Unit 7: Psychiatric-Mental Health Nursing

Unit 7: Psychiatric-Mental Health Nursing
An important aspect of professional nursing is the use of therapeutic intervention for clients who are
experiencing emotional distress. A client does not have to have a psychiatric diagnosis to be in emotional
distress, and often clients and their families may respond to illness or injury with anxiety and fear that can be
manifested in a variety of behaviors. The principles of psychiatric-mental health nursing and therapeutic
interventions can be applied to any client, family, or group in need.
To plan appropriate interventions, nurses need to have an understanding and knowledge of personality
development and other theories to analyze behaviors of the client or others. Theories, principles, and
treatment modalities are the science of psychiatric-mental health nursing.
The manner the nurse selects to use the science of mental health nursing is based in part on that nurse's
personal attributes. Personal experiences, the ability to implement principles and theories, and the
willingness to use therapeutic communication constitute the art of psychiatric-mental health nursing. This
creative aspect of each nurse is the therapeutic use of self involved in planning and implementing effective
nursing interventions for dealing with clients who are experiencing emotional distress.
Implementing the art of psychiatric-mental health nursing is an important way to convey to clients the caring
aspect of nursing. Perceiving clients' concerns and responding therapeutically will encourage clients to
share more information with the nurse. Awareness of the client's attitudes, values, and fears will enable the
nurse to individualize client care. Physical, psychological, social, and spiritual needs should be the concern
of a nurse who wants to provide holistic care. Nurses can determine specific client needs by assessing
verbal and nonverbal behaviors. Application of the nursing process to meet client needs will ensure
comprehensive nursing care.
The following principles of psychiatric-mental health nursing help form the basis of the therapeutic use of
self.
 Be aware of your own feelings and responses.

 Maintain objectivity while being aware of your own needs.
 Use empathy (recognizing/identifying somewhat with client's emotions to understand behavior), not
sympathy (close identification/ duplication of client's emotions).
 Focus on the needs of the client, not on your own needs; be consistent and trustworthy.
 Accept clients as they are; be nonjudgmental.
 Recognize that emotions influence behaviors.
 Observe a client's behaviors to analyze needs/problems.
 Accept client's needs to use defenses/behaviors to deal with emotional distress.
 Accept client's negative emotions.
 Avoid verbal reprimands, physical force, giving advice, or imposing your own values on clients.
 Avoid intimate relationships while maintaining a caring attitude.
 Assess clients in the context of their social/cultural group.
 Recognize that client communication patterns (verbal and nonverbal) vary with different cultural
groups.
 Teach/explain on client's level of capability.
 Treat clients with respect, caring, and compassion.
Asking yourself, "What is this client's need at this time?" can assist you in determining the best
response to questions.
Overview of Psychiatric-Mental Health Nursing
THEORETICAL BASIS
Medical-biologic Model
1. Emotional distress is viewed as illness.
2. Symptoms can be classified to determine a psychiatric diagnosis.
3. DSM IV*
1. Description of disorders
2. Criteria (behaviors) that must be met for diagnosis to be made
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3. Axis: the dimensions and factors included when assessing a client with a mental disorder
1. I and II: clinical syndromes (e.g., bipolar, antisocial personality, mental
retardation)
2. III: physical disorders and symptoms (e.g., cystic fibrosis, hypertension)
3. IV: psychosocial and environmental problems: acute and long-term severity of
stressors
4. V: functioning of client, rating of symptoms and their effect on activities of daily
living (ADL) or violence to self/others
4. Diagnosed psychiatric illnesses are within the realm of medical practice and have a particular
course, prognosis, and treatment regimen.
5. Treatment can include psychotropic drugs, electroconvulsive therapy (ECT), hospitalization, and
psychotherapy.
6. There is no proven cause, but theory is that biochemical/genetic factors play a part in the
development of mental illness. Theories with schizophrenia and affective disorders include
1. Genetic: increased risk when close relative (e.g., parent, sibling) has disorder
2. Possible link to neurotransmitter activity
* American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.)
Psychodynamic/Psychoanalytic Model (Freud)

1. Instincts (drives) produce energy.
2. There are genetically determined drives for sex and aggression.
3. Human behavior is determined by past experiences and responses.
4. All behavior has meaning and can be understood.
5. Emotionally painful experiences/anxiety motivate behavior.
6. Client can change behavior and responses when made aware of the reasons for them.
7. Freud's theory of personality
1. Id: present at birth; instinctual drive for pleasure and immediate gratification, unconscious.
Libido is the sexual and/or aggressive energy (drive). Operates on pleasure principle to
reduce tension or discomfort (pain). Uses primary process thinking by imagining objects to
satisfy needs (hallucinating).
2. Ego: develops as sense of self that is distinct from world of reality; conscious,
preconscious, and unconscious. Operates on reality principle which determines whether
the perception has a basis in reality or is imagined. Uses secondary process thinking by
judging reality and solving problems.
1. Functions of the ego
1. control and regulate instinctual drives
2. mediate between id drives and demands of reality; id drives vs
superego restrictions
3. reality testing: evaluate and judge external world
4. store up experiences in "memory"
5. direct motor activity and actions
6. solve problems
7. use defense mechanisms to protect self
2. Levels of awareness
1. Preconscious: knowledge not readily available to conscious awareness
but can be brought to awareness with effort (e.g., recalling name of a
character in a book)
2. Unconscious: knowledge that cannot be brought into conscious
awareness without interventions such as psychoanalysis, hypnotism, or
drugs
3. Conscious: aware of own thoughts and perceptions of reality
3. Superego: develops as person unconsciously incorporates standards and restrictions from
parents to guide behaviors, thoughts, and feelings. Conscious awareness of
acceptable/unacceptable thoughts, feelings, and actions is "conscience."
8. Freud's psychosexual developmental stages
1. Oral
1. 0-18 months
2. Pleasure and gratification through mouth
3. Behaviors: dependency, eating, crying, biting
4. Distinguishes between self and mother
5. Develops body image, aggressive drives
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2. Anal
1.18 months-3 years
2.Pleasure through elimination or retention of feces
3.Behaviors: control of holding on or letting go
4.Develops concept of power, punishment, ambivalence, concern with cleanliness
or being dirty
3. Phallic/Oedipal
1. 3-6 years
2. Pleasure through genitals
3. Behaviors: touching of genitals, erotic attachment to parent of opposite sex
4. Develops fear of punishment by parent of same sex, guilt, sexual identity
4. Latency
1. 6-12 years
2. Energy used to gain new skills in social relationships and knowledge
3. Behaviors: sense of industry and mastery
4. Learns control over aggressive, destructive impulses
5. Acquires friends
5. Genital
1. 12-20 years
2. Sexual pleasure through genitals
3. Behaviors: becomes independent of parents, responsible for self
4. Develops sexual identity, ability to love and work
Psychosocial Model (Erikson)

1. Emphasis on psychosocial rather than psychosexual development
2. Developmental stages have goals (tasks)
3. Challenge in each stage is to resolve conflict (e.g., trust vs mistrust)
4. Resolution of conflict prepares individual for next developmental stage
5. Personality develops according to biologic, psychologic, and social influences
6. Erikson's psychosocial development tasks
1. Trust vs mistrust
1. 0-18 months
2. Learn to trust others and self vs withdrawal, estrangement
2. Autonomy vs shame and doubt
1. 18 months-3 years
2. Learn self-control and the degree to which one has control over the environment
vs compulsive compliance or defiance
3. Initiative vs guilt
1. 3-5 years
2. Learn to influence environment, evaluate own behavior vs fear of doing wrong,
lack of self-confidence, overrestricting actions
4. Industry vs inferiority
1. 6-12 years
2. Creative; develop sense of competency vs sense of inadequacy
5. Identity vs role diffusion
1. 12-20 years
2. Develop sense of self; preparation, planning for adult roles vs doubts relating to
sexual identity, occupation/career
6. Intimacy vs isolation
1. 18-25 years
2. Develop intimate relationship with another; commitment to career vs avoidance
of choices in relationships, work, or life-style
7. Generativity vs stagnation
1. 21-45 years
2. Productive; use of energies to guide next generation vs lack of interests, concern
with own needs
8. Integrity vs despair
1. 45 years to end of life
2. Relationships extended, belief that own life has been worthwhile vs lack of
meaning of one's life, fear of death
Interpersonal Model (Sullivan)

1. Behavior motivated by need to avoid anxiety and satisfy needs
2. Sullivan's developmental tasks
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1. Infancy
1. 0-18 months
2. Others will satisfy needs
2. Childhood
1. 18 months-6 years
2. Learn to delay need gratification
3. Juvenile
1. 6-9 years
2. Learn to relate to peers
4. Preadolescence
1. 9-12 years
2. Learn to relate to friends of same sex
5. Early adolescence
1. 12-14 years
2. Learn independence and how to relate to opposite sex
6. Late adolescence
1. 14-21 years
2. Develop intimate relationship with person of opposite sex
Therapeutic Nurse-Client Relationship (Peplau)

1. Based on Sullivan's interpersonal model
2. Therapeutic relationship is between nurse (helper) and client (recipient of care). The goal is to work
together to assist client to grow and to resolve problems.
3. Differs from social relationship where both parties form alliance for mutual benefit.
4. Therapeutic use of self
1. Focus is on client needs but nurse is also aware of own needs.
2. Self-awareness enables nurse to avoid having own needs influence perception of client.
3. Determine what client/family needs are at the time.
5. Three phases of nurse-client relationship
1. Orientation
1. Nurse explains relationship to client, defines both nurse's and client's roles.
2. Nurse determines what client expects from the relationship and what can be
done for the client.
3. Nurse contracts with client about when and where future meetings will take
place.
4. Nurse assesses client and develops a plan of care based on appropriate nursing
diagnoses.
5. Limits/termination of relationship are introduced (e.g., "We will be meeting for 30
minutes every morning while you are in the hospital.").
2. Working phase
1. Client's problems and needs are identified and explored as nurse and client
develop mutual acceptance.
2. Client's dysfunctional symptoms, feelings, or interpersonal relationships are
identified.
3. Therapeutic techniques are employed to reduce anxiety and to promote positive
change and independence.
4. Goals are evaluated as therapeutic work proceeds, and changed as determined
by client's progress.
3. Termination
1. Relationship and growth in nurse and client are summarized.
2. Client may become anxious and react with increased dependence, hostility, or
withdrawal.
3. These reactions are discussed with client.
4. Feelings of nurse and client concerning termination should be discussed in
context of finiteness of relationship.
6. Transference and countertransference
1. Transference: occurs when client transfers conflicts/feelings from past to the nurse.
Example: Client becomes overly dependent, clinging to nurse who represents
(unconsciously to client) the nurturing client desires from own mother.
2. Countertransference: occurs when nurse responds to client emotionally, as if in a
personal, not professional/therapeutic, relationship. Countertransference is a normal
occurrence, but must be recognized so that supervision or consultation can keep it from
undermining the nurse-client relationship. Example: Nurse is sarcastic and judgmental to
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client who has history of drug abuse. Client represents (unconsciously to nurse) the
nurse's brother who has abused drugs.
3. Interventions
1. Reflect on reasons for behaviors of client or nurse.
2. Establish therapeutic goals for this relationship.
3. If unable to control these occurrences, transfer client to another nurse.
Human Motivation/Need Model (Maslow)

1. Hierarchy of needs in order of importance
1. Physiologic: oxygen, food, water, sleep, sex
2. Safety: security, protection, freedom from anxiety
3. Love and belonging: freedom from loneliness/alienation
4. Esteem and recognition: freedom from sense of worthlessness, inferiority, and
helplessness
5. Self-actualization: aesthetic needs, self-fulfillment, creativity, spirituality
2. Primary needs (oxygen, fluids) need to be met prior to dealing with higher-level needs (esteem,
recognition).
3. Focus on provision of positive aspects such as feeling safe, having someone care, affiliation
Behavioral Model (Pavlov, Skinner)

1. Behavior is learned and retained by positive reinforcement.
2. Motivation for behavior is not considered.
3. Behaviors that are not adequate can be replaced by more adaptive behaviors.
Community Mental Health Model

1. Emotional distress stems from personal and social factors
1. Family problems (e.g., divorce, single parenthood)
2. Social factors (e.g., unemployment, lack of support groups, changing mores)
2. Health care a right
3. Decreased need for hospitalization, increased community care
4. Collaboration of social and health care services
5. Comprehensive services
1. Emergency care
2. Inpatient/outpatient services
3. Substance-abuse treatment
4. Transitional living arrangements (temporary residence instead of inpatient care)
5. Consultation and education to increase knowledge of mental health
6. Prevention
1. Primary prevention
1. Minimize development of serious emotional distress: promote mental health,
identify persons at risk.
2. Anticipate problems such as developmental crises (e.g., birth of first child, midlife
crisis, death of spouse).
2. Secondary prevention: early case finding and treatment (drug therapy, outpatient, short-
term hospitalization).
3. Tertiary prevention: restore client to optimal functioning; facilitate return of client to home
and community by use of social agencies.
NURSING PROCESS
1. Applies to all clients, not only to those with psychiatric diagnosis; incorporates holism.
2. Utilized in a unique manner for psychosocial assessment.
3. Sets goals (with client, whenever possible) that can be measured in behavioral terms (e.g., client
will dress self and eat breakfast before 9 a.m.).
4. Uses principles of therapeutic communication for interventions.
5. Evaluates whether, how well goals were met.
Physical Assessment
1. Subjective reporting of health history
2. Objective data (general status and appearance)
1. Age: client's appearance in relation to chronologic age
2. Attire: appropriateness of clothing to age/situation
3. Hygiene: cleanliness and grooming, or lack thereof
4. Physical health: weight, physical distress
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5. Psychomotor: posture, movement, activity level
6. Sleep and rest
3. Neurologic assessment/level of consciousness
Mental Status Assessment
Emotional Status Assessment

