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Library of Congress Control Number: 2014944300

ISBN: 978-0-8036-6054-0

Library of Congress Cataloging-in-Publication Data

Names: Townsend, Mary C., 1941- author. | Morgan, Karyn I., author.
Title: Psychiatric mental health nursing : concepts of care in evidence-based
practice / Mary C. Townsend, Karyn I. Morgan.
Description: Ninth edition. | Philadelphia, PA : F. A. Davis Company, [2018]

| Includes bibliographical references (p. ) and index.

Identifiers: LCCN 2017009564| ISBN 9780803660540 | ISBN 0803660545
Subjects: | MESH: Psychiatric Nursing—methods | Mental Disorders—nursing |

Evidence-Based Nursing
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6054_FM_i-xx 16/08/17 2:42 pm Page vii

THIS BOOK IS DEDICATED TO:

FRANCIE

God made sisters for sharing laughter

and wiping tears

–Mary Townsend

To my friend and mentor, Chaplain (Colonel) Thomas W. Elsey

He was dearly loved and will be deeply missed

October 26, 1942–November 10, 2015

–Karyn Morgan
6054_FM_i-xx 16/08/17 2:42 pm Page viii

Reviewers

Theresa Aldelman Ruth Burkhart

Bradley University New Mexico State University/Dona Ana Community
Peoria, Illinois College
Las Cruces, New Mexico
Fredrick Astle
University of South Carolina Annette Cannon
Columbia, South Carolina Platt College
Aurora, Colorado
Carol Backstedt
Baton Rouge Community College Deena Collins
Baton Rouge, Louisiana Huron School of Nursing
Cleveland, Ohio
Elizabeth Bailey
Clinton Community College Martha Colvin
Pittsburgh, New York Georgia College & State University
Milledgeville, Georgia
Sheryl Banak
Baptist Health Schools – Little Rock Mary Jean Croft
Little Rock, Arkansas St. Joseph School of Nursing
Providence, Rhode Island
Joy A. Barham
Northwestern State University Connie Cupples
Shreveport, Louisiana Union University
Germantown, Tennessee
Barbara Barry
Cape Fear Community College Karen Curlis
Wilmington, North Carolina State University of New York Adirondack
Queensbury, New York
Carole Bomba
Harper College Nancy Cyr
Palatine, Illinois North Georgia College and State University
Dahlonega, Georgia
Judy Bourrand
Samford University Carol Danner
Birmingham, Alabama Baptist Health Schools Little Rock – School of Nursing
Little Rock, Arkansas
Susan Bowles
Barton Community College Carolyn DeCicco
Great Bend, Kansas Our Lady of Lourdes School of Nursing
Camden, New Jersey
Wayne Boyer
College of the Desert Leona Dempsey, PhD, APNP (ret.), PMHCS-BC
Palm Desert, California University of Wisconsin Oshkosh
Oshkosh, Wisconsin
Joyce Briggs
Ivy Tech Community College Debra J. DeVoe
Columbus, Indiana Our Lady of Lourdes School of Nursing
Camden, New Jersey
Toni Bromley
Rogue Community College Victoria T. Durkee, PhD, APRN
Grants Pass, Oregon University of Louisiana at Monroe
Monroe, Louisiana
Terrall Bryan
North Carolina A & T State University J. Carol Elliott
Greensboro, North Carolina St. Anselm College
Fairfield, California

viii
6054_FM_i-xx 16/08/17 2:42 pm Page ix

Reviewers ix

Sandra Farmer Eleanor J. Jefferson

Capital University Community College of Denver
Columbus, Ohio Platt College
Metropolitan St. College
Patricia Freed Denver, Colorado
Saint Louis University
St. Louis, Missouri Dana Johnson
Mesa State College/Grand Junction Regional Center
Diane Gardner Grand Junction, Colorado
University of West Florida
Pensacola, Florida Janet Johnson
Fort Berthold Community College
Maureen Gaynor New Town, North Dakota
Saint Anselm College
Manchester, New Hampshire Nancy Kostin
Madonna University
Denise Glenore Livonia, Michigan
West Coast University
Riverside, California Linda Lamberson
University of Southern Maine
Sheilia R. Goodwin Portland, Maine
Winston Salem State University
Salem, North Carolina Irene Lang
Bristol Community College
Janine Graf-Kirk Fall River, Massachusetts
Trinitas School of Nursing
Elizabeth, New Jersey Rhonda Lansdell
Northeast MS Community College
Susan B. Grubbs Baldwyn, Mississippi
Francis Marion University
Florence, South Carolina Jacqueline Leonard
Franciscan University of Steubenville
Elizabeth Gulledge Steubenville, Ohio
Jacksonville State University
Jacksonville, Alabama Judith Lynch-Sauer
University of Michigan
Kim Gurcan Ann Arbor, Michigan
Columbus Practical School of Nursing
Columbus, Ohio Glenna Mahoney
University of Saint Mary
Patricia Jean Hedrick Young Leavenworth, Kansas
Washington Hospital School of Nursing
Washington, Pennsylvania Jacqueline Mangnall
Jamestown College
Melinda Hermanns Jamestown, North Dakota
University of Texas at Tyler
Tyler, Texas Lori A. Manilla
Hagerstown Community College
Alison Hewig Hagerstown, Maryland
Victoria College
Victoria, Texas Patricia Martin
West Kentucky Community and Technical College
Cheryl Hilgenberg Paducah, Kentucky
Millikin University
Decatur, Illinois Christine Massey
Barton College
Lori Hill Wilson, North Carolina
Gadsden State Community College
Gadsden, Alabama Joanne Matthews
University of Kentucky
Ruby Houldson Lexington, Kentucky
Illinois Eastern Community College
Olney, Illinois
6054_FM_i-xx 16/08/17 2:42 pm Page x

x Reviewers

Joanne McClave JoAnne M. Pearce, MS, RN

Wayne Community College Idaho State University
Goldsboro, North Carolina Pocatello, Idaho

Mary McClay Karen Peterson

Walla Walla University DeSales University
Portland, Oregon Center Valley, Pennsylvania

Susan McCormick Carol Pool

Brazosport College South Texas College
Lake Jackson, Texas McAllen, Texas

Shawn McGill William S. Pope

Clovis Community College Barton College
Clovis, New Mexico Wilson, North Carolina

