NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 1

FACTORS AFFECTING MENTAL HEALTH MAINTENANCE

PSYCHIATRIC-MENTAL HEALTH NURSING:
1. Interpersonal Communication
OVERVIEW (Mrs. Arcuino) • A relationship is only as good as the intent of the interaction that
a. Mental Health- a state of emotional, psychological, and social wellness occurs during interpersonal communications between 2 or more
evidenced by satisfying relationships, effective behavior and coping, individual.
positive self- concept, and emotional stability. • Powell (1995) discusses 5 levels of communication that affect an
individual’s personal growth and maturity during interpersonal
b. Mental illness- a clinically significant behavioral or psychological encounters.
syndrome or pattern that occurs in an individual and that is associated • The levels range from 5 to 1, with level 5 indicating superficial
with present distress (eg. a painful symptom) or disability (eg. Impairment communication in which no emotions are shared. Level 1 reflects
in one or more important areas of functioning) or with a significantly open communication in which two individuals share their emotions.
increased risk of suffering death, pain, disability, or an important loss of
freedom.

c. Coping Mechanism- any conscious or nonconscious adjustment or

adaptation that decreases tension and anxiety in a stressful experience
or situation.

d. Psychiatric- Mental Health Nursing- is a specialized field of nursing

practice that involves the care of individuals with mental health disorder
to help them recover and improve the quality of life.

e. Mental Health- Mental Illness Continuum- a process of defining mental

health and mental illness, both are dynamic and subject to change.

FACTORS AFFECTING MENTAL HEALTH

1. Individual or personal. Factors include a person’s biologic make-up,
autonomy and independence, self- esteem, capacity for growth, vitality,
ability to find meaning life, emotional resilience or hardiness, sense of
belonging, reality orientation, and coping or stress management abilities. 2. Ego Defense Mechanism
• Also referred as defense mechanism, are considered protective
2. Interpersonal, or relationship. Factors include effective barriers used to manage instinct and affect in stressful situation
communication, ability to help others, intimacy, and a balance of (Freud, 1946).
separateness and connectedness. • They may be used to resolve a mental- conflict, to reduce anxiety or
fear, to protect one’s self- esteem, or to protect one’s sense of
3. Social/ Cultural, or environmental. Factors include a sense of security.
community, access to adequate resources, intolerance of violence,
support of diversity among people, mastery of the environment, and a 3. Significant Others or Support Role
positive, yet realistic, view of one’s world. • Some people may also reach out to individuals or groups for support
during periods of increased stress or anxiety.
CHARACTERISTICS OF MENTAL HEALTH
According to Maslow, mentally healthy people who achieve self- Ego Defense
actualization are able to: Definition Example
Mechanism
❖ Have positive self- concepts and relate well to people and
their environment. Overachievement in
Nurse with low self-
❖ Form close relationships with others. Mechanism
on area to offset real
esteem working double
❖ Make decisions pertaining to reality rather than fantasy. or perceived
Compensation shifts so that her
deficiencies in
❖ Be optimistic and appreciate and enjoy life. another area
supervisor will like her.
❖ Be independent or autonomous in thought and action,
relying on personal standards of behavior and values. Teenager forbidden to
Expression of an
❖ Be creative, using a variety of approaches as they perform emotional conflict
see X-rated movie is
tasks or solve problems. tempted to do so by
through the
friends and develops
Conversion development of a
blindness, and the
Self-actualized individuals display behavior that is consistent as they physical symptom,
teenager is
appreciate and respect the rights of others. They also display a usually sensorimotor
unconcerned about the
willingness to listen and learn from others, and show reverence for the in nature.
loss of sight.
uniqueness of and difference in others.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 2

Failure to Excusing own Student blames failure

acknowledge an behavior to avoid on teacher being mean
unbearable Rationalization guilt, responsibility,
Waiting 3 days to seek
condition; failure to conflict, anxiety, or
Denial help for severe
admit the reality of a loss of self-respect
abdominal pain
situation or how to
admit the reality of a
Acting the opposite Person who despises
situation
of what one thinks or the boss tells everyone
Reaction feels what a great boss she
Ventilation of intense formation is
feelings toward
Person who is mad at
persons less
Displacement the boss yells at his or
threatening than the
her spouse
one who aroused Moving back to a A 5-year-old asks for a
those feelings previous bottle when new baby
Regression developmental stage brother is being fed
Dealing with Amnesia that prevents to feel safe or have
emotional conflict by recall of yesterday’s needs met
a temporary auto accident.
Dissociation
alteration in
Excluding Woman has no
consciousness or
emotionally painful or memory before age 7,
identity
anxiety-provoking when she was removed
Repression thoughts and from abusive parents
Immobilization of a Lack of a clear sense of
feelings from
portion of the identity as an adult
conscious
personality resulting
awareness
Fixation from unsuccessful
completion of tasks
Overt or covert Nurse is too busy with
in a developmental
antagonism toward tasks to spend time
stage
remembering or talking to a dying
Resistance
processing anxiety- patient.
Modeling actions Nursing student
producing
and opinions of becoming a critical care
information
influential others nurse because this is
while searching for the specialty of an
Identification Substituting a Person who has quit
identity, or aspiring to instructor she admires
socially acceptable smoking sucks on hard
reach a personal,
Sublimation activity for an candy when the urge to
social, or
impulse that is smoke arises
occupational goal
unacceptable
Separation of the Person shows no
emotions of a painful emotional expression Replacing the Woman who would like
event or situation when discussing desired gratification to have her own
from the facts serious car accident Substitution with one that is more children opens a day
Intellectualization
involved; readily available care center
acknowledging the
facts but not the
emotions
Conscious exclusion Student decides not to
of unacceptable think about a parent’s
Accepting another Person who dislikes
thoughts and illness to study for a
person’s attitudes, guns becomes an avid Suppression
feelings from test
Introjection beliefs, and values hunter, just like a best
conscious
as one’s own friend
awareness

Exhibiting Person who cheats on

Unconscious Man who has thought acceptable behavior a spouse brings the
blaming of about same-gender Undoing to make up for or spouse a bouquet of
unacceptable sexual relationship but negate unacceptable roses
Projection
inclinations or never had one beats a behavior
thoughts on an man who is gay
external object
FACTORS AFFECTING MENTAL ILLNESS
1. Individual factors include biologic make-up, intolerable or unrealistic
worries or fears, inability to distinguish reality from fantasy, intolerance of
life’s uncertainties, a sense of disharmony in life, and a loss of meaning
in one’s life.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 3

2. Interpersonal factors include ineffective communication, excessive ➢ In England during the Renaissance (1300- 1600), people with mental
dependency on or withdrawal from relationships, no sense of belonging, illness were distinguished from criminals. Those considered harmless
inadequate social support, and loss of emotional control. were allowed to wander the countryside or live in rural communities, but
the more “dangerous lunatics” were thrown in prison, chained and
3. Social/ Cultural factors include lack of resources, violence, starved.
homelessness, poverty, an unwarranted negative view of the world, and ➢ In 1547, the Hospital of St. Mary of Bethlehem was officially declared
discrimination such as stigma, racism, classism, ageism, and sexism. It a hospital for the insane.
is important to note that some of these social/ cultural factors can result ➢ By 1775, visitors at the institution were charged a fee for the privilege
in isolation, feelings of alienation, and maladaptive, violent, or criminal
of viewing and ridiculing the inmates, who were seen as less than human
behavior.
animals.
CHARACTERISTIC OF MENTAL ILLNESS ➢ During this same period in the colonies, the mentally ill were
• Feels inadequate considered evil or possessed and were punished. Witch hunts were
• Has poor self- concept conducted, and offenders were burned at the stake.
• Is unable to cope ➢ In the 1970s, a period of enlightenment concerning persons with
• Is unable to establish a meaningful relationship mental illness began. Philippe Pinel in France and William Tuke in
• Displays poor judgement England formulated the concept of asylum as a safe refuge or haven
• Is irresponsible or unable to accept responsibility for actions • Is offering protection at institutions where people had been whipped, beaten
pessimistic and starved because they were mentally ill.
• Unable to perceive reality ➢ The period of scientific study and treatment of mental disorders began
• Does not recognize potential and talents because of poor self- concept with Sigmund Freud (1856- 1939) and others such as Emil Kraepelin
• Avoids problem rather than coping with them or attempting to solve them (1856- 1926) and Eugene Bleuler (1857- 1939). With these men, the
• Desires or demands immediate gratification study of psychiatry and the diagnosis and treatment of mental illness
started in earnest. Freud studied the mind, its disorders, and their
DIAGNOSIS OF A MENTAL ILLNESS treatment as no one had done before.
The diagnosis of a client’s mental illness is achieved through examination ➢ A great leap in the treatment of mental illness began in about 1950
and analysis of date. with the development of psychotropic drugs or drugs used to treat mental
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition illness.
(DSM 5), is a taxonomy published by the American Psychiatric ➢ Chlorpromazine (Thorazine), an antipsychotic drug and lithium, an
Association and described all mental disorders, outlining specific antimanic agent were the first drugs to be developed.
diagnostic criteria for each based in clinical experience and research. All
mental health clinicians who diagnose psychiatric disorders use this MENTAL ILLNESS IN THE 21ST CENTURY
diagnostic taxonomy. ➢ Mental disorders are the leading cause of disability in the United
States and Canada for persons 15 to 44 years of age.
The DSM-5 has three purposes:
➢ Deinstitutionalization, a deliberate shift from institutional care in state
a. To provide a standardized nomenclature and language for all mental
health professional. hospitals, to community facilities. Some believe that deinstitutionalization
b. To present defining characteristics or symptoms that differentiate has had a negative as well as positive effects.
specific diagnoses. ➢ Although deinstitutionalization reduced the number of public hospital
c. To assist in identifying the underlying causes of disorders. beds by 80%, the number of admissions to those beds corresponding
increased by 90%. Such findings have led to the term revolving door
HISTORICAL PERSPECTIVES OF THE TREATMENT OF MENTAL effect.
HEALTH ILLNESS ➢ Although people with severe and persistent metal illness have shorter
➢ People of ancient times believed that any sickness indicated hospital stays, they are admitted to hospitals more frequently.
displeasure of the gods and was punishment for signs and wrongdoing.
➢ Mental disorders were viewed as either divine or demonic, depending HEALTHY PEOPLE 2020 MENTAL HEALTH OBJECTIVES
on their behavior. Individuals seen as divine were worshipped and ▪ Reduce the suicide rate.
adored; those seen as demonic were ostracized, punished, sometimes ▪ Reduce suicide attempts by adolescents.
burned at the stake. ▪ Reduce the proportion of adolescents who engage in disorders eating
behaviors in an attempt to control their weight.
➢ Aristotle (382-322 BC) attempted to relate mental disorders to physical
▪ Reduce the proportion of persons who experience major depressive
disorders and developed his theory that the amounts of blood, water, and episode.
yellow and black bile in the body controlled the emotions. These four ▪ Increase the proportion of primary care facilities that provide mental
substances, or humors, corresponded with happiness, calmness, anger health treatment onsite or by pain referral.
and sadness. Imbalances of the four humors were believed to cause ▪ Increase the proportion of juvenile residential facilities that screen
mental disorders. admissions for mental health problems.
➢ In early Christian times (1-1000AD), primitive beliefs and superstitions ▪ Increase the proportion of persons with serious mental illness who are
were strong. All disease were again blamed on demon, and the mentally employed.
ill were viewed as possessed. Priests performed exorcisms to rid ▪ Increase the proportion of adults with mental health disorders who
sufferers of evil spirits. When failed, they used more severe and brutal receive the treatment.
measures, such as incarceration in dungeons, flogging and starving.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 4

▪ Increase the proportions of persons with co- occurring substance abuse ✓ Sexual drive channeled into socially
and mental disorders who receive treatment for both disorders. ▪ Increase 5–11 or appropriate activities such as school work and
depression screening by primary care providers. ▪ Increase the number Latency 13 sports.
of homeless adults with mental problems who receive mental health years ✓ Formation of the superego.
services.
✓ Final stage of psychosexual development.
PSYCHOANALYTIC THEORY ✓ Begins with puberty and the biologic
Genital 11–13 capacity for orgasm; involves the capacity for
➢ Sigmund Freud (1856–1939) developed psychoanalytic theory in the
true intimacy.
late 19th and early 20th centuries in Vienna.
➢ Psychoanalytic theory supports the notion that all human behavior is
PSYCHOSOCIAL THEORIES
caused and can be explained (deterministic theory).
✓ Erik Erikson (1902–1994) was a German-born psychoanalyst, who
➢ Freud believed that repressed (driven from conscious awareness)
extended Freud’s work on personality development across the life span
sexual impulses and desires motivate much human behavior.
while focusing on social and psychological development in the life stages.
➢ After several years of working with these women, Freud concluded
✓ In each stage, the person must complete a life task that is essential to
that many of their problems resulted from childhood trauma or failure to
his or her well-being and mental health. These tasks allow the person to
complete tasks of psychosexual development. These women repressed
achieve life’s virtues: hope, purpose, fidelity, love, caring, and wisdom
their unmet needs and sexual feelings as well as traumatic events. The (Erikson, 1963).
“hysterical” or neurotic behaviors resulted from these unresolved
Stage Virtue Task
conflicts.
Viewing the world as safe and
➢ Freud conceptualized personality structure as having three Trust vs. mistrust reliable; relationships as
components: the id, ego, and superego (Freud, 1923, 1962). Hope
(infant) nurturing, stable, and
➢ The id is the part of one’s nature that reflects basic or innate desires dependable
such as pleasure-seeking behavior, aggression, and sexual impulses. Autonomy vs.
The id seeks instant gratification, causes impulsive unthinking behavior, Achieving a sense of control and
shame and doubt Will
and has no regard for rules or social convention. free will
(toddler)
➢ The superego is the part of a person’s nature that reflects moral and Beginning development of a
ethical concepts, values, and parental and social expectations; therefore, Initiative vs. guilt
Purpose conscience; learning to manage
it is in direct opposition to the id. (preschool)
conflict and anxiety
➢ The third component, the ego, is the balancing or mediating force Industry vs. Emerging confidence in own
between the id and the superego. The ego represents mature and inferiority (school Competence abilities; taking pleasure in
adaptive behavior that allows a person to function successfully in the age) accomplishments
world. Identity vs. role
Formulating a sense of self and
confusion Fidelity
PSYCHOSEXUAL THEORY belonging
(adolescence)
Freud based his theory of childhood development on the belief that sexual Intimacy vs. Forming adult, loving
energy, termed libido, was the driving force of human behavior. isolation (young Love relationships, and meaningful
Phase Age Focus adult) attachments to others
✓ Major site of tension and gratification is the Generativity vs.
Being creative and productive;
mouth, lips, and tongue; includes biting and stagnation Care
Birth to sucking activities. establishing the next generation
(middle adult)
Oral 18 Ego integrity vs. Accepting responsibility for
✓ Id is present at birth. Wisdom
months despair (maturity) oneself and life
✓ Ego develops gradually from rudimentary
structure present at birth.
INTERPERSONAL SOCIAL THEORY
✓ Anus and surrounding area are major
source of interest. ✓ Harry Stack Sullivan (1892–1949) was an American psychiatrist who
extended the theory of personality development to include the
✓ Voluntary sphincter control (toilet training) is
significance of interpersonal relationships.
acquired.
Anal 18–36 ✓ Sullivan believed that one’s personality involves more than individual
✓ Genital is the focus of interest, stimulation,
characteristics, particularly how one interacts with others. He thought that
and excitement.
inadequate or non-satisfying relationships produce anxiety, which he saw
✓ Penis is organ of interest for both sexes. as the basis for all emotional problems.
✓ Masturbation is common ✓ The importance and significance of interpersonal relationships in one’s
✓ Penis envy (wish to possess penis) is seen life is probably Sullivan’s greatest contribution to the field of mental health.
in girls; oedipal complex (wish to marry ✓ Sullivan established five life stages of development— infancy,
Phallic 3–5
opposite sex parent and be rid of same-sex childhood, juvenile, preadolescence, and adolescence, each focusing on
/oedipal years
parent) is seen in boys and girls. various interpersonal relationships.
✓ Resolution of oedipal complex.
Stage Ages Focus
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 5

