious.
Interventions
for
and
Disorder
Conduct
Oppositional
Defiant
Disorder
Both ODD and conduct disorder require interventions that address overt and
covert behaviors. Multimodality treatment programs using family and
community resources are considered to be the most successful forms of
intervention (Sadock & Sadock, 2003).
Providing nursing interventions for a client with ODD can be quite challengin
because the client may have a chronologic age of 10 years, maturational age
as that of a teenager, and frustration tolerance of a 2-year-old (Imperio,
2001). Inpatient treatment is used if the client is unmanageable at home or
has been placed in a treatment center by a judge's order of detention (eg,
juvenile detention center or residential treatment center).
The primary treatment is family intervention focusing on assessment of
Providing interventions for clients with the diagnosis of conduct disorder can
also be quite challenging. The following nursing interventions incorporate th
suggestions of boys with the diagnosis of conduct disorder and living in a
reform school:
Establish trust by being honest.
Maintain control by setting limits for manipulative, acting-out behavior.
Be
consistent
with
limit-setting.
whichever
is
appropriate.
Assistance
in
Meeting
Basic
Needs
adolescent develop internal limits, problem-solving skills, and selfresponsibility for acts of antisocial behavior, which may include physical
violence, theft, fire-setting, assault, or callous or manipulative behavior. The
client may have to be removed from home to benefit from a consistent
therapeutic
environment.
P.477
DRUG
for
SUMMARY
Childhood
GENERIC
(TRADE)
NAME
TABLETABLE
and
Adolescent
DAILY DOSAGE
RANGE
amphetamine
(Adderal)
560 mg
pemoline
(Cylert)
18.75112.5
mg
Drug
Class:
Antidepressants
bupropion
(Wellbutrin)
150300
venlafaxine
(Effexor)
25150
mg
mg
Drug
Class:
olanzepine
(Zyprexa)
Antipsychotics
2.510
mg
risperdione
(Risperdal)
0.54 mg
ziprasidone
(Geodon)
Note:
20160
mg
reuptake inhibitor, has recently been approved by the FDA for the
treatment of ADHD in children aged 6 and over, adolescents, and
adults.
Young clients with conduct disorder often have underlying medical problems;
therefore, nursing interventions may include treatment for a medical
condition such as epilepsy or a closed head injury. Because conduct disorder
do not resolve without intervention, appropriate planning and treatment are
essential.
Client
and
Family
Education
Both the client and family require education about the etiology of conduct
disorder or ODD, and should be informed that adequate treatment of the
client's clinical symptoms and any comorbid psychiatric
P.478
disorders such as depression, PTSD, or seizure disorder often make such
disruptive disorders go away. The rationale for the use of any psychoactive
inconsistent and sometimes brutal. Rarely are such children held accountabl
for their actions; parents often surrender to the demands of the child or
adolescent. Children said to have conduct disorder or ODD may just need
help fitting into society through discipline, mentoring, job training, and
coaching in independent living skills (Bates, 1999).
Interventions
for
Autistic
Disorder
Assistance
in
Meeting
Basic
Needs
Behavior
Management
Client
and
Family
Education
The client and family members are educated about the newest and different
forms of educational interventions available in the treatment of autistic
disorder. Occupational therapy is used to develop or improve fine motor or
sensory skills. Physical therapy is provided to improve gross motor skills.
Virtual reality may be used to create a simplified world made up of only wha
the client is taught. For example, two autistic children ages 7 and 9 years
were taught by a word recognition therapist to walk to a stop sign, look for
cars, recognize cars, follow their motion, and cross the street only when the
cars passed. The client may also be enrolled in special-education classes or
extended day services that incorporate behavioral methods in their
curriculums.
Family members are also taught the concepts and skills of behavior
modification. They may also be instructed in the use of facilitated
communication techniques in which a child is taught to pick out letters or
pictures on a computer or letter/picture board to indicate their needs or
express their feelings (Mercer, 2002; Sadock & Sadock, 2003). Family
caregivers are also educated about the benefits of respite services.
Interventions
for
Depression
Unlike adults, children may not have the vocabulary to accurately describe
how they feel. Up to a certain age, they simply do not understand such
complex concepts as self-esteem,
guilt,
or
concentration.
If they do not understand the concepts, they cannot
Assistance
in
Meeting
Basic
Needs
Interventions
for
Anxiety
Assistance
in
Meeting
Basic
Needs
are media reports about threats of terrorism and war. Minor anxieties can
develop into more severe problems (eg, nightmares, insomnia, nocturnal
enuresis, aggression, withdrawal, or separation anxiety) if children are not
encouraged to talk about their worries or fears. Pharmacologic intervention
may be utilized in symptom management. Children should also be given an
opportunity to describe interventions that would make them feel better or
safer (Pearson, 2003; Sadock & Sadock, 2003).
Client
and
Family
Education
Give parents reassurance that anxiety disorders are readily and effectively
treated. Family interventions are critical in the management of phobias or
separation anxiety disorder, especially in children who refuse to socialize or
attend school. Parents are taught how to provide firm encouragement of
school attendance while obtaining available, appropriate mental health
support (Pearson, 2003; Sadock & Sadock, 2003).
Special
Needs
of
Adolescents
Continuum
of
Care
Inpatient
Hospitalization
Day-Treatment
Hospitals
ADOLESCENT
EMOTIONAL
RESPONSES/BEHAVIORS
Fear
NURSING
INTERVENTIONS
Resentment
Embarrassment
Homesickness
Guilt
Manipulative
behavior
Be consistent in expectations
regarding rules and regulations for
all clients.
State the limits and behaviors
expected from the client.
Explore the client's perceptions and
feelings.
Avoid arguing, debating, or
bargaining with the client.
Confront the client, if necessary,
regarding any manipulative ploys.
Avoid a personal relationship.
Hostile,
aggressive
behavior
feelings.
Inform the client that he or she is to
take responsibility for his or her
actions.
Be supportive and provide positive
feedback when the client controls
hostile or aggressive behavior.
Alternative
Families
Individual
Psychotherapy
Avoid discussing symptoms with the child unless the child refers to them
Attempt to understand the child's feelings and point of view.
Individual psychotherapy may focus on specific problems, such as poor selfconcept, feelings of depression, extreme dependency, or the inability to
communicate.
Family
Therapy
(Systems
Therapy)
Group
Therapy
Play
Therapy
Play therapy usually is used with children between the ages of 3 and 12
years. The child is given the opportunity to act out feelings such as anger,
hostility, frustration, and fear. Various toys, puppets, or materials such as
crayons and finger paints may be used. A dollhouse and dolls can be used to
simulate family, sibling, or peer relationships. For example, a young girl may
play with a doll and punish it or refer to it as a bad girl, treating the
doll the way she is treated by her parents. Watching a child at play gives the
caregiver the opportunity to learn about a child's real and imaginary
emotional life.
Behavioral
Therapy
Therapies involving art or music allow the child or adolescent to express her
or himself in these disciplines and can be effective with those who have
difficulty communicating with others. For example, a 7-year-old depressed
child is able to draw a picture of his fear of death after separation from his
father, who is hospitalized for treatment of Hodgkin's disease. He had
overheard family conversations regarding the seriousness of his father's
condition and feared that his father would never return home.
Evaluation
The evaluation of nursing interventions for children and adolescents who are
seen in the clinical setting for the treatment of psychiatricmental
disorders is an ongoing process. Consideration is given to the developmenta
stage of the client and to whether any changes in mood or behavior have
occurred since the initial assessment. The efficacy of prescribed medication
reviewed. Family dynamics are reassessed. Socialization and progress in
school are discussed. See Nursing Plan of Care 28-1: The Depressed
Adolescent Client .
Key
Concepts
Although
studies
regarding
the
development
of
psychiatricmental
DEPRESSED
ADOLESCENT
CLIENT
Nick, a 17-year-old male high school honor student, had qualified for the
state swimming finals in the 100-meter free-style event and as a member of
the 200-meter medley relay team. The weekend before the scheduled finals,
Nick was a passenger in an automobile accident and sustained minor injuries
The driver of the automobile, his best friend, was critically injured. Nick
became despondent, withdrawn, easily angered, and lost interest in his
academics and sports activities. He informed the swimming coach that he
intended to withdraw from the state finals. The coach overheard Nick tell a
peer that if his friend died, life would not be worth living. The coach spoke t
Nick privately and suggested a referral to the school nurse practitioner. Nick
agreed and was seen that same day.
DSM-IV-TR
Rationale
Verbalizing feelings is
difficult for an adolescent but
it is necessary if effective
coping skills are to be
developed.
Rationale
OUTCOME: The client will express his grief without verbalizing selfblame.
Planning/Implementation
Rationale
properly.
P.483
Although symptoms of ADHD are typically present before age 3 and affec
approximately 3% to 7% of prepubertal elementary school children,
diagnosis is usually not made until academic and social functioning are
impaired.
Children with disruptive behavior disorders (eg, ODD and conduct
disorders) are impaired by frequent, severe disruptive behavior.
Tic disorders, manifested by involuntary movements or noise, are
relatively common in childhood and last less than 1 year.
Although the symptoms differ and may not be readily recognizable,
children and adolescents experience anxiety disorders, mood disorders,
and adjustment disorders similar to those experienced by adults.
For additional study materials, please refer to the Student Resource CD-ROM
located in the back of this textbook.
P.484
P.485
P.486
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
would
A friend comes to you for advice. Her 5-year-old son has been wetting
the bed every night for the past several months. She is at her wits'
end
and says she can't understand why he keeps doing
thisafter all, he's been toilet trained for 2 years.
Identify some
common causes for this type of behavior regression. What questions
REFLECTION
Reflect on the chapter opening quote. What does the author imply in the fina
statement For behind the parent stood the school and behind the
teacher, the home ?
MULTIPLE
CHOICE
QUESTIONS
Determining
educational
experiences
Questioning
sexual
experiences
Answer
Depression is a major risk factor for suicide, the third leading cause of death
in the adolescent population. Therefore, the nurse needs to question the
client directly about any suicidal thoughts. Questions about educational
b. Maintenance of safety
c.
Medication
evaluation
d. Stabilization of mood
View
Answer
2. B
An adolescent with a conduct disorder demonstrates disruptive behavior
Answer
Children who live with mentally ill parents are at risk for parental abuse and
a.
Behavioral
techniques
b. Cognitive therapy
c. Play therapy
d.
View
4. C
Recreational
activities
Answer
Play therapy is often used with younger children because they have a limited
ability to express themselves verbally. In this therapy, play materials are
provided for the child to act out feelings and behaviors. Behavioral
techniques, cognitive therapy, and recreational activities would be
inappropriate for use with a younger child because of his or her stage of
growth and development.
5. When assessing a child with a history of Tourette's syndrome,
which of the following would the nurse expect to find?
a.
Aggressive
behaviors
b. Aversion to touch
c. Motor or vocal tics
d. Poor educational achievement
View
5. C
Answer
Internet
Resources
Disorders:
http://www.adaa.org/AnxietyDisorderInfor/Children
&
Family
Gilliam Autism
InfoID=a9220
WebGuide:
Rating
No3.pdf
http://www.cfw.tufts.edu
Scale:
http://www.agsnet.com/group.asp?nGroup
Selected
References
108 , 1033.
Diagnostic
and
statistical
in
nursing
child
Adaptation
for
Suggested
Readings
for
practitioners'
prescribing
reference .
29.
Pfeffer, C. R. (2000). Helping children cope with death. Psychiatric
1 7 (9), 4547.
Times,
Chapter
Suicidal
29
Clients
1996
Learning
Objectives
clues.
clients.
Key
Terms
Alexithymia
Altruistic
Anomic
Egoistic
suicide
suicide
suicide
Euthanasia
Parasuicide
Physician-assisted
suicide
Postvention
Primary
prevention
Psychological
Secondary
autopsy
prevention
(PAS)
Tertiary
prevention
Trichotillomania
Statistics indicate that more individuals die from suicide than from homicide
In the year 2000, suicides accounted for 29,350 deaths in America, occurrin
1.7 times more frequently than homicides. Overall, suicide is the eleventh
leading cause of death for all Americans, and is ranked as the third leading
cause of death among young people in the age groups of 10 to 14 years, 15
to19 years, and 20 to 24 years. Moreover, males are four times more likely
to die from suicide than females. However, females are more
P.489
likely to attempt suicide than males (National Center for Health Statistics
[NCHS], 2003; National Center for Injury Prevention and Control [NCIPC],
2003).
This chapter addresses the etiology of suicide and identifies those individual
or groups at risk for attempting suicide. It focuses on the role of the nurse i
the treatment and prevention of suicide.
Etiology
The need to be loved and accepted, along with a desperate wish to
communicate feelings of loneliness, alienation, worthlessness, helplessness,
and hopelessness, often results in intense feelings of anxiety, depression,
and anger or hostility directed toward the self. If no one is available to talk
to or listen to such feelings of insecurity or inadequacy, a suicide attempt
may occur in an effort to seek help or end an emotional conflict. Various
theories have been proposed to explain the possible factors that influence
suicidal behavior. A summary of the major ideas of these theories follows.
Genetic
and
Biologic
Theories
Genetic
Markers
Relationship
of
Neurochemical
Binding
Sites
Twin
and
Adoption
Studies
Studies also have focused on suicidal behavior among twins and adoptees
(Sadock & Sadock, 2003). According to the studies of twins, suicide among
identical twins was significantly higher (11.3%) than suicide among fraterna
twins (1.8%). A DanishAmerican adoption study revealed that adoptee
suicide victims experiencing a situational crisis or impulsive suicide attempt
or both had more biologic relatives who had committed suicide than
members of the control group had.
Sociologic
Theories
Psychological
Theories
Both Sigmund Freud and Karl Menninger believed suicide was a result of
anger turned inward. According to Freud, suicide represented aggression
against an introjected love object. He also doubted that suicide would occur
without an earlier repressed desire to kill someone else. Menninger, building
on Freud's theory, believed that suicide was an inverted homicide act
because of anger toward another person. He also believed that an individual
has a self-directed death instinct composed of the wish to kill, the wish to be
killed, and the wish to die (Sadock & Sadock, 2003).
Theory
of
Parasuicidal
Behavior
Other
Psychological
Factors
A cry for help: Some people attempt suicide hoping to draw attention to
themselves to receive help. For example, a 49-year-old woman in
Individuals
at
Risk
for
Self-Destructive
Behavior
One out of every ten persons entertains recurrent or persistent thoughts of
suicide. Suicide attempts generally are reported as accidents to spare
families the stigmatizing impact of suicide and to facilitate insurance
coverage that otherwise would not occur in the event of suicide.
SUPPORTING
EVIDENCE
FOR
PRACTICE
29.1
Parental
PROBLEM
Suicidal
UNDER
Ideation
Footnote
Source: Murphy, S. A., Tapper, V. J., Johnson, L. C., & Lohan, J. (2003).
Suicide ideation among parents bereaved by the violent deaths of their
children. Issues in Mental Health Nursing, 24 , 525.
Clients
With
Psychiatric
Disorder
At some point in their career, clinicians face a 50% risk that a client will
commit suicide. Psychiatric disorders, such as major depression, bipolar
disorder, schizophrenia, schizoaffective disorder, personality disorders,
eating disorders, and alcoholism or drug abuse are considered among the
most serious of risk factors (Ayd & Palma, 1999; Lott, 2000). For example,
male clients who are depressed successfully commit suicide approximately
five times more often than females who are depressed. Approximately 4,000
clients with the diagnosis of schizophrenia commit suicide per year;
approximately 5% of clients diagnosed with antisocial personality disorder
commit suicide per year; and approximately 10% to 15% of individuals who
abuse alcohol commit suicide per year. Although 20% of clients with the
diagnosis of anxiety attempt suicide, they are usually unsuccessful (Sadock
Sadock, 2003).
Clients
With
Alexithymia
Clients
With
Medical
Illnesses
The presence of a neurologic disorder raises the overall suicide risk. Suicide
is more frequent at particular moments of a disease's natural course, such a
the period following diagnosis and the period after hospitalization. For
example, suicides have been reported to account for up to 13 times the
expected death rate in clients with Huntington's disease. Epilepsy raises the
expected death rate due to suicide fivefold in men and twofold in women.
Suicide after traumatic brain injury is two to three times higher than in the
general population. In clients with spinal cord injury, the period immediately
after the injury is one of particular vulnerability. Approximately 83% of the
suicides occur within 6 months of the injury and 90% occur within 5 years
(Sherman,
2000).
Euthanasia
and
Physician-Assisted
Suicide
(PAS)
Euthanasia , defined as a health care provider's deliberate act to cause a
client's death, and physician-assisted suicide (PAS) , defined as the
imparting of information or means to enable suicide to occur, have become
controversial issues in the health care industry (Sadock & Sadock, 2003).
The increase in human longevity, development of modern medical
In 1997, voters in the state of Oregon approved a Death With Dignity Act.
This act applies to adults diagnosed with a terminal illness that is expected
to cause death within 6 months. It requires a client to make two oral
requests and one written request to a physician and to wait at least 15 days
after the initial oral request before receiving a prescription for lethal drugs.
A second physician's opinion is required to verify the initial diagnosis; that
the client is capable of and did make an informed decision; and that the
decision was made voluntarily. Factors affecting client requests in Oregon fo
assistance with suicide included pain, fatigue, dyspnea, loss of
independence, and poor quality of life (Kirk, 1998; Libow, 2000).
Regardless of the situation, nurses are ethically bound to protect clients who
are at risk for self-harm, with the assumption that nurses will do nothing to
harm or shorten the lives of clients in their care. The question, though, is
raised: Is it ethical to participate in physician-assisted suicide?
Caring for clients who make such
personal moral beliefs. Although a
participate, the nurse may not be
become an unknowing participant
Adolescent
Clients
According to the latest statistics for adolescents, the rate of suicide has
quadrupled since 1950 from 2.5 suicides to
P.493
11.2 suicides per 100,000 adolescents in the year 2000 (NCHS, 2003).
High-Risk
Population
Groups
officers and air-traffic controllers who work long hours and often experience
disruptions of family and social life may develop a major depressive disorder
or substance-related disorder due to ineffective coping. Thus, suicide may be
a means for them to escape feelings of hopelessness or helplessness.
Several studies have indicated that occupations with the highest risk of
suicide include anesthesiologists, psychiatrists, and dentists (Crisis
Intervention Network, 2002).
Self-Awareness
Prompt
What are your personal thoughts about the act of suicide? What factors have
contributed to your feelings and beliefs? Do you feel competent to provide
care for a person who attempts suicide? Why or why not?
The
Nursing
Process
Assessment
Suicide is considered more preventable than any other cause of death
(Badger, 1995). This statement is based on the assumption that all suicidal
persons are ambivalent about life and therefore are never 100% suicidal.
The decision to provide care for a suicidal client requires the use of excellen
assessment skills and crisis intervention techniques (see Chapter 12 for
information
about
crisis
intervention).
Suicidal
Suicidal
life
Assessment
of
Suicide
Risk
P.494
not a single event. Assessing individual suicide risk factors generally
requires in-depth knowledge of a client. Also, obtaining information from
other sources (eg, family, significant other, family physician, teacher, or
therapist if the client is being seen as an outpatient client) may be
necessary before the degree of suicidal risk can be determined (Lott, 2000).
Table 29-1 presents some key behaviors or symptoms and the degree of
suicide risk associated with each.
When assessing a client's suicide risk, keep in mind that approximately 80%
of all potential suicide victims give some clue before exhibiting selfdestructive behavior. Regard all behaviors and comments about suicide
seriously. Clues may provide an indication of a client's suicidal intent. Be
alert when the client:
thought
Asks suspicious questions such as, How often do the night personnel
make rounds? How many of these pills would it take to kill a
person?
How high is this window from the ground?
How
long does it take to bleed to death? and so forth
Fears being unable to sleep and fears the night
Is depressed and cries frequently
Keeps away from others due to self-imposed isolation, especially in
secluded areas or behind locked doors
Is tense and worried and has a hopeless, helpless attitude
INTENSITY OF RISK
BEHAVIOR OR
SYMPTOM
Low
Moderate
High
Anxiety
Mild
Moderate
High, or panic
state
Depression
Mild
Moderate
Severe
Isolation,
withdrawal
Some
feelings of
isolation, no
withdrawal
Some
feelings of
helplessness,
hoplessness,
and
withdrawal
Hopeless,
helpless,
withdrawn, and
selfdeprecating
Daily
functioning
Fairly good
in most
activities
Moderately
good in some
activities
Resources
Several
Some
Few or none
Coping
Generally
Some that
Predominantly
strategies,
devices being
used
constructive
are
constructive
destructive
Significant
others
Several who
are
available
Few or only
one available
Psychiatric
help in past
None, or
positive
Yes, and
moderately
Negative view of
help received
attitude
toward
satisfied
Lifestyle
Stable
Moderately
stable
Alcohol or drug
Infrequently
Frequently
use
to excess
excess
Previous
suicide
attempts
None, or of
low lethality
One or more,
of moderate
lethality
Multiple attempts
of high lethality
Disorientation,
disorganization
None
Some
Marked
Hostility
Little or
none
Some
Marked
Vague,
fleeting
thoughts
but no plan
Frequent
thoughts,
occasional
ideas about
a plan
Frequent or
constant thought
with a specific
plan
Suicide
plan
Unstable
to
Continual
abuse
Assessment
After
Suicide
Attempt
the most appropriate setting for the client's care. For example, a client who
attempted suicide by shooting himself in the head may need to be monitored
closely in the critical care unit. A female client who attempted suicide by
overdosing on sleeping pills refuses inpatient hospitalization after being
treated in the emergency department. Her husband, who is present during
the assessment, informs the nurse that his mother-in-law lives with them
and that she is willing to stay with his wife during the day until he returns
home from work. The nurse assesses the client's home environment,
relationship with her husband and mother-in-law, and motivation to receive
treatment on an outpatient basis. The nurse also discusses a proposed plan
of care with the husband and client, with the understanding that a
reassessment may be conducted at the discretion of the nurse.
Assessment
Tools
Hopelessness Scale (Beck, Steer, Beck, & Newman, 1993). This tool is
helpful because hopelessness is considered the best-proven clinical predictor
of eventual suicide other than a previous attempt. Also inquire about the
symptoms of subjective (emotional) intent and objective (purpose of)
suicidal planning to aid in assessing actual suicidal intent. Ask the client
whether fatality is perceived, and how rescuable the client thinks he or she
would be if medical attention were immediately available. Although suicide
attempts ultimately may be carried out impulsively, most are well planned.
BOX
29.1
SAD
PERSONS
Assessment
Scale
Sex: Men commit suicide more frequently than women do; however, women
make more suicide attempts.
Age: Those at greater risk of suicide are younger than 19 and older than 45
Organized plan: The more organized the plan for committing suicide, the
greater the risk.
No spouse: Single, divorced, widowed, or separated individuals are at
greater risk for suicide than those who are married.
Sickness: Individuals who experience a chronic or debilitating illness are at
greater risk.
