Varcarolis' Foundations of Psychiatric Mental Health Nursing

A Clinical Approach, 8th Edition

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 Varcarolis'
FOUNDATIONS of

PSYCHIATRIC-MENTAL
HEALTH NURSING
A Clinical Approach 8�
MARGARET (PEGGY) JORDAN HALTER, PhD, APRN
Clinical Nurse Specialist
Cleveland Clinic Akron General
Akron, Ohio;
Adjunct Faculty
Ohio State University
Columbus, Ohio

ELSEVIER
 R
3251 Riverport Lane
St. Louis, Missouri 63043

VARCAROLIS' FOUNDATIONS OF PSYCHIATRIC-MENTAL

HEALTH NURSING: A CLINICAL APPROACH, EIGHTH EDITION ISBN: 978-0-323-38967-9

Copyright© 2018,Elsevier Inc.

Previous editions copyrighted 2014,2010,2006,2002,1998,1994,1990.

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods, they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
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to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any
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material herein.

Library of Congress Cataloging-in-Publication Data

Names: Halter, Margaret J. (Margaret Jordan), editor.

Title: Varcarolis' foundations of psychiatric mental health nursing : a
clinical approach I [edited by] Margaret Jordan Halter.
Other titles: Foundations of psychiatric mental health nursing
Description: Eighth edition. I St. Louis, Missouri : Elsevier, [2018]1
Preceded by Varcarolis' foundations of psychiatric mental health nursing.
7th ed. I [edited by] Margaret Jordan Halter. c2014.1 Includes
bibliographical references and index.
Identifiers: LCCN 20170150751 ISBN 9780323389679 (pbk. : alk. paper)
Subjects: I MESH: Mental Disorders--nursing I Psychiatric Nursing
Classification: LCC RC440 I NLM WY 160 I DDC 616.89/0231--dc23 LC record available at
https://lccn.loc.gov/2017015075

Senior Content Strategist: Yvonne Alexopoulos

Content Development Manager: Lisa P. Newton
Publishing Services Manager: Jeff Patterson
Senior Project Manager: Tracey Schriefer
Design Direction: Paula Catalano
W(lt ing to�e thcr
to grtl " libr:ui.e in
d-c=..,·dupi:hg ·uu:htrie!'i
Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2

This book is dedicated to people who are living with and recovering
from mental illness and to the future registered nurses
who will focus on supporting their recovery.

My dream is that scientific understanding and advances

will not only provide even better treatments,
but will also prevent, and even cure, psychiatric disorders.

Dedicated to my husband, Paul.

Your kindness and love of life shine
through your daughters and granddaughters.

I miss you every day.

 My ancestors were storytellers. Boxes of diaries, articles, and books fill an unused closet and
detail many of their moves and thoughts. The family tree includes a newspaper editor, a historian,
a poet, and a nonfiction writer. One great aunt, Ella Chalfant, published a book titled A Goodly
Heritage in 1 955. Her book centered on inheritance laws in the 1 800s and featured copies of wills
demonstrating the disenfranchisement of women (e.g., a husband needed to will a wife her own
clothing on his death) . She was likely an early feminist.
As a registered nurse, I did have the opportunity to write some non-fiction in the form of
nurses notes. As a tenure-track faculty member, I was required to write some stories in the form
of presentations, research, and publications.
A 2004 phone call finally put me on the path to join my ancestors in their vocation. A pleasant
voice with a slight New York accent says, "Peggy? Hi, this is Betsy Varcarolis:' I knew the name
at once-my undergraduates used her book. She went on, "The reason I'm calling is that I very
much enjoyed your article, 'Stigma and help seeking related to depression: A study of nursing
students: I would like to feature it as an Evidence-Based Practice box in the fifth edition of my
book:' I was thrilled-what an honor!
This was the beginning. After that call, my work progressed from chapter reviewer to chap­
ter writer to textbook editor. I spent several years as an apprentice of Elizabeth Varcarolis, the
creative power who conceived of Foundations of Psychiatric Mental Health Nursing in 1 990. She
went on to make this textbook a leader in the specialty of psychiatric nursing. Betsy has the rare
gift of making the complex understandable and of making impersonal learning a joint process in
which the experts talk with the students rather than just providing information.
In this 8th edition of the book, Elizabeth Varcarolis continues to be honored for her work
with her name in the title. Sincere thanks and gratitude go out to Betsy for enriching my life. The
profession of psychiatric nursing, countless students, and recipients of psychiatric-mental health
care have benefited from her wisdom. I wish for Betsy all the best as she enjoys her retirement
hand-in-hand with her husband, Paul.
My heartfelt appreciation also goes out to the talented group of writers who contributed to the
8th edition. We have a talented pool of veteran writers, and their knowledge and passion con­
tinue to influence psychiatric nursing. A few new writers whose expertise was both recognized
and sought after agreed to join us in this edition. It has truly been a joy working with each of you.
Thanks for the countless hours you spent researching, writing, and rewriting!
A huge debt of gratitude goes to the many educators and clinicians who reviewed the manu­
script and offered valuable suggestions, ideas, opinions, and criticisms. All comments were appre­
ciated and helped refine and strengthen the individual chapters.
Throughout this project, a number of people at Elsevier provided superb support. I am grateful
for Tracey Schriefer, our Senior Project Manager, who nudged me to meet deadlines, and Paula
Catalano, a talented and creative designer. Yvonne Alexopoulos, Senior Content Strategist, kept
me on a straight path and helped me work through some thorny issues. Lisa Newton, Content
Development Manager, was my ever-optimistic colleague who celebrated each milestone with a
smiley emoji and an exclamation mark! My sincere thanks go out to my whole Elsevier family.

