SBSCN Acn-Iii

Occupational Therapy 1
Liaquat University of Medical and Health Sciences

Jamshoro Sindh
College of Nursing, JPMC
Occupational Therapy
ACN III Practical Scenario

(Assignment # 1)
Aster Ghulam
BScN Year II
Mrs. Munira A. Ali

Professional with a baccalaureate degree in occupational therapy uses creative and
manual techniques to assist client is working towards specific psychotherapeutic goals also
may work with clients to develop independent living skill to smooth the transition between
hospital and community.
Definition
Occupational Therapy is serves deliver to empower the client to advocate his own
need with knowledge and a wide array of resource client controls or his life based on choices
of acceptable options that minimized physical and psychological alliance on other in making
decision and performing everyday activities.
Goals
The goal of occupation therapy is to enable individual to achieve competency and
satisfaction in life’s chosen role and in the activities that support function of these roles.
Assessing Task and Activities
Occupational therapists use variety of assessment tools to measure baseline and
discharge performance in tasks and activities of importance to client.
Assessing role and community integration outlines taxonomy of three types of life
roles. Self maintenance role is associated with the care of self and examples are of parent
homemaker, caregiver and home maintainer, self enhancement role to contribute to a person’s
accomplishment. They include friends, hobbyist reader, and participant in organization role
that support the productive activities of person, self advancement role include activities of a
person, self maintenance roles include self care, care of home and family, self enhancement
role include play and leisure while the self advancement roles are close to the occupational
function of one of work. Community integration refers to ability of person to line work and
enjoy his or her free time within community setting. Several assessments can be used to
assess community integration.

 The Craig handicap assessment and reporting technique reflect the language of
international classification of impairment, disability and handicap.
 The registration to normal living index is an easy to use. Items assessment that
focuses on participation in community activities important to person.
 The community integration measure uses ten items together information about the
person qualitative experience of living in a community. This easy to use measure was
developed for use of who have brachia injury.
Many assessment of health related quality of life have been developed for use with
people with chronic illness.
Activities of Daily Living
 It generally includes mobility at home feeding, dressing, bathing, grooming, toileting,
basic communication and personal hygiene.
 Observation of the activities identified by the client as problems should be done at the
time of day. When these activities are normal done if possible.
 Many people may have strong feeling of modesty regarding personal care. Those
feelings should be respected. If many activities are evaluated by functional
independence measurement.
The Katz Index evaluated sex functions.
 Functional Independence Measure uses a seven point’s scale to evaluate 18 items in
the area of self care, sphincter control, mobility locomotion, communication and
social cognition is function independence measure is intended to measure disability. It
is effectiveness. Functional Independence Measure has good to excellent reliability
also predict functional status at discharge and length of stay.
 Klein Bell Activities Daily Living Scale – in 1982, is one of the most responsive
assessment because of large number of items. It documents basic ADL skill including
dressing, elimination, mobility, bathing, hygiene, eating and emergency telephone
communication. Each area is broken down into task and task is broken down in step
by step simple behavioral items.
 Functional Status Index – Jette (1980) assessed level of performance, degree of
difficulties and degree of pain in 5 areas; mobility hand activities, personal care, home
chores, social and role activities. This assessment provides excellent overview of
activities and daily living but may not be useful for treatment planning as assessment.
 Safe and Safer – two assessment developed recently focus on evaluating functional
performance and safety of activities of daily living concurrently. It is process of
standardization assesses independence and required supervision in bathing, dressing,
feeding bowel and bladder control. The safety assessment of function and the
environment for rehabilitation.
 Instrumental Activities of Daily Living – include meal planning preparation service
and clean up, marketing for food and clothing and routine and seasonal care of the
home and one’s clothing yard work and other maintenance task may have been
responsibility of client evaluation are more complex and more attention is to basic
activities of daily living takes in most rehabilitation programs.
 Assessment of Motor and Process Skills – the assessment of motor and process skill
(Fisher 1993-1995) is an innovative assessment through which the therapist can
simultaneously assess performance of instrumental activities daily living takes and the
motor and process performance component that contribute to completion of these
task.

Jamshoro Sindh
Occupational Therapy
ACN III Major NCP

(Assignment # 2)
Aster Ghulam
BScN Year II
Mrs. Munira A. Ali

Scenario
Mrs. Iqbal is a 78 years old woman, recently admitted to Medical Ward Unit-III after
a cerebral vascular accident. Now, she is only stable. Her medical course in acute care
hospital is difficult. Her cerebral vascular accident right sided leaving her with hemiplegia.
She lives alone having been widowed two years ago. Now she has continued to live with her
son’s family, an hour away from hospital. Mrs. Iqbal interested in gardening, cooking,
embroidering, etc.
According to this situation, we will perform her functional instrument measures.
 Self care
 Eating
 Grooming
 Bathing She needs helper and supervision.
 Dressing upper body
 Dressing lower body
 Toileting
 Sphincter Control
 Bladder management She needs total assistance
 Bowel management
 Transfer
 Bed, chair, wheel chair Helper + maximum assistance
 Toilet
 Locomotion
 Walk/Wheel chair Needs helper
 Stairs Modified independence (device)
 Communication
 Expression Auditory + visual (Both) – Moderate
Assistance
Vocal + Nonvocal (Both) – Minimal
assistance.
 Social cognition
 Social interaction It is not testable due to risk.
 Problem solving
 Memory
NURSING CARE PLAN
TITILE: Bathing/Hygiene Self-Care Deficit
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
Subjective Data: Short-term Goals:  Provide time for a rest  The client’s increased The client has
Client verbalized that I am  The client will participate period during the client’s activity increases his or verbalized that I
Bathing/Hygiene self-care deficit.

disturbed due to self initiated in self-care activity daily schedule. her need for rest. now participate in
goal direct activities and poor within one week. self-care activities
personal hygiene. Inability to  Observe the client for signs  The client may be and also estab-
Long-term Goals:
follow though with completion of fatigue and monitor his or unaware of fatigue or lished adequate
 The client will adequate
of daily tasks, apathy and unable her sleep patterns. may ignore the need for balance of rest,
balanced of rest and
to use energy productivity. rest. sleep and activity.
sleep pattern.
Objective Data: Decrease stimuli before  Limiting stimuli will The client was
A 78 years old client was  The client will 
demonstrate to initiate bedtime (dim lights, turn off help encourage rest and taking her treat-
admitted in Medical Unit-III television). sleep. ment effectively,
after attack of CVA. She is daily tasks with maintaining
looking untidy, uncombed hair. assistance.
 Use comfort measures or  Comfort measures and adequate nutrition
Chills and rashes, facial sleeping medication if medications can enhance and also meeting
grimaces, restlessness and  The client will personal needs
established normal needed. the ability to sleep.
uncomfortable. with assistance.
nutritional eating pattern
till discharge.  Encourage the client to  Talking with the client
Vital signs: follow a routine of sleeping during night hours will
Blood Pressure: 150/100 mmHg at night rather than during interfere with sleep by
Pulse Rate: 100 beat/min the day, limit interaction stimulating the client and
Resp. Rate: 22 per min. with the client at night and giving attention for not
Investigation allow only a short nap sleeping. Sleeping exces-
Hb: 9 mg/dl during the day. sively during the day
Urine D/R: Normal may decrease the client’s
CT Scan was done appeared ability to sleep at night.
normal.
 Monitor the client’s calorie,  The client may be
protein and fluid intake. You unaware of physical
may need to record intake needs or may ignore
and output. feelings of thirst and
hunger.
Interventions Rationales
 The client may need a high-calorie diet and supplemental feeding.  The client’s increased activity increases nutrition requirements.
 Provide foods that the client can carry with him or her.  If the client is unable or unwilling to sit and eat, highly nutritious foods that
require little effort to eat may be effective.
 Monitor the client’s elimination patterns  The client may be unaware of or ignore the need to defecate. Constipation is
a frequent adverse effect of antipsychotic medications.
 If necessary, assist the client with personal hygiene, including mouth  The client may be unaware of or lack interest in hygiene. Personal hygiene
care, bathing, dressing, and laundering clothes. can foster feelings of well-being and self-esteem.
 Encourage the client to meet as many of his or her own needs as  The client must be encouraged to be as independent as possible to promote
possible. self-esteem.
References
 Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
 Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health
Nursing. 5th Edition. Lippincott Philadelphia.
 Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Care Plans.7th Edition. Lippincott Philadelphia.
 Tromblhy, C.A. and Radomski, M.V. (2001). Occupational therapy for physical
dysfunction. 5th Edition. Lippincott Philadelphia.

Jamshoro Sindh
Stress
ACN III
Aster Ghulam
BScN Year II
Mrs. Ruth K. Alam

Stress and anxiety are universal experiences that can be either catalysis for positive
change or sources of discomfort and particularly nurses are involved with stress management
from teaching perspective helping clients learn to cope with stress imposed by illness, injury,
disability or treatment. Approaches caring for client who are experiencing high level of
anxiety can be also provoking for nurse successful stress management is necessary for
wellness of both client and nurses.
Definition
According to Hans Selye (1974), “stress is nonspecific response to any demand made
on the body.”
Selye termed such demands stressors, any situation, event or agent that produce stress
is considered a stressor. Stressor s can be internal or external. A stressor is a stimulus that
evokes the need to adopt.
Factors Effecting Stress Responses
The response of any individual to stress depends upon the following major factors.
 Emotional factors – much stress occurs through emotions, such as:
 Aggression
 Impatient
 Anxiety
 Fear
 Anger
 Fight
 Loss of something valuable.
 Diet – contributes to physical stress
- Malnutrition and over nutrition.
- Imbalance diet.
- Excessive smoking
- Excessive alcohol.
 Financial Factors
 Unemployment.
 Poverty
 Price hike.
 Physiological Factors
 Adolescence
 Pregnancy.
 Overwork.
 Major Event in Life
 Marriage
 Death of close relative or friends.
 Divorce.
 Moving to new home/place.
 Frustration
 Fails to attain goals. Frustration is associated with motivation. The more motivated, more
frustration we experienced when goal is blocked.
 Conflict
 Physical Factors
 General illness
 Pain
 Disease
 Injury
 Starvation
 Physical handicap.
 Medication
 Hospitalization
 Operation
 Chemical stress
 Individual perception
 Work related stress.
 Environmental Factors
 Maladjustment in family, poor working conditions, inadequate facilities, unreasonable
demands of other downy, intolerable political situation and cultural values.
 Most major cause is posttraumatic stress disorder.
Psychiatric Assessment
Farzana, 17 years female, resident of Gulshan-e-Iqbal, Karachi admitted on
05-12-2006 in Psychiatric Ward and was allotted Bed No. 10.
Presenting Problems
 Physical dimension
• Family health history
- Mother died two years ago with tuberculosis and diabetes.
- Father is alive with no active history of illness.
- Two sisters healthy and married.
- One brother health and unmarried.
- No history of any illness in the family and use of drugs.

• Individual Health History
- No history of any other illness except, anger, guilt, sometimes weeping, lack
of sleep and lack of appetite.
- No any physical illness.
• Daily Activities
- Sitting ideally, most of times.
- Sometimes cleaning and off and on sleeping.
• Sexuality Pattern
- Unmarried.
- Regular menstruation cycle.
- No any other significant.
 Intellectual dimension
• Difficult to express feelings.
 Emotional dimension
• Denial of feeling or emotional numbness.
 Social dimension
• Impaired social interaction.
• Decreased concentration.
• Difficulty with interpersonal problem.
 Spiritual dimension
• Sometimes praying.
• Believe on remedies and hakeems.
Mental Status Examination (MSE)
 Appearance
• Young girl.
• Small height.
• Healthy.
• Wearing shalwar kameez
• Appropriate culture and clean clothing and appropriate hygienic condition.
 Behavior
• Decrease concentration.
• Activities mild retarded.
• Rapid walking.
• Frustration and irritability.
 Communication
• Slow speaking.
• Low volume.
• Most of time silent.
 Cognitive pattern
• Loose memory
• Remote
 Mood and Affect
• Disorganized.
 Sensory perceptions
• Thinking impaired.
Nursing Diagnosis
 Posttraumatic stress disorder
 Risk for other directed violence.
Other Related Nursing Diagnosis

 Dysfunctional grieving.
 Anxiety.
 Ineffective coping.
 Social isolation.
 Ineffective role performance.
 Risk for suicide.
Short-term Goals
The client will:
• Identify the traumatic event.
• Demonstrate decreased physical symptoms.
• Verbalize need to grieve loss.
• Establish an adequate balance of rest, sleep and activity.
• Demonstrate decreased anxiety, fear, guilt and so forth.
• Participate in treatment program.
Long-term Goals
The client will:
• Begin the grieving process.
• Express feelings directly and openly in nondestructive ways.
• Identify strengths and weaknesses realistically.
• Demonstrate an increased ability to cope with stress.
• Eliminate substance use.
• Verbalize knowledge of illness, treatment plan, or safe use of medications, if any.

Nursing Interventions and Rationales
• When you approach the client, be • The client’s fear may be triggered by
nonthreatening and professional. authority figures or other
characteristics.
• Remain nonjudgmental in you • It is important not to reinforce blame

interactions with the client that the client may have internalized
related to the experience.
• Initially, assign the same staff members • Limiting the number of staff
to the client if possible try to respect the members who interact with the
client’s fears and feeling. Gradually client at fist will facilitate familiarity
increase the number and variety of staff and trust. The client may have strong
members interacting with the client. feelings of fear or mistrust about
working with staff members with
certain characteristics. These
feelings may have been reinforced in
previous encounters with
professionals and may interfere with
the therapeutic relationship.
• Educate yourself and other staff • Learning about the client’s

members about the client’s experience experience will help prepare you for
and about posttraumatic behavior. the client’s feelings and the details
of his or her experience.
• Examine and remain aware of your own • Traumatic evens engender strong
feelings regarding both the client’s feelings in others and may be quite
traumatic experience and his or her threatening. You may be reminded
feelings and behavior. Talk with other of a related experience or of your
staff members to ventilate and work own vulnerability, or issues related
through your feelings. to sexuality, morality, safety, or
well-being. It is essential that you
remain aware of your feelings so
that you do not unconsciously
project feelings, avoid issues, or be
otherwise nontherapeutic with the
client.
• Be consistent with the client; convey • The client may test limits or the
acceptance of him or her as a person therapeutic relationship. Problems
while setting and maintaining limits with acceptance, trust, or authority
regarding behaviors. often occur with posttraumatic
behavior.
• Assess the client’s history of substance • Clients often use substances to help
use. repress emotions.
• Be aware of the client’s use or abuse of • Substance use undermines therapy

substances. Set limits and consequences and may endanger the client’s
for this behavior; it may be helpful to health. Allowing input from the
allow the client or group to have input client or group may minimize power
into these decisions. struggles.
• Encourage the client to express his/her • Identification and expression of

feelings through talking, writing or in feelings are central to the grieving
which the client is comfortable. process.
• Teach the client and the family or • Knowledge about posttraumatic

significant others about posttraumatic behavior may help alleviate anxiety
behavior and treatment. or guilt and may increase hope for
recovery.
• Give the client positive feedback for • The client may feel that he/she is
expressing feelings and sharing burdening others with his/her
experiences. Remain nonjudgmental problems. It is important not to
toward the client. reinforce the client’s internalized
blame.
• If the client has a religious or spiritual • Guilt and forgiveness often are
orientation, referral to a member of the religious or spiritual issues for the
clergy or a chaplain may be appropriate. client.
• Encourage the client to make realistic • Integrating traumatic experiences

plans for the future, integrating his or and making future plans are
her traumatic experience. important resolution steps in the
grief process.
• Provide social skills and leisure time • Social isolation and lack of interest
counseling, or refer the client to a in recreational activities are common
recreational therapist as appropriate. problems following trauma.
• Talk with the client about employment, • Problems with employment

job-related stress, and so forth. Refer the frequently occur in clients with
client to vocational services as needed. posttraumatic behavior.
• Help the client arrange for follow-up • Recovering from trauma may be a
therapy as needed. long-term process. Follow-up
therapy can offer continuing support
in the client’s recovery.
Evaluation
 The client has expressed feeling directly and openly in nondestructive ways.
 The client has eliminated the substance use.
 The client has verbalized the knowledge of illness, treatment plan, and safe use of
medications.
 The client has identified support system in the community.

References
 Alfred S (1998). Basics of Psychology for Nurses. 2nd Edition.
 Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
 Johnson. (1989). Mental Health Nursing. 2nd Edition. Lippincott Philadelphia.
Liaquat University of Medical and Health Sciences, Jamshoro Sindh
BScN Year-II, Session 2006-2008
Schizophrenia
Advance Concept of Nursing

Abdul Hakeem
Mrs. Mustaqima Begum
January 18, 2008

Introduction
Imran Ali, a 34 years old male has been admitted to Psychiatric Unit by his brothers. His
brother stated that, he was alright six months back then he developed loosing interest in normal
activities and started unrelated behavior and became unaware of his environment. He eats and drinks
normally but speaks irrelevant words, phrases or sentences. He attends on calling but does not give
proper answer to question. He also removes his clothes and does not feel any shame or guilt on to be
naked.
Sometimes he becomes aggressive and throws anything like stone, log, etc. on the person or
any object in front of him. He awakes day and night without sleeping. He does not maintain personal
hygiene and looks like bizarre person. He is unaware about his previous life.
NURSING CARE PLAN
Patient’s Name: Mr. Imran Ali
Age: 34 Years
Medical Diagnosis: Schizophrenia
Nursing Diagnosis: Risk for violence: Self directed or directed at others related to responding to delusional thoughts or hallucinations.
Assessment Nursing Planning Interventions Rationales Evaluation
Diagnosis
Subjective Data Immediate • Reassure the client that • The client is less likely to Immediate
Risk for violence: Self directed or directed at others related to responding to

According to the client’s brother, The client will: the environment is safe feel threatened, if the
“Mr. Imran Ali does not interest in • Be free from injury. by briefly and simply surroundings are known. The client:
normal living activities, unaware of • Not harm others or explaining routines, • Is free from
environment, does not feel shame or guilt destroy property. procedures and so forth. injury.
on to be naked, speaks continuously • Establish contact
meaningless wording, does not maintain with reality. • Protect the client from • Client safety is a priority. • Does not harm
hygienic condition and when aggressive harming himself or Self destructive ideas may others or
• Demonstrate or
delusional thoughts or hallucinations.
throws any thing to any person or object others. come from hallucinations property.
verbalize decreased
present in front of him. or delusions.
psychotic symptoms
and feelings of • Has established
Objective Data
anxiety, agitation, • Remove the client from • The benefit of involving the contact with
A 34 years old male brought to the group, if his behavior client with the group is
and so forth. reality.
Psychiatric Ward by his brothers with the becomes too bizarre, outweighed by the groups
complaint of psychiatric problem. Client disturbing or dangerous need for safety and
is unaware of environment, bizarre facial Stabilization • Participated in
The client will: to others. protection. therapeutic
expressions, disoriented feeling of
agitation, disorganized, illogical • Take medications as milieu.
• Help the client’s group • The client’s group benefits
thinking, having clothing but prescribed.
accept the client’s from awareness of others’ Stabilization
continuously trying to open or tear the • Express feelings in
“strange” behavior. Give needs and can help the
clothes. Aggressive behavior towards an acceptable
simple explanations to the client by demonstrating Takes medication as
others and property. manner.
client’s group as needed empathy. prescribed.
(e.g., “[client] is very sick
Vital Signs
right now; he needs our Expresses feelings in
Blood Pressure 100/70 mmHg
understanding and an acceptable manner.
Temperature 97 °F
support”).
Pulse 88 bpm
Respiratory Rate 20 per min Community
Reflection
Once, we reached at 08:30 AM at College, we found that a pre-clinical conference is arranged
for us. In this pre-clinical conference, our Instructor gave us instruction about how to assess and deal
the psychotic clients. Along with others psychotic diseases, we also discussed “Schizophrenia”.
It is psychotic disorder in which client suffers from hallucination, delusion, illusion and
thought disorders. All students gave their views and at last our Instructor summarized the disease.
Then we went on clinical in Psychiatric Ward-20.
We introduced ourselves with Head Nurse and other staff members of the ward and Doctors
too. Their attitude was very supportive. They guide us, on the basis of their experiences to deal the
psychiatric clients. Doctors gave lectures to differentiate between psychotic and neurotic disorders
clients. Then I went to ward and selected my client. He was suffering with schizophrenia.
The client was sitting on bed. He is looking angry, irritable with his attendant and asking him
that he wants to kill him. I asked the attendant to leave the client alone for few minutes and try to built
relationship and trust with client. I also started assessment and observed that the client is looking
untidy, wearing dirty clothes. He is also looking miserable. Whenever, his relatives try to wake him,
he starts verbalizing doubt about them and also blamed them. I gained his confidence and heard his
point of view. I read the history and other health assessment milestone of psychiatric clients, then
I discussed with attendant, who was in very problematic situation to deal with him. He told that “he is
sick since last six months and have complaint of schizophrenia; sign was arising with hallucination,
delusion and illusion.”
I discussed the client’s condition with doctors and nurses of Ward to gain practical tips, to
how to deal with this client. It was my first experience to deal with psychiatric client. I learned about
the psychiatric diagnosis and difference between psychiatric and neurotic disorders. I also learned
about different counseling techniques; how to deal the psychiatric clients. I share my experience with
my classmates in past clinical experience and learn how to deal psychiatric clients in future.
References
 Carpenito, L.J. (1997). Nursing Diagnosis: Application to Clinical Practice, (7th ed.).
Lippincott Philadelphia.
 Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care
Plans, (7th ed.). Philadelphia: Lippincott.
 Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing,
(5th ed.). Philadelphia: Lippincott.
 http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med Bulletin;
57:101-113.
College of Nursing, JPMC, Karachi
Personality Disorders
Advanced Concept of Nursing III
Bushra Sultana
Dated: _______________
Personality is the totality of those aspects of behavior, which give meaning to an
individual in society and differentiate him from other member in the community.
One of the oldest methods of describing personality difference is to categorize people
into different types on the basis of major characteristics. All individuals are roughly classified
into type A and type B personalities.
Type A Personality – people with this type of personality tend to be hard driving,
competitive, ambitious, impatient and hostile.
 They tend to talk rapidly and give single word immediate answers, with acceleration
at the end of sentences; the volume of speech is loud.
 They show a tense and hostile facial expression.
 They show tense posture and usually sit on the edge of the chair.
 The feel intense time urgency.
 They have a tendency to interrupt the speaker.
 They are constantly preoccupied with responsibilities.
 They are usually not satisfied with their job and want to move up.
Type B Personality – people with this type of personality have a calm and relaxed
attitude towards life. They are patience and easy going in their daily life.
 The rate of speech is slow, with frequent pauses. The volume of speech is low.
 Facial expression is relaxed and friendly.
 They show a relaxed and comfortable posture.
 The rarely interrupt the speaker.
 They are usually satisfied with their job.
A Personality Disorder is defined as “an enduring pattern of inner experience and
behavior that deviates markedly from the expectations of the individual’s culture, is pervasive
and inflexible has an onset in adolescence or early adulthood is stable over time and leads to
distress or impairment.”
There are two classifications to classify the personality disorder.
ICD-10 – used by WHO, deals with whole system and accounts for the course of
disease.
DSM-IV – used by Americans and measure problems quantitatively and is based on
Axis.
DSM-IV-TR classified the personality disorders as:
 Cluster A Disorders – including paranoid, schizoid and schizocypal personality.
Common traits – they often appear odd and eccentric.
 Cluster B Disorders – including antisocial, borderline, histrionic and narcissistic
personality disorder.
Common traits – these are typical exhibit dramatic, emotional and erotic behavior.
 Cluster C Disorders – including dependent, avoidant and obsessive compulsive
personality disorder.
Common traits – they characteristically display anxious and fearful behaviors.
Cluster A Disorders
A peculiar, fears social relationship, genetic, familial association with psychotic illness
Personality Characteristics Patient Snapshot
Disorder
Paranoid • Distrustful. A 45 years old female hospitalized aide
• Suspicious says that she was laid off because she

worked to hard and made her supervisor
• Attributes responsibility
look lazy. She says that when the same
for own problem to
things happened in a pervious job. She filed
others
a law suit against that hospital.
Disorder
Schizoid Long standing pattern of The parents of a 26 years old man say that
voluntary social withdrawal they are concerned about him because he
without psychosis. has no friends and spends most of his time
hiking in the woods.
On examination, you find him contended
with his solitary life and has no evidence of
formal though disorder.
Schizotypal Peculiar appearance magical An oddly dressed 32 years old lady says she
thinking odd thought patterns likes to walk in the woods because the birds
and behavior without communicate with her. She never goes out
psychosis, most patient also on Thursday because this is dangerous day.
have major depressive She has few friends.
disorder.
Cluster B Disorders
Emotional, inconsistent or dramatic genetic or familial association with mood disorders
substance abuse and somato form disorder
Histrionic Theatrical, extroverted, 28 years old man comes to your office in a
emotional, life of the party, black velvet beret and a cap by lined with
cannot maintain intimate red satin. He reports that his mild sore
relationships. throat felt like a hot poker. When he
swallowed and says that he feels so warm
that he must have a fever of at least 106.
Narcissistic Pompous with a sense of A 38 years old man asks you to refer him to
special entitlement; lacks a physician who attended a top medical
empathy for others. school. He says that he knows you will not
be offended because you understand that he
is better than your other patients.
Disorder
Antisocial Refuses to confirm to social A 35 years old man brags that he has been
norms shows no concern for sexually assaulting women ever since high
others and does not learn school, but has never been caught. He has
from experience associated often been unemployed and has been
with conduct disorder in arrested for shoplifting several times.
childhood and criminal
behavior in adulthood.
Borderline Erratic, unstable behavior A 20 years old female college student tells
and mood boredom; feelings you that because she was afraid to be alone
of aloneness i.e., feeling again. She tried to commit suicide after a
alone in the world not merely man with whom she had two dates did not
loneliness impulsiveness. call her again. After your interview, she
Suicide attempts and tells you that all of the other doctors she has
minipsychotic episodes i.e., seen were terrible and that you are the only
brief periods of loss of doctor who ahs ever understood her
contact with reality. Self problem (use of splitting as a defense
mutilation (cutting or mechanism).
burning oneself). Often
comorbid with mood
disorders and eating
disorders.
Cluster C Disorders
Fearful, anxious, genetic or familial association with anxiety disorders
Avoidant Timid, sensitive to rejection A 35 years old woman, who works as a
and socially withdrawn laboratory assistant lives with her elderly
feelings of inferiority. mother and rarely socializes. She reports
that when coworker ask her to join them for
lunch. She refuses because she is afraid that
they will not like her.
Disorder
Obsessive Perfectionistic, orderly, A 33 years old man reports that each night
compulsive stubborn, indecisive, feelings he creates a detailed schedule of his
of imperfection. activities for the next day. He tells you that
his wife of six months recently moved out
because she could not confirm to his rigid
rules.
Dependent Allows other people to make A 32 years old woman says that her
decisions and assume husband is angry because she calls him at
responsibility for them the office many times each day to ask him
because of poor self to make trivial everyday decisions for her.
confidence may be abused by
domestic partner.
Each individual personality disorder affects approximately one percent of the
population, although many patients have features of more than one personality disorders.
Personality disorders have a genetic association with some psychiatric disorders. These are
more common in relatives of patient with personality disorders than in general population.
Psychological factors may be also implicated.
Helgeland, et al. (2005) conducted a research and expected the following hypothesis
to be confirmed.
 Adolescent with disruptive behavior disorders would be more likely to have
personality disorder as adult than would adolescent with emotional disorders.
 Disruptive behavior disorders in adolescent would be associated with higher rates of
cluster B personality disorders in adulthood than cluster A and cluster C personality
disorders.
 Emotional disorder in adolescent would be associated with development cluster C
personality disorders in adulthood.

Method
One hundred and thirty subjects, with age mean 43.2 years had been diagnosed with
emotional and disruptive behavior disorder during adolescent age mean 14.6 years and
rediagnosed based on hospital records. According to DSMIV, were interviewed with the
structured interview for DSM IV personality to establish whether they suffered from
personality disorder at 28 years follow up.
Results
Adolescent with disruptive behavior disorder were not more likely to have personality
disorder in adulthood than ones with emotional disorders. They were significantly more
likely to have cluster B personality disorder at follow up than adolescent with emotional
disorder. Logistic regression analysis revealed that disruptive behavior disorders in females
were significantly more strongly associated with a high risk of cluster B diagnosis at follow
up than in men.
Emotional disorders were significant and independent predictors of cluster C
personality disorders in women but not in men. Disruptive behavior disorders were
significant and independent predictor of antisocial personality in men.
Conclusion
In the conclusion it is said to be that these results support the view that personality
disorders can be traced back to adolescent, emotional and disruptive behavior disorders. The
moderating effect of gender in cluster B and cluster C personality disorders suggested that
sociocultural and biological factors may contribute to different adult outcomes in men and
women with similar adolescent psychiatry disorders.

References
 Fadem, B., & Simring, S.S. (2003). High-yield psychiatry. USA.
 http/www.ajp.psychiatryonline.org. Retrieved on September 10, 2007.
Liaquat University of Medical & Health Sciences, Jamshoro Sindh

Bipolar Disorder
Daisy Nasreen
Dated: _______________
Happiness, sadness, excitement,
and apathy are just a few of the many
emotions we experience in everyday
life. We all have our ups and downs, our
"off" days and our "on" days. But if
you're suffering from bipolar disorder,
these peaks and valleys are more severe.
Bipolar disorder—also known as manic depression or manic-depressive illness—involves
dramatic shifts in mood from the highs of mania to the lows of major depression.
What is Bipolar Disorder?
Unlike ordinary mood
swings, the cycles of bipolar
disorder are much more intense
and disruptive to daily
functioning. More than just a
fleeting good or bad mood, these
episodes last for days, months, or sometimes even years. And your mood isn’t the only
casualty of the disease. In addition to emotional well-being, bipolar disorder affects your
energy, activity level, judgment, critical thinking skills, appetite, and sleep.
While dealing with bipolar disorder isn’t always easy, it doesn’t have to run your life.
With proper treatment and a solid support system, people with bipolar disorder are capable of
leading rich and fulfilling lives. They can hold jobs, sustain loving marriages, raise children,
and be productive members of society. But in order to successfully manage bipolar disorder,
it is essential to fully understand the condition and its challenges.

Causes and Triggers
Bipolar disorder has no single cause and none of the exact cause was found, yet.
It appears that some people are genetically predisposed to have bipolar disorder and that the
brain is the center of the illness. Yet not everyone with the genetic tendency displays bipolar
disorder, so several other factors must be involved in producing the illness. These other
environmental and psychological factors are called triggers. Although triggers may set off a
bipolar episode in someone predisposed to the disorder, most bipolar episodes occur without
an obvious trigger.
Bipolar Disorder Causes and Risk Factors
 Biological Causes
Genetics - Bipolar disorder runs in families, with genetics believed to play a
significant role. A person with this inherited vulnerability may develop bipolar disorder in
response to environmental triggers such as a traumatic experience or drug abuse.
Neurotransmitter Imbalance - serotonin, dopamine, and norepinephrine are three
neurotransmitters—or chemical messengers in the brain—that help regulate our moods. It is
believed that imbalances in these biochemicals are responsible for the mood swings of
bipolar disorder.
Brain Metabolism - brain imaging scans reveal significant differences between the
metabolism of a normal brain and a bipolar brain. During normal mood, brain activity and
blood flow across the two sides of the brain are basically equal. But in a manic or depressed
state, different areas of the brain are more active than others.
Hormonal Imbalances – have been found in many people with bipolar disorder. In
particular, high levels of the stress hormone cortisol and abnormal levels of thyroid hormone
are believed to contribute to manic and depressive mood episodes.

Biological Rhythms – disturbances in circadian rhythms have been implicated in
bipolar disorder. Some researchers believe that the biological clock that regulates our sleep-
wake cycle is abnormally fast in people with bipolar disorder.
 Bipolar Disorder Triggers
Stress - Severe stress or emotional trauma can trigger either a depressive episode or a
manic episode in an individual predisposed to bipolar disorder. Stress can also prolong a
bipolar mood episode.
Major Life Event - such as getting married, going away to college, or starting a new
job can trigger a mood episode.
Substance Abuse - While substance abuse doesn’t cause bipolar disorder, it can bring
on manic or depressive episodes and worsen the course of the disease. Drugs such as cocaine,
ecstasy, and amphetamines can trigger mania, while alcohol and tranquilizers can trigger
depression.
Medication-Induced Mania - Certain medications, most notably antidepressant drugs,
can trigger a manic episode. If antidepressants are prescribed during the depressive phase of
bipolar disorder, they must be taken with a mood stabilizer in order to avoid this
complication. Other drugs that may induce mania include over-the-counter cold medicine,
appetite suppressants, caffeine, corticosteroids, and thyroid medication.
Seasonal Changes - Episodes of mania and depression often follow a seasonal pattern.
Manic episodes are more common during the summer, and depressive episodes more
common during the fall, winter, and spring. These patterns are believed to be tied to seasonal
fluctuations in light.
Sleep Deprivation - Sleep deprivation—even as little as skipping a few hours of sleep
—can trigger an episode of mania.

Signs and Symptoms
Bipolar disorder involves periods of elevated mood, or mania, alternating with periods
of depression. A person with bipolar disorder typically cycles between these two extremes,
often with periods of normal mood in between. The pattern of symptoms differs from person.
Some people are more prone to either mania or depression, while others experience equal
numbers of manic and depressive episodes. The frequency and duration of the mood episodes
also varies widely. While a few individuals experience only one or two periods of mood
disruption, most people with bipolar disorder suffer from multiple, recurring manic and
depressive episodes.
There are four types of mood episodes that can occur in bipolar disorder: mania,
hypomania, depression, or a mixed episode.

Manic Phase - in this phase patient showed signs of:
 Feeling of euphoria extreme, optimism and inflated self esteem.
 Rapid speech, racing thoughts.
 Agitations and increased physical activities.
 Poor judgments.
 Recklessness or taking chances not normally taken.
 Difficulty in sleeping.
 Inability to concentrate.
 Aggressive behavior.
Depressive Phase - it includes:
 Persistence feeling of sadness, anxiety, guild and hopelessness.
 Disturbance in sleep and appetite.
 Fatigue and loss of interest in daily activities.
 Problem in concentrating.
 Irritability.
 Chronic pain without unknown cause.
 Recurring thoughts of suicide.
Hypomania
It is a less severe form of mania. People in a hypomanic state feel euphoric, energetic,
and productive, but their symptoms are milder than those of mania and cause less impairment
to functioning. Unlike manics, people with hypomania never suffer from delusions and
hallucinations. They are able to carry on with their day-to-day lives. To others, it may seem as
if the hypomanic individual is merely in an unusually good mood. But unfortunately,
hypomania often escalates to full-blown mania or is followed by a major depressive episode.

 Bipolar II Disorder – Hypomania and Depression
In Bipolar II disorder, the person doesn’t experience full-blown manic episodes.
Instead, the illness involves episodes of hypomania and severe depression. In order to be
diagnosed with Bipolar II Disorder, you must have experienced at least one hypomanic
episode and one major depressive episode in your lifetime. If you ever have a manic episode,
your diagnosis would be changed to Bipolar I Disorder.
 Cyclothymia – Hypomania and Mild Depression
Cyclothymia, also known as cyclothymic disorder, is a milder form of bipolar
disorder. Like bipolar disorder, cyclothymia consists of cyclical mood swings. However, the
highs and lows are not severe enough to qualify as either mania or major depression. To be
diagnosed with cyclothymia, you must experience numerous periods of hypomania and mild
depression over at least a two-year time span. Because people with cyclothymia are at an
increased risk of developing full-blown bipolar disorder, it is a condition that should be taken
seriously and treated.

 Rapid Cycling – Frequent episodes in Bipolar I or Bipolar II Disorder
Rapid cycling is a subtype of bipolar disorder characterized by four or more manic,
hypomanic, or depressive episodes within one year. The shifts from low to high can even
occur over a matter of days or hours. People with Bipolar I and Bipolar II disorder can
experience rapid cycling. According to the National Institute of Mental Health, rapid cycling
usually develops later in the course of bipolar disorder.
Diagnostic Criteria
 Presence of a single major depressive episode.
 The major depressive episode is not better accounted for by Schizoafective Disorder
and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional
Disorder or Psychotic Disorder.
 There has never been a manic episode, a mixed episode or a hypomanic episode. This
exclusion does not apply if all to the manic-like, mixed-like or hypomanic-like
episodes are substance or treatment induced or due to the direct physiological effects
of a general medical condition.
 Severity/Psychotic/Remission specifiers chronic features include:
- With Catatonic features.
- With melancholic features
- With atypical features
- With postpartum onset.
Therapeutic Modalities
 Pharmaceutical
• Lithium Therapy: Carbamazepine and Lithonate
- Relief from neuroplastic conjunction.
- Effective regulating bipolar depression.

- More effect in long-term treatment.
• Anti-Convulsant Therapy: Valproate or Depakote
- Effective for regulating mood and improve for indication for mania.
• Atypical Anti-Psychotic Drug: Clozopin
- This medication used to prevent manic episode.
 Electroconvulsive Therapy (ECT)
This therapy was discovered in the mid 1920s and at the time, it was the only
treatment available and was frequently used and misused. DePaulo & Ablow, (1989)
stated that it induces a seizure by applying electric current. It provides the most rapid
relief of any treatment for severe depression. Most of the severely ill patients who fail
to respond to medication respond to ECT. This form of treatment should be
considered when drug therapy has failed, when the patient is at high risk for suicide or
starvation, or when depression is judged to be overwhelmingly severe. It is also
particularly useful when the depressed person is troubled by delusions or
hallucinations.
High success rates for treating both unipolar and bipolar depression and
mania. Electroconvulsive therapy usually applied for all pharmaceutical treatment. It
gives muscles relaxant to prevent convulsions.
 Supportive Psychotherapy
Supportive psychotherapy with medication treatment is most appropriate or
patients with severe forms of depressive illness. Bachelor (1996) and Bloch (1979)
stated the objectives for supportive psychotherapy, which are:
• Promote the patient’s best psychological and social functioning.
• Bolster self esteem and self confidence.

• Make the patient aware of what can and cannot be achieved, both personal
limitations and the limitations of treatment.
• Prevent undue dependence on professional support and unnecessary
hospitalizations.
• Promote the best use of available support from family and friends.
Nursing Intervention
 Maintain Safe Environment
• Decrease environmental stimuli,.
• Carefully observation of the patient.
• Setting boundaries.
• Explain the reason of limits.
• Focus on what they can do rather what they can not do.
 Promote Physical Health
• Assist patient in grooming and personal hygiene.
• Provide patient with portable food/finger food.
• Give high caloric and high protein diet.
• Ensure adequate water intake.
• Provide with sufficient sleep hours.
• Environment should be quite.
• Elimination pattern.
 Communication
• Listen attentively.
• Use simple and clear sentences.

• Use firm, low pitch voice.
• Emphasize on here and now.
• Avoid loud demanding tone.
 Reinforcement of Reality
• Do not challenge the client/delusion.
• Do not encourage.
• Focus on reality.
• Reinforcement of reality.
• Observation for ‘carrying out’ behavior.
Nursing Diagnosis
Major Depressive Disorder, recurrent.
 Fear related to unfamiliar environment.
 Moderate4 anxiety related to anticipated transfer to nursing home.
 To assist the patient in meeting self care needs.
 Provide opportunities for the patient express feelings about self and illness.
 Observed for signs suicidal intent.
Conclusion
Bipolar disorder also known as ‘manic depression’ or ‘manic-depressive illness’
involves dramatic shifts in mood from the highs of mania to the lows of major depression.
Unlike ordinary mood swings, the cycles of bipolar disorder are much more intense and
disruptive to daily functioning. More than just a fleeting good or bad mood, these episodes
last for days, months, or sometimes even years. It has no single cause and no exact cause was
observed, yet. It may be due to genetic reason or due to neurotransmitter imbalance, brain
metabolism, hormonal imbalances, biological rhythms, stress, major life event,
substance abuse, medication-induced mania, seasonal changes or sleep deprivation.

It can be treated by using various therapies; these include pharmaceutical therapy,
Electroconvulsive Therapy (ECT) and supportive psychotherapy. Electroconvulsive therapy
usually applied for all pharmaceutical treatment. It gives muscles relaxant to prevent
convulsions. It provides the most rapid relief of any treatment for severe depression. Most of
the severely ill patients who fail to respond to medication respond to ECT. This form of
treatment should be considered when the patient is at high risk for suicide or starvation, or
when depression is judged to be overwhelmingly severe. It is also particularly useful when
the depressed person is troubled by delusions or hallucinations. On the other hand,
supportive psychotherapy - with medication treatment is most appropriate for patients with
severe forms of depressive illness.

