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Chapter One

Foundations of Psychiatric Mental Health Nursing


Mental Health
The WHO defines health as a state of complete physical, mental, and social
wellness, not merely the absence of disease or infirmity
Mental health is influenced by indi!idual factors, including biologic ma"eup,
autonomy, and independence, self#esteem, capacity for growth, !itality, ability
to find meaning in life, resilience or hardiness, sense of belonging, reality
orientation, and coping or stress management abilities$ by interpersonal
factors, including effecti!e communication, helping others, intimacy, and
maintaining a balance of separateness and connectedness$ and by
social%cultural factors, including sense of community, access to resources,
intolerance of !iolence, support of di!ersity among people, mastery of the
en!ironment, and a positi!e yet realistic !iew of the world &damn, that was a
mouthful'(
Mental Illness
The )P) &*+++( defines a mental disorder as ,a clinically significant
beha!ioral or psychological syndrome or pattern that occurs in an indi!idual
and that is associated with present distress or disability or with a significantly
increased ris" of suffering death, pain, disability, or an important loss of
freedom-
.e!iant beha!ior does not necessarily indicate a mental disorder
Diagnostic and statistical manual of mental disorders
The DSM-IV-TR is a ta/onomy published by the )P) The .0M#12#T3
describes all mental disorders, outlining specific criteria for each based on
clinical e/perience and research
The .0M#12#T3 has 4 purposes5
o To pro!ide standardi6ed nomenclature and language for all mental
health professionals
o To present defining characteristics or symptoms that differentiates
specific diagnoses
o To assist in identifying the underlying causes of disorders
) multia/ial classification system that in!ol!es assessment on se!eral a/es,
or domains of information, allows the practitioner to identify all the factors that
relate to a persons condition
o )/is 1 is for identifying all ma7or psychiatric disorders e/cept M3 and
personality disorders 8/amples include depression and
schi6ophrenia
o )/is 11 is for reporting mental retardation and personality disorders as
well as prominent maladapti!e personality features and defense
mechanisms
o )/is 111 is for reporting current medical conditions that are potentially
rele!ant to understanding or maintaining the person9s mental disorder
as well as medical conditions that might contribute to understanding
the person
o )/is 12 is for reporting psychosocial and en!ironmental problems that
may affect the diagnosis, treatment, and prognosis of mental
disorders 1ncluded are problems with the primary support group, the
social en!ironment, education, occupation, housing, economics,
access to health care, and the legal system
o )/is 2 presents a :lobal )ssessment of Functioning which rates the
person9s o!erall psychological functioning on a scale of + to ;++ This
represents the clinician9s assessment of the person9s current le!el of
functioning
)ll clients admitted to a hospital or psychiatric treatment will ha!e a multia/is
diagnosis from the .0M#12#T3
Period of Enlightenment and Creation of Mental Institutions
1n the ;<=+9s Phillippe Pinel in France and Willian Tu"es of 8ngland
formulated the concept of asylum as a safe refugee or ha!en offering
protection at institutions where people had been beaten, whipped, and
star!ed for their mental illness
1n the >0, .orothea .i/ &;?+*#;??<( began a crusade to reform the treatment
of mental illness after a !isit to the Tu"es9 institution in 8ngland 0he was
instrumental in opening 4* state hospitals that offered asylum to the suffering
;++ years after establishment of the first asylum, state hospitals were in
trouble )ttendants were accused of abusing the residents, the rural locations
of the hospitals were !iewed as isolating patients from their families and
homes, and the phrase insane asylum too" on a negati!e connotation
Develoment of Psychoharmacology
1n the ;=@+9s the de!elopment of sychotroic drugs were used to treat
mental illness
Chlorproma6ine &Thor6ine(, an antipsychotic drug, and lithium, an anti#manic
agent, were the first drugs to be de!eloped
;+ years later, monoamine o/idase inhibitors, haloperidol &Haldol(, an
antipsychotic$ tricyclic antidepressants$ and antian/iety agents
&ben6odia6epines(, were introduced
Aecause of these new drugs, hospital stays were shortened, and many
people were well enough to go home
Move to!ard Community Mental Health
The enactment of the Community Mental Health Centers )ct came about in
;=B4
Deinstitutionali"ation# a deliberate shift from institutional care in state
hospitals to community facilities, began
1n addition to deinstitutionali6ation, federal legislation was passed to pro!ide
an income for disabled persons5 001 and 00.1 This allowed people with
mental illnesses to be more independent financially and not to rely on family
for money
Mental Illness in the $%
st
Century
The .epartment of Health and Human 0er!ices &.HH0( estimates that @B
million )mericans ha!e a diagnosable mental illness
The term Revolving door effect is used to e/plain how people with se!ere
and persistent mental illness ha!e shorter hospital stays, but they are
admitted more freCuently People with se!ere and persistent mental illness
may show signs of impro!ement in a few days but are not stabili6ed Thus,
they are discharged into the community without being able to cope with
community li!ing 0ubstance abuse issues cannot be dealt with in the 4#@
days typical for admissions in the current managed care en!ironment
Many pro!iders belie!e today9s clients are to be more aggressi!e than those
in the past Aetween DE and ?E in clients seem in Psychiatric 839s are
armed People not recei!ing adeCuate mental health care commit about ;,+++
homicides each year
1n state prisons, ; in ;+ prisoners ta"e psychotropic medications and ; in ?
recei!es counseling or therapy for mental health issues
?@E of the homeless population has a psychiatric illness and%or a substance
abuse problem
The >nited 0tates has the largest percentage of mentally ill citi6ens &*=;E(
and pro!ided care for only ; in 4 people who needed it &Ai7l et al, *++4(
Persons with minor or mild cases are most li"ely to recei!e treatment while
those with se!ere and persistent mental illness were least li"ely to be treated
Cost containment and managed care
Managed Care is a concept designed to purposely control the balance
between the Cuality of care pro!ided and the cost of that care 1n a managed
care system, people recei!e care based on need rather than reCuest
Case management or management of care on a case#by#case basis
represented an effort to pro!ide necessary ser!ices while containing costs
The client is assigned a case manager, a person who coordinates all types of
care needed by the client
1n ;==B, Congress passed the Mental Health Parity )ct, which eliminated
annual and lifetime dollar amounts for mental health care for companies with
more than @+ employees Howe!er, substance abuse was not co!ered by this
law, and companies could limit the number of days in the hospital or the
number of clinic !isits per year Thus, parity did not really e/ist
Psychiatric &ursing Practice
1n ;?<4, Finda 3ichards impro!ed nursing care in psychiatric hospitals and
organi6ed educational programs in state mental hospitals in 1llinois 3ichards
is called the first )merican psychiatric nurse
The first training of nurses to wor" with persons with mental illness was in
;??* The care focused on nutrition, hygiene and acti!ity Nurses adapted
medical#surgical principles to the care of clients with psychiatric disorders and
treated them with tolerance and "indness
Treatments such as insulin shoc" therapy &;=4@(, psychotherapy &;=4B(, and
electrocon!ulsi!e therapy &;=4<( reCuired nurses to use their medical s"ills
more e/tensi!ely
Gohn Hop"ins was the first school of nursing to include a course on
psychiatric nursing in its curriculum
1n ;=@+, the National Feague for Nursing &which accredits nursing programs(
reCuired schools to include an e/perience in psychiatric nursing
1n ;=<4, the )N) de!eloped Standards of care, which states the
responsibilities for which nurses are accountable
Psychiatric nursing practice has been profoundly influenced by Hildegard
Peplau and Gune Mellow, who wrote about the nurse#client relationship,
an/iety, nurse therapy, and interpersonal nursing therapy
Psychiatric Mental Health &ursing Phenomena of Concern
The maintenance of optimal health and well#being and the pre!ention of
psychobiologic illness
0elf#care limitations or impaired functioning related to mental and emotional
distress
.eficits in the functioning of significant biologic, emotional, and cogniti!e
symptoms
8motional stress or crisis components if illness, pain, and disability
0elf#concept changes, de!elopmental issues, and life process changes
Problems related to emotions such as an/iety, anger, sadness, loneliness,
and grief
Physical symptoms that occur along with altered psychological functioning
)lterations in thin"ing, percei!ing, symboli6ing, communicating, and decision
ma"ing
.ifficulties relating to others
Aeha!iors and mental states that indicate the client is a danger to self or
others or has a significant disability
1nterpersonal, systemic, sociocultural, spiritual, or en!ironmental
circumstances or e!ents that affect the mental or emotional well#being of the
indi!idual, family, or community
0ymptom management, side effects%to/icities associated with
psychopharmacologic inter!ention, and other aspects of the treatment
regimen
Standards of Psychiatric mental health clinical nursing ractice'
0tandard 1 )ssessment
o The psychiatric#mental health nurse collects health data
0tandard 11 .iagnosis
o The psychiatric#mental health nurse analy6es the data in determining
diagnoses
0tandard 111 Outcome identification
o The psychiatric#mental health nurse identifies e/pected outcomes
indi!iduali6ed to the client
0tandard 12 Planning
o The psychiatric#mental health nurse de!elops a plan of care that
prescribes inter!entions to attain e/pected outcomes
0tandard 2 1mplementation
o The psychiatric#mental health nurse implements the inter!entions
identified in the plan of care
0tandard 2a Counseling
o The psychiatric#mental health nurse uses counseling inter!entions to
assist clients in impro!ing or regaining their pre!ious coping abilities,
fostering mental health, and pre!enting mental illness and disability
0tandard 2b Milieu Therapy
o The psychiatric#mental health nurse pro!ides structures, and maintains
a therapeutic en!ironment in collaboration with the client and other
health care practitioners
0tandard 2c 0elf#care acti!ities
o The psychiatric#mental health nurse structures inter!entions around
the client9s acti!ities of daily li!ing to foster self#care and mental and
physical well#being
0tandard 2d Psychobiologic 1nter!entions
o The psychiatric#mental health nurse uses "nowledge of psychobiologic
inter!entions and applies clinical s"ills to restore the client9s health and
pre!ent further disability
0tandard 2e Health teaching
o The psychiatric#mental health nurse, through health teaching, assists
clients in achie!ing, satisfying, producti!e, and healthy patterns of
li!ing
0tandard 2f Case Management
o The psychiatric#mental health nurse pro!ides case management to
coordinate comprehensi!e health ser!ices and ensure continuity of
care
0tandard 2g Health promotion and maintenance
o The psychiatric#mental health nurse employs strategies and
inter!entions to promote and maintain mental health and pre!ent
illness
(reas of ractice
Counseling
o 1nter!entions and communication techniCues
o Problem sol!ing
o Crisis inter!ention
o 0tress management
o Aeha!ior modification
Milieu therapy
o Maintain therapeutic en!ironment
o Teach s"ills
o 8ncourage communication between clients and others
o Promote growth through role modeling
0elf#care acti!ities
o 8ncourage independence
o 1ncrease self#esteem
o 1mpro!e function and health
Psychobiologic inter!entions
o )dminister medications
o Teaching
o Obser!ations
Health teaching
Case management
Health promotion and maintenance
(dvanced level functions
Psychotherapy
Prescripti!e authority for drugs &in many states(
Consultation
8!aluation
Self-a!areness issues
Self-a!areness is the process by which the nurse gains recognition of his or
her own feelings, beliefs, and attitudes
Chapter Two
Neurobiologic Theories and Psychopharmacology
The &ervous system and ho! it !or)s
The cerebrum is the center for coordination and integration of all information
needed to interpret and respond to the en!ironment
The cerebellum is the center for coordination of mo!ements and postural
ad7ustments
The brain stem contains centers that control cardio!ascular and respiratory
functions, sleep, consciousness, and impulses
The limbic system regulates body temperature, appetite, sensations, memory,
and emotional arousal
&eurotransmitters
Neurotransmitters are the chemical substances manufactured in the neuron
that aid in the transmission of information throughout the body
o They either e/cite or stimulate an action in the cells &e/citatory( or