Transcultural
Considerations
in the Filipino culture. However, the suicide of elderly Eskimos who could no
longer participate as productive members of a tribe was expected (Andrews
& Hanson, 2003).
Culturally sanctioned suicide has been practiced by the Japanese (hara-kiri)
and Hindu widows (suttee). Members of militant groups in the Middle East
(eg, Palestine and Iraq) still practice culturally sanctioned suicide, such as
by attaching explosives to themselves and detonating them when
approaching specific targets. Suicide patterns among Native
P.496
American youths vary widely among tribes, depending on physical
environment, the process of imitation, social environment (ie, group
integration, cohesion, and regulation), poverty, and economic change.
Suicide is the second leading cause of death among Native American
adolescents. Nearly half of emotionally distressed Native American
Nursing
Diagnosis
Outcome
Identification
Examples
Suicide
of
NANDA
Nursing
Diagnoses:
Risk for Injury related to a recent suicide attempt and the verbalization,
Next time I won't fail.
Risk for Suicide related to stated desire to end it all
purchase of a handgun
and recent
Planning
Interventions
Implementation
Establishment
of
Safe
Environment
Suicide
Prevention
Tertiary
prevention is used to reduce residual disability after an illness.
For example, a residential treatment center, halfway house, or rehabilitation
center may be used to treat a recovering alcoholic client who previously
attempted suicide and is recovering from severe depression, but needs the
supervision and support of others to avoid a relapse.
Suicide
Precautions
Bailey and Dreyer (1977) discuss a suicidal intention rating scale (SIRS) tha
provides a guide for managing clients considered to be self-destructive.
Table 29-2 summarizes this rating scale, clinical symptoms, and nursing
interventions for each level.
Suicide
Contract
RATING
SYMPTOMS
INTERVENTIONS
Zero
No evidence of past or
present suicidal
ideation
Implement interventions
nursing plan of care
per
One
plus
Two
plus
Three
plus
Suicidal threat
verbalized
Four
plus
Actively attempted
suicide or hospitalized
to prevent self-
destructive
impulses
Seclusion
and
Restraint
staff to observe the client's behavior more readily. Objects that could prove
to be dangerous to the client are removed by searching the client's clothing,
carry-in items, and body in a dignified and professional manner. The body
search includes checking any part of the body in which harmful objects migh
be stored, such as body orifices and the hair.
Street clothes are removed, and the client is placed in a seclusion gown.
Clothing and bed linens are removed from the room because these items
have been used to attempt suicide by hanging oneself.
Assistance
in
Meeting
Basic
Human
Needs
Clients at risk for suicide often neglect personal care. Therefore, provide
assistance with activities of daily living until the client is able to assume
responsibility for self-care. In addition, assist with meeting the client's
nutritional needs and establishing an adequate
schedule. Medical care is provided as needed.
sleeprestactivity
Medication
Management
Interactive
Therapies
Encourage the client to engage in an activity that is an outlet for tension and
anger. For example, a sport such as volleyball or running, or an activity such
as working with sandpaper or pounding wood, allows the client to express
feelings while also providing him or her with an opportunity to interact with
staff and peers.
Client
and
Family
Education
Commonly, health care providers tend to believe that suicidal clients or their
family members know all about the factors that place an individual at risk fo
Continuum
of
Care
Special
Considerations:
Adolescent
Clients
following:
BOX
29.2
Examples of
Strategies
Family
Intervention
and
Prevention
Obtain permission from client to contact the client's health care provider
in the event of a crisis or an emergency.
Recognize changes in mood or behavior that could indicate a plan for
self-injury (eg, irritability, anger, agitation, withdrawal, or selfdeprecating comments) and notify the client's health care provider.
Anticipate future stressors and assist client to use appropriate coping
skills.
Set limits on repeated discussions about suicide or previous attempts.
Keep a 24-hour emergency hotline phone number readily available.
Encourage the client to continue with outpatient treatment.
Attend a family caregiver support group meeting.
Do not hesitate to notify the police if the client exhibits unmanageable
self-destructive
behavior.
Repeating
risk
assessment
throughout
treatment
therapy
coupled
Working with the teen's school counselors on a weekly basis initially and
then at regularly scheduled, less frequent intervals
Being aware that finances may be an issue; however, risk is the key
consideration
for
Interventions
Attempt
continuing
After
with
treatment
Successful
Suicide
CLINICAL
The
Client
EXAMPLE
Who
29.1
Commits
Suicide
SM, a 35-year-old teacher and father of three children, had been admitted
to the neuropsychiatric unit with the diagnosis of depression. During the
intake interview, SM exhibited symptoms of suicidal ideation because he
made statements such as I'd be better off dead,
My family
would be better off without me, and Yes, I have thought about
killing myself.
SM was placed on strict suicide precautions and
antidepressant medication and began attending therapy sessions on the
unit. Within 3 weeks, the suicidal precautions were lifted, and SM was
granted lawn privileges but was to be supervised by one of the unit's
employees. SM appeared to be improving and was granted a day pass to
visit his family 4 weeks after his admission. At approximately 3:00 pm the
day after SM visited his family, he asked for lawn privileges to play tennis.
Although SM was supervised by a hospital employee, he was able to run
away and leave the facility's grounds. Later that evening, SM's family
notified the facility that he had secured a handgun and committed suicide.
P.500
Psychological
Autopsy
Example
This interaction among the staff, in which the staff reviews the client's
behaviors and suicidal act, is referred to as a psychological
autopsy . It is
a process used to examine what clues, if any, were missed so that staff
members can learn from the evaluation of a particular situation. This proces
also provides staff with an opportunity to self-assess their behavior and
responses and discuss their concerns with peers.
Postvention
for
Bereaved
Survivors
feelings of shock and grief. During the second phase, survivors are given the
opportunity to develop new coping methods to help prevent the developmen
Children who are survivors require special attention because they are quite
vulnerable to the death of a parent, relative, peer, or close family friend.
They may feel that they caused the death by wishing Daddy dead or
telling the person that I hate her. As a result of such feelings,
children may be unable to work through the grieving process, become
preoccupied with the subject of suicide, develop self-destructive behavior,
exhibit signs of depression, or have difficulty working through the
developmental tasks of childhood. The following are helpful as preventive
and postventive measures with children who are survivors:
Allow the child to express feelings.
Assist the child in developing a meaningful relationship with others.
Encourage the development of positive coping skills.
Teach the child assertiveness.
Allow the child to develop ideas and values.
Expose the child to principles on human behavior during the preventive
or postventive process.
Evaluation
Evaluation of the client's progress in attaining expected outcomes is an
ongoing process because the client's mood, affect, and behavior may
If the client is not hospitalized, information is obtained from the client and
family or significant others who have agreed to provide supportive care. The
was cited for failure to yield the right of way. Carol stated that she felt
alienated from her parents because her brother was their favorite child and
they still question her about the details of the accident. She commented tha
she believed her parents wished she had died rather than her brother. Carol
informed the nurse during the assessment that she was tired of being
depressed and was willing to seek help. Her employer had promised her that
her job will be available when she is ready to return to work.
DSM-IV-TR
DIAGNOSIS: Major depressive disorder, severe, without
psychotic features
treatment,
supportive
employer
Rationale
A safe environment
promotes physical safety.
This intervention
encourages the client to
assume responsibility for
and control of her behavior.
Rationale
Encourage
Verbalization of feelings
enables the client to explore
the cause of self-blame and
low self-esteem.
verbalization
of
feelings.
long-term
therapy.
Rationale
P.502
Key
Concepts
minorities,
For additional study materials, please refer to the Student Resource CD-ROM
located in the back of this textbook.
P.503
P.504
Chapter
CRITICAL
Worksheet
THINKING
QUESTIONS
You notice that your 13-year-old neighbor always wears black, refuses to
make eye contact, is often alone, and has a defeated posture. Your
mother and the boy's mother are good friends. You are concerned about
the teen's increasing isolation. Describe several interventions that might
be appropriate in this situation and explain your rationale for selecting
them.
REFLECTION
MULTIPLE
CHOICE
QUESTIONS
Answer
Answer
2. A
Although the client's risk for suicide is ever-present, the greatest risk for
suicide occurs during the recovery period from depression. At this time,
individuals with severe depression experience the energy level to follow
through with self-destructive thoughts.
b. Degree of suicidal intent is not a static quality and may change dayto-day.
c. Following a suicidal gesture, the client will be grateful to be alive.
d. Questions related to the specific details of a suicide plan are not
therapeutic.
View
3. B
Answer
View
4. A
Answer
The priority intervention for a client with suicidal intent is to encourage the
client to verbalize negative feelings. Doing so helps clients to explore the
reasons underlying the suicidal ideation and provides them with support.
Pointing out the positive aspects of living is inappropriate and nontherapeutic. Providing activities to keep the client busy ignores the client's
needs. Telling the client that thoughts of suicide will decrease is false
reassurance.
5. A client has committed suicide while hospitalized on an inpatient
psychiatric unit. The nursing staff and treatment team participate in
a process of reviewing the client's behaviors and the completed
suicide despite all precautions implemented on the unit. The staff is
engaging in which of the following?
a.
Psychological
b.
Postvention
c.
Treatment
autopsy
process
analysis
d. Team discussion
View
5. A
Answer
Interaction with the staff, in which the staff reviews the client's behaviors
and suicidal act, is referred to as a psychological autopsy, a process used to
examine what clues, if any, were missed so that staff members can learn
from the evaluation of a particular situation. This process also provides staff
members with an opportunity to self-assess their behavior and responses
and discuss their concerns with peers. Postvention is a therapeutic program
for bereaved survivors of a suicide. Treatment analysis and team discussion
are general terms related to client care.
Internet
Crisis
Resources
Intervention
Network:
http://www.crisisinterventionnetwork.com/sfs.html
National Center for Health Statistics:
http://www.cdc.gov/nchs/fastats/suicide.htm
National Center for Injury Prevention and Control:
http://www.cdc.gov/ncipc/factsheets/suifacts.htm
Selected
References
Ayd, F. J., Jr., & Palma, J. M. (1999). Suicide: Risk recognition and
prevention. Psychiatric Times, 16 (5), 3641.
Badger, J. M. (1995). Reaching out to the suicidal patient. American
Journal of Nursing, 95 (3).
Bailey, D., & Dreyer, S. (1977). Care of the mentally ill . Philadelphia: F.
A. Davis.
Beck, A. T., Steer, R. A., Beck, J. S., & Newman, C. F. (1993).
Hopelessness, depression, suicidal ideation, and clinical diagnosis of
depression. Suicide and Life-Threatening Behavior , (2).
Boyle, J. S. (2003). Culture, family, and community. In M. M. Andrews &
J. S. Boyle (Eds.), Transcultural concepts in nursing care (4th ed., pp.
315360). Philadelphia: Lippincott Williams & Wilkins.
Buchanan, M. J. (2002). Leaving the root intact. Advance for Nurses, 3
(4), 2122.
Cohen, D. (2000). Caregiver stress increases risk of homicidesuicide.
Geriatric Times, 1 (4), 2627.
Crisis Intervention Network. (2002). Suicide fact sheet . Retrieved
Philadelphia:
Lippincott-Raven.
Times,
17 (7), 7172.
Murphy, S. A., Tapper, V. J., Johnson, L. C., & Lohan, J. (2003). Suicide
ideation among parents bereaved by the violent deaths of their children.
Issues in Mental Health Nursing, 24 , 525.
National Center for Health Statistics. (2003). Fast stats: Suicide .
Retrieved July 1, 2003, from
http://www.cdc.gov/nchs/fastats/suicide.htm
National Center for Injury Prevention and Control. (2003). Suicide in the
United States . Retrieved July 1, 2003, from
http://www.cdc.gov/ncipc/factsheets/suifacts.htm
Robie, D., Edgemon-Hill, E. J., Phelps, B., Schmitz, C., & Laughlin, J. A.
(1999). Suicide prevention protocol. American Journal of Nursing, 99
(12), 5357.
Sadock, B. J., & Sadock, V. A. (2003). Kaplan and Sadock's synopsis of
psychiatry: Behavioral sciences/clinical psychiatry (9th ed.). Philadelphia:
Lippincott Williams & Wilkins.
Schultz, J. M., & Videbeck, S. D. (2002). Lippincott's
manual
of
Suggested
Readings
and
56 (7), 4748.
Management,
29 (10), 3334.
Sherman, C. (2000). Adolescent suicide pacts are rare, but lethal. Clinical
Psychiatry News, 28 (2), 26.
Chapter
30
MENTAL
HEALTH
ASSOCIATION,
2003
Chemical dependency is a serious public health
problem. For people with mental illness,
comorbid chemical dependency can be a
catastrophic life problem.
VACCARO,
Learning
1999
Objectives
diagnosis.
diagnosis.
Articulate the barriers to effective treatment of a client with
a dual diagnosis.
Interpret the five categories that have been developed to
describe the dually diagnosed client.
State why it is difficult to assess a client with a dual
diagnosis.
Summarize the following phases of treatment for clients with
a dual diagnosis: acute stabilization, engagement, prolonged
stabilization, rehabilitation and recovery, and continuum of
care.
Explain why evaluation of a dually diagnosed client's
progress is an ongoing process.
Key
Terms
CAMI
Dual
diagnosis
MICA
MICAA
Persuasion
Self-medication
Vulnerability
hypothesis
model
DSM-IV-TR
DIAGNOSIS
Antisocial
disorder
personality
Schizophrenia
60%
Bipolar
40%
disorder
Major depressive
disorder
30%
Anxiety
30%
disorders
Eating
disorders
25.7%
Phobic
disorders
25%
Etiology
of
Dual
Diagnosis
Vulnerability
Model
The vulnerability
model of dual diagnosis is based on the
assumption that drug use causes a mental disorder. For example,
daily marijuana use doubles the risk for psychosis; daily cocaine
users have a seven times greater risk of a psychotic episode than
nonusers; and dependence on alcohol doubles the risk of
psychosis (Kosta, 2002; Miller, 1994; Miller, Eriksen, & Owley,
1994).
Attempts to identify what determines vulnerability are numerous.
For example, alcoholic personality subtypes have been identified,
and several personality traits have been described. They include
emotional insecurity, anxiety, unsatisfied dependence needs,
narcissism, externalization of blame, and the use of defense
mechanisms such as denial.
Self-Medication
Hypothesis
The self-medication
hypothesis of dual diagnosis is based on
the assumption that individuals with a psychiatric disorder use
drugs to help them feel calmer or to alleviate clinical symptoms
to achieve emotional homeostasis. Self-medication often leads to
physical or psychological dependency on drugs or alcohol,
creating a complex dual diagnosis problem (Kosta, 2002). For
example, clients experiencing positive and negative symptoms of
schizophrenia self-medicate with alcohol or drugs to decrease
anxiety and decrease the intensity of hallucinations. Using
substances does not result in the uncomfortable adverse effects
of neuroleptic drugs, and to some degree is a socially accepted
behavior. Table 30-2 lists seven major psychiatric disorders and
shows how much each one increases an individual's risk for
substance-related
2003).
disorders
(National
Mental
Health
Association,
Clinical
Symptoms
and
Diagnostic
Characteristics
Clients with a dual diagnosis often are dissatisfied with life
circumstances, have inadequate or ineffective support systems,
live in a nontherapeutic home environment, and have a history of
self-medication (National Alliance for the Mentally Ill, 2003;
Zahourek, 1996).
P.508
PSYCHIATRIC
Antisocial
Manic
DISORDERS
personality
disorder
episode
14.5%
Schizophrenia
10.1%
Panic
disorder
4.3%
Major
depressive
episode
4.1%
Obsessivecompulsive
disorder
3.4%
Phobias
2.4%
The frequent use of drugs and alcohol interferes with the action
of any psychiatric medications the client may be taking.
Substance-related disorders often exacerbate clinical symptoms
of an existing disorder or precipitate additional symptoms.
Symptoms commonly seen include irritability, depression,
sedation, hostility, aggression, delusions, hallucinations, poor
impulse control, and suicidal or violent behavior. Lack of selfesteem and social skills contributes to disinterest in activities of
daily living. Clients also have little interest in the future.
Many individuals are at risk for health problems, may have
medical problems including acquired immunodeficiency syndrome
(AIDS) or tuberculosis, are homeless, and are not motivated to
receive treatment. If they do enter treatment, they often fail to
keep scheduled appointments or follow through on referrals.
Relapses and repeated institutionalizations are not uncommon.
Several barriers to effective treatment have been identified.
These are listed in Box 30-1.
The DSM-IV-TR does not have a specific classification or category
for dual diagnosis. The multiaxial system (discussed in Chapter
9) is used to list the clinical diagnosis or diagnoses and the
presence of any comorbid personality disorder.
Four categories have been developed to describe the client with a
dual diagnosis (Krausz, 1996; Sciacca, 2003).
Category 1: The primary diagnosis is a major mental illness
such as schizophrenia with a subsequent secondary diagnosis
of a substance-related disorder such as alcohol dependence.
Category 2: The primary diagnosis is a substance-related
disorder such as cocaine abuse that results in a secondary
mental illness such as organic mood disorder, organic anxiety
disorder, organic delusional disorder, or antisocial behaviors
that decrease or disappear when substance abuse is
discontinued.
Category 3: Mental illness and substance-related disorder
occur simultaneously with no apparent etiologic relationship.
Category 4: Substance-related disorder and mood disorder
occur due to an underlying traumatic experience.
BOX
30.1
Barriers to Effective
Dual
Diagnosis
Treatment
of
illness.
Footnote
Source: Faltz, B. G., & Callahan, P. (2002). Special care
concerns for patients with dual disorders. In M.A. Boyd (Ed),
Psychiatric nursing: Contemporary practice (2nd ed., pp.
874893). Philadelphia: Lippincott Williams & Wilkins.
Self-Awareness
Prompt
The
Nursing
Process
Assessment
Clients with a dual diagnosis are difficult to assess because they
are not a homogenous group. In addition, clients often are poor
historians and are noncompliant during the assessment process.
They may present for assessment on a voluntary basis because
they desire help (eg, the client who utilizes alcohol to cope with
clinical symptoms of depression recognizes the fact that he or
she is dependent on alcohol); they may be adjudicated by the
court system to be evaluated prior to sentencing for a crime (eg,
the client has a personality disorder, is addicted to cocaine, and
Nursing
Diagnoses
Outcome
Identification
Planning
Interventions
Implementation
Clients enter treatment at various stages of their disorders.
Therefore, flexible treatment programs that can meet the
individual needs of each client are considered the most effective.
Box 30-2 summarizes treatment approaches for dually diagnosed
clients.
Different phases of treatment are provided for clients with a dual
diagnosis. These phases (referred to as a disease and
recovery model ) include acute stabilization, engagement,
prolonged stabilization, and rehabilitation and recovery (Minkoff,
2000; Osher and Olfed, 1989).
BOX
30.2
Treatment
Diagnosed
Approaches
Clients
for
Dually
Footnote
Sources: Miller, N. (1994). Prevalence and treatment models for
addiction in psychiatric populations. Psychiatric Annals, 2 4,
39406; Minkoff, K. (1994). Models of addition treatment in
psychiatric population. Psychiatric Annals, 24, 413418;
Zahourek, R.P. (1996). The client with dual diagnosis. In S. Lego
(Ed.), Psychiatric nursing: A comprehensive reference (2nd ed.,
pp. 275284). Philadelphia: Lippincott-Raven.
Youth Action and Policy Association NSW (YAPA). (2003).
Fact sheet: Take action now on dual diagnosis. Retrieved
September 4, 2003, from
http://www.yapa.org.au/facts/DualDiagnosis.pdf
Dual diagnosis info sheet: Concepts and treatment issues.
(2003). Retrieved September 4, 2003, from
http://www.dlcas.com/course5.html
P.511
Acute
Stabilization
symptoms of other serious psychiatric disorders, such as posttraumatic stress disorder or bipolar disorder. In addition, the
medical needs of clients requiring detoxification, such as the
pregnant client who continues to abuse substances, or clients
who have an exacerbated medical disorder or illness that
interferes with outpatient treatment, such as the client with HIV
infection who is addicted to pain medication, are met.
Psychopharmacologic agents may be used depending on the
client's underlying psychiatricmental health disorder. (See
Chapter 15, Psychopharmacology;
Chapter 18, Schizophrenia and
Schizophrenic-Like Disorders; and Chapter 26, SubstanceRelated Disorders for information about medication
management.)
Engagement
Engagement involves four steps: establishing a treatment
relationship with the client; educating the client (referred to as
persuasion) about the illnesses; active treatment when the
nurse provides various interventions to enable the client to
maintain stabilization by complying with treatment; and relapse
prevention in which the nurse helps the client overcome denial
and other resistances to treatment.
Establishing a treatment relationship with a client may require
many contacts by the psychiatricmental health nurse. Clients
often struggle with issues of authority and control and feel
threatened. Education (persuasion) focuses on helping clients
recognize problematic behaviors and symptoms and identifying
methods to activate change. Medication management is stressed
to help clients maintain stability. Medication noncompliance is
associated with increased behavior problems after discharge and
accounts for frequent relapse and rehospitalization. Peer-group
discussions, family education, social-network interventions, and
self-help groups are just a few of the educational interventions
provided.
During active treatment, specific abstinence-related strategies,
such as the identification of specific stressors and development
Prolonged
Stabilization
Rehabilitation
and
Recovery
Evaluation
Key
Concepts
CLINICAL
The
EXAMPLE
Dually
30.1
Diagnosed
Client
hallucinations and
past psychiatric
local community
his recent admission
DSM-IV-TR
Diagnoses
Recommendations
hypothesis.
Chapter
Worksheet
CRITICAL
THINKING
QUESTIONS
REFLECTION
Reflect on the opening chapter quote by Vaccaro. Explain your
interpretation of the phrase catastrophic life problem.
What nursing challenges do you think you would encounter if you
were to develop a nursing plan of care for such a client? Do you
feel adequately prepared to provide care for such a client?
Explain your answer.
MULTIPLE
CHOICE
QUESTIONS
View
1. D
c.
Self-medication
d.
Vulnerability
Answer
model
model
Answer
Answer
Answer
is
established.
Answer
Internet
Resources
Selected
References
abuse:
Suggested
Readings
6162.
Practitioner,
2 2(10),
101104.
4750.
Schmidt, J., & Williams, E. (1999). When all else fails, try
harm reduction. American Journal of Nursing, 99(10),
6770.
