2993_FM_i-xvi 14/01/14 5:31 PM Page i

4 TH EDITION

Neeb’s Fundamentals
of Mental Health
Nursing
Linda M. Gorman, RN, MN, PMHCNS-BC, FPCN
Clinical Nurse Specialist/Nursing Consultant
Private Practice
Studio City, California

Robynn F. Anwar, MST, MSN, Ed

Nursing Faculty/CNA and Multi-Skilled Coordinator
Camden County College, Camden Campus
Camden, New Jersey
2993_FM_i-xvi 14/01/14 5:31 PM Page ii

F.A. Davis Company

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Copyright © 2014 by F. A. Davis Company
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Library of Congress Cataloging-in-Publication Data
Gorman, Linda M., author.
Neeb’s fundamentals of mental health nursing / Linda M. Gorman, Robynn F. Anwar. — Fourth edition.
p. ; cm.
Fundamentals of mental health nursing
Preceded by: Fundamentals of mental health nursing / Kathy Neeb. 3rd ed. c2006.
Includes bibliographical references and index.
ISBN 978-0-8036-2993-6 (pbk. : alk. paper)
I. Anwar, Robynn F., author. II. Neeb, Kathy, 1952- Fundamentals of mental health nursing. Preceded by
(work): III. Title. IV. Title: Fundamentals of mental health nursing.
[DNLM: 1. Mental Disorders—nursing. 2. Nursing, Practical. 3. Psychiatric Nursing—methods. WY 160]
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2993_FM_i-xvi 14/01/14 5:31 PM Page iii

To Corie, who saw me as an author many years ago.

(LG)

To Mayme, I realize how much easier this journey would have been
if you were here. Wasim and Andrea, I appreciate your belief in my
abilities. “Mom Bessie,” who renewed her practical nurse license at
age 94. Linda, thank you for being my mentor through this process.
Shirley, Toni, and Ted—Thank you.
(RA)
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2993_FM_i-xvi 14/01/14 5:31 PM Page v

Preface

N
eeb’s Fundamentals of Mental Health Chapters 1 to 9 provide the basics of
Nursing is a psychiatric nursing text mental health nursing concepts, with an
tailored specifically to the needs of emphasis on communication. Chapters 10
the LVN/LPN student. We understand that to 22 are “clinical” chapters in that they
many students at this level of preparation cover specific diagnoses and/or populations.
do not have the opportunity for clinical ex- Many of the chapters include the following
perience in a psychiatric setting, but they will new or enhanced key features:
encounter patients with mental health issues
in their rotations. Students will encounter • Neeb’s Tip will give a “clinical pearl” that
patients and their families with psychiatric succinctly describes a key take-away from
diagnoses as well as a variety of psychosocial the chapter.
issues and behaviors that challenge them. This • Critical Thinking Questions are expanded
text will provide the basic knowledge and and interspersed in the chapters to empha-
skills to address many of these challenges, size a concept and challenge the student to
with an emphasis on communication. This apply the concept just covered. Many of
new edition also brings enhancements via the these include case-based scenarios.
Internet through DavisPlus. • Toolbox provides additional resources for
Our goal with this text is to provide basic students who want more information.
information about mental health theories, These can be further explored on the
personality development, coping and com- book’s Web site.
munication styles, psychiatric diagnoses, and • Pharmacology Corner in Chapters 10 to 20
nursing actions, all as they pertain to the prac- and 22 covers important current informa-
tice of the LVN/LPN. tion about medications used for the spe-
The impact of psychiatric disorders con- cific population that will pertain to the
tinues to be a concern in the United States. LVN/LPN scope of practice.
Depression, anxiety, eating disorders, and • Clinical Activities are suggestions for the
substance abuse continue to be major health student to utilize when caring for patients
problems. How society responds to debilitat- with a particular disorder.
ing mental illness has been the subject of • Classroom Activities include suggestions
much debate. Clearly the need for nurses to for projects or actions that students
have education in caring for people with and faculty can use in the classroom
mental health issues is essential. to enhance learning.
The Fourth Edition of Neeb’s Fundamentals • Case Studies are in-depth, with questions
of Mental Health Nursing brings new authors to help the student apply knowledge
who have expanded on the foundations that learned in the chapter.
Kathy Neeb created so successfully in the first • Multiple Choice Questions—At least
three editions. The new authors bring broad 10 questions are provided at the end of
experience in psychiatric nursing, education, the chapters, with the answers/rationales
and clinical practice. New chapters in this in Appendix A. Additional NCLEX
Fourth Edition include postpartum issues questions are on the book’s Web site.
as well as separate chapters on depressive • Sample Care Plans are provided in the
and bipolar disorders. We have added more clinical chapters.
features to enhance the concepts and make • Appendix E, which is new, matches com-
them more meaningful and current. mon behaviors with nursing diagnoses.

v
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vi Preface

Internet-based enhancements include pod- LVN/LPN student will not be using the
casts, updated references, and other resources Manual routinely, a familiarity with the
such as drug monographs and Neeb’s blog. terminology that is used by other health-care
Neeb’s blog will provide an opportunity for professionals is essential. The chapter titles
the student to reflect on learning and experi- reflect the new terminology where changes
ences that can be shared with others. For have been made.
the instructor, this Fourth Edition provides We, as practitioners and educators in the
access to PowerPoint presentations, test bank field of mental health, have seen the impact
questions, and other expanded features. of mental health issues on our patients and
This edition coincides with the publica- society. We hope that the students who
tion of the DSM-5, Diagnostic and Statistical utilize this book will gain a new perspective
Manual for Mental Disorders by the American that includes up-to-date knowledge as well
Psychiatric Association that was published as empathy for the suffering these disorders
in 2013. The terminology used throughout can cause. We hope this book will con-
this edition reflect the changes in this tribute to knowledgeable and compassion-
major psychiatric reference. Although the ate LVNs/LPNs.
2993_FM_i-xvi 14/01/14 5:31 PM Page vii

Reviewers

PATTI A LFORD , RN, BSBM D EBORAH B. H ARRIS , BSN, MSN, RN

Instructor Director, Practical Nursing Program
Kilgore College Valley Vocational Technical Center
Longview, Texas Fishersville, Virginia
R UTH F EE B LACKMORE , MSN, RN, CNOR E ULA J ACKSON , ADN, BS, MSN, CNE, P H D
Faculty of Nursing Nursing Facilitator/Clinical Instructor
Isabella Graham Hart School of Practical Reid State College and University of Phoenix
Nursing Evergreen, Alabama
Rochester, New York
L INDA J OHNSON , RN, PHN, MSN, DHA
R ENEÉ T. B URWELL , AASN, BSN, MSE D, E DD Assistant Director Vocational Nursing Program
Coordinator of Health Science Programs Los Medanos College
Charlotte Technical Center Pittsburg, California
Port Charlotte, Florida
E THEL J ONES , E D S, DSN, RN, CNE
J OYCE C ANAVAN , BS E D , MSN, RN Nursing Instructor
Mental Health, Lead Instructor H. Councill Trenholm State Technical College
Anamarc College Montgomery, Alabama
El Paso, Texas
TAMMY K RELL , MSN, RN
TAMMIE C OHEN , RN, BSN Coordinator of PN Program
Nursing Instructor, Faculty Advisor Chairperson Western Wyoming Community College
Western Suffolk BOCES Evanston, Wyoming
Northport, New York
SUSAN R. LEFERSON, RN, BSN, MSBA, COHC
W ENDY C. FARR , RN, BSN, MSN E D , I NS Nurse Educator
Practical Nursing Instructor Medical Careers Institute, School of Health
Southern Crescent Technical College Sciences of ECPI University
Thomaston, Georgia Manassas, Virginia
B RIAN F ONNESBECK , RN, MN, BSN, ADN R IMINA L EWIS , MSN/E D , RN
Associate Professor of Nursing and Health Sciences Instructor, Practical Nurse Program
Lewis-Clark State College Savannah Technical College
Lewiston, Idaho Savannah, Georgia
C HERYL G ILBERT, RN, BHA G AYLA L OVE , MSN, BSN, RN, CCM
Assistant Director, Vocational Nursing Program Program Coordinator, Practical Nursing
Chaffey College, Chino Campus Southern Crescent Technical College
Chino, California Griffin, Georgia
P EGGY G RADY, RN, ASN K IMBERLY K. M C C LURE , MSN, RN
Assistant Director, PN Program Vocational Nursing Instructor
Clinical Instructor Victoria College
Southern Crescent Technical College Victoria, Texas
Griffin, Georgia

vii
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viii Reviewers

C AROL A. M ILLER , BSN P HYLLIS ROWE , DNP, RN, ANP

Nursing Instructor Professor, Nursing
Southeastern Technical Institute Riverside City College
Easton, Massachusetts Riverside, California
J OHN H. N AGELSCHMIDT, MSN, RN E LLEN S ANTOS , MSN, RN, CNE
Nursing Instructor Instructor of Practical Nursing
Assabet Valley Regional Technical High School Assabet Valley Regional Technical School
Marlborough, Massachusetts Marlborough, Massachusetts
D IANA N OBLEZA , MSN, RN J UDITH M. S HAFFER , RN, BSN, MSN E D
Instructor and CFO STUDENT
Pinelands School of Practical Nursing & Allied Practical Nursing Educator
Health, Inc. ECPI University
Toms River, New Jersey Raleigh, North Carolina
S ALLIE N OTO , RN, MS, MSN C LAUDIA S TOFFEL , MSN, RN, CNE
Director, CTC School of Practical Nursing Professor of Nursing, Practical Nursing Program
Career Technology Center Coordinator
Scranton, Pennsylvania West Kentucky Community and Technical
College
M ARY A. O LSON , MA, RN
Paducah, Kentucky
PN Program Director
St. Paul College K ENDRA S TRENTH , RN, MSN, DNP, BC
Saint Paul, Minnesota Instructor
Bishop State Community College
K RISTI P FEIL , MSN, RN
Mobile, Alabama
VN Nursing Faculty
Victoria College B ARBARA TAYLOR , RN, MSN
Victoria, Texas LPN Instructor
Walton Career Development Center
M ARYELLEN P ICCHIELLO , MS, RN
DeFuniak Springs, Florida
LPN Instructor
Ocean County Vocational Technical School S ANDRA D. T HOMPSON , RN
Toms River, New Jersey Coordinator
Mercer County Technical Education Center
J ENNIFER P ONTO , RN, BSN
Princeton, West Virginia
Instructor, Vocational Nursing
South Plains College P EGGY VALENTINE , RN, BSN, MSN C
Levelland, Texas Director of Nursing
Skyline College
C INDY P RICE , MSN, RN
Roanoke, Virginia
Practical Nurse Instructor
Mid-East Career and Technology Center FAYE WARNER , RN, MSN
Zanesville, Ohio LPN Instructor
Kaynor Regional High School
C YNTHIA ROBERTS , MS, RN
Waterbury, Connecticut
Program Director
Isabella Graham Hart School of Practical
Nursing
Rochester General Health System
Rochester, New York
2993_FM_i-xvi 14/01/14 5:31 PM Page ix

Consultants to Previous Editions

B RENDA A GEE , RN, MSN C HRISTINE D. H ERDLICK , RN, BA

Nursing Instructor Nursing Instructor
Delaware Technical and Community College Marshalltown Community College
Georgetown, Delaware Marshalltown, Iowa
E THEL AVERY, RN, MSN, E D S D EBRA H ODGE
Instructor Licensed Practical Nursing
H. Councill Trenholm State Technical College West Virginia Academy of Careers and
Montgomery, Alabama Technology
Beckley, West Virginia
S HARON M. E RBE , RN, BSN, MSN( C )
Nursing Coordinator P HYLLIS L ILLY, RN, BSN
WSWHE BOCES Instructor
Hudson Falls, New York Isabella Graham Hart School of Practical
Nursing
G LORIA F ERRITTO , RN, BSN, PHN
Rochester General Hospital
Assistant Director, Vocational Nursing Program
Rochester, New York
Maric College
Vista, California M AUREEN L. M C G ARY, RN, MSN, NP-C
Former Program Head, Practical Nursing
F RANCES F RANCIS , RN, BS
Virginia Western Community College
Practical Nursing Instructor
Wirtz, Virginia
Hazard Regional Technology Center
Hazard, Kentucky B ETTY R ICHARDSON , RN, P H D, LPC,
LMFT, CS, CNAA
S UE G ARLAND , RN, MSN, ARNP
Instructor, Practical Nursing Program
Division Chair, Allied Health and Related
Austin Community College
Technologies
Austin, Texas
Practical Nursing Program Coordinator
Big Sandy Community and Technical College ROBIN A. S PIDLE , RN, P H D
Paintsville, Kentucky Payson, Arizona
N ANCY T. H ATFIELD , RN, BSN, MA J UDY S TAUDER , RN, MSN
Instructor, Practical Nursing Program Coordinator
Career Enrichment Center Practical Nursing Program of Canton City
Albuquerque Public Schools Schools
Albuquerque, New Mexico Canton, Ohio

ix
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Acknowledgments

W
e want to acknowledge our Devel-
opment Editor, Julie P. Scardiglia.
Julie guided us through the writ-
ing process. Her enthusiasm, encouragement
and, of course, her attention to detail kept us
on track throughout the revision process. Her
suggestions, responsiveness, availability for
many conference calls, and organization skills
helped us produce a revision that taps into
today’s student’s needs. She worked closely
with us every step of the writing process. We
are thankful for all her help.
Jacalyn Clay, our Project Editor from F.A.
Davis, provided us with the support and re-
sources to develop a project that expands on
Kathy Neeb’s original ideas. We appreciate all
the guidance she provided to us.
—L INDA G ORMAN
ROBYNN A NWAR

xi
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Table of Contents

unit 1 Foundations for Mental Health Nursing

chapter 1 History of Mental Health Nursing 3
The Trailblazers 3
The Facilities 8
The Breakthroughs 8
The Laws 11
chapter 2 Basics of Communication 15
Communication Theory 16
Types of Communication 16
Challenges to Communication 19
Therapeutic Communication 21
Adaptive Communication Techniques 28
chapter 3 Ethics and Law 33
Professionalism 33
Ethics 34
Confidentiality 38
Responsibility 41
Accountability 41
Abiding by the Current Laws 41
Patients’ Rights 42
Patient Advocacy 45
Community Resources 45
chapter 4 Developmental Psychology Throughout
the Life Span 51
Developmental Theorists: Newborn to Adolescence 52
Developmental Theorists: Adolescence to Adulthood 56
Stages of Human Development 63
chapter 5 Sociocultural Influences on Mental Health 75
Culture 75
Ethnicity 78
Nontraditional Lifestyles 79
Homelessness 81
Economic Considerations 82
Abuse 83
Poor Parenting 83
chapter 6 Nursing Process in Mental Health 89
Step 1: Assessing the Patient’s Mental Health 90
Step 2: Nurses Diagnosis: Defining Patient Problems 95
Step 3: Planning (Short- and Long-Term Goals) 95
Step 4: Implementations/Interventions 96
Step 5: Evaluating Interventions 100
chapter 7 Coping and Defense Mechanisms 105
Coping 105
Defense Mechanisms 107

xiii
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xiv Table of Contents

chapter 8 Mental Health Treatments 113

Psychopharmacology 114
Milieu 123
Psychotherapies 123
Terrorism 136
Legal Considerations 137
chapter 9 Complementary and Alternative Treatment
Modalities 143
Mind, Body, and Belief 144
Common Complementary and Alternative Treatments 144
Primary Sensory Representation 152

unit 2 Threats to Mental Health

chapter 10 Anxiety, Anxiety-Related, and Somatic Symptom
Disorders 159
Anxiety Disorders 160
Etiology of Anxiety and Stress 161
Differential Diagnosis 161
Types of Anxiety and Anxiety-Related Disorders 162
Medical Treatment of People With Anxiety-Related Disorders 167
Alternative Interventions for People With Anxiety and
Anxiety-Related Disorders 168
Nursing Care for People With Anxiety and Anxiety-Related
Disorders 168
Somatic Symptom and Related Disorders 170
chapter 11 Depressive Disorders 181
Types of Depressive Disorders 181
Etiology of Depressive Disorders 185
Treatment of Depressive Disorders 185
Nursing Care of the Patient With Depressive Disorders 186
chapter 12 Bipolar Disorders 193
Characteristics of Bipolar Disorders 193
Etiology of Bipolar Disorders 195
Treatment of Bipolar Disorders 196
Nursing Care of the Patient With Bipolar Disorders 198
chapter 13 Suicide 205
The Reality of Suicide 205
Etiology of Suicide 207
Treatment of Individuals at Risk for Suicide 208
Nursing Care of the Suicidal Patient 209
chapter 14 Personality Disorders 217
Types of Personality Disorders 218
Psychiatric Treatment of Personality Disorders 223
Nursing Care of Patients With Personality Disorders 223
chapter 15 Schizophrenia Spectrum and Other Psychotic
Disorders 231
Symptoms 233
Etiology of Schizophrenia 234
Psychiatric Treatment of Schizophrenia 235
Nursing Care of the Schizophrenic Patient 238
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Table of Contents xv

chapter 16 Neurocognitive Disorders: Delirium

and Dementia 245
Delirium 245
Dementia 247
Nursing Care of Patients With Delirium and Dementia 253
chapter 17 Substance Use and Addictive Disorders 261
Alcohol 264
Other Substances 270
Nursing Care of Patients With Substance Use Disorders
(Including Alcohol) 278
chapter 18 Eating Disorders 287
Anorexia Nervosa 287
Bulimia 290
Similarities Between Anorexia and Bulimia 292
Morbid Obesity 292
Nursing Care of Patients With Eating Disorders 294

unit 3 Special Populations

chapter 19 Childhood and Adolescent Mental Health
Issues 303
Depression, Bipolar Disorder, and Suicide in Children
and Adolescents 304
Attention Deficit/Hyperactivity Disorder 308
Autism Spectrum Disorder 312
Conduct Disorder 315
chapter 20 Postpartum Issues in Mental Health 323
Postpartum Blues 323
Postpartum Depression 324
Postpartum Psychosis 326
Nursing Care of Women With Postpartum Mental Disorders 328
chapter 21 Aging Population 335
Alzheimer’s Disease and Other Cognitive Alterations 338
Cerebrovascular Accident (Stroke) 338
Depression in the Elderly 339
Medication Concerns 340
Paranoid Thinking 340
Insomnia 341
End-of-Life Issues 342
Social Concerns 343
Nursing Skills for Working With Older Adults 344
Restorative Nursing 345
Palliative Care 347
chapter 22 Victims of Abuse and Violence 353
The Abuser 354
The Victim 355
Categories of Abuse 356
Treatment of Abuse 361
Nursing Care of Victims of Abuse 362
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xvi Table of Contents

Appendices
appendix A Answers and Rationales 370
appendix B Agencies That Help People Who Have
Threats to Their Mental Health 387
appendix C Organizations That Support the Licensed
Practical/Vocational Nurse 388
appendix D Standards of Nursing Practice for LPN/LVNs 390
appendix E Assigning Nursing Diagnoses to Client
Behaviors 393
Glossary 395
Index 405
2993_Ch01_001-014 14/01/14 5:16 PM Page 1

UNIT 1
Foundations for Mental
Health Nursing
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2993_Ch01_001-014 14/01/14 5:16 PM Page 3

C HA PT E R 1
History of Mental
Health Nursing
Learning Objectives Key Terms
1. Identify the major trailblazers to mental health nursing. • American Nurses
2. Know the basic tenets or theories of the contributors to Association (ANA)
mental health nursing. • Asylum
3. Define three types of treatment facilities. • Deinstitutionalization
4. Identify three breakthroughs that advanced mental health • Free-standing treatment
nursing. centers
5. Identify the major laws and provisions of each that influenced • National Association
mental health nursing. for Practical Nurse
Education and Service
(NAPNES)
• National Federation of
Licensed Practical
Nurses (NFLPN)
• National League for
Nursing (NLN)
• Nurse Practice Act
• Psychotropic
• Standards of care

■ The Trailblazers were the nurses who took the risks? Who were
the ones who spoke out on behalf of the
For centuries, nurses have been many things patient and the profession? In times when
to many people. People have nurses to thank nursing was considered only “women’s work,”
for cooking, cleaning, and ministering to and when women were not politically active,
those who fought battles. the major trailblazers were female.
Long before people knew what aerobic or
anaerobic microorganisms were, nurses knew Florence Nightingale
when to open or close the windows. Nurses Florence Nightingale (1820–1910) (Fig. 1-1).
helped women give birth to their young and has been called the founder of nursing. Her
nursed the babies when mothers were unable story and her contributions are numerous
to or when mothers died during or shortly enough to fill many volumes. She was born
after giving birth. The first flight attendants of wealth and was highly educated. When she
were nurses. For centuries, nurses have gone was very young, she realized she wanted to be
about the business of caring for people, but a nurse, which did not please her parents.
they have not always done that quietly. Who Conditions in hospitals were poor, and her
3
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4 UNIT 1 | Foundations for Mental Health Nursing

The tidal wave of deeper souls

Into our inmost being rolls,
And lifts us unawares
Out of all meaner cares.
Honour to those whose words or deeds
Thus help us in our daily needs,
And by their overflow
Raise us from what is low!
Thus thought I, as by night I read
Of the great army of the dead,
The trenches cold and damp,
The starved and frozen camp,
The wounded from the battle-plain,
In dreary hospitals of pain,
Figure 1-1 Florence Nightingale at work
during the Crimean War. The cheerless corridors,
The cold and stony floors.
Lo! in that house of misery
parents wanted her to pursue a life as wife, A lady with a lamp I see
mother, and society woman. Pass through the glimmering gloom,
Florence worked hard to educate herself And flit from room to room.
in the art and science of nursing. Her And slow, as in a dream of bliss,
mission to help the British soldiers in the The speechless sufferer turns to kiss
Crimean War earned her respect around the Her shadow, as it falls
world as a nurse and administrator. This was Upon the darkening walls.
no easy task because many of the soldiers at As if a door in heaven should be
the Barrack Hospital at Scutari resented her Opened and then closed suddenly,
intelligence and did what they could to The vision came and went,
undermine her work. The light shone and was spent.
The relationship between sanitary con- On England’s annals, through the long
ditions and healing became known and Hereafter of her speech and song,
accepted due to her observations and dili- That light its rays shall cast
gence. Within 6 months of her arrival in From portals of the past.
Scutari, the mortality rate dropped from A Lady with a Lamp shall stand
42.7% to 2.2% (Donahue, 1985, p. 244). In the great history of the land,
She insisted on proper lighting, diet, clean- A noble type of good,
liness, and recreation. She understood that Heroic womanhood.
the mind and body work together and Nor even shall be wanting here
that cleanliness, the predecessor to today’s The palm, the lily, and the spear,
sterile techniques, is a major barrier to infec- The symbols that of yore
tion and promotes healing. She carefully Saint Filomena bore.
observed and documented changes in the She was a crusader for the improvement of
conditions of the soldiers, which led to care and conditions in the military and civil-
her adulation as “The Lady with the ian hospitals in Britain. Among her books are
Lamp” (from the poem “Santa Filomena” Notes on Hospitals (1859), which deals with
by H. W. Longfellow). the relationship of sanitary techniques to
Santa Filomena medical facilities; Notes on Nursing (1859),
by Henry Wadsworth Longfellow which was the most respected nursing text-
Whene’er a noble deed is wrought, book of the day; and Notes on Matters Affect-
Whene’er is spoken a noble thought, ing the Health, Efficiency and Hospital
Our hearts, in glad surprise, Administration of the British Army (1857)
To higher levels rise. (Donahue, 1985, p. 248).
2993_Ch01_001-014 14/01/14 5:16 PM Page 5

CHAPTER 1 | History of Mental Health Nursing 5

The first formal nurses’ training pro- or “psychiatric hospitals” to care for the men-
gram, the Nightingale School for Nurses, tally ill. There is a monument to her that sym-
opened in 1860. The goals of the school bolized her efforts on the Women’s Heritage
were to train nurses to work in hospitals, Trail in Boston.
to work with the poor, and to teach. This
meant that students cared for people in Linda Richards
their homes, an idea that is still gaining While Dorothea Dix was working for politi-
in popularity and professional opportunity cal help in mental health, a nurse named
for nurses. Florence Nightingale died at Linda Richards (1841–1930) (Fig. 1-3) was
the age of 90. pushing to upgrade nursing education. She
was the first American-trained nurse, and in
Dorothea Dix 1882 she opened the Boston City Hospital
Dorothea Dix (1802–1887) (Fig. 1-2) was a Training School for Nurses to teach the
schoolteacher, not a nurse. She believed that specialty of caring for the mentally ill. By
people did not need to live in suffering and 1890, more than 30 asylums in the United
that society at large had a responsibility to aid States had developed schools for nurses.
those less fortunate. Her primary focus was Linda Richards was among the first nurses
the care of prisoners and the mentally ill. She to teach and work seriously with planning
lobbied in the United States and Canada for and developing nursing care for patients. In
the improvement of standards of care for the cooperation with the American Nurses
mentally ill and even suggested that the gov- Association (ANA) and the National League
ernments take an active role in providing help for Nursing (NLN), she was instrumental in
with finances, food, shelter, and other areas developing textbooks specifically for nurses
of need. She learned that many criminals were that had stated objectives for outcomes of
also mentally ill, a theory that is borne out nursing education and patient care.
in studies today. Because of the efforts of
Dorothea Dix, 32 states developed asylums

Linda Richards
America's First Trained Nurse
Born in Potsdam, 1841

Figure 1-2 Dorothea Dix. Figure 1-3 Linda Richards.

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6 UNIT 1 | Foundations for Mental Health Nursing

Harriet Bailey
The first textbook focusing on psychiatric
nursing was written in 1920 by Harriet Bailey.
It included guidelines for nurses who provided
care for those with a mental illness. Bailey un-
derstood that nurses caring for these patients
needed proper training. After she published
her book, the NLN began requiring all stu-
dent nurses have a clinical rotation in a psy-
chiatric setting (Videback, 2013).
Effie Jane Taylor
Effie Jane Taylor (Fig. 1-4) initiated the first psy-
chiatric program of study for nurses, in 1913.
She is also well known for her development and
implementation of patient-centered care, put-
ting emphasis on the emotional and intellec- Figure 1-5 Mary Mahoney.
tual life of the patient. Effie Taylor received a
diploma in nursing from Johns Hopkins School
of Nursing, later to become a nursing professor Americans in the field of nursing. An award
in psychiatry (American Association for the in her name is presented at the annual ANA
History of Nursing, Inc., 2007). convention to a person who has worked to
Mary Mahoney promote equal opportunity for minorities in
nursing. During her career, it was necessary to
Mary Mahoney (1845–1926) (Fig. 1-5) is open separate schools of nursing for African
considered to be America’s first African- American students because they were banned
American professional nurse. Her contribu- from the schools for white students. Two of
tions were primarily in home care and in the these separate schools were Spelman Seminary
promotion of the acceptance of African (currently known as Spelman College) in
Georgia and Tuskegee Institute in Alabama.
Hildegard Peplau
Dr. Hildegard Peplau (1909–1999) (Fig. 1-6)
was a nurse ahead of her time. She believed
that nursing is multifaceted and that the
nurse must educate and promote wellness as
well as deliver care to the ill. In her book,
Interpersonal Relations in Nursing (1952),
Dr. Peplau brought together some interper-
sonal theories from psychiatry and melded
them with theories of nursing and communi-
cation. She believed that nurses work in
society—not merely in a hospital or clinic—
and that they need to use every opportunity
to educate the public and follow role models
in physical and mental health. Peplau saw the
nurse as:
Figure 1-4 Effie Jane Taylor. (From Yale Univer- 1. Resource person. Provides information.
sity, Harvey Cushing/John Hay Whitney Medical 2. Counselor. Helps patients to explore their
Library.) thoughts and feelings.
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CHAPTER 1 | History of Mental Health Nursing 7

Rutgers University to provide training for clin-

ical nurse specialists for psychiatric nursing.

Hattie Bessent
In the early 1980s, the National Institute of
Mental Health granted money to be used for
the education and research of minority nurses
who were choosing to upgrade to master’s and
doctorate levels of practice. Hattie Bessent
(Fig. 1-7) is credited with the development
and directorship of that program. In 2008 the
ANA presented Dr. Bessent with its Hall of
Fame Award.

■■■ Critical Thinking Question

The “trailblazers” were risk takers. One of the
professional responsibilities of nursing is to try
to give something back to our profession. How
will you, as an individual, become a trailblazer?
What direction should nursing as a whole take
Figure 1-6 Hildegard Peplau. to strengthen the profession? What criteria
should be important when deciding what level
of preparation in nursing should allow the nurse
to be a specialist in mental health?
3. Surrogate. By role-playing or other means
helps the patient to explore and identify
feelings from the past.
■■■ Classroom Activity
4. Technical support. Coordinates professional • Have students (and colleagues) research trail-
services (Peplau, 1952). blazers in nursing and, on an assigned day,
come to class with a prop and a brief explana-
In addition to this, she believed in build- tion of the trailblazers and their contributions
ing a collaborative therapeutic relationship to nursing.
between the nurse and the patient. In her
book she cites four stages of this relationship
(Peplau, 1952):
1. Orientation. Patient feels a need and a
will to seek out help.
2. Identification. Expectations and perceptions
about the nurse-patient relationship are
identified.
3. Exploration. Patient will begin to show
motivation in the problem-solving
process, but some testing behaviors may
be seen; patient may have a need to “test”
the nurse’s commitment to his/her indi-
vidual situation.
4. Resolution. Focus is on the patient’s
developing self-responsibility and
showing personal growth.
In 1954, the first graduate-level nursing
program was developed by Dr. Peplau at Figure 1-7 Hattie Bessent.
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8 UNIT 1 | Foundations for Mental Health Nursing

■ The Facilities
People who have mental illnesses are every-
where; popular statistics say that about one in
every three Americans will experience some
form of mental illness at some point in life.
The trailblazers in nursing realized that men-
tal illness is different from medical-surgical
disorders. They understood that each person’s
mind is truly unique and therefore nurses
need information and training specific to
those illnesses. To help meet those needs, they
took action to improve the quality of care for Figure 1-8 ByBerry, later to be renamed
those patients. This was not enough, however, Philadelphia State Hospital.
and it became evident that persons with mod-
erate to severe mental disorders were often
better served through care in special facilities. Today, hospitals handle patients with
psychological needs according to the size of
Asylums the hospital and its resources. To comply with
These special facilities were called asylums, regulations surrounding mental health issues,
which Webster Online, in part, defines as in smaller communities these patients may be
“1: a place of refuge; 2: protection given to seen in a hospital emergency room and then
criminals and debtors; 3: an institution for referred to other clinics or hospitals. Commu-
the care of the needy or sick and especially of nities large enough to support such programs
the insane.” Patients in asylums were fre- may provide in-house mental health treat-
quently treated less than humanely. Custodial ment as well as outpatient treatment and
care was provided, but patients were often aftercare. Metropolitan areas commonly pro-
heavily medicated. Nutritional and physical vide treatment via several options, including
care was minimal, and often these patients hospitals and free-standing treatment centers.
were volunteered for various forms of experi-
mentation and research. Free-Standing Facilities
One of the largest asylums in the United Free-standing treatment centers may be
States was known as ByBerry, later to be re- called detoxification (detox) centers, crisis
named Philadelphia State Hospital (Fig. 1-8). centers, or similar names. Most people are
This facility reportedly provided inhumane familiar with the Betty Ford Center. Many
treatment to its patients. With the onset of free-standing treatment centers provide care
deinstitutionalization and due to the poor ranging from crisis-only to more traditional
conditions, this facility saw its last patient 21-day stays. As with the Betty Ford Center,
in 1990. a stay can last up to 120 days. This, too,
depends largely on the size and needs of the
Hospitals individual community. More discussion on
As treatment facilities evolved, the term the types of treatment facilities occurs in the
asylum and the connotations associated with section on The Laws.
it became unpopular. In 1753, Pennsylvania
Hospital established a facility to treat those ■ The Breakthroughs
with mental disorders. The hospital was
established by Dr. Thomas Bond and It was not until 1937 that formal clinical
Benjamin Franklin. Until the Community rotations in mental health began for nurses.
Mental Health Act of 1963 was passed, Today, these rotations are required for stu-
housing of this clientele was primarily han- dents in nursing programs, but students in
dled by individual state hospital systems. practical or vocational nursing are usually
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CHAPTER 1 | History of Mental Health Nursing 9

exposed to mental health theory and very a large decline in population. It became
short observational experiences. In 1955, costly to run these large buildings and con-
theory relating to mental health nursing tinue to employ staff. The combination of
became a requirement for licensure for all these effects, as well as new laws pertaining
nurses. to the care of the mentally ill, resulted in a
Throughout the 1800s and early 1900s, movement called deinstitutionalization.
progress was made in developing humane, People who had formerly required long
effective treatment of mental illnesses. With hospital stays were now able to leave the
the best knowledge available to them as institutions and return to their communities.
a profession, nurses were forward thinkers Once discharged, some went to group homes
in providing specialized care to people and others to their own homes. Deinstitu-
unfortunate enough to have illnesses that tionalization was and still is a controversial
were somehow different from the tubercu- issue, but it was a huge step in returning a
losis, smallpox, and influenza that filled sense of worth, ability, and independence to
hospitals. There was one major difference, those who had been dependent on others for
however: Medicines existed to help in treat- their care for so long.
ing those diseases. At that time, no one had
been able to find pharmacologic help for ■■■ Critical Thinking Question
people with emotional, behavioral, or phys- The laws have said that people who have mental
ical brain disorders. That would change in illnesses should be treated using the least restric-
the 1950s. tive alternative. Deinstitutionalization allows
these people to live among us in the community.
Psychotropic Medications Consider the following scenario: Your city has just
purchased the house next door to you, and the
In the early 1950s, chemists were experi- plan is to develop this into a halfway house for
menting with combinations of chemicals women who have been child abusers. You are the
and their effects on people. In 1955, a group parent of a 3-year-old and you are also a mental
of psychotropic medications called pheno- health nurse. What would you do? What are your
thoughts and feelings about this situation?
thiazines was discovered to have the effect of
calming and tranquilizing people. One well
known phenothiazine is Thorazine. What a
world of possibility this opened for people Nursing Organizations and
living with and caring for those with mental Recommendations
disorders! Suddenly it was possible to control A natural progression from the break-
behavior to a degree, and patients were able throughs that were happening in nursing
to function more independently. Other forms was the development of organizations for
of therapy became more effective because nurses. The American Nurses Association
patients were able to focus differently. Some (ANA) is recognized as an organization for
patients improved so dramatically that it was registered nurses (RNs). One of its goals is
no longer necessary for them to remain to promote standardization of nursing prac-
hospitalized and dependent on others. tice in the United States. It also promotes
Between the mid-1950s and the mid-1970s, the certification of nurses who meet specific
the number of patients hospitalized with criteria. The concept of psychiatric nurse
mental illnesses in the United States was cut specialists, clinicians, or advanced practice
approximately in half, mainly because of the nurses is a result of the work of the ANA.
use of psychotropic drugs. The American Psychiatric Nurses Associa-
tion provides leadership in recommending
Deinstitutionalization standards of care for nurses who care for
The use of phenothiazines (see Chapter 8) people with mental illness. This organization
became so effective that state hospitals invites nurses who are RN-prepared. Further
and other facilities dedicated to the care and information can be obtained at its Web site,
treatment of people with mental illness saw www.apna.org.
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10 UNIT 1 | Foundations for Mental Health Nursing

■■■ Classroom Activity and LVNs. NAPNES is a multidisciplinary

• List the standards of psychiatric/mental health organization of individuals, facilities, and
clinical nursing practice and give an example schools that advocate for professional prac-
of a nursing behavior or action that correlates tice of practical and vocational nursing. Visit
with each standard. the NAPNES Web site at www.napnes.org
(www.nursingworld.org/scopeandstandardsof-
practice)
to read the NAPNES position paper, dated
July 18, 2004, “Supply, Demand and Use of
Licensed Practical Nurses.”

The National League for Nursing evolved

Tool Box | Organizations for Practical and
from the National League for Nursing Educa-
Vocational Nurses
tion and became known as the NLN in 1952. National Federation of Licensed Practical
NLN is the accrediting agency for many Nurses, Inc. (NFLPN)
schools of nursing across the United States www.nflpn.org
with its specific focus on nursing education. National Association for Practical Nurse
Every state has adopted its own code or set Education and Service, Inc. (NAPNES)
of rules by which all nurses are expected to www.napnes.org
perform. This is called the Nurse Practice Act
and is based on federal guidelines that have
been adapted to the needs of the individual The National Coalition of Ethnic Minority
state. The Nurse Practice Act is discussed in Nurse Associations (NCEMNA) is made up
more detail in Chapter 3. of five national ethnic nurse associations:
Sigma Theta Tau is an honor society Asian American/Pacific Islander Nurses Asso-
for nurses who have shown special talents ciation, Inc. (AAPINA), National Alaska
in research or leadership. It is open to Native American Indian Nurses Association,
baccalaureate-degree nursing students, grad- Inc. (NANAINA), National Association of
uate students in nursing, and leaders in the Hispanic Nurses, Inc. (NAHN), National
nursing community. Black Nurses Association, Inc. (NBNA), and
Specific to the licensed practical/vocational Philippine Nurses Association of America,
nurse are two organizations: National Feder- Inc. (PNAA). Goals include advocating for
ation of Licensed Practical Nurses (NFLPN) equity and justice in nursing and health care
and National Association for Practical Nurse for ethnic minority populations and endorse-
Education and Service (NAPNES). NFLPN ment of best practice models for nursing prac-
welcomes licensed practical nurses (LPNs), tice, education, and research for minority
licensed vocational nurses (LVNs), and practical/ populations. More information can be located
vocational nursing (PN) students in the at its Web site, www.ncemna.org.
United States. In September 1991, a new The American Assembly for Men in
category of affiliate membership was estab- Nursing (AAMN) provides a framework for
lished to allow those who have an interest male nurses, as a group, to meet to discuss
in the work of NFLPN but who are neither and influence factors that affect men as
LPNs nor PN students to join. The NFLPN nurses. Among its objectives is to encourage
has a published set of Nursing Practice Stan- men of all ages to become nurses and join
dards for the LPN (Appendix D). The standards together with all nurses in strengthening
can be found online at www.nflpn.org/ and humanizing health care. The organiza-
practice-standards4web.pdf. tion also supports men who are nurses to
NAPNES was founded by practical nurse grow professionally and demonstrate the
educators in 1941 and identifies itself as the increasing contributions being made by
world’s oldest nursing organization dedicated men in the nursing profession. As do the
exclusively to the promotion of quality nurs- other professional organizations, AAMN
ing service through the practice of LPNs advocates for continued research, education,
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CHAPTER 1 | History of Mental Health Nursing 11

and dissemination of information about nursing in general. But mental health has
men’s health issues, men in nursing, and remained a challenge. There were ethical con-
nursing knowledge at the local and national siderations that had not surfaced in earlier
levels. years. Psychotropic and (also known as psy-
choactive) medications were benefiting many
patients but had their own problems as well;
Tool Box | Nursing Organizations side effects were not always pleasant. More
ANA: American Nurses Association:
drugs were being developed, and more ques-
www.nursingworld.org/
APNA: American Psychiatric Nurses tions arose: How much is too much to give
Association: people? Do we keep them completely se-
www.apna.org/ dated? People were asking which was worse:
NLN: National League for Nursing: the illness or the medication? People are still
www.nln.org/ asking that question. Other concerns have
NFLPN: National Federation of Licensed arisen, for example, how some psychotropic
Practical Nurses: drugs are associated with diabetic mellitus.
www.nflpn.org/ Nonetheless, it was necessary to begin reg-
NAPNES: National Association for Practical ulating the health-care industry a bit more.
Nurse Education and Services: A series of laws governing various aspects of
www.napnes.org/ care for persons with mental illnesses were
NCEMNA: National Coalition of Ethnic
Minority Nurse Associations: passed. The laws have changed somewhat
www.ncemna.org/ and have been renamed in some cases, but the
AAPINA: Asian American / Pacific Islander collective intention is to provide funding,
Nurses Association, Inc.: treatment, and ethical care for this segment
www.aapina.org/ of society.
NANAINA: National Alaska Native American
Indian Nurses Association:
www.geronurseonline.org/ (see partner ■■■ Critical Thinking Question
Your employer has announced that your com-
organizations) pany is changing its medical insurance policy.
NAHN: National Association of Hispanic The company will be providing you with a set
Nurses: amount of money to spend on insurance bene-
www.nahnnet.org/ fits. The three insurance services you have to
NBNA: National Black Nurses Association: choose from offer either family coverage or
www.nbna.org/ mental health services. You are a single parent
PNAA: Philippine Nurses Association of with two preschoolers. You also have a diagnosis
America: of bipolar disorder for which you need medica-
www.mypnaa.org/ tions, therapy, and periodic hospitalization.
What will you choose?
AAMN: American Assembly for Men in
Nursing:
http://aamn.org/
Hill-Burton Act
In 1946, Senators Lister Hill and Harold
Appendix C of this text provides more Burton collaborated and created the
contact information for these and other agen- Hill-Burton Act, a federal law. It was the first
cies designed to promote and assist nurses, major law to address mental illness. It pro-
particularly at the LPN and LVN level of vided money to build psychiatric units in
preparation. hospitals. Today, the many soldiers returning
from the Afghanistan war who suffer from
■ THE LAWS post-traumatic stress disorder know they
will not be turned away because of financial
Over the years many changes and advance- difficulties, as the Hill-Burton Act protects
ments have been made in medicine and those who have no insurance coverage.
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12 UNIT 1 | Foundations for Mental Health Nursing

National Mental Health Act Tool Box | Community Mental Health

of 1946 Act 1963
www.mass.gov/eohhs/gov/departments/
The National Mental Health Act of 1946 dmh/about-the-department-of-mental-
was a result of the first Congress held after health.html
World War II. It provided money for nursing Omnibus Budget Reconciliation Act
and several other disciplines for training and www.gpo.gov/fdsys/pkg/BILLS-103hr
research in areas pertaining to improving 2264enr/pdf/BILLS-103hr2264enr.pdf
treatment for the mentally ill. The National
Institute of Mental Health (NIMH) was
established as part of the National Mental to be identified as “clients” who purchase
Health Act of 1946. The NIMH continu- services from health-care providers. Persons
ously updates the public on mental health of very young or very old age or persons with
issues. Since 1999, NIMH has been research- certain physical, intellectual, or communica-
ing autism. The agency also started the Army tion difficulties became politically recognized
Study to Assess Risk and Resilience in Service as “vulnerable.” The outcome was the devel-
Members (Army Starrs). The Army Starrs will opment of the Patient Bill of Rights, which is
look at the many factors that will be facing discussed in more detail in Chapter 3.
those who had to encounter battle.
Community Mental Health ■■■ Clinical Activity
Centers Act of 1963 Discussion Questions: In clinical post-conference,
The Community Mental Health Centers Act discuss your answers to these questions.
1. Identify ways that (a) the delivery of psychiatric/
resulted from President John F. Kennedy’s mental health nursing and (b) roles, functions,
concern for the treatment of the mentally ill. activities, and settings have changed.
Its main purpose was to provide a full set of 2. What issues or trends do you perceive in
services to the people living in a particular psychiatric/mental health in the future.
community. These services were to include
inpatient care, outpatient care, emergency
care, and education. This was to be a national
effort, funded federally at first. The goal was ■■■ Key Concepts
for the centers to generate enough services
1. Mental health nursing has a long and
so that, eventually, the community could
rich history. It has evolved from very
support it financially.
rudimentary skills before the time of
In 1981, the bill was amended in Congress.
Florence Nightingale to the specialty
Called the Omnibus Budget Reconciliation
area of nursing today.
Act (OBRA), it allows money to be allocated
differently. There is currently less money avail- 2. Patients with mental illness are treated in
able in the federal budget, and that money can many different types of facilities, depend-
be withheld at any time. Unfortunately, with ing on the diagnosis and the availability
the turmoil in the insurance and health-care of care in the particular community.
delivery systems today, mental health benefits
3. The 1950s were important years in the
are often among the first services to be cut
mental health field. The first psychotropic
back or eliminated.
medications were developed, making
Patient Bill of Rights it possible for people to return to their
homes and communities (deinstitutional-
In 1980, the image of the patient was chang-
ization). These medications also allowed
ing. The Civil Rights Movement of the 1960s
other treatment forms to be used more
was giving way to the provision of rights for
effectively.
all groups of people. Patients were beginning
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CHAPTER 1 | History of Mental Health Nursing 13

4. Nurses at all levels of preparation are Henry, G.W. (1921). Nursing mental disease, by
integral parts of the mental health Harriet Bailey, R.N. Bangor, Maine, 175 pages.
(New York: The Macmillan Company, 1920).
treatment team. Our observations, The American journal of psychiatry, 77(3),
documentation, and interpersonal 473–474. Retrieved from www.focus.
skills make nurses effective tools in psychiatryonline.org/data/Journals
patient care. Peplau, H.E. (1952). Interpersonal Relations in
5. Since 1955, all nursing curriculums Nursing. New York: GP Putnam’s Sons.
Longfellow, H.W. (1857) Santa Filomena. The
are required to provide mental health Atlantic Monthly, 1(1) 22–23.
theory. Verghese, M. (2010). Essentials of Psychiatric and
6. A series of laws over the past 50 years Mental Health Nursing. 3rd ed., pp. 254–255.
have provided for money, education, Kalk, New Delhi: Elsevier.
research, and improvements in the care Videbeck, S. L. (2013). Psychiatric-Mental Health
Nursing. 6th ed. Philadelphia: Lippincott
of the mentally ill. Financial difficulties Williams & Wilkins.
in the insurance and health-care indus- Webster Online (2004). www.merriam-webster.
tries contribute to cutbacks in money com
and services for care and treatment of
the mentally ill. WEB SITES
Famous Nurses
www.pulseuniform.com/nursing/famous-nurses.asp
REFERENCES Hill Burton Act
www.hhs.gov/ocr/civilrights/understanding/Medical
American Association for the History of Nursing, %20Treatment%20at%20Hill%20Burton%20Funded
Inc, (2007). Euphemia (effie) jane taylor. %20Medical%20Facilities/index.html
Retrieved from www.aahn.org/gravesites/ Mental Health Issues
taylor.html. www.nami.org
Donahue, M.P. (1985). Nursing, the Finest Art. National Institute of Mental Health
St. Louis: CV Mosby. www.nih.gov/about/almanac/organization/NIMH.htm
2993_Ch01_001-014 14/01/14 5:16 PM Page 14

14 UNIT 1 | Foundations for Mental Health Nursing

Test Questions
Multiple Choice Questions
1. The main goal of deinstitutionalization 6. The following nursing organizations
was to: specifically represent minority nurses.
a. Let all mentally ill people care for (select all that apply)
themselves. a. NACE
b. Return as many people as possible to a b. AAPINA
“normal” life. c. NAPNES
c. Keep all mentally ill people in locked d. PNAA
wards. e. NANAINA
d. Close all community hospitals. 7. In the past facilities that housed patients
2. A major breakthrough of the 1950s that who were needy, sick, or insane were
assisted in the deinstitutionalization known as:
movement was: a. Detox centers
a. The Community Mental Health b. Asylums
Centers Act c. Outpatient clinics
b. The Nurse Practice Act d. Hospitals
c. The development of psychotropic 8. What institute was established as result
medications of the National Mental Health Act of
d. Electroshock therapy 1946?
3. The set of regulations that dictates the a. NLN
scope of nursing practice is called: b. NFLPN
a. National League for Nursing c. Hill-Burton Act
b. American Nurses Association d. NIMH
c. Patient Bill of Rights 9. Florence Nightingale’s focus in the
d. Nurse Practice Act Crimean War was:
4. As a result of deinstitutionalization and a. Mental health
changes in the health-care delivery system, b. Upgrading education
nurses can expect to care for people with c. Clean environment
mental health issues in which of the d. Writing care plans
following settings? 10. The first psychotropic medications were
a. Psychiatric hospitals only introduced in the:
b. Outpatient settings only a. 1950s
c. Medical-surgical hospital settings b. 1930s
d. All of the above c. 1980s
5. Which of the following trailblazers in d. 1920s
nursing was not a nurse?
a. Hildegard Peplau
b. Linda Richards
c. Harriet Bailey
d. Dorothea Dix
2993_Ch02_015-032 14/01/14 5:16 PM Page 15

C HA PT E R 2
Basics of Communication
Learning Objectives Key Terms
1. Identify three components needed to communicate. • Aggressive
2. Differentiate between effective and ineffective communication
communication. • Aphasia
3. Identify six types of communication. • Assertive
4. Identify five challenges to communication. communication
5. Identify common blocks to therapeutic communication. • Communication
6. Identify common techniques of therapeutic communication. • Communication block
7. Identify five adaptive communication techniques. • Dysphasia
8. Define key terms. • Hearing-impaired
• Ineffective
communication
• Laryngectomy
• Message
• Neurolinguistic
programming (NLP)
• Nonverbal
communication
• Receiver
• Sender
• Social communication
• Therapeutic
communication
• Verbal communication
• Visually impaired

H
uman beings communicate. Every- wrong. What is really being communicated
thing people do or say has a message here?
and a meaning. Sometimes, the People of different cultures communicate
words and the actions send different mean- differently. Men and women communicate
ings to different people. For example: Sally differently. Hearing-impaired people com-
and Jim meet for shift report in the morning. municate differently from people who are
Sally’s eyes are red and swollen, and she is not hearing impaired. A hearing-impaired
unusually quiet. Jim asks her if something person may use a hearing aid, technology,
is wrong, and she responds, “No, everything is and amplifiers. People in the medical profes-
just fine.” Jim has observed some changes sions communicate differently from people
in Sally’s behavior and appearance. Sally in business professions by using terminology
has verbally communicated that nothing is which relates to the medical profession rather

15
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16 UNIT 1 | Foundations for Mental Health Nursing

than to the business world. People commu- ■ Types of Communication

nicate all the time in everything they do.
Communication is an ongoing process of
sending and receiving messages.
Verbal and Written
Communication
■ Communication Theory Verbal communication is the process of
exchanging information by the spoken or
Sender, Receiver, and written word. It is, therefore, the subjective
part of the process. In the example given
Interpretation of Message earlier, Sally’s reply that “everything is just
One of the challenging parts of communi- fine” is an example of verbal communication.
cating with others is that the process re- The expertise a nurse develops in the areas of
quires three parts: a sender, a message, written and verbal communication is largely
and a receiver (Fig. 2-1). That means the responsible for the credibility of that nurse.
sender is only partially responsible for the Critical thinking is essential to understanding
communication. Sally cannot totally control Sally’s reply.
Jim’s interpretation of her message.
Sally is the sender, sending a message
to Jim, the receiver, in the above scenario. Neeb’s In a discussion class on the topic of
As it turns out, Sally is a victim of severe ■ Tip words and gestures and what they
allergies. She was visiting her friend who has mean, one African American female
cats. Sally is very allergic to them, and the student spoke up. She shared with
redness and swelling were symptoms of her the class that “gals” in her world
allergic response. She simply did not wish was a demeaning term relating to
to burden Jim with her problem during shift the degrading role of the African
report, so she opted to respond by telling him American woman in history. It is
everything was “just fine.” important to know that the mean-
ing of a word can change from one
generation to the next. In the 1950s
■■■ Classroom Activity and 1960s, being part of the “guys”
• What was your initial interpretation of what Sally or the “gals” was a good thing.
was communicating? On what did you base your It demonstrated acceptance and
interpretation? What “spoke” louder to you: Sally’s belonging to one’s social group.
words or her actions and appearance? What is
the danger in making this assumption about
Sally’s message?
Nonverbal Communication
Nonverbal communication is more subtle,
It is very important for the sender and receiver but it is the greatest influence on commu-
to double-check the message. In nursing, this nication. It consists of people’s actions, tone
is crucial because nurses use their own profes- of voice, the way they use their body, and
sional “language”; when dealing with the their facial expressions. It is more subjective
health and safety of patients, nurses need to since nonverbal communication can be
be very sure that there are not “mixed” or interpreted many different ways by the re-
“missed” messages. ceiver (Fig. 2-2). In the example above,
Sally’s body language communicated that
she was not “fine.”
Sender Sends Message to Receiver This points out the need to be careful
with hand gestures that can be misinter-
preted. Many people use hand gestures when
Figure 2-1 A basic flow of communication. speaking. People do it often without thinking.
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CHAPTER 2 | Basics of Communication 17

People must be ready to learn from each other

every day. Nurses need to be prepared to
make known those terms or gestures that are
uncomfortable for them and their patients.
They must make a conscious effort not to use
those words when in the company of those
they may offend (Box 2-1.)
Aggressive and Assertive
Communication
The terms aggressive and assertive are some-
times used interchangeably in American cul-
Figure 2-2 Nonverbal communication is ture, but they have very different meanings.
estimated to be 70% of the message we send.
The old saying is true: A picture is worth a Aggressive Communication
thousand words!
Aggressive communication is communica-
tion that is not self-responsible. Aggressive
However, making the “OK” sign with one’s statements most often begin with the word
fingers, which is normally a sign of encour- “you.” Aggressive communication, like aggres-
agement, agreement, or congratulations, is a sive behavior, is meant to harm another per-
vulgarity in some cultures. son. It is a form of the defense mechanism
projection, or blaming, and it attempts to
put the responsibility for the interaction on
the other person. Aggressive communication
Cultural Considerations is also highly subjective as demonstrated in
Identify the diverse cultures and generations nonverbal communication.
in your community and define a gesture EXAMPLE
that you use that means something different
to others. “You make me so angry when you don’t help
with the housework!”

l Box 2-1 Examples of Communication With Cultural Implications

Words that are seemingly harmless to some people can be very hurtful to others. People
do not usually know that until they take the time to ask! These are the examples of commu-
nication that may have different cultural implications. How many more can your class
identify?
• Eye contact with strangers or those in perceived positions of power or respect is not considered
appropriate among some populations.
• Hand gestures may communicate different meanings to different groups of people.
• Slang terms may be inappropriate or offensive, or may exclude people who do not understand
the meaning of the word.
• Gender-reference terms such as “you guys” when the group is mixed or not male.
• Terms such as “master” and “slave” frequently used in computer-related issues may offend
African American people and others.
• African American women displayed in subservient roles.
• Distortion or omission of important developments in the lives of African Americans.
• Pictures or photographs that do not portray accurate skin tones, hair texture, and physical
features of certain ethnic groups.
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18 UNIT 1 | Foundations for Mental Health Nursing

Assertive Communication Therapeutic Communication

Assertive communication, on the other In therapeutic communication, the nurse
hand, is self-responsible. Assertive state- understands that in order to acquire cer-
ments begin with the word “I.” They deal tain desired information from the patient,
with thoughts and feelings, and they deal with unique techniques of communication will
honesty. have to be instituted. They will be individu-
EXAMPLE alized to the patient as well as to the mental
health disorder. Therapeutic communication
“I feel angry when you don’t help with the is a language of its own. It requires testing
housework!” new methods of communicating and new
Assertive behavior and communication are ways of listening. Therapeutic communica-
also techniques of personal empowerment. tion is purposeful: Nurses are trying to de-
People choose to think or feel a certain way; termine the patient’s needs. Sometimes, for
others do not have the power to make people various reasons, the patient is not comfort-
think or feel anything they do not choose to able sharing his or her needs and concerns.
think or feel. To be able to say “I think” or At those times, it is up to the nurse to try to
“I feel” keeps people in control of their emo- uncover the problem by using two tools:
tions, yet it allows honest, open expression of techniques of therapeutic communication
the feelings they have as a result of someone and “active” or “purposeful” listening (or
else’s behavior. Still, the feelings and thoughts “listening between the lines”). The tech-
belong to the person choosing them, not to niques and blocks to them will be discussed
anyone else. at the end of this chapter. In addition it is
essential to identify the components of any
mental health disorder to provide effective
■■■ Critical Thinking Question therapeutic communication.
Write one feeling statement and one thinking
statement for the following situation: A co-worker
who is a BSN-prepared nurse is routinely coming Neurolinguistic Programming
late to work and overstaying breaks, causing Neurolinguistic programming (NLP) is a
patients to have unsafe care and you to have form of communication developed prima-
extra work. You speak to your nurse manager,
who appears to ignore your concerns, so you
rily by Milton Erickson, a hypnotherapist;
approach the co-worker. John Grinder, a psychologist and linguistics
professor; and Richard Bandler, a mathe-
matician and editor (Grinder & Bandler,
1981). It is a way of framing statements and
Social Communication questions while attempting effective com-
People usually alter their style of communi- munication. One of the theory’s tenets, not
cating according to who is receiving the unlike other communication theories, is
message. Social communication is the day- that humans cannot fail to communicate.
to-day interaction people have with personal The theory builds on the idea that humans
acquaintances. For example, teenagers usually tend to communicate in basically three ways:
communicate with their peer group in a hearing, seeing, and touching. Choice of
different manner than they do with their par- wording can make a difference in how the
ents. So, too, do nurses communicate differ- words a nurse says to a patient are actually
ently with their patients than they do with “heard” by that patient, as communication
their friends or family. must have a sender and a receiver. NLP is
Nurses may use slang or “street language,” one method being taught to health-care
and they may be less literal and purposeful in providers to assist in the successful comple-
their social interactions. Quite simply, social tion of the communication loop.
interaction has a different purpose than a NLP is not hypnosis; it is a form of com-
nurse’s professional communication. munication. NLP can be used in conjunction
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CHAPTER 2 | Basics of Communication 19

with hypnosis and other treatment modali- while having laryngitis; signing a check
ties. In most states, hypnosis can only be per- while your arm is in a cast; or reading traffic
formed legally by professionals specially signs after your eyes were dilated. These are
trained and licensed to do so. uncomfortable situations, but for the most
Further explanation and some simple part, they are temporary. What about pa-
examples of NLP phrasing are provided in tients and coworkers for whom disabilities
Chapter 9. are permanent?
People Who Are Hearing-
■■■ Critical Thinking Question Impaired
Turn the following aggressive statements into
assertive statements. The nurse must be very patient when com-
• “You make me so angry when you stop at the municating with people who are hearing-
bar before you come home.” impaired. A nurse needs to be aware that the
• “You always take the ‘easy’ assignment, and that’s hearing-impaired person’s frustration is even
not fair.” greater than that of the nurse in trying to
• “Mark always gets the days off he asks for; why
can’t I?” communicate. Try to establish a trusting,
team-approach relationship with hearing-
impaired patients. Let them know you will try
whatever it takes for you to be able to under-
■ Challengesto stand each other. Find out what has worked
Communication for that person in the past.
Not all hearing-impaired people use sign
Communicating is something that humans language; some use lipreading. However,
often take for granted—until they no longer lipreading may be inaccurate and could lead
can do it: for example, answering the telephone to incorrect communication. Sometimes writ-
ing a note or providing the patient with a
journal is an effective way to communicate
■■■ Clinical Activity with a person who is deaf or hard of hearing.
Community Resources Worksheet Keep in mind the key factor is communica-
Contact a community agency in your commu- tion and not the patient’s grammatical or
nity. Explain that you are a student nurse and that spelling abilities.
you are trying to determine the resources avail-
able in your community. People Who Are Visually
1. Your name:________
2. Name of agency: Impaired
3. Who are the target groups for this agency? When a person is visually impaired, the
a. Gender nonverbal part of communication can be a
b. Age
c. Specific disabilities, such as speech, hearing, challenge. Nursing is a highly affective art,
and visual or other impairments. so certain nonverbal cues, such as tone of
4. How do people access this agency? voice, body position, and facial expressions,
5. What are the agency’s fees for services? “speak” most strongly to patients. How does
6. What types of insurance does the agency a sightless person or someone who is severely
accept?
7. What hours is the agency open? impaired visually interpret these nonverbal
8. Do people need appointments to come to this cues?
agency? Nurses must learn to become detail-
9. Where does the agency keep patient oriented storytellers. It is important to learn
records?
10. What is your impression of this agency?
to describe to a visually impaired patient the
11. Would you feel comfortable coming to this location of the call signal, what the call signal
agency or referring a patient here? Why or sounds like, what the people in the hall are
why not? laughing at, why the voices suddenly switch
to a whisper when another person enters the
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20 UNIT 1 | Foundations for Mental Health Nursing

room, and who has just entered. Imagine (“voice box”). Imagine what it would be like
walking into a crowded lunchroom, and to be able to speak one day and have no voice
everybody stops speaking. How does that at all the next. The larynx is a body part that
feel? Similarly, sightless people cannot see is very much taken for granted. How do such
a wave of the hand or see when someone people answer the phone? How does a person
leaves or enters a room; these events must be order a pizza? How would such people express
verbalized. their emotions? Call for help?
Patient teaching takes on a new dimen-
sion because it involves physically moving, People With Language
touching, or verbally explaining in much Differences
more detail than usual. Learning to eat can
be difficult for a newly sightless person. Today’s society is global. Even though English
Usually, the teaching involves relating the is the predominant language in the United
food position to the numbers on a clock States, it may not be the primary language for
face. Sightless patients need to rely on their many of the people nurses work with and care
other senses to compensate for the eyes they for. As a nurse, you may find yourself in an
cannot use. area where you are the one who does not
Sometimes individuals have more than one speak the primary language. How will you
need to be considered when the nurse com- communicate? How will you ensure safe care
municates with them. For example, some of your patients? If the physician with a thick
people are both hearing impaired and visually accent gives a verbal order, how will you know
impaired. When communicating with these you have heard it correctly? What about those
individuals, a nurse needs to be creative. people who say they are speaking English, but
Investigate methods that have worked for you are not able to understand them? It can
this person in the past and explore methods be very embarrassing and potentially insulting
such as a conversation board or printing the for all parties involved. Techniques for ensur-
message on the person’s palm. ing understanding are discussed at the end of
As emphasized in any nursing fundamen- this chapter.
tals class, when beginning and exiting the
patient’s room, the nurse needs: to identify People Who Have Aphasic/
him-/herself, explain what procedure is being Dysphasic Disorders
performed, make sure the patient is safe, and A person with aphasia/dysphasia has
identify when leaving. either no speech or great difficulty with
speech. The amount of speech a patient
People Who Have possesses is related to many things, such
Laryngectomies as age, cause of difficulty, and severity of
Some people live with partial or total involvement. There are different types of
laryngectomy—the removal of their larynx aphasia (Table 2-1).

l Table 2-1 Types of Aphasia

Types of Aphasia Description
Expressive Difficulty expressing himself or herself in written or verbal forms
of communication
Receptive Difficulty interpreting or understanding written or verbal forms of
communication.
Global Combination of receptive and expressive forms of aphasia
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CHAPTER 2 | Basics of Communication 21

It is up to the physician and the speech Before reviewing therapeutic communi-

therapist to determine the cause and extent of cation techniques, ineffective ones will be
involvement, but the nurse will be part of the reviewed. There is an old saying that “the
plan of care. This will be a very individualized road to defeat is paved with good inten-
type of communication skill. Patients may tions.” Sometimes, nurses’ good intentions
know that the nurse has asked them for the get them in trouble with their communica-
comb; they may think they are handing tion skills. Nurses can sometimes uninten-
the nurse the comb, but they actually hand tionally set themselves up for ineffective
the nurse the coffee cup. A patient may try to communication. The following is a list
read aloud a passage from a book, but what of ways nurses “block,” or impede, helpful
comes out of the patient’s mouth may be a interactions with patients:
long line of obscenities. The patient would be
1. False reassurance/social clichés. These are
very embarrassed if he or she knew what was
phrases nurses use in an effort to sound
said. The nurse must be very understanding
supportive. In social communication
and willing to try repeatedly to have correct
they sound friendly, but in a therapeutic
communication with persons with various
relationship they invalidate the patient’s
forms of aphasia. Nurses also must remember
concerns.
that any “nasty words” are not to be taken
personally; chances are very good that those EXAMPLE EFFECT ON PATIENT
words are really a sincere attempt by the “Don’t worry! • Tells patient his or her
patient to say, “Thank you, nurse.” See the Everything will concerns are not valid
section headed “Adaptive Communication be just fine.” • May jeopardize patient’s
Techniques.” trust in nurse
2. Minimizing/belittling. These, too, are
■■■ Classroom Activity used socially to try to relieve the ten-
• Contact a representative from Americans with
Disabilities, your state’s Services for the Blind, or sions of others. There is security in
any of your local agencies that serve populations numbers, and sharing that many people
with special communication needs. Invite some- are experiencing the same thing as the
one from one of these agencies to be a guest individual is somehow supposed to
speaker. make the problem seem lighter. In
therapeutic use, the implications are
different.
■■■ Clinical Activity
In a clinical rotation, assign students (simulate if EXAMPLE EFFECT ON PATIENT
in the classroom) to care for a person with a com- “We have all • Implies that the patient’s
munication challenge. Have the students describe felt that way feelings are not special.
how they altered their usual communication pat-
terns to work with this individual. sometimes.”
3. “Why?” This simple word needs to be
eliminated in therapeutic interactions.
■ Therapeutic “Why” connotes disapproval or dis-
Communication pleasure. “Why ask why?” is a good
question for the health-care provider
It is possible to have a helping, therapeutic to remember. The patient often does
conversation with most people, but it takes not know “why” and can end up feeling
some practice. These “techniques” need to be responsible for providing an answer
practiced in much the same way that one anyway. The nurse often needs to know
learns any other language: by hearing them, “why,” but there are other ways to ask
practicing them, and making them part of that are less stress-producing for the
one’s professional (and social) vocabulary. patient.
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22 UNIT 1 | Foundations for Mental Health Nursing

EXAMPLE EFFECT ON PATIENT “Can you,” “Will you,” “Are they,” and
“Why did you • Patient feels obligated “May I.” It does not help to add please,
refuse your to answer something he as in “Please, may I ask you a question?”
breakfast?” or she may not wish to or “Will you please take out the trash?”
answer or may not be This courtesy still leaves the possibility
able to answer for the receiver to say “yes” or “no.” The
• Probes in an abrasive please makes it sound more polite in
way social venues, but the same questions
can be made assertive and therapeutic
4. Advising. Alcoholics Anonymous some- by stating or asking for what one wants
times uses the statement, “Don’t ‘should’ (“I need to ask you a question” or
on yourself.” Nurses also must not “Please take out the trash”).
“should” on their patients. This sets the
stage for expectations that the patient The general rule for making an open-ended
may not be able to meet. It also sets question from a closed-ended question is to
up, in the patient’s mind, some sort of simply drop off the first one or two words.
value system that puts the nurse’s value This can also be accomplished by adding
as the “right” one. It can sound very words like how and what to the beginning of
judgmental. the question.
Closed: “Can I help you?”
EXAMPLE EFFECT ON PATIENT Open: “How can I help you?” or “What
“You should eat • Places a value on the can I do to help you?”
more.” action EXAMPLE EFFECT ON PATIENT
“If I were you, • Gives the idea that the
I would take nurse’s values are the “Can you tell me • Allows a “yes” or “no”
those pills so “right” ones how you feel?” answer
I would feel • Sounds parental “Do you smoke?” • Discourages further
better.” “Can I ask you a exploitation of the
few questions?” topic
5. Agreeing or disagreeing. Socially, people • Discourages patient
agree or disagree for several reasons. from giving information
Sometimes people are just expressing
7. Providing the answer with the question.
their opinion. Sometimes they are try-
ing to make a favorable impression. This is a technique that television inter-
Therapeutically, it is wise for nurses viewers use frequently. The interviewee
to avoid statements that express their may say, “The interviewer put words
own opinions or values. Even though into my mouth.” For instance, a ques-
some situations appear similar, there tion that answers itself is, “Didn’t you
may be factors, which make them know that the committee would reject
different. the proposal?” Occasionally, the body
language of the interviewer or the sender
EXAMPLE EFFECT ON PATIENT may influence the answer. A better way
“You were wrong • Places a “right” or to ask this question is, “What were your
about that.” “wrong” on the action thoughts about how the committee
“I think you’re might react?”
right.” EXAMPLE EFFECT ON PATIENT
6. Closed-ended questions. These are forms of “Are you afraid?” • Combines a closed-
questions that make it possible for a one- “Didn’t the food ended question with a
word “yes” or “no” answer. They discour- taste good?” solution
age the patient from giving full answers “Do you miss • Discourages patient
to the questions. Closed-ended questions your mom from providing his or
are those that start with such phrases as today?” her own answers
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CHAPTER 2 | Basics of Communication 23

8. Changing the Subject. Nurses sometimes patient to determine the best way to help the
do this inadvertently. When schedules patient help himself or herself. If the nurse
are busy and several patients need a can look at the relationship with that attitude,
nurse’s attention at the same time, the there is no “right” or “wrong,” because each
nurse’s agenda takes over, and the nurse person is different. No two patients are the
starts to see to personal needs. It is very same, so what is helpful to each one is “right”
easy for a nurse to give a quick answer to for that patient.
a patient’s question and then proceed
EXAMPLE EFFECT ON PATIENT
with one’s own agenda. Unfortunately,
that may send the message to the patient “That’s the way • Can sound judgmental
that the nurse does not care or that this to think about it! • Can set the patient up
problem is not worthy of a nurse’s time. Good for you!” for failure if the approval
This patient may be reluctant to offer “That’s not a or disapproval does not
more information to that nurse in the good idea.” help; can lower the
future. nurse’s credibility
Changing the subject may also reflect the Techniques of Therapeutic/
nurse’s comfort (or discomfort) level with
the subject. If the nurse just experienced the
Helping Communication
death of a loved one from a heart attack, for Hildegard Peplau envisioned the nurse as a
example, it may be very uncomfortable to “tool” for ensuring positive interpersonal
answer a patient’s questions about recovery relationships with patients. Nurses are with
and prognosis following his or her bypass the patient for approximately 8–12 hours
surgery. The nurse may answer quickly and daily. Compare that with the amount of time
move on to a more comfortable topic, such a physician is able to spend with the patient,
as, “Well, your physician has advanced your and it is easy to see how the nurse becomes
diet; that’s good news!” the therapeutic tool that helps the patient
help himself or herself. This observation was
EXAMPLE EFFECT ON PATIENT noted by Florence Nightingale in her book,
The patient is • Discounts the Notes on Nursing (Nightingale, originally pub-
asking a question importance of the lished in 1859).
about his/her patient’s need to Patients develop a different kind of rap-
prognosis and explore personal port with nurses because they learn to trust
the nurse thoughts and feelings them. Although nurses’ technical skills are
responds with, • May be a reflection very important and must never be allowed
“Did the doctor of the nurse’s own to get rusty, it is the appropriate use of
say anything discomfort level with their verbal and nonverbal communication
about discharging this topic skills that cements the relationship with
you today?” patients and that ultimately promotes their
healing.
9. Approving or Disapproving. This is similar
The previous section pointed out some of
to minimizing or agreeing. The patient
the bad habits of conversation. It is now
perceives a value system that puts the
time to learn new effective methods of com-
nurse in the position of the expert, and,
munication. These will feel awkward at first,
in many ways, the nurse is. That puts a
but with practice and trust, they will help
big responsibility on a nurse’s shoulders,
improve the quality of interactions not only
however, and that responsibility includes
with patients, but in most interpersonal
being supportive without being judg-
communication as well. They are “tricks of
mental or portraying a personal idea of
the trade” that may be as small as a one-word
what is right or wrong, good or bad.
change in the way a sentence or request is
The nurse is in a partnership of sorts with presented, but they get a lot of mileage in
the patient. The nurse collaborates with the the way people respond.
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24 UNIT 1 | Foundations for Mental Health Nursing

Neeb’s The listed communication methods in different ways. The American vocabu-
■ Tip will not all work for all people in lary pronounces many words the same
all circumstances, but if you use but spells them differently.
them faithfully you will see improve- English is a very complex language to
ments in the way you relate to learn. Some people use terms very literally.
your patients and in the way they Nursing is a profession that is filled with
respond to you. inference and nuance; it is highly affective.
Because of that, it is very important to clarify
terms with patients and other workers. Nurses
1. Reflecting, repeating, parroting. This tech- must be sure that the terms they choose are
nique seems to be the easiest to learn and correct and mean the same thing to all parties
therefore is used the most often. Parrots involved in the interaction. The technique is
are often trained to repeat words or easy to learn: Simply asking “When you say
phrases, such as “Polly want a cracker?” ‘I can’t do that,’ what do you mean?” is one
way of clarifying a statement. The patient
Reflecting, repeating, and parroting refer may mean “I am not physically able” or “I am
to this technique because that is what the not morally able” or “I do not know how to
nurse does: He or she picks a word or phrase do that” or any number of things that the
that seems to be a key word or idea in what word can’t may mean. If the nurse does not
the patient is trying to communicate. It some- try to clarify that simple word, she could
times involves a degree of guessing on the part incorrectly infer the patient’s level of ability
of the nurse to check out the perceived mes- or cooperation.
sage. For instance, if the patient says, “I want
to get out of here; everyone is against me,” the EXAMPLE EFFECT ON PATIENT
nurse has several options for checking the “When you say • Encourages patient to
main concern of the patient. The nurse will ‘tired,’ do you restate the comment
repeat a word or phrase from the patient’s mean it in a • Improves chances that
statement to reflect, or parrot, whatever is physical way the message sent is the
perceived to be the main concern. The nurse or an emotional message received
could say “Everyone?” or “Against you?” to way?”
try to encourage the patient to expand on
these ideas. Caution: Because this technique 3. Open-ended questions. These are the
might seem obvious to the patient, use par- essence of successful nurse-patient
roting sparingly. It will not take the patient communication. They are also among
too many times of hearing his or her words the hardest techniques to learn, because
repeated before perhaps suggesting that the people are constantly bombarded with
nurse look into having a good audiometric incorrect usage in social interaction and
examination! in the world of talk shows and news
reporters.
EXAMPLE EFFECT ON PATIENT
One of the goals of helping communica-
Patient: “I’m so • Encourages exploring
tion is to get the patient to participate, so it is
tired of all of this.” the meaning of the
important that the nurse present questions in
Nurse: “Tired?” statement
a way that will encourage the patient to pro-
• Caution: Use sparingly,
vide information without the nurse’s sounding
can be irritating if
persistent or intrusive. Such a perception by
overused.
the patient will be a major interference in
2. Clarifying terms. People live and work future attempts at communication. The nurse
in a global society. Nurses interact with needs to be able to detect cues provided by the
many different people as patients and patient when they would like to discontinue
coworkers. Nurses sometimes use words communication.
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CHAPTER 2 | Basics of Communication 25

In some instances, “yes” or “no” may be all These two examples show ways to be
the nurse needs to know or all that the patient assertive, direct, and self-responsible while
is capable of responding at the time. In those still maintaining politeness and allowing
instances, closed-ended questions may be the patient to have some control over his or
used until the patient is able to provide more her care.
information. Otherwise, open-ended ques- EXAMPLE EFFECT ON PATIENT
tions will get more productive results.
“Mrs. Smith, • States purpose for the
EXAMPLE EFFECT ON PATIENT I need to ask you interaction
“How are you • Discourages “yes” or a few questions, • Keeps speaker assertive
feeling today?” “no” answers please.” and self-responsible
“What can • Encourages patient to “I want to switch
I do to help, express self in his or shifts with Mary
Mr. Jones?” her own terms next Tuesday,
please.”
Using open-ended questions can be helpful 5. Identifying thoughts and feelings. This is
in understanding the patient’s pain level. Ask- another difficult technique to master.
ing the patient “Are you in Pain?” (closed- Because words, which convey thoughts
ended question) may not bring an accurate and feelings, are used incorrectly more
picture. Depending on the patient’s culture or frequently than not, it is hard to rein-
religious preference, or both, “pain” may or force proper usage. The rule is simple:
may not be acceptable. The patient may A feeling is an emotion. A “feeling state-
answer “yes” or “no” on the basis of those be- ment” must identify an emotion that
liefs. If Ms. Green has a chemical dependency one is experiencing or is trying to explore
that has not been shared with you, she may with a patient. For example, “I feel
say “yes” to get the benefit of the pain med- proud that I earned this promotion” or
ication. Pain is a very individual experience “I feel frightened to walk alone at night.”
and is subjective. What one person considers
to be extreme pain, another might brush off A thought is an opinion, idea, or fact that
as a minor irritation. The closed-ended nature one wishes to express. “I think I deserve this
of this question does not require the patient promotion” and “I think security needs to be
to provide useful, measurable information improved in the parking area” are examples of
that allows the nurse to be helpful or thera- “thinking statements.”
peutic. A more helpful form of this question “I feel security needs to be improved in the
would be in an open-ended format, such as, parking area” and “I feel the patient needs a
“Ms. Green, on a scale of 0 to 10, how do you different pain medication” are incorrect uses
rate your pain?” or “Ms. Green, please tell me of the word “feel.” There is no emotion iden-
about your pain.” tified in these statements. “Feeling” is certainly
implied, but implied thoughts and feelings
4. Asking for what you need or want. This need to be clarified to avoid mistaken conclu-
relates to the discussion on assertive ver- sions. In both of these statements “feel” should
sus aggressive communication. Nurses be replaced with “think” for correct usage.
can ask for what is needed and wanted Using words pertaining to thought and
from patients and coworkers and still feeling correctly will minimize the amount of
maintain a pleasant, professional tone time the nurse must spend clarifying and will
of voice. This technique requires the maximize the quality of the interaction. In the
user to start the sentence with the words mental health specialty, it becomes even more
“I want” or “I need.” Taking the direct important for the nurse to use such terms
approach with people is usually the safest appropriately to help the patient identify
way to be sure that the receiver gets the and label his or her emotions and thoughts to
message the sender intended to send. facilitate therapy.
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26 UNIT 1 | Foundations for Mental Health Nursing

EXAMPLE EFFECT ON PATIENT your pet when you think you’d like to talk
“I feel angry • Helps the patient to about it.”
when you are identify and label Socially, chances are that the nurse might
not honest thoughts and emotions take the “sympathy” option, which would be
with me.” • May give insight to appropriate with people who are not patients.
“I think honesty underlying concerns Patients need the nurse to be sensitive but still
is important in or complications of be the helper. The “empathy” option is more
all relationships.” healing appropriate in most therapeutic situations.

6. Using empathy. Empathy is also tied into

EXAMPLE EFFECT ON PATIENT
feelings. There is a big difference between “It must feel • Acknowledges patient’s
sympathy and empathy. Sympathy is used very demeaning feelings
socially when people wish to share emo- when others are • Keeps nurse in position of
tional experiences. It is not a therapeutic dishonest.” control and helpfulness
technique because it involves experienc- “I can only
ing the emotion. Empathy involves iden- imagine how
tifying emotions without experiencing difficult this
the emotion. Nurses need to use empathy has been.”
with patients. They need to be able to 7. Silence. Silence serves many functions
identify the emotion and relate to it while in communication, yet many people are
keeping the focus on the patient’s needs. very uncomfortable with it. American so-
Nurses must help patients deal with their ciety seems to value conversation. People
feelings and still maintain professional use vocabulary and the ability to talk
control of the situation; the nurse needs about a variety of topics as a measure of
to remain the helper. intelligence and social grace. Watch what
Sympathy often allows both persons to be- happens at a social gathering or in the
come emotionally invested in the moment. break room when a short silence occurs.
The focus is shared by both people. In thera- Often, people fidget nervously or make
peutic relationships, the focus must remain “small talk” just to break the silence.
on the patient. Silence, as a therapeutic technique of com-
Consider the following situation: A nurse munication, serves two main purposes: First,
notices a patient crying in the lounge. The it allows the nurse and the patient a short
nurse wants to help, so he approaches the time to collect their thoughts and, second, it
patient, sits down, and offers his assistance. shows patience and acceptance on the part of
The patient tells the nurse of the news that the nurse. Sitting quietly for a period of time,
that she just found out that her pet died. The usually 2 to 3 minutes, and maintaining an
pet had been her “family” since her divorce. open body posture sends the message that the
The pet had always “been there for her,” and nurse is willing to wait if the patient has more
the pet has died while she has been in the to say or that the nurse accepts the fact that
hospital and could not be there. The nurse’s the interaction may be over for the present.
response options are: Silence can be just as powerful and effective
Sympathy: Remembering his own favorite as any verbal interaction.
pet who died, the nurse says, “I understand Caution: Do not allow the silence to go on
your feelings; my pet died suddenly, too.” too long. If nothing has been said by either
OR party within 2 to 3 minutes, it is wise to sug-
Empathy: Remembering his own pet gest to the patient that it might be time for a
who died, the nurse allows himself to feel rest. Then the nurse should take cues from the
that pain and then says, “I am so sorry. It patient’s response. Perhaps the conversation
must be very painful to lose something will begin again, or maybe the patient will be
you feel so close to. I’d like to hear about grateful for the suggestion to rest. Either way,
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CHAPTER 2 | Basics of Communication 27

the nurse can let the patient know that he or Using this combination of offering assis-
she is there if the patient wants to talk again tance and asking an open-ended question
at another time. serves several purposes: The nurse has main-
EXAMPLE EFFECT ON PATIENT tained rapport and has gotten Mrs. Brown to
divulge her level of prior knowledge, and the
Sit quietly near • Shows the nurse is nurse has let Mrs. Brown know that the nurse
the patient comfortable with presumes she has had a conversation with the
whatever the patient physician. What if Mrs. Brown hesitates or
says and willing to tells the nurse outright that the physician has
hear more not been in yet? The nurse should use the
• Allows both to collect techniques of stating his or her needs and
their thoughts using empathy, and tell the patient very hon-
estly, “Mrs. Brown, I can sense your frustra-
Neeb’s Silence demonstrates that the nurse tion, but I cannot legally (or ethically) give
■ Tip is willing to hear more. you that information until you and your
physician have discussed it first. I’ll be happy
to call your physician to let her know that you
8. Giving information. This is very different
wish to see her as soon as possible. After you
from the communication block of giving
have talked, I’ll be happy to answer any ques-
advice. Giving information relates to the
tions you may have.”
helping relationship because it involves a
form of teaching. EXAMPLE EFFECT ON PATIENT
As mentioned earlier, physicians are usu- “Mrs. Brown, • Increases rapport
ally with their patients for very short periods I would be glad • Eases patient’s anxiety
of time, whereas nurses are usually with the to explain this • Honestly confirms that
same patients for an 8–12 hour shift. It is very diagnosis to you. the physician has given
natural for nurses and patients to have more Tell me what the prior information
quality time for talking. This is one reason doctor has said, • Suggests collaboration
patient teaching is becoming a bigger part of and I’ll clarify it
a nurse’s responsibility in all levels of nursing. for you any way
Nurses provide information in all phases I can.”
of hospitalization, from preoperative teaching 9. Using general leads. This is a method of
to discharge planning. It involves using pam- encouraging the person to continue
phlets, videos, resource manuals, or other speaking. It lets the speaker know that
resource persons. one is listening and interested in hearing
more. The technique is fairly simple:
Neeb’s Most state nurse practice acts still It involves verbal and usually nonverbal
■ Tip place the stipulation that the nurse communication. Examples of general
may not legally give information to leads are saying “Yes?” while maybe rais-
the patient before the physician has ing the eyes, “Go on” while maintaining
given the initial information. This eye contact and possibly nodding the
means that nurses may not give lab head in an affirmative motion, or just
reports, read diagnostic information, saying “and then?” if the person pauses
talk about possible treatments, and in the middle of a statement or concern.
so forth until these have first been
discussed between physician and EXAMPLE EFFECT ON PATIENT
patient. How do nurses know this “Go on” while • Feels valued and
has occurred? Nurses use therapeu- nodding head listened to
tic techniques that allow them to and maintaining
ask questions that get results. eye contact
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28 UNIT 1 | Foundations for Mental Health Nursing

10. Stating implied thoughts and feelings. speech-read (also called lip-read)? Is he or she
This takes a combination of skills. It reliant on a hearing aid? What is the emo-
requires using some guessing (as in tional attitude of the patient?
reflecting), using empathy, and making Communicating can be very frustrating
an observation about a behavior or for hearing-impaired patients as well as for
condition the nurse sees in the patient. the nurse. Hearing-impaired patients often
use sign language, but most “hearing” people
This technique is helpful in initiating
do not know sign language. Sometimes writ-
conversation that might be difficult to start
ing with pencil and paper is effective, but it
with other techniques. It is hard to deny that
is slow. Speech reading is helpful to some
something is not right when someone identi-
hearing-impaired people, but it is not always
fies a specific behavior or action that supports
accurate. Because many words that look the
the suggestion that something is different
same are in fact very different in meaning,
about the patient. Nurses are assessing their
and because not all speaking people say
patient’s physical and emotional states all
words the same way (because of dialect or
the time.
different primary language from that of the
When a patient is reluctant to share this
hearing-impaired person), speech reading can
situation, the nurse can preface the question
be misleading at best.
with an observation and then follow with an
educated guess at the emotion that is being
experienced. Tool Box | This Web site can be used to
access American Sign Language vocabulary:
EXAMPLE EFFECT ON PATIENT http://commtechlab.msu.edu/sites/aslweb/
“Ms. Johnson, • Lets the patient know browser.htm
you’re not smiling you are paying attention
today like you to him or her
usually do. I sense • Identifies a specific People Who Are Visually
something is behavior or change in Impaired
bothering you. behavior, which lowers Adaptive devices such as audio books, Braille-
How can I help?” the chance of denying it prepared computers, and seeing-eye dogs can
• Patient hears that the be extremely helpful. The type of adaptive
nurse cares and wishes device depends on the type and severity of the
to help impairment. Technology has provided some
methods, such as the ability to change the
■ Adaptive Communication font size on a computer up to 500%. Visually
Techniques impaired people often have heightened senses
of hearing, touch.
Some populations of people, such as those
mentioned in the previous section, require Neeb’s Do not assume that visually impaired
special considerations when nurses are com- ■ Tip people may be hearing impaired,
municating with them. These are some ways too. It usually is not necessary to talk
of facilitating communication with people slower or louder to a person with a
who live with certain disabilities or who have visual impairment.
varied amounts of ability.
People Who Have
People Who Are Hearing- Laryngectomies
Impaired Technology has developed several different
When communicating with a patient who is aids that amplify the vibrations of speech. For
hearing-impaired, it is important to know the some patients with laryngectomies, placing
extent of the impairment. Does the person an amplifier over the area of the larynx and
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CHAPTER 2 | Basics of Communication 29

talking will produce a buzzing sound that for each patient. The physician and speech
replicates their former voice. It is a monotone pathologist or therapist are excellent resource
sound, but it greatly improves the ability of people to help in deciding what type of
these patients to communicate in a more adaptive technique will be the most effec-
natural manner. Not everyone can use these tive. The nurse’s documentation of the
devices, however. Some people need to rely responses of a patient to the various tech-
on communication boards and pictures to niques will also help in these decisions.
communicate. Some people make use of new Techniques range from changing the rate
computer-assisted devices. The patient will be or pitch of speech to using objects, pictures,
in close contact with a speech therapist. spelling boards, or computerized equipment
Nurses need to be involved with the therapist if the patient has access to them (Fig. 2-3).
as well, so that the patient has continuity of However, nurses should not answer for the
therapy and good evaluation of the ability to patient. Finishing sentences or trying to play
use the devices. The patient’s plan of care guessing games with people who have these
needs to identify how the speech therapist types of disorders is usually not in the best in-
treatment plan can continue when the patient terest of the patient. It may take a longer time
is discharged from therapy. The goal is to re- for these patients to process the information
store the person to his or her surgical maximal
ability of speech. It can be a frightening and
frustrating time for the patient and the health-
care team, but the rewards are great when A B C D E F
speech, at whatever level, begins to return.
G H I J K L
People With Language
Differences M N O P Q R
Honesty is the best policy here. This discus- S T U V W X
sion comes up in several sections of this text,
but it is much better to apologize and admit End of Period
Y Z word .
when one is not receiving the sender’s mes-
sage. Serious mistakes can be made when one 1 2 3 4 5 6
assumes the meaning of the message. It is also
important to remember that communicating 7 8 9 0 YES NO
is often a highly cultural activity; people are
not always comfortable asking for correction
or clarification from someone of a different
gender, age, or social or professional status.
Using assertive, honest communication skills
will usually get positive results.

Neeb’s As a caregiver, the nurse needs to

■ Tip practice active listening. When not
positive about the meaning of a
message, ask!

People Who Have Aphasic/

Dysphasic Disorders
This is another area that offers many options
for adaptive techniques. Nurses must be aware Figure 2-3 Picture board for patients with
of the type and degree of aphasia/dysphasia aphasia.
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30 UNIT 1 | Foundations for Mental Health Nursing

and get the answer out. Be patient. When the 5. Nurses need to be aware of what blocks
patient is getting frustrated or is truly unable therapeutic communication.
to respond properly, it may be because the
words the nurse used were unfamiliar or 6. Nurses need to be aware what techniques
maybe too much time has passed and the pa- to use to encourage effective, helping
tient has forgotten the question. Gentle hints communication with patients.
or rephrasing the question may be enough to 7. Special techniques are used when com-
help the patient. It may be just one word that municating with populations who have
makes the difference between the patient’s special communication needs.
being successful or not.
Communication in all forms is essential to
the work of a nurse. Taking the time to learn
and use these techniques can make relation- REFERENCES
ships with patients and coworkers very pleas- Grinder, J., and Bandler, R. Trance Formations—
ant and rewarding. Neuro-Linguistic Programming and the Struc-
ture of Hypnosis, Moab, Utah: Real People
Press, 1981.
■■■ Key Concepts Nightingale, F. (1969). Notes on Nursing: What
It Is, and What It Is Not. New York: Dover
1. Humans cannot not communicate. Inter- Publications.
personal communication is a complex Townsend, M.C. (2012) Psychiatric Mental
process. Health Nursing. 7th ed. Philadelphia:
F.A. Davis.
2. Therapeutic or helping communication
is a language that is learned and shared WEB SITES
by nurses. It is a purposeful skill that Communication
requires practice. http://www.natcom.org/discipline
3. People communicate verbally and non- Therapeutic Communication
http://nursingplanet.com/pn/therapeutic_communi-
verbally. Nonverbal communication cation.html
sends a stronger message than verbal Laryngectomy Speech
communication. http://emedicine.medscape.com/article/883689-
overview
4. Communication can be assertive or
aggressive. Assertive statements are the Hard of Hearing
www.ada.gov/hospcombrscr.pdf
more helpful of the two; they start with Neurolinguistic Programming
the word “I.” Aggressive statements are http://infed.org/mobi/neuro-linguistic-programming-
designed to place responsibility on learning-and-education-an-introduction/
another person. They start with the
word “you.”
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CHAPTER 2 | Basics of Communication 31

Test Questions
Multiple Choice Questions
1. Which of the following is an example of a 6. Your patient has refused all of your
therapeutic, open-ended question? attempts to care for him. You say:
a. “Why did you do that, Mrs. Jones?” a. “I’d like to help you; what can I do?”
b. “How can I help you, Mr. Thompson?” b. “Why don’t you like me?”
c. “Can I help you, Ms. Greene?” c. “What is the matter with you?”
d. “Please, can I ask you a question, Mark?” d. “You must do this; physician’s orders!”
2. The purpose of “therapeutic communica- 7. Your patient is Jewish and refuses to eat
tion” is to: non-kosher food. You say:
a. Develop a friendly, social relationship a. “I will ask the dietitian to come and
with the patient. talk with you.”
b. Develop a parental, authoritarian b. “The dietitian will come to see you.”
relationship with the patient. c. “It’s the best we can do. You need
c. Develop a helping, purposeful relation- to eat.”
ship with the patient. d. “You’re right. The hospital food does
d. Develop a cool, businesslike relation- leave much to be desired!”
ship with the patient. 8. Your patient is commenting that the
3. You observe a patient in the family physician has not been in to visit for
lounge. She appears to be talking to her- two days. You say:
self. You want to find out what is wrong. a. “I hate it when that happens!”
Your best approach to her might be: b. “What do you need to know?”
a. “Who are you talking to?” c. “Well, he is very busy!”
b. “Please stop talking. You are disturbing d. “You feel ignored by your physician?”
the other people.” 9. Your patient, who is usually very
c. “I saw your lips moving. Can you tell talkative, does not respond to you
me what you are talking about?” when you enter the room. You say:
d. “Why are you talking to yourself?” a. “Ms. Smith, you are so quiet this
4. Your patient asks you the results of his afternoon. Is something bothering
blood tests. You respond: you?”
a. “They are all negative.” b. “Ms. Smith, is something bothering
b. “Why do you want to know?” you?”
c. “I think you should wait until your c. “Can I help you?”
physician comes in.” d. “Why are you so quiet this
d. “I am not able to tell you right now, afternoon?”
but I will call your physician and have 10. Ms. Smith responds to your question
her stop in to explain them to you.” (see #9), “I feel like nobody cares.” You
5. Your patient is a single parent who has just respond:
been diagnosed with terminal cancer. She is a. “Why do you say that?”
concerned about returning to work and asks b. “Like nobody cares? Please try to
many questions. Finally, the patient says, describe the emotion you are truly
“What do you think I should do?” You say: ‘feeling.’”
a. “I think you should just stay busy.” c. “Ms. Smith, you’re wrong about that.
b. “I wouldn’t worry about it.” Of course we care.”
c. “What are your thoughts about d. “Ms. Smith, maybe the doctor can
returning to work?” change the dosage of your medica-
d. “Oh, you’ll be just fine. There are lots tion. You’ll feel better.”
of people worse off than you.”
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C HA PT E R
3
Ethics and Law
Learning Objectives Key Terms
1. Define professionalism. • Accountability
2. Demonstrate understanding of the Nurse Practice Act. • Advocacy
3. State the importance of honesty and accuracy in verbal • Civil law
reporting and written documentation. • Commitment
4. State the importance of confidentiality. • Confidentiality
5. Define HIPAA and its role in health-care delivery. • Culture
6. Define the Joint Commission and its role in health-care • Culture of nurses
delivery. • Doctrine of privileged
7. Explain the Good Samaritan Act. information
8. Explain involuntary commitment. • Ethics
9. Define patient advocacy. • Health Insurance
Portability and
Accountability Act
(HIPAA)
• Intentional
• Patient Bill of Rights
• Professional
• Proxemics
• Responsibility
• Tort
• Unintentional

■ Professionalism are considered professional nurses; the

licensed practical nurse (LPN) or licensed
Professional is a word with many different vocational nurse (LVN) is considered a non-
meanings. Merriam-Webster Online defines professional. In areas with union represen-
professional as an adjective meaning “charac- tation in nursing, the two levels usually
terized by or conforming to the technical or belong to separate organizations. Some
ethical standards of a profession.” It may be a nursing groups believe that only RNs who
term that requires a nurse to rely on the ther- are baccalaureate-prepared and beyond are
apeutic communication skill of clarifying. considered professional.
Nursing is a profession. Nurses care for Nevertheless, all nurses are expected to be-
patients and perform designated services have in a professional manner; they are to per-
for a salary. As a profession, however, the form at the highest level of preparation they
different levels of nursing disagree as to have achieved. Nurses are to abide by federal,
who is a “professional nurse.” All nurses re- state, and local guidelines. Another aspect
ceive pay for their work, yet it is commonly of professionalism is the duty to stay in-
accepted that only registered nurses (RNs) formed in the nursing field. Participating

33
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34 UNIT 1 | Foundations for Mental Health Nursing

in professional organizations and continuing Standards of Care

education programs is important.
The National Federation of Licensed Practical
Professional behavior is maintained despite
Nurses (NFLPN) has adopted Standards
any personal problems a nurse is experienc-
of Nursing Practice for LPNs/LVNs (see
ing. A nurse’s personal problems are to be
Appendix D). These standards include a code
handled outside of the work environment.
of conduct. The American Nurses Association
Nurses are expected to be respectful of the be-
(ANA) has written a variety of standards of
liefs of their patients and coworkers and not
care covering topics important to the nursing
to force their personal beliefs on others at
profession. Some of these are relevant to
work. Nurses are expected to perform hon-
LVNs/LPNs. The purpose of the ANA is
estly. They are expected to report any infrac-
fostering high standards of nursing practice,
tions they notice in other nurses. In short,
promoting the rights of nurses in the work-
nurses are expected to behave and perform in
place, projecting a positive and realistic view
a manner that promotes the pride and repu-
of nursing, and lobbying Congress and regu-
tation of the nursing profession, and not as a
latory agencies on health-care issues affecting
detriment to that profession.
nurses and the public. A set of Standards of
Psychiatric–Mental Health Clinical Nursing
■■■ Critical Thinking Question Practice, written by the American Psychiatric
You are an LPN or an LVN on the surgical unit of Nurses Association (APNA), is available at
the county hospital. In shift report, you are told that
you will be getting a new postoperative patient
the APNA Web site as well as ANA Web site.
within the hour. When the patient arrives, a police The revised standards are to be published in
officer is in attendance. The officer tells you that 2014.
this patient is a suspect in a homicide. The officer
instructs you to report anything the patient says
to you. When you begin your postoperative vital Tool Box | ANA materials can be accessed at:
signs, the patient says, “Nurse, I shot the guy and he www.nursingworld.org
deserved it. I’ll do it again if I have to. I can tell you, Standards of Psychiatric–Mental Health
because you can’t tell anyone!” How will you handle Clinical Nursing Practice draft Web site:
this situation? www.apna.org/fi les/public/12-11-20-P M H _
N ursing_ Scope_ and_ Standards_ for_ P ublic_
Comment.pdf
■ Ethics

Part of being a professional is to conduct

oneself in an appropriate and ethical man- Nurse Practice Act
ner. Nurses deal with ethical issues on a daily Nurses must be aware of their state’s Nurse
basis, so it is important to consider one’s Practice Act and perform within its parame-
own values and professional ethics. The ters. The Nurse Practice Act dictates the ac-
Codes of Ethics of the American Nurses ceptable scope of nursing practice for the
Association and the National Federation different levels of nursing. When a nurse is
of Licensed Practical Nurses (Appendix D) questioning whether or not to perform a cer-
have established guidelines for the nursing tain skill or perhaps is accused of wrongdoing,
profession. These guidelines provide a frame- the Nurse Practice Act typically is consulted
work for action rather than give answers to to find out if that nurse is performing at the
questions. accepted level of preparation. For example,
if a state does not allow the LPN/LVN to
Tool Box | The Code of Ethics from supervise patient care yet an LPN or LVN is
the American Nurses Association can be the only licensed staff on duty on the night
reviewed at: shift, the Nurse Practice Act for that state
www.nursingworld.org/codeofethics may have been ignored, and that nurse could
be held liable for damages in a court of law.
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CHAPTER 3 | Ethics and Law 35

This can be an ethical dilemma as well. It series of check marks and arrows to indicate
may be the facility’s interpretation that it is assessments of all systems have been made.
permissible to allow that LPN/LVN to func- The nurse then initials the check marks and
tion as supervisor if an RN is on call. This arrows and uses a full signature at the bottom
may or may not be the interpretation of the of the page. Only situations outside of the es-
particular state. The Board of Nursing in a tablished normal parameters are mentioned
particular state can give the answer. Any nurse in some sort of nurse’s note. Although this
has the right and responsibility to make that type of charting saves time, it is sometimes
phone call. challenged legally because it is not always
enough documentation. Yet flow sheet chart-
ing is gaining popularity in documenting
■■■ Classroom Activity health care.
• In Appendix E, review NFLPN Nursing Practice Many facilities use flow-sheet charting,
Standards Legal/Ethical Status. Write a paragraph
on how each of these standards relates to a prac-
and an increasing number are using electronic
tical/vocational nurse. programs designed for patient charting that
are specific for a facility. “Epic” is one of the
electronic programs used by many facilities.
Accuracy Neeb’s The nurse needs to be proficient in
The ultimate goal of the helping person in ■ Tip reading, writing, and spelling skills.
health care is to “do no harm.” Safety for their Nursing programs use a system
patients and themselves must be in nurses’ including testing to determine if
thoughts at all times. nursing candidates are proficient
Harm can be described as intentional or in reading, writing, and math prior
unintentional and falls under the category to being admitted into a program
of a tort, which relates to civil law. Civil (e.g., HESI’s, TEAS V). Not only might
laws protect patients/persons and their gaps in reading, writing, and spell-
property. ing be a source of extreme embar-
A nurse’s best defense is the quality of ver- rassment to the nurse, but they are
bal and written communication. In her book, also unacceptable as professional,
Legal, Ethical, and Political Issues in Nursing, safe nursing practice. It is important
Tonia Aiken indicates that spelling errors are to note as well that this is a much
crucial in liability cases, as they reflect on a more common problem in the
nurse’s general ability to care for patients. United States than one might think
Legally, the general assumption is “if it is not and that it is not just people from
charted, it has not been done.” Some situa- other countries who experience this
tions can impede nurses’ efforts at accuracy in difficulty. Basic computer skills are
charting. First of all, nurses are busy. Patient also increasingly required.
care is the primary focus of a nurse’s workday.
Many times, it seems that the shift is over be- It is imperative that the nurse take (sub-
fore it starts. Charting may be scaled down to junctive) as much time as necessary to carry
a minimum, especially if the employer does out complete, accurate documentation on
not pay for overtime. As accurate charting is each patient. A nurse’s competency to practice
part of nursing care, this became the rationale nursing can be questioned if for some reason
for developing different types of charting. the documentation is subpoenaed in a court
Some facilities use a form of charting that case and spelling and grammar are of poor
may be called “charting by exception.” This quality according to American standards.
type of documentation is based on flow-sheet All agencies have an established method
charting. Normal values, the guidelines for for verbal reporting. It may be a taped shift
which are established at the facility, are writ- report, a grand rounds type of report, or a
ten on the chart form, and the nurse uses a one-on-one report with the patient’s care
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36 UNIT 1 | Foundations for Mental Health Nursing

plan. Again, it is important for the nurse to what he or she wants to hear.” Honesty is a
spend as much time as needed to get the mes- concept that can be highly cultural.
sage from his or her day’s work to the receiver The professional choice is always to tell the
for the oncoming shift. Be thorough but as truth. It may be painful, frightening, or embar-
concise as possible. It is usually standard pro- rassing to admit personal conflicts or errors or
cedure to discuss vital signs, physical assess- omissions in patient care, but nurses will avoid
ments, any visits from physicians or visitors, further potential harm to their patient as well as
new orders, responses to medications and to their professional reputation by admitting to
treatments, and any change in condition. mistakes and taking the appropriate corrective
An area that is sometimes forgotten is the measures. Nurses are human. Despite their
mental, emotional, and behavioral status of best efforts and multiple medication checks,
the patient, especially on a medical surgical nurses make mistakes. Recognizing them, ad-
unit. Usually, the patient’s mental, emotional, mitting them, and taking corrective measures to
and behavioral status is mentioned only if ensure the patient’s safety are the signs of sound
something seems inappropriate. Physical heal- judgment and professional nursing behavior.
ing is to a large extent a result of attitude and Honesty can also mean the difference between
emotional condition; therefore, nurses should keeping and losing your nursing license.
include the patient’s psychological status in
their verbal report. A nurse should always Impaired Nurses
check with the incoming nurse to be sure that Inappropriate use and misuse of mind-altering
there are no further questions and inform that chemicals such as alcohol or prescription and
nurse of anything he may not have completed. nonprescription drugs can render a nurse
legally unsafe. Continuing to practice nursing
while using these chemicals displays unpro-
■■■ Critical Thinking Question fessional behavior and poor judgment. A
You are the nurse who is supervising care on the
shift 2100 to 0700. Another nurse who works this nurse in this situation who is fearful of losing
shift routinely has poor-quality charting. Nothing his or her license or unable to seek help may
is hidden or omitted from the chart, but it contains consider inaccurate charting, omission of
many misspelled words and many grammatical certain charting, or blatant lying about a sit-
errors. You decide to “keep the peace” and say uation as a way to remain employed. The
nothing because you get along well with this
nurse and the patients like the individual. Patient patient’s safety is not the nurse’s primary con-
X falls out of bed on your shift, and the family sues cern when this happens. Most states have
for negligence. The other nurse is found incompe- developed programs to assist impaired nurses
tent by virtue of written documentation that the as a way to protect the public. According to
lawyers cannot decipher. To your dismay, you are the Recovery and Monitoring Program
also implicated as the supervising nurse on that
shift because you did nothing to improve the (RAMP) in New Jersey, if a health profes-
quality of this nurse’s writing skills. What are your sional is impaired and working with patients,
feelings? What might this mean for you? What an occupational hazard eventually will occur,
will your defense be to the court? How will you possibly causing an injury or even a death.
handle this differently in the future?

■■■ Critical Thinking Question

Honesty You are working on an Oncology unit, and a nurse
who has been considered reliable and account-
It may seem insulting to discuss honesty and able by all of his/her coworkers in the past is now
integrity with nursing students. After all, suspected of some type of impairment due to re-
honesty, or “veracity” as it is also called, is one cent changes in behavior. This nurse frequently
of the qualities of professionalism. The dis- offers to give your patients pain medicines if you
are busy. The nurse’s coworkers have noted that
cussion is necessary, though, because honesty immediately before or after giving a narcotic, the
means different things to different people. It nurse usually has to use the bathroom. How
may mean “surviving” or “helping someone would you approach this situation?
less able than myself ” or “telling the physician
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CHAPTER 3 | Ethics and Law 37

Culture of Nurses of professionalism and basic tenets of

communication.
A commonly accepted definition of culture
The field of study called proxemics is
includes nonphysical traits, rituals, values,
also cultural. Proxemics concerns space,
and traditions that are handed down from
time, and waiting, which are all influenced
generation to generation. Nursing is an occu-
by one’s culture. If you have ever traveled
pation that passes its professional values, rit-
between the northern and southern tier of
uals, and traditions from generation to
the United States, you may have noticed
generation (Fig. 3-1). The affective, or attitu-
a cultural difference in time and waiting.
dinal, components of nursing are behaviors
People in the northern states tend to be
that nurses typically learn from role modeling
much more rushed. They may watch the
other nurses. This concept spawned the term
clock in restaurants, in classrooms, and
culture of nurses (Neeb, 1994).
while on hold on the telephone. In the
As mentioned earlier, nurses live and
southern states, life is a bit slower-paced.
work in a global community. Nurses were
That hamburger does not have to be served
born and raised in many different places.
in 2 minutes; people just wait and relax.
They have different ideas about politics and
This is not an issue of right or wrong, good
social issues. However, when nurses come
or bad. It is an issue of differences in the
together as a profession, they meld these
way people are acculturated.
ideas into consistent behaviors to provide
For nurses from countries in which time-
their patients with the best possible care.
liness is not an issue, punching a time clock
Nurses may need to give up some personal
or serving a medication within the allotted
ideas while working to make the whole of
time may not be a priority. As nurses know,
nursing greater than the sum of its parts.
however, this sort of timeliness is a very im-
This means that skills such as spelling and
portant part of nursing culture. A patient who
grammar that may be “correct” or actually
is in pain and asks for a pain medication
considered unimportant in personal situa-
expects the nurse to be prompt with it. If
tions are not acceptable for practicing
the nurse replies, “I’ll be there in a minute,” the
nursing in the United States (Aiken, 2004).
patient might hear the word “minute” and
This is not an issue of labeling a nurse’s
take it quite literally. After all, the patient is
personal or cultural belief system as right,
the one in need. It may actually have taken
wrong, good, or bad. Rather, it means
the nurse 15 minutes to return with the med-
that nurses must remember the components
ication, and in that time he or she may have
answered two more call signals, helped some-
one to the bathroom, and taken a physician’s
order. However, that patient who is waiting
for the medication knows only that the nurse
did not return in a minute. Depending on
that patient’s culture, he may have used the
call signal immediately after 1 minute passed
or may feel it is grossly disrespectful to ask
again and thus suffer silently.
Space and distance also constitute a big
part of nursing culture. Nurses must touch
patients in order to do their jobs. Nurses
Figure 3-1 The culture of nursing. Through
role modeling, professional values, rituals, make full body assessments, catheterize, give
and traditions are passed from one generation suppositories, and perform prenatal and post-
of nurses to the next. (From Sorrell and Redmond natal checks. Male and female nurses work on
(2007): Community-Based Nursing Practice: male and female patients. In a way, nurses
Learning Through Students’ Stories. Philadelphia: become desensitized to these functions, as
F.A. Davis Company, with permission.) they become a routine part of their jobs.
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38 UNIT 1 | Foundations for Mental Health Nursing

Some patients are very timid and modest. The doctrine of privileged information
In some cultures, strangers may not touch is a bond between patient and physician.
strangers in certain ways, and these individuals Under this doctrine, the physician has the
may prefer to have family members perform right to refuse to answer certain questions
those tasks. Some nurses feel uncomfortable (e.g., in a court of law) and can cite “privi-
waking postoperative patients for their routine leged physician-patient information.” Nurses
vital signs check because in their culture it is are usually not included in this relationship.
not proper to awaken sick people; it is proper If information is requested of nurses in a legal
to let them sleep and not disturb them. Nurses situation, they must answer as truthfully as
need to be aware of four types of spaces: they can. How does one maintain honesty
public, social, personal, and intimate. Nurses and confidentiality at the same time? First
are often in intimate space in their practice, and foremost, a nurse should communicate
especially when giving direct care. honestly to the patient that he or she cannot
Proxemics is a very complex field of study; make promises. When the nurse senses that
this discussion has touched only on some the patient is revealing information that is
basics. It is important for nurses to under- potentially legally sensitive, it is a good idea
stand, however, that the concepts of space, to tell the patient right away that nurses are
time, and waiting are highly cultural in their not protected by the doctrine of privileged in-
interpretation. formation. The nurse should tell the patient
that he or she can call the physician, but if the
Tool Box | 2011 A guide to cross-cultural
patient still chooses to share such informa-
etiquette and understanding can be found at tion, a good technique is to tell the patient
www.culturecrossing.net/ the information will have to be shared with a
supervisor or others involved in the patient’s
treatment. The 1976 case of Tarasoff vs.
Nurses must work together for the better- Regents of the University of California is the
ment of patient care. When in doubt, ask. standard for the doctrine of privileged infor-
Learn from each other. There is no better way mation. The doctrine also protects intended
for personal and professional enrichment. victims of patients who may be hospitalized
or incarcerated. A nurse should inform the
■ Confidentiality patient that only those parts of the conversa-
tion that are directly related to his or her care
Confidentiality is so important that it is will be shared, but that if information is
singled out as one of the federal and state requested by a legal representative, the nurse
patient rights. Confidential means (1): marked will be required to answer.
by intimacy or willingness to confide; (2): pri-
vate, secret (confidential information); (3): en- Neeb’s When you sense that the patient
trusted with confidences, and (4): containing ■ Tip is telling you information that is
information whose unauthorized disclosure potentially legally sensitive, it is a
could be prejudicial to the national interest good idea to tell the patient right
(Merriam-Webster online). away that you as a nurse are not
Trusting a friend with a secret only to hear protected by the Doctrine of Privi-
that secret had been repeated to someone else leged Information.
is a break in confidentiality. In a manner of
speaking, a patient’s diagnosis and plan of Temptations are common, especially for
care are a secret to everyone but the patient the student nurse. It is fun and exciting to
and the health-care team; this information is learn new information and to see your skills
very private and must be kept that way. But making a difference in someone’s recovery. It
what happens when the patient shares some- is easy to start chatting about your experi-
thing that must be passed on? ences to another student or to a staff nurse,
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CHAPTER 3 | Ethics and Law 39

but be careful. The person nearby (e.g., in the

elevator with you) may be a friend or family
member. Unless specifically indicated by
the patient, these people do not ordinarily
have rights to information about the patient.
There are many horror stories about innocent
conversations that were overheard by the
“wrong” people, which resulted in negative
consequences to the patient and/or the nurse
involved.
Whoever said hospitals were quiet places
probably never worked in one. Nurses and Figure 3-2 Maintaining privacy is a patient
physicians talk often, and usually not quietly. right and conveys caring to the patient.
“Dr. X is on the phone about Mrs. D’s bowel (Photograph by Wendy Hope.)
surgery,” calls the unit coordinator to the
nurse across the hall. “Is Mr. B’s insulin up “cheat sheet” was found on the floor. The
yet?” asks the nursing assistant from the report sheet had fallen from a nurse’s pocket
kitchenette. “Nurse Y needs to know.” This and had been picked up by a patient’s family
happens not only in the hospital, but also in member. This person could have brought the
physicians’ offices. Consider a situation in a paper to the desk immediately and the story
physician’s office where a nurse shouts from would have ended there, but that was not the
the front desk that she just received Mrs. A’s case. At the end of the shift, the family mem-
urine specimen results. “My goodness! ber brought the piece of paper to the nurse in
Mrs. A has enough E. coli in her urine to kill charge. None of the items on the list had been
a horse.” Unfortunately for Mrs. A, she was carried out, according to the family member
the last person to enter the office with the last who had been there the greater part of the day.
name starting with an “A”. The physician’s of- Unfortunately for the nurse, the tasks had
fice was not equipped with a glass partition been charted as being completed. This display
between the waiting room and the front desk. of unprofessional and irresponsible behavior
How many other patients or people pass- was one thing; the family member main-
ing through the area might have heard those tained, however, that anyone could have
interchanges? How would the patient feel if picked up that piece of paper and learned
he or she knew that personal information many personal things about the patient. It
had been handled so thoughtlessly? Remem- contained information not only about that
ber that patients can interpret messages dif- patient but perhaps information about other
ferently than a nurse. These breaches of patients assigned to that nurse. The family
confidentiality happen all the time, but that member sued for breach of confidentiality and
does not make them acceptable. Nurses won the suit. Granted, this is a drastic example
must take the extra steps required to give or of what can happen, and laws regarding
receive information quietly to the appropri- these situations vary from state to state. The
ate people (Fig. 3-2). story emphasizes that nurses must be careful
Charts, too, can put confidentiality at risk. with patient information of any kind and
How many eyes may have seen a chart acci- always maintain honesty in documentation.
dentally left open when the nurse went to In these days of computerized, paperless doc-
answer a call signal? What about the report umentation, nurses are vulnerable to breeches
sheet? Some nurses call these sheets their of confidentiality. The Health Insurance
“brain’s cheat sheet.” Nurses should be sure to Portability and Accountability Act of 1996
keep their reports with them at all times. Here (HIPAA) and the Joint Commission (JC) are
is an example how a simple act of dropping a intimately involved in documentation and
piece of paper led to a major event. The nurse’s privacy issues.
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40 UNIT 1 | Foundations for Mental Health Nursing

Health Insurance Portability consent (discussed in the Crisis Intervention

section in Chapter 8).
and Accountability Act
The Health Insurance Portability and Joint Commission
Accountability Act of 1996 (HIPAA) was The Joint Commission (JC) is the leading
developed by the Department of Health national accrediting body of health-care
and Human Services to provide national organizations. Earning accreditation by the
standards pertaining to the electronic trans- Joint Commission indicates commitment to
mission and communication of medical quality on a daily basis within the entire
information between patients, providers, facility. Two other goals of a JC accreditation
employers, and insurers. HIPAA allows are reducing the risk of undesirable patient
more control on the part of the patient outcomes and encouraging continuous
as to what part of his or her information is improvement. Originally established to sur-
disclosed. It addresses the security and pri- vey hospitals, the accreditation can now be
vacy involved with medical records and how achieved by long-term care facilities, mental
that information is identified and passed health agencies, home health, and hospices to
between care providers. For example, Social provide quality care, including mental health
Security numbers, which were routinely and substance abuse treatment to children,
used as a patient identifier in the recent adolescents, and adults. Accredited facilities
past, now are either not used or are used in and clinics have demonstrated compliance
some manner that is difficult to track, such with the highest standards of clinical care and
as a partial number or a backward number. administrative quality.
HIPAA was implemented in April of 2003. In 2004, the JC established the National
Some areas of health care, such as workers’ Patient Safety Goals (NPSG). These goals are
compensation, are either exempt from revised annually. Sentinel events, identifying
HIPAA rules or are slightly less stringent in the sources of hospital acquired infections
the passing of information. (HAI), ensuring two-patient identifiers, and
a list of “dangerous abbreviations” are among
these goals.
■■■ Clinical Activity
During your clinical rotation, observe the facility’s
Health Insurance Portability and Accountability
Act (HIPAA) policy. Where is the policy located? Tool Box | Joint Commission Web site at:
Note during your clinical experience if the www.j ointcommission.org
HIPAA policy is violated by whom and how
many times.
National Patient Safety Goals:
www.j ointcommission.org/standards_
information/npsgs.aspx

In June of 2004, the U.S. Department of

Health and Human Services Substance Abuse
and Mental Health Services Administration ■■■ Critical Thinking Question
Center for Substance Abuse Treatment pub- You have just started working on the medical
unit in your hospital. You have been assigned a
lished a 25-page document entitled “The female patient called “Ms. X.” You are curious
Confidentiality of Alcohol and Drug Abuse about the fact that Ms. X is not using her real
Patient Records Regulation and the HIPAA name. While reading her chart, you learn she is
Privacy Rule: Implications for Alcohol and in an abusive relationship. You see the warning
Substance Abuse Programs.” The document that “Ms. X’s husband is not allowed in the unit
at any time.” When you go to meet the patient,
is located at www.samhsa.gov. It carefully you are shocked; Ms. X is your next-door neigh-
details what can and cannot be disclosed bor. What do you do? What do you say to her
and strongly emphasizes the patient’s rights husband? What do you say when your family
(discussed later in this chapter) and the asks you, “What happened?”
necessity for the patient’s signed informed
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CHAPTER 3 | Ethics and Law 41

■ Responsibility more assertively. The responsibility nurses

have for each other professionally may be
Responsibility is a key concept at all levels of different from the kind they have for their
nursing practice; however, responsibility does patients, but it is every bit as important, for
not necessarily mean independence. Respon- it ultimately affects the quality of care nurses
sibility for the professional RN can mean dif- are able to give.
ferent things than it does for the LPN/LVN.
Nurses are expected to know their scope of ■ Accountability
practice for their state. Responsibility means
performing to the best of one’s ability within Accountability is part of working indepen-
the boundaries of that scope of practice. dently within his/her scope of practice. A
Sometimes this means knowing when to say nurse is accountable for his/her own actions.
“No.” Sometimes it means calling the state Being accountable is important in all settings,
governing agency to ask specific questions. including hospital, long-term care, home care,
Responsible behavior for a nurse also office setting, and psychiatric facilities. It
means keeping his or her personal life in a means knowing when to ask for help, finding
manageable state. “Nurse, heal thyself ” is a reference to refresh the memory, or looking
not an unrealistic statement. Nurses need to up a medication that is not familiar. It means
be physically and emotionally prepared to be doing everything the nurse possibly can to en-
helpful to patients, and this cannot be done sure that he/she is providing the safest, most
if one’s personal health is neglected. Nobody accurate care to patients. It means that when
wants to be tended by a nurse who is not the nurse says he will follow through with an
sleeping well or is preoccupied with personal order or a request, he will do so.
problems. A good rule for nurses is to follow
the recommendations in their personal lives ■■■ Critical Thinking Question
that they would give to their patients. You depend on the other staff members to come
It is the nurse’s responsibility to commu- to work. What happens when you must work
nicate with patients and coworkers. Nurses one or two people short? Who really suffers as a
must be alert to changes in patients’ condi- result? How do you feel when your “buddy” or
helper overstays a break or mealtime? What is
tions, both physical and psychological. The your response to that? How does that affect the
actions nurses perform, the observations they amount of time your patients may have needed?
make, and the documentation they complete What about your ability to perform safely when
are the most effective ways to be helpful and you are filling in for someone who is not there?
to ensure continuity of care for patients.
Nurses also have a responsibility to their
coworkers. Agencies have different ways of or- ■ Abiding by the Current
ganizing the way nurses perform their jobs.
Some agencies practice “team” nursing, and Laws
some assign primary-care patients for whom
the nurse is responsible for managing care Good Samaritan Laws
during the entire hospitalization. Some facil- Good Samaritan laws offer immunity for
ities use a “buddy” system to ensure help for citizens who stop to help someone in need of
lifting and to cover the patient load during medical help. Nurses, physicians, and other
breaks or meetings. Regardless of the system medically trained personnel may not always
used, each nurse is in some way interdepen- be protected by Good Samaritan laws.
dent on other staff members. The Good Samaritan law came out of tort
Nurses also have a responsibility to com- law. A tort is a “a wrongful act other than a
municate effectively with coworkers. Being breach of contract for which relief may be
familiar with the techniques of communica- obtained in the form of damages or an
tion discussed in Chapter 2 will ensure that injunction” (Merriam-Webster Online). The
nurses are able to address these behaviors Good Samaritan law varies from state to
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42 UNIT 1 | Foundations for Mental Health Nursing

state, so it is important to understand the embarrassing to be labeled “mentally ill”; this

implication of this law in your state. The basis diagnosis can follow a person for life and
for all Good Samaritan laws, however, is that affect his or her personal and professional
a third party cannot be charged with negli- relationships. Being diagnosed with a mental
gence unless help is given recklessly or that illness could possibly hinder a person from
person makes the situation significantly attaining life insurance. It is no wonder that
worse, according to the guidelines for that sometimes people allow themselves to be hos-
particular state. pitalized for a mental illness only as a last
resort. Patients who agree to voluntary treat-
ment are legally allowed to sign themselves
Tool Box | Link to Good Samaritan laws in out; this is often discouraged by the treatment
other states: staff except under certain situations, and it
www.heartsafeam.com/pages/faq _ good_ is possible for the staff to institute an invol-
samaritan
untary commitment for a patient if they
consider him or her to be potentially danger-
ous. Voluntary and involuntary commitment
Involuntary Commitment is discussed again in Chapter 8.
Each state has its own regulations about Nurses must be aware of all laws and cir-
people who need to be hospitalized against cumstances affecting the commitment. They
their will. This action is reserved for people must maintain the physical and emotional
exhibiting behavior that makes them poten- safety of the patient during the time of
tially dangerous to themselves or to others. hospitalization. Confidentiality is crucial.
The average length of time for involuntary Educating the public will be helpful in con-
commitment is approximately 48 to 72 hours tinuing to eliminate the negative implications
but could be more or less depending on state of issues surrounding mental illness.
law. During this time, the person is observed
and examined by the medical and nursing ■ Patients’ Rights
staff. The patient has full ability to exercise his
or her rights under the Patient Bill of Rights In the 1960s, civil rights was at the forefront.
in that state. At the end of the legal “hold,” Gaining rights for oppressed people of many
the patient chooses either to leave or to stay backgrounds was actively sought by groups
for further treatment. Most of the time, the such as the American Civil Liberties Union
patient realizes a need for help and stays. (ACLU). It was largely due to the efforts of
Sometimes it is the professional opinion of this group that civil rights were addressed for
the treatment team that the patient remains people in prisons and for those warehoused
a threat to self or the community but that the in institutions for the mentally ill.
patient cannot make the appropriate decision. By the 1980s, the Patient Bill of Rights
This then becomes an issue of proving incom- became a requirement for people receiving care
petence and becomes part of the legal system. in a facility, as well as for the health-care work-
ers providing that care. These requirements
Voluntary Commitment vary from state to state but are based on federal
Most patients who are hospitalized for some guidelines and are supported in most states.
type of mental illness are there voluntarily; Agencies in states subscribing to a Patient Bill
that is, at some point they realized they of Rights are to have the rights listed and
needed help. It does not mean they will be displayed in a prominent place in the facility.
happy to be there, of course. There remains a Patients are to be informed of the implications
stigma in the United States about being hos- of their rights and are to be given a copy of the
pitalized for problems relating to a person’s Bill of Rights upon admission to the health-
emotions or behavior. Many times, society care facility. This also is mandated when care
assumes that these disorders are weaknesses is provided in the home. Table 3-1 lists fre-
in character rather than illnesses. It can be quently adopted patient rights.
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CHAPTER 3 | Ethics and Law 43

l Table 3-1 Most Frequently Adopted Patient Rights

Patient Right Description Nursing Considerations
1. Treatment in the Patients are not to be Patients are not to be hospitalized if they
least restrictive held in any stricter can be treated as outpatients and are not
alternative conditions than to be kept in lockup if not dangerous, and
their behavior or so on. Check the agency protocol and physi-
diagnosis warrants. cian’s orders for the individual patient. You
must still maintain safety for the patient
and others.
2. Freedom from Restraining can be Be aware of the individual’s diagnosis and corre-
restraints and with either physical lating orders.
seclusion (except or chemical restraints. • Make accurate observations and documenta-
in emergencies) Many areas require tion about the patient’s physical and behav-
specific diagnosis- ioral response to restraint.
related restraint • One guideline is to check circulatory func-
orders. tion every half hour and to exercise and
reposition the patient in restraint at least
every 2 hours.
3. Give or refuse All patients have the Nurses can reinforce the physician’s explanation
consent for right to say yes or no of treatment. Examine the patient’s understand-
medications/ to treatments that ing; if there is little or no understanding of treat-
treatments affect them. This must ment, the nurse needs to have the physician
(including be informed consent, return and explain again to the patient and
electroconvulsive meaning the patient significant others.
therapy and fully understands the
psychosurgery) treatment, potential
outcomes, and
potential effects of
refusal.
4. Possess and have Anything of a per- Carefully document any teaching about safety
access to personal sonal nature that the of personal items. If your local laws allow, have
belongings patient wishes to the patient sign a waiver of responsibility for
remain with him or personal items.
her must be given to
the patient.
5. Daily exercise Patient needs some Exercise is according to patient’s ability and
form of physical activity order. Exercise can range from passive
activity at least once range of motion (PROM) to the most strenuous
daily. activity the patient can safely perform.
6. Visitors Patient can visit with Determine at time of intake who will be visiting
anyone he or she regularly. In cases of family concern over certain
chooses. people the patient may wish to visit, safety must
be a key issue. At times, nurses may need to
monitor visits and visitors. Carefully document
the patient’s emotional and physical outcome
of visits.
Continued
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44 UNIT 1 | Foundations for Mental Health Nursing

l Table 3-1 Most Frequently Adopted Patient Rights—cont’d

Patient Right Description Nursing Considerations
7. Writing materials Paper, pencils, pens, Unless contraindicated for safety reasons, nurses
and so forth must be can assist in ensuring that these items are avail-
available to patients. able at all times. If safety is an issue (e.g., stab-
bing self or others with a sharp object), this
condition needs to be noted in charting.
8. Uncensored Mail must not be If patient is unable to physically open the mail
mail opened before the or if there is concern that cognitively the patient
patient receives it. will lose a check, for example, the nurse or
another agent of the facility may witness the
opening of the mail. Arrangements can be
made with a family member or guardian to
sign checks or see to the patient’s affairs if the
patient is unable to do so.
9. Courts and Legal access remains Patients can call an attorney at any time. Nurses
attorneys intact for anyone and agency representatives may be asked to
who is hospitalized, help them. In cases when this seems inappropri-
whether voluntarily ate, patient, staff, and family can discuss alterna-
or involuntarily. tives in a family conference. Any outcomes
need to be incorporated into the care plan and
documented.
10. Employment Wages are not to Under certain legal conditions, compensation
compensation be withheld during may be withheld for reasons other than a stay in
hospitalization. a health-care facility. This would be confidential
information but must be incorporated into the
care plan and documentation.
11. Confidentiality Information about Discussion of the patient’s condition must take
(records, treatment, the patient is to be place only in designated places and with desig-
and so on) kept secure and nated persons.
private. • Many states have cautioned nurses against
giving any information regarding the patient
over the telephone. In some states, a nurse
can be in jeopardy of losing a license for
releasing information over the phone.
• Be careful of the wording in your charting.
• Release information only to those people who
are specifically required or legally entitled to
have it.
12. Be informed of Patients must have The nurse or the facility representative will
these rights full understanding of explain in detail the meaning of these rights
their civil rights while for the patient. Depending on your local law
under facility care. and agency policy, the patient may be asked to
sign a document stating that these rights have
been explained. Usually, a copy is then kept
with the patient record and the patient keeps
a personal copy.
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CHAPTER 3 | Ethics and Law 45

In addition to these frequently adopted a moral, legal, and ethical responsibility to

patient rights, some states have adopted a set report known or suspected abuse of people
of patient rights for psychiatric patients. who cannot care for themselves. Part of a
These rights may include the patient’s right to: nurse’s scope of practice is to be a voice, or an
advocate, for the patients under his or her
• Marry or divorce
care. This is the meaning of patient advocacy.
• Sue or be sued
Sometimes the nurse is just not sure if
• Be actively involved in his or her care
abuse is occurring. It is usually better to err
• Be employed if possible
on the side of safety for a patient and to
• Retain licenses (driver’s license, license to
report the concern to a supervisor. In most
practice one’s profession)
areas, it is acceptable to contact the investi-
gating agency directly. Regardless of the pro-
■■■ Clinical Activity cedure a nurse chooses to report his or her
Ask one of the nurses on staff: Where are patient concerns, always check the agency’s policy
files kept? How do you maintain confidentiality? and procedure for such reporting and for the
documentation that is required.