▪ Primary need exists for bodily ❖ Parataxic mode begins in early childhood as the child begins to
contact and tenderness. connect experiences in sequence. The child seeks to relieve anxiety by
▪ Prototaxic mode dominates (no repeating familiar experiences, though he or she may not understand
Birth to
relation between experiences). what he or she is doing. Sullivan explained paranoid ideas and slips of
Infancy onset of
▪ Primary zones are oral and anal. the tongue as a person operating in the parataxic mode.
language
▪ If needs are met, infant has sense
of wellbeing; unmet needs lead to ❖ Syntaxic mode, which begins to appear in school-aged children and
dread and anxiety. becomes more predominant in preadolescence, the person begins to
▪Parents are viewed as source of perceive him or herself and the world within the context of the
praise and acceptance. environment and can analyze experiences in a variety of settings.
▪ Shift to parataxic mode;
experiences are connected in Therapeutic Community or Milieu
sequence to each other.
➢ Sullivan envisioned the goal of treatment as the establishment of
Language ▪ Primary zone is anal.
Childhood satisfying interpersonal relationships.
to 5 years ▪ Gratification leads to positive self-
esteem. ➢ In the concept of therapeutic community or milieu, the interaction
▪ Moderate anxiety leads to among clients is seen as beneficial, and treatment emphasizes the role
uncertainty and insecurity; severe of this client to-client interaction. Until this time, it was believed that the
anxiety results in self-defeating interaction between the client and the psychiatrist was the one essential
patterns of behavior. component to the client’s treatment.
▪ Shift to the syntaxic mode begins ➢ The concept of milieu therapy, originally developed by Sullivan,
(thinking about self and others based involved clients’ interactions with one another, including practicing
on analysis of experiences in a interpersonal relationship skills, giving one another feedback about
variety of situations). behavior, and working cooperatively as a group to solve day-to-day
▪ Opportunities for approval and problems.
Juvenile 5–8 years
acceptance of others.
▪ Learn to negotiate own needs. ATTACHMENT THEORY
▪ Severe anxiety may result in a need ➢ Theory based on the classic works of Bowly and Ainsworth that define
to control or in attachment of bonding as an evolutionary and biological process of
restrictive, prejudicial attitudes. eliciting and maintaining physical closeness between a child and a parent
▪ Move to genuine intimacy with or primary caregiver.
friend of the same sex. ➢ This theory also infers that the infant’s relationships with early
▪ Move away from family as source caregivers are responsible for influencing future interactions and
8–12 of satisfaction in relationships. relationships.
Preadolescence
years ▪ Major shift to syntaxic mode occurs. ➢ Bowly described separation anxiety as a predictable process involving
▪ Capacity for attachment, love, and several stages: protest, despair and detachment.
collaboration emerges or fails to ➢ Situations that interfere with the closeness of the attachment produce
develop. anxiety, anger and protest.
▪ Lust is added to interpersonal
➢ Protest behaviors are thought to have adaptive properties and reflect
equation.
the infant’s attempt to restore closeness.
▪ Need for special sharing
relationship shifts to the opposite ➢ Prolonged separation produces despair, and the infant’s response
sex. moves from anxiety and anger to despondency.
▪ New opportunities for social ➢ Detachment behaviors are similar to despair in that child appears
Puberty to listless, is apathetic, and socially isolates and withdraws from the
Adolescence experimentation lead to the
adulthood caregiver even when she returns.
consolidation of self-esteem or self-
ridicule.
▪ If the self-system is intact, areas of BEHAVIORAL THEORIES
concern expand to include values, ❑ Behaviorism is a school of psychology that focuses on observable
ideals, career decisions, and social behaviors and what one can do externally to bring about behavior
concerns. changes. It does not attempt to explain how the mind works.
❑ Behaviorists believe that behavior can be changed through a system
Sullivan also described three developmental cognitive modes of of rewards and punishments.
experience and believed that mental disorders are related to the ❑ Example: For adults, receiving a regular paycheck is a constant
persistence of one of the early modes. positive reinforcer that motivates people to continue to go to work every
day and to try to do a good job. It helps motivate positive behavior in the
❖ Prototaxic mode characteristic of infancy and childhood, involves workplace
brief, unconnected experiences that have no relationship to one another. ❑ Ivan Pavlov: Classical Conditioning- behavior can be changed through
Adults with schizophrenia exhibit persistent prototaxic experiences. conditioning with external or environmental conditions or stimuli.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 6

❑ B.F. Skinner: Operant Conditioning- people learn their behaviors from • Certain mood
their history or past experiences, particularly those experiences that were disorders
repeatedly reinforced. Temperature, • Anxiety
• Raphe nuclei
sleep, hunger, • Personality
COGNITIVE THEORIES Serotonin •
consciousness disorders
✓ Jean Piaget (1896–1980) explored how intelligence and cognitive Hypothalamus
, behavior •
functioning develop in children. Schizoaffective
✓ He believed that human intelligence progresses through a series of disorders
stages based on age, with the child at each successive stage
demonstrating a higher level of functioning than at previous stages. AMINO ACIDS
✓ Piaget strongly believed that biologic changes and maturation were
responsible for cognitive development. Gamma
• Throughout
aminobutyric Inhibitory • Anxiety states
cerebral cortex
Piaget’s four stages of cognitive development are as follows: acid
1. Sensorimotor—birth to 2 years: The child develops a sense of self as
separate from the environment and the concept of object permanence, NEUROPEPTIDES
that 122 is, tangible objects do not cease to exist just because they are
out of sight. He or she begins to form mental images. Hypothalmic •
Alertness; • Stress
hormones: Hypothalamus
inflammatory response
2. Preoperational—2 to 6 years: The child develops the ability to express epinephrine, • Adrenal
response • Anxiety states
self with language, understands the meaning of symbolic gestures, and histamine Medulla
begins to classify objects.
Blood pressure
3. Concrete operations—6 to 12 years: The child begins to apply logic regulation,
to thinking, understands spatiality and reversibility, and is increasingly Pituitary cellular
•
social and able to apply rules; however, thinking is still concrete. hormones: renewal,
Endocrine
vasopressin, healing,
disorder
4. Formal operations—12 to 15 years and beyond: The child learns to growth stimulation
• Pituitary with
think and reason in abstract terms, further develops logical thinking and hormone, of
gland associate
reasoning, and achieves cognitive maturity. thyroid- thyroxine
d
stimulating secretion to
depressed
NEUROBIOLOGICAL THEORIES hormone, control
mood
▪ An important theory of modern psychiatric therapy is that all behaviors corticotropin metabolism;
are a reflection of brain function, and all thought process represent a corticosteroid
range of functions mediated by nerve cells (neurons) in the brain. release
▪ The brain controls complex behaviors as normal feeling, learning,
thinking and speaking, it is the origin of disorders of affect (emotion), SYSTEMS THEORY
perception, and cognition (thought) that characterizes diverse mental o Systems theory is a way of viewing a person, families, groups, and
disorders. society.
Control, Important in o General system theory (Ludwig von Bertalanffy), a system is a set of
Neurotransmi Sites of components or units interacting with each other within a boundary that
Effect or these
tter Secretion filters the kind and rate of flow of inputs and outputs to and from the
Response Disorders
system.
BIOGENIC AMINES o System can be open or closed.
o Open systems are open to the exchange of matter, energy, and
• Nigrostriatum information about their environment.
Fine (substantia o Closed system has rigid, impenetrable boundaries. Boundaries are
movement, nigra) • Bipolar easily defined in physical and biological systems but are difficult to
sensory • Mesolimbic disorder delineate in social systems such as organizations.
Dopamine
integration, and limbic •
emotional system Schizophrenia HUMAN NEEDS THEORY
behavior • Posterior ▪ All theories about human development and behavior address human
pituitary needs, but Maslow’s explication of human needs fits well into a model of
personhood and nursing.
• Locus
“Fight or Flight” ceruleus
• Certain mood
Norepinephrin response • Adrenal
disorders
e (sympathetic Medulla •
• Addictions
system) Amygdaloid
body
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 7

maintain harmony and balance with their

environment by a process of interaction and
adjustment.

Nursing Nursing is a unique profession concerned with all the

variables affecting a person’s response to stressors.

Health Wellness is the ability of the person’s flexible line of

defense to maintain equilibrium against any stressor.

Environment The environment includes all internal and external

factors. The internal environment is the flexible line
of defense against stressors, such as ego
functioning or cognitive abilities. The external
environment is the normal line of defense and
consists of coping abilities, lifestyle and
developmental stage.
WELLNESS- ILLNESS CONTINUUM
❖ Develop by Dunn, who viewed health and illness as dynamic and OREM’S SELF-CARE MODEL
moving along a continuum rather than circumscribed states.
❖ High- level wellness is an integrated method of functioning oriented Person The person is a total being with universal
toward maximizing the client’s optimal level of functioning. developmental needs and is capable of continuous
❖ High- level wellness occurs when the physical and psychological self- care.
needs are met in ways that support maximum functioning, leaving the
person with an energy reserve from which to draw. Nursing Nursing consists of deliberate and purposeful
❖ Low- level wellness or severe illness is the inability of people to meet actions to provide assistance to those who are
their needs in a way that allows them to function and the depletes their unable to meet health related self- care needs.
energy reserve.
Health Health is a state of being whole, sound, and fully
STRESS ADAPTATION THEORY integrated. It includes physiological and
psychobiological mechanisms in relation to and in
➢ Seyle’s contribution to defining health was his explanation of stress
interaction with other human beings.
relative to adaptation. He asserted that a stress response occurs
whenever a person encounters continuous stress. Environment Orem presented a limited view of the environment
➢ The following process explains this stress reaction: that comprise the factors and conditions that can be
a. Alarm reaction (1st phase)- mobilizes the body’s defenses and regulated in caring for clients. The individual and the
homeostatic responses against the stressor- “fight or flight response”. b. environment form in an integrated functional whole
Stage of resistance (2nd phase)- the body attempts to reduce damage or system.
from the stressor.
c. Stage of exhaustion (3rd stage)- evolves after the body’s attempts to
adapt to change fail to manage the stressors if appropriate intervention to ORLANDO’S NEEDS-ORIENTED THEORY
reduce the stress are unsuccessful.
Person People are developmental beings with needs and
NURSING THEORIES AND MODELS are distinct in their responses, thoughts, and
➢ The major concepts in nursing theory have been identified as human feelings.
beings, nursing, health, and the environment.
➢ Human beings are described as holistic and interactive, a developing Nursing Nursing consists of understanding and providing the
system in interaction with the environment. client’s immediate need for help to avoid, relieve,
➢ The description of nursing includes the nursing process, the recipient diminish or cure her sense of helplessness, until she
of care, and the role of the nurse. experiences an increased sense of well- being and
➢ The environment includes various aspects of society: events, an improvement of behavior.
conditions and elements that make up the client’s surroundings.
Health Health is a sense of adequacy or well- being,
➢ Health is depicted as a state of wellness or optimal functioning.
comfort, and fulfilled needs.

NEUMAN’S SYSTEM MODEL Environment Orlando did not define the environment.

Person People are a unique composite of characteristics

within a normal given range of response. People ROY’S ADAPTATION MODEL
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 8

Therapeutic Relationship- Is a close, helping relationship based on

Person Roy describes the person as a biopsychosocial
trust, which allows the nurse and client to work collaboratively
being in constant interaction with a changing
environment.
Phases of Therapeutic Relationship
• Initiating/ Orienting Phase
Nursing The goal of nursing is to contribute to the person’s
health, quality of life, and dying with dignity by • Working Phase
promoting adaptation. Nurses assess behavior and • Terminating Phase
the stimuli that influence adaptation.
Milieu Therapy
Health Health is a state and a process of being and • Refers to the socio-environmental therapy in which the attitudes and
becoming an integrated, whole person. It is a behavior of the staff in a treatment service and the activities prescribed
reflection of the level of adaptation. for the client are determined by the client’s emotional and interpersonal
needs (Shahrokh & Hales, 2003)
Environment The environment includes conditions, circumstances • Promotes personal growth and client interactions
and influences that surround and affect the • Focus: social relationship, occupational and recreational activities
development and behavior of the person.
Therapeutic Milieu
• “therapeutic environment”
PEPLAU’S INTERPERSONAL THEORY • An environment structured to provide clients with the opportunity to
interact with staff and other clients.
Person Persons are described as unique in experiences, • Includes safe physical surroundings,
beliefs, expectations and patterns of relation to all treatment team members and other clients
others. The client is viewed “as a person responding
in the situation and in relation to whatever or TREATMENT MODALITIES AND PSYCHOTHERAPIES
whoever is in it with him or her illusionary or real”. 1. Therapeutic Milieu
2. Crisis and Disaster Intervention
Nursing Nursing is a significant, therapeutic, interpersonal 3. Individual Psychotherapy
process. It functions co- operatively with other 4. Group Therapy
human processes that make health possible for 5. Family Therapy
individuals in the community. 6. Couple Therapy
7. Psychopharmacologic Therapy
Health Health “is a word symbol that implies forward 8. Biological Therapy
movement of personality and other ongoing human 9. Electroconvulsive Therapy
processes in the direction of creative, constructive, 10.Complementary Therapy
productive, personal and community living”.
Therapeutic Milieu:
Environment The environment includes the physiological, INTERVENTIONS USED:
psychological and social fluidity that is the context of 1. CLIENT EDUCATION
the nurse- client relationship. - “sharing information”
- Promotes self-care and independence, prevents complications and
reduce recidivism, and hospital readmissions

PSYCHIATRIC-MENTAL HEALTH NURSING: Educational Strategies:

THERAPEUTIC MANAGEMENT 1. Prioritize the client’s needs and focus on everyday issues
2. Present specific information
(Mrs. Pangilinan) 3. Utilize different educational approaches depending on the client’s
Communication - Refers to the giving and receiving of information ability
involving 3 elements: 4. Involve the client’s family members and support persons in the
• Sender educational process
• Message 5. Educate and reinforce information while providing care
• Receiver
2. SPIRITUALINTERVENTIONS
Factors Influencing Communication: • Communicating acceptance and respect for the client’s spiritual beliefs
Environmental Factors Attitude • Providing privacy and quiet as needed for ritual or devotional practice
Sociocultural or Ethnic Background Interpersonal Perceptions • Praying or meditating with the client
Past Experiences Knowledge of Subject Matter • Collaborating with the client’s spiritual counselor
Ability to Relate to Others
3. PERSONAL & SLEEP HYGIENE MANAGEMENT
Therapeutic Communication- Is the process of conveying information - Nursing interventions:
through a complex variety of verbal and non-verbal behaviors • promoting participation in bathing, dressing, and eating
• encouraging independence
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 9