Peggy Halter

vi
Lois Angelo, APRN Mary A. Gutierrez,PharmD,BCPP Jane Stein-Parbury,RN,BSN,MEd, PhD,
Case Manager Professor of Pharmacy Practice (Psychiatry) FRCNA
Newton-Wellesley Hospital Chapman University School of Pharmacy Adjunct Professor
Newton, Massachusetts Irvine, California University of Technology Sydney
Sydney, Australia
Natalie K. Boysen,BSN,RN Monica J. Halter,APRN, PMHNP-BC
Genesis East Medical Center Psychiatric Nurse Practitioner Christine Tackett,MSN RN
Emergency Services Psychological and Behavioral Consultants Associate Professor
Davenport, Iowa Cleveland, Ohio Herzing University
Akron, Ohio
Leslie A. Briscoe,MSN,RN, PMHCNP Edward A. Herzog,APRN-CNS
Psychiatric Nurse Practitioner Senior Lecturer, College of Nursing Christine Tebaldi,RN,MS, PMHNP-BC
Louis Stokes Cleveland VA Medical Center Kent State University Director, Clinical Business Development
Geriatric Psychiatry: Outpatient and Consul- Kent, Ohio McLean Hospital
tation/Liaison Service Belmont, Massachusetts
Cleveland, Ohio Jerika T. Lam,PharmD,AAHIVP,
Nursing Editorial Advisory Panel FCSHP Elizabeth M. Varcarolis,RN,MA
Wolters Kluwer Publishing Assistant Professor of Pharmacy Practice Professor Emeritus
Clinical Drug Information I Nursing Chapman University School of Pharmacy Formerly Deputy Chairperson and Psychiat­
division Irvine, California ric Nursing Coordinator Department of
Hudson, Ohio Nursing
Laura G. Leahy,DrNP,APN,PMH-CNS/ Borough of Manhattan Community College,
Alison M. Colbert,PhD,APRN,BC FNP,BC Associate Fellow
Assistant Professor Family Psychiatric Advanced Practice Nurse Albert Ellis Institute for Rational Emotional
Duquesne University School of Nursing APN Solutions, LLC Behavioral Therapy (REBT)
Pittsburgh, Pennsylvania Sewell, New Jersey Former Major, Army Nurse Corps Reserve
New York, New York
Carissa Enright,MSN,RN,PMHNP BC Lorann Murphy,MSN,PsychBC
Associate Clinical Professor Clinical Nurse Specialist Kathleen Wheeler,PhD, PMHNP-BC,
Texas Woman's University Lutheran Hospital APRN,FAAN
Dallas, Texas Cleveland, Ohio Professor
Fairfield University Egan School of Nursing
Jill Espelin,DNP,PMHNP-BC,CNE, Cindy Parsons,DNP,PMHNP-BC, Fairfield, Connecticut
APRN FAANP
Assistant Professor Associate Professor of Nursing Kimberly M. Wolf,PhD,MS,PM­
Central Connecticut State University University of Tampa HCNS-BC
New Britain, Connecticut Tampa, Florida Hennepin County Medical Center Inpatient
Provider
Jodie A. Flynn,MSN,RN,SANE-A, Donna Rolin,PhD,APRN,PM­ Minneapolis, Minnesota
SANE-P,D-ABMDI HCNS-BC,PMHNP-BC Associated Clinic of Psychology Outpatient
Instructor Assistant Professor Provider
Capital University Director of Family Psychiatric Mental Health Minneapolis, Minnesota
Columbus, Ohio Nurse Practitioner Graduate Program University of North Dakota PMHNP
University of Texas at Austin, School of Program Director
Christina Fratena,MSN, PMHCNS-BC Nursing Grand Forks, North Dakota
Clinical Instructor of Nursing Austin, Texas Duquesne University Adjunct Faculty
Malone University Pittsburgh, Pennsylvania
Canton, Ohio L. Kathleen Sekula,PhD,PMHCNS,
FAAN Sandy Snelson Yaklin,MSN,APRN,
Faye J. Grund,PhD,APRN, PMHNP-BC Professor PMHNP-BC,CNE, CHPN
Dean Coordinator: Forensic Graduate Programs Bluebonnet Trails Community Service
Dwight Schar College of Nursing and Health Duquesne University School of Nursing Round Rock, Texas
Sciences Pittsburgh, Pennsylvania
Ashland University
Mansfield, Ohio

vii
viii CONTR I B U TOR LIST

Rick Zoucha,PhD,PMHCNS-BC, BJ Garrett,MSN,NE,RN Linda Wendling,MS,MFA

CTN-A,FAAN Associate Professor Learning Theory Consultant
Joseph A. Lauritis, C.S.Sp. Endowed Chair Austin Community College University of Missouri-St. Louis
for Teaching and Technology Austin, Texas St. Louis, Missouri
Professor and Chair of Advanced Role and Chapter Review Questions TEACH for Nurses and PowerPoints
PhD Programs
Duquesne University Linda Turchin, RN,MSN,CNE
Pittsburgh, Pennsylvania Associate Professor of Nursing
Fairmont State University
Fairmont, West Virginia
ANCILLARY WRITERS Case Studies and Nursing Care Plans
Teresa S. Burckhalter,MSN, RN,BC Chapter Review Questions
Adjunct Faculty Pre/Posttests
University of South Carolina Beaufort Student Review Questions
Beaufort, South Carolina
Test Bank
Nancy Bryan, RN, MSN Chris Paxos, PharmD, BCPP, BCPS, CGP
Nurse Educator Associate Professor, Pharmacy Practice
Roseman University of Health Sciences Assistant Professor, Psychiatry
College of Nursing Northeast Ohio Medical University
Henderson, Nevada Pharmacotherapy Specialist, Psychiatry
Cleveland Clinic Akron General
Lori J. Cline, RN, MNSc Rootstown, Ohio
Lecturer, Clinical Instructor, and
Group Therapist Victoria Plagenz, RN, BSN, MS, PhD
College of Nursing- University of Central Arkansas Assistant Professor
and University of Arkansas at Little Rock University of Great Falls
Group Therapy- Little Rock Community Mental Nursing
Health Center Great Falls, Montana
Little Rock, Arkansas
Jeffrey A. Robbins, RN, BSN, MBA
Leslie A. Folds, EdD, PMHCNS-BC, CNE Clinical Nursing Instructor, Psychiatric Nursing
Associate Professor of Nursing UTA College of Nursing
Belmont University Arlington, Texas
Nursing Department
Nashville, Tennessee