In 1990, the U.S. Congress passed the ■ Community Resources

Patient Self-Determination Act (PSDA), which
all health-care agencies must follow. PSDA According to the provisions of the Commu-
includes the following patient rights: nity Mental Health Centers Act, every com-
munity offers some form of help to people in
1. The right to facilitate their own health need. This help can be in the form of hospital
care decisions emergency rooms, shelters, crisis centers, or
2. The right to accept or refuse medical social service offices. Most communities have
treatment a list available for the asking. Clinics and hos-
3. The right to make an advance health care pitals provide lists to people who are at risk
directive or who ask for the resources. Depending on
the facility’s policies, the nurse may be able to
■■■ Clinical Activity help patients choose a community resource to
Compare the current year and the year when access after discharge. Be sure to provide
the Patient Bill of Rights became effective. Inter- information on fees for the services provided
view a nurse who was working in the field prior
to the bill’s passage and a nurse working after the
by the individual agencies. They vary greatly
bill’s passage. Determine how the Bill of Rights in relation to offered services, fees, and ac-
has affected or changed their interactions with ceptable insurance. Some are free, whereas
patients. some provide assistance on a “sliding scale” or
according to ability to pay. Many states have
reduced resources for mental health care in
■ Patient Advocacy the past two decades, which has contributed
to many societal problems as well as frustra-
With the emergence of the Patient Bill of tion for nurses. This situation needs to be
Rights, patient advocates and patient om- addressed. It is important for nurses to iden-
budsmen began speaking out for patients’ tify what resources are available through col-
needs. These individuals are either volunteers leagues within their agency.
within the community or paid workers from If a patient is unaware of community re-
an agency whose job is to ensure that patients, sources at the time of discharge, the nurse can
especially those considered vulnerable, are suggest that, if the time comes, the patient
being treated in a safe, legal manner. can find resources online or in the local phone
Everyone is responsible for reporting abuse book. The nurse can also inform the patient
and neglect of those who are considered vul- that it is always acceptable to call the local
nerable. Nurses and health-care workers have hospital to request a list. Shelters for victims
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46 UNIT 1 | Foundations for Mental Health Nursing

of abuse usually are not advertised; these are and to the credibility of the nurse. A
kept confidential to maintain safety for the nurse will be judged by correct spelling
people who need them. and grammar (American format) in a
court case. A nurse’s competency can
be questioned if his or her spelling and
■■■ Key Concepts grammar are poor.
1. It is the nurse’s responsibility to know 4. Cultural considerations such as space,
the Code of Ethics and standards of time, waiting, language, and touch
nursing practice for the state in which (to name a few) are important parts of
he or she is practicing. They will vary the nurse-patient relationship. They are
from state to state. also important in the culture of nursing.
2. Collaborative practice means working A nurse’s personal beliefs may be differ-
together with all levels of nursing and all ent from the standards that are part of
ancillary disciplines to provide the best the culture of nurses.
possible care for the patient. 5. The patient’s well-being and wishes, the
3. Honesty in nursing practice and excel- state Nurse Practice Act, and agency
lence in verbal and written communica- policy dictate how nurses can care for the
tion are crucial to the care of the patient patient in a safe and respectful manner.

CASE STUDY
1. Nurse P, LPN, had worked for Agency family member noticed that the patient
X, a nursing home in a small Midwestern was missing an amount of cash and a
community, for 10 years. Over the years, wedding ring, which the patient kept in
Nurse P gained the trust and respect of the purse “for safe-keeping.” The patient
everyone she worked with or cared for on recalled asking Nurse P to retrieve the
the job. Nurse P’s reputation was very glasses from the purse. Other patients and
good in the community as well. On one staff had also seen Nurse P in the patient’s
particular day, a patient asked Nurse P, purse. The case went to small claims court.
“Go to my purse and get my glasses, would Nurse P was found guilty and was made
you please?” This apparently had happened to pay restitution. In addition, Nurse P’s
many times before, so Nurse P sensed no license to practice nursing in that state was
reason for concern. Several hours later, a revoked.

1. What could Nurse P have done to avoid this situation?

2. What are your thoughts about this situation? For the patient? For Nurse P? For the
“fairness” of the situation?
3. What are your feelings about this situation?
4. What are Nurse P’s chances of becoming licensed again? In her state? In another state?
What would the situation be if this were your state?
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CHAPTER 3 | Ethics and Law 47

REFERENCES The Joint Commission

www.jointcommission.org
Aiken, T. D. (2004). Legal, Ethical, and Political
Issues in Nursing. 2nd ed. Philadelphia: RAMP
www.njsna.org/displaycommon.cfm?an=1&
FA Davis. subarticlenbr=40
American Nurses Association. (2001). American
Public Health Law
Nurses Association Code of Ethics for Nurses www.publichealthlaw.net/Reader/docs/Tarasoff.pdf
with Interpretive Statements. Washington,
National Patient Safety Goals
D.C.: American Nurses Publishing. www.ispn-psych.org/docs/standards/scope-
Fossett, B., and Nadler-Moodie, M. (2004). standards-draft.pdf
Psychiatric Principles and Applications for Patient and Physician Relationship
General Patient Care. 4th ed. Brockton, MA: http://depts.washington.edu/bioethx/topics/physpt.
Western Schools. html
Kelly-Heidenthat, P., and Marthaler, M. T. HIPAA
(2005). Delegation of Nursing Care. Canada: www.hhs.gov/ocr/privacy/Community Mental Health
Thomas Delmar Learning. Centers Act
Merriam-Webster. (2012). Retrieved from history.nih.gov/research/downloads/PL88-164.pdf
www.merriam-webster.com/ Tarasoff Decision
National Federation of Licensed Practical http://www.adoctorm.com/docs/tarasoff.htm
Nurses. (2003). Nursing Practice and Stan-
dards. Raleigh, NC.
Neeb, K. (1994, October). The culture of nurses.
Nursingworld Journal, 20, 1.

WEB SITES
Nursing Standards
www.ncsbn.org/regulation/boardsofnursing
The Nurse Practice Act
www.nursingworld.org/MainMenuCategories/Tools/
State-Boards-of-Nursing-FAQ.pdf
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48 UNIT 1 | Foundations for Mental Health Nursing

Test Questions
Multiple Choice Questions
1. The code of behavior that combines new nurse forgot my medication this
professional expectations that border on morning. It’s my heart medication and
legal issues is called: I need it. Would you get it for me?” You
a. Commitment see the medication has been charted
b. Ethics already. Your next action would be:
c. Nurse Practice Act a. Refuse the patient, telling her, “You’re
d. Patient Bill of Rights mistaken, Mrs. G. That medication is
2. The document that defines the scope of signed for, so you must have gotten it.”
nursing practice in each state is called: b. Give Mrs. G her heart medication and
a. Commitment assume she is right.
b. Ethics c. Call the physician.
c. Nurse Practice Act d. Inform your supervisor of the entire
d. Patient Bill of Rights situation.
3. The set of rules designed to protect 6. The Health Insurance Portability and
patients and others who are described Accountability Act:
as “vulnerable” is called: a. Requires patients to be treated in
a. Doctrine of Privileged Information designated regional treatment centers.
b. Collaborative practice b. Approves of patient records being
c. Nurse Practice Act transported in personal vehicles by
d. Patient Bill of Rights medical staff.
c. Allows patients to have some say in
4. Sandra is an RN who is working with what medical information can be
you. Sandra is from the local pool/registry divulged and to whom.
and you are the staff LPN or LVN at the d. Prohibits all transmission of medical
facility. You see Sandra charting her med- records electronically.
ications and treatments before she admin-
isters them. Choose the best therapeutic 7. Mr. Ouch has just had bilateral total knee
communication technique to use when replacement. He is in your transitional
approaching Sandra. care unit. He repeatedly calls out in pain,
a. “Why are you doing that?” disturbing the other residents, yet he re-
b. “I am concerned about the legality and fuses to take the prescribed pain medica-
safety of charting before giving medica- tion, stating, “You’re all just trying to
tions, Sandra.” knock me out.” You:
c. “You know it is wrong to chart before a. Shut his door, leaving him alone with
giving the medications.” some privacy until he settles.
d. “You really shouldn’t do that, Sandra.” b. Offer another pain relief technique,
realizing he has the right to refuse
5. A few hours later, Sandra gets sick and medication.
goes home. You know that she charted c. Have additional staff come to the
before giving her medications, and you room to assist while you administer a
saw her passing some medications. You prescribed injection.
are not sure who got their medications d. Inform him his behavior is not appro-
and who did not. Mrs. G, a patient who priate and is disruptive to others, and
is alert and oriented and a reliable histo- that he needs to stop calling out.
rian for herself, sees you and says, “That
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CHAPTER 3 | Ethics and Law 49

8. The licensed vocational nurse/licensed 10. Mr. B. is a 65-year-old attorney who has
practical nurse (LPN/LVN) knows that been admitted to your floor for blood
his or her scope of practice includes all work and neurological examinations.
of the following except: He is loud and verbally demanding of
a. Administering nursing care under the the staff. He says, “I know my rights.
direction of a registered nurse (RN) You nurses have to do whatever I ask.
b. Documenting the patient’s data It’s your job.” The nurse responds:
c. Independently ordering medications a. “That is not one of your rights, Mr. B.”
for the patient b. “You are taking time away from other
d. Assisting the physician or registered patients, Mr. B.”
nurse with more complex care and c. “The Patient’s Bill of Rights does make
procedures some provisions, Mr. B. Let me sit
9. The patient is semiconscious and is in and talk with you about those rights.”
need of emergency surgery to relieve a d. “Why are you so angry, Mr. B?”
subdural hematoma. The nurse knows
that:
a. Emergency situations do not require
prior consent.
b. He or she must obtain written consent
for invasive procedures.
c. This is not a function of the LPN/
LVN; the nurse should call his or her
supervisor.
d. The patient must be alert in order to
obtain informed consent.
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C HA PT E R
4
Developmental
Psychology Throughout
the Life Span
Learning Objectives Key Terms
1. Identify major theories of personality development from • Accommodation
newborn through adult development. • Assimilation
2. Identify developmental tasks from prenatal development • Autonomy
through death, according to the major theorists. • Behavior
3. Identify possible outcomes of ineffective development, • Behavioral theorist
according to the major theorists. • Ego
4. Identify the five stages of grief/death according to Kübler-Ross. • Id
• Lunar month
• Maslow’s Hierarchy of
Needs
• Menarche
• Operant conditioning
• Psychoanalytic
• Psychosexual
• Puberty
• Superego
• Unconscious

T
he study of developmental psychology The characteristics may cover beliefs from sev-
encompasses the study of human eral of the individual theorists you will study.
growth and development, which is
a specialty subdivision of psychology. This Neeb’s Remember, these are only theories.
chapter covers only the very basics of human ■ Tip Many scientific studies have been
development. A sample of the main theorists performed in the specific disci-
in the field of child development is presented, plines; however, it has yet to be
along with others whose theories are applied proven that any one is true for every-
more in the areas of adult personality develop- one in every instance. Each person is
ment. For the separate developmental age unique. Individuals are subjected to
groups, a chart is shown delineating the general different factors such as genetics
physical and behavioral traits that are com- and environment, which may affect
monly seen in these age groups (pages 64-68). development.

51
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52 UNIT 1 | Foundations for Mental Health Nursing

Each person develops at his or her own Bear in mind that the life span of young
pace. While reading and learning about these Western Europeans during these years was
theories, compare them with your personal much shorter than it is today, so that 12 years
experiences and observations, as well as with of age seemed much older than it does by
the patient assessments you will be perform- today’s standards.
ing. Some theorists may have more validity to One of Freud’s main tenets, or beliefs, is
you than others. that behaviors resulting from ineffective per-
sonality development are unconscious. He be-
■■■ Critical Thinking Question lieved that ineffective personality development
Do other cultures use any of these developmental was in some way related to the relationship of
theories when observing human development? the child to the parent and that it was related
to what he called psychosexual development.
Freud’s theories have validity for some
■ Developmental people today, but others denounce them.
Theorists: Newborn Although the reader is not expected to “con-
vert” to any of the theories discussed in this
to Adolescence text, it is necessary to have a working knowl-
edge of the main theories of personality de-
Sigmund Freud (1856–1939) velopment. Freud is of particular interest
The theories of Sigmund Freud (Fig. 4-1) are because, in addition to his highly debated
considered controversial in today’s world. Sig- ideas, he was the first to also offer a reasonably
mund Freud was an Austrian neurologist. He organized method of treatment. Because he
believed, after observing behaviors of chil- was the first publicized theorist, all other the-
dren, that the personality was developed as ories have evolved as a result of his. Sigmund
early as age 5 years and fully developed by age Freud’s beliefs surface in almost every topic
12 years. He said that the personality must covered in this text. All other theorists com-
develop in a certain way and at strictly de- pare their theories with Freud’s, either in
fined ages and that failure to progress in this agreement or in opposition.
manner would certainly lead to dysfunction. Table 4-1 shows Freud’s psychosexual or
psychoanalytic stages of development. In-
cluded in the table are some of the expected
behaviors Freud thought one might witness
as a child passes through these ages. The last
column lists some behaviors that have been
suggested as outcomes of failure to progress
through his idea of proper personality devel-
opment. Discussion of Freud and his theories
continues later in this chapter.
Erik Erikson (1902–1994)
Erik Erikson (Fig. 4-2) was a psychoanalyst
and a follower of Freud. Erikson took Freud’s
main concepts and expanded them to include
nonphysical criteria. Erikson understood that
people are individuals and that no matter
how young the person, everyone is different.
Erikson’s observations indicated a variable that
was different from the psychosexual and age-
specific theory offered by Freud. That variable
is called an emotional component. Table 4-2
Figure 4-1 Sigmund Freud. shows Erikson’s Eight Stages of Development.
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 53

l Table 4-1 Freud’s Stages of Development (Psychoanalytic or

Psychosexual Stages)
Examples of
Stage of Approximate Unsuccessful
Development Ages Tasks/Characteristics Task Completion
Oral Birth–18 months Use mouth and tongue to deal Smoking, alcoholism,
with anxiety (e.g., sucking, obesity, nail biting,
feeding) drug addiction,
difficulty trusting
Anal 18 months–3 Muscle control in bladder, Constipation, perfec-
years rectum, anus provides sensual tionism, obsessive-
pleasure and parent pleasing; compulsive disorder
toilet training can be a crisis
Phallic 3–6 years • Learn sexual identity and Homosexuality,
awareness of genital area as transsexuality, sexual
source of pleasure; conflict identity problems in
ends as child represses urge general, difficulty
and identifies with same-sex accepting authority
parent
• Electra Complex: “Penis
envy”—Daughter wants
father for herself; discovers
boys are different from her
• Oedipus Complex: Son
wants mother to himself;
father is a rival
Latency 6–12 years Quiet stage in sexual develop- Inability to conceptu-
ment; learns to socialize alize; lack of motiva-
tion in school or job
Genital 12 years– Sexual maturity and satisfac- Frigidity, impotence,
adulthood tory relationships with the premature ejaculation,
opposite sex serial marriages,
unsatisfactory
relationships

Frequently, his stages are identified by the ■■■ Clinical Activity

words highlighted in the column headed Select an adult patient during your clinical experi-
Developmental Tasks. Note that the develop- ence, and compare his biological age with Erikson’s
mental tasks are always listed as contradictions developmental stages. Is your patient’s age appro-
(i.e., trust versus mistrust) of each other. This priate to his developmental task?
• Young Adult
is one way that Erikson indicated his ideas • Adulthood
about emotional fluctuation in people. • Maturity

■■■ Classroom Activity

• Describe which of the following stages you have
experienced according to Erik Erikson: Jean Piaget (1896–1980)
• Adolescence
• Young Adult Jean Piaget (Fig. 4-3) was a Swiss psychologist
• Adulthood whose outlook on development was com-
• Maturity pletely different from those of his colleagues
Freud and Erikson. Piaget’s theory is called
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54 UNIT 1 | Foundations for Mental Health Nursing

according to the expected ability for that

organism. Piaget believed that intelligence
consists of coping with the environment
(Dennis & Hassol, 1983). He believed that a
person must complete each stage of develop-
ment before he or she can progress to the next
stage. Table 4-3 on page 56 shows the four
stages of Piaget’s theory of development.

■■■ Critical Thinking Question

Jamie is 2 years old. Jamie’s parents are becoming
frustrated because Jamie is “so naughty.” They say
that Jamie is always saying “No!” and “Mine!” They
say that Jamie is fascinated by playing with the
dirty diapers. They feel responsible for what they
believe is “disgusting” behavior and wonder what
they are doing “wrong.” They are quick to point out
that “Jamie’s older sibling never did these things. Is
there something wrong with us? Is there some-
thing wrong with Jamie? Please help us!”
Figure 4-2 Erik Erikson.

Cognitive Development. Cognitive means the

Lawrence Kohlberg
ability to reason, make judgments, and learn. (1927–1987)
Piaget believed that development was not as Lawrence Kohlberg (Fig. 4-4) believed in
much a part of chronological age as of expe- Piaget’s theories, but he perceived that very
riential age. Piaget was so sure of his ideas that young people have the ability to understand
he said they were applicable to any living or- and judge right and wrong. Kohlberg’s theory
ganism; the catch is to make the observations is therefore called the Development of Moral
and comparisons about the cognitive process Judgment.

l Table 4-2 Erikson’s Eight Stages of Development

Examples of
Approximate Developmental Unsuccessful Task
Stage Ages Tasks Examples Completion
Sensory Birth– Trust vs. mistrust Nurturing people Suspiciousness,
18 months build trust in the trouble with per-
newborn. sonal relationships
Muscular 1–3 years Autonomy vs. “No!”—Toddler Low self-esteem, de-
shame and doubt learns environment pendency (on sub-
can be manipulated. stances or people)
Locomotor 3–6 years Initiative vs. guilt Child learns Passive personality,
assertiveness strong feelings of
can manipulate guilt
environment—
disapproval leads to
guilt in the toddler.
Latency 6–12 years Industry vs. Creativity or shyness Unmotivated,
inferiority develops. unreliable
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 55

l Table 4-2 Erikson’s Eight Stages of Development—cont’d

Examples of
Approximate Developmental Unsuccessful Task
Stage Ages Tasks Examples Completion
Adolescence 12–20 years Identity vs. role Individual integrates Rebellion, substance
confusion life experiences or abuse, difficulty keep-
becomes confused. ing personal relation-
ships; may regress to
child-play behaviors
Young Adult 18–25 years Intimacy vs. Main concern is Emotional immatu-
isolation developing intimate rity; may deny
relationship with need for personal
another. relationships
Adulthood 21–45 years Generativity vs. Focus is on estab- Inability to show
stagnation lishing family and concern for anyone
guiding the next but self
generation.
Maturity 45 years– Integrity vs. Individual accepts Has difficulty deal-
death despair own life as fulfilling; ing with issues of
if not, he or she aging and death;
becomes fearful of may have feelings
death. of hopelessness

Neeb’s Caution: Morality, the ideas that

■ Tip people consider to be “right” and
“wrong,” is highly cultural.

Kohlberg was a professor at Harvard Uni-

versity for many years. He developed and
published his theory of moral development in
1958 as his doctoral thesis. It was based on
some of the ideas of Jean Piaget. His true
interest was in the mechanisms people use to
justify their decisions. Although he was inter-
ested in the morality of his subjects, he was
especially interested in how people support
their decisions. He studied only male subjects
ranging in age from 10 to 16 years. Kohlberg’s
theory is expressed in three levels. Each level
has two sections. Table 4-4 shows these stages.
Kohlberg believed that these stages build
on the learning achieved from the stage before
it. Therefore, the stages must be experienced
in the exact order, and one is not to back-
track, or revert to a previous stage. Part of his
belief was that moral development can be
promoted via formal education. In fact, there
is a mild resurgence of Kohlberg’s theory
emerging in some classroom environments
today. Kohlberg’s theory has been criticized Figure 4-3 Jean Piaget.
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56 UNIT 1 | Foundations for Mental Health Nursing

l Table 4-3 Developmental Theory of Jean Piaget

Stage Approximate Age Expected Ability
Sensorimotor Birth–2 years • Uses senses to learn about self
• Schemata develop, which are plans or ways of
learning to assimilate and accommodate. They
include the behaviors of looking, hearing, and
sucking.
Preoperational 2–7 or 8 years 2–4 years:
• Thinks in mental images
• Symbolic play
• Develops own languages
4–7 or 8 years:
• Egocentrism—sees only own point of view but
cannot do this until age 7 or 8. With age, this ability
develops.
Concrete 8–12 years • Ability for logical thought increases.
Operational • Moral judgment begins to develop.
• Numbers and spatial ability become more logical.
Formal 12 years–adult • Develops adult logic.
Operations • Able to reason things out.
• Able to form conclusions.
• Able to plan for future.
• Able to think in concepts or abstracts.

responses that daily problems and stressors

can produce. Psychologist Carol Gilligan
published a book in 1982 indicating that
boys, girls, men, and women are all able to
feel compassion and morality but that the
genders process their morality from different
perspectives, a variable that was not consid-
ered in Kohlberg’s study.

■■■ Classroom Activity

• As a class, develop a safety checklist for toddlers/
preschool-age children. This checklist can be used
as a tool for new parents, day-care providers, or
others in your community.

Figure 4-4 Lawrence Kohlberg.

■ Developmental
Theorists: Adolescence
on the grounds that it is sexist and culturally to Adulthood
biased. It indicates that some cultures and
peoples never progress to the highest level Sigmund Freud (1856–1939)
and suggests that behaviors that are accept- In addition to his five psychosexual stages of
able in some cultures are “wrong.” Kohlberg’s development, Sigmund Freud had a model
theory also does not consider the emotional for the components of personality. He said
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 57

l Table 4-4 Lawrence Kohlberg’s Theory of Development of Moral Reasoning

Why We Should What If We Do
Stage “Right” Behaviors Do “Right” Not Do “Right”
Level I: Preconventional
1. Punishment Do not do it if it To avoid punishment I will be punished and
and obedience will result in and to see what one I do not like that.
orientation punishment. can “get away with”
2. Concerned with It is “right” if I (or if To help me get my I will lose recognition
having own we) get something needs and wants for the importance of
needs met I want out of it. fulfilled “others.”
Level II: Conventional
3. ”Good boy, good “Good” means Self and others think we Avoiding “blame” is
girl” orientation living up to what is are “good.” more ethical than
expected of us. getting a “reward.”
4. ”Law and order” “Right” means It maintains social “Law” will have less
obeying the laws structure. importance than the
and rules. will of “society.”
Level III: Postconventional ( Principled Level)
5. Social Contact “Right or good” We blend together for May become aware
is behaving accord- the greatest good and that “moral” and “legal”
ing to a general the welfare of all. may not be the same
consensus.
6. Universal “good” Universal rules of Live within the universal Few people reach this
justice and equality “good” according to according to Kohlberg.
for all prevail. This is own conscience. Therefore, in his own
the “ideal” accord- manual, the latest revi-
ing to Kohlberg. sions do not measure
this stage.

that the personality consists of three parts: the to id. Ego keeps id under control (in a mentally
id, the ego, and the superego. Remember that healthy individual) by responding in an
Freud believed that all the components of unconscious form of a “now, wait a minute”
human behavior are set in the unconscious. attitude. For example, perhaps you had an
The behaviors may appear to be very purpose- exam that was in a subject you felt fairly con-
ful and deliberate, but in Freud’s theories, they fident about, so you chose to study less than
are supposedly responses to situations of you would for other exams. You went partying
which people are not aware. with friends for the weekend instead. Think
Id is the part of the personality that is about this as id behavior. As you entered the
concerned with the gratification of self. The testing area, a gnawing feeling started to enter
sayings “pleasure principle” or “if it feels good, your consciousness. You sensed “butterflies”
do it!” are attitudes that arose from those who in the pit of your stomach. You saw the first
believe that all people have underdeveloped question on the exam and your mind went
ids. These individuals promote the idea that temporarily blank. That is the ego response. It’s
people need to allow the id to take care of telling you there are two sides to every situa-
“me, myself, and I.” tion. In this scenario, the ego is telling the id,
Ego, in Freud’s world, had a different con- “Hmm. Maybe you aren’t quite as confident as
notation from the modern-day common use of you thought you were!” And the id says, “This
the word. Ego, as Freud taught, is the balance test was made just for me.”
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58 UNIT 1 | Foundations for Mental Health Nursing

The third part of the personality theory of that a person’s childhood contributed and
Sigmund Freud is the superego. The superego influenced a child’s personality in later life.
could be called the “killjoy” of the personality. Horney believed that safety and security are
It is the conscience. It is the part of the per- important factors in a child’s life. Without
sonality that allows people to determine what it in their earlier years, difficult behaviors
is right, wrong, good, and bad. The values could be the results. Horney emphasized
exhibited by the superego are not to be con- that it is the responsibility of the parents to
fused with the same terms used by Lawrence provide that safe and secure environment
Kohlberg; according to Freud, having these (Dewey, 2007).
values is not a matter of choice or of learning.
A person who is well-adjusted, or mentally Ivan Pavlov (1849–1936) and
healthy, has all three components of the per- B. F. Skinner (1904–1990)
sonality, according to Freud. Freud would Pavlov and Skinner worked on “conditioning,”
expect anyone in whom any of the compo- or manipulating, behaviors. They are called
nents is absent or out of balance to display behavioral theorists because they believed
maladaptive behaviors. Defense mechanisms that working with different behaviors and
have been associated strongly with Freud’s different stimuli could obtain different re-
theories. Discussion of these defense mecha- sponses. Behavior modification is a direct
nisms and maladaptive behaviors is found in result of their work.
later chapters of this book. Pavlov (Fig. 4-6) worked on involuntary
responses. His well-known study was carried
Karen Horney (1885–1952) out with dogs, steaks, and a bell. When the
Karen Horney (Fig. 4-5) was a psychoanalyst dogs saw a choice piece of meat, they salivated
and one of the very few early female theo- in preparation for eating it. Pavlov incorpo-
rists. Her ideas were very close to those of rated the ringing of a bell when the meat was
Freud; however, she believed that the causes presented so that, in time, the researcher rang
of abnormal behaviors or mental illness were
related to ineffective mother-child bonding.
Karen Horney developed the psychoanalytic
social theory where she strongly believed

Figure 4-5 Karen Horney. Figure 4-6 Ivan Pavlov.

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CHAPTER 4 | Developmental Psychology Throughout the Life Span 59

the bell and the dogs’ association of meat with around in and contained an apparatus for the
the sound of the bell stimulated the salivation animal to operate voluntarily in response to
response. This was a great breakthrough in the different stimuli. There are three main parts
study of causes of behavior and ways in which to Skinner’s theory: response, stimulus, and
behavior can be manipulated. reinforcer. Table 4-5 defines these parts.
B. F. Skinner (Fig. 4-7) worked on operant Skinner’s theory led to the development of
conditioning, which is based on voluntary re- behavior modification. It is possible to “mod-
sponses. Operant conditioning, very simply ify” or change any behavior by using appro-
stated, means taking a behavior and operating priate stimuli and reinforcers to obtain the
on it by changing the variables or conditions desired behavior.
surrounding the behavior. Skinner is known Both positive and negative behaviors can
for the “Skinner boxes” in which he kept the be changed. Today, it is generally believed that
animals he studied. These so-called boxes positive reinforcing is the most effective way
were cages big enough for the animal to move of changing a behavior. Pointing out the pos-
itive qualities in a person or patient or focus-
ing on the abilities (positive) rather than the
disabilities (negative) seems to yield the best
results. For instance, pretend that the behav-
ior a supervisor wants to operate on is getting
a particular coworker to arrive to work on
time. The supervisor has two possible paths
to follow: One is positive reinforcing; the
other, negative reinforcing.
EXAMPLES
Negative: “Nurse M, you are routinely late
for work. This is very difficult on your
patients and on the rest of the staff. One more
instance of being late, and you will be fired.”
Positive: “Nurse M, you are still occasionally
late for work. I have noticed, however, that
you have been late only three times this
month. If you continue to improve your
timeliness, I will be able to give you a raise at
Figure 4-7 B. F. Skinner. your next review.”

l Table 4-5 Operant Conditioning: B. F. Skinner

Skinner’s Theory Explanation
Response Any movement or observable behavior that is to be studied. The response
is measured for frequency, duration, and intensity (e.g., chicken rings bell
in cage).
Stimulus The event that immediately precedes or follows the operant behavior.
The object is to find the stimulus that gets the chicken to ring the bell
(e.g., food, noise, boredom).
Reinforcer A variable that will cause the operant behavior to repeat predictably or
increase in frequency. Sometimes this is called a “reward.” The reinforcer
has to be meaningful to the person whose behavior is being “operated”
on (e.g., chicken pecks bell and food drops into tray; when chicken wants
food, it knows that pecking the bell will produce food).
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60 UNIT 1 | Foundations for Mental Health Nursing

The positive reinforcement method seems times this hierarchy is depicted as a large
to give some dignity and positive self-regard triangle or a staircase to help visualize the pro-
to the employee. It allows the employee to gression from the “basic” needs to the
understand the consequences and to make “higher” needs of people (Fig. 4-9). The steps
choices about being late. It will then be up are as follows:
to the supervisor to follow through with
1. Physiological needs
whichever consequences are earned by Nurse
2. Safety and security
M. In the 1960s, positive reinforcement
3. Love and belonging
was used with chickens as a form of enter-
4. Self-esteem
tainment on New Jersey’s Atlantic City
5. Self-actualization
boardwalk.
Abraham Maslow (1908–1970) Physiological Needs
These are elements people need to survive:
Abraham Maslow (Fig. 4-8) is one of a group
food, water, oxygen, clothing, absence of
of theorists described as person-centered,
extremes in temperature, ability for body
patient-centered, or humanist. Person-centered
excretions, and sexual activity. These are con-
theories involve observing and treating the
sidered necessary for life to continue. Without
whole person. Nursing is highly centered in
food, clothing, and a shelter that is clean and
the person-centered and behaviorist theo-
of a comfortable temperature, an individual
ries. One of the main ideals embraced by
could die; without sexual activity, the species
the nursing profession is Maslow’s Hierar-
could die. The physiological needs can be con-
chy of Needs. This hierarchy, or orderly
sidered needs for survival. When preparing a
progression of development, takes in the
plan of care for a patient, if the physiological
physical components of personality devel-
needs are not categorized as a priority, he/she
opment as well as the emotional compo-
will not survive. Can the patient proceed to
nents. Self-esteem is a tenet of humanistic
the next level of the hierarchy pyramid with-
psychology.
out water or fluids? Can the patient survive
Maslow’s Hierarchy of Needs has five lev-
without oxygen? Can the patient survive with-
els. Maslow said that one must pass through
out elimination? These are the questions that
these stages in order and that it is not possible
a nurse must ask when doing a patient assess-
for a person to move up to the next level until
ment. Being able to identify what takes prior-
the previous level has been mastered. Many
ity can assist the nurse while taking the
National Council Licensure Examination
(NCLEX) as well as providing patient care.
Maslow’s theory is an important component
of the nursing discipline.
Safety and Security
It is important that people feel safe and
free of fear. When individuals feel comfort-
able that their physical needs are being met,
they begin to feel a sense of safety that they
can maintain their survival. Bear in mind
that having these basic needs met does not
necessarily mean living in wealth or with
steady employment. People who live on the
street for whatever reason learn to survive
and are proud of their ability to survive in
conditions that most people would consider
Figure 4-8 Abraham Maslow. deplorable. For some people, street life is a
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 61

SELF-
ACTUALIZATION
(The individual
possesses a
feeling of self-
fulfillment and
the realization
of his or her
highest potential.)

SELF-ESTEEM
ESTEEM OF OTHERS
(The individual seeks self-respect
and respect from others, works to
achieve success and recognition in
work, and desires prestige from
accomplishments.)

LOVE AND BELONGING

(Needs are for giving and receiving of
affection, companionship, satisfactory
interpersonal relationships, and
identification with a group.)

SAFETY AND SECURITY

(Needs at this level are for avoiding harm, maintaining
comfort, order, structure, physical safety, freedom from Figure 4-9 Maslow’s Hierarchy of
fear, and protection.)
Needs. (From Townsend (2011): Essentials
PHYSIOLOGICAL NEEDS of Psychiatric Mental Health Nursing, 5th ed.
(Basic fundamental needs include food, water, air, sleep, exercise,
elimination, shelter, and sexual expression.)
Philadelphia: F.A. Davis Company, with
permission.)

choice, and they meet the criteria of Maslow’s something special and good about me.” Find-
hierarchy. ing that “something” and learning to accept,
appreciate, and acknowledge one’s positive
Love and Belonging traits is the goal of the fourth need of
It is a popular belief within psychology that Maslow’s hierarchy: esteem or self-esteem.
loneliness is a major cause of depression. Self-esteem is the ability to be confident
Quotes such as “Man does not live by bread that one is a person with good qualities and
alone” and “No man is an island” have im- that others know and appreciate these quali-
plied this for many years, and it is now being ties. This sounds easier to achieve than it often
borne out scientifically. People need to feel is. When someone compliments a person on
loved, appreciated, and part of a group. The a new piece of clothing, a haircut, or a job
opening song in the television comedy well done, what is that person’s usual re-
“Cheers” expresses the importance of every- sponse? “Oh, this old thing? Do you really
one knowing each other’s name and being think so? I think it’s way too short now” or
happy that you are there. The focus of that “It was nothing, really” are responses people
sense of love and belonging may change over often give. In addition to the effect it has on
the life span. For babies and young children, effective communication, responding in this
the love needs to come from parents or other manner does not show positive self-esteem.
caregivers; in adolescence and adulthood, the One of the most difficult things for people to
focus may change to a significant life partner do is to learn to say “Thank you” when given
or a peer group, or both. Regardless of the a compliment. “Thank you” not only ac-
developmental stage of life, people need to knowledges the other person’s positive regard
feel loved. for a quality one possesses, but it reinforces to
one’s “self ” that “Yes, I did do that well and I
Self-Esteem do deserve the recognition.” Unfortunately,
The “higher” needs begin with the idea that people sometimes interpret this simple re-
“If I am loved by someone, there must be sponse as “false pride” and consider it to be
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62 UNIT 1 | Foundations for Mental Health Nursing

in poor taste to acknowledge themselves in a

positive manner. Women have been socialized
this way for years, and although there has been
some improvement over the past 20 years,
there is much work yet to be done in this area.
Self-Actualization
The fifth and final rung on Maslow’s hierar-
chy ladder is called self-actualization. This
means achievement, taking risks, and work-
ing to one’s individual potential. The self-
actualized person is a problem solver. Situa-
tions can be creatively dealt with when a
person is confident enough to stretch the lim-
its of ability. Taking the risk to stretch bound-
aries by joining the nursing profession is an
example of seeking out self-actualization. Figure 4-10 Carl Rogers. (Courtesy of Bonnie
Even though it may not feel comfortable yet, Drumwright, PhD, Gold River, CA.)
it is a process for self-improvement.
Gender differences have been a subject of
discussion since the beginning of time. Men he or she lives in. He did not think it was ap-
and women have always said that they just do propriate to put a value on another person’s
not understand each other. Proof of that exists perception of the world, so he said that every
now. Scientists can truthfully, confidently, person deserved to be treated with respect
and nonjudgmentally say that “Yes, there are and “unconditional positive regard” just by
differences in the way men and women think, virtue of being a human being.
communicate, and process life.” Psychologist He also differed from Maslow in the area
Carol Gilligan studied this phenomenon of self-actualization. Rogers believed that self-
(Gilligan, 1982). She hypothesized that one actualization is the basic motivator for people
of these fundamental differences appears to and that all people have a built-in desire to
affect Maslow’s hierarchy: women tend to achieve their capabilities.
value relationships as a basic need, and men Nursing practice is based very strongly in
tend to value achievement as a basic need. Rogers’ theory. His eight steps to being a
This is not an issue of right or wrong; no helping person are listed in Table 4-6.
value statement is being made. It is impor-
tant, however, that nurses who are observing Carl Jung (1875–1961)
and collecting data on their patients under- Although he broke from some of Freud’s
stand that differences in patient attitudes ideas, Carl Jung (Fig. 4-11), a Swiss psychol-
and responses to treatment may be related to ogist, also believed in the effects of the uncon-
gender. scious mind. He included in his definition
of “unconscious” both repressed personal
Carl Rogers (1902–1987) experiences and representations of universal
Carl Rogers (Fig. 4-10) was also a person- human experiences, those experiences all
centered or humanistic psychologist. Although people have. He used different terminology
he believed that all people need to be “prized to describe the various parts of human per-
and loved,” his theory is a bit different from sonality, and he believed that healthy person-
Maslow’s. The phrase associated with Carl alities are a balance between the conscious
Rogers is “unconditional positive regard.” and the unconscious. “Self ” to Jung meant
Rogers believed that each individual may the deep, inner part of people. He believed
have different ideas about life and the world that males and females are different organisms
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 63

l Table 4-6 Rogers’ Eight Steps

Empathy “Walk in another’s shoes.”
Respect Care for patient as a person, not just a patient.
Genuineness Helper is a sincere/authentic role model.
Concreteness Identify patient’s feelings by careful listening and stereotyping.
Confrontation Discuss discrepancies in behavior.
Self-Disclosure Share self, as is appropriate to situation.
Immediacy of Relationships Helper selectively shares own feelings.
Self-Exploration The more we explore ourselves, the greater/better the coping/
adapting.
Source: Prochaska, J. O. (1984). Systems of Psychotherapy. Pacific Grove, CA: Brooks-Cole.

■ Stages of Human
Development
Nurses are entrusted with caring for people
of all ages. Many nursing program mission
statements refer to the concept that nursing
must cover a continuum of experiences
throughout the life span. It becomes the
nurse’s responsibility to have a working
knowledge of the main physical and behav-
ioral changes that can be expected within cer-
tain age groups. It is also important to have
some idea of the complications that might
occur if developmental tasks are not com-
pleted successfully. This is called the study of
Figure 4-11 Carl Jung. developmental psychology. Table 4-7 identi-
fies the life stages, some of the expected
major physical development, expected behav-
but that each contains part of the other. The ioral development, and possible outcomes of
human endocrine system shows that men failure to meet certain developmental tasks.
have traces of female hormones and women This chart incorporates traits from all the
have traces of male hormones. To Jung, it log- theorists identified in this text. It is not a sub-
ically followed that this fact affects the way stitute for knowing the concepts of the indi-
each person develops his or her personality. vidual theorists.
Therefore, he used the term “anima” to de- Life is an accumulation of experiences.
scribe the feminine tendencies in men and the Some of those are positive and some are not.
term “animus” to describe the male character- Each person has to deal with gains and losses
istics in women. as he or she travels through life. Patients may
“Mask” is a word Jung used to define the be in different stages of loss with their illness.
part of the personality that one presents Each age group has its own set of gains and
socially. It hints at the idea that one’s inner- losses. Learning to deal with these ups
most self may be different from his or her and downs early in life can make the more
public self. significant experiences less difficult to cope
(Text continued on page 68)
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64 UNIT 1 | Foundations for Mental Health Nursing

l Table 4-7 Overall View of Human Development

Age Range
(ages vary
somewhat Expected Expected Potential Outcome
according Physical Behavioral of Ineffective
Life Stage to theorist) Development Development Development
Prenatal Conception • Cells differenti- • Fetus kicks and • Threats to mother’s
through ate (specialize) may respond health of primary
10th lunar by the end of to stimuli such as concern (e.g., smok-
month the first familiar voices, ing, drugs, malnutri-
(lunar month trimester. music. tion); mother’s
= 28 days) • Intrauterine prenatal habits
conditions of seem to have a
mother may strong influence
affect prenatal on the developing
development. baby.
• Alcohol consump-
tion during preg-
nancy of special
concern; can lead
to a condition
called fetal alcohol
syndrome (FAS),
which can cause
physical anomalies
as well as cognitive,
emotional, and
behavioral compli-
cations in child.
Newborn 1st month • May have flat- • Bonding (e.g., • Angry crying
of life tened nose, touching, talking) • Mistrust
unevenly of parents and • Withdrawal
shaped head, baby is said to be • Stress, which
bruises from crucial to develop- slows further
the passage ment of trust. development
through the • Sucking reflex
birth canal; • Can see
these physical 7–10 inches
characteristics • Likes bright colors
will change over • Likes to be talked to
the first month • Prefers female
of life. voices
• Likes touch, cud-
dling, rocking,
and the like
• Will not be
“spoiled” by this
attention
• Can hold head up
for a few seconds
• Follows light with
eyes
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 65

l Table 4-7 Overall View of Human Development—cont’d

Age Range
(ages vary
somewhat Expected Expected Potential Outcome
according Physical Behavioral of Ineffective
Life Stage to theorist) Development Development Development
Infant 2nd month– Infants are all very 2–4 months: • Poor parent-child
11/2 years of much alike (physi- • Begins to laugh relationship
life cally and develop- • Follows people’s can lead to mis-
mentally) until the movements with trust and poor
age of 10 months. eyes self-concept.
5–7 months:
• Failure-to-thrive
syndrome
• Holds head erect • Separation anxiety
• Turns head toward
voices
• Babbles/coos
• Drinks from a cup
8–10 months:
• Sits up alone
• Says “mama,”
“dada”; under-
stands “no” and
“bye-bye”
Toddler 11/2–3 years • Long trunk • Toilet training • Anger
• Short legs • Learning sex roles • Regression
• Brain about 3/4 by copying behav- • Reversion to infant-
of full size in iors of same-sex age behaviors
order to be able parent
to support fu- • Self-centered
ture growth and • Does not share
development • Wants things now
• Walking • Both boys and girls
learning auton-
omy (indepen-
dence) by using
the word “no”
• Assimilation,
which is taking in
and processing of
information via the
senses
• Accommodation,
which is the ability
to adjust to new
information or
situations
Continued
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66 UNIT 1 | Foundations for Mental Health Nursing

l Table 4-7 Overall View of Human Development—cont’d

Age Range
(ages vary
somewhat Expected Expected Potential Outcome
according Physical Behavioral of Ineffective
Life Stage to theorist) Development Development Development
Preschool 3–6 years • Medical and • Cognitive devel- • Enuresis—the
(Early dental examina- opment is a pri- involuntary bed-
Childhood) tions important mary activity; wetting in pre-
• Nutrition can many questions; school and school-
be challenging; “Why” a frequently age children who
children are used word. have been toilet
starting to pick • Socializes trained; often due
and choose their • Play important for to poor personal
favorite foods; self-expression relationships
time to start and anxiety relief • Encopresis—
teaching good • Reading is the involuntary bowel
nutrition. best parent-child movements in the
• Lead poisoning activity. same population
still a threat: it • Aggressive behav- as enuresis
tastes sweet ior (roughhousing)
and may still be • Active imagination
found in some possibly leading to
older plumbing nightmares
or in old paint • Mixed feelings
layers in housing about going to
units. school
School Age 6–12 years • Body thinning • Learning to share • Shyness and/or
out and growth • Peer group activi- fear of school if
slowing ties important trust and auton-
temporarily • Beginning to show omy have not
• Forming friend- acceptance of developed fully;
ships with same- moral issues by may be a result of
sex friends questions and not being included
• Losing baby discussions in peer groups; has
teeth and gain- • Reversibility: the been defined as a
ing permanent ability to put “silent prison”
teeth things in an order • Gangs—can be the
• By age 6, brain or sequence or to result of negative
almost full size; group things types of peer
neurological according to groups
system develops common traits • Stuttering—
from head down repetitive or pro-
• By age 6 or 7, longed sounds or
vision at its peak speech flow that is
• Vision and hear- interrupted; seems
ing screening to happen four
usually begun times more often
by the time the in boys: may be
child enters stress-related
school
• Agility increases
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 67

l Table 4-7 Overall View of Human Development—cont’d

Age Range
(ages vary
somewhat Expected Expected Potential Outcome
according Physical Behavioral of Ineffective
Life Stage to theorist) Development Development Development
School Age • Scoliosis (lateral • Accidents—the
—cont’d curvature of leading cause of
the spine) death in children;
screening possi- teaching safety to
bly encouraged families and chil-
• Late childhood dren is important.
(10–11 years • Child abuse/
old)—beginning neglect noted
of sexual devel- more frequently; all
opment, espe- health-care person-
cially in girls, who nel have the duty
now are matur- to report abuse or
ing about 2 years suspected abuse
ahead of boys (discussed in more
• Colds frequent, detail in Chapters 5
due to social and 22).
habits
Adolescent 12–18 years • Growth spurt • Learning • Anorexia/bulimia
(musculoskeletal independence frequent dangers
system) • Learning self- for males as well as
• Endocrine sys- sufficiency females; usually
tem maturing • Learning new from white, mid-
(hormones) social roles dle-class families
• Secondary sex • Mood swings • Males who mature
characteristics • Boredom later seem to have
developing • Introspection the hardest time
(facial and • Preoccupation adjusting.
underarm hair, with body image • Suicide a major
males’ shoulders • Own “language” concern for this
broaden, females’ • Peer group very age group, usually
hips broaden important—teens because of feeling
and breasts need intimacy unimportant and
develop) • Possible experi- not being taken
• Puberty— mentation with seriously by adults
individual is alcohol, drugs, sex
capable of • Communication
reproducing between parent
• Menarche— and adolescent
female’s first crucial
menstrual • Talking on phone/
period, which internet for hours
happens around
age 11–15 (it is
important to
know that nutri-
tion and exercise
affect this)

Continued
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68 UNIT 1 | Foundations for Mental Health Nursing

l Table 4-7 Overall View of Human Development—cont’d

Age Range
(ages vary
somewhat Expected Expected Potential Outcome
according Physical Behavioral of Ineffective
Life Stage to theorist) Development Development Development
Young Adult 18–35 years • Body usually in • Intimacy the main • Problems with de-
optimal physical task to accomplish veloping intimacy
condition • Schooling and • Difficulty leaving
career planning parent's homes
important
• Marriage and
family decisions
made
Adult 30–60 years • Gradual decline • Generativity, or • Disappointment
in hearing and passing down val- with own
visual acuity ues and skills to the achievements/
• Body beginning next generation next generation
to shorten (personally and • Stress demands
somewhat as professionally)— from different
musculature and a major task of the generations
bone structure adult
change
• Lung and car-
diac capacity
beginning
to decrease
somewhat
Older Adult 60 years– • Visual and hear- • Acceptance of • Fear of death and
death ing acuity con- limitations on dying
tinue to decline independence • Difficulty with
• Body becomes and physical retirement—
susceptible to ability identity is often
an increasing • Acceptance of associated with
number of phys- the idea of death career
ical and emo- and beginning to • Depression relating
tional illnesses prepare for it to aging, loss of
• Acceptance of friends, and so on
retirement
• Increases in stress
throughout the life
span

with. Overuse of defense mechanisms (see ■■■ Classroom Activity

Chapter 7) can be curtailed with effective • As a class, develop a teaching plan that could
stress-management techniques, which can be be used with children who are experiencing
learned very early in life. It is important for the divorce of their parents. The checklist
should be detailed enough to accommodate
nurses to understand the developmental age-appropriate communication and informa-
stages throughout life, and this includes the tion. The class might prefer to do a separate
end of life. The process of death and dying is checklist for each developmental group.
one that all people will face at some point.
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 69

Death and Dying

Losing a loved one at any age or for any reason
is a difficult experience. Separation, loss, and
grief are human conditions that are unavoid-
able. Today’s world presents conflicting phe-
nomena. People have a better quality of life
and better health care than ever before. Because
of this, the average life expectancy is 78.7 years
(CDC–National Center for Health Statistics).
On the other hand, people exist in a fast-
paced and competitive society, which causes
high levels of stress and encourages people to Figure 4-12 Elisabeth Kübler-Ross.
make unhealthy choices in their diets and (Courtesy of Ken Ross, Scottsdale, AZ.)
lifestyles. This results in people dying of my-
ocardial infarctions in their 30s and 40s. Au- Her idea implies that the end result of expe-
tomobile accidents and recreational activities riencing the five stages of grief or dying is the
are taking the lives of children at higher num- ability to die in peace and with dignity. These
bers than ever before. According to the Centers stages apply to the dying people and those
for Disease Control and Prevention (CDC), they leave behind and to other major losses
violence is a global cause of death. Even though in life. These stages are listed in Table 4-8.
people know intellectually that they will die, Death, and the activities that accompany
they often struggle with death as if it is unex- it for the dying person and those left behind,
pected. We have been called a “death-denying is not only physiological; it is also deeply
society.” rooted in cultural and spiritual tradition. Just
Psychologist Dr. Elisabeth Kübler-Ross as every person is unique in life, so will the
(Fig. 4-12), who died in 2004 at age 78, was rituals surrounding the activities of death be
a leader in the study of the process of death very personal and individual.
and dying. She made her reputation by learn- Dr. Kübler-Ross emphasized the impor-
ing about the activities of the mind and body tance of communicating throughout the dying
at and around the time of death. Her initial process. People who are in comas or in the end
studies were based on only 200 subjects, all stage of death may not be able to respond to
of whom had cancer; yet her theory has verbal cues or participate in conversation, but
survived and has spanned more than 40 years. it is widely believed that they continue to hear

l Table 4-8 Five Stages of Grief/Death and Dying by Dr. Elisabeth

Kübler-Ross
Stage Key Words Expected Behaviors
Denial “Not me!” Refuses to believe that death is coming; states “That
doctor doesn’t know what he/she is talking about!”
Anger “Why me?” Expresses envy, resentment, and frustration with
younger people and/or those who are not dying
Bargaining “If I could have one May become very religious or “good” in an effort to
more chance . . .” gain another chance at life or more time to live
Grief/Depression Realizes that “bargain- Becomes depressed, weepy; may “give up,” quit
ing” is not working and taking medications, quit eating, and so forth
death is approaching
Acceptance “OK . . . but I don’t have Enters a state of expectation; may begin to call
to like it!” family members near; needs to complete “unfin-
ished business”; prepares spiritually to die
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70 UNIT 1 | Foundations for Mental Health Nursing

what is going on in their environment. For this state’s recognition of an advance directive or
reason, nurses must be careful in talking to the “living will” (where the wishes of the dying
patient and the family, even immediately after person are placed on a legal document,
the patient’s death. Again, people from some signed by the person while competent, and
cultures and religions believe that the “spirit” witnessed), and the family’s wishes. Advance
or “soul” remains in the room for a period of directives also identify who the decision
time after death. Regardless of the belief sys- maker(s) will be if the person is unable to
tem, it is a sign of respect to the patient and speak for him/herself.
the significant others to include the patient in Euthanasia (sometimes called “mercy
the conversation and continue to speak in killing”) is illegal in the United States, but
terms of the reality of the situation. “physician-assisted suicide” (also called aid in
dying) is now legal in some states. These
Neeb’s Dr. Kübler-Ross’ theory also empha- topics will continue to be debated. Competent
■ Tip sizes the fact that hearing is the last adults have the right to decline any medical
sense to leave a person before death.
treatment even if it hastens death. All of these
Children go through the same stages as can bring out strong emotions for families
adults; and as with adults, they may need and the nurse who is caring for people at the
special help to come to terms with losing a end of their lives. Nurses need to be educated
loved one. The help nurses give to younger about the ethical and legal considerations
patients must be age-appropriate. Infants and around providing end of life care.
toddlers may not be able to understand what The nurse’s responsibilities at the patient’s
happened, but they do sense the change. death vary from state to state. For instance,
Keep their routine as normal as possible. Pro- in some states nurses are allowed to pro-
vide them with physical closeness and a safe nounce the death of a patient; in other states
environment. this must be done only by a physician. Death
Children from 2 to 6 years of age may have is defined differently from state to state. Phys-
the sense that death is reversible. How often ical signs such as vital signs, skin color and
do they see cartoon characters “die” and then temperature, presence or absence of activity
immediately return to animated life? When on electroencephalogram (EEG) and electro-
the reality that grandmother or grandfather cardiogram (ECG), and the ability to be
is not coming back to life is understood, it is viable, or to live without mechanical assis-
important that the child understands that tance, are criteria used by states to define
he or she did not cause the death of the death. It is the nurse’s responsibility to know
loved one. the legal definition of death in the state in
Children ages 6 to 12 are at varying which he or she is working.
degrees of understanding. It is important to
allow and encourage children to talk about ■■■ Critical Thinking Question
their feelings. Recent incidents of violence Your patient is in a monogamous homosexual
involving this age group have provided the relationship and is in the final stage of life. Death
is imminent, but the patient is still alert and
opportunity for grief counselors to intervene oriented. Family and partner are in the room. The
with children who have survived the ordeals. patient asks you to ask the physician to “put me
Teens are bridging the gap from childhood to sleep.” The patient’s partner weeps but sup-
to adulthood and may respond to grief and ports the request; the family members threaten
loss as an adult at times and then as children. to sue if the physician does “any such thing.”
What are your thoughts and feelings about this
Provide structure, routine, and an environ- request? What will you do to help the patient?
ment in which they may freely express their The family? The partner? What if this were your
thoughts and feelings. parent or child who was about to die? What
When caring for dying patients, the nurse would you think and feel then?
needs to be aware of the existence of and
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 71

■■■ Key Concepts 2. Dr. Elisabeth Kübler-Ross developed

a theory of five stages that people go
1. There are many theories about personal- through when they are grieving or dying.
ity development in human beings. Although others have presented theories
Although they are only theories, there on this topic, hers remains the most
are strong indications of validity in all commonly accepted theory in nursing.
of them. The licensed practical nurse
(LPN) and the licensed vocational 3. Each person is an individual and will go
nurse (LVN) must have a working through stages of development or grief at
knowledge of some of the more com- his or her own pace. These theories are
monly accepted theories of human guidelines to help nurses understand
development throughout the life what patients may experience as they
span. go through certain stages in their lives.

CASE STUDY
Mr. Y, a 24-year-old construction worker, conversations were held in his room while
suffered a traumatic brain injury after he was in the coma. When he awakened
falling from scaffolding when his safety from the coma, he was able to tell most of
equipment failed. He was comatose for what was said. He wondered why “nobody
8 days. During this time, family and answered me when I talked to you.” He
friends kept a constant vigil. His wife especially wanted to reassure his wife that
was 6 months pregnant and fearful about “Nothing would keep me from seeing that
having to raise the baby alone. Many baby!”

1. What suggestions could a nurse have made to the family of this patient regarding
patients who are comatose?
2. How can a nurse help the patient who has concerns about “memories” he or she acquired
while in a coma (e.g., what is real and what is not, what things might have been said in
confidence, and so forth)?

REFERENCES Dennis, L.B., and Hassol, J. (1983). Introduction

Barry, P. D. (2002). Mental Health and Mental to Human Development and Health Issues.
Illness. 7th ed. Philadelphia: JB Lippincott. Philadelphia: WB Saunders.
Barger, R. N. (2000). A Summary of Lawrence Dewey, R. (2007). Karen Horney’s theory. Retrieved
Kohlberg’s Stages of Moral Development. Notre from www.intropsych.com/ch11_personality/
Dame, IN: University of Notre Dame. karen_horneys_theory.html
Centers for Disease Control and Prevention. Gilligan, C. (1982). In a Different Voice: Psycho-
National Center for Health Statistics. (n.d.). logical Theory and Women’s Development.
Retrieved from www.cdc.gov/nchs/fastats/ Cambridge, MA: Harvard University Press.
lifexpec.htm Kübler-Ross, E. (1969). On Death and Dying.
Centers for Disease Control and Prevention. New York: Macmillan.
(n.d.). Retrieved from www.cdc.gov/ Lickona, T. (1991). Educating for Character:
violenceprevention/globalviolence/index. How Our Schools Can Teach Respect and
html Responsibility. New York: Bantam.
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72 UNIT 1 | Foundations for Mental Health Nursing

WEB SITES Horney

www.muskingum.edu/~psych/psycweb/history/
Kübler-Ross horney.htm
www.nlm.nih.gov/changingthefaceofmedicine/ www.learning-theories.com/
physicians/biography_189.html
http://currentnursing.com/nursing_theory/theory_
Skinner
www.simplypsychology.org/operant-conditioning.
of_psychosocial_development.html
html
Piaget
http://webspace.ship.edu/cgboer/piaget.html
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CHAPTER 4 | Developmental Psychology Throughout the Life Span 73

Test Questions
Multiple Choice Questions
1. A 4-year-old patient comes into the clinic 5. The infant mortality rate is highest in
with her father. She is being checked for mothers who are:
a recurring ear infection. As you prepare a. Over 35 years old
her to see the physician, she says to you, b. Over 30 years old
“I love my Daddy. I’m going to marry c. Under 20 years old
him like Mommy someday!” Which one d. Under 15 years old
of Freud’s stages of development is she 6. The term anima from Carl Jung’s theory
most likely demonstrating? describes:
a. Genital a. Male characteristics in women
b. Oral b. Feminine characteristics in men
c. Anal c. Male characteristics in men
d. Phallic d. Feminine characteristics in women
2. Patient Y is 20 years old. Y is a perfection- 7. According to Erikson’s theory, the devel-
ist and very routine-oriented. Freudian opmental task stage a 3- to 6-year-old
theorists would say that Patient Y did needs to accomplish is:
not successfully complete which of the a. Identity
following stages of development? b. Industry
a. Genital c. Intimacy
b. Oral d. Initiative
c. Anal
d. Phallic 8. Infants seem to be very much alike
(developmentally) until the age of:
3. Patient Y (from question 2) is being treated a. 2 months
by a behavioral psychologist. When Patient b. 6 months
Y begins to miss meals and activities be- c. 10 months
cause of the need to complete routines d. 12 months
perfectly, the staff is to intervene. Patient Y
failed to come to dinner on your shift. You 9. A toddler’s ability to take in or acknowl-
go to check on the patient and see Y care- edge changes in the environment is
fully placing personal items in a special called:
place in the bathroom. Your best response a. Adjustment
to Y from a behavioral and therapeutic b. Assimilation
background would be: c. Accommodation
a. “Y, where were you at dinner tonight?” d. Autonomy
b. “Y, you blew it. You didn’t come to 10. The parents of a 2-year-old arrive at the
dinner and you know what that means: hospital to visit the child. The child is in
no pass for the weekend.” the play room and ignores the parents
c. “Y, I am just here to remind you it is during the visit. This 2-year-old behavior
dinnertime.” indicates:
d. “Y, it is not appropriate to miss dinner. a. The child is withdrawn
What is the consequence of that, b. The child is more interested in playing
according to your care plan?” with other children
4. In prenatal development, cell differentiation c. The child has adjusted to the hospital-
is normally completed by the end of the: ized setting
a. First trimester d. A normal pattern
b. Second trimester
c. Third trimester
d. First lunar month
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C HA PT E R
5
Sociocultural Influences
on Mental Health
Learning Objectives Key Terms
1. Define culture. • Abuse
2. Identify factors to consider when assessing culture and • Culture
ethnicity. • Ethnicity
3. Differentiate between religion and spirituality. • Ethnocentrism
4. Define ethnicity. • Homeless
5. Identify parenting styles. • Parenting
6. Differentiate between abuse and neglect. • Prejudice
7. Define stereotype. • Religion
8. Define prejudice. • Stereotype
9. Define homelessness.
10. Identify some possible reasons for homelessness.
11. Identify nursing care for people who are homeless.

■ Culture
M
any professionals in the field of
psychology believe that social and
cultural environments have a great Culture is a term that is often misused. Cul-
influence on the way people develop and ture is a shared way of life, the combination
process life. They believe that positive or neg- of traditions and beliefs that make a group of
ative social and cultural experiences early people bond together (also see Chapter 3).
in life result in similar positive or negative Culture is not based on one’s color of skin or
behavior and beliefs in adulthood. country of origin. For example, in the 1960s,
a group of young people who were speaking
Neeb’s Part of the nurse’s role is to learn out against the politics and morals of their
parents began living in groups (Fig. 5-1). The
■ Tip about traits that are common
among people and those that are area they chose to start this movement was
different. It is important to under- the Haight-Ashbury district in San Francisco.
stand people’s customs and beliefs They called themselves “hippies,” and they
to avoid unrealistic expectations of shared a way of life that consisted of exper-
patients. imenting with drugs; living together with-
out being married (or “free love,” as it was
termed); dressing in ripped, dirty clothing;
Culture and ethnicity are among the topics not cutting their hair; and doing just about
that are said to have the greatest influence on everything else that was opposite to the values
people throughout their life span. of the “older generation.” This group believed

75
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76 UNIT 1 | Foundations for Mental Health Nursing

Tool Box | Transcultural Nursing Assessment

Tool
www.culturediversity.org/assesmnt.htm

■■■ Clinical Activity

While preparing a care plan for an assigned
patient, ask the patient about his or her culture.
Determine if any of the patient’s traditions or
beliefs have been included in the plan of care.

Figure 5-1 The hippies of the 1960s repre-

sented their own unique culture. A psychoanalyst named Karen Horney
(see Chapter 4) proposed the theory that
some cultural traditions and beliefs cause
in loving everyone, regardless of race, creed, disturbances in personal relationships and
and color—as long as the individual em- that this can lead to some forms of emotional
braced the beliefs of the group. The group’s disturbances. Today, one can look at other
symbols were the daisy and the peace sign, groups who have a shared belief system and a
and “flower power” and “power to the people” shared way of life. Madeleine Leninger, a
represented some of the ideals they followed. nurse theorist, also realized the importance of
Much to the chagrin of the over-30 age transcultural nursing. Leninger established
group, these young people fit the definition the Culture Care Theory. It was while caring
of a “culture.” It was called a “subculture” for children that she found how their behav-
or “counterculture” at the time. Today, the ior needs were related to their culture; with-
“goth” statement many youth are making out understanding each of these cultures,
may be equated to the statements of their par- functioning as a health-care provider was
ents or grandparents in the 1960s. difficult (Leininger, 2006)

■■■ Clinical Activity

As a class, formulate a list of 10 questions you can
Neeb’s Nurses may discover that when it use during your clinical experience while doing
■ Tip comes to being knowledgeable assessments on someone of a different culture or
about other cultures, they have been alternative lifestyle. Questions are subject to the
living in a glass jar—only seeing instructor’s approval.
other cultures but unaware of how
to interact with them.
Religious beliefs are often included in dis-
cussions of culture; however, it is important to
note that the religion is not usually the culture.
Bringing cultural competence to patient For people who practice Judaism or Islam, the
care is a primary responsibility of the nurse. relationship between their religious beliefs and
Culturally diverse nursing care takes into their cultural beliefs is so entwined that it is
account the following areas: communication, hard to separate those traits. However, the hip-
space, social organization, time, environmen- pie group mentioned earlier contained people
tal control and biological variation according raised in many different religions.
to the Transcultural Assessment Model devel- Religion is the belief in a higher power. This
oped by Giger and Davidhizar (Giger, 2013). belief system can be very strong—so strong that
Culturally diverse care means the nurse is people have fought wars over religion and even
adapting care in a manner congruent with the now continue to wage war in the name of
patient’s culture. religion. Rituals or worship services are usually
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CHAPTER 5 | Sociocultural Influences on Mental Health 77

l Box 5-1 Cultural Assessment—Questions to Ask

• Where was the patient born? If the patient is an immigrant, how long has he or she been in this
country?
• What is the patient’s ethnic affiliation? How strong is the ethnic identity?
• Who are the patient’s major support people? Does patient live in an ethnic community?
• Who in the family takes responsibility for health concerns and decisions?
• Are there any activities in which the patient may decline to participate because of culture or
religious taboos?
• Does the patient have any special food preferences, or food refusals because of culture or religion?
• What are the patient’s primary and secondary languages, and speaking and reading abilities?
• What is the patient’s religion, what is its importance in daily life, and what are current practices?
• What is the patient’s economic situation? Is income adequate for his or her needs?
• What are the patient’s health beliefs and practices?
• What are the patient’s perceptions of the health problems and expectations of health care?
Source: Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company.

■■■ Critical Thinking Question Native Americans into one large group; there
Your patient is from a different country and speaks are many nations and many tribes, each
only minimal English. Your translator has seen the with its own set of beliefs. One belief is that
patient and has gone over the hospital routines, certain numbers are sacred to some Native
rules, and patient’s rights. The patient’s mother Americans, and they may attribute special
insists on staying in the room 24 hours a day and
refuses to let you perform assessments and care
qualities to the four directions of north,
for the patient. The patient is in pain, but the south, east, and west.
mother will not allow pain medication to be Spirituality and religion are extremely
given. The patient will not accept the food from important to some patients and unimportant
the hospital. You smell food cooking and enter or nonexistent to others, although both are
the room to find the mother cooking on a hot
plate, which is a fire code violation. What can you
different. Nurses must be comfortable talking
do in this situation? to patients about their religious and spiritual
needs without pushing personal values on
patients. A patient’s success at recuperating
included in organized religions. Religion is from an illness or a surgical procedure may be
often the subject of stereotype. A stereotype is deeply tied to his or her spirituality. Nurses
a fixed notion or conviction about a group of who are not comfortable in these situations
people or a situation. should offer to call the chaplain in the facility
or a spiritual leader of the patient’s choice.
Religions involve items considered sacred.
■■■ Classroom Activity Such items may include books (e.g., Bible,
• Interview a person whose religion is different
from your own. You may use the interview Koran), jewelry (brooch, pin, or cross), the
format from Chapter 6. Present the interview person’s dress (headwear, loose-fitting cloth-
results orally or in writing to the class. Discuss ing), or other type of personal effects. It is
what you thought you knew about the religion generally believed that patients should be
prior to the interview. Discuss what you learned
after the interview. Review literature on that
allowed to keep these items when possible. In
specific religion and compare the information situations in which a patient may be in poor
from the interview. mental health and possession of these items
is of actual or potential danger to the patient
or others in the area, it may be necessary to
Native Americans are an example of a remove the items. If that becomes necessary,
group that worships different gods or spirits. enlisting the assistance of a representative
Of course, it is improper to categorize all from the particular religion may be helpful.
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78 UNIT 1 | Foundations for Mental Health Nursing

perfect position to teach and model inter-

Tool Box | Religion Diversity
www.bbc.co.uk/religion/religions/ personal relationships and, it is hoped, to
make great strides in eliminating prejudg-
ment of others.
Health care may not be completely free
■■■ Classroom Activity
• Have a culture awareness day presentation. of guilt in the area of race. A study was con-
Describe the following traditions for your religion ducted at Emory University School of Med-
or culture: icine in Atlanta, Georgia (Todd et al., 2000).
• Foods For 40 months, researchers studied 217
• Music patients who sought treatment for long bone
• Weddings
• Death practices fractures. Of these patients, 127 were black
• Myths and 90 were white. Patients with this type of
fracture usually require some type of pain
medication. The study showed that, even
though the injuries and pain levels were
■ Ethnicity similar, 43% of the black patients received
no pain medication, compared to 26% of
Ethnicity defines one’s more personal traits white patients. The study could not deter-
and identifies a person with his or her shared mine the exact rationale for the outcome.
heritage. Language, country of origin, and Did some patients refuse medication? Did
skin color are parts of one’s ethnicity. There some not ask? Was it a cultural choice?
can be different ethnic groups within a cul- Did medical staff make assumptions about
ture. For example, a blonde, blue-eyed woman drug misuse in some people? Nurses should
exhibits physical characteristics of her ethnic be wary of statistics and be careful about
background. However, these characteristics silent stereotypes.
say little about her culture; that would require
speaking to her and obtaining some informa-
tion. People are generally very proud of their ■■■ Critical Thinking Question
culture and ethnicity. Many communities Should a patient’s identification bracelet specify if
have festivals that celebrate their different the patient has insurance coverage? If the patient
does not have any coverage, will the care be the
cultures and ethnic groups. These festivals do same as if the patient had coverage?
much to educate the community about the
various people living together in it. Some-
times one can learn a lot about a group of
people from the kind of food they eat, and The hurt of prejudice has led to an emer-
these celebrations are usually overflowing gence of ethnocentrism, which is when people
with foods of the particular group. believe that their particular ethnic or religious
group has rights and benefits over and above
those of others. Gangs, supremacist groups,
Neeb’s Education can help eliminate prej- and terrorist groups may have had their roots
■ Tip udice, which is judging a person or in hate and prejudice.
situation before all the facts are Sadly, society is reminded of the plight
known. Prejudice is a destructive of the Jewish people, who lived through the
behavior; it is hurtful and it shuts horror of concentration camps. The United
the door on the enrichment of the States shows the scars of the inhumane treat-
society. ment of the African and African American
people, who have been fighting for their civil
Laws in the United States are intended rights for over 200 years. And it remains a
to minimize displays of prejudice relating to topic of debate today. The validity of affirma-
race, creed, gender, age, and so on. Unfor- tive action is being questioned and, in fact,
tunately, it is impossible to legislate the being called by some a form of discrimination
beliefs of individual people. Nurses are in a against other people. In 2008 the citizens of
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CHAPTER 5 | Sociocultural Influences on Mental Health 79

the United States elected their first African ■ Nontraditional Lifestyles

American president, which gave many hope
that some social scars will heal. Religion, cul- The definition of “family” is changing (Fig. 5-2).
ture, and ethnicity, as well as prejudice caused Gay marriage and civil unions have opened
by any of those characteristics, are personal very active debates. In June 2013, the
and deeply felt by members of the respective U.S. Supreme Count knocked down the
groups. It is important to keep the lines of Defense of Marriage Act to pave the way for
communication open. People learn by sharing federal recognition of same sex marriages.
with each other, so it is much better to ask a Same-sex marriages are now legal in many
person about something than to make an states. It is becoming more common in
assumption about it. Making such an assump- schools and clinics for children to have “two
tion is stereotyping, which can end a helping mommies” or “two daddies.” People with
relationship between nurse and patient. lesbian, gay, bisexual, and transgender (LGBT)
Many mental health professionals believe lifestyles are “out” in the open and living life
that people raised in an atmosphere of preju- as normally as the more traditional father/
dice and stereotype tend to become angry, mother/children families of decades earlier. All
hateful, and aggressive adults. There is no age groups are affected. However, despite signs
proof that all people who are subjected to of increased acceptance, LGBT individuals as
prejudice and stereotype develop into adults well as their families may still struggle with
with such negative attitudes. This is one of the facing being “different.”
dangers in reading statistics on these topics: People have been leading different lifestyles
Statistics can be very misleading and can in all along but were far less comfortable profess-
fact support the negative stereotypes. ing it in years past. Aging happens to all,
regardless of lifestyle preference. By the year
2030, according to the National Gay and
■■■ Classroom Activity Lesbian Task Force, there will be approxi-
• Interview a person who is from a culture differ-
ent from your own. You may use the interview mately four million gay elders requiring
format from Chapter 6. Present the results orally social services and living in long-term care
or in writing. This will reinforce the information facilities. How will that change the way nurses
presented in Chapter 6, as well as provide first- provide care? Overtly, probably very little;
hand information pertinent to this chapter. good nursing care will remain good nursing
care. However, nurses may need to learn to
alter their communication style to ask for and
accept people’s preferences for roommate,
l Box 5-2 Enhancing Cultural type of clothing to wear, or activities to
Sensitivity attend. Activities may cross gender barriers in
a different way than they do today. Who
• Know your own attitudes, values, and shares bathrooms may become a different pri-
beliefs. ority. Clearly, in the not too distant future,
• Be aware of your own ethnocentrism. nurses practicing in clinics and long-term care
• Be aware of your own prejudices that may or assisted living facilities can expect some
influence your assessment.
• Maintain an open mind and seek out more changes in the clientele as well as the way in
information about your patient’s culture, which those people will require assistance.
beliefs, and values. Additionally, more individuals are choos-
• Communicate your interest about the ing to start and raise families as single parents.
patient’s beliefs and values. Parents are adopting children from other
• Approach the patient as an individual. countries, other ethnicities, and other races.
Avoid assuming that all people from one One family may now include parents and sib-
cultural background hold the same beliefs. lings with assorted skin tones and languages.
Source: Gorman and Sultan (2008). Psychosocial Nursing for General The global family is rapidly and constantly
Patient Care, 3rd ed. Philadelphia: F.A. Davis Company. evolving.
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80 UNIT 1 | Foundations for Mental Health Nursing

A B

C D

Figure 5-2 The definition of “family” is changing. A, Traditional family, with a mother, father, and
their biological children. B, Single-parent family. (Courtesy of Robynn Anwar.) C, Gay couple and
child. (Photograph by Creatas.) D, “Blended” family, in which each spouse has his or her own children,
whom they bring into a new family.
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CHAPTER 5 | Sociocultural Influences on Mental Health 81

■ Homelessness

Homelessness is not a mental illness (Fig. 5-3).

It receives brief mention in this text because
many of the people in the United States who
are homeless also have some threat to their
mental health.
The picture of the homeless population is as
varied as those who have homes. Some people
are working full-time but are homeless. They
might be victims of the economy, foreclosures,
or other situations not related in any way to
having a mental illness. Since 2008, tent cities Figure 5-4 Tent city for the homeless in
have appeared across America (Fig. 5-4). A Camden, New Jersey. (Courtesy of Robynn
Anwar.)
small number of people choose to live on the
streets. Others have been forced to live on the
street or in a shelter as a result of forces out of is linked to the rising cost of rental housing and
their control. poverty (National Coalition for the Homeless,
Many more of the homeless are suffering 2009). Because of the diagnosis, the availability
from a variety of mental illnesses. Some people of benefits for the mentally ill, and the nature
are homeless as an indirect result of the health- of the illnesses, people with certain illnesses
care delivery system. Approximately one-third have a difficult time trying to live independ-
of the homeless population in the United ently with their illness. They end up out of
States is mentally ill, with many more having work, out of money, and out of a home. They
substance abuse issues (Mental Health Asso- may be noncompliant with their medications,
ciation of Colorado). The rise in homelessness have no access to getting refills, lose the med-
ication, or have it stolen on the streets. A large
number of people who use community-based
mental health services are the poor, especially
the homeless poor (Barry, 2002). Tragically,
many of the homeless are also veterans. Serv-
ices are available through Veterans Affairs,
but the person may have challenges in how to
access them.

■■■ Critical Thinking Question

You are the only source of income for your family.
You are laid off because of a merger of two agen-
cies. How long can you survive with no income?
How will you pay for insurance? Jobs are not plen-
tiful; the outlook for comparable employment
in the near future is bleak. How close are you
to living on the street? What will be the plan of
action for you and your family?

In the 1950s, deinstitutionalization led to

the discharging of people who were techni-
Figure 5-3 Homelessness is not a mental ill- cally able to be “in the community” but who
ness, but many homeless people face threats were not always able to cope with the stresses
to their mental health. (Courtesy of Telecom of caring for themselves, caring for their
Pioneers, Nova 5 Chapter #5, Brooklyn, NY.) families, and maintaining employment. For
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82 UNIT 1 | Foundations for Mental Health Nursing

some mentally ill people, this kind of pressure Shelters of varying types exist in many
and competition is the factor that keeps them cities. They are funded and staffed in different
ill. The Urban Institute Study of 2000 estimates ways. For example, some are church funded
there are approximately 3.5 million people and some rely on grants and underwriting by
annually who are homeless. Approximately large businesses. Some are completely oper-
one-third of those are children (Box 5-3.) ated by volunteers and some have some paid
In 1987, the Health Resources and Ser- staff. Depending on the resources available,
vices Administration–Health Care for the shelters for homeless people provide anything
Homeless (HRSA–HCH) was formed to pro- from meals and overnight shelter to health
vide information and help create plans to help care, dental care, and assistance with job
the homeless. The problem is that funding of placement.
federal programs depends on statistics, and it Often, however, behavioral conditions exist
is extremely difficult to get accurate numbers in such shelters. Homeless people may be
because they change markedly approximately required to stay drug- and alcohol-free and to
every 2 months (Society Magazine, 1994). show proof that they are compliant with med-
Patients may be brought to a facility through ications or some other criteria to help them
the emergency department or by a law enforce- return to an improved lifestyle.
ment agency. Sometimes medication is given to What techniques do nurses need to help
stabilize the patient, and he or she is returned patients who may be homeless and physically
to the community; other times the patient is or mentally compromised?
admitted to a medical unit. Unfortunately,
1. Treat the whole person, not the
sometimes the mental health issue is overlooked
homelessness.
because of the health-care provider's focus
2. Treat the person as any other patient.
being on physical health.
3. Maintain all patient rights.

■ Economic Considerations
l Box 5-3 Homeless in America.
Who Are They? A study by Eron and Peterson in 1982 found
that the lower the socioeconomic status, the
Approximate
higher the incidence of abnormal behavior
Group Percentage
Families with children 23% in U.S. society. That statement, however, is
(2007) not completely accurate. The study showed
Children under the age 39% that the statement applies more strongly to
of 18 (2003) patients with schizophrenia than it does to
People between the 25% those with mood disorders. The implication
ages of 25–34 (2004) is that there are always other variables
People ages 55–64 besides socioeconomic status. For example,
(2004) 6% people who live in poverty or underprivi-
Single females (2007) 65% leged circumstances will very likely have
Single males (2007) 35% greater stressors than will people of higher
Veterans of wars (served 40%
socioeconomic status. So, is it the lack of
in the armed forces)
African American (2006) 42% money or increased stress that leads to the
Caucasian (2006) 38% disorder? Such questions make it very diffi-
Hispanic (2006) 20% cult, if not impossible, to make absolute
Native American (2006) 4% statements about the correlation between
Asian (2006) 2% disease and any variable. Behaviorists em-
Note: These numbers are approximations phasize that people always have a choice. If
and will vary according to the study and the the foregoing statements about poverty and
area of the country. illness were completely true, then it would
Source: National Coalition for the Homeless (2009). Who is Homeless? follow that all people in that same circum-
Retrieved from http://nationalhomeless.org/factsheets/who.html. stance would be mentally ill.
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CHAPTER 5 | Sociocultural Influences on Mental Health 83

However, this is simply not the case. What was parented. That means all the cultural and
variable causes some people to be ill and others religious values that have been planted in one
not to be ill? Is it choice? Is it genetic? Is it parent’s belief systems are brought out in the
learned behavior? This is part of the intrigue open and blended with those values from
of the study of the mind. the other parent’s upbringing. Then, it is up
to the parents to take one day at a time and
■ Abuse learn from their mistakes. Sometimes parent-
ing is learned from friends and neighbors.
Abuse is misuse of a person, substance, or Sometimes schools, health-care facilities, and
situation. Sometimes people say that they communities offer classes for parents.
cannot be abusing because they know what
they are doing. This is not true. Anyone who ■■■ Critical Thinking Question
misuses or overuses a person, a substance, or You are home one evening and you hear the
a situation (such as gambling or power) is 18-month-old child of your upstairs neighbors.
displaying abusive behavior. The child has been crying for 3 hours. You have
Some individual forms of abuse are dis- heard no footsteps in the apartment. The answer-
ing machine picks up each time you attempt to
cussed in Chapter 22. Abuse in general is a call. You become concerned and call the building
growing phenomenon in society. People de- supervisor to open the apartment. When you get
bate about whether a higher incidence of in, you find unsanitary conditions, and the parents
abuse exists now or whether people are just are not in the apartment. You look outside and
talking about it more openly. Violence is a see the parents several apartments down, party-
ing with friends. What are your responsibilities?
learned behavior. It is well documented that How will you respond to the parents? Whom will
in the majority of physical abuse situations, you notify? The parents tell you to mind your own
the abuser was abused at some point. business. What will you say to them? What will
When it comes to substance abuse, the you do if it happens again?
findings are not quite as conclusive. Some
studies indicate that this type of abuse may
be genetic, learned, or possibly due to a Reactions to altered parenting styles are
chemical imbalance in the body. A phenom- varied. Again, there is no “perfect” situation
enon called the “addictive personality” is or guarantee of being “good” parents. Parent-
defined as grouping abuse disorders together. ing is stressful. No matter what patients are
It is important for nurses to understand that concerned about during their hospitalization,
there may be more than one cause for a it is almost certain that their children will be
particular mental health problem. Good a paramount focus of attention. Nurses can
communication and data-collecting skills will help parents not only through the stress of
help the nurse find potential causes for each being hospitalized and apart from their chil-
patient’s mental health problem. dren, but also with the stresses of parenting in
general by helping parents choose healthy
lifestyles. Good nutrition, moderate exercise,
■ Poor Parenting and “adult time” apart from the children can
be effective stress relievers.
What is a “good” parent? Is it the parent who
Diana Baumrind (1971) has classified
lets the child do anything the child wants? Is
three different types of parents. They are
it the parent who buys all the newest fads for
described as follows:
the child? Is it the parent who teaches strict
values and ethics? Maybe it is the parent who 1. Authoritarian parent: This parent sets up
is with the child at all times. Parenting is the very strict rules. The child has little or
method of raising children that is used by par- no voice in family decisions. This style
ents or other primary caregivers. Parenting is of parenting is evidenced by novelty
a learned behavior; it is not an innate skill. So, clothing imprinted with the saying,
how do parents learn to be parents? Typically, “Because I’m the Mommy/Daddy, that’s
one tends to parent based on the way he or she why!” This authoritarianism can lead
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84 UNIT 1 | Foundations for Mental Health Nursing

to a rebellious, hostile child who may ■■■ Clinical Activity

enter adulthood angry, violent, unwill- Choose someone you know who is a parent.
ing to obey laws, and unable to make This can be a family member, friend, neighbor,
consistent decisions. or anyone you feel comfortable with. Using the
2. Authoritative parent: This style of parenting parenting definitions of Diana Baumrind, iden-
tify what basic parenting style you think this
has firm, consistent rules and limits, while parent uses.
allowing for discussion and occasional flex-
ibility of those rules according to special
circumstances. Children are allowed some
freedom, within set limits, and some voice ■■■ Key Concepts
in decisions. Researchers think that this is
the preferred style of parenting. It offers a 1. Culture, ethnicity, sexual orientation,
balance between rules and responsibilities, and religion are deeply rooted human
which allows the child to learn to make experiences. They are not “good” or
appropriate choices and accept the out- “bad”; they are different for each indi-
comes of those choices. vidual or group of individuals who
3. Permissive parent: This is the type of claim membership in that culture,
parent many adolescents wish they had. ethnic group, or religion.
This style of parenting provides little
2. People have many more similarities than
structure and few guidelines. The child
they have differences. It is important for
is not sure of his or her boundaries. If
nurses to concentrate on the similarities
one does not learn boundaries, it be-
among people and to be comfortable
comes difficult to learn how to control
asking questions about the background
oneself and how to behave in certain
of their patients and coworkers. Role
situations. Permissive parents can be in
modeling cooperative relationships can
danger of being accused of neglect. The
be very helpful in teaching others about
parent acts as the child’s friend rather
cultural sensitivity.
than the parent of the child.

CASE STUDY
Harold is a 76-year-old nursing home who can participate in his care. He no
resident. He has type 1 diabetes and gives longer meets the criteria for skilled-care
himself his own insulin. He has the diagno- nursing. A decision must be made about
sis of paranoid schizophrenia but has been his future, as he will no longer be eligible
asymptomatic for 1 year. Harold is also a to remain in this nursing home. Harold
severe alcoholic, and he periodically leaves wishes to be his own advocate and is found
the nursing home against medical advice to be legally capable of making his own
and is gone for 2 to 3 days. He has friends decisions. The outcome for this patient is
“on the street” because, before being insti- that he chooses to “take my chances” and
tutionalized, that is where he lived. Harold return to the streets. He has not been seen
goes to the local shelter for meals and again by any of the nursing home staff. No
knows he can go to the hospital to get his further information is available about this
insulin. He has no family in the vicinity patient.
1. Considering Maslow’s Hierarchy of Needs, how would you classify Harold?
2. What are the arguments both for and against his decision to leave the nursing home?
3. Do you consider Harold to be mentally healthy and competent? Why or why not?
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CHAPTER 5 | Sociocultural Influences on Mental Health 85

REFERENCES Merriam-Webster. (2012). Merriam-Webster; an

Encyclopedia Britannica Company. Retrieved
Barry, P.D. (2002). Mental Health and Mental
from www.merriam-webster.com/dictionary/
Illness. 7th ed. Philadelphia: J. B. Lippincott.
homeless
Baumrind, D. (1971). Current patterns of
National Coalition for the Homeless. (2009).
parental authority. Developmental psychology
Who is homeless? http://nationalhomeless.org/
(monograph 1), 4, 1–103.
factsheets/who.html
Cummins, H.J. (June 22, 2003). Coming out,
Purtilo, R., and Haddad, A. (2002). Health
moving on. Minneapolis, MN: Star Tribune.
Professional and Patient Interaction. 6th ed.
Eron, L.D., and Peterson, R.A. (1982). Abnor-
Philadelphia: W.B. Saunders
mal behavior: Social approaches. In M.R.
Social science and the citizen: Counting home-
Rosenzweig and L.W. Porter (Eds.), Annual
less (1994, November/December). Society
review of psychology 33, 231–65.
Magazine.
Galanti, G. (1991). Caring for Patients From
Todd, K.H., Deaton, C., D’Adamo, A. P., and
Different Cultures—Case Studies From
Goe, L. (2000). Ethnicity and analgesic
American Hospitals. Philadelphia: University
practice. Annals of emergency medicine, 35,
of Pennsylvania Press.
11–16.
Giger, JN. (2013). Transcultural Nursing.
St Louis: Mosby.
Gorman, L.M., and Sultan, D.F. (2008). Cul- WEB SITES
tural considerations. In Psychosocial Nursing Cultural Competence
for General Patient Care. 3rd ed., pp. 49–56. www.nooruse.ee/e-ope/mitmek_oendus/transcultural_
Philadelphia: F.A. Davis. nursing.pdf
Kaplan, B.J. (November 2002). Gay elders face Homelessness
uncomfortable realities in LTC. Caring for the http://nationalhomeless.org/factsheets/who.html
Ages, American Medical Directors Association Culture
(November 2002), Vol. 3, No. 11. www.uniteforsight.org/cultural-competency/module1
Leininger, M. (2006). Part one: Madeleine M. Parenting
Leininger’s theory of culture care diversity www.oberlin.edu/faculty/ndarling/lab/psychbull.pdf
and universality. In M. Parker (Ed.), Nursing www.devpsy.org/teaching/parent/baumrind_styles.
Theories and Nursing Practice. 2nd ed., html
pp. 309–320. Philadelphia: F.A Davis. Gay and Lesbian Task Force
Martin, M.L. (2000). Ethnicity and Analgesic http://ngltf.org/
Practice: An Editorial. Annals of emergency Religion
medicine, 35, 77–81. www.religionfacts.com/
Mental Health Association of Colorado. Home-
lessness. www.mhacolorado.org/file_depot/
0-10000000/Homelessness.pdf
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86 UNIT 1 | Foundations for Mental Health Nursing

Test Questions
Multiple Choice Questions
1. The concepts of space, time, and waiting 6. Parents accompany their ill 8-year-old
are: child to the clinic. The child was diag-
a. Religious nosed last month with type 1 diabetes
b. Cultural and is insulin dependent. The parents
c. Economic admit they are not administering the
d. Ethnic insulin, as their religious beliefs do not
2. The condition of judging a person or allow foreign substances in any form
situation before all the facts are known is for any reason. A check of the patient’s
called: chart clearly indicates that diabetes
a. Hatred teaching had been done with this family
b. Abuse unit at last month’s visit. Your initial
c. Prejudice nursing action is:
d. Stereotype a. Report the parents for child endan-
germent, as nurses are mandatory
3. Homelessness is being blamed, in part, on: reporters.
a. Deinstitutionalization b. Inform the parents that this child
b. Access to community services could die without the required
c. Mental illness insulin.
d. All of the above c. Leave the room and call a doctor or
4. Nurses who care for patients who are RN to the room stat.
homeless understand that in the United d. Collect information pertaining to what
States: the religion would allow and facilitate
a. Homelessness is classified as a mental discussion with the doctor.
illness. 7. When collecting data during an intake
b. Approximately one-third of the home- interview, the nurse understands: (select
less are mentally ill. all that apply)
c. All the homeless have some form of a. Most homeless people are unemployed.
mental illness. b. Culture is a shared belief system.
d. People must be mentally ill to choose c. Prejudice exists within the health-care
to be homeless. delivery system.
5. A patient is admitted with the diagnosis d. There is no correlation between
of paranoid behavior. The patient claims mental illness and the condition of
to be of a religion requiring the wearing homelessness.
of very heavy necklaces. You research the 8. The most common reasons for homeless-
religion and determine this to be true, ness include: (select all that apply)
but the patient has been seen violently a. Economic setbacks
flinging a necklace at his or her room- b. Lack of ambition and laziness
mate. Your best nursing action is: c. Major health expenses
a. Call an assistance code. d. Desire to live independently
b. Remove all religious items. E. Mental health
c. Do nothing: it is his or her religious
right. 9. Language, country of origin, and skin
d. Enlist the assistance of a religious color define:
representative to negotiate removal a. Religion
of the item(s) in question. b. Culture
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CHAPTER 5 | Sociocultural Influences on Mental Health 87

c. Ethnocentrism b. The parents are always reminding the

d. Ethnicity child that they are the parents.
10. Diana Baumrind describes authoritative c. The child has a minimum amount of
parenting as: guidelines.
a. The child has little or no voice in any d. The child has rules and has limits set.
of the family’s decisions.
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C HA PT E R 6
Nursing Process
in Mental Health
Learning Objectives Key Terms
1. Define the role of the LPN/LVN in the five steps of the nursing • Affect
process. • Awareness
2. Identify the components of a mental health status • Data collection
assessment. • Evaluation
3. State the need for the nursing process in mental health issues. • Formal teaching
4. State the concepts of patient interviewing. • Implementation
5. Prepare a patient interview. • Informal teaching
6. Collaborate in creating a nursing process for a given, hypo- • Judgment
thetical patient. • Memory
7. State the concepts of patient teaching. • Mood
8. Prepare and implement a teaching exercise. • North American Nursing
Diagnosis Association
(NANDA)
• Nursing diagnosis
• Nursing Interventions
Classification (NIC)
• Nursing Outcomes
Classification (NOC)
• Nursing process
• Orientation
• Patient interview
• Patient teaching
• Plan of care
• Scope of practice
• Subjective
• Thinking/cognition

T
he nursing process is a tool used produce a favorable outcome for the patient.
throughout all areas and levels of nurs- In preparing to care for the patient with the
ing (Fig. 6-1). The nursing process use of the nursing process, the nurse will need
is a formula for nurses to provide individual to incorporate critical thinking to arrive at the
patient care and learn how to organize and planned outcome. It is part of the culture of
implement that care in a systematic, universal nurses to be part of a positive outcome.
way. The nursing process also allows the nurse Scope of practice, determines that the reg-
to determine if the plan and interventions istered nurse (RN) and the licensed practical

89
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90 UNIT 1 | Foundations for Mental Health Nursing

Nursing
Assessment Planning Intervention Evaluation
diagnosis

Figure 6-1 Steps in the nursing process.

nurse/licensed vocational nurse (LPN/LVN) best choices concerning that person. Nurses
play different roles in the nursing process. In collect data about the patient and his or her
the early 1950s, Hildegard Peplau (Chapter 1) condition. In most cases, this is accomplished
hypothesized that nurses are a tool best with the help of a form that is used by the
utilized in relationship to the patient and the facility. Nurses also use nonverbal communi-
environment and in collaboration with other cation skills to assess the patient’s attitude,
nurses and health-care professionals. She tone of voice, facial expression, and so on.
stressed the phases of a working relationship The problem with many of these generic
that included a termination phase where forms is that they are written in closed-ended
nurses prepare both themselves and their format. They are very impersonal and may
patients for termination of the relationship. not reflect the specific information needed
Her model is still widely used in nursing about that patient.
process and nursing practice today. It is during the data collection/assessment
part of the nursing process that the mental sta-
Neeb’s LPNs/LVNs should know and under- tus exam is performed. The mental status exam
■ Tip stand their scope of practice in order is a series of questions and activities that check
to provide safe and effective health eight areas: the patient’s (1) level of awareness
care. and orientation, (2) appearance and behavior,
(3) speech and communication, (4) mood and
affect, (5) memory, (6) thinking/cognition,
In the early 1970s, the American Nurses (7) perception, and (8) judgment. These
Association (ANA) developed Standards of examinations are of varying lengths and
Practice for RN and LPN/LVN prepared formats, but they all assess the patient’s mental
nurses. The association differentiated between capabilities.
the RN’s role and the LPN’s role in the nursing Table 6-1 lists areas to be included in a
process. Individual state Nurse Practice Acts mental status examination. It also suggests the
and Boards of Nursing may also offer their type of assessment made and ideas for ques-
own interpretation of the ANA guidelines tions or commands used by members of the
relating to the role and scope of practice for health-care team to make the assessments, as
the LPN/LVN prepared nurse in the nursing well as some parameters for responses of a
process. The following provides step-by-step person with normal and abnormal mental
implementation of the nursing process. functioning.
■ Step 1: Assessing the
Patient’s Mental Health Tool Box | Mental Health Status Examina-
tions Components
Assessment is the first step in the nursing www.ncbi.nlm.nih.gov/books/N BK 320/
process. The role of the LPN/LVN in Step 1
is to assist with the assessment. The registered
nurse is responsible for the initial assessment There are many ways to improve the
when the patient is admitted or transferred in quality of data collection. Two ideas for im-
a facility. Data collection is made during proving data collection in the form of inter-
every contact a nurse has with a patient. It is views are listed here. Remember, this is not
essential to the well-being of the patient and an exhaustive list of reasons to interview
in assisting the medical team in making the patients. For the purposes of this text, the
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CHAPTER 6 | Nursing Process in Mental Health 91

l Table 6-1 Mental Health Status Examination

Suggested Methods Alterations
Area of Type of of Assessment and to Normal
Assessment Assessment Normal Parameters Assessment
Appearance Objective and Clean, hair combed; clothing Displays either
subjective intact and appropriate to weather unusual apathy
observations or situation. or concern about
such as dress, Teeth in good repair. appearance.
hygiene, pos- Posture erect.
ture; and about Cooperates with health-care
the patient’s personnel.
actions and
reactions to
health-care
personnel.
Behavior Objective Cooperates with health-care Displays uncoopera-
personnel. tive, hostile, or
suspicious-type
behaviors toward
health-care personnel.
Level of Subjective and Awareness is measured on a con- Outcome is not
Awareness objective assess- tinuum that ranges from uncon- within normal limits
ment of the pa- sciousness to mania. “Normal if the patient is diffi-
tient’s degree of alertness” is the desired behavior. cult to arouse and
alertness (wake- There is usually a standard guide- keep awake or finds
fulness). line for helping with this assess- it difficult to feel
ment, but subjective observations calm.
can be documented as well, if the
patient cannot stay awake for
even short intervals or is overly
active and has difficulty staying in
one place for any period of time.
Orientation The degree of Orientation measures the person’s Abnormal results of
patient’s knowl- ability to know who he or she is, orientation are the
edge of self. where he or she is, and the day patient’s inability to
and time, usually within 1 or correctly answer
2 days of the actual day and time. questions pertaining
Measurement techniques are to the patient or to
accomplished by asking the commonly known
patient, “What is your name?” social information.
“Where are you right now?” and
“Tell me what the day and date
are.” Asking “Who is the president
of the United States?” is used
here as well. Nurses frequently
document this as “oriented ×3,”
but it is best to also write down
the objective data on which this
routine answer is based.

Continued
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92 UNIT 1 | Foundations for Mental Health Nursing

l Table 6-1 Mental Health Status Examination—cont’d

Suggested Methods Alterations
Area of Type of of Assessment and to Normal
Assessment Assessment Normal Parameters Assessment
Thinking/ Subjective Formal testing may be undertaken Behaviors including
Content of assessment of by the psychologist or psychiatrist flight of ideas, loose
Thought what the patient to determine the patient’s general associations, phobias,
is thinking and thought content and pattern. delusions, and obses-
the process the Nurses may contribute to the sions may become
patient uses in assessment of thought by docu- apparent. These
thinking. menting statements the patient alterations in “normal”
makes regarding daily cares and thought processes
routines. are defined and
discussed in future
chapters that relate
to specific illnesses.
Memory Subjective Recent memory: Recall of events Inability to accurately
assessment of that are immediately past or up to perform recent or
the mind’s ability within 2 weeks before the assess- remote recall exer-
to recall previ- ment. One measurement tech- cises within parame-
ously known re- nique is to verbally list five items. ters; may indicate
cent and remote After 1 minute, patient should be symptoms of delirium
(long-term) able to recall 4–5 of those items. or dementia.
information. Continue with assessment and at
5 minutes, patient should be able
to recall 3–4 of the items.
Remote memory: Recall of events
of the past beyond 2 weeks prior
to assessment. Patients are often
asked questions pertaining to
where they were born, where they
went to grade school, and so on.
Speech and Objective and Patient can coherently produce Limited speech
Ability to subjective as- words appropriate to age and production; rate of
Communicate sessment of as- education. speech is inconsis-
pects of patient’s Rate of speech reflects other tent with other psy-
use of verbal psychomotor activity (e.g., faster chomotor activity.
and nonverbal if patient is agitated). Volume is not appro-
communication. Volume is not too soft or too loud. priate to situation
Stuttering, repetition of words, (speaks at a very loud
and words that the patient “makes volume even when
up” (neologisms) are also assessed. asked to speak more
quietly).
Stuttering, word
repetition, or neolo-
gisms may indicate
physical or psycho-
logical illness.
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CHAPTER 6 | Nursing Process in Mental Health 93

l Table 6-1 Mental Health Status Examination—cont’d

Suggested Methods Alterations
Area of Type of of Assessment and to Normal
Assessment Assessment Normal Parameters Assessment
Mood and Subjective and Mood is the stated emotional Mood and affect do
Affect objective assess- condition of the patient and not match (e.g., facial
ment of the should fluctuate to reflect situa- expression does not
patient’s stated tions as they occur. change when stating
feelings and Facial expression and body lan- opposite feelings).
emotions. guage (affect) should match
Affect measures (be congruent with) stated mood.
the outward Affect should change to fluctuate
expression of with the changes in mood.
those feelings.
Abstract Subjective Give patient a “proverb” to inter- Patient cannot inter-
Thinking/ assessment of a pret, such as “You can’t teach an pret the sayings in an
Judgment patient’s ability old dog new tricks.” Patient should acceptable manner.
to make appro- be able to give some sort of Patient cannot
priate decisions acceptable interpretation such as complete problem-
about his or her “old habits are hard to break” or “it solving questions
situation or to is hard to learn something new.” appropriately.
understand Or give the patient a situation to The patient might
concepts. solve (judgement). answer very literally,
For example, ask the patient what “Dogs can’t learn
he or she would do if a small child anything when they
were lost in a store. An appropri- get old” or “I would
ate response might be “to call the go through the
manager” or “to try to calm the child’s pockets to
child.” see if there were any
phone numbers in
them.”
Perception Assesses the way All five senses are monitored for Presence of halluci-
a person experi- interaction with the patient’s nations and illusions.
ences reality. reality. These are discussed
Assessment is Patient’s insight into his or her further in Chapter 15.
based on the condition is also assessed. Individuals who are
patient’s state- not within normal
ments about his boundaries of judg-
or her environ- ment or insight will
ment and the not be able to state
behaviors associ- understanding of the
ated with those origin of the illness
statements. and the behaviors
Nurses and associated with it.
health-team
members must
document this
often-subjective
information in
objective terms.
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94 UNIT 1 | Foundations for Mental Health Nursing

word interview pertains to any nurse-patient ■■■ Critical Thinking Question

interaction that requires a nurse to obtain Pick a student partner to interview. Select any
specific information from a patient. The topic and develop a 5-minute interview. Write it
patient interview is usually the primary twice: once with only closed-ended questions
method of data gathering. It is important to and aggressive statements, and once with only
open-ended questions and assertive statements.
collect data about the whole person. Data Compare the two versions. How was it different
related to thoughts and feelings are as im- as the interviewer and how was it different for
portant to any nurse-patient interview as the the interviewee?
physical data collected.

■■■ Classroom Activity profitable experience for both the nurse and
• Group activity: Discuss the normal parameters the patient.
presented and your perception of what is normal
in light of the mental health status examination. 2. Helping Interview
The helping interview is used to determine or
isolate a particular concern of the patient and
to help the patient learn to help herself or
1. Intake/Admission Interview himself (Fig. 6-2). Patients may trust nurses
Most facilities have developed standard in- because nurses have built a rapport with them
terview forms that suit their particular and are usually more easily accessible than
needs. The forms are written in a very physicians. It is always important to remem-
matter-of-fact way and are usually in a ber, though, not to help to the point of inter-
closed-ended format (Chapter 2). Patients fering with the patient’s ability to help herself
who are frightened, angry, or just too ill at or himself.
the moment may easily refuse to answer Consider a situation in which the patient is
those closed-ended questions. The patient not progressing according to a “normal” post-
may have heard the questions before and operative course. The nurse notices the patient
feel frustrated by what he or she perceives weeping and senses that a need is not being
to be inefficiency or poor communication met. The nurse can use this opportunity and
among the staff when the same questions observation to begin obtaining information
are repeated. This can set up both the nurse
and the patient for a difficult time. It is up
to the nurse to rephrase the questions in an
open-ended format that will seem more
individualized to the patient.
EXAMPLE
Standard form: “Do you smoke or use alco-
hol? _____ YES _____ NO.”
Nurse interviewer: “I am required to provide
you with information about the hospital’s
policies on the use of tobacco and alcohol.”
This statement might then be followed by
the standard closed-ended question, “Do
you use any tobacco or alcohol?” Figure 6-2 The helping interview allows
the nurse to determine a patient’s special
Questions can be changed from the needs and concerns. (From Williams and
closed-ended type to open-ended in most Hopper (2011). Understanding Medical-Surgical
cases. Practice and patience on the part of Nursing, 4th ed. Philadelphia: F.A. Davis Company,
the nurse interviewer will make this a more with permission.)
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CHAPTER 6 | Nursing Process in Mental Health 95

from the patient that may help explain the Tool Box | Nursing Diagnoses:
delayed postoperative progress. http://www.nanda.org
Guidelines for Nurse-Patient
Helping Interview It is the registered nurse’s responsibility to
1. Be honest: Tell the patient the purpose of assimilate the data that has been collected
the interview. and choose one or more potential nursing
2. Be assertive: If the interview is mandatory diagnoses for the patient. The LPN/LVN
(e.g., intake, preoperative), the patient needs to understand the function of the
must understand that it is required. nursing diagnosis. In collaborative nursing
Contract for a mutually acceptable time practice, LPN/LVNs can make suggestions
to conduct the interview so that the pa- and offer rationales to the RN that may be
tient will be aware of the time involved. incorporated into the patient’s plan of care.
3. Be sensitive: Sometimes the questions are An emerging format for writing a diagnos-
very difficult or embarrassing for the pa- tic statement for a patient’s plan of care is the
tient to answer. The nurse should assure P.E.S. Model. The components of this model
the patient that he or she understands the are: P, the problem or need; E, the etiology or
patient’s feelings and that the information cause; and S, the signs, symptoms, or risk fac-
shared by the patient is part of the pa- tors. The nurse blends these components into
tient’s medical record. Only the patient, a “neutral” statement that avoids value-laden
the patient’s designee, and people who are or judgmental language. The nursing diagno-
involved in his or her caregiving will have sis is not a medical diagnosis as used by physi-
access to this information. cians. Rather it is a common language among
4. Use empathy: The nurse should let the nurses to help clarify the patient’s needs (see
patient know that he or she is interested Appendix E, Assigning Nursing Diagnoses to
in what is being said and that the nurse Client Behaviors).
is there to be helpful. Acknowledge the
patient’s feelings but do not judge the ■ Step 3: Planning (Short-
patient.
5. Use open-ended questions: Personalize the and Long-Term Goals)
questions as much as possible. Use this
The LPN/LVN role is again as a partner in
time to discuss and clarify as much infor-
care planning. The ANA believes that the RN
mation as you can to avoid having to
has the primary responsibility for this step of
repeat parts of the interview later.
the nursing process. Planning care involves
■ Step 2: Nursing setting short-term and long-term goals from
the patient’s perspective, not from the nurse’s
Diagnosis: Defining perspective. It is for this reason that the
Patient Problems patient and significant others must be in-
volved in the plan of care. Recovery will hap-
Processing the collected data is a function of pen much more quickly if the patient plays
the registered nurse, according to the ANA. an active role in decision making and does
Once data is collected, nursing diagnoses are not have the impression that treatment is
identified. Nursing diagnoses are a universal being done to or for him or her but rather
language on which the interventions are collaboratively with the person.
based. There are different models or theories Prioritizing the goals is the second part of
of nursing diagnosis that may be used and planning care. This is one area in which the
recommended by your work setting. These patient and the nurse might not see things
include nursing diagnoses published by the the same way. Nurses and patients look at the
North American Nursing Diagnosis Asso- same problem from two different perspec-
ciation (NANDA). tives, and the patient’s priority may be quite
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96 UNIT 1 | Foundations for Mental Health Nursing

different from the nurse’s priority. Whenever prior teaching. Relaying information about
possible, the patient’s priority should be implementation (putting the care plan into
considered. When there is a threat to life or action) and patient progress to the RN will
health that is a direct response to the patient’s provide the information the team needs to
priority, however, the nurse must intervene offer the best possible care for the patient.
and explain the reason that the patient’s Nurses also need to understand and specify
wishes will have to wait a while. the rationale (reason) for the implementa-
The aim of selecting goals that will im- tions that are selected and be prepared to ex-
prove mental health status is to keep the plain them to patients and families provided
mind-body connection intact. It is estimated the patient consents to their involvement.
that about 95% of physical healing is related Table 6-2 provides information about the
to a positive mental attitude (PMA). It will nursing process.
be of great help to the patient if the nurse States differ in the role the LPN plays in
is able to detect alterations in that mental outcome statements or performing an evalu-
attitude and set goals with the patient to ation of interventions. In much the same
maintain the best outlook and strongest pos- way NANDA developed problem or nursing
sible effective coping skills. In planning the diagnostic standards, work is being done to
patient’s goals, there should be a short-term standardize outcome statements. Nursing
and long-term goal for the patient. Both goals Interventions Classification (NIC) is a com-
should be realistic and measurable with a tar- prehensive standardized language. It provides
get date for them to be completed. a number of direct and indirect intervention
labels with definitions and possible nursing
■ Step 4: Implementations/ actions. The interventions address general
Interventions practice and specialty areas (Doenges and
Moorhouse, 2003).
The LPN’s role is to assist with identifying
and carrying out the specific steps that will ■■■ Clinical Activity
help the patient reach the goals. Nurses are If your clinical affiliates will allow, arrange to shadow
able to provide input about new interven- a nurse from the mental health unit. Write a sum-
tions that may be helpful, and the LPN/LVN mary of the following experience:
• Observations of the nurse-patient relationship
is often the person who begins to help adapt • Communication style
certain procedures to assist the patient. A • Understanding
nurse may use this opportunity to conduct • Patient responses
some new patient teaching or to reinforce

l Table 6-2 The Nursing Process

Nursing
Diagnosis Implementation/
Assessment (NANDA) Planning Intervention Evaluation
Subjective/ Relates to Planning the Defines what actions Patient’s outcome.
Objective the assess- patient’s the nurse/health-care The nurse/health-care
ment data outcome: provider will provide. provider can deter-
to deter- Short-term The nurse/health-care mine if the plan and
mine how goals provider should be the interventions
the nurse Long-term goals able to provide a provide the expected
will plan Must be: rationale for each outcome. Determine
for the care Measurable and action/treatment which interventions
needed. realistic with provided. can be terminated.
target dates.
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CHAPTER 6 | Nursing Process in Mental Health 97

Tool Box | The nursing process is a system-

legal ramifications to teaching as well. Even
atic approach in providing care. with standardized teaching tools, nurses still
http://nursingworld.org/E speciallyF orY ou/ need to be aware of some principles of teach-
W hat-is-N ursing/Tools-Y ou-N eed/ ing and learning. Nurses have an advantage
Thenursingprocess.html in teaching because, with the exception of
nursing diagnosis, the same format they
learned for nursing process can be used for
setting up a teaching plan.
■■■ Critical Thinking Question Teaching in any form is most effective
Your state Nurse Practice Act allows you, the LPN/ when it is started as soon as possible after
LVN, to oversee care and function as a charge admission. Nurses teach patients in different
nurse, as long as a registered nurse is on call. Your
medical patient has gone out on a 3-hour pass ways. Teaching falls under the categories of
with relatives and returns to your agency refusing either formal teaching or informal teaching.
to perform the guidelines as stated in the care Formal teaching is any situation in which
plan. Your patient is argumentative but answers a class is scheduled or a specific objective
questions appropriately. Your data collection must be met. The instructor is often a staff
includes fruity odor on breath, mood swings, and
hunger. You need to re-evaluate and revise the nurse who has worked in the specific area
care plan but are unable to make contact with the being taught. Formal teaching involves a
RN on call. What would you consider to be appro- nurse instructor and one or more patients.
priate nursing diagnoses? What interventions can Usually a preset curriculum is used in these
you perform and still remain within your state’s
scope of nursing practice?
classes. The time to teach in the formal set-
ting will most likely be limited by the facility
according to staffing needs, because the nurse
instructor probably also has a patient assign-
Patient Teaching ment. Examples of formal teaching include
Many implementations or interventions that diabetic teaching and back-care classes.
are helpful to the patient involve patient
teaching. Frequently, facilities have special ■■■ Classroom Activity
teams or departments to carry out certain • Divide the class into groups of five. Each group
teaching (e.g., diabetes education), but teaching should provide a presentation of the steps in
is becoming a bigger part of a nurse’s respon- the nursing process using different learning
sibility. This is true at all levels of nursing styles.
preparation. The doctor is still responsible
for the initial information given, but the nurse
does the “fine-tuning” required to send pa- Informal teaching, or adjunctive teaching,
tients home safely. Nurses teach about medica- happens anytime, anywhere, whenever the
tions, coping strategies, adaptive equipment, patient needs information. The patient may
and anything else the patient requires, not only see the nurse in the hall, or the nurse may no-
for the period of hospitalization, but also for tice that the patient is working with the
the time when the patient leaves the facility. colostomy bag in his room or reading the ex-
Individual states and facilities set the guidelines ercise pamphlet. These are excellent times to
regarding teaching responsibilities for doctors reinforce what the patient has learned or to
and nurses. make gentle suggestions for improving his or
Everyone needs a little help to get started her technique.
with teaching, regardless of what sort of
teaching will be done. Like the forms used for
the patient interviews, the facility may use ■■■ Clinical Activity
Review the medication chart of your assigned
standardized classes or teaching sheets. This patient and provide an informal teaching about
practice helps ensure that continuity exists in one of the medications. Write the outcome of the
teaching and that the critical information has informal teaching.
been given to the patient. There are some
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98 UNIT 1 | Foundations for Mental Health Nursing

Principles of Learning nurse-teacher will need to adapt the care

Nurse-teachers need a basic understanding of plan to meet a particular patient’s need.
the principles of learning and teaching. Some A nurse-teacher who is not comfortable
of these principles are listed here: with the material will be less helpful to
the patient than one who can individual-
1. Each person learns differently. Some ize the curriculum to the various needs
people process information visually, of the class.
others by hearing, and still others by 3. Have a teaching plan: A good teaching
hands-on (tactile) learning. plan will improve a nurse’s confidence
2. Each person learns at his or her own pace. and delivery of the material. A teaching
The larger the class, the more levels of plan is constructed in much the same
ability the nurse will have to work with. way as the nursing process. A very simple
Some patients catch on more quickly than format, such as APIE for the nursing
others. process, may be easily transformed into
3. People learn best when the information a teaching format. An example of the
is meaningful to them. Nurses should APIE format follows.
think of their own education: The things • A = Assessment. What is the need for
they are interested in are the things they the teaching? Who are the patients?
work harder at. Subjects that they do not How much time is available? Assessing
like seem to be hard or boring, yet they the need to teach can be as simple as
are required for graduation. Patients may one or two statements. For example,
not see the importance of the class that “Good afternoon, everyone. My name
they may be required to attend as a crite- is Sandy. This is the class about bipolar
rion for discharge. care, and it is open to anyone diagnosed
4. Learning is most effective when the in- with bipolar disease.” Assessment can
formation is presented in small segments. also be enhanced by the use of a pre-test
This may be dictated by the facility, but or questions to the class to determine
when the nurse can be flexible, it is best their past knowledge in this area.
to present only as much as the patient • P = Plan. In true nursing process,
can absorb. this is often called the goal. Nurse-
5. Success breeds success: Positive reinforce- teachers need to ask themselves a
ment will help the patient succeed at few questions, such as: What do you
learning the required task. The stronger plan to accomplish in the session?
the positive reinforcement, the greater How do you think you will do it?
the learning. Once patients have been Again, this can be accomplished in
successful, they will want to continue one or two statements. For example,
to learn. “This is the first in a series of three
classes, and the task for today is to
Neeb’s Active listening enables the nurse to
learn about the different types of
■ Tip focus on the patient’s strengths. appliances and equipment you have
available to you.” What is accom-
plished in the first session is consid-
Principles of Teaching ered as a short-term goal and the
1. Know the patients: What are their abili- accomplishments in the third session
ties? What is their prior level of knowl- will be the long-term goal.
edge? What are the cultural or language • I = Implementation. This is the step-
differences of the patients in the class? by-step method nurse-teachers use to
2. Know the material: It is not as important accomplish the plan. It is similar to
to give a perfect lecture or demonstration the implementation portion of the
as it is to be able to interpret the ques- nursing process. The nurse-teacher
tions patients may have. Sometimes the will have as many or as few steps as
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CHAPTER 6 | Nursing Process in Mental Health 99

needed. In prepared curricula, the the teaching. This requires familiarity with
steps are written out, but it may or some commonly used methods of teaching.
may not be necessary to perform each Teachers tend to teach according to the
step. This will depend on the patient method of learning they prefer. For instance,
group. Chances are good that a class if nursing students prefer lecture classes, they
or skill will never be taught exactly the probably feel most comfortable teaching in a
same way twice. There will, however, lecture format. If a specific nursing instructor
be critical items that nurses need to was particularly helpful to a nurse as a stu-
cover with all patients to meet legal dent, the nurse may prefer to role-model that
and safety issues. teacher’s methods when teaching patients. No
• E = Evaluation. In a teaching plan, teaching method is better or worse than any
nurses evaluate the patient’s learning other method. What makes the difference
as well as the teaching performance. is the learning style of the patients and the
Some questions that nurse-teachers rapport that nurses build with them. Because
need to reflect on for this part of the classes in facilities generally have more than
teaching plan are: How do you know one “pupil,” the nurse-teacher will need to be
the patient has grasped the concepts able to use different methods of presenting.
and skills from the class? What do you Because people’s personalities are different,
look for? Do you need to ask for a each group will have a different dynamic and
return demonstration? Does it need to each class will be different.
be perfect? How did you do? Did you The typical methods used in health teach-
achieve the plan? Did you have enough ing are lecture and demonstration.
time? Too much time? What will you
1. Lecture: This is a method designed for
do differently next time? How did
information giving. It is unilateral; the
your students evaluate the session?
nurse talks, and the patients listen. It is
Evaluation criteria may change from
interactive only when there is some form
time to time as well.
of question-answer period or brainstorm-
4. Be flexible: To the extent that the facility’s
ing. Lecturing is an excellent method
program allows, be familiar enough
of introducing a topic to patients and
with the material to be able to build in
giving them some theory. It is a way to
extra practice time for the tactile learn-
explain the significance so the material
ers, extra videos for the visual learners,
becomes meaningful.
or time to review verbally for the audi-
tory learners. Be able to teach in several In preset programs, the lectures are usually
different styles. prepared in either text or outline form, so
5. Be able to evaluate the learning: In health the nurse-teacher has to invest minimal time
teaching in the facility, evaluation can be researching, writing, or setting up for the
in the form of a question-answer session, lectures. Lecture classes may include videos,
a short quiz, or a return demonstration. slides, or charts. Learning from the lecture
6. Plan to allow a few minutes after the class method is traditionally evaluated through
for questions: Even though the nurse may quizzes or question-and-answer sessions. Be-
ask for and welcome questions during cause not all patient participants are comfort-
the session, there are always people who able answering in a group, it may be difficult
are not comfortable asking questions in a to assess how much learning each individual
group. These people will want your time achieves.
in private, so allow some time to clarify
their concerns at the time or to set up a Neeb’s Not everyone has the same learning
time to help individuals later in the day. ■ Tip style.

Once the plan has been developed, the 2. Demonstration: Demonstration is an

nurse needs to think about how to implement excellent technique to follow in an
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100 UNIT 1 | Foundations for Mental Health Nursing

introductory lecture. For visual and tac- know something, he or she should admit
tile learners, it is a preferred method of it. The nurse should look up the informa-
learning. tion and either bring it to the individual
who asked or bring it to the next session
In prepared programs, the demonstration
of the class.
outline will be provided. The nurse-teacher is
• Have fun! Teaching can be a very reward-
responsible for having the equipment ready for
ing part of nursing. There is no better way
each patient. In diabetic teaching, for example,
to reinforce nursing knowledge than to
the nurse needs to have ready the syringes,
teach it to someone else. It is one way of
sterile saline for injection, gloves, injection pad,
being generative, and it is one way in
and any other equipment that the agency uses.
which nurses can keep the nursing culture
Demonstrations are effective because, after
alive.
the initial demonstration, the nurse-teacher
can have the individual perform a return
demonstration. One-on-one help can be pro- ■ Step 5: Evaluating
vided if needed. This allows the nurse to make Interventions
more objective assessments of the patient’s
learning and therefore predict the patient’s In this final step of the nursing process, the
ability to safely perform the technique after LPN/LVN plays an assisting role. The LPN/
discharge. It also allows the nurse to individ- LVN’s observations and documentation
ualize the technique or provide options to the about the effect of the interventions on the
patient. patient and progress in attaining the goal
Evaluation for this method of teaching is are of great importance. Accuracy in verbal
usually the return demonstration. The nurse and written reporting of the patient’s
watches each patient perform the technique at progress will help determine whether the
a level that is safe for the patient to perform interventions are helpful or whether they
when at home and not under the guidance of need to be re-evaluated and changed. In some
the health-care professional. If a home care instances, some of the interventions can be
nurse is assigned to the patient, patient teach- terminated, depending on the patient’s
ing continues; the nurse also teaches the family progress (DeWit, 2009)
or significant others. Nursing Outcomes Classification (NOC)
is also a standardized language, which provides
Additional Patient Teaching outcome statements; a set of indicators de-
Tips scribing specific patient, caregiver, family, or
• It is customary to assess eye contact and community states related to the outcome; and
to equate eye contact with interest and a five-point measurement scale to facilitate
attentiveness. It is important for the tracking patients across care settings. It can
nurse-teacher to remember that this is a help demonstrate patient progress even when
cultural behavior. Not all cultures believe outcomes are not fully met. NOC also is
that eye contact is a positive thing; in- applicable in all care settings and specialties
deed, many cultures consider direct meet- (Doenges and Moorhouse, 2003).
ing of eyes a sign of blatant disrespect for
people who are older or in a position of
respect or authority. Nurses and teachers ■■■ Critical Thinking Question
are respected in those cultural groups, Select a topic to teach the class. This can be any
and it would be a mistake on the part of topic with which you are comfortable. You have
the nurse to assume that the lack of direct 10 minutes (classroom instructor may choose
own time limit) to teach your topic. Develop a
eye contact is a sign of disinterest in or teaching plan. Teach your topic. Evaluate your
disrespect for the material. teaching. What would you do differently the
• Be honest: Nobody said a nurse must have next time?
all the answers. If a nurse-teacher does not
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CHAPTER 6 | Nursing Process in Mental Health 101

■■■ Key Concepts nurses need a basic knowledge of both

skills. Individual states and facilities set
1. Nursing process is an example of collabo- the guidelines for teaching within the
rative nursing practice. RNs are primarily scope of the nurse’s practice.
responsible for the steps of the nursing
process; LPN/LVN-prepared nurses 4. Nursing process is a helpful tool for
assist in data collection, planning, imple- preparing a teaching plan.
menting, and evaluating the nursing 5. The ANA has set guidelines that dic-
process. tate the roles of the RN and the LPN/
2. The nursing process format can be used LVN in collaborating in the nursing
by other health-care disciplines to create process.
a care plan. 6. New models for collaborative nursing
3. Nurses are conducting more interviewing and nursing outcome statements are
and teaching on a daily basis. Entry-level being developed.

CASE STUDY
Mark is a 15-year-old student who has reliable source of information about
recently quit attending his high school himself at this time.
classes. Mark has always been a straight-A The physician notifies Mark’s parents
student who participated in many social and explains that Mark may have several
and athletic activities at his school. conditions, including but not limited to
Today, Mark’s friend Tony brings Mark serum hepatitis.
to the clinic that is part of your commu- Meanwhile, you continue to admit
nity’s hospital. Tony tells you, “Mark got Mark to the hospital for further testing
in with a bad group. He’s been doing’ and medical care. He is placed in enteric
the stuff real bad. He’s been doing the isolation as a precaution. An IV is started
needles and the smoking. He’s been with and you begin to explain the hospital
me for two days, man, and he’s real sick. routines to Mark. After you tell him that
Help him.” he must remain in his room for now and
You and the physician undertake an as- that his visitors will be limited during
sessment of Mark and find that he has yel- the time of the isolation precautions,
lowing of his sclera. He has a fruity odor he becomes angry. He conveys to you
on his breath and is vomiting copiously. that this is “an invasion of his privacy”
Mark’s level of consciousness is guarded; and that “you nurses are all part of the
he is in and out of coherence and is not a conspiracy.”

1. How would you start the nursing process for this patient?
2. Describe some questions you would ask as part of the mental status exam
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102 UNIT 1 | Foundations for Mental Health Nursing

REFERENCES Nursing Process

http://nursingworld.org/EspeciallyForYou/What-
DeWit, S. (2009). Fundamental Concepts and is-Nursing/Tools-You-Need/Thenursingprocess.html
Skills for Nursing. 3rd ed., pp. 48–55.
Mental Status Exam
Philadelphia: Elsevier. www.dshs.wa.gov/manuals/socialservices/sections/
Doenges, M.E., and Moorhouse, M.F. (2012). MSE_GUIDELINES.shtml
Application of Nursing Process and Nursing Patient Teaching
Diagnosis: An Interactive Text for Diagnostic www.upmc.com/patients-visitors/education/pain-
Reasoning. 4th ed. Philadelphia: F.A. Davis control/pages/default.aspx
Company.
Martin, D.C. (1990). The Mental Status Exami-
nation. Retrieved from http://www.ncbi.
nlm.nih.gov/books/NBK320/
Townsend, M.C. (2012). Psychiatric Mental
Health Nursing, 7th ed., Philadelphia: F.A.
Davis Company.