• praising involvements Crisis and Disaster Intervention:

• Relaxation techniques Crisis- any serious interruption in the steady state or equilibrium of a
• Avoid use of caffeine person, family, or group
• Use bed and bedroom for sleep only - Common response to crisis:
• High-anxiety-emotional shock
4. PAIN MANAGEMENT - Hyperactivity - Shaking of hands
- GOAL: to reduce or eliminate pain, or make the pain more manageable. - Increased RR - Nausea/vomiting
- Nursing interventions: - loud screaming/crying - rapid speech
• acknowledging the presence of pain - flushed face - emotionally out of control
• listening attentively to the client’s description of pain • Stunned-inactive response
• providing pain management education to establish a comfort function - Inactivity - diaphoresis
goal of pain-relief measures. - Cold, clammy skin - Increased pulse
- Decreased BP - palor
5. PROTECTIVE CARE - aimless wandering - nausea/vomiting
- focuses on providing observation and care so that the client does not - syncope
injure himself, others, or become injured when around other clients.
- Clients must be supervised to prevent the use of poor judgment, loss of Types of Crises:
self- respect, destruction of property, embarrassment of others, or leaving • SITUATIONAL CRISIS
the clinical setting without permission - an extraordinarily stressful event that affects an individual, or family
regardless of age, socioeconomic status, or sociocultural status
6. BEHAVIOR THERAPY • MATURATIONAL CRISIS
- Is a mode of treatment that focuses on modifying observable behavior - is an experience in which one’s lifestyle is continually subject to change.
by means of systematic manipulation of the environment and variables
related to the behavior Phases of a Crisis
Behavior Therapy Techniques: • Precrisis
a) Behavior Modification • Impact
• Pavlov’s Theory of Conditioning - a stimulus elicits a response • Crisis
• Skinner’s – the results of a person’s behavior determine whether the • Resolution
behavior will recur in the future • Postcrisis
b) Systematic Desensitization - Eliminates the client’s fears or anxieties
by stressing relaxation techniques that inhibit anxious responses CRISIS INTERVENTION
c) Aversion Therapy - Uses unpleasant or noxious stimuli to change - Is an active but temporary entry into the life situation of an individual, a
inappropriate behavior family, or a group during a period of stress
d) Cognitive Behavior Therapy - Uses confrontation as a means of Steps in Crisis Intervention
helping clients restructure irrational beliefs and behavior 1. Assessment
e) Assertiveness Training - Clients are taught how to relate 2. Planning
appropriately to others using frank, honest, and direct expressions, 3. Implementation
whether these are positive or negative in nature. 4. Resolution
f) Implosive Therapy - Persons are exposed to intense forms of anxiety
producers, either in imagination or in real life and encouraged to face Goals:
feared situations • To decrease emotional stress and protect the client from additional
g) Limit-setting - Limits reduce anxiety, minimize manipulation, provide stress
framework for client functioning, and enable a client to learn to make • To assist the client in organizing and mobilizing resources or support
requests. systems
• To return the client to a precise or higher level of functioning
7. ADJUNCTIVE or MANAGEMENT THERAPY
• Uses occupational, art, music, psychodrama, recreational, play, pet, DISASTER INTERVENTION
speech, and nutritional therapies - Involves the provision of post disaster support services during the early
• Purpose: phase of a disaster
− to promote personal change
− to develop responsibility and accountability Role of the Nurse:
− to express creative needs • To provide emotional support while assessing the individual’s emotional
− to express feelings or conflicts the client is unable to express verbally and physical needs
• To provide client education
• To assist individuals toward the resolution phase of the crisis

Psychotherapy - the treatment of emotional and personality problems

and disorders by psychological means
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 10

Individual Psychotherapy Dysfunctional Families

• A confidential relationship between client and therapist that may occur - Family under stress when issues persist and go unresolved
in the therapist’s office, outpatient clinic, or mental hospital - Communication is not open, direct, or honest
GOAL: • alleviate client’s emotional difficulties - Children and adults may perform roles that are inappropriate to their
age, sex, or personality
Modes of Individual Psychotherapy:
a. Brief Cognitive Therapy Family Therapy - Is a method of treatment in which family members gain
- Time-limited, goal-oriented, here-and- now approach insight into problems, improve communication, and improve functioning
- The therapist assumes an active role while working with individuals to of individual members as well as the family as a whole
solve present- day problems by identifying distorted thinking that causes GOAL:
emotional discomfort, exploring alternate behaviors, and creating change • To facilitate positive changes in the family
• Fostering open communication of thoughts and feelings
b. Behavior Therapy • Promoting optimal functioning in interdependent roles
- Focuses on modifying overt symptoms without regard to the client’s
private experience or inner conflicts Approaches to Family Therapy:
- The role of the therapist/nurse is to help the client analyze behavior, • INTEGRATIVE APPROACH
define problems, and select goals – the family needs to share concern for
each member’s welfare
c. Cognitive – Behavioral Therapy GOALS:
- Combines the individual goals of cognitive therapy (cognitive • identify and remove the pathogenic or intrapersonal conflict
restructuring) and behavioral therapy (behavioral modification • improve communication and problem- solving
techniques) • promote more healthy relationships within the family
- The nurse works with the client to identify thoughts and behaviors that
are causing distress and to change those thoughts to readjust the • PSYCHOANALYTIC APPROACH
behavior - Intensive and long-term therapy that focuses on cognitive, affective, and
behavioral components of family interaction
d. Brief Interpersonal Psychotherapy GOAL:
- assessment focuses on an interpersonal inventory of the client’s • to guide the family members who exhibit pathology into clarifying old
relationships with members of his or her family of origin misunderstandings and misinterpretations between themselves and
- Role of the therapist: parents and members of the family origin and establishing and adult-to-
• reinforces the client’s self-esteem adult relationship
• Employs a conversational, goal- focused approach
• BOWEN APPROACH
Child Psychotherapy - Focuses on guiding one or more family members to become a more
- The need for psychotherapy for a child is based upon his current solid, defined self in the face of emotional forces created by marriage,
problem, life history, level of development, ability to cooperate in children, or the family of origin.
treatment, and what interventions - Result is to gain the clarity and conviction to carry through one’s own
are most likely to help with the presenting concerns positions, such as parents, spouse, or dependent child

Play Therapy • STRUCTURAL APPROACH

- Is usually used with children between the ages of 3 and 12 years - Observing the activities and functions of
- The child is given the opportunity to act out feelings such as anger, family members
hostility, frustration and fear - Therapy is short term and action oriented, with the focus on changing
- Various toys, puppets, or materials such as crayons and finger paints the family organization and its social context
may be used - Guidance is given toward developing clear boundaries for individual
members and changing the family’s structural pattern
Behavior Modification
- Is a treatment approach, based on the principles of Operant • INTERACTIONAL or STRATEGIC APPROACH
Conditioning that replaces undesirable behavior with more desirable ones - communication is the foundation of this
through positive or negative reinforcement approach
- The therapist studies the interactions between and among family
Family, Couple, and Group Therapy members, recognizing that change in one family member occurs in
Family – is a group of individuals who interact, support, and influence relation to change in another family member
each other in performing basic functions - Therapy is based on the concept of homeostasis

Couple – two adults who have a close or intimate relationship • SOCIAL NETWORK or SYSTEMIC APPROACH
- Therapy emphasizes the natural healing
Group – at least three individuals who gather together to share or discuss powers of the family
common problems or concerns - It involves bringing several people together as a social network
- Family members are helped to set goals for optimal outcomes or solving
of problems
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 11

• BEHAVIORIST APPROACH • Cardiovascular disease • Hypertension

- The family is a system of interlocking behaviors, that one type of • Glaucoma • Diabetes
behavior causes another • Parkinson’s disease • Peptic Ulcer disease
- Therapy includes interpreting family members’ behavior but not • Seizure disorder • Pregnancy
necessarily changing it
- Therapy is based on am awareness process as well as on behavioral Adverse Effects:
change • Drowsiness • Dry mouth
• Nasal congestion • Blurred vision
Couple Therapy • Photosensitivity • Orthostatic hypotension
- An intervention involving two individuals sharing a common relationship
- Is a way of resolving tension or conflict in a relationship and to resolve Nursing Implication:
troublesome behavior and/or dysfunctional interaction problems within • Evaluate blood pressure, complete blood count, glucose level, lipid
the relationship panel, liver function test
GOAL: • Screen for personal and family history of metabolic problems
• To resolve problems and conflicts that couples are unable to handle • Know that antipsychotic agents may provoke seizures in clients with
themselves seizure disorders
• Establishment of trust and loyalty • Observe client for signs of weight gain, jaundice, high fever, upper
• Enhancement of sexual intimacy abdominal pain, nausea, diarrhea, and skin rash
• Improvement in listening and expressive skills
• Establishment of empathy for each individual Commonly Used Antipsychotic Drugs:
Nurse-Therapist’s Role: • Chlorpromazine (Thorazine) 25-2000 mg • Haloperidol (Haldol) 100mg
• To assist clients in dealing constructively with thoughts, emotions, and • Thioridazine (Mellaril) 10-800 mg
behaviors • Mesonidazine (Serentil) 30-400 mg
• To persuade each partner in the relationship to take responsibility in • Fluphenazine (Proxilin) 1-40 mg
understanding the psychodynamic makeup of the personality
• To alleviate the disturbances, to reverse or change maladaptive patterns ANTI-ANXIETY AGENTS AND HYPNOTICS
of behavior, and to encourage personality growth and development • are Central Nervous System depressants
Anti-anxiety Agents – “anxiolytics”
Group Therapy - Is a method of therapeutic intervention based on the - May also be used to manage withdrawal symptoms associated with
exploration and analysis of both internal (emotional) and external chronic alcoholism, to control convulsions, and to produce skeletal
(environmental) conflicts and the group process muscle relaxation
- Advantages: Hypnotics – are used to induce a state of natural sleep, reduce periods
• Decreased isolation and dependence of involuntary awakenings during the night, and increase total sleep time
• Opportunities for helping others
• Interpersonal learning and development of coping skills Types of Anti-anxiety Agents:
• Decreased transference to the therapist while developing the 1) Benzodiazepines – used primarily as anti-anxiety
ability to listen to other group members - May be used to treat insomnia
Nurse-Therapist’s Role - Work selectively on the lymbic
• To guide individuals through a problem- solving process by anticipating system of the brain
and responding to the needs and concerns of group members Paradoxical excitation – a rebound phenomenon that may occur after
the abrupt discontinuation of Benzodiazepines
Psychopharmacologic Therapy - The client may become more anxious, exhibit aggressive or antisocial
Psychopharmacology- Is the study of the regulation and stabilization of behavior, or experience withdrawal symptoms of confusion
emotions, behavior, and cognition through the interactions of endogenous
signaling substances or chemicals in the brain Common Drugs:
Clinical Psychopharmacology- Is the study of drug effects in clients and • Chlordiazepoxide (Librium) • Clonazepam (Kloropin)
the expert use of drugs in the treatment of psychiatric conditions • Diazepam (Valium) • Lorazepam (Ativan)
• Alprazolam (Xana)
ANTIPSYCHOTIC AGENTS
• Used primarily to treat most forms of psychosis (schizophrenia, 2) Nonbenzodiazepine – used to relieve muscle tension associated with
schizoaffective disorder, delusional disorder, mood disorder with anxiety or for
psychosis, psychoses associated with delirium and dementia) insomnia
• Also used to manage confusion, behavior problems, and personality Common Drugs:
disorders • Meprobamate (Equanil)
• Provide symptom control by blocking the dopamine receptors in the • Buspirone (Buspar)
brain
Antihistamines as Anxiolytics and Hypnotics
Contraindications: • Hydroxyzine Hcl (Atarax / Iterax) • Hydroxizine Pamoate (Vistaril)
• Hypersensitivity • Severe depression • Diphenhydramine Hcl (Benadryl)
• Bone marrow depression • Blood dyscrasias
• Brain damage • History of impaired liver function
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 12

Adverse Effects: • Patients with severe liver or kidney disease

• Drowsiness • Dizziness
• Dry mouth • Blurred vision Adverse Effects:
• hypotension - Dry mouth -tachycardia - Blurred vision
- urinary retention - Constipation
Beta blockers as Anxiolytics - Used to diminish tachycardia, benign
essential tremors, impulsitivity, and agitation associated with anxiety Nursing Implications:
• Propanolol (Inderal) • Atenolol(Tenormin) - Assess level or severity of depression, including presence of suicidal
• Metoprolol(Lopressor) • Nadolol (Corgard) ideation
- Note any adverse effects
Adverse Effects: - Client education: avoid taking OTC cold remedies or other drugs without
- Hypotension - Bronchospasm physician’s knowledge, avoid excessive exercise and high temperatures
- Bradycardia - Depression
- Dizziness - Fatigue Atypical Antidepressants- Second-line therapy when clients do not
respond to the use of SSRIs or TCAs
Selective Serotonin Reuptake Inhibitors and Atypical
Antidepressants as Anxiolytics Contraindications:
• Sertraline (Zoloft) • Fluoxitine (Prozac) - Cardiac or neurologic disorders - Uncontrolled hypertension
• Paroxitine(Paxil) - Seizure disorder - lactation

Nursing Implications: Nursing Implication:

• Assess client’s mental and physical status • Monitor vital signs to detect potential adverse effects such as
• Administer daily dose at bedtime hypertension, hypotension, or arrhythmias
• Observe therapeutic effects and adverse reactions • Administer with food
• Client education: avoid smoking, alcoholic beverages, caffeinated drinks • Client education: avoid use of alcohol, sleep- inducing drugs, and OTC
drugs, avoid prolonged exposure to sunlight
ANTIDEPRESSANTS - Used to treat depressive disorders caused by
emotional or environmental stressors Ex.
Types: • Bupropion (Wellbutrin) • Maprotiline (Ludiomil)
• Selective Serotonin Reuptake Inhibotors (SSRIs) • Mirtazapine (Remeron)
• Tricyclic Antidepressants (TCAs)
• Atypical Antidepressants Monoamine Oxide Inhibitors- Prescribed for clients with treatment-
• Monoamine Oxide Inhibitors (MAOIs) resistant depression; clients who have depression associated with
anxiety attacks, phobic attacks; clients who fail to respond to TCAs
Selective Serotonin Reuptake Inhibitors - First line of therapy for
treating depression Contraindications:
- Asthma - Hypertension - Arrhythmias
Serotonin Syndrome - 60 years above - 16 years below - cerebrovascular disease
– accumulation of serotonin - congestive heart failure - hyperthyroidism
- Characterized by confusion, delirium, agitation, irritability, tremor, - pregnancy -glaucoma
seizures, diaphoresis, vomiting, diarrhea, tachycardia, severe respiratory
depression, and coma Adverse Effects:
- Abnormal heart rate - Orthostatic hypotension
Adverse Effects: - Headache - Vertigo
- Nausea - Tremor - Sexual dysfunction - Vomiting - insomnia
-Diarrhea -Insomnia - headache - drowsiness - dizziness
- blurred vision - loss appetite
Nursing Implications:
- Avoid use if pregnant or lactating
- Reporting unusual adverse effects Ex.
- Client education: avoid taking grapefruit juice with fluvoxamine and • Isocarboxazid (Marplan) • Phenelzine ( Nardil)
sertraline, monitor blood pressure and heart rate before and after each • Tranylcypromine (Parnate)
dose change
Nursing Implication:
Tricyclic Antidepressants- Generally used to treat symptoms of • Observe the client for signs of therapeutic effects, adverse effects, and
depression such as insomnia, decreased appetite, decreased libido, drug or food interactions
excessive fatigue, indecisiveness, difficulty thinking and concentrating, • Client education: avoid food containing tyramine and tryptophan,
irritability, and feelings of worthlessness caffeine-containing beverages, beer and wine, report symptoms of severe
headache or heart palpitations
Contraindications:
• Pregnant • Breastfeeding • Patients recovering from MI
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 13