Susan Justice, MSN, RN, CNS

Assistant Clinical Professor, Lead Faculty
UT Arlington College of Nursing
Arlington, Texas

ix
We are living in an age of fast-paced discoveries in neurobi­ • Introduction: Provides a brief overview of the disorder and
ology, genetics, and psychopharmacology. Researchers con­ identifies disorders that fall under the umbrella of the gen­
tinue to seek the most effective evidence-based approaches for eral chapter name.
patients and their families. Legal issues and ethical dilemmas • Epidemiology: Helps the student understand the extent of
faced by the health care system are magnified accordingly. Given the problem and characteristics of those who may be more
these challenges, keeping up and knowing how best to teach likely to be affected. This section includes information such
our students and serve our patients can seem overwhelming. as 1 2 -month prevalence, lifetime prevalence, age of onset,
With contributions from many knowledgeable and experienced and gender differences.
nurse educators, our goal is to bring to you the most current and • Comorbidity: Describes the most common conditions
comprehensive trends and evidence-based practices in psychi­ that are associated with the psychiatric disorder. Knowing
atric-mental health nursing. that comorbid disorders are often part of the clinical
picture of specific disorders helps students as well as cli­
nicians understand how to better assess and care for their
CONTENT NEW TO THIS EDITION
patients.
The following changes reflect contemporary nursing practice • Risk Factors: Provides current views of causation. This
and psychiatric-mental health care and are considered in detail section is being updated to increasingly focus on genetic
in this 8th edition: and neurobiological factors in the etiology of psychiatric
• Full Diagnostic and Statistical Manual of Mental Disorders, diagnoses.
5th edition (DSM-5) diagnostic criteria are provided for • Clinical Picture: This section presents an overview of the
major disorders within the clinical chapters. disorder(s), DSM-5 criteria for many of the disorders, and
• Genetic underpinnings of psychiatric disorders and genetic strong source material.
implications for testing and treatment choices are empha­ • Assessment:
sized. •General Assessment: Identifies assessment for specific
• Chapter 30 reintroduces completely updated dying, death, disorders, including assessment tools and rating scales.
and grieving concepts and nursing care. The rating scales included help to highlight important
• The five chapter review questions included in previous areas in the assessment of a variety of behaviors or mental
editions of Foundations have been doubled to ten. conditions.
• The latest U.S. Food and Drug Administration approved • Self-Assessment: Discusses the nurse's thoughts and feel­
medications are featured in all clinical chapters. ings that should be addressed to enhance self-growth and
• Screenings and severity rating scales are introduced in provide the best possible and most appropriate care to the
Chapter 1 and included throughout most clinical chapters patient.
that provide quantifiable data to supplement categorical • Assessment Guidelines: Provides a summary of specific
criteria. areas to assess by disorder.
• The Manual of Psychiatric Nursing Care Planning has been • Diagnosis: NANDA-I-approved nursing diagnoses are used
updated and realigned to more closely match this edition of in all nursing process sections. Some critical issues in psychi­
Foundations. These revisions increase continuity between atric-mental health nursing are best addressed by essential
academic learning and clinical support. non-NANDA-I diagnoses such as disturbed thought processes
Refer to the To the Student section of this introduction on and nonadherence.
page xii for examples of thoroughly updated familiar features • Outcomes Identification: Nursing Outcomes Classification
with a fresh perspective, including Evidence-Based Practice (NOC) provides a link to the NANDA-I diagnoses. They are
boxes, Considering Culture boxes, Health Policy boxes, Key introduced in Chapter 1 and used throughout the text when
Points to Remember, Assessment Guidelines, Vignettes, and appropriate.
other features. • Planning: Students are encouraged to develop patient­
centered priorities in conjunction with patients, families,
and others.
ORGANIZATION OF THE TEXT
• Implementation: Interventions follow the standards set
Chapters are grouped in units to emphasize the clinical forth in the Psychiatric-Mental Health Nursing: Scope and
perspective and facilitate location of information. The Standards of Practice ( 2 0 1 4 ) . This publication was devel­
order of the clinical chapters approximates those found in oped collaboratively by the American Nurses Associa­
the DSM-5. All clinical chapters are organized in a clear, tion, the American Psychiatric Nurses Association, and
logical, and consistent format with the nursing process as the International Society of Psychiatric-Mental Health
the strong, visible framework. The basic outline for clinical Nurses. These standards are incorporated throughout the
chapters is: chapters.

