PHYCHOSOCIAL INTEGRITY

PYCHOSOCIAL INTEGRITY MODULE

Abuse/Neglect
Abuse is the willful infliction of physical injury, emotional anguish, or both on another person.
It is a pattern of behavior that dominates, controls, lowers self-esteem or takes away choice.

A. Types of Abuse
♦ Physical Abuse - physical harm or injury caused by beating, hitting, cutting,
burning or raping; assault is a threat of violence; battering is repeated physical
abuse.
♦ Sexual Assault - pressured or forced sexual contact, including sexually
stimulated talks or actions, inappropriate touching or Intercourse, incest and
rape.
♦ Emotional or psychological abuse - it may be intimidation or the attempt to
instill fear, social isolation of victim or violation of personal rights.
♦ Economic Abuse- financial exploitation of a victim by restricting access to
money, food, clothing or transportation.
♦ Neglect - withholding or failing to provide proper personal care in any of these
areas: physical, emotional, medical, education and abandonment.

B. Victims of Abuse
- Victims may be children and adolescents, siblings, partners and
elders.

C. Physiological Responses to Abuse

♦ Unexplained bruises, lacerations, abrasions, head injuries,
fractures
♦ Multiple injuries especially to head, face, throat, trunk or sexual organs.
♦ Malnutrition, dehydration
♦ Stress-related responses such as headaches, GI symptoms, anxiety, depression,
chronic pain, insomnia, and menstrual problems
♦ Eating disorders, anorexia, bulimia
♦ Death

D. Psychological responses to Abuse

♦ Fear
♦ Lowered self-esteem
♦ Helplessness
♦ Behavioral problems in Children
♦ Hopelessness
♦ Depression
♦ Isolation
♦ Post traumatic Stress Disorder: psychiatric condition that occurs after
a traumatic event, characterize by hyper arousal, irritability, hyper
vigilance, poor sleep, intrusive thoughts, nightmares, flashbacks,
difficulty concentrating, avoidance and numbing.
 E. Characteristics of Victims
♦ Feelings of powerlessness, guilt and shame
♦ Low self-esteem, feelings of helplessness and
hopelessness
♦ May protect perpetuator and accept responsibility for
abuse
♦ May blame self in an attempt to control situation
♦ May deny severity of situation and feelings of anger and
terror.

F. Characteristics of Perpetrators
♦ Use threats and intimidation to control the victim
♦ Hostile, may blame others for own problems
♦ Often suffered from abuse, neglect or severe discipline as
a child
♦ Impulsive and immature with low self-esteem
♦ Have unmet dependency needs
♦ May have substance abuse problems
♦ Have high expectations of others' behavior
♦ Poor parenting skills and high expectations of child

• Nurses must be aware of possible abuse, particularly if injuries are

unexplained or explanation does not match physical picture.
• Mandatory reporting laws require nurses report suspected abuse in all states;
there are civil and criminal penalties for not reporting.

Child Abuse
Child Abuse is inflicting injury to a child or adolescent that can range from minor ruise to
severe neurological trauma or death. Major types of child abuse include physical, emotional,
sexual, neglect and exploitation.

Assessment:

Physical signs
• Bruises in various stages of healing, often on head and neck
• Bite marks
• Burns
• Fractures, scars or serious internal injuries
• Lacerations or welts
• Bald spots from hair being pulled
Behavioral signs
• Behavioral extremes aggressive to passive
• Fear of parents or caregivers
• Extreme rage or passivity
• Apprehension when other children cry
• Verbal reports of abuse
• Hyperactivity, distractibility or hypervigilance
• Disorganized thinking, self-injurious or suicidal behavior
• Cheating, lying, low academic performance
• Poor relationship with peers
• Regressive behaviors
Assessment of the physically of the physically or emotionally abused child:
• Observe for physical and behavioral signs
 • Be concerned if there has been a delay in seeking treatment
• Vague accounts of events around injuries
• Injuries that do not match report of cause
• Resistance to leaving child alone with healthcare provider
• Assess for shaken baby syndrome: whiplash-like closed head and neck injuries that can
result in death caused by hemorrhage or cerebral edema; caused by violent shaking of
young infants; respiratory distress and retinal bleeding are key indicators; it is a medical
emergency.
• Be alert to Munchausen's syndrome by proxy: injury or illness induced in child by
caregiver in order to meet caregiver's needs to be important and receive positive
reinforcement from healthcare providers.

Planning/Implementation
• Report cases of suspected abuse to child protective services
• Support the child during a thorough physical assessment.
• Assess injuries.
• Provide treatment and medication for injuries.
• Encourage child to discuss fears.
• Reassure child that he/she is not to blame.
• Assess parents/caregiver's ability to cope with situation.
• Use a nonpunitive approach with parents/caregivers.
• Provide parent education
• Provide referral for community resources such as support groups, Parents Anonymous,
parenting classes, and employment counseling.
Elder Abuse
Elder abuse can be physical, sexual, psychological or emotional injury to an elderly
person (over age 65); it is one of the most unreported crimes. Neglect can include
unintentional failure to care for the elder person's needs or an intentional neglect such
as abandonment. In this type of abuse, the victims may attempt to dismiss injuries as
accidental, and abusers may prevent victims from receiving proper medical care to
avoid discovery; victims are often socially isolated; victims may be care providers for
the abusers.

Assessment:
1. Physical Abuse: violence that results in bodily harm or injury.
- Fractures
- Bruises
- Punctures
- Lacerations
- Burns
1 Sexual abuse
- Torn or stained underclothing
- Discomfort or bleeding in the genital area
- Difficulty in walking or sitting
- Unexplained genital infection or disease.
5. Psychological Abuse: verbal assaults, threats or intimidation; violation of personal
rights; unreasonable confinement, forced isolation; abandonment or threats If
abandonment.
- Confusion
- Fearful and agitated
- Changes in appetite and weight
- Withdrawn and loss of interest in self and
social activities, -i. Neglect: not providing needed care
 - Disheveled appearance
- Dehydration and malnutrition
- Dressed inadequately or inappropriately
- Lacking physical needs
- Skin breaks
- Signs of medication overdose

Analysis:
• Perpetrators are usually family members.
• Abusers may have personal problems and lack of support
• Abuser may be stressed by caring for elder
• There may be a history of family violence
• There may be unresolved previous conflicts and power struggles
• Abuse may be in retaliation for past behavior of elder.
• Cultural devaluation of elders
Planning/Implementation:
• Report cases of suspected abuse
• Treat existing injuries
• Assess for untreated medical conditions
• Assess imminent danger
• Refer to protective services for adults
• Explore alternative living arrangements that are least restrictive and
disruptive to the victim
• Encourage counseling and provide referrals to emergency community
resources.
• Arrange counseling and treatment for the abuser.

Sexual Abuse
Sexual abuse includes sexual harassment, rape, sexual assault and child sexual abuse;
it is an act of violence, not of sexuality; intended to injure or intimidate the victim.

• The victim is not required by law to report the rape or assault

• The victim is often blamed by others and often receives no support
from significant others.
• Acquaintance rapes involve someone known to the victim.
• Statutory rape is the act of sexual intercourse with someone under the
age of legal consent even if there is consent from the minor.

Assessment:
• Female client:
- Obtain the date of the last menstrual period.
- Determine form of birth control used and last act of intercourse before
rape.
- Duration of intercourse, orifices violated and penile penetration
- Use of condom by perpetrator
• Shame, embarrassment and humiliation
• Anger and revenge
• Fear of telling others for fear of not being believed
• Anxiety
• Rape Trauma Syndrome: sleep disturbances, nightmares; loss of appetite,
fears, anxiety, phobias, suspicion; decrease in activities and motivation;
disruptions in relationship with partner, family, friends; self blame, guilt,
 shame; lowered self-esteem, feelings of worthlessness; somatic complaints.

Analysis:
a. Interpersonal theory
• Rapist is emotionally immature, powerless, and unsure of self
• Uses rape as a method to exert power, intimidate or inflict pain
b. Interpersonal theory
• Rapists do not have normal interpersonal involvement
• Rapist is preoccupied with own fantasies
c. Social learning theory
• Society accepts and glamorizes violence
• Aggression is learned through family, peers and culture
d. Feminist
• Rape is the result of deep-rooted socioeconomic tradition of male
dominance
• Women are devalued by society

planning/Implementation
► Initial response must include non-judgmental listening and psychological
support.
► Identify immediate concerns and priorities.
► Treat physical injuries.
► Provide client safety.
►Encourage the client not to shower, bathe, douche or change clothing
► Preserve evidence
► Allow client to discuss feelings about assault
► Support decision-making and active problem solving using mutual goal setting.
► Test for pregnancy and sexually transmitted diseases.
► Assist with development of a safety plan if the victim is returning to the
environment with the abuser.

Client Education:

► Reassure client that rape is not his/her fault and survival was the most important
outcome.
► Advise about potential for pregnancy and sexually transmitted disease.
► Provide information about community services.

Partner Abuse
It is the physical or psychological violence toward an intimate partner intended to
intimidate or degrade the partner. The abuse can be physical, economic, social or

Assessment:

• Identification is of ultimate response

• Observe for physical and emotional signs of abuse
• Assess history of intimate attachment relationship.
• Observe for extreme jealousy or passiveness
• Determine whether conflict resolution styles are authoritative or equal
• Do not ask client about whether he or she is being abused, since client may not
identify the behavior as abuse; ask instead more general questions, (e.g. " Have
you ever been pushed or shoved during an argument?")
• Assess beliefs about abuse and responsibility for violent acts.
Analysis:
• Attacks escalate in severity and frequency over time.
• Violence often follows a pattern of escalating tension, abuse and remorse
whereby abuser promises to change and treats victim well for brief periods.
• Psychological abuse may be the most devastating with constant threats of
violence or even death.

Reasons Victims may have Difficulty Leaving Abusive Relationships:

• Financial dependency
• Religious beliefs about marriage
• Emotional attachment to a spouse or partner
• Not wanting to view the relationship as pathological
• Victim may blame self and feel if he or she only does better the abuse will stop.
• Fears for safety.
• Not wanting to disrupt children's lives
• Abuser may threaten to have victim committed as mentally ill.
• Shame involved in admitting abuse.

Planning/Implementation:
• Treat existing injuries.
• Assess imminent danger
• Assure client that he/she is not to blame for the abuse
• Provide information to client about laws, ordinances and their rights.
• Provide referral and phone number of community resources such as
women's shelters or safe houses even if the victim does not want to use
them presently.
• Use mutual goal setting; allow the client to decide on goals.
• Assist the client to mobilize available support systems.
• Assist with the development of a safety plan if returning to previous
environment.
Safety plan for Continued Violence:
■ Ask neighbors to phone police if violence begins.
■ Establish code with family and friends to signify violence.
■ Plan an escape route to use if the abuser blocks main exit.
■ Identify a place to go and how to get there.
■ Have an escape bag that has extra clothing for self and
children.
■ Have children's favorite toys available in a safe place
■ Have extra copies of important papers hidden and available, such as driver's
licenses, birth certificates, marriage license, insurance papers, social
security numbers, bank account numbers, important phone numbers and
extra cash.

Domestic violence
Violence is aggressive drives expressed with the intent of injuring or harming oneself or
others. It is a learned behavior, stemming directly from exposure and imitation or
indirectly as seen when an individual using inappropriate measures channels aggressive
impulses such as passive-aggressive behaviors.

Indications of Abuse
• Multiple injuries
• Injuries that do not fit description of accident
 • Old, healed fractures, scars, burns
• Poor hygiene
• Retarded growth or development with no medical explanation
• Child does not seek comfort from caregiver
• Young child does not cry when parents leave
• Grabbing behavior/lap hunger
• Provocative behaviors
• Delinquent or runaway behaviors
• Teenage pregnancy
• Bruised or swollen eyes
• Bald patches where hair has been pulled-out
• Dislocated joints
• Sexual acting out in young child
• Sexually transmitted disease in young child
• Bruised or edematous genitals

Five Forms of Domestic Abuse

A. Physical
o Inflicting or attempting to inflict physical injury or illness-grabbing, pinching,
shoving, slapping, hitting, hair puling, biting, arm twisting, kicking, punching
o Withholding access to resources necessary to maintain health-foods or fluids,
sleep, medication, medical care, hygienic assistance
B. Sexual
o Coercing or attempting to coerce any sexual contact without consent -for
example, marital rape, acquaintance rape, forced sex, bestiality, forced
prostitution, unprotected sex, fondling, use of pornography
o Attempting to undermine the victim's sexuality- for example, treating him/her
in a sexually derogatory manner, criticizing sexual performance, accusations
of infidelity, withholding sex
C. Psychological
o Instilling or attempting to instill fear- for example, intimidation, threatening
physical harm to self, victim and others, menacing, blackmail, harassment,
mind games
o Isolating or attempting to isolate victims from friends, family, school and/or
work- for example, withholding access to phone, transportation, undermining
victim's personal relationships, harassing others
D. Emotional
o Undermining or attempting to undermine victim's sense of self-worth-for
example, constant criticism, belittling victim's abilities and competency, name
calling, insults, silent treatment, manipulating victim's feelings and emotions
to induce guilt.
E. Economic
o Making or attempting to make the victim financially dependent- for example,
maintaining total control over financial resources, forbidding employment,
withholding money or access to money.

Behavioral Interventions

Behavior Modification refers to a systematic employment of rewards and

punishments to modulate or change behavior.

A. Major Features:
o Governed by the premise that behavior is learned and directed by both
 reward and punishment reinforcers.
o Alterations in consequences result in modified behavior.
o Can be applied in various clinical settings.
B. Process of Treatment
o Identify the behavior to be changed (e.g., adolescent throws temper
tantrum when told he/she is grounded.
o Obtain baseline data regarding the behavior (e.g. frequency)
o Identify the conditions and reinforcers that promote the behavior (e.g.
adolescent allowed to use the telephone to stop temper tantrum)
o Identify the conditions and reinforcers that will change or eliminate the
behavior.
C. Techniques:
o Systematic Desensitization - planned progressive exposure to stimuli that elicit fear
or anxiety while the fear response is suppressed. The stimulus least likely to evoke
fear or anxiety is introduced initially, followed by gradual exposure to more
fearful stimuli.
o Token Economy - the term used to describe the use of operant principles in the
management of behavior with groups of patients in inpatient or outpatient partial
hospital programs.
o Tokens (tangible conditioned reinforcers) are presented to patients contingent on
specific target behaviors. Tokens can be exchanged for positive reinforcers, such as
privileges and favorite foods.
o Time out is a negative-consequence technique in which the person is removed from
a setting where ongoing reinforcers are available. When a patient is exhibiting
aggressive behavior that is followed by social reinforcement from other patients,
the patient may be moved to another room where no social reinforcement is
available.
Self-control- patients do the assessment, change their behaviors, provide their own
reinforcement, and evaluate the results.
o Aversion- use of positive reinforcers (rewards)

Behavioral Nursing Interventions

Baseline Observations (assessment)
1. Appropriate behavior present
2. Inappropriate behavior present
3. Age-appropriate behavior absent
Assessment of these behavioral categories includes:
o Frequency or duration of each response or both
o Description of the stimulus conditions that precede responses and follow the
behavior
o Validation of potential reinforcers.

Problem Specification (Behavioral Nursing Diagnosis)

1. Select the response to be changed

2. Define the response so everyone can recognize it.
3. Gather baseline data (frequency, duration of behavior,
discriminative and reinforcing stimuli.

Formulation of Treatment Plan (Outcome Identification)

1. State the specific response to be changed.

2. State how the response is to be changed; include the present status
 o Increase the rate of the response
o Decrease the rate of the response
o Teach a new response
3. Identify the discriminative and reinforcing stimuli available for use.
4. Select and write the intervention plan in detail (with rationales)

Intervention
1. Implement the treatment plan as written
2. Provide reinforcers for those persons implementing the plan.

Evaluation
1. State the outcome of the intervention
2. Determine whether the response changed as planned.
3. Specify what additional changes are required.
4. State techniques for maintaining the desirable change.

Chemical Dependency

Substance abuse is defined as the purposeful use, for at least 1 month, of a drug that
results in adverse effects to oneself or others.
Substance dependence occurs when the use of the drug is no longer under control
and continues despite adverse effects.
Chemical dependence is a chronic, progressive disease that can be fatal if left
untreated

CHEMICAL DEPENDENCE

Chemical dependence is a chronic, progressive disease that can be fatal if left untreated.
• A medical and spiritual illness with well-defined signs and symptoms including
denial and relapse.
• Disease progression and the course of illness are predictable and treatable.
• Treatment focus is abstinence (voluntarily going without drugs), medications as
appropriate, education, lifestyle change, and increasing self-awareness and
personal growth.

Chemical dependence as defined by the American Society of Addiction medicine

(ASAM): It is a primary, chronic relapsing disease with genetic, psychosocial and
environmental factors influencing it; the disease is often progressive and fatal; it is
characterized by continuous periodic impaired control over the substance; preoccupation
with the substance; use- of the substance despite adverse consequences; and distortions
in thinking, most notably denial.

Concepts:
a. Physical dependence: an altered physical state produced by the repeated
administration of the drug, which necessitates its continued administration to
prevent a withdrawal syndrome; cross-dependence: dependence on more
than one chemical or substance.
 b. Addiction: the compulsive use of a substance with physical and psychologic
dependence.
c. Habituation: repeated use of a substance that results in psychologic
dependence.
d. Tolerance; greatly increased amounts of the substance are required to
achieve the desired effect, or there is a greatly diminished effect with regular
use of the same dose.
e. Withdrawal: a substance-specific syndrome after cessation or reduction of
intake.

• Health care professionals are at risk to develop addictive disorders because of

high stress and pressure of their jobs and exposure to substances. Problems
with impaired health professionals' job performance compromise teamwork
and result in danger to the clients and the professionals themselves. It is the
responsibility of health professionals to report concerns about a colleague to
supervisor, and for supervisor to take appropriate actions.

Signs and symptoms of chemically dependent nurses include the following:

a. Decreased work performance: charting and client care
b. Sudden mood changes; inappropriate affect; often irritable or suspicious.
Absenteeism (before or after days off or payday)
d. Frequent night shift work; working all the time
e. Nurses' clients consistently complain of inadequate or no relief of pain after
medication administration.
f. Frequent errors of judgment and decision-making.
g. Problem behavior in handling drugs (offering to give medications for the
other nurses, missing drugs, "wasting" of drugs frequently, inaccurate record
keeping)
h. Smell of alcohol on breath
i. Frequently leaving the unit
j. Bizarre behavior (paranoia, hallucinations, aggressiveness, elated or
depressed mood)

Contributing factors to the development of the disease:

• Alcohol and other drug use
• Changes in brain chemistry and function
• Biology
• Environment
• Psychologic
• Psychosocial factors

Assessment for addictive behaviors and Substance Abuse:

1. CAGE (have you ever attempted to:

o CUT back on your alcohol?
o Been ANNOYED by comments made about your drinking?
o Felt GUILTY about your drinking?
o Had an EYE-OPENER in the morning to calm your nerves?
A positive answer to two of the screening question indicates a need for further
assessment.
2. Physical assessment and systems review: blackout/lost consciousness;
changes in bowel movement; weight loss or weight gain; experiencing stressful
situation; sleep problems; chronic pain; concern over substance use
 3. Personal family assessment: persons with positive family history are at risk of developing an addictive disorder.
4. Chemical use assessment:
o Identify type of substance used.
o Identify type of compulsive behavior.
o Pattern and frequency of substance use.
o Amount
o Age at onset
o Age of regular use
o Period of abstinence in history
o Previous withdrawal symptoms
o Date of last substance use/compulsive behavior
Symptoms:
• Sleep/appetite disturbance
• Tolerance/withdrawal/progression
• Loss of control of substance use and behavior; preoccupation with use
• Continued use despite negative consequences
• Denial: distortions in thinking, feeling, and behavior
• Physical, interpersonal, social, occupational, legal and spiritual problems
• Hospitalization, incarceration, thoughts of suicide.
• Feelings of hopelessness and helplessness Recovery components:
• Abstinence: medications to help stop using mood-altering substances
• Social support: 12-step group
• Cognitive restructuring
• Relaxation training
• Education: disease/recovery process
• Practice recovery skills
• Coping skills training
• Psychotherapy: group therapy/group counseling
• Exercise/nutrition/sleep
• Changes in negative lifestyle habits

Alcohol Intoxication
- It is the development of substance-specific syndrome due to a recent ingestion of a substance (alcohol); clinically
significant maladaptive behavioral or psychological changes due to the effect of the substance on the central nervous
system.

Assessment of a client with acute alcohol intoxication:

• Disinhibition
• Impaired judgment
• Fuzzy thinking
• Depressed psychomotor activity
• Slurred speech
• Short attention span
• Loud talk
• Memory deficits
• Blackout: a period in which the drinker functions socially but for which the
drinker has no memory.
• Drowsiness
• Ataxia
 • Nystagmus
• Respiratory depression Stupor
• Possible coma and death

Nursing Diagnoses:

a. Safe and effective care environment

• High risk for injury
• Sensory perceptual alteration: visual, auditory, kinesthetic, gustatory,
tactile, olfactory
• High risk for violence: self-directed or directed at others,
b. Psysiologic integrity
• Altered nutrition: less than body requirements
• Impaired physical mobility
• Sleep pattern disturbance
• Changes in activity or energy level
• Self-care needs
c. Psychosocial Integrity
• Anxiety
• Ineffective individual coping
• Chronic low self-esteem
• Depression
d. Health promotion/maintenance
• Ineffective family coping: compromised
• Altered family processes
• Noncompliance

Plan/Implementation
• Focus is on safety.
• Maintain safe environment
• Orient to time, place and person
• Maintain adequate nutrition and fluid balance
• Monitor for beginning of withdrawal signs and symptoms.

Alcohol Withdrawal
- A substance-specific syndrome after cessation or reduction of alcohol intake.

Assessment:
4 manifestations of withdrawal syndrome
a. Tremulousness
b. Visual, tactile and auditory hallucinations
c. Alcohol withdrawal seizures
d. Delirium tremens

Withdrawal syndrome is a progressive process and involves 4 stages:

1. Stage 1: emerges within 8 hours plus after cessation; symptoms include mild tremors, nausea, intense anxiety and
nervousness, tachycardia, increased blood pressure, diaphoresis.
2. Stage 2: symptoms include profound confusion, gross tremors, nervousness and hyperactivity, insomnia, anorexia,
general weakness, disorientation, illusions, nightmares; auditory and visual hallucinations begin.
3. Stage 3: within 12 to 48 hours after cessation; symptoms include all those of stages 1 and 2, as well as severe
hallucinations and grand mal seizures ("rum fits")
 4. Stage 4: occurs 3 to 5 days after cessation; symptoms include initial and continuing delirium tremens.

Nursing Diagnoses:
• Risk for injury: potential for complications of substance withdrawal
• Risk for injury: potential for relapse
• Altered family process: addictive disorder
• Knowledge deficit: addictive disorder
• Anxiety
• Ineffective coping
• Impaired social interactions
• Ineffective denial
• Self-esteem disturbance
• Dysfunctional grieving
• Impaired adjustment
• Disturbed sleep pattern
• Chronic pain
• Altered health maintenance
• Hopelessness
• Powerlessness
• Spiritual distress
• Altered perception related to hallucinations.

Nursing Considerations:
• Maintain safe environment
Create a low-stimulation environment
• Monitor for vital signs and withdrawal symptoms (nausea/vomiting, tremors, paroxysmal sweat, anxiety, agitation,
tactile disturbances, auditory hallucinations, visual disturbances, headache or fullness in head, disorientation and
sensorium)
• Remain with the client.
• Institute seizure precautions.
• Maintain adequate nutrition and fluid intake. Offer fluids and light foods, as tolerated, during periods of lucidity.
• Maintain normal comfort measures.
• Monitor for covert substance use during detoxification period.
• Give vitamin/mineral supplement, especially B-Complex vitamins.
• Provide emotional support and reassurance to client and family.
• Provide reality orientations and address hallucinations in a therapeutic manner
• Advise client of the depressive uneasy feelings and fatigue that is usually experienced during withdrawal.
Begin to educate the client about the disease of addiction and the initial treatment goal of abstinence.
• Administer anticonvulsant medications as ordered and other medications as
ordered.

Alcohol Treatment:
A. Drag therapy options:
• Antidepressant agent: Bupropion (Wellbutrin)
• Benzodiazepine: drug of choice for alcohol withdrawal and benzodiazepine withdrawal.
chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan)
• Disulfiram (Antabuse) to prevent relapse into alcohol abuse (the client must
be alcohol-free for 12 hours before administering this drug);
Explain side effects if ingested with alcohol: headache, severe gastrointestinal distress, tachycardia, and
hypotension.
 Naltrexone (Trexan, ReVia) to prevent relapse into alcohol abuse; to reduce alcohol craving; explain transient side effects
like nausea, gastrointestinal distress, musculoskeletal pain, sleep disturbances, anxiety.
• Selective serotonin reuptake inhibitors: fluoxetine (Prozac), paroxetine (Paxil)

B. Detoxification: the acute phase of treatment.

• Involves close observation and safety measures to prevent severe reaction while withdrawing from alcohol
• Fluids are used when dehydration is determined.
• Magnesium sulfate 50% solution and high doses of chlordiazepoxide (Librium) or other benzodiazepines are used
to prevent alcohol withdrawal seizures.
• Thiamine 50 to 100 mg IM to treat malnutrition.
• Education and group process are frequently used after detoxification when client is able to understand instructions.

C. Rehabilitation
• Aim is to build treatment motivation and overcome denial in clients and significant others.
• The client with alcoholism has to learn to give up alcohol forever.
• The person is helped to learn new ways of problem solving and living a satisfying life without alcohol; this is
enhanced by a therapeutic relationship that expands the alcoholic's self-confidence, coping skills, feelings of self-
worth, and attempts to become more independent.

* Alcoholic Anonymous (AA) is a self-help group of recovering persons with alcoholism.

• A 12-step program enables members to achieve and maintain sobriety at

their own pace.

-12-Step model teaches that there is no effective cure for addiction

- Encourage 12-step involvement
-Regular meeting attendance diminishes ambivalence and promotes j acceptance about never engaging in
addictive behaviors again.
- Key elements of 12-step framework are acceptance, surrender, processing, grief, higher power, and power of the
group.
• Run entirely by individuals recovering from alcoholism
• Requires members to devote themselves completely to mutual help.
• Remarkable success with chronic alcoholism
• Has member groups for families of alcoholics who themselves suffer from
codependency. (Dependency on the individual with alcoholism)
a. Al-Anon - an organization of friends and families of|
alcoholics
b. Alateen - organization of teenagers affected by alcoholism
c. ACOA - an Al-Anon organization for adult children of
alcoholics
► The emphasis of Alcoholics Anonymous is on changing oneself to make the most of one's life, develop a healthier lifestyle,
education, guidance in relating to the alcoholic family member, the sharing of problems and experiences, and support
based on a 12-step program.

