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THERAPEUTIC RELATIONSHIP- one in which the nurse
and patient experience mutual trust and respect.
Purpose: -assist the patient in gaining insight and to
encourage the patient to make necessary changes.
Therapeutic use of self- how the nurse uses her
experience and education in the process of therapeutic
-believed to be the most important
factor in therapy
Four phases of
therapeutic relationship
Develop self-awareness of feelings, fears
Conduct a self-assessment of professional assets and
Research any information available; review records
Plan meeting with patient

 Determine patient’s chief complaint
Based on complaint, help patient identify problems
Meet with patient
Establish trust through open communication
Define, in collaboration with patient, patient goals
Explore insight, judgment, stressors, feelings
Recognize and work through resistance to therapy
Assess implementation of coping mechanisms
Begin to prepare for termination

Evaluate accomplishment of goals
Resolve feelings of rejection, sadness or loss related to
termination of therapy
Evaluate general progress of therapy
Help patient to define next step in therapy, if necessary
Guidelines for
After the initial interview, a therapeutic communication
process is established.
Empathetic communication- a skill acquired through self-
awareness and perceptive listening.
The following guidelines can be integrated so the patient is
the focus of the verbal and non-verbal interaction.
 Be congruent in what you are saying and what your body
language is conveying.
Use clear, concise words that are adapted to the
individual’s intelligence and experience.
Do not say “I understand” or “You’ll be okay”. Nonverbally
or verbally say, “I care about you” or “I want to help you”.
Use appropriate silence to give the patient time to organize
his thoughts and respond.
Let the patient set the pace of the interaction– do not hurry
Accept the patient as he is, without making judgments.
Offer a collaborative relationship in which you are willing to
work with the patient in resolving problems and making
Use open-ended questions to encourage expression of
feelings and thoughts.
Explore ideas completely. Do not drop a subject that the
patient has introduced without some resolution.
Clarify statements and relationships when necessary. Do
not try to read the patient’s mind or interpret what he says.
Give positive feedback every chance you get. Praise
the patient for communication and attempts at
problem-solving or decision making.
Encourage expression of feelings.
Paraphrase statements and feelings to facilitate
Translate feelings into words so that hidden meanings
can be discovered.
Focus on reality, especially if the patient
misinterprets facts or if he is misinterpreting the truth.
Offer teaching and information, but avoid giving
Search for mutual, intuitive understanding. Encourage
the patient to ask for clarification if he does not
understand what is being said. Do not use phrases or
slang that can be misunderstood.
Encourage an appropriate plan of action, such as
problem solving or self care.
Summarize at the end of the conversation to focus on
the important points of the communication and
validate the patient’s understanding.
Remember, the more personal and intense a feeling
or thought is, the more difficult it is to communicate.
Give the patient time to express his deepest feelings.
The keyword is listen.
Provide the patient with an atmosphere where
emotional catharsis can be experienced.
Recognize and work through transference, if it
Recognize and work through countertransference, if
it occurs.
Barriers to
In communicating with psychiatric patients, the nurse
should be aware of actions that block communication:
oUsing inappropriate clichés or words that the patient
does not understand.
oInferring to the patient that you are in a hurry or
preoccupied with other tasks.
oShowing anger or anxiety, especially when these
feelings provoke an argument with the patient.
oIncorrectly interpreting what the patient expresses.
oOffering therapy when the timing is wrong or when the
patient is not ready to hear what is being
oGiving false reassurance about progress.
oDiscounting the patient’s feelings by stating “I
oExpressing opinions and giving advice, especially
when these feelings provoke an argument with the
oBeing insincere.
oInterrupting while the patient is talking.
oTransference that cannot be resolved between the
patient and the therapist.
oCountertransference that cannot be resolved by the
oShowing disrespect for or ignoring communication
with family members or significant others.
Psychiatric health
Name: ___________________________________________________
Age: ________________________Marital Status: _______________
Sex: ________________________Occupation: _________________
Family history of psychiatric illness:_______________________
Suicidal tendencies:______________________________________
Dates, treatment: _________________________________________
Substance abuse:_________________________________________
Physical Abuse:__________________________________________
Sexual abuse:____________________________________________
Mood swings:_____________________________________________
Aggressive behavior:______________________________________
Level of stressors:________________________________________
Post-traumatic response:_________________________________
Coping skills:_____________________________________________
Nutritional Status:________________________________________
Sleep patterns:___________________________________________
Physical limitations:_______________________________________
Alcohol use:______________________________________________
Stress-related illnesses:___________________________________
Chief complaint:__________________________________________
Precipitating event of present problem:____________________
Circumstances under which symptoms began:_____________
Congruency of speech and affect:__________________________
Reality oriented
Rigidity in thinking
Loose associations
Word Salad
Flight of ideas
Clang association
Interpersonal relationships:______________________________
Support system:_________________________________________
Obsessive thoughts:_____________________________________
Ability to handle stressors:_________________________________
Ability to control behavior:_________________________________
Psychotropic medications:_________________________________
Occupational stressors:____________________________________
Financial stressors:________________________________________
Cultural factors:___________________________________________
Religious factors:__________________________________________
Significant losses:_________________________________________
Significant sexual history:__________________________________
Name: ___________________________________________________
Age:_________________________ Sex:___________________
Levels of Consciousness
Overly meticulous
Slapping gait
Bodily mannerisms
High energy
Low energy
Affect and Mood
Thought Processes
Somatic complaints
Suicidal plans
Suicidal thoughts
Cognitive Functioning
Attention span
General intelligence level
Ability to concentrate
Abstract thinking
Concrete thinking
Assessment of initial clinical interview
Defense mechanisms, or coping strategies, are
unconscious intrapsychic processes implemented to
cope with anxiety. The use of some of these
mechanisms is healthy, while the use of others is
A person overemphasizes one aspect of the
personality in an effort to make up for what he or she
considers a deficiency in another aspect.
An obese woman is obsessed about how her make
up and hair look. Or, a homely schoolgirl attempts to
impress her peers by making straight A’s.
The process of turning psychological conflicts into
physical symptoms. The patient often realizes some
secondary gain from the pain.
A wife is told her husband is having an affair, and she
starts having headaches. He calls through the day
checking to see how she is feeling.
This is usually refusal to recognize or deal with reality. A
protective mechanism is utilizes in traumatic situations when a
person cannot comprehend the overwhelming onslaught of
tragedy. However, denial can be maladaptive if it persists
without resolution.
A mother refuses to participate in funeral arrangements after
her child is killed in a car wreck.
A man comes to the emergency room with chest pain,
insisting he be treated only for indigestion, refusing to realize he
may be having a heart attack.
An unacceptable feeling, emotion, or reaction, such
as anger, is unconsciously discharged or transferred
toward someone or something other then the source of
the feeling.
The man comes home angry because his boss
chewed him out, and he kicks the dog.
The extreme imitation of another person who us feared or
respected. Characteristics of the person being imitated are
incorporated into the personality.
A boy who idolizes his father tells his new friends his
nickname is “Smokey.” this is his father’s nickname, not his .
The use of rational explanation to justify unacceptable
behavior or feelings.
An executive who has just been admitted to a chemical
dependency unit attempts to convince the other patients that
he us different because of his professional and financial
The incorporation of another person’s values into
one’ own lifestyle and philosophy.
A college student follows his parents’ instruction to
abstain from casual sex.
The process in which an individual attributes his or
her own feelings to others.
An adolescent who is hostile towards his parents
states that the parents are hostile to him.
The process of justifying one’s behavior by using an
excuse that is directed toward another person or situation.
The reasons used to explain unacceptable behavior are often
exaggerated and untrue.
A student fails an exam and blames it on poor lectures by
the instructor.
Behavior that is directly opposite of the way the person
actually feels. This is typically passive-aggressive behavior.
A secretary is very nice and polite to her boss, but actually
dislikes him and talks about him negatively to others.
Falling back into an earlier mode of behavior and
feelings that is more comfortable and less demanding.
A six-year-old boy assumes a fetal position and starts
wetting the bed after he is told his parents are getting a
The unconscious process of blocking painful or
threatening thoughts, feeling, and experiences from the
conscious so that the painful issues are not controlled or
A woman who was sexually abused as a child blocks the
experience from her conscious and is confused about her
inability to respond sexually to her husband.
Directing sexual or aggressive impulses into a more
socially accepted activity.
The football star would like to have sex with his girlfriend
but puts all of his energy into playing the sport.
The conscious process of ignoring painful thoughts
or impulses.
A man agrees to go to marriage counseling with his
wife and “forgets” to show up for the appointment. (This
may also be resistance to therapy.)
Words or behavior that attempt to annul actions that
have met disapproval or caused feelings of guilt.
A husband goes on a drinking binge and the next day
sends his wife flowers.
-Anxiety is a vague sense of apprehension or impending dread that
something as yet unknown is going to happen.
oIncreasing awareness
oPositively motivated
oSlight irritability
oMotivated toward learning and creativity
oStimulated toward action
oSlight increased in vital signs
oBeginning to be restless