References
 Carson, V.B. (2000). Mental health nursing. 2nd Edition. USA.
 Bipolar Disorder. Article. Retrieved from http://www.healthline.com/glaecontent/
bipolar-7?utm-medium=yahoo&utm_source… on November 15, 2007.
Nursing Care Plan & Reflection Log
Daisy Nasreen
January 24, 2008

Nursing Care Plan
Introduction
A 40 years old male named Khalid has been admitted to Psychiatric Ward at Bed No. 12 by
his parents with complaint of hypermania. According to his mother, he was alright one week back.
Suddenly, he developed a behavioral change and start shouting on others. He has no regard for eating,
drinking, hygiene, grooming, resting or sleeping and have extremely poor judgment. Besides these he
also developed psychotic symptoms like hallucination or delusions.
His parents also added that sometimes he showed very depressive mood and during this he
never eats and never sleep. Therefore, we brought him to the hospital for treatment.
NURSING CARE PLAN
Patient’s Name: Mr. Khalid
Age: 40 Years
Medical Diagnosis: Bipolar Disorder
Nursing Diagnosis: Risk for other directed violence related to risk of behaviors in which an individual demonstrates that he can be physically, emotionally, and/or
sexually harmful to others.
Assessment Nursing Planning Interventions Rationales Evaluation
Diagnosis
Subjective Data Immediate • Provide safe environment. • Physical safety of the client Immediate
Risk for other directed violence related to risk of behaviors in which an

According to the client’s mother, The client will: and other is a priority. The The client demons-
individual demonstrates that he can be physically, emotionally,

“Mr. Khalid does not interest in • Demonstrate decreased client may be used many trated decreased
normal living activities, unaware restlessness, hyperactivity, common items and restlessness, hyper-
of environment, does not maintain and agitation environmental situations in activity & agitation
hygienic condition, restlessness, • Demonstrate decreased a destructive manner. and also not harm
agitation, hyperactivity, hostile hostility. • Decrease environmental • The client’s ability to deal others or himself.
behavior, threatened or actual and/or sexually harmful to others.
• Not harm others and stimuli whenever possible. with stimuli is impaired.
aggression towards self or others himself. Respond to cues of Stabilization
and low self-esteem. agitation by removing The client be free
Stabilization stimuli and perhaps of restlessness,
Objective Data hyperactivity and
A 40 years old male brought to The client will: isolating the client; a
private room may be agitation.
Psychiatric Ward by his parents • Be free of restlessness,
with the complaint of psychiatric hyperactivity and agitation. beneficial
problem. Client is unaware of • Be free of threatened or • Provide a consistent, • Consistency and structure He also be free of
environment, bizarre facial actual aggression toward structured environment. Let can reassure the client. The threatened and
the client know what is client must know what is actual aggression
expressions, disoriented feeling of self or others.
agitation, disorganized, expected of him. Set goals expected before he can toward self or
with the client as soon as work toward meeting those others.
restlessness, hostile behavior
towards others and self. possible. expectations.
• Give simple direct • The client is limited in the
Vital Signs explanations. Do not argue ability to deal with complex
Blood Pressure 100/80 mmHg with the client. stimuli. Stating a limit tells
Temperature 99 °F the client what is expected.
Pulse 100 bpm Arguing interjects doubt
Respiratory Rate 28 per min and undermines limits.
Nursing Care Plan
• Encourage the client to verbalize feelings such as anxiety and anger. Explore • Ventilation of feelings may help relieve anxiety, anger, and so forth.
ways to relieve tension with the client as soon as possible.
• Encourage supervised physical activity. • Physical activity can diminish tension and hyperactivity in a healthy, nondestructive
manners.
• Give the client positive feedback for controlling aggression, fulfilling • The client is limited in the ability to deal with complex stimuli. Stating a limit tells
responsibilities, and expressing feelings appropriately, especially angry feelings. the client what is expected. Arguing interjects doubt and undermines limits.
• Do not attempt to discuss feelings when the client is agitated. • Positive feedback provides reinforcement for desired behaviors and can enhance self-
esteem. It is essential that the client receive attention for positive behaviors, not only
for unacceptable behaviors.
• Encourage the client to seek a staff member when he is becoming upset or • Seeking staff assistance allows intervention before the client can no longer control
having strong feelings. his or her behavior and encourages the client to recognize feelings and seek help.
• Withdraw your attention (ignore the client) when the client is verbally abusive. • Withdrawing attention can be more effective than negative reinforcement in
Tell the client that you are doing this, but you will give attention for appropriate decreasing unacceptable behaviors. The client may be seeking attention with this
behavior. If the client and others, and then withdraw your attention from the behavior. It is important to reinforce positive behaviors rather than
client. unacceptable ones.
• Do not argue with the client. • Arguing with the client can reinforce adversarial attitudes and undermine limits.
• Calmly and respectfully assure the client that you will provide control if he • The client may fear loss of control and may be afraid of what he may do if he begins
cannot control himself, but do not threaten the client. to express anger. Showing that you are in control without competing with the client
can reassure the client without lowering his self-esteem.
Depression 52
Occupational therapy
Reflection
Introduction
To fulfill my clinical requirements and to gain new experiences as a BSc Nursing student,
I went to Psychiatric Ward. It was my second clinical week at Psychiatric unit. I wished staff members
and with a permission of Head Nurse, I went to my client, which I selected last week.
A 40 years old male was sitting on the bed uncomfortably and depressed mood. I wished to
the client but he had not responded to me. I tried to draw his attention again. He looked at me and
murmured, which I could not heard clearly. I asked him “why are you worried?” He told me, “I am
worried about my family due to financial problems, as I am jobless. This is the main reason of worry.”
He further verbalized that “I have four children and how being a jobless, I cannot cope with the
situation to meet my expenses”.
Analysis
I analyzed the client’s problem. He was in critical condition and unable to manage the
conditions. I suggested him to put his children in Government School, they will provide assistance to
your children and they get good education. I also told him that now-a-days women are working at
home and becoming a helping hand for the family. I also asked him that I will also help to obtain job.
Similarly, I spend some more time with him and discuss various matters and also counsel, motivate
and encourage him to cope with the situation, instead of becoming depressive.
The Society for the Promotion of Occupational Therapy (1917) defined occupational therapy
as “Occupational therapy is a health profession that helps people participate fully in life.”
Occupational therapy also refers to the use of meaningful occupation to assist people who
have difficulty in achieving healthy and balanced life, and to enable an inclusive society so that all
people can participate to their potential in daily occupations of life (Elizabeth & Helene, 2007)
Occupational Therapists and Occupational Therapy Assistants work with a variety of individuals who
have difficulty accessing or performing meaningful occupations.

Depression 53
Occupational therapy
Learning
I have learned from this situation that, if we listen attentively and spend time with the clients
suffering from psychiatric disorders, we can motivate and encourage them to overcome their problems
and to cope with the situation so that they can spend a successful independent life in society.
Future Consideration
If God provides me opportunity, I will solve the problems and give guidelines for living
successful lives to all the clients suffering from psychiatric and disabled clients so that they
can cope with the situation and become a useful citizen of their country, instead of becoming
dependent on others.
Depression 54
References
 Elizabeth, A., & Polatajko, H.J. (2007). Enabling Occupation II: Advancing an Occupational
Therapy Vision for Health, Well-Being & Justice Through Occupation. Ottawa: CAOT
Publications ACE.
 Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing Care
Plans, (7th ed.). Philadelphia: Lippincott.
Depression
Farzana Gulzar
Dated: ______________
Depression 55
The term ‘depression’ is used to define normal sadness and pain and with the illness
of depression. Sadness is overwhelming and the person feel hopeless, helpless, there is
noticeable change in eating habits and sleeping pattern, either sleeping too much or inability
to feel rested after sleep.
A person with depression loses energy and can describe recurring thought of death or
suicide needs to be seen by a physician immediately. Depression carries with it disturbance in
emotional, cognitive behavioral, somatic and spiritual dimensions of the individuals.
World Health Organization has predicted that by 2020 depression will be the second
most common cause of morbidity worldwide (WHO, 2000).
The following are the risk factors for depression:
 Prior episodes of depression.
 Family history of depressive disorder.
 Prior suicide attempts.
 Female gender.
 Age of onset under 40 years.
 Postpartum period.
 Medical comorbidity.
 Lack of social support.
 Stressful life situations.
 Current alcohol or substance abuse.
The main two causes of depression are:
The Biological cause of mood disorder includes altered neurotransmitter activity,
primarily decreased availability of serotonin and norepinephrene and abnormalities of the
limbic-hypothalanie – pituitary adrenal axis.

Depression 56
The Psychological etiology of depression includes loss of a parent in childhood,
social loss during adult life (loss of spouse), low self esteem, loss of hope and negative
interpretation of life events, for example, taking a genuine compliment as insincere and
undeserved.
Drugs that may induce depression include:
 Analgesics and non-steroidal anti-inflammatory agents.
 Antihypertensive.
 Antimicrobials.
 Anti-Parkinsonian drugs.
 Anti-Psychotic drugs.
 Cardiovascular agents.
 Sedatives and anti-anxiety drugs.
 Steroids and hormones.
 Stimulants and appetite suppressant.
Characteristics of depression are:
 Turned corners of mouth.
 Furrowed brow.
 Hunched, dejected posture.
 Decreased level of arousal.
The principal symptoms of depression are:
 Depressed mood.
 Loss of pleasure or interest in all or nearly all of one’s usual activities and past times.
 Insomnia or sometimes hypersomnia.

Depression 57
 Anorexia and weight loss or sometimes hyperphagia and weight gain.
 Mental slowing and loss of concentration.
 Feeling of guilt.
 Worthlessness and helplessness.
 Thought of death and suicide.
 Overt suicidal behavior.
Signs or depression include:
Mnemonic Signs Comments
S Sleep Insomnia and early awakening.
I Interest Involvement in usual activities and motivation

are decreased.
G Guilt Many patient feel excessive self-blame.
E Energy Loss of vigor is common (hard to get though

routine task).
C Concentration Cognitive problems (e.g., difficulty in paying

attention and memory disturbance.
A Appetite Decreased desire for food and sex.
P Psychomotor activity Decreased physical activity, psychomotor

retardation, less common psychomotor
agitation occurs.
S Suicidal ideation Thoughts of self destruction are present in

many patients.
The pathogenesis for depression included:
 The etiology of major depression is undoubtedly complex and yet not known, because
depressive episodes can be triggered by stressful life events in some people but not in
others.
 Greek believed that depression was caused by excessive amount of black bile.
Depression 58
 Current theory states that depression is associated with regional brain dysfunction.
 Observed symptoms and behaviors are related with disturbed chemistry.
 Two neurotransmitters are correlated with depression that are, Serotonin and
norepinephrine.
 The first function in thermoregulation feeding regulation of mood and emotion.
 It also involved in control of sleep, wakefulness, and sexual behavior.
 The second function is rather famous for its sympathetic nervous system control that
includes regulation of blood pressure, fight or flight syndrome. It is also involved in
sleep and wakefulness and hypothalamic function of thermoregulation, thirst and
hunger. Depression is caused by a functional insufficiency of monoamine
neurotransmitter in the brain.
The diagnostic criteria for depression includes a self-rating depression scale (SDS) for
the quantitative measurement of depression as an emotional disorder based upon an
operational definition was first published in 1965 (Zung, 1965).
There are three approaches for treatments of depression. These are:
 Pharmacological Treatment consists of:
• Heterocyclic antidepressants.
• Selective serotonin reuptake inhibitors (SSR’s).
• Monoamine oxidase inhibiters (MAOIs).
It is challenging to support people taking antidepressant beyond the initial
treatment period, and there is considerable noncompliance with drug treatment
(Pevler, 1999).
 Electroconvulsive Therapy consists of:

Depression 59
• Safe and effective.
• Works quickly.
Depression 60
 Psychological Treatment
• Psychoanalytic, interpersonal family, behavioral and cognitive therapy.
• Psychological treatment in conjunction with medication is more effective than
either type of treatment alone.
Psychological therapies and counseling are widely acknowledged to have a
place in the treatment of depression and anxiety disorder (Simpson, 2000).
Nursing diagnosis for depression includes:
 Hopelessness related to long term stress.
 Loss of belief in God, evidenced by vegetative symptoms of depression.
 Verbalization of despair and abandonment by God.
Conclusion
Depression is defined operationally as a syndrome comprised of co-existing signs and
symptoms that signify the presence of pathologic disturbance or change in four areas;
somatic, psychologic, psychomotor, and mood.
The incidence of depression among people with chronic physical health problem has
been shown to be much higher than was previously expected. Treating depression is
problematic because of stigma attached to mental illness, difficulties in diagnosis and lack of
awareness among the practitioners (Kisley & Goldberg, 1997).
Patients need to be aware that they are unwell, that depression is treatable illness and
that services are available. Great distribution of information among professionals is need,
non-stigmatizing services, early diagnosis, proper assessment are important.
Main obstacles in treatment are lack of time for proper assessment, lack of sources,
fragmentation of services, absence of protocol and lack of training skills.

Depression 61
References
 Clinical Research Education. Nursing Standard 2002; 16(26).
 Carson, V.B. (2000). Mental health nursing. 2nd Edition. USA.
 Fadem, B., & Simring, S.S. (2003). High-yield psychiatry. USA.

Jamshoro Sindh
Obsessive-Compulsive Disorder

(Assignment # 1)
Farzana Kouser
BScN Year II
Mrs. Munira A. Ali

Depression 62
Obsess thoughts are persistent, intrusive thoughts that are troublesome to the client,
producing significant anxiety. Compulsions are ritualistic behaviors, usually repetitive in
nature, such as excessive hand-washing or checking and rechecking behavior. Obsessive-
compulsive disorder, or OCD, is characterized by the presence of obsessions or compulsions
that cause the client significant distress or impairment, and the adult client recognizes
(at some time) as excessive and as produced by his or her own mind (APA, 2000).
Etiology
Compulsive behavior is thought to be a defense that is perceived by the client as
necessary to protect him- or her-self from anxiety or impulses that are unacceptable. Specific
obsessive thoughts and compulsive behaviors may be representative of the client’s anxiety.
Many obsessive thoughts are religious or sexual in nature and may be destructive or
delusional. For example, the client may be obsessed with the thought of killing his or her
significant other or may be convinced that he or she has a terminal illness. The client also
may place unrealistic standards on him- or her-self or others. Many people have some
obsessive thoughts or compulsive behaviors but do not seek treatment unless the thoughts or
behaviors impede their ability to function (Valente, 2002).
Epidemiology
Obsessive-compulsive disorder is equally common in adult men and women, thought
more boys than girls have onset in childhood; there is also some evidence of a familial
pattern. Up to 2.5% of the population may have OCD at some point in there lives. OCD can
occur with other psychiatric problems, including depression, phobias, eating disorder,
personality disorder, and overuse of alcohol or anxiolytic medications APA, 2000).
Nursing Diagnoses Address in this Care Plan
 Anxiety
 Ineffective coping
Depression 63
Related Nursing Diagnoses Addressed in the Manual
 Ineffective Health Maintenance
 Risk for Injury
 Disturbed Thought Processes
 Impaired Social Interaction
General Interventions
In early treatment, nursing care should be aimed primarily at safety concerns and
reducing anxiety. Do not prevent the client from performing compulsive acts unless they are
harmful. Initial nursing care should allow the client to be undisturbed in performing rituals
(unless harm), as drawing undue attention to or attempting to forbid compulsive behaviors
increases the client anxiety.
Depression
Depression 64
Karim Bux
January 18, 2008

Depression 65
Introduction
Miss. Shumaila, a 24 years old lady admitted in Psychiatric Ward, Bed No. 7 with
history of insomnia, anorexia and weight loss. She was social and enjoys parties and having a
number of friends. Her past history revealed that she was all right before three months ago,
when an incident changes her life i.e., her engagement was broken. Furthermore, she failed in
her final examination. After these incidences, she become isolated and loss interest in life.
She is single child of her parents. Her mother is working in an office and father is a
businessman. Both are very busy, therefore, she becomes an isolated child.
Depression 66
NURSING CARE PLAN
Patient’s Name: Miss. Shumaila
Age: 24 Years
Medical Diagnosis: Depression
Nursing Diagnosis: Impaired social interaction related to loss of intimate relationship
Assessment Nursing Expected Interventions Rationales Evaluation
Diagnosis Outcome
Subjective Data Short term goals Introduction to the client. To establish a therapeutic Short term Goal
Impaired social interaction related to loss of intimate relationship

According to the client’s parent, “she is The client will relationship. The Client verbalized
feeling difficulty in falling asleep, demonstrate Assess the level of severity It provides a baseline data for the satisfaction with
anorexia and loss weight ,does not increased and condition of the patient. management of situation. quantity and quality of
taking part in any activity and mostly involvement in Encourage patient to express Assist client to examine social social interaction.
lives alone, calm and quite, and social interaction how she feels by scheduling at experience and verbalize feelings Client communicated
complains headache, chest, back pain with in one week. least 10 minutes, twice a day and encourage therapeutic and participated with
and indigestion after engagement focus on client problem / topic. relationship. others and community
broken and failed in BA examination,”. The client will Continually assess the client’s Depressed clients have potential She reestablished or
participate in daily potential for suicide. for suicide that may be change by maintained relation-
Objective Data activities. pre effective interventions. ships and a social life
An adult girl of moderate build and Evaluate patient communi- Improve communication skills and and also established
with rough, unhygienic and Long term goals cation skills and help her to interactive process. support system.
inappropriate dressing and face. The client will be find alternative during
Looks pale, sad, with inappropriate able to initiate interaction with patient. Long term
interaction with Help the client to obtain a Help patient in achieving goal, and Client participated in
eye contact, facial grimaces present,
others to maintain realistic perception of self by improves self-concept. normal daily activities
and malnourished. relationship and focusing on and enhancing and normal routine life.
Delayed response with slow motor social life. strength during conferences
behavior, gait slow, restlessness, with patient. The client verbalized
confused and tremors present Allow client to choose social Promote self-confidence and social satisfaction with quality
communications with low volume, interactions for role play for interaction by allowing practice in of interactions.
and slurred speech, 10 minutes twice a day time. a safe environment.
Oriented and Poor in judgment and Involve patient in daily care to Improve self-concept, and increase The client identified
in decision making. help the patient in planning motivation. Decrease feelings of and demonstrated a
Suicidal ideas, feeling of and decision making about powerlessness. number of measures
helplessness, and hopelessness own care. that increase social
Initiate referrals to support Client’s contact with community interaction.
groups prior to discharge. group to interact to decrease social
isolation.
Depression 67

Diagnosis Outcome
Vital Signs
Assign one staff permanent for the Limiting the number of new contacts
Blood Pressure 100/70 mmHg
care of the client. will facilitate familiarity and trust among
Temperature 97 °F client and staffs.
Pulse 88 bpm
Use silence and active listening Your presence and use of active listening
when interacting with the client. will communicate your interest and
concern.
Use simple, direct sentences and It will encourage the client to express her
ask open ended questions. feelings.
Encourage the client to express her Expressing of feelings may help to

feelings in comfortable way. relieve despair, and hopelessness.
Interact with the client on the topic It establishes trust and encourages
of her choice and don’t probe for communication on difficult topics.
information.
Educate the client about problem- Successful use of problem solving

solving, selection and process facilitates the client’s confidence
implementation of alternatives and in the use of coping skills.
evaluation of results.
Teach and encourage the client to It will increase the confidence and social
practice social skills, and give interaction of the client and prevents
feedback to the client regarding social isolation and depression.
interactions.
Encourage the client to pursue Recreational activities can help the

personal interests, hobbies, and client’s social interaction and provide
recreational activities enjoyment.
Depression 68

Diagnosis Outcome
Help the client to participate in Increase social skills by providing social
group interactions. contact.
Include client in group activities Reinforcement encourages positive

and assign activities that will be behavior and enhances self-esteem.
easily accomplished and provide
positive reinforcement.
Discuss with support system ways Support system understanding facilitates

in which they can facilitate client the maintenance of new behavior after
interaction. discharge.
Involve client and family in Family involvement enhances the

planning, implementing and effective ness of the interventions.
promoting in reduction or
elimination of impaired social
interaction.
Encourage the client to participate Increases social contacts and interact

in diversional activities, especially -ional skills.
those involving groups, daily.
Encourage the client to use It will increase self-esteem and self-

assistive or corrective devices. confidence.
Limit the amount of time client Provide opportunities for client to

can spend alone in the room. practice new role behavior in a safe and
supportive environment.
Document all the procedure in the For continuation of nursing care in the
client’s file. next shift.
Reflection
We reached at 08:30 AM at Ward # 20, and introduced ourselves with Head Nurse and
other staff members of the ward and Doctors too. Their attitude was very supportive. They
guide us, on the basis of their experiences to deal the psychiatric clients. One of the Doctors
gave us lecture to differentiate between psychotic and neurotic disorders clients. Then I went
to ward and selected my client. He was suffering with depression.
With the assistance of 2nd Year Student Nurse, I took history and physical examination
of the client. As the client had depression, I thought her attendant must have knowledge about
her disease, cause of disease and most of all is about persistent low mood and feeling of
hopelessness. I decided to give health talk to client and her attendant.
Promotion of the human functioning and development with social group in accord
with human potential know human limitation and human desire to be normal (Oren, 1995).
I gave health talk about depression and its feeling of hopelessness and worthlessness.
Help the client understanding how physical, intellectual, sociocultural, psychological, and
spiritual health are related and can lead to overall sense of well being. Help and improve the
client’s self esteem by suggesting simple success oriented task. Client cannot leave alone in
suicidal condition and never leave some suicidal material near to client. Communicate using
simple direct sentence, avoiding complex sentence of the direction. Provide positive feedback
as the client achieves goals of treatment. Listen the client very attentively. Spend time with
the client to provide support and reminder of the reality.
A client suffering from depression requires long term management and follow up for
good prognoses. The effectiveness of psychotherapy depends on the psychopathology of the
family members. Therefore the family therapy may be provided in case of out patient.
The client will not leave alone and after discharge the relative may be educated
for care of the client.
References
 Carpenito, L.J. (1997). Nursing Diagnosis: Application to Clinical Practice.
7th Edition. Lippincott Philadelphia.
Care Plans.7th Edition. Philadelphia: Lippincott.
Nursing. 5th Edition. Philadelphia: Lippincott.
 http://www.google.com. Scott J (2001). Cognitive therapy for depression. British
Medical Bulletin; 57:101-113.
Therapeutic Communication
Khar-un-nisa
Dated: _______________
Introduction
Sears (2004), reported that “to be an effective communication we must be willing to
let go of judgment accept our own imperfection and have a desire to connect with others
feeling and need.
Michael Zychowicz introduced therapeutic communication as, “Nurses interact with
many people daily and success depends upon effective interpersonal skills.”
Communication is the modes of behavior that one individual employs, conscious or
unconscious, to affect another: not only the spoken and written word, but also gestures, body
movements, somatic signals, and symbolism in the arts.” It is necessary for nurses to have
good skills. Ruesch (1972) stated that communication may be verbal or nonverbal.
Therapeutic Communication is an interpersonal interaction between the nurse and
client during which the nurse focuses on the client’s specific needs to promote an effective
exchange of information (DeVito, 2004)
Sears (2004), stated that, “if a nurse had use empathy, instead of judgment and advice,
she would have learned what really was happening and would have the offered
appropriate intervention to prevent such a tragedy from recurring if therapeutic
communication had been used.”
Factors influencing communication are the ways we taught to communicate in our
society seems to be harmful to esteem and destroys intimacy (Sears, 2004). Similarly,
Zychowicz, reported the factors influencing communication are: culture, perceptions and
values, content of the message (toxic versus non-toxic words).
Therapeutic communication skills depends upon facilitative questions and statements
(encourage patients to answer in their own words and broad open ended questions), reflection
(reflect content or feeling of message to patient, patient can hear and think about what they
said, and can be over used easily), restatement (for example, patient: “I think I study as hard
as anyone else, but all my efforts seem to go down the tube. I don’t know what else to do.”
Nurse: “It sounds as if you are frustrated because even when you think you try hard, you
don’t get the result you want. Perhaps you also feel a little sorry for yourself.”), clarifying
(clarify a point that the patient makes and ensure there is no miscommunication), conveying
information (convey direct information for example, patient: “I feel nauseous and have
diarrhea. Why do I feel so sick?” Nurse: “You may be having a side effect from the lithium
you are taking. We should check your level.”), providing feedback, stating observations,
connecting islands of information, confrontation, summarizing, silence (usually not
comforting socially, conveys acceptance, support, and concern and allows patient to organize
thoughts or reflect), and humor (can help pt diffuse emotionally charged situation, and be
careful with whom you use humor).
Nonviolent communication process is changing lives every day. It provides an easy
to grasp, effective method to get the root of conflict, violence and pain peacefully. The
nonviolent communication process is now being taught in corporations, classrooms, prisons
and medication centers around the globe. Steps of nonviolent communication process include
observing – what patients are seeing, hearing, thinking and smelling, understanding – how a
patient feels when they observe the former, recognizing – the need or the unmet need of the
patient, and learning – what the patient wants to fulfill their needs (Sears, 2004).
Barriers to therapeutic communication include giving advice, giving false
reassurance, changing the subject, being judgmental, giving directions, excessive questioning,
using emotionally charged words, challenging, making stereotypical comments, self-focusing
and behavior. Beside these barriers, one of the main barriers is patients with special needs
like: (1) hearing impaired patient, (2) visually impaired, (3) speech impaired/Aphasic,
(4) non English or Urdu speaking, (5) the emotional patient, (6) low IQ patient, and
(7) the older patient.

To check patients with special needs including hearing impaired patient it is necessary
to check and see the patient wears a hearing aid, be sure it is working, minimize background
noise, always face the patient, speak with a normal tone and pace, observe that does the
patient use sign language?, pay attention to non verbal communication from you and the
patient and use a pen and paper if necessary.
For visually impaired patients, use a normal tone and pace, look at and speak to the
patient, tell the patient when you leave and enter the room, orient the patient to the immediate
area, and ask for permission before touching the patient.
Speech impaired/Aphasic patient should be assessed by how well the patient
communicates, adapt to the patients ability for communication, allow time for the patient to
respond, don’t answer questions for the patient, use closed questions when possible, repeat or
rephrase questions when needed, and speak directly to the patient, not and intermediary
For non-English speaking patients, use an interpreter, use pictures if needed, and try
not to use colloquial phrases. Similarly, for the emotional patient, observe that emotions are
neither good or bad, actions based on emotion can be good or bad, allow the patient or family
member to express their emotion, let them know it is OK to express emotion, when a person
is angry; recognize and acknowledge that anger and bring it to their attention, give
permission.
Low IQ patient requires time and patience, do not hurry, may need to interview family
guardian for additional information, and direct questions toward the patient. Same procedure
may be used for the older patient (Michael Zychowicz).
Techniques to Facilitate Therapeutic Communication
 Accepting – indicating reception.
 Broad openings – allow the client to take the initiative in introducing the topic.
 Consensual validation – search for mutual understanding, for accord in the meaning
of the word.
 Encouraging expression – asking the client to appraise the quality of his or her
experiences.
 Exploring – delving further into a subject or idea.
 Focusing – concentrating on a single point.
 Formulating a plan of action – asking the client to consider kinds of behavior likely
to be appropriate in future situations.
 Giving information – making available the facts that the client needs.
 Presenting reality – offering for consideration that which is real.
 Reflecting – directing client actions, thoughts and feelings back to client.
 Suggesting collaboration – offering to share, to strive, to work with the client for his
or her benefit.
 Translating into feelings – seeking to verbalize client’s feelings that he or she
expresses only indirectly.
 Advising – telling the client what to do.
 Agreeing – indicating accord with the client.
 Belittling feelings expressed – misjudging the degree of the client’s discomfort.
 Challenging – demanding proof from the client.
 Defending – attempting to protect someone or something from verbal attack.
 Disagreeing – opposing the client’s ideas.
 Disapproving – denouncing the client’s behavior or ideas.
 Giving approval – sanctioning the client’s behavior or ideas.

 Giving literal responses – responding to a figurative comment as though it were a
statement of fact.
 Indicating the existence of an external source – attributing the source of thoughts,
feelings and behavior to others or to outside influences.
 Interpreting – asking to make conscious that which is unconscious, telling the client
the meaning of his or her experience.
 Introducing an unrelated topic – changing the subject.
 Making stereotypes comments – offering meaningless clichés or trite comments.
 Probing – persistent questioning of the client.
 Reassuring – indicating there is no reason for anxiety or other feelings of discomfort.
 Rejecting – refusing to consider or showing contempt for the client’s ideas of
behaviors.
 Requesting an explanation – asking the client to provide reasons for thoughts,
feeling, behaviors, events.
 Testing – appraising the client’s degree of insight.
 Using denial – refusing to admit that a problem exists.
Points to Consider when Working on Therapeutic Communication Skills
 Remember that nonverbal communication is just as important as the words you speak.
Be mindful of your facial expression, body posture, and other non-verbal aspects of
communication as you work with clients.
 Ask colleagues for feedback about your communication style. Ask them how they
communicate with clients in difficult or uncomfortable situations.
 Examine your communication by asking questions such as “How do I relate to men?
To women? To authority figures? To elderly persons? To people from cultures

different from my own?” “What types of clients or situations make me
uncomfortable? Sad? Angry? Frustrated?” Use these self-assessment data to improve
your communication skills.
Conclusion
Communication is the process people use to exchange information through verbal and
nonverbal messages. To communicate effectively, the nurse must be skilled in the analysis of
both content and process as, it includes establishing rapport, actively listening, gaining the
client’s perspective, exploring client’s thoughts and feelings, and guiding the client in
problem solving.
Therapeutic communication is and interpersonal interaction between the nurse and
client during which the nurse focuses on the needs of the client to promote an effect exchange
of information between the nurse and client. Nurse should have knowledge about the crucial
components of therapeutic communication that are: confidentiality, privacy, respect for
bounding, self-disclosure, use of touch, and active listening and observation skills.
Effective use and working knowledge of therapeutic communication techniques will
enhance patient care and interactions with family and patients through the concept of
“therapeutic use of communication”.

References
 Carson, V.B. (2000). Mental Health Nursing: The Nurse patient journey. 2nd Edition.
USA.
 DeVito, J.A. (2004). The interpersonal communication handbook. (10th ed.) Boston:
Pearson Education.
 Sears, M. (2004). Using Therapeutic communication to connect with patients.
Retrieved from http//www.nonviolent-communication.com/press/article_PDF/
Melanie_Sears/Therapeutic_Communication on September 15, 2007.
 Summers, L.C. (2002). Mutual timing: An essential component of provider/patient
communication. Journal of the American Academy of Nurse Practitioners.
14(1):19-25.

Khar-un-nisa
January 24, 2008

Nursing Care Plan
Introduction
A 30 year old female, Sultana has been admitted to Psychiatric Ward at Bed No. 11 by
her parents with complaint of depression. According to her mother, she was alright one year
back. She also stated that “the client has less abilities and strength in developing relationship
with others and said that people will defeat me and criticize me; therefore, she has lack of
involvement in job performance and seek of evaluation from others. She has depressed mood,
feeling of worthlessness and looking pale.”
Her mother also stated that signs and symptoms observed by her include depress
mood, hopelessness, suicidal attempts, ideas of guilt or worthlessness, impaired
concentration, loss of interest, sleeplessness, disturbed appetite, decreased sexual desires,
feeling of tiredness, unknown fear, negative thinking, headache, persistent backache, chest
pain, palpitation, hyperventilation and wiping episodes occurred.
Therefore, we brought her to the hospital for treatment.

NURSING CARE PLAN
Patient’s Name: Mrs. Sultana W/o Shahid Age: 30 Years Bed No. 11 Ward No.: 20 Date of Admission: 24-09-2007.
Nursing Diagnosis: Chronic Low Self-Esteem related to long-standing negative self-evaluation/feelings about self or self-capabilities.
Subjective Data: Short-term Goals:  Encourage the client to  When the client can focus The client has
Chronic Low Self-Esteem related to long-standing negative self-evaluation/feeling

The client’s mother verbalize  The client will verbalize become involved with staff on other people or demonstrated
that she has less abilities and increased feelings of self- and other clients in the interactions cyclic, behavior
strength to develop and self worth. milieu through interactions negative thoughts are consistent with
evaluation thinking about  The client express and activities. interrupted. increased self-
criticism of other as evidence by feelings directly and  Give the client positive  Positive feedback esteem.
lack of job performance, openly. feedback for completing increases the likelihood
hopelessness, suicidal attempts,  The client evaluate own responsibilities and inter- that the client will continue The client has
self-depreciation, loss of self- strengths realistically. acting with others. the behavior. made plans for
confidence, ideas of guilt or  Involve the client in  The client needs to the future
worthlessness, disturbed sleep Long-term Goals: consistent with
pattern, decreased sexual about self or self-capabilities  The client will
activities that are pleasant or experience pleasurable
personal
recreational as a break from activities that are not
desires, loss of energy and demonstrate behavior self-examination. related to self and strengths and
fatigue, appetite and weight consistent with increased problems. expressed
changes, headache, persistent self-esteem.  If negativism dominates the  The client will feel you are satisfaction
backache, chest pain,  The client makes plans client’s conversation, it may acknowledging his or her with self and
palpitation, hyperventilation and for the future consistent help to structure the content feelings yet will begin personal
wiping episodes. with personal strengths. of interactions, for example, practicing the conscious qualities.
 The client expresses by making an agreement to interruption of negativistic
Objective Data:
satisfaction with self and listen to 10 minutes of thought and feeling
A 30 years old client looked pale
personal qualities. “negative” interaction, after patterns.
with depressed mood. She is
having low self-esteem. Her which the client will interact
communication is slow and on a positive topic.
irregular, loss of interest,  Provide simple activities  The client may be limited
insufficient thinking, worrying, that can be accomplished in his or her ability to deal
and restlessness. easily and quickly. Begin with complex tasks or
with a solitary project; stimuli. Any task that the
Vital signs: progress to group occupa- client is able to complete
Blood Pressure: 110/70 mmHg tional and recreational provides in opportunity for
Pulse Rate: 70 beat/min therapy sessions. Give the positive feedback to the
Resp. Rate: 20 per min. client positive feedback for client.
Temp. 98° F participat6ion
Nursing Care Plan
 Give the client honest praise for accomplishing small responsibilities by  Clients with low self-esteem do not benefit from flattery or undue praise.
acknowledging how difficult it can be for the client to perform these Positive feedback provides reinforcement for the client’s growth and can
tasks. enhance self-esteem.
 Gradually increase the number and complexity of activities expected of  As the client’s abilities increase, he or she can accomplish more complex
the client; give positive feedback at each level of accomplishment. activities and receive more feedback.
 It may be necessary to stress to the client that he or she should begin  The client will have the opportunity to recognize his or her own
doing things to feel better, rather than waiting to feel better before doing achievements and will receive positive feedback. Without this stimulus, the
things. client may lack motivation to attempt activities.
 Explore with the client his or her personal strengths. Making a written  While you can help the client discover his or her strengths, it will not be
list is sometimes helpful. useful for you to list the client’s strengths. The client needs to identify them
but may benefit from your supportive expectation that he or she will do so.
Reflection
Introduction
The day when I went to Psychiatric Ward as a clinical attachment as BSc Nursing
student to gain new experiences, it was my second clinical week in Psychiatric unit. I wished
to the staff members. With the permission of Head Nurse, I selected the patient, who was 30
years old female, lying on bed admitted in ward with complaint of depression with sign and
symptoms of depress mood, hopelessness, suicidal attempts, ideas of guilt or worthlessness,
impaired concentration, loss of interest, sleeplessness, disturbed appetite, decreased sexual
desires, feeling of tiredness, unknown fear, negative thinking, headache, persistent backache,
chest pain, palpitation, hyperventilation and wiping episodes occurred.
I introduced myself to the selected client, but she didn’t talk to me. So I came back to
staff room and thought, why she ignored me. Sometime later, I understand that, if I am
interested in doing work that has emotional and spiritual impact on my client then the most
powerful way of dealing with therapeutic communication.
Analysis
According to Sears (2004), “If a nurse had use empathy, instead of judgment
and advice, she would have learned what really was happening and would have
offered appropriate intervention to prevent such a tragedy from recurring if therapeutic
communication had been used.”
Devito (2004) defined therapeutic communication as an interpersonal interaction
between the nurse and client during which the nurse focuses on the client’s specific needs to
promote an effective exchange of information.

I have analyzed that without having the skills of therapeutic communication most of
the people cannot tell you what their request and often are out of touch with their feelings and
needs. This is why as a Nurse, I need to identify what they are feeling and needing.
I do this my translating their judgments and thoughts into feelings and needs. I again went to
her and used therapeutic communication technique and encouraged her to talk with me.
I spend some time with the client, and asked her small questions to build a trustworthy
relationship between client and me. Now she is ready to answer my questions and give
information about her feelings. I heard the client carefully and observed that if we spend
more time with them and give opportunity to express their feelings and needs, they feel more
relaxed and look better.
One should get the feedback when a client state that “I feel better and relax, as you are
the only one, I can talk about my feelings.”
Learning
I had learned that clients need to resolve whatever they are dealing with on an
emotional level. I learned therapeutic communication technique to deal effectively to the
clients having psychiatric disorders and others too and to say that therapeutic communication
skill is one of the successful techniques to spend life with success.
Assists and educates clients to select choices which will support positive changes in
their effects, cognition, behavior and relationship (CAN, 1997b, p.68).
Insha Allah! If Allah gives the opportunity, the trick to giving therapeutic
communication is to practice and try using this technique in all areas where I connect such as
staff members, clients, friends and also family members because:
“God loves those who love mankind first”

References
 Sears, M. (2004). Using therapeutic communication to connect with patients.
Retrieved from http://www.nonviolentcommunication.com/press/article_PDF/
Melanie_Sears/Therapeutic_Communication.
 Schultz, J.M., & Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Anger
Musarrat Begum

Dated ______________
Definitions
Anger is a reaction to an inner emotion and not planned action. It is also stated that “It
is phychophysiological response to pain, perceived suffering or distress, or threat. Anger is
often a response to the perception of threat due to a physical conflict, injustice, negligence,
humiliation or betrayal.
There are two ways in which we express anger, they are:
Actively – in the case of active emotion, the angry person “Lashes out” verbally or
physically at a target.
Passively – when anger is a passive emotion, it is often characterized by silent
sulking, passive aggressive behavior, and tension.
Human often experience anger empathetically, for example, after reading about other
being treated unjustly, one may experience anger, even though he/she is not the victim.
Common factors that predispose anger include: fatigue, hunger, pain, suffering,
sexual frustration, stress, recovery from illness, puberty, use of certain drugs, hormonal
changes associated with premenstrual or menopause.
Physiological disorders includes: physical withdrawal, bipolar disorder, borderline
personality disorder, other emotional disorder or situational behaviors also contribute.
Genetic predisposition – at the end of 19th century, Signund Freud, the father of
Psychology argued that one born with an innate loving instinct. However, anger and hostility
arise when the individual’s need for love is unmet. In 1998, the American Psychologist
Association concluded that people are not genetically predisposed to violence and that
violence cannot be scientifically related to natural evolutionary process. At the beginning of
21st century, it is general censuses among psychologist that a combination of nature and
nurture is involved in the manifestation of anger and therefore that neither should be ignored.
Physiological progression of anger – neuroscience has shown that emotions are
generated by multiple structures in the brain, such as amygdala. Amygdala is responsible for
identifying threat and reacting according to initiate action within the body. Jone (2003-2004)
reported that left prefrontal cortex has also been identified involved in activating anger.
The action of amygdale causes the body’s muscles tense up. Inside the brain,
neurotransmitter chemical known as catecholamines are released causing an increase in
energy that generally lasts several minutes. Heart rate increases, blood pressure rises, the rate
of breathing increases, additional brain neurotransmitters and the hormones adrenaline and
noradrenaline are released.
The body will start to relax back toward its resting state when the target of anger is no
longer accessible or an immediate threat. It is difficult to relax from an angry state within a
short time. This is an account of the adrenaline caused arousal that occurs during anger. This
invariably lasts as substantial time (many hours) potentially days during which time the anger
threshold is lowered.
Religious perspective on anger - in Islam, anger is seen as sign of weakness.
Mohammad (Peace be Upon Him) said “The strong is not the one who overcomes the people
by his strength, but the strong is one who control himself while in anger.” In Christianity,
Bible warns, “Do not let the sun go down on your anger.” In Hindusim, “Anger is equated
with sorrow as a form of unrequited desire. Anger is considered to be packed with more evil
power than desire.
Signs and symptoms of anger include: heightened blood pressure, increase of stress
hormones (particularly catecholamines, as corticosteroids are more typical of fear), shortness
of breath, trembling, heightened senses, animated and exaggerate body movement, stiffness
of posture, constipation, dilated pupils, increase physical strength, speech and motion are
faster and more intense, tense muscles, criticism, irritation, hatred, passive-aggressive
behavior, anxiety, apathy, and sleeplessness.
Dealing with Anger – there are various strategies for dealing with anger; some
address individual episodes of anger, and other address an ongoing tendency toward anger.
Dealing with each instance of anger represents a choice. The basic alternatives are to
respond with hostile action, including overt violence, respond with inaction, such as
withdrawing or stonewalling, initiate a dominance contest, work to better understand and
constructively resolve the issue and harbor resentment.
Other strategies address ongoing tendencies toward anger -
In the 1960s and 1970s, theories about dealing with anger in a therapeutic process
were based upon expressing the feeling through action. This ranged from pillow hitting
strategies to radical and extreme therapies such as scream therapy. Scream therapy is a
treatment in which patients stand in a room and simply scream for hours. On end, supposedly
relieving the tension or feeling spawned from the initial anger.
Cognitive behavioral therapy – research showed that people who suffer from
excessive anger often harbor irrational thoughts and belief towards negatively. It has been
shown that with therapy by a trained professional, individual can bring their anger to
manageable level. In order for a cathartic affects to occur, the source of the anger must be
damaged or destroyed by the aggrieved party.
Conclusion
Anger is a reaction to an inner emotion and not a planned action. We can express
anger actively and passively. Common factors that predispose one to anger are physiological
disorder and genetic predisposition, physiological progression of anger. Neuroscience has
shown that emotions are generated by multiple structures in the brain, such as amygdale.
Religious perspective on anger in Islam, Christianity and Hindusim. Dealing with anger some
address individual episodes of anger and others address on ongoing tendency toward anger.
References
 Jones, H.E., et al. (2004). Contributions from research on anger and cognitive
dissonance to understanding the motivation functions of asymmetrical frontal brain
activity. Biological Psychology.
Advance Concept of Nursing-III
Musarrat Begum
January 24, 2008

NURSING CARE PLAN
Name: Miss. Momal D/o Rushan Ali Age: 18 Years Sex: Female Date of Admission: 24th September, 2007.
Psychiatric Diagnosis: Anger (The Client who will not eat)
Nursing Diagnosis: Imbalanced Nutrition Less than Body Requirement
Subjective Data: Short-term Goals:  Reassure the client and their  For cooperation. The client has
(Intake of nutrient insufficient to meet metabolic needs).