WEB SITES
Nursing Diagnosis
NANDA; http://www.nanda.org
Nursing Classifications (NIC & NOC)
www.ncvhs.hhs.gov/970416w6.htm
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CHAPTER 6 | Nursing Process in Mental Health 103

Test Questions
Multiple Choice Questions
1. The nursing process is a method for: 6. According to ANA, the RN is the pri-
a. Systematic organization and imple- mary person for developing this part of
mentation of patient care the care plan:
b. Documenting patient needs a. Nursing diagnosis
c. Differentiating the RN role from the b. Implementation/interventions
LPN/LVN role c. Evaluation
d. Data collection d. Assessment
2. You are assisting in collecting data on a 7. Which of the following is/are part of
new patient in your unit. The physician the principles of teaching? (select all that
suspects alcohol abuse. You want to learn apply)
the patient’s history and frequency of a. Being flexible
alcohol use. Your best choice for collect- b. Evaluate the learning
ing these data might be to ask: c. Teach without a teaching plan
a. “Do you use alcohol?” d. Know the patient
b. “How often do you get drunk?” 8. The Mental Health Status Examination
c. “How many times a week would you includes: (select all that apply)
say you drink alcohol?” a. Memory
d. “Why do you use alcohol? It’s bad b. Judgment
for you.” c. Mood and tone
3. When conducting patient teaching, the d. Mood and affect
best method to evaluate the success of e. Level of awareness and orientation
the patient is: 9. NANDA is responsible for:
a. Lecture a. Interventions
b. Redemonstration b. Implementation
c. Implementation c. Appearance
d. Assessment d. Nursing diagnosis
4. The mental status exam takes place in 10. Dianne was sitting in her hospital bed
what part of the nursing process? holding the orange given to her to prac-
a. Assessment tice her insulin injections. When the
b. Plan nurse entered the room, Dianne asked
c. Implementation when she was going to inject herself
d. Evaluation instead of the orange. This statement
5. Which of the following are components indicates that Dianne is ready for:
of the planning part of the nursing a. Discharge to home
process? (select all that apply) b. More time injecting the orange
a. Short-term goals c. Informal teaching
b. Long-term goals d. Formal teaching
c. Subjective
d. Objective
e. Evaluation
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C HA PT E R
7
Coping and Defense
Mechanisms
Learning Objectives Key Terms
1. Define coping. • Adaptation
2. Differentiate between effective and ineffective coping. • Coping
3. Define defense (coping) mechanisms. • Defense mechanisms
4. Identify main defense mechanisms. • Effective coping
• Ineffective coping

■ Coping goals of a change in behavior emphasize

demonstration of specific effective coping
“Deal with it.” “Get a grip.” “Don’t make a skills. Biology plays a role in coping in the
mountain out of a molehill.” These are pieces presence of some psychiatric disorders. What
of advice that most people have heard or have is an effective coping skill, and how do nurses
given at some point. But what do they mean? observe and measure it?
What is coping? Coping is the way one
adapts to a stressor psychologically, physically, Tool Box | Managing Stress
and behaviorally. It is the ability one develops www.webmd.com/balance/stress-
to deal consciously with problems and stress. management/stress-management-
topic-overview
Neeb’s As a health-care provider, it important
■ Tip to realize that coping is individualized.
Effective coping skills are those that are
specifically identified to offer healthy choices
Individuals have different methods of to the patient. For example, it is very com-
coping or dealing with their stressors. What mon to see patients use a variety of coping
makes some people very successful at han- mechanisms to help deal with hospitalization.
dling stress and others not successful at all? Hospitalization is a stressful experience for
What allows some people to have a drink or patients and families, with so many unknown
run to reduce their stress and causes others to and unfamiliar things, noises, and interrup-
become addicted to the same behavior? The tions. The patient may not understand the
answers to these questions are, of course, illness or the implications of the treatment
complex. plan. Mealtimes may be different from the
Cultures, religions, and individual belief routine at home. The patient’s plans are dis-
systems seem to be the lead factors in this rupted, financial status is altered, and there is
mystery. Personal choices also play a support- a possible temporary loss of independence.
ing role. It is not the value of a behavior that Effective coping can be more challenging to
nurses observe; it is the desired outcome that a one-income family. Allowing the patient
is important. The short-term and long-term and his or her family members to be active
105
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106 UNIT 1 | Foundations for Mental Health Nursing

participants in the treatment plan will in- then provide information that will reinforce
crease the patient’s ability to use effective cop- the patient’s positive feelings. Providing hon-
ing skills (Fig. 7-1). The patient should be est, positive feedback about the patient’s
included in the decision making as to which progress in a given lifestyle change will let the
new behaviors are acceptable and which ones patient know that others are noticing the hard
are not. Practicing these new behaviors in a work that he or she has done.
safe place, such as a hospital or organized
group setting, is the secret to success. This will Neeb’s Think about when you are verbaliz-
probably require a lifestyle change for the pa- ■ Tip ing your thoughts and feelings and
thinking, “Just listen to me and vali-
tient, and it will be hard work. As the saying
date what I am saying.” This is no dif-
goes, “Old habits die hard,” but old habits can
ferent from what the patient expects
die and healthy new ones can replace them.
when expressing his or her thoughts
This process of effective coping is sometimes
and feelings.
called adaptation. Allowing the patient to
“practice” the new coping techniques will Often, the dividing line between effective
promote confidence and decrease the stress and ineffective coping is in the degree of
that can accompany change. The patient will tension and the past experience with it. For
adapt to the stress by using the new tools. instance, a little worry or anxiety can be a
Chapters 8 & 9 will introduce the reader to positive thing. A bride making preparations
other interventions that can be used for cop- for her wedding is stressed, but the expecta-
ing effectively with stress. tion is that the outcome will be positive. Most
of the time when there is a little tension,
■■■ Clinical Activity people are more alert and ready to respond.
Assist in a group session and provide instructions
and demonstrate a relaxation technique. Ask for
The “fight or flight” mechanism can actually
feedback after the session. help people adapt to a new situation. Too
much worry begins to cloud the conscious-
ness and interferes with a person’s ability to
One of the most helpful actions a nurse make appropriate choices and recall the new
can take is to actively listen to the patient’s adaptive tools he or she has learned (Fig. 7-2).
thoughts and feelings about the stressor and For example, a bride can become paralyzed
with all the decisions to be made and then
become unable to proceed, demonstrating in-
effective coping (see below).
Ineffective coping is when the techniques
people try are not successful or are hazardous.
People often allow themselves to fall into
habits that give them the illusion of coping.
For example, a person might have a drink
every time an experience is frustrating. People
usually have difficulty understanding that
they are using ineffective methods of coping.
Ineffective coping is one’s rationale for his or
her behavior. These habits are called defense
mechanisms.
Figure 7-1 Involving patients and their
families in the treatment plan can go a ■■■ Critical Thinking Question
long way toward reducing the stress of Imagine that you are admitted into the hospital
hospitalization. (From Williams and Hopper with an undetermined illness. Describe how it
(2011). Understanding Medical-Surgical Nursing, would affect you financially, as a student, and as a
4th ed. Philadelphia: F.A. Davis Company, with parent, and the stress each situation would create.
permission.)
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CHAPTER 7 | Coping and Defense Mechanisms 107

■■■ Classroom Activity

• List three situations that were very uncomfort-
able for you. What defense mechanisms did
you use? How will you respond to each of these
situations in a more effective manner?
• List three situations in which you observed
someone else using defense mechanisms. How
can you help him or her to cope in a more effec-
tive manner?

tend to have their own repertoire of them and

to use them (unconsciously) over and over.
Periods of high stress are not the times to try
something new, so the psyche uses the old
“standbys” to get over yet another hump in
life. Some of the commonly used defense
mechanisms are shown in Table 7-1.

■■■ Critical Thinking Question

Nurse D, LVN, has been routinely calling in “sick” on
his weekends to work. This has created a hardship
for the patients and the staff. On Monday, Nurse D
reports for the assigned work shift but is called
to the nurse manager’s office. The nurse manager
Figure 7-2 A little anxiety can be positive informs Nurse D of the pattern that has devel-
in some situations. oped in his attendance and gives him a chance
to explain the situation. Nurse D says, “Well, I am
a single parent and I need to take care of my chil-
■ Defense Mechanisms dren. You should assign single people without
families to work the weekends. If you cared a little
more about your employees, we wouldn’t have
Defense mechanisms are mental pressure to call in so often.”
valves. Defense mechanisms give the illusion Nurse D is quiet for a second and then says
that they are helping to alleviate a person’s with a shaky voice, “You make me so nervous that
stress level, when in reality they mask the I’ve started needing a couple of drinks at night so
stress and may actually end up increasing it. I can sleep. I could quit drinking any time, if you’d
just let me have my weekends off.”
Defense mechanisms come out of the ego What defense mechanisms do you hear Nurse
mechanism of Freud’s theory of personality. D using? How many of them have you used? If
Although they appear to be very purposeful, you were the nurse manager, what would you say
they exist, for the most part, on the uncon- to Nurse D? Using three of the suggested nursing
scious level. diagnoses listed in Appendix E, complete a nurs-
ing process for Nurse D.
The purpose of defense mechanisms is to
reduce or eliminate anxiety. Surprisingly,
when used in very small doses, they can be
helpful. It is when they are overused that ■■■ Classroom Activity
they become ineffective and can lead to a • In a group, watch a television newscast as assigned
breakdown of the personality. Again, people by the instructor. Pick one topic. Each group should
are not born with these behaviors; they are watch its assigned newscast at the assigned time.
learned as responses to stress. Many times, 1. Identify all of the defense mechanisms you can
within that news interview.
they are developed by the time people are 2. In what ways do hearing defense mechanisms
10 years old. change the way you may listen to and process
Because the main purpose of defense what you hear in the media?
mechanisms is to decrease anxiety, people
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108 UNIT 1 | Foundations for Mental Health Nursing

l Table 7-1 Commonly Used Defense Mechanisms

Mechanism Description Examples
Denial • Usually the first defense • The alcoholic states, “I can quit
learned and used. any time I want to.”
• Unconscious refusal to see • Is not consciously lying.
reality.
Repression • An unconscious burying or Demonstrating emotions toward
“forgetting” mechanism. a person, but unable to identify
• Excludes or withholds from the specific reason.
people’s consciousness
events or situations that are
unbearable.
• A step deeper than “denial.”
Dissociation • Painful events or situations • Patient who had been sexually
are separated or dissociated abused as a child describes the
from the conscious mind. situation as if it happened to a
• Could be described as an friend or sibling.
out-of-body experience. • Police visit parent to inform
parent of death of child in car
accident. Parent tells police,
“That’s impossible. My child is
upstairs asleep. You must have
the wrong house.”
Rationalization Substituting acceptable rea- • “I failed the test because the
sons for the true reasons for teacher wrote bad questions.”
personal behavior because • “The patient kept interrupting
admitting true reasons is too me so I got distracted and he
threatening. caused me to make a mistake."
Compensation Making up for something a • A small boy who wants to be a
person perceives as an inade- basketball center; instead be-
quacy by developing some comes an honor roll student.
other desirable trait. • The physically unattractive
person who wants to model
instead becomes a famous
designer.
Reaction Formation Similar to compensation, except • The small boy who wants to
(Overcompensation) the person usually develops the be a basketball center becomes
opposite trait. a political voice to decrease
the emphasis of sports in the
elementary grades.
• The physically unattractive per-
son who wants to be a model
speaks out for eliminating
beauty pageants.
Regression • Emotionally returning to an • Children who are toilet trained
earlier time in life when there beginning to wet themselves.
was far less stress. • During serious illness, a patient
• Commonly seen in patients exhibits behavior more appro-
while hospitalized. Note: priate for a younger develop-
Everyone does not go back to mental age, such as excessive
the same developmental age. dependency.
This is highly individualized.
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CHAPTER 7 | Coping and Defense Mechanisms 109

l Table 7-1 Commonly Used Defense Mechanisms—cont’d

Mechanism Description Examples
Sublimation Unacceptable traits or • Burglar teaches home safety
characteristics are diverted classes.
into acceptable traits or • Person who is potentially physi-
characteristics. cally abusive becomes a profes-
sional sports figure.
• People who choose to not have
children run a day-care center.
Projection Attributing feelings or im- • Wife tells patient's nurse, "My
pulses unacceptable to husband is worried about going
oneself to others. home." (Wife is the one who
worried.)
• Young soldier is fearful of up-
coming deployment and says,
"Those other guys are a bunch
of cowards."
Displacement The “kick-the-dog syndrome.” Parent loses job without notice;
Transferring anger and hostility goes home and verbally abuses
to another person or object spouse, who unjustly punishes
that is perceived to be less child, who slaps the dog.
powerful.
Restitution (Undoing) Makes amends for a behavior • Giving a treat to a child who
one thinks is unacceptable. is being punished for a
Makes an attempt at reducing wrong-doing.
guilt. • The person who finds a lost wal-
let with a large amount of cash,
does not return the wallet, but
puts extra in the collection plate
at the next church service.
Isolation Emotion that is separated from “I wasn’t really angry; just a little
the original feeling. upset.”
Conversion Reaction Anxiety is channeled into physi- • Nausea develops the night before
cal symptoms. Note: Often, the a major exam, causing the person
symptoms disappear soon after to miss the exam.
the threat is over. • Nausea may disappear soon after
the scheduled test is finished.
Avoidance Unconsciously staying away “I can’t go to the class reunion
from events or situations that tonight. I’m just so tired, I have
might open feelings of aggres- to sleep.”
sion or anxiety.
Scapegoating Blaming others "I didn't get the promotion be-
cause you don't like me."
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110 UNIT 1 | Foundations for Mental Health Nursing

■■■ Key Concepts REFERENCES

Gorman, L.M., and Sultan, D.F. (2008).
1. Stress and people’s responses to it are Psychosocial Nursing. 3rd ed. Philadelphia:
very individualized. People are not F.A. Davis.
stressed by the same things, nor do they Townsend, M.C. (2012). Psychiatric Mental
deal with their stress in the same ways. Health Nursing. Philadelphia: F.A. Davis.
2. Defense mechanisms are believed to be
WEB SITES
part of the ego of Freud’s description
of personality. They are based in the Defense Mechanisms
unconscious, for the most part, but http://psychcentral.com/lib/2007/15-common-
defense-mechanisms/all/1/
they can appear to be very deliberate.
Freud and the Ego Development
3. Use of defense mechanisms for a short http://psychology.about.com/od/eindex/g/
period can be helpful. The mechanisms def_ego.htm
www.childstudy.net/cdw.html
act like a pressure valve and allow the www.childstudy.net/FREUD.html
psyche to put the stress into perspective. Coping Mechanisms
If the patient then deals with the prob- http://changingminds.org/explanations/
lem, the outcome can be an effective behaviors/coping/coping.htm
coping technique; if not successful, the
patient’s anxiety level may increase.
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CHAPTER 7 | Coping and Defense Mechanisms 111

Test Questions
Multiple Choice Questions
1. A person who always sounds as though he and in tears. Today, Tara bought two
or she is making excuses is displaying: expensive concert tickets for her daugh-
a. Denial ter and a friend. This is an example of:
b. Fantasy a. Denial
c. Rationalization b. Undoing
d. Transference c. Symbolization
2. The alcoholic who says, “I don’t have a d. Conversion
problem. I can quit any time I want to; 7. Shirley, a 70-year-old woman, went to
I just don’t want to” is displaying: a photo shoot for a portrait. As soon as
a. Denial the photographer began to photograph
b. Fantasy Shirley, she started to display signs of
c. Dissociation regression by: (select all that apply)
d. Transference a. Posing as a young adolescent
3. Your young male patient who tells you b. Posing as her mother
that he may not be big enough for the c. Pouting when poses were suggested
basketball team, but says “that’s no by the photographer
problem because I’m a 4.0 student and d. Stopping the session to make two
on the principal’s list” is displaying: ponytails, one on each side of her
a. Denial head
b. Transference 8. After receiving disappointing news
c. Dissociation about a job promotion, John stated,
d. Compensation “I didn’t get the promotion because
4. Mr. V becomes angry that Mrs. V spent I write with my left hand.” This is an
the whole day shopping with her friends. example of:
Upon her return home, he hits her and a. Avoidance
tells her, “It’s your own fault. Stay home b. Regression
once in a while!” Mr. V is displaying: c. Projection
a. Repression d. Denial
b. Regression 9. Effective coping skills are described as:
c. Dissociation a. Being able to make choices that are
d. Projection healthy and individualized
5. You overhear someone jokingly repeating b. The excessive usage of any defense
the social cliché, “Stop Smoking, Lose mechanism
Weight, Exercise, Die Anyway” as he c. Imitating the coping behavior of
orders a big burger and super-sized fries. others
That cliché is an example of: d. Working on the problem until totally
a. Rationalization exhausted
b. Repression 10. The use of defense mechanisms is related
c. Regression to what part of Freud’s personality the-
d. Rebellion ory? (select all that apply)
6. Yesterday, Tara became drunk and inap- a. Id
propriate at a family function. Tara’s b. Ego
16-year-old daughter was embarrassed c. Superego
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C HA PT E R 8
Mental Health Treatments
Learning Objectives Key Terms
1. Describe a therapeutic milieu. • Akathisia
2. Identify classifications of psychotropic medications. • Antidepressants
3. Identify uses, actions, side effects, and nursing considerations • Antimanic agents
for selected classifications of psychotropic medications. • Antiparkinson agents
4. Describe psychoanalysis. • Antipsychotics
5. Describe behavior modification. • Behavior modification
6. Identify the nurse’s role in counseling. • Cognitive
7. Describe three types of counseling. • Counseling
8. Describe electroconvulsive therapy and the nurse’s role in it. • Crisis
9. Identify the five phases of crisis and the nurse’s role in them. • Dystonia
10. Define and discuss terrorism as it relates to mental health in • Electroconvulsive
today’s world. therapy (ECT)
• Hypnosis
• Milieu
• Monoamine oxidase
inhibitors (MAOI)
• Person-centered
• Psychoanalysis
• Psychopharmacology
• Rational-emotive
therapy (RET)
• Stimulants
• Tardive dyskinesia

P Neeb’s Accurate and timely observations

eople who have alterations to their
mental health have special needs. ■ Tip and data collection by the nurse
When emotional health is threatened, may be the instrument that keeps
many other daily activities can be altered as the patient from traveling a swift
well. Cognitive ability (the ability to think downward spiral.
rationally and to process those thoughts)
can be decreased. Emotional responses can Patients can develop a sense of helplessness
be decreased or even absent in some condi- and hopelessness about themselves and their
tions. These alterations can be extremely conditions. Nurses can be the tools that help
frightening to a patient who may already the patient regain control. A nurse may be ob-
feel unable to control his or her life; this serving the patient’s treatments and therapies
can lead to a deepening of the mental dis- or may be an active part of them. Either way,
order or even the development of another the nurse will be making observations about
disorder. the patient’s reactions and participating in the

113
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114 UNIT 1 | Foundations for Mental Health Nursing

plan of care. This chapter discusses some of schizophrenia and other acute or chronic
the more frequently used methods for treating psychotic behavior including violent or po-
alterations in mental health. tentially violent behavior. Antipsychotics are
classified as typical or atypical. Typical an-
■ Psychopharmacology tipsychotic agents treat the positive symptoms
of schizophrenia, such as hallucinations,
Since the introduction of the phenothiazines delusions, and suspiciousness. Atypical an-
in the 1950s, the number of medications tipsychotic agents reduce the negative symp-
available for treating patients who have men- toms of schizophrenia, such as flat affect,
tal health disorders, comprising the field of social withdrawal, and difficulty with abstract
psychopharmacology, has increased greatly. thinking. (See Chapter 15 for further discus-
The reasons for using medications are twofold: sion of these symptoms.)
First, the medications control symptoms, thus Side Effects: Antipsychotics have many un-
helping the patient to feel more comfortable pleasant side effects. Sometimes people are re-
emotionally. Second, the medications are luctant to take these medications because they
usually used in connection with some other are afraid that the side effects will be worse
type of therapy. The patient is generally more than the illness. Some of these side effects are
receptive and able to focus on therapy if med- photosensitivity (especially with Thorazine),
ications are also used. Several classifications darkening of the skin from increased pigmen-
of psychoactive drugs (also referred to as tation, anticholinergic effects such as dry
psychotropics) are discussed below; however, mouth, and a group of side effects called ex-
there are far too many drugs to discuss each trapyramidal symptoms (EPS). There is less
one individually in this text. In most cases, risk of EPS with the atypical agents, but early
only the most common information is pre- observation and reporting of any possible EPS
sented about a medication. Nurses should are crucial to minimizing these effects on the
consult a pharmacology or drug reference patient. The EPS include:
book for more specific information before
1. Drug-induced parkinsonism (pseudo-
administering these medications or instruct-
parkinsonism). Symptoms appear 1 to
ing patients on their use.
8 weeks after the patient begins the med-
ication. The major symptom is akinesia
Tool Box | What is psychopharmacology? (muscle weakness), shuffling gait, drool-
www.ascpp.org/resources/information- ing, fatigue, mask-like facial expression,
for-patients/what-is-psychopharmacology/ tremors, and muscle rigidity.
2. Akathisia. Symptoms appear 2 to 10 weeks
after the patient starts taking the medica-
Antipsychotics (Neuroleptics/ tion. Symptoms are agitation and motor
restlessness, and they seem to appear more
Major Tranquilizers) frequently in women. There is no absolute
Action: Typical antipsychotic agents act on the reason for this, but it is suggested that it
central nervous system (CNS). Their main ac- may be due to hormonal interaction with
tion is to block the dopamine receptors. the medication.
Dopamine is a neurochemical that the human 3. Dystonia. Symptoms appear 1 to 8 weeks
body contains naturally. However, if it is over- after the patient starts taking the medica-
produced or utilized incorrectly, it can cause tion. Symptoms manifest as bizarre
someone to exhibit psychotic behavior. Atyp- distortions or involuntary movements
ical antipsychotic agents block both serotonin of any muscle group. Tongue, eyes, face,
(a neurochemical) and dopamine. neck (torticollis), or any larger muscle
Uses: Antipsychotics are used to treat psy- mass can become tightened into an un-
chotic behavior such as schizophrenia and natural position or have irregular spastic
other disorders. The antipsychotic will treat movements.
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CHAPTER 8 | Mental Health Treatments 115

4. Tardive dyskinesia (TD). Symptoms Antipsychotic medication should be dis-

appear within 1 to 8 weeks after the continued slowly. If medication is ordered
patient starts taking the medication. The once daily, teaching patients to take the
frequently seen manifestations are rhyth- medication 1 to 2 hours before going to bed
mic, involuntary movements that look works well and promotes sleep. Antacids de-
like chewing, sucking, or licking motions. crease the absorption of antipsychotics, so
Frowning and blinking constantly are these types of medications should be taken
also common. TD is irreversible. 1 to 2 hours after oral administration of
antipsychotics.
Neuroleptic malignant syndrome (NMS)
Box 8-1 provides some of the most com-
is an uncommon but potentially fatal reaction
monly used antipsychotic agents.
to treatment with neuroleptic medications.
Also see Chapter 15, Table 15-6, Compar-
Symptoms include muscle rigidity, hyper-
ison of Side Effects Among Typical and Atyp-
pyrexia, fluctuations in blood pressure, and
ical Antipsychotic Agents.
altered level of consciousness. Early recogni-
tion and immediate medical care are impor- Antiparkinson Agents
tant. Some antipsychotics, such as Clozaril, are
known to cause serious blood dyscrasias and
(Anticholinergics)
require regular monitoring of blood counts. Action: Antiparkinson agents (also called an-
Contraindications: Antipsychotics should ticholinergics) (Fig 8-1) inhibit the action of
be used carefully in patients who are hyper- acetylcholine. Acetylcholine increases as
sensitive to medications or who have brain dopamine decreases at its receptor sites (the
damage or blood dyscrasias. cholinergic effect). When the amount of
Nursing Considerations: acetylcholine available to interact with
dopamine is decreased, there is a better bal-
• Careful teaching by doctors and nurses ance between the two neurochemicals, and
can help the patient to understand that the symptoms of parkinsonism decrease.
these are very strong medications. Uses: Antiparkinson agents help decrease
• The possibility of seizures increases in the effects of drug-induced and non–drug-
patients who require antipsychotic induced symptoms of parkinsonism that often
medications. occur with antipsychotics.
• Observe for any sign of EPS or NMS Side Effects: Blurred vision, dry mouth,
and carefully monitor blood work for dizziness, drowsiness, confusion, tachycardia,
abnormal results. urinary retention, constipation, and changes
• Careful instruction to the patient and in blood pressure.
family regarding wearing a wide-brimmed Contraindications: Patients with known hy-
hat, covering all exposed skin, and using a persensitivity should not use these medications.
sunscreen when in the sun will help lessen
chances of the patient’s suffering sunburn,
especially if the patient is using Thorazine.
• Temperature extremes should be avoided. l Box 8-1 Commonly Used
• Patients should be taught to avoid alcohol. Antipsychotic Agents
• Over-the-counter (OTC) medication and Typical: Thorazine (chlorpromazine), Haldol
other products should not be taken with- (haloperidol), Stelazine (trifluoperazine),
out doctor approval. Mellaril (trioridazine), Loxitane (loxapine),
• It is important to instruct the patient not Prolixin (fluphenazine), Moban (molindone),
to alter the dose without first discussing it Navane (thiothixene), Serentil (mesoridazine),
with the doctor. Trilafon (perphenazine);
• Occasionally, the patient might experience Atypical: Risperdal (risperidone), Clozaril
some gastric distress with oral antipsy- (clozapine), Seroquel (quetiapine), Zyprexa
chotics, so give them to the patient with (olanzapine), Geodon (ziprasidone), and
food or milk. Abilify (aripiprazole)
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116 UNIT 1 | Foundations for Mental Health Nursing

ANTIPARKINSON AGENTS
Inhibits the action of acetylcholine. Acetylcholine increases as dopamine
decreases at its receptor sites. When the amount of acetylcholine
available to interact with dopamine is decreased, there is a better balance
between the two neurochemicals, and the symptoms of parkinsonism decrease.

USES SIDE EFFECTS NURSING PATIENT TEACHING

Decrease the effects Blurred vision, dry CONSIDERATIONS Use hard, sugarless
of drug-induced and mouth, dizziness, Should be avoided in candy to combat the
non–drug-induced drowsiness, children under 12 effects of dry mouth.
symptoms of confusion, tachycardia, years of age. Increase dietary
parkinsonism. urinary retention, Use with caution with roughage to maintain
constipation, and the elderly. bowel functioning.
changes in blood
Blood pressure should May cause drowsiness,
pressure.
be monitored carefully. so should not drive or
operate equipment
until the response to
medication is
established.

Figure 8-1 Antiparkinson agents.

People with glaucoma, myasthenia gravis, pep- Antianxiety Agents (Anxiolytics/

tic ulcers, prostatic hypertrophy, or urine re-
tention should not take these medications.
Minor Tranquilizers)
These agents should be avoided in children Action: Antianxiety agents depress activities of
under the age of 12 years and used with cau- the cerebral cortex (Fig. 8-2).
tion with the elderly. Uses: Antianxiety agents decrease the ef-
fects of stress, anxiety, and mild depression.
Neeb’s Assess if your patient has glaucoma. They can be used preoperatively to help pro-
■ Tip mote sedation.
Side Effects: The use of antianxiety agents
can cause physical and psychological depend-
Nursing Considerations: ence. Other side effects include drowsiness,
• Monitor blood pressure carefully (at least lethargy, fainting, postural hypotension, nau-
every 4 hours when beginning treatment). sea, and vomiting. If discontinued abruptly,
• Encourage using hard, sugarless candy or severe side effects, including nausea, hypoten-
saliva substitute to combat the effects of sion, and fatal grand mal seizures, can occur
dry mouth. anywhere from 12 hours to 2 weeks after the
drug is stopped.
Box 8-2 provides some of the most com- Contraindications: Patients with known
monly used antiparkinson agents. hypersensitivity should not use these med-
ications. People with a history of chemical
l Box 8-2 Commonly Used dependency are not good candidates for this
classification of drug because of the potential
Antiparkinson Agents
for addiction.
Akineton (biperiden), Cogentin (benztropine), Nursing Considerations:
Artane (trihexyphenidyl), Mirapex (pramipex-
ole), Benadryl (diphenhydramine) • Nurses should monitor blood pressure
before and after giving this medication
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CHAPTER 8 | Mental Health Treatments 117

ANTIANXIETY DRUGS
Depress activities of the cerebral cortex.

USES SIDE EFFECTS NURSING PATIENT TEACHING

Decrease the effects of Can cause physical CONSIDERATIONS Teach the patient and
stress or mild and psychological Administer family that it is not
depression without dependence, intramuscular (IM) safe to drive or use
causing sedation. drowsiness, lethargy, dosages deeply, alcohol while using
fainting, postural slowly, and into large this classification of
hypotension, nausea, muscle masses. medication.
and vomitting. Z-track method of IM Instruct to change
administration is positions slowly.
preferred.
Discontinue slowly.

Figure 8-2 Antianxiety drugs.

and monitor for signs of orthostatic Antidepressants (Mood

hypotension, especially if taking tricyclics
(Townsend, 2012).
Elevators)
• The patient should rise slowly from sitting Antidepressants have several subgroups and
or lying positions to prevent a sudden different drug references that subdivide the
drop in blood pressure. antidepressants differently. There are similari-
• When possible, these types of drugs ties and differences among the subgroups
should be given at bedtime to help (Fig. 8-3). Antidepressants generally take
promote sleep, minimize side effects, several weeks to see a change in mood.
and allow a more normal daytime Selective Serotonin Reuptake
routine.
• Administer intramuscular (IM) dosages Inhibitors (SSRIs) (Bicyclic
deeply and slowly into large muscle Antidepressants)
masses. The Z-track method of IM Action: These drugs increase the availability of
administration is preferred. serotonin, which is decreased in the brains of
• It is important to teach the patient and depressed individuals.
family that it is not safe for the patient Uses: Treatment of depression, anxiety, ob-
to drive or use alcohol while using this sessive disorders, impulse control disorders.
classification of medication. Side Effects: Potential for increased suicidal
tendencies, sedation, dry mouth, agitation,
Box 8-3 provides some of the most com-
postural hypotension, headache, arthralgia,
monly used antianxiety agents.
dizziness, insomnia, confusion, and tremors.
Contraindications: Patients with known hy-
persensitivity should not use these medica-
l Box 8-3 Commonly Used tions. People using monoamine oxidase
Antianxiety Agents inhibitors (MAOIs) or who are within 14 days
of discontinuing MAOIs should not use these
Xanax (alprazolam), BuSpar (buspirone), medications. People using certain herbal prepa-
Librium (chlordiazepoxide), Serax (oxazepam), rations including but not limited to St. John’s
Klonopin (clonazepam), Valium (diazepam),
Ativan (lorazepam), and Atarax or Vistaril
wort, ginseng, brewer’s yeast, vitamin B6, and
(hydroxyzine) ginkgo biloba should not use SSRIs without
consulting their physician.
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118 UNIT 1 | Foundations for Mental Health Nursing

ANTIDEPRESSANTS
Medications that acts to prevent,
cure, or alleviate mental depression.

USES SIDE EFFECTS NURSING PATIENT TEACHING

Treatment of Drowsiness, dry mouth, CONSIDERATIONS Instruct to protect from
depression and some agitation, postural Encourage patients to sunburn.
anxiety disorders. hypotension, vertigo, continue taking the Teach to change
constipation, urine medication during this positions slowly.
retention, weight gain, time, although they Teach diet restrictions
blurred vision, may not feel any with MAOIs.
photosensitivity, and change in their mood
suicidal tendencies. for up to 3 weeks after Use other medications
beginning the only with physician
medication. approval.
Discontinue slowly.
Observe for suicidal
ideation.

Figure 8-3 Antidepressants.

Note: In October 2004, producers of SSRIs

were required by the F.D.A. to place a boxed- l Box 8-4 Commonly Used SSRI
in warning on the medication container cau- Agents
tioning about the danger of increased risk of Celexa (citalopram), Prozac (fluoxetine),
suicidal tendencies in children, adolescents, Zoloft (sertraline), Luvox (fluvoxamine), Paxil
and young adults while taking this medication. (paroxetine), Lexapro (escitalopram)
Nursing Considerations:
• Do not abruptly discontinue the medica- Tricyclic Antidepressants
tion, except under the supervision of a
Action: These drugs increase the level of sero-
health-care provider. Serotonin syndrome,
tonin and norepinephrine, thereby increasing
which includes altered mental status,
the ability of the nerve cells to pass informa-
restlessness, tachycardia, and labile blood
tion to each other. Patients with depressive
pressure, can occur with abrupt discontin-
disorders generally have decreased amounts of
uation as well as when SSRIs are com-
these two neurochemicals.
bined with some other medications.
Uses: Treatment of symptoms of depres-
• Caution should be used with driving or
sion, including (but not limited to) sleep dis-
activities that require alertness.
turbances, sexual function disturbances,
• Alcohol and CNS depressants should be
changes in appetite, and cognitive changes.
avoided.
Side Effects: Sedation, lethargy, dry mouth,
• Hard, sugarless candy or saliva substitute
constipation, tachycardia, postural hypoten-
can be used to treat dry mouth.
sion, urine retention, blurred vision, weight
• The patient should change positions
gain, and changes in blood glucose.
slowly to avoid a sudden drop in blood
Contraindications: Patients with known
pressure.
hypersensitivity should not use these med-
• Monitor the patient for suicide ideation.
ications. Women who are pregnant or
Box 8-4 provides some of the most com- breastfeeding and individuals with kidney
monly used SSRI agents. disease, liver disease, or a recent myocardial
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CHAPTER 8 | Mental Health Treatments 119

infarction should not take these medica- Serotonin Norepinephrine

tions. Anyone who has asthma, seizure dis- Reuptake Inhibitors (SNRIs)
orders, schizophrenia, benign prostatic
Action: These drugs increase the availability of
hypertrophy, or alcoholism should use tri-
serotonin and norepinephrine, which are de-
cyclic antidepressants with extreme caution.
creased in the brains of depressed individuals.
Nursing Considerations:
The uses, contraindications, side effects,
• Patients should not stop using these med- and nursing considerations for the SNRI an-
ications abruptly. tidepressants are similar to those for SSRIs.
• Medications (including over-the-counter Box 8-7 provides some of the most com-
medications such as cold preparations) monly used SNRI agents.
that contain antihistamines, alcohol,
sodium bicarbonate, benzodiazepines, Monoamine Oxidase Inhibitors
and narcotic analgesics can increase the (MAOIs)
effects of tricyclic antidepressants. Action: Monoamine oxidase inhibitors
• Nicotine, barbiturates, and the hypnotic (MAOIs) prevent the metabolism of neuro-
chloral hydrate decrease the effect of the transmitters by an enzyme, monoamine oxi-
tricyclic antidepressant. dase. Too much monoamine oxidase can lead
• Serotonin syndrome can occur if combined to destructive, psychotic behaviors.
with St John’s wort. Uses: MAOIs are generally used for patients
Box 8-5 provides some of the most com- with varied types of depression who have not
monly used tricyclic antidepressant agents. been helped by other antidepressants.
Side Effects: Postural hypotension, photosen-
Tetracyclic Antidepressants sitivity (sunburn potential), headache, dizziness,
(Heterocyclic Antidepressants) memory impairment, tremors, fatigue, insom-
nia, weight gain, and sexual dysfunction.
The actions, uses, contraindications, side
Contraindications: Patients with known hy-
effects, and nursing considerations for the
persensitivity should not use these medica-
tetracyclic antidepressants are similar to those
tions. MAOI medications should be given
for SSRIs.
carefully to patients who have asthma, con-
Box 8-6 provides some of the most com-
gestive heart failure, cerebrovascular disease,
monly used tetracyclic antidepressant agents.
glaucoma, blood pressure conditions, schizo-
phrenia, alcoholism, liver or kidney disorders,
or severe headaches, as well as to those who
l Box 8-5 Commonly Used Tricyclic are over 60 years old or pregnant. There are
Antidepressant Agents many drug-drug interactions that may occur
if MAOI agents are combined with other
Elavil (amitriptyline), Tofranil (imipramine), medications. Other prescriptions and over-
Pamelor or Aventyl (nortriptyline), Asendin the-counter products should be taken only
(amoxapine), Norpramin (desipramine),
after consulting a doctor or a pharmacist.
Anafranil (clomipramine), Sinequan (doxepin),
Surmontil (trimipramine), Vivactil (protiptyline) Nursing Considerations:
• Teach patients to avoid foods containing
the amino acid tyramine, a precursor
of norepinephrine, while taking these
l Box 8-6 Commonly Used
Tetracyclic Antidepressant
Agents l Box 8-7 Commonly Used SNRI
Agents
Ludiomil (maprotiline), Wellbutrin or Zyban
(bupropion), Remeron (mirtazapine), Desyrel Serzone (nafazodone), Effexor (venlafaxine),
(trazodone) Cymbalta (duloxetine)
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120 UNIT 1 | Foundations for Mental Health Nursing

medications. MAOIs block the metabo- information as possible to allow the patient
lism of tyramine, resulting in increased to make safe, informed choices.
norepinephrine. A hypertensive crisis Box 8-9 provides nursing considerations
may occur. Foods containing significant for all antidepressants.
amounts of tyramine include
• Aged cheese (cheddar, Swiss, provolone, Antimanic Agents (Mood
blue cheese, parmesan) Stabilizing Agents)
• Avocados (guacamole) Lithium carbonate was the drug of choice for
• Yogurt, sour cream treatment and management of bipolar mania
• Chicken and beef livers, pickled herring, for many years. In recent years, several other
corned beef antimanic agents (Fig. 8-4) have become
• Bean pods treatment options. Other medications being
• Bananas, raisins, and figs used as mood stabilizers include some anti-
• Smoked and processed meat (salami, convulsants and calcium channel blockers.
pepperoni, and bologna)
• Yeast supplements Lithium Carbonate
• Chocolate Action: The exact action of lithium is not
• Meat tenderizers (MSG), soy sauce completely known at this time. It is not me-
• Beer, red wines, and caffeine tabolized by the body. One hypothesis about
Box 8-8 provides some of the most com- the action of lithium is that there seems to be
monly used MAOI agents. a connection between lithium and constancy
of sodium concentration, which might help
Alternative Treatments regulate and moderate information along the
for Depression nerve cells, thus preventing mood swings. An-
People are seeking alternatives to the prescrip- other possibility is that lithium increases the
tion antidepressant drugs available through reuptake of norepinephrine and serotonin,
traditional western medicine. Some reasons thereby decreasing hyperactivity.
they seek alternatives include cultural prefer- Uses: Lithium is used for the manic phase
ences, cost of medications, insurance issues, of bipolar disorder and sometimes for other
and unpleasant side effects they may experi- depressive or schizoaffective disorders.
ence with the medications they have used. Side Effects: Side effects can be numerous.
One such alternative is a chemical called Some of the more common ones are thirst and
SAMe (“sammy”). SAMe is a combination of dry mouth, nausea and vomiting, abdominal
an amino acid (methionine) and ATP. It is pain, and fatigue.
used as an antidepressant and sold in the
United States as a dietary supplement. Other
alternative forms of therapy are explored in l Box 8-9 Nursing Considerations
Chapter 9. for All Antidepressants
The nurse’s role is the same with these
alternative choices as it is with prescription • Reinforce the teaching that these medica-
medications. Nurses must encourage their tions take several weeks to become effec-
patients to discuss the use of supplements tive. Encourage patients to continue taking
with their physicians and to provide as much the medication during this time, although
they may not feel any change in their
mood right away.
• All antidepressant medications should be ta-
l Box 8-8 Commonly Used MAOI pered gradually rather than abruptly discon-
Agents tinued to prevent withdrawal symptoms.
• It is imperative that all patients receiving
Nardil (phenelzine), Parnate (tranylcypromine), antidepressant medications be monitored
Marplan (isocarboxazid) for suicide potential throughout treatment.
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CHAPTER 8 | Mental Health Treatments 121

ANTIMANIC AGENTS

USES SIDE EFFECTS NURSING PATIENT TEACHING

To stabilize the manic Thirst, dry mouth, CONSIDERATIONS Instruct patient to have
phase in bipolar fatigue, nausea, Observe for signs of periodic lab tests to
disorder. abdominal pain, toxicity: severe monitor lithium blood
tremors, headache, diarrhea, muscle levels.
drowsiness, and weakness, persistent Teach patient to have
confusion. nausea and vomiting, adequate fluid and
and seizures. sodium intake.
Dehydration and fever Teach patient the signs
can cause toxicity. of toxicity and to notify
the physician if any
indication of toxicity.
Hard, sugarless candy
can be helpful for dry
mouth and thirst.
Instruct patient that
pregnancy and breast-
feeding are not
recommended while
taking these
medications.

Figure 8-4 Antimanic agents.

Contraindications: Consistent with those of taught to inform the physician immedi-

the other categories listed earlier. ately if they are ill.
Nursing Considerations: • Hard, sugarless candy can be helpful to
decrease dry mouth and thirst.
• Encourage patients to keep all appoint-
ments for blood work and evaluation of Box 8-10 provides some of the most com-
drug effectiveness. Therapeutic serum lev- monly used forms of Lithium
els are between 0.5 and 1.2 mEq/L for
most patients (1.0 to 1.5 in acute mania). Anticonvulsants
Symptoms of lithium toxicity begin to Action: The action of anticonvulsants in the
appear at blood levels greater than treatment of bipolar disorder is not clear.
1.5 mEq/L. Signs of toxicity include se- Uses: These drugs stabilize the manic
vere diarrhea, persistent nausea and vom- episodes in bipolar disorders.
iting, muscle weakness, tremors, blurred Side Effects: Nausea, vomiting, indigestion,
vision, slurred speech, and seizures. drowsiness, dizziness, prolonged bleeding,
• Lithium crosses the placenta and milk headache, confusion.
barriers, so women of childbearing years Contraindications: Patients with known hy-
may need to be counseled regarding the persensitivity or with bone marrow suppression
effects of this drug on their pregnancy should not use these medications. Caution
and breastfeeding.
• Dehydration and fevers can cause
increased danger of toxicity. l Box 8-10 Commonly Used forms
• Adequate fluid and sodium intake are es- of Lithium
sential. Patients should not decrease their Eskalith, Lithonate, Lithane, Lithobid (all are
dietary intake of salt (unless instructed to lithium carbonate)
do so by the physician) and should be
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122 UNIT 1 | Foundations for Mental Health Nursing

should be used with patients with renal, cardiac, used calcium channel blockers are Calan or
or liver disease. Caution should also be used Isoptin (verapamil).
with the elderly and children.
Nursing Considerations: Stimulants
Stimulants (Fig. 8-5) are readily available over
• Do not stop the medication abruptly.
the counter as well as by prescription. They
• The medication should be tapered when
are found over the counter in diet prepara-
therapy is discontinued.
tions, pills to prevent sleep, cigarettes, and
• Teach patients to avoid alcohol.
caffeinated beverages such as coffee, energy
• Nonprescription medications should not
drinks, and soda. They are used medically
be used without doctor approval.
to combat narcolepsy and attention-deficit/
• Patients should not drive or operate dan-
hyperactivity disorder in children.
gerous equipment until the effects of the
Amphetamines are one type of stimulant.
medication are known.
Amphetamines can be abused, and they have
Box 8-11 provides some of the most com- many “street names,” including “uppers,”
monly used anticonvulsant agents. “speed,” and “bennies.” The ease with which they
are available should not diminish the power and
Calcium Channel Blockers potential danger of the drug (see Chapter 17).
The action, uses, side effects, contraindica- Action: Stimulants provide direct stimula-
tions, and nursing considerations are similar tion of the central nervous system (CNS).
to those for anticonvulsants. Postural hy- Uses: These drugs promote alertness, dimin-
potension and bradycardia are additional ish appetite, and combat narcolepsy (sleep dis-
side effects. The patient should rise slowly order related to abnormal rapid eye movement
from sitting or lying positions to prevent a sleep). They are used in the treatment of
sudden drop in blood pressure. Commonly attention-deficit/hyperactivity disorder (ADHD).
Side Effects: Increased or irregular heartbeat,
hypertension, hyperactivity, dry mouth, hand
l Box 8-11 Commonly Used tremor, rapid speech, diaphoresis, confusion,
Anticonvulsant Agents depression, seizures, suicidal ideation, and
Tegretol (carbamazepine), Depakene (valproic insomnia.
acid), Depakote (divalproex) Contraindications: Patients with known hy-
persensitivity should not use these medications.

STIMULANTS
A substance that increases performance temporally.

USES SIDE EFFECTS NURSING PATIENT TEACHING

Promotes alertness, Rapid or irregular CONSIDERATIONS Diabetic patients
diminishes appetite, heartbeat, Tolerance, physical should monitor insulin
and combats hypertension, and psychological carefully and inform
narcolepsy. hyperactivity, hand dependence, the physician of any
Treatment of attention- tremor, rapid speech, especially with long- changes.
deficit/hyperactivity confusion, depression, term use. Patients should use
disorder (ADHD). seizures, and suicidal Amphetamines can extreme caution when
thoughts. cause changes in driving or operating
insulin requirements in machinery.
diabetic patients.

Figure 8-5 Stimulants.

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CHAPTER 8 | Mental Health Treatments 123

Pregnant or lactating women should not use who goes to an event such as a concert or a
this classification of drugs. Because these are ballgame that he does not feel excited about.
chemicals that increase stimulation of the CNS That person might begin screaming or singing
and respiratory systems, they should not be along and generally getting into the spirit of
given to people who are alcoholic, manic, or things shortly after arriving at the event.
who display suicidal or homicidal ideations.
People who have heart disease or glaucoma ■■■ Critical Thinking Question
also should not use these drugs because of the You are to go on an assigned unit in a mental
potential effect of the medications. Elderly health floor to monitor a group discussing anger.
You are feeling apprehensive and fearful about
people and patients who have diabetes, hyper- being on the same unit as these patients. De-
tension, or other cardiovascular conditions scribe how you might feel after hearing how the
should use these drugs cautiously and with patients’ home life relates to this anger.
careful monitoring.
Nursing Considerations:
The milieu is the setting that will provide
• Tolerance and physical and psychological safety and help during the patient’s stay. The
dependence can occur with CNS stimu- milieu therapy is intended to combine the
lants, especially with long-term use. social and the therapeutic environments. In
• Do not discontinue medication abruptly. that way, every contact between nurse and
• Monitor for suicide potential. patient gives the opportunity for a thera-
• Diabetic patients who take amphetamines peutic interaction. The milieu must be com-
should be informed that the ampheta- fortable and safe. Patients need to feel
mines may cause changes in their insulin accepted as they learn new behaviors. It is
requirements. best to have the milieu as appropriate to the
• These medications can also cause changes situation as possible. Obviously, nurses can-
in judgment; therefore, people should be not move walls and change decorating
counseled to use extreme caution when themes in the hospital, but they can allow
driving or operating equipment and the patient to choose the room for therapy
should avoid these activities if possible. or move to an area where the patient is more
• Encourage frequent rinsing of the mouth comfortable. If the patient is on a psychi-
with water or use of hard, sugarless candy atric unit rather than a medical or surgical
or saliva substitute to relieve dry mouth. unit, he or she is usually allowed to walk
Box 8-12 provides some of the most com- from area to area on the unit. A nurse can
monly used stimulant agents. keep the area calm and quiet and arrange for
roommate changes if needed. There are
■ Milieu many things a nurse can and must do to
maintain a milieu that is conducive to a pa-
One of the areas that nurses have some control tient’s progress. As the patient progresses,
over is the therapeutic environment itself. In the milieu will be changed to allow the pa-
mental health terminology, this therapeutic en- tient to take on more responsibility.
vironment is called the milieu, or therapeutic
milieu. It is believed that the environment has ■ Psychotherapies
an effect on behavior. Think about a person
Psychotherapy (Fig. 8-6) is the term used to
describe the form of treatment chosen by the
l Box 8-12 Commonly Used psychologist or psychiatrist or other mental
health therapist to treat an individual. The
Stimulant Agents
goals of psychotherapy are to:
Dexedrine (dextroamphetamine), Desoxyn
(methamphetamine), Ritalin (methylphenidate), 1. Decrease the patient’s emotional
Adderal (dextroamphetamine/amphetamine) discomfort.
2. Increase the patient’s social functioning.
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124 UNIT 1 | Foundations for Mental Health Nursing

PSYCHOTHERAPIES
Therapies selected by a psychologist or psychiatrist.

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

For treatment of 1. Patient states CONSIDERATIONS Practice new coping
various alterations to improvement in Positive reinforcement behaviors.
mental health. emotional discomfort. of patient’s progress. Help patient develop
2. Patient returns to Honest communication. insight into his or her
comfortable social illness.
functioning.
3. Patient behaves in
a manner appropriate
to the situation.

Figure 8-6 Psychotherapies.

3. Increase the patient’s ability to behave or It is typical for the psychoanalyst to be po-
perform in a manner appropriate to the sitioned at the head of the patient and slightly
situation. behind, so that the patient cannot see the ther-
apist. This decreases any kind of nonverbal
These goals are achieved in a variety of ways,
communication between the two people. The
including therapeutic relationships, open and
patient is typically on the “couch,” relaxed and
honest venting of feelings and thoughts, allow-
ready to focus on the therapist’s instructions.
ing the patient to practice new coping skills,
Some of the techniques used in psycho-
helping the patient to gain insight into the
analysis are as follows.
problem, and consistency in the team ap-
proach to the patient’s care and treatment. Pos-
itive reinforcement of progress is encouraged.
Free Association
Some therapies may be focused on gaining in- In free association, the patient is allowed to
sight into the reasons for current behavior and say whatever comes to mind in response to a
others are more focused on changing specific word that is given by the therapist. For exam-
behaviors. ple, the therapist might say “mother” or
Several types of therapy are typically used. “blue,” and the patient would give a response,
Nurses may or may not be actively involved also typically one word, to each of the words
in the therapy, but to provide continuity in the therapist says.
the care of the patient, they must understand The therapist then looks for a theme or
the basic ideas of the types of therapy. pattern to the patient’s responses. So, if the
patient responds “evil” to the word “mother”
Psychoanalysis or “dead” to the word “blue,” the therapist
Psychoanalysis is the form of therapy that might pick up one potential theme, but if the
originated from the theories of Sigmund patient responds “kind” and “true” to the
Freud. In psychoanalysis, the focus is on the words “mother” and “blue,” the therapist
cause of the problem, which is buried some- might hear a completely different theme. The
where in the unconscious. The therapist theme may give the therapist an idea of the
tries to take the patient into the past in an cause of the patient’s emotional disturbance.
effort to determine where the problem
began. Chances are, according to Freud, Dream Analysis
that the problem is related to poor parent- Because Freudians believe that behavior is
child relationships and ineffective psycho- rooted in the unconscious and that dreams are
sexual development. a manifestation of the troubles people repress,
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CHAPTER 8 | Mental Health Treatments 125

what better way to get an idea of the problem

than to monitor and interpret dreams? The
patient is asked to keep a “dream log.” He/she
is asked to awaken immediately after a dream
and to write down the dream details right
away in a notebook kept next to the bed. This
is easier said than done, as many people re-
member only bits and pieces of a dream upon
awakening. Psychoanalysts believe that dreams
truly are the mirror to the unconscious and
that it is possible to train the self to awaken
long enough to record the dream. The dreams
are then interpreted in much the same way
as free association. Significant people or situ-
ations in the dreams are explored with the
patient, and possible meanings are offered by
the therapist.
Hypnosis
Many people are afraid of hypnosis. For many
years, it was reputed to be quackery and pre-
sented in stage shows in which people did Figure 8-7 In hypnotherapy, a patient in a
things such as cluck like chickens, which state of very deep relaxation is guided by the
served as entertainment. Granted, this sort of therapist.
thing can happen. Fraternity and sorority
members love to invite stage performers to
hypnotize pledgees during rush. Certainly, suggestions and typically include positive,
people like the entertainer David Copperfield affirming statements for the patient to think
have made comfortable livings with hypnosis. about as well as instructions to help the per-
Hypnotherapy, as professional therapists son accomplish self-hypnosis.
prefer to call it, is used for certain people in Of course, just as there are unethical peo-
certain instances. It is not a magic solution to ple in all walks of life, a small number of ther-
problems. It takes practice on the part of the apists may abuse this relationship, although
patient. It can, however, be a very effective it is very uncommon. People do not generally
tool for unlocking the unconscious or for lose control when under hypnosis; they will,
searching further into a technique called “past in most cases, still realize what is comfortable
life regression.” and acceptable to them personally, and they
Hypnosis is very deep relaxation. A person will not allow themselves to go deeper into
who has listened to a relaxation tape and felt hypnosis or to perform behaviors that they
the effects of it or who has driven a car and no- find objectionable.
ticed that 20 minutes have passed that he or Hypnosis and hypnotherapy are discussed
she cannot account for has been hypnotized. in more depth in Chapter 9.
In hypnotherapy, the relaxation is guided
by the therapist, who has been trained in Catharsis
techniques of trance formation and who Catharsis is “the act of purging” or “elimi-
then asks certain questions of the patient or nation of a complex (problem) by bringing
uses guided imagery to help picture the sit- it to consciousness and affording it expres-
uation in an effort to find the cause of the sion” (Merriam-Webster Online, 2013). In
problem (Fig. 8-7). At the end of the session, psychoanalysis, the therapist helps the pa-
the therapist will leave some helpful hints for tient see the root of the problem and then,
the patient. These are called posthypnotic by talking or expressing feelings, allows
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126 UNIT 1 | Foundations for Mental Health Nursing

the patient to learn to evacuate this problem However, anyone who has tried to lose weight
from the psyche. This can take place in con- or stop smoking might have a rebuttal to that
junction with other forms of psychotherapy. theory.
Psychoanalysis is undertaken on a one- Behavior can be changed, according to be-
on-one basis between patient and therapist. havior modification theory, by either positive
The nurse can be helpful in the treatment or negative reinforcement. Positive reinforce-
process by allowing the patient to talk about ment is the act of rewarding the patient with
the experiences in therapy and by carefully something pleasant when the desired behav-
documenting the patient’s responses. ior has been performed. For instance, if
Mrs. P has the habit of using foul language
Behavior Modification in an attempt to have a need met, it might
The treatment method known as behavior be assumed that the desired behavior change
modification is based on the theories of would be for her to come to a staff member
the behavioral theorists (Skinner, Pavlov, and and ask quietly for what she needs. Mrs. P
others). It is a common treatment modality loves to be outside but is not allowed out
used in multiple treatment settings (Fig. 8-8). except at supervised times. A suitable positive
The purpose of behavior modification is to reinforcer might be to allow 15 additional
eliminate or greatly decrease the frequency of minutes outdoors when she remembers to
identified negative behaviors. One of the ask for her needs quietly. Generally, when the
basic beliefs of behavior modification is that unacceptable behavior is exhibited by Mrs. P,
whenever a behavior is removed, it must be the staff would either ignore it (because cor-
replaced by another behavior. Therefore, re- recting it would in itself be a form of rein-
placing the negative behaviors with ones that forcing the behavior) or quietly tell her that
are more desirable is a major function of this is not acceptable behavior and then acknowl-
type of psychotherapy. edge her only when the desired change has
As Skinner and Pavlov showed, behaviors been demonstrated.
can be learned and unlearned. The process of
finding the appropriate stimuli and reinforcers ■■■ Classroom Activity
determines the effectiveness of the change in • Write out one behavior you personally would like
behavior. According to some behaviorists, it to change. Include what a person could give you
takes approximately 20 repetitions of a behav- to create a change.
ior to make it a part of a person’s lifestyle.

BEHAVIOR MODIFICATION
Variables are manipulated for behavioral changes.

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

To remove or greatly Positive reinforcement CONSIDERATIONS Communication skills
diminish behaviors of new behaviors. Positive reinforcement are important.
that are inappropriate Clearly stated of new behaviors. Ensure patient’s
or unhealthy. expectations and Clearly stated understanding of the
appropriate behaviors. expectations and reasons for the
Consistently upholding appropriate behaviors. changes in behavior.
the patient’s care plan. Consistently upholding
the patient’s care plan.

Figure 8-8 Behavior modification.

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CHAPTER 8 | Mental Health Treatments 127

Negative reinforcement is interpreted by considered a questionable alternative to other

some as punishment. Great care must be kinds of treatment.
taken when performing behavior modifica-
tion with certain populations of people. It can Cognitive Therapies
look like an infraction of the Patient Bill of
Rights and could be reported by someone Rational-Emotive Therapy
who does not understand the situation. (RET)
Negative reinforcement is the act of re- Dr. Albert Ellis, a “reformed” psychoanalyst,
sponding to the undesired behavior by taking and other cognitive therapists have developed
away a privilege or adding an unwanted re- theories proposing that people teach them-
sponsibility. Critics of the legal system in this selves to be ill because of the way they think
country sometimes cite imprisonment and about their situations. Cognitive means “of, re-
capital punishment as forms of negative rein- lating to, or being conscious of mental activity
forcement. Parents who “ground” a child after (as thinking, remembering, learning or using
the child behaves unacceptably are using neg- language)” (Merriam-Webster Online, 2013).
ative reinforcement; requiring that child to Cognitive therapy emphasizes ways of rethink-
perform extra household tasks for a stated pe- ing situations. The therapist confronts the pa-
riod of time is reinforcing the fact that the tient with certain behaviors and then works
negative behavior has consequences. The out ways of thinking about them differently.
child may not repeat the negative behavior Rational-emotive therapy (RET) is one of
after either of these parental choices. the best-known cognitive therapies (Fig. 8-9).
Whatever option is chosen, it is important Dr. Ellis’s theory is based on an A-B-C
to have the behaviors and consequences format:
clearly stated. In a facility, this will be incor-
• A is the activating event, or the subject of
porated into the plan of care. At home, it can
the faulty thinking.
be stated in family meetings, agreed upon ver-
• B is the belief system a person has adopted
bally by the family members, or made known
about the activating event.
by some other method of clear communica-
• C is the consequence to continuing the
tion. The patient must have the ability to un-
belief system.
derstand the ramifications of the behavior to
be changed and the purpose for the type of Dr. Ellis has made up terminology that he
consequence that is chosen. If the person is uses with his therapy, such as “musturba-
not capable of understanding the situation or tion” (the act of insisting that something
is not able to remember due to some other must go a certain way), “awfulizing” (the be-
problem, behavior modification could be lief that something is not just inconvenient

COGNITIVE THERAPY: RATIONAL-EMOTIVE THERAPY (RET)

Dr. Albert Ellis

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

For any mental health Patient will be able to CONSIDERATIONS Perform “homework.”
alteration that is remain “undisturbed” Patients will probably Avoid the words
consciously controlled. as a result of not be inpatients. “must” and “should.”
rethinking activating
events, belief system,
and consequences.

Figure 8-9 Cognitive therapy: rational-emotive therapy.

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128 UNIT 1 | Foundations for Mental Health Nursing

or unpleasant, but the extreme of “awful”), psychodynamic psychotherapy in that the

and “catastrophizing” (at which point, one therapist and the patient will actively work to-
has lost control of the situation). In RET, gether to help the patient recover from the
there are no “musts” or “shoulds.” Feeling mental illness. People who seek CBT can ex-
sad about an unpleasant experience (such as pect their therapist to be problem-focused and
the death of a loved one) is acceptable and goal-directed in addressing the challenging
normal, but becoming depressed about the symptoms of mental illnesses. Because CBT is
death is “awfulizing” and therefore consid- an active intervention, one can also expect to
ered by him to be unhealthy. do homework or practice outside of sessions.
It is common for RET to be performed in RET and other forms of cognitive therapies
groups. The patients are given homework to are gaining in popularity because usually they
complete in the period between sessions. The are significantly more short-term than psycho-
expected outcome is that patients will no analysis and therefore less costly to the patient.
longer “disturb ourselves by the way we
think” (Ellis, 1988). Person-Centered/Humanistic
Therapy
■■■ Clinical Activity Theorists Abraham Maslow and Carl Rogers
Throughout your clinical experience, observe pa- are most frequently credited with the concept
tients on the unit when they are instructed by the of person-centered, or humanistic, therapy
health-care provider that they “must or should” (Fig. 8-10). In this form of treatment, all
behave in a specific manner. During clinical post-
conferences, discuss these episodes and whether caregivers are to focus on the whole person
the outcome was negative. and to work in the “present.” It is not impor-
tant in humanistic treatment to understand
the cause of the problem or what happened
An offshoot of RET is known as cognitive in the person’s past; what is important is the
behavior therapy (CBT). CBT is behavioral here and now.
therapy that focuses on examining the rela-
tionships between thoughts, feelings, and be- Unconditional Positive Regard
haviors. By exploring patterns of thinking that This is the phrase used by therapists who fol-
lead to self-destructive actions and the beliefs low Rogerian theory. Unconditional positive
that direct these thoughts, people with mental regard means full, nonjudgmental acceptance
illness can modify their patterns of thinking of the patient as a person. It also means that
to improve coping. CBT is a type of psy- the patient must work at accepting himself or
chotherapy that is different from traditional herself. Being self-aware and having feelings

PERSON-CENTERED/ HUMANISTIC THERAPY

Abraham Maslow and Carl Rogers

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

All aspects of patient Patient will feel CONSIDERATIONS Remain centered in
care. accepted as a human, Maintain the three the present.
All forms of mental which will allow patient basic qualities of Practice accepting
health alterations. to be self-aware and Rogerian theory self unconditionally.
self-accepting. 1. Empathy
2. Unconditional
positive regard
3. Genuineness.

Figure 8-10 Person-centered/humanistic therapy.

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CHAPTER 8 | Mental Health Treatments 129

that are congruent (equal) to that self-concept may be asked to facilitate (lead) a group discus-
are some of the goals of humanistic therapy. sion sometimes. If nurses have the opportunity,
Rogers believed that people who care for they should take it. It is very interesting to see
other people must have three qualities. These the dynamics of the group and the way the
qualities are: facilitator guides patients through issues.
• Empathy (the ability to identify with the Neeb’s These are confidential sessions, even
patient’s feelings without actually experi- ■ Tip if they are group oriented. Patients
encing them with the patient) are there to work; others are there by
• Unconditional positive regard invitation for special reasons.
• Genuineness (honesty)
Although nurses may not be active partic- Pastoral or Cultural Counseling
ipants in the actual therapy sessions with their Some people prefer to obtain assistance or
patients, it is important for nurses to main- counseling from their church or spiritual lead-
tain these three qualities in all therapeutic re- ers (Fig. 8-12). Sessions are often free, or on a
lationships. When a patient feels betrayed, it “free-will” or “ability to pay” status. The person
usually results in deterioration of the nurse- who provides therapy in this time or circum-
patient relationship and loss of credibility for stance may or may not be trained in traditional
the nurse in that situation. mental health theories and modalities.
In some Christian faiths, nurses may have an
Counseling opportunity to serve in ways they could not in a
Counseling is licensed and regulated differently traditional setting. For example, “parish nurses”
not only state by state, but also sometimes mu- are licensed nurses who work through their
nicipality by municipality (Fig. 8-11). Some church and perform tasks ranging from simply
states require that a person be prepared at a PhD visiting a homebound church member to actu-
level to practice therapy independently; in some ally performing care and counseling or referrals
areas, only certain types of therapy are licensed. for that individual. Depending on the particular
Nurses prepared at an LPN/LVN level or at an church organization, nurses who serve as parish
RN level can, in some localities, practice forms nurses may serve in a volunteer capacity or in a
of treatment. It is up to nurses to do the appro- paid position. Training sessions are offered in
priate research to determine their rights, respon- some locales for nurses who wish to provide this
sibilities, and regulations in their locality, if service, although many churches do not yet re-
counseling is a path they wish to pursue. Nurses quire formal training for all their nurses.
may be asked or required to accompany their Nurses may be in a position to counsel pa-
patients to counseling sessions at times. They tients of their cultural or religious groups

COUNSELING

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

All forms of mental Patient will gain insight CONSIDERATIONS Patient must work at
health alterations. to situation and May be facilitator. gaining confidence
receive tools to make Nurse-counselor to try options.
changes in his or her licensing requirements
life. vary by state.
Confidentiality is
mandatory.

Figure 8-11 Counseling.

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130 UNIT 1 | Foundations for Mental Health Nursing

PASTORAL COUNSELING OR CULTURAL COUNSELING

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

All forms of mental Patient gains tools CONSIDERATIONS Patient works with
health alterations. from a religious/cultural May act as “parish teaching from
background to be able nurse” (or similar title) religious or cultural
to make changes in his representative of a affiliation to regain
or her life. specific religion or mental health.
cultural group in home
visits or health facility
visits. May be a paid
or volunteer position.

Figure 8-12 Pastoral or cultural counseling.

when the patient enters the health-care system. patients of the opposite sex. Women of
Here are some examples: Islamic faith often wear a hijab (head cov-
ering) that completely covers the hair.
• Patients who profess Judaism, especially if
those individuals observe kosher practices, Neeb’s As a health-care provider, acknowl-
may have concerns about dietary selections, ■ Tip edge and validate patients’ beliefs
may refuse to have certain procedures done regarding their religion or culture.
between sundown Friday and sundown
Saturday, and may insist on being admitted
• Some Native American patients may have
to a Jewish hospital if one is available.
healing traditions that conflict with tradi-
• Patients of Islamic faith follow rituals that
tional Western medicine. Remember that
may conflict with schedules and routines
it is not appropriate to label all Native
within the hospital. Prayer times are pro-
Americans as one group; many tribes
scribed by their faith and are strictly fol-
have their own unique beliefs and tradi-
lowed; therefore, medication times,
tions. Shamans, healers, and medicine
treatment times, or attendance at therapy
men are examples of people who may
may meet with some conflict on the part
be present in the room with the Native
of that patient. Prayers can be postponed
American patient.
in case of a conflict in schedules. Islamic
belief follows holy times that are different
from the traditional holidays or holy days ■■■ Critical Thinking Question
celebrated in the social calendar in the Maya is a new employee on your medical floor.
Maya is Muslim. She has been given permission to
United States or those traditionally cele- wear her hijab. Maya “disappears” at odd times in
brated within Christianity or Judaism. addition to her assigned breaks. Today is excep-
Also, the patient may have some dietary tionally busy. Staffing is short, and there are new
concerns; those of Islamic faith observe patients on the floor. The patient in the private
halal practices, which is similar to the room down the hall is deteriorating; she has the
potential for stroke and is waiting to be trans-
Judaism practice of kosher foods. Patients ferred to the Emergency Department. Where is
of both faiths may have some concerns Maya? You find her on her knees deep in prayer.
with the contents of their medications, You try to tell her that things are very critical right
such as gel caps. Nurses need to be aware now. She is needed; can’t she pray later? Maya
of the potential conflicts between hospital tells you she needs to pray now and that she will
only be a few more minutes. What priorities must
routines and the religious obligations of be addressed? Whose priorities are they? What
their patients. Nurses of Islamic faith may potential problems could arise from this situation?
find that one of their challenges working What are some potential resolutions?
within their belief system is caring for
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CHAPTER 8 | Mental Health Treatments 131

Table 8-1 examines a number of concepts (AA) and similar 12-step groups are well-
that may affect certain cultural groups’ will- established, ongoing groups. They are held
ingness to seek and comply with mental not only in the treatment facility, but also in
health treatment. the community. Meeting times are established
and published so that people know when
Group Therapy and how to access them. As a rule, AA meet-
Group therapy is a very broad topic. Groups ings are “closed” meetings; that is, only alco-
are formed for many reasons; they can be holics are welcome. Sometimes, maybe once
ongoing or short-term, depending on the a month or once quarterly, a meeting is ad-
needs of the patients or the type of disorder. vertised as “open,” so that other interested
Group therapy can include formal psy- persons (and students) are welcome. Many
chotherapy groups where patients meet with people who have experienced alcoholism or
a therapist regularly as part of their treatment. other chemical dependencies have benefited
Self-help programs are also a form of group from this 12-step approach to healing, and it
therapy. For example, Alcoholics Anonymous is said that this type of peer group help is the

l Table 8-1 Concepts That May Affect Certain Cultural Groups’ Seeking
or Complying With Mental Health Treatment
Caucasian • Stigma remains attached to mental illness but is weakening somewhat.
• Generally have more access to health insurance and to mental health
professionals.
• Tend to be more receptive to taking medications than other groups may be.
African • More likely than whites to receive initial treatment for mental health in
American emergency rooms (it is thought this may be because this population delays
treatment).
• Approximately 20% of African Americans do not have health insurance.
• More likely to receive treatment from primary health-care provider rather
than a mental health specialist.
• If any treatment is rendered, it may be substandard.
• Statistics may be skewed to show overrepresentation of African Americans
having mental illness.
Hispanic • Mental illness among Hispanics is about equal to that of Caucasians.
• Currently the highest group not having health insurance.
• Language barriers.
• Young Hispanics tend to have higher rates of depression, anxiety disorders,
and suicide.
• Hispanics born in the United States tend to be diagnosed with a mental
illness more frequently than those born in Mexico.
Native • Suicide rate approximately 50% higher than that of the general U.S.
Americans population.
• Mental health treatment options very limited.
• Lack of research into mental health issues for Native Americans. Also difficult
to design and provide effective mental health care.
• Cultural stigmas.
Asian • Cultural stigmas; depending on the group, the stigma is expressed
Americans differently.
• Language barriers.
• Tend to seek mental health services at lower rates than Caucasians.
• Goal is to restore balance in life; often accomplished through exercise or
diet rather than a mental health system.
Office of Minority Health. (2013). Accessed at http://minorityhealth.hhs.gov
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132 UNIT 1 | Foundations for Mental Health Nursing

most beneficial for this type of illness. Other

types of support groups may have different
formats.

Tool Box | Alcohol Anonymous (AA)

www.aa.org

■■■ Clinical Activity

Attend an open AA meeting. Describe your views
about AA prior to attending and write about your
feelings after attending..

Group therapy also includes family ther-

apy. Family counseling sessions are often set
up with individual therapists with a specialty
in the problem area for that family. It is ex-
pected that the whole family attend, but there
may be times when only certain members are
asked to attend or when the individuals will
“break out” with another therapist and then
return to the family group later. Figure 8-13 This obviously happy couple is
Marriage counseling is set up either with an a reminder that people can find creative, ef-
individual counselor or in a group with other fective ways to manage conflicts within their
relationships. A therapist may help them
couples. Many times, peer counselors are used. with suggestions, but they must try those
These are people who have experienced similar suggestions themselves and find what works
obstacles in their marriage and found creative, for them. (Courtesy of Robynn Anwar.)
effective ways to manage their conflicts
(Fig. 8-13). Sometimes, people choose to seek
help from a spiritual leader. It is important for some patients. They envision the old movies
us to remember that the therapists and coun- in which the patient flopped relentlessly
selors are tools. They do not heal the patient; on the table. Fortunately, that is a no longer
the patient heals himself or herself. Patients the case.
must take the suggestions given by the thera- Because of these misperceptions, it is im-
pist, try them, and see what works for them. portant for health-care providers to educate
Nurses can help patients by reinforcing the others (Fig. 8-14). Patients are generally given
good work they do in learning to keep them- a sedative before the treatment. Nurses care-
selves healthy. Nurses can also help by remind- fully monitor blood pressure and pulse before
ing patients gently that they do their own and after treatment. The amount of electricity
healing. Sometimes, when the road to healing used is individualized to the patient. A treat-
gets rocky, patients may use the therapist as a ment usually lasts only a few minutes, and
scapegoat. Rather than agree or disagree with if one is slow to look, he or she might miss
the patient, the nurse needs to remember the seeing a patient’s so-called convulsion. Often,
therapeutic communication skills, empathize only a toe or a finger may twitch slightly;
with the hard work that is being done by the there are no more uncontrolled seizures on
patient, and encourage the patient to discuss the treatment table.
the frustration with the therapist. ECT has a few side effects that can be
fairly unpleasant. The patient may feel con-
Electroconvulsive Therapy fused and forgetful immediately after the
Electroconvulsive therapy (ECT), or elec- treatment. This can be from a combination of
troshock therapy, as it is sometimes still called, the ECT itself and the pretreatment medica-
is a form of treatment that is frightening to tion. If there has been a stronger seizure, the
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CHAPTER 8 | Mental Health Treatments 133

ELECTROCONVULSIVE THERAPY (ECT)

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

Depression or Patient will state and CONSIDERATIONS May be disoriented
schizophrenia that exhibit appropriate Monitor vitals before after treatment.
does not respond to mood and affect or a and after treatment. May lose short-term
other treatments. measurable Maintain safety after memory.
improvement in mood the treatment. Side effects last
and affect.
Premedicate if about 24 hours.
ordered.

Figure 8-14 Electroconvulsive therapy.

patient may have some muscle soreness. Reminding the patient to empty his or her
Patients are secured with restraints during the bladder and to remove dentures, contact
treatment, however, so movement is minimal. lenses, hairpins, and so on is also important.
Because of the possibility of confusion and Ensuring that the patient is kept safe after
forgetfulness, it is common to restrict the pa- therapy is also a major concern.
tient’s activity for 24 hours after a treatment,
and it is recommended that the nurse stay Humor Therapy
with the patient until the patient is oriented Many studies have been done over the years
and able to care for himself or herself. ECT showing the effects of smiles, hugs, and
is not used indiscriminately as it once was. laughter on mental health as well as physical
Today, it is used when other therapies have conditions such as cancer (Fig. 8-15). The
not been helpful, and it is usually reserved for movie Patch Adams, based on a real-life doc-
severe or long-term depression and certain tor, portrayed the potential of humor therapy.
types of schizophrenia. Viewers saw breakthroughs take place in pa-
The nurse’s responsibilities include careful tients previously thought untreatable.
monitoring of vital signs and accurate docu- Humor therapy uses many modalities,
mentation relating to the patient’s subjective from clowns to movies to just 10 good “belly
and objective response to the treatment. The laughs” daily. Whatever the medium, laughter
patient should have nothing by mouth alters outlooks and neurochemical produc-
(NPO) for at least 4 hours before a treatment. tion. Patients can show remarkable progress.

HUMOR THERAPY

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

All forms of mental Patients respond and CONSIDERATIONS Patient identifies how
health alterations and react to the humor. Assist in determining humor improves
physical conditions. Patients interact. appropriate patients. situations.
Patients may show Assist in humor Patient helps in
improvement in “application.” seeking out
physical condition. opportunities to apply
humor in his or her
life.

Figure 8-15 Humor therapy.

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134 UNIT 1 | Foundations for Mental Health Nursing

In fact, this kind of intervention has brought including mental health units and long-term
responses such as singing, hand clapping, and care facilities. Pet therapy benefits children,
laughter from dementia patients who do not adolescents and adults with therapeutic effects.
usually respond to other programming.
Neeb’s After reviewing the various modali-
Neeb’s The danger in humor therapy is that ■ Tip ties for treating mental health disor-
■ Tip what some people find funny, others ders: if you were using one of the
find offensive. Be sensitive to varied modalities, could you discuss it as
reactions. Remember some people easily as if you were talking about a
are fearful of clowns. vitamin?

Smiles are always appropriate. A brave Crisis Intervention

nurse wearing a red rubber nose when walk-
ing into the room of an appropriate patient PHASES OF CRISIS
might ease that person’s pain—either mental Although crisis is a highly individual situa-
or physical—even if only for a short while. tion, most experts agree that people experi-
Humor is important for nurses as well as for encing a crisis pass through the five phases
the patient, since caring for others on a daily described in Table 8-2.
basis can create unwarranted stresses. Crisis can happen at any time to anyone. It
can involve one’s child, next-door neighbor, or
Pet Therapy patient. Crisis is defined in several ways. In the
Pet therapy has been found to reduce stress in health fields, a crisis is a sudden, unexpected
patients. Unfortunately, not everyone can event in a person’s life that drastically changes
have a pet, due to finances, allergies, or living his or her routine. Crisis has been defined as a
arrangements. state in which the body is out of homeostasis.
The well-renowned Dr. Oz sees pet therapy It is thought of as a situation in which a person
as a stress reliever, especially for lack of social may “lose control of feelings and thoughts,
interaction, such as the loss of a significant thus experiencing an extreme state of emo-
other. Pets are not judgmental. According to the tional turmoil” (Shives and Isaacs, 2002).
National Institutes of Health (NIH), pet ther- A person in crisis is at risk for physical and
apy can be used in several health-care settings, emotional harm inflicted by self or by others.

l Table 8-2 The Five Phases of Crises

Phase Behaviors
Precrisis Person feels “fine.” Will often deny stress level and, in fact, state a feeling of
well-being.
Impact Person feels anxiety and confusion. May have trouble organizing personal life.
High stress level. Person will acknowledge feeling stress but may minimize
its severity.
Crisis Person denies problem is out of control. Withdraws or rationalizes behaviors
and stress. Uses defense mechanism of projection frequently. This may last
varied amounts of time.
Adaptive Crisis is perceived in a positive way. Anxiety decreases. Person attempts to
regain self-esteem and is able to start socializing again. Person is able to
do some positive problem solving.
Postcrisis Surprisingly, both positive and negative functioning may be seen. Person may
have developed a more positive, effective way of coping with stress or may
show ineffective adaptation, such as being critical, hostile, depressed, or may
use food or chemicals such as alcohol to deal with what has happened.
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CHAPTER 8 | Mental Health Treatments 135

Examples of people who may be experiencing at a different level than it would be from a law
a crisis are those who have lost a job suddenly enforcement or emergency dispatch viewpoint.
or were divorced recently, are in an abusive Since this text is meant to be an overview to
relationship, have experienced the death of a prepare nurses at an entry level of practice, we
loved one, or are contemplating or attempt- will look at the goals of crisis intervention from
ing suicide. An important concept to remem- a health-care perspective.
ber is that each person has a different set of
1. Ensure safety: Assess the situation. If the
stressors and a different way of dealing with
nurse or the patient is in physical danger,
stress. What is a crisis for one person may be
the nurse should signal for help. The nurse
simply a minor nuisance for another person.
should not leave the patient unless danger to
Many employers recognize the potential
the nurse is imminent. It may sound harsh,
for crisis and offer some type of employee as-
but the nurse will be no good to anyone if
sistance program (EAP). The service is confi-
he or she is hurt, or worse. The nurse must
dential, and usually the initial call is free to
take care of his or her own safety, and then
the employee. EAPs vary in what they are able
take care of the patient’s safety.
to provide and may act as a referral service for
2. Diffuse the situation: Nurses should do this
the employee. Nurses should ask the patient
verbally, when at all possible. A person in
if his or her employer provides this benefit.
crisis is most likely not in control of his or
her thoughts, feelings, or actions. Physical
GOALS OF CRISIS INTERVENTION attempts at restraining or calming are best
Nurses often have the unique opportunity of left until all verbal attempts have been
often being present for the first three phases of made, and only when there is enough help
the crisis and not for the outcome (Fig. 8-16). to do it safely for the patient and the staff.
In many agencies, nurses are not involved with 3. Determine the problem: The nurse should
longer term treatment, but they may very easily attempt to find out from the patient’s
be the ones who walk into the room during a viewpoint the cause of the crisis. It is
suicide attempt or who may take the call at the very important that the nurse not push
nursing station from a distraught parent who is the patient for any reason and remain
about to hurt his or her child. calm during the intervention. The last
The goals of crisis intervention change ac- thing a patient in crisis needs is a nurse
cording to the degree of treatment in which the in panic. There is time for nurses to
nurse will be involved. Crisis intervention for talk about their feelings when the
the health-care provider is obviously provided patient is safe.

CRISIS INTERVENTION

USES DESIRED OUTCOMES NURSING PATIENT TEACHING

For states of extreme Patient returns to CONSIDERATIONS Determine stressors.
emotional or physical pre-crisis (or higher) Assess for the level of Work with new coping
turmoil in which level of functioning. crisis patient is techniques.
patients feel out of experiencing. Access support
control of self or Assess suicide system before stress
situation. potential. reaches crisis.
Use verbal and
nonverbal
communication skills
to diffuse situation.

Figure 8-16 Crisis intervention.

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136 UNIT 1 | Foundations for Mental Health Nursing

4. Decrease the anxiety level: The nurse’s ■■■ Classroom Activity

adrenaline level will probably be at an • Look in your city’s telephone book for agencies
all-time high, but it won’t be even close that handle crisis intervention. Contact one in
to that of the person in crisis. The nurse person. Inform the agency that this is a school
should make every attempt to reassure project and you wish to ask them a few ques-
tions, such as: Whom does the agency service?
the patient that he or she is in a safe What are its hours of operation? How is the
place. The nurse should gently but firmly agency funded? What does the emergency care
tell the patient that he or she is con- cost the patient? Who is its staff? Write a short re-
cerned, wants to help, and will do what- port of your findings. If possible, appoint some-
ever is possible to make the situation one to compile all the information so that each
student nurse has a “starter set” to be able to
more comfortable but that the patient’s help others.
help and cooperation are needed. Caution:
Nurses must be very careful with physi-
cal contact at this point. Touch as a non- Crisis, if treated in an appropriate and
verbal communication skill may be timely way, is usually temporary. Crisis inter-
interpreted inaccurately as aggression or vention theories are changing to try to keep
sexual innuendo by a patient whose up with the current concepts of illness.
thoughts and feelings are in turmoil. Nevertheless, people will always be experienc-
5. Return the patient to pre-crisis (or better) ing crisis. When crisis happens, it is impor-
level of functioning: A nurse may or may tant that the person who is there to help
not be able to calm the patient to the understand that this is a very frightening
point that he or she is able to under- time for the person in turmoil. Nurses must
stand what just happened. It might understand that they are in a special position
take a longer-term session of treatment as they have some knowledge of crisis and
to help the patient gain that kind of communication skills and are able to help,
insight. No matter what level of inter- yet they must always be aware of the legal
vention the patient requires, the ulti- ramifications of intervention.
mate goal is for him or her to learn the
■ Terrorism
skills necessary to cope with stress in
a more positive way than before the
crisis. Much of that learning will come September 11, 2001, changed life in the
from the role modeling from the nurses. United States. Citizens of the United States
Quite often the most effective techniques became aware of a way of life experienced rou-
are nonverbal where actions speak louder tinely by some of the country’s global neigh-
than words. bors. Suicide bombers, anthrax, sarin gas, and
tainted water and food sources—American
■■■ Critical Thinking Question citizens suddenly had a new kind of connec-
With a student partner, role-play one or more of
the following potential crises (or think up your tion to those in other countries who have been
own). Think about your communication tech- falling victim to terror for generations. Reality
niques. Do they change when dealing with crisis? was attached to what many Americans knew
If so, how? What about your nonverbal communi- only from movies or the evening news. That
cation techniques? way of life, that behavior, is called terrorism.
• Parent whose child has been abducted at the
mall Terror, according to Webster Online (2013),
• Man who calls the clinic, stating he has just killed is “1: a state of intense fear; 2a: one that in-
his wife spires fear, b: a frightening aspect, c: a cause
• Woman who is frantically seeking shelter from an of anxiety, d: an appalling person or thing;
abusive relationship 3: violence (as bombing) committed by
• You find a friend of your adolescent daughter
slashing her wrists. groups in order to intimidate a population or
• Alcoholic, the main wage earner for the family, government into granting their demands.”
who has just been fired from his job Some words, such as fear and anxiety,
which are used to define terrorism are also
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CHAPTER 8 | Mental Health Treatments 137

symptoms of many mental illnesses. Perhaps Exactly what a nurse is able to do depends
the most frightening part of this definition is greatly on his or her locale, level of prepara-
that humans do not always know the source tion, state’s nurse practice act, and comfort
of the terror and thus are unable to defend level. Staying within the legal parameter of
themselves. They may feel a loss of personal one’s nursing licensure is of major impor-
control over their life and safety. It is difficult tance; nurses should do only what they know
for adults to accept and deal with what has and what is legal. The truth is that anyone can
become an ever-present possibility in what sue anyone for anything. The good news is
Americans had always assumed was a safe that most states will find in favor of the med-
place to live. How, then, do people help their ical professional who has, in good faith and
children to process the potential dangers in in accordance with his or her licensure, made
the world at the same time they are moving an effort to help a person in a crisis situation.
through the normal stages of growth and de- The Good Samaritan law protects nurses as
velopment? How can people convey the mes- well. The Good Samaritan law does not gen-
sage that while bad things happen, people are erally cover nurses within the confines of their
basically good and not to fear them? How do employment, however; only when acting to
adults, parents, teachers, and health-care assist in a crisis or emergency situation are
professionals prepare to help others who ex- nurses protected.
perience crisis, post-traumatic stress, depres-
sion, and other potential effects of terror?
Suggestions will be offered in various chapters Neeb’s Remember: Crisis intervention has
throughout this text; however, to borrow an ■ Tip something in common cardiopul-
monary resuscitation (CPR): Once a
idea from the sports world, the best defense
nurse starts and makes that com-
is a good offense. Nurses need to be ready for
mitment to help, he/she cannot quit
the possibility of patients experiencing some
until physically unable to continue.
effect of terrorism and must be willing to dis-
Starting to provide help and then
cuss the situation with that patient. As with
changing one’s mind can be inter-
so many other areas of nursing, it means
preted as neglect or abandonment,
nurses must take stock of their own thoughts
and in such an instance, the nurse
and feelings about the topic.
could be found at fault.

■ Legal Considerations
The Patient’s Perspective: What happens to
The Nurse's Perspective: Today’s society is a the patient experiencing the crisis? Because of
litigious one. It is easy to be tempted to stay the nature of crisis, the patient probably does
uninvolved when people call out for help. In not have a valid insight into the situation. The
some states, nurses, physicians, and anyone patient is very likely to be concerned about
else in the health fields are required by law to personal safety. On top of that, fear and in-
help. Some localities require health-care pro- ability to perceive the situation as it really is
fessionals to post identifying insignia on their will interfere with communication. In most
vehicles. Most states do not require this yet, instances, the medical staff will encourage the
but many are considering it. This puts nurses patient to accept some form of treatment. The
in a sensitive position. Nurses want to help, patient then has two choices: voluntary or in-
but nursing curriculum at the entry level pro- voluntary commitment.
vides very little in the way of hands-on crisis Voluntary treatment happens when the pa-
intervention techniques. What if something tient gives informed consent to be hospital-
goes wrong? Crisis intervention literature sug- ized or accept some formal treatment
gests that nurses risk a higher liability if they program. Informed consent means that the
fail to try to help. In other words, it is safer patient has been made aware of his or her be-
legally for a nurse to do something to help haviors, the implications of the behaviors, and
than to do nothing. expectations from the treatment. Informed
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138 UNIT 1 | Foundations for Mental Health Nursing

consent can be verbal, nonverbal, or written. Bill of Rights and most often the patient
Implied consent allows people who are uncon- keeps a copy of the rights.
scious to be treated in such a way as to pre- The Community Mental Health Centers
serve life. If the patient is an adult of legal age Act made provisions for community-based
who is considered to be competent in the eyes treatment. Communities develop centers and
of the law (or an adolescent who has acquired provide treatment according to the needs of the
legal emancipation), this patient can also sign area; not all centers provide all types of treat-
himself or herself out at any time. ment or 24-hour service. However, the com-
Involuntary commitment varies somewhat munity is supposed to provide some method of
from state to state. Many states have the emergency psychiatric treatment to help people
capability to place a “hold” on the patient, in crisis as well as those who are chronically
usually for 48 to 72 hours. During this time, mentally ill. These centers can be in the form
the patient is confined to the treatment set- of freestanding crisis centers or walk-in clinics,
ting. Usually, a social worker is assigned to and many are connected with the community
visit the patient and act as an advocate for hospital. In reality though, many communities
him or her. The goal of the hold period is for may have minimal resources to provide these
the patient to see the need for help with his services, so nurses should know what is avail-
or her crisis and then consent to voluntary able in their communities
treatment. If, at the end of the hold period,
the patient does not consent to treatment, ■ Summary
he or she is free to leave the facility, as long
as no other manifestation of crisis has sur- Table 8-3 summarizes treatment modalities
faced during the hold. that may be used alone or in conjunction
In either instance, patients maintain all with medications to treat a wide variety of
civil rights while in the treatment setting. mental health issues. The common uses and
The patient is covered under the Patient's desired outcomes are covered.

l Table 8-3 Summary of Commonly Used Treatment Modalities

Treatment
Modality Uses Desired Outcomes
Psychotherapy For treatment of various 1. Patient states improvement in
alterations to mental emotional discomfort.
health. 2. Patient returns to comfortable social
functioning.
3. Patient behaves in a manner
appropriate to the situation.
Behavior To remove or greatly di- Former undesirable behaviors have been
Modification minish behaviors that are replaced by new, healthy behaviors.
inappropriate or unhealthy.
Rational-Emotive Short-term, problem- Patient will be able to remain “undis-
Therapy (RET)/ focused therapy for any turbed” as a result of rethinking activating
Cognitive mental health alteration events, belief system, and consequences.
Behavior that is consciously
Therapy(CBT) controlled.
Person-Centered/ All aspects of patient care. Patient will feel accepted as a human,
Humanistic All forms of mental health which will allow patient to be self-aware
alterations. and self-accepting.
Patient will gain insight into the situation
and receive tools to make changes in his
or her life.
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CHAPTER 8 | Mental Health Treatments 139

l Table 8-3 Summary of Commonly Used Treatment Modalities—cont’d

Treatment
Modality Uses Desired Outcomes
Pastoral All forms of mental health Patient gains tools from a religious/
Counseling alterations. cultural background to be able to make
or Cultural changes in his or her life.
Counseling
Group Therapy Many uses, including Patient gains knowledge that there are
family, couples, self-help. others with similar problems.
Patient learns from peers and helps others.
Electro-Convulsive Depression or schizophre- Patient will state and exhibit appropriate
Therapy (ECT) nia that does not respond mood and affect or a measurable
to other treatments. improvement in mood and affect.
Humor Therapy All forms of mental health Patients respond and react to the humor.
alterations and physical Patients interact.
conditions. Patients may show improvement in
physical condition.
Crisis Intervention For states of extreme emo- Patient returns to precrisis (or higher)
tional or physical turmoil in level of functioning.
which patients feel out of
control of self or situation.

■■■ Key Concepts and type of illness. Counselors may be

licensed and the nurse’s role in counsel-
1. The place in which treatment is given ing regulated differently from state to
must be conducive to therapy. Milieu is state and municipality to municipality.
the word used to describe the environ- Counseling is given individually or
ment of the treatment area. in group settings, according to the
2. Psychopharmacology is very important situation.
to the effective treatment of the patient. 5. ECT is used for specific situations. Pre-
There are many classifications of psychoac- medication is usually ordered. It is the
tive medications and many individual role of the nurse to monitor vital signs,
medications within each classification. It is maintain safety, and document post-
the nurse’s responsibility to consult a drug treatment observations.
reference regarding all the psychotropic
medications they give their patients. It also 6. Crisis intervention is very individualized.
is part of the nurse’s role to reinforce teach- Crisis has five phases, and each person
ing about the medications to the patient. experiences them differently.

3. Psychotherapy, sometimes in conjunction 7. Employee support systems are becoming

with medications, is often used to treat more accessible through employers. They
patients. There are several methods of psy- are confidential and free or reasonably
chotherapy, including psychoanalysis, be- priced.
havior modification, rational-emotive 8. Pastoral or cultural counseling may be
therapy, and humanistic, or person- the treatment of choice for an individual.
centered, therapy. Nurses must do all they can to help the
4. Counseling is carried out in different patient receive care that is personally
ways, depending on the patient’s needs meaningful.
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140 UNIT 1 | Foundations for Mental Health Nursing

CASE STUDY
Andrea, an emergency room nurse from responders are directing Andrea and her
San Diego, is on vacation with her friend. friend away from the site. Andrea tells them
Andrea selected a road trip to a major theme she is a nurse and offers to help. At this
park. There are two adults and two children moment, her help is not wanted, but all are
in the vehicle. They are about minutes from directed to a “holding” area. The children,
the gate, Andrea sees smoke on the horizon. whose ages are 4 and 13 (Olivia and Trinity),
The radio in the vehicle alerts Andrea and are crying and asking Andrea questions
her friend that the theme park has just about the smoke. If you were Andrea, what
experienced an explosion. Details are would your emotional response be? How
sketchy, but there are numerous injuries. would you answer and calm the children?
The park has been closed. As Andrea and After a few minutes, the police accept
her friends approach what was the entrance Andrea’s offer to help the wounded. The
to the park, they witness many individuals children become hysterical at Andrea's leav-
running, injured, and crying. People are ing the vehicle, yet Andrea feels responsible
on fire and rolling. There is a very unpleas- to help. What should Andrea do? What
ant odor. Police, firefighters, and first stages of crisis is she experiencing?

REFERENCES Treatment. 6th ed. Philadelphia: Lippincott

Williams and Wilkins
CNN.com/Health. Report: Minorities lack
Shives, L.R., and Isaacs, A. (2002). Basic Concepts
proper mental health care. Dr. David Satcher,
of Psychiatric–Mental Health Nursing. 5th ed.
U.S. Surgeon General. August 27, 2001.
Philadelphia: JB Lippincott.
Deglin, J.F., Vallerand, A.H., and Sanoski, C.A.
Townsend, M.C. (2012). Essentials of Psychi-
(2011). Davis’s Drug Guide for Nurses. 12th ed.
atric and Mental Health Nursing. 7th ed.
Philadelphia: F.A. Davis.
Philadelphia: F.A. Davis.
Ellis, A. (1988). A Guide to Rational Living.
Venes, D. (2013). Taber’s Cyclopedic Medical
From the video series Thinking Allowed.
Dictionary. 22nd ed. Philadelphia: F.A. Davis.
Oakland, CA: InnerWork.
Webster Online. (2005). www.merriam-webster.
Meadows, M. (1997, September). Closing the
com
Gap: Mental Health and Minorities. Cultural
Considerations in Treating Asians. A Newslet-
ter of the Office of Minority Health. WEB SITES
Office of Minority Health. (2013). Accessed at
http://minorityhealth.hhs.gov Psychotherapies
www.nimh.nih.gov/health/topics/psychotherapies/
Oz, M.C., and Roizen, M.F. (2008). That Lovin’ index.shtml
Feeling. In You Being Beautiful: The Owner’s www.apa.org/helpcenter/understanding-psychotherapy.
Manual to Inner and Outer Beauty (p. 292). aspx
New York: Free Press. Pet Therapy
Sadock, B.J., and Sadock, V.A. (2008). Kaplan http://consensus.nih.gov/1987/1987HealthBenefits
and Sadock’s Concise Handbook of Clinical Petsta003html.htm
Psychiatry. Philadelphia. Lippincott Williams Psychotropic Medications
and Wilkins. www.nami.org/Template.cfm?Section=Policymakers_
Sadock, B.J., Sadock, V.A. (2013). Kaplan & Toolkit&Template=/ContentManagement/
Sadock’s Pocket Handbook of Psychiatric Drug HTMLDisplay.cfm&ContentID=18971
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CHAPTER 8 | Mental Health Treatments 141

Test Questions
Multiple Choice Questions
1. Which of the following is not a behavior 5. Psychopharmacology (psychotropic drug
noted in the crisis phase of crisis? therapy) is used:
a. Denial a. As a cure for mental illness
b. Feeling of well-being b. Only to control violent behavior
c. Use of projection c. To alter the pain receptors in the brain
d. Rationalization d. To decrease symptoms and facilitate
2. One of the first statements a nurse might other therapies
make to a person who has been abused 6. Avoiding such foods as bananas, cheese,
might be: and yogurt should be emphasized to
a. “Why didn’t you leave the first time patients who are taking:
you were attacked?” a. Prozac
b. “Do you want to prosecute or not?” b. Lithium
c. “What do you think made that person c. MAOIs
hit you?” d. Tricyclic antidepressants
d. “You’re safe here. I would like to 7. The goals of crisis intervention include
help you.” all of the following except:
3. A therapeutic environment (milieu) is a. Safety
best defined as: b. Increasing anxiety
a. An environment in which a patient c. Taking care of the precipitating
is under a 72-hour hold event
b. An environment that is locked and d. Return to pre-crisis or better level
supervised of functioning
c. An environment that is structured to 8. In order for psychotherapy to be
decrease stress and encourage learning effective, it is necessary to do all of
new behavior the following except:
d. An environment that is designed to a. Encourage the patient to repress
be homelike for persons who are feelings.
hospitalized for life b. Reinforce appropriate behavior.
4. Which of the following is false regarding c. Establish a therapeutic patient-staff
ECT? relationship.
a. It is used to treat depression and d. Assist patient to gain insight into
schizophrenia. problem.
b. It is used to stop convulsive seizures.
c. Fatigue and disorientation are immedi-
ate side effects.
d. Memory will gradually return.
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142 UNIT 1 | Foundations for Mental Health Nursing

Test Questions cont.

9. Your patient, Mrs. L, is on your unit 10. James is a 13-year-old who has been
for bowel resection. She is exhibiting transferred to your medical-surgical unit
signs of nervousness and anxiety, which after being stabilized in the ED. He slit
she attributes to the upcoming surgery. both wrists and took an overdose of his
You note from her record that she has Wellbutrin. You know medications such
a history of ethyl alcohol (ETOH) as Wellbutrin:
abuse. Which of the following classifica- a. Are antidepressants and should have
tions of drugs would be potentially ad- stopped his suicidal impulse
dictive for her? b. Have no particular nursing considera-
a. Lithium salts tions for children and adolescents
b. Antianxiety drugs c. Are antidepressants and may have an
c. Antipsychotic drugs increase in the suicidal ideation for
d. Anticholinergics children and adolescents
d. Are not effective as antidepressants for
children or adolescents
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C HA PT E R
9
Complementary
and Alternative
Treatment Modalities
Learning Objectives Key Terms
1. Differentiate between alternative and complementary • Alternative medicine
medicine. • Aromatherapy
2. Identify integrative medicine. • Beliefs
3. Identify the concept of the mind-body connection. • Biofeedback
4. Identify support for patient beliefs and models. • Complementary
5. Identify three alternative and complementary treatment medicine
modalities. • Holistic
6. Identify three types of massage. • Hypnotherapy
7. Differentiate between trance and sleep. • Integrative medicine
8. Identify the three primary channels of experience. • Mind-body connection
9. Define key terms. • Models
• Placebo
• Presupposition
• Rapport
• Reflexology
• Reiki
• Trance

M
edicine is a rapidly evolving field, additional options. In general, alternative
and sometimes it is tempting for practices/medicines replace those of conven-
the nurse to assume that every tional medicine, and complementary methods
patient is knowledgeable about the current are used together with traditional treatments.
state of the art. For some patients, conven- Many of these have been used for centuries.
tional Western medicine is not the only These present different choices to the phar-
course. Many factors affect a patient’s choice maceutical products dispensed at the local
of treatment modalities; education, experi- pharmacy. Often, these methods differ con-
ence, economic status, belief system, and siderably from what is acceptable medical care
culture are a few considerations. in Western culture. Complementary or alter-
There are many other means of treating ill- native methods may lack extensive scientific
ness and promoting good health in addition research to prove their effectiveness or even
to traditional medicine. Complementary their safety according to the standards of con-
and alternative medicine (CAM) presents ventional medicine. Those practices that do

143
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144 UNIT 1 | Foundations for Mental Health Nursing

have at least some research validating that based on beliefs, values, education, and expe-
they are safe and do work comprise integra- rience. Models are pictures or ideas that peo-
tive medicine, which provides the best ple form in their minds to explain how things
of both worlds. work. Models help people understand and
An alternative practice, for example, would interact with others and their environment,
be to use an herbal preparation to combat de- and they help people to formulate beliefs.
pression instead of physician-ordered prescrip- To a large extent, a person’s beliefs will de-
tion medication. A complementary treatment termine the success of a given treatment. This
might consist of using biofeedback to reduce can be plainly seen when a placebo medica-
the symptoms of anxiety associated with men- tion is given and is effective in relieving symp-
tal illness while the patient continues to par- toms like severe pain, even though the placebo
ticipate in psychotherapy and take antianxiety is no more than a sugar pill. This illustrates
medications. Both approaches address a key that what the patient believes and expects the
concept in alternative and complementary placebo to do can be more important than the
medicine: the mind-body connection. actual composition of the tablet.
Even though the nurse might not be
■ Mind, Body, and Belief directly involved in the application of a com-
plementary or alternative treatment, support-
The ways in which people’s minds and bodies ing the patient’s cultural and belief systems is
are interconnected stretch beyond the obvious an important role in helping him or her move
physical world in which people live. First, forward on a path to wellness. Each patient will
there is the brain, an organ directly connected have a different level of acceptance of various
to the body by tissue such as nerves and blood complementary and alternative approaches.
vessels. The brain is contained within the How nonjudgmental, open, and accepting of
bony cavity of the skull, which constitutes its different ideas for the success of the different
protection and support. The mind represents methods is up to the patient. The nurse can
the cognitive, emotional, and logical re- ease that process by also remaining nonjudg-
sponses that make people individual human mental, open, and accepting and at the same
beings. The mind is clearly more than just the time being aware of any safety concerns for the
brain, the sum of its cells, chemicals, electrical patient.
activity, and connections. As always, the boundaries of legal and
It may seem strange to think that there was acceptable nursing practice vary from state to
ever a question about the interconnectedness state. Nurses need to check with their state’s
of the mind and the body. It has long been board of nursing or other regulating agencies
known that disease affects the mind, but con- to determine acceptable standards of practice
ventional medicine has only recently started in regard to using alternative, integrative, and
to accept that the reverse is also true, that the complementary therapies.
mind affects the disease. People’s thoughts
and emotions affect the way their bodies ■ Common
function, even on a cellular level. This holistic Complementary and
view makes complementary and alternative
medicine increasingly popular choices for the Alternative Treatments
treatment of all types of illness, including
mental disorders. Biofeedback
Important to the effectiveness of any type Stress-related anxiety is the common element
of treatment are the patient’s beliefs. Nursing of disorders relating to mental illness. It is
requires respect for the beliefs and values of known that the direct effects of sustained stress
other people and cultures as fundamental to can be devastating (see Chapter 7, Coping and
good practice. It is useful to remember that Defense Mechanisms). In a critical moment or
everyone has a different way of viewing the progressively over time, the biological response
world. Everyone forms models of the world to stress can impair the cognitive function of
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CHAPTER 9 | Complementary and Alternative Treatment Modalities 145

the mind and cloud a person’s thinking. Pro- Biofeedback is being used with good
longed stress can lead to emotional anguish results for conditions including insomnia,
that is experienced as fear, anxiety, anger, and some types of seizures, functional nausea and
depression. Prolonged stress can also lead to vomiting, tinnitus, and phantom limb pain.
exhaustion and possible death. Anxiety con- As with other forms of therapy, biofeedback
tributes to physical symptoms—many of which practitioners must be aware of functional or
can be reduced or controlled by biofeedback even psychological symptoms that are actually
techniques. Biofeedback is a training program caused by organic problems and require dif-
designed to develop one’s ability to control the ferent treatment. It may not be appropriate
autonomic nervous system. While biofeedback to use biofeedback to treat extreme or acute
only recently has become a complementary states of mental illness, like severe depression,
medical therapy, it has been widely accepted mania, agitation, schizophrenia, paranoia,
by traditionalists in the West because of its use obsessive-compulsive disorder (OCD), delir-
of scientific measuring devices and proven ium, and identity or dissociative disorders.
techniques. Critics have pointed out that the major effects
The primary purpose of biofeedback train- from biofeedback can be more economical and
ing is to teach patients to recognize tension easily obtained through relaxation training.
within the body and to respond with relax- Patients with strong faith they can influ-
ation (Fig. 9-1). Typically, training for ence their own health are the most likely to
patients takes place in a series of one-hour ses- be successful at mastering biofeedback. The
sions, sometimes spaced a week apart. The experience of gaining control of one’s physical
patient is taught to obtain a deep level of reactions can have a tremendous effect on
relaxation as a means to control a light, how the person will view stressful situations
buzzer, image, or a video game, to which he in the future. As an educational tool for more
or she is attached by electrodes and cables. skeptical patients, learning biofeedback can
The machine is then gradually adjusted to demonstrate that they have a great deal more
greater sensitivity, and the patient learns control over their responses and symptoms
improved control. When training is com- than they first expected.
pleted, all that is needed to obtain relaxation
and symptom resolution at any time or place Aromatherapy
is recall of the particular thought and feeling Aromatherapy may well be one of the oldest
that worked in the clinic. methods used to treat illness in human
beings. Related to herbal therapy, aromather-
apy provides treatment by both the direct
pharmacological effects of aromatic plant sub-
stances and the indirect effects of certain
smells on mood and affect. Throughout
human history and in many cultures, there
are accounts of the use of aromatics to treat
varying forms of illness. Applied in salves or
ointments, used in incense, reduced to essential
oils for topical application, or even ingested,
these substances often appeal to patients who
are seeking a “natural” approach to healing
People’s response to the sense of smell has
strong significance in their lives. People asso-
ciate certain aromas with certain situations,
Figure 9-1 Biofeedback training teaches conditions, and emotional states. Many indi-
patients to recognize tension and respond viduals are able to relive particularly strong
with relaxation. (Courtesy of Santé Rehabilitation memories when exposed to an aroma that was
Group, Euless, TX) present when the remembered event occurred.
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146 UNIT 1 | Foundations for Mental Health Nursing

For example, the fragrance of baking cookies also perceived by the public to be better, or
or apple pie reminds some people of being at safer, because they can be purchased over the
home and even experiencing some of the emo- counter and do not require a trip to the doc-
tions connected to that memory. The ability tor’s office. There are literally hundreds of
for a particular smell to create positive alter- products available to consumers seeking relief
ations in mood makes aromatherapy attractive through herbal and nutritional means.
to many people and has created a large market
in everyday products designed to evoke calm Neeb’s Belief plays a considerable role in
and well-being. Scented candles and personal ■ Tip the acceptance and use of these
care products like bath oils, shampoos, and products.
body lotions are especially popular. With rapid changes in society since World
Treatment for anxiety-based mental illness War II has come people’s awareness that their
and depression using aromatics like lavender, lives are no longer as pastoral, calm, and idyl-
thyme, gardenia, and other botanicals is be- lic as they would like to remember them to
coming a more acceptable adjunct to conven- be. This awareness became more evident after
tional methods. It is important to be aware the events of September 11, 2001. In a world
that the oils and plant matter used in aro- full of processed food, the quality of modern
matherapy can be toxic if improperly admin- nutrition has come into question, and there
istered and should be kept out of the reach is growing conviction that artificial additives
of children and the cognitively impaired. lack the ability to provide the basics needed
Applied to skin, many plant oils are caustic for good health.
or can trigger an allergic reaction. The nurse Daily, people are assured in the popular
should observe and assess to determine if the press and the news media that the solution
products used are effective and if there are any to many of their problems can be found in
side effects noted. As with all alternative treat- nutritional and herbal supplements. Lack of
ment, it is advisable to find a competent and cortisol has been blamed for weight gain, and
knowledgeable practitioner to benefit fully taking compounds rich in HGH (human
from the potential of aromatherapy. growth hormone) has been credited with
reversing aging. Infomercials tout the benefits
■■■ Classroom Activity of taking coral calcium and even improving
• Bring several different aromatic herbs into class, sexual performance with herb-based prepara-
pass them around, and have each student sniff tions. The Internet is flooded with supple-
the plant or a form of the plant. Students should
discuss their immediate feelings after inhaling
ments that promise to improve people’s lives
the aromas. by making them healthier and stronger.
Some herbs have been researched and
proven in their effectiveness in treating disease
conditions. This should not be surprising, for
Herbal and Nutritional many modern medications were developed
Therapy from herbal and other botanical origins.
Growing steadily in the United States today Native Americans knew the value of the inner
is the use of herbal compounds and nutri- bark of the willow tree, gathered and used for
tional supplements to treat illness. The pop- its ability to reduce fever and ease pain. They
ularity of self-treatment with herbs is in large also used foxglove in their sweat lodges to
part due to the desire of many people to energize the frail and restore vitality to the
return to a simpler lifestyle and as a means to elderly. Little did they know that the salicylate
avoid costly prescription medications. Most in willow bark and digitalis in foxglove were
herbal products are considered nutritional the reasons for their effectiveness.
supplements rather than medications, so There is a tradition in Europe of using
these products avoid regulation by the Food herbal medications and nutritional supple-
and Drug Administration (FDA). They are ments to treat disease. For example, people in
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CHAPTER 9 | Complementary and Alternative Treatment Modalities 147

Germany routinely plant and harvest herbs in Massage, Energy, and Touch
their garden plots to create remedies for com-
Widespread among complementary and
mon ailments. Some herbal preparations are
alternative treatment methods are modalities
available there only by a doctor’s prescription,
centered on manipulating the body’s energy
and others can only be obtained through a
fields. Massage in one form or another has
licensed pharmacist. In the United States, the
probably been known to man since before the
use of fresh or garden-grown herbs is discour-
dawn of history. Touch and movement are es-
aged because of the difficulty in determining
sential to life and well-being in both physical
the strength of the active compounds pro-
and psychological ways. Massage is the
duced by plants under different growing con-
manipulation of the body using methodical
ditions. Europeans are guided by generations
pressure, friction, and kneading. People are
of experience and practice to safely use avail-
shaped, almost literally, by their childhood
able botanicals.
experiences of touching. An infant has limited
Unfortunately, the belief in the relative
sensory discrimination but will react posi-
safety of herbs is a misunderstanding that has
tively to being cuddled and held, and even to
caused much concern among health-care
the feel of a snugly wrapped blanket.
providers. Deciding on an appropriate dose is
difficult, because herbal preparations do not
Tool Box | Types of Massage Therapy
have to conform to any specific guidelines
www.massagetherapy.com/glossary/index .php
regulating strength or purity. People tend to
think that if a small amount of the product is
effective, more is better still. Some herbs are Massage has evolved into many variations
very toxic, particularly in pure form. Many as a result of its success (Fig. 9-2). Use of
herbs interact negatively with prescription touch is common to many different treatment
medications. This point demonstrates the approaches, but there can be great variation
need for the nurse to include direct questions in philosophical, theoretical, and practical
to the patient about the use of any CAMs. ideas about how touch is applied. Western
Nurses need to be able to teach their patients variations of massage include Swedish, which
the importance of consulting with a physician was developed in the early nineteenth century
before beginning any sort of herbal therapy. and is the type most people are familiar with.
Table 9-1 describes the five most often used It is characterized by long, smooth strokes
herbal medications and nutritional supple- that go toward the direction of the heart.
ments in the treatment of mental illness in The manipulation of specific body sites to
this country. relax muscle groups is known as trigger point
massage. Conventional medical science has
Neeb’s During the admission interview, generated a similar trigger point therapy in
■ Tip ask the patient if he or she is taking which injections of steroids are applied at
any alternative or complementary
these key areas in place of massage to both
products. Some of these may be
relax the muscle group and reduce local in-
contraindicated with medications
flammation.
ordered by the physician.
Of course, there are also other means of
massage available. Rolfing is a therapy de-
signed to realign the body with gravity
Tool Box | The National Institutes of Health
through fascial manipulation, a vigorous form
division called the National Center for Comple-
mentary and Alternative Medicine (NCCAM)
of bodywork that is finding increasing accept-
is an excellent resource for obtaining informa- ance. Eastern massage traditions have fol-
tion on a specific CAM, including scientific lowed a different path. It is widely believed
data if available. This is available at among Eastern practitioners that the body is
www.nccam.nih.gov/ governed by energy paths, called meridians.
This energy is perceived as the life force, or
148
l Table 9-1 Common Herbal and Dietary Therapies

Specific Active Usual Side Contra- Drug/Food Inter- Patient

Therapy Ingredients Dose Uses Effect Indications actions Teaching
Ginkgo Biloba Ginkgentin, 120–140 mg Short-term Bleeding, Pregnant May increase the ef- Do not use if on
Ginkolic acid PO daily, memory loss contact or breast- fects of anticoagulant Coumadin or
depending though research dermatitis, feeding, and antiplatelet drugs. aspirin.
on what is is conflicting as nausea, children; use Avoid foods contain- Works well for
treated; to benefits vomiting, cautiously ing large amounts of people over
divide into diarrhea, for patient tyramine: aged meat 50 as well as
2993_Ch09_143-156 14/01/14 5:20 PM Page 148

2–3 equal headache; taking anti- and cheese, red wine, younger adults.
doses rarely, coagulants, pickled herring, May take
subdural MAOI med- yogurt, raisins, sour 6–8 weeks to
hematoma, ications cream, and other experience
seizures because foods high in tyra- benefits.
(especially Ginkgo mine; also OTC cold Use with some
in children) Biloba can and flu preparations. fruits and nuts can
act as an cause a poison
MAOI ivy-like reaction.
Kava Kava Kavapyrones, 10–110 mg Antidepressant, Drowsiness, Pregnancy, Do not use with: Symptom relief
Piper methys- PO dried kava antianxiety, changes in breastfeeding Alcohol: increases risk may occur in as
ticum, Kava extract three antipsychotic, reflex and Skin yellow- of kava toxicity. little as 1 week.
pepper times daily, to use as sleep judgment, ing from Alprazolam: risk for Potential for
or freshly aide nausea, accumula- coma exists. significant ad-
prepared kava muscle tion of plant CNS depressants: kava verse reactions
beverages, weakness, pigment potentiates these. when using kava.
400–900 g blurred can occur in Levodopa: can in- Alcohol and CNS
weekly vision, chronic use. crease Parkinson-like medications are
decreased Liver disease symptoms. Phenobar- enhanced with
platelet bital: can increase kava.
counts, effects.
decreased
urea and
bilirubin
levels,
 dry skin, is a
dopamine
antagonist
St. John’s Wort Hypericum 300 mg PO Antidepressant Severe Pregnant or MAOIs, antidepres- Avoid prolonged
perforatum three times photosensi- breastfeed- sants, digoxin, birth exposure to
daily for 4–6 tivity, dry ing, children; control pills sunlight.
weeks mouth, use cau- May increase the
constipa- tiously for effects of MAOIs,
tion, GI patient OTC flu and cold
upset, sleep taking anti- medications,
distur- coagulants, alcohol; do not
2993_Ch09_143-156 14/01/14 5:20 PM Page 149

bances, MAOI use with

restlessness medication these types
of chemicals.
Omega 3 Fatty Alpha- 1–2 g PO Depression, Loose Use cau- May increase effects If taking anti-
Acids (Dietary linolenic acid daily for postpartum stools with tiously for of anticoagulants coagulant drugs
Supplement) (ALA), docosa- health, depression, higher patients or high doses of
hexaenoic cognitive bipolar doses; taking anti- aspirin, practice
acid (DHA), enhancement disorder, “fishy” reflux coagulants good safety. The
and eicosa- anxiety, oils may increase
pentaenoic dementia clotting time.
acid (EPA)
3:2 EPA to
DHA (fish oil)
Sam-E (Supple- s-adenosyl-L- See manufac- Depression Mild and Can cause Patients with
ment for methionine turer’s transient mania in bipolar disorder
Naturally specifications anxiety, patients with should not use
Produced and use as insomnia, bipolar except under
Body directed by a heartburn, disorder; supervision of
Substance physician loose rule out physician. Enteric
bowels before coated prepara-
beginning tions may reduce
treatment. gastric upset.
Source: Spidle, R.A. (2006). Alternative and Complementary Treatment Modalities. In Neeb, K. (2006). Fundamentals of Mental Health Nursing. Philadelphia, F.A. Davis, pp. 164–166.

149
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150 UNIT 1 | Foundations for Mental Health Nursing

Japanese form of acupressure that uses pres-

sure from the fingers to free energy flow.
Reflexology is also based upon the belief that
energy pathways and zones cross the body,
connecting vital organs and body parts
(Fig. 9-3). Reflexologists use massage of the
feet to act upon these pathways, unblocking
and renewing the energy flow.
Therapeutic touch also deserves mention.
Reiki is representative of methods of touch
healing that are often associated with mas-
sage. Reiki is a term that means “universal life
energy” and refers to the process whereby this
energy is drawn along the body’s meridians.
Unlike methods that use physical movement,
pressure, or massage to unblock these chan-
Figure 9-2 Massage can be an effective tool nels, Reiki uses the flow of life energy itself
for relieving tension. (Courtesy of everything- to accomplish the task. Practitioners are
jersey.com) “attuned” to the energy channels and can
manipulate them hands-on, hands just above
the body, or even at a distance. Reiki tech-
chi, ki, or prana. When the life force is niques can even be employed as part of a
obstructed, emotional and physical illnesses more traditional massage session to enhance
result. Various types of pressure, massage, and the physical benefits of the massage. Reiki has
other techniques are employed along these been demonstrated to increase warmth in the
meridians to release the flow of chi, restore areas being treated and also to produce relax-
balance, and improve health. Shiatsu is a ation in the subject.

Brain

Ear
Glands
Eye
Nose
Sinuses
Throat
Lungs
Shoulder Thalamus Shoulder

Diaphragm Heart
Liver Spleen
Gallbladder
Stomach
Kidneys Adrenal glands

Pancreas
Spine
Colon Colon
Bladder

Appendix Small intestine

Pelvis/buttock Pelvis

Sciatic nerve

Figure 9-3 Reflexology foot diagram.

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CHAPTER 9 | Complementary and Alternative Treatment Modalities 151

Hypnotherapy hypnosis. In some states a therapist must be

certified or licensed, but in others no one
Hypnotherapy is one of the most controver-
but a psychologist, psychiatrist, medical doc-
sial complementary and alternative modali-
tor, or other professional may practice the
ties. Hypnosis is a means for entering an
techniques.
altered state of consciousness, and in this
Milton H. Erickson, M.D. (1901–1980),
state, using visualization and suggestion to
was one of the best-known figures in the
bring about desired changes in behavior and
development of hypnosis for modern therapeu-
thinking. Called trance, people enter this
tic purposes. Dr. Erickson was a victim of polio,
state of focused attention every day. The Eng-
which left him partially paralyzed. He had little
lish language even contains references to this
strength in his arms and upper body and was
common experience of “zoning out.” Trance
confined to a wheelchair. As if that were not
is not sleep but rather describes a state of
enough, he was dyslexic, tone-deaf, color-blind,
mind wherein a person is less aware of what
and had heart problems. Left alone during long
is going on around him or her and instead is
periods of illness, Erickson became a master of
very focused on an internal experience, like a
observation and learned that subtle changes in
memory or an imagined event.
facial expression, skin color, nuance of voice,
Everyone responds to suggestion to some
and physical posture could tell him much about
extent. A person who is watching television
a person’s inner state.
and wants a snack after seeing commercials for
Dr. Erickson structured his therapeutic
a favorite fast-food restaurant has responded
approach to patients in a new way. He refused
to suggestion. Fortunately, people’s minds fil-
to allow his own past disabilities ruin his living
ter out suggestions that are unacceptably dan-
of life to its fullest and therefore refused to let
gerous so they are not persuaded to imitate
old problems get in the way of his patients’
some of the more unsafe things seen on TV.
enjoyment of living. Erickson ignored the past
Neeb’s A hypnotherapist uses suggestion, history of presenting patients, preferring
■ Tip both direct and indirect, to help the instead to focus on present and future out-
patient create change. comes. In one classic case, Erickson gave the
task of tending violets to a woman with depres-
The general public has been subjected to an sion. Combined with other therapeutic sugges-
enormous amount of misinformation about tions, she was kept too busy and involved in
hypnosis by stage hypnotists, movies, and her community to remain depressed.
books. As a result, hypnotherapy is widely Traditional hypnotherapy and psychother-
misunderstood and wrongly feared by many apy center on diagnosing problems and treat-
people. Watching a stage hypnotist appear to ing symptoms. Erickson promoted well-being,
make a volunteer cluck like a chicken or dance and study of his methods has challenged a
on a table certainly does not inspire confi- whole new generation of hypnotherapists to
dence in hypnosis as a therapeutic tool. It is do the same. Later, John Grinder and Richard
very hard for some people to overcome these Bandler would develop the field of neurolin-
fears, especially the stubborn belief in the guistic programming (NLP), based in large
myth that hypnosis is somehow “mind con- part upon their study of the extraordinary
trol” exercised for evil (or entertainment) pur- sensory acuity of Milton Erickson.
poses by the therapist.
Whereas some researchers and practition- Neurolinguistic Programming
ers contend that hypnosis cannot stand on Investigating the techniques and methods
its own as a treatment modality, others are of many successful therapists, Bandler and
equally convinced that even lay practitioners Grinder searched for ways to make psy-
can deliver effective therapy with a mini- chotherapy more consistently effective. It was
mum of training and practice. No doubt this through these explorations that they realized
controversy will continue, as there are at that language cues could be used to under-
present few regulations governing the use of stand how an individual experiences his or her
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152 UNIT 1 | Foundations for Mental Health Nursing

world. Using those cues, a practitioner can People observe their world through distinct
help patients change their experiences and re- channels of experience, tending to prefer one
spond to problems in a different way. Unlike channel over another, but eventually using them
traditional hypnosis, neurolinguistic pro- all for important cues and sensory information
gramming (NLP) does not use lengthy trance about their environment and other people.
sessions and instead depends upon patients to
take an active part in their treatment. When ■ PrimarySensory
John Grinder and Richard Bandler began de-
veloping NLP, they based this extraordinary
Representation
new type of therapy on a basic set of ideas, or The three primary methods of sensory repre-
presuppositions. sentation are the visual, auditory, and kines-
Presuppositions are the assumptions peo- thetic channels (seeing, hearing, and touching).
ple make when forming communication. Of course, people also use taste and smell to
They are most often not spoken or written, gather information, but these paths are rarely
but understood within the context of what is the most important channel, and they are gen-
being communicated. For example, if the erally ignored.
statement “I am so happy today!” is made, the Paying attention to speech patterns gives
presupposition, or unspoken assumption, is the practitioner a starting point for meaning-
that the speaker is not normally happy. Peo- ful communication with the patient. The
ple’s daily communications are filled with most obvious way to do this is to listen to the
such assumptions, things that they take for predicates a person uses while describing
granted. NLP differs from other therapies in thoughts and ideas. The practitioner can then
that there is no presupposition that the pa- determine positive rapport if the person
tient is somehow “broken” and requires “fix- favors sight, hearing, or touch and match
ing.” Instead, practitioners are taught that those predicates, using the same language pat-
patients are whole individuals who already terns to create a starting point for meaningful
possess the internal resources they need to re- communication. Recognizing these patterns
cover from their illness. All that is required is can help improve a nurse’s communication
to direct the patient to those resources and with patients. Table 9-2 illustrates types of
enable their use. word patterns people use.

l Table 9-2 Representational System Predicates

Visual (Seeing) Auditory (Hearing) Kinesthetic (Touch)
an eyeful clear as a bell all washed up
appears to me clearly expressed boils down to
beyond the shadow call on chip off the old block
of a doubt
bird’s-eye view describe in detail come to grips with
catch a glimpse of earful control yourself
clear cut express yourself cool, calm, collected
dim view give an account of firm foundations
eye to eye give me your ear get a handle on
get a perspective on grant an audience get in touch with
scope out heard voices hand in hand
hazy idea hidden message hang in there
horse of a different color hold your tongue hold on
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CHAPTER 9 | Complementary and Alternative Treatment Modalities 153

l Table 9-2 Representational System Predicates—cont’d

Visual (Seeing) Auditory (Hearing) Kinesthetic (Touch)
in light of idle talk hold it
in view of inquire into keep your shirt on
make a scene keynote speaker know how
mental image loud and clear lightheaded
mind’s eye manner of speaking moment of panic
naked eye pay attention to pain in the neck
paint a picture power of speech pull some strings
photographic
memory outspoken sharp as a tack
plainly seen rings a bell slipped my mind
pretty as a picture to tell the truth start from scratch
sight for sore eyes unheard of underhanded
under pressure

Of course, just about everyone uses all three to the message that is being sent. This is a
forms of predicates at one time or another. powerful tool in creating and maintaining
The most important thing to remember is to rapport, the foundation to a therapeutic
match the dominant, or most used, form. relationship.