Observation of mood (prolonged emotion) and affect (physical manifestations of mood). That is, sad mood
may be evidenced by crying or downcast appearance; joyful mood may be expressed by smiling or happy
affect.
1. Appropriateness
2. Description: flat, sad, smiling, serious
3. Stability
4. Specific feelings and moods
Cognitive Assessment
Evaluation of thought, sensorium, intelligence
1. Intellectual performance
1. Orientation to person, place, and time
2. Attention and concentration
3. Knowledge/educational level
4. Memory: short and long term
5. Judgment
6. Insight into illness
7. Ability to use abstraction
2. Speech
1. Amount, volume, clarity
2. Characteristics: pressured, slow or fast, dull or lively
3. Specific aberrations, i.e., echolalia (imitating and repeating another's words or phrases) or
neologisms (making up of own words that have special meaning to client).
3. Thoughts
1. Content and clarity
2. Characteristics: spontaneity, speed, loose associations, blocked, flight of ideas, repetitions
Social/Cultural Considerations
1. Age: assess for developmental tasks and developmental crises, age-related problems.
1. 0-18 months: development of trust and sense of self, dependency
2. 18 months-3 years: development of autonomy and beginning self-reliance, toilet training
3. 3-6 years: development of sexual identity, relationships with peers, adjustment to school
4. 6-12 years: mastery of skills, beginning self-esteem, identification with others outside
family, social relationships
5. 12-18 years: sense of self solidifies, separation and individuation often follow some
disorganization and rebellion, substance abuse
6. 18-25 years: identification with peer group, setting of personal and career goals to master
future
7. 25-38 years: take place in adult world, commitments made relating to career, marriage,
parenthood
8. 38-65 years: review of past accomplishments; may set new and reasonable goals; midlife
crises when present achievements have not met goals set in earlier stages of
development
9. 65/70 to death: loss of friends/spouse, retirement, loss of some social/physical functions
2. Family/community relationships
1. Role of client in family
2. Family harmony, family support for or dependency on client
3. Client's perception of family
4. Availability of community support groups to client (include government social agencies;
religious, ethnic, and volunteer agencies)
3. Socioeconomic group/education
1. Factors that relate to how client is approached and how client perceives own present state
2. Determination of level of teaching and need for social services
4. Cultural/spiritual background
1. Assess behaviors in context of client's culture.
2. Avoid stereotyping persons as having attributes of their culture/subculture.
3. Note client's religious/philosophic beliefs.
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ANALYSIS
Select nursing diagnoses based on collected data. Decide which is most important. Specific nursing
diagnoses will be given when discussing particular disorders, but those nursing diagnoses generally
appropriate to the client with psychiatric-mental health disorders include
1. Anxiety
2. Ineffective family coping
3. Ineffective individual coping
4. Decisional conflict
5. Fatigue
6. Fear
7. Hopelessness
8. Knowledge deficit
9. Powerlessness
10. Sleep pattern disturbances
11. Altered thought processes
12. Risk for violence
13. Impaired verbal communication
14. Impaired social interaction
15. Altered role performance
16. Spiritual distress
17. Self-esteem disturbance
18. Social isolation
19. Altered family processes
20. Defensive coping
21. Ineffective denial
22. Noncompliance
23. Body image disturbance
24. Risk for self-mutilation
25. Rape-trauma syndrome
26. Impaired adjustment
PLANNING AND IMPLEMENTATION
Goals
1. Client will
1. Participate in treatment program.
2. Be oriented to time, place, and person and exhibit reality-based behavior.
3. Recognize reasons for behavior and develop alternative coping mechanisms.
4. Maintain or improve self-care activities.
5. Be protected from harmful behaviors.
2. There will be mutual agreement of nurse and client whenever possible.
3. Short-term goals are set for immediate problems; they should be feasible and within client's
capabilities.
4. Long-term goals are related to discharge planning and prevention of recurrence or exacerbation of
symptoms.
Interventions
The nurse will use therapeutic intervention and the nurse-client relationship to help the client achieve the
goals of therapy. Interventions must be geared to the level of the client's capability and must relate to the
specific problems identified for the individual client, family, or group.
Therapeutic Communication
1. Facilitative: use the following approaches to intervene therapeutically
1. Silence: client able to think about self/problems; does not feel pressure or obligation to
speak.
2. Offering self: offer to provide comfort to client by presence (Nurse: "I'll sit with you." "I'll
walk with you.").
3. Accepting: indicate nonjudgmental acceptance of client and his perceptions by nodding
and following what client says.
4. Giving recognition: indicate to client your awareness of him and his behaviors (Nurse:
"Good morning, John. You have combed your hair this morning.").
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5. Making observations: verbalize what you perceive (Nurse: "I notice that you can't seem to
sit still.").
6. Encouraging description: ask client to verbalize his perception (Nurse: "Tell me when you
need to get up and walk around." "What is happening to you now?").
7. Using broad openings: encourage client to introduce topic of conversation (Nurse: "Where
shall we begin today?" "What are you thinking about?").
8. Offering general leads: encourage client to continue discussing topic (Nurse: "And then?"
"Tell me more about that.").
9. Reflecting: direct client's questions/ statements back to encourage expression of ideas
and feelings (Client: "Do you think I should call my father?" Nurse: "What do you want to
do?").
10. Restating: repeat what client has said (Client: "I don't want to take the medicine." Nurse:
"You don't want to take this medication?").
11. Focusing: encourage client to stay on topic/point (Nurse: "You were talking about. . . .").
12. Exploring: encourage client to express feelings or ideas in more depth (Nurse: "Tell me
more about. . . ." "How did you respond to . . . ?").
13. Clarification: encourage client to make idea or feeling more explicit, understandable
(Nurse: "I don't understand what you mean. Could you explain it to me?").
14. Presenting reality: report events/situations as they really are (Client: "I don't get to talk to
my doctor." Nurse: "I saw your doctor talking to you this morning.").
15. Translating into feelings: encourage client to verbalize feelings expressed in another way
(Client: "I will never get better." Nurse: "You sound rather hopeless and helpless.").
16. Suggesting collaboration: offer to work with client toward goal (Client: "I fail at everything I
try." Nurse: "Maybe we can figure out something together so that you can accomplish
something you want to do.").
2. Ineffective communication styles: the following nontherapeutic approaches tend to block
therapeutic communication and are sometimes used by nurses to avoid becoming involved with
client's emotional distress; often a protective action on part of nurse.
1. Reassuring: telling client there is no need to worry or be anxious (Client: "I'm nervous
about this test." Nurse: "Everything will be all right.").
2. Advising: telling client what you believe should be done (Client: "I am going to. . . ." Nurse:
"Why don't you do . . . instead?" or "I think you should do. . . .").
3. Requesting explanation: asking client to provide reasons for his feelings/behavior. The
use of "why" questions should be avoided (Nurse: "Why do you feel, think, or act this
way?").
4. Stereotypical response: replying to client with meaningless clichés (Client: "I hate being in
the hospital." Nurse: "There's good and bad about everything.").
5. Belittling feelings: minimizing or making light of client's distress or discomfort (Client: "I'm
so depressed about. . . ." Nurse: "Everyone feels sad at times.").
6. Defending: protecting person or institutions (Client: "Ms. Jones is a rotten nurse." Nurse:
"Ms. Jones is one of our best nurses.").
7. Approving: giving approval to client's behavior or opinion (Client: "I'm going to change my
attitude." Nurse: "That's good.").
8. Disapproving: telling client certain behavior or opinions do not meet your approval (Client:
"I am going to sign myself out of here." Nurse: "I'd rather you wouldn't do that.").
9. Agreeing: letting client know that you think, feel alike; nurse verbalizes agreement.
10. Disagreeing: letting client know that you do not agree; telling client that you do not believe
he is right.
11. Probing: questioning client about a topic he has indicated he does not want to discuss.
12. Denial: refusing to recognize client's perception (Client: "I am a hopeless case" Nurse:
"You are not hopeless. There is always hope.").
13. Changing topic: letting client know you do not want to discuss a problem by introducing a
new topic (Client: "I am a hopeless case." Nurse: "It's time to fill out your menu.").
Therapeutic Groups
1. Groups of clients meet with one or more therapists. They work together to alleviate client problems
in
1. Interpersonal relations/communication
2. Coping with particular stressors (e.g., ostomy groups)
3. Self-understanding
2. Purposes
1. Increase self-awareness
2. Improve interpersonal relationships
3. Make changes in behavior
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4. Deal with particular stressors
5. Enhance teaching/learning
3. Structure of groups
1. Leader(s) chosen
2. Selection of members
3. Size: 5 to 10 members
4. Physical arrangements
5. Time/place of meetings
6. Open: accept members anytime
7. Closed: do not add new members
4. Group dynamics
1. System of interactions
2. Collective activity
3. Process: all activities/interactions
4. Content: topics discussed
5. Stages of group development
1. Beginning stage
1. Anxiety in new situation
2. Information given
3. Group norms established
2. Middle stage
1. Group cohesiveness
2. Members confronting each other
3. Reliance on group member leading to self-reliance
4. Sense of trust established
3. Termination stage
1. Individual member may leave abruptly
2. Group decides work is done
3. Ambivalence felt about termination
4. Ideally, group members have met goals
6. Role of the nurse
1. Explain purpose and rules of group
2. Introduce group members
3. Promote group cohesiveness
4. Focus on problems of group and group process
5. Encourage participation
6. Role model
7. Facilitate communication
8. Set limits
Table 7.1 (below) lists types of therapeutic groups.
Family Therapy
1. Client is whole family, although a family member may be "identified client."
2. Purposes
1. Improve relationships among family members
2. Promote family function
3. Resolve family problem(s)
3. Process
1. Problem(s) are identified by each family member.
2. Members discuss their involvement in problem(s).
3. Members discuss how problem(s) affect them.
4. Members explore ways each of them can help resolve problem(s).
1. Assess interactions among family members
2. Make observations to family members
3. Encourage expression of feelings by family members to one another
4. Assist family in resolving problems
Milieu Therapy
1. Total environment (milieu) has an effect on individual's behavior, including
1. Physical environment (i.e., cleanliness, noise, colors, fresh air, light)
2. Relationships of staff to staff, staff to clients, and client to clients
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3. Atmosphere of safety, caring, mutual respect (e.g., client-run community meeting,
community-set standards for behaviors)
2. Purposes
1. Improve client's behavior
2. Involve client in decision making of unit
3. Increase client's sense of autonomy
4. Increase communication among clients and between clients and staff
5. Set structure of unit and behavioral limits
6. Form a sense of community
1. Involve clients in decision making
2. Promote involvement of all staff
3. Promote development of social skills of individual clients (e.g., nurse serves as role
model)
4. Encourage sense of community in staff and clients
Crisis Intervention
1. Client cannot resolve problem with usual problem-solving skills. Problem is so serious that
functioning (homeostasis) is threatened. Crisis can be developmental (e.g., birth of first child) or
situational (e.g., home destroyed by fire). Generally lasts for a few days but can continue for weeks;
is usually limited to 6 weeks
2. Purposes
1. Support client during time of crisis
2. Resolve crisis
3. Restore client at least to precrisis level of functioning
4. Allow client to attain higher level of functioning through acquiring greater skill in problem
solving
3. Process
1. Crisis event occurs: client unable to solve problem.
2. Increase in level of client's anxiety.
3. Client may use trial and error approach.
4. If problem unresolved, anxiety escalates and client seeks help.
1. Assess client's perception of problem: realistic/distorted
2. Determine situational supports (e.g., family, neighbors, agencies)
3. Explore previous coping behaviors of client
4. Offer support in resolving crisis
5. Enlist help of situational supports
6. Help client develop new, more effective coping behaviors
7. Convey hope to client that crisis can be resolved
8. Work with client as he resolves crisis
Behavior Modification
1. Based on theory that all behavior is learned as a result of positive reinforcement. Behaviors can be
changed by substituting new behaviors.
2. Purpose: change unacceptable or maladaptive behaviors
3. Process
1. Determine the unacceptable behavior.
2. Identify more adaptive behavior to replace the unacceptable behavior.
3. Apply learning principles.
1. Respond to unacceptable behavior by negative reinforcement (punishment) or by
withholding positive reinforcement (ignore behavior).
2. Determine what client views as reward.
4. When desired behavior occurs, present positive reinforcement (reward).
5. Consistently reward desired behavior.
6. Consistently respond to unacceptable behavior with negative reinforcement/ ignoring
behavior.
4. Types
1. Counterconditioning: specific stimulus evokes a maladaptive response that is replaced
with a more adaptive response.
2. Systematic desensitization
1. Expose to small amount of stimulus while ensuring relaxation (client cannot be
anxious and relaxed at same time).
2. Continue relaxing client while increasing amount of stimulus.
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3. Fear response to stimulus is eventually extinguished.
3. Token economy: Tokens (rewards such as candy) are used to reinforce desired
behaviors.
Psychotropic Medications
A variety of agents is used to control disordered thinking, anxiety, and mood disorders. Effects, side effects,
and nursing implications are summarized with each disorder.
TABLE 7.1 Types of Therapeutic Groups
Type Goal(s) Example

Task Accomplish outcome Select field trip
Teaching/ learning Gain knowledge/skills Identify side effects of medications
Social/support Give and receive support Postmastectomy clients
Psychotherapy Insight/behavioral change Overcome shyness
Activity Increase social interaction/self-esteem Grooming, manicures