Chapter
31
Learning
Objectives
Key
Terms
Abuse
Attempted
Child
rape
abuse
Discipline
Domestic
violence
Emotional
abuse
Emotional
Family
neglect
violence
Incest
Munchausen's syndrome by proxy
Neglect
Rape
Rape-trauma
syndrome
Sexual
abuse
Sexual
coercion
Sexual
harassment
rape
Violence
Workplace
violence
P.517
Much has been written and a great deal of public concern has been expresse
about the physical or sexual abuse of children, women, and the elderly. In
addition, youth and workplace violence have been recognized as serious and
widespread public health problems affecting individuals of all ethnic and
socioeconomic backgrounds. Consider the following stories recently covered
the news media:
University professor accused of child pornography
Child sex abuse epidemic
and an arsenal of
Contrary to public belief, recent research has shown that the vast majority o
people who are abusive or who commit violent acts do not suffer from menta
illness. A certain small subgroup of people, such as clients with neurologic
impairment due to head injury; a disease such as Huntington's chorea; or a
psychotic disorder are at risk of becoming abusive or violent (eg, threatenin
hitting, fighting, or otherwise hurting another person). However, the conditi
likely to increase the risk of violence are the same whether a person has a
mental illness or not (American Psychiatric Association, 2003).
This chapter discusses the etiology of abuse and violence. General topics
include child abuse, abuse of women, elder abuse, youth violence, and
workplace violence. Although the focus of domestic violence and sexual abus
is primarily on women, information about male victims is incorporated when
Abuse
Elements
of
Abuse
The
Abuser
Abusive individuals usually are young and select a mate who is indifferent,
passive, or of little help to them. Generally, abusers keep to themselves and
may move from place to place. Other common characteristics include low se
concept, immaturity, fear of authority, lack of skills to meet their own
emotional needs, belief in harsh physical discipline, fear of spoiling a child,
poor impulse control, and unreasonable expectations for a child. Abusers oft
use alcohol or other substances to cope with stress. The mate, who usually
knows about the abuse, either ignores it or may even participate in it.
The
Abused
Quillian,
1995).
A Crisis
A crisis (eg, loss of job, divorce, illness, or death in the family) is usually th
precipitating event that sets the abusive person into action. The individual
overreacts because he or she is unable to cope with numerous or complex
stressors. The person becomes frustrated and anxious and suddenly loses
control.
P.518
Child
Abuse
879,000 children in the United States experienced or were at risk for child
abuse or violence in the year 2000. Of the 300 fatalities that were reported
2000, 85% were children younger than 6 years of age. Furthermore, 63% of
child victims suffered neglect; 19% were physically abused; 10% were sexu
mainly within the family, where the abusers are parents or parent substitute
in the institutional setting, such as daycare centers, child-care agencies,
schools, welfare departments, correctional settings, and residential centers;
society, which allows children to live in poverty or to be denied the basic
Characteristics
of
Potentially
Abusive
Parent
Parents who are potentially abusive often display characteristic warning sign
However, evidence of these signs does not automatically imply that abuse w
inevitably occur. Box 31-1 highlights some of the typical warning signs. Such
characteristics displayed for a short time may indicate anxiety in a new moth
or father. However, if the characteristics persist, the parent should seek hel
Characteristics
of
an
Abused
Child
The abused or neglected child is usually younger than 6 years of age, is mor
vulnerable to abuse than others, and
P.519
may have a physical or mental handicap. Emotionally disturbed,
temperamental, hyperactive, or adopted children also demonstrate a higher
incidence of abuse. Children with congenital anomalies or chronic medical
conditions are also at risk for abuse because of the demands of care placed
the parents or caretakers. The child, in an attempt to get attention,
BOX
31.1
Profile
of
Potentially
Abusive
Parents
Denial of pregnancy by a mother who has made no plans for the birth of
the child and refuses to talk about the pregnancy
Depression
during
pregnancy
Fear of delivery
Lack of support from husband or family
Undue concern about the unborn child's gender and how well it will perfo
Fear that the child will be one of too many children
Birth of an unwanted child
Indifference or a negative attitude toward the child by the parent after
delivery
Resentment toward the child by a jealous parent
Inability to tolerate the child's crying; viewing child as being too
demanding
Classifications
of
Child
Abuse
Physical abuse of a child involves the infliction of bodily injury that results
from punching, beating, kicking, biting, burning, shaking, or otherwise harm
a child. Indicators of actual or potential physical abuse have been categorize
as physical, behavioral, and environmental, briefly discussed below (Figure 3
1 ).
FIGURE 31.1 Examples of child abuse: (A) bruising on a child's body; (B)
cigarette burns; (C) rope burn. (From: Pillitteri, A. [2003]. Maternal and
child health nursing [4t h ed.]. Philadelphia: Lippincott Williams & Wilkins.)
Physical
Indicators . The most common indicators of physical abuse of a
child are bruises involving no breaks in skin integrity. The bruises are usuall
seen on the posterior side of the body or on the face, in unusual patterns or
with cigarettes, tying with a rope, or the application of a hot iron. Common
burned areas include the buttocks, palms of hands, soles of feet, wrists,
ankles, or genitals. Lacerations, abrasions, welts, and scars may be noted on
enlarged joints; head injuries; and internal injuries. Such bodily injuries mus
be evaluated with respect to the child's medical history, developmental abili
to injure self, and behavioral indicators (which are discussed later).
and
Environmental
abuse depend on the age at which the child is abused, as well as the frequen
and the severity of abuse. The behavioral profile of a physically abused child
presented in Box 31-2 . If a child exhibits such behaviors, observation for
bodily injuries is crucial.
BOX
31.2
Behavioral
Profile
of
Physically
Abused
Child
compliance
temper
to
avoid
confrontation
tantrums
behavior
Child
Neglect
Child neglect is the failure to provide for a child's basic emotional, physical,
educational needs. Examples of child neglect include withholding shelter,
adequate nutrition, adequate clothing, and proper medical or dental care.
Abandonment of a child or lack of adequate
P.521
CLINICAL
The
EXAMPLE
Physically
31.1
Abused
child
KW, the 22-year-old boyfriend of JN, was accused of beating her 5-year-old
daughter severely enough to cause permanent brain damage. The child was
beaten with a stick and forced to drink dishwashing liquid because she was
too sassy. After the beating, the child was kept on the floor of the
apartment because she appeared to be unconscious at times. JN force-fed he
daughter oatmeal and bananas in an effort to revive her. Two days later, the
child was taken to the hospital and was found to have burn marks on her
buttocks, a head injury, and bruises on her body. JN was charged with child
abuse, and KW was sentenced to 15 years in prison for aggravated child
abuse.
Physical
include weight loss due to inadequate nutrition, dental caries due to lack of
appropriate nutrition or dental care, or symptoms of an undiagnosed medica
condition such as anemia or pneumonia. The child may also look unkempt an
lack adequate clothing (eg, no shoes or adequate clothing for seasonal weat
changes).
Emotional
Abuse
or
Neglect
CLINICAL
The
EXAMPLE
Neglected
31.2
Child
FR, a young, single working mother, entrusted the care of her 1- and 2-year
old children to her 8-year old daughter while she worked as a waitress from
approximately 7:00 p.m. to midnight. Before she left for work each evening,
FR locked the younger children in their bedrooms and instructed the older
daughter to stay indoors and keep an eye on the children.
One
evening, a fire began on the second floor of the apartment, killing the two
younger children by smoke inhalation. The 8-year-old was able to escape the
fire. FR told the authorities she made minimum wage and was unable to affo
to pay a babysitter, so she worked at night while her older daughter was
home.
Emotional neglect occurs when parents or other adults responsible for the
child fail to provide an emotional climate that fosters feelings of love,
belonging, recognition, and enhanced self-esteem. Examples of emotional
neglect include ignoring the child, providing minimal human contact, and fai
to provide opportunities to foster growth and development. Children who are
emotionally abused or neglected may develop serious behavioral, cognitive,
emotional, or mental disorders.
us! , It's all your fault we don't have enough money. You're sick all t
time, and The family got along fine until you started to act so
selfish.
Behavioral indicators of an emotionally abused or neglected child
are listed in Box 31-3 .
treatment of the children in the family; and abuse of drugs or alcohol by the
parents or caretaker.
Child
Sexual
Abuse
BOX
31.3
Behavioral Indicators
or Neglected Child
of
an
Emotionally
Abused
Stuttering
Enuresis
or
encopresis
depression
attempts
Have primary caretakers who are mentally ill or who have a developmen
delay
BOX
31.4
Indicators
of
Sexually
Abused
Child
PHYSICAL
INDICATORS:
infections
BEHAVIORAL
INDICATORS:
peer
Delinquency,
relationships
truancy,
acting-out,
or
running-away
behavior
describe the sexual abuse of children: sexual misuse, rape, and incest. Sexu
misuse of a child is defined as sexual activity that is inappropriate because
the child's age, development, and role within the family unit. Examples inclu
fondling, genital manipulation, voyeurism, or exhibitionism.
CLINICAL
The
EXAMPLE
Sexually
Abused
31.3
Child
P.523
Rape refers to actual penetration of an orifice of a child's body during sexua
activity. Oral penetration is the most frequent type of penetration experienc
by very young children.
Domestic
Domestic
Violence
violence , is defin
parents, and the elderly are also at risk (Makar, 2000). Figure 31-2 depicts
annual national morbidity rate associated with domestic violence.
Domestic violence is the single greatest cause of injury to women. Although
Between 1,500 and 2,000 women are murdered each year by their curre
or former partner as compared with approximately 430 men.
Approximately 33% of all women with children in homeless shelters cite
domestic violence as the primary cause of their homelessness.
P.524
SUPPORTING
EVIDENCE
FOR
PRACTICE
31.1
Domest
believed domestic violence was rare or very rare in their practice; and 45.2%
seldom or never asked about anxiety, depression, or chronic pelvic pain whe
evaluating an injured client. One fourth of the clinicians and approximately
50% of the assistants reported that they did not feel confident in asking abo
domestic violence. Few (23%) felt that they had strategies to aid victims or
felt comfortable referring victims (16.2% assistants, 37.1% clinicians) or
batterers (14.6% assistants, 22.4% clinicians).
Footnote
Source: Sugg, N. K., Thompson, R. S., Thompson, D. C., Maiuro, R., & Riva
R. P. (1999, Jul/Aug). Domestic violence and primary care: Attitudes,
practices, and beliefs. Archives of Family Medicine, 8 , 301306.
Supporting Evidence for Practice 31-1 highlights a study addressing the need
for identifying potential victims of domestic violence.
Factors
Contributing
to
Domestic
Violence
the abuser and the female as the abused. Professional staff who have worke
with and studied men who physically abuse others have developed a profile
male abusers. Male abusers usually have low self-esteem, believing that a m
should be the head of the household and have the final say in
P.525
family decisions. Due to their insecurities and fears, batterers experience
extreme jealousy. Because they grew up in violent homes, they have not
developed positive ways to communicate feelings and needs, or the ability to
compromise. They use force or violence to solve problems, typically blaming
everyone and everything but themselves for their actions. Because batterers
do not want to face the seriousness of their behavior and its consequences,
denial is a common defense mechanism.
BOX
31.5
Factors
Contributing
to
Domestic
Violence
Forms
of
Domestic
Violence
Dynamics
of
Domestic
Violence
Tension-Building
Phase
Acute
Battering
Phase
During the acute battering phase, the batterer loses control of behavior
because of blind rage. The battered person also loses control and is unable t
stop the physical abusiveness experienced. Both persons are in a state of
shock immediately after the incident. The batterer is unable to recall his or h
behavior; the battered person depersonalizes during the abusive incident an
is unable to recall in detail what occurred.
Loving
Phase
As both calm down, the batterer may exhibit feelings of remorse, beg
forgiveness, promise not to abuse in the future, and state that he or she
cannot live without the battered partner. During this loving phase, the abuse
person believes the batterer's promises and forgives the batterer because th
battered partner then feels less helpless. The batterer interprets such behav
as an act of love and acceptance by the battered partner.
Barriers
to
Leaving
Violent
Relationship
According to the NCADV (2003), the reasons why women stay in a violent
relationship fall into three major categories. They include lack of resources,
lack of institutional responses, and traditional ideology.
P.526
Lack
of
Resources
Most victims of domestic violence have at least one dependent child and do
have the financial resources (eg, unemployed, lack access to cash or bank
accounts) to maintain adequate living standards for themselves and their
dependent children. If they leave home, women fear being charged with
desertion, losing custody of their children, and losing any joint assets they m
have with their spouse.
Lack
of
Institutional
Responses
Many victims of domestic violence report negative experiences with the polic
and their clergy. Police often treat domestic violence as a domestic dispute
instead of a crime and try to dissuade women from filing charges. Restrainin
orders rarely prevent a released abuser from returning and repeating an
assault. Prosecutors are often reluctant to prosecute cases. Clergy and secu
counselors usually focus on saving the marriage rather than the goal of
stopping the violence.
Traditional
Ideology
The victim may not believe that divorce is a viable option because her childr
need their father and a single parent family is unacceptable. She may blame
See Clinical
Example
CLINICAL
Family
EXAMPLE
31.4
Violence
JW, a 43-year-old investment banker, was beaten, bruised, and afraid. She
stood in her bedroom pointing a pistol at her angry, abusive husband. Both
eyes were swollen, choke marks were on her neck, and bruises were evident
on several areas of her body. She killed her husband with the pistol. When
questioned by police, she stated that he was totally out of control after
drinking beer. His blood alcohol level was 0.236. (A person is considered
legally intoxicated if the level is above 0.10.) JW described her husband as a
hard worker and good father who was a loving person when he was sober bu
totally different person when intoxicated. He had beaten her on several
occasion in the past 6 months but never to the point of choking and punchin
her. In the past, JW's husband would wake up in the morning after physicall
abusing her and ask, Did I do that? He would promise such behavio
wouldn't happen again
and she would believe him.
Adult
Sexual
Abuse
Sexual Harassment,
Coercion
Sexual
Stalking,
and
Sexual
Studies suggest anywhere between 40% to 70% of women and 10% to 20%
men have experienced sexual harassment in the workplace. Approximately
15,000 sexual harassment cases are brought to the office of the Equal
Employment Opportunity Commission each year. The number of complaints
filed by men has more than tripled in recent years. Currently, approximately
11% of claims involve men filing against female supervisors (D. B. Pargman
Diversity Training, 2003).
Rape
Legally, the term rape has traditionally referred to forced vaginal penetratio
of a woman by a male assailant. Many states have now abandoned this conc
in favor of the gender-neutral concept of sexual assault. Although
P.527
the legal term for male rape is sodomy , many research articles use the
terminology sexual assault by an intimate partner
or simply state
male rape
(National Center for Victims of Crime [NCVC], 2003b).
The NCVC reports that over 700,000 women are raped or sexually assaulted
annually. Of these victims, 61% are under the age of 18. Cases of male rape
are so underreported that most people assume incorrectly that they do not
exist (AMA, 2003; NCVC, 2003a). According to statistics cited in the Nationa
Violence Against Women Survey, 10% to 11% of rape victims are men.
Approximately 1 out of 6 boys is sexually assaulted by age 16 (Silent Tears,
2003).
Essential
Elements
of
Rape
Rape statutes vary from state to state, and in some states a wife may charg
her husband with rape. Attempted rape is defined as an assault in which o
vaginal, or anal penetration is intended but does not occur. Statutory rape
the act of sexual intercourse or sexual assault on an individual younger than
the age of consent (usually 16 years) (NCVC, 2003a; Roye & Coonan, 1997)
Rape-Victim
Profile
experience rape. According to the National Institute of Justice and the Cente
for Disease Control, 86% of heterosexual men raped and/or physically
assaulted were raped/assaulted by other men who were strangers or
acquaintances
(NCVC,
2003b).
Both lesbians and homosexual males are also at risk for rape by their intima
partners; however, few data are available regarding the prevalence in lesbia
or male homosexual relationships (Kimberg, 2001).
Motives
for
Rape
Subclassifications
of
Rape
Marked victim rape, in which the offender assaults a woman he has been
acquainted with in some way
P.528
Accessory-to-sex rape, which refers to a vulnerable victim's inability to
give consent (as in the case of a person who is mentally retarded)
Emotional
Reactions
to
Rape
The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text
Revision (DSM-IV-TR) recognizes the reaction to rape as a post-traumatic
stress disorder (PTSD) (American Psychological Association, 2000). Rapetrauma syndrome is a North American Nursing Diagnosis Association (NAND
nursing diagnosis used to describe a victim's response to rape, including an
With the acute phase of rape trauma, the victim is disrupted by the crisis an
displays emotional reactions of anger, guilt, embarrassment, humiliation,
denial, shock, disbelief, or fear of death; multiple physical or somatic
complaints; or a wish for revenge. After several weeks, the acute-phase
reactions give way to deeper, more long-term feelings or reorganization that
cause the victim to change daily life patterns, experience recurring dreams a
nightmares, seek support from friends and family, initiate or refuse counseli
or develop irrational fears (phobias). One or more six major phobic reactions
may occur: (1) fear of being indoors if the rape occurred in the home; (2) fe
of the outdoors if the victim was sexually assaulted outside the home; (3) fe
of crowds; (4) fear of being alone; (5) fear of people around the victim while
the person engages in daily activities; and (6) fear of sexual activity if the
person had no prior sexual experience (Sadock & Sadock, 2003).
Long-Term Reactions to Rape . Long-term reactions to rape and sexual
assault may take several years to resolve, especially if the person goes
through legal court action. During this time, the victim may move into a new
residence, change his or her telephone number, change jobs, or move to a n
state. If the victim is married, severe marital conflict may occur (Sadock &
Sadock,
2003).
Adult
Survivors
of
Childhood
Sexual
Abuse
Much attention has been paid in recent years to identifying and treating adu
survivors of childhood sexual abuse or incest. Although most attention has
been given to women, men suffer from childhood sexual abuse as well. Both
male and female victims of abuse often go through life asking themselves w
they did to deserve feelings of guilt, distrust, and alienation.
They may lack self-confidence or self-respect or lose the ability to trust peo
They may cope with the past abuse by using alcohol or other substances;
engage in self-harming activities such as cutting, scratching, or burning
oneself; or exhibit obsessive behavior and strict routines. Conversely, some
survivors cope by breaking ties with or confronting the abuser; speaking abo
the abuse and seeking support; working to protect children from abuse; or
writing about abuse (Healthy Place.com, 2003).
Elder
Abuse
Abuse of the elderly was ignored, overlooked, or perhaps thought not to exis
until health care professionals began to appreciate the extent of the problem
long buried in family guilt, denial, and cover-up. Interest in elderly abuse
increased in the 1980s, and a profile of elderly abuse emerged that demande
attention and research interest (Lachs & Pillemer, 1995). The National Elder
Abuse Incidence Study, conducted in 1996, states that at least 500,000
persons aged 60 years and over living in domestic settings were abused,
Six types of elder abuse have been defined by the National Center on Elder
Abuse (1998). They include physical abuse, sexual abuse, emotional or
psychological abuse, abandonment (also referred to as neglect ), financial or
material exploitation, and self-neglect. Many states have adopted laws simila
to child-abuse laws to prevent elder abuse. For example, in the state of
Florida, Chapter 400 of the Florida Statutes mandates the standard of nursin
care for residents of long-term care facilities, and violations to this chapter
reported to the Department of Children and Family Services or the long-term
care ombudsman (advocate for the elderly). Unfortunately, the abuse of elde
individuals who reside alone or with family members often goes undetected
(Douris & Pritchard, 1999).
Emotional
Response
to
Elder
Abuse
Many times, elderly persons are expected to meet the needs of their grown
children. These family members may become abusive if the elderly parent is
unable to communicate clearly with them or is unable to meet their emotion
needs. Elderly persons may not report abusive behavior because of fear of
retaliation by the abuser, fear of rejection, low self-esteem (whereby they fe
they deserve such treatment), loyalty to caretakers, or lack of contact with
helping persons.
Violence
FORMS
EXAMPLES
Physical
Emotional
Abandonment
Leaving
disabled
elderly
person
unsupervised
or
eyeglasses
Financial
exploitation
or material abuse
Sexual
abuse
Self-neglect
The Centers for Disease Control and Prevention's (CDC) Injury Center define
violence as threatened or actual physical force or power initiated by an
individual that results in, or has a high likelihood of resulting in,
P.530
physical or psychological injury or death (NCIPC, 2003). Homicide is the
second leading cause of death for people ages 10 to 19; the number one cau
of death among African Americans ages 15 to 24; and the second leading ca
of death for Hispanic youths (NCIPC, 2001). Workplace violence has emerge
as an important safety and health issue in today's society. Its most extreme
form, homicide, is the third-leading cause of fatal occupational injury in the
United States (Occupational Safety & Health Administration [OSHA], 2003).
Following is a discussion of youth and workplace violence.
Youth
Violence
Youth violence may involve a youth victim, a youth perpetrator, or both. The
rate of youth violence in America is unlike that in any other developed count
According to a survey by the Children's Defense Fund, nearly 16 children per
day died in 1997 as a result of firearms homicide, suicide, or unintentional
shooting (Character Counts, 2003). More than 400,000 youth ages 10 to 19
Etiology
of
Youth
Violence
Lethal violence among youths has escalated during recent years because of
increased access to and use of firearms. Also, gang-related violence has
increased rapidly since the 1960s. Status within and among gangs is a major
issue, and threats to gang status may lead to violence between individuals o
groups. Family problems such as poor monitoring or supervision of children,
parental drug or alcohol abuse, and poor emotional attachment to parents or
caretakers contribute significantly to delinquency. Exposure to violence at
home is the most accurate predictor of membership in a delinquent group.
Children who are themselves not victims of, but are witnesses to such violen
can subsequently become violent themselves (Thornton, Craft, Dahlberg,
Lyncy, & Baer, 2000).
Those who study the etiology of criminal and violent adolescent behavior are
looking beyond broad demographic characteristics such as race, age, and
income level. Research findings support the conclusion that no single cause
accounts for all episodes of violence. Almost always, youths who perpetrate
acts of violence against others or themselves have a long history of mental
Emotional
Response
of
Victims
of
Youth
Violence
Each year many children and adolescents sustain injuries from violence, lose
friends or family members to violence, or are adversely affected by witnessi
a violent or catastrophic event. They are vulnerable to serious long-term
Workplace
Violence
P.531
13% of all homicides occur in an office or factory. Most of the deaths occur a
a result of robbery.
The severity and frequency of assaults against employees in the health care
setting have dramatically increased in the past decade. According to OSHA,
health care and social-service workers are at high risk for workplace violenc
with nursing staff in all work settings as the most frequent victims of assaul
The National Institute for Occupational Safety and Health reports that 9,000
health care providers are attacked on the job daily. Other occupations that
regularly face violence in the workplace include police officers, security guar
taxi drivers, prison guards, bartenders, and high-school teachers (OSHA,
2003).
Predictors
of
Workplace
Violence
customers
dissatisfied
with
treatment
delinquents
criminals
Classification
of
Workplace
Violence
Incidents
Type II: Incidents of violent acts or threats by someone who receives servic
from the workplace or from the victim.