Delirium Tremens
- Signs and symptoms most commonly occur 24 to 72 hours after the last drink, but may not arise until 7 days
after.;Withdrawal delirium which lasts 2 to 3 days.

Assessment:
• Disorientation
• Fluctuating consciousness
• Hallucinations
 • Agitation
• Low-grade fever
• Confusion
• Severe autonomic arousal
• Increased psychomotor activity
• Sleep disturbances
• At onset, uncontrolled and unexplained tachycardia, tachypnea
• Marked tremors/seizures
• Diarrhea and vomiting
• Diaphoresis
• Death (10-15% from cardiac failure)
*Delirium Tremens is a medical emergency. *

Nursing Diagnoses:
• Risk for injury
• Sleep disturbances
• Anxiety
• Ineffective denial
• Ineffective individual coping
• Chronic pain

Nursing Considerations:
• Provide a safe environment.
• Remain with the client.
• Monitor the client's vital signs
• Maintain a peaceful environment
• Maintain adequate nutrition and fluid intake.
• Provide reality orientation.
• Provide comfort measures.
• Administer medications as ordered.

Chronic Alcohol Dependence

A. Alcohol Chronic Brain Syndrome (Dementia)
Alcoholic dementia typically occurs after 15 to 20 years of continuous drinking. It has three primary causes:
- Alcohol is directly toxic to neurons
- Alcoholism causes a destructive nutritional deficit
- Alcoholism causes end organ failure such as cirrhosis and cardiomyopathy, which in turn, affect the central nervous
system

Assessment:
• Amnesia
• Slowness of thinking
• Impaired judgment
• Hallucinations
• Delusions
• Illusions
• Alterations in memory
• Alteration in abstract thinking
Nursing Considerations:
• Promote safety.
• Provide a set routine for care.
• Monitor home setting for indicators of stress overload in family members as well as patient
• Enhance orientation by providing family pictures, bold-faced clocks and calendars, signs and written reminders.
• Plan activities of daily living based on client's established patterns.
• Promote adequate nutrition.
• Administer medications as ordered.

B. Wernicke's Syndrome
- A reversible alcohol-induced amnestic disorder caused by a diet deficient in thiamine secondary to the poor
nutritional intake that often accompanies chronic alcoholism.

Assessment:
• Marked diplopia (from palsy of the third and fourth cranial nerve)
• Hyperactivity and delirium (stimulation of cortical brain and thalamic lesions)

• Coma (lesions in the cranial nerve nuclei and in the mesencephalon and
diencephalons of the brain)

Nursing Considerations
• Provide vitamin/mineral supplement; Vit B complex; thiamine
• Protect client from injury
• Provide non-stimulating and a safe environment.
• Approach client with delirium in a clam and reassuring manner.
• Keep explanations direct and simple.
• Orient as needed.
• Anticipate anxiety and intervene appropriately.
• Administer short-acting anxiolytics and low-dose neuroleptics to manage
severe agitation and sensory-perceptual disturbances sparingly.

C. Korsakoff's Psychosis
- Often follows Wernicke's encephalopathy and is associated with prior peripheral neuropathy.

Assessment:
• Loss of recent memory
• Confabulation (filling in blanks in memory by making up factors to cover up the deficit)
• Vulnerable to others' suggestions
• Poor judgment
• Unable to reason critically.

Nursing Considerations:
• Treated with thiamine and can often be partially reversed. Thiamine (vitamin Bl) may need to be replaced when a
patient is in withdrawal to decrease ataxia and the other symptoms of thiamine deficiency. It can be given IM or by
intravenous infusion with glucose.
• Give client specific, simple directions for activities of daily living.
 • Use concrete symbols, such as photographs of client's past, to strengthen sense of continuity.
• Demonstrate acceptance nonverbally to reinforce verbal communications.
• Talk about familiar subjects, establish eye contact and face directly when addressing the client.
• Continually assess physical and mental status.

Non-Alcoholic Substance Abuse

A. Barbiturates and other sedatives drugs (e.g. meprobamate, glutethimide, chlordiazepoxide, secobarbital, diazepam,
alprazolam)
- CNS depressant
Are used to relieve anxiety or to produce sleep.
- Produce both physical and psychological dependence
- Used to treat insomnia, to soften withdrawal from heroin, and as anticonvulsants.
- There is a general, depressant, withdrawal syndrome associated with these drugs.
Persons who become chronic and compulsive users of theses drugs tend to have a variety of underlying psychologic
difficulties: persistent anxiety or a sense of insecurity; attempts to relieve hostile and aggressive impulses; efforts to
reduce tension or escape through the drug's euphoric effect.

Signs and Symptoms of Abuse

• Unsteady gait
• Slurred speech
• Sustained nystagmus
• Confusion
• Irritability
• Insomnia
• Decreased awareness of external stimuli
• Shortened attention span
• Decreasing intellectual ability

Withdrawal Signs and Symptoms

- Symptoms usually begin 8 to 12 hours after the last dose.
• Anxiety
• Muscle twitching
• Tremor
• Progressive weakness
• Dizziness
• Distorted visual perception
• Nausea and vomiting
• Insomnia
• Orthostatic hypotension
• Convulsions
• Delirium beginning approximately 16 hours after the last dose and lasting up to 5 days.

Nursing Considerations:
• Detoxification requires a cautious and gradual reduction of these drugs; reduce the patient's regular dose by 10% each
day. Sudden withdrawal may result in acute psychosis, seizures and death.
• Supportive treatment
• Gradual withdrawal reduces the incidence of seizures
• Monitor client's vital signs
• Attend to physiologic and safety needs, especially if seizures occur
• Promote rest and calm environment.
B. Opioids (Narcotics)
- Opium, morphine, codeine, heroin, hydromorphone, Demerol and methadone
- Emotional dependence on the drug (to alter mood) occurs first, followed by physical dependence.
- Psychologically, individuals addicted to opiates show a similarity to those using alcohol in some aspects of personality
traits (e. emotional immaturity, dependent, hostile, and aggressive behavior; and a tendency to take drugs to relieve
inner tensions
- Availability (abuse may begin after surgery or illness), curiosity, peer pressure urban versus rural differences and social
class may play roles in the use of narcotics.
- Have a sedative effect on the CNS
- Addiction tends to be chronic with a high rate of relapse.

Signs and Symptoms of Abuse

• Feelings of euphoria
• Sedation
• Reduced libido
• Memory and concentration difficulties
• Analgesia
• Constricted pupils/pinpoint pupils: a sign of opioid overdose
• Respiratory depression
• Hypotension
• Vomiting (Morphine)

Withdrawal signs and Symptoms

• Early symptoms: yawning, tearing, rhinorrhea and sweating
• Intermediate symptoms: flushing, piloerection, tachycardia, tremor, restlessness and irritability
• Late-Appearing symptoms: muscle spasm, fever, nausea, diarrhea, vomiting, repetitive sneezing, abdominal cramps,
backaches, chills, dilated pupils
Nursing Considerations:
• Monitor the client's vital signs.
• Remain with the client
• Offer foods and fluids as tolerated
• Provide a soothing environment
• Opiate detoxification is achieved by the gradual reduction of an opiate dose over several days or weeks.
• If ordered, administer methadone.
Methadone maintenance is the treatment of opiate addiction with a daily-stabilized dose of methadone. Patient and
family education while taking methadone:
- Take drug exactly as prescribed
- Avoid use of alcohol
Take drug with food to minimize nausea
- Eat small frequent meals to minimize nausea and loss of appetite
- Avoid driving a car or performing other tasks that require alertness
- Administer mild laxative for constipation
- Report severe nausea, vomiting, constipation, and shortness of breath or difficulty breathing.
• Naltrexone (Trexan), an opiate antagonist; binds to opiate receptors in the
CNS and competitively inhibits the action of opioid drugs.
- Use cautiously in narcotic addiction because may produce withdrawal symptoms.
- Do not administer unless patient has been opioid-free for 7 to 10 days.
- The interaction between opiates and naltrexone can cause respiratory depression and death.
Patient and Family education:
- Know that this drug will help facilitate abstinence from alcohol and blocks the effects of narcotics
- Wear a medical identification tag to alert emergency personnel that you are taking this drug.
 - Avoid use of heroin or other opiate drugs.
- Report any signs and symptoms of adverse effects: anxiety, nervousness, abdominal cramps, nausea, vomiting,
skin rash, chills, joint and muscle pain, headache, low energy, difficulty sleeping.

C. Stimulants
- Amphetamines, cocaine
- CNS stimulants
- Chronic and compulsive abuse results in tolerance and habituation
- "Crack" cocaine is the most addictive drug introduced in western society.
- Individuals addicted to amphetamines or cocaine tends to use other drugs,
such as barbiturates, alcohol or opiates.
Signs and Symptoms of Abuse
Euphoria
Initial CNS stimulation
Agitation
Wakefulness
Decreased appetite
Insomnia
Paranoia
Aggressiveness
Dilated pupils
Sweating
Persecutory delusions
Increased blood pressure and heart rate.

Withdrawal Signs and Symptoms

• Depression
• Psychomotor retardation at first then agitation
• Fatigue then insomnia
• Severe dysphoria and anxiety
• Cravings
• Vivid, unpleasant dreams
• Increased appetite
Amphetamine withdrawal is not as pronounced as cocaine withdrawal

Nursing Considerations:
• Monitor client's vital signs
• Monitor the client for suicidal ideation
• Promote sleep and rest
• Administer antidepressants, if ordered
• Remain with disoriented or frightened client; orient client to reality.
• Establish a trusting relationship with the client to alleviate any anxiety or
• paranoia
• Provide well-balanced meal
• Provide a safe environment
• Set limits on the client's attempt to rationalize behavior to reduce
• inappropriate behavior.
• "Cold turkey" withdrawal without medical supervision causes agitation,
• irritability, and severe depression frequently with suicidal ideation
• Withdrawal from cocaine causes intense craving for the drug. Amino acids
 catecholamine precursors such as tyrosine and phenylalanine, tricyclic
antidepressants, and the dopamine agonist bromocriptine
are three approaches used to increase the availability of neurotransmitters.

D. Cannabis Derivatives
- Marijuana, hashish, THC

Signs and Symptoms of Abuse

• Euphoria or dysphoria
• Relaxation or drowsiness
• Heightened perception of color and sound
• Poor coordination
• Spatial perception and time distortion
• Unusual body sensations (weightlessness, tingling)
• Dry mouth
• Dysarthria
• Food cravings
• Reddened eyes
• Dilated pupils
• High dosage may produce hallucinations and delusions.

Withdrawal Signs and Symptoms

• Insomnia
• Irritability
• Anorexia
• Agitation
• Restlessness
• Tremors
• Depression
• Chronic respiratory problems

Nursing Considerations:
• Attend to physiologic and safety needs
• Monitor respiratory problems
• Know that physicians rarely order medication to ease withdrawal.

E. Hallucinogens
- Lysergic acid diethylamide (LSD), Phencyclidine (PCP)

LSD:
- A hallucinogenic drug and mimics hallucinations seen in psychoses.

PCP
"Crystal" elephant tranquilizer\ "angel dust"
-Is considered an extremely dangerous "street" drug
-Cardinals Signs of PCP use are blank stare, ataxia,muscle rigidity, nystagmus and tendency
toward violence
Overdoses or "bad trip" is characterized by erratic, unpredictable behavior; withdrawal
symptoms; disorientation; self-mutilation; or self-destructive behavior.

Signs and Symptoms of Abuse

• Euphoria or dysphoria
• Altered body image
• Distorted or sharpened visual and auditory perception
• Depersonalization
• Bizarrere behavior
• Confusion
• Incoordination
• Impaired judgment and memory
• Signs of sympathetic and parasympathetic stimulation
• Palpitations
• Blurred vision
• Dilated pupils
• Sweating

Withdrawal Signs and Symptoms

• LSD: flashbacks at a later time; apprehension; panic
• PCP: depression; lethargy; craving; hypertension; seizures; bizarre behavior

NURSING Considerations:

• Overdoses are treated with sedatives, decreased environmental stimuli, and protecting client from harming self
and others,
• Monitor client's vital signs and safety
• Monitor the client for suicidal ideation
• Promote sleep and rest
• Remain with disoriented or frightened client
• Orient client to reality.
• Administer antidepressants if ordered Administer diazepam if the client has severe
anxiety during flashbacks, as ordered

Coping Mechanisms

Coping: cognitive, physical, or emotional attempts to manage stress; implies that He client is attempting to lower tension in
order to manage the situation effectively.

a. Adaptive coping behaviors: the client is capable of mobilizing internal/external resources and is able
to sustain general homeostasis
b. Maladaptive coping behaviors: can result to disorganization because
resources cannot be mobilized; ineffective and destructive behavior appear;
and general homeostasis is not preserved.

Defense Mechanisms

Definition: Defense mechanisms are automatic, psychological processes caused by internal or external
perceived dangers or stressors that threaten self-esteem and I disrupt ego function.

Characteristics:
1. The purpose is to attempt to reduce anxiety and to reestablish equilibrium.
2. Use of defense mechanisms may be a conscious process but usually takes place at the unconscious
level.
3. Defense mechanisms are compromise solutions
4. Defenses may be pathological or adaptive.

Ego-Defense Mechanisms:
a. Compensation: covering up weaknesses by emphasizing a more desirable
trait or by overachievement in a more comfortable area.
Example: A high school student too small to play football becomes the star long-distance runner for the
track team.

b. Denial: an attempt to screen or ignore unacceptable realities by refusing to

acknowledge them.
Example: A woman, though told her father has metastatic cancer, continues to plan a family reunion 18 months
in advance.
c. Displacement: the transferring or discharging of emotional reactions from one
object or person
Example: a husband and wife are fighting, and the husband becomes so angry he hits a wall instead of his wife.

d. Identification: an attempt to manage anxiety by imitating the behavior of someone feared or respected.
Example: A student nurse imitates the nurturing behavior she observes one of her instructors using with
clients.

e. Intellectualization: a mechanism by which an emotional response that normally would accompany an

uncomfortable or painful incident is evaded by
the use of rational explanations that remove from the incident any personal - significance and feelings,
Example: The pain over a parent's sudden death is reduced by saying; " He
wouldn't have wanted to live disabled."

f. Introjection: a form of identification that allows for the acceptance of others' and values into oneself, even
when contrary to one's previous assumption.
Example: A 7-year old tells his sister: "Don't talk to strangers." He has Tiecied this value from the instructions of
parents and teachers.

g. Minimiization: not acknowledging the significance of one's behavior.

Example: A person says, "Don't believe everything my wife tells you. I wasn't so drunk
I couldn't drive,"

h. Projection: a process in which blame is attached to others or the environment r for unacceptable desires, thoughts,
shortcomings, and mistakes.
Example: A mother is told her child must repeat a grade in school, and she s blames this on the teacher's poor
instruction.

i. Realization: justification of certain b$ i 1 m by faulty logic and ascription or motives that are socially
acceptable but did not in fact inspire the Hpior
Example: A mother spanks her toddler too hard and says it was alright because swidn't feel it through the diaper
anyway.

j. Reaction formation: a mechanism that causes people to act exactly opposite to

Example: An executive resents his bosses for calling in a consulting firm to recommendations for change in his
department but verbalizes complete men for the idea and is exceedingly polite and cooperative.

k. Regression: resorting to an earlier, more comfortable level of functioning that is characteristically less demanding
and responsible,
Example: An adult throws a temper tantrum when he does not get his own way.
l. Repression: an unconscious mechanism by which threatening thoughts, ladings, and desires are kept from becoming
conscious; the repressed material is denied entry into consciousness.
Example: A teenager, seeing Ms best friend killed in a car accident, becomes amnesic about the circumstances
surrounding the accident.

m. Sublimation: Displacement of energy associated with more primitive sexual oraggressive drives into socially
acceptable activities.
Example: A person with excessive, primitive sexual drives invests psyche energy into a well-defined religious value
system.

n. Substitution: the replacement of a highly valued, unacceptable or unavailable object by a less valuable,
acceptable or available object.
Example: A woman wants to marry a man exactly like her dead father ar. settles for someone who looks a little bit
like him.

O.Undoing: an action or words designed to cancel some disapproved thoughts,

impulses, or acts in which the person relieves guilt by making reparation.
Example: A father spanks his child and the next evening brings home a preseJ for the child.

Crisis Intervention

Crisis:
Definition: an experience of being confronted by a stress in which the individual i^ unable to cope/problem-solve.

Crisis Situation
a. Change or loss threatens the individual's equilibrium.
b. Anxiety and tension accompany the experience, making it more difficult to
cope.
c Hopelessness or helplessness results in a state of disorganization where
previous experience and coping fail to enable the individual to problems
solve.
d. Hopelessness: a subjective state in which an individual sees limited or m
alternatives or personal choices available and is unable to mobilize energjf on
own behalf.
e. Helplessness: a state that may arise when a client has a condition in which
he or she depends on an outside source for life support.
f. Loss of equilibrium ensues.
g. Crises are generally time-limited, lasting from 4 to 6 weeks during which time
there is a potential for either increased psychological vulnerability of personal
growth.

Precipitating Factors
• Threat to individual security, which may be loss or threat of loss.
- Situational crisis: actual or potential loss (job, friend,
mate, etc)
- Developmental or maturational crisis: any change, i.e., marriage, new
baby
- Adventitious crisis: crisis of disaster
- Two or more severe problems arising concurrently.
 • Precipitants typically occur within two weeks of onset of
disorganization.
Stages of Crisis
1. Initial increase in tension as the stimulus continues and further discomfort is
experienced.
2. Failure to succeed in coping with the stimulus while continuing to
experience distress.
3. Additional tension forces mobilization of internal and external resources
whereby emergency problem-solving efforts are attempted; the problem may
be redefined or the individual may resign himself or herself and give up
certain aspects of his or her goal that the client perceives as unattainable.
4. If the problem remains unresolved and cannot be ignored, tension builds and
major disorganization results.

Characteristics of a Crisis
• Crisis is self-limiting, acute and lasts 1-6 weeks.
• Crisis is initiated by a triggering event.

• The stimulus is beyond the person's usual experience.

• Previously developed coping mechanisms are ineffective
• Anxiety, tension, and disorganization ensue
• The individual perceives a threat to own integrity and/or established
goals.

Types of Crises
• Situational crises involve an external event that disturbs the individual's
equilibrium (loss, change) and threatens the consistency between self-
behaviors and values or beliefs.
• Maturational crises involve normal life transitions that evoke changes in
individual self-perception in role, status, and integrity.
• Adventitious crises involve external events such as natural disasters or other
events of catastrophic proportion that are unpredictable and often engender
fear, confusion, and loss of consistency with internalized beliefs, values and
behavior.
• Cultural crises accompany culture shock while adapting or adjusting to a
new culture or returning to one's own culture after being assimilated into
another.

Maturational Crisis
(Developmental)
• Predictable events in the normal course of life and formerly used coping
mechanisms no longer work.
• The way these crises are resolved affects the ability to pass through
subsequent stages

Examples:
• Passing from school age to adolescence.
• Passing from adolescent to adult.
• Leaving home
 • Getting married
• Having a baby
• Beginning a career

Situational Crisis
• Unanticipated or sudden events arising from an external source that threaten
the individual's integrity
Examples:
• Job Loss,
• Death Of Loved One
• Abortion
• Job Change
• Financial Change
• Divorce
• Pregnancy
• Severe Illness
• Life events

Adventitious Crisis
• An unplanned, accidental event that is not part of everyday life.
Example
• May be a natural disaster
• Flood, fire or earthquake
• National disaster
• War, riot
• Crime of violence
• Rape, murder, spousal or child abuse.

Nursing Diagnoses
• Risk for self-directed violence
• Risk for self-mutilation
• Ineffective individual coping
• Ineffective family coping
• Hopelessness
• Impaired adjustment
• Powerlessness
• Post-trauma response
• Altered role performance
• Situational low self-esteem
• Spiritual distress
• Acute confusion
• Impaired verbal communication
• Decisional conflict
• Sensory/perceptual alterations (illusions, cognitive distortions)
• Altered thought process: visual hallucination, auditory hallucination, ideas of
reference, delusions, inability to make decisions
• Social Isolation
• Potential self-care deficits
Implementation
• Focus on immediate problem
• Use reality-oriented approach
• Stay with "here and now" focus
• Set limits.
• Stay with the client or have significant persons available if necessary
• Explore available coping mechanisms
- Develop strengths and capitalize on them
- Do not focus on weakness or pathology
- Help explore the available situational supports.
• Clarify the problem and help the individual understand the problem and
integrate the events in his life.
• Actively encourage the client to express feelings, thoughts, and amotions
regarding the crisis situation.

Rape Trauma
Rape is a forced act of sexual intercourse.

Assessment
Rape Trauma Syndrome
• Initial response may be deceptively calm, but this usually masks distress,
denial or emotional shock.
• There is a high level of anxiety and fear related to future attacks
• Victim may develop phobic reactions
• Have difficulty with decision-making
• Flashbacks, violent dreams, and preoccupation with future danger are
common
• Experience guilt, doubts, fear, anger, and hatred of the perpetrator
• Have problems with intimate relationship
• Depression
• Feelings of helplessness and vulnerability
• Post traumatic stress disorder
• Problems with sexuality

Nursing Interventions
• Provide immediate privacy for examination
• Choose a staff member of the same sex to be with the victim.
• Remain with the victim
• Administer physical care.
- Do not allow client to wash genital area or void before
examination
- Keep client warm.
- Prepare client for complete physical examination to be completed by
physician.
• Test for pregnancy and sexually transmitted disease.
• Demonstrate a non-judgmental and supportive attitude.
 • Express warmth, support and empathy in relating to the victim
• Listen to what the victim says and document all information
• Encourage the victim to relate what happened, having her tell you in her
own words if it appears that she would like to talk about the experience.
• Do not insist if client chooses not to talk; allow the victim to cope in her
own way.
• During the interview, continue to be sensitive to the victim's feelings and
degree of control.

Cultural Diversity

Culture is a pattern of learned behavior based on values, beliefs and perceptions of

the world
• Subculture: a smaller group within a large cultural group that share
values,
beliefs, behaviors and language ® Ethnicity: ethnic affiliation and a
sense of belonging to a particular cultural group.
• Ethnocentrism: is the belief that one's own culture is more important than,
and preferable to, any other.

Culture and Mental Health

• Ideas about mental health, mental illness, psychiatric problems, and
treatments are based on cultural values and understanding
• What is considered normal or abnormal depends on the specific cultural
viewpoint.

Values: a set of personal beliefs about what is meaningful and significant in life
They provide general guidelines for behavior and are standards of conduct in
which people or groups of people believe
Every society has basic values about the relationship between humans and
mature, sense of time, a sense of productivity and interpersonal relationships.

Attitudes and perceptions

• Natural biases refer to how nurses' points of view cause them to notice some
mugs and not others
• Negative bias is a refusal to recognize there are other points of view
Generalizations are a way of organizing information; arising out of natural
biases, they are changeable starting places for comparing typical behavioral
patterns with what is actually observed.
• Stereotypes are also a way of organizing information; arising out of negative
biases, they are images frozen in time that cause us to see what we expect to
see, even when the facts differ from our expectations; stereotypes can be
favorable or unfavorable, and either kind is potentially harmful.
• Prejudice is negative feelings about people who are different from oneself
• Discrimination is prejudice that is expressed behaviorally; examples are
racism, ageism, heterosexism, and sexism.
• Open-mindedness is a positive outcome in an attempt by the nurse to be
more sensitive to diverse cultural groups and being willing to support clients
m their own cultural beliefs and practices.
 CARING for a Culturally diverse population
1.Effective advocacy for culturally diverse groups depends on a balance of
knowledge, sensitivity and skills
2.Nurses must understand their own ethnocentrism and acquire knowledge
about other cultural groups.
3.Sensitivity includes examining how our own attitudes, values and
prejudices affect our own nursing practice
4.Communication is an important skill in caring for clients from diverse
backgrounds; it includes learning client's level of fluency in spoken and
written English, and determining the most important style of
communication.
5.Becoming culturally competent and confident in managing diversity
requires practice and patience.
6.Recognize that it is the client's or family's right to make their own health
care choices.
7.Convey respect and cooperate with traditional helpers and
caregivers.

Ways of Conveying Cultural Sensitivity

• Always address client^ support people and other health care personnel by
their last names until they give you permission to use other names. In some
culture, the more formal style of address is a sign of respect, whereas the
informal use of first names may be considered disrespect.
• When meeting a person for the first time, introduce yourself by your full name
and then explain your role.
• Be authentic with people and be honest about the knowledge you lack about
their culture.
• Use language that is culturally sensitive
• Find out what the client thinks about his or her health problems, illness, and
treatments.
• Do not make any assumptions about the client, and always ask about anything
you do not understand.
• Show respect for the client's values, beliefs and practices, even if they differ
from your own or from those of the dominant culture.
• Show respect for the client's support people.
• Make a concerted effort to obtain the client's trust, but do not be surprised if
it develops slowly or not at all.

Health-Related Practices of Asian, African American and Hispanic People

Asian
• Coining and cupping are traditional medical practices, not forms of
abuse.
• Fevers are treated by wrapping the ill person in warm blankets and having him
or her drink warm liquids.
• Do not provide ice water unless requested. May prefer hot liquids, such as tea.
• Rich tradition of herbal remedies. Health care providers should be sure to
discuss the use of home or herbal remedies to avoid potential di^ interactions.
• Instruct on the use of Western medication because traditional Chinese
medicine is taken differently.
African American
• Menstruation is believed to rid the body of dirty or excess blood. With too
little flow, they may fear bad blood is staying in the body; too much flow can
weaken the body.
• Have rich tradition of herbal remedies.
• May avoid dairy products due to high incidence of lactose intolerance Check
for family history
• Focus on present time may interfere with use of preventive medicine and
follow-up care.

Hispanic
• Certain foods or medications upset hot-cold body balance. Try offering
alternative foods or liquids for medications.
• Do not provide ice water unless requested.
• Respect postpartum prescriptions for rest
• Sponge baths may be preferred after giving birth.
• Allow family members to spend as much time with the patient as possible
and provide non-technical care.
• Strong beliefs in fate and external control over events may lead to less
adherence to medical regimens.