EXAMPLES
■■■ Clinical Activity
(Visual) Interact with a patient to determine if the person
favors sight, hearing, or touch. Afterward, commu-
Mary: “I can’t picture myself getting any nicate with patient on his or her level. In post-
better.” conference, share with fellow students if this
Nurse: “In light of your progress, see your- enhanced your rapport with the patient.
self going back to school. How does
that look to you?”
(Auditory) ■ Summary
James: “I’ve heard that the doctor is tuned
in to the newest treatments.” Nursing practice is evolving and is incorpo-
Nurse: “He can describe those in detail to rating “alternative” or “complementary” ther-
you. I’ll tell him you want to hear apies into traditional care delivery systems
about them.” (Table 9-3). State boards of nursing can
determine at what level and scope of practice
(Kinesthetic) nurses should provide the alternative therapy.
Diane: “I couldn’t come to grips with the
situation. I was under too much pres-
sure all the time.” Tool Box | In 2003, the Minnesota Board of
Nurse: “It is hard to get in touch with what’s Nursing adopted guidelines and statements for
important when you feel that way.” appropriate use of complementary therapy in
Minnesota. Those guidelines can be found at
These exchanges demonstrate communica- http://mn.gov/health-licensing-boards/
tion on more than one level. By using the nursing/licensees/practice/integrative-
same language used by the patient, the nurse therapies.
can establish that she or he is listening closely
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154 UNIT 1 | Foundations for Mental Health Nursing

l Table 9-3 Alternative Therapies

and Lifestyle

Alternative
Mind-Body
Experience

Nutritional

Hands -on

Therapy
Therapy

Therapy
Herbal
Disorder
Anxiety √ √ √ √ √
Arthritis √ √ √ √ √
Asthma √ √ √ √ √
Cancer √ √ √ √
Prevention
and Treatment
Congestive √ √ √ √ √
Heart Failure
Coronary Heart √ √ √ √
Disease
Depression √ √ √ √ √
Diabetes √ √ √ √ √
GERD √ √ √ √ √
Gastrointestinal √ √ √ √ √
Problems
Migraine √ √ √ √ √
Headache
Tension √ √ √ √ √
Headache
Hepatitis √ √ √ √ √
Hypercholes- √ √ √ √ √
terolemia
Hypertension √ √ √ √ √
Irritable Bowel √ √ √ √ √
Syndrome
Musculoskeletal √ √ √ √ √
Problems
Upper √ √ √ √ √
Respiratory
Infection
Urinary Tract √ √ √ √ √
Infection
Source: Adapted from Complementary and alternative medicine. (2009). In D. Venes (Ed.), Taber’s cyclopedic medical dictionary (21st ed.,
pp. 2540–2552). Philadelphia, F.A. Davis.
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CHAPTER 9 | Complementary and Alternative Treatment Modalities 155

■■■ Key Concepts 9. Hypnotherapy and neurolinguistic

programming are two prominent
1. Alternative and complementary treat- modalities that address mental and bod-
ments provide options for patients other ily illness by empowering change in the
than those offered by conventional patient’s thought patterns. Both tightly
(Western) medicine. Alternative modali- focus on communication patterns and
ties are used instead of, and complemen- the patient-therapist relationship.
tary are used in addition to, conventional
practices.
REFERENCES
2. The mind-body connection is an impor-
tant concept in all types of medical treat- Complementary and alternative medicine.
ment. Disease and wellness affect the (2009). In D. Venes (Ed.), Taber’s Cyclopedic
whole person. Holistic treatments ad- Medical Dictionary. 21st ed., pp. 2540–2552.
Philadelphia: F.A. Davis.
dress both the illness and the person. F.Y.I.—A Publication of the Minnesota Board of
3. An individual has beliefs, based upon his Nursing (2003). Complementary therapies.
or her model of the world. These beliefs Spring/Summer 2003, 19(1), 7.
must be respected by the nurse. National Center for Complementary and Alterna-
tive Medicine. Available at http://nccam.nih.gov
4. Anxiety is common to disorders relating Skidmore-Roth, L. (2010). Mosby’s Handbook
to mental illness. Prolonged stress and of Herbs and National Supplements. 4th ed.
anxiety lead to physical as well as mental St. Louis: Mosby-Elsevier.
and emotional afflictions.
5. Biofeedback is a technique that teaches WEB SITES
the patient to recognize and control Biofeedback
stress responses in the body. It is widely Association for Applied Psychophysiology and
accepted because of its use of scientific Biofeedback: www.aapb.org
measuring devices to demonstrate the Biofeedback Certification Institute of America:
effectiveness of the treatment. www.bcio.org
Mind Body Connection
6. Aromatherapy uses a person’s emotional http://familydoctor.org/familydoctor/en/
response to smell as well as the pharma- prevention-wellness/emotional-wellbeing/
cological effects of various fragrant botan- mental-health/mind-body-connection-how-
your-emotions-affect-your-health.html
ical and other substances to treat illness.
Aromatherapy
7. Herbal and nutritional therapies are be- National Association for Holistic Aromatherapy:
coming more prevalent as the public em- www.naha.org
braces “natural” healing. Many modern Massage
American Massage Therapy Association:
medications have evolved from unculti- www.amtamassage.org
vated botanical products. Relative safety Reflexology
and effectiveness is still in question, as Association of Reflexologists: www.reflexology.org
the industry is largely unregulated, with International Institute of Reflexology:
no set standards for these products. www.reflexology-usa.net
Reiki
8. Other types of alternative and comple- www.holistic-online.com/Reiki/hoI_Reiki_home.htm
mentary therapy focus on manipulation, Milton Erickson
strengthening, and removing blockage Milton Erickson Foundation:
from the free flow of energy in the www.erickson-foundation.org
human body. Massage and therapeutic Neurolinguistic Programming
touch modalities are successful groups www.holistic-online.com/hol_neurolinguistic.htm
of both stand-alone and adjunctive National Center for Complementary and
treatment for disease. Alternative Medicine
http://nccam.nih.gov
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156 UNIT 1 | Foundations for Mental Health Nursing

Test Questions
Multiple Choice Questions
1. Alternative therapy modalities are used: 6. Of the following, which are either com-
a. Infrequently, as they have no value to plementary or alternative modalities?
patients today a. ECT, Reiki, rolfing
b. In combination with conventional b. Hypnotherapy, shiatsu, antianxiety
therapies medications
c. In place of conventional therapies c. NLP, psychotherapy, SAM-e
d. Only when there is no hope for d. Aromatherapy, biofeedback, massage
recovery 7. Mr. Douglas wants to know more about
2. A treatment modality used with massage therapy. Which one of the
conventional medical therapies is: following is not a massage modality?
a. A medical approach a. Reiki
b. A model approach b. Trigger point
c. A holistic approach c. Rolfing
d. A complementary approach d. Swedish
3. When traditional medicine is combined 8. Which of the following is false about
with less traditional methods, it is: trance?
a. Integrative medicine a. It is an altered state of consciousness,
b. Exclusive medicine just like sleep.
c. Based on the physician’s opinions b. Humans move in and out of trance
d. Biofeedback states during the day.
4. The mechanism that describes thought c. It is a state of relaxed awareness.
and expectation affecting health is: d. Trance is a common experience even
a. A complementary therapy if you are not aware of it.
b. A misconception that is dangerous to 9. Which of the following statements
the patient indicates a visual channel preference
c. An integrated therapy for information?
d. The mind-body connection a. “That really feels good! My gut feeling
5. Mrs. Lucas is telling you about her ideas is that it will work!”
for curing her depression by taking herbal b. “It sounds good to me; this idea is
medication. She is convinced that because worth paying attention to.”
St. John’s wort is a natural product, it c. “I can see the solution, and clearly
is better for her than her prescription it will work.”
therapy. You should: d. “I smell a rat. I think the whole thing
a. Quickly get the drug handbook and stinks.”
show her she is wrong. 10. Which of the following should be
b. Remain open and supportive. avoided when communicating with a
c. Point out to her that herbal therapy is mentally ill patient?
contraindicated. a. Having an expectation that the patient
d. Suggest some available brands for her will get better
to use. b. Making the presupposition that the
patient will not improve
c. Taking the time to convey respect for
the patient
d. Demonstrating through your expres-
sion and posture that you are listening
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UNIT 2
Threats to Mental
Health
2993_Ch10_157-180 14/01/14 5:21 PM Page 158
2993_Ch10_157-180 14/01/14 5:21 PM Page 159

C HA PT E R 10
Anxiety, Anxiety-Related,
and Somatic Symptom
Disorders
Learning Objectives Key Terms
1. Define anxiety disorders. • Anxiety
2. Identify the changes in DSM-5 and how they relate to current • Compulsion
anxiety disorders • Conversion
3. Identify the new classified anxiety disorders. • Dysmorphophobia
4. State physical and behavioral symptoms of anxiety disorders. • Eustress
5. Identify treatment modalities for anxiety disorders. • Free-floating anxiety
6. Identify nursing interventions in anxiety disorders. • Generalized anxiety
7. Define the difference in diagnosing somatic symptom disorders
disorder and diagnosing somatic symptoms • Hypochondriasis
8. Identify medical treatments for people with somatic • “La belle indifference”
symptoms and related disorders. • Malingering
9. Identify nursing interventions for people with somatic • Obsession
symptoms and related disorders. • Obsessive-compulsive
disorder (OCD)
• Panic disorder
• Phobia
• Post-traumatic stress
disorder
• Primary gain
• Secondary gain
• Signal anxiety
• Somatization
• Somatoform disorder
• Somatoform pain
disorder
• Stress
• Stressor
• Survivor guilt

159
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160 UNIT 2 | Threats to Mental Health

■ Anxiety Disorders
Stress produces anxiety. Stress is everywhere in
today’s society. Most often, stress is associated
with negative situations, but the good things
that happen to people, such as weddings and
job promotions, also produce stress. This stress
from positive experiences, such as becoming
newly married, promoted at work, or some-
thing similar, is called eustress. It can produce
just as much anxiety as the negative stressors.
A stressor is any person or situation that pro-
duces anxiety responses. Stress and stressors are
different for each person; therefore, it is impor-
tant that the nurse ask what the stress produc-
ers are for that patient. What is extremely
stressful for one person (driving in rush hour
traffic, for example) might be relaxing to some-
one else (go with the traffic flow and relax after
a busy day). Figure 10-1 Anxiety ranges in severity from mild
Anxiety can be described as an uncomfort- through panic. “The Scream,” a famous painting
able feeling of dread that is a response to ex- by Norwegian artist Edvard Munch, depicts a
treme or prolonged periods of stress. According person in a very high state of anxiety.
to Gorman and Sultan (2008), anxiety is an
unpleasant feeling of tension, apprehension,
and uneasiness or a diffuse feeling of dread or response to a known stressor (e.g., “Finals are
unexplained discomfort. only a week away and I’ve got that nagging nau-
The four commonly accepted levels of sea again.”). Both types of anxiety are involved
anxiety are: in the various anxiety disorders.
Nurses working with children and teenagers
• Mild
must be aware that they also experience anxiety
• Moderate
and stress. They may not be able to verbalize
• Severe
their feelings, and they may display symptoms
• Panic
differently than adults do. Some indicators of
Hildegard Peplau teaches that a mild amount stress and anxiety in these age groups include
of anxiety is a normal part of being human and decline in school performance, changes in eat-
that it is necessary to change and develop new ing habits and sleeping patterns, and with-
ways of coping with stress (Fig. 10-1). drawal from friends and usual activities. Nurses
Anxiety may also be influenced by one’s can be instrumental in screening children and
culture. It may be acceptable for some people adolescents for signs of anxiety.
to acknowledge and discuss stress, but others The Diagnostic & Statistical Manual, 5th
may believe that one should keep personal edition (DSM-5, 2013) has made a number
problems to oneself. This can be a challenge of revisions to anxiety disorders from the
to the nurse during an assessment. 4th edition known as DSM-IV-TR (2000).
Anxiety is usually referred to in one of two These will be noted in this chapter. In
ways: free-floating anxiety and signal anxiety. DSM-5, some disorders that were previously
Free-floating anxiety is described as a feeling of listed as anxiety disorders, including post-
impending doom. The person might say some- traumatic stress disorder and obsessive com-
thing like “I just know something bad is going pulsive disorder, have now been listed under
to happen if I go on vacation,” without knowing new categories. In this text these will be
when or where the event might occur. Signal discussed in the section “Types of Anxiety and
anxiety, on the other hand, is an uncomfortable Anxiety-Related Disorders” in this chapter.
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 161

■ Etiology of Anxiety they placed the participants into individual,

private hotel rooms. Several days later, they
and Stress tested the individuals for symptoms. People
who had described themselves as happier, con-
Psychoanalytic theory says that there is a con-
tented types of personalities demonstrated
flict between the id and the superego, which
cold/flu symptoms only one third as often as
causes anxiety. At some time in the individual’s
the individuals who did not use those kinds of
development, this conflict was repressed but
words to describe themselves and their stress
emerged again in adulthood. When conflict
level. This is one study. Experts do not know all
emerges, patients realize they have “failed,” and
of the variables, but it does make a fairly strong
the manifestations of anxiety are once again felt.
argument for a positive correlation between
Biologically the basic stress response is called
emotional stress and physical illness.
the fight-or-flight response and contributes to
The LPN/LVN will frequently encounter
feelings of anxiety. In this response to stress the
stress in medical-surgical patients. Physical and
blood vessels constrict because epinephrine and
emotional symptoms can interrelate. It is im-
norepinephrine have been released. Blood pres-
portant for nurses to recognize the relationship
sure rises. If the body adapts to the stress, hor-
between physical and emotional responses to
mone levels adjust to compensate for the
stress. Nurses can be instrumental in gaining
epinephrine-norepinephrine release, and the
accurate planning and interventions for their
body functions return to homeostasis. If
patients by providing accurate assessment and
the body does not adapt to the stress, there are
documentation of the patient’s symptoms as his
many long-term health problems that can be
or her body adapts to stress. Table 10-1 gives
created including lowered immunity, heart dis-
examples of medical conditions and the effects
ease, and many other conditions (Fig. 10-2).
of the body’s adaptation response to stress.
Studies are continually being conducted try-
ing to correlate the condition of stress to phys-
ical illness. In 2002, researchers at Carnegie ■ Differential Diagnosis
Mellon University in Pittsburgh (Cohen, 2003)
studied 334 paid individuals. They introduced Differentiating normal anxiety from an anxiety
a rhinovirus into the participants’ noses. Then disorder can be challenging. Because so many
symptoms are associated with anxiety disorders,
it is important for people to have a complete
• “Fight or flight” physical workup before being checked for these
• Blood vessels constrict disorders. The symptoms of anxiety disorders
CRISIS • Norepinephrine and are listed with each of the specific disorders (see
epinephrine released and section “Types of Anxiety Disorders”). Symp-
blood pressure rises
toms of anxiety disorders can mimic those seen
in diabetes, cardiac problems, medication side
• Hormone levels adjust effects, electrolyte imbalances, or physical
ADAPTATION • Body functions return trauma. The physician must rule out a systemic
to homeostasis infection or an allergy that might be related to
chills or swallowing difficulty. Hot flashes,
OR which can occur in some anxiety states, could
be related to a fever or to menopause. The
• Immune system becomes
challenged physician must always consider the possibility
• Lymph nodes increase of drug or alcohol abuse as partial causes for the
EXHAUSTION in size symptoms. Certainly, more than one condition
• Potential for cardiac and can occur simultaneously. A psychiatric evalu-
renal failure ation is often needed to confirm a diagnosis of
• Death may occur an anxiety disorder.
Common symptoms of anxiety can be
Figure 10-2 General Adaptation Syndrome present in many other conditions. It is easy to
(GAS) model of stress. see how mistakes in diagnosing can happen.
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162 UNIT 2 | Threats to Mental Health

l Table 10-1 Adaptation Responses to Stress and the Outcome of Stress

on the Body
Stress-Related Body’s Adaptation Outcome of Stress
Medical Condition to the Stress on the Body
Lowered Immunity Interferes with effectiveness of Increased susceptibility to colds,
the body’s antibodies; possibly viruses, and other illnesses
related to interactions among
the hypothalamus, pituitary
gland, adrenal glands, and the
immune system.
Burnout Associated with stress-related Emotional detachment
depression.
Migraine, Cluster, and Tightening skeletal muscles, Nausea, vomiting, tight feeling in
Tension Headaches dilating of cranial artery. or around head and shoulders,
tinnitus, inability to tolerate light,
weakness of a limb
Hypertension Role of stress is not positively Resistance to blood flow
known but is thought to con- through the cardiovascular
tribute to hypertension by nega- system, causing pressure on the
tively interacting with the arteries; can lead to stroke, heart
kidneys and endocrine system. attack, and kidney failure.
Coronary Artery Stressor increases the amount of Constricted coronary vessels, in-
Disease epinephrine and norepinephrine. creased pulse and respirations
Cancer Same mechanisms that lower Lowered immunity may allow for
immunity. overcolonization of opportunis-
tic cancer cells.
Asthma Automatic nervous system stim- Wheezing, coughing, dyspnea,
ulates mucus, increases blood apprehension; may lead to respi-
flow, and constricts bronchial ratory infections, respiratory fail-
tubes; may be associated with ure, and/or pneumothorax.
other stress-related conditions
such as allergy and viral infection.

Symptoms of anxiety may include: Formerly found with anxiety was Obsessive-
Compulsive Disorder (OCD) and Post-
• Muscle aches Traumatic Stress Disorder (PTSD). In this
• Shakes chapter, revisions from DSM-IV-TR will be
• Palpitations mentioned periodically as a comparison.
• Dry mouth
• Nausea ■ Types of Anxiety and
• Vomiting
• Diarrhea Anxiety-Related
• Hot flashes Disorders
• Chills
• Polyuria Generalized Anxiety
• Insomnia Disorder (GAD)
• Difficulty swallowing
In generalized anxiety disorder, the anxiety
DSM-5 has made changes in some disor- (also referred to as “excessive worry” or “severe
ders that were once categorized under anxiety. stress”) itself is the expressed symptom. It is
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 163

diagnosed when excessive worry is related Neeb’s Panic symptoms can develop sud-
to two or more things and lasts 6 months ■ Tip denly and unexpectedly in the sus-
or longer. ceptible person. People with history
Patients who have GAD may display any of panic disorder need to be pre-
number of symptoms. The DSM-IV-TR lists pared to identify early signs in the
18 symptoms of anxiety, and the patient must hope that they can gain some con-
show six or more in order to be considered to trol before the symptoms are out of
have GAD. DSM-5 has reduced the symp- control.
toms to include at least 3 of the following:
• Restlessness
• Easily fatigued Phobia
• Difficulty concentrating or mind going This is the most common of the anxiety disor-
blank ders. Phobia is defined as an “irrational fear.”
• Irritability The person is very aware of the fear and even of
• Muscle tension the fact that it is irrational, but the fear contin-
• Sleep disturbances ues. People develop phobias to many different
These symptoms become pervasive as the things—approximately 700 different things, in
person is unable to control the worry and fact (Box 10-1). Snakes, spiders, enclosed spaces,
other symptoms. All aspects of life become in- and the number 13 are some of the more com-
volved. This disorder can be debilitating. mon phobias (Fig. 10-3). People also develop
phobias of things such as caring for their chil-
dren (because they might hurt them) and eating
Neeb’s Generalized anxiety disorder can be in places other than their own home.
■ Tip paralyzing and impact all areas of a The psychoanalytic view of phobias that
person’s life. the fear is not necessarily from the object itself
but rather a displaced, unconscious fear that
Panic Disorder is displaced on the object/event such as a
Panic disorder is a recurrent condition that is a snake or height. Learning theory views pho-
state of extreme fear that cannot be controlled. bias as learned responses. When the person
It is an abrupt surge of intense fear or discom- avoids the phobic object, fears is escaped and
fort that reaches a peak in a short period of that is a powerful reward. Most phobias start
time. It can lead to intense fear and worry about in childhood but people can develop them
it happening again. It is also referred to as later in life. In older people it is common is
“panic attack,” and people may not consider it see fear of falling or choking.
to be a serious disorder initially. In the past,
panic disorder was linked to agoraphobia.
DSM-5 now has them as two separate disorders.
Some traits of panic disorder include: l Box 10-1 Some Common Specific
Phobias
• Fear (usually of dying, losing control of
oneself, or of “going crazy”) Acrophobia: Fear of height
• Dissociation (a feeling that it is happening Ailurophobia: Fear of cats
to someone else or not happening at all) Carcinomatophobia: Fear of cancer
Decidophobia: Fear of making decisions
• Nausea Nyctophobia: Fear of darkness
• Diaphoresis Odontophobia: Fear of teeth or dental
• Chest pain surgery
• Increased pulse Scoleciphobia: Fear of worms
• Shaking Thanatophobia: Fear of death
• Unsteadiness
Source: Adapted from Townsend (2012). Essentials of Psychiatric
• Feelings of being suffocated or unable to Mental Health Nursing, 7th ed. Philadelphia: F.A. Davis Company,
catch one’s breath with permission.
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164 UNIT 2 | Threats to Mental Health

Social phobias are those in which people

avoid social situations as a result of fear of
humiliation or being judged negatively. This
reaction is out of proportion to the situation.
There are correlations between people with
this type of phobia and self-medicating with
alcohol and/or drugs.
EXAMPLE
Social phobias: The fear of speaking in pub-
lic and the fear of using public facili-
ties such as bathrooms or laundromats
are examples of social phobias.
A
Specific phobias include having an irra-
tional fear of a specific object or situation.
These are the classic phobias that most people
are familiar with.
EXAMPLE
Specific phobias: Claustrophobia (fear of
enclosed places), hematophobia (fear of
blood), and acrophobia (fear of heights).

Tool Box | For a comprehensive list of

phobias go to
B http://phobialist.com/# A-

Figure 10-3 A, Fear of snakes (ophidiophobia),

and B, fear of spiders (arachnophobia), are two ■■■ Clinical Activity
of the most common phobias. (Courtesy of the When your hospitalized patient has a phobia
University of Texas Libraries, The University of Texas such as agoraphobia, anticipation of the patient’s
at Austin.) reaction to leaving his/her room for testing
must be addressed with the patient to prevent
distress.
It is not uncommon for more than one
phobia to develop in a person. They most
often begin in childhood, perhaps repeated Obsessive-Compulsive
into a traumatic event.
Phobias have three subcategories: agora-
Disorder
phobia, social phobia, and specific phobias. Obsessive-compulsive disorder (OCD) is
Agoraphobia is the irrational fear of reoccurring thoughts, ideas, and actions
being in open spaces and being unable to that interfere with a person’s daily ability to
leave or being very embarrassed if leaving function. DSM-5 no longer categorizes
is required. OCD as an anxiety disorder but puts it in
its own category. This disorder is now be-
EXAMPLE lieved to be a neurological short circuit that
Agoraphobia: People who fear shopping causes repetitive behaviors. A genetic link
in large malls or who fear going to among families who display OCD has also
sporting events may actually fear the been suggested. OCD is different than
possibility of being unable to escape obsessive compulsive personality disorder.
in the event of an accident. See Chapter 14.
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 165

OCD has two components: the obses- ■■■ Critical Thinking Question
sion (repetitive thought, urge, or emotion) Tommy has come to your clinic with numerous
and the compulsion (repetitive act that cracks on his hands, which are bleeding and very
may appear purposeful). It is not uncom- sore. Tommy tells you that he just has to wash his
mon for people to be double and triple hands all the time. His mother says he will wash
for 2 to 3 hours at a time, and he will not stop
checking that doors are locked before one when she tells him to. The physician has diag-
is able to sleep or leave the house. When nosed Tommy with OCD and has explained the
these obsessive thoughts and compulsive illness to Tommy and his mother. When the physi-
actions begin to prevent a person from cian leaves the room, Tommy’s mother begins to
sleeping or leaving the house, it becomes cry: “What did he just say? What am I supposed
to do? What did I do wrong that Tommy got this
OCD. The person with this kind of disor- illness?” What will you tell her? What areas will you
der is unable to stop the thought or the explore with her?
action. Behaviors become very ritualistic
(Fig. 10-4).
Behaviors in patients with OCD vary.
Some people wash their hands unceasingly. ■■■ Classroom Activity
Others have a strict ritual that, if interrupted, • See the movie As Good as It Gets for a depiction
of OCD.
requires starting over from the beginning.
Some people have to check something or
clean something over and over. People with
this disorder tend to be perfectionistic and ■■■ Clinical Activity
very rule-oriented. When caring for a patient with OCD, identify what
Physical symptoms also vary. If the person the staff has been doing to accommodate the
patient’s obsessions and compulsions.
is prevented from performing the obsession
or compulsion, the anxiety converts itself into
somatic (body-related) symptoms.
A related disorder to OCD is hoarding dis- Post-Traumatic Stress
order. This is a new disorder in DSM-5. Disorder
Hoarding disorder is severe distress caused by Post-traumatic stress disorder (PTSD) is
persistent difficulties discarding or parting developed in response to an unexpected
with possessions. emotional or physical trauma that could not
be controlled. A victim of PTSD will prob-
ably have reoccurring, intrusive, disturbing
memories of the incident that may last over
a period of time. This disorder was once
viewed as an anxiety problem in DSM-IV-TR,
but the current view is that it belongs in a
new category—Trauma and Stress or Related
Disorders (DSM-5, 2013). So now it is
viewed less as an anxiety problem and more
related to the physical and emotional re-
sponses to a trauma. One reason for this
change is the increasing recognition that
people suffering from PTSD often are more
Figure 10-4 Compulsive behaviors include
troubled with pervasive sadness, aggressive
refusing to step on a crack in the sidewalk. behaviors, and dissociative symptoms such
The behavior is very ritualistic, and perform- as flashbacks than anxiety symptoms. Young
ing the action reduces the person’s anxiety. children can also suffer from PTSD.
(Courtesy of the National Institute of Mental Health, People who have fought in wars, who have
Bethesda, MD.) been raped, or who have survived violent
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166 UNIT 2 | Threats to Mental Health

storms or other actual or threatened traumatic PTSD symptoms may appear immediately
events are examples of those who are suscep- or be repressed until years later. Symptoms of
tible to suffering from this disorder. Police, PTSD can include:
fire, and rescue personnel are at risk for PTSD
• “Flashbacks,” in which the person may
when they see victims of violence and de-
relive and act out the traumatic event
struction whom they cannot help. The assault
• Social withdrawal
on the United States during the attacks on the
• Nightmares
World Trade Center towers, the Pentagon,
• Insomnia
and the passengers and crew on the ill-fated
• Feelings of low self-esteem as a result of
flight in Pennsylvania on September 11,
the event
2001, has brought new attention to the con-
• Changes in the relationship with a signifi-
dition of post-traumatic stress disorder. The
cant other and difficulty forming new
horror of witnessing tragedy such as this now
relationships
reaches anyone with a television or Internet;
• Irritability and outbursts of anger toward
such a person can also suffer from PTSD.
another person or situation, apparently
People in countries far away are able to expe-
for no obvious reason
rience tragedy in “real time.” Certainly those
• Depression
citizens who were on the scene and attempt-
• Distress when thinking about the event
ing to save lives, saw destruction the likes of
• Making efforts to avoid reminders of
which most of us, hopefully, will never expe-
the event
rience directly. They and their families will
deal with the post-traumatic effects of that Self-medicating with alcohol and other
day for some time to come. substances to treat the discomfort is a concern
with many patients. The evaluation process
should include a substance abuse assessment
■■■ Critical Thinking Question and treatment if needed.
Think for a moment where you and your family
members were on September 11, 2001. Think Trust and communication and listening
about the things you felt and shared with each skills are very important tools for nurses who
other at that time. Do you feel as though you have patients with PTSD. Encouraging ex-
might have experienced a mild, moderate, or pression of thoughts and feelings surrounding
severe PTSD from 911?
Magnify that as you think, “what if I were the
the experience and the survivor guilt is an im-
one standing on that sidewalk watching people portant first step in the patient’s ability to
die or jump from those buildings, wanting to help identify the source of the problem and begin
and knowing I couldn’t?” Dramatic? Maybe. Realis- the process of healing (Fig. 10-5). It is impor-
tic? Yes. And just a very slight taste of the intensity tant to validate the patient’s feelings regarding
of the fears and flashbacks people with PTSD
experience.
the situation. Honesty and genuineness in
communicating with these patients will help
to build a working rapport.
A term associated with PTSD is “survivor Family members and significant others
guilt.” This is the feeling of guilt expressed by such as spouses can suffer from the effects of
survivors of a traumatic event. A Vietnam vet- PTSD as well. Often, these people experience
eran may say, “Why me? Why did that lady the same trauma, even though they were not
and her kids get blown away and I lived? They present for the original event. The term “vic-
didn’t deserve that.” Another concern associ- arious trauma” may apply in this situation.
ated with PTSD is the suicide rate among
military who served in the wars. Since the ■■■ Classroom Activity
Afghanistan war began, there has been a rise • Watch the movies “Coming Home” and “The Best
Years of Our Lives” to get a perspective of the
in suicide among military, suggesting that return to civilian life after war.
PTSD is a factor. This population continues • Watch the movie "Nuts" about trauma after rape
to be in need for more mental health services and incest.
(Drummond, 2012).
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 167

■■■ Critical Thinking Question ■ Medical Treatment of

Jeanne is a 21-year-old single woman admitted
for pneumonia. Her social history indicates that
People With Anxiety and
she survived a house fire when she was 10 years Anxiety-Related Disorders
old and that her twin sister died in that fire.
Today is the day for the monthly fire drill at the Treatment is individualized to the patient and
hospital. You note that Jeanne is not in her bed.
You are unable to find her during the drill. After
may include one or more of the following:
the drill, you search her room and find her sit- psychopharmacology, individual psychother-
ting on the floor of the closet. She is wrapped in apy, group therapy, systematic desensitization,
a blanket and is crying. She does not respond to hypnosis, imagery, relaxation exercises, and
your verbal cues. What do you think is happen- biofeedback.
ing to her? What illness might she have? How
will you get her out of the closet? What can you
Psychotherapy includes individual treatment,
do to help her? group therapy, and systematic desensitization

Pharmacology Corner
Medications are being used effectively to
control chronic anxiety. The most common
are anti-anxiety medications, which include
benzodiazepines. See Table 10-2 for a list of
common anti-anxiety medications. The
benzodiazepines are commonly used and are
effective in most cases. Use of the anti-
anxiety drugs is short-term whenever possi-
ble because of the strong potential for
dependency. Individuals with anxiety disor-
ders who are chemically dependent are man-
aged with other medications having calming
qualities but not the same high potential for
addiction as the anti-anxiety drugs. Hydrox-
yzine hydrochloride (Atarax) and clonidine
(Catapres) are examples.
The antidepressant class of selective sero-
tonin reuptake inhibitors (SSRIs) is being
used as primary treatment in many cases of
GAD, panic disorders, social phobias, OCD,
and PTSD. For example, the FDA has
approved fluoxetine, paroxetine, and fluvox-
amine for treatment of OCD. Sometimes
higher doses of the drugs than are used with
depression are needed, so close monitoring of
Figure 10-5 Encouraging the patient’s expres-
sion of thoughts and feelings about the
side effects is important. For PTSD, paroxe-
traumatic experience, as in this painting, is tine and sertraline have been approved by the
an important first step in identifying the FDA. Panic disorders have been successfully
problem and beginning the healing process. treated with paroxetine, fluoxetine, and ser-
(Courtesy of the National Institute of Mental Health, traline. Dosing increases must be done slowly
Bethesda, MD.) as these patients are especially sensitive to
overstimulation from these medications.
More research in under way to identify more
effective medications for these conditions.
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168 UNIT 2 | Threats to Mental Health

method of relaxation. Biofeedback done

l Table 10-2 Commonly Used effectively alters the brain to a slower wave
Anti-Anxiety frequency and can actually increase the im-
Medications mune response for humans. The patient
Alprazolam (Xanax) should discuss with the doctor if biofeedback
Buspirone (BuSpar) is appropriate. The nurse may assist with pro-
Chlordiazepoxide (Librium) viding information and resources.
Clonazepam (Klonopin)
Clonidine (Catapres) Hypnotherapy
Diazepam (Valium) Hypnosis, done by a qualified, licensed ther-
Hydroxyzine (Atarax) apist, may be helpful. It will assist the patient
Lorazepam (Ativan) in relaxation. Some people joke about “going
Oxazepam (Serax) to my happy place,” but there is validity in
Prazepam (Centrax) finding pleasure or a lighthearted memory.
Zolpidem (Ambien) Patients need to continue to take time to do
the relaxation as directed by the therapist.
Hypnosis is not a “one-time” therapy. It, like
techniques to help the patient experience the biofeedback, needs to be done routinely to be
anxiety-producing situation in a controlled effective. The nurse’s role may be as simple as
environment and integrate the painful feelings to remind the patient to find quiet time for
associated with the anxiety. Patients concentrate this, or if the patient is being seen as an out-
on esteem needs and reality. patient, the nurse may ask the patient how
frequently she or he has been able to do the
■ Alternative Interventions self-hypnosis and what kind of results the
for People With Anxiety patient has experienced thus far.
and Anxiety-Related Additional Alternative
Disorders Interventions
The following may provide additional relief:
Aromatherapy • Stress and relaxation techniques
Essential oils, such as peppermint or eucalyp- • Yoga
tus, are popular aids in relaxation. Methods of • Acupuncture
application include using diffusers (machines • Kava
that turn the oil into droplets that diffuse into
the air), placing a drop on a piece of clothing, ■ Nursing Care for People
or applying directly to the skin, such as the
temple area. Patients can purchase these essen-
With Anxiety and Anxiety-
tial oils and equipment at specialty stores, Related Disorders
some bath oil supply stores, or even in some
pharmacies. There are online resources as well. Common nursing diagnoses for people with
Prescriptions are not needed, but patients anxiety and anxiety-related disorders:
should be cautioned to use essential oils in • Anxiety, coping, ineffective
very small amounts (drops at a time) and that • Fear
some individuals may experience allergic • Thought process, disturbed
responses, especially if the oils are applied • Violence, risk for
directly to the skin.
General Interventions
Biofeedback 1. Maintain a calm milieu: Patients who
Biofeedback is a form of behavior modifica- have anxiety disorders need to have a
tion. It is a system of progressive relaxation. calm and safe treatment area. Minimiz-
There are many tapes and products on the ing the stimuli helps the patient to
market to assist patients in this “do-it-yourself” keep centered and focused.
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 169

2. Maintain open communication: Encour- treatment plan, or to other people and

age the patient to verbalize all thoughts situations should be documented. The
and feelings. Honesty in dealing with data collected and documented will
patients helps them learn to trust others allow the nurse to provide accurate
and increases their self-esteem. Patients feedback.
will feel the value that nurses have in that 5. Encourage activities: Activities that are
relationship. Observe the patient’s non- enjoyable and nonstressful help the
verbal communication. As previously patient in several ways. Activities pro-
stated, affect and body language often re- vide a diversion, give the patient time
veal more about a patient’s thoughts and to concentrate on something other
feelings than the words that are spoken. than the anxiety-producing situation,
3. Observe for signs of suicidal thoughts: Pa- and give an opportunity to provide
tients with anxiety disorders, especially positive feedback to the patient about
those suffering with PTSD, are at risk the progress he or she is making. These
for suicide as a result of feelings of low activities should be purposeful, not just
self-esteem or decreased self-worth. “busy work.” The patient should not be
Nurses must be alert to this possibility put in a situation of competition as a
and should observe and confront the result of activities. Competition could
patient and document any suspicions increase the anxiety and be counterpro-
or statements the patient expresses. ductive to treatment.
4. Document any changes in behavior: Any
change, no matter how small, can be Table 10-3 summarizes the types of anxiety
significant to the patient’s care. Positive and related disorders, the general symptoms,
or negative alterations in the way a and common nursing actions for them, and
patient responds to the nurse, to the Table 10-4 outlines a Nursing Care Plan for

l Table 10-3 Nursing Care for Patients With Anxiety and Related
Disorders
Disorders Symptoms Nursing Actions
Generalized Muscle aches, shakes, • Provide calm milieu
Anxiety Disorder palpitations, dry mouth, • Open communication done calmly
nausea, chills, vomiting, and clearly
hot flashes, polyuria, • Focus on brief messages
difficulty swallowing, • Teach early signs of escalating anxiety
feeling of dread • Suicide precautions if the person indi-
cates any self-destructive thoughts
• Document behavior changes
• Encourage activities
• Promote deep breathing and other
relaxation methods
• Reassurance
Panic Disorder Fear, dissociation, nau- Same as above
sea, diaphoresis, chest • Stay with patient during attack
pain, increased pulse,
shaking, unsteadiness,
paralysis
Phobia Irrational fear of a Same as above
particular object or • Focus on nonthreatening topics
situation • Reassure about patient’s safety
Continued
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170 UNIT 2 | Threats to Mental Health

l Table 10-3 Nursing Care for Patients With Anxiety and Related
Disorders—cont’d
Disorders Symptoms Nursing Actions
Obsessive-Compulsive Repeated thoughts Same as above
Disorder and/or repeated actions • Allow patient to express the anxiety
• Recognize and accept need for
obsessions and compulsions
• Allow time for rituals
• Provide structured schedule and give
patient some control
• Explore alternative methods of
anxiety reduction
Post-Traumatic “Flashbacks,” social with- Same as above
Stress Disorder drawal, low self-esteem, • Keep patient oriented to the present
relationships that may • Encourage patient and significant
change or be difficult to others to attend groups for patients
form, irritability, anger with PTSD
seemingly for no reason, • Encourage patient to talk about trau-
depression, chemical matic events if he/she is able
dependency

l Table 10-4 Nursing Care Plan for Patient With Anxiety

Assessment/ Nursing Interventions/
Data Collection Diagnosis Plan/Goal Nursing Actions Evaluation
Patient is: Anxiety Demonstrates a • Calm environment Patient appears
• Restless sense of increased • Promote relax- more relaxed
• Irritable comfort ation techniques and verbalizes
• Pacing including deep more positive
• Hyperventilating breaths outcomes
• Verbalizing • Soothing music
negative thoughts • Verbalize reassur-
and expecting ance about cur-
a calamity rent situation
resolving

a patient with anxiety. See Figure 10-6 concept SSD is characterized by somatic symptoms
map care plan for panic disorder and GAD. that are either very distressing or result in
significant disruption of functioning, as well as
■ Somatic Symptom excessive and disproportionate thoughts, feel-
ings, and behaviors regarding those symptoms.
and Related Disorders To be diagnosed with SSD, the individual must
be persistently symptomatic (typically at least
Somatic Symptom Disorder for 6 months). It is a category of disorders in
(SSD) DSM-5 as well as a specific diagnosis.
Somatic refers to the body. The new term so- In the past the term somatoform disorders
matic symptom disorders (SSD) replaces the was more associated with physical symptoms
old term somatoform disorders in DSM-5. with no organic cause. This still may be
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 171

Panic Disorder and

Generalized Anxiety
Disorder

S & Sx: S & Sx:

• Palpitations • Verbalizes lack
• Sweating of control over
• Dyspnea life situation
• Chest pain • Nonparticipation
• Dizziness in decisions of
• Paresthesia personal care

Nsg. Dx: Nsg. Dx:

Panic Anxiety Powerlessness

Nursing Actions: Nursing Actions:

• Stay with client; offer • Encourage client to take
reassurance of safety responsibility for
• Remain calm aspects of own care
• Use simple explanations • Assist client to set
• Low stimuli environment realistic goals
• Tranquilizers, as ordered • Identify areas of control
• Encourage verbalization • Encourage verbalization
of current situation of aspects of life not
• Teach ways to interrupt within client's control
escalating anxiety

Medical RX:
Alprazolam 0.5 mg
tid

Outcomes: Outcomes:
• Client recognizes • Client performs
signs and symptoms activities of daily
of escalating anxiety living independently
and intervenes to • Client makes indepen-
prevent panic dent decision regard-
• Client uses adaptive ing life situation
activities (exercise, • Client accepts
relaxation) to aspects of life out
maintain anxiety at of his/her control
manageable level

Figure 10-6 Concept map care plan for panic disorder and generalized anxiety disorder. (From Townsend
(2011): Essentials of Psychiatric Mental Health Nursing, 5th ed. Philadelphia: F.A. Davis Company, with permission.)
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172 UNIT 2 | Threats to Mental Health

the case in SSD but is not required. A promi- Differential Diagnosis

nent feature is excessive focus on one’s physical
People with somatic disorders present many
symptoms, that interferes with one’s daily
challenges in obtaining an accurate diagnosis.
functioning. These symptoms may or may not
Nurses must be alert to physical illness that may
be associated with an actual medical condition.
actually be causing the symptoms. Multiple
For example, a patient with a small sore seeks
sclerosis, for example, can present with many
multiple opinions out of fear of skin cancer.
and varied symptoms that may be as yet undi-
Despite negative biopsies, the patient keeps
agnosed. Discuss with the patient’s medical
checking it, talking about it, and seeking other
doctor all possibilities for physical illness rather
possible providers who might offer other tests
than a somatoform disorder. These patients can
despite great financial burden. In SSD high
end up being subjected to many tests, proce-
levels of worry about one’s health becomes the
dures, and even surgeries with no improvement
central focus in the person’s life even to the
in symptoms. It is important to avoid labeling
point of becoming the person’s identity. These
a person with SSD just because a physical basis
patients are high users of the health-care sys-
for symptoms cannot be found.
tem, often seeking out different specialists and
testing. So nurses will encounter these patients
more often in nonpsychiatric settings. There is Somatic Symptom Related
a definite anxiety component to this disorder Disorders
as the individual worries excessively. Although In addition to SSD, several related disorders
distress is normal with a new symptom, exag- are covered in this text including conversion
gerated responses before a diagnosis would be disorder, illness anxiety disorder, and factitious
a factor in considering SSD diagnosis. In the disorder. In DSM-IV-TR additional diagnoses
past the term hypochondriasis might be used included dysmorphophobia and somatoform
to describe someone with SSD. A patient who pain disorder.
focuses extensively on physical symptoms is
sometimes referred as suffering from somati- Conversion Disorder
zation or somatizing. Conversion reaction, as defined in the defense
mechanisms (see Chapter 7), is converting
Etiology of Somatic Symptom anxiety into a physical symptom. Conversion
Disorder disorder is the illness that emerges from over-
Biologically, research has been conducted use of this mechanism. In conversion disorder,
concerning the possibility of a genetic or there is a loss or decrease in physical function-
biological predisposition to somatic difficul- ing that cannot be explained by any known
ties. For example some individuals may have medical disorder or pathophysiological mech-
increased sensitivity to pain. Early childhood anism. Paralysis and blindness are two of the
traumatic experiences are also associated with more common examples of this disorder. It is
SSD. Psychological theories include physical common for the dysfunction to somehow be
symptoms rooted in unconscious mecha- deeply connected to denial and to a prior neg-
nisms that develop to deny, repress, or atively perceived experience (e.g., someone
displace anxiety. who loses the sense of vision after watching a
pornographic movie). Age of onset is usually
adolescence and young adulthood, but it can
occur later in life as well. Conversion disorder
Cultural Considerations is also referred to as Functional Neurological
How an individual experiences a bodily Symptom Disorder. The rationale is that per-
sensation can be linked to one’s cultural sons diagnosed with Functional Neurological
perspective. Some symptoms may be more Symptom Disorder will likely be seen by a
or less acceptable to acknowledge in dif- neurologist.
ferent cultures. The symptoms, although not supportive of
organic disease, are very real to the patient.
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 173

The nurse should not convey to a patient the symptoms of the illness, while the person
that he or she thinks the patient is “faking” with illness anxiety disorder is afraid he or she
the illness; it is real to the patient. The patient will get a serious disease.
is truly experiencing the symptoms. Even
though the patient is concerned enough Factitious Disorder
about the symptoms to consult a physician, Falsification of medical or psychological signs
he or she may give the impression of really and symptoms in oneself or others is called a
not caring about the problem. “La belle in- factitious disorder. The diagnosis requires
difference” is the clinical term used to de- demonstrating that the individual is taking se-
scribe this condition. cretive actions to misrepresent, simulate or
The belief about this disorder is that the cause signs or symptoms of illness or injury in
symptom, e.g., the paralysis or blindness, is al- the absence of obvious external rewards. When
lowing the patient to avoid a situation that is the individual falsifies information for another
unacceptable to him or her. This unacceptable as in a child or pet, the diagnosis is factitious
situation is the source of extreme anxiety, disorder imposed on another or by proxy.
which is converted into the dysfunction. The
dysfunction, then, is relieving the anxiety. This
is called primary gain and is believed to be the ■■■ Critical Thinking Question
function of the paralysis or blindness. Second- Penny is a 35-year-old married mother of three
ary gain is the extra benefits one may acquire children, ages 2 years, 3 years, and 4 months. She
works as a clerk in a large office. She has been
as a result of staying ill. Secondary gain in- visiting the clinic regularly since her last preg-
cludes extra emotional support such as sympa- nancy. She is experiencing severe, intermittent
thy and love or financial benefits. Much of this pain in her right arm and left foot. The pain does
is occurring at the unconscious level. not interfere with her life as a wife and mother,
Malingering is a situation for achieving and she is not able to detect any kind of pattern
to the pain. She tells you that she is not espe-
personal gain that differs from the others cially concerned about the pain. “When it gets
mentioned. Malingering is a conscious effort too bad for me, my husband cooks and cleans
to avoid unpleasant situations. The patient the kitchen.”
“fakes” or pretends to have the symptoms. Penny says that she thinks the source of her
pain is related to “the day I banged my right hip
real hard on the door of the copy machine.” She
■■■ Critical Thinking Question also has begun expressing concern that things are
Will the DSM-5 change reduce the social negativ- going so well for her that she “just has the feeling
ity associated with the word hypochondriasis? that something terrible is about to happen.” What
is your preliminary impression of Penny’s illness?
What other information might you want to obtain
from Penny?
Illness Anxiety Disorder
In this disorder somatic symptoms are not
present or if present, are only mild in intensity.
The person’s distress is not from the physical Medical Treatment of Patients
complaint itself but rather from his/her anxiety
about the meaning, significance, or cause of
With Somatic Symptom
the complaint. Historically these patients are and Related Disorders
often referred to popularly as hypochondriacs. Patients with these disorders are usually admit-
These people are sometimes referred to as “pro- ted to a medical unit rather than a psychiatric
fessional patients.” Hypochondriasis has been unit. Treatment focuses on the symptoms,
a recognized, official diagnosis according to which more than likely are medical in nature.
DSM-IV-TR. In DSM-5 hypochondriasis was The patient does not generally display unusual
changed to Illness Anxiety Disorder. or unmanageable behavior that indicates the
A major difference between illness anxiety need for mental health unit admission.
disorder and conversion disorder is that the Treatment is, of course, individualized
person with conversion disorder focuses on for each patient. Once a somatic disorder is
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174 UNIT 2 | Threats to Mental Health

diagnosed, the ongoing involvement of a

psychiatrist is helpful to give insight to l Table 10-5 Commonly Used
managing this patient. Some approaches Medications for
that may be used to treat these disorders in- Somatic Symptom
clude individual and group psychotherapy, and Related Disorders
hypnosis and relaxation techniques. It is Medications are ordered judiciously for
beneficial for the therapist to help the pa- these disorders. When a medication is used,
tient express the underlying cause of the it is generally an antidepressant or an anti-
anxiety. Hypnosis can be very effective in anxiety agent.
making this determination. Behavior mod- Amitriptyline (Elavil)
ification can be effective if the patient is Bupropion (Wellbutrin)
prone to secondary gains from the somatic Doxepin (Sinequan)
symptoms. Methods of stress management Fluoxetine (Prozac)
are also taught as the person learns new Paroxetine (Paxil)
ways to handle anxiety. Patients may resist Sertraline (Zoloft)
accepting that their problem has a strong Trazodone (Oleptro)
psychological or emotional component and
therefore cannot understand how a para-
lyzed limb or pain has anything to do with in addition to biofeedback, hypnosis, relax-
anxiety. People who have a somatic symp- ation, and imagery.
tom disorder may feel insulted, become re-
sistive to treatment, and search for other Massage
ways to explain the physical problem. Massage therapies are believed to not only re-
Alternative Interventions lieve tensions and discomforts in the muscu-
loskeletal system, but also may assist with
for Patients With Somatic blood and lymph flow. Massage may be effec-
Symptom and Related tive, especially with medication, to assist the
Disorders patient to overcome physical symptoms.
Alternative treatment of choice is related to Caution should be used, however, not to
the particular condition or symptom set. actually emphasize the body complaint and
Choices may include the following treatments reinforce the illness.
Herbal/Nutritional Supplements
It is possible that a patient is experiencing a
Pharmacology Corner nutritional deficiency or possibly a condition
Medications are used sparingly because such as arthritis along with the somatoform
these patients typically have a history of disorder. Herbs or supplements geared to the
being overprescribed. When medications are specific pain issue may help the patient to
ordered for a patient, the classifications of experience less pain, either physically or
choice are usually selective serotonin reup- psychologically.
take inhibitors (SSRIs) (e.g., fluoxetine);
other antidepressants, particularly the tri-
Nursing Care of the Patient
cyclics, such as imipramine; anti-anxiety With Somatic Symptom
drugs; or combinations of these medica- and Related Disorders
tions. At this time, if medications are con- Common nursing diagnoses include the
sidered, SSRIs are greatly preferred over the following:
other classes of antidepressants and probably
should be first-line agents. See Table 10-5 • Anxiety
for medications commonly used to treat • Coping, ineffective
somatic symptom and related disorders. • Sensory perception, disturbed
• Thought processes, disturbed
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 175

Table 10-6 summarizes the symptoms and that nothing life-threatening is causing the
nursing interventions for the somatic symptom symptoms. The nurse has said that the staff is
disorders discussed previously. Figure 10-7 is attempting to help the patient but has
a concept map of somatoform disorders. stopped short of promising improvement or
of “curing” the patient.
Communication Skills
Honesty in dealing with the patient is very Socialization and Group
important. Gaining trust that will encourage Activities
the patient to verbalize thoughts and feelings Keeping the patient focused on other topics
about the physical and emotional aspects of may help in the recovery. Nurses will
this type of disorder is crucial. Do not dis- involve the patient in the goal setting and
count the patient’s disorder. An example of a interventions of the care plan. Aiding the
way to be honest about the situation follows. patient in learning assertive communication
skills can be helpful. Working with other
EXAMPLE health-care staff in occupational therapy,
Nurse: “Ms. P, your physician can find no recreational therapy, and social activities can
physical or life-threatening conditions also act to divert the patient’s focus from the
at this time. We will continue to ob- dysfunction.
serve and examine you. We will make
every attempt to help you improve.” Support
In this way, the patient understands that It is important for the nurse caring for patients
nothing is showing up in the tests that have with somatoform disorders to remember
been made to this point. The person hears to pay attention to the patient but not to

l Table 10-6 Nursing Care for Patients With Somatic Symptom and Related
Disorders
Type Symptoms Nursing Interventions
Somatic Symptom • High level of anxiety about • Listen to patient’s concerns but then
Disorder health focus on other issues
• Excessive time and energy • Promote trust
devoted to symptoms • Encourage patient to express
• May or may not have an or- self about other issues than the
ganic disorder symptoms
Conversion • Loss or decrease in physical • Use therapeutic communication
Disorder functioning that seems to skills.
have a neurological connec- • Encourage therapy (occupational
tion (paralysis, blindness) therapy, physical therapy, etc.).
• Indifference to the loss of • Provide emotional support.
function • Respond to the patient’s symptoms
• Primary and secondary gain as real.
Illness Anxiety • “Professional patient” • Do not reinforce the symptom.
Disorder • Intense fear of becoming • Be nonjudgmental.
seriously ill • Continue to focus on trusting
• Preoccupation with the idea relationship.
of being seriously ill and not
being helped—may be con-
cerned about not being
taken seriously or evaluated
properly
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176 UNIT 2 | Threats to Mental Health

Somatoform
Disorders

S & Sx: S & Sx: S & Sx: S & Sx:

• Physical • Repressed • Past • Loss or
complaints anxiety experience alteration to
• Absence of • Learned with life- physical function
pathophysiology maladaptive threatening • Repressed
• Focus on self coping skills illness to self severe anxiety
and physical (pain) or significant
symptoms others

Nsg Dx: Nsg Dx: Nsg Dx: Nsg Dx:

Ineffective Chronic Pain Fear (of having Disturbed Sensory
Coping a serious disease) Perception

Nursing Actions: Nursing Actions: Nursing Actions: Nursing Actions:

• Ongoing assessment • Ongoing assessment • Ongoing assessment • Assess level of
• Accept that symptom is • Accept that pain is real • Refer all new physical disability
real to the client to the client complaints to • Encourage performance
• Identify personal gains • Provide pain physician at level of ability
• Fulfill client’s needs medication • Limit amount of time • Assess level of
• Do not give positive • Provide comfort client discusses disability
reinforcement to measures symptoms • Maintain
symptoms • Distract client with • Encourage nonjudgmental attitude
• Discuss client activities verbalization of fears • Assist client as
fears/anxieties • Identify adaptive associated required
• Teach adaptive coping coping strategies with illness with self-care deficits
strategies • Role-play more • Give positive
adaptive coping reinforcement for
strategies independent
performance

Medical RX:
Amitriptyline 50 mg
qd for chronic pain

Outcomes: Outcomes: Outcomes: Outcomes:

• Client recognizes • Client recognizes • Client decreases • Performs self-care
signs of signs of rumination about independently
escalating anxiety escalating anxiety physical symptoms • Demonstrates more
• Client is able to • Client connects pain • Fear of serious illness adaptive coping
intervene before the to onset of anxiety has diminished strategies
exacerbation of • Client is able to cope • Client uses adaptive • Discusses feeling
physical symptoms adaptively without coping mechanisms associated with
experiencing pain the stressful event

Figure 10-7 Concept map care plan for somatoform disorder. (From Townsend (2011): Essentials of Psychiatric
Mental Health Nursing, 5th ed. Philadelphia: F.A. Davis Company, with permission.)
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 177

reinforce the symptom. The nurse should al- reinforcing the problem. Nurses should docu-
ways make a thorough head-to-toe assessment. ment all findings in a matter-of-fact way.
This shows the patient that the nurse is con- Patients need to know that they are being
cerned for the patient’s health but will not taken seriously, even though they may not
be focusing on the area of dysfunction or agree with the medical findings of their illness.

■■■ Key Concepts 4. Somatic symptom disorder is character-

ized by somatic symptoms that are either
1. Anxiety disorders have many common very distressing or result in significant
characteristics. Psychoanalytic theories disruption of functioning, as well as ex-
propose that it is important to find the cessive and disproportionate thoughts,
underlying cause of the anxiety. Biologi- feelings, and behaviors regarding those
cal theories postulate that the causes symptoms. The symptoms may or may
are not the primary concern, but rather not have an organic cause.
the physical reasons may result in the
anxiety. 5. Treatment and nursing care for patients
with somatoform disorders may be difficult
2. Medications and therapies should be and long-term, as these are chronic disor-
individualized for the patient. ders. Patients may use the defense mecha-
3. Trust and communication techniques are nisms of denial and conversion reaction.
important tools for the nurse caring for a 6. DSM-5 (2013) is the current major for
patient with an anxiety disorder. Main- psychiatry.
taining a calm milieu is also essential.

CASE STUDY
A patient comes for his scheduled appoint- infected with something serious, since his
ment with Dr. Sneeze. The patient is a symptoms do not seem to subside. Dr. Sneeze
well-known politician. He has been the delivers the news to the patient that he is
subject of negative press in recent months. “healthy.” His examination and lab work
His main symptoms are general malaise, do not show any physical illness, and the
sneezing, chronic headache, and “feeling doctor suggests perhaps the symptoms are
like I have a constant cold.” Dr. Sneeze or- “most likely viral in nature and probably
ders blood work and a chest x-ray and does stress and anxiety related.” Dr. Sneeze
a complete physical exam of the patient. suggests the patient take over-the-counter
You have collected vital signs and the medications for his symptoms and find
health history when you roomed the pa- methods to reduce his stress. Dr. Sneeze
tient. The patient does not have a young leaves the room. The patient expresses his
family at home but is on the road cam- extreme disappointment at not being given
paigning and meeting his constituents “something to take” and asks you to explain
almost daily. He believes he has become to him how stress can give one a cold.

1. How will you respond to the patient’s request for medication?

2. What are your thoughts about the patient’s expectation for receiving medications? How
will you discuss that with him?
3. What alternatives (for example, dietary, herbal, etc.) can you discuss with him or ask the
doctor to discuss with him?
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178 UNIT 2 | Threats to Mental Health

REFERENCES Sierpina, V.S. (2001). Integrative Health Care—

Complementary and Alternative Therapies for
American Psychiatric Association. (2000).
the Whole Person. Philadelphia: F.A. Davis.
Diagnostic and Statistical Manual of Mental
Somatic symptom disorders. (2012). In American
Disorders IV-Text Revision. Washington DC,
Psychiatric Association DSM-5 Development.
Author. (Known as DSM-IV-TR.)
Retrieved from www.dsm5.org/proposedrevision/
American Psychiatric Association. (2013).
Pages/SomaticSymptomDisorders.aspx
Diagnostic and Statistical Manual of Mental
Townsend, M. (2008). Essentials of Psychiatric
Disorders 5. Washington, DC, Author.
and Mental Health Nursing. 4th ed., p. 389.
(Known as DSM-5.)
Philadelphia: F.A. Davis.
Anderson, R.A. (2001). Clinician’s Guide to
Townsend, M. (2012). Essentials of Psychiatric and
Holistic Medicine. New York: McGraw-Hill.
Mental Health Nursing: Concepts of Care in
Braiker, H. (2002). September 11 Syndrome.
Evidence-Based Practice. 7th ed. Philadelphia:
New York: McGraw-Hill.
F.A. Davis.
Cohen, S. (2003). Sociability and Susceptibility to
the Common Cold. Washington, DC:
Carnegie Mellon University (copyright WEB SITES
American Psychological Society), 14(5) Anxiety
September 2003. www.adaa.org/finding-help/treatment/complementary-
David, J., and Kupfer, M. (n.d.). Retrieved from alternative-treatment
http://www.dsm5.org/Pages/Default.aspx http://www.drugs.com/condition/anxiety.html
Drummond, K. (2012). Army suicides: July deaths Stress Theory
set a magic new record. Forbes. Retrieved from www.currentnursing.com/nursing_theory/Selye’s_
www.forbes.com/sites/katiedrummond/2012/0 stress_theory.html
8/16/army-suicide-rate/ PTSD
Gorman, L.M. and Sultan, D.F. (2008). Psy- Ptsd.va.gov for Veteran’s Administration Resources for
chosocial Nursing for General Patient Care. PTSD
www.nami.org/Template.cfm?Section=posttraumatic_
Philadelphia: F.A. Davis.
stress_disorder
Nicholson, R.A. (2003). Chill Out: Anger Can
Give You a Headache. St. Louis, MO: Saint Conversion Disorder
http://emedicine.medscape.com/article/805361-
Louis University. overview
Shives, L., and Isaacs, A. (2002). Basic Concepts
of Psychiatric-Mental Health Nursing. 5th ed.
Philadelphia: JB Lippincott.
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CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 179

Test Questions
Multiple Choice Questions
1. Your significant other is a veteran of the 6. Which of the following is true regarding
war in Iraq. It is very difficult for him or a phobic disorder?
her to drive through a parking ramp be- a. It involves repetitive actions.
cause “There are people hiding behind b. It involves a loss of identity.
the pillars! They have guns! Be careful!” c. It results in sociopathic behavior.
This person is most likely experiencing: d. It is an irrational fear that is not
a. Auditory hallucinations changed by logic.
b. Flashbacks 7. In obsessive-compulsive disorder, a com-
c. Delusions of grandeur pulsion is:
d. Free-floating anxiety a. A repetitive thought
2. Ms. T cannot leave her home without b. A repetitive action
checking the coffee pot numerous times. c. A repetitive fear
This makes her late to many functions, d. A repetitive illusion
and she misses engagements on occasion 8. The medication(s) of choice for the
because of it. Ms. T probably is suffering treatment of OCD is (are): (select all
from what kind of disorder? that apply)
a. Generalized anxiety disorder a. Paxil (paroxetine)
b. Phobia b. Prozac (fluoxetine)
c. Post-traumatic stress disorder c. Luvox (fluvoxamine)
d. Obsessive-compulsive disorder d. Effexor (venlafaxine)
3. Mr. L has a severe fear of needles. He is 9. The three subcategories of phobia
hospitalized on your medical unit. The include all EXCEPT:
lab technician enters to draw blood for a. Agoraphobia
the routine CBC, and Mr. L begins to cry b. Social phobia
out, “Get away from me! I can’t breathe! c. Acrophobia
I’m having a heart attack!” Your first d. Specific phobia
response to Mr. L would be:
a. “I’ll take your vital signs and call my 10. Which of the following are NOT
supervisor.” nursing intervention(s) for people with
b. “Why do you think you’re having a anxiety disorders? (select all that apply)
heart attack, Mr. L?” a. Maximize stimuli to create diversion
c. “Don’t worry. She’s done this many from the anxiety.
times before.” b. Encourage the patient to verbalize all
d. “Mr. L, relax. Take a few deep breaths. thoughts and feelings.
I’ll stay with you.” c. Observe the patient’s nonverbal com-
munication for data on a patient’s
4. Which of the following is not an anxiety thoughts and feelings.
disorder? (select all that apply) d. Observe for signs of suicidal thoughts.
a. Panic disorder e. Document only positive changes in
b. Obsessive-compulsive disorder behavior.
c. Multiple personality disorder f. Discourage activities; activities might
d. Agoraphobia only increase a patient’s anxiety level.
5. A patient with an obsessive-compulsive
disorder is:
a. Suspicious and hostile
b. Flexible and adaptable to change
c. Extremely frightened of something
d. Rigid in thought and inflexible with
routines and rituals
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2993_Ch11_181-192 14/01/14 5:22 PM Page 181

C HA PT E R 11
Depressive Disorders
Learning Objectives Key Terms
1. Define depressive disorders. • Depression
2. Identify three types of depressive disorders. • Dysthymic disorder
3. Describe common physical and behavioral symptoms of • Major depressive disorder
major depressive disorder. • Mood
4. Identify treatment modalities for depressive disorders.
5. Describe key nursing care interventions for depressive disorders.

F
eeling down, discouraged, and depressed
is something all people experience at Cultural Considerations
some time in their lives. Periods of emo- Depression crosses all cultures and
tional highs and lows are normal. Depressive socioeconomic groups. However, depres-
disorders are very different from a transient sive disorders may be misdiagnosed or
bout of the “blues” or depressed mood. underdiagnosed in some cultures due to
Depression is a painful and debilitating illness language barriers and lack of access to
that affects all areas of one’s life. There are sev- mental health services. This is particularly
eral types of depression that are collectively true in cultures that are more fearful of
called depressive disorders. These can change being “labeled” with a psychiatric diagno-
or distort the way a person sees himself, his life, sis. Some cultures may express depressive
and those around him. People who suffer from symptoms as physical symptoms, such as
depression usually see everything with a more fatigue and headache, while others may
negative attitude. They cannot imagine that be more prone to speak in psychological
any problem or situation can be solved in a terms of sadness and guilt.
positive way. Depression can take a variety
of forms and affect all age groups. Depressive
disorders all have similar symptoms that vary
by duration, timing and presumed etiology. to work, sleep, study, eat, and enjoy once-
It is more common in women, but men pleasurable activities. These symptoms must
with depression may be underdiagnosed last at least 2 weeks and very often last much
(Figure 11-1). See Box 11-1 for list of general longer to receive this diagnosis. Major depres-
facts about depressive disorders. sion is disabling and prevents a person from
functioning normally. Some people may ex-
■ Types of Depressive perience only a single episode of depression
within their lifetime, but more often a person
Disorders has multiple episodes. Major depressive dis-
order affects approximately 5% to 8% of the
Major Depressive Disorder U.S. population age 18 and older annually. A
Major depressive disorder, or major depression, person has a 16.6% chance of developing a
is characterized by a combination of symptoms major depressive disorder in one’s lifetime
that severely interfere with a person’s ability (Kessler, 2005).
181
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182 UNIT 2 | Threats to Mental Health

Major depressive disorder is characterized

by a classic cluster of symptoms. Behavioral
and physical symptoms include:
Five or more of the following for at least a
2-week period that represent a change in
functioning:
• Sad mood
• Sleep pattern disturbances
• Increased fatigue
• Increased agitation
• Feelings of guilt or worthlessness
• Weight loss or gain
Figure 11-1 Depression is less reported • Decreased interest in pleasurable activi-
in the male population, but this may be ties (anhedonia)
caused by male tendency to mask • Decreased ability to think, remember,
emotional disorders with behaviors such as or concentrate
alcohol abuse. • Recurrent thoughts of death or
suicide
These symptoms are often the same behav-
iors someone experiences in a low period of
l Box 11-1 General Information his or her life, but the duration and intensity
are increased (Figures 11-2 and 11-3).
About Depressive
Disorders
• Common not only in the United States but Tool Box | Clinicians use a number of
also internationally. depression scales to follow the severity of
• Most common reason for seeking out the patient’s symptoms over time. These
mental health professional. include:
• Nearly twice as many women as men 1. Beck Depression Inventory,
are affected by a depressive disorder www.ibogaine.desk.nl/graphics/
annually. However, men frequently 3639 b1c_2 3.pdf_
suffer from depression that may be 2. Hamilton Depression Rating Scale,
masked. www.psy-world.com/online_ hamd.htm
• The elderly are prone to depression often
related to multiple losses and decline of
health, among other variables.
• Depressive disorders are being diagnosed Differentiating a grief response to a
earlier in life than they were in previous major life loss from major depressive disorder
generations, including in children and can be difficult as some of the symptoms,
adolescents.
such as sadness, insomnia, and poor appetite,
• Because symptoms can be hidden and
vague, the primary physician is often the may resemble a depressive episode. See
first to identify depression. Table 11-1 for tips to differentiate grief from
• Symptoms often go unrecognized and depression.
can be a factor in poor work perform-
ance, family conflict, and substance
abuse. Neeb’s A period of depression following the
• Once one is diagnosed with a depressive ■ Tip death of a loved one is normal.
disorder, there is a high probability of When this response goes on longer
recurrence. than expected and interferes with a
person’s self-esteem, it may indicate
Source: Adapted from Kessler et al. (2005): “Major Depressive Disorders
Among Adults—National Institute of Mental Health.” a depressive disorder.
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CHAPTER 11 | Depressive Disorders 183

depressive disorder. It affects approximately

5% to 6% of the U.S. population age 18 and
older at some point in their lifetimes (Kessler,
2005). It often begins in childhood, adoles-
cence, or early adulthood. About 40% of adults
with dysthymic disorder also meet criteria for
major depressive disorder or bipolar disorder.
Dysthymic disorder is characterized by a
depressed mood for most of the day, for more
days than not, as indicated by either subjective
account or observation by others, for at least
2 years and 1 year in children. These symptoms
are less severe than those of major depressive
disorder but have gone on for long periods.
Symptoms often include:
• Poor appetite or overeating
Figure 11-2 Sadness becomes depression • Insomnia or hypersomnia
when it lasts a long time and interferes with • Low energy or fatigue
day-to-day functioning.
• Low self-esteem
• Poor concentration or difficulty making
decisions
• Feelings of hopelessness

■■■ Critical Thinking Question

Describe the behaviors that would differentiate
dysthymic disorder from major depressive disorder.

Postpartum Depression
Postpartum “blues” is a common response a few
days after giving birth and may be related to
fatigue, hormone changes, and anxiety. It resolves
in a short time with rest and support. Postpar-
tum depression, also called postpartum onset de-
pression, occurs up to 6 months after childbirth
Figure 11-3 Insomnia is a common symptom and is a much more serious condition. Postpar-
of depression. tum onset depression is classified as a major de-
pressive disorder with the same classic cluster of
symptoms as above with the addition of lack of
Neeb’s The classic image of a depressed
interest in the baby, which can progress to rejec-
■ Tip person does not fit all patients. Some tion of the baby and lead to a psychotic state. A
may have more of the physical signs,
such as loss of appetite, insomnia,
patient suffering from this disorder needs inten-
and early morning wakening, and
sive treatment with medications and psychother-
not display the outward sadness that
apy. See Chapter 20 for more information.
is usually associated with depression. Major Depressive Disorder
With Seasonal Pattern
Dysthymic Disorder Previously called seasonal affective disorder
Dysthymic disorder is a less severe form of (SAD), this is a depression associated with
depression that is characterized by its chronic seasonal patterns. Symptoms generally are
nature. It is sometimes called persistent exacerbated during the winter months and
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184 UNIT 2 | Threats to Mental Health

l Table 11-1 Differentiating Grief From Depression

Uncomplicated Grief Major Depression
Reaction • Labile • Mood consistently low
• Heightened when thinking • Prolonged, severe symptoms
of loss lasting more than 2 months
Behavior • Variable, shifts from sharing • Completely withdrawn or fear
pain to being alone of being alone
• Variable restriction of pleasure • Persistent restriction of pleasure
Sleep Patterns • Periodic episodes of inability • Wakes early morning
to sleep
Anger • Often expressed • Turned inward
Sadness • Varying periods • Consistently sad
Cognition • Preoccupied with loss • Focused on self
• Self-esteem not as affected • Feels worthless; has negative
self-image
History • Generally no history of • History of depression or other
depression psychiatric illness
Responsiveness • Responds to warmth and • Hopelessness
support • Limited response to support
• Avoids socializing
Loss • Recognizable, current • Often not related to an
identified loss
Source: Adapted from Ferszt (2006): How to distinguish between grief and depression? Nursing, 36(9), 60–61; Brown-Saltzman (2006). Transforming
the Grief Experience. In Johnson, Gorman, Bush (eds.). Psychosocial Nursing along the Cancer Continuum, 2nd ed., pp. 293–314, Oncology
Nursing Press: Pittsburgh, PA.

subside during the spring and summer. This ■■■ Clinical Activity
type of depression is thought to be related to Review your depressed patient’s risk factors, in-
the hormone melatonin. During months of cluding medications and medical conditions that
longer darkness, there is increased production could contribute to the depression.
of melatonin that seems to trigger depressive
symptoms in some people.
■■■ Critical Thinking Question
Substance-Induced Your patient with Stage II lung cancer shows signs
of depression. Besides the emotional stress of
Depressive Disorder having cancer, what other factors could be
contributing to the depression?
Substance-induced depressive disorder is de-
pressed mood from the physiological effects of
withdrawal, intoxication, or after exposure to a
substance. This can include drugs of abuse such and 11-3 for medical conditions associated
as alcohol, opioids, sedatives, and anti-anxiety with depression and medications that con-
medications as well as exposure to toxins. tribute to depression.
Premenstrual Dysphoric
Depressive Disorder Disorder
Associated With Another This form of depressive disorder was added to
Medical Condition the Diagnostic and Statistical Manual 5th
This condition is characterized by a prominent edition in 2013. The features include a con-
and persistent depression that is judged to be sistent pattern of markedly depressed mood,
the result of direct physiological effects of a excessive anxiety, and mood swings during
general medical condition. See Boxes 11-2 the week prior to menses, which start to
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CHAPTER 11 | Depressive Disorders 185

levels of these neurotransmitters, giving strong

l Box 11-2 Medical Conditions credibility to these theories. Family history re-
Associated With mains an important risk factor indicating ge-
Depression netic links. Psychological theories have focused
• Stroke (especially frontal lesions) on personal history of deprivation, trauma,
• Myocardial infarction and significant loss. Classic psychoanalytic the-
• Adrenal disorders ory views depression as the reaction to the loss
• Dementia of a significant person who has been both
• Diabetes hated and loved. An individual can also be
• Cancer prone to low self-esteem and a sense of help-
• Hypothyroidism lessness due to environmental factors and have
• Brain tumors a tendency toward depression. Physical illness
• Parkinson’s disease and medications are also frequent contributors
• Multiple sclerosis to depressive symptoms.
• Chronic pain
• Chronic kidney disease
■ Treatment of Depressive
Source: From Gorman and Sultan (2008): Psychosocial Nursing for
General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, Disorders
with permission.
Treatment involves a combination of pharma-
cological and psychotherapeutic approaches.
l Box 11-3 Drugs That Can Cause This approach has the best outcomes. The ad-
Depression vent of so many new antidepressants has pro-
Antihypertensive Cancer chemothera- vided many more opportunities for successful
agents including: peutic agents treatment (see Pharmacology Corner). Indi-
• Reserpine including: vidual psychotherapy to address past losses
• Beta blockers • Vincristine and stressors, short-term cognitive behavioral
• Methyldopa • Vinblastine therapy to develop new strategies to alter neg-
Oral contraceptives • Interferon ative thinking, and group therapy to address
Steroids • Procarbazine socialization and poor self-esteem can all be
Psychoactive agents • L-asparaginase helpful. For the patient with severe depression
Benzodiazepines Alcohol who does not respond to drugs or psychother-
Anabolic steroids Amphetamine or
apeutic approaches, electroconvulsive therapy
Amphotericin-B cocaine withdrawal
Opioids is sometimes suggested. It can be used in con-
junction with other modalities such as med-
Source: From Gorman and Sultan (2008): Psychosocial Nursing for ication. People may have a therapeutic session
General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company,
with permission.
of 6–10 treatments over 4–8 weeks. Patients
are given sedation prior to the treatment. The
side effect of memory loss is frequently seen.
improve after the onset of menses and then
become minimal or absent after menses. Alternative Treatments
Light Therapy
■ Etiology of Depressive Light therapy is being prescribed and used suc-
Disorders cessfully in the treatment of depression with sea-
sonal pattern. It consists of special lights to be
Depressive disorders are complex and may
have multiple etiologies. Biochemical theories
have become more important with the identi- ■■■ Classroom Activity
• Arrange for a psychiatrist to talk to the class
fication of insufficiency of neurotransmitters, about psychotherapy and pharmacotherapy in
especially norepinephrine and serotonin. These depressive disorders.
insufficiencies may be the result of inherited or • Arrange for a hospital social worker to discuss
environmental factors. The effectiveness of an- depression with physical illness.
tidepressants seems to result from enhancing
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186 UNIT 2 | Threats to Mental Health

used for certain amounts of time during the day. effects in some patients with mild depression.
Also, exposure to natural light has been shown St. John’s wort probably should not be used
to reduce depression and increase alertness. with selective serotonin reuptake inhibitors
(SSRIs) or monoamine oxide inhibitors
Herbal and Nutritional Therapy (MAOIs) (Skidmore-Roth, 2010).
General dietary changes such as avoiding
caffeine, sugar, and alcohol or adding servings
of whole grains and vegetables may help a
■ Nursing Care of the
person with mild depression. Herbs such as Patient With Depressive
St. John’s wort, kava, gingko, fish oil, and SAMe Disorders
have been shown to provide antidepressant
Common nursing diagnoses with this popu-
lation include the following:
Pharmacology Corner
• Hopelessness
Antidepressants are the medications of • Self-care deficit
choice in treating depressive disorders. See • Self-esteem, disturbed, deficit
Table 11-2 for the categories of antidepres- • Social interaction, impaired
sants. They are also used to treat depression
associated with bipolar disorders, schizophre- General Nursing Interventions
nia, and dementia. Selected agents may be
used to treat anxiety disorders and bulimia as • Identify small, achievable goals the patient
well. Some of the target symptoms that anti- can meet. Provide support and encourage-
depressants may treat include sadness, inabil- ment. Break down tasks into small parts
ity to experience pleasure, change in appetite, for the severely depressed patient. For
insomnia, restlessness, poor concentration, example, rather than encouraging the
and negative thoughts. These medications patient to get dressed, have the patient
work to increase concentration of neurotrans- focus on putting on a t-shirt.
mitters such as serotonin and norepineph- • Encourage the patient to speak about his
rine. The early antidepressants were called or her concerns without judgment. Use
tricyclics and MAOIs. The newer antidepres- open-ended questions, such as “Tell me
sants, including SSRIs, SNRIs, and hetero- what concerns you today.” Avoid blanket
cyclics, also called tetracyclics, have much reassurance like “you are doing fine” or
better side-effect profiles. The anticholinergic minimizing the patient’s feelings as in
actions of tricyclics and the rigid dietary “you’re lucky you have a job.” This might
restrictions needed for MAOIs often limit the alienate a patient who is not feeling fine.
use of these medications, but they can still be Help a patient who verbalizes hopeless-
effective for some patients who are resistant ness to focus on describing his feelings
to the other categories. These medications all and concerns. Then discuss one concern
require several weeks of use before some im- at a time to prevent it from being over-
provement in depression can be expected; whelming for the patient.
they should not be stopped abruptly. These • Encourage independence.
medications are all oral preparations. Some- • Avoid activities that might tax memory or
times combinations of antidepressants may concentration if the patient is struggling
be prescribed. See Chapter 8 for more infor- with these.
mation on these medications. • Monitor patient compliance with antide-
When severely depressed patients are pressants. Include education about
started on antidepressants, they need close potential side effects and not to expect
monitoring. As the drugs take effect, the results for several weeks.
person’s mood begins to lift and he or she • Encourage participation in activities to re-
may have the increased energy to imple- duce time spent ruminating on negative
ment a suicide plan. thoughts.
• Promote a trusting relationship.
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CHAPTER 11 | Depressive Disorders 187

l Table 11-2 Antidepressants

Drug Category Examples Important Considerations
Tricyclics amitriptyline (Elavil), Major side effects are anticholinergic symp-
nortriptyline (Pamelor), toms requiring close monitoring. Symptoms
desipramine (Norpramine) include: dry mouth, urinary retention, con-
stipation, blurred vision, sedation. Use with
extreme caution in the elderly.
SSRIs (selective paroxetine (Paxil), sertraline SSRI withdrawal syndrome can occur with
serotonin reuptake (Zoloft), fluoxetine (Prozac) sudden discontinuation; includes dizziness,
inhibitors) nausea, cholinergic rebound (salivation,
loose stool)
SNRIs (serotonin duloxetine (Cymbalta), Monitor for insomnia, restlessness
norepinephrine venlafaxine (Effexor)
reuptake inhibitors)
Heterocyclics bupropion (Wellbutrin), Monitor for dizziness, headache,
mirtazapine (Remeron), tachycardia
trazodone (Oleptro)
MAOIs (monoamine phenelzine (Nardil), Serious, potentially fatal hypertensive crisis
oxidase inhibitors) tranylcypromine (Parnate), may occur in presence of foods high in
isocarboxazid (Marplan) tyramine (aged cheeses, red wine, smoked
and processed meats). Special diet must
be followed.
Source: Adapted from Townsend (2012), Gorman & Sultan (2008), and Pederson & Leahy (2010).

• Encourage the patient to challenge nega- physician immediately. See Chapter 13 for
tive thoughts. For example, identify an more interventions for suicidal patients.
alternative solution to one problem, and
Table 11-3 provides the nursing care plan
encourage one example such as why the
for depressed patients.
patient is a good parent.
• Promote physical activity where possible,
for example, ambulating in the hall twice ■■■ Clinical Activity
a day. Focusing on physical activity can • Review effective interventions used by the nurs-
promote the patient’s sense of well-being. ing team to approach the depressed patient.
• Promote the patient’s self-esteem by identi- • Identify small goals that the depressed patient
has achieved.
fying improvements or recent successes.
The depressed patient may tend to focus
only on negatives.
• If a patient gives any clues of contemplating Neeb’s As antidepressant drugs take effect,
suicide, notify other team members and the ■ Tip the patient may initially feel more
energized before the mood lifts. A sui-
cidal patient can be at increased risk
during this period because he or she
Neeb’s Depressive disorders can contribute has more energy to initiate a suicide
■ Tip to confusion and social withdrawal plan while still feeling hopeless. Any
in the elderly and can lead to misdi- patient who is suicidal should be
agnosis of dementia (sometimes closely monitored during the first few
called pseudodementia). These pa- weeks on antidepressants. All antide-
tients need multidisciplinary assess- pressants carry a black box warning
ment to obtain the correct diagnosis from the FDA about increased risk of
and treatment. suicidality in children and adolescents.
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188 UNIT 2 | Threats to Mental Health

l Table 11-3 Nursing Care Plan for the Depressed Patient

Data Nursing
Collection Diagnosis Plan/Goal Interventions Evaluation
Withdrawn, Impaired To participate in Spend time with patient Track
refusing to social conversation with each day without pres- frequency of
leave his interaction nurse once a day. sure or demands. Ask patient talking
room Establish a trust- questions that do not with others.
ing relationship. require demanding Verbalizes
answers. Accept periods concerns to
of silence. nurse.
Encourage participation
in structured activities
if possible to reduce
pressure on patient to
“perform.”

■■■ Clinical Activity ■■■ Key Concepts

Review the side-effect profile of your patient’s
antidepressants and incorporate teaching as 1. Depressive disorders are treatable, and
appropriate to promote patient compliance. most people respond positively to the
appropriate medications.
2. Major depressive disorder is a debilitating
■■■ Critical Thinking Question illness that often recurs in one’s lifetime.
A patient is complaining of nausea and dizziness. 3. Depression is the most common reason for
In reviewing the medications from home, the
patient has been taking paroxetine for 5 years. seeking out a mental health professional
The patient is now NPO due to surgery. What do 4. Mood disorder due to a general medical
you need to know about this medication that
could be a factor in the patient’s postoperative condition is frequently seen in physically
recovery? ill patients in the hospital.
5. Nursing care of the depressed patient
should include promotion of self-esteem
and socialization.
■■■ Critical Thinking Question
Identify some of the differences in side-effect 6. Antidepressants are very effective in treat-
profiles from tricyclic antidepressants and from ing depression, but side-effect profiles may
SSRIs.
require a change in drug as needed.
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CHAPTER 11 | Depressive Disorders 189

CASE STUDY
Marge is a 55-year-old single woman who approached her with concern. Marge has
works as a librarian. Over the past few agreed to see her physician for a checkup.
months she has had increasing difficulty in Marge presents to the doctor with a de-
sleeping, poor concentration, and an over- pressed appearance. On specific question-
whelming sense of sadness. Her mother ing she reports feeling that she no longer
died 1 year earlier, and Marge attributed feels competent in her job despite ad-
these changes to a grief reaction. However, vanced degrees and certification and over
as time has gone on, the symptoms have 20 years’ experience. These feelings have
become more distressing. She has stopped increased over the past 3 months and occur
exercising, has turned down social invita- daily.
tions, and spends most of her time alone at The physician considers major depres-
home. She has begun missing work because sive disorder as a diagnosis and prescribes
of oversleeping, and her supervisor has paroxetine.

1. What teaching would you provide to the patient about the antidepressant?
2. What other forms of treatments might be proposed?
3. What other concerns would you have for this patient?

REFERENCES National Institute of Mental Health. Major

Depressive Disorders Among Adults. Retrieved
American Psychiatric Association. (2000).
from http://mentalhealth.gov/statistics/
Diagnostic and Statistical Manual of Mental
1MDD_ADULT.shtml
Disorders IV-Text Revision. Washington DC,
Pederson, D.D., and Leahy, L.G. (2010). Pocket
Author. (Known as DSM-IV-TR)
Psych Drugs. Philadelphia: F.A. Davis.
American Psychiatric Association. (2013). Diagnos-
Sadock, B.J., and Sadock, V.A. (2007). Synopsis of
tic and Statistical Manual of Mental Disorders 5.
Psychiatric/Behavioral Sciences/Clinical Psychiatry.
Washington, DC, Author. (Known as DSM-5)
Philadelphia: Lippincott Williams & Wilkins.
Brown-Saltzman, K. (2006). Transforming the
Skidmore-Roth, L. (2010). Mosby’s Handbook
Grief Experience. In R.C. Johnson, L.M.
of Herbs and Natural Supplements. 4th ed.
Gorman, and N.J. Bush (Eds.). Psychosocial
St. Louis: Mosby-Elsevier.
Nursing Along the Cancer Continuum. 2nd
Townsend, M.C. (2012). Psychiatric Mental Health
ed., pp. 293–314. Pittsburgh, PA: Oncology
Nursing. 7th ed. Philadelphia: F.A. Davis.
Nursing Press.
Ferszt, G. G. (2006). How to distinguish between
WEB SITES
grief and depression? Nursing, 36(9), 60–61.
Gelenberg, A. J. (2010). Practice Guideline for National Institute of Mental Health
the Treatment of Patients With Major Booklet on Depression
Depressive Disorder. 3rd ed. American Psychi- www.nimh.nih.gov/health/publications/depression/
atric Association. Retrieved from http:// complete-index.shtml
psychiatryonline.org/content.aspx?bookid= National Alliance on Mental Illness:
28&sectionid=1667485#654166 What is Depression?
Gorman, L., and Sultan, D. (2008). Psychosocial www.nami.org/Template.cfm?Section=depression
Nursing for General Patient Care. 3rd ed. American Psychological Association:
Philadelphia: F.A. Davis. Depression
Kessler, R.C., Berglund, P., and Demler, O. www.apa.org/topics/depress/index.aspx
(2005). Lifetime prevalence and age-of-onset American Psychiatric Association Major
distributions of DSM-IV disorders in the Depressive Disorder Guidelines
National Comorbidity Survey Replication. http://psychiatryonline.org/content.aspx?bookid=28&
Archives of general psychiatry, 62(6), 593–602. sectionid=1667485#654166
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190 UNIT 2 | Threats to Mental Health

Test Questions
Multiple Choice Questions
1. Ms. S is admitted to your medical unit 5. The nursing interventions for a patient
with a diagnosis of dehydration and a with major depression would include all
history of depression. She tells you, “I of the following except:
just can’t eat. I’m not hungry.” Your best a. Active listening skills
therapeutic response would be: b. Maintaining safe milieu
a. “You aren’t hungry?” c. Encouraging adequate nutrition
b. “If you can’t eat, what is that candy bar d. Reassuring the patient everything will
wrapper doing in your bed?” be “just fine”
c. “Why aren’t you hungry?” 6. Your new patient is taking an MAOI for
d. “You really should try to eat some real severe depression. What would you tell
food.” the Dietary Department about her
2. Your patient has a diagnosis of major de- upcoming meals?
pressive disorder and has been started on a. No caffeine
sertraline (Zoloft) 50 mg bid. After tak- b. No processed lunch meat
ing the medications for three days, the c. No extra salt
patient says, “I don’t think this medicine d. Gluten-free diet
is working. I don’t want to take it any 7. Your patient with major depressive disor-
longer.” What would be your best der isolates herself in her room for the
response? whole day. You find her sitting and star-
a. I’ll let your doctor know and he may ing out the window. What is the best
order a different medication. therapeutic response when you walk in
b. These medications usually take a few the room?
weeks to bring about an improvement a. “Come with me. It’s time for group
to your symptoms. therapy.”
c. The important thing now is getting b. “I’d like to introduce you to other
you more involved in patient activities. patients.”
d. It is important to eat a more balanced c. “What are you thinking about?”
diet to help this medication work. d. Make frequent short visits to her room
3. Your patient appears withdrawn and and just sit there.
depressed. Which of the following would 8. Your patient, Mr. A, had a recent myocar-
not be an effective intervention? dial infarction and open heart surgery
a. Develop a trust. with an uncomplicated recovery. His wife
b. Show acceptance. tells you that Mr. A has changed and is
c. Be judgmental. now uncommunicative, sad, and discour-
d. Be honest. aged about the future. How would you
4. The nurse who is assessing a patient with respond to Mrs. A?
major depression would expect to observe a. I’ll let the doctor know.
which of the following symptoms? b. This is normal. I would just ignore it
a. Euphoria for now.
b. Extreme fear c. Tell me more about the changes in his
c. Extreme sadness behavior.
d. Positive thinking d. We should get a psychiatric consult.
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CHAPTER 11 | Depressive Disorders 191

Test Questions cont.

9. Mrs. J has been diagnosed with dys- 10. Which of the following is not true about
thymic disorder and has been taking depression?
paroxetine for 3 years. On arrival in your a. It is more common in men than in
mental health clinic, she presents very women.
differently than on her last visit. She is b. It is common after myocardial infarc-
cheerful, energetic, and talkative. Previ- tion.
ously she had been fatigued and negative. c. Grief after a major loss can mimic
What should you do? depression.
a. Encourage the patient to no longer d. Children and adolescents can suffer
take her antidepressant. from depression.
b. Get more information from the patient
about how she is feeling.
c. Recommend that she not be seen in
the clinic today.
d. Talk with the patient’s husband to con-
firm these behavior changes.
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C HA PT E R 12
Bipolar Disorders
Learning Objectives Key Terms
1. Describe three different types of bipolar disorders. • Bipolar disorder
2. Describe factors that make bipolar disorder difficult to • Cyclothymic
diagnose. • Hypomania
3. Describe nursing interventions for behaviors associated • Mania
with mania.
4. List three medications useful in treatment of bipolar disorders
and the potential side effects of each.
5. Describe two teaching points for bipolar patients on mood
stabilizers.

■ Characteristics of Bipolar with bipolar disorder. Patients may also abuse

alcohol or other substances in an effort to
Disorders self-medicate to feel better. Bipolar disorder
can be confused with depression, personality
Bipolar disorder (previously known as manic
disorders, schizophrenia, substance abuse,
depression) is characterized by marked shifts
and anxiety disorders. Clues that the illness is
in mood, energy, and ability to function, often
bipolar disorder include early onset, family
with profound depressions to periods of hy-
history of bipolar disorder, recurrent depres-
peractivity or mania with periods of normalcy.
sions, repeated loss of efficacy of antidepres-
The common forms of bipolar disorders in-
sants, and hyperactivity during depressive
clude bipolar I, bipolar II, and cyclothymic,
episodes (Akiskai, 2009).
as well as several others. These are listed in
See Box 12-1 for general information
Table 12-1. Bipolar disorders are often hard to
about bipolar disorders.
diagnose until the behavior becomes exagger-
ated, such as grandiosity, high-risk behaviors, Manic Phase
violence. During hypomania phases (less
The manic phase may last from days to months
severe hyperactivity), a person may be highly
and cause marked disruption of occupational
productive, so this disorder might not get
and social functioning. It can include the
diagnosed. Some highly creative people, such
following symptoms:
as Ernest Hemingway and Jackson Pollock,
had this disorder. Cyclothymic disorder is a • Easily distracted
chronic disorder marked by multiple episodes • Little need for sleep (may feel rested after
of hypomania and depression. 3 hours of sleep)
Mania episodes (also known as manic) are • Poor temper control, easily agitated and
characterized by a distinct period of abnor- irritable
mality and persistently elevated, expansive, or • Reckless behavior and lack of self-control,
irritable mood. Extreme mania can include including:
psychotic behaviors such as hallucinations • Drinking, and/or drug use, binge eating
and delusions. There is a high risk of suicide • Poor judgment

193
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194 UNIT 2 | Threats to Mental Health

l Table 12-1 Forms of Bipolar Disorders

Type Description
Bipolar I The classic image of bipolar disorder—a full syndrome of
manic symptoms and most likely depression episodes
Bipolar II At least one bout of major depression with episodic occurrence
of hypomania. This patient may never have experienced a full
episode of mania.
Cyclothymic A chronic mood disturbance of at least 2 years (one year in
children) duration involving numerous episodes of hypomania
and depressed mood but of less intensity.
Bipolar disorder due to Prominent and persistent disturbance in mood characterized
another medical condition by mania that is a direct result of physiological effects of a
general medical condition
Substance/medication - Disturbance characterized by elevated, expansive mood with
induced bipolar disorder or without depression that is the direct result of the physiologi-
cal effects of a substance, e.g., alcohol, amphetamines, cocaine,
heavy metals
Source: Adapted from Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (2013), American Psychiatric Association; and Townsend
(2012), Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. Philadelphia: F.A. Davis Company, with
permission.

l Box 12-1 General Facts About

Bipolar Disorders
• 3.9% of the American population will suffer
from this disorder in their lifetime.
• Affects males and females at approximately
the same rate.
• Episodes may or may not be associated
with periods of depression
• It is usually initially diagnosed between
ages 15 and 24.
• After the first episode, there is a high risk of
recurrence.
• Some have periodic episodes separated by
years, and others have much more frequent
cycles. Figure 12-1 Depiction of bipolar disorder.
• There is strong evidence for a genetic/
inherited link, but a specific genetic defect
has not yet been identified. • Sex with many partners (promiscuity)
• Occurs in children but is difficult to diag- • Spending sprees
nose. Symptoms can be confused with • Very elevated mood
attention-deficit/hyperactivity disorder or • Excess activity (hyperactivity)
substance abuse. • Increased energy
Sources: NIMH: www.nimh.nih.gov/health/publications/bipolar- • Racing thoughts, flight of ideas
disorder/complete-index.shtml . Kessler RC, Chiu WT, Demler O, • Talking a lot
Walters EE. Prevalence, severity, and comorbidity of twelve- • Very high self-esteem (false beliefs
month DSM-IV disorders in the National Comorbidity Survey
Replication (NCS-R). Archives of General Psychiatry, 2005 about self or abilities)
Jun;62(6):617–27. • Very involved in activities
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CHAPTER 12 | Bipolar Disorders 195

In the early phase of a manic episode, an in- • Eating problems

dividual can become more engaging and out- • Loss of appetite and weight loss
going with high achievement, energy, and • Overeating and weight gain
success. As a manic phase accelerates, this in- • Fatigue or lack of energy
dividual can become frenzied and out of con- • Feeling worthless, hopeless, or guilty
trol, leading to impaired decision making and • Loss of pleasure in activities once enjoyed
even altered appearance. For example, females • Loss of self-esteem
experiencing a manic episode may apply their • Thoughts of death and suicide
make-up in a distorted manner, especially lip- • Trouble getting to sleep or sleeping too
stick. The person may be more reckless in other much
areas such as business decisions and potentially • Pulling away from friends or activities
hazardous actions. The individual in a manic that were once enjoyed
phase may be prone to abuse substances such
The conversion to manic phase from the
as tranquilizers and/or alcohol to sleep and
depressed phase may appear quickly. Some-
control some aspects of this behavior. Sub-
times the two phases of manic and depres-
stance abuse may also trigger bipolar disorders.
sion overlap. They may occur together or
The presence of substance abuse with bipolar
quickly one after the other in what is called
disorder increases the negative outcomes and
a mixed state.
can confuse the illness presentation.
Neeb’s Patients in a manic phase can go Tool Box | General Behavior Inventory,
■ Tip for days without sleep and not which has been useful as a self-report monitor-
feel tired. ing tool in bipolar disorder, is found in Depue,
R. A., Slater, J. F., Wolfstetter-Kausch, H.,
Klein, D., Goplerud, E., & Farr, D. (1981). A
■■■ Classroom Activity behavioral paradigm for identifying persons at
• Watch films depicting people with bipolar disor- risk for bipolar depressive disorder: A concep-
der, including Pollack and Lust for Life. tual framework and five validation studies.
Journal of Abnormal Psychology, 90, 381–437.
Mood Disorder Questionnaire: Five-question
Depressed Phase screening tool:
The depressed phase of bipolar disorder is www1.nmha.org/bipolar/q uestionnaire.cfm
similar to those described for major depressive
disorders in Chapter 11. The following symp-
toms may be seen: ■■■ Critical Thinking Question
Your patient on the surgical unit has a diagnosis of
• Low mood or sadness cyclothymic disorder. Describe what behaviors
• Difficulty concentrating, remembering, or you might expect postoperatively.
making decisions

■ Etiology of Bipolar
Cultural Considerations
Disorders
• Bipolar disorder is more common in
higher socioeconomic groups. Biological theories predominate as the cause of
• As with other psychiatric disorders, mis- bipolar disorder. Studies indicate this disorder
diagnosis can occur due to misunder- is caused by an imbalance in neurotransmit-
stood practices and language barriers. ters, particularly norepinephrine, dopamine,
Bipolar disorder can be misdiagnosed as and serotonin. Increased levels are believed to
schizophrenia when culturally accepted be present in manic episodes and decreased
behaviors are misunderstood. in depressive ones. A genetic link has also
been demonstrated through family studies. A
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196 UNIT 2 | Threats to Mental Health

combination of genetics and biochemical fac- (Hirschfeld, 2008). Medications, the most
tors, along with environmental triggers such common being mood stabilizers, are the pri-
as stressful life events, may present the most mary treatment. These can be used during an
comprehensive picture. Medical conditions exacerbation as well as for control of fre-
and medications can trigger an episode in sus- quency and intensity of future episodes (see
ceptible people. See Box 12-2 for drugs and the Pharmacology Corner).
medical conditions that can precipitate a Treatment should include psychotherapy
manic state. in combination with medications to reduce
the severity of relapse and promote medica-
■■■ Critical Thinking Question tion compliance. Early diagnosis is also con-
Your new patient on the substance abuse unit has sistent with improved outcomes. Patients are
a diagnosis of bipolar disorder I as well as alcohol sometimes resistant to taking these medica-
use disorder. How would alcohol use contribute tions when they have stabilized due to poten-
to symptoms in bipolar I?
tial side effects. Therefore, education on
medication compliance is an essential part
of the treatment plan. After a manic phase,
■ Treatment of Bipolar psychotherapy and family therapy may help
Disorders patients and families cope with the shame and
long-term effects of the manic phase. During
Treatment for bipolar disorder often starts a manic phase, the patient may have hurt
emergently when family members realize the loved ones emotionally with words and ac-
patient is in a mania state. People are more tions. As life becomes flatter and less exciting
likely to seek treatment for themselves during without mania, the patient may need support
depressive phases than during manic phases. to cope with life with less highs and more
When someone is in a state of euphoria, he stability. It is common for patients to use al-
or she is less prone to accepting treatment and cohol and sedative drugs to try to sleep during
less likely to think there is a need for it manic episodes as well as stimulants during

Pharmacology Corner
l Box 12-2 Drugs and Physical Mood stabilizers are the cornerstone treat-
Illnesses That Can ment of bipolar disorders. See Table 12-2
Cause Manic States for a listing of mood stabilizer medications.
Drug Related Infections These include lithium and a number of
anticonvulsants including carbamazepine,
Steroids Influenza valproic acid, and lamotrigine. These medica-
Levodopa Q fever tions often are a lifelong regimen. People with
Amphetamines St. Louis encephalitis bipolar disorder may also continue on antide-
Tricyclic Red-like infections pressants and may require anti-anxiety and/or
antidepressants antipsychotic drugs such as olanzapine during
Monoamine oxidase Hyperthyroidism the acute manic phase. The antipsychotic
inhibitors aripiprazole is also used to treat bipolar
Methylphenidate Multiple sclerosis disorder. Many patients will continue on
more than one medication to remain in
Cocaine Systemic lupus
erythematosus remission. Patients must be counseled to re-
port side effects rather than stop medications
Thyroid hormone Brain tumors
abruptly. If side effects are too distressing,
Stroke alternative medication combinations can be
Source: Adapted from Gorman and Sultan (2008), Psychosocial prescribed. See Chapter 8 for additional
Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis information on mood stabilizers.
Company, with permission.
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CHAPTER 12 | Bipolar Disorders 197

l Table 12-2 Mood Stabilizers

Drug Category Drug Examples Important Considerations
Lithium Carbonate Lithium, Eskalith, Lithobid Toxic symptoms can occur even at normal
blood levels, so monitoring of adverse
effects must be ongoing. May take several
weeks to achieve full therapeutic effect.
Used with caution in the frail elderly who
are at risk for dehydration. Rapid discontin-
uation can increase risk of relapse. Patient
needs to report all other medications to
avoid drug interactions.
Anticonvulsants carbamazepine (Tegretol), Monitor CBC for possible blood dyscrasias.
gabapentin (Neurontin), Increased risk for suicide. May take several
valproic acid (Depakene), weeks to take effect.
lamotrigine (Lamictal)
Source: Adapted from Townsend (2012), Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. Philadelphia:
F.A. Davis Company, with permission.

depressive phases, so substance abuse coun- can cause tremors, confusion, seizures, coma,
seling may be part of the treatment plan. and even death. Early warning signs of toxicity
Treatment should also include monitoring include nausea, vomiting, and sedation. See
adequate fluid and food intake, as these can Table 12-3 for signs of lithium toxicity. Lithium
become compromised during all phases of takes about 7–10 days to reach the desired effect
this disorder. and is only available orally.
In the early phases of a manic episode, al- A variety of anticonvulsants are used as mood
ternative treatment that includes herbs such stabilizers. Regular CBCs to monitor for anemia
as chamomile and valerian can help with mild and blood dyscrasias are an important part of
anxiety and insomnia. the follow-up and patient teaching. Each anti-
Lithium requires close monitoring, including convulsant has a specific side-effect profile, so
regular blood levels. Therapeutic levels are be- this should be incorporated in patient teaching.
tween 0.5 and 1.2 mEq/L for most patients (1.0 Compliance with medication regimen is
and 1.5 in acute mania). There is a narrow range an ongoing issue with bipolar patients. If
between therapeutic and toxic levels, so close
monitoring is needed. The blood levels can be-
come elevated in dehydration, profuse sweating, l Table 12-3 Signs of Lithium
and chronic diarrhea leading to toxicity. Toxicity Toxicity
Serum Levels Symptoms
Neeb’s Lithium has a FDA black box warning 1.5–2.0 mEq/L Blurred vision, ataxia,
■ Tip that toxicity can occur at doses close tinnitus, nausea, vomit-
to therapeutic levels. It should be pre- ing, diarrhea
scribed when there are resources to 2.0–3.5 mEq/L Excessive output of
provide ongoing blood tests. dilute urine, increased
tremors, muscle irri-
tability, confusion
↑ 3.5 mEq/L Seizures, coma, oliguria,
Neeb’s Lithium toxicity can develop quickly, arrhythmias, cardiovas-
■ Tip especially in dehydration. Patient cular collapse
education must be an ongoing
process so patients are reminded to Source: Adapted from Townsend (2012), Psychiatric Mental Health
Nursing: Concepts of Care in Evidence-Based Practice, 7th ed.
monitor themselves. Philadelphia: F.A. Davis Company, with permission.
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198 UNIT 2 | Threats to Mental Health

they are in a euphoric state, they may believe ■■■ Critical Thinking Question
they don’t need medications. When they are A 29-year-old patient with a history of bipolar I
in remission, they may be more concerned disorder is NPO for surgery. He is routinely taking
about side effects and stop their medications. lithium and lamotrigine. Since he is unable to take
Patient teaching and follow-up counseling these medications, what concerns would you
have and what would you monitor?
continue as part of the nursing care of these
patients.
See Table 12-4 for the side effects of mood
stabilizers.
■ Nursing Care of the
Neeb’s Bipolar patients on medications Patient With Bipolar
■ Tip should be counseled to use birth
control as many of these medications
Disorders
are not safe to use in pregnancy. Common nursing diagnoses for patients with
Patients need to be counseled to bipolar disorder include the following:
speak with their physicians about
associated risks. • Anxiety
• Coping, ineffective
• Nutrition, imbalanced: less than body
Neeb’s Anticonvulsant drugs have an ad- requirements
■ Tip verse effect of increased risk of suici- • Self-care deficit
dality. Patients taking such drugs • Sleep pattern, disturbed
must be monitored closely for • Thought process, disturbed
worsening depression and suicidal
thoughts or behaviors. General Nursing
Interventions
• Provide clear, firm limits. Clearly define
Cultural Consideration what is expected and what is not allowed.
Ethnically diverse populations may metab- For example, if the patient needs to
olize medications differently. pace, set a specific area where that can
be done; if he is talking too loudly, point

l Table 12-4 Side Effects of Mood Stabilizing Agents

Side Effects Medication Nursing Implications
Drowsiness, dizziness, Lithium, anticonvulsants Educate patient on safety, driving.
Determine if dosing schedule allows
evening dose.
Dry mouth Lithium Sugarless candies, saliva substitute
GI upset Lithium, anticonvulsants Administer meds with meals.
Fine hand tremors Lithium Report to MD, dosage adjustment may
be needed, avoid caffeine.
Polyuria, dehydration Lithium Monitor I&O and weight.
Weight gain Lithium Need to maintain adequate sodium
even if reducing calories.
Increased suicide risk Anticonvulsants Monitor for worsening depression,
suicide risk.
Source: Adapted from Townsend (2012), Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed., pp. 622–623.
Philadelphia: F.A. Davis Company, with permission.
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CHAPTER 12 | Bipolar Disorders 199

this out and encourage the need to lower ■■■ Critical Thinking Question
his voice. A 45-year-old patient with a long history of bipo-
• Focus on reality, especially when the lar II disorder has been in remission for 5 years.
patient describes grandiose ideas. Present She tells you she has stopped taking her valproic
reality without arguing with patient. acid because she feels so good and the medica-
tion prevented her from losing weight. How
• Remove hazardous objects from the should you respond?
patient’s room. Promote safety for all
involved in the patient’s care by identify-
ing signs of increasing potential for
violence. ■■■ Clinical Activity
Identify the family support network for the bipolar
• Reduce external stimulation such as extra- patient and ensure that they are knowledgeable
neous noise. on monitoring signs of manic episodes.
• Provide an outlet for excess energy by
letting the patient pace or exercise.
• Encourage activities that don’t require a Table 12-5 provides the nursing care plan
lot of concentration for patients with bipolar disorders.
• Encourage patient compliance with
medication regimens and lab testing.
• Take the time to establish a relationship ■■■ Classroom Activity
• Review the drug categories for treatment of
with the patient to promote a sense of bipolar disorder and develop patient teaching
safety. materials for each.
• Identify ways to ensure the patient is
eating and drinking adequately; for exam-
ple, provide food that is easy to eat on
the move. ■■■ Key Concepts
• Encourage the patient to complete
thoughts or actions rather than jumping 1. Bipolar disorders can include severe de-
from item to item. pressions with periods of extreme mania,
• If the patient is depressed, see the nursing as well as severe depressions with minor
interventions in Chapter 11. bouts of mania.
2. The manic phase can last for days, weeks,
Neeb’s Patients can move quickly from or months and cause severe disruption in
all areas of functioning.
■ Tip social, affable, highly energetic,
fun behavior to angry, violent 3. Lithium remains a recognized treatment
behavior. for bipolar disorder and requires moni-
toring of blood levels to ensure safety.
Neeb’s Patients in a manic phase exhibit 4. A number of new medications to treat
■ Tip poor insight and judgment, so this bipolar disorder are now used as well,
provides a challenge to nurses to including many anticonvulsants.
manage inappropriate behavior. 5. Ongoing medication management is
challenging as the euphoric patient will
often deny the need for these medications.
■■■ Clinical Activity
• Monitor lithium levels. 6. Primary nursing interventions for a
• Review potential medication side effects that patient in mania include maintenance
can contribute to the patient’s symptoms as well of safety, promotion of health, and
as compliance with mood stabilizers.
medication compliance.
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200 UNIT 2 | Threats to Mental Health

l Table 12-5 Nursing Care Plan for Patients With Bipolar Disorders
Nursing
Data Collection Diagnosis Plan/Goal Interventions Evaluation
Inappropriate Ineffective Patient will Calmly point out to Patient is able
behavior including coping display more patient what behavior is to control one
loud conversation, socially accept- not appropriate, e.g., behavior for a
swearing, able behaviors “you’re talking too loud set period of
domineering again.” Avoid sounding time.
angry or judgmental.
Set limits on swearing.
Do not argue, bargain, or
threaten patient. Explore
how the patient can vent
his frustration/energy in
more socially acceptable
ways. Provide alternative
ways to express self.

CASE STUDY
Jonathan is a 30-year-old single attorney lot of attention in the office for a recent
living in New York City. He recently joined successful litigation. However, his assistant
a prestigious law firm and is anxious to notes he is increasingly irritable and de-
make a strong impression with the partners. manding, often changing from charming to
He has a long history of success in life, in- angry at the slightest frustration. A woman
cluding graduating from a top law school in the office reports him to the superiors for
with excellent scores, making a large in- inappropriate sexual advances. When he is
come, and having many friends and associ- brought into the office to discuss the allega-
ates. He is gregarious and always seems to tions, he explodes and storms out of the
be the center of attention wherever he is. office. Later that night he is arrested in a
His new position is more stressful than his bar for fighting with a patron and tells the
previous jobs were. He has been sleeping police he is friends with the chief of police
only 2 to 3 hours a night and then coming and will get the officer fired.
in to the office at 4 a.m. to keep up with Jonathan is brought to the ER by the
the workload. He drinks heavily at night to police and acknowledges he had been diag-
try to sleep and uses stimulants in the nosed with bipolar disorder in college but
morning to keep going. He has received a stopped taking his lithium a year ago.

1. What other information would you need to know regarding what type of bipolar
disorder he has?
2. What were the early signs that Jonathan was escalating into a manic phase?
3. What questions would you ask him regarding his history?
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CHAPTER 12 | Bipolar Disorders 201

REFERENCES Sorrel, J.M. (2011). Caring for older adults with

bipolar disorder. Journal of psychosocial nursing
Akiskai, H.S. (2009). Mood disorders: Treatment
and mental health services, 49(7), 21–25.
of bipolar disorder. In B.J. Sadock, V.A.
Townsend, M.C. (2012). Psychiatric Mental
Sadock, and P. Ruiz. (Eds.), Kaplan & Sadock’s
Health Nursing. 7th ed. Philadelphia:
Comprehensive textbook of Psychiatry. 9th ed.,
F.A. Davis.
pp. 1743–1813. Philadelphia: Wolters
Ward, T. D. (2011). The lived experience of
Kluwer/Lippincott Williams and Wilkins.
adults with bipolar disorder and comorbid
Carson, V.B., and Yambor, S.L. (2012). Manag-
substance abuse disorder. Issues in mental
ing patients with bipolar disorder at home.
health nursing 32(1), 22–27.
Home health nurse 30(5), 280–91.
Gorman, L.M. and Sultan, D.F. (2008).
Psychosocial Nursing for General Patient Care.
3rd ed. Philadelphia: F.A. Davis. WEB SITES
Kessler, R.C., Chiu, W.T., and Demler, O. National Alliance for the Mentally Ill infor-
(2005). Prevalence, severity, and comorbidity mation on bipolar disorder
of twelve-month DSM-IV disorders in the www.nami.org/Content/NavigationMenu/Mental_
National Comorbidity Survey Replication. Illnesses/Bipolar1/Home_-_What_is_Bipolar_
Archives of general psychiatry, 62(6):617–627. Disorder_.htm
McMurrach, S. (2012). Course outcomes and National Institute of Mental Health
psychosocial interventions for first-episode https://infocenter.nimh.nih.gov/subject.cfm?
mania. Bipolar disorders 14(6), 1–12. category=1000
National Institutes of Mental Health. Bipolar American Psychiatric Association
disorder. Retrieved from www.nimh.nih.gov/ Guidelines for Bipolar Disorders
health/topics/bipolar-disorder/index.shtml http://psychiatryonline.org/guidelines.aspx
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202 UNIT 2 | Threats to Mental Health

Test Questions
Multiple Choice Questions
1. Mrs. A is admitted to the medical/surgical 5. Which of the following drugs is NOT
unit with a diagnosis of dehydration and classified as mood stabilizer?
pneumonia. She has a history of bipolar a. Carbamazepine
disorder and is controlled on lithium. As b. Olanzapine
her nurse, you know you must: c. Valproic acid
a. Treat her carefully because she may d. Gabapentin
become catatonic. 6. Your manic patient says, “Everything
b. Observe for signs of lithium toxicity I do is great.” How should you respond?
from dehydration. a. “Yes, I am happy for you.”
c. Alert the other staff of the “psych” b. “Is there a time in your life when
patient on the unit. things didn’t go as planned?”
d. Treat the medical illness only. c. “No one can be great at everything.”
2. Mrs. D has an appointment with the d. “Keep it up.”
doctor. She began taking lithium one 7. Your manic patient has lost 5 pounds
month ago as prescribed. She now states and is underweight. Which meal is most
that her mouth and lips are constantly appropriate?
dry and she sometimes feels confused. a. Grilled chicken and baked potato
She says, “I stagger like I’m drunk some- b. Spaghetti and meatballs
times when I walk.” You suspect: c. Chili and crackers
a. She is drinking to combat her depres- d. Chicken fingers and French fries
sion.
b. She is making it up to get different 8. A newly admitted patient in an acute
medications. manic state has a nursing diagnosis of
c. She took too much lithium. risk for injury related to hyperactivity.
d. She is dehydrated. Which nursing intervention is most
appropriate?
3. Marge is a 68-year-old woman with a a. Place the patient in a room with an-
long history of bipolar disorder I. She is other hyperactive patient.
brought to the emergency room by her b. Have the patient sit in his room while
sister, who reports that Marge has been you review all the rules of the unit.
increasingly agitated, is unable to sleep, c. Administer antipsychotic medication
and told her daughter that the mayor was as ordered prn by the physician.
calling her for advice on running the city. d. Reinforce previously learned
The behavior is an example of: coping mechanisms to calm the
a. Delusions of grandeur patient down.
b. Delusions of persecution
c. Auditory hallucinations 9. Which statement is most true about
d. Schizophrenia bipolar disorder?
a. Bipolar disorders all follow the same
4. The physician orders lithium carbonate pattern of behavior.
600 mg tid for a newly diagnosed bipolar b. Bipolar disorders always include
patient. The therapeutic blood level for periods of major depression.
acute mania is: c. Manic depression is the same as
a. 1.0–1.5 mEq/L hypomanic disorder.
b. 10–15 mEq/L d. Patients with bipolar II have major
c. 0.5–1.0 mEq/L depression with hypomanic symptoms.
d. 5–10 mEq/L
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CHAPTER 12 | Bipolar Disorders 203

Test Questions cont.

10. Which category of medication would 11. What is cyclothymic disorder?

not be given to a patient with bipolar a. A chronic mood disorder of at least
disorder? 2 years
a. Stimulant b. A one-time event of hypomania
b. Antidepressant c. A continuous state of hypomania for
c. Antipsychotic 2 years
d. Anti-anxiety d. A chronic depression for 2 years
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C HA PT E R 13
Suicide
Learning Objectives Key Terms
1. Identify main populations at risk for suicide. • Lethality
2. Identify myths and truths about suicide. • Suicide
3. Identify warning signs of suicide. • Suicide attempt
4. Identify nursing care for people who are suicidal. • Suicide contract
5. Describe the management of a suicidal patient in the acute • Suicide ideation
hospital. • Suicide pact
• Survivor of suicide

■ The Reality of Suicide • Suicide crosses all cultural, age, gender,

race, and socioeconomic groups.
Suicide is defined as self-inflicted death, with • The actual ratio of attempts to completed
evidence that the person intended to die. Many suicides is probably at least 10 to 1.
people experience momentary self-destructive • A high percentage of people who complete
thoughts during a bout of depression or a set- suicide have made a previous attempt.
back in life, but they do not take action on • The risk of completed suicide is more than
these thoughts. Thinking about suicide does 100 times greater than average in the first
not mean the individual will act on those year after an attempt—80 times greater
thoughts; however, anyone who talks about, for women, 200 times greater for men,
threatens, or makes a suicide attempt must be 200 times greater for people over 45, and
taken seriously. Because suicide is viewed as un- 300 times greater for white men over 65.
acceptable in Western culture, it generates anx- • Suicide rates are highest in the age group
iety that has led to a number of myths. See of 45–54 years, with the over-85 group
Table 13-1 for a list of common myths. close behind (Fig. 13-1).
Here are some important facts about sui- • Veterans returning from war have a higher
cide in the United States: rate of suicide than civilians.
• Suicide is the third leading cause of death
• Suicide is the 10th leading cause of death among adolescents and young adults.
in the United States, accounting for more • Suicide pacts or copycat suicides among
than 1% of all deaths. some adolescent groups have been seen in
• More people die from suicide than from some communities.
homicide. • Single auto crashes are generally investi-
• More years of life are lost to suicide than gated as possible suicides.
to any other single cause except heart dis- • 8.3% of adults have serious thoughts of
ease and cancer. suicide during any year.
• 37,000 Americans died by suicide in • The most common methods of suicide
2010, which included four times as include firearms, hanging, and overdose.
many men as women; an additional The lethality of suicide methods is a factor
500,000 Americans attempt suicide in the assessment of the patient. Men more
annually. commonly use the highly lethal methods of
205
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206 UNIT 2 | Threats to Mental Health

l Table 13-1 Clearing Up the Myths About Suicide

Myth Truth
Asking people about their Most people are not afraid to talk about their thoughts of
suicidal thoughts will make committing suicide and are usually grateful that someone is
them more likely to act on them. available and cares. Talking can reduce the sense of isolation.
All people who attempt suicide People can become overwhelmed with life circumstances
have a psychiatric disorder. without having a psychiatric disorder.
A person who talks about Approximately 80% of individuals who attempt or complete
suicide will not do it. suicide give some definite verbal or indirect clues. As many
as 50% have seen their physician within the previous month,
often with vague somatic complaints.
A person who attempts suicide Almost 75% of those individuals who complete suicide have
will not try again. attempted it at least once before.
People who attempt suicide are Many individuals are ambivalent and are using the suicide as
always determined to die. a cry for help.
People who attempt suicide Even if the suicide attempt is manipulative, the individual
just want attention. may go on to complete the suicide.
As the person becomes less As the depression begins to lift, the individual’s energy level
depressed, the risk of suicide can increase before feelings of hopelessness are relieved. Once
decreases. the individual makes the decision that suicide is an effective
solution to the problems, his or her mood may even elevate.
Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.

• For every person who commits suicide,

six persons on average are left behind as
survivors of suicide.
(References include: National Center for
Health Statistics Suicide and Self-Inflicted
Injury, 2012; Mental Health America: Suicide,
2012; National Health and Nutrition Exami-
nation Survey, 2010; Substance Abuse and
Mental Health Services Administration News-
room, 2012; CDC Morbidity and Mortality
Weekly Report, 2013.)

■■■ Classroom Activity

• Discuss factors that contribute to suicide in
today’s society.
• Discuss the impact on yourself of suicide of
well-known people.

Figure 13-1 Older adults often have difficulty

Suicide remains a major public health
coping with loss, loneliness, and depression,
and they have very high rates of suicide. problem, and all nurses must be familiar with
risk factors, warning signs, and interventions
to provide support to individuals at risk.
firearms and hanging, accounting for their Suicide can be a long-planned action or an im-
higher death rate. Those who overdose have pulsive act when the person is overwhelmed.
a greater chance of surviving because they People with a variety of psychiatric disorders,
receive treatment if found in time. including depression, bipolar disorder, anxiety
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CHAPTER 13 | Suicide 207

Cultural Considerations l Box 13-1 Risk Factors for Suicide

White males constitute the largest group of Risk factors for suicide include the following:
suicides. Native American males are also at • More than 90% of people who die by
high risk. African American females tend to suicide have a mood disorder and/or a
have a lower rate (Goldston, 2008). Some substance abuse disorder. Mood disorder
can include depression or bipolar disorder.
groups are less prone to suicide based on
• Suicide risk can increase at the beginning
religion; for example, Roman Catholics. of treatment with antidepressants as the
Some cultures, however, are more tolerant return of energy brings increased ability to
than others of suicide. act out self-destructive thoughts.
• Alcohol is involved in many suicides.
• Prior suicide attempt
disorders, personality disorders, and sub- • Family history of mental disorder, sub-
stance abuse, may consider suicide. Drugs or stance abuse, family violence, sexual abuse,
or suicide
alcohol can contribute to accidental overdoses
• Exposure to the suicidal behavior of others,
when the individual’s judgment is impaired such as family members, peers, or media
or be part of the self-destructive cycle. The figures
Diagnostic and Statistical Manual of Mental • Poor support system
Disorders (DSM-5) has created a new cate- • Grief from recent loss
gory, named Suicidal Behavior Disorder, for • Untreated symptoms in terminal illness
an individual who has initiated a behavior
Source: From U.S. Public Health Service (1999) and Centers for Disease
with the expectation that it would lead to Control and Prevention (2010).
the individual’s own death within the last
24 months. Psychotic individuals can also ex-
perience hallucinations in which they believe hopelessness, shame, and guilt; and humili-
they are being told to kill themselves by voices ation, have been linked to suicidal ideation.
or powers outside of themselves. Being alert to Suicide may be viewed by some as a relief
signals that the patient is at risk for suicide re- from overwhelming suffering (physical or
quires good observation skills and communi- emotional); some see it as a way to reunite
cation with the patient and health-care team. with a loved one who has died. A psychotic
individual may view suicide as a way to stop
hallucinations, or the hallucinations may be
■■■ Critical Thinking Question telling the patient to commit suicide.
Your teenager tells you a friend swore her to See Box 13-1 for a list of common risk fac-
secrecy that she was going to kill herself because tors for suicide.
her boyfriend rejected her. Your teen asks you not
to tell anyone. What action should you take?
Suicide crosses all age groups. See Chapter 19
for more information on suicidal behavior in
children and adolescents. Older adults, espe-
cially those facing health issues and multiple
■ Etiology of Suicide losses, may be at risk for suicide. It is common
for suicidal older adults to have seen a health-
Research shows that the risk for suicide is as- care provider in the prior year, so identifying any
sociated with changes in brain chemicals risk factors in elderly patients is an important
called neurotransmitters, including serotonin. part of the care plan. White elderly men are
Decreased levels of serotonin have been found known to have one of the highest suicide rates.
in people with depression, impulsive disor-
ders, a history of suicide attempts, and suicide The Warning Signs of Suicide
victims (National Institute of Mental Health One of these signs does not necessarily mean
Statistics on Suicide, 2012). the person is considering suicide, but several
Psychological factors, such as anger of them may signal a call for help. Eight out
turned on oneself; an overwhelming sense of of 10 people considering suicide give some
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208 UNIT 2 | Threats to Mental Health

sign of their intentions, so these warning signs way. Television, movies, and computer
can save lives if recognized in time. People games that show death often do so in a
who talk about suicide, threaten suicide, or way that is glamorous or humorous.
call suicide crisis centers are 30 times more Young people may not make the connec-
likely to kill themselves. Suicidal people often tion between the fantasy of the media and
reach out for help and generally retain some the reality of life, or they become so
ambivalence or contradictory feelings experi- caught up in seeking revenge or making
enced simultaneously. Consequently, getting others suffer that they do not consider the
help to someone who is considering suicide finality of what they are attempting.
can save a life. Most people who consider 2. Person starts giving away personal items:
suicide have some level of ambivalence. When someone has made the decision to
The suicide warning signs from the National terminate his or her own life, it becomes
Center for Health Statistics on Suicide include no longer necessary to keep certain things.
the following: Some people will even attempt to give
• Verbal suicide threats, such as “You’d be away a beloved pet. However, these indi-
better off without me,” “Maybe I won’t be viduals do want those items cared for. In
around,” or “I won’t be here when you an attempt to “tie up loose ends,” they
come back to work” decide who will get certain items. The
• Expressions of hopelessness and helpless- items will be given away for reasons other
ness and the inability to see alternatives than “because I am going to kill myself,”
• Previous suicide attempts although people sometimes use that hon-
• Talking about suicide methods to which est approach and are not taken seriously.
the person has access Usually, these people will simply say that
• Saving pills it is time to clean out a certain room or
• Asking questions/researching about differ- that they no longer need a certain item
ent methods of committing suicide and they would like it to go to a special
• Daring or risk-taking behavior friend. Individuals may also write or
• Personality changes change a will when contemplating suicide.
3. Person starts talking about death and sui-
• Depression
• Lack of interest in future plans cide or becomes preoccupied with learning
about these things: Curiosity about death
(National Center for Health Statistics is not unusual. People tend to be curious
Suicide and Self-Inflicted Injury, 2012) about what they do not know. When this
Other warning signs may include the curiosity becomes a preoccupation and a
following: single thought for the patient, it signals
1. Noticeable improvement in mood occurs: that the patient has ideas of attempting
When this happens in a suicidal person, it suicide. Reporting this to the charge
is often a sign that the person has made nurse and documenting the concerns are
the decision that has been causing per- required.
sonal conflict. The pain that is being expe-
rienced will soon be over for that person. ■■■ Classroom Activity
The feelings of those who will be left be- Movies with suicide themes include The Hours and
hind may or may not be a consideration. Whose Life Is It Anyway?
It has been said that suicide is the ultimate
controller. For some people, this may be
the only situation they have felt they could ■ Treatment of Individuals
control in their lives. Some people are not at Risk for Suicide
concerned about the survivors because
their own pain overrides that of others. Suicide is a major public health concern. Pre-
Some people, especially younger ones, vention is focused on identifying people who
may view death in a more romanticized display the warning signs and risk factors, and
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CHAPTER 13 | Suicide 209

providing them with support and interven-

tions. Anyone who talks about suicide must Pharmacology Corner
be taken seriously and interventions insti- Suicidal patients may benefit from taking
tuted immediately to address her or his con- anti-anxiety medication, such as lorazepam,
cerns and problems. Individual and group to reduce feelings of intense anxiety or dis-
psychotherapy; emergency psychiatric care tress. In addition, antipsychotic and anti-
such as hotlines and on-call mental health manic medications may be prescribed as
professionals; pharmacological treatment for needed for patients with bipolar or psy-
depression, psychosis, and anxiety; and inpa- chotic disorders. If antidepressants are being
tient hospitalization if the person is at high started, it is important to remember that it
risk for suicide are some of the approaches. will take a number of weeks to lift depres-
Patients who make multiple suicide attempts sion, so other interventions must be used in
need ongoing psychotherapy to address their the interim to prevent suicide. Antidepres-
issues and impulses. Patients at low to mod- sants could actually increase suicide risk if
erate risk for suicide can be followed as out- the patient gets a sudden burst of energy to
patients with adequate support built in the act out the plan before the depression lifts.
treatment plan, such as family and friends, However, untreated depression puts the pa-
suicide contracts, medications, and regular tient at greater risk, so antidepressants are
mental health appointments. generally seen as protection against suicide.
Family and friends of anyone who com- Patients at high risk for suicide may need
mits suicide need special support. These indi- to have medications administered in liquid
viduals are referred to as survivors of suicide or parenteral form to avoid “cheeking” and
and are at risk for long-term emotional dis- hoarding pills that could be collected to use
tress, especially related to guilt and anger and for an overdose. Outpatients should be
their elusive search for “why?” The stigma of given only a few days’ supply of any med-
suicide adds to the complexity of a lifetime of ication that could potentially be used in a
trying to recover. Support groups are available suicide attempt. Overdosing on antidepres-
in many communities for survivors of suicide. sants is a highly lethal method of suicide, so
caution must be taken with how these are
Tool Box |
dispensed for someone at high risk.
• Suicidology.org has many resources for Adequate symptom management for
suicidal patients, their families, and profes- pain and other distressing symptoms must
sionals, including support programs for be provided to the patient with a serious or
survivors: terminal illness. A patient’s belief that his or
www.suicidology.org/suicide-survivors her symptoms cannot be controlled could
• National Suicide Prevention Lifeline offers a be a contributing factor in hopelessness and
24/7 free and confidential, nationwide net- suicide.
work of crisis centers: 1-800-273-TALK
(8255)
• Federal government mandated suicide pre- • Anxiety
vention hotline number: 1-888-SUICIDE • Coping, ineffective
(1-888-784-2433) • Self-concept, disturbed
• Spiritual distress
• Thought processes, altered
■ Nursing Care of the
Nursing responsibilities for patients who
Suicidal Patient are suicidal are many. The goal, of course, is
Common nursing diagnoses in those at risk always to prevent the suicide. Because the
for suicide include the following: nurse may not know when suicide potential
exists, especially for a first attempt, using ex-
• Hopelessness cellent observational skills and communication
• Violence to self, risk for skills is mandatory. Nurses are bound (under
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210 UNIT 2 | Threats to Mental Health

the Meier v. Ross General Hospital case) to ■■■ Clinical Activity

report any reasons they have to suspect the • If your patient has been identified as suicidal,
patient may be suicidal. Nurses must report review the care plan for all the safety measures in
their observations to their team and document place for this patient.
actions in the health-care record. A nurse • Review policies from assigned hospitals on how
to manage suicidal patients.
should never take the responsibility of helping
a suicidal person on his or her own. Once a
nurse suspects suicidal ideation, informing all 3. Communication: Ask outright if the patient
members of the health-care team is essential so is considering suicide and, if so, how and
appropriate treatment and patient safety can when. Asking a patient to talk about suici-
be ensured. If a patient is considered suicidal, dal thoughts does not enhance the chance
the following interventions can be helpful. of completing a suicide. Rather, it demon-
General Nursing Interventions strates caring and acknowledges his or her
value as a person. Ask if the patient has at-
1. Monitoring frequently: Check on the suici-
tempted suicide in the past. In addition, be
dal patient frequently but avoid a pre- prepared to talk to the patient about his or
dictable routine and ensure that the her feelings, work to reframe hopelessness,
patient is checked during extra-busy times and assist in problem solving to identify
like shift change. If the patient is actively alternative solutions to problems the
suicidal, a psychiatric consultation will be patient views as insurmountable. When
required and the patient may be placed on talking to someone who is suicidal, avoid
1:1 precautions until the patient can be platitudes like “think what this would do to
moved to an appropriate treatment set- your children.” Often the suicidal person is
ting. On 1:1 precautions the nurse will be so immersed in feelings of hopelessness and
required to accompany and remain with isolation that he is unable to identify with
the patient in the bathroom. Nurses must how others are feelings. In addition, the pa-
follow their agency policies on providing tient may view that the family will be better
safety for the suicidal patient. off without him. When working on prob-
2. Safety: Keep any potentially harmful items
lem solving, break down one problem into
away from the patient, such as knives, manageable steps rather than looking at the
scissors, glass, razor blades, belts, nail files, whole picture, which can be overwhelming.
electrical cords, and even linens. Inform Most people who are suicidal have ambiva-
visitors of this so they do not bring items lent or mixed feelings about taking action.
patient may request. Ensure that windows Supporting the reasons the person does not
cannot be opened. The room may need to want to commit suicide can help the per-
be searched periodically, and the patient son to reevaluate the situation.
may need a body search and close moni-
toring in the bathroom. It is common for
patients who are at very high risk for sui- Neeb’s • If you suspect someone is suicidal,
cide to wear paper gowns and to have
■ Tip be direct in asking about his or her
paper bedding. Large objects that can be plans.
used to break a window also need to be • Suicide is an emotional subject and
removed. Plastic trash bags should not be great care must be taken with any-
used in the patient’s room. one who expresses suicidal ideation.
Report any suicidal ideation or be-
Tool Box | American Association of Suicidol- havior immediately.
ogy Guidelines for Inpatient and Residential • The hopelessness experienced by
Patients Known to Be at Elevated Risk for a suicidal patient can be draining
Suicide at: and overwhelming for the nurse.
http://www.suicidology.org/c/document_ Recognize that team members
library/get_ fi le? folderId= 266& name= need extra support when working
D LF E -613.pdf with anyone who is suicidal.
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CHAPTER 13 | Suicide 211

■■■ Clinical Activity ■■■ Critical Thinking Question

If your patient has a history of suicide attempts, Your 85-year-old patient is a recent widower. He is
discuss any concerns with your instructor. in the hospital for recovery from a recent fall. He tells
you he wants to go home so he can be with his
wife. How would you respond to that statement?