Self-Awareness
Prompt
Do you know anyone who has been victimized by abuse or violence? How has
Emotional
Violence
Responses
of
Victims
of
Workplace
The
Nursing
Process
Assessment
Assessment
of
Abuse
in
Children
Biopsychosocial
Data
STDs. Testing for the human immunodeficiency virus (HIV) may be necessary
P.532
Play therapy and art therapy can serve as assessment tools when child abus
is suspected. A mature, patient, empathetic approach is used, focusing on
physical, behavioral, and environmental indicators of abuse as well as family
dynamics. Evidence of malnutrition, dehydration, old fractures, bruises,
internal injuries, or intracranial hemorrhage may be present. Behaviorally, t
child may exhibit withdrawal, low self-esteem, oppositional behavior,
compulsive behavior, hypervigilance or an increased awareness of the
environment, and a fearful attitude toward parents.
Documentation
of
the
Assessment
emergency medical care. The victim may present with multiple bruises or
injuries, somatic complaints or symptoms associated with trauma that may n
be observable, or characteristic behavioral reactions such as acute anxiety
reaction, depression, or suicidal ideation. (See Chapter 12 for information on
crisis
intervention.)
Biopsychosocial
Data
Assessment
Tools
Several assessment tools may be used to gather data about a person's risk
being a victim of violence. Campbell (1986) developed a Danger Assessment
Instrument for assessing the potential for homicide. The questions denote ri
factors that have been statistically associated with homicides of abused
women. They focus on the frequency of abuse, type of abuse, presence of
lethal weapons in the home, forced sex, use of drugs or alcohol, jealous
behavior or violence toward family members by the abuser, and suicidal
ideation verbalized by the abused. Grant (1996a) refers to the Migrant
Clinicians Network Domestic Violence Assessment Form developed by
McFarlane for use in a migrant health center setting. Four questions are pos
Within the last year, have you been hit, slapped, kicked, or otherwise
physically hurt by someone? (The perpetrator is then identified, the
frequency of abuse noted, and the area of injury noted on a body map.)
If pregnant, since the pregnancy began, have you been hit, slapped,
kicked, or otherwise physically hurt by someone? (The frequency of abus
is noted and the area of injury is noted on a body map.)
Within the last year, has anyone forced you to have sexual activities? (T
perpetrator is then identified and the frequency of abuse is noted.)
Are you afraid of your partner or anyone you identified?
Figure 31-3 , the Abuse Assessment Screen, is a similar form developed by
Nursing Research Consortium on Violence and Abuse.
Documentation
of
Data
During the initial assessment of victims of sexual abuse such as rape, the
nurse may experience strong reactions, including conflict over who is to blam
P.533
anxiety about the possibility of becoming a sexual assault victim him- or
herself; anger and hostility toward the victim, the rapist, and society for
allowing such an act to occur; or a desire to learn more about rape to resolv
personal feelings.
FIGURE
Guidelines
for
Collection
of
Data
Guidelines for interviewing rape victims in crisis have been identified by Gra
(1996b). Assessment data to be collected if the client is able and willing to
answer questions include: the victim recounting the events of the rape or
attempted rape; legal information, including the names of persons who have
been notified, such as the police; what evidence has been preserved; and
support persons or systems available to the abused person. Specific
information focuses on demographic data, crisis status, type of assault,
Medical
Data
Behavioral
and
Emotional
Responses
years)
Collection
Evidence
and
Documentation
of
Physical
If the victim gives consent and is able to tolerate the procedure, a gynecolo
examination usually is
P.535
performed after a rape situation, along with a pregnancy test if indicated, an
laboratory tests. The date of the victim's last menstrual period is obtained.
MYTH
FACT
Attractive women
provoke men into
raping them.
If a woman struggles,
friendly to strangers
outside their homes
are raped.
include husbands,
and boyfriends
ex-husbands,
neighbors,
Women cry
rape
to get
revenge.
Transcultural
Considerations
During assessment, keep in mind that abuse and violence affect individuals
all ethnic and socioeconomic backgrounds and cannot be predicted by
demographic features. Certain cultural practices, however, do place women
risk for abuse. For example, in some cultures, the genitalia of females are
mutilated when they reach puberty. Women are also abused and disfigured
region of residence, and type of metropolitan area all are associated with ris
of victimization of children (Finkelhor & Leatherman, 1994). For example,
Hispanic and African American children, those living in Mountain and Pacific
states, and those from large cities were at greater risk for victimization.
African American youths demonstrated elevated rates for sexual assault and
kidnapping; low-income children demonstrated high rates of family assault a
general violence. Approximately 6.2 million youths participated in this nation
survey. Additionally,
behavior is so great
impossible, to define
would be universally
Nursing
Diagnoses
Outcome
Identification
Stated outcomes focus on reducing anxiety, fear, pain, and the potential for
injury or violence; improving communication, coping, self-esteem, or selfconcept; identifying members of support system(s) and the appropriate use
them; and assisting the victim in returning to a precrisis level of functioning
Planning
Interventions
and
Implementation
reducing fear. Clients who are victims of abuse and violence may experience
Examples of NANDA
and Violence
Nursing
Diagnoses:
Abuse
Interventions
for
Child
Abuse
Multidisciplinary
Approach
Behavioral
Interventions
Behavioral strategies have been developed to help young children cope with
traumatic events such as abuse, incest, and violence. Therapeutic approache
include deep-breathing exercises, progressive muscle relaxation, exposure
techniques (exposure to reminders of a traumatic event), thought-replaceme
and thought-stopping, positive imagery, psychoeducation and cognitive
reframing, and addressing grief reactions including survivor's guilt
(Bates, 1999).
Continuum
of
Care
family therapy and using community support systems help prevent the
repetition of abuse. Support services available for victims of child abuse and
their families include:
Visiting or public health nurses
Protective services for children
Emergency shelters for children
Daycare centers or nurseries
Self-help groups such as Parents Anonymous
Telephone
hotlines
Homemaker
services
counseling
Parent-education
Foster-home
classes
care
Transportation
services
Counseling
Assertiveness-training
Prevention
of
classes
Child
and
groups
Abuse
and
Neglect
The nurse may help prevent child abuse by recognizing early signs of abuse,
supporting and working for legislation to interrupt the child-abuse syndrome
promoting educational courses on family interpersonal relationships and
childrearing practices, promoting community awareness programs,
participating in continuing-education courses, and participating in nursing
research of child abuse and effective treatment measures.
When reporting child abuse, the report may be made by telephone, in person
or in writing to the children's services board of a local welfare department
P.537
or to the local police department. The following information is stated:
Name and address of the suspected victim
Child's
age
Interventions
Violence
for
Victims
of
Physical
Abuse
and
Safe
Environment
so that the victim only needs to tell the story once in detail. This way the
victim does not have to re-live the incident psychologically over and over ag
by repeating the story.
Supportive
Therapies
Interactive therapies that are available include individual, couples, and fami
therapy. Additionally, referrals may be made to self-help groups and a
community mental health social worker who is familiar with additional servic
that are available.
Continuum
of
Care
If the victim prefers to return home, an action plan is developed in the even
that the violence recurs (Box 31-6 ). The victim also is given emergency
telephone numbers and informed of available options (Grant, 1996a). They
include:
Legal assistance to obtain a restraining or protection order
Temporary custody of minor children
Emergency
financial
Temporary
emergency
Assistance
from
local
Advocacy
services
Community
counseling
Vocational
counseling
Legal-aid
assistance
housing
women's
organizations
services
services
nursing care by the visiting nurse, food from Meals on Wheels, assistance fro
a visiting homemaker program, visits by persons involved in a foster
grandparent program, and transportation for the elderly provided by
community organizations may be helpful.
BOX
31.6
Action
Plan
to
Avert
Domestic
Violence
access
to
emergency
transportation.
Interventions
for
Victims
of
Sexual
Abuse
Survivors of sexual assaults were treated much differently in the past than
they are today. Many communities now employ what is known as a mobile
sexual assault response team (SART), which consists of a law enforcement
officer, nurse examiner, and victim advocate practicing in a freestanding
facility no longer associated with a specific hospital. Initial contact with the
team begins at the time the victim or a support person reports the assault.
report may be made to any member of the team, who then responds to the
location of the victim, including the crime scene if necessary. The team
approach is designed to provide a safe environment, empower the survivor,
and begin the process of rehabilitation while simultaneously providing
RNs or NPs trained to collect forensic evidence from sexual assault survivors
(Liddell, 2002).
Crisis
Intervention
Continuum
of
Care
adults. This may be due in part to the relative unavailability of the elderly,
disinterest in older adults, or the stigma associated with this type of
victimization. Older adult assessment forms may ask for information regardi
elder abuse but do not assess for a past history of incest or sexual abuse.
Many survivors exhibit symptoms of depression or anxiety.
The topic of elderly survivors of sexual abuse and their need for nursing
interventions as they review the life process is addressed by Walker (1992).
After an elderly person is identified as a survivor of sexual abuse, nursing c
should focus on improving coping skills and increasing self-esteem. Encourag
the individual to vent emotions, and provide supportive measures such as
individual therapy as necessary.
Interventions
Violence
for
Victims
of
Youth
or
Workplace
Evaluation
Key
Concepts
Abuse of children, women, and the elderly, as well as youth and workpla
violence, have become widespread public health problems affecting
individuals of all ethnic and socioeconomic backgrounds.
Factors that may contribute to child abuse include parental stress, marit
problems, financial difficulties, or parentchild conflict.
Youth and gang-related violence have escalated during recent years due
increased access to and use of firearms. Exposure to violence at home is
the most accurate predictor of membership in a delinquent group.
Predictors of workplace violence include angry or dissatisfied
clients with certain psychiatric disorders, domestic batterers,
severe cases of premenstrual tension, disgruntled older male
fearing a potential loss of their job, juvenile delinquents, and
criminals.
customers,
women wit
employees
career
For additional study materials, please refer to the Student Resource CD-ROM
located in the back of this textbook.
P.540
Following the well-baby visits, Andrea asked the nurse if she could speak to
her about a problem that she was having. Andrea related that her husband o
years had been under a considerable amount of stress at work for the past 6
months and had lost his temper on several occasions. He began drinking
alcohol nightly and has become quite critical of her at times. She questions
whether she and the children are to blame for his anger because they have
purchased a larger home and incurred more bills since the birth of the twins
Andrea revealed bruise marks on both upper extremities and a bruise directl
under her right lower eyelid. She stated that her husband became angry whe
she confronted him about his behavior and she feared that he might injure t
children.
DSM-IV-TR
fear that her husband could harm the children, ineffective communication wi
husband
OUTCOME: The client will identify the source of her situational low
self-esteem and work through that issue.
Planning/Implementation
Rationale
Verbalization of feelings
allows the client to identify,
accept, and work through
feelings.
Rationale
skills
within
Rationale
Clients in abusive
relationships often lack
confidence and exhibit poor
communication
skills.
Development of positive
communication and coping
skills within the family unit
will enable the family to
resolve conflict.
P.541
P.542
P.543
Chapter
Critical
Worksheet
Thinking
Questions
Child abuse and neglect are epidemic in the United States. What might b
the role and responsibility of nursing in responding to this crisis?
Explore your feelings about child abuse. How might you cope with meeti
the parents of a child you are caring for whom you suspect is being
abused?
Reflection
Multiple
Choice
Questions
Answer
P.544
2. Which of the following would the nurse interpret as most indicativ
of child abuse?
Answer
The most common indicators of physical abuse of a child are bruises involvin
no breaks in skin integrity. The bruises are usually seen on the posterior sid
of the body or on the face, in unusual patterns or clusters, and in various
stages of healing, making it difficult to determine the exact age of a bruise.
Abdominal pain, a common complaint in children, can be an indication of chi
abuse; however, it is a less common indicator. Symptoms of dehydration ma
be normal after vomiting and diarrhea due to fluid loss. Temperature
elevations typically indicate an inflammatory or infectious process and occur
before other signs and symptoms are noted.
eater
Answer
conflict. Parents or other persons may lose control of their feelings of anger
frustration and direct such feelings toward a child. Therefore, teaching abou
managing stressful life events would be most helpful in preventing future
episodes. Information about child care, such as handling eating problems an
maintaining regular check-ups, would be helpful to promote a healthy child.
Education about interacting with the child's teacher would help to foster an
interest in the child's well-being.
her when she visits friends or family members he does not like. Whic
intervention would be the priority?
a. Encouraging the client to leave her husband before the situation
becomes worse
b. Instructing the client to talk about her feelings to her husband
c. Providing the client with information about domestic violence and
community
resources
Answer
The client's safety is the priority. Once the client's medical condition is
stabilized, often a referral to a local domestic violence shelter may be made
ensure a safe environment and to assist the victim and the victim's family.
Other interventions include empowering the victim through supportive
therapies and exploring continuum of care to assist the victim to regain con
of his or her own life. Each victim's situation is unique and the decision to ta
action varies among individuals. Encouraging the client to leave her husband
instructing the client to talk about her feelings to her husband, and telling th
a. Anxiety
b. Caregiver Role Strain
c.
Ineffective
Coping
Answer
A major factor associated with elder abuse is dependency of the older adult
adult children or caretaker due to severe physical or mental disabilities or
Internet
Advocates
Resources
for
Victims
of
Violence:
http://www.alaska.net/~avv/
Safety
&
Health
Administration:
http://www.osha.gov
Crisis
Selected
Online:
http://www.rapecrisisonline.com
References
Reviews
8 (5), 167184.
Douris, K., & Pritchard, M. (1999). When you suspect elder abuse. Advance
for Nurse Practitioners, 7 (4), 22.
Flannery, R. B., Jr. (1995). Violence in the workplace . New York: Crossroa
Press.
Flannery, R. B., Jr. (1997). Violence in America: Coping with drugs,
distressed families, inadequate schooling and acts of hate . New York:
Continuum.
Grant, C. A. (1996a). The client who has been battered. In S. Lego (Ed.),
Psychiatric nursing: A comprehensive reference (2nd ed., pp. 296304).
Philadelphia:
Lippincott-Raven.
Grant, C. A. (1996b). The client who has been raped. In S. Lego (Ed.),
Psychiatric nursing: A comprehensive reference (2nd ed., pp. 305315).
Philadelphia:
Lippincott-Raven.
Grinfield, M. J. (2000). The big picture: Averting the course of violence.
Psychiatric Times, 17 (1), 1, 34.
Healthy Place.com. (2003). Safeline: Information for adult survivors of
childhood sexual abuse . Retrieved September 14, 2003, from
http://www.healthyplace.com/communities/abuse/safeline/survivors.htmm
Kimberg, L. (2001). Addressing intimate partner violence in primary care
practice. Medscape Women's Health, 6 (1).
Psychiatry
Lachs, M. S., & Pillemer, K. (1995). Abuse and neglect of elderly persons.
New England Journal of Medicine , (2).
update:
Muscari, M. E. (2003). Coach and activist: The NP's role in preventing yout
violence. Advance for Nurse Practitioners, 11 (2), 3741.
National Center for Injury Prevention and Control. (2001). Child
maltreatment:
Overview . Retrieved July 11, 2003, from
http://www.cdc.gov/ncipc/factsheets/cmfacts.htm
National Center for Injury Prevention and Control. (2002). Youth risk
behavior surveillance U. S. Retrieved July 11, 2003 , from
http://www.cdc.gov/ncipc/factsheets/yvfacts.htm
National Center for Injury Prevention and Control. (2003). Youth
Overview . Retrieved July 11, 2003, from
http://www.cdc.gov/ncipc/factsheets/yvfacts.htm
violence:
National Center for Victims of Crime. (2003a). Get help on child victims an
14,
2003,
from
http://www.ncvc.org/gethelp/malerape/
National Center on Elder Abuse. (1998). The National Elder Abuse Incidenc
Study . Retrieved December 13, 2003, from
http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/ABuseReport_Full.p
National Coalition Against Domestic Violence. (2003). The problem:
to leaving a violent relationship . Retrieved July 7, 2003, from
http://www.ncadv.org/problem/barriers.htm
Barrier
North Carolina Rape Crisis. (2003). What is rape? Retrieved March 3, 2004
from
http://www.rapecrisisonline.com/articles.htm
Occupational Safety & Health Administration. (2003). Workplace
Retrieved July 13, 2003, from
violence .
http://www.osha.gov/SLTC/workplaceviolence/
Petrocelli, W., & Repa, B. (1998). Sexual harassment on the job . Berkeley
CA: Nolo Press.
Quillian, J. P. (1995). Domestic violence: Continuing education forum.
Resnick, P. J., & Kausch, O. (1995). Violence in the workplace: Role of the
consultant. Consulting Psychology Journal: Practice and Research, 47 ,
213222.
Roye, C. F., & Coonan, P. R. (1997). Adolescent rape. American Journal of
Nursing, 97 (4), 45.
Sugg, N. K., Thompson, R. S., Thompson, D. C., Maiuro, R., & Rivars, R. P.
(1999, Jul/Aug). Domestic violence and primary care: Attitudes, practices,
and beliefs. Archives of Family Medicine, 8 , 301306.
Thornton, T. N., Craft, C. A., Dahlberg, L. L., Lyncy, B. S., & Baer, K.
(2000). Best practices of youth violence prevention: A sourcebook for
community action . Atlanta: National Center for Injury Prevention and
Control.
Walker, K. (1992). That was then: Elderly survivors of incest. Journal of
World Health Organization, Regional Office for Africa. (2002). Press release
Trauma among children who are victims of violence. Retrieved July 7, 2003
from
http://www.afro.who.int/press/2002/pr2002091602.html
Suggested
Readings
for
Muscari, M. E. (2003). Coach and activist: The NP's role in preventing yout
violence. Advance for Nurse Practitioners, 11 (2), 3741.
violenc
Paulk, D. (2001). Munchausen syndrome by proxy: Tall tales and real hurts
Clinician
Reviews,
11 (8), 5157.
Chapter
32
or AIDS are
education and
will abate only
providers and
1996
Learning
Objectives
Key
Terms
Acquired
immunodeficiency
AIDS-related
complex
syndrome
(ARC)
Homophobia
Human
immunodeficiency
Neuropsychiatric
Opportunistic
Secondary
virus
(HIV)
syndromes
infectious
infectious
diseases
diseases
(AIDS)
Stigmatization
P.546
Although acquired immunodeficiency syndrome (AIDS) emerged
in 1981 as an unidentified killer of young men, neither a cure for the
disease nor a preventive vaccine has been developed. The human
immunodeficiency virus (HIV) was identified in 1986 as the virus
that causes AIDS. The medical conditions (eg, persistent generalized
lymphadenopathy, lymphoma, and pneumonia) and neuropsychiatric
phenomena (eg, delirium, dementia, depression, and anxiety)
associated with HIV-positive status and AIDS are pandemic (Sadock
& Sadock, 2003). Global statistics indicate that there are 5.3 million
new cases of AIDS per year. At the end of the year 2001, an
estimated 40 million individuals were living with the AIDS virus,
while 3 million people had died. In North America approximately
940,000 cases of AIDS affecting adults and children were reported to
the Centers for Disease Control and Prevention.
In the United States in 2001, approximately 500,000 to 600,000
citizens were diagnosed as HIV-positive and another 320,000 citizens
had AIDS. An estimated 21.8 million deaths have occurred since the
epidemic began (Centers for Disease Control and Prevention [CDC],
2001; Seattle Biomedical Research Institute, 2003).
Acquired immunodeficiency syndrome is associated with numerous
biopsychosocial complications, secondary infectious diseases, and
AIDS-related disorders. Nurses play a key role in recognizing these
conditions. Each of the conditions is usually treated by medication
that puts the client at risk for the development of adverse effects on
the central nervous system as well as increases the risk for
development of neuropsychiatric disorders.
This chapter focuses on the etiology of AIDS; the clinical symptoms
of AIDS, secondary infectious diseases, and AIDS-related disorders;
the psychosocial impact of these disorders; and the effects of these
disorders on family dynamics. The role of the psychiatricmental
health nurse and application of the nursing process are also
discussed.
Etiology
of
AIDS
intravenous
drug
users
AIDS
in
Adolescents
FIGURE
Clinical
Picture
Associated
With
AIDS
Secondary
Diseases
or
Opportunistic
Infectious
FIGURE
illness.
P.549
nausea and vomiting
constant
fever
chronic
headaches
diarrhea
painful
mouth
infections
hypotension
liver and kidney failure
severe
respiratory
distress
incontinence
central nervous system dysfunction with psychomotor retardation
Early
Symptomatic
HIV
Infection
HIV Infection
Syndromes
and
Neuropsychiatric
Clients infected with the AIDS virus may develop an extensive array
of neuropsychiatric
syndromes (neurologic symptoms occurring as
the result of organic disturbances of the central nervous system that
constitute a recognizable psychiatric condition) such as HIVassociated dementia and HIV encephalopathy (Edgerton & Campbell,
1994). HIV-associated dementia is found in a large portion of clients
infected with HIV; however, other causes of dementia (eg, vascular
BOX
32.1
Neurologic
Manifestations
With HIV/AIDS
Associated
change
secondary
Drugdrug
to
interactions
AIDSdementia
between
complex
psychotropics
and
antiretrovirals
neuropathies
Psychosocial
Impact
of
AIDS
social agencies, landlords, and health care workers. For many, this
constant rejection causes a re-living of the coming-out
process,
with a heightening of the associated anxiety, guilt, and
internalized self-hatred. The fear of spreading AIDS to others can
lead to further isolation and abandonment, commonly at a time when
there is an ever-greater need for physical and emotional support.
Clients with AIDS may respond with intense anger and hostility as
their conditions deteriorate and they confront the everyday realities
of this illness: loss of job and home, forced changes in lifestyle, the
perceived lack of response by the medical community, and the oftencrippling expense associated with the illness.
HIV
Infection
and
Psychiatric
Disorders
The
adjustment
Worried
reaction,
and
psychosis.)
Well
interventions
BOX
for
anxiety
anxiety-related
disorders).
32.2
Behavioral
With
and
Manifestations
Associated
HIV/AIDS
Confrontation
(eg,
anger,
Impaired
social
Impaired
occupational
aggressiveness,
hostility,
or
impulsivity)
functioning
functioning
Grief
Reaction
to
HIV/AIDS
First
in
dying
patients
(Kbler-Ross,
Stage
paralysis
or
Second
regression.
Stage
Third
Stage
The
Nursing
Assessment
Example
Process
Self-Awareness
Prompt
CLINICAL
EXAMPLE
32.1
Phases
of
Assessment
Clients may enter the health care system at different phases of their
illness depending on their biopsychosocial and spiritual needs. Ripich
(1997) discusses three phases of the HIV continuum (ie, from the
time the client tests positive with HIV infection, to the development
of AIDS including the progression of the disease). Following is a
discussion of the psychiatricmental health nurse's role in the
assessment of each of the phases. (Note: The focus of discussion
here is on assessment and treatment of the psychosocial impact of
HIV/AIDS. The reader is referred to medicalsurgical texts for a
complete discussion of the complex medical assessment and
treatment.)
Early-Phase
Assessment
Clients who first learn that they are HIV-positive are considered to
be in the early phase of the HIV continuum. The major thrust of the
assessment at this time is to obtain data that will enable the nurse
to (1) formulate a plan of care to improve or stabilize the client's
emotional and physical well-being and (2) empower the client to
maintain a sense of control over as many aspects of his or her life as
possible.