oHeadaches oPalpitations
oNausea oRestlessness
oSweating oPerceptions begin to alter
oHeightening tension oSlight increase in vital signs
oAlert but focus narrows oCommunication decreases
oConcentration decreases
oUrinary frequency

oPerceptions become oIntense feeling of dread or

distorted threat
oCommunication becomes oDramatic increase in vital
distorted signs
oDiarrhea oDiaphoresis
oPalpitations oChest pain
oNausea and vomiting

oFeelings of terror oReality distorted

oUnable to communicate oCannot attend to details
oPotential for violence to self oFight/flight instincts take
and others over
oCannot carry out ADLs
oIncreasing vital signs in early
stage of panic, but vital signs
may suddenly drop in panic
sustained without relief or
oNervous oSomatic symptoms:
o Restlessness
o Muscle tension
oIrritable o Breathlessness
oRapid speech o Chest pain/tightness
o Palpitations
o Sweating
oTearful o Headache
oClenches jaws o Fatigue
o Insomnia
oTalks in vague terms
o Dysphasia
oPacing o Nausea/vomiting
oDemanding of others o Diarrhea
o Anorexia
Expresses feelings of:

oCLIENT NEED: Psychosocial integrity

Listen to patient; Talking helps to alleviate anxiety
Provide the patient with a structured environment, as
Help patient identify the source of anxiety
Encourage physical activity, such as walking when agitated
Facilitate development of insight between feelings,
thoughts, actions
Empathize with the distress, according to the level of
Discover with patient what helped to relieve anxiety in the
Help patient identify behaviors that increase anxiety
Recognize cognitive distortions and give feedback to
correct them
Help patient recognize how he sets himself up in a stress
crisis cycle
Administer medications, if prescribed
Encourage relaxation techniques, diaphragmatic breathing,
Patient teaching
Relaxation techniques
Guided imagery
Teach benefits of biofeedback, how it works to relieve
Side effects of medication
Diaphragmatic breathing
Visualization techniques
Effective coping mechanisms to modify response to stress
Teach alternatives in handling stressors one at a time as
they arise.
Nursing diagnoses
Anxiety Coping, ineffective
Communication, impaired
verbal Sensory/perceptual
Family coping, compromised
ineffective Hopelessness
Fear Noncompliance
Knowledge deficit Self-esteem, situational low
Post-Traumatic stress
PTSD is a syndrome of psychological and physical symptoms
that occur following a dramatically traumatic event. The
symptoms may not appear until months after the experience.
The symptoms usually appear when the patients “relives” the
event in some way (such as in flashbacks or nightmares).
• Cycle of anxiety and depression
• Nightmares
• Emotional or physic, numbing (The tendency to separate
oneself from emotions)
• Panic
• Anger
• Fear
• Memory Impairment
• Suicidal Ideation
• Anhedonia (Absence of pleasure living)
• Impulsive
• Rage/ Violence upon impulse
• Obsessive thoughts
• Employment record (Often unable to hold a job related to
difficulty with authority figures)
• Guilt (For being a survivor)
• Isolated
• Difficulty concentrating
• Insomia
• Flashbacks
•Difficulty controlling emotions
Client need
• Psychosocial Integrity

