Psychiatric Nursing

Psychiatric Nursing
I. Etiology of Mental Health and Mental Illness A. Biochemical research 1. Much productive research has been focused in this area in the past few decades 2. Study of the brain and its functioning has helped researchers understand which parts of the brain are involved in each mental illness 3. Medications are increasingly more effective as a result of better understanding of the neurotransmitters involved and their functioning 4. The major neurotransmitters are norepinephrine, dopamine, serotonin, and gamma-aminobutyric acid (GABA) 5. Neuroimaging through the PET scan or the CT and MRI allows researchers and diagnosticians to study the brain without surgery 6. Researchers and diagnosticians can study brain functioning through the use of PET scans and other techniques B. Genetic research 1. Studies for genes that cause mental illness are difficult and inconclusive 2. They do show that familial and genetic factors are part of most major psychiatric illnesses C. Psychological theories 1. Psychoanalytic theory a. developed by Sigmund Freud b. introduced concept of the mind as a structure incorporating the id, ego and superego c. part of each person’s mental functioning is conscious and part unconscious d. treatment includes helping make the unconscious conscious

e.
Types of Defense Mechanisms

Defense mechanisms are used to defend the ego from conflicts between the id and superego

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Compensation - extra effort in one area to offset real or imagined lack in another area o Example: Short man becomes assertively verbal and excels in business. Conversion - A mental conflict is expressed through physical symptoms o Example: Woman becomes blind after seeing her husband with another woman. Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu." Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute o Example: Adolescent lashes out at parents after not being invited to party. Dissociation - walling off specific areas of the personality from consciousness o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest. Fixation - becoming stagnated in a level of emotional development in which one is comfortable o Example: A sixty year old man who dresses and acts as if he were still in the 1960's. Identification - subconsciously attributing to oneself qualities of others o Example: Elvis impersonators. Intellectualization - use of thinking, ideas, or intellect to avoid emotions o Example: Parent becomes extremely knowledgeable about child's diabetes. Introjection - incorporating the traits of others o Example: Husband's symptoms mimic wife's before she died. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others o Example: Woman who is jealous of another woman's wealth accuses her of being a gold-digger. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses o Example: "I didn't get chosen for the team because the coach plays favorites." Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior o Example: Recovered smoker preaches about the dangers of second hand smoke. Regression - retreating to an earlier and more comfortable emotional level of development o Example: Four year old insists on climbing into crib with younger sibling.

2.

3.

4.

5.

6.

Interpersonal theory a. originally developed by Harry Stack Sullivan b. personality develops according to the clients’ perception of how others view them c. a healthy personality was the result of healthy relationships; d. influenced Hildegard Peplau, considered to be the ‘mother of psychiatric nursing’ e. Peplau wrote the book “Interpersonal Relations in Nursing” which became the foundation for the nurse-client relationship f. Peplau stated that the nurse client relationship was one where the i. client received unconditional acceptance ii. relationship between nurse and client was client centered iii. client developed according to the client's perceived readiness Psychosocial developmental theory a. developed by Erik Erikson b. describes eight psychosocial stages of development in the human lifecycle c. development is successful if the person is able to resolve the conflict that arises during each stage d. if the person does not effectively resolve the conflict then development is arrested at that stage Cognitive behavioral theory (CBT) a. focus on the premise that a person’s thoughts control their behavior b. if a client is feeling or behaving in an unwanted way, then it is important to identify the thoughts that are causing these feelings or behaviors c. the treatment is for the client to replace the current thoughts with ones that produce a more desirable outcome d. CBT is used to help clients manage symptoms of their illness and live a fuller life Behavioral theory a. belief is that mental illness symptoms are a result of learned behavior b. through the use of positive and negative reinforcement unacceptable learned behavior can be replaced by a more desired behavior c. some of the problems currently treated using behavioral therapy is phobias, sexual dysfunction, and eating disorders d. commonly used behavioral techniques include assertiveness training and desensitization Stress management a. stress: a universal phenomenon, stress requires change or adaptation so that the person can maintain equilibrium b. stress can be internal or external c. nature of stressor involves i. intensity ii. scope iii. duration iv. other stressors: their number and nature d. categories of stressors - and examples i. physical - drugs or alcohol ii. psychological - such as adolescent emotional upheaval, or unexpressed anger iii. social - isolation, interpersonal loss iv. cultural - ideal body image v. microbiologic - infection e. the greater the stressor as perceived by the client, the greater the f. stress response g. stress response involves both localized and general adaptation

STRESS RESPONSE A. Local responses to stress: Local Adaptation Syndrome (LAS): 1. Examples a. Blood clotting b. Wound healing c. Reflex pain response d. Inflammatory response 2. Characteristics a. Localized response b. Adaptive (that is, requires a stressor) c. Short-term d. Restorative B. Whole-body response to stress: General Adaptation Syndrome (GAS) 1. Involves primarily nervous and endocrine systems, in 3 stages 2. Stage 1: Alarm reaction - exposure to adverse stimulus; body mobilized to resist in form of compensatory behavior a. Fight or flight response 1. Increased cardiac output 2. Increased heart rate 3. Increased respiratory rate 4. Pupils dilate 5. Increased mental alertness b. Sympathetic Nervous System response 1. Increased epinephrine a. Increased heart rate b. Increased oxygen intake c. Increased blood sugar 2. Increased norepinephrine a. Increased blood flow to skeletal muscle b. Involves increased arterial blood pressure c. Posterior Pituitary: Increased ADH 1. Increased water reabsorption 2. Decreased urine output d. Anterior Pituitary: Increased ACTH 1. Increased cortisol secretion a. Body turns fat and proteins into glycogen b. Increased protein catabolism c. Increased fat catabolism 2. Increased aldosterone secretion: a. Body reabsorbs more sodium, more water b. Kidneys produce less urine c. Kidneys secrete more potassium 3. Stage 2: Resistance - When stimulus is excessive or prolonged, alarm and mobilization give way to resistance a. Stabilization b. Hormonal levels return to normal c. Parasympathetic nervous system activates d. Body adapts to stressors 4. Stage 3: Exhaustion - If stressor continues, energy wanes and body weakens a. Physiological response as noted in alarm reaction b. Decreased energy levels c. Decreased physiologic adaptation d. Death

h.

i.

factors affecting stress response i. personal: heredity, gender, race, age personality, cognitive ability ii. sociocultural: finances, support systems iii. interpersonal: self-esteem, prior coping mechanisms iv. spiritual: belief system v. environmental: crowding, pollution, climate vi. occupational: work overload, conflict, risk physiologic indicators of stress