Death/Dying/End of life
Death is cessation of physiologic processes that sustain life; loss of
life
• Death represents the ultimate loss
• Death is part of the continuum of life and as such is a universal and
inevitable part of human experience
• Death is often viewed as a mystical event that may generate great fear and
anxiety

Dying is the dynamic and individualized process of death

• Responses to the dying process are highly individualized and may be greatly
influenced by the client's physical status and personality; the interaction of
client and family will have a strong bearing on the client's healthy
progression through the process.
• Regardless of the age, a life-threatening illness produces a family crisis.

Nurse's Response
• To be effective in helping the dying person, the nurse must explore his or
her own beliefs, feelings and behaviors in regard to death.
• The nurse who is unaware of his or her own feelings, fears and beliefs about
death may unintentionally limit client's expression of feelings.
• Exploring one's own beliefs about death and how people respond to it
enables the nurse to maintain objectivity and facilitate the client's grief
work.

Establishing Priorities:
• Priorities may be determined by the client's psychologic and physical status
and cultural influences.
• The next most important action is helping the client effectively manage the
existing stage of grief.
 • Help the client and the family effectively communicate their feelings and
thoughts by creating an accepting environment, role modeling and
discussing the normal grief process and death and dying issues.
Clinical Signs of Death
- Total lack of response to external stimuli
- No muscular movement, especially breathing
- No reflexes
- Flat ECG
- In instances of artificial support, absence of electric currents from the brain for at
least 24 hours is an indication of death.

Concept of death/loss
A. Childhood
• Preschool children (aged 3 to 5) fear separation from parents and do not
understand the finality of death
• Children aged 5 to 6 see death as reversible
• Children aged 6 to 9 begin to accept death as a destructive force and as a
final event
• Children at age 10 realize that death is inevitable
• Adolescents intellectualize awareness of death, but tend to repress feelings
about it.
B. Early and middle Adult
• View loss and death as normal developmental tasks
• Potential loss from impaired health or body function
• Change in various role functions
C. Older Adult
• Loss of health, function, and/or independence
• Potential change in living accommodations
• Loss of longtime mate or significant other
• Multiple losses and deaths of friends, family and significant others

Stages of Death/Dying by Kubler-Ross

a. Denial: disbelief or refusal to acknowledge that loss or death is
happening
b. Anger: expression of overt hostility toward loss object, dying person, or
others
c. Bargaining: attempts to negotiate to prolong one's life or to erase the
loss
d. Depression: sense of sadness over loss or death
e. Acceptance: comes to terms with loss or death

Assessment
Psychosocial Clinical manifestations of clients who are going through the dying
process
• Depression and withdrawal
• Fear and anxiety
• Focus is internal
• Agitation and restlessness
Nursing Interventions for clients and families facing death
• Recognize that client and families have own way of dealing with death
and dying
• Use silence and personal presence along with techniques of therapeutic
communication
• Accept and support the client's and family's use of coping mechanisms
• Accept denial and negative responses from clients and families
• Encourage client to participate in decisions
• Encourage client and family to discuss feelings related to death and dying.
• Encourage family to communicate openly with the client; acknowledge
the family's grief.
• Support the client and the family as they work through the dying process
• Assist client and family to adapt to changes in roles and lifestyles.

Suicide
• Suicide is the intentional and voluntary taking of one's life.
• Clients contemplating suicide often perceive themselves as isolated.
• Warning signs that may indicate the risk for suicidal ideations and
self-
injurious behavior include changes in personal habits such as appetite,
sleep patterns, personal appearance, personality, sue of alcohol and other
drugs, as well as bodily complaints, self-depreciating comments, making
wills and/or giving away personal/meaningful belongings.
• The most predictive psychiatric disorder for suicide is the presence of a
mood disorder.

COMMON Myths of Suicide

• People who talk about suicide won't actually commit suicide.

• People who are serious about suicide will show warning signs or give clues
• Young children do not commit suicide
• An improvement in mood means the risk for suicide is over
• Only people who are depressed commit suicide
• A written or verbal safety contract is a guarantee that the client will not kill
himself

Suicide Assessment
During the initial assessment, question the client about any thoughts or feelings
related to killing or harming himself or herself; determining suicidal ideations, how
the client has sought help, what kind of plan the client has made, the mental status
of the client, the client's available support systems, and the client's lifestyle are all
part of the nursing assessment.
i. Ask questions like "Have you had any thoughts about life not being
worth living?" (Passive suicidal ideations)
ii. Move from general to specific questions like: "Have you
had any ideas about killing yourself?"
iii. If the client answers yes, ask the client, "Have you thought of/or made
any plans on how you might harm or kill yourself?"
iv. Assess levels of lethality ("do you have a gun in your home?")
B. Clients may lack the emotional or psychic energy to action suicidal ideations as
a result of some of the negative neurovegetative symptoms they experience; thus the
nurse must be aware that a sudden sense of peace or wellness reported by the client
may indicate that the client has sufficient psychic energy to carry out a suicidal act.

Nursing Diagnoses
a. Risk for self directed violence
b. Ineffective individual coping
c. Hopelessness
d. Powerlessness
e. Chronic low self-esteem
f. Altered thought process
g. Social isolation
h. Defensive
coping

Nursing interventions to reduce risk for suicide

* Inpatient treatment is indicated if the client is felt to be at high risk for self-
directed violence.
• Place the client on constant observation for the first 24 hours or until the
degree of suicidal risk is lessened.
• Place the client on q 15 minute checks thereafter
• On admission remove any items that could be used by the client to harm
self
• Keep the unit free of materials that can be readily used to harm self; keep
windows locked, count silverware.
• Give client a roommate to reduce opportunity for solitude
• Realize that despite all proper precautions, a client may still take own life
after hospitalization; the ultimate decision to live belongs with the client.

Family Dynamics
• Within each family there are a distinct set of rules and roles that govern each
family member's behavior and their interactions with one another. The role each
person assumes is determined by the number of persons within the family.
individual personalities and the family circumstances. The rules define what actions,
feelings and relationship patterns are acceptable.

Family Developmental Tasks

Stage Task
Early marriage( stage of adjustment) Psychologic and physical
separation
from family of origin
o Establishment of roles o
Division of tasks and
responsibilities
o Formulation of new rituals
o Development of new relationships
with family of origin and in-laws
 o Establish personal boundaries
o Form mutually-respectful and
effective communication patterns
o Develop a mutually
satisfying sexual
relationship
o Decide and plan for children
o Prepare for childbirth and
emerging
parental roles.

COUPE WITH CHILDREN o Adjust to parental role and

lifestyle
changes arising from taking care of
infant/child
o Refine communication patterns with
mate and children
o Reaffirm mutually satisfying
relationship with mate and
children
o Respond to complex
demands of family members,
including
mate,
children, and in-laws
o Prepare children for healthy
social relationships in the
home,
community, and society
o Encourage healthy
separation
of children from family system

Middle-aged/older couple o Adjust to midlife biologic, social, an

emotional changes
o Establish relationship with
grandchildren
o Appraise whether lifelong goals have been
established or met
o Foster generational transmission of
cultural/social/ethnic beliefs a: values
in grandchildren.
 Family Issues

A. Divorce

For many people, the divorce of their parents marks a turning point in their lives, whether the
divorce happened many years ago or is taking place right now.

Reasons why parents are divorcing:

o It may include serious problems like alcoholism or abuse

o Often couples divorce because they can no longer live together in harmony.
One parent may have changed in some ways, and the other could not adapt.
Some couples may have simply drifted apart over time. Others find that they
no longer love each other as they once did.

Common feelings of Children:

o It's common for teens to think that their parents' divorce is somehow their
fault, but nothing could be further from the truth.
o Some teens may wonder if they could have helped to prevent the split.
Others may wish they had prevented arguments by cooperating more within
the family.
o If your parents are divorcing, you may experience a variety of feelings, and
your emotions may change frequently, too.
o May feel angry, upset, or sad.
o Might feel protective of one parent or blame one for the situation
o May feel abandoned, afraid, worried, or guilty.
o May also feel relieved.

Effects of Divorce
Moving and changing schools, spending time with both parents separately, and
dealing with some parents' unpleasant feelings toward one another. Issues of
money may change for your parents, too. A parent who didn't work during the
marriage may need to find a job to pay for rent or a mortgage. There are
expenses associated with divorce, from lawyers' fees to the cost of moving to
a new place to live. Your family may not be able to afford all the things you
were used to before the divorce.
Some teens have to travel between parents, and that may pose problems both
socially and practically.
Parents may go to court to determine custody arrangements. You may end up
living with one parent most of the time and visiting the other, or your parents
may split their time with you evenly. Often, it takes a while for tody
arrangements to be finalized. This can give people time to adapt to these big
changes and for families to figure out together what works best.
What Parents and Children Can Do to Make Divorce Easier

Keep the peace. Dealing with divorce is easiest when parents get along. Teens find it
espceially hard when their parents fight and argue or act with bitterness toward each
other. You can't do much to influence how your parents behave during a divorce, but
you can ask them to do their best to call a truce to any bickering or unkind things they
might be saying about each other. No matter what problems a couple may have faced,
as parents they need to handle visiting arrangements peacefully to minimize the stress
their kids may feel.

Be fair. Most teens say it's important that parents don't try to get them to "take sides.
You need to feel free to relate to one parent without the other parent acting jealous
hurt. or mad. It's unfair for anyone to feel that relating to one parent is
being disloyal to the other or that the burden of one parent's happiness is on your

Keep in touch. Going back and forth between two homes can be tough, especially if
its far apart. It can be a good idea to keep in touch with a parent you see irsen
because of distance.

Work it out. You may want both parents to come to special events, like games,
meets, plays, or recitals. But one parent may find it difficult to attend if the other is
present. It helps if parents can figure out a way to make this work, especially
because a teen may need to feel the support and presence of both parents even more
during divorce. You might be able to come up with an idea for a compromise or
solution to this problem and suggest it to both parents,

Talk about the future. Lots of teens whose parents divorce worry that their own
plans for the future could be affected. Some are concerned that the costs of divorce
(like legal fees and expenses of two households) might mean there will be less money
for college or other things.

Pick a good time to tell your parents about your concerns - when there's enough I time
to sit down with one or both parents to discuss how the divorce will affect you. Don't
worry about putting added stress on your parents. It's better to bring your concerns
into the open than to keep them to yourself and let worries or resentment build. There
are solutions for most problems and counselors who can help teens and their parents
find those solutions.

Live your life. Sometimes during a divorce, parents may be so caught up in their own
changes it can feel like your own life is on hold. In addition to staying focused on
your own plans and dreams, make sure you participate in as many of yours normal
activities as possible. When things are changing at home, it can really help to keep
some things, such as school activities and friends, the same. Take care of yourself,
too, by eating right and getting regular exercise - two great stress busters!

Let others support you. Talk about your feelings and reactions to the divorce with
someone you trust. If you're feeling down or upset, let your friends and family
members support you.

Bring Out the positive. There will be ups and downs in the process, but teens can
cope successfully with their parents' divorce and the changes it brings. You may
even discover some unexpected positives. Many teens find their parents are actually
happier after the divorce or they may develop new and better ways of relating to
both parents when they have separate time with each one.

B. Sibling Rivalry

o Sibling rivalry is the jealousy, competition and fighting between brothers

and sisters. It is a concern for almost all parents of two or more kids.
Problems often start right after the birth of the second child.
o Sibling rivalry usually continues throughout childhood and can be very
frustrating and stressful to parents.

Factors that contribute to sibling rivalry:

• Each child is competing to define who they are as an individual. As they

discover who they are, they try to find their own talents, activities, and
interests. They want to show that they are separate from their siblings.
• Children feel they are getting unequal amounts of your attention, discipline,
and responsiveness.
• Children may feel their relationship with their parents is threatened by the
arrival of a new baby

• Children's developmental stages affect how well they can share parent's
attention and get along with one another.
• Children who are hungry, bored or tired are more likely to start fights.
• Children may not know positive ways to get attention from their brother or
sister. so they pick fights.
• Family dynamics play a role. For example, one child may remind a parent
of a relative who was particularly difficult, and this may subconsciously influence
how the parent treats that child.
• Children will fight more with each other in families where there is no. -
understanding that fighting is not an acceptable way to resolve conflicts.
Families that don't share enjoyable times together will probably have more
conflict.
• Stress in the parent's lives can decrease the amount of attention parents give
the children and increase sibling rivalry.
• Stress in children's lives can shorten their fuses, and create more conflict.
• How parents treat their kids and react to conflict can make a big difference
in how well siblings get along.

Plan

Tips for Parents

• Never compare your children. This one is a "biggie",

• Don't typecast. Let each child be who they are. Don't try to pigeonhole
or label them.
• Don't play favorites.
• Set your kids up to cooperate rather than compete. For example, have
them race the clock to pick up toys, instead of racing each other.
• Pay attention to the time of day and other patterns in when conflicts usually
occur. Perhaps a change in the routine, an earlier meal or snack, or a well-r tinned
activity when the kids are at loose ends could help avert your kids' conflicts.
• Teach your kids positive ways to get attention from each other. Show them
how to approach another child and ask them to play.
• Being fair is very important, but it is not the same as being equal. Your
children need to learn that you will do your best to meet each of their unique needs.
Even if you are able to do everything totally equally, your children will still feel as
if they're not getting a fair share of attention, discipline, or responsiveness from you.
• Plan family activities that are fun for everyone. If your kids have good
experiences together, it acts as a buffer when they come into conflict. It's easier to
work it out with someone you share warm memories with.
• Make sure each child has enough time and space of their own. Kids
need chances to do their own thing, play with their own friends without
their sibling, and they need to have their space and property protected.

• Set aside "alone time" for each child. Each parent should spend some
one on-one with each kid on a regular basis. Try to get in at least a few
minute! each day. It's amazing how much even just 10 minutes of
uninterrupted one-on-one time can mean to your child.
• When you are alone with each child, ask them once in a while what
they like most and least about each brother and sister. This will help
you keep tabs a their relationships, and also remind you that they
probably do have soi4 positive feelings for each other!
• Listen—really listen—to how your children feel about what's going on J the
family. They may not be so demanding if they know you at least can how they feel.
• Celebrate your children's differences.
• Let each child know they are special—just for whom they are.

Resolving conflicts:

• Help your kids develop the skills to work out their conflicts on their own Teach
them how to compromise, respect one another, divide things fairly etc. Give them the
tools, and then express your confidence that they can work it out, by telling them,
"I'm sure you two can figure out a solution."Don't get drawn in.
• Don't yell or lecture. It won't help.
• It doesn't matter "who started it," because it takes two to make a quarrel Hold
children equally responsible when ground rules get broken.
• In a conflict, give your kids a chance to express their feelings about
each other. Don't try to talk them out of their feelings. Help your kids
find words for their feelings. Show them how to talk about their feeling,
without yelling, name-calling, or violence.
• Encourage win-win negotiations, where each side gains something.
• Give your kids reminders. When they start picking on each other, help
them remember how to state their feelings to each other. Don't solve the
problem for them, just help them remember how to problem solve.
• Model good conflict resolution skills for your kids.
When to intervene:

• Dangerous fights need to be stopped immediately. Separate the children.

When they have calmed down, talk about what happened and make it very
clear that no violence is ever allowed. Involve your children in setting ground
rules. Ground rules, with clear and consistent consequences for breaking
them, can help prevent many squabbles

Grief and Loss

Loss is the actual or potential situation in which something that is valued is

changed no longer available or gone,

Types of Loss
• Actual: can be identified by others and can arise in response to an
anticipation of a situation, (e.g. death of significant other)
• Perceived: is experienced by one person but cannot be verified by
others eg, loss of self-esteem)
• Anticipatory: is experienced before the loss actually occurs (e.g.,
terminal illness)

Physiological responses related to loss or grief

• Crying and sobbing
• Sighing respirations
• Shortness of breath and palpitations
• Fatigue, weakness and exhaustion
• Insomnia
• Loss of appetite
• Choking sensation
• Tightness in chest
• Gastrointestinal disturbances

Physiological Responses related to loss or grief

• Intense loneliness and sadness
• Depressed mood
• Anxiety or panic episodes
• Difficulty concentrating and focusing
• Anger or rage directed toward self or others
• Ambivalence and low self-esteem
• Somatic complaints

Grief is a pervasive, individualized and dynamic process that may result in I

emotional or spiritual distress because of loss or death of a loved one or
cherished object.
a) Abbreviated grief: mild anxiety and sorrow experienced for a brief period
but genuinely felt.
b) Anticipatory grief: anxiety and sorrow experienced prior to an expected loss
or death
c) Disenfranchised grief: a response to a loss or death in which the individual
is not regarded as having the right to grieve or is unable to acknowledge that
loss to other persons (e.g., a gay partner unable to acknowledge the loss of
his or her significant other)
 d) Dysfunctional grief: unresolved or inhibited grief that does not lead to
successful conclusion.

Assessment of grieving patient

Stages of Grief (note: each individual processes grief in different ways and i
different rates.)
a. Shock and disbelief (1 to 3 weeks)
Numbness
Denial
Passive
Unaware of others
b. Searching and protesting (3 weeks to 4 months)
- Crying and yearning
- Guilt
- Intense and conflicting emotions, such as sadness and
anger
- Empty feeling
- Identification and preoccupation with thoughts of loss or
death
- Dependent
- Self-destructive behaviors
c. Disorientation (4 to 14 months)
- Depression and despair
- Apathy and loss of interest
Aimlessness
- Disorganization
- Insomnia
- Inability to maintain work and family responsibilities
- Confusion and slowed thinking
- Social withdrawal
d. Reorganization and resolution (14 months throughout rest of life)
- Acceptance of loss, letting go
- Awareness of having grieved
- Ability to talk about deceased or loss without intense pain
- New or renewed social relationships
- New or renewed interest
- Process that may typically last up to 1 year

Stages of Grief according to George Engel

a) Shock and disbelief: refusal to accept loss; stunned feelings; intellectual
acceptance but emotional denial
b) Developing awareness: as awareness increases, the bereaved experiences
severe anguish
c) Restitution: mourning is the next stage where the work of restitution takes
place Rituals of mourning.
d) Resolution of the loss: occurs as the mourner begins to deal with the void,
e) Idealization: negative feelings are repressed and only the pleasant memories are
remembered
f) Outcome: behavior influenced by several factors, importance of lost objects
 as source of support, degree of dependence on relationship with support,
degree of ambivalence toward lost object and number of previous grief
experience as source of support, degree of dependence on relationship with
support person, degree of ambivalence toward lost object and number of previous
grief experience

NURSING INTERVENTIONS
• Establish rapport and build trust
• Facilitate grief work of client and family.
• Encourage clients to express feelings and assist them to identify their
fears concerning the loss
• Accept negative feelings and use of defense mechanisms
• Provide clients with opportunities to release tension and guilt
• Promote an adequate balance of rest, sleep and activities
• Explain grieving and mourning processes and relate to client and
family responses
• Assist grieving person to seek new meanings with both dead or loss, as
well as life
• Encourage clients to implement religious beliefs and rituals
surrounding death or loss
• Mobilize the client's support systems.
• Refer client and family to self-help groups for survivors of loss, families
for mentally ill persons, and individuals who are psychiatrically
disabled.

Mental Health Concepts

Mental Health
• Related to the ability to see oneself as others do and fit into the culture
and society where one lives; indicators of mental health include
positive attitudes toward self growth development, self-
actualization integration autonomy, reality perception, and
environmental mastery.

Mental Illness
• Is the inability to see oneself as others do and not having the ability to
conform to the norms of the culture and society.

*Mental health and mental illness can be viewed as end points on a continuum,
with movement back and forth throughout life.

*The mental health-mental illness continuum cuts across physical, personal,

interpersonal, and societal levels.
 *Factors contributing to mental health-mental illness continuum include
cultural, interpersonal, and intrapersonal factors.

Social Determinants of Mental Health and Mental Illness

1. Stress
a. Social
• Poverty
• Poor housing
• Unemployment
• Crowding
• High rate of mobility
b. Personal
• Maturational (adolescence, aging)
• Role changes
• Situational (Loss, Divorce, separation, Illness)
2. Individual
a. Genetic information
b. Constitutional traits
c. Developmental traits
• Coping mechanisms
• Ego strength
• Developmental stage
• Temperament
• Familial predisposition
3. Support System
a. Social
• Churches and synagogues
• Schools
• Social welfare
• Community resources
b. Personal
• Family network
• Friends
• Clergy
Therapeutic Models

Psycholytic (Freud)
• Focuses on intrinsic (innate) drives and motivations.
• Individuals are motivated by unconscious desires and conflicts.
• Emotional disturbance stems from emotionally painful
experiences,
• Feelings are repressed. Unresolved unconscious conflicts remain
in the mind. Symptoms and defense mechanisms develop
• Proposed a three-part structure of personality
Id-present at birth and is unconscious
• Unconscious impulses toward fulfillment of needs
• Maximize pleasure and avoid discomfort
• Pleasure principle
Ego-mediates between ID and SUPEREGO -
 • The ability to delay desires for instant gratification and redirect
it into more realistic and appropriate ways to meet one's needs.
• Reality principle
Superego-Moral judge
• Provides the individual with standard by which to regulate one's
moral conduct and takes pride in one's accomplishment
• Internalized all knowing parent

♦ Unresolved conflict between the id and superego can lead to a

fixation or
blockage in a development

* Results in excessive dependence and manipulation

Psychosexual Stages of Freud

Age Stages

Infancy(Birth to 18 months) Oral

Toddler (18months to 3 years) Anal

Preschool( 3-6 years) Phallic/Oedipal

School age (6-12) Latency

Adolescence(12-20) Genital

Interpersonal (Sullivan)
• Focus of theory is on relationships between people.
• Early learning experience set up the style of interaction seen in an
individual.
• Emotional disturbance results from problematic interpersonal interaction.
• Interpersonal relationships and anxiety facilitate development of the selfl
system.

Behavioral theory
The focus of behavioral theory is on a person's actions, not on thoughts and feelings

B.F. Skinner's theory-

• Emphasizes the functional analysis of behavior. Focuses on the basic
relationship between the stimulus and the response, investigating situations
that cause responses to occur most predictably
Reinforcements are consequences that lead to an increase in behavior; punishment
are consequences that lead to a decrease in the behavior.

Cognitive Theory

Jean Piaget

• Identified four major stages of cognitive development: sensorimotor

preoperational, concrete operational, and formal operational.

Aaron Beck's cognitive theory

• Focuses on how people view themselves and their world.

Level of Growth and Development by Erickson (Psychosocial Stages)

• Each stage of development is an emotional crisis involving positive and
negative experiences.
• Growth or mastery of critical tasks is the result of having more positive that
negative experiences; non mastery of tasks inhibits movement to the next
stage.
• The degree of mastery of each stage is related to the degree of maturity
attained by the adult.

1. Birth to 18 months
• Sensory stage
• Developmental Task: Trust vs. mistrust
• Child learns to develop trusting relationships

2. 1-3 years
• Muscular stage
• Developmental task: Autonomy vs. shame and doubt
• Child starts the process of separation; starts learning to live autonomously.

3. 3-6 years
• Locomotors stage
• Developmental task: Initiative vs. guilt
• Learns about environmental influences; becomes more aware of own
identity.

4. 6-12years

• Latency
stage
• Developmental task: Industry vs. inferiority
• Energy is directed at accomplishments, creative activities, and learning

5. 12-20years
• Adolescent
• Developmental task: Identity vs. role confusion
• Transitional period; movement toward adulthood; starts
incorporating beliefs and value systems that have been acquired previously.

6. 18-25 years
• Young Adult
• Developmental task: Intimacy vs. isolation
• Learns the ability to have intimate relationship

7. 24-45years
• Adulthood
• Developmental task: Generativity vs.
stagnation
• Emphasis on maintaining intimate
relationships; movement toward developing a family.

8. 45years - death
• Maturity
• Developmental task: Integrity vs. despair
• Acceptance of life as it has been; acceptance of both good and bad aspects
of past life; maintaining a positive self-concept.

Maslow1 s Hierarchy of Needs

• Abraham Maslow identified basic physiological needs and growth-related
metaneeds; his humanistic theory emphasized health rather then illness.
• Maslow conceptualized theses needs on a hierarchy, often symbolized by a
pyramid.
• There are five levels of needs in the hierarchy (from bottom to top of the pyramid)
as physiological needs, safety needs, love and belonging needs, esteem and
recognition needs, and self-actualization needs.

1. Physiological needs include the needs for oxygen, food, water, sleep, shelter and
sexual expression.
2. Safety needs include physical safety, avoiding harm, and attaining security and
order
3. Love and belonging needs include companionship, the giving and receiving of
affection and identification with a group.
4. Esteem and recognition needs include self-esteem, the respect of others,
prestige, and success at work.
5. Self-actualization is the fulfillment of one's unique potential.

Need "Motivation to Satisfy

Need

need Challenging Projects, Opportunities for Innovation

 for self and Creativity* Learning at a High Level,
actualization Important Projects, Recognition of Strength*
need for 'intelligence, Prestige and Status,
self esteem Acceptance, Group Membership. Association
social needs- * ** with Successful Team. Love and Affection*
belongings Physical Safety, Economic Security* Freec
need for safety and from Threats, Comfort, Peace.
security Water, Food, Sleep, Warmth, Health,
physical survival needs "Excercfse Sex.

Mastow*s Hierarchy of Needs

Treatment Modalities for Mental Illness

1. Psychotherapy
a. Definition: goal-oriented, restorative emotional experience with a therapist in
order to effect behavioral change, including
• Increased sense of well-being and self-esteem
• Improved psychologic performance
• Enhanced social and interpersonal adeptness
• Expanded biologic function length
of treatment
• Less focus on long-term length because of managed care; however, a long-term
approach enables the client to gain insight and develop new coping mechanisms.
• More likely to be a short-term approach, such as crisis intervention or brief,
problem-focused approach and time limited.