Margaret McIlwain Karen Pounds

Gordon College Northeastern University
Barnesville, Georgia Boston, Massachusetts

Nancy Miller Konnie Prince

Minneapolis Community and Technical College Victoria College
Minneapolis, Minnesota Victoria, Texas

Vanessa Miller Cheryl Puntil

California State University Fullerton Hawaii Community College
Fullerton, California Hilo, Hawaii

Mary Mitsui Larry Purnell

Emporia State University University of Delaware
Emporia, Kansas Newark, Delaware

Cheryl Moreland, MS, RN Susan Reeves

Western Nevada College Tennessee Technological University
Carson City, Nevada Cookeville, Tennessee

Daniel Nanguang Debra Riendeau

El Paso Community College Saint Joseph’s College of Maine
El Paso, Texas Lewiston, Maine

Susan Newfield Sharon Romer

West Virginia University South Texas College
Morgantown, West Virginia McAllen, Texas

Dorothy Oakley Lisa Romero

Jamestown Community College Solano Community College
Olean, New York Fairfield, California

Christie Obritsch Donna S. Sachse

University of Mary Union University
Bismarck, North Dakota Germantown, Tennessee

Sharon Opsahl Betty Salas

Western Technical College Otero Junior College
La Crosse, Wisconsin La Junta, Colorado

Vicki Paris Sheryl Samuelson, PhD, RN

Jackson State Community College Millikin University
Jackson, Tennessee Decatur, Illinois

Lillian Parker John D. Schaeffer

Clayton State University San Joaquin Delta College
Morrow, Georgia Stockton, California
6054_FM_i-xx 16/08/17 2:42 pm Page xi

Reviewers xi

Mindy Schaffner Dorothy Varchol

Pacific Lutheran University Cincinnati State
Tacoma, Washington Cincinnati, Ohio

Becky Scott Connie M. Wallace

Mercy College of Northwest Ohio Nebraska Methodist College
Toledo, Ohio Omaha, Nebraska

Janie Shaw Sandra Wardell

Clayton State University Orange County Community College
Morrow, Georgia Middletown, New York

Lori Shaw Susan Warmuskerken

Nebraska Methodist College West Shore Community College
Omaha, Nebraska Scottville, Michigan

Joyce Shea Roberta Weseman

Fairfield University East Central College
Fairfield, Connecticut Union, Missouri

Judith Shindul-Rothschild Margaret A. Wheatley

Boston College Case Western Reserve University, FPB School
Chestnut Hill, Massachusetts of Nursing
Cleveland, Ohio
Audrey Silveri
UMass Worcester Graduate School of Nursing Jeana Wilcox
Worcester, Massachusetts Graceland University
Independence, Missouri
Brenda Smith, MSN, RN
North Georgia College and State University Jackie E. Williams
Dahlonega, Georgia Georgia Perimeter College
Clarkston, Georgia
Janet Somlyay
University of Wyoming Rita L. Williams, MSN, RN, CCM
Laramie, Wyoming Langston University School of Nursing & Health
Professions
Charlotte Strahm, DNSc, RN, CNS-PMH Langston, Oklahoma
Purdue North Central
Westville, Indiana Rodney A. White
Lewis and Clark Community College
Jo Sullivan Godfrey, Illinois
Centralia College
Centralia, Washington Vita Wolinsky
Dominican College
Kathleen Sullivan Orangeburg, New York
Boise State University
Boise, Idaho Marguerite Wordell
Kentucky State University
Judy Traynor Frankfort, Kentucky
Jefferson Community College
Watertown, New York Jan Zlotnick
City College of San Francisco
Claudia Turner San Francisco, California
Temple College
Temple, Texas

Suzanne C. Urban
Mansfield University
Mansfield, Pennsylvania
6054_FM_i-xx 16/08/17 2:42 pm Page xii
Acknowledgments
Amy M. Romano, Content Project Manager, Nursing,
F.A. Davis Company, for all your help and support in
preparing the manuscript for publication.
Sharon Y. Lee, Production Editor, for your support
and competence in the final editing and production
of the manuscript.
The nursing educators, students, and clinicians, who
provide critical information about the usability of the
textbook and offer suggestions for improvements.
Many changes have been made on the basis of your
input.
To those individuals who critiqued the manuscript for
this edition and shared your ideas, opinions, and sug-
gestions for enhancement. I sincerely appreciate your
contributions to the final product.
My husband, Jim, and children and grandchildren,
Kerry and Ryan, Tina and Jonathan, Meghan,
Matthew, and Catherine for showing me what life is
truly all about.
Mary C. Townsend
xii
First of all, sincere thanks to Mary Townsend for hav-
ing the confidence in me to be included in authoring
this exceptional text. I have the utmost respect for
what you have created and for your foresight in rec-
ognizing the most relevant issues in the changing face
of psychiatric mental health nursing care.
My thanks also to Susan Rhyner for the encourage-
ment, humor, and passion that have made this work
enjoyable. Thanks to Amy Romano, Andrea Miller,
and Christine Becker for your expertise and accessi-
bility in preparing the manuscript. I, too, appreciate
all the reviewers who have offered feedback and their
unique expertise. Thanks to Jennifer Feldman, MLIS,
AHIP, for sharing your skills and research assistance.
I have learned just how true it is that it “takes a village”
and I am grateful for each of you.
Special thanks to Erin Barnard, Alan Brunner, Fred
Frese, Emmy Strong, and the others who coura-
geously allowed their stories to be told. Your contri-
butions to student learning and to breaking down the
barriers of stigmatization are immeasurable.
I appreciate each of you more than I can say.
Karyn I. Morgan
6054_FM_i-xx 16/08/17 2:42 pm Page xiii