PHYSIOLOGIC INDICATORS OF STRESS 1. Increased Blood Pressure 2. Tachycardia 3. Tachypnea 4. Sweaty palms 5. Cold Hands and Feet 6. Decreased urine output 7. Dilated Pupils 8. Change in appetite 9. Gastrointestinal changes: nausea, vomiting, diarrhea 10. Headache 11. Restlessness 12. Insomnia 13. Muscle tension

j.

emotional/behavioral indicators of stress A. Behavior Patterns 1. Substance use/abuse 2. Changes in eating habits 3. Changes in activity B. Mood 4. Loss of self esteem 5. Feelings of inadequacy 6. Increased irritability 7. Crying B. Cognitive 8. Lack of motivation 9. Forgetfulness 10. Tendency to make mistakes 11. Decreased productivity 12. Poor judgment 13. Inability to concentrate 14. Preoccupation

k.

stress can cause a variety of emotional and physical disorders STRESS-RELATED DISORDERS 1. Hypertension 2. Ulcers 3. Skin Disorders 4. Cardiovascular disorders 5. Increased cholesterol 6. Migraines 7. Eating Disorders 8. Depression 9. Substance Abuse 10. Asthma 11. Cancer 12. Rheumatoid Arthritis 13. Anxiety disorders 14. Dysrhythmias 15. Muscle tension/aches 16. Sleeping disorders 17. Gastrointestinal upset/disorders

18. Endocrine disorders

l.

stress management strategies 1. 2. 3. 4. Balanced diet Adequate rest Regular physical exercise Relaxation techniques such as a. Breathing exercises b. Meditation c. Progressive relaxation d. Prayer e. Guided imagery f. Relaxation response g. Yoga h. Biofeedback 5. Hypnosis or self-hypnosis 6. Humor 7. Therapeutic touch or massage 8. Social support 9. Spirituality 10. Crisis intervention 11. Cognitive restructuring: Nurse and client analyze client's appraisal of stressors. Emphasis is on restructuring client's unrealistic or negative thinking.

7.

The non-compliant client does not cooperate with the treatment plan i. behavior characteristics I. does not take prescribed medication II. continues activities restricted by provider of care, such as smoking III. does not follow prescribed activities, such as exercise ii. nursing interventions I. explore the reasons for non-compliance I. lack of understanding - reinforce teaching II. lack of family support - involve family and support groups III. side effects - refer to provider of care IV. finances and access - refer to Social Services V. negative attitude toward treatment encourage expression II. express genuine concern for client III. discuss imporvement potential Crisis intervention a. definition - crisis: temporary personality disorganization with an acute emotional state. Crisis is a normal response to threatening environment. b. types and phases of crisis response i. panic state: acute crisis where client temporarily loses control I. emotional reactions are overwhelming II. decision making and problem solving abilities are inoperative III. thinking is scattered IV. social isolation V. immobilization (unable to act) ii. exhaustion crisis I. under emergency conditions II. person has lost effective coping III. cannot continue to function

m.

c.

d.

e.

shock crisis I. sudden external change II. causes release of emotions III. overwhelms client iv. four phases of crisis (average crisis four to six weeks but may vary widely) I. vulnerable state II. precipitating event I. developmental change (maturational crisis) II. a life change (situational crisis) III. loss of loved one or job (situational crisis) IV. environmental disaster or war (adventitious crisis) III. acute crisis IV. reorganization findings of crisis i. mild to severe anxiety ii. anger iii. crying, social isolation, helplessness iv. impaired cognitive processes; inability to concentrate; confusion v. insomnia vi. regression vii. nausea and vomiting treatment: crisis intervention i. objective: to help the client through the current crisis ii. brief supportive interventions focused on the phase of crisis iii. allow free discharge of emotions iv. enhance client's cognitive processes v. pharmacologic: trazodone (Desyrel), alprazolam (Xanax) vi. occupational therapy vii. recreational therapy nursing care in crisis i. provide a quiet, restful environment ii. help the client solve problems iii. let the client ventilate iv. correct any misperceptions about the crisis that the client may have v. help the client to identify support systems, alternative solutions vi. help the client to deal with long term impact of crisis vii. encourage relaxation strategies viii. assist the client in the development of new coping skills ix. give medications as ordered loss i. ii. a universal phenomenon; it occurs across the lifespan there are many types of loss I. loss of external objects II. loss of significant other: through death, divorce III. loss of environment: by moving, taking a new job, hospitalization IV. loss of an aspect of self: may include a body part, physiologic or psychologic function iii. response to loss depends on I. one's personality II. culture III. previous experience with loss IV. one's values V. perceived value of loss VI. support system types of grief

iii.

8.

Grief a.

b.

i. ii. iii.

iv.

v.

anticipatory grief: person learns of impending loss and responds with processes of mourning, coping, interaction, planning, and psychosocial reorganization disenfranchised grief: person experiences a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported mourning: process used to resolve grief tasks of mourning (common to the models of grief) spell RE-A-L I. Real: accept that the loss is real II. Experience the emotions associated with the loss III. Adjust or re-adjust to life and activities IV. Let go: move on with one's own life grief theory models FOUR THEORETIC MODELS OF GRIEF A. Elizabeth Kubler-Ross: Five Stages 1. Denial a. Unconscious avoidance which varies from a brief period to the remainder of life b. Allows one to mobilize defenses to cope c. Positive adaptive responses - verbal denial; crying d. Maladaptive responses - no crying, no acknowledgement of loss 2. Anger a. Expresses the realization of loss b. May be overt or covert c. Positive adaptive responses - verbal expressions of anger d. Maladaptive responses - persistent guilt or low self esteem, aggression, self destructive ideation or behavior 3. Bargaining a. An attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in near future b. Maladaptive responses - bargains for unrealistic activities or events in distant future 4. Depression and Withdrawal a. Sadness resulting from actual and/or anticipated loss b. Positive adaptive response - crying, social withdrawal c. Maladaptive responses - self-destructive actions, despair 5. Acceptance a. Resolution of feelings about death or other loss, resulting in peaceful feelings b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business B. John Bowlby: Four Stages of Separation and Loss 1. Shock 2. Despair 3. Detachment 4. Resolution C. E. Lindemann 1. Shock 2. Acute mourning

3. Resolution of grief D. J.W. Wooden 1. Accepting the reality 2. Experiencing the pain 3. Adjusting to the changed environment 4. Withdrawing and reinvesting emotional energy c. nursing care in grief i. support client's effective coping mechanisms ii. don't take client's responses personally iii. listen attentively iv. help client with problem solving and decision making as indicated v. encourage the client and/or significant others to ventilate vi. utilize therapeutic touch as appropriate vii. assist in discussions of future plans as appropriate

II.

