MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Peñablanca, Cagayan

INSTRUCTIONAL LEARNING GUIDE

NCM 117: Care of Clients with

Maladaptive Patterns of
Behaviors (Acute and Chronic)
LECTURE

INTERSESSION CLASS, F.Y. 2020-2021

 TABLE OF CONTENTS

MIDTERM PERIOD
1. Introduction to Psychiatric Nursing
a. Current Theories and Practice
b. Neurobiologic Theories and Psychopharmacology
c. Neurobiologic Causes of Mental Illness

2. Building nurse-client relationship

a. Self-awareness and Therapeutic Use of Self
b. Therapeutic Communication

3. Mental Status Examination

4. Grief and Loss
5. Anger, Hostility and Aggression
6. Abuse and Violence
a. Characteristics of Violent Families
b. Intimate Partner Violence
c. Child Abuse
d. Elder Abuse
e. Rape and Sexual Assault

7. Trauma and stress Related Disorders-

a. PTSD
b. Acute Distress Syndrome
c. Dissociative Disorders

8. Anxiety and Anxiety Disorders – Sir JP

9. Obsessive-Compulsive Disorder
[Link] and Other Related Disorders

FINAL TERM
1. Mood disorders Sir Kit
a. Major Depressive Disorder
b. Bipolar Disorder
c. Other Related Disorders

2. Personality Disorders
a. Cluster A
b. Cluster B
c. Cluster C

3. Substance abuse - Sir Rich Conag

4. Eating Disorders
a. Anorexia Nervosa
b. Bulimia Nervosa
5. Neurodevelopmental disorder
a. ADHD
b. Autism
6. Cognitive disorders
a. Mental Retardation
b. Alzheimer’s Disease
 7. Sexual Disorders
Self-assessment Exercises
Chapter Evaluation

APPENDICES
 Rubrics
 List of additional references
 Acknowledgement and Disclaimer

MIDTERM PERIOD

CHAPTER 1
Introduction to Psychiatric Nursing
Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
1. Describe the characteristics of mental health and illness
2. Discuss the purpose of DSM and the significant changes from its
previous versions
3. Identify historical landmarks in psychiatric care
4. Discuss trends in treating clients with mental disturbances
5. Discuss functions of the brain and its neurotransmitters
6. Identify and familiarize the different drugs given to patients with
mental disorders
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
1. Individual assignment
2. Case analysis
3. Critical thinking activity

Let’s Begin!

KEY TERMS
 Mental Health
 Mental Illness
 Psychiatric nursing
 Psychopharmacology
 neurotransmitters

I. Current theories and Practice

 Mental Health – a state of emotional, psychological and social wellness

evidenced by satisfying interpersonal relationships, effective behavior and
coping, positive self-concept and emotional stability.
 Factors affecting mental health:
 o Individual: personal factors; biologic make-up, autonomy
and independence, self-esteem, capacity for growth,
vitality, ability to find meaning in life, emotional resilience,
sense of belonging, reality orientation and coping-stress
management
o Interpersonal: relationship; effective communication,
ability to help others, intimacy, balance of separateness
and connectedness
o Social/cultural: environmental; sense of community,
access to adequate resources, intolerance of violence,
support of diversity, mastery of environment, realistic
view of one’s world
Criteria of Mental Health:
Autonomy
Tolerance of life’s complexities
Mastery of the environment
Outlook is positive
Self-esteem
Potentials realized and maximized
Happy with self and can laugh at mistakes
Emotionally flexible
Reality testing is intact
Evolving self

 Mental Illness – any alterations in the above criteria and causes significant
distress and impaired functioning; includes disorders that affect mood,
behavior, and thinking such as depression, schizophrenia, anxiety disorders
and addictive disorders.

Diagnostic and Statistical Manual of Mental Disorders

- Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) –
developed by the American Psychiatric Association to diagnose mental
disorders
Purposes:
- Provide a standardized nomenclature
- Present defining characteristics or symptoms
- Assist in identifying the underlying cause of disorders
-
- Reading assignment!
Research on the historical perspectives of the treatment of mental illness. Make a fishbone
diagram to outline the significant dates in the history of Psychiatric Nursing.

II. Neurobiologic Theories and Psychopharmacology

Overview of the anatomy and physiology of the nervous system

o Cerebrum – 2 hemispheres with four lobes; responsible for the
organization of thoughts, body movement, memories, emotions
and moral behavior The cerebrum is the center for
coordination and integration of all information needed to
interpret and respond to the environment.
 o The cerebellum is the center for coordination of
movements and postural adjustments.
o The brain stem contains centers that control
cardiovascular and respiratory functions, sleep,
consciousness, and impulses.
o The limbic system regulates body temperature, appetite,
sensations, memory, and emotional arousal.

Neurotransmitters
- are the chemical substances manufactured in
the neuron that aid in the transmission of
information throughout the body.
- They either excite or stimulate an action in
the cells (excitatory) or inhibit or stop an
action (inhibitory).
- After neurotransmitters are released into the
synapse (point of contact between the
dendrites and the next neuron) and relay the
message to the receptor cells, they are either
transported back from the synapse to the
axon to be stored for later use (reuptake) or
are metabolized and inactivated by enzymes,
primarily monoamine oxidase (MAO)

 Dopamine - generally excitatory and is synthesized from tyrosine, a

dietary amino acid. Antipsychotic medications work by blocking dopamine
receptors and reducing dopamine activity.

 Norepinephrine and Epinephrine - most prevalent neurotransmitter;

plays a role in mood regulation; also known as noradrenaline and
adrenaline; controls the fight-or-flight response in the peripheral nervous
system.

 Serotonin - A neurotransmitter found only in the brain, is derived from

tryptophan, a dietary amino acid; mostly inhibitory, involved in the control
of food intake, sleep and wakefulness, temperature regulation, pain
control, sexual behavior, and regulation of emotions; antidepressants
block serotonin reuptake, thus leaving it available longer in the synapse,
which results in improved mood.

 Histamine – involved in peripheral allergic responses, control of gastric

secretions, cardiac stimulation and alertness

 Acetylcholine It can be excitatory or inhibitory. It is synthesized from

dietary choline found in red meat and vegetables and has been found to
affect the sleep- wake cycle and to signal muscles to become active.

 Glutamate - excitatory amino acid that at high levels can have major
neurotoxic effects.

 Gamma-Aminobutyric Acid (GABA) - major inhibitory neurotransmitter

in the brain and has been found to modulate other neurotransmitter
systems rather than to provide a direct stimulus.
 NEUROBIOLOGIC CAUSES OF MENTAL ILLNESS

 Current theories and studies indicate that several mental disorders may be
linked to a specific gene or combination of genes but that the source is not
solely genetic; nongenetic factors also play important roles.
 Two genetic links to Alzheimer’s disease are chromosomes 14 and 21.
 Stress and the Immune system (Psychoimmunology)
 Infection as a possible cause

PSYCHOPHARMACOLOGY

 Efficacy refers to
the maximal
therapeutic effect
that a drug can
achieve.
 Potency describes
the amount of the
drug needed to
achieve that
maximum effect;
low-potency drugs
require higher doses
to achieve efficacy,
whereas high-
potency drugs
achieve efficacy at
lower doses.
 Half Life is the time it takes for half of the drug to be removed from the
bloodstream. Drugs with shorter half- life may need to be given three or four
times a day, but drugs with a longer half-life may be given once a day.
 The FDA may issue a black-box warning when a drug is found to have
serious or life-threatening side effects. This means that package inserts must
have a highlighted box, separate from the text, which contains a warning
about the serious side-effects.

 ANTIPSYCHOTIC DRUGS
- Neuroleptics; major neuroleptics; are used to treat the symptoms of
psychosis, such as the delusions and the hallucinations seen in schizophrenia,
schizoaffective disorder, and the manic phase of bipolar disorder.
- work by blocking receptors of the neurotransmitter, dopamine.
- Dopamine receptors are classified into subcategories (D1, D2, D3, D4, and
D5) and D2, D3, and D4 have been associated with mental illness.
- The typical antipsychotic drugs are potent antagonists (blockers) of D2,
D3, and D4. This makes them effective in treating target symptoms but also
produces many extrapyramidal side effects because of the blocking of the D2
receptors.
- atypical antipsychotic drugs such as clozapine (Clozaril) are relatively
weak blockers of D2, which may account for the lower incidence of
extrapyramidal side effects. The newer antipsychotics also inhibit the
reuptake of serotonin, increasing their effectiveness in treating the
depressive aspects of schizophrenia.

TYPICAL/CONVENTIONAL ATYPICAL
(higher EPS) (Lower EPS)
Target symptom (+) Target symptom (+) (-)
(-dol, -zine) (-pine, done)

High Potency - Clozapine (Clozaril)

- Haloperidol (Haldol) - Olanzapine (Zyprexa)
- Fluphenazine (Prolixin) - Quetiapine (Seroquel)
- Trifluoperazine (Stelazine) - Risperidone (Risperdal)
- Thiothixine (Navanel) - Ziprasidone (Geodon)
- Paliperidone (Invega)
(extended release preparation, given
1 dose/day = increased drug
compliance)
Moderate Potency
- Perphenazine (Trilafon)
- Loxapine (Loxitane) Clozapine: S/E is AGRANULOCYTOSIS
- Molindone (Moban) WOF: signs and symptoms of
infection

Fever
Malaise
Ulcerative sore throat
Leucopenia
The drug must be discontinued
immediately if the WBC drops by
50% or to less that 3,000.

Low Potency Novel Antipsychotic

- Chlorpromazine (Thorazine) - Aripiprazole (Abilify)
- Thioridazine (Mellaril) - Dopamine system stabilizer
- Lesser S/E
- Increases/decreases dopamine
level

Extrapyramidal Side Effects

- are the major side effects of antipsychotic drugs.
o acute dystonia (prolonged involuntary muscular contractions that
may cause twisting of the body parts, repetitive movements, and
increased muscular tone)
o pseudoparkinsonism, and
o akathisia (intense need to move about). Blockage of the D2
receptors in the midbrain region of the brain stem is responsible for
the development of EPS. Included in the EPS are:
 DYSTONIA AKATHISIA PSEUDOPARKINSONIS
M
- acute - The most common - Mask-like
- abnormal postures EPSE appearance
caused by spasms - Restless movement, - Akinesia
Types: pacing, inability to - Shuffling gait
- Torticollis keep still - Cogwheel’s rigidity
- Oculogyric crisis - Major reason why
- Opisthotonus patients stop taking
- Writer’s cramp meds
- Laryngeal-
pharyngeal
constriction

 Neuroleptic Malignant syndrome

- potentially fatal idiosyncratic reaction to an antipsychotic.
- Symptoms include rigidity, high fever; autonomic instability such as unstable
blood pressure, diaphoresis, and pallor; delirium; and elevated levels of
enzymes, particularly creatine and phosphokinase.
- Clients with NMS are confused and often mute; they may fluctuate from
agitation to stupor.
- Dehydration, poor nutrition, and concurrent medical illness all increase the
risk of NMS.
- Treatment includes immediate discontinuation of the antipsychotic and the
institution of supportive medical care to treat dehydration and hyperthermia.
  Tardive Dyskinesia
- ssyndrome of permanent involuntary movements. This is most commonly
caused by the long-term use of antipsychotic drugs.
- The symptoms of TD include involuntary movements of the tongue, facial,
and neck muscles, upper and lower extremities, and truncal musculature.
Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other
excessive unnecessary facial movements are characteristic.
- IRREVERSIBLE

 ANTICHOLINERGIC SIDE
EFFECTS
- Orthostatic hypotension
- Dry mouth
- Constipation
- Urinary hesitance/retention
- Blurred near vision
- Dry eyes
- Photophobia
- Nasal congestion
- Decreased memory

 ANTIDEPRESSANTS
- interact with the two
neurotransmitters, norepinephrine
and serotonin.
Antidepressants are divided into four
groups:
 Tricyclic and the related
cyclic antidepressants
 Selective serotonin reuptake inhibitors (SSRIs)
 MAO inhibitors (MAOIs)
 Other antidepressants such as venlafaxine (Effexor), bupropion (Wellbutrin),
duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone).

- must be used with extreme caution for several reasons:

▪ A life-threatening side effect, hypertensive crisis, may occur if the client
ingests food containing tyramine (an amino acid) while taking MAOIs.
Mature or aged cheese
Aged meats (sausage, pepperoni)
Tofu
ALL tap beers and microbrewery beer.
Sauerkraut, soy sauce, or soybean
condiments
Yogurt, sour cream, peanuts, MSG
▪ MAOIs cannot be given in combination with other MAOIs, tricyclic
antidepressants, Demerol, CNS depressants, and hypertensives, or
general anesthetics.
▪ MAOIs are potentially lethal in overdose and pose a potential risk for
clients with depression who may be considering suicide.

Take note!
SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those
who are potentially suicidal or highly impulsive because they carry no risk of
lethal overdose in contrast to the cyclic compounds and the MAOIs. However,
SSRIs are only effective for mild to moderate depression.

▪ The major actions of antidepressants are with the monoamine

neurotransmitter systems in the brain, particularly norepinephrine and
serotonin.
▪ Norepinephrine, serotonin, and dopamine are removed from the synapses
after release by reuptake into presynaptic neurons. After reuptake, these
three neurotransmitters are reloaded for subsequent release or
metabolized by the enzyme MAO.
▪ The SSRIs block the reuptake of serotonin; the cyclic antidepressants and
venlafaxine block the reuptake of norepinephrine primarily and block
serotonin to some degree; and the MAOIs interfere with enzyme
metabolism.

 Mood stabilizing drugs

- are used to treat bipolar disorder by stabilizing the client’s mood, preventing
or minimizing the highs and lows that characterize bipolar illness, and
treating acute episodes of mania.
- Lithium is considered the first-line agent in the treatment of bipolar disorder;
normalizes the reuptake of certain neurotransmitters such as serotonin,
norepinephrine, acetylcholine, and dopamine. It also reduces the release of
norepinephrine through competition with calcium.
- Lithium produces its effects intracellularly rather than within neuronal
synapses.
- Lithium serum levels should be about 1.0 mEq/L. Levels less than 0.5 mEq/L
are rarely therapeutic, and levels of more than 1.5 mEq/L are usually
considered toxic.
- If Lithium levels exceed 3.0 mEq/L, dialysis may be indicated.
- The mechanism of action for anticonvulsants is not clear as it relates to their
off-label use as mood stabilizers.

 Antianxiety drugs (Anxiolytics)

- Benzodiazepines mediate the actions of the amino acid GABA, the major
inhibitory neurotransmitter in the brain. Because GABA receptor channels
selectively admit the anion chloride into neurons, activation of GABA
receptors hyperpolarizes neurons and thus is inhibitory.
- Benzodiazepines produce their effects by binding to a specific site on the
GABA receptor.

 Stimulants
- the primary use of stimulants is for ADHD in children and adolescents,
residual attention deficit disorder in adults, and narcolepsy.
- Stimulants are often termed indirectly acting amines because they act by
causing release of the neurotransmitters (norepinephrine, dopamine, and
serotonin) from presynaptic nerve terminals as opposed to having direct
agonist effects on the postsynaptic receptors. They also block the reuptake of
these neurotransmitters.
- By blocking the reuptake of these neurotransmitters into neurons, they leave
more of the neurotransmitter in the synapse to help convey electrical
impulses in the brain.

II. Psychosocial Theories and Therapy

 Sigmund Freud, the Father of Psychoanalysis

- Founded the personality components; Id, Ego, and Superego

- Major points: believes that human behavior is caused and can be explained
(deterministic theory)
- Repressed sexual impulses and desires motivate human behavior
o Id: The part of ones nature that reflects basic or innate desires such
a pleasure seeking behavior, aggression, and sexual 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 expectations; therefore, it is
the directional opposite to the id.
o Ego: The balancing or mediating force between the id and the
superego. The ego represents mature and adaptive behavior that
allows a person to function successfully.
 Levels of Consciousness
1. Conscious – perceptions, thoughts, emotions that exist on the person’s
awareness
2. Preconscious/subconscious – thoughts and emotions are not currently in the
person’s awareness but can be recalled with some effort
3. Unconscious – realm of thoughts and feelings that motivate a person even
though he is totally unaware of them

Freudian Slip “slips of the tongue”

- Freud believed that much of what we do and say is motivated by our
subconscious thoughts or feelings

 Psychosexual development
- Oral (birth to 18 months)
o Site of gratification: MOUTH
o Behaviors: dependency, eating, crying, biting
o Develops body image, aggressive drives

- Anal (18 to 36 months)

o Pleasure through the anus (elimination or retention)
o Behaviors: control of holding on or letting go
o Develops concept of power, punishment, ambivalence, concern with
cleanliness or being dirty

- Phallic/Oedipal (3 to 5 years)
o Pleasure through genitals
o Behviors: touching of genitals (masturbation is common), erotic
attachment of parent of opposite sex
o Develops fear of punishment by parent of the same sex, guilt and
identification
- Latency (5 to 11 or 13 years)
o Pleasure through school work, social relationships and knowledge
o Behaviors: sense of industry and mastery
o Learns to control over aggressive and destructive impulses

- Genitals (11 or 13 years)

o Pleasure through genitals with orgasm
o Behaviors: becomes independent, responsible for self
o Develops sexual identity, ability to love and work

 Ego Defense Mechanisms

- Methods of attempting to protect the self and cope with basic drives or
emotionally painful; thoughts, feelings or events
Assignment!

Research on the different ego defense mechanisms and provide an example for each type

 Transference and Countertransference

- Transference occurs when the client onto the therapist/nurse attitudes and
feelings that the client previously felt in other relationships.
- Countertranference occurs when 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 while

focusing on social and psychological development in life stages (Psychosocial
Theory of Development)
 Trust vs. Mistrust (infant)
 Autonomy vs. Shame and Doubt (toddler)
 Initiative vs. guilt (preschool)
 Industry vs. Inferiority (school age)
 Identity vs. Role confusion (adolescence)
 Intimacy vs. isolation (young adult)
 Generativity vs. stagnation (middle adult)
 Ego integrity vs. despair (maturity)
- Erikson believed that psychosocial growth occurs in sequential stages, and
each stage is dependent on the completion of the previous stage/life task.

- Piaget explored how intelligence and cognitive functioning develop in

children.
 Sensorimotor (birth to 2 years): The child develops a sense of self as
separate from the environment and the concept of object permanence.
Begins to form mental images.
 Preoperational (2-6 years): Child begins to express himself with language,
understands the meaning of symbolic gestures, and begins to classify
objects.
 Concrete operations (6-12 years): Child begins to apply logical thinking,
understands reversibility, is increasingly social and able to apply rules;
however, thinking is still concrete.
  Formal operations (12 to 15 years and beyond): Child learns to think and
reason in abstract terms, further develops logical thinking and reasoning,
and achieves cognitive maturity.

 Harry Stacks Sullivan: Interpersonal Relationships and Milieu

therapy
- The importance and significance of interpersonal relationships in one’s life
was Sullivan’s greatest contribution to the field of mental health.
- Sullivan developed the first therapeutic community or milieu with young men
with schizophrenia in 1929. He found that within the milieu, the interactions
among clients were beneficial, and then the treatment should emphasize on
the roles of the client-client interaction.
- Milieu therapy is used in the acute care setting; one of the nurses’ primary
roles is to provide safety and protection while promoting social interaction.

 Hildegard Peplau: Therapeutic nurse-patient relationship (The

bomb- diggity of nursing)

- Developed the concept of the therapeutic nurse-patient relationship, which

includes 4 phases: orientation, identification, exploitation, and
resolution.
o The orientation phase is directed by the nurse and involves
engaging the client in treatment, providing explanations and
information, and answering questions. During this time the nurse
would orient the patient to the rules and expectations (if in an acute
setting).
o The identification phase begins when the client works
interdependently with the nurse, expresses feelings, and begins to
feel stronger. This phase can begin either within a few hours to a
few days; the patient can identify the nurse and environment on his
own. They “come together”. Kinky.
o In the exploitation phase, the client makes full use of the services
offered. He moves toward independence.
o In the resolution phase, the client no longer needs professional
services and gives up dependent behavior.
- Keep in mind that after the resolution phase, the client can regress and move
back into the above mentioned phases.
- Peplau defined anxiety as the initial response to a psychic threat, describing 4
levels of anxiety: acute, moderate, severe, and panic.
o Acute anxiety/Mild is a positive state of heightened awareness
and sharpened senses, allowing the person to learn new behaviors
and solve problems. The person can take in all available stimuli
(perceptual field).
o Moderate anxiety involved a decreased perceptual field (focus on
immediate task only); the person can learn new behavior or solve
problems only with assistance. Another person can redirect the
person to the task. Remember, this is the ideal anxiety state for
teaching a client regarding health concerns such as diabetes, as
Cathy says so.
o Severe anxiety involves feelings of dread or terror. The person
CANNOT 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 ER thinking he
is having a heart attack. In lecture, Cathy stated that this person
can still be “talked down”. The first priority is to move the person
away from all stimuli, and then attempt to talk with them to calm
down.
o Panic anxiety can involve loss of rational thought, delusions,
hallucinations, and complete physical immobility and muteness. The
person my bolt and run aimlessly, often exposing himself and
others to injury.

 Humanistic Theories; Maslow’s Hierarchy of needs.

- He used a pyramid to arrange and illustrate the basic drives or needs to
motivate people.
- The most basic needs, physiologic needs, need to be met first. This includes
food, water, shelter, sleep, sexual expression, and freedom of pain. These
MUST be met first.
- The second level involves safety and security needs, which involve protection,
security, freedom from harm or threatened deprivation.
- The third level is love and belonging needs, which include enduring intimacy,
friendship, and acceptance.
- The fourth level involves esteem needs, which includes the need for self-
respect and esteem from others.
- The highest level is self-actualization, the need for beauty, truth, and justice.
Few people actually become self-actualized.
- Remember, traumatic life experiences or compromised health can cause a
person to regress to a lower level of motivation.

 Pavlov: Classic conditioning (Behavior theory)

- Pavlov believed that behavior can be changed through conditioning with
external or environmental conditions or stimuli.

 Crisis Intervention
 Maturational 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 job.
 Adventitious crises, sometimes called social crises, include natural
disasters like floods, earthquakes, or hurricanes; war, terrorist attacks;
riots; and violent crimes such as rape or murder.

III. TREATMENT MODALITIES

1. Individual Psychotherapy
o Method of bringing about change in a person by exploring his or her
feelings
o One-on-one relationship between the therapist and client
o Aim: desire to understand, improve interpersonal relationships, get
relief from emotional pain or unhappiness

2. Group Therapy
o Group: number of persons who gather in a face-to-face setting to
accomplish tasks
o Group content: refers to what is said in the context of the group
o Group process: refers to the behavior of the group and its individual
members (seating arrangements, tone of voice etc) Read on:
STAGES OF GROUP DEVELOPMENT
o Clients participate in sessions with a group of people
o The members share a common purpose
o Group rules are established and must be observed
o Therapeutic results of GP:
1. Socialization. The cultural group into which weare born begins
the process of teaching social norms. This is continued throughout
our lives by members of other groups with which we become
affiliated.
2. Support. One’s fellow group members are available in time of
need. Individuals derive a feeling of security from group
involvement.
3. Task completion. Group members provide assistance in
endeavors that are beyond the capacity of one individual alone or
when results can be achieved more effectively as a team.
4. Camaraderie. Members of a group provide the joy and pleasure
that individuals seek from interactions with significant others.
5. Informational. Learning takes place within groups. Knowledge is
gained when individual members learn how others in the group
have resolved situations similar to those with which they are
currently struggling.
6. Normative. This function relates to the ways in which groups
enforce the established norms.
o Psychotherapy groups: learn about their behavior and to make
positive changes in their behavior by interacting and
communicating with others as member of the group
o TWO types of groups:
 Open groups are ongoing and run indefinitely, allowing
members to join or leave the group as they need to.
 Closed groups are structured to keep the same members in
the group for a specified number of sessions.
o Family therapy
 form of group therapy in which the client and his or her
family members participate
 Goals: understand family dynamics, mobilize the family’s
inherent strengths and functional resources, restructure
maladaptive family behavioral styles, strengthen family
problem-solving behaviors
o Support groups
 Goal: help members who share a common problem cope with
it
 The group leader explores members’ thoughts and feelings
and creates an atmosphere of acceptance
 provide a safe place for group members to express their
feelings of frustration, boredom, or unhappiness and also to
discuss common problems and potential solutions.
o Self-help groups
 members share a common experience, but the group is not a
formal or structured therapy group.
  have a rule of confidentiality: whoever is seen at a meeting or
what is said at the meetings cannot be divulged to others or
discussed outside the group

 Psychiatric Rehabilitation
o Providing services to people with severe and persistent mental
illness to help them live in the community
o Often called community support services/ community support
programs
o Focuses on client’s strengths wherein the client actively participates
in program planning
o Programs assist clients with ADLs (transportation, shopping, food
preparation, money management and hygiene)

Diagnostic Statistical Manual 5 for Psychiatric Disorders

- The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the
handbook used by health care professionals in the United States and much of
the world as the authoritative guide to the diagnosis of mental
disorders. DSM contains descriptions, symptoms, and other criteria for
diagnosing mental disorders. It provides a common language for clinicians to
communicate about their patients and establishes consistent and reliable
diagnoses that can be used in the research of mental disorders. It also
provides a common language for researchers to study the criteria for
potential future revisions and to aid in the development of medications and
other interventions.
- Many of the changes in DSM–5 were made to better characterize symptoms
and behaviors of groups of people who are currently seeking clinical help but
whose symptoms are not well defined by DSM–IV (meaning they are less
likely to have access to treatment). Our hope is that by more accurately
defining disorders, diagnosis and clinical care will be improved and new
research will be facilitated to further our understanding of mental disorders
Teacher’s Insight:

Nurses must be aware of their own beliefs and feelings about mental
disorders and the role of drugs in treating such conditions. Nurses who work
with mentally disturbed clients must understand that some disorders are
quite similar with physical illness therefore a careful assessment of the signs
and symptoms must be employed so that the client will be given appropriate
treatment. Our role in treating these conditions is critical because we have a
direct contact with the clients.
 Chapter 1 Assessment

A. What do I know?
1. In your own words, describe mental health. Describe the
characteristics, behaviors and activities of someone who is mentally
healthy as well as those who are mentally disturbed.

B. Multiple Choice questions. Choose the BEST answer and provide a short
rationale
1. The world's most commonly used psychoactive compound is:
a. theobromine
b. caffeine
c. librium
d. ethanol
2. Which of the following drugs facilitate the action of GABA at its receptors ?
a. ethanol
b. barbiturates
c. benzodiazepines
d. all of the above
3. At the GABAa receptor level:
a. benzos can close the ion channel in the absence of GABA
b. barbiturates can open the ion channel in the absence of GABA
c. benzos can open the ion channel in the absence of GABA
d. barbiturates can close the ion channel in the absence of GABA
4. Which of the following is a direct pharmacological antagonist?
a. Morphine
b. Methadone
c. Disufiram
d. Naltrexone
5. Which of the following is a tricyclic antidepressant?
a. Paroxetine
b. Venlafaxine
c. Amitryptylline
d. Escitalopram
 CHAPTER II
Building Nurse-Client Relationship and Therapeutic Communication

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
1. Describe how the nurse can use therapeutic communication in treating
patients with mental illness
2. Describe the importance of self-awareness

 Prepare your books and notebooks. Highlight concepts that need to be

reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.
Activities:
1. Assignment
2. Critical thinking exercise

Let’s Begin!