Contents

UNIT 1 Summary and Key Points 82

Review Questions 83
Basic Concepts in Psychiatric-Mental
Health Nursing 1 Chapter 5 Ethical and Legal Issues 86
Objectives 86
Chapter 1 The Concept of Stress Adaptation 2 Homework Assignment 86
Ethical Considerations 88
Objectives 2 Legal Considerations 92
Homework Assignment 2 Summary and Key Points 101
Stress as a Biological Response 3 Review Questions 102
Stress as an Environmental Event 5
Stress as a Transaction Between the Chapter 6 Cultural and Spiritual Concepts
Individual and the Environment 7 Relevant to Psychiatric-Mental
Stress Management 8
Summary and Key Points 9 Health Nursing 105
Review Questions 10 Objectives 105
Homework Assignment 105
Chapter 2 Mental Health and Mental Illness: Cultural Concepts 106
Historical and Theoretical Concepts 12 How Do Cultures Differ? 106
Objectives 12 Application of the Nursing Process 108
Homework Assignment 12 Spiritual Concepts 120
Historical Overview of Psychiatric Care 13 Addressing Spiritual and Religious Needs
Mental Health 14 Through the Nursing Process 123
Mental Illness 15 Summary and Key Points 128
Psychological Adaptation to Stress 16 Review Questions 129
Mental Health/Mental Illness
Continuum 22 UNIT 3
Summary and Key Points 23 Therapeutic Approaches in Psychiatric
Review Questions 23
Nursing Care 133
UNIT 2
Chapter 7 Relationship Development 134
Foundations for Psychiatric-Mental
Objectives 134
Health Nursing 27 Homework Assignment 134
Role of the Psychiatric Nurse 135
Chapter 3 Concepts of Psychobiology 28 Dynamics of a Therapeutic Nurse-Client
Objectives 28 Relationship 136
Homework Assignment 28 Conditions Essential to Development
The Nervous System: An Anatomical of a Therapeutic Relationship 139
Review 29 Phases of a Therapeutic Nurse-Client
Neuroendocrinology 39 Relationship 141
Genetics 45 Boundaries in the Nurse-Client
Psychoneuroimmunology 48 Relationship 143
Psychopharmacology and the Brain 49 Summary and Key Points 144
Implications for Nursing 49 Review Questions 145
Summary and Key Points 50 Chapter 8 Therapeutic Communication 147
Review Questions 51
Objectives 147
Chapter 4 Psychopharmacology 54 Homework Assignment 147
Objectives 54 What Is Communication? 148
Homework Assignment 54 The Impact of Preexisting Conditions 148
Historical Perspectives 55 Nonverbal Communication 150
The Role of the Nurse in Therapeutic Communication Techniques 152
Psychopharmacology 55 Nontherapeutic Communication Techniques 154
How Do Psychotropics Work? 57 Active Listening 154
Applying the Nursing Process in Motivational Interviewing 156
Psychopharmacological Therapy 57 Process Recordings 157
Feedback 160

xiii
6054_FM_i-xx 16/08/17 2:42 pm Page xiv

xiv Contents

Summary and Key Points 160 Phases of Crisis Intervention: The Role
Review Questions 161 of the Nurse 239
Disaster Nursing 241
Chapter 9 The Nursing Process in Application of the Nursing Process to
Psychiatric-Mental Health Nursing 164 Disaster Nursing 242
Objectives 164 Summary and Key Points 249
Homework Assignment 164 Review Questions 250
The Nursing Process 165
Why Nursing Diagnosis? 175 Chapter 14 Assertiveness Training 253
Nursing Case Management 176 Objectives 253
Applying the Nursing Process in Homework Assignment 253
the Psychiatric Setting 178 Assertive Communication 254
Concept Mapping 179 Basic Human Rights 254
Documentation of the Nursing Process 179 Response Patterns 254
Summary and Key Points 185 Behavioral Components of Assertive
Review Questions 185 Behavior 256
Techniques That Promote Assertive
Chapter 10 Therapeutic Groups 188 Behavior 257
Objectives 188 Thought-Stopping Techniques 258
Homework Assignment 188 Role of the Nurse in Assertiveness
Functions of a Group 189 Training 259
Types of Groups 189 Summary and Key Points 262
Physical Conditions That Influence Group Review Questions 263
Dynamics 190
Therapeutic Factors 191 Chapter 15 Promoting Self-Esteem 266
Phases of Group Development 191 Objectives 266
Leadership Styles 192 Homework Assignment 266
Member Roles 193 Components of Self-Concept 267
Psychodrama 193 Development of Self-Esteem 268
The Role of the Nurse in Therapeutic Groups 194 Manifestations of Low Self-Esteem 270
Summary and Key Points 195 Boundaries 271
Review Questions 196 The Nursing Process 273
Summary and Key Points 277
Chapter 11 Intervention With Families 199 Review Questions 277
Objectives 199
Homework Assignment 199 Chapter 16 Anger and Aggression Management 280
Stages of Family Development 200 Objectives 280
Major Variations 202 Homework Assignment 280
Family Functioning 204 Anger and Aggression, Defined 281
Therapeutic Modalities With Families 208 Predisposing Factors to Anger and
The Nursing Process—A Case Study 214 Aggression 281
Summary and Key Points 219 The Nursing Process 283
Review Questions 220 Summary and Key Points 289
Review Questions 290
Chapter 12 Milieu Therapy—The Therapeutic
Community 223 Chapter 17 Suicide Prevention 293
Objectives 223 Objectives 293
Homework Assignment 223 Homework Assignment 293
Milieu, Defined 224 Historical Perspectives 294
Current Status of the Therapeutic Epidemiological Factors 294
Community 224 Risk Factors 296
Basic Assumptions 224 Predisposing Factors: Theories of Suicide 298
Conditions That Promote a Therapeutic Application of the Nursing Process
Community 225 With the Suicidal Client 299
The Program of Therapeutic Community 226 Summary and Key Points 312
The Role of the Nurse in Milieu Therapy 229 Review Questions 313
Summary and Key Points 230 Chapter 18 Behavior Therapy 318
Review Questions 231
Objectives 318
Chapter 13 Crisis Intervention 234 Homework Assignment 318
Objectives 234 Classical Conditioning 319
Homework Assignment 234 Operant Conditioning 320
Characteristics of a Crisis 235 Techniques for Modifying Client Behavior 320
Phases in the Development of a Crisis 235 Role of the Nurse in Behavior Therapy 322
Types of Crises 237 Summary and Key Points 324
Crisis Intervention 239 Review Questions 325
6054_FM_i-xx 16/08/17 2:42 pm Page xv