• Establish a trusting, therapeutic relationship
• Discover the circumstances surrounding the traumatic
• Focus on the reality of present event instead of the past
• Encourage participation in group therapy
• Encourage patient to resume responsibility for behavior and
• Help patients gain insight into victim role and to break away
from it.
•Administer anti-anxiety agents: often Xanax is prescribe.
• Instruct patients to restructure outcome by relieving
traumatic event (restricting, with the help of a skilled
therapist, may help the patient to resolve the dysfunctional
response to the trauma).
• Discuss with patient how trauma is causing psychological
• Encourage significant others to participate in therapy.
Patient teaching
• Teach relaxation techniques, such as diaphragmatic breathing.
• Teach significant others to be supportive.
• Teach patient that PTSD is a chronic condition.
• Teach alternative ways to cope with stressors

Associated nursing
• Anxiety
• Grieving, dysfunctional
• Non-compliance
• Hopelessness
• Social Isolation
• Social Interaction, impaired
• Coping, ineffective individual
• Fatigue
• Family processes, altered
• Fear
• Powerlessness
• Violence, high risk for
• Family coping, disabled, ineffective
• Personal Identity disturbance
Dysfunctional Grieving
Grieving is considered to be a dysfunctional when the period of
bereavement and mourning lasts for more than six months. The
acute period of grieving usually last from three to twelve weeks.

• Allow the patient time to work through the initial stage of denial
(A protective mechanism for coping with a loss).
• Social Isolation.
• Nutritional status
• Weight loss
• Suicidal Ideation or plans
• Degree of ambivalence in the relationship (Ambivalence may
complicate moving through the grieving process).
• Helplessness or hopelessness
• Insomnia
• Depression

Client need
• Psychosocial Integrity

• Encourage patient to talk about loss, ventilate feelings
• Encourage participation in grief support groups
• Encourage significanct others to be supportive
• Be with patient for short periods rather than staying for long
time (Allow sometime alone)
• Allow patient reminisce about positive experiences and
loved ones
• Administer anti-anxiety or anti-depressant medication very
• Allow patient to cry or express anger

Patient teaching
• Teach the importance of support group therapy
• Tell the patient about the stages of death and dying and
help him to identify where he is in the grief process

Associated nursing
• Adjustment, impaired
•Coping, ineffective individual
• Denial, ineffective
• Family processes, altered
• Grieving Dysfunctional
• Personal identity disturbance
• Hopelessness
• Social isolation
• Sleep pattern disturbance
• Anxiety
• Family coping, compromise, ineffective
• Decisional conflict
• Home maintenance management, impaired
• Fear
• Nutritional: less than body requirements, altered
•Social interaction, impaired
Stage of death and dying
Elisabeth Kubler-ross
Stage 1: shock and denial
Initial reaction is shock, followed by denial of the event. At
first, denial is a protective mechanism to help the patient
deal with the initial onslaught. However, if denial persists, it
may become a mal adaptive defense mechanism.

Stage 2: Anger
The patient become increasingly frustrated, irritable, and
then angry. He or She asks “Why Me?” the patient may be
increasingly difficult to handle. The anger may be directed at
self or others.
Stage 3: Bargaining
Patient attempts to negotiate with friends, physicians, or
God to escape ordeal.
Stage 4: Depression
Patient begins to show signs of helplessness and
hopelessness, insomnia, withdrawal and possibly suicidal
Stage 5: Acceptance
Patient knows that death or loss is Inevitable and accepts
the universality of what is happening in his or her life

These stages apply to any grief process whether the person

has lost a loved one has been told they are suffering a
terminal illness, has suffered a loss such as divorce or
bankrupicy, or suffered a disturbance in body image, such
as in amputation or mastectomy.
Depression is a pathological response to a loss or
disappointment, unresolved conflicts, unmet emotional
needs, or chronic stressors. It is characterized by guilt,
withdrawal, hopelessness, and repressed anger.

• Helplessness
• Fatigue
• Weight loss or gain
• Risk of suicide
• Family history of depression
• Level of anxiety
• Relationship to significance others
• Methods of coping with anxiety, stressors
• Past losses that may not be resolve
• Appropriateness for ECT (If depression has not responded to other treatment)
• Hopelessness
• Psychomotor retardation
• Nutritional status
• Suicidal plan
• Medications that may cause depression
• Support system
• Anger, especially if repressed or turn inward
• Number of significant stressor at any given time
• Recent loss
• Weakness
Nursing invention
• Assist with ADLs if severely depress
• Establish contract if patient expresses suicidal ideations
• Encourage proper nuitrition and fluid intake
• Offer non judgemental acceptance
• Encourage the patient to regain internal control
• Monitor for any self destructive environment with purposeful activities
• Facilitate expression of anger, guilt, helplessness through supportive
• Help patient to resolve loss related to depression
• Help patient resolve negative thinking throught cognitive therapy
• Administer medication as prescribe
Patient teaching
• Informed the patient that it may take two weeks for anti-
depressants to take effect
• teach side effects of medication
• Teach that depression may be related to certain physiological
or chemical imbalances and that medication may fill the gap
• Teach patient that depression is often related to loss

Associated nursing diagnosis

• Activity and tolerance, high risk for
• Fatigue
• Family Coping, compromised, ineffective
• Fear
• Grieving, dysfunction
• Nutrition; less than body requirements, altered
• Anxiety
• Social Isolation
• Violence, high risk for self directed at others
• Denial, Ineffective
• Coping, Ineffective individual
• Grieving, anticipatory
• Hopelessness
• Social Interaction, impaired
• Sleep pattern disturbance
Suicide is the intentional planned act of taking ones own life. In
psychiatric nursing the term suicide may be used
interchangeably with suicidal ideation, gestures or plan.