4. Contract: The treating team may want to

consider making a suicide contract with ■■■ Critical Thinking Question
the patient. This is a written agreement Your patient with multiple chronic health prob-
between the patient and the treating lems has been diagnosed by the psychiatrist as
team where the patient agrees to inform actively suicidal. She is too ill to be transferred to
the psychiatric unit. Describe what actions the
the team before taking any action to team should take to prevent a suicide attempt on
harm him- or herself. See the Toolbox to your medical surgical unit.
access a sample contract. A contract is
helpful for some patients who are waver-
ing on what to do. Table 13-2 provides the nursing care plan
for suicidal patients.

Tool Box | Example of suicide contract at ■■■ Classroom Activity

www.suicide.org/no-suicide-contracts.html Obtain information about local suicide prevention
programs such as counseling centers and hotlines.

5. Discharge planning: Any patient with Neeb’s Patients who are terminally ill may ver-
suicidal ideation needs close follow-up at ■ Tip balize vague suicidal thoughts such as
“I would kill myself if my pain gets too
time of discharge from the hospital.
bad.” Encourage your patient to talk
Mental health follow-up, hotline numbers,
about fears and discomforts. Patients
involving family/friends in the discharge
with good symptom management are
plan, and ensuring that discharge prescrip-
much less likely to think about suicide.
tions are dispensed in small amounts are
some things to be incorporated in the plan.
(Guptill, 2011; Puskar & Urda, 2011; ■■■ Clinical Activity
Rittenmeyer, 2012; Sun, 2011). When administering medications to suicidal
patients, consider having a colleague with you to
See Box 13-2 for suggestions on talk- double-check that the patient has swallowed
ing with a suicidal patient to evaluate the pills.
lethality.

l Box 13-2 Talking With a Suicidal Patient to Evaluate Lethality

1. Do you think about hurting or killing yourself? If yes↓
2. Do you have a plan? How have you considered doing it? If yes↓
3. Do you think you may or will do something to act on your thoughts? If yes, where and when?
Do you feel you have control over your own behavior?
4. Do you have the means available (such as rope, rolled-up sheet, gun, saved-up pills [note
lethality of plan])?
5. Have you ever tried to harm yourself in the past? If yes, how? Did you expect to survive?
6. Are you willing to contract or notify staff whenever you feel you may act on these thoughts?
Our side of the contract is to be available and actively help you during these times.
If the patient denies having a suicide plan, ask about other plans for the future and support systems.
1. What do you see yourself doing in a week, in a month, and in a year from now?
2. Do you feel optimistic or pessimistic about the future?
3. Do you have family members or friends with whom you can freely discuss your problems?
Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.
2993_Ch13_205-216 14/01/14 5:24 PM Page 212

l Table 13-2 Nursing Care Plan for Suicidal Patients

Assessment/ Interventions/
Data Nursing Nursing
Collection Diagnosis Plan/Goal Actions Evaluation
Patient Hopelessness Verbalize Listen to patient’s concerns Patient agrees
describes possible and worries. to try one
hopelessness; solutions Avoid minimizing them. alternative
unable to view to current Help patient identify one solution to
the future in problems problem and discuss alter- recent
a positive native ways to view it. problem.
manner; denies Provide a different perspective
options on the problems.
to resolve Appeal to the patient’s am-
dilemmas; bivalence by stressing reasons
verbalizes he does not want to do this.
suicide as only Describe a recent situation
alternative where you observed the
patient being successful.

■■■ Key Concepts skills, including working collaboratively

with team members to keep the patient
safe.
1. Suicide is the 10th leading cause of death
in this country and remains a serious 3. The most common psychiatric diagnoses
public health problem. All nurses must for suicidal patients include depression
be aware of risk factors and warning and substance abuse.
signs for suicide in their patients and
4. Most people considering suicide have
take action as needed.
some ambivalence, so they will often
2. Caring for a suicidal patient requires ex- leave clues as to their plans.
cellent observation and communication

CASE STUDY
Jeff is a 54-year-old man who is recently di- irritable, and much less sociable. They call
vorced with four grown children. He is living him to go out, but he repeatedly declines.
alone in a furnished apartment and was re- One friend calls Jeff’s ex-wife to tell her that
cently laid off from his accounting job. He Jeff called him and was quite emotional, say-
spends most days alone and has started drink- ing he feels guilty for the way he treated her
ing in the morning. He recently got a DUI and his children over the years. Jeff told the
and had to give up his driver’s license. He has friend he feels like a failure in life and won-
been a hunter all his life and has a variety of ders if his kids would be better off if he were
guns in a local storage unit. He has several not around. The friend tells Jeff’s ex-wife that
close friends who report that Jeff is depressed, he believes Jeff is thinking of moving away.

1. With the information presented, what signs would suggest that Jeff may be suicidal?
2. What suggestions would you give Jeff’s ex-wife and his friend to address potential suicidal
ideation?
3. If Jeff’s ex-wife brought him to your mental health clinic, what information would you
want to know initially?
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CHAPTER 13 | Suicide 213

REFERENCES U.S. Surgeon General and of the National

Action Alliance for Suicide Prevention.
American Psychiatric Association. (2013).
2012. Office of the Surgeon General (U.S.):
Diagnostic and Statistical Manual of Mental
National Action Alliance for Suicide
Disorders 5. Washington, DC, Author.
Prevention (U.S.). Washington D.C.:
(Known as DSM-5)
US Department of Health and Human
Centers for Disease Control and Prevention
Services, September 2012. http://www.ncbi.
(2013). Suicide Among Adults Aged 35–64
nlm.nih.gov/books/NBK109922/
Years United States 1999–2010. Morbidity
Puskar, K., and Urda, B. (2011). Examining the
and mortality report 6/13/13. http://www.cdc.
efficacy of no-suicide contracts in inpatient
gov/mmwr/preview/mmwrhtml/mm6217a1.
psychiatric settings: implications for psychiatric
htm?s_cid=mm6217_w
nursing. Issues in mental health nursing, 32(12),
Centers for Disease Control and Prevention.
785–788.
(2010). Violence Prevention. Retrieved from
Rittenmeyer, L. (2012). Assessment of risk for
www.cdc.gov/ViolencePrevention/suicide/risk
in-hospital suicide and aggression in high-
protectivefactors.html
dependency care environments. Critical Care
Gelenberg A.J., et al. (2010). Practice Guideline
nursing in clinics of North America, 24(1),
for the Treatment of Patients with Major
41–51.
Depressive Disorder. 3rd ed. American
Substance Abuse and Mental Health Services
Psychiatric Association. Retrieved from
Administration Behavioral Health,
http://psychiatryonline.org/content.aspx?boo
United States, 2012 at http://samhsa/gov
kid=28&sectionid=1667485#654166
Sun, F.K. (2011). A concept analysis of suicidal
Goldston, D.B., et al. (2008). Cultural consider-
behavior. Public health nursing, 28(5),
ation in adolescent suicide prevention and
458–468.
psychosocial treatment. American psychologist,
U.S. Public Health Service. The surgeon
63, 14–31.
general’s call to action to prevent suicide.
Gorman, L., and Sultan, D. (2008). Psychosocial
Washington D.C.: US Department of Health
Nursing for General Patient Care. 3rd ed.
and Human Services, 1999. Retrieved from
Philadelphia: F.A. Davis.
www.surgeongeneral.gov/library/calltoaction/
Guptill, J. 2011. After an attempt: caring for the
default.htm.
suicidal patient on the medical-surgical unit.
Medical-surgical nursing, 20(4), 163–167.
Mental health America: Suicide. 2012. Retrieved WEB SITES
from www.nmha.org/go/suicide National Suicide Prevention Lifeline
National Center for Health Statistics suicide and www.suicidepreventionlifeline.org
self-inflicted injury. 2012. Retrieved from National Alliance on Mental Illness
www.cdc.gov/nchs.fastfacts/suicide.htm www.Nami.org
National Health and Nutrition Examination Suicide Prevention Advocacy network
Survey. 2010. Retrieved from www.cdc.gov/ http://capwiz.com/spanusa/home/Alliance of Hope
nchs/nhanes.htm for Suicide Survivors
National Institute of Mental Health statistics on allianceofhope.org/
suicide. 2012. Retrieved from www.nimh. Suicide Prevention, awareness, and support
gov/health/publications/suicide-in-the-us- www.suicide.org
statistics-and-prevention/index.shtml American Association of Suicidology has
National Strategy for Suicide Prevention: Goals resources on multiple topics
and Objectives for Action: A report of the www.Suicidology.org
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214 UNIT 2 | Threats to Mental Health

Test Questions
Multiple Choice Questions
1. A nursing intervention that is appropriate 5. Your charge nurse tells you that Mr. P
for a patient who is suicidal is: must be placed on suicide precautions.
a. Report the patient to the police. The first intervention you begin is:
b. Ignore the patient’s suicidal comments, a. Place Mr. P in a locked unit.
considering them “attention getting.” b. Begin one-on-one observation at least
c. Tell the patient that he or she “has so every 15 minutes.
much to live for!” c. Call the security code over the public
d. Listen to the patient’s concerns and address system.
worries d. Allow Mr. P to shave and carry out his
2. A person is more likely to commit suicide bedtime care.
when he or she: 6. Further discussion with Mr. P reveals he
a. Is in deepest depression is of a religious sect that believes there is
b. Has a sudden lift from previous honor in dying for one’s religion. He does
depressed mood not understand why everyone is so afraid
c. Is confused to die in this country. As his nurse, you:
d. Is feeling loved and appreciated a. Document the discussion and remove
3. Your patient tells you, “I am just a burden. the suicide precautions, citing religious
Everyone would be better off if I was freedom.
dead.” Nurses are aware that: b. Encourage him to present his beliefs at
a. Suicide talk is just an attention-getting group tomorrow.
device. c. Document the discussion but tell him
b. Suicide is an impulsive act; it is not that the suicide precautions remain in
thought out. effect.
c. Suicidal talk or ideation can lead to d. Thank him for his explanation and
suicidal behavior. bring him his next dose of medication.
d. Suicidal people seldom really attempt 7. Which of the following people is at
suicide. highest risk for suicide based on the
4. Mr. P is brought to the hospital by his information provided?
wife. She states that he has been treated a. Nancy is a 33-year-old mother of two
for depression recently, but that tonight who just lost her mother in a motor
he said, “You and the kids don’t need me vehicle accident.
messing up your lives.” Mr. P tells you b. Jim is a 68-year-old man who is a
he has been thinking about suicide for recent widower and has a long history
some time now. A nursing diagnosis for of alcohol abuse.
Mr. P would be: c. Carol, age 18, has a long history of
a. Knowledge deficit related to family sickle cell disease and is depressed over
needs chronic pain and the inability to attend
b. Ineffective individual coping as her prom.
evidenced by manipulation of wife’s d. Hans is a 55-year-old man with end
feelings stage pancreatic cancer who is entering
c. Anxiety related to hospitalization a hospice program.
d. Potential for violence, self-directed, as
evidenced by stating suicidal thoughts
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CHAPTER 13 | Suicide 215

Test Questions cont.

8. Susan is 27 years old and has been 10. The fact that Susan is telling you she has
admitted from the ED with an overdose another plan indicates what?
of an antidepressant. She tells you, “My a. She is reaching out for help and is
boyfriend broke up with me and I can’t ambivalent about wanting to die.
live without him.” What is your best b. She is committed to her suicide plan.
response? c. She is psychotic.
a. “You are young. You will find someone d. She needs antidepressants started
else.” right away.
b. “Forget him. You can do better than
him. He isn’t worth losing your life for.”
c. “Why did he break up with you?”
d. “You must have been feeling very sad
when he told you.”
9. The next day, Susan tells you that she has
another plan to “finish the job when I get
out of here. Please don’t tell anyone.”
What would be your best response?
a. “You are safe here.”
b. “What are you planning to do?”
c. “I won’t tell anyone if you promise not
to do anything to yourself.”
d. “I was hoping you were feeling better.”
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2993_Ch14_217-230 14/01/14 5:25 PM Page 217

C HA PT E R 14
Personality Disorders
Learning Objectives Key Terms
1. Define and differentiate between personality and personality • Antisocial personality
disorder. disorder
2. Describe three personality disorders as designated by DSM-5. • Avoidant personality
3. Describe two behavioral symptoms of each of these three per- • Borderline personality
sonality disorders. • Dependent personality
4. Identify nursing interventions for these three disorders. disorder
5. Discuss some of the challenges in caring for a patient with • Histrionic personality
borderline personality disorder. disorder
• Narcissistic personality
• Obsessive-compulsive
personality disorder
• Paranoid personality
disorder
• Personality
• Personality disorder
• Schizoid personality
disorder
• Schizotypal personality
disorder
• Self-mutilating behavior

P
ersonality is defined as the complex in different areas of life do they become per-
characteristics that distinguish an indi- sonality disorders. Personality disorders are
vidual. It includes one’s thoughts, feel- frequently seen in the general population and
ings, and attitudes. Personality traits are may coexist with other psychiatric disorders.
enduring patterns of perceiving, relating to, It is common that more than one personality
and thinking about the environment and disorder exists in these patients. Patients with
oneself that are exhibited in a wide range these disorders can present challenges for
of social and personal contexts. Personality the nurse as maladaptive mechanisms includ-
development occurs in response to a number ing manipulation are used to cope with the
of biological and psychological influences. stresses of their illnesses.
Theorists include Erik Erikson. Personality
disorders occur when these traits become in-
flexible and maladaptive, and cause either sig- Cultural Considerations
nificant functional impairment or subjective Personality development is impacted by
distress (Townsend, 2012). Most people dis- culture. Thoughts, feelings, and attitudes
play some traits of these disorders from time are influenced by the cultural values
to time, but only when they are consistent be- surrounding people.
haviors that contribute to some dysfunction
217
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218 UNIT 2 | Threats to Mental Health

There are 10 personality disorders as de- of other people. The person displays consis-
scribed in DSM-5. These 10 disorders are tent mistrust of others’ motives. These indi-
grouped in 3 clusters based on their similarities. viduals may seem “normal” in their speech
and activity, except for the fact that they feel
1. Cluster A (Behaviors described as odd)
people treat them unfairly. People with para-
• Paranoid personality disorder
noid personality disorder are prone to filing
• Schizoid personality disorder
lawsuits when they feel wronged in some way.
• Schizotypal personality disorder
They also seem to be hypersensitive to activity
2. Cluster B (Behaviors described as dramatic)
in their environment. They tend to be
• Antisocial personality disorder
guarded and secretive since they can’t trust
• Borderline personality disorder
others. They may have difficulty maintaining
• Histrionic personality disorder
focused eye contact, for example, because
• Narcissistic personality disorder
they are so alert to other activity around
3. Cluster C (Behaviors described as
them. People with paranoid personality
anxious or fearful)
disorder are not easily able to laugh at them-
• Avoidant personality disorder
selves; they take themselves very seriously.
• Dependent personality disorder
They may not show tender emotions and may
• Obsessive-compulsive personality
seem cold and calculating in their relation-
disorder
ships. They are reluctant to confide in others.
Generally, the personality disorders include They tend to take comments, events, and
one or more of the following traits: situations very personally. They have an
excessive need to be self-sufficient which can
• Negative affect: frequently experiences
create challenges if they become ill. As a
negative emotions
general rule this person would probably avoid
• Detachment: withdrawal from others
the health-care system if possible.
• Antagonism: difficult to get along with
Patients with paranoid personality disorder
• Disinhibition: impulsive
are not psychotic and do not have hallucinations
• Inflexible
and delusions; they are, however, suspicious of
Personality disorders often have their roots other people and situations. The suspiciousness
in difficult relationships with parental figures. may cross into other areas of the person’s life.
Though each disorder has its own dynamics, For instance, it may be very challenging to enlist
this relationship is the thread that runs the cooperation of a person with this disorder
through all of them. Genetics may be a factor when it comes to taking medications if the
in some of these disorders as well. patient suspects ulterior motives.
Paranoid personality seems to have a high
■■■ Classroom Activities incidence of occurrence within families with
• Watch films that include people with personality schizophrenia, which supports the theories of
disorders and discuss characteristics: One Flew
Over the Cuckoo’s Nest (antisocial), Fatal Attraction
the geneticists. Difficult parental relationships
(borderline), Wall Street (narcissistic). where the child is used as a scapegoat for par-
• Share experiences of people you have known ents’ aggression can be a contributor as well.
who exhibit various personality disorders.

Cultural Considerations
■ Types of Personality Members of minority groups or immi-
Disorders grants may be prone to some paranoid
traits due to their unfamiliarity with soci-
Cluster A ety’s rules and expectations. This would
not be considered a paranoid personality
Paranoid Personality Disorder disorder unless it becomes pervasive and
Individuals with paranoid personality present creates more problems for the person.
with behaviors of suspiciousness and mistrust
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CHAPTER 14 | Personality Disorders 219

Schizoid Personality Disorder schizophrenia, giving strength to genetic and

People with schizoid personality disorder have biological factors.
a pattern of detachment from social relation-
ships and a restricted range of expression of Tool Box | Psych Central overview on
emotions in interpersonal settings. They may schizotypal personality disorder:
appear shy and introverted. They have trouble psychcentral.com/disorders/sx 33.htm
developing friendships. They tend to respond
in a very serious, factual manner that is pleas-
ant but not warm or inviting. They may be Cluster B
described by others as cold.
It is unusual to see patients hospitalized for Antisocial Personality Disorder
this disorder because they are so quiet that the This group of people probably causes the great-
disorder often goes unnoticed. They often are est amount of trouble for society. Sometimes
described by others as “loners.” It is common referred to as sociopathic, people with this dis-
to see people with this type of personality order have a disregard for the rights of others.
become very engrossed in books. The books It often leads them to a path of violating rules,
may be a substitute for human companion- lying, stealing, participating in a variety of
ship. Partly because of this aversion to social illegal activities, and other infringements of the
interaction, people with schizoid personalities law. The disorder seems to affect males more
tend to be very intellectual and can be very frequently than females and affects about 1%
successful in life if they choose a career that of the U.S. population (Lenzenweger, M. F.,
fits their personality. They may appear indif- Lane, M. C., Loranger, A. W., & Kessler, R. C.
ferent to the approval or criticism of others. [2007]). The serial killer Ted Bundy is one of
It is believed that ineffective and unemo- the best-known sociopaths. As these individu-
tional parenting may contribute to this als end up in the court systems, they may be-
disorder. A family history of schizophrenia or come part of the health-care system to avoid
schizotypal personality disorder supports a legal consequences or due to court order. These
genetic link. individuals have difficulty handling frustration
and anger. They seldom feel affection, loyalty,
Schizotypal Personality Disorder guilt, or remorse and show very little concern
Behavior in this disorder is often odd and ec- for the rights or feelings of anyone else. It is
centric but not to the level of schizophrenia rare that they display true remorse for their
(see Chapter 15). Although under stress, this acts. People who have this disorder are also at
person may decompensate with psychotic high risk for substance abuse. In addition, a
symptoms such as delusions and hallucina- pattern of impulsiveness and irresponsibility
tions. Aloof and isolated, these individuals are major features, with actions poorly
often appear to be in their own world with lan- planned. This type of person has difficulty with
guage and gestures that only they understand close relationships and may move from jobs
and reduced capacity for close relationships. and relationships frequently.
Often appearing blank and apathetic, their In spite of the inability to feel or show af-
emotional responses may seem inappropriate. fection, patients with antisocial/sociopathic
They also may display paranoia and social personality disorder are usually gregarious, in-
anxiety. Diagnosis is made by a mental health telligent, and likable but can quickly move to
professional who looks at symptoms and aggression if frustrated. Most people with this
life history. disorder are able to control their behavior out
Origins of this disorder may include poor of fear of punishment; only those with
relationships with parental figures where there extreme cases are unable to do so.
is discomfort with affection and closeness, Because people with antisocial personality
leading to distrust in personal relationships. disorder are frequently highly intelligent,
In addition, this disorder is more common they learn the “jargon” of psychology and
among first-degree relatives of people with know how to manipulate it. Those with
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220 UNIT 2 | Threats to Mental Health

antisocial personality disorder are difficult to 20% of psychiatric inpatients (BPD Resource
treat as the individual often has little moti- Center, 2012). Borderline personality disor-
vation to change. der (also known as BPD) is much more
It is widely believed that the roots of this common in females. “Instability” is often the
disorder stem from dysfunctional parenting first word one thinks of when considering
and family life. This may be from a permissive BPD. Individuals with this disorder often ex-
or authoritarian parenting style that does not hibit both clinging and distancing behavior
include guidelines for appropriate social be- as they struggle with fears of separation and
havior and includes abuse. A chaotic family abandonment. They are known for intense
life is often found. This personality disorder and chaotic relationships as well as self-
may be displayed in childhood with signs of destructive, impulsive, and dramatic coping.
callousness and lack of empathy. Some evi- A chronic sense of emptiness, poor self-image,
dence also exists that there may be brain ab- and excessive self-criticism are part of this
normalities in how the individual processes disorder. These individuals operate using in-
emotions. Childhood bullying and cruelty, grained behavior patterns that involve manip-
animal abuse, as well as manipulative behav- ulating others to achieve their goals to reduce
iors are seen at an early age. Individuals may anxiety. These patients may also utilize self-
have been diagnosed with conduct disorder mutilating behaviors, including self-inflicted
before age 15 (see Chapter 19). These behav- cuts (known as cutting), which usually are not
iors can run in families, so a genetic link is performed with suicidal intent. The cutting
also suspected. can be a way to reduce tension, inflict pain to
validate one’s feelings and challenge a perva-
Neeb’s Patients with antisocial personality sive sense of emptiness, or seek attention.
■ Tip can be challenging as they can use Substance abuse is also often a factor as the
unscrupulous means to accomplish
person tries to control the anxiety.
their goals without the staff realizing
The origins of BPD can include coming
it. Rather than telling the patient,
from an abusive background and a childhood
“you shouldn’t do that,” reword to
where one was dismissed by authority figures.
“you are expected to ...” to establish
Poor relationships with parental figures where
clear expectations that you are not
the child grows up facing issues around aban-
negotiating.
donment and dependency are often seen. De-
fense mechanisms of denial, projection, and
splitting (inability to integrate positive and
■■■ Critical Thinking Question
You are working on a substance abuse unit. When negative feelings at the same time) are known
you walk on the unit, you see a patient named to be commonly used. Splitting is manifested
Brad with a number of nursing staff. He is telling by a patient who needs to see others as all
funny anecdotes about celebrities, and many of good or all bad. For example, a nurse who is
the nurses seem to be enjoying themselves. Brad caring during one shift may become to the
is quite handsome and charming. After this occur-
rence, Brad asks one of the nurses for a special patient the idealized “perfect” nurse, and then
privilege to take a walk off the unit. How would the nurse who sets limits on another shift is
you advise this nurse to handle this request? called “mean.”
When the nurse denies the patient’s request,
he quickly changes from charming to cruel as he
insults the nurse and then knocks over a lamp.
Neeb’s Recognizing staff splitting is essential
How should the staff respond? ■ Tip for good care of the patient. If a pa-
tient complains about other staff
members, never encourage him or
her. Rather, point out that the patient
Borderline Personality Disorder needs to address the concerns with
This diagnosis is the most frequent personal- the individual and not complain
ity disorder seen in the clinical setting, mak- about staff members to others. Avoid
ing up 2%–6% of the general population and taking sides or acting as intermediary.
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CHAPTER 14 | Personality Disorders 221

Tool Box | AHRQ National Guidelines

Clearinghouse on borderline personality
disorder:
www.guideline.gov/content.aspx ? id= 14327
& search= borderline+ personality# Section420

■■■ Clinical Activity

When you are informed that your patient has a
borderline personality, get specific information on
interventions that the team has been using to
avoid getting in the middle of conflict between
the patient and staff. Figure 14-1 Self-inflicted lacerations on teenage
girl’s arms.

Neeb’s Though cutting behaviors are more

maintaining close, intimate relationships is
■ Tip common in adolescents, they can common despite the gregarious and seductive
occur in adults.
behaviors.
This disorder is more common in women.
Tool Box | Borderline Personality Disorder Childhood experience of needing to be dra-
pamphlet for patients and families: matic to get recognition or needs met, lack of
www.nimh.nih.gov/health/topics/border- feedback from parents about appropriate be-
line-personality-disorder/index .shtml havior all contribute to the development of
BPD Central with information for patients this disorder.
and families:
www.bpdcentral.com/ Neeb’s Histrionic traits do not mean the
■ Tip person has histrionic personality
disorder. To have the disorder,
the person would have consistent
■■■ Critical Thinking Question problems functioning in life as a
A 25-year-old woman is admitted from the ER to
your unit with superficial cuts on both arms, a result of these traits.
high blood alcohol level, and a complaint that she
was attacked by her boyfriend. She is emotional
and angry. As you sit with her to complete the ad- Narcissistic Personality Disorder
mission, she shares with you that she cut her arms
to get her boyfriend to “love” her. You are called
Those who have this disorder tend to display
out of the room. When you return, the patient an exaggerated impression of self with an
yells at you and says she wants another nurse. She inflated sense of self-importance. They are
does not trust you. preoccupied with fantasies of unlimited suc-
This patient was diagnosed with borderline cess. Another characteristic is limited ability
personality. Describe why she may have reacted so
negatively to you when you returned to the room.
to empathize with others’ problems because
they see everything through their own eyes.
They also tend to be hypersensitive when they
receive criticism. They have a tendency to
Histrionic Personality Disorder overestimate their abilities, are attention
This disorder is characterized by dramatic, ex-
cessive, extroverted behavior in someone who
has a pattern of strong emotions. Excessive Cultural Considerations
attention seeking, seductive and provocative Cultural background can dictate social be-
behaviors are additionally seen. Some may de- havior. So this should be taken into con-
scribe the person as theatrical. They are known sideration when a diagnosis of histrionic
to be highly distractible and even flighty. disorder is being made.
Delaying gratification is difficult. Difficulty in
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222 UNIT 2 | Threats to Mental Health

seeking, and are surprised if they do not re- Dependent Personality Disorder
ceive admiration from others. While project- Dependent personality is a pervasive and ex-
ing an image of invulnerability, their deep cessive need to be taken care of that leads to
sense of emptiness is hidden from others. submissive and clinging behaviors and fears
These individuals have difficulty maintaining of separation. These behaviors tend to elicit
close relationships. caregiving response in others including
People with this disorder will seem to take nurses. People with dependent personality
criticism lightly. In reality, deep feelings of disorder want others to make decisions for
anger, resentment, and poor self-esteem are them and tend to feel inferior and sug-
being repressed. Friends will be chosen ac- gestible, with a sense of self-doubt. These
cording to how good they make the person individuals tend to appear helpless and to
with the narcissistic personality feel. avoid responsibility. On the other hand, in-
Often these people are children of narcis- dividuals with this disorder tend to take
sistic parental figures who were critical and de- everything to heart and go out of their way
manding of their children. The children then to satisfy people they feel close to and try to
model their behavior. Narcissistic traits are change those personality traits that people
particularly common in adolescents though criticize.
they will not necessarily have the personality There seems to be an inordinate amount of
disorder. fear among people who experience dependent
personality disorder. It may be the fear of crit-
■■■ Critical Thinking Question icism that brings about the inability to make
You are working on a psychiatric unit, and your decisions. Inability to make decisions can be
patient with narcissistic disorder tells you that she
plans to get the lead in a play once she leaves the severe enough as to limit a person’s ability to
hospital. She tells you she has always been success- have meaningful social interactions. In addi-
ful in every audition she has had. What concerns tion recognition that overuse of dependency
would you have for this patient? How would you behaviors can lead to a disturbed nurse-
respond to her statements? patient relationship.
Seriously overprotective parents who dis-
courage independence and promote de-
Cluster C pendence in the child for the parents’ needs
can be a contributing factor. Chronic phys-
Avoidant Personality Disorder ical illness in childhood can predispose to
These individuals are extremely sensitive and this disorder.
may avoid social situations to protect themselves
from possible rejection. However, these people
also have a strong need to be accepted. Often Cultural Considerations
labeled shy, these individuals are awkward in Nurses must be cautioned here because
social situations. They often view others as crit- the behaviors that have been discussed as
ical. They want a close relationship but avoid it symptomatic of dependent personality
because of fear of being rejected. Characteristics disorder are behaviors and conditions that
include low self-esteem, avoidance of close rela- are expected in certain cultures, especially
tionships, anxiety, and anhedonia, or lack of among females.
pleasure in life. They are very hesitant to engage
in new activities due to fear of failure. Highly
critical parental figures are believed to be the
Obsessive-Compulsive
origin. There also may be a hereditary link.
Personality Disorder
Neeb’s The patient with avoidant personal- These individuals are disciplined and rigid
■ Tip ity disorder desperately wants social to an extreme. They are meticulous and de-
contact but goes to lengths to dis- mand accuracy and discipline in others.
courage it out of fear of rejection. They are preoccupied with details, rules, and
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CHAPTER 14 | Personality Disorders 223

order. They display a stubborn streak in

order to maintain control so things are done Pharmacology Corner
their way. They may appear polite and for- Many patients with these disorders experi-
mal but can be autocratic and critical with ence anxiety, so anti-anxiety medications are
others. They demonstrate persistence at tasks often prescribed. Borderline patients have
long after the behavior has ceased to be func- been treated with SSRIs (selective serotonin
tional or effective and continuance of the reuptake inhibitors) to manage impulsivity.
same behavior despite repeated failures or Antipsychotics may be used with patients
obvious annoyance by others. The fear of with psychotic features such as schizotypal
making mistakes can lead to an inability to disorders. For patients prone to violence, an-
make any decisions. tipsychotics may also be needed. Because
The origins include overcontrolling par- many of these patients are susceptible to
ents, and the disorder does run in families. substance abuse to self-medicate, close mon-
This personality disorder differs from what is itoring of drug abuse should be included in
known as OCD (obsessive-compulsive disor- the treatment plan.
der). OCD is a disorder that is characterized
by obsessions and compulsions in an effort to
maintain control (Chapter 10).
Neeb’s Compliance with a prescribed med-
■ Psychiatric Treatment ■ Tip ication regimen can be challenging.
of Personality Disorders Some may have a tendency to
avoid following instructions or act
Because these personality disorders become impulsively.
engrained early in life, treatment is often
difficult. People with personality disorders
may not seek treatment as part of their ■■■ Critical Thinking Question
disorder until the disorder drains their Your patient with a diagnosis of avoidant person-
ality requests alprazolam before group therapy
coping reserves. At times they will demon- session. Describe what this medication accom-
strate resistance to treatment. Treatment plishes for the patient and alternative approaches
may be pushed on them after a crisis or due in place of medication.
to entrance into the legal system. Psy-
chotherapy, cognitive behavior therapy,
and group therapy may be useful in some
situations. Maintaining a long-standing ■ Nursing Care of Patients
trusting relationship with a therapist can With Personality
be advantageous. Medications to treat anx-
iety, depression, and delusions are often Disorders
used. Family members of people with
Common nursing diagnoses with personality
personality disorders often benefit from
disorders include the following:
family therapy and psycho-education around
coping with them. • Coping, defensive
• Personal identity, disturbed
Neeb’s Though people with personality dis- • Self-esteem, disturbed
■ Tip orders may not seek mental health • Self-mutilation, risk for
treatment, they often use the • Social interactions, impaired
health-care system for other prob- • Violence, self-directed, risk for
lems. Patients with personality dis-
orders present many challenges to
nurses. These patients may display Neeb’s Nurses need to display much pa-
rigid behavior patterns and be so- ■ Tip tience and acceptance as part of the
cially inappropriate. care plan.
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224 UNIT 2 | Threats to Mental Health

General Nursing Interventions ■■■ Clinical Activities

for Personality Disorders • Be alert to possible manipulation or staff
splitting; patients may view nursing students
See Table 14-1 for a summary of nursing in- as being more vulnerable and try to take
terventions for each personality disorder advantage of them.
and Table 14-2, which details the nursing • At the same time, make efforts to avoid stereo-
care plan for patients with borderline typing or judging such patients based on infor-
mation that they have a personality disorder.
personality.

l Table 14-1 Nursing Interventions for Personality Disorders

Type Symptoms Nursing Interventions
Antisocial • Requires immediate self-gratification • Promote positive, healthy interper-
• Often in trouble with the law sonal relationships
• Has difficulty handling frustration • Monitor for violent behaviors
and anger • Provide feedback on negative
• Seldom feels affection, loyalty, guilt, behaviors
or remorse • Encourage appropriate expression
• Shows very little concern for the of angry feelings
rights or feelings of others • Support analysis of feelings
• Good at manipulating others for • Point out impact of manipulative
personal gain behavior
• High risk for substance abuse • Avoid negotiating rewards
• Usually gregarious, charming, • Set limits
intelligent, and likable
Avoidant • Avoids social situations • Promote self-esteem by acknowl-
• Preoccupied with thoughts of being edging any success
rejected or criticized • Encourage participation in support-
• Low self-esteem ive social situations
• Avoids new activities for fear of being • Provide emotional support
embarrassed • Teach calming techniques to use to
deal with anxiety
• Reinforce strengths
Borderline • Moods unstable and changeable • Remain calm in presence of pa-
• Uncertainty regarding self-concept tient’s drama
• Substance abuse • Build trusting relationship
• Suicide attempts • Set limits and establish clear ground
• Anhedonia rules that are followed by everyone
• Difficulty handling strong emotion • Establish therapeutic communication
• Bored and empty feelings • Demonstrate positive role modeling
• Fear of being alone • Monitor for self-destructive behaviors
• Self-destructive behaviors • Provide safety/security
• Self-mutilation • Communicate a consistent plan of
• Manipulative care among all staff
• Encourage patient to verbalize
feelings rather than act them out
• Avoid power struggles
• Involve family and friends in
treatment plan
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CHAPTER 14 | Personality Disorders 225

l Table 14-1 Nursing Interventions for Personality Disorders—cont’d

Type Symptoms Nursing Interventions
Dependent • Dependent and submissive • Allow patient to make some deci-
• Want others to make decisions for sions for his or her treatment
them • Reinforce the patient’s decisions
• Tend to feel inferior and suggestible • Encourage patient to make truthful,
and have a sense of self-doubt positive self-statements each shift
• Tend to appear helpless and avoid • Recognize patient's insecurities and
responsibility anxieties.
• Tend to take everything to heart—
will go out of their way to satisfy
people they feel close to and try to
change those personality traits that
people criticize
• Inordinate amount of fear
Histrionic • Dramatic • Support healthy coping
• Emotional • Reassurance
• Provocative • Support consistent healthy
• Suggestible relationships
• Give appropriate feedback
Narcissistic • Exaggerated self-image • Encourage patient to learn to ac-
• Appears self-centered cept limitations in self and others
• Lacks empathy for others’ problems • Give patient feedback on how oth-
• Expresses need for self-importance ers are responding to patient
• Takes criticism lightly but in reality • Prepare patient for possible setbacks
represses feelings of anger and • Recognize the patient is very sensi-
resentment tive to hurt feelings
• Sense of entitlement • Encourage the patient to talk about
• Cheerful, carefree mood which can his or her vulnerabilities
quickly change to distress if criticized
Obsessive- • Rigid behavior • Understand patient’s fears and be
Compulsive • Preoccupied with rules flexible as to his/her needs
• Formal • Allow patient to make simple
• Perfectionistic decisions with limited choices
• Intense fear of making mistakes • Establish trusting, supportive
• Though calm on outside, dealing relationship
with intense conflict and hostility • Discuss alternative strategies for
dealing with new situations
• Support healthy coping mecha-
nisms to deal with stress
Paranoid • Suspicious and mistrustful of other • Avoid situation that the patient may
people perceive as demeaning
• May seem “normal” in speech and ac- • Encourage trusting relationship
tivity • Encourage verbalizing one's
• Believe that people treat them perceptions of the situations
unfairly • Reinforce trusting behaviors
• Hypersensitive to activity in the • Acknowledge other possible expla-
environment nations for others motives
• Difficult to maintain focused eye
contact
Continued
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226 UNIT 2 | Threats to Mental Health

l Table 14-1 Nursing Interventions for Personality Disorders—cont’d

Type Symptoms Nursing Interventions
• Not easily able to laugh at themselves
• Take themselves very seriously
• May not show tender emotions
• May seem cold and calculating in
their relationships
• Tend to take comments, events,
situations personally
• Few social interactions
• Loners
• Appear to be shy and introverted
Schizoid • Detached • Acceptance of behavior
• Chooses solitary activities • Encourage appropriate brief social
• Avoids social situations interactions
• Loner • Meet patient on his/her own
• Often excel in fields where limited terms
interaction needed • Help patient understand how be-
haviors may contribute to satisfac-
tory relationships
Schizotypal • Eccentric behavior • Brief, concrete conversations that
• Inappropriate affect are focused on reality
• Aloof • Acceptance of behavior
• Psychotic symptoms under stress • Encourage appropriate social be-
haviors
• Recognize need for personal space
• Reinforce reality gently

l Table 14-2 Nursing Care Plan for Patients With Borderline Personality
Disorder
Assessment/ Nursing Interventions/ Evaluation
Data Collection Diagnosis Plan/Goal Nursing Actions Criteria
After drinking Risk for Verbalize alterna- Provide safe, secure Able to de-
heavily, got in self- tive coping mech- environment; scribe alterna-
physical fight directed anisms when Convey accept- tive coping
with acquaintance, violence under stress ance of patient as a mechanisms;
then made person; Able to utilize
attempt at Discuss alternative these coping
cutting wrists ways to express mechanisms
anxiety, irritation; next time in
Identify alternative a stressful
actions to reduce situation
destructive
impulses
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CHAPTER 14 | Personality Disorders 227

■■■ Key Concepts 4. People with personality disorders often

present challenges to nursing staff when
1. Personality disorders are maladaptive re- receiving care for physical ailments due
sponses to personality development. to their challenging behaviors, which can
include poor interpersonal skills, nega-
2. People with personality disorders are sel- tive emotions, and inflexibility.
dom hospitalized for them. They do not
see a need for obtaining help and are not 5. Common traits of people with personal-
always taken seriously by the medical ity disorders include socially inappropri-
community. ate behavior, negative emotions, and
difficulty with close relationships.
3. Borderline personality disorder is the
most common one seen in the mental
health setting.

CASE STUDY
Marsha is a 25-year-old woman who is She describes a chaotic childhood in
brought to the emergency room by her which her mother was away a lot and
girlfriend after threatening to take sleep- Marsha moved around to live with a variety
ing pills when her boyfriend broke off of relatives. She barely finished high school
their relationship. On questioning Marsha, and has struggled to find unskilled jobs.
she acknowledges a long history of prob- On interviewing her you find her cheer-
lems. She has made multiple suicide ful and charming. She does not appear
attempts, which include cutting her arms depressed. When you leave the room to at-
and taking handfuls of sleeping pills. tend to another patient, she cries out that
Each attempt occurred after a rejection she is being ignored. She calls multiple
by a boyfriend or in earlier years by her friends to visit in the ER so she will not be
parents. Marsha describes falling in love alone, thus creating a chaotic environment
easily and a history of intense relation- that must be monitored by security.
ships that often are discontinued by the Her long-term psychiatrist comes to see
man after Marsha becomes increasingly her and tells you she is treating Marsha for
clinging and demanding. borderline personality disorder.

1. Which behaviors in this case study are indicative of this diagnosis?

2. What treatment options are used to treat this disorder?
3. What medications would you expect her to have prescribed?

REFERENCES BPD Resource Center. Retrieved from http://

bpdresourcecenter.org/factsStatistics.html
American Psychiatric Association. (2013).
Cloninger, C.R., and Surakic, D.M. (2009).
Diagnostic and Statistical Manual of Mental
Personality disorders. In B. J. Sadock,
Disorders 5. Washington, DC, Author.
V.A. Sadock, & P. Ruiz (Eds.), Kaplan &
(Known as DSM-5)
Sadock’s Comprehensive Textbook of Psychiatry.
ARHQ National Guidelines Clearing House,
9th ed. Philadelphia: Wolters Kluwer/
Borderline Personality Disorder. (2009).
Lippincott Williams & Wilkins.
Retrieved from http://www.guideline.gov/
Lenzenweger, M.F., Lane, M. C., and Loranger,
content.aspx?id=14327&search=borderline+
A. W. (2007). DSM-IV personality disorders
personality#Section420
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228 UNIT 2 | Threats to Mental Health

in the National Comorbidity Survey Replica- NIH Information About Personality

tion. Biological psychiatry, 62(6), 553–564. Disorders
Puskar, K. R., et al. (2006). Self-cutting behavior http://www.nlm.nih.gov/medlineplus/personality
in adolescents. Journal of emergency nursing disorders.html
32(5), 444–446. Antisocial Personality
Townsend, M. (2012). Psychiatric Mental Health http://www.nlm.nih.gov/medlineplus/ency/article/
Nursing. 7th ed. Philadelphia: F.A. Davis. 000921.htm
Paranoid Personality Disorder
WEB SITES http://www.nlm.nih.gov/medlineplus/ency/article/00093
8.htm
National Alliance on Mental Illness Informa-
tion on Borderline Personality Disorder
http://www.nami.org/Template.cfm?Section=By_
Illness&Template=/TaggedPage/TaggedPageDisplay.cfm
&TPLID=54&ContentID=44780
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CHAPTER 14 | Personality Disorders 229

Test Questions
Multiple Choice Questions
1. When setting limits with patients with 5. A patient who is in trouble with the law
personality disorders, the consequences to would probably have which of the follow-
those limits should be set: ing personality disorders?
a. When the behavior is done a. Narcissistic
b. Just before the nurse anticipates the b. Schizoid
behavior c. Antisocial
c. When the staff or family complains d. Borderline
about the behavior 6. Patients who display very bizarre behavior
d. When the limit is set most likely have which of the following
2. David, 30 years old, comes to your unit types of personality disorder?
for treatment of multiple broken bones a. Narcissistic
following a car accident. He is friendly b. Schizotypal
and flirtatious but very demanding. As c. Antisocial
you take your data from him, you learn d. Borderline
that the police have been looking for him 7. Which intervention describes an impor-
for petty theft. He laughs and says, “Like tant component in treatment of personal-
they don’t have better things to do!” He ity disorders?
states he has changed jobs three times in a. Antidepressants are most effective with
the past year and has just broken off his most personality disorders.
second engagement. His former fiancée is b. Inpatient psychiatric hospitalization is
visiting and privately tells you that you particularly effective.
need to be careful because “he doesn’t al- c. Self-awareness by the nurse is necessary
ways tell the truth.” You suspect which of to ensure a therapeutic relationship.
the following personality disorders? d. Long-term psychoanalysis is the
a. Paranoid treatment of choice.
b. Dependent
c. Antisocial 8. Your patient has been admitted with a di-
d. Schizoid agnosis of bilateral pneumonia. You have
trouble communicating with this patient,
3. A primary mechanism used by people who is pouty and is demanding of your
with personality disorders is: constant attention. She talks for long peri-
a. Manipulation ods about the smallest details of her life.
b. Depression Besides the pneumonia, you ask the physi-
c. Projection cian if the patient has a history of which
d. Euphoria of the following personality disorders?
4. For the patient with a personality disor- a. Schizoid
der, which of the following behaviors b. Antisocial
would be the most difficult for the pa- c. Narcissistic
tient to comply with? d. Borderline
a. Listening to music
b. Abiding by the rules in the hospital
c. Playing volleyball
d. Developing a friendship
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230 UNIT 2 | Threats to Mental Health

Test Questions cont.

9. Nursing care for people with personality 10. You are caring for a 25-year-old male
disorders includes all of the following who has been admitted for infections
except: that resulted from self-inflicted burns.
a. Unconditional positive regard This is not the first admission for this
b. Trust young man, but he is new to you as a
c. Limit setting new nurse on the unit. You have not
d. Vague communication (to decrease read his entire chart, but you suspect he
feelings of inferiority) has a history of which one of the follow-
ing personality disorders?
a. Narcissistic
b. Borderline
c. Schizoid
d. Passive-aggressive
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C HA PT E R 15
Schizophrenia Spectrum
and Other Psychotic
Disorders
Learning Objectives Key Terms
1. Define schizophrenia. • Catatonia
2. Differentiate between positive and negative symptoms seen • Delusions
in schizophrenia. • Echolalia
3. Identify two other psychotic disorders. • Echopraxia
4. Identify treatment modalities for people with schizophrenia. • Extrapyramidal
5. Describe catatonic features in schizophrenia symptoms (EPS)
6. Identify nursing care for people with schizophrenia. • Hallucinations
• Illusions
• Psychosis
• Schizophrenia
• Schizoaffective disorder
• Schizophrenia spectrum
disorder

he term schizophrenia (which literally

T
condition continues. As a chronic illness,
means “split mind”) was first used by schizophrenia is characterized by remissions
Swiss psychiatrist Eugen Bleuler and exacerbations throughout one’s life. The
(Fig. 15-1). Schizophrenia is a serious, first psychotic break often responds well to
chronic, psychiatric disorder characterized by treatment, but the relapse rate is high and the
impaired reality testing, hallucinations, delu- person may become increasingly disabled.
sions, and limited socialization. It is a psy- Schizophrenic individuals are vulnerable
chotic thought disorder where hallucinations to substance abuse as they self-medicate to
and delusions dominate the patient’s think- control their symptoms, contributing to
ing, leading to confusing and bizarre behav- co-occurring disorder (see Chapter 17).
iors. People with schizophrenia have a “split” These patients can also be at risk for suicide,
between their thoughts and their feelings and which may be manifested as voices telling
between their reality and society’s reality, the person to kill her/himself or a means to
which can lead to unusual and frightening be- end suffering.
haviors. Schizophrenia is a frequent cause for DSM-5 now categorizes schizophrenia under
long psychiatric hospitalizations. The suffer- the global title of schizophrenia spectrum
ing for a schizophrenic patient and his/her disorders (2013). In the past, schizophrenia
family can last a lifetime as this crippling was divided into five subtypes of catatonic,

231
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232 UNIT 2 | Threats to Mental Health

Neeb’s Sudden onset of hallucinations and

■ Tip delusions requires quick action to
identify the cause. Causes can in-
clude medical conditions, metabolic
changes, and drug reactions.

■■■ Classroom Activities

• View and discuss movies that feature schizo-
phrenic characters, including A Beautiful Mind
and I Never Promised You a Rose Garden.

■■■ Critical Thinking Question

Your patient has a diagnosis of schizophreniform
disorder. How is this different from a diagnosis of
schizophrenia?

l Table 15-1 Other Disorders

With Schizophrenic
Figure 15-1 Eugen Bleuler (1857–1940) was a Features
Swiss psychiatrist who coined the term schizo-
phrenia and contributed to the understanding of Type Characteristics
the disorder. Delusional Delusions without the
Disorder other symptoms or dis-
abilities of schizophrenia
Schizoaffective Symptoms of schizophre-
delusional, disorganized, undifferentiated, and nia along with symptoms
residual, but in 2013 these were eliminated. of major depression or
The new term of schizophrenia spectrum dis- manic episode that re-
orders reflects a gradient of psychopathology quires treatment of both
that a patient can experience from least to most disorders
severe. Disorders such as schizophreniform and Schizophreniform Schizophrenia symp-
schizoaffective would be the less severe forms. toms without the level of
See Table 15-1 for other disorders with schiz- impairment of function-
ophrenic features. ing usually seen in schiz-
ophrenia and lasting
In addition, psychoses can occur in bipolar
more than 1 month and
disorder and major depression. Another psy- fewer than 6 months
chotic disorder is brief psychotic disorder,
Schizotypal A personality disorder
which includes postpartum psychosis (see
characterized by odd
Chapter 20) as well as psychosis due to sub- and eccentric behavior
stance abuse or medical conditions. Medical that does not decom-
conditions that can contribute to psychoses pensate to the level of
include brain tumors, CNS infections, delir- schizophrenia (see
ium, and endocrine disorders. All of these dis- Chapter 14)
orders, though not schizophrenia, have some
Source: Adapted from Diagnostic and Statistical Manual of Mental
of the same symptoms but different etiology Disorders, 5th Edition (Copyright 2013). American Psychiatric
and duration of disability. Association, Townsend (2012), and Goldberg (2007).
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CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 233

Frequently, schizophrenia is initially diag-

nosed in adolescents and younger adults be-
tween the ages of 16 and 35 with the occurrence
of the first psychotic break, though later onset
does occur. A common scenario is a young
person who has left home for college or the mil-
itary and suddenly exhibits psychotic behavior
(Fig. 15-2), though premorbid personality may
indicate this individual was withdrawn, had
problems with social relationships, and exhib-
ited possible antisocial behavior. Schizophrenia
is rare in young children. The National Institute
of Mental Health (NIMH) estimates that nearly
3 million Americans will develop schizophrenia
during the course of their lives. That is about
1.1% of the U.S. population (National Institute
of Mental Health, 2012).

Figure 15-2 Schizophrenia can create extreme

■■■ Classroom Activities distress.
• Contact a local NAMI (National Alliance on Mental
Illness) support group and attend a meeting if
possible. symptoms are those found among people
who do not have the disorder but are missing
or lacking among individuals with schizo-
■ Symptoms phrenia and reflect a lessening or loss of nor-
mal functions. These may include avolition
• The presence of delusions, hallucinations, (a lack of desire or motivation to accomplish
and/or disorganized speech for a signifi- goals), lack of desire to form social relation-
cant portion of time during a 1-month ships, inappropriate social behavior such as
period. At least one of these must be pacing or rocking, and blunted affect and
present for the diagnosis. emotion. These symptoms make holding a job,
• Grossly abnormal motor behavior and/ forming relationships, and other day-to-day
or negative symptoms (see below for functions especially difficult for people with
explanation) schizophrenia.
• One or more areas of functioning, such as Positive symptoms are those that are found
work, school, personal relationships, or among people with schizophrenia but not
self-care, are impaired. Some disturbance present among those who do not have the dis-
needs to be evident for at least 6 months. order. They reflect an excess or distortion of
• Schizophrenia can also have features of normal functions such as delusions, thought
catatonia, which include any of the fol- disorders, and hallucinations. People with
lowing: motor immobility to stupor, ex- schizophrenia may hear voices other people
cessive motor activity, peculiar voluntary don’t hear or believe other people are reading
movements, and echolalia or echopraxia. their minds, controlling their thoughts, or
Schizophrenia’s symptoms are typically de- plotting to harm them. Other positive symp-
scribed as “negative” or “positive.” Negative toms can include magical thinking (belief that
one’s thoughts can control others), neologisms
(invents new words that only have meaning to
the individual), concrete thinking (literal in-
Cultural Considerations terpretation of the environment), loose asso-
Schizophrenia crosses all races and cultures. ciations (ideas shift from unrelated one to
another), echopraxia (repeating movements of
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234 UNIT 2 | Threats to Mental Health

Cultural Considerations l Table 15-3 Recognizing

Hallucinations
One’s culture often influences the content
of hallucinations and delusions. Familiar- Affected Sense Example
ity with the patient’s culture can provide Visual “I watch gypsies bring
insight into the origin of some of these different babies to my
behaviors. apartment each night.”
Auditory (most “The voices are calling
common) me a prostitute.”
others), and echolalia (parrot-like repeating Tactile “When I touched my
words spoken by others). Most schizophrenics arm, I could tell my arm
have a mixture of both positive and negative is made of stone.”
symptoms. Olfactory “I don’t want to stay in
See Tables 15-2 and 15-3 for lists of com- that room. I can smell
mon delusions and hallucinations. the odors of the people
who died there.”
Neeb’s Schizophrenia is a debilitating and
Gustatory “I taste milk in my
■ Tip painful lifelong disease for the pa- mouth all the time.”
tient and family requiring long-term
management and compassion. Kinesthetic (bodily “It feels as if the rats in
movement or my head are eating up
sense) my brain.”
■■■ Critical Thinking Question
Your schizophrenic patient tells you that his Source: Adapted from Gorman and Sultan (2008). Psychosocial
mother has communicated with him that he Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis
Company, with permission.
needs to leave the hospital right now to help save
the mayor from peril. What type of delusions and
hallucinations is this patient experiencing?
■ Etiology of Schizophrenia
No single cause has been identified, but it is
l Table 15-2 Common Delusions now known that schizophrenia is a brain dis-
order. Disruption of neurotransmitters, in-
Delusion Example cluding dopamine, has been identified. Some
Grandeur (belief of “I am Napoleon dysfunction in neuron functioning has also
exaggerated Bonaparte.” been found. Some cerebral changes in the
importance) brain have also been suggested in the limbic
Paranoia (belief of “The FBI is following system and prefrontal cortex. These factors
deliberate harassment me and wants to may contribute to the problems with atten-
and persecution) kill me.” tion and information processing. The person
Reference (belief that “Those people on
the thoughts and the TV show are
behavior of others talking to me.”
is directed toward
self )
Cultural Considerations
Physical sensations “I have no blood Behaviors that may be normal in some
(belief that parts of in me.” cultures can be confused with psychotic
body are diseased, behavior. For example, speaking in tongues
distorted, or missing) and talking to spirits may be normal
Thought insertion “The devil made behavior in some cultures. If psychotic
me say that.” behavior is suspected, it is important to
Source: Adapted from Gorman and Sultan (2008). Psychosocial obtain information on what is normal
Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis behavior for the culture of your patient.
Company, with permission.
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CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 235

is unable to filter stimuli, leading to disor-

ganization of mental functioning. While Pharmacology Corner
family dysfunction may exist, it appears that Antipsychotic medications are key to a pa-
psychological factors by themselves do not tient’s returning to a stable state. Once
cause this condition. There is also evidence achieved, maintenance therapy is established
of genetic predisposition, and the most sig- to prevent exacerbations. Most schizophren-
nificant risk factor is having a close relative ics will relapse once off their medications, so
with this disorder. incorporating a plan for medication compli-
ance is essential. Once established on appro-
■ Psychiatric Treatment priate medications, the patient is usually
of Schizophrenia more open to counseling and supportive in-
terventions. It can take time to establish
A comprehensive, multidisciplinary treat- the appropriate medication and dosages so
ment plan including pharmacotherapy, so- the patient and family must be monitored
cial support, social/life skills training, closely. Some patients may require longer
self-help groups, and family therapy can be periods of trials for months or even years to
helpful to maintain the patient effectively. find the best available medication, the right
Gaining life skills to deal with everyday dosage, and manageable side-effect profile.
challenges, occupational training, and fam- A trial of any one medication should last for
ily education have been helpful. Intensive a substantial period, usually 6 to 8 weeks,
individual psychotherapy is generally not as unless intolerable side effects occur early.
effective, but reality-based therapy to pro-
mote trust can be incorporated into the
plan. Ongoing support can promote com- These agents are generally used to treat the
pliance with antipsychotic medications. positive symptoms of schizophrenia. Atypical
Management of antipsychotic medications antipsychotics have been available since the
is generally the primary treatment. See 1990s and are weaker dopamine receptor an-
Pharmacology Corner. tagonists but more potent antagonists of
serotonin receptors. New atypicals are added
Tool Box | Brief Psychiatric Rating Scale to the market regularly. These drugs treat
(BPRS)—Standardized tool to track response both the positive and negative symptoms
to treatment: and generally have fewer side effects. Even
http://www.public-health.uiowa.edu/icmha/ though the atypical agents have a better side-
outreach/screening.html effect profile for long-term treatment, the
Treating Schizophrenia Guideline from typical or older agents may be chosen for
American Psychiatric Association: short-term management of psychosis or
http://psychiatryonline.org/content.aspx ? long-term management of symptoms that
bookid= 28 & sectionid= 166309 3 do not respond to the atypical agents. See
Table 15-4 for a list of the common typical
and atypical antipsychotics with their side-
effect profile. Most of these agents are avail-
■■■ Classroom Activities able only in oral form. A few are available as
• Invite a local mental health professional to class
to discuss the treatment approaches to schizo- a long-acting injection that is given every
phrenic patients in your community. few weeks. These include haloperidol,
fluphenazine, and risperidone. These can be
effective if a patient refuses or is unable to
Most people respond to one of the typical take oral medications. Some medications
or atypical agents to a degree at the first psy- come in liquid forms or quick dissolving
chotic episode. Typical antipsychotics have tablets, which can also be useful if the pa-
been around since the 1950s and work by tient is not cooperative with taking oral
blocking postsynaptic dopamine receptors. medication.
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236 UNIT 2 | Threats to Mental Health

l Table 15-4 Comparison of Side Effects Among Typical and Atypical

Antipsychotic Agents
Anti- Orthostatic Weight
Class Generic Name EPS Sedation cholinergic Hypotension Gain
Typicals Chlorpromazine 3 4 3 4 *
(Thorazine)
Fluphenazine 5 2 2 2
(Prolixin)
Haloperidol 5 2 2 2
(Haldol)
Loxapine 3 2 2 2 *
(Loxitane)
Perphenazine 4 2 2 2 *
(Trilafon)
Pimozide 4 2 3 2 *
(Orap)
Prochlorperazine 3 2 2 2 *
(Compazine)
Thioridazine 2 4 4 4 *
(Mellaril)
Thiothixene 4 2 2 2 *
(Navane)
Trifluoperazine 4 2 2 2 *
(Stelazine)
Atypicals Aripiprazole 1 2 1 3 2
(Abilify)
Asenapine 1 3 1 3 4
(Saphris)
Clozapine 1 5 5 4 5
(Clozaril)
Iloperidone 1 3 2 3 3
(Fanapt)
Lurasidone 1 3 1 3 3
(Latuda)
Olanzapine 1 3 2 2 5
(Zyprexa)
Palperidone 1 2 1 3 2
(Invega)
Quetiapine 1 3 1 3 4
(Seroquel)
Risperidone 1 2 1 3 4
(Risperdal)
Ziprasidone 1 3 1 2 2
(Geodon)
Key: 1=Very low, 2=low, 3=moderate, 4=high, 5=very high
+Weight gain occurs, but incidence is unknown.
Source: From Townsend (2012): Psychiatric Mental Health Nursing,7th ed. Philadelphia: F.A. Davis, with permission.
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CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 237

■■■ Critical Thinking Question Neeb’s Extrapyramidal symptoms can be

You realize your schizophrenic patient has been ■ Tip devastating to quality of life. Close
“cheeking” his risperidone (hiding the pill in his monitoring to treat these and pre-
cheek). What might be some of the reasons the vent long-term consequences must
patient is doing this? Identify two alternatives for
be part of the treatment plan.
taking this medication.

Managing the side effects of antipsychotics Tool Box | Abnormal Involuntary Move-
can promote patient compliance. Typical an- ment Scale (AIMS): This tool is a rating scale
tipsychotics are more prone to extrapyramidal developed by the National Institute of Mental
symptoms (EPS) as well as anticholinergic Health to measure involuntary movements as-
effects, though the drugs can be particularly ef- sociated with tardive dyskinesia (available at:
fective in controlling psychotic symptoms. See www.atlantapsychiatry.com/forms/AIM S.pdf
Box 15-1 and Table 15-5 for lists of extrapyra-
midal and anticholinergic side effects. Ex-
trapyramidal symptoms are generally managed
with anticholinergic drugs such as benztropine,
biperiden, trihexyphenidyl, dopaminergic ag- ■■■ Clinical Activity
onists such as amantadine, or antihistamines • Review chart for CBC results if the patient is on
clozapine.
such as diphenhydramine. • Review chart for evidence of side effects of an-
The atypicals are generally less associated tipsychotic medications.
with extrapyramidal symptoms than the typ- • Discuss management of side effects with patient
ical agents, but there is a wide range of other and his/her family.
side effects, so close monitoring of the pre-
scribed drug is essential. Some atypicals are
prone to anticholinergic effects. Serious side
effects in specific atypicals can include re- ■■■ Critical Thinking Question
duced seizure threshold, blood dyscrasias, and Your patient with schizophrenia has been taking
cardiac arrhythmias. One of the most serious clozapine for 2 years. He is now in the hospital and
is agranulocytosis, which is a rare blood com- is NPO awaiting an appendectomy. What con-
plication of clozapine requiring close moni- cerns would you have that the patient has been
without his medications for 2 days? Why is the MD
toring of the white blood cell count. The monitoring his WBC counts closely?
specific side effects of the atypicals must be
reviewed and monitored whenever these
drugs are ordered.

l Box 15-1 Extrapyramidal Side

Neeb’s Compliance to antipsychotics re- Effects
■ Tip mains a lifelong challenge for the • Dystonia: muscle rigidity, torticollis (neck
schizophrenic patient and his/her turned in awkward angle)
family. It is important to regularly • Pseudoparkinsonism or dyskinesia: stiff-
monitor medication compliance ness, tremors, shuffling gait
and the current side-effect profile. • Akathisia: restlessness, inability to sit still
Education must be reinforced each • Tardive dyskinesia: late onset movement
time the patient is seen in any disorder that includes lip smacking,
health-care setting. grimacing, tongue protrusion
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238 UNIT 2 | Threats to Mental Health

some control to look at alternative ways

l Table 15-5 Anticholinergic Effects to view reality.
Symptom Action • Work to slowly build trust in small ways.
Dry mouth Offer sugarless candy, good Avoid overreacting to patient’s bizarre
oral hygiene, saliva substitute behavior or appearance
Orthostatic Instruct patient to get out of • Maintain a calm, consistent environment
hypotension bed slowly, monitor BP with a regular routine
• Even though he/she appears to be in an-
Constipation Promote high-fiber diet, flu-
ids, stool softeners, laxatives other world, continue to include the patient
as needed in conversations and activities. Acknowledge
his/her presence and importance.
Urinary Instruct patient to report
retention symptoms promptly • Focus on reality, e.g., rather than listen to
a long monologue about a delusion, talk
Dry eye Lubricant eye drops
about the schedule for the day.
Source: Adapted from Gorman and Sultan (2008). Psychosocial • Never argue with the patient about what
Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis he or she is experiencing.
Company, with permission.
• Incorporate Quality and Safety Education
for Nurses (QSEN) competencies to main-
tain a safe environment for the psychotic
■ Nursing Care of the patient (qsen.org), e.g., remove sharp
objects, provide adequate supervision.
Schizophrenic Patient • Take action to provide medications before
agitation escalates. Make sure there are
The nursing care of the schizophrenic patient orders for prn medications for agitation.
requires knowledge and compassion. Com- • Never reinforce hallucinations, delusions,
mon nursing diagnoses for the schizophrenic or illusions. An example of an inappropri-
patient include: ate response is, “Jesus wants you to take
• Self-care deficit these pills," That response reinforces the
• Sensory perception, disturbed delusion about Jesus.
• Social isolation • Avoid whispering or laughing when the pa-
• Thought processes, disturbed tient cannot hear the whole conversation;
• Violence, risk for such behavior can promote paranoia.
• Avoid putting the patient into situations
General Nursing that are competitive or embarrassing.
Interventions • Build trust by using therapeutic commu-
• Watch for clues that patient is hallucinat- nication skills.
ing, e.g., darting eyes, mumbling to self, • If the patient is catatonic, provide for basic
staring at a vacant wall for long periods. physical needs and safety, and make brief
You can also ask the patient if he is hear- supportive contacts with the patient with-
ing voices. out pressuring the patient to communicate.
• If the patient is hallucinating, your response Table 15-6 provides the nursing care plan
could be, “I don’t see the devil standing for patients with schizophrenia.
there, but I understand how upsetting this
is for you.” In this way you are acknowledg-
ing what the patient is experiencing with- Neeb’s It is important for the nurse to avoid
out reinforcing it as your reality. ■ Tip reinforcing psychotic thinking, as in
• If your patient is delusional, reinforce re- delusions. For example, avoid asking
ality, “that man works for the hospital not the patient what “they” are telling
the FBI,” “Yes, there was a man at the the patient. Rather, let the patient
nurse’s station, but I did not hear him talk know you are concerned but do not
about you.” Remind the patient he has hear these voices.
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CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 239

Neeb’s Remember that schizophrenic pa- Tool Box | National Institute of Mental
■ Tip tients are often very concrete Health information for Patients and Families
thinkers, so it is important to speak on Schizophrenia:
clearly and plainly. Make only one http://www.nimh.nih.gov/health/topics/
request at a time.
schizophrenia/index .shtml

■■■ Classroom Activity

• Have a mental health counselor from a local
clinic present information on managing schizo- ■■■ Critical Thinking Question
phrenia to your class. Your 19-year-old patient with a new diagnosis of
schizophrenia begins yelling “Stay away, don’t
touch me” as you walk into his room. His mother is
in the room and is trying to comfort the patient.
What approaches might be helpful for the patient
See Table 15-7 for interventions for patients and his mother?
with schizophrenia who are hallucinating.

l Table 15-6 Nursing Care Plan of the Schizophrenic Patient

Data Nursing Interventions/ Evaluation
Collection Diagnosis Plan/Goal Nursing Actions Criteria
Patient is mumbling Social Patient will spend • Approach Patient will par-
to himself, looks isolation time in a social patient for brief ticipate in unit
suspiciously at staff, activity. periods in a non- activity once a
avoids contact with threatening day.
staff, other people manner.
avoid patient. • Avoid touching
patient without
asking permission.
• Talk about
concrete unit
activities.
• Demonstrate ac-
ceptance of pa-
tient’s behavior
and appearance
by avoiding re-
acting to bizarre
behavior. Point
out possible
alternative
behaviors once
relationship
established.
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240 UNIT 2 | Threats to Mental Health

l Table 15-7 Suggested Interventions for Patients With Schizophrenia

Who Are Hallucinating
Suggested Action Rationale
1. ”Mr. R, I don’t see any bugs. It is time 1. This lets the patient know you heard him
for lunch. I will walk to the dining room but brings him immediately into the reality
with you.” of time of day and the need to go to the
dining room.
2. ”I see a crack in the wall, Mr. R. It is 2. This is in response to a probable illusion.
harmless; you are safe. Susan is here It lets the patient know that you see some-
to take you down to Occupational thing. It validates his fear but tells him
Therapy now.” what you see and then moves him into
the here and now.
3. ”I know that your thoughts seem very 3. Again, you are validating the patient’s con-
real to you, Ms. C, but they do not seem cern without exploring and focusing on
logical to me. I would like you to come to the delusion.
your room and get dressed now, please.”
4. ”Ms. C, It appears to me that you are 4. This is a method of validating your impres-
listening to someone. Are you hearing sion of what you see. This is as far as you
voices other than mine?” will go into exploring what she may be
hearing.
5. ”Thank you, Ms. C. I want to help you 5. In this statement, you respond to her in
focus away from the other voices. I am real; the present and reinforce her response to
they are not. Please come with me to the you. This response attempts to redirect her
reading room.” thinking.
Source: Adapted from Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia:
F.A. Davis Company, with permission.

■■■ Key Concepts gradient of less to more severe conditions.

Schizophrenia is usually diagnosed in a
1. Schizophrenia is a chronic, serious, often person’s late teens and young adulthood
debilitating psychiatric disorder that im- but often continues for the rest of the
pacts all aspects of the patient’s life and patient's life.
his/her loved ones. 5. Hallucinations and delusions are exam-
2. Schizophrenia is now known to be a ples of positive symptoms that present
brain disorder. challenges to all health-care professionals.
3. Not all psychoses are schizophrenia. 6. The main treatment for schizophrenia re-
Other psychotic disorders can include mains antipsychotic medications. Be-
brief psychotic disorder, psychosis in cause of the side-effect profile of these
bipolar disorder, substance abuse, and medications, close monitoring is needed
major depression. to achieve the best outcomes and patient
compliance.
4. Schizophrenia is now viewed as a spec-
trum disorder, which means there is a
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CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 241

CASE STUDY
Ralph is a 20-year-old college student who is reported to his parents that he needed
admitted to your psychiatric facility by his immediate hospitalization.
parents. Ralph is in his second year at an The parents report that Ralph had a
out-of-state college. Over the past 6 months, normal childhood and never displayed any
he has been exhibiting increasingly bizarre unusual behavior until the last year. The
behavior, such as walking the halls of his parents tell you they feel guilty that they
dorm at night knocking on doors, asking did not monitor his behavior more closely
strange questions, mumbling to himself, and in the last few months.
sleeping on the floor during the day. He has On meeting Ralph he avoids eye contact
also been exhibiting disruptive behaviors in and appears to be talking to someone he
class. Students report being afraid of him sees in the corner of the room. When his
and he has become increasingly isolated. parents walk into the room, he begins hit-
Most recently he became violent in the ting his head repeatedly against the wall.
school cafeteria. Then the school counselor

1. How should you respond to Ralph when first meeting him?

2. How would you respond to the parents’ fears?
3. What medications might be useful for this patient?

REFERENCES interventions for schizophrenia and the margin-

alization of person-centered alternatives. Issues
American Psychiatric Association. (2000).
in Mental Health Nursing. 33(2),127–132.
Diagnostic and Statistical Manual of Mental
National Institutes of Mental Health. Schizophrenia.
Disorders IV-Text Revision. Washington DC,
Retrieved from http://www.nimh.nih.gov/
Author. (Known as DSM-IV-TR)
statistics/1SCHIZ.shtml
American Psychiatric Association. (2013). Dia-
Townsend, M. (2012). Psychiatric Mental Health
gnostic and Statistical Manual of Mental Dis-
Nursing. 7th ed. Philadelphia: F.A. Davis.
orders 5. Washington, DC, Author. (Known
as DSM-5)
Bauer, S.M., et al. (2011). Culture and the WEB SITES
prevalence of hallucinations in schizophrenia. National Alliance on Mental Illness: Infor-
Comprehensive psychiatry, 52(3), 319–325. mation on schizophrenia for patients,
Collier, E. (2011). Schizophrenia in older adults. families and professionals
Journal of psychosocial nursing and mental www.nami.org/Content/ContentGroups/Illnesses/
health services, 49(8), 17–21. Onset_Schizophrenia.htm
Goldberg, R J. (2007). Practical Guide to the National Institute of Mental Health: What
Care of the Psychiatric Patient. 3rd ed. Is Schizophrenia?
St Louis: Mosby-Elsevier. www.nimh.nih.gov/health/publications/
Gorman, L., and Sultan, D. (2008). Psychosocial schizophrenia/index.shtml
Nursing for General Patient Care. 3rd ed. QSEN
Philadelphia: F.A. Davis. http://qsen.org/about-qsen/
Harris, B.A. (2012). Schizophrenia. A critical
nursing perspective of pharmacological
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242 UNIT 2 | Threats to Mental Health

Test Questions
Multiple Choice Questions
1. Brian, an 18-year-old with schizophrenia, 5. Which of the following is not a sign of
has a negative attitude, is delusional, hears untreated schizophrenia?
voices, and is withdrawing from others. A a. Loss of reality
nursing intervention that is appropriate for b. Living in one’s own world
promoting activity for Brian is: c. Maintaining satisfactory performance
a. Tell him “the voices” told you he on the job
should participate in the weekly party. d. Delusions, hallucinations
b. Remind him that he does not want to 6. A nursing intervention for a person with
get worse by sitting alone. schizophrenia is to:
c. Tell him he must join the party; it is a. Reinforce the hallucinations.
part of his care plan. b. Keep the person oriented to reality and
d. Invite him to join in the party. to the present.
2. Shawna is a 22-year-old woman who has c. Encourage the patient to begin
episodes of extreme muscle rigidity and psychoanalysis.
hyperexcitability. She sometimes repeats a d. Encourage competitive activities.
word or a phrase over and over. Attempts 7. Mr. S states, “Look at the snakes on the
to move her are met with even more mus- ceiling.” You see some cracks in the
cle resistance. What is she exhibiting? plaster. Mr. S is experiencing a (an):
a. Catatonia a. Hallucination
b. Disorganized schizophrenia b. Illusion
c. Brief psychotic disorder c. Delusion
d. Schizotypal personality d. Flashback
3. Mr. G is calling out, “Nurse!” When you 8. Your best response to Mr. S might be:
arrive in his room, he tells you to be care- a. “How many snakes do you see, Mr. S?”
ful of the snake in the corner. You do b. “Yes, I see them, too. Let’s go to the
not see anything in the corner. Mr. G is dayroom.”
experiencing a (an): c. “I see some cracks in the plaster, but I
a. Hallucination do not see snakes. Let’s go to the day
b. Attention-getting behavior room.”
c. Illusion d. “I don’t think your medication is work-
d. Delusion ing. I’ll call the doctor.”
4. Of the following responses, which would 9. A patient who repeats a word or part of a
be your best response to Mr. G regarding word over and over might be said to have
the snake? which of the following symptoms?
a. “Don’t worry; I’ll get rid of it.” (You a. Echolalia
pretend to remove the snake.) b. Echopraxia
b. “I don’t see a snake; what else do you c. Echocardia
see that isn’t there?” d. Word salad
c. “I don’t see a snake. It is time for your
group meeting. I’ll walk with you to
the meeting room.”
d. “Where is it? I hate snakes. Let’s get
out of here.”
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CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 243

Test Questions cont.

10. An individual stands on the train track 12. The primary goal in working with an ac-
with the train coming nearer. The per- tively psychotic, suspicious patient is to:
son exclaims, “I am invincible! The train a. Improve her relationship with her parents
will not hurt me.” This is an example of: b. Encourage participation in individual
a. Delusions of grandeur psychotherapy
b. Echolalia c. Decrease her anxiety and increase trust
c. Sensory hallucinations d. Promote healthy living habits
d. Extrapyramidal symptoms 13. The most current thinking on the cause
11. Which of the following pairs of symp- of schizophrenia is:
toms are closely associated with EPS? a. A brain disorder
a. Muscle rigidity and protruding b. Primarily a disturbed mother/child
tongue relationship
b. Overly emotional, depressed c. Brain damage caused by the mother’s
c. Shuffling gait and depression use of tranquilizers during pregnancy
d. Fatigue and painful joints d. Alternation in opioid receptors
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C HA PT E R 16
Neurocognitive Disorders:
Delirium and Dementia
Learning Objectives Key Terms
1. Describe the differences between delirium and dementia. • Agnosia
2. Define neurocognitive disorders. • Agraphia
3. List the most common forms of dementia. • Alzheimer’s disease
4. List common causes of delirium. • Apraxia
5. Describe effective treatments for each. • Chemical restraint
• Delirium
• Dementia
• Mild neurocognitive
disorder
• Neurocognitive disorder
• Nocturnal delirium
• Physical restraint
• Pseudodementia
• Vascular dementia

N
eurocognitive disorder is the new memory deficit, language disturbance, and/or
global term that includes the diag- perceptual disturbance. Delirium may in-
noses of delirium and dementia clude alterations in sleep-wake cycle, including
(DSM-5, 2013). In the past these were re- hypervigilant state to stupor. The patient may
ferred to as organic mental syndromes and exhibit nocturnal delirium, known as sundown-
disorders by the American Psychiatric Associ- ing, when confusion and agitation increase at
ation. The disorders in this category all in- dusk. See Table 16-1 for types of delirium with
clude deficits in cognitive function. common symptoms. Delirium usually develops
quickly and often fluctuates throughout the day.
■ Delirium The condition often resolves once the cause is
identified and treated. Delirium should be con-
Delirium is an acute reaction to underlying sidered when the person exhibits sudden onset of
physiological (e.g., toxins, drug reactions, illness) confusion, memory impairment, incoherence,
or psychological stress (e.g., sensory overload). It fluctuating levels of consciousness, sleep-wake
is a temporary condition that is characterized by cycle disruption, hallucinations, and/or delusions.
a disturbance in attention (i.e., reduced ability to Delirium is an extremely common condi-
direct, focus, sustain, and shift attention) and tion seen in the acute hospital, nursing home,
orientation to the environment. For example, and home settings, particularly in the elderly.
the patient may need questions repeated due to DSM-5 reports that delirium occurs in 15%–
inattention, is easily distracted, or needs repeated 53% of older individuals postoperatively and
orientation to the situation. It can also include 70%–87% of those in ICU. The condition also
245
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246 UNIT 2 | Threats to Mental Health

l Table 16-1 Types of Delirium

Hypoactive- Hyperactive-
Assessments Hypoalert Hyperalert Mixed
Level of alertness Lethargic, falls asleep Overly attentive Alternates between hyper-
between questions, to cues alert and hypoalert states
difficult to arouse within hours or days
Motor activity Decreased activity Moves quickly Alternates within one
episode of delirium
Ability to follow Follows a simple May be combat- Alternates between hypoac-
commands command, e.g., lift ive, pulls at tubes, tive and hyperactive states,
your foot tries to climb out may be unpredictable
Is passively of bed
cooperative
Thinking ability Difficulty in Easily distracted, Alternates between hypoac-
focusing attention, Rambles tive and hyperactive states
disorganized May mumble, in an unpredictable manner
swear, or yell
Source: Adapted from Forrest et al. (2007) and Gorman & Sultan (2008).

contributes to mortality. DSM-IV-TR reports

that 15% of elderly people die within one Pharmacology Corner
month of an episode of delirium. Common Prescribing medications to control delirium
causes can include electrolyte imbalance, poor symptoms is risky because these medications
oxygenation, medication side effects or misuse, can mask or compound the confusion and
urinary tract infections, and dehydration. See agitation. However, at times low-dose an-
Table 16-2 for a more comprehensive list of tipsychotic medications such as haloperidol,
causes. Identifying the cause can be challenging risperdal, and olanzapine may be needed to
in people with complex medical conditions, as address agitation. The benefits of the med-
multiple factors may contribute to the delirium. ications must be weighed against the possible
Substance-induced delirium is a separate cate- side effects. Generally, anti-anxiety medica-
gory when delirium developed during or within tions like lorazepam should be avoided as
a month after severe intoxication or withdrawal they further confuse the picture of alterations
from a substance capable of producing delirium. in consciousness.
Treatment of Delirium
Neeb’s Your patient with delirium needs
Treatment of delirium must be focused on
finding and treating the cause. Often symp- ■ Tip to be monitored closely. He can
appear normal at times and then
toms of delirium can resolve quickly once the suddenly become agitated and try
appropriate treatment for the cause is begun. to get out of bed unsupervised.
Supportive interventions to maintain patient
safety, control agitation, prevent further com-
plications, and reorient can be very helpful. ■■■ Critical Thinking Question
An 81-year-old woman is admitted from the ER
with a diagnosis of delirium manifested by acute
■■■ Clinical Activity confusion, rambling speech, and new onset of
If your patient has a delirium diagnosis or exhibits incontinence. Her husband reports this all started
a sudden change in consciousness and/or behav- 24 hours ago after several episodes of diarrhea.
ior, review his or her medical record for possible She had recently been in the hospital for compli-
causes, including medication side effects, recent cations from diabetes. List the possible causes of
lab results, and recent infections. delirium that should be evaluated.
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CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 247

l Table 16-2 Causes of Delirium

Biological Factors Other Factors
Hypoxia Medication side effect
Nutritional deficiencies, e.g., iron, B12 Anesthesia reaction
Electrolyte imbalances, e.g., ↑ calcium Overdose of medication
Hypoglycemia/hyperglycemia Substance abuse/withdrawal, e.g., alcohol,
Renal failure, hepatic encephalopathy cannabis, opioids, anxiolytics, sedatives
Sepsis and other infections including UTI Sensory overload and deprivation
Metabolic disorders, e.g., acid-base imbalance Head trauma
Medication or anesthesia reaction
Hypothyroidism
Cardiac insufficiency
Primary brain disorders, e.g., brain tumors,
Parkinson’s disease
Pain
Source: Gorman & Sultan (2008) and Townsend (2012).

■ Dementia 1906 as a form of impairment of brain func-

tion (Fig. 16-1). Alzheimer’s disease accounts
Dementia is defined as a gradual loss of pre- for 60%–80% of dementias. It is estimated
vious levels of cognitive functioning, which that 13% of Americans over 65 years old have
can include memory, language, executive this diagnosis and incidence increases with age.
functions (includes organizing), and attention The impact on society is a major one as people
in a state of being fully alert. In DSM-5 it is are living longer. It is not reversible. Alzheimer’s
classified as a major neurocognitive disorder. disease is the sixth leading cause of death in
In contrast to delirium, dementia is a slowly the United States. The cause of death is often
progressive condition that eventually impacts aspiration pneumonias, infections, and com-
all aspects of mental and social functioning. plications from falls, which are all outcomes
Primary dementias, including Alzheimer’s
disease, are those where the dementia itself is
the major cause. Secondary dementia, includ-
ing vascular and HIV-related, is caused by
another disease or condition.
Depression is a common disorder in the
elderly. Sometimes depression can mimic
dementia; in that case, it is referred to as
pseudodementia. Depression in the elderly
can be confused with dementia with the
following symptoms:
• Forgetfulness
• Little effort to complete responsibilities
• Limited communication
One differentiation is that the depressed
patient generally remains oriented to time
and place, unlike the dementia patient.
Alzheimer’s Disease Figure 16-1 Alois Alzheimer (1864–1915)
This most common form of dementia was was a German neurologist who first identified
initially recognized by Dr. Alois Alzheimer in Alzheimer’s disease in 1906.
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248 UNIT 2 | Threats to Mental Health

of immobility, swallowing disorders, and mal-

nutrition that are present in late stages of the l Box 16-2 Warning Signs of
disease (Alzheimer’s Association, Alzheimer’s Alzheimer’s Disease
Disease 2013 Facts and Figures, 2013). See 1. Asking the same question over and over
Box 16-1 for the symptoms of Alzheimer’s again.
disease and Box 16-2 for warning signs. 2. Repeating the same story, word for word,
again and again.
3. Losing one’s ability to pay bills or balance
Tool Box | Review the government’s one’s checkbook.
National Plan to Address Alzheimer’s Disease 4. Getting lost in familiar surroundings, or
(2012) at misplacing household objects.
http://aspe.hhs.gov/daltcp/napa/N atlP lan. 5. Relying on someone else, such as a
shtml spouse, to make decisions or answer
questions they previously would have
handled themselves.
In addition to symptom assessment, the 6. Finding it hard to remember things.
diagnosis of Alzheimer’s disease is made by 7. Losing things or putting them in odd
MRI or PET scan, which can detect physical places.
and chemical changes in the brain. The Source: Adapted from National Institute on Aging (2012). Alzheimer's
changes seen in the brain include development Disease Fact Sheet.
of plaque (chemical deposits made of degen-
erating nerve cells and proteins called beta acetylcholine is reduced as well. Some of the
amyloid) and tangles (malformed nerve cells). medications that are being used to slow the
These plaques and tangles are greatly increased progression of this disease increase the level
in someone with this form of dementia. As of acetylcholine. There are genetic markers
they increase, they create a toxic environment for some forms of this disease. Research is
for normal brain cells. It is known that an ongoing as to the causes of these brain changes
enzyme used to produce the neurochemical (Fig. 16-2). A rare form of the disease is ge-
netic and accounts for less than 5% of cases.
Other specific causes are still unclear.
l Box 16-1 Symptoms of Alzheimer’s The presence of the diagnosis of mild neu-
rocognitive disorder (previously called mild
Disease cognitive impairment) is a risk factor. Mild
• Memory loss that disrupts daily life neurocognitive disorder is a condition in
• Challenges in planning or solving problems which a person has mild deficits with mem-
(executive functions) ory, language, or another essential cognitive
• Difficulty completing familiar tasks at home, ability. The person begins making changes in
at work, or at leisure his/her life to compensate for these, and it
• Confusion with time or place begins to affect daily living. Mild cognitive
• Trouble understanding visual images and
spatial relationships
disorder is not normal aging.
• New problems with words in speaking or Many people fear that forgetfulness is
writing a sign of developing Alzheimer’s disease.
• Misplacing things and losing the ability to See Table 16-3 for the differences between
retrace steps Alzheimer’s disease and normal aging.
• Decreased or poor judgment
• Withdrawal from work or social activities The Stages of Alzheimer’s Disease
• Changes in mood and personality Alzheimer’s disease has been divided into stages.
• Agnosia: loss of ability to recognize objects
• Agraphia: difficulty writing and drawing STAGE 1: NO IMPAIRMENT
• Apraxia: inability to carry out motor activi- (NORMAL FUNCTION)
ties despite intact motor function
The person does not experience any mem-
Source: Adapted from Alzheimer’s Association and Townsend (2012). ory problems. An interview with a medical
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CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 249

l Table 16-3 Differentiating

Alzheimer’s Disease
From Normal Aging
Alzheimer’s
Disease Normal Aging
Making poor Making a bad decision
judgments and once in a while
A decisions a lot of
the time
Problems taking Missing a monthly
care of monthly payment
bills
Losing track of the Forgetting which day
date or time of it is and remembering
year it later
Trouble having a Sometimes forgetting
conversation which word to use
B
Misplacing things Losing things from
often and being time to time
Extreme Shrinkage of Severely unable to find
Cerebral Cortex Enlarged them
Ventricles
Source: The National Institute on Aging. Retrieved from www.nia.
nih.gov/alzheimers/publication/understanding-alzheimers-
disease/what-are-signs-alzheimers-disease

symptoms of dementia can be detected during

a medical examination or by friends, family,
Extreme or coworkers.
Shrinkage of
C Hippocampus STAGE 3: MILD COGNITIVE DECLINE
(EARLY-STAGE ALZHEIMER’S CAN BE
Figure 16-2 Changes in the Alzheimer’s DIAGNOSED IN SOME BUT NOT ALL
brain. A. Metabolic activity in a normal brain. INDIVIDUALS WITH THESE SYMPTOMS)
B. Diminished metabolic activity in Alzheimer’s
diseased brain. C. Late-stage Alzheimer’s disease Friends, family, or coworkers begin to notice
with generalized atrophy and enlargement of difficulties. During a detailed medical inter-
the ventricles. (Source: Alzheimer’s Disease Education view, doctors may be able to detect problems
& Referral Center, A Service of the National Institute in memory or concentration. Common stage
on Aging.) 3 difficulties include:
• Noticeable problems coming up with the
professional does not show any evidence of right word or name
symptoms of dementia. • Trouble remembering names when intro-
duced to new people
STAGE 2: VERY MILD COGNITIVE • Having noticeably greater difficulty per-
DECLINE (MAY BE NORMAL AGE- forming tasks in social or work settings
RELATED CHANGES OR EARLIEST SIGNS
• Forgetting material that one has just
OF ALZHEIMER’S DISEASE) read
The person may feel as if he or she is having • Losing or misplacing a valuable object
memory lapses—forgetting familiar words • Increasing trouble with planning or
or the location of everyday objects. But no organizing
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250 UNIT 2 | Threats to Mental Health

STAGE 4: MODERATE COGNITIVE • Remember their own name but have

DECLINE (MILD OR EARLY-STAGE difficulty with their personal history
ALZHEIMER’S DISEASE) • Distinguish familiar and unfamiliar faces
At this point, a careful medical interview but have trouble remembering the name
should be able to detect clear-cut symptoms of a spouse or caregiver
in several areas: • Need help dressing properly and may,
without supervision, make mistakes such
• Forgetfulness of recent events as putting pajamas over daytime clothes
• Impaired ability to perform challenging or shoes on the wrong feet
mental arithmetic—for example, counting • Experience major changes in sleep
backward from 100 by 7s patterns—sleeping during the day and
• Greater difficulty performing complex becoming restless at night
tasks, such as planning dinner for guests, • Need help handling details of toileting
paying bills, or managing finances (for example, flushing the toilet, wiping
• Forgetfulness about one’s own personal or disposing of tissue properly)
history • Have increasingly frequent trouble
• Becoming moody or withdrawn, espe- controlling their bladder or bowels
cially in socially or mentally challenging • Experience major personality and behav-
situations ioral changes, including suspiciousness
STAGE 5: MODERATELY SEVERE
and delusions (such as believing that their
COGNITIVE DECLINE (MODERATE OR
caregiver is an impostor) or compulsive,
MID - STAGE A LZHEIMER ’ S D ISEASE )
repetitive behavior like hand-wringing or
tissue shredding
Gaps in memory and thinking are noticeable, • Tend to wander or become lost
and individuals begin to need help with day-
to-day activities. At this stage, those with STAGE 7: VERY SEVERE COGNITIVE
Alzheimer’s may: DECLINE (SEVERE OR LATE-STAGE
ALZHEIMER’S DISEASE)
• Be unable to recall their own address or
telephone number, or the high school or In the final stage of this disease, individuals
college from which they graduated lose the ability to respond to their environ-
• Become confused about where they are or ment, to carry on a conversation, and, even-
what day it is tually, to control movement. They may still
• Have trouble with less challenging mental say words or phrases. At this stage, individuals
arithmetic; e.g., counting backward from need help with much of their daily personal
40 by subtracting 4s or from 20 by 2s care, including eating or using the toilet. They
• Need help choosing proper clothing for may also lose the ability to smile, to sit with-
the season or the occasion out support, and to hold their head up. Re-
• Still remember significant details about flexes become abnormal. Muscles grow rigid.
themselves and their family Swallowing is impaired.
• Still require no assistance with eating or (Reprinted with permission, Alzheimer’s
using the toilet Association.)

STAGE 6: SEVERE COGNITIVE DECLINE

Neeb’s Alzheimer’s disease is a progressive
(MODERATELY SEVERE OR MID-STAGE ■ Tip illness that will eventually lead to
the patient’s death. The nurse should
ALZHEIMER’S DISEASE)
be aware of signs of late-stage
Memory continues to worsen, personality Alzheimer’s disease (Stage 7) when
changes may take place, and individuals need hospice care may be an appropriate
extensive help with daily activities. At this referral. Signs such as bedbound,
stage, individuals may: incontinent, multiple infections, aspi-
• Lose awareness of recent experiences as rations can indicate the patient is
well as of their surroundings appropriate for hospice care.
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CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 251

■■■ Classroom Activity

• View and discuss recent movies that address
dementia, including Iron Lady, The Savages, and
The Notebook.

Tool Box | The mini-mental state exam

(MMSE) is a widely used test of cognitive
function. It is a 30-point questionnaire used
extensively with dementia patients to track
changes over time. Available online at
http://en.wikipedia.org/wiki/M ini% E 2% 8 0% Figure 16-3 Alzheimer’s disease makes a tremen-
9 3mental_ state_ ex amination. dous impact on the family.

Treatment of Alzheimer’s Disease Neeb’s People with early-stage Alzheimer’s

No treatment is available to stop the deteri- ■ Tip disease should be encouraged to
oration of brain cells in Alzheimer’s disease. complete an advance directive so
The U.S. Food and Drug Administration they can document their wishes for
(FDA) has currently approved five drugs that care and treatment as the disease
temporarily slow worsening of symptoms for progresses.
about 6 to 12 months (see the Pharmacology
Corner). However, researchers around the
world are studying numerous treatment
strategies that may have the potential to Pharmacology Corner
change the course of the disease. Approxi-
mately 75 to 100 experimental therapies Cholinesterase inhibitors are the class of
aimed at slowing or stopping the progres- medications used in treatment of early to
sion of Alzheimer’s are in clinical testing in moderate Alzheimer’s disease. They are ef-
human volunteers (Alzheimer’s Association, fective for only about half of the individuals
Alzheimer’s Disease 2013 Facts and Figures, who take them. These drugs act by inhibit-
2013). ing acetylcholinesterase, which increases the
In addition to the medications, supportive concentrations of acetylcholine in the brain.
care, maintaining safety, prevention of infec- They have been found to slow the process of
tions, and caregiver support are the major dementia in some people but not control it.
interventions. Once diagnosed, the patient Another medication, memantine, is used in
and his/her family need to develop a plan to moderate to severe Alzheimer’s disease. It
provide care as the disease progresses. This is works as a receptor antagonist of N-methyl-
important in the early stages so the patient D-aspartate (NMDA) and has been shown
can participate in decisions about future care to slow down progression of cognitive de-
while he/she still can. For example, identify- cline and daily functioning in some patients
ing options for home caregivers or facilities in with more advanced disease. The two types
the area based on the patient’s wishes can be of drugs may be given together in some
documented early on. Family members of cases. See Table 16-4 for the cholinesterase
Alzheimer’s patients need to be prepared for inhibitors used to treat Alzheimer’s demen-
what to expect as it progresses (Fig. 16-3). tia. Early treatment with these medications
with mild neurocognitive disorder may
be helpful.
■■■ Clinical Activity When extreme agitation requires the use
If your patient has dementia, talk with patient’s of antipsychotic medications in dementia
family about how they are coping.
Continued
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252 UNIT 2 | Threats to Mental Health

Pharmacology Corner— Neeb’s It can be challenging to give oral

cont’d ■ Tip medications to dementia patients.
An effective strategy is to crush the
patients, it must be recognized that the pills and put them in sweet foods
FDA has ordered black-box warnings on like pudding.
atypical antipsychotics due to increased risk
of death in the elderly with psychotic be- Neeb’s Close monitoring of side effects
haviors associated with dementia. These
deaths were cardiovascular related. In 2008
■ Tip of all medications can be challeng-
ing as the patient may not be able
all typical antipsychotics were added to this to tell you what he/she is experi-
warning. Therefore close monitoring is encing e.g., dry mouth, itching,
required when any of these medications constipation.
are used. This presents a dilemma to the
clinician. These medications can control
behavior and promote safety, but there is a ■■■ Critical Thinking Question
risk for untoward effects. Generally, the Your 72-year-old patient with advanced dementia
adage “start low and go slow” when using has been screaming all night, calling for her
mother. All attempts to console her are ineffective.
any medications in this population is Every time someone walks by her room, her
particularly true. screaming increases. You have orders for several
Other medications to treat depression, medications to control agitation, including
anxiety, and insomnia may be utilized. Be- haloperidol and lorazepam. Before administering
cause depression and anxiety are especially one of these, what should you consider?
common if the person is aware of the de-
cline, these medications can be very helpful.
Be aware that paradoxical reactions (drug ■■■ Clinical Activity
has opposite effect than what it is intended Monitor side effects of any medications your
for) sometimes occur in the elderly with patient is taking. Your observation is most impor-
anti-anxiety medications. tant as your patient may not be able to verbalize
about symptoms.
Managing anxiety with these medications
can be useful to reduce the patient’s suffering
and disruptive behaviors.
Other Forms of Dementia
The second most common form of dementia
is vascular and is caused by small strokes
l Table 16-4 Cholinesterase which over time result in interruption of
Inhibitors blood flow to the brain. Vascular dementia
is sometimes referred to as multi-infarct de-
Cholinesterase mentia. Progression of this form of dementia
Inhibitor Side Effects can vary from Alzheimer’s disease depending
Tacrine (Cognex) Dizziness, headache, on the occurrence of vascular events, i.e.,
GI upset progression of dementia occurs with each
Donepezil (Aricept) Insomnia, dizziness, new stroke. So an individual with vascular
headache, GI upset dementia can remain stable for longer peri-
Rivastigmine Dizziness, headache, ods if there are no new strokes. There are a
(Excelon) fatigue number of other forms of dementia includ-
Galantamine Dizziness, headache, ing dementia associated with Parkinson’s
(Razadyne) GI upset disease, Lewy bodies, substance abuse, HIV,
and traumatic brain injury among others.
Source: Adapted from Townsend (2012): Psychiatric Mental Health
Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. These dementias can also exist in the mild
Philadelphia: F.A. Davis Company, with permission. neurocognitive disorder forms as in mild
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CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 253

neurocognitive disorder due to HIV infec- ■ Nursing Care of Patients

tion as an example. Each of these forms of
dementia has its own unique components With Delirium and
in addition to core diagnostic features of Dementia
dementia.
Common nursing diagnoses in patients
Differential Diagnosis of with delirium and dementia include the
Delirium and Dementia following:
A new patient presenting with confusion and • Anxiety
agitation can sometimes be misdiagnosed. • Injury, risk for
Symptoms of delirium and dementia can • Memory, impaired
seem similar, especially on first meeting a • Self-care deficit
patient. See Table 16-5 and Box 16-3 to dif- • Sensory perception, disturbed
ferentiate between delirium and dementia • Sleep pattern, disturbed
and common factors leading to misdiagnosis. • Thought processes, disturbed

l Table 16-5 Characteristics of Delirium and Dementia

Delirium Dementia
• Fluctuating levels of awareness and • Slow, insidious onset with less fluctuation of
symptoms symptoms
• Sudden onset • Deterioration of cognitive abilities
• Clouding of consciousness • Impaired long- and short-term memory
• Perceptual disturbances (hallucinations, (memory impairment always present)
illusions) • Personality changes
• Memory disturbance, more often for • May focus on one thing for a long time
recent events • Often irreversible
• Highly distractible
• Reversibility possible with treatment
Source: Adapted from Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with
permission.

l Box 16-3 Factors That Contribute to Misdiagnosis in Dementia

and Delirium
• Some symptoms of dementia and delirium are similar.
• Several causes may occur simultaneously to bring about dementia.
• Delirium occurring in a patient with a dementia can exacerbate already existing symptoms.
• Health-care personnel may harbor unfounded beliefs that serious memory deficits, confusion,
and other progressive intellectual deficits are a normal part of the aging process.
• Health-care personnel may harbor unfounded beliefs that confusion always indicates Alzheimer’s
disease in an older patient.
• Confusion and behavioral changes may be the first signs of medical illness in the elderly.
• Head injuries and other conditions causing brain tissue trauma may present with symptoms
similar to those of dementia.
• Confusion is an adverse reaction to many medications.
Source : Gorman, L., Raines, M., & Sultan, D. (1989): Psychosocial Nursing for the Nonpsychiatric Nurse. Philadelphia: F.A. Davis Company. Table 8.1,
page 131.
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254 UNIT 2 | Threats to Mental Health

General Nursing Interventions 4. Use clear, simple verbal communication:

Sensory overload is a common experi-
The nursing interventions for patients with
ence for patients experiencing delirium
either or both of these diagnoses are based
and dementia. To avoid a behavioral
on the patient’s symptoms.
“short circuit,” it is a good idea to use
1. Collect data: Collect information on vital simple communication and activity in
signs, medications used by the patient, the room. Keep the area quiet. Keep
circumstances immediately preceding curtains drawn or partially open; keep
symptoms, and any other information televisions and radios off or at a very
the patient or person who may be ac- low volume. The stimulation can be
companying the individual can provide. adjusted according to the patient’s
Note anything that is considered to be a tolerance. Focus on one task at a time.
change in the patient’s condition. Ques- Do not give the patient two to three
tion family/caregivers on interventions instructions at the same time.
that have been useful in the past. 5. Allow time for patient to respond: The
2. Stay calm: Be ready for anything. Patients ability to function cognitively and
with symptoms of delirium and/or physically is diminished when a person
dementia can be very changeable. No is in delirium or dementia. Nurses and
matter what the situation, nurses must other health-care workers must remem-
diffuse the situation calmly and return ber to plan to allow more time for per-
the situation to safety. It is very impor- forming care. Patience is an important
tant to make every attempt to maintain intervention. This can be frustrating
the patient’s dignity during periods of ex- for caregivers, but by following this
citability. Due to memory deficits, these plan the patient will have more oppor-
patients can exhibit impulsive behaviors tunities to remain independent and
and labile emotions as they forget the reduce his/her anxiety. This will make
context of the situation. The nurse re- the nurse’s job easier with better
maining calm will reinforce maintaining outcomes.
a calm environment. 6. Use touch when appropriate: It is im-
possible not to touch this group of
Neeb’s A patient with early to moderate patients. There is a danger for misinter-
pretation of that touch, however. Peo-
■ Tip dementia may suffer intense anxiety ple who have a threat to their ability
due to confusion and awareness of
losing his/her memory. This can be to process and understand information
the cause of agitation and paranoia. may not remember the situation as it
actually happened. They may have for-
gotten the episode of incontinence and
3. Do not argue: Patients with dementia not understand why “that nurse had
and/or delirium have cognitive impair- to touch me there!” Having a second
ment. They do not have the capacity to person—another nurse or a family
make rational decisions during the agi- member—in the room can be a helpful
tated episode. Attempting to model the protection for both the nurse and the
desired behavior or simply waiting a few patient. Documenting all actions and
minutes and attempting the verbal in- patient responses very carefully is also
struction again may prove to be successful necessary.
techniques. These patients may no longer 7. Wandering: Patients in a state of delir-
have the filters to control their behavior ium or dementia may wander. This is
or act in a socially acceptable manner. a major safety risk that frequently
Distraction can be helpful in some cases. encourages nurses to request restraint
Be aware that patients may use disruptive orders from the physician. Restraints
behaviors such as swearing, insulting should only be used as last resort
others as a way to express frustration. when alternative interventions are
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CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 255

unsuccessful. Interventions to use ear- maintain the patient’s dignity and allow
lier include: him or her to do as much independ-
• Providing a safe environment where ently as able.
the patient can walk or pace 9. Provide adequate stimulation: It is as
• Distracting patient to other activities detrimental to understimulate people
• Putting up large signs in the area re- with cognitive disorders as it is to over-
minding patient of his room or areas load them. The brain needs some en-
off limits couragement to activate. This will be a
• Using alarms on the patient or to off- “trial-and-error” situation between the
limit areas (e.g., exit door to stairwell) nurse and the patient, and it will be
• Engaging family and volunteers to different for every patient. Some success
closely watch the patient’s movements has been made with music, pets, art,
When the physician has ordered re- and physical therapies.
straints, the nursing responsibilities include 10. Maintain appropriate milieu: People liv-
careful observation and documentation of ing with irreversible, progressive demen-
alternative interventions that have been tia require special attention to the milieu.
tried. Physical restraints are defined as any Acceptance is mandatory. In dementia,
physical method of restricting an individ- nurses should not emphasize “reality
ual’s freedom of movement, activity, or nor- orientation” such as repeated attempts
mal access to his/her body and cannot be to ask or remind patient of his name, the
easily removed. For physical restraints, each year, and current location—especially in
state has guidelines for how often to check, later stages of the disease. Changes in the
release, and reposition or exercise the pa- brain will not allow the memory to func-
tient. Assessing for signs of dermal ulcers tion successfully and may, in fact, cause
and stiffness of muscles helps to maintain the patient to experience frustration, feel
skin integrity and full range of motion. agitation, and increase acting-out behav-
Chemical restraints are defined as the use iors if “reality orientation” is emphasized.
of a medication as a restriction to manage Reality orientation may be helpful in
the patient’s behavior or restrict the patient’s delirium and early stages of dementia
freedom of movement, and are not a stan- where the patient gains a sense of com-
dard treatment or dosage for the patient’s fort from being reoriented, but with
condition. Again, each state may have short-term memory gaps this may be
guidelines on the use of chemical restraints. helpful only for a brief time.
For chemical restraints, the nurse must doc- Having old photos of the patient
ument the effect of the medication and any or familiar smells such as perfume or
possible side effects. Many medications favorite foods in the environment can
have side effects, such as confusion, restless- have a reassuring effect. Many dementia
ness, and forgetfulness, and may be coun- facilities ask families to bring in special
terproductive for people with delirium and personal items such as photos or memen-
dementia. Medications should not be used tos that can be housed in a “memory
as a substitute for appropriate activities, box” in the patient’s room to provide a
programming, and personal interaction. calming influence from familiar items.
8. Assist with ADLs as appropriate to the situ- 11. Emotional support: The patient often ex-
ation: The nurse will be doing as much periences anxiety as he/she realizes loss of
for the patient physically as the individ- mental abilities. The person can become
ual condition requires. For temporary panicky when disoriented. A consistent,
delirium and early stages of dementia, calm environment is important. Patients
the nurse may only have to use some ver- can also suffer from depression, especially
bal cues as to what the patient needs to in early stages when the full impact of
do. For deeper delirium and later stages the progressive disease is made. Family
of dementia, performing total care for caregivers also need much support as
the patient may be necessary. Always caring for this patient is exhausting. They
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256 UNIT 2 | Threats to Mental Health

often need assistance in identifying Neeb’s Family members must be provided

support groups and resources for addi- ■ Tip information on being a caregiver
tional caregivers and facilities. and how to cope with the long-
See Table 16-6 for the nursing care plan of term emotional strain.
confused patients.
Tool Box | The 36-Hour Day: A Family
Guide to Caring for Persons With Alzheimer
Cultural Considerations Disease, Related Dementing Illnesses, and
Memory Loss in Later Life (3rd Edition) by
The type of care the family wants for the Mace and Rabin is a must read for family
dementia patient will be influenced by caregivers.
culture. In some cultures the family will
maintain the patient in the home no mat-
ter how difficult the care. Incorporating Neeb’s Review agency policies on use of
important cultural values in the discharge ■ Tip restraints. Be aware of alternatives
plan is essential. to restraints that are useful with the
Language barriers can also add to com- patient.
plications in understanding the dementia
patient’s needs, especially if the patient is in
a facility. It is important for these patients ■■■ Classroom Activity
• Arrange a visit to a local dementia facility. Inter-
to have access to people who speak the view the staff to learn how they do this work
same language and have similar cultural ex- every day.
periences to enhance reality orientation and • Identify local resources such as support groups
correctly assess cognitive function. or adult day care for people with dementia.

l Table 16-6 Nursing Care Plan of the Confused Patient

Nursing
Data Collection Diagnosis Goal Interventions Evaluation
Confused as to Disturbance Reduced • Encourage family to Patients will
time, place in sensory episodes of provide familiar items have periods
Becomes perception agitation in patient’s room, e.g., of calmness.
agitated when old photos, mementos.
efforts made to • Place a large sign on
reorient patient door to identify patient’s
room, bathroom.
• Spend time with patient
to reminisce about an
important event in
the past.
• Play music or TV shows
that are meaningful
from patient’s past.
• Judge whether reorient-
ing patient regularly is
effective. If it increases
agitation, then avoid this.
• Distract the patient with
concrete activities like
sorting papers of the
same color.
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CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 257

■■■ Critical Thinking Question 3. Alzheimer’s disease is by far the most

In report you are told that your 90-year-old patient common form of dementia.
with moderate dementia has been awake all night,
pacing the floor. In the morning you find him sound 4. Alzheimer’s disease is a terminal illness
asleep at 10 a.m. What should be your plan for the which has a tremendous impact on the
day shift? patient’s family and society.
The next day, this patient is very agitated and
repeatedly insists on walking out the unit door. The 5. Other causes of dementia include
MD leaves an order for soft restraints to prevent vascular insufficiency, substance abuse,
wandering. Before applying these, what interven- and Parkinson’s disease.
tions should you try?
6. Medications such as anti-anxiety and an-
tipsychotics often have a side effect of
■■■ Key Concepts confusion and should be chosen carefully
in people with dementia. Medications
1. Delirium is a frequent diagnosis in the are chosen to treat specific behaviors;
acute hospital setting due to complex they are not a substitute for more direct
medical conditions, medication side interventions.
effects, and sensory overload. 7. Care of the dementia patient should
2. Delirium is usually reversible once the focus on maintenance of safety, preven-
cause is identified; dementia is usually tion of infection, and family support.
irreversible.

CASE STUDY
Mrs. G is 84-year-old widow who lives her refrigerator and sees very little food. He
alone. She has episodes of anxiety and asks her what she eats, and she says “yogurt.”
paranoia in her apartment. She calls her She cannot think of anything else. She re-
son at odd hours, telling him that a neigh- ports fear of using the stove so she only
bor is spying on her. Despite these episodes eats cold foods. He looks at her mail and
she seems to function normally and is able notices a past due notice on her water bill.
to care for herself. Her son reports that her She says she is sure she paid that. He is get-
memory seems to be getting poorer, and ting concerned and takes her to a geriatric
he notices that she leaves notes to herself physician for an evaluation. Mrs. G has
around the apartment reminding her to been a widow for 2 years.
lock the door, brush her teeth, or water the The physician does a complete assessment
plants. He also notices that she looks as in the office and orders an MRI. A diagnosis
though she has lost weight recently, though of early to moderate stage Alzheimer’s disease
she tells him she is eating well. He looks in is made.

1. What actions would you suggest the patient and her son institute at this time?
2. How would you differentiate between dementia and depression?
3. What safety measures need to be implemented?
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258 UNIT 2 | Threats to Mental Health

REFERENCES nih.gov/alzheimers/publication/alzheimers-
disease-fact-sheet
Alzheimer’s Association. (2013). Alzheimer’s Dis-
Rabins, P., et al. (2007). Practice Guidelines for
ease 2013 Facts and Figures (Vol. 2). Chicago:
the Treatment of Patients With Alzheimer’s Dis-
Alzheimer’s Association. www.alz.org/
ease and Other Dementias in Late-Life. 2nd
alzheimers_disease_facts_and_figures.asp
ed. Retrieved from http://psychiatryonline.org/
Alzheimer’s Association. Stages of Alzheimers
guidelines.aspx
disease. Retrieved from alz.org/alzheimers_
Stanley. M., Blair, K.A., and Beare, P.G. (2005).
disease_stages_of_alzheimers.asp
Gerontological Nursing: Promoting Successful
American Psychiatric Association. (2000). Dia-
Aging With Older Adults. 3rd ed. Philadelphia:
gnostic and Statistical Manual of Mental Dis-
F.A. Davis.
orders IV-Text Revision. Washington DC,
Townsend, M.C. (2012). Psychiatric Mental Health
Author. (Known as DSM-IV-TR)
Nursing. 7th ed. Philadelphia: F.A. Davis.
American Psychiatric Association. (2013). Dia-
gnostic and Statistical Manual of Mental Dis-
orders 5. Washington, DC, Author. (Known WEB SITES
as DSM-5) The Alzheimer’s Association has chapters
Forrest, J., Willis, L., and Holm, K. (2007). throughout the country and provides many re-
Recognizing quiet delirium. American Journal sources and local support groups for caregivers.
Nursing, 107(4), 35–39. http://www.alz.org
Gorman, L., Raines, M., and Sultan, D. (1989). National Institute on Aging, Alzheimer’s
Psychosocial Nursing for the Nonpsychiatric Disease Education and Referral Center
Nurse. Philadelphia: F.A. Davis. http://www.nia.nih.gov/alzheimers/publication/
Gorman, L., & Sultan, D. (2008). Psychosocial alzheimers-disease-fact-sheet
Nursing for General Patient Care. 3rd ed. Psychiatry online guidelines for dementia
Philadelphia: F.A. Davis. http://psychiatryonline.org/content.aspx?bookid=28&
National Institute on Aging. (2012). Alzheimer’s sectionid=1679489
Disease fact sheet. Retrieved from www.nia.
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CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 259

Test Questions
Multiple Choice Questions
1. You are working the night shift in your 4. Donepezil (Aricept) is a medication
surgical unit. Ms. Y, one day postopera- approved for the treatment of symptoms
tive for total hip replacement, is taking of Alzheimer’s-type dementia. Nurses
several medications for pain, along with must be alert to which of the following
an antibiotic. She is 70 years old and side effects?
presented as alert and oriented prior to a. Tachycardia
surgery. She lives independently. Ms. Y b. Insomnia
suddenly begins screaming and thrashing c. Mania
in bed, begging you to “Get the spiders d. Weight gain
out of my bed!” What is the best explana- 5. Which statement is not true about
tion for Ms. Y’s behavior? Alzheimer’s disease?
a. Delusions a. It is a dementia disorder.
b. Delirium b. It may occur in middle to late life.
c. Dementia c. It is a chronic disease.
d. Sepsis d. It is caused by hardening of the arteries.
2. The best nursing intervention for you, the 6. Which of the following would you expect
LPN/LVN, to help Ms. Y is: to see in a patient who is diagnosed with
a. Inform the charge nurse and doctor neurocognitive disorder?
immediately. a. Intact memory
b. Turn on the light and ask her where b. Appropriate behavior
the spiders are. c. Disorganization of thought
c. Stop her pain medications. d. Orientation to person, place, and time
d. Check her medical record for a
diagnosis of mental illness. 7. Ms. P has been admitted to your unit
with a diagnosis of right tibial fracture.
3. Mr. H has been admitted to your nursing Her emergency department notes say that
home in Stage 6 Alzheimer’s disease. His she fell at home. She admits to having “a
wife is crying and says to you, “Nurse, lot to drink” over the past week. She is
when will he get better? I don’t know disoriented to time, forgets where she is
what I will do without him home. Why momentarily, is easily distracted, and has
can’t the doctor fix him?” Your best re- a short attention span. She does not an-
sponse to Mrs. H is: swer questions appropriately. Her family
a. “Hopefully with time he will improve.” reports that her behavior has been more
b. “Maybe you should stop visiting for a and more erratic over the past 6 months
few days and then you’ll feel better.” with periods of confusion. Her son re-
c. “You sound really worried. Tell me ports she has been a heavy drinker all her
what the doctor has told you about his life. She is probably experiencing:
condition.” a. Delusions
d. “Mrs. H, your doctor has explained b. Delirium
that Mr. H will not get better. You c. Dementia
need to make a plan for the future.” d. Dilemma
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260 UNIT 2 | Threats to Mental Health

Test Questions cont.

8. Your patient, who is recovering from an 9. Mr. F is brought in by a family member

exacerbation of an AIDS-related infec- who expresses concern over his memory
tion, is opting to be treated by family and loss. The physician diagnosed the patient
friends at home. The family has expressed with vascular dementia (multi-infarct
concern because they sense a change in dementia). You realize this disorder:
the patient’s cognitive abilities. Part of the a. Is irreversible
discharge teaching for this family might b. May progress rapidly or slowly
include: c. Indicates the patient has most likely
a. “It’s nothing, really. Patients sometimes experienced more than one CVA
get confused in the hospital.” d. All of the above
b. “Keep an eye on him. You don’t want 10. The use of reality orienting techniques is
him to start wandering.” usually helpful with which patient?
c. “You’re concerned about the change a. Patient in Stage 7 Alzheimer’s disease
in his ability to remember things? Let b. Patient with advanced vascular dementia
me call the doctor for you. This is c. Elderly patient who is confused and
something that you need to discuss screaming out for her mother
together.” d. Patient who is recovering from delir-
d. “I thought something was strange!” ium and seems more relaxed when
reminded of where she is
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C HA PT E R 17
Substance Use
and Addictive Disorders
Learning Objectives Key Terms
1. Describe substance use disorder and how it impacts society. • Addiction
2. Define co-dependency. • Alcohol abuse
3. Define co-occurring disorders. • Alcohol dependence
4. Identify common medical treatments for addictive disorders. • Alcoholism
5. Identify nursing interventions for patients with addictive • Binge drinking
disorders. • Co-dependency
• Co-occurring disorder
• Detoxification
• Dysfunctional
• Psychoactive drugs
• Substance abuse
• Substance dependence
• Tolerance
• Withdrawal

M
ind- or mood-altering substances recent years its use has become much less ac-
have been used throughout human ceptable in U.S. society (Fig. 17-1).
history. Today these include alco- Substance abuse is a major health problem
hol, sedatives/hypnotics, narcotic analgesics, in the United States. Overall 14.6% of
stimulants, hallucinogens, and cannabis as the population has had a substance abuse dis-
well as psychoactive drugs. Most of these order at some time in their lives (Kessler,
categories of substances can be and are used Berglund et al., 2005). Substance abuse con-
legally and therapeutically. They all have tributes to higher health-care costs, significant
the strong potential to be abused and to disability, and suicide attempts (Cook &
become addictive. These substances taken in Alegría, 2011). The National Survey on Drug
excess activate the brain’s reward system and Abuse and Health conducts an annual survey
can lead to neglecting normal activities in of Americans’ use of alcohol and other sub-
favor of seeking out this substance again and stances and provides the following data from
again. 2011.
People use these substances for a variety of
reasons: to relieve physical and emotional • 8.7% of Americans age 12 or older were
pain, relax, elevate mood, enhance socializa- current (past month) illicit drug users,
tion, improve alertness, and alter perceptions meaning they had used an illicit drug
of reality. Alcohol and caffeine are probably during the month prior to the survey in-
the most used socially acceptable substances. terview. Illicit drugs include marijuana/
Tobacco was also part of that group, but in hashish, cocaine (including crack),
261
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262 UNIT 2 | Threats to Mental Health

Generally, substance use becomes a prob-

lem when it:
1. Interferes with normal functioning
2. Continues despite negative consequences
3. Hurts others
Substance abuse and substance depen-
dence have been traditionally separated as two
distinct diagnoses. Because these two desig-
nations are sometimes confusing and difficult
to differentiate, the DSM-5 (2013) has com-
bined abuse and dependence into substance
use disorder with a graded clinical severity of
mild, moderate, and severe. In addition to
substance use disorder, there are diagnostic
categories for substance-induced intoxication
and withdrawal. Each category has specific
criteria to be met to be given the diagnosis for
each substance. At least two criteria are re-
quired to make a diagnosis for a particular
substance use disorder. However because the
Figure 17-1 As this poster says, nicotine is an
addiction, and it can be the most difficult one
terms “abuse” and “dependence” are so com-
to overcome. (Courtesy of the National Institute mon in today’s culture, they will still be used
on Drug Addiction, National Institutes of Health, throughout this chapter along with substance
Bethesda, MD.) use disorder.
People with psychiatric disorders com-
heroin, methamphetamines, hallucino- monly abuse many drugs and alcohol as a way
gens, inhalants, or prescription-type to self-medicate to reduce feelings of anxiety, in-
psychotherapeutics used nonmedically; somnia, depression, loneliness, rapid thoughts,
marijuana remains the most widely used frightening hallucinations, and other distressing
illegal drug. symptoms. Commonly referred to as a co-
• An estimated 20.6 million persons (8% occurring disorder (also called dual diagnosis),
of the population age 12 or older) were this form of substance use disorder adds
classified with substance dependence or additional complications to the psychiatric
abuse in the past year based on criteria diagnosis in terms of daily management, treat-
specified in the Diagnostic and Statistical ment, and recovery. Co-occurring disorders are
Manual of Mental Disorders, 4th edition the rule rather than exception when working
(DSM-IV-TR). with a patient with a psychiatric disorder.
• Of these, 2.6 million were classified with Co-occurring disorders can start with self-
dependence or abuse of both alcohol and medicating to treat symptoms of a psychiatric
illicit drugs, 3.9 million had dependence diagnosis, or substance abuse can be the initial
or abuse of illicit drugs but not alcohol, diagnosis that leads to other psychiatric disor-
and 14.1 million had dependence or ders as a complication. See Figures 17-2 and
abuse of alcohol but not illicit drugs. 17-3 on pages 263 and 264. Outcomes for
treatment are more effective when the sub-
stance use treatment is integrated into the treat-
Tool Box | National Survey on Drug Use ment for the psychiatric disorder (Clark, 2012).
and Health: Summary of National Findings: Health-care professionals are not immune
www.samhsa.gov/data/N SD U H /2k11R esults/ to problems with alcohol and drugs. In fact,
NS D U H results2011.pdf they tend to abuse alcohol or prescribed
drugs. Since they do not fit the image of a
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CHAPTER 17 | Substance Use and Addictive Disorders 263

■■■ Critical Thinking Question

You are working in an outpatient mental health
Cultural Considerations
clinic. A new patient with a long history of schizo- Substance abuse crosses all cultures and
phrenia tells you he needs to leave the clinic for
an hour to meet someone who gives him “special ethnic groups. Some groups are known to
medicines” that he calls herbs to help him sleep. have a higher incidence that may reflect
What concerns would you have? What action genetic risk and/or cultural patterns. For
would you take? example, Native Americans have a high
rate of alcoholism. Genetic factors that
predispose them to poor metabolism of
Neeb’s All psychiatric patients should alcohol as well as other factors such as
■ Tip be screened for substance abuse unemployment and poverty are contribu-
disorders. tors. Asians have a lower rate of substance
abuse. Genetic intolerance for alcohol
substance abuser, it can be easier for health- creating an unpleasant sensation may
care professionals to deny the problem. Many be a factor in the lower incidence of
states have developed drug diversion pro- alcoholism (Townsend, 2012).
grams to provide confidential treatment and
rehabilitation.
• The same (or a closely related) substance
is taken to relieve or avoid withdrawal
■■■ Classroom Activity symptoms (e.g., alcohol and tranquilizers
• Movies that address substance abuse include
Days of Wine and Roses, Lost Weekend, I’m Dancing to sleep)
as Fast as I Can, 28 Days, and Flight. • The substance is often taken in larger
• Obtain information on how your state addresses amounts or over a longer period than was
substance abuse in nurses. intended (analgesics originally used for
pain relief then continued when source of
pain resolved)
Some of the characteristics of progressive
• There is a persistent desire or unsuccessful
substance use disorder include (American
effort to cut down or control substance use
Psychiatric Association, 2000, 2013):
• A great deal of time is spent in activities
• A need for markedly increased amounts of necessary to obtain the substance (e.g., vis-
the substance to achieve intoxication or iting multiple doctors or driving long dis-
desired effect (tolerance) tances to a source), in use of the substance,
• Markedly diminished effect with contin- or to recover from its effects
ued use of the same amount of the sub- • Important social, occupational, or recre-
stance (tolerance) ational activities are given up or reduced
• There is a characteristic withdrawal syn- because of substance use (e.g., quitting
drome for the substance school, giving up a favorite sport)

Mental Substance Further

disorder abuse decline

Mental
Substance
disorder such Further
abuse
as psychosis, decline
disorder
depression
Figure 17-2 Common pathways in
co-occurring disorders.
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264 UNIT 2 | Threats to Mental Health

occasions and religious ceremonies. Eight per-

Worsening
Alcoholism
depression
cent of Americans are dependent on alcohol
at any one time (Kessler, Berglund et al.,
2005). It is quickly absorbed in the body
with initial effects of intoxication producing
relaxation, euphoria, and loss of inhibition.
Self– The legal blood level of intoxication is 0.08–
Worsening medication 0.10 g/dL in most states (known as blood
depression to function alcohol level). Higher levels of alcohol pro-
duce the central nervous system depressant
qualities that lead to staggering gait, labile
Increasing emotions, incoherent speech, poor judgment,
alcohol to
sleep
and belligerent/aggressive behavior, and even-
tually can lead to coma and respiratory depres-
sion in extremely high levels (greater than
Figure 17-3 An example of the cycle of decline
in co-occurring disorders.
0.4 g/dL). Alcohol content varies with the
type of beverage. The same amount of alcohol
is present in:
• The substance use is continued despite
knowledge of having a persistent or recur- • 12 ounces of most beers
rent physical or psychological problem • 5 ounces of wine
that is likely to have been caused or exac- • 1.5 ounces of 80-proof distilled spirits
erbated by the substance (e.g., current such as whiskey or vodka
cocaine use despite recognition of cocaine-
induced depression, or continued drink- Neeb’s For most adults, low risk alcohol use
ing despite recognition that an ulcer was ■ Tip —up to fourteen drinks per week for
made worse by alcohol consumption) men and seven drinks per week for
• Failure to fulfill major role obligations women and older people—causes
at work, school, or home (e.g., repeated few, if any, problems (National Insti-
absences or poor work performance re- tute of Alcohol Abuse and Alco-
lated to substance use; substance-related holism “Rethinking Drinking”).
absences, suspensions, or expulsions from
school; neglect of children or household) Alcoholism is defined as a chronic illness
• Recurrent substance use in situations in characterized by compulsive and uncontrolled
which it is physically hazardous (e.g., consumption of alcoholic beverages usually to
driving an automobile or operating a the detriment of the drinker’s health, personal
machine when impaired by substance use) relationships, and social standing. Addiction
• Recurrent substance-related legal prob- to alcohol has been referred to as alcohol de-
lems (e.g., arrests for substance-related pendence, alcohol abuse, and now alcohol
disorderly conduct) use disorder.
• Continued substance use despite having Given the same amount of alcohol, women
persistent or recurrent social or interper- have higher blood alcohol concentrations than
sonal problems caused or exacerbated by men, even with size taken into consideration.
the effects of the substance (e.g., argu- Differences in fat and body water content lead
ments with spouse about consequences of to women being more prone to long-term ef-
intoxication, physical fights) fects of heavy alcohol use (Fig. 17-4) (National
Institute of Alcohol Abuse and Alcoholism).
■ Alcohol Early signs of serious problems with alco-
hol use in men and women can include:
As the most commonly abused substance
worldwide, alcohol is readily available in most • Drinking in secret
cultures and is often included in important • Drinking first thing after waking up
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CHAPTER 17 | Substance Use and Addictive Disorders 265

Neeb’s Any alcohol use in children and

■ Tip teens is a cause for concern. They
may access alcohol from their
homes or homes of acquaintances,
at parties, or by buying it with
fake identification or from older
friends. Seeing their parents drink-
ing may give a double message to
children or teens who are eager to
be grown up. Experimenting with
alcohol by adolescents is common,
and it is difficult to know which
ones will move to a lifetime of
struggles with alcohol. A high per-
centage of adult alcoholics started
drinking as teenagers, so any sign
Figure 17-4 The use—and abuse—of alcohol of alcohol use by a child or teen
occurs in person of all ages, races, and cultural
must be addressed and needs
backgrounds, and in women as well as men.
(Courtesy of the National Institute on Alcohol Abuse
parental intervention.
and Alcoholism, National Institutes of Health,
Bethesda, MD.)

Impact on the Family

• Gulping the first drink
• Preoccupation with alcohol Family members and friends often develop
• Onset of blackouts (lapses in memory re- protective behaviors, sometimes called co-
sulting from persistent heavy drinking) dependency or enabling to control, hide, or
deny the alcoholic’s behavior to maintain a
In 2011, nearly one-quarter (23.1%) of sense of normalcy for the family. These can
persons aged 12 or older participated in binge include finding excuses for the drinker’s alco-
drinking (National Survey on Drug Use and hol use, covering up the drinker’s unacceptable
Health by Substance Abuse and Mental behavior, and self-blame for the drinking. Co-
Health Services Administration, 2011). Binge dependency may be seen with use of other
drinking is defined as having five or more substances besides alcohol.
drinks (four drinks for women) on the same Alcoholism is a family disease. More than
occasion on at least one day. Binge drinking half of all adults have a family history of
can lead to serious health consequences from alcoholism or problem drinking, and one in
alcohol poisoning when alcohol reaches toxic four children grow up in a home where some-
levels, as well as risky behaviors when under one drinks too much (National Institute of
its influence. Alcohol Abuse and Alcoholism).