inhibit or stop an action &inhibitatory(
o )fter neurotransmitters are released into the synapse &point of contact
between the dendrites and the ne/t neuron( and relay the message to
the receptor cells, they are either transported bac" from the synapse to
the a/on to be stored for later use &reupta"e( or are metaboli6ed and
inacti!ated by en6ymes, primarily monoamine o*idase +M(,-'
Doamine, a neurotransmitter located primarily in the brain stem .opamine
is generally e/citatory and is synthesi6ed from tyrosine, a dietary amino acid
o )ntipsychotic medications wor" by bloc"ing dopamine receptors and
reducing dopamine acti!ity
&oreinehrine and Einehrine
o Norepinephrine, the most pre!alent neurotransmitter, is located
primarily in the brain stem 1t plays a role in mood regulation
o 8pinephrine is also "nown as noradrenaline and adrenaline
8pinephrine has limited distribution in the brain but controls the fight#
or#flight response in the peripheral ner!ous system
Serotonin
o ) neurotransmitter found only in the brain, is deri!ed from tryptophan,
a dietary amino acid
o The function of serotonin is mostly inhibitory, in!ol!ed in the control of
food inta"e, sleep and wa"efulness, temperature regulation, pain
control, se/ual beha!ior, and regulation of emotions
o 0ome antidepressants bloc" serotonin reupta"e, thus lea!ing it
a!ailable longer in the synapse, which results in impro!ed mood
Histamine
o The role of histamine in mental illness is under in!estigation
(cetylcholine
o )cetylcholine is a neurotransmitter found in the brain, spinal cord, and
peripheral ner!ous system 1t can be e/citatory or inhibitory 1t is
synthesi6ed from dietary choline found in red meat and !egetables and
has been found to affect the sleep#wa"e cycle and to signal muscles to
become acti!e
o 0tudies ha!e shown that people with )l6heimer9s disease ha!e
decreased acetylcholine secreting neurons
.lutamate
o :lutamate is an e/citatory amino acid that at high le!els can ha!e
ma7or neuroto/ic effects
.amma-(mino/utyric (cid +.(0(-
o :)A) is a ma7or inhibitory neurotransmitter in the brain and has been
found to modulate other neurotransmitter systems rather than to
pro!ide a direct stimulus
o .rugs that increase :)A) function such as ben6odia6epines are used
to treat an/iety and to induce sleep
&euro/iologic causes of mental illness
Current theories and studies indicate that se!eral mental disorders may be
lin"ed to a specific gene or combination of genes but that the source is not
solely genetic$ nongenetic factors also play important roles
Two genetic lin"s to )l6heimer9s disease are chromosomes ;D and *;
The Human :enome Pro7ect, funded by N1H and the >0 .epartment of
8nergy, is the largest of its "ind 1t has identified all human .N) 1n addition,
the pro7ect also addresses the ethical, legal, and social implications of human
genetics research
Stress and the Immune system +Psychoimmunology-
This is a relati!ely new field of study, which e/amines the effect of
psychological stressors on the body9s immune system
Infection as a ossi/le cause
0ome researchers are focusing on infection as a cause of mental illness
0tudies such as this are promising in disco!ering a lin" between infection and
mental illness
The &urse1s role in research and education
The nurse must ensure that client9s and families are well informed about
progess in these areas and must also help them to distinguish between facts
and hypotheses The nurse can e/plain if or how new research may affect a
client9s treatment or prognosis The nurse is a good resource for pro!iding
information and answering Cuestions
Psychoharmacology
8fficacy refers to the ma/imal therapeutic effect that a drug can achie!e
Potency describes the amount of the drug needed to achie!e that ma/imum
effect$ low-potency drugs reCuire higher doses to achie!e efficacy, whereas
high-potency drugs achie!e efficacy at lower doses
Half Fife is the time it ta"es for half of the drug to be remo!ed from the
bloodstream .rugs with shorter half#life may need to be gi!en three or four
times a day, but drugs with a longer half#life may be gi!en once a day
The F.) may issue a blac"#bo/ warning when a drug is found to ha!e
serious or life#threatening side effects This means that pac"age inserts must
ha!e a highlighted bo/, separate from the te/t, which contains a warning
about the serious side#effects
(ntisychotic drugs
)lso "nown as neuroleptics, are used to treat the symptoms of psychosis,
such as the delusions and the hallucinations seen in schi6ophrenia,
schi6oaffecti!e disorder, and the manic phase of bipolar disorder
)ntipsychotic9s wor" by bloc"ing receptors of the neurotransmitter, dopamine
.opamine receptors are classified into subcategories &.;, .*, .4, .D, and
.@( and .*, .4, and .D ha!e been associated with mental illness
The typical antipsychotic drugs are potent antagonists &bloc"ers( of .*, .4,
and .D This ma"es them effecti!e in treating target symptoms but also
produces many extrapyramidal side effects because of the bloc"ing of the .*
receptors
Newer, atypical antipsychotic drugs such as clo6apine &Clo6aril( are relati!ely
weak blockers of D2, which may account for the lower incidence of
e/trapyramidal side effects
The newer antipsychotics also inhibit the reupta"e of serotonin, increasing
their effecti!eness in treating the depressi!e aspects of schi6ophrenia
E*trayramidal Side Effects
&8P0( are the ma7or side effects of antipsychotic drugs They include acute
dystonia &prolonged in!oluntary muscular contractions that may cause
twisting of the body parts, repetiti!e mo!ements, and increased muscular
tone(, pseudopar"insonism, and a"athisia &intense need to mo!e about(
Aloc"age of the .* receptors in the midbrain region of the brain stem is
responsible for the de!elopment of 8P0 1ncluded in the 8P0 are5
o Torticollis 5 twisted head and nec"
o Opisthotonus 5 tightness of the entire body with head bac" and an
arched nec"
o Oculogyric crisis 5 eyes rolled bac" in a loc"ed position
1mmediate treatment with anticholinergic drugs usually brings rapid relief
Pseudopar"insonism , or drug#induced Par"insonism if often referred to by the
generic label of 8P0 0ymptoms include a stiff, stooped posture$ mas"#li"e
facies$ decreased arm swing$ a shuffling festinating gait$ drooling$ tremor$
bradycardia$ and coarse pill rolling mo!ements of the thumb and fingers while
at rest
Treatment of these symptoms can include adding an anticholinergic agent or
amantadine, which is a dopamine agonist that increases transmission of
dopamine bloc"ed by the antipsychotic drug
&euroletic Malignant syndrome
&NM0( is a potentially fatal idiosyncratic reaction to an antipsychotic .eath
rates ha!e been reported at ;+E to *+E
0ymptoms include rigidity, high fe!er$ autonomic instability such as unstable
blood pressure, diaphoresis, and pallor$ delirium$ and ele!ated le!els of
en6ymes, particularly creatine and phospho"inase
Clients with NM0 are confused and often mute$ they may fluctuate from
agitation to stupor
.ehydration, poor nutrition, and concurrent medical illness all increase the
ris" of NM0
Treatment includes immediate discontinuation of the antipsychotic and the
institution of supporti!e medical care to treat dehydration and hyperthermia
Tardive Dys)inesia
&T.( is a syndrome of ermanent in!oluntary mo!ements This is most
commonly caused by the long#term use of antipsychotic drugs
There is no treatment a!ailable
The symptoms of T. include in!oluntary mo!ements of the tongue, facial,
and nec" muscles, upper and lower e/tremities, and truncal musculature
Tongue thrusting and protruding, lip smac"ing, blin"ing, grimacing, and other
e/cessi!e unnecessary facial mo!ements are characteristic
One T. has de!eloped, it is irre!ersible
(granulocytosis
0ome antipsychotics produces agranulocytosis This de!elops suddenly and
is characteri6ed by5
o Fe!er
o Malaise
o >lcerati!e sore throat
o Feucopenia
The drug must be discontinued immediately if the WAC drops by @+E or to
less that 4,+++
(ntideressant drugs
)lthough the mechanism of action is not completely understood,
antidepressants somehow interact with the two neurotransmitters,
norepinephrine and serotonin
)ntidepressants are di!ided into four groups5
o Tricyclic and the related cyclic antidepressants
o 0electi!e serotonin reupta"e inhibitors &0031s(
o M)O inhibitors &M)O1s(
o Other antidepressants such as !enlafa/ine &8ffe/or(, bupropion
&Wellbutrin(, dulo/etine &Cymbalta(, tra6odone &.esyrel(, and
nefa6odone &0er6one(
M)O1s ha!e a low incidence of sedation and anticholinergic effects, they
must be used with e/treme caution for se!eral reasons5
o ) life#threatening side effect, hypertensi!e crisis, may occur if the
client ingests food containing tyramine &an amino acid( while ta"ing
M)O1s
Mature or aged cheeses
)ged meats &sausage, pepperoni(
Tofu
)FF tap beers and microbrewery beer
0auer"raut, soy sauce, or soybean condiments
Hogurt, sour cream, peanuts, M0:
o M)O1s cannot be gi!en in combination with other M)O1s, tricyclic
antidepressants, .emerol, CN0 depressants, and hypertensi!es, or
general anesthetics
o M)O1s are potentially lethal in o!erdose and pose a potential ris" for
clients with depression who may be considering suicide
0031s, !enlafa/ine, nefa6odone, and bupropion are often better choices for
those who are potentially suicidal or highly impulsi!e because they carry no
ris" of lethal o!erdose in contrast to the cyclic compounds and the M)O1s
Howe!er, 0031s are only effecti!e for mild to moderate depression
The ma7or actions of antidepressants are with the monoamine
neurotransmitter systems in the brain, particularly norepinephrine and
serotonin
o Norepinephrine, serotonin, and dopamine are remo!ed from the
synapses after release by reupta"e into presynaptic neurons )fter
reupta"e, these three neurotransmitters are reloaded for subseCuent
release or metaboli6ed by the en6yme M)O
o The 0031s bloc" the reupta"e of serotonin$ the cyclic antidepressants
and !enlafa/ine bloc" the reupta"e of norepinephrine primarily and
bloc" serotonin to some degree$ and the M)O1s interfere with en6yme
metabolism
Mood sta/ili"ing drugs
Mood stabili6ing drugs are used to treat bipolar disorder by stabili6ing the
client9s mood, pre!enting or minimi6ing the highs and lows that characteri6e
bipolar illness, and treating acute episodes of mania
Fithium is considered the first#line agent in the treatment of bipolar disorder
o Fithium normali6es the reupta"e of certain neurotransmitters such as
serotonin, norepinephrine, acetylcholine, and dopamine 1t also
reduces the release of norepinephrine through competition with
calcium
o Fithium produces its effects intracellularly rather than within neuronal
synapses
o Fithium serum le!els should be about ;+ m8C%F Fe!els less than +@
m8C%F are rarely therapeutic, and le!els of more than ;@ m8C%F are
usually considered to/ic
o 1f Fithium le!els e/ceed 4+ m8C%F, dialysis may be indicated
The mechanism of action for anticon!ulsants is not clear as it relates to their
off#label use as mood stabili6ers
o 2alporic acid and topiramate are "nown to increase the le!els on the
inhibitatory neurotransmitter, :)A) Aoth are thought to stabili6e
mood by inhibiting the "indling process
The "indling process can be described as the snowball#li"e
effect seen when minor sei6ure acti!ity seems to build up into
more freCuent and se!ere sei6ures 1n sei6ure management,
anticon!ulsants raise the le!el of the threshold to pre!ent these
minor sei6ures 1t is suspected that this same "indling process
may occur in the de!elopment of full#blown mania with
stimulation by more freCuent, minor episodes
(ntian*iety drugs +(n*iolytics-
Aen6odia6epines mediate the actions of the amino acid :)A), the ma7or
inhibitory neurotransmitter in the brain Aecause :)A) receptor channels
selecti!ely admit the anion chloride into neurons, acti!ation of :)A)
receptors hyperpolari6es neurons and thus is inhibitory
Aen6odia6epines produce their effects by binding to a specific site on the
:)A) receptor
Stimulants
Today, the primary use of stimulants is for ).H. in children and adolescents,
residual attention deficit disorder in adults, and narcolepsy
0timulants are often termed indirectly acting amines because they act by
causing release of the neurotransmitters &norepinephrine, dopamine, and
serotonin( from presynaptic ner!e terminals as opposed to ha!ing direct
agonist effects on the postsynaptic receptors They also bloc" the reupta"e of
these neurotransmitters
Ay bloc"ing the reupta"e of these neurotransmitters into neurons, they lea!e
more of the neurotransmitter in the synapse to help con!ey electrical
impulses in the brain
Cultural considerations
19m not going to go much into this Gust "now that clients from !arious cultures
may metaboli6e medication at different rates and therefore reCuire alterations
in standard dosages
Psychosocial Theories and Therapy
Sigmund Freud, the Father of Psychoanalysis
Founded the personality components; Id, Ego, and Superego
o Id: The part of ones nature that reflects basic or innate desires
such a pleasure seeking behavior, aggression, and seual
impulses! The id seeks instant gratification, causes impulsive
thinking behavior, and has no rules or regard for social
convection!