As noted in Box 32-3 , the client in the early phase of HIV/AIDS may
exhibit various clinical phenomena when told he or she is HIVpositive. The client is faced with many difficult decisions because life
goals may not be achievable, and living day-to-day becomes the
ultimate goal (Ripich, 1997).
The initial assessment of the client suspected of having HIV infection
or AIDS generally occurs in the primary care setting unless the client
has been admitted
psychiatric setting,
psychiatricmental
assessment usually
evaluation,
baseline
laboratory
P.553
comorbid neuropsychiatric
(Kongable, 1998).
BOX
syndrome
or
psychiatric
disorder
32.3
Clinical Phenomena
HIV/AIDS
of
Early-Phase
Denial
Shock, anger, panic
Fear
of
incapacitation
ideation
ideation
issues
issues
Effective
coping
skills
spiritual,
financial,
legal)
(Burnett,
Middle-Phase
2001)
Assessment
BOX
32.4
Clinical Phenomena
HIV/AIDS
of
Middle-Phase
self-esteem
Late-Phase
Assessment
By the late phase, the client ideally has reached a realistic level of
acceptance of his or her health status and uncertain future and may
elect to begin a life-review
process (ie, reflecting on one's life and
finding peace with it) and make final preparations for death (Ripich,
1997). During the late phase of the HIV continuum, the nurse
assesses the client for:
Changes in mental status (eg, clinical symptoms of dementia,
delirium, acute psychosis, severe anxiety, personality change,
depression, or suicidal ideation)
An ability to maintain independence and control of his or her
environment
Physical or cognitive changes that interfere with activities of
daily living
Any concerns about changes in medical status
Box 32-5 lists the clinical phenomena related to late-phase
HIV/AIDS.
BOX
32.5
Clinical Phenomena
HIV/AIDS
of
Late-Phase
Transcultural
Considerations
Cultural
Beliefs
and
Myths
each other
Is the result of a sick world
Is the result of a government germ-warfare experiment
CULTURE
WOMEN
MEN
African-American
64%
50%
Hispanic
18%
20%
White
18%
30%
Heterosexual
75%
15%
MSM*
n/a
42%
IDU* *
25%
25%
Another myth is that the cause of AIDS has been fabricated to allow
pharmaceutical companies and the health care system to profit
financially from the sale of expensive drugs and use of specific
treatment
protocols.
It is important to recognize that such myths exist. Be sure to assess
the client for beliefs in such myths. The psychiatricmental health
must be prepared to discuss them if the client or a family member
introduces
the
subject.
Ethnic Issues of
Stigmatization
Homophobia
and
Assessment
Syndrome
for
Immune
Recovery
Assessment
as
Secondary
Prevention
Nursing
Diagnoses
Examples of
HIV/AIDS
NANDA
Nursing
Diagnoses:
to
HIV/AIDS
Outcome
Identification
and
medications
Planning
Interventions
and
Implementation
Major clinical advances that began in 1996 have dramatically
changed the treatment and course of
P.556
HIV/AIDS. These significant gains have come from a clearer
understanding of the pathogenesis of HIV infection, the development
of stronger and more effective therapeutic agents, the development
of combination therapies, and the use of carefully selected
complementary therapies. A holistic, multidisciplinary approach that
augments the available treatment and management options for
clients is used to improve palliative outcomes and enhance overall
well-being.
Early-Phase
Planning
and
Implementation
Middle-Phase
Planning
and
Implementation
Clinical phenomena of the middle phase may last for years. They
include changes in physical appearance such as weight loss, somatic
preoccupation in anticipation of changes in physical status, and an
actual decline in physical condition as the illness progresses. Medical
problems may include infections such as toxoplasmosis, herpesvirus,
cryptococcal meningitis, lymphomas, and toxic effects of treatment.
Central nervous system pathology may contribute to deficits in
Assistance
With
Meeting
Basic
Needs
After the client's clinical symptoms have been identified and the
client's preferences and resources regarding the best possible
approach to care are known, interventions are provided by the
psychiatricmental health nurse personally or in collaboration with
members of the treatment team if a multidisciplinary treatment team
approach is used.
Interventions usually focus on the progression of intellectual and
cognitive dysfunction, impaired sensorimotor function, and the
presence of personality or behavioral disturbances (Ripich, 1997).
They include:
Assisting the client with activities of daily living if the client has
impaired sensorimotor function or intellectual and cognitive
dysfunction
Providing
adequate
nutrition
Medication
Management
Assistance
With
Emotional
Needs
of control
Finding new meaning in life while adapting to limitations of his or
her illness
Coping with possible condemnation and rejection from society,
family, friends, and health care workers
Maintaining continuing communication among all involved social
and medical agencies and providers
Resolving multiple and complex financial and legal concerns
Reconciling with estranged family members or significant others
Facing and discussing death and dying issues while maintaining
respect and dignity
Discussing and exploring ethical and moral beliefs about rational
suicide
Late-Phase
Planning
and
Implementation
experiencing their own grief. This may be done without the physical
presence of the client (Lego, 1996; Ripich, 1997).
Client
and
Family
Education
SUPPORTING
EVIDENCE
FOR
PRACTICE
32.1
that
Footnote
Source: Leserman, J., Petitto, J. M., Golden, R. N., Gaynes, B. N.,
Gu, H., Perkins, D. O., Silva, S. G., Folds, J. D., & Evans, D. L.
(2000). Impact of stressful life events, depression, social support,
coping, and cortisol on progression of AIDS. The American Journal of
Psychiatry, 157 (8), 12211228.
Community
Support
Groups
of helping the person with AIDS retain legal and personal control
over his or her life for as long as possible.
Continuum
of
Care
Evaluation
Traditional evaluation strategies are effective when stated outcomes
reflect realistic, attainable expectations. In other words, outcomes
should reflect the uncertainty of the client's life. Failure to develop
such outcomes often results in client frustration (Ripich, 1997).
During the evaluation process, the nurse may identify the need to
make several adjustments due to the progression of the disease
process and development or existence of a comorbid mental illness.
Continuum of care is evaluated to determine if all possible support
systems are in place as the client deals with the final stage of life.
Chapter 6 addresses loss, grief, and end-of-life care. See Nursing
Plan of Care 32-1 : The Client With AIDS.
Key
Concepts
Although AIDS emerged in 1981 and the HIV virus was identified
in 1986, there is still neither a cure for the disease nor a
preventive
vaccine.
Global statistics indicate that there are 5.3 million new cases of
AIDS per year. In the United States, approximately 500,000 to
600,000 citizens were diagnosed as HIV-positive and another
Ineffective
coping
skills
Rationale
The client may not
recognize positive
coping skills.
Encourage
of anger.
verbalization
of
cause
Rationale
aware of the
relationship between his
anger about his illness
and his anxious
behavior.
Provide
information
about
HIV/AIDS.
NURSING
Rationale
The client may identify
external stimuli or
verbalize habits that
interfere with
relaxation.
purposefully relax
before retiring.
P.560
Assessment is ongoing as clients experience the clinical
Chapter
Critical
Worksheet
Thinking
Questions
developmental,
social,
and
psychological
issues,
Reflection
According to the chapter opening quote by Sadock and Sadock,
clients with HIV infection may develop neuropsychiatric phenomena.
Prepare an educational tool to inform HIV-infected clients and their
families or significant others about the neuropsychiatric syndromes
and psychiatric disorders associated with AIDS. What approach would
you use? Explain the rationale for your approach. Would you provide
the clients and other attendees an opportunity to interact with you
and others during the discussion?
Multiple
Choice
Questions
Answer
Answer
For the client with AIDS, emotional crises may result from the
client's increasing isolation as he or she attempts to cope with the
nearly universal stigma faced on a daily basis. AIDS clients
experience rejection from all parts of society, including significant
others, families, friends, social agencies, landlords, and health care
workers. For many, this constant rejection causes a reliving of the
coming-out process,
with a heightening of the associated
anxiety, guilt, and internalized self-hatred. The fear of spreading
AIDS to others can lead to further isolation and abandonment,
commonly at a time when there is an ever-greater need for physical
and emotional support. Support groups have become a key element
in providing treatment. The other options may play a role in how an
individual copes with the disease; however, they are not the most
important.
3. The nurse assesses the client recently diagnosed with AIDS
for which of the following expected psychological responses?
a. Anxiety and depression
b.
Cognitive
impairment
View
3. A
Answer
Answer
During the late phase of HIV/AIDS, the nurse would encourage the
client to review his or her life. The nurse remains available and
assists the client in expressing his or her feelings regarding this final
stage of life. Clients often want to review happier times or talk about
regrets during a life review process. Ensuring financial support is
highly individualized. Depression and fear of deformity are
associated with the early phase of this disease.
5. Which intervention would the nurse implement to ensure
the continuum of care for a client with HIV/AIDS?
a. Assisting family to discuss feelings about client's diagnosis
b. Encouraging client to learn about the disease process
c. Helping client identify fears related to dying
d. Referring client to community AIDS support groups
View
5. D
Answer
Internet
Resources
Clearinghouse:
Selected
References
syndrome.
manual
of
Readings
10 (7), 4549.
Resource,
Chapter
33
Aging Clients
Needs
with
Psychosocial
Learning
1994
Objectives
Key
Terms
Aging
Dementia syndrome of depression
Ego
preoccupation
Ego
transcendence
Failure to thrive
Polypharmacy
Primary
aging
Reminiscence
Secondary
aging
Self-actualization
P.565
The number of individuals over the age of 65 (referred to as late
adulthood ) is rapidly expanding. Several agencies have provided
statistics regarding the population of individuals aged 65 years and
older. On July 1, 2000, the Administration on Aging (AOA) indicated
that approximately 15% of the United States population of 248.5
million persons, or 35 million individuals, were 65 years of age or
older. Of this group, approximately 10 million were between the ages
of 65 and 69 years; 9 million were between the ages of 70 and 74
years; 7.5 million were between the ages of 75 and 79 years; 5 million
were between the ages of 80 and 84 years; and approximately 4
million were over 85 years of age. It is estimated that by the year
2020, approximately 52 million persons will be 65 years of age or older
(Administration on Aging [AOA], 2001).
The public has become increasingly sophisticated in its knowledge and
expectations of older-adult health care. As a result, the health care
profession has been required to pay greater attention to specialization,
thereby responding to the increasing consumer demand. Public
pressure is enhanced further when families themselves form
organizations to better highlight these needs and focus attention on
various areas. For example, the Alzheimer's Association in the United
States, formed in 1980, now has over 200 local chapters across the
country (Alzheimer's Association, 2003).
Nursing has also addressed the issue of health care for the elderly. The
aging person, like any other younger human being, has certain
psychosocial, physical, and environmental needs that he or she strives
to satisfy throughout life. Therefore, an understanding of the aging
person's life experiences and goal achievements is necessary for the
development of a therapeutic milieu to meet the aging person's needs
as he or she continues to achieve his or her goals.
The American Nurses Association (ANA) first acknowledged nursing of
Etiology
of
Aging
Gender
According to statistics provided by the AOA, women live longer than
men by approximately 7 years and will continue to do so until the year
2050. By the year 2050, the composition of the U.S. population is
estimated to differ markedly from that of today (AOA, 2001). Factors
assumed to influence or contribute to women's longevity include
endocrine metabolism before menopause that protects against
circulatory or cardiovascular diseases, higher activity level, less
occupational stress, better weight control, and less use of tobacco.
P.566
THEORY
DAMAGE
Free
BIOLOGIC
CHANGES
THEORIES
radical
theory
Cross-link
theory
Immunologic
theory
Somatic
mutation
Error
theory
PROGRAM
THEORY
POPULAR
THEORIES
Stressadaptation
theory
Culture,
Ethnicity,
and
Race
among whites over age 75. The overall life expectancy of the Native
American is shorter than that of all other U.S. races, at 65 years of
age. Adherence to a set of cultural beliefs, values, and practices makes
outside intervention for treatment of conditions such as malnutrition,
alcohol abuse, and tuberculosis for Native Americans difficult at best
(AOA, 2001; Sadock & Sadock, 2003, University of Missouri, 2003c).
Intelligence
and
Personality
Familial
Longevity
Familial longevity patterns are indicators of potential lifespan. A 45year-old man from a family with a record of long-lived greatgrandparents, grandparents, and parents probably will live longer than
a man of the same age whose family history includes heart attacks by
his father and grandfather in middle age. Many conditions that
contribute to a shortened lifespan can be prevented, delayed, or
minimized with effective interventions such as regular medical
checkups; minimal use of substances such as coffee, cigarettes, or
alcohol; work satisfaction; healthy eating habits; and adequate
Genetic
Influences
Genetic disease may also affect lifespan. For example, persons with
Down syndrome, cystic fibrosis, or Tay-Sachs disease typically
experience shortened lifespans. Genetic factors have also been
implicated in disorders commonly occurring in older adults (eg,
coronary artery disease,
P.567
hypertension, arteriosclerosis). Although people have minimal, if any,
control over intrinsic factors influencing the aging process, a high
quality of life can possibly promote one's sense of physical, mental,
and social well-being (Sadock & Sadock, 2003).
Secondary
or
Extrinsic
Factors
level
education
health practices and related diseases
societal
attitude
Developmental
Tasks
of
Aging
satisfactory
living
arrangements
comfortable
routines
Establishing
Satisfactory
Arrangements
Living
THEORIST
SUMMARY OF THEORY
Piaget
(1961)
Erikson
(1963)
Peck
(1968)
preoccupation
Body transcendence versus body
preoccupation
Ego transcendence versus ego preoccupation
Neugarten
(1968)
Interiority
is characteristic of aged
persons and indicates a growing interest in inner
development during later life.
Jung
(1971)
Kohlberg
(1973)
Native
American
Elderly
African
American
Elderly
Hispanic
Elderly
Asian
American
Elderly
The number of Asian American elders living below the poverty level
(13%) is slightly higher than that of the white older population (10%).
Approximately 80% of Asian American elderly live alone, as more adult
married children work and become Westernized. This creates a
pressing need for more affordable housing, congregate housing, and
nursing facilities (American Association of Retired Persons [AARP],
2003; DuPuy, 2002).
Adjusting
to
Retirement
Income
Native
American
Elderly
The average Native American barely lives long enough to reach the age
African
American
Elderly
African American male elders generally have fewer personal postretirement resources than white males and are more dependent on
Social Security and Supplemental Security Income. Many African
American elderly males regard themselves as unretired-retired
because they generally continue to work after retirement age unless
they are forced to retire because of a physical or mental disability
(University of Missouri, 2003a). No information is available concerning
retirement and African American elderly females.
Hispanic
Elderly
Asian
American
Elderly
Asian Americans are more likely than white elderly to continue working
after age 65. Social Security is the only source of retirement income
for 34% of elderly Asian Americans (Social Security Administration,
Establishing
Comfortable
Routines
Retirement is a time for the pursuit of leisure and for freedom from the
responsibility of previous working commitments. It allows one to
establish a comfortable routine such as participating in a weekly
bowling league during the day, doing volunteer work, or developing
new hobbies. Conversely, retirement may be a time of stress,
especially for the workaholic
or type A personality, who needs
to be busy all the time. All my husband does is get in my way. He's
always underfoot like a little puppy dog. I wish he were still
working,
I thought we'd do things together such as golf, bowl,
or play bridge. He's not interested in doing anything,
and I
don't enjoy life any more. There's nothing to look forward to now that I
am retired
are just a few comments by persons having difficulty
adjusting to new routines during retirement. On the positive side, a
senior citizen thoroughly enjoying retirement made the following
comment: I don't know how I managed to work before. I don't
have enough time in the day to do everything.
Native
American
Elderly
African
American
Elderly
Hispanic
Elderly
Hispanic elderly tend to view themselves as old much earlier in life (eg,
60 years of age as compared with age 65 for African Americans and
white Americans) and expect fewer remaining years of life than any
other group. Established negative attitudes and expectations about
aging limit their ability to establish comfortable routines enjoyed by
their elderly counterparts (University of Missouri, 2003b).
Asian
American
Elderly
Asian American men can expect to live to age 84 and women can
expect to live to age 88. With longer life expectancies, they will live
more years in retirement, allowing them the opportunity to establish a
comfortable retirement routine. As a result of longer life expectancy,
there is a demand for social and community outreach programs to
provide bilingual, bicultural services (DuPuy, 2002).
Maintaining Love,
Relationships
Sex,
and
Marital
Most older people want and are able to lead an active, satisfying
sex life. When problems occur they should not be viewed as
inevitable, but rather as the result of disease, disability, drug
reactions, or emotional upset and as requiring medical care
(National Institute on Aging, 1981). Walker (1982, p. 171) states,
The notion that old age will be sexless has been proven false in
study after study. Provided that they are healthy, elderly people are
capable of an active sex life into their 80s and 90s. Sexual
performance may be slowed somewhat with aging, but sexual pleasure
and capacity remain intact.
Sexual problems can arise in later years due to physiologic changes,
fear of impotence, fear of a heart attack because of physical exertion,
Native
American
Elderly
African
American
Elderly
Hispanic
Elderly
Nearly twice as many Hispanic men as women age 65 years and older
are married and living
white older population.
more favorable chance
elderly Hispanic women
About the same proportion of Hispanic and white women are widowed
(AARP, 2003).
Asian
American
Elderly
Keeping
Active
and
Involved
SUPPORTING
EVIDENCE
for
Practice
33.1
UNDER
and contact with available family and friends. Subjects were also asked
if they had children, a partner, or a full-time or part-time job. A nineitem version of the Health Locus of Control instrument was used to
obtain data. Results of the study indicated that better subjective
memory was associated with youth, health, education, and internal
orientation. Higher memory capacity was associated with younger age,
fewer health problems, being female, frequent contact with
family/friend, higher internal locus of control, and self-perception as
active. Intact memory capacity was associated with being female and
self-perception as active. Self-perception had greater impact than the
hours per week the subject was engaged in activity. The researchers
suggest that increasing an elder's social activity may support
successful aging.
SUPPORT FOR PRACTICE :Psychiatricmental health nurses
working with older clients need to keep this study in mind and design
nursing interventions to improve cognitive functioning and reduce
anxiety about memory loss. Furthermore, the nurse should encourage
elder clients to engage in physical and social activities.
Footnote
Source: Stevens, F. C. J., Kaplan, C. D., Ponds, R. W., Diederiks, J. P.
M., & Jolles, J. (1999). How ageing and social factors affect memory.
Age and Ageing, 28 (4), 379384.
Native
American
Elderly
African
American
Elderly
Hispanic
Elderly
Of all minority older persons aged 65 years and older, Hispanic elderly
are the least educated. Approximately 10% have had no education and
only 27% have graduated from high school. Language and
transportation barriers, living in isolated areas, living on an inadequate
income, and functional limitations can contribute to lack of motivation,
thus preventing Hispanic elderly from becoming active and involved
within the community (AARP, 2003).
Asian
American
Elderly
statement: I cry inside every day. Each time they come to visit
me, I beseech them to take me home All I want is to hold my
daughter's hand and be surrounded by those people and things I
love.
The following poem appeared in a local newspaper along with a drawing
of a forlorn-looking elderly woman sitting alone in her home:
Next year.
They said they'll come down for Christmas next year.
Excuses
again.
Native
American
Elderly
Most elderly Native Americans have large extended families and are
able to stay in touch with family members. Sharing of responsibilities
by family members, respect for others, and allowing for individual
freedom are integral parts of the Native American lifestyle. Generosity
is valued, especially in helping family members and others who are less
fortunate (University of Missouri, 2003c).
African
American
Elderly
Hispanic
Elderly
Asian
American
Elderly
Sustaining and
Mental Health
Maintaining
Physical
and
Native
American
Elderly
African
American
Elderly
More than 50% of African American elderly are in poor health. They
experience multiple chronic illnesses (eg, diabetes, hypertension, and
obesity) that can progress into more severe complications. Also, they
tend to be institu tionalized for psychiatricmental health disorders
(eg, multi-infarct and alcoholic dementia) more often than whites.
Their admissions to psychiatricmental health facilities are less likely
to be voluntary (University of Missouri, 2003a).
Hispanic
Elderly
Physical health is ranked as the most serious concern and fear that
Hispanic elderly face. Their work, primarily unskilled labor, which often
involved hard physical labor, has left them vulnerable to a variety of
illnesses and disabilities. Hypertension, cancer, diabetes, arthritis, and
high cholesterol are the leading medical problems found among the
Hispanic elderly. In addition, Hispanic elderly who experienced
functional limitations are at risk for mood disorders, such as
depression (University of Missouri, 2003b).
Asian
American
Elderly
Self-Awareness
Prompt
P.573
Native
American
Elderly
The meaning of life for elderly Native Americans does not rely upon
individual success. Ego transcendence occurs as the elderly present
African
American
Elderly
EGO
TRANSCENDENCE
EGO
PREOCCUPATION
Zest
Apathy
Resolution
Passivity
and
fortitude
Positive
Negative
self-concept
self-concept
Is unable to appreciate
life; displays a pessimistic
attitude; may be irritable,
bitter, or gloomy in
emotional
reactions
P.574
Hispanic
Elderly
Asian
American
Elderly
Psychodynamics
of
Aging
BOX
33.1
Elderly
Responses
to
Despair*
Difficulty
falling
asleep
Suspiciousness
Persecutory
Depressed
thoughts
mood
Hypochondriasis
Anxiety
Footnote
Reactions are listed in order of descending prevalence.
Anxiety
Anxiety disorders were believed to decline with age. Experts are now
beginning to recognize that anxiety and aging are not mutually
exclusive. Although anxiety is as common in the elderly as in the
Loneliness
Loneliness is considered the reactive response to separation from
persons and things in which one has invested oneself and one's
energy
(Burnside, 1981, p. 66). Burnside lists five causes of
loneliness in the elderly (from most common and severe to least
common and severe):
Death of a spouse, relative, or friend.
P.575
Loss of a pet: Some elderly persons relate to pets as though they
are family members, and the death of a longtime pet can be very
traumatic.
The inability to communicate in the English language: People feel
isolated and lonely if they are in a foreign environment or are
unable to understand what is being said.
Pain: People often complain of loneliness when pain occurs during
the late-evening or early-morning hours because no one is around
to provide comfort.
Certain times of the day or night: Changes in living habits due to
institutionalization in a nursing home may cause loneliness because
Guilt
As elderly clients experience the life-review process, reminiscing about
the past, guilt feelings may emerge from past conflicts or regrets. For
example, an elderly man revealed guilt about not lending his daughter
and son-in-law money several years ago when they were in a financial
bind. At the time of the request, the man felt that the couple should be
able to support themselves. Young people don't appreciate things
given to them on a silver platter. They need to work for what they get.
Then they'll take care of it were his words of advice when they
asked for help. He went on to state that they had plenty of money now,
but money doesn't keep one company.
Feelings of guilt may
also occur when a client considers past grudges, actions taken against
others, outliving others, or unemployment or retirement.
