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Related Disorders
Most psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressive
behavior caused by:
• Paranoid delusions
• Auditory (command) hallucinations
• Dementia, delirium
• Head injury
• Intoxication with alcohol or drugs
• Antisocial and borderline personality disorders
Intermittent Explosive Disorder:
Rare psychiatric diagnosis involving discrete episodes of aggressive impulses resulting
in serious injury or property damage
Episodes are out of proportion to any provocation, and the person is remorseful and
embarrassed afterward.
Acting Out
An immature defense mechanism in which the person deals with emotional conflict or
stress by actions rather than reflection or feelings; the person is trying to feel less
powerless or helpless by acting out.
Aggressive Clients
• Lithium for bipolar disorder, conduct disorder, or mental retardation
• Carbamazepine (Tegretol) or valproate (Depakote) for dementia, psychosis, or
personality disorders
• Atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), and
olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality
disorders
• Benzodiazepines for older adults with dementia
• Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses
Evaluation
• Was the client’s anger defused in an early stage?
• Did the angry, hostile, and potentially aggressive client learn to express feelings
verbally and safely without threats or harm to others or destruction of property?
• Was the client’s anger defused in an early stage?
• Did the angry, hostile, and potentially aggressive client learn to express feelings
verbally and safely without threats or harm to others or destruction of property?
Community-Based Care
Self-Awareness Issues
• How nurse handles own angry feelings
• Comfort with expression of anger from others
• Ability to be calm, nonjudgmental
• Nurse must have assertive communication skills, conflict resolution skills, ability to see
that client’s behavior/anger is not personal or a sign of nurse’s failure, and ability to
deal with own fear when clients are aggressive or threatening
Abuse and Violence
Abuse is the wrongful use and maltreatment of another person……can be child, spouse,
partner, or elder parent
Victims of abuse and trauma can have both physical and psychological injuries, including:
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt
• Feelings of being degraded or dehumanized; low self-esteem
• Relationship problems; mistrust of authority figures
Assessment
• It is necessary to identify victims of abuse in all settings, since they often do not seek
treatment directly
• SAFE questions can be used to assess:
– Stress/Safety
– Afraid/Abused
– Friends/Family
– Emergency plan
Child Abuse
Child abuse is intentional injury of a child, including:
– Physical abuse or injuries
– Sexual assault or intrusion
– Neglect or failure to prevent harm (failure to provide adequate physical or
emotional care or supervision; abandonment)
– Psychological abuse
All states have mandatory child abuse reporting laws that include nurses.
Parents who abuse children:
• Have minimal parenting knowledge and skills
• Are emotionally immature and needy
• Are incapable of meeting their own needs, much less those of a child
• Often raise their children the way they were raised, including corporal punishment and
abuse
• Expect the child to meet all their needs for love and affection
Assessment
Suspect child abuse when there are:
• Unusual injuries such as scalding and cigarette burns
• Delays in seeking treatment, inconsistent history, or illogical explanation for the
injuries
• Urinary tract infections; red, swollen, or bruised genitalia; tears of vagina or rectum
• Old injuries that were not treated
• Multiple, unexplained bruises
Treatment and Intervention
• Getting the child to a safe place once abuse is identified
• Family therapy
• Individual therapy for the child
• Intensive involvement of social service agencies
• Treatment for parents for any substance abuse or psychiatric issues
Elder Abuse
Elder abuse is maltreatment of older adults by family members or caretakers, including:
– Physical, sexual, or psychological abuse or neglect
– Self-neglect
– Financial exploitation
– Denial of adequate medical treatment
Assessment
Possible indicators of physical abuse:
• Malnourished, dehydrated
• Rashes, sores, lice
• Smell of urine, feces, dirt
• Failure to keep needed medical appointments
• Untreated medical condition
Rape
Rape is a crime of violence and aggression expressed through sexual means. The act is against
the victim’s will or against someone who cannot give consent.
• The victim can be any age
• Half of rapes are committed by someone known to the victim
• Rape is underreported to the police
Community Violence
Of great concern are homicides and suicides associated with schools.