MOOD ELEVATORS ANTICONVULSANTS

- “stimulants” or “psychostimulants” - Used to treat seizure disorders
- used to potentiate antidepressant medications in treatment-resistant - used to reduce seizure-induced aggressive behavior
depression
Contraindications:
Contraindications: - CNS depression - Liver disease
• During or within 14 days of the administration of MAOIs - Pregnancy - lactating women
• Glaucoma
• Advanced arteriosclerosis Adverse Effects:
• Cardiovascular disease - Dizziness - Sedation
• Drug or alcohol abuse - hepatic or renal damage - bone marrow depression
• Moderate to severe hypertension - blurred vision -GI upset

Adverse Effects: Nursing Implication:

- Appetite suppression - sleep disturbances - Administer with meals or fluid to reduce gastric irritation
- GI disturbances - Arrhythmias - Monitor for adverse effects
- Mild increase in pulse and blood pressure - Client education: avoid drinking grapefruit juice because it may interfere
with drug metabolism, avoid use of antacids because they reduce the
Nursing Implication: serum level of anticonvulsant medication
- Assess client’s blood pressure, pulse, weight, sleep habits
- Assess CNS activity Ex.
- Administer stimulants no later than 6pm to avoid insomnia - Carbamazepine (Tegretol)
- Client education: avoid use of alcohol or OTC drugs including nose - Phenytoin (Dilantin)
drops and cold remedies - Pregabalin (Lyrica)

Ex. Somatic Therapies- The Biologic treatment of mental disorders

• Methylphenidate (Ritalin) Ex.
• Modafinil (Provigil) • Lobotomy
• Dexmethylphenidate (Focalin) • Sterilization and Clitoridectomy
• Insulin shock therapy
MOOD STABILIZERS • Physiotherapy (hydrotherapy and massage) • Clinical
- “Antimanic Agents” psychopharmacology
- Prevent or diminish the frequency and intensity of manic behavior, mood • Phototherapy
swings, aggressive behavior, and dyscontrol syndrome • ECT
- Treatment of major depressive disorder, schizoaffective disorder,
therapy resistant schizophrenia, and chronic aggression • Lobotomy
– “Psychosurgery”
Contraindications: - An invasive surgical intervention where it severs fibers connecting one
- Pregnancy - Severely impaired kidneys part of the brain with another, or removes or destroys brain tissues.
- Designed to affect the client’s psychological state, including modification
Adverse Effects: of disturbed behavior, thought content, or mood
- Nausea - Polyuria
- Fine hand tremors -polydipsia
- muscle weakness - edema INVASIVE PROCEDURES PERFORMED ON CLIENTS WHO
EXHIBITED “INAPPROPRIATE” OR AGGRESSIVE SEXUAL
BEHAVIOR:
Nursing Implication: • Sterilization - Ligation of the fallopian tubes in a woman and
- Obtain laboratory tests and ECG for baseline information excision of a part of the vas deferens in a man
- Give during or after meals
- Monitor serum lithium levels at least twice a week • Clitoridectomy - Surgical removal of part of the clitoris

Client education: • Insulin Shock Therapy - a form of psychiatric treatment in which

- maintain high fluid intake (8-10 glasses daily) patients were repeatedly injected with large doses of insulin in order to
- Avoid exercise in warm weather produce daily comas over several weeks
- Avoid taking other medications without physician’s knowledge
• Physiotherapy - Is the application of hydrotherapy and massages to
Ex. induce relaxation in clients
• Lithium carbonate (Eskalith) • Lithium Citrate (Cibalith-S)
• Electroconvulsive Therapy (ECT)- Uses electric currents to induce
convulsive seizures in neurons in the entire brain to alleviate symptoms
Electrodes are applied to the client’s scalp
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 14

• Bitemporal or Bilateral (BL)

PSYCHIATRIC-MENTAL HEALTH NURSING:
• Right unilateral nondominant temporal
• Bifrontal SOCIAL AND EMOTIONAL CONCERNS
(Mr. Bernardo)
• Electroconvulsive Therapy (ECT)
Indications: Legal and Ethical Issues
• Clients with depression Rights of Clients and Related Issues:
• Schizophrenia • Clients receiving mental health care retain all civil rights afforded to
• Depressive phase of bipolar disorder all people except the right to leave the hospital in the case of
• Clients at risk for suicide involuntary commitment.
• Clients who exhibit therapy-resistant depression • They have the right to refuse treatment, to send and receive sealed
• Delusional depression mail, and to have or refuse visitors.
• Obsessive-compulsive disorder • Any restrictions (e.g., mail, visitors, clothing) must be made for a
verifiable, documented reason.
Adverse Effects: • These decisions can be made by a court or a designated decision-
• Headache making person or persons, for example, a primary nurse or treatment
• Nausea team, depending on local laws or regulations. Examples include:
• Disorentation • A suicidal client may not be permitted to keep a belt,
• Memory disturbance shoelaces, or scissors because he or she may use these items
for self-harm.
Role of the Nurse: • A client who becomes aggressive after having a particular
• Educate the client about the procedure visitor may have that person restricted from visiting for a period
• Obtain informed consent of time.
• Preparing the client for treatment • A client making threatening phone calls to others outside the
• Providing care during the procedure hospital may be permitted only supervised phone calls until his
• Assisting with post-treatment recovery or her condition improves.

Complementary Therapies - Refers to various disease-treating and Highlights of Patient’s Bill of Rights
disease- preventing practices or therapies that are not considered to be • To be informed about benefits, qualifications of all providers,
conventional medicine taught in medical schools, not typically used in available treatment options, and appeals and grievance procedures
hospitals, and not generally reimbursed by insurance companies • Least restrictive environment to meet needs
- “integrative medicine” or “holistic medicine” • Confidentiality
• Choice of providers
Ex. • Treatment determined by professionals, not third-party payers
• Acupuncture - Hair-thin needles are inserted to either stimulate or • Parity
sedate selected points going from the head to the feet to correct • Nondiscrimination
imbalance of chi or qi • All benefits within scope of benefit plan
• Aromatherapy- Essential plant oils are used to promote health and well- • Treatment that affords greatest protection and benefit
being by inhalation of their scents or fragrances • Fair and valid treatment review processes
• Treating professionals and payers held accountable for any injury
• Massage Therapy- Is considered to be a science of muscle
caused by gross incompetence, negligence, or clinically unjustified
relaxation and stress reduction
decisions
• Others:
− Acupressure
Involuntary Hospitalization
− Art therapy
• Most clients are admitted to inpatient settings on a voluntary basis.
− Biofeedback
− Chinese Herbal Medicine • (which means they are willing to seek treatment and agree to be
− Dance and Movement Therapy − Guided Imagery hospitalized)
− Hypnosis • Health care professionals respect these wishes unless clients are
− Therapeutic or Healing Humor dangers to themselves or others (i.e., they are threatening or have
attempted suicide or represent a danger to others).
• Clients hospitalized against their will under these conditions are
committed to a facility for psychiatric care until they no longer pose
a danger to themselves or to anyone else.
• Civil commitment or involuntary hospitalization curtails the client’s
right to freedom (the ability to leave the hospital when he or she
wishes).
• A person can be detained in a psychiatric facility for 48 to 72 hours
on an emergency basis until a hearing can be conducted to
determine whether or not he or she should be committed to a facility
for treatment for a specified period.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 15

Release from the Hospital Seclusion

• Clients admitted to the hospital voluntarily have the right to leave, - is the involuntary confinement of a person in a specially constructed,
provided they do not represent a danger to themselves or others. locked room equipped with a security window or camera for direct visual
• They can sign a written request for discharge and can be released monitoring
from the hospital against medical advice. - For safety, the room often has a bed bolted to the floor and a mattress.
• If a voluntary client who is dangerous to him or herself or to others - Any sharp or potentially dangerous objects, such as pens, glasses,
signs a request for discharge, the psychiatrist may file for a civil belts, and matches, are removed from the client as a safety precaution.
commitment to detain the client against his or her will until a hearing - A client in seclusion is monitored one-to-one for the first hour and then
can take place to decide the matter may be monitored by audio and video equipment.
• While in the hospital, the committed client may take medications and - The nurse or designated care provider also implements and documents
improve fairly rapidly, making him or her eligible for discharge when offers of food, fluids, and opportunities to use the bathroom per facility
he or she no longer represents a danger. policies and procedures.
- For adult clients, use of restraint and seclusion requires a face-to-face
Mandatory Outpatient Treatment evaluation by a licensed independent practitioner within 1 hour of restraint
Legally assisted or mandatory outpatient treatment is the requirement or seclusion and every 8 hours thereafter, a physician’s order every 4
that clients continue to participate in treatment on an involuntary basis hours, documented assessment by the nurse every 1 to 2 hours, and
after their release from the hospital into the community. close supervision of the client.
- This may involve taking prescribed medication, keeping - For children, the physician’s order must be renewed every 2 hours, with
appointments with health care providers for follow-up, and a face-to-face evaluation every 4 hours.
attending specific treatment programs or groups. The goal of seclusion is to give the client the opportunity to regain self-
- Benefits of mandated treatment include shorter inpatient control, both emotionally and physically.
hospital stays, though these individuals may be hospitalized
more frequently; reduced mortality risk for clients considered Confidentiality
dangerous to themselves or others; and protection of clients - Both civil (fines) and criminal (prison sentences) penalties exist for
from criminal victimization by others violation of patient privacy. Protected health information is any individually
- Voluntary clients may sign a written request for discharge identifiable health information in oral, written, or electronic form.
against medical advice. - Mental health and substance abuse records have additional special
- Mandated outpatient treatment is sometimes also called protection under the privacy rules.
conditional release or outpatient commitment.
- Communities counter that they deserve protection against Duty to Warn Third Parties
dangerous people with histories of not taking their medications - One exception to the client’s right to confidentiality is the duty to warn.
and who may become threats. - mental health clinicians may have a duty to warn identifiable third parties
of threats made by clients, even if these threats were discussed during
Conservatorship and Guardianship therapy sessions otherwise protected by privilege.
- People who are gravely disabled; are found to be incompetent; cannot
provide food, clothing, and shelter for themselves even when resources Duty to Warn Third Parties
exist; and cannot act in their own best interests may require appointment For example: if a man were admitted to a psychiatric facility stating he
of a conservator or legal guardian. was going to kill his wife, the duty to warn his wife is clear.
In these cases, the court appoints a person to act as a legal guardian who However, if a client with paranoia were admitted saying, “I’m going to get
assumes many responsibilities for the person, such as giving informed them before they get me” but providing no other information, there is no
consent, writing checks, and entering contracts. specific third party to warn.
- The client with a guardian loses the right to enter into legal contracts or Decisions about the duty to warn third parties are usually made by
agreements that require a signature (e.g., marriage or mortgage). psychiatrists or by qualified mental health therapists in outpatient settings.
When making a decision about warning a third party, the clinician must
Least Restrictive Environment base his or her decision on the following:
- Clients have the right to treatment in the least restrictive environment • Is the client dangerous to others?
appropriate to meet their needs. • Is the danger the result of serious mental illness?
- client does not have to be hospitalized if he or she can be treated in an • Is the danger serious?
343outpatient setting or in a group home. • Are the means to carry out the threat available?
- It also means that the client must be free of restraint or seclusion unless • Is the danger targeted at identifiable victims?
it is necessary. • Is the victim accessible?
- Restraint is the direct application of physical force to a person without
his or her permission to restrict his or her freedom of movement. Insanity Defense
- The argument that a person accused of a crime is not guilty because
Restraint that person cannot control his or her actions or cannot understand the
Human restraint = occurs when staff members physically control the wrongfulness of the act is known as the M’Naghten Rule.
client and move him or her to a seclusion room. - When the person meets the criteria, he or she may be found not guilty
by reason of insanity.
Mechanical restraints = are devices, usually ankle and wrist restraints, -verdict of guilty but insane ~ Ideally, this means that the person is held
fastened to the bed frame to curtail the client’s physical aggression, such responsible for the criminal behavior but can receive treatment for mental
as hitting, kicking, and hair pulling. illness.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 16

Nursing Liability
- Nurses are responsible for providing safe, competent, legal, and ethical ETHICAL ISSUES
care to clients and families. Ethics is a branch of philosophy that deals with values of human conduct
- Nurses are expected to meet standards of care, meaning the care they related to the rightness or wrongness of actions and to the goodness and
provide to clients meets set expectations and is what any nurse in a badness of the motives and ends of such actions.
similar situation would do. Utilitarianism is a theory that bases decisions on “the greatest good for
the greatest number.”
Torts - A tort is a wrongful act that results in injury, loss, or damage. Torts (Decisions based on utilitarianism consider which action would produce
may be either unintentional or intentional. the greatest benefit for the most people.)
- Unintentional Torts: Negligence and Malpractice. Negligence is an Deontology is a theory that says decisions should be based on whether
unintentional tort that involves causing harm by failing to do what a an action is morally right with no regard for the result or consequences.
reasonable and prudent person would do in similar circumstances.
- Malpractice = a type of negligence that refers specifically to Autonomy refers to a person’s right to self-determination and
professionals such as nurses and physicians independence.