Therapeutic Communication - Characterizes the Nurse-Client Relationship A. Nurse-client relationship: a therapeutic professional relationship in which two people interact 1. The nurse who possesses the skills and ability to provide counseling, crisis intervention, health teaching, etc. and 2. The client who seeks help for some problem B. Phases of the nurse-client relationship A. Initiating or orientation 1. Sets time, place and duration of sessions 2. Establishes boundaries of the relationship 3. Identifies the problem and expectations-that is, goal setting 4. Usually an anxious time for both client and nurse a. Client may be late for the session b. Client may exhibit anxious mannerisms c. Nurse's own anxiety may prompt nurse to use techniques that block communication B. Working 1. Boundaries of the relationship are accepted by the client and the nurse and a therapeutic relationship is established 2. Nurse uses interpersonal skills to communicate with the client 3. Client identifies problems, develops insights to the problems 4. Client learns adaptive coping skills and problem solving C. Termination 1. Actually begins with the first session and ends when identified treatment goals are met 2. Anticipate problems of termination a. Client may become too dependent on nurse b. Client may recall previous separation experiences, and feelings of rejection, depression, and/or abandonment 3. Client and nurse summarize and evaluate work 4. Client and nurse express thoughts and feelings about termination C. Five characteristics of nurse-client relationship 1. Mutual definition: together, nurse and client define relationship 2. Goal direction: purpose, time, and place are specific 3. Specified boundaries: in time, space, content, and confidentiality 4. Therapeutic communication: nurse eases trust and open communication by these interpersonal techniques 5. Nurse helps client toward resolution 6. Therapeutic communication a. Consider the developmental level, culture, and physical condition of the client

b. c. d. e. f. g. h.

i.

Focus not on subjective inferences but on actual objective behaviors Focus not on judgment but on description Instead of offering advice and solutions, share information and explore alternatives Focus not on "why" but on how and what For confused or disoriented clients, focus on reality orientation Ask open-ended questions and seek information Focus on nursing interventions To ease this process, use specific techniques THERAPEUTIC COMMUNICATION TECHNIQUES Not Necessarily Verbal

1.

Acceptance - Recognizing the other person without inserting your own values or judgments. May be verbal or nonverbal; with or without understanding 2. Listening - Consciously receiving the client's message. Includes listening actively, responsibly, and seriously 3. Empathy - Experiencing another's feeling temporarily; truly being with and understanding another through active listening 4. Silence - Suspending talk for a therapeutic reason 5. Neutral response - Showing interest and involvement without saying anything else 6. Eye contact - As appropriate to the client's culture Verbal

7.

Self-disclosure - Sharing personal information at an opportune moment to convey understanding or to role model behavior 8. Clarification - Putting into words vague ideas or unclear thoughts of the client. Purpose is to help nurse understand, or invite the client to explain 9. Restating - Repeating to the client the main thought he has expressed to indicate the nurse is listening and interested. May encourage the client to elaborate 10. Refocusing - Picking up on central topics or "cues" given by the client 11. Open-ended questions - Asking questions that cannot be answered "yes" or "no." Used to broaden conversational opportunities and to enable the client to communicate. 12. Incomplete sentences - Encouraging the client to continue with phrases such as "Go on…" 13. Focusing - Helping the client to explore a specific topic

j.

Certain techniques block therapeutic communication

NINE INEFFECTIVE COMMUNICATION TECHNIQUES

1. Giving advice - Telling the client what to do. Giving an opinion
or making decisions for the client. Implies the client cannot handle life decisions and that the nurse is accepting responsibility for client.

2. False reassurance - Using clichés, pat answers, cheery words
and comforting statements as an attempt to reassure client.

3. Changing the Subject - Introducing new topics inappropriately.
May result from poor listening skills

4. Social Response - Responding in a way that either focuses 5. 6. 7. 8. 9.
attention on the nurse instead of the client, or is not goaldirected on behalf of the client. Invalidation - Ignoring or denying the client's thoughts or feelings. Overloading - Talking rapidly, changing subjects or asking for more information than can be absorbed at one time; for example, asking two questions at once. Underloading - Remaining silent and unresponsive, not picking up cues and failing to give feedback. Incongruence - Sending verbal and nonverbal messages that contradict one another; often called a double message. Value Judgments - Giving one's own opinion, evaluating , moralizing or implying one's own values by using words such as "should," "ought," "good," or "bad."

7.

Other types of therapeutic interventions a. Group therapy b. Family therapy c. Milieu therapy d. Occupational therapy

III.

Psychiatric Disorders A. Schizophrenia and other psychotic disorders 1. Definition: according to the DSM IV TR, psychosis is the presence of varying combinations of delusions, hallucinations, disorganized speech or disorganized or catatonic behavior 2. Types of psychotic disorders a. brief psychotic disorder i. a disorder involving an onset of psychotic symptoms for at least one day but less than one month and does not meet the criteria for other psychotic disorders. ii. diagnostic criteria include the presence of I. delusions II. hallucinations III. disorganized speech IV. grossly disorganized or catatonic behavior b. schizoaffective disorder i. a period of illness during which there are findings of a mood disorder concurrent with the findings of schizophrenia c. schizophrenia 3. Schizophrenia a. definition: a multifaceted psychosis with early onset; criteria from DSM IV as follows: i. when disease is in active phase, client shows psychotic behaviors. ii. findings involve many psychological processes iii. previously, client had functioned at a higher level iv. schizophrenia normally sets in before 30 years of age v. findings last six months or more vi. not caused by affective or organic mental disorder vii. involves hallucinations and/or delusions b. general characteristics of schizophrenia - six losses: S-S-O-B-ER TYPES OF SCHIZOPHRENIA

1. Paranoid a. Dominant: hallucinations and delusions. b. No disorganized speech 2. Disorganized a. Dominant: disorganized speech and behavior and inappropriate affect 3. Catatonic a. Motor immobility b. Excessive, purposeless motor activity 4. Residual a. No longer has active phase symptoms b. Negative symptoms 5. Undifferentiated a. Has active phase symptoms b. No one clinical presentation dominates Self-care often fails Social adjustment is impaired Orientation to the environment is lost Boundaries between self/others dissolve External/internal stimuli are confused (delusions/hallucinations) vi. Reality testing fails etiologies of schizophrenia i. genetic I. genetic research does show that some clients have a predisposition to inheriting schizophrenia II. the risk of developing schizophrenia is greater in people identified with specific chromosomes III. when one identical twin is raised by adopted parents, the incidence of developing schizophrenia is as great as if raised by natural parents ii. biochemical I. dopamine hydrochloride - too much neurotransmitter for neural activity II. research has suggested abnormalities of neurotransmitters norepinephrine, serotonin, acetylcholine and GABA (gamma aminobutyric acid). iii. psychosocial - prefrontal lobes of the brain are extremely responsive to environmental stress a. poor relationships with primary caretaker b. dysfunctional family systems c. double-bind communication d. stressful life events e. decreased socio-economic status (SES)

i. ii. iii. iv. v.

c.

d.

findings of schizophrenia i. positive symptoms - reflect an excess or distortion of normal function I. hallucinations II. delusions III. looseness of associations IV. agitated or bizarre behaviors negative findings - reflect a decrease or loss of normal function I. apathy

ii.

iii.

iv.

v.