KEY TERMS
 Self-awareness
 Therapeutic use of self
 Johari’s window
 Verbal communication
 Non verbal communication
 Non-therapeutic communication

Components of a Therapeutic Relationship

 Trust – builds when the client is confident in the nurse and the nurse’s
presence conveys integrity and reliability
o CONGRUENCE: occurs when words and actions match
o Trusting behaviors: friendliness, caring, interest, understanding,
consistency, suggesting without telling, treating the client as a
human being, approachability, listening, keeping promises,
providing schedule of activities, honesty
 Genuine Interest
o When the nurse portrays confidence with himself and the client
perceives him as a genuine person
o Nurses must be open and honest; display congruent behavior
 Empathy
o Ability of the nurse to perceive the meanings and feelings of the
client
o ESSENTIAL skill
o Being able to put self in the client’s shoes
 Acceptance
 Positive regard
o Appreciates the client as a unique, worthwhile human being;
conveys respect

 SELF AWARENESS AND THERAPEUTIC USE OF SELF

o the process of developing an understanding of one’s own values,
beliefs, thoughts, feelings, attitudes
o Values: abstract standards that give a person a sense of right and
wrong
o Values clarification steps:
 Choosing: when the person considers a range of possibilities
and freely chooses the value that feels right
 Prizing: person considers the value
 Acting: adopts the value
o Beliefs: ideas that one holds to be true
o Attitudes: general feelings or frame of reference around which the
person organizes knowledge about the world

Therapeutic Use of Self

- When the nurse begins to use aspects of his personality, experiences, values,
feelings, intelligence, needs, coping skills to establish relationship with the
clients
- Therapeutic tool to promote client’s growth
- Johari’s window

Types of relationship:
o Social: initiated for the purpose of friendship, socialization,
companionship
o Intimate: involves two people who are emotionally committed to
each other
o Therapeutic: client-centered
- Therapeutic relationship: focuses on needs, experiences, feelings and ideas of
the client only.
- Phases of nurse-client relationship:
Orientation: Working: Termination/
Resolution:
Contract setting Promote positive
Assess client’s self-concept Feelings
problems Redefine goals as associated with
Listen to what the appropriate impending loss
client is not Increase client’s Evaluate progress
saying independence Acknowledge
Maintain Develop positive client’s angry
professional coping skills feelings
relationship Encourage Referral to
Establish trust verbalization of appropriate
and rapport feelings resources
Define goals with

 ROLES OF THE NURSE

 Teacher
 Caregiver
 Advocate
 Parent surrogate

 THERAPEUTIC COMMUNICATION
  Communication: the process that people use to exchange information
 Verbal communication – use of written or spoken words to convey a
message
 Non-verbal communication- behavior that accompanies the verbal
content
 An interpersonal interaction between the nurse and the client during
which the former focuses on the client’s specific needs
 GOALS:
o Establish a therapeutic nurse–client relationship.
o Identify the most important client concern at that moment (the
client-centered goal).
o Assess the client’s perception of the problem as it unfolded. This
includes detailed actions (behaviors and messages) of the
people involved and the client’s thoughts and feelings about the
situation, others, and self.
o Facilitate the client’s expression of emotions.
o Teach the client and family necessary selfcare skills.
o Recognize the client’s needs.
o Implement interventions designed to address the client’s needs.
o Guide the client toward identifying a plan of action to a
satisfying and socially acceptable resolution.
Establishing a therapeutic relationship is one of the most important
responsibilities of the nurse when working with clients. Communication is the
means by which a therapeutic relationship is initiated, maintained, and
terminated.

Characteristics of therapeutic communication:

1. Is purposeful and goal-directed
2. Has well-defined boundaries
3. Is client-focused
4. Is nonjudgmental
5. Uses well-planned, selected techniques

PRINCIPLES OF THERAPEUTIC INTERACTION

1. Plan to interview at an appropriate time: It is unwise to plan to talk with
a client during visiting hours, during change of shift, or when the client is
distracted by environmental stimuli.
2. Ensure privacy: It is both a legal mandate and an ethical obligation that
nurses respect the client’s confidence; this includes spoken words and medical
records. No one wants to discuss private matters when or where other people
are listening.
3. Establish guidelines for the therapeutic interaction: the nurse should
share certain information such as the nurse’s name and affiliation, purpose of
the interaction, the expected length of the contact with the client, and the
assurance of confidentiality.
4. Provide for comfort during the interaction: Discomfort can be distracting.
Pain interferes with a person’s ability to concentrate, thus, communication
becomes impaired.
5. Accept the client exactly as is: Being judgmental blocks communication.
6. Encourage spontaneity: The nurse gathers more data when the client is
talking freely. Also, the client experiences relief and freedom from worries by
talking without inhibition.
7. Focus on the leads and cues presented by the client: Asking questions
just for the sake of talking or for the satisfaction of one’s own curiosity does not
contribute to effective interviewing.
8. Encourage the expression of feelings: Simply allowing the client to talk is
not interviewing
9. Be aware of one’s own feelings during the interaction: The nurse's
feelings influence the interaction. For example, the nurse who becomes anxious
may change the subject or make comments that finalize the session.

PRIVACY AND RESPECTING BOUNDARIES

-Privacy is desirable but not always possible in therapeutic communication. An
interview or conference room is optimal if the nurse believes this setting is not
too isolative for the interaction. The nurse also can talk with the client at the end
of the hall or in a quiet corner of the day room or lobby, depending on the
physical layout of the setting.

Proxemics is the study of distance zones between people during

communication. People feel more comfortable with smaller distances when
communicating with someone they know rather than with strangers (Northouse
& Northouse, 1998).
• Intimate zone (0 to 18 inches between people): This amount of space
is comfortable for parents with young children, y desire personal contact,
or people whispering. Invasion of this intimate zone by anyone else is
threatening and produces anxiety.
• Personal zone (18 to 36 inches): This distance is comfortable between
family and friends who are talking.
• Social zone (4 to 12 feet): This distance is acceptable for
communication in social, work, and business settings.
• Public zone (12 to 25 feet): This is an acceptable distance between a
speaker and an audience, small groups, and other informal functions (Hall,
1963).

Touch
- Touching a client can be comforting and supportive when it is welcome and
permitted. The nurse should observe the client for cues that show if touch is
desired or indicated.
- Example: Holding the hand of a sobbing mother whose child is ill is appropriate
and therapeutic. If the mother pulls her hand away, however, she signals to the
nurse that she feels uncomfortable being touched. The nurse also can ask the
client about touching (e.g., “Would it help you to squeeze my hand?”).
-Although touch can be comforting and therapeutic, it is an invasion of intimate
and personal space. As intimacy increases, the need for distance decreases.

Knapp (1980) identified five types of touch:

• Functional-professional touch is used in examinations or procedures
such as when the nurse touches a client to assess skin turgor or a
masseuse performs a massage.
• Social-polite touch is used in greeting, such as a handshake and the “air
kisses” some women use to greet acquaintances, or when a gentle hand
guides someone in the correct direction.
 • Friendship-warmth touch involves a hug in greeting, an arm thrown
around the shoulder of a good friend, or the back slapping some men use
to greet friends and relatives.
• Love-intimacy touch involves tight hugs and kisses between lovers or
close relatives.
• Sexual-arousal touch is used by lovers.

Four types of touch:

A—Functional–professional touch;
B—Social–polite touch
C—Friendship–warmth touch;
D—Love–intimacy touch.

ACTIVE LISTENING AND OBSERVATION

Active listening- means refraining from other internal mental activities and
concentrating exclusively on what the client says.
Active observation - means watching the speaker’s nonverbal actions as he
or she communicates.

Active listening and observation help the nurse to:

• Recognize the issue that is most important to the client at this time.
• Know what further questions to ask the client.
• Use additional therapeutic communication techniques to guide the client
to describe his or her perceptions fully.
• Understand the client’s perceptions of the issue instead of jumping to
conclusions.
• Interpret and respond to the message objectively.

Peplau (1952) used observation as the first step in the therapeutic interaction.
The nurse observes the client’s behavior and guides him or her in giving detailed
descriptions of that behavior. The nurse also documents these details. To help
the client develop insight into his or her interpersonal skills, the nurse analyzes
the information obtained, determines the underlying needs that relate to the
behavior, and connects pieces of information (makes links between various
sections of the conversation).
A common misconception by students learning the art of therapeutic
communication is that they always must be ready with questions the instant the
client has finished speaking. Hence, they are constantly thinking ahead
regarding the next question rather than actively listening to what the client is
saying. The result can be that the nurse does not understand the client’s
concerns, and the conversation is vague, superficial, and frustrating to both
participants. When a superficial conversation occurs, the nurse may complain
that the client is not cooperating, is repeating things, or is not taking
responsibility for getting better.

EMPATHY is the ability to place oneself into the experience of another for a
moment in time. Nurses develop empathy by gathering as much information
about an issue as possible directly from the client to avoid interjecting their
personal experiences and interpretations of the situation. The nurse asks as
many questions as needed to gain a clear understanding of the client’s
perceptions of an event or issue.

VERBAL COMMUNICATION SKILLS

USING CONCRETE MESSAGES

-The nurse should use words that are as clear as possible when speaking to the
client so that the client can understand the message. Anxious people lose
cognitive processing skills—the higher the anxiety, the less ability to process
concepts—so concrete messages are important for accurate information
exchange.
- In a concrete message, the words are explicit and need no interpretation; the
speaker uses nouns instead of pronouns—for example, “What health symptoms
caused you to come to the hospital today?” or “When was the last time you took
your antidepressant medications?” Concrete questions are clear, direct, and
easy to understand. They elicit more accurateresponses and avoid the need to
go back and rephrase unclear questions, which interrupts the flow of a
therapeutic interaction.

Abstract messages, in contrast, are unclear patterns of words that often

contain figures of speech that are difficult to interpret. They require the listener
to interpret what the speaker is asking.
-For example, a nurse who wants to know why a client was admitted to the
unit asks, “How did you get here?” This is an abstract message: the terms
“how” and “here” are vague. An anxious client might not be aware of
where he or she is and reply, “Where am I?” or might interpret this as a
question about how he or she was conveyed to the hospital and respond,
“The ambulance brought me.” Clients who are anxious, from different
cultures, cognitively impaired, or suffering from some mental disorders
often function at a concrete level of comprehensionand have difficulty
answering abstract questions. The nurse must be sure that statements
and questions are clear and concrete.

USING THERAPEUTIC COMMUNICATION TECHNIQUES

-The nurse can use many therapeutic communication techniques to interact with
clients. The choice of technique depends on the intent of the interaction and the
client’s ability to communicate verbally. Overall the nurse selects techniques
that will facilitate the interaction and enhance communication between client
and nurse.
-Techniques such as exploring, focusing, restating, and reflecting encourage the
client to discuss his or her feelings or concerns in more depth.
-In contrast, there are many non therapeutic techniques that nurses should
avoid. These responses cut off communication and make it more difficult for the
interaction to continue. Many of these responses are common in social
interaction such as advising, agreeing, or reassuring. Therefore it takes practice
for the nurse to avoid making these typical comments.

THERAPEUTIC COMMUNICATION TECHNIQUES

Therapeutic Examples Rationale
Communication
Technique
Accepting— “Yes.” An accepting response indicates
indicating “I follow what you the nurse has heard and followed
Reception said.” the train of thought. It does not
Nodding indicate agreement but is
nonjudgmental.
Facial expression, tone of voice,
and so forth also must convey
acceptance or the words will lose
their meaning.
Broad openings— “Is there something Broad openings make explicit that
allowing the client you’d like to talk the client has
to take the about?” the lead in the interaction. For the
initiative in “Where would you client who is
introducing like to hesitant about talking, broad
the topic begin?” openings may
stimulate him or her to take the
initiative.
Consensual “Tell me whether For verbal communication to be
validation— my understanding meaningful, it is
searching for of it agrees with essential that the words being
mutual yours.” used have the
understanding, for “Are you using this same meaning for both (all)
accord word to convey participants.
in the meaning of that . . . ?” Sometimes words, phrases, or
the slang terms
words have different meanings and can
be easily
misunderstood.
Encouraging “Was it something Comparing ideas, experiences, or
comparison— like . . . ?” relationships
asking that “Have you had brings out many recurring
similarities similar themes. The client
and differences be experiences?” benefits from making these
noted comparisons
because he or she might recall
past coping
strategies that were effective or
remember
that he or she has survived a
similar situation.
Encouraging “Tell me when you To understand the client, the
description of feel nurse must see
perceptions— anxious.” things from his or her perspective.
asking the “What is Encouraging
client to verbalize happening?” the client to describe ideas fully
what he “What does the may relieve
or she perceives voice seem the tension the client is feeling,
to be saying?” and he or she
might be less likely to take action
on ideas that
are harmful or frightening.
Encouraging “What are your The nurse asks the client to
expression— feelings in consider people and events in
asking client to regard to . . . ?” light of his or her own values.
appraise “Does this Doing so encourages the client to
the quality of his or contribute to make his or her own appraisal
her your distress?” rather than accepting the opinion
experiences of others.
Exploring—delving “Tell me more about When clients deal with topics
further into a that.” superficially,
subject or idea “Would you describe exploring can help them examine
it more fully?” the issue
“What kind of more fully. Any problem or
work?” concern can be
better understood if explored in
depth. If the client expresses an
unwillingness to explore a subject,
however, the nurse must respect
his or
her wishes.
Focusing— “This point seems The nurse encourages the client
concentrating on a worth to concentrate
single point looking at more his or her energies on a single
closely.” point, which may prevent a
“Of all the concerns multitude of factors or problems
you’ve from overwhelming the client. It is
mentioned, which is also a useful technique when a
most client jumps from one topic
troublesome?” to another.
Formulating a “What could you do It may be helpful for the client to
plan of to plan in advance
action—asking the let your anger out what he or she might do in future
client harmlessly?” similar situations.
to consider kinds of “Next time this Making definite plans increases
behavior likely to comes up, what the likelihood
be might you do to that the client will cope more
appropriate in handle it?” effectively
future in a similar situation.
situations
General leads— “Go on.” General leads indicate that the
giving “And then?” nurse is listening
encouragement to “Tell me about it.” and following what the client is
continue saying without taking away the
initiative for the interaction.
They also encourage the client to
 continue if he or she is hesitant or
uncomfortable about the topic
Giving “My name is . . .” Informing the client of facts
information— “Visiting hours increases his or her knowledge
making available are . . .” about a topic or lets the client
the facts “My purpose in know what to expect. The nurse is
that the client being functioning as a resource person.
needs here is . . .” Giving information also builds
trust with the client.
Giving “Good morning, Mr. Greeting the client by name,
recognition— S . . .” indicating awareness of change,
acknowledging, “You’ve finished or noting efforts the client has
indicating your list of things to made all show that the nurse
awareness do.” recognizes the client as a person,
“I notice that you’ve as an individual. Such recognition
combed your hair.” does not carry the notion of value,
that is, of being “good” or “bad.
Making “You appear tense.” Sometimes clients cannot
observations— “Are you verbalize or make themselves
verbalizing what uncomfortable understood. Or the client may not
the when . . . ?” be ready to talk.
nurse perceives “I notice that you’re
biting your lip.”
Offering self— “I’ll sit with you The nurse can offer his or her
making awhile.” presence, interest, and desire to
oneself available “I’ll stay here with
understand. It is important that
you.” this offer is unconditional, that is,
“I’m interested in the client does not have to
what respond verbally to get the
you think.” nurse’s attention.
Placing event in “What seemed to Putting events in proper sequence
time or lead helps both the nurse and client to
sequence— up to . . . ?” see them in perspective.
clarifying the “Was this before orThe client may gain insight into
relationship of after . . . ?” cause-andeffect behavior and
events “When did this
consequences, or the client may
in time happen be able to see that perhaps some
things are not related. The nurse
may gain information about
recurrent patterns or themes in
the client’s
behavior or relationships
Presenting reality “I see no one else in When it is obvious that the client
—offering the is misinterpreting
for consideration room.” reality, the nurse can indicate
that “That sound was a what is real. The
which is real car nurse does this by calmly and
backfiring.” quietly expressing
“Your mother is not the nurse’s perceptions or the
here; facts not by way
I am a nurse.” of arguing with the client or
belittling his or her
experience. The intent is to
indicate an alternative
 line of thought for the client to
consider, not
to “convince” the client that he or
she is wrong.
Reflecting— Client: “Do you Reflection encourages the client
directing client
think to recognize
actions, thoughts, I should tell the and accept his or her own
and feelings back to
doctor . . . ?” Nurse: feelings. The nurse
client “Do indicates that the client’s point of
you think you view has
should?” value, and that the client has the
Client: “My brother right to
spends all my have opinions, make decisions,
money and then has and think
nerve to ask for independently.
more.”
Nurse: “This causes
you to feel angry?”
Restating— Client: “I can’t
The nurse repeats what the client
repeating the sleep. has said in approximately or
main idea I stay awake all nearly the same words the client
expressed night.” has used. This restatement lets
Nurse: “You have the client know that he or she
difficulty sleeping.”communicated the idea
Client: “I’m really effectively. This encourages the
mad, client to continue.
I’m really upset.” Or if the client has been
Nurse: “You’re reallymisunderstood,
mad he or she can clarify his or her
and upset.” thoughts.
Seeking “I’m not sure that I The nurse should seek
information— follow.” clarification throughout
seeking to make “Have I heard you interactions with clients. Doing so
clear that correctly?” can help the nurse to avoid
which is not making assumptions that
meaningful understanding has occurred when
or that which is it has not. It helps the client to
vague articulate thoughts, feelings, and
ideas more clearly.
Silence—absence Nurse says nothing Silence often encourages the
of verbal but client to verbalize,provided that it
communication, continues to is interested and expectant.
which maintain eye Silence gives the client time to
provides time for contact and conveys organize
the interest. thoughts, direct the topic of
client to put interaction, or
thoughts or focus on issues that are most
feelings into words, important.
regain composure, Much nonverbal behavior takes
or place duringsilence, and the nurse
continue talking needs to be aware of
the client and his or her own
nonverbal
behavior.
Suggesting “Perhaps you and I The nurse seeks to offer a
collaboration— can relationship in which the client
offering to share, to discuss and discover can identify problems in living
strive, the with
to work with the triggers for your others, grow emotionally, and
client for anxiety.” improve the
his or her benefit “Let’s go to your ability to form satisfactory
room, and I’ll help relationships. The
you find what your nurse offers to do things with,
looking for.” rather than for,
the client.
Summarizing— “Have I got this Summarization seeks to bring out
organizing straight?” the important
and summing up “You’ve said points of the discussion and to
that that . . .” increase the
which has gone “During the past awareness and understanding of
before hour, you and I have both participants.
discussed . . .” It omits the irrelevant and
organizes the pertinent aspects of
the interaction. It allows both
client and nurse to depart with
the same ideas and provides a
sense of closure at the
completion of each discussion.
Translating into Client: “I’m dead.” Often what the client says, when
feelings— Nurse: “Are you taken literally, seems meaningless
seeking to verbalize suggesting that you or far removed from reality.
client’s feelings feel lifeless?” To understand, the nurse must
that he Client: “I’m way out concentrate on
or she expresses in the ocean.” what the client might be feeling to
only Nurse: “You seem to express
indirectly feel himself or herself this way.
lonely or deserted.”
Verbalizing the Client: “I can’t talk
Putting into words what the client
implied— to you oranyone. It’s
has implied or said indirectly
voicing what the a waste of tends to make the discussion less
client time.” obscure. The nurse should be as
has hinted at or Nurse: “Do you feel direct as possible without being
suggested that no oneunfeelingly blunt or obtuse. The
understands?” client may have difficulty
communicating directly. The
nurse should take are to express
only what is fairly obvious;
Otherwise the nurse may be
jumping toconclusions or
interpreting the client’s
communication.
Voicing doubt— “Isn’t that unusual?” Another means of responding to
expressing “Really?” distortions of
uncertainty about “That’s hard to reality is to express doubt. Such
the believe. expression permits the client to
reality of the become aware that others do not
client’s necessarily perceive events in the
perceptions same way or draw the same
 conclusions. This does not mean
the client will alter his or her point
of view, but at least the nurse will
encourage the client to reconsider
or reevaluate what has happened.
The nurse neither agreed nor
disagreed; however, he or she has
not let the misperceptions and
distortions pass without
comment.

NON THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUES EXAMPLES RATIONALE
Advising—telling “I think you should . Giving advice implies that only the
the client what to . .” nurse knows what is best for the
do “Why don’t client.
you . . .”
Agreeing— “That’s right.” Approval indicates the client is
indicating accord “I agree.” “right” rather than “wrong.” This
with the client gives the client the impression that
he or she is “right” because of
agreement with the nurse. Opinions
and conclusions should be
exclusively the client’s. When the
nurse agrees with the client, there is
no opportunity for the client to
change his or her mind
without being “wrong.”
Belittling Client: “I have When the nurse tries to equate the
feelings nothing intense and overwhelming feelings
expressed— to live for . . . I wish the client has expressed to
Misjudging I was dead.” “everybody” or to the nurse’s own
the degree of the Nurse: “Everybody feelings, the nurse implies that the
client’s discomfort gets discomfort is temporary, mild, self-
down in the limiting, or not very important.
dumps.” OR The client is focused on his or her
“I’ve felt that way own worries and feelings; hearing
myself.” the problems or feelings of others is
not helpful.
Challenging— “But how can you Often the nurse believes that if he
demanding be or she can challenge the client to
proof from the President of the prove unrealistic ideas, the client
client United will realize there is no “proof” and
States?” then will recognize reality. Actually
“If you’re dead, challenging causes the client to
why is your defend the delusions or
heart beating?” misperceptions more strongly than
before.
Defending— “This hospital has a Defending what the client has
attempting to fine criticized implies that he or she has
protect someone reputation.” no right to express impressions,
or something from “I’m sure your opinions, or feelings. Telling the
verbal attack doctor client that his or her criticism is
 has your best unjust or unfounded does not
interests change the client’s feelings but only
in mind.” serves to block further
communication.
Disagreeing— “That’s wrong.” Disagreeing implies the client is
opposing the “I definitely “wrong.” Consequently the client
client’s ideas disagree feels defensive about his or her
with . . .” point of view or ideas.
“I don’t believe
that.”
Disapproving— “That’s bad.” Disapproval implies that the nurse
denouncing the “I’d rather you has the right to pass judgment on
client’s behavior wouldn’t . . .” the client’s thoughts or actions. It
or ideas further implies that the client is
expected to please the nurse.
Giving approval “That’s good.” “I’m Saying what the client thinks or
— glad feels if “good”
sanctioning the that . . .” implies that the opposite is “bad.”
client’s Approval, then, tends to limit the
behavior or ideas client’s freedom to think, speak, or
act in a certain way. This can lead to
the client’s acting in a particular
way just to please the nurse.
Giving literal Client: “They’re Often the client is at a loss to
responses— looking in describe his or her feelings, so such
responding to a my head with a comments are the best he or she
figurative television can do. Usually it is helpful for the
comment as camera.” nurse to focus on the client’s
though it were a Nurse: “Try not to feelings in response to such
statement of fact watch statements.
television.” OR
“What channel?”
Indicating the “What makes you The nurse can ask, “What
existence of say that?” happened?” or “What events led
an external “What made you do you to draw such a conclusion?”
source— that?” But to question “What made you
attributing the “Who told you that think that?” implies that the client
source of you was made or compelled to think in a
thoughts, feelings, were a prophet?” certain way. Usually the nurse does
and behavior to not intend to suggest that the
others or to source is external but that is often
outside influences what the client thinks.
Interpreting— “What you really The client’s thoughts and feelings
asking to make mean is . . .” are his or her own, not to be
conscious that “Unconsciously interpreted by the nurse or for
which isyou’re hidden meaning. Only the client can
unconscious; saying . . .” identify or
telling the client confirm the presence of feelings.
the
meaning of his or
her
experience
Introducing an Client: “I’d like to The nurse takes the initiative for the
unrelated topic die.” interaction away from the client.
—changing the Nurse: “Did you This usually happens because the
subject have nurse is uncomfortable, doesn’t
visitors last know how to respond, or has a topic
evening?” he or she would rather discuss.
Making “It’s for your own Social conversation contains many
stereotyped good.” clichés and much meaningless chit-
comments— “Keep your chin chat. Such comments are of no
offering up.” value in the nurse–client
meaningless “Just have a relationship.
clichés or positive attitude Any automatic responses will lack
trite comments and you’ll be better the nurse’s consideration or
in no time.” thoughtfulness.
Probing— “Now tell me about Probing tends to make the client
persistent this feel used or invaded. Clients have
questioning problem. You know the right not to talk about issues or
of the client I have concerns if they choose. Pushing
to find out.” and probing by the nurse will not
“Tell me your encourage the client to talk.
psychiatric
history.”
Reassuring— “I wouldn’t worry Attempts to dispel the client’s
indicating about anxiety by implying that there is not
there is no reason that.” sufficient reason for concern
for “Everything will be completely devalue the client’s
anxiety or other all right.” feelings. Vague reassurances
feelings “You’re coming without accompanying facts are
of discomfort along just meaningless to the client.
fine.”
Rejecting— “Let’s not When the nurse rejects any topic,
refusing to discuss . . .” he or she closes it off from
consider or “I don’t want to exploration. In turn, the client may
showing hear feel personally rejected along with
contempt for the about . . .” his or her ideas.
client’s
ideas or behaviors
Requesting an “Why do you think There is a difference between
explanation— that?” asking the client to
asking the client “Why do you feel describe what is occurring or has
to provide reasons that taken place
for thoughts, way?” and asking him to explain why.
feelings, Usually a “why”
behaviors, events question is intimidating. In addition,
the client is
unlikely to know “why” and may
become defensive
trying to explain himself or herself.
Testing— “Do you know what These types of questions force the
appraising the kind of client to try to
client’s degree of hospital this is?” recognize his or her problems. The
insight “Do you still have client’s
the idea acknowledgement that he or she
that . . . ?” doesn’t know
these things may meet the nurse’s
needs but is
 not helpful for the client.
Using denial— Client: “I’m The nurse denies the client’s
refusing to admit nothing.” feelings or the seriousness of the
that a problem Nurse: “Of course situation by dismissing his
exists you’re or her comments without
something— attempting to
everybody’s discover the feelings or meaning
something.” behind them.
Client: “I’m dead.”
Nurse: “Don’t be
silly.”

INTERPRETING SIGNALS OR CUES

Cues - are verbal or nonverbal messages that signal key words or issues for the
client.
-Finding cues is a function of active listening.
-Cues can be buried in what a client says or can be acted out in the
process of communication.
- cue words introduced by the client can help the nurse to know what to
ask next or how to respond to the client.
- The following example illustrates questions the nurse might ask when
responding to a client’s cue:
Client: “I had a boyfriend when I was younger.”
Nurse: “You had a boyfriend?” (reflecting) “Tell me about you and your
boyfriend.” (encouraging
description) “How old were you when you had this boyfriend?” (placing
events in time or sequence)

Using the theme, the nurse can assess the nonverbal behaviors that
accompany the client’s words and build responses based on these cues. In
the following examples of identifying themes, the underlined words are
THEMES and CUES to help the nurse formulate further communication.