• Potential for suicide, especially plan
• Support systems
• Ability to implement coping mechanism
• Possibility of a suicide pact, especially with adolescent
• Signs of self destructive behavior
• Perception of patient problem of circumstances
• Coping abilities
• Recent significant loss that has not been resolved
• Potential for impulsive behavior, especially self-destructive
• History of suicide in family

Client need
• Psychosocial integrity

• Suicide precautions
• Restrain, if necessary, to provide for safety
• Document, in detail, all contacts with the patient
• Search belongings for dangerous objects
• 1:1 supervision prn
• Encourage patient to verbalize feeling
• Negotiate contact that patient will seek help if suicide impulse
• Explore alternatives and assist in problem-solving
Associated nursing diagnoses
• Family coping, compromised, ineffective
• Anxiety
• Hopelessness
• Knowledge deficit
• Trauma, high risk for
• Coping, Ineffective individual
• Fear
• Injury, high risk for
• Powerlessness
• Spiritual distress: distress of human spirit
It is estimated that 14-20 million Americans are alcoholics. Another 60
million are indirectly affected by alcoholism as significant others, family
members, or co-workers. An alcoholic is a person who drinks alcohol (in
any form) ona a regular basis, and this drinking causes a problem, This
may be any kind of problem: financial. Interpersonal relationships, job-
related, or driving while intoxicated.

• Orientation
• Ederna (Indicative of poor circulatory status)
• Kind of alcohol ingested
• How much alcohol is ingested regularly
• History of blackouts
• Disorientation
• Hallucination
•Suicidal Ideayions
•Weight loss
•Recent Trauma (from injuries while drunk)
•How often alcohol is ingested
•Ability to implement coping mechanisms
•Paranoid ideations
•Delirium tremes (DTs)(onset 24-72 hours after last drink)
Withdrawal Symptoms
•Loss of appetite
•Inability to concentrate
•Uncoodinated movements

Wernicke’s syndrome
•Clouding of consciousness
•Paralysis of eye nerves
•Thiamine deficiency
•General malnutrition
•Memory loss

korsakoff’s Syndrome
•Peripheral neuropathy
•Memory loss
•Nutritional deficiencies thiamine and niacin
Characteristics of the alcoholic personality:
• Low Frustration tolerance
-The alcoholic uses the frustrations of daily stressors as an excuse to
• Anger
-The alcoholic is often angry about his dependency and circumstances of
his life in general. He has much difficulty expressing this anger in positive
ways, and drinking allows for this ventilation.
• Dependence-independence
-A conflict between the desire to be independent and the need to be
dependent exist with the alcoholic .He uses drinking to resolve the conflict,
which, of course, is never resolved.
• A feeling of power
-The alcoholic has a need to be powerful, in control, important, and
respected. The feeling is often frustrated, and he uses this is an excuse to
• Underlying Depression
-Depression is believed to be the primary stimulus for the person to start
drinking. Initially, the alcoholic may feel some relief, but ultimately, drinking
only intensifies the depression.
• Denial
-This defense mechanism is commonly used by alcoholics. Alcoholic may
deny how much he drinks, that drinking is a problem or that he even drinks at
all. He also may use projection (to blame others) or rationalization (to justify
action) when drinking does cause a problem.

Acute phase:
• Monitor I&O
• Implement appropriate safety measures if patient confused
• Monitor for withdrawal symptoms
•Orient to reality if disoriented or confused
•Changes in vital signs
•Check stool for blood
•Assist patient to overcome denial that alcohol is a problem
•From 24-74 hours following admission, monitor for DTs
•Administer thiamine supplements, if prescribed.
•Be aware of the alcoholic personality and do not allow for
•Provide quiet structured environment
•Observe for oversedation if medication is prescribed
•Avoid sudden movements when approaching patient (especially
if delusional or hallucinating)
•Administer Librium according to withdrawal protocol
•Encourage high protein, high calorie diet
rehabilitation phase
•Help patient to establish effective coping skills.
•Treat depression with psychotherapy and medications, as
•Help patient gain in sight into taking responsibility for own
•Instruct that alcohol affects every system and organ in the body
•Teach that denial of alcoholism and codependency is the most
common barrier to effective treatment
•Teach that a strong support system is essential in maintaining
•Instruct women of the dangers of alcohol to the infant while
pregnant (fetal alcohol syndrome is the most common cause of
mental retardation in children)
• Anxiety
• Decisional conflict
• Coping ineffective individual
• Family processes, altered
• Injury, high risk for
• Powerlessness
• Self-esteem disturbance
• Social isolation
• Sensory/ perceptual alterations
• Aspiration, high risk for
• Denial, ineffective
•Family coping, disabling, ineffective
•Nutrition: less than body requirements,altered
•Role performance, altered
•Sexual dysfunction
•Trauma, high risk for
•Violence, high risk for self-directed or directed at others
 An alcoholic patient has developed Korsakoff’s psychosis.
Which of these symptoms is associated with this condition?
1. Delusions and fearfulness
2. Suspiciousness and paranoia
3. Amnesia and confabulation
4. Ideas of reference and tearfulness
Answers: 3. Amnesia and confabulation
Rationale: Amnesia and confabulation are symptoms related to the loss of short-term
memory. Confabulation occurs in an attempt to conceal the problem. The condition can
be traced to degenerative changes in the thalamus resulting from severe thiamine
Nursing process: Assessment
Client need: Psychological integrity
Substance abuse is a common, growing health problem in this country. Substances
most abused are marijuana, cocaine, heroin, barbiturates, sedatives, tranquilizers,
stimulants, narcotics, and inhalants.

signs of drug abuse:
•Change in the attitude or mood swings
•Defensive attitude concerning behavior
•New and unusual patterns of behavior
•Friends who use drugs
•Alterations in personal appearance
•Withdrawal from family relationships
•Change in performance at work or school

Signs of barbiturates, sedatives, tranquilizers:

•Decreased respirations
•Appears intoxicated
•Slurred speech
oDecreased heart rate
oUncoordinated movement
oSleeps more than 10 hours

Signs of marijuana:
•Red eyes
•Lack of coordination
•Very talkative
•Dry mouth
•Craving sweets
•Altered perceptions
•Lack of concentrations
Signs of cocaine:
•Increased heart rate
•Needle marks
•Paranoid ideations
•Intense euphoria, often followed by depression
•Increased blood pressure
•Sniffles, nose
•Extreme restlessness
Signs of heroin (others opiates include Morphine, Codeine, Demerol,
Lomotil, Dilaudid, Percodan, Talwin):
•Mood swings
•Skin abscesses
•Swollen lymph glands
•Rapid tolerance
•Quickly addictive
•Signs of withdrawal soon after last dose
•Insensitivity to pain
•Thrombosis of veins
•Depressed CNS function
•Depressed cardiac function
•Clouded mental function
Signs of hallucinogens (LSD, PCP, mescaline)
•Obsession with detail
•Increasing anxiety
•Unpredictable, dangerous
•Violence with PCP
•Nausea/ vomiting
•Flushed skin
•Increased pulse
•Mood swings
•Emotionally unstable
•Synaesthesia (sees sounds and smells colors)
•Panic attacks
•Altered perceptions
•Abdominal cramping
•Muscle twitching
Signs of inhalants:
•Fast high
•Watery eyes
•Lack of coordination
•Odor of substance
•Can cause sudden death from respiratory arrest or cardiac dysrhythmias
•Ringing in ears
•Nausea and vomiting
•Bad breath
•Uncontrolled behavior
Signs of narcotics:
•Not sensitive to pain
•Runny nose
•Needle marks
•Dilated pupils
•Watery eyes
•Nausea, vomiting
•Constricted pupils
•Cold, clammy skin
Signs of stimulants (Methamphetamine or speed, Dexedrine amphetamines):
•Weight loss
•Loss of appetite
•Increased blood pressure
•Loss of sleep
Signs and symptoms of withdrawal from drugs:
•Increasing restlessness
•Runny nose
•Insomnia or restless sleep
•Muscle spasms
•Abdominal cramping
•Watery eyes
•Dilated pupils
•Cold, clammy skin with goosebumps
•Back pain
Physiological integrity
Psychosocial integrity
•Determine type of drug abused
•Check neurologic reflexes
•Reorient patient, if confused
•Implement appropriate safety measures
•Determine stage of withdrawal
•Prepare to use restraints if necessary
•Confront patient if he is denying addiction
•Encourage patient to comply with biofeedback and relaxation
•Provide quite, structured environment
•Monitor changes in vital signs
•Treat symptoms for type of drug used and withdrawal
•Prepare for possible emergency
•Approach and/ or touch patient with caution Encourage adequate
nutritional and fluid intake
•Be alert that friend may try to smuggle drugs to patient
•Encourage patient to participate in group therapy
•Encourage patient to establish support system, such as Narcotics
•Administer medications as prescribed for withdrawal
•Educate patient and family about dangers of drug abuse
•Tell patient what to expect when withdrawal begins
•Teach alternative ways to handle stressors and develop new coping skills
•Emphasize that abstinence must become way of life
•Educate regarding addictive nature of the drug abused
•Teach the benefits of relaxation techniques, especially guided imagery and
• Activity intolerance
•Cardiac output ,decreased
•Family coping ,compromised,ineffective
•Injury, high risk for
•Personal identity disturbance
•Sexual dysfunction
•Skin integrity ,high risk for
•Thought processes ,altered
•Sleep pattern disturbance
•Airway clearance, ineffective
•Aspiration, high risk for
•Coping ,ineffective individual
•Nutrition :less than body requirements ,altered
•Sensory / perceptual alterations
•Role performance ,altered
•Self-mutilation ,high risk for
•Spiritual distress(distress of the human spirit)
•Violence ,high risk for: self directed or directed at others
-A delusional patient has false ,fixed beliefs that he holds
to ,despite proof that he is wrong .The delusional person
misinterprets and distorts reality in order to preserve
delusions. The delusional patient is usually paranoid
•Events that preceded delusional thinking
•Recent stressful events
•Nutritional status
•General content of delusions
•Potential for aggression or violence
•Suicide intentions/ plans
•Sensory misperceptions
•Pattern of activity before and during delusion thinking
•Psychosocial integrity
•Establish trusting ,Therapeutic relationship
•Avoid asking details about delusions (this may encourage
delusional thinking )
•Do not encourage competitive activities with others
•Suicide precautions
•Exercise moderation when approaching patient
•Communicate clearly in simple sentences
•Do not confront or argue
•Do not attempt to convince patient that delusions are not
true by participating in the event: for example, do not taste
patients food in order to convince him it is not poisoned
•Reinforce reality to environment and circumstances
•Attempt to assign same nurses to patient as much as
possible so patient can become familiar with staff
•Impose limits within environment for actions and verbal
•Reorient to reality prn
•Allow patient to participate in plan of care as much as
•Be consistent in scheduling visits
•Do not talk alone or whisper to others in patient’s presence
•Do not attempt to convince patient that delusions are not
true by participating in the event: for example, do not taste
patient’s food in order to convince him it is not poisoned.
•Inform daily schedules and explain any deviation form that if
changes occur
•Explain medication regimes
•Do not overemphasize any information as this may make
patient suspicious
•Coping, ineffective individual
•Injury high risk for
•Thought process, altered
•Denial, ineffective
•Family coping, disabling, ineffective
•Knowledge deficit
•Violence, high risk for: self-directed or directed at others
•Personal identity disturbance
•Self-esteem disturbance
•Communication, impaired verbal
Mania and depression are two poles of the same process,
thus the name, bipolar. Mania is a state of euphoria in which
the patient becomes hyperactive, excited and grandiose.
On the surface, the mania appears to be the opposite of the
depression. However, the manic state is also believed to be
a way of compensating for, or denying the presence of, the
• Impaired judgment
• Flight of ideas
• Level of agitation
• Inflated self-esteem
•Delusions of grandiosity
•Short attention span (easily distracted)
•Emotional labile (from euphoria to rage in seconds)
•Psychosocial integrity
•Provide quite, non stimulating environment
•Provide finger foods to eat while pacing around
•Monitor for injuries (may be too hyperactive to note injury
•Encourage compliance with medications, especially if
•Provide for short periods of sleep if unable to sleep at night
•Limit interpersonal interactions and competitive activities
with others
•Encourage exercise, such as walking, jogging, as an outlet
for energy
•Monitor fluid and electrolyte imbalances, especially