II. poverty of speech or content of speech III. poor social functioning IV. anhedonia V. social withdrawal alterations in thinking I. types of delusions I. ideas of reference II. persecution III. grandeur IV. somatic delusions V. jealousy VI. control/being controlled VII. thought-broadcasting VIII. thought insertion IX. thought withdrawal II. associative looseness III. neologisms IV. concrete thinking V. echolalia VI. clang association VII. word salad alterations in perceiving I. hallucinations I. auditory II. visual III. olfactory IV. gustatory V. tactile II. loss of ego boundaries alterations in behavior I. bizarre behavior I. extreme motor agitation II. stereotyped behaviors III. automatic obedience IV. waxy flexibility II. stupor III. negativism IV. agitated behavior

d. associated findings a. depression/suicide b. water intoxication c. substance abuse d. violent behavior e. types of schizophrenia
a.

type I
o o o o o o o o o

acute onset of primarily positive symptoms normal premorbid functioning normal social functioning during remission normal CT scan normal neuropsychological test results favorable response to antipsychotic meds appear early in illness often precipitate hospitalization alterations in thinking, perceiving and behavior insidious onset of primarily negative symptoms premorbid history of emotional problems chronic deterioration demonstration of atrophy on CT scan

b.

type II
o o o o

o o o

abnormalities on neuro-psychological testing poor response to antipsychotic meds interferes with person's ability to 1. initiate and maintain relationships 2. initiate and maintain conversations 3. hold a job 4. make decisions 5. maintain adequate hygiene and grooming

4.

Treatments in schizophrenia and other psychotic disorders a. psychopharmacology i. typical and atypical antipsychotic agents and side effects

COMMON SIDE EFFECTS OF ANTISPYCHOTICS AND NURSING INTERVENTIONS

b.

c.

d. e.

antiparkinsonian agents: used to counteract these extrapyramidal findings, primarily with typical antipsychotics individual psychotherapy i. long-term therapy ii. difficult because schizophrenia impairs interpersonal functioning iii. focused, supportive problem-solving is most useful group therapy in schizophrenia i. oriented toward providing support, an environment in which the client can develop social skills, and a format that allows friendships to begin ii. some success with long-term work iii. less success if client actively delusional and/or psychotic social skills training i. role play to simulate anticipated interactions ii. teach eye contact, interpersonal skills, voice, posture vocational/rehabilitation often succeeds

ii.

5.

i. long-term treatment ii. includes job training iii. promotes semi-independent daily activities iv. raises self esteem f. family therapy i. to help families cope with psychotic and residual symptoms of schizophrenia ii. to help reduce relapse rate Nursing care in schizophrenia and other psychotic disorders a. protect client and others from harm, including suicide precautions as indicated

SUICIDE PRECAUTIONS 1. Remove all harmful objects from the environment 2. One to one monitoring of the client day and night, having the client in view at all times even during toileting, gradually progress to 15 minute and then hourly checks 3. Ask client exactly how she/he would commit suicide. Assess how lethal the attempt would be, and how quickly it could be carried out. 4. Keep client within one arm's length distance or less at all times 5. Use plastic utensils 6. Keep electrical cords to a minimum length 7. Take all potentially harmful gifts from visitors 8. Keep all windows locked and if possible keep client in room with unbreakable glass in windows 9. Do not assign a private room b.

c.

administer medications as ordered monitor for side effects

COMMON SIDE EFFECTS OF ANTISPYCHOTICS AND NURSING INTERVENTIONS

d. e.

establish trust, decrease anxiety encourage or reinforce i. client's sense of control ii. reality orientation iii. self-care

f. g. h. i.

help client set realistic goals provide safe and successful experiences assist with hygiene and/or feeding as indicated teach client i. importance of medication compliance ii. medications and side effects iii.

B. Mood disorders (affective disorders) 1. Definition a. elevated or depressed mood, with disturbances in behavioral response b. divided into bipolar and depressive disorders c. bipolar disorders: mood disorders that include one or more manic or hypomanic episodes and usually one or more depressive episodes d. mania i. person's elevated mood described as euphoric ii. inflated self-esteem iii. impaired judgment iv. constant physical activity v. pressured speech vi. racing thought patterns vii. requires hospitalization e. hypomania i. findings less severe ii. does not impair social, occupational or interpersonal functioning iii. treated in outpatient setting f. the seven traits typical of mood disorders i. impair job functioning ii. impair social activities iii. impair relationships iv. necessitate hospitalization (in most cases) v. no time longer than two weeks has client had delusions or hallucinations without the mood disturbance vi. findings are not superimposed on a. schizophrenia b. delusional disorder c. psychotic disorder vii. findings are not caused by organic disease g. etiology - unknown; possible genetic, biochemical 2. predisposition a. psychosocial theories of depression 1. Freud: anger internalized and directed against ego 2. Seligman: depression results from learned helplessness: individual who fails over time learns to expect poor outcomes and eventually gives up 3. Beck: cognitive theory: over time, cognition is altered, resulting in negative attitudes; events can trigger depression b. biological cycles affect mood (via Circadian rhythm) 1. melatonin levels increase with darkness and decrease with light; levels are highest prior to bedtime 2. melatonin levels are lower than normal in depressed individuals 3. seasonal affective disorder (SAD) results from melatonin levels decreasing in fall and

winter months (periods of light-phase shortening) c. biochemical theories of mood disorders i. mania • probably a genetic factor • biochemical influences o possible deficiency of neurotransmitter GABA (gamma aminobutyric acid) o possible excess of norepinephrine and dopamine hydrochloride o possible increase in electrolytes: sodium and calcium ii. depression • possible deficit of serotonin, dopamine, norepinephrine • possible deficit of TSH (thyroid-stimulating hormone) and/or other neuroendocrine disturbances • depression is more common in viral infections (AIDS, mononucleosis, hepatitis) • possible deficit in vitamin intake or metabolism: (vitamin B complex, folic acid) • genetics may be involved 2. Types of mood disorders: mania, bipolar, depression i. mania - DSM IV criteria for mania ii. period of abnormally/persistently elevated mood or irritability iii. at least three of these six signs • grandiosity • decreased sleep • hypertalkative, with pressured speech and flight of ideas or racing thoughts • highly goal-directed activity (sexual, work) • highly distractible • pursues pleasure, but overestimates own skill and luck