Contents xv

Chapter 19 Cognitive Therapy 327 The Chemically Impaired Nurse 440

Objectives 327 Codependency 441
Homework Assignment 327 Treatment Modalities for Substance-Related
Historical Background 328 Disorders 442
Indications for Cognitive Therapy 328 Non-Substance Addictions 447
Goals and Principles of Cognitive Therapy 328 Summary and Key Points 450
Basic Concepts 329 Review Questions 451
Techniques of Cognitive Therapy 331
Role of the Nurse in Cognitive Therapy 333
Chapter 24 Schizophrenia Spectrum and Other
Summary and Key Points 336 Psychotic Disorders 456
Review Questions 337 Objectives 456
Homework Assignment 456
Chapter 20 Electroconvulsive Therapy 340 Nature of the Disorder 457
Objectives 340 Predisposing Factors 458
Homework Assignment 340 Other Schizophrenia Spectrum
Electroconvulsive Therapy, Defined 341 and Psychotic Disorders 463
Historical Perspectives 341 Application of the Nursing Process 467
Indications 342 Treatment Modalities for Schizophrenia
Contraindications 342 and Other Psychotic Disorders 479
Mechanism of Action 343 Summary and Key Points 488
Side Effects 343 Review Questions 489
Risks Associated With Electroconvulsive
Therapy 343 Chapter 25 Depressive Disorders 494
The Role of the Nurse in Electroconvulsive Objectives 494
Therapy 344 Homework Assignment 494
Summary and Key Points 346 Historical Perspective 495
Review Questions 347 Epidemiology 495
Types of Depressive Disorders 497
Chapter 21 The Recovery Model 350 Predisposing Factors 500
Objectives 350 Developmental Implications 504
Homework Assignment 350 Application of the Nursing Process 509
What Is Recovery? 351 Treatment Modalities for Depression 519
Guiding Principles of Recovery 351 Summary and Key Points 527
Models of Recovery 353 Review Questions 527
Nursing Interventions That Assist
With Recovery 359 Chapter 26 Bipolar and Related Disorders 533
Summary and Key Points 360 Objectives 533
Review Questions 361 Homework Assignment 533
Historical Perspective 534
UNIT 4 Epidemiology 534
Types of Bipolar Disorders 534
Nursing Care of Clients With Alterations Predisposing Factors 537
in Psychosocial Adaptation 363 Developmental Implications 538
Application of the Nursing Process
to Bipolar Disorder (Mania) 540
Chapter 22 Neurocognitive Disorders 364 Treatment Modalities for Bipolar
Objectives 364 Disorder (Mania) 547
Homework Assignment 364 Summary and Key Points 555
Delirium 365 Review Questions 555
Neurocognitive Disorder 366
Application of the Nursing Process 374 Chapter 27 Anxiety, Obsessive-Compulsive,
Medical Treatment Modalities 386 and Related Disorders 559
Summary and Key Points 393 Objectives 559
Review Questions 394 Homework Assignment 559
Chapter 23 Substance-Related and Historical Aspects 560
Epidemiological Statistics 560
Addictive Disorders 399 How Much Is Too Much? 562
Objectives 399 Application of the Nursing Process—
Homework Assignment 400 Assessment 562
Substance Use Disorder, Defined 400 Diagnosis and Outcome Identification 571
Substance-Induced Disorders, Defined 401 Planning and Implementation 574
Predisposing Factors to Substance- Evaluation 578
Related Disorders 401 Treatment Modalities 580
The Dynamics of Substance-Related Summary and Key Points 586
Disorders 403 Review Questions 587
Application of the Nursing Process 425
6054_FM_i-xx 16/08/17 2:42 pm Page xvi

xvi Contents

Chapter 28 Trauma- and Stressor-Related UNIT 5

Disorders 591
Psychiatric Mental Health Nursing
Objectives 591
Homework Assignment 591 of Special Populations 731
Historical and Epidemiological Data 592
Application of the Nursing Process— Chapter 33 Children and Adolescents 732
Trauma-Related Disorders 592 Objectives 732
Application of the Nursing Process— Homework Assignment 732
Stressor-Related Disorders 600 Neurodevelopmental Disorders 733
Treatment Modalities 606 Disruptive Behavior Disorders 754
Summary and Key Points 610 Anxiety Disorders 763
Review Questions 611 Quality and Safety Education for
Chapter 29 Somatic Symptom and Dissociative Nurses (QSEN) 765
General Therapeutic Approaches 767
Disorders 614 Summary and Key Points 768
Objectives 614 Review Questions 769
Homework Assignment 614
Historical Aspects 615 Chapter 34 The Aging Individual 773
Epidemiological Statistics 616 Objectives 773
Application of the Nursing Process 616 Homework Assignment 773
Treatment Modalities 632 How Old is Old? 774
Summary and Key Points 637 Epidemiological Statistics 775
Review Questions 638 Theories of Aging 776
The Normal Aging Process 779
Chapter 30 Issues Related to Human Special Concerns of the Elderly Population 785
Sexuality and Gender Dysphoria 641 Application of the Nursing Process 791
Objectives 641 Summary and Key Points 798
Homework Assignment 641 Review Questions 801
Development of Human Sexuality 642
Variations in Sexual Orientation 644 Chapter 35 Survivors of Abuse or Neglect 806
Gender Dysphoria 646 Objectives 806
Application of the Nursing Process Homework Assignment 806
to Gender Dysphoria in Children 647 Predisposing Factors 807
Gender Dysphoria in Adolescents Application of the Nursing Process 809
and Adults 650 Treatment Modalities 822
Sexual Disorders 652 Summary and Key Points 824
Application of the Nursing Process Review Questions 825
to Sexual Disorders 659
Summary and Key Points 668 Chapter 36 Community Mental Health Nursing 831
Review Questions 668 Objectives 831
Homework Assignment 831
Chapter 31 Eating Disorders 673 The Changing Focus of Care 832
Objectives 673 The Public Health Model 833
Homework Assignment 673 The Community as Client 834
Epidemiological Factors 674 Summary and Key Points 858
Application of the Nursing Process 676 Review Questions 858
Treatment Modalities 690
Summary and Key Points 693 Chapter 37 The Bereaved Individual 862
Review Questions 693 Objectives 862
Homework Assignment 862
Chapter 32 Personality Disorders 697 Theoretical Perspectives on Loss and
Objectives 697 Bereavement 863
Homework Assignment 697 Length of the Grief Response 867
Historical Aspects 699 Anticipatory Grief 867
Types of Personality Disorders 700 Maladaptive Responses to Loss 868
Application of the Nursing Process 707 Application of the Nursing Process 869
Treatment Modalities 721 Additional Assistance 875
Summary and Key Points 725 Summary and Key Points 878
Review Questions 726 Review Questions 879
6054_FM_i-xx 16/08/17 2:42 pm Page xvii

