tangential

blocking
scapegoating
cgnfidenWty
thebry base
social skills

s&&&=sd && m;

t.,dshn*-p ', , a-5.

kg'wmq~ . om&.
e@a,l?J%t.&d,$aW ~

~ ~

0 UT'MNE
--.

Group Work
P r a c e S ~ ~ Conmlt
a6
Roles
Role d t h e Grow Leader
&DUP 8ft'tl~

:g~ag@
a f Gronp Dmlopnrent
Group h e 8
?h2ps df Grotlp1
Foms~d Gronps
Psychotherapy Gmups
=@& crrapterr
a
uroup rroms .:lL~ I

. > >. ,
., . .
. .
not :M
appptiate inappropriate

&&&*;@a*E
, m;,-ms
components af an interaction are content and process:

look at the no- developing in the group, and deter-

es of d e c t i v e group action.

marl&&&&ng or h @ k gkg&&'
!&h&&on-a
m (amw-~&

Be&& m-

L -
.-.. I..
spqmam d n d aql i ~ q 3sasels moph ssar$oxd &o& UO W q m
p 0; pddns %upagopm ~&WOJ 'smamoxd Bq.~o~dra Qowesm!
$@rnwm a* d n d aql sadpue pue 1sa6fiasse~sanrasqos-1
duo$ a q .slapxaI
~ q s o m a q q a q mued m q m d n d
~r?yl pqou uaaq e q 11q%naq.ss$aqmam v 30 %UQLO~WJ p a '&
ngou (iltqnp~ sazeasuomap spml am $eyl mom
.- p m l&m
- p a s ~uamaBE.mmua'uuexa101 i&gpn~ Y%wuemapun :Brq~onaj
aql SpIIpnl JapBJi aQJ0 S l O P l '~ ~~ 0 .Pa9
8 ?~PWJE Tv u I
S D
dm3 atp aqsse prre u a ~ e 3 ~ maAp3ag m qapom s p q a-
~ q d e l~o q'JWW v l O ~ q e~pasapImm
q aq m ~apealdnoB aw
 I
I;ommynWon smcture m e f a to the exchange of though- and
messages. L ~ o katwho talks to whom, who listens to whom, aad who
respomb to wkm Also be awatx of who do= not partidpate in the
communication Smctuce.
SocimneCriC structure & fato prefmence and intapersonal
macy.Look at who refers to w h m iD the group and who sits next to
whom carefuny obgewe phHiml proxbify, fadal qmssion, m e of
Mice, and eye eontact
The environment Mmnc& the gratqh and development of the
@up. Group enpironmenf include$room s&et phydd location, type
of iimimCie,, mnfkrtable chairs], seating aanganats, and edu-
cational rwmces ( i . ~blackboard,
, video). 6bsex&%on &the @oup
atmosphere. is imptmt, Ts the guup mngerrid and frimdly? Are
unplmmt feelings expressed? Do group membem cT.imgrec.7 Are
memhtem sparttaneous or WitMrawn?

FUNCTIONS OF CRWUPS
W e are two basic functions oFgrpups: task and maintenanm The
task function keeps the gzoup on target and g& the jab done, Some
behaviors that omm daring task are initiating artiviQ, s e w fnfar-
miltian, g%ng or uking fmfee&actC, wortbat@+ surmnarizing, and
evalqa&. %k functidn can be slowmoving m 6 be d e b 9 & need
tobe defixed, and ~ m d n to 5 wntmt
The &&ee h & m i is to stwng&en the group spidt and
$a&& tbe me& of p u g members. Some behaviors dmZng mainte-
nance are standard setting1CQnsWUstesting, en~uraghg, enmgtzing,
- "
and a m i n s a BOUD feeha .,~~ functions ereate an &ec.
tive g&up atmosphere among pronp members so t h y can attempt to
worktogetha in a smooth and maan& If maintenance func-
rions are ipadqateI nonfunctianal bef~avimssuch aS the folkmi%
usuauy occur:
W Blocking-resjstiug eontributiam of other group members or
going off on a tangent with welated infarmation
W Domibati@-manipulatiw&conwolung
GXovnk+-ho~'singmom& dismpting the group, mimicking
anothCr group mernba:
6 Self-confessing-telling all, using the group a s o u n b g bomd
m t h d r a ~ - p u B n g away from the group althou$h remain-
ing phsgiraIly in the group; sometimes - 8- to other* or
wandering f r m the subject
4 &apegoating-someone bearing the Mame for o T h S I
 I aewnqcr~y i,~scrcunity
'.La*i3
gfigtita~iom [,
wuw$u@pum .I,
2 comic% .Ft'ustmon arwhtlon
:Resistance
8 CGihesiqn r.rmng,m& brooirvuar%
<,~.
neVd roles
oraanes?:
4 co~rab~m$m,g: workmg @g;@per .yetwe proRlem
.summariq~~ sq~vrng:,
wa~u&trng

be no break and wayone is ixpxied to remain in the mom during

the session Startin$ and finishing the session on time will conti-ibute
to an organized group style.
Reserve time at the end of the swsion for sllmmarizing. At h t
the group leader can summarize by da&kg the b e or problem dis-
cussed and focus on ideas that emerged h the group and any goals
or actions decided on Later, as the group's cohesivenm and wUabo-
Iaung spirit is in placa thegroup leader can ask for a p u p member
to volunteer to summarize for thegroup what happened at the session 1 Function 1
GROUP PHASES mslc
The group phases on be divided ioto the foUowing categories: initial
or orientation, worktng, termination, and d u a t i o n In orientation
phase, the p u p settles down to work The members size each other
up and 1ookt;arapproval,acceptaace, aad respert Qesbons the group
1
croup Database
Maintenance