Neeb’s Binge drinking in college age adults

■■■ Critical Thinking Question
■ Tip may be seen as a rite of passage for Your patient is a 16-year-old girl admitted from
many, but it can lead to serious the ER with moderate injuries from a car accident.
damage and even death. Students She was the driver. The other teens in the car were
and parents need to be advised of also injured. The patient is awake and tells you
the effects of toxic levels of alcohol. that her parents cannot know that she had had a
Many colleges now provide specific “couple of drinks” at a party just prior to driving
her friends home. How would you respond?
information to students about the Should the parents be told? Does that make you
risk of alcohol poisoning from binge an enabler if you choose not to share this?
drinking.
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266 UNIT 2 | Threats to Mental Health

Tool Box | Adult Children of Alcoholics Etiology of Alcohol Abuse

(ACOA) has support groups for people who Alcoholism runs in families. Biological off-
grew up in a dysfunctional family related to spring of alcoholic parents have a significantly
alcoholism: greater incidence of alcoholism than offspring
www.adultchildren.org/ of non-alcoholic parents. This supports the
genetic theories. The genes a person inherits
partially explain this pattern, but lifestyle
Alcohol’s Impact on Health is also a factor. Currently, researchers are
Alcoholism is the third leading cause of working to discover the actual genes that put
preventable death in the United States people at risk for alcoholism. The link be-
(Kessler, Berglund et al., 2005; Kessler, Demler tween depression and alcoholism also suggests
et al., 2005). It can become a chronic medical biological factors. These facts support the
illness. Heavy drinking contributes to heart view of alcoholism as a disease. Recent devel-
disease, some cancers, liver failure, and stroke opments in medications to treat alcoholism
as it affects most organs in the body. It leads demonstrate the role of biological cravings to
to more complications in the presence of di- induce a sense of well-being (see Pharmacol-
abetes. It also contributes to countless traffic ogy Corner for Alcohol Abuse). Disturbance
accidents, falls, domestic violence, suicides, in neural pathways that establish a biological
participating in risky activities, industrial craving to induce well-being is one of the the-
accidents, and other unsafe activities as judg- ories. Social factors, stress, and how readily
ment is impaired. Alcohol abuse is often available alcohol is also are factors that may
unrecognized and undertreated in the over increase the risk for alcoholism. Growing up
65 age group. Whether a lifelong pattern or a in a home where alcohol is used as a major
new coping mechanism in facing problems, coping mechanism for stress also puts a per-
heavy drinking can be confused with demen- son at risk. But, just because alcoholism tends
tia, mask depression, and contribute to falls or to run in families does not mean that a child
fires in the home. Alcohol can also contribute of an alcoholic parent will automatically be-
to adverse reactions to many medications. Fetal come an alcoholic too. Some people develop
alcohol syndrome includes physical, mental, alcoholism even though no one in their fam-
and/or learning disabilities in a child exposed ily has a drinking problem.
to alcohol in utero.
Alcohol Withdrawal
It is estimated that about 25% of admissions
Tool Box | The National Institute on Alcohol
to the acute hospital are alcohol related
Abuse and Alcoholism has information on re-
search and the current picture of alcohol use in (National Institute of Alcohol Abuse and
the United States. Alcoholism). Nurses will see patients who are
http://niaaa.nih.gov/ known alcoholics and those where the diag-
nosis is not known. Awareness of the signs of
alcohol withdrawal is essential for all nurses.
Neeb’s Long-term alcohol abuse can con- Signs include:
■ Tip tribute to a form of dementia in • Autonomic hyperactivity (high blood
later life. pressure, tachycardia, fever)
• Hand tremor
Tool Box | Use the CAGE questionnaire • Insomnia
as a four-question tool to identify problems • Nausea and/or vomiting
with alcohol use. CAGE questionnaire is • Anxiety
found at: • Transient visual, tactile, or auditory hallu-
http://www.integration.samhsa.gov/clinical- cinations or illusions
practice/sbirt/CAG E _ q uestionaire.pdf • Early signs of delirium
• Grand mal seizures
2993_Ch17_261-286 14/01/14 5:26 PM Page 267

CHAPTER 17 | Substance Use and Addictive Disorders 267

Withdrawal symptoms can occur as early ■■■ Classroom Activity

as 8 hours after the last drink in a heavy • Role-play with classmates how to ask patients
drinker. Analgesics and recovery from anes- about their alcohol and drug use.
thesia can precipitate a withdrawal reaction.
It may look like a classic delirium. Screening
patients about alcohol use is increasingly ■■■ Clinical Activity
common as part of the routine admission Any patient who indicates a history of problems
assessment in the general hospital. with alcohol should be monitored for withdrawal.

Neeb’s The U.S. Preventative Services Task

■ Tip Force (2012) recommends that pri- Tool Box | The Clinical Institute Withdrawal
mary care providers screen for alco- Assessment for Alcohol Scale, known popularly
hol abuse in all adults and pregnant at CIWA-Ar, is a useful tool used by many
women to identify problem drinkers hospitals to monitor patients at risk for with-
earlier. drawal syndrome. Available at Sullivan, J. T.,
et al. (1989). Assessment of alcohol withdrawal:
The revised Clinical Institute withdrawal
Questions that can be asked routinely on assessment for alcohol scale. British Journal of
admission to identify patients at risk for with- Addiction, 84, 1353–7 and at:
drawal include: http://ireta.org/sites/ireta.sitesq uad.net/fi les/
CIW A-Ar.pdf.
• How often do you drink alcohol?
• How much do you usually drink?
• When was the last time you used alcohol
or any drug? ■■■ Critical Thinking Question
Your 80-year-old patient is two days post-op
• Have you had any problems because of recovering from a fractured hip. Until now, her
drinking or drug use? recovery has been routine. She calls you to her
bedside and looks anxious and tremulous. She
tells you that a glass of wine would help make her
Neeb’s The routine admission questions more comfortable. What would you do?
■ Tip noted above can also be used to
screen for use of other substances.
Neeb’s An individual desperate for alcohol
Withdrawal symptoms are generally most ■ Tip may take alcohol-based medications
intense on the second day of abstinence. The like cough syrup to control withdrawal.
physician can order a detoxification regimen
that will prevent or reduce the alcohol-
induced delirium. Withdrawal from alcohol Treatment of Alcoholism
is very uncomfortable but generally not life Perhaps the single most effective treatment for
threatening. Generally, withdrawal is managed alcoholism is Alcoholics Anonymous (AA).
with longer acting CNS depressants such as AA is a nationwide organization begun in
diazepam and chlordiazepoxide, which have 1935 by two alcoholic men who bonded and
anticonvulsant actions and are relatively safe. vowed to support each other through recov-
These are administered routinely and tapered ery. AA has groups in most communities and
down over several days. Fluids, vitamins, and internationally. It is run by alcoholics, but
electrolyte replacement are also part of the there is no leader in the group.
treatment plan. One of the main tenets of AA is anonymity.
Withdrawal can induce an extreme form People identify themselves by first names only.
of delirium sometimes referred to as delirium Someone usually starts the topic or introduc-
tremens or “DTs,” evidenced by impaired tions or asks an opening question, but the
consciousness and memory as well as halluci- group runs itself. It is based on twelve steps,
nations and severe tremors. and frequently one step is discussed each
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268 UNIT 2 | Threats to Mental Health

week or on a designated week per month. Tool Box | A Brief Guide to Alcoholics
AA meetings are closed—that is, nobody except Anonymous is available at
the alcoholics themselves are allowed to attend. http://aa.org/lang/en/catalog.cfm? origpage=
There is usually a group that has an open meet- 18 & product= 8 t
ing monthly or quarterly. If the meeting is listed
as open, any interested person may attend.
There are corresponding groups for families ■■■ Classroom Activity
of the alcoholic (Al-Anon) and a special group • Attend an open meeting of Alcoholics Anony-
for teenagers (Alateen). Adult Children of Al- mous and identify how the meeting provided
coholics (ACoA) is a branch of AA formed for support to the attendees.
people who are now adults but grew up in an
alcoholic home and were not able to get help at
the time. These groups all follow a similar model. One of the slogans of AA is “One Day at a
Table 17-1 lists the twelve steps of AA Time.” Members of AA believe that they are
(Alcoholics Anonymous, 1981). Other twelve- always in a state of recovery, not that they have
step groups serving other dependency needs, recovered. Recovery from alcoholism is a process.
including narcotics, cocaine, and gambling, With very few exceptions, an alcoholic who is
have modeled themselves after the AA model. recovering cannot ever have another drink, or
he or she risks returning to the abusive patterns.
Other forms of treatment often include
Neeb’s AA is usually a lifetime commitment. family therapy, short-term hospitalization for
■ Tip It is known internationally and the detoxification, and individual and group ther-
person can reach out to any group apy to learn new coping mechanisms. Life
when away from home without alcohol presents many challenges to

l Table 17-1 The Twelve Steps and Twelve Traditions of Alcoholics

Anonymous
The Twelve Steps of Alcoholics The Twelve Traditions of Alcoholics
Anonymous Anonymous
1. We admitted we were powerless over 1. Our common welfare should come first; per-
alcohol—that our lives had become sonal recovery depends upon A.A. unity.
unmanageable. 2. For our group purpose, there is but one
2. Came to believe that a Power greater than ultimate authority—a loving God as He may
ourselves could restore us to sanity. express Himself in our group conscience. Our
3. Made a decision to turn our will and our leaders are but trusted servants; they do not
lives over to the care of God as we under- govern.
stood Him. 3. The only requirement for A.A. membership
4. Made a searching and fearless moral is a desire to stop drinking.
inventory of ourselves. 4. Each group should be autonomous except
5. Admitted to God, to ourselves and to in matters affecting other groups of A.A. as a
another human being the exact nature of whole.
our wrongs. 5. Each group has but one primary purpose—
6. Were entirely ready to have God remove to carry its message to the alcoholic who still
all these defects of character. suffers.
7. Humbly asked Him to remove our short- 6. An A.A. group ought never endorse, finance,
comings. or lend the A.A. name to any related facility
8. Made a list of all persons we had harmed or outside enterprise, lest problems of
and became willing to make amends to money, property, and prestige divert us from
them all. our primary purpose.
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CHAPTER 17 | Substance Use and Addictive Disorders 269

l Table 17-1 The Twelve Steps and Twelve Traditions of Alcoholics

Anonymous—cont’d
The Twelve Steps of Alcoholics The Twelve Traditions of Alcoholics
Anonymous Anonymous
9. Made direct amends to such people wher- 7. Every A.A. group ought to be fully self-
ever possible, except when to do so supporting, declining outside contributions.
would injure them or others. 8. Alcoholics Anonymous should remain
10. Continued to take personal inventory and forever non-professional, but our service
when we were wrong promptly admitted it. centers may employ special workers.
11. Sought through prayer and meditation to 9. A.A., as such, ought never be organized; but
improve our conscious contact with God, we may create service boards or committees
as we understood Him, praying only for directly responsible to those they serve.
knowledge of His will for us and the 10. Alcoholics Anonymous has no opinion on
power to carry that out. outside issues; hence the A.A. name ought
12. Having had a spiritual awakening as the never be drawn into public controversy.
result of these steps, we tried to carry this 11. Our public relations policy is based on
message to alcoholics and to practice attraction rather than promotion; we
these principles in all our affairs. need always maintain personal anonymity
at the level of press, radio, and films.
12. Anonymity is the spiritual foundation of
all our traditions, ever reminding us to
place principles before personalities.
Source: The Twelve Steps and Twelve Traditions are reprinted with permission of Alcoholics Anonymous World Services, Inc. (A.A.W.S.). Permission to
reprint the Twelve Steps and Twelve Traditions does not mean that A.A.W.S. has reviewed or approved the contents of this publication, nor that
AA agrees with the views expressed herein. AA is a program of recovery from alcoholism only—use of the Twelve Steps and Twelve Traditions in
connection with programs and activities that are patterned after AA but address other problems, or in any other non-AA context, does not
imply otherwise.

the alcoholic. It can include reorganizing one’s

life around different friends and social activities Pharmacology Corner
and repairing family relationships. Pharmaco- Three drugs have been approved by the
logical therapy is also part of treatment. See Food and Drug Administration to treat
Pharmacology Corner under Alcohol. alcoholism. Many other approaches are being
researched.
■■■ Critical Thinking Question 1. Disulfiram (Antabuse) was the first
Your friend stopped drinking about one year ago medicine approved for the treatment of
after she was in a car accident in which she was
driving impaired with her three-year-old in the
alcohol abuse and alcohol dependence.
car. She has been attending AA regularly. She is It works by causing a severe adverse re-
now going through a divorce and tells you she is action when someone taking the med-
so stressed and depressed that she has no more ication consumes alcohol. This reaction
energy to get to the AA meetings. What would be includes palpitations, nausea and vom-
your concerns? How can you help her?
iting, severe headache, and shortness of
breath with exposure to any alcohol.
2. Naltrexone is sold under the brand
■■■ Critical Thinking Question names Revia and Depade. An extended-
Your 35-year-old patient is being treated for alcohol- release form of naltrexone is marketed
related liver disease. He tells you he stopped drinking under the trade name Vivitrol. These
last month but is worried about his relationship with
his fiancée, who is a heavy drinker. What would be
drugs works by blocking the “high”
your concerns? What suggestions can you make? that people experience when they
drink alcohol or take opioids like
Continued
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270 UNIT 2 | Threats to Mental Health

Pharmacology Corner— l Table 17-2 Commonly Used

cont’d Medications for
Withdrawal
heroin and cocaine so it blocks the
“reward” when taking a drink or the Management of
opioid. Alcohol and Other
3. Acamprosate (Campral) works by reduc- Substances
ing the cravings for alcohol for some- Alcohol Withdrawal
one who is in recovery. Chlordiazepoxide (Librium)
See Table 17-2 for medications com- Diazepam (Valium)
monly used to manage withdrawal. Oxazepam (Serax)
Nutritional supplements (vitamins, magnesium,
thiamine)
Anticonvulsants such as carbamazepine,
valproic acid
Neeb’s Any patient on Antabuse must be Serotonin reuptake inhibitors (SSRIs) such as
■ Tip advised to avoid taking any sub- paroxetine, sertraline to treat anxiety and
stance with an alcohol base, includ- depression
ing cough syrups and mouthwashes.
Opioid Withdrawal
The patient should carry information Naltrexone (Revia)
so emergency personnel know this Naloxone
information. Nalmefene (Revex)
Buprenorphine
Buprenorphine and naloxone (Suboxone)
Clonidine (Catapres)
■■■ Critical Thinking Question
Your 50-year-old patient on Antabuse tells you he Heroin Withdrawal and Maintainence
is thinking of having a drink to test his response Methadone hydrochloride (Dolophine)
when he goes out on pass. What would you ad- Stimulants
vise this patient? What actions should you take Chlordiazepoxide (Librium)
after hearing this information? Haloperidol (Haldol)

■ Other Substances methamphetamines has been a problem as

are “club drugs,” including ecstasy, ketamine,
There are a wide variety of substances that are and rohypnol (Fig. 17-5). Club drugs are
abused. See Table 17-3 for a summary of the short-acting benzodiazepines that are slipped
effects of commonly abused substances. Signs into an alcoholic drink, causing the unsus-
and symptoms of substance use disorders vary pecting victim to become incapacitated and
as to the type of drug. Poly-drug use is com- unable to resist a sexual assault. The form of
mon and can create a confusing clinical pic- methamphetamine known as crystal meth is
ture. The individual may use one drug to produced illegally from ephedrine and creates
counteract or enhance the effects of the first a highly addictive stimulant that is usually
drug. Drugs are often combined with alcohol. smoked. A new drug referred to as “bath
For example, cocaine users commonly use salt” has recently been receiving national at-
alcohol to get to sleep or calm down. Many tention. This stimulant can produce a para-
drug and alcohol combinations have a syner- noia reaction.
gistic effect that can be life threatening. Pat- DSM-5 now categorizes each substance by
terns of drug use vary as new substances are substance-induced intoxication and with-
discovered. Nurses should be aware of newer drawal disorders. Each disorder has its own
drugs that may be used by their patient pop- criteria for diagnosing based on the specific
ulation. For example, in some communities substance used. A diagnosis of substance use
(Text continued on page 276)
 l Table 17-3 Comparing Commonly Abused Substances
Drug Intoxication Overdose Withdrawal Nursing Considerations
Amphetamines, Signs: Euphoria, high Signs: Ataxia, high Signs: Depression, agitation, • Crystal meth made from ephedrine
including Dexedrine, energy, impaired judg- temperature, seizures, insomnia, confusion, vivid & pseudoephedrine products
methamphetamine ment, anxiety, weight hypertension, arrhyth- dreams followed by • Tolerance can develop fairly rapidly
(crystal meth) loss, anorexia, increased mias, respiratory distress, extreme lethargy • User often also uses alcohol and
libido, aggressive be- cardiovascular collapse, Treatment: Antidepressants, other substances to relax
havior, paranoia, panic coma, brain damage, counseling, suicide • May cause a paradoxical reaction
disorders, insomnia, and death precautions in children
delusions (often seen
2993_Ch17_261-286 14/01/14 5:27 PM Page 271

Treatment: Supportive • May be used initially to lose weight

with long-term use) • Crystal meth users prone to dental
problems
• Withdrawal is difficult and relapse
is common
• Remains in urine for up to 3 days
Cannabis, including Signs: Euphoria; Signs: Extreme paranoia, Signs: Irritability, anxiety, • Most widely used illicit drug
marijuana and intensified perceptions; psychosis, delirium insomnia, anorexia, restless- • Impaired judgment may contribute
hashish impaired judgment and Treatment: Antipsychotics ness, tremors, fever, to accidents
motor ability; increased headache • Respiratory damage from inhaled
appetite; weight gain, Treatment: Supportive substances can occur
sinusitis, and bronchitis • Legal in some states for medical
with chronic use; reasons
anxiety, paranoia; red • Remains in urine for up to 7 days
conjunctiva • May exacerbate psychiatric
symptoms in mentally ill patients
• May negatively affect fertility
• May therapeutically reduce nausea
and vomiting, intraocular pressure,
and stimulate appetite
Continued

271
 l Table 17-3 Comparing Commonly Abused Substances—cont’d

272
Drug Intoxication Overdose Withdrawal Nursing Considerations
Cocaine, including Signs: Euphoria, Signs: High temperature, Signs: Fatigue, vivid dreams, • Crack is smoked or injected IV;
crack grandiosity, sexual pupil dilation, tachycardia, depression, anxiety, suicidal has a rapid onset and high
excitement, impaired seizures, arrhythmias, behavior. bradycardia dependency rate
judgment, insomnia, transient venospasms Treatment: Support • Tolerance develops rapidly
anorexia; nasal perforation possibly causing MI or counseling, antidepressants • Cocaine is inhaled, snorted, or
associated with inhaled CVA, coma, death injected IV
route; psychosis associ- Treatment: Supportive • High risk of acquiring HIV, hepatitis,
ated with long-term bacterial endocarditis, and os-
abuse teomyelitis from shared IV needles
2993_Ch17_261-286 14/01/14 5:27 PM Page 272

or promiscuous sexual relations

• May be used to control appetite
Hallucinogens, Signs: Dilated pupils, Signs: Panic, suicidality, Signs: re-experiencing • Flashbacks can occur for up to
including LSD, diaphoresis, palpitations, psychosis with perceptual symptoms 5 years
psilocybin, and tremors, enhanced hallucinations, cerebral • Could precipitate a psychiatric
mescaline perceptions of colors, tissue damage, seizures, disorder in susceptible persons
sounds, depersonaliza- hyperthermia, death
tion, grandiosity Treatment: Diazepam or
chloral hydrate; quiet
environment antipsy-
chotics
Inhalants, including Signs: Euphoria, impaired Treatment: Supportive Signs: None • Most available substance for
glue, gasoline, judgment, blurred vision, younger children
cleaning solutions, unsteady gait, nausea/ • Intoxication period is brief (15–
aerosol propellants vomiting, wheezing, 45 minutes)
like deodorants or hypoxia • Can cause permanent CNS damage
hair spray, and paint • Death from aspiration of emesis
thinner can occur
• May be difficult to detect specific
substance used
• Particularly irritating and/or flam-
mable substances can cause
trauma and burns in nose, mouth,
and airways
 Nicotine, including Signs: Produces a sense Signs: Tachycardia, hyper- Signs: Insomnia, depression, • Monitor for weight gain
cigarettes, chewing of anxiety reduction, tension, abnormal irritability, anxiety, poor • Monitor for hypotension with
tobacco, and relief from depression, dreams concentration, increased clonidine
nicotine gum or and satisfaction appetite • Hospitalized smoker may need
patch Treatment: Transdermal nicotine replacement to control
nicotine patches in decreas- withdrawal
ing doses, nicotine gum,
nicotine nasal spray, and
clonidine for severe anxiety,
behavioral modification.
Long-term smokers may
2993_Ch17_261-286 14/01/14 5:27 PM Page 273

need to remain on nicotine

therapy for some time. New
medications now available
(see Pharmacology Corner)
Opioids, including Signs: Euphoria, analgesia, Signs: Dilated pupils, Signs: Yawning, insomnia, • High risk of acquiring HIV, hepati-
heroin, morphine, slurred speech, drowsi- respiratory depression, anorexia, irritability, rhinor- tis, bacterial endocarditis, and os-
meperidine, ness, impaired judgment, seizures, cardiopul- rhea, muscle cramps, chills, teomyelitis from shared IV needles
OxyContin, constricted pupils monary arrest, coma, nausea, and vomiting, feel- • May be obtained illegally or
propoxyphene, death ings of doom and panic through prescription abuse
hydrocodone, and Treatment: Naloxone, Treatment: Detoxification, • At high risk for overdose after detox
codeine supportive possibly with clonidine if the same pre-detox dose is taken
for severe anxiety and • Monitor for hypotension with
methadone, naloxone, clonidine
and/or buprenorphine • Abuse of Suboxone is a growing
to block euphoria problem
Continued

273
274
l Table 17-3 Comparing Commonly Abused Substances—cont’d
2993_Ch17_261-286 14/01/14 5:27 PM Page 274

Drug Intoxication Overdose Withdrawal Nursing Considerations

Phencyclidine Signs: Impulsive behavior, Signs: Hallucinations, Signs: None • Have adequate staff available
(PCP, angel dust) impaired judgment, psychosis, seizures, because behavior is unpredictable
belligerent behavior, respiratory arrest, stroke and patient may become violent.
assaultive behavior, Treatment: Gastric lavage; • Drugs remain in urine for several
ataxia, muscle rigidity, cranberry juice or am- weeks
nystagmus, hyperten- monium chloride to • Avoid using phenothiazines
sion, numbness or acidify urine (if awake); because they can potentiate the
diminished response to quiet environment; effects of PCP
pain haloperidol or diazepam;
fluids
Sedatives, Signs: Relaxation, Slurred Signs: Hypotension, Signs: Insomnia, tachycardia, • Abrupt barbiturate withdrawal can
hypnotics, and speech, labile mood, nystagmus, stupor, hand tremor, agitation, be life-threatening
antianxiety drugs inappropriate sexual cardio-respiratory panic disorder, nausea and • Alcohol will potentiate drug effects
including behavior, loss of depression, renal failure, vomiting, anxiety, tinnitus and can contribute to overdose
barbiturates and inhibitions, drowsiness, seizures (barbiturates) (with benzodiazepines), • Cross-tolerance may develop
benzodiazepines impaired memory coma, death seizures, and cardiac arrest between alcohol and other CNS
Treatment: Benzodi- Treatment: Detoxification depressants.
azepine antagonist using gradually reduced • Shorter-acting benzodiazepines
(flumazenil); induce dosages of a similar drug, have a greater risk of producing
vomiting, if awake; anticonvulsants, and addiction and more severe re-
activated charcoal; support and counseling bound anxiety than longer-acting
cardio-respiratory support ones
 Club Drugs Signs: Euphoria, muscle Signs: Confusion, halluci- Signs: Not physiologically • Can cause memory loss and brain
including ecstasy relaxation, poor judgment nations, severe anxiety, addictive, but psychological damage
(MDMA), rohypnol, hypertension, seizures, dependence can cause
ketamine high temperature depression, flashbacks
Treatment: Supportive
Steroids (anabolic), Signs: Dramatic increase Signs: Liver damage, Signs: Depression, fatigue, • Masculinization of women and
including in muscle mass, irritability, increased cholesterol, anorexia, decreased libido feminization of men is common
testosterone, increased blood sugar, hypertension, paranoia, • May be self-injected
stanozolol, acne, edema from fluid hostility, hyperactivity, • Repeated use can produce
oxymetholone retention, unwanted manic symptoms dependence symptoms
2993_Ch17_261-286 14/01/14 5:27 PM Page 275

secondary sex Treatment: Supportive

characteristics
Source: Adapted from Gorman & Sultan (2008) and Townsend (2012, DSM-5).

275
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276 UNIT 2 | Threats to Mental Health

• Change in sleep patterns

• Increased isolation
• Irritability
• Mood swings
Lifelong struggles with substance use often
begin in childhood and adolescence. Younger
brains are thought to be more vulnerable to
the addiction cycle. Therefore, intervention
with young people is essential to prevent ad-
diction. Children and teens are still develop-
ing judgment and decision-making skills, so
they may be swayed to try things as part of
Figure 17-5 “Homemade” methamphetamine peer pressure or to self-medicate.
tablets. (Courtesy of Drug Enforcement Agency, U.S.
Department of Justice, Washington, D.C.)
■■■ Critical Thinking Question
Your 15-year-old nephew has been arrested for pos-
disorder is based on a pattern of continued session of a prescription analgesic that he stole from
use despite substance-related problems. a friend’s parent’s medicine cabinet. You had noticed
Use of opioid drugs for nonmedical use is a that recently he had more mood swings than usual,
growing problem. This can include the use of had been doing poorly in school, and was increas-
pain medication to achieve a high or to relax ingly irritable. What other signs would you look for
that he is using these drugs? What concerns would
rather than for physical pain relief. Desperate you have for his future?
actions such as stealing drugs from family/
friends, forging prescriptions, and doctor shop-
ping are signs that the person needs help. Peo-
ple with chronic pain who regularly take Tool Box | The Drug Abuse Screening Tool,
analgesics may be at increased risk to misuse known as DAST, is used in some settings. The
prescribed analgesic at times of stress, new 20-question self-screening tool is available at
onset of more medical problems, and mental www.integration.samhsa.gov/clinical-
health issues. They need to be educated on the practice/screening-tools
appropriate use of these medications and
monitored closely (Pergolizzi et al., 2012).
Older adults are more likely to abuse prescrip-
tion tranquilizers, sedatives, and analgesics. Etiology of Substance Use
Substance Use in Children Disorders
and Teens The causes of substance use disorders are sim-
ilar to those of alcohol abuse, but with the
Children and teens can also be at risk for
wide variety of drugs abused, there are some
substance disorders. The use of inhalants,
differences. Biological theories look at the role
including household items such as hair spray
of specific brain dysfunction and view addic-
and aerosol whipped cream, is most common
tion as a brain disease. A drug will stimulate
in children. These easily obtained substances
a specific brain pathway that includes an
can contribute to sudden changes in behavior.
altered state and brain changes leading to
Cough syrups and prescription drugs from
craving this drug again. Cocaine has been
parents are other sources for children and
studied the most, and it is believed that
teens. Signs of substance use in children and
cocaine abusers have a deficiency of dopamine
teens can include:
and norepinephrine that creates more craving.
• Change in functioning at school Other mind-altering drugs may be influenced
• Loss of interest in sports by different pathways.
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CHAPTER 17 | Substance Use and Addictive Disorders 277

Psychological factors include use of drugs

to relieve feelings of depression, anxiety, and Cultural Considerations
low self-esteem. Sociocultural theories look at Disparities in availability of treatment for
the impact of peer group and culture on the substance-related disorders for some eth-
use of specific drugs. nic groups and those of lower socioeco-
Treatment of Substance nomic status have led to greater problems
in some communities (Cook & Alegría,
Use Disorders 2011).
As with alcoholism, the twelve-step program
provides an important treatment and support
for the individual with substance abuse. The
People who take drugs intravenously are at
same philosophy of acknowledging one’s
risk of HIV, sexually transmitted diseases, and
powerlessness over a substance and the im-
hepatitis from infected needles. Treatment for
portance of group support are the foundation
substance abuse should include a medical
of these programs.
work-up for these potential problems as well
In addition, some people benefit from in-
as education on prevention.
patient drug rehabilitation programs, which
can include detoxification depending on the
drug. Family therapy, individual psychother-
apy, peer counseling with former addicts, and ■■■ Clinical Activity
• Review the medical record for what substances
group therapy can also be helpful in many your patient was abusing, the last time they were
cases. Cognitive behavior therapy (CBT) can used, and the potential complications.
also be useful. This approach is a short-term • Your patient who is an IV drug abuser should be
therapy that emphasizes learning the connec- screened for HIV, sexually transmitted diseases,
and hepatitis.
tion between stressors and symptoms, teach- • Education may need to be provided on prevention
ing new coping skills, and challenging of these diseases.
distorted thinking. Most substance abuse pro-
grams involve the family in the treatment
plan. Heroin addiction may be treated with
methadone maintenance when a long-acting ■■■ Classroom Activity
opioid is taken daily to avoid the withdrawal • Identify resources for drug abusers in your
community, such as methadone maintenance
symptoms without the high from taking programs and halfway houses for recovering
other opioids. See the Pharmacology Corner addicts.
for other medications used to treat addictions
and withdrawal.
It is now commonplace for employers to re-
quest a drug screening of a urine or hair sam- ■■■ Critical Thinking Question
ple as a condition of employment or as a You work at a methadone clinic and see the
same patients daily for their medication dose.
routine test while employed. Many companies You notice that one patient arrives disheveled
have struggled with drug abuse with their em- with slurred speech. What actions should
ployees and have found this to be a deterrent. you take?
In the hospital setting, awareness of a pa-
tient’s past substance abuse history is important
information to prevent/control withdrawal syn-
dromes. In addition, a recovering substance ■■■ Critical Thinking Question
abuser may be hesitant to take analgesics or You are asked to submit a urine test as a condition
of employment for a new job at a local hospital.
tranquilizers for fear of returning to a past What is your response to this request? What
lifestyle. It is important to work with the are the pros and cons of this for employer and
patient to address these fears and identify employee?
alternative interventions if possible.
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278 UNIT 2 | Threats to Mental Health

to help with nicotine withdrawal in addition

Pharmacology Corner to nicotine replacement in the form of
A variety of medications are used in the lozenges or patches.
treatment of substance use disorders. Phar- Herb and plant products to treat distress-
macology can be used in some cases to re- ing symptoms may be helpful and include
place the illicit substance, as in methadone chamomile, valerian, kava kava, and St. John’s
(see below), or to reduce the drug cravings wort. The last is contraindicated if the pa-
by interacting with the receptor system in tient is taking antidepressants, narcotics, or
the brain affected by the substance. Exam- amphetamines.
ples include buprenorphine and naloxone Commonly used medications to treat
for opioid addiction. These substances also withdrawal are covered in Table 17-2.
reduce the physical signs of withdrawal.
Medications are used in detoxification Neeb’s The Clinical Institute Withdrawal
programs for many drugs, including opioids,
barbiturates, sedatives, and tranquilizers. They ■ Tip Assessment for Alcohol Scale, known
popularly at CIWA-AR, is also a use-
are used to control withdrawal symptoms and ful tool used by many hospitals to
discourage continued use of the abused sub- monitor patients at risk for with-
stance. Most are used for only short periods drawal syndromes from opioids
until withdrawal is complete; however, in and benzodiazepines.
some cases, they may be used for longer peri-
ods to control cravings for the drug.
Methadone, a synthetic narcotic that resem- ■■■ Clinical Activity
bles morphine and heroin but does not pro- • Review agency policy on the management of
drug withdrawal regimens.
duce the euphoric effects, is used daily on a • Identify coping mechanisms your substance
long-term basis to treat heroin addiction. Both abusing patient uses to cope with stress now
physical and psychological dependence are that he/she is not using.
maintained on methadone, but the euphoric • Monitor for potential complications during
effects of heroin are blocked. Patients usually detoxification.
make daily trips to a methadone clinic to ob-
tain the drug. Buprenorphine, an opioid with
agonist and antagonist action, has been used as ■■■ Critical Thinking Question
Your 19-year-old patient is admitted for surgery
an alternative to methadone. Naltrexone also after he broke his ankle in a car accident. His sister
reduces the euphoric sensation from narcotics, confides in you that he has been taking frequent
and clonidine decreases discomfort during doses of the tranquilizer lorazepam that he was
narcotic withdrawal. The newest opioid with- taking from his mother’s prescription. He has asked
her to bring these to the hospital. The patient’s sis-
drawal treatment uses Suboxone (buprenor- ter has them but now wonders if that is the right
phine and naloxone). Addiction specialists thing to do. What concerns would you have about
must be certified to prescribe this regimen. this drug? What action should you take?
Patients on this medication must be monitored
closely if they have conditions that require use
of analgesics. Administering analgesics could ■ Nursing Care of Patients
precipitate a withdrawal syndrome. With Substance Use
Benzodiazepines and sedative withdrawal
is more risky because of the risk for seizures Disorders (Including
and delirium. Tapering the dose of the iden- Alcohol)
tified or similar drug, along with anticon-
vulsants and antidepressants, is usually used. Common nursing diagnoses in patients
Withdrawal from stimulants may require with substance-related disorders include the
use of tranquilizers and antidepressants. following:
Bupropion and varenicline (Chantix) work • Coping, ineffective
in combination with behavioral treatments • Denial, ineffective
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CHAPTER 17 | Substance Use and Addictive Disorders 279

• Family coping: compromised General Nursing Interventions

• Injury, risk for
Caring for patients with a variety of substance
• Sleep pattern, disturbed
use disorders requires patience, knowledge,
• Thought processes, disturbed
teamwork, and compassion. These patients
• Violence, risk for
present many challenges as there can be many
People who abuse drugs, alcohol, and complications related to the substance itself
other substances often use similar coping and/or the withdrawal process. In addition, the
mechanisms to deal with their problems. See same coping mechanisms the patient has used
Table 17-4 for a list of common coping styles for years to hide the addiction and problems it
used by substance users. Understanding these created are often still in use. These can include
coping mechanisms can help professionals denial, manipulative behavior, and rationaliza-
understand behaviors and identify appropri- tion. The nurse may be in a role of limit setter
ate interventions. and rule enforcer, which can be challenging.

l Table 17-4 Common Coping Styles of Substance Abusers

Coping Style Definition Behaviors
Denial Person minimizes or does not • “I only have two drinks a day; I
acknowledge the problem or could stop any time.”
the results of the problem • Refuses to admit drug problems
even when strong evidence is that are obvious to others.
presented. • Family may participate in denial
by covering up the problems
created by the abuser.
Projection Blames others for his or her • Avoids taking responsibility for
drinking and substance abuse. own unacceptable behavior.
• “My brother is the one with the
problem. He drinks more than
I do.”
• “I’d stop if everyone would leave
me alone.”
Rationalization Justifies intolerable behavior • Excuses reinforce denial.
by giving plausible excuses. • “My kids are always in trouble.
They make me take these pills”
• “I only drink beer.”
Minimizing Avoids conflict by reducing • Places less value on the behavior
the impact of the behavior. and the impact of the problem.
• “You worry too much.”
• “I’m not hurting anyone.”
Manipulation Plays one person against • Convinces one or two people
another in order to get one’s that he or she will improve if they
way or cover up or avoid a will help.
problem. • If he or she fails, it is the fault of
the helper.
Grandiosity Maintains a sense of superi- • Lacks concern for others’ feelings.
ority and irresponsibility
particularly evident when
intoxicated.
Source: Adapted from Gorman and Sultan (2008): Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with
permission.
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280 UNIT 2 | Threats to Mental Health

The nurse may also be faced with patients who Neeb’s Recognize that maintaining sobriety
are intoxicated on the substance. This can ■ Tip or abstinence from drugs or alcohol
mean dealing with offensive, abusive behaviors is a lifelong process. During periods
that require maintenance of safety for all in- of stress or illness, the urge to use
volved as well as limit setting. these substances can increase. The
See Table 17-5 for specific interventions patient needs added supports at
related to alcohol and drug abuse disorders. these times

Neeb’s Patients with a substance abuse history

■ Tip often refuse analgesics for fear this will
lead to abusing the substance again. Neeb’s People with a drug abuse past may
Working with the patient to try alter- ■ Tip have learned to use charm and ma-
nate methods of pain control as well as nipulation to get the drugs they are
appropriate ordering of analgesics by seeking. Family, friends, and health-
the physician (e.g., use of long-acting care providers may have difficulty
opioids rather than injectable to re- trusting them in recovery because of
duce the high) can be helpful. being taken advantage of in the past.

l Table 17-5 Problems With Substance Abuse: Symptoms and Nursing

Interventions
Types Symptoms Nursing Interventions
Alcohol Abuse • Inability to cut down or stop • Communicate honestly
using • Assist patient in identifying
• Daily use common thoughts and feelings
• Binges that last 2 days or more • Convey acceptance of individual
• Blackouts, which increase • Challenge rationalizations or denial
• Impaired social function with reality
• May use drugs in addition to • Encourage participation in support
alcohol to manage symptoms groups and maintain consistency
• Increase in alcohol tolerance with new behaviors learned in
• Drinking in “secret” group
• Preoccupation with alcohol • Confront use of maladaptive
• Gulping first drink defense mechanism
• Inability to discuss problems • Support any acknowledgement of
• Loss of control the abuse
• Rationalization of drinking • Support and give positive
• Failure in efforts to control reinforcement of progress
drinking • Set firm limits as needed
• Grandiose and aggressive • Provide information about
behavior substance abuse, causes, and
• Trouble with family, employer treatment
• Self-pity • Monitor for withdrawal syndromes
• Loss of outside interests and complications from substance
• Unreasonable resentment abuse
• Neglecting food • Support of drug/alcohol-free lifestyle
• Tremors (hands) • Recognize that patient may have
• Morning drinking setbacks with drinking but
• Prolonged intoxication encourage to restart treatment
• Physical and moral deterioration • Avoid any enabling of patient's
• Impaired thinking bad behavior
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CHAPTER 17 | Substance Use and Addictive Disorders 281

l Table 17-5 Problems With Substance Abuse: Symptoms and Nursing

Interventions—cont’d
Types Symptoms Nursing Interventions
• Free-floating anxiety
• Obsession with drinking
• Constant use of alibis
Substance Use • Similar to alcohol abuse with • See “Alcohol Abuse”
addition of: • Encourage patient to be tested for
• Red, watery eyes HIV if drug use included use of
• Runny nose needles
• Hostility • Monitor drug testing if ordered
• Paranoia • Be aware of attempts to manipu-
• Needle tracks on arms or legs late you
• Erratic, unpredictable behavior
• Risky behaviors including stealing,
lying to obtain drug
• May use alcohol too to
self-medicate for symptoms
• Other symptoms depending on
drug being used
Co-dependence • Significant others beginning to • Encourage participation in
lose their own sense of identity assertiveness classes
and purpose, existing solely for • Promote self-care and problem
the abuser solving
• Actions of significant others • Encourage attendance at support
taking away opportunity for user groups
to take responsibility for his or • Challenge rationalizations/denial
her own actions about substance abuser
• Lowered self-esteem • Help person identify self-
• Taking part in actions that are destructive patterns
self-destructive and reinforce • Encourage activities to promote
drug seeker’s/drinker’s problems self-esteem and individuality

The nursing care plan for a patient abusing Neeb’s Denial is a powerful coping mech-
alcohol is provided in Table 17-6. ■ Tip anism common in alcohol and
substance use disorders that gets
■■■ Critical Thinking Question reinforced by the effects of the sub-
Your 45-year-old patient is admitted to the hospital stance. Patients may minimize the
with multiple injuries that she states she sustained effects of the substance abuse even
in a fall at home. When the husband of the patient when presented with objective data
arrives, he smells of alcohol, is belligerent, and de- like a blood alcohol level or toxicol-
mands his wife be released. After security asks him
to leave, the wife tells you that he has never acted ogy screen. Look for slightest indica-
like this before and she is sorry she upset him by tion of insight and emphasize that
telling him their son acted out in school. She de- rather than support the denial.
nies he hurt her and says that she tripped down
the stairs because she left some of the younger
son’s toys there. You wonder if the wife is covering
up her husband’s drinking problem as an enabler.
What would you consider as possible nursing diag-
noses for this patient? If the husband comes back,
what actions should you consider?
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282 UNIT 2 | Threats to Mental Health

l Table 17-6 Nursing Care Plan for Patients Abusing Alcohol

Assessment/ Nursing Interventions/ Evaluation
Data Collection Diagnosis Plan/Goal Nursing Actions Criteria
• History of heavy Ineffective Acknowledges Demonstrate Patient
drinking denial drinking is out acceptance by acknowledges
• Minimizes of control avoiding criticism or need for help
negative Asks for help judgment of his Patient attends
effects of behavior AA meeting
drinking Identify recent Patient shares
• Denies concern inconsistencies in his one emotion
about recent behavior
erratic behavior Help patient identify
• Blames his feelings/events that
spouse lead to recent binge
for recent Foster problem solving
argument to identify new ways
to cope with stress
Provide information
about Alcoholics
Anonymous
Set limits on
manipulative behavior
Promote taking
responsibility for
hurting spouse’s
feelings

■■■ Key Concepts 5. Co-dependency is often seen in family

and friends of substance abusers as they
1. Substance abuse and dependence are try to help the person by covering up or
growing disorders in the United States enabling addictive behaviors.
with wide ranging impacts on health,
safety, and family life. 6. Longer-acting tranquilizers are used as
the initial treatment to detoxify from
2. Poly-drug use is common as the person alcohol.
tries to self-medicate to decrease discom-
forts from another drug. This contributes 7. Serious complications from alcohol abuse
to more complications and possible syner- include heart disease, liver failure, and
gistic effects that can be life-threatening. some cancers.
3. Dependency on a substance occurs when 8. Acute withdrawal is commonly seen
one is unable to control its use, even while in the acute hospital setting when the
knowing that it interferes with normal patient is without the abusing substance
functioning and more of the substance is for hours or days.
required to produce the desired effects. 9. Nursing management of patients with
4. The presence of substance abuse with a substance use disorders requires keen
psychiatric disorder is called a co-occurring observation, setting limits, involvement
disorder or dual diagnosis. It is commonly of the family, and compassion.
seen in the psychiatric population and
needs to be included in the screening.
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CHAPTER 17 | Substance Use and Addictive Disorders 283

CASE STUDY
Jim is a 26-year-old first-year resident in friend based on his back pain. As time
medicine at a large university hospital. His went on, he needed more pain medication
father and mother are both physicians, and to sleep and then started taking a pill
he felt pressure to graduate from medical during his shift when he felt jumpy.
school with high honors. He struggled Colleagues reported Jim was irritable
throughout medical school to maintain and at other times almost euphoric. He was
passing grades but achieved more success in called in by his supervisor when he made a
his last year as he realized how much he prescribing error. Jim felt he needed more
wanted to be a doctor when he was work- Vicodin to function and then he would not
ing with patients. After graduation, he make errors. Then Jim’s friend said he could
ranked high enough to be selected for a not write any more prescriptions for him.
residency at a prestigious hospital. During This friend suggested he pursue pain man-
medical school, he was in a car accident agement referral. Jim was not interested
that left him with residual back pain, and pursued other routes to get pain med-
which he managed with yoga and occa- ication, including writing his own prescrip-
sional ibuprofen. tions to a fake patient. He had a minor car
Once his residency began, he was work- accident when he fell asleep at the wheel.
ing long hours. Often on his feet for long When he returned home from work one
hours, his back pain increased. He no day, the police arrived with a warrant for
longer had time for yoga and ibuprofen unlawful prescription writing. A local
was no longer helping. He had an old pre- pharmacist had become suspicious and
scription for Vicodin, which he took at reported it to the police.
night when he was not on call. It helped Jim is now in police custody. Jim’s father
him sleep and be more rested to function and his hospital supervisor arrived and
well at the hospital. He obtained a pre- proposed a drug treatment program. Jim
scription for more Vicodin from a doctor agreed.

1. Upon entering your drug treatment facility, what information would you want to know
in the admission profile about Jim’s drug use?
2. In reviewing Jim’s case study, at what point did the Vicodin use turn from therapeutic
to substance abuse?
3. Identify two interventions you would use initially to support Jim.

REFERENCES Gorman, L., and Sultan, D. (2008). Psychosocial

American Psychiatric Association. (2000). Diag- Nursing for General Patient Care. 3rd ed.
nostic and Statistical Manual of Mental Disorders Philadelphia: F.A. Davis.
IV-Text Revision. Washington DC, Author. Kessler, R.C., Berglund, P., and Demler, O.
(Known as DSM-IV-TR) (2005). Lifetime prevalence and age-of-onset
American Psychiatric Association. (2013). Diagnos- distributions of DSM-IV disorders in the
tic and Statistical Manual of Mental Disorders 5. National Comorbidity Survey Replication.
Washington, DC, Author. (Known as DSM-5) Arch Gen Psychiatry, 62(6), 593–602. doi:
Clark, H. Prevention and impact of co-occurring 62/6/593 [pii] 10.1001/archpsyc.62.6.593
disorders. Retrieved from www.nami.org/ Kessler, R.C., Demler, O., and Frank, R.G.
MSTemplate.cfm? (2005). Prevalence and treatment of mental
Cook, B.L., and Alegría, M. (2011). Racial-ethnic disorders, 1990 to 2003. N England Journal
disparities in substance abuse treatment: The of Medicine, 352(24), 2515–2523.
role of criminal history and socioeconomic sta- Ling, W., Mooney, L., and Wu, L.T. (2012).
tus. Psychiatric Services, 62(11), 1273–1281. Advances in opioid antagonist treatment for
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284 UNIT 2 | Threats to Mental Health

opioid addiction. Psychiatric Clinics of North Townsend, M. (2012). Psychiatric Mental Health
America, 35(2), 297–308. Nursing. 7th ed. Philadelphia: FA Davis.
Lingford-Hughes, A.R., Welch, S., and Peters, L. U.S. Preventive Services Task Force. (2012). U.S.
(2012). Evidence-based guidelines for the Preventive Services task force issues draft rec-
pharmacological management of substance ommendation on screening & behavioral
abuse, harmful use, addiction and comorbid- counseling to reduce alcohol misuse. Retrieved
ity: recommendations from BAP. Journal of from www.uspreventiveservicestaskforce.org
Psychopharmacology, 26(7) 899–952.
National Institute of Alcohol Abuse and Alco- WEB SITES
holism. (2010). Rethinking drinking. Retrieved
http://niaaa.nih.gov/publications/brochures- All the support programs for substance abuse
and-fact-sheets have web sites with resources including how
National Survey on Drug Use and Health. (2012). to locate a nearby group and 24-hour-a-day
Results from the 2011 National Survey on support. These include:
Drug Use and Health: Summary of national Ca.org Cocaine Anonymous
findings. Retrieved from www.samhsa.gov/ Aa.org Alcoholics Anonymous
data/NSDUH/2k11Results/NSDUHresults Na.org Narcotics Anonymous
Al-anon.org Al-anon for loved ones of alcoholics
2011.pdf
Pergolizzi, J.V., Gharibo, C., and Passik, S. National Institute of Alcohol Abuse and
(2012). Dynamic risk factors in the misuse alcoholism
of opioid analgesics. Journal of Psychosomatic www.niaaa.nih.gov/
Research, 72(6), 443–451. Alcohol and substance abuse help for veterans
Stewart, S., and Conrod, P. (2008). Anxiety and www.mentalhealth.va.gov/substanceabuse.asp
Substance Abuse Disorders: The Vicious Cycles National Institute on Drug Abuse
of Comorbidity. New York: Springer. http://www.drugabuse.gov
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CHAPTER 17 | Substance Use and Addictive Disorders 285

Test Questions
Multiple Choice Questions
1. The defense mechanism most frequently c. “Sally, why do you keep lying for Susie?
demonstrated by the chemically dependent Just because she’s in trouble doesn’t
person is: mean you have to cover up for her.”
a. Undoing d. “Susie, this is just a stage you’re going
b. Rationalization through. Everybody does it; it’s not a
c. Denial big deal. You’re young! Have fun!”
d. Reaction formation 6. Sally and Susie seek treatment. Susie is
2. Nurses know that alcohol functions as a: treated as an inpatient and Sally as an out-
a. CNS depressant patient. The nurse planning discharge
b. CNS stimulant teaching from their programs will encour-
c. Major tranquilizer age them to:
d. Minor tranquilizer a. Attend weekly AA and Al-Anon
3. The patient who is experiencing delirium meetings.
tremens is most likely to exhibit which of b. Check back into the hospital unit weekly.
the following symptoms? c. Attend weekly sessions with the
a. Tremors psychologist.
b. Auditory hallucinations d. Attend weekly Adult Children of
c. Confusion Alcoholics meetings together.
d. All of the above 7. Your patient admits to using an illegal
4. Sally and Susie are twins. They are 20 years substance daily, thinking about it when
old. Susie has a habit of drinking too not actually using it, and spending a lot
much when they go out, and this has been of time figuring out where to get it. This
more frequent. They were out celebrating patient could have:
their birthday last night, and this morning a. A delusion
Susie is vomiting. Sally calls her sister’s b. DTs
teacher. “Susie is really ill. I think she has c. An addiction
the flu; anyway, she can’t come to school d. Dementia
today. She said she has a test today and an 8. One of the major skills a person/family
assignment that she was supposed to pick can learn during substance abuse treat-
up. I can come in and get the assignment ment is:
for her. When can she make up the test?” a. Honest communication
Sally’s behavior might indicate: b. Co-dependency
a. Collaboration c. Denial
b. Compensation d. Scapegoating
c. Lying 9. Your spouse has been an alcoholic for
d. Co-dependency many years. She/he has been sober for the
5. You are Sally and Susie’s friend. A thera- last two years but has begun drinking
peutic response to them might be: again. She/he drives drunk. You fear for
a. “Sally and Susie, you are really going to your spouse’s life, so you begin driving
get in trouble if you keep partying like him/her places. You are displaying what
that. It’s bad for you.” kind of behavior?
b. “Sally and Susie, I care for you both, a. Dry drunk
but Susie, you misuse alcohol. You b. Co-dependent
both need help. Sally, you are not help- c. Compassionate
ing Susie by ‘taking care’ of her; she d. Tough love
needs to do it herself.”
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286 UNIT 2 | Threats to Mental Health

Test Questions cont.

10. Which of the following medications is 12. A patient is suspected of methampheta-

most likely to be ordered for a patient mine abuse. What symptom would you
experiencing alcohol withdrawal? be most likely to see?
a. Haloperidol a. Weight loss
b. Chlordiazepoxide b. Incontinence
c. Methadone c. Weight gain
d. Chlorpromazine d. GI bleed
11. Your patient just attended her first AA
meeting. Which statement reflects she
understands the purpose of AA?
a. “Once I dry out, I know I can have
an occasional drink.”
b. “If I lose my job, AA can help me find
another one.”
c. “AA is only for people who have hit
bottom.”
d. “AA can help me stay sober.”
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C HA PT E R 18
Eating Disorders
Learning Objectives Key Terms
1. Define anorexia. • Anorexia nervosa (also
2. Describe the similarities and differences between anorexia called anorexia)
and bulimia. • Binge eating disorder
3. Define morbid obesity. • Body image
4. Discuss bariatric or “weight loss” surgery. • Body mass index (BMI)
5. Identify populations at risk for eating disorders. • Bulimia
6. Identify possible causes of eating disorders. • Morbid obesity
7. Describe nursing interventions for patients with eating disorders. • Obesity
• Purging

D
ieting is a national obsession, espe- ■■■ Classroom Activity
cially with women. Numerous fit- • Discuss with classmates their experiences with
ness clubs are filled with individuals eating disorders in themselves or friends.
trying to attain the idealized thin, muscular
body. The Barbie doll became the idealized
female body shape for several generations. or overeating. Rather, they are psychiatric
Extreme thinness is increasingly common in disorders with substantial emotional and
models and celebrities. It seems that it has physical consequences.
become accepted behavior to be obsessed
with body weight and shape and to view food
as a source of stress. Self-esteem and happi-
■ Anorexia Nervosa
ness in young girls are often linked to weight The term anorexia (as used in anorexia ner-
and body shape. When this social influence vosa) is really a misnomer because this condi-
is combined with certain biological, psycho- tion has very little to do with reduced appetite.
logical, and family dynamic factors, it could It has more to do with the person’s morbid fear
be the beginning of an eating disorder, in- of obesity causing anxiety and obsessive fear
cluding anorexia nervosa and bulimia ner- of losing control of food intake. In fact, the
vosa (Yager & Andersen, 2005). Obesity and person is often hungry and views the discom-
morbid obesity are not considered eating fort of hunger as a reminder of the deprivation
disorders, but their effects often lead to he or she needs to inflict on himself or herself.
emotional distress. Eating disorders have Only in the late stages is appetite actually lost.
little to do with simply not eating enough The distorted body image causes the patient
to have a personal view as fat even though
Tool Box | The National Eating Disorders appearing emaciated (Fig. 18-1). No amount
Association Information and Referral hotline of weight loss relieves the anxiety, causing
is 800-931-2237 and web site at: this deadly cycle to continue. Complications
www.nationaleatingdisorders.org can continue for years, even after successful
treatment.

287
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288 UNIT 2 | Threats to Mental Health

combination. Successful treatment is mea-

sured by weight gain, return of menstruation
(usually absent in anorexic women), and re-
duced number of compulsive behaviors. Full
recovery of weight, growth and development,
menstruation, and normal eating behavior
occurs in at least 50%–70% of treated adoles-
cents (Yager & Anderson, 2005). The increased
awareness of this disorder is leading many to
receive earlier treatment, which improves the
prognosis.
Symptoms of Anorexia Nervosa
Some of the behaviors, signs, and symptoms
associated with anorexia nervosa are listed in
Box 18-1.

Tool Box | Four questions to help screen for

Figure 18-1 In anorexia nervosa, patients view
eating disorders by Cotton, Ball, & Robinson
their bodies in a distorted way. (Photograph
are available at:
by Stockbyte.)
www.ncbi.nlm.nih.gov/pmc/articles/P M C
149 48 02/.
Neeb’s Body image is a very personal per-
■ Tip spective. When working with pa-
tients with eating disorders, take the
time to learn about how they view Cultural Considerations
their bodies. Avoid stereotyping and
Anorexia nervosa is most common in
reacting emotionally to their ap-
higher socioeconomic classes.
pearance. The fact that they look
thin to you does not mean that is
how they see themselves.
l Box 18-1 Behaviors, Signs, and
Women have a 0.3%–1.0% lifetime risk of Symptoms of Anorexia
suffering from anorexia nervosa. Men have a Nervosa
prevalence of 1/10th of that risk (Hoek & van
Hoeken, 2003; Yager & Andersen, 2005). • Excessive weight loss, usually more than
Anorexia nervosa is viewed by many experts as 25% of body weight prior to dieting
representing struggles with autonomy and sex- • Refusal to maintain normal weight
uality. Onset generally peaks in the early to late • Intense fear of being fat
teens (Anderson & Yager, 2009). Poorer prog- • Restricting food intake often to only
200–300 calories per day
nosis is associated with an older age of onset, a • Excessive exercise
lower minimum weight, and vomiting. • Obsessive thoughts
Anorexic patients will go to great extremes • Perfectionist
to deprive themselves of food and use meth- • Absence of menstrual cycle
ods such as excess exercise to burn up calories • Distorted body image
and purging. Purging, which causes elec- • Physical signs can include slow pulse rate,
trolyte imbalance and arrhythmias through electrolyte imbalances, fatigue, dry skin
inducing vomiting or overuse of laxatives, is and lanugo (fine body hair)
usually combined with compulsive exercise Source: Adapted from Gorman & Sultan (2008), Townsend (2012),
to accelerate weight loss, making a lethal and Anderson & Yager (2009).
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CHAPTER 18 | Eating Disorders 289

Extreme weight loss is usually hidden to approach as they are relieved they no longer
avoid exposure of the illness. Some ways the have to make decisions about food; however,
individual achieves this are by wearing baggy the team must consider the ethics of involun-
clothes, moving food around on the plate to tary re-feeding. Every effort must be made for
give the impression of eating, exercising in the patient to eat voluntarily (American Psy-
secret, not eating unless certain demands chiatric Association, 2006). Others become
about food combinations are met, or giving more anxious and resentful with forced re-
excuses for not eating, such as snacking before feeding and need to try to take more drastic
dinner. Once weight loss is exposed, the in- measures to take control of their intake by, for
dividual often objects to treatment and denies example, hiding weights in clothes to feign
the seriousness of the condition in an effort weight gain or changing drip rates on tube
to continue to control the illness. feedings. Total parenteral nutrition can be
associated with many complications, so is
Etiology of Anorexia Nervosa usually avoided if possible.
Causes of anorexia nervosa include genetic Behavior programs often include building
and biological factors along with psychological in rewards for weight gain and restrictions for
ones. Dopamine regulation and dysfunction weight loss as well as keeping a food diary.
of the hypothalamus are viewed as important Therapeutic approaches should focus on in-
contributors. Psychological theory suggests creasing socialization and self-esteem. Suc-
that the core of anorexia is the child’s fear cessful treatment has focused on the goals of
of maturing and unconscious avoidance of returning to normal weight, stopping abnor-
developmental tasks. By not eating, the person mal eating behaviors, dismantling unhealthy
forestalls sexual development and remains a thoughts, treating comorbidities, and plan-
child in the family. Other dynamics include ning for relapse prevention (Anderson &
overly demanding parents and profound dis- Yager, 2009). The dietary regimen generally
turbance in the mother/child relationship. promotes slow, steady weight gain of no more
Anorexia can represent a way to maintain con- than 3 pounds per week ( Yager & Anderson,
trol over parental figures. Anorexia requires a 2005).
strong need to control one’s intake, which
counteracts feelings of loss of control and
avoidance of conflict. Neeb’s Patients with anorexia often have a
■ Tip strong need to control their environ-
Treatment of Anorexia ment, leading to power struggles
Nervosa with the nurses.
Treatment generally focuses on a collabora-
tive approach between the following: internal
medicine; behavioral approaches; nutrition Neeb’s It is very stressful to care for a patient
counseling; individual, group, and family ■ Tip who refuses to eat. Nurses caring
therapy; and pharmacological management. for these patients may experience
Specialized inpatient treatment programs are frustration and anxiety as no matter
available in some areas. what they do, the patient will not
Mortality rate for anorexia can be high, eat. Collaborating with the interdis-
with serious complications including bone ciplinary team is essential.
loss, heart failure, serious arrhythmias, and
electrolyte imbalances. Close medical moni-
toring is essential for the patient with this dis-
■■■ Classroom Activity
order. A patient with severe anorexia may • Obtain information about local eating disorders
require long-term hospitalization with some treatment programs and review and discuss with
form of artificial nutrition if severely malnour- classmates.
ished. Some anorexics do better with this
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290 UNIT 2 | Threats to Mental Health

■■■ Clinical Activity

Monitor electrolytes of your patient with anorexia
nervosa.

■■■ Critical Thinking Question

Parents bring in their 14-year-old daughter, Amanda,
to your primary care office to seek help. Amanda
appears pale and thin despite being dressed in
a long, baggy dress. As you prepare her for her
physical exam by the nurse practitioner, you are
shocked by her thin body. Her spine and ribs are
most prominent, she has no breasts, and her
skin is dry with a fine layer of hair over her body.
Amanda asks you if you think she is fat. How
would you respond?

■ Bulimia
Bulimia (also called bulimia nervosa) is binge
eating followed by purging in an effort to
control weight. Binging is eating large quan-
tities of food at one sitting. The binge eating
is followed by purging, usually in the form of Figure 18-2 Bulimic woman vomiting after
self-induced vomiting, though laxatives and eating a large meal.
diuretics can also be used. The purging is
often a result of the shame and guilt of the
binge. Bulimia was officially designated as a It is common that these behaviors are hidden
psychiatric disorder in 1980 and is harder to for years. It affects a larger cross section of
diagnose than anorexia. Many of the behav- the population than anorexia does. Those
iors are in private, and the person may appear with bulimia rapidly consume huge amounts
to be a normal weight to others (Fig. 18-2). of food—as much as 8,000 calories in a
2-hour period several times daily. Bulimia,
like anorexia, tends to be manifested during
Pharmacology Corner: adolescence. The binge may be triggered by
a stressful event, feelings about weight and
Anorexia appearance, hunger from dieting, or negative
There are no medications to specifically self-image. Many celebrities have acknowl-
treat anorexia, but medications can be use- edged a history of bulimia which has given
ful to help manage some of the behaviors, this disorder more public attention. This dis-
for example, anxiety and depression as well order is much more common in females
as obsessive-compulsive behaviors, which though does exist in males.
can be seen in some anorexics. Fluoxetine
(Prozac) as well as other SSRIs have been
used in some cases; however, side-effect Cultural Considerations
profiles can be high due to the patient
being underweight. Anti-anxiety medica- Bulimia tends to occur in cultures where
tions given prior to meals have been useful thinness is highly valued and where there
for some. is an abundance of food.
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CHAPTER 18 | Eating Disorders 291

Binge eating disorder is recognized by on dieting and how to control their weight.
psychiatry as a disorder on its own. Individu- Their self-concept is closely tied to their
als with this disorder are more often obese or appearance.
exhibit fluctuations in weight. This diagnosis
is believed to be more common than anorexia Etiology of Bulimia
or bulimia. Binge eating disorder is character- Because bulimia has close ties to depression,
ized by eating large amounts of food rapidly bulimics may have abnormalities in levels of
when not hungry, eating alone, and experi- serotonin. An impaired satiety mechanism
encing feelings of disgust and guilt after also could be a factor as the person may not
overeating. The person with binge eating dis- recognize when he/she has had enough to
order generally does not purge. To receive this eat. Psychological theories include low self-
diagnosis the binging must occur at least once esteem, presence of conflict in parental rela-
per week for 3 months. tionships, and family history of alcoholism
and abuse. These individuals are more likely
Neeb’s People with bulimia often keep their to have comorbid psychiatric disorders, such
■ Tip disorder secret and are only found as borderline personality disorder, panic dis-
out when a friend or relative finds order, substance use disorder, and major
evidence of purging behaviors such depression. Childhood obesity may be a con-
as vomiting or laxatives. tributing factor.

Treatment of Bulimia
Symptoms of Bulimia The patient must acknowledge the disorder.
Box 18-2 lists the most common symptoms Bulimics may suffer in silence for years be-
of bulimia. Bulimic individuals often are fore acknowledging the need for treatment.
very self-conscious about their weight and Individual, group, and family therapy are
appearance, and may focus a lot of their time important components of treatment to gain
insight into feelings that lead up to the need
to binge as well as to treat depression or
l Box 18-2 Behaviors, Signs, and other disorders. Keeping a food diary with
Symptoms of Bulimia associated feelings is a common behavioral
approach. Complications of bulimia include
• Extreme dieting electrolyte imbalance, dehydration, and tears
• Use and abuse of laxatives or syrup of in the gastric or esophageal mucosa that re-
ipecac (to induce vomiting) quire involvement of internal medicine and
• Use and abuse of diuretics
• Obsession with food and eating
dentistry. The support group Overeaters
• Poor self-concept Anonymous has been helpful for bulimics.
• Thoughts of harming self
• Routine use of bathroom immediately after
eating ■■■ Critical Thinking Question
• Erosion of tooth enamel or hoarseness Your friend Carole constantly talks about her
from vomiting weight. She needs frequent reassurance that she
• Extreme sensitivity to body shape and is attractive, but then criticizes herself for being
weight fat. She is not overweight in your opinion. She is
• Poor self-concept part of group that meets monthly at a restaurant
• More likely to appear normal weight or for drinks and dinner. You notice that she eats a
slightly overweight very large, high-calorie meal each time but visits
• Impulsive the restroom two to three times during the
evening. You are wondering if she has bulimia.
• Feeling depressed, guilty, worthless What else would you look for to consider bulimia?
Source: Adapted from Gorman & Sultan (2008) and Townsend What concerns would you have for her?
(2012).
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292 UNIT 2 | Threats to Mental Health

Pharmacology Corner: ■ Morbid Obesity

Bulimia Morbid obesity often leads to a lifetime of
Because of the high correlation with de- emotional, social, and physical problems.
pression, patients with bulimia are often Potential health problems include a wide
on SSRI antidepressants. Some antidepres- range of chronic conditions, including hyper-
sants, including fluoxetine, paroxetine, tension, cardiac problems, diabetes, respiratory
and fluvoxamine, are particularly helpful insufficiency, and joint and back disorders.
if there are obsessive-compulsive features Risk of death increases with a body mass
with the bulimia. Other medications to index (BMI) greater than 30. (See Box 18-3
treat additional psychiatric disorders such to determine BMI.) Nutritional deficiencies
as anxiety disorder, substance abuse, and are also extremely common because the obese
bipolar disorder may be used as well. person may lack a well-balanced diet or
experience protein deficiencies related to
crash dieting. Obesity is not classified as a
psychiatric disorder, but it may include features
■ Similarities Between of binge eating disorder and depression.
Anorexia and Bulimia Society often views morbidly obese individ-
uals as undesirable. They may be abused by
There are many similarities between these strangers and treated with contempt by family
two eating disorders, and long-term anorex- members. Even health-care professionals may
ics may develop bulimia in later life. See view them as emotionally disturbed, though
Table 18-1 for a summary of the differences there is no increased incidence of psychopathol-
between them. ogy in morbidly obese people. Others may

l Table 18-1 Comparison of Anorexia Nervosa and Bulimia

Anorexia Nervosa Bulimia
Epidemiology • More than 95% female • 90% female
• Younger adolescent onset • Young adult onset more likely
fairly rare • 2–3 times more frequent than anorexia
Appearance • Emaciated • Normal or overweight
• Below normal weight • Weight fluctuations
Family • Rigid, perfectionistic • More overt conflict
• Overprotection
Behavior • Introverted • Impulsive
• Socially isolated • More histrionic, acting out
• High achiever • Depressed
• Excessive exercise
Signs • Cachexia • Dehydration
• Hair loss • Chronic hoarseness
• Amenorrhea • Chipmunk facies (parotid gland
• Dry skin enlargement)
• Pedal edema
Prognosis • 5%–18% mortality rate • Death is rarer
• Frequent lifelong problems • Lifelong problems with food
with food
• Bulimia
• Depression
Source: Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.
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CHAPTER 18 | Eating Disorders 293

time to talk with the client, and a belief that

l Box 18-3 Example of Body Mass this recommendation will not make any dif-
Index Calculation ference. Yet it has been found that a client is
BMI = Weight (in kilograms) ÷ Height in more likely to try to lose weight if he or she
meters squared is advised to do so by a health-care profes-
Example: sional. However, extremely obese people may
What is the BMI of a 180-pound woman who avoid regular medical care because of shame
is 5 feet tall (60 inches)? about their weight. The U.S. Preventive Serv-
First convert pounds to kilograms and inches ices Task Force has recommended that health-
to meters: care providers identify people with a BMI
180 pounds ÷ 2.2= 81.81 kg
greater than 30 and refer them for weight loss
60 inches = 1.52 meters
1.52 x 1.52 = 2.31 (meters squared) counseling (2012).
81.81 ÷ 2.31 = 35.41 BMI Obesity in children and teens is a serious
health concern in the United States and glob-
ally. Long-term emotional effects include de-
pression, social isolation, poor self-esteem,
Tool Box | BMI Calculator: and poor academic performance. These can
www.bmi-calculator.net/ (also see Box 18 -3) lead to lifelong problems (Cornette, 2008).
All nurses will encounter morbidly obese
patients in their practices. Sensitivity to the
patient’s fears, embarrassment, and coping
Cultural Considerations mechanisms should be incorporated in the
Morbid obesity affects all ages and races, treatment plan. Having properly sized equip-
although it is much more common in ment like wheelchairs and beds and scales can
lower socioeconomic groups. Obesity is avoid embarrassment.
equally distributed between men and Etiology of Morbid Obesity
women. Childhood obesity is also consid-
ered a national health problem that can Causes of morbid obesity are complex. Genetic
lead to a lifetime of problems. factors are considered a predisposing factor.
Abnormalities in the brain related to satiety,
abnormalities of the thyroid gland, and de-
view these individuals as lazy, unkempt, and creased insulin production are some of the
lacking in self-control. Many experts promote many factors that may contribute to morbid
viewing these individuals as having a chronic obesity. Psychological theories include ten-
illness rather than a cosmetic problem. dency toward depression and use of food to
Morbidly obese people face discrimination comfort oneself related to past traumas such as
particularly in the workplace because they are sexual abuse. Overeating as a learned response
viewed as less healthy, less diligent, and less in- to stress, tension, and boredom, along with
telligent than their thinner peers. Certainly, a sedentary lifestyle and poor nutrition, must
with this kind of reaction, it is no wonder that be incorporated into the complex picture.
these people often experience poor self-esteem, Treatment of Morbid Obesity
feelings of isolation and helplessness, and loss
Obesity is a complex issue, and any weight-
of control. Morbidly obese individuals often
loss program needs to include a multidisci-
have subjected themselves to many weight-loss
plinary approach. The U.S. Preventative
strategies only to regain the weight, which in-
Services Task Force (2012) developed federal
creases the stress on the body.
guidelines for clinicians to help their patients
Some educators have noted that fewer than
lose weight. It recommends that successful
50% of health-care professionals advise obese
weight-loss programs need to include:
patients to lose weight (Goldsmith, 2000).
Reasons for this low percentage include dis- • Behavioral management activities such as
comfort about addressing the subject, lack of setting weight-loss goals
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294 UNIT 2 | Threats to Mental Health

• Improving diet or nutrition and increasing ■■■ Critical Thinking Question

physical activity Your 35-year-old patient is in the hospital for
• Addressing barriers to change; self- complications from a recent abdominal surgery.
monitoring This man weighs more than 400 pounds. He is
• Strategizing how to maintain lifestyle withdrawn and appears depressed. When you
bring in his dinner tray, he tells you to take it
changes. away as he does not want to eat because the
When these measures have been unsuc- doctor told him he has to lose 100 pounds
quickly. How should you respond? What
cessful, some people pursue surgical inter- options can be given to this patient?
ventions, called bariatric surgery. The most
common surgeries are the lap band and the
gastric bypass. The lap band creates restric-
tion of the stomach using a silicone band, ■ Nursing Care of Patients
which can be adjusted by addition or re- With Eating Disorders
moval of saline through a port placed just
under the skin. This operation can be per- Common nursing diagnoses in patients with
formed laparoscopically. In gastric bypass, eating disorders include the following:
a small stomach pouch is created with a • Body image, disturbed
stapler device and connected to the distal • Coping, ineffective
small intestine. Generally, bariatric surgery • Nutrition, imbalanced: less than body
is considered only for people with a BMI requirements
greater than 40 or for those with a BMI • Powerlessness
greater than 35 with serious medical compli- • Self-esteem, disturbed
cations related to the excess weight, such as
diabetes. After weight loss surgury, patients
need support and education to adjust to
their new bodies. Pharmacology Corner:
Behavioral approaches to address triggers Morbid Obesity
for overeating can be part of counseling. In 2012 the FDA approved two weight loss
Self-help groups like Overeaters Anonymous drugs—the first new drugs in more than
or Weight Watchers can be a major source of 12 years. Qsymia (formerly called Qnexa)
support. Web-based support programs to combines the appetite suppressant phenter-
manage weight are increasingly popular. These mine and the anti-seizure/migraine drug
support programs can be helpful even after topiramate. Phentermine was once widely
bariatric surgery. prescribed as the “phen” part of the fen-
phen weight loss drug that was popular in
the 1990s. This combination was with-
■■■ Clinical Activity drawn from the market after its use was
Attend an Overeater’s Anonymous meeting in linked to high blood pressure in the lungs
your community. and heart valve disease. The problems were
related to the “fen” or fenfluramine part
of the combination, not the phentermine.
The other drug approved for weight loss
Cultural Considerations is Belviq (lorcaserin), which promotes a
small amount of weight loss with fewer side
Some cultures are more accepting of obe- effects by activating serotonin receptors that
sity than others. Knowing the patient’s affect appetite. Both of these new drugs
cultural group can give some insight into should not be used in pregnancy. Xenical is
whether obesity is considered a problem the only other FDA-approved weight loss
to the patient. drug and is sold over the counter as Alli.
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CHAPTER 18 | Eating Disorders 295

• Nutrition, imbalanced: more than body the caloric intake or the healthy food
requirements choices, not the weight change. How
nurses word the reinforcement can be
General Nursing Interventions crucial to the patient’s willingness to
continue the plan of care (Berkman et
1. Promote positive self-concept: Gaining the
al., 2006; Crisafulli, Von Holle, & Bulik,
patient’s trust and giving positive rein-
2008; Silber, Lyster-Mensh, & DuVal,
forcement for the progress the patient
2011).
makes will help the patient learn to
4. Promote self-acceptance: Anxiety over
change his or her lifestyle.
one’s body image is a frequent contrib-
2. Promote healthy coping skills: Nurses who
utor to distress in these patients. Pro-
understand that developing healthy coping
moting self-acceptance, feedback, and
skills is time consuming and difficult for
realistic expectations are all important.
anyone with an eating disorder are able to
Encourage the patient to think about
demonstrate confidence that the patient
accomplishments unrelated to body
can change. Empathy for the depth of
weight.
these disorders will help gain the patient’s
trust and cooperation. The nurse must be See Table 18-2 for specific interventions
careful not to be manipulated into nega- for each eating disorder.
tive behaviors by the patient with anorexia.
Setting limits on behavior is part of the
plan of care. Having the patient consis- ■■■ Critical Thinking Question
You are caring for a 21-year-old woman with
tently stay within those limits is part of anorexia nervosa. She is in the hospital receiving
teaching new lifestyle behaviors. enteral feedings due to extreme weight loss. She
3. Promote adequate nutrition: The physi- just started eating small amounts of food as well.
cian and dietitian or nutritionist will When you walk in the room, you see the patient
meet with the patient to discuss calorie staring at her tray and looking very anxious. She
tells you, “Take this away.” How should you respond?
and nutrient requirements. Most of these What factors might have triggered this reaction?
patients will have nutritional deficiencies—
even those who are overweight. Nurses
are responsible for monitoring the The nursing care plan for patients with eat-
patient’s ability and willingness to con- ing disorders is provided in Table 18-3.
sume the specified amount of food.
Usually, smaller and more frequent meals
are tolerated better than the traditional ■■■ Classroom Activity
three larger meals. For a person with • If caring for an anorexic patient, review the care
an aversion to food, presenting a large plan so consistent behavioral approaches are
tray of food can be overwhelming and followed.
discouraging. Positive reinforcement • Review recommendations from the nutritionist.
• For the morbidly obese patient, identify ahead
for complying with caloric intake can of time what resources are available to assist in
be helpful. Note: When implementing patient care, for example, scale, bed, proper size
this type of behavior modification, the wheelchair, and proper size patient gown.
nurse would be better served to praise
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296 UNIT 2 | Threats to Mental Health

l Table 18-2 Nursing Interventions for Eating Disorders

Type Nursing Interventions
Anorexia Nervosa • Promote positive self-concept and healthy body image.
• Promote healthy coping skills.
• Promote adequate nutrition.
• Support patient being open about fears and concerns.
• Report any evidence of patient sabotaging treatment plan.
• Encourage patient to talk about his/her body image and promote realistic
image.
• Allow some control in decision making.
• Monitor patient during meal times and right after for support for anxiety
as well as to control sabotage.
• Monitor for hiding food.
• Establish goals with patient and team for weight gain.
• Establish appropriate behaviors in terms of exercise and food preparation.
• Avoid focusing on food all the time. Encourage other interests.
Bulimia Nervosa • Approach with positive, realistic expectations of food intake.
• Help patient identify feelings when he or she gets the urge to binge or purge.
• Encourage eating in public.
• Monitor for eating in secret.
• Provide support during meals and discourage use of bathroom after eating.
• Promote a realistic body image by discussing how patient views self.
• Help patient identify feelings associated with eating.
• Incorporate ways to promote improved self-concept.
Morbid Obesity • Work with patient, family, physician, and dietitian to formulate healthy
meal plans.
• Encourage patient to participate in groups to promote acceptance of
self and development of self-esteem.
• Make efforts to promote improved self-concept.
• Respect privacy.
• Work with patient to identify small, achievable goals in weight loss plan.
• Encourage keeping a diary of food intake.
• Discuss feelings associated with eating.
• Work with team to develop a realistic exercise regimen.
• Help patient look at weight loss in small increments rather than total
weight loss goal.
• Promote dignity by being sensitive to patient’s appearance in public.
• Plan ahead to right-size equipment available, such as wheelchairs.
• Promote positive self-image and acceptance of body by emphasizing
personal traits other than weight.
• Continue to provide support and education after weight loss surgery.

l Table 18-3 Nursing Care Plan for Patients With Anorexia

Nursing
Assessment Diagnosis Goal Interventions Evaluation
Emaciated Body image Refers to Avoid overreacting or insincere response Makes one
patient disturbance her body to self-deprecating comments. positive or
describes in a more Rather, listen to patient and then less negative
self as fat; positive comment on how you see her. comment
Wears baggy way Encourage discussion of positive traits. about herself
clothes
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CHAPTER 18 | Eating Disorders 297

■■■ Key Concepts 4. Eating disorders are serious and can

be fatal as a result of malnutrition and
1. Eating disorders of one type or another electrolyte disturbances.
affect large numbers of people in the 5. Eating disorders may be related to emo-
United States. tional or physical causes. Obesity may
2. Though most common in women, have genetic and emotional causes.
anorexia and bulimia are increasingly 6. Nursing interventions for eating disorder
common in men. center on promoting self-esteem and
3. Bariatric surgery is becoming far more trust.
common than in years past. There are
many physical and emotional considera-
tions required when caring for patients
undergoing this surgery.

CASE STUDY
Penny is a 22-year-old woman who has night she becomes increasing anxious.
recently graduated from college. She has Penny has kept bags of cookies and potato
struggled with her weight all her life. She chips hidden and often eats entire packages
frequently refers to herself as fat and unat- of these items. While she is eating these
tractive though her weight appears normal items, she reports feeling relaxed, but
for her height. Friends frequently encour- shortly after, her stomach aches and she
age her to be more accepting of herself. She feels anxious and guilty. She often reduces
is currently job hunting and spends most her anxiety by sticking her finger down her
days at a coffee shop searching for jobs on throat to induce vomiting. After vomiting,
her computer. She rarely eats during the she collapses in bed and often cries herself
day, but while alone in her apartment at to sleep.

1. What disorder is Penny most likely suffering from?

2. How could Penny get help for her eating disorder?
3. If Penny came to your mental health clinic, what nursing interventions should be
considered?

REFERENCES Berkman, N.D., Bulik, C.M., and Brownley,

K.A. (2006). Management of eating disor-
American Psychiatric Association. (2006).
ders. Evidence Report/Technology Assessment
Treatment of patients with eating disorders.
(Full Report) (135), 1–166.
American Journal of Psychiatry 163(7 Suppl),
Cornette, R. (2008). The emotional impact of
4–54
obesity on children. Worldviews of Evidence-
American Psychiatric Association. (2013). Dia-
Based Nursing, 5(3), 136–141.
gnostic and Statistical Manual of Mental Dis-
Cotton, M.A., Ball, C., and Robinson, P.
orders 5. Washington, DC, Author. (Known
(2003). Four simple questions to help screen
as DSM-5)
for eating disorders. Journal of General Inter-
Anderson, A.E., & Yager, J. (2009). Eating
nal Medicine 18(1), 53–56.
disorders. In B.J. Sadock, V.A. Sadock, & P.
Crisafulli, M.A., Von Holle, A., and Bulik, C.M.
Ruiz (Eds.), Kaplan & Sadock’s Comprehensive
(2008). Attitudes towards anorexia nervosa:
Textbook of Psychiatry. 9th ed. Philadelphia:
The impact of framing on blame and stigma.
Wolters Kluwer/Lippincott Williams & Wilkins.
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298 UNIT 2 | Threats to Mental Health

International Journal of Eating Disorders, Yager, J., and Andersen, A.E. (2005). Clinical
41(4), 333–339. practice. Anorexia nervosa. New England
Goldsmith, C. (2000). Obesity: Epidemic of the Journal of Medicine, 353(14), 1481–1488.
21st century. Newsweek, May 8, 2000.
Gorman, L., and Sultan, D. (2008). Psychosocial WEB SITES
Nursing for General Patient Care. 3rd ed.
Philadelphia: FA Davis. National Institute of Mental Health provides
Hoek, H.W., and Van Hoeken, D. (2003). Re- information on diagnosis and treatment of
view of the prevelance and incidence of eating eating disorders.
disorders. International Journal of Eating www.nimh.nih.gov/health/publications/eating-
Disorders, 34(4), 383–396. disorders/index.shtml
Ogden, C., and Carroll, M. (2010). Prevalence Eating Disorder Referral and Information
of overweight, obesity and extreme obesity Center with specific information on males
among adults through 2007-8. Retrieved with eating disorders:
from cdc.gov/nchs/fastats/overwt.htm www.edreferral.com/males_eating_disorders.htm
Silber, T.J., Lyster-Mensh, L.C., and DuVal, J. National Alliance on Mental Illness with
(2011). Anorexia nervosa: Patient and detailed information on eating disorders:
family-centered care. Pediatric Nursing, http://www.nami.org/Content/NavigationMenu/
37(6), 331–333. Inform_Yourself/About_Mental_Illness/By_Illness/
Townsend, M. (2012). Psychiatric Mental Health Eating_Disorders.htmWeight Control Information
Nursing. 7th ed. Philadelphia: F.A. Davis. Center through the National Associations
U.S. Preventive Services Task Force. (2012).
of Diabetes, Digestive, and Kidney Disease
www.win.niddk.nih.gov/
Screening for and management of obesity
in adults. Retrieved from www.uspreventive- National Eating Disorders Association pro-
servicestaskforce.org/uspstf11/obeseadult/ vides a hotline and information for patients
obesesum.htm with eating disorders and their families.
Yager J. (2006). Treatment of Patients With Eating www.nationaleatingdisorders.org/
Disorders. 3rd ed. Retrieved from http:// Overeaters Anonymous
psychiatryonline.org/content.aspx?bookid= overeatersanonymous.org
28&sectionid=1671334
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CHAPTER 18 | Eating Disorders 299

Test Questions .

Multiple Choice Questions

1. The eating disorder that is characterized 5. A key nursing intervention to help
as an aversion to food is called: patients with eating disorders is:
a. Morbid obesity a. Let the patient know he or she will be
b. Bulimia nervosa watched closely at mealtimes.
c. Anorexia nervosa b. Have the patient chart his or her own
d. Pica intake and output.
2. Your patient with anorexia is admitted to c. Lock the patient’s bathroom door for
your medical surgical unit for malnutri- 2 hours after meals.
tion. She tells you she does not want to d. Encourage the patient to express
eat when her tray is delivered. Which underlying feelings about food,
statement is the best response? body image, and self-worth.
a. “The doctor said you will need a 6. Bulimia nervosa is characterized by all the
feeding tube if you don’t eat.” following except:
b. “Tell me what happens to you when a. Binging on food
you see the food tray.” b. Purging the food after eating it
c. “I will ask the doctor to order an c. Being able to control eating pattern
appetite stimulant.” d. Obsession with body shape and size
d. “You have to eat or you will starve.” 7. Donald has just been admitted to your
3. Your 19-year-old patient has a diagnosis surgical unit. He has just had stomach
of anorexia nervosa. You notice that she stapling surgery. You prepare your list for
seems to spend more time playing with postoperative care and include therapeu-
her food than eating it. You know that tic communication statements such as:
patients with anorexia: a. “You must be so relieved to be on your
a. Will eat normally if ignored way to being thin.”
b. Fear being fat b. “What is the first meal you plan to eat?”
c. Have an accurate body image c. “I’m interested to know if the rest of
d. Will binge and purge your family is also heavy.”
4. An appropriate nursing diagnosis for a d. “I’m here to help you any way I can.”
patient with anorexia might be: 8. It is Donald’s second postoperative day.
a. Altered nutrition; less than required He is scheduled to have his first oral
amount, as evidenced by distress in liquids. As you check on his progress at
eating lunch, you note he has not touched his
b. Altered nutrition; more than required food. “I’m afraid to eat,” he tells you.
amount, as evidenced by eating meals Your response might be:
of 2000 calories or more six to seven a. “It’s OK for you to eat now. You won’t
times per day choke.”
c. Altered body image as evidenced by b. “Afraid to eat, meaning. . .?”
stating the wish that others look as c. “It’s important that you eat, or the
good as the patient doctor may need to order the IV
d. Fluid excess related to increased weight feedings again.”
gain d. “Why are you afraid to eat?”
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300 UNIT 2 | Threats to Mental Health

Test Questions cont.

9. Your new admission, a 14-year-old female, 10. In bulimia, the purging is done to
presents with multiple symptoms includ- achieve which of the following?
ing recent extreme dieting, use of laxatives a. Feelings of euphoria at getting rid
and diuretics, thoughts of suicide, impul- of the food
sive behavior, and erosion of the enamel b. A need to gain attention
on her teeth. The patient’s medical diag- c. A release of tension followed by
nosis most likely is: depression and guilt
a. Anorexia nervosa d. A way to gain control
b. Binge eating
c. Bulimia nervosa
d. Morbid obesity
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U
UNNIITT 32
Special
ThreatsPopulations
to Mental
Health
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C HA PT E R 19
Childhood and Adolescent
Mental Health Issues
Learning Objectives Key Terms
1. Identify child and adolescent populations at risk for mental • Attention-deficit/
health disorders. hyperactivity disorder
2. Describe the impact of autism spectrum disorder on the (ADHD)
family. • Autism spectrum
3. Define three mental health conditions of childhood/adolescent disorder
age groups. • Bipolar disorder
4. Identify treatment modalities used in childhood/adolescent • Bullying
age groups. • Conduct disorder
5. Identify two medications used to treat attention-deficit/ • Cyberbullying
hyperactivity disorder. • Hyperactivity
6. Identify age-appropriate nursing care for two selected mental • Impulsivity
health issues.

T
oday, children are displaying behav- may encounter. The frequency of divorce,
iors and being diagnosed with mental less traditional family roles, and parents
disorders that two or three genera- working outside of the home has led to a
tions ago were nonexistent or at least not so generation that must cope with stresses ear-
readily observed in society. Many factors lier in life. Many children are dealing with
contribute to this, including greater access anxieties that were unknown in previous
to mental health information by parents generations, which contributes to a variety
and teachers. However, stresses on children of disorders.
today are much different than in previous Children and adolescents are at risk for
generations and are contributing as well. developing many of the same mental health
The fast pace of life, the Internet, social disorders as adults. Family history of sub-
media, continuous exposure to news, instant stance abuse, schizophrenia, and bipolar dis-
access to information, and exposure to vio- order will impact the development of mental
lence at a young age all lead to children health problems in children and adolescents.
growing up more quickly and having to deal Family dynamics will influence the develop-
with many issues that previous generations ment of many disorders as well.
never addressed until they were much older. The Centers for Disease Control and
The growing trend toward bullying and Prevention’s National Health and Nutrition
especially cyberbullying, where the Internet Examination Survey (NHANES) data show
is used to embarrass or shame peers, has that approximately 13% of children ages 8
added another stressor that young people to 15 had a diagnosable mental disorder

303
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304 UNIT 3 | Special Populations

within the previous year (CDC, 2013). The ■ Depression, Bipolar

most common disorder among this age group
is attention-deficit/hyperactivity disorder Disorder, and Suicide
(ADHD), which affects 8.5% of this popu- in Children and
lation. This is followed by mood disorders Adolescents
broadly at 3.7% and major depressive dis-
order specifically at 2.7%. Other less com-
mon disorders include conduct, anxiety,
Depression
and eating disorders. Mental disorders in Children and adolescents do exhibit symp-
children can lead to a lifetime of problems toms of major depressive and dysthymic dis-
including poor peer relationships, problems orders. The symptoms are the same as in the
in school, substance use and risk-taking adult illness (see Chapter 11). In addition to
behaviors as well as being more likely to the classic general symptoms of depression,
develop a chronic psychiatric illness. Forty children may exhibit a change in their school
percent of children with mental disorders routines, such as truancy or dropping sports/
will develop a second one (CDC, 2013). Of clubs, changes in sleep habits, and extreme
concern is that many children do not get ad- irritability. They may become inattentive,
equate early treatment, perhaps due to de- experience a drop in grades, lose interest, or
nial on the part of parents and teachers; lack become anxious about being at school. Ado-
of mental health services, especially in the lescents who become depressed may show all
schools; lack of funding; and stigma. This of the classic symptoms of depression and
chapter will discuss depression, bipolar dis- those connected with childhood but may also
order, suicide, ADHD, autism spectrum dis- be trying to deal with changes happening in
order, and conduct disorder. their bodies, hormones adjusting, and social
role and peer group changes. Adolescent
Neeb’s • The parents of children with any symptoms of depression may include rebel-
lion, intense ambivalence, anger, rage, pes-
■ Tip mental health disorder are under simism, and low self-esteem (Figs. 19-1 and
tremendous stress. This stress may
be expressed as frustration, irritabil- 19-2). Estimates are that 8.2% of youths
ity, extreme fatigue, depression, and between ages 12 and 17 suffer from major
increased use of alcohol/drugs. depression in the past year, with girls at twice
the risk (SAMHSA National Survey on Drug
Use and Health, 2008). In children, it is be-
lieved that the major factor in development
Neeb’s • Other siblings in the home are also of depression is family influence. If parents
■ Tip at high risk for acting out, as they are depressed, the children are three times
often feel ignored with all the at-
more likely to be depressed than their age-
tention on their sibling with the
mates. Environment and biochemical imbal-
mental health disorder.
ances in the brain are also possible causes.

Tool Box | National Institute of Mental

■■■ Classroom Activity Health Information on Childhood and Ado-
• Participate/volunteer in a pediatric camp for lescent Depression:
children and teens with emotional problems. www.nimh.nih.gov/health/topics/depression/
depression-in-children-and-adolescents.shtml

■■■ Clinical Activity

Review the patient’s medical chart for family his- Neeb’s Depression in children and teens
tory and social worker’s notes on family dynamics
and coping when caring for a child with mental ■ Tip may be masked as withdrawn, anti-
health issues. social behavior; avoiding school; or
loss of confidence.
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 305

Figure 19-2 Children who are depressed may

seem bored and unusually irritable.
Figure 19-1 Adolescent symptoms of depres-
sion may include rebellion, intense ambiva-
lence, anger, rage, pessimism, and low
self-esteem. improved treatment. Interestingly, in the
past, children who were diagnosed with
bipolar disorder (perhaps inaccurately) had
Bipolar Disorder a greater tendency toward anxiety and de-
Bipolar disorder is more difficult to diagnose pression as adults rather than bipolar symp-
in childhood and may be confused with con- toms. DSM-5 has a new diagnostic category
duct disorder or attention-deficit/hyperactivity under Depressive Disorders named Disrup-
disorder (ADHD). Some experts think bipolar tive Mood Dysregulation Disorder. This
disorder has been overdiagnosed in children disorder is characterized by severe temper
and teens. DSM-5 requires bipolar disorder to outbursts with irritable or angry mood in at
include distinct episodes of mania that differ least two settings in children but no clear
from baseline personality with or without de- manic episodes. This new diagnostic cate-
pression episodes. (See Chapter 12 for more gory may include some children that were
information on bipolar disorder.) Children previously diagnosed as bipolar. Substance
with bipolar disorder generally do not have the use could also contribute to symptoms of
typical cycling of mania to depression as seen this disorder.
in adults. Some behaviors associated with Children and teens with any of the follow-
childhood mania include episodes of: ing need a thorough evaluation by a child
psychiatrist to obtain an accurate diagnosis:
• Hyperactivity
extreme mood swings of depression and hy-
• Grandiose delusions
peractivity, delusions of grandeur, pressured
• Irritability
speech, euphoria, and decreased need for
• Rapid speech/racing thoughts
sleep. Accurate diagnosis is essential so the
• Reduced need and desire for sleep
appropriate medications and other treatments
Hopefully, more accurate diagnosis of can be started. As with adults, the major
bipolar disorder in children will lead to contributor to this disorder is family history.
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306 UNIT 3 | Special Populations

Tool Box | NIH brochure for children and

and transgender youths are at especially
teens and their parents on bipolar disorder: high risk as they struggle with fitting in
www.nimh.nih.gov/health/publications/ with their peers. Gender dysphoria, also
bipolar-disorder-in-children-and-teens-easy- known as gender identity disorder, where
to-read/who-develops-bipolar-disorder.shtml the child or teen is struggling with his/her
sexual identity, can increase the risk for
depression and suicide.
Suicide Signs of suicide risk can include:
Suicide is the second leading cause of death • Talking a lot about death
in teenagers (Fig. 19-3). The frequency of • Asking questions about death
suicide attempts in adolescents has taken an • Giving away possessions
alarming increase in recent years. Eleven • Artwork or play with death themes
and a half percent of females and 5.4% of • Loss of interest in friends/sports
males of high school age have attempted • Evidence of substance abuse
suicide (National Institute of Mental Health • Poor sleeping habits
Statistics on Suicide, 2012). Peer pressures • Expression of hopelessness, self-hate
with the increased use of social media and • Previous suicide attempts
the presence of bullying have left some vul-
nerable teens viewing their lives as hopeless. Young people’s methods of suicide may
In addition, young people may view suicide be similar to those of adults, for example,
in a more romanticized way and be desensi- using firearms or hanging, but also include
tized to death, which may be a contributor impulsive acts (especially common in young
in suicide pacts. Depression and bipolar children) such as jumping out of a window
disorders are major contributors to suicide or running in front of cars. As with adults,
risk, but others, including substance abuse talking about suicide and previous attempts
and ADHD, can also be factors. Younger are common warnings that must be taken
children can also attempt suicide and may seriously.
think of it as a magical way to get back at
parents or others. Lesbian, gay, bisexual, Neeb’s Children can be very sensitive to re-
■ Tip jection, which can lead to suicidal
thoughts and impulsive acts. Any
time a child mentions any thought
about suicide, investigate fully. Never
minimize his/her concerns.

■■■ Clinical Activity

Be aware of your patient’s changes in behavior
that can signal exacerbation of depression, bipolar
disorder, or suicidal intent.

Cultural Considerations
Figure 19-3 Suicides among teenagers are
growing alarmingly. Many of the teens who These conditions cross all ethnic groups.
attempt suicide state feelings of anger and In the past, these disorders were less fre-
frustration about not being listened to or not quently diagnosed in non-Caucasian soci-
being taken seriously as the reason for their ety, but now parents and the education
action. (Courtesy of Centers for Disease Control and system are more informed to improve
Prevention, National Center for Injury Prevention earlier identification across all groups.
and Control, Atlanta, GA.)
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 307

■■■ Critical Thinking Question

Your new patient is a 10-year-old boy who has just
Pharmacology Corner:
been admitted to the pediatric unit after being Depression, Bipolar
hit by a car. His injuries are not life threatening. A Disorder, and Suicide
neighbor told the paramedics she saw the boy
run into the street right at the car. She thought he Antidepressants are not always helpful and
did it on purpose in a suicide attempt. The boy’s can be dangerous in the younger age group
parents report he has been bullied by two older with depression. In September 2004, the
boys lately and has been very upset, but they
refuse to consider this a suicide attempt. What Food and Drug Administration (FDA) of
other information would you want to know about the United States recommended that a
the patient and family? What interventions should strong caution be placed on antidepressant
the staff consider for this boy? medications for children and teenagers due
to increased risk of suicide. The caution that
suicide can be a side effect of antidepressants
led to the black box warning that is now on
Treatment of Children and all antidepressants. Doctors and parents
Adolescents With Depression, need to weigh the benefits against potential
Bipolar Disorder, and Suicide risks of using these medications. SSRIs
Treatment of depression and bipolar disorder including fluoxetine and escitalopram have
in these age groups is challenging. Group ther- been approved for treatment in adolescents.
apy, family therapy, individual psychotherapy, Monoamine oxidase inhibitors (MAOIs)
and partial or day-hospital programs have are not often used because of the food con-
been shown to be helpful for many in this age traindications associated with them. Some
group. Treatment should focus on strengthen- tricyclic antidepressants can cause cardiac
ing coping skills and support. Parental in- arrest and death in children and adolescents.
volvement is essential for recovery. Psycho- Still, medications may be needed and should
education focuses on teaching patients and be used cautiously and monitored carefully.
parents life skills, communication, problem Bipolar disorder is treated with mood sta-
solving, and early signs of relapse to cope with bilizers as in adults as well as with antipsy-
these disorders. chotics if needed. See Chapter12. Children
Any sign of suicide risk in a child/teen and adolescents may need to remain on
requires immediate intervention including medications for years, so accurate diagnosis
psychiatric evaluation. See Chapter 13 for and long-term management of side effects
specific interventions. is essential.
Suicidal behavior is treated with antide-
pressants and anti-anxiety medications.
See Chapter 13.
Neeb’s Denial of a child’s suicide risk can When children are diagnosed with a
■ Tip lead to tragedy when the call for serious psychiatric disorder early in life, the
help is not recognized out of a belief long-term side effects of effective medica-
that a child would not attempt tions are a major concern and must be
suicide. weighed with the potential benefits. Parents
may be faced with difficult choices and will
need counseling and support as these deci-
Tool Box | Compassionate Friends is a sions are needed.
national support program for parents whose
children have died, including those who have
died from suicide. Information on Surviving Tool Box | FDA black box warning info on
Your Child’s Suicide: antidepressants:
www.compassionatefriends.org/Brochures/ www.fda.gov/D rugs/D rugSafety/Information
surviving_y our_c hilds_s uicide.aspx byD rugClass/U CM 09 627 3
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308 UNIT 3 | Special Populations

Neeb’s Ensure that parents are familiar with 5. Encourage the completion of simple tasks.
■ Tip all potential side effects and required Give the child honest feedback on all
monitoring for their child. successes.
6. Provide a safe environment where the
child feels comfortable to share fears and
Nursing Care of Children and concerns and has an outlet for pent-up
Adolescents With Depression, energy and frustration.
Bipolar Disorder, and Suicidal 7. Respond to any self-destructive behavior
Behavior with concern and action to maintain
safety. Encourage the child who has self-
Common nursing diagnoses for children destructive thoughts to talk with an adult.
and adolescents with depression include the Children should be taught to never keep
following: secret another’s suicidal plan.
• Anxiety See Chapters 11, 12, and 13 for more in-
• Coping, ineffective terventions for depressive disorders, bipolar
• Hopelessness disorders, and suicide. See Nursing Care Plan
• Injury, risk for in Table 19-1.
• Self-esteem, low

General Nursing Interventions

■■■ Critical Thinking Question
1. Communicate honestly and effectively The mother of your 14-year-old patient who has
and at an age-appropriate level. been admitted after a suicide attempt asks to talk
2. Identify limits and boundaries. Explain to you. She is understandably quite distressed and
what is appropriate behavior and what asks you to make sure the doctor starts her son
on an antidepressant. What teaching needs to be
is not acceptable. Be clear and concise. given to the family about antidepressants and
Place the emphasis in the “positive.” For teens who have suicidal thoughts?
example, to an angry individual a nurse
might say, “You may hit the punching
bag in the gym, but not another person.”
3. Focus on child/adolescent’s strengths. They ■ Attention-Deficit/
should be structured but able to flex fre- Hyperactivity Disorder
quently with the child/adolescent’s needs.
4. Support the individual; encourage verbal- Attention-deficit/hyperactivity disorder (ADHD)
ization of feelings and thoughts. Do not is a pattern of behavior involving inattention
minimize the child’s fears and concerns. and/or hyperactivity/impulsivity. For this di-
Young children especially can benefit agnosis the child must display symptoms in
from art therapy to express their feelings. more than one setting for example at home,

l Table 19-1 Nursing Care Plan for the Depressed Child

Nursing
Data Collection Diagnosis Plan/Goal Intervention Evaluation
Child is increas- Low self- Child will Encourage the child to Child returns
ingly isolated, esteem demonstrate talk about his fears and to one activity
refusing to go to increased insecurities in a supportive he previously
school, drops out feelings of setting without judgment; enjoyed;
of sports, is irrita- self-worth Plan activities that provide Able to ver-
ble, reports feeling opportunities for success; balize his
unable to meet Avoid minimizing his fears; strengths and
teachers’ and par- Give immediate feedback successes
ents’ expectations on any successes
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 309

in church, at school, or while in the shopping

mall. This disorder leads to problems in so- l Box 19-1 Symptoms of ADHD
cial, education, and/or work performance. It Inattentive symptoms:
is grouped under Neurodevelopmental Dis- 1. Fails to give close attention to details or
orders in DSM-5. The diagnosis is generally makes careless mistakes in schoolwork
made by the age of 12. ADHD can continue 2. Has difficulty keeping attention during
into adulthood, and generally adults with tasks or play
ADHD remember having behavior problems 3. Does not seem to listen when spoken to
by the age of 12. About half of children with directly
ADHD continue to have troublesome symp- 4. Does not follow through on instructions
toms of inattention or impulsivity as adults. and fails to finish schoolwork, chores, or
duties in the workplace
However, adults are often more capable of 5. Has difficulty organizing tasks and activities
controlling behavior and masking difficulties. 6. Avoids or dislikes tasks that require sus-
ADHD in children younger than age seven is tained mental effort (such as schoolwork)
a bit more challenging to diagnose, since the 7. Often loses toys, assignments, pencils,
younger child is prone to shorter attention as books, or tools needed for tasks or
a result of the child’s developmental stage. activities
ADHD is more common in males and does 8. Is easily distracted
seem to have a pattern of running in families. 9. Is forgetful
The troublesome behaviors must be present Hyperactivity/Impulsivity symptoms:
for at least 6 months to a degree that is mal- 1. Fidgets with hands or feet or squirms in
adaptive and inconsistent with developmental seat
level to confirm this diagnosis. 2. Leaves seat when remaining seated is
The symptoms of ADHD are divided expected
into inattentive and hyperactivity/impulsivity 3. Runs about or climbs in inappropriate
(Box 19-1). Children can have one or situations
both categories of symptoms to receive 4. Has difficulty playing quietly
5. Is often “on the go,” acts as if “driven by a
this diagnosis.
motor”
ADHD can be confused with depression, 6. Talks excessively
lack of sleep, learning disabilities, bipolar dis- 7. Blurts out answers before questions have
order, tic disorders, and general behavior been completed
problems. Every child suspected of having 8. Has difficulty waiting for his/her turn
ADHD should be carefully examined by a 9. Interrupts others
doctor to rule out other possible conditions
Source: Adapted from Diagnostic and Statistical Manual of Mental
or reasons for the behavior before pursuing a Disorders, Fifth Edition (Copyright 2013). American Psychiatric
Association.

diagnosis with other professionals such as

Cultural Considerations teachers, psychologists, and other therapists.
In the past, ADHD was diagnosed mainly Because children with ADHD put great
in Caucasians and under recognized in demands on family life, they may be at
other ethnic groups. Now with improved higher risk for punitive responses from par-
diagnostic tools and more awareness, this ents and teachers, which can increase their
disorder is recognized in many ethnic distress. The presence of ADHD puts the
groups. Cultural norms also need to be child at risk for a lifetime of maladaptive
taken into consideration when determin- behaviors and impaired social relationships,
ing what is considered “normal” behavior so early identification and treatment are im-
for children within a particular group. portant. In addition, children with ADHD
Children need to be assessed in their na- are prone to substance abuse, depression,
tive language to avoid confusion about anxiety, conduct disorders, and learning dis-
their concerns. abilities. Children with this disorder are gen-
erally of average or above-average intelligence
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310 UNIT 3 | Special Populations

but do not always perform at their level of school and home life can make a difference.
intelligence. This can include a system of rewards and con-
A definitive cause of ADHD has not been sequences to help guide their child’s behavior
confirmed. See Box 19-2 for list of potential and handle disruptive behaviors. Support
causes. Combinations of organic, genetic, and groups can help parents connect with others
environmental factors may put a person at who have similar problems. Parents need on-
higher risk. It is common that parents of the going support programs.
ADHD child showed signs of hyperactivity in
their childhoods, indicating a strong genetic
Tool Box | National Institute of Mental
component. Abnormal levels of neurotransmit- Health ADHD publication:
ters are associated with many of the symptoms www.nimh.nih.gov/health/publications/
of ADHD, as is abnormal brain function. attention-defi cit-hyperactivity-disorder/
Chaotic family life is also a factor. Some children how-is-adhd-treated.shtml
have benefitted from diet modifications such as Children and Adults with ADHD (CHADD)
eliminating foods like milk products or sugar. provides resources to children and parents:
www.Chadd.org

■■■ Clinical Activity

Identify triggers in the environment that lead to
your ADHD patient’s disruptive behavior. Pharmacology Corner:
Attention-Deficit/
Hyperactivity Disorder
Treatment of Children and
Medications are the most common treatment
Adolescents With Attention- approach. As with other illnesses affecting
Deficit/Hyperactivity Disorder young people, use of medication is contro-
Though medications are commonly used to versial. Physicians must consider the physical
treat ADHD, they should be used in com- maturity of a child’s brain, liver, and kidneys
bination with other therapies. Psychotherapy as well as the child’s ability to handle other
for the child and family is often helpful, effects of medication before prescribing.
along with cognitive behavior therapy that Psychostimulants (also known as stimu-
focuses on learning new coping mechanisms. lants) are the most commonly used ADHD
The child needs to learn the consequences drugs. Although these drugs are called stimu-
of impulsive behavior and identify alterna- lants, they actually have a calming effect on
tives, and learn how to improve social skills. people with ADHD by increasing the levels
Close involvement of the child’s teachers can of neurotransmitters. These medications can
help with learning and behavior. increase the child’s ability to concentrate and
Parents need to develop skills to address reduce hyperactivity and impulsiveness. New
their child’s disruptive behaviors. A structured long-acting formulations, liquids, powders
that can be sprinkled on food, and transder-
mal patches are available for some of these
l Box 19-2 Possible Causes of ADHD medications to help with compliance. The
• Genetics—family history is a strong predictor major side effects of these agents include over-
• Altered secretion of neurotransmitters like stimulation, restlessness, insomnia, anorexia,
dopamine weight loss, headache, and irritability
• Altered brain anatomy (Roman, 2011). See Table 19-2 for the com-
• Prenatal exposure to alcohol mon pharmacological treatment of ADHD.
• Exposure to lead Nursing considerations for children on
• Reaction to food dyes, additives, sugar stimulant medications include:
• Chaotic family life
• Administer after eating or with meals to
Source: Adapted from National Institutes of Mental Health (2012)
and Townsend (2012).
reduce effect on appetite.
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 311

• Injury, risk for

Pharmacology Corner: • Self-concept, alteration in
Attention-Deficit/ • Self-esteem
Hyperactivity • Social interaction, impaired
Disorder–cont’d
• Generally administer them no later than General Nursing Interventions
6 hours before bedtime to avoid inter- 1. Effective communication: Therapeutic
ference with sleep. communication with the child/adolescent
• The school nurse and teachers should and the involved family members is
be informed that the child needs the always indicated. Teaching/modeling
medications. skills to assist with interpersonal family
• Some schools require the school nurse communication is helpful.
to administer the medications. 2. Assist with behavior modification tools:
• Monitor adolescents who may share Limit setting, reward systems, and
medications with others. positive reinforcement may be helpful.
• Monitor the child’s weight and blood Facilitate agreement between the par-
pressure. ents and child/adolescent regarding
• Prepare parents to monitor for impact what will be used as the reward, what
on the child’s growth. is fair, and what the consequence to
inappropriate behavior will be. Consis-
tency among all parties is crucial in
Neeb’s Children may avoid taking their this modality.
■ Tip medication out of fear or anger, or to 3. Promote self-esteem: Help the child com-
avoid side effects. They may hide it plete a task and reward with praise or
from their parents or school nurse, so other rewards. Give positive feedback
close monitoring and promoting for all appropriate behavior. Teach alter-
open communication are important. native behaviors. It can be helpful to
break down tasks into small steps to
reduce frustration from poor attention
Nursing Care of Children and span. Reinforce socially acceptable be-
Adolescents With Attention- havior rather than giving a lot of atten-
Deficit/Hyperactivity Disorder tion to negative behaviors.
4. Low stimulation environment: Identify
Common nursing diagnoses for children and
the signs when behavior is beginning
adolescents with attention-deficit/hyperactivity
to escalate and intervene to reduce stim-
disorder include the following:
ulation. Physical activity can be a good
• Coping, ineffective outlet for pent-up energy, followed by a
• Family coping, compromised quieter environment.

l Table 19-2 Common Pharmacological Treatment of ADHD

Drug Category Drugs
Psychostimulants Dextroamphetamine/amphetamine (Adderal)
Methylphenidate (Ritalin, among other trade names)
Nonstimulant Atomoxetine (Strattera)
Miscellaneous Bupropion (Wellbutrin)
Clonidine
Source: Adapted from Townsend (2012): Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based
Practice, 7th ed. Philadelphia: F.A. Davis Company, with permission.
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312 UNIT 3 | Special Populations

5. Reinforce information about medications: in social communication and social interac-

The physician should discuss the effects tion with problems in maintaining relation-
and side effects of any medications or- ships as well as repetitive patterns of behavior.
dered. Family members may have fur- It is called a spectrum disorder because it
ther questions for nurses. Be prepared can be present in a mild form with some
to assist with clarification about the peculiar behaviors and mild social isolation
medication(s). Stress the importance but otherwise normal behavior; or to the
of compliance with the regimen to the other extreme it can be severe, with profound
child and parents. disability in all aspects of life. Asperger’s
6. Promote a safe environment as these chil- syndrome is a mild form of ASD. Autism
dren are susceptible to falls and accidents. spectrum disorder is a neurodevelopmental
7. Family support and education: Living with disorder in DSM-5. It must be present from
a child with ADHD can be very stressful infancy or early childhood but may not be
for a family. detected until later because of minimal social
(Pati, 2011; Primich & Iennaco, 2012) demands and support from parents or care-
givers in early years.
■■■ Critical Thinking Question
Your 6-year-old patient has recently been diag- ■■■ Classroom Activity
nosed with ADHD. The patient’s mother tells you • View the movie Rainman about an adult with
she has been giving him Ritalin at bedtime so he autism.
will sleep better. What teaching would you pro-
vide to the mother to minimize side effects for
the patient? Neeb’s DSM-5 now views autism spectrum
■ Tip disorder to include what was previ-
ously known as Asperger’s syndrome,
■■■ Critical Thinking Question though this is a term that is still com-
Your neighbor comes to you for advice with her monly used. These individuals have
10-year-old child. He is failing in school, unable
to concentrate, and becomes very antsy in class.
less problems with language and
Your neighbor wants to change his school as she cognition than more severe forms of
thinks the teacher is at fault. What suggestions ASD. This syndrome was originally
would you make? named after an Austrian pediatrician
who first described it. Sometimes
these people are referred to as hav-
■■■ Classroom Activity ing high functioning autism.
• Identify local resources for ADHD in your
community.
• Ask a local elementary school teacher or school Tool Box | Pediatric screening tools for
nurse to discuss management of a child with autism at the CDC Autism Spectrum Disor-
ADHD in the classroom. ders Web site:
www.cdc.gov/ncbddd/autism/hcp-screening.
html
■ Autism Spectrum
Disorder
The single most common symptom or
Autism spectrum disorder (ASD) is a gen- manifestation of ASD is impaired social
eral term that includes classic autism and interaction. Learning disabilities, avoiding
Asperger’s syndrome. These disorders are making eye contact, and inability to make
now classified as ASD rather than treated as friends or respond to other people’s emotions
separate disorders (DSM-5). ASD is a com- are other symptoms. Children with this dis-
plex developmental disorder of brain function order may twirl their hair and/or perform
accompanied by intellectual and behavioral self-injuring or self-mutilating behaviors,
deficits characterized by persistent difficulties such as biting themselves or hitting their
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 313

head on objects. Repetitive patterns can in- Disease Control and Prevention, “Autism
clude excessive adherence to routines, ritual- Spectrum Disorders,” 2012). This is a 78%
istic behavior, and repetitive speech or motor increase from 2002, reflecting the increased
patterns such as rocking or spinning. awareness of parents and doctors to the early
Children with ASD commonly exhibit the signs. ASD affects males three to four times
following symptoms: more frequently than it affects females.
Sadly, at this point in time, it is not curable
• No response to their name by 12 months
and most individuals will require lifelong
• Not pointing at objects to show interest
treatment. Children with severe autism are
(e.g., not pointing at an airplane flying
considered disabled for life. Autism should
over) by 14 months
not be confused with or misdiagnosed as
• Not playing “pretend” games (e.g., pre-
schizophrenia, although some behaviors may
tending to “feed” a doll) by 18 months
be similar.
• Avoiding eye contact and wanting to be
Causes of autism are not confirmed. Ge-
alone
netics, viral infections, and chemicals found
• Having trouble understanding other
in the environment are suspected causes or
people’s feelings or talking about their
contributors to development of autism. For
own feelings
parents with one autistic child, there is about
• Delayed speech and language skills
a 5% chance of having a second child with
• Repeating words or phrases over and over
autism. Serotonin levels have been shown
(echolalia)
to be diminished in the left frontal lobe of
• Giving unrelated answers to questions
many with autism. Fragile X syndrome, con-
• Getting upset by minor changes
genital rubella, exposure to some medications
• Obsessive interests
in utero, and tuberous sclerosis have been
• Flapping their hands, rocking their body,
suggested as possible causes of ASD. The
or spinning in circles
increased incidence of ASD has led to more
• Unusual reactions to the way things
emphasis on research.
sound, smell, taste, look, or feel
• Appearing to be in their own world
(Adapted from CDC Facts about ASD,
Neeb’s Some people continue to believe
2012) ■ Tip that autism is caused by childhood
vaccines. This has led some parents
To make the diagnosis, doctors may also to refuse vaccines for their infants,
look at failure to meet certain developmental which can expose them to nor-
tasks, such as a baby not babbling or per- mally preventable illnesses and
forming gestures (pointing, grasping, etc.) contribute to endangerment of
by age 12 months, or, at any age, losing others. If parents are concerned
any language or social skills that had been about vaccines, encourage them
acquired. Sometimes the child may appear to discuss their concerns with
to have normal development and then stop the physician before making any
gaining new skills. There are several inven- decisions.
tories that the physician, psychologist, or
psychiatrist might administer to help with
diagnosing. Parents often notice the signs Tool Box | National Institute of Health Fact
Sheet on Autism:
by age 2 when the child is not developing
www.ninds.nih.gov/disorders/autism/detail_
language skills and/or showing difficulty autism.htm
with social interaction as in not making eye Services for people with autism and Asperger’s
contact or makes repetitive nonpurposeful syndrome provide resources and support:
movements. aspergersyndrome.org
The incidence of ASD is on the rise. The CDC Fact Sheet about ASD
CDC reports that 1 in 88 U.S. children www.cdc.gov/ncbddd/autism/facts.html
have autism spectrum disorder (Centers for
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314 UNIT 3 | Special Populations

Cultural Considerations Pharmacology Corner:

ASD has been underdiagnosed in the
Autism Spectrum Disorder
Latino and black populations due to lack Research trials for drugs to treat autism are
of awareness by parents and health-care ongoing, but so far there is no definitive
professionals. This has led to later diag- pharmacological treatment. Doctors may
nosis and treatment in these populations. prescribe medication for difficult symptoms
Previously viewed as a disorder mainly such as deliberate self-injury, aggression,
in Caucasian children, more resources are and uncontrollable temper tantrums. The
now available to identify and treat this FDA has approved the use of risperidone
disorder in other races. (Risperdal) and aripiprazole (Abilify) for
children with these symptoms. Patients on
these medications require close monitoring.
Treatment of Children and The dosage is based on the weight of the
Adolescents With Autism child and clinical response.
Spectrum Disorder
Although there is no cure for autism at this
time, early identification is important. Early ■■■ Clinical Activity
Review possible side effects of any medications
intervention services help children from birth your ASD patient is taking. Reinforce education
to 3 years old learn important skills and en- on medications to parents and the patient.
hance development by taking advantage of
the brain’s ability to adapt.
Services can include therapy to help the child Nursing Care of Children
talk, walk, and interact with others. Many new and Adolescents With Autism
treatment programs that incorporate intensive
speech, occupational, and physical therapies as Spectrum Disorder
well as behavioral training and management Common nursing diagnoses for children and
may be appropriate for some. These are home- adolescents with autism include the following:
and school-based intensive programs that have • Injury, risk for
shown some success. Therapies may incorporate • Self-care deficit
a structured reward system for responding to • Social interaction, impaired
people. Each child must be evaluated individu- • Verbal communication, impaired
ally for the best treatment. There are also many
unproven treatments that parents will pursue in General Nursing Interventions
a desperate effort to treat their child.
1. Maintain safety: Therapists may prescribe
Neeb’s Having a child with ASD creates special equipment or even special cloth-
■ Tip tremendous physical, emotional, and ing, such as helmets and arm covers, to
financial stress on the family. These help maintain safety. The goal of this in-
families need information on all re- tervention is to discourage and prevent
sources available in the community. self-destructive behavior. Assisting par-
ents to identify situations that may trig-
ger the unwanted behavior is also helpful
Neeb’s Parents may be desperate for alter- in preventing or de-escalating the behav-
■ Tip native treatments and may share ior. Monitor the child closely and remove
approaches that you find question- any items in the environment that may
able. It is important to maintain cause injury.
their trust and encourage them to 2. Reinforce medical and counselor teaching:
be open to standard medical treat- Work with the parents and child on
ment and investigate thoroughly social skills. Provide praise and positive
any alternative approach. reinforcement for both the parents and
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 315

child. Technology is assisting with inter- 7. Parental support: Having an autistic

ventions for some patients. Virtual real- child affects the entire family on a daily
ity equipment and tablet computers are basis. They need support and resources.
being used in some settings and with
See Nursing Care Plan in Table 19-3.
some success to help with teaching and
behavioral training. The child may be
able to relate more to these images than ■■■ Clinical Activity
through interaction with others. Pet • If your ASD patient is hospitalized, encourage
therapy, where a child can interact with his or her family to bring in familiar objects and
advise staff about usual routines.
a dog, cat, or through horseback riding, • Talk with a social worker about potential support
has shown success. resources for the parents and siblings in the home.
3. Maintain effective communication with
all parties: Speak to the child or adoles-
cent in simple, direct, age-appropriate
■■■ Classroom Activity
language. Acceptance of behavior is • Identify ASD resources in your community
important. Ensure that the family and and invite some representatives to your class
others involved in the day-to-day care to discuss.
of the patient feel comfortable discussing • Arrange an observation in a school for children
concerns. with special needs such as autism.
4. Maintain consistency of caregivers: The
child may do better with familiar people.
Try to reduce the amount of stimulation ■■■ Critical Thinking Question
from strangers. Keep expectations realis- An 8-year-old boy diagnosed with autism is admit-
tic, and recognize that progress is slow ted to your pediatric unit for an upcoming surgery.
When you walk into his room, he is standing in the
and regression to previous behaviors may corner staring at one spot and does not respond
occur, especially under stress. Support to your greeting. Identify two approaches you
independence where possible. would use to make contact with him.
5. Avoid overstimulating the child: Deter-
mine if the child becomes more stressed
with physical contact. The child may ■ Conduct Disorder
be uncomfortable with being touched.
Check with the family on what the child Conduct disorder is a disorder of childhood
will accept. and adolescence that involves long-term
6. Establish a routine schedule with the (chronic) behavior problems associated with
child that all staff follows as much as physical aggression, defiance, rule breaking,
possible. and disturbed peer relationships. Sometimes

l Table 19-3 Nursing Care Plan for the Autistic Child

Nursing
Data Collection Diagnosis Plan/Goal Intervention Evaluation
8-year-old autistic Impaired verbal Child will • Assign consistent Child has
boy in the hospital communication demonstrate caregivers reduced
is frequently one alternative • Ask parents to bring frequency
banging his head behavior indicat- in familiar objects of head
on the wall and ing reaction to from home and banging
does not speak caregiver, e.g., review usual routine
to any of the staff facial expression, • Give positive feed-
eye contact back for alternative
behaviors
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316 UNIT 3 | Special Populations

these children are viewed as “bad” or delin- that are sometimes seen in conduct disorder
quent rather than having a psychiatric disor- including callousness and lack of remorse.
der. These children exhibit a repetitive and When a person with conduct disorder has
persistent pattern of behavior in which the these traits, he/she is harder to treat. Conduct
basic rights of others or major age-appropriate disorder may be preceded by oppositional
societal norms or rules are violated. Conduct defiant disorder (ODD) in some children,
disorder is now categorized under Disruptive, which is a pattern of negativistic and hostile
Impulse Control and Conduct Disorders in behavior toward authority figures.
DSM-5. The diagnosis of conduct disorder is Causes/contributing factors to conduct
based on the presence of a pattern of aggres- disorder include a variety of factors:
sive behavior to people and/or animals, de-
• Victim of child abuse/neglect
struction of property, deceitfulness, or theft
• Drug addiction or alcoholism in the
and/or serious violation of rules. The diagno-
parents
sis is much more common among boys. The
• Family conflicts
onset can be in childhood or adolescence. For
• Genetic defects
an accurate diagnosis, the behavior must be
• Poverty
far more extreme than simple adolescent re-
• Exposure to toxins
bellion or boyish enthusiasm. It is a pattern
• Head trauma, brain disorder
of behavior; a one-time incident does not
• Prenatal exposure to cocaine
diagnose the condition. Some behavior pat-
• History of attention-deficit/hyperactivity
terns might be bullying, displaying or using
disorder
a weapon, arson, lying, fighting, animal abuse,
• Substance abuse
truancy from school, chronic rule breaking,
and running away from home (Fig. 19-4). Treatment of Children and
Careful screening and medical testing are Adolescents With Conduct
important, as much change is happening
developmentally in this age group. Conduct
Disorder
disorder has been known to be a precursor of Medical treatment for conduct disorder first in-
bipolar disorder and/or antisocial personality cludes a thorough assessment. Sometimes, there
in adulthood for some. Conduct disorder can is an underlying medical condition in conduct
occur with or be confused with ADHD, disorder, such as closed head injury or a seizure
mood disorders, and learning disabilities. disorder. The physician will need to assess and
DSM-5 has noted several specific patterns treat the underlying disorder as well as the be-
haviors associated with the conduct disorder.
Once the diagnosis is made, treatment in-
cludes counseling for the parents and family as
well as the affected child. A child psychiatrist
can work with the patient to address past trau-
mas and anger issues. Parenting skills, consis-
tency in limit setting, and progressing maturity
of the child may, over time, often lessen or
eliminate the behaviors of conduct disorder, es-
pecially as the child moves out of adolescence.
Parent Management Training is an approach
that teaches skills to parents about more effec-
tive ways to respond to episodes of aggression.
Figure 19-4 Recurrent bullying is a behavior Teachers need to have skills to address these
that may indicate a conduct disorder, and it issues. Residential treatment is sometimes pre-
can be found among both boys and girls. scribed for children with this disorder. Group
(Courtesy of U.S. Department of Health and Human therapy of some form can help the child relate
Services, Office of Women’s Health, Fairfax, VA.) more appropriately to his/her peer group.
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 317

■■■ Clinical Activity Nursing Care of Children and

When your patient has conduct disorder, recog-
nize possible contributing factors, which can
Adolescents With Conduct
include ADHD, child abuse, substance abuse, Disorder
and lack of parental guidance. Common nursing diagnoses for children and
adolescents with conduct disorder include the
Neeb’s It is important to maintain a calm but following:
■ Tip firm approach that does not com- • Coping, defensive
municate fear or avoidance. The child
• Injury, risk for
may have learned to use aggressive
• Other-directed violence, risk for
behavior to keep people away and
• Self-esteem, disturbed
maintain power over others.
• Social interaction, impaired

Tool Box | American Academy of Child and General Nursing Interventions

Adolescent Psychiatry has information on 1. Maintain safety: Maintaining physical
Conduct Disorder Resources With Practice safety and psychological and emotional
Parameters at safety is the primary nursing interven-
www.aacap.org/cs/ConductD isorder.R esource
Center tion for children and adolescents who
have conduct disorder.
2. Communicate honestly and effectively:
Neeb’s Parents of a child with conduct dis- Communicate at an age-appropriate
■ Tip order are faced with many stresses as level the behaviors that are acceptable.
they must deal with others who are Communicate the effect that inappro-
hurt by their child as well as the priate behavior has on others around the
child’s behavior. They need resources child. Communicate the consequences
to help them, such as legal, emo- of inappropriate behavior and, most
tional, and financial. importantly, be consistent with enforc-
ing those consequences. Recognize that
the child may have poor skills in social
■■■ Critical Thinking Question
Ben is 11 years old and was brought to your mental situations and may need coaching or
health clinic by his single mother after the school positive reinforcement.
has expelled him for repeated “bullying” of younger 3. Assist with behavior modification tools:
children. One of the children attempted suicide Limit setting, reward systems, and
after being repeatedly humiliated by Ben. Ben’s positive reinforcement may be helpful.
mother is desperate for help and tells you she
wants to turn Ben into the juvenile authorities to Set realistic expectations according to
institutionalize him. What would you say to this the child’s age and ability level. Consis-
mother? What other options might be appropriate? tency among all parties is crucial.
4. Model and educate the family with respect
to appropriate roles: In other words, par-
ents need to be parents. The child needs
Pharmacology Corner: to be the child. The parent should be in
Conduct Disorder “control” of the situation. The child has
Medications such as antipsychotic risperi- input; negotiation is healthy, depending
done can contribute to symptom control for on the age of the child, but the child
extreme agitation. These work most effec- does not always “win.” When the child
tively along with counseling. ADHD med- does not “win” and behavior limits are
ications such as stimulants, along with exceeded or violated, the consequences
antidepressants and clonidine, have been for the inappropriate behavior must be
used with success for some. enacted. Parents may find this difficult
and exhausting. They will need support
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318 UNIT 3 | Special Populations

and positive reinforcement from the Recently, black box warnings have been
nurse and medical or counseling staff. applied to certain antidepressants when
When the child is involved in hurting used with children and adolescents;
others or in risky behaviors, the adults some antidepressants may actually
have to take control to stop these increase the chance for suicide.
behaviors.
5. Reinforce information about medications: 3. Incidence of autism spectrum disorder
The physician should discuss the effects has shown a dramatic increase in the last
and side effects of any medications or- few years. It is a serious disorder that has
dered. Family members may have further lifelong effects.
questions for nurses. Be prepared to assist 4. Parents, family members, and other
with clarification about medications. primary caregivers need to be involved
in the treatment of children and adoles-
■■■ Key Concepts cents. Consistency of care is crucial.
Parents may need counseling in order
1. Children and adolescents do experience to become more effective in their role
threats to their mental health. They have as parents.
the same illnesses as adults but may
5. ADHD and conduct disorders present
manifest them in different ways. Some
challenges to nurses working with chil-
illnesses continue into adulthood.
dren and teens.
2. Medications and therapy are effective for
a great many people in these age groups.

CASE STUDY
Sharon, a 15-year-old girl, was brought to stealing money from other students’ lock-
your family practice clinic by her mother. ers. When asked about her behavior at
Her mother explained that Sharon was sus- home, Sharon reports that her mother fre-
pended from school for assaulting a teacher quently “gets on my nerves” and, at those
and needed a “doctor’s evaluation” before times, Sharon leaves the house for several
she could return to class. The history reveals days. The family history indicates that
that this is Sharon’s tenth school suspension Sharon’s father was incarcerated for auto
during the past 3 years. She has previously theft and assault. Sharon’s mother fre-
been suspended for fighting, carrying a quently leaves Sharon and her 8-year-old
knife to school, smoking marijuana, and brother unsupervised overnight.