According to attendant, the  The client will family. able to eat and
Imbalanced nutrition less than body requirement

client may not eat for physical or establish adequate  Strictly monitor intake and  Information on intake and shown interest
psychological reasons. She is nutrition, hydration output in an unobtrusive way. output is necessary the during eating.
refusing to eat and unaware of and elimination. Record the type and amount of client’s nutrition state.
the need or desire to eat, lack of food and the times of eating. She has better
appetite, lack of interest in Long-term Goals:  Weight the client regularly, at  Being matter of fact about than before.
eating, aversion to eat, weight  The client will the same time of day and in a weight measurement will
loss (around 10 Kg), difficulty in demonstrate weight matter of fact manner. help to separate issues of
eating, malnutrition, inadequate gain, if appropriate. weight and eating from
hydration, electrolyte imbalance,  The client will emotional issues.
starvation, difficulty in demonstrate in food  Provide nursing care and  The client physical health is
swallowing, lack of awareness and fluid intake. facilitate medical treatment for a priority many physical
of need for food and fluids, physical problem related to problems can contribute to
delusion, anger and hostility, client no eating. result from the client not
manic behavior, low self-esteem, eating.
gait and disturbance in  Provide fruit juice and food  Fruit, juice and foods high
elimination. high in fiber. in fiber content promote
adequate elimination.
Objective Data:
 Try to accommodate the client  Reinforcing previous
18 years old female client
normal or previous eating normal eating habit
Momal lying on bed well
habits as much as possible. increases the likelihood that
oriented with time, place and
 Make culturally or ethnically the client will eat.
person. She is looking:
appropriate food available. The  The client may be more apt
 Pale, irritable.
client significant others may be to eat food that are
 Aggressive behavior. able to provide guidance or culturally acceptable or
 Refused from eating. food acceptable to the client. provide by family members
 Dry mucus membrane or significant others.
 Dehydrated  Gradually decrease the  The transition from feeding
frequency of suggestions and the client to independent
allow the client to take eating is more likely to be
responsibility for eating, again, successful if it is gradual.
record change.
Nursing Care Plan

According to file
documentation
Weight: 38 Kg (previous
weight 48 Kg), unhygienic
condition, uncombed hair.
Vital signs:
Blood Pressure: 80/50 mmHg
Pulse Rate: 136 beat/min
Resp. Rate: 30 per min.
Serum Electrolyte
Na: 120
Ka: 3
Cl: 82
Urea: 48
Hb: 8 gm
Communication
Reflection
Introduction
The day when I was to go and join the Psychiatric Ward as a clinical attachment as
BSc Nursing student was to become a door to new experiences. It was my first clinical week
in Psychiatric Ward. I wished and introduced myself to staff. There was one Ward Manager,
two Staff Nurses and one Student Nurse in the ward. It was basically a psychiatric ward but
in those days my clinical attachment was there.
It is my first day in this ward. I was very impressed with the ward management and
communication skills of Head Nurse. She distributes all ward work equally and accordingly.
She also communicates with each and every person of the ward in verbal and nonverbal ways
and conveys right information and condition of the client to the doctor and possesses good
communication with subordinates and assigned duties by herself and they were directly
accountable to her.
She also communicates each and every person who was related with her ward, her
clients and her work. Even with the relatives of the client, she made conversation and
convincing them by giving information about their patients.
According to Huston & Marquis (2003), “Communication is a complex exchange of
thoughts, ideas or information on at least two levels: verbal and nonverbal communication is
so complex, many models exist to explain how organization and individual communicate.
In all communication, there is at least one sender, one receiver and one message.”
It is very necessary for a Nurse Manager rather for all nurses that they should be good
in communication because a nurse is always in contact with many peoples at a time.
Insha Allah, if Allah provide me opportunity to work as a manager then I try to follow
good nurses and a good experiences, as I gained a good experience of communication from
that Ward Manager.

Anxiety Disorder 95
References
 Huston, C.J. and Marquis, B.L. (2003). Leadership Roles and Management Functions
in Nursing Theory and Application. 4th Edition. New York: Lippincott Williams and
Wilkins.
BScN Year-II Session 2006-2008
Anxiety Disorder
Mariam Fozia

Anxiety Disorder 96
Introduction
Anxiety is a universal phenomenon and every body feels some degree of anxiety
before and during stressful situation like examination, interview or stage performance. Grave
situation like sudden onset of serious illness, death of a loved one, loss of job, or a critical
accident also produces a certain level of anxiety. In all such situation this state of anxiety is a
natural response of the body. Within limits, it enables the individual to cope with the stressful
situation in a better way and hence is termed “normal anxiety”. It is a feeling of dread
apprehension that is often accompanied by different physical and psychological signs and
symptoms. Anxiety is a result of different physical, psychological, socio-cultural and
environmental problems. Contrary to normal anxiety, anxiety disorder is not help to the
individual instead it produces a severe state of inner tension and interferes with normal
activities of the individual.
Anxiety is defined as a “state in which an individual or group experiences feelings of
uneasiness, apprehension and activation of the autonomic nervous system in response to a
vague nonspecific threat. Anxiety is manifested by disturbances of mood, thinking and
behavior.” It is debilitating and should not be taken lightly.
Anxiety Disorders are possibly the most common and frequently occurring mental
disorders. They include a group of conditions that share extreme anxiety as the principle
disturbance of mood or emotional tone. Anxiety, which may be understood as the
pathological counterpart of normal fear is manifest by disturbances of mood as well as of
thinking behavior and physiological activity. Included in this category are panic disorders
with or without a history of agoraphobia. Agoraphobia with or without a history of panic
disorder generalized anxiety disorder specific phobia, social phobia obsessive compulsive
disorders, acute stress disorder and post traumatic stress disorder.
Physical and Psychological Symptoms

Anxiety Disorder 97
 Physical Symptoms
 Gastrointestinal
• Dry mouth.
• Difficulty in swallowing.
• Epigastric discomfort.
• Aerophagy.
• Diarrhea (usually frequency).
 Respiratory
• Feeling of chest constriction.
• Difficulty in inhaling.
• Over breathing.
 Cardiovascular
• Palpitations.
• Awareness of missed beats.
• Feeling of pain over heart.
 Genitorurinary
• Increased frequency.
• Failure of erection.
• Lack of libido.
 Nervous System Fatigue
• Blurred vision.
• Dizziness.
• Headache.
Anxiety Disorder 98
• Sleep disturbance.
 Psychological Symptoms
• Apprehension and fear.
• Irritability.
• Difficulty in concentrating.
• Distractibility.
• Restlessness.
• Sensitivity to noise.
• Depersonalization.
• Derealization.
Anxiety Disorder 99
Causative Factors
 No specific causative factor of anxiety disorders has been identified.
 A physiological or neurochemical predisposition is associated with the development
of anxiety disorders.
 A genetic factor.
 The anxiety disorder represents a conflict between two divergent drives or desires that
have been repressed into the unconscious mind.
 To potent developmental stressors.
 Environmental factors.
Treatment
 Counseling and Psychotherapy
Anxiety disorders are responsive to counseling and to a wide variety of
psychotherapies. During the past several decades, there has been a increasing
enthusiasm for focused time limited therapies that address ways of coping with
anxiety symptoms directly rather than exploring unconscious conflict or other
personal vulnerabilities.
 Pharmacotherapy
The medications typically used to treat clients with anxiety disorder
benzodiazepines, antidepressants and newer compounds such as buspirone.
 Combination Treatment
Some clients with anxiety disorders may benefit both from psychotherapy and
pharmacotherapy treatment either combined or used in sequence. It is likely that such
combinations are not uniformly necessary and are probably more cost effective when
reserved from patients with more complex complicated or severe disorders.

Anxiety Disorder 100
Panic disorders are extremely debilitating and common yet respond well to treatment,
if started early enough in the course of the disease. It is not a condition to be taken lightly in
view of its effect on the quality of the sufferer’s life.
Anxiety Disorder and Dissociative Disorders
Essentials of Diagnosis
 Overt anxiety or an overt manifestation of a defense mechanism (such as a phobia) or
both.
 Not limited to an adjustment disorder.
 Somatic symptoms referable to the autonomic nervous system or to a specific organ
system (e.g., dyspnea, palpitations, paresthesias).
 Not a result of physical disorders. Psychiatric conditions (e.g., schizophrenia) or drug
abuse (e.g., cocaine).
Conclusion
Stress, fear and anxiety all tend to be interactive. The principle components of anxiety
are psychologic (tension, fears, difficulty in concentration, apprehension) and somatic
tachycardia, hyperventilation, palpitations, tremor, and sweating. Other organ systems
(gastrointestinal) may be involved in multiple system complaints, fatigue and sleep
disturbances are common. Anxiety may be free floating resulting in acute anxiety attacks.
References
 Taylor, C.M. Essentials of Psychiatric Nursing.
Mariam Fozia

Nursing Care Plan
Introduction
A 40 years old lady was admitted to Psychiatric ward. Her attendant stated that she
was fine a month ago. She suddenly developed signs and symptoms of lack of concentration,
irritability, poor appetite, sleeplessness, hopelessness, fear, restlessness, increased motor
movements, false beliefs and increased level of anxiety.
Anxiety is the state in which an individual or group experiences feelings of
uneasiness, apprehension and activation of the autonomic nervous system in response to a
vague nonspecific threat.

NURSING CARE PLAN
Name: Shazia Age: 40 Years Sex: Female
Psychiatric Diagnosis: Anxiety
Nursing Diagnosis: Altered perception related Anxiety due to divorce.
Subjective Data: Short-term Goals: • Introduce yourself and try to • To establish a trustworthy Short-term Goals:
Significant others anxiety due to divorce related to divorce

The client’s attendant, she was The client will feel spend more time with the relationship. The client verbalized
fine a month ago, suddenly she relaxed with appro- client. that she feel relax and
develop sign and symptoms of priate social behavior comfortable and can
lack of concentration, irritability, and cope to reduce • Assist the client to identify • To cope with anxiety and to call the nurse by
poor appetite, sleeplessness, anxiety level and fear. anxious feelings. reduce its level. name. Expressed
hopelessness, fear, restlessness, reduce anxiety level
increased motor movements, Long-term Goals: • Encourage patient to • Verbalizing feelings will and fear. Immobility
false beliefs and increased level The client will make verbalize feelings of anxiety. reduce level of anxiety. dependence.
of anxiety. full attention. Discuss
current events, and
• Discuss relationship between • To differentiate changes
Objective Data: oriented with the date Long-term Goals:
increased anxiety and between anxiety and
A 40 years lady having history and time. The client The client made
behavior pattern. Note time behavior pattern.
of anxiety due to divorce is relates an increase in decision about reality,
and occasion.
lying on the bed uncomfortably. psychological and and feelings. Also
She is looking restlessness, pale, physiological comfort. cope with the anxiety
insomnia, loss of appetite and • Teach relaxation techniques. • Enables client to reduce level and pain.
poor confidence. anxiety and fear levels Accurately described
whenever occur. relationship between
Vital Sign anxiety and behavior
Blood Pressure: 120/70 mmHg • Encourage the client to use • Family support can help to pattern.
Temperature: 99°F support system. reduce anxiety and fear.
Pulse: 100 bpm
Respiratory Rate: 24 per min. • Observe for side effects of • To reduce side effects of
analgesic. medication and further
follow up.
• Assess vital signs. • To collect basic data for

further follow up.
Anxiety
Reflection
Introduction
On clinical visit of Psychiatric unit (Ward 20), with the permission of the Head Nurse,
I selected a client who was 40 years old lady. She was lying on the bed with complaint of
anxiety due divorce. She was well one month age but suddenly appeared signs and symptom
of dry mouth, excessive perspiration, increased restlessness, pounding of heart, change in
urinary pattern, lack of concentration, loneliness, false beliefs, hopelessness, fear,
sleeplessness and increased level of anxiety.
Analysis
I analyzed the client’s condition. She is looking restless, uncomfortable and pale.
When I addressed her, she not responds. So I took interview of her attendant. The client’s
attendant informed that, “after the incidence of divorce, she was fine a month age, she
suddenly shows signs and symptoms of fear, hopelessness, low concentration, sleeplessness,
etc. The condition of the client was disturbed, restless, sleeplessness and uncomfortable due
to her disease. She also showed loss of appetite, weakness, fear of the people.”
Conclusion
The clients suffering for such psychiatric disorder not only need special nursing
interventions, but also require full attention from the family members to spend more time to
with the client, as altered perception related to anxiety can cause biochemical or
psychological changes, which disturbed the coping pattern of the client, which can be
improved through nursing interventions.

Anxiety
Learning
I had learned many thing though this clinical practice such as how to take a history of
the client suffering from psychiatric disorder; how to diagnose and make nursing care plan,
etc. I examined the client that was admitted in psychiatric ward with the complaint of
increased level of anxiety due to divorce, fear and unable to cope with the situation. During
my observation, I provided her comfortable bed, tried to spend more time with the client,
encourage and motivate to express her feelings, which enables her to cope with the situation
and reduce anxiety.
In future, I will like to work with clients suffering with anxiety especially in elderly
age. By spending more time with them, I will try to develop a trustworthy relationship and
motivate them to cope with their present sufferings and encourage them to express their
feelings, which in results enable me to provided necessary nursing care and intervention, to
not only reduce mental disorder but also enable them to spend useful and independent lives.
Culture 106
References

Jamshoro Sindh
Culture
ACN III
Muhammad Farooq Saeed

BScN Year II
Mrs. Ruth K. Alam

Culture 107
Culture refers to dynamic and integrated structures of knowledge, beliefs, behaviors,
ideas, attitudes, habits, languages, symbols, rituals, and practices that are unique to particular
group of people. This structure provides the group of people a general design for living.
Ethnicity is a cultural group’s perception of itself, identity, or is a sense of
belongingness and a common social heritage that is passed from one generation to the next.
Race is the grouping of people based on biological similarities. Members of a racial
group have similar physical characteristics as blood group, facial features, and color of skin,
hair and eyes.
Culture diversity refers to the differences among people that result from racial, ethnic,
and cultural variables. Cultural beliefs, values, customs, and behaviors are transmitted from
one generation to another through interaction, daily activities, and celebrations. For instance,
the birth of a child is celebrated according to the family’s cultural norms, which may includes
prayers, blessings, special naming ceremonies, and religious rites. Grand parents, other
elders, and parents teach children cultural expectation and norm through role modeling,
demonstrations and discussion.
Cultural messages are transmitted in a variety of setting such as homes, schools,
religious organization, and communities. Media such as radio, TV, internet etc are powerful
transmitters and shapers of culture.
Culture is not static nor is it uniform among all members within a given cultural
group. Culture is transmitted through crises and the way a family deal with crises. The crises
may cause a family that is part of culture with a strong sense of responsibility to family and
blood relatives to become closer, or conversely, the same situation may cause a family that is
from a culture that values independence and individuality to withdraw and create distance
among its members, which are rooted in the family’s cultural background and heritage.
Culture 108
Components of Culture
According to Stewart there are five components of culture.
 Activity – identify how people organize and values work.
 Social Relations – explains the importance and structure of friendships, gender roles
and class.
 Motivation – describes the values and methods of achievements,
 Perception of work – refers to the interpretation of life events and religious beliefs.
 Perception of self and the individual – refers to personal identity, value and respect for
individuals.
This model is helpful to the nurse in planning the care of another ethnic group. Work,
social relationships, success, religion, and self identity influence cultural groups, attribute to
health and illness and the cultural group response to health events. If a culture values
relationships more than work, the culture may sanction on extended period of illness and a
lengthy time away from employment site. However, if a culture measures achievement by
output at work, illness may be intercepted in a negative manner. Members of the later culture
may deny illness and delay seeking appropriate health care.
Characteristics of Culture
Spradley and Allender identified five characteristics of culture. According to them
culture is:
 Learned pattern of behaviors are acquired as children imitate adults and develop
actions and attitudes acceptable by others in society.
 Not inherited or innate, but, it is integrated throughout all the interrelated components.
Activities, relationships, motivations, world views, and individuality are permeated
with consistent patterns of behaviors to form a cohesive whole.

Culture 109
 Shared by every one who belongs to the cultural group. Behavioral patterns are not
individually defined, but, rather, are accepted and practical by all.
 Tacit (unspoken), in that acceptable behavior is understood by everyone in the cultural
group, regardless of whether beliefs are written down or spoken. Cultural beliefs are
commonly known and adopted.
 Dynamic and it is constantly changing.
Cultural Influences on Health Care Beliefs and Practices
Each cultural group has a body of knowledge and beliefs health about diseases.
Cultural practices can positively and negatively affect health and disease distribution, as in
culture where raw foods are not consumed, the incidence of shigellosis may be lower than
culture where consumption of meat and fish is common. Cultural taboo against protein during
pregnancy has a harmful or destructive affect on fatal development.
 Mental problems considered as magic effects or saya.
 According to African American diseases is caused by disharmony in relationships,
evil spirits or it is sent by God as a punishment for a serious infraction against Him or
another person.
 Hispanic American believe that disease have natural cause as an act of God, as
punishment for sin, or as the result of witchcraft or a curse by an enemy, imbalance
between wet and dry or cold and hot forces.
 Asian American believes that disease is due to Yin and Yong. They also view as
disease caused by such power, as God, evil spirit or ancestral spirits.
 Native American believes that illnesses are due to use of witchcraft can.
Culture 110
Peter Morley’s four views about origin of diseases
 Supernatural traces diseases to metaphysical forces such as witchcraft, sorcery and
voodoo. In this view, an individual might ascribe illness to evil spirits or to a curse by
a powerful spiritual person.
 Non supernatural traces disease to accepted cause and effect relationship, even
though their relationship may lack scientific rationale. As people of many cultures
relate the colic pain of infant to the breast milk of nursing mother impure by sexual
relations because in this culture sexual relations are prohibited for nursing mother.
 Immediate: according to them diseases is due to known pathogenic or other agents as
depression caused by neurotransmitters imbalance.
 Ultimate describes determinates for disease, as smoking resulting in lung cancer.
Folk Medicine, Healers and Practices

Cultural group Traditional healers Healing practices.
European Nurse Exercise, Medications, modified diets,
American Physician amulets and religious healing rituals.
African Elderly woman healers, Herbs, poultices, religious healing

American Granny , voodoo healer through rituals, talismans worm
around the wrist or neck or carried in
Spiritualist, root doctor. a pouch to ward off disease
Hispanic Curandero, Espiritualist Hot and cold application, Herbal teas,

American Yerbero, Santiguadora. Prayers and religious medals,
Brujo, and Sobadora. massage, Azabache and three bath.
Asian American Herbalist Hot and cold, Herbs and soups,

Physician Cupping, pinching and rubbing,
Medication, Acupuncture, application
of tiger balm or energy balancing.
Native Shaman Plants and herbs, Blessed medicine,

American Medicine man /woman burned sweet grass, Estafiate (dried
leaves), the blessing ceremony ritual
and sand paintings.
Culture 111
Cultural and Racial Influences on Client Care
Client’s cultural backgrounds and preferences influence the manner whereby they
interact with other people and with the world around them. All human beings are not share
the same language. This culture differences can leads to misunderstanding and frustration, for
which an interpreter may be needed for translation. In case of restricted communication the
alternatives are gestures, flash cards translators, and family members. Orientation to space,
the distance that a person prefers to maintain from another is determined different by deferent
culture as the Arabic, Southern European and African origin frequently sit or stand relatively
close to each other (0 to 18 inches), where as people from Asian, Northern European and
north American origin are more comfortable with a larger personal space more tan 18 inches.
Touch is perceived negatively or positively by different culture. Orientation to time, some
people are very conscious about time and appointment thus the nurse must also be very
attentive to the time schedule. Social organization refers to the ways whereby cultural groups
determine rules of acceptable behavior and roles of individual members. It includes family
structure, gender roles and religion.
Family structure as nuclear and extended family, functional and dysfunctional family,
the chief values of the family as responsibility, satisfaction and flexibility affect the
psychiatric patient differently in different culture. Gender roles vary according to culture
context as husband, father or head of the family is the chief authority. Spiritual and religious
beliefs have important in life, and has a great significance at the time of illness.
Biological variation distinguishes one culture or racial group from other include hair
texture, skin color, thickness of lips, eye shape and body structure. Enzymatic differences and
susceptibility to diseases varies from culture to culture.

Culture 112
Assessment
Having examined culture and influences it may have had in developing personal
beliefs about sickness and health, the next step to providing culturally appropriate care is to
assess the client’s cultural background. Spradley and Allender identify six categories of
information necessary for a comprehensive cultural assessment of the client.
 Ethnic or racial background. Where did the client group originate, and how does that
influence the status and identity of group members?
 Language and communication patterns. What is the preferred language spoken, and
what are the currently based communication patterns?
 Cultural values and norms. What are the values, beliefs, and standards regarding
things as roles of education, family functions, child rearing, work and leisure, aging,
death and dying, and rites of passage?
 Biological factors. Are there physical or genetic traits unique to the ethnic or racial
groups that predispose group members to certain condition or illnesses?
 Religious beliefs and practices. What are the group’s religious beliefs, and how do
they influence life events, roles, health and illness?
 Health beliefs and practices. What are the group’s beliefs and practices regarding
prevention, causes, and treatment of illnesses?

Culture 113
Cultural Assessment Interview Guide
Name:_______________________ Father / Husband name:______________________

Primary language: When speaking:_____________ When writing:_________________
Date of birth:_____________ Education level:_________________ Sex:____________
To which ethnic group do you have belong? __________________________________
To what extent do you identify with your cultural group?________________________
Who is the spokesperson for your family? ____________________________________
Describe some of the customs or beliefs that you have about the following:
Health:__________________________________________________________
Life:____________________________________________________________
Illness:__________________________________________________________
Death:___________________________________________________________
How do you best learn information?
Reading: __ Having some explain verbally: __ Having someone demonstrate: __
Describe some of your family’s dietary habits and your personal food preferences:____
______________________________________________________________________
Are there any foods forbidden from your diet for religious or cultural reasons:________
______________________________________________________________________
Describe your religious affiliation:__________________________________________
What role do your religious beliefs and practices play in your life during times of good health
and bad health: _________________________________________________________
On whom do you rely on for health care services or healing:______________________
What type of cultural health practices have you been exposed:____________________
Are there any sanctions or restrictions in your culture about which the person taking care to
you should know:_______________________________________________________
Describe your current living arrangement:____________________________________
Describe your strength:___________________________________________________
Who/what is your primary source of information about health?____________________
Is there any important thing else about your cultural beliefs that you want to tell me:
_______________________________________________________________________
Culture 114
Nursing Diagnosis
 Coping individual ineffective.
 Coping, family, ineffective, compromised
 Social interaction. Impaired
 Anxiety
 Body image disturbance.
 Breast feeding ineffective
 Communication, verbal impaired.
 Decisional conflict
 Fear
 Grieving, anticipatory
 Health maintenance altered
 Health seeking behaviors
 Noncompliance
 Nutrition, altered. More than body requirements.
 Pain
 Role performance, altered
 Sleep pattern disturbed
 Spiritual distress.
Depression 115
Scenario
Kulsoom is a 22 years old married young adult female admitted to psychiatric ward
through emergency with the complains of headache, feeling of guilt, hopelessness and
worthlessness, decreased sleep, restlessness, tension and anxiety. According to her husband,
she was alright two months before, but after she married through court against the wishes of
her parents in other ethnic group her parents and community opposed us and tried to arrest
both of us through police. They were caused severe agony, tension and discouragement.
Kulsoom took it very severely and tried once to kill herself by taking excessive oral pills, but
on emergency care she was recovered and was admitted to psychiatric ward for further
management. Her family and she were unable to cope with situation.
Patient Assessment
 Presenting Problem
• Severe depression.
 Physical Dimension
• Family history
- Mother and father alive, both alive, mother is house wife and father works in
foreign country and both of them are healthy. No family mental illness history.
- Father is cigarette smoker, and no drug user.
• Individual Health
- Loss of appetite and history of constipation from one week with frequent
urination.
- Limited social activities, disturbed sleeping pattern, restlessness, and no use of
any drug.
- Doesn’t meet her relatives and friends and not take part in any activity.
Depression 116
• Sexuality
- Young adult female, married, regular menstrual cycle, ineffective coping,
decreased desire for intercourse, no sexual abnormality.
- Anxious about current problem
 Emotional Dimension
• She was very anxious about ignorance and negative behavior of other against
them, worried about current problem and with depressed mood.
 Intellectual Dimension
• She is with depressed mood, feeling of hopelessness and helplessness regarding
other. Delusion, auditory hallucination present and decreased decision making and
problem solving ability. Low self-esteem.
 Social Dimension
• Low self concept and self esteem.
• Ignored by parents and relatives, house wife, mistrust.
• Dependent on family (husband) support.
 Spiritual Dimension
• Muslim, prays irregularly.
• Satisfied with his religious beliefs, activities and motivation, .
• Believes on faith, folk remedies, herbal medicines, religious healing, and rituals.
Mental Status Examination
 Appearance
• A 22 years old adult of moderate build and normal height, with rough, uncleaned
and inappropriate dressing and face. Looks pale, anxious, sad, inappropriate eye
contact, depressed facial grimaces present, and malnourished.

Depression 117
 Behavior
• Co-operative to health worker, delayed response with slow motor behavior, gait
slow, restlessness, tremors present.
 Communication
• Slow communications with low volume, interrupted and slurred and speech.
 Cognitive
• Oriented to time, place and person.
• Poor in judgment and in decision making.
 Thought Process
• Suicidal ideas, idea of helplessness, thought blocking, delusion.
 Mood and Affect
• Verbalized displayed depressed, anxious and confused mood about current
problem, and congruent mood expressions.
 Sensory Perception
• Auditory hallucination and delusion present.
 Insight
• Partial
 Treatment
• Tab: Diamecron 1 x OD
• Tab: Depex 40 mg BD
• Tab: Xanax 1 mg HS
 The goals will be achieved after several teaching sessions with patient.
Depression 118
Nursing Diagnosis
 Ineffective individual coping related to social stigma.
Planning
 Short-term Goals
• The client will verbalize increased adaptation to change in health status within a
week.
• The client will demonstrate measures necessary to increase independence within
one week
• The client will identify the stressor and learn the strategy to cope with them within
five days.
• Client will identify alternative ways of dealing with emotional problem and
participate in the treatment program within five days.
 Long-term Goals:
• The client and family will maintain open communication.
• The client will demonstrate the behavior and thinking according to develop
effective coping mechanism and use it effectively till discharge
• The client will demonstrate plan for using alternate ways of dealing with stress
and emotional problems when they occur after discharge.
• The client will maintain satisfying relationship in the community and on job.
• The community leader will verbally express more positive thoughts regarding
adaptation of other culture.

Depression 119
Nursing Interventions Rationales

• Introduction to the patient. • Establish a therapeutic relationship
with client and relatives
• Assess and determine the client • For baseline data for future planning
strength and weaknesses to develop to help the client in successful coping
the method and level of adaptation. ability enhancement.
• Assess causative and contributing • To provide baseline data for planning,
factors as disapproval, inadequate management and developing and
support system and culture. enhancing coping ability of the client.
• Check vital signs. • To see the effectiveness of medication
and severity of disease.
• Establish rapport by spending time, • Coping effectively requires successful
provision of support system, management of task.
conveying of honesty and empathy.
• Encourage the client to ventilate her • Ventilating feeling can help the client
feelings. Convey your acceptance of to identify, and work through the
the client’s feeling. feeling and to remain nonjudgmental.
• Sit with the client many times to • Communication of the concerns and
discuss the current concern, feelings, supportive environment can facilitate
know her perception about stressor development of the coping behavior.
and help to realize and face reality.
• Involve the client as much as • Assess the client and promote the
possible in her treatment. Provide sense of the control and responsibility
with achievable task, goal and
activities, and opportunity to make
decision.
• Convey your interest in the client • Your presence demonstrate interest
and approach her for interaction at and caring and convey the client your
least once per shift or allow visit to continued caring.
significant others.
• Provide the opportunity for the • Client need to develop skills and
client to express emotion and fears replace the behavior, create the
to release tension and help the client supportive environment and develop
identify the situation which would coping ability in the client to pace this
promote more comfortable feeling. critical situation.
• Teach relaxation techniques such as • Reduce the stress and provide
exercise, deep breathing, imaginary alternative coping strategies.
to decrease physical tension.
• Assist the client to develop • To overcome on the maladaptive
appropriate effective coping condition.
strategies
• Identify previous coping • Determine the successful strategies,
mechanisms, and assist patient to helps to have satisfaction in activities.
fined new one.
Depression120

• Help the client find alternatives or • Helps client continue to have
modification in previous lifestyle satisfaction in activities and provides
behavior by using assistive devices, a sense of control in lifestyle.
participation in activities and
learning new behavior.
• Encourage independence in self care • Provides a sense of control and
activities by focusing on patient’s increase self-esteem and adjustment.
strengths rewarding small success.
• Assess the client with achievable • To assist the client, promote positive
task, goal, and opportunities to make self-esteem and sense of control.
decision.
• Teach the client social skills and • Client may lack skills and confidence
encourage for practice with staff in social interaction, and enhances
members and other clients. Give the coping ability.
client feedback regarding the social
interaction.
• Provides the client familiar needed • Promotes the client’s sense of control
objects for activities. in meeting safety and security need.
• Encourage the client to identify and • Increase the client support system
develop relationship with supportive may help decrease future suicidal
people outside the hospital behavior.
environment.
• Assist the client to identify and use • Procedure to reach the short-term and
available support system before the long-term goal.
discharge from hospital and help to
use the plan of care and in the
community
• Provide social reinforcement and • Reinforcement encourages positive
other behavioral rewards for behavior and enhances self-esteem
demonstration of adaptation and coping mechanism.
• Assist the client in identifying and • Support system can facilitate the
developing support system and plan client’s coping ability and strategies.
for their use.
• Be alert to the client’s behaviors, as • These behaviors may indicate the
less talkative, comments about client decision to commit suicide.
death, frustration, low tolerance,
dependence, and disinterest in
surrounding and concealing feelings.
• Do not joke about death, belittle the • Client ability to understand and use
client’s wishes, feelings, or make obstruction
insensitive remarks such as every
body want to live to change
behavior.
Depression121

• Allow the client to develop solution • To develop new behavior to solve her
that the best fit her concern. The problem and improve the self-esteem.
nurse role is to provide assistance
and feedback encourages creative
approaches to problem solving.
• Encourage the client to pursue • Recreational activities can help
personal interest, hobbies and increase the client social interaction
recreational activities. and may provide social action.
• Provide client with an environment • Appropriate level of sensory input
that will optimize sensory input. decreases disorganization, confusion
This includes hearing aids, and maximizing the client coping
eyeglasses, pencil and paper, ability.
decreased noise and appropriate
lighting.
• Schedule a meeting with the • Promotes the development of a
identified support system to assist trusting relationship and provides the
them in understanding alternatives in support system with the information
the client’s health. that they utilize, be more effective.
• Provide client with group interaction • Assess the client to express personal
4-6 member for 15-30minutss. importance to other while enhancing
interpersonal relationship skills.
• Develop trusting and respectful • This will help in coping, problem
relationship among client, family solving and decrease the conflict
and community. among the community members.
• Teach coping strategies for • Coping strategies to maintain healthy
managing tension and strain in the emotional and psychological health
event of previous techniques losing may be necessary. This is especially
their effectiveness. true for individual from a culture that
discourages placing individual needs
or emotion ahead of those of the
family.
• Discuss examples with the family • Increases awareness of problems in
and community of ineffective coping the community and stimulates
in order to begin problem solving. interest.
• Educate the community about • Increases awareness in the targeted
cultural diversity, adaptation and community and enhances adaptation
coping mechanism through TV, of the other culture and importance of
radio, news papers, seminars, and effective coping mechanisms.
internet.
• Document the procedure in the • For continuation of the patient care in
patient file. the next shift.
Depression122
Evaluation
 The client has verbalized an increased adaptation to change in health status.
 The client has demonstrated measures necessary to increase independence.
 The client has identified the stressor and learnt the strategy to cope with them.
 The client has identified alternative ways of dealing with emotional problem and
participated in the treatment program.
 The client has demonstrated the behavior and thinking according to develop effective
coping mechanism and use it effectively till discharge.
 The client and family have maintained open communication.
 The client has demonstrated plan for using alternate ways of dealing with stress and
emotional problems when they occur after discharge.
 The client maintained satisfying relationship in the community and on job.
 The client was taking her treatment effectively and taking care of her mother and was
using coping measures and planned strategy effectively.
 The client and family verbally indicated a more positive adaptation and agreed to
accept their marriage.
 The community leader verbally expressed more positive thoughts regarding
adaptation of other culture.

Depression123
References
 Benner, C.V. Mental Health Nursing. 2nd Edition. USA.
 Cox, H. (1997). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s,
Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. Davis,
F.A. Company Philadelphia.
USA.
 http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med
Bulletin; 57:101-113.
 White Lois (2001). Foundation of Nursing. 6th Edition. USA.

Depression124

Jamshoro Sindh
Depression

(Assignment # 1)

BScN Year II
Mrs. Munira A. Ali

Depression125
Depression is a mood disorder in which a persistent feeling of sadness often

accompanied by feeling of hopelessness, inadequacy and unworthiness. In depression, the
client self seems worthless, world meaningless, hopeless and misery with high risk of suicide.
The activities, voice and behavior become lower and client worry about the past failure and
thinks that his/her future may be dark. According to WHO, it occurs in 20 – 30% of all
clients.
Etiology
 Socioeconomic Causes
 Separation of parents, failure in love or divorce..
 Injustice.
 Unemployment.
 Poverty
 Death of a believed person.
 Stress.
 Family conflicts.
 Failure in exams.
 Organic Causes
 Genetic factors.
 Neurochemical factors:
- According to Biogenic Amine Theory, there is disturbance in the non-
epinephrine, serotonin and dopamine. These will be decreased.
- According to Permissive Theory, serotonin and non-epinephrine are decreased
in depression.
 Infections attack like influenza, epilepsy, dementia, etc.
 Endocrine disorder.
 Separation of loss of any part of the body, as eye, hand, etc.
 Psychological factor (according to Frued):
- Anal fixation and oral fixation
 Cognitive theory – lack of positive reinforcement.
 Drugs – antischezophrenic drugs.
 Oral contraceptive
 Antihypertensive.
Depression126
Clinical Features
 Appearance
 Improper dress and hair style.
 Improper eye contact.
 Skin rashes.
 Malaise, lethargic, fatigue.
 Self blaming with slow speech.
 Restlessness and dissatisfaction.
 Slow working with decreased motor activity.
 Decreased thinking process.
 Sadness, hopelessness and worthlessness.
 Behavior
 Anxious.
 Negative thinking.
 Dull emotions.
 Rigid
 Delirium.
 Over consciousness.
 Profound retardation of though.
 Nausea, vomiting.
 Difficulty in planning,
 Fearfulness.
 Loss of appetite.
 Self-accusation and even of death.
 Illusionary falsification are common (Colarel syndrome)
 Hallucination is occurring in one-third of the cases.
 Every task seems to burden.
Diagnostic Criteria for Major Depression
Five or more symptoms from the following have been present during the same two
week period and represent a change from previous functioning as in depressed mood and lost
of interest or pleasure.
Depression127
 Depressed mood most of the day, nearly everyday.

 Markedly diminished interest or pleasure in all or almost all activities most of the day
nearly everyday.
 Significant weight loss when not dieting or weight gain (change of more than 5% of
the body weight) or decrease/increase in appetite nearly everyday.
 Insomnia or hypersomnia nearly everyday.
 Psychomotor agitation or retardation nearly everyday.
 Fatigue or loss of energy everyday.
 Feeling so worthlessness or excessive or inappropriate guilt, nearly everyday.
 Diminished ability to think or concentrate indecisiveness nearly everyday.
 Recurrent thoughts of death, recurrent suicidal ideation without a specific plan,
suicidal attempts.
Nursing Diagnosis
 High risk for self-directed violence.
 Self-esteem disturbance.
 Powerlessness.
 Spiritual distress.
 Altered though processes.
 Altered nutrition, less than body requirements.
 Sleep pattern disturbance.
 Self-care deficit.
Interventions
 Psychotherapy.
 Cognitive-behavioral therapy – helps to change the negative thinking and
unsatisfying behavior associated with depression.
 Interpersonal therapy – focuses on improving troubled personal relationships and
adapting to new life roles that may have been associated with person’s depression.
 Medication
 Tricyclic antidepressants – elevate mood in depressed individuals, reestablish their
normal sleep, appetite and energy level.
Depression128
 Selective serotonin reuptake inhibitors – they act specifically on the

neurotransmitter serotonin.
 Serotonin and Norepinephrine reuptake inhibitors – useful as first-line treatments
in people taking an antidepressant for the first time and for people who have not
responded to other medications.
 Monoamine oxidase inhibitors – often effective in individuals who do not respond
to other medications or who have “atypical” depressions with marked anxiety,
excessive sleeping, irritability, hypochondria, or phobic characteristics.
 Electroconvulsive therapy (ECT).
 Electroconvulsive therapy is a treatment for sever mental illness in which a brief
application of electric stimulus is used to produce a generalized seizure. It is a
highly effective treatment for severe depressive episodes.
Remarks
In depression, the client seems self worthless, world meaningless, hopeless and
misery with high risk of suicide. The activities, voice and behavior become lower and client
worry about the past failure and thinks that his/her future may be dark. According to WHO, it
occurs in 20 – 30% of all clients. Most of the patients recover and some of them advanced
into bipolar disease. It requires long term management and follow up for good prognoses.
The effectiveness of psychotherapy depends on the psychopathology of the family members.
Therefore the family therapy may be provided in case of out patient. The client will not leave
alone and after discharge the relative may be educated for care of the patient.
Depression129

Jamshoro Sindh
Depression
ACN III Major NCP

(Assignment # 2)

BScN Year II
Mrs. Munira A. Ali

Depression130
Scenario
Miss. Saima, a 20 years old girl admitted in Psychiatric unit with history of insomnia,
anorexia and weight loss. She was social and enjoys parties and having a number of friends.
Her past history revealed that she was all right before three months ago, when an incident
changes her life i.e., her engagement was broken. Furthermore, she failed in her final
examination. After this incident, she become isolated and loss interest in life. She is single
child of her parents. Her mother is working in an office and father is a businessman. Both are
very busy, therefore, she becomes an isolated child.
Assessment
 Presenting problem – severe depression.
• Family history
- Mother and father alive, both alive, mother is house wife and father works in
foreign country and both of them are healthy. No family mental illness history.
- Father is cigarette smoker, and no drug user.
• Individual Health
- Loss of appetite and history of constipation from one week and frequent urination.
- Limited social activities, disturbed sleeping pattern, and restlessness.
- No use of any drug.
- Doesn’t meet her relatives and friends and not take part in any activity.
• Sexuality
- Young adult female, single, regular menstrual cycle. No sexual abnormality,
anxious about current problem and ineffective social interaction.
• She is very anxious about failure, and broken engagement, worrying about future
and with depressed mood. Look fearful, helpless, and feeling of insecurity and.
• She is with depressed mood, feeling of hopelessness and helplessness regarding
other. Delusion, auditory, hallucination present and decreased decision making
and problem solving ability. Low self-esteem.
• Low self concept and self esteem.
Depression131
• Ignored by relatives, student, mistrust

• Dependent on family support with inability to develop relationship with relatives.
• She takes less part in occasions.
• She cannot cope with job current environment, so she isolated.
• Muslim, prays irregularly and satisfied with his religious beliefs, activities and
motivation.
• Believes on faith, folk remedies, herbal medicines, religious healing, and rituals.
 Appearance
• A 20 years old adult of moderate build and normal height, with rough, unclean and
inappropriate dressing and face. Looks pale, anxious, sad, inappropriate eye
contact, depressed facial grimaces present, and malnourished.
 Behavior
• Co-operative to health worker, delayed response with slow motor behavior, gait
slow, restlessness, tremors present.
 Communication
• Slow communications with low volume, interrupted and slurred speech.
 Cognitive
• Oriented to time, place and person.
• Poor in judgment and in decision making.
 Thought Process
• Suicidal ideas, idea of helplessness, thought blocking, delusion.
 Mood and Affect
• Verbalized and displayed depressed, anxious and confused mood about current
problem, and congruent mood expressions.
 Sensory Perception:-
• Auditory hallucination and delusion present.
 Insight
• Partial
Treatment
Depression132
 Tab: Diamecron 1 x OD
 Tab: Depex 40 mg BD
 Tab: Xanax 1 mg HS
Depression133
NURSING CARE PLAN
Title: Impaired social interaction related to loss of intimate relationship

Diagnosis Outcome
Subjective Data Short term goals Introduction to the client. To establish a therapeutic Short term Goal

According to the client’s parent, “she is The client will relationship. The Client verbalized
feeling difficulty in falling asleep, demonstrate Assess the level of severity It provides a baseline data for the satisfaction with
anorexia and loss weight ,does not increased and condition of the patient. management of situation. quantity and quality of
taking part in any activity and mostly involvement in Encourage patient to express Assist client to examine social social interaction.
lives alone, calm and quite, and social interaction how she feels by scheduling at experience and verbalize feelings Client communicated
complains headache, chest, back pain with in one week. least 10 minutes, twice a day and encourage therapeutic and participated with
and indigestion after engagement focus on client problem / topic. relationship. others and community
broken and failed in BA examination,”. The client will Continually assess the client’s Depressed clients have potential She reestablished or
participate in daily potential for suicide. for suicide that may be change by maintained relation-
Objective Data activities. pre effective interventions. ships and a social life
An adult girl of moderate build and Evaluate patient communi- Improve communication skills and and also established
with rough, uncleaned and Long term goals cation skills and help her to interactive process. support system.
inappropriate dressing and face. The client will be find alternative during
Looks pale, sad, with inappropriate able to initiate interaction with patient. Long term
interaction with Help the client to obtain a Help patient in achieving goal, and Client participated in
eye contact, facial grimaces present,
others to maintain realistic perception of self by improves self-concept. normal daily activities
and malnourished. relationship and focusing on and enhancing and normal routine life.
Delayed response with slow motor social life. strength during conferences
behavior, gait slow, restlessness, with patient. The client verbalized
confused and tremors present Allow client to choose social Promote self-confidence and social satisfaction with quality
communications with low volume, interactions for role play for interaction by allowing practice in of interactions.
and slurred speech, 10 minutes twice a day time. a safe environment.
Oriented and Poor in judgment and Involve patient in daily care to Improve self-concept, and increase The client identified
in decision making. help the patient in planning motivation. Decrease feelings of and demonstrated a
Suicidal ideas, feeling of and decision making about powerlessness. number of measures
helplessness, and hopelessness own care. that increase social
Vital Signs Initiate referrals to support Client’s contact with community interaction.
Blood Pressure 100/70 mmHg groups prior to discharge. group to interact to decrease social
Temperature 97 °F isolation.
Pulse 88 bpm
Depression134

Diagnosis Outcome
Assign one staff permanent for the Limiting the number of new contacts
care of the client. will facilitate familiarity and trust among
client and staffs.
Use silence and active listening Your presence and use of active listening
when interacting with the client. will communicate your interest and
concern.
Use simple, direct sentences and It will encourage the client to express her
ask open ended questions. feelings.
Encourage the client to express her Expressing of feelings may help to

feelings in comfortable way. relieve despair, and hopelessness.
Interact with the client on the topic It establishes trust and encourages
of her choice and don’t probe for communication on difficult topics.
information.
Educate the client about problem- Successful use of problem solving

solving, selection and process facilitates the client’s confidence
implementation of alternatives and in the use of coping skills.
evaluation of results.
Teach and encourage the client to It will increase the confidence and social
practice social skills, and give interaction of the client and prevents
feedback to the client regarding social isolation and depression.
interactions.
Encourage the client to pursue Recreational activities can help the

personal interests, hobbies, and client’s social interaction and provide
recreational activities enjoyment.
Depression135

Diagnosis Outcome
Help the client to participate in Increase social skills by providing social
group interactions. contact.
Include client in group activities Reinforcement encourages positive

and assign activities that will be behavior and enhances self-esteem.
easily accomplished and provide
positive reinforcement.
Discuss with support system ways Support system understanding facilitates

in which they can facilitate client the maintenance of new behavior after
interaction. discharge.
Involve client and family in Family involvement enhances the

planning, implementing and effective ness of the interventions.
promoting in reduction or
elimination of impaired social
interaction.
Encourage the client to participate Increases social contacts and interact

in diversional activities, especially -ional skills.
those involving groups, daily.
Encourage the client to use It will increase self-esteem and self-

assistive or corrective devices. confidence.
Limit the amount of time client Provide opportunities for client to

can spend alone in the room. practice new role behavior in a safe and
supportive environment.
Document all the procedure in the For continuation of nursing care in the
client’s file. next shift.
Therapeutic Communication136
References
 Benner, C.V. Mental Health Nursing. 2nd Edition. USA.
 Cox, H. (1997). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s,
Psychiatric, Gerontic, and Home Health Considerations. 3rd Edition. Davis,
F.A. Company Philadelphia.
USA.
 http://www.google.com. Scott J (2001). Cognitive therapy for depression. B Med
Bulletin; 57:101-113.
 White Lois (2001). Foundation of Nursing. 6th Edition. USA.