X
 TO T H E I N STR U CTOR xi

Nursing Intervention Classifications (NIC) (20 1 3 ) also pro­ • A DSM-5 Webinar explaining the changes in structure and
vides direction for interventions. disorders from the DSM-IV-TR is available for reference.
• Evaluation: Evaluation of nursing care is addressed as essen­
tial in order to support current planning and intervening. For Stud ents
Evaluation also provides direction in modifying the plan of Student Resources on Evolve, available at http:/Ievolve.elsevier.com/
care and updating priorities. Varcarolis, provide a variety of valuable learning resources. The
Evolve Resources page near the front of the book gives login instruc­
TEACHING AND LEARNING RESOURCES tions and a description of each resource.
• Animations of the neurobiology of select psychiatric disor­
For I n structors ders and medications make complex concepts come to life
Instructor Resources on Evolve, available at http://evolve with multidimensional views. You can find these illustrations
. elsevier.com!Varcarolis, provide a wealth of material to help in the textbook with the icon next to them .
you make your psychiatric nursing instruction a success. In • The Answer Keys to Critical Thinking Guidelines provide
addition to all of the Student Resources, the following are pro­ possible outcomes for the Critical Thinking questions at the
vided for faculty: end of each chapter.
• TEACH for Nurses Lesson Plans, based on textbook chap­ • Case Studies and Nursing Care Plans provide detailed case
ter Learning Obj ectives, serve as ready-made, modifiable studies and care plans for specific psychiatric disorders to
lesson plans and a complete roadmap to link all parts of the supplement those found in the textbook.
educational package. These concise and straightforward les­ • Glossary provides an alphabetical list of nursing terms with
son plans can be modified or combined to meet your partic­ accompanying definitions.
ular scheduling and teaching needs. • NCLEX® Review Questions, provided for each chapter, will
• PowerPoint Presentations are organized by chapter with help you prepare for course examinations and for your RN
approximately 750 slides for in-class lectures. These are licensure examination.
detailed and include customizable text and image lecture • Pretests and Posttests provide interactive self-assessments
slides to enhance learning in the classroom or in web-based for each chapter of the textbook, including instant scoring
course modules. If you share them with students, they can and feedback at the click of a button.
use the note feature to help them with your lectures. We are grateful to educators who send suggestions and pro­
• Audience Response Questions for i> clicker and other sys­ vide feedback and strive to incorporate these ideas from this
tems are provided with two to five multiple-answer questions huge pool of experts into reprints and revisions of Foundations.
per chapter to stimulate class discussion and assess student We hope that this 8th edition continues to help students learn
understanding of key concepts. and appreciate the scope and practice of psychiatric-mental
• The Test Bank has more than 1 800 test items, complete with health nursing.
the correct answer, rationale, cognitive level of each ques­ Peggy Halter
tion, corresponding step of the nursing process, appropriate
NCLEX Client Needs label, and text page reference(s).
Psychiatric-mental health nursing challenges us to understand the CHAPTER FEATURES
complexities of the brain and human behavior. We focus on the
origin of psychiatric disorders, including biological determinants Vignettes are short stories that describe the unique circumstances
along with environmental factors. In the chapters that follow, you surrounding individual patients with psychiatric disorders.
will learn about people who experience psychiatric disorders and Self-Assessment sections explore thoughts and feelings you
how to provide them with quality nursing care in any setting. As may experience working with patients who have psychiatric dis­
you read, keep in mind these special features. orders. These thoughts and feelings may need to be addressed
to enhance self-growth and provide the best possible and most
appropriate care to the patient.
READING AND REVIEW TOOLS Assessment Guidelines in the clinical chapters provide
Objectives and Key Terms and Concepts introduce the chapter summary points for patient assessment.
topics and provide a concise overview of the material discussed. Evidence-Based Practice boxes demonstrate how current
Key Points to Remember listed at the end of each chapter research findings affect psychiatric-mental health nursing prac­
reinforce essential information. tice and standards of care.
Critical Thinking activities at the end of each chapter are Guidelines for Communication boxes provide tips for com­
scenario-based critical thinking problems for practice in apply­ municating therapeutically with patients and their families.
ing what you have learned. Answer Guidelines can be found on Considering Culture boxes reinforce the importance of pro­
the Evolve website. viding culturally competent care.
Ten multiple-choice Chapter Review questions at the end of FDA-Approved Drug tables present the latest information
each chapter help you review the chapter material and study for on medications used to treat psychiatric disorders.
exams. Answers are conveniently provided following the ques­ Patient and Family Teaching boxes underscore the nurse's
tions. Answers along with rationales and textbook page refer­ role in helping patients and families understand psychiatric dis­
ences are located on the Evolve website. orders, treatments, complications, and medication side effects,
among other important issues.
Case Studies and Nursing Care Plans present individualized
ADDITIONAL LEARNING RESOURCES histories of patients with specific psychiatric disorders following
Your Evolve Resources at http://evolve.elsevier.com/Varcarolis the steps of the nursing process. Interventions with rationales
offer more helpful study aids, such as additional Case Studies and evaluation statements are presented for each patient goal.
and Nursing Care Plans.