b. bipolar disorders onset usually before age 30
i. bipolar disorder, mixed: both manic and depressive episodes present • bipolar I o consists of one or more periods of major depression plus one or more periods of clear-cut mania o findings as in Definition of mood disorder (on page 18 of this lesson) o no marked drop in social and job functioning o manic episode requires hospitalization • bipolar II o consists of one or more periods of major depression plus periods of hypomania o includes all symptoms in Definition of mood disorder (on page 18 of this lesson) and does not require hospitalization bipolar disorder, manic: fulfills criteria for manic episode (see Findings below) bipolar disorder, depressed: major depressive episode and at least one manic episode, current or past cyclothymic mood disorder • many milder findings of mania and depression • periods of normal mood are short

ii.
iii.

iv.

c. depression i. includes all 7 typical traits of mood disorders ii. specific criteria for depression (see Findings below) 3. Findings a. mania

•

usually does not require hospitalization

i.
ii.

iii.
iv. v. vi. vii.

elation, euphoria; inappropriate laughter; very talkative irritable, hostile, aggressive flight of ideas, delusions of grandeur, exhibitionism, sexual acting-out reduced sleep unlimited energy; no time for food or drink impulsive, easily distracted manipulative behavior

b. depression i. melancholia, crying, absence of pleasure; slumped posture ii. apathy; loss of desire for food and/or sex iii. slower reactions iv. low self-confidence; inhibition, introversion v. ruminating, decreased communication, social isolation vi. fatigue and/or insomnia vii. decreased concentration viii. poor hygiene ix. hopelessness, pessimism x. self-destructiveness 5. Treatments treatments for mania i. pharmacologic • lithium carbonate (Lithane), carbamazapine (Carbatrol), valproic acid (Depakene) • antipsychotics: chlorpromazine (Thorazine), haloperidol (Haldol) occupational therapy recreational therapy

ii.
iii.

b. depression i. pharmacologic antidepressants ANTI DEPRESSANTS 1. Types A. SSRI's - Selective Serotonin Reuptake Inhibitors 1. Inhibit neurotransmitter reuptake of serotonin 2. Fewer side effects than tricyclics or MAO inhibitors B. Tricyclics and tetracyclic antidepressants 1. Prevent nerve endings from taking up norepinephrine and serotonin 2. Increase the action of norepinephrine and serotonin in nerve cells C. MAO Inhibitors (Monoamine oxidase inhibitors) 1. Lower the production of monoamine oxidase

2. 3. 4. 5. 6. 7.

2. Thus the central nervous system stores more endogenous epinephrine, norepinephrine, serotonin, and dopamine Contraindications: convulsive disorders, prostatic hypertrophy, severe renal, cardiac or hepatic disease Administer with food to prevent GI disturbance Therapeutic effect may take up to three weeks Teach client about potential for drowsiness or dizziness Teach client to avoid drinking alcohol Do not stop taking antidepressants suddenly
•

ii.
iii. iv. v. vi.

tricyclic antidepressants - amitriptyline HCl (Elavil), doxepin (Sinequan), imipramine (Tofranil) • monoamine oxidase inhibitors - phenelzine (Nardil), tranylcypromine (Parnate) • selective serotonin reuptake inhibitors (SSRI) fluoxetine (Prozac), sertraline (Zoloft) ECT: electroconvulsive therapy psychotherapy occupational therapy recreational therapy cognitive therapy

6. Nursing care in mood disorders a. mania a. b. c. d. e. f. g. h. i. j. k. l. protect client and others from harm provide quiet environment with few stimuli give medications as ordered; be sure client swallows meds establish trust relationship do not argue with client or provoke hostility redirect client to task at hand set firm, consistent limits; explain them simply allow client to express anger in positive ways offer finger foods increase client's fluid intake to at least 1000cc/day allow client to pace teach client i. acceptable ways to release anger ii. medications and side effects iii. importance of taking medication

b. depression a. monitor suicidal thoughts b. take suicide precautions as indicated and observe for suicide warning signs WARNING OF SUICIDAL THOUGHTS OR PLANS 1. Previous suicide attempt 2. Threatening to commit suicide 3. Giving away prized possessions 4. Collecting and discussing information on suicide methods 5. Expressing hopelessness, helplessness, and anger at self or world 6. Death or depression in talk, writing, or artwork 7. Client states or suggests he/she would not be missed

8. Client expresses no hope for the future 9. Self-mutilation 10. Recent loss of friend or family member through natural death, accident or suicide; other major loss such as job or divorce 11. Acute personality changes such as unusual withdrawal or aggressiveness, moodiness, or taking risks 12. Sudden change in academic performance, truancy, or running away 13. Physical symptoms such as insomnia or excessive sleeping, headaches, stomach aches 14. Use or increased use of potentially addictive substances 15. Low self esteem; feeling worthless, ashamed, guilty, self-hating c. d. e. f. g. h. i. j. k. l. build trust with client speak slowly and clearly in simple sentences administer medications as ordered encourage client to ventilate provide relaxation exercises help with hygiene and feeding as indicated help client assess negative thoughts more objectively divert client from morose thoughts encourage client to focus on positive attributes teach client i. medications and side effects ii. importance of taking medication iii. problem-solving techniques

C. Suicide prevention 1. Definitions a. suicide is a self-harming act intended to produce death b. degrees 1. completed suicide: life ends 2. attempted suicide: failed self-destructive act 3. suicide ideation: thoughts of ending one's life 2. Epidemiology a. women attempt more than men b. men are more often successful c. second leading cause of death in adolescence d. black males have higher incidence 3. Etiology a. depression b. delusions/hallucinations in psychotic clients c. hopelessness d. environmental factors: work or school performance, loss of job, death of loved one, unsatisfying interpersonal relationships 4. Findings a. statements about suicide b. anger, sadness, hopelessness, negative view of future c. recent loss of job, loved one d. perceived lack of support system e. self-mutilation f. treatment for suicidal condition 1. objective: to treat the condition that underlies the suicidal thoughts 2. medications: antidepressants, antianxiety, and/or antipsychotics as indicated 3. suicide precautions g. nursing care 1. administer medications as ordered