EVALUATION
1. How well have goals been met? If not met, why not?
1. Review prior steps of nursing process.
1. Do you need more assessment data?
2. Were nursing diagnoses prioritized?
3. Were goals feasible and measurable?
4. Were interventions appropriate?
2. Revise goals as necessary.
2. Client
1. Enrolled/participates in appropriate treatment program.
2. Expresses concerns/needs and develops a therapeutic relationship with nurse.
3. Identifies causes for behavior; learns and uses alternative coping mechanisms.
4. Demonstrates ability to care for self at optimum level and to identify areas where
assistance is needed.
5. Does not engage in harmful behaviors; shows increased ability to control destructive
impulses.
3. Client's behavior demonstrates optimal orientation to reality (e.g., can state name, place); interacts
appropriately with others.
BEHAVIORS RELATED TO EMOTIONAL DISTRESS
Anxiety
1. General information
1. One of the most important concepts in psychiatric-mental health nursing.
2. Anxiety is present in almost every instance where clients are experiencing emotional
distress/have a diagnosed psychiatric illness.
3. Experienced as a sense of emotional or physical distress as the individual responds to an
unknown threat or thwarting of unmet needs.
4. The ego protects itself from the effects of anxiety by the use of defense mechanisms (see
Table 7.2).
5. Physiologic responses are related to autonomic nervous system response and to level of
anxiety.
1. Subjective: client experiences feelings of tension, need to act, uneasiness,
distress, and apprehension or fear.
2. Objective: client exhibits restlessness, inability to concentrate, tension, dilated
pupils, changes in vital signs (usually increased by sympathetic nervous system
response, may be decreased by parasympathetic reactions).
6. Anxiety can be viewed positively (motivates us to change and grow) or negatively
(interferes with problem-solving ability and affects functioning).
1. Trait anxiety: individual's normal level of anxiety. Some people are usually rather
intense while others are more relaxed; may be related to genetic
predisposition/early experiences (repressed conflicts).
2. State anxiety: change in person's anxiety level in response to stressors
(environmental or any internal threat to the ego).
7. Levels of anxiety
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1. Mild: increased awareness; ability to solve problems, learn; increase in
perceptual field; minimal muscle tension
2. Moderate: optimal level for learning, perceptual field narrows to pay attention to
particular details, increased tension to solve problems or meet challenges
3. Severe: sympathetic nervous system (flight/fight response); increase in blood
pressure, pulse, and respirations; narrowed perceptual field, fixed vision, dilated
pupils, can perceive scattered details or only one detail; difficulty in problem
solving
4. Panic: decrease in vital signs (release of sympathetic response), distorted
perceptual field, inability to solve problems, disorganized behavior, feelings of
helplessness/terror
2. Nursing interventions
1. Determine the level of client's anxiety by assessing verbal and nonverbal behaviors and
physiologic symptoms.
2. Determine cause(s) of anxiety with client, if possible.
3. Encourage client to move from affective (feeling) mode to cognitive (thinking) behavior
(e.g., ask client, "What are you thinking?"). Stay with client. Reduce anxiety by remaining
calm yourself; use silence, or speak slowly and softly.
4. Help client recognize own anxious behavior.
5. Provide outlets (e.g., talking, psychomotor activity, crying, tasks).
6. Provide support and encourage client to find ways to cope with anxiety.
7. In panic state nurse must make decisions.
1. Do not leave client alone.
2. Encourage ventilation of thoughts and feelings.
3. Use firm voice and give short, explicit directions (e.g., "Sit in this chair. I will sit
here next to you.").
4. Engage client in motor activity to reduce tension (e.g., "We can take a brisk walk
around the day room. Let's go.").
Defense Mechanisms
Usually unconscious processes used by ego to defend itself from anxiety and threats (see Table 7.2.).
TABLE 7.2 Defense Mechanisms
Type Characteristics Example

Denial Refusal to acknowledge a part of reality A client on strict bed rest is walking down the hall;
shows refusal to acknowledge need to stay in bed
because of illness. A client states admission to the
mental hospital is for reasons other than mental
illness.
Repression Threatening thoughts are pushed into the "I don't know why I have to wash my hands all the
unconscious, anxiety and other symptoms are time, I just have to."
observed; client unable to have conscious
awareness of conflicts or events that are
source of anxiety.
Suppression Consciously putting a threatening/distressing A nurse must study for the NCLEX, but she has had
thought out of one's awareness. a heated argument with her boyfriend. She decides
not to think about the problem until she finishes
studying, then she will attempt to resolve it.
Rationalization Developing an acceptable, justifiable (to self) A friend tells you that he has been in an automobile
reason for behavior accident because the car skidded on wet leaves in
the road; you go to the scene of the accident, but
there are no leaves; friend admits to you and to self
that he was probably driving too fast.
Reaction-formation Engaging in behavior that is opposite of true A man has an unconscious desire to view
desires pornographic films; he circulates a petition to close
the theater where such films are shown.
Sublimation Anxiety channeled into socially acceptable A student is upset because she received a failing
behavior grade on a test; she knows that she will feel better if
she goes jogging and runs a few miles.
Compensation Making up for a deficit by success in another A young man who cannot make any varsity teams
area becomes the chess champion in his school.
Projection Placing own undesirable trait onto another; A student who would like to cheat on an exam states
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blaming others for own difficulty that other students are trying to cheat; a paranoid
client claims that the FBI had him committed to the
mental hospital.
Displacement Directing feelings about one object/person The head nurse reprimands you; you do not argue
toward a less threatening object/person even though you do not agree with her reprimand;
when you return home that evening you are hostile
towards your roommate.
Identification Taking onto oneself the traits of others that You greatly admire the clinical specialist in your
one admires hospital; unconsciously you begin to use the
approaches she uses with clients.
Introjection Symbolic incorporation of another into one's John becomes depressed when his father dies;
own personality John's feelings are directed to the mental image he
has of his father.
Conversion Anxiety converted into a physical symptom A young woman unconsciously desires to strike her
that is motor or sensory in nature mother; she develops sudden paralysis of her arms.
Symbolization Representing an idea or object by a substitute A man who was spurned by a librarian develops a
object or sign. dislike of books and reading.
Dissociation Separation or splitting off of one aspect of A student who prides herself on being prompt does
mental process from conscious awareness. not recall the times that she arrived late for class.
Undoing Behavior that is opposite of earlier Joan tells an ethnic joke to a coworker, Sally; Sally,
unacceptable behavior or thought a member of that ethnic group, is offended; the
following week Joan offers to work the weekend for
Sally.
Regression Behavior that reflects an earlier level of When a new baby is brought home, 5-year-old Billy begins
development. Adults hospitalized with serious to wet his pants although he had not done this for the past
illnesses sometimes will engage in regressive 2 1/2 years.
behaviors.
Isolation Separating emotional aspects of content from A client discusses his terminal diagnosis in clinical terms.
cognitive aspects of thought. He does not express any emotion.
Splitting Viewing self, others, or situations as all good A client tells you that you are the best nurse. Later
or all bad. tells you that you are incompetent and she will report
you.
Disorders of Perception
Occur with increased anxiety, disordered thinking/impaired reality testing
1. Illusions
1. General information: stimulus in the environment is misperceived (e.g., car backfiring is
perceived as a gunshot; a bathrobe in an open closet is perceived as a person in the
closet); may be visual, auditory, tactile, gustatory, olfactory.
2. Nursing intervention: show/explain stimulus to client to promote reality testing.
2. Delusions
1. General information: fixed, false set of beliefs that are real to client.
1. Grandiose: false belief that client has power, wealth, or status or is famous
person
2. Persecutory: false belief that client is the object of another's harassment or
harmful intent
3. Somatic: false belief that client has some physical/physiologic defect
1. Avoid arguing: client cannot be convinced, even with evidence, that the belief is
false.
2. Determine client's need (grandiose delusion may indicate low self-esteem;
provide opportunities to succeed at task that will enhance self-concept).
3. Reduce anxiety to encourage decreased need to use delusions.
4. Accept client's need for delusion, present (but do not insist that client accept)
reality.
5. After therapeutic relationship has been established, you can express doubt about
delusions to client.
6. Direct client's attention to nondelusional, nonthreatening topics (e.g., current
events, client's hobbies or interests).
3. Ideas of reference
1. General information: belief that events or behaviors of others relate to self (e.g., telephone
rings in nurse's station, client believes "they" are calling for him; two nurses are talking
and laughing, client believes nurses are talking/laughing at him).
2. Nursing interventions are the same as for delusions.
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4. Hallucinations
1. General information: sensory perceptions that have no stimulus in environment; most
common hallucinations are auditory and visual (e.g., hearing voices; seeing persons,
animals, objects).
1. Encourage client to describe hallucination.
2. Accept that this is a real experience for client.
3. Present reality.
4. Example: nurse sees client in listening attitude or responding to auditory
hallucinations. Nurse: "You seem to be listening/talking." Client: "The voices are
telling me to hurt myself." Nurse: "I don't hear the voices. Tell me what the voices
are saying to you."
Withdrawal
1. General information: withdrawal from social interaction by not talking, walking away, turning away,
sleeping or feigning sleep
1. Use silence.
2. Offer self.
3. Discuss nonthreatening topics that will not provoke increased anxiety.
4. Be consistent; keep promises, promote trust.
Hostility and Aggression

1. Hostile behavior: responding to nurse with anger, insults, threats.
2. Assaultive behavior: attempting to physically harm others.
3. Usually nurse is not real object of client's anger, but is convenient target for angry
feelings/verbalizations.
1. Hostility
1. Recognize own response of anger or defensiveness.
2. Determine source of client's anger.
3. Accept angry feelings.
4. Attempt to have client verbalize feelings and channel into acceptable behaviors.
2. Physical aggression/assaultive behaviors (client may act on increased anxiety by throwing
objects or attempt to physically harm others)
1. Assess for increased anxiety.
2. Maintain distance, at least arm's length.
3. Attempt to have client verbalize feelings.
4. Talk client down.
5. Obtain help if client becomes assaultive.
Self-mutilation
1. General information: behaviors cause physical injury but are not motivated by the desire to die.
1. Assess for suicide risk.
2. Offer support.
3. Protect client from carrying out self-mutilation actions.
4. Remove objects that can be used for self-harm.
5. Observe for changes in behaviors and attitudes.
Suicide
1. Ideation: verbalization of wish to die (overt or disguised)
2. Gestures: engaging in nonlethal behaviors (e.g., superficial scratches, ingestion of
medication in amounts that are not likely to cause serious injury/death)
3. Actions: engaging in behaviors or planning to engage in behaviors that have potential to
cause death
4. May or may not be associated with a psychiatric disorder
5. Groups at risk (see Table 7.3)
2. Assessment findings
1. Verbal cues
1. Overt: "I'm going to kill myself."
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2. Disguised: "I have the answer to my problems."
2. Behavioral cues
1. Giving away prized possessions
2. Getting financial affairs in order, making a will
3. Suicidal ideation/gestures
4. Indications of hopelessness, depression
5. Behavioral and attitudinal changes (e.g., neat person becomes sloppy,
depressed person suddenly becomes alert/positive, increased use of drugs
and/or alcohol, alcohol withdrawal).
3. For lethality assessment (see Table 7.4)
1. Contract with client to report suicide attempt.
2. Assess suicide risk.
1. Ask client if he thinks about, intends to harm himself.
2. Ask client if he has formulation of plan; if details are worked out, when? where?
how?
3. Check availability of method (e.g., gun, pills).
3. Keep client under constant observation.
4. Remove any objects that can be used in suicide attempt (e.g., shoe laces, sharp objects).
5. Therapeutic intervention
1. Support aspects of wish to live; clients often ambivalent: wish to live and wish to
die.
2. Use one-to-one nurse/client relationship (let client know you care for him).
3. Allow client to express feelings of hopelessness, helplessness, worthlessness.
4. Provide hope.
5. Provide diversionary activities.
6. Utilize support groups (e.g., family, clergy).
6. Following a suicide
1. Encourage survivors to discuss client's death, their feelings and fears.
2. Provide anticipatory guidance to family who may experience problems at
holidays, anniversaries.
3. Hold staff meetings to ventilate feelings.
TABLE 7.3 Groups at Increased Risk for Suicide
– Adolescents/young adults (ages 15–24)

– Elderly
– Terminally ill
– Persons who have experienced loss/stress
– Survivors of persons who have committed suicide
– Individuals with bipolar disorders
– Depressed persons (when depression begins to lift)
– Substance abusers
– Persons who have attempted suicide previously
– More women attempt suicide; more men complete suicide
TABLE 7.4 Lethality Assessment
– Plans for suicide: when? where? how?

– Means available: what will be used? Is it available to client?
– Lethality of means (e.g., tranquilizers are less lethal when used alone than when combined with
alcohol; guns are more lethal than plan to cut wrists)
* Most lethal: gunshot, hanging, jumping from high places, carbon monoxide, potent poisons (e.g.,
cyanide)
* Less lethal: nonprescription drugs, wrist cutting, tranquilizers without CNS depressants
* Males tend to use more lethal means
– Possibility of "rescue"
– Support systems available or sense of isolation
– Availability of alcohol or drugs
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– Severe/panic level of anxiety
– Hostility
– Disorganized thinking
– Preoccupation with thought of suicide plan
– Prior suicide attempts