Solutions emphasize:
• Problem-solving skills, anger management, and social skills development
• Parenting programs that promote strong bonding between parents and children and
conflict management in the home
• Mentoring programs for young people
A history of violence, victimization, and witnessing of violence can lead to problems with
aggression, depression, relationships, achievement, and abuse of drugs and alcohol
PTSD
Disturbing behavior resulting after a traumatic event at least 3 months after the trauma
occurred
Up to 60% of persons at risk (combat veterans, victims of violence and natural disasters)
develop PTSD.
Dissociative Disorders
Dissociation is a subconscious defense mechanism that helps a person protect the emotional
self from recognizing the full impact of some horrific or traumatic event by allowing the mind
to forget or remove itself from the painful situation or memory.
Dissociation can occur both during and after the event and becomes easier with repeated
use.
Dissociative disorders include:
• Amnesia
• Fugue
• Dissociative identity disorder (formerly multiple personality disorder)
• Depersonalization disorder
Data Analysis
Nursing diagnoses include:
• Risk for Self-Mutilation
• Ineffective Coping
• Post-Trauma Response
• Chronic Low Self-Esteem
• Powerlessness
Outcome Identification
The client will:
• Be physically safe
• Distinguish between self-harm ideas and taking action on those ideas
• Learn healthy ways to deal with stress
• Express emotions nondestructively
• Establish social support network in the community
Intervention
• Promoting the client’s safety
• Helping the client cope with stress and emotions using grounding techniques
• Helping to promote the client’s self-esteem
• Establishing social support
Evaluation
Is the patient:
• Learning to protecting him- or herself?
• Learning to manage stress and emotions?
• Able to function in their daily lives?
Self-Awareness Issues
• Becoming comfortable asking all women about abuse (SAFE questions)
• Listening to accounts of abuse from clients and families
• Recognizing client’s strengths, not just problems
• Working with perpetrators of abuse; dealing with own feelings about abuse and
violence
Grief and Loss
Grief refers to the subjective emotions and affect that are a normal response to loss.
Experiences of grief and loss are essential and normal in the course of life; letting go,
relinquishing, and moving on happen as we grow and develop.
Grief and loss are uncomfortable.
Types of Losses
Losses may be planned, expected, or sudden. Loss of a loved one is probably the most
devastating type of loss, but there are many other types of losses:
• Physiologic (loss of limb, ability to breathe)
• Safety (domestic violence, posttraumatic stress disorder, breach of confidentiality)
• Security/sense of belonging (relationship loss [death, divorce])
• Self-esteem (ability to work, children leaving home)
• Self-actualization (loss of personal goals, such as not going to college, never becoming
an artist or dancer)
The therapeutic relationship and therapeutic communication skills are paramount when
assisting grieving clients. Using these skills, nurses may promote the expression and release
of emotional as well as physical pain during grieving.
There are many similarities among theorists about grief. Not all clients follow predictable
steps or make steady progress.
Dimensions of Grieving
• Cognitive responses to grief
– Questioning and trying to make sense of the loss
– Attempting to keep the lost one present
• Emotional responses to grief
• Spiritual responses to grief
• Behavioral responses to grief
• Physiologic responses to grief
Cultural Considerations
All cultures grieve for lost loved ones, but the rituals and habits surrounding death
vary among cultures, for instance, how shock and sadness are expressed, how long
mourning should last, and so forth. Many cultural bereavement rituals have their roots
in a major religion.
Nurses should be sensitive to cultural differences and ask how the mourners can be
assisted.
Nurse’s Role
The nurse must encourage clients to discover and use effective and meaningful grieving
behaviors:
• Praying
• Staying with the body
• Performing rituals
• Attending memorials and public services
Disenfranchised grief is grief over a loss that is not or cannot be openly acknowledged,
mourned publicly, or supported socially:
• A relationship has no legitimacy
• The loss itself is not recognized
• The griever is not recognized
Complicated grieving is a response that lies outside the norm of grieving in terms of
extended periods of grieving: responses that seem out of proportion or responses that are
void of emotion
Outcome Identification
Grieving
The client will:
• Identify the effects of his or her loss
• Seek adequate support
• Apply effective coping strategies while expressing and assimilating all dimensions of
human response to loss in his or her life
Anticipatory Grieving
The client will:
• Identify the meaning of the expected loss in his or her life
• Seek adequate support while expressing grief
• Develop a plan for coping with the loss as it becomes a reality
Dysfunctional Grieving
The client will:
• Identify the meaning of his or her loss
• Recognize the negative effects of the loss on his or her life
• Seek or accept professional assistance to promote the grieving process
Intervention
• Regarding perception of the loss
– Explore perception and meaning of the loss
• Regarding adequate support
– Help the client reach out and accept what others want to give
• Regarding adequate coping behaviors
– Shift from an unconscious defense mechanism to conscious coping
– Compare and contrast past coping
– Encourage the client to care for self
Essential communication and interpersonal skills to assist grieving:
• Use simple, nonjudgmental statements
• Refer to a loved one or object of loss by name (if acceptable in the client’s culture)
• Appropriate use of touch indicates caring
• Respect the client’s unique process of grieving
• Respect the client’s personal beliefs
• Be honest, dependable, consistent, and worthy of the client’s trust
• Offer a welcoming smile and eye contact
Evaluation
Evaluation of progress is based on the goals established for the client.