Theme of sadness:
Client: “Oh, hi, nurse.” ( face is sad; eyes look teary; voice is low,
with little inflection)
Nurse: “You seem sad today, Mrs. Venezia.”
Client: “Yes, it is the anniversary of my husband’s
Nurse: “How long ago did your husband die?” (Or the nurse can use the other
cue.)
Nurse: “Tell me about your husband’s death, Mrs. Venezia.”

Theme of loss of control:

Client: “I had a fender bender this morning. I’m OK. I lost my wallet, and I
have to go to the bank to cover a check I wrote last night. I can’t get in
contact with my husband at work. I don’t know where to start.”
 Nurse: “I sense you feel out of control.” (translating into feelings)

TYPES OF CUES:
1. Overt cues are clear statements of intent such as, “I want to die.” The
message is clear that the client is thinking of suicide or self-harm.
2. Covert cues are vague or hidden messages that need interpretation and
exploration.
-for example, if a client says, “Nothing can help me.” The nurse is unsure,
but it sounds as if the client might be saying he feels so hopeless and
helpless that he plans to commit suicide.
-The nurse can explore this covert cue to clarify the client’s intent and to
protect the client.

Other word patterns that need further clarification for meaning include
metaphors, proverbs, and clichés. When a client uses these figures of
speech, the nurse must follow up with questions to clarify what the client is
trying to say.

Metaphor is a phrase that describes an object or situation by comparing it to

something else familiar.
Client: “My son’s bedroom looks like a bomb went off.”
Nurse: “You’re saying your son is not very neat.” (verbalizing the implied)

Proverbs are old, accepted sayings with generally accepted meanings.

Client: “People who live in glass houses shouldn’t throw stones.”
Nurse: “Who do you believe is criticizing you but actually has similar problems?”
(encouraging description of perception)

Cliché is an expression that has become trite and generally conveys a

stereotype.
-For example, if a client says “she has more guts than brains,” the implication is
that the speaker thinks the woman to whom he or she refers is not smart, acts
before thinking, or has no common sense. The nurse can clarify what the client
means by saying, “Give me one example of how you see Mary as having more
guts than
brains” (focusing).

NONVERBAL COMMUNICATION SKILLS

-Nonverbal communication is behavior that a person exhibits while delivering
verbal content.
- It includes facial expression, eye contact, space, time, boundaries, and body
movements. Nonverbal communication is as important, if not more so, than
verbal communication.
- It is estimated that one-third of meaning is transmitted by words and two-thirds
is communicated nonverbally.

Knapp and Hall (2002) list the ways in which nonverbal messages
accompany verbal messages:
• Accent: using flashing eyes or hand movements
• Complement: giving quizzical looks, nodding
• Contradict: rolling eyes to demonstrate that the meaning is the opposite
of what one is saying
 • Regulate: taking a deep breath to demonstrate readiness to speak, using
“and uh” to signal the wish to continue speaking
• Repeat: using nonverbal behaviors to augment the verbal message such
as shrugging after saying, “Who knows?”
• Substitute: using culturally determined body movements that stand in
for words such as pumping the arm up and down with a closed fist to
indicate success.

THE MEANS OF NON –VERBAL COMMUNICATION

1. Physical appearance including adornment

Personal appearance, body shapes, size, hair styles. Clothing and
adornment are sometimes rich sources of information about a person.
Clothing may convey social and financial status, culture, religion and
selfconcept.
2. Posture and gait
The way people walk and carry themselves are often reliable indicators of
self-concept: mood and health.,e.g., erect posture and a n active,
purposeful
walk suggest a feeling of well-being, while tens posture suggests anxiety
or
anger.
3. Facial expressions
The face is the most expressive part of the body. Feeling of joy, sadness,
fear, surprise, anger and disgust can be conveyed by facial expressions.
Many facial expressions convey a universal meaning, e.g, the smile
conveys happiness.
4. Eye Contact
The eyes may provide the most revealing and accurate of all
communication
signals, because they are a focal point on the body. Mutual eye contact
acknowledges recognition of the other person and a willingness to
maintain communication, e.g., patient who feels weak or defenseless often
avoids eye contact.
5. Body movements and gestures
Body movements may sometimes take the place of speech, eg, a shrug of
the
shoulders to say," I don't know". Some of the basic communication
gestures are the same throughout the world and convey the same
message, e.g, nodding the head is almost universally used to indicate yes,
and the hand shake is a victory sign.
6. Touch.
Touch is the most personal form of communication because it brings
people into a close relationship, e.g, hand patting, put your hand on
patient's shoulder.
7. Tone of voice
It can cause people to listen to speech or to be inattentive and
unresponsive.
An individual's personal warmth, honesty and competence is often
displayed by the tone he uses with others, the pause, volume, and rate of
speech.
8. Symbols
A symbol is a sign that represents an idea. e.g, means male, and means
female.
9. Signals
A signal is assign to give instructions or warning. E.g, the patient puts on
the signal light when he wishes to call a nurse, traffic signals, etc.

Facial Expression - The human face produces the most visible, complex, and
sometimes confusing nonverbal messages (Weaver, 1996).
-Facial expressions can be categorized into expressive, impassive, and
confusing:
• An expressive face portrays the person’s moment-by-moment
thoughts, feelings, and needs. These expressions may be evident
even when the person does not want to reveal his or her emotions.
• An impassive face is frozen into an emotionless, deadpan
expression similar to a mask.
• A confusing facial expression is one that is the opposite of what
the person wants to convey.
A person who is verbally expressing sad or angry feelings while
smiling is an example of a confusing facial expression. (Cormier et
al., 1997; Northouse & Northouse, 1998).
- To ensure the accuracy of information, the nurse identifies the nonverbal
communication and checks its congruency with the content (van
Servellen, 1997). An example is “Mr. Jones, you said everything is fine
today, yet you frowned as you spoke. I sense that everything is not really
fine” (verbalizing the implied).

Body Language - (gestures, postures, movements, and body positions) is a

nonverbal form of communication.

Closed body positions, such as crossed legs or arms folded across the chest,
indicate that the interaction
-might threaten the listener, who is defensive or not accepting.
-A better, more accepting body position is to sit facing the client with both
feet on the floor, knees –parallel ,hands at the side of the body, and legs
uncrossed or crossed only at the ankle.
-Hand gestures add meaning to the content. A slight lift of the hand from
the arm of a chair can punctuate or strengthen the meaning of words.
- Holding both hands with palms up while shrugging the shoulders often
means “I don’t know.” Some people use many hand gestures to
demonstrate or act out what they are saying, while others use very few
gestures.
Closed body position
Accepting body position

Vocal Cues - are nonverbal sound signals transmitted along with the content.
The voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment
the sender’s message.
 Volume, the loudness of the voice, can indicate anger, fear, happiness, or
deafness.
 Tone can indicate if someone is relaxed, agitated, or bored.
 Pitch varies from shrill and high to low and threatening.
 Intensity is the power, severity, and strength behind the words, indicating
the importance of the message.
 Emphasis refers to accents on words or phrases that highlight the subject
or give insight on the topic.
 Speed is number of words spoken per minute. Pauses also contribute to
the message, often adding emphasis or feeling.

The use of extraneous words with long, tedious descriptions is called

CIRCUMSTANTIALITY, it can indicate the client is confused about what is
important or is spinning an untrue story (Morley et al., 1967).
It is important for the nurse to validate these nonverbal indicators rather than to
assume that he or she knows what the client is thinking or feeling (e.g., “Mr.
Smith, you sound anxious. Is that how you’re feeling?”).

Eye Contact
-The eyes have been called the mirror of the soul because they often
reflect our emotions.
-Messages that the eyes give include humor, interest, puzzlement, hatred,
happiness, sadness, horror, warning, and pleading.
- looking into the other person’s eyes during communication, is used to
assess the other person and the environment and to indicate whoseturn it
is to speak
- it increases during listening but decreases while speaking (Northouse &
Northouse, 1998).
-While maintaining good eye contact is usually desirable, it is important
that the nurse doesn’t “stare”
at the client.

Silence - Silence or long pauses in communication may indicate many different

things.
- It is important to allow the client sufficient time to respond, even if it
seems like a long time. It may confuse the client if the nurse “jumps in”
with another question or tries to restate the question differently.

UNDERSTANDING THE MEANING OF THE COMMUNICATION

- Few messages in social and therapeutic communication have only one level of
meaning; messages often contain more meaning than just the spoken words
(deVito, 2002). The nurse must try to discover all the meaning in the client’s
communication.
- For example, people who outwardly appear dominating and strong and often
manipulate and criticize others in reality may have low self-esteem and feel
insecure. They do not verbalize their true feelings but act them out in behavior
toward others. Insecurity and low self-esteem often translate into jealousy and
mistrust of others and attempts to feel more important and strong by dominating
or criticizing them.

UNDERSTANDING CONTEXT
- Understanding the context of communication is extremely important in
accurately identifying the meaning of a message.
-Think of the difference in the meaning of “I’m going to kill you!” when stated in
two different contexts: anger during an argument, and when one friend discovers
another is planning a surprise party for him or her. -Understanding the context of
a situation gives the nurse more information and reduces the risk of
assumptions.
- To clarify context, the nurse must gather information from verbal and
nonverbal sources and validate findings with the client.

BARRIERS OF THERAPEUTIC COMMUNICATION.

1. Language Differences.
When English is the clients’ second language, they may have problems
navigating through the health care system. An inability to communicate
effectively with health care providers adversely affects clients’ responses
to interventions.
2. Culture Differences
Some of the communication variables that are culture specific include eye
contact, proximity to others, direct versus indirect questioning, and the
role of social small talk.
3. Gender
Sending, receiving, and interpreting messages can vary between men and
women. The effect and use of nonverbal cues are often gender dependent.
For example, women tendto be better decoders of nonverbal cues, and
men prefer more personal distance between themselves and others than
do women.
4. Health status
The client who is oriented will communicate more reliably than a client
who is delirious, confused, or disoriented.
5. Developmental level.
Communicating with children requires the use of different words and
approaches than those used with adults because a child cannot think in
abstract concepts. Relating at the client’s developmental level is
necessary for understanding.
6. Emotion
When the nurse or the client is anxious, communication may change, stop,
or take a nonproductive course. Nurses should be aware of their own
feelings and try to control them in order to ensure progress in the
interview.
7. Use of health care jargon.
Nurses and other health care providers have a language unique to their
subculture. Nurses who use health care jargon with clients are likely
contributing to blocked communication. Terms or phrases such as ‘‘CBC,’’
‘‘BP,’’ and ‘‘take your vitals’’ are often misinterpreted by clients and
families. It is important that nurses use language that is easily understood
and explain medical terminology so that it is clear to clients and families.
Teacher’s Insight:
- Nurses must be aware that there are various treatments and therapies
available to manage mental disorders. These treatments may work differently
from one client to another that’s why nurses must carefully assess patients in
order for him to facilitate which therapy is appropriate for them.

Chapter Assessment
A. Fill in the blanks. Write the name of the appropriate theorist
1. The client is the key to his or her own feelings __________________________
2. Social and psychological factors influence development
___________________
3. Behavior change occurs through conditioning with environment stimuli
_______
4. People make themselves unhappy by clinging to irrational fears
_____________
5. Behaviors learned from past experiencing that is reinforcing
________________

B. Drill.
A 35 year old man has been hospitalized for two days for treatment of
hepatitis A. When the nurse enters the client’s room, he asks the nurse to
leave him alone and stop bothering him. Which of the following responses
by the nurse would be MOST appropriate?
A. “I understand and I will leave you alone for now”
B. “Why are you angry with me?”
C. “Are you upset because you do not feel better?”
D. “You seem upset this morning”

A 58 year old woman states she is afraid to have her cast remove from her
fractured arm. Which of the following is the most appropriate response by
the nurse?
A. “I know it is unpleasant. Try not to be afraid. I will help you.”
B. “You seem very anxious. I will stay with you while the cast is removed.”
C. “I don’t blame you. I’d be afraid also.”
D. “My aunt just had a cast removed and she’s just fine.”

A 28 year old woman comes to the clinic because she thinks she is
pregnant. She tells the nurse she wants the pregnancy terminated
because she and her husband do not want to have children, and then
begins to cry. Which of the following statements by the nurse is the MOST
appropriate?
A. “Are you upset because you forgot to use birth control?”
B. “Why are you so upset? You’re married. There is no reason not to have
the baby.”
C. “If you’re so upset, why don’t you have the baby and put it up for
adoption?”
D. “You seem upset. Let’s talk about how you’re feeling.”

A 68 year old man is in the terminal stage of carcinoma of the lungs. A

family member asks the nurse, “How much longer will it be?” Which of the
following responses by the nurse would be MOST appropriate?
A. “I cannot say exactly. What are your concerns at this time?”
B. “I don’t know. I’ll call the doctor.”
C. “This must be a terrible situation for you.”
D. “Don’t worry, it will be very soon.”

A 51 year old man is admitted to the hospital with a diagnosis of a manic

depressive disorder. The man approaches the nurse and says, “Hi, baby”
and opens his robe, under which he is naked. Which of the following
comments by the nurse would be MOST appropriate?
A. “This is inappropriate behavior. Please close your robe and return to
your room.”
B. “Please wear your clothes and join us for lunch in the dining room.”
C. “I am offended by your behavior and will have to report you.”
D. “Do you need some assistance while dressing today?”

An 82 year old woman is placed in Buck’s traction. The nurse assigned to

her prepares to assist her with a bath. The woman says, “You’re too young
to know how to do this. Get me somebody who knows what they’re doing.”
Which of the following responses by the student nurse would be MOST
appropriate?
A. “I am young, but I graduated from nursing school.”
B. “If I don’t bathe you now, you’ll have to wait until I’m finished with my
other clients.”
C. “Can you be more specific about your concerns?”
D. “Your concerns are unnecessary. I know what I’m doing.”

A 72 year old woman is admitted to the hospital with an abdominal mass

and is scheduled for an exploratory laparotomy. She asks the nurse
admitting her, “Do you think I have cancer?” Which of the following
responses by the nurse would be MOST appropriate?
A. “Would you like me to call your doctor so that you can discuss your
specific concerns?”
B. “Your test showed a mass. It must be hard not knowing what is wrong.”
C. “It sounds like you are afraid that you are going to die from cancer.”
D. “Don’t worry about it now. I’m sure you have many healthy years
ahead of you.”

A 23 year old woman is admitted to the post partum unit following a

miscarriage. The next day the nurse finds the woman crying while looking
at the babies in the newborn nursery. What would be MOST appropriate?
A. Assure the woman that the loss was “for the best.”
B. Explain to her that she is young enough to have more children.
C. Ask her why she is looking at the babies.
D. Acknowledge the loss and be supportive.

An 84 year old man is hospitalized with Alzheimer’s disease. His daughter

tells the nurse that caring for him is too hard, and that she feels guilty
placing him in a nursing home. Which of the following statements by the
nurse is MOST appropriate?
A. “It’s hard to be caught between taking care of your needs and your
father’s needs.
B. “Would you like me to help you find a nursing home?”
C. “Don’t feel guilty. The only solution is to place your father in a nursing
home.”
D. “I think I would feel guilty too if I had placed my father in a nursing
home.”

When did this happen?

A. Therapeutic
B. Non-therapeutic

Was this something like?

A. Therapeutic
B. Non-therapeutic

Tell me about it.

A. Therapeutic
B. Non-therapeutic

That is bad.
A. Therapeutic
B. Non-therapeutic

But how can you be the President of the Philippines?

A. Therapeutic
B. Non-therapeutic

I don’t want to hear about it.

A. Therapeutic
B. Non-therapeutic

But Dr. B is a very able psychiatrist.

A. Therapeutic
B. Non-therapeutic
 CHAPTER III
Mental status Examination
Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Identify categories used to assess the client’s mental health
 Formulate questions to obtaian information in each category
 Describe the client’s functioning in terms of self-concept, roles and
relationships
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Abstract thinking
 Thought process
 Affect
 Mood
 Thought content
 Hallucination
 Delusion
 Psychomotor retardation

 Assessment
- First step in the nursing process
- Involves collection, organization and analysis of information
- Psychiatric nursing: psychosocial assessment (Mental Status Exam)
- Factors affecting psychosocial assessment:
o Client participation/ feedback
o Client’s health status
o Client’s previous experiences
o Client’s ability to understand
o Nurse’s attitude and approach

 Content of Assessment
o History
o General appearance
o Mood and affect
o Thought process and content
o Sensorium and intellectual process
 o Judgment and insight
o Self-concept
o Roles and relationships
o Physiologic and self-care concerns

1. History
a. Age
b. Demographic profile
c. Cultural considerations
d. Spiritual beliefs
e. Developmental stage

2. General Appearance and Motor Behavior

a. Assess overall appearance including dress, hygiene and grooming
b. Automatisms: repeated, purposeless behavior indicative of anxiety
(drumming of fingers, twisting locks of hair, tapping the foot)
c. Psychomotor retardation: overall slowed movement
d. Waxy flexibility: maintenance of posture or position over time even
when it is awkward or uncomfortable
e. Neologism: coining new words

3. Mood and Affect

a. Mood: refers to the client’s pervasive and enduring emotional state
i. Labile: rapidly changing mood
b. Affect: outward expression of emotion
i. Blunted affect: showing little or a slow-to respond facial
expression
ii. Broad affect: displaying a full range of emotional expression
iii. Flat affect: showing no facial expression
iv. Inappropriate affect: displaying a facial expression that is
incongruent with mood or situation; often silly or giddy
regardless of circumstances
v. Restricted affect: displaying one type of expression, usually
serious or somber

4. Though process and content

a. Thought process: how the client thinks
b. Thought content: what the client actually says
Examples:
▪ Circumstantial thinking: term used when a client eventually
answers a question but only after giving excessive unnecessary
detail
▪ Circumstantial thinking: term used when a client eventually
answers a question but only after giving excessive unnecessary
detail
▪ Flight of ideas: excessive amount and rate of speech composed
of fragmented or unrelated ideas
▪ Ideas of reference: client’s inaccurate interpretation that general
events are personally directed to him or her such as hearing a
speech on the news and believing the message had personal
meaning
▪ Loose associations: disorganized thinking that jumps from one
idea to another with little or no evident relation between the
thoughts
 ▪ Tangential thinking: wandering off the topic and never providing
the information requested
▪ Thought blocking: stopping abruptly in the middle of a sentence
or train of thought; sometimes unable to continue the idea
▪ Thought broadcasting: a delusional belief that others can hear or
know what the client is thinking
▪ Thought insertion: a delusional belief that others are putting
ideas or thoughts into the client’s head—that is, the ideas are
not those of the client
▪ Thought withdrawal: a delusional belief that others are taking
the client’s thoughts away and the client is powerless to stop it
▪ Word salad: flow of unconnected words that convey no meaning
to the listener

5. Sensorium and Intellectual Process

a. Orientation: refers to the client’s recognition of person, place and
time
b. Memory: assess recent and remote memory
c. Ability to concentrate: ask client to perform certain tasks such as:
i. Spell the word “world” backwards
ii. Begin with number 20, subtract 5 then add 5
iii. Repeat the days of the week backwards

6. Abstract Thinking and Intellectual Abilities

o Lack of formal education could hinder this assessment
o Abstract thinking: making interpretations to a certain situation
 Example: “Aanhin mo ang damo kung patay na ang kabayo”
o Concrete Thinking

7. Sensory and Perceptual alterations

a. Hallucination: false sensory perceptions
i. Auditory
ii. Visual
iii. Tactile
iv. Gustatory

8. Judgment and Insight

a. Judgment: ability to interpret one’s environment and situation correctly and
to adapt one’s behavior and decisions accordingly
b. Insight is the ability to understand the true nature of one’s situation and
accept some personal responsibility for that situation

9. Self-concept
a. The way one views oneself in terms of personal worth and dignity
b. Ask the client to describe himself or herself

10. Roles and Relationships

CHAPTER IV
 GRIEF AND LOSS

 Grief: subjective emotions and affect that are a normal response to the
experience of loss
 Grieving/Bereavement: process by which a person experiences the grief
 Anticipatory grieving: when people facing an imminent loss begin to
grapple with the possibility of loss or death in the future
 Mourning: outward expression of grief

 Types of Losses
1. Physiologic loss: amputation, loss of a body part
2. Safety loss: loss of a safe environment; domestic violence
3. Loss of security and a sense of belonging: the loss of a loved one
4. Loss of self-esteem: change in how a person is valued at work or in
relationships
5. Loss related to self-actualization: an external or internal crisis that blocks
or inhibits striving toward fulfillment

 Grieving Process
A. Kubler-Ross Stages of grieving
1. Denial: shock and disbelief
2. Anger
3. Bargaining
4. Depression
5. Acceptance

B. Bowlby’s Phases of Grieving

- Humans instinctively attain and retain affectional bonds with significant
others (attachment behaviors)
- 4 phases of grieving process:
o Experiencing numbness and denying the loss
o Emotionally yearning for the lost loved one and protesting the
permanence of loss
o Experiencing cognitive disorganization and emotional despair with
difficulty functioning in the everyday world
o Reorganizing and reintegrating the sense of self to pull life back
together

C. Engel’s Stages of Grieving

1. Shock and disbelief
2. Developing awareness
3. Restitution
4. Resolution of the loss
5. Recovery

D. Horowitz’s Stages of Loss and Adaptation

1. Outcry: first realization of the loss
2. Denial and intrusion
3. Working through
4. Completion

 Tasks of Grieving (Rando)

- Recognize: experiencing the loss
- React: emotional response to loss
- Recollect and re-experience: memories are reviewed
- Relinquish: accepting that the world has changed
- Readjust: beginning to return to daily life
- Reinvest: Accepting changes that have occurred

 Dimensions of Grieving
1. Cognitive Responses to grief
- Questioning and trying to make sense of the loss
- Attempting to keep the lost one present
2. Emotional response to grief
- Anger, sadness, anxiety, resentment, guilt, feeling numb, profound sorrow,
loneliness
- Depression, apathy, despair
3. Spiritual Responses to grief
- Disillusioned and angry with God
- Anguish of abandonment or perceived abandonment
- Hopelessness, meaninglessness
4. Behavioral Responses to Grief
- Easiest to observe
- Tearful sobbing, restlessness, irritability and hostility
- Keeping valuables of lost loved one
5. Physiologic Responses to grief
- Headaches, insomnia, impaired appetite, lack of energy
Nurse: Ano ang
Management of Loss: pagkakaintindi mo sa
sinabi ng doctor sayo?
1. Explore the client’s perception of loss
a. What does the client feel about the loss? Client: Well, sabi nya
kailangan ko raw
b. How is the loss going to affect the client’s life? maoperahan sa dibdib

2. Explore the client’s coping skills. Use effective communication skills

Nurse: I wonder if you are upset with your upcoming surgery?
Client: I’m not having surgery. I don’t need it

Remember: the client’s behavior reflects his coping skills

**adaptive denial: the client gradually adjusts to the reality of loss

3. Obtain support.
4. Promote coping behaviors. Give the client the opportunity to compare and
contrast ways in which he or she has coped with significant loss in the past
and helping him or her review his/her strengths and renew a sense of
personal power. Assist the client with activities such as offering food
without pressuring the client to eat
5. Promote communication and interpersonal skills
a. Use simple, non-judgmental statements to acknowledge loss “ I
want you to know that I am thinking of you”
b. Referring to a loved one by name
c. Light touch or pat on the shoulder indicates caring
d. Respect each client’s ways of grieving
e. Respect the client’s personal beliefs
f. Being honest, dependable, consistent and worthy of the client’s
trust
g. Smile and maintain eye contact during conversation
h. Offer presence and broad opening
 i. Use focusing
j. Voice doubt if necessary
6. Establish rapport and maintain interpersonal skills:
a. Attentive presence
b. Active listening
c. Respect

 Assessment:
Case Scenario

Juan Dela Cruz is a 45 year old man struggling with the recent passing of his wife in a vehicular
accident. He has two grown children aged 26 and 28 who have families of their own and are living far
from him. He has been increasingly withdrawn from friends and other family members telling them
“Ayos lang ako. Gusto ko lang mag-is”. He isn’t eating, losing weight, not sleeping very well and has
been neglecting his personal hygiene and grooming.
What are the possible nursing diagnoses that can be derived from the scenario?
How can you help Mr. DC cope up with the loss?

Self-assessment

Think about a significant loss in your own life. How did others respond to you? What was
helpful? What do you take from that experience that will influence how you respond to
others?

CHAPTER 5
ANGER, HOSTILITY AND AGGRESSION

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Define and discuss anger, hostility and aggression
  Describe psychiatric disorders that may be associated with anger,
hostility and aggression
 Describe the signs and symptoms associated with aggression
 Identify and employ interventions when dealing with hostile and
aggressive clients
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Acting out
 Anger
 Catharsis
 hostility

Terminologies:
 Anger: normal human emotion; is a strong, uncomfortable, emotional
response to a real or perceived
 Hostility, also called verbal aggression, is an emotion expressed through
verbal abuse, lack of cooperation, violation of rules or norms, or
threatening behavior
 Physical aggression is behavior in which a person attacks or injures
another person or that involves destruction of property

 ONSET
- Anger becomes negative when the person denies it, suppresses it, or
expresses it inappropriately
- A person may deny or suppress (i.e., hold in) angry feelings if he or she is
uncomfortable expressing anger. Possible consequences are physical
problems such as migraine headaches, ulcers, or coronary artery disease and
emotional problems such as depression and low self-esteem
- Some people try to express their angry feelings by engaging in aggressive
but safe activities such as hitting a punching bag or yelling (catharsis)
- men who experience angry outbursts have twice the risk of stroke as men
who control their tempers.
- Effective methods of anger expression, such as using assertive
communication, should replace angry, aggressive outbursts of temper such
as yelling or throwing things
- Anger suppression is especially common in women (Davila, 1999) who have
been socialized to maintain and enhance relationships with others and to
avoid the expression of so-called negative or unfeminine emotions such as
anger.
- Hostile and aggressive behavior can be sudden and unexpected.
- Phases of aggressive incidents:
o Triggering phase
 o Escalation phase
o Crisis phase
o Recovery phase
o Postcrisis phase

 Related Disorders
1. Paranoid delusions
2. Aggressive behaviors seen in patients with dementia, delirium, head
injuries, alcohol intoxication
3. Major depression. Anger attacks involve verbal expressions of anger or
rage but no physical aggression
4. Intermittent explosive disorder is a rare psychiatric diagnosis
characterized by discrete episodes of aggressive impulses that result in
serious assaults or destruction of property
5. Acting out is an immature defense mechanism by which the person deals
with emotional conflicts or stressors through actions rather than through
reflection or feeling
6. Temper tantrums are a common response from toddlers whose wishes are
not granted. As a child matures, he or she is expected to develop impulse
control (the ability to delay gratification) and socially appropriate behavior

 Management
1. For aggressive clients with psychoses, use cocktail method (Haloperidol
and Lorazepam)
2. Manage the environment. Planned activities or groups such as card
games, watching and discussing a movie, informal discussions give the
clients the opportunity to talk about events or issues when they are calm
3. Schedule one-on-one interactions
4. Ensure safety and security
5. During the triggering phase, approach the client in a nonthreatening, calm
manner. Convey empathy for the client’s anger and frustration. Suggest to
express the anger verbally.
6. Give medications as ordered
7. During the escalation phase, the nurse takes control of the situation. The
nurse should provide directions to the client in a calm, firm voice. The
client should be directed to take a time out for cooling off in a quiet area
or his or her room
a. The nurse should tell the client that aggressive behavior is not
acceptable and that the nurse is there to help the client regain
control
8. If the client is unwilling to accept direction, initiate “show of force”. The
presence of additional staff (4 to 6 staff) convinces the client to accept
medication and take the time
9. Restrain or seclude the patient if the condition worsens. Ensure that the
order is signed by the physician
[Link] phase: encourage the client to talk about the situation or
triggers that led to the aggressive behavior.
a. Help the client to relax, perhaps sleep and return to a calmer state
[Link] the postcrisis phase, the client is removed from restraint or seclusion as
soon as he or she meets the behavioral criteria

Teacher’s insight:
It is important to practice and gain experience in dealing with hostile and
aggressive clients. The way we respond also affects how the patient would
 react. There is a risk for staff injury that’s why there is a need to practice
safety techniques to reduce such incidents.