Malpractice Beneficence refers to one’s duty to benefit or to promote the good of

Clients or families can file malpractice lawsuits in any case of injury, loss, others.
or death. For a malpractice suit to be successful, that is, for the nurse,
physician, or hospital or agency to be liable, the client or family needs to Nonmaleficence is the requirement to do no harm to others either
prove four elements: intentionally or unintentionally. Justice refers to fairness, treating all
1. Duty: A legally recognized relationship (i.e., physician to client, nurse people fairly and equally without regard for social or economic status,
to client) existed. The nurse had a duty to the client, meaning that the race, sex, marital status, religion, ethnicity, or cultural beliefs.
nurse was acting in the capacity of a nurse.
2. Breach of duty: The nurse (or physician) failed to conform to Veracity is the duty to be honest or truthful.
standards of care, thereby breaching or failing the existing duty. The
nurse did not act as a reasonable, prudent nurse would have acted in Fidelity refers to the obligation to honor commitments and contracts.
similar circumstances.
3. Injury or damage: The client suffered some type of loss, damage, or Ethical Dilemmas in Mental Health
injury. ethical dilemma is a situation in which ethical principles conflict or when
4. Causation: The breach of duty was the direct cause of the loss, there is no one clear course of action in a given situation.
damage, or injury. - For example, the client who refuses medication or treatment is allowed
In other words, the loss, damage, or injury would not have occurred if the to do so on the basis of the principle of autonomy.
nurse had acted in a reasonable, prudent manner.
Grief and Loss
Intentional Torts - Psychiatric nurses may also be liable for intentional Grief - refers to the subjective emotions and affect that are a normal
torts or voluntary acts that result in harm to the client. Examples include response to the experience of loss.
assault, battery, and false imprisonment. Grieving, also known as bereavement, refers to the process by which a
person experiences the grief. It involves not only the content (what a
Assault involves any action that causes a person to fear being touched person thinks, says, and feels) but also the process (how a person thinks,
in a way that is offensive, insulting, or physically injurious without consent says, and feels).
or authority. Anticipatory grieving is when people facing an imminent loss begin to
(Examples include : making threats to restrain the client to give him or her grapple with the possibility of the loss or death in the near future.
an injection for failure to cooperate. ) Mourning is the outward expression of grief. Rituals of mourning include
having a wake, sitting shiva, holding religious ceremonies, and arranging
Battery involves harmful or unwarranted contact with a client; actual harm funerals.
or injury may or may not have occurred.
(Examples include : touching a client without consent or unnecessarily TYPES OF LOSSES
restraining a client.) Examples of losses related to specific human needs in Maslow’s
hierarchy are as follows:
False imprisonment is defined as the unjustifiable detention of a client, Physiologic loss: Examples include amputation of a limb, a mastectomy
such as the inappropriate use of restraint or seclusion. or hysterectomy, or loss of mobility
Safety loss: Loss of a safe environment is evident in domestic violence,
Prevention of Liability child abuse, or public violence.
Steps to Avoid Liability: Loss of security and a sense of belonging: The loss of a loved one
• Practice within the scope of state laws and nurse practice act. affects the need to love and the feeling of being loved.
• Collaborate with colleagues to determine the best course of action. Loss of self-esteem: Any change in how a person is valued at work or
• Use established practice standards to guide decisions and actions. in relationships or by him or herself can threaten self-esteem.
• Always put the client’s rights and welfare first. Loss related to self-actualization: An external or internal crisis that
• Develop effective interpersonal relationships with clients and families. blocks or inhibits striving toward fulfillment may threaten personal goals
• Accurately and thoroughly document all assessment data, treatments, and individual potential.
interventions, and evaluations of the client’s response to care.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 17

THE GRIEVING PROCESS Rando (1984) describes tasks inherent to grieving that she calls the
Kübler-Ross’s Stages of Grieving “six Rs:”
Elisabeth Kübler-Ross (1969) established a basis for understanding how 1. Recognize: Experiencing the loss, understanding that it is real, and
loss affects human life. that it has happened
1. Denial is shock and disbelief regarding the loss. 2. React: Emotional response to loss, feeling the feelings
2. Anger may be expressed toward God, relatives, friends, or health care 3. Recollect and reexperience: Memories are reviewed and relived
providers. 4. Relinquish: Accepting that the world has changed (as a result of the
3. Bargaining occurs when the person asks God or fate for more time to loss) and that there is no turning back
delay the inevitable loss. 5. Readjust: Beginning to return to daily life; loss feels less acute and
4. Depression results when awareness of the loss becomes acute. overwhelming
5. Acceptance occurs when the person shows evidence of coming to 6. Reinvest: Accepting changes that have occurred; reentering the world,
terms with death. forming new relationships and commitments

Bowlby’s Phases of Grieving DIMENSIONS OF GRIEVING

John Bowlby, a British psychoanalyst, proposed a theory that humans 1. Cognitive Responses to Grief
instinctively attain and retain affectional bonds with significant others 2. Emotional Responses to Grief Anger
through attachment behaviors. 3. Spiritual Responses to Grief
Bowlby described the grieving process as having four phases: 4. Behavioral Responses to Grief
1. Experiencing numbness and denying the loss 5. Physiologic Responses to Grief
2. Emotionally yearning for the lost loved one and protesting the
permanence of the loss CULTURAL CONSIDERATIONS
3. Experiencing cognitive disorganization and emotional despair with Universal Reactions to Loss
difficulty functioning in the everyday world - Although all people grieve for lost loved ones, rituals and habits
4. Reorganizing and reintegrating the sense of self to pull life back surrounding death vary among cultures.
together - Each culture defines the context in which grieving, mourning, and
integrating loss into life are given meaningful expression.
Engel’s Stages of Grieving - Universal reactions include the initial response of shock and social
George Engel (1964) described five stages of grieving as follows: disorientation, attempts to continue a relationship with the deceased,
1. Shock and disbelief anger with those perceived as responsible for the death, and a time for
2. Developing awareness mourning.
3. Restitution
4. Resolution of the loss Culture-Specific Rituals
5. Recovery - acculturation (altering cultural values or behaviors as a way to adapt to
another culture).
Horowitz’s Stages of Loss and Adaptation - Many such expressions are culturally related, and health care providers
Mardi Horowitz (2001) divides normal grief into four stages of loss and must be aware of such instances.
adaptation: - religious or spiritual beliefs and practices regarding death frequently
1. Outcry guide the client’s mourning.
2. Denial and intrusion
3. Working through African Americans
4. Completion - less formal Baptist and Holiness traditions may involve singing, speaking
in other languages, and liturgical dancing.
- the deceased is viewed in church before being buried in a cemetery
- Mourning may also be expressed through public prayers, black clothing,
and decreased social activities.
- The mourning period may last a few weeks to several years.

Muslim Americans
- Islam does not permit cremation.
- It is important to follow the steps of the burial procedure, which specify
Washing (Same Gender)
Dressing
positioning of the body.

Tasks of Grieving Haitian Americans

Grieving tasks, or mourning, that the bereaved person faces involve - Some Haitian Americans practice vodun (voodoo), also called “root
active rather than passive participation. medicine.”
- It is sometimes called “grief work” because it is difficult and requires - vodun is the practice of calling on a group of spirits with whom one
tremendous effort and energy to accomplish. periodically makes peace during specific events in life.
- The death of a loved one may be such a time.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 18

- This practice can be found often throughout the American South and in - The nurse can help the client identify his or her support systems and
some communities within New York City. reach out and accept what they can offer.

Chinese Americans Coping Behaviors

- Chinese have strict norms for announcing death, preparing the body, - The nurse must be careful to observe the client’s behavior throughout
arranging the funeral and burial, and mourning after burial. the grief process and never assume that a client is at a particular phase.
- Burning incense and reading scripture are ways to assist the spirit of the - The nurse must use effective communication skills to assess how the
deceased in the afterlife journey. client’s behavior reflects coping as well as emotions and thoughts.
- For 1 year after death, the family may place bowls of food on a table for
the spirit. NURSING INTERVENTIONS
• Explore client’s perception and meaning of his or her loss.
Japanese Americans • Allow adaptive denial.
- Close family members may bathe the deceased with warm water and • Encourage or assist the client in reaching out for and accepting support.
dress the body in a white kimono after purification rites. • Encourage client to examine patterns of coping in past and present
- For 2 days, family and friends bearing gifts may visit or offer money for situation of loss.
the deceased while saying prayers and burning incense. • Encourage client to review personal strengths and personal power.
• Encourage client to care for him or herself.
Filipino Americans • Offer client food without pressure to eat
- Most Filipino Americans are Catholic, and depending on how close one
was to the deceased, wearing black clothing or armbands is customary Anger, Hostility, and Aggression
during mourning. Anger - results when a person is frustrated, hurt, or afraid.
- Family and friends place wreaths on the casket and drape a broad black Hostility - also called verbal aggression, is an emotion expressed
cloth on the home of the deceased. through verbal abuse, lack of cooperation, violation of rules or norms, or
- Family members commonly place announcements in local newspapers threatening behavior.
asking for prayers and blessings on the soul of the deceased. Physical aggression - is behavior in which a person attacks or injures
another person or destroys property.
DISENFRANCHISED GRIEF - Disenfranchised grief is grief over a loss
that is not or cannot be acknowledged openly, mourned publicly, or Some people try to express their angry feelings by engaging in aggressive
supported socially. but safe activities such as hitting a punching bag or yelling. Such
For example, nurses who work in areas involving organ donation or activities, called catharsis, are supposed to provide a release for anger.
transplantation are involved intimately with the death of clients who may - cathartic activities may be contraindicated for angry clients.
donate organs to another person.
Hostility and Aggression
COMPLICATED GRIEVING- complicated grieving to be a response - Hostile and aggressive behavior can be sudden and unexpected
outside the norm, occurring when a person is void of emotion, grieves for - triggering phase (incident or situation that initiates an aggressive
prolonged periods, or has expressions of grief that seem disproportionate response), an escalation phase, a crisis phase, a recovery phase, and a
to the event. postcrisis phase.
- become obsessively preoccupied with the deceased person or lost
object.
Attentive presence is being with the client and focusing intently on Five-Phase Aggression Cycle
communicating with and understanding him or her.
- The nurse can maintain attentive presence using open body language
such as standing or sitting with arms down, facing the client, and
maintaining moderate eye contact, especially as the client speaks.

Assessment
Perception of the Loss
- Assessment begins with exploration of the client’s perception of the
loss.
- What does the loss mean to the client?
Other questions that assess perception and encourage the client’s
movement through the grief process include:
• What does the client think and feel about the loss?
• How is the loss going to affect the client’s life?
• What information does the nurse need to clarify or share with the client?

Support
- Purposeful assessment of support systems provides the grieving client
with an awareness of those who can meet his or her emotional and
spiritual needs for security and love.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 19

Abuse and Violence CHILD ABUSE - Child abuse or maltreatment generally is defined as the
abuse or the wrongful use and maltreatment of another person. intentional injury of a child. It can include physical abuse or injuries,
- Victims of abuse are found across the life span, and they can be: neglect or failure to prevent harm, failure to provide adequate physical or
spouses or partners, children, or elderly parents. emotional care or supervision, abandonment, sexual assault or intrusion,
~ Family violence encompasses spouse battering; neglect and physical, and overt torture or maiming.
emotional, or sexual abuse of children; elder abuse; and marital rape.
Types of Child Abuse
Characteristics of Violent Families Sexual abuse involves sexual acts performed by an adult on a child
Social Isolation younger than 18 years.
Members of these families keep to themselves and usually do not invite Examples include incest, rape, and sodomy performed directly by the
others into the home or tell anyone what is happening. person or with an object, oral–genital contact, and acts of molestation
Abuser tell children that a parent, sibling, or pet will die if anyone outside such as rubbing, fondling, or exposing the adult’s genitals.
the family learns of the abuse.
Neglect is malicious or ignorant withholding of physical, emotional, or
Abuse of Power and Control educational necessities for the child’s well-being.
~ abusive family member almost always holds a position of power and Child abuse by neglect is the most prevalent type of maltreatment and
control over the victim (child, spouse, or elderly parent). includes refusal to seek health care or delay doing so; abandonment;
~ The abuser belittles and blames the victim, often using threats and inadequate supervision; reckless disregard for the child’s safety;
emotional manipulation.
~ The abuser exerts not only physical power but also economic and social Treatment and Intervention
control. The first part of treatment for child abuse or neglect is to ensure the
child’s safety and well-being.
Alcohol and Other Drug Abuse This may involve removing the child from the home, which also can be
Substance abuse, especially alcoholism, has been associated with family traumatic.
violence A relationship of trust between the therapist and the child is crucial to
Women whose partners abused alcohol were more likely than other help the child deal with the trauma of abuse.
women to be assaulted by their partners. Social service agencies are involved in determining whether returning
Alcohol is also cited as a factor in acquaintance rape or date rape the child to the parental home is possible based on whether parents can
show benefit from treatment.
Intergenerational Transmission Process Family therapy may be indicated if reuniting the family is feasible.
Intergenerational transmission suggests that family violence is a learned Parents may require psychiatric or substance abuse treatment.
pattern of behavior.
For example, children who witness violence between their parents learn ELDER ABUSE - Elder abuse is the maltreatment of older adults by
that violence is a way to resolve conflict and is an integral part of a close family members or others in a caregiver role.
relationship. ~ It may include physical and sexual abuse, psychological, abuse,
neglect, self-neglect, financial exploitation, and denial of adequate
INTIMATE PARTNER VIOLENCE - Intimate partner violence is the medical treatment.
mistreatment or misuse of one person by another in the context of an ~ It is estimated that one in 10 people over age 65 are injured, exploited,
emotionally intimate relationship. abused, or neglected by their caregivers, but few elder maltreatment
cases are reported.
Psychological abuse (emotional abuse) includes name-calling, Persons who abuse elders are almost always in a caregiver role
belittling, screaming, yelling, destroying property, and making threats as
well as subtler forms, such as refusing to speak to or ignoring the victim. Treatment and Intervention
Physical abuse ranges from shoving and pushing to severe battering ~ Relieving the caregiver’s stress and providing additional resources may
and choking and may involve broken limbs and ribs, internal bleeding, help correct the abusive situation and leave the caregiving relationship
brain damage, and even homicide intact.
~ In other cases, the neglect or abuse is intentional and designed to
Cycle of Abuse and Violence- cycle of violence or abuse is another provide personal gain to the caregiver, such as access to the victim’s
reason often cited for why women have difficulty leaving abusive financial resources. In these situations, removal of the elder or caregiver
relationships. is necessary.
~ A typical pattern exists; usually, the initial episode of battering or
violence is followed by a period of the abuser expressing regret, RAPE AND SEXUAL ASSAULT- Rape is the perpetration of an act of
apologizing, and promising it will never happen again. sexual intercourse with a person against his or her will and without her
~ He professes his love for his wife and may even engage in romantic consent, whether that will is overcome by force, fear of force, drugs, or
behavior (e.g., buying gifts and flowers). intoxicants.
~ A woman can obtain a restraining order (protection order) from her
county of residence that legally prohibits the abuser from approaching or A phenomenon called date rape (acquaintance rape) may occur on a first
contacting her. date, on a ride home from a party, or when the two people have known
each other for some time.
~It is more prevalent around or on college campuses.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 20