•Monitor lithium blood levels
•Sexually uninhibated
•Administer medications, if prescribed
•Listen attentively, being alert not to feed into grandiosity and
enhance manic behavior
•Limit foods and drinks that contain caffeine
•Observe sleep patterns
•Provide activities that will keep patient busy but not
overstimulate him
•Encourage salt intake of 3-6 g per day (Lithium is a salt and
reduce sodium intake can cause retention of Lithium and
subsequent toxicity)
•Instruct patient that adequate salt intake is essential to
prevent fluid and electrolyte imbalances
•Instruct patient the importance of taking Lithium as
•Instruct patient that Lithium may cause weight gain and
recommended exercise that will offset that additional weight
•Teach patient the importance of taking Lithium for life
•Coping ineffective individual
•Fluid volume deficit
•Personal identity disturbance
•Sexual patterns, altered
•Sleep pattern disturbance
•Social interaction, impaired
•Communication, impaired verbal
•Family processes, altered
•Injury, high risk for
•Nutrition: less than body requirements, altered
•Self-esteem disturbance
•Violence, high risk for: Self-directed or directed at others
•Self-care deficit: bathing, hygiene
Obsessions are recurring thoughts that become prevalent in
the consciousness and may be considered as senseless, or
repulsive. Compulsions are the repetitive acts that follow
obsessive thoughts. Compulsive rituals are performed to
temporarily reduce the anxiety that obsessions cause.
Common examples are washing, cleaning, counting, and
double checking.
•Level of anxiety
•Ritualistic activities
•Sexual activities
•Setting fires
•Level of anxiety, especially if escalating
•Neglect of ADLs in order to perform rituals
•Use of defense mechanism
•Ability to cope with stressors
•Nutritional status
•Isolation from others
•Level of magical thinking
•Level of regression
•Hand washing
•Use of medications
•Factors in environment that cause escalating anxiety
•Kind of ritualistic activity that relieves anxiety
•Precipitating event prior to compulsive behavior
•Ability to express negative or positive emotions
•Sleep patterns
•Level of rigidity in thinking
•Be cautious that patient has strong dependency needs
•Prevent injuries from rituals
•Do not interfere with rituals until anxiety is decreased (may
cause patient to panic)
•Allow time for the patient to perform rituals
•Be alert to increasing anxiety
•Focus therapy on the rituals and anxiety, not the individual
•Refer to support group, as appropriate
•Implement desensitization techniques to relieve anxiety
•Provide structured, yet flexible environment
•Assist patient in choosing alternative behaviors to
compulsive rituals
•Exercise limit-setting that will not increase anxiety
•Give patient specific times to exercise compulsive behavior;
gradually decrease those time periods
•Teach relaxation techniques and diaphragmatic breathing
•Instruct patient on responsibility of rituals that may be illegal
•Compulsive activities reinforce obsessions and more
compulsive behavior
•Relief on anxiety is only temporary
•Adjustment, impaired
•Communication, impaired verbal
•Family coping, disabling, ineffective
•Injury, high risk for
•Knowledge deficit
•Social interaction, impaired
•Self-esteem disturbance
•Social isolation
•Thought processes, altered
•Coping, ineffective individual
•Nutrition: less than body requirements, altered
•Role performance, altered
•Self-mutilation, high risk for
•Sleep pattern disturbance
•Violence, high risk for: self-directed or directed at others
-Borderline is a personality disorder in which the person
experiences impulsiveness, anger ,rage ,and self-destructive
tendencies. It is a difficult disorder to treat related to the
resistance of the patient to therapy.
•Intense anxiety
•May suffer episodes of depression with intense feeling and
•Exploitation of others
•Cannot integrate positive and negative qualities of oneself
or others; cannot see self as an integrated whole
•Uncannily manipulative
•Extremely dependent
•Paranoid tendencies
•Can become psychotic if under stress and abusing drugs
•Labile moods
•Explosive anger , rage
•Splitting: All or nothing attitudes ; sees everyone or
everything as either all good or all bad
•Self-destructive behavior
•Intense interpersonal relationships, may see other person as
all good, but may suddenly reverse and see the other
person as all bad
•Insatiable emotional needs
•Very demanding of staff
•Cannot tolerate being alone
Psychosocial integrity
• Assist the patient in finding ways to control emotions and
impulses, such as diaphragmatic breathing, relaxation
• Be aware of transference issues which are common with
patient (the borderline likes to defeat efforts the therapist)
• Encourage patient to accept responsibility in
interpersonal relationships
• Help patient find alternative ways to resolve conflict other
than self-destructive activities
•Administer biofeedback therapy as a way to tolerate
•Facilitate the integration of the positive and negative
qualities of the person and accept oneself as a whole
•Take appropriate safety measures to prevent self-
destructive behavior
•Teach family the danger of self-destructive tendencies and
take appropriate precautions when at home
•Diaphragmatic breathing to assist in controlling impulses
and anger
•Instruct family members on the characteristics of disorder,
particularly in regards to splitting, impulsiveness and anger
•Communication impaired verbal
•Family coping, compromised, ineffective
•Social interaction, impaired
•Injury, high risk for
•Coping, ineffective individual
•Violence, high risk for: self-directed or directed at others
•Self-mutilation, high risk for
Anorexia nervosa is an eating disorder in which food intake is
severely restricted. It most commonly occurs in adolescent
females. Bulimia is closely related to anorexia. The bulimic patient
gorges and then induces vomiting. Excessive use of laxatives is
also common. Bulimia may occur with anorexia often become
bulimic. However, bulimic patients are almost never anorexic. Most
adolescents who have eating disorders are high achievers in
academics and extracurricular activities, and compulsive
behaviors may be directed at these activities.
• Appetite
• Level of self-esteem
• Menstrual cycle (may cease)
•Use of laxatives
•Self-induced vomiting
•Muscle atrophy
•Family dynamics
-Control issues
-Tendency toward perfection
- Tendency toward overprotection
- Much difficulty resolving conflicts
- Mother and / or father domineering, perfectionist
• Serum albumin
•Thyroid function
•Electrolytes, especially potassium
• Psychosocial integrity
•Physiological integrity
•Encourage patient to eat with others
•Guide patient into creating a reasonable exercise program
•Praise patient if she has gained weight
•Encourage family members to participate in therapy