Late-life
Depression
Somatic
Complaints
Paranoid
Reactions
P.576
paranoid reactions in the elderly. A strange environment also may
contribute to confusion and suspicious behavior among the elderly.
(See Chapter 15 regarding medications and Chapter 19 for additional
information about delusional disorders.)
Dementia
As noted in Chapter 24 , dementia is an acquired organic syndrome
defined by the presence of cognitive deficits such as impairment of
memory, abstract thinking, and judgment. The elderly are at risk for
dementia due to irreversible deterioration of the brain, mini-strokes
caused by hypertension, chronic substance abuse, neurologic diseases,
brain tumors, and metabolic diseases.
However, elderly clients have also been mistakenly diagnosed with
dementia due to a failure in recognizing a psychiatric disorder.
Depression by far remains the most frequent psychiatric disorder
mimicking or associated with dementia in the elderly. Clinical
symptoms of mania, psychosis, anxiety, personality disorders, and
conversion disorders also have been misdiagnosed as dementia (Read,
1991). Table 33-4 distinguishes the characteristics of dementia from
the dementia syndrome of depression (the rapid onset and short
duration of clinical symptoms that are often misdiagnosed as dementia
in clients who are severely depressed).
Delirium
Delirium is characterized by a disturbance of consciousness and
impairment of attention that fluctuates during the course of the day. It
is usually due to disturbance of brain physiology by a medical disorder
or ingested substance. It is one of the most common
psychiatricmental
health
diagnoses
in
the
elderly
population.
pharmacologic
adverse
effects,
and
The
Nursing
Process
Assessment
The assessment of the psychosocial needs of elderly clients is
multifaceted, focusing on the collection of demographic data, the
interview process, and the review of medical records. Many longstanding psychosocial issues not addressed in earlier years, as well as
the psychodynamics of aging discussed previously, may be present.
These issues may cause serious problems for family members or
caregivers to cope with. In addition, what looks like dementia or a
similar mental syndrome may, in fact, be clinical symptoms of heart
failure, pneumonia, or another medical disorder.
The
Assessment
Setting
DEMENTIA
Insidious,
indeterminate
DEMENTIA SYNDROME OF
DEPRESSION
onset
Rapid onset
Depressed
Client gives
answers
Client
near-miss
conceals
disabilities
mood
Fluctuation in level of
cognitive
impairment
P.577
The
Interview
Assessment
Tools
Special
Assessment
Concerns
The management of pain, polypharmacy (use of multiple over-thecounter drugs, prescription drugs, or a combination of both), getting a
good night's sleep, and loss of appetite or involuntary weight loss are
four recurring special concerns that may be identified during the
assessment of psychosocial needs of the elderly.
BOX
33.2
Comprehensive
Assessment
Geropsychiatric
Name:
Date of Birth:
Sex:
Marital
Status:
Religion:
Educational
Medical
Level:
Diagnosis:
Findings
(include
dates
obtained):
Neurologic
Findings
(include
tests
performed):
Presenting
Mental
Symptoms:
Status:
Functional
Behavioral
Status:
Assessment:
Systems
(include
preference/belief/support,
family dynamics):
Family
social
cultural
Input:
functioning,
beliefs,
religious
financial
resources,
and
Pain
The elderly, who have medical problems or chronic diseases, are twice
as likely to experience pain when compared with younger adults.
Moreover, elderly clients who experience pain are prone to the
development of behavioral disturbances, depression, or anxiety.
Behavioral disturbances are often seen in elderly clients who are
unable to verbally express that they are in pain (eg, clients with
aphasia, clients who are delirious, or clients with impaired cognition)
or who are unable to express anger regarding their medical condition.
Clients experiencing pain may also develop depression or anxiety due
to separation from family or fear of the unknown prognosis of their
P.578
medical condition. Assessment of pain is the key to proper diagnosis
and treatment. Because there are no biologic markers for the presence
of pain, an accurate conclusion about a client's pain can only be
determined by assessment and a thorough interview (Battista, 2002).
Failure to recognize pain as the underlying cause of changes in the
elderly person's behavior, mood, or affect may result in the
inappropriate treatment of clinical symptoms with psychoactive drugs
instead of pain medication.
Pain assessment includes an evaluation of the onset, location,
intensity, pattern, duration, quality of pain, precipitating and relieving
factors, and the effect pain has on function, mood, and sleep
(American Geriatric Society, 1998). In addition to pain assessment, the
psychiatricmental health nurse collects data about the type and
quantity of medication that the elderly client takes to provide
information about possible adverse effects or interactions that may
complicate the client's situation. (See Chapter 8 for additional
information
regarding
pain
assessment.)
Polypharmacy
A history of polypharmacy to treat pain or other conditions such as
heart failure, hypertension, or arthritis can place clients at risk for
adverse effects of drug interactions (eg, dizziness, confusion, or
unstable gait) or physiologic changes (eg, electrolyte or metabolic
SleepRest
Activity
(Insomnia)
The elderly client may experience episodic, acute insomnia that lasts
from 1 night to a few weeks, or chronic insomnia that lasts for 1 month
or longer. The consequences of lost sleep include fatigue, lack of
energy, difficulty concentrating, and irritability. Lack of sleep, which
has an adverse effect on occupational and social functioning, also leads
to accidents and traffic fatalities (Nadolski, 2003). Common causes of
insomnia in the elderly client may include environmental changes,
disruption in the client's sleeping environment (eg, phone calls or
noise), emotional stress, pain, medication (eg, central nervous system
stimulants, diuretics, or decongestants), poor sleep hygiene, or the
presence of a specific sleep disorder. (Chapter 8 discusses primary and
secondary
insomnia.)
When assessing the client's sleep problems, ask the client to describe:
when the problem began
his or her sleep hygiene habits
usual retirement and wake-up time
his or her sleep environment
Involuntary
Weight
Loss
Barriers
to
Assessment
Provider-Related
Barriers
stigmatizing the client, especially if the client has never been treated
by a mental health professional, or the nurse's uncertainty about when
to initiate an assessment for mental health problems. In addition, time
constraints imposed on the nurse may lead to feelings of being rushed
and obtaining incomplete data when discussing mental health issues
with elderly clients. Other barriers include lack of provider or referral
access due to limitations of health care coverage; and reimbursement
considerations such as precertification requirements for a mental
health
consultation.
Client-Related
Barriers
Illness-Related
Barriers
Transcultural
Considerations
Nursing Diagnoses
Identification
and
Outcome
Planning
Interventions
and
Implementation
Emphasis is placed on maximizing the older person's independence by
assisting with the basic human needs identified by Maslow (1968);
meeting emotional needs; and maintaining life with dignity and comfort
until death.
of aging
Anxiety related to perceived change in socioeconomic status
secondary to retirement
Ineffective Coping related to changes in physical environment
secondary to relocation
Disturbed Sleep Pattern related to pain secondary to arthritis
Ineffective Health Maintenance related to lack of motivation
secondary to divorce
Risk For Loneliness related to loss of usual social contacts
secondary to loss of driving ability
Powerlessness related to unmet dependency needs
Risk for Relocation Stress related to high degree of environmental
change secondary to change in available caregiver
Assisting
With
Meeting
Basic
Human
Needs
Need
for
Survival
Pain
Management.
increasing
develop
percentage
the body's
CLASSIFICATION
GENERIC
(TRADE)
TOTAL
DAILY
DOSAGE
Antipyretic/analgesic
acetaminophen
(Tylenol)
4000 mg
Non-steroidal
antiinflammatory
celecoxib
(Celebrex)
etodolac (Lodine)
ketoprofen
(Oruvail)
naproxen (Naprosyn)
rofecoxib (Vioxx)
400 mg
1000 mg
2000 mg
1000 mg
50 mg
Opioid
dextropropoxyphene
(Darvon)
dihydrocodeine
(Panlor
SS)
390 mg
5 tabs
carbamazepine
(Tegretol)
1200 mg
1800 mg
analgesic
Anticonvulsant
gabapentin
(Neurontin)
Stabilization
of
SleepRest
Activity.
Interventions
for
Involuntary
Weight
Loss.
change
gradually
Need
for
Positive
Self-Esteem
Need
for
Self-Actualization
Life-Review
Process.
Reminiscence.
Self-actualization may also be achieved through reminiscence. In
contrast to the life-review process, reminiscence is a therapeutic
process of consciously seeking and sharing memories of past
significant experiences and events. This process may occur with an
individual client or in groups. Nursing interventions are similar to those
used in the life-review process (Neff, 1996).
Grief
Work.
The loss of a spouse has been rated as the most stressful life event
across all ages and all cultural backgrounds. Loss of an adult child is
equally as stressful to many elderly individuals who rely on their
children to provide emotional or financial support. Some elderly clients
are unable to complete the task of self-actualization until they work
Psychodynamic
Psychotherapy.
Medication
Management
Continuum
of
Care
BOX
33.3
Community Continuum
Interventions
of
Care
activities
and
stimulation,
self-actualization
therapy: Assessment to
Evaluation
During the evaluation process, the nurse determines whether any
barriers have interfered with the plan of care. The nurse and client
evaluate whether the client's psychosocial needs have been met, and if
they have not, what changes are necessary. Input from family or a
significant other may be solicited.
Key
Concepts
DAILY
DOSAGE
RANGE
IMPLEMENTATION
desipramine
(Norpramin)
1.52
mg/kg
nortriptylene
(Pamelor)
11.2
mg/kg
ileus.
citalopram
(Celexa)
1030
mg
sertraline
(Zoloft)
2575
mg
methylphenilate
(Ritalin)
2.520
mg
pemoline
18.7537
Monitor
(Cylert)
mg
liver
function;
Chapter
Critical
Worksheet
Thinking
Questions
Reflection
Multiple
Choice
Questions
Answer
a.
Decreased
productivity
Answer
The older adult has a need for love, belonging and self-actualization. A
lack of support systems leads to feelings of isolation and despair,
predisposing the client to depression. Decreased productivity and
sensory impairment may play a role in depression, but these are not
the highest priority. A rigid lifestyle, such as with type A personality,
may predispose the client to physical illness, such as heart attacks.
P.588
3. The nurse understands that an elderly client who has a
positive approach and finds meaning in life possesses which of
the following characteristics?
a. Ego preoccupation
b. Ego transcendence
View
3. B
c.
Passive
acceptance
d.
Reminiscence
ability
Answer
Paranoia
Somatization
Answer
Encouraging
participation
in
decision-making
Answer
To help meet love and belonging needs, the nurse would encourage
Internet
Administration
Divorce
Elderly
Resources
on
Statistics:
Research:
Aging:
http://www.aoa.gov
http://www.divorcereform.org
http://www.research.aarp.org/
Selected
References
http://www.alzheimers.org/
76 (9), 923929.
geriatric
primary
care
givers into the treatment team . Paper presented at the 12th Annual
United States Psychiatric & Mental Health Congress, Atlanta, GA.
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York:
W. W. Norton.
Ho, V. (2002, Apr 3). Culture shift strains social services as elderly
Asians' numbers rise. Seattle Post .
Jung, R. J., & Grossberg, G. T. (1993, Jul/Aug). Diagnosis and
treatment of psychiatric disorders in the nursing home. Nursing
Home Medicine .
Khin, N. A., & Sunderland, T., III. (2000). Geriatric treatment.
Psychiatric Times, 27 (1), 4748.
Maslow, A. H. (1968). Toward a psychology of being . New York: D.
Van Nostrand.
Monarch Pharmaceuticals. (2000). Trend watch: Depression and the
elderly. Clinical Geriatrics, 8 (6), 7275.
Nadolski, N. (2003). Getting a good night's sleep: Diagnosing and
treating insomnia. American Journal for Nurse Practitioners Spring
Supplement , s2s14.
National Council on the Aging. (2003). Facts about older Americans
and pain . Retrieved August 17, 2003, from http://www.orthomcneil.com/resources/misc/seniors_facts_bottom.htm
National Institute on Aging. (1981, Oct). Age page: Sexuality in
later life . Washington, DC: U.S. Department of Health and Human
Services.
American
elderly . Retrieved
http://www.iml.umkc.edu/casww/natamers.htm
United States Census Bureau. (1997). Demographic state of the
nation, 1997 . Retrieved March 4, 2004 from
http://www.census.gov/prod/2/pop/23/p23-193.pdf
Walker, J. I. (1982). Everybody's guide to emotional well-being .
San Francisco: Harbor.
Suggested
Readings
preventing
complications.
8 (8), 3437.
Peterson, K. S. (2000, Mar 7). Black couples stay the course. USA
Today .
Riley, J. B. (2001). Spiritual eldering. Advance for Nurses, 2 (1),
2324.
Schultz, J. M., & Videbeck, S. L. (2002). Lippincott's manual of
psychiatric nursing care plans (6th ed.). Philadelphia: Lippincott
Williams & Wilkins.
Scott, A. (2002). No time for the pain: Improvement needed in pain
management for the elderly. Advance for Nurses, 3 (4), 2527.
Sheahan, S. L. (2000). Medication use and misuse by the elderly.
Advance for Nurse Practitioners, 8 (12), 4142, 47, 76.
Sherer, R. A. (2001). Assisted living offers independence, but
health care needs may be unmet. Geriatric Times, 2 (2), 46.
Sussman, N., Hardy, M., & Magid, S. (2002). Psychiatric
manifestations of NSAIDs in older adults. Geriatric Times, 3 (1),
2932.
Thomas, M. (2003). Epidemiology and psychosocial aspects of
chronic pain in older adults. Geriatric Times, 4 (4), 2931.
Tully, J. (1999). Dealing with death: Good-by, old friend. American
Journal of Nursing, 99 (8), 24dddd.
Wiseman, R. (2000). Polypharmacy in the elderly population.
Continuing education course 101. Vital Signs, 20 (10), 2023.
Chapter
34
Seriously and
Ill, Homeless,
Clients
Persistently Mentally
or Incarcerated
Learning
2002
Objectives
Key
mental
illness.
Terms
program
Deinstitutionalization
Hate crime
Impulse
Mercy
control
disorders
bookings
Home
Ministries
P.590
Serious and persistent mental illness (SPMI) , also referred to as
severe and persistent mental illness , is the current accepted term
denoting a variety of psychiatricmental health problems that lead
to tremendous disability. Although commonly associated with illnesses
such as schizophrenia, the term SPMI includes people with wideranging psychiatric diagnoses (eg, bipolar disorder, severe major
depression, substance-use disorders, and personality disorders)
persisting over long periods (ie, years) and causing disabling
symptoms that significantly impair functioning.
The symptoms of SPMI can be ongoing throughout the lives of some
individuals, whereas others may experience periods of remission.
Every aspect of living can be affected by the illness, including family
and social relationships, physical health status, the ability to obtain
employment and housing, and even the ability to accomplish routine
activities of daily living. Persons with SPMI are often shunned by
society and isolated from the community. Their behavior is often
bizarre, including responding to hallucinations by shouting in public or
talking or gesturing to themselves. Their appearance may be
disheveled because hygiene and other self-care activities are
neglected due to the severity of the symptoms. Often, these persons
are unable to live independently and need assisted-living situations.
Such clients go through the revolving doors of acute psychiatric care.
They may be sent to group homes, to one of the few remaining state
institutions, to jails, or they may become homeless. Understanding
this population and their special problems and needs is important for
the
psychiatricmental
health
nurse.
of the Seriously
Mentally Ill
and
Persistently
Self-Awareness
Prompt
Think about clients you have met with serious and persistent mental
illness. What problems did they have? What were your attitudes and
feelings about their behaviors and their illness?
Deinstitutionalization
Deinstitutionalization , the process by which large numbers of
psychiatricmental health clients were discharged from public
psychiatric facilities over the past 40 years, created an influx of
seriously and persistently mentally ill clients back into the community
to receive outpatient care. Deinstitutionalization is a major factor in
the current problems of the mentally ill. Since 1960, more than 90%
of state psychiatric hospital beds have been eliminated. This process
began in 1955, and accelerated with the Civil Rights legislation of the
1960s as well as the withdrawal of federal-government financing for
state-hospital clients in the 1970s (see Chapter 7 ). See Clinical
Example 34-1 for an example .
Transinstitutionalization
Transinstitutionalization is the process of transferring statehospital clients to other facilities. Nursing-home placement and
incarceration remain a significant component of
transinstitutionalization. According to Andrew Sperling, director of
policy for the National Alliance for the Mentally Ill (NAMI), it appears
that there are still a large number of people with SPMI being placed in
nursing homes (MacNeil, 2001). Furthermore, America's jails and
prisons are now surrogate psychiatric hospitals for thousands of
individuals with the most severe brain diseases (Treatment Advocacy
Center [TAC], 2003).
CLINICAL
EXAMPLE
A Client
After
34.1
Deinstitutionalization
Inappropriate
Services
Use
and
Lack
of
Community
Categories of Seriously
Mentally Ill Clients
and
Persistently
Nursing-Home
Residents
An act of Congress and a Supreme Court decision to perform preadmission screening and resident reviews (PASRRs) prior to admission
have not stopped the inappropriate placement of mentally ill adults
into nursing homes that do not provide psychiatric services (see
Chapter 7 ). According to the Inspector General's office, there are
people in nursing homes who are seriously and persistently mentally ill
(eg, schizophrenia, bipolar disorder, and personality disorder) and in
need of more than casual mental health services. For example, 3.8%
of clients with chronic schizophrenia reside in nursing homes (Begley,
2002). Researchers in San Diego found that although older people with
schizophrenia did not have more physical illnesses than
nonmentally ill people in the same age range, their illnesses were
often more severe (Cohen, 2001). Of the top primary diagnoses at
P.592
the time of admission for nursing-home residents, mental disorders
ranked second (17%) only to diseases of the circulatory system (27%)
(Clinical Psychiatry News, 2001).
Federal agencies have accepted state recommendations to improve
nursing-home admission criteria for clients with mental illness and to
provide appropriate mental health services. However, the individual
The
Homeless
they:
Live in transitional or supportive housing
Ordinarily sleep in transitional or supportive housing but are
spending 30 or fewer consecutive days in a hospital or other
institution
Are being evicted within a week from a private dwelling and
without resources to obtain access to alternative housing
Are being discharged from an institution in which they resided for
more than 30 consecutive days and without resources to obtain
access to alternative housing (United States Department of
Housing and Urban Development, 2002)
Although several national estimates are available about homelessness,
many are dated, or based on dated information. By its very nature,
homelessness is impossible to measure with 100% accuracy. Recent
studies suggest that the United States generates homelessness at a
much higher rate than had been previously thought. The best
approximation of homelessness is from an Urban Institute study in the
year 2000, which states that about 3.5 million people1.35 million
of them childrenare likely to experience homelessness in a given
year (National Coalition for the Homeless [NCH], 2002b).
Clients deinstitutionalized from 1970 through the 1990s often ended
up homeless due to lack of adequate psychiatricmental health and
social services. Statistics released by the Treatment Advocacy Center
in 1999 indicate that 200,000 individuals with schizophrenia or bipolar
CLINICAL
The
EXAMPLE
Homeless
Client
34.2
With
SPMI
DN was removed from her parents' home at the age of 8 after physical
and sexual abuse. She lived in five different foster homes until the
age of 15, when she was placed in a group home. At age 17, she ran
away from the group home and lived on the streets or in shelters in
between the times she was hospitalized. DN's situation includes risk
factors for homelessness, including the presence of positive symptoms
of schizophrenia (hallucinations and delusions), a personality disorder,
and a chaotic family experience until age 18.
P.593
Veterans (approximately 40% of the homeless population)
HIV/AIDS victims (approximately 3%20% of the homeless
population)
Domestic-violence victims (unable to estimate but considered to
be one of the primary causes of homelessness)
Substance abusers (unable to estimate due to refusal to admit to
illegal use of substances)
The rates of both chronic and acute health problems are extremely
high among the homeless, who are far more likely to suffer from every
category of chronic health problem. In addition, the problems
associated with homelessness, although affecting every aspect of
living, can have specific consequences depending on the age and
gender of the individual affected.
Children, Adolescents, and Young Adults . Numerous
psychiatricmental health problems that manifest in
adolescence
and young adulthood have their roots in early childhood. Studies have
also shown that an important risk factor for infants and children is the
occurrence of psychopathology in the primary caregivers (Office of
Disease Prevention and Health Promotion [ODPHP], 1998). For
example, preschool and school-age children of women who are
homeless and mentally ill are at high risk for physical and emotional
illnesses, as well as developmental delays. Poor nutrition, chronic
stress of the caregiver who is homeless, and lack of access to
preventive health care are contributing factors. The adolescent
population is at high risk for being physically and sexually abused.
They are also at high risk for using drugs and alcohol to cope with
homelessness.
Women . Women who are homeless have often experienced domestic
violence. When mental illness is present, the combination of the illness
and lack of adequate resources is a causative factor in homelessness.
A history of unwanted pregnancies and sexually transmitted diseases,
and the risk for rape and violence, also are common in homeless
women.
The Elderly . The elderly, although constituting a small percentage of
the homeless population, generally have problems related to dementia
often caused by chronic use of substances. A study of elderly
homeless men identified that this population was poorer, in poorer
health, and more likely to have alcohol-use disorders than their
younger counterparts (DeMallie, North, & Smith, 1997).
Hate Crimes Against the Homeless. Hate crime is defined by the
U.S. Congress as a crime in which the defendant intentionally selects a
victim (or in the case of a property crime, the property that is the
object of the crime) because of the victim's race, color, or national
origin (Title 18 U.S.C. Section 245) (NCH, 2002a).
Over the past several years, advocates and homeless-shelter workers
have received news reports of homeless individuals, including children,
being harassed, kicked, set on fire, beaten to death, and even
decapitated. From 1999 through 2001, there were 110 murders of
people without housing by housed people and 140 victims of nonlethal violence in 82 cities in 32 states and Puerto Rico (NCH, 2002a).
Most hate violence is committed by individual citizens who harbor a
strong resentment toward a certain group of people; who violently act
out their resentment toward the perceived growing economic power of
a particular racial or ethnic group; or who take advantage of
vulnerable and disadvantaged persons to satisfy their own pleasure.
The
Incarcerated
CLINICAL
EXAMPLE
34.3
FR was never able to secure employment due to his SPMI and has
depended on welfare and group-home living. He had a substanceabuse problem and when drinking would frequently destroy property
or become involved in fights. Thus he has a history of being
incarcerated. FR also has a history of obesity and diabetes mellitus,
has had one myocardial infarction, and continues to smoke and not
manage his diabetes well.
Clients at Risk for Incarceration . Most crimes for which the
seriously and persistently mentally ill are arrested are minor.
However, some mentally ill offenders require incarceration to protect
society. These offenders often include individuals with impulse control
disorders, sexual disorders, substance-abuse disorders, bipolar
disorders, personality disorders, and as noted earlier, psychotic
disorders.
The Client With an Impulse Control Disorder . Many psychological
problems are characterized by a loss of control or a lack of control in
specific situations. Usually this lack of control is part of a pattern of
behavior that also involves other maladaptive thoughts and actions,
such as substance abuse (Psychology Information Online, 2003).