Treatment and Intervention the top five cosmetic surgery procedures in 2008 included:
~ Victims of rape fare best when they receive immediate support and can - breast augmentation (307,230 procedures)
express fear and rage to family members, nurses, physicians, - rhinoplasty or nose reshaping (279,218 procedures)
and law enforcement officials who believe them. - liposuction (245,138 procedures)
~ Education about rape and the needs of victims is an ongoing - blepharoplasty or eyelid surgery (221,398 procedures)
requirement for health care professionals, law enforcement officers, - abdominoplasty or tummy tuck (121,663 procedures)
and the general public. Because the client constantly seeks medical attention, he or she
frequently submits to unnecessary surgery.
CARE OF CLIENTS WITH SOMATOFORM & • BDD may be equally common in women and men of various cultures.
DISSOCIATIVE ANXIETY DISORDERS • Average age of onset is 16, although diagnosis often doesn’t occur for
(Mr. Bernardo) another 10 to 15 years.
• The type and frequency of somatic symptoms differ across cultures.
• Anxiety can occur under many guises that are not readily recognized • For example, there is a higher reported frequency of somatization
by the nurse or practicing clinician. disorder in Greek and Puerto Rican men than in men in the United States.
• For example, clients may experience anxiety as the result of a specific
medical condition (eg, hyperparathyroidism), as a result of treatment for ❖ Somatization Disorder
a specific medical condition (eg, thyroid medication, or as a result of
• disorder was originally described by
changes in employment or lifestyle due to a medical condition (eg,
Briquet in 1859.
myocardial infarct).
• A.k.a. Briquet’s Syndrome.
• is a chronic, severe anxiety disorder in which a client expresses
Somatoform disorder is the diagnosis given to clients who
emotional turmoil or conflict through significant physical complaints
present with symptoms suggesting a physical disorder without
(including pain and GI, sexual, and neurologic symptoms), usually with a
demonstrable organic findings to explain the symptoms (ie, no medical
loss or alteration of physical functioning.
condition can be diagnosed by a physician).
• a loss or alteration is not under voluntary control and is not explained as
a known physical disorder.
Biologic and Genetic Factors
• often familial
• serotonin and endorphins play a role in the central nervous system
• etiology is unknown
modulation of pain.
• The onset usually occurs before age 30 years; however, it may begin as
• chemical imbalances of serotonin and endorphins may predispose
early as teenage years
individuals to the development of pain disorder.
• The symptoms are not intentionally produced or feigned.
• An imbalance of the neurotransmitter, serotonin, may also be a possible
• anxiety and depression often are seen, and the client may make
cause of body dysmorphic disorder.
frequent suicide threats or attempts. • may exhibit antisocial behavior
Somatoform Disorders
❖ Conversion Disorder
• Five somatoform disorders are often encountered in general medical
settings. They include: • is a somatoform disorder that involves motor or sensory problems
1. body dysmorphic disorder suggesting a neurologic condition.
2. somatization disorder • The phrase la belle indifference is used to describe client reactions such
3. conversion disorder as showing inappropriate lack of concern about the symptoms and
4. pain disorder displaying no anxiety.
5. hypochondriasis. ~ This is because the anxiety has been relieved by the conversion
disorder.
•Clients may also exhibit a pseudoneurologic manifestation (sensory or
❖ Body Dysmorphic Disorder (BDD)
motor loss that does not follow neurologic function but rather comes and
• (historically known as dysmorphobia)
goes with stress or a functional need).
• referred to as imagined ugliness.
~ For example, when suddenly awakened or startled, the sensory or
• preoccupied with an imagined defect in physical appearance or a vastly
motor loss is briefly gone.
exaggerated concern about a minimal defect.
• The person believes or fears that he or she is unattractive.
Conversion symptoms serve four functions:
• The most common age of onset of BDD is from adolescence through
• Permit the client to express a forbidden wish or impulse in a masked
the third decade of life.
form.
~ Prognosis is unknown because this disorder can persist for several
• Impose punishment via the disabling symptom for a forbidden wish or
years
wrong-doing.
• Ritualistic behaviors including obsessive–compulsive traits (eg,
• Remove the client from an overwhelming life-threatening situation
camouflaging, comparing, scrutinizing, mirror gazing, and skin picking)
(primary gain).
and a depressive syndrome are frequently present.
• Allow gratification of dependency (secondary gain) (Maldonado, 1999).
• Previous research suggests that this group has poor mental health–
related quality of life and high lifetime rates of psychiatric hospitalization,
•Primary gain allows relief from anxiety by keeping an internal need or
suicidal ideation, and suicide attempts
conflict out of awareness.
Reported rates of clients with BDD treated in cosmetic surgery and
•Secondary gain refers to any other benefit or support from the
dermatology settings range from 6% to 15%.
environment that a person obtains as a result of being sick.
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 21

~Examples of secondary gain are attention, love, financial reward, and two or more definitive personalities that alternatively take over the
sympathy. person’s behavior.
• Malingering and factitious disorder must be differentiated from • depersonalization disorder experiences an uncomfortable, distorted
conversion disorder. perception of self, body, and one’s life that is associated with a sense of
unreality
• Malingering disorder
~ It is characterized by the voluntary production of false or grossly
exaggerated physical or psychological symptoms.
CARE OF CLIENTS WITH ANXIETY
• Clients are consciously motivated by external incentives that fall into one DISORDERS (Mrs. Pangilinan)
of three categories: Anxiety
1. to avoid difficult or dangerous situations, responsibilities, or • is a vague feeling of dread or apprehension
punishment • is used to describe feelings of uncertainty, uneasiness, apprehension,
2. to receive compensation, free hospital room and board, a free source or tension that a person experiences in response to an “unknown” object
of drugs, or a haven from police. or situation
3. to retaliate when the client feels guilt or suffers a financial loss, legal
penalty, or job loss. Adaptation
- term referring to the ability to adjust to new information or
❖ Pain Disorder experiences
• International Association for the Study of Pain (IASP) defines pain as
“an unpleasant sensory and emotional experience associated with actual Anxiety Disorder
or potential tissue damage, or described in terms of such damage” • a group of conditions in which the affected person experiences
• states that “pain that occurs in the absence of tissue damage or persistent anxiety that he or she cannot dismiss and that interferes
pathophysiological change usually happens for psychological reasons.” with his or her daily activities
• The diagnosis of pain disorder is given when an individual experiences
significant pain without a physical basis for pain or with pain that greatly Types of Anxiety:
exceeds what is expected based on the extent of injury. 1. Signal Anxiety – is a response to an anticipated event
• may occur at any stage of life 2. Anxiety Trait – is a component of personality that has been present
• it occurs more frequently in the over a long period and is measurable by observing the person’s
fourth or fifth decade of life psychologic, emotional, and cognitive behavior
• is more frequent in women who complain of chronic pain such as 3. Anxiety State – occurs as the result of a stressful situation in which
headaches and musculoskeletal pain the person
• is more common in persons with blue-collar occupations. loses control of her or his emotions
4. Free-floating Anxiety – is anxiety that is always present and is
❖ Hypochondriasis accompanied by a feeling of dread
• is a somatoform disorder in which a client presents with unrealistic or - The person may exhibit ritualistic and avoidance behavior (phobic
exaggerated physical complaints. disorder)
• Minor clinical symptoms are of great concern to the person and often
result in an impairment of social or occupational functioning. Levels of Anxiety
• The disorder can occur at any age, but is more common in the second Anxiety Psychological Physiologic
and third decade of life Description
Level Responses Responses
• Preoccupations usually focus on bodily functions or minor physical - Wide
abnormalities. is a sensation
perceptual field
• persons are commonly referred to as “professional patients” who shop that
- Sharpened - Restlessness
for doctors because they feel they do not get proper medical attention. something is
MILD senses - fidgeting
• Such clients often elicit feelings of frustration and anger from health care different and
ANXIETY - Increased - Difficulty
providers. warrants
motivation sleeping
• The client becomes preoccupied with the fear of developing or already special
- Effective
having a disease or illness in spite of medical reassurance that such an attention
problem
illness does not exist. solving
is the
Dissociative Disorders disturbing - Perceptual - Muscle
• Dissociation is the state in which a person becomes separated from feeling that field narrowed tension
reality. something is - Selective - Diaphoresis
• essential feature: of dissociative disorders is a disruption of integrated MODERATE
definitely attention - Pounding
functions of consciousness, memory, identity, or perception of the ANXIETY
wrong; the - Increased use pulse
environment. person of - Headache
• Dissociative amnesia (formerly known as psychogenic amnesia) is becomes automatism - Dry mouth
characterized by the inability to recall an extensive amount of important nervous or
personal information because of physical or psychological trauma. agitated
• dissociative identity disorder (DID), formerly known as multiple SEVERE The ability to - perceptual - Severe
personality disorder, in which a person is dominated by at least one of ANXIETY perceive is field reduced to headache
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 22

further one detail or - Nausea, • COGNITIVE BEHAVIOR THEORY

reduced, and scattered details vomiting - Anxiety is a learned or conditioned response to a stressful event or
focus is on - Cannot and diarrhea perceived danger (Aaron Black)
small or complete tasks - Trembling - According to this theory, conceptualization or faulty, distorted, or
scattered - Cannot solve - pale counterproductive thinking patterns accompany or precede the
details problems or development of anxiety
learn effectively
- Inability to • SOCIO-CULTURAL THEORY
communicate - As a person’s personality develops, his or
clearly her impression of self may be negative.
- perceptual - The person experiences difficulty adapting to everyday social or cultural
field reduced to - Totally demands because of his low self-concept and inadequate coping
focus on self immobile or mechanisms
Complete - Cannot mute Etiology of Anxiety
disruption of process any - Dilated pupils
PANIC • EXISTENTIAL THEORIES
the ability to environmental - Increased
perceive stimuli blood • It embraces personal freedom and choice. It purports that humans
takes place - Distorted pressure and choose their own existence and meaning
perceptions pulse • Developmental theories
- May be • Present systematic ways of thinking about how human beings grow from
suicidal babies to adolescents to adults to elderly people, and the various changes
they undergo as they make this passage
Normal vs. Abnormal Anxiety Pathologic anxiety:
✓ if a person feels anxious when no real threat exists • NEUROTRANSMITTER AND NEUROENDOCRINOLOGY THEORIES
✓when a threat has passed long ago but continues to impair the person’s • There are theories implicating acetylcholine, noradrenaline, serotonin,
GABA and dopamine
functioning
• The neuroendocrine hypothesis of aging purposes that aging results
✓When a person substitutes adaptive coping mechanisms with
from the functional perturbations, both in neuronal control and in
maladaptive ones endocrine outputs, of the hypothalamic- pituitary-adrenal axis. These
✓Unrelieved anxiety causes physical and emotional problems perturbations result in dysfunction in the activity of various endocrine
glands and their target organs
Etiology of Anxiety
• GENETIC THEORY • NEUROANATOMINAL THEORIES
- Anxiety may have an inherited component • It delineates the neuroanatomical and neurochemical networks involved
- Heritability refers to the proportion of a disorder that can be attributed to in the representation of cognitive and affective mental states to both self
genetic factors and other
- Methods to determine prevalence of anxiety in relatives:
• Family history ANXIETY DISORDERS
• Family study - comprise of group of conditions that share a key feature of excessive
anxiety with ensuring behavioral, emotional, cognitive, and physiologic
• BIOLOGIC THEORY responses
- Studies have evaluated the links between anxiety and the following: - Characterized by symptoms of extreme anxiety and avoidance behavior
• Catecholamines (are any actions a person takes to escape from difficult thoughts and
• neuroendocrine measures feelings. These behaviors can occur in many different ways and may
• Neurotransmitters: include actions that a person does or does not do.
✓ Serotonin
✓ gamma-aminobutyric acid (GABA) 1. Panic Disorder
✓ cholecystokinin and autonomic reactivity - Is a real illness with both physical and psychological component
- Is characterized by recurrent unexpected panic attack that cause
• PSYCHOANALYTIC THEORY constant concern
Anxiety is the result of unresolved, unconscious conflicts between - Panic Attack is the sudden onset of intense apprehension
impulses for aggressive or libidinal gratification and the ego’s recognition - ONSET: begins during late teen or early 20’s
of the external damage that could result from gratification - may occur on both men and women – women are twice as likely to be
(Sigmund Freud) affected

• INTERPESONAL THEORY 3 Types of Panic Attack:

Anxiety is being generated from problem in interpersonal relationships. a) Unexpected Panic Attack
(Harry Stack Sullivan) - Occur without warning and for no discernable reason
b) Situational Panic Attack
- Occur in response to specific environmental stimuli or events that are
anxiety producing
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 23

c) Situational Predisposing Panic Attack - ONSET: middle adolescence (peak age)

- An attack with a potential to reoccur when an individual’s anxiety level - Symptoms:
increase • Fear of embarrassment or inability to perform
• Avoidance or dreaded endurance of behavior
CLINICAL SYMPTOMS: or situation
− Palpitations − Diaphoresis − Tremors • Belief that others judging him/her negatively
− SOB − Feeling of choking − Chest pain • Anxiety can be severe or panic level
− Nausea - vertigo - fear of dying
- chills or hot flashes - fear of losing control - paresthesia SPECIFIC PHOBIA
- Is characterized by significant anxiety provoked by a specific feared
DIAGNOSTIC CHARACTERISTICS: object or situation, which often leads to avoidance behavior
• Period of intense fear or discomfort - 5 Subtypes:
• Evidence of at least 4 clinical symptoms 1. Natural Environmental Phobia
• Sudden onset of symptoms, peaking within 10 minutes 2. Blood-injection Phobia
• Lasts usually between 1 minute and 1 hour 3. Situational Phobia
4. Animal Phobia
TREATMENT: 5. Others (fear of space, sound, costumed characters)
• Cognitive-behavioral techniques
• Deep breathing and relaxation techniques - ONSET: occurs in childhood or adolescence - SYMPTOMS:
•Medications (Benzodiazepines, SSRI depressants, Tricyclic • Marked anxiety response to the object or situation
antidepressants) • Avoidance or suffered endurance of object or situation
• Significant distress or impairment of daily routine, occupation or social
NURSING DIAGNOSES: functioning
• Risk for injury • Adolescents or adults recognizes fear as excessive or unreasonable
• Anxiety
• Powerlessness - TREATMENT:
• Ineffective Role Performance • Behavior Therapy
• Situational Low Self-Esteem a) Systematic Desensitization
> is a psychological process by which a response is repeatedly elicited in
NURSING INTERVENTIONS: situations where the action tendency that arises out of the emotion proves
• Provide a safe environment and ensure client’s privacy during panic to be irrelevant
attack
• Remain with the client during panic attack a) Flooding
• Help client to focus on deep breathing • Relaxation techniques
• Talk to client in calm, reassuring voice • Assertiveness Training
• Teach client to use relaxation techniques • Medications
• Engage client to explore how to decrease stressors and anxiety- - Benzodiazepine (Alprazolam)
provoking situations - Nonbenzodiazepine Anxiolytic (Buspirone)
- Tricyclic antidepressant (Imipramine)
2. Phobias - SSRI antidepressant (Sertraline, Venlafaxine, Paroxetine)
- Is the irrational fear of an object, activity or situation that is out of
proportion to the stimulus and results in avoidance of the identified object, COMMON PHOBIAS:
activity or situation • Acrophobia – fear of heights
- 3 Major Types: • Agoraphobia – fear of open places
a. Agoraphobia • Algophoia – fear of pain
b. Social Phobia • Androphobia – fear of men
c. Specific Phobia • Astrophobia – fear of storms, lightning, thunder • Autophobia – fear of
being alone
AGORAPHOBIA • Aviophobia – fear of flying
- An anxiety about or avoidance of places or situations from which escape • Claustrophobia – fear of enclosed places
might be difficult or help might be unavailable • Entomophobia – fear of insects
- Symptoms: • Hematophobia – fear of blood
• Avoids being outside alone or at home alone • Hydrophobia – fear of water
• Avoids traveling in vehicles • Iarrophobia – fear of doctors
• Impaired ability to work • Necrophobia – fear of dead bodies
• Difficulty meeting responsibilities • Nyctophobia – fear of night
• Ochlophobia – fear of crowds
SOCIAL PHOBIA • Ophidiophobia – fear of snakes
- “Social Anxiety Disorder” • Pathophobia – fear of disease
- Is characterized by anxiety provoked by certain types of social or • Pyrophobia – fear of fire
performance situations which often leads to avoidance behavior • Sitophobia – fear of flood
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 24