2.Crisis Intervention
Definition: a time-limited (approximately 4 to 6 weeks), directive approach to
help a client cope with a crisis. Crisis Therapy
• Includes helping an individual or family cope with a present intolerable situation.
• Focuses on here-and-now rather than the past
• Deals directly and briefly with the individual's present situation to return client
to previous level of coping.
- Clarifies situation and identifies problem
- Appraises previous adaptive coping patterns and attempts to adapt to present
situation
- Teaches client new coping skills
- Identifies current options and mobilizes external and internal resources
• Expands the client's problem-solving and decision-making skills,
thereby promoting growth and adaptation and enhanced ability to manage
future crises
• Minimizes the deleterious effects of present stressors. The
process of crisis therapy includes:
Establishing a nurse-client relationship.
Providing immediate and ongoing emotional support through the use
of self and available resources.
Helping the client identify viable options for managing the current
crisis.
Emphasizing that the relationship is time-limited with here-and-now
 focus.
Establishing a termination date at the beginning of the relationship.
Actively encouraging the client to express feelings, thoughts, and
emotions regarding the crisis situation.
Facilitating formation of new and adaptive coping skills.
Having the client take more responsibility in subsequent sessions.

3. Behavior Modification
a. Definition: refers to a systematic employment of rewards and punishments
to modulate or change behavior. Major features:
• Governed by the premise that behavior is learned and directed by both
reward and punishment reinforces.
• Alterations in consequences result in modified behavior.
b. Process of treatment
• Identify the behavior to be changed.
• Obtain baseline data regarding the behavior.
• Identify the conditions and reinforcers that will change or
eliminate
behavior.
c. Techniques: systematic desensitization, ignoring the behavior, time out,
token economy, aversion

4. Therapeutic Milieu / Milieu Management

a. Purposeful use of all interactions to assist client in developing interpersonal
and social skills in a conducive physical and emotional environment.
b. Governs (increases or decreases) environmental stimuli to provide limits,
protect client, and promote optimal functioning.
c. Nurse's Role:
- Provide 24-hour milieu management
- Afford positive role modeling
- Plan/coordinate care
- Facilitate formation of adaptive coping behaviors.
d. Activities
• Government: distributes power, promotes open
communication;
negotiate with staff, run unit activities.
• Self-care: client required to maintain room, personal hygiene,
clothing,
nutrition, diversional activities, socialization to foster independence.
• Occupational therapy: specific programs developed by
occupational
therapists to encourage nonverbal expressions, increase self-esteem,
and expand skills of daily living
• Activity therapy: art, music and recreation planned by nurses or
activity
therapists to increase social skills and self-integrity, decrease
regression, and facilitate an optimal level of functioning.
• Health education: focuses on signs and symptoms, causes,
treatment of
specific mental disorders; role of client and family in symptom
 management and relapse prevention.

5. Therapeutic Groups (psychotherapy): more closely resemble real-life

situations than does one-to-one therapy.

a. Leading these groups requires training beyond basic nursing education.

b. Beginning nurse may co lead a group.
c. Group members provide feedback to each other.
d. Variety of responses and reactions available are exhibited in group settings.
e. Three stages of development:
• Group orientation and development of identity
• Group interaction and observation of dynamics
• Resolution of dynamics and production of insights.
f. members may examine patterns of relating to each other and authority figures in
supportive atmosphere.
g. There are usually 2 therapists and 7 to 12 clients.

6.Familytherapy: focuses on the family rather than on the individual

a. Major problem:
• Impaired communication
Maladaptive subsystems or family alliances
• Inconsistent or unclear family rules
b. Major objective: to reestablish effective communication between family
• Family can reassess and recognize dysfunctional alliances
• Family can resolve to accept individuality of members.
• Family can express feelings and thoughts in an accepting climate.
difference between family therapy and group therapy
• In family therapy, the participants enter therapy with a long-standing
astern of roles and interactions, which the nurse therapist must learn.
• In group therapy, the relationship between participants begins with the
first session; they have no history of relationship.

7. Self-help Groups: use persons who have themselves surmounted problems. .

Nurses may serve as consultants/resource persons.
Examples of self-help groups:
Recovery, Inc.
• Parents without Partners
• Groups for colostomy clients
• Overeaters Anonymous
• Reach for Recovery
• Alcoholics Anonymous
• Narcotics Anonymous
• Depressive Anonymous
• Cocane Anonymous
• Groups for child/wife abusers (Parents Anonymous)
 Psychopathology
Bipolar Disorder (manic-depressive disorder)
• An individual has moods alternating between depression and elation

Categories of Bipolar Disorder

1. Bipolar I disorder: characterized by the occurrence of one or more manic
episodes and one or more depressive episodes.

2.Bipolar II disorder: characterized as less severe and has one or more hypomanic
(mild mania) episodes and one or more depressive episodes.

3. Bipolar disorder is further classified as mixed (i.e., the individual has rapidly
alternating moods), manic (i.e., the individual is currently in a manic state), or
depressed (i.e., the individual is in the depressed phase, but there is also a history of
manic episodes.

Assessment: Bipolar Disorder

1. Affect
a. Powerlessness, worthlessness
b. Helplessness
c. Fear and crying
d. Anger, hostility (directed inward in depression, outward in elation)
e. Elation in mania
f. Sadness in depression
g. Anxiety
h. Depression related to guilt and repressed hostility; leads to self
condemnation and punishment

2. Cognition
a. Limited perception, interests, judgment, and decision-making skills
b. Impaired concentration and transient memory difficulties
c. Delusional thinking (e.g., grandiose and persecutory in mania)
d. Talkative, flight of ideas in elated stage
e. Distorted cognitions, negative self-talk, overgeneralization in depression

3. Behavior
a. Decreased (psychomotor retardation) or increased motor activity (agitation
or hyperactivity in mania)
b. Decreased or increased communication
c. Changes in social interactions: withdrawn in depression and intrusiveness in
mania
d. Self-care deficits
e. Self-destructiveness (e.g., suicide attempt, substance misuse)
4. Physical normal patterns and significant changes over the past 6 to 12 months
a) Appetite and eating patterns
b) Sleeping patterns
c) Interest in sex
d) Weakness, fatigue or increased energy in mania
e) Constipation/diarrhea
5. Strengths and capabilities
a) Usual coping strategies
b) Family and peer relationships
c) Hobbies and pastimes (often limited in depression)

Depression
Assessment
1.Signs and Symptoms
a) Affect: quiet, sad, unhappy, helpless, hopeless, withdrawn, apathetic
Cognition: cognitive triad (negative view of self, world and the future),
difficulty making decisions
b) Behavior: decreased activity, inhibited, social isolation
c) Physical changes mild physical discomforts, fatigue, sleep and appetite
disturbances

2. Priority for care

a) Safety
b) Physical needs
c) Self-esteem
3.Suiside Potential
a.Suicidal Risk: persons at high risk for suicide include
• Adolescents and white males 50 years and older
• Single males
• Persons with psychiatric disorders
• Young African-American males
• Persons with inadequate support systems
• Persons with depression
• Persons with substance abuse
• Persons with hallucinations
• Those with a history of family suicide
• Previous attempters
• Those with histories of violent or aggressive behavior
• Persons who are cognitively impaired
• Those with poor impulse control
b.Suicidal plan
• Method - assess degree of lethality (margin of error)
• Availability (the more available, the higher the risk)
• Specificity of plan.
c. Change in behavior (e.g., calmness: may mean person has worked out a plan
and no longer feels ambivalent); as depression lifts, the client may have
energy to carry out plan
d. Giving away valued possessions: saying goodbye, making amends, asking
medical questions
e. Ambivalent feelings
• Coexistence of opposing emotions in client
• Inability to express anger and hostility effectively, turns hate and
aggression inward, leading to self-destructive thoughts or actions
• Feelings of ambivalence are common in severely depressed clients,
particularly when depression is related to the loss of significant other.
f. Significant changes in activities of daily living (work habits, sleep patterns,
eating patterns, social interactions, memory or thought process disturbances,
 impaired decision making and judgment.

Mania
Assessment
1. Physical needs
a. Nutrition: decreased appetite or unwillingness to stop activity to eat may
lead to weight loss
b. Hydration
c. Sleep/rest: activity pattern and insomnia may lead to exhaustion
d. Elimination: may be incontinent; constipation
e. May ignore injuries or symptoms of physical illness
f. Hygiene and grooming: inappropriate dress; excessive make up; diaphoresis
2. Affect
a. Degree of euphoria or expansive mood
b. Lability: rapid mood change from happy to sad without apparent
provocation
c. Anger
d. Anxiety
e. Irritability and low tolerance to frustration
3. Cognition
a. Feelings of worthlessness, loneliness are masked by elation
b. Flight of ideas
c. Delusions of grandeur, persecution or both
d. Feelings of inadequacy, low self-esteem
e. Short attention span, easily distracted
f. Perceptual-sensory disturbances
4. Behavior
a. Degree and appropriateness of activity
b. Aggression, manipulation, acting out
c. Demanding, verbally hostile
d. Pressured, circumstantial, and tangential speech (talkative)
e. Easily distracted by extraneous external stimuli
f. Impulsivity
g. Extreme involvement in pleasurable activities such as exorbitant
spending sprees, promiscuity, unwise business ventures
h. Superficial relationships
i. Decreased need for sleep
j. Profound intrusiveness

Bipolar Disorder

Etiology

A. Biological causative theories of depressive disorders

1. Alterations in neurochemical functioning
The biogenetic amines most often identified as relevant in depression are
dopamine, serotonin and norepinephrine
Also indicated are the dysregulation of acetylcholine and gamma-
aminobutyric acid (GABA)
There can be alteration in the amount of specific neurotransmitters or a
change in neurosynaptic receptor sites in the brain.
The result of these changes can be a significant change in mood.
 2. Genetic predisposition
Currently believed to be a significant contributor to depression in offspring
of individuals who have suffered from major depression

3. Endocrine or hormonal change

Strongly affect an individual's mood and emotions
Irregularities in the thyroid (such as insufficient secretion of thyroxin) seen as
especially important in relation to major depression

4. Circadian rhythms
Indviduals exhibiting changes in circadian rhythms are at increased risk for
developing depressive symptoms and major mood disorders as well.

B. Psycological Theories

1.Derived from the psychoanalytic, cognitive, interpersonal, and behavioral

2. Psychonalytic perspective
• Freud believed that depression occurs because of an ego or object loss in
early life.
• The loss had a profound effect on the development of mental difficulties in
later life
• Freud explained depression as an anger turned inward.
• The loss of a person or object was usually the trigger of the depression
• In order to help clients regain or attain an improved mental health status Freud
developed psychoanalysis to help the client to gain insight into the meanings
of thoughts, feelings and actions.
3. Cognitive perspective
• Cognitive theorists believe that depression is the outcome when an individual
perceives all stressful situations as negative.
• The person sees most situations in a negative light because of early life
experiences of loss of significant people in his or her life and spends most of
life believing that life is negative.
4. Behavioral Perspective
• Individuals develop depression when feelings of helplessness, unworthiness
and powerlessness are the norm during the developmental years.
• Once learned, these attitudes are used to evaluate life situations and the
individual finds most of life outcomes negative.
5. Sociological perspective
• Sociological theorists use the medical, social learning, stress, and
antipsychiatric models to explain the development of depression.
• The medical model theorists believe that depression is treatable using
medications, changes in nutrition, and ECT treatments
• Social learning theorists believe that the individual becomes depressed
because of repetitive reinforced learned negative attitudes and outlook.
• Stress theorists believe that the individual becomes depressed because of an
inability to incorporate life experiences, perceptions, social support
biopsychosocial powerlessness, and occurrence of stress into life.
• Antipsychiatric theorists believe that depression is not an abnormal state but
rather a reaction to oppression and socioeconomic inequality.
 Plan/Implementation
A. High risk for violence, self-directed related to depressed mood, feelings of
worthlessness, hopelessness, and suicide ideation or plan.
• The client's safety is the nurse's number one priority.
• The danger for self-harm is more prominent as the client begins to regain
strength and hope; frequently assess clients for levels
hopeful/hopelessness, self-esteem, and be alert for signs and symptoms of
thoughts or plans for suicide
• History of violence is always important in determining seriousness of the
client's present risk for self-harm.
• The client often displays ambivalence or expresses sadness, dejection,
hopelessness or loss of pleasure or purpose in life.
• Nurse must be alert for overt signs of hopelessness: refusal to eat; withdrawal
form the milieu; resisting or refusing medications; suddenly gives away possessions;
refusal to sign a "no self-harm" contract.

B. High Risk for violence, directed at others related to poor impulse control and labile effect

• Decrease the environmental stimuli when client becomes agitated

• Continually monitor client's ability to tolerate frustration an/or individual
• situation
• Provide a safe environment, removing objects and barriers to prevent
accidental/purposeful injury to self or others.
• Increase environmental stimulation gradually
• Offer alternatives when available
• Always try to convey realistic positive feedback, especially as client
attempts to handle frustration in a positive manner.

C. Ineffective individual coping related to lack of energy, inability to concentrate or make

decisions
• Provide a safe environment for the client
• Observe the client closely, especially after the antidepressant medication(s)
begins to raise the client's mood, after any sudden dramatic behavioral
change or during unstructured time on the unit.
• Encourage the client to focus on strengths rather than weaknesses.
• Encourage identification of individuals who are supportive and encouraging
to the client.
• Assist the client to learn strategies that will effect more positive thinking
cognitive. behavioral, imagery)
• Encourage the client to express feelings and needs.
• Inform family and friends that the client may direct anger toward them, but
that he or she is learning more effective coping skills to deal with feelings.
Assist the client to gradually become involved with activities on the unit.

D. NUTRITION, altered, less/more than body requirements related to inappropriate nutrition

intake to meet metabolic needs; lack of interest in eating; aversion to eating
dysfunctional eating pattern.

1. During manic episodes

• Offer frequent carbohydrate and protein-rich snacks
• Offer nutritious finger foods and sandwiches
 • Offer easy-to-carry drinks that are high in vitamins, minerals, and
electrolytes
• Assess fluid and electrolyte status, especially sodium and lithium levels.
• Continually assess urinary output
• Assess daily bowel movements for frequency and consistency
• Administer high fiber foods unless contraindicated
• Offer frequent liquids and snacks to maintain hydration.

2. During depression
• Monitor and record daily intake and output
• Explain to client the importance of maintaining an adequate intake of food
and fluids to prevent malnutrition
• Determine client's daily caloric intake needs.
• Monitor body weight, depending on the seriousness of the depression and
weight problem and response to being weighed
• As possible, obtain and offer client desirable amounts of foods frequently
throughout the day
• Monitor laboratory studies as indicated (such as serum albumin, prealbumin
glucose, electrolytes, nitrogen balance)

E. Sleep pattern disturbance related to biochemical alterations or psychological

stress, lack of re ognition of fatigue/need to sleep, hyperactivity
1. During manic episode
• Identify with client the environmental stimuli that might prevent or
interrupt
sleep
• Restrict intake of caffeine
• Offer small snack/warm milk at bedtime or when awake during the
night
• Encourage routine bedtime relaxation techniques.
• Collaboratively administer medications as indicated.
2. During depression
• Identify nature of sleep disturbance and variations from usual pattern.
• Assess what client does when awakened or when client is unable to fall
asleep, and make a plan with the client to change pattern as necessary
• Identify previous nighttime rituals that may have been effective and
reestablish when possible.
• Decrease intake of caffeine especially later in afternoon or at nighttime.
• Restrict evening fluids and have client void before retiring.
• Reduce environmental stimuli (lights, noises, television, radios, etc.)
• Encourage use of bedtime relaxation techniques.
• Collaboratively administer hypnotic or sedative medications only if other
methods fail.
F. Spiritual distress related to a sense of no purpose or joy in life; lack of
connectedness to others; misperceived shame and guilt
• Allow client to express feelings and thoughts about religious doubt or fear
of abandonment
• Explore with the client alternative or past effective religious or spiritual
practice or ritual as an illness-prevention measure.
• Eliminate ore reduce causative and contributing factors of illness if possible
• Encourage client to discuss thoughts and feelings.
Specific Treatment Modalities
1.Electroconvulsive therapy (ECT)
• ECT is used for the treatment of depression.
• The procedure involves the application of pulses of electrical energy to the
• forehead and temporal area of the scalp, sufficient to cause a brief
• convulsion or seizure; usually carried out under anesthesia
• A series of ECT are usually carried out over a short period of time
• The effects of ECT are usually very positive for the treatment of
depression
• The side effects are low and seem to be limited to short-term, temporary
• memory deficits; deaths have been reported in clients who undergo ECT,
but they are infrequent.

2. Antidepressant medications
A. Tricyclic Antidepressants (TCAs)
• TCAs block monoamine (norepinephrine and serotonin) reuptake,
thus intensifying the effects of norepinephrine and serotonin.
• TCAs can elevate mood, increase activity and alertness, decrease
client's preoccupation with morbidity, improve appetite, and regulate sleep
patterns. The initial mechanism of the TCAs is said to take about 1 to 3 weeks
to develop while the maximum response is achieved in approximately 6 to 8
weeks.
• Dosing with TCA is individualized and based on clinical response
or plasma mig levels (must be above 225 ng/mL for antidepressant effects to
occur)
• The normal route for administration is by mouth: amitriptyline and
mipramine may be given by IM injection; intravenous administration is not
used.
• Other uses for the TCAs are to treat clients with chronic insomnia, attention
deficit/hyperactivity disorder, and panic disorder.
• Clients who are elderly, have glaucoma or constipation, or have prostatic
hypertrophy can be especially sensitive to anticholinergic effects, making
mipramine (a TCA with weak anticholinergic effect) more appropriate for He
with these clients.
• Itace-daily dosing at bedtime has several advantages, including ease of Siting
as part of daily routine, promotion of sleep through sedative effect, jisd reduced
intensity of the daytime side effects.
• s are still the preferred class of drugs for the treatment of major
repression
• A major consideration for clients at risk for suicide who are taking TCA
medications is availability of large amounts of TCA medication; clients nking
TCAs should always be hospitalized until the danger of suicide has
•
been ruled out, and they should not have access to a large quantity of the
medication.
 TCAs
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Maprotiline (Ludiomil)
Nortriptyline (Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)

Nursing Responsibilities:
- Educate the client early about potential side effects.
- Inform client that the side effects will diminish with time.
- Advise client that first-time treatment for major depression should continue I for
6 to 12 months.
- Warn client of a possible significant weight gain.
- Monitor for improvement. If no change or minimum change after 2 to m weeks,
it may be necessary to change the medication.

B.Selective Serotonin Reuptake Inhibitors (SSRIs)

• It has the same efficacy as the TCAs, causes fewer side effects than thel TCAs
or MAO inhibitors, and has a decreased time between the time on initial dose
and the reporting of initial reduction of the signs and symptoms! of the
depression.
• SSRIs do not cause hypotension, sedation, or anticholinergic effects, as dol the
TCAs; the only side effects usually reported are nausea, insomnia, and! sexual
dysfunction.
• All of the SRRIs have been found to be effective in the treatment ofi obsessive-
compulsive disorder (OCD)
• Mechanism of action: block the reuptake of serotonin and intensify thel
transmission at serotonergic synapses; the effects can usually be seen after ll to
3 weeks and are equivalent to those produced from TCAs
• Evaluate clients frequently for safety and desired effect of medication.

SSRIs
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)

Nursing Responsibilities:
- Inform client to take medications as prescribed; abrupt discontinuation
 of
the drug is contraindicated.
- Continuesly monitor client for side effects or adverse effects,
particularly
in the area of sexual dysfunction; client may be reluctant to discuss

C. Monoamine Oxidase Inhibitors (MAOIs)

- MAOIs are still used to treat major depression but only as a second or
third

- There is also the danger of taking MAOIs and other antidepressant

medications.
- MAOIs decrease the amount of monoamine oxidase in the liver, which
breaks down the amino acids tyramine and tryptophan
Has a very dangerous adverse effect such as hypertensive crisis when clients ingest
tyramine-rich foods.

Foods to avoid:
All cheeses except cream or cottage
Meats and fish: aged/cured
Fruits and vegetables: broad bean pods, tofu, soybean extracts
Alcohol: draft beer
Other sauerkraut, soy sauce, yeast extract, soups (especially miso)
DRUGS: other antidepressant drugs; nasal and sinus decongestants; allergy,
hey fever, and asthma remedies; narcotics (especially meperidine);
epinephrine; cocaine; amphetamines

Conaume with caution:

- mozzarella, cottage, ricotta, cream, processed
- Meats and fish: fresh: chicken liver, meats, liver, herring
- Fruits and vegetables: raspberries, bananas, small amounts only of avocado,
- Alcohol: wine
- other monosodium glutamate, pizza, small amounts only of chocolate,
- caffeine, nuts, dairy products
- Drugs: insulin, oral hypoglycemics, oral anticoagulants, thiazide diuretics,
anticholinergic agents, muscle relaxants

MAOIs
- Phenelzine (Nardil)
- Tranylcypromine
(Parnate)

Nursing responsibilities
- Educate client concerning a tyramine-restricted diet.
- Caution client about side effects and adverse effects of the MAOIs
- Educate client about careful use of over-the-counter or other prescript
 medications
- Monitor efficacy of drugs and continuously reeducate client concern abrupt
discon inuation of medication or not taking medications as prescribed.

D. Atypical Antidepressants
• Bupropion (Wellbutrin) is similar in structure to amphetamines; :
suppress appetite; is without the usual cardiotoxic, anticholinergic and d
adrenergic side effects (therefore can be used more readily with eldJ
clients); daily dose should be limited to 450 mg/day to reduce risk! seizures
at higher doses.
• Trazodone (Desyrel) is a second-line agent for the treatment of depressJ
usually used in combination with another antidepressant agent; usJ prescribed
for treatment of insomnia because of its very pronounJ sedative effect.

Most Common Adverse Effects from Antidepressant Medications

a. Orthostatic hypotension
• The most serious of the common adverse responses to
TCAs
• Advise client to rise slowly
b. Anticholinergic
• Dry mouth, blurred vision, photophobia,
constipation, uriJ hesitancy, tachycardia
• Advise clients to use sugarless mints, ice chips for dry
mouth
• Advise to drink adequate fluid, eat bulk-forming foods
to pre J constipation
• Monitor clients with BPH for increased difficulty with
urination

c. Sedation '
• A common response to TCAs; the cause is blockade of
histanJ receptors in the CNS
• Clients should be advised to avoid hazardous activities
if sedatioJ present
d. Cardiac toxicity
• TCAs can adversely affect the heart's function: by
decreasing vaJ influence and by acting directly to bundle of His to slow
conduction
• Clients over 40 or who have a family history of heart
disease sh<J have baseline ECG and periodically during the treatment.
e. Seizures
• Caution must be taken with clients who have seizure
disorders
f. Hypomania
• If hypomania develops, client should be evaluated for
adverse effect
or symptoms of bipolar disorders.
g. Sexual Dysfunction
• Anorgasmia, delayed ejaculation, decreased libido
 h. Hypertensive Crisis from dietary tyramine
• Although MAOIs normally produce hypotension these
drugs can be
the cause of severe hypertension if client eats tyramine-rich food

Mood Stabilizer Medications

a. Lithium: the drug of choice for controlling manic episodes in clients with
bipolar disorder; it is also used for long-term prophylaxis against recurrent
mania and depression
• It has a short half-life and high toxicity; is excreted by the kidneys
• Instruct client to maintain a constant sodium intake; sodium depletion will
decrease renal excretion of lithium, which will cause the drug to
accumulate and lead to lithium toxicity
• Serum lithium should be monitored frequently to detect lithium toxicity,
since the therapeutic level and the toxic levels are very close; the
therapeutic range is 0.8 to 1.4 mEq/L, while the toxic level is 1.5 mEq/L
or greater.
• In clients with mania, lithium reduces euphoria, hyperactivity, and other
symptoms but does not cause sedation; antimanic effects are usually seen
in 5 to 7 days after initial doses, although the full effect does not usually
occur for 2 to 3 weeks.
• For many clients, adjunctive therapy with a benzodiazepine can be used to
provide the sedation clients need
• Some adverse effects at therapeutic drug levels: fine hand tremors,
gastrointestinal upset, thirst and muscle weakness
• At toxic levels, more adverse effects are seen, such as: persistent GI upset,
coarse hand tremors, confusion, hyperirritability of muscles, ECG changes,
sedation, incoordination; at levels in the blood above 2.5 mEq/L, death has
resulted

b. Carbamazepine (Tegretol) and Valproic Acid (Depakote)

• These drugs are usually reserved for clients who cannot tolerate lithium
or who have not responded to lithium.

4.Group and Individual Therapies

a. Cognitive therapy
• The therapist helps the client address negative cognitive processing
• Once the underlying cognitive schemata and specific distortions inl thinking
are identified, the client is asked to identify automatic thoughts. I silent
assumptions, and arbitrary inferences so that negative thoughts and 1
assumptions can be examined logically, challenged against realistic I
attributes, and subsequently validated or refuted.
• It has been effective in treating clients with unipolar mild to moderate 1
depression
b. Behavioral therapy
• It is based on learning theory
• Abnormal or negative behaviors, such as symptoms of depression and I mania,
represent behaviors acquired as a result of negative i environmental events
that are reinforced.
• Using role-modeling, role playing, and situational analysis, clients are
 assisted in learning and practicing different adaptive behaviors that elicit
positive environmental reinforcement
c. Interpersonal therapy
• Is based on beliefs that depression develops from pathologic early
interpersonal relationship patterns that continue to be repeated in adulthood.
• The emphasis for this therapy is on relationships and social functioning
• The goal of the therapy is to understand the social context of current
problems based on earlier relationships and to provide symptomatic relief by
solving or managing current interpersonal problems.
d. Psychodynamic therapy
• Depression is derived from early childhood loss of a significant object.
• There is ambivalence about the object, which then affects the libido and
produces an intrapsychic conflict during the oral or anal stage of
psychosexual development.
• The client's self-esteem is damaged, and there is a repetition of the primary
loss pattern occurring throughout life
• The psychodynamic therapist establishes a relationship with the client and
helps uncover repressed experiences.
e. Family therapy
• Is an assessment, intervention and evaluation of family functional and
dysfunctional patterns of behavior and relating
• The goal is to help family members identify and change behaviors that
maintain depression and dependence among the family members

f. Group therapy
• Consists of persons coming together to receive psychotherapy
• The phases of group work are orientation, working and termination

Schizophrenia
A. Is one of a cluster of related psychotic brain disorders of unknown
etiology
B. Is a combination of disordered thinking, perceptual disturbances,
behavioral abnormalities, affective disruptions, and impaired social
competency

Symptoms of schizophrenia typically include the following:

a. Dilusional ideation: a false belief brought about without appropriate vernal
stimulation and inconsistent with the individual's own knowledge and
experience.
b. Hallucinations: false sensory perceptions that may involve any of the five
senses (auditory, visual, tactile, olfactory, and gustatory)
c. Disorganized speech patterns
d. Bizarre behaviors

D. Atleast two of these symptoms must be present for a significant portion of

thetime during a 1 -month period.