Psychiatric Disorders (DSM IV)
DISORDERS OF INFANCY, CHILDHOOD, AND ADOLESCENCE
Overview
1. A specific group of disorders beginning in infancy, childhood, or adolescence.
2. Clients in these age groups may also evidence other disorders such as depression or
schizophrenia.
3. Intellectual, behavioral, and/or emotional dysfunction of the young client also has an effect on the
family, which may require nursing intervention.
Assessment
Newborn/Infants
1. Maturation
2. Developmental level
3. Sensorimotor capabilities
4. Bonding
5. Response to cuddling
Children/Adolescents
1. Motor skills
2. Communication abilities
3. Vocational/academic skills
4. Social and behavioral problems
5. Behavioral changes
6. Growth and development: physical/emotional
7. Self-concept
8. Knowledge of disorder
Parent/Family
1. Response to infant/child/adolescent with disorder
2. Guilt, sense of loss
3. Sibling jealousy/resentment
4. Knowledge of disorder
5. Expectations
6. Plans for future (home care/institutionalization)
Analysis
Nursing diagnoses for a child/family with a psychiatric-mental health disorder may include
1. Client
1. Anxiety
2. Total incontinence
4. High risk for injury
6. Self-care deficits
8. Sensory-perceptual alterations
9. Sexual dysfunction
10. High risk for violence
2. Parents/family
1. Anxiety
2. Disabling, ineffective family coping
3. Altered family process
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4. Anticipatory grieving
6. Altered parenting
Planning and Implementation
Goals
1. Client will
1. Communicate thoughts and feelings about self-concept.
2. Perform tasks at optimal level of capability.
3. Develop trusting relationship with care givers.
2. Parents/family will
1. Communicate feelings and responses to child and to disorder.
2. Demonstrate knowledge of disorder.
3. Formulate plans for child's care.
Interventions
1. Client
1. Establish a therapeutic relationship by accepting client and client's limitations.
2. Promote communication by use of therapeutic techniques, play therapy.
3. Encourage independence in task performance with guidance and support.
2. Parents/family
1. Promote communication by accepting family responses.
2. Provide information about disorder.
3. Contact appropriate person/agency for consultation with family about care and assistance
with the child.
Evaluation
Client
1. Demonstrates trust in care givers.
2. Relates feelings about self verbally or symbolically.
3. Performs activities of daily living (ADL) and tasks at optimal level.
Parents/Family
1. Relate positive/negative responses to child.
2. Demonstrate understanding of disorder and child's potential.
3. With consultant, formulate a plan for child's care.
Specific Disorders
Mental Retardation
1. Significant subaverage intelligence (IQ of 70 or below) resulting in maladaptive behaviors
with onset before age of 18 years
2. Etiology
1. Heredity 5%
2. Early alterations in embryonic development 30%
3. Perinatal problems 10%
4. Acquired in infancy/early childhood 5%
5. Environmental/other mental disorders 15%-20%
6. Unknown etiology 30%-40%
3. Degrees of retardation
1. Mild mental retardation (IQ 50-70)
1. 85% of cases
2. educable to 6th grade level
3. able to become self-supporting
2. Moderate mental retardation (IQ 35-49)
1. 10% of cases
2. educable to 2nd grade level
3. able to perform skills but will need supervision at work
3. Severe mental retardation (IQ 20-34)
1. 3%-4% of cases
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2. may learn to talk/communicate
3. able to perform simple tasks and elementary hygiene
4. Profound mental retardation (IQ below 20)
1. 1%-2% of cases
2. some speech/communication possible
1. Intellectual impairment (determine degree)
2. Sensorimotor impairment
3. Communication, social, behavioral impairment
4. Lack of self-esteem and poor self-image
5. Sense of loss, guilt, nonacceptance or unrealistic expectations on part of parents/family
1. Promote optimal functioning in ADL and feelings of accomplishment, self-worth.
2. Provide opportunities for client/family to communicate thoughts, feelings.
3. Provide positive reinforcement for every success.
4. Accept client's limitations and set goals accordingly.
5. Provide support and information about disorder to family.
6. Accept family's response to client.
Other Disorders of Childhood/Adolescence

1. Separation anxiety: excessive anxiety and worry about being separated from
person(s)/places to which child has become attached (e.g., refusal to leave mother/home
to attend school)
2. Reactive/attachment disorder: reluctance to enter social relationships with others, creating
an interference with social growth
3. Overanxious disorders: pervasive, unrealistic worry or concern about competency;
somatic complaints without physical basis
2. Assessment findings: excessive anxiety related to separation, social interaction, and achievements
3. Nursing intervention: provide information regarding available mental health services for child and
family.
Disorders with Physical Manifestations

1. Important to rule out any physiologic cause
2. Often related to stress or conflict in the family
3. May affect child's family/social interactions and development
1. Enuresis: urinary incontinence (bedwetting) after age 5 not caused by physical disorder
2. Encopresis: fecal incontinence after age 4 not caused by physical disorder
3. Tics: involuntary, repetitive movements
4. Stuttering: repetition of sounds, words or frequent hesitations in speaking
1. Provide information about the disorders and emphasize that they are treatable.
2. Determine whether family therapy may be indicated, as well as individual therapy for child.
3. Offer support and help child/family overcome feelings of shame or guilt.
4. For enuresis and encopresis, utilize toilet training techniques.
5. Encourage discussion of client/family response to symptoms.
PERVASIVE DEVELOPMENTAL DISORDERS
Autistic Disorder
1. Develops prior to 3 years of age.
2. Child does not relate to people, but may become attached to objects.
3. This is a rare disorder, may have a physiologic basis.
4. Chronic disorder, more than 2/3 of these children remain severely handicapped and
dependent on care givers.
5. Special education is necessary.
6. Family may choose institutionalization for optimum care.
1. Infant not responsive to cuddling; may even show an aversion to being touched
2. No eye contact or facial responsiveness
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3. Impaired or no verbal communication
4. Echolalia (repetition of words/phrases spoken by others)
5. Inability to tolerate change
6. Ritualistic behavior
7. Fascination with movement, spinning objects
8. Labile moods
9. Unresponsive or overresponsive to stimuli
10. High risk for developing seizure disorders
1. Provide parents/family with support and information about the disorder, opportunities for
therapy and education for the child.
2. Assist child with ADL.
3. Promote reality testing.
4. Encourage child to develop a relationship with another person.
5. Maintain regular schedule for activities.
6. Provide constant routine for child (place for eating, sitting, sleeping).
7. Protect child from self-injury.
8. Provide safe environment.
9. Institute seizure precautions if necessary.
Eating Disorders
1. Gross disturbances in eating behaviors
2. Pica: persistent eating of substances such as plaster, paint, or sand
3. Bulimia nervosa: binge eating; the ingestion of large amounts of food in short time, often
followed by self-induced vomiting. May be accompanied by affective disorders and fear of
being unable to stop this behavior. Manifested by fluctuations in weight caused by binges
of eating and fasting.
4. Anorexia nervosa: refusal to eat or aberration in eating patterns resulting in severe
emaciation that can be life threatening. Characterized by a fear of becoming fat, and a
body-image disturbance where clients claim to feel fat even when extremely thin. This
disorder is most common (95%) in adolescent and young adult females. There is a
mortality rate of 15%-20%.
2. Assessment findings (anorexia nervosa)
1. Weight loss of 15% or more of original body weight
2. Electrolyte imbalance
3. Depression
4. Preoccupation with being thin; inability to recognize degree of own emaciation (distorted
body image)
5. Social withdrawal and poor family and individual coping skills
6. History of high activity and achievement in academics, athletics
7. Amenorrhea
1. Monitor vital signs.
2. Measure I&O.
3. Weigh client 3 times/week at the same time (check to be sure client has not hidden heavy
objects or water loaded before being weighed, weigh in hospital gown).
4. Do not comment on weight loss or gain.
5. Set limits on time allotted for eating.
6. Record amount eaten.
7. Stay with client during meals, focusing on client, not on food.
8. Accompany client to bathroom for at least 1/2 hour after eating to prevent self-induced
vomiting.
9. Individual/family therapy may be necessary.
10. Encourage client to express feelings.
11. Help client to set realistic goal for self and to reduce need for being perfect.
12. Encourage client to discuss own body image; present reality; do not argue with client.
13. Teach relaxation techniques.
14. Help client identify interests and positive aspects of self.
DELIRIUM, DEMENTIA, AND OTHER COGNITIVE DISORDERS
Overview
1. A group of disorders with a known or presumed etiology.
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2. Frequently manifest as dementia or delirium.
3. May be substance induced (drugs or alcohol) or caused by a disease process; etiology may be
unknown.
4. It is important for the nurse to assess behaviors rather than focus on medical diagnoses.
5. Behaviors related to impaired brain functioning may be temporary or permanent, with increasing
degeneration and eventual loss of brain function.
6. Not exclusive to old age, may complicate illnesses in any age group.
Types
1. Delirium/Rapid Development
1. Manifested by reduced awareness of environment, disorders of perception, thought,
speech, and attention deficits.
2. Usually of brief duration.
3. May occur postoperatively or following head injury, intoxication from drugs/alcohol, acute
disease, or injury.
2. Dementia/Gradual Development
1. Loss of intellectual abilities resulting in impaired social and occupational functioning.
2. May be temporary, or progressive loss may occur.
3. Found predominantly in elderly.
4. Personality changes are usually an exaggeration of former character traits (e.g.,
suspicious, nontrusting person becomes paranoid); but alteration can also occur (e.g.,
formerly neat and orderly person pays no attention to hygiene, becomes sloppy and dirty).
5. Memory impairment; short-term memory loss may be most obvious.
6. Organic etiology may be known; conditions include intoxication, infections, tumors,
circulatory disorders (cerebral atherosclerosis), trauma, Huntington's chorea, Korsakoff's
syndrome, Creutzfeld-Jakob disease, neurosyphilis.
7. Specific etiology may not be known (e.g., Alzheimer's disease, Pick's disease).
8. Frequently these clients cannot perform basic ADL.
Assessment
1. Mental status assessment, especially orientation to time and place, memory, and judgment
2. Nutritional status
3. Ability to perform ADL, self-care
4. Presence of confabulation (making up information to fill in memory gaps)
5. Behavioral/social changes
6. Disorders of perception
7. Impaired motor skills, coordination
8. Change in sleep patterns
9. Elimination: constipation/incontinence
10. Family response to client's condition
Analysis
Nursing diagnoses for clients with these disorders may include
1. Anxiety
3. Ineffective individual/family coping
4. Altered family processes
5. High risk for fluid volume deficit
7. Nutrition less than body requirements
8. Self-care deficits
10. Sleep pattern disturbance
Planning/Implementation
Goals
1. Client will
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1. Be protected from injury.
2. Retain optimal cognitive function and self-care abilities.
3. Have fear/anxiety minimized.
4. Maintain adequate nutrition/hydration.
2. Family will communicate feelings about client.
Interventions
1. Institute safety measures: side rails, frequent checks, restraints only as last resort and for
protection of client as ordered by physician.
2. Maintain reality orientation.
1. Client may not be capable of reality testing.
2. Continue to address client by name.
3. Maintain awareness of client's limitations in this area.
4. Do not tell client to "remember"; severe memory loss may make client incapable of
memory.
3. Assist/support with self-care needs; arrange for necessary assistive devices, help with feeding;
encourage fluids.
4. Avoid "insight" therapy and discussion of impaired mental functioning as this may increase anxiety.
5. Provide spouse/family with information about client's capabilities.
6. Provide support for spouse/family; encourage continued interaction with client.
Evaluation
1. Client
1. Remains free from injuries.
2. Retains cognitive functions and self-care ability as far as possible; interacts with others
appropriately.
3. Maintains appropriate weight.
2. Family
1. Expresses sense of loss or frustration related to client's condition.
2. Continues contact with client.
SUBSTANCE USE DISORDERS
Overview
1. The use of chemical agents (alcohol and drugs) to change behavior and mood
2. Abuse: continued use despite problems (social, occupational, psychologic) that are caused by
substance or continued use in hazardous situations (e.g., operating machinery, driving)
3. Dependence
1. Need for larger amounts (tolerance)
2. Unsuccessful attempts to decrease/ discontinue use
3. Inability to function as usual in work, social activities
4. Withdrawal symptoms (psychologic/physical distress when substance is
reduced/discontinued)
4. Addiction: compulsive use of a substance; physiologic and psychologic dependence
PSYCHOACTIVE SUBSTANCE-INDUCED ORGANIC MENTAL DISORDERS
The use of substances that result in intoxication or withdrawal syndromes, delirium, hallucinations,
delusions, mood disorders.
Assessment
1. Determine substances used, amount and last time taken, and if combined with other drugs
2. Pupillary changes, changes in vital signs or level of consciousness
3. Presence of dehydration
4. Presence of nutritional and vitamin deficiencies
5. Suicide potential: ideation, gestures
6. Level of anxiety
7. Use of denial/projection
8. Symptoms of overdose (will be drug-specific; see Table 7.5)
9. Drug-use patterns: what, when, why substances are used
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Analysis
Nursing diagnoses for clients with a psychoactive substance abuse disorder may include
1. Anxiety
3. Fear
4. High risk for fluid volume deficit
7. Self-care deficit
9. Sensory-perceptual alterations
Planning and Intervention
Goals
Client will…
2. Receive adequate hydration and nutrition.
3. Terminate use of substance being abused without withdrawal symptoms; emergency care will be
provided if symptoms cannot be avoided.
4. Have decreased feelings of anxiety.
5. Receive information and consider help for substance-abuse disorder
Interventions
1. Assess drug use pattern: identity, recent use, and frequency of use of prescription and
nonprescription drugs, other substances (e.g., alcohol, nicotine).
2. Support client during acute phase of detoxification or withdrawal.
1. Stay with client; reassure that current manifestations are temporary.
2. Monitor vital signs, level of consciousness.
3. Institute suicide precautions.
4. Administer medications (to prevent withdrawal) as ordered.
5. If client is experiencing panic, talk down, possibly with assistance of family/friends.
6. If client is hallucinating, reinforce reality, speak in a calm voice.
7. Confront client's use of denial.
8. Monitor your own responses of sympathy/ anger.
9. Be aware of transference/ countertransference.
10. Maintain course of action in plan of care; client must follow plan.
11. Involve staff in negotiating care plan revisions.
3. Rehabilitation/longer-term care
1. Provide nonthreatening environment.
2. Set limits on unacceptable behavior.
3. Provide adequate diet and fluids.
4. Provide information relating to substance abuse and rehabilitation programs.
Evaluation
1. Client experienced no injury.
2. Vital signs are stable.
3. Withdrawal proceeded without symptoms; client remains drug/alcohol free.
4. Client can discuss substance-abuse problem and requests or agrees to consider
rehabilitation/therapy for problem.
TABLE 7.5 Commonly Abused Drugs
Drug Effect Dependence Assessment Overdose Nursing Interventions