• Thanatophobia – fear of death • Contamination

• Trypanophobia – fear of needles - Obsessions are considered senseless sand cannot be eliminated by
• Topophobia – fear of particular space logic or reasoning
• Zoophobia – fear of animals
- COMMON COMPULSIONS:
NURSING DIAGNOSIS: • Checking rituals
• Fear • Counting rituals
• Social Isolation • Washing and scrubbing until the skin is raw
• Ineffective Coping • Praying or chanting
• Ineffective Role Performance • Touching, rubbing, or tapping
• Hoarding items
• Overanxious disorder • Ordering
• Is a childhood anxiety disorder subtype characterized by anxiety that is • Exhibiting rapid performance
not focused on a specific situation or object • Having aggressive urges
• Instead, overanxious children are general “ worriers” who tend to worry
excessively or unrealistically about future or past events. - ONSET:
Males – childhood
3. Generalized Anxiety Disorder (GAD) Females – 20’s
- Characterized by unrealistic or excessive anxiety and worry occurring
for days but not in a 6-month period - SYMPTOMS:
• Recurrent, persistent, unwanted, intrusive thoughts, impulses, or
- SYMPTOMS: images beyond worrying about realistic life problems
• Uncontrollable worrying • Attempts to ignore, suppress, or neutralize obsessions with compulsions
• Significant distress or impaired social or occupational functioning that are mostly ineffective
• Restlessness
• Easily fatigued - TREATMENT:
• Difficulty concentrating or mind going blank • Behavioral Therapy
• Irritability a) Exposure
• Muscle tension b) Response Prevention
• Sleep disturbance • Deep breathing and relaxation techniques
• Medications:
- Medications: - Benzodiazepine (Alprazolam, Clonazepam)
• Nonbenzodiazepine (Buspirone) - Nonbenzodiazepine (Buspirone)
• SSRI Antidepressant (Fluozetine, Paroxetine, Sertraline) - TCAs (Clomipramine)
• Alpha-adrenergic Agonist (Propanolol) - SSRI antidepressants (Fluoxetine, Fluvoxamine)
- Nursing Diagnoses:
• Anxiety NURSING DIAGNOSES:
• Knowledge Deficit about Coping with Anxiety • Anxiety
• Ineffective coping
- Nursing Interventions: • Fatigue
• Actively listen to the client, and encourage discussion of feeling • Situational Low Self-Esteem • Impaired Skin Integrity
• Reassure the client about safety, and verbalize that the nurse is
concerned about the client’s well-being - NURSING INTERVENTIONS:
• Use touch as appropriate to convey warmth and support • Offer encouragement, support, and compassion
• Help the client acknowledge the anxiety rather than deny or • Be clear with the client that you believe he or she can change
intellectualize about it • Encourage the client to talk about feelings, obsessions, and rituals in
• Point out observations of behaviors that may indicate anxiety detail
• Explore coping mechanisms and defensive behaviors • Gradually decrease time for the client to carry out ritualistic behaviors
• Discuss the expectations and needs that lead to the anxiety • Encourage client to use techniques to manage anxiety responses
• Assist client to complete daily routine and activities within agreed time
4. Obsessive-Compulsive Disorder limits
Characterized by recurrent • Encourage the client to develop and follow a written schedule with
obsessions (a persistent, painful, intrusive thought, emotion, or urge that specified times and activities
one is unable to suppress or ignore) or compulsions (the performance of
a repetitious, uncontrollable, but seemingly purposeful act to prevent 5.Post-Traumatic Stress Disorder
some future event or situation) or a combination of both, that interferes Is a syndrome that develops after an individual sees, is involved in, or
with normal life hears about a traumatic experience
Characterized by the re-experiencing of an extremely traumatic event,
COMMON OBSESSIVE THOUGHTS: avoidance of stimuli associated with the event, numbing of
• Religion • Sexuality responsiveness, and persistent increased arousal
• Violence • The need for symmetry or exactness
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 25

- Begins within 3 months to years after the event and may last a few • Work with the client to construct realistic goals and subgoals
months or years • Encourage the client to create a structured plan for self-care activities
- Women are more susceptible than men because they are exposed to • Identify signs of physical injury, and initiate appropriate medical
more personal violence treatment
- more prevalent in adults because they tend to be exposed to
precipitating situations 6. Acute Stress Disorder
Is the development of anxiety, dissociation ( is a mental process of
COMMON ANTECEDENTS: disconnecting from one’s thoughts, feelings, memories or sense of
• Sexual abuse identity), and other symptoms within 1 month of exposure to an extremely
• Assaultive violence traumatic stressor
• Accidents Is differentiated from PTSD (symptoms occur during or immediately after
• Traumatic losses (sudden death of spouse, diagnosis of a life- the trauma)
threatening illness in self or loved ones) Last for at least 2 days and either they resolve within 4 weeks after the
• Acts of terrorism conclusion of the event – if not, diagnosis is changed to PTSD
• Witnessing a violent act
• Natural disaster - SYMPTOMS:
• War-related trauma • Exposure to traumatic event causing intense fear, helplessness, or
horror
CLINICAL MANIFESTATIONS: • Marked anxiety symptoms or increased arousal
• Recurrent and intrusive distressing recollection • Significant distress or impaired functioning • Persistent re-experiencing
• Recurrent distressing dreams of the event
• Acting or feeling as if the event were • 3 of the following symptoms:
recurring ✓ Sense of emotional numbing or detachment
• Intense psychological distress to internal or external cues symbolizing ✓ Feeling dazed
an aspect of the event ✓ Derealization • is a mental state where you feel detached from your
• Physiologic reactions on exposure to stimuli that resemble an aspect of
surroundings • People and objects around you may seem unreal
the event
• Avoidance of activities, places or people, thoughts, feelings, or ✓ Depersonalization
conversations associated with the trauma > derealization disorder occurs when you persistently or repeatedly have
• Inability to recall an important aspect of the trauma the feeling that you’re observing yourself from outside your body or you
• Feeling of detachment or estrangement from others have a sense that things around you aren’t real, or both.
• Insomnia ✓ Dissociative amnesia
• Labile emotion
• Decreased concentration NURSING INTERVENTIONS:
• Hypervigilance • Maintain a calm, non-judgmental approach to convey acceptance
• Exaggerated startle response toward the client
• During interactions, use short, simple sentences to reduce the client
DIAGNOSTIC CHARACTERISTICS: heightened response to environmental stimuli
- Exposure in traumatic event involving: • Assist the client in meeting basic needs and encourage verbalization of
• Experience or witness of, or confrontation with, events involving death feelings
(actual or threatened) • Use a firm approach to provide external controls for the client who may
• Intense fear, helplessness or horror be at risk for self-harm to others
- symptoms occurring for longer than 1 month
- Evidence of impairment in functioning NURSING INTERVENTIONS:
- Persistent heightened feelings of arousal • Encourage client to eat a well-balanced diet
• Attempt to channel the client’s behavior by engaging the client in
NURSING DIAGNOSES: physical activities that provide an outlet for tension or frustration
• Post Trauma Syndrome • Promote sleep
• Powerlessness
• Risk for Self-directed violence or violence directed at others 7.Separation Anxiety Disorder
Characterized by excessive anxiety that is severe and persistent when
MEDICATIONS: the child is separated from the parent, a significant other, the home, or
• SSRI Antidepressants (Paroxetine, Sertraline) familiar surroundings
• Anti-anxiety drugs (Diazepam, Chlordiazepoxide) ONSET: preschool age; at any time before age 18 years

NURSING INTERVENTIONS: SYMPTOMS:

• Establish the setting for the interaction by sitting in the client’s direct • Psychophysiologic Symptoms (headache, nausea, vomiting,
visual field and speaking clear, low, soothing voice stomachache)
• Listen attentively, and stay with the client as the trauma is shared • Reluctance or refusal to go to sleep at night
• Try to understand the loss of control inherent in the traumatic situation • Refusal to stay alone at home
• Encourage the client to express thought and feelings • Social withdrawal
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 26

DIAGNOSIS: - The client will demonstrate an improved ability to express self

• Symptoms must have been present for at least 4 weeks - The client will express optimism about the present
- The client will socialize with at least one peer daily
TREATMENT: The Nursing Process
• Parent education - The client will express confidence in self
• Family therapy - The client will verbalize a reduction in frequency of flashbacks
- The client will identify factors that can be controlled by self
Related Disorders - The client will identify stimuli that precipitate the onset of acute anxiety
• Anxiety due to a general medical condition
• > when a person suffers from anxiety disorder due to another medical • PLANNING INTERVENTION - Focus is on the 6 areas:
condition, the presence of that medical condition leads directly to the 1. Acceptance that the experience of anxiety is natural and inevitable
anxiety experienced. 2. Understanding that one’s level of anxiety may fluctuate
• The anxiety is the predominant feature and may take the form of panic 3. Understanding that shame is a self- imposed response to anxiety
attacks, obsessive- compulsive behavior, or generalized anxiety 4. Ability to learn and apply self-help techniques to reduce anxiety
• Symptoms: Palpitations, Perspiration 5. Ability to remain calm in anxiety- producing situations
6. Development of problem-solving and coping skills
• Adjustment anxiety (adjustment disorder) The Nursing Process
• > is an emotional or behavioral reaction to a stressful event or change
in person’s life. The reaction is considered an unhealthy or excessive • IMPLEMENTATION
response to the event or change within three months of it happening - Maintain a calm, nonjudgmental approach
• > symptoms mainly include nervousness, worry, difficulty concentrating - Use short, simple sentences
or remembering things, and feeling overwhelmed. - Assist the client in meeting basic needs and encourage verbalization of
• > children who have an adjustment disorder with anxiety may strongly feelings
fear being separated from their parents and loved ones - Encourage client to eat a well-balanced diet
- Attempt to channel client’s behavior by engaging the client in physical
The Nursing Process activities that provide an outlet for tension or frustration and promote
• Assessment sleep
- Identify patient’s level of anxiety
- Determine whether a threat of self-harm or harm to others exists • Interactive Therapies
- Obtain a thorough history focusing on the client’s physiologic, emotional, - Individual Psychotherapy
behavioral and cognitive functioning – keeping in mind the client’s chief - Educational and supportive counseling
complaint and presenting problem - Relaxation techniques
- Participate in diversional activities and hobbies
Screening Tools and Assessment Scales: - Encouraged to express his or her feelings and concerns
• DREAMS and HARM mnemonic for screening clients for PTSD The Nursing Process: Implementation
D – detachment
R – re-experiencing E – event - Cognitive-Behavioral Therapy
A – avoidance - Involves teaching the client to recognize and change certain negative or
M – month faulty cognitions, and acts by using behavioral techniques to desensitize
S – sympathetic fears or anxiety
H – hyperarousal - Others:
A – avoidance - Virtual reality
R – re-experiencing M – month - Group therapy
- Family therapy
• NURSING DIAGNOSES: - Environmental modification
- Anxiety r/t impending divorce as evidenced by client’s apprehension, The Nursing Process: Implementation
lack of self-confidence, and statement of inability to relax
- Impaired Verbal Communication r/t decreased attention secondary to • Alternative / Behavioral Therapies
obsessive thoughts - Visual imagery
- Ineffective Coping r/t poor self-esteem and feelings of hopelessness - Eye movement desensitization and reprocessing
secondary to chronic anxiety - Change of pace or scenery
- Post-Trauma Syndrome r/t physical and sexual assault - Exercise or massage
- Powerlessness r/t obsessive-compulsive behavior - Transcendental meditation
- Disturbed Sleep pattern r/t excessive hyperactivity secondary to - Biofeedback
recurring episodes of panic - Systematic desensitization
- Impaired Social Interaction r/t high anxiety secondary to fear of open - Exposure and response prevention
places - Relaxation exercise
- Therapeutic touch
• OUTCOME IDENTIFICATION - Healing touch
- The client will verbalize feelings r/t anxiety - Hypnosis
- The client will relate decreased frustration with communication - Implosion therapy (Flooding)
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 27

• Medication Management 4 temperament traits:

CLIENT EDUCATION/NURSING RESPONSIBILITIES: 1. High harm avoidance- exhibit fear of uncertainty, social inhibition,
- Instruct client to avoid use of alcohol and sleep-inducing or over-the- shyness with strangers, rapid fatiguability and pessimistic worry in
counter drugs anticipation of problems
- Do not drive a car if dizziness or drowsiness occurs 2. High Novelty seeking- results in someone who is quick-tempered,
- Instruct client about the potential for drug dependence and withdrawal curious, easily bored, impulsive, extravagant and disorderly
syndrome if drug id discontinued abruptly 3. Reward dependence- defines how a person responds to social cues.
- Monitor liver function and blood count in clients receiving long-term The people are tender-hearted, sensitive, sociable and socially
therapy dependent
- Monitor for respiratory distress, palpitations, and constipation 4. Highly persistent people- they are hardworking and ambitious
- Monitor for dizziness, nervousness, GI disturbances, dreams overachievers who respond to fatigue or frustration as a personal
nightmares, or excitability challenge

• Anxiolytics (antipanic or antianxiety agent) Psychodynamic theories:

• > are category of drugs used to prevent anxiety and treat anxiety related Character- consists of concepts about the self and the external world. It
to several anxiety disorders. develops over time as a person comes into contact with people and
• > Alprazolam (Xanax) situations and confronts challenges
• >Chlordiazepoxide (Librium)
• > Clonazepam (Klonopin) 3 major character
• >Diazepam (Valium) Self-directedness- is the extent to which a person is responsible,
• > Lorazepam (Ativan) reliable, resourceful, goal-oriented and self-confident
Cooperativeness- refers to the extent to which a person sees him or
• EVALUATION herself as an integral part of human society
- Focuses on the client’s response to Self-transcendence- describes the extent to which a person considers
treatment him or herself to be an integral part of the universe.
- Discuss the continuum of care with the client, stressing the importance
of maintaining contact with support people
Psychopharmacology
- It focuses on the client’s symptoms rather than the particular subtype
CARE OF CLIENTS WITH PERSONALITY
DISORDERS (Mrs. Jumao-as) 4 symptom categories
1. cognitive-perceptual distortions- they lack correspondence between
the way a stimulus is commonly perceived and the way an individual
▪ Personality perceives it under given conditions; our mind convinces us of something
- Can be defined as an ingrained, enduring pattern of behaving and that isn’t really true (magical thinking, odd beliefs, illusions,
relating to the self, others and the environment; it includes perceptions, suspiciousness). Responds to low dose antipsychotic medications
attitudes and emotions 2. Affective symptoms
3. Mood dysregulation- refers to a poor ability to manage emotional
▪Personality Disorders responses or to keep them within an acceptable range of typical
- Are diagnosed when there is impairment of personality functioning and emotional reactions (moods swings- lithium, carbamazepine, valproate or
personality traits that are maladaptive low dose of neuroleptics such as haldol) (emotional detachment, cold and
aloof emotions and disinterest in social relations- selective serotonin
Maladaptive or dysfunctional personality traits: reuptake inhibitors(SSRI), atypical antipsychotics such as Risperidone,
1. Negative behaviors toward others olanzapine ,quetiapine)(Atypical depression- SSRI, monoamine oxidase
2. Anger and/or hostility inhibitor (MAOI)antidepressants or low-dose antipsychotic medications)
3. Irritable, labile moods 4. Aggression and behavioral dysfunction- people who exhibits cruel
4. Lack of guilt or remorse, emotionally cold and uncaring behaviors, poor social judgement (Lithium, anticonvulsant mood
5. Impulsivity, distractibility, poor judgment stabilizers and benzodiazepines and low-dose of neuroleptics)
6. Irresponsible
7. Risk-taking, thrill-seeking behaviors Cluster A
8. Mistrust 1. Paranoid Personality Disorder
9. Exhibitionism - It is characterized by pervasive mistrust and suspiciousness of others
10. Entitlement - The clients use the defense mechanism of projection, which is blaming
11.Dependency, insecurity other people, institutions or events of their own difficulties
12.Eccentric perceptions - Conflict with authority figures on the job is common
Biologic theories: Characteristics:
Temperament- refers to the biologic processes of sensation, association - Aloof and withdrawn
and motivation that underlie the integration of skills and habits based on - Appear guarded and hypervigilant
emotion - Restricted affect and may be unable to demonstrate warmth or empathic
emotional response
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 28