o Superego: The part of ones nature that reflects moral and
ethical concepts, values, parental and social epectations;
therefore, it is the directional opposite to the id!
o Ego: The balancing or mediating force bet"een the id and the
superego! The ego represents mature and adaptive behavior that
allo"s a person to function successfully!
Psychoseual development
o #ral $birth to %& months'
o (nal $%& to )* months'
o Phallic+#edipal $) to , years'
o -atency $, to %% or %) years'
o .enital $%% or %) years'
Transference and /ountertranference
o Transference occurs "hen the client onto the therapist+nurse
attitudes and feelings that the client previously felt in other
relationships!
o /ountertranference occurs "hen the therapist+nurse displaces
onto the client attitudes or feelings from his or her past!
Developmental Theorists; Erikson and Piaget
Erikson focused on personality development across the life span "hile
focusing on social and psychological development in life stages!
o Trust vs! 0istrust $infant'
o (utonomy vs! Shame and 1oubt $toddler'
o Initiative vs! guilt $preschool'
o Industry vs! Inferiority $school age'
o Identity vs! 2ole confusion $adolescence'
o Intimacy vs! isolation $young adult'
o .enerativity vs! stagnation $middle adult'
o Ego integrity vs! despair $maturity'
Erikson believed that psychosocial gro"th occurs in se3uential stages,
and each stage is dependent on the completion of the previous
stage+life task!
Piaget eplored ho" intelligence and cognitive functioning develop in
children!
o Sensorimotor $birth to 4 years': The child develops a sense of
self as separate from the environment and the concept of ob5ect
permanence! 6egins to form mental images!
o Preoperational $47* years': /hild begins to epress himself "ith
language, understands the meaning of symbolic gestures, and
begins to classify ob5ects!
o /oncrete operations $*7%4 years': /hild begins to apply logical
thinking, understands reversibility, is increasingly social and
able to apply rules; ho"ever, thinking is still concrete.
o Formal operations $%4 to %, years and beyond': /hild learns to
think and reason in abstract terms, further develops logical
thinking and reasoning, and achieves cognitive maturity!
Harry Stacks Sullivan: nterpersonal !elationships and "ilieu therapy
The importance and significance of interpersonal relationships in
one8s life "as Sullivan8s greatest contribution to the field of mental
health!
Sullivan developed the first therapeutic community or milieu "ith
young men "ith schi9ophrenia in %:4:! ;e found that "ithin the
milieu, the interactions among clients "ere beneficial, and then the
treatment should emphasi9e on the roles of the client7client
interaction!
o 0ilieu therapy is used in the acute care setting; one of the
nurses8 primary roles is to provide safety and protection "hile
promoting social interaction!
Hildegard Peplau: Therapeutic nurse#patient relationship $The %om%#
diggity of nursing&
1eveloped the concept of the therapeutic nurse7patient relationship,
"hich includes < phases: orientation, identification, eploitation, and
resolution!
o The orientation phase is directed by the nurse and involves
engaging the client in treatment, providing eplanations and
information, and ans"ering 3uestions! 1uring this time the
nurse "ould orient the patient to the rules and epectations $if
in an acute setting'!
o The identification phase begins "hen the client "orks
interdependently "ith the nurse, epresses feelings, and begins
to feel stronger! This phase can begin either "ithin a fe" hours
to a fe" days; the patient can identify the nurse and
environment on his o"n! They =come together>! ?inky!
o In the eploitation phase, the client makes full use of the
services offered! ;e moves to"ard independence!
o In the resolution phase, the client no longer needs professional
services and gives up dependent behavior!
o ?eep in mind that after the resolution phase, the client can
regress and move back into the above mentioned phases!
Paplau defined aniety as the initial response to a psychic threat,
describing < levels of aniety: acute, moderate, severe, and panic!
o (cute aniety is a positive state of heightened a"areness and
sharpened senses, allo"ing the person to learn ne" behaviors
and solve problems! The person can take in all available stimuli
$perceptual field'!
o 0oderate aniety involved a decreased perceptual field $focus
on immediate task only'; the person can learn ne" behavior or
solve problems only with assistance! (nother person can
redirect the person to the task! 2emember, this is the ideal
aniety state for teaching a client regarding health concerns
such as diabetes, as /athy says so!
o Severe aniety involves feelings of dread or terror! The person
/(@@#T be redirected to a task; he focuses only on scattered
details and has physiologic symptoms such as tachycardia,
diaphoresis, and chest pain! The client may go to the E2
thinking he is having a heart attack! In lecture, /athy stated that
this person can still be =talked do"n>! The first priority is to
move the person a"ay from all stimuli, and then attempt to talk
"ith them to calm do"n!
o Panic aniety can involve loss of rational thought, delusions,
hallucinations, and complete physical immobility and muteness!
The person my bolt and run aimlessly, often eposing himself
and others to in5ury!
Humanistic Theories; "aslo'(s Hierarchy of needs)
Everyone should kno" this one! It is outlined on page ,* in your
book!
;e used a pyramid to arrange and illustrate the basic drives or needs
to motivate people!
o The most basic needs, physiologic needs, need to be met first!
This includes food, "ater, shelter, sleep, seual epression, and
freedom of pain! These 0AST be met first!
o The second level involves safety and security needs, "hich
involve protection, security, freedom from harm or threatened
deprivation!
o The third level is love and belonging needs, "hich include
enduring intimacy, friendship, and acceptance!
o The fourth level involves esteem needs, "hich includes the
need for self7respect and esteem from others!
o The highest level is self7actuali9ation, the need for beauty,
truth, and 5ustice! Fe" people actually become self7actuali9ed!
o 2emember, traumatic life eperiences or compromised health
can cause a person to regress to a lo"er level of motivation!
Pavlov: *lassic conditioning $+ehavior theory&
Pavlov believed that behavior can be changed through conditioning
"ith eternal or environmental conditions or stimuli!
*risis ntervention
0aturational crises, sometimes called developmental crises, are
predictable events in the normal course of a life, such as leaving home
for the first time, getting married, having children, etc!
Situational crises are unanticipated or sudden events that threaten an
individuals integrity; such as a death of a loved one and loss of a 5ob!
(dventitious crises, sometimes called social crises, include natural
disasters like floods, earth3uakes, or hurricanes; "ar, terrorist attacks;
riots; and violent crimes such as rape or murder!