Contents xvii

Chapter 38 Military Families 883 Appendix E Assigning NANDA International

Objectives 883 Nursing Diagnoses to Client
Homework Assignment 883 Behaviors Appendix-26
Historical Aspects 884 Glossary Glossary-1
Epidemiological Statistics 884
Application of the Nursing Process 884 Index Index-1
Treatment Modalities 894
Summary and Key Points 897 Ebook Bonus Chapters
Review Questions 898
Chapter 39 Complementary and Psychosocial
Appendix A Answers to Chapter Review Therapies 903

Questions Appendix-1 Chapter 40 Relaxation Therapy 929

Appendix B Examples of Answers to Chapter 41 Theoretical Models of Personality
Communication Exercises Appendix-3 Development 940
Appendix C Mental Status Assessment Appendix-6 Chapter 42 Forensic Nursing 959
Appendix D DSM-5 Classification: Categories
and Codes Appendix-10
6054_FM_i-xx 16/08/17 2:42 pm Page xviii
To the Instructor
Currently in progress, implementation of the recom-
mendations set forth by the New Freedom Commis-
sion on Mental Health has given enhanced priority
to mental health care in the United States. Moreover,
at the 65th meeting of the World Health Assembly
(WHA) in May 2012, India, Switzerland, and the
United States cosponsored a resolution requesting
that the World Health Organization, in collaboration
with member countries, develop a global mental
health action plan. This resolution was passed at the
66th WHA in May 2013. By their support of this res-
olution, member countries have expressed their
commitment for “promotion of mental health, pre-
vention of mental disorders, and early identification,
care, support, treatment, and recovery of persons
with mental disorders.” With the passage of this res-
olution, mental health services may now be available
for millions who have been without this type of care.
More recently, national initiatives have sought to
address the growing crises of deaths related to sui-
cide and opiate overdoses. Mental health and mental
illness continue to gain attention globally in the wake
of these and other critical issues but much still needs
to be done to reduce stigmatization and premature
loss of life in this population.
Many nurse leaders see this period of mental health-
care reform as an opportunity for nurses to expand
their roles and assume key positions in education, pre-
vention, assessment, and referral. Nurses are, and will
continue to be, in key positions to assist individuals to
attain, maintain, or regain optimal emotional wellness.
As it has been with each new edition of Psychiatric
Mental Health Nursing: Concepts of Care in Evidence-Based
Nursing, the goal of this ninth edition is to bring to prac-
ticing nurses and nursing students the most up-to-date
information related to neurobiology, psychopharmacol-
ogy, and evidence-based nursing interventions. This edi-
tion includes changes associated with the latest( fifth)
edition of the American Psychiatric Association’s Diag-
nostic and Statistical Manual of Mental Disorders (DSM-5).
Content and Features New to the Ninth
Edition
All content has been updated to reflect the current
state of the discipline of nursing.
All nursing diagnoses are current with the
NANDA-I 2015–2017 Nursing Diagnoses Definitions
and Classifications.
xviii
Communication Exercises are included in Chapters
13, Crisis Intervention; 17, Suicide Prevention; 21, The
Recovery Model; 22, Neurocognitive Disorders; 23, Sub-
stance Use and Addictive Disorders; 24, Schizophrenia
Spectrum and Other Psychotic Disorders; 25, Depres-
sive Disorders; 26, Bipolar and Related Disorders; 27,
Anxiety, Obsessive-Compulsive, and Related Disor-
ders; 30, Issues Related to Human Sexuality; 31, Eating
Disorders; 32, Personality Disorders; 35, Survivors of
Abuse or Neglect; and 37, The Bereaved Individual.
These exercises portray clinical scenarios that allow the
student to practice communication skills with clients.
Examples of answers appear in an appendix at the back
of the book.
A new feature, “Real People, Real Stories,” in-
cludes interviews conducted by one of the authors,
Karyn Morgan, in which individuals discuss their
experience of living with a mental illness and their
thoughts on important information for nurses to
know. These discussions can be used with students
to explore communication issues and interventions
to combat stigmatization and to build empathy
through understanding individuals’ unique experi-
ences. “Real People, Real Stories” interviews are in
Chapters 8, Therapeutic Communication; 17, Sui-
cide Prevention; 23, Substance Use and Addictive
Disorders; 24, Schizophrenia Spectrum and Other
Psychotic Disorders; 25, Depressive Disorders; 30, Issues
Related to Human Sexuality and Gender Dysphoria;
and 38, Military Families.
New QSEN icons (in addition to the existing QSEN
Teaching Strategy boxes) have been added selectively
throughout chapters to highlight content that reflects
application of one or more of the six QSEN compe-
tencies (patient-centered care, evidence-based prac-
tice, teamwork and collaboration, maintaining safety,
quality improvement, and informatics).
Chapter 4, Psychopharmacology, has been moved
from DavisPlus to the textbook. While each class of
psychoactive substances is discussed in this chapter,
lists of commonly used agents have been retained in
the chapters that discuss specific disorders. For exam-
ple, a list of commonly used antipsychotic agents
(along with dosage ranges, half-life, and pregnancy
categories) appears in Chapter 24, Schizophrenia
Spectrum and Other Psychotic Disorders. These lists
also appear online at DavisPlus.
New content on motivational interviewing appears
in Chapters 8 and 23.
6054_FM_i-xx 16/08/17 2:42 pm Page xix
New content describing the concept of emotional
intelligence is included in Chapter 14, Assertiveness
Training.
New content on RAISE (Recovery After an Initial
Schizophrenia Episode), based on the NIMH initia-
tive is included in Chapter 24.
New content on gender dysphoria and transgender
issues appears in Chapter 21.
Updated and new psychotropic drugs approved
since the publication of the eighth edition are included
in the specific diagnostic chapters to which they apply.
Features That Have Been Retained
in the Ninth Edition
The concept of holistic nursing is retained in the
ninth edition. An attempt has been made to ensure
that the physical aspects of psychiatric-mental health
nursing are not overlooked. In all relevant situations,
the mind/body connection is addressed.
Nursing process is retained in the ninth edition as
the tool for delivery of care to the individual with a psy-
chiatric disorder or to assist in the primary prevention
or exacerbation of mental illness symptoms. The six
steps of the nursing process, as described in the
American Nurses Association Standards of Clinical Nurs-
ing Practice, are used to provide guidelines for the nurse.
These standards of care are included for the DSM-5
diagnoses, as well as those on the aging individual, the
bereaved individual, survivors of abuse and neglect, and
military families, and as examples in several of the ther-
apeutic approaches. The six steps include:
Assessment: Background assessment data, including
a description of symptomatology, provides an ex-
tensive knowledge base from which the nurse may
draw when performing an assessment. Several
assessment tools are also included.
Diagnosis: Nursing diagnoses common to specific
psychiatric disorders are derived from analysis of
assessment data.
Outcome Identification: Outcomes are derived from
the nursing diagnoses and stated as measurable
goals.
Planning: A plan of care is presented with selected
nursing diagnoses for the DSM-5 diagnoses, as well
as for the elderly client, the bereaved individual,
victims of abuse and neglect, military veterans and
their families, the elderly homebound client, and
the primary caregiver of the client with a chronic
mental illness. The planning standard also includes
tables that list topics for educating clients and fam-
ilies about mental illness. Concept map care plans
are included for all major psychiatric diagnoses.
Implementation: The interventions that have been
identified in the plan of care are included along with
To the Instructor xix
rationales for each. Case studies at the end of each
DSM-5 chapter assist the student in the practical
application of theoretical material. Also included as
a part of this particular standard is Unit 3, Therapeu-
tic Approaches in Psychiatric Nursing Care. This
section of the textbook addresses psychiatric nursing
intervention in depth and frequently speaks to the
differentiation in scope of practice between the basic-
level psychiatric nurse and the advanced practice–
level psychiatric nurse.
Evaluation: The evaluation standard includes a set of
questions that the nurse may use to assess whether
the nursing actions have been successful in achiev-
ing the objectives of care.
Following are additional features of this ninth
edition:
■ Internet references for each DSM-5 diagnosis, with
website listings for information related to the
disorder.
■ Tables that list topics for client/family education
(in the clinical chapters).
■ Boxes that include current research studies with
implications for evidence-based nursing practice
(in the clinical chapters).
■ Assigning nursing diagnoses to client behaviors
(diagnostic chapters).
■ Taxonomy and diagnostic criteria from the DSM-5
(2013). Used throughout the text.
■ All references have been updated throughout the
text. Classical references are distinguished from
general references.
■ Boxes with definitions of core concepts appear
throughout the text.
■ Comprehensive glossary.
■ Answers to end-of-chapter review questions
(Appendix A).
■ Answers to communication exercises (Appendix B).
■ Sample client teaching guides (online at www
.davisplus.com).
■ Website. An F.A. Davis/Townsend website that con-
tains additional nursing care plans that do not ap-
pear in the text, links to psychotropic medications,
concept map care plans, and neurobiological con-
tent and illustrations, as well as student resources
including practice test questions, learning activities,
concept map care plans, and client teaching guides.
Additional Educational Resources
Faculty may also find the teaching aids that accompany
this textbook helpful. These Instructor Resources are
located at www.davisplus.com:
■ Multiple choice questions (including new format
questions reflecting the latest NCLEX blueprint).
■ Lecture outlines for all chapters
6054_FM_i-xx 16/08/17 2:42 pm Page xx
xx To the Instructor
■ Learning activities for all chapters (including
answer key)
■ Answers to the Critical Thinking Exercises from the
textbook
■ PowerPoint Presentation to accompany all chapters
in the textbook
■ Answers to the Homework Assignment Questions
from the textbook
■ Case studies for use with student teaching
Additional chapters on Theories of Personality
Development, Relaxation Therapy, Complementary
and Psychosocial Therapies, and Forensic Nursing are
presented online at www.davisplus.com.
It is hoped that the revisions and additions to
this ninth edition continue to satisfy a need within
psychiatric-mental health nursing practice. The mis-
sion of this textbook has been, and continues to be, to
provide both students and clinicians with up-to-date
information about psychiatric-mental health nursing.
The user-friendly format and easy-to-understand lan-
guage, for which we have received many positive com-
ments, have been retained in this edition. We hope that
this ninth edition continues to promote and advance
the commitment to psychiatric/mental health nursing.
Mary C. Townsend
Karyn I. Morgan
6054_Ch01_001-011 27/07/17 5:24 PM Page 1