Impulse control disorders are characterized by a person's failure to
resist an impulse, thus not preventing oneself from performing an act
that will be harmful to self or others. Researchers believe that impulse
control problems may be related to functions in specific parts of the
brain, and may be due to a hormonal imbalance or the abnormal
transmission of nerve impulses. Although the specific etiology is
unknown, a person who has had a head injury or the diagnosis of
temporal lobe epilepsy is at higher risk for developing an impulse
control disorder. Diagnosis is only made after all other medical and
psychiatric disorders that might account for the symptoms have been
ruled out (Psychology Information Online, 2003). Examples of impulse
control disorders that often lead to incarceration are listed in Table
34-1 .
The Client With a Sexual Disorder . Individuals with the diagnosis of a
sexual disorder may be incarcerated due to exhibitionism, voyeurism,
rape, or pedophilic behavior. Alexander (1999) examined 79 studies
TYPE OF DISORDER
DESCRIPTION OF DISORDE
Intermittent
explosive
Kleptomania
Pathological
Pyromania
gambling
inmates with SPMI who are incarcerated have life-long drug or alcohol
disorders. Their reported rates of current substance-use problems,
including the abuse of alcohol, range from 62% to 72%. More than
half of incarcerated mentally ill clients report having used drugs or
alcohol while committing their current offense (Watson, Hanrahan,
Luchins, & Lurigio, 2001). Clients with a dual diagnosis are more likely
to become homeless, to be hospitalized, to have greater difficulty
sustaining employment, and to be noncompliant with treatment.
The Client With Bipolar Disorder . The prevalence of bipolar disorder in
the prison population is approximately 6%, compared with 1% in the
community at large. Prominent bipolar symptoms such as agitation,
impulsivity, poor judgment, and psychosis increase the risk of criminal
behavior. Comorbidity with a substance-use disorder is greater than
with any other Axis I disorder. Offenses for which clients with bipolar
disorder are usually incarcerated cover a broad spectrum, but violent
crimes are twice as common as property or drug-use crimes. Crimes of
noncompliance (ie, failure to heed the police) are also frequently
committed (Sherman, 2001).
The Client With a Personality Disorder . Individuals with a personality
disorder make up a large proportion of the violent mentally ill;
antagonistic and hostile traits are noted in eight of the different
personality disorders (Kravitz & Silberberg, 2001). Antisocial,
borderline, and schizotypal personality disorders are the most common
types noted in clients who are incarcerated.
Clients with antisocial personality disorder fail to conform to social
norms with respect to lawful behaviors. They violate the rights of
others and repeatedly perform acts that are grounds for arrest.
Clinical features also include deceitfulness, impulsivity, irritability and
aggressiveness, recklessness, irresponsibility, lack of remorse, and
the presence of a conduct disorder before the age of 15 years.
Clients with borderline personality disorder exhibit impulsivity that is
potentially self-damaging. They have difficulty controlling anger,
thereby posing a threat to the safety of others, and they exhibit
transient stress-related paranoid behavior. Clients with the diagnosis
of schizotypal personality disorder exhibit suspiciousness or paranoid
The
Nursing
Process
Assessment
Assessment of a client with SPMI must be comprehensive, focusing on
physical health status, current clinical symptoms, self-care abilities,
living situation, coping skills and available support systems,
compliance with medications, and the presence of substance abuse.
Assessment may occur in a variety of settings including the hospital,
Physical
Health
Status
Current
Clinical
Symptoms
Self-Care
Abilities
Assess the client's self-care abilities and the ability to provide for
basic physical needs (ie, grooming, bathing, feeding, and toileting).
Many clients with SPMI experience frequent decompensations (ie,
return of psychotic symptoms) and find that negotiating activities of
Current
Living
Situation
Coping
Skills
and
Support
Systems
Compliance
With
Medication
Substance-Abuse
Problems
Because substance abuse is often a problem for the client with SPMI
and often contributes to arrest and incarceration, assessment is key.
A screening tool, such as the CAGE questionnaire for alcoholism
discussed in Chapter 26 , is useful in determining the coexistence of a
substance-abuse problem. Questions focus on the specific substances
and the amount, frequency, and length of time used. The client also is
asked whether he or she has received any treatment for substance
abuse. Inadequate treatment often leads to continued substance
abuse and repeated incarceration (Watson et al., 2001).
Nursing
Diagnoses
Many nursing diagnoses can apply to the client with SPMI. Priorities
are established based on the client's physical health status, potential
for harm to self or others, current symptomatic behaviors, self-care
abilities, coping skills, and available support systems. See the
accompanying Examples of North American Nursing Diagnosis
Association (NANDA) Nursing Diagnoses box.
(failure
to
take
prescribed
psychotropic
Outcome
Identification
Planning
Interventions
interactions
with
others.
Implementation
Since
deinstitutionalization,
the
psychiatricmental
health
nurse
in
physical
health
Providing
medication
management
and
education
care
approach
or
with
psychosocial
rehabilitation
Providing
Safe
Environment
Outpatient
civil
commitment
Pretrial
diversion
Probation
Fitness to
stand trial
Promoting
Physical
Health
Providing Medication
Education
Management
and
Using
CognitiveBehavioral
Therapy
Orienting
to
Reality
clients improve their ability to test reality and regain control of their
environment. The nurse may reinforce reality through the use of a
calendar and large posterboards that include the date, weather,
names of staff, and schedule of activities for the unit. When the client
experiences hallucinations or delusions, the nurse intervenes by
accepting that the hallucinatory voice or delusional thought is real to
the client. Explaining to the client that the nurse neither believes what
the client believes, nor hears what the client hears, reinforces reality.
A helpful technique includes directing the client to tell the voices that
they hear to go away. This technique helps the client learn to push the
voices aside rather than pay attention to what they are saying.
Focusing on something concrete in the immediate environment also
helps the client by distracting him or her from the voices or the
delusional thought. Simple physical activities, such as writing,
drawing, or using an exercise bike, can redirect energy to acceptable
activities and help distract the client.
When a client demonstrates loose associations, the nurse clarifies the
meaning of the client's communication and focuses the client on
here-and-now
issues. Telling the client that the nurse does
not understand what the client is trying to say is important feedback
to the client's communication. Encouraging the client to explain in
another way communicates the nurse's interest in understanding the
client's
experience.
Promoting
Self-Care
Clients with SPMI often neglect personal hygiene. They may not have
access to supplies or may lack motivation to attend to personal
hygiene. During cognitivebehavioral therapy, the nurse encourages
the client to maintain personal hygiene, and uses techniques such as
positive reinforcement to improve the client's efforts. Telling the client
in a matter-of-fact manner that it is time to take a shower, and then
providing the materials needed for showering, provides necessary
cues. If the client is completely unable to perform self-care, the nurse
provides care in an accepting, nonjudgmental manner. The nurse
continues to encourage the client in self-care measures, however. A
regular routine for hygiene activities helps to structure the client's
Enhancing
Self-Esteem
The client with SPMI often has great difficulty feeling positive about
her- or himself due to repeated failures in multiple areas of living.
During cognitivebehavioral therapy, the nurse communicates
respect for the client and identifies those areas in which the client has
been able to function. Encouraging the client to identify positive selfstatements and provide examples of positive functioning promotes
self-esteem.
Other
Identifying
nursing
positive
interventions
coping
may
include:
skills
assertiveness
skills
Providing
Support
experience of
her current
describes
from the
Employing
Approach
the
Psychosocial
Rehabilitation
Using
(ACT)
the Assertive
Model
Community
Treatment
Providing
Continuum
of
Care
Welcome
Home
Ministries
(WHM)
Box
Basic
34.1
Principles
of
the
Assertive
Community
Treatment
(ACT)
Model
Footnote
Source: Assertive Community Treatment Association. (2003). Act
model . Retrieved December 16, 2003, from
http://www.actassociation.org/actModel/
P.602
of
Care
for
Virtually every homeless person with SPMI has had prior experience
with the mental health service delivery system. The complex problems
of this population also illustrate the importance of providing additional
services to augment psychiatricmental health treatment. These
services include targeting and improving physical health status,
locating housing, and providing appropriate services so that
individuals with mental illness can maintain their housing (ODPHP,
1998). Providing these services is costly and often results in
fragmentation. Goldman (2000) describes fragmentation in the
community-support movement for clients with SPMI. Studies on issues
such as employment, income support, transportation, and housing,
which have been included with treatment, have revealed
fragmentation of the system of services needed. A lack of adequate
resources that are comprehensive and coordinated continues to be a
major issue in the treatment of clients with SPMI.
of
Care
for
Discharge planning and follow-up (ie, continuum of care) are the key
components of correctional-facility psychiatricmental health
programs, although they are the weakest elements of programs
nationwide. Released offenders have a variety of service needs that
must be addressed. Case management that begins in the correctional
facility and continues into the community can provide continuing
contact between community-treatment staff and criminal-justice staff.
Linkage should be made to the following programs if continuum of
care is to occur:
entitlement to Supplemental Security Income (SSI) and Medicaid
money management and representative payee programs
rehabilitation
housing
medical care (Watson et al., 2001)
Concerns
About
Managed
Care
The managed-care system was founded in the 1990s with the primary
motive of reducing expenditures by withholding services that are
considered unnecessary and substituting less expensive services
(Parron, 1999). Managed care requires using less costly alternative
treatments whenever possible. Therefore, brief sessions of
psychotherapy have replaced the former, lengthy model of
psychotherapeutic sessions. Psychotropic drugs are ordered as a first
choice.
The shorter length of stays in acute-care facilities and the reliance on
medication as the first, and sometimes only, treatment can be
problematic. Hospitalization provides a stopgap-type approach to the
problem of SPMI. The client is admitted during an acute psychotic
episode and, in many cases, the episode is related to the fact that the
client has not used prescribed medication or followed the prescription
for continued treatment given at the previous inpatient admission. For
many clients with SPMI, acceptance of the illness and of the need to
take medication is difficult; therefore, noncompliance is common. For
other clients, the unpleasant adverse effects of neuroleptic
medications contribute to refusal to continue taking them. One study
suggests that noncompliance with neuroleptic medications accounts
for at least 40% of all rehospitalizations and at least 33% of all acutecare inpatient costs for people with SPMI (Friedrich, Lively, &
Buckwalter, 1999).
Educating
the
Family
the family's areas of concern, the nurse teaches them about the
illness, symptom management, use of medications, and measures to
enhance the client's medication compliance. The nurse also
encourages the family members to use support groups such as NAMI.
The family members are encouraged to maintain normal daily
activities and to participate in social and recreational activities that
are pleasurable.
Evaluation
The nurse evaluates the outcomes of client care and the degree to
which established goals have been met. For clients with SPMI, care is
ongoing and includes the provision of support necessary for
community living. Recurrence of symptoms is common. When services
are coordinated and comprehensive, the client may receive support to
avoid hospitalization and maintain community housing and support
systems. See Nursing Plan of Care 34-1 : The Client With Serious and
Persistent Mental Illness.
P.603
herself. She had been homeless for the first 3 months of this current
year. This was her 19th psychiatric admission, with the first admission
occurring when she was 9 years old. Past history reveals that her
father and older brothers physically and sexually abused her and that
she lived in a series of foster homes and group homes from the ages
of 10 to 18. She also has a history of drinking alcohol and smoking
pot, beginning at age 9. During adolescence, she abused cocaine and
heroin and resorted to prostitution to obtain money for drugs. She has
been noncompliant with past treatment recommendations, including
outpatient treatment and psychotropic medications.
DSM-IV-TR
DIAGNOSIS: Schizoaffective disorder, depressive
Posttraumatic stress disorder; Alcohol abuse; Cannabis abuse
type:
Rationale
DM needs constant
supervision and
limitation of
opportunities to harm
herself.
Encourage DM to sign a no
self-harm
contract.
Rationale
presents a different
viewpoint that DM can
begin to integrate into
her thoughts.
Rationale
NURSING
support.
Rationale
to
Rationale
for
medication.
DM may be noncompliant
because of adverse
effects of prescribed
medication.
Writing a specific
behavioral contact is an
effective method of
minimizing
treatment
noncompliance.
P.604
Key
Concepts
transinstitutionalization,
and
lack
of
abuse.
Chapter
Critical
Worksheet
Thinking
Questions
Reflection
The chapter-opening quotes include statistics that indicate the need
for psychiatricmental health nurses to provide care for the
seriously and persistently mentally ill, homeless, or incarcerated
clients. Reflect on your psychiatric nursing curriculum. Most
curriculums address the issues of chronic mental illness, but may not
address psychosocial needs of the homeless or incarcerated client. Are
the psychosocial needs of these clients included in the curriculum? If
not, determine why. If they are addressed, are the nursing
interventions realistic? Explain your answers.
Multiple
Choice
Questions
c. Poor hygiene
d. Lack of education
View
Answer
1. A
Risk factors for homelessness in a client with a history of serious and
persistent mental illness include presence of positive symptoms of
schizophrenia; concurrent drug or alcohol abuse; presence of a
personality disorder; high rate of disorganized family functioning from
birth to age 18; and lack of current family support. Physical illness,
poor hygiene, and lack of education have not been identified as
possible risk factors.
P.608
2. The nurse uses which of the following interventions to
establish rapport and provide support for the client with
serious and persistent mental illness?
a. Teaching social skills
b.
Providing
cognitive
restructuring
Answer
Answer
Aggressive
tendencies
Answer
4. C
Although assessing for physical illness, hallucinations and delusions,
and aggressive tendencies is important, assessing for suicidal
thoughts is most important because suicide is the leading cause of
death in jails and prisons, and most jail suicides occur in the mentally
ill
population.
Answer
Internet
Resources
Association:
http://www.pbs.org/wgbh/pages/frontline/shows/crime/jailed/
National Coalition for the Homeless:
http://www.nationalhomeless.org/
Psychology
World
Information
Socialist
Selected
Web
Online:
Site:
http://www.psychologyinfo.com/
http://www.wsws.org/
References
37 (6), 1621.
crimes
Post .
Suggested
Readings
analysis
paper . Unpublished
APPENDICES
and
Schizophrenic-Like
Disorders
251
SUPPORTING
PRACTICE
EVIDENCE
FOR
Toward
Schizophrenia
and
Electroconvulsive
Medication
Therapy
Compliance
224
252
245
298
Stress
Disorder
Disorder
304
339
Disorder
Disorder
466
467
EXAMPLES OF STATED
OUTCOMES
Schizophrenia
249
Disorders
Anxiety-Related
Personality
Cognitive
307
Disorders
Disorders
Disorders
326
346
369
Disorders
Disorders
419
445
249
Disorders
Personality
Cognitive
307
Disorders
Disorders
346
369
Disorders
419
496
555
D
In the psychiatricmental health clinical setting, street
clothes typically are worn. Street clothes should be neat,
clean, and professional in appearance. Slacks, sweater, and
loafers would be appropriate. The clothing items listed in
the other options, for example, sandals, shorts, blue jeans,
or mini-skirt, are inappropriate because they are not
professional in appearance. In addition, they could be
interpreted as being too casual or provocative.
D
When in doubt
always best to
instructor, who
proceed. Your
Chapter
D
Chapter
B
The client described has obvious self-care deficits, which are
addressed by Orem's Behavioral Nursing theory. Leininger's
theory focuses on cultural care; Peplau's Interpersonal
theory focuses on communication and relationships; and
Roy's Adaptation theory focuses on coping mechanisms to
adapt to internal and external stimuli.
D
Roy's Adaptation theory focuses on coping mechanisms to
adapt to internal and external stimuli. Levine's theory
focuses on conservation; Henderson's theory focuses on
needs; Peplau's Interpersonal theory focuses on
communication and relationships.
A
The eclectic approach refers to an individualized approach
that incorporates the client's own resources as a unique
person with the most suitable theoretical model or models.
This approach is not limited because the nurse therapist
realizes that there is no one way to deal with all of life's
stresses or problems. Interaction-oriented approach
incorporates the use of the nurse as a therapeutic tool.
Although all theories are considered to be research based,
more than one theory here is being used.
A
Chapter
C
The nurse's priority is to respect the client's belief, thereby
providing culturally competent care. Questioning the validity
of the belief would interfere with the development of trust
and undermine the nurseclient relationship. There is no
reason to expect that the client's response to treatment
would be poor. Seeking assistance from family members
would not be the priority. Additionally, they too may have
the same belief.
D
Communication is key. Therefore, using the services of a
translator is best to ensure that the messages from the
sender and receiver are clear and interpreted accurately.
Gestures and pictures would be helpful but only in addition
to the use of a translator. Evaluating the client's ability to
understand written English would be ineffective and
probably
time-consuming.
Assigning
P.611
the client to a private room would have little effect on
communication, and doing so isolates the client.
A
Applying cultural care accommodation/negotiation, the
nurse adapts nursing care to accommodate the client's
beliefs and negotiates with the client about incorporating
the tribal healer into his or her plan of care. Cultural care
preservation/ maintenance involves assisting the client in
maintaining health practices derived from the client's
membership in a specific ethnic group. Cultural care
repatterning/restructuring involves educating the client to
change practices that are not conducive to health. Leininger
does not identify supporting/providing as a culturally
congruent nursing care mode.
C
Applying knowledge of ethnopharmacology, the nurse would
anticipate that the client would need a lower than usual
adult dose of the medication because the client would be
considered a poor metabolizer of the drug. Because
of this decreased metabolism, standard (equal) or higher
doses would lead to increased incidence of side effects. The
drug must be given as prescribed; changing the schedule of
administration would have no effect on the client's
metabolism of the drug.
B
To elicit the most appropriate information, the nurse would
use indirect questioning, thereby allowing the client to tell
the story in his or her own words and providing an
opportunity for the client to express feelings. Using yes/no
direct questioning limits the amount of information provided
and does not provide an opportunity for expressing feelings.
Additionally, this type of questioning could intimidate the
client. A supportive and empathetic approach, rather than a
confrontational approach, is most effective. Asking the
Chapter
A
The client's statement indicates a lack of understanding or
awareness of the procedure, which would lead the nurse to
investigate whether the client has given informed consent.
Although identifying possible disagreement between the
client and family and evaluating for anxiety may be
surrounding issues, the key here is the client's
understanding. More information is needed to determine if
ethical principles are being followed.
A
Continuing to restrain a client by failing to adhere to
policies regarding frequency of assessment suggests false
imprisonment, the intentional and unjustifiable detention of
a person against his or her will. If policies were followed,
assessment findings may have indicated that the client's
restraints were no longer needed. Breach of client privacy
involves invasion of the person's life and sharing of client
information with others without the client's consent.
Defamation involves injury to the person's reputation or
character through oral or written communications.
Negligence refers to conduct that falls below the standard of
care established by law, placing the client at an
unreasonable risk of harm.
C
Failure to maintain client confidentiality occurs when a copy
of a client's record is sent to another agency without the
client's written consent. Discussion during a treatment team
meeting (because all members are involved with the client's
care), explaining to visitors about not discussing a client's
Chapter
D
The client's statements indicate bereavement. Bereavement
refers to feelings of sadness, insomnia, poor appetite,
deprivation, and desolation. Mourning refers to an outward
expression of grief about the loss of a love object or person.
Anger is a stage of grief exhibited by statements such as
Why me
and It's not fair,
and difficult,
demanding behavior. Acceptance is a stage of grief in which
the client demonstrates an inner peace about death.
B
Discussing end-of-life care wishes indicates anticipatory loss
in which the client demonstrates an understanding that a
loss will occur. A perceived loss refers to a loss that is
recognized only by the client and usually involves an ideal
or fantasy. A temporary loss refers to a loss that is short
term and not permanent. Sudden loss is one that occurs
without warning.
D
Preschool children, between the ages of 3 to 5 years, do not
view death as permanent and irreversible. Rather they view
it as a temporary trip in which the person still functions
actively. Therefore, they expect the person to come back.
Children between the ages of 5 to 6 see death as a
reversible process that others experience, whereas children
between the ages of 6 to 9 begin to accept death as a final
state, conceptualized as a destructive force.
A
Palliative may be provided in the early stages of a chronic
disease unlike hospice care, which requires that the
individual be terminally ill with a prognosis of 6 months or
less if the illness runs its normal course. Palliative care and
hospice care are supported by various insurance
reimbursement programs, provide care in various settings,
and provide spiritual support for family members.
C
In 1991, the American Nurses Association issued a position
statement that stated that promotion of comfort and
aggressive efforts to relieve pain and other symptoms in
dying patients are the obligations of the nurse. The Agency
for Health Care Policy and Research provided a definition of
pain and specific components of a pain assessment. The
Joint Commission on Accreditation of Healthcare
Organizations issued pain treatment standards that
Chapter
B
The utilization reviewer determines whether a client's
clinical symptoms meet the appropriate psychiatric or
medical necessity criteria or clinical guidelines. A case
manager acts as a coordinator of a client's care and
determines the providers of care for a client with a specific
condition. The primary nurse is the nurse responsible for the
client's care 24 hours a day. The community mental health
nurse provides services to the psychiatric client in the
community.
A
As a result of managed care, length of stays have been
shortened, resulting in assessment and planning occurring in
a much shorter time-frame. Regardless of the system for
reimbursement, all treatment team members and family
members still need to be involved in planning care and
clients still need follow-up.
B
The priority would be to initiate a review of the client's
behavior with the treatment team to determine the client's
current condition and validate the daughter's observations.
From there specific interventions would be planned to
address the client's behavior. Explaining about medications
may be appropriate but later, after more information is
obtained. Speaking to the nursing assistants about the
client's behavior would help to gather more information but
this would not be the priority. Referring the daughter to the
Chapter
A
Asking the client a general lead-in question such as
What are you feeling?
provides information about
the client's affect or feelings, or emotions. Asking if the
client is happy or sad or asking if the client is upset labels
the emotion and does not allow the client to verbalize the
emotion or feeling. Asking the client about what brought
him to the hospital does not address the client's emotion or
affect. Rather it focuses on the client's chief complaint or
problem.
B
Chapter
A
The client's statement about only drinking on weekends
reflects denial of the problem. Therefore, ineffective denial
is most appropriate. Although situational self-esteem may
be a problem, it is not the priority at this time. There is no
evidence to suggest that the client is confused. Although the
client may be at risk for injury possibly due to alcohol
ingestion or withdrawal, the priority is to have the client
admit that he has a problem with alcohol.
D
The most appropriate outcome would be the client spending
time with peers and staff members in unit activities. By
participating in unit activities with others, the client is no
longer socially isolated. In addition, this participation helps
to foster a beginning sense of trust. Asking for permission
to be excused from activities would only serve to reinforce
the client's isolation. The ability to identify positive qualities
in oneself and others is important but unrelated to the
problem of social isolation. Stating that the level of trust is
improved, though also important, does not indicate that the
client's social isolation is being addressed.
D
Because the client is homeless, has delusions, and responds
to auditory hallucinations, the client is at risk for injury.
Therefore, the priority need is his physical safety. This need
must be met before any higher level needs, such as selfesteem, love and belonging, and self-actualization, are
addressed.