2. do mouth checks to be certain client swallows oral medications 3. institute suicide precautions 4. encourage relaxation strategies 5. encourage appropriate expressions of emotions 6. redirect or set limits on ruminations about suicide or previous attempts 7. help client explore stressors and coping mechanisms 8. help client explore alternative behaviors D. Personality disorders 1. Definition a. an enduring pattern of inner experience and behavior that becomes recognizable during adolescence or early adult life b. experience and behavior deviate markedly from the expectations of the individual’s culture 2. Etiology a. genetic factors: monozygotic twins both develop personality disorders more than dizygotic twins b. biologic factors: there is research evidence that correlates high levels of certain hormones with development of a personality disorder c. psychoanalytic theory: personality disorders develop in individuals who have difficulty developing an individual self separate from parents d. developmental theories: according to Erickson, individuals pass through developmental stages by resolving the conflicts of that stage. If a crisis occurs the person may not resolve those conflicts and the individual may not successfully complete that stage. If that happens each subsequent stage will be effected 3. Findings a. individual’s behavior and inner experience deviates from the expectations of the culture b. behavior and experience is inflexible and pervasive across a broad range of personal and social situations c. behavior and experience pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (DSM IV TR) 4. Treatment a. psychopharmacology: medications do not treat the personality disorder, but can relieve the symptoms such as anxiety, anger, impulsivity, and hallucinations b. psychotherapy 1. individual therapy 2. family therapy 3. group therapy 4. milieu therapy 5. Types of personality disorders a. borderline personality disorder 1. definition (DSM IV TR) 2. pervasive pattern of unstable relationships, self-image and affects 3. marked impulsivity 4. frantic efforts to avoid real or imagined abandonment 5. chronic feelings of emptiness 6. difficulty controlling anger b. etiology 1. impaired development of object relations; separation-individuation process is arrested 2. issues of dependence, independence, and control are mixed with fear of abandonment, loss of love, or engulfment by mother

c. findings 1. personal relationships are unstable; lonely; emotions shallow 2. images of self and others are primarily bad; feels inadequate 3. anger, hostility 4. projection of hostility onto others 5. acts out and denies responsibility for actions 6. poor judgment 7. impaired problem solving 8. very "black or white" thinking 9. regression 10. marked mood swings 11. demanding 12. sarcastic 13. manipulative 14. behaves self-destructively 15. splitting d. treatment 1. pharmacologic a. antianxiety agents: oxazepam (Serax) b. antidepressants: carbamazapine (Carbatrol) 2. psychotherapy e. nursing care in borderline personality disorder 1. protect client and others from harm 2. administer medications as ordered 3. establish a trusting relationship 4. set limits, and provide a structured environment 5. use a calm, controlled approach; see that other staff stay consistent 6. do not argue with client 7. encourage client to evaluate consequences of actions 8. divert anger, or let client ventilate it in positive ways 9. set limits on manipulative behaviors by communicating expected behaviors 10. teach client 11. medications and their side effects 12. anger-control strategies 13. relaxation strategies b. paranoid personality disorder i. definition: the client • demonstrates pervasive distrust and suspiciousness of others • assumes that others will exploit or harm them • preoccupied with unjustified doubts about the loyalty or trustworthiness of friends regardless of the lack of evidence (DSM IV TR) ii. findings • suspicious of other people and of health care providers • misinterpret others mistakes as deliberate attempts to harm client • tend to bear grudges and not forgive others for mistakes • reacts angrily to what is perceived as an insult

attracted to cults where others have similar suspicions to their own • needs to feel in control in relationships • may experience short-term psychosis iii. treatment • psychopharmacology: may be resistant and untrusting of medication; antipsychotics may relieve psychotic symptoms • psychotherapy: Assess ability to tolerate any grouporiented treatment; may be too threatening iv. nursing care in paranoid personality disorder • encourage a structured, predictable schedule • nurses manner needs to be detached but supportive • bring medications with individual packets closed • avoid arguing with the client • client may be distrustful of praise, viewing the nurse as attempting to be controlling • give the client an option whenever possible c. obsessive compulsive personality disorder i. definition • a pattern of preoccupation with orderliness, perfectionism, and control ii. findings • display an excessive devotion to work and productivity to the exclusion of leisure activities and friendships. • there may be a great concentration on household chores, excessive cleaning • unable to discard objects which are worn out or worthless, even when no sentimental value is attached. They are termed ‘pack rats’ • have difficulty working with others on a project, believing their way is the best way to accomplish the task. Tend to prefer to work alone • tend to be rigid and stubborn (DSM IV TR) iii. treatment • psychopharmacology: medication used to treat findings such as anxiety or depression. • psychotherapy iv. nursing care in obsessive compulsive personality disorder • avoid engaging in power struggles as the need for control is high in these clients • promote a predictable, structured schedule as much as possible • notify about changes to schedule ahead of time to allow the client to plan 2. Anxiety disorders 1. Definition: group of disorders in which anxiety is predominant symptom. Degrees range from mild anxiety to severe (panic attack) b. seven types i. GAD: generalized anxiety disorder ii. phobic disorders iii. panic disorder iv. dissociative disorder v. somatoform disorder vi. obsessive-compulsive disorder (OCD) vii. PTSD: Post-traumatic stress disorder 2. Etiology b. found equally in men and women c. hereditary predisposition d. biochemical dysfunction i. decreased ability of GABA receptors to decrease anxiety

•

current belief that the norepinephrine system mediates the fight/flight response; anxiety may be affected by an inappropriate activation of this system iii. problems in the neurotransmission of serotonin may also be the cause of anxiety disorders; medications that regulate serotonin (SSRI’s) have been effective in treating some anxiety disorders e. genetic factors i. twin studies show that if one twin has an anxiety disorder, the second twin is more likely to have the disorder if they are identical twins f. psychologic and interpersonal factors i. early psychic trauma ii. pathogenic parent-child relationship iii. pathogenic family patterns iv. loss of social supports 3. Findings b. fear, dread, or apprehension c. feeling powerless d. crying e. irritability f. scattered thoughts, inability to concentrate or solve problems g. preoccupation with self h. rapid speech, hyperventilation, tachycardia i. palpitations, chest pains, jittery behavior j. diaphoresis k. insomnia l. diarrhea and/or urinary urgency and frequency 4. Treatments for anxiety disorders b. pharmacologic: anxiolytics (antianxiety drugs) such as alprazolam (Xanax) and diazepam (Valium) c. psychotherapy d. occupational therapy e. recreational therapy 5. Nursing care b. provide a nondemanding environment; stay with client if indicated c. acknowledge client's feelings of fear, worry, helplessness d. do not force contact with feared item or situation e. if client demonstrates compulsive behavior, allow the compulsion but set reasonable limits f. provide distracting activities g. allow temporary dependence h. speak calmly, slowly and clearly i. assist client in ADL as indicated j. encourage relaxation techniques and regular physical exercise k. administer medications as ordered l. limit caffeine intake m. limit contact with other clients or family members who are also anxious n. teach client i. medications and side effects ii. relaxation techniques iii. identify triggers iv. explore alternative behaviors 3. Substance abuse 1. Definitions b. maladaptive behaviors resulting from the regular intake of large amounts of addictive chemicals c. addictive chemicals include alcohol, stimulants, depressants, hallucinogens, narcotics. d. levels of substance abuse i. abuse is pathologic use of mood-altering chemicals that continues for at least 1 month, which impairs social or occupational functioning

ii.