might ask are the following: Why are we here? What are we going
to set as our goals and how are we gain$ to get this done? There is Phases
usuall-j a polite atmosphere with dependency needs being expressed
toward the gfoup leader. The group discusses its purpose, and group orlentation
mles are discussed to arrive at a g o r p cantract Conilktwill &ace as WOrRIng
group members become preoccupied with wntFol and paver. During Termination
the co& phase, the group may even insist that the leader "5x it?for
EValUatlon
t h a n Carl Rogers describes this first stage as lnilling around, with
group members demomfratfng a resistance to e&pressing. Pasl pason-
 Yalom has described cuatim f a e s that occur in the p u p .
Some of Yalonts cur&% factors W d e the foil*
Installation and maintaunee of hope
'Others have the same problems as I do."
m UM6aliW
"We are people-all in the same boat'*
H A&miml hts, feelings, coptng sl(llls,and social support.
'? am n w putting then& of others above my anm ae]E8
I Self-wldersstanding June32D-.$eptemBW I!
T amleambgwhpl Wnkand feeltheway1 do. IY2%e@ks, eVew Wedbesday)
I have some hang-ups from lox ago."
Group cohesiveness
T be- to a group now, and I ain being accepted ?q
others."
m Catharsis
'T gn kgbming to express my posith~andnegative feelings
w a r d other group membm. I Eke being able to say what
bothem me!

TYPES OF GROUPS
Nurses may encounter many types-of groups. The primary parpose of
a group is to be therapeufic to the gmup m e m k through support-
ing,educating, motiva~g,and problem solving with them. A gmup
needs a purpose statement*length oftime to meet and date, time+ and
place of meeting. Becoming moxe popular in outpatient settings are
closed groups with specific membmhfp, specific time flames, and a
set number of sessions. See F g u e 7-2 for a typical announcement of a
speeiahzd gmup meetin& Following are some sample groups

The tea- group presents specific information Active partidpatian

by the members is- encouraged Ceg, a four-week nutritional g r o q led
by the dieticianfor catdiac elients, a ~lledicationgroup m-led by a nurse
and pharmacist for inpatient ps;]rchit.ricclients).

Discussion Group ib
The d i s ~ ~ ~ sgroup
i o n encourages communication and ' ~ bbuilding
e of
the indi~dual'sself-esteem. It usually had an educational and %&ha-

porthe empathy and -bing loneliness. In most cases, &mt@
must have a rea* abiiiy suitable for na~lgathgin eqfompace and
hand m m b t i a nto operate a wmputes moase.
FQcuSedTask Groups
Group -d occur in a wide varietg- of situations in our work env2-
ronment task groups? team meetings, and mmdtees. We are
asslgntd themes or problenns t~ mlve through working with others,If
a w om mi tree is not fuilctioningat an optfnxun l e d obsewe lowvvork
behavioz sod&zhg, pbyfuhms, casual wnvezsing, attitude Boring
not humesd wasting my meldand leadershir, style (no dkctiola),A
$ o q fa& must look at the time avaikhleand wUt dedsions need to
bemade. AUocath?g five minnw to agenda setting can save time and
make cemb that each undmtands the problems to be dis-
cum?& an& h resourm needed. Setting priodtia and h e b i t s
allom the p u p to be 8 d e yet have a sense of o m a t i o n List
p r a b l m on a c b a l k b d or flip &art and then number according to
importancepergroup comensus-Why are we-herel Vhat are w&sup-
posed to do? How are We ping m get it all dane? Vhat is our h e
fkme?What are ow go&? {ag., protocol far tbe sujcidaI p%tient,doc-
umentation guiddim~for a mental status exam, a stahdard of *ire thaf
meets JCQlHD crlterial? Task p u p s are dear, wnciser and amm-
plished pro+ide consistency and continuiq for the patient care and
intrease team-unitefficiency and overaIJ safisfaction
Psychotherapy Group
AIlotbm type of group is: a psyddtlrerapy p u p led by a therapiiFt
Group therapis@oul be p~ydxhtrists,pqch010gist social wmkersLor
ahneed practice nurses.It is imprtant &at the p u p therapfisx have
Parpert knowledge apd eqdcnce in the dynamim oaf hwnan behaviar
and psy&opatholag~n The group is approached k m the theBpisVs
theo'pbase. A theory base is asystematic, organized knowledge base
tha~help$ m e d y n e , predia, or a p w a phenomenon leg., whatis
hap* in tbe group, to the group members). This theorg base
serves as a gtrtde for a
h
tetherapistwhen leading the goup intera&oZ3:
therefore,dMng a t h e m h e is Nte different from qerimenM,g,
pmrtieing, or "doing t h q y by the seat of your pan='
The Maring are mample of theurakal approache%:
Dialectical Behavioral Therapy. Dialectical behavioral t b q q
is cognitive-behavioralthesapywith the addftionof psych.ciocial
skills. DBT WSdeveloped by M a h a I i
n w for a sueaiflc -i6:
I
baddine pmnality disorder. Thwapy plus ski& mi&g
den@'efnotionalre$ulato~mdindulatb~lrloo^ at the Mm&-
edness d b W ~ r apatwns
l mtributes to interpwonaI eEecti-ese.
P
l group &mis on the i n W u a l witbin tfie goup. Role-
O ~ t a lThr:
plqhg is used to help the idvidaaI pupmember explore his o ~ h e r
feeliqp, Some therapists use the hot seat approach.A person w e n -
mfes on his OP her pmhlem as the g r o q ohm.
I trzlnsaettonal AnalYsls. ~ m mabas^
cafian pttezm a r ~obsemd
t
p b h v i o m and comma-
and analyzed according to the rmdult-child-
I parenttramaction m d e ~
I OonrmunlcaTio~Theory. The gmnp is eked far idkctive eom-
munication patternr;. Panems am identified and problem solved
h u g h the estabhbent of feedbad channels. The therapist models
gaod ~ u n i c a styles ~ nto clfminish &sfinmianal m-rion
by the gmup members.
In psychofhrapy groups*the grow memberis m selected for a,
p u p through an interviewing pm-, and pmom&im grid b W -
iors ate considered. The group eq&ence W Escilitate behaviard
changes and allow fur reaIiy t&stingand risk-* in as& en*-
ment. The goal is rhat the group membm e q m h n ~ ean
. inaease
in wtag and belongmg and a dewease ia IoneIinms and isdafion
pgYChodmma. A g r a q memba dr "
rly aefs out or reliveg a
@EmasEdI& ifet rts the grow m d e s a Mfe e n m e a t for the
climt tt, deal with difhd't ~ e s o issues
~ ~in%e
d h w and now. The
Other g m p me;mbas act a8 an interactiod audience. Mmm fl81410)
OM pssrchodrama toda~itis & P F ~ F us~d 6~ O S W -
ked clienrgmqs.
Clie*rtswiih ehmnic inePtaI illnesses arre fkeipently isolated and need
b dweIap and wss theirsocial shtns.The he goaloft& group
is to * e w e the ~m0unCof anxiety experend by clients in social
interactions and provide a safe e d r ~ n m e nwhere
t they can be social
a d $iendly. POXa gmup of e l d e x ~ a ~ ~ c$map i n gmay be appro-
priate: Per$ons wfth mebltal jllnmses way enjw @amhg a barbeae
With outd00T galne5 and acli@ies. Dav-hosM dienrs mau enimr =
 CPOUQ Process
.&.