1. Given this information, what suggestions could be made to help this mother cope with
the teen’s behavior? How would you approach Sharon on first meeting her?
2. What possible diagnoses do you think would be considered?

REFERENCES Beck-Little, R., and Catton, G. (2011). Child

and adolescent suicide in the United States:
American Academy of Child and Adolescent
a population at risk. Journal of Emergency
Psychiatry. (2008). The depressed child.
Nursing, 37(6), 587–589.
Retrieved from http://aacap.org/cs/root/
Black, D.W., and Andreasen, N C. (2011).
facts_for_families/the_depressed_child
Introductory Textbook of Psychiatry. 5th ed.
American Psychiatric Association. (2013). Diagnos-
Washington D.C.: American Psychiatric
tic and Statistical Manual of Mental Disorders 5.
Publishing.
Washington, DC, Author. (Known as DSM-5)
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Centers for Disease Control and Prevention. nih.gov/health/publications/attention-deficit-

(2012). Autism Spectrum Disorders. Re- hyperactivity-disorder/how-is-adhd-treated.
trieved from http://www.cdc.gov/ncbddd/ shtml
autism/index.html Pati, A. (2011). Early assessment and diagnosis
Centers for Disease Control and Prevention. for children with hyperactivity disorder.
(2012). Facts about ASD. http://www.cdc Nursing Children and Young People, 23(7), 5.
.gov/ncbddd/autism/facts.html Primich, C., and Iennaco, J. (2012). Diagnosing
Centers for Disease Control and Prevention. adult attention-deficit hyperactivity disorder:
(2013). Mental health surveillance among The importance of establishing daily life con-
children—United States, 2005–2011. Mor- texts for symptoms and impairments. Journal
bidity and mortality reports, May 17, 2013. of Psychiatric and Mental Health Nursing,
Cooper, G.D., Clements, P.T., and Holt, K. 19(4), 362–373.
(2011). A review and application of suicide Roman, M.W. (2011). New additions to the
prevention programs in high school settings. psychopharmacopia: Extended release formu-
Issues Mental Health Nursing, 32(11), lations. Issues in Mental Health Nursing,
696–702. 32(11), 717–719.
Goldberg, R.J. (2007). Practical Guide to the Shimshock, C.M., Williams, R.A., and Sullivan,
Care of the Psychiatric Patient. 3rd ed. B.J. (2011). Suicidal thought in the adoles-
St. Louis: Mosby Elsevier. cent: Exploring the relationship between
Kowatch, R.A., et al. (2005). Treatment guide- known risk factors and the presence of suici-
lines for children and adolescents with bipo- dal thought. Journal of Child and Adolescent
lar disorder: Child Psychiatric Workgroup Psychiatric Nursing, 24(4), 237–244.
on Bipolar Disorder. Journal of the American Substance Abuse and Mental Health Services
Academy of Child Adolescent Psychiatry, 44(3), Administration (SAMHSA). (2008).
213–235. SAMHSA’s national survey on drug use
Lack, C.W., and Green, A.L. (2009). Mood and health: Youth depression. Retrieved from
disorders in children and adolescents. Journal http://www.samhsa.gov/data/2k8State/Ch6.htm
of Pediatric Nursing, 24(1), 13–25. Substance Abuse and Mental Health Services
Lynch, E. (2010). Making sense of autism. Administration (SAMHSA). (2012). National
Nursing Standards, 25(2), 18–19. Survey on Drug Use and Health at http://www
McCann, T.V., Lubman, D.I., and Clark, E. .samhsa.gov
(2012). The experience of young people with Townsend, M.C. (2012). Psychiatric Mental Health
depression: A qualitative study. Jornal of Psy- Nursing. 7th ed. Philadelphia: F.A. Davis.
Chiatry and Mental Health Nursing, 19(4),
334–340. WEB SITES
McKinney, E.S. (2009). Maternal-Child Nursing.
3rd ed. St. Louis: W.B. Saunders. Autism Society
www.autism-society.org
National Health and Nutrition Examination
Survey. (2010). Retrieved from http://www Children and Adults with ADHD
CHADD.org
.cdc.gov/nchs/nhanes.htm
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www.stopbullying.gov/
Major depressive disorders in children.
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statistics/1MDD_CHILD.shtml and parents
National Institute of Mental Health (2012). kidshealth.org
Statistics on suicide. Retrieved from http:// National Alliance on Mental Illness
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suicide-in-the-us-statistics-and-prevention/ American Academy of Child and Adolescent
index.shtml Psychiatry has detailed information on a
National Instititues of Mental Health. (2012). variety of children’s disorders
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disorder? Retrieved from http://www.nimh.
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Test Questions
Multiple Choice Questions
1. An 8-year-old child is in the waiting 5. Which of the following groups of med-
room. This child has a diagnosis of con- ications are most commonly used with
duct disorder. You call another patient ADHD?
to the room but notice this child begin- a. CNS depressants
ning to act out inappropriately. Your first b. CNS stimulants
concern and nursing action would be: c. Antidepressants
a. Ask the parent to take the child d. Antipsychotics
outside until they are called for their 6. Martin is 7 years old and has a diagnosis
appointment. of ADHD. He has broken his arm and
b. Provide an environment of safety for requires surgery to have it set. You are the
the child and parent. nurse doing the admission checklist with
c. Change the rooming order and take Martin and his family. You know that
this parent and child ahead of the people with ADHD:
patient just called. a. Have normal or above average
d. Wait a few minutes; the child will intelligence
probably calm down soon. b. Are impulsive
2. The child with autism has difficulty with c. Are inattentive or easily distracted
trust. With this in mind, which of the d. All of the above
following nursing actions would be most 7. The single most common symptom of
appropriate? autism is:
a. Encourage staff to hold the child as a. Strong ability to make friends
much as possible. b. Impaired social functioning
b. Support different staff caring for child c. Appropriate emotional responses
so she gets used to other people. d. Achieving and maintaining age-
c. Encourage the same staff person to care appropriate developmental tasks
for the child each day.
d. Avoid talking to the child so she will 8. The parents of 6-year-old Anna say, “Nurse,
not be fearful of you. why us? The doctors tell us Maria has the
most difficult of all childhood develop-
3. Your 5-year-old patient is not talking to mental disorders to cure. What did we do
you or the social workers. You suggest wrong? What can we do for her?” Your
giving her some toys and drawing best response might be:
materials. Your rationale for this is: a. “The doctor is correct.”
a. It gives you one less person to work b. “Her medications should help calm her
with at the moment. somewhat.”
b. You know children can be bribed. c. “We have specialists here who can help
c. You think she might talk if she were you. I will call someone.”
distracted. d. “Maybe she will outgrow the autism.”
d. Children often communicate feelings
through their play.
4. Which of the following activities is most
helpful for a child with ADHD?
a. Checkers
b. Pool
c. Video games
d. Volleyball
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CHAPTER 19 | Childhood and Adolescent Mental Health Issues 321

Test Questions cont.

9. Which of the following parental traits 10. What is the major concern in administer-
would be most likely to predispose to ing antidepressants to depressed children?
conduct disorder in the child? a. Side effect of dry mouth may affect
a. Overprotective parents appetite.
b. Parents with very high expectations of b. The child may not want to swallow
academic excellence these pills.
c. Chaotic home life with both parents c. The child is at higher risk for suicide.
being heavy drinkers d. The child needs to stop drinking milk
d. One parent with a physical disability with these medications.
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C HA PT E R 20
Postpartum Issues
in Mental Health
Learning Objectives Key Terms
1. Differentiate between postpartum blues and postpartum • Postpartum blues
depression. • Postpartum depression
2. Define postpartum psychosis. • Postpartum psychosis
3. Discuss nursing interventions for new mothers who are
feeling depressed.
4. Discuss possible side effects of psychotropic medications
during pregnancy and breastfeeding.

Postpartum Blues
E
ven though childbirth is exhilarating ■
for most women, postpartum blues is
a common and normal reaction right Postpartum blues (sometimes called tran-
after birth. On the other extreme are major sient depressive symptoms) is an extremely
psychiatric disorders of postpartum depres- common response to the sudden changes
sion and postpartum psychosis that are much immediately after childbirth. It occurs in
rarer and much more serious. Other issues can about 70% of new mothers (Pillitteri, 2007).
include grief response after fetal demise and The major cause is believed to be the plum-
birth of a sick/imperfect baby. An example is meting levels of estrogen and progesterone
giving birth to an infant that does not meet right after birth. The greater the hormone
the mother’s expectations, including an infant shift, the greater chance of developing post-
of the wrong sex or one who is physically chal- partum blues (Elder, 2004). Other factors
lenged. All of these can contribute to poor include fatigue and stress of delivery along
bonding with the infant that can affect the with the immediate postpartum responsibil-
health of the whole family (Pillitteri, 2007). ities. Symptoms include tears, rapid mood
shifts, anxiety, and feeling overwhelmed.
The symptoms typically peak at the fourth
Cultural Considerations or fifth day after birth and resolve by day 10
Postpartum mental disorders cross all cul- (Ricci, 2007). The disorder is generally self-
tures. Each culture has expected behaviors limiting and does not reflect psychopathol-
of new mothers, and knowledge of these ogy or the care the mother is able to provide
can make for more accurate screening of to the new baby. The presence of postpartum
possible psychiatric disorders. blues does increase the risk for postpartum
major depression.

323
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324 UNIT 3 | Special Populations

Treatment of Postpartum Blues depression in women in the general popula-

tion peaks in the 25–44 age group. The
Postpartum blues requires no psychiatric
symptoms are the ones typically seen in de-
treatment. Families should be educated dur-
pression (see Chapter 11) with the addition
ing the prenatal period of the frequency of
of impaired ability to care for the baby. The
this transient condition. Emotional support,
majority of sufferers of postpartum depres-
compassion, and rest generally help resolve
sion have had some type of mental health
this problem in a matter of days. If the blues
disorder earlier in life, such as a depression.
go on for a longer period of time (as in more
The new mother may hide the symptoms for
than 2 weeks), there is evidence of intense
fear of being viewed as a bad mother. It is
anxiety about the infant, agitation, feelings of
not uncommon for the depression to begin
inadequacy, and being overwhelmed most of
during pregnancy so this disorder is some-
the time. More intervention is needed. This
times referred to as depression with peripar-
could signal that postpartum blues has moved
tum onset. The symptoms must occur within
into postpartum depression.
6 months of delivery and be noticeable for
at least 2 weeks to be given this diagnosis.
■■■ Critical Thinking Question This depression can lead to denial of the
Your postpartum patient is ready to be discharged infant, inability to care for the infant, and
home. Her family is surrounding her, and they are
all thrilled that she had a healthy baby boy. The even thoughts of hurting the infant, as well
new mother keeps crying and asks her family to as suicidal thoughts or acts in rare, extreme
leave her alone. They are shocked and wonder cases.
why she is not happy. What would you tell the The strongest risk factor is depression in a
family? How would you help the patient? previous pregnancy or postpartum depres-
sion. See Box 20-1 for symptoms of postpar-
Neeb’s New mothers and their families need tum depression and Box 20-2 for factors that
contribute to postpartum depression.
■ Tip to be prepared for postpartum blues
and reassured that the mother’s re-
sponse is not abnormal. New moth-
ers may not verbalize their feelings Tool Box | Edinburgh Postnatal Depression
out of fear of appearing to be a bad Scale (EPDS) at:
mother. http://www.perinatalweb.org/index .php?
option= content& task= view& id= 8 6
This 10-item self-assessment tool can be
■■■ Clinical Activity used by the new mother to monitor her
• Incorporate support, reassurance, and rest in the symptoms of depression.
care of the new mother.
• Provide education and resources, such as a lacta-
tion consultant, if needed, to this patient.
Tool Box | National Alliance on Mental Ill-
ness Fact Sheets on Pregnancy and Depression:
http://www.nami.org/Content/N avigation-
■■■ Classroom Activity M enu/Inform_ Y ourself/About_ M ental_ Illness/
Promote discussion with classmates who are
mothers about their feelings during the post-
By_I llness/P regnancy_a nd_D epression.htm
partum period.

■ Postpartum Depression Cultural Considerations

The Edinburgh Postnatal Depression Scale
Postpartum depression is a serious disorder is also available in Spanish:
that occurs in about 10% of births (Pillitteri, http://www.perinatalweb.org/index .php?
2007). Some feel this condition is underdiag- option= content& task= view& id= 8 6
nosed and undertreated particularly because
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CHAPTER 20 | Postpartum Issues in Mental Health 325

Cultural Considerations Treatment of Postpartum

Depression
Perinatalweb.org has resources for women Postpartum depression is a serious disorder
from different ethnic groups to address their that requires treatment. Early intervention
concerns about postpartum depression. is associated with a good prognosis. When
the diagnosis of postpartum depression
is made, the mother is usually placed on
l Box 20-1 Symptoms of Postpartum antidepressants and begins some form of
Depression psychotherapy. If the new mother is breast-
feeding, she may be reluctant to take med-
• Anxiety ications. See the Pharmacology Corner for
• Irritability
• Loss of interest in new baby
more information on the risks associated
• Views infant as demanding with antidepressants. Discussion with the
• Withdrawn physician and pharmacist can be helpful
• Irrational guilt to determine the risk to the baby. Some
• Sleep disturbances women may continue psychotherapy only,
• Loss of appetite pursue alternative treatments such as light
• Inability to concentrate therapy, or choose to stop breastfeeding.
• Feels inept at caring for baby The woman should be followed closely
• Does not feel bond or love of new baby for at least 6 months after successful treat-
• Excessive anxiety over baby’s health ment. During treatment the family must
• Feelings of worthlessness be involved to provide support and ensure
• Poor concentration
• Loss of appetite
safety of the baby and mother. Treatment
will help with establishing a healthy bond
Note: For a postpartum depression diagnosis, between the mother and baby. If left
the symptoms must persist for at least 2 weeks.
untreated, this depression can continue
Source: Adapted from (Berga, S. L., Parry, B. L., & Moses-Kolka, E. L. for months or even years. The mother
(2009). Psychiatry and Reproductive Medicine. In B. J. Sadock, V.
A. Sadock, & P. Ruiz (eds.). Kaplan & Sadock’s Comprehensive
should be aware that once she is diagnosed
Textbook of Psychiatry (9th ed.), pp. 2539–62. Philadelphia: Lippin- with postpartum depression, she is at high
cott Williams & Wilkins; Pillitteri, A. (2007). Maternal and Child risk for recurrence of it with subsequent
Health Nursing: Care of Childbearing and Childrearing Families
(5th ed). Philadelphia: Lippincott Williams & Wilkins;
pregnancies.
A new mother who has any symptoms of
or is at risk for postpartum depression should
l Box 20-2 Contributing Factors to take steps right away to get help. Some help-
ful tips if a mother is experiencing early
Postpartum Depression signs of postpartum depression include (U.S.
• Hormone fluctuations National Library of Medicine, 2010; Pearlstein
• Personal and/or family history of depression et al., 2009):
or any mood disorder
• History of premenstrual dysphoric • Ask for help in caring for the baby
disorder • Talk about these concerns with the
• Stressful relationship with partner patient’s doctor and nurses
• Lack of social support • Talk about one's feelings
• Major life stressors around the pregnancy • Avoid making major life changes during
• Ambivalence about the pregnancy pregnancy or right after delivery
• Sleep disturbance • Encourage realistic expectations of
• Medical problems during the pregnancy or herself
just after birth
• Take time to get out of the house without
• History of a troubled childhood
• Pregnancy under age 20 the baby, visit with friends, spend time
• Abuse of alcohol, illegal substances alone with partner, participate in exercise
program
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326 UNIT 3 | Special Populations

• Join a support group with other new The earliest signs of postpartum psychosis
mothers are:
• Ensure adequate rest, e.g., sleep when the
• Restlessness
baby is sleeping, arrange for child care so
• Irritability
mother can sleep
• Insomnia
• Comply with any treatment recommen-
dations for depression These can progress quickly to:
• Rapidly shifting moods
■■■ Critical Thinking Question • Erratic or disorganized behavior
You are working in a postpartum clinic. Your new • Delusions of grandeur or persecution
patient is 4 weeks post-delivery. Her husband ap-
proaches you with concerns about why is his wife
• Extreme impulsivity
so tired and irritable. On further questioning, he • Disorganized speech and behavior
tells you she is in bed most of the day and family • Hallucinations
members are caring for the baby. What would you • Disorientation/confusion
ask the patient when you see her for the initial
screening? Delusional beliefs are common and often
center on the infant, as in the infant is evil or
the infant can read the mother’s mind. Audi-
■■■ Clinical Activity tory hallucinations that instruct the mother
• Be aware of your postpartum patient’s history to harm herself or her infant may also occur.
and family history for psychiatric disorders. The mother may deny the existence of the
• Review current and past psychiatric medications. child, leading to not caring for the infant.
Risk for infanticide, as well as suicide, is
significant in this population (Massachusetts
■ Postpartum Psychosis General Hospital Center for Women’s Mental
Health, 2010).
Postpartum psychosis is a psychiatric emer- In addition to bipolar disorder, postpartum
gency. It is sometimes called puerperal psy- psychosis can also be categorized as Brief Psy-
chosis. It is rare as it occurs in about 0.1–0.2% chotic Disorder with postpartum onset in
of pregnancies (Berga, Parry, & Moses-Kolka, someone without a psychiatric history (DSM
2009). The majority of women with this disor- -5, 2013). Postpartum depression can also
der have had symptoms of mental illness before move to a psychosis with paralyzing depression
pregnancy. It is most common in first pregnan- with hallucinations and delusions in rare cases.
cies and is generally evident within a few weeks Postpartum psychosis right after delivery
of delivery. This disorder occurs most frequently needs to be differentiated from delirium. Delir-
in women with a history of bipolar disorder ium could be a reaction to many factors during
pre-pregnancy. Postpartum psychosis can actu- delivery such as anesthesia dehydration.
ally be an episode of bipolar illness. See Chapter
12 for detailed information on bipolar disorder. Tool Box | National Alliance on Mental
In fact, postpartum recovery time is considered Illness has information on bipolar disorder
a high-risk period for bipolar disorder recur- and pregnancy at:
rence in at-risk women (Sharma & Pope, www.nami.org/Content/N avigationM enu/
2012). Any woman with a history of bipolar M ental_I llnesses/Bipolar1/P regnancy_a nd_
Bipolar_ D isorder.htm
disorder should be monitored closely during
pregnancy as recurrence of mania symptoms
may occur. Women with a history of bipolar
disorder are usually advised to discontinue
Treatment of Postpartum
lithium and some other bipolar medications Psychosis
due to possible adverse effects on the fetus. This Immediate medical and psychiatric treatment
puts the woman at high risk for recurrence. See must be instituted when postpartum psychosis
the Pharmacology Corner for more information. is diagnosed (Fig. 20-1). Severe overactivity
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CHAPTER 20 | Postpartum Issues in Mental Health 327

■■■ Critical Thinking Question

You are doing a home health 6-week follow-up
visit for a postpartum patient with a history of
bipolar disorder. When you walk in the house, the
patient is agitated and tells you the baby is driving
her crazy and she wants to get rid of him. What
would you do?

Pharmacology Corner
Figure 20-1 New mother with postpartum Treatment of postpartum depression and
psychosis is hearing distressing voices.
psychosis usually requires psychoactive
medications. Concern about the safety of
and delusions may require rapid tranquil- these medications to the infant during
ization by antipsychotic drugs. Mood stabi- pregnancy and during breastfeeding is a
lizing drugs such as lithium are also useful major issue in treatment. Informed deci-
in treatment and possibly for prevention of sions by the new mother as to the burden
episodes in women at high risk (i.e., women and benefit of medications require thor-
who have already experienced manic or psy- ough patient education. In other words, if
chotic episodes). Immediate safety of the in- the medications prevent serious disorders
fant must be determined. In some cases are they worth the risk to the baby. Some
electroconvulsive (electroshock) treatment concerns include:
is used. If the woman exhibits signs of
• Antidepressants are excreted in breast
psychosis during pregnancy, antipsychotic
milk. The infant could be subject to the
medications may need to be started. The
drug’s side effects. The antidepressants
family needs to consult with experts about
that have been identified as safest to
the possible risks to the fetus from these
the infant include paroxetine, sertraline,
medications.
and nortriptyline (ACOG Committee
The location of treatment is an issue;
Practice Bulletin, 2008). These have
hospitalization is disruptive to the family. It
been found to have minimal side effects
is possible to treat moderately severe cases
to the infant. The woman should be
at home, where the sufferer can maintain
on the lowest dose possible and time
her role as a mother and build up her rela-
breastfeeding so that it does not occur
tionship with the newborn. This requires
when concentration of the antidepres-
the presence, around the clock, of compe-
sants is high. The infant should be
tent adults (such as father or grandparent)
monitored closely for side effects and
and frequent visits by professional staff. If
normal growth.
hospital admission is necessary, there are
• Some studies report the fetus is at in-
advantages in conjoint mother and baby
creased risk for complications when
admission; however, multiple factors must
exposed to antidepressants during
be considered in the subsequent discharge
pregnancy. So starting antidepressants
plan to ensure the safety and healthy devel-
during pregnancy or during subsequent
opment of both the baby and mother. This
pregnancies, must be discussed in detail
plan often involves a multidisciplinary
with the physician.
team structure to follow up on the mother,
• Since the risk for postpartum depres-
the baby, their relationship, and the entire
sion and psychosis in women with a
family. Family therapy is essential in the
history of bipolar disorder is high,
treatment process as family members may
considerations about continuing mood
be traumatized by the patient’s bizarre
behavior. Continued
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328 UNIT 3 | Special Populations

Pharmacology Corner— ■ Nursing Care of Women

cont’d With Postpartum Mental
stabilizers during pregnancy must be Disorders
discussed and the risks and benefits
Nursing diagnoses for women with postpar-
weighed. Risks to the fetus may in-
tum mental disorders include the following:
clude a number of congenital malfor-
mations, especially with lithium. In • Anxiety
addition, the pregnant woman on • Coping, ineffective
lithium is more vulnerable to lithium • Injury, risk for
toxicity due to fluid shifts. The psychi- • Sleep pattern disturbance
atrist should be consulted for alterna- • Thought processes, disturbed
tive medications if the woman wishes • Violence to self/others, risk for
to become pregnant.
• For women with bipolar disorder, General Nursing Interventions
breastfeeding may be problematic.
First is the concern that on-demand 1. Safety: Maintain safety of the patient and
breastfeeding may significantly disrupt her infant. Any risk factors for this disorder
the mother’s sleep and thus may in- need to be identified early in the pregnancy
crease her vulnerability to relapse as a routine part of prenatal care. Anyone
during the acute postpartum period. at risk should be monitored closely and the
Second, there have been reports of patient and family educated on what to
toxicity in nursing infants related to look for. If the patient or infant is at any
exposure to various mood stabilizers, risk, immediate action must be taken to
including lithium and carbamazepine, protect them. Safety also involves educat-
in breast milk. Lithium is excreted ing the new mother about risks associated
at high levels in the mother’s milk. with psychiatric medications.
Exposure to carbamazepine and val- 2. Compassion and support: Adequate sup-
proic acid in the breast milk has been port for the new family must be in place.
associated with hepatotoxicity in the Helping the family with options for the
nursing infant (Massachusetts General mother to get enough rest, resources for
Hospital Center for Women’s Mental infant care, and support groups should
Health, 2010). be in place.
• Antipsychotic and anti-anxiety medica- 3. Ongoing monitoring for high-risk pa-
tions are often needed to treat psychosis tients: Be aware that patients with any
as well as depression. The psychiatrist history of mental disorders, substance
will identify those with less risk to the abuse, and family conflict are at higher
mother and infant. Antipsychotics are risk for postpartum mental disorders.
generally viewed as having less risk to This information should be identified
mother and infant (Berga, Parry, & during pregnancy so adequate support
Moses-Kolka, 2009). and prevention strategies can be imple-
mented. Listen to family members who
may observe the mother’s behavior.
Home health visits should be arranged
Tool Box | An excellent Web site for moni- for any mother at high risk for postpar-
toring the current knowledge about medica- tum psychiatric disorders. The patient’s
tions and breastfeeding is psychiatrist needs to be involved in the
http://tox net.nlm.nih.gov> ; click on treatment plan.
“ LactM ed.” 4. Education: The new family needs educa-
tion about the stresses of pregnancy and
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CHAPTER 20 | Postpartum Issues in Mental Health 329

childbirth. Education of the new family Neeb’s Women often have unrealistic ex-
about postpartum blues and its transient ■ Tip pectations of themselves with a new
nature should be included in childbirth baby, thinking that other women are
classes and doctor visits. Also, education better mothers.
on infant care and breastfeeding can reas-
sure the mother of her skills.
5. Medication management: Because the use Neeb’s Lactation consultants can be help-
of psychiatric medications in this popu- ■ Tip ful as a new mother may feel inad-
equate if having difficulty with
lation involves some risks, providing
breastfeeding.
support and education is essential.
6. Further Interventions: See Chapters
10,11,12, and 15 for specific interven- ■■■ Clinical Activity
tions for anxiety, depression, mania, and • Obtain information on how psychiatric disorders
psychosis. are addressed in local obstetrics clinics.
• Obtain information on local support groups for
new mothers.
Tool Box | PEP (Postpartum Education
for Parents) Warmline: (805) 564-3888. Post-
partum Distress Support 24/7
The nursing care plan for patients with
postpartum issues is provided in Table 20-1.
Neeb’s Monitor coping mechanisms and
■ Tip evidence of family conflict in prena-
tal visits to give information on how
the mother will react after birth.

l Table 20-1 Nursing Care Plan for Patients With Postpartum Disorders
Nursing
Behaviors Diagnosis Goals Interventions Evaluation
New mother is Ineffective Patient will Provide support and Patient verbal-
avoiding caring coping verbalize her reassurance. izes feelings of
for new baby for feelings. Communicate your competence in
the first 6 weeks. She will spend observations to MD. caring for baby.
She has verbalized more time caring Educate patient and Patient and baby
feelings of inade- for baby. family about postpar- remain safe.
quacy and lack of She will verbalize tum depression. Patient partici-
attachment to new optimism regard- Encourage patient to pates in treat-
baby. ing caring for complete small tasks ment plan.
She cries frequently new baby. in caring for baby.
and expresses Family will main- Reinforce successes
feelings that baby tain safe environ- in baby care.
would be better ment for patient Assist family in main-
off without her. and baby. taining adequate
caregiving for baby.
Educate on treatment
options for this
depression.
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330 UNIT 3 | Special Populations

■■■ Key Concepts 4. Postpartum psychosis is a rare disorder

and often associated with a history of
1. Postpartum blues are a very common bipolar disorder.
reaction to plummeting hormones right
after delivery. These blues generally do 5. Pharmacological treatment of these dis-
not require any psychiatric treatment. orders may be associated with risks dur-
ing pregnancy and breastfeeding.
2. Women with postpartum blues that go
on for more than 2 weeks should be 6. Any pregnant woman with a history
evaluated for postpartum depression. of psychiatric disorders should have
psychiatric follow-up.
3. Postpartum depression is often associated
with a previous history of mood disorders.

CASE STUDY
Janice is a 21-year-old experiencing her first her behavior 4 weeks ago when she became
pregnancy. She lives with the father of the more withdrawn and tearful. The boyfriend
baby and has additional support from her said she told him she does not want to
mother and grandmother. Janice has a his- think about the baby and does not want to
tory of substance abuse, including cocaine participate in preparations. She says she is
and opioids, as well as depression, but she too tired to think about it. The boyfriend
denies any drug use during the pregnancy. works long hours to make ends meet and
She is in her 8th month of pregnancy. confides in you that he does not know what
Upon arrival at the clinic, she appears tear- they will do when the baby comes, if she
ful, unkempt, and sad. Her boyfriend tells remains in this condition. He is considering
you she has been sleeping for days and does having Janice’s mother take the baby if this
not talk to him. He noticed a big change in continues.

1. Given this information, what would be your primary concern for Janice?
2. What would you ask Janice when you go in to see her?
3. What support options should be recommended for the boyfriend/father?

REFERENCES Kaplan & Sadock’s Comprehensive Textbook of

ACOG Committee on Practice Bulletins— Psychiatry. 9th ed. pp. 2539–62. Philadelphia:
Obstetrics. ACOG Practice Bulletin: Clinical Lippincott Williams & Wilkins.
management guidelines for obstetrician- Elder, C. R. (2004). Beyond baby blues.
gynecologists number 92. Use of psychiatric Nursing Spectrum. Retrieved from nsweb.
medications during pregnancy and lactation. nuirsingspectrum.com/ce/ce72.htm
Obstet Gynecol. 2008(111), 1001–1020. Henshaw, C., & Cox, J. (2004). Post natal blues.
American Psychiatric Association. (2013). Dia- J Psychosomatic Obstetrics and Gynecology 25,
gnostic and Statistical Manual of Mental Disor- 267–72.
ders 5. Washington, DC, Author. (Known as Massachusetts General Hospital Center for
DSM-5) Women’s Mental Health (2010). Postpartum
Berga, S. L., Parry, B. L., & Moses-Kolka, E. L. Psychiatric Disorders. Retrieved from http://
(2009). Psychiatry and Reproductive Medicine. www.womensmentalhealth.org/specialty-
In B. J. Sadock, V. A. Sadock, & P. Ruiz (eds.). clinics/postpartum-psychiatric-disorders/
2993_Ch20_323-334 14/01/14 5:29 PM Page 331

CHAPTER 20 | Postpartum Issues in Mental Health 331

McCoy, S, J. (2011). Postpartum depression. U.S. National Library of Medicine. (2010).

South Med J 104(2), 128–32. Post Partum Depression. Retrieved from
McKinney, E. S., James, S. R., Murray, S. S., www.ncbi.nlm.nih.gov/pubmedhealth/
Ashwill, J. W. (2009). Maternal-Child PMH0004481/
Nursing. 3rd ed. St. Louis: Saunders.
Pearlstein, T., Howard, M., Salisbury, A., & WEB SITES
Zlotnick, C. Postpartum depression. Am J Postpartum Health Alliance offers informa-
Obstet Gynecol. 2009(200), 357–364.
tion for families after the delivery of a baby.
Pillitteri, A. (2007). Maternal and Child Health www.postpartumhealthalliance.org
Nursing: Care of Childbearing and Childrear- Postpartum Support International (PSI).
ing Families. 5th ed. Philadelphia: Lippincott
Williams & Wilkins. The purpose of PSI is to increase awareness
Ricci, S. S. (2007). Essentials of Maternity, among public and professional communities
Newborn and Women’s Health Nursing. about the emotional changes that women ex-
Philadelphia: Lippincott Williams & perience during pregnancy and postpartum.
Wilkins. http://postpartum.net
Sharma, V., & Pope, C. J. (2012). Pregnancy National Alliance on Mental Illness
and bipolar disorder. J Clinical Psychiatry, http://www.nami.org/Content/NavigationMenu/
73(11):1447-55. Inform_Yourself/About_Mental_Illness/By_Illness/
Pregnancy_and_Depression.htm
Townsend MC (2012). Psychiatric Mental Health
Nursing. 7th ed. Philadelphia: FA Davis.
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332 UNIT 3 | Special Populations

Test Questions
Multiple Choice Questions
1. Which statement reflects postpartum 5. Which of the following is a good nursing
psychosis? intervention for a new mother with post-
a. “I wish my baby had more hair.” partum blues?
b. “My baby has evil eyes.” a. “Let your mother take care of the baby
c. “I don’t think I will be good at for the first few days.”
breastfeeding.” b. “Recognize that it is normal to feel
d. “I am exhausted and want to sleep very emotional right after the baby is
rather than see the baby right now.” born.”
2. Which of the following statements best c. “Let’s ask the doctor to order an anti-
reflects postpartum blues? depressant to start today.”
a. “I wonder if I will be good at d. “It is important to stop crying around
breastfeeding.” your new baby.”
b. “I wish the baby had never been born.” 6. You are caring for a woman who has just
c. “I am exhausted so I won’t feed the had a stillbirth. Which of the following
baby this morning.” statements reflects an understanding of
d. “I can’t stop crying every time I look at grief after loss of a baby?
the baby.” a. “You’re young; you can have more
3. Which of the following is true about children.”
postpartum blues? b. “It’s best to put this behind you.”
a. The blues start several months after the c. “Would you like to have some private
baby is born. time with the baby’s body?”
b. The blues occur in the majority of d. “I will leave you alone so you can have
women a few days after childbirth. privacy to grieve by yourself.”
c. The diagnosis of postpartum blues is a 7. Which of the following is a sign that
psychiatric diagnosis. postpartum blues is progressing to
d. The postpartum blues are usually a depression?
precursor to poor bonding with the a. The new mother is crying for the first
infant. 4 days after delivery.
4. What is the most important risk factor b. The new mother verbalizes anxiety and
for postpartum depression? fear that she feels nothing for her new
a. Past history of depression in a previous baby 2 weeks after delivery.
pregnancy c. The new mother tells you that she has
b. History of pre-eclampsia in a previous heard from her deceased grandmother
pregnancy that the baby is evil.
c. History of conflict within the family d. The new mother wants to sleep for
during the pregnancy long periods 2 days after delivery.
d. The baby being born with multiple
anomalies
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CHAPTER 20 | Postpartum Issues in Mental Health 333

Test Questions cont.

8. What is the major risk factor of mood 10. What of the following is true about
stabilizers during pregnancy? postpartum psychosis?
a. Contributes to pre-eclampsia a. It is a medical emergency.
b. Increased risk of malformations in b. It may be evidence of bipolar disorder.
neonate c. The baby’s safety may be compromised.
c. Increased risk of postpartum depression d. All of the above
d. Increased cholesterol levels postpartum
9. Which of the following is true about
postpartum depression?
a. It is more common than postpartum
blues.
b. It is less common in Hispanic women.
c. It can be safely treated with
antidepressants.
d. Diet and exercise can usually improve it.
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C HA PT E R 21
Aging Population
Learning Objectives Key Terms
1. Discuss concepts of aging. • Ageism
2. Define ageism. • Cerebrovascular disease
3. Discuss social trends in the aging population. • Elder abuse
4. Identify five mental challenges of the older adult. • Elderly
5. Identify medical treatment for the older adult. • Geriatrics
6. Identify nursing actions for general care of older patients. • Gerontology
• Insomnia
• Omnibus Budget
Reconciliation Act
(OBRA)
• Palliative care
• Restorative nursing

erontology means the study of older

G
When children are 10 years old, they
adults. Geriatrics is the branch of cannot wait to be 16 so they can drive a car.
medicine caring for older adults. The Sixteen-year-olds want to be 18 so they can
study of older adults is a specialty in nursing. be out on their own. When they turn 30, the
With more and more North Americans reach- idea of time passing begins to take on a differ-
ing age 65 within the next 10 to 15 years, learn- ent tone for some people. In a society that
ing the complications, abilities, and best ways promotes the image of youth, many people of
to assist that population is a very timely study. this age see youth vanishing. They might feel
According to the Administration on Aging they are not as fast or as thin or as healthy as
of the Department of Health and Human they were in their 20s. Still, they see healthy,
Services, “The population of 65+ will increase happy people over age 65 working, recreating,
from 35 million in 2000 to 55 million in 2020.” and socializing. Life expectancy in the United
States is in the 76 for men and the early 81for
Neeb’s Aging begins at the moment of women (World Health Organization, 2011).
■ Tip birth. So, what is this process of aging?
Aging happens to everyone, and nobody
has control over it. It is a condition of time ■■■ Classroom Activity
passing. It is also a condition that researchers • Develop three age range groups in your class
are beginning to redefine: What is “old age”? and describe what you have in common with
the people in your age group.
■■■ Critical Thinking Question
How do you define your current perception of
age-young, young-old, old, or old-old, and what The majority of people over 65 are intel-
are you using to measure age? What is your view lectually intact and able to care for themselves
when you meet people in each of these groups? (Fig. 21-1). Only about 0.4% of people over
age 65 live in institutional setting such as
335
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336 UNIT 3 | Special Populations

nursing home or to a family member’s home.

Coronary disease such as arteriosclerosis and
respiratory disorders such as pneumonia occur
more frequently in this age group, and pa-
tients are less responsive to the treatments than
younger people are. Older people are sicker
longer. Nutrition is challenged. Elderly people
may not be able to afford to buy nutritious
foods, and the food they do prepare does not
taste as it once did because their taste buds are
less sensitive. It is essential that this aging
group have all of their survival needs met.
A phenomenon called ageism, which is oc-
curring in the United States, is discrimination
against a group of people on the basis of their
age. It assumes that most older people are inca-
pable of functioning in and contributing to so-
ciety. What thoughts arise as one sees that the
car ahead of him is being driven by an older per-
son who can barely see over the steering wheel?

Figure 21-1 Most older adults are indepen-

dent and fully able to care for themselves. ■■■ Classroom Activity
(Courtesy of Robin Anwar.) • Answer the following questions and share your
responses to the questions with your classmates:
How I will look at 75 years of age?
Will I be independent?
nursing homes (Administration on Aging, What will I be doing at 75?
2011). These numbers are slowly on the rise
as children of the 1950s and 1960s (often re-
ferred to as “baby boomers”) enter advanced The retirement age has changed drasti-
age. Older people are usually basically men- cally as a result of the economy and Social
tally healthy; that is, they are able to accept Security benefits. The expected age for re-
and deal with the changes and losses they are tirement is currently 67 for people currently
experiencing. in the workforce to attain full retirement
Of course, many challenges are involved benefits. Those who have retired from their
with aging. People aging normally may expe- careers can live a comfortable life provided
rience a loss in visual and hearing acuity. their retirement funds are adequate (U.S.
Many of these individuals live on fixed in- Social Security Administration, Retirement
comes that are not adequate to meet their Planner: Full Retirement Age, 2012).
needs for housing, food, and health care. Whereas people now may conceivably
Safety is also an issue. Criminals are finding change careers at least five times during their
that older adults are easy targets and are rob- working years, the elderly people of today
bing and mugging them in higher numbers most likely had one or two jobs over their life-
than in generations past. For aging adults, the time and worked 20–30 years at each job.
need to face death becomes more of a reality. That job probably represented a large part of
Certain illnesses become more prevalent as the person’s identity, and retirement may lead
one ages. Alzheimer’s disease (see Chapter 16) to feelings of low self-esteem and depression
may become more prominently manifested in when the person has to redefine who he or she
an older person, rendering the individual in- is. Self-esteem is viewed as a need according
capable of caring for himself or herself and to Maslow, and something that was sought
possibly requiring a major lifestyle changes. after in youth and provides, prestige, and
This can include the individual’s move to a power (Green, 2000).
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CHAPTER 21 | Aging Population 337

Retirement also means a decrease in in- The Omnibus Budget Reconciliation

come, which can have a negative impact on a Act (OBRA) is a federal act that provides
person’s lifestyle. Today many elderly people standards of care for older adults. One of the
have to make a choice whether to buy groceries provisions of OBRA is ensuring proper assess-
or purchase their prescribed medication. ment of elderly people.
The need for intimacy never leaves us. As
human beings, the need to love and be loved
is one of the primary needs for survival of the Tool Box | Information About Elders and
individual and the species (Fig. 21-2). As peo- Mental Health Services
ple age and spouses and friends die, who is http://www.asaging.org/blog/aca-could-
benefi t-elders-mental-health-problems-
there to love older people? Prospects for mar- will-it
riage are slim. Children and grandchildren may
live on the opposite side of the country. In ad-
dition, older adults may be forced to live with
their adult children, which is not always the It is for this reason that only registered
ideal situation. Older individuals are at risk for nurses (RNs) may conduct or coordinate
elder abuse (physical and emotional abuse of initial assessments of elderly individuals. The
older people) by their children or caregivers. LPN/LVN role is to assist the registered nurse
Elder abuse is discussed further in Chapter 22. through active listening and competent ob-
Aging has many challenges, yet most indi- servation. This responsibility is especially im-
viduals are able to cope with the changes portant in long-term care facilities since the
brought about by aging and progress through role of the LPN/LVN is to administer routine
this life stage with dignity. They are proud of and prn medications. Other health-care team
their families and their personal accomplish- members assist with the registered nurse’s as-
ments. They can see the contributions that sessment by providing input as to the resi-
they have passed on to others. People who have dent’s ability and responses to the treatment
learned to adapt to change throughout life plan. OBRA also set the standards for provid-
have the best chances of progressing through ing education for the majority of nurse’s aides
old age with the same kind of resilience. who are employed by long-term care facilities;
Older adults with mental illness whether the Department of Health and Senior Services
these were diagnosed earlier in life or are a regulates the curriculum.
new diagnosis face many challenges on top of Nurses are caring for the older individual
the aging process. For example an elderly per- not only in the health-care facility but also in-
son with schizophrenia, generalized anxiety creasingly in the privacy of the person’s own
disorder, or a personality disorder will need home (Fig. 21-3). Multidisciplinary teams are
added support as the person declines.

Figure 21-3 Increasingly, nurses are caring for

older adults in their own homes. (From Sorrell
Figure 21-2 Pets can fulfill the need for com- and Redmond (2007): Community-Based Nursing
panionship and intimacy in an older person’s Practice: Learning Through Students’ Stories. Philadelphia:
life. (Courtesy of Robin Anwar.) F.A. Davis Company, with permission.)
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338 UNIT 3 | Special Populations

assisting and monitoring the physiological ■ Cerebrovascular

needs of the elderly in the home. Because it
is believed that people will stay healthier and Accident (Stroke)
maintain more control of their lives if they
A cerebrovascular accident (CVA), or stroke, is
can stay in their own homes, the home health
a medical disorder that has implications for
industry is growing. One of the primary con-
mental health workers. A CVA is a devastating
cerns for nurses and others caring for older
and frightening experience for the patient and
adults is to help them maintain a good quality
family. The probability of a CVA in the elderly
of life. Nurses caring for patients in their
is higher. Depending on the location and size of
homes need to be aware of some of the major
the brain and blood vessel involvement, many
mental and emotional disturbances they may
physical and cognitive functions may be tem-
encounter, as well as the physical diagnoses of
porarily or permanently affected (Fig. 21-4).
the patient. The elderly are prone to a number
Some of the mental health issues associated with
of major disorders that impact their emo-
CVA are depression and aphasia.
tional well-being. These are covered in the
next sections (Box 21-1). Depression Associated
With CVA
■ Alzheimer’s Disease Patients realize the losses associated with their
and Other Cognitive stroke. They may not be able to express them
Alterations verbally or physically, but they do realize that
they cannot do things independently. Self-
As stated in Chapter 16, when a person has esteem decreases as they realize they may be
been diagnosed with Alzheimer’s disease, it
has most likely been taking its toll on the in- Left-side infarct Right-side infarct
dividual for many years. It is in the later stages
that the debilitating effects are most observ-
able. This disease may necessitate the person’s
leaving the home she has lived in all of her
adult life. It may mean living apart from a
spouse whom she may not appear to remem-
ber. Socializing will be curtailed because of the
inability to relate to others easily. Alzheimer’s
disease has an impact not only on the patient
but also on all the people in that person’s life,
which may include the health-care provider.
Further information on Alzheimer’s disease Right-sided weakness Left-sided weakness or
and the care of patients with this disorder is or paralysis paralysis
included in Chapter 16. Aphasia (in left–brain- Impaired
dominant clients) judgement/safety risk
Depression related to Unilateral neglect more
l Box 21-1 Some Concerns of Aging disability common common
Adults Indifferent to disability

Alzheimer’s disease and other cognitive Figure 21-4 The location of a stroke is a key
impairments factor in the physical and cognitive functions
Cerebrovascular (stroke) that may be affected. A stroke on the left side
Depression of the brain affects the right side of the body;
Medication concerns a stroke on the right side of the brain affects
Paranoid thinking the left side of the body. (From Williams and
Insomnia Hopper (2011). Understanding Medical-Surgical
End of Life issues Nursing, 4th ed. Philadelphia: F.A. Davis Company,
with permission.)
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CHAPTER 21 | Aging Population 339

incontinent, unable to eat independently, or The physician and speech therapist will de-
unable to communicate with their families. termine the proper plan of speech therapy.
Depression may develop. They worry about Nurses need to closely follow this plan and
the effect of their stroke not only on them- document the patient’s progress and emotional
selves but also on their spouses and other fam- responses to speech therapy.
ily members. Will this be permanent or only
temporary? Will it happen again? How long
will I be this way? ■■■ Critical Thinking Question
As these worries become more pronounced, You are celebrating your retirement when the
the patient may become more depressed. The room goes dark. You wake up in a busy room with
physicians, nurses, and therapists will try to lights and noise and many people. You think you
explain these concerns to the patient and fam- recognize some of them and you try to call out to
them, but they just stand there and look at you.
ily, but the patient may still feel out of control Someone you do not know is trying to say some-
of his or her destiny. Nurses may see the pa- thing to you and keeps shining a flashlight in your
tient crying and refusing to perform tasks that eye. Your life partner is crying. What happened to
he or she could do after the stroke. The patient you? Why is nobody answering you? What are you
may avoid eye contact with the nurse or refuse feeling now? What do you wish someone would
do to help you?
to interact with family members. All these
behaviors may indicate depression in the pa-
tient who has had a CVA. By recognizing and
confronting these behaviors, the nurse can
help the patient understand that the nurse is
■ Depression in the
really there to help and is concerned with the Elderly
patient’s thoughts and feelings.
Being honest and generous with positive It is not “normal” to feel depressed all the
reinforcement for attempts to overcome the time despite the fact the person is getting
feelings of depression will also be helpful older. Major depression in the elderly popu-
in building the patient’s confidence and self- lation can show itself differently than in other
esteem. age groups. In addition to the information
discussed in Chapter 11, nurses observing
Aphasia and assisting elderly people should collect
Aphasia, a speech disorder that may be found subjective and objective data for physical
in patients who have had a CVA, is classified symptoms that can mask depression, e.g.,
as expressive, receptive, and/or global (see confusion, constipation, headaches, and other
Chapter 2). A patient with aphasia may need body aches. Often these patients will discuss
to learn to talk all over again. Communication these physical symptoms rather than admit to
is such a basic need that the nurse and the pa- being depressed.
tient must work at any threat to this ability These symptoms are similar to other afflic-
very diligently. The nurse should give the per- tions common in the elderly population, such
son time to speak, write, or show what is as drug side effects (Box 21-2), electrolyte
needed, and praise him or her for all efforts to imbalances, and dementia. Nurses must get
communicate. One communication technique accurate information, document it, and be
that is effective, especially in expressive aphasia, certain that appropriate medical care is
is to associate the object with the word. The obtained to rule out other ailments.
more senses a person can engage, the better the
reinforcement for the learning.
■■■ Clinical Activity
Neeb’s Patience is mandatory. The goal of During clinical preconference at a nursing home,
determine how many residents have been diag-
■ Tip communicating with a person who nosed as depressed. Develop a care plan that will
has aphasia is to keep him/her in- address depression.
volved in the recovery.
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340 UNIT 3 | Special Populations

to immediately mark on a calendar the appro-

l Box 21-2 Common Drug Side Effects priate date and time a dose is taken. In this
for Elderly Patients way, the patient can double-check that the
Dry Mouth medications are taken correctly and will be
Constipation less anxious about it. Also, new technology is
Orthostatic hypotension available to create reminder alarms.
Urinary complications Nurses also must be aware of the patient’s
Confusion/disorientation/mental sluggishness weight, nutrition, and activity levels. It is very
fatigue easy for older people to become toxic from
Mood swings/irritability their medications, regardless of whether they
are at home or in a facility. Patients with drug
toxicity or overdose can present with symp-
■ Medication Concerns toms similar to those of a mental illness or
other physical illness. It is not uncommon for
The process of pharmacokinetics is slower and a proper dose of a medication for an older
less complete in older people. Because circu- adult to be as little as 25% of the “usual” rec-
latory, hepatic, and renal function start to de- ommended adult dose. It is the nurse’s respon-
crease normally with age, it is easier for these sibility to ask specific questions of the doctor
persons to become toxic. Adverse effects of regarding medication doses.
many medications are more likely to develop Similarly, side effects to medications can
in the elderly. Nurses who work in facilities look like other symptoms. Nurses can teach
that care for older adults must be very alert to patients and families about this possibility.
the effects of the medications they give their Table 21-1 shows some of the common side
patients as well as to the possible signs of side effects of drugs on older people, disorders that
effects and toxicity. The nurse needs to report may have similar symptoms, and some nurs-
any concerns to his or her charge nurse imme- ing actions that can be taken and taught to
diately and document observations accurately. the patient.
If the state allows a licensed practical nurse/
licensed vocational nurse (LPN/LVN) to con- ■ Paranoid Thinking
tact the physician by telephone, the LPN or
LVN will also take that responsibility. Paranoid thinking may be a result of fear about
Patients who live at home may lose track the social environment. As stated earlier, cer-
of their medication routine. They may forget tain people see elderly persons as “easy marks.”
to take medications or forget they have taken What was once a situation that was not threat-
them and take another dose. Many pills look ening (such as a walk around the block) can
alike. When visual acuity is lessened and become very frightening for the person who
lighting inadequate, patients may mistake one has slowed reaction time and diminished
pill for another—for example, they may take physical capacity for self-protection. Paranoid,
two lanoxin tablets instead of one lanoxin and fearful thinking can be a defense mechanism
one furosemide, especially if they put all of against these kinds of disabilities, making the
their medications in one container. These fear the reason to avoid leaving the house. This
types of mistakes can be lethal. self-imposed isolation can bloom into feelings
To help with this situation, nurses have of loneliness, which can lead to illness that
systems available for teaching patients and is more serious. Validate what the person is
families. Containers are available for planning expressing, even when it has taken the form of
which medications are taken at what time, being paranoid. Investigate the person’s fearful
enabling the nurse and patient to set up the thinking. Age-related hearing loss (presbycusis)
patient’s medications for a week or longer and and vision loss as well as early onset of demen-
for different times of day. If the patient is re- tia can all contribute to paranoid thinking.
liable, this will serve as a reminder to take a Paranoid thinking can also occur when a pa-
particular dose. If the patient still needs some tient is entering a long-term care facility and is
reassurance, the nurse can instruct the patient exposed to new caregivers and a roommate.
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CHAPTER 21 | Aging Population 341

l Table 21-1 Common Drug Side Effects and Nursing Actions for Elderly
Patients*
Side Effect Other Possibilities Nursing Actions
Dry Mouth • Stress response; electrolyte 1. Offer sips of water or ice chips.
imbalance 2. Offer hard, sugar-free candy (such as
• Vitamin B deficiency lemon drops) if patient is able to suck
on them without choking.
3. Provide oral care with light application
of lubricant such as petroleum jelly;
saliva substitute.
4. Review lab work or call physician.
Constipation • Fluid and nutritional 1. Assess diet for fiber and fluid intake.
deficiency, hemorrhoids, 2. Assess area for signs of hemorrhoids
or rectal pain or other inflammation.
• Hypothyroidism 3. Assess need for laxatives as ordered by
physician.
4. Discuss need for physical activity as
condition warrants.
Orthostatic • Heart disorders 1. Assess vital signs.
Hypotension • Dehydration 2. Teach patient how to get out of bed
or chair slowly.
3. Tell patient to stay sitting for a few
minutes until dizziness goes away.
Urinary • Prostate problems 1. You must: Keep track of frequency,
Complications • Bladder problems amount, color, and odor of urine, and
• Uterus problems abdominal girth.
• Urinary tract infections 2. Report signs of urinary tract infection
• Cancers to physician.
Confusion/ • Hypoglycemia 1. Give sweetened drink. If patient is
Disorientation/ • Head injury (e.g., fall) still confused after 10 minutes, call
Mental • Infection/fever physician.
Sluggishness • Depression 2. Check vital signs and signs of infection.
• Vitamin deficiency 3. Attempt to validate whether patient
• Transient ischemic attack (TIA) has had recent head trauma.
• Brain tumor
• Dehydration
• Alcohol and/or tranquilizer use
Fatigue • Infectious process 1. Assess vital signs.
• Anemia 2. Assess stress level.
• Hypothyroidism 3. Encourage activity if appropriate.
• Stress 4. Assess sleep pattern.
• Narrowing of coronary arteries
Mood Swings/ • Psychological disorders 1. Use verbal and nonverbal communi-
Irritability • Electrolyte imbalances cation skills to assess cause.
2. Request lab work.
*Always report these side effects to the charge nurse, document carefully, and notify the physician if that is allowed for LPN/LVN practice in your state.

■ Insomnia pain, urinary incontinence, napping during

the day, or sometimes a condition nicknamed
Insomnia, or inability to sleep, is seen fre- “sundowner syndrome,” in which the person
quently in the older adult. It can be a result of turns around daytime and nighttime hours.
many conditions, including depression, fear, These people sleep much of the day and are
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342 UNIT 3 | Special Populations

wide awake and active during the night. This means to them. It is the nurse’s responsibility
syndrome is sometimes seen in patients who and privilege to be able to help someone
have Alzheimer’s disease. Lack of rapid eye through this stage of life according to that
movement (REM) sleep from insomnia can individual’s needs and wants.
have negative effects on anyone, even con- One issue a patient may experience is wid-
tributing to psychotic behavior. To someone owhood. The surviving spouse must learn to
with Alzheimer’s disease or other cognitive live independently or face an alternative form
problems, the effects of insomnia can intensify of housing. Finances and household chores may
the symptoms of the cognitive disorder. have been “gender-specific” in that relationship,
The nurse needs to concentrate on keeping and now the surviving person is forced to as-
communication open with these patients. sume responsibilities formerly done by the de-
Nurses will need to be sure that they and their ceased. The subjects of dating and working may
patients are using words in the same way. For become delicate issues for the survivor: Families
instance, if the patient says, “I do not sleep at may have strong opinions about what the
night because I am worried,” the word wor- newly widowed person “should” do. Nurses can
ried should be explored. What is the patient play an advocacy role with widowed persons.
worried about? What can be done to elimi- Active listening skills, validating the person’s
nate the worry? How severe is the worry? thoughts and feelings, and offering information
Using a 1 to 5 rating scale, the nurse can more about various services available to widowed per-
objectively document the impact of the sons are skills that can be very helpful.
“worry” on the patient. In addition, the nurse Nurses can be effective in helping people
should ask the patient about his or her defi- through the dying process. Death of the body
nition of not sleeping all night; perhaps the as everyone knows it is inevitable. People need
patient had taken naps throughout the night. to know it is “OK” to die. Elisabeth Kübler-
Ross and others who teach about death and
■ End-of-Life Issues dying tell us that helping people to resolve life
issues can help them to die with peace and dig-
Life can end at any age; however, death is more nity. Again, nurses who choose to work in hos-
common among the older population. Nurses pice, home care, and long-term care settings
who work in areas such as long-term care, home have a special opportunity to be there for peo-
care, or hospice have a great opportunity to learn ple at this very important stage of life. Using
about and assist people with end-of-life issues. humor and laughter appropriately, maintain-
These opportunities also exist when working in ing the hope patients may still have, and reas-
acute hospitals and clinics. It may not be feasible suring them that they will not be forgotten
for professional counselors to meet the needs of after death are some good techniques nurses
older adults dealing with these profound issues. can learn to use to help people prepare to die.
Many people in this population will prefer the Elisabeth Kübler-Ross’s five stages of grieving
services of their own spiritual leader, but since continue to be taught and used in nursing pro-
the duties of many such leaders are overwhelm- grams. Not everyone experiences each step nor
ing, the appropriate clergy may not be available in the order listed (Kübler-Ross,1969):
at the moment of immediate need. However,
nurses are there, and they have all the tools 1. Denial
needed to be the helpers. 2. Anger
3. Bargaining
4. Depression
Neeb’s Nurses must take self-inventory of 5. Acceptance
■ Tip their beliefs surrounding the sub-
jects of death and dying. Nurses must not ignore the incidence of
suicide among the aging populations. This
It is also very important for nurses to dis- chapter has alluded to many losses that peo-
cuss and understand their patients’ religious ple are likely to face as they age. Compound
and cultural beliefs about what the end of life the sadness of losing jobs, friends, and other
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CHAPTER 21 | Aging Population 343

aspects of earlier life with physical illness

and altered physical ability, and it may be-
come clearer why some elders feel helpless
or hopeless and opt for suicide. According to
the National Institute of Mental Health, per-
sons age 65 and older rate of suicide is higher
than the national average for all age groups.
They account for approximately 13% of the
U.S. population, yet they accounted for
14.3% of all suicide deaths in the United
States in the year 2007. The highest rates
were found in white men age 85 and older.
Figure 21-5 The demographic changes in
Follow the screening suggestions provided
the American population mean that a more
in Chapter 13 when considering the possi- ethnically and culturally diverse group will be
bility that an older person may be at risk for seeking assistance in long-term care facilities.
suicide. Nurses must be ready to offer culturally
sensitive care.
■ Social Concerns
see much younger family members than they
Older adults, like younger adults, in today’s might anticipate. The upcoming older genera-
world may find themselves in financial trou- tion is very diverse. Those of varied ethnic and
ble. Many are facing financial challenges liv- cultural backgrounds will be seeking assistance
ing on fixed incomes. Many exist only on in long-term care facilities (Fig. 21-5). Nurses
Social Security benefits. Retirement age has must be prepared to learn about older patients’
increased over the years, and politicians are customs, ask the proper questions upon intake
discussing raising it yet again, potentially re- data collecting, and be ready to offer care ac-
quiring people to continue working longer cording to customs that may be different from
before they become eligible to receive the their own and different from those they were
Medicare and/or Social Security benefits they trained in.
have earned. This will impact future genera-
tions. Perhaps today’s seniors have inadequate ■■■ Classroom Activity
personal and supplemental insurance, so they • Divide the class into five groups. Each group
will not seek medical help when they need it. represents a decade from the past 50 years. Each
They may find their heat and power cut off group should list the music, television shows,
due to inability to pay utilities on their fixed and fads popular during their assigned decade
and add to a chart.
income. Most municipalities are enacting
laws and emergency funds to help avoid this
life-threatening situation. Nurses can help
provide the necessary information to help el- ■■■ Clinical Activity
ders who are opting to remain at home or in Using the chart developed in the classroom activity,
ask your patients to provide more information
assisted living. about music, television shows, and fads they
As baby boomers age, nurses will see a sig- believed were popular during those times.
nificant increase in this demographic they are
caring for. The average age of patients will be
older, and the concerns nurses face will relate One of the cultural demographics to con-
more frequently to issues pertaining to people sider is the group of elders who have lived a
in the final stages of life. gay or bisexual lifestyle. Nurses need to antic-
It is worth mentioning again at this time ipate issues surrounding grooming, room-
that the family unit of the older population mates, bathroom-sharing, family preferences,
may have a different look as well. People are and potentially even a different definition
opting to have children later in life. Nurses may of “appropriate behavior” for those with a
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344 UNIT 3 | Special Populations

different lifestyle. Individuals may be reluc- that the person is called socially. Nurses should
tant to share this type of information unless not do this until invited to do so, however.
nurses communicate acceptance. The nurse’s Also, it is not acceptable to assign nicknames
role will need to become even more flexible. such as granny or honey arbitrarily to patients.
Nurses will need to be very open with their In home care and long-term care, there is a
communication and with the type of ques- danger of becoming too familiar. The facility
tions they must learn to ask in order to pro- becomes the residents’ home, and they become
vide the best care to all entrusted to their care. friendly with each other. This informal atmos-
phere sometimes spreads among the staff. This
■ Nursing Skills for Working is a time when nurses must remember their
With Older Adults professional role. They can be pleasant and
friendly while still being professional.
The following are some general skills a nurse
should learn to use to more effectively work
■■■ Critical Thinking Question
with the elderly population. You refer to an 87-year-old resident as “grandmom,”
1. Respect: In the United States, a hand- yet the resident does not have any children as a
result of several miscarriages. Describe the emo-
shake is a sign of respect and coopera- tional effect this title might have on the patient.
tion. It is usually given at the beginning
and ending of business meetings, and
it is customary to shake hands at more Under no circumstances should an older
formal social functions or when being adult be treated as a child. As abilities dimin-
introduced to someone new. Shaking the ish and the older adult begins to become in-
hand of an elderly patient will convey re- continent and loses the ability to feed and
spect and cooperation and is an effective dress himself or herself, some caregivers take
way to begin the nurse-patient partner- on a parental role. It can be easy to deal with
ship. There are citizens and residents of an elderly person as one would deal with a
the United States whose culture does not child. Elderly patients have had careers and
participate in hand shaking, but this raised families. They are now adults who have
does not mean they lack respect for special needs in order to help them maintain
others. If you sense that shaking hands their adult dignity.
is not acceptable to that patient, then
communicate to others that this action
should not be used. Neeb’s It is important to remember that the
Using the proper name of the patient also ■ Tip elderly is a population of people
who have been and still are produc-
shows respect for that person. “Mr. Washington” tive members of society.
or “Mrs. Jones” is the best way to address the
patient. If the patient prefers, the nurse may
call him or her by the first name or the name 2. Goal setting: When preparing the plan
of care with an older patient, nurses
must remember to discuss goals that are
l Box 21-3 Skills for Working With measurable and attainable. Self-esteem
Older Adults and pride in one’s accomplishments are
as important when one is 80 as they were
• Respect when one was 20. Success breeds success,
• Goal setting and meeting small goals is an encourage-
• Patience and understanding ment to the older person to attempt
• Humor
bigger goals. The patient will see that
• Safety
• Independence the nurse was there to help reach that
• Acceptance goal and, again, the relationship will
strengthen.
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CHAPTER 21 | Aging Population 345

3. Patience and understanding: Older 6. Independence: The older adult should be

patients who have some challenge to allowed to perform without assistance as
their physical or cognitive functioning much as possible. Do not assume that
may be slower to respond to verbal cues the older person is unable to do things
and may not be able to sprint down the independently. Follow the guidelines on
halls at the pace that nurses generally the patient’s care plan. If the level of care
travel. Be patient and recognize the care is complete, then provide complete care.
may take longer than expected. Plan for If the level of care indicates the patient
this. Nurses should convey the message needs partial or complete care, then
that they have plenty of time (even honor those directions. This is one of
though they may not). The patient who the fallacies in long-term care: Too much
feels burdensome will be less likely to focus is placed on the staff to provide
attempt activities or collaborate in the care by a specific time and not on pro-
plan of care. He or she will be very sen- moting independence. On the other
sitive to any nonverbal communication hand, nurses should offer assistance as
expressed by the nurses. It is important necessary. Nurses should let the patient
during these times that the nurse’s ver- know that they would like to help in
bal and nonverbal responses are congru- whatever way they can. Because of the
ent. It is therefore important to focus loss in hearing and visual acuity that
entirely on that person at that time. often accompanies aging, nurses may
Acknowledge any accomplishment, need to arrange for adaptive equipment
however small. The focus should be on that can help the patient to maintain as
the residents’ strengths and not their much independence as possible with
weaknesses. daily activities.
7. Acceptance: In rapidly increasing num-
bers, people of diverse backgrounds and
Neeb’s Not everyone appreciates humor,
lifestyles are approaching the time of life
■ Tip and not everyone finds humor in that may require living in long-term care
the same things.
centers or assisted living communities.
4. Humor: Humor that is appropriate to Those who will be caring for this diverse
the age and condition of the patient will population must be in touch with their
help smooth over some of the harder own thoughts and feelings about work-
times for the nurse and the patient. ing with groups of people and must be
prepared to flex care to meet their needs.
Nurses should take their cues about humor
from the patient. If the patient jokes about a Neeb’s Remember that humans are
situation, it is probably acceptable to go along
with the humor. Never embarrass or make fun ■ Tip much more alike than they are
different.
of the patient. Taking a situation in stride at
the patient’s suggestion, however, can be a
Basic human needs as defined by Maslow
very healthy mechanism for dealing with
and others are important for all groups of
some of the hardships associated with aging.
people. Table 21-2 summarizes some of the
5. Safety: Ensuring safety in the care facility concerns of aging adults and techniques
and teaching safety to the patient who nurses can use to more effectively help this
remains at home are very important. population.
With vision, hearing, and other senses
losing accuracy, it is easier for the older ■ Restorative Nursing
person to misjudge space, sound, and
temperature. This could lead to falls, Restorative nursing is part of rehabilitation
burns, and inability to hear the doorbell and focuses on maintaining dignity and
or the telephone ringing. achieving optimal function for patients and
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346 UNIT 3 | Special Populations

l Table 21-2 Concerns of Aging Adults and Helping Techniques

Factors Associated With This
Concern Concern Helping Techniques
Alzheimer’s • Debilitating effects are observable. Respect for the individual
Disease • Patients may need to leave the Realistic goal setting
and Other home they have lived in all of their Maintaining patience and
Cognitive adult lives; living apart from a understanding
Impairments spouse. Effective communication; allowing
• Socializing will be curtailed. time for the patient to respond
Appropriate use of humor
Teaching and promoting safety
Promoting independence
Cerebrovascular • Physical and cognitive functions See “Alzheimer’s Disease”
Accident (stroke) may be temporarily or permanently Allowing venting of emotions
affected. Assisting with communication
• Depression is evident. techniques
• Aphasia may be present. Allowing patient to verbalize; not
automatically answering for patient
Depression • Symptoms may be different from See “Alzheimer’s Disease”
those in other age groups. Allowing venting of thoughts and
• Constipation; headaches, other feelings
pains, and fatigue may be Teaching about patient’s
indicators. medications
• Difficulty breathing for which Encouraging involvement in group
there is no diagnosis may occur. activities as able
Focus on positives
Medication • Pharmacokinetics is slower and Providing patient with information
Concerns less complete. about medication
• Circulatory and renal function is Instructing patient to notify physician
decreased. immediately if signs of side effects
• It becomes easier for elderly occur
people to experience side effects
or become toxic.
• Patients who live at home may
forget to take medications or
forget they have taken them and
take another dose.
• Visual acuity is lessened; patients
may mistake one pill for another.
• Nurse should advise patient to
maintain weight, nutrition, and
activity levels.
Paranoid • Fear about the environment Allowing venting of feelings
Thinking • Slowed reaction time and Not reinforcing the paranoid thoughts
diminished physical capacity Speaking in terms of the “here and now”
• Feelings of loneliness and isolation Provide aids for hearing and vision loss
Insomnia • Depression, fear, pain, urinary Discussing underlying feelings
incontinence, napping during the Teaching relaxation methods
day are common. Encouraging patient to seek
• Decreased REM sleep can medical evaluation
contribute to psychotic behavior; Discourage daytime napping
insomnia can intensify the Keep sleep diary
symptoms of cognitive disorders.
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CHAPTER 21 | Aging Population 347

in residents’ condition that cannot be proven

to be medically unavoidable are not allowed.
Including restorative nursing care in a patient’s
care plan can prevent declines in condition
that occur gradually, over time, such as loss of
mobility, contractures, and loss of self-care
ability. Restorative nursing is to be provided
to any resident, regardless of his or her cogni-
tive ability: The resident with dementia and
the transitional care resident recuperating
from knee surgery are equally in need of
restorative nursing services.

■ Palliative Care
Palliative care is specialized care for people
with serious illness that focuses on address-
ing management of uncomfortable symp-
toms and the stress of advanced illness. It is
about keeping patients and families comfort-
able and promoting the best quality of life
Figure 21-6 Restorative nursing is concerned
with providing individualized restorative ex-
that one can provide to someone facing an
ercise to help patients achieve maximum advanced illness. It is often associated with
function and maintain their dignity. the last phase of life but it can begin earlier
in the course of serious illness. Hospice is a
specialized aspect of palliative care. Hospice
residents (Fig. 21-6). Some articles refer to care is specialized services for a patient with
restorative nursing as “good, old-fashioned a terminal illness with less than 6 months to
nursing care”—arguably a subjective state- live. In addition to working with grief and
ment, and likely related to the professional bereavement with the patient and significant
age of the writer. Goals include indepen- persons in that patient’s life, nurses choosing
dence, promoting self-esteem for the patient, to work in a palliative setting will need to
and allowing the patient to maintain as much be comfortable with issues such as pain,
control over his or her life and daily living symptom management, sedation and opioid
activities as possible. medication, artificial nutrition and hydra-
Most skilled nursing facilities are required tion, assisted suicide, and coordinating or
to provide at least one designated nursing as- providing complementary therapies. In ad-
sistant and nurse who are specially trained dition, nurses will need to sharpen their
and part of the “restorative” team. They work communication skills and be very cognizant
in conjunction with physical therapy and re- of religious, cultural, ethical, and legal issues,
habilitation departments to provide individ- especially surrounding an individual’s wishes
ualized restorative exercise and training to and advance care planning as the end of life
assist residents to achieve their maximum approaches.
ability. It is widely documented that the preferred
Restorative nursing is also part of a long- place of death of a patient is in his or her own
term care facility’s documentation and reim- home. Sometimes that is not possible. Because
bursement requirements. State and federal of that, many long-term care facilities are
surveys grade the facility on its restorative pro- designing special units dedicated for pallia-
gram. OBRA long-term care laws require that tive care. Organizations such as The Center to
residents either maintain or improve their Advance Palliative Care are attempting to show
condition at the time of admission. Declines the need for hospital-based and out-patient
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348 UNIT 3 | Special Populations

palliative care, as well. Palliative care can be ■■■ Key Concepts

provided in the acute hospital, long-term care
facilities, and in the home. 1. The concept of old age is changing.
Nurses are receiving special training and People are living longer and better after
certification in this new specialty area. The age 65. Older patients are being cared for
good news is that LPN/LVN nurses are in facilities and in their homes. Diversity
more than welcome into the fold. To en- among aging persons is on the rise. Nurses
courage LPN/LVN nurses to participate in must be prepared to flex the care required
palliative nursing, the Hospice and Pallia- to provide the best care possible to many
tive Nurses Association (HPNA) has devel- different groups of elders. Nurses have an
oped a set of competencies that can be active part in helping the patient maintain
purchased online (see the Web sites list at a good quality of life.
end of this chapter). Certification as a hos- 2. Normal conditions of aging include
pice and palliative nurse (CHPLN) is also diminished hearing, vision, and other
available. sensory acuity. Alzheimer’s disease and
other cognitive disorders are not consid-
ered a part of normal aging.
Tool Box | Palliative Training Tools
http://www.capc.org/ 3. Afflictions affecting the older adult can
be mental or physical, or a combination
of these. Medication side effects and
drug toxicity can share the same symp-
toms as disorders that affect the elderly
Tool Box |Information on certification for population. Accuracy of observation,
LPN/LVNs in hospice and palliative nursing is
documentation, and prompt reporting
available at:
www.nbchpn.org are crucial to a nurse’s responsibility in
HPNA has a position statement on the value caring for elderly people. Excellent
of the LVN/LPN in hospice and palliative communication skills are necessary.
nursing, which is available at 4. Palliative care and hospice provide spe-
http://hpna.org/D isplayP age.aspx ? Title= cialized care for people facing advanced
P osition Statements
and terminal illnesses.

CASE STUDY
Mr. Jacobs is admitted as a new resident in CHF and has an order for acetaminophen
your nursing home. He is 76 years old and with hydrocodone for pain.
has a diagnosis of congestive heart failure Five days later, Mr. Jacobs has had a
(CHF). He has fallen at home several times change in mood. His family comes to visit
recently, and his adult children are con- and finds that he is combative and forget-
cerned that he will become seriously in- ful. One of his children is crying. She looks
jured. They have told him he needs to “go at you and says, “What have you done to
there for a while until you get stronger.” him? He’s never been like this before.”
They tell the staff, confidentially, that they What thoughts cross your mind? How do
plan this to be a permanent placement and you respond to the personal attack? How
will be selling Mr. Jacobs’s home to pay for will you attempt to resolve this situation?
his care. Mr. Jacobs will be started on How would you like to be treated if you
digoxin, furosemide, and potassium for the were the family member?
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CHAPTER 21 | Aging Population 349

REFERENCES Townsend, M.C. (2012) Psychiatric and Mental

Health Nursing. Philadelphia: F.A. Davis
Administration on Aging (2011). A profile of
U.S. Social Security Administration. (2012). Retire-
Older Americans 2011. Retrieved at http://
ment planner; full retirement age. Retrieved from
www.aoa.gov/Aging_Statistics/Profile/2011/
http://www.ssa.gov/retire2/retirechart.htm
4.aspx
World Health Organization. (2011). Interna-
Barry, P. D. (2002). Mental Health and Mental
tional Life Expectancy List. Retrieved at
Illness. 7th ed. Philadelphia: JB Lippincott.
http://en.wikipedia.org/wiki/List_of_
Ferrell, B. R., and Coyle, N. (2010). Textbook
countries_by_life_expectancy
of Palliative Nursing. New York: Oxford
University Press.
Furman, J. (2005, May 10). The impact of the WEBSITES
president’s proposal on social security solvency Center to Advance Palliative Care
and the budget. Retrieved from http://www. http://www.capc.org
cbpp.org/cms/?fa=view&id=261 International Association for Hospice and
Green, C. D. (2000, August). Classics in the Palliative Care
history of psychology. Retrieved from http:// www.hospicecare.com
psychclassics.yorku.ca/Maslow/motivation.htm National Hospice and Palliative Care
Kaplan, B. J. (November 2002). Gay Elders Face Organization
Uncomfortable Realities in LTC. Caring http://www.nhpco.org/
for the Ages (American Medical Directors Hospice and Palliative Nurses Association
Association), Vol. 3, No. 11. http://hpna.org
Kessler, D. (n.d.). The five stages of grief—Elisabeth National Advisory Council on Aging
Kübler-Ross & David Kessler. Retrieved from http://www.nia.nih.gov/about/naca
http://grief.com/the-five-stages-of-grief/ Minnesota Board of Aging
Koffman, J., and Higginson, I. J. (2004). Dying www.mnaging.org/Alzheimer’s Association
to Be Home? Preferred location of death of http://www.alz.org/alzheimers_disease_what_is_
first-generation Black Caribbean and native- alzheimers.asp
born White patients in the United Kingdom. Restorative Nursing
Journal of Palliative Medicine, 7(5):, 628–636. www.restorativenursing.com
Kübler-Ross, E. (1969). On Death and Dying. Elisabeth Kübler-Ross Foundation
New York: Touchstone. http://www.ekrfoundation.org/
National Institute of Mental Health (2012). National Institute on Aging
Suicide in the U.S.: Statistics and Prevention http://www.nia.nih.gov/
(NIH Publication No. 06-4594). Retrieved National Board for Certification of Hospice
from http://www.nimh.nih.gov/health/ and Palliative Care Nurses
publications/suicide-in-the-us-statistics- http://www.nbchpn.org
and-prevention/index.shtml
Minnesota Board on Aging. (November 2002).
Spotlight on Aging: A Newsletter for Seniors
and Their Families. St. Paul.
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Test Questions
Multiple Choice Questions
1. One effective communication technique 5. “Losses” that are associated with the
for assisting a patient with aphasia is: process of aging frequently cause:
a. Try to guess the word or finish the a. Presbycusis
sentence. b. Depression
b. Associate the word with the object. c. Dementia
c. Tell the patient to think about it while d. CHF
you make the bed. 6. When an older patient begins to show
d. None of the above. signs of dementia, physicians and nurses
2. According to OBRA, who is responsible should assess all of the following except:
for completing the assessment of an older a. Medication routines
adult? b. Nutritional intake
a. All health staff c. Circulatory function
b. Nursing assistants d. Behaviors assumed to be part of “normal
c. LPN/LVN aging”
d. RN 7. The speech impairment that affects many
3. Mrs. Brown, who is usually alert and people who have had a stroke is called:
oriented, is showing signs of confusion. a. Affect
Her vital signs are all within normal b. Aphasia
limits. She has recently been started on c. Autism
furosemide for congestive heart failure. d. Ageism
The nurse suspects: 8. Nurses understand that one of the rea-
a. Just normal aging sons that older people become toxic from
b. Stroke their prescription medications is:
c. Medication side effect a. Drugs are metabolized faster in older
d. Depression people.
4. A 73-year-old patient in your long-term b. Drugs are metabolized slower in older
care center has become withdrawn and people.
cranky. You try to find a method to initi- c. Drugs are ineffective in older people.
ate communication and activity with the d. Drugs need to be ordered in stronger
patient. Which of the following state- doses for older people.
ments is the best choice to try communi- 9. Your patient is admitted with bruises on
cating with your patient? his head and upper arms. His son is with
a. “Why are you staying over here by him and jokes about the bruises, stating,
yourself?” “Dad is getting so clumsy. He falls out of
b. “Your daughter wants you to make his wheelchair a lot.” You glance at the
friends here.” patient, who says nothing, is looking
c. “I need a partner for the card game; I’d down, and is avoiding eye contact. You
like to have you be my partner.” become alert for the possibility of:
d. “The doctor said the more you do, the a. Blood dyscrasias
better off you’ll be.” b. Vitamin deficiency
c. Elder abuse
d. Self-inflicted wounds
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CHAPTER 21 | Aging Population 351

Test Questions cont.

10. The federal law that mandates special 12. In the orientation class mentioned
care and assessment skills for the older above, you notice one of the housekeep-
population is called: ers crying. She shares with the group
a. OBE that her grandmother has “old timer’s or
b. OPRAH something and she doesn’t remember me
c. COBRA anymore.” You respond to her:
d. OBRA a. “It must be difficult for you to see
11. When orienting new nursing assistants your grandmother with Alzheimer’s
and other staff to your long-term care disease.”
facility, you remind them: b. “It’s called Alzheimer’s disease. Many
a. Memory loss is a normal part of of our residents have that illness.”
aging. c. “How old is your grandmother?”
b. Memory loss is not a normal part of d. “Who else has a relative with
aging. Alzheimer’s?”
c. Stress decreases as people age.
d. All of the above
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C HA PT E R 22
Victims of Abuse
and Violence
Learning Objectives Key Terms
1. Define abuse. • Abuser
2. Define victim. • Child abuse
3. Differentiate among different kinds of abuse. • Date rape
4. Identify characteristics of an abuser. • Domestic violence
5. Identify nursing care to help survivors of abuse. • Economic abuse
• Elder abuse
• Emotional abuse
• Incest
• Neglect
• Physical abuse
• Rape
• Respite care
• Safe house
• Sexual abuse
• Sexual harassment
• Shaken baby syndrome
• Survivor
• Verbal abuse
• Victim

A
buse and violence are unfortunately Physical abuse includes any action that
commonplace in today’s society. The causes physical harm to another person. Hit-
news, television dramas, and movies ting; burning; withholding food, water, and
expose people to more violence than they did other basic needs; and other activities that go
in the past. Violence in the workplace, road beyond accidental contact are all considered
rage, and school violence are commonplace. physical abuse. A rule of thumb for defining
Violence in the home is on the increase. Child the line between an accident and physical
abuse, domestic violence, and elder abuse are abuse is when the recipient says, “Stop. You’re
examples of family violence that take a terrible hurting me,” or something similar. If the ac-
toll on society. All of these have tremendous tivity stops and does not repeat itself, that be-
negative effects. More than 50% of Americans havior may well have been just an accident. If
have experienced violence in the family the behavior persists, if the request to stop is
(Carson & Smith DiJulio, 2006). Abuse can ignored or mocked by the perpetrator, or if
take the form of physical, emotional, sexual, the activity is repeated in future situations,
and economic abuse, as well as neglect. there is a strong chance that the perpetrator

353
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354 UNIT 3 | Special Populations

is guilty of abuse. Neglect can include failure are learned behaviors. Children who
to provide for the basic needs of someone grow up witnessing violence in the home
who is dependent on the caregiver, e.g. a child, and perhaps their community are sensi-
elderly parent. Emotional abuse can include tized to believe that this is the right be-
verbal abuse, humiliation, excessive criticism, havior, and they will very likely continue
and lack of emotional support. Sexual abuse such actions into adulthood. Abusers
can include rape as well as any inappropriate retreat to these childhood memories and
sexual contact without consent. resort to abuse when they are stressed.
Victims are often too fearful or ashamed They may never have developed skills
to report abuse, become adept at hiding the to solve problems or deal with conflict.
signs, and/or use massive denial to convince Rather, they learned that violence is the
themselves that the abuse is not that bad. way to achieve a goal.
This contributes to the abuse cycle, which • Low self-esteem/need for power: Abusers
can go unnoticed by outsiders. Health-care often have a poor self-image. They feel
professionals must be vigilant to recognize frustrated and minimized as persons. They
the overt and covert signs of abuse. Every have poor interpersonal relationships and
state mandates that suspected child abuse may not have had their ideas and accom-
be reported, and many states are enacting plishments validated by people important
similar laws for domestic violence and elder to them. Close relationships are difficult
abuse. The Joint Commission expects the because others become afraid of the
accredited institutions to provide assessment abuser. Therefore, they resort to physical,
of potential victims of abuse. Nurses are in verbal, or emotional abuse of others in
a key position to identify and offer help to a an attempt to bring a personal sense of
potential victim. power and importance to themselves.
Sexual abuse is almost always not about
■ The Abuser sex; it is about conquering and winning. It
is about demeaning another human being
The abuser is usually in a position of domi- in order to feel a sense of strength. It is a
nance or power over a potential victim. The short-term “fix” for the abuser and
following may cause a person to abuse another: a lifelong scar for the abused. The abuser
may also be isolated and lack a support
• History of being a victim: “Violence
system in dealing with stress.
begets violence. People—especially
• Impairment from alcohol/substance use:
children—tend to imitate what they see”
Committing abusive acts while under
(Rubin, Peplau, and Salovey, 1993). That
the influence of a substance is a major
statement remains the belief of researchers
contributor to violence. When a person’s
today. It is accepted that (except in rare
judgment is impaired and his/her ability
situations with a genetic or biological con-
to control impulses is altered, a person
nection) violence, aggression, and abuse
who is prone to these acts may abuse
others. Easy access to weapons while
impaired adds to the risk associated
Cultural Considerations with substance abuse.
Abuse crosses all cultures, ethnic, and • Biological theories: Brain disorders,
socioeconomic groups. At times some be- alteration in brain function, and genetic
haviors may appear abusive to us but are influences may also be factors in indi-
culturally appropriate. For example, there viduals with a greater tendency toward
can be man’s expectation of a wife’s sub- violence.
servience in some cultures. This needs to • Other factors: The abuser may also be
be taken into consideration before assum- under stress (e.g., poverty) and have
ing she is being abused. limited access to support resources to
deal with problems, limited coping
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CHAPTER 22 | Victims of Abuse and Violence 355

mechanisms to deal with conflict, and they think and feel, or to speak out for
difficulty trusting others. what they need and want, may not be
able to call up the strength they need to
How can an abuser be identified? Abusers
ward off an attack. They may be easily
may present with some of the following traits
manipulated by the abuser into believing
in connection with a victim:
either that they deserved the attack or
• Inconsistent explanation of injuries of the that the abuser is truly repentant and will
victim not abuse again. They will begin to make
• Failure to show empathy for the victim up reasons to excuse the abuser’s behav-
• Demand to take victim home and refusal ior and may accept the responsibility for
of hospitalization for the injured victim the abuser’s actions.
• Speaks for the victim 2. Reliance on the abuser: People who are re-
• Criticizes the victim liant on the abuser for financial support
• Abuses family pets as well as emotional and physical support
are vulnerable to attacks from the abuser.
Neeb’s Because abuse in a family is often This holds true for all age groups of peo-
■ Tip hidden, recognize that it can be ple who are abused.
difficult to identify an abuser.
See Table 22-1 for characteristics of vic-
tims of child abuse, domestic violence, and
■ The Victim elder abuse. Health-care professionals often
see victims of abuse without realizing it.
Though victims of abuse have a broad range
Patients who are abused may be fearful of
of traits, the two most common include:
sharing this information but may leave
1. Low self-esteem: People who have not clues. Box 22-1 lists common warning signs
learned to be assertive and to say what of abuse.

l Table 22-1 Characteristics of Victims of Abuse

Type of Victim Characteristics
Child; all ages, with greatest • Self-blame for family conflict
risk under age 4 (including • Low self-esteem
infants) and for fatalities • Fear of parent or caretaker
under 2 years of age • Cheating, lying, low achievement in school
• Signs of depression, helplessness
• One child sometimes singled out in family due to being
labeled as “difficult,” product of unwanted pregnancy,
reminds the parents of someone they dislike or even
themselves, prematurity (inhibited parent-child bonding),
chronic illness
Domestic/spouse/intimate • Low self-esteem
partner • Self-blame for partner’s actions
• Sense of helplessness to escape abuse
• Isolation from family and friends
• Views self as subservient to partner
• Economic dependence on abuser
Elder • Older than 75 years of age
• Mentally or physically impaired
• Isolated from others
• Female
Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.
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356 UNIT 3 | Special Populations

l Box 22-1 Common Warning Signs of Abuse

• Delay in seeking treatment for injuries, minimizing injuries
• History of being accident prone
• Pattern of injuries not accidental looking; for example, identical burns on bottom of feet, identi-
cal injuries on both sides of head
• Multiple injuries in varying stages of healing
• Conflicting stories from victim and abuser about cause of injury
• Inconsistency between history and injury
• Unusual, even bizarre explanation for injuries
• Repeated visits to emergency rooms or clinics
• Previous report of abuse
• Patient reporting abuse
• Patient fearful of caregiver or partner
• Visits variety of doctors, emergency rooms for treatment to avoid a record of treatment
Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with
permission.

■■■ Clinical Activity birth to 2 years have the highest death rate. Re-
If your patient has been the victim of abuse, ported cases of child abuse have steadily in-
obtain information from the team on the abuser creased over the last few years, but many cases
and how to handle this person if he or she is are not reported. Children are a most vulnera-
present. ble segment of the population because they de-
pend on others for all their needs. Parents are
the most common abusers (80% of reported
cases). See Box 22-2 for signs of child abuse.
■■■ Classroom Activity
• Ask members of local law enforcement to speak Parents who abuse a child may have unre-
to your class about the types of abuse they see alistic expectations of a child, such as being
in your community and the options for victims able to control crying or following instructions
of abuse. perfectly. Shaken baby syndrome is a form of
• Identify local abuse hotlines and local domestic child abuse that occurs when a caregiver shakes
violence shelters.
a baby in an effort to stop crying, which con-
tributes to infant deaths each year (Center for
Disease Control and Prevention, 2010). Some-
■ Categories of Abuse times a child with special needs or emotional
problems is singled out for abuse as the parents’
The most common categories of abuse include frustration tolerance is more severely tested.
child abuse, sexual abuse, domestic violence
(spousal abuse), and elder abuse.
l Box 22-2 Signs of Child Abuse
Child Abuse
Child exhibits some of the following:
Child abuse includes physical, emotional, and
sexual abuse, as well as neglect. It occurs at • Fear of returning home
all socioeconomic levels. The U.S. Children’s • Antisocial behavior, such as lying or stealing
• Fear and anxiety when asked about injuries
Bureau tracks reports of child abuse nation- • Going to lengths to hide injuries
wide and reported that 9.1 per 1000 children • Lack of reaction to frightening event
were reported as abused or neglected in 2011. • Unexplained, unusual injuries
Abuse includes neglect (75% reported cases), • Changes in behavior, school performance
physical abuse (15% of reported cases), and • Neglect—malnutrition, lack of medical care
sexual abuse (10% of reported cases). The
Source: Adapted from Gorman and Sultan (2008). Psychosocial
youngest children (birth to 1 year) have the Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis
highest rates of victimization and those from Company, with permission.
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CHAPTER 22 | Victims of Abuse and Violence 357

though the child may hate the abusive situa-

tion, he or she never gets an opportunity to
observe healthy parenting or to learn adaptive
coping mechanisms to deal with frustration
without violence. Other long-term effects
of being a victim of child abuse include low
self-esteem, high risk for substance abuse, ten-
dency toward depression, difficulty trusting
in close relationships, and violent lifestyle in-
cluding crime. Incarcerated youths frequently
have a history of being abused and neglected.

■■■ Critical Thinking Question

A 4-year-old child with autism is admitted to your
unit from the ER with burns on both hands and
bruises on one arm. The child’s parents are at the
bedside and very concerned. They have told the
doctors that the child reached up and put her
hands in a pot of hot water on the stove. How
would you react to these parents? Describe factors
Figure 22-1Maybe it’s not your child who that might indicate this could be child abuse.
needs a time out.

Each year, newborns are abandoned or

even killed when new mothers panic. Many Tool Box | National Child Abuse Hotline:
states have passed laws for safe surrender 800 4 A Child
sites of newborns if a mother is unable to
keep her child. Rather than abandoning an
infant through neglect, mothers can leave Sexual Abuse
the infant at community locations that often
include hospitals and fire stations. Many Sexual abuse is violent or nonviolent sexual
at-risk teenagers who might be pregnant are contact or sexual activity that is not wanted
often not aware of this law, so community by the receiver. It is generally inflicted on
education that reaches teens in their com- someone the abuser considers less powerful
munities must be provided to prevent ne- physically or emotionally. The abuser is usu-
glect, abandonment, and often death of ally a close, significant figure in the abused
these infants. person’s life and knows how to manipulate
the potential victim into submission. It can
Neeb’s It is important to know the law in involve unwanted advances, inappropriate
■ Tip your state regarding safe surrender sexual contact, sexual harassment, and rape.
sites. This information must be dis- Girls are the most frequent victims of
seminated to pregnant teens and childhood sexual abuse. Eighty percent of sex-
other women. ually abused children know their abuser, and
about 50% of cases involve a parent or care-
An early sign of child abuse in the victim giver (Mulryan, Cathers, & Fagin, 2000).
can be changes in behavior and school per- Long-term effects of sexual abuse include fear
formance. Another sign can be abuse of fam- of intimacy, sexual problems, eating disorders,
ily pets by the child. Children may try to deal and an overwhelming sense of powerlessness.
with the situation by controlling another Children may feel threatened, be confused
being or seeking an outlet for their anger about their feelings, and question if this ac-
through a more vulnerable victim. tivity is right. The abuser is usually a trusted
Victims of child abuse are at an increased person initially to the child, which adds to the
risk of becoming abusers as adults. Even confusion. Children do not always have the
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358 UNIT 3 | Special Populations

words to express what is happening to them. ■■■ Critical Thinking Question

They may also be so fearful that they say The nurse from the local grammar school calls
nothing. They may fear other family members your clinic asking for help. She tells you a parent
will be hurt if they speak up. Victims may of a 6-year-old has accused the teacher of sexually
block out the memory of these incidents until molesting her child. The nurse does not know
what to do. What would be your first action?
later in life, when a major event or trauma
triggers memory recall. Exploiting children in
pornography has been increasing with access
to the Internet and is another facet of sexual Domestic Violence
abuse. Signs of sexual abuse in children could
include frequent urinary tract infections; Domestic violence takes many forms, in-
torn, bloody underclothing; and sudden cluding physical, emotional, sexual, and
onset of sexually related behavior in addition economic abuse. Domestic violence is also
to other signs of child abuse as listed above. called spousal or intimate partner abuse or
Incest is defined as sexual activity between violence. One in every four women will
persons so closely related that they are forbid- experience domestic violence in her lifetime
den by law to marry. The most frequent occur- (CDC, 2010). Domestic violence can in-
rence of incest is in girls under 18, although volve physical injury, use of intimidation,
it can happen to persons of any age group denigration, and control, which can include
(National Center for Victims of Violent restricting access to family finances.
Crimes, 2012). Though most often domestic abuse in-
Rape is forcible, degrading, nonconsensual volves women, men can also be victims.
sexual intercourse accompanied by violence They may be less prone to report it out of
and intimidation. It often goes unreported. embarrassment, so the frequency of this is
When a victim does seek medical care, most less known.
hospital emergency rooms and urgent care This type of abuse often incorporates the
centers have rape kits to assist in proper col- children. For example, an abusive domestic
lection of evidence such as sperm, hair, and partner might say, “If you go out with your
other fibers that may be compared with others friends tonight, I’ll see to it that your kids are
to identify a suspect. It is important that the taken away; you’re unfit to be their mother
person who was raped not clean up before (father) if you go out at night and leave
going to the emergency department. Although them. You do not deserve them!” Or “Leave,
evidence must be kept intact, one of the and when you get back the kids and I will be
victim’s first instincts is to “wash away” the gone and you won’t see them again!” The
incident both physically and psychologically children are used as a way to control and in-
by showering. Nurses should discourage that timidate. This type of button pushing is very
activity until evidence and DNA sources effective at negatively controlling someone’s
can be collected. Date rape (also known as behavior out of fear of the consequences.
acquaintance rape) most frequently occurs Abusers also use the family pet as a means to
among teens and young adults. control; for example, “I will kill the dog if
An alarming reality in the United States is you leave me.”
that rape happens to elderly people. That Pediatricians and veterinarians receive
population is often assaulted in their private training on identifying signs of domestic
residences and in long-term care and assisted violence since they may observe clues of a
living facilities. troubled family. In a 2001 study of women
visiting a pediatric clinic, researchers found
that more than 16%, or 553 mothers, had
■■■ Clinical Activity been physically abused at some point in their
Ensure that appropriate tests are completed as
part of the workup for victim of sexual abuse (e.g., lifetime. The researchers strongly encourage
screening for STIs or sexually transmitted infections, screening for domestic violence as part of the
pregnancy test, HIV test). office intake protocol (Parkinson, Adams, &
Emerling, 2001).
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CHAPTER 22 | Victims of Abuse and Violence 359

The abuse cycle in domestic violence has • Lack of support; does not know where to
been shown to follow a pattern that was go if he/she left abuser
originally identified by Walker in 1979. • Religious beliefs; will not consider divorce
• Denial; thinks of the good times and
1. Tension-building: The recipient of the
hopes that things can improve so there
abuse is compliant, believing that in
can be good times again
some way he or she is at fault and
deserves the abuse. These individuals
remain accepting and continue to be Neeb’s Because it is common that a woman
supportive even though they know the ■ Tip may return to a domestic violence
situation, staff need to understand
behavior is inappropriate. The victim
they cannot push a patient to leave
is probably using denial as a defense
the abuser. It has to come from the
mechanism. The perpetrator is using
victim. It may take multiple episodes
verbal abuse and minor beating, and
before the patient is able to leave.
also is aware that the behavior is not
appropriate. In assessing for domestic violence, some
2. Acute battering incident: The victim signs that a patient might be a victim include:
senses that the beating is coming and injuries while pregnant when there is resent-
may even provoke it to get it over with. ment of a pregnancy, wearing clothes and
Some triggering event occurs, which makeup to cover up injuries, lack of care for
may be something minor like a miscom- own chronic illnesses, social isolation, use of
munication or dropping a dish. The vic- alcohol or drugs to cover hurt, acting guilty
tim may try to hide and will probably for seeking medical treatment, and history
not seek help until the next day, if at all. of rape. Sutherland, Fantasia, Fontenot, and
The police may be called, but by the time Harris (2012) recommend the following
they arrive, the victim may have already questions be incorporated in screening for
forgiven the perpetrator. This kind of intimate partner violence.
physical abuse usually happens in
private. 1. Have you ever been abused or threatened
3. Honeymoon: The perpetrator is contrite, by your partner?
loving, and very sad about the incident 2. In the past year, have you been physically
of abuse that has occurred. He or she hurt by someone?
may well try to make amends with gifts. 3. Have you ever been forced to have sex?
The abuser promises to get help but only
after discussing how the abuse has taught Tool Box | National Domestic Violence
the other a lesson, such as “Don’t make Hotline: 1_800_799_SAFE(7233)
me mad!” The victim wants desperately
to believe this, will forgive the perpetra-
tor, and will begin to think that the rela-
■■■ Critical Thinking Question
tionship will return to “normal.” The Your pregnant patient has been admitted with a
victim is still very much in love with the broken ankle from a fall. When you walk into the
perpetrator and believes this love will room, the woman is crying on the phone telling
conquer all and the abuse will stop. someone she is sorry and it will not happen again.
What would be your first action in response to
This cycle of domestic violence leads to the hearing this?
often-asked question: Why does a victim of
domestic violence stay in the relationship?
Some of the most common reasons for stay- Elder Abuse
ing include:
Elder abuse includes neglect as well as physi-
• Fear of retaliation for self or children cal, sexual, and emotional abuse. Exploitation
• Fear of loss of custody of children of the person’s financial reserves by family,
• Dependent financially on the abuser hired help, or strangers is economic abuse
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360 UNIT 3 | Special Populations

(sometimes called fiduciary abuse). Elder Caregivers of dementia patients should be

abuse can occur in the home or in residential counseled about dealing with the stress of
facilities. Elder abuse affects 10% of the geri- this role. They need to be given resources for
atric population. (National Center on Elder support and respite care. Local programs
Abuse, 2013; Gray-Vickrey, 2000). This prob- such as through the Alzheimer’s Association
lem is greatly underreported and will continue or local senior centers may offer support
to increase as the population grows older. groups and caregiver resources to help pre-
One problem in reporting it is the incon- vent elder abuse.
sistency of laws defining elder abuse. Some Specific examples of elder abuse can
states do not include neglect, psychological include:
abuse in their definition, so it is essential
• Hitting
for nurses to be aware of how elder abuse is
• Shoving
defined in the state where they are working
• Social isolation
or reside. Because the abuser is often the
• Leaving in soiled linens
victim’s caregiver, even including the elderly
• Withholding food/water
spouse, victims rarely report the abuse. They
• Inappropriate restraints
fear reprisals or abandonment because they
• Threats
are dependent on the caregiver. Society’s lack
• Being forced to sign over financial affairs,
of interest in elderly people may add to the
change a will
underreporting.
• Sexual molestation
Caring for a loved one with a cognitive
• Insulting
impairment increases a caregiver’s risk for
engaging in abusive behaviors (VandeWeerd, See Box 22-3 for the characteristics of
Paveza, & Fulmer, 2005). Caregivers with no victims and abusers in elder abuse.
history of being an abuser can reach a point
of frustration and fatigue that leads to behav-
iors they would normally find unacceptable,
such as slapping or degrading their loved one.
Elder abuse can also be difficult to detect by
professionals because common signs such as
bruising and skin tears may be common in
older populations. The patient with dementia
is particularly vulnerable because he or she is
unable to speak up or will not be believed be-
cause of his or her intermittent confusion.
Neeb’s Economic or fiduciary abuse can be
■ Tip evidenced when a patient gives
hired caregivers liberal access to
personal financial information. It is
important to determine that the
patient is doing this voluntarily and
is competent to make reasonable
decisions.

Tool Box | Fifteen Questions and Answers

About Elder Abuse at:
http://www.nlm.nih.gov/medlineplus/
elderabuse.html Figure 22-2 Could she be a victim of elder
abuse?
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CHAPTER 22 | Victims of Abuse and Violence 361

l Box 22-3 Characteristics of Victims and Abusers in Elder Abuse

Victim
• Evidence of malnutrition, dehydration, poor hygiene, pressure ulcers, not receiving needed
medical care
• Unusual injuries such as twisting fractures, cigarette burns on face or back, perforated eardrums
from being slapped
• Evidence of sexually transmitted infections, unusual genital injuries
• Deterioration in mental status including confusion and depression
• Sudden lack of funds in person who previously had resources
• Frail, dependent, possible mental impairment requiring care from family member or hired help
• Extreme dependency, attachment to new caregiver
• Evidence of inappropriate use of restraints
Abuser
• Often lives with victim, lacks resources to live elsewhere
• Refusal to allow diagnostic tests, hospitalization
• Often much younger than patient
• Cashes victim’s social security or pension checks
• Sudden, intense involvement with patient with little input from other family members
• Discourages patient from contacting others
• Evidence of drug or alcohol abuse or mental illness
• Expects dependent elder to meet his or her needs
• Caregiver overwhelmed with patient’s care needs, demonstrates frustration and resentment,
isolated with limited assistance
• Elderly spouse with dementia
• Coerces senior to change will to his or her benefit
• Shows no guilt or rationalizes actions
Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with
permission.

■■■ Critical Thinking Question ■ Treatment of Abuse

You are working in home health care. You visit
your 90-year-old patient in her home. The Victims of abuse often require immediate
daughter, who is the caregiver, is not home. The crisis intervention and then long-term
door to the house is unlocked and the patient is
tied in bed with a restraint. You call your super-
psychological help. The immediate crisis
visor, and the daughter walks in as you are on intervention may include getting out of the
the phone. The daughter is frantic and tells you abusive situation.
she had to leave for a while to buy groceries. Some strategies for crisis intervention that
She had no one to watch her mother. What ac- your agency may arrange include: help in
tions should you take? Should this be reported
as elder abuse?
providing a domestic violence shelter, ar-
ranging respite care for an overwhelmed
caregiver of a child or elderly parent, imme-
diate social work referral for options if
■■■ Classroom Activity patient cannot return home, and contacting
• Research the elder abuse laws in your state. law enforcement. Domestic violence shelters
• Identify resources for caregivers of dementia or safe houses are available in major cities
patients in your community.
• Talk to staff at local nursing homes and assisted where women can bring children and even
living centers to find out how they address pets and be protected from the abuser. The
potential elder abuse. locations of these shelters are confidential so
the victim can feel safe. Victims may need
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362 UNIT 3 | Special Populations

advice on how to seek out help without Neeb’s Victims of abuse may seek out drugs
arousing the suspicion of their abuser. For ■ Tip or alcohol to self-medicate feelings
example, victims may have their computers of fear, anxiety, and shame. Sub-
and cell phones tracked by a suspicious stance use may be the initial symp-
abuser. Anyone who is sexually abused may tom that brings the victim to a
need testing for sexually transmitted infec- health-care provider.
tions, HIV, and pregnancy. Children and
teens also need evaluation for substance
abuse if they were exposed to drugs as part
of the abuse. Children exposed to sexual ■ Nursing Care of Victims
abuse need access to specialists in the field. of Abuse
Repression of trauma can lead to a lifetime
of emotional problems, so therapy is very Common nursing diagnoses for the victims
important. Play and art therapy can be im- of abuse include the following:
portant tools for children to communicate
• Anxiety
their feelings.
• Caregiver role strain
Abusers and victims need specialized coun-
• Family coping, disabling
seling programs as well as access to support
• Parenting, impaired
resources such as local and national hotlines.
• Post-trauma response
Ongoing individual and group psychotherapy
• Powerlessness
is often part of the treatment plan for both
• Violence, risk for
as well. Mandated therapy for abusers who
are convicted of crimes may be part of their General Nursing Interventions
rehabilitation. Treatment for abusers can in-
1. Ensure safety: The survivor of abuse
clude resources for parenting skills and anger
will be confused and fearful. The nurse
management.
needs to reassure the patient that every-
thing possible is being done to ensure
his/her safety. Social work involvement
Tool Box | Parents Anonymous is a national is essential. The nurse should obtain a
organization for parents with issues around
list of people who are considered “safe”
child abuse. It is based on the Alcoholics
Anonymous model. by the patient, and ask if the patient
http://P arentsanonymous.org would like those people to be called.
If the patient wishes to press charges,
offer assistance with making the appro-
priate phone calls. Call for assistance
from a physician and counselor if none
■■■ Classroom Activity is in the immediate area. Alert security
• Identify local parenting education programs. staff members according to agency
protocol to prevent the alleged abuser
from causing more harm. Maintain a
calm milieu. If the abuse victim is a
young child or frail elder who cannot
Pharmacology Corner speak for himself or herself, immediate
Victims of abuse may need medications for involvement of the interdisciplinary
anxiety and depression. Both victims and team is essential to determine the next
abusers may have issues around substance steps. Providing a safe, calm, secure en-
abuse. Abusers may need medications to vironment will reassure the patient.
manage substance abuse, control angry im- 2. Know your own thoughts and feelings
pulses, and manage anxiety. about abuse: The nurse is responsible for
helping the patient through this initial
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CHAPTER 22 | Victims of Abuse and Violence 363

horrifying experience. A nurse who has with abuse and violence. Familiarity
been abused or who has been an abuser with these policies and procedures will
may find it difficult to be therapeutic for help save time and convey confidence.
the patient. Nurses should remember The patient may be confused and embar-
that they may be treating the survivor as rassed about the situation. It may well
well as the abuser. Nurses are responsible have taken every bit of courage the per-
to help all patients. Abusers are in need son had just to get to the facility. The
of help as much as the person who is nurse’s smooth handling of the situation
abused. It is worthwhile to mention may provide the extra bit of confidence
that nurses face stressful situations daily. the victim needs to actually go through
Nurses must also be aware of their own with the examination. Collection of
safety and avoid putting themselves in physical evidence, observations, and
a risky situation if a potential abuser screening questions may be part of the
threatens violence to someone reporting nurse’s role in potential abuse cases. In
the abuse. most jurisdictions, with the exception of
persons legally classified as “vulnerable,”
Neeb’s Suspecting someone of abuse can notification of police, taking of pictures,
■ Tip lead to stress for the health-care etc., may only be done with the patient’s
team. It is important to have a team consent.
plan of care when working with a Many hospitals and trauma centers have
potential abuser. One nurse should some sort of abuse-advocacy program. A rep-
not carry all the burden of this diffi- resentative should be contacted immediately
cult situation. Seek out support from to visit the victim. The abuse program repre-
coworkers. sentative will be able to offer support and
provide information on safe houses and other
3. Remain nonjudgmental/show empathy: services that may be available to the victim
This is a crisis situation in many ways. and his or her children.
Recalling communication skills and Nurses who are caring for a survivor of
helping the patient to verbalize any abuse need to be aware of their state’s law
concerns, thoughts, and feelings are regarding children who may have witnessed
crucial. Remaining technically correct the abuse. In some states, a child who sees
in performing any procedures or sample or hears abuse is also considered to have
collections is imperative to avoid con- been abused. Nurses and other health-care
tamination. Maintaining professional- providers are most likely mandated reporters
ism and confidentiality for both the and, as such, find themselves in an ethical
survivor and the abuser is mandatory. bind: They want to help and support the
Calling for help from counselors, patient/survivor; however, they must tell
advocates, or people chosen by the pa- that individual that if a child saw or heard
tients will help maintain a calm milieu. the abuse, the nurse must, as a mandated
Nurses are not expected to condone reporter, report this fact to the child protec-
or accept the action but to respect and tion agency. The patient/survivor may be
help the person, regardless of the situa- forced, in a sense, not to divulge the whole
tion. If a patient who may be a victim situation to the nurse.
wishes to return home with a possible The physician or counselor will discuss
abuser, the nurse can offer support, treatment options with the survivor and the
education, and resources but cannot abuser. Legal counsel may be requested
force a patient into different actions. as well. A law enforcement agency may be
4. Know your agency policy and use your present also. Nurses now can take a more
resources: Every health-care agency has its advocacy-oriented role for the patient. Be
own policies and procedures for dealing supportive.
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364 UNIT 3 | Special Populations

Neeb’s Whenever you suspect abuse, get ■■■ Classroom Activity

■ Tip other staff members involved, includ- • Consider an open discussion with classmates
ing your supervisor, social worker, about their experiences with any kind of abuse.
and physician. Each person can use a diary format to write ex-
periences and feelings to keep private or share
with others if they wish.
See Table 22-2 for a nursing care plan for
a child who may be the victim of abuse.
See Table 22-3 for a review of nursing in-
■■■ Clinical Activity terventions for victims of various types of
Be aware of your emotional reaction when deal- abuse.
ing with patients who are victims of abuse or
abusers.

l Table 22-2 Nursing Care Plan for a Potentially Abused Child

Nursing
Data Collection Diagnosis Goal Interventions Evaluation
Child admitted with Family coping, Keep child • Ensure the • Child remains
broken bones, burns disabling safe and child’s safety safe.
of unclear etiology. provide per agency • Parent ac-
Child abuse by intervention policy as first knowledges
parent is suspected for parent. priority. stressors and
by health-care team. • Establish a agrees to help.
trusting • Safe, appropri-
relationship ate discharge
with child plan is in
and parent. place.
• Monitor parent
interactions
with child.
• Demonstrate
acceptance.
• Explain all
procedures
thoroughly
to child and
parent.
• Encourage
parent to
talk about
stresses.
• Ensure that
appropriate
people are
contacted
regarding
reporting
possible
abuse.
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CHAPTER 22 | Victims of Abuse and Violence 365

l Table 22-3 Nursing Interventions for Victims of Abuse

Type of Abuse Indicators of Abuse Nursing Interventions
Sexual • Violent or nonviolent sexual con- • Carefully use rape kit and preserve
tact or activity that is not wanted evidence.
by the receiver that could include: • Provide safety and privacy.
foreplay, touching, kissing, and • Be nonjudgmental.
mutual masturbation, as well as • Show empathy.
oral sex and intercourse • Be advocate for patient.
• Frequent bladder or vaginal • Maintain calm milieu.
infections • Know own thoughts and feelings
• Bloody underwear regarding abuse and abuser.
• Evidence of “incest”—sexual inter- • Know agency policies.
course between persons so closely • Assist with contacting outside
related that marriage is illegal agencies (e.g., lawyer, clergy), as
• Evidence of rape—forcible, de- requested by patient.
grading, nonconsensual sexual
intercourse accompanied by
violence and intimidation
• “Date rape”—seen frequently in
high school and college students
(belief surrounding date rape is
that the person who pays for the
date is entitled to sex from the
other person)
Physical • Any actions that cause physical • Provide safety.
harm to another, such as: • Be nonjudgmental.
• Hitting • Show empathy and reassurance.
• Burning • Take the time to develop trusting
• Withholding food, water, and relationship.
other basic needs • Be advocate for patient.
• Other activities that go beyond • Maintain calm milieu.
accidental contact • Reinforce self-esteem.
• Request to stop ignored or • Reinforce that victims should not
mocked by the perpetrator blame themselves for the abuse.
• Activity repeating itself in future • Know own thoughts and feelings
situations regarding abuse and abuser.
• Frequent visits to emergency • Know agency policies.
department (for all forms of • Assist with contacting outside
abuse) agencies (e.g., lawyer, clergy),
• Excessive bruising or bruising on as requested by patient.
unusual areas of body • Involve agency social worker.
• Withdrawal from friends and
social groups
Emotional • Willful use of words or actions that • Same as for physical abuse
undermine self-esteem—includes • Counter patient’s self-depreciating
the “silent treatment” (causes the comments.
other person to guess at the • Reinforce positive traits.
problem) and other types of game
playing, name calling, frequent
degrading and harsh and/or cruel
criticism
Continued
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366 UNIT 3 | Special Populations

l Table 22-3 Nursing Interventions for Victims of Abuse—cont’d

Type of Abuse Indicators of Abuse Nursing Interventions
Child Abuse/ • Sexual, physical, and/or emotional • Same as for physical abuse
Neglect abuse—act of commission (doing) • Encourage use of play and art
or omission (not doing) for child to express feelings.
• Victim may believe that abuse is • Provide touch and support if
child’s own fault the child will accept.
• Child confused about what is • If child uncomfortable being
happening and why touched, respect that and
• Abuser often larger, more provide support in other ways.
powerful than the child, which • Accept that child may be
is intimidating mistrustful.
• Excessive absences from school
• Child may display inappropriate
behaviors, e.g., sexual
Domestic • Physical, emotional, sexual, and • Same as for physical abuse
Violence “button-pushing” kinds of abuse • Recognize that victim may
• Most typically reported by women return to abuser initially.
• Kept isolated from friends and family • Help identify possible threats
• Withdrawal from friends and social that victim is facing, e.g., child
groups custody, loss of financial security.
• Use of substance abuse to cover
distress
Elder • Victim is usually dependent on • Same as for physical abuse
abuser in some way • Listen to patient’s concerns and
• May be slapped, burned, tripped, report them even if patient is
neglected, humiliated confused.
• Can include economic abuse where • Provide follow-up in the home.
victim’s funds are misused or stolen

■■■ Key Concepts 4. Nurses must be sensitive to the needs

of the abused person as well as those
1. Abuse takes many forms and is being re- of the abuser. Careful attention to
ported in higher numbers annually. physical assessment, communication,
2. Victims of abuse are often in a vulnerable and emotional support are components
position to their abusers, who may have of nursing care for people who are suf-
the need to exert power and control. fering the effects of abuse.
3. Abuse happens in all age and socioeco- 5. The nurse has a responsibility to know
nomic groups. Men can also be victims, state laws regarding one’s obligation to
though this is believed to be underre- report evidence of child abuse, domestic
ported. The youngest children are the violence, and elder abuse.
most vulnerable to abuse.
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CHAPTER 22 | Victims of Abuse and Violence 367

CASE STUDY
Mrs. Jones leaves your long-term care facil- with skin tears on both arms and bruises
ity for a weekend with her daughter and over her right eye and on her right cheek.
son-in-law. She seems apprehensive but She is crying. Her daughter says, “Doesn’t
tells you, “I just worry that I’m a bother to that look awful? Gram took a tumble from
them.” You bathed her and helped her the toilet. “Gram” says nothing until her
pack, and now you document that she is daughter leaves, then says to you, “I worry
gone until Sunday afternoon and that you about her. Her husband is a nice man, but
are concerned about her apprehension. You he gets so mad at us sometimes. I really
note no other physical or mental abnor- can’t blame him; he has a lot on his mind,
malities. Sunday afternoon, she returns and I can’t give them any more money.”

1. What are your responsibilities according to your facility? According to the state? Accord-
ing to your personal belief system?
2. How would you proceed?

REFERENCES Tjaden, P., & Thoennes, N. (2000). National In-

stitute of Justice and the Centers for Disease
Carson, V. B., & Smith-Dijulio, K. (2006). Family
Control and Prevention. “Extent, Nature and
violence. In E. M. Varcarolis, V. B. Carson,
Consequences of Intimate Partner Violence:
& N. C. Shoemaker (Eds.). Foundations of
Findings from the National Violence Against
Psychiatric Mental Health Nursing. 5th ed.,
Women Survey.”
p. 512. Philadelphia: Saunders.
U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention.
Administration for Children and Families, Ad-
(2010). Preventing Shaken Baby Syndrome.
ministration on Children, Youth and Families,
Retrieved from www.cdc.gov/Concussion/
Children’s Bureau. (2012). Child Maltreatment
pdf/Preventing_SBS_508-a.pdf
2011. Available from http://www.acf.hhs.gov/
Centers for Disease Control and Prevention.
programs/cb/research-data-technology/
(2010). National Intimate Partner and Sexual
statistics-research/child-maltreatment
Violence Survey. Retrieved from http://
Vandeweerd, C., Paveza, G.J., & Gulmer, T.
www.cdc.gov/violenceprevention/pdf/cdc_
(2005). Abuse and neglect in older adults
nisvs_overview_insert_final-a.pdf
with Alzheimer’s disease. Nursing Clinics of
Gray-Vickery, P. (2000). Combating abuse, Part 1:
North America, 41, 43–56. Vandeweerd
Protecting the older adult. Nursing 30, 34–38.
Walker, L. (1979). The battered woman. New
The Joint Commission retrieved at http://www.
York: Harper & Row.
jointcommission.org/
Mulryan, K., Cathers P., & Fagin, A. (2000).
Combating abuse part II: Protecting the WEB SITES
child. Nursing, 30, 39–45. National Center for Victims of Crimes
National Center on Elder Abuse. (2013). Ncvc.org
Retrieved from http://www.ncea.aoa.gov/ National Center on Elder Abuse
Library?Data/index.aspx http://www.Ncea.aoa.gov
National Center for Victims of Violent Crimes. U.S. National Library of Medicine infor-
Retrieved from www.ncvc.org mation on elder abuse
Parkinson, G.W., Adams, R.C., & Emerling, http://www.nlm.nih.gov/medlineplus/elderabuse.html
F.G. (2001). Maternal domestic violence The National Domestic Violence Hotline
screening in an office-based pediatric practice. http://www.thehotline.org/
Pediatrics 108(3):E43. Child Welfare Information Gateway
Rubin, Z., Peplau, H., & Salovey, P. (1993). https://www.childwelfare.gov/preventing/
Psychology. Boston: Houghton-Mifflin. Safe Surrender Sites information
Sutherland, M. A., Fantasia, H. C., Fontenot, H., https://www.childwelfare.gov/systemwide/laws_
& Harris, A. L. (2012). Safer sex and partner policies/statutes/safehaven.cfm
violence in a sample of women. Journal for
Nurse Practitioners, 8, 717–24.
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368 UNIT 3 | Special Populations

Test Questions
Multiple Choice Questions
1. When caring for someone who has been 5. A 38-year-old female presents to urgent
abused, the nurse can be therapeutic by: care. She has a 3-year-old and a 4-year-old
a. Showing empathy child with her. She is frightened and badly
b. Ensuring safety bruised. “He’ll kill us all if he knows we
c. Contacting counselors and advocates came here,” she screams. You:
d. All of the above a. Ask her to please not scream—she is
2. Which of the following is the best ap- alarming the other patients.
proach when caring for a rape victim? b. Ask, “Who will kill you?”
a. Ask why it happened. c. Bring her and her children to a room
b. Document the information in the immediately.
patient’s own words. d. Ask her to sit for a moment while you
c. Offer to take the patient home after contact someone who can provide
your shift. safety for her.
d. Ask what the victim was wearing. 6. Mrs. Smith arrives for her appointment.
3. When a survivor of abuse and the She has had a positive home pregnancy
abuser both present at your facility, test and suspects she is pregnant. She
your responsibility is to care for the: has a black eye and a lacerated upper lip,
a. Survivor only and admits her husband hit her because
b. Abuser only “I did something stupid. I fell asleep and
c. Both people supper burned. It’s my fault. He works
d. Neither one; call the physician hard. He deserves a decent meal. I’m
OK.” You tell her:
4. Mrs. X has been caring for her mother a. “Nobody deserves to be hit. Here is
at home. Mrs. X’s mother has stage three the name of an organization that can
Alzheimer’s disease and is requiring more help.”
of Mrs. X’s time. Mrs. X says to you, b. “You need to leave him right away
“I just don’t know what to do. I can’t before he hurts your baby too.”
stand it anymore. I love my mother, c. “Why do you stay and let him do
but I don’t have any time for myself and that?”
I can’t afford a nursing home.” You say: d. “Has he done this before?”
a. “Mrs. X, hang in there. Things have a
way of working out.”
b. “Why don’t your sisters and brothers
help out a little?”
c. “There are agencies that provide respite
care for people in your situation. If you
like, I could tell the social worker that
you would like some information on
this service.”
d. “It’s got to be hard to put up with this
all day when you aren’t trained for it.”
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CHAPTER 22 | Victims of Abuse and Violence 369

Test Questions cont.