- Responses may become sarcastic for no apparent reason - Magical thinking, clairvoyance
- Constant mistrust and suspicion - Experience anxiety around with unfamiliar people
- They see malevolence in the actions of other people
- Spend disproportionate time examining and analyzing the behavior and Nursing interventions:
motives of others to discover hidden and threatening meanings - Development of self-care and social skills and improved functioning in
- Feel attacked by others the community
- Establish a daily routine for hygiene and grooming tasks
Nursing interventions: - Nurse can then role-play interactions that clients would have with each
- Establish rapport of these people
- Minimize potential for aggressive behavior
- Support adaptive behaviors Cluster B
- Nurses must be scrupulously attentive to keeping their word in all 1. Antisocial Personality Disorder
situations - Is characterized by a pervasive pattern of disregard for and violation of
- Nurses must approach these clients in a formal, businesslike manner the rights of others and by the central characteristics of deceit and
and refrain from social chit-chat or jokes manipulation
- Nurses must be on time and be straightforward
- Let the patient be involved on their care plan Symptoms:
- Teach the client to validate ideas before taking action - Using charm or wit to manipulate others for personal gain or personal
pleasure - Arrogance, a sense of superiority and being extremely
2. Schizoid Personality Disorder opinionated
- Is characterized by a pervasive pattern of detachment from social - Recurring problems with the law, including criminal behavior
relationships and a restricted range of emotional expression in - Impulsiveness or failure to plan ahead
interpersonal settings - Hostility, significant irritability, agitation, aggression or violence
- These loners choose solitary activities that do not require much - Lack empathy for others and lack of remorse about harming others
participation with others - Poor or abusive relationships
- Clients remain in the parental home well into adulthood if they can - Being consistently irresponsible and repeatedly failing to fulfill work or
maintain adequate separation and distance from other family members financial obligations
- They are more attached to computers or electronics for work or past
time Behavior problems:
- aggression toward people and animals
Characteristics: - Destruction of property
- Constricted affect and little emotion - Deceitfulness
- Aloof and indifferent - Theft
- Appears to be emotionally cold, uncaring or Unfeeling - Serious violation of rules
- Do not report leisure or pleasurable activities - Do not report feeling of
distressed Nursing interventions:
- Promoting responsible behavior
Nursing interventions: - Limit setting
- Focus on improved functioning in the community - Consistent adherence to rules and treatment plan
- Nurse will make referrals to social services or appropriate local agencies - Confrontation
for assistance if the client needs housing - Effective problem-solving skills
- If the person has an identified family member as his or her primary - Decreased impulsivity
relationship, the nurse must ascertain whether that person can continue - Expressing negative emotions such as anger or frustration - Taking a
in that role time-out from stressful situations
- Help the client obtain services and health care, manage finances and so - Enhancing role performance
on - Identifying barriers to role fulfillment
- Decreasing or eliminating use of drugs and alcohol
3. Schizotypal Personality Disorder
- Is characterized by a pervasive pattern of social and interpersonal 2. Borderline Personality Disorder
deficits marked by acute discomfort with and reduced capacity for close - Is characterized by a pervasive pattern of unstable interpersonal
relationships as well as by cognitive or perceptual distortions and relationships, self-image and affect as well marked impulsivity
behavioral eccentricities
Symptoms:
Characteristics: - Fear of abandonment
- Odd appearance - Unstable relationships
- Unkempt and disheveled and their clothes are often ill-fitting, do not - Unclear or shifting self-image
match and may be stained - Impulsive, self-destructive behaviors - Self-harm
- They wander aimlessly - Extreme emotional swings
- Speech is coherent, but may be loose, digressive or vague - Chronic feelings of emptiness
- Acute discomfort in relationships - Explosive anger
- Frequently use words incorrectly which makes their speech bizarre - Feeling suspicious or out of touch with reality
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 29

Nursing intervention: Symptoms:

- Promote client’s safety - Oversensitive and easily hurt by criticism or disapproval
- Help client to cope and control emotions - Have few, if any, close friends and reluctant to become involved with
- Cognitive restructuring techniques others unless certain of being liked
- Structuring time - Experience of extreme anxiety and fear in social settings and in
- Teaching social skills relationships, leading them to avoid activities or jobs that involve being
- Teaching effective communication skills - Entering therapeutic with others
relationship - Tend to be shy, awkward and self-conscious in social situations due to
fear of doing something wrong or being embarrassed
3. Histrionic Personality Disorder - Tend of exaggerate potential problems
- Is characterized by a pervasive pattern of excessive emotionality and - Seldom try anything new or take chances
attention seeking - Poor self-image, seeing themselves inadequate and inferior

Symptoms: Nursing intervention:

- Be uncomfortable unless he or she is the center of attention - Show support and reassurance
- Dress provocatively and/or exhibit inappropriately seductive or flirtatious - Help them practice self-affirmations and positive self-talk - Promote self-
behavior esteem
- Shift emotions rapidly - Act very dramatically
2. Dependent Personality Disorder
Nursing Intervention: - Is characterized by a pervasive and excessive need to be taken care of,
- Give appropriate feedbacks which leads to submissive and clinging behavior and fears of separation
- Discuss social situations
- Explore personal strengths and assets Characteristic:
- Encourage client to use assertive communications - Avoidance of personal responsibility
- Difficulty being alone
4. Narcissistic Personality Disorder - Fear of abandonment and a sense of helplessness when relationships
- Is characterized by a pervasive pattern of grandiosity, need for end
admiration and lack of empathy - Oversensitivity to criticism
- Individual psychotherapy is most effective treatment - Pessimism and lack of self-confidence - Trouble making everyday
decisions
Symptoms: - Anxious, pessimistic
- Exaggerated sense of self-importance
- Sense of entitlement and require constant, excessive admiration Nursing interventions:
- Expect to be recognized as superior even without achievements that - Foster autonomy and self-reliance
warrant it - Identify strengths and needs
- Exaggerate achievements and talents - Assist them in areas wherein they did not succeed
- Be preoccupied with fantasies about success, power, brilliance, beauty – Teach problem-solving and decision-making
or the perfect mate - Provide support and positive feedback
- Believe they are superior and can only associate with equally special
people 3. Obsessive-compulsive Personality Disorder
- Monopolize conversations and belittle or look down on people they - Is characterized by a pervasive pattern
perceive as inferior of preoccupation with perfectionism, mental and interpersonal control and
- Expect special favors and unquestioning compliance with their orderliness at the expense of flexibility, openness and efficiency
expectations
- Take advantage of others to get what they want Characteristic:
- Have an inability or unwillingness to recognize the needs and feelings - Perfectionism to the point that it impairs the Ability to finish tasks
of others - Stiff, formal or rigid mannerisms
- Be envious of others and believe others envy them - Being extremely frugal with money
- Behave in an arrogant or haughty manner, coming across as conceited, - An overwhelming need to be punctual
boastful and pretentious - Extreme attention to detail
- Insist on having the best of everything - Excessive devotion to work at the expense of family or social
relationships
Nursing Interventions: - Hoarding worn or useless items
- Self-awareness - Sets the limits - Inability to share or delegate work because of a fear it won’t be done
right
Cluster C - A fixation with lists
1. Avoidant Personality Disorder - A rigid adherence to rules and regulations
- Is characterized by a pervasive pattern of social discomfort and - An overwhelming need for order
reticence, low self-esteem and hypersensitivity to negative evaluation - Sense of righteousness about the way things should be done
- A rigid adherence to moral and ethical codes
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 30

Nursing interventions: A phase when the nurse explores client’s perception and
- Help clients to accept or tolerate less-than-perfect work or decisions identify problems
made on time may alleviate some difficulties at work or home
- Encourage client to take risks, such as letting someone else plan a
family activity The phase when the nurse develops a plan of care and
realistic goals:
Depressive behavior
- Is characterized by a pervasive pattern of depressive cognitions and During interaction with the level III Nursing Students with
behavior in various contexts. It occurs more often in people with relatives the psychiatric patient s in the Psychia Ward, different
who have major depressive disorders
therapeutic communication techniques were utilized.
Passive-aggressive behavior School phobia is usually treated by:
- Is characterized by a negative attitude and a pervasive pattern of
passive resistance to demands for adequate social and occupational Sheba only attends social events when a family member is
performance also present. She exhibits behavior typical of anxiety
disorder of:

Aine is a client with a fear of air travel. She is being treated

in a mental institution for phobic disorder. The treatment
Situation: Nurse Grace also discusses the different Ego method involves systematic desensitization. The nurse
Defense Mechanism. She gives example to the students would consider the treatment successful if:
and let them identify the ego defense mechanism used.
Teenager forbidden to see X-rated movie is tempted to do A 20-year-old female has an intense fear of spiders. Initial
so by friends and develops blindness, and the teenager is intervention for the client should be to:
unconcerned about the loss of sight. CONVERSION
A 30-year-old male has an intense fear of riding an elevator.
He claims, “As if I will die inside.” This has affected his
studies and the client is suffering from: CLAUSTROPHOBIA
Person who is mad at the boss yells at his or her spouse
DISPLACEMENT Mr. Jan was recently admitted to a psychiatric unit because
of severe obsessive-compulsive behavior. The most
therapeutic initial response by the nurse is:
Nursing student becoming a critical care nurse because this
is the specialty of an instructor, she admires.
A client has been diagnosed with obsessive-compulsive
IDENTIFICATION
disorder. The nurse would expect to find the clinical
manifestation of: PERSISTENT UNWANTED THOUGHTS
A 5-year-old asks for a bottle when new baby brother is
being fed. REGRESSION
A client diagnosed with obsessive-compulsive disorder is
Person who cheats on a spouse brings the spouse a constantly checking the oven to make sure it is off. This is
bouquet of roses. UNDOING an example of a type of obsessive thought content of:

Situation: Clinical Teacher KZ discusses to Level III Nursing Nurse Ai is developing a care plan for a female client with
students the phases of Nurse-Client interaction and the post-traumatic stress disorder. An initial thing to is to:
activities each phases. The phase of interaction when the
A physiologic response to generalized anxiety include:
nurse sets a one on one relationship by being acquainted
MUSCLE TENSION
with client is:
The appropriate discharge criteria for patient with chronic
A phase when the nurse sets an objectives and plan of care
anxiety disorder is the patient will:
of interaction:
Mrs. Angie Ty has been a psychiatric Nurse for 5 years she
A phase when the client demonstrate independence at
has observed the different types of personality disorders
work and do selfcare:
and described them as follows: It is a personality disorder
where a mistrust and suspiciousness of others, they also
 NCM117 Psychiatric Mental-Health Nursing | MidTerm Exam Study Guide 31

appear guarded and hypervigilant: PARANOID A harmful or unwarranted contact with a client; actual
PERSONALITY DISORDER harm or injury may or may not have occurred: BATTERY

The patient disregards and violates the rights of others and Is the perpetration of an act of sexual intercourse with a
they usually use charm or wit to manipulate others for person against his or her will and without her consent,
personal gain and they are arrogant and extremely whether that will is overcome by force, fear of force, drugs,
opinionated: NARCISSISTIC PERSONALITY DISORDER or intoxicants: RAPE

The patient is oversensitive and easily hurt by criticism and It may include physical and sexual abuse, psychological,
low self-esteem and they also experience extreme anxiety abuse, neglect, self-neglect, financial exploitation of elderly
and fear in social settings and in relationships leading them and denial of adequate medical treatment: ELDER ABUSE
to avoid activities: AVOIDANT PERSONALITY DISORDER
Situation: Kyle, a 3rd year nursing student was preparing
The patient fears abandonment, avoids personal her report about the topic somatoform and dissociative
responsibility and they need to be taken care of: disorders. The state in which a person becomes separated
BORDERLINE PERSONALITY DISORDER from reality: DISSOCIATION

The patient is stiff and preoccupied with perfection and A somatoform disorder in which a client presents with
orderliness: OBSESSIVE COMPULSIVE PERSONALITY unrealistic or exaggerated physical complaints:
DISORDER HYPOCHONDRIASIS

Mrs. Dee Yon has been discussing the different types of This diagnosis is given when an individual experiences
personality disorders and its nursing interventions: All of significant pain without a physical basis for pain or with
these are nursing interventions for caring a patient with a pain that greatly exceeds what is expected based on the
paranoid personality disorder except: TALKING TO THE extent of injury: PAIN DISORDER
PATIENT WITH JOKES AND CHIT CHATS
Characterized by the voluntary production of false or
All of these are nursing interventions for caring a patient grossly exaggerated physical or psychological symptoms:
with avoidant personality disorder except: DISCOURAGE MALINGERING DISORDER
THEM
Is used to describe client reactions such as showing
All of these are nursing interventions for caring a patient inappropriate lack of concern about the symptoms and
with dependent personality disorder except: ASSIST THEM displaying no anxiety: LA BELLE INDIFFERENCE
ALL THE TIME
Situation: Steph was reviewing her lesson about
All of these are nursing interventions for caring a patient Somatoform and Dissociative disorders and its related
with borderline personality disorder except: JUST LET THE disorders before Mid-Term Exam: Related disorder of
PAIR OF SCISSORS OR ANY SHARP OBJECTS BE AT THE Somatoform the fabricates symptoms into a substitute by
PATIENT’S ROOM inflicting harm:

All of these are nursing interventions for caring a patient Also known as the Briquet's Syndrome: SOMATIZATION
with obsessive compulsive personality disorder except: DISORDER

Situation: Nurse Ken was reviewing her topics about Social

and emotional concerns concerning abuse and rape. A
wrongful act that results in injury, loss, or damage. Torts
may be either unintentional or intentional: TORTS

A type of negligence that refers specifically to professionals

such as nurses and physicians: MALPRACTICE