&-help grow for the client Wbaf infomation would the

n m e garher prior to nbkmg this mwmmd&on?
5 R What grade of education the dienttbished,
Q B. Characteristics ofthe dent's neigbboxhood
Q C, The Jient's reading ability and band coordinatioa
CI D. The &enre ability to perfom independent transfers.

F. betine the following.

: Briefly answer the following.

1. D&e norm as it pertains to group and give emnpIe6 ofan
"-pWand impkit norm.
Stressor8 in Adult and Teenage Pregmcy
Nwsing Care of the Unwed Prepant Teenager
Primary Bonding
Coping with a StiIIborn or Malformed Infant
Posp~.imaDepression
Mother$ wiih Mental Diordw
The Hospitalized Child

--
Coping Mefhods ofthe Hoapitdbed ChiId

postpatturn depression
teratogenic
mpion
 .mESSORS IN AR@;&TH
~DTEENAGE PI@GNANCY
,,-

"~he.p%g&nt t g w h a m e dif&cult&e x&ptingto the.q=-

.$OD of prqgnmcy mle 8%3.&e :muat face the admLal
ghysid, and n r e t a h ~ l i c & g c ~ q f ~ ~ b ~hadtime ,~she~
adj,ustto fhe changes ~f,&olqsm ?be
@ must.adaptto tbe role of
parmrhoed We seill the mle &age to a8uIthowd She. mast
BQwon'sstage &Wmtitymd,t:&e me-timeac~ompj&h
o-ffin~ey&ns bdlaffm. She mmt disc@i+?t*vJio~&~& as
:%eke she who, she 8 pipason, ~g foI
%dependence is blrs&ed by t& and em&od r
pJ@p&@,Em in & s0pbistr&etletl s&q6 w a g &
.G-ge &m pqpmq and p m e o 6 & kcg
d.knowledge:@esriseto aqggtz4 t&qe&tic fw? %.y~un$
',@!WUg'& WO* 5 a b 's@ d@&$bping and has not y&
;r w e
l!?abiIligfl2Id& at:fhhgs4$wtiinmthep9niculmiastanee.
mtho~tthis &iE$ .she has ,&tienl~+resng&ing rhe f i i t q .@,m
Q?hile shehas fnom StteSSDr;S b face, theadol-t h Im.mpG
m ~ gil
m ml$.;p~.n~!,,m,&trgl4a
~ ,e&@$O:n h~ bmn pinon hold @,&li@ S h e l $ , s t i U ~ L ~d dhd owp i~n g~ha~
rn~
.rrer:eon~~s@@~qqv@kkschoQI. self-concept X her . m a l pirtner refrws to acknowl+ his @a-
pation ar mte, the pirh &kdngqt~&I-ed. Ew m y m y also