Other manifestations include social impairment and cognitive impairment; the

subtypes of schizophrenia have similar features, but differ in their clinical
presentations

Critical essential features of each type of schizophrenia

 1. Paranoid type
Auditory hallucinations
Preoccupation with one or more delusions usually of a persecutory
nature
May appear hostile or angry
None of the following are present: flat or inappropriate affect, disorganized speech
or behavior, or catatonic behavior; in catatonic behavior, the body remains in a
fixed position, wax-like state
2. Catatonic type
Stupor (state of daze or unconsciousness) or extreme motor agitation
• Excessive negativism
• Inappropriate or bizarre body postures
Echolalia (an involuntary parrot-like repetition of words spoken by others) or
echopraxia (a meaningless imitation of motions made by others)
3. Residual type
Absence of prominent psychotic symptoms
Social withdrawal and inappropriate affect
• Eccentric behavior
• Past history of at least one episode of schizophrenia

4. Disorganized type
• Disorganized speech
• Disorganized behavior
• Inappropriate or flat affect

5. Undifferentiated type
• Disorganized behaviors
• Psychotic symptoms (including delusions and hallucinations)

Analysis/Etiology
A. Generally the individual is fairly normal early in life, experiences subtle chan
after puberty, and undergoes severe symptoms in the late teens to early adulthood

B. Several factors have been identified as having a high correlation or associati

with the development of schizophrenia; they include:
1. Brain structures and functioning
a. An overactive basal ganglia
b. Enlarged ventricles, cerebral atrophy, decreased cerebral blood flo
decreased brain volume, and reduced glucose metabolism in the frontal
temporal lobes
c. Imbalance between dopamine and serotonin neurotransmitter syste
usually with an excess of dopamine
d. Low levels of neurotransmitter GAB A (gamma-aminobutyric acid)
2. Genetic factors
a. Increased risk for clients with a positive family history of schizophrenia
b. The risk for the development of schizophrenia increases for those with fi
degree relatives diagnosed with schizophrenia
3. Psychological factors
a. Studies have shown that stress does affect relapse and exacerbation
schizophrenic manifestations
b. The existence of several factors together such as genetic predisposition
 schizophrenia along with the presence of stressful events may contribute
the development of schizophrenia
4. Environmental factors
a. Observation have suggested that exposure to infectious agents such
viruses in early infancy may contribute to the development of schizophrenia
b. Research studies have indicated an association between schizophrenia
complications during pregnancy or labor such as oxygen deprivation, sh
gestation periods, and low birth weights

Assessment

A. Positive symptoms indicate a distortion or excess of normal functioning; they

often occur as the initial symptoms of schizophrenia and precipitate the need for
hospitalization; they include:
1. Delusions - fixed false beliefs or ideas
Paranoid type: the individual believes others are out to get him or her; the liient
may be hostile, suspicious, and aggressive
Grandiose type: the individual has excessive feelings of importance and power
over others
Religious type: the individual has delusions that focus on a religious context
Somatic type: the individual has delusions that are fixed on irrational reliefs
about his or her body
Nihilistic: the client has delusions of nonexistence
Persecutory: the client has delusions that others are out to get or are plotting against
him or her.
Thought broadcasting: the individual has the delusional belief that others can
hear his or her thoughts
Thought insertion: the individual has the delusional belief that others have the
ability to put thoughts in a person's mind against the person's will.
Thought control: the individual has the delusional belief that others can control
a person's thoughts against one's will.

2.Hallucinations, usually auditory

3.Psychosis:a disorderly mental state in which a client has difficulty distinguishing
reality from his or her own internal perceptions,
4.Illussionss: inaccurate perception or misinterpretation of sensory impressions
5.Agitations
6.Hostility
7.Bizarre behaviors (catatonic, etc.)
8.Association disturbances
a. Echolalia: repeating the words of another person for no logical reason
b. Echopraxia: purposeless imitation of movements exhibited by others
c. Clang associations: rhyming words in a sentence that make no sense
d. illogical thinking patterns
e. Neologisms: inventing new words, which are meaningful only to that
person
f. Word salad: combining words in a sentence that have no
connection and make no sense
B. Negative symptoms indicate a loss or lack of normal functioning; they devel
over time and hinder the person's ability to endure life tasks; they include:

1. Anhedonia: diminished ability to experience pleasure or intimacy

2. Alogia: poverty of speech
3. Anergia: lack of energy
4. Avolition: lack of motivation and goals
5. Ambivalence: inability to make a decision because of conflicting emotions.
6. Affect disturbances
a. Blunted
b. Flat
c. Inappropriate
7. Restricted emotion
8. Social withdrawal
9. Dependency
10. Lack of ego boundaries
11. Concrete thought processes
12. Lack of self-care
13. Sleep disturbance

Nursing Diagnoses

• Impaired thought processes related to possible hereditary factors, delusion

thinking, hallucinations, or inaccurate interpretation of the environment
• Anxiety related to inaccurate interpretation of the environment, unfamiliar
environment, repressed fear, or panic level of stress
• Individual ineffective coping related to inability to trust, low self-esteem, a
inadequate support systems
• Social isolation related to lack of trust, regression to earlier level of function,
delusional thinking, or past experiences of difficulty in interactions with
others.
• Risk for violence, self-directed or directed toward others related to lack of
trust, panic-level anxiety, command hallucinations, delusional thinking or
perception of the environment as threatening
• Sensory-perceptual alterations: auditory/visual related to hallucinations,
delusional thinking, withdrawal into self, or perception of the environment
as threatening
• Impaired verbal communication it\ate& to inability to trust, regression to
earlier level of development, or disordered and unrealistic thinking
• Self-care deficit related to withdrawal into self, regression to earlier level of
development, or perceptual or cognitive impairment
• Sleep pattern disturbance related to repressed fears, hallucinations, or
ielusional thinking
• Chronic low self-esteem related to withdrawal into self, lack of trust,
poor serialization skills, or chronic illness

PLANNING/ Implementation

A.Psychopharmacology

1. Typical Antipsychotics (traditional)

a. Also referred to as neuroleptic medications
b. Effectively treat only the positive symptoms of schizophrenia and have
no therapeutic effect on the negative symptoms
c. Most common side effects are the extrapyramidal side effects.
 2. Atypical Antipsychotics
a. Effective in treating the positive and negative symptoms of schizophrenia
b. Minimal to no risk of developing EPS
c. Decreased risk for development of tardive dyskinesia (TD)

3. Anti-parkinosonism (anticholinergics)
a. Increase dopamine levels
b. May be helpful in the management of negative symptoms of schizophrenia
c. Used to prevent or manage EPS of antipsychotic medications; common
nrieholinergic side effects are dry mouth, blurred vision, constipation,
decreased
d. Lacrimation, photophobia, urinary hesitance, tachycardia, and nausea.

Nursing Considerations for General Nursing Considerations and

Clients Taking
Drug Class andAntipsychotic
Name
Medications
J/traditional
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (TWLAFON)
Thioridazine (Mellaril)
Thiotixene (Navane)
Trifluoperazine (Stelazine)
Interventions
1. Assess client's response to
medication and for any possible drug
interaction.
2. Monitor client for extrapyramidal
symptoms and other adverse
reactions
3. Administer the Abnormal and
Involuntary Movement Scale (AIMS)
to assess the client for signs of tardive
dyskinesia.
4. Assess for signs of NMS and

provide emergency care for client is

suspected.
Atypical
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Zeldox)
5. Monitor the client's vital signs for
hypotension, orthostatic hypotension
and tachycardia
6. Monitor the client's body weight
for weight gain.
7. Monitor the client for any seizure
activity.
8. Instruct the client to avoid being
overheated in the sun; use sun block;
avoid taking hot baths.

Anti-Parkinsonism/anticholinergics (Benadryl)
• Benztropine (Cogentin) • Ethopropazine (Parsidol)
• Biperiden (Akineton) • Procyclidine (Kemadrin)
• Diphenhydramine • Trihexyphenidyl (Artane)
 1. Suggest chewing sugarless gum or
hard candy to offset side effect of dry
mouth
2. Suggest rinsing mouth frequently to
decrease side effect of dry mouth
3. Encourage use of stool softeners,
increasing water intake, and dietary
fiber to decrease side effect of
constipation.
4. Suggest use of saline nasal sprays
to decrease side effect of nasal
congestion
5. Instruct client to use caution due to
temporary side effect of blurred vision.
Vision will return to previous
condition in few weeks.
6. Instruct client to report any eye
pain immediately.
7. Instruct client on need to use
caution in the sun, wear sunscreen,
sunglasses, and avoid becoming
overheated because of side effects of
photophobia and photosensitivity.
8. Instruct client to use caution with
sudden changes in body positions due
to possible orthostatic hypotension
9. Monitor client for signs of urinary
retention and hesitation

Extrapyramidal Side Effects from Antipsychotic Medications

Akathisia Motor restlessness, inability to remain

still, can also occur as subjective
feeling
Akinesia Absence of movement or difficulty
with movement

Dystonias Muscle spasms, spastic movements of

the neck and back; can be painful and
frightening for the client

Pseudo-parkinsonism Shuffling and slow gait, mask-like

facial expression, tremors, pill-rolling
movements of the hands, stooping
posture, rigidity

Tirdive dyskinesia Involuntary and abnormal movements

of the mouth, tongue, face and jaw,
may progress to the limbs, irreversible
condition, may occur in months after
antipsychotic medication use
Neuroleptic Malignant Syndrome A potentially lethal side effect that
(NVMS) requires emergency treatment;
manifest symptoms like hyperthermia,
muscle rigidity, tremors, altered
consciousness, tachycardia,
hypertension and incontinence

Individuaal and Group Intervention

Management of delusions and hallucinations
a. Estaablish a trusting, therapeutic relationship with the client by being honest,
supportive and consistent
b. Encourage client to express feelings and thoughts.
c. Assess for signs that the client is possibly having delusions or
hallucinations.
d. Communicate with the client using clear, direct statements.
e. Provide an environment with a low degree of stimulation
f. Express to the client that you understand that he or she believes the delusion
x hallucination but you do not share in the delusional belief or • filiation.
g. Avoid arguing with the client about the delusion or hallucination
h. Provide reality testing and focus on reality
i. If the client is experiencing a visual hallucination, provide a room with
adequate lighting.

2. General nursing considerations and interventions

a. Provide an environment that is safe for the client and others
b. Avoid any physical contact or touching of the client
c. Encourage the client to verbalize feelings and thoughts openly
d. Utilize therapeutic communication techniques with the client.
e. Identify support systems for the client
f. Assess for self-destructive behaviors and provide needed precautions
g. Provide opportunities that promote socialization and decrease isolation.

C. Milieu therapy: a method of psychotherapy that controls the environment of the

client to provide interpersonal contacts in order to develop trust, assurance and
personal autonomy
a. Provide for the client's safety and the safety of others in the milieu.
b. Provide a supportive environment that is structured and predictable
c. Collaborate with the multidisciplinary team regarding the client's plan of
care
d. Collaborate with the client regarding his or her plan of care
e. Encourage the client to participate in milieu groups and activities that
promote socialization
i. Assist client with ADLs as needed, but encourage independence as client
progresses.

D. Family therapy
a. Involve the family to determine use of appropriate community
resources
 b. Educate the family about the chronic illness of schizophrenia, implications,
early signs and symptoms of relapse, disease management, medication
!
management, and community support systems available. '
c. Provide an outlet for the family to discuss their feelings'and explore
alternative effective coping skills.
Personality Disorders
1.Personality disorders are diagnosed when personality patterns or traits are
enduring, pervasive, maladaptive, and cause significant functional at or
subjective distress.

2.patterns of inner experience and behavior that differ from cultural

3.Result in problems in living rather than in clinical symptoms

4. Clients frequently experience their personality patterns as natural or

comfortable ego-syntonic) rather than painful or uncomfortable (ego dystonic)

5. If personality patterns are experienced as egosyntonic, clients rarely seek :o

ease their distress.

6.Frequently overlap: individuals may exhibit patterns or traits associated with

AM one personality disorder

7.Develop before or during adolescence and persist throughout life; symptoms

may less obvious by middle or old age.

8.Are Organized into three diagnostic clusters

a. Cluster A disorders: individuals with these disorders appear odd and eccentric
b. Clusterer B disorders: individuals with these disorders appear dramatic and

c. Cluster C disorders: individuals with theses disorders appear anxious and

farful.

Diagnostic Criteria for each personality

Paranoid personality Disorder

A. A pervasive distrust and suspiciousness of others such that their motives are
interrpreted as malevolent, beginning by early adulthood and present in a variety
of contexts, as indicated by four (or more) of the following:
1.Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her 1 Is preoccupied with unjustified
doubts about the loyalty or trustworthiness of friends or associates
3. Is reluctant to confide in others because of unwarranted fear that the
information will be used maliciously against him or her
4. Reads hidden demeaning or threatening meanings into benigm
remarks or events
5. Persistently bears grudges, i.e., is unforgiving of insults, injuries, on
slights
 6. Perceives attacks on his of her character or reputation that are not
apparent to others and is quick to react angrily or to counterattack
7. Has recurrent suspicions, without justification, regarding fidelity of
spouse or sexual partner
B. Does not occur exclusively during the course of Schizophrenia, a Mood
Disorder With Psychotic Features, or another Psychotic Disorder and is net I
due to the direct physiological effects of a general medical condition

2. Schizoid personality disorder

A pervasive pattern of detachment from social relationships and a restricted rang? of

expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:

1. Neither desires nor enjoys close relationships, including being part of

a family
2. Almost always chooses solitary activities
3. Has little, if any, interest in having sexual experiences with another
person
4. Takes pleasure in few, if any, activities
5. Lacks close friends or confidants other than first-degree
relatives
6. Appears indifferent to the praise or criticism of others
7. Shows emotional coldness, detachment, or flattened
affectivity

3. Schizotypal personality disorder

A. A pervasive pattern of social and interpersonal deficits marked by acute

discomfort with, and reduced capacity for, close relationships as well as by
cognitive or perceptual distortions and eccentricities of behavior, beginning
by early adulthood and present in a variety of contexts, as indicated by five
(or more) of the following:
1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms (e.g., superstitiousness, belief in
clairvoyance, telepathy, or "sixth sense"; in children and adolescents,
bizarre fantasies or preoccupations)
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical,
over elaborate, or stereotyped)
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behavior or appearance that is odd, eccentric, or peculiar
8. Lack of close friends or confidants other than first-degree
relatives
9. Excessive social anxiety that does not diminish with familiarity and
tends to be associated with paranoid fears rather than negative
judgments about self
toes not occur exclusively during the course of Schizophrenia, a Mood
Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive
Developmental Disorder.
 4.Antisocial Personality Disorder

A.There is a pervasive pattern of disregard for and violation of the rights of

ochers occurring since age 15 years, as indicated by three (or more) of the
following:
1. Failure to conform to social norms with respect to lawful behaviors as
indicated by repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning
others for personal profit or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, as indicated by repeated physical fights
or assaults
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations
7. Lack of remorse, as indicated by being indifferent to or rationalizing
having hurt, mistreated, or stolen from another
B. The individual is at least age 18 years.
C. There is evidence of Conduct Disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course
of Schzophrenia or a Manic Episode

5. Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration,

and lack of empathy, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements

and talents, expects to be recognized as superior without commensurate
achievements)
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty,
or ideal love
3. Believes that he or she is "special" and unique and can only be understood
by, or should associate with, other special or high-status people far
institutions)
4. Requires excessive admiration
5. Has a sense of entitlement, i.e., unreasonable expectations of especially
favorable treatment or automatic compliance with his or her expectations
6. Is interpersonally exploitative, i.e., takes advantage of others to achieve his
or her own ends
7. Lacks empathy: is unwilling to recognize or identify with the feelings and
needs of others
8. Is often envious of others or believes that others are envious of him or
her
9. Shows arrogant, haughty behaviors or attitudes

6. Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and

affects, and marked impulsivity beginning by early adulthood and present in :
variety of contexts, as indicated by five (or more) of the following:
 1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized
by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or
sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g..
spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior
6. Affective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours and
only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms

7. Histrionic Personality Disorder

A pervasive pattern of excessive emotionality and attention seeking, beginning by

early adulthood and present in a variety of contexts, as indicated by five (or more)
of the following:
1. Is uncomfortable in situations in which he or she is not the center of
attention
2. Interaction with others is often characterized by inappropriate sexually
reductive or provocative behavior
3. Displays rapidly shifting and shallow expression of emotions
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in
detail
6. Shows self-dramatization, theatricality, and exaggerated expression of
emotion
7. Is suggestible, i.e., easily influenced by others or circumstances
8. Considers relationships to be more intimate than they actually are

9.Avoidant Personality Disorder

A pervasive and excessive need to be taken care of that leads to submissive and
changing behavior and fears of separation, beginning by early adulthood and
present in a variety of contexts, as indicated by five (or more) of the following:

1. Has difficulty making everyday decisions without an excessive amount

of advice and reassurance from others
2. Needs others to assume responsibility for most major areas of his or her
life
3. Has difficulty expressing disagreement with others because of fear of loss
of support or approval. Note: Do not include realistic fears of retribution.
4. Has difficulty initiating projects or doing things on his or her own
(because of a lack of self-confidence in judgment or abilities rather than a
lack of motivation or energy)
5. Goes to excessive lengths to obtain nurturance and support from others,
to the point of volunteering to do things that are unpleasant
 6. Feels uncomfortable or helpless when alone because of exaggerated fears
of being unable to care for himself or herself
7. Urgently seeks another relationship as a source of care and support when
a close relationship ends
8. Is unrealistically preoccupied with fears of being left to take care of
himself or herself

9. Avoidant Personality Disorder

A pervasive pattern of social inhibition, feelings of inadequacy, and

hypersensitivity to a negative evaluation, beginning by early adulthood and
present in a variety of contexts. as indicated by four (or more) of the following:

1. Avoids occupational activities that involve significant interpersonal

contact, because of fears of criticism, disapproval, or rejection
2. Is unwilling to get involved with people unless certain of being liked
3. Shows restraint wi hin intimate relationships because of the fear of
ben shamed or ridiculed
4. Is preoccupied with being criticized or rejected in social situations
5. Is inhibited in new interpersonal situations because of
feelings inadequacy
6. Views self as socially inept, personally unappealing, or inferior to
others
7. Is unusually reluctant to take personal risks or to engage in any
activities because they may prove embarrassing

10. Obsessive-compulsive Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and menai

and interpersonal control, at the expense of flexibility, openness, and efficiency
beginning by early adulthood and present in a variety of contexts, as indicated by
four (or more) of the following:

1. Is preoccupied with details, rules, lists, order, organization, or schedules

to the extent that the major point of the activity is lost
2. Shows perfectionism that interferes with task completion (e.g., is unable to
complete a project because his or her own overly strict standards are DOI
met)
3. Is excessively devoted to work and productivity to the exclusion of leisure
activities and friendships (not accounted for by obvious economic necessity)
4. Is over conscientious, scrupulous, and inflexible about matters of moralit.
ethics, or values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have no
sentimental value
6. Is reluctant to delegate tasks or to work with others unless they submit to
exactly his or her way of doing things
7. Adopts a miserly spending style toward both self and others; money is
viewed as something to be hoarded for future catastrophes
8. Shows rigidity and stubbornness

Etiology/Analysis

A. Neurobiological theories
 • Limbic system dysregulation and CNS irritability Decreased levels of
serotonin (5-HT)
• Elevated levels of norepinephrine
• Abnormal levels of dopamine may be associated with borderline and
schizotypal personality disorders
• Schizotypal personality disorder may be a milder form of
schizophrenia
• Genetic factors
B. Intrapersonal theories
Perfectionistic standards imposed on them by their parents or others
during chilidhood
Hostility toward the self may be projected onto others resulting in fear,
mistrust, and defensive withdrawal to avoid being hurt.
An underdeveloped superego may result in a failure to both internalize
authority and cultural morals and to experience guilt when violating rules
Anxiety may manifest itself as a personality disorder
C.SocialTheories
Social oppression may have a negative effect on the development of self-
esteem and a healthy identity
A changing societal value system may be reflected in the behavior
associated with Cluster B disorders.
D. Family theories
Inability to manage conflict, inconsistent parenting may affect personality
development
A chaotic and abusive environment may be associated with the
development
of borderline personality disorder
Growing up in a multigenerational enmeshed family system and failure to
individuate the self may be associated with the dichotomous thinking or
splitting.

Assessment: Diagnostic Clusters 7

Cluster A: Odd, Eccentric

• Paranoid Personality Disorder: Marked distrust of others, including the
belief, without reason, that others are exploiting, harming, or trying to
deceive him or her; lack of trust; belief of others' betrayal; belief in hidden
meanings; unforgiving and grudge holding.
• Schizoid Personality Disorder: Primarily characterized by a very limited
range of emotion, both in expression of and in experiencing; indifferent to
social relationships.
• Schizotypal Personality Disorder: Peculiarities of thinking, odd beliefs, and
eccentricities of appearance, behavior, interpersonal style, and thought (e.g.,
belief in psychic phenomena and having magical powers).

Cluster B: Dramatic, Erratic

• Antisocial Personality Disorder: Lack of regard for the moral or legal
standards in the local culture, marked inability to get along with others or
abide by societal rules. Sometimes called psychopaths or sociopath.
• Borderline Personality Disorder: Lack of one's own identity, with rapid
changes in mood, intense unstable interpersonal relationships, marked
impulsively, instability in affect and in self-image.
 • Histrionic Personality Disorder: Exaggerated and often inappropriate
displays of emotional reactions, approaching theatricality, in everyday
behavior. Sudden and rapidly shifting emotion expressions.
• Narcissistic Personality Disorder: Behavior or a fantasy of grandiosity, a
lack of empathy, a need to be admired by others, an inability to see the
viewpoints of others, and hypersensitive to the opinions of others.

Cluster C: Anxious, fearful

• Avoidant Personality Disorder: Marked social inhibition, feelings of
inadequacy, and extremely sensitive to criticism
• Dependent Personality Disorder: Extreme need of other people, to a point
where the person is unable to make any decisions or take an independent
stand on his or her own. Fear of separation and submissive behavior.
Marked lack of decisiveness and self-confidence
• Obsessive-Compulsive Personality Disorder: Characterized by
perfectionism and inflexibility; preoccupation with uncontrollable patterns
of thought and action

Common Coping Mechanism

Mechanism Definition Result Personality

Disorders Involved

Projection Attributing one's Leads to prejudice, Typical of paranoid

own feelings or suspiciousness, and and schizotypal
thoughts to others excessive worrying personalities; used
about external dangers by people with borderline,
antisocial, or narcissitic
personality when under acute
stress.
Splitting Use of black-or- Allow a person to avoid Typical of borderline
white, all-or-nothing the discomfort of having both personality
thinking to devide loving and hateful feelings
peopleinto groups of for the same person as well as
idealized all good saviors feelings of uncertainty and
and vilified all bad evildoers helplessness
 Acting out A direct behavioral Leads to acts that are Very
common in
expression of an often irresponsible, people with
unconscious wish or reckless, and foolish, antisocial or
impulse that enables Includes many
borderline
a person to avoid delinquent,

personality
thinking about a promiscuous,and
painful situation or substance-abusing
experiencing a acts, which can
painful emotion become so habitual
that the person
remains unaware and
dismissive of the
feelings that initiated
the acts
Turning Expressing the angry Includes failures and Dramatic in
people
aggression feelings one has illnesses that affect with
borderline
against self toward others by others more than personality
hurting one's self oneself and silly,
directly (for provocative
example, through clowning
self-mutilation) or
indirectly (for
example, body
dysmorphic
disorder); when
indirect, it is called
passive aggression
Fantasizing Use of imaginary Is associated with Used by people
with
relationships and eccentricity, avoidant
or schizoid
private belief avoidance of
personality, who, in
systems to resolve interpersonal contrast
to people
conflict and to intimacy, and with
psychoses, do
escape from painful avoidance of not
believe and thus
realities, such as involvement with
the do not act on their
loneliness outside world
 fantasies
Hypochondriasis Use of health Provides one with Used by people
with
complaints to gain nurturant attention

dependent,
attention from others; may be
histrionic, or
a passive expression

borderline
of anger toward

personality
others

Planning/Implementation
a. Basic principles of nursing intervention
1. Recognize that clients have the right to change or not to change
2. Help clients to see how behavior affects their lives to motivate
them to develop a more adaptive lifestyle.
3. Interventions should be based on short-term goals and focus on
small steps designed to improve role functioning and decrease
distress
4. Maintain hope for each client's improvement; all clients have the
potential for change
5. Identify your own emotional responses when caring fro clients
with personality disorder.
b. Specific strategies:
1. Cluster A disorders (paranoid personality, schizoid
personality, and schizotypal personality)
a. Approach people in a gentle, interested, but nonintrusive
manner
b. Respect client's needs for distance and privacy
c. Be mindful of own nonverbal communication as a client may
perceive
others as threatening
d. Gradually encourage interaction with others, if appropriate

2. Cluster B disorders (antisocial personality, borderline

personality,
histrionic personality, and narcissistic personality)
a. Be patient as clients display emotional and erratic
behavior
b. Provide a consistent and structured milieu to avoid
manipulation and
power struggles
 c. Safety is always the first priority of care-protest client from
suicide and
self-mutilation until they can protect themselves
d. Set limits as necessary to help clients maintain impulse control
in order
to protect themselves and others from injury
e. Help clients recognize and discuss their fear of
abandonment
f. Encourage direct communication to minimize attention seeking
through
the use of dramatic, seductive behavior.
g. Help clients who display a sense of entitlement to
acknowledge the
needs of others.
h. Help client recognize the presence of dichotomous thinking or
splitting in which self and others are perceived as all good or all
bad.

3. Cluster C disorders (avoidant personality, dependent

personality, and obsessive-compulsive personality)
a. Point out avoidance behaviors and related losses and secondary
gains
b. Provide problem solving and assertiveness training to
increase self-
confidence and independence
Encourage expression of feelings to decrease rigidity and need for
control
Help clients recognize any impairment or distress related to their
need for
perfection and control
Help clients acknowledge and discuss their sense of inadequacy and
fear of
rejection.

C.Psychopharmacology
• Antipsychotic agents
• Selective serotonin reuptake inhibitors

D.Individual and Group therapy

A decision for participation is based on a client's level of function and

specific needs
Self-help groups may increase client's self-awareness and assist them in
coping with problems in living
Behavioral therapy
Impulse control training is designed to support client safety by
decreasing the risk of suicide or self-mutilation through the use of anti-
harm contacts, staff and client monitoring, identifying triggers and
patterns related to self-destructive behavior, and identifying alternative
coping strategies.
Limit setting is designed to discourage the tendency to test and
 manipulate others.
- It involve establishing a structured
environment with clear ground rules
- Limit setting reflects 3 principles: limits must
be clearly stated, necessary and enforceable.