Non#!iolent crisis inter!ention
The heart of crisis inter!ention is5
Care
Welfare
0afety &I;'(
0ecurity
People in crisis need care and welfare
0taff responses should be safety and security
(n*iety2
1ncrease or change in beha!ior Can be anything different from usual
beha!ior &e/citement, pacing(
Nursing inter!entions5
o )s" ,What9s going onJ-
o :i!e supporti!e care and let the patient "now that you9re there
Defensive2
Foss of rationality
Nursing inter!entions5
o .irect approach to setting limits
o Ta"e away pri!ileges
o :i!e the patient some control and choices
(cting out erson2
Foss of rational control
Nursing inter!entions5
o 8!erything Cathy showed us on non#!iolent physical crisis inter!ention
Tension-Reduction2
0ubsiding of energy
Nursing inter!entions5
o 8stablish therapeutic rapport
o Prime time to tal" and teach about pre!entions of beha!ior
3hat if the atient simly refuses4
0et limits'
Ma"e the limits reasonable and enforceable
Releasing5 Venting5 Mad as hec)6
)llow the patient to do this'
Gust stay calm as a nurse
While they9re !enting, they9re also releasing This is a good thing
Intimidation2
This is NOT ) :OO. TH1N:
What if the patient tells youKJ
o 1 "now what car you dri!e
o 1 "now your last name
o 1 "now you ha!e * dogs and 19m going to "ill them
Nursing inter!entions5
o :et a witness' .o not be by yourself with this patient'
&on-ver/al /ehavior that affect ro*emics
Factors that affect5
o 0i6e, gender, disability, en!ironment, agitation, history, and speed
;?#4B- is personal space &usually how wide ones arm length is(
)lways be the closest to the door
7inesics +0ody language-
Facial e/pressions, stance, posture, breathing, hand gestures
When approaching a client, stand at D@ degree angle
0tand with hands to side &especially when with a paranoid client(
Mo!e when the patient mo!es
Ae as calm as possible
Paraver/al communication
@@E non!erbal
<E !erbal
4?E para!erbal it9s not what you say$ it9s how you say it'
T2C &total !oice control(
o Tone
o 2olume
o Cadence
)lways remember not to lose eye contact
If you1re /eing gra//ed5
:ain physiologic ad!antage
o Lnow where the wea" point of grab is
o Fe!erage# use what you ha!e'
o MomentumMit comes in handy
:ain psychological ad!antage
o 0tay calm
o Ha!e a plan
o .on9t forget the element of surprise
&on-Violent hysical control and restraint should /e used as a 8(ST RES,RT'
Mood disorders
Categories of Mood disorders
>nipolar
o Ma7or depression
Aipolar
o Mania
o .epression
o Period of normalcy
9niolar2 Ma:or deression
0ad mood or lac" of interest in life for * or more wee"s
)nother D symptoms must also be present
o Change in appetite &increase or decrease(
o Change in sleep patterns &too much or too little(
o >nable to concentrate and ma"e decisions
o Foss of self#esteem &guilt# how you were raised$ how worthy a person
percei!es themsel!es(
Those at ris"5
o PM0%PM..
o 0uffering from an/iety and irritability
o PP depression
o Chronic illness &dialysis(
o PT0.
o :rief and loss
Can be obser!ed by others, or the depression is 7ust in one9s ,head-
Incidence
Ma7or depression occurs at least twice as often in women
0ingle and di!orced people ha!e the highest rates of depression
Treatments
Psychotherapy &groups, counselor(
Psychopharmacology &Meds(
8CT
Electroconvulsive theray
The biggest concern is memory loss
Patient is pre#medicated, much li"e a pre#op patient
8lders are treated for depression with 8CT more freCuently than younger
persons
o 8lder persons ha!e increased intolerance of side effects of
antidepressants
o 8CT produces a more rapid response
Suicidal Ideation
0afety is primary concern
Watch for o!ert cues of suicide &Ob!ious( acti!e
Co!ert cues are more subtleMpassi!e
People who suddenly are happier are of great concern$ may ha!e made the
suicidal plan are content with their decision
People whose meds are finally wor"ingMha!e enough energy to carry out the
act
Client1s (ffect
Compare !erbal with non#!erbal beha!iorsMdo they match upJ
)social 5 Withdrawal from family and friends
)nhedonic 5 Fose sense of pleasure
When confronting these client9s about their beha!ior, use ,1- statements
o =1 really wish you9d 7oin the group-
;udgment
Feel o!erwhelmed with normal acti!ities
.ifficulty with tas" completion
)lways e/hausted
Self Concet
3uminate 5 Worry to e/cess
Fac" energy for normal acti!ities &always tired(
Interventions
)ssess safety for client &P31O31TH'(
Perform suicide lethality assessment
Orient client to new surroundings &they need structure(
Offer e/planations of unit routine &again, need structure(
0tart to promote a therapeutic relationship$ schedule short interaction times
Patient and <amily teaching
0tress importance of follow#up careM"eep it structured$ ma"e appointment
for them
0tress importance of continuing medications$ assess if they can afford them
Ma"e phone number lists of how to get help if they need it
0iolar disorder
Condition with cyclic mood changes
Person has manic episodes, periods of profound depression, and times of
normal beha!ior in#between
Occurs eCually in men and women$ often seen in highly educated people
Clinical course of mania
8pisode of unusual, grandiose, or agitated mood lasting at least one wee"
with three or more of the following symptoms5
o 8/aggerated self#esteem
o 0leeplessness
o Pressured speech
o Flight of ideas
o 3educed ability to filter out stimuli
o .istractibility
o More acti!ities with increased energy
Drug treatment
Fithium
o Fithium is not metaboli6ed$ rather, it is reabsorbed by the pro/imal
tubule and e/creted in the urine
o Thought to wor" in the synapse to increase destruction of dopamine
and norepinephrine$ decreases sensiti!ity to postsynaptic receptors
&Aasically# when a person is in a manic phase, they are synapsing
super fast Fithium helps slow this synapsing down(
o Onset of action is @#;D days$ other drugs must be used during the
acute phases to reduce symptoms of mania or depression
o Maintenance lithium le!el is +@#;+ m8C%F
4 is to/ic' .uh
o Fithium is a salt contained in the human body 1t not only competes for
salt receptor sites but also affects calcium, potassium, and magnesium
ions as well as glucose metabolism
M>0T complete an electrolyte blood panel &focus on Chloride(
o Ha!ing too much salt in the diet can cause the lithium le!el to be too
low
o Not ha!ing enough dietary salt can cause the lithium le!els to be too
high
o Persistent thirst and diluted urine can indicate the need to call the M.$
lithium dosage may need to be reduced
)nticon!ulsant drugs5 mechanism is unclear, but they raise the brains
threshold for dealing with stimulation$ this pre!ents the person from being
bombarded with e/ternal and internal stimuli
o Tegretol
Huge concern about agranulocytosis &a decrease in WAC(
Need serum le!els monitored ;* hours after last dose
o .epa"ote
Need to monitor serum le!el, CAC with platelets, li!er function
including ammonia le!el &ammonia is a by#product of li!er
metabolism(
o Llonopin
)nticon!ulsant and ben6odia6epine
.rug dependence can occur
Monitor CAC, li!er function
Withdrawal drug slowly to pre!ent :1 issues
Cannot be used alone to manage bipolar$ must be used in
con7unction with lithium or another mood stabili6er
Helful hints to care for /iolar clients
Hou can9t teach a manic client
0afety is a huge issue because their 7udgment is poor
Only spend short periods of time with patient
Must be fle/ible in ta"ing inta"e assessment$ may need to obtain data in
se!eral short sessions as well as tal"ing to family members
)s" the client to e/plain any coded speech
)ssist the client to meet socially accepting beha!iors ,Lathy, you are too
close to my face Please stand bac" two feet-
Feed them finger foods high in calories while in a manic phase$ pro!ide
nutritional support'
>se simple sentences when communicating 1t is also helpful to as" client to
repeat brief messages to ensure they ha!e heard and incorporated them
o =Please spea" more slowly 19m ha!ing trouble following you-
)!oid becoming in!ol!ed in power struggles o!er who will dominate the
con!ersation
Suicide
D out of @ who actually commit suicide ha!e made at least one prior attempt
1n a ma7ority of cases, there are clear indicators hat the person was !ery
troubled
Few than ;@E of suicide !ictims lea!e suicide notes
The suicide ris" is greatest in the =+ days following a ma7or depressi!e
episode
=sur!i!or guilt- happens when ; or more family members feel guilty that they
are still li!ing
=0eparation an/iety- may cause they sur!i!ing to ,7oin the belo!ed deceased-
Ma"e the patient sign a ,contract for life-
Crisis inter!entionMmay need ;5; care The client is no more than *#4 feet
away from a staff member at any time, including going to the bathroom
)n/iety disorders N 0ubstance abuse
Incidence
Most common emotional disorder in the >0
Pre!alent in women$ age OD@
Physiologic resonses
Flight or fight responses
0ympathetic fibers increase the !ital signs
)drenal glands release adrenalin which causes the body to5
o Ta"e in more o/ygen
o .ilate the pupils &brings more light into eyes$ better !ision(
o 1ncrease the arterial blood pressure and heart rate
o Constrict peripheral !essels &ma"es s"in cool and pale(
o 1ncrease glycogenolysis to free glucose for fuel &glycogen is being
bro"en down in the li!er(
o 0hunt blood from :1 and reproducti!e organs
Psychological resonse
.ifficulty with logical thought
1ncreased agitation with motor acti!ity
1ncreased !ital signs
Client will try to change the feelings of discomfort by5
o Changing beha!ior by adaptation
o Changing beha!ior with defense mechanisms
(n*iety disorders
Panic disorder
Phobic disorder
)goraphobia
Obsessi!e#compulsi!e
PT0.
:enerali6ed an/iety
)n/iety related to medical conditions
0ubstance#induced an/iety disorder
Develoment of (n*iety Disorders
Predisposing factors
o Onset5 )cute or insidious &builds up(
o Precipitating e!ent
o Chronic stressors
o >nusual beha!ior
o Fears disproportionate to reality
8evels of an*iety
Mild5
o Psychological5 Wide perceptional field, sharpened senses, increased
moti!ation, effecti!e problem sol!ing, increased learning ability,
irritability
o Physiologic5 3estlessness, fidgeting, ,butterflies-, difficulty sleeping,
hypersensiti!ity to noise
Moderate5
o Psychological5 perceptual field narrowed to immediate tas", selecti!ely
attenti!e, cannot connect thoughts or e!ents independently, increased
use of automatisms
o Physiologic5 Muscle tension, diaphoresis, pounding pulse, H), dry
mouth, high !oice pitch, faster rate of speech, :1 upset, freCuent
urination
0e!ere5
o Psychological5 Perceptual field narrowed to one detail or scattered
details$ cannot complete tas"s$ cannot sol!e problems or learn
effecti!ely$ beha!ior geared toward an/iety relief and is usually
ineffective$ doesn9t respond to redirection$ feels awe, dread, or horror$
cries$ ritualistic beha!ior
o Physiologic5 0e!ere H), N%2, diarrhea, rigid stance, !ertigo, pale,
tachycardia, chest pain
Panic5
o Psychological5 Perceptual field reduced to focus on self$ cannot
process any en!ironmental stimuli$ distorted perceptions$ loss of
rational thought$ doesn9t recogni6e potential danger$ can9t
communicate !erbally$ possible delusions or hallucinations$ may be
suicidal
o Physiologic5 May bolt and run ,R totally immobile and mute$ dilated
pupils, increased blood pressure and pulse$ flight, fright, or free6e
Seyle Resonse to stress
)larm reaction
o Physiologic response
o Aody prepares to defend itself
3esistance stage
o Aody will defend by flight or fight
o 1f the stress is gone$ body rela/es
8/haustion stage
o Negati!e response to an/iety and stress
o Aody stores are depleted
Panic disorders
)n episode lasting ;@#4+ minutes in which a client e/periences rapid, intense,
escalating an/iety$ great emotional discomfort$ and physiologic discomfort
.efined as recurrent, une/pected panic attac"s followed by a month of
persistent concern or worry about ha!ing another attac"
<@E with panic disorder ha!e spontaneous attac"s with no triggers
Others ha!e attac"s stimulated by phobias or chemical changes within the
body
Treatment
Psychotherapy
o Positi!e reframing
o )sserti!eness training
Psychopharmacology
o 0031s
o )n/iolytics
o )ntidepressants
o M)O1s
Pho/ias
)n illogical, intense, persistent fear of a specific ob7ect or social situation that
causes e/treme distress and interferes with having a normal life
Treatment for phobias5
o Psychopharmacology
)n/iolytics
Aen6odia6epines
0031s
Aeta Aloc"ers
o Psychotherapy
Aeha!ioral therapy
0ystemic desensiti6ation
=Flooding- :etting rid of fear all at one time
,/sessive-Comulsive Disorder +,CD-
Obsessions5 3ecurrent thoughts, ideas, !isuali6ations, or inappropriate
impulses that disturb a person9s life$ has no control over them
Compulsions5 Aeha!iors or rituals continuously carried out to get rid of the
obsessi!e thoughts and reduce an/iety
Higher incidence with groups in higher economic status and with more
education
Nursing inter!entions5
o 3emember, a lot of the time people feel guilty about their thoughts and
beha!iors
o .o not try to stop the act unless the act is harmful &dangerous(
o Tal" to them' >se ,1- statements
o 1f they are too down on themsel!esMlimit your time with them For
instance, ,1 hate myself No one cares about me 19m fat and ugly- The
nurse would then say, ,1 am going to come bac" in 4+ minutes 1n that
time frame, 1 want you to thin" of your good Cualities-
o .o not argue with OC. person
o 1n7ect reality 1f a teenager thin"s she is pregnant despite a negati!e
pregnancy test, tell her the T80T 10 N8:)T128 Ta"e them bac" into
reality
o 1f they repetiti!ely do an act o!er and o!er again$ help them set a goal
For instance, ,Fet9s try to only wash your hands once e!ery ten
minutes-
Post Traumatic Stress disorder
Three clusters if symptoms are present
o 3eli!ing the e!ent
Memories, dreams, or flashbac"s
o )!oiding reminders of the e!ent
0taying away from any stimuli that could be associated with the
trauma
o Aeing on guard &hyper#arousal(
Fess responsi!e to stimuli
1nsomnia, irritability, or angry outbursts
)t ris" people include5
o Combat !eterans
o 2ictims of !iolence
o )bused !ictims
o Children in traffic accident &and the parents(
Only DBE of parents sought help for their children L1.0 N88.