I ADULT PREGNANCY TEENAGE PREGNANCY I

:<,:
....
r x x ~ ; x s ~ ~ ~ y , ~ !~wa >~ i~~ut1 ~~ ~..I~NIIUwlm normona Goan!
rt r9. g~, p !wgm
~i PEaught:g~,bg @g$:grl?hcy . .ah bV edofescenceandh~
~

gj;-

.':,&U{@~~tp.$.Ne:f&leo,P:~efie
.&djus~ta.;.&:~fe;af:~gg~-~n~~~~#~
.,. %b.t&g:R&:rtf:mr@wb
~4GWW7Bll~h
the'.sWg,eof ,Ama,mBli& ~ e ~ s & ~ e . u j % & e n ~ f ~ ~
:fn@iwwgng:.@:qainlthe &&the stage ofin1-ae,yaanb
.s.@ge&'f.mptivlp sirn~ttane.~~s!~aope\ni,M'kfie
&~ ,,:.,.~;,; . . .
k & .; :
8,
stage ofg@nerafWty
g !,,,.-
$-p,d -?<; .' o+v@f@plnqgQefiqehcewijlle hcreasing
*sa . ,:.Y .. ..., ,,
,-- aependen~:qu%ed by p.m~n,ancy
 trnononal ~ s ~ k07~ Eraterm
t s ancl cnua care

,,j@w,which %&her lowers her seIf-worth as well as gSng her : wponsibilitp for pa- more &n than yotmgs adelescents, the
a d s 4 finaneiaI burdenss wst nXi0tity still reject the g i 5 Unfortnnate& the old= a d o k c a t is
Temagers are categorizes according to yo- middle, and late also the one mest 6rejected &the W y Tkib gscl is &ie to rrc-
adoles&n= Pregnanq has been increasing in the youngest grmp. og&e fbe h h n a n o d a l , and motional p m b h to be faced as a
Thisyoung adolescent thinla in the present She g i x s little thought to single mother. W i m t tip needed suppopt, she is apt to bemme
the possible effects of coitus. Knowledge of her body, pregnancy, and d-ed Bnd to fbi that no one ma.A l h u g h &ols are now
contraception is limited and what knowledge she does haw is often , mare leniem the older adoiescent is &en &rmd to quit sdhool
imrrect There is usually no lasting relationship be- the young Ibextux of f b n e j d an$ time ConsWnB. M Q Bpregnant
~ adole5cents
teen and her boy&iendShe often becomes p r w t following the first keep their inht3, bur abortion and a&ption are a"ept&Ie akm-
sexual experience. Denial is a common defense mechanism and she tives %r some,
may deny the pregnancy even when it is evident to others. If she
accepts the pregnancy, 6b.e often d&es responsibility This blame is 'Uwglnsleareof thr unwed Pregn;mt:feenmf@r
placed on her sexual partner, who is then despised.Adoptionis seldom
considerzd. More ofteq, thebalgr is turned over to the grandparents to Xt%$ easy to stemtype all a@zed p ~ mado1wcnts,t but-&qde not
raise as the mother's sibhg. b~rntl~ inti,oix cafeg~zyA I t h ~ ~ t h earma marry pmbtems,,sqme~
The middle adolescentis a littlemore sophisticated in her knowl- m&gw ltre prouddef6:ppepmeyand lmk forward w ~ae exp&-
edge.She is aw& of the possible eeects of coitus. She knows h u t m m of motkrhocrd & with any a*g cJient it 1s importsnt t W rtre
contraceptives but manytimes fails to use thea There are many the- n=*,get to ' b o u * & w.
ories to "plain this. If the gfrl irlllses contraceptives, she is obviously .Mazy Aan is Bkea ykvs old. She pwents h e r a t &e
planning on having s d relationships, which goes against her clinic b a m e she h& h a
sms
sd8ome perfads. She:& not w-
ie
parentally instilled values and makes her a %ad" girl If coitus is not tain hCMt She st@wetly f i e her blood pressure h
planned, she can save her selfconcept by blaming "the moment? or ,takenq d 4submits telqmanty to a we&t check @he rerebels
passion. Pregnancy is actually sought by some middle teens because it ~ t t h e m - ~ & & , g ~ & ~ ~ ~ @
means maturity and independence to them It may also be a rebellious sa- 90 not do elmP
act sainst her parents. In somegroups, it is sirnpIy the *id1thing to do.
TKmaWr the reason, the Zpiddle adolacent usuaUy denies responsi- X h y Ami acted @ s& did because @hewgs~Eghtenedde&
bility forthe prepmq. She o f t a blames her paenI5, W gs &at &.e e l dd
i not undmtand. She was emiboulasse& selfcon-
The middle teen rarely has a desire to m a ~ her y boyfj!iend,but @
:&I & .anddisbtfiul of a t h e new pmple mrmd her:
she does need his support. Wahout his suppork she experiences Before the nmse can &e&dy help &Q he or she must
increased anxiety. Even thrmgh she may have msciously or nncon- 3wdop.a trusting relati-hip. ' UST takes thne; several *its may ~&
B
sciously sought the pregnancy, she often has unrealistic fantasies and ..~@eiLIt wdald bc id& if ow m s e . mw M q Ann each time she
ambivalent feelings about motherhood The pregnant teen demon- ~toth~clinicBdwelop~tthenrusgne& explainanpro.
m
mates her extreme anxiety fh~oughrebellion, anger, disinterest and $ W m befm they am done in terms t b t tfte r e q q mde~statldri;
boredom, as well as numerous somatic complaints. She is usual& very Magdmn is,still demloping ber aB@ytq W ing & d rather than
frghtened of media care arrd seeks care late, ifat all. Because of anx- +p&c terms. Sin@ she is weriendn$ s m , egpi-11s should,be
ietyand distrust of authority, she may be uncooperative during exam- &$bPlt ,using visual kteriBls whenmrpgssibla Developing
inations and may not follow through on directions. TYLe baby may be Wt ab4 iavobw wntinuity, accepting M a q withput clific'imj
raised bythe grandpments. In other cases,the teenis forced to assume ,a pp- dm-, and .mm
complete care to the detriment of her education and s o d life. tvith.the. ti~d@l&~ent is ngt m y T& ~amse
The late adolescent girl freqwnfly aims her relationship with ,&.dd nut fqwW&i$akss ,M@QApn's nee& o n &~&& vfsit&&q
her sexual partner as meaningM and often has planned to m a w M ,&XI, a>&@&
ag & ~ t ~ l 3 . i 3 p i to&&
to a m o n whom she
at some time in the future. Even if marriage is not sought when preg- has~ b & d w,'w@,-
q
' &&.i @-magwc o & ~ m w , ~ a
c9m a h ,be m&
=> '