Behavioral modification
• For clients who are helpless and dependent, the goal is
to increase
coping skills and independent functioning.
- Explore client dichotomous thinking or the tendency to
see themselves totally dependent or totally independent. - Provide
assertiveness training • For clients who are socially isolative
related to fear of rejection, the goal is to increase self-confidence
- They need to acknowledge their fear of
criticism and rejection
- Help clients identify what they would gain and lose by
risking
criticism and rejection
Provide assertiveness training
• For clients who are socially isolated, respect their need to be
isolative
while gradually encouraging interaction with others. If
appropriate, help clients identify the interpersonal effects of
social isolation and the I feelings associated with them.
• For clients who seek out relationships with others through
behavior thai is attention seeking (dramatic, seductive) but
superficial, help them tc interact in a more direct fashion. Help
clients identify what they would I gain and lose by communicating
more directly.
• For clients whose relationships are based on manipulation, call
attention to their attempts at manipulation and help them to
identify ways tc interact that are more collaborative and less
power-based.

g. Psychological comfort promotion - anxiety reduction

• Some clients avoid decisions to avoid the anxiety of failure.
Encourage decision making to support a sense of competence and
an internal locu of control. Point out that an imperfect decision
may be better than DO decision and that many decisions can be
remade
• Some clients become perfectionist to guard against the anxiety of
feeling inferior. Explore why they fear the evaluation of others.
• Anxiety prevents some clients from asking for help. Help clients
identify what they would gain and lose by asking for help.

Manipulative Behavior
• Influencing others or events to meet own needs without regard for
other's needs.

Assessment
 A. Uses bargains, threats, demands, or intimidation to get own way
B. Shows ability to identify and use other people's weaknesses fro
own
benefit
C. Makes continuous, unrealistic demands
D. Pits one individual against another, e.g., clients against staff and
primitive defense mechanism of splitting
E. Pretends to be helpless and sorry fro behavior
F. Lies to gain sympathy of staff or other clients
G. Acts out even when given acceptable behavioral
alternatives
H. Keeps all relationships on a superficial level
I. Uses flattery, charm, and excessive compliments to have needs met
J. Exploits the generosity of others
K. Identifies with staff or authority figure and acts as if he/she is not
incarcerated
L. Finds a way around the unit rules and expectations
M. Uses sexuality to gain control over others - may even approach the
staff sexually

Implementation
Set clear and realistic limits with appropriate consequences. Be consistent
and firm in setting behavioral expectations and limits.
Confront client about the manipulative behavior. Do not try to out
manipulate -dient is a master at it
Reinforce adaptive behavior through positive feedback and realistic praise
Do not be influenced by client's charming ways - all directed toward
manipulating you
Do not be intimidated by client's behavior
Clearly and consistently communicate care plans and client's behavior to
other staff. Present a united front
Accept no flattery, gifts, or favors.

Aggressive Behavior
• It is a physical, symbolic or verbal behavior that is forceful or hostile
and enacted to intimidate others; aggression occurs on a continuum
ranging from verbal angry affect to physical aggression directed at a
person and/or the environment.
• A defensive response to anxiety and loss of self-esteem and power

Assessment
1.Agressive behaviors
a. Increase in motor agitation or restlessness
b. Verbal threat or abusive language
c. Tense and angry affect
d. Demanding
e. Self-directed anger
f. Manipulative
g. Uncooperative
h. Increased tone or rate of speech
i. Threatening posture, such as clenched fist
2. Level of control
a. Ability to listen and follow directions
b. Ability to identify source of anger and verbalize feelings
appropriately
c. Ability to explore alternative ways of expressing
anger
3. Nurse's perception of impending violence.

Analysis
A.dynamics

behavior is a response to a perceived threat.

Feelings of anxiety occur, accompanied by helplessness and frustration
Judgment, reasoning and cognitive integrity decrease as anxiety increases,
Verbal or physical aggression occurs as an attempt to alleviate anxiety.
B. Assault Cycle

1.Triggering phase
• The tenant exhibits changes in their baseline behavior or mood.
He or she may appear upset, angry, withdrawn or demanding.

2. Escalation phase
• The tenant progresses to the point where s/he becomes
clearly agitated, provocative and verbally abusive.
Adrenaline is building up in the body, which interferes with
the ability to think rationally and react rationally.

3. Crisis phase
• The tenant is now definitely out of control, assaultive or physically
threatening. At this point, the safety of others is jeopardized.

4. Recovery phase
• The tenant begins to return to their baseline behavior and
mood.
Heightened adrenaline remains in the body for at least
ninety minutes, causing the tenant to react more forcefully if
provoked.

5. Post-crisis depression phase

• The tenant may feel remorseful, ashamed, humiliated
about the incident/outburst.

C. Compensatory mechanisms used to reduce and avoid stress include

denial: displacement; hostility that can be directed on self or the environment;
rigidity: projection; and repression

D. Effects of compensatory mechanisms on behavior:

• Need for approval results in compliance to demand
• Necessary compliance creates resentment
• Hostility develops and fosters feeling of guilt
• Self-doubt increases anxiety and tension
 • Increased anxiety and tension reduce interpersonal relationships and
reality testing
• Overwhelming anxiety may precipitate an episode of delusion
or hallucination.

Plan/implementation
1. Observe client acutely for clues that client is getting out of
control
a. Note rising anger-verbal and nonverbal behavior
1. Note erratic or unpredictable response to staff or other
clients
2. Intervene immediately when loss of control is
imminent
3. Use a nonthreatening approach to client
4. Set firm limits on unacceptable behavior
5. Maintain calm manner and do not show fear
6. Avoid engaging in an argument or provoking client
7. Summon assistance only when indicated; sudden involvement of
many people will increase client's agitation,
8. Remove client from the situation as soon as possible
9. Use seclusion or restraints only if necessary (last option)
10. Attempt to calm client so that he/she may regain control
11. Be supportive and stay with the client
12. Use problem-solving focus following outburst of aggressive behavior.
a.Encourage discussion of feelings
surrounding incident.
b. Attempt to look at causal factors of
the behavior
c. Examine client's response to stimulus and alternative
responses
d. Point out consequences of aggressive behavior
Discuss client's role of taking responsibility for his or her aggressive
behavior

Eating Disorders

A. ANOREXIA nervosa
• A potentially life-threatening disorder characterized by an intense fear
of gaining weight or becoming fat. The psychological aversion to food
results in emaciation, physical problems, and possible death.

Characteristics
A. Almost exclusively female-95 percent
B. Most common in adolescent girls and young adults (age 12 to
mid 30s)
C. Often unnoticed in early stages; female "goes on diet to lose weight"
D. Dynamics of disorder

1. History of a "model child"

2. Overprotected by parents in rigid, enmeshed family structure
3. Conflict erupts at adolescence between poor involvement and family
 loyalty
4. Becomes negative due to power struggles with family over pressure
to eat
5. Intense fear of obesity leads anorectic to report feeling fat.
6. Not a disturbance in appetite but distorted body image perceptions;
related to disturbance in sense of self, identity, and autonomy
7. Hormone altered - whether cause or effect is yet to be determined
8.Anorectics do not want treatment. Potentially lethal disease
9. Many anorectics have a single episode, and then recover. Factors
associated with positive prognosis include: onset of problem before
age 15 and weight gain within 2 years.
Assessment
A. Assess weight: refusal to maintain body weight at or above a normal
weight fen
age and height (loss of 15 percent or greater average body weight)
B. No menstrual period for 3 months.
C. Assess for physical symptoms.
1. Malnutrition
2. Fractures
3. Teeth enamel eroded and poor gums
4. Hypotension, hypothermia
5. Anemia and decreased white blood cells
6. Hypoproteinemia
7. Sleep disturbances
9. Cold intolerance (cyanosis and numbness of extremities)

D. Monitor for potential complications

1. Severe electrolyte imbalance (decreased serum potassium, kidney
failure)
2. Heart failure and coma, possible death.

Analysis/Nursing Diagnoses
1. Anxiety related to low self-concept, feelings of inferiority, and unmet
dependency needs
2. Disturbed body image related to unrealistic appraisal of body size,
underestimating food requirements and a desire for slimness
3. Ineffective family coping: compromised, related to overprotection
and! unwillingness to allow client to separate (meet developmental
tasks), unrealistic expectations, and an inability to cope with client's
eating I disorder.
4. Risk for fluid volume deficit related to inadequate intake and
purging
5. Ineffective coping related to deficit in self-care activities, altered role
I performance, quest fro thinness, and delay in mastery of
developmental I tasks.
6. Ineffective health maintenance related to inadequate health practices,
health beliefs, and alterations in self-image, preoccupation with food,
and a denial I of one's own hunger.
7. Imbalanced nutrition: less than body requirements, related to a
 disturbed I body image and a dysfunctional emotional conditioning in
relationship to food.

Implementation
A. Actions to improve nutritional status (to stabilize medical
condition)
1. Diet.
a. High protein, high carbohydrate, especially amino acids
b. Identify foods client prefers.
c. Small, nutritious, attractive feedings
. 2. Nasogastric feedings: if client refuses to eat, administer tube
feedings as ordered.

B. Psychological care
I Care plan.
a. Formulate plan that all staff agree on. Do not allow
manipulation.
Do not engage in power struggle.
b. Do not focus on food, taste, recipes, etc.
c. Remain with client when eating or monitor when client eats
with
others.
d. Do not accept excuses to leave eating area (to vomit)
e. Ensure that weight is taken same time everyday with client
dressed in only a hospital gown.
2 Therapy
a. Medications: antidepressants - selective serotonin reuptake
inhibitors
(SSRI)
b. Focused on behavior therapy.
(1) Set limits with positive and negative
reinforcement)
(2) Establish contracts that specifies weight gain or
loss correlated with privileges/restrictions
c. Insight-oriented therapy: correcting client’s body
perceptions and
misconceptions about feelings, needs, self-worth, and autonomy
d. Family therapy: important focus as issues of control and
autonomy are connected to eating.

B. Bulimia nervosa
• Eating disorder characterized by loss of control during binge
eating, frequently followed by self-induced vomiting.
Characteristics
A. Etiology is unknown but this disorder is often accompanied
by an underlying psychopathology
B. More common in women than men.
C. Begins in adolescence or early adulthood and often follows a chronic
course over many years.
D. Generally aware that eating patterns are abnormal (in contrast to
anorectics)
E. Typically evidences impaired impulse control, low self-esteem,
and depression.

Assessment
1. Compulsive eating binges characterized by rapid consumption of
excessive amounts of high caloric foods in brief periods followed by
induced purging (vomiting, enemas, laxatives, or diuretics)
2. Periods of severe dieting or fasting between binges.
3. Sporadic vigorous exercising between binges.
4. Weight may be within normal range with frequent fluctuations above
or below normal range because of alternating binging and fasting
5. Lack of control over eating during episode.
6. Depression and self-deprecating thoughts follow binges
7. Bingeing and purging pattern occurring at least biweekly, for past 3
months.
8. Extroverted
9. Possible intermittent substance abuse.
10. Very concerned with bocty image and appearance
11. Repeated attempts to control or lose weights.
12. Assess for physical symptoms: enlarged parotid glands; dental
erosion and caries; electrolyte imbalance (hypokalemia); fluid
retention
13. Subtypes:
a. Purging type: engages in purging behavior
b. Nonpurging type: uses fasting or excessive exercise,
not purging

Analysis/Nursing diagnoses
1. Anxiety related to low self-concepts and feelings of inferiority.
2. Disturbed body image related to unrealistic appraisal of body size
and
a desire for slimness
3. Ineffective family coping: compromised, related to unrealistic
expectations and an inability to cope with client's eating disorder
4. Risk for fluid volume deficit related to purging
5. Ineffective coping related to deficits in self-care activities, altered
role performance, quest for thinness, and shame and guilt over secret
binges.
6. Ineffective health maintenance related to inadequate health
practices
and alterations in self-image
7. Imbalanced nutrition: less than body requirements related to self-
induced vomiting and purging.
8. Imbalanced nutrition: more than body requirements, related to an
 abnormality in amount of food consumed and a dysfunctional
emotional conditioning in relationship to food.
9. Self-esteem disturbance related to low self-confidence, feelings of
inferiority, and unrealistic expectations of self and others.
Plan/Implementation
A. Client is usually not hospitalized but does require therapy.
B. Behavior modification and insight-oriented therapy used with
limited access.
C. Provide a nonjudgmental, accepting environment.
D. Set realistic limits; keep client under close observation to prevent
purging
E. Help client to identify feelings associated with binging and purging
episodes.
F. Shift focus from food, exercise, and eating to emotional issues.
G. Combination of cognitive-behavioral therapy and
psychopharmacology (SSRI antidepressants) more effective.

Anxiety
Definition
Apprehension, dread, uneasiness, or uncertainty generated by a real or
perceived threat whose actual source is unidentifiable.

Levels of Anxiety

a. Mild
i. Associated with the tension of everyday life
ii. The person is alert; the perceptual field is increased, and learning is
facilitated
iii. The affect is positive
b. Moderate
i. Focus is on immediate concerns
ii.The perceptual field is narrowed
iii. Low-level sympathetic arousal occurs
iv. Tension and fear are experienced
c. Severe
i. Focus is on specific details and behavior is directed toward
relieving anxiety
ii. The perceptual field is significantly reduced, and learning cannot
occur
iii. The sympathetic nervous system is aroused
 iv. Severe emotional distress is experienced
d. Panic
i. Associated with dread and terror
ii. Details are blown out of proportion, the personality is
disorganized, and the person is unable to function
iii. Physiological arousal interferes with motor activities iv.
Overwhelming emotions cause regression to primitive or childish
behavior.

Anxiety Disorders

Definition:
• Anxiety disorders are those disorders in which the predominant
disturbance is one of anxiety.
• The individual with an anxiety disorders uses rigid, repetitive, and
maladaptive behaviors to try to control anxiety. Anxiety may be
manifested as panic, generalized anxiety, phobias or obsessive
compulsive behavior

Characteristics
A. Repression and projection are common defense mechanisms
B. Patterns of behavior are used in a rather stereotyped and rigid
way
C. Client becomes more dependent and disabled as time goes on
D. Client is almost always unaware of his or her maladaptive
behavior patterns
E. The disorder that manifests is the client's attempt to deal with
anxiety
F. Secondary gains become associated problems.
G. Client has little difficulty talking, but conversation may be vague and
unrevealing
H. Low self-esteem is often observable in disorder
I. Reality is not grossly distorted
J. Personality is not grossly disorganized

Etiology
1. Biological Factors
a. Anxiety results from improper functioning of the body
systems involved
in the normal stress response
b. Hyperactivity of the autonomic nervous system is
associated with
anxiety
c. Several neurotransmitters have been associated with anxiety
• A low level of gamma-aminobutyric acid (GABA),

• a neurotransmitter that inhibits the reactivity of neurons, is

associated with anxiety
• Norepinephrine is associated with the "fight or
flight"
 reaction
• Panic attacks, sudden episodes of symptoms such as
dizziness, dyspnea, Tachycardia, palpitations, and feelings
of impending doom and death, have been related to high
levels of norepinephrine
2. Interpersonal Factors
a. Mild or moderate levels of anxiety may be expressed as
anger
b. Severe anxiety produces confusion, forgetfulness, and
decreased learning
Assessment
1. Should include data to determine the level and stage of
anxiety.
2. Should focus cm the physical, affective, cognitive, social and
spiritual symptoms of stress:
Increased blood pressure, respiration, and heart rate, sweaty palms,
diaphoresis, dilated pupils, dyspnea or hyperventilation, vertigo or
lightheadedness, blurred vision, urinary frequency, headache, sleep
disturbance, muscle weakness or tension, anorexia, nausea and
vomiting.

Abnormal laboratory findings, including elevated

adenocorticotropic hormones, Cortisol, catecholamine levels and
hyperglycemia, may be evidence of anxiety

Affective symptoms include depression, irritability, apathy,

crying, hypercriticism, and feelings of guilt, grief, anger,
worthlessness, apprehension, and helplessness

Cognitive symptoms include an inability to concentrate,indecisiveness,

inability to learn and reason, lack of interest, and forgetfulness

Social symptoms include changes in the quality and

quantity of communications, fear of social interactions, and social
withdrawal

Spiritual symptoms include feelings of hopelessness and despair,

fear of death, and inability to find life meaningful

Nursing Diagnoses
1. Anxiety (panic) related to situational and maturational crisis
2. Fear related to phobic stimulus
3. Ineffective individual coping related to ritualistic behaviors,
obsessive lights
4. Powerlessness related to fear of disapproval from others
Social isolation related to repressed fears

Implmentation
A. Coping Strategies
i. Include specific actions as Breathing exercises, Guided imagery,
Meditation, listening to music, progressive muscle relaxation,
recreational activities, crying, eating, exercising, sleeping, laughing
 B. "Problem-focused coping" is task oriented and designed to eliminate
or change the source of the anxiety or deal with the consequences of
the stressor.
i. Assessment of the facts
ii. Development of goal
iii. Determination of alternatives for coping with the problem
iv. Identification of the risks and benefits of each possible coping
alternative
v. Selection of an alternative
vi. Implementation of the selected alternative
vii. Implementation of the selected alternative
viii. Evaluation of the outcome
ix. Modifications of actions based on evaluation.

C. "Emotional-focused coping" reinterprets the meaning of the situation

i. Defense mechanisms are automatic unconscious emotionally
focused coping strategies
ii. Defense mechanisms are often used to delay the onset of anxiety

Psychopharmacology
1. Anxiolytics are used to treat anxiety
2. Benzodiazepines are the most commonly used and most effective
medications for treatment of the symptoms of anxiety
• Prolonged use may lead to dependency and abuse
• Benzodiazepines appear to increase the effectiveness of
GABA and may also alter the brain's metabolism of
serotonin and Norepinephrine
• All Benzodiazepines are readily absorbed in the GI tract
after oral administration
• The onset of action is very rapid and peak levels are often
reached within an hour or less
• Common side effects include ataxia, drowsiness, and
impaired cognition, memory, and coordination
■ Long acting Benzodiazepines tend to cause
early morning drowsiness
■ Short-acting Benzodiazepines may lose their
 effectiveness during the night leading to
nocturnal wakefulness and fatigue during the
day
■ Benzodiazepines reduce rapid-eye-
movement (REM) sleep

3. Non-benzodiazepine sedative-hypnotics are a new class of drugs used for

short-term treatment of insomnia associated with anxiety
• Zolpidem (Ambien) has a short half-life
• Little potential for dependency
4. Serotonin and Dopamine Agonist: Buspirone (Buspar)
• Generally takes 2-3 weeks for the Antianxiety effects to become
apparent and 4-6 weeks to be fully effective
• Not habit-forming and does not potentiate the depressant effects of
alcohol, barbiturates, and other CNS medication
• Because it does not have an immediate calming effect it should not be
used as a prn medication for anxiety
• Withdrawal symptoms do not occur when the drug is discontinued

5. Barbiturates and sedative-hypnotic drugs

• Very addictive and dangerous in overdose
• Tolerance occurs with long-term use
• Depresses the respiratory system

6. Beta Blockers have a calming effect on the CNS

• Propranolol (Inderal) is sometimes used
• Are effective in the treatment of physical symptoms of anxiety
such as tremors and tachycardia

7. The antihistamine Diphenhydramine (Benadryl) is occasionally used to

treat sleep disorders associated with anxiety
• Shortens the time of sleep onset, but does not improve the quality
of
sleep
• Anticholinergic effects such as blurred vision and urinary
hesitancy

8. Antidepressants

High sedating antipsychotic are sometimes used to treat sleep

disorders i^sociated with anxiety in elderly clients.

A. Generalized Anxiety Disorder

Assessment
A. Client has unrealistic, diffuse persistent anxiety about two or
more life
experiences.
B. Client cannot control anxiety by defense mechanisms
 C. The individual's worry is out of proportion to the true impact of the
worried
event or situation
D. Psychological symptoms:
1. Lack of concentration on work
2. Feelings of depression and guilt
3. Harbored fear of sudden death or insanity
4. Dread of being alone
5. Confusion
5. Rumination
6. Agitation and restlessness
7. Impatience
8. Difficulty making decisions
E. Physiological symptoms
1. Tremors
2. Dyspnea
3. Palpitations
4. Tachycardia
5. Numbness of extremities
6. Sleep disturbance

Implementation
1. Recognize behavior in client that denotes anxiety
2. Maintain calm, serene approach because nurse's anxiety reinforces
client's anxiety.
3. Help client to develop conscious awareness of anxiety
4. Help client identify and describe feelings and source of anxiety
5. Provide physical outlet for anxiety
6. Remain with client
7. Decrease environmental stimuli
8. Avoid reinforcing secondary gains (attention, sympathy)

B. Phobic and Panic Disorders

Assessment
A. Fear is recognized by individual as excessive or unreasonable in
proportion
to reality.
B. A compelling desire exists to avoid subject or situation
C. Client has unrealistic, irrational fear of object or situation that presents
no
actual danger.
D. Client uses projection, displacement, repression, and sublimation
E. Client transfers anxiety or fear from its source to a symbolic idea or
situation
F. Phobic disorders are classified into different types:
1. Agoraphobia - intense, excessive anxiety or fear about being in
places or situations from which escape might be difficult or
embarrassing
2. Acrophobia - a fear of high places
3. Social phobia - desire to avoid social situations in which
individual fear they will behave in an embarrassing way.
 G. Panic attacks are characterized by severe anxiety with intense symptoms
of palpitations, sweating, shaking, dyspnea, fear of losing control,
choking, fear of losing their mind, or dying.

Implementation
1. Draw client's attention away from phobia
2. Have client focus on awareness of self
3. Do not force client into situation feared.
4. Slowly develop sound, therapeutic relationship with client.
5. Assist client to go through desensitizing process.

C. Obsessive-Compulsive Disorder

Assessment
A. Client has anxiety associated with persistent, undesired ideas, thoughts,
or
images that are experienced as senseless or repugnant
B. Client releases anxiety through repetitive, ritualistic, stereotyped
acts.
C. Personality characteristics:
1. Insecure, guilt-ridden
2. Sensitive, shy
3. Straight-laced
4. Fussy and meticulous
D. Client uses repression, isolation and undoing to reduce anxiety
E. Unable to control feelings of hostility and aggression
F. Behavior interferes with social or role functioning
G. Symptoms are distressing to client
H. Most common obsessions are thoughts of violence, contamination, and
doubt
I. Most common compulsions involve handwashing, counting, checking,
and touching

Implementation
1. Allow punishment of criticism
2. Allow episodes of compulsive acts, setting limits only to prevent
harmful
3. Engage in alternative activities with client
4. Limit decision making for client
5. Provide for client's physical needs
6. Convey acceptance of client regardless of behavior
7. Establish routine to avoid anxiety-producing changes
8. Gear assignments to those which are routine and can be done with
perfection, such as straightening linen or cleaning.
9. Plan therapy, any change in routine or one-to-one contact after
completion of a compulsive episode

Post-Traumatic Stress Disorder

Definition:
• Condition follows a traumatic event that is outside the range of
 common experience (rape, military combat, assault, etc.)
Characteristics:
A. Traumatic event is consistently reexperienced in dream state, as
flashbacks,
connected to events that trigger memory.
B. As event is reexperienced, client suffers behavioral and
emotional symptoms. (Abreaction occurs: vivid recall of painful
experience with emotion appropriate to the original situation
C. Individual is not able to adjust to the event
D. Persistent avoidance of stimuli associated with trauma occurs.
E. Persistent symptoms of increased arousal, such as difficulty
falling/staying asleep and irritability exist.
Assessment
A. Assess for symptoms of anxiety and depression.
1. Emotional instability
2. Feelings of detachment or guilt
3. Nightmares, difficulty sleeping
4. Withdrawal and isolation
5. Self-destructive behavior
B. Aggressive or acting-out behavior
1. Explosive or unpredictable behavior
2. Impulsive behavior; change in lifestyle
Implementation
A. Implement treatment protocol for anxiety disorders
B. Assist client to go through recovery process
1. Deal with conscious awareness of traumatic
experience
2. Adjust to acceptance of experience
C. Protect client from self-destructive behaviors or acting-out
behaviors
D. Recovery process follows four stages:
1. Recovery - reassure client that he is safe following experience
of the traumatic event
2. Avoidance - client will avoid thinking about traumatic
event; support client
3. Reconsideration - client deals with event by confronting it,
talking about it, and working through feelings.
4. Adjustments - client rehabilitates and adjusts to
environment following event; functions and is able to view
future positively.

Somatoform Disorders
Definition
• Also called psychosomatic disorders, are physical symptoms that may
involve any organ system, and whose etiologies are in part precipitated
by psychological factors.

Characteristics
A. An individual must adapt and adjust to stresses in life.
1. The way a person adapts depends on the
 individual's characteristics
2. Emotional stress may exacerbate or precipitate an
illness
B. Psychosocial stress is an important factor in symptom formation.
1. Stress imposes demands and requirements on the person.
2. Symptoms reflect adaptive and coping patterns as well as the
reaction of a particular organ system
3. The way an individual reacts to stress depends on his or her
physiological and psychological make-up.
C. There is a synergistic relationship between repressed feelings and
overexcited organs
D. Any body system may be involved and result in a psychosomatic
disorder
E. Structural changes may take place and pose a life-threatening
situation.
F. Defense mechanisms used include repression, denial, projection,
conversion,and introjection
G. Psychosomatic illness provides individuals with coping
mechanisms.
1. Means of coping with anxiety and stress
2. Means of gaining attention in a socially acceptable
way
3. Means of adjusting to dependency needs.
4. Means of coping with anger and aggression
5. Rationalization for failures
6. Means of punishing self and others.
H. Somatoform disorder result in impairment in social, occupational, and
other areas of functioning.