H8FP
0ymptoms of PT0. occur 4 months or more after the trauma
0ome more signs of PT0.5
o Ha!e issues with authority figures
o Their first emotions are anger, rage, and guilt
o Their guilt comes out as anger &!iolent beha!ior(
o 1solate themsel!es
o Cry
o .on9t want to tal" about it
o .rug and alcohol abuse
o Nightmares
o Manifests in physiological symptoms &H), :1 distress(
o 1rritable
o 1nsomnia
Nursing inter!entions5
o Ha!e specific staff members assigned to client to facilitate building
trust
o Consistency is the "ey
o Ae non#7udgmental$ encourage client to tal"
o Help them ac"nowledge where grief is coming from
o 1n!ol!e family
o :i!e positi!e feedbac"
:oals for PT0.5
o 0hort term 5 0afety, decrease insomnia, identify source, grie!e'
o Fong term 5 )ccept the fact that the e/perience happened and li!e
healthy
Su/stance a/use
19m not going to go much into these notes$ there wasn9t much information in
the lecture that is not in the pac"et
O!erdose of alcohol5
o )lcohol is a depressant$ decreased respirations and blood pressure,
!omiting may cause aspiration
O!erdose of ben6odia6epines reCuire a gastric la!age including instillation of
acti!ated charcoal
0timulants
o Cocaine, amphetamines, and 3italin
o 1ncreases H3 and AP$ decreases cardiac output and o/ygen
o Cocaine specifically causes M19s
3ithdra!al
Two purposes5
o 0afe withdrawal with medication
0uppress symptoms of abstinence
)round the cloc" schedule and P3N
Ne!er, e!er go cold tur"ey
o Pre!ent relapse
May need to go to )) for rest of life
Cogniti!e disorders
Delirium
.isturbance of consciousness accompanied by change in cognition$
disoriented
o )lert and oriented to person only
o Typically ha!e problems recalling on memory and time
.e!elops o!er a short period of time
8asily distracted
.ifficulty concentrating
1llusions, hallucinations
Onset is rapid
Arief duration
Fe!el of consciousness is impaired
0lurred speech
)n/ious mood
Causes of Delirium
Metabolic
1nfectionM>T1
Fow sodium
o Normal is ;4@#;D@ m8C%F
o )lways chec" electrolytes'
.rug related
o Or, withdrawal from drugs and alcohol
o 0edati!es and ben6odia6epines cause confusion
8ffects of anesthesia
The nursing rocess2 (ssessment
1nter!iew with simple Cuestions and e/planations
FreCuent brea"s
History of onset$ not reliable from client
o 1nter!iew family members$ as"5 ,1s the how your mom typically actsJ-
Mood%)ffect
o FreCuently assess moods$ moods change Cuic"ly
Thought process%content
o Many ha!e !isual hallucinations
o 2ery restless$ hard to "eep in bed
&ursing rocess2 .oals
Free from in7ury
o Fall precautions
.emonstrate increased orientation
o >se reality orientation and !alidate feelings
)deCuate balance of acti!ity and rest
o Help the patient "eep days and nights straight
)deCuate nutrition
o Often forget to eat$ needs nutritional supplements
3eturn to optimal le!el of functioning
) goal needs a timeline to ma"e it measurable'
&ursing rocess2 Intervention
Patient safety
Managing confusion
o Often frightened at night
Promote comfort and rest
)deCuate fluids and nutrition
o )lways offer little sips of water'
&ursing rocess2 Evaluation
0uccessful treatment of underlying causes for delirium returns client to former
le!el of functioning
Client and family education about a!oidance of recurrence
Monitor chronic health problems
Careful use of medications
No alcohol or other non#prescribed drugs
.ementia
Dementia
More progressi!e, gradual, and permanent
1n!ol!es multiple cogniti!e deficits
o Primarily memory impairment
1n!ol!es at least one of the following5
o )sphasia &deterioration of language function(
o )pra/ia &impaired ability to e/ecute motor functions(
o )gnosia &inability to name or recogni6e ob7ects(
o .isturbance in e/ecuti!e functioning &ability to thin" abstractly and to
plan, initiate, seCuence, monitor, and stop comple/ beha!ior(
May also present5
o 8cholalia &echoing what is heard(
o Palilalia &repeating words or sounds o!er and o!er(
Clinical course of Dementia
Mild5
o Forgetfulness
o .ifficulty finding words
o FreCuently loses ob7ects and e/periences an/iety about these losses
o Occupational and social settings are less en7oyable, and the person
may a!oid them
Moderate5
o Confusion is present along with memory loss
o The person cannot complete comple/ tas"s but remains oriented to
person and place
o 0till recogni6es familiar people
o 0ome assistance with care
o 8/ecuti!e functioning suffers &especially with ).Fs(
0e!ere5
o Personality and emotional changes occur
o May be delusional, wander at night, forget the names of spouse and
children and reCuire assistance in ).Fs
o Most li!e in 8CF
Causes of Dementia
.ecreased metabolic acti!ity
:enetic component
1nfection
)l6heimer9s disease &I;(
Creut6feld#Gacob disease &CN0 disorder$ de!elops at D+#B+ years Causes by
infectious particle that is resistant to boiling(
Par"inson9s disease
Huntington9s disease &inherited gene$ brain atrophy, demyelination, and
enlargement of the brain !entricles Aegins in late 4+9s(
2ascular .ementia &I*(
o 0ymptoms similar to )l6heimer9s, but more abrupt, followed by rapid
changes in functioning$ a plateau$ more abrupt changes, another
plateau, and so on
o Caused by decreased blood supply to the brain
Culture
Nati!e )mericans and 8astern countries hold elders in a position of authority,
respect, power, and decision ma"ing for family$ this does not change despite
memory loss or confusion
May feel they are being disrespectful and reluctant to ma"e decisions or plans
for elders with dementia
Treatment for Dementia
>nderlying cause
o 8/ample5 2ascular dementia can be helped by diet, e/ercise, control
of hypertension or diabetes
Psychopharmacology
o Cogne/ and )ricept are cholinesterase inhibitors and ha!e shown
therapeutic effects$ slow the progress of dementia They do not
reverse damage already done'
Must ha!e li!er function tests done with Cogne/
Flu#li"e symptoms, diarrhea, sleep disturbances are common
o Tegretol and .epa"ote help stabili6e mood and diminish aggressi!e
outbursts
These doses are often P#*%4 less lower than prescribed for
sei6ures, therefore, does not need to be in the ,therapeutic
le!el- for blood wor"
o Aen6odia6epines may cause delirium and can worsen already
compromised cogniti!e abilities
&ursing rocess2 (ssessment
History
o 3emember, inter!iew family
Motor beha!ior and general appearance
o .isplay aphasia
o Con!ersation repetiti!e
o )pra/ia &such as combing hair(
o :ait disturbance
o Uninhibited behavior$ ne!er ha!e displayed these beha!iors before
Mood and )ffect
o :rie!e at first
o 8motional outbursts are common
o Pattern of withdrawal$ lethargic, apathetic, loo" da6ed and listless
Thought process and content
o 8/ecuti!e functioning impaired
o Ha!e to stop wor"ing
o Client may accuse others of stealing lost ob7ects
0ensorium and 1ntellectual Processes
o First affects recent and immediate memory, e!entually impairs the
ability to recogni6e family members and oneself
o Confabulation 5 clients ma"e up answers to fill in memory gaps$ often
inappropriate words or fabricated ideas &0C38W HO>, )00HOF8(
o 2isual hallucinations are common
Gudgment and insight
o >nderestimate ris"
0elf concept
o 1nitially grie!e, and then slowly lose sense of self
3oles and 3elationships
Physiologic and self#care considerations
o )ltered sleep#wa"e cycle
o 0ome clients ignore internal cues such as hunger or thirst
o Neglect bathing and grooming$ become incontinent
Read the &ursing Diagnoses and &ursing .oals on your o!n' Too damn la"y
to tye out'
&ursing Process2 Interventions
.emonstrate caring attitude
Leep clients in!ol!ed$ relate to en!ironment
2alidate client9s feelings of dignity
Offer limited choices
3eframing &offering alternate points of !iew to e/plain e!ents(
0ee page D?<Mthere9s a good table there about inter!entions
0)F8TH'
o Physical and Chemical restraint should be the last option
&ursing rocess2 Evaluation
:oals change as disease progresses
3eassessment is !ital'
Client always needs assessed, goals and inter!entions constantly re!ised
8!aluation is a continuing process
3ememberK short term goals= all goals need a time frame'
0chi6ophrenia
Types of schi6ophrenia
Paranoid schi6ophrenia
o 0uspiciousness
o Hostility
o .elusions
o )uditory hallucinations
o )n/iety and anger
o )loofness
o Persecutory schemes
o 2iolence
.isorgani6ed schi6ophrenia
o 8/treme social withdrawal
o .isorgani6ed speech or beha!ior
o Flat or inappropriate affect
o 0illiness unrelated to speech
o 0tereotyped beha!iors
o :rimacing mannerisms
o 1nability to perform acti!ities of daily li!ing
Catatonic schi6ophrenia
o 0ignificant psychomotor disturbances
o 1mmobility
o 0tupor
o Wa/y fle/ibility
o 8/cessi!e purposeless motor acti!ity
o 8cholalia
o )utomatic obedience
o 0tereotyped or repetiti!e beha!ior
>ndifferentiated schi6ophrenia
o >ndifferentiated schi6ophrenia does not meet the criteria for paranoid,
disorgani6ed, or catatonic schi6ophrenia
o .elusions and hallucinations
o .isorgani6ed speech
o .isorgani6ed or catatonic beha!ior
o Flat affect
o 0ocial withdrawal
3esidual schi6ophrenia
o .iagnosed as schi6ophrenic in the past
o Time limited between attac"s but may last for many years
o The client e/hibits considerable social isolation and withdrawal and
impaired role functioning
Interventions
)ssess the client9s physical needs
0et limits on the client9s beha!iors when it interferes with others and becomes
disrupti!e
Maintain a safe en!ironment
1nitiate one#on#one interaction and progress to small groups as tolerated
o )lthough, reintegrating the client into the milieu as soon as possible is
essential
0pend time with the client e!en if client is unable to respond
Monitor for altered thought processes
Maintain ego boundaries and a!oid touching the client
o Touching others without warning or in!itation
o 1ntruding in others9 li!ing spaces
o Tal"ing to or caressing inanimate ob7ects
o >ndressing, masturbating, or urinating in public
Fimit the time of interaction with the client
o 1nitially, the client may only tolerate @#;+ minutes of contact at one
time
)!oid an o!erly#warm approach$ a neutral approach is less threatening
.o not ma"e promises to the client that cannot be "ept
8stablish daily routines
)ssist the client to impro!e grooming and to accept responsibility for self#care
0it with the client in silence if necessary
Pro!ide short, brief and freCuent contact with the client
Tell the client when you are lea!ing
Tell the client when you do not understand
.o not ,go along- with the clients delusions or hallucinations
Pro!ide simple concrete acti!ities such as pu66les or word games
3eorient the client as necessary
Help the client establish what is real and unreal
0tay with the client if he is frightened
0pea" to the client in a simple direct and concise manner