nancy is discovered, recognition and support ffom Yhe SeYual partner ,;~e+i&;;i&
seem8 to be important Athough older adobe& males tend to ampt yVrth s.Iftile, or a , l e ~ ~ W 1~ .~ e r & ybfiaw
~. ~ ~
~
Chapter 8 ~ ~ O U U I~
IU~ 1 e cOFmMawrnai ana m ~ l a
care

%m&nzss T& n a m@t.@ktbeinitia@ee,%uchm %fayAnn,

.:&ere are Scmw tkings +need@ &class." isleas e f f w kbecause
@e %ddlesWt may
or .mq not comply.
To detennfne Mmy Am-1~6nee&, the nurse shbuld g&er Mgr-

FIGURE 8-2 Characterrstics of tne Adolescent Communication

. 1
.
mt.(en &qt:
B Ph.attpi+q$aancya n d , p . d o dmwn to her
Her Eeuel of anxi*
W effed tbe grqnancy has on kretreladionship with her
W a n d her b o r n a d
pattern. I oElth whatotbep Mopmental srresmrs she is dealbg
'
. The 1 4 of her need for fuEument fo Maslm &b
.W @b@idqgicaLq i low and belonging RePzds being met??
the teemger will ~nrPacenonwerbally. Ho-, few a d o l e s w wiII R How she sees kg & i m n
o E e ~information without dire3 questioning. You@ and middle
m a g e m && in speck& tams and respmd IftaaOyto cpe-sW11~.If 'R m a t plans she has for hemelfmd her babjr
the nmse ash *Canp teII me abozlt it'? the msvw is lib:& to be R DVhat shc?.fMs #he.needs fmm theawse
~ ~

simply TeahhP To get tbe right the m e should say TEIIme The nussingm:m@then d~,&mil&thatshe;&s tbe fo&*

.. .. -
abaut it"Teen8 also use the hngu@ge&@ermtlx strmgfhs and wwe9ses:
Mm5e I hew gou have a new motoxbike."
Qtent: Qh yeah, its wmo!
sw8n~tno WeiIR~~ee~en
She a m p a responsibilityfor 8hehas ngt .told her
Nurse: *It'searn01 Wt does &at mean?"
the -4 m y and fearS rep-
C3.t- Tmlred y a squid It8 qurll, realbad"
,Shehas mnttriaed suppun Her fntm plans are
Nme: You mwn it% cool'? h m her bofiead
m e %ght Its sb-a-ad bikk"