xii
UNIT I Fou n d ations i n Theory Theory of Object Relations, 30
Theories ofMoral Development, 30
1 Mental Health and Mental Illness. 1 Ethics of Care Theory, 31
Margaret Jordan Halter Conclusion, 32
Mental Health and Mental Illness, 2 3 Psychobiology and Psychopharmacology, 36
Mental Health Continuum, 3 Mary A. Gutierrez, Jerika T Lam
Risk and Protective Factors, 4 Structure and Function of the Brain, 3 7
Individual Attributes and Behaviors, 4 Functions and Activities of the Brain, 37
Social and Economic Circumstances, 5 Cellular Composition of the Brain, 40
Environmental Factors, 5 Organization of the Brain, 40
Perceptions of Mental Health and Mental Illness, 6 Visualizing the Brain, 43
Social Influences on Mental Healthcare, 6 Disturbances ofMental Function, 45
Legislation and Mental Health Funding, 9 Action of Psychotropic Drugs, 48
Mental Health Parity, 9 Drug Agonism and Antagonism, 49
Patient Protection and Affordable Care Act of 2010, 9 Antianxiety and Hypnotic Drugs, 49
Epidemiology of Mental Disorders, 1 0 Antidepressant Drugs, 51
Classification ofMental Disorders, 1 1 Mood Stabilizers, 55
Psychiatric-Mental Health Nursing, 1 1 Anticonvulsant Drugs, 55
What Is Psychiatric-Mental Health Nursing? 1 1 Antipsychotic Drugs, 56
Classification of Nursing Diagnoses, Outcomes, and Drug Treatment for Attention-Deficit/Hyperactivity
Interventions, 1 2 Disorder, 59
Levels of Psychiatric-Mental Health Clinical Nursing Drug Treatment for Alzheimer's Disease, 59
Practice, 1 2 Herbal Treatments, 59
Future Issues for Psychiatric-Mental Health
Nurses, 1 3 UNIT II Fou n d ations for Pra cti ce
Educational Challenges, 1 3
An Aging Population, 1 4 4 Treatment Settings, 62
Cultural Diversity, 1 4 Monica J. Halter, Christine M. Tebaldi
Science, Technology, and Electronic Healthcare, 1 4 Background, 63
Advocacy and Legislative Involvement, 1 4 Continuum of Care, 64
2 Theories and Therapies, 18 Outpatient Care Settings, 64
Margaret Jordan Halter Primary Care Providers, 64
Psychoanalytic Theories and Therapies, 19 Specialized Psychiatric Care Providers, 65
Psychoanalytic Theory, 19 Patient-Centered Medical Homes, 65
Psychodynamic Therapy, 20 Community Mental Health Centers, 66
Interpersonal Theories and Therapies, 2 1 Psychiatric Home Care, 66
Interpersonal Theory, 21 Assertive Community Treatment, 66
Interpersonal Therapy, 21 Intensive Outpatient Programs and Partial
Implications ofInterpersonal Theory to Nursing, 22 Hospitalization Programs, 67
Behavioral Theories and Therapies, 22 Other Outpatient Venues for Psychiatric Care, 67
Classical Conditioning Theory, 22 Emergency Care, 67
Behavioral Theory, 23 Prevention in Outpatient Care, 68
Operant Conditioning Theory, 23 Primary Prevention, 68
Behavioral Therapy, 23 Secondary Prevention, 68
Cognitive Theories and Therapies, 25 Tertiary Prevention, 68
Rational-Emotive Therapy, 25 Outpatient Psychiatric Nursing Care, 68
Cognitive-Behavioral Therapy, 25 Promoting Recovery and Continuation of Treatment, 68
Humanistic Theories, 26 Inpatient Care Settings, 69
Theory ofHuman Motivation, 26 Crisis Stabilization/Observation Units, 69
Biological Theories and Therapies, 28 General Hospital and Private Hospital, 69
Biological Model, 28 State Hospital, 69
Developmental Theories, 29 Considerations for Inpatient Care, 69
Cognitive Development, 29 Entry to Acute Inpatient Care, 69

xiii
xiv CONTE NTS

Rights of the Hospitalized Patient, 70 Failure to Protect Patients, 99

Teamwork and Collaboration, 70 Laws Relevant to Psychiatric Nursing, 99
Therapeutic Milieu, 71 Tort Law, 99
Unit Design, 72 Standards for Nursing Care, 101
Inpatient Psychiatric Nursing Care, 72 State Boards ofNursing, 1 01
Specialty Treatment Settings, 73 Professional Associations, 1 01
Pediatric Psychiatric Care, 73 Institutional Policies and Procedures, 1 01
Geriatric Psychiatric Care, 73 Custom as a Standard of Care, 1 02
Veterans Administration Centers, 73 Acting on Questionable Practice, 102
Forensic Psychiatric Care, 74 Negligence, Irresponsibility, or Impairment, 1 02
Alcohol and Drug Use Disorder Treatment, 74 Documentation of Care, 103
Self-Help Options, 74 Medical Records and Quality Improvement, 1 03
5 Cultural Implications, 77 Medical Records as Evidence, 1 03
Rick Zoucha, Kimberly Wolf Guidelines for Electronic Documentation, 1 03
Minority Status, Race, Ethnicity, and Culture, 78 Forensic Nursing, 103
Minority Status, 78 Violence in the Psychiatric Setting, 104
Race, 78
Ethnicity, 78
Culture, 78 UNIT Ill Psychoso c i a l N u rs i n g Too l s
Measuring Race and Ethnicity in the United States, 78
Demographic Shifts in the United States, 79 7 The Nursing Process and Standards of Care, 108
Basic Worldviews, 79 Elizabeth M. Varcarolis
Western Tradition, 79 Quality and Safety Education in Nursing, 1 1 0
Eastern Tradition, 80 Standards of Practice i n Psychiatric-Mental
Indigenous Culture, 80 Health Nursing, 1 1 0
Impact of Culture, 80 Standards o f Practice for Psychiatric-Mental Health
Cultural Barriers to Mental Health Services, 81 Nursing: Standard 1: Assessment, 110
Communication Barriers, 81 Age Considerations, 1 1 1
Stigma ofMental Illness, 83 Language Barriers, 1 1 1
Misdiagnosis, 83 Psychiatric-Mental Health Nursing
Cultural Concepts ofDistress, 83 Assessment, 1 1 2
Genetic Variation in Pharmacodynamics, 84 Standards o f Practice for Psychiatric-Mental Health
Populations at Risk for Mental Illness and Inadequate Nursing: Standard 2: Diagnosis, 115
Care, 85 Diagnostic Statements, 1 1 S
Immigrants, 8S Types of Nursing Diagnoses, 1 1 S
Refugees, 8S Standards o f Practice for Psychiatric-Mental
Cultural Minorities, 8S Health Nursing: Standard 3: Outcomes
Culturally Competent Care, 85 Identification, 116
Cultural Awareness, 86 Standards of Practice for Psychiatric-Mental Health
Cultural Knowledge, 86 Nursing: Standard 4: Planning, 116
Cultural Encounters, 86 Standards of Practice for Psychiatric-Mental Health
Cultural Skill, 86 Nursing: Standard 5: Implementation, ll8
Cultural Desire, 87 Standard SA. Coordination of Care, 1 1 8
6 Legal and Ethical Considerations, 91 Standard SR Health Teaching and Health
Margaret Jordan Halter, Diane K. Kjervik Promotion, 1 1 8
Ethical Concepts, 92 Standard SC Consultation, 1 1 8
Mental Health Laws, 93 Standard SD, Prescriptive Authority and
Admission and Discharge Procedures, 93 Treatment, 1 1 8
Admission Procedures, 93 Standard SE. Pharmacological, Biological, and
Voluntary Admissions, 93 Integrative Therapies, 1 1 8
Discharge Procedures, 94 Standard SF. Milieu Therapy, 1 1 8
Patients' Rights Under the Law, 95 Standard SG. Therapeutic Relationship and
Right to Treatment, 9S Counseling, 1 1 9
Right to Refuse Treatment, 9S Standard SH. Psychotherapy, 1 1 9
Right to Informed Consent, 96 Standards o f Practice for Psychiatric-Mental Health
Rights Regarding Psychiatric Advance Directives, 97 Nursing: Standard 6: Evaluation, 119
Rights Regarding Restraint and Seclusion, 97 Documentation, 119
Rights Regarding Confidentiality, 98 Documentation of "Nonadherence," 1 1 9
 CO NTE NTS XV