SELF-ASSESSMENT

1. Discuss the interventions the nurse(s) might use for a client who becomes
aggressive without warning. Give the rationale for each intervention
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________

2. What activities do you usually do to control your anger? How do these

activities help you cope up with the situation?

CHAPTER 6
ABUSE AND VIOLENCE

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Discuss the characteristics, risk factors and family dynamics of
abusive and violent behaviour
 Examine incidence and trends in domestic violence
 Apply the nursing process in the care of clients experiencing abuse
and violence
 Evaluate own responses, feelings and attitude about abusive and
violent behavior
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Child abuse
 Violence
 Rape
 Elder abuse
 Cycle of violence
 Family volence

 Abuse: wrongful use and

maltreatment of another person
 Victims of abuse can have physical injuries as well as psychological responses
needing medical attention
 Domestic violence remains undisclosed for months or even years because
victims fear their abusers
 Victims often contain their anger and resentment
 Survivors: often feel guilt and shame
o Children: miss school
o They feel degraded, humiliated and dehumanized.
o Self-esteem is low and they view themselves as unlovable
o They find it hard to trust others
o They are likely erratic, intense and perceived as unpredictable

CHARACTERISTICS OF VIOLENT FAMILIES

 Family violence encompasses spouse battering; neglect and physical,

emotional, or sexual abuse of children; elder abuse; and marital rape
 Social isolation: families keep it to themselves
 Abuse of power and control: abuser exerts physical, economic and social
control over the victims
 Alcohol and other drug abuse: an abusive person is likely to use alcohol or
other drugs; ALCOHOL is also cited as a factor in acquaintance or date
rape
 Intergenerational Transmission Process: means that patterns of violence
are perpetuated from one generation to the next through role modeling
and social learning; family violence is a learned pattern of behavior

INTIMATE PARTNER VIOLENCE

o Mistreatment of misuse of one person by another in the context of
an emotionally intimate relationship
o Psychological abuse (emotional abuse): name-calling, belittling,
screaming, yelling, destroying property and making threats
o Physical abuse: shoving and pushing to severe battering and
choking and may involve broken limbs, bleeding and even death
o Battering during pregnancy leads to miscarriage and other maternal
and fetal conditions
o Violence also occurs in same-sex relationship. Sodomy (anal
intercourse) is considered as a crime in USA

CYCLE OF ABUSE AND VIOLENCE

- A typical pattern exists; usually the initial episode
of battering or violence is followed by a period of
period of
the abuser expressing regret, apologizing, and Violent
remorse or
Behavior
promising it will never happen again. He professes contrition
his love for his wife and may even engage in
romantic behavior (e.g., buying gifts and flowers).
This period of contrition or remorse sometimes is
called the honeymoon period. Tension
building
- After this honeymoon period, the tension-building
phase begins (arguments, silence); it ends with
another violent episode
- The honeymoon period may last weeks or even
months, however the violent episodes continue to arise and may even worsen
- Remember: The cycle does not apply to all. Some may experience only one or
two of the cycle
- Assessment is critical when it comes to abuse. Most women do not seek
direct help
- Nurses may ask the following questions to assess the safety of the victim:
o Do you feel safe in the relationship?
o Are you concerned for your safety?
o Are family or friends concerned for your safety?
o if you feel threatened or unsafe, do you have someone to call?
o Do you have a safe place to go if you need to?

Below are things that you need to remember when working with victims:

DON’T DO
Don’t disclose client communications Do ensure and maintain the client’s
without the client’s consent. confidentiality.
Don’t preach, moralize, or imply that Do listen, affirm, and say “I am sorry
you doubt the client. you have been hurt.”
Don’t minimize the impact of violence. Do express: “I’m concerned for your
Don’t express outrage with the safety.” Do tell the victim: “You have
perpetrator. Don’t imply that the a right to be safe and respected.”
client is responsible for the abuse. Do say: “The abuse is not your fault.”
Don’t recommend couples’ Do recommend a support group or
counseling. individual counseling.
Don’t direct the client to leave the Do identify community resources and
relationship. Don’t take charge and do encourage the client to develop a
everything for the client safety plan. Offer to help the client
contact a shelter, the police, or other
resources

CHILD ABUSE
- Maltreatment; unintentional injury of a child; can include physical abuse or
injuries, neglect or failure to prevent harm, failure to provide adequate
physical or emotional care, abandonment, sexual abuse
- LI: Research on the recent statistics for child abuse a.)national b)
regional c. )local
- Types of child abuse:
o Physical abuse: often result from unreasonably severe corporal
punishment or unjustifiable punishment
o Sexual abuse involves sexual acts performed by an adult on a child
younger than 18 years (incest, rape, and sodomy performed directly
by the person or with an object; oral-genital contact; and acts of
molestation such as rubbing, fondling, or exposing the adult’s
genitals)
o Neglect is malicious or ignorant withholding of physical, emotional,
or educational necessities for the child’s well-being
o Psychological abuse (emotional abuse) includes verbal assaults,
such as blaming, screaming, name-calling, and using sarcasm;
constant family discord characterized by fighting, yelling, and chaos
- Parents (abusers): often have minimal parenting knowledge and skills.
 o they do not understand their children’s needs; they get mad
because they are emotionally (not being able to meet their own
needs) or financially unequipped
o lack of education and poverty contribute also to child abuse but can
also happen to families who have successful careers and are

Warning Signs of Abused Children

- Serious injury, such as fractures, burns (usually have identiafiable shape
or may have “stocking and glove” distribution, or lacerations with no
reported history of trauma
- Delay in seeking treatment for a significant injury
- Child or parent gives a history inconsistent with severity of injury, such as
a baby with contrecoup injuries to the brain (shaken baby syndrome) that
the parents claim happened when the infant rolled off the sofa
- Inconsistencies or changes in the child’s history during the evaluation by
either the child or the adult
- Unusual injuries for the child’s age and level of development, such as a
fractured femur on a 2 month old or a dislocated shoulder in a 2 year old
- High incidence of urinary tract infections; bruised, red, or swollen
genitalia; tears or bruising of rectum or vagina
- Evidence of old injuries not reported, such as scars, fractures not treated,
multiple bruises that parent/caregiver cannot explain adequately
- Sexual abuse: children may have urinary tract infections, bruised or
swollen genitalia, tears in the rectum or vagina)
- Children tend to become anxious and frightened; they either cling or
reject adult attention entirely

financially stable
Treatment:
- Ensure safety and well-being of the child
- Establish trust and rapport with the patient
- Play therapy: to help the child with communication
o Therapist establishes a friendly relationship
o Accepts the child as he is
o Creates a permissive relationship; child has freedom of expression
o Validates (acknowledge and reflect) child’s feelings
o Responsibility for decisions and change is left mostly to the child
o Child directs the therapeutic process; therapist follows
o Therapeutic interaction is not rushed
o Limits are set only when necessary
for child’s outcomes
- Arrange for social services (whether the
child will be returned home)
- Family therapy
- Parents: rehabilitation/ manage substance
abuse
- Foster care maybe necessary

ELDER ABUSE
- is the maltreatment of older adults by family
members or caretakers.
- Physical, sexual, psychological, neglect, self-neglect, financial exploitation,
denial of medical treatment
- Statistics: 1 out of 10 elders aged 65 and above are injured and exploited
- Most abused: WOMEN
- Abusers: living with the patient
- Assessment: may have bruises; lack of needed medical treatment; restrained;
self-neglect involves the elder’s failure to provide for himself
 Possible indicators of elder abuse:
- PHYSICAL ABUSE INDICATORS
o Frequent, unexplained injuries accompanied by a habit of seeking
medical assistance from various locations
o Reluctance to seek medical treatment for injuries, or denial of their
existence
o Disorientation or grogginess indicating misuse of medications
o Fear or edginess in the presence of family member or caregiver
- PSYCHOLOGICAL OR EMOTIONAL ABUSE INDICATORS
o Helplessness
o Hesitance to talk openly
o Anger or agitation
o Withdrawal or depression
- FINANCIAL ABUSE INDICATORS
o Unusual or inappropriate activity in bank accounts
o Signatures on checks that differ from the elder’s
o Recent changes in will or power of attorney when elder is not
capable of making those decisions
o Missing valuable belongings that are not just misplaced
o Lack of television, clothes, or personal items that are easily
affordable
o Unusual concern by the caregiver over the expense of the elder’s
treatment when it is not the caregiver’s money being spent
- NEGLECT INDICATORS
o Dirt, fecal or urine smell, or other health hazards in the elder’s living
environment
o Rashes, sores, or lice on the elder
o Elder has an untreated medical condition or is malnourished or
dehydrated not related to a known illness
o Inadequate clothing
- INDICATORS OF SELF-NEGLECT
o Inability to manage personal finances, such as hoarding, squandering,
or giving away money while not paying bills
o Inability to manage activities of daily living such as personal care,
shopping, housework
o Wandering, refusing needed medical attention, isolation, substance use
o Failure to keep needed medical appointments
o Confusion, memory loss, unresponsiveness
o Lack of toilet facilities, living quarters infested with animals or vermin
- WARNING INDICATORS FROM CAREGIVER
o Elder is not given opportunity to speak for self, to have visitors, or to
see anyone without the presence of the caregiver
o Attitudes of indifference or anger toward the elder
o Blaming the elder for his or her illness or limitations
o Defensiveness
 o Conflicting accounts of elder’s abilities, problems, and so forth
o Previous history of abuse or problems with alcohol or drugs
- Treatment:
o Abuse may develop gradually as the burden exceeds the caretaker’s
physical or emotional resources
o Relieve the caregiver’s stress; provide additional resources
o Discuss concerns related to suspected abuse or neglect
 Include in the treatment plan and enlist their active support and
participation
o Involve professionals from other disciplines (to assist in the evaluation)
o Continued contact with a trusted family physician

RAPE AND SEXUAL ASSAULT

- Rape: Perpetration of an act of sexual intercourse with a person against his
or her will and without her consent
- It is a crime of violence and humiliation
- It is considered rape if the victim is incapable of exercising rational judgment
because od mental deficiency or because he/she is a minor
- Only requires a SLIGHT penetration of vulva or rectum; SODOMY; victim
maybe battered or injured
- Can occur between strangers, acquaintances, married persons, same sex
- Date rape (acquaintance rape) – may occur on the first date, a ride
home, or when two people have known each other for some time; more
prevalent around or on college campuses; increases with consumption of
alcohol
- it is a highly unreported crime
- unreported cases: due to victim’s feelings of shame and guilt; fear of further
injury
- victims: any age (15 months to 82 years old)
- Highest incidence: Women (16-24 years old)
- Male rape is also significantly unreported; occurs between gay partners or
strangers; prevalent in prisons

DYNAMICS OF RAPE
- Men who commit rape:
30 years and above
(50%), 21 to 29 years
old (25%); Race (57%
are white); alcohol
involvement (34%)
- Women are in frequently
life-threatening
situations so their
motivation is to SURVIVE
or STAY ALIVE
- Degree of submission is
higher when the
perpetrator is armed
- RESULT: physical and psychological trauma is SEVERE!
- Victims especially women tend to less likely care for themselves which make
them more vulnerable to medical conditions (depression, malnutrition etc);
they experience fear, helplessness, shock and disbelief, guilt, humiliation
 Interventions:
- Provide immediate support and encourage verbalization of feelings
- Educate family about the warning signs of violence and the needs of victims
- Allow the victim to proceed at his/her own pace
- Allow the victim to have control of herself
o Allow victim to make decisions
o Secure consent before gathering evidences
- Give prophylactic treatment for STI
- Facilitate HIV testing
- For pregnancy: Prophylaxis includes ethinyl estradiol and norgestrel
- Encourage patient to join support groups
- Arrange for further counseling (provides emotional support)
- Facilitate supportive therapy: gaining control, promoting independence,
relieving feelings of helplessness, regaining trust, dealing with feelings of
guilt and shame
- Initiate group therapy
- **it takes 1 year or more for rape survivors to regain previous levels of
functioning

Profile of an ABUSER WARNING SIGNS OF CHILD

Social Isolation ABUSE
Low Self-esteem Child or parent giving a history
Abused as a child inconsistent with the severity of
injury
Poor impulse control High incidence of UTI, swollen or
Poor coping skills bruised rectum and genitalia
Extreme jealousy Injuries not usual for the child’s
Drug or alcohol abuse age and level of development
Lacerations, scars, multiple bruises
on various stages of healing
Delay in seeking treatment for a
significant injury
Teacher’s Insight:
Nurses must be open when dealing with victims and abusers. Often, they
become reluctant to ask questions because of their personal beliefs and
misconceptions about abuse. Clients with these case are sensitive and have low
self-esteem. Nurses must be able to facilitate positive self-concept among these
patients. We should facilitate acceptance to promote healing.

ACTIVITY!
 Movie analysis
1. Watch the documentary in the link provided and answer the following
guide questions:
a. What did you feel while watching the video?
b. What do you think are the reasons why victims choose to stay
silent?
c. What are your thoughts about “stigma”?
d. What was the worst thing that you have heard about rape victims?
e. What are possible ways that you can do to help these victims?

Video link: [Link]

 Things to ponder:
2. Is spanking a child an acceptable form of discipline? Why or why not?
State circumstances to justify your answer
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________
3. What factors should the nurse consider when dealing with abusers? What
about when dealing with victims?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________
 CHAPTER VII
TRAUMA AND STRESS-RELATED DISORDERS
Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Discuss the characteristics, risk factors and dynamics of trauma
related disorder
 Identify factors leading to PTSD
 Describe responses of clients with PTSD
 Provide health education associated to trauma and stress among
patients, families and concerned individuals
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
  Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Acute stress disorder
 Adaptive disorder
 PTSD
 Depersonalization
 Derealization
 Dissociation
 Hyperarousal
 Falshbacks
 Intrusive thoughts

POSTTRAUMATIC STRESS DISORDER (PTSD)

- disturbing pattern of behavior
demonstrated by someone who has
experienced, witnessed or been
confronted with a traumatic event (ex.
natural disaster)
- The patient was exposed to the event
which caused intense fear or terror
LI: What is “Life Events Checklist”
and “PTSD Checklist”?
- Signs and symptoms:
o Re-experiencing the trauma
through memories, dreams,
“flashbacks”
o Avoidance
o Negative cognition
o Being on guard “HYPERAROUSAL”
o Hyperarousal: insomnia, hypervigilance, irritability, angry outburst
o Numbing or general unresponsiveness
o Losing a sense of connection and control over his life
o Seeks comfort, safety but can become isolated over time
- Symptoms occur 3 months or more after the trauma/event (Acute stress
disorder lasts 3 days up to 1 month)
- PTSD is chronic; onset maybe delayed for months or even years
- Patients often develop psychiatric disorders (depression, anxiety disorders,
substance abuse)
- Can occur at any age
- Prevalence: increased in combat veterans and victims of natural disasters
- 50% of patients recover within 3 months

 DSM-5 DIAGNOSTIC CRITERIA

- Applicable to adults, adolescence and children older than 6 years
Criterion A: stressor (one required)
The person was exposed to: death, threatened death, actual or threatened
serious injury, or actual or threatened sexual violence, in the following way(s):
 Direct exposure
 Witnessing the trauma
 Learning that a relative or close friend was exposed to a trauma
 Indirect exposure to aversive details of the trauma, usually in the course of
professional duties (e.g., first responders, medics)
Criterion B: intrusion symptoms (one required)
The traumatic event is persistently re-experienced in the following way(s):
 Unwanted upsetting memories
 Nightmares
 Flashbacks
 Emotional distress after exposure to traumatic reminders
 Physical reactivity after exposure to traumatic reminders
Criterion C: avoidance (one required)
Avoidance of trauma-related stimuli after the trauma, in the following way(s):
 Trauma-related thoughts or feelings
 Trauma-related external reminders
Criterion D: negative alterations in cognitions and mood (two
required)
Negative thoughts or feelings that began or worsened after the trauma, in the
following way(s):
 Inability to recall key features of the trauma
 Overly negative thoughts and assumptions about oneself or the world
 Exaggerated blame of self or others for causing the trauma
 Negative affect
 Decreased interest in activities
 Feeling isolated
 Difficulty experiencing positive affect
Criterion E: alterations in arousal and reactivity
Trauma-related arousal and reactivity that began or worsened after the
trauma, in the following way(s):
 Irritability or aggression
 Risky or destructive behavior
 Hypervigilance
 Heightened startle reaction
 Difficulty concentrating
 Difficulty sleeping
Criterion F: duration (required)
Symptoms last for more than 1 month.
Criterion G: functional significance (required)
Symptoms create distress or functional impairment (e.g., social,
occupational).
Criterion H: exclusion (required)
Symptoms are not due to medication, substance use, or other illness.

RELATED DISORDERS
 Adjustment disorder:
o Reaction to a stressful event (financial, work-related stressors)
that causes problems for the individual.
o Symptoms develop within a month lasting for no more than 6
months
o Treatment: outpatient counseling
 Acute Stress Disorder:
o Occurs after a traumatic event
o Re-experiencing, avoidance, hyper arousal
o Symptoms occur 3 days to 4 weeks after the event
 oTreatment: Cognitive behavioral therapy to prevent progression
to PTSD
 Reactive attachment disorder (RAD)/ Disinhibted social
engagement disorder (DSED)
o Occur before 5 years old
o Result of trauma (child abuse or neglect)
o S/sx: disturbed inappropriate social relatedness; exhibits minimal
social and emotional responses to others, lacks positive effect,
sad, irritable, afraid

Etiology/Occurrence:
- Exposure to trauma
- Adolescents are more likely to develop PTSD than children; they are at
increased for suicide, substance abuse, poor social support, academic
problems and poor physical health
- Children: they develop PTSD if with a history of parental major depression
and abuse

Treatment/Interventions:
**usually outpatient treatment
- Counseling (individual or group)
- CBT
- Exposure therapy: help the client face troubling thoughts and regain
control over it.
o Confronts the feared emotions associated with the trauma
o While doing so, the nurse uses various relaxation techniques to help
the client tolerate and manage the anxiety response
o Ex: returning to where the incident happened, imagined
confrontation
- Adaptive Disclosure: specialized CBT approach developed by the military
to offer an intense, specific, short-term therapy for active-duty military
personnel
o Incorporates explosive therapy + empty chair technique (the patient
says what he/she wants to anyone whether dead or alive)
o The therapy consists of six sessions
- Cognitive processing therapy: successful in treating rape victims with
PTSD
o Involves structured sessions that focus on examining beliefs that
interfere with daily functioning (shame, guilt, self-blaming)
- Psychopharmacology: Give SSRI as prescribed; second generation
antipsychotic (Risperidone)

Nursing Interventions:
- Be nonthreatening and professional when approaching the client
- Assign the same staff member to the client to respect his/her fears and
feeling. Then, gradually increase the number and variety of staff members
interacting with the client
- Educate yourself and other staff members about the client’s experience
- Promote self-awareness
- Remain nonjudgmental
- Be consistent with the client; convey acceptance
- Encourage verbalization of feelings
- Give positive regard for every task done
- Help the client practice stress management and relaxation techniques,
assertiveness and self-defense

DISSOCIATIVE DISORDERS
- Dissociation: a subconscious defense mechanism that helps a person
protect her emotional help or reduce anxiety
o Allows mind to forget or remove itself from the painful sensation
- Dissociative disorders: disruption in the usually integrated functions of
consciousness, memory, identity and environmental perception
- Dissociative amnesia: client cannot remember important personal
information (traumatic or stressful nature). Includes a fugue experience
where the client suddenly moves to a new geographic location without
memory in the past and assume a new identity
- Dissociative identity disorder (DSM IV: multiple identity disorder): displays
two or more distinct identities or personality; involves inability to recall
personal information
- Depersonalization/derealization disorder: persistent feeling of being
detached from his mental process or body (depersonalization); sensation
of being in a dream-like situation (derealization)
- D.O are usually rare but prevalent in population where there is a history of
child abuse (physical and sexual)

Significant assessment:
- Hyperalert/ hyperarousal
- Anxious and agitated
- Displays a wide range of emotions
- Patient may appear frightened (screams, cries, attempts to run or hide)
- Flashbacks
- Some reports hallucination
- Self-destructive thoughts and impulses
- Fantasies of taking revenge against abusers
- Client is oriented to reality except during flashbacks or dissociation
episode (memory gap)
- Low self-esteem
- Difficulty dealing with others
- Disturbance in sleep patterns

Priority nursing diagnoses:

- Risk for self-mutilation
- Risk for suicide
- Ineffective coping
- Chronic low self-esteem
- Powerlessness
- Disturbed sleep pattern
- Spiritual distress
- Social isolation

Interventions:
- Promoting client’s safety: CLOSE MONITORING!
o Initiate SUICIDE PRECAUTION
o Discuss self-harm thoughts
- Help client cope up with stress and emotions
o Use grounding techniques to help the client who is dissociating or
having flashbacks
 o Validate client’s feelings
o Dissociation: client may assume a body position – do not attempt to
grab or reposition him/her
o Use supportive touch
o Reach deep breathing and relaxation techniques
o Use distraction techniques (physical exercise, listening to music,
writing journals)

Teacher’s Insight:
Traumatic events may be horrific. Nurses must remain nonjudgmental of the
client. They must facilitate effective coping skills to help the client regain
control and independence

Chapter Assessment
Critical thinking:
1. Have you experienced a traumatic situation/event in your life that
caused drastic change on how you deal with daily dealings?

1. Judy is assigned in the emergency department with a woman who was raped 1 hour ago. In
planning care, it is important for Judy to remember which of the following?
A. Angry feelings need to be set aside until physical care is completed.
B. Evidence collection according to procedures is the priority.
C. The nurse will need to make decisions for this client.
D. The woman may feel threatened by some of the procedures.
2. . Nurse Lila is assessing an elderly female in the emergency department. There are many
bruises present on her body in varying stages of healing. After documenting the bruising in the
assessment, what should Lila do next?
A. Ask the client when and how the bruises occurred
B. Call the nursing supervisor immediately
C. Follow the facility's policy and procedures for reporting abuse
D. Notify the physician that abuse is suspected
3. A coherent elderly woman has been financially and emotionally abused by her adult children
for the past several years, but has failed to report the abuse to anyone. The most likely reason
for neglecting to report the abuse includes which of the following?
A. She cannot claim abuse if there is no evidence of physical harm
B. Laws do not provide protection against abuse when the suspect(s) is/are family
members
C. She has no financial resources to hire legal representation against her children
D. She is emotionally close to her children and does not want to bring them harm
4. Lila is collecting assessment data on a patient who is suspected to be a victim of violence. She
would note which assessment data to support the suspicion that the patient is a victim of
abuse? (Select all that apply)
1. Has few friends
2. Holds a dominant role in the family
3. Is in charge of the family finances
4. Moderate amount of alcohol use in the home
5. Reports father was abusive during childhood
A. 1, 3, 4 C. 1, 3
B. 1, 4, 5 D. 2, 5
5. Lila is caring for a 16-year-old boy with a history of sexual abuse. Lila might expect this
adolescent to:
A. Experience nightmares and flashbacks
B. Have no ill effects due to his age
 C. Reject his mother for not protecting him
D. Want to confront the perpetrator
6. Which of the following behaviors would first alert Nurse Lila or teacher to suspect sexual abuse
in a 7-year-old child?
A. Extreme friendliness to peers
B. Learning problems and shyness
C. Telling sexually explicit stories to peers
D. Withdrawn behavior and enuresis
7. A frightened young woman calls the emergency department and tearfully tells Nurse Rhoda,
“I've been raped! Please help me!” Before telling the client what to do, Rhoda would need to
know if:
A. If the client was injured, was in a safe place, and had transportation available
B. If the client knew her assailant, knew her location, and had notified the police
C. If she has insurance, if she could get to the hospital by herself, and if pregnancy is a
possibility
D. If she had bathed, douched, or changed clothes
8. The pediatric nurse is caring for a 15-month-old child recently admitted to the hospital for a
fractured femur. Which of the following data obtained during the assessment would raise the
nurse’s suspicion that the child has suffered physical abuse?
A. The parents appearing overprotective of the child
B. Bruises over the child’s boney prominences
C. The injury occurring several days before the parents sought treatment
D. Both parents reporting the exact same details pertaining to the injurious event

CHAPTER VIII
ANXIETY AND ANXIETY DISORDERS
OBSESSIVE-COMPLUSIVE DISORDER

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Describe anxiety as a response to stress
 Describe the levels of anxiety with behavioural changes related to
each level
 Discuss the use of defense mechanisms by people with anxiety
disorders
 Evaluate the effectiveness of treatment including medications for
clients with anxiety disorders
 Apply the nursing process to the care of clients with anxiety
disorders
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment
Let’s Begin!

KEY TERMS
 Anxiety
 Agoraphobia
 Compulsion
 Mild anxiety
 Moderate anxiety
 Severe anxiety
 Panic anxiety
 Primary gain
 Secondary gain
 Systematic desensitization
 Positive reframing

Anxiety
- Vague feeling of dread or
apprehension
- Response to internal and external
stimuli with behavioral, emotional,
cognitive and physical symptoms
- Unavoidable and is considered
normal when it is appropriate to
the situation

Fear
- Feeling afraid or threatened by a clearly IDENTIFIABLE external stimulus
- A basic emotion, involving the activation of the “fight-or-flight” response
of our autonomic nervous system. Almost instantaneous to any imminent
threat.
- When the fear response triggers when there is no obvious external
danger, a spontaneous or uncued panic attack occurs.
- Panic attack accompanied by a subjective sense of impending doom.