.
71se schaaI.has a program for ISha has an ~ 1 n r d k d c 8 i ~
To express m&m, a teen rnag say, *I don'tha= my W on pptgllmtt~ sf p*@mcJ ma
' m hung wetB A "bummd means thing.^ ate not- good
sFaighr" or T pmutJl~od
Young and middle &&wmay not be ware of their ferns
tw the~maynotbave the words ta enpress their feelings. meflan ado-
I She feds she needs prepma- Herphysid s a w i
timfor labof md delivery @ $
belong l n@& are
in^
lescent descrk%an expdence, shema$ start over several time%beca~se
she bas a feat- of not b&g & m o d . It takes good obserpath and
md pwnthood threatened
timing to initiate thempeufic communicationWth the adolescent. She has the ,sapportof her
bogfrmdJ'spayens
We: Sfou lo& Me you b v e lM go- last &end Bad
m M a l y h 1 " ~A&qArm,liks all feem&sG needs fbf: suppost o f h e r ~ M She p
client T\Tab'pkceofcak:aa map neitrd el^ .@.,gainingit & , r e f e d to so&~shces or a &&ing
Nme: %at L see yau have a sad face. What did the doctor nme might EX@& s ~ p k o whena &e s bh her -psrents. M q Ann
e
tell PUP ma$ &$-fitt&,d* m&j ,demommw how
&@!migh&& ,rn:!&..- E& family nejem her,she,a need a
CIfefi: *Oh,n&g! ref&& ma six*.,
Nurse: %e cadiimed fhe ppregm~xy,didn't Be?" ,S.~ce~h%$@~:@@&edae:nwj?m*@&-, be
Client: T s a real b-aP @ g & ~ ; h 3 m.@ ,&& q , &&. NeDa@@ or
~
individUany during her clinic visits. Preparation for labor should
ihcIude relaxation exercises and some type of breathing techniques to
lessen anxiety during labor: Probably the most important thing the
nurse can do for Mary Am, and teenagers like her, is to provide sup-
port and be there when she needs someone.
Doring labor, Mary AM has the same needs rn any other moth-
er relief of paitt i n f o m o ~ and
~ emotional support She needs to
have the person she trusts, whether it be her mother, her bqhend, or
both, with ha.
To help the young mother after birth, the nurse should manipu-
late the environment to provide sqccess experiences for her. She
should provide compliments and gently wnect mistakes. If the girl
decides to keep her baby, rooming-in should be encouraged so that the
mother can learn to eare for her infant with the nurse's help. If she is
planning on putting the baby up for adoption, she may want to see the
chlld and care for it while the baby is in the hospital When the baby
is adopted, she will face separation anxiety, but not seeing the baby Flburr: u-5 some oonalng Denavlon are eye-to-eyecontact and
often muses lasting anxiety. Sics the young mother is in the hospital holding the baby no more than 17 Inches from the parent'sface.
for such a shoa time, referral for home health nursing &ce is usu-
ally indicated.
mother fuaher responds by smiling. Eye contact, skin-to* contact,
PRIMARY BONDING and touchmg seem to be essential to the pro- Ipigure 8-41. If not
intedmxl with bonding occurs automatidy The p r o w can be
Primary bondingis the process of establishing an intimate interde- enhanced premtaDy and postnatally
pendent attachment a m o ~ gmother, fkther, and infant @gwe 8-31. Bondmg is enrnuraged prenatally by allowing parents to Iisten to
Research on bondmg, which began to surface in the 1960s indicates fetal heart tones, teachkg them to massage the mother's abdomen
that bonding is impurtant to the child's future interpmonal relatian- and showing them how to feel and recognize fetal parts. In the post-
ships. It also shows that infirm not bonded to their mothem h the crit- natal period, the parent is taught to hold the infant no more than sev-
icaI immediate postparhnn period were more apt to be abused and enteen inches flom the &GZ The infant cannot see clearly beyond sm
neglected. Children who were not bonded expeximxd more anxiety enteen inches Eye-to-eye contact is important Talking to the infant
and wereless able to cope with s m s . The bonded person is the child's should be encouraged. Some mothers feel ulcomfortabletalking to an
P m support infant They may feelas ifthey are taIking to a dolLor a wall. The nurse
Bonding nomdly begins in the prenatal period when the moth- can help by pointing out the babys responses.
er feels quickening (the Grst movemeats of the baby,) The mother
then can be seen massaging her growing abdomen, delighting in fetal
movements, and taIking to the fetus. The immediate postpartum peri-
od seems to be most mcial Some mothers who have had negative
feelings about being pregnant have effeaiveIy bonded ta the infant
during the time just after birth. Although bonding may occur late, it
seems to be mare diBcult and intervention is usually essential
Natural bonding is initiatd by either the parent or the infant
through behavior to which the other person responds. The baby aies
and the mother picks the baby up and cuddles him or h a The baby
stops crying and molds himself or herself to the moth& body The FIGURE 8-4 Factors that enhance bonding.
.-
l?&q
- ?* '4 Chapter 8
A

-
mowing the mother to care for the bab, hduding feeding,
w g i n g diapers, and bathing, abo enwurages bonding. The young
mothet in particular shodd be encouraged to pro* physicaI cate for
her infirrrt Eooming-in helps the bonding process. The nurse super-
vbing the infads care should compliment the mother and
correctians. It" the mother is having drffculty with the baby's cate and
becomes upset, it is important that the nurse not take over.The. moth-
er sometimes believe6 the baby evaluates her agaiwlt the more skiUed
nurse and her sdf-concept is lowered. OE course this is not tme,but it
is nonetheless a real c o r n to the mother. Instead*fo m,the
nurse should help the mother to relax and then assist her with mg-
gestions. If the environment is manipulated to give €he mother suceess,
her self<oncept is enhanced
The unwed teenager sometbnes opts to turn herb* over to her
mother to raise, hoping to later assume the rhothering role. This may
be impossible The infant who has bonded to the grandmother may
refase to relate to the teen as a mnthe~

COPING WITH A STILLBORN OR

MALFORMED INFANT
Whenever a problem m delivery occm or is anticipated, at times the
father is banned or banished h m the scene. The infkt is Then taken
quickly to the nursq, and bonding with both parents is intermpted If
the mother is awake, she quiekty becomes aware that something is
wrong and anxiety results. Ifshe is a n a t h e w , amdegris only delqed.
Parents dream of having a perfect child. When a malformed or
saiously ill infant is born the parent9 must grieye for the loss of the
dream child before they can even begin to aecept the real child Denial
is offen the mechanism used. Denialis &ested by a refusal to name
the baby, by refusing to see, touch,or talk to the babs The psents may
withdram They may accuse the hospitd of changing bahies or of not
doing what they could to s m the infant The parents often feel guilv
about malformations and wonder what rhey have done to cause it
They are embarrassed and feel inadequate as people. Having a mal-
formed child can be a blow to fhe self-concept
Sometimes the motha is given a tran@er to help calm her.
Rather rhmdelay the grief p e e s , tt is better to handle it with the 8Up-
pok of the nwsing st&. Denial may Issen anxieq, but the problem
st3l rernains. The parents should see the child as early as possible No
matter how deformed the child is, reality is usuallyless disturbingthan
the paxents' imagination.
The mother skouId be +.he one to mske the choice of movlog to
a private room or off the flool: If she decides to leave the m a f e w
 The nurse should point out the baby%healthy a s p If the ehild
has a name, it should be used and the child should ah3ys be referred
to by the correct sex As they care for the child nurses should be alert
for s i p of anxi* in the mother and &ow her to withdraw from the
child if the mother feels the need
If the infant dies or was born dead, allowing the parents m see
the child prevents deniaL The infant may have been deformed
and the death anticipated, but the event is stressfuI.This parent
too, needs to have time with the baby to wmpIete the gnef process.
Crying should be enwuraged Nurses may also feel like crying. By
doing so, they share the sadness with the m ts.