ii.

dependence is a more severe level of abuse that involves impaired ability to control use of substance and results in withdrawal (adverse consequences) when substance is discontinued or reduced. There are three types of dependence • psychologic dependence: pleasure that intensifies craving for substance; often begins in teens and twenties. • physiologic dependence: after repeated use, physiology changes; and after substance is reduced or removed, withdrawal symptoms appear • tolerance: drug dosage must keep increasing to achieve same effect

2. Alcohol Although alcohol is a legal substance, problem drinking has detrimental physiologic and social effects. b. dependence i. daily intake of large quantities, or ii. excessive drinking limited to weekends; or iii. periods of abstinence with binges lasting for weeks or longer c. etiology unknown i. stress has been implicated ii. some research suggests a familial tendency d. produces withdrawal symptoms

WITHDRAWAL EFFECTS OF ABUSED SUBSTANCES 1. Narcotics a. Runny nose, watery eyes b. Severe anxiety to panic; irritability c. Gooseflesh; tremors d. Loss of appetite; nausea and vomiting e. Muscle cramps f. Tachycardia; Hypertension g. Increased respirations h. Increased temperature i. Insomnia 2. Alcohol 1. Acute withdrawal symptoms a. Tremors, Agitation, Tachycardia b. Nausea and vomiting; abdominal cramps c. Diaphoresis d. Visual or tactile hallucinations Severe Withdrawal - delirium tremens (DTs) a. Confusion, Disorientation b. Visual, tactile hallucinations c. Diaphoresis, Fever d. Tachycardia e. Grand mal seizures

b.

3. Sedatives/Hypnotics 1. Weakness, Nausea and vomiting 2. Hypertension, Tachycardia, Orthostatic hypotension 3. Gross tremors 4. Agitation , Anxiety 5. Disorientation 6. Hallucinations, Delirium

7. Convulsions 4. Stimulants 1. Fatigue 2. Depression 3. Disturbed sleep 4. Apathy 5. Cravings 5. Hallucinogens - No withdrawal symptoms reported but flashbacks can occur episodically after use 6. Marijuana 1. Irritability 2. Insomnia 3. Loss of appetite 4. Tremors 5. Perspiration 6. Nausea e. findings of chronic alcohol use i. anemia ii. hypertension iii. tachycardia iv. hepatomegaly v. ascites vi. cirrhosis vii. gastritis viii. esophagitis ix. malabsorption syndrome x. fatigue xi. depression xii. impaired judgment; cognitive impairment xiii. tremors xiv. delirium tremens xv. Korsakoff's Psychosis • a form of amnesia • loss of short-term memory • disorientation and confabulation f. treatment of alcohol dependence i. benzodiazepines to treat withdrawal, antipsychotics if hallucinosis develops ii. vitamin and nutritional therapy, especially thiamine iii. medication assistance to avoid relapse • disulfiram (Antabuse) alcohol abuse deterrent-client becomes ill if drinks alcohol • Naltrexone or Nalmefine-lower cravings and client has less pleasure from drinking iv. support groups (Alcoholics Anonymous) g. nursing care in alcohol dependence i. during acute withdrawal • stay with client • provide quiet environment • administer medications as ordered • monitor vital signs - temperature over 100 degrees Farenheit and pulse in excess of 100 beats per minute may indicate alcohol withdrawal delerium (delerium tremens) • protect the client from harm • institute seizure precautions as indicated • maintain adequate fluid intake • monitor intake and output ii. during abstinence • provide emotional support • provide nutritious diet • encourage the development of new coping skills

provide relaxation exercises inform client about support groups and rehab programs 3. Use of psychoactive drugs (prescription or "street"): stimulants, depressants, hallucinogens, and narcotics b. stimulants i. include cocaine, crack, amphetamines ii. effects of abuse of stimulants • psychomotor agitation • mood swings • tachycardia • hypertension • dilated pupils • perspiration and chills • insomnia • impaired cognitive function • seizures • if discontinued, withdrawal follows iii. overdose may cause lethal cardiac or respiratory arrest iv. emergency care of overdose on stimulants: cardiopulmonary support c. depressants i. include barbiturates, tranquilizers, sedatives and hypnotics ii. findings of depressant use • slurred speech • impaired cognitive function; confusion • emotional lability • lack of coordination • cold and clammy skin • produce withdrawal symptoms iii. overdose can lead to respiratory depression, coma iv. emergency care of overdose • respiratory support • keep client awake and moving d. narcotics i. include: heroin, morphine, meperidine, codeine, methadone ii. findings • euphoria • tranquility • drowsiness • constricted pupils • clouded sensorium iii. overdose threatens life: depresses respiratory function and alters level of consciousness iv. emergency care includes cardiopulmonary support

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e. hallucinogens i. include: LSD, PCP, marijuana, mescaline, psilocybin ii. findings • tachycardia • hypertension • dilated pupils • hallucinations • nausea • impaired attention and judgment • aggressive behavior iii. potentially life threatening iv. potentially psychotic long-term effects 4. Treatment: drug rehabilitation 5. Nursing care in substance abuse b. protect the client and others from harm c. help client through drug rehabilitation as indicated d. provide emotional support e. help the client develop a support system f. provide emergency care for overdose 4. Eating disorders 1. A subcategory of disorders that includes multiple types of eating behavior disturbances 2. Types of eating disorders b. anorexia nervosa i. weight loss through restriction of food intake leading to emaciation ii. may involve purging behaviors iii. tend to reject mature-appearing body iv. tendency to asceticism c. bulimia nervosa i. eating binges alternate with dieting or purging ii. purging behaviors may include self-induced vomiting, misuse of emetics and cathartics or laxatives iii. more likely than those with anorexia to show impulsive or chaotic behavior iv. usually near normal weight

v. vi. vii. viii.