Anxiety Disorders
- Group of conditions that share a key feature of excessive anxiety
- Patients demonstrate unusual behaviors such as panic without any
apparent reason
- Patients experience significant distress over time and impairs their daily
routines

FEAR and ANXIETY RESPONSE PATTERNS

FEAR
- an alarm reaction that occurs in response to immediate danger
 Three components:
o Cognitive-subjective
 “I feel afraid” ; “ Im terrified”
o Physiological
  Increased heart rate, heavy breathing, heightened
amount of sweating, and shaking/rattling of hands.
o Behavioral
 A strong urge to flee, run away or hide

ANXIETY
- general feeling of apprehension about possible future danger
- A complex blend of unpleasant emotions and cognitions; focusing on the
future and more detached than fear.
- Adaptive value: plan and prepare for possible threats or events.
- Mild to moderate cases: enhances learning and performance.
- Chronic or severe: maladaptive.

 Three components:
o Cognitive-subjective
 Negative mood, worrying about the future, and a sense
of being unable to control or predict future threats.
o Physiological
 Creates a state of tension, and chronic overarousal.
 Aids in readiness for danger should it occur.
 Primes a person for the fight-or-flight response.
o Behavioral
 Strong tendency to avoid events or situations where
danger may be encountered.
 No immediate urge to flee as with fear.

Most common way of distinguishing between fear and anxiety response

patterns, all lies on whether there is a clear or obvious source of danger

ANXIETY AS A
RESPONSE TO
STRESS

Stress: wear and

tear that life causes
on the body; occurs
when a person is
unable to deal with
life’s situations

Hans Selye –
identified the
physiological aspects
of stress

Three Stages:
1. ALARM REACTION STAGE
o Stress stimulates the body to send messages from the hypothalamus
to the effector organs to prepare for potential defense
2. RESISTANCE STAGE
o Fight or fligh response
 o Rest-digest response
3. EXHAUSTION STAGE
o Occurs when the person has responded negatively to anxiety and
stress

 Physiologic response
- Anxiety causes uncomfortable cognitive, psychomotor, and physiologic
responses such as difficulty with logical thought, increasingly agitated
motor activity, and elevated vital signs.
- To reduce these uncomfortable feelings, the person tries to reduce the
level of discomfort by implementing new adaptive behaviors or defense
mechanisms
- Adaptive behaviors such as guided imagery, relaxation techniques can
help control anxiety

 LEVELS OF ANXIETY

LEVELS SIGNS AND NURSING

SYMPTOMS INTERVENTIONS
MILD Irritability  Encourage
- a sensation that I’m awake, alert, alive verbalization of
something is Increased motivation feelings (EVOF)
different and and learning ability  Does not require
warrants special direct intervention
attention. POWER OF  Teaching can be
PERCEPTION effective

“Mild anxiety is good

anxiety”
MODERATE Selective inattention  EVOF
- is the disturbing Purposeless pacing  Ensure that the
 feeling that Vital signs changes patient follows what
something is the nurse is saying
definitely wrong; NARROWED  Give short, simple
the person PERCEPTION and easy to
becomes nervous understand sentences
or agitated  Redirect the client to
the topic
 Relaxation techniques
 Give PRN medications
SEVERE Don’t know what to do  Goal: lower the
- primitive and Don’t know what to say anxiety level
survival skills take Ritualistic behavior  PRN meds
place Cannot complete tasks  Use kind, simple
cries directions
Chest pain, N&V,  Use time-out
diarrhea, (seclusion)
Feels awe, dread,  Remain with the
horror person
 Talk to client in low,
LIMITED PERCEPTION calm and soothing
voice
 Walking with him may
be effective if the
patient cannot sit still
 Relaxation techniques

PANIC Duration: 5-30 mins  IM medications

Doesn’t recognize (anxiolytics)
potential danger  Physical restraint
Delusion/ hallucination  PRIORITY: SAFETY
May bolt or run
Immobile/mute
Suicidal

DISTORTED
PERCEPTION

GENERAL INTERVENTIONS TO MANAGE ANXIOUS BEHAVIOR

 Remain with the client at all times when levels of anxiety are high
 Move the client to a quiet area with minimal or decreased stimuli such
as small room or seclusion area
 PRN medications may be given to high levels of anxiety
 Remain calm when you approach the client
 Use short, simple and clear statements
 Avoid asking or forcing the client to make choices
 Maintain self-awareness
 Encourage participation in relaxation exercises

ANXIETY DISORDERS and ANXIETY RELATED DISORDERS

 Agoraphobia
 Panic Disorder
 Specific Phobia
  Social Anxiety Disorder
 Generalized Anxiety Disorder
 Selective mutism
 Substance/medication-induced anxiety disorder
 Separation anxiety disorder

Etiology:

Biological Causal Factors:

- The Limbic System
- Neurotransmitters: GABA (major inhibitory neurotransmitter),
Norepinephrine, and Serotonin (dysfunctional)
- Heritability: proportion of a disorder that can be attributed to genetic
factors

Psychological Causal Factors:

- Conditioning of fear, panic, or anxiety.
- People who have perceptions of lack of control of themselves or their
environment seem more vulnerable to developing anxiety disorders.
- Freud believed that innate anxiety is the main stimulus

Social Causal Factors:

- Environment raised in
- Parenting Styles

AGORAPHOBIA
- “fear of the marketplace”
- Fear that some patients have of being in open spaces like shops and
markets
- Fear of being separated from a source of security; fear where escape may
be difficult
- DSM-5 Criteria

- onset of symptoms most commonly occurs in the 20s and 30s

- Diagnosed more commonly in women than in men

- Demonstrates primary and secondary gains
- Primary gain: relief of anxiety achieved by performing the specific
anxiety-driven behavior (staying in the house)
- Secondary gain: attention received from others as a result of these
behaviors

Social Anxiety Disorder (Social Phobia)

- is an excessive fear of
situations in which a
person might do
something
embarrassing or be
evaluated negatively by
others.
- The individual has
extreme concerns about
being exposed to
possible scrutiny by
others and fears social
or performance
situations in which embarrassment may occur.
- In some instances, the fear may be quite defined, such as the fear of
speaking or eating in a public place, fear of using a public restroom, or
fear of writing in the presence of others.
- In other cases, the social phobia may involve general social situations,
such as saying things or answering questions in a manner that would
provoke laughter on the part of others.
- Exposure to the phobic situation usually results in feelings of panic
anxiety, with sweating, tachycardia, and dyspnea.
- Onset of symptoms of this disorder often begins in late childhood or early
adolescence and runs a chronic, sometimes lifelong, course.
- It appears to be more common in women than in men (Puri & Treasaden,
2011). Impairment interferes with social or occupational functioning, or
causes marked distress.

SPECIFIC PHOBIA
- is identified by fear of specific objects or situations that could conceivably
cause harm (e.g., snakes, heights),
but the person’s reaction to them is
excessive, unreasonable, and
inappropriate
- The phobic person may be no more
(or less) anxious than anyone else
until exposed to the phobic object
or situation. Exposure to the phobic
stimulus produces overwhelming
symptoms of panic, including
palpitations, sweating, dizziness,
and difficulty breathing
- Phobias may begin at almost any
age. Those that begin in childhood
often disappear without treatment,
but those that begin or persist into
adulthood usually require
assistance with therapy.
- The disorder is diagnosed more often in women than in men

List of

Phobias
Achluophobia Fear of darkness
Acrophobia Fear of heights
Aerophobia Fear of flying
Algophobia Fear of pain
Alektorophobia Fear of chickens
Agoraphobia Fear of public spaces or crowds
Aichmophobia Fear of needles or pointed objects
Amaxophobia Fear of riding in a car
Androphobia Fear of men
Anginophobia Fear of angina or choking
Anthophobia Fear of flowers
Anthropophobia Fear of people or society
Aphenphosmphobia Fear of being touched
Arachnophobia Fear of spiders
Arithmophobia Fear of numbers
Astraphobia Fear of thunder and lightning
Ataxophobia Fear of disorder or untidiness
Atelophobia Fear of imperfection
Atychiphobia Fear of failure
Autophobia Fear of being alone
B
Bacteriophobia Fear of bacteria
Barophobia Fear of gravity
Bathmophobia Fear of stairs or steep slopes
Batrachophobia Fear of amphibians
Belonephobia Fear of pins and needles
Bibliophobia Fear of books
Botanophobia Fear of plants
C
Cacophobia Fear of ugliness
Catagelophobia Fear of being ridiculed
Catoptrophobia Fear of mirrors
Chionophobia Fear of snow
Chromophobia Fear of colors
Chronomentrophobia Fear of clocks
Claustrophobia Fear of confined spaces
Coulrophobia Fear of clowns
Cyberphobia Fear of computers
Cynophobia Fear of dogs
D
Dendrophobia Fear of trees
Dentophobia Fear of dentists
Domatophobia Fear of houses
Dystychiphobia Fear of accidents
E
Ecophobia Fear of the home
Elurophobia Fear of cats
Entomophobia Fear of insects
Ephebiphobia Fear of teenagers
Equinophobia Fear of horses
F, G
Gamophobia Fear of marriage
Genuphobia Fear of knees
Glossophobia Fear of speaking in public
Gynophobia Fear of women
H
Heliophobia Fear of the sun
Hemophobia Fear of blood
Herpetophobia Fear of reptiles
Hydrophobia Fear of water
Hypochondria Fear of illness
I-K
Iatrophobia Fear of doctors
Insectophobia Fear of insects
Koinoniphobia Fear of rooms full of people
L
Leukophobia Fear of the color white
Lilapsophobia Fear of tornadoes and hurricanes
Lockiophobia Fear of childbirth
M
Mageirocophobia Fear of cooking
Megalophobia Fear of large things
Melanophobia Fear of the color black
Microphobia Fear of small things
Mysophobia Fear of dirt and germs
N
Necrophobia Fear of death or dead things
Noctiphobia Fear of the night
Nosocomephobia Fear of hospitals
Nyctophobia Fear of the dark
O
Obesophobia Fear of gaining weight
Octophobia Fear of the figure 8
Ombrophobia Fear of rain
Ophidiophobia Fear of snakes
Ornithophobia Fear of birds
P
Papyrophobia Fear of paper
Pathophobia Fear of disease
Pedophobia Fear of children
Philophobia Fear of love
Phobophobia Fear of phobias
Podophobia Fear of feet
Pogonophobia Fear of beards
Porphyrophobia Fear of the color purple
Pteridophobia Fear of ferns
Pteromerhanophobia Fear of flying
Pyrophobia Fear of fire
Q-S
Samhainophobia Fear of Halloween
Scolionophobia Fear of school
Selenophobia Fear of the moon
Sociophobia Fear of social evaluation
Somniphobia Fear of sleep
T
Tachophobia Fear of speed
Technophobia Fear of technology
Tonitrophobia Fear of thunder
Trypanophobia Fear of needles or injections
U-Z
Venustraphobia Fear of beautiful women
Verminophobia Fear of germs
Wiccaphobia Fear of witches and witchcraft
Xenophobia Fear of strangers or foreigners
Zoophobia Fear of animals

Etiology:
- Developed when a child experiences normal incestuous feelings toward the
opposite-gender parent and fears aggression from the same-gender parent
- To protect themselves, these children repress this fear of hostility from the
same-gender parent, and displace it onto something safer and more neutral,
which becomes the phobic stimulus.
- The phobic stimulus becomes the symbol for the parent, but the child does
not realize this.
- Classic conditioning in the case of phobias may be explained as follows:
o a stressful stimulus produces an “unconditioned” response of fear.
o When the stressful stimulus is repeatedly paired with a harmless
object, eventually the harmless object alone produces a “conditioned”
response: fear. This becomes a phobia when the individual consciously
avoids the harmless object to escape fear
- Cognitive theorists espouse that anxiety is the product of faulty cognitions or
anxiety-inducing self-instructions. Two types of faulty thinking have been
investigated: negative self-statements and irrational beliefs.
o Cognitive theorists believe that some individuals engage in negative
and irrational thinking that produces anxiety reactions. The individual
begins to seek out avoidance behaviors to prevent the anxiety
reactions, and phobias result
- Temperament Children experience fears as a part of normal development.
Most infants are afraid of loud noises. Common fears of toddlers and
preschoolers include strangers, animals, darkness, and fears of being
separated from parents or attachment figures
- Certain early experiences may set the stage for phobic reactions later in life.
Some researchers believe that phobias, particularly specific phobias, are
symbolic of original anxiety-producing objects or situations that have been
repressed.
- Examples include:
o A child who is punished by being locked in a closet develops a phobia
for elevators or other closed places.
o A child who falls down a flight of stairs develops a phobia for high
places.
o A young woman who, as a child, survived a plane crash in which both
her parents were killed has a phobia of airplanes

Generalized Anxiety Disorder

- is characterized by persistent, unrealistic, and excessive anxiety and worry,
which have occurred more days than not for at least 6 months, and cannot
be attributed to specific organic factors, such as caffeine intoxication or
hyperthyroidism
- symptoms cause clinically significant distress or impairment in social,
occupational or other areas of functioning
-

- The patient avoids activities or events that may result in negative outcomes
- May begin in childhood or adolescence
- Depressive symptoms are common with numerous somatic complaints
- Chronic in nature with exacerbations and fluctuations that are usually
associated with stress
Etiology:
- Psychodynamic theory: inability of the ego to intervene when conflict occurs
between the id and superego
- Unsatisfactory parent-child relationship
- Overuse of ineffective defense mechanisms
- Cognitive theory: faulty, distorted or counterproductive thinking patterns
accompany or precede maladaptive behaviors and emotional disorders
- Genetics
- Neurobiological alterations (limbic system and diencephalon)
- Abnormal elevations of blood lactate
- Neurotransmitter imbalances (norepinephrine)

SELECTIVE MUTISM
- Diagnosed in children when they fail to speak in social situations even
though they are able to speak
- Lack of speech interferes with social communication

SUBSTANCE/MEDICATION-INDUCED ANXIETY DISORDER

- Anxiety directly caused by drug abuse, medication or exposure to toxin
- s/sx: prominent anxiety, panic attacks, phobias, obsessions or compulsions

SEPARATION ANXIETY DISORDER

- Excessive anxiety concerning separation from home or from persons,
parents or caregivers whom the client is attached.
- Occurs before 18 years of age

Reading assignment: Hamilton Anxiety Rating Scale

OBSESSIVE-COMPULSIVE DISORDER
- The manifestations of obsessive-
compulsive disorder (OCD)
include the presence of
obsessions, compulsions, or
both, the severity of which is
significant enough to cause
distress or impairment in social,
occupational, or other important
areas of functioning (APA, 2013).
- The individual recognizes that
the behavior is excessive or
unreasonable but, because of the
feeling of relief from discomfort
that it promotes, is compelled to
continue the act. Common
compulsions include hand
washing, ordering, checking,
praying, counting, and repeating
words silently

- Obsessions: recurrent,

that cause marked anxiety

- Compulsions: ritualistic or repetitive behaviors or mental acts that a person
carries out in an attempt to neutralize anxiety
 o Checking rituals (making sure the door is locked)
o Counting rituals
o Washing and scrubbing
o Praying/chanting
- OCD is diagnosed when these thoughts when it compels the person to act
these behaviors
- Can start in childhood, especially in males; commonly begins in the 20s
- Related disorders:
o Excoriation disorder: skin-picking (dermatillomania), self-soothing
behavior in an attempt to comfort themselves
 The behavior can cause significant distress to the individual and
may also lead to medical complications and loss of occupational
functioning
 Alternative therapies: yoga, acupuncture and biofeedback

o Trichotillomania: chronic repetitive hair-pulling, self soothing behavior

that can cause impairment
 Occurs mainly in females
 Treatment: behavioral therapy
o Body dysmorphic Disorder
 Preoccupation with an imagined or slight defect in physical
appearance
 Patient worries about the defect, often blames all of life’s
problems
 Submits self to elective cosmetic surgery to fix the defect
 Treatment: SSRI

o Hoarding disorder: progressive, debilitating, compulsive disorder

recently diagnosed on its own
 Diagnosis: between 20s and 30s
 Involves excessive acquisition of animals, apparently useless
things
 Treatment: CBT, self-help groups
o Onychophagia: chronic nail-biting
  Onset: childhood
 Treatment: SSRI
o Kleptomania: compulsive stealing, reward seeking behavior
 Reward is not the stolen item but the thrill of stealing and not
getting caught
 More common in females with concurrent diagnosis of
depression and substance abuse
o Oniomania: compulsive buying
 Pleasure is acquiring the purchased object rather than actually
using it
 Spending behavior is often out of control, beyond financial
means

 TREATMENT/INTERVENTIONS TO PATIENTS WITH ANXIETY

DISORDERS

- Individual psychotherapy
o Anxiety is lessened when clients are given the opportunity to discuss
their difficulties with a concerned therapist
o Insight-oriented psychotherapy: focuses on helping patients
understand the hypothesized unconscious meaning of the anxiety
o The therapist can use logical and rational explanations to increase the
client’s understanding about various situations that create anxiety
- Cognitive Therapy
o Relates how individuals respond in stressful situations to their
subjective cognitive appraisal of the event
o Automatic negative appraisals provoke self-doubts, negative
evaluations and negative predictions
o Therapists assist the individual to reduce anxiety by altering cognitive
distortions
(anxiety is the result of exaggerated, automatic thinking)
o CT is brief and time limited (5-20 minutes), structured and orderly, to
encourage self-sufficiency
o Establish a therapeutic relationship with the patient
o Encourage patient to face frightening situations to be able to view
them realistically
- Behavior Therapy
o Behavior modification
o Systematic desensitization (Joseph Wolpe, 1958)
 Client is gradually exposed to the phobic stimulus, either in a
real or imagined situation
o Implosion Therapy (Flooding)
 Therapeutic process in which the client must imagine situations
or participate in real-life situations that he or she finds extremely
frightening for a prolonged period of time
 Relaxation technique is not a part of this technique
 Allow plenty of time for each session
o Positive Reframing
 Turning negative messages into positive messages
o Decatastrophizing
 Therapists use questions to more realistically appraise the
situation
  Client uses thought stopping and distraction techniques
o Assertiveness training
 Helps the person take more control over life’s situations
 Helps the person negotiate interpersonal situations and foster
self-assurance
- Psychopharmacology
o Antianxiety agents
 Also called anxiolytics and minor tranquilizers
 Antihistamines (Hydroxyzine)
 Benzodiazepines
 Alprazolam (Xanax)
 Chlordiazepoxide (Librium)
 Clonazepam (Klonopin)
 Clorazepate (Tranxene)
 Diazepam (Valium)
 Lorazepam (Ativan)
 Oxazepam
 Azaspirodecanedione (Buspirone)
o depress subcortical levels of the CNS, particularly the limbic system
and reticular formation.
o They may potentiate the effects of the powerful inhibitory
neurotransmitter gamma-aminobutyric acid (GABA) in the brain,
thereby producing a calmative effect.
o All levels of CNS depression can be affected, from mild sedation to
hypnosis to coma. Note: Buspirone does not depress the CNS.
Although its action is unknown, the drug is believed to produce the
desired effects through interactions with serotonin, dopamine, and
other neurotransmitter receptors.
o Contraindications: hypersensitivity to drugs
 Not to be taken in combination with other CNS depressants
 Pregnancy and lactating; narrow-angle glaucoma, shock and
coma
o Drug interactions:
 Increased effects when taken concomitantly with alcohol,
barbiturates, narcotics, neuroleptics, antidepressants and
neuromuscular blocking agents
 Increased effect when taken with herbal depressants (Kava,
valerian)
 Decreased effect with smoking and caffeine consumption

CHAPTER QUIZ

Test 1. MCQ. Choose the best answer among the given choices. Justify your
answer by giving a brief rationale.s

1. Ms. T. has been diagnosed with agoraphobia. Which behavior would be most
characteristic of this disorder?
a. Ms. T. experiences panic anxiety when she encounters snakes.
b. Ms. T. refuses to fly in an airplane.
c. Ms. T. will not eat in a public place.
d. Ms. T. stays in her home for fear of being in a place from which she cannot
escape.
2. Which of the following is the most appropriate therapy for a client with
agoraphobia?
a. 10 mg Valium qid
b. Group therapy with other agoraphobics
c. Facing her fear in gradual step progression
d. Hypnosis

3. With implosion therapy, a client with phobic anxiety would be:

a. Taught relaxation exercises
b. Subjected to graded intensities of the fear
c. Instructed to stop the therapeutic session as soon as anxiety is experienced
d. Presented with massive exposure to a variety of stimuli associated with the
phobic object/situation

4. A client with OCD spends many hours each day washing her hands. The most
likely reason she washes her hands so much is that it:
a. Relieves her anxiety
b. Reduces the probability of infection
c. Gives her a feeling of control over her life
d. Increases her self-concept

5. The initial care plan for a client with OCD who washes her hands obsessively
would include which of the following nursing interventions?
a. Keep the client’s bathroom locked so she cannot wash her hands all the time.
b. Structure the client’s schedule so that she has plenty of time for washing her
hands.
c. Place the client in isolation until she promises to stop washing her hands so
much.
d. Explain the client’s behavior to her, since she is probably unaware that it is
maladaptive.

6. A client with OCD says to the nurse, “I’ve been here 4 days now, and I’m
feeling better. I feel comfortable on this unit, and I’m not ill-at-ease with the staff
or other patients anymore.” In light of this change, which nursing intervention is
most appropriate?
a. Give attention to the ritualistic behaviors each time they occur and point out
their inappropriateness.
b. Ignore the ritualistic behaviors, and they will be eliminated for lack of
reinforcement.
c. Set limits on the amount of time Sandy may engage in the ritualistic behavior.
d. Continue to allow Sandy all the time she wants to carry out the ritualistic
behavior.
7.A client who is experiencing a panic attack has just arrived at the emergency
department. Which is the priority nursing intervention for this client?
a. Stay with the client and reassure of safety.
b. Administer a dose of diazepam.
c. Leave the client alone in a quiet room so that she can calm down.
d. Encourage the client to talk about what triggered the attack.

[Link] has a diagnosis of generalized anxiety disorder. Her physician has

prescribed buspirone15 mg daily. Janet says to the nurse, “Why do I have to take
this every day? My friend’s doctor ordered Xanax for her, and she only takes it
when she is feeling anxious.” Which of the following would be an appropriate
response by the nurse?
a. “Xanax is not effective for generalized anxiety disorder.”
b. “Buspirone must be taken daily in order to be effective.”
c. “I will ask the doctor if he will change your dose of buspirone to prn so that
you don’t have to take it every day.”
d. “Your friend really should be taking the Xanax every day.”

Test II. Test your critical thinking skills

Sarah, age 25, was taken to the emergency department by her friends. They were
at a dinner party when Sarah suddenly clasped her chest and started having
difficulty breathing. She complained of nausea and was perspiring profusely. She
had calmed down some by the time they reached the hospital. She denied any
pain, and electrocardiogram and laboratory results were unremarkable.

Sarah told the admitting nurse that she had a history of these “attacks.” She began
having them in her sophomore year of college. She knew her parents had
expectations that she should follow in their footsteps and become an attorney.
They also expected her to earn grades that would promote acceptance by a top Ivy
League university. Sarah experienced her first attack when she made a “B” in
English during her third semester of college. Since that time, she has experienced
these symptoms sporadically, often in conjunction with her perception of the need
to excel. She graduated with top honors from UST. Last week Sarah was promoted
within her law firm. She was assigned her first solo case of representing a couple
whose baby had died at birth and who were suing the physician for malpractice.
She has experienced these panic symptoms daily for the past week, stating, “I feel
like I’m going crazy!” Sarah is transferred to the psychiatric unit. The psychiatrist
diagnoses panic disorder.

Answer the following questions related to Sarah:

1. What would be the priority nursing diagnosis for Sarah?
2. What is the priority nursing intervention with Sarah?
3. What medical treatment might you expect the physician to prescribe?