UNIT 1
Basic Concepts in
Psychiatric-Mental
Health Nursing
6054_Ch01_001-011 27/07/17 5:24 PM Page 2

CORE CONCEPTS
Adaptation
1 The Concept of Stress
Adaptation
CHAPTER OUTLINE
Objectives Stress Management
Maladaptation Homework Assignment Summary and Key Points
Stressor Stress as a Biological Response Review Questions
Stress as an Environmental Event
Stress as a Transaction Between the Individual
and the Environment

K EY T E R M S
adaptive responses maladaptive responses
fight-or-flight syndrome precipitating event
general adaptation syndrome predisposing factors

O B J EC T I V E S
After reading this chapter, the student will be able to:

1. Define adaptation and maladaptation. 5. Explain the concept of stress as a transaction

2. Identify physiological responses to stress.
3. Explain the relationship between stress and
“diseases of adaptation.”
4. Describe the concept of stress as an environ-
mental event.
between the individual and the environment.
6. Discuss adaptive coping strategies in the
management of stress.

HOMEWORK ASSIGNMENT
Please read the chapter and answer the following questions:

1. How are the body’s physiological defenses
affected when under sustained stress? Why?
2. In the view of stress as an environmental
event, what aspects are missing when
considering an individual’s response to a
stressful situation?
3. In their study, what event did Miller and
Rahe (1997) find produced the highest
level of stress reaction in their participants?
4. What is the initial step in stress
management?