•Help her to gain insight related to unrealistic perceptions
of the body image
•Discourage patient from wearing tight-fitting clothes(she
may feel fat if clothes are tight )
•Allow patient to select foods from menu
•Weigh weekly; do not put much emphasis on this procedure
•Offer supportive therapy in resolving control issues
•Be confrontive regarding issues related to self-destructive
•If bulimia is suspected, stay with patient for 1-2 hours after
•Teach patient basic nutrition ,including the food pyramid ,
and her specific needs for growth and development
•Teach assertiveness skills
•Teach how family dynamics may be contributing to the
•Coping, ineffective individual
• Growth and development, altered
•Parental role conflict
•Sexual dysfunction
•Body image disturbance
•Constipation perceived
•Family coping, compromised, ineffective
•Nutrition: less than body requirements, altered
•Social interaction, impaired
•Personal identify disturbance
Antisocial is a personality disorder more common to men
and women and is characterized by charming manipulative-
ness, disregard for others, and open defiance of legal
authorities. The manipulation is an attempt to control
behavior of others for the purpose of gaining power and
control over other people and situations. Antisocial is a very
difficult disorder to treat because the patient sees no need
for change, and, therefore, is very resistant to change.
•Charming, often handsome
•Often exhibits illegal behaviors
•Always seeking quick gratification of needs
•No conscience
•Unable to maintain relationships
•Much difficulty with authority figures
•Will not take responsibility for actions
•Resistance to change because the patient does not see need
for change
•Does not learn from past mistakes or experiences
•Manipulates, lies without regard for others
•No sense of delayed gratification
•No sense of loyalty
•Cannot conform to rules or norms of society
•Sexually promiscuous, may marry many times
•Inclined to use drugs and alcohol
•Pretends to participate in therapy, but actually attempts to
manipulate it
Psychosocial integrity
• Provide consistency in setting limits
• Clearly communicate expectations and limits
• Provide consistency in setting limits
• Confront patient with patterns of behavior
• Provide positive verbal feedback when patient stay within
the limits set
• Facilitate gaining insight into failure of relationships
• Encourage patient to participate in therapy
• Encourage patient to seek therapy for alcohol and drug
abuse if these problems exist
•Assist patient in developing an awareness of the behavior
and why he is doing it
•Encourage patient to accept responsibility for own behavior
•Set strict limits on behavior to avoid manipulation
•Facilitate patient gaining insight into IPR
•Coping, ineffective individual
•Knowledge deficit
•Family coping compromised, ineffective
•Family processes, altered
•Role performance, altered
Schizophrenia is a psychotic disorder characterized by
withdrawal, blunted affect, autism, ambivalence, loss
associations, and impaired interpersonal relationships. The
degree of impairment depends upon each individual’s
coping skills and functional ability. Because schizophrenia
is not a single disorder, but rather it is a group of disorders,
there are five types:
Characterized by stupor, mutism, rigid posture, or bizzare
psychomotor excitement
Characterized by flat affect ,loosening of associations,
incoherence , extreme withdrawl, fragmented delusions, and
Characterized by systematic delusions and hallucinations
Characterized by psychotic symptoms , incoherence, delusions,
hallucinations(usually auditory, anger , and
Characterized by psychotic symptoms, incoherence,
hallucinations, and the symptoms of disorganized behavior.
• Autism
•Disturbances thought process
•Impaired interpersonal relationships
•Restricted speech patterns
•Impaired role function
• Impaired role function
• Magical thinking
• Dispersonalization
• Loosening of association
• Flat, Blunted effect
• Ideas of reference
• Loss of boundaries or no sense of self
• Lack of motivation or interest
• Disturbances in psychomotor activity
• Rocking back and forth
• Ritualistic behavior
• Depressed or angry mood
• Delusion
• Disturbances in perception
• Hallucination
- Contact with reality
- Level of anxiety
- Level of fear related to the hallucination
- Whether hallucinations are auditory or visuals
- Use of coping mechanisms, particularly projection and
• Suicidal Ideation or plan
• Do not take or ask detailed questions about hall
• Instruct patient to tell voices to go away
• Do not touch patient or approach in an unexpected manner
• Closely observe patient when taking medications
• Promote maintenance of ADL
• Provide structured activities
• Maintain eye contact
• Encourage adequate nutrition
• Monitor for side effects, EPS
• Do not hide medications in food or drink
• Ask patient to repeat statements when they are not understood
• Reorient patient to reality as required
• Encourage adequate rest
• Provide quiet environment
• Encourage patient to substitute reality oriented interactions for
• Offer medication in liquid if checking is suspect
• Restructure reality in a way that the patient can understand and
• Encourage patient to participate in therapy when able to respond
• Encourage resocialization especially in groups
• Communicate in simple, stated sentences
• Encourage adequate exercise
• Be prepared to set limits if necessary
• Avoid feeding into hallucination or delusion
• Administer antipsychotic medications as prescribe
• Avoid approaching patients suddenly or touching patient
• Facilitate insight into interpersonal relationship
• Do not argue with patient
• Hallucination are very powerful and their influence should
not be taken lightly
• Teach side effect, especially EPS
• Teach perpose of therapy
• Teach significant others how to be supportive of patient at
times with contact with reality is poor
• Teach patient action antipsychotic medications
• Anxiety
• Coping ineffective family
• Hopelessness
• Fear
• Role performance, altered
• Sleep pattern disturbance
• Social Isolation
• Injury, high risk for
• Body image disturbance
• Fatigue
• Coping ineffective individual
• Family process, altered
• Non compliance
• Self cared deficit, Bathing or hygiene
• Spiritual distress
• Powerlessness
• Social interaction
• Communication
Unit 4:
Concepts of
special concern
- The Patient Suffering RApe
- The patient suffering a crisis
- the patient with a phobia
- the patient in pain
Rape is a physical violence in which the act of intercourse takes
place. Rape has nothing to do with sexual passion. It has more
to do with anger, rage, power and control. The composite of a
rape victim is a single female student, young, black, from a
lower socio economic class