CHAPTER IX
SCHIZOPHRENIA SPECTRUM and OTHER PSYCHOTIC DISORDERS

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Describe the positive and negative symptoms of schizophrenia
 Evaluate effectiveness of antipsychotic in treating schizophrenia
 Apply the nursing process to the care of patients with
schizophrenia
 Familiarize and utilize the therapeutic modalities of schizophrenia
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Alogia
 Anhedonia
 Hallucinations
 Delusions
 Psychosis
 Positive symptoms
 Negative symptoms

SCHIZOPHRENIA

- The term schizophrenia was coined in 1908 by Swiss psychiatrist Eugene

Nleuler (“schizo”-split; “phren” – mind)
- Causes: genetic predisposition, biological dysfunction, physiological factors,
psychosocial stress
- Treatment is multidisciplinary; pharmacology, psychosocial care, social skills
training, rehabilitation, family therapy

Assignment! Please read the chapter and answer the following questions:
1. An alteration in which of the neurotransmitters is most closely associated
with the symptoms of schizophrenia?
2. What is schizoaffective disorder?
3. How do delusions differ from hallucinations?
 4. What was the first atypical antipsychotic to be developed? Why is this drug
not considered a first-line treatment for schizophrenia?
- schizophrenia probably is responsible for lengthier hospitalizations, greater
chaos in family life, more exorbitant costs to individuals and governments, and
more fears than any other
- potential for suicide is a major concern
- Prevalence: 1% in the general population
- Symptoms appear in late adolescence or early adulthood
- Phases of schizo: premorbid, prodromal, active, residual phase

Phase I: Premorbid Phase

- Often indicates social maladjustment, social withdrawal, irritability and
antagonistic thoughts and behavior
- Premorbid personality: very shy and withdrawn, poor relationships, doing
poorly in school, antisocial behavior, quiet, passive and introverted

Phase II: Prodromal Phase

- Certain signs and symptoms that precede the characteristics manifestations
fully developed
Average length: between 2-5 years
- Patient experiences substantial functional impairment and nonspecific
symptoms s/a:
o Sleep disturbance
o Fatigue
o Depressed mood
o Poor concentration
o Deterioration in role functioning
o Positive symptoms: perceptual abnormalities, ideas of reference,
suspiciousness, psychosis

Phase III: Schizophrenia

- Psychotic symptoms are prominent
- DSM-5 Criteria
o A. Two (or more) of the following, each present for a significant portion of
time during a 1-month period (or less if successfully treated). At least one
of these must be (1), (2), or (3):
 1. Delusions
 2. Hallucinations
 3. Disorganized speech (e.g., frequent derailment or incoherence)
 4. Grossly disorganized or catatonic behavior
 5. Negative symptoms (i.e., diminished emotional expression or
avolition)
o B. For a significant portion of the time since the onset of the disturbance,
level of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level achieved
prior to the onset (or when the onset is in childhood or adolescence, there
is failure to achieve expected level of interpersonal, academic, or
occupational functioning).
o C. Continuous signs of the disturbance persist for at least 6 months. This
6-month period must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e., active-phase symptoms)
and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be
manifested by only negative symptoms or by two or more symptoms
 listed in Criterion A present in an attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
o D. Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either (1) no major
depressive or manic episodes have occurred concurrently with the active
phase symptoms; or (2) if mood episodes have occurred during active-
phase symptoms, they have been present for a minority of the total
duration of the active and residual periods of the illness.
o E. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition.
o F. If there is a history of autism spectrum disorder or a communication
disorder of childhood onset, the additional diagnosis of schizophrenia is
made only if prominent delusions or hallucinations, in addition to the
other required symptoms of schizophrenia, are also present for at least 1
month (or less if successfully treated).
Specify if: First episode, currently in acute, partial, or full remission;
Multiple episodes, currently in acute, partial or full remission; Continuous;
Unspecified.
Specify if: With catatonia
- Diagnostic Criteria for Catatonia Specifier
o The clinical picture is dominated by three (or more) of the following
symptoms:
 1. Stupor (i.e., no psychomotor activity; not actively related to
environment)
 2. Catalepsy (i.e., passive induction of a posture held against
gravity)
 3. Waxy flexibility (i.e., slight, even resistance to positioning by
examiner)
 4. Mutism (i.e., no, or very little, verbal response [exclude if
known aphasia])
 5. Negativism (i.e., opposition or no response to instructions or
external stimuli)
 6. Posturing (i.e., spontaneous and active maintenance of a
posture against gravity)
 7. Mannerism (i.e., odd, circumstantial caricature of normal
actions)
 8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-
directed movements)
 9. Agitation, not influenced by external stimuli
 10. Grimacing
 11. Echolalia (i.e., mimicking another’s speech)
 12. Echopraxia (i.e., mimicking another’s movements

Specify current severity

Phase IV: Residual Phase

- With remissions and exacerbations
- Residual phase follows an active phase of illness
- Symptoms of acute stage are absent or no longer prominent but negative
symptoms may remain
- Prognosis is difficult to predict
- Return to complete premorbid functioning is not common
- Predisposing factors:
o Biological: genetics
o Biochemical: disturbance/imbalance in the neurotransmitters
 Dopamine hypothesis: excess of dopamine-dependent neuronal
activity in the brain
o Physiological factors
 Viral infection
 Anatomical abnormalities (ventricular enlargement)
- Psychological factors
o Faulty family relationship

Types of Schizophrenia and Other Psychotic Disorders

- Delusional disorder
o Presence of delusions for at least 1 month
o If present at all, hallucinations are not prominent and behavior is not
bizarre
o DSM-5: a specifier may be added to denote if the delusions are
considered bizarre (thought is clearly implausible, not understandable
and not derived from ordinary life experiences)
o Subtypes:
 Erotomatic type
 the individual believes that someone, usually of a higher status, is in
love with him or her
 famous persons are often the subject of delusions
 Grandiose Type
 Patients have irrational ideas regarding their own worth, talent,
knowledge or power
 Jealous Type
 Content centers on the idea that the person’s sexual partner is
unfaithful
 The patient searches for evidences to justify the delusion
 Persecutory type
 Most common type
 Individual believe that they are being persecuted or malevolently
treated in some way
 Somatic Type
 Individuals with somatic delusions believe they have some type of
general medical condition
 Mixed Type
 When the disorder is mixed, delusions are prominent, but no single
theme is predominant

- Brief Psychotic Disorder

o identified by the sudden onset of psychotic symptoms that may or may
not be preceded by a severe psychosocial stressor
 o symptoms last at least 1 day but less than 1 month; eventual full
return to the premorbid level of functioning
o positive emotional turmoil and overwhelming confusion
o impaired reality testing
 incoherent speech
 delusions
 hallucinations
 bizarre behavior
 disorientation

- Substance/Medication-induced Psychotic Disorder

o Hallucinations and delusions occur along with substance intoxication or
withdrawal
o Diagnosis is made when symptoms are more excessive and more
severe than those usually associated with intoxication or withdrawal

- Schizophreniform Disorder
o Identical to those of schizophrenia with the exception that the duration,
including prodromal, active and residual phase is at least 1 month but
less than 6 months
o Has good prognosis if the affect is not blunted or flat
o Catatonic features may be associated

- Schizoaffective Disorder
o Manifested by schizophrenic behavior with a strong element of
symptomatology associated with the mood disorders
o Client may appear depressed with psychomotor retardation, suicidal
ideation or euphoria, grandiosity and hyperactivity
o Hallucinations and/or delusions occur for at least 2 weeks in the
absence of a major mood episode

Assessment of Schizophrenia
- Positive symptoms
o Delusions: fixed, false beliefs
 Delusion of persecution
 Delusion of grandeur
 Delusion of reference
 Delusion of control or influence
 Somatic delusion
 Nihilistic delusion
o Religiosity: excessive demonstration of or obsession with religious
ideas and behavior
o Paranoia: extreme suspiciousness
o Magical thinking: believes his thoughts or behaviors have control over
a specific situation or people
o Associative looseness
o Neologisms
o Concrete thinking
o Clang association
 o Word salad
o Circumstantiality
o Tangentiality
o Mutism
o Perseveration
o Hallucination: false sensory perceptions not associated with real
external stimuli
 Auditory
 Visual
 Tactile
 Gustatory
 Olfactory
o Illusions: misinterpretations of real external stimuli
o Echolalia, echopraxia, identification and imitation
o Depersonalization

- Negative symptoms:
o Inappropriate affect
o Bland or flat affect
o Apathy
o Avolition
o Ambivalence
o Deteriorated appearance
o Anergia
o Waxy flexibility
o Posturing
o Pacing and rocking
o Anhedonia
o Regression

 Nursing interventions/ management of patients with

schizophrenia
- Observe client for signs and symptoms of hallucinations “Are you hearing
voices?”
o Do not reinforce the hallucination. Use “the voices” instead of words
like “they” that imply validation. Let the client know that you do not
share the perception. Say, “Even though I realize that the voices are
real to you, I do not hear any voices speaking.” It is important for the
nurse to be honest, and the client must accept the perception as
unreal before hallucinations can be eliminated.
- Avoid touching the client before warning him or her that you are about to do
so
- Convey an attitude of acceptance
- Help the client to understand the connection between increased anxiety and
the presence of hallucinations
- Distract the client from the hallucination; involvement in interpersonal
activities will help
- For delusions, do not argue or deny the belief; use reasonable doubt as a
therapeutic technique “I understand that you believe this is true, but I find it
hard to accept”
- Suspicious clients:
o Promote trust; use the same staff as much as possible; be honest
o Avoid physical contact
o Warn the client before touching
o Avoid laughing or whispering or talking quietly where the client can see
but cannot hear what is being said
o Provide individually packaged or canned food
o Mouth check is necessary when giving medications
o Encourage one-to-one activities; competitive activities are very
threatening
o Maintain assertive, matter-of-fact, yet genuine approach
- Risk for self-harm or other-directed
o Maintain low level of stimuli in client’s environment
o Observe client’s behavior frequently
o Remove all dangerous objects
o Maintain a calm attitude toward the client
o Have sufficient staff available to indicate a show of strength
o If client is not calmed by talking down, use mechanical restraints
(should be used only as a last resort)
o Restraint: observe client at least every 15 minutes to ensure circulation
to extremities is not compromised; assist with hydration and nutrition
- Communication
o Maintain consistency
o Attempt to decode incomprehensible communication patterns. Seek
validation
o Orient the client to reality as required. Call the client by name
o Avoid abstracts and clichés
o Speak plainly and clearly in words
- Family therapy
o Discuss nature of the illness
o Management of illness
  Medication management
 Side effects of meds
 Relaxation techniques
 Social skills training
 Daily living skills training
- Individual psychotherapy
o Reality-oriented
o Focus: must reflect efforts to decrease anxiety and increase trust
 Explore the client’s behavior within relationships
 Help the client identify sources of real or perceived danger or
ways of reacting appropriately
- Group therapy
o Usually OPD
- Behavior therapy
- Social skills training
- Milieu therapy
- Psychopharmacology

CHAPTER ASSESSMENT

1. Tony, age 21, has been diagnosed with schizophrenia. He has been socially
isolated and hearing voices telling him to kill his parents. He has been
admitted to the psychiatric unit from the emergency department. The initial
nursing intervention for Tony is to:
a. Give him an injection of Thorazine.
b. Ensure a safe environment for him and others.
c. Place him in restraints.
d. Order him a nutritious diet.

2. The primary goal in working with an actively psychotic, suspicious client

would be to:
a. Promote interaction with others.
b. Decrease his anxiety and increase trust.
c. Improve his relationship with his parents.
d. Encourage participation in therapy activities.

3. The nurse is caring for a client with schizophrenia. Orders from the
physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2
mg benztropine PO bid prn. Why is chlorpromazine ordered?
a. To reduce extrapyramidal symptoms
b. To prevent neuroleptic malignant syndrome
c. To decrease psychotic symptoms
d. To induce sleep

4. The nurse is caring for a client with schizophrenia. Orders from the
physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2
mg benztropine PO bid prn. Because benztropine was ordered on a prn basis,
which of the following assessments by the nurse would convey a need for this
medication?
a. The client’s level of agitation increases.
b. The client complains of a sore throat.
c. The client’s skin has a yellowish cast.
d. The client develops tremors and a shuffling gait.

5. Clint, a client on the psychiatric unit, has been diagnosed with

schizophrenia. He begins to tell the nurse about how the CIA is looking for him
and will kill him if they find him. The most appropriate response by the nurse
is:
a. “That’s ridiculous, Clint. No one is going to hurt you.”
b. “The CIA isn’t interested in people like you, Clint.”
c. “Why do you think the CIA wants to kill you?”
d. “I know you believe that, Clint, but it’s really hard for me to believe.”

6. Clint, a client on the psychiatric unit, has been diagnosed with

schizophrenia. He begins to tell the nurse about how the CIA is looking for him
and will kill him if they find him. Clint’s belief is an example of a:
a. Delusion of persecution
b. Delusion of reference
c. Delusion of control or influence
d. Delusion of grandeur

7. The nurse is interviewing a client on the psychiatric unit. The client tilts his
head to the side, stops talking in midsentence, and listens intently. The nurse
recognizes from these signs that the client is likely experiencing:
a. Somatic delusions
b. Catatonic stupor
c. Auditory hallucinations
d. Pseudoparkinsonism

8. The nurse is interviewing a client on the psychiatric unit. The client tilts his
head to the side, stops talking in midsentence, and listens intently. The nurse
recognizes these behaviors as a symptom of the client’s illness. The most
appropriate nursing intervention for this symptom is to:
a. Ask the client to describe his physical symptoms.
b. Ask the client to describe what he is hearing.
c. Administer a dose of benztropine.
d. Call the physician for additional orders.

9. When a client suddenly becomes aggressive and violent on the unit, which
of the following approaches would be best for the nurse to use first?
a. Provide large motor activities to relieve the client’s pent-up tension.
b. Administer a dose of prn chlorpromazine to keep the client calm.
c. Call for sufficient help to control the situation safely.
d. Convey to the client that his behavior is unacceptable and will not be
permitted.

10. The primary focus of family therapy for clients with schizophrenia and
their families is:
a. To discuss concrete problem solving and adaptive behaviors for coping
with stress
b. To introduce the family to others with the same problem
c. To keep the client and family in touch with the health care system
d. To promote family interaction and increase understanding of the illness

Critical thinking
Sara, a 23-year-old single woman, has just been admitted to the psychiatric
unit by her parents. They explain that over the past few months she has
become more and more withdrawn. She stays in her room alone, but lately
has been heard talking and laughing to herself. Sara left home for the first
time at age 18 to attend college. She performed well during her first
semester, but when she returned after Christmas, she began to accuse her
roommate of stealing her possessions. She started writing to her parents that
her roommate wanted to kill her and that her roommate was turning
everyone against her. She said she feared for her life. She started missing
classes and stayed in her bed most of the time. Sometimes she locked herself
in her closet. Her parents took her home, and she was hospitalized and
diagnosed with schizophrenia. She has since been maintained on
antipsychotic medication while taking a few classes at the local community
college. Sara tells the admitting nurse that she quit taking her medication 4
weeks ago because the pharmacist who fills the prescriptions is plotting to
have her killed. She believes he is trying to poison her. She says she got this
information from a television message. As Sara speaks, the nurse notices that
she sometimes stops in midsentence and listens; sometimes she cocks her
head to the side and moves her lips as though she is talking.

Answer the following questions related to Sara:

1. From the assessment data, what would be the most immediate nursing
concern in working with Sara?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________
2. What is the nursing diagnosis related to this concern?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________

3. What interventions must be accomplished before the nurse can be

successful in working with Sara?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________
 FINAL PERIOD
CHAPTER X
MOOD DISORDERS

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Discuss epidemiological statistics related to mood disorders
 Describe various types of depressive disorders and Bipolar
disorders
 Identify signs and symptoms of mood disorders
 Formulate nursing diagnoses and goals of care for clients with
depression
 Identify and employ appropriate nursing interventions for
behaviors associated

 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Melancholia
 Bipolar disorder
 Dysthymic
 Mania
  Cyclothymic
 Mania
 Depression
 Suicide
 ECT

Reading assignment: Please read the chapter and answer the following
questions:
- Alterations in which of the neurotransmitters are most closely associated
with depression?
- Describe the differences between moderate and severe depression?

 Depression
- One of the oldest and still one of the frequently diagnosed psychiatric
illnesses
- Patients feel bout of “blues” (a feeling of sadness or downheartedness)
- Alteration in mood; there is a loss of interest in usual activities, changes in
appetite and sleep

Mood: pervasive and sustained emotion

Affect: outward expression of emotion

Epidemiology:
- Major Depressive Disorder (MDD) is one of the leading cause of disability
- Incidence of depressive disorders is higher in women; beginning at the age
of 10 up to middle ages; gender difference is less pronounced between ages
44 and 65 but after the age of 65, women are again likely to become more
depressed than men
- Reasons for increased incidence among women: societal roles, economic
opportunities, gender socialization/ gender stereotypes
- Faulty marriage or ineffective interpersonal relationships is known to be a
risk factor

TYPES OF DEPRESSIVE DISORDERS

Major Depressive Disorder
- Characterized by depressed mood or loss of interest or pleasure in usual
activities
- impaired social and occupational functioning that has existed for at least 2
weeks, no history of manic behavior, and symptoms that cannot be
attributed to use of substances or a general medical condition.
- Diagnosis is specified according to whether it is a single episode (person’s
first encounter with a major depressive episode) or recurrent (has history of
depressive episodes)
- The diagnosis will also identify the degree of severity (mild, moderate,
severe)n or wether there is evidence of psychotic, catatonic or melancholic
features

Diagnostic Criteria for MDD

A. Five (or more) of the following symptoms have been present during the
same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood, or (2) loss of
 interest or pleasure. Note: Do not include symptoms that are clearly due to
another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad, empty, or hopeless) or observation made by
others (e.g., appears tearful). Note: In children and adolescents, can be
irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most

of the day, nearly every day (as indicated by either subjective account or
observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in appetite
nearly every day. Note: In children, consider failure to make expected weight
gain.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by

others, not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be

delusional) nearly every day (not merely self-reproach or guilt about being
sick).

8. Diminished ability to think or concentrate, or indecisiveness,nearly every

day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal

ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide.

B. The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or

another medical condition.
Note: Criteria A-C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses
from a natural disaster, a serious medical illness or disability) may include the
feelings of intense sadness, rumination about the loss, insomnia, poor
appetite, and weight loss noted in Criterion A, which may resemble a
depressive episode. Although such symptoms may be understandable or
considered appropriate to the loss, the presence of a major depressive episode
in addition to the normal response to a significant loss should also be carefully
considered. This decision inevitably requires the exercise of clinical judgment
based on the individual’s history and the cultural norms for the expression of
distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by

schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional
disorder, or other specified and unspecified schizophrenia spectrum and other
psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Specify:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern

PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA)

- Symptoms are milder than MDD
- Pts describe their mood as sad or “down in the dumps”
- No evidence of psychotic symptoms
- ESSENTIAL FEATURE: CHRONIC DEPRESSED MOOD (irritability in children
and adolescents) for at least 2 YEARS (1 year for children and adol)
- Early onset: occurring before age 21
- Late onset: at age 21 or older

PREMENSTRUAL DYSPHORIC DISORDER

- Markedly depressed mood, excessive anxiety, mood swing and decreased
interest in activities during the week prior to menses improving shortly after
the onset of menstruation

SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER

- symptoms associated with a substance/medication-induced depressive
disorder are considered to be the direct result of physiological effects of a
substance (e.g., a drug of abuse, a medication, or toxin exposure), and they
cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
- Depressed mood is associated with intoxication or withdrawal from
substances
- Medications known to evoke mood symptoms: anesthetics, analgesics,
anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian
agents, antiulcer agents, cardiac medications, oral contraceptives,
psychotropic medications, muscle relaxants, steroids, and sulfonamides

DEPRESSIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION

- symptoms associated with a major depressive episode that are the direct
physiological consequence of another medical condition
PREDISPOSING FACTORS-
- Biological Theories
o Genetics: monozygotic twins; family history
o Biochemical influences: deficiency in norepinephrine, serotonin and
dopamine
 o Areas of the brain affected by depression and the symptoms that they
mediate include the following:
 Hippocampus: Memory impairments, feelings of worthlessness,
hopelessness, and guilt
 Amygdala: Anhedonia, anxiety, reduced motivation
 Hypothalamus: Increased or decreased sleep and appetite;
decreased energy and libido
 Other limbic structures: Emotional alterations
 Frontal cortex: Depressed mood; problems concentrating
 Cerebellum: Psychomotor retardation/agitation
- Psychosocial theories
o Loss of a loved one causes melancholia (profound painful dejection,
cessation of interest in the outside world, loss of capacity tolove,
inhibition of all activities and lowering self-esteem)
o Primary disturbance in depression is cognitive rather than affective
(cognitive theory)
 Cognitive therapy focuses on helping the individual to alter
mood by changing the way he thinks
- Depression in children (DISRUPTIVE MOOD DYSREGULATION
DISORDER)
o 1. Up to age 3: Signs may include feeding problems, tantrums, lack of
playfulness and emotional expressiveness, failure to thrive, or delays in
speech and gross motor development.
o 2. From ages 3 to 5: Common symptoms may include accident
proneness, phobias, aggressiveness, and excessive self-reproach for
minor infractions.
o 3. From ages 6 to 8: There may be vague physical complaints and
aggressive behavior. They may cling to parents and avoid new people
and challenges. They may lag behind their classmates in social skills
and academic competence.
o 4. From ages 9 to 12: Common symptoms include morbid thoughts and
excessive worrying. They may reason that they are depressed because
 they have disappointed their parents in some way. There may be lack
of interest in playing with friends.

POSTPARTUM DEPRESSION
- Varies from a feeling of the “blues”, to moderate depression, to psychotic
depression or melancholia
- Maternity blues:
o Tearfulness
o Despondency
o Anxiety
o Impaired concentration
o Usually begin within 48 hours of delivery, peak at about 3-5 days and
last approximately 2 weeks
o May be associated with hormonal changes
- Moderate postpartum depression
o Depressed mood varying from day to day with more bad days than
good, worsens toward evening and associated with fatigue, irritability,
loss of appetite, sleep disturbances and loss of libido
o The mother expresses concern about not being able to care for her
baby
- Postpartum melancholia or depressive psychosis
o Depressed mood, agitation, indecisiveness, lack of concentration, guilt
and abnormal attitude towards body functions
o Risks for suicide and infanticide

APPLICATION OF THE NURSING PROCESS

- Assessment
o Types of Depression
 Transient Depression
 Symptoms of this level is not necessarily dysfunctional but may include
the following alterations:
 Affective: sadness, dejection, feeling downhearted, having the
“blues.”
 Behavioral: some crying possible.
 Cognitive: some difficulty getting mind off of one’s disappointment.
 Physiological: feeling tired and listless.
 Mild: occurs when the grief process is triggered in response to
the loss of a valued object or loved one; grief is prolonged or
exaggerated but able to work through the stages of grief;
symptoms subside thereafter
 Affective: denial of feelings, anger, anxiety, guilt, helplessness,
hopelessness, sadness, despondency.
 Behavioral: tearfulness, regression, restlessness, agitation, withdrawal.
 Cognitive: preoccupation with the loss, self-blame, ambivalence,
blaming others.
 Physiological: anorexia or overeating, insomnia or hypersomnia,
headache, backache, chest pain, or other symptoms associated with
the loss of a significant other.
  Moderate: grief is prolonged or exaggerated; person is fixed in
the anger stage; anger is turned inward to self; person is unable
to function without assistance (Dysthymia)
 Affective: feelings of sadness, dejection, helplessness, powerlessness,
hopelessness; gloomy and pessimistic outlook; low self-esteem;
difficulty experiencing pleasure in activities.
 Behavioral: sluggish physical movements (i.e., psychomotor
retardation); slumped posture; slowed speech; limited verbalizations,
possibly consisting of ruminations about life’s failures or regrets; social
isolation with a focus on the self; increased use of substances possible;
self-destructive behavior possible; decreased interest in personal
hygiene and grooming.
 Cognitive: slowed thinking processes; difficulty concentrating and
directing attention; obsessive and repetitive thoughts, generally
portraying pessimism and negativism; verbalizations and behavior
reflecting suicidal ideation.
 Physiological: anorexia or overeating; insomnia or hypersomnia; sleep
disturbances; amenorrhea; decreased libido; headaches; backaches;
chest pain; abdominal pain; low energy level; fatigue and listlessness;
feeling best early in the morning and continually worse as the day
progresses. This may be related to the diurnal variation in the level of
neurotransmitters that affect mood and level of activity
 Severe: intensified symptoms; loss of contact with reality;
complete lack of pleasure in all activities, and ruminations about
suicide are common. Major depressive disorder is an example of
severe depression
 Affective: feelings of despair, hopelessness and worthlessness, flat
affect, apathy
 Behavioral: severe psychomotor retardation; curling up position, non-
existent communication, sometimes delusional; poor grooming and
personal hygiene
 Cognitive: delusional thinking (somatic and persecutory); confusion,
indecisiveness; lack of concentration; self-blame, suicidal thoughts
** due to low energy level, the patient may be unable
to carry out suicide plans but the desire is strong
 Psychological: general slow down of entire body

**assessment rating scales: Zung Self-Rating Depression Scale and Beck

Depression Inventory; Hamilton Depression Rating Scale

Transient
Mild Severe
Depression
Depression Moderate Depression
(Life's Depression
(Normal (Major
everyday
grief (Dysthymia) Depressive
disappoinme
response) Disorder)
nts)
- Diagnosis
o Risk for suicide
o Complicated grieving
o Low self-esteem
o Powerlessness
o Spiritual distress
o Social isolation/ Impaired social interaction
o Disturbed thought process
o Imbalanced nutrition: less than body requirements
o Insomnia
o Self-care deficit
- Planning / Implementation
o Risk for Suicide / Risk for self-inflicted, Checkpoint:
life threatening injury Ask the client directly, “Have you
 Hallmark of suicide: HOPELESSNESS, thought about killing yourself?” or
HELPLESSNESS, WORTHLESSNESS, LOW “Have you thought about harming
SELF-ESTEEM yourself in any way?” “If so, what
 Create a safe environment for the
do you plan to do? Do you have
client. No sharps and other potentially
the means to carry out this plan?”
harmful objects. SAFETY is our
The risk of suicide is greatly
PRIORITY.
increased if
 Supervise closely during meals and
medication administration the client has developed a plan
 Formulate a short-term verbal or and particularly if means exist
written contract that the client will not for the client to execute the plan.
harm himself during a specific period of time. Renew as
necessary
 An attitude of unconditional acceptance of the client should be
conveyed
 Secure that nurse or staff is always available if thoughts of
suicide emerge
 Be direct. Open and matter-of-fact approach. Listen actively and
encourage verbalization of feelings
 Maintain close observation of the client. Provide one-on-one
contact depending on the level of suicide precaution
 Place client in a room near the nurse’s station
 Accompany patient to off-ward activities if attendance is needed
 Make rounds at irregular intervals (especially at night, toward
early morning, at change of shift)s
 Encourage client to express angry feelings within appropriate
limits
 Orient the client to reality as required
 Spend time with the client
 Approach: ACTIVE FRIENDLINESS
o Complicated grieving
 Disorder that occurs after the death of a loved one or any loss
that is significant to the individual
  Determine stage of grief in which the client is fixed. Identify
behaviors associated with this stage to gather baseline data
 Develop a trusting relationship. Show empathy, concern and
unconditional positive regard. Be honest and keep all promises
 Communicate to the client that crying is acceptable
 Assist patient in problem solving as he attempts to discover
adaptive coping strategies
 Provide positive regards for every decisions made
 Encourage client to reach out for spiritual support
 Encourage individual to attend support groups
o Low self-esteem/ Self-care deficit
 Be accepting and spend time with the client; focus on strengths
and accomplishments
 Promote attendance in therapy groups that offer client simple
methods of accomplishments
 Encourage client to be independent as possible
 Teach assertiveness techniques
 Teach effective communication techniques such as “I” messages
 Offer recognition and positive reinforcement for independent
accomplishments
 Show the client how to perform activities with which she is
having difficulty
 Provide simple, concrete demonstrations of activities
 Keep strict records of food and fluid intake. Offer nutritious
snacks in between meals
 Provide measures that promote sleep
o Powerlessness – lived experience of lack of control over a situation
 Encourage client to take as much responsibility as possible for
his own self-care practices
 Help the client to set realistic goals
 Help client to identify areas of his life that can be controlled

 Treatment Modalities for Depression

1. Individual Psychotherapy
o Phase I: the client is assessed to determine the extent of the illness;
gather complete information about the patient’s condition
 Severe depression: interpersonal psychotherapy with
antidepressant
 Client is encouraged to continue working and participating in
regular activities during therapy
o Phase II:
 Treatment focuses on helping the client resolve complicated
grief reactions
 Ex: resolving ambivalence with a lost relationship; assistance
with a new relationship
o Phase III:
 Therapeutic alliance is terminated. Put emphasis on
reassurance, clarification of emotional states, improvement of
communication, testing perceptions to enhance social
functioning
 2. Group therapy
o Done after the acute phase of the disease
o Provides an atmosphere for individuals where they may discuss issues
in their lives
o It provides a feeling of security
3. Family therapy
4. Cognitive therapy
o Patient is taught to control thought distortions
o Objective: to obtain symptom relief as quickly as possible, assist the
client in identifying dysfunctional patterns of thinking
o Change automatic thoughts:
 Personalizing: Im the only one who fsailed
 All or nothing: im a complete failure
 Mind reading: he thinks im foolish
 Discounting positives: the other questions were so easy. Any
dummy could’ve gotten it right
o Ask client to describe evidence that both supports or disputes
automatic thoughts
5. Electroconvulsive therapy
o Induction of grand mal seizure through application of electrical currents
to the brain
6. Psychopharmacology – Antidepressants (Review psychopharmacology)
o Selective Serotonin Reuptake Inhibitors
o Tricyclic antidepressant
o Monoamine oxidase inhibitors

BIPOLAR AND RELATED DISORDERS

 Bipolar disorder: mood cycles of mania and depression

o characterized by mood swings from profound depression to extreme
euphoria with intervening episodes of normalcy; delusions may or
may not be present
o Mania: alteration in mood that is expressed by feelings of elation,
inflated self-esteem, grandiosity, hyperactivity, agitation
 Disturbance is sufficiently severe which may cause marked
impairment
o Hypomania: milder symptom; not severe enough to cause impairment
o Incidence is higher in population age of 18 years old and above;
equal ratio between men and women; average onset is at early 20s;
occurs more frequently among higher socioeconomic classes
  Types of Bipolar D/os:
o Bipolar I Disorder
 diagnosis given to an individual who is experiencing a manic
episode or has a history of one or more manic episodes.
 May also have depressive episodes
o Bipolar II Disorder
 Characterized by recurrent bouts of major depression with
episodic occurrence of hypomania.
o Cyclothymic Disorder
 Chronic mood disturbance of at least 2 years in duration;
involves numerous periods of elevated mood that does not meet
criteria for a hypomanic episode
o Substance/Medication-induced Bipolar Disorder
 Symptoms occurs as a direct result of substance abuse
 Mood may be elevated, expansive or irritable, inflated self-
esteem, impairment in social, occupational and other important
areas of functioning