3eassure the client that the en!ironment is safe
3emo!e the client from group situations if the client9s beha!ior is too bi6arre,
disturbing, or dangerous to others
o 3eassure others that the client9s inappropriate beha!iors or comments
are not his fault &without !iolating confidentiality(
0et realistic goals
1nitially do not offer choices to the client, and gradually assist the client in
ma"ing own decisions
>se canned or pac"aged food, especially with the paranoid schi6ophrenic
client
Pro!ide a radio or tape player at night for insomnia
8/plain to the client e!erything that is being done
0et limits on the client beha!ior if the client is unable to do so
.ecrease e/cessi!e stimuli in the en!ironment
Monitor for suicide ris"
)ssist the client to use alternati!e means to e/press feelings through must or
art therapy or writing
&ursing interventions for the client e*eriencing delusions
)s" the client to describe the delusion
Ae open and honest in interactions to reduce suspiciousness
Focus the con!ersation on reality based topics rather than the delusion
8ncourage the client to e/press feelings and focus on the feelings that the
delusions generate
1f the client obsesses on the delusion, set firm limits on the amount of time for
tal"ing about the delusion
.o not dispute with the client or try to con!ince the client that the delusions
are false
2alidate if part of the delusion is real
3ecogni6e accomplishments and pro!ide positi!e feedbac" for successes
&ursing interventions for the client e*eriencing hallucinations
Monitor for hallucination cues
o 0ee blue bo/ on page *=B
8licit description of hallucination to protect the client and others
o The nurses understanding of the hallucination helps the nurse "now
how to calm or reassure the client
1nter!ene with one on one contact
.ecrease stimuli or mo!e the client to another area
)!oid con!eying to the client that others are also e/periencing the
hallucination
3espond !erbally to anything real the client tal"s about
)!oid touching the client
8ncourage the client to e/press feelings
.uring a hallucination, attempt to engage the client9s attention through a
concrete acti!ity
o Teaching the client to tal" bac" to the !oices forcefully also may help
him or her manage auditory hallucinations
)ccept and do not 7udge or 7o"e about the client9s beha!ior
Pro!ide easy acti!ities and a structured en!ironment with routine acti!ities of
daily li!ing
Monitor for signs or increasing fear, an/iety, or agitation
Pro!ide seclusion if necessary
)dminister medications as prescribed
8anguage and communication distur/ances
Clang association 5 3epetition of words or phrases that are similar in sound
but in no other way
8cholalia 5 3epetition of words or phrases heard from another person
Mutism 5 )bsence of !erbal speech
Neologism 5 ) new word de!ised that has a special meaning to the client
Word salad 5 Form of speech in which words or phrases are connected
meaninglessly
Fatency of response 5 hesitation before the client responds to Cuestions This
latency or hesitation may last 4+#D@ seconds and usually indicates the client9s
difficulty with cognition or thought processes
Thought broadcasting 5 belie!e that others can hear their thoughts
Thought withdrawal 5 belie!e others are ta"ing their thoughts
Thought insertion 5 others are placing thoughts in their mind against their will
(/normal motor /ehaviors
)"athisia 5 .isplaying motor restlessness and muscular Cui!ering$ the client is
unable to sit or lie Cuietly
8chopra/ia 5 3epeating the mo!ements of another person
Wa/y fle/ibility 5 ha!ing one9s arms or legs placed in a certain position and
holding that same position for hours
.ys"inesia 5 1mpairment of the power of !oluntary mo!ements
Child and adolescent disorders
Psychiatric disorders are not diagnosed as easily in children as they are in adults
Children lac" the abstract cogniti!e abilities and !erbal s"ills to describe what
is happening
Mental retardation
Mild retardations5 1Q @+#<+
Moderate retardation5 1Q 4@#@+
0e!ere retardation5 1Q *+#4@
Profound retardation5 1Q less than *+
(dolescent deression
0ome issues are due to bac"ground and family issues
Transition into adulthood often !ery difficult
.epression is almost always due to a combination of factors
Aoys are more successful in committing suicide$ more !iolent in attempts
o )cetaminophen affects li!er
o 1buprophen affects "idneys
Presents as ,classic- symptoms in girls
1n boys, depression is more li"ely to be ,acted out- with aggressi!e beha!ior
such as ris" ta"ing, substance abuse, confrontations with authority
o .rin"ing in teenage years &ages ;@#;<( stops emotional growth Lids
that grow into adults are stuc" in this stage &1dentity !s 3ole
confusion( They learn that drin"ing is the way to cope This is not
awesome
First ma7or episode are during adolescent years$ often between the ages of
;@#;=
Manic depression
o Teens may be sad and gloomy one day and e/cited and ele!ated the
ne/t
o Mood stabili6ers are important in decreasing mood swings
Fithium &chec" blood le!els'(
.epa"ote
Tegretol
Neurontin
1n depression, one of the first cues is a large drop in school performance
Other symptoms disguised5
o .rug%alcohol abuse
o Fac" of concentration
o 3estlessness or hyperacti!ity
o )nti#social beha!ior &conduct disorder(
8/treme fatigue, sleep all the time but are not rested
0uicide warning signsK
o Constant insomnia$ may be on computer at all hours of the night
o Changes in beha!ior
o .ropping gradesMagain, school is a huge issue
1nter!entions for suicide
o High ris" teens ma"e their decisions after a ,disaster- has occurred5
brea"#ups, academic failure, fight with parents, or run#in with authority
o )lcohol is in!ol!ed in P of all suicides$ seriously impairs 7udgement
0uicide is not chosen$ it happens when pain e/ceeds resources for pain
Tal" to your "ids'
o The best place is in the car when they9re trapped, haha
0tart with the basics$ ,How are you doingJ-
Then, praise
Then get down and dirty to the real sub7ect
Childhood Schi"ohrenia
:roup of disorders of thought processes characteri6ed by gradual
disintegration of mental function
Occurs in adolescents or as young adults
0uicide is the I; cause of death in young people with schi6ophrenia
Treatment and prognosis
o Fifetime of therapy and family support
o Medications
o 0truggle for family to stay in!ol!ed
Often re7ected or 7ust can9t ta"e anymore disruption in their
li!es
,/sessive-Comulsion disorder
0ymptoms often begin slowly and gradually during their childhood or teenage
years and increase in se!erity as time goes on
Though a chronic disease, there will be periods of reduced symptoms
followed by ,flare#ups-, often stressful times in person9s life
3elief is only temporary$ usually both obsessions and compulsions occur
together
3ecogni6e thoughts or beha!iors are irrational$ but are compelled to continue
them ,against their will-
Treatment5
o 8/posure and response pre!ention
o 0031s help reduce symptoms of OC.Mmonitor for side effects
Compulsions
o Washing, cleaning, constant chec"ing, mental counting rituals
o Touching, ordering, rearranging
o )s"ing for reassurance or confessing
o MasturbationMespecially seen in children who ha!en9t yet disco!ered
this is socially unacceptable beha!ior
(utistic disorder
Most pre!alent in boys$ identified no later than 4#years of age
Child has little eye contact, few facial e/pression, doesn9t use gestures to
communicate
.oes not relate to parents or peers, lac"s spontaneous en7oyment, apparent
absence of mood and emotional affect, can not be engaged in play or ma"e
belie!e
3epetiti!e motor beha!iors such as hand#flapping, body twisting, or head
banging
May impro!e as child acCuires language s"ills
0hort term impatient therapy is used when beha!iors such as head banging
or tantrums are out of control
o Haldol or 3isperadol may be effecti!e &prn, of course(
:oals of treatment5
o 3educe beha!ioral symptoms
o Promotes learning and de!elopment
o Fanguage s"ills de!elopment
(ttention deficit disorder
Characteri6ed by patterns of inattention, hyperacti!ity, and impulsi!eness
)ccount for most mental health referrals
Needs to be physically seen for a renewal of ).H. drugs monthly
Often diagnosed when a child starts school
.istinguishing bipolar disorder from ).H. can be difficult but is crucial
because treatment is so different for each disorder
0igns and symptoms
o 1nattenti!e beha!iors
o Hyperacti!e%impulsi!e beha!iors
Fidgets
Often lea!es seat
Can9t play Cuietly
1nterrupts
Cannot wait turn
Treatment
o The most effecti!e treatment combines pharmacotherapy with
beha!ioral, psychosocial, and educational inter!entions
Psychopharmacology
o Methylphenidate &3italin(
o )mphetamine compound &)dderall(
The most common side effects of these drugs are insomnia,
loss of appetite, and weight loss or failure to gain weight
:i!ing stimulants during daytime hours usually combats
insomnia
:i!e the child brea"fast and snac"s to gain weight
o )tomo/etine &0trattera(
Non#stimulant drug$ is an antidepressantMselecti!e
norepinephrine reupta"e inhibitor
Most common side effects were decreased appetite, N%2,
tiredness, and upset stomach
Can cause li!er damage, must ha!e li!er function tests
periodically
0trategies for Home and 0chool
o Aeha!ioral strategies are necessary to help the child master
appropriate beha!iors
o 8ffecti!e approaches5
Pro!ide consistent rewards
ConseCuences for beha!ior
Offer consistent praise
>se time out
:i!e !erbal reprimands
>se daily report cards for beha!ior
Point system for positi!e and negati!e beha!ior
Therapeutic play$ use play to understand thoughts and feelings
and helps with communication
8ducate parents'
Cultural considerations
o Parents from different cultures ha!e a different threshold for tolerating
specific types of beha!ior
:eneral appearance and Motor beha!ior
o 0peech is unimpaired, but the child cannot carry on a con!ersation$ he
interrupts, blurts out answers before the Cuestion is finished, and fails
to pay attention to what is said
Mood and affect
o Mood may be labile, e!en to the point of !erbal outbursts or temper
tantrums
o )n/iety, frustration, and agitation are common
Gudgment and insight
o May fail to percei!e harm or danger and engage in impulsi!e acts such
as running into the street and 7umping off of high ob7ects
Physiologic and 0elf#care considerations
o Children with ).H. may be thin if they do not ta"e time to eat properly
or cannot sit through meals
o May be a history of physical in7uries due to ris"#ta"ing beha!iors
Nursing diagnoses
o 3is" for in7ury
Child will remain free from in7ury
1f the child is engaged in a potentially dangerous acti!ity,
the first step is to stop the beha!ior