Jamshoro Sindh

HIV AIDS
ACN III
Mukhtari Sardar
BScN Year II
Mrs. Ruth K. Alam

HIV AIDS is the second leading cause of death. About half of all new HIV infections
are among young people under age 25, with most being infected though sexual transmission.
In women, ages 13 to 24, about 49% are infected heterosexually and 13% are infected via
injecting drug use. As AIDS increases among people in the childbearing years, the number of
children with HIV is expected to increase. HIV belongs to a group of viruses known as
retroviruses, which indicates that the virus carries its genetic material in ribonucleic acid
(RNA) rather than deoxyribonucleic acid (DNA). Manifestations of HIV infection range from
mild abnormalities in the immune response without overt signs and symptoms to profound
immunosuppression associated with various life-threatening infections and malignancies.
Definition
Acquired immunodeficiency syndrome (AIDS) is defined as the most severe form of a
continuum of illnesses associated with human immunodeficiency virus (HIV) infection.
General Transmission
HIV is transmitted by way of body fluids that contain HIV-1 or CD4 + T
lymphocytes. These fluids include serum, seminal fluid, vaginal secretions, amniotic fluid,
and breast milk (i.e., HIV may be transmitted in utero from mother to child and later through
breast milk). Some recent strains of HIV-1 have heightened virulence and infectious ability.
Transmission to Health Care Providers
The incidence of HIV for health care workers who are exposed to HIV through
needle-stick injury is estimated to be about 0.3%. Large scale studies of exposed health care
workers continue to be conducted by the Central Disease Control (CDC) and other groups.
Prevention of Transmission
Epidemiologic evidence indicates that HIV is transmitted only through intimate
sexual contact, parenteral exposure to infected blood or blood products, and perinatal
transmission from mother to neonate.

Standard Precautions
 Hand washing
 Gloves
 Mask, Eye protection, face shield
 Gown
 Patient care equipment
 Environmental control
 Linen
 Occupational health and blood-borne pathogens
 Patient placement.
The three types of Transmission-Based Precautions are referred to as Airborne
Precautions, Droplet Precautions, and Contact Precautions. They can be used singularity or in
combination, but they are always to be used in addition to Standard Precautions.
Clinical Manifestations
The clinical manifestations of AIDS are widespread and may affect virtually any
organ system. The following limited to the most common clinical manifestations and effects
of severe HIV infection.
 Respiratory Manifestations
 Pneumocystis carinii Pneumonia.
 Mycobacterium avium Complex.
 Tuberculosis.
 Gastrointestinal Manifestations
 Oral Candidiasis.
 Wasting Syndrome
 Oncologic Manifestations
 Kaposi’s Sarcoma.
 B-Cell Lymphomas.
 Neurologic Manifestations
 HIV Encephalopathy.
 Cryptococcus neoformans
 Progressive Multifocal Leukoencephalopathy
 Depressive Manifestations
 Integumentary Manifestations
 Endocrine Manifestations.
 Manifestations Specific to Women
 Patient’s Name: Zaibunisa
 Age: 21 Years
 Sex Female
 Address: Quarter # 10, Street # 5, Hijrat Colony, Karachi.
Presenting Problems
- No any physical influences by emotional.
- She has 3 sisters and 2 brothers.
- Her parents are alive.
- No any drug habits and mental illness.

• Individual Health History
- No mental illness present.
- No any history of hypertension or diabetic.
- She spend whole day with talking and walking here and there.
- Elimination pattern is normal.
- Sleep pattern is decrease.
- No use of tobacco, drugs or alcohol.
• Sexual Pattern
- Sexual pattern is disturbed.
• Less mental potential skill and self-esteem.
• Altered thought process.
• Poor interpersonal relationship, mistrust on others.
• Suspicious concept.
• Aggressive behavior.
• Anxiety.
• Fear
• Hopelessness and worthlessness.
• Decrease religious practices due to mental illness.
• Believes on folk remedies and alternative healings by Hakeem.

Mental Status Examination (MSE)
 Appearance
• Poor grooming.
• Impaired hygienic condition.
• Facial expression suspicious and sad.
• Eye contact is not appropriate.
• General health not satisfactory.
• Malnourished.
 Behavior
• Decrease concentration.
• Poor social interpersonal relationship.
• Rapid talking and walking.
• Frustration and irritability.
 Psychomotor Behavior
• Is not good.
• Activities mild retarded.
• Motor behavior is brisk and slow in activity.
 Communication
• Speech rate and volume slow.
• Amount
- Talkative and self-talking.
- Logic – interrupted.
- Clarity – clear.
 Thought process
• Feel delusion so that altered though process and loosing of association.
 Mood and Affect
• Patient looks sad and congruency.
• Loose memory
• Remote
 Sensory perceptions
• She has little knowledge of self perception.
• Illusion is present.
• Thinking impaired.
 Ensight
• Absent.
• Judgments not contact.
Nursing Diagnosis
 Impaired skill integrity.
 Diarrhea.
 Abdominal cramps.
 Risk for infection.
 Altered nutrition – less than body requirements.
 Altered thought processes.
 Anticipatory grieving.
Other Related Nursing Diagnosis
 Anxiety.
 Ineffective coping.
 Ineffective role performance.

Short-term Goals
The client will:
• Identify decreasing episodes of diarrhea and abdominal cramping.
• Verbalize adequate maintenance of fluid status.
• Demonstrate decreased anxiety, fear, guilt and so forth.
• Participate in treatment program.
Long-term Goals
The client will:
• Free from diarrhea till discharge.
• Exhibits return to normal bowel pattern.
• Identify strengths and weaknesses realistically.
• Demonstrate an increased ability to cope with weaknesses.
• Verbalize knowledge of illness, treatment plan, or safe use of medications, if any.
• Assess patient’s normal bowel habits. • Provides baseline for evaluating

effectiveness of measures.
• Monitor vital signs • Provides baseline for evaluating

effectiveness of measures planned.
• Assess for signs and symptoms of

diarrhea: frequent, loose stools,
abdominal pain or cramping.
- Measure amount of liquid stools. • Quantifies loss of fluids.
- Identify exacerbating and alleviating • Provides basis for nursing measures.
factors
• Obtain stool cultures as prescribed by • Identifies pathogenic organism

physician, Administer antimicrobial
therapy as prescribed.
• Initiate measures to reduce hyperactivity • Bowel rest may decrease acute

of bowel. episodes.
- Maintain food and fluid restrictions - Reduces stimulation of bowel.
as prescribed by physician.
- Discourage smoking - Nicotine acts as bowel stimulant.
- Avoid bowel irritants such as foods - Prevents stimulation of bowel

high in fat, fried foods, raw and abdominal distention.
vegetables and fruits, nuts, onions,
popcorn, carbonated beverages,
spicy foods, and foods of extreme
temperatures.
- Offer small, frequent meals.
• Administer anticholinergic antispas- • Decreases intestinal spasms and

modics as prescribed. motility.
• Administer opiates or opiate-like • Decreases intestinal spasms and

medications as prescribed by physician. motility.
• Maintain fluid intake of at least 2500 ml • Prevents hypovolemia.

unless contraindicated.
• Explain the interventions required to • Most acute episode of diarrhea are

prevent future episodes managed with the symptomatic
therapy with fluid and electrolyte
replacement.
• Explain the effects of diarrhea on • To prevent diarrhea in future.

hydration.
Evaluation
 The client has verbalized normal bowel habits.
 The client reported decreasing episodes of diarrhea and abdominal cramping.
 The client maintained adequate fluid intake.
 The client maintained body weight and reported no additional weight loss.
 The client identified and avoided foods that irritate the gastrointestinal tract.
References
 Agency for Health Care Policy and Research (1994). Evaluation and management of
early HIV infection. Clin Pract Guideline No 7. USA.
 Management of Patients with HIV Infection and AIDS. pp. 1340-1379.
 Carpenito, L.J. (1997). Nursing Diagnosis. Application to Clinical Practice.
2nd Edition.
 Johnson. (1989). Mental Health Nursing. 2nd Edition. Lippincott Philadelphia.

Jamshoro Sindh

(Assignment # 1)
Mukhtari Sardar
BScN Year II
Mrs. Munira A. Ali

Therapeutic communication represents the points of interpersonal connection, through
which clients are able to tell the story of their journey and the nurse is able to provide
encouragement, support and resourceful information. As patients speak of their immediate
experiences and the life events that led up to their current circumstances, they give voice to
their fears, feelings, beliefs, hopes, desires and private realities.
Definition
Therapeutic communication is defined as a form of communication with a health
related purpose that develops as a continuous interaction between nurse and patient.
Purposes
The primary purpose of therapeutic communication is to help client come to know
themselves in ways that allow them to recognize possibilities in their lives and to alter
ineffective life pattern. The nurse’s role in the communication process is to help patients
transform vague, tangential, or distorted statements into clear, concrete, workable statements
that have common meaning to both. The nurse uses these mutually developed statements as
the basis for therapeutic intervention. The nurse enlists the patients as collaborators in the
process of self-discovery and uses words, actions and knowledge to help patients develop a
more positive view of themselves and more adaptive ways of interacting in the world.
Responsibilities of the Nurse
 Communication occurs within designated time frames and terminates when
therapeutic goals are achieved.
 Responsibility for the structure and conduct of the conversation is ultimately the
nurse’s.
 Communication is purposeful and directed towards mutually established goals.
 The focus of the conversation is always on the needs and concerns of the patient.
 The purpose is for the patient to achieve greater self-understanding from the
relationship.
 Self-disclosure of the nurse’s private life is limited and acceptable only under certain
circumstances.
 Conversation does not always reflect adherence to the rules of social etiquette.
 Formally terminates with the end of the session or relationship.
Preparing the Details for a Therapeutic Interaction
The physical setting, timing, and therapeutic approach all can influence the sending
and receiving of effective communication.
 Physical Setting – use the room for each session away from the mainstream of
activity.
 Time – is an important variable to consider when planning for a therapeutic
interaction.
 Therapeutic Approach – successful communication is dependent on your ability to
learn your client’s language.
Strategies for Therapeutic Communication
 Using active listening.
 Facilitating active communication
 Using minimal encouragers.
 Asking questions.
• Open-Ended Questions.
• Closed-Ended Questions.
• Focused Questions.
Factors that Enhance Therapeutic Relationships
 Advocacy – is a broad concept that recognized as an essential role for the psychiatric
nurse.
 Caring – is an intangible interactive process with physical, psychosocial, and spiritual
dimensions that finds expression through actions designed to promote the health and
well-being of client.
 Mutuality – involves inclusion and connection; it implies equal partnership in achieve
a goal.
 Unconditional Acceptance – It is easier to respect people, whose ideas and values
parallel our own. Unconditional acceptance as the capacity of the nurse to affirm the
client’s humanity and to validate his or her life experience without questioning its
validity or judging it in any way.
 Empathy – represents a mutual interpersonal process in which the nurse is able to
capture the inner struggle of the client, bring together different aspects of the client’s
situation in a meaningful way, and communicate that understanding in a way that is
understood as truth by the patient.
 Authenticity – means being real with the patient, not hiding behind the mask of
professionalism.
 Trust – is a mutual process and is the foundation of the nurse-patient relationship.


Jamshoro Sindh
ACN III Major NCP

(Assignment # 2)
Mukhtari Sardar
BScN Year II
Mrs. Munira A. Ali

Scenario
A 30 years old female verbalized that she has less abilities and strength in developing
relationship with others. I feel people will defeat me and criticize me, therefore, I have lack
of involvement in job performance and seek of evaluation from others. She has depressed
mood, feeling of worthlessness and looking pale.

NURSING CARE PLAN
TITILE: Low Self-Esteem
Subjective Data: Short-term Goals:  Encourage the client to  When the client can focus The client has
Client verbalized that she has  The client will verbalize become involved with staff on other people or demonstrated
Chronic Low Self-Esteem.

less abilities and strength to increased feelings of and other clients in the interactions cyclic, behavior
develop and self evaluation self-worth. milieu through interactions negative thoughts are consistent with
thinking about criticism of other  The client express and activities. interrupted. increased self-
as evidence by lack of job feelings directly and  Give the client positive  Positive feedback esteem.
performance. openly. feedback for completing increases the likelihood
 The client evaluate own responsibilities and inter- that the client will continue The client has
Objective Data: strengths realistically. acting with others. the behavior. made plans for
A 30 years old client looked pale  Involve the client in  The client needs to the future
and depressed mood, feeling of Long-term Goals: activities that are pleasant or experience pleasurable consistent with
despair, worthlessness and  The client will recreational as a break from activities that are not personal
having low self-esteem, demonstrate behavior self-examination. related to self and strengths and
communication was slow and consistent with problems. expressed
irregular. increased self-esteem.  If negativism dominates the  The client will feel you are satisfaction
 The client makes plans client’s conversation, it may acknowledging his or her with self and
Vital signs: for the future consistent help to structure the content feelings yet will begin personal
Blood Pressure: 110/70 mmHg with personal strengths. of interactions, for example, practicing the conscious qualities.
Pulse Rate: 70 beat/min  The client expresses by making an agreement to interruption of negativistic
Resp. Rate: 20 per min. satisfaction with self listen to 10 minutes of thought and feeling
Temp. 98° F and personal qualities. “negative” interaction, after patterns.
which the client will interact
on a positive topic.
 Provide simple activities  The client may be limited
that can be accomplished in his or her ability to deal
easily and quickly. Begin with complex tasks or
with a solitary project; stimuli. Any task that the
progress to group occupa- client is able to complete
tional and recreational provides in opportunity for
therapy sessions. Give the positive feedback to the
client positive feedback for client.
participat6ion
 Give the client honest praise for accomplishing small responsibilities by  Clients with low self-esteem do not benefit from flattery or undue praise.
acknowledging how difficult it can be for the client to perform these Positive feedback provides reinforcement for the client’s growth and can
tasks. enhance self-esteem.
 Gradually increase the number and complexity of activities expected of  As the client’s abilities increase, he or she can accomplish more complex
the client; give positive feedback at each level of accomplishment. activities and receive more feedback.
 It may be necessary to stress to the client that he or she should begin  The client will have the opportunity to recognize his or her own
doing things to feel better, rather than waiting to feel better before doing achievements and will receive positive feedback. Without this stimulus, the
things. client may lack motivation to attempt activities.
 Explore with the client his or her personal strengths. Making a written  While you can help the client discover his or her strengths, it will not be
list is sometimes helpful. useful for you to list the client’s strengths. The client needs to identify them
but may benefit from your supportive expectation that he or she will do so.
References
USA.
 Tromblhy, C.A. and Radomski, M.V. (2001). Occupational therapy for physical
dysfunction. 5th Edition. Lippincott Philadelphia.

Jamshoro Sindh
Aging People
ACN III
Muhammad Yousaf
BScN Year II
Mrs. Ruth K. Alam

Old age is generally considered to begin between the ages of sixty and sixty-five
years. The process of growth and development involves a series of changes that usually occur
in an elderly and predicable sequence but at variable rates. The onset and the effect of those
changes are influenced by numerous biological, physical, psychosocial and environment
factors. In older adulthood, the process of aging becomes progressively more rapid.
Therefore, elder people can be defined as, those people who are physically weak and unable
to perform heavy work due to age factor. In our society, when any person’s age is more than
60-65 years, they were respected and given more importance.
According to the famous poet William Shakespeare, “A human being posses different
states in their life from birth to death, one of them is an old age when a man reached at this
stage they have facing different problems in their life.” There are so many roles of the elder
people in the society. The most important role of the elder once is decision making of the
family in which they have a great importance in the family. They know very well about the
ups and downs of the life because of having more experience of life in the society.
In Pakistani culture, the elder people are respected, and regarded by their family. They
are the caretakers of the family, well oriented about the situation, make plans and create
better ways for their family and society. According to experience of life, the major task of old
age is primary concerned with the maintenance of social contacts and relationship. Elder
people centers in main cities or community and town serving as a key point from where the
aged can make use of their talents and skills for new nation building activity and also keep
themselves within the main stream of society. It is very important to promote a sharing of
experience and information.
We have observed on of the main social problem faced by the elder couple having no
children. In this stage of life, they are facing lot of problems especially about their health
care. They need more attention and if one of them is disabled they need nursing care for their
survival. They also face economical problems, as they are unable to earned enough money to
meet their daily requirements. Their health is also not permitting them to perform all
activities of daily life requirements. If they become poor they are treated in the hospital or
may be a nurse attached to take care of them at home. Mental illness in old age is broadly
classified as being either organic or functional. Organic mental disorder (dementia) affects
around 10% of those aged over 65 years. A small number of older people are also affected by
schizophrenia. Affective disorder includes depression, other persistent mood disorders mania
and manic depressive illness. Common health problem of ole people include eye disease,
hearing problem, painful joint and loss of memory. Illness can severely disturb an elder
adult’s ability to function independently. The client is under increase physical and emotional
stress, which increases the risk for complications because of the lack of physiologic
resources. During this age disease like cardiac diseases, respiratory diseases, diabetic
mellitus, renal function failure, etc., whose signs and symptoms include hypertension,
hyperglycemia, sleep disturbance and general weakness. The oldest people may display some
overall decrease in sleep efficiency but not enough for average are in fact in sleeping pills are
not a good idea for the elder people. Reynolds (1991) suggests that the eldest may have better
sleep hygiene than younger person. Brief naps during the day may be refreshing for them so
long as their nighttime sleep is not affected. However, they can enjoy the world through all of
their sense, sometimes with the aid of assistive/prosthetic devices. Every care plan for the
oldest should include health maintenance monitoring of all sense including drug effects.
Psychiatric Disorder
 Depression
 Delirium and Dementia
 Disturbance intellectual function
 Disorientation
 Poor memory
 Liable mood
 Anxiety
 Schizophrenia
 Meaningless character.
 Altered level of conscious
 Poor judgment
 Altered attention spasm.
Assessment Criteria
 Physical dimension:
• Family history
- No any previous family history of illness
- Client’s perception of the quality of his/her relationship and of himself or
herself within these relationships.
- Present time he/she takes excessive drugs.
• Individual health history
- Sleep pattern is very disturbed; some time takes day nap and also lesser
activity.
- Clients may be dissatisfied and experiencing discomfort.
- Spends most of time in his/her room.
- Not taking proper diet.
• Emotion dimension
- Aggression.
- Egocentricity.
- Racism.
- Sexism
- Complaining critical
- May discouraged other from befriending.
• Intellectual dimension
- Partially think about disease and understand to take medication.
- Decreased self-esteem.
- Difficulty in decision making.
• Social dimension
- Does not share any activity with anyone.
- Does not want to make relationships with others.
- Does not trust on any person.
• Spiritual dimension
- Client spiritual beliefs and feelings.
- Support from spiritual beliefs.
- Client relationships to higher power.
- Spent more time in pray for satisfaction.
 Appearance
• Client is looking normal hygienic.
• Facial expression anxious and suspicious.
• Eye contact excessive and sometime absent.
• General health is normal.
 Behavior
• Unable to talk properly.
• Talkative.
• Not trust on others.
• Tremor present.
• Motor Behavior
- Gait is very slow
- Level of activity low.
 Communication Pattern
• Speak rapidly and loudly.
• Whispering and talkative
• Illogical speech.
• Loose memory
• Remote
 Thought process
• Delusion
• Positive obsession and idea of suicidal
 Sensory perception
• Tactile hallucination
 Ensight
• Partially absent.
Nursing Diagnosis
 Sleep pattern disturb
 Altered thought process

 Impaired social interaction
 Anxiety.
Short-term Goals
The client will:
 Participate in therapeutic relationship.
 Verbalize decrease feeling of anxiety.
 Increase contact with other.
 Demonstrate increased interpersonal contact.
 Identify strategy to prevent feeling of anxiety and stress.
Long-term Goals
The client will:
 Express satisfaction with leisure and social activities.
 Demonstrate increase communication, social and leisure activity skill.
 Maintain on-going interpersonal relationships that are satisfying.

• Assess the level of anxiety. • For baseline data and to know the
cause.
• Monitor anxiety behavior and • Identification of the behavior and

relationship to activity, events, people, causative factors enhances
etc. intervention plan
• Assist the level of coping mechanisms • To improve effective coping patterns

and sense of ability to manage
anxiety
• Provide reassurance and comfort by staying • To reduce the effects of anxiety.

with the patient.
• Speak slowly and calmly and monitor • To provide calm environment and
anxiety and relationship to activity events. help the client to understand her
anxiety.
• Encourage significantly others to stay • Provide emotional support and

within patient limit and not to force encourage sharing may help a client
conversation. clarify her fear.
• Monitor vital sign at least every 4 • Assists in deter-mining the effect of

hourly while awake. anxiety
• Assist patient to develop coping skills. • Determine what has helped in past
Review past coping behaviors and and determines if the measures are
success or lack of success. still useful.
• Administer anti-anxiety medication as • Effectiveness of medication is

ordered by the doctor. Monitor and determined so that modification
document effects of medication can be provided if needed.
Medication helps to reduce
anxiety to a manageable level.
Evaluation
 Client verbalized the techniques to reduce anxiety.
 Client was using coping mechanism effectively and was ready to participate and face
the daily needs.
 Client has implemented a plan to reduce the risk for anxiety.

References
 Alford DM (2004). Nursing Care of the Oldest Old. [Online] available.
dalfordl@airmail.net.
2nd Edition.
USA.
 Marry, T.C. (1941). Psychiatric Mental Nursing.
 Rogers D (1979). Nursing Care of Elderly People. p 368.
 Schultz, J.M. and Videbeek, S.L. Psychiatric Nursing. 7th Edition.
Crises Intervention

Naseem Akhter
Dated: ______________
Crisis is defined as an upset in the persons steady state provoked when an individual
finds an obstacle to important life goal (Caplan). It is also defined as a response condition
wherein psychological homeostasis has been disrupted, one’s usual coping mechanism have
failed to reestablish homeostasis, and some evidence of functional impairment
(Everly & Mitchell, 1961, 1964).
Types of Crisis – Origin of crisis is as important as the types of crisis. Hoff (1989)
pointed out that if we know how the crisis began, we have better opportunity to intervene
effectively. There are three types of crisis origin.
Developmental or Transitional Crisis – these are the transitions between the stages of
life that we all go through. These major times of transition are often marked by “rites of
passage” at clearly defined moments e.g., puberty, adulthood, getting married, retirement,
becoming an elder or dying.
Situational Crisis – sometimes called “accidental crisis” are more culture and
situation specific e.g., loss of job, income, home, accident, loss through separation or divorce.
Complex Crisis – these are not part of our everyday experience or shared accumulated
knowledge, so we find them harder to cope with. It includes: (1) severe trauma – such as
violent personal assault, natural or man made disaster often directly involving both
individuals and their families, (ii) crisis associated with severe mental illness – the stress of
crisis can precipitate episodes of mental illness in those who are already venerable e.g.,
(PTSD) developmental, situational and complex crises may overlap and one may lead to the
other.
Stages of Crisis – A crisis can be thought of as having three stages: (1) pre-crisis,
(2) crisis, and (3) post-crisis.
Pre-crisis Stage – is stage of maintaining or attempting to maintain equilibrium. If the
individual’s problem solving method is successful, the person avoids a crisis and reverts to a
state of dynamic equilibrium. If the problem is too severe or if the balancing factors are
inadequate, equilibrium is not maintained, the problem is not solved and a crisis results.
Crisis Stage – is the reaction to the event. Reactions to such events or traumas are
highly individuals. In this the balancing factors have failed and individual fall in a crisis state.
Interpersonal conflicts are great, anxiety and tension increase. Individual makes erratic
attempts to solve the problem. This state is so disruptive that an individual cannot maintain
this state for long time. Crisis states are time limited and do not last longer than six weeks.
Post-crisis Stage – because the crisis phase is time limited, every one who experience
a crisis enter the post-crisis phase. During this phase the individual arrives at or develop a
new equilibrium. This equilibrium may be close of to that of pre-crisis state or it may be more
positive or more negative state. If the new equilibrium is more positive the person experience
growth, a better social network, new found problems solving abilities or improved self image.
If new equilibrium is more negative that individual may lose skills, adopt a regressive stance
or develop socially unacceptable behaviors.
Effects of balancing factor in stressful events are:
Human organism
↓
Stressful event State of equilibrium Stressful event
↓
State of disequilibrium
↓
Need to restore equilibrium
Balancing factor present Balancing factor absent

Realistic perception of event Distorted perception of event
+ and
Adequate situational support No adequate situation support
+ and
Adequate coping mechanism No adequate coping mechanism
Result in Result in
Resolution of problem Problem unresolved
↓ ↓
Equilibrium regained Disequilibrium continues
↓ ↓
No Crises Crisis
Crisis Intervention is defined as the provision of emergency psychological care to
victim as to assist those victims in returning to an adaptive level of functioning and to prevent
or mitigate the potential negative impact of psychological trauma (Everly & Mitcheel, 1999).
Eighty percent of people are able to work through these situations themselves with
support from significant others. Twenty percent have difficulties that require intervention and
assistance. While there is no single model of crisis intervention, there is a common agreement
on general principles to be employed to alleviate the acute distress of victim.
There are five basic principles of crisis intervention. These are:
Intervene Immediately – by definition crisis is emotionally hazardous situation that
place victims at high risk for maladaptive coping or even for being immobilized, the presence
on site of emergency mental health personnel as quickly as possible is paramount.
Stabilize – one important immediate goal is stabilization of the victim community
actively mobilizing resources and support network. Such mobilization provides the needed
tools for victims to begin to function independently.
Facilitate Understanding – is another important step in restoring victims to pre-crisis
level of functioning to facilitate their understanding of what has occurred by gathering the
facts, listening to the victim’s recount events, encouraging the expression of difficult emotion
and helping them understanding the impact of critical event.
Focus on Problem Solving – actively assisting victims to use available resources to
regain control is an important strategy. Assisting the victim in solving problem within the
context of what the victim feels is possible enhances independent functions.
Encourage Self-Reliance – emphasis on restoring self-reliance in victims as an
additional means to restore independent functioning and to address the aftermath of traumatic
events. Victims should be assisted in assessing the problem at hand in developing practical
strategies to address those problems and finding those strategies to restore a more normal
equilibrium.
Summary
A crisis is a period of transition in the life of individual, family or group, presenting
individuals with a turning point in their lives, which may be seen as challenge or a threat a
make or break, new possibility or risk, a gain or a loss, or both simultaneously. Most crises
are part of normal range of life experience that most people can expect and the most people
recover without professional intervention. However, there are crises outside the bounds of
person’s everyday experience or coping mechanism which may require expert help to achieve
recovery. The need for crisis intervention services is clear. Yet the efforts to provide those
services must well-timed and well-measured. Consideration of aforementioned principles
may assist the crisis worker in the most effective application of crisis intervention strategies.
References
 Flannery, R.B., & Everly, G.S., et al. (2000). Crisis intervention. Retrieved from
www.goolge.com/pk. Retrieved on September, 10, 2007.
 Kneisl, C.R., & Wilson, H.S. Psychiatric nursing. 4th Edition.

Jamshoro Sindh
Personality Disorder
ACN III Major NCP

(Assignment # 2)
Naseem Akhter
BScN Year II
Mrs. Munira A. Ali

NURSING CARE PLAN
TITILE: Ineffective Coping.
 Low frustration tolerance. Short-term Goals:  Encourage the client to • These clients frequently The client has
 Impulsive behavior.  The client will verbalize identify the action that deny responsibility for verbalized feeling
inadequate choices of practiced responses and/or inability to use available resources.

 Poor judgment. express feelings precipated hospitalization. consequences through especially anger.
Ineffective coping related to inability to form a valid appraisal of the stressors,

 Conflict with authority especially anger. their own action.
 The client demonstrates  Give positive feedback for  Honest identification of The client has
 Difficulty following rules
adequate daily living honesty. The client may try the consequences for the demonstrates
and obey laws.
skill. to avoid responsibility by client behavior is adequate daily
 Lack of feeling of remorse.
acting as though he or she necessary for future living skills.
 Socially unacceptable
Long-term Goals: is helpless. behavior change.
behavior.
 The client will maintain  Identify unacceptable  You must supply clear
 Dishonesty.
satisfactory work behavior either general or concrete limit when the
 Ineffective interpersonal
performance. specific. client is unable or
relationship.
 Meet own needs without unwilling to do.
 Manipulative behavior
interfering on the right of  Develops specific cones-  Unpleasant consequences
 Failure to learn or change other. quences for unacceptable may help decrease
behavior based on past behavior. unacceptable behavior.
experience or punishment.
 Avoid any discussion about  The client my attempt to
 Failure to accept or handle why requirement exist. bend the rule just this one
responsibility. with numerous excuses
and justification.
 Inform the client of  The client must be aware
unacceptable behavior and of expectations and
the resulting consequences consequences.
in advance of their
occurrence.
 Communicate & document  The client may attempt to
in the client care plan all gain favor with staff
behaviors & consequences member or play one staff
in specific terms. member against other.
Date Assessment Nursing Goal/Planning Nursing Intervention
 Avoid try to coax or 
convince the client to do
the right thing.
 Avoid immediate positive 

feedback or reward for
acceptable behavior.
 Encourage the client to 
identify sources of
frustration and any
unpleasant consequences
that result.
 Explore alternative 
socially, legally acceptable
method of dealing with
frustration.
 Help the client try •
alternative as situation
arise. Give positive
feedback, when the client
uses these alternatives.

Jamshoro Sindh
(Assignment # 1)
Naseem Akhter
BScN Year II
Mrs. Munira A. Ali

Personality disorder is evidenced by a client’s enduring pattern of thinking, behaving
and behaving that deviates markedly from the expectations of his or her culture (APA 2000).
The individual has difficulties with impulse control; interpersonal functioning; cognition or
affect. These maladaptive coping patterns and skewed perceptions of self or others are long
standing and are present in many life situations, even though they are ineffective or cause
significant distress or impaired functioning. Clients with other psychiatric diagnoses may also
have a personality disorder that makes their care more complex.
Types
 Paranoid personality disorder
 Schiziod and schizotypal personality disorder
 Antisocial personality disorder
 Borderline personality disorder
 Dependent personality disorder
 Passive aggressive personality disorder
Etiology
 No clear etiology has been identified
 May be environmental and hereditary factors involved
 Genetic and experimental factors
 Behavioral problems
 History of abused or neglected as a child
 History of physical or sexual abuse
 Loss of parent
Symptoms
 Anxiety
 Depression
 Poor adjustment
 Chronic medical condition
 Mood disorder and mood swing
 Impaired thoughts
 Aggressive behavior
 Suicidal behavior
 Self mutilating behavior
 Extreme stress
 Unusual perceptual experience
 Beliefs in superstition
 Low self esteem
 Powerless
 Delusions
Nursing Diagnoses
 Disturbed thought process
 Ineffective therapeutic regimen management
 Impaired adjustment
 Social isolation
 Risk for self mutilation
 Powerlessness
General Intervention
 Treatment focused on symptom management (e.g., aggression or depression).
 The client behavior is self centered and based on desire of movement.
 Personality disorders are at increase risk for suicide and self-injury. Ensuring the
client safety is a key nursing goal.
 Build trust relationship and minimize manipulative behavior. The client safety is
always primary nursing goal.
 Development of basic skill and confidence.
 Communicating clear consistence expectations can be helpful.
 Facilitate the client accepting responsibility.
 Encouraging direct expression of feeling.
 Promoting effective coping skill.
 Do not discuss yourself, other staff member or other client with the client.
 Do not attempt to be popular, liked, or the favorite staff member of this client.
 Give attention and support when the client behavior is appropriate.
 Give the client positive feedback when he or she is able to express anger verbally or
in non-destructive manner.
Jamshoro Sindh

(Assignment # 1)
Naseem Akhter
BScN Year II
Mrs. Munira A. Ali

Personality disorder is evidenced by a client’s enduring pattern of thinking, behaving
and behaving that deviates markedly from the expectations of his or her culture (APA 2000).
The individual has difficulties with impulse control; interpersonal functioning; cognition or
affect. These maladaptive coping patterns and skewed perceptions of self or others are long
standing and are present in many life situations, even though they are ineffective or cause
significant distress or impaired functioning. Clients with other psychiatric diagnoses may also
have a personality disorder that makes their care more complex.
Types
 Paranoid personality disorder
 Schiziod and schizotypal personality disorder
 Antisocial personality disorder
 Borderline personality disorder
 Dependent personality disorder
 Passive aggressive personality disorder
Etiology
 No clear etiology has been identified
 May be environmental and hereditary factors involved
 Genetic and experimental factors
 Behavioral problems
 History of abused or neglected as a child
 History of physical or sexual abuse
 Loss of parent
Symptoms
 Anxiety
 Depression
 Poor adjustment
 Chronic medical condition
 Mood disorder and mood swing
 Impaired thoughts
 Aggressive behavior
 Suicidal behavior
 Self mutilating behavior
 Extreme stress
 Unusual perceptual experience
 Beliefs in superstition
 Low self esteem
 Powerless
 Delusions
Nursing Diagnoses
 Disturbed thought process
 Ineffective therapeutic regimen management
 Impaired adjustment
 Social isolation
 Powerlessness
 Treatment focused on symptom management (e.g., aggression or depression).
 The client behavior is self centered and based on desire of movement.
 Personality disorders are at increase risk for suicide and self-injury. Ensuring the
client safety is a key nursing goal.
 Build trust relationship and minimize manipulative behavior. The client safety is
always primary nursing goal.
 Development of basic skill and confidence.
 Communicating clear consistence expectations can be helpful.
 Facilitate the client accepting responsibility.
 Encouraging direct expression of feeling.
 Promoting effective coping skill.
 Do not discuss yourself, other staff member or other client with the client.
 Do not attempt to be popular, liked, or the favorite staff member of this client.
 Give attention and support when the client behavior is appropriate.
 Give the client positive feedback when he or she is able to express anger verbally or
in non-destructive manner.
References
2nd Edition.
USA.
 http://www.google.com. Scott, J. (2001). Cognitive Therapy for Depression. B Med
Bulletin; 57:101-113.

Jamshoro Sindh
Sexuality
ACN III
Naseem Akhter
BScN Year II
Mrs. Ruth K. Alam

Human sexuality is an area in which treatment team member’s feelings are often
evoked and must be consider because it is basic to everyone, sexuality may be a factor with
any client in a number of ways.
Adequate knowledge base sexuality is a life long process. In the past decades,
sexuality has been refined in a holistic perspective and has become recognized as an
important component of the total person interacting with the environment.
Definition
 Sexuality is defined as the characteristic quality of the male and female reproductive
elements.
 It also refers to the constitution of an individual in relation to sexual attitudes and
behavior.
Problems of Sexuality
 A change in sexual habits and feelings, such as first sexual activities, marriage or loss
of a sexual partner.
 Injury, illness and disability (disturbed body image).
 Traumatic experience i.e., incest, rape.
 Post traumatic stress disorder (sexual, emotional, or physical abuse).
 Crime i.e., exhibitionism, rape, incest, etc.
 Feeling guilty about masturbation.
 Lack of social skill in the area of social and intimate relationship.
 Side effects from psychotropic medications.
 Menopausal symptoms.
 Chromosomal abnormalities
 Psychosis
Stages of Human Psychosexual Development
Stages Characteristics
Prenatal Chromosomal and hormonal factors influence the gender of

the fetus. The gender of the fetus is determined by the 7th
week.
Birth - 2 years Gender is assigned at birth. Societal influence reinforces the

child’s sexual identity. The infant is in the oral phase of
development. Infants exhibit reflexive signs of sexual arousal.
Physical affection toward the child is essential for normal
psychosocial development.
2 – 5 Years The child is in the anal phase of development. The concept of

privacy is manifest. Self exploration of the genitals occurs.
Awareness and mimicking behaviors begins. Association b/w
genitals and pleasure begins. The child has an attraction to the
opposite sex parent.
5 – 12 Years Sex play between age mates occurs. Curiosity about

reproduction occurs. Friendships develop predominantly with
same sex age mates.
13 – 20 Years Sexual self consciousness begins. There is an increase in

sexual fantasy. Dating the opposite sex occurs. Physical
changes occur. Menarche, breast enlargement, and widening of
the hips in females. Broadening shoulders increase in muscle
mass and development of body hair in males occur.
Masturbation, petting, and intercourse occur.
Young adulthood Individual is learning how to handle sexuality responsibly.

Sexual experimentation and focus on sexual technique
develop. Individual establishes long term relationships.
Pregnancy and childbearing are possible.
Middle Adulthood Self acceptance is achieved. Performance anxiety decreases

Frequency of intercourse decreases. Hormonal changes and
menopause occur. Secondary sex characteristics decrease.
Late Adulthood Sexual activity is focused on intimacy rather than intercourse.

Sexual accommodation is made for physical handicaps.
Frequency of intercourse decreases.
Factors
The following factors include:
 Predisposing factors
 Precipitant factors
 Maintaining factors
Drugs known to have side effects that can disturb sexual function:
 Antianxiety
 Antidepressants
 Anticholinergics
 Narcotics
 Alcohol
 Sedative hypnotics
 Antihypertensive
 Antipsychotics
 Hormones.
Nurse’s Role in Discussing Sexuality
The nurse must become educated regarding sexuality and sexual health through the
life span. It is important for the nurse to examine his/her own beliefs and feelings concerning
sexuality, sexual function, and what is considered sexually normal and abnormal. Many
nurses have difficulty providing care in the area of sexuality. The PLISSIT model is helpful
for the nurse to providing care in the area of sexuality.
Permission - Convey to person and significant others a willingness to discuss sexual
thought and feelings
Limited Information - Provide the person and significant other with information on
the effects certain situations (e.g., pregnancy) conditions (e.g., cancer) and treatments
(e.g., medications) can have on sexuality and sexual function.

Specific Suggestions - Provide specific instructions that can facilitate positive sexual
functioning (e.g., changes in coital positions).
Intensive Therapy - Refers people who need more help to appropriate health care
professionals (e.g., sex therapist, surgeon).
Assessment
 Age, sex, marital status and relationship status
 Sexual orientation/preference
 Number of children and siblings
- Client’s perception of the quality of his/her relationship with significant or
partner.
- How has your health problem affected your ability to function as a wife,
mother, partner, etc?
- How has your health problem affected your ability to function sexually?
- No mental illness, use of drugs, any other physical problem.
• Individual health history
- Any physical illness i.e., Diabetes, Myocardial infarction, any surgical
procedure, psychological illness i.e., depression, anxiety
• Activities of daily living
- Daily activities are disturbed.
- Diet and elimination may or may not be normal.
- Sleep pattern disturbed
• Sexuality
- Sexually active or not.

- Interest in sexuality.
- Questions about sexual functioning and sexual concerns.
- Body changes.
- Coping skills may be uncomfortable exploring sexual issues.
- Control of life and safe measures.
Anger, fear, shame, depression, anxiety, confusion, fear of pain, etc.
Self destructive thoughts, impaired perceptions, difficult in concentration, disinterest
or other cognitive symptoms
Socially interaction with the partner, interpersonal relationship with the partner, trust
or mistrust on partner, self esteems in sexuality
Religious beliefs in regard to sexual behavior and sexual knowledge, sexual concerns
may conflict with the religious beliefs and cultural values.
Nursing Diagnoses
 Sexuality dysfunction
 Ineffective sexuality pattern
Related Diagnoses
 Postrauma syndrome
 Deficient knowledge

 Powerlessness.
Short-term Goals
 The client will discuss her/his feelings about her/his family situation.
 The client will discuss the connection b/w her own lack of a stable, loving
relationship with the partner.
 The client will identify the behavior when she/he relating to the partner
 The patient will use spiritual resources to alleviate the spiritual distress
Long-term Goals
 The client will recognize the link between the meaningful relationship with partner
and her/his willingness to engage in sexual intercourse.
 The client will identify practices and coping patterns that will help her/his to achieve
meaningful relationships with partner and will acknowledge restoration of sexual
desire.
 The client will find spiritual comfort.
Help the client to complete a family A family genogram is the non-

genogram. emotional method of diagramming
and examining family patterns
Teach client about family patter – how A family approach provides with a
behavior and attitudes are transmitted from way of analyzing and problem solving
one generation to other. about own situation.
Help client to recognize the patterns of A family approach provides with a

relationship in family. way of analyzing and problem solving
about own situation.
Encourage client to identify and discuss the By recognizing and discussing own
feelings about the parents and the feelings and changing behavior.
subsequent relationships.
Encourage to identify alternative ways of Identifying alternative modes of

interaction with partner in meaningful ways behaving before a situation presence
but without premature intimacy. itself is an empowering strategy.
Encourage the client that it is possible to Encouragement provides hope for

change unhealthy patterns of behavior. pursuing change.
Encourage client to role-play various By asking the client to role-play to

situation in which interact with partner. allowing to see own behavior in a
different and more objective way.
Ask the client to analyze the responses to To characterize own behavior and
behavior that received from the partner. recognizing there is change to made.
Explore alternative behaviors, ways of By establishing realistic boundaries

acting, that are friendly and interested but are helping the client to assume
with clear boundaries of sexual control over body and sexual
involvement. activities.
Ask the client to keep a record of feelings. The on-going recording and follow-up
discussion of client’s feeling expend
awareness and understanding of
behavior.
Discuss the meaning of sexual expression. Sexual expression is an intimate way

of relating to another in a committed
relationship.
Assess the client’s understanding of the It is important that ask to discuss the
information presented. information.
Discuss the spiritual significance of Sexuality is an expression of our

sexuality. spirituality. In that sexuality
transcends the individual and it’s
creative.
Discuss with client the spiritual resources May find spiritual support and
(prayer, medication, a reading of scripture strength from these resources.
or other inspirational materials) that might
be helpful and supportive.
Ask the client to might support in efforts to Offering the self is caring therapeutic
attain comfort and consolation. modality that shows support and help
for the client who is spiritual distress.
Give homework assignments in which the The client focused on the areas for
client keeps a journal of interactions with change and active participation in the
partner and try out new behavior. change.
Evaluation
The client has met all of the short-term goals and able to examine the family situation,
easily recognized that the pattern of relating to partner was linked to early family experiences
and the behavior.
The client has met all of the expected outcomes. The client involved social activities
with groups of friends and to seek a committed relationship with a partner before engaging in
sexual activity.
References
 Barbara, W.F. and Richard, W.J. (1990). Bailliere’s Nurses’ Dictionary. Bailliere
Tindall Limited London.
 Brunner and Suddarth, D.S. (1988). Textbook of Medical-Surgical Nursing. (6th ed.).
Philadelphia J.B. Lippincott Company.
2nd Edition.
Nahid Jamal

Nursing Care Plan
Introduction
Disturbed thought process describes an individual with altered perception and
cognition that interferes with daily living. Causes are biochemical or psychological
disturbance. For example, depression, personality disorders, etc.
Focus of nursing is to reduce disturbed thinking and promote reality orientation.
Nurse should be cautioned when using this diagnosis as a (waste basket) diagnosis. All
patients with disturbed thinking or confusion, frequently confusion in older adults is
erroneously attributed to aging. Metabolic disorder depression causes impaired thinking in
older adults and remain additional information.
Disturbed thought process individual experiences a disruption in such mental
activities as conscious thought, reality orientation, problem solving, judgment, and
comprehension related to coping personality and mental disorder.