8 Therapeutic Relationships, 124 Perception, 1 60

Elizabeth M. Varcaro/is Individual Temperament, 1 60
Concepts of the Nurse-Patient Relationship, 125 Social Support, 1 61
Importance of Talk Therapy, 1 25 Support Groups, 1 61
Goals and Functions, 1 25 Culture, 1 61
Social Versus Therapeutic, 1 25 Spirituality and Religion, 1 62
Relationship Boundaries and Roles, 1 26 Nursing Management of Stress Responses, 1 62
A Focus on Self-Awareness, 1 2 8 Measuring Stress, 1 62
Peplau's Model of the Nurse-Patient Relationship, 1 29 Assessing Coping Styles, 1 64
Preorientation Phase, 1 30 Managing Stress through Relaxation
Orientation Phase, 1 30 Techniques, 1 64
Working Phase, 1 32 Biofeedback, 1 64
Termination Phase, 1 32 Deep Breathing Exercises, 1 65
Factors that Promote Patients' Growth, 1 33 Guided Imagery, 1 66
Genuineness, 1 33 Progressive Relaxation, 1 66
Empathy, 1 33 Meditation, 1 66
Positive Regard, 1 33 Other Ways to Relax, 167
9 Therapeutic Communication, 137 Physical Exercise, 1 67
Elizabeth M. Varcarolis Cognitive Reframing, 1 67
Introduction, 1 38 Journaling, 1 67
Saying the Wrong Thing, 1 38 Humor, 1 68
Benefits of Therapeutic Communication, 1 38
The Communication Process, 1 38
Factors that Affect Communication, 140 UNIT IV Psyc h o b i o l o g i c a l D i sorders
Personal Factors, 1 40
Environmental Factors, 1 40 11 Childhood and Neurodevelopmental Disorders. 171
Relationship Factors, 1 40 Cindy Parsons
Verbal and Nonverbal Communication, 140 Risk Factors, 1 73
Verbal Communication, 1 40 Biological Factors, 1 73
Nonverbal Communication, 1 40 Psychological Factors, 1 73
Interaction of Verbal and Nonverbal Environmental Factors, 1 73
Communication, 1 40 Health Policy, 1 74
Communication Skills for Nurses, 141 Cultural, 1 75
Therapeutic Communication Techniques, 1 41 Child and Adolescent Psychiatric-Mental Health
Nontherapeutic Communication Techniques, 1 45 Nursing, 1 75
Cultural Considerations, 1 47 Application of the Nursing Process, 1 75
Information Communication Technologies, 1 48 Assessment, 1 75
Evaluation of Communication Skills, 1 49 Data Collection, 1 75
The Clinical Interview, 1 49 Mental Status Examination, 1 76
Preparing for the Interview, 1 49 Play Therapy, 1 77
Introductions, 1 50 Bibliotherapy, 1 77
Initiating the Interview, 1 50 Advanced Practice Interventions, 1 78
Tactics to Avoid, 1 50 N eurodevelopmental Disorders: Clinical Picture, 1 78
Helpful Guidelines, 1 50 Communication Disorders, 1 79
Attending Behaviors: The Foundation of Motor Disorders, 1 79
Interviewing, 1 50 Developmental Coordination Disorder, 1 79
Clinical Supervision and Debriefing, 1 51 Stereo typic Movement Disorder, 1 79
10 Stress Responses and Stress Management, 156 Tic Disorders, 1 79
Margaret Jordan Halter Specific Learning Disorder, 180
Responses to and Effects of Stress, 157 Intellectual Disability, 1 80
Early Stress Response Theories, 1 57 Application of the Nursing Process, 1 80
General Adaptation Syndrome, 1 58 Assessment, 1 80
Bad Stress Versus Good Stress? 1 59 Diagnosis, 1 8 1
Critique of the GAS, 1 59 Outcomes Identification, 1 8 1
Neurotransmitter Stress Responses, 1 59 Implementation, 1 8 1
Immune System Stress Responses, 1 59 Psychosocial Interventions, 1 81
Mediators of the Stress Response, 160 Evaluation, 1 8 1
Stressors, 1 60 Autism Spectrum Disorder, 181
xvi CONTE NTS