Application of the Nursing Process

Assessment:
- Manic states come in 3 stages: hypomania, acute mania and delirious mania
o Stage 1: Hypomania
 Disturbances is not sufficiently severe to cause marked
impairment
  Mood: cheerful and expansive; irritability escalates when desires
are not fulfilled
 Cognition: perception of self is exalted; flight of ideas; easily
distracted by irrelevant stimuli
 Activity and behavior: increased motor activity; extroverted and
sociable however, they lack depth and personality; talk and
laugh loudly; increased libido
o Stage II: Acute Manic
 Symptoms in hypomania are intensified
 Mood: euphoria and elation
 Fragmented perception; psychosis may be noted; flight of ideas,
pressured speech (loquaciousness)
 Sexual interest is increased; poor impulse control; very
manipulative; appears inexhaustible; the need for sleep is
diminished; grooming and hygiene is neglected
 Disorganized dressing (flamboyant or bizarre)
o Stage III: Delirious Mania
 Severe clouding of consciousness
 Relieved by antipsychotics
 Labile mood; exhibits feelings of despair quickly converted to
ecstasy
 Evident panic anxiety
 Activity: agitated and purposeless movements; may post injury
to self and others
Diagnosis and Interventions:
- Risk for injury/ Risk for violence: Self-directed or to others
o Maintain low environmental stimuli
o Observe client’s behavior frequently
o Maintain close observation
o Remove all potentially dangerous objects
o Intervene at the first sign of increased anxiety, agitation or aggression
 You seem anxious (angry, frustrated) about this situation. How
can I help you?
o maintain calm attitude
o initiate least restrictive alternative if patient becomes violent or hostile
- Imbalanced Nutrition: Less than body requirements / Insomnia
o Collaborate with dietician to determine calories needed
o High protein, high calorie, finger food and drinks
o Maintain accurate record of intake and output
o Avoid caffeinated drinks
o Provide nursing measures to promote sleep (back rub
- Disturbed thought processes/ Disturbed sensory perception
o Acknowledge, present reality and refocus client
- Impaired social interaction
o Limit setting on inappropriate behaviors
o Do not argue, bargain or try to reason out with the patient. Merely
state limits and expectations

 Treatment Strategies
 o Psychopharmacology: mood stabilizers (Lithium)
 Reduces risk for suicide
 Improves functioning
 Prevents relapse: JUST REMEMBER
LITHIUM  Blood is drawn in the
Level is 0.6-1.2 mEq/L morning, 8-12 hours
1-2 weeks lag period before therapeutic effects after the last dosage
occur  No parenteral forms
Toxic level is greater 1.5 meq/L/ Teratogenic  Contraindications:
Half-life is 24 hours Pregnancy, Renal
1 week – unstable ; 1 month – stable (check blood disease/ CVD
levels)
Urination and thirst
Metallic taste/ Mild hand tremors = normal side effect

CHAPTER ASSESSMENT

I. Multiple choice. Select the BEST answer from the options given
and justify your answer.

1. Margaret, a 68-year-old widow, is brought to the emergency department by her sister-

in-law. Margaret
has a history of bipolar disorder and has been maintained on medication for many years.
Her sister-in-
law reports that Margaret quit taking her medication a few months ago, thinking she
didn’t need
it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-
law reports
that Margaret eats very little, is losing weight, and almost never sleeps. “I’m afraid she’s
going to just
collapse!” Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for
Margaret is:
a. Imbalanced nutrition: less than body requirements related to not eating
b. Risk for injury related to hyperactivity
c. Disturbed sleep pattern related to agitation
d. Ineffective coping related to denial of depression
2. Margaret, age 68, is diagnosed with bipolar I disorder, current episode manic. She is
extremely hyperactive
and has lost weight. One way to promote adequate nutritional intake for Margaret is to:
a. Sit with her during meals to ensure that she eats everything on her tray.
b. Have her sister-in-law bring all her food from home because she knows
Margaret’s likes and dislikes.
c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat
“on the run.”
d. Tell Margaret that she will be on room restriction until she starts gaining
weight.
3. The physician orders lithium carbonate 600 mg tid for a newly diagnosed client with
Bipolar I Disorder.
There is a narrow margin between the therapeutic and toxic levels of lithium.
Therapeutic range for
acute mania is:
a. 1.0 to 1.5 mEq/L
b. 10 to 15 mEq/L
c. 0.5 to 1.0 mEq/L
 d. 5 to 10 mEq/L
4. Although historically lithium has been the medication of choice for mania, several
others have been
used with good results. Which of the following are used in the treatment of bipolar
disorder? (Select
all that apply.)
a. Olanzepine (Zyprexa)
b. Paroxetine (Paxil)
c. Carbamazepine (Tegretol)
d. Lamotrigine (Lamictal)
e. Tranylcypromine (Parnate)
5. Margaret, a 68-year-old widow experiencing a manic episode, is admitted to
the psychiatric unit after being brought to the emergency department by her
sister-in-law. Margaret yells, “My sister-in-law is just jealous of me! She’s trying
to make it look like I’m insane!” This behavior is an example of:
a. A delusion of grandeur
b. A delusion of persecution
c. A delusion of reference
d. A delusion of control or influence
6. The most common comorbid condition in children with bipolar disorder is:
a. Schizophrenia
b. Substance disorders
c. Oppositional defiant disorder
d. Attention-deficit/hyperactivity disorder
7. A nurse is educating a client about his lithium therapy. She is explaining signs
and symptoms of lithium toxicity. Which of the following would she instruct the
client to be on the alert for?
a. Fever, sore throat, malaise
b. Tinnitus, severe diarrhea, ataxia
c. Occipital headache, palpitations, chest pain
d. Skin rash, marked rise in blood pressure, bradycardia
8. A client experiencing a manic episode enters the milieu area dressed in a
provocative and physically revealing outfit. Which of the following is the most
appropriate intervention by the nurse?
a. Tell the client she cannot wear this outfit while she is in the hospital.
b. Do nothing and allow her to learn from the responses of her peers.
c. Quietly walk with her back to her room and help her change into
something more appropriate.
d. Explain to her that if she wears this outfit she must remain in her room.
9. The nurse is prioritizing nursing diagnoses in the plan of care for a client
experiencing a manic
episode. Number the diagnoses in order of the appropriate priority.
____ a. Disturbed sleep pattern evidenced by sleeping only 4-5 hours per night
____b. Risk for injury related to manic hyperactivity
____ c. Impaired social interaction evidenced by manipulation of others
____d. Imbalanced nutrition: Less than body requirements evidenced by loss of
weight and poor skin turgor
10. A child with bipolar disorder also has attention-deficit/hyperactivity disorder
(ADHD). How would these co-morbid conditions most likely be treated?
a. No medication would be given for either condition.
b. Medication would be given for both conditions simultaneously.
c. The bipolar condition would be stabilized first before medication for the
ADHD would be given.
d. The ADHD would be treated before consideration of the bipolar disorder.
II. Enumerate at least 10 therapeutic communication strategies for patients
with depressive disorders. Provide an example for each strategy and give
the appropriate rationale.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______

III. Enumerate cues for a patient who is attempting suicide.

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________

CHAPTER XI
PERSONALITY DISORDERS

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Identify various types of personality disorders
  Describe the symptomatology associated with each cluster of
personality disorder
 Identify risk factors of personality disorders and its epidemiology
 Apply the nursing process in caring for patients with personality
disorders
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 antisocial personality disorder
 avoidant personality disorder
 borderline personality disorder
 dependent personality disorder
 histrionic personality disorder
 narcissistic personality disorder
 object constancy
 obsessive-compulsive personality disorder
 paranoid personality disorder
 schizoid personality disorder
 schizotypal personality disorder
 splitting

 Personality: Greek “persona” the totality of emotional and behavioral

characteristics that are particular to a specific person and that remain
somewhat stable and predictable over time
 Personality traits: characteristics with which an individual is born or
develops early in life
 Personality disorders: occur when personality traits become rigid and
inflexible and contribute to maladaptive patterns of behavior
o lifelong pattern, fixated at certain age
o they are not aware that something is wrong with them (poor insight)
 Three clusters of Personality Disorders
o Cluster A : Odd and eccentric
 Paranoid PD
 Schizoid PD
 Schizotypal PD
o Cluster B: dramatic, emotional or erratic
 Antisocial PD
 Borderline PD
 Histrionic PD
 Narcissistic PD
o Cluster C: anxious and fearful
 Avoidant PD
  Dependent PD
 Obsessive-compulsive PD

Cluster A:
Paranoid Personality Disorder
- Pervasive, persistent and inappropriate mistrust to others
- Highly suspicious; constantly on guard, hypervigialnt
- Appear tense and irritable
- Extremely oversensitive and tend to misinterpret even minute cues within
the environment
- Constantly tests the honesty of others
- Diagnostic criteria:
o A. A pervasive distrust and suspiciousness of others such that their
motives are interpreted as malevolent, beginning by early adulthood
and present in a variety of contexts, as indicated by four (or more) of
the following:
1. Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her
2. Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates
3. Is reluctant to confide in others because of unwarranted fear that
the information will be used maliciously against him or her
4. Reads hidden demeaning or threatening meanings into benign
remarks or events
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries,
or slights)
6. Perceives attacks on his or her character or reputation that are
not apparent to others and is quick to react angrily or to
counterattack
7. Has recurrent suspicions, without justification, regarding fidelity
of spouse or sexual partner
o Does not occur exclusively during the course of schizophrenia, a
bipolar disorder or depressive disorder with psychotic features, or
another psychotic disorder and is not attributable to the physiological
effects of another medical condition.

Schizoid Personality Disorder

- Profound defect in the ability to form personal relationships
- Cold, aloof and indifferent
- Work in isolation and are unsociable
- Invests enormous affective energy to intellectual pursuits
- Serious about everything
- Diagnostic Criteria:
o A. A pervasive pattern of detachment from social relationships and a
restricted range of expression of emotions in interpersonalmsettings,
beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:
 1. Neither desires nor enjoys close relationships, including being
part of a family
 2. Almost always chooses solitary activities
 3. Has little, if any, interest in having sexual experiences with
another person
 4. Takes pleasure in few, if any, activities
  5. Lacks close friends or confidants other than first-degree
relatives
 6. Appears indifferent to the praise or criticism of others
 7. Shows emotional coldness, detachment, or flattened
affectivity
o B. Does not occur exclusively during the course of schizophrenia, a
bipolar disorder or depressive disorder with psychotic features, another
psychotic disorder, or autism spectrum disorder and is not attributable
to the physiological effects of another medical condition.

Schizotypal Personality Disorder

- “latent schizophrenics”
- Aloof and isolated; apathetic
- Magical thinking, ideas of reference, illusions and depersonalization
- “sixth sense”; superstitiousness
- Speech is bizarre; tangential thinking
- Psychotic symptoms but usually sudden or brief
- “living in their own world”
- Diagnostic criteria:
A. A pervasive pattern of social and interpersonal deficits marked by acute
discomfort with, and reduced capacity for, close relationships as well as by
cognitive or perceptual distortions and eccentricities of behavior, beginning by
early adulthood and present in a variety of contexts, as indicated by five (or
more) of the following:
1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms (e.g., superstitiousness, belief in
clairvoyance, telepathy, or “sixth sense;” in children and adolescents,
bizarre fantasies or preoccupations)
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical,
overelaborate, or stereotyped)
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behavior or appearance that is odd, eccentric, or peculiar
8. Lack of close friends or confidants other than first-degree relatives
9. Excessive social anxiety that does not diminish with familiarity and
tends to be associated with paranoid fears rather than negative judgments
about self
B. Does not occur exclusively during the course of schizophrenia, a bipolar
disorder or depressive disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder.

CLUSTER B
ANTISOCIAL PERSONALITY DISORDER
- Pattern of socially irresponsible, exploitative and guiltless behavior
- Exploit and manipulate others for personal gain
- No consistent employment and stable relationships

BORDERLINE PERSONALITY DISORDER

- Pattern of intense and chaotic relationships
- With affective instability and fluctuating attitudes toward other people
- Impulsive, directly/indirectly self-destructive; lacks sense of identity
A pervasive pattern of instability of interpersonal relationships, self-image, and
affects, and marked impulsivity beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include
suicidal or self-mutilating behavior covered in criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense
of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not
include suicidal or self-mutilating behavior covered in criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to marked reactivity of mood (e.g., intense episodic
dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more
than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

HISTRIONIC PERSONALITY DISORDER

- Colorful, dramatic and extroverted behavior in excitable, emotional people
- Difficulty maintaining long-lasting relationships
- Needs constant affirmation of approval and acceptance from others
- Self-dramatizing, attention seeking, overly gregarious and seductive
- Manipulative; exhibitionistic behavior
- Pays attention to detail
- Portray themselves as carefree and sophisticated
- A pervasive pattern of excessive emotionality and attention seeking,
beginning by early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
1. Is uncomfortable in situations in which he or she is not the center of
attention.
2. Interaction with others is often characterized by inappropriate sexually
seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in
detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of
emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.

NARCISSISTIC PERSONALITY DISORDER

- Exaggerated sense of self worth
- Lacks empathy
- Hypersensitive to evaluation of others
- A pervasive pattern of grandiosity (in fantasy or behavior), need for
admiration, and lack of empathy, beginning by early adulthood and present
in a variety of contexts, as indicated by five (or more) of the following:
 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements
and talents, expects to be recognized as superior without commensurate
achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance,
beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be
understood by, or should associate with, other special or high-status people
(or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially
favorable treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve
his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and
needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.

AVOIDANT PERSONALITY DISORDER

- Extremely sensitive to rejection
- Extreme shyness
- Feels awkwardness and uncomfortable in social situations
- Timid, withdrawn, cold and strange
- Slow and constrained speech; fragmented thoughts
- Often expresses feelings of being unwanted

DEPENDENT PERSONALITY DISORDER

- Pattern of relying excessively on others for emotional support
- Allows others to make decisions
- Tolerates mistreatment of others
- Feels helpless when alone
- Demeans oneself to gain acceptance
- Lacks self-confidence (apparent in their posture, voice and mannerisms)
- Typically passive; overly generous and thoughtful; underplay own
attractiveness and achievements; suffering is done in silence

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

- Very serious and formal; have difficulty expressing emotions
- Overly disciplined, perfectionist and preoccupied with rules; inflexible
- Intense fear of making mistakes
- Lack spontaneity; meticulous and work diligently and patiently at tasks that
require accuracy and discipline
- High regard with matters of organization and efficiency; rigid and unbending
about rules and procedures
- “bureaucratic personality” or the so-called company man; views self as loyal,
dependable; emotional behavior is considered immature and irresponsible
- Defense mechanisms: isolation, intellectualization, rationalization and
undoing

Treatment/Management:
- Psychopharmacology
o Focuses on the client’s symptom categories (cognitive-perceptual
distortions, affective symptoms and mood dysregulation, aggression
and behavioral dysfunction, and anxiety)
 o Aggression: Lithium, anticonvulsant mood stabilizers
o Cognitive-perceptual disturbances: responds to antipsychotics
o Mood dysregulation/ anxiety: SSRI and low dose of MAOIs
- Individual and Group Psychotherapy
o Focus on building trust, teaching basic living skills, providing support,
decreasing distressing symptoms and improving interpersonal
relationships
- Cognitive behavioral therapy: thought stopping, positive self-talk,
decatastrophizing

Personality Disorder Nursing Approaches/Interventions

Paranoid Serious and straightforward approach
Schizoid Improve client’s functioning; assist
patient to develop interpersonal
relationships
Schizotypal Self-care needs; social skills training
Antisocial Limit setting; confrontation; anger
management
Borderline Promote SAFETY; promote coping
skills; cognitive restructuring
techniques;
Histrionic Social skills training; provide factual
feedback about behavior
Narcissistic Matter-of-fact approach; self-care skills
avoidant Support and reassure; cognitive
restructuring
Dependent Foster self-reliance and autonomy
Obsessive-compulsive Encourage negotiation

Chapter Assessment
Critical Thinking Exercises

Case Study 1:

Lana, age 32, was diagnosed with borderline personality disorder when she was
26 years old. Her husband took her to the emergency department when he
walked into the bathroom and found her cutting her legs with a razor blade. At
that time, assessment revealed that Lana had a long history of self-mutilation,
which she had carefully hidden from her husband and others. Lana began long-
term psychoanalytical psychotherapy on an outpatient basis. Therapy revealed
that Lana had been physically and sexually abused as a child by both her mother
and her father, both now deceased.
She admitted to having chronic depression, and her husband related episodes of
rage reactions. Lana has been hospitalized on the psychiatric unit for a week
because of suicidal ideations. After
making a no-suicide contract with the staff, she is allowed to leave the unit on
pass to keep a dental appointment that she made a number of weeks ago. She
has just returned to the unit and says to her nurse, “I just took 20 Desyrel while I
was sitting in my car in the parking lot.”

Answer the following questions related to Lana:

1. The nurse is well acquainted with Lana and believes this is a manipulative
gesture. How should the nurse handle this situation?
2. What is the priority nursing diagnosis for Lana?
3. Lana likes to “split” the staff into “good guys” and “bad guys.” What is the
most important intervention for splitting by a person with borderline personality
disorder?

Communication Exercises. Write the appropriate response of the nurse based

on the given statements by the patient. Identify the therapeutic communication
technique used in each item and justify your answer.

1. Nathan, age 37, has been admitted to the hospital for a psychiatric evaluation
after being arrested for armed robbery of a convenience store. He has a history
of encounters with law enforcement since early adolescence. He has been
diagnosed with antisocial personality disorder. Nathan says to the nurse, “Hey
pretty lady! Where have you been all my life?”
• How would the nurse respond appropriately to this statement by Nathan?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________

2. “I really got a bum rap! I had no intentions of hurting anyone. The gun only
had one bullet in it! I just wanted to scare that clerk into giving me a few bucks!
Just my bad luck an off-duty cop had to walk in about that time.”
• How would the nurse respond appropriately to this statement by Nathan?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________

3. “You’re really cute. Are you married? I’m pretty sure my lawyer can get me
out of this rap, and I’ll be a free man! Why don’t you give me your phone number
and I’ll call you sometime. We could go out and have some fun!”
• How would the nurse respond appropriately to this statement by Nathan?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________

CHAPTER XII
SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain
the following Intended Learning Outcomes:
 Define addiction, intoxication and withdrawal
 Discuss predisposing factors implicated in the etiology of
substance-related and addictive disorders.
  Identify nursing diagnoses common to clients with substance-
related and addictive disorders, and select appropriate nursing
interventions for each
 Describe relevant outcomes for clients with substance-related
disorder
 Describe various modalities relevant to treatment of individuals
 Apply the nursing process in caring for clients with addictive
disorders
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of
this chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Amphetamines
 Codependency
 Cannabis
 Detoxification
 Intoxication
 Withdrawal
 Disulfiram
 Opioids
 Phenylcyclidine
 Wernicke’s encephalopathy
 Korsakoff’s psychosis

Homework assignment:
1. What are the physical consequences of thiamine deficiency in chronic
alcohol use?
2. Define tolerance as it relates to physical addiction to a substance
3. Describe two types of toxic reactions that can occur with the use of
hallucinogens
4. What is substitution therapy?

SUBSTANCE USE DISORDER

- Socially maladaptive behavior characterized by abuse of substance or the
regular use of such substance impairs the functioning of individual

 Substance Abuse vs. Substance dependence

 Physical dependence vs. Psychological dependence
 Substance intoxication vs. Substance withdrawal

Definitions:
 Substance Abuse
o Using a drug in a way that is inconsistent with medical and social
norms and despite negative consequences
  Substance Dependence – more serious problem
o Tolerance – takes higher dose of substance to bring about the
same effect
o Withdrawal symptoms – substance-specific manifestations that
occur upon reduction/ cessation of substance
 Intoxication – occurs when substance is within the body -
effects on CNS
o Unsuccessful attempts to give up the substance
o More time to get, more time to take the substance
 Physical Dependence – with withdrawal symptoms
 Psychological Dependence
o Takes the substance to avoid undesirable effects of withdrawal
o Stimulants – physical and psychological
o Depressants - physical

CNS Stimulants
 Amphetamines
o Methamphetamine HCl – Shabu
o Dextrin, Ritalin, Benzedrine
 Ritalin - ADHD
o Brings about euphoria – exaggerated form of well-being
o Pupils dilate
o Cannot sleep, no appetite
o Does not get tired
o Dependent: remain energetic, wants to be slim

 Cocaine
o Not used for therapeutic use
o Almost the same effect as amphetamines
 More potent that amphetamines
o Euphoria, increased VS, bronchodilation, energetic
o Taken through snorting or sniffing

 Ecstasy
o Rush then crash if next dose is not taken
o Takes next dose even if the first one does not lose its effect yet
 If they fail, they feel painful depression - Crash
o Fatigability, painful depression w/c may cause them to commit
suicide
o Methylenedioxymethamphetamine (MDMA)
o Snorting, sniffing results to red nose w/ lesion
o Heightened sexuality and increases feeling of closeness and
empathy, “club drug”
o Symptomatic management
o May be diagnosed w/ urine test – w/in 1 to 2 days to trace
substances
o Urine should not be diluted
CNS Depressants
 Alcohol
o Most commonly abused substance
o Oldest anti-anxiety
 Sedative/ Hypnotics
o Valium – same effect as alcohol
 o Dangerous to mix alcohol and sedative
o If taken therapeutically, no alcohol

 Narcotics - Opioids
o Papaver somniferum – derivatives of opiates
o Opium, heroine, codeine (cough syrup), morphine (Demerol)
o Can only bought w/ prescription
o Euphoria, sleepy, decreased VS, decreased RR
o Heroin - most common
 Tell-tale Sign: Pinpoint pupil non- reactive to light
 Severe CNS depression – Narcan (Naloxone)
 Can be passed through the placenta – shrill cry of neonates
 Taken via IV push or main line – w/ needle marks
 Risk for blood-borne infections
o Effects of Heroin:
 Euphoria w/ sleepiness
o Relieve physical and emotional pain
 Morphine
o Potent respiratory depressant
o RR < 12 – overdose
o Antidote: Narcan – narcotic agonist
 Pupils constriction
 decreased VS
o Withdrawal from Heroine
 Early – can be likened to beginning respiratory infection
o Runny nose
o Teary eyes
o Sneezing
o Abdominal cramps
o Muscle cramps

 Inhalants
o Gasoline, glue, solvents, thinner, nail polish remover, spray paint,
rugby (used by street boys)
o Headache, decreased LOC, dizziness, lack of coordination,
mirthfulness, mouth ulcers, slurred speech, unsteady gait, tremors,
muscle weakness, blurred vision, GI upset, nausea and vomiting
o Rugby - decreased hunger
o DEATH – severe CNS depression

 Must only take for 2 weeks to avoid addiction

Hallucinogens
 Mind altering drugs/ psychomimetics
 Distortion in time and space
 Colorful surroundings: psychedelic
 Synethesia – “blending of senses”, see odor, frightening hallucination
(bad trip)
 Effect of substance can last
 Mescaline

 Cannabinols
o Least potent
o Marijuana, hemp grass
 o Dried leaves and dried into rolls – tyonke, dyutsa –
euphoria/floating, tachycardia, dry mouth, increase in appetite,
hallucinations, RED EYES or conjunctival irritation, loss of
motivation, change in decision making/judgement, may lead to
sterility due to decreased testosterone.
o Dagta of cannabis – hashish; increase in appetite with preference
for sweets – hash brownies/ space cakes/ space brownies

 PCP – Phencyclidine/ Ketamine

o Veterinary anesthesia
o Heightened sexuality and closeness
o Distortion in memory, dissociation, near death experience
o K-hole experience – do not remember anything that happened

 LSD
o Bloodshot eyes – conjunctival irritation

ALCOHOLISM
 Commonly abused substance
 Etiology:
o Biologic – genetics

o Psychodynamic
 Lack of adaptive coping
o Denial
o Projection
o Rationalization
 Fixated in oral stage
o Inconsistency, poor role modeling, lack of nurturing,
lack of adaptive coping
 Id – strong
 Ego – weak (alcohol as coping)

o Personality Profile – weak ego, dependent, manipulative

o Behavioral
 Learned behavior

o Social - Peer pressure

 Group therapy – mgt is better in groups
o Give up a drinking friend
o Relapse – go back to alcohol-drinking friends

Blood Alcohol Concentrations/ Levels (BAC/ BAL) to Behavioral

Manifestations of Intoxication
- Breath analyzer level

BAL BEHAVIORS
0.05 %  Loss of inhibition
Up to 0.1 %  Anxiety relief, euphoria, loud speech
0.10 to 0.15  Slurred speech, motor incoordination,
% moodiness (LEGAL INTOXICATION)

0.2 – 0.3 %  Irritability, black out (memory impairment/

does not remember what happened), tremor,
ataxia, stupor

0.3 % and up  Unconsciousness

Alcohol Metabolism – 10 mL in 90 mins

Complications of Alcohol Use
 GI – stomach absorbs alcohol – does not need to reach intestines
o Malnutrition – early satiety
o Inflammation – esophagitis
 CNS – due to deficiency in Vitamin B
o Neuritis – tingling sensation
o Wernicke’s - Korsakoff’s syndrome
 Reproductive System
o Impotence -  Testosterone
 CV
o Cardiomyopathy, CHF
 Fetal Alcohol Syndrome

Nursing Diagnosis r/t Chemical Dependence

 Ineffective denial
 Ineffective individual coping
 Altered family process
o Family can contribute to drinking behaviors
o Enabling behavior – kunsintidor
o Codependency – behaviors of relatives of alcoholics; adjust to the
alcoholic
 Anxiety – before and during withdrawal
 Altered sensory perception
o Hallucination – withdrawal
 Altered thought processes
 Impaired verbal communication – slurring
 Sleep pattern disturbance
 Altered nutrition
o Vitamin B supplement
 Self-esteem disturbance
 Alteration in social interaction
 Risk for violence

PSYCHODYNAMICS OF SUBSTANCE DEPENDENCE

Unresolved Needs of Early Attachments

 Id  Ego
  Strong oral  Uses denial (should be confronted),
tendencies rationalization (do not allow to explain
 Demanding/ manipulative inappropriate behavior) and projection
(blaming others for behavior)
* Learn to delay gratification  Accept the person, not the behavior – “tough
love”
 Uses escape behavior provided by alcohol
 Inferior feeling

 In psych, do not manage diagnosis, manage behavior

 Set limits, no bargaining, maintain consistency
 Patient must know that there is a connection between anxiety and
maladaptive behavior
Management of Alcoholism
 Short-term – Detoxification
o Process of safely withdrawing from the substance
o Best done in a controlled environment -
Institution
o Search things and confiscate anything that has alcohol
o Disulfiram Therapy