NURSING CARE PLAN
Name: Perveen Age: 50 Years Sex: Female
Psychiatric Diagnosis: Disturbed Though Process
Nursing Diagnosis: Altered perception related to disturbed thought process due to biochemical alterations.
Subjective Data: Short-term Goals: • Inform and reassure client. • Establish relationship. Short-term Goals:
Altered perception related to disturbed thought process due to biochemical alterations

The client’s attendant, she was The client will feel The client verbalized
fine a month ago, suddenly she relaxed with appro- • The client must lying in • To handle client easily. that she feel relax and
develop sign and symptoms of priate social behavior. comfortably and relaxed comfortable and
lack of concentration, irritability, reduce disturb
poor appetite, sleeplessness, Long-term Goals: • Use communication helps • To encourage client. thoughts.
hopelessness, fear, restlessness, The client will make client to maintain own
increased motor movements, full attention. Discuss individuality. Long-term Goals:
false beliefs and increased level current events, well The client made
of anxiety. oriented to time and decision about reality,
• Provide company of family • To change the thinking.
place and express feeling and follow
or friends.
Objective Data: feelings constructively through with
A 50 years lady lying on the bed appropriate action to
with uncomfortably, untidy and • Diversional therapy • To decrease anxiety. change provocative
in unhygienic conditions. She is situations in personal
looking restlessness insomnia, • Avoid making promises that environment physio-
loss of appetite and poor cannot be fulfilled. logical reaction to
confidence. panic attack decease.
• Verify your interpretation, • To decrease fear. Expressed panic
Vital Sign what client is experiencing. attack about road
Blood Pressure: 120/80 mmHg traffic accident and
Temperature: 98°F • Provide balanced diet. • To improve the general blood injury and its
Pulse: 100 bpm health, alternative method of effect in future.
Respiratory Rate: 24 per min. coping Accurately described
relationship between
Investigation revealed: • Assist the client to set limits panic attack and
Hb: 11.12 on own behavior. occurrence of physio-
Blood Sugar: 120 mg/dl logical symptoms
Urine D/R: Normal • Encourage family to bring • To divert clients attention.
familiar objects from home.
Disturbed Thought Process
Reflection
Introduction
To fulfill my requirement of BSc Nursing, I went to Psychiatric unit (Ward 20). With
the permission of the Head Nurse, I selected a client who was 50 years old lady. She was
laying on the bed with complaint of disturbed though process. To relate this disease altered
perception causes are biochemical or psychological disturbances, for example, depression,
personality disorder, etc. The focus as nursing is to reduce disturbed thinking and promote
reality orientation. This psychotic disorder of impaired thinking is occurred more frequently
in older adults.
Analysis
I analyzed the client’s condition and observe reduce the client’s problem as nurse
gives and discuss alternative methods of coping like taking a walk instead of crying,
cognitive therapy and behavior therapies given, encourage and support the client in decision
making process, helps the client to recognize behaviors that stimulate rejection, provide client
sensor input that is sufficient and meaningful.
Conclusion
Thought process describes as altered perception and cognition. Disturbances
personality, depression and anxiety cause biochemical or psychological disturbances. Focus
of nursing is to reduce the symptoms of disease and promote reality orientation. Impaired
thinking in older adults’ problem solving, judgment and comprehension related to coping
personality are common psychotic disorders.

Disturbed Thought Process
In future, if I get a chance to work with clients suffering of disturbed thought process,
I will spend more time with them and help them to overcome their problems. This will
develop a trustworthy relationship and motivate them to cope with their present status of
mental disorder and become one of the useful independent lives.
Learning
I learned from this clinical about many things. I start the client that come psychiatric
ward with the complaint of disturbed thought process. The clients that are depressed,
confused, dementia, psychological disturbed. I give comfortable bed and reduce anxiety. Give
good environment because client already disturbed.

Family Therapy200
References
Family Therapy
Nahid Jamal

Family Therapy201
Introduction
Family therapy is based on family system theory, which understands living organisms.
Problems are treated by changing the way the system works.
Family system theory is based on major concepts such as:
 Identifying client.
 Homeostasis (balance) means family system seeks to maintain it customary
organization and functioning.
 Extended family field – nuclear family – grand parents and other members at the
extended family intergenerational transmission of attitudes, problems, behaviors and
other issues.
 Differentiation – maintain ability of each family member.
Family therapy is a type of psychotherapy. It helps families or individuals within a
family to understand and improve the way family members interact with each other and
resolve conflicts.
Issues in which Family Therapy is Important
 To assist in resolving pathological conflicts and anxiety.
 Family environment (marital problems).
 Family critical upsets e.g., divorce.
 Influence the orientation of the family identify and values towards health, eating
disorders such as anorexia or bulimia.
 Modify behavior (work stress).
 Family therapies are based on behavioral or psychodynamic principles.
 Emotional abuse or violence.
 Financial problems.
 Chronic health problems such as asthma or cancer.

Family Therapy202
 Substance abuse.
 Parenting skills.
 Depression or bipolar disorder.
The Work of Family Therapy
 In family therapy, families together in therapy session.
 Family members may also see a Family Therapist individually.
 Family therapy may include nonfamily members such as school teacher, other health
care providers or representatives of social services agencies.
 Family Therapist, you and your family will examine your family ability to solve
problems and express thoughts and emotions. Explore family roles, rules and behavior
patterns according to believe, solves problems.
 Family therapy helps you identify your family’s strength.
 To provide confidence.
 To set individual and family goals and work on ways to achieve them.
 Family therapy is based on family system theory, which understands living organism.
Choose of Good Family Therapist
 Family therapists are licensed mental health professionals.
 Master’s or Doctoral degree.
 Graduate training in marriage and family therapy.
 Training under supervision of other experts.
 American Association and Marriage and Family Therapy, which sets eligibility
criteria.
Conclusion
Family Therapy203
Family therapy refers to the use of meaningful family to assist people who have
difficulty in achieving health members. Family therapy is a form of psychotherapy that
involves all the members of a nuclear or extended family. Family therapy understands,
improves and resolves conflicts.

Suicide 204
References
 Corit, P.C. (1999). Family Therapy.
 Kissane, D.W. (2006). Family Therapy.
 Mackenzie, M. (2005). American Family Therapy Association Inc.
 Polatajko, H.J. (2007). Enabling Therapy and Justice through therapy.
Ottawa: CAOT Publications ACE.
LIAQUAT UNIVERSITY OF MEDICAL

AND HEALTH SCIENCE
JAMSHORO SINDH
Suicide
ACN III
Parveen Akhter
BScN Year-II Student
Madam Yasmin
Suicide 205
23rd July, 2005

Suicide 206
OBJECTIVES
At the end of this presentation, the participants will

be able to:
1. Define suicide.
2. Explain epidmiology and risk factors.
3. Enumerate causes.
4. Describe suicide as a symptom of psychiatric

illness.
5. Explain predisposing factors – theories of

suicide.
6. Describe diagnosis of suicide.
7. Illustrate application of the nursing process with

suicidal client.
8. Describe suicide precautions – sample

protocol.
Suicide 207
SUICIDE
Introduction
Suicide is not a disorder, but it is a behavior. According to
Ghosh and Victor (1994), the life is a gift of God and that
taking it is strictly forbidden.
Historical Perspectives
More than 90 percent of suicides are by individuals who are
psychiatrically ill at the time of suicide (Conwell and
Henderson 1996).
In the Middle Ages, suicide was viewed as a selfish or criminal
act. Most philosphers of the 17th and 18th centuries
condemned suicide, but some writers recognized a connection
between suicide and melancholy or other severe mental
disturbances (Minois 1999).
Most religions consider suicide as a sin against God. Judaism,
Christianity, Islam, Hinduism, and Buddhism all condemn
suicide. In 1995, Pope John II restated Church opposition to
suicide, euthanasia, and abortion as crimes against life, not
unlike homicide and genocide (Medscape Psychiatry 2001).
Definition
Suicide is defined as the intentional taking of one’s own life or
Informal, the ruin or destruction of one’s own interest. It may
also be defined as a person who commits or attempts self
destruction.
Indirect self destructive behavior refers to activities that are
potentially detrimental to a person’s physical, psychological,
social and spiritual well being (these behaviors may result in
death but without the persons conscious intent or awareness.
Examples of these behaviors include anorexia, bulimia with
purging, use of alcohol or other drugs of abuse and engaging
in unprotected sex with multiple partners.
Suicide 208
In direct self-destructive behavior, the person has an

awareness of the desired outcome. Examples of self-
destructive behaviors include wrist lashing, self-mutilation,
buying, a gun and monitors for the purpose of ending life and
taking an overdose of prescribed medications.
Para-suicidal behaviors are those actions that are intentionally
self-injuries, such as cutting the wrists or taking a non lethal
overdose of drugs (Kreitman 1977; Linehan 1993).
The suicidal ideation refers to a person’s thoughts about
suicide.
The suicide attempt or suicide gesture is the use of direct self-
destructive behavior for the express purpose of killing oneself.
The term “completed suicide” refers to willful self-inflicted, life
threatening acts that result in death.
The term “level of lethality of suicide threat” refers to the
seriousness of a suicide threat – the degree to which it is likely
to result in death.
Suicide 209
Epidemiological Factors
Approximately 30,000 persons in the United States end their
lives each year by suicide. These statistics have established
suicide as the eight leading cause of death among adults and
the third leading cause of death-behind accidents and
homicide-among young Americans (ages 15 to 24 years)
(Crisis Hotline 2001). Suicide has become a major health-care
problem in the United States today.
Risk Factors
Marital Status – the suicide rate for single persons is twice
that of married person. Divorced, separated, or widowed
persons have rates four to five times greater than those of
married persons (Nicholas and Golden 2001).
Gender – women attempt suicide more, but men succeed
more often. Successful suicides number about 70% for men
and 30% for women. This has to do with the lethality of the
means. Women tend to overdose; men use more lethal means
such as firearms. This difference between men and women
may also reflect a tendency for women to seek and accept
help from friends or professionals, whereas men often view
help-seeking as a sign of weakness (Murphy 1998).
Age – suicide risk and age are positively correlated. The rates
rise sharply during adolescence, peak between 30 and 40,
and level off until age 65, when it rises again for the remaining
years (Murphy 1998).
The suicide rate among adolescents has tripled during the
past 30 years (Nicholas and Golden 2001). Several factors put
the adolescent at risk for suicide, including impulsive and high
risk behaviors, untreated mood disorders e.g., major
depression and bipolar disorder), access to lethal means (e.g.,
firearms), and substance abuse.
Suicide 210
The suicide rate for the elderly has risen 9 percent between
1980 and 1992. Although the elderly make up only 13 percent
of the population, they account for 25 percent of all suicides.
Eighty one percent of elderly suicides are male which is
13 times greater than for females (Hospice Association 2002).
Religion - Protestants have significantly higher rates of
suicide than Catholics and Jews (Kaplan and Sadock 1998). A
strong feeling of cohesiveness and integration within a
religious organization seems to be a more important factor
than single religious affiliation.
Socioeconomic Status – individuals in the very highest and
lowest social classes have higher suicide rates than those in
the middle classes (Kaplan and Sadock 1998). With regard to
occupation, suicide rates are higher among physicians,
musicians, dentists, law enforcement officers, lawyers and
insurance agents.
Ethnicity – With regard to ethnicity, most studies demonstrate

that white are at highest risk for suicide, followed by Native
Americans, African, Americans, Hispanic Americans and Asian
Americans (Ghosh and Victor 1994).
Spiritual Factors – According to the Vanzant (1992) spirit is

the life essence, which is covered and protected by the
skeletal frame we call the body. Spirit has only one purpose
and mission, which was determined by God at the time of
creation. Everything that has life can create life, nurtures life or
serves a purpose in life is spirit.
Frankl (1964) observed that when people find life meaningless

and without purpose and God seems distant and uncaring,
there is no reason to like. He also viewed hope has an
expression of a healthy spirit and a prerequisite to survival and
believed that hopelessness, an expression of a depleted spirit,
could be fatal.
Suicide 211
Other Risk Factors – individuals with mood disorders (major

depression and bipolar disorder) are far more likely to commit
suicide than those in any other psychiatric or medical risk
group. Suicide risk may increase early during treatment with
antidepressants, as the return of energy brings about an
increased ability to act out self-destructive wishes. Other
psychiatric disorders that may account for suicidal behavior
include psychoactive substance abuse disorders, and panic
disorders (Murphy 1994).
Several, insomnia are associated with increased suicide risk,

even in the absence of depression. Use of alcohol, and
particularly a combination of alcohol and barbiturates,
increases the risk of suicide. Psychosis, especially with
command hallucinations, poses a higher than normal risk.
Affliction with a chronic painful or disabling illness also
increases the risk of suicide.
Higher risk is also associated with a family history of suicide,
especially in a same-sex parent, and with previous attempts.
Between 50 percent and 80 percent of those who ultimately
commit suicide have a history of a previous attempt (Crisis
Hotline 2001). Loss of a loved one through death or
separation and lack of employment or increased financial
burden increase risk.
Suicide 212
Causes
There are so many causes but some of them are mention

below:
1. Prior family history or tendencies.
2. Early trauma.
3. Rigid, disorganized or dysfunctional family system.
4. Disturbed parent child relationship.
5. Unresolved loss.
6. History of abuse.
7. Lost of both parents early in life.
8. Loss of job, money and social position.
9. Somatic symptoms (insomnia, headaches, stomach

aches).
10. Suffering from a major physical illness such as stroke,

cancer or diabetes.
11. History of diagnosed depression.

Suicide 213
Suicide as a Symptom of Psychiatric Illness
Suicide is one of the outcomes of untreated depression from

15% to 20% of all patients diagnosed with major depression
complete suicide. Additionally, patients with psychotic
depression have a high risk for completing suicide. This is due
to the combination of symptoms including:
1. Depression.
2. Delusions.
3. Guilt.
4. Paranoid thoughts.
5. Social withdrawal.
6. Hopelessness and feelings of worthlessness.
7. Somatic symptoms (insomnia, headaches, stomach

aches).
8. Irritability.
9. Feeling of exhausted.
10. Headaches.
11. Muscle aches.
12. Trouble sleeping.
13. Change in appetite.
14. Constipation.
15. Weight loss.
16. Everyone would be better off, if I died.
17. I wish I were dead.

Suicide 214
Presenting Symptoms/Medical-Psychiatric Diagnosis
Psychiatric disorders in which suicide may be a risk include

anxiety disorders, schizophrenia, and borderline and antisocial
personality disorders (Medscape Psychiatry 2001). Other
chronic and terminal physical illnesses have also precipitated
suicidal acts
Predisposing Factors – Theories of Suicide
Anger Turned Inward – suicide was a response to the

intense self-hatred that an individual possessed and occurred
as a result of an earlier repressed desired to kill someone else
(Freud 1957). He also interpreted suicide to be an aggressive
act towards the self that often was really directed towards
others.
Hopelessness – Ghosh and Victor (1994) identify

hopelessness as a central underlying factor in the
predisposition to suicide.
Desperation and Guilt – desperation is another important

factor in suicide. With desperation, an individual feels helpless
to change, but he or she also feels that life is impossible
without such change. Guilt and self-recrimination are other
aspects of desperation (Hendin 1991).
History of Aggression and Violence – some studies have

indicated that violent behavior often goes hand-in-hand with
suicidal behavior (Ghosh and Victor 1994).
Shame and Humiliation – some individuals have views

suicide as a “face-saving” mechanisms – a way to prevent
public humiliation following a social defeat such as a sudden
loss of status or income. Often these individuals are too
embarrassed to seek treatment or other support systems.
Suicide 215
Developmental Stressors – have associated developmental

level with certain life stressors and their correlation to suicide.
The stressors of conflict, separation and rejection are
associated with suicidal behavior in adolescence and early
adulthood. The principal stressor associated with suicidal
behavior in the 40- to 60-year-old group is economic
problems. Medical illness plays an increasingly significant role
after age 60 and becomes the leading predisposing factor to
suicidal behavior in individuals over age 80.
Sociological Theory – Durkheim (1951) proposed

relationship between suicide and social conditions and
described three social categories of suicide. Egotistical
suicide is the response of the individual who feels separate
and apart from the mainstream of society. Altruistic suicide
is the opposite of egoistic suicide. The individual who is prone
to altruistic suicide is excessively integrated into the group.
Anomic suicide occurs in response to changes in an
individual’s life (e.g., divorce, and loss of job) that disrupts
feelings of relatedness to the group.
Biological Theories
Genetics – twin studies has shown a much higher

concordance rate between monozygotic twins than between
dizygotic twins. These results suggest a possible existence of
genetic predisposition toward suicidal behavior (Ghosh and
Victor 1994).
Neurochemical Factors – a number of studies have been

conducted to determine if there is a correlation between
neurochemical functioning in the central nervous system and
suicidal behavior. Some studies have revealed a deficiency of
serotonin in depressed clients who attempted suicide (Kaplan
and Sadock 1998).
216 Suicide
Suicide Risk Factors and Protective Factors
Risk Factors Protective Factors

• Previous suicide attempt. • Effective and appropriate clinical care for mental,
• Mental disorders, particularly mood disorders physical and substance abuse disorders.
such as depression and bipolar disorder. • Easy access to a variety of clinical interventions
• Co-occurring mental and alcohol and substance and support for help seeking.
abuse disorders. • Restricted access to highly lethal methods of
• Family history of suicide. suicide.
• Family and community support.
• Hopelessness.
• Support from on-going medical and mental
• Impulsive and/or aggressive tendencies.
health care relationships.
• Barriers to accessing mental health treatment.
• Learned skills in problem solving, conflict
• Relational, social, work, or financial loss. resolution and nonviolent handling of disputes.
• Physical illness. • Cultural and religious beliefs that discourage
suicide and support self-preservation instincts.
Contd.
217 Suicide
Risk Factors Protective Factors

• Easy access to lethal methods, especially guns.
• Unwillingness to seek help because of stigma
attached to mental and substance abuse
disorders and/or suicidal thoughts.
• Influence of significant people – family members,
celebrities, peers who have died by suicide –
both through direct personal contact or
inappropriate media representations.
• Cultural and religious beliefs – for instance, the
belief that suicide is a noble resolution of a
personal dilemma.
• Local epidemics of suicide that have a
contagious influence.
• Isolation, or a feeling of being cut off from other
people.
218 Suicide
Assessing the Degree of Suicidal Risk
Intensity of Risk
Behavior
Low Moderate High
Anxiety Mild Moderate High or panic
Depression Mild Moderate Severe
Isolation; withdrawal Some feelings of isolation; Some feelings of helpless- Hopeless, helpless,
no withdrawal ness, hopelessness and withdrawal and self-
withdrawal deprecating.
Daily functioning Fairly good in most Moderately goo in some Not good in any
activities activities activity.
Resources Several Some Few or none
Coping strategies being Generally constructive Some that are constructive Predominantly
used destructive
Significant others Several who are available Few or only one available Only one or none
available
Contd.
219 Suicide
Intensity of Risk
Behavior
Low Moderate High
Psychiatric help in past None, or positive attitude Yes, and moderately Negative view of
toward satisfied with results help received
Lifestyle Stable Moderately stable Unstable
Alcohol or drug use Infrequently to excess Frequently to excess Continual abuse
Previous suicide attempts None, or of low lethality One or more of moderate Multiple attempts of
lethality high lethality
Disorientation; None Some Marked
disorganization
Hostility Little or more Some Marked
Suicidal plan Vague, fleeting thoughts Frequent thoughts, Frequent or
but no plan occasional ideas about a constant thought
plan with a specific plan
Suicide 220
Diagnosis
1. Self-destructive behavior related to wish to punish other
for their perceived lack of support and love.
2. Suicidal thoughts related to feelings of hopelessness and
despair.
3. Altered role of performance related to unemployment.
4. Ineffective individual coping related to disease process.
5. Altered nutrition less than body requirements related to
conflict over sexual maturation, evidenced by loss of
30% pre-illness weight.
6. Self-esteem disturbed related to perceived feelings of
loss of control.
Purposes of Suicide
Shneidman (1996) identified what he calls the “Ten
Commonalties of Suicide”.
1. The common purpose of suicide is to seek a solution.
2. The common goal of suicide is cessation of
consciousness.
3. The common stimulus of suicide is unbearable
psychological pain.
4. The common stressor in suicide is frustrated
psychological needs.
5. The common emotion in suicide hopelessness and
helplessness.
6. The common cognitive state in suicide is ambivalence.
7. The common perceptual state in suicide is constriction.
8. The common action in suicide is escape.
9. The common interpersonal act in suicide is
communication of intention.
10. The common pattern in suicide is consistency of lifelong
styles.
Suicide 221
Application of the Nursing Process with the Suicidal

Client
Assessment
The following should be considered when conducting suicidal
assessment demographics, presenting symptoms/ medical-
psychiatric diagnosis, suicidal ideas or acts, interpersonal
support system, analysis of the suicidal crises, psychiatric/
medical/family history, and coping strategies.
Demographics – the following demographics are assessed.
Age – suicide is highest in persons older than 50 years.
Adolescents are also at high risk.
Gender – males are at higher risk than females.
Ethnicity – Caucasians are at higher risk than are Native
Americans, who are at higher risk than African Americans.
Martial Status – single, divorced, and widowed are at higher
risk than married.
Socioeconomic Status – individuals in the highest and lowest
socioeconomic classes are at higher risk than those in the
middle classes.
Occupation – professional health-care personnel and
business executives are at highest risk.
Method – use of firearms presents a significantly higher risk
than overdose of substances.
Religion – Protestants are at greater risk than Catholics or
Jews.
Family History – higher risk if individual has family history of
suicide.
Suicide 222
Interpersonal Support System

Does the individual have support persons on whom he or she
can rely during a crisis situation? Lack of a meaningful
network of satisfactory relationships may implicate an
individual at high risk for suicide during and emotional crises.
Analysis of the Suicidal Crisis
The Precipitating Stressor – life stresses accompanied by
an increase in emotional disturbance include the loss of a
loved person either by death or by divorce, problems in major
relationships, changes in roles, or serious physical illness.
Relevant History – has the individual experienced numerous
failures or rejections that would increase his or her
vulnerability for a dysfunctional response to the current
situation?
Life-Stage Issues – the ability to tolerate losses and
disappointments is often compromised if those losses and
disappointments occur during various stages of life in which
the individual struggles with developmental issues (e.g.,
adolescence, midlife).
Psychiatric / Medical / Family History
The individual should be assessed with regard to previous
psychiatric treatment. Medical history should be obtained to
determine presence of chronic, debilitating, or terminal illness.
Family history should also be obtained to find out any
depressive disorder in the family, and has a close relative
committed suicide in the past?
Coping Strategies
How has the individual handled previous crisis situations?
How does this situation differ from previous ones?
Suicide 223
Basic Suicide Precautions - Sample Protocol
1. Promote coping skills such as decision making, practical

living skills and activities that prepare for return to the
community.
1. To guide and supervise client activities.
2. Support formal and informal group activities to promote

sharing, cooperation, compromise and leadership.
3. Provide for basic needs of the client, including safety,

privacy, activities of daily living and shelter.
4. Stay with the client while all medications are taken.
5. The plan may be started without a physician’s order, but

a psychiatric consultation must be arranged as soon as
possible.
6. Provide one-to-one nursing supervision. The nurse must

be in the room with the client at all times. When the client
uses the bathroom, the bathroom door must remain
open. Stay within arm’s reach of the client at all times.
Staff should sit next to the client’s bed at night.
7. Use no restraints on general hospital floors.
8. Do not allow the client to leave the unit for tests or

procedures.
9. Allow visitors and telephone calls unless the client

wishes otherwise. The nurse maintains one-to-one
supervision during visits.
Suicide 224
10. Look through the client’s belongings in the client’s

presence and remove any potentially harmful objects,
e.g., pills, matches, belts, razors, tweezers, and mirrors
or other glass objects.
11. If suicide precautions are initiated after the client has

been on the unit for any length of time, make a complete
search of the room.
12. Check that visitors do not leave potentially harmful

objects in the client’s room.
13. Serve the client’s meals in an isolation meal tray that

contains no glass or metal silverware.
14. Prior to instituting these measures, explain to the client

what you will be doing and why physician must also
explain this to the client. Document this explanation in
the chart.
15. Do not discontinue these measures without an order

form a psychiatrist.
Suicide 225
Scenario
Mr. Kamran, a 30 years old man, was alright two years back,
then he had a road traffic accident while going to a picnic by
coach and developed multiple injuries on the body especially
his genital area.
He was hospitalized for about one month, after which he was

discharged from hospital, but after one week of discharge he
again visited doctor in Outpatient Department, complaining of
sexual weakness along with lack of interest in life and daily
quarrels with feelings of hopelessness for future. He always
feel alone and absence of support. He has unsuccessfully
tried several times to end his life.
226 Suicide
NURSING CARE PLAN

Patient Name: Mr. Kamran
Age 30 years
Sex Male
Medical Diagnosis Suicide
Nursing Diagnosis Hopelessness
Assessment Nursing Goal Intervention Evaluation
Diagnosis
Subjective Data Short Term Goal
Hopelessness related to absence of support system and

According to the client’s parents, he is a • The client will • Evaluation of suicidal is an
perception of worthlessness evidenced by verbal cues.

Identify stressors in client’s
unmarried man. He is alright before one week ongoing process accomplished
verbalize a measure life that precipitated current
and perform his duty well. Sudden he through continuous reassessment
of hope and crises.
changes his behavior and become of the client as well as
aggressive. At home everyone feel his
acceptance of life • Determine coping behaviors determination of goal
and situations over
behavior and worried about his condition. He previously used and client’s achievement. Once the
which he has no
is not taking proper food and drinks. He does perception of effectiveness immediate crises have been
control.
not take part in any activities. His condition then and now. resolved, extended
becomes more and more serious and he id • Encourage the client to psychotherapy may be indicated.
developing abnormal behavior. • The client will make
explore and verbalize feeling
positive statements Objective
Objective Data and perceptions.
about his life. The client develops and
Mr. Kamran, 30 years old man came in • Provide expressions of hope maintains a more positive self-
Psychiatric OPD with complain of abnormal Long Term Goal to client in positive low-key concept and learns more effective
behavior. He looks irritate, drozy, pale and manner.
weak. His walking is imbalance and he
• The client will find a ways to express feeling to others
job. • Help client identify areas of and look free of tension.
speaks loudly.
life situation that are under
Vital Signs own control. Subjective
• The client will The clients recognized that he
• Blood Pressure 100/70 mmHg
participate in group • Identify sources that client
achieved successful interpersonal
• Temperature 98 °F activities. may use after discharge relationships and feel accepted
• Pulse 70 bpm when crises occur or feelings by others and achieve sense of
• Respiratory rate 20 per min of hopelessness and belonging.
possible suicidal ideation
prevail.
References
1. Harber, Hoskins and Leach (1978). Comprehensive
Psychiatric Nursing. 3rd Edition. USA; p 920.
2. Carson Verna Benner (2000). Mental Health Nursing.
2nd Edition. USA; pp 886-900.
3. Wilson S Holly and Kneisl Carol Ren (1979). Psychiatric
Nursing. Wesley California; pp 554-644.
2. Mosby S. Medical Nursing and Allied Health Dictionary. 4th
Edition; p 552.
3. Shives Louise Rebraca and Isaacs Ann (2002). Suicide In:
Basic Concepts of Psychiatric-Mental Health Nursing. 5th
Edition. Lippincott William and Wilkins Philadelphia; pp 512-
527.
4. The Suicidal Client In: Therapeutic Approaches in Psychiatric
Nursing Care. Pp 256-265.
5. Taylor Monat Cecelia (1994). Essential of Psychiatric Nursing.
14 Edition. USA; pp 242-247.
6. Townsend Marry C (1941). Psychiatric Mental Nursing. pp
450-459.
7. Jacobs (2000). A 52 Year Old Suicidal Man. JAMA
283(20):2693. Assessed by http://www.google.com on July 15,
2005.
8. http://www.yahoo.com.esk. com.askjeeves. Assessed on July
15, 2005.
9. http://www.msn.search.com.lycos.search.lycos.com. Assessed
on July 15, 2005.
10. http://www.hotpot.search.hotpot.com. Assessed on July 15,
2005.
Jamshoro Sindh
Community Grief and Disaster Response
ACN III
Riffat Yasmin
BScN Year II
Mrs. Ruth K. Alam

Terrorism, large-scale violence, and disaster are severely disturbing problems that
engender feelings of profound grief, anxiety, vulnerability and loss of control throughout the
communities that they affect, whether local or worldwide incidence like the terrorist attack on
the World Trade Center, awareness of these issues have increase profoundly. Biological and
chemical weapon attack, and natural disaster or major accident also trigger this type of
response, which has been called incidence, stress or disaster response, thought deliberate
human attack general result in more severe stress.
Definition
Community grief refer to grief shared by member of community in response to a
significance loss or change such as natural disaster, accident, or crime in which many people
are killed or injured.
Risk Factor
 Health for example, injury, disability, or illnesses.
 Job or status.
 Loved one death or separation.
 Termination of a relationship.
 Traumatic loses inability to share grief with others.
 Lack of interpersonal support.
Assessment
• Denial of loss
• Difficulty in accepting significant loss
• Denial of feeling
• Difficulty in expressing feeling
• Fair of intensity of feeling

• Rumination
• Feeling of despair, hopelessness, disillusionment.
• Feeling of helplessness and powerlessness.
• Loss of interest in activity of daily living.
• Anhedonia (inability to experience pleasures).
• Ambivalent feeling towards the lost person or object.
• Gilt feeling
• Crying
• Anxiety
• Agitation
 Emotional and Intellectual dimension
• Fatigue
• Self destructive behavior.
• Accident proneness.
• Anger, hostility, or aggressive behavior.
• Depressive behavior
• Withdrawn behavior
• Beliefs toward highest power action that effected on him or herself.
• Faith on any folk remedies or any other alternatives.
Nursing Diagnosis
 Ineffective health maintenance.
 Disturb sleep pattern.
Short-term Goals
The client will be:
• Be free of self inflicted harm.
• Identify the loss.
• Verbalize or demonstrate decrease suicidal aggressive behavior.
• Express feeling verbally and nonverbally.
Long-term Goals
The client will be:
• Demonstrate reestablished relationship or social support in the community.
• Participate in continue therapy, if indicated.
• Progress through the grieving process.
Initially, assigned the same staff member to The client may be overwhelmed by
the client then gradually vary the staff and fear facing the loss. The client
people. ability to respond to other may be
impaired. Limit the number of new
contact provides consistency and
facilitate familiarity.
After establishing rapport with the client Your presence and telling the client
bring up the loss in a supportive manner, if you will return the demonstrate caring
the client refuse to discuss it, withdraw and and support. The client may need
state your intention to return. emotional support to face and express
painful feeling.
Encourage the client to recall experience Discussing the lost object or person
and talk about the relationship with the lost help the client identifies and expresses
person. Discuss change in the client feeling what the lost means to him or her and
towards self, others and the lost person. his or her feeling.
Encourage appropriate expression of all Feelings are not inherently bad or

types of feeling toward the lost person or good. Giving the client support for
object. Ensure the client that negative expressing feelings may help the
feeling like anger and resentment are client except uncomfortable feeling.
normal and healthy in grieving.
Convey to the client although feeling may The client may fear the intensity of
be uncomfortable, they are natural and his or her feeling.
necessary and they will not harm him or her.
Provide opportunities for the client to Physical activity provides a way to

release tension, anger, show physical relieve tension in a health, non-
activity, and promote this as a healthy mean destructive manner.
of dealing with stress.
Encourage the client to talk with other about The client needs to develop
the loss, his or her feeling, and change independence skill of communicating
resulting from the loss. feeling and expressing grief to others.
Facilitate sharing, ventilating, feeling, and Sharing grief with other can help the
support among client. Use longer groups for client identify and express feeling and
our general discussion of loss and grief. For feel normal. Dwelling on grief in
ever help the client understand that they are social interaction can result in other
limits to sharing grief in our social contexts. person discomfort with their own
feeling and avoid the client.
Teach the client and significant other about The client and significant other may
the grief process. have little or no knowledge of grief or
the process involved in recovery.
In each interaction with the client try to The client need to integrate the loss
include some discussion of goal, the future, into his or her life.
and discharge plan.
Evaluation
 The client has express feeling verbally and nonverbally be free of self inflected harm.
 The client has verbalized the knowledge of grief process and verbalize acceptance of
laws.
References
2nd Edition.
USA.
Bulletin; 57:101-113.

Jamshoro Sindh
Community Grief and Disaster Response
ACN III
Riffat Yasmin
BScN Year II
Mrs. Ruth K. Alam

Terrorism, large-scale violence, and disaster are severely disturbing problems that
engender feelings of profound grief, anxiety, vulnerability and loss of control throughout the
communities that they affect, whether local or worldwide incidence like the terrorist attack on
the World Trade Center, awareness of these issues have increase profoundly. Biological and
chemical weapon attack, and natural disaster or major accident also trigger this type of
response, which has been called incidence, stress or disaster response, thought deliberate
human attack general result in more severe stress.
Definition
Community grief refer to grief shared by member of community in response to a
significance loss or change such as natural disaster, accident, or crime in which many people
are killed or injured.
Risk Factor
 Health for example, injury, disability, or illnesses.
 Job or status.
 Loved one death or separation.
 Termination of a relationship.
 Traumatic loses inability to share grief with others.
 Lack of interpersonal support.
Assessment
• Denial of loss
• Difficulty in accepting significant loss
• Denial of feeling
• Difficulty in expressing feeling
• Fair of intensity of feeling

• Rumination
• Feeling of despair, hopelessness, disillusionment.
• Feeling of helplessness and powerlessness.
• Loss of interest in activity of daily living.
• Anhedonia (inability to experience pleasures).
• Ambivalent feeling towards the lost person or object.
• Gilt feeling
• Crying
• Anxiety
• Agitation
 Emotional and Intellectual dimension
• Fatigue
• Self destructive behavior.
• Accident proneness.
• Anger, hostility, or aggressive behavior.
• Depressive behavior
• Withdrawn behavior
• Beliefs toward highest power action that effected on him or herself.
• Faith on any folk remedies or any other alternatives.
Nursing Diagnosis
 Ineffective health maintenance.
 Disturb sleep pattern.
Short-term Goals
The client will be:
• Be free of self inflicted harm.
• Identify the loss.
• Verbalize or demonstrate decrease suicidal aggressive behavior.
• Express feeling verbally and nonverbally.
Long-term Goals
The client will be:
• Demonstrate reestablished relationship or social support in the community.
• Participate in continue therapy, if indicated.
• Progress through the grieving process.
Initially, assigned the same staff member to The client may be overwhelmed by
the client then gradually vary the staff and fear facing the loss. The client
people. ability to respond to other may be
impaired. Limit the number of new
contact provides consistency and
facilitate familiarity.
After establishing rapport with the client Your presence and telling the client
bring up the loss in a supportive manner, if you will return the demonstrate caring
the client refuse to discuss it, withdraw and and support. The client may need
state your intention to return. emotional support to face and express
painful feeling.
Encourage the client to recall experience Discussing the lost object or person
and talk about the relationship with the lost help the client identifies and expresses
person. Discuss change in the client feeling what the lost means to him or her and
towards self, others and the lost person. his or her feeling.
Encourage appropriate expression of all Feelings are not inherently bad or

types of feeling toward the lost person or good. Giving the client support for
object. Ensure the client that negative expressing feelings may help the
feeling like anger and resentment are client except uncomfortable feeling.
normal and healthy in grieving.
Convey to the client although feeling may The client may fear the intensity of
be uncomfortable, they are natural and his or her feeling.
necessary and they will not harm him or her.
Provide opportunities for the client to Physical activity provides a way to

release tension, anger, show physical relieve tension in a health, non-
activity, and promote this as a healthy mean destructive manner.
of dealing with stress.
Encourage the client to talk with other about The client needs to develop
the loss, his or her feeling, and change independence skill of communicating
resulting from the loss. feeling and expressing grief to others.
Facilitate sharing, ventilating, feeling, and Sharing grief with other can help the
support among client. Use longer groups for client identify and express feeling and
our general discussion of loss and grief. For feel normal. Dwelling on grief in
ever help the client understand that they are social interaction can result in other
limits to sharing grief in our social contexts. person discomfort with their own
feeling and avoid the client.
Teach the client and significant other about The client and significant other may
the grief process. have little or no knowledge of grief or
the process involved in recovery.
In each interaction with the client try to The client need to integrate the loss
include some discussion of goal, the future, into his or her life.
and discharge plan.
Evaluation
 The client has express feeling verbally and nonverbally be free of self inflected harm.
 The client has verbalized the knowledge of grief process and verbalize acceptance of
laws.
References
2nd Edition.
USA.
Bulletin; 57:101-113.

Jamshoro Sindh
Delusional Disorder

(Assignment # 1)
Riffat Yasmin
BScN Year II
Mrs. Munira A. Ali

The primary feature of a delusional disorder is the persistence of a delusion or false
belief that is limited to a specific area of thought and not related to any organic or major
psychiatric disorder. The different types of delusion disorders include:
Erotomaniac - This is an erotic delusion that is love by another person usually famous
person the may come into contact with the law as he or she write letter make telephone call.
Grandiose - The client usually convinced that a spouse or partner is unfaithful has
created a fantastic invention has a religious calling or believes.
Jealous - The client believes that a spouse is not a true. The client may fallow the
partner read mail and so forth.
Persecutory - This type of delusion is the most common. The client believe that he or
she is being spied on followed harassed drugged and may seek to remedy.
Somatic - The client believe that he or she emit a foul odor from somebody orifice has
infestation of bugs or parasites.
Etiology
No clear etiology has been identified but severe stress, hearing impairment and low
socioeconomic status may be risk factors
Epidemiology
Delusion disorder are most prevalent in people 40to 55 years old, thought the age of
onset ranges from adolescence to old age.
Nursing Diagnosis
 Disturb thought processes
 Ineffective role performance
 Risk for other directed violence

Because the delusion may persist despite effort to extinguish it, the goal is not to
eliminate the delusion but to contain its effect on client’s life. It is important to provide the
client with a safe person with whom he or she can discuss the delusional belief and validate
perception or plan of action to prevent the client from acting base on that delusional belief.
 Give the client now that all feeling ideas, beliefs, are permissible to share with you.
 Give the client feedback that other does not share his or her perception and belief.
 Assist the client to identify difficulties in daily life that are caused by or related to
delusional ideas.
 Explore with the client ways he or she can redirect some of energy or anxiety
generated by the delusional ideas.
 Encourage the client to use his or her contact person as often as needed. It may be
helpful to use telephone contact rather than always scheduling an appointment.

References
2nd Edition.
USA.
Bulletin; 57:101-113.

Jamshoro Sindh
Delusional Disorder
ACN III Major NCP

(Assignment # 2)
Riffat Yasmin
BScN Year II
Mrs. Munira A. Ali

NURSING CARE PLAN
TITILE: Anxiety Related to Disturb Thought Process
 Erratic, impulsive behavior. Short-term Goals:  The client may need to be • The client’s physical The client has
 Poor judgment.  The client will be free secluded or restrained if he or safety, health and well- verbalized decrease
Disturb thought process related to impaired social interaction.