Application of the Nursing Process, 1 82 13 Bipolar and Related Disorders, 222

Assessment, 1 82 Margaret Jordan Halter
Diagnosis, 183 Clinical Picture, 223
Outcomes Identification, 1 83 Bipolar I Disorder, 223
Implementation, 1 83 Bipolar II Disorder, 223
Psychosocial Interventions, 1 83 Cyclothymic Disorder, 224
Psychobiological Interventions, 1 83 Other Bipolar Disorders, 224
Evaluation, 1 83 Epidemiology, 224
Attention-Deficit/Hyperactivity Bipolar I and Bipolar II Disorders, 224
Disorder, 1 83 Children and Adolescents, 225
Application of the Nursing Process, 1 84 Cyclothymic Disorder, 225
Assessment, 1 84 Comorbidity, 225
Diagnosis, 1 8 5 Bipolar I Disorder, 225
Outcomes Identification, 1 85 Bipolar II Disorder, 225
Implementation, 1 85 Cyclothymic Disorder, 225
Psychosocial Interventions, 1 85 Risk Factors, 225
Psychobiological Interventions, 1 85 Biological Factors, 225
Evaluation, 1 86 Environmental Factors, 226
Quality Improvement, 1 87 Psychological Factors, 226
12 Schizophrenia Spectrum Disorders, 191 Application of the Nursing Process, 226
Edward A. Herzog Assessment, 226
Delusional Disorder, 1 92 General Assessment, 226
Brief Psychotic Disorder, 1 92 Self-Assessment, 230
Schizophreniform Disorder, 1 92 Diagnosis, 230
Schizoaffective Disorder, 1 92 Outcomes Identification, 230
Substance Induced Psychotic Disorder and Psychotic Planning, 230
Disorder Due to Another Medical Condition, 1 92 Implementation, 231
Schizophrenia, 1 92 Depressive Episodes, 231
Clinical Picture, 192 Manic Episodes, 231
Epidemiology, 1 93 Psychopharmacological Interventions, 233
Comorbidity, 1 93 Agitation, 233
Risk Factors, 1 94 Mood Stabilization, 233
Biological Factors, 1 94 Anticonvulsant Drugs, 235
Application of the Nursing Process, 1 96 Electroconvulsive Therapy, 236
Assessment, 1 96 Teamwork and Safety, 237
Prodromal Phase, 196 Seclusion and Restraint, 237
General Assessment, 1 97 Support Groups, 237
Self-Assessment, 200 Health Teaching and Health Promotion, 237
Diagnosis, 20 1 Advanced Practice Interventions, 238
Outcomes Identification, 2 0 1 Evaluation, 238
Phase I: Acute, 201 Quality Improvement, 238
Phase II: Stabilization, 202 14 Depressive Disorders, 242
Phase III: Maintenance, 202 Margaret Jordan Halter, Mallie Kozy
Planning, 202 Disruptive Mood Dysregulation Disorder, 243
Phase I: Acute, 202 Persistent Depressive Disorder, 243
Phase II: Stabilization and Phase III: Premenstrual Dysphoric Disorder, 244
Maintenance, 202 Substance/Medication-Induced Depressive
Implementation, 202 Disorder, 244
Phase I: Acute, 202 Depressive Disorder Due to Another Medical
Phase II: Stabilization and Phase III: Condition, 244
Maintenance, 203 Major Depressive Disorder, 245
Health Teaching and Health Promotion, 208 Clinical Picture, 245
First-Generation Antipsychotics, 21 1 Epidemiology, 245
Other Side Effects ofFGAs, 21 4 Comorbidity, 246
Second-Generation Antipsychotics, 21 4 Risk Factors, 246
Evaluation, 2 1 7 Biological Factors, 246
Quality Improvement, 2 1 8 Psychological Factors, 248
 CO NTE NTS xvi i