 Long-term
o Rehabilitation
o Foundation is abstinence

Detoxification
 Assessment
 Withdrawal Symptoms
o Earliest: Tremors

 Stage 1 – 6 to 8 hours after last drink

o Tremors, headache, n/v, anxiety, sweating
 Stage 2 – 8 to 12 hours
o Stage 1 + anorexia and insomnia
o May start hallucinations
 Intensifying anxiety = decreased perception
 NOT managed with antipsychotics
 Given anxiolytics
 Side effect: decreased seizure threshold – more prone to seizure
o Perception:

 Stage 3 – 2 to 3 days later

o Stage 2 + seizure
o Cannot be managed at home
o Risk for aspiration

 Stage 4 – 2 to 5 days after delirium tremens

o CNS Depressants
 Intoxication – depressant
 Withdrawal – stimulant
o CNS Stimulant
 Intoxication – stimulant
 Withdrawal - Depressant
o Delirium tremens – excitability, agitated, disoriented and confused,
increased VS, seizures, red eyes
 Most extreme withdrawal symptom

Goal and Priority Management of Withdrawal Patients

 Ensure physiologic integrity and safety of patient
o Quiet, non-stimulating environment
 Cluster care
o VS q hour or 2 hours
o Safety – put up side rails
 Restraints (last resort)
 o Offer emotional support
o Reorient patient
o Well-lighted room
 Illusion – misinterpretation of external stimuli
 Hallucination – false perception
o Present reality
o Offer to stay
o Antianxiety meds
 Seizure
o Anticonvulsants
o Dilantin
o MgSO4 – enhance absorption of Vit D
 AntiHTN
 Bloodshot eyes – no management

Long term - Rehabilitation – foundation is abstinence

 Remain sober

Goals:
 To give up alcohol
o Disulfiram or Antabuse Therapy
 If drank alcohol  Disulfiram reaction: HA, n/v, hypoBP, DOB,
retching
o Meds are for safe withdrawal and to prevent relapse

 Livea positive lifestyle; use other coping strategies

o Things you do everyday in life
o Group therapy – Alcoholics anonymous group
o Group - collection of people working together working towards a
common goal
o 8-10 persons
o Brings interpersonal learning; more input and feedback
o Instilling of hope and universality
o Altruism – feeling of helping others
o Cohesiveness and unity is important; must give up denial
 Metabolism of alcohol lasts for 1.5 hours and gives off acetaldehyde –
acetaldehyde dehydrogenase – gives off acetic acid

Therapeutic Goal: Abstinence from the substance

Nursing Interventions:
 Providing for physical and nutritional needs
 Confrontation
 Tough love – accept person
 Group work – alcoholics anonymous; leader is a reformed alcoholic
 Education

Summary of symptoms associated with the syndromes of intoxication and

withdrawal

CHAPTER ASSESSMENT
 Class of drugs Intoxication withdrawal comments
alcohol Aggressiveness, Tremors, Alcohol withdrawal
impaired nausea/vomiting, begins within 4-12
judgment, malaise, hr after last drink.
impaired attention, weakness, May progress to
irritability, tachycardia, delirium tremens
euphoria, sweating, elevated on 2nd or 3rd day.
depression, blood pressure, Use of Librium or
emotional lability, anxiety, depressed Serax is common
slurred speech, mood, irritability, for substitution
incoordination, hallucinations, therapy
unsteady gait, headache,
nystagmus, insomnia, seizures
flushed face
Amphetamines Fighting, Anxiety, depressed Withdrawal
and related grandiosity, mood, irritability, symptoms usually
substances hypervigilance, craving for the peak within 2–4
psychomotor substance, fatigue, days, although
agitation, impaired insomnia or depression and
judgment, hypersomnia, irritability may
tachycardia, psychomotor persist for months.
pupillary dilation, agitation, paranoid Antidepressants
elevated blood and suicidal may be used
pressure, ideation
perspiration or
chills, nausea and
vomiting
caffeine Restlessness, headache Caffeine is
nervousness, contained in
excitement, coffee, tea, colas,
insomnia, flushed cocoa, chocolate,
face, diuresis, some over-the-
gastrointestinal counter analgesics,
complaints, muscle “cold”
twitching, rambling preparations, and
flow of thought stimulants
and speech,
cardiac
arrhythmia,
periods of
inexhaustibility,
psychomotor
agitation
Cannabis Euphoria, anxiety, Restlessness, Intoxication occurs
suspiciousness, irritability, immediately and
sensation of insomnia, loss of lasts about 3
slowed time, appetite, hours. Oral
impaired depressed mood, ingestion is more
judgment, social tremors, fever, slowly absorbed
withdrawal, chills, headache, and has longer
tachycardia, abdominal pain lasting effects.
conjunctival
redness, increased
appetite,
hallucinations
Coccaine Euphoria, fighting, Depression, Large doses of the
grandiosity, anxiety, irritability, drug can result in
hypervigilance, fatigue, insomnia convulsions or
psychomotor or hypersomnia, death from cardiac
agitation, impaired psychomotor arrhythmias or
 judgment, agitation, paranoid respiratory
tachycardia, or suicidal paralysis.
elevated blood ideation, apathy,
pressure, pupillary social withdrawal
dilation,
perspiration or
chills, nausea/
vomiting,
hallucinations,
delirium
Inhalants Belligerence, Intoxication occurs
assaultiveness, within 5 minutes of
apathy, impaired inhalation.
judgment, Symptoms last 60–
dizziness, 90 minutes. Large
nystagmus, slurred doses can result in
speech, unsteady death from CNS
gait, lethargy, depression or
depressed cardiac arrhythmia
reflexes, tremor,
blurred vision,
stupor or coma,
euphoria, irritation
around eyes,
throat, and nose
Nicotine Craving for the Symptoms of
drug, irritability, withdrawal begin
anger, frustration, within 24 hours of
anxiety, difficulty last drug use and
concentrating, decrease in
restlessness, intensity over
decreased heart days, weeks, or
rate, increased sometimes longer
appetite, weight
gain, tremor,
headaches,
insomnia
Opioids Euphoria, lethargy, Craving for the Withdrawal
somnolence, drug, nausea/ symptoms appear
apathy, dysphoria, vomiting, muscle within 6–8 hours
impaired aches, lacrimation after last dose,
judgment, or rhinorrhea, reach a peak in the
pupillary pupillary dilation, 2nd or 3rd day,
constriction, piloerection or and subside in 5–
drowsiness, slurred sweating, diarrhea, 10 days. Times are
speech, yawning, fever, shorter with
constipation, insomnia meperidine and
nausea, decreased longer with
respiratory rate methadone.
and blood pressure
Phencyclidine and Belligerence, Delirium can occur
related substances assaultiveness, within 24 hours
impulsiveness, after use of
psychomotor phencyclidine, or
agitation, impaired may occur up to a
judgment, week following
nystagmus, recovery from an
increased heart overdose of the
rate and blood drug
pressure,
diminished pain
 response, ataxia,
dysarthria, muscle
rigidity, seizures,
hyperacusis,
delirium
Sedatives, Disinhibition of Nausea/vomiting, Withdrawal may
hypnotics, and sexual or malaise, progress to
anxiolytics aggressive weakness, delirium, usually
impulses, mood tachycardia, within 1 week of
lability, impaired sweating, anxiety, last use. Long-
judgment, slurred irritability, acting barbiturates
speech, orthostatic or benzodiazepines
incoordination, hypotension, may be used in
unsteady gait, tremor, insomnia, withdrawal
impairment in seizures substitution
attention or therapy
memory
disorientation,
confusion

CHAPTER ASSESSMENT

Select the answer that is most appropriate for each of the following questions.

1. Mr. White is admitted to the hospital after an extended period of binge alcohol
drinking. His wife reports that he has been a heavy drinker for a number of years.
Lab reports reveal he has a blood alcohol level of 250 mg/dL. He is placed on the
chemical addiction unit for detoxification. When would the first signs of alcohol
withdrawal symptoms be expected to occur?
a. Several hours after the last drink
b. 2 to 3 days after the last drink
c. 4 to 5 days after the last drink
d. 6 to 7 days after the last drink

2. Symptoms of alcohol withdrawal include:

a. Euphoria, hyperactivity, and insomnia
b. Depression, suicidal ideation, and hypersomnia
c. Diaphoresis, nausea and vomiting, and tremors
d. Unsteady gait, nystagmus, and profound disorientation

3. Which of the following medications is the physician most likely to order for a
client experiencing alcohol withdrawal syndrome?
a. Haloperidol (Haldol)
b. Chlordiazepoxide (Librium)
c. Methadone (Dolophine)
d. Phenytoin (Dilantin)

4. Dan, who has been admitted to the alcohol rehabilitation unit after being fired for
drinking on the job, states to the nurse, “I don’t have a problem with alcohol. I can
handle my booze better than anyone I know. My boss is a jerk! I haven’t missed any
more days than my coworkers.” The nurse’s best response is:
a. “Maybe your boss is mistaken, Dan.”
b. “You are here because your drinking was interfering with your work, Dan.”
c. “Get real, Dan! You’re a boozer and you know it!”
d. “Why do you think your boss sent you here, Dan?”

5. Dan, who has been admitted to the alcohol rehabilitation unit after being fired for
drinking on the job, states to the nurse, “I don’t have a problem with alcohol. I can
handle my booze better than anyone I know. My boss is a jerk! I haven’t missed any
more days than my coworkers.” The defense mechanism that Dan is using is:
a. Denial
b. Projection
c. Displacement
d. Rationalization

6. Dan has been admitted to the alcohol rehabilitation unit after being fired for
drinking on the job. Dan’s drinking buddies come for a visit, and when they leave,
the nurse smells alcohol on Dan’s breath. Which of the following would be the best
intervention with Dan at this time?
a. Search his room for evidence.
b. Ask, “Have you been drinking alcohol, Dan?”
c. Send a urine specimen from Dan to the lab for drug screening.
d. Tell Dan, “These guys cannot come to the unit to visit you again.”

7. Dan begins attendance at AA meetings. Which of the statements by Dan reflects

the purpose of this organization?
a. “They claim they will help me stay sober.”
b. “I’ll dry out in AA, then I can have a social drink now and then.”
c. “AA is only for people who have reached the bottom.”
d. “If I lose my job, AA will help me find another.”

8. From which of the following symptoms might the nurse identify a chronic cocaine
user?
a. Clear, constricted pupils
b. Red, irritated nostrils
c. Muscle aches
d. Conjunctival redness

9. An individual who is addicted to heroin is likely to experience which of the

following symptoms of withdrawal?
a. Increased heart rate and blood pressure
b. Tremors, insomnia, and seizures
c. Incoordination and unsteady gait
d. Nausea and vomiting, diarrhea, and diaphoresis

10. A polysubstance abuser makes the statement, “The green and whites do me
good after speed.” How might the nurse interpret the statement?
a. The client abuses amphetamines and anxiolytics.
b. The client abuses alcohol and cocaine.
c. The client is psychotic.
d. The client abuses narcotics and marijuana.

Communication Exercises. Write the appropriate response of the nurse based on

the given statements by the patient. Identify the therapeutic communication
technique used in each item and justify your answer.
1. Tom is a patient on the Alcohol Treatment Unit. He says to the nurse, “My boss
and my wife ganged up on me. They think I have a drinking problem. I don’t have
a drinking problem! I can quit any time I want to!”
• How would the nurse respond appropriately to this statement by Tom?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________

2. Tom says to the nurse, “My head hurts. I didn’t sleep very well last night. I’m
getting shaky and it’s hot in here! I could sure use a cup of coffee and a
cigarette.”
• How would the nurse respond appropriately to this statement by Tom?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________
3. Tom says, “Sure, I missed a couple days of work. Everyone gets sick now and
then. I don’t think my wife cares about what happens to me. She and my boss got
together and decided I needed to be here, or I lose my job!”
• How would the nurse respond appropriately to this statement by Tom?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________

CHAPTER XIII
EATING DISORDERS
COGNITIVE DISORDERS

Before you proceed…

 Set your learning goals. At the end of this chapter, you are expected to attain the
following Intended Learning Outcomes:
 Identify and differentiate the various types of eating and cognitive
disorders
 Describe the symptomatology associated with anorexia nervosa,
bulimia nervosa, and obesity, as well as various cognitive disorders
and use the information in client assessment
 Identify risk factors of eating and cognitive disorders and its
epidemiology
 Apply the nursing process in caring for patients with eating and
cognitive disorders
 Prepare your books and notebooks. Highlight concepts that need to be
reinforced. Jot down supplemental information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of this
chapter is also provided along with other resources to facilitate better
understanding of the topics.

Activities:
 Critical thinking exercise
 Assignment

Let’s Begin!

KEY TERMS
 Amenorrhea
 Anorexia nervosa
 Anorexiants
 Binge eating
 Bulimia nervosa
 Emaciated
 Obesity
 Purging
 Mental retardation
 Alzheimer’s disease

EATING DISORDERS
Anorexia Nervosa
 Does not eat
 Self-imposed starvation

Etiology:
  Biologic factors:
o Genetic predisposition
o Dysfunction of the hypothalamus
o decreased Serotonin
 Developmental factors:
o Overprotective/ domineering enmeshed family
 decreased Control and helplessness
o Disturbed body image
o Conflicts about growing up – doesn’t like to be a grown up
o Sees herself as fat
o Preoccupied with losing weight and is afraid of gaining weight
 Social factor:
o “Thin is in”

Assessment:
 Refusal to maintain body wt at or above minimum normal weight
 Must lose 15 to 25% below normal weight
 Intense fear of gaining wt
 decreased VS
 Absence of at least 3 consecutive menstrual cycles
 Lanugo – endo changes
 Hypoglycemia, fluid and electrolyte imbalance
 Compulsive people, good girl in the family, achievers

Management:
 Goal: Gradual steady weight gain of 1-2 lbs/wk

 3 Major Objectives:
o To re-establish appropriate eating behavior
 Re-feeding Program
o Desired weight gain – 1 to 2 lbs/ wk
o 500 – 1000 kcal/day in divided amount
o Small, frequent feeding
o Monitoring the client’s weight before breakfast after
voiding, same clothes and weighing scale
 Behavior Modifications Contract
o For active participation of patient, set limits and
conditions
o Agree that all food will be eaten for a specified time
o Include patient in tx planning, do not force like parents
o Expected wt gain
o Encourage participation
 Sit w/ client during meals
o Observe how much was eaten and remind contract
o Stay in public place
o Stay for at least 1 hour after
 DO NOT GIVE LAXATIVE. May disturb the already disturbed
GI, verify with doctor, give stool softener
 Increase self- esteem
o Identify good points
o Give recognition when she gains weight
 Assist in expression of feelings
o Journaling

Other Treatment Modalities

 Behavior modification
 Pharmacotherapy w/ antidepressant
o Elavil (Amitriptyline), Prozac (Fluoxetine HCl)
 Family therapy
 Psychotherapy – should have ff-up
o Discharge if patient has gained almost 90% of IBW
Bulimia Nervosa
 Characterized by binge eating
o Taking in a lot of food over a short period of time

Assessment:
 Recurrent episodes of binge-eating
 A feeling of lack of control over eating behaviors
 Inappropriate compensatory behavior to lose weight (the use of ipecac syrup
to induce vomiting)
 Self-evaluation overly influenced by body shape and weight
 Love-hate relationship
 Normal/ a little above/ below the normal weight

 Focus on feelings not on behaviors

Nursing Interventions:
 Set limit to binge-eaters – adhere to meal schedule
 Assist in identifying feelings associated with binge/ purge and facilitate
expression of feelings/ alternative ways
 Improve self-esteem

Other treatment modalities:

 Use of antidepressants
 Cognitive behavior therapy

COGNITIVE DISORDERS
 Used to be called Organic Mental Disorders
 Disorders that affect consciousness, memory, orientation, attention,
perception and language disturbance

Delirium: Acute confusional state

 Causes:
o Physical illness
 CHF, uremia, pneumonia, metabolic d/os, CVA, DHN, infx, etc
o Prescription Drugs:
 Polypharmacy w/ drugs and anticholinergic effects
Dementia: Progressive cognitive deterioration
 Causes:
o Reversible conditions like:
 Encephalopathy
 Infxs like syphilis
 Toxic conditions due to substances like alcohol, metal

Dementia of the Alzheimer’s Type

 Etiology: Unknown but with various theories like
o Genetics
o Toxin
o Infection
o Cholinergic deficit – acetylcholine
 May use cholinesterase blockers
o Structural
 Neurofibrillary tangles
 Neuritis/ senile block
 Acetylcholinesterase
 Downhill trend

Stages:
 Mild (2 to 3 yrs)
o Forgetfulness is the hallmark
o 4 A’s
  Amnesia – short term/ recent first
 Aphasia – loss of expressive ability
 Apraxia – loss of purposeful bodily mov’t
 Agnosia – loss of ability to recognize
o Word and name-finding difficulties
o Problem in decision making, judgment and reasoning
o Repetitive questioning
o Difficulty performing usual activities
o Not too deteriorated yet
o Goal: ensure optimum activities, place wall clock and calendar inside
room

 Moderate (3 to 4 years)
o Confusion and disorientation
o Wandering and sleep disturbance
o The other 3A’s – apraxia, agnosia, aphasia
 Expressive aphasia
 Perceptive aphasia
 Global aphasia
o Needs assistance and supervision with ADL’s
o Direct the client step-by-step
o Approach in full view
o Use vivid colors
o Reorient every interaction you have
o Environment – same, consistent
o Sleep-wake cycle disturbance
 Insomnia – known cause first
 Environmental modifications

 Severe (5 to 10 years)
o Personality with emotional changes
o Deterioration in all areas of function
o Requires 24° supervision, close supervision or both
o Irritable and combative
 Give time
 Distract when angry

Nursing Diagnosis
 Risk for injury
 Altered thought process (memory, confusion, deterioration)
 Impaired communication
 Impaired socialization
 Altered role performance
 Self-care deficit
 Sleep pattern disturbance
 Low esteem
 Caregiver role strain

Interventions:
 Goal: Promote optimum function and have patience
o Promote client’s safety and protection from injury
 Non-slippery floor
 Test temperature
o Structure environment and routine
  Rearrange room
 Client does not want change
 Consistent, highly structured
o Promote adequate sleep, proper nutrition, hygiene and activity
 Time away – if insists, leave for a while and return after 15 mins
 Can do what he can do/ able to do
 Warm milk, warm bath, quiet environment
 o Promote interaction & involvement
 Reminiscing activities
o Early stage
 Gardening
 Interactive activities
o Provide emotional support, acceptance, increase worth by letting
them perform what they know
 Allow verbalization of feelings
o Do not come from the side, approach from the front
o Reorient patient
o Family/ caregiver support

SELECTED CHILDHOOD DISORDERS

Autistic Disorder
 Self-absorbed
 Does not pay attention to others

 Etiology:
o Genetic
o Biochemical - PKU

Impairments of a Child w/ Autism

 Impairment in social interaction
o Prefer to be with inanimate objects
o Things that spin
o Security object
 Impairment in verbal communication
o Does not know how to communicate w/ others
o If talks – echolalia
o Does not establish eye contact
 Disturbed personal identity
o Uses third person
 Engages in repetitive activities
 Head banging, sometimes ignores nutrition
o Self-absorbed

Characteristics of a Nurse:
 Accepting
 Reality-based
 Safe
 Consistent

Interventions:
 Goal: Optimize function

 Accepting
o Eye contact
o Spend time with child
 Reality-based
o Impaired personal identity
o Reinforcing identity
 Safe
o Self-harm
o Pad side of bed
o Helmet
 Consistent
o Same environment

Antipsychotic Drugs - Haldol

Care of a Child with Attention Deficit (Hyperactivity) Disorder (ADHD)

 Genetic
  Biochemical – too much stimulant
 Min brain d/o
 Psychosocial factors
o Stress/ disequilibrium in the family
 Get attention of child before giving instructions
 Child knows that the other children does not like him because of his
hyperactivity
o  self-esteem

Manifestations:
 Impulsivity leads AD
 Inattention/ distractibility leads to AD
 Hyperactivity leads to ADHD

Management:
 Set Limits
o Does not benefit in a lenient upbringing
o Should not be scolded and point out what is socially unacceptable
o Quiet, non-stimulating environment
o Classroom – front
 Enhance self-worth
o Behave – award
o Give recognition to good points
 Short term activities
 Remove the child from the upsetting situation (time out)
 Set time frame

Drugs: Stimulants
 Improve attention span
 Enhance concentration
 Ritalin (Methylphenidate HCl) – paradoxic effect, help client focus

 Side Effects:
o Insomnia – give at daytime: AM til noon
o decreased Appetite – give after meals
o Tics – report

MENTAL RETARDATION
 Developmental disorder of sub-average intellectual capacity
 Ave IQ: 90 – 110
 Difficulty in ADLS
 decreased Adaptive ability

Etiology:
- Prenatal
o Chromosomal aberration – 21 chromosomes
o German measles – 1st trimester
o Malnourish mother
o PKU
o Cardiac condition of mother resulting to decreased oxygenation
o FAS
o Maternal malnutrition

- Perinatal
o Cerebral anorexia
o Traumatic delivery (forcep or vaccum)
o Abruption placenta
o Multiple births
o Placenta previa
- Postnatal
o Infection
o Head injury
o Malnutrition
o Lead intoxication
o Poor parenting (decreased environmental stimulation)

Developmental age/mental age

- Highest capability that a child can reach regardless of the chronological age

Degree Range IQ Description Mental Age

Profound Less than 20 IQ
Severe 20-40  Abilities of 3 0 - 3
y/o
Contribute to self-
care
Moderate 40 – 55  Self-care 3-8
IQ  Until grade 2
only
 Trainable:
unskilled and
skilled work
 May need
support even
in just minimal
 stressor
Mild 55-70  Until grade 6 8-12
 Educable:
Vocational
 Cannot move
around
 neighborhood
Borderline 70-85 Slow learning

Interventions:
 Goal: Optimize function
 Planning must not be on chronological age but on developmental age
 Teach from simple to complicated
o Use visual aids
 Be patient - repetition
 Do not be overprotective
o Protect from possible injury
 Protect from teasing of others/ help them become more acceptable to others
o Help them smell good
o Teach social phrases
 Support – parents
 Parents must not reject their child

CHAPTER ASSESSMENT
Select the answer that is most appropriate for each of the following questions.
1. An example of a treatable (reversible) form of neurocognitive disorder (NCD) is
one that is caused by which of the following? (Select all that apply.)
a. Multiple sclerosis
b. Multiple small brain infarcts
c. Electrolyte imbalances
d. HIV disease
e. Folate deficiency
‘
2. Mrs. G has been diagnosed with NCD due to Alzheimer’s disease. The cause of this
disorder is which of the following?
a. Multiple small brain infarcts
b. Chronic alcohol abuse
c. Cerebral abscess
d. Unknown

3. Mrs. G has been diagnosed with NCD due to Alzheimer’s disease. The primary
nursing intervention in working with Mrs. G is which of the following?
a. Ensuring that she receives food she likes, to prevent hunger
b. Ensuring that the environment is safe, to prevent injury
c. Ensuring that she meets the other patients, to prevent social isolation
d. Ensuring that she takes care of her own ADLs, to prevent dependence

4. Which of the following medications have been indicated for improvement in

cognitive functioning in mild to moderate Alzheimer’s disease? (Select all that
apply.)
a. Donepezil (Aricept)
b. Rivastigmine (Exelon)
c. Risperidone (Risperdal)
d. Sertraline (Zoloft)
e. Galantamine (Razadyne)

5. Mrs. G, who has NCD due to Alzheimer’s disease, says to the nurse, “I have a date
tonight. I always have a date on Christmas.” Which of the following is the most
appropriate response?
a. “Don’t be silly. It’s not Christmas, Mrs. G.”
b. “Today is Tuesday, Oct. 21, Mrs. G. We will have supper soon, and then your
daughter will come to visit.”
c. “Who is your date with, Mrs. G?”
d. “I think you need some more medication, Mrs. G. I’ll bring it to you now.”

6. In addition to disturbances in cognition and orientation, individuals with

Alzheimer’s disease may also show changes in which of the following? (Select all that
apply.)
a. Personality
b. Vision
c. Speech
d. Hearing
e. Mobility

7. Mrs. G, who has NCD due to Alzheimer’s disease, has trouble sleeping and
wanders around at night. Which of the following nursing actions would be best to
promote sleep in Mrs. G?
a. Ask the doctor to prescribe flurazepam (Dalmane).
b. Ensure that Mrs. G gets an afternoon nap so she will not be overtired at bedtime.
c. Make Mrs. G a cup of tea with honey before bedtime.
d. Ensure that Mrs. G gets regular physical exercise during the day.

8. The night nurse finds Mrs. G, a client with Alzheimer’s disease, wandering the
hallway at 4 a.m. and trying to open the door to the side yard. Which statement by
the nurse probably reflects the most accurate assessment of the situation?
a. “That door leads out to the patio, Mrs. G. It’s nighttime. You don’t want to go
outside now.”
b. “You look confused, Mrs. G. What is bothering you?”
c. “This is the patio door, Mrs. G. Are you looking for the bathroom?”
d. “Are you lonely? Perhaps you’d like to go back to your room and talk for a while.”

9. A client says to the nurse: “I read an article about Alzheimer’s and it said the
disease is hereditary. My mother has Alzheimer’s disease. Does that mean I’ll get it
when I’m old?” The nurse bases her response on the knowledge that which of the
following factors is not associated with increased incidence of NCD due to
Alzheimer’s disease?
a. Multiple small strokes
b. Family history of Alzheimer’s disease
c. Head trauma
d. Advanced age

10. Mr. Stone is a client in the hospital with a diagnosis of vascular NCD. In
explaining this disorder to Mr. Stone’s family, which of the following statements by
the nurse is correct?
a. “He will probably live longer than if his disorder was of the Alzheimer’s type.”
b. “Vascular NCD shows step-wise progression. This is why he sometimes seems
okay.”
c. “Vascular NCD is caused by plaques and tangles that form in the brain.”
d. “The cause of vascular NCD is unknown.”

Critical thinking exercise:

Joe, a 62-year-old accountant, began having difficulty remembering details

necessary to perform his job. He was also having trouble at home, failing to keep his
finances straight, and forgetting to pay bills. It became increasingly difficult for him
to function properly at work, and eventually he was forced to retire. Cognitive
deterioration continued, and behavioral problems soon began. He became stubborn,
verbally and physically abusive, and suspicious of most everyone in his environment.
His wife and son convinced him to see a physician, who recommended
hospitalization for testing. At Joe’s initial evaluation, he was fully alert and
cooperative but obviously anxious and fidgety. He thought he was at his accounting
office and he could not state what year it was. He could not say the names of his
parents or siblings, nor did he know who the president of the Philippines. He could
not perform simple arithmetic calculations, write a proper sentence, or copy a
drawing. He interpreted proverbs concretely and had difficulty stating similarities
between related objects. Laboratory serum studies revealed no abnormalities, but a
CT scan showed marked cortical atrophy. The physician’s diagnosis was
neurocognitive disorder due to Alzheimer’s disease.

Answer the following questions related to Joe:

1. Identify the pertinent assessment data from which nursing care will be
devised.
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________

2. What is the primary nursing diagnosis for Joe?

_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________

3. How would outcomes be identified?

_______________________________________________________________________________
_______________________________________________________________________________
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