ix. 3. Etiology b. genetic/biochemical theories i. a gene involved in controlling appetite is more frequently found among anorexic persons ii. abnormalities in the activity of certain hormones (example: thyroid stimulating hormone) have been found in clients with eating disorders c. psychoanalytic theory i. conflicts stem from oral phase of development ii. clients often have anxious, compulsive mothers iii. obsessive-compulsive control of body and life, via food iv. controlling bodily functions is critical to client's attempt at self-control d. interpersonal theory i. results from dysfunctional family relationships ii. parents avoid their own conflicts by controlling child iii. child's self-identity becomes blurred iv. during adolescence parents become overcontrolling and demanding v. demands thwart client's attempts at autonomy vi. adolescent attempts to control self through controlling food intake. e. cognitive theory i. eating-disorder behaviors are learned ii. society glorifies thinness iii. for the adolescent or young adult, thinness equates with self-worth 4. Findings of eating disorder b. personal relationships become superficial and distant c. social contact avoided especially if food is involved d. preoccupation with food, meal planning, caloric intake and methods to avoid eating e. eats in private f. mood irritable and defiant g. exercises excessively h. physical findings i. weight falls below 85% of normal ii. bradycardia iii. anemia iv. amenorrhea v. decreased renal function vi. dental problems vii. fluid and electrolyte imbalances viii. delayed skeletal maturation 5. Treatment of eating disorders b. objective: to correct underlying cause and prevent complications of weight loss c. client may require hospital care d. nutritional planning e. psychotherapy: individual and/or family f. group therapy g. occupational therapy h. recreational therapy i. if underlying depression, treat with antidepressants 6. Nursing care

tend to be outgoing and sensitive to others major issue: control self/environment through eating behaviors drive for thinness population at risk • adolescents and young adults • in industrialized countries • models, dancers and gymnasts at higher risk potentially life threatening

b. c. d. e. f. g. h.

monitor weight as prescribed monitor client's eating/record intake and output administer nasogastric feedings if ordered encourage oral hygiene set limits on eating including time allotted for meals stay with client during meals accompany client to bathroom after meals to prevent self-induced vomiting i. encourage client to express feelings j. encourage socialization k. monitor for findings of electrolyte imbalance or dehydration l. assist client to identify strengths m. teach client i. relaxation techniques ii. alternative coping methods iii. assertiveness skills H. Autism 7. Definition: syndrome in which child does not relate to people b. may become attached to objects c. develops before age three 8. Etiology unknown 9. Findings b. does not respond to human touch c. lack of eye contact d. talks poorly or not at all e. ritualistic behavior f. cannot deal with change g. emotional lability h. may be self destructive (head-banging, hair pulling, finger/hand biting) i. failure to develop friendships or play with other children j. posture or gait abnormalities: poor coordination, tiptoe walking, peculiar hand movements (flapping, clapping) 10. Treatment b. special education c. may need full time care (institution) 11. Nursing care b. support parents emotionally c. protect the child from self harm d. help child with hygiene and feeding as indicated e. maintain consistency in schedule f. allow ritualistic behavior 5. 1. Definition - abuse may be physical, sexual, psychological or physiological b. victims powerless to stop abuse c. may be directed toward a child, a spouse, the elderly d. rape is a violent sexual abuse e. abusers i. often blame victim ii. demonstrate poor impulse control iii. have frequently been victims of abuse themselves 2. Findings b. physical abuse i. broken bones and/or dislocations ii. welts, and/or bruises c. sexual abuse i. bruising or bleeding in genital or anal area, ii. pain or itching in genital area, iii. rape, evidence of sexual intercourse, iv. genitourinary infections d. general neglect i. malnutrition

ii. habitual behaviors: rocking, head banging iii. learning disorders iv. social isolation v. aggressive behavior 3. Treatment b. in general, cases of abuse must be reported (refer to state statutes for variations) c. removal of victim from source of abuse d. protective services e. directing abuser to help or therapy 4. Nursing care b. provide emotional support c. document all signs of abuse d. file appropriate reports (report of suspected abuse is mandatory in most states) e. assist in placement for protection f. assist abuser in obtaining appropriate counseling Points to remember Defense Mechanisms
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People use defense mechanisms to relieve anxiety. They are usually unconscious; that is, the client is not aware of their use. Watch for excessive use of these mechanisms.

Therapeutic Communication
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Show positive regard for the client. Give eye contact without staring. Show empathy and genuine caring. Show respect. Use open-ended questions. Be aware of your own body language. Appear relaxed. Use an open body posture. Do not cross your arms. Respect confidentiality.

Grief
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The distinction between grieving and depression can be a matter of degree. Look for signs of clinical depression. Grieving takes time; the amount of time varies with individuals. The stages of grief are not linear; they may come and go. Grief follows death; but also follows divorce, loss of job, loss of financial status, loss of limb or other physical disability, etc. Chronic grief is an exaggerated, prolonged grief response characterized by efforts to keep the deceased alive; chronic grief does not reach resolution. The mourner is unable to get on with life. Pay attention to culturally diverse ways of responding to grief. This is important in assessment of grief reaction and in respecting the customs and rituals of a cultural group. Encourage client and family to talk about their feelings. Beware of personal reaction to death and over identification with client. When necessary, seek assistance to cope with personal issues. Teach clients and their families about the up-and-down process of grieving. Refer to appropriate support groups

Stress Management
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Severity of reaction to a stressor depends on how it is interpreted/perceived by the individual, the meaning or significance given to it. Learn about support groups in your community for appropriate referral. Stress is a normal part of life. People differ in how they cope with stressors.

• • • • • • • • • • • • • • •

Physical and emotional stressors trigger the same stress response; however the magnitude of the response may vary. There are individual differences in response to same stress. Duration and intensity of physiologic indicators are directly related to the duration and intensity of the stress. Stress is classified as mild, moderate or severe. Prolonged stress decreases the adaptive capacity of the body. There are limits to a client's ability to handle stress. Schizophrenia is the most common psychotic disorder. It originates from complex genetic, biological, and psychosocial factors. Extrapyramidal side effects of antipsychotic medications must be treated. Depression can be mild, moderate, or severe. Mild depression is often undiagnosed. Antidepressants take 2 to 3 weeks to take effect. Many people have fleeting thoughts of killing themselves at some point in their lives. Cognitive Triad of Depression - negative view of self, negative view of the world, negative view of the future. Anorexia nervosa and bulimia are conditions that primarily occur among adolescent and young women. The 3 phases of a therapeutic relationship are: (1) initial phase, (2) working phase and (3) termination phase.