Application of the Nursing Process, 248 Cultural Considerations, 282

Assessment, 248 Application of the Nursing Process, 282
General Assessment, 248 Assessment, 282
Key Assessment Findings, 251 General Assessment, 282
Areas to Assess, 251 Self-Assessment, 283
Age Considerations, 252 Diagnosis, 283
Self-Assessment, 253 Outcomes Identification, 284
Diagnosis, 253 Planning, 284
Outcomes Identification, 253 Implementation, 284
Planning, 253 Mild to Moderate Levels ofAnxiety, 284
Implementation, 253 Severe to Panic Levels ofAnxiety, 284
Counseling and Communication Counseling, 285
Techniques, 253 Teamwork and Safety, 285
Health Teaching and Health Promotion, 255 Promotion of Self- Care Activities, 285
Promotion ofSelf-Care Activities, 255 Pharmacological Interventions, 287
Teamwork and Safety, 255 Psychobiological Interventions, 290
Psychobiolocial Interventions, 256 Complementary and Integrative Therapy, 290
Pharmacological Interventions, 256 Health Teaching, 290
Biological Interventions, 263 Advanced Practice Interventions, 290
Electroconvulsive Therapy, 263 Evaluation, 29 1
Transcranial Magnetic Stimulation, 264 Quality Improvement, 29 1
Vagus Nerve Stimulation, 265 16 Trauma, Stressor-Related, and Dissociative
Deep Brain Stimulation, 265 Disorders, 294
Light Therapy, 266 Kathleen Wheeler
St. John 's Wort, 266 Trauma-Related Disorders in Children, 295
Exercise, 266 Posttraumatic Stress Disorder, 295
Advanced Practice Interventions, 266 Clinical Picture, 296
Evaluation, 266 Epidemiology, 297
Quality Improvement, 267 Comorbidity, 297
15 Anxiety and Obsessive-Compulsive Disorders, 270 Risk Factors, 298
Margaret Jordan Halter Biological Factors, 298
Anxiety, 2 7 1 Psychological Factors, 298
Levels of Anxiety, 2 7 1 Environmental Factors, 299
Mild Anxiety, 271 Application of the Nursing Process, 299
Moderate Anxiety, 271 Assessment, 299
Severe Anxiety, 272 Developmental Assessment, 300
Panic, 272 Diagnosis, 300
Defenses Against Anxiety, 272 Outcomes Identification, 300
Anxiety Disorders, 273 Implementation, 300
Clinical Picture, 273 Interventions, 300
Separation Anxiety Disorder, 273 Advanced Practice Interventions, 301
Specific Phobias, 275 Psychopharmacology, 301
Social Anxiety Disorder, 275 Evaluation, 302
Panic Disorder, 275 Attachment Disorders, 302
Agoraphobia, 277 Trauma-Related Disorders in Adults, 302
Generalized Anxiety Disorder, 277 Posttraumatic Stress Disorder, 302
Other Anxiety Disorders, 278 Epidemiology, 303
Obsessive-Compulsive Disorders, 278 Comorbidity, 303
Obsessive-Compulsive Disorder, 279 Risk Factors, 303
Body Dysmorphic Disorder, 280 Application of the Nursing Process, 303
Hoarding Disorder, 280 Assessment, 303
Trichotillomania and Excoriation Diagnosis, 303
Disorder, 280 Outcomes Identification, 303
Other Compulsive Disorders, 281 Implementation, 303
Risk Factors, 2 8 1 Psychoeducation, 304
Biological Factors, 281 Psychopharmacology, 304
Psychological Factors, 282 Advanced Practice Interventions, 306
xviii CONTE NTS

Evaluation, 306 Pharmacological Interventions, 325

Acute Stress Disorder, 306 Health Teaching and Health
Diagnosis, 306 Promotion, 325
Outcomes Identification, 306 Case Management, 326
Implementation, 306 Advanced Practice Interventions, 326
Advanced Practice Interventions, 307 Evaluation, 326
Evaluation, 307 Factitious Disorder, 327
Adjustment Disorder, 307 Clinical Picture, 327
Dissociative Disorders, 307 Factitious Disorder Imposed on Self, 327
Depersonalization/Derealization Disorder, 307 Factitious Disorder Imposed on Another, 327
Dissociative Amnesia, 308 Epidemiology, 328
Dissociative Identity Disorder, 308 Comorbidity, 328
Epidemiology, 308 Risk Factors, 328
Comorbidity, 308 Biological Factors, 328
Risk Factors, 308 Psychological Factors, 328
Biological Factors, 309 Application of the Nursing Process, 328
Psychological Factors, 309 Assessment and Diagnosis, 328
Environmental Factors, 309 Self-Assessment, 328
Cultural Considerations, 309 Planning and Implementation, 328
Application of the Nursing Process, 309 Evaluation, 328
Assessment, 309 Malingering, 328
Life Events, 309 18 Eating and Feeding Disorders, 333
Memory, 309 Carissa R. Enright
Suicide Risk, 31 0 Anorexia Nervosa, 334
Impact on Patient and Family, 31 0 Epidemiology, 334
Assessment Tools, 31 0 Comorbidity, 335
General Guidelines for Assessment, 31 0 Risk Factors, 335
Self-Assessment, 31 0 Biological Factors, 335
Diagnosis, 3 1 0 Psychological Factors, 335
Outcomes Identification, 3 1 0 Environmental Factors, 335
Planning, 3 1 1 Application of the Nursing Process, 336
Implementation, 3 1 1 Assessment, 336
Psychoeducation, 31 1 General Assessment, 336
Pharmacological Interventions, 31 1 Self-Assessment, 336
Advanced Practice Interventions, 31 1 Diagnosis, 337
Evaluation, 312 Outcomes Identification, 337
17 Somatic Symptom Disorders, 315 Planning, 338
Lois Angelo Implementation, 338
Clinical Picture, 3 1 6 Acute Care, 338
Somatic Symptom Disorder, 31 6 Psychosocial Interventions, 338
Illness Anxiety Disorder, 31 7 Pharmacological Interventions, 339
Conversion Disorder, 31 7 Complementary and Integrative Approaches, 339
Psychological Factors Affecting Medical Health Teaching and Health Promotion, 339
Condition, 31 7 Teamwork and Safety, 339
Epidemiology, 3 1 9 Advanced Practice Interventions, 339
Risk Factors, 3 1 9 Evaluation, 340
Biological Factors, 31 9 Bulimia Nervosa, 341
Psychological Factors, 31 9 Epidemiology, 342
Cultural Considerations, 320 Comorbidty, 342
Application of the Nursing Process, 320 Risk Factors, 342
Assessment, 320 Biological Factors, 342
Self-Assessment, 321 Psychological Factors, 343
Nursing Diagnosis, 323 Environmental Factors, 343
Outcomes Identification, 323 Application of the Nursing Process, 343
Implementation, 323 Assessment, 343
Psychosocial Interventions, 325 General Assessment, 343
Promotion of Self-Care Activities, 325 Self-Assessment, 343