 Agitation from self-inflected she attempts self-mutilation or being are priorities. feeling of fear, guilt
 Feeling of distress harm. harm. and anxiety.
 Illogical thinking, irrational  The client will  Try to substitute a physically  Substitute behaviors
ideas. verbalize feelings of safe behavior for harmful may satisfy the client’s The client has
fear, guilt and anxiety, practices, even if the new need for compulsive expressed feeling
 Extreme intense feeling.
and express feelings behavior is compulsive or behaviors but protect nonverbally in safe
 Refusal to except actual
nonverbally in a safe ritualistic. For example, if the the client’s safety and manner.
information from other.
manner. client is cutting himself or provide a transition
 Socially inappropriate or
herself, direct him or her toward decreasing
odd behavior in certain
Long-term Goals: toward tearing paper. these behaviors.
situation.
 The client will manage  If the client’s behaviors are  Preventing feelings
his or her anxiety not harmful, try not to call may help diminish the
response attention to the compulsive client’s anxiety and
independently. acts initially. thus diminish
 The client will obsessive thoughts and
demonstrate decrease compulsive acts.
in obsessive thought to  Encourage the client to  Expressing feelings
a level at which the verbally identify his or her may help diminish the
client can function concerns, life stresses, fears, client’s anxiety and
independently. and so forth. thus diminish
 The client will obsessive thoughts &
maintain adequate compulsive acts.
psychological  Encourage the client to  The client may be
functioning follow express his or her feelings in uncomfortable with
through with continue way that are acceptable to the some ways of
therapy if needed. client. expressing emotions or
find them unacceptable
initially.
 Difficulty or slowness completing  If the client is ruminating •
daily living activities because of (e.g., on his or her
ritualistic behavior. worthlessness),
acknowledge the clients
feelings, but then try to
redirect the interaction.
Discuss the client’s
perceptions of his or her
feelings and possible ways
to deal with these feelings.
If the client continues to
ruminate, withdraw your
attention and state when
you will return or will be
available for interaction
again.
 Do not argue with the •
client about the logic of
delusional fears.
Acknowledge the client’s
feelings, interject reality
briefly, and move on to
discuss a concrete subject.
• Observe the client’s •
eating, drinking, and
elimination patterns, and
assist the client as
necessary.
• Assess and monitor the •
client’s sleep patterns,
and prepare him or her
for bedtime by decreasing
stimuli, giving a backrub,
and other comfort
measures or medications.
• You may need to allow •
extra time, or the client
may need to be verbally
directed to accomplish
activities of daily living
(personal hygiene,
preparation for sleep, and
so forth).
• Provide opportunities for •
the client to participate in
activities that are easily
accomplished or enjoyed
by the client; support the
client for participation.
• Teach the client and •
family or significant
others about the client’s
illness, treatment or
medications, if any.
Sharifa Bibi
January 24, 2008

Nursing Care Plan
Introduction
A 34 years old client named Razia residing in a rented house at Karachi. According to
the client, she worked in a private firm as a receptionist. She has two children one daughter
and one son. She is spending her time with her family happily and satisfactorily. But after the
death of her husband in road traffic accident two months back. She went into minor shock
and after recovery she was suffering from depression and therefore she was admitted in the
hospital for treatment.

NURSING CARE PLAN
Patient’s Name: Razia W/o Akram Ward No: 20 Bed No. 8 Date of Admission: 02-09-2007.
Age: 34 Years
Nursing Diagnosis: Ineffective individual coping related to depression in response to identifiable stressor (Death of Husband).
Date Assessment Nursing Planning Interventions Rationales Evaluation
Diagnosis
Subjective Data Short term goal • Assess the causative and • To identify the stressors of the Short term goal
Ineffective individual coping related to depression in response to

The client verbalize that she is The client will contributive factors towards situation. The client verbalized
suffering from tension due to verbalize the feeling loss related grief. the feeling related to
the death of her husband and related to her • Establish report by spend • To provide supportive her emotional state.
I cannot live without him, my emotional state. time with client. companionship to build good
life is nothing. Long term goal
identifiable stressor (Death of Husband).

rapport.
Long term goal • Offer support and • Let the client know that, we are The client made
Objective Data The client will: encourage expression of her understanding her feeling. decision and follow
A 34 years old client sitting on • Make decision feelings. through with appro-
bed, low mood, low self and follow up. priate actions to
• Listen carefully as client • To collect facts and observe
esteem, anxiety, lacks • Through with change provocative
spoke. facial expression.
interpersonal skills, loneliness, appropriate situations in personal
headache, restlessness, • Encourage the client to • To motivate the client towards environment.
actions to change develop interest in the routine life.
insomnia, loss of appetite, poor provocative
judgment, and suicidal ideas. activities.
situations in
• Mobilize into a gradual • To reduce the chances of social
personal
increase in activity in daily and drawl.
environment.
Vital Signs routine for a set time span.
Blood Pressure 110/70 mmHg • Facilitate emotional support • To develop the self esteem and
Temperature 99 °F from others. self concept.
Pulse 90 bpm • Promote hopefulness and • To maintain the reality contract,
Respiratory Rate 22 per min setting of realistic goals and reduce the potential
with client and family. complication of depression.
Psychotic Disorder
Reflection
Introduction
During my clinical day, as I entered in Psychiatric Ward, I saw all the clients admitted
in the ward and also observed a silent environment. It was round time. One of the nurses was
busy with medication. She wants to complete administrating medication before round. During
that time, suddenly one of the client hold the medicine tray and start shouting over the nurse
“that you are my enemy, you stolen my things, I will se you.” The attendant of that client hold
him and ward staff also rush over there to handle the situation. On doctor’s advice the Charge
Nurse administered injection to the client. Within a few minutes, the client becomes relaxed
and slept. I was surprised and anxious to saw this situation. The Charge Nurse told me that
this client has history of psychotic attacks and he become normal after the attack. After
getting necessary psychotic medications, he becomes normal and relaxed.
After spending some time in the ward and observing clients suffering from various
psychotic diseases, I went to that client and still found him sleeping. I interviewed his
attendant. According to him, he was fine one year back, but after having fall from ladder, he
complained headache. All necessary diagnosis was carried out including MRI, but reports
were found clear. Now from the last few months we observed aggressive behavior, trying to
threat others, self harming attitude, suicidal ideas, uncomfortable and sleeplessness.
We brought him to the hospital for treatment. While taking interview, the client awake up. He
is looking fresh and calm.
I addressed him by asking small question for which he replied satisfactorily but with
impaired speaking power. I spend some time with him and talked about his activities. This
helps in developing of trustworthy environment and relationship.

Psychotic Disorder
After spending time with the client, I learned that, if we spend some time with
psychotic clients and heard them what they feel, we can help, motivate and encourage them
to become one of the good and useful citizens of the country.
In future, if an opportunity comes in my life, I would like to devote my services for
such clients and especially for those who were suffering from both physical and mental
disorders. I also try to help and encourage my colleagues to make efforts to spend some time
for rehabilitations of such clients.

References
Self Awareness
Advance Concept in Nursing-III
Sharifa Bibi
BScN Year II
Mrs. Durr-e-Shahwar
Self awareness is a unique type of consciousness in that it is not always present, and is
not sought after. Repetitive tasks, as well as some school of thought in art theory and
existentialism seek to reduce self-awareness, at least temporarily. Meditation usually is used
to increase and develop self-awareness. Self awareness remains a critical mystery in
physiology, psychology, biology and artificial intelligence.
According to Locke (1689), personal identity (the self) depends on consciousness not
on substances, nor on the soul.
Self awareness can be defined as the concept in which individual know about one self
for self awareness. You can relate yourself with other for similarity.
Self consciousness is a personal understanding of the core of one’s own identity in
which one individual knows about behavior, thought, attitude and identity by the self
consciousness. One becomes able to know more about oneself internally in the environment.
Self consciousness play an important role in behavior because of self consciousness one
known more and recognize oneself and also modify behavior positively and reflect back
toward culture awareness and religious living standards.
Human self-awareness leads us to recognize three core features of the human
conditions:
The human imagination has no physical boundaries, but our bodies do. In our minds,
we can instantly travel to the ends of the universe, the center of the earth, even the center of
the sun. As seen as we discover something with any instrument, we can make images of it in
our minds. The boundless production of fiction literature is evidence of the creative powers
of the human imagination.
Human spirits can motivate the noblest and holiest thoughts, the most altruistic
actions, and the most beneficial generosities. But they can also produce the most horrible
cruelties and violence against countless people, including suicide of the perpetrators. Our will
effortlessly moves our thoughts one way and then another, untamed by moral law or
conscience. Leaders can sway whole populations to do things – benevolent or malevolent –
that individuals would never, on their own, have contemplated. How can these two extremes
coexist in the same individual? We don’t observe such extremes in other animals. They are
exclusive to the human condition.
Human actions and our very lives are motivated by hope – that we can make a
difference that we can learn and grow and build and make things better. Yet physically
speaking we know that we are mortal, we are made of dust, and we will return to dust.
Despite this realization, hope springs eternal. Without hope, as Albert Camus said, the only
serious philosophical question is why we should not commit suicide. Hope gets us up in the
morning, and drives us forward every day. Aspirations – for hope, meaning, significance,
purpose, identity, peace, happiness, beauty, love – are all aspects of human spirituality.
Unlike self-awareness, self-consciousness has connotations of being unpleasant, and
is often linked to self-esteem. Self-consciousness is credited with the development of identity,
because it is during periods of self-consciousness that people come closest to knowing
themselves objectively. Self-consciousness plays a large role in behavior, as it is common to
act differently when people lose themselves in a crowd. Self-consciousness affects people in
varying degrees, as some people are in constant self-monitoring, while others are completely
oblivious about themselves.
As already stated above that, personal identity (the self) depends on consciousness,
not on substance non on the soul. We are the same person to the extent that we are conscious
of our past and future thoughts, an action in the same way as we are conscious of our present
thoughts and action. Personal identity is only founded on the repeated act of consciousness.
When one is feeling self-conscious, one can feel too aware of even the smallest of
one’s own actions. Such awareness can impair one’s ability to perform complex actions.
For example, a piano player may “choke”, lose confidence, and even lose the ability to
perform when they notice the audience. As self-consciousness fades one may regain the
ability to focus.
Goldberg et al. (2006) has demonstrated the functional separation of sensory
processing and self awareness. Self awareness appears to be process in the superior
frontal gyrus.
In theatre, self-awareness refers to a fictional character, who is depicted as breaking
character, perhaps by breaking the fourth wall. Theatre also concerns itself with awareness
besides self-awareness. There is a possible fractal correlation between the experience of the
theatre audience and individual self-awareness.
In end it can be concluded that self-awareness is a unique type of consciousness in
that it is not always present, and is not sought after. Self awareness remains a critical mystery
in physiology, psychology, biology and artificial intelligence.
The human imagination has no physical boundaries, but our bodies do. We detect
something with any instrument; we can make images of it in our minds. Human spirits can
motivate the noblest and holiest thoughts, the most altruistic actions, and the most beneficial
generosities. But they can also produce the most horrible cruelties and violence against
countless people, including suicide of the perpetrators. Human actions and our very lives are
motivated by hope. We can make a difference that we can learn and grow and build and make
things better.
Personal identity (the self) depends on consciousness, not on substance non on the
soul. We are the same person to the extent that we are conscious of our past and future
thoughts, an action in the same way as we are conscious of our present thoughts and action.
Personal identity is only founded on the repeated act of consciousness and self-awareness.
References
 http://en.wikipedia.org/wiki/Self-awareness. Retrieved on August 16, 2007.
 www.google.com.pk/self awareness. Retrieved on August 16, 2007.
OBJECTIVES
At the end of this presentation, the students will be able
to:
1. Define the terms:

 Self awareness
 Self consciousness
2. Identify the basis of personal identity.
3. Explain the physiological location for self

awareness.
SELF AWARENESS
Definition
Self awareness can be defined as the concept in which

individual know about one self for self awareness. You
can relate yourself with other for similarity.
Self awareness remains a critical mystery in physiology,

psychology, biology and artificial intelligence.
SELF CONSCIOUSNESS
Definition
Self consciousness is a personal understanding of the

core of one’s own identity in which one individual
knows about behavior, thought, attitude and identity by
the self consciousness. One becomes able to know more
about oneself internally in the environment.
Self consciousness play an important role in behavior

because of self consciousness one known more and
recognize oneself and also modify behavior positively
and reflect back toward culture awareness and religious
living standards.
THE BASIS OF PERSONAL IDENTITY
According to Locke (1689), personal identity (the self)

depends on consciousness not on substances, nor on the
soul.
We are the same person to the extent that we are

conscious of our past and future thoughts, an action in
the same way as we are conscious of our present
thoughts and action. Personal identity is only founded
on the repeated act of consciousness.
THE PHYSIOLOGICAL LOCATION
FOR SELF AWARENESS
Goldberg et al. (2006) has demonstrated the functional

separation of sensory processing and self awareness.
Self awareness appears to be process in the superior
frontal gyrus.
Human self awareness leads us to recognize three core

features of human condition:
1. The human imagination.
2. Human spirits.
3. Human actions and our very lives are motivated by

hope.
CONCLUSION
The human imagination has no physical boundaries, but
our bodies do, in our minds, we can instantly travel to
the ends of the universe, the center of the earth and even
the center of the sun. We detect something with any
instrument; we can make images of it in our minds.

REFERENCES
 http://en.wikipedia.org/wiki/Self-awareness.
Retrieved on August 16, 2007.
Shamim Lawrence

Nursing Care Plan
Introduction
A 25 years old lady was admitted in Psychiatric Ward. According to client’s attendant,
she was fine, but after separation, signs and symptoms of depression, sleeplessness, weight
loss, loss of appetite, restlessness, self abusive behavior (nail biting), lack of self esteem,
loneliness, and suicidal attempts appeared.
Self esteem is defined as, “the state in which an individual experiences or is at risk of
experiencing negative self-evaluation about self or capabilities”.
Self esteem is one of the four components of self concept. Disturbed self esteem is the
general diagnostic category. Chronic low self esteem and situational low self esteem
represent specific types of disturbed self esteem. Thus involving more specific interventions
initially the nurse sufficient clinical data validate character overt or covert inability to set
goals, lack of poor problem solving, signs of depression, lack of sleep and change in eating
habits. Poor body presentation, posture, eye contact, movements, self abusive behavior and
suicidal attempts are also recognized as sign and symptoms of low self esteem.
Having the above mentioned signs and symptoms; the client’s relatives had brought
her to Psychiatric Ward and admitted for treatment.

NURSING CARE PLAN
Name: Fouzia Age: 25 Years Sex: Female
Psychiatric Diagnosis: Disturbed Self-esteem.
Nursing Diagnosis: Disturbed self esteem related to separation.
Subjective Data: Short-term Goals: • Inform and reassure client • To establish a trustworthy Short-term Goals:
Disturbed self esteem related to separation.

The client’s attendant, she was The client will feel relationship. The client verbalized
fine, but after separation, she comfortable and that she feel relax and
developed sign and symptoms of relaxed with improved • Client must be relaxed and • To handle the client easily. comfortable and can
depression, sleeplessness, self esteem level. comfortable. call the nurse by
weight loss, loss of appetite, name. Expressed
restlessness, poor body Long-term Goals: • Provide privacy and a safe • To keep the client tension improved self esteem
presentation, posture, eye The client will make environment. free. level.
contact movements, self abusive full attention toward
behavior and suicide attempts. herself and discuss
• Encourage the client to • To reduce depression and
current events. She Long-term Goals:
express feelings especially improve self esteem.
Objective Data: also well oriented with The client made
about way she thinks or views
A 25 years lady having history the date and time. decision about reality,
self.
of disturbed self esteem related The client relates an and feelings. Also
to separation is to lying on the increase in psycho- cope with the anxiety
bed uncomfortably. She is logical and physio- • Explore realistic alternatives. • To change the thinking. level and took part in
looking restlessness, pale, logical comfort. daily activities.
insomnia, loss of appetite, poor • Use diversional therapy. • This increase anxiety and
confidence and self abusive improve self esteem.
behavior (nail biting).
• Provide balanced diet. • To improve the general
Vital Sign health of the client.
Blood Pressure: 90/60 mmHg
Temperature: 98°F • Avoid criticism. • To encourage and give
Pulse: 70 bpm respect to the client.
Respiratory Rate: 20 per min.
Weight: 40 Kg • Administered medication as • For accurate treatment of the
Jaundice: Negative prescribed by the doctor. disease.
Odema: Negative
Disturbed Self Esteem
Reflection
Introduction
On my clinical visit of Psychiatric unit (Ward 20), with the permission of the Head
Nurse, I selected a client who was 25 years old lady. She was lying on the bed with complaint
of depression, sleeplessness, loss of weight, loss of appetite, restlessness, poor body
presentation, posture, eye contact movements, self abusive behavior (nail biting), lack of self
esteem, loneliness, and suicidal attempts.
Analysis
I analyzed the client’s condition. She is looking sleeplessness, restless, uncomfortable
pale, lack of self presentation, eye contact movements, and self abusive behavior (nail biting).
On addressing her, she not responded, therefore, I took interview of her attendant. She told
me that “the client was alright and enjoying her life with her In-laws. One day she receipt a
notice of separation and after that sign and symptoms were appeared which are restless,
sleeplessness, uncomfortable, poor body presentation, posture, eye contact movements, etc.
She also showed loss of appetite, weakness, loss of weight and self abusive behavior along
with suicidal attempts.”
Conclusion
Disturbed self esteem is the general diagnostic category of reduced self concept.
Chronic low self esteem and situational low self esteem represent specific types of disturbed
self esteem involving lack of poor problem solving, signs of depression, lack of sleep and
change in eating habits, poor body presentation, posture, eye contact, movements, self
abusive behavior and suicidal attempts by the client. To improved self esteem levels of such
client, specific nursing interventions are required, which enable the client to cope with the
situation and live useful independent life.

Disturbed Self Esteem
Learning
I had learned from this clinical practice about many things. I started my observations
by taking history of the client which is one of the important parts of nursing diagnosis.
During my observation, I provided her comfort and tried to spend more time with the client,
encourage and motivate the client to express her feelings, which enables her to cope with the
situation and improve the self esteem level.
In future, I will like to work with clients suffering from disturbed/impaired self
esteem levels. By spending more time with them, I will try to develop a trustworthy
relationship and motivate them to cope with their present sufferings and encourage them to
express their feelings, which in results enable me to provided necessary nursing care and
intervention, to not only reduce mental disorder but also enable them to spend useful and
independent lives.
References
 Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric
Nursing Care Plans.7th Edition. Philadelphia: Lippincott.
 Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental
Health Nursing. 5th Edition. Philadelphia: Lippincott.
Schizophrenia
ACN III
Sultan Mohammad
Madam Yasmin
OBJECTIVES
At the end of this presentation, the participants

will be able to:
9. Define Schizophrenia.
10. Describe phases and classification of

schizophrenia.
11. Explain the positive and negative

symptoms of schizophrenia.
12. Describe predisposing factors, nursing

diagnosis and medical management of
schizophrenia.
13. Explain nursing intervention and

psychological therapies.
SCHIZOPHRENIA
“Schizophrenia is a severe mental disorder characterized by

psychotic symptoms, thought disorder, hallucination,
delusions, paranoia and impairment in job and social
functioning”.
Medical model diagnostic term for a disintegrative life pattern
characterized by thinking disorder withdrawal from reality,
regressive behavior, poor communication and impair
intrapersonal relationship (Holly WS).
The American Psychiatric Association (1980) defines
Schizophrenic disorder as a large group of disorder usually of
psychotic proportion, manifested by characteristic
disturbances of language and communication thought,
perception, affect and behavior (Jeanette L 1988).
Description of Schizophrenia
Schizophrenia is a particular form of psychosis, a term
encompassing several severe mental disorders that result in
the loss of contact with reality along with major personality
derangement.
The illness can be described as a collection of particular
symptoms that usually in four basic categories; formal though
disorder, perception disorder, feeling or emotional disturbance
and behavior disorders.
1. Formal Thought Disorder – people with schizophrenia
describe strange or unrealistic thoughts. Their speech is hard
to follow due to disordered thinking. Phrases seem
disconnected, and ideas move from topic to topic with no
logical pattern, in what is being said.
They possess extraordinary powers, super human strength, or
superior insights, they may believe that their thoughts are
being controlled by others or being broadcast over the public
airways or that outside thoughts are being implanted in their
heads. When such ideas are persistent, organized, they are
called decisions.
2. Perception Disorder – in perception disorder regularly
report unusual sensory experience, when the illness is in
acute stage. These perceptions are in the form of auditory
hallucination, command hallucination, visual hallucination.
i) Auditory Hallucination – They are hearing someone talk
to them, when in reality no one is there. The voice may
be that of someone the individual recognizes or the voice
may be unknown to the person.
ii) Command Hallucination – when the voice or voices tell
the individual to harm themselves or some one else, in
some manner. The voices may tell the individual to jump
off of a bridge or building.
iii) Visual Hallucination – perceive some one or some things
that is not actually these depending on the nature of
hallucination, and whether the individual perceive it as
threatening, the situation can be very frightening.
3. Feeling or Emotional Disturbance – events that would
normally make a person happy or sad, such as wedding or
funeral, often produce no emotional response in person with
schizophrenia. Their facial expressions remain the same
regardless of what happens around them. Such responses are
called flatness of affect, which together with thought disorders
are important sign of schizophrenia.
It may be frequently result in social withdrawal. Schizophrenic
patient avoids to contacts with friends and loses interest in
daily life and events.
4. Behavior Disorder – peculiar repetitive moments also seen
in schizophrenia, constantly shake their heads. They can
stand in same position for several hours, unable to talk or eat.
Schizophrenics may also become assaultive, making them
dangerous to others, they may be overly intrusive.
Phases of Schizophrenia
Phase I – The schizoid personality – different social
relationship and have a very limited range of emotional
experience and expression. Do not enjoy close relationships
and prefer to be “loners”.
Phase II – Prodromal Phase – social withdrawal impairment in
role functioning. Due to disturbances in communication and
lack of energy, the length of this phase is prolonged lasting for
many years.
Phase III – Schizophrenia – in this phase, psychotic symptom
are prominent.
Phase IV – Residual Phase – Schizophrenia is characterized
by periods of remission and exacerbation.
Classification of Schizophrenia
1. Catatonic Schizophrenia – it is characterized by various
motor disturbances, including catatonic posture and waxy
flexibility.
2. Paranoid Schizophrenia – a person suffers from delusions
of persecution, grandeur or control.
3. Disorganized Schizophrenia – Characterized by
disturbances of thought and a flattened or silly affect.
4. Undifferentiated Schizophrenia – it is characterized by
fragments of the symptoms of different types of schizophrenia.
5. Residual Type – Absence of delusions, hallucination
Symptoms of Schizophrenia
1. Positive Symptoms – refer to thoughts, perceptions, and

behaviors that are ordinarily absent in people in the general
population, but are present in persons with schizo-affective
disorders, depending on their severity, and may be absent for
a long periods in some patients.
 Hallucinations – are “false perception” that are, hearing,

seeing, feeling or smelling things that are not actually
there. The most common type of hallucination is auditory
hallucinations.
 Delusions – are “false beliefs” that is the belief which the

patient holds, but which others can clearly see is not
true. Some patients have paranoid delusions, believes
that others want to hurt them. The patients hold these
beliefs strongly and cannot usually be talked out of them.
 Thinking Disturbances – the patient talk in a manner that

is difficult to follow. For example, the patient may jump
from one topic to the next, stop in the middle of the
sentence, make up new words, or simply be difficult to
understand.
 Disorganized Behavior – inappropriate sexual behavior,

restless cogitative behavior, waxy flexibility.
2. Negative Symptoms
Negative symptoms are the opposite of positive symptoms.

They are the absence of thoughts, perceptions, or behaviors,
that are, ordinarily present in people in the general population.
These symptoms are often stable throughout much of the
patient’s life.
 Blunted Affect – the expressiveness of the patient’s face

voice tone, and gestures is diminished or restricted,
however this does not mean that the person is not
reacting to his or her environment or having feelings.
 Apathy – the patient dose not feel motivated to persue

goals and activities. The patient may feel lethargic or
sleepy. Patient with apathy has little sense of purpose in
their lives and have few interests.
 Anhedonia – the patient feel no pleasure from activities

that he or she used to enjoy or that occur enjoy. The
person may not enjoy watching sunset, going to the
movies or a close relationship with another person.
 Poverty of Speech or Content of Speech – the patient

says very little or when he or she talk, it does not amount
to much. Sometime conversing with the patient can be
unrewarding.
 Inattention – the patient has difficulty attending and is

easily distracted. This can interfere with activities such
as work, interacting with others and personal care skills.
Predisposing Factors
1. Genetic
• Twin studies.
• Adoption studies.
2. Biochemical
• The Dopamine Hypothesis.
3. Physiological Influences
• Viral infection.
• Anatomical abnormalities.
• Histological changes.
• Physical condition.
4. Psychological
• Dysfunctional family system.
• Poor parent-child relationship.
5. Environmental Influences
• Sociocultural factors – lower socioeconomic class.
• Stressful life event.
• Was born in the winter.

Nursing Diagnosis
1. Altered thought process related to delusional thinking, as

evidenced by verbalizations that coworkers are plotting
against patient, extreme suspicion and anxiety.
8. Sensory/perceptual alteration, hallucination, auditory and

visual related to social withdrawal as evidenced by
listening to sounds.
9. Ineffective individual coping related to lack of trust in

others evidenced by refusal to take medicine.
10. Social isolation related to inability to accept

shortcomings in others, evidenced by excessive criticism
of friends.
Medical Management
Patients with schizophrenia often do not respond to treatment

or only partially improve and remain functionally impaired.
Neuroleptic drug therapy greatly shortens episodes of

psychosis.
Antipsychotic drugs also referred to neuroleptics, are essential

to the management of schizophrenia.
Tablet Haloperidol 10 – 20 mg daily.
Tablet Clozapine is also effective against psychotic symptoms

without causing extrapyramidal manifestations side effect,
bone marrow suppression.
Resperidone (Risperdal) is more effective in the treatment of

schizophrenia than Haloposidal in positive and negative
symptoms of schizophrenia; a dosage 3 mg twice a day.
1. Administer antipsychotic medication for example,

stalazine, canpozine, clopazine, risperdal.
2. Assure the patient that you understand that these

experiences must be frightening.
3. Show respect for patient as individual by speaking

directly to them.
4. When patient are hallucinating, attempt to distract them

and focus their attention on real object and situation.
5. Encourage realistic perceptions by using social

reinforces for example, attention, praise.
6. Provide structured environment.
7. To decrease stimuli that may precipitate hallucination.
8. Use concrete, simple, communication rather than

abstract laughty ones.
9. Encourage the expression of feeling for example, fear,

anxiety in a realistic manner.
Psychological Therapies
• Behavioral Therapy is based on the belief that may of
our actions are the result of things that we have learned.
It is a very directive therapy, which sets objectives
(in collaboration with patient) for the patient to attain.
Patients are given homework assignments.
It is particularly good for treating phobias, obsessional
and compulsive behavior and can also be helpful for
anxiety management and exposure therapy.
• Anxiety Management includes education about the
nature of anxiety e.g., fight or flight response, stress
management and problem solving.
• Cognitive Therapy is based on thinking, which includes
exposure, assertiveness and social skill raining.
• Compliance Therapy for severe mental illness, which is
reluctant to take medication; it is the form of counseling.
• Counseling in primary care 6 – 12 sessions.
• Family interventions for people with schizophrenia.
• Interpersonal therapy.
• Problem solving.
• Psychodynamic therapy.
Scenario
Critical Thinking Skills
Jamila, a 23 years old woman, has just been admitted to the

psychiatric unit by her parents. They explain over a few
month, she become more withdrawn. She says in her room
alone, but she has been heard talking and laughing to herself.
Jamila left her home at the age of 18 years, to attend college.

She performed well during the first semester when she
returned to home on Eid festival, she blames her roommate
steals her possession, and started writing to her parents that
her roommate wanted to kill her and turning everyone against
her. She got feared for her life and started missing classes
and stayed on bed most of the time. Her parents took her
home and she was hospitalized and diagnosed with paranoid
schizophrenia and started antipsychotic medication.
Jamila tells the admitting nurse that she quite taking her
medication 4 weeks ago because the pharmacist who fills the
prescription is plotting to have her killed. She believes, he is
trying to poison her. She says that she got this information
from a TV message.
As Jamila speaks, the nurse notices that sometime she stops

in mid-sentence and listens.
NURSING CARE PLAN
Patient Name: Miss Jamila
Age 23 years
Sex Female
Medical Diagnosis Schizophrenia
Nursing Diagnosis Thought Disorder
Diagnosis
Subjective Data Altered thought Short Term Goal • Be sincere and honest when Objective
According to the parents, Jamila left her process related The client will be free The patient seen a decreased
communicating with client
home at the age of 18 years and attend the to delusional from injury and anxiety level and reality base
avoid vague or evasive
college. She performed well during her first thinking, as deceased anxiety level. thinking, increase attention
remark.
semester. evidence by span and feeling of wellness.
When she come to home on Eid festival, she verbalization Long Term Goal • Do not make promises that
blaming her roommate that she wanted to kill that coworkers The client will identify you can’t keep. Subjective
her and after that she did not take interest in are plotting trusting characteristic in • Encourage the client to talk The patient recognizes the
the study and wanted to live alone in the against patient a relationship till to with you, but do not try for delusional thought and will
room. She did not want to talk with anyone extreme hospitalization. information. adopt social relation.
and did not take part in any activity of daily suspicion and
life. anxiety. • Interact with the patient on
the basis of real things.
Objective Data • Do not be judgmental or
A 23 years old female, college student was
brought to the Psychiatric unit by her parents joke about the client belief.
with a complain of psychiatric problem, false • Give positive feedback for
believe and looking non-reality base-thinking the client success.
disoriented and short attention span, impaired • Never convey to the client
judgment incoherence speech, inappropriate
that you accept the
affect, unhygienic condition and felling of
delusions as reality.
confusion.
Vital Signs
• Temperature 99 °F
• Pulse 80 bpm
• Respiratory rate 22 per min
NURSING CARE PLAN
Patient Name: Mr. Kamran
Age 30 years
Sex Male
Medical Diagnosis Suicide
Nursing Diagnosis Hopelessness
Diagnosis
Subjective Data Hopelessness Short Term Goal Evaluation of suicidal is an
According to the client’s parents, he is a related to • The client will • Identify stressors in client’s ongoing process
unmarried man. He is alright before one week absence of accomplished through
verbalize a measure life that precipitated current
and perform his duty well. Sudden he support system continuous reassessment of
of hope and crises.
changes his behavior and become and perception the client as well as
aggressive. At home everyone feel his of
acceptance of life • Determine coping behaviors determination of goal
and situations over
behavior and worried about his condition. He worthlessness previously used and client’s achievement. Once the
which he has no
is not taking proper food and drinks. He does evidenced by perception of effectiveness immediate crises have been
control.
not take part in any activities. His condition verbalcues. then and now. resolved, extended
becomes more and more serious and he id • Encourage the client to psychotherapy may be
developing abnormal behavior. • The client will make indicated.
explore and verbalize feeling
positive statements
Objective Data and perceptions.
about his life. Objective
Mr. Kamran, 30 years old man came in • Provide expressions of hope The client develops and
Psychiatric OPD with complain of abnormal Long Term Goal to client in positive low-key maintains a more positive
behavior. He looks irritate, drozy, pale and manner.
weak. His walking is imbalance and he
• The client will find a self-concept and learns more
job. • Help client identify areas of effective ways to express
speaks loudly. feeling to others and look free
life situation that are under
Vital Signs own control. of tension.
• The client will
participate in group • Identify sources that client
Subjective
• Temperature 98 °F activities. may use after discharge The client recognized that he
• Pulse 70 bpm when crises occur or achieved successful
• Respiratory rate 20 per min feelings of hopelessness interpersonal relationships
and possible suicidal and feel accepted by others
ideation prevail. and achieve sense of
belonging.
References
References
1. Wilson S Holly. Psychiatric Nursing. Wesley California;
p 825.
3. Lancaster Jeanette (1988). Adult Psychiatric Nursing.
3rd Edition. New York; pp 369-372.
5. Taylor Monat Cecelia (1994). Essential of Psychiatric Nursing.
6. Sundeen and Stuart (1991). Principles and Practice of
Psychiatric Nursing. 4th Edition. Philadelphia; p 494.
7. Carson Verna Benner. Mental Health Nursing.
nd
8. White Lois (2001). Foundation of Nursing. 6th Edition. USA; p
1195.
9. http://www.schizophrenia.com/family52.overview.htm.
10. http://www.schizophrenia.com/ami/index.htl accessed on July
13, 2005.
11. Http://www.schizophrenia.com/ecgslo.php accessed on July
10, 2005.
12. Townsend Marry C (1941). Psychiatric Mental Nursing. pp
450-459.
Shagufta Majeed

Nursing Care Plan
Introduction
Faizan, a 33 years old client admitted in Psychiatric unit sitting on bed but frequently
changing place from bed to chair and chair to bed. His appearance is disheveled and his
hygiene is poor. I try to interview the client, but his answers were irrelevant. So I interviewed
his brother and discovered that Faizan has been sleeping poorly, unable to concentrate on
daily activities, show aggressive behavior, suspiciousness, hallucination and delusion.
Faizan’s brother also described that he show this behavior off and on from last five years and
diagnosed with schizophrenia from last four years, but now this has been working as clerk
from last ten years but now he did not show interest in job and did not go to office from last
one month. Faizan’s brother told that Faizan is married and have two daughters and one son.
They lived in a house on rent in a joint family system. So I diagnosed that Faizan’s thought
process is altered.
NURSING CARE PLAN
Patient’s Name: Faizan
Age: 30 Years
Medical Diagnosis: Schizophrenia
Nursing Diagnosis: Disturbed thought process related to as evidenced by inability to evaluate reality secondary to schizophrenia.
Date Assessment Nursing Planning Interventions Rationales Evaluation
Diagnosis
Subjective Data Short term goal • Be sincere and hones when • Delusional clients are extremely Short term
Disturbed thought process related to as evidenced by inability

As the client’s brother verbalized The client will communicating with the client. sensitive about others and can goal
that the client shows aggressive free from injury. Avoid vague or evasive recognize insincerity. Evasive The client
behavior even sometime lash out Demonstrate remarks. comments or hesitation reinforces becomes free
to evaluate reality secondary to schizophrenia

on family members. He also decreased anxiety mistrust or delusions. from injury and
shows suspiciousness toward his level. • Be consistent in setting • Clear, consistent limits provide a his anxiety
sisters that they are hostile to me. expectations, enforcing rules, secure structure for the client. level decreased
As he stated that the client did not Long term goal and so forth. as now he did
sleep even two or more days. He Interact on reality • Do not make promises that you • Broken promises reinforce the not show
told that the client hear voices of based topic. cannot keep. client’s mistrust of others. aggressive
unfamiliar person and client said Sustain attention behavior after
• Encourage the client to talk • Probing increases the client’s
that Bush has send army for me. and concentration two days.
with you, but do not pry for suspicion and interferes with the
to complete task
Objective Data information. therapeutic relationship.
or activities. Long term
A 30 years old client sitting on • Explain procedures, and try to • When the client has full know-
bed, but frequently changing his be sure the client understands ledge of procedures, he or she is goal
place. Sometimes on bed and then the procedures before carrying less likely to feel tricked by the Client able to
on chair. He was not fully them out. staff. realize things in
oriented with time, place but some better
• Give positive feedback for the • Positive feedback for genuine
oriented with persons. way.
client’s successes. success enhances the client’s
Non reality based thinking, labile His attention
sense of well being and helps
affect, short attention and span span increased
make nondelusional reality a
impaired judgments, dist- and now he
more positive situation for the
ractibility, impulsivity, restless, complete daily
client.
and anxious. activities with
• Recognize the client’s delusions • Recognizing the client’s concentration
Vital Signs as the client’s perception of the perceptions can help you after five days.
Blood Pressure 110/70 mmHg environment. understand the feelings he or she
Temperature 99 °F • Initially, do not argue with the is experiencing.
Pulse 90 bpm client or try to convince the • Logical argument does not dispel
Respiratory Rate 22 per min client that the delusions are delusional ideas and can interfere
false or unreal. with the development of trust.
Nursing Care Plan
Intervention Rationale
• Interact with the client on the basis of real things; do not dwell on the delusional • Interacting about reality is healthy for the client.
material.
• Engage the client in one-to-one activities at first, then activities in small groups, • A distrustful client can best deal with one person initially. Gradual introduction of
and gradually activities in larger groups. others as the client tolerates is less threatening.
• Recognize and support the client’s accomplishments. • Recognizing the client’s accomplishments can lessen anxiety and the need for
delusions as a source of self-esteem.
• Show empathy regarding the client’s feelings; reassure the client of your • The client’s delusions can be distressing. Empathy conveys your caring, interest,
presence and acceptance. and acceptance of the client.
• Do not be judgmental or belittle or joke about the client’s beliefs. • The client’s delusions and feelings are not funny to him or her. The client may not
understand or may feel rejected by attempts at humor.
• Never convey to the client that you accept the delusions as reality. • Indicating belief in the delusion reinforces the delusion (and the client’s illness).
• Directly interject doubt regarding delusions as soon as the client seems ready to • As the client begins to trust you, he or she may become willing to doubt the
accept this. Do not argue, but present a factual account of the situation. delusion if you express your doubt.
• Ask the client if he or she can see that the delusions interfere with or cause • Discussion of the problems caused by the delusions is a focus on the present and is
problems in his or her life. reality based.
Cognitive-Behavioral Therapy 292
Schizophrenia
Reflection
Introduction
It was my second clinical day in Psychiatric Unit. After getting introduction
with all health team members, I took permission from the Head Nurse to go the
clients’ bedside and select a client with the diagnosis of Schizophrenia.
Schizophrenia is a mental disorder and it meant for splint mind. Due to this
mental disorder, individual become unable to differentiae between real and unreal, to
think logically and to deal with others persons effectively.
The age of my client was 33 years. He was sitting on the bed uncomfortably
and his dress was dirty. He was not looking neat and clean. According to his attendant,
client is educated and a Government employee. But unfortunately due to that mental
disorder, he is unable to care himself and also not cooperative with his attendant in the
process of bathing and grooming.
Analysis
According to Orem’s theory (1971) a definition of nursing emphasis on the
clients self care needs. Nursing has a special concern; man’s needs for self-care action
and the provision and management of it on a continuous basis in order to sustain life
and health, recover from disease or injury and cope with their effects. Self-care is a
requirement of every person, men, women and child. When self-care is not
maintained, illness, diseases or death will occur. Nurses sometimes manage and
maintain required self-care continually for persons who are totally incapacitated. In
other instances, nurses help persons to maintain required self-care by performing
some but not all care measures by supervising others who assist clients and by
instructing and guiding individuals as they gradually more toward self-care.

Schizophrenia
According to the Orem, nursing care is necessary when the client is unable to
meet or fulfill biological, psychological developmental or social needs. The nurse
determines whey a client is unable to meet these needs and what must be done to
enable the client to meet them.
Learning
I learned from this experience that self-care is one of the basic human needs
necessary for survival and health. The extent to which basic needs are met is a major
factor in determining person’s health status. The goal of nursing is increase, the client
ability to independently meet these needs. Maintenance of personal hygiene is
necessary for an individual’s comfort, safety and well being.
Some people are capable of meeting their own hygienic needs, ill or physically
challenged people may require assistance. So in future, if I get a chance then I will
assist my clients in maintaining their self-care needs and I will educate my students
and colleagues about the importance of self-care need and guide them how they can
assess client’s self-care need and fulfill them.

References
 Erb, K., & Wilkinson, B. (1998). Fundamentals of Nursing: Concepts,
Process and Practice, (5th ed.). New Jersey: Prentice Hall Health.
Nursing Care Plans, (7th ed.). Philadelphia: Lippincott.