Psychologists and others have struggled for many
years to establish an effective definition of the term
stress. This term is used loosely today and still lacks
a definitive explanation. Stress may be viewed as an
individual’s reaction to any change that requires an
adjustment or response, which can be physical, men-
tal, or emotional. Responses directed at stabilizing
internal biological processes and preserving self-
esteem can be viewed as healthy adaptations to
stress.
Roy (1976), a nursing theorist, defined an adaptive
response as behavior that maintains the integrity of
the individual. Adaptation is viewed as positive and is
correlated with a healthy response. When behavior

2
6054_Ch01_001-011 27/07/17 5:24 PM Page 3

CHAPTER 1 ■ The Concept of Stress Adaptation 3

disrupts the integrity of the individual, it is perceived Stress as a Biological Response

as maladaptive. Maladaptive responses by the individ-
ual are considered to be negative or unhealthy.
Various 20th-century researchers contributed to
several different concepts of stress. Three of these
concepts include stress as a biological response,
stress as an environmental event, and stress as a
transaction between the individual and the environ-
ment. This chapter includes an explanation of each
of these concepts.
CORE CONCEPT
Stressor
A biological, psychological, social, or chemical factor
that causes physical or emotional tension and may con-
tribute to the development of certain illnesses.
In 1956, Hans Selye published the results of his re-
search on the physiological response of a biological
system to an imposed change on the system. Since his
initial publication, his definition of stress has evolved
to “the state manifested by a specific syndrome which
consists of all the nonspecifically induced changes
within a biologic system” (Selye, 1976). This combi-
nation of symptoms has come to be known as the
fight-or-flight syndrome. Schematics of these biologi-
cal responses, both initially and with sustained stress,
are presented in Figures 1–1 and 1–2. Selye called this
phenomenon the general adaptation syndrome. He
described three distinct stages of the reaction:
1. Alarm reaction stage: During this stage, the physi-
ological responses of the fight-or-flight syndrome
are initiated.

HYPOTHALAMUS

Stimulates

Sympathetic Nervous System

Innervates

Adrenal Eye Lacrimal Respiratory Cardiovascular GI system Liver Urinary Sweat Fat
medulla glands system system system glands cells

Pupils Bronchioles Gastric and Ureter Lipolysis

dilated dilated intestinal motility
Respiration motility Bladder
rate increased Secretions muscle
Sphincters contracts
contract Sphincter
relaxes

Norepinephrine Secretion Force of cardiac Glycogenolysis Secretion

and epinephrine increased contraction and
released Cardiac output gluconeogenesis
Heart rate Glycogen
Blood pressure synthesis

FIGURE 1–1 The fight-or-flight syndrome: The initial stress response.

Another random document with
no related content on Scribd:
 Pivoted Searchlight Made of an Old
Milk Strainer
By JOHN J. SPAULDING

Both as a safety device and a practical novelty, a homemade

searchlight for a canoe, or other small craft, is worth while making.
An old milk strainer was used for the reflector of that shown, and
many equally serviceable makeshifts can be devised easily from old
cans, or formed from sheet metal. The detailed construction, as
indicated, is suggestive only, since local conditions and materials
available will govern the design of the fittings. The light has a double
control, one cord governing the vertical adjustment, and another,
arranged like that of a ship’s wheel, the horizontal pivotal range. The
vertical adjustment is desirable, but not essential. The control cords
are run in screw eyes along the coaming of the craft, so that one
person can paddle the canoe, and adjust the searchlight as well. Dry
cells, stored under the bow deck, or in a box set at some other
convenient place, supply the current for the 6-volt lamp.
 Canoeing and Boating at Night Is
Safer and More Pleasurable if the
Craft is Equipped with a
Searchlight. This One was Made of
Pick-Up Materials at Small Cost

The Support for the Reflector is

Pivoted in the Deck, Reinforced as
Indicated

The main dimensions of the fittings, as detailed, are: strainer, 10

in. in diameter and 10 in. long; vertical support, 12¹⁄₂ in. over all, and
6 in. wide at the upper portion; the wood used is ¹⁄₂ and ³⁄₄ in. thick,
except that for the pivot post, which is 1 in. thick. The reflector is
fitted with a wooden block through which the porcelain socket is set,
as shown. A knife switch, placed near the stern of the craft, controls
the connection with the battery circuit.
The inside of the reflector should be polished with emery cloth,
and if the surface is rough, it may be painted with white enamel. The
outer surfaces of the metal part are painted black. The wooden parts
may be painted, or given several coats of spar varnish, to withstand
the weather.
Gravity-Feed Coal Hopper on Truck
 The Large Capacity of the Hopper and the Ready Portability of This
Arrangement Are Practical Features

In the large farm kitchen, in the workshop, and even for firing a
small furnace, a coal hopper that will hold considerable coal, and
that can be rolled along the floor easily, is a convenience. Such an
arrangement, made from a section of galvanized-iron pipe, 10 in. in
diameter and 30 in. long is shown in the sketch. The pipe was cut at
one end, as shown, so that when the coal was poured into the
hopper, it would feed out. A truck, mounted on casters, was made,
12 in. wide, 5 in. high, and 25 in. long. The hopper was mounted on
one end of it, and bolted securely at the sides and end. The coal is
shoveled into the hopper at the bin, and the load pushed to the
furnace, where it can be easily used as needed. The construction
can be made larger for use with a coal scoop, in firing a boiler or
large furnace.—L. R. Markwood, Factoryville, Pa.
 Taking Photographs in Falling Snow
Falling snowflakes in a camera photograph—the large feathery,
slow falling kind—often make an exquisitely beautiful picture out of a
commonplace scene. And while the great majority of the attempts to
get them prove failures, the photographer—usually an amateur-
needs only to provide an avenue in front of his lens a short distance,
that is free from falling flakes by the use of a shelter such as a tree
or porch. The slow snapshot necessary in cloudy weather will not
stop the motion of the flakes nearest the camera and these passing
through greater angles of space in equal length of time than those
farther away, will blur on the negative. We made some excellent
outdoor views in deep snow, while heavy snow was falling, with
flakes splendidly decorating the darker regions of figures and foliage,
by holding a felt hat and two umbrellas in a line in front of the
camera, and above the range of the lens.—J. Cecil Alter, Cheyenne,
Wyo.
 A Double-Contact Vibrator