7. Your 20-year-old female patient in the 9. A woman who was sexually assaulted
emergency department has multiple cuts, 6 months ago has been attending a
bruises, and burns. When you ask how support group for rape victims. She has
she got these, she is vague and says she is learned that the most likely reason the
just clumsy. She tells you she is anxious to man raped her is:
get home to her boyfriend so he will not a. He was high and did not know what
get angry that she is away from home, he was doing.
but hopes she can get a prescription for b. He had a need to control her and
a tranquilizer. What does this response dominate her.
indicate to you? c. She met him in a bar and was
a. She has an anxiety disorder. impaired when they went to her
b. She is accident prone. apartment.
c. She may be caught up in the cycle of d. He had a strong need for sex.
abuse. 10. Which of the following is not an exam-
d. She has a substance abuse problem. ple of economic abuse in the elderly?
8. A young woman is brought into the a. Caregiver is using a patient’s ATM
ER after a sexual assault. Your primary card for personal use.
nursing intervention should be: b. Patient’s son is asking to see patient’s
a. Help her bathe and clean up to make will.
her feel more relaxed. c. Caregiver is encouraging patient to
b. Discuss the importance of follow-up no longer see her son and daughter.
treatment for possible sexually transmit- d. Hired caregiver is named power of
ted disease. attorney for finances for his elderly
c. Provide her with physical and emotional patient.
support during evidence collection.
d. Give her a list of community resources.
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A P PEN D I X
A
Answers and Rationales

CHAPTER 1 4. d. Deinstitutionalization and changes in

the health-care delivery system en-
History of Mental Health Nursing courage people with mental health is-
1. b. The main goal of deinstitutionalization
sues to be treated in a variety of
was to allow as many people as possi- health-care settings. Nurses will care
ble to return to the community and for patients with mental illnesses in
lead as normal a life as they could. Not all of the settings listed.
all mentally ill people would be able to 5. d. Dorothea Dix is the only one on this
do that because of the severity of their list who is not a nurse.
illnesses. On the other hand, not all 6. b, d, e. AAPINA represents Asian
mentally ill people had to be kept in American and Pacific Islander
locked units, nor do they today. Com- nurses; PNAA represents
munity hospitals were to be kept open, Philippine nurses; NANAINA
but many state hospitals closed be- represents Alaska Native
cause of the decline in census. American Indian nurses.
2. c. The development of psychotropic 7. b. Asylums were originally described
(psychoactive) medications in the 1950s as places of refuge. The meaning is
was a keystone to allowing people to much different today.
return to their homes. The Commu-
8. d. The National Institute of Mental
nity Mental Health Centers Act came
about 10 years later. The Nurse Prac- Health was established in 1946.
tice Act dictates the scope of practice 9. c. Florence Nightingale recognized the
for nurses; and electroshock therapy, relationship between sanitary condi-
now called electroconvulsant therapy, tions and healing.
took place in hospitals. 10. a. Phenothiazines were the first psy-
3. d. The Nurse Practice Act, which is writ- chotropics drugs introduced in the
ten specifically for each state, is the set 1950s.
of regulations that dictates the scope
of nursing practice. The NLN and CHAPTER 2
the ANA are national nursing associa-
tions that set recommendations for the Basics of Communication
practice, education, and well-being of 1. b. This option offers assistance in a way
nurses. The Patient Bill of Rights is a that encourages the patient to say what
document to protect the patient. he or she needs. Option A used the
Nurses must know the parameters of word “why,” which has negative conno-
this document for ethical practice, but tations. C is closed-ended and allows a
it does not dictate the scope of nursing “yes” or “no” answer. D is also closed-
practice. ended. Adding the “please” does not
make it a correctly formatted question.
370
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APPENDIX A | Answers and Rationales 371

2. c. Nurse-patient communication is pur- stating what he or she needs at the

poseful and helpful. Option A would moment. B uses the word “why,”
change the focus of the nurse-patient and C has a very authoritarian tone.
relationship and lower the chances for D is a command that is very authori-
a successful therapeutic relationship. tarian and even threatening.
Sometimes nurses and patients do 7. a. Here, the nurse tells the patient that
become friends, but this cannot get he or she understands the special con-
in the way of the professional relation- cerns of the religion and culture of
ship of the nurse to the patient. B sug- Judaism but does not make a promise
gests that the nurse is somehow “the that the dietitian will come, which
boss.” Patients sometimes have that would build false hope. Option B is
perception, but the nurse is really a incorrect because it does make that
“partner” in collaboration with the promise. C does not give any indica-
patient. D suggests a distance that tion that compromise is possible or
would place the nurse too far from that the nurse is “hearing” the true
the patient emotionally. It would be concern. D is agreeing and is a block
difficult to discuss some of the inti- to therapeutic communication.
mate details the patient needs to dis-
cuss if the relationship is too distant 8. d. This is stating an implied thought
and formal. or feeling. The nurse is checking out
the fact that the patient is feeling
3. c. This option combines an observation ignored. Option A makes light of the
with a closed-ended question. In this patient’s concern to see the physician.
instance, it can be effective. Even with B is not helpful for the patient and
the closed-ended question, it is the shows no sensitivity for the patient’s
best of the four choices. Option A im- desire to see the physician. C is a
plies playing into a hallucination and block because it shows disapproval
assumes that the patient intends to be for the patient’s concern and sides
talking to someone else. B is intended with the physician rather than the
to quiet the patient by using guilt. patient.
Asking the patient to be quiet will dis-
courage the patient from wanting to 9. a. This option is more correct than B
confide in you. D uses the word “why” because it offers an observation be-
without prefacing it with an observa- fore using a closed-ended question.
tion, thus opening up the possibility B and C are simply closed-ended
of the patient’s feeling defensive. questions. D is an observation, but
it uses “why,” which tends to leave
4. d. This option honestly tells the patient people feeling defensive.
that you cannot give that information.
The physician must explain the results 10. b. “I feel like” is not a “feeling” state-
first. Option A oversteps the bound- ment at all, but rather a thought
aries of the nurse. B uses the “why” statement. There is no emotion
word. C gives advice, by using the identified. Option B encourages
word “should.” the nurse and patient to explore
what emotional response is being
5. c. This puts the conversation back to the experienced by the patient in a safe
patient and allows venting of concerns. environment. Options A and C are
Options A and B give advice; D gives nontherapeutic techniques. Option
false reassurance and also belittles the D is nontherapeutic in many ways:
patient’s concerns. changes the subject, does not reflect
6. a. This is correct because it tells the what the patient has said, and im-
patient the nurse is concerned yet plies the nurse is not interested in
leaves the patient responsible for pursuing the patient’s feelings.
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372 APPENDIX A | Answers and Rationales

CHAPTER 3 regulation relating to other areas

of confidentiality and how files are
Ethics and Law shared among providers. It does not
1. b. Ethics is a code of professional expec- force anyone to treat in a particular
tations that does not have legal force facility, but it would raise questions
behind it. The issues border on legal about transporting records in per-
implications, but ethics comes more sonal vehicles, etc.
out of expectations that patients have 7. b. Offer another pain relief technique.
of nurses than out of actual legal Mr. Ouch does have the right to re-
bounds. fuse medication. He also has the
2. c. Each state has a Nurse Practice Act right to privacy, but the option pro-
that defines the scope of practice for vided borders on punitive and may
RNs, LPNs, and LVNs in that state. be a threat to patient safety. It is also
3. d. The Patient Bill of Rights is designed appropriate to discuss acceptable be-
to define the rights of all patients in havior and the effect he is having on
health-care facilities. These will change the other residents—just not now.
somewhat from state to state. People Wait for a time when he is reasonably
who are institutionalized for some comfortable and willing to negotiate
reason may be termed “vulnerable” treatment. Bringing in more staff and
because they may be unable to speak performing an invasive technique is
for themselves or provide for their own not only threatening, but it violates
safety. All who care for people in these many of the Patient Bill of Rights.
facilities must treat them in accordance 8. c. The LPN/LVN works under the
with the Patient Bill of Rights. direction of the registered nurse or
4. b. This is an honest, assertive technique physician and cannot order medica-
that shows one nurse voicing a con- tion independently. It is not accept-
cern to another nurse. Options A, C, able practice for the LPN/LVN by
and D are all forms of blocks to thera- the Nurse Practice Act.
peutic communication. 9. c. It is the LPN/LVN’s responsibility to
5. d. Most Nurse Practice Acts require that contact his/her supervisor.
LPNs follow the chain of command. 10. c. Mr. B should have received a copy of
In this situation, speaking with the the Bill of Rights. The nurse can re-
nurse in charge is the best choice. view to which right the patient is re-
Option A is a block to therapeutic ferring and discuss why he felt his
communication because it is argumen- rights have been violated.
tative and voices disagreement with
the patient. B is not safe: Even though CHAPTER 4
it is always important to listen to pa-
tients, a nurse must never assume the Developmental Psychology
patient is right. C is inappropriate at Throughout the Life Span
this time; it must first be determined 1. d. This patient is demonstrating the
that an error has occurred. Once this Electra complex, which is part of the
is established, the RN or the LPN, if phallic stage of Freud’s developmental
allowed by state and/or agency policy, stages.
should inform the physician. 2. c. Unsuccessful completion of the anal
6. c. The Health Insurance Portability and stage would lead to these behaviors
Accountability Act allows patients to and to more serious disorders, ac-
have a greater say in how their records cording to psychoanalytic theory.
are shared and with whom. It also has These people would be termed “anal
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APPENDIX A | Answers and Rationales 373

retentive” in some social and profes- 16–20 years. “Intimacy” (the stage at
sional circles today. which the main concern is developing
3. d. This option states that Y’s behavior is intimate relationships with others)
not appropriate and lets Y tell you that begins at approximately age 18 and
the consequences have been discussed. continues through approximately
Y is able to make a choice. Options A age 25.
and B sound harsh and threatening 8. c. It is believed that infants develop in
and are not helpful forms of commu- a very similar rate and pattern (physi-
nicating. C is very close to letting the cally, behaviorally, and cognitively)
nurse “care-take” for Y. In behavior until the age of 10 months. Again,
modification, Y would most likely be this is based on generalizations; there
responsible for his or her own actions are always exceptions (e.g., a child
and choices. who is longer than most of his or her
4. a. Cell differentiation, the process whereby particular age group because of the
cells “specialize” into their particular gene pool from parents who are taller
type, is generally complete by the than the average).
end of the first trimester (third lunar 9. b. Assimilation is the process of taking
month). in and processing information. It
5. d. Women are successfully having chil- is generally learned by experiencing
dren at young ages; however, it is through the senses. “Accommoda-
generally believed that a woman’s tion” is the process of working with
body is not completely mature until the information that has been assimi-
the age of 18 years. Because the young lated and making that information a
woman’s body is not completely ma- working part of the toddler’s daily
ture, it is difficult to sustain her health life. “Autonomy” is the stage or task
and the life of the fetus. Therefore, in- Erikson believes a toddler should be
fant mortality as well as danger to the achieving. “Adjustment” is a general
mother’s health is greatest before this term related to change. It is not
age. Older women are next in line as always a healthy response to change.
a risk group for infant mortality be- 10. d. According to Jean Piaget, the 2-year-old
cause of changing hormones that can child is in the preoperational stage,
jeopardize the woman’s ability to sup- where the child is demonstrating
port a fetus and carry it to term. Cer- interest in something other than
tainly, there are exceptions in both parents.
of these age groups regarding preg-
nancy and successful delivery. These CHAPTER 5
are broad, general beliefs that are held
among many in the medical and nurs- Sociocultural Influences on Mental
ing community. Health
6. b. Option A describes “animus,” the 1. b. Proxemics, or spatial distances vary
balance to the female, according to among the cultures. What is comfort-
Jung. able and appropriate for some is not
appropriate for others.
7. d. According to Erikson, the stage or task
for children in the 3- to 6-year-old 2. c. Prejudice means to “pre-judge.” It is
group is the stage or task of “initia- making a decision about a person, situ-
tive.” The stage or task of “industry” ation, etc., prior to having all necessary
(the stage at which integration of life information.
experiences or the confusion of those 3. b. Homelessness is not a mental illness
experiences develops) covers ages but may be a condition of mental
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374 APPENDIX A | Answers and Rationales

illness. It is difficult for this popula-

tion of people to access the health-care
CHAPTER 6
and community services available. Nursing Process in Mental Health
4. b. Approximately one-third of the home- 1. a. Nursing process is a systematic way
less in the United States are mentally ill. of collecting data to have consistency
5. d. Enlist the assistance of a religious rep- in patient care. Options B and C
resentative to negotiate removal of the are incorrect, even though nurses do
item(s) in question. Other safety ac- document patient needs and RN and
tions may also be required, but right LPN/LVN roles are different in the
now, relating to this individual at his nursing process. Patient needs are not
or her spiritual level is necessary not usually documented as part of the
only for the patient’s religious freedom nursing process per se. D is incorrect
of expression, but also to get him or because the nurse needs to know the
her to be able to cooperate with addi- difference between medical and nurs-
tional nursing actions. ing care prior to writing the nursing
process. Only nursing care is incorpo-
6. d. Actually, all of the responses are cor- rated into the nursing process.
rect. Nurses are mandatory reporters
for suspected abuse/neglect/endan- 2. c. This is the best choice of those listed.
germent of children. Certainly, the It asks what you need to know, but it
child could ultimately die from un- asks from the patient’s perspective. It is
controlled diabetes. It is appropriate less judgmental than the other choices.
to call the RN and MD to the exam 3. b. Return demonstration (redemonstra-
room, but a stat call would not be tion) is the best method for evaluating
necessary. You are there: The best the patient’s learning. Option A is a
choice is to sit with the family for a method of teaching. C and D are steps
time, gain their trust, and collect in the nursing process and steps in
more information that could be developing a teaching plan.
used to modify the care plan or as- 4. a. Mental status examinations are made
sist the MD in appropriate referrals as part of the assessment or data col-
for the best care of this child and lection part of the nursing process.
family.
5. a, b. Planning is the third component in
7. b, c, d. Many homeless fall into the “work- the Nursing Process. In the planning
ing poor” category and are actually process the nurse plans measurable
working full-time jobs. Approxi- and realistic goals, both for long and
mately one-third of the homeless short term.
also have a mental illness, quite
often schizophrenia. 6. a. The registered nurse initiates the nurs-
ing diagnosis from the patient’s data
8. a, c, e. Though mental illness is a com- collection or assessment. The LPN/
mon cause of homelessness, the LVN can assist in this step.
economy and loss of assets from
health-care expenses has been 7. a, b, d. The principle of teaching enhances
contributing factors for some. the patient’s understanding of the
nurses’ rationale for the specific
9. d. Ethnicity is defined by a personal interventions in their care.
trait or common characteristics relat-
ing to a specific group of people. 8. a, b, d, e. Tone is not part of the mental
status exam.
10. d. Authoritative parenting focuses on
the setting of rules and limits setting 9. d. The North American Nursing Diagno-
by the child. sis Association (NANDA) is a universal
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APPENDIX A | Answers and Rationales 375

and systematic approach in defining a Posing as an adolescent reminded

person’s needs according to his/her her of being young and innocent.
assessment using nursing diagnosis. Shirley knew when she pouted at
10. d. Formal teaching occurs when the an earlier age that she got her way
patient is ready. The nurse can then and was considered cute.
prepare a teaching plan. The nurse 8. c. John blamed the search committee,
will also schedule a specific time for who are all right handed, for denying
teaching and feedback of the learned him the job instead of the possibility
information. of not being qualified.
9. a. For healthy outcomes, a person has
CHAPTER 7 to have effective coping to engage in
Coping and Defense Mechanisms selecting appropriate choices.
1. c. Rationalization is the defense mecha- 10. a, b, c. The personality is made up of
nism that sounds like “excuses.” these three components accord-
ing to Freud’s theory.
2. a. Denial is the refusal to accept situa-
tions for what they really are. This is
a classic example of denial.
CHAPTER 8
3. d. This child is using compensation, Mental Health Treatments
which is finding some other strength 1. b. Options A, C, and D are commonly
that will make up for a real or imag- seen in the crisis (or third) phase of
ined inadequacy. crisis; feeling of well-being is observed
4. d. He is “blaming” his wife for his actions in the pre-crisis phase of crisis, when
rather than taking responsibility for his the patient thinks and states that
thoughts, feelings, and actions. everything is “fine.”
5. a. Rationalization. Certainly, eating a 2. d. The patient needs to know that he or
meal of burgers and fries does not she is away from the stress, even if it is
depict mental illness. Even though only temporary. The person may not
the person may be joking, and there be able to think rationally, and to hear
is an element of truth, this statement that safety and help are being offered
depicts an “excuse” for one’s behavior can be the start of stress reduction and
and choice of menu selection. intervention. The following explain
why the other options are not correct.
6. b. Undoing. This is a tricky one. Many A: “Why” needs to be avoided when
may have chosen C, Symbolization. possible to decrease the chance of the
The reason this would be more likely statement sounding judgmental and
an example of “undoing” is because allowing the patient to feel defensive.
Tara is trying to make up for a nega- B: Besides the fact that this is a closed-
tive behavior that affected her daugh- ended question, the person may not
ter. While words have not been know the answer to this. It may, in
spoken, there is not really an “emo- fact, be one of the major causes of the
tion” that is being represented, as stress that led to the crisis. C: This is
would be the case in symbolization. an open-ended statement and will be
Rather, Tara seems to be offering the valid to ask—later. As one of the first
tickets to “undo” the embarrassment questions a person in crisis hears, it
she caused her daughter by her drunk can lead to increased confusion and
and inappropriate public behavior. guilt. He or she might not have a clue
7. a, c, d. Shirley is returning to a time as to what led to the attack or may be
when her stress level was minimal. blaming himself or herself needlessly.
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376 APPENDIX A | Answers and Rationales

Because nobody deserves to be abused, 8. a. Repression is a defense mechanism

asking the question of the person ex- and is therefore counterproductive in
periencing crisis can sound as though therapy. All other choices are correct.
the nurse thinks the perpetrator had 9. b. The antianxiety drugs are potentially
just cause to abuse. addictive. Patients with addictive ten-
3. c. Milieu is the therapeutic environment. dencies may become addicted to these
It should be stress-free, or at least min- medications more easily than they
imally stress-producing, and should would to drugs from other categories.
make the patients feel comfortable to 10. c. Antidepressants all carry a FDA black
practice new, healthy behaviors. It box warning that these medications
might be locked, depending on the may increase suicide risk in children
patients, but it is not required to be. and adolescents.
The patients will not usually be hospi-
talized “for life” (however, some might
be); a 72-hour-hold situation should
CHAPTER 9
have a milieu that corresponds to the Alternative and Complementary
needs of the patient being held. Treatment Modalities
4. b. ECT is not used to treat convulsive 1. c. The definition of an alternative therapy
disorders. That is a mistake people is one that is used in place of conven-
make because of the name “electrocon- tional medicine. Option A suggests
vulsive therapy.” The treatment causes that such therapy has no value, which
a light seizure but does not treat seizure is very dependent upon the patient’s
disorders. Options A, C, and D are all beliefs. Option B is the definition of
true about ECT. complementary therapies. Option D
5. d. The use of psychoactive medications is incorrect; many cultures and people
can change the person’s ability to use alternative modalities as first-line
think and process information and treatment for all types of illness.
help him or her to feel different about 2. d. Complementary therapies are used
the situation, which may allow other with conventional medicine. Option
therapies to work in adjunct to the A is vague; medical treatment is not
medication, to help the person toward defined simply by Western standards.
wellness. These medications do not Option B is incorrect because a
cure mental illness. They are used for model refers to a picture an idea.
more than just violent behavior, and Option C infers that conventional
although they may have an effect on medicine is holistic, when in fact it
pain receptors, that is a side effect is disease-oriented.
rather than a primary use for this 3. a. Integrative refers to the use of conven-
group of medications. tional and less traditional methods
6. c. Patients treated with the MAOI group in harmony. Option B is incorrect
of medications should avoid certain because such combinations are not
foods and beverages that contain tyra- exclusive to any one belief system.
mine to avoid hypertensive crisis. Option C would leave the decision
7. b. One of the goals of crisis intervention making to a physician without patient
is to decrease anxiety. The person may input, which is not holistic. Biofeed-
feel a temporary increase in anxiety back, option D, is a complementary
(e.g., at the time of being arrested or therapy.
taken to the “detox” center), but that 4. d. The mind-body connection correctly
should resolve fairly quickly with effec- describes why belief and expectation
tive intervention. have an effect on health and disease.
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APPENDIX A | Answers and Rationales 377

Option A is an incorrect definition; 10. b. Presupposing, or assuming, that the

complementary therapies are used with patient will not improve will directly
conventional medicine. Option B is an and indirectly negatively affect the
opinion based on the notion that the thoughts, feelings, and actions of the
mind and body operate independently nurse as well as the patient. Often
of one another. Option C describes a mentally ill patients are more sensitive
treatment modality rather than a to unspoken assumption, especially
mechanism. when it is communicated nonverbally.
5. b. Regardless of the nurse’s own feelings, Options A, C, and D will positively
remaining open and supportive en- impact unspoken communication and
courages communication and rapport. improve chances for better rapport.
Option A would have the effect of de-
stroying rapport by making Mrs. Lucas CHAPTER 10
wrong for her beliefs. Option C might Anxiety, Anxiety-Related Disorders,
be an observation better reported to and Somatic Symptom Disorders
the physician for his decision. Option
D would have the LPN/LVN perform- 1. b. The vividness of the description suggests
ing well outside of his or her scope of that the person is having a flashback.
practice in most states. Auditory hallucinations would most
likely involve “voices” or “hearing” the
6. d. Aromatherapy, biofeedback, and mas- guns. Delusions of grandeur might
sage are either alternative or comple- cause the person to go after the people
mentary. In options A, B, and C, ECT with guns, while being unarmed himself
(electroconvulsive therapy), antianxiety or herself. Free-floating anxiety would
medications, and psychotherapy are be less descriptive. The person would
considered conventional. not know the cause of the anxiety.
7. a. Reiki is a therapy involving energy 2. d. Repetitive behavior that interferes with
manipulation and unblocking energy daily functioning is indicative of OCD.
flow. Options B, C, and D are all
forms of massage therapy. 3. d. This is the best of the four choices be-
cause you are simply stating for the
8. a. Trance is an altered state of con- patient to relax. You are helping him
sciousness, but it is assuredly not reoxygenate and refocus and you are
sleep. Much of the therapeutic value calming him by offering to stay with
of the work done in trance is lost if him. It also buys you some time to
the client falls asleep. Options B, C, make a visual assessment. Option A
and D are all correct statements would be appropriate nursing actions,
about trance. but not as the first priority. Your first
9. c. This statement uses “see” and “clearly” action needs to be calming the patient
to communicate that the speaker and continuing to assess. B and C are
prefers a visual channel. Through the nontherapeutic responses.
predicates “feels good” and “gut feel- 4. c, d. Multiple personality disorder (also
ing” in option A, the speaker reveals known as dissociative identity disor-
a kinesthetic channel preference. In der) is considered to be a dissocia-
option B, the speaker demonstrates tive disorder rather than an anxiety
an auditory preference through the disorder. Some theorists believe that
predicates “sounds good” and “paying the dissociative disorders are also
attention to.” Option D reflects the anxiety disorders, but most are now
rarely used olfactory preference; many differentiating the two types of dis-
practitioners treat these predicates as orders. Obsessive compulsive disor-
kinesthetic for therapeutic purposes. der has traditionally been classified
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378 APPENDIX A | Answers and Rationales

as an anxiety disorder but that has

changed in DSM-5 since it is now
CHAPTER 11
known to be neurologically based. Depressive Disorders
5. d. Rigid and inflexible behaviors are 1. a. This is selective reflecting. You have
characteristic of OCD. These persons repeated the patient’s exact words in a
would like to be able to control those way that encourages her to either ex-
behaviors, but without treatment it is plain herself or rephrase her response
very difficult for them. They are not in some way. Options B, C, and D are
usually hostile, unless they are pre- all blocks to therapeutic communica-
vented from performing the obses- tion. B is challenging her, C uses the
sion or compulsion, because that word “why,” and D is giving advice.
decreases the anxiety. 2. b. Selective serotonin reuptake inhibitors
6. d. Phobia is an irrational fear that like Zoloft typically take anywhere
cannot be changed by reason or from 2–6 weeks to impact target symp-
logic. The patient usually under- toms like sadness, low energy, loss of
stands it is irrational, but the fear appetite, and negative thoughts.
remains. 3. c. Communicating in a judgmental
7. b. A compulsion is a repetitive act; an manner is always a block to therapeu-
obsession is a repetitive thought. tic, helping relationships.
8. a, b, c. Luvox (fluvoxemine), Prozac 4. c. Major depression usually manifests
(fluoxetine), and Paxil (paroxe- itself with symptoms of extreme sad-
tine) are the current drugs of ness that is the prevalent mood for a
choice for OCD. Venlafaxine is period of at least 2 weeks. Euphoria
also used in treating many men- would be more indicative of bipolar
tal disorders. So be careful! All depression.
sound similar and are spelled 5. d. This is false reassurance, which is
similarly. never appropriate in therapeutic rela-
9. c. Acrophobia is a form of specific tionships. The other choices are all
phobia since it is fear of a specific appropriate nursing interventions for
situation (heights). a person who is depressed.
10. a, e, and f are NOT appropriate nursing 6. b. Patients taking monoamine oxidase
interventions. Stimuli should inhibitors (MAOIs) must avoid
be diminished to decrease the processed foods to avoid a hyperten-
stressors present. All changes sive crisis.
in behavior and responses to 7. d. Rather than pressure the patient to
treatment should be docu- socialize, sitting with the patient
mented. Activities should be shows acceptance and readiness to
encouraged, but only those listen when patient talks.
that are enjoyable and do not
produce additional stress. 8. c. Though symptoms of depression are
People need to acknowledge quite normal, using an open-ended
the stressors and deal with sentence demonstrates concern about
them. Avoiding or creating the changes in behavior.
“diversion” is not the best 9. b. You want to know more about the
nursing care. Creating an en- patient’s changes in behavior before
vironment where individuals jumping into a plan of action.
feel comfortable and want to 10. a. Though men frequently suffer from
participate in activities is depression, it is more common in
more therapeutic. women.
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APPENDIX A | Answers and Rationales 379

CHAPTER 12 The other choices contain incorrect

information.
Bipolar Disorders 10. a. Stimulants could easily precipitate a
1. b. Dehydration can precipitate serious manic episode or intensity a current
side effects from lithium, including one. All the others may be utilized
tremors, seizures, and coma. effectively.
2. d. One of the main side effects of lithium 11. a. Cyclothymic disorder is a chronic
is dehydration and fluid and elec- mood disturbance of at least a 2-year
trolyte imbalance. Her dry lips, stag- duration involving numerous episodes
gering gait, and feeling confused of hypomania and depressed mood
could all be symptoms dehydration but of less intensity.
and sodium depletion. We don’t have
enough information about this situa- CHAPTER 13
tion to know if other factors are in-
volved, such as taking incorrect dose. Suicide
1. d. Teaching skills to help the patient deal
3. a. Delusions of grandeur are evidenced
by the patient believing that the mayor with the problems of day-to-day life
is seeking out her opinion. This is un- will be helpful in the long run. Option
likely and demonstrates an unrealistic B is a mistake made by people who be-
sense of self importance. lieve the myth that some suicide at-
tempts are not serious. C is a block to
4. a. 1.0–1.5 mEq/L is the therapeutic therapeutic communication (disagree-
serum concentration for acute mania. ing) and may give false hope. The
For maintenance the level is usually patient does not see that there is much
lower. to live for, or the suicide would proba-
5. b. Olanzapine is an antipsychotic. It may bly not have been attempted. A is also
be used in the treatment of psychotic incorrect because reporting the patient
behavior in bipolar disorder but may to the police is not required in most
be used in combination with a mood communities and could be a threat to
stabilizer. the patient.
6. b. By encouraging the patient to reflect 2. b. People are more likely to carry out the
on past disappointments, you are en- suicide when they appear to feel better.
couraging focus on what the person This is when they have the energy to
has been through. At the same time create a plan and carry it out. When
you are not negating the positive feel- they are deeply depressed or confused,
ing he/she has now. Neither are you they often are not able to think clearly
reinforcing unrealistic thinking. enough to do these things. When peo-
7. d. The manic patient needs foods that are ple feel loved and appreciated, they are
easy to eat while pacing or moving less likely to think about suicide. This
around. The other foods require the may be a temporary feeling on their
patient to sit down for a meal, and the part, however.
patient may not be able to do that. 3. c. If a person is talking about suicide, the
8. c. Given these choices, this patient would possibility for carrying it out is very
benefit from medication to help pre- real and must be taken seriously. In
vent injury from hyperactivity. very few situations is suicidal ideation
a manipulative or attention-seeking
9. d. To be given the diagnosis of Bipolar II behavior. Suicide may be an impulsive
the individual must have recurrent act but the person is usually thinking
depression with bouts of hypomania. about it for some time.
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380 APPENDIX A | Answers and Rationales

4. d. This man has definite potential for

self-harm. He is not attempting
CHAPTER 14
to manipulate his wife’s feelings, Personality Disorders
although she may feel that he is. 1. d. Consequences should always be stated
5. b. Your first action is to place the at the time the limits are set, to in-
patient on one-on-one observation. crease consistency. The problems with
Some facilities accomplish this by options A through C are as follows. A:
having staff perform rounds at a When the behavior occurs, the patient
minimum of every 15 minutes; most may be testing, but if the conse-
facilities assign a staff person to stay quences are not known, the patient
with the patient. There is no need has not been given enough informa-
to place the patient in a locked unit tion to make an appropriate choice. B:
at this time, nor is it appropriate Anticipating a behavior is presuming,
to publicize the precautions to the and you may be presuming incor-
whole facility. It would not be appro- rectly. This sets up negative expecta-
priate to give him his razor, as this tions from the patient. C: The limits
could be an implement he could use should not be set for the convenience
to perform the suicide. of the staff or family or anyone but the
6. c. Document the discussion but explain patient. Family should be involved in
that the precautions remain in effect. the care plan if the patient is agreeable.
It is for his safety and the safety of 2. c. David is most likely displaying signs
others that the precautions are policy, of antisocial personality disorder evi-
generally. You may thank him for denced by information that he tends
sharing his beliefs, and depending on to lie, has committed a crime, and his
where he is in his treatment, it may patterns with job and personal rela-
become appropriate for him to share tionships. He is not exhibiting signs
his belief system with others. of suspiciousness or paranoia, nor is
7. b. Older men who live alone with a his- he behaving in a dependent manner.
tory of alcohol abuse are at one of the 3. a. Manipulation is used frequently by
highest risks for suicide. Though any patients with personality disorders.
of the other examples could be suici- This mechanism can be used with
dal they do not represent the most other disorders but it is a primary
frequent statistically. mechanism in personality disorders.
8. d. This response is supportive and em- 4. d. Interpersonal relationships are among
pathetic. Responses A and B reflect the most difficult activities for a per-
insensitivity to the patient’s distress. son with a personality disorder to de-
Asking the question of response C velop. They can participate in group
has nothing to do with the depth of activities because they can excel and
distress this patient must have felt, bring attention and gratification to
so it inappropriate. themselves, but developing a close per-
9. b. By asking the patient directly what sonal relationship is very difficult.
she plans to do you are gaining im- 5. c. Antisocial (sociopathic) personality
portant information and communi- is usually the type of disorder in which
cating your concern to the patient. a person would be in trouble with
Since she told you her plan, you the law.
know she is reaching out for help. 6. b. Schizotypal personality disorder is
10. a. By reaching out to you, she is commu- characterized by bizarre and unusual
nicating her mixed feelings about sui- behaviors—some of which may be also
cide and is indirectly asking for help. seen in schizophrenia.
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APPENDIX A | Answers and Rationales 381

7. c. The nurse needs to understand how reality. The other responses play into
he/she reacts to the challenging the hallucination or border on belit-
behaviors exhibited by people with tling the patient.
personality disorders. Medications, 5. c. Patients with schizophrenia do not
long-term therapy, and in-patient function well in society without treat-
hospitalization are rarely effective. ment. Even with treatment, some
8. c. Characteristics of narcissistic person- patients have a difficult time. The
ality include exaggerated sense of self- “reality” of schizophrenic people is
importance and lack of concern for their own reality and not the reality
the nurse’s time. of the rest of society.
9. d. Vague communication is not accept- 6. b. It is important always to deal with
able. Honesty and clarity in commu- reality and the present when dealing
nication are always necessary. The with people with schizophrenia. Never
patient may feel inferior, which may reinforcing hallucinations and directing
be part of the manipulation. The people away from situations that are
nurse needs to confront the feelings stressful or competitive are also impor-
of inferiority or any others that the tant. ECT is not a nursing function.
patient might state. 7. b. This time you are dealing with an
10. b. Borderline personality. This group illusion. There is something on the
tends to engage in self-mutilating ceiling, and the patient is misinter-
behaviors. preting what is there.
8. c.
CHAPTER 15 Once again, maintaining honesty and
reality is the best response.
Schizophrenia Spectrum and Other 9. a. Echolalia is the behavior or symptom
Psychotic Disorders of catatonic schizophrenia involving
1. d. Inviting the patient to the party brings the patient repeating a word or part of a
him into the present and allows him word or phrase over and over. Ecopraxia
to make the choice for himself. This is repetitive movement or actions.
will help increase self-esteem and di- 10. a. Delusions of grandeur include believ-
minish other symptoms. Option A ing one is not subject to the laws of
begins to reinforce the hallucinations, nature.
which is never appropriate for nurses. 11. a. Muscle rigidity and protruding tongue
B and C are forms of demands, which are classic symptoms of EPS in addi-
may cause the patient to revert to neg- tion to restlessness and tremors.
ative and possibly aggressive behaviors.
12. c. Decreasing anxiety and promoting
2. a. Shawna’s symptoms are consistent with trust are both realistic goals. Both of
patients who have catatonic schizo- these are a process that can be helped
phrenia. Option D, schizotypal, is a over time.
type of personality disorder but not
actually a form of schizophrenia. 13. a. We now know that schizophrenia is a
brain abnormality.
3. a. This is an example of a hallucination.
The patient is seeing something that is
not there. There is nothing actually
CHAPTER 16
visible that could be misinterpreted Neurocognitive Disorders: Delirium
as a snake; if there were, this would and Dementia
be an illusion. 1. b. Delirium is probably the best choice,
4. c. This is the honest response, and it since the patient presented as alert
focuses on returning the patient to and oriented before surgery. Nothing
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382 APPENDIX A | Answers and Rationales

indicates dementia at this point. She is physician, who must be the one to
not delusional; she is having a halluci- give the initial information. You have
nation. The dilemma may be in what maintained dignity for all, while
the nurse chooses to do next. behaving professionally.
2. a. Your best action is to call your charge 9. d. Vascular or multi-infarct dementia is
nurse and/or physician immediately. usually the result of several smaller
Your state Nurse Practice Act will dic- strokes. The patient has usually had
tate whom you should call first. Turn- conditions such as high blood pres-
ing on the light may be helpful, but sure for quite some time. The condi-
asking about the spiders plays into the tion displays many of the same
hallucination, which is not therapeu- behaviors as other types of dementia
tic. Stopping the patient’s pain med- but is also usually irreversible.
ications is not an independent nursing 10. d. The patient with delirium receives
function; you need to make that call the greatest benefit from reorientation
to the physician first. Checking her techniques. In advanced dementia,
medical record should have been done repeated attempts at orientation can
earlier, and it will not be helpful to her contribute to anxiety.
right now.
3. c. By reflecting back to Mrs. H your ob- CHAPTER 17
servation, you are promoting good
communication and emotional support. Substance Use and Addictive
The other choices are all blocks to ther- Disorders
apeutic or helping communication. 1. c. Denial is the most common defense
4. b. Aricept can cause insomnia. It can also mechanism used by people who are
cause bradycardia not tachycardia. chemically dependent. Rationalization
is also used by some patients.
5. d. Although Alzheimer’s type dementia is
not a result of aging or arteriosclerosis, 2. a. Alcohol is a CNS depressant that can
these conditions may be present in lead to impaired judgment, confusion,
addition to the dementia. lethargy, and coma in large amounts,
The “high” that people feel is tempo-
6. c. You would expect to see memory and rary and very misleading.
other cognitive processes impaired in
someone with an organic mental disor- 3. d. Tremors, confusion, and hallucinations
der. The person will probably not be are the classic symptoms of delirium
oriented to at least one of the three tremens.
spheres of person, place, or time. 4. d. Sally may very well be codependent in
7. b. These symptoms are consistent with a her sister’s alcohol abuse. Sally is tak-
person’s having delirium. The admis- ing responsibility for Susie’s behavior
sion of alcohol use adds to this conclu- instead of having Susie take care of
sion. Time or decompensation of herself.
memory and behavior might change 5. b. This response addresses both sisters
this initial diagnosis to a form of de- and tells them they both need help.
mentia. Alcohol-related dementia can It is honest and caring, and puts the
develop in someone with a long his- responsibility on them to help them-
tory of alcoholism. selves through this situation.
8. c This is the best option. You are showing 6. a. Susie should be encouraged to attend
concern for the patient, the family, and weekly AA meetings and Sally to at-
their situation. You have stated the im- tend weekly Al-Anon meetings. We do
plied message and offered to get the not know from the information if they
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APPENDIX A | Answers and Rationales 383

are adult children of alcoholics. There 4. a. A nutritional deficit, and probably

is no need to check into the unit a fluid imbalance, exists in patients
weekly, but they can be told that it is who are anorectic. The fluid imbal-
acceptable to call or check in if they ance is caused by the lack of intake
choose to do so. The psychologist will and perhaps vomiting. There is also
tell them the meeting schedule; this a body image disturbance, but it is a
would not be a nursing function for negative self-perception rather than
discharge planning. a positive one.
7. c. These behaviors are the classic ones 5. d. Unlocking the feelings surrounding
that indicate an addiction. an eating disorder can be very helpful
8. a. Honest communication is necessary to the patient and treatment team.
for the person and family to heal. Focusing on the food and the destruc-
tive behaviors associated with the food
9. b. Codependent. In an effort to be caring, puts the emphasis on the wrong area.
you are inadvertently making excuses
and encouraging the drinking behavior. 6. c. Patients with bulimia nervosa cannot
control their eating. They binge and
10. b. Chlordiazepoxide is often used to purge, and they are overly concerned
safely detoxify a person from heavy and preoccupied with body shape
alcohol use. It is relatively safe and and size.
reduces the risk for complications
from alcohol such as seizures. 7. d. This statement conveys your desire to
help with ANY concern this patient
11. d. Alcoholics Anonymous is a lifelong may have postoperatively. The other
commitment as one admits power- options do show a concern and inter-
lessness over alcohol and remains in est in this patient, but focusing on
need of this support. food and weight may limit the pa-
12. a. Methamphetamine abuse often tient’s willingness to offer other needs.
includes appetite suppression and The patient may also not be ready to
weight loss. talk about weight yet. This is a hope-
ful yet traumatic step for many.
CHAPTER 18 8. b. This response is a combination of the
Eating Disorders therapeutic techniques of parroting
and open-ended question. It uses the
1. c. Anorexia nervosa is the fear of food. patient’s words and leaves the question
Bulimia nervosa is termed “binge eat- open for Donald to elaborate. The
ing.” Pica is an eating disorder seen in other choices are nontherapeutic and
young children. do not allow for patient expression.
2. b. This response is therapeutic— 9. c. These are the classic symptoms of
demonstrating your efforts to help bulimia.
the patient identify the feelings she ex-
periences when trying to eat. Reponses 10. c. After binging, the person seeks a re-
A and D are threats, and appetite stimu- lease of tension related to shame and
lants are not useful since the disorder guilt by purging.
is unrelated to appetite.
3. b. Patients who have anorexia have an
CHAPTER 19
intense fear of being fat. They have an Childhood and Adolescent Mental
inaccurate sense of their size and body Health Issues
image and will not develop normal 1. b. Safety for children with conduct disor-
eating patterns without much help der is primary in importance. Chances
and behavior modification. are that the child will not settle
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384 APPENDIX A | Answers and Rationales

quickly, and asking the parent to leave 9. c. Chaotic home life is a common thread
with the child is not a supportive ac- in children with conduct disorder.
tion for either the parent or child. 10. c. The FDA has issued a black box
2. c. Exposing the child to one new person warning on all antidepressants to
rather than several will help the child monitor children and teens for sui-
develop a relationship. More than one cide when taking these medications.
person and touching the child may
increase anxiety. Isolating the child at CHAPTER 20
the same time will reinforce fears.
Postpartum Issues in Mental Health
3. d. Children often act out or draw pictures
about what is troubling them. Offering 1. b. Projecting evilness onto the infant is
toys or drawing materials and observ- a sign of postpartum psychosis. The
ing the child discreetly can tell you other responses are all normal reflec-
much about what he or she has experi- tions of anxiety about the baby or the
enced. It may also serve as a diversion, mother.
but offering toys or drawing materials 2. d. Highly labile emotions related to the
is meant to encourage self-expression baby are a common sign of postpar-
rather than serve as a diversion from tum blues. Response B and C are signs
the situation. of more serious disorders that could
4. d. Physical activity is a good outlet for impact the infant’s care. Response A is
the ADHD child. Checkers and video a normal concern of a new mother.
games are too sedentary, and pool 3. b. Postpartum blues usually start a few
requires concentration that may be days after birth. These blues are com-
difficult for the child. mon and not a psychiatric diagnosis
5. b. CNS stimulants are effective with nor reflect problems in bonding.
ADHD to increase levels of neuro- 4. a. Postpartum depression is closely related
transmitters to elicit a calming effect. to depression in a previous pregnancy.
6. d. All of these choices apply to ADHD. The other choices may be factors that
could contribute to depression but are
7. b. The most common symptom of autism not the most important cause. The
is impaired social functioning. The pa- other responses are not appropriate.
tient does not make strong friendships. Antidepressants are not needed for
Emotions may be completely opposite postpartum blues.
of what would be appropriate, and the
patient may achieve an appropriate 5. b. Giving the new mother information
developmental task and then regress, on this being a normal response is an
or may not achieve appropriate devel- important intervention.
opmental tasks at all. 6. c. This response demonstrates sensitivity
8. c. This is the best choice of the options for the need to grieve this loss. The
listed, because it implies the nurse other responses demonstrate insensitiv-
heard the parents’ concerns and recog- ity to the depth of the loss.
nized the need to get them appropriate 7. b. This statement is concerning that this
help right away. The other options are new mother may be progressing to
either nontherapeutic or provide false depression or some other disorder.
hope to the parents. They may sound More follow-up and support is needed.
polite but are not helpful for the par- Response C could be an indicator of
ents, who are concerned they did a postpartum psychosis. A and D are
something wrong and want to know more likely to associated with postpar-
how they can help their child. tum blues.
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APPENDIX A | Answers and Rationales 385

8. b. Mood stabilizers have been linked to can also change after a stroke, but
malformations in neonates. that is not a speech difficulty.
9. c. Antidepressants are an effective treat- 8. b. Drugs are metabolized more slowly
ment of postpartum depression. The in older people, which results in a cu-
other responses are inaccurate. Diet mulative effect that leads to toxicity.
and exercise may be helpful in depres- 9. c. These could be symptoms of elder
sion but would not be the major treat- abuse. The location of the bruises is
ment for this psychiatric disorder. consistent with shaking or beating.
10. d. All of these choices must be addressed The lack of eye contact or verbal re-
in postpartum psychosis. This is an sponse indicates that the patient may
emergency for safety of the newborn. fear. More investigation is needed
that the beatings might get worse.
CHAPTER 21 10. d. OBRA stands for Omnibus Budget
Aging Population Reconciliation Act. It establishes stan-
dards for the care of the older adult.
1. b. Reinforce the word by showing or han-
dling the object. Trying to guess the 11. b. Progressive memory loss is not a nor-
word or finishing the patient’s sentence mal part of aging. When memory loss
can be frustrating and insulting and is apparent, more evaluation of the
can discourage the patient from at- causes and nursing interventions to
tempting to communicate. Asking the deal with it are important.
patient to think about the word while 12. a. Providing support to a coworker is
you do something else is distracting. most important. The other choices
2. d. Federal regulations require that the are more clinical questions.
assessment be conducted by an RN
for purposes of consistency. All other CHAPTER 22
people on the health-care team supply Victims of Abuse and Violence
input and documentation to assist
with the assessment. 1. d. Showing empathy for the patient,
offering to provide further assistance,
3. c. Medication side effect would be the and reassuring safety will help the
most obvious possibility, as the medica- patient to trust you and probably to
tion is a recent change in routine, and be more comfortable and compliant
normal vital signs should help rule out with examinations.
the possibility of a recent stroke. De-
pression is a more distant possibility. 2. b. Getting a statement in the patient’s
own words and documenting it in the
4. c. You have been assertive and told the medical record are required. Option
patient what you wanted in a way that A is information that the patient may
encouraged the patient to participate not know. The word “why” is counter-
in a specific activity. This also supports productive in therapeutic communica-
the person’s self-esteem. tion. C is not recommended for reasons
5. b. The losses experienced as people age of liability for both the nurse and the
are frequent causes of depression. patient. It is most likely a violation of
6. d. Dementia is not a part of normal your agency policy as well as a violation
aging. Other possibilities for unusual of professional ethics. Option D is in-
behavior should be ruled out before appropriate as it has nothing to do with
diagnosing a person with dementia. the rape.
7. b. Aphasia is the speech complication 3. c. You need to be helpful to both people.
that often results from stroke. Affect You will need to take care of the physical
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386 APPENDIX A | Answers and Rationales

and emotional health of both patients, be true, but she has to make that de-
and you will do it according to the de- cision on her own. The organization
gree of immediacy called for. A physi- you offered her in option A may assist
cian must be called if one is not in the with that as well. “Why” is a nonther-
area, but until he or she arrives, your apeutic response. Asking if he’s done
nursing care, observation, and docu- that before does make an attempt at
mentation will help ensure the best gathering information and showing
possible care for the patients. concern, but the more immediate
4. c. You let Mrs. X know that you hear need now is to support her and offer
her concern and need for help. You her some options for assistance.
are offering the best help you can at 7. c. There is evidence to indicate the pos-
the moment, while allowing her to sibility of the abuse cycle. All the
make the decision about speaking to other responses may be accurate, but
the social worker. there is not enough information to
5. c. While some patients may express determine this. This woman may
displeasure at someone going ahead, believe she must return to the home
most will realize something is terribly where abuse is probably occurring.
wrong. Apologize for their inconven- 8. c. Physical and emotional support is the
ience and have someone assist them most important initial intervention.
as soon as possible. Attending to this The other interventions may be
woman, her immediate needs, and needed later in the visit.
those of her children is the best nurs- 9. b. Rape is an act of violence and not
ing choice. You may also let her know related to sexual desire.
that someone will be in who can help
her with safety issues, but it is impor- 10. b. The son may need to see the will to
tant to get her in a quiet, safe room. obtain information for financial plan-
After all, the perpetrator may be right ning of patient’s resources. Responses
behind her. She knows that. A and C indicate the caregiver is over-
stepping his/her boundaries. Would
6. a. You are showing empathy, being non- need more information to determine
judgmental, and offering the patient if response D is appropriate.
assistance. Offering to her that she
needs to leave sounds helpful and may
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A PPE NDIX
B
Agencies That Help People
Who Have Threats to Their
Mental Health
1. National Institute of Mental Health 6. American Association of Retired
(NIMH) Persons (AARP)
6001 Executive Boulevard, Room 8184, Widowed Persons Services
MSC 9663 Social Outreach and Support
Bethesda, MD 20892-9663 1909 K Street NW
(301) 443-4513; 1-866-615-6464; Washington, DC 20049
301-443-8431 (TTY) (202) 728-4370
Fax: (301) 443-4279 www.aarp.org
www.nimh.nih.gov 7. National Hospice & Palliative Care
2. Depression and Bipolar Support Organization (NHPCO)
Alliance 1731 King Street
730 Franklin Street, Suite 501 Alexandria, VA 22314
Chicago, IL 60610-7224 Phone: (703) 837-1500; Fax: (703)
(800) 826-3632; Fax: (312) 642-7243 837-1233
www.dbsalliance.org www.nhpco.org
3. National Alliance on Mental Illness* 8. Child Abuse Prevention Association
3803 N. Fairfax Drive 503 E. 23rd Street
Arlington, VA 22203 Independence, MO 64055
Main: (703) 524-7600; (816) 252-8388; Fax (816) 252-1337
Helpline: (800) 950-6264; www.childabuseprevention.org
Fax: (703) 524-9094 9. National Council of Alcohol and
www.nami.org Drug Dependence
*Most states have a chapter of Alliance for the Mentally Ill (AMI)
as well.
217 Broadway, Suite 712
New York, NY 10007
4. Child Welfare Information Gateway Hope Line: (800) NCACALL; FAX:
www.childwelfare.gov/ (212) -269-7510
5. Mental Health America (formerly www.ncadd.org
known as National Mental Health 10. Alcoholics Anonymous
Association) Mailing Address:
2001 N. Beauregard Street, 12th Floor A.A. World Services, Inc.
Alexandria, VA 22311 P.O. Box 459, Grand Central Station
Phone: (800) 969-6642; Fax: (703) New York, NY 10163
684-5968 (212) 870-3400
www.mentalhealthamerica.net http://aa.org
387
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A P PEN D I X
C
Organizations That Support
the Licensed Practical/
Vocational Nurse
The following is a partial list of organizations relationships. Some states have local associa-
that support and foster the role of the licensed tions of NFLPN.
practical/vocational nurse in the United States. 3. American Psychiatric Nurses Association
1. National Association for Practical Nurse (APNA)
Education and Service (NAPNES) 3141 Fairview Park Drive, Suite 625
1940 Duke Street, Suite 200 Falls Church, VA 22042
Alexandria, VA 22314 (855) 863-APNA (2762); Fax: (855)
(703) 933-1003; Fax: (703) 940-4089 883-APNA (2762)
www.napnes.org www.apna.org/membership
NAPNES is the oldest association that ad- APNA is a resource for psychiatric mental
vocates the practice, education, and regulation health nursing. It offers affiliate memberships
of practical and vocational nurses, practical for LPN/LVNs.
nurse educators, practical nursing schools, prac- 4. American Association for Men in Nursing
tical nursing educators, and students. NAPNES P.O. Box 130330
has consistent state members througout the Birmingham, AL 35213
U.S. Publications: Journal of Practical Nursing. (205) 956-0146; Fax: (205) 956-0149
2. National Federation of Licensed Practical www.aamn.org
Nurses (NFLPN) Founded in 1973, the purpose of AAMN
111 West Main Street, Suite 100 is to provide a framework for nurses, as a
Garner, NC 27529 group, to meet, and to discuss and influence
(919) 779-0046; Fax: (919) 779-5642 factors that affect men as nurses. Check the
www.nflpn.org Web site for local chapter information.
The Mission of the National Federation of 5. NCEMNA, National Coalition of Ethnic
Licensed Practical Nurses, Inc., is to foster Minority Nurse Associations Inc.
high standards of nursing care and promote 6101 West Centinela Avenue, Suite 378
continued competence through education/ Culver City, CA 90230
certification and lifelong learning, with a (310) 258-9515; Fax: (310) 258-9513
focus on public protection. www.ncemna.org
NFLPN is committed to quality and NCEMNA is a national collaboration of
professionalism in the delivery of nursing ethnic minority nurse associations. The site
care, working with other organizations and provides announcements about NCEMNA’s
groups in a cooperative progressive spirit unique programs and activities, as well as direct
to build strong professional and public links to each member association’s Web site.

388
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APPENDIX C | Organizations That Support the Licensed Practical/Vocational Nurse 389

6. National Association of Hispanic Nurses, The National Black Nurses Association’s

Inc. (NAHN) mission is to provide a forum for collective ac-
Mailing Address: 6301 Ranch Drive, tion by black nurses to investigate, define, and
Little Rock, AR 72223 advocate for the health-care needs of African
DC Office: 750 First Street NE, Suite Americans and to implement strategies that
700, Washington, DC 20002 ensure access to health care that is equal to or
501-367-8616 | fax 501-227-5444 | above health-care standards of the larger society.
www.nahnnet.org 8. Philippine Nurses Association of America,
NAHN promotes the professionalism and Inc. (PNAA)
dedication of Hispanic nurses by providing 8303 Windfern Road
equal access to educational, professional, and Houston, TX 77040
economic opportunities for Hispanic nurses. www.mypnaa.org
7. National Black Nurses Association, Inc. PNAA upholds the positive image and
(NBNA) welfare of its constituent members, promotes
8630 Fenton Street, Suite 330 professional excellence, and contributes to
Silver Spring, MD 20910-3803 significant outcomes to health care and soci-
(301) 589-3200; Fax: (301) 589-3223 ety as well as unifies Filipino-American nurses
www.nbna.org in the United States and its territories.
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A P PEN D I X
D
Standards of Nursing Practice
for LPN/LVNs
■ National Federation ■ NFLPN Nursing Practice
of Licensed Practical Standards
Nurses (NFLPN) Code
for Licensed Practical/ Introductory Statement
Definition: Practical/vocational nursing means
Vocational Nurses the performance for compensation of author-
ized acts of nursing that utilize specialized
• Know the scope of maximum utilization knowledge and skills and that meet the health
of the LPN/LVN as specified by the nurs- needs of people in a variety of settings under
ing practice act and function within its the direction of qualified health professionals.
scope. Scope: Practical/vocational nursing com-
• Safeguard the confidential information prises the common case of nursing and, there-
acquired from any source about the fore, is a valid entry into the nursing profession.
patient. Opportunities exist for practicing in a
• Provide health care to all patients regard- milieu where different professions unite their
less of race, creed, cultural background, particular skills in a team effort for one com-
disease, or lifestyle. mon objective—to preserve or improve an
• Refuse to give endorsement to the sale individual patient’s functioning.
and promotion of commercial products or Opportunities also exist for upward mo-
services. bility within the profession through academic
• Uphold the highest standards in personal education and for lateral expansion of knowl-
appearance, language, dress, and demeanor. edge and expertise through both academic
• Stay informed about issues affecting the and continuing education.
practice of nursing and delivery of health
care and, where appropriate, participate in Standards
government and policy decisions. Education
• Accept the responsibility for safe nursing The licensed practical/vocational nurse:
practice by keeping oneself mentally and
physically fit and educationally prepared 1. Shall complete a formal education pro-
to practice. gram in practical nursing approved by the
• Accept the responsibility for membership appropriate nursing authority in a state.
in NFLPN and participate in its efforts to 2. Shall successfully pass the National
maintain the established standards of Council Licensure Examination for
nursing practice and employment policies Practical Nurses.
that lead to quality patient care. 3. Shall participate in initial orientation
within the employing institution.

390
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APPENDIX D | Standards of Nursing Practice for LPN/LVNs 391

Legal/Ethical Status • Implementation: The plan for nursing

The licensed practical/vocational nurse: care is put into practice to achieve the
stated goals and includes:
1. Shall hold a current license to practice nurs- • Observing, recording, and reporting
ing as an LPN/LVN in accordance with the significant changes which require
law of the state wherein employed. intervention or different goals
2. Shall know the scope of nursing practice • Applying nursing knowledge and
authorized by the Nursing Practice Act skills to promote and maintain
in the state wherein employed. health, to prevent disease and dis-
3. Shall have a personal commitment to ability, and to optimize functional
fulfill the legal responsibilities inherent capabilities of an individual patient
in good nursing practice. • Assisting the patient and family with
4. Shall take responsible actions in situations activities of daily living and encour-
wherein there is unprofessional conduct aging self-care as appropriate
by a peer or other health-care provider. • Carrying out therapeutic regimens
5. Shall recognize and have a commitment and protocols prescribed by an RN,
to meet the ethical and moral obligations physician, or other persons author-
of the practice of nursing. ized by state law
6. Shall not accept or perform professional • Evaluations: The plan for nursing care
responsibilities which the individual and its implementations are evaluated
knows (s)he is not competent to perform. to measure the progress toward the
stated goals and will include appropri-
Practice ate persons and/or groups to determine:
The licensed practical/vocational nurse: • The relevancy of current goals in
relation to the progress of the indi-
1. Shall accept assigned responsibilities vidual patient
as an accountable member of the health- • The involvement of the recipients of
care team. care in the evaluation process
2. Shall function within the limits of • The quality of the nursing action in
educational preparation and experience the implementation of the plan
as related to the assigned duties. • A reordering of priorities or new
3. Shall function with other members of goal setting in the care plan
the health-care team in promoting and 5. Shall participate in peer review and other
maintaining health, preventing disease evaluation processes.
and disability, caring for and rehabilitat- 6. Shall participate in the development of
ing individuals who are experiencing an policies concerning the health and nurs-
altered health state, and contributing to ing needs of society and in the roles and
the ultimate equality of life until death. functions of the LPN/LVN.
4. Shall know and utilize the nursing
process in planning (assessing [data gath- ■ Continuing Education
ering]), implementing, and evaluating
health services and nursing care for the The licensed practical/vocational nurse:
individual patient or group.
• Planning (assessing [data gathering]): 1. Shall be responsible for maintaining the
The planning of nursing includes: highest possible level of professional
• Assessment of health status of the indi- competence at all times.
vidual patient, the family, and commu- 2. Shall periodically reassess career goals
nity groups and select continuing education activities
• An analysis of the information gained which will help to achieve these goals.
from assessment 3. Shall take advantage of continuing edu-
• The identification of health goals cation opportunities which will lead to
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392 APPENDIX D | Standards of Nursing Practice for LPN/LVNs

personal growth and professional devel- 2. Shall present personal qualifications that
opment. are indicative of potential abilities for
4. Shall seek and participate in continuing practice in the chosen specialized nursing
education activities which are approved area.
for credit by appropriate organizations, 3. Shall present evidence of completion
such as the NFLPN. of a program or course that is approved
by an appropriate agency to provide
the knowledge and skills necessary for
■ NFLPN Specialized effective nursing services in the special-
ized field.
Nursing Practice 4. Shall meet all of the standards of practice
Standards as set forth in this document.
(Reference: NFLPN, Nursing Practice Stan-
The licensed practical/vocational nurse:
dards for the Licensed Practical/Vocational
1. Shall have had at least one year’s experi- Nurse (2003) available at www.nflpn.org/
ence in nursing at the staff level. practice-standards4web.pdf.)
2993_App-E_393-394 14/01/14 5:15 PM Page 393

A PPE NDIX
E
Assigning Nursing Diagnoses
to Client Behaviors
Common behaviors are matched with examples of corresponding nursing diagnoses.

Behavior Nursing Diagnosis

Aggression, hostility Risk for injury; Risk for other directed violence
Anorexia or refusal to eat Impaired nutrition: less than body requirements
Anxious behavior Anxiety
Body image issues such as negative Disturbed body image
attitude toward body part
Confusion, memory loss Impaired memory; Confusion; Disturbed thought
processes
Delusions Disturbed thought processes
Denial of problems Ineffective denial
Depressed mood Disturbed self-esteem; Disturbed self-concept;
Grieving; Hopelessness
Detoxification, withdrawal from substances Risk for injury
Difficulty sleeping Disturbed sleep pattern
Difficulty with interpersonal relationships Impaired social interactions
Expresses anger at God Spiritual distress
Expresses lack of control over personal Powerlessness
situation
Flashbacks, nightmares, obsession with Post-trauma response
traumatic experience
Hallucinations Disturbed sensory perceptions; Disturbed thought
processes
Highly critical of self Disturbed self-esteem
Inability to meet basic needs Self-care deficit
Loose associations or flight of ideas Disturbed thought processes
Manic hyperactivity Risk for injury, disturbed thought processes
Manipulative behavior Ineffective coping; Impaired social interactions
Overeating, compulsive Risk for imbalanced nutrition: more than body
requirements
Phobias Anxiety; Fear
Continued

393
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394 APPENDIX E | Assigning Nursing Diagnoses to Client Behaviors

Behavior Nursing Diagnosis

Physical symptoms as coping behavior Ineffective coping
Potential or anticipated loss of significant Grieving
entity
Projection of blame, rationalization of Defensive coping
failures, denial of personal responsibility
Ritualistic behaviors Anxiety; Ineffective coping
Inappropriate sexual behaviors Impaired social interaction
Self-inflicted injuries (non–life-threatening) Self-mutilation; Risk for self-mutilation
Stress in caring for another person Caregiver role strain; Compromised family coping
Substance use as a coping behavior Ineffective coping; Ineffective denial
Suicidal gestures, threats, ideation Risk for violence to self; Hopelessness
Suspiciousness Disturbed thought process; Ineffective coping
Violent behavior Risk for violence; Ineffective coping; Risk for injury
Withdrawn behavior Social isolation
Source: Adapted from Townsend (2012): Psychiatric Mental Health Nursing, 7th ed. Philadelphia: F.A. Davis Company, with permission.
2993_Glos_395-404 14/01/14 5:30 PM Page 395

Glossary

Abuse: Physical, verbal, or emotional Alzheimer’s disease: A form of progressive

mistreatment of self or others; misuse dementia.
of chemicals, food, or other substances. American Nurses Association (ANA): A
Abuser: One who mistreats others. national nursing organization established
Accommodation: Process of adjusting one’s for registered nurses.
schema to fit changing situations (Piaget). American Psychiatric Nurses Association
Accountability: When a health-care worker (APNA): A national nursing association
accepts responsibility for any actions dedicated to psychiatric mental health
performed while caring for a patient. nursing.
Adaptation: The effective coping to changes Anhedonia: Inability to experience pleasure.
that are external and internal. Anorexia nervosa: Serious aversion to food,
Addiction: A chronic brain disease character- which can lead to malnutrition and death.
ized by compulsive and maladaptive use of Also called anorexia.
a substance or behavior (e.g., gambling). Antidepressant: Classification of psy-
Advocacy: Act of ensuring that patients, choactive medication used to treat
especially those classified as “vulnerable,” depression.
are being treated in a safe, legal manner. Antimanic agent: Classification of psy-
Affect: The outward display or expression of choactive medication used to treat manic
a feeling or mood. behavior, such as in bipolar disorder.
Ageism: Form of discrimination against Antiparkinson agent: Classification of
people on the basis of age. medication used to treat the symptoms
Aggressive communication: Form of com- of both drug-induced and non-drug-
munication that hurts another and is not induced parkinsonism.
self-responsible (“you” statements). Antipsychotics: Classification of psychoac-
Agnosia: Loss of ability to recognize objects. tive medications used to treat psychotic
Agraphia: Difficulty writing and drawing. behavior found in disorders such as
Akathisia: Restlessness; an urgent need for schizophrenia and organic brain
movement. disorders.
Alcohol abuse: Compulsive use of alcohol Antisocial personality disorder: A pat-
usually lasting 1 month or longer. tern of irresponsible, exploitive, and
Alcohol dependence: Improper use of guiltless behavior with tendency to
alcohol with impairment of social or fail to conform to the law and exploit
occupational functioning, which leads to and manipulate others for personal
signs of tolerance or withdrawal. gain. Popularly known as sociopathic
Alcoholism: A complex, progressive disease personality.
characterized by significant physical, Anxiety: Feelings of uneasiness or
social, and/or mental impairment apprehension.
directly related to alcohol dependence Aphasia: Inability to communicate through
and addiction. speech caused by brain dysfunction.
Alternative medicine: Modalities that Apraxia: Inability to carry out motor activities
replace those of conventional medicine. despite intact motor function.
395
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396 Glossary

Aromatherapy: Related to herbal therapy; Biofeedback: Method of teaching patients

provides treatment by both direct phar- to recognize tension within the body and
macological effects of the aromatic plant to respond with relaxation.
substances and indirect effects of certain Bipolar disorder: A disorder characterized by
smells on mood and affect. mood swings from profound depression to
Assertive communication: Self-responsible extreme euphoria with intervening periods
statements that begin with the word “I” of normalcy.
and deal with thoughts, feelings, and Body image: Individual’s perception of his
honesty. or her body.
Assimilation: Taking in, processing, incor- Body mass index (BMI): An approximation
porating new information (Piaget). of body fat based on a calculation of
Asylum: Old term for institution for the care weight divided by the square of one’s
of the needy, especially the mentally ill. height in adults.
Attention-deficit/hyperactivity disorder Borderline personality: A disorder charac-
(ADHD): The display of a persistent terized by a pattern of intense and chaotic
pattern of inattention and/or hyperactiv- relationships with emotional instability
ity-impulsivity that is more frequent and and tendency toward self-destructive
severe than is typically observed in individ- behavior.
uals at a comparable level of development. Bulimia: Eating disorder in which a
Autism spectrum disorder: A group of person experiences eating binges along
disorders that are characterized by im- with purging. Also called bulimia
pairment in several areas of development, nervosa.
including social interaction, skills, and Bullying: A form of aggressive behavior
interpersonal communication. manifested by the use of force or coercion
Autonomy: Development of a sense of self to affect others, particularly when the
and independence (Erikson). behavior is habitual and involves an
Avoidant personality: An individual with imbalance of power.
extreme sensitivity to rejection leading to Catatonia: Rigidity and inflexibility of mus-
avoidance of social contacts. cles, resulting in immobility or extreme
Awareness: Having a realization, perception, agitation.
or knowledge. Cerebrovascular disease: A disorder of the
Behavior: Any action or activity that can be blood vessels related to the brain.
observed. Chemical restraint: The use of medication
Behavior modification: Form of treatment as a restriction to manage behavior or
in which variables are manipulated to en- restrict patient freedom of movement.
courage and reinforce desired behavioral Child abuse: The physical, emotional, or
changes. sexual mistreatment of children.
Behavioral theorist: Scientists who have Civil law: Body of laws dealing with rights of
developed theories about human thought private citizens.
and behavior including Watson, Pavlov, Codependency: Maladaptive coping be-
and Skinner. haviors that reinforce another person’s
Beliefs: Concepts, opinions, and ideas that addictive behavior by allowing that per-
are accepted as true and are usually not son to avoid consequences of his/her
exactly the same for each individual. actions. Also called enabling.
Binge drinking: Episodic, excessive drinking. Cognitive: Pertaining to the thought
Four or more alcoholic drinks (for women) process and the ability to think.
or five or more alcoholic drinks (for men) Cognitive Behavior Therapy (CBT): Psy-
on the same occasion on at least one day. chotherapeutic approach that combines
Binge eating disorder: Recurrent episodes behavior therapy with cognitive psychol-
of binge eating that leads to feelings of ogy, It is a problem-focused and action-
distress. Not associated with purging. oriented short-term therapy.
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Glossary 397

Collaborative: Form of care in which nurses episodes of hypomania and depressed

work together and with other disciplines mood.
for the betterment of patient care. DSM-IV: Diagnostic and Statistical Manual
Commitment: The act of forced hospitaliza- of Mental Disorders, 4th ed.
tion, frequently against the patient’s will DSM-5: Diagnostic and Statistical Manual
when the patient's safety is compromised. of Mental Disorders, 5th edition. Major
Communication: Method of transmitting psychiatric reference by the American
messages between a sender and a receiver. Psychiatric Association.
Can be verbal or nonverbal. Data collection: Gathering of information
Communication block: Method of commu- about a patient; part of nursing process.
nication that impedes helpful interactions Date rape: Unwanted sexual intercourse
with patients. between people who are aqcuainted and
Community Mental Health Centers in which the party who pays for the date
Act of 1963: A result of President expects sex in return.
John F. Kennedy’s concern for the treat- Defense mechanisms: Group of behaviors
ment of the mentally ill. used to reduce or eliminate anxiety.
Complementary medicine: A wide variety Unconsciously falling into habits that
of alternative practices such as acupunc- give the illusion of coping but produce
ture and hypnosis that are recognized and ineffective results.
accepted by mainstream medicine; done Deinstitutionalization: A policy in which
in conjunction with traditional medicine. people who had formerly required long
Compulsion: Unwanted, repetitive urge hospital stays became able to leave the
to perform or the actual performance of institutions and return to their commu-
a behavior. nities and homes.
Conduct disorder: A repetitive and persis- Delirium: Acute brain syndrome; rapid
tent pattern of behavior in which the basic onset of cognitive impairments such as
rights of others or major age-appropriate loss of memory and disorientation.
societal norms or rules are violated. Delirium tremens (DTs): Form of delirium
Confidentiality: The act of maintaining from withdrawal from alcohol in which
privacy of patient information. the person experiences, among other
Conversion: Transference of anxiety into symptoms, tremors, hallucinations,
physical symptoms. delirium, and diaphoresis.
Co-occurring disorder: Existence of both a Delusion: Fixed, false belief relating usually
substance abuse disorder and a serious to persecution or grandeur.
mental illness. Also called dual diagnosis. Dementia: Gradual progression and deteri-
Coping: The act of successfully adapting psy- oration of cognitive functioning that
chologically, physically, and behaviorally interferes with memory, language, and/or
to problems or stressors. executive functions, such as organizing
Counseling: One of several forms of therapy. and abstraction. Also referred to as major
Crisis: A state of psychological disequilibrium. neurocognitive disorder.
Culture: Nonphysical traits, rituals, values, Dependent: Relying on another person or
and traditions that are handed down to substance.
others from generation to generation. Dependent personality disorder: Charac-
Culture of nurses: Professional values, rituals, terized by a pervasive and excessive need
and traditions passed down from one to be taken care of.
generation of nurses to the next. Depression: An alteration in mood that is
Cyberbullying: The use of the Internet and expressed by feelings of sadness, despair,
social media to harm other people in a and pessimism.
deliberate, repeated, and hostile manner. Detoxification: The process of withdrawal of
Cyclothymic: Characterized by chronic the substance through supervised medical
mood disturbance involving numerous interventions to prevent complications.
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398 Glossary

Dissociate: To separate a strong emotional depression or schizophrenia not respond-

response from the consciousness. ing to other forms of treatment. A
Dissociative disorders: Disruption and or current is passed through the patient,
discontinuity in the normal integration resulting in mild seizure and temporary
of consciousness, memory, identity. This amnesia.
category includes dissociative identify Emotional abuse: Willful use of words or
disorder (multiple personality). actions that undermine another person’s
Doctrine of Privileged Information: A bond self-esteem.
between patient and physician. Under this Empathy: Therapeutic communication tech-
doctrine, the physician has the right to re- nique of understanding another person’s
fuse to answer certain questions (e.g., in emotion without actually experiencing the
a court of law) and can cite “privileged emotion.
physician-patient information.” Ethics: The basic concepts and fundamental
Domestic violence: Intentionally inflicting moral principles that govern conduct.
or threatening physical injury or cruelty Ethnicity: The condition of identifying
to one’s partner. Also known as intimate with an ethnic group.
partner abuse, spouse abuse. Ethnocentrism: When individuals believe
Dysfunctional: Having abnormal or that their particular ethnic or religious
ineffective function in mental health group has rights and benefits over those
pertaining to coping and relationships. of others.
Dysmorphophobia: Preoccupation with an Eustress: Type of stress that results from
imagined defect in appearance. positive experiences (experiences such as
Dysphasia: Difficulty in speaking. raises, promotions).
Dysthmic disorder: A chronic form of Evaluation: Part of nursing process that
depression with somewhat milder symp- summarizes nursing interventions and
toms than major depressive disorder. the outcomes.
Dystonia: A disorder in which the symp- Extrapyramidal symptoms (EPS): A vari-
toms manifest as bizarre distortions or ety of responses associated with drugs
involuntary movements of any muscle that antagonize the dopamine receptors
group. outside the pyramidal tract, causing a
Echolalia: Repetition of phrases, words, or variety of effects including tremors and
part of a word; often part of catatonia. rigidity.
Echopraxia: Repeating the movements of Feeling: Emotion.
others. Feeling statement: Statement that must
Economic abuse: Using another’s resources identify an emotion that one is experi-
for one’s own personal gain without per- encing or trying to explore (e.g., “I feel
mission or making the victim financially proud” or “I feel frightened”).
dependent on the abuser. Also called Formal teaching: Teaching that is planned
fiduciary abuse. and scheduled.
Effective coping: Skills that reduce tension Free-floating anxiety: Anxiety that has no
and do not create more problems for an identifiable cause; feeling of “impending
individual. doom.”
Ego: Second part of Freud’s personality devel- Free-standing treatment centers: Treatment
opment, balancing the id; the ego meets centers that provide care ranging from
and interacts with the outside world. crisis care to traditional 21-day stays. They
Elder abuse: Physical, emotional, or sexual may be called detoxification (detox) centers,
abuse of older adults. crisis centers, or other similar terms.
Elderly: Pertaining to older people, often Generalized anxiety disorders: An anxiety
described as people over 65 years old. disorder that has no identifiable cause
Electroconvulsive therapy (ECT): Electro- and that is characterized by excessive
convulsive therapy, reserved for types of worry or severe stress and a feeling of
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Glossary 399

“impending doom;” it typically lasts severe enough to cause marked impair-

6 months or longer. ment in social or occupational function-
Geriatrics: Branch of medicine that deals ing. Also known as hypomanic episode.
with the illnesses and treatment of elderly Id: First part of Freud’s personality theory,
people. which is preoccupied with self-gratification.
Gerontology: The study of aging and old age. Illusion: A misperception of a real external
Hallucination: False sensory perception; stimulus.
can affect any of the five senses. Implementation: Part of the nursing process
Health-illness continuum: Theory that that identifies specific actions a nurse will
physical and mental health and illness do to help a patient meet a goal; nursing
fluctuate somewhat on a daily basis, while intervention.
staying within a social norm of behavior. Impulsivity: The trait of acting without re-
Health Insurance Portability and Account- flection and thought to the consequences.
ability Act (HIPAA): Regulations devel- Incest: Sexual activity between people who
oped by the Department of Health and are so closely related that marriage is illegal.
Human Services to provide national Ineffective communication: A breakdown
standards pertaining to the transmission either in the sender’s process of delivery
and communication of medical informa- of a message or how that message is
tion among patients, providers, employers, received.
and insurers. Ineffective coping: The use of coping skills
Hearing impaired: A loss of hearing function that do not reduce tension and/or that
that may be congenital or due to normal are hazardous to an individual.
aging or other causes. It interferes with Informal teaching: Teaching that is provided
communication between the sender and at unplanned or unscheduled times.
the receiver. Insidious: Referring to onset that is so
Hill-Burton Act: The first major act or law gradual it is hardly noticed.
to address mental illness in the U.S. It Insomnia: Difficulty sleeping.
provided money to build psychiatric units Integrative medicine: The combination
in hospitals. of conventional and less traditional
Histrionic personality disorder: Associated treatment methods.
with extreme dramatic, excessive behaviors Intentional: An act that may result in injury
in someone who has a pattern of strong or property damage, and that is deter-
emotions. mined to be planned or deliberate.
Holistic view: Viewing a person as a whole. Judgment: Subjective assessment of a patient’s
Homeless: The state of being without a ability to make appropriate decisions.
permanent place of residency or home. “La belle indifférence”: Inappropriate lack
Hyperactivity: Excessive psychomotor ac- of concern for symptoms.
tivity that may be purposeful or aimless. Laryngectomee: Person who has had a
Hypochondriasis: Condition of unrealistic or laryngectomy.
exaggerated concern over minor symptoms. Laryngectomy: Partial or total removal of
Hypnosis: Form of therapy that is meant to the larynx (“voice box”).
produce a state of increased relaxation Lethality: The level of risk of death in the
and increases openness to suggestions for suicide method.
behavior modification. Lunar month: Twenty-eight–day cycle in
Hypnotherapy: The means for entering an prenatal development.
altered state of consciousness, and in this Major depressive disorder: Psychiatric illness
state, the use of visualization and sugges- characterized by depressed mood or loss of
tion to bring about desired changes in interest or pleasure in usual activities that
behavior and thinking. impacts one’s life for at least 2 weeks.
Hypomania: A mild form of mania that is Malingering: Deliberate faking or exagger-
associated with hyperactivity but is not ating of symptoms.
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400 Glossary

Mania: Predominant mood that is elevated, service through the practice of licensed
expansive, or irritable with frenzied motor practical nurses (LPN) and licensed
activity. Also known as manic episodes. vocational nurses (LVN).
Maslow’s Hierarchy of Needs: An orderly National Federation of Licensed Practical
progression of development that takes in Nurses (NFLPN): An organization in
the physical components of personality the United States formed for practical/
development as well as the emotional vocational nursing students.
components. National League for Nursing (NLN): An
Memory: Mental function that enables a organization that emphasizes nursing
person to store and recall information. education, development, and leadership.
Menarche: First menstrual period. National Mental Health Act of 1946: Part
Mental health: State of being able to func- of the result of the first Congress to be
tion with successful adaptation to stressors. held after World War II, providing money
Mental illness: Disorders characterized for training and research in nursing care
by dysregulation of mood, thought, (and other patient care disciplines) to im-
and/or behavior as recognized by the prove care for people with mental illnesses.
Diagnostic and Statistical Manual of Neglect: Deliberate deprivation of necessary
Mental Disorders. and available resources such as medical or
Message: Information that may be verbal or dental care.
non-verbal and that is transmitted from Neurocognitive disorder: A disorder char-
the sender. It is part of the communication acterized by deficits in thinking, memory,
process. and/or judgment
Mild cognitive disorder: Less severe form Neurolinguistic programming (NLP):
of cognitive impairment than dementia. The theory that language cues can be
Milieu: Environment for treating patients. used to understand how an individual
Mind-body connection: An interconnec- experiences his or her world, allowing a
tion of the mind and body in which the practitioner to help a patient change her
mind influences the body’s responses. or his experience and respond to prob-
Models: Pictures or ideas that we form in lems in a different way; uses visual,
our minds to explain how things work. auditory and kinesthetic channels.
They help us understand and interact Nocturnal delirium: Increased confusion and
with other people and our environment, agitation at dusk. Also called sundowning.
and help us to formulate beliefs. Nonverbal communication: Actions, the
Monoamine oxidase inhibitor (MAOI): way we use our body, and facial expres-
Group of antidepressant medications that sion that are used in communications.
work by blocking the enzyme monoamine North American Nursing Diagnosis
oxidase. Association (NANDA): A nursing
Mood: An individual’s sustained emotional organization that establishes and oversees
tone, which influences behavior, person- standardized language for nurses to im-
ality, and perception. prove communication and outcomes.
Morbid obesity: Condition of being Nurse Practice Act: An act based on federal
abnormally overweight; weight that is guidelines adapted to the needs of indi-
100 pounds or more above established vidual states that dictates the acceptable
norms. scope of practice for the different nursing
Narcissistic personality: A disorder that levels.
displays exaggerated self-love and self- Nursing diagnosis: Nonmedical statement
importance. of an existing or potential problem.
National Association for Practical Nurse Nursing Interventions Classification
Education and Service (NAPNES): The (NIC): A comprehensive standardized
world’s oldest nursing organization, it is language of intervention labels and
devoted to promoting quality nursing possible nursing actions.
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Glossary 401

Nursing Outcomes Classification (NOC): Parkinsonism: Group of symptoms that

A standardized language that provides mimic Parkinson's Disease including
outcome statements and a set of indica- tremors and rigidity.
tors that describe the specific patient, Patient Bill of Rights: Federal and state
caregiver, family, or community states guidelines to ensure the civil rights of
related to outcome. people who are entrusted to the care
Nursing process: Established system of data of health-care providers in hospitals,
collecting and care planning performed nursing homes, and so on.
by nurses. Patient interview: An interaction between
Nurse Practice Act: Act that dictates the the patient or client and the health-care
acceptable scope of nursing practice for provider in order to collect patient data.
the different levels of nursing. Patient teaching: Any set of planned educa-
Obesity: A body mass index greater than 30. tion activities designed to improve patients
Omnibus Budget Reconciliation Act health behaviors and health status.
(OBRA): A federal act that provides Person-centered: Humanistic theory of
standards of care for older adults. unconditional positive regard for the
Obsession: Repetitive thought that cannot person, involving treatment of the whole
be ignored by the patient. person rather than just the illness.
Obsessive Compulsive Disorder (OCD): Personality: Sum of the behaviors and
The presence of obsessions and compul- character traits of a person.
sions that the individual feels compelled Personality disorder: Nonpsychotic,
to think about and perform that interfere maladaptive behavior that is used to
with daily functioning. satisfy the self.
Obsessive-compulsive personality disorder: Phobia: Irrational fear.
Characterized by preoccupation with Physical abuse: Any actions by omission or
rules, orderliness, and control. commission that cause physical harm to
Operant conditioning: A method of learning another.
that occurs through rewards and punish- Physical restraint: Any physical method of
ments for desired or undesired behaviors. restricting an individual’s freedom of
Orientation: Measurement of knowledge movement, activity, or normal access
of person, place, and time in the mental to his/her body that cannot be easily
health assessment. removed.
Palliative care: Specialized care that focuses Placebo: A neutral, inactive agent given in
on patients with advanced illness and place of medication that produces symp-
their families by providing expert symp- tom relief or other desired effects based
tom management and the promotion of upon the patient’s expectations and
the best quality of life. beliefs.
Panic disorder: Condition of having one or Plan of care: Nursing process and medical
more panic attacks, followed by the fear orders that dictate a patient’s daily care.
of having others. Postpartum blues: A transient, self-limiting
Paranoid personality disorder: Consistent period of sadness that occurs in a woman
pattern of suspiciousness and mistrust immediately after the birth of her baby.
that interferes with functioning in Postpartum depression: A clinical depres-
society. sion that occurs in a woman shortly after
Paraphilic disorders: Intense and persistent the birth of her baby.
sexual interest that goes outside the Postpartum psychosis: A sudden onset of
bounds of usual behavior. These include psychotic symptoms that occurs in a
pedophilia, exhibitionism, voyeurism, woman after the birth of her baby.
and sadism. Post-traumatic stress disorder: Reaction to
Parenting: Raising children; referring to witnessing or experiencing severe trauma
styles of raising children. that was not expected (e.g., rape, war).
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402 Glossary

Prejudice: Prejudging people or situations Reiki: A form of energy work incorporating

before knowing all the facts. touch that manipulates the client’s energy
Presupposition: Assumptions we make along body meridians or pathways.
when forming communication. Religion: Set of beliefs about one’s spiritual-
Primary gain: Relief of anxiety by use of ity, rituals, and worship.
defense mechanisms or the act of remain- Respite care: Relief supplied to primary
ing physically or mentally unhealthy. caregivers.
Professional: Referring to performing a Responsibility: Accountability.
skill for pay. Restorative: Pertaining to rehabilitation
Proxemics: Study of spatial relationships that focuses on maintaining dignity and
including space, time, and waiting, which achieving optimal function.
are all influenced by one’s culture. Safe house: Specified “secret” place for people
Pseudodementia: Depression in the elderly who are being abused to go for shelter.
that mimics dementia. Schizo-affective disorder: A disorder mani-
Psychoactive (psychotropic) drugs: Any fested by schizophrenic behaviors with
drug that alters mood, perception, a strong element of mood disorders, in-
mental functioning, and/or behavior. cluding depression or mania.
Psychoanalysis: Method of psychotherapy Schizoid personality disorder: A pattern of
based in Freudian theory; uses free associ- extreme detachment from social relation-
ation and dream interpretation as part of ships and a restricted range of emotional
the treatment. Treatment in this style is responses.
usually long-term. Schizophrenia: Serious mental health
Psychopharmacology: Medications as they disorder characterized by impaired com-
are used and prescribed for mental illness. munication, alteration of reality, and
Psychosexual: Referring to Freud’s theory of deterioration of personal and vocational
personality and development in which be- functioning.
havior is related to the sexual gratification Schizophrenia spectrum disorder: The
or lack of it received in early development. gradient of psychopathology seen in
Psychosis: A mental state in which there is a schizophrenia from least to most severe.
severe loss of contact with reality. Schizotypal personality disorder: A per-
Puberty: Stage of development at which sonality disorder characterized by odd
sexual organs mature and one is capable and eccentric behaviors but not to the
of reproducing. degree of schizophrenia.
Purging: The act of attempting to rid the Scope of practice: Terminology used by
body of calories by self-induced vomiting national and state/provincial licensing
or the excessive use of laxatives or diuretics. boards for various professions that defines
Rape: Violent sexual act that is performed the procedures, actions, and processes that
against one’s will. are permitted for the licensee.
Rapport: The matching of speech patterns Secondary gain: Response to illness that
using auditory, kinesthetic, and visual results in attention, monetary benefits,
references, which provide a starting point and the like.
for meaningful communication. Self-mutilating behavior: Deliberate, self-
Rational-emotive therapy (RET): Form injurious behavior such as cutting with
of therapy involving a rational balance the intent of causing nonfatal injury to
between thinking and feeling. attain the relief of tension.
Receiver: The recipient of a message (infor- Sender: The party who transmits a message
mation) sent by a sender. (information) to a receiver.
Reflexology: Massage and manipulation of Sexual abuse: Unwanted sexual contact.
the feet that acts upon energy pathways Sexual harassment: Unwanted sexual innu-
in the body, unblocking and renewing endo, often inflicted by a workplace supe-
the energy flow. rior on an employee or a subordinate.
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Glossary 403

Shaken baby syndrome: A condition that Suicide: The act of purposefully taking one’s
results from an infant’s being shaken own life.
violently by the extremities or shoulders, Suicide attempt: Any act with the intention
usually out of frustration and rage over of taking one’s own life in which the in-
the child’s crying. dividual survived.
Signal anxiety: Stress response to a known Suicide contract: Contract between the pa-
stressor. tient and nurse (or significant other) in
Social communication: The day-to-day inter- which the patient will call the designated
action with personal acquaintances. Slang person when the patient has thoughts of
or “street language” may be used. Less lit- suicide.
eral and purposeful in social interactions. Suicide ideation: Thoughts about harming
Sociopathic: See antisocial personality disorder. oneself.
Somatic: Relating to or affecting the body. Suicide pact: Agreement made among a
Somatic symptom disorders: A persistent group of people (often adolescents) to kill
pattern of excessive and disproportionate themselves together.
thoughts, feelings, and/or behaviors re- Superego: Third part of Freud’s personality
lated to somatic symptoms. theory; the conscience, which deals with
Somatization: Emotional turmoil that is morality.
expressed by physical symptoms, often Survivor: One(s) remaining after the death
loss of functioning of a body part. of another.
Somatoform disorder: Physical discomfort Survivor guilt: Feeling of guilt at being a
that resembles a medical condition that has survivor; often seen in post-traumatic
no logical explanation or medical basis. stress disorder.
Somatoform pain disorder: Anxiety that Survivor of suicide: Family or friend of an
results in severe pain when no physical individual who commits suicide.
cause can be found. Sympathy: Nontherapeutic technique of expe-
Standards of care: Guidelines established riencing the emotion along with the patient.
by specific health-care organizations with Tardive dyskinesia (TD): Involuntary
the expectation that care being provided movements due to side effects of some
does not fall below the minimum expec- antipsychotic drugs.
tations of these organizations. Therapeutic communication: Communica-
Stereotype: A general opinion or belief. tion that attempts to determine a patient’s
Stimulants: Classification of medication needs. Also called active or purposeful
that directly stimulates the central communication.
nervous system. Thinking/cognition: The mental action or
Stress: Emotional strain or anxiety. process of acquiring knowledge and un-
Stressor: Condition that produces stress in derstanding through thought, experience,
an individual. and the senses.
Subjective: Based on personal feelings or Thought: An opinion, idea, or plan that is
beliefs; often relates to patients reporting formed in one's mind.
symptoms in their own words. Tolerance: The need for increasingly larger
Substance abuse: The maladaptive and con- or more frequent doses of a substance to
sistent use of a substance accompanied by obtain the desired effects.
recurrent and significant negative conse- Tort: An action that wrongly causes harm to
quences such as interpersonal, social, another but is not a crime and is dealt
occupational, and legal problems. with in civil court.
Substance dependence: A cluster of cogni- Trance: A state of altered awareness of a
tive, behavioral, and physiological symp- client’s surroundings that brings the indi-
toms that indicate that the individual vidual’s focus of attention to an internal
continues use of the substance despite experience, such as a memory or an
significant substance-related problems. imagined event.
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404 Glossary

Unconscious: Referring to ideas and behav- Verbal communication: Process of exchang-

iors that are concealed from awareness. ing information by the spoken or written
Unintentional: An act that may result in word; the objective part of the process of
injury or property damage and that is communication.
determined to be accidental. Victim: A person who is harmed by another.
Vascular dementia: Dementia caused by Visually impaired: Describes a person
disruption in blood flow to brain, as in with loss of complete or partial visual
strokes. functioning.
Verbal abuse: Method of harming an- Withdrawal: Negative physiological and
other by using degrading, harsh, or psychological reactions that occur when
foul language. a substance is reduced or no longer taken.
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Index
A Advice, giving, as communication block, 27
Advocacy, definition of, 395
AA (Alcoholics Anonymous), 267–268, 268t–269t, 387
Affect, definition of, 395
AAMN (American Association for Men in Nursing), 10, 388
Ageism, definition of, 395
AAPINA (Asian American/Pacific Islander Nurses
Aggressive communication, 17, 395
Association), 10
Aging population, 335–348
AARP (American Association of Retired Persons), 387
abuse. See Elder abuse
Abuse and violence, victims of, 353–366
Alzheimer’s disease, 338, 346t
abuser
cerebrovascular accident (stroke), 338–339, 338f, 346t
characteristics of, 354–355
aphasia, 339
definition of, 395
depression associated with CVA, 338–339
child abuse, 356–357
cognitive impairments, 338, 346t
nursing care plan, 364t
depression, 339, 346t
nursing interventions, 366t
drug side effects, 340, 341t
signs of, 356
end-of-life issues, 342–343
child neglect
insomnia, 341–342, 346t
nursing interventions, 366t
medication concerns, 340, 341t, 346t
domestic violence, 358–359
nursing skills for working with older adults,
nursing interventions, 366t
344–345, 346t
pattern typically followed, 359
overview, 335–338, 348
elder abuse, 359–361, 360f
palliative care, 347–348
characteristics of victims and abusers, 361t
paranoid thinking, 340, 346t
economic abuse, 359–360
restorative nursing, 345, 347, 347f
nursing interventions, 366t
social concerns, 343–344, 343f
emotional abuse, 354
Agnosia, definition of, 395
nursing interventions, 365t
Agoraphobia, 164
neglect, 353, 366t
Agraphia, definition of, 395
nursing care, 362–366
Ailurophobia, 163
general nursing interventions, 362–364,
Akathisia, 114, 395
365t–366t
Alcohol abuse, 264–270
nursing care plans, 364t–366t
definition of, 395
nursing diagnoses, 362
etiology, 266
overview, 83, 353–354, 395
impact on health, 266
physical abuse, 353
impact on the family, 265
nursing interventions, 365t
nursing care plan, 282t
sexual abuse
nursing interventions, 280t–281t
nursing interventions, 365t
treatment, 267–270, 268t–270t
treatment, 361–362
withdrawal, 266–267, 270t
respite care, 361
Alcohol dependence, 264, 395
safe houses, 361
Alcoholics Anonymous (AA), 267–268, 268t–269t, 387
verbal abuse, 354
Alcoholism, definition of, 264, 395
victims, characteristics of, 355, 355t
Alternative and complementary treatment, 143–155
warning signs, 356t
anxiety disorders, 168
Abuse, substance. See Substance use and addictive disorders
aromatherapy, 145–146, 168
Accommodation, 65t, 395
biofeedback, 144–145, 145f, 168
Accountability, 41, 395
definitions
Accuracy, 35–36
alternative medicine, 395
Acrophobia, 163–164
complementary medicine, 397
Adaptation, definition of, 395
herbal and nutritional therapy, 146–147,
Addiction, definition of, 395
148t–149t, 174
Addictive disorders. See Substance use and addictive
hypnotherapy, 151, 168
disorders
massage, energy, and touch, 147, 150, 150f, 174
ADHD (attention-deficit/hyperactivity disorder), 308–312
mind, body, and belief, 144
definition of, 396
neurolinguistic programming, 151–152
nursing care, 311–312
overview, 143–144, 153, 154t, 155
treatment, 310–311
primary sensory representation, 152–153, 152t–153t
Adolescents. See Children and adolescents
somatic symptom and related disorders, 174
Adult stage of human development, 68t
405
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406 Index

Alzheimer, Alois, 248, 248f calcium channel blockers, 122

Alzheimer’s disease, 247–252, 338 definition of, 395
definition of, 395 lithium, 120–121, 121f, 197t
differentiating from normal aging, 249t commonly used forms of lithium, 121
overview, 247–248, 249f nursing considerations, 121
stages, 248–251 toxicity, 197, 197t
1: no impairment (normal function), 248–249 nursing considerations, 121f
2: very mild cognitive decline, 249 side effects, 198t
3: mild cognitive decline, 249 Antiparkinson agents (anticholinergics), 115–116, 116f
4: moderate cognitive decline, 250 commonly used agents, 116
5: moderately severe cognitive decline, 250 definition of, 395
6: severe cognitive decline, 250 nursing considerations, 116, 116f
7: very severe cognitive decline, 250 Antipsychotics (neuroleptics/major tranquilizers), 114–115
symptoms, 248 commonly used agents, 115
treatment, 251–252, 251f, 252t atypical, 115
warning signs, 248 typical, 115
American Association for Men in Nursing (AAMN), 10, 388 definition of, 395
American Association of Retired Persons (AARP), 387 nursing considerations, 114–115, 236t–238t
American Nurses Association (ANA), 5, 9, 34, 90, 395 side effects, 114–115, 236t–238t
American Psychiatric Nurses Association (APNA), 9, 388, 395 Antisocial personality disorder, 219–220
Standards of Psychiatric–Mental Health Clinical Nursing definition of, 395
Practice, 34 nursing interventions, 224t
Amphetamines, 271t Anxiety disorders, 159–170
Anabolic steroids, 275t alternative interventions, 168
Anhedonia, 182 aromatherapy, 168
definition of, 395 biofeedback, 168
Anorexia nervosa, 287–290 hypnotherapy, 168
definition of, 395 definition of anxiety, 160, 395
etiology, 289 differential diagnosis, 161–162, 161–163
nursing care plan, 296t DSM-5 revisions to anxiety disorders, 160, 162–163
similarities to bulimia, 292, 292t etiology of anxiety and stress, 161, 161f, 162t
symptoms, 288–289 generalized anxiety disorder (GAD), 162–163, 171f
treatment, 289 medical treatment, 167–168
Answers to test questions, 370–386 medications, 167, 168t
Antabuse (disulfiram), 269–270 nursing care, 168–170, 169t–170t, 171f
Antianxiety agents (anxiolytics/minor tranquilizers), nursing care plan, 170t
116–117, 117f nursing diagnoses, 168
nursing considerations, 116–117, 117f obsessive-compulsive disorder (OCD), 164–165,
Anticholinergics, 115–116, 116f 165f
commonly used agents, 116 overview, 160, 160f, 177
definition of, 395 panic disorder, 163, 171f
nursing considerations, 116, 116f phobia, 163–164, 164f
Anticholinergic side effects of antipsychotics, 238t post-traumatic stress disorder (PTSD), 165–166,
Anticonvulsants, 121–122 167f
commonly used agents, 122 Anxiolytics/minor tranquilizers, 116–117, 117f
nursing considerations, 121–122 nursing considerations, 116–117, 117f
Antidepressants (mood elevators), 117–120 Aphasia, definition of, 395
alternative treatments for depression, 120 Aphasic/dysphasic disorders
commonly used agents, 117 communication challenges, 20–21, 29–30, 339
definition of, 395 picture board for patients, 29f
monoamine oxidase inhibitors (MAOIs), 119–120 types of aphasia, 20t
commonly used agents, 120 APIE format, 98–99
nursing considerations, 119–120 A = assessment, 98
nursing considerations, 120 P = plan, 98
overview, 118f I = implementation, 98–99
selective serotonin reuptake inhibitors (SSRIs, E = evaluation, 99
bicyclic antidepressants), 117–118 APNA (American Psychiatric Nurses Association),
nursing considerations, 118, 118f 9, 388, 395
serotonin norepinephrine reuptake inhibitors (SNRIs), 119 Standards of Psychiatric–Mental Health Clinical Nursing
commonly used agents, 119 Practice, 34
tetracyclic antidepressants (heterocyclic antidepressants), 119 Apraxia, definition of, 395
commonly used agents, 119 Arachnophobia, 164f
tricyclic antidepressants, 118–119 Aromatherapy, 145–146
commonly used agents, 119 anxiety disorders, 168
nursing considerations, 119 definition of, 396
Antimanic agents (mood stabilizing agents), 120–123 Asian American/Pacific Islander Nurses Association
anticonvulsants, 121–122 (AAPINA), 10
commonly used agents, 122 Assertive communication, 18, 396
nursing considerations, 121–122 Assessing the patient’s mental health, 90–95
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Index 407

Assimilation, 65t, 396 Bullying, 303, 396–397

Asylums, 8, 396 ByBerry (Philadelphia State Hospital), 8, 8f
Attention-deficit/hyperactivity disorder (ADHD), 308–312
definition of, 396
nursing care, 311–312 C
treatment, 310–311 Calcium channel blockers, 122
Autism spectrum disorder, 312–315 Cannabis, 271t
definition of, 396 Carcinomatophobia, 163
nursing care, 314–315 Catatonia, 233
treatment, 314, 316t definition of, 396
Autonomy, 65t, 396 Catharsis, 125–126
Avoidance, 109t Cerebrovascular accident (stroke), 338–339, 338f
Avoidant personality, definition of, 396 aphasia, 339
Avoidant personality disorder, 222 depression associated with, 338–339
nursing interventions, 224t Cerebrovascular disease, definition of, 396
Awareness, 90, 91t Charting, 35
definition of, 395 by exception, 35
flow-sheet charting, 35
legality challenges, 35
B Chemical restraint, definition of, 396
Bailey, Harriet, 6 Chi, 150
Behavior, definition of, 396 Child Abuse Prevention Association, 387
Behavioral theorists, 58 Children and adolescents, 303–318
Behavior modification, 126–127, 126f adolescent stage of human development, 67t
definition of, 396 attention-deficit/hyperactivity disorder (ADHD), 308–312
Beliefs, definition of, 396 nursing care, 311–312
Bessent, Hattie, 7, 7f possible causes, 310
Bicyclic antidepressants, 117–118 symptoms, 309
nursing considerations, 118, 118f treatment, 310–311
Binge drinking, 265, 396 autism spectrum disorder, 312–315
Binge eating disorder, 291, 396 nursing care, 314–315, 315t
Biofeedback, 144–145, 145f bullying and cyber bullying, 303
anxiety disorders, 168 child abuse, 356–357, 364t
definition of, 396 nursing care plan, 364t
Bipolar disorders, 193–200 nursing interventions, 366t
characteristics, 193–195, 194t signs of, 356
cyclothymic disorder, 193, 194t conduct disorder, 315–318
depressed phase, 195 nursing care, 317–318
hypomania phases, 193 treatment, 316–317
manic phase, 193–195 depression, bipolar disorder, and suicide, 304–308
children and adolescents, 305 bipolar disorder, 305
definition of, 396 depression, 304, 305f
etiology, 195–196 nursing care, 308, 308t
drugs that can cause manic states, 196 suicide, 306–307, 306f
nursing care, 198–199 treatment, 307
general nursing interventions, 198–199 developmental psychology of, 52–63. See also
nursing care plan, 200t Developmental psychology
nursing diagnoses, 198 neglect, 366t
overview, 199 overview, 303–304, 318
treatment, 196–198, 197t–198t substance use and addictive disorders, 276
Bisexual lifestyle, 79 suicide, 306–307, 306f
Bleuler, Eugen, 231, 232f Child Welfare Information Gateway, 387
Blues, postpartum, 323–324 Civil law, 35, 396
definition of, 401 Civil unions, 79
treatment, 324 Claustrophobia, 164
Body image, 287, 288f Club drugs, 270, 275t
definition of, 396 Cluster A, personality disorders, 218–219
Body mass index (BMI), 292 paranoid personality disorder, 218
definition of, 396 schizoid personality disorder, 219
Borderline personality, definition of, 396 schizotypal personality disorder, 219
Borderline personality disorder, 220–221, 226t Cluster B, personality disorders, 219–222
nursing care plan, 226t antisocial personality disorder, 219–220
nursing interventions, 224t borderline personality disorder, 220–221
Bulimia, 290–292 histrionic personality disorder, 221
definition of, 396 narcissistic personality disorder, 221–222
etiology, 291 Cluster C, personality disorders, 222–223
similarities to anorexia, 292, 292t avoidant personality disorder, 222
symptoms, 291 dependent personality disorder, 222
treatment, 291–292 obsessive-compulsive personality disorder, 222–223
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408 Index

Cocaine, 272t Conversion reaction, 109t

Co-dependency, 265, 281t, 396 Co-occurring disorders (dual diagnosis)
Cognitive behavior therapy (CBT), 128, 138t definition of, 397
Cognitive, definition of, 396 substance use and addictive disorders, 262, 263f–264f
Cognitive Development theory (Piaget), 54 Coping, definition of, 397
Cognitive impairments, 338 Coping and defense mechanisms, 105–110
Cognitive therapies, 127–128 coping, 105–106, 106f–107f
cognitive behavior therapy (CBT), 128, 138t effective, 105–106
rational-emotive therapy (RET), 127–128, 127f ineffective, 106
Collaborative, definition of, 396 defense mechanisms, 107–110
Commitment, definition of, 396 commonly used, 108t–109t
Communication, 15–30 overview, 110
aggressive, 17 Counseling, 129–132
assertive, 18 definition of, 397
challenges to, 19–21, 28–30 group therapy, 131–132
aphasic/dysphasic disorders, 20–21, 20t, 29–30, 29f overview, 129f
hearing-impaired, 19, 28 pastoral or cultural counseling, 129–131, 130f, 131t, 132f
language differences, 20, 29 Crisis, definition of, 397
laryngectomies, 20, 28–29 Crisis intervention, 134–136
visually impaired, 19–20, 28 goals, 135–136, 135f
communication theory, 15 nursing considerations, 135f
cultural implications, examples of, 17 phases of crisis, 134–135, 134t
definition of, 16, 396 Cultural or pastoral counseling, 129–131, 130f, 131t, 132f
ineffective, 21–23 Culture, 75–77, 75f
1. false reassurance/social clichés, 21 definition of, 397
2. minimizing/belittling, 21 Culture of nurses, 37–38, 38f
3. “why?”, 21–22 definition of, 397
4. advising, 22 Cyberbullying, 303, 397
5. agreeing or disagreeing, 22 Cyclothymic, definition of, 397
6. closed-ended questions, 22 Cyclothymic disorder, 193, 194t
7. providing the answer with the question, 22
8. changing the subject, 23
9. approving or disapproving, 23 D
neurolinguistic programming, 18–19 Data collection, 90, 397
nonverbal, 16–17, 17f Date rape, 358, 397
overview, 15–16, 30 Death and dying, 69–70
social, 18 Decidophobia, 163
therapeutic/helping, 18, 21–28 Defense mechanisms, 107–110
1. reflecting, repeating, parroting, 24 commonly used, 108t–109t
2. clarifying terms, 24 definition of, 397
3. open-ended questions, 24–25 Deinstitutionalization, 9, 397
4. asking for what you need or want, 25 Delirium, 245–246
5. identifying thoughts and feelings, 25–26 causes, 247t
6. using empathy, 26 definition of, 397
7. silence, 26–27 differential diagnosis, 253, 253t
8. giving information, 27 treatment, 246
9. using general leads, 27 types, 246t
10. stating implied thoughts and feelings, 28 Delirium tremens (DTs), 267, 397
techniques, 23–28 Delusional disorder, 232t
types of communication, 16 Delusions
Communication block, definition of, 396 common, 234t
Community Mental Health Centers Act of 1963, 12, 396–397 definition of, 397
Community resources, 45–46 Dementia, 247–253
Compensation, 108t Alzheimer’s disease. See Alzheimer’s disease
Complementary medicine, 143 definition of, 397
definition of, 397 differential diagnosis, 253, 253t
See also Alternative and complementary treatment miscellaneous types, 252–253
Compulsion, 165, 397 vascular dementia, 252, 403
Conduct disorder, 315–318 Denial, 108t, 279t
definition of, 397 Dependent, definition of, 397
nursing care, 317–318 Dependent personality disorder, 222
treatment, 316–317 nursing interventions, 225t
Confidentiality, 38–39, 39f Depressed phase, bipolar disorders, 195
definition of, 397 Depression and Bipolar Support Alliance, 387
doctrine of privileged information, 38 Depressive disorders, 181–189
Conversion, definition of, 397 associated with another medical condition, 184–185
Conversion disorder, 172–173 associated with cerebrovascular accident (stroke),
nursing care, 172–173175t 338–339
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children and adolescents, 304, 305f Dysmorphophobia, definition of, 397

cultural considerations, 181 Dysphasia, definition of, 397
definition of, 397 Dysphasic/aphasic disorders
drugs that can cause, 185 communication challenges, 20–21, 29–30, 339
dysthymic disorder, 183 picture board for patients, 29f
elderly patients, 339 types of aphasia, 20t
etiology, 185 Dysthymic disorder, 183, 397
major depressive disorder, 181–183, 183f Dystonia, 114, 397
differentiating grief from, 182, 184t
major depressive disorder with seasonal pattern,
183–184 E
nursing care, 186–188 Eating disorders, 287–297
general nursing interventions, 186–187 anorexia nervosa, 287–290
nursing care plan, 188t etiology, 289
nursing diagnoses, 186 nursing interventions, 296t
overview, 181, 182f, 188 similarities to bulimia, 292, 292t
postpartum, 183, 324–326 symptoms, 288–289
treatment, 325–326 treatment, 289
premenstrual dysphoric disorder, 184–185 binge eating disorder, 291
substance-induced depressive disorder, 184 bulimia, 290–292
treatment, 185–186 etiology, 291
alternative treatment, 186 nursing interventions, 296t
medications, 186, 187t similarities to anorexia, 292, 292t
Detoxification, 268, 397 symptoms, 291
Developmental psychology, 51–71 treatment, 291–292
adolescence to adulthood, 56–63 morbid obesity, 292–294
Freud, 56–58 etiology, 293
Horney, 58, 58f nursing interventions, 296t
Jung, 62–63, 63f treatment, 293–294
Maslow, 60–62, 60f–61f nursing care, 294–296
Pavlov, 58–59, 58f general nursing interventions, 295, 296t
Rogers, 62, 62f, 63t nursing care plan, 296t
Skinner, 58–60, 59f, 59t nursing diagnoses, 294
newborn to adolescence, 52–56 overview, 287, 297
Erikson, 52–53, 54f, 54t–55t Echolalia, definition of, 398
Freud, 52, 52f, 53t Echoparaxia, definition of, 398
Kohlberg, 54–56, 56f, 57t Economic abuse, 359–360
Piaget, 53–54, 55f definition of, 398
overview, 51–52, 71 Economic considerations, 82–83
stages of human development, 63–70 ECT (electroconvulsive therapy), 132–133, 132f
adolescent, 67t definition of, 398
adult, 68t Effective coping, definition of, 398
death and dying, 69–70 Ego, definition of, 398
infant, 65t Elder abuse, 359–361, 360f
newborn, 64t characteristics of victims and abusers, 361t
older adult, 68t definition of, 398
prenatal, 64t economic abuse, 359–360
preschool (early childhood), 66t nursing interventions, 366t
school age, 66t–67t Elderly. See Aging population
toddler, 65t Electroconvulsive therapy (ECT), 132–133, 132f
young adult, 68t definition of, 398
Displacement, 109t Ellis, Albert, 127
Dissociate, definition of, 397 Emotional abuse, 354
Dissociation, 108t definition of, 398
Disulfiram (Antabuse), 269–270 nursing interventions, 365t
Dix, Dorothea, 5, 5f Empathy, 26, 398
Doctrine of privileged information, 38, 397 End-of-life issues, 342–343
Domestic violence, 358–359 Energy, massage, and touch, 147, 150, 150f
definition of, 397 “Epic” charting program, 35
nursing interventions, 366t EPS (extrapyramidal symptoms), 114–115,
pattern typically followed, 359 236–237
Dream analysis, 124–125 akathisia, 114
Drug-induced parkinsonism, 114 definition of, 398
DTs (delirium tremens), 267 drug-induced parkinsonism, 114
definition of, 397 dystonia, 114
Dual diagnosis, 262, 263f–264f. See also Co-occurring tardive dyskinesia, 115
disorders Erikson, Erik, 52–53, 54f, 54t–55t
Dysfunctional, definition of, 397 eight stages of development, 54t–55t
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410 Index

Ethics and law, 11–12, 33–46 Geriatrics, 335

abiding by current laws, 41–42 definition of, 398
Good Samaritan laws, 41–42 Gerontology, 335
involuntary commitment, 42 definition of, 398
voluntary commitment, 42 Gilligan, Carol, 62
accountability, 41 Global aphasia, 20t
accuracy, 35–36 Glossary, 395–403
charting, legality challenges to, 35 Good Samaritan laws, 41–42
Community Mental Health Centers Act of 1963, 12 Grandiosity, 279t
community resources, 45–46 Grief, differentiating from depression, 182, 184t
confidentiality, 38–39, 39f Grief/death and dying, stages of, 69–70, 69t
culture of nurses, 37–38, 38f children, 70
ethics, 34, 398 elderly, 342
Health Insurance Portability and Accountability Act Group therapy, 131–132
(HIPAA), 40, 398
Hill-Burton Act, 11
honesty, 36
H
Hallucinations
impaired nurses, 36 definition of, 398
Joint Commission (JC), 40 recognizing, 234t
National Mental Health Act of 1946, 12 Hallucinogens, 272t
NFLPN Nursing Practice Standards, 391 Harm, intentional and unintentional, 35
Nurse Practice Act, 34–35 Health-illness continuum, definition of, 398
overview, 46 Health Insurance Portability and Accountability Act
patient advocacy, 45 (HIPAA), 40, 398
Patient Bill of Rights, 12, 42, 401 Hearing impaired, 15
patients’ rights, 42–45, 43t–44t communication challenges, 19, 28
professionalism, 33–34 definition of, 398
psychotherapies and, 137–138 Helping interview, 94–95, 94f
responsibility, 41 Hematophobia, 164
standards of care, 34 Herbal and nutritional therapy, 146–147, 148t–149t
Ethnicity, 78–79 depressive disorders, 186
definition of, 398 somatic symptom and related disorders, 174
Ethnocentrism, 78 Heterocyclic antidepressants, 119
definition of, 398 commonly used agents, 119
Eustress, 160 Hierarchy of Needs (Maslow), 60, 61f, 391
definition of, 398 love and belonging, 61
Evaluation, definition of, 398 physiological needs, 60
Expressive aphasia, 20t safety and security, 60–61
Extrapyramidal symptoms (EPS), 114–115, 236–237 self-actualization, 62
akathisia, 114 self-esteem, 61–62
definition of, 398 Hill-Burton Act, 11, 398
drug-induced parkinsonism, 114 HIPAA (Health Insurance Portability and
dystonia, 114 Accountability Act), 40, 398
tardive dyskinesia, 115 History, 3–13
breakthroughs, 8–11
F deinstitutionalization, 9
nursing organizations and recommendations, 9–11
Factitious disorder, 173
Feeling, definition of, 398 psychotropic medications, 9
Feeling statement, definition of, 398 facilities, 8
Fiduciary abuse, 359 asylums, 8
Fight-or-flight response, 161, 161f free-standing facilities, 8
Flow-sheet charting, 35 hospitals, 8
Formal teaching, 97, 398 laws, 11–12
Free association, 124 Community Mental Health Centers Act of 1963, 12
Free-floating anxiety, 160 Hill-Burton Act, 11
definition of, 398 National Mental Health Act of 1946, 12
Free-standing treatment centers, 8, 398 Patient Bill of Rights, 12, 42, 401
Freud, Sigmund, 52, 52f, 53t, 56–58 overview, 12–13
psychoanalytic or psychosexual stages of trailblazers, 3–7
development, 52, 53t Bailey, 6
Bessent, 7, 7f
Dix, 5, 5f
G Mahoney, 6, 6f
Gay lifestyle, 79 Nightingale, 3–5, 4f
Gay marriage, 79 Peplau, 6–7, 7f
Generalized anxiety disorder (GAD), 162–163, 171f, 398 Richards, 5, 5f
nursing care, 169t Taylor, 6, 6f
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Index 411

Histrionic personality disorder, 221

nursing interventions, 225t
L
La belle indifférence, 173, 399
Holistic view, definition of, 398
Language differences and communication challenges,
Homeless, definition of, 398
20, 29
Homelessness, 81–82, 81f
Laryngectomee, definition of, 399
deinstitutionalization and, 82–83
Laryngectomy
nursing techniques, 82
communication challenges, 20, 28–29
Honesty, 36
definition of, 399
Horney, Karen, 58, 58f
Learning, principles of, 98
Hospice and Palliative Nurses Association (HPNA), 348
Legal matters. See Ethics and law
Hospitals, 8
Lesbian, gay, bisexual, and transgender (LGBT)
Humanist theories, 60
lifestyles, 79
Humor therapy, 133–134, 133f
Lethality, definition of, 399
Hyperactivity, definition of, 398
Light therapy
Hypnosis, 125, 125f
depressive disorders, 186
definition of, 399
Lithium, 120–121, 121f, 197, 197t
Hypnotherapy, 151
commonly used forms of lithium, 121
anxiety disorders, 168
nursing considerations, 121
definition of, 399
toxicity, 197, 197t
Hypochondriasis, 172–173
Longfellow, H.W., 4
definition of, 399
Love and belonging
Hypomania, definition of, 399
Maslow’s Hierarchy of Needs, 61
Lunar month, definition of, 399
I
Id, definition of, 399 M
Illness anxiety disorder, 173 Mahoney, Mary, 6, 6f
nursing care, 175t Major depressive disorder, 181–183, 183f
Illusions, 238, 399 definition of, 399
Impaired nurses, 36 differentiating grief from, 182, 184t
Implementations/interventions, 96–100 Major tranquilizers. See Antipsychotics
definition of implementation, 399 Malingering, 173
evaluating, 100 definition of, 399
nursing process, 96t Mania, definition of, 399
patient teaching, 97–100 Manic phase, bipolar disorders, 193–195
principles of learning, 98 Manipulation, 279t
principles of teaching, 98–100 Maslow, Abraham, 60–62, 60f–61f
Impulsivity, definition of, 399 Hierarchy of Needs, 60, 61f, 391
Incest, 358 love and belonging, 61
definition of, 399 physiological needs, 60
Ineffective communication, definition of, 399 safety and security, 60–61
Ineffective coping, definition of, 399 self-actualization, 62
Infant stage of human development, 65t self-esteem, 61–62
Informal teaching, 97, 399 Massage, energy, and touch, 147, 150, 150f
Inhalants, 272 Memory, definition of, 399
Insidious, definition of, 399 Menarche, 67t
Insomnia definition of, 399
definition of, 399 Mental health, definition of, 399
elderly patients, 341–342 Mental Health America, 387
Intake/admission interview, 94 Mental health status examination, 91t–93t
Integrative medicine, definition of, 399 Mental illness, definition of, 399
Intentional, definition of, 399 Message, 16, 399
Involuntary commitment, 42 Methamphetamine, 271t, 276f
Isolation, 109t Mild neurocognitive disorder, 248
Milieu, 123
J definition of, 399
Mind, body, and belief, 144
Joint Commission (JC), 40
Mind-body connection, definition of, 399
Judgment, definition of, 399
Minimizing, 279t
Jung, Carl, 62–63, 63f
Minor tranquilizers, 116–117, 117f
nursing considerations, 116–117, 117f
K Models, definition of, 399
Ki, 150 Monoamine oxidase inhibitors (MAOIs), 119–120
Kohlberg, Lawrence, 54–56, 56f, 57t commonly used agents, 120
development of moral reasoning, 54–56, 57t definition of, 399
Kübler-Ross, Elisabeth, 69–70, 69f, 69t nursing considerations, 119–120
stages of grief/death and dying, 69–70, Mood, definition of, 399
69t, 342 Mood stabilizing agents. See Antimanic agents
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412 Index

Morbid obesity, 292–294 NHPCO (National Hospice & Palliative Care

definition of, 400 Organization), 387
etiology, 293 NIC (Nursing Interventions Classifications), 97–98
treatment, 293–294 definition of, 400
Myths concerning suicide, 206t Nicotine, 273t
Nightingale, Florence, 3–5, 4f
N NIMH (National Institute of Mental Health), 12
NLN (National League for Nursing), 5, 10, 400
NAHN (National Association of Hispanic Nurses), 10, 389 NOC (Nursing Outcome Classifications)
NANDA (North American Nursing Diagnosis definition of, 400
Association), 95, 400 Nocturnal delirium, 245
NAPNES (National Association for Practical Nurse definition of, 400
Education and Service), 10, 388, 400 Nontraditional lifestyles, 79–80, 80f
Narcissistic personality, definition of, 400 Nonverbal communication, 16–17, 17f
Narcissistic personality disorder, 221–222 definition of, 400
nursing interventions, 225t North American Nursing Diagnosis Association (NANDA),
National Alaska Native American Indian Nurses 95, 400
Association (NANAINA), 10 Nurse Practice Act, 10, 34–35
National Alliance on Mental Illness, 387 definition of, 400
National Association for Practical Nurse Education and Nursing diagnosis, 95
Service (NAPNES), 10, 388, 400 common behaviors and corresponding nursing
National Association of Hispanic Nurses (NAHN), 10, 389 diagnoses, 393–394
National Black Nurses Association (NBNA), 10, 389 definition of, 400
National Coalition of Ethnic Minority Nurse Nursing interventions, 281t
Associations (NCEMNA), 10, 388 Nursing Interventions Classifications (NIC), 96
National Council of Alcohol and Drug Dependence, 387 definition of, 400
National Federation of Licensed Practical Nurses (NFLPN), Nursing organizations, history of, 9–11
10, 34, 388, 400 Nursing Outcome Classifications (NOC), 97
Code for Licensed Practical/Vocational Nurses, 390 definition of, 400
Standards of Nursing Practice, 34, 390–392 Nursing process in mental health, 89–101, 90f, 96t
National Hospice & Palliative Care Organization definition of, 400
(NHPCO), 387 overview, 89–90, 90f, 101
National Institute of Mental Health (NIMH), 12, 387 step 1: assessing the patient’s mental health, 90–95
National League for Nursing (NLN), 5, 10, 400 helping interview, 94–95, 94f
National Mental Health Act of 1946, 12, 400 intake/admission interview, 94
National Mental Health Association, 387 mental health status examination, 90, 91t–93t
NBNA (National Black Nurses Association), 10, 389 step 2: nursing diagnosis: defining patient
NCEMNA (National Coalition of Ethnic Minority Nurse problems, 95
Associations), 10, 388 step 3: planning (short- and long-term goals),
Neglect, 353, 366t 95–96
definition of, 400 step 4: implementations/interventions, 96–100
Neurocognitive disorders, 245–257 nursing process, 96t
definition of, 400 patient teaching, 97–100
delirium, 245–246 principles of learning, 98
causes, 247t principles of teaching, 98–100
differential diagnosis, 253, 253t step 5: evaluating interventions, 100
treatment, 246 Nyctophobia, 163
types, 246t
dementia, 247–253
Alzheimer’s disease. See Alzheimer’s disease O
differential diagnosis, 253, 253t Obesity, definition of, 400
miscellaneous types, 252–253 OBRA (Omnibus Budget Reconciliation Act),
vascular dementia, 252, 403 337, 400
nursing care, 253–257 Obsession, 165
general nursing interventions, 254–256 definition of, 400
nursing care plan, 256t Obsessive-compulsive disorder (OCD), 164–165, 165f
nursing diagnoses, 253 definition of, 400
overview, 245, 257 compulsion, 165
Neuroleptic malignant syndrome, 115 nursing care, 170t
Neuroleptics. See Antipsychotics obsession, 165
Neurolinguistic programming, 18–19, 151–152 Obsessive-compulsive personality disorder, 222–223
definition of, 400 definition of, 400
presuppositions, 152 nursing interventions, 225t
Newborn stage of human development, 64t Odontophobia, 163
NFLPN (National Federation of Licensed Practical Nurses), Older adults. See Aging population
10, 34, 388, 400 Omnibus Budget Reconciliation Act (OBRA),
Code for Licensed Practical/Vocational 337, 400
Nurses, 390 Operant conditioning, 59, 59t
Standards of Nursing Practice, 34, 390–392 Ophidiophobia, 164f
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Index 413

Opioids, 273t carcinomatophobia, 163

Orientation, definition of, 400 claustrophobia, 164
common, list of, 163
decidophobia, 163
P definition of, 401
Palliative care, 347–348 hematophobia, 164
definition of, 400–401 nursing care, 169t
Panic, definition of, 401 nyctophobia, 163
Panic disorder, 163, 171f odontophobia, 163
nursing care, 169t ophidiophobia, 164f
Paranoid personality disorder, 218 scoleciphobia, 163
nursing interventions, 225t–116t social phobias, 164
Paranoid thinking in older adults, 340 thanatophobia, 163
Parenting, 83–84 Physical abuse, 353
authoritarian, 83–84 definition of, 401
authoritative parents, 84 nursing interventions, 365t
definition of, 401 Physical restraint, definition of, 401
permissive parents, 84 Physician-assisted suicide, 70
poor, 83–84 Physiological needs
Pastoral or cultural counseling, 129–131, 130f, 131t, 132f Maslow’s Hierarchy of Needs, 60
Patient advocacy, 45 Piaget, Jean, 53–54, 55f
Patient Bill of Rights, 12, 42, 401 developmental theory of, 56t
Patient interview, 94 Placebos, 144, 401
definition of, 401 Planning (short- and long-term goals), 95–96
Patients’ rights, 42–45 Plan of care, 95, 401
most frequently adopted, 43t–44t PNAA (Philippine Nurses Association of America), 10
Patient Bill of Rights, 12, 42, 401 Positive regard, unconditional, 128–129
Patient Self-Determination Act (PSDA), 45 Postpartum issues, 323–330
for psychiatric patients, 45 nursing care, 328–329
Patient teaching, 97–100 general nursing interventions, 328–329
Pavlov, Ivan, 58–59, 58f nursing care plan, 329t
Peplau, Hildegard, 6–7, 7f, 160 nursing diagnoses, 328
collaborative therapeutic relationship, 7 overview, 323, 330
nursing functions, 6–7 postpartum blues, 323–324, 401
Personality, definition of, 401 treatment, 324
Personality disorders, 217–227 postpartum depression, 183, 324–326, 401
cluster A, 218–219 contributing factors, 325
paranoid personality disorder, 218 symptoms, 325
schizoid personality disorder, 219 treatment, 325–326
schizotypal personality disorder, 219 postpartum psychosis, 326–328, 401
cluster B, 219–222 treatment, 326–328
antisocial personality disorder, 219–220 Post-traumatic stress disorder (PTSD), 165–166, 167f
borderline personality disorder, 220–221 definition of, 401
histrionic personality disorder, 221 nursing care, 170t
narcissistic personality disorder, 221–222 Prana, 150
cluster C, 222–223 Prejudice, 78, 401
avoidant personality disorder, 222 Premenstrual dysphoric disorder, 184–185
dependent personality disorder, 222 Prenatal infants, stage of human development, 64t
obsessive-compulsive personality disorder, 222–223 Preschool children (early childhood), stage of human
definition of, 401 development, 66t
nursing care, 223–226 Presuppositions, 152, 401
general nursing interventions, 224t–226t Primary gain, 173
nursing care plan for borderline personality disorder, 226t definition of, 401
nursing diagnoses, 223 Primary sensory representation, 152–153, 152t–153t
overview, 217–218, 227 Professional, definition of, 401
psychiatric treatment, 223 Professionalism, 33–34
Person-centered, definition of, 401 Projection, 109t, 279t
Person-centered/humanistic therapy, 60, 128–129, 128f Proxemics, 37–38
unconditional positive regard, 128–129 definition of, 401
Pet therapy, 134 PSDA (Patient Self-Determination Act), 45
Phencyclidine, 274t Pseudodementia, 247
Philadelphia State Hospital (ByBerry), 8, 8f definition of, 401
Philippine Nurses Association of America (PNAA), 10, 389 Psychoactive (psychotropic) drugs, 9, 114, 261
Phobias, 163–164, 164f definition of, 401
acrophobia, 163–164 Psychoanalysis, 124–125
agoraphobia, 164 definition of, 401
ailurophobia, 163 dream analysis, 124–125
arachnophobia, 164f free association, 124
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414 Index

psychoanalytic or psychosexual stages of development Religion, 76–77

(Freud), 52, 53t definition of, 402
psychoanalytic social theory (Horney), 58 Repression, 108t
Psychopharmacology, 114–123 Respite care, 361, 402
antianxiety agents (anxiolytics/minor tranquilizers), Responsibility, 41, 402
116–117, 117f Restitution (undoing), 109t
antidepressants (mood elevators). See Antidepressants Restorative, definition of, 402
(mood elevators) Restorative nursing, 345, 347, 347f
antimanic agents (mood stabilizing agents). See RET (rational-emotive therapy), 127–128, 127f, 401
Antimanic agents (mood stabilizing agents) Richards, Linda, 5, 5f
antiparkinson agents (anticholinergics), 115–116, 116f Rogers, Carl, 62, 62f
antipsychotics (neuroleptics/major tranquilizers), 114–115 eight steps to being a helping person, 62, 63t
definition of, 401 Rolfing, 147
stimulants, 122–123, 122f
Psychosexual, definition of, 401
Psychosis, 232 S
definition of, 401 Safe house, 361, 402
postpartum, 326–328, 401 Safety and security
treatment, 326–328 Maslow’s Hierarchy of Needs, 60–61
Psychotherapies, 123–136 SAMe, 120
behavior modification, 126–127, 126f, 138t Scapegoating, 109t
catharsis, 125–126 Schizoaffective disorder, 232t, 402
cognitive therapies, 127–128 Schizoid personality disorder, 219
cognitive behavior therapy (CBT), 128, 138t nursing interventions, 226t
rational-emotive therapy (RET), 127–128, 127f, 138t Schizophrenia spectrum and other psychotic disorders,
counseling, 129–132 231–241
group therapy, 131–132, 138t definition of, 402
overview, 129f delusions, common, 234t
pastoral or cultural counseling, 129–131, 130f, 131t, etiology, 234–235
132f, 138t hallucinations, recognizing, 234t
crisis intervention, 134–136, 138t nursing care, 238–240
goals, 135–136, 135f nursing care plans, 239t–240t
phases of crisis, 134–135, 134f nursing diagnoses, 238
electroconvulsive therapy (ECT), 132–133, 132f, 138t nursing interventions, 238–239, 240t
humor therapy, 133–134, 138t other disorders with schizophrenic features, 232t
hypnosis, 125, 125f overview, 231–234, 232t, 233f, 240
legal considerations, 137–138 psychiatric treatment, 235, 237
overview, 124–125, 124f, 138–139, 138t–139t side effects of antipsychotic agents, 236t–238t
person-centered/humanistic therapy, 128–129, 128f, 138t symptoms
unconditional positive regard, 128–129 negative, 233–234
pet therapy, 134 positive, 233–234
psychoanalysis, 124–125 Schizophreniform disorder, 232t
dream analysis, 124–125 Schizotypal personality disorder, 219, 232t
free association, 124 definition of, 402
Psychotropic (psychoactivve) medications, 9, 114, 261 nursing interventions, 226t
definition of, 401 School age children, stage of human development, 66t–67t
PTSD (post-traumatic stress disorder), 165–167, 167f Scoleciphobia, 163
definition of, 401 Scope of practice, 89
nursing care, 170t Secondary gain, 173
Puberty, 67t, 401 definition of, 402
Purging, 288, 401 Sedatives, hypnotics, and antianxiety drugs (commonly
abused), 274t
Selective serotonin reuptake inhibitors (SSRIs, bicyclic
R antidepressants), 117–118
Rape, 358, 401 nursing considerations, 118, 118f
Rapport, 152 Self-actualization
definition of, 401 Maslow’s Hierarchy of Needs, 62
Rational-emotive therapy (RET), 127–128, 127f Self-mutilating behavior, 220, 221f, 402
definition of, 401 Sender, 16, 402
Rationalization, 108t, 279t Serotonin norepinephrine reuptake inhibitors (SNRIs), 119
Reaction formation (over-compensation), 108t commonly used agents, 119
Receiver, 16, 401 Sexual abuse, 357–358
Receptive aphasia, 20t definition of, 402
Reflexology, 150, 150f nursing interventions, 365t
definition of, 402 Sexual harassment, 357
Regression, 108t definition of, 402
Reiki, 150 Shaken baby syndrome, 356, 402
definition of, 402 Shiatsu, 150
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Index 415

Signal anxiety, 160, 402 Substance use and addictive disorders, 261–283
Skinner, B.F., 58–60, 59f, 59t alcohol, 264–270
operant conditioning, 59, 59t etiology of abuse, 266
SNRIs (serotonin norepinephrine reuptake inhibitors), 119 etiology of alcohol abuse, 266
commonly used agents, 119 impact on health, 266
Social communication, 18, 402 impact on the family, 265
Social phobias, 164 nursing care plan, 282t
Sociocultural influences on mental health, 75–84 nursing interventions, 280t–281t
abuse, 83 symptoms, 280t–281t
cultural assessment questions, 77 treatment, 267–270, 2268t–270t
cultural sensitivity, enhancing, 79 withdrawal, 266–267, 270t
culture, 75–77, 75f children and teens, 276
economic considerations, 82–83 co-occuring disorders (dual diagnosis), 262,
ethnicity, 78–79 263f–264f
homelessness, 81–82, 81f etiology, 276–277
nontraditional lifestyles, 79–80, 80f nursing care, 278–282
overview, 75, 84 coping styles of substance abusers, 279t
poor parenting, 83–84 diagnoses, 278–279
Sociopathic, definition of, 402 general nursing interventions, 279–281,
Somatic symptom and related disorders, 170–177 280t–281t
alternative interventions, 174 nursing care plan, 282
herbal/nutritional supplements, 174 overview, 261–264, 282
massage, 174 substances other than alcohol, 270–276,
medical treatment, 173–174 271t–275t
medications, 174t amphetamines, 271t
nursing care, 174–177, 175t, 176f anabolic steroids, 275t
communication skills, 175 cannabis, 271t
socialization and group activities, 175 club drugs, 275t
support, 175, 177 cocaine, 272t
nursing diagnoses, 174 hallucinogens, 272t
overview, 177 inhalants, 272
somatic symptom disorder (SSD), 170, 172 methamphetamine, 271t, 276f
differential diagnosis, 172 nicotine, 273t
etiology, 172 nursing interventions, 281t
nursing care, 175t opioids, 273t
somatic symptom related disorders, 172–173 phencyclidine, 274t
conversion disorder, 172–173, 175t sedatives, hypnotics, and antianxiety drugs, 274t
factitious disorder, 173 symptoms, 281t
illness anxiety disorder, 173, 175t tobacco, 261, 262f
Somatization, definition of, 402 treatment, 277–278
Somatoform disorder, 170, 402 Suicide, 205–212
Somatoform pain disorder, 402 attempts, 205
SSRIs (selective serotonin reuptake inibitors), 117–118 children and adolescents, 306–307, 306f
nursing considerations, 118, 118f cultural considerations, 207
Standards of care, 5, 34 definition of, 402
definition of, 402 etiology, 207–208
Standards of nursing practice for LPNs/LVNs, 390–392 risk factors, 207
National Federation of Licensed Practical Nurses warning signs, 207–208
(NFLPN) Code for Licensed Practical/ lethality, 205–206, 211
Vocational Nurses, 390 methods, 206–207
NFLPN Nursing Practice Standards, 390–392 myths concerning, 206t
NFLPN Specialized Nursing Practice Standards, 392 nursing care, 209–212
Stereotype, 77 general nursing interventions, 210–211
definition of, 402 nursing care plan, 212t
Stimulants, 122–123, 122f nursing diagnoses, 209
commonly used agents, 123 talking with suicidal patient to evaluate lethality, 211
definition of, 402 overview, 205–207, 206f, 212
nursing considerations, 123 pacts, 205
Stress, definition of, 402 risk factors, 207
Stress adaptation responses, 162t treatment of individuals at risk, 208–209
Stressor, 160, 402 Suicide attempt, definition of, 402
Stroke, 338–339, 338f Suicide contract, definition of, 402
aphasia, 339 Suicide ideation, definition of, 403
depression associated with, 338–339 Suicide pact, definition of, 403
Sublimation, 109t Sundowner syndrome (nocturnal delirium), 245, 341
Substance abuse, definition of, 402 Superego, definition of, 403
Substance dependence, definition of, 402 Survivor, definition of, 403
Substance-induced depressive disorder, 184 Survivor guilt, 166, 403
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416 Index

Survivor of suicide, definition of, 403 antiparkinson agents (anticholinergics), 115–116,

Swedish massage, 147 116f
Sympathy, 26, 403 antipsychotics (neuroleptics/major tranquilizers),
114–115
stimulants, 122–123, 122f
T psychotherapies. See Psychotherapies
Tarasoff vs. Regents of the University of California, 38 Tricyclic antidepressants, 118–119
Tardive dyskinesia (TD), 115, 403 commonly used agents, 119
Taylor, Effie Jane, 6, 6f nursing considerations, 119
Teaching, principles of, 98–100 Twelve-step groups, 268, 268t–269t
Terrorism, 136–137
Test question answers and rationales, 370–386
Tetracyclic antidepressants (heterocyclic antidepressants), 119 U
commonly used agents, 119 Unconscious, definition of, 403
Thanatophobia, 163 Unconscious behaviors, 52
Therapeutic/helping communication, 18, 21–28, 403 Unintentional, definition of, 403
techniques, 23–28
Thought, definition of, 403
Tobacco, 261, 262f V
Vascular dementia, 252, 403
Toddler stage of human development, 65t
Verbal abuse, 354, 403
Tolerance, 263, 403
Verbal communication, definition of, 403
Tort, 35, 403
Victim, definition of, 403
Touch, massage, and energy, 147, 150, 150f
Victims of abuse, characteristics of, 355, 355t
Trance, definition of, 403
Violence. See Abuse and violence, victims of
Tranquilizers
Visually impaired people
major. See Antipsychotics
communication challenges, 19–20, 28
minor, 116–117, 117f
definition of, 403
Transgender lifestyle, 79
Voluntary commitment, 42
Treatments, 113–140
milieu, 123
overview, 113–114
psychopharmacology, 114–123
W
Warning signs of suicide, 207–208
antianxiety agents (anxiolytics/minor tranquilizers), Withdrawal, 263
116–117, 117f definition of, 403
antidepressants (mood elevators). See Antidepressants
(mood elevators)
antimanic agents (mood stabilizing agents). See Y
Antimanic agents (mood stabilizing agents) Young adult stage of human development, 68t

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