Psychosomatic Disorders

Assessment
A. Assess which body system is involved that resulted in somatoform
disorder.
1. Gastrointestinal system
a. Peptic ulcer
b. Colic
c. Ulcerative colitis

2. Cardiovascular system
a. Hypertension
b. Tachycardia
c. Migraine headaches
3. Respiratory system
a. Asthma
b. Hay fever
c. Hiccoughs
d. Common cold
e. Hyperventilation
4. Skin - most expressive organ of emotion
a. Blushing
b. Flushing, perspiring
c. Dermatitis
 5. Nervous system
a. Chronic general fatigue
b. Exhaustion
6. Endocrine
a. Dysmenorrhea
b. Hyperthyroidism
7. Musculoskeletal system
a. Cramps
b. Rheumatoid arthritis
8. Other
a. Diabetes mellitus
b. Obesity
c. Sexual dysfunctions
d. Hyperemesis gravidarum
e. Accident proneness
B. Evaluate history for physical symptoms of several years' duration
C. Observe closely and assess client's present condition
1. Collect data about physical illness-symptoms
(multiple sources)
2. Psychosocial adjustment
3. Life situation
4. Coping mechanisms that work for client
5. Strengths of client
6. Problem-solving ability
D. Note if symptoms are intermittent
E. Assess what kinds of things aggravate or relieve symptoms

Implementation
A. Provide restful, supportive environment.
1. Balance therapy and recreation
2. Decrease stimuli
3. Provide activities that deemphasize the client's physical
symptoms
B. Care for the "total" person - physical and emotional.
C. Realize physical symptoms are real and that person is not faking
D. Recognize that treatment of physical problems does not relieve
emotional
problems
E. Reduce demands on client
F. Develop nurse-client relationship
1. Respect the person and the person's problems
2. Help client to express his or her feelings
3. Help client to express anxiety and explore new
coping mechanisms
4. Allow client to meet dependency needs
5. Allow client to feel in control
G. Help client to work through problems and learn new methods of
responding
to stress.

Conversion Disorder

Assessment
 A. Establish psychosomatic origin by assessing physical condition and
ruling
out any organic basis for symptoms (i.e., neurological examinations,
laboratory tests)
B. Identify conversion behavior/symptoms. Conversion behavior is the
development of a physical symptom (blindness, paralysis, deafness)
with no
physical etiology identified.
C. Evaluate client's attitude toward condition*. "La Belle indifference"
client's
lack of concern or indifference toward physical symptom - a definite
clue
that condition is a conversion disorder.
D. Identify primary gain.
1. Keeps internal conflict or need our of awareness
(repression)
2. Symptom has symbolic value to client
E. Identify secondary gain.
1. Provides additional advantages that result from particular
behaviors that are not connected to the primary gain, such as
avoidance, attention, or sympathy.
2. Reinforces maladjusted behavior
F. Assess whether symptoms disappear under hypnosis.

Implementation
A. Establish therapeutic nurse-client relationship
B. Reduce pressure on client
C. Control environment
D. Provide recreational and social activities
E. Do not confront client with his or her illness
F. Divert client's attention from symptom

G. Do not feed into secondary gains through anticipating client needs.

Hypochondriasis

Assessment
A. Preoccupation with an imagined illness for which no observable
symptoms
or organic changes exist.
B. Evaluate severe, morbid preoccupation with body functions or fear of
serious disease
C. Assess whether client shows lack of interest in environment
D. Assess whether client shows severe regression.
E. Determine if client goes from doctor to doctor to find cure or enjoys
recounting medical history
F. Differentiate from malingering - deliberately making up illness to
prolong
hospitalization.

Implementation
______________________________________________________________
 A. Accept client; recognize and understand that physiological complaints
are
not in client's conscious awareness
B. Provide diversionary activities in which client can succeed in building
self-
esteem
C. Use friendly, supportive approach but do not focus on physical
condition
(i.e., avoid asking "How are you today?")
D. Help client to refocus interest on topics other than physical
complaints
E. Provide fro client's physical needs; give accurate information and
correct
any misinformation
F. Assist client to understand how he or she uses illness to avoid dealing
with
life's problems.
G. Be aware of staffs negativity, as it may lead to exacerbation of
client's
I symptoms.

Dissociative Disorders
Definition:
• This disorder involves disruption in the usually integrated functions of
consciousness, identity, memory, or perception of the environment

Characteristics
A. Client attempts to deal with anxiety through various disturbances or
by
blocking certain areas out of the mind from conscious awareness
B. Client has a psychological retreat from reality
C. Repression is used to block awareness of traumatic event
D. Manifestations:
1. Amnesia - circumscribed, selective or generalized, and
continuous loss of memory
2. Fugue - condition experienced as a transient disorientation -
client is unaware he/she has traveled to another location. Client
does not remember period of fugue.
3. Dissociative identity disorder (DID) - dominated by two or
more personalities, each of which controls the behavior while
in the consciousness.
4. Depersonalization - alteration in perception or experience of
self; sense of detachment form self.

Assessment
A. Determine that symptoms are not of organic origin
B. Assess what from the dissociative disorder is manifesting
C. Evaluate degree of interference in lifestyle and interpersonal
relationships
D. Assess presence of accompanying symptoms such as depression,
suicide
ideation, use of alcohol, and drugs, etc.
 E. Note inconsistencies in elapsed time
F. Note complaints of voices "inside" the head talking to one
another, as
opposed to hallucinations that are "outside" the head
implementation
A. Support therapeutic modality as established by treatment team.
B. Reduce anxiety-producing stimuli
C. Redirect client's attention away from self
D. Avoid sympathizing with client
E. Increase socialization activities
F. Therapy.
1. Hypnosis
2. Abreaction (assisting client to recall past, painful
experiences)
3. Cognitive restructuring
4. Behavioral therapy
5. Psychopharmacology (antianxiety and
antidepressants)
Religious and Spiritual Influences on Health
I. African-Americans
A. Communication
1. Languages include English and Black English
2. Head nodding does not necessarily mean agreement.
3. Direct eye contact is often viewed as being rude
4. Nonverbal communication is very important
5. It is considered intrusive to ask personal questions of
someone on initial I contact or meet ng.
B. Time orientation and space
1. Oriented more to the present than the future
2. Close personal space is important
3. Touching another's hair is sometimes viewed as offensive.
C. Social roles
1. Large extended family networks are important
2. Many single parent, female-headed households
3. Religion is usually Protestant (Baptist)
4. Strong church affiliation with community is important.
5. Social organizations are strong within communities
D. Health and Illness
1. Harmony with nature
2. No separation of body, mind, spirit.
3. Illness is a disharmonious sate that may be caused by
demons or spirits.
4. Illness can be prevented by nutritious meals, rest, and
cleanliness
E. Health Risks
1. Sickle cell anemia
2. Hypertension
3. Coronary heart disease
4. Cancer (especially stomach and esophageal)
5. Lactos
e intolerance
6.Coccidioidomy
 cosis
F. Implementation
1. Avoir* stereotyping
2. Do noi label Black English as an unacceptable form of
language
3. Clarify meaning of client's verbal and nonverbal behavior.
4. Be flexible and avoid rigidity in scheduling care.
5. Encourage involvement with family
6. A folk healer or herbalist may be consulted before an
individual seeks medical treatment.

II. Asian-Americans
A. Communication
1. Languages include Chinese, Japanese, Korean, Vietnamese,
English
2. Silence is valued
3. Eye contact is considered rude
4. Criticism or disagreement is not expressed verbally
5. Head nodding does not necessarily mean agreement
6. The word "no" is interpreted as disrespect for
others.
B. Time and space
1. Oriented more to present
2. Social distance is important
3. Usually do not touch others during conversation
4. Touching is unacceptable with members of opposite sex.
5. The head is considered sacred; therefore touching someone
on the head is disrespectful.
C. Social roles
1. Devoted to tradition.
2. Large extended family networks
3. Loyalty to immediate and extended family and honor are
valued.
4. Family unit is very structured and hierarchical.
5. Men have the power and authority, and women are expected to be
obedient.
6. Education is viewed as important.
7. Religions include Taoism (Buddhism), Islam, and
Christianity
8. Social organizations are strong within the
community.
D. Health and Illness
1. Health is a state of physical and spiritual harmony with
nature and a balance between positive and negative energy forces.
2. A healthy body is viewed as a gift from ancestors.
3. Illness is viewed as an imbalance between yin and yang.
4. Yin foods are cold, and yang foods are hot; cold foods are
eaten
when one has a hot illness, and hot foods are eaten when one has a
cold illness.
6. Illness is contributed to prolonged sitting or lying, or to
overexertion.
E. Health Risks
 1. Hypertension
2. Cancer (stomach and liver)
3. Lactose intolerance
4. Thalassemia
5. Coccidioidomycosis
F.Implementation
1. Avoid physical closeness and excessive touching; only
touch a client's head when necessary, informing the client before
doing so.
2. Limit eye contact
3. Avoid gesturing with hands.
4. Clarify responses to questions
5. Be flexible and avoid rigidity in scheduling care
6. Encourage involvement with family
7. A healer may be consulted before an individual seeks out traditional
treatment

III. European (White) - Origin Americans

A. Communication
1. Language include national languages, English
2. Silence can be used to show respect or disrespect for
another, depending on situation
3. Eye contact is viewed as indicating trustworthiness
B. Time orientation and space
1. Future oriented
2. Aloof and tend to avoid close physical contact
3. Handshakes are used for formal greetings
C. Social roles
1. The nuclear family is the basic unit; the extended family is
also important
2. The man is the dominant figure
3. Religion includes Judeo-Christian
4. Community social organizations are important.
D. Health and Illness
1. Health is usually viewed as an absence of disease or illness
2. Have a tendency to be stoical when expressing physical
concerns
3. Primarily rely on modern Western health care delivery
system
E. Health risks
1. Breast cancer
2. Heart disease
3. Diabetes mellitus
4. Thalassemia
F. Implementation
1. Monitor and assess client's body language
2. Respect client's personal space

IV. Hispanic-Americans
A. Communication
 1. Languages include Spanish and Portuguese, with various
dialects
2. Tend to be verbally expressive, yet confidentiality is
important
3. Eye behavior is significant; for example, the "evil eye" can
be
given to a child if a person looks at and admires a child without
touching the child.
4. Avoiding eye contact indicates respect and attentiveness
5. Direct confrontation is disrespectful, and the expression of
negative feelings is impolite.
6. Dramatic body language, such as gestures or facial expressions, is
used to express emotion or pain.
B. Time orientation and space
1. Oriented more to present .
2. Comfortable with close proximity to others.
3. Very tactile and use embraces and handshakes.
4. Value the physical presence of others.
5. Politeness and modesty are
essential.
C Social roles
1. The nuclear family is the basic unit; also there are large
extended
family networks
2. The extended family is highly regarded
3. Needs of the family take precedence over individual family
members seeds.
4. Men are the decision makers and breadwinners, and women are the
caretakers and the homemakers.
5. Religion includes Catholicism
6. Strong church affiliation
7. Social organizations strong within the
community
D.Health and Illness
1. Health may be a reward from God or a result of good luck
2. Health results from a state of balance between "hot and
cold" forces and "wet and dry" forces
3. Illness occurs as a result of God's punishment for sins
4. Folk medicine traditions
E.Health Risks
1. Lactose intolerance
2. Diabetes mellitus
3. Parasites
4. Coccidioidomyco
F. Implementation
1. Communicate with male head of family
2. Protect privacy
3. Offer to call priest or other clergy because of the
significance of religious practices related to illnesses.
4. Always touch a child when examining him or her
5. Be flexible and avoid rigidity in scheduling care

V. Native Americans
A. Communication
1. Languages include English, Navajo, and other tribal
languages
2. Silence indicates respect for the speaker
3. Speak in a low tone of voice and expect others to be
attentive
4. Eye contact is avoided because it is a sign of disrespect
5. Body language is important
B. Time orientation and space
1. Oriented more to present
2. Personal space is very important
3. Will lightly touch another person's hand during greetings
4. Massage is used for the newborn infant to promote bonding
between infant and mother.
5. Touching a dead body is prohibited in some tribes
C. Social roles
1. Very family oriented
2. Basic family unit is the extended family, which often
includes people from several households
3. In some tribes, grandparents are viewed as family leaders
4. Elders are honored
5. Children are taught to respect traditions
6. The father does all the work outside the home, and the
mother assumes responsibility for domestic duties.
7. Sacred myths and legends provide spiritual guidance
8. Religion and healing practices are integrated
9. Community social organizations are important
D. Health and illness
1. Health is a state of harmony between the person, the family,
and the environment.
2. Illness is caused by supernatural forces and disequilibrium
between person and environment
3. Traditional health and illness beliefs may continue to be
observed; natural and magicoreligious folk medicine tradition
4. Traditional healer: medicine man or woman
E. Health Risks
1. Alcohol abuse
2. Accidents
3. Heart disease
4. Diabetes mellitus
5. Tuberculosis
6. Arthritis
7. Lactose intolerance
8. Gallbladder disease
9. American Eskimos are susceptible to glaucoma
F. Implementation
1. Clarify communication
2. Understand that the client may be attentive even when eye contact
is absent
3. Be attentive to own use of body language.
4. Obtain input from members of extended family.
5. Encourage client to personalize space in which health care is
delivered.
 6. In the home, assess for the availability of running water, and
modify infection control and hygiene practices as necessary.

VI. Prolongation of Life

A. Christian science religion is unlikely to use medical means
to prolong life.
B. Jewish faith generally opposes prolonging life after
irreversible brain damage.

VII. Death and Dying Practices

A. Autopsy may be prohibited, opposed, or discouraged by
Eastern
Orthodox, Muslims, Jehovah's Witnesses, and Orthodox Jews
B. Organ donation is prohibited by Jehovah's Witnesses and
Muslims
C. Buddhists in America encourage organ donation and
consider it an act of mercy
D. Cremation is discouraged, opposed, or prohibited by the
Mormon,
Eastern Orthodox, Islamic and Jewish faiths
E. Hindus prefer cremation and cast the ashes in a holy river.

Religions and Dietary

Practices I Seventh Day
Adventist
• Alcohol, coffee and tea prohibited
• Some groups prohibit
meat 3. Baptist
• Alcohol prohibited
• Discourage consumption of coffee and tea
C. Buddhism
• Alcohol and drug use discouraged
• Some sects are vegetarian
D. Roman Catholicism
• Avoid meats on Ash Wednesday and Good Friday
• Optional fasting during Lent season
• During Lent, discourage meat on Friday
• Children and the ill are exempt from
fasting E Mormon
• Alcohol, coffee and tea prohibited
• Limited consumption of meat
• First Sunday of the month is time for
fasting F. Hinduism
• Beef and veal prohibited

• Many individuals are vegetarians

• Limited consumption of meat
• Fasting occurs on specific days of the week according to which god
the person worships
 • Children are not allowed to participate in fasting
• Fasting rituals vary from complete abstinence to consumption of only
one meal per day
G. Islam
• Pork prohibited
• Any meat product not ritually slaughtered is prohibited
• Avoidance of alcohol or drugs
• During Ramadan (ninth month of Mohammedan year), fasting occurs
during daytime

H. Jehovah's Witness
• Prohibition of any foods to which blood has been added
• Can consume animal flesh that has been drained
I. Judaism
• Dietary kosher laws must be adhered to by Orthodox believers
• Meats allowed include animals that are vegetable eaters, oioven-
hoofed animals, and animals that are ritually slaughtered
• Fish that have scales and fins are allowed
• Any combination of meat and milk is prohibited.
• During Yom Kippur, 24-hour fasting
• During Passover week, only unleavened bread is eaten.
J. Pentecostal
• Alcohol is prohibited
• Avoid consumption of anything to which blood has been added
• Some individuals avoid pork
K. Russian Orthodox
• Abstinence from meat and dairy products on Wednesday, Friday, and
during Lent
• During Lent, all animal products, including dairy products are
forbidden
• Fasting during Advent
• Exceptions from fasting include illness and pregnancy.

Sensory and Perceptual Alterations

A. Delirium
• Acute, usually reversible brain disorder characterized by clouding of
the consciousness (decreased awareness of the environment and a
reduced ability to focus and maintain attention.
• Develops over a short period of time (usually hours to days) and tends
to fluctuate during the course of the day.

Assessment
Delirium has a sudden onset and an identifiable cause
1. A positive history for delirium includes:
a. A thorough medical evaluation revealing abnormal lab results
b. An EEG confirming cerebral dysfunction
c. More than one examination at different times of the day detects
fluctuations in levels of consciousness that characterize the
syndrome.
 d. Identification of the underlying cause of the delirium
e. Ruling our other reasons for delirium (depression, anxiety,
dementia, or
personality disorder)

2. Presenting signs and symptoms

a. Fluctuating levels of consciousness (i.e., alternating periods of
coherence with periods of confusion); disorientation that worsens at
the end of the day, usually referred to as sundown syndrome
b. Alternating patterns of hyperactivity (typical of drug withdrawal) to
hypoactivity (typical of metabolic imbalance)
c. Hyperactive behaviors
• Rambling, bizarre, incoherent, rapid, pressured, or
loud speech
• Restlessness, irritability, euphoria
• Calling out for help, striking out at others, bizarre and
destructive behaviors, combativeness, anger, profanity
d. Hypoactive behaviors
• Limited, dull patterns of speech
• Lethargy, apathy, withdrawn behavior
• Reduced alertness or awareness of the environment
f. Cognitive changes
• Disorganized thinking
• Diminished ability to focus attention, easily distracted
• Disorientation to time and place
• Impairment in recent and remote memory
• Visual or auditory hallucinations, frightening delusions
g. Predominant emotion is fear with a high level of anxiety.
Nursing Diagnoses
1. Acute confusion related to alcohol or drug abuse, medication ingestion,
fluid and electrolyte imbalances, infection
2. Anxiety related to fear of cognitive and behavioral deficits
3. Altered thought processes related to distractibility, decreasing
judgment, memory loss, confabulation, delusions, hallucinations,
illusions
4. Bathing/hygiene/dressing/grooming/feeding self-care deficits related
to inability to sequence skills necessary to perform these skills
5. Impaired verbal communication related to aphasia, agraphia,
agnosia
6. Risk for injury or risk for trauma related to aggressive behavior,
labile emotions, impaired judgment, illusions, delusions, or
hallucinations
7. Sleep pattern disturbance related to fear, anxiety, sundowning,
agitation

Nursing Interventions
1. Maintain nutrition and fluid balance
2. Restrain only when necessary since it increases agitation and fear
3. Safety is a priority; one-on-one observation
4. Repetitive orientation
 5. Don't reinforce hallucinations
6. Lighted room
7. Family members present

B. Dementia
A chronic, irreversible brain disorder characterized by impairments in
memory, abstract thinking, and judgment, as well as changes in
personality
• Chronic development of multiple cognitive deficits
manifested by memory impairment and one or more of the
following cognitive disturbances:
▪ Aphasia, a loss of the ability to understand or use
language
▪ Apraxia, an inability to carry out skilled and purposeful'movement; the
inability to use objects properly
▪ Agnosia, an inability to recognize familiar
situations, people or stimuli; not related to
impairment in sensory organs
▪ Disturbance in executive functioning (i.e.,
planning, organizing,sequencing, abstracting)
• Course is insidious and progressive, characterized by gradual onset
and continuing cognitive decline
• Cognitive deficits cause a significant impairment in social or
occupational functioning and represent a significant decline from
previous level of functioning

Assessment
Dementia is a progressive disease and symptoms can be divided into three
stages
1. Stage 1 (typically lasts 1 to 3 years)
a. Difficulty performing complex tasks related to a decline in recent
memory;forgetfulness, missed appointments; clients often recognized
and are frightened by their confusion
b. Declining personal appearance, inappropriate dress for weather
c. Lack of spontaneity in verbal and nonverbal communication
d. Disoriented to time but can remember people and places
e. Decreased concentration, increased distractibility, impaired
judgment

2. Stage 2 (lasting approximately 2 to 10 years)

a. Poor impulse control with frequent outbursts and tantrums; labile
emotions;catastrophic reactions or overreactions to minor stresses
occur frequently
b. Wandering or aggressive behavior, hallucinations, delusions
c. Aphasia, which begins with the inability to find words and eventually
limits a person to as few as six words
d. Hyperorality, the need to taste, chew and examine any object small
enough to be placed in the mouth
e. Perseveration phenomena, repetitive behaviors such as lip licking,
fingertapping, pacing, or echolalia
f. Confabulation, the filling in of memory gaps with imaginary
 information in an attempt to distract others from observing the deficit
g. Agraphia, the inability to read or write
h. Agnosia, the inability to recognize familiar situations, people, or stimuli
(auditory agnosia; astereognosia or tactile agnosia; alexia or visual
agnosia)

3. Stage 3 (lasting 8 to 10 years before death occurs)

a. Kluver-Bucy syndrome develops, which includes the continuation of
hyperorality and the development of binge eating
b. Hyperetamorphosis, the need to compulsively touch and examine very
object in the environment.
c. Progressive deterioration in motor ability including inability to walk,
sit up,or even smile
d. Progressive decrease in response to environmental stimuli leading
to
total nonresponsiveness or vegetative state
e. Severe decline in cognitive function, losing ability to recognize others
or even self
f. May scream spontaneously or be able to say only one word; frequently
becomes mute

Nursing Diagnoses
1. All nursing diagnoses for clients with delirium are also appropriate for
clients with dementia, plus the following:
2. Compromised/disabling ineffective family coping related to changing
roles, physical exhaustion, financial problems
3. Risk for and/or caregiver role strain related to lack of respite resources
or support from significant others, unpredictable illness course,
insufficient finances, aggressive behavior or emotional outbursts of
care receiver
4. Visual/auditory/tactile sensory/perceptual alterations related to
biochemical imbalances for sensory distortion, agnosia, astereognosia,
alexia
5. Self-esteem disturbance related to loss of independent functioning,
loss of capacity for remembering, loss of capability for effective verbal
communication
6. Risk for violence: self-directed or directed to others related to
confusion, agitated state, suicidal ideation, delusions, hallucinations,
illusions

Nursing Interventions
1. Individualized attention
2. Consistent social interaction
3. Group activities, exercise, stimulation of senses
4. Lighted room, personal belongings, clear simple instructions
5. Find out source of anxiety; try to alleviate-coping mechanisms to
defend self become emphasized during anxiety.
Nursing Interventions for Clients with Cognitive Impairment (confused
clients)

1. Provide simple, clear instructions focusing on one task at a time

2. Break tasks into very small steps
3. Speak slowly and in a face-to-face position when communicating with
clients
4. Allow the client to have familiar objects around him or her to maintain
reality orientation and enhance self-worth and dignity
5. Discuss topics that are meaningful to the client
6. Refrain from arguing or convincing client that delusions are not
real
7. Provide a simple, structured environment with consistent caregiver to
minimize confusion and provide a sense of security and stability
8. Encourage reminiscence and discussion of life review
9. Encourage family/caregivers to express feelings, particularly anger
and frustration

Specific Treatment Modalities

A. Psychopharmacology
1. Cholinesterase inhibitors can slow down progression of mild to
moderate dementia
• Tacrine (Cognex) effects can be seen in 6 weeks; can cause
elevation in liver enzymes, discontinue therapy if it occurs

• Donepezil (Aricept), slows deterioration of mild to

moderate
dementia without serious liver toxicity

2. Management of anxiety, aggression, and agitation

• Lorazepam (Ativan). Less accumulation and less confusion
than other anxiolytics. Watch for sedation and falls
• Trazodone (Desyrel). Can decrease agitation and aggression
without decreasing cognitive performance
• Buspirone (Buspar) Not sedating and has fewer
side effects.

B. Behavior Modification
• Physical restraints used only as a last resort
• Reality orientation
• Discuss meaningful topics (significant life-events, family, work or
hobbies)
• Communicate in a calm manner with use of simple, clear
instructions
• Avoid arguing with the client

C. Reminiscence or life review therapy

D. Validation Therapy - interact with clients on a topic they initiate in a
place and time where they feel most secure.
Types of Degenerative Conditions

Dementia, Alzheimer's Type (DAT)

A. Most common form of dementia
B. Unknown etiology but diffuse atrophy of cerebral cortex occurs.
C. Usually begins after age 60 but can be observed at age 40
D. Symptoms gradually and progressively worsen

Pick's Disease
A. Rare heredodegenerative process of frontal lobe not associated with
normal aging
B. Becomes well advanced in 2 to 3 years
C. Characterized by changes in personality early in course of illness
D. Similar to Alzheimer's but involvement spares parietal lobes
E. These clients act dull and lack initiative; otherwise their disease
resembles
Alzheimer's

Huntington's Chorea
A. Genetically transmitted disorder caused by a single autosomal
dominant gene
B. Onset of symptoms - age 30 to 50 years
C. Progressive mental and physical deterioration inevitable
D. Characterized by personality changes with psychotic behavior,
intellectual impairment, and, finally, total dementia

Korsakoff s Syndrome
A. A disorder that occurs in chronic alcoholism and is often associated
with
Wernicke's encephalopathy.
1. Wernicke's Encephalopathy
a. Acute, life-threatening condition that can occur as a
result of chronic alcoholism (inadequate diet
leading to thiamine deficiency)
b. Usual symptoms are cloudy consciousness,
impaired mentation, ataxia, peripheral neuropathy
c. Treatment is oral vitamin B complex and thiamine
100 mg IM stat if client presents with the above
symptoms and has a history of alcohol abuse
2. Korsakoff's is a chronic condition that remains after
Wernicke's encephalopathy is treated.
B. Most important feature is recent memory impairment, especially in
learning new information
1. Confabulation (making up stories) accompanies
memory impairment
2. Memories fro past events are not usually affected.

Assessment for all cognitive disorders

A. Assess onset, which is generally slow.
B. Evaluate if illness is stabilized or in remission
 C. Assess for increasing deterioration
D. Look for the following symptoms:
1. Cognitive impairment
a. Disorientation
b. Severe loss of memory
c. Judgment impairment
d. Loss of capacity to learn
e. Perceptual disturbances
f. Decreased attention span
g. Paranoid ideation
h. Decreased motivation, interests, and self-
concern i. Loss of normal inhibitions j.
Loss of insight
2. Affective impairment

a. Labile mood, irritableness, and

explosiveness
b. Depression
c. Withdrawal
d. Anxiety
3. Behavioral impairment

b. Ritualistic, stereotyped behavior

to deal with environment
c. Possible combativeness
d. Possible inappropriate and
regressive behavior
e. Alterations in sexual drives and activity
f. Neurotic or psychotic behavior as client's defenses
break
down
E. Assess psychological reactions to organic brain disorder
1. Change in self-concept
2. Anger and frustration
3. Denial used as
defense
4. Depression
5. Acceptance of limitations
6. Assumptions of "sick" role by dependency and lack of
motivation

Implementation for all cognitive disorders

A. Meet client's physical needs
1. Avoid fostering dependence
2. Establish routine for activities of daily living
B. Help client maintain contact with reality
1. Give feedback
2. Avoid small chatter
3. Personalize interaction
4. Supply stimulation to motivate client
5. Keep client from becoming bored and distracted
C. Assist client in accepting the diagnosis
1. Be supportive
 2. Maintain therapeutic communication
3. During denial phase, listen and accept; do not
argue
4. Assist development of awareness
5. Help client develop the ability to cope with his or
her altered identity
D. Focus interactions with client and establish consistent contact
1. Have short, frequent contacts with client
2. Use concrete ideas in communicating with client
3. Maintain reality orientation by allowing client to talk about his
or her past and to confabulate to protect one's self-esteem
4. Acknowledge client as an individual
E. Provide activities that increase success of client
1. Social groups
2. Occupational therapy
3. Allow client, as interested, to do small chores
around unit
F. Provide supportive environment
1. Ensure a consistent staff and environmental
structure
2. Do not change schedule suddenly
3. Provide handrails, walkers, wheelchairs, as
necessary
4. Ensure that the floor is not slippery and that the environment is
well lighted.