Findings for Overdose
Barbiturates
Antianxiety drugs, Reduction in Psychologic at first, Irritability, Slurred speech, Keep person awake
hypnotics anxiety, escape then physiologic; weight loss, lethargy, respiratory and moving to prevent
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from stress withdrawal similar to changes in depression, coma; coma; maintain airway.
alcohol withdrawal, to mood or motor use combined with
point of delirium. coordination alcohol can be lethal
Cross-tolerance to
other depressants
Opioids/Narcotics
Heroin, morphine, Euphoria, dysphoria, Psychologic dependence Pinpoint pupils, Depressed Provide emergency
meperidine, methadone and/or apathy rapidly leading to mental clouding, consciousness and support of vital functions.
physical; signs of lethargy, impaired respirations, dilated In withdrawal, administer
withdrawal: cramps, memory and pupils with anoxia or methadone or Narcan as
nausea, vomiting, judgment, polydrug use ordered.
diarrhea; sleep evidence of
disturbance, chills and needle tracks,
shaking inflamed nasal
mucosa if drug is
snorted
Stimulant
Cocaine/Crack Increased self- Dopamine deficiency Increased vital Delirium, tremors, high Emergency support of
esteem, energy, results in psychologic signs, headache, fever (106+) vital functions, reduce
sexual desire, dependency to produce chest pain, convulsions, CNS stimulation.
euphoria; decreased feelings of well-being depression and/or cardiac/respiratory
anxiety paranoia, arrest
inflamed nasal
passages if
snorted
Amphetamines
Amphetamine, Depressed appetite; Long-term use or high Same as cocaine, Same as cocaine Same as cocaine, plus
dextroamphetamine, increased activity, doses may produce plus suicidal suicide precautions.
methamphetamine awareness, sense of delirium, paranoid-like ideation Observe for increased
well-being delusions, withdrawal, anxiety to panic, which
depression, fatigue, may potentiate assaultive
sleep disturbances behavior.
Phencyclidine (PCP) Euphoria, Not reported Vomiting, Violent behavior, Monitor vital signs.
psychomotor hallucinations, suicide, respiratory Observe for suicidal or
agitation, emotional paranoid ideation, arrest, delirium, coma, assaultive behavior.
lability agitation increased blood Provide nonthreatening
pressure and pulse environment, reality
orientation, support.
Hallucinogens
LSD, mescaline Disordered Not reported "Bad trip," high Reduced LOC Same as PCP, plus talk
perceptions, anxiety to panic; client down.
depersonalization hallucinations
may occur long
after drug has
been metabolized;
flashbacks may
produce long-
lasting psychotic
disorders
Cannabis
Marijuana, hashish, Euphoria, intense Not reported Increased pulse Panic reaction, In panic, talk down. In
THC perceptions, rate and nausea, vomiting, severe depression,
relaxation, appetite; depression and institute suicide
lethargy impaired disorders of precautions.
judgment and perception
coordination
Specific Disorders
Alcohol Abuse/Dependence
1. Alcohol is a legal substance and there are millions of social drinkers.
2. Alcohol is classified as a central nervous system depressant.
3. Alcohol abuse/dependence is a major problem in this country with over 18 million adults
identified as alcohol abusers.
4. Only approximately 5% of alcohol abusers are the "skid row" type.
526
5. Incidence is increasing in women and adolescents.
6. Considered a disease that can be arrested but not cured.
7. Important to assess history of alcohol consumption for clients admitted to hospital for non-
alcohol-related disorders, because they may go into withdrawal.
8. Socioeconomic as well as a physiologic problem, resulting in increased health care costs
and loss of productivity if ability to maintain a job is impaired.
9. Alcohol used with other substances (barbiturates, antianxiety drugs) may have lethal
consequences.
10. Long-term use may result in loss of health (gastritis, pancreatitis, cirrhosis, hepatitis,
malnutrition, cardiac and neural disorders) and life (suicide, automobile accidents).
11. Directly related problems include withdrawal, delirium tremens, and alcohol-related
dementia
1. Withdrawal
1. alcohol consumption reduced/discontinued following continuous
consumption for many days or longer
2. withdrawal is progressive and has four stages:
1. at least 8 hours after last drink; symptoms include mild
tremors, tachycardia, increased blood pressure, diaphoresis,
nervousness
2. gross tremors, hyperactivity, profound confusion, loss of
appetite, insomnia, weakness, disorientation, illusions, auditory
and visual hallucinations
3. 12-48 hours after last drink: symptoms include (in addition to
those found in I and II) severe hallucinations, grand mal
seizures
4. 3-5 days after last drink (24-72 hours if untreated): delirium
tremens, confusion, agitation, severe psychomotor activity,
hallucinations, insomnia, tachycardia
3. withdrawal may last less than a week or may evolve into alcohol
withdrawal delirium (delirium tremens).
4. 10%-15% mortality rate from hypoglycemia/electrolyte imbalances.
2. Delirium tremens (DTs)
1. history of alcohol abuse usually for more than 5 years.
2. may be preceded by seizures.
3. symptoms occur 2-3 days after alcohol reduced/discontinued.
4. signs include tachycardia, increased blood pressure, agitation,
delusions, hallucinations.
3. Alcohol hallucinosis: hallucinations only
4. Alcohol-related dementia: caused by poor nutrition
1. Korsakoff's psychosis is sometimes preceded by Wernicke's
encephalopathy. Confusion and ataxia are predominant symptoms.
2. thiamine deficiency results in Korsakoff's dementia/psychosis;
symptoms include chronic disorientation, confabulation. It is irreversible.
3. large doses of thiamine may prevent the development of Korsakoff's
psychosis. See Table 7.6.
2. Medical management
1. Vitamin and nutrition therapy
2. Antianxiety drugs (Librium or Valium)
3. Disulfiram (Antabuse)
1. Produces unpleasant reaction (thirst, sweating, palpitations, vomiting, dyspnea,
respiratory and cardiac failure) when taken with alcohol.
2. 500 mg/day for 1-2 weeks; usual maintenance dose is 250 mg/day.
3. Duration of action is 1/2 to several hours; no alcohol should be taken at least 12
hours before taking drug.
4. Increases effects of antianxiety drugs and oral anticoagulants.
5. Side effects include headache, dry mouth, somnolence, flushing.
6. Nursing responsibilities
1. teach client the nature of severe reaction and importance of avoiding all
alcohol (including cough medicine, foods prepared with alcohol, etc.).
2. teach client to carry an identification card in case of accidental alcohol
ingestion.
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3. monitor effects of antianxiety drugs if being taken at the same time.
4. monitor for bleeding if taking oral anticoagulants.
4. High doses of chlordiazepoxide (Librium) to control withdrawal in acute detoxification.
1. Dependent personality; often using denial as a defense mechanism
2. Tendency to minimize and underreport amount of alcohol consumed
3. Intoxication: blood alcohol level 0.15 (150 mg alcohol/100 ml blood). Legal level 0.08-0.10.
4. Signs of impaired judgment, motor skills, and slurred speech
5. Behavior may be boisterous and euphoric or aggressive, or may be depressed and
withdrawn
6. Signs of withdrawal, DTs, or alcohol-related dementias
1. Stay with client.
2. Monitor vital signs and blood sugar levels.
3. Observe for tremors, seizures, increased agitation, anxiety, disorders of perception.
4. Administer medications as ordered; observe effects/side effects of tranquilizers carefully.
5. If disorders of perception occur, explain that these are part of the withdrawal process.
6. Provide fluids, adequate nutrition, and quiet environment.
7. When client is stable, provide information about rehabilitation programs (Alcoholics
Anonymous); at this stage client may be willing to consider a program to stop drinking.
8. Provide information about Alanon (for spouse and adult family members), Alateen (for
children), and ACOA (for adult children of alcoholics).
TABLE 7.6 Phases of Alcohol Addiction
Phase Features
Prealcoholic Drink almost every day to reduce tension
Increase in amount of alcohol ingested
Addiction Blackouts
Secret drinking
Large amounts ingested
Dependence Physical craving for alcohol
Makes up reasons for drinking
Reduced nutrition
Aggressive behavior
Pressure from family and/or employer to reduce/stop drinking
Chronic Long periods of intoxication
Impaired thinking
Less alcohol produces sedation tremors
Psychoactive Drug Use

1. Drugs abused may be prescription or "street" drugs
2. Types of drugs frequently abused
1. Barbiturates, antianxiety drugs, hypnotics
2. Opioids (narcotics): heroin, morphine, meperidine, methadone, hydromorphone
3. Amphetamines: amphetamine, dextroamphetamine, methamphetamine (speed),
some appetite suppressants
4. Cocaine, hydrochloride cocaine (crack)
5. Phencyclidine (PCP)
6. Hallucinogens: LSD, mescaline, DMT
7. Cannabis: marijuana, hashish, THC
2. Assessment findings and nursing interventions for overdoses vary with particular drug; see Table
7.5 - Commonly Abused Drugs.
3. Polydrug abusers
1. Common pattern of drug use
2. Synergistic effect: drugs interact so that effect is greater than if each drug is taken
separately
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3. Additive effect: two or more drugs with same action are taken together (e.g., barbiturates
with alcohol will result in heavy sedation).
Impaired Nurses
1. Most nursing licenses are suspended or revoked for substance abuse while on duty.
2. Substances include alcohol and/or prescription drugs pilfered from unit drug stocks.
3. Stealing drugs may result in criminal prosecution.
4. Work-related stress and easy access to drugs are factors relating to nurses' substance
abuse.
5. Substance use results in impaired judgment and psychomotor abilities, resulting in unsafe
nursing practice.
2. Assessment of impairment
1. Alcohol odor on breath
2. Frequent lateness/absences
3. Shortages in narcotics
4. Clients do not obtain pain relief after "receiving" pain reduction medication from nurse
5. Nurse makes frequent trips to bathroom/locker room
6. Changes in locomotion, psychomotor skills, pupil size, and mood/affect
3. Nurses' responsibilities related to impaired nurse colleague
1. Client safety is first priority.
2. ANA code of ethics (and some state laws) require nurse to safeguard clients.
3. Interventions for suspected substance abuse by co-worker
1. Obtain information about legal issues, treatment options, and institutional
policies.
2. Document observations related to behaviors and narcotic charting.
3. If possible, have other co-workers verify your information.
4. Arrange meeting with peer(s), nurse, supervisor, nurse advocate (where
possible) and confront nurse with documentation.
5. Let nurse know you care about him/her and will help.
6. Help nurse work through denial.
7. Provide plan to offer recovery program (e.g., include "recovering" nurse buddy).
8. Offer hope, support (moral and financial) to aid nurse in treatment.
9. Explain institutional policies regarding future employment.
10. If nurse continues to deny substance abuse, consider following steps
1. advocate should protect nurse's rights.
2. suspension/dismissal from job.
3. report to licensing board.
4. if theft of drug from unit has occurred, report to law enforcement
agency.
SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
Overview
1. Characterized by disordered thinking, delusions, hallucinations, depersonalization (feeling of being
strange, not oneself), impaired reality testing (psychosis), and impaired interpersonal relationships.
2. Regression to the earliest stages of development is often noted (e.g., incontinence, mutism).
3. Onset is usually in adolescence/early adulthood (15 to 35 years of age).
4. Client may be seriously impaired and unable to perform ADL.
5. Etiology is not known; theories include
1. Genetic: 1% of population.
2. Biochemical: neurotransmitter dysfunction i.e. dopamine, serotonin.
3. Interaction of predisposing risk and environmental stress.
6. Prior to onset (premorbid) client may have been suspicious, eccentric, or withdrawn.
Classifications
1. Disorganized: incoherent; delusions are not organized; social withdrawal; affect blunted, silly, or
inappropriate
2. Catatonic: psychomotor disturbances
1. Stupor: mute, little reaction or movement
2. Excitement: purposeless, excited motor activity
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3. Posturing: voluntary, inappropriate, bizarre postures
3. Paranoid: delusions and hallucinations of persecution/grandeur
4. Undifferentiated: disorganized behaviors, delusions, and hallucinations
Assessment
1. Four A's
1. Affect: flat, blunted
2. Associative looseness: verbalizations are disorganized
3. Ambivalence: cannot choose between conflicting emotions
4. Autistic thinking: thoughts on self, extreme withdrawal, unable to relate to outside world
2. Any changes in thoughts, speech, affect
3. Ability to perform self-care activities, nutritional deficits
4. Suicide potential
5. Aggression
6. Regression
7. Impaired communication
Analysis
Nursing diagnoses for clients with schizophrenic disorders may include
1. Anxiety
5. Altered nutrition
6. Powerlessness
9. Sensory-perceptual alteration
Goals
Client will….
1. Develop a trusting/therapeutic relationship with nurse.
2. Be oriented, able to test reality.
4. Be able to recognize impending loss of control.
5. Adhere to medication regimen.
6. Participate in activities.
7. Increase ability to care for self.
Interventions
1. Offer self in development of therapeutic relationship.
2. Use silence.
3. Set time for interaction with client.
4. Encourage reality orientation but understand that delusions/hallucinations are real to client.
5. Assist with feeding/dressing as necessary.
6. Check on client frequently, remove potentially harmful objects.
7. Contract with client to tell you when anxiety is becoming so high that loss of control is possible.
8. Administer antipsychotic medications as ordered (see Table 7.7 for side effects and dosages);
observe for effects.
1. Reduction of hallucinations, delusions, agitation
2. Postural hypotension
1. Obtain baseline blood pressure and monitor sitting/standing.
2. Client must lie prone for 1 hour following injection.
3. Teach client to sit up or stand up slowly.
4. Elevate client's legs while seated.
5. Withhold drug if systolic pressure drops more than 20-30 mm Hg from previous
reading.
3. Photosensitivity
530
1. Advise use of sun screen.
2. Avoid exposure to sunlight.
4. Agranulocytosis
1. Instruct client to report sore throat or fever.
2. Institute reverse isolation if necessary.
5. Elimination
1. Measure I&O.
2. Check bladder distention.
3. Keep bowel record.
6. Sedation
1. Avoid use of heavy machinery.
2. Do not drive.
7. Extrapyramidal symptoms
1. Dystonic reactions
1. sudden contractions of face, tongue, extraocular muscles
2. administer antiparkinson agents prn (e.g., benztropine [Cogentin] 1-8
mg or diphenhydramine [Benadryl] 10-50 mg), which can be given PO
or IM for faster relief; trihexyphenidyl [Artane] 3-15 mg PO only, can
also be used prn).
3. remain with client; this is a frightening experience and usually occurs
when medication is started.
2. Parkinson syndrome
1. occurs within 1-3 weeks
2. tremors, rigid posture, masklike facial appearance
3. administer antiparkinson agents prn.
3. Akathisia
1. motor restlessness
2. need to keep moving
3. administer antiparkinson agents.
4. do not mistake this for agitation; do not increase antipsychotic
medication.
5. reduce medications to see if symptoms decrease.
6. determine if movement is under voluntary control.
4. Tardive dyskinesia
1. irreversible involuntary movements of tongue, face, extremities
2. may occur after prolonged use of antipsychotics
5. Neuroleptic malignant syndrome
1. occurs days/weeks after initiation of treatment in 1% of clients
2. elevated vital signs, rigidity, and confusion followed by incontinence,
mutism, opisthotonos, retrocollis, renal failure, coma, and death
3. discontinue medication, notify physician, monitor vital signs, electrolyte
balance, I&O
6. Elderly clients should receive doses reduced by one-half to one-third of
recommended level
9. Encourage participation in milieu, group, art, and occupational therapies when client able to tolerate
them.
Evaluation
Client
1. Stays with nurse prescribed period of time.
2. Is oriented to reality, can state name, place, and date.
3. Can feed/dress self with specified amount of assistance.
4. Has not attempted/will not attempt to injure self or others.
5. Adheres to medication regimen with minimal side effects.
6. Participates in activities.
TABLE 7.7 Antipsychotic Medications
Dosages
531
Drug Acute Symptoms Maintenance/ Range/ Profound Side Effects
Day Day
Chlorpromazine 25–100 mg IM q1–4h 200–600 mg 25–2000 Sedation
(Thorazine) prn PO mg PO Anticholinergic effects: dry mouth, blurred
vision, constipation, urinary retention, postural
hypotension
Thioridazine (Mellaril) 200–600 mg PO in 150–300 mg 50–800 Sedation
divided doses PO mg PO
Fluphenazine HCl 1.25 mg IM, max 10 1–5 mg PO 1–30 mg Extrapyramidal effects: dystonic reactions
(Prolixin, Permitil) mg IM, divided doses PO (muscular contractions of tongue, face, throat;
opisthotonos); tremors, rigid posture; akathisia
(restlessness); tardive dyskinesia
Fluphenazine -- 25 mg IM 25–100 Extrapyramidal
decanoate/enanthate q2wk mg IM
(Prolixin, Permitil)
Trifluoperazine(Stelazine) 1–2 mg IM q4h; 2–4 2–4 mg PO 2–80 mg Extrapyramidal
mg PO, max 10 mg PO
qd
Perphenazine (Trilafon) 5–10 mg IM q6h, 16–64 mg PO 4–64 mg Extrapyramidal
max 30 mg IM qd PO
Haloperidol (Haldol) 2–10 mg IM in 2–8 mg PO 1–100 mg Extrapyramidal
divided doses PO
Thiothixene (Navane) 8–16 mg IM in 6–10 mg PO 6–60 mg Extrapyramidal
divided doses PO
Loxapine (Loxitane) -- 60–100 mg 30–250 Extrapyramidal
PO mg PO
Clozapine (Clozaril) -- 300–450 mg 75–700 Agranulocytosis; sedation
PO mg PO
Risperidone (Risperdal) -- 4–8 mg PO 4–8 mg Insomnia, extrapyramidal
PO
MOOD DISORDERS
Overview
1. Characterized by disturbance in mood (affect) that is either depression or elation (mania); occur in
a variety of patterns, alone or together (see Figure 7.1). Disturbance is beyond normal range of
mood experienced by most people.
2. Bipolar disorder: components of both depression and elation (formerly called manic-depression)
3. Cyclothymic disorder: milder symptoms of both mania and depression, often separated by long
periods of normal mood
4. Dysthymic disorder: long-standing symptoms of depression alternating with short periods of normal
mood; client usually able to maintain roles in job, school, etc.
5. Etiology is unknown; theories include
1. Genetic: approximately 7% of general population; risk is 20% if a close relative has
depression
2. Biochemical: dysregulation in norepinephrine and serotonin
3. Psychoanalytic: anger turned inward (i.e., anger toward significant other is turned into
anger toward self)
Assessment
1. Mood: dysphoric; blue/sad or elated/aggressive
2. Presence of psychomotor agitation, retardation, or hyperactivity
3. Disorders of cognition: narrowed perception and interests, impaired concentration, grandiose
delusions, flight of ideas in elation stage
4. Sexual functioning changes
5. Appropriateness of appearance/dress
6. Appetite
7. Potential for suicide
532
Analysis
Nursing diagnoses for clients with affective disorders may include:
1. Constipation
Goals
Client will…
2. Receive adequate rest and sleep.
3. Maintain adequate intake of fluids and nutrients, regular elimination.
4. Develop trusting/therapeutic relationship with nurse.
5. Be oriented to reality.
6. Participate in planned activities.
Interventions
1. Assess for suicide potential.
2. Encourage verbalization of feelings of hopelessness and helplessness.
3. Provide quiet environment for rest and sleep.
4. Provide small, attractive meals; encourage intake of fluids.
5. Maintain bowel record.
6. Use silence and broad openings, focus on client's verbal/nonverbal behaviors.
7. Present reality but accept client's need for delusions.
8. Accept client's negative responses, hostility.
9. Provide activities and tasks to raise client's self-esteem.
10. Assist with self-care as needed.
11. If client is agitated
1. Work with client on a one-to-one basis.
2. Walk with client; provide some diversional activity.
3. Reduce environmental stimuli (e.g., put in a quiet room, dim lights).
Evaluation
Client
1. Has gained or maintained weight.
2. Reports any suicidal ideation.
3. Sleeps a specified number of hours.
4. Can meet own needs for ADL.
5. Has realistic appraisal of self.
Specific Disorders
Bipolar Disorder (Manic Episode)