When the Vibrator Touches One Contact, the Coil on the Opposite Side
Attracts the Vibrator, This Process being Repeated Alternately

A double-contact vibrator, which eliminates sticking contacts,

spring troubles, and other sources of annoyance, in addition to
producing a fine high tone, is shown in the sketch. It is an instrument
easy to construct, by reason of its simplicity. Special care in making
the vibrator D will insure good vibration. The springs, holding the
contacts, are of phosphor bronze The contacts may be made of
silver platinum, or other metals, which will not burn and break
contact. The coil B are of the common bell-ringing type. The springs
on the vibrator should not be too long, nor too weak; experimenting
will determine the length at which they will work best. The
adjustment is made at the thumbscrews A. The coils are supported
on metal brackets, bolted to a wooden base. The method of hooking
up the vibrator in the key circuit is shown in the diagram.—J. L.
Taylor, Barker, N. Y.
 Battery Buzzer Converted into a Telegraph
Sounder

The Amateur can Practice the Morse Code Handily on This Sounder, Made
from a Buzzer

An ordinary battery buzzer may readily be converted into a

telegraph sounder for use in practicing the Morse code. All that is
necessary is to connect the vibrator contact C of the buzzer to the
binding post that is not insulated from the frame. The other
connections of the key and battery are the same as in any ordinary
telegraph or buzzer circuit. In the diagram, C represents the vibrator
contact; D, the wire connecting the contact and the uninsulated
binding post, and F, the uninsulated binding post; E is the telegraph
key, and B, the dry cells.—Clarence F. Kramer, Lebanon, Ind.
 Lawn Seats Built on Tree Stumps

These Practical Lawn Seats Show the Possibilities of Stumps as Supports

for This Purpose. The Conservation-Chair Design Is Especially Interesting

A practical use to which stumps, left from the felling of trees, are
put in a city park is as supports for lawn benches. This obviates the
need of grubbing them out, while the work of preparing them to
receive the seats is less than would be required to remove the
stumps. Of course, the location of the stump will determine whether
it is worth while as a support for a seat, or had better be grubbed out.
Many designs are possible, and the position and size of the stumps
available will suggest suitable construction. The woodwork for the
seats is simple, and the benches can be made removable for the
winter if desired.—C. L. Meller, Fargo, N. D.
A Hinged Box Cover Made without Hinges
 When a wooden box with a hinged cover is desired, especially a
small one, hinges are not always at hand, and are sometimes
difficult to obtain. Under these circumstances a good substitute is to
make the box as shown in the sketch, using the extension of one
end and nails, or screws, driven through the back corners of the lid,
as a hinge arrangement. This makes the use of hinges unnecessary,
and is serviceable even for permanent use. Where hinges projecting
from the surface of the box are objectionable, this method of
construction is especially desirable. It is best to make the hinged
ends with the grain vertical, and to round off the hinged corners of
the lid slightly.—R. J. Rohn, Chicago, Ill.
Automatic Flash Light Snaps Chicken-Coop
Marauder
This Photographic Evidence Was Proof Positive as to the Identity of the
Thief in the Night
 After the wire fence around the chicken house had been torn up,
and the place entered 13 nights in two weeks, I decided on more
preparedness. Various ways and means failed, so I used a
comparatively slight knowledge of photography in the process.
I mounted my flash lamp on a piece of board, 1 by 4 by 8 in. long,
and fastened this to a base, as shown. I attached a weight to the
lamp, which was supported by a hinged drop, halfway down the
upright board, which in turn was supported by a nail, to which was
attached a string. The flash was set off by a slight pull of the string,
which dropped the weight. This contrivance I concealed in the
chicken yard, and the camera in the chicken house. That night I
opened the lens of the camera in the dark, and attached the string to
a loose board in the fence. The next morning, before daybreak, I
closed the lens again. The flash had been set off during the night.
Also there were drops of blood on the ground. I could hardly wait
until the plate was developed. The result, as reproduced, was hardly
what I expected.—H. U. Scholz, Medford, Ore.
 A Fishing-Tackle Outfit in a Shotgun Shell
At the camp or on the trail, an emergency fishing-tackle outfit is
almost as handy as matches, compass, and knife, and it may even
be the means of saving one’s life. A convenient way to carry such an
outfit is in two old shotgun shells, telescoped. The hooks, on a cork,
and the sinkers are fitted snugly into the shell. Several yards of line
are then wound on the outside. This outfit can be stowed into a
pocket handily, always ready for use.—E. Everett Buchanan, Jr.,
Elmira, N. Y.
 A Split-Bamboo Lettering Pen

This Pen, Cut from a Piece of Bamboo and Fitted with a Spring Fountain
Device, Is Especially Useful for Marking Packages

Marking of packages and similar lettering can be done neatly with

a pen made in a few minutes from split bamboo fitted with a short
section of watch spring. Select a piece of bamboo, ¹⁄₄ by ¹⁄₁₆ in. and
about 7 in. long, and finish the end, as at A. Trim the end to an
angle, as at B, and then point it, as at C. Split the point carefully, as
at D, and smooth away the tufts at the edges. Cut a piece of watch
spring the width of the pen point and bind it into place, arched as
shown. To use the pen, insert ink into the arch of the spring, and it
will work much like a fountain pen.—Raymond H. Lufkin, Dorchester,
Mass.
 How to Make a Houseboat
By H. SIBLEY

Thewithhouseboat shown is of the scow design, 6 ft. wide by 20 ft. long,

the cabin extending beyond the scow 1 ft. on each side. The
scow tapers up at the forward end and is protected with a heavy
sheet-iron plate so that the craft may be snubbed up on sandbars
without danger of springing a leak, even though a submerged log be
struck while running at full speed.
The power plant consists of a standard 4-hp. reversing gasoline
engine which drives the paddles at their most efficient speed, 45
revolutions per minute through a 13-to-1 reduction. Cast-iron hubs,
into which are inserted cold-rolled steel spokes, and wood paddles
bolted to their ends constitute the propeller wheels. The cruising
speed is about 4 miles an hour.