G. Assist client to function at the highest level possible

1. Increase self-esteem
2. Avoid dependency
3. Allow and encourage personalization of client's room
and environment
4. Do not isolate client from others on the unit
5. Dress client in his or her own clothing.

Stress Management

A. Definition of Stress
1. A physical, a chemical, or an emotional factor that causes bodily or
mental tension and that may be a factor in disease causation; a state
resulting from factors that tend to alter an existing equilibrium.
2. Selye's Definition of Stress
a. A state manifested by a specific syndrome that consists of all
the nonspecifically induced changes within the biologic
system.
b. The body is the common denominator of all adaptive
responses
c. Stress is manifested by the measurable changes in
the body
d. Stress causes a multiplicity of changes in the body.

B. General Aspects of stress

1. Body responses to stress are a self-preserving mechanism that
automatically and immediately becomes activated in times of danger.
 a. Caused by physical or psychological stress
b. Caused by changes in internal and/or external
environment.

Selye's Theory of Stress

A. General Adaptive Syndrome (GAS)
1. Alarm stage
a. Shock: the body translates as sudden injury, and the GAS
becomes
activated
b. Counter shock: the organism restored to its
preinjury condition
2. Stage of resistance: the organism is adapted to the injuring agent.

3. Stage of exhaustion: if stress continues, the organism loses its

adaptive capability and goes into exhaustion.

B. Local Adaptive Syndrome (LAS)

1. Selective changes within the organism
2. Local response elicits general response.
3. Ability of parts of the body to respond to a specific injury is impaired
if the whole body is under stress.

Psychological Stress
Definition: All processes that impose a demand or requirement upon the
organism, the resolution or accommodation of which necessitates work or
activity of mental apparatus.

Characteristics
A. May involve other structures or systems, but primarily affects mental
apparatus
1. Anxiety is a primary result of psychological stress
2. Causes mental mechanisms to attempt to reduce or relieve
psychological discomfort

B. Causes of psychological Stress

1. Loss of something of value
2. Injury/pain
3. Frustrations of needs and drives
4. Threats to self-concept
5. Many illnesses cause stress
6. Conflicting cultural values
7. Future shock: physiological and psychological stress resulting
from an overload of the organism's adaptive systems and
decision-making processes brought about by too rapidly
changing values and technology.
8. Cultural shock: stress developing in response to transition of
the individual from a familiar environment to unfamiliar one.
9. Social stress: stress that develops as a result of social rather
than psychological problems.
Assessment
A. Assess increased anxiety, anger, helplessness, hopelessness, guilt,
shame,
disgust, fear, frustration, or depression.
B. Evaluate behaviors resulting from stress
1. Apathy, regression, withdrawal
2. Crying, demanding
3. Physical illness
4. Hostility, manipulation
5. Senseless violence, acting out

Plan/Implementation
1. Gather information about client's internal and external
environment
2. Modify external environment so that adaptation responses are within
the capacity of the client
3. Support the efforts of client to adapt or to respond
4. Provide client with the materials required to maintain constancy of
internal environment
5. Understand body's mechanisms for accommodating stress
6. Prevent additional stress
7. Reduce external stimuli
8. Reduce or increase physical activity depending on the cause of and
response to stress.

Stress Management
1. Become aware of your stressors and your emotional and physical reactions.
• Notice your distress. Don't ignore it. Don't gloss
over your problems.
• Determine what events distress you. What are you telling
yourself about meaning of these events?
• Determine how your body responds to the stress. Do you
become nervous or physically upset? If so, in what specific
ways?

2. Recognize what you can change.

• Can you change your stressors by avoiding or eliminating them
completely?
• Can you reduce their intensity (manage them over a period of
time instead of on a daily or weekly basis)?
• Can you shorten your exposure to stress (take a break, leave the
physical premises)?
• Can you devote the time and energy necessary to making a
change (goal setting, time management techniques, and delayed
gratification strategies may be helpful here)?
3. Reduce the intensity of your emotional reactions to stress.
• The stress reaction is triggered by your perception of
danger...physical danger and/or emotional danger. Are you
viewing your stressors in exaggerated terms and/or taking a
difficult situation and making it a disaster? Are you expecting
to please everyone?
• Are you overreacting and viewing things as absolutely critical
 and urgent? Do you feel you must always prevail in every
situation?
• Work at adopting views that are more moderate; try to see the
stress as something you can cope with rather than
something that overpowers you.
• Try to temper your excess emotions. Put the situation in
perspective. Do not labor on the negative aspects and the "what
if s."
4. Learn to moderate your physical reactions to stress.
• Slow, deep breathing will bring your heart rate and
respiration back to normal.
• Relaxation techniques can reduce muscle tension.
• Electronic biofeedback can help you gain voluntary control
over such things as muscle tension, heart rate, and blood
pressure.
• Medications, when prescribed by a physician, can help in the
short term in moderating your physical reactions. However,
they alone are not the answer. Learning to moderate these
reactions on your own is a preferable long-term solution.

5. Build your physical reserves.

• Exercise for cardiovascular fitness three to four times a
week (moderate, prolonged rhythmic exercise is best, such as
walking, swimming, cycling, or jogging).
• Eat well-balanced, nutritious meals.
• Maintain your ideal weight.
• Avoid nicotine, excessive caffeine, and other stimulants.
• Mix leisure with work. Take breaks and get away when
you can.
• Get enough sleep. Be as consistent with your sleep schedule
as possible.

6. Maintain your emotional reserves.

• Develop some mutually supportive
friendships/relationships.
• Pursue realistic goals that are meaningful to you, rather than
goals others have for you that you do not share.
• Expect some frustrations, failures, and sorrows.
• Always be kind and gentle with yourself - be a friend to
yourself.

Stress Reduction Techniques Nursing Implications

1. Identify stressors (e.g., work, 1. Have client examine own
reaction to
relationships, environment, health, age, life occurrences. Discern between
positivefinances, spiritual and emotional and negative stressors; explain that
factors, stress is unavoidable and can
be used to motivate.

2. Modify or eliminate stressors 2. Review possibilities for simple and

major changes; discuss
alternatives, advantages and
 disadvantages of reducing stressors.

3. Develop effective coping mechanisms 3. Assist client ways to relax. Guide

• Daily exercise patient through relaxation
exercises to
• Develop alternative ways to relax experience its usefulness.
• Relaxation techniques
(progressive relaxation,
autogenic training,
guided imagery,
meditation
• Diaphragmatic breathing;
periodic deep breathing

Therapeutic Environment

A. A therapeutic relationship is a nurse-client interaction that focuses on

client
needs and is goal-specific, theory-based and open to supervision

B. Purpose: provide counseling, crisis intervention, individual

psychotherapy,
health teaching

C. Characteristics:
• Mutually-defined relationships
• Mutually collaborative
• Goal-directed
• Interpersonal techniques facilitate trust and open communication
• Fosters development of therapeutic relationship
• Relationship differs from friendship
- Specific boundaries established
- Purpose, time, and place of interaction are specific
- Professional demeanor and objectivity maintained.
• Nurse assists client with problem identification and resolution
• Successful relationship leads to mutual growth for client and nurse

D. Phases of the Nurse-Client Relationship:

1. Initiating or orienting phase: establishes boundaries
o When, duration of meeting, place, number of sessions, how often nurse
will meet with client. o Focus of
relationship defined with client
■ Major treatment goals are
identified o Usually time of anxiety for
client and nurse o Preparation for
termination begins at this stage
2. Working phase: exhibits reduction of anxiety in both client and
nurse
o Client accepts boundaries of relationship
 o Nurse uses interpersonal skills that foster communication
o Client confronts problems and feelings
o Client develops insights, learns adaptive coping skills and problem
solving o Nurse and client see each
other as unique people
3. Terminating phase: begins at first session and ends when identified
treatment goals have been met; focuses on loss, separation anxiety.
o Client and nurse summarize and evaluate work of
relationship o Both express thoughts and feelings about
termination

E. The physical component of the relationship includes all procedures and

technical
skills that nurses do for clients.

F. The psychosocial component involves qualities such as positive

regard,
nonjudgmental attitude, acceptance, warmth, empathy, and authenticity

G. The spiritual component is the feeling of connectiveness with clients and

the
respect for the diversity of spiritual needs among clients.

H. The power component includes beliefs and about external and internal
locus of control.

Therapeutic Communication
• It is the process of influencing the behavior of others by sending,
receiving and interpreting messages; feedback and consideration of the
context complete the cycle.
• It is the foundation of interpersonal relationships and is a key process
needed to use the nursing process.
• Communication includes spoken words, paralanguage, the thinking
process, emotions, nonverbal behavior, and the culture of the
individuals sending and receiving the message.
• Nonverbal communication includes body language, eye contact,
personal space, and the use of touch.
• Characteristics of effective helpers include a nonjudgmental approach,
acceptance, warmth, empathy, authenticity, congruency, patience,
trustworthiness, self-disclosure, and humor.
• Therapeutic communication requires the components of empathy,
positive regard and positive sense of self.

Effective Communication Techniques

1. Offering self: making self available and showing interest and
concern. Example: "I'll stay with you/*
2. Active listening: paying close attention to verbal and nonverbal
communications,
patterns of thinking, feelings and behaviors.
Example: Face the patient, maintain eye contact; be open, alert and patient;
respond appropriately.

3. Silence: planned absence of verbal remarks to allow patients to

 think and say
more.
Example: maintain eye contact; convey interest and concern in facial
expression.
4. Empathy: recognizing and acknowledging patients'
feelings. Example: "I can hear how painful it is for you to
talk about this."
5. Questioning: using open-ended questions to achieve relevance and
depth in discussion.
Example: "What happened? Tell me about it."

6. General Leads: using neutral expressions to encourage patients to

continue talking.
Example: "Go on, I'm listening." "I hear what you are saying."
7. Restating: repeating the exact words of patients to remind them of what
they said; to let them know they are heard.
Example: "You say you are going home soon." "Your mother wasn't happy
to see you?"

8. Verbalizing the implied: rephrasing patients' words to highlight an

underlying message.
Example: patient: "There is nothing to do at home." Nurse: "It sounds as
if you might be bored at home."

9. Clarification: asking patients to restate, elaborate, or give examples of

ideas or feelings.
Example: "What do you mean by 'feeling sick inside'?"
10. Making observations: commenting on what is seen or heard to
encourage discussion.
Example: "You seem restless." "I noticed you had trouble making a
decision about...."

11. Presenting reality: offering a view of what is real and what is not
without arguing with the patient.
Example: "I know the voices are real to you, but I don't hear them."
12. Encouraging description of perception: asking for patients' views of their
situations.
Example: "what do you think is happening to you right now?"

13. Placing an event in time or sequence: asking for relationships among

events Example: "When did you do this?" "Then what happened?" "What led
up to...?"

14. Identifying themes: asking patients to identify recurrent patterns in

thoughts, feelings, and behaviors.
Example: "So what do you do each time you argue with your wife?" "What
feeling do you get when you see your father?"

15. Summarizing: reviewing main points and

conclusions. Example: "Let's see, so far you have
said..."
16. Focusing: pursuing a topic until its meaning or importance is
clear. Example: "explain more about..." "What happen when you
feel this way?"

17. Interpreting: providing a view of the meaning or importance of something.

Example: "It sounds as if this is very important to you." "You seem to get in
trouble when you..."

18. Encouraging evaluation: asking for patients' views of the meaning

or importance of something.
Example: "So what does all this mean to you?" "How serious is this for you?"

19. Suggesting collaboration: offering to help patients solve problems.

Example: "I can help you understand this better." "Let's see if we can find an
answer,"

20. Giving information: providing information that will help patients make
better choices.
Examples: "I can tell you about your medicines." "There are self-help groups
available."

21. Rehearsing: requesting a verbal description of what will be said or

done. Example: "Tell me exactly what you will say to your wife on
Friday."

22. Role playing: practicing behaviors; the nurse plays a particular

role. Example: "I'll play your wife. What do you want to say to
me?"

23. Supportive confrontation: acknowledging the difficulty in changing, but

pushing for action.
Example: "I know this isn't easy to do, but I think you can do it."
"It's hard, but give it a try."

24. Limit setting: discouraging nonproductive feelings and behaviors,

and encouraging productive ones.
Example: "You're slipping into your aggressive tone again. Try it again.
"That is a negative comment about yourself. Tel me something
positive about yourself."

25. Feedback: pointing out specific behaviors and giving impressions of

reactions.
Example: "I thought you conveyed anger when you said..." "When you
said...I felt..."

26. Encouraging evaluation: asking patients to evaluate their actions and the
outcomes.
Example: "How well did it work when you tried..." "What was your
husband's reaction?"

27. Reinforcement: giving feedback on positive

behaviors.
Example: "This new approach worked for you. Keep
it up."

Non-therapeutic Communication
• Non-therapeutic communication blocks the exchange of information
between the nurse and the client. Eliminating communication barriers
is essential for open communication.
• Non-therapeutic communication involves the use of barriers such as
giving reassurance, rejecting, giving approval or disapproval, agreeing
or disagreeing, giving advice, probing, and interpreting.
• Non-therapeutic communication involves displaying a lack interest in
the person communicating that is demonstrated through a closed
posture, restlessness, and inattentiveness

Ineffective Communication Techniques

1. Stereotypical comments
Example: "What's the matter, cat got your
tongue?" "Still water runs deep."

2. Parroting
Example: Client: "I'm so sad."
Nurse: "You're so sad."

3. Changing the topic

Example: Client: "I was so afraid I was going to have another panic
attack." Nurse: "What does your husband think about your
panic attacks?"

4. Disagreeing
Example: "I don't see any reason for you to think that way."
"No, I think that is a silly response from your mother."

5. Challenging
Example: "Is that a valid reason to become
angry?" "You weren't really serious,
were you?"

6. Requesting an explanation
Example: "Why did you react that
way?""Why can't you just leave
home?"

7. False reassurance
Example: "Don't worry anymore."
"I doubt that your mother will be angry about your failing math."

8. Belittling expressed feelings

Example: "That was four years ago, it shouldn't bother you
now." "You shouldn't feel that all men are bad."

9. Probing
Example: "I'm here to listen. I can't help you if you won't tell me
everything." "Tell me what secrets you keep from your wife."

10. Advising
Example: "You sound worried. I think you'd better talk to your doctor or your
rabbi."
11. Imposing values
Example: Client: (with head down and low tone of voice) " I was going to go
on the cruise, but my mother is coming to stay with me." Nurse: "You must
be looking forward for her arrival."

12. Double/multiple questions

Example: "What makes you feel that you should stay? How would you get
along if you left?"

PSYCHOTROPIC DRUGS
Antipsychotic Drugs

A. Also known as ataractic or neuroleptic

B. Action: to block the dopamine receptors in the CNS
C. Antipsychotic drugs relieve positive psychotic symptoms and assist in
controlling behavior - medication can calm an excited client without
producing marked impairment of motor function or sleep.
D. Most common are phenothiazine derivatives (typical: Thorazine,
Stelazine, Trilafon, and the long-acting phenothiazine, Prolixin)
E. Another common antipsychotic drug (classification-butyrophenones)
is haloperidol (Haldol)
1. Less sedative than phenothiazines
2. Indicated fro use with psychosis, Tourette's disorder, and as
antiemetic
3. Incidence of severe extrapyramidal side effects
4. Other side effects include leukocytosis, blurred vision, dry
mouth, and urinary retention
5. Avoid alcohol and other CNS depressants
F. Clozapine (Clozaril) and Loxitane are antipsychotics for management
of psychotic symptoms in clients who do not respond to other
antipsychotics.
1. Side effects similar to other antipsychotics; be aware of blood
dyscrasias (leucopenia, neutropenia, agranulocytosis,
eosinophilia)
2. Requires weekly WBC count to determine potential for
agranulocytosis. (Drug is discontinued if WBC is < 2000 juL or
granulocyte is < 1000L)
3. Monitor monthly bilirubin, liver function studies.
G. Other classes of drugs are thioxanthenes (Taractan and Navane) and
dibenzoxapines (Loxitane)
H. Other classes of drugs are the "atypical" antipsychotics such as
Risperdal, Seroquel, and Zyprexa.
 1. These drugs have few or no extrapyramidal
symptoms.
2. Target positive and negative symptoms of
schizophrenia I. Side effects
1. Blood dyscrasias
a. Agranulocytosis occurs in first 4-18 weeks of
treatment.
Symptoms: fever, sore throat, malaise, infection
b. Leukopenia, preceded by altered
white blood count
2. Extrapyramidal side effects (EPSEs), affecting the voluntary
movements and skeletal muscles.
a. Parkinsonism: symptoms occur 1 to 4 weeks; signs are
similar to classic Parkinsonism: rigidity, shuffling
gait, pill-
rolling hand movement, tremors, dyskinesia, and
mask like face.
b. Akathisia: very common; occurs in 1 to 6 weeks; signs:
uncontrolled motor restlessness, foot tapping,
agitation,pacing
c. Dystonia: occurs early, 1 to 2 days; signs: limb and
neckspasms; uncoordinated jerky movements;
difficulty in speaking and swallowing; and rigidity
and spasms of muscles.
d. Tardive dyskinesia; develops late in treatment;
Antiparkinson drugs are of no help in decreasing
symptoms. This is a permanent side effect; signs:
shuffling gait, drooling, and general dystonic
symptoms
3. Hypotension: orthostatic hypotension may occur. Monitor
closely when client is elderly. Keep client supine for 1 hour and
advise to change positions slowly.
4. Anticholinergic effects: dry mouth, blurred vision, tachycardia,
nasal congestion, and constipation. Treat symptomatically.
5. Neuroleptic malignant syndrome - a rare complication caused
by an antipsychotic. It is a medical emergency and must be
recognized and treated immediately
a. Signs and symptoms: irregular vital signs,
hyperpyrexia, altered mental status, autonomic
instability, elevated creatinine phosphokinase, and
possible acute renal failure
b. Treatment: immediate discontinuation of drug,
medical monitoring, administration of a dopamine-
enhancing drug and/or Dantrium

Antiparkinson Drugs (Antidyskinetics)

A. The term extrapyramidal disease refers to a motor disorder often

associated with pathologic dysfunction in the basal ganglia.
Antiparkinson drugs block the extrapyramidal symptoms.
1. Clinical symptoms of the disease include abnormal involuntary
movement, change in tone of the skeletal muscles, and a
 reduction of automatic associated movements
2. Reversible extrapyramidal reactions may follow the use of
certain drugs - the most common are the phenothiazine
derivatives.
B. Antiparkinson drugs act on the extrapyramidal system to reduce
disturbing symptoms experienced from antipsychotic medications.
1. They are usually given in conjunction with
antipsychotic
drugs
2. The most common drugs are anticholinergics: Artane, Cogentin,
Kemadrin, and Akineton.
3. Side effects are dizziness, gastrointestinal disturbance,
headaches, urinary hesitancy, and memory impairment
C. Benadryl, an antihistamine is often given in place of Artane or
Cogentin,because it does not cause as many untoward side effects as
the other antiparkinson drugs.
D. Other drugs occasionally ordered in this category are Amantadine,
benzodiazepines, propranolol, clonidine, nifedipine (Procardia),
verapamil, and dantrolene (Dantrium) used for treating neuroleptic
malignant syndrome.

Antianxiety Drugs

A. Drugs induce sedation, relax muscles, and inhibit convulsions; major

use toreduce anxiety
B. Demand is great for relief from anxiety and they are safer than sedative-
hypnotics
C. Potentiate drug abuse. Greatest harm occurs when combined with
alcohol
D. Prescribed for neuroses, psychosomatic disorders, but do not modify
psychotic behaviors.
E. Drugs from two major classes.
1. Benzodiazepines: safer and more common (Librium, Valium,
Ativan, restoril, Centrax, Serax, and Xanax - being tested for
use in depression, panic, and obsessive-compulsive disorders)
2. Nonbenzodiazepines: Vistaril, Buspar
E. Side effects.
1. Drowsiness (avoid driving or working around
equipment)
2. Blurred vision, constipation, dermatitis, mental confusion,
anorexia, polyuria, menstrual irregularities, and edema
3. Habituation and increased tolerance
4. Pancytopenia, thrombocytopenia, and
agranulocytopenia
5. Withdrawal symptoms occur with prolonged use (6+ months)
and high doses

Antidepressant Drugs

A. Tricyclics, one of the most commonly used antidepressants; includes

Elavil, Norpramin, Tofranil, Aventyl, Vivactil, and Pamelor.
 1. Blocks uptake of norepinephrine and serotonin
2. A lag period of 1 to 6 weeks between starting the medication
and experiencing symptom relief exists
3. Anticholinergic effect - produces antagonism of the
parasympathetic system

4. Side effects:
a. Anticholinergic effects: dry mouth, blurred vision,
constipation, postural hypotension
b. CNS effects: tremor, agitation, angry
states, mania, seizures
c. Cardiovascular effects: palpitations. Exerts a quinidine
like
effect on the heart, so assess any client with a history of
myocardial infarction
d. Alterations in sexual functioning
e. Orthostatic hypotension
f. Sedation
g. Weight gain
h. Most side effects appear in first 1 to 2 weeks and diminish
over a period of a few weeks or months.
5. If client is switched from a tricyclic drug to MAOI, a period of 1
to 3 weeks must elapse between drugs.
6. Blood levels assay provide therapeutic levels of tricyclic
antidepressants

B. MAO inhibitors include Marplan, Nardil, and Parnate

1. MAO inhibitors are toxic, potent, and produce many side
effects
2. They should not be the first antidepressant drug used; side effects
are more dangerous than TCA
3. Side effects;
a. Most dangerous is hypertensive crisis
b. Drug interactions can cause severe hypertension,
hypotension, or CNS depression
c. Postural hypotension, headaches, constipation, anorexia,
diarrhea, and chills
d. Tachycardia, edema, impotence, dizziness, insomnia,
and
restlessness
e. Manic episodes and anxiety
4. All clients must be warned not to eat foods with high tyramine
content (aged cheese, wine, beer, chicken liver, yeast), drink
alcohol or take other drugs, especially sympathomimetic drugs
(amphetamines, L-dopa, epinephrine)
5. MAO inhibitors must not be used in combination with
tricyclics

C. Hypertensive Crisis, due to elevated tyramine levels

• Severe symptoms: throbbing, occipital headache, confusion,
drowsiness, vomiting, stiff neck, chills, chest pain
• Monitor for potential complications: encephalopathy,
heart failure
 • Treatment
a. Drug of choice: Regitine IV 5 mg with close monitoring;
antihypertensive
b. Monitor vital signs, ECG, and neurological signs; BP
q 5 min.
c. Norepinephrine is administered
for severe hypotension

D. Trazodone HC1 (Desyrel) is a class of antidepressant drugs unrelated

to
tricyclics
1. Inhibits the reuptake of serotonin
2. Well-tolerated with minimal side effects (sedation and
orthostatic hypotension)
3. Warning: has been associated with priapism - persistent
abnormal erection. If symptom occurs, immediately
discontinue drug.

E. Serotonin
1. Relatively free of side effects
2. Useful in treatment of severely depressed and
melancholic
clients
3. Some clients experience heightened anxiety, nausea, vomiting,
and dizziness
4. Some clients experience abnormal ejaculation, and
male impotence
F. Selective Serotonin reuptake inhibitors (SSRIs)
1. Examples are Prozac, Zoloft, Paxil, and Luvox
2. Exhibit less side effects than other antidepressant
drugs
a. Anticholinergic side effects such as dry mouth,
constipationare fewer
b. Side effects observed are nausea, the most common,
anxiety or nervousness, insomnia, drowsiness, and
headache

Anti manic Drugs (Mood Stabilizers)

A. These drugs control mood disorders, especially the manic phase

B. Elevate mood when client is depressed; dampen mood when client is
in
manic episode
C. Baseline studies of renal, cardiac, and thyroid status must be obtained
before
lithium therapy
D. The most common form of drug is lithium carbonate. Other forms:
lithium
citrate, Tegretol, Klonopin, Valproic acid
E. Drug must reach a certain blood level before it is effective.
1. Stabilizing concentration occurs in 5 to 7 days; therapeutic
effect 7 to 28 days or more
F. Lithium is metabolized by the kidney.
 1. Deficiency of sodium results in more lithium being
reabsorbed, thus increasing risk of toxicity
2. Excessive sodium causes more lithium to be excreted and may
lower level to a nontherapeutic range

3. Normal dietary intake of sodium with adequate fluids to

prevent dehydration is necessary
4. Diuretics will increase absorption of lithium
leading to toxic
effects
5. Serum levels measured 2 to 3 times weekly (12 hours after last
doe) in beginning of therapy; for long-term maintenance
therapy, every 2 to 3 months.
G. Drug concentration and side effects
1. Therapeutic range of serum levels is 0.6 to 1.2 mEq/L; for
acute manic state, 1.0 to 1.5 mEq/L
2. Side effects occur at upper ranges, usually above
1.5 mEq/L
3. Gastrointestinal disturbances, metallic taste in mouth, muscle
weakness, fatigue, thirst, polyuria, and fine hand tremors are
common side effects
4. Hypothyroidism is a long-term side effect of
lithium therapy
H. Lithium toxicity
1. Appears when blood levels exceed 1.5 to 2.0
mEq/L.
2. Central nervous system is the chief target
3. Initial symptoms include nausea, vomiting, drowsiness,
tremors, slurred speech, blurred vision, muscle twitching,
oliguria
4. If drug is continued, coma, convulsions, and death
may result
5. Treatment for toxicity: gastric lavage, correction of fluid
balance, administration of Mannitol to increase urine excretion