1. Onset usually before age 30
2. Characterized by hyperactivity and euphoria that may become sarcasm or hostility
1. Hyperactivity to the point of physical exhaustion
2. Flamboyant dress/makeup
3. Sexual acting out
4. Impulsive behaviors
5. Flight of ideas: inability to finish one thought before jumping to another
533
6. Loud, domineering, manipulative behavior
7. Distractibility
8. Dehydration, nutritional deficits
9. Delusions of grandeur
10. Possible short-term depression (risk of suicide)
11. Hostility, aggression
1. Lithium carbonate (Eskalith, Lithane, Lithotabs)
1. Initial dosage levels: 600 mg tid, to maintain a blood serum level of 1.0-1.5
mEq/liter; blood serum levels should be checked 12 hours after last dose, twice a
week.
2. Maintenance dosage levels: 300 mg tid/qid, to maintain a blood serum level of
0.6-1.2 mEq/liter; checked monthly.
3. Toxicity when blood levels higher than 2.0 mEq/liter: tremors, nausea and
vomiting, thirst, polyuria, coma, seizures, cardiac arrest
2. Antipsychotics may also be given for hyperactivity, agitation, psychotic behavior.
Chlorpromazine (Thorazine) and haloperidol (Haldol) are most commonly used (see Table
7.7 - Antipsycotic Medications).
1. Determine what client is attempting to tell you; use active listening.
2. Assist client in focusing on a topic.
3. Offer finger foods, high-nutrition foods, and fluids.
4. Provide quiet environment, decrease stimuli.
5. Stay with client, use silence.
6. Remove harmful objects.
7. Be accepting of hostile statements.
8. Do not argue with client.
9. Use distraction to divert client from behaviors that are harmful to self or others.
10. Administer medications as ordered and observe for effects/side effects.
1. Teach clients early signs of toxicity.
2. Maintain fluid and salt intake.
3. Avoid diuretics.
4. Monitor lithium blood levels.
11. Assist in dressing, bathing.
12. Set limits on disruptive behaviors.
Major Depression
1. Characterized by loss of ambition, lack of interest in activities and sex, low self-esteem,
and feelings of boredom and sadness.
2. Etiology may be physiologic or response to an actual or perceived loss.
3. These clients are at high risk for suicide, especially when depressed mood begins to lift
and/or energy level increases.
1. Tricyclic antidepressants: amitriptyline HCl (Elavil), doxepin (Sinequan), imipramine
(Tofranil); see Table 7.8
2. Monoamine oxidase inhibitors (MAOIs): isocarboxazid (Marplan), tranylcypromine
(Parnate); see Table 7.8
3. Selective serotonin reuptake inhibitors (SSRI): fluoxetin (Prozac), sertraline (Zoloft)
4. Electroconvulsive therapy (ECT)
1. Feelings of helplessness, hopelessness, worthlessness
2. Reduction in normal activities or agitation
3. Slowing of body functions/elimination
4. Loss of appetite
5. Inappropriate guilt
6. Self-deprecation, low self-esteem
7. Inability to concentrate, disordered thinking
8. Poor hygiene
9. Slumped posture
10. Crying, ruminating (relates same incident over and over)
11. Dependency
12. Depressed children: possible separation anxiety
13. Elderly clients: possible symptoms of dementia
534
14. Somatic and persecutory delusions and hallucinations
1. Monitor I&O.
2. Weigh client regularly.
3. Maintain a schedule of regular appointments.
4. Remove potentially harmful articles.
5. Contract with client to report suicidal ideation, impulses, plans; check client frequently.
6. Assist with dressing, hygiene, and feeding.
7. Encourage discussion of negative/positive aspects of self.
8. Encourage change to more positive topics if self-deprecating thoughts persist.
9. Administer antidepressant medications (see Table 7.8) as ordered.
1. Tricyclic antidepressants (TCAs)
1. effectiveness increased by antihistamines, alcohol, benzodiazepines
2. effectiveness decreased by barbiturates, nicotine, vitamin C
2. Monoamine oxidase inhibitors (MAOIs)
1. effectiveness increased with antipsychotic drugs, alcohol, meperidine
2. avoid foods containing tyramine (e.g., beer, red wine, aged cheese,
avocados, caffeine, chocolate, sour cream, yogurt); these foods or
MAOIs taken with TCAs may result in hypertensive crisis.
3. Be sure client swallows medication. If side effects disappear suddenly,
cheeking/hoarding may have occurred. These medications can be used to
attempt suicide.
4. Antidepressant medications do not take effect for 2-3 weeks. Encourage client to
continue medication even if not feeling better. Be aware of suicide potential
during this time.
5. Warn client not to take any drugs without consulting physician.
10. Assist with ECT as ordered.
1. Give normal pre-op preparation, including informed consent (see Perioperative
Nursing in Unit 4).
2. Remove all hairpins, dentures.
3. Ensure client is wearing loose clothing.
4. Check vital signs after the procedure.
5. Reorient and assure that any memory loss is temporary.
6. Assist to room or to care of responsible party if outpatient.
Dysthymic Disorder
1. General information: chronic mood disturbance of at least two years' duration for adults, one year
for children
1. Normal moods for a period of weeks, followed by depression
2. Insomnia/hypersomnia
3. Social withdrawal
4. Loss of interest in activities
5. Recurrent thoughts of suicide and death
3. Nursing interventions: same as for major depression.
TABLE 7.8 Antidepressant Medications
Drug Initiating Dosage Maintenance Side Effects

Tricyclics
Amitriptyline (Elavil, 75–100 mg 50–150 mg PO at Constipation, blurred vision, drowsiness,
Endep) PO bedtime; 80–100 mgIM orthostatic hypotension, urinary retention,
in divided doses dry mouth
Amipramine (Tofranil) 75 mg PO tid 50–150 mg PO As above
Amoxapine (Asendin) 50-mg PO tid 75–200 mg PO As above
Doxepin (Sinequan) 75–150 mg 50–150 mg PO As above
PO
Clomipramine 75–250 mg 50–150 mg PO Oversedation, anticholinergic effects,
(Anafranil) PO in divided sexual dysfunction, tremors
doses
Monoamine Oxidase
Inhibitors (MAOIs)
535
Isocarboxazid 30 mg PO in 10–30 mg PO As for tricyclics, plus angina,
(Marplan) divided doses hypoglycemia, hypertensive crisis
precipitated by ingestion of foods with
tyramine or concurrent use of tricyclics
Phenalizine (Nardil)60 mg PO in 30–60 mg PO As above
divided doses
Tranylcypromine 20 mg PO in 10–30 mg PO As above
(Parnate) divided doses
Atypical Antidepressants
Trazadone (Desyrel) 150 mg PO in 100–400 mg PO in Hypotension, priapism, drowsiness,
divided doses divided doses anxiety
Fluoxetine (Prozac) 20 mg PO 20–40 mg per day Nausea, headache, anxiety
Sertraline (Zoloft) 50 mg PO 50–200 mg per day Headache, nervousness
NEUROTIC DISORDERS
In DSM IV, the disorders formerly categorized as neurotic disorders are included in Anxiety, Somatoform,
and Dissociative Disorders. Reality testing is intact.
ANXIETY DISORDERS
Overview
1. Common element is anxiety, manifested in a variety of behaviors (see also Behaviors Related to
Emotional Distress in Unit 7).
2. Therapy relates to reduction of anxiety; when anxiety is reduced, the symptoms will be alleviated.
3. Types include generalized anxiety disorder, panic disorder, phobic disorders, and obsessive-
compulsive disorders.
Assessment
1. Level of anxiety: may be to point of panic
2. Vital signs: may be elevated
3. Reality testing: should be intact; can recognize that thoughts are irrational but cannot control them
4. Physical symptoms: no organic basis
5. Memory: possible memory loss or loss of identity
6. Pattern of symptoms: chronic with a pattern of waxing and waning or sudden onset
Analysis
Nursing diagnoses for the client with an anxiety disorder may include
1. Anxiety
2. Fear
4. Powerlessness
5. Disturbance in self-concept
Goals
Client will…
1. Develop a trusting/therapeutic relationship with nurse.
2. Recognize causes of anxiety and develop alternative coping mechanisms.
3. Reduce/alleviate symptoms of anxiety.
Interventions
1. Encourage discussion of anxiety and relationship to symptoms.
2. Provide calm, accepting atmosphere.
536
3. Administer antianxiety medications (for short-term use only) as ordered and monitor effects/side
effects.
1. Diazepam (Valium): 5-20 mg PO daily; 2-10 mg IM or IV daily
2. Chlordiazepoxide (Librium): 20-100 mg PO daily; 50-100 mg IM or IV daily
3. Alprazolam (Xanax) 0.75-4 mg PO daily
4. Oxazepam (Serax) 30-120 mg PO daily
5. Triazolam (Halcion) 0.25-0.5 mg HS
6. Side effects
1. Client may become addicted.
2. Additive effect with alcohol.
3. Dizziness may occur when treatment initiated.
4. Lower doses for elderly client.
5. Do not stop abruptly; taper doses.
4. Teach client about self-medication regimen and side effects.
Evaluation
Client
1. Can discuss causes of anxiety with nurse.
2. Demonstrates constructive coping mechanisms and ability to reduce anxiety.
3. Demonstrates knowledge of effects and hazards of antianxiety medications.
Specific Disorders
Phobic Disorders
1. Irrational fears resulting in avoidance of objects or situations.
2. Repressed conflicts are projected to outside world and eventually are displaced onto an
object or situation.
3. Client can recognize that fear of these objects/situations is irrational, but cannot control
emotional response when confronting or thinking about confronting the particular
object/situation.
1. Agoraphobia: most serious phobia; fear of being alone or in public places; may reach point
where client panics at thought of being in public places and cannot leave home.
2. Social phobias: fear of being in situations where one may be scrutinized and embarrassed
by others.
3. Specific phobias: irrational fear of specific objects/situations (e.g., snakes, insects,
heights, closed places).
1. Know that behavior modification and systematic desensitization most commonly used;
client cannot be "reasoned" out of behavior.
2. Do not force contact with feared object/situation, may result in panic.
3. Administer antianxiety medications (diazepam [Valium], imipramine [Tofranil]) as ordered.
4. Instruct in and encourage use of relaxation techniques.
Generalized Anxiety Disorder