POSTPARTUM DEPRESSION
As previously stated, pregnruyr i s a -cant strPsscn. with normal
mood flucflations.Repressive s y m m mqy o m or,ifaIready pres-
ent, map worsen The continuing stigma ofmenfd ilhess contrhtes
to the undeneporhg of depressive symptoms by p m t and lactat-
ing women. Some contributing fadom to depression during pre-
cy and lactation are:
r chronic f i ~ ~ dsaain al
Everyday life hassles
EI Disrupted or abusive relatiomhips
Unstable housing -gemen&
S SocialisoIation
Homonal influences and fluctnations
W H f t q of depression or medical problems
r Lack of community resources
postdel&my,some women may have a brief period ofthe "blues:
d e other women are dinically depressed or psychotic It is impor-
cant to rewgnize the symptom of pos- depression:
Letdown feeling
r IlTitabiity
Loss of appetite
IInsomnia
Wety
The mather cria easily and may complain of discomfort and an inabil-
ityto concentrate. It is impor€antto diffkntiate the symptom ofpost-

episodes, intensity, and *ten= of symptoms. -

parnun blues and postpartum depression in terms of the number of
.,
in a foster home, or the parental rights of the parent have been temu
nated Due to the complexity ofthese issue,women's mental h e m is
a major issue of the millennium. Continued reseveh is needed in the
area@of pregnancy and kcfation and their relationship to a woman'
mental health and women's rights.

THE HOSPITALIZED CHILD

The child's response to hospitakation depends in part on his or he-
developmenral stage. Very young children do not understand wby the
must be hospitalized and often see it as punishment If the d 3 d ha.,
any concept af illness, it is thought to be due to &obedience. Although
r e p s f o n is a defense mechanism obsmed in aU age groups, it is
most common in the verqi young child One who h a been drhki.ng
from a cup may seek comfort in a bottle during hospitalization
When the hospitalized child is removed from all that is familia
he or she Iwks to the bonded pason for support If that person is
misslng, anxiety increases. This is h o r n as separation anxiety, which
is normally seenin children between seven months and threeyears of
age. In the hospital, sepaation an~ietymay be seen m children up to
hur or tke years of age and occasionally in oJda children W e n the
parent leaves, the child exhibiting separation anxiety responds with
temper t;lntrums, crying,md atfempts at clingkg to the parent It is
important to the child that at least one parent remain and participate
m his or her care if at all possibl~Ifboth parents must leave, theybeed
to understand that separation anxiety is a n m a l reaction The child
who is old enough to uadmtaad should be toId that the parent is leav-
ing but will return. It is best that the par& not sne& am The nurse
should be sure that the child has his or her securlty blanket or a
favorite toy nearby
Although preschoolers sdfl see hospitalization as punishment
thae is an increased awareness of the hospital experience. Fantasies
me c o m m a intrusive procedures can be d e veIy f?tghWg
through fantasy. The preschooler knows the missing parent will
return However, he or she worries that the parent wiII not be able to
find him or her, particularly ifthe child is moved Bleeding is extreme-
frightming as children think all their blood may wme outA small
bandage o h lessens m e t y as efTectnrely as a kiss.
The school-age child's hospiiahtion causes anxi* mainly
because of immobility, a possibility of bodily ham, and a loss of
friends and parents. This child may be embarrassed w h n forced to
sullrenderprivacy. Though he or she is not expect& to have separation
anxi*, the child sees the loss of parents as a stress and is relieved
when the parent is around This child's concept 0fiUms-s is dependent
 ~na~srna~~ ~~
E I S , ~ U L ~ W ~ I ~ ~ , ~ ~ W . ~am :WmT m crwa m

stregs. Hm and why are common words in the preschooI grdup. At

other time,&klreX~ display dependenceby saying '?XiiIlyou stay with
me?" or hostility with '"Iwill ha flu.' Regression to a more secure
stage &devebpent i8 most comm0.n in this age grou
Denial is the mosr c o m m o n mechanismseen in children and
adolescents, but the agial is usually temparkuy. Children who use
denial do not a m the extent of their illness. They may be m m o p
erative, overfflmpllaisaut, or even stoic about painful pr0cedm'~S.
Another ~i~eehanism is inte7leohlakation. Cbildren who fhts
method disassociate themselves from the i1lnes.s and view it objective-
ly. They display an inter~stin factual @pacts; it is as if they were dis-
oussing someone else,
Some children cape by acting out Children who itct exhibit
a@mSOn and uicaopefativeness. Theae Mdrm may disconnect N
&om their m,hide their medications, or refuse to Stay in bed
Children who are depressed often act om Almost all ehildren use
mauipulation, which e f f e w lessens anxiety.
ChiMre~need ,to know what procednm win. be done and fore
warned about dismmfort The infarmation needs to be presented in a
w q the ehild undefstwds. Pupp&, stmyteying, gatilw,. a d riddling
equipment are ways of preparing children for proeedureS. Presdhool -,ma&+is::&>&, ....- ~ ~~.+