This may reCuire physical inter!ention if the child is
running into a street or 7umping off of a high place
)ttempting to tal" or reason to a child engaged in a
dangerous acti!ity is unli"ely to succeed because of
their inability to pay attention and to listen
When the incidence is o!er and the child is safe, tal" to
the child about the beha!ior
o 1neffecti!e role performance
Will not !iolate others boundaries
:i!e positi!e feedbac" for meeting e/pectations
0tate acceptable beha!ior clearly
o 1mpaired social interactions
.emonstrate age#appropriate social s"ills
0uper!ise the child closely while he is playing
1t is often necessary to act first to stop the harmful
beha!ior by separating the child from the friend
o 1mpro!ed role performance
0implify instructions and directionsMgi!e one step of a process
at a time
:i!e the child positi!e feedbac" and sense of accomplishment
Manage the en!ironment
Minimal noise and distraction
Face the teacher in the front row and away from window
or door
o 1neffecti!e family coping
Will complete tas"s
Face the child on his le!el and use good eye contact
:i!e the child freCuent brea"s
3outines are important$ child with ).H. do not ad7ust to
changes readily
o Parental support
Fisten to parent9s feelings
Aecause these children often are not diagnosed until the *
nd
or
4
rd
grade, they may ha!e missed much basic learning for
reading and math Parents should "now that it ta"es time for
them to catch up to other children the same age
o 8!aluation
Medications are often in decreasing hyperacti!ity and
impulsi!ity relati!ely Cuic"ly
1mpro!ed sociability, peer relations, and academic achie!ement
happen more slowly
Conduct disorder
Characteri6ed by persistent antisocial beha!ior in children and adolescents
that significantly impair their ability to function in social, academic, or
occupational area
o 0ymptoms are clustered into D areas
)ggression to people and animals
.estruction to property
.eceitfulness and theft
0erious !iolation of rules and the law
o More symptoms
.ecreased self#esteem
Poor frustration tolerance
Tempter often out of control
8arly onset of se/ual beha!ior, alcohol and substance abuse,
smo"ing, ris"y beha!ior
)nti#social
0ee more in the red bo/ on page D@<
Types of conduct disorder
o Classified by age of onset
)dolescent#onset type is defined by no beha!iors of conduct
disorder until after ;+ years of age
Feast li"ely to be aggressi!e
Ha!e more normal peer relationships
Fess li"ely to ha!e persistent conduct disorder or
antisocial personality disorder as adults
Childhood#onset type in!ol!es symptoms before ;+ years of
age
Physically aggressi!e
.isturbed peer relationships
More li"ely to ha!e persistent conduct disorder and to
de!elop antisocial personality disorder as adults
o Can be classified as5
Mild 5 few conduct problems causing minor harm to others
Fying, truancy, staying out late without permission
Moderate 5 Number of conduct problems increase as does the
amount of harm to others
2andalism and theft
0e!ere 5 Many conduct problems that cause considerable harm
to others
Forced se/, cruelty to animals, weapons, burglary,
robbery
Treatment of conduct disorder
o M>0T A8 :8)38. TOW)3. .828FOPM8NT)F ):8
o 0chool aged5
Child, family, and school en!ironment are the focus of
treatment
Family therapy is essential
o )dolescents
3ely less on their parents, so treatment is based on indi!idual
therapy
Conflict resolution, anger management, social s"ills
Try to "eep the adolescent in his en!ironment &home(
o Medications ha!e little effect
)ntipsychotics for clients who present a clear danger to others
Mood stabili6ers for clients with labile moods
Cultural considerations
o Ae careful of diagnosis of Conduct disorder, must "now history and
circumstances of each child
High areas of crime rates
Could be a matter of sur!i!al
Nursing process
o 3is" for Other#directed !iolence
The client will not hurt others or damage property
08T F1M1T0
1nform the client of the rule or limit
8/plain the conseCuences if bro"en
0tate e/pected beha!ior
Aeha!ioral contract
Time out$ not a punishmentMa place to regain self control
:i!e client a schedule of daily acti!ities
o Noncompliance
The client will participate in treatment
More li"ely to participate in treatment and daily routines
if they ha!e input concerning the schedule
o 1neffecti!e coping
The client will learn effecti!e problem#sol!ing and coping s"ills
Help identify the problem and to sol!e problems
effecti!ely
o 1mpaired social interaction
The client will use age#appropriate and acceptable beha!iors
when interacting with others
Teach social s"ills
.iscuss the news, sports, or other topics as the client may not
"now how to ha!e a normal con!ersation
o Chronic low self#esteem
The client will !erbali6e positi!e, age#appropriate statements
about self
,ositional Defiant disorder
Consists of an enduring pattern of uncooperati!e, defiant, and hostile
beha!ior toward authority figures without ma7or antisocial !iolations
) certain le!el of oppositional beha!ior is common in children in adolescence
Oppositional defiant disorder is diagnosed only when beha!iors are more
freCuent and intense than unaffected peers and cause dysfunction in social,
academic, or wor" situations
TIC disorders
0udden, rapid, recurrent, non#rhythmic motor mo!ement or !ocali6ation
0tress and fatigue e/acerbates tics
Treatment5 3isperadol and Rypre/ia
Comple/ !ocal tics
o Coprolalia 5 >se of socially unacceptable words, often obscene
o Palilalia 5 3epeating own sounds or words
o 8cholalia 5 3epeating the last heard sound, word, or phrase
Tourette1s syndrome
Multiple motor tics and one or more !ocal tics
May occur many times a day for o!er a year
>sually identified by < years of age
Elimination disorders
8ncopresis 5 repeated passage of feces into inappropriate places such as
clothing or floor by a child who is at least D years of age either chronically or
de!elopmentally Often in!oluntary, but can be intentional &oppositional
defiant disorder or conduct disorder( )ssociated with constipation that occurs
for psychological, not medical reasons
8nuresis 5 3epeated !oiding of urine during the day or night into clothing or
bed by a child at least @ years of age
Treated with imipramine &Tofranil(, an antidepressant with a side effect of
urinary retention
o Was once treated with !asopressin which decreases circulatory
!olume
8ating disorders
The distinguishing factor of anore/ia includes an earlier age of onset and below#
normal body weight$ the person fails to recogni6e the eating beha!ior as a problem
Clients with bulimia ha!e a latter age at onset and a near#normal body weight They
usually are ashamed and embarrassed by the eating disorder
8ating disorders appear to be eCually common among Hispanic and white women
and less common among )frican )merican and )sian women
(nore*ia &ervosa
) life#threatening eating disorder characteri6ed by the client9s refusal or
inability to maintain a minimally normal body weight, intense fear of gaining
weight or becoming fat, significantly disturbed perception of the shape or si6e
of the body, and steadfast inability or refusal to ac"nowledge the seriousness
of the problem or e!en that one e/ists
Has e/perienced amenorrhea for at least 4 consecuti!e cycles
Complaints of constipations and abdominal pain
Cold intolerance
Hypotension, hypothermia, bradycardia
o 1ntra!ascular !olume is decreased$ less blood to pump through heart,
also due to e/cessi!e e/ercise
8le!ated A>N
o Normal le!els5 ;+#*+ mg%dl
o >rea is formed in the li!er and is the end product of protein
metabolism
o 1n anore/ia, the body has already used fat for energy$ it is now
brea"ing down muscles for energyMthe reason for the ele!ated A>N
.ecreased albumin
o Normal le!els5 4@#@ g%dl
o Measures amount of protein in the body$ albumin is a protein formed in
the li!er
o )lbumin tests are a great indicator of nutritional status
Feu"openia and mild anemia
o Not enough food and nutrients to replenish cells
Has a preoccupation with food and food#related acti!ities
Can be di!ided into * subgroups5
o 3estricting subtype 5 lose weight primarily through dieting, fasting, or
e/cessi!ely e/ercising
o Ainge eating and purging subtype 5 engage regularly in binge eating
followed by purging
8ngage in unusual or ritualistic food beha!iors
o 3efusing to eat around others
o Cutting food into minute pieces
o Not allowing the food they eat to touch their lips
8/cessi!e e/ercise is common
.iagnosed between ;D and ;? years of age
Pleased with their ability to control their weight and may e/press this
)s the illness progresses, depression and lability in mood become more
apparent
1solate themsel!es
Aelie!e peers are 7ealous of their weight loss and belie!e family and health
care professionals are trying to ma"e them ,fat and ugly-
Clients who use la/ati!es are at a greater ris" for medical complications
)utonomy may be difficult in families that are o!erprotecti!e or in with
enmeshment &lac" of clear boundaries( e/ists Ay losing weight, these clients
ha!e some control in their li!es
Ha!e body image disturbance &page D+=(
Can be !ery difficult to treat because they are often resistant, appear
uninterested, and deny their problems
Treatment5
o Focusing on weight restoration
o Nutritional rehabilitation
o 3ehydration
o Correction of electrolyte imbalances
o 0e!erely malnourished indi!iduals may reCuire TPN, tube feedings, or
hyperalimentation to recei!e adeCuate nutritional inta"e
o )ccess to the bathroom is super!ised to pre!ent purging as clients
begin to eat more food
o Weight gain and adeCuate food inta"e are most often the criteria for
determining the effecti!eness of treatment
o )mitriptyline &8la!il( and the antihistamine cyproheptadine &Periactin(
in high doses &up to *?mg%d( can promote weight gain in inpatients
o Olan6apine &Rypre/a( has been used with success because of both its
antipsychotic effect &on bi6arre body image distortions( and associated
weight gain
o Fluo/etine &Pro6ac( has shown some effecti!eness in pre!enting
relapse in clients whose weight has been partially or completely
restored$ close monitoring is needed because weight loss can be a
side effect
Family members often describe clients with anore/ia as perfectionists with
abo!e a!erage intelligence, dependable, eager to please, and see"ing
appro!al before their condition began
Clients with anore/ia appear slow, lethargic, and fatigued$ they may appear
emaciated, depending on the amount of weight loss May be slow to respond
and ha!e difficulty deciding what to say
3eluctant to answer Cuestions fully because they do not want to ac"nowledge
any problem
Often wear loose clothing in layers
0eldom smile, laugh, or en7oy any attempts at humor
0ulimia &ervosa