1. Persistent anxiety for at least one month
2. Cannot be controlled by client or displaced, remains free-floating and diffuse
1. Motor tensions: trembling, muscle aches, jumpiness
2. Autonomic hyperactivity: sweating, palpitations, dizziness, upset stomach, increased pulse
and respirations
3. Affect: worried and fearful of what might happen
4. Hyperalert: insomnia, irritability
2. Encourage discussion of anxiety and its source.
3. Provide calm, relaxing atmosphere.
537
4. Administer antianxiety drugs, as ordered.
5. Observe for effects and side effects.
6. Monitor vital signs.
7. Assess for level of anxiety.
Panic Disorder (with/without Agoraphobia)

1. General information: acute, panic-like attack lasting from a few minutes to an hour.
1. Sudden onset of intense fear/terror
2. Symptoms: include dyspnea, palpitations, chest pain, sensation of smothering or choking,
faintness, fear of dying, dizziness
3. When severe, symptoms mimic acute cardiac disease that must be ruled out.
4. Client may be seen in ER.
3. Nursing interventions: same as for generalized anxiety disorder.
Obsessive-compulsive Disorder (OCD)

1. Obsession
1. Recurrent thoughts that client cannot control; often violent, fearful, or doubting in
nature (e.g., fear of contamination).
2. Client cannot keep thoughts from intruding into consciousness; eventually resort
to defense of undoing (performing ritual behavior).
2. Compulsion
1. Action (ritual behavior) that serves to reduce tension from obsessive thought.
2. Client may not desire to perform behavior but is unable to stop, as this is the only
relief from distress.
3. May interfere with social/occupational functioning.
1. Allow compulsive behavior, but set reasonable limits.
2. Permit client to complete behavior once started; aggression may result if behavior is not
allowed or completed.
3. Engage client in alternative behaviors (client will not be able to do this alone).
4. Provide opportunities to perform tasks that meet need for perfectionism (e.g., stacking and
folding linens).
5. As compulsive behavior decreases, help client to verbalize feelings, concerns.
6. Help client to make choices, participate in decisions regarding own schedule.
7. Administer clomipramine (Anafranil) as ordered. Gradual decrease in symptoms may take
2-3 months. Often used with behavior modification therapy (see Table 7.8 -
Antidepressant Medications).
Posttraumatic Stress Disorder (PTSD)

1. Disturbed/disintegrated response to significant trauma
2. Symptoms occur following crisis event such as war, earthquake, flood, airplane crash,
rape, or assault
3. Reexperiencing of traumatic event in recollections, nightmares
1. Psychic numbing: not as responsive to persons and events as to the traumatic experience
2. Sleep disturbances (e.g., nightmares)
3. Avoidance of environment/activities likely to arouse recall of trauma
4. Symptoms of depression
5. Possible violent outbursts
6. Memory impairment
7. Panic attacks
8. Substance abuse
1. Arrange for individual or group psychotherapy with others who experienced same trauma
(e.g., Vietnam war veterans).
2. Provide crisis counseling, family therapy as needed.
3. Provide referrals.
SOMATOFORM DISORDERS
538
Overview
1. Anxiety is manifested in somatic (physical) symptoms.
2. There is organic pathology but no organic etiology.
3. Symptoms are real and not under voluntary control of the client.
4. Defense used is somatization or conversion: anxiety is transformed to a physical symptom.
Specific Disorders
Somatization Disorder
1. Multiple, recurrent somatic complaints (fatigue, backache, nausea, menstrual cramps)
over many years
2. No organic etiology for these complaints
1. Complaints chronic but fluctuating
2. History of seeking medical attention for many years
3. Symptoms of anxiety and depression
4. Somatic complaints may involve any organ system
1. Be aware of own response (irritation/impatience) to client.
2. Rule out organic basis for current complaints.
3. Focus on anxiety reduction, not physical symptoms.
4. Minimize secondary gain.
Conversion Disorder
1. Sudden onset of impairment or loss of motor or sensory function.
2. No physiologic cause.
3. Defenses used are repression and conversion; anxiety is converted to a physical
symptom.
4. Temporal relationship between distressing event and development of symptom (e.g.,
unconscious desire to hit another may produce paralysis of arm).
5. Primary gain: client is not conscious of conflict. Anxiety is converted to a symptom that
removes client from anxiety-producing situation.
6. Secondary gain: gain support and attention that was not previously provided. Tends to
encourage client to maintain symptoms.
1. Sudden paralysis, blindness, deafness, etc.
2. "La belle indifférence": inappropriately calm when describing symptoms
3. Symptoms not under voluntary control
4. Usually short term; symptoms will abate as anxiety diminishes
1. Focus on anxiety reduction, not physical symptom.
2. Use matter-of-fact acceptance of symptom.
3. Encourage client to discuss conflict.
4. Do not provide secondary gain by being too attentive.
5. Provide diversionary activities.
6. Encourage expression of feelings.
Pain Disorder
1. General information: complaint of severe and prolonged pain
1. Pain impairs social/occupational function
2. Pain often severe
3. Sleep may be interrupted by experience of pain
1. Pain management
2. Encourage participation in activities
Hypochondriasis
539
1. Unrealistic belief of having serious illnesses.
2. Belief persists despite medical reassurance.
3. Defenses used are regression and somatization.
1. Preoccupation with bodily functions, which are misinterpreted.
2. History of seeing many doctors, many diagnostic tests.
3. Dependent behavior: desires/demands great deal of attention.
1. Rule out presence of actual disease.
2. Focus on anxiety, not physical symptom.
3. Set limits on amount of time spent with client.
4. Reduce anxiety by providing diversionary activities.
5. Avoid negative response to client's demands by discussing in staff conferences.
6. Provide client with correct information.
DISSOCIATIVE DISORDERS
Overview
1. Sudden change in client's consciousness, identity, or memory.
2. Loss of memory, knowledge of identity, or how individual came to be in a particular place.
3. Defenses are repression and dissociation.
Specific Disorders
Dissociative Amnesia
1. General information: inability to recall information about self with no organic reason
1. No history of head injury
2. Retrograde amnesia, may extend far into past
1. Rule out organic causes.
2. Reassure client that his/her identity will be made known to him/her.
3. Provide safe environment.
4. Establish nurse-client relationship to reduce anxiety.
Dissociative Fugue
1. Client travels to strange, often distant place; unaware of how he traveled there, and
unable to recall past.
2. May follow severe psychologic stress.
1. Memory loss
2. May have assumed new identity
3. No recall of fugue state when normal functions return
3. Nursing interventions: same as for psychogenic amnesia.
PERSONALITY DISORDERS
Overview
1. Patterns of thinking about self and environment become maladaptive and cause impairment in
social or occupational functioning or subjective distress.
2. Usually develop by adolescence.
3. Most common is borderline personality disorder.
Specific Disorders
Borderline Personality Disorder

1. General information: clients are impulsive and unpredictable, have difficulty interacting;
characterized by behavior problems
1. Unstable, intense interpersonal relationships
2. Impulsive, unpredictable, manipulative behavior; prone to self-harm
540
3. Marked mood shifts from anger to dysphoric
4. Uncertainty about self-image, gender identity, values
5. Chronic intolerance of being alone, feelings of boredom
6. Splitting: distinct separation of love and hate. Views others as all good or all bad.
7. Use of projection and regression
1. Protect from self-mutilation, suicidal gestures.
2. Establish therapeutic relationship, be aware of own responses to manipulative behaviors.
3. Maintain objectivity.
4. Use a calm approach.
5. Set limits.
6. Apply plan of care consistently.
7. Interact with clients when they demonstrate appropriate behavior.
8. Teach relaxation techniques.
Antisocial Personality Disorder

1. Chronic history of antisocial behaviors (e.g., fighting, stealing, aggressive behaviors,
substance abuse, criminal behaviors).
2. These behaviors usually begin before the age of 15 and continue into adult life.
3. May be hospitalized for injuries.
1. Manipulative behavior, may try to obtain special privileges, play one staff member against
another
2. Lack of shame or guilt for behaviors
3. Insincerity and lying
4. Impulsive behavior and poor judgment
1. Provide model for mature, appropriate behavior.
2. Observe strict limit-setting by all staff.
3. Monitor own responses to client.
4. Demonstrate concern, interest in client.
5. Reinforce positive behaviors (socialization, conforming to limits).
6. Avoid power struggles.
Psychologic Aspects of Physical Illness
STRESS-RELATED DISORDERS
Overview
1. Actual physiologic change in structure/function of organ or system
2. May be referred to as psychosomatic or psychophysiologic disorders
3. Theorized that client's response to stress is a factor in etiology of disease
4. Stress/anxiety not the sole cause but may be a causative factor in the development/exacerbation of
physical symptoms
5. See Table 7.9 for types of disorders with a stress component.
Assessment
1. Health history, family history
2. Physical symptoms
3. Social/cultural considerations
4. Coping behaviors
Analysis
Nursing diagnoses for stress-related disorders may include any nursing diagnosis specific to the physiologic
problem as well as….
3. Health-seeking behaviors
541
Goals
Client will…
1. Receive appropriate treatment for any physical symptoms (e.g., maintenance of blood pressure
within normal range).
2. Recognize relationship of stress to physical symptom(s).
3. Acknowledge coping patterns that may affect recurrence of physical symptoms.
4. Recognize relationship of self-concept, self-esteem, role performance to disorder.
5. Develop alternative coping behaviors.
Interventions
1. Provide nursing care specific to physical symptoms.
2. Establish nurse-client relationship.
3. Encourage discussion of psychosocial problems.
4. Explain relationship of stress to physiologic symptoms.
5. Encourage client to devise alternative coping behaviors, changes in environment, attitude.
6. Role play new behaviors with client.
Evaluation
1. Goals specific to client's physical symptoms have been met.
2. Client
1. Is able to relate stress to physical symptoms.
2. Develops alternative coping behaviors.
3. Engages in role playing of new behaviors.
TABLE 7.9 Types of Stress-Related Disorders
Systems Examples
Respiratory Asthma, common cold
Circulatory Hypertension, migraine headaches
Digestive Peptic ulcers, colitis
Skin Hives, dermatitis
Musculoskeletal Rheumatoid arthritis, chronic backache
Nervous Fatigue
Endocrine Dysmenorrhea, diabetes mellitus

VICTIMS OF ABUSE
Overview
1. Abuse is physical or sexual assault, emotional abuse, or neglect.
2. Victims are helpless or powerless to prevent the assault on their bodies or personalities.
3. Sometimes victims blame themselves for the assault.
4. The abusers often blame the victims, have poor impulse control, and use their power (physical
strength or weapon) to subject victims to their assaults.
5. Victims include children, spouse, elderly, or rape victims; each will be described separately.
Child Abuse
Overview
1. Over one million cases reported each year
2. Suspected child abuse must be reported
3. Abusing adults (parents) often have been victims of abuse, substance abusers, have poor impulse
control
4. Battered-child syndrome: multiple traumas inflicted by adult
5. Sexual abuse/incest: common types of child abuse
6. Health care workers often experience negative feelings toward abuser
7. (see Growth and Development Issues - Child Abuse in Unit 5).
Assessment
542
1. Physical signs/behaviors or physical/sexual abuse (see Table 7.10)
2. Signs of neglect: hunger, poor hygiene/nutrition, fatigue
3. Signs of emotional abuse: habitual behaviors (thumb sucking, rocking, head banging),
conduct/learning disorders
Analysis
1. Situational low self-esteem
2. Fear
3. Pain
4. Altered parenting
5. Posttrauma response
6. Powerlessness

1. Goals
1. Client (child) will be safe until home assessment made by child welfare agency.
2. Child will participate with nurse (therapist) for emotional support.
3. Client (parent(s)) will be able to contact agencies to deal with own rage/helplessness.
4. Parent(s) will participate in therapy (group or other required).
2. Interventions
1. Provide nursing care specific to physical/emotional symptoms.
2. Conduct interview in private with child and parent(s) separated.
3. Inform parent(s) of requirement to report suspected abuse.
4. Do not probe for information or try to prove abuse.
5. Be supportive and nonjudgmental.
6. Provide referrals for assistance and therapy.
3. Evaluation
1. Physical symptoms have been treated.
2. Child safety has been ensured.
3. Parent(s) have agreed to seek help.
TABLE 7.10 Symptoms of Child Abuse
Physical Abuse Sexual Abuse