AND HEALTH SCIENCE
JAMSHORO SINDH
Cognitive-Behavioral Therapy
ACN III
Shahnawaz
Madam Yasmin
23rd July, 2005

OBJECTIVES

be able to:
1. Define and Describe Cognitive Theory,

Behavior and Cognitive Behavioral Therapy.
2. Differentiate between Cognitive and Behavioral

Therapies.
3. Explain the indication.
4. Formulate the nursing diagnoses.
5. Identify the cognitive-behavioral interventions,

nursing and psychological intervention.
COGNITIVE-BEHAVIORAL THERAPY
Introduction
Cognitive-behavioral therapy combines two very effective

kinds of psychotherapy, cognitive therapy and behavior. It
approaches to treatment useful for the patients experiencing
ineffective individual coping, fear, and powerlessness and self-
concept disturbance.
Cognitive-behavioral therapy is based on the notion that the

way we think about something influences the way we behave
and feel. Negative patterns of thinking tend to be automatic
and pervasive, coloring individuals’ perceptions of the world
around them and affecting their mood and self-esteem.
Cognitive-behavioral therapy used often and successfully with
depressed patients suggests that the depressed unrealistic
negative thought processes are central to becoming and
staying depressed (Belsky 1984).
Definitions
To understand the term cognitive-behavioral therapy it is

necessary to go through the definitions of term’s cognitive
theory and behavior.
Cognitive Theory
Cognitive theorists seek to help clients understand how

negative and conflicting thought patterns influence their
appraisals of certain situations, with the result that their
emotional reactions to these situations – such as anger,
depression, and fear – are exaggerated or inappropriate.
Nurses in the teaching-learning, reasoning, understanding and

remembering can use principles of cognitive learning. Thought
and memory enter into every cognitive action.
Cognitive therapy offers a way of effecting behavioral and

emotional change through analysis and revision of the client’s
thinking and perception.
Behavior
Wolpe’s Definition of Behavior
According to Wolpe, behavior is a conditioned response, that
is, a response, which has been rewarded. Many behaviors
become habits, which are established, long-standing patterns
of response to stimuli. Maladaptive behaviors are thought to
have begun in response to uncomfortable levels of anxiety
and to have been rewarded by decreased anxiety.
Miller and Dollard’s Definition of Behavior
According to Miller and Dollard, behavior reflects a way of
coping with conflict and its associated anxiety. There are two
kinds of conflicts. An avoidance-avoidance conflict occurs
when one must choose between two undesirable alternatives.
An approach-avoidance conflict occurs when one has
ambivalent feelings about an object: one wishes,
simultaneously, toe approach and avoid it.
 Cognitive-behavior therapy uses confrontation as a

means of helping clients restructure irrational beliefs and
behavior.
 The therapist confronts the client with a specific irrational
thought process and helps to rearrange maladaptive
thinking, perceptions or attitudes.
 Cognitive behavior therapy is considered a choice of
treatment for depression and adjustment difficulties.
 Cognitive-behavioral therapy is based on the notion that
the way we think about something influences the way we
behave and feel. Negative patterns of thinking tend to be
automatic and pervasive, coloring individual’s
perceptions of the world around them and affecting their
mood and self-esteem.
 Cognitive behavioral therapy, used often and
successfully with depressed older people, suggests that
the depressed elder’s unrealistic negative thought
processes are central to becoming and staying
depressed (Belsky 1984).
 Cognitive-behavioral therapy focuses on symptoms and
thought processes (rather than a hypothetical
unconscious cause) and fosters a sense of self-
responsibility and self-control, the patients are often
receptive and willing to try it.
 Cognitive and behavioral approaches can be integrated,
using the social-learning concept as a framework.
A comparison of Cognitive Therapy and Behavioral Therapy
can be observed through the following given table.
A Comparison of Cognitive Therapy and Behavioral

Therapy
Cognitive Therapy Behavioral Therapy

Similarities
Formulate symptoms in Same
behavioral terms, and design
specific set of operations to alter
maladaptive behavior.
Collaborate with and coach
client regarding reactive
responses.
Same
Seek to alleviate overt
symptoms or behavioral
problems directly.
Same
Stress here and now, not the
past.
Differences
Use induced and spontaneous Apply techniques of systematic
images to identify desensitization by inducing a
misconceptions and test predetermined sequence of
distorted views against reality. images alternating with periods
of relaxation.
Modify attitudes, beliefs, or Modify behavior directly
modes of thinking that influence (through reciprocal inhibition,
behavior. systematic desensitization and
so on).
Modify ideational content (e.g., Modify behavior directly.
irrational premises and
inferences) to aid change in
behavior.
Work with internally experienced Work with observable behavior.
cognitive structures (schemas)
that influence client’s
perceptions, interpretations, and
images.
Indications
Cognitive-behavioral therapy is a clinically and research
proven break through in mental health care, which is used in
the following conditions.
1. Depression and mood swings.
2. Shyness and social anxiety.
3. Panic attacks and phobias.
4. Obsessions and compulsions.
5. Chronic anxiety or worry.
6. Post traumatic stress symptoms.
7. Eating disorders and obesity.
8. Insomnia and other sleep problems.
9. Difficulty establishing staying in relationship.
10. Problem with marriage or other relationship.
11. Job career of school difficulty.
12. Feeling stressed out.
13. Insufficient self-esteem.
14. In educate coping skills self- or ill-chosen method of
coping.
15. Passivity – Procrastination and “passive aggression”.
16. Substance abuse co-dependency and “enabling”.
17. Trouble keeping feeling such as anger sadness, fear,
guilt, shame, eagerness, excitement, etc. within bounds.
18. Over-inhibition of feeling or expression.
Nursing Diagnoses
There are six basic commonalties that link delirium, dementia,

and amnestic disorders: impaired cognition, alteration in
thought processes, impaired communication, behavioral
disturbances, self-care deficits and impaired socialization. A
comorbid medical condition may exist. These commonalties
are considered during the formulation of the nursing
diagnoses.
Comprehensive Assessment of Impaired Cognition and

Behavioral Manifestations
History – include data regarding birth, developmental stages,

medical history, medication, time of onset of clinical
symptoms, rate of progression, and any family history of
dementia.
Physical Examination – mental status evaluation: obtain

information regarding any past psychiatric treatments. General
physical and neurologic examination.
Studies – Complete blood count, sedimentation rate,

chemistry panel (electrolytes, calcium, albumin, BUN,
creatinine, transminase, blood sugar), thyroid function tests,
VDRL or RPR, urinalysis, serum B12 and folate levels, human
immunodeficiency virus (HIV), if permission is granted.
Imaging – Chest x-ray, head computed tomography scan (CT

scan), Electrocardiogram (ECG).
Additional Studies – Electroencephalogram (EEG),

Neuropsychiatric testing, Head magnetic resonance imaging
(MRI) if vascular dementia suspected, Lumbar puncture (LP),
Drug and alcohol toxicology, Heavy metal screen.
Cognitive Behavioral Interventions

It is preferable to try cognitive-behavioral therapy alone before
prescribing medications, this is for several reasons.
It would seem that cognitive behavior therapy, when applied to
the patients, is a heuristic process. In practice, the preparation
and ongoing evaluation of the treatment’s success, and its
impact upon the client’s broader mental state, guarantee a
collaborative approach sensitive to changes.
The use of specific, individualized assessment tools such as
the Beliefs About Voices Questionnaire, go further in providing
the individuality that successful symptom management
requires. The client who combats the fear to concentrate on
conversations or television will require a strategy that assists
cognitive functioning, not a strategy to assist affect regulation.
Medications – Used judiciously, medication can be an
effective adjunct to psychotherapy for mental disorders in
patients. The high incidence of adverse drug reactions was
observed in elderly patients, therefore careful monitoring and
conservative dosages are required. Moreover, medical and
nursing personnel caring for these patients taking
psychoactive medication require special training and ongoing
staff development.
The goals of cognitive behavioral intervention are the
following:
• Alter pain perception.
• Alter pain behavior.
• Provide clients with greater sense of control over pain.
Many cognitive behavioral pain relies strategies are also used
to relieve stress.
Interventions such as progressive relaxation, guided imagery,
therapeutic touch and biofeedback.
Types of Distraction
1) Visual distraction.
i) Reading or watching television.
ii) Watching a baseball game.
iii) Guided imagery.
2) Auditory distraction.
i) Humor.
ii) Listening to music.
3) Tactile distraction.
i) Slow, rhythmic breathing.
ii) Massage.
iii) Holding or stroking a pet or toy.
4) Intellectual distraction
i) Crossword puzzles.
ii) Card games (e.g. bridge)
iii) Hobbies (e.g., stamp collecting, writing story).
Milieu Therapy – a broad, all-encompassing intervention,
may be adapted to meet the needs of most of the nursing
diagnostic categories. In particular, milieu therapy is
appropriate for clients experiencing diversional activity deficit,
self-care deficit, sleep pattern disturbance, self-concept
disturbance, high risk for violence, altered thought processes,
powerlessness, and impaired physical mobility.
Precaution
Benzodiazepine drugs such as alprazdom (Xanall) plus certain
other types of tranquilizers can be habit forming, if taken over
a long time or in high doses.
304 Cognitive-Behavioral Therapy
Interventions within a Therapeutic Milieu
Structure Containment Support Involvement Validation

Regular meal times Physical aspects of Nourishment Mutual goal setting Reality orientation
Scheduled activities the facility include the Medication Self-care Feedback and acceptance
Predictability and interior design, safety Social support Client contracting Interaction and contact
routine features, atmosphere, Reassurance Community meetings with the world
Consistency space, privacy, lighting Visitors Family involvement Music, touch, warmth, and
Bowel/bladder location, temperature, Physical therapy Client self-evaluation creative expression
program noise, odors, colors, and occupational Suggestion box Sensory stimulation
Shift change infection control, therapy Client autonomy and Focus on positive aspects
Medication time restraints, confine- Spiritual expression decision making of behavior
Vita signs ment, isolation, Consistent positive Group work “Downplay” of negative
Regular MD visits “homey” atmosphere staff attitudes Newspaper and TV
Primary nursing of client rooms, Handrails One-on-one relationships
Care planning roommates, access to Mutual goal setting Excursions outside
Evaluation public transportation, Exercise
“knock before
entering” policy
1. Use environmental manipulation to assist patient to

cooperate with plan for activities of daily living.
2. Allow use of toilet articles brought from home, play soft

music or relaxation tapes at rest or bedtime.
3. Give positive reinforcement with praise, smiles and

rewarding experiences for cooperation in activities.
4. Establish an effective communication pattern depending

on degree of deterioration.
5. Speak calmly, clearly and slowly one sentence at a time

and repeat as necessary, use short and simple
sentences.
6. If patient is confrontive yelling or belligerent do not argue

or raise your voice, speak gently and calmly and patient
will calm down.
Psychological Intervention
Psychological interventions in psychosis have been found to

produce positive responses in about 50% cases however,
isolating the determinant factors that predict improved
psychotic symptomatology have not been clearly
demonstrated. Psychotic symptomatology refers to a broad
range of features commonly associated with various
psychiatric disorders.
Generally, symptom management is achieved by enabling the

client to link feelings and patterns of thinking and connect
them to subjective distress and life disruption. This is usually
done by examining the evidence in support of and against the
distressing belief, using reasons and logic to find an
acceptable explanation and challenging habitual patterns of
thinking. The necessary collaboration and assessment is
therapeutic in itself and the added focus and direction
provided by specific interventions serves to guide and develop
practice.
Psychological preparation of children for surgery using

behavioral strategies (e.g., relaxation and training in coping
skills) has been beneficial in reducing postoperative anxiety
and distress and generally improving psychological
adjustment.
Scenario
Mr. Jim, a 58 years old man, was seen by the nurse

practitioner, two weeks after the death of his wife. They had
been married 30 years and never had any children.
Jim’s sister and brother-in-law suggested that he tell his

primary clinician that he was having difficulty adjusting to the
death of his wife. During the visit, Jim confided in the nurse
that he had not been sleeping well. His affect was blunted as
he stated that he thought he would be the first to die. He
informed the nurse that he did not want to take any medication
for insomnia or depression but that he was willing to try
alternative measures to sleep better at night.
NURSING CARE PLAN

Name: Mr. Jim
Age 58 Years
Sex Male
Medical Diagnosis Depression
Nursing Diagnosis Sleep pattern disturbance with depression.
Assessment Nursing Expected Intervention Rationale Evaluation

Diagnosis Outcomes
Subjective Data Short term goals • Suggest sleep preparatory • Carbohydrates stimulate • Client kept a
According to the patient, after the death •
difficulty remaining asleep and statement by client that he is not
Disturbed sleep pattern related to depression as evidenced by
Will verbalized activities such as quiet music, secretion of insulin. Insulin sleep diary for
of his wife, he was having difficulty
adjusting to the death of his wife and decreased warm fluids, and decreased decreases all amino acids 7 days.
was not sleeping well. His affect was number
complaints
of active exercise at least one
hour prior to scheduled sleep
but tryptophan in larger
quantities in the brain
• Follow up visit
blunted as he stated that he thought he in one week.
would be the first to die. He did not want regarding loss time. Provide high carbohydrate increases production of
to take any medication for insomnia or of sleep. snacks. serotonin, a neuro- • He was able to
depression, but that he was willing to try transmitter then reduces sleep 5-6 hours
alternative measures to sleep better at • Will report an sleep. each night.
night. improvement in • Assist to bathroom or bedside • The urge to void interrupts • He was able to
sleeping well.
his sleep commode, or offer bedpan at the sleep cycle during the discuss his
Objective Data pattern. 09:00 PM. night. feelings with his
Mr. Jim, a 58 years old male come in
Psychiatric OPD with complain of Long term goals
• Maintain room temperature at • Environment temperature sister and
i.e., the most conducive to brother-in-law
disturbed sleep pattern related to 68 to 72°F.
depression.. He looks irritate and drozy. • Will demons- sleep. and had
decided to
His walking is imbalance. He looks pale trated at least 6
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted attend grief
and week with slow speak. sleep. counseling at
uninterrupted therapeutics prior to 09:00 PM.
Vital Signs sleep night. • Once patient is sleeping place, • Promotes uninterrupted their church.
• Blood Pressure 120/80 mmHg put do not disturb sign on door. sleep.
• Temperature 98 °F • Increase exercise and activities • Promote regular diurnal
• Pulse 70 bpm during the day as appropriate rhythm.
• Respiratory rate 20 per min for patient’s condition.
References
1. Shives Louise Rebraca and Isaacs Ann (2002).
Cognitive Behavioral Therapy In: Basic Concepts of
Psychiatric-Mental Health Nursing. 5th Edition. Lippincott
Williams and Wilkins Philadelphia; p 418.
13. Harber, Hoskins and Leach (1978). Behavioral and
Cognitive Theory and Application In: Comprehensive
Psychiatric Nursing. 3rd Edition. USA; pp 467-484.
14. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-397-
50642-2; pp 386-390.
15. Elsevier Nam Boodiri (2005). Cognitive Therapy In:
Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal
Electric Press Delhi; p 347,
16. Townsend Marry C (1941). The nursing process across
the life span In: Psychiatric Mental Nursing. pp 893-896.
17. Cox HC, Hinz MD, Lubno MA, Newfield SA, Ridenour
NA, Salater MM, Sridaromount KL (1996). Clinical
Applications of Nursing Diagnosis – Adult, Child,
Women’s, Psychiatric, Gerontic, and Home Health
Considerations. McGraw Hill New York; pp 397-398.
18. http://www.google.com. Scott J (2001). Cognitive therapy
for depression. B Med Bulletin; 57:101-113.
19. http://www.google.com. Bryant RA, Sackville T, Dang TS,
Moulds M, Guthrie R (1999). Treating Acute Stress
Disorder: An Evaluation of Cognitive Behavior Therapy
and Supportive Counseling Techniques.
20. http://www.yahoo.com. Bush JW. The Basis of Cognitive
Behavior Therapy.
21. http://www.yahoo.com. Holland M, Baguley I, Davies T
(1999). Psychological Methods of Treating Hallucinations
and Delusions: 1. B J Nursing; 8(15):998-1001.

AND HEALTH SCIENCE
JAMSHORO SINDH
ACN III
Shahnawaz
Madam Yasmin
23rd July, 2005

OBJECTIVES

be able to:


Therapies.
8. Explain risk factors.
9. Describe nursing diagnoses.
10. Discuss cognitive-behavioral interventions,

Introduction

Vague, abstract, and “mysterious” approaches to therapy are

not tolerated well by patients. They seek a therapeutic
relationship that provides some reciprocity. Nurses caring for
them must invest themselves through active involvement and
judicious self-disclosure to foster trust and a warm, caring
relationship.

A combination of cognitive and behavioral approaches has

been found to work best with the elderly. These approaches
are “practical” and very specific, providing concrete goals
(e.g., behavior change or correction of negative thought
patterns) and ongoing evaluation of progress through self-
monitoring of goals accomplishment.
Definitions
Cognitive Theory
The interactive relationship between people and their
environments makes it important to emphasize the clients’
active participation in the process of change: defining
problems, selecting behavioral objectives, and evaluating
outcomes.
Cognitive therapy is a collaborative ‘hypothesis-testing’
approach that uses guided discovery to identify and re-
evaluate distorted cognitions and dysfunctional beliefs.
However, the common misconception that cognitive therapy
uses a fixed set of behavioral (e.g., activity scheduling) and
cognitive (e.g., challenging automatic thoughts) techniques is
unfortunate. The therapy is not simply technique drive. The
interventions are selected on the basis of a cognitive
conceptualization the uniquely identifies the likely core
negative beliefs of that individual and explains the onset and
maintenance of their depression. If the patient shows a low
level of functioning, behavioral techniques may be used to
improve activity levels and improve moods, but the goal is still
to identify and modify negative cognitions and maladaptive
underlying beliefs.
Behavior
Wolpe’s Approach to Behavioral Therapy
The behavioral therapist, in contrast to practitioners using
other therapeutic approaches, takes total responsibility for the
cure of the client. The client exhibits maladaptive behavior,
and the therapist has the tools to correct it. The goals of
treatment are to decondition anxiety and to alter maladaptive
behavior.
Deconditioning of anxiety is central to behavioral therapy four
methods are used.
1. Assertive behavior is the expression of emotion
appropriate to the current situation rather than an
expression of anxiety.
2. Systematic desensitization is a step-by-step use a
counteracting emotion to overcome an undesirable
emotional habit and can occurs in four steps (a) training
in deep muscle relaxation, (b) use of a scale of
subjective anxiety, (c) construction of anxiety hierarchies,
and (d) use of relaxation techniques in conjunction with
desensitization.
3. Evoking strong anxiety is used as another way to
decondition anxiety. In this, two techniques are used;
(a) flooding and (b) abreaction.
4. Operant conditioning is a method that deals with
conditioned motor and cognitive behaviors rather than
autonomic behavior. The point of operant conditioning is
to elicit adaptive motor and cognitive behaviors.

Miller and Dollard’s Approach to Behavioral Therapy
There are four fundamentals of learning: A drive – is
motivation; it can be primary (biological) or secondary
(learned). A cue – is a stimulus, a push to respond.
A response – is a thought, feeling, or action caused by the
cue. A reinforcement – is a reward for a response. Miller and
Dollard consider a decrease in fear and anxiety to be the
major reinforcement in neurotic behavior.
Four principles of learning are based on these fundamentals:
1. Extinction – is a decrease in the rate of neurotic behavior
when the behavior is not reinforced.
2. Spontaneous recovery – is the tendency for neurotic
behavior to recur periodically, even in the absence of
reinforcement.
3. Generalization – is the tendency to transfer the learning
in one situation to similar situations.
4. Discrimination – is the ability to notice the similarities and
differences in like situations.
Cognitive-behavior therapy uses confrontation as a means of

helping clients restructure irrational beliefs and behavior. In
other words, the therapist confronts the client with a specific
irrational thought process and helps to rearrange maladaptive
thinking, perceptions or attitudes. Thus, by changing thoughts,
a person can change feelings and behavior. Cognitive
behavior therapy is considered a choice of treatment for
depression and adjustment difficulties. Rational emotive
therapy is a type of cognitive therapy that is effective with
groups whose members have similar problems.
and pervasive, coloring individual’s perceptions of the world
Cognitive behavioral therapy, used often and successfully with
depressed older people, suggests that the depressed elder’s
unrealistic negative thought processes are central to
becoming and staying depressed (Belsky 1984).
Because cognitive-behavioral therapy focuses on symptoms
and thought processes (rather than a hypothetical
unconscious cause) and fosters a sense of self-responsibility
and self-control, the patient are often receptive and willing to
try it. Furthermore, in cognitive-behavioral therapy, the
patients are not required to reveal their private thoughts to the
clinician.
Cognitive and behavioral therapies differ in some important
aspects, but they also have aspects in common. Cognitive and
behavioral approaches can be integrated, using the social-
learning concept as a framework. As you study the rest of this
section, which deals with the teaching-learning process, you
will see areas in which an integration of the two approaches is
possible. A comparison of Cognitive Therapy and Behavioral
Therapy can be observed through the following given table.

Therapy

Similarities
responses.
Same
problems directly.
Same
past.
Differences
of relaxation.
so on).
behavior.
images.
Risk Factors
coping.
Nursing Diagnoses

diagnoses.


dementia.





staff development.
following:
to relieve stress.
iv) Reading or watching television.
v) Watching a baseball game.
vi) Guided imagery.
iii) Humor.
iv) Listening to music.
iv) Slow, rhythmic breathing.
v) Massage.
vi) Holding or stroking a pet or toy.
iv) Crossword puzzles.
v) Card games (e.g. bridge)
vi) Hobbies (e.g., stamp collecting, writing story).
Precaution

“knock before
entering” policy





sentences.

will calm down.


practice.

adjustment.
Scenario

been married 30 years and never had any children. Jim’s
sister and brother-in-law suggested that he tell his primary
clinician that he was having difficulty adjusting to the death of
his wife. During the visit, Jim confided in the nurse that he had
not been sleeping well. His affect was blunted as he stated
that he thought he would be the first to die. He informed the
nurse that he did not want to take any medication for insomnia
or depression but that he was willing to try alternative
measures to sleep better at night.
References
50642-2; pp 386-390.
Behavior Therapy.
NURSING CARE PLAN

Name: Mr. Jim
Age 58 Years
Sex Male

Diagnosis

Will verbalized activities such as quiet music, secretion of insulin. Insulin sleep diary
adjusting to the death of his wife and decreased warm fluids, and decreased decreases all amino acids for 7 days.
complaints
• Follow up
blunted as he stated that he thought he visit in one
of sleep. snacks. serotonin, a neuro- week.
to take any medication for insomnia or
depression, but that he was willing to try transmitter then reduces • He was able
alternative measures to sleep better at • Will report an sleep. to sleep 5-6
night. improvement in • Assist to bathroom or bedside • The urge to void interrupts hours each
sleeping well.
his sleep commode, or offer bedpan at the sleep cycle during the night.
Objective Data pattern. 09:00 PM. night. • He was able
• Maintain room temperature at • Environment temperature to discuss his
i.e., the most conducive to feelings with
depression.. He looks irritate and drozy. • Will demons- sleep. his sister and
brother-in-law
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted and had
and week with slow speak. sleep. decided to
Vital Signs sleep night. • Once patient is sleeping place, • Promotes uninterrupted attend grief
counseling at
• Blood Pressure 100/65 mmHg put do not disturb sign on door. sleep. their church.

AND HEALTH SCIENCE
JAMSHORO SINDH
ACN III
Shahnawaz
Madam Yasmin
23rd July, 2005

OBJECTIVES

be able to:


Therapies.
13. Explain risk factors.
14. Describe nursing diagnoses.
15. Discuss cognitive-behavioral interventions,

Introduction

Vague, abstract, and “mysterious” approaches to therapy are

not tolerated well by patients. They seek a therapeutic
relationship that provides some reciprocity. Nurses caring for
them must invest themselves through active involvement and
judicious self-disclosure to foster trust and a warm, caring
relationship.

A combination of cognitive and behavioral approaches has

been found to work best with the elderly. These approaches
are “practical” and very specific, providing concrete goals
(e.g., behavior change or correction of negative thought
patterns) and ongoing evaluation of progress through self-
monitoring of goals accomplishment.
Definitions
Cognitive Theory
The interactive relationship between people and their
environments makes it important to emphasize the clients’
active participation in the process of change: defining
problems, selecting behavioral objectives, and evaluating
outcomes.
Cognitive therapy is a collaborative ‘hypothesis-testing’
approach that uses guided discovery to identify and re-
evaluate distorted cognitions and dysfunctional beliefs.
However, the common misconception that cognitive therapy
uses a fixed set of behavioral (e.g., activity scheduling) and
cognitive (e.g., challenging automatic thoughts) techniques is
unfortunate. The therapy is not simply technique drive. The
interventions are selected on the basis of a cognitive
conceptualization the uniquely identifies the likely core
negative beliefs of that individual and explains the onset and
maintenance of their depression. If the patient shows a low
level of functioning, behavioral techniques may be used to
improve activity levels and improve moods, but the goal is still
to identify and modify negative cognitions and maladaptive
underlying beliefs.
Behavior
Wolpe’s Approach to Behavioral Therapy
The behavioral therapist, in contrast to practitioners using
other therapeutic approaches, takes total responsibility for the
cure of the client. The client exhibits maladaptive behavior,
and the therapist has the tools to correct it. The goals of
treatment are to decondition anxiety and to alter maladaptive
behavior.
Deconditioning of anxiety is central to behavioral therapy four
methods are used.
1. Assertive behavior is the expression of emotion
appropriate to the current situation rather than an
expression of anxiety.
5. Systematic desensitization is a step-by-step use a
counteracting emotion to overcome an undesirable
emotional habit and can occurs in four steps (a) training
in deep muscle relaxation, (b) use of a scale of
subjective anxiety, (c) construction of anxiety hierarchies,
and (d) use of relaxation techniques in conjunction with
desensitization.
6. Evoking strong anxiety is used as another way to
decondition anxiety. In this, two techniques are used;
(a) flooding and (b) abreaction.
7. Operant conditioning is a method that deals with
conditioned motor and cognitive behaviors rather than
autonomic behavior. The point of operant conditioning is
to elicit adaptive motor and cognitive behaviors.

Miller and Dollard’s Approach to Behavioral Therapy
There are four fundamentals of learning: A drive – is
motivation; it can be primary (biological) or secondary
(learned). A cue – is a stimulus, a push to respond.
A response – is a thought, feeling, or action caused by the
cue. A reinforcement – is a reward for a response. Miller and
Dollard consider a decrease in fear and anxiety to be the
major reinforcement in neurotic behavior.
Four principles of learning are based on these fundamentals:
1. Extinction – is a decrease in the rate of neurotic behavior
when the behavior is not reinforced.
5. Spontaneous recovery – is the tendency for neurotic
behavior to recur periodically, even in the absence of
reinforcement.
6. Generalization – is the tendency to transfer the learning
in one situation to similar situations.
7. Discrimination – is the ability to notice the similarities and
differences in like situations.
Cognitive-behavior therapy uses confrontation as a means of

helping clients restructure irrational beliefs and behavior. In
other words, the therapist confronts the client with a specific
irrational thought process and helps to rearrange maladaptive
thinking, perceptions or attitudes. Thus, by changing thoughts,
a person can change feelings and behavior. Cognitive
behavior therapy is considered a choice of treatment for
depression and adjustment difficulties. Rational emotive
therapy is a type of cognitive therapy that is effective with
groups whose members have similar problems.
and pervasive, coloring individual’s perceptions of the world
Cognitive behavioral therapy, used often and successfully with
depressed older people, suggests that the depressed elder’s
unrealistic negative thought processes are central to
becoming and staying depressed (Belsky 1984).
Because cognitive-behavioral therapy focuses on symptoms
and thought processes (rather than a hypothetical
unconscious cause) and fosters a sense of self-responsibility
and self-control, the patient are often receptive and willing to
try it. Furthermore, in cognitive-behavioral therapy, the
patients are not required to reveal their private thoughts to the
clinician.
Cognitive and behavioral therapies differ in some important
aspects, but they also have aspects in common. Cognitive and
behavioral approaches can be integrated, using the social-
learning concept as a framework. As you study the rest of this
section, which deals with the teaching-learning process, you
will see areas in which an integration of the two approaches is
possible. A comparison of Cognitive Therapy and Behavioral
Therapy can be observed through the following given table.

Therapy

Similarities
responses.
Same
problems directly.
Same
past.
Differences
of relaxation.
so on).
behavior.
images.
Risk Factors
coping.
Nursing Diagnoses

diagnoses.


dementia.





staff development.
following:
to relieve stress.
vii) Reading or watching television.
viii) Watching a baseball game.
ix) Guided imagery.
v) Humor.
vi) Listening to music.
vii) Slow, rhythmic breathing.
viii) Massage.
ix) Holding or stroking a pet or toy.
vii) Crossword puzzles.
viii) Card games (e.g. bridge)
ix) Hobbies (e.g., stamp collecting, writing story).
Precaution

“knock before
entering” policy




sentences.

will calm down.


practice.

adjustment.
Scenario

been married 30 years and never had any children. Jim’s
sister and brother-in-law suggested that he tell his primary
clinician that he was having difficulty adjusting to the death of
his wife. During the visit, Jim confided in the nurse that he had
not been sleeping well. His affect was blunted as he stated
that he thought he would be the first to die. He informed the
nurse that he did not want to take any medication for insomnia
or depression but that he was willing to try alternative
measures to sleep better at night.
References
50642-2; pp 386-390.
Behavior Therapy.
NURSING CARE PLAN

Name: Mr. Jim
Age 58 Years
Sex Male

Diagnosis

Will verbalized activities such as quiet music, secretion of insulin. Insulin sleep diary
adjusting to the death of his wife and decreased warm fluids, and decreased decreases all amino acids for 7 days.
complaints
• Follow up
blunted as he stated that he thought he visit in one
of sleep. snacks. serotonin, a neuro- week.
to take any medication for insomnia or
depression, but that he was willing to try transmitter then reduces • He was able
alternative measures to sleep better at • Will report an sleep. to sleep 5-6
night. improvement in • Assist to bathroom or bedside • The urge to void interrupts hours each
sleeping well.
his sleep commode, or offer bedpan at the sleep cycle during the night.
Objective Data pattern. 09:00 PM. night. • He was able
• Maintain room temperature at • Environment temperature to discuss his
i.e., the most conducive to feelings with
depression.. He looks irritate and drozy. • Will demons- sleep. his sister and
brother-in-law
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted and had
and week with slow speak. sleep. decided to
Vital Signs sleep night. • Once patient is sleeping place, • Promotes uninterrupted attend grief
counseling at
• Blood Pressure 100/65 mmHg put do not disturb sign on door. sleep. their church.
Panic Disorder346
BScN Year II, Session 2006-2008
Advanced Concept of Nursing
Shagufta Rani
Dated: ______________
Panic Disorder347
Definition
The mental status examination is the most important diagnostic tool a psychiatrist has
to obtain information to make an accurate diagnosis.
Background
The mental status examination comes from the psychiatric tradition. It is considered
to be analogous to the physical examine in general medicine (Siassi, 1984). Although usually
described as a type of interview. The mental status examination is really a protocol for
organizing one’s observations of the client. The examination actually takes place throughout
the interview.
Legally, a mental status examination, if conducted against the patient’s will be
considered assault with battery. It is important to secure the patient’s permission or to
document that a mental status is being done without the patient’s approval if in an emergency.
The mental status examination being the moment the patient enters in the office.
When patient enter the office, pay grooming, hygiene, gait and also note things such as
whether the patient is dressed appropriately according to the season. For example, note
whether the patient has come to the clinic in the summer, with three layers of clothing and a
jacket. These types of observations are important and may offer insight into the patient’s
illness.
The next step for the interviewer is to establish adequate rapport with the patient by
introducing himself or herself. Speak directly tot the patient. During this introduction and pay
attention to whether the patient is maintaining eye contact. If patient appears uneasy as they
enter the office attempt to ease the situation by offering small talk or even a glass of water.
Beginning with open-ended questions is desirable in order to put the patient further at
ease and to observe the patient’s stream of thoughts (content) and thought process. Begin the
examination with questions, such as “What brings you here today?” or “Tell me about
yourself.” These types of questions elicit responses that provide the basis of the interview.
Panic Disorder348
Keep in mind throughout the interview to look for nonverbal cues from patient. For example,
not if he or she is avoiding eye contact, acting nervous, playing with their hair, or tapping
their foot repeatedly.
In addition to the patient’s responses to questions, as the interview progresses, more
specific or close-ended questions can be asked in order to obtain specific information needed
to complete the interview. For example, if the patient is reporting feelings of depression, but
only states “I am just depressed.” determining both the duration and frequency of these
depressive episodes is important. Ask leading questions such as “How long have you had
these feelings?” or “When did these feelings begin?” “How many days in the past week have
you felt this way?” These types of question help patients understand what information is
needed from me.
For safety reasons, both the patient and interviewer should have access to the door in
case of an emergency during the interview process. The interviewer develops his or her own
comfortable pace and should not feel rushed to complete the interview in any time. The
process of conducting an accurate history and mental status examination takes practice and
patience, but it is very important in order to evaluate and treat patients effectively.
The following areas are typically covered in the mental status examination section of
a report.
General Appearance and Behavior – when patient enter in the office; pay close
attention to his or her personal grooming, hygiene, gesture, gait, posture and level of activity
of the patient. Note the patient’s sex, age, race, ethnic background and nutritional status by
observing the patient’s current body weight and appearance. Also note the patient’s facial
expressions and behavior. Record whether the patient is hostile, defensive, friendly and
cooperative.
Panic Disorder349
Speech – document information on all aspects of the patient, speech including quality,
quantity, rate and volume of speech. You observe, is the client’s speech coherent. Is it slow or
fast? Are there long silence? Does the client’s speech appear pressure? Does the client use
usual words? Also note tone of the patient during speech.
Mood – the mood of the patient is defined as “sustained emotion that the patient is
experiencing.” Ask questions such as “How do you feel most days?” Describe the patient’s
mode such as depressed, anxious, good, tired, euphoric, irritable, etc.
Affect – a patient’s affect is define in terms of expansive (contagious), euthymic
(normal), constricted (limited variation), blunted (minimal variation) and flat (no variation). A
patient whose mode could be defined as expensive may be so cheerful and full of laughter
that is difficult to refrain from smiling while conducting the interview. A patient’s affect is
determined by the observations made by the interviewer during the interview.
Thought Process – record the patient’s thought process information. The process of
thoughts can be described as looseness of association (irrelevance), flight of ideas (change
topics), racing (rapid thoughts), tangential (departure from topic with no return), neologism
(creating new words), circumstantial (being vague), word salad (nonsensical responses e.g.,
Jabber Wocky), derailment (extreme irrelevance), clanging (rhyming words), punning
(talking in riddles), thought blocking (speech is halted). Take all of these things into account
when documenting the patient’s thought process.
Thought Content – to determine whether or not a patient is experiencing
hallucinations, ask some of the following questions. Do you hear voices when no one else is
around? Can you see things that no one else can see? Do you have other unexplained
sensations such as smells, sounds, or feeling?
Importantly, always ask about command type hallucinations and inquire what the
patient will do in response to these commanding hallucinations. For example, when the
voices tell you do something, do you obey their instructions or ignore them? Types of
Panic Disorder350
hallucinations include auditory (hearing things), visual (seeing things), gustatory (tasting
things), tactile (feeling sensation), and olfactory (smelling things).
To determine if a patient is having delusion, ask some of these questions. “Do you
have any thoughts that other people think are strange?” “Do you have any special powers or
abilities?” “Does the television or radio give you special messages?”
Types of delusion include grandiose (delusion of grandeur), religious (delusion of
special status with God), persecution (belief that someone wants to cause them harm),
erotomanic (belief that someone famous is in love with them), jealousy (belief that everyone
wants what they have), thought insertion (belief that someone is putting ideas or thoughts into
their mind) and ideas of reference (belief that everything refers to them).
Obsession and Compulsions – ask the following questions to determine if a patient
has any obsessions or compulsions. “Are you afraid of dirt?” “Do you wash your hands often
or count things over and over?” “Do you perform specific acts to reduce certain thoughts?”.
Phobias – determine of patient having any fears that cause them to avoid certain
situations. Some possible questions to ask include: “Do you have any fears, including fear of
animals, needles, heights, snakes, public speaking or crowds?
Suicidal Ideation – inquiring about suicidal ideation at each visit always is very
important. In addition, the interviewer should inquire about past acts of self-harm or violence.
Ask the questions when determining suicidal ideation. “Do you have any thoughts of wanting
to harm or kill yourself?”
Homicidal Ideation – inquiring about homicidal ideation is also important during
interview. Ask these types of questions to help determine homicidal ideation. “Do you have
nay thoughts of waning to hurt anyone?” “Do you have nay feelings or thoughts that you
wish someone were dead?” If the reply tone of these questions is positive, ask the patient if
he or she has any specific plans to injure someone and how she or he plans to control these
feelings if they occur again.

Panic Disorder351
Cognitive Functioning – can he client think abstractly? A commonly used strategy
for assessing abstract thinking is to ask the client to interpret a proverb. For example, Don’t
count your chickens before they are hatched. An answer that suggests the ability to think
abstractly might be something like “it means don’t jump the gun. It is not a good idea to
assume that everything is going to work out in your favor.” The client who responds, “well,
chickens come from eggs and you shouldn’t count eggs because you might break them” may
tend to think more concretely.
Consciousness – levels of consciousness are determined by the interviewer and are
rated as: coma – characterized by unresponsiveness, stuporous – characterized by response to
pain, lethargic – characterized by drowsiness, and alert – characterized by full awareness.
Orientation – to elicit responses concerning orientation. Ask the questions to the
patient. What is you full name? (patient), Do you know where you are? (place) What is the
month, the date, the year and the time? (time) Do you know why you are here? (situation).
Concentration and Attention – ask the patient to subtract 7 from 100, then to repeat
the task from that response. This is known as “serial 7s”.
Reading and Writing – ask the patient to write a simple sentence (noun/verb), then
ask patient to read a sentence (e.g., close your eyes). This part of the mental status
examination evaluates the patient’s ability to sequence.
Memory – to evaluate a patient’s memory, ask various types of questions. For
example, What was the name of you grade teacher? (for remote memory), What did you eat
for dinner last night (for recent memory). Repeat these three words, pen, chair, flag
(immediate memory). Tell the patient to remember these words then after 5 minutes, have the
patient to repeat the words.
Abstract Thought – assess the patient’s ability to determine similarities. Ask the
patient, “How two items are alike?” For example, an apple and an orange (good response is
“fruit” and poor response is “round”). Assess the patient’s ability to understand proverbs. For
Panic Disorder352
example “Don’t cry over spilled milk” (good response is don’t get upset over the little things;
poor response is spilling milk is bad).
General Knowledge – test the patient’s knowledge by asking some questions like:
“How many towns in the Karachi?” “Who is the president of the Pakistan?” the interviewer
always should take into consideration the patient’s educational background.
Intelligence – based on the information provided by the patient throughout the
interview. The level of intellectual functioning based upon patient’s educational history,
vocabulary, general information and ability of reasoning.
Insight and Judgment – assess the patient’s understanding of the illness.
Judgment – estimate the patient’s judgment based on the history on an imaginary
scenario. To elicit responses that evaluate a patient’s judgment adequately, ask patient, “What
would you do if you smelled smoke in a crowded theatre?” (good response is to call 9 or get
help; poor response is do nothing or light a cigarette).
Impulsivity – estimate the degree of the patient’s impulse control. Ask the patient
about doing things without thinking or planning. Ask about hobbies such as painting and coin
collecting, etc.
Overview of Taking History
The history and mental status examination are crucial first step in the assessment and
are the only diagnostic tools. Psychiatrists have to select treatment for each patient. Every
component of the patient history is crucial to the treatment and care of the patient.
The patient history should begin with:
Identifying Data – ask patients their name or what name he or she prefers to be
called. Also ask the patient’s marital status, occupation, religious belief, living circumstances,
sex and race.
Chief Complaint – this is the patient’s problem or reason for the visit. Most often, this
is recorded as the patient’s own words, in quotation marks.

Panic Disorder353
History of Present Illness – the important part of taking a history of present illness is
listening. This is the patient’s story of the presenting problem. This is usually involves a
triggering event or something that caused the patient to choose this point in life to seek help.
Past Medical History – list medical problems and all medical illness. Even the most
minute detail of patient’s medical history from as far back as childhood, could play a
significant role in the presenting problem. Be certain to inquire about specific events that may
have occurred in childhood, such as falls, head trauma, seizures, and injuries with loss of
consciousness. All of these could be relevant to their current problem.
Past Surgical History – list all surgical procedures the patient has undergone,
including dates.
Past Psychiatric History – list all of the patient’s treatment and therapy based. For
example individual, couples, family, group, etc. Inquire about past psychotherapies
medication and response, competence and dosages.
Family History – list any psychiatric or medical illness, and methods of treatment
such as hospitalization of family members and responses.
Social History – obtain a complete social history of the patient. Ask patients about
their marital status, employment status and obtain information related to it. Record an
accurate educational history, sex and age of the patient. List the patient’s toxic habits. For
example use of tobacco or alcohol. Ask patient’s housing status and supporting to him.
Record legal problems, this should include jail time, probation and arrest. Patient’s
history also includes hobbies, social activities and friends circle. Inquire about the patient’s
and his or her parents religious beliefs like “did the patient grow up in a strict religious
environment?
Prenatal and Development History – record any relevant prenatal and development
history. Ask about patient’s birth history. Inquire the patient how old they were when they
spoke their first word or took their first step.

Panic Disorder354
Conclusion
They mental status examination and history are the most important diagnostic tools.
A psychiatrist has to obtain information to make an accurate diagnosis although these
important tools have been standardized in their own right.
When the patient enters in the office, pay close attention to their personal grooming,
hygiene, dressing, gait, gesture and posture. The interview establishes adequate rapport with
the patient. It is important to secure the patient’s permission or to document that a mental
status examination is being done without the patient’s approval in an emergency situation.
The process of conducting, taking accurate history and mental status examination
takes practice and patience. The interviewer should not feel rushed to complete the interview
in anytime. Beginning with open-ended questions and as the interview progresses, close
ended questions can be asked in order to obtain specific information. Every component of the
patient history is crucial to the treatment and care of the patient.
The patient history should begin with identifying patient data, chief compliant, history
of present illness, past medical and surgical histories, past psychiatric history, family history,
social history and prenatal and development history. Once the history and mental status
examination completed, document this event accurately and efficiency is important.

Panic Disorder355
References
 Carson, V.B. Mental Health Nursing: The Nurse patient journey. 2nd Edition.
 Hecker, J.E., & Thope, G.L. (2005). Introduction to clinical, psychology sciences,
practice and ethics. 1st edition. India: Publisher Person Education Pvt. Ltd.
 Schmetzer, A.D. Article. Retrieved on September 25, 2007 from
www.google.com.pk/.
Panic Disorder
Sajida Siddique
Mrs. Durr-e-Shahwar
Panic Disorder356
A Case Study
It is the first time Celia had a panic attack. She was working at McDonald’s. It was
two days before her 20th birthday. As she handling a customer a big Mac, she had worst
experience of her life. The earth began to seem to open up beneath her. Her heart began to
pound. She felt she was smothering. She broke into a flop sweat and she was sure she was
going to die. After about 20 minutes of terror, the panic disorder subsided. Trembling, she got
in her car and raced home, and barely left the house for next three months.
Since that time, Celia has had about three attacks a month. She does not know when
they are coming. During attach, she feels dread scaring, chest pain, smothering and choking,
dizziness and shakiness. She sometimes thinks this is all not real and she is going crazy. She
also thinks she is going to die (Seligman, 1993).
What is Panic Disorder?
Afridi (2003) reported that “panic disorder and social phobia re the varieties of
anxiety disorder. To make the correct distinction in them is important. Many people with any
type of anxiety disorder are typically misdiagnosed as begin ‘depressed’. This occur because
any one with an anxiety disorder, including panic and social anxiety is naturally depressed
over their. The panic is disorder is the anxiety that caused by ‘depression’.”
Definition
Panic means sudden uncontrolled fear especially in commercial dealing. When panic
attack becomes common occurrence, and not provoked by any particular situation and person
begins to worry about having attack and change behavior as a result of worry, the diagnose is
panic disorder. People who have panic disorder will often fear that they have life threatening
illness.
People with panic disorder may continue to believe that they are about to die of heart
attack or some other crisis. They may seek medical care frequently from physician to
physician to find out what is wrong with them. The other common belief about people of
Panic Disorder357
panic disorder is that they are going crazy and losing control. Many people with panic
disorder feel ashamed of their disorder and try to hide it from other if left untreated. They
may become demoralize and depressed.
Theories of Panic Disorder
Biological theories of panic disorder have been concerned with poor regulation of
neurotransmitters in particular part of the brain and with the role of genetics theories of panic
disorder.
Neurotransmitter theories – most of the modern theories of the biology of panic
disorder have been the result of the medication effect of the neurotransmitter (and the other
reason norepinephrine). Other researches suggested that when people are given drugs that
alter the activity of the norepinephrine can produce panic attack. Some women with panic
attack increase in during their premenstrual period and the postmentural period due to the
ovarian hormones or progesterone.
Kindling Model – of panic disorder that draws a link between the anticipatory anxiety.
Suffocation False Alarm Theory – another theory of why people with panic disorder
have panic attacks, when they hyperventilate, inhalation carbon dioxide. Suffocation false
alarm theory, each of these procedures elevates levels of carbon dioxide in the blood and
brain. People who develop panic disorder may be hypersensitive to carbon dioxide, the brain
register ‘suffocation’ and this triggers the autonomic nervous system into a full fight or flight
response.
Genetic Theories – finally panic disorder appears to run in families. One family
history study of panic disorder found that rarely one-fourth of the first degree relative of
patient with panic disorder also had a history of panic disorder.