Characteri6ed by recurrent episodes &at least twice a wee" for 4 months( of
binge eating followed by inappropriate measures to a!oid weight gain such as
purging &!omiting, la/ati!es, diuretics, enemas, or emetics(, fasting, or
e/cessi!ely e/ercising
8ngaging in binge eating secretly
Ainging or purging episodes are often precipitated by strong emotions and
followed by guilt, remorse, shame, or self#contempt
3ecurrent !omiting destroys tooth enamel, has dental caries and ragged or
chipped teeth .entists are often the first health care professionals to
recogni6e this
Aulimia is typically diagnosed at ;? or ;=
Clients with bulimia are aware that their eating beha!ior is pathologic and go
great lengths to hide it from others
Clients with a co#morbid personality disorder tend to ha!e poorer outcomes
than those without
Most are treated on an outpatient basis
)ntidepressants are more effecti!e than the placebos in reducing binge
eating
Clients are often focused on pleasing others and ha!e a history of impulsi!e
beha!ior such as substance abuse and shoplifting as well as an/iety,
depression, and personality disorders
May be underweight, o!erweight, but are generally close to e/pected body
weight for age and si6e
)ppear open and willing to tal"$ initially pleasant and cheerful as though
nothing is wrong
&ursing outcomes>interventions
1mbalanced Nutrition5 Fess than%More than body reCuirements
The client will establish adeCuate nutritional eating patterns
o 1mplement and super!ise the regimen for nutritional rehabilitation
o ) diet of ;*++#;@++ calories is ordered, with gradual increases in
calories until clients are ingesting adeCuate amounts for height, acti!ity
le!el, and growth needs
0tart slowlyMwill ha!e massi!e diarrhea
o The client with anore/ia may be critically malnourished
TPN through central line
8lectrolyte balance
Tube feeds
o ) liCuid protein supplement is gi!en to replace any food not eaten to
ensure consumption to ensure total number of calories prescribed
o Must monitor meals and snac"s and will sit at the table during eating
away from the other clients
) ma7or goal is to first get them to the table
o .iet be!erages and food substitutions may be prohibited
o 0pecified time may be set for consuming each meal and snac"
o .iscourage clients from performing food rituals such as cutting food
into tiny pieces or mi/ing foods in unusual combinations
o Ae alert for any attempts by client to hide or discard food
o Must remain in !iew of staff for ;#* hours to ensure they do not !omit$
access to bathrooms is super!ised
o Client is weighed daily on awa"ening and after they ha!e emptied their
bladder Ha!e the client wear a hospital gown each time they are
weighed$ they may attempt to place ob7ects in their clothing to gi!e the
appearance of weight gain
o 1n bulimia, the clients should sit at a table in a "itchen or dining room
o Write out a grocery list, it is easier to follow a nutritious eating plan
1neffecti!e coping
The client will eliminate use of compensatory beha!iors such as e/cessi!e
e/ercise and use of la/ati!es and diuretics
The client will demonstrate coping mechanisms not related to food
The client will !erbali6e feelings of guilt, anger, an/iety, or an e/cessi!e need
for control
o Help the client recogni6e emotions such as an/iety or guilt by as"ing
them to describe what they are feeling$ allow adeCuate time for
response .o not as" ,are you an/iousJ 0adJ- because the client may
Cuic"ly agree rather than struggle for an answer
o 8ncourage self#monitoring &page D;D($ a beha!ior#cogniti!e approach
.isturbed body image
The client will !erbali6e acceptance of body image with stable body weight
o Help clients identify areas of personal strength that are not food#
related broadens clients9 perceptions of themsel!es
0omatoform disorders
Somati"ation2 The transference of mental e/periences and states into bodily
symptoms
Somatoform disorders2 Characteri6ed as the presence of physical symptoms that
suggest a medical condition without demonstrable organic basis to account fully for
them The three central features of somatoform disorders are as follows5
Physical complaints suggest ma7or medical illness but ha!e no demonstrable
organic basis
Psychological factors and conflicts seem important in initiating, e/acerbating,
and maintaining the symptoms
0ymptoms or magnified health concerns are not under the client9s conscious
control
The fi!e specific somatoform disorders are as followed5
0omati6ation disorder 5 Characteri6ed by multiple physical symptoms 1t
begins by 4+ years of age, e/tends o!er se!eral years, and includes a
combination of pain and :1, se/ual, and pseudoneurologic symptoms
o Client9s 7ump from one physician to the ne/t, or may see se!eral
pro!iders at once in an effort to obtain relief of symptoms
o They tend to be pessimistic about the medical establishment and often
belie!e their disease could be diagnosed of the pro!iders were more
competent
Con!ersion disorder 5 1n!ol!es une/plained, usually sudden deficits in sensory
or motor function &blindness, paralysis( These deficits suggest a neurological
disorder but are associated with psychological factors )n attitude of la belle
indifference, a seemingly lac" of concern or distress, is the "ey feature
Pain disorder 5 Pain is the primary physical symptom which is generally
unrelie!ed by analgesics and greatly affected by psychological factors in
terms of onset, se!erity, e/acerbation, and maintenance
Hypochondriasis 5 Preoccupation with the fear that one has a serious disease
&disease con!iction( or will get a serious disease &disease phobia( 1t is
thought that clients with this disorder misinterpret bodily sensations or
functions
Aody dysmorphic disorder 5 Preoccupation with an imagined or e/aggerated
defect in personal appearance such as thin"ing one9s nose is too large or
teeth are croo"ed and unattracti!e
Symtoms of a somati"ation disorder
Pain symptoms 5 complaints of headache, pain in the abdomen, head, 7oints,
bac", chest, rectum$ pain during urination, menstruation, or se/ual
intercourse
:1 symptoms 5 nausea, bloating, !omiting &other than pregnancy(, diarrhea, or
intolerance of se!eral foods
0e/ual symptoms 5 0e/ual indifference &don9t care to do the dirty(, erectile or
e7aculatory dysfunction, irregular menses, e/cessi!e menstrual bleeding
Pseudoneurologic symptoms 5 1mpaired coordination or balance, paralysis or
locali6ed wea"ness, difficulty swallowing or lump in throat, aphonia &loss of
speech sounds(, urinary retention, swollen tongue, hallucinations, double
!ision, blindness, deafness, sei6ures$ disassociati!e symptoms such as
amnesia$ or loss of consciousness other than fainting
Related disorders2
Malingering 5 The intentional production of false or grossly e/aggerated
physical or psychological symptoms$ it is motivated by e/ternal incenti!es
such as a!oiding wor", e!ading criminal prosecution, obtaining financial
compensation, or obtaining drugs Their purpose is some e/ternal incenti!e or
outcome that they !iew as important and results directly from their illness
People who malinger can stop the physical symptoms as soon as they ha!e
gained what they wanted
Factitious disorder 5 This is also "nown as Munchausen syndrome Occurs
when a person intentionally produces or feigns physical or psychological
symptoms solely to gain attention
o Munchausen syndrome by pro/y occurs when a person inflicts illness
or in7ury to someone else to gain the attention of emergency medical
personnel or to be a ,hero- for sa!ing the !ictim This occurs most
often in people who are in or familiar with medical professions, such as
nurses, physicians, medical technicians, or hospital !olunteers
Primary gain 5 .irect e/ternal benefits that being sic" pro!ides, such as relief
of an/iety, conflict, or distress
0econdary gains 5 1nternal or personal benefits recei!ed from others because
one is sic", such as attention from family members and comfort measures
&being brought tea, recei!ing a bac" rub(
Treatment2
Treatment focuses on managing symptoms and impro!ing Cuality of life
) trusting relationship helps to ensure that client9s stay with and recei!e care
from one pro!ider instead of ,doctor shopping-
0031s are commonly used for depression that may accompany somatoform
disorders
(ssessment
The nurse must in!estigate physical health status thoroughly to ensure there
is no underlying pathology reCuiring treatment 1t is important not to dismiss
all future complaints because at any time the client could de!elop a physical
condition that would reCuire medical attention
1n many cases, the client9s appearance brightens and they loo" much better
as the assessment inter!iew begins because they ha!e the nurse9s undi!ided
attention
Client9s often ha!e sleep pattern disturbances, lac" basic nutrition, and get no
e/ercise
&ursing diagnoses
1neffecti!e coping
o The client will identify the relationship between stress and physical
symptoms
Emotion-focused coping strategies help the clients rela/ and
reduce feelings of stress This includes progressi!e rela/ation,
deep breathing, guided imagery, and distractions such as
music
Problem-focused coping strategies help to resol!e or change a
client9s beha!ior or situation or to manage life stressors This
includes learning problem sol!ing methods
The nurse should help the client role play the abo!e situations
1neffecti!e denial
o The client will !erbally e/press emotional feelings
The nurse should not attempt to confront clients about somatic
symptoms or attempt to tell them that these symptoms are not
,real-
8ncourage the client to write in a daily 7ournal
Fimiting the time that clients can focus on physical complaints
alone may be necessary
The nurse may ha!e to e/plain to the family about primary and
secondary gains$ this will encourage relati!es to stop
reinforcing the ,sic" role-
1mpaired social interactions
o The client will follow an established daily routine
The nurse must help the client to establish this that includes
impro!ed health beha!iors
The challenge for the nurse is to !alidate the client9s feelings
while encouraging him to participate in acti!ities
The nurse should help the client plan social contact with others,
what to tal" about &other than the client9s complaints(, and can
impro!e the client9s confidence in ma"ing relationships
)n/iety
o The client will demonstrate alternati!e ways to deal with stress,
an/iety, and other feelings
.isturbed sleep pattern
o The client will demonstrate healthier beha!iors regarding rest, acti!ity,
and nutritional inta"e
The nurse e/plains that inacti!ity and poor eating habits
perpetuate discomfort and that often it is necessary to engage
in beha!iors e!en though one doesn9t feel li"e it
Fatigue
Pain