Make an evaluation of the client’s status based on the theoretical tasks and
phases of grieving.
Self-Awareness Issues
• Examining one’s own experiences with grief and loss
• Taking a self-awareness inventory and reflecting on the results may be helpful.
Level Psychological Responses Physiological Responses
Mild Wide perceptual field Restlessness
Sharpened senses Fidgeting
Increased motivation GI butterflies
Effective problem solving Difficulty sleeping
Increased learning ability Hypersensitivity to noise
Irritability
Moderate Perceptual field narrowed to immediate task Muscle tension
Selectively attentive Diaphoresis
Cannot connect thoughts or events independently Pounding pulse
Increased use of automatisms Headache
Dry mouth
High pitch voice
Fast rate of speech
GI upset
Frequent urination
Severe Perceptual field reduced to one detail or Severe headache
scattered details Nausea, vomiting and diarrhea
Cannot complete tasks Trembling
Cannot solve problems or learn effectively Rigid stance
Behavior geared towards anxiety relief and is Vertigo
usually ineffective Pale
Doesn’t respond to redirection Tachycardia
Feels awe, dread or horror Chest pain
Cries
Ritualistic behavior
Panic Perceptual filed reduced to focus on self May bolt and run
Cannot process any environmental stimuli or
Distorted perceptions Totally immobile and mute
Loss of rational thought Dilated pupils
Doesn’t recognize potential danger Increased blood pressure and
Can’t communicate verbally pulse
Possible delusions and hallucination Fight, flight or freeze
May be suicidal
Anxiety and Stress-Related Illness
Anxiety
vague feeling of dread
unwarranted by the situation
with no identifiable stimulus
accompanied by feelings of uneasiness and apprehension
o Fear
o there is an identifiable threatening object
has healthy and harmful facets
it is an internal warning device
produces physiologic and emotional changes at each level
o mild
o moderate
o severe
o panic
WORKING WITH ANXIOUS CLIENTS
ETIOLOGY
Stress: People handle stress in different ways. Stress is part of everyday
life. Selye identified responses to stress on the body in stages:
alarm reaction
resistance
exhaustion
Biologic theories:
o Anxiety may have an inherited component
o neurotransmitter γ-aminobutyric acid (GABA)
o Serotonin plays a part in OCD
Psychodynamic theories:
o overuse of defense mechanisms
o results from problems in interpersonal relationships
o “learned” behavioral response
CULTURAL CONSIDERATIONS
People from Asian cultures often somatize anxiety into expressions of pain in
the body.
Hispanics may identify illnesses as “hot” or “cold” and eat either “hot” or
“cold” foods to counteract them.
TREATMENT
Effective treatment usually involves a combination of medication (anxiolytics
and antidepressants) and therapy.
Cognitive-behavioral therapy includes:
o positive reframing - turning negative messages into positive ones
o decatastrophizing - making a more realistic appraisal of the situation
PANIC DISORDER
o involves 15- to 30-minute episodes of intense, escalating anxiety with emotional fear
and physiologic discomfort
o 75% have spontaneous attacks of panic with no environmental trigger
o Onset peaks: late adolescence and in the mid-30s
o Treatment:
o Selective serotonin reuptake inhibitors (SSRIs)
o cyclic antidepressants
o benzodiazepines are used
Data Analysis
Nursing diagnoses include:
Risk for Injury
Anxiety
Fear
Social Isolation
Situational Low Self-Esteem
Ineffective Coping
Powerlessness
Ineffective Role Performance
Disturbed Sleep Pattern
Outcome Identification
The client will:
Be free of injury
Verbalize feelings
Use effective coping techniques
Manage own anxiety response
Verbalize sense of personal control
Sleep at least 6 hours per night
Intervention
Promoting safety and comfort
Using therapeutic communication
Managing anxiety
Client and family teaching
PHOBIAS
o an illogical, intense, persistent fear of a specific object or social situation
o cause extreme distress and interferes with normal life functioning
o People with phobias understand that their fear is unusual and irrational but feel
powerless to control it.