children need ta follow their usual routine. School-age children heed &r@m&d&$.wi@~l~p~.
to knowfhat their thiilgs at home wilI not be @sturbedvvbilethey W . .: . . # -

away: An duldren need to have their He rourines changed as little as

possible for a s e w of senuity.
I pffer to move the mether & the matsmiQ flwon Th- mofher
shauld be the one to make the &oice of moving to a m t e mom
or to another department Ethe mother d d e s to move, she should
be cited by the riming ST& sb she does not feel forgotten.
Parents need to have trutlfd information about their childJs
id a d q w i t h a play thempist Observe the therapist's
onses to and &em on children
an agescppropri;ne a* far a pediauic client
haalte a list of bonding behaviors observed while visiting or car-
jng fm a mother and her newborn.
condition and be e n m a g d to talk together regarding their feel- With a small group of classmates, discuss feehgs towards the
ings. The nurse canbest help b y w the parent know it is & right birth of a malformed child.
to about the event and by followingthe parents cues. The nurse
can point out the baby's healthy aspm. The child's name and sex
should be used. The nurse needs to be alat to signs of &eQ in the

F
P-t
Mild deprmion occurs in a large percentage of p o s r p m
clients. It lasts only one to two weeks and requires no treatment
"I% mother, however, needs support ~ndetstandingmt and nutri- OW AND COMPREHEND
' Multiple choice. Select the one best answer
tion S m depression oceurs in 1 to 2 percent of p o s t p a m
dknts and requires immediate detection and treatmeflt When a L DPhieh factor wntributes to &notional W e s t a t i o m of
woman with a &om mental &order b- pre$nsnt the risk pregnancy?
versus benefit of wnGnuing me$ication must be msidered. Q A. psychotic disorders
Collaboration between all provkh lobstetria, primary care, and Q B. somatic disorders
mental health) must o m as a pmtection to both mother and child.
The child'$ response to hospidkation depends on the devel-
' Q C neurotic disorders
O D. normal physiological dlanges
opmental l e d ofthe child and the parents' concept of iIks. Other
factors are previous h o s p i ~ t i o n sthe
, child's support system and 3. which developmentaltasks must the pregnant teen
the Ehild's &ping methods. a~omp~7
The h o a v i W child has beenmoved f?om all that is fam& Q R autonomy and generati*
lat He or shiis sometimes subjected to embarrassing procedurRs O B. trust and initiative
and strict d e s . There is often an inteauption in his or her dard- a C. identity and intimacy
opmental needs. P D. autmomy and identity
The hospitalized child should have a parent near and be told ~ factor commonly present when a middle adolescent
3. S e l e the
what is going to happen and why His m her routine should be becomes pregnant
a g e d as M e as possible. Children cope d t h stress in diffmt PGipmee
ways. The vay young child cries, has tantrums, and ehgs to the LI B. failure of birth-wntml methods
w e n t Olda chiIdren may use denjaI,intelleczualization,aacting 0U4 Q C. owwhelming pasgion
P D. rebeDon againsf her parents
% Boading should be encouraged because it

SUGGESTED RCTlVltlES - P A. assmes that the child will not be abused

GI B. pxwnts postnatal complicatiom and depression.
Q C, aids in involution and hoflllonal *ability,
Attend a prenatal class in wbich preparation for Iabor and 0 D. is impo-t in the chilchild'sfuture interpersonal
delivery is discrussed relationships.
B Voluntee~time in a home for upwed mothers, if one is *a-
able in your area
5. When teadung parents to bold th& inf&S, whkh -&on
wonld the n m indude to promote bonding? "Hold fhe
infant
P d no more than 17 inches from the fabe!'
O B. only when the chdd is wmpped securely."
P C, in the football hold for safety dw e in baadIingfl
a D,m y -from the face to avoid disease miss^."
6. Which &&me mechanfstn would the nurse expect &ompar-
ents of a maEo111led child?
P k rationalimpion
0 B. i n t e f l a l i z a t i a
0 C. deniai
0 D, reattion f o r m a h
il The mother of a malfonaed child can be& be helped by
U A. giving atmnqUfllzer m allmiare &eQ.
B. being transferred Emm the s&tssful matem* depart-
ment
0 C. w&im her face mliw an&for&g her m touch the
*t-
0 D. allowing her to talk about hex feelin@if she des$es.
8. Whl& defense meohmbm is most wmnody seen the
pug hospttakd ehild?
0 tl denial
0 B. r a p s i o n
a Gf w y
0 D. identification
9. Sel& the moat common defense mechanism seen in
y5ungepregnant adolseent
P A denirzl
P B.reg~ssion
P GfantaSy
0 D. identifieation
10. Which stressor is most likdyto mme anxiety in a hospital-
k d , school-age child?
P R immobiliy
13B. lack of opponunity Em cratbit)i
a Cmi&ngschoal
D. loss of independence