B
Axis II addresses personality disorders and mental
retardation.
Borderline
personality
disorder
is
coded
P.614
on Axis II of the DSM-IV-TR. Axis I identifies clinical
disorders and other conditions that may be a focus of
attention. Axis III involves general medical conditions. Axis
IV addresses psychosocial and environmental problems.
D
The client is verbalizing difficulty with feelings about his
capabilities demonstrating a negative perception of himself
that has persisted over a fairly long period of time.
Therefore, the priority nursing diagnosis would be chronic
low self-esteem. There is no information in the client's
statements to suggest that he is experiencing problems with
cognition, which would suggest disturbed thought processes
or problems indicating anxiety. Disturbed body image would
be appropriate if the client verbalized feelings indicating an
altered view of his body's structure, function, or
appearance.
Chapter
10
B
Nonverbal communication, which involves gestures, body
language, and other things such as facial expression, may
be a more accurate reflection of the client's feelings
regardless of whether a client tells the nurse what is or is
not expected. Nonverbal communication is assessed to
determine whether it is congruent with what is being said
verbally. Both verbal and nonverbal communication are
necessary to obtain a complete client assessment. Although
verbal communication may be misinterpreted, this is not the
reason to pay close attention to the client's nonverbal
communication.
D
Telling the client that she will do the right thing provides
Chapter
11
A
In milieu therapy, clients are encouraged to participate in
group activities and free-flowing communication in which
clients have the freedom to express themselves in a socially
acceptable manner. All clients are treated as equally as
possible with respect to rules, restrictions, and policies.
Therefore, schedules, rules, and policies are the same for
everyone.
C
To maintain the therapeutic milieu, the nurse is consistent
with the limits that are set, thus maintaining the same rules
for all clients. Allowing the client to stay up or using this as
a reward interferes with the foundation of the milieu. An
attitude of overall acceptance and optimism is conveyed
with any conflicts in staff about issues being handled and
resolved to ensure the milieu.
B
When acting as the mother surrogate, the nurse assists the
client to perform activities of daily living. Here,
P.615
this would be assisting the client to bathe and change her
clothes. Rather than allowing the client to make decisions or
encouraging a family member to talk to the client, the nurse
would work with exploring the client's feelings about the
need for assistance. Putting the client in a private room
would be inappropriate and avoid dealing with the client's
problem.
C
Measures to help promote sleep include avoiding exercising
before bedtime. Exercise stimulates body functions and is
not considered relaxing. Drinking coffee before midday
Chapter
12
B
The client's complaints are suggestive of the initial impact
phase associated with a high level stress and inability to
reason logically, apply problem solving behavior, and
function socially. The client often experiences feelings of
confusion, chaos, anxiety, helplessness, and possibly panic.
In the precrisis phase, the client is in a state of equilibrium.
Postcrisis involves some adaptation and resumption of
normal activities at different levels. In resolution, the client
perceives the crisis in a positive way and engages in
successful problem solving.
C
Although all of the factors listed may be playing a role, the
couple's recent move to a new state and being away from
Chapter
13
D
Countertransference, an emotional reaction to the client, is
based on the therapist's unconscious needs
P.616
and conflicts. Such a response could interfere with
therapeutic interventions during the course of treatment.
Transference refers to the client's unconscious assignment
to the therapist of feelings and attitudes originally
associated with important figures in his or her early life.
Parataxis refers to the presence of distorted perception or
judgment exhibited by the client during therapy and is
thought to be the result of earlier experiences in
interpersonal relationships. Psychoanalysis is the term used
by Freud to understand and describe the psychotherapeutic
process as an interpersonal experience between client and
therapist.
C
Counseling involves interventions to assist clients in
improving or regaining their previous coping abilities,
fostering mental health, and preventing mental illness and
disability. Clarifying reasons for admission is an example of
the nurse acting as a counselor. Assigning responsibilities
for running a community meeting is an example of the nurse
acting as a leader or clinical manager. Conducting a
thorough assessment is an example of the nurse acting in
the caregiver role. Teaching a small group is an example of
the nurse acting as an educator.
A
Chapter
14
B
The family belief that disagreement represents betrayal
interferes with development of autonomy in the child. This
causes confusion and encourages dependency, not
adolescent rebellion. This belief does not provide a united
front but rather a control over others that inhibits growth
and development. It is not limit-setting that is too strict,
but rather an authoritarian approach that leads to power
struggles.
D
Role reversal is common in dysfunctional families because of
the lack of leadership in the family unit. Encouragement of
individual autonomy, identification of family problems, and
disagreements between spouses are characteristics of
healthy families.
A
The parents feeling overwhelmed and powerless with the
care of their son indicates that they are having difficulty
coping as a family. Thus, compromised family coping is most
appropriate. Although impaired social interaction and
deficient knowledge may be problems that occur, they are
not reflected in the
therapeutic regimen
statements involving
such as maintaining
C
Referrals to community agencies would provide the family
with essential and additional means of support
P.617
Chapter
15
B
Haloperidol acts on dopamine, blocking its action. It does
not affect other neurotransmitters such as acetylcholine,
serotonin,
or
histamine.
A
Clozapine is specifically associated with agranulocytosis.
Therefore, the nurse would monitor the complete blood cell
count for changes in white blood cell count. Other laboratory
studies may be indicated based on the client's condition.
Liver and renal functions studies are commonly done for
many drugs because most drugs are metabolized by the
liver and excreted by the kidneys.
A
of
parkinsonism.
B
Ingestion of foods high in tyramine while receiving MAOI
therapy can lead to hypertensive crisis. Gastrointestinal
upset is an adverse effect commonly seen with many
pharmacologic agents. Neuromuscular adverse effects are
associated with antipsychotic agents. Urinary retention is
associated with anticholinergic agents.
A
To prevent the possibility of lithium toxicity, the nurse
would instruct the client to maintain an adequate intake of
sodium and water. Foods high in tyramine are to be avoided
when a client is receiving MAOI therapy. Establishing a
regular sleep schedule would be helpful for clients receiving
hypnotic agents. Monitoring for an increased temperature
suggestive of infection would be important for clients
receiving clozapine (due to possible agranulocytosis).
Chapter
16
A
Electroconvulsive therapy is thought to correct the
biochemical abnormalities of serotonin and dopamine during
the transmission of nerve impulses between synapses. It
can result in transient memory disturbances but this is an
adverse effect of the treatment, not the reason for its use.
It does not enhance drug therapy; rather it is commonly
used in clients who have not responded to drug therapy. It
Chapter
17
D
Holistic nursing focuses on searching for patterns and
causes of illness, not symptoms; emphasizing the
Chapter
18
B
Clients with schizophrenia, disorganized type, need direction
and limit-setting when performing activities. Communication
must be clear, simple, and directed at the client's level of
functioning. Thus telling the client that it is time to shower
and that the nurse will assist is the most appropriate
statement. Stating that clients on this unit take showers is
demanding and not therapeutic. Additionally, the client may
be unable to understand the implications of this statement
as it affects him. Because of the client's current symptoms,
the client will most likely be unable to comprehend the
significance of feeling better if he showers. Additionally, this
statement could be viewed as false reassurance. Also, in
light of the client's current symptoms, he is unable to make
decisions; therefore, asking him if he would like to take a
shower would be inappropriate.
A
Clients with schizophrenia, paranoid type, tend to
experience persecutory or grandiose delusions and auditory
hallucinations in addition to behavioral changes such as
anger, hostility, or violent behavior. Abnormal motor
activity, posturing, autism, stupor, and echolalia are
associated with schizophrenia, catatonic type. Flat affect,
anhedonia, and alogia are negative symptoms associated
with schizophrenia in general. Schizophrenia, disorganized
type, is characterized by withdrawal, incoherent speech, and
lack of attention to personal hygiene.
A
The most appropriate outcome for a client with disturbed
thought processes from delusions would be the client's
ability to talk about concrete events without talking about
delusions. This would indicate that the client is in touch with
Chapter
19
A
Clients with delusional disorder have no insight into their
condition and refuse to acknowledge negative feelings,
thoughts, motives, or behaviors in themselves and project
such feelings onto others by blaming them for their
problems. Regression, suppression, or sublimation is not
associated
with
delusional
disorder.
C
For a client exhibiting delusions of persecution, the priority
intervention is to present reality as a means to assure the
client that he or she is safe. The client believes that he or
she is being conspired against, spied on, poisoned or
drugged, cheated, harassed, or maliciously maligned in
some way. Establishing trust, reducing anxiety, and
encouraging activities would then follow as the client's
symptoms stabilize.
C
The client is exhibiting clinical symptoms of delusional
disorder, erotomanic type. Here the client believes that
someone of elevated status is in love with her. Delusional
disorder, jealous type, also called conjugal type, is noted
when the client is convinced that his or her mate or
significant other is unfaithful. Delusional disorder, grandiose
type, occurs when the client believes he or she possesses
unrecognized talent or insight or has made an important
discovery.
C
A client with a delusional disorder is generally threatened by
any close or physical contact such as that which may occur
with a physical examination. Postponing the exam to a later
time when a significant other can be present to provide
support or administering medication to stabilize the
symptoms if a medical emergency exists may be necessary.
Unusual body postures and bizarre behaviors typically are
not seen. Clients, when questioned, usually respond by
denying the existence of any problem or pathology.
B
If a client with a delusional disorder is belligerent, agitated,
or suicidal or exhibiting aggressive or violent behavior,
injectable or depot antipsychotics are the drugs of choice
and very effective in controlling the client's feelings of
Chapter
and
20
A
The biogenic amine hypothesis identifies that decreased
levels of the chemical compounds norepinephrine and
serotonin are involved in depression. Although altered
dopamine levels may also be involved, acetylcholine is not
addressed in this hypothesis. Tyramine is associated with
causing severe adverse reactions in clients receiving MAOIs
but it is not associated with any etiology of mood disorders.
Hormones from the thyroid gland have been associated with
mood disorders, but this etiology involves neuroendocrine
regulation, not biogenic amines.
A
An increased incidence of mood disorders is associated with
family history of mood disorders. The belief is that there is
a genetic predisposition to the development of mood
disorders. Lack of trust, male gender, and poor appetite are
not considered risk factors for mood disorders.
C
A client with a cyclothymic disorder displays numerous
periods of hypomania and depression that do not meet the
criteria for a major depressive episode. Feelings of
grandiosity with increased spending may be associated with
manic episodes of bipolar disorder. Feelings of depression
and decreased sleep are associated with a major depressive
disorder. Periods of
P.620
depression accompanied by anxiety may be associated with
depressive disorder not otherwise specified.
D
Chapter
21
D
Clinical symptoms of generalized anxiety disorder include
unrealistic or excessive anxiety and worry about several
events in one's life. Fear and avoidance of specific situations
or places characterizes phobias. Persistent obsessive
thoughts are associated with obsessivecompulsive
disorder. Re-experiencing feelings associated with traumatic
events typically is noted with post-traumatic stress disorder.
B
Chapter
22
B
Hypochondriasis is a somatoform disorder in which a client
presents with unrealistic or exaggerated physical
complaints. Minor clinical symptoms are of great concern to
the person. The symptoms are not used to avoid situations;
however, they often result in an impairment of social or
occupational functioning. Preoccupations usually focus on
bodily functions or minor physical abnormalities. The
diagnosis of pain disorder is given when an individual
experiences significant pain without a physical basis for pain
or with pain that greatly exceeds what is expected based on
the extent of injury. Conversion disorder is a somatoform
disorder that involves motor or sensory problems suggesting
a neurological condition. Malingering is the production of
false or grossly exaggerated physical or psychological
symptoms that are consciously motivated by external
P.621
incentives to avoid an unpleasant situation, eg, to avoid
work.
C
Conversion disorder is a somatoform disorder that involves
motor or sensory problems suggesting a neurological
condition. It is an anxiety-related disorder and the
symptoms are real. Therefore, impaired mobility is the most
appropriate nursing diagnosis. Fatigue is not related to the
situation presented. Although conversion disorder may
promote a chronic sick role, there is no indication to
determine if the condition is chronic. In addition, it is
unrelated to problems with health maintenance. Conversion
disorders develop with anxiety, not problems with selfesteem, and allow a gratification of feelings of dependency.
B
Somatization disorder is a free-floating anxiety disorder in
which a client expresses emotional turmoil or conflict
Chapter
23
B
A client with borderline personality disorder would most
likely exhibit impulsive, unpredictable behavior related to
gambling, shoplifting, sex, and substance abuse.
Contributing to unstable, intense interpersonal relationships
are inappropriate, intense anger; unstable affect reflecting
depression, dysphoria, or anxiety; disturbance in selfconcept, including gender identity; and the inability to
control one's emotions. A client with a somatoform disorder
develops physical symptoms in response to anxiety, not
anger.
C
Splitting is the inability to integrate and accept both positive
and negative feelings at the same moment. The person can
handle only one type of feeling at a time, such as pervasive
negativism or anger. Denial involves the unconscious refusal
to face thoughts, feelings, or needs that are considered
intolerable. Rationalization is an attempt to justify actions,
ideas, or feelings with acceptable reasons. Projection occurs
when a client assigns undesired traits or characteristics to
another.
C
Depersonalization refers to complaints of feeling strange or
unreal. Therefore, the nurse would focus on reinforcing the
reality of the situation. Challenging the feelings or
attempting to identify the origin of the feelings would be
ineffective. Diversional activities take the focus away from
the
client's
complaints.
A
Therapeutic limit-setting is accomplished by clearly
identifying the boundaries for activity or behavior and
maintaining them consistently. Attempting to negotiate or
explain the reasons for limit-setting does little to ensure
their effectiveness. Substituting persuasive statements
Chapter
24
D
Clients with dementia often seem to exhibit increased
confusion, restlessness, agitation, wandering, or combative
behavior in the late afternoon and evening hours. This
phenomenon, referred to as the sundown syndrome, may be
due to a misinterpretation of the environment, lower
tolerance for stress at the end of the day, or
overstimulation due to increased environmental activity
later in the day. Amnesia refers to a loss of memory.
Degeneration refers to a breakdown or deterioration in
function. Perseveration is the inappropriate continuation or
repetition of a behavior such as giving the same details over
and over even when told one is doing so.
C
Alzheimer's disease is a chronic progressive disease that
occurs over a long period of time. Its onset is gradual and
continues to worsen as time passes. Medications have been
Chapter
C
25
Chapter
26
B
According to the biochemical theory of addiction, all drugs
of abuse stimulate the neurotransmitter dopamine. Nicotine
acts on a receptor for acetylcholine. Norepinephrine and
serotonin have not be associated with drugs of abuse.
D
The development of Korsakoff's psychosis and Wernicke's
encephalopathy is associated with alcohol consumption and
a deficiency of thiamine. Vitamin C, vitamin A, and niacin
have not be implicated.
B
Cocaine is a stimulant that causes an immediate change in
vital signs, including blood pressure and pulse. Research has
shown cocaine to be a common cause of sudden heart attack
in healthy young people. Alcohol and marijuana have not
been associated with sudden heart attack. Myocardial
infarction may occur with the use of steroids, specifically
anabolic steroids. However, the incidence of myocardial
infarction with steroids is much less than that associated
with cocaine.
B
A planned intervention for a client with an alcohol problem
involves an organized, deliberate confrontation of a client
who uses or abuses substances generally used to encourage
a person to enter treatment. It also can be used once a
person has entered treatment. It does not assist the family
to identify client problems, prepare the client for a
treatment program, or teach the client about Alcoholics
Anonymous.
C
A client undergoing detoxification from alcohol is at risk for
injury secondary to the development of seizures that may
occur as withdrawal occurs. Anxiety, tremors, and
headaches are possible; however, none of these is as
serious a complication as seizures. Nor do they pose as
great a risk for safety to the client.
Chapter
27
B
Turner's syndrome, seen in females, occurs as the result of
a missing sex chromosome (XO grouping instead of XX
combination). The female appears short in stature and lacks
functioning gonads. Therefore, the client will be unable to
have children. Early menopause is not associated with this
disorder.
B
Preschoolers normally demonstrate curiosity about sexual
identity. Between the ages of 3 and 6 years, the preschooler
identifies with the same sex, may ask questions about the
origin of babies, and may ask about the anatomic
differences between sexes. These are considered to be
normal behaviors for children in this age group. Parents
need to be instructed to answer the child's questions
honestly and at the level that the child will understand.
Sexual aggression has been linked to general aggression in
children between the ages of 5 or 6 up until puberty. These
children describe a history of neglect and physical abuse; a
dysfunctional relationship with parents who quarrel or abuse
alcohol; physical or sexual aggression against their mother
or siblings by their father or another male figure;
confrontation with adult sexuality at an early age; or
exposure to distorted or deviant sexuality such as
pornography.
B
The nurse should set appropriate limits for this client,
informing the client that the behavior is unacceptable.
Ignoring the client's behavior would be inappropriate
because the client's behavior is inappropriate. Holding a
community meeting would do little to limit the client's
inappropriate behavior at the current time. However, it
could be used later on to help educate the client. Requesting
the client's doctor speak with the client passes the
responsibility to another. The nurse needs to enforce
consistent limits.
B
The nurse would assess the client's medication history.
Medications or substances can diminish libido or inhibit
sexual function by causing changes in the blood flow to the
genital area or the nervous system control of the area. The
age of onset for puberty, difficulty with childbirth, and high
fat intake have not been associated with a loss of interest in
sexual activity.
P.624
D
The most common barrier identified to taking sexual history
is the nurse's discomfort and embarrassment with the topic.
Other factors may include failure to view the client's sexual
history as relevant to the plan of care; inadequate training
of the health care professional; fear of offending the client
by asking personal questions; and the perception by the
health care provider that any sexual concern of the client
will be overly complex and time-consuming for the provider
to assess, much less manage.
Chapter
C
28
Chapter
29
B
Feelings of hopelessness and helplessness are key indicators
suggesting suicide. Joking indicates a coping mechanism.
Engaging in weekend drinking episodes suggests a
substance abuse problem. Seeking help for symptoms of
depression indicates the client's desire for a positive
change.
A
Although the client's risk for suicide is ever-present, the
greatest risk for suicide occurs during the recovery period
from depression. At this time, individuals with severe
depression experience the energy level to follow through
with self-destructive thoughts.
B
A client's degree of suicidality is not a static quality,
Chapter
30
D
The vulnerability model of dual diagnosis is based on the
Chapter
31
D
In any situation involving abuse, the abuse must be
reported to the appropriate community agency. Helping the
child describe the abuse, confronting the father, and
documenting complete assessment data are important and
can be addressed once the abuse is reported.
A
The most common indicators of physical abuse of a child are
bruises involving no breaks in skin integrity. The bruises are
usually seen on the posterior side of the body or on the
face, in unusual patterns or clusters, and in various stages
of healing, making it difficult to determine the exact age of
a bruise. Abdominal pain, a common complaint in children,
can be an indication of child abuse; however, it is a less
common indicator. Symptoms of dehydration may be normal
after vomiting and diarrhea due to fluid loss. Temperature
elevations typically indicate an inflammatory or infectious
process and occur before other signs and symptoms are
noted.
D
Chapter
32
C
The client's statement indicates feelings of hopelessness,
having done all that he was told and yet still being sick.
There is no indication that the client's thought processes are
impaired, or that he is demonstrating inappropriate or
ineffective coping. The client's statement about doing
everything he was told indicates that he has a sound
knowledge base about the disorder.
A
For the client with AIDS, emotional crises may result from
the client's increasing isolation as he or she attempts to
cope with the nearly universal stigma faced on a daily basis.
AIDS clients experience rejection from all parts of society,
including significant others, families, friends, social
agencies, landlords, and health care workers. For many, this
constant rejection causes a reliving of the coming-out
process,
with a heightening of the associated anxiety,
guilt, and internalized self-hatred. The fear of spreading
AIDS to others can lead to further isolation and
abandonment, commonly at a time when there is an evergreater need for physical and emotional support. Support
groups have become a key element in providing treatment.
The other options may play a role in how an individual copes
with the disease; however, they are not the most important.
A
The most common and expected psychological response to
the diagnosis of AIDS is anxiety and depression. Cognitive
impairment, delusions, and hallucinations may be noted
during the late phase of the disease. Somatic symptoms are
not common.
B
Chapter
33
D
Refraining from the use of abusive substances would be an
important topic to include in a teaching program
P.627
for seniors about healthy living. Persons with poor diets,
who experience poor living conditions, who have substance
abuse problems, or who ignore or minimize health problems
are at risk for a shortened life span. Intrinsic factors of
aging, such as culture, ethnicity, race, intelligence, and
gender, cannot be controlled. Although monitoring blood
pressure is a health promotion activity, monthly monitoring
does not ensure that the client has the necessary knowledge
of when to report changes in blood pressure or adhere to a
Chapter
34
A
Risk factors for homelessness in a client with a history of
serious and persistent mental illness include presence of
positive symptoms of schizophrenia; concurrent drug or
alcohol abuse; presence of a personality disorder; high rate
of disorganized family functioning from birth to age 18; and
lack of current family support. Physical illness, poor
hygiene, and lack of education have not been identified as
possible risk factors.
C
The nurse provides support to the client by listening to the
client's story. The nurse enhances the client's feelings of
being understood through the use of active listening skills,
remembering that the client's perspective is important
because this determines what the client views as problems
and determines how the client will respond to perceived
problems. Teaching social skills is a component of the
psychosocial rehabilitation approach. Establishing reality
contact is a component of the cognitive behavioral
approach.
A
Directing the client to tell the voices to go away is a reality
orientation technique that helps the client learn to push the
voices aside rather than pay attention to what they are
saying. Listening carefully to the message of the voices
reinforces the validity of the voices to the client and is
inappropriate. It also infers that the nurse also hears the
voices. Telling the client that the voices are only his
imagination invalidates the voices. When the client
experiences hallucinations or delusions the nurse intervenes
by accepting that the hallucinatory voice or delusional
thought is real to the client. Exploring with the client the
origin of the voices infers the reality of the voices to both
the client and the nurse.
P.628
C
Although assessing for physical illness, hallucinations and
delusions, and aggressive tendencies is important, assessing
for suicidal thoughts is most important because suicide is
the leading cause of death in jails and prisons, and most jail
suicides occur in the mentally ill population.
B
Clients with serious and persistent mental illness often
neglect personal hygiene. They may not have access to
supplies or may lack motivation to attend to personal
hygiene. Telling the client in a matter-of-fact manner that it
is time to take a shower and then providing the materials
needed for showering provide necessary cues. If the client is
completely unable to perform self-care, the nurse provides
care in an accepting, nonjudgmental manner. Thus the
nurse encourages the client to maintain personal hygiene by
using techniques such as positive reinforcement for the
client's efforts to improve. Doing so helps to improve the
client's self-esteem and sense of control. The nurse does
not assist with hygiene measures to make the care easier,
make the client feel better, or ensure that the client is not
offensive to his peers.
STUDENT
RESOURCE
CD-ROM