o clients develop anticipatory anxiety when thinking about the possibility of encountering
the phobic object
o Types of phobia:
Social phobia involves severe anxiety, even panic, when confronted with
situations involving people, such as making a speech, having dinner with others, or
meeting new people; or fear of eating in public, using public bathrooms, or being the
center of attention
Specific phobias occur more often in women; social phobias occur in men and
women equally; peak onset is childhood and mid-20s.
Etiology
Biologic (phobias run in families, hormonal functions, or neurotransmitter
activity)
Psychodynamic (faulty thinking, belief one doesn’t control the environment, or
learned by modeling from parents)
OBSESSIVE-COMPULSIVE DISORDER
OCD involves:
Obsessions
o recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses that
cause marked anxiety and interfere with interpersonal, social, or occupational
functioning.
Compulsions
o ritualistic or repetitive behaviors or mental acts that a person carries out
continuously in an attempt to neutralize anxiety
o Examples:
o repeated checking or counting rituals
o excessive handwashing
o repeating words
o touching rituals
o symmetry rituals
o cleanliness
o The person knows the rituals are unreasonable but feels forced to continue
them in an attempt to relieve anxiety caused by obsessions.
Data Analysis
Anxiety
Ineffective Coping
Fatigue
Situational Low Self-Esteem
Impaired Skin Integrity (if scrubbing or washing rituals)
Outcome Identification
The client will:
Complete daily routine within realistic time frame
Demonstrate effective use of relaxation techniques
Discuss feelings with others
Demonstrate effective use of behavior therapy techniques
Spend less time performing rituals
Intervention
Using therapeutic communication
Teaching relaxation and behavioral techniques
Completing a daily routine
Providing client and family education
Evaluation
• Based on established goals
• Integrating loss into life
SELF-AWARENESS ISSUES
Stress and anxiety are common experiences for all people.
Persons with anxiety disorders often “look well enough” to control their
behavior.
Avoid trying to “fix” client’s problems.
ANTIANXIETY DRUGS
Indications:
anxiety disorders
insomnia
obsessive-compulsive disorder
depression
posttraumatic stress disorder
alcohol withdrawal
Benzodiazepines are the antianxiety agents used most frequently (buspirone [BuSpar] is the
only common nonbenzodiazepine in wide use). They moderate the actions of GABA.
A wide variety of benzodiazepines are used. They vary in half-life, how they
are metabolized, and effectiveness. Some are used primarily for insomnia, due to
sedation side effects.
Common side effects are drowsiness, sedation, poor coordination, memory
impairment, clouded sensorium, and hangover effect in the morning. The biggest
problem is psychological dependence: Long-term use can result in overuse or abuse.
Client teaching for anxiolytics: Avoid alcohol, and be aware of sedating side
effects when driving.
Mood Disorders
Everyone has episodes of feeling sad, low, and tired, accompanied by anergia (lack of energy),
exhaustion, agitation, noise intolerance, and slowed thinking processes. Work, family, and
social responsibilities drive most people to go through their daily routines, knowing that this
mood and the feelings will pass. Mood disorders are diagnosed when these alterations in
emotions are pervasive and interfere with the person’s ability to live life.
CATEGORIES
Major depressive disorder: 2 or more weeks of sad mood, lack of interest in
life activities, and other symptoms
Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of
mania and/or depression and normalcy
RELATED DISORDERS
Dysthymic disorder: sadness and low energy, but not severe enough to be
diagnosed as major depressive disorder
Cyclothymic disorder: mood swings not severe enough to be diagnosed as
bipolar disorder
Seasonal affective disorder (SAD)
Depressive personality disorder
Postpartum or “maternity” blues
Postpartum depression
Postpartum psychosis
ETIOLOGY
Biologic theories include genetics (mood disorders run in families) and
neurochemical theories (dysregulation of serotonin and norepinephrine, and
neuroendocrine or hormonal fluctuations).