Immediately following rape:
• Trauma such as laceration, conclusion, bites,
• Pelvic exam collect specimen
• Rectal exam
• Drug screen
• Wet mounth test for motile sperm
• Any samples from public area or under fingernails
• History of sexually transmitted diseases
• Pain, particularly pelvic and back injuries
• VDRL (may need to be repeated)
• Blood alcohol level
• Feeling of guilt and shame
• Wood’s light to detect presence of sperm
• Serum pregnancy (if negative may need to be repeated 10 days
after rape)
• Date of late menstrual period
• Support of significant other
• Sleep disturbances, nightmares
• Sexual dysfunction
• Resentment, rage toward self or assailant(s)

• Physiological integrity
• Physiological intergrity
• Remain with patient, offering empathy and support
• Provide quiet, private environment
• Treat injuries
• Explain procedures and reasons for obtaining specimens
• Chart sites of trauma with descriptions
• Help the patient focus on rape as an act of violence, not
• Collect data about assault that is legally required:
- Where
- When
- Description of assailants (s)
- Description of weapons
- Description of possible witnesses
• Allow patient to cry, express feelings of anger
• Do not permit patient to go home alone from hospital after
being treated for rape
• Be alert to potential for suicidal behavior
• Refer to sex counseling if appropriate
• Encourage patient to seek therapy in a rape support group
• Attempt to calm patient in an empathetic manner if histrionic
•Instruct family on how to be emotionally
• Instruction regarding legal rights
• Instruct family or significant others not to be over
• Teach patient how sex counseling might help of
sexual dysfunction results
• Anxiety
• Caregiver role strain, high risk for
• Denial, Ineffective
• Family Coping
• Grieving, anticipatory
• Injury
• Post trauma response
• Body image disturbance
• Coping
• Fear
• Violence
• Infection
• Pain
• Powelessness
• Sexual dysfunction
• Social isolation
• Trauma
• Rape trauma
• Skin integrity
• Sleep pattern disturbance
• Rape trauma syndrome
The patient suffering
A crisis
A crisis is a severe internal upheaval that result from a
traumatic event or a perceived threat. It is usually related to a
loss of dramatic challenge. How each individual response to the
crisi determines wheather the experience will be resolve in
personal growth or psychological disorganization

• Nature of loss
• How patient has responded in past
• Support systems available
• Sleep disturbances
• Evaluate level of anxiety
• Abuse of prescribe medication
• Risk for suicide
• Increasing blood pressure
• Chest pain
• Increasing heart rate
• Diarrhea
• Powerlessness
• Ambivalence
• Coping mechanisms used
• Problem solving and decision making
• Ability to perform ADL
• Extreme hyper activity
• Increased alcohol abused
• Denial that event has happen
• Weightless
• Palpitations
• Increasing respirations
• Nausea
• Depression
• Anger
• Lack of insight
• Redirect patient in simple clearly stated sentences
• Monitor for suicidal tendencies
• Assist in decision making needs
• Provide safe environment
• Support family members with crisis intervention
• Discourage dependence upon others for problem solving
and decision making
• Encourage expression of anger and helplessness
• Gently reorient if denial persist
• Encourage use of relaxation techniques
• Administer medication to reduce anxiety
• Refer to pastoral counseling if appropriate
• Emphasize strength

• Teach immediate coping skills required for getting through
initial impact
• Instruct significant others how to be emotionally supportive
• Coping ineffective family Spiritual distress
•Mobility Social Isolation
• Trauma
•Anxiety Decisional conflict
• Coping
• Injury Post trauma response
• Violence Communication
• Fear
• Denial
A phobia is a fear of an object, place, or action that
symbolizes a perceive danger. It believe that feat replaces the
anxiety, and when the patient avoids the feared object,
anxiety is decreased. Common phobias are acrophobia (high
places), agoraphobia (open places), Claustrophobia (closed
places), and nyctophobia (night or darkness).
• Degree of impairment caused by the phobia.
• The specific object that forms the basis for the phobia.
• Rigidity in thinking and problem solving.
• Physical symptoms
- Sweating
- Dizziness
- Dyspnea
- Chest pain
- Palpitation
- Tingling in sculp
- Rembling
• Degree of internal control the patient feels in his or her life
• Use of coping mechanism especially displacement projection
and depression
• Assertiveness in interpersonal relationship
• Degree of insights

• Psychosocial integrity

• Assist patient to develop insight into fear and anxiety
• Encourage relaxation techniques such as medication and
• Administer medication as prescribe
• Implement the technique of desensitization
• Establish routine of ADL that is not threatening
• Facilitate insight that phobia is symbolic of anxiety and in
itself is not meaningful

• The meaning of desensitization technique and how it works
• Teach stress management
• Instruct side effects of medication and that medication are
only temporary
• Activity in tolerance
• Anxiety
• Denial
• Fear
• Non compliance
• Social Isolation
• Sleep pattern disturbance
• Communication
• Desicional conflict
• Mobility
• Powerlessness
• Social Interaction, Coping