Pattern of bruises/welts Pain/itching of genitals
Burns (cigarette, scalds, rope) Bruised/bleeding genitals
Unexplained fractures/dislocations Stains/blood on underwear
Withdrawn or aggressive behavior Withdrawn or aggressive behavior
Unusual fear of parent/desire to please parent Unusual sexual behaviors
Spouse Abuse
Overview
1. Estimates of five million women assaulted by mate each year
2. Stages
1. Tension builds: verbal abuse, minor physical assaults
1. Abuser: often reduces tension with alcohol/drugs
2. Abused: blames self
2. Acute battering: brutal beating
1. Abuser: does not recall incident
2. Abused: depersonalizes, may seek separation/divorce
Both parties in shock
3. Honeymoon: make-up stage
1. Abuser: apologizes and promises to control self
2. Abused: feels loved/needed; forgives/believes abuser
4. Cycle repeats with subsequent battering usually more severe
Assessment
1. Headache
2. Injury to face, head, body, genitals
543
3. Reports "accidents"
4. Symptoms of severe anxiety
5. Depression
6. Insomnia
Analysis
2. Anxiety
3. Pain
4. Ineffective, disabling family coping

Goals: Client will
1. Admit self and/or children are victims of abuse
2. Describe plan(s) for own/children's safety
3. Name agencies that will assist in maintaining a safe environment
Interventions
1. Crisis stage
1. Provide safe environment
2. Treatment of physical injuries; document
3. Encourage verbalization of actual home environment
4. Provide referral to shelters
5. Encourage decision making
2. Rebuilding stage: therapy (individual, family and/or group)
Evaluation
Client will be protected from further injury
Elder Abuse
Overview
1. Estimates one-half million to over one million cases per year.
2. Women, over age 70, with some physical/psychological disability are most frequent victims.
3. Neglect is most common, followed by physical abuse, financial exploitation, and sexual
abuse/abandonment.
4. Victims do not always report abuse because of fear of more abuse/abandonment by caretaker(s).
Assessment
1. Malnutrition
2. Poor hygiene, decubiti
3. Omission of medication/overmedication
4. Welts, bruises, fractures
Analysis
2. Fear
3. Anxiety
5. Powerlessness
6. Situational low self-esteem

Goals
1. Client will be free from injury.
2. Client will receive adequate nutrition, hydration, prescribed medication.
3. Client will notify nurse if further abuse takes place.
4. Caregiver will verbalize plans to meet own needs.
5. Caregiver will seek assistance to meet client's needs when necessary.
544
Interventions
1. Refer to state laws for reporting elder abuse and nurse's liability.
2. Obtain client's consent for treatment and/or transfer.
3. Document physical/emotional condition of client.
4. Refer client/caregiver to agencies for assistance.
5. Encourage client and caregiver to discuss problems.
6. Encourage communication between client and caregiver.
Evaluation
1. Client will remain free of injury, effects of neglect.
2. Caregiver will utilize support systems for self.
Rape
Overview
1. Estimates of occurrence vary; only ten percent reported
2. Most victims are female between ages of 15-24 years
3. Response to rape
1. Shock: panic to overly controlled
2. Outward adjustment: "manages" life but may make drastic changes (e.g., moves, leaves
school/job)
3. Integration: acknowledges response (e.g., depression, fear, rage)
Assessment
1. Physical injury
2. Emotional response: controlled/hysterical
Analysis
1. Rape trauma syndrome
1. Acute: immediate to two weeks (anger, fear, self-blame)
2. Long-term: nightmares, phobias, seeks support
2. Silent reaction: anxiety, changes in relationships with men, physical distress, phobias
3. Posttrauma response
Goals: Client will….

1. Express response to assault
2. Verbalize plan to handle immediate needs
3. Seek assistance from rape counselor
4. Discuss need for follow-up counseling
5. Report (long-term) reduction of physical and emotional symptoms.
Interventions
1. Give emotional support in nonjudgmental manner.
2. Maintain confidentiality: client must give consent for reporting rape and for medical examination.
3. Listen to client, encourage expression of feelings.
4. Document physical findings. Put evidentiary garments in paper bag.
5. Provide referral to rape counselor and follow-up care.
Evaluation
1. Client seeks support from family/agencies.
2. Client verbalizes emotional response to rape.
3. Long-term: client reports return to prerape life-style.
CRITICAL ILLNESS
Overview
1. Individuals in critical life-threatening situations have realistic fears of death or of permanent loss of
function.
545
2. Clients and their families may respond to these crises with denial, anger, hostility, withdrawal, guilt,
and/or panic.
3. Loss of control and a sense of powerlessness can be overwhelming and detrimental to chance of
recovery.
Assessment
1. Physiologic needs (first priority)
2. Anxiety level of client/family
3. Client/family fears
4. Coping behaviors of client/family
5. Social and cultural considerations
Analysis
Nursing diagnoses for the psychologic component of critical illness may include
1. Anxiety
2. Hopelessness
5. Fear
6. Powerlessness
7. Altered self-concept
Goals
1. Client will..
1. Receive treatment for physiologic problems.
2. Experience decrease in level of anxiety/fear.
3. Discuss anxiety/fears with nurse.
2. Family will…
1. Be informed of client's condition on regular basis.
2. Discuss anxiety/fears with nurse.
3. Provide appropriate support to client.
Interventions
1. Provide nursing care specific to physiologic problems.
3. Explain all procedures slowly, clearly, concisely.
4. Provide opportunities for client to discuss fears.
5. Provide opportunities for client to make decisions, have as much control as possible.
6. Encourage family to ask questions.
7. Recognize negative family responses as coping behaviors.
8. Encourage family members to support each other and client.
Evaluation
1. Goals specific to client's physiologic status have been met.
2. Client
1. Demonstrates a decrease in anxious behaviors.
2. Is able to express fears verbally.
3. Has participated in decisions whenever possible.
3. Family members
1. Have discussed fears.
2. Demonstrate support for each other and for client.
CHRONIC ILLNESS
Overview
1. Chronic illnesses, such as diabetes mellitus, multiple sclerosis, or illnesses/injuries resulting in loss
of function or loss of a body part necessitate adaptation to the inherent changes imposed.
2. Clients/families may respond to the losses associated with chronic illness with a variety of
behaviors and defenses, including recurrent depression, anger and hostility, denial, or acceptance.
546
Assessment and Analysis
Same as stress-related disorders (see Psychologic Aspects of Physical Illness) as well as
1. Ineffective family coping
2. High risk for violence, self-directed
Planning and Intervention
Goals
1. Client will…
1. Receive appropriate treatment for any physiologic symptoms.
2. Be able/willing to discuss responses to illness.
3. Recognize effect of illness on aspects of self-concept.
4. Develop realistic plans for activities and role functions.
5. Contract with nurse to report depression/suicidal ideation.
2. Family will….
1. Be able to discuss responses to client illness.
2. Develop plans to deal with alterations in client's behaviors and functions.
Interventions
1. Provide nursing care specific to physiologic problems.
2. Develop nurse/client relationship through active listening, acceptance of positive and negative
client responses.
3. Encourage client to plan activities within present capabilities.
4. Provide information about illness, suggestions for activities.
5. Contract with client to request support in times of depression and to report suicidal ideation.
6. Encourage family members to discuss their response to client's illness.
7. Be accepting and nonjudgmental of negative responses (e.g., anger, hopelessness).
8. Support family efforts to develop plans for their participation in client's care.
Evaluation
1. Client
1. Receives appropriate treatment for any physiologic problems.
2. Recognizes/discusses positive and negative responses to illness.
3. Understands effects of feelings about body image, self-esteem, role function.
4. Agrees to report depression or suicidal thoughts.
2. Family
1. Discusses positive and negative responses to client's illness.
2. Plans/engages in appropriate activities with client.
AIDS
Overview
1. In the U.S., many thousands of reported cases and deaths, estimates between 1 and 2 million
infected.
2. Highest risk populations: homosexual/bisexual men, I.V. drug users and their sexual partners,
hemophiliacs, newborns from infected mothers.
3. Approximately 60% of persons with AIDS develop neurological symptoms.
4. Health care workers may have difficulty caring for these clients because of fear of contagion,
knowledge deficit, bias against life-style, or burnout.
5. Families/partners will require support, education, and/or counseling.
Assessment
1. Physical symptoms
1. Fever
2. Fatigue
3. Weight loss
4. Diarrhea
5. Opportunistic infections
2. Neurological and emotional responses
1. Depression
2. Panic disorders
3. Paranoid reaction
547
4. HIV dementia complex
3. See AIDS, in Unit 4, for other physical assessment findings.
Analysis
1. Anxiety
2. Fear
6. Powerlessness
8. Social isolation
Goals
1. Client will…
1. Communicate responses (physical and psychologic) to disease process
2. Maintain ADL as long as possible
3. Report suicidal ideation/impulses
2. Family/partners will…
1. Seek support and education relating to care of HIV-positive client
2. Communicate responses to client's illness to nurse/support group
3. Health care workers will…
1. Discuss feelings of homophobia, addictophobia, and fear of infection
2. Attend groups for education and support
Interventions
1. Monitor cognitive and affective domain.
2. Encourage communication of fears and concerns.
3. Maintain nonjudgmental attitude.
4. Assist client/family through grieving process.
5. Provide opportunities for decision making to client and/or caregivers.
Evaluation
1. Client participates in care decisions.
2. Client and caregivers discuss responses to illness.
3. Client expresses anger but does not harm self.
DEATH AND DYING
Overview
1. One of the most difficult issues in nursing practice
2. Often difficult for nurses to maintain objectivity because of identification and response to death
based on own value system and personal experiences
Assessment
1. Stage of dying (Kubler-Ross); see Table 7.11
2. Physical discomfort
3. Emotional reaction (withdrawal, anger, acceptance) and stage of dying
4. Desire to discuss impending death, value of own life
5. Level of consciousness
6. Family needs
548
TABLE 7.11 Stages of Dying
1. Denial and isolation

2. Anger
3. Bargaining
4. Depression
5. Acceptance
Analysis
Nursing diagnoses for the dying client may include
1. Anxiety
2. Pain
4. Fear
6. Hopelessness
7. Impaired mobility
8. Powerlessness
Goals
1. Client will…
1. Be maintained in optimum comfort.
2. Not be alone.
3. Have opportunity to discuss what death means and to progress through stages of dying.
2. Family will have opportunity to be with client as much as they desire.
Interventions
1. Recognize clients/families have own way of dealing with death and dying.
2. Support clients/families as they work through dying process.
3. Accept negative responses from clients/families.
4. Encourage clients/families to discuss feelings related to death and dying.
5. Support staff and seek support for self when dealing with dying client and grieving family.
Evaluation
1. Client
1. Takes opportunity to discuss feelings about impending death and eventually
acknowledges inevitable outcome.
2. Is comfortable and participates in self-care for as long as possible.
2. Family discusses feelings about loss of loved one.
GRIEF AND MOURNING
Overview
1. Response to loss (person, body part, role)
2. Biologic, psychologic, social implications
3. Family system effects
4. Mourning is process to resolve grief
1. Shock, disbelief are short term
2. Resentment, anger
3. Concentration on loss
1. Possible auditory, visual hallucinations
2. Possible guilt
3. Possible fear of becoming mentally ill
4. Despair, depression
5. Detachment from loss
6. Renewed interest, investment in others/interests
549
Assessment
1. Weight loss
2. Sleep disturbance
3. Thoughts centered on loss
4. Dependency, withdrawal, anger, guilt
5. Suicide potential
Analysis
2. Hopelessness
Goals
Client/family will…
1. Discuss responses to loss.
2. Resume normal sleeping/eating patterns.
3. Resume ADL as they accept loss.
Interventions
1. Encourage client/family to express feelings.
2. Accept negative feelings/defenses.
3. Employ empathic listening.
4. Explain mourning process and relate to client/family responses.
5. Refer client/family to support groups.
Evaluation
Client/family
1. Express feelings.
2. Progress through mourning process.
3. Seek necessary support groups.
550

Unit 7: Psychiatric-Mental Health Nursing

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Unit 7: Psychiatric-Mental Health Nursing

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Unit 7: Psychiatric-Mental Health Nursing

 Be aware of your own feelings and responses.

Overview of Psychiatric-Mental Health Nursing

Psychodynamic/Psychoanalytic Model (Freud)

Psychosocial Model (Erikson)

Interpersonal Model (Sullivan)

Therapeutic Nurse-Client Relationship (Peplau)

Human Motivation/Need Model (Maslow)

Behavioral Model (Pavlov, Skinner)

Community Mental Health Model

Mental Status Assessment

Emotional Status Assessment

PLANNING AND IMPLEMENTATION

Table 7.1 (below) lists types of therapeutic groups.

TABLE 7.1 Types of Therapeutic Groups

Type Goal(s) Example

BEHAVIORS RELATED TO EMOTIONAL DISTRESS

TABLE 7.2 Defense Mechanisms

Type Characteristics Example

Hostility and Aggression

TABLE 7.3 Groups at Increased Risk for Suicide

– Adolescents/young adults (ages 15–24)

TABLE 7.4 Lethality Assessment

– Plans for suicide: when? where? how?

DISORDERS OF INFANCY, CHILDHOOD, AND ADOLESCENCE

Planning and Implementation

Other Disorders of Childhood/Adolescence

Disorders with Physical Manifestations

PERVASIVE DEVELOPMENTAL DISORDERS

DELIRIUM, DEMENTIA, AND OTHER COGNITIVE DISORDERS

SUBSTANCE USE DISORDERS

PSYCHOACTIVE SUBSTANCE-INDUCED ORGANIC MENTAL DISORDERS

Planning and Intervention

TABLE 7.5 Commonly Abused Drugs

Drug Effect Dependence Assessment Overdose Nursing Interventions

TABLE 7.6 Phases of Alcohol Addiction

Psychoactive Drug Use

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Planning and Implementation

TABLE 7.7 Antipsychotic Medications

Planning and Implementation

Bipolar Disorder (Manic Episode)

TABLE 7.8 Antidepressant Medications

Drug Initiating Dosage Maintenance Side Effects

Planning and Implementation

Generalized Anxiety Disorder

Panic Disorder (with/without Agoraphobia)

Obsessive-compulsive Disorder (OCD)

Posttraumatic Stress Disorder (PTSD)

Borderline Personality Disorder

Antisocial Personality Disorder

Psychologic Aspects of Physical Illness

Planning and Implementation

TABLE 7.9 Types of Stress-Related Disorders

Planning and Implementation

TABLE 7.10 Symptoms of Child Abuse

Physical Abuse Sexual Abuse

Planning and Implementation