Psychodynamic theories tend to “blame” clients and families for illness and
have little use today. The exception is Beck, who viewed depression as resulting
from specific cognitive distortions in susceptible people—cognitive therapy is used
in the treatment of depression.
CULTURAL CONSIDERATIONS
• Depression, often masked by other symptoms
• Somatic complaints may accompany depression.
MAJOR DEPRESSIVE DISORDER
Twice as common in women and more common in single or divorced people
Involves 2 or more weeks of sad mood, lack of interest in life activities, and
at least four other symptoms, such as anhedonia and changes in weight, sleep,
energy, concentration, decision making, self-esteem, and goal setting
Untreated, can last 6 to 24 months; recurs in 60% of people
Symptoms range from mild to moderate to severe.
interact unfavorably
with a variety of
prescription and over-
the-counter drugs
lethal in overdose
dry mouth
blurred near vision
constipation
urinary retention
sedation
weight gain
orthostatic
hypotension
nausea
Psychotherapy
Psychotherapy in conjunction with medication is considered the most effective
treatment
Useful therapies include behavioral, cognitive, interpersonal, and family therapy,
depending on client needs.
Data Analysis
Nursing diagnoses may include:
Risk for Suicide
Imbalanced Nutrition
Anxiety
Ineffective Coping
Hopelessness
Ineffective Role Performance
Chronic Low Self-Esteem
Disturbed Sleep Pattern
Impaired Social Interaction
Outcomes
The client will:
Not injure self or others
Carry out activities of daily living independently
Establish a balance of rest, sleep, and activity
Establish a balance of adequate nutrition, hydration, and elimination
Evaluate self-attributes realistically
Socialize with staff, peers, and family/friends
Return to occupation or school activities
Comply with medication regimen
Verbalize symptoms of recurrence
Intervention
Providing for the client’s safety and the safety of others
Promoting a therapeutic relationship
Promoting activities of daily living and physical care
Using therapeutic communication
Managing medications
Providing client and family teaching
BIPOLAR DISORDER
Bipolar disorder involves mood swings of depression (same symptoms of major
depressive disorder) and mania
Major symptoms of mania:
o grandiose mood
o Agitation
o exaggerated self-esteem
o sleeplessness
o pressured speech
o flight of ideas
o being easily distractible
o intrusive behavior with lack of personal boundaries
o high-risk activities with potentially severe consequences, and poor judgment.
Data Analysis
Nursing diagnoses may include:
Risk for Other-Directed Violence
Risk for Injury
Imbalanced Nutrition
Ineffective Coping
Noncompliance
Ineffective Role Performance
Chronic Low Self-Esteem
Disturbed Sleep Pattern
Fatigue
Self-Care Deficits
Outcomes
The client will:
Not injure self or others
Establish a balance of rest, sleep, and activity
Establish adequate nutrition, hydration, and elimination
Participate in self-care activities
Evaluate personal qualities realistically
Engage in socially appropriate, reality-based interaction
Verbalize knowledge of illness and treatment
Intervention
Providing for safety of client and others
Meeting physiologic needs
Providing therapeutic communication
Promoting appropriate behaviors
Managing medications
Client and family teaching
Evaluation
• Based on client’s mood at “normal” level
• Medication compliance is essential.
SUICIDE
Families need support when a member has committed suicide or is making attempts to do so.
They may feel guilty, angry, and ashamed, and they are at increased risk for suicide
themselves.
Assessment
Populations at risk
Warnings of suicidal intent
Risky behaviors
Lethality assessment
Outcomes
The client will:
Be safe from harming self or others
Engage in a therapeutic relationship
Establish a no-suicide contract
Create a list of positive attributes
Generate, test, and evaluate realistic plans to address underlying issues
Intervention
Using an authoritative role
Providing a safe environment
Initiating a no-suicide contract
Creating a support system list
Supervision
SELF-AWARENESS ISSUES
Nurses and other staff members need to deal with their own feelings about
suicide.
Depressed or manic clients can be frustrating and require a lot of energy to
care for.
Keeping a journal may help deal with feelings; also, talking to colleagues is
often helpful.