Panic Disorder358
Symptoms of Panic Attack
 Heart palpitation.
 Pounding heart beat.
 Tingling sensation.
 Chill or hot flashes.
 Sweating.
 Trembling or shaking.
 Sensation of shortness of breath.
 Feeling of choking.
 Chest pain and discomfort.
 Nausea and upset stomach.
 Feeling of unreality.
 Fear of losing control.
 Going crazy.
 Fear of dying.
Most people who developed panic disorder were between late adolescence and their
mid 30s. The panic disorder can be deliberating in its own right. People panic disorder often
also suffers from chronic generalized anxiety, depression and alcohol abuse. About one-third
to one an a half of people diagnosed with panic disorder and develops agoraphobia.
Agoraphobia is the fear of places where help might not be available in case of an
emergency. The people with agoraphobia fear crowded places such as market, the shopping
mall, enclose space which as buses, subways. They also fear of open fields particularly they
are alone.
Types of Phobia
Panic Disorder359
Agoraphobia – fear of places where help might not be available in case of emergency.
Specific Phobia – fear of specific object, place or situation.
Natural Environmental Type – events or situation in the natural environment. Person
has external fear of storms, height, or water.
Situational Type – public transportation, bridges, elevators, flying, driving, etc.
Blood, Injection, Injury Type – the person become panic when see any blood injury
or injection.
Social Phobia – fear of being judged or embarrassed by other. Person avoids all social
situations.
Placed Avoided by People with Agoraphobia
Most of the people suffering from agoraphobia avoids to public places like shopping
mall, theaters, buses, supermarket, trains, stores, subways, planes, tunnels, elevators,
restaurants, and railway station, etc.
Sample Structured Interview
 Have you ever had a panic attack when you suddenly frightened, anxious or extremely
uncomfortable?
 Have you ever had four attacks like that in a four weeks period? If no, did you worry
a lot about having another one? How long did you worry?
 When was the last bad one expected?
 What was the first thing you noticed during the attacks?
 Were you short of breath? Have trouble catching your breath? Did you feel dizzy like
you might faint? Did you then race or pound?
 Did you tremble? Did you sweat? Did you feel if you were choking? Did you have
nausea?
 Did things around you seem unreal and did you feel detached from part of your body?
Panic Disorder360
Investigation
 Neuropsychological test.
 Intelligence test.
 Magnetic resonance imaging (MRI) is the newest of the brain imaging techniques and
holds several advantages over both computed tomography (CT) and PET.
 Two other tests that are sometimes used to record the brain activity are: EEG a graph
of the electrical activity in the brain, and PET scan of the human brain. PET scan
provide picture of the activity in the brain.
 Event Related Potential (ERP) is a component of EEG, when person has a thought or
senses something in the environment.
In short, CT, PET, MRI, EEG and ERP are use to investigate the structural and
functional differences between the brain of the people with psychological disorder.
Treatment of Panic Disorder
By using Drugs and Medicines:
Tricyclic Antidepressants – increase level of norepinephrine and a number of other
neurotransmitters. Side effects include dry mouth, blurred vision, difficulty in urinating,
constipation, increase heart rate, sweating, sleep disturbance, hypotension, dizziness, fatigue,
weakness, weight gain and sexual dysfunction.
Serotonin Reuptake Inhibitors – increase levels of serotonin. Side effects include
gastrointestinal upset, irritability initial feelings of agitation, insomnia, drowsiness, tremor
and sexual dysfunction.
Benzodiazepines – suppress the central nervous system and influence functioning in
the neurotransmitter systems. Side effects include addictive interfere with cognitive and motor
functions; withdrawn symptoms are irritability, tremors, insomnia, anxiety, tingling
sensation, etc.
Panic Disorder361
By Relaxation Exercises:
Relaxation exercises can be used to combat the everyday anxiety and the tension
associated with anger that arises in most people’s lives.
Six-second Quieting Response – is a simple breathing technique that one can use
very quickly and in almost any situation to relax when you feel anxious or angry. Draw a
long, deep breath, hold it for 2 or 3 seconds, exhale slowly and completely and as you exhale,
let your jaw and shoulders drop. Feel relaxation flow into your arms and hands.
Quick Head, Neck, and Shoulder Relaxers – These exercises involve tensing or
stretching certain muscles. If you have had a significant injury, such as whiplash or an injured
back, you should not try these exercises without first consulting your physician or physical
therapist.
Some of the muscles that most commonly tense up when we are anxious or angry are
the neck and shoulder muscles. A quick way to release some of this tension is to first tighten
the neck and shoulder muscles as much as possible, then hold this for 5 to 10 seconds. Then
completely release the muscles. Repeat this number of times, focusing on the contrast
between the tension and the relaxation.
Some neck and shoulder tension can also be released by gently rotating you shoulders
first forward and then backward. You can also gently rotate your head from side to side and
from front to back in a circular motion. Then repeat the movements in the opposite direction.
Continue this exercise a number of times until you feel more relaxed. Perform this exercise
very slowly and gently or you may strain neck muscles.
Cognitive Behavioral Therapy – is highly effective in eliminating panic disorder.
There are numbers of component of the cognitive behavior therapy.

Panic Disorder362
References
 Afridi (2005). Panic Disorder: A report. Pakistan.
 Practice guideline for treatment of patient with panic disorder. American Psychiatric
Association. 1998.
 Hocksema, S.N. Abnormal Psychology. 2nd Edition. An International Edition.

Panic Disorder363
Objectives
At the end of this session, the learners will be able to:
 Define teacher.
 Discuss the various styles of teaching.
 Describe the blend of various styles of teaching.
 Enlist some important tips for effective teaching.

Lesson Plan
Subject:
Level of students: BScN-II
Topic: Demonstration of various teaching styles.
Venue: Classroom CoN,
JPMC, Karachi.
Time Objectives Content Method of Evaluation

Teaching
45 minutes
At the end of this

session, the learners
will be able to:
• Definition of • Lecture method. • Question
• Define Teacher teacher. and answer
• Discussion
• Discuss various • Various styles
styles of teaching. of teaching. • Role play
• Quiz.
• Describe the • The blend of • Whiteboard with
blend of various various styles marker.
styles of teaching. of teaching.
• Overhead
• Enlist some • Some projector with
important tips for important tips transparencies.
effective for effective
teaching. teaching.
Assignment: Pre-reading. Reference:

Felder, R.M., & Saloman, B. (2003). Learning
styles and strategies In: Varlla, M.C. Guide to
learning style. Pennsylvania State University.

Sajida Siddique

Introduction
Celia had a panic attack. She was working at McDonald’s. She had worst experience
of her life. The earth began to seem to open up beneath her. Her heart began to pound. She
felt she was smothering. She broke into a flop sweat and she was sure she was going to die.
After about 20 minutes of terror, the panic disorder subsided. Trembling, she got in her car
and raced home, and barely left the house for next three months.
During attach, she feels dread scaring, chest pain, smothering and choking, dizziness
and shakiness. She sometimes thinks this is all not real and she is going crazy. She also thinks
she is going to die (Seligman, 1993).

Focus Assessment
Subjective Data/Objective Data
 Heart palpitation.
 Pounding heart beat.
 Increased blood pressure
 Tingling sensation.
 Feeling of choking.
 Chest pain and discomfort.
 Feeling of unreality.
 Fear of dying.
 Chill or hot flashes.
 Flush/pallor, sweating, paresthesia.
 Insomnia,
 Lack of concentration,
 Irritability
 Nightmares.
 Pupil dilation
 Trembling or shaking and weakness.
 Sensation of shortness of breath.
 Nausea and upset stomach.
 Going crazy.
 Depression and alcohol abuse.
 Feeling of dread, fright, apprehension and/or behaviors of avoidance, narrowing of
focus or danger, deficits in attention, performance and control.

 Verbal reports of panic, obsessions, crying, dysfunctional immobility, aggression,
compulsive mannerisms, escape, hypervigilance, and increased questioning/
verbalization.
 Muscle tightness, fatigue and urinary frequency/urgency.
 Anorexia
 Nausea/vomiting
 Diarrhea/urge to defecate
 Dry mouth/throat.
Diagnosis Consideration
 Neuropsychological test.
 Intelligence test.
 Magnetic resonance imaging (MRI).
 Computed tomography (CT) and PET.
 EEG
 PET.
 Event Related Potential (ERP) is a component of EEG.
In short, CT, PET, MRI, EEG and ERP are use to investigate the structural and
functional differences between the brain of the people with psychological disorder.
Nursing Diagnosis
Fear related to thought disorder.
Planning
 By using Drugs and Medicines:
Tricyclic Antidepressants.
Serotonin Reuptake Inhibitors.

Benzodiazepines
 By Relaxation Exercises:
 Six-second Quieting Response
 Quick Head, Neck, and Shoulder Relaxers.
Expected Outcomes
 Communicates within normal limits of volume.
 Communicates appropriately.
 Verbalizes feelings of anger, fear, frustration.
 Verbalizes how anger affects her verbal communication.
 Maintains as much control as possible.
 Verbalizes goals and expectation.
 Verbalizes feelings of loss of control and helplessness.
Nursing Interventions
The nursing interventions for the diagnosis fear are:
 Assess possible contributing factors
Perception of threatening stimulus
Unfamiliar environment
Intrusion on personal space
Life- style change (promotion, marriage/ divorce, retirement)
Biologic and physiologic change (dysfunction, disability, pain)
Self-esteem threat (abandonment, rejection)
 Distorted perceptions of dangerous stimulus
 Age-related fears
 Unfamiliar environment
Orient to environment using simple explanation.
Speak slowly and calmly.
Avoid surprises and painful stimuli.
Use soft lights and music.
Remove threatening stimulus.
Plain one-day-at-a-time familiar routine.
Encourage gradual mastery of a situation.
Provide transitional object with symbolic safeness.
 Intrusion on personal space
Allow personal space
Move person away from stimulus
Remain with person until fear subside
Later, establish frequent
Use touch as tolerated
 Threat to self-esteem
Encourage person to face the fear
 Distorted perceptions
 Explore superficial interactions
 Fear of imaginary animals, intruders.
 Fear of pain.
 Fear of death.
Rationales
 Psychological defense mechanisms are distinctly individual and can be adaptive or
maladaptive.
 Fear differs from anxiety in that fear is a feeling aroused by an identified threat
(specific object) anxiety is a feeling aroused by a threat that cannot be easily
identified.
 Both fear and anxiety lead to disequilibrium.
 Activity uses energy and dissipates the physical reaction to fear.
 Anger may be an adaptive response to certain fears.
 Safety feelings increase when a person identifies with another person who has
successfully dealt with a similar fearful situation.
 A sense of adequacy in confronting danger reduces fear. Fear disguises itself. The
expressed fear may be substitutes for other fear are not socially acceptable. Awareness
of factors that cause nitrifications of fear enhances controls and prevents heightened
feelings. Fear is reduced when the safe reality of a situation is confronted.
 Fear can become anxiety fear becomes internalized and serves to disorganize instead
of becoming adaptive.
 Individuals interpret the degree of danger from a threatening stimulus. The
physiologic and psychological systems react with equal intensity to the perceived
threat increase BP, decrease heart rate, and respiratory rate.)
 Fear is adaptive and is a healthy response to danger.
 Fear is different from phobia.
Evaluation
 Voice raised only occasionally at 24 hours.
 Requests, observations, questions expressed verbally in an appropriate manner.

 Verbalized frustration, fear, anger and loss of control; expressed fear and concern over
loss of independence.
 Apologized for shouting and belittling behavior; verbalized ways in which she used
anger to avoid dealing with loss of control and loss of independence.
 Described feeling dependent on nursing staff for satisfaction of basic needs.
 Established own schedule for ADL and dressing changes; consulted with physical
therapist and chose time for therapy.
 Identified realistic expectations for therapy, discharge, and rehabilitation; established
goal for living situation. Identified changes that had occurred since hospital
admission; expressed her perception of the effect of these changes on life-style;
identified need to regain control and to learn to care for self.
 Identified social supports, age, physical condition, life-style, and stamina; expressed
desire to talk with discharge planner to facilitate interim plan for extended care
facility.
 After establishing schedule for ADL, began active participation in own care; self
sufficient in ADL by 72 hours.

References
 Practice guideline for treatment of patient with panic disorder. American Psychiatric
Association. 1998.
 Hocksema, S.N. Abnormal Psychology. 2nd Edition. An International Edition.
Sajida Siddique

Nursing Care Plan
Introduction
A 25 years old client named Khatoon w/o Rehman residing in own house in a
combined family at Karachi. According to the client, she was alright one week back. After
seeing a road traffic accident and major blood injury, she developed the behavioral change
with the signs and symptoms of lack of appetite, irritability, lack of sleep, fear and poor
concentration, restlessness, up-set, poor confidence, fear and unreliability feelings, pounding
of the heart, fear of dying, trembling or sucking and weakness, sensation of shortness of
breath.
She was brought by her family member to the hospital and admitted in Psychiatric
unit for treatment.

NURSING CARE PLAN
Name: Mrs. Khatoon W/o Rehman Age: 25 Years Sex: Female Date of Admission: 26th September, 2007.
Psychiatric Diagnosis: Panic Disorder
Nursing Diagnosis: Ineffective Individual Coping related to Blood Injury.
Subjective Data: Short-term Goals: • Assess possible contributing • Build up trust. Short-term Goals:
Ineffective Individual Coping related to Blood Injury

The client verbalized that she The client will factors The client called the
has seen a road traffic accident verbalize the • Perception of threatening • Give help in assisting the nurse by her name
with major injuries and blood. feelings of being stimulus client. and remove
After that she developed heart comfortable and • Unfamiliar environment • Client feels comfortable and hesitation.
palpation, pounding of the relaxed. She also confidence The client felt
heart, increase blood pressure, develops ability to relaxed, satisfied and
• Intrusion on personal space • Decrease the fear.
tingling sensation, feeling of take decision with comfortable
chocking, chest pain, full concentration • Life- style change (promotion, • Decrease the anxiety level.
discomfort, feeling of and confidence. marriage/ divorce, retirement) Long-term Goals:
unreality, fear of dying, chill • Biologic and physiologic • Client enables to take proper The client made
and hot flushes, sleeplessness, Long-term Goals: change (dysfunction, disability, decisions. decision about reality,
lack of concentration, The client will make pain) feeling and follow
irritability and nightmares, full attention and • Self-esteem threat (abandon- • Develop the feeling of through with
sensation of short-ness of free from action to ment, rejection) comfortable. appropriate action to
breath, going crazy, change probative • Distorted perceptions of • Verbalizes feeling of panic change provocative
depression, feeling of dread, situations in dangerous stimulus attack. situations in personal
and fright. personal physio- • Age-related fears • Decrease the fear level. environ-ment
logical reaction to • Orient to environment using • Verbalizes the feeling of physiological reaction
Objective Data: panic attack simple explanation. chocking. to panic attack
A 25 years old client sitting on decrease • Speak slowly and calmly. • Identifies event that increase decease. Expressed
bed looking upset and irritable, panic attack about
the attack
restlessness, lack of road traffic accident
• Avoid surprises and painful • Identifies increase panic
concentration, insomnia, loss and blood injury and
of appetite and poor stimuli. attack as a precursor to its effect in future.
confidence. alteration in behavior. Accurately described
• Use soft lights and music. • Decrease in restlessness. relationship between
Vital Sign • Plan one-day-at-a-time familiar • Identifies effective coping panic attack and
Blood Pressure: 150/90 mmHg routine. mechanisms. occurrence of physio-
Temperature: 99°F • Encourage gradual mastery of • Uses relaxation techniques to logical symptoms
Pulse: 120 bpm a situation. decrease anxiety.
Respiratory Rate: 30 per min. • Remain with person until fear • Uses support of family.
subside Later, establish
frequent
• Distorted perceptions • Activities divert the attention
Panic Disorder377
Panic Disorder
Reflection
Introduction
I was deputed at Psychiatric Ward to fulfill my clinical requirement of BSc
Nursing. Therefore, I reached at 08:00 AM at Psychiatric Ward.
I learned that mental status examination is one of the most important
diagnostic tools in the psychiatric to obtain information and to make an accurate
diagnosis. I also learned that mental status examination is considered to be analogous
to the physical examination in the general medicine.
After lecture, with the permission of Head Nurse, I went in the female ward
and
selected a client admitted at Psychiatric ward. She was suffering from panic disorder
related to mental illness.
I examined the client by use of mental status examination and history taking
technique. I felt that these methods were very useful to obtain complete information.
Today I was very excited because when I performed mental status examination of the
client, our teacher appreciated and encouraged for my best efforts.
It is a great opportunity for me; therefore I tried my best to gain more
knowledge especially in terms of managing the clients having psychiatric disorders.
In future, if I get a chance to work with such clients, I will spend more time
with them so that trustworthy relationship develops. I encourage and motivate them to
cope with their present status of mental disorder and become one of the useful
independent lives.
Panic Disorder378
References
 Practice guideline for treatment of patient with panic disorder. American
Psychiatric Association. 1998.
Nursing Care Plans.7th Edition. Philadelphia: Lippincott.
 Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental
Health Nursing. 5th Edition. Philadelphia: Lippincott.

AND HEALTH SCIENCE
JAMSHORO SINDH
Panic Disorder
ACN III
Sultan Salahuddin
Panic Disorder379
Madam Yasmin
23rd July, 2005

Panic Disorder380
OBJECTIVES

will be able to:
14. Define panic disorder.
15. Explain panic attach and its signs and

symptoms.
16. Describe predisposing factors of panic

disorder.
17. Discuss epidemiology of panic disorder.
18. Explain nursing diagnosis and nursing

intervention for panic disorder.
Panic Disorder381
PANIC DISORDER
Introduction
Panic disorder is an anxiety disorder, characterized by

unexpected panic attack. Panic involves the disorganization of
the personality. It is a frightening and paralyzing experience
for the individual in which a person is unable to communicate
or functioning effectively. The prolonged period of panic would
result in exhaustion and death.
Definition
The current definition of panic disorder is derived from the

Diagnostic and Statistical Manual of Mental Disorders. For the
diagnosis, the patient should experience recurrent panic
attacks and are distinguished from “provoked” or “situationally
bound” attacks, which also occur in panic disorder and are
linked to specific environmental cues. The panic attack itself is
characterized by a sudden crescendo of a autonomic arousal
and fear, lasting approximately 10 to 30 minutes. At least 4 of
a possible 13 symptoms should be present for a “full-blown”
attack, although “limited symptoms” attacks also occur and are
clinically important.
Panic Disorder382
Diagnostic Crietera for Panic Disorder and Panic Attacks

1) The patient must have both:
a) Recurrent unexpected panic attacks.
b) At least one of the attacks followed by at least one
month of ≥1 of the following:
• Persistent concern about having additional attacks.
• Worry about the implications of the attack or its

consequences.
• A significant change in behavior related to the attack.
2) A panic attack is defined as a discrete period of intense fear

or discomfort with ≥4 of the following symptoms that develop
abruptly and peak in intensity within 10 minutes:
a) Palpitations, pounding heart, or accelerated heart rate.
b) Sweating.
c) Trembling or shaking.
d) Sensations of shortness of breath or smothering.
e) Feelings of choking.
f) Chest pain or discomfort.
g) Nausea or abdominal distress.
h) Feeling dizzy, unsteady, lightheaded, or faint.
i) Derealization or depresonalization.
j) Fear of losing control or going crazy.
k) Fear of dying.
l) Paresthesias.
m) Chills or hot flushes.
Panic Disorder383
Predisposing Factors of Panic Disorder
Psychodynamic Theory – it focuses on the inability of the

ego to intervene when conflict occurs between the id and the
superego, producing anxiety. When developmental defects in
ego functions compromise the capacity to modulate anxiety,
the individual resorts to unconscious mechanisms to resolve
the conflict. Overuse or ineffective use of ego defense
mechanisms results in maladaptive responses to anxiety.
Cognitive Theory – the main thesis of the cognitive view is

that faulty, distorted, or counterproductive thinking patterns
accompany or precede maladaptive behaviors and emotional
disorders. When there is a disturbance in this central
mechanism of cognition, there is a consequent disturbance in
feeling and behavior. The individual feels vulnerable in a given
situation, and the distorted thinking results in an irrational
appraisal, fostering a negative outcome.
Biological Aspects – research investigations into the

psychobiological correlation of panic disorders have implicated
a number of possibilities.
Genetics – panic disorder has a strong genetic element. The

concordance rate for identical twins is 30 percent, and the risk
for the disorder in a close relative is 10 to 20 percent.
Neuroanatomical – modern theory on the physiology of

emotional states places the key in the lower brain centers,
including the limbic system, the diencephalon and the reticular
formation. Structural brain imaging studies in patients with
panic disorder have implicated pathological involvement in the
temporal lobes, particularly the hippocampus.
Panic Disorder384
Biochemical – abnormal elevations of blood lactate have been

noted in clients with panic disorder. Likewise, infusion of
sodium lactate into clients with anxiety neuroses produced
symptoms of panic disorder. Although several laboratories
have replicated these findings of increased lactate sensitivity
in panic-prone individuals, no specific mechanism that triggers
the panic symptoms can be explained.
Neurochemical – stronger evidence exists for the involvement

of the neurotransmitter norepinephrine in the etiology of panic
disorder. Norepinephrine is known to mediate arousal, and it
causes hyperarousal and anxiety.
Medical Conditions – the following medical conditions have

been associated to a greater degree with individuals who
suffer panic disorders than in the general population:
1) Abnormalities in the hypothalamic-pituitary-adrenal and

hypothalamic-pituitary-thyroid axes.
2) Acute myocardial infarction.
3) Pheochromocytomas.
4) Substance intoxication and withdrawal (cocaine, alcohol,

marijuana, opioids).
5) Hypoglycemia.
6) Caffeine intoxication.
7) Mitral valve prolapse.
8) Complex partial seizures.

Panic Disorder385
Epidemiology of Panic Disorder
 1.7% of the United States population (2.4 million

Americans) experiences panic disorder.
 Women are twice as likely as men to develop panic

disorder.
 Panic disorder typically strikes in young adulthood.

Roughly half of all people who have panic disorder
develop the condition before the age of 24 years.
 Heredity, other biologic, cognitive and psychodynamic

factors are involved in the panic disorder.
 Appropriate treatment by an experienced professional

can reduce or prevent panic attacks in 70% to 90% of
people with panic disorder.
 Research shows that about 30% of people with panic

disorder use alcohol and 17% use drugs such as
cocaine and marijuana.
 The epidemiological research also shows that

approximately 20% of people with panic disorder attempt
suicide.
Panic Disorder386
Treatment and Medication of Panic Disorder
 Most specialists agree that a combination of cognitive

and behavioral therapies is the best treatment for panic
disorder.
 Medication might also be appropriate in some cases.
 Combination therapy ( a combination of both medication

and cognitive-behavioral therapy) more useful and
effective in panic disorder.
 Remember that part of the treatment for panic disorder is

to treat the anxiety surrounding the fear of experiencing
another panic attack. This fear is called “anticipatory
anxiety”. The person may also have phobias, or irrational
fear, about places or situations where the panic attacks
have occurred and try to create a zone of safety for him-
or her-self by avoiding those places or situations.
Panic Disorder387
Drugs Used for Treating Panic Disorder
1) Tricyclic antidepressants (TCAs)
 Imipramine (Tofranil) 50 to 300 mg per day
 Clomipramine (Anafranil) 25 to 250 mg per day
 Nortriptyline (Pamelor) 25 to 100 mg per day
 Desipramine (Norpramin) 25 to 300 mg per day
2) Selective serotonin reuptake inhibitors (SSRIs)
 Fluoxetine (Prozac) 20 to 80 mg per day
 Paroxetine (Paxil) 10 to 50 mg per day
 Sertraline (Zoloft) 50 to 200 mg per day
 Fluvoxamine (Luvox) 500 to 300 mg per day
3) Monoamine oxidase inhibitors (MAOIs)
 Phenelzine (Nardil) 45 to 90 mg per day
 Tranylcypromine (Parnate) 30 to 60 mg per day
4) Benzodiazepines
 Alprazolam (Xanax) 2 to 10 mg per day
 Lorazepam (Ativan) 2 to 6 mg per day
 Clonazepam (Klonopin) 1 to 3 mg per day

Panic Disorder388
Duration of Treatment
Much of the success of treatment depends on patient’s

willingness to carefully follow the outlined treatment plan. This
is often multifaceted, and it won’t work overnight, but if you
stick with it, we should start to have noticeable improvement
within about 10 to 20 weekly sessions. If client continue to
follow the program, within one year we will notice a
tremendous improvement.
Panic Disorder389
Treating Patients with Panic Disorder
Patient meets DSM-IV

criteria for panic disorder
Yes Offer alcohol detoxification

Is current alcohol abuse and maintenance program
present? with follow up to reassess
panic disorder
No
Yes
Is rapid action needed for Consider short-term
the patient to function? therapy with a
benzodiazepine while long-
No
Offer treatment with

antidepressants or CBT (4
to 12 sessions)
Antidpressants: Continue
for 6 months and
Reassess at 2 and 10 consider
weeks to discuss medication with-
effectiveness and side drawal with
monthly follow
up for relapse.
Is the patient panic-free or Yes CBT: Follow

patient monthly
functioning well? for relapse after
sessions are
No discontinued.
Offer additional treatment Benzodiazepines: Taper

with another therapy, benzodiazepine.
If unsuccessful,
combination therapy, offer CBT during
increased medication tapering period.
dosage, or additional CBT
Panic Disorder390
Nursing Diagnosis/Outcome Identification
Nursing diagnosis are formulated from the data gathered

during the assessment phase and with background knowledge
regarding predisposing factors to the disorder. Some common
nursing diagnoses for clients with panic disorder include:
1) Panic anxiety related to real or perceived threat to

biological integrity or self-concept evidenced by any or
all of the physical symptoms identified by the DSM-IV-TR
as being descriptive of panic or generalized anxiety
disorder.
2) Powerlessness related to impaired cognition evidenced

by verbal expressions of no control over life situation and
non-participation in decision making related to own care
or life situation.
3) Ineffective individual coping is related to anxiety as

evidenced by his/her excessive dependency on (which
thing has lost).
4) Ineffective family coping is compromised related to

anxiety as evidenced by inability to set realistic limits on
his/her demands for attention.
Panic Disorder391
Nursing Interventions for Panic Disorder
1. Remain with the client at all times when levels of anxiety

are high (severe or panic).
2. Move the client to a quiet area with minimal or

decreased stimuli (such as small room or seclusion
area).
3. Offer reassurance of safety and security to the client.
4. Use short, simple and clear statements.
5. Be aware for your own feelings and level of discomfort.
6. Administer tranquilizing medication, as ordered by

physician. Assess for effectiveness and for side effects.
7. When level of anxiety has been reduced, explore

possible reasons for occurrence.
8. Encourage the client’s participation in relaxation

exercises (such as deep breathing, progressive muscle
relaxation, medication and imagining being in a quiet
peaceful place).
9. Teach the client to use relaxation techniques

independently.
10. Help the client to see that mild anxiety can be a positive
catalyst for change and does not need to be avoided.
Panic Disorder392
Scenario
Ms. M is a 29 years old lady brought to the hospital
Emergency Department by her mother with symptoms of
shortness of breath, fear of dying, palpitations and chest
discomfort. She is full time student and works a job. She told
that during the prior three weeks, she experienced four
episodes of these symptoms.
Her mother said that “Ms. M has experienced anxiety since

early childhood and first underwent psychotherapy when she
was 9 only. The symptoms included anxiety and worry.
Ms. M has no other past medical and surgical history. CBC

and Thyroid function test, are in normal limits.
She told that I always had trouble dealing with people in social
situations. I was really shy. I don’t think anyone diagnosed me
with anxiety until I was in my 20s. Eventually, I found a
therapist who said, “absolutely you have anxiety that’s causing
depression” and started treating me with tab. Clonazepam,
which really helped.
Panic Disorder393
NURSING CARE PLAN

Name: Ms. M
Age 29 Years
Sex Female
Medical Diagnosis Panic Disorder
Assessment Nursing Expected Outcome Intervention Rationale Evaluation

Diagnosis
Subjective Data
She told that during the prior 3 weeks,
Short term goals
The client will respond
• Stay with the client and offer • The client may fear for her Short term
Ms. M has been
evidenced by all of the physical symptoms identified by the DSM-

Panic anxiety related to perceived threat to biological integrity as
she experienced 4 episodes of to relaxation techniques reassurance of safety and life. reduced her
palpitation and chest discomfort. with a decreased security. anxiety level
Following two of these episodes, she anxiety level by 2-3 • Maintain a calm, non- • Anxiety is contagious and severe to
wen to the emergency department for days. threatening matter-of-fact may be transferred from moderate.
treatment. She total that her symptoms approach. staff to client or vice versa.
were due to anxiety and panic. Long term goals Long term
The client will be able • Keep immediate surrounding • A stimulating environment Ms. M verbalized
Objective Data to recognize symptoms low in stimuli. may increase level of symptoms of
Ms. M, a 29 years old female has of onset of anxiety and anxiety. onset of anxiety
• •
IV-TR criteria.
experienced anxiety since early to intervene before Administer tranquilizing Antianxiety medication and able to
childhood and first underwent reaching panic level by medication as ordered by provides relief from the intervene before
psychotherapy when she was 12. Her 1 week to 3 weeks. physician. immobilizing effects of reaching panic
anxiety was treated with a variety of anxiety. level.
antidepressants, without improvement.
She is smoker and sometimes uses • When the level of anxiety • Recognition of precipi-
alcohol. There is no association of mood has been reduced, explore tating factors is the first
and anxiety disorder with her family. possible reasons for step in teaching client to
occurrence. interrupt escalation of
Vital Signs anxiety.
• Blood Pressure 100/80 mmHg • Teach relaxation techniques, • Relaxation techniques
• Temperature 98 °F which reduce the anxiety. result in a physiological
• Pulse 70 bpm response opposite that of
• Respiratory rate 22 per min the anxiety response.
Depression394
References
1. Wilson S Holly. Psychiatric Nursing. Wesley California;
p 718.
40. Lancaster Jeanette (1988). Adult Psychiatric Nursing.
3rd Edition. New York; p 228.
42. Taylor Monat Cecelia (1994). Essential of Psychiatric
Nursing. 14 Edition. USA; p 456.
43. Sundeen and Stuart (1991). Principles and Practice of
Psychiatric Nursing. 4th Edition. Philadelphia;
pp 576-577.
2nd Edition. USA; p 621.
45. White Lois (2001). Foundation of Nursing. 6th Edition.
USA; p 813.
46. Townsend Marry C (1941). Psychiatric Mental Nursing.
pp 516-517.
47. http://www.apa.org/pubinfo/panic.html.
48. http://www.aafp.org/afp/980515ap/saeed.html.
49. Http://www.google.com. Gorman JM (2001). A 28-Year-
Old Woman with Panic Disorder. JAMA; 286:450-457.
LIAQUAT MEDICAL AND HELATH SCIENCES

JAMSHORO SINDH
Depression395
Depression
ACN III
Safrunisa
BScN Year II Student
Madam Yasmin
23rd July, 2005

Depression396
OBJECTIVES

will be able to:
19. Define Depression.
20. Enumerate causes and characteristics of

depression.
21. Describe levels of depression.
22. Discuss pathogenesis of depression.
23. Explain treatment of depression.

Depression397
DEPRESSION
Definition
Authors defined depression, time to time. Some of these
definitions are as under:
 Depression is a decrease of vital functional activity.
 It is a mood disturbance characterized by feelings of
sadness despair and discouragement resulting from and
normally proportionates to some personal loss of tragedy
(Lois White).
 An abnormal, emotional state characterized by
exaggerated feelings of sadness melancholy dejection
worthlessness, emptiness and hopelessness that are
inappropriate and out of proportion to reality (Schultz and
Videbeck).
Causes of Depression
In people with terminal illness include:
 Uncontrolled pain.
 Constipation.
 Anorexia and fatigue.
 Abnormal metabolic condition.
 Hypercalcemia, anemia, hypothyroidism.
 Sepsis contributing tumor of central nervous system or
radiation therapy.
 Medication such as corticosteroid and chemotherapeutic
agent.
 Financial condition.
 Loss of someone or something.
 Limited social support and diminished function habitually
using and limited emotional range.
Depression398
Characteristics of Depression
1. Depress mood.
2. Loss of pressure and interest in all or nearly all of one’s

usual activities and past time.
3. Insomnia or some time hypersomnia.
4. Anorexia and weight loss or sometime hyperphagia and

weight gain.
5. Mental showing and loss of concentration feeling of guilt.
6. Worthlessness and helplessness.
7. Thought of death and suicide.
8. Anhedonia.
9. Change in sleep pattern.
10. Lack of energy.

Depression399
Levels of Depression
Depression can be classified into effective, psychological,

cognitive and behavioral manifestation. There are three levels
of depression.
Mild Depression – is characterized by its transitory nature. It

is often participate by events in a person’s life but may occur
for no clearly definable reasons. Events that may trigger mild
depression include disappointments at school or work such
as, failure in a test and failure to receive a promotion. The loss
of someone or something highly valued or meaningful such as
friend loves family member home or job ordinarily bring on
deep sadness of limited duration. The manifestation of a mid
transitory depression or almost exclusively emotional in nature
mildly depressed people describe themselves as feeling
some. Psychological change such as alteration sleeps pattern
because it is emotional change, the person may increase use
of drugs, alcohol to try to diminish their low mood.
Moderate Depression – People experiencing a moderate

level of depression are more likely to experience their
condition as which persists over time and often leads them to
seek help moderate effective cognitive behavioral and
physiological changes occur.
Effective Change – moderately depressed people describe

their mood as one of despondency, dejection and gloom
feeling of low self-esteem contribute to feelings of
powerlessness, helplessness and effectiveness. Anxiety and
anger may or may not felt. It may show diurnal variation that is
a pattern of changes whereby certain time of the day such as
morning and evening are consistently better and worse.
Moderately depressed people or unable experience pleasure
from activities. They ordinarily enjoy their Jove de vivre seems
to have vanished.
Depression400
Cognitive Changes – these people thoughts are showed and

their interests are narrow concentration become difficult and
indecisiveness and self-doubt are common. Their thoughts
tend to be ruminative, they go over the same content and
issue with no movement forward or recognition of alternatives.
Their thoughts have an absesional quality.
A pessimistic out look that included self-blame combines to
create a hopeless attitude about the possibility of change or
the motivation to change suicidal thoughts may introduce as
an aspect of hopelessness.
Behavioral Change – depressed people tend to withdraw
socially. Initially the withdrawal may appear to be simply a
reluctance to socialize or interact with others. It may extend to
other spheres of life such as school work and community
involvement tears and irritability may be evident seemingly
with no provocation change in personal hygiene may be
noted.
A formerly meticulous stylish dressed person may begin to
appear at work with unwashed, uncombed hair and wrinkled,
uncoordinated clothes. They may also be a slowing of
movement and speech or agitated increasing but aim less
activity such as pacing some. Such people will escalate their
normal use of alcohol or drugs in an attempt to anesthetize
their depression, anxiety or anger.
Physiological Changes – it is very common for people with
moderate levels of depression to experience somatic
complaints such as headaches, chest or back pain, indigestion
nausea and vomiting, constipation. Frequently they will seek
medical care for these symptoms without associating them
with other affective cognitive or behavioral change though the
problem is not in true nature.
They may frequently weight loss or increase the weight.
Menstrual changes such as amenorrhea are common, as is
decrease sexual desire. Responsiveness feeling, fatigue and
weakness, sleep is desire but not satisfying some time
difficulty. A falling (initial insomnia and middle insomnia) when
person awake during sleep the return to sleep terminal
insomnia early morning awaking.
Depression401
Severe Depression
People who experience severe depression have intense

pervasive and persistent manifestations of depression. Severe
depression may or may not include a psychotic dimension.
Effective Change – despair and hopelessness, the

predominant feeling there seem no light at the end of dark
tunnel, feeling of worthlessness and guilt are evident sense of
isolation, loneness and over whelming feeling of bottomless,
emptiness, envelops the severely depressed person.
Cognitive Change – confusion inability to concentrate and

indecisiveness are evident. These people have no interest in
mobilizing themselves and no motivation to do so. Self-
destructive thoughts occur as a solution to the hopelessness
of their situation and wish to die. These people feelings like
delusion of cancer and delusions of poverty.
Behavioral Change – These people develops psychomotor

retardation. Their motor activity comes to a near-halt. Slow
walking, the skiing hair, clothing posture is poor. After sits
slumped or curledup amount of speech, they do not attend to
their hygiene need.
Physiological Change – Elimination is sluggish constipation

may urinary retention or amenorrhea, lack of sexual interest,
hypersomnia can occur. Person often feels worse in the
morning and better as the day progresses.
Depression402
Pathogenesis
Major depression in undoubtedly complex and not yet know
because depressive episodes can be triggered by stressful life
events in some people but not in other. It would appear that for
some people a predisposition to depression exists social
developmental and biological factors including genetic
heritage.
The Greeks were the first to introduce the term melancholia.
They believed that depression was caused by excessive
amount of black bile.
Two neurotransmitters are correlated with depression;
serotonin and norepinephrine. First serotonin which originates
in the dorsal and median raph nuclei of the brain stem is
widely distributed in the forebrain. This function of this system
is thermo regulation feeding and regulation of mood and
emotion it is also involved in the control of sleep wakefulness
and sexual behavior (when serotonin is involved one is either
awake, sleeping or having sex). It is also hypothesized
effective disorders.
The norepinephrine or noradrenergic pathway arises from the
locus. Coeruleus and cells are scattered throughout the
ventral and lateral segmental region of the medulla and the
fibers are distributed throughout the neocortex and involve the
hypothalamus. Norepinephrine as serotonin is involved in
sleep and wakefulness as well as the hypothalamic function of
thermo regulation thirst and hunger. This is why when people
are depressed, they complain of decreased or increased
appetite and weight loss or gain.
1. Depression can induce with resepine.
2. The drugs used to treat depression intensity monoamine.
Mediated neurotransmission although these observation
do indeed support the monamine hypothesis. It is likely
that this somewhat simplistic theory will be need
refinement as our understanding of brain depends.
Depression403
Treatment
Depression can be treated with three modalities; drugs,

electroconvalsive therapy (ECT) and psychotherapy. Each
modality has a legitimate role.
Drugs – are the primary therapy for major depression

currently available antidepressants are:
Selective Serotonin Reuptake Inhibitors (SSRIs)
Generic Name Trade Potential Side Effects

Name
Fluoxetine Prozac Abnormal dreams, anxiety, diarrhea,

drowsiness, excessive sweating,
headache, insomnia, nervousness,
pruritus, seizures, tremors.
Fluvoxamine Luvox Constipation, diarrhea, dizziness, dry

month, drowsiness, dyspesia,
headache, insomnia, nausea,
nervousness, weakness.
Paroxetine Paxil Anxiety, constipation, diarrhea,

dizziness, drowsiness, dry mouth,
ejaculatory disturbance, headache,
insomnia, nausea, sweating,
weakness, tremors.
Depression404
Tricyclic Antidepressants
Generic Name Trade Potential Side Effects

Name
Amitriptyline Elavil Arrhythmia, blurred vision,
hydrochloride constipation, dry eyes, dry mouth,
hypotension, lethargy, sedation.
Clomipramine Anafranil Arrhythmia, blurred vision,
hydrochloride constipation, dry eyes, dry mount,
lethargy, male sexual dysfunction.
Imipramine Tofranil Arrhythmia, blurred vision,
hydrochloride constipation, drowsiness, dry eyes,
dry mouth, fatigue, hypotension,
urinary retention.
Electroconvalsive Therapy (ECT) – was discovered in mid

1920. At that time it was only the treatment available and was
frequently used and misused in 1960. It was used for general
anesthesia and muscle relaxant. Most common ECT treatment
was given three times in a week. The physician recommends
ECT for a particular patient under what circumstances would
you can concern about that recommendation.
ECT is a procedure, wherein the client is treated with pulses of

electrical energy sufficient to cause a brief convulsion or
seizure (Bolwig 1993). Electroconvulsive therapy is carried out
under anesthesia. Muscle-depolarizing agents are also given
so that no actual convulsive movements occur; the primary
effect of ECT is on the brain itself. Studies show that clients do
not find the actual ECT treatment frightening, painful, or
unpleasant. Although deaths have occurred from ECT,
particularly in elderly clients or those with heart disease, the
risk is quite low. Side effects depend on the specific technique
used but are mostly limited to memory deficits (Frisch and
Frisch 1998).
Depression405
Psychotherapy – is often called the talking cure because of

its dependence on verbal interaction taking about difficult
emotional. Situations with a competent and understanding
therapist has helped many patients and families develop a
better understanding of their psychotherapy was originally
developed by friends and his colleagues in the 19th century as
long term intervention to correct early psychological trauma
and facilitate personality change. However, trends in
psychiatry have forced psychotherapy into a time limits
structure. The goals of brief psychotherapy are to help
patients, overcome or modify feeling with their meeting
personal goal. Brief psychotherapy models narrow the goal of
personality change to focus on specific behavior and conflicts
or issues that can be treated successfully in a short period.
Depression406
Scenario
Miss Saira, a 20 years old girl admitted in Psychiatric unit with
history of insomnia, anorexia and weight loss. She was social
and enjoy parties and having a number of friends. Her past
history revealed that she was all right before three months
ago, when an incident changes her life i.e., her engagement
was broken. Furthermore, she failed in her final examination.
After this incident, she become isolated and loss interest in
life.
She is single child of her parents. Her mother is working in a

office and father is a businessman. Both are very busy,
therefore, she becomes an isolated child.
Depression407
Assessment
Saira, 20 years young girl brought to Psychiatric Ward by her

parent. According to her parent, she was alright two months
back. She was very active and taking part in all activities. She
was a student of BA Part-II. She was also engaged two years
back but suddenly her engagement was broken due to some
family inter fair and she also fails in her BA final examination.
After these incidences, she is feeling difficulty in falling asleep
along with anorexia and weight loss. She is not taking part in
any activity and mostly lives alone, calm and quite. She does
not share with others and sometimes she complains
headache, chest and back pain and indigestion. She sits with
depressed mood without any facial expression, loss of
concentration, feeling of guild unwashed and uncombed hair
wrinkled uncoordinated cloth her speed is very slow head is
down no eye contact, slow body movement, looking lethargic.
No hope is seen in her eye. Her vital signs are:
 Blood pressure: 100/70 mmHg.
 Temperature: 97°F
 Pulse: 88 beat per minute.
Nursing Diagnosis
 Impaired social interaction related to loss of intimate
relationship.
 Hopelessness related to lifestyle of helplessness related
to sedation.
 Altered thought process related to loss of belief in
transcendent values.
Depression408
Intervention
Encourage patient to express how she feels by scheduling at

least 10 minutes, twice a day focus on this topic.
 Evaluate patient communication skills and help him or

her to find alternative ones during interaction with
patient.
 Help patient obtain a realistic perception of self by

focusing on and enhancing strength during conferences
with patient.
 Allow patient to choose social interactions for role-play

for 10 minutes twice a day.
 Involve patient in daily care to help the patient to make

decision about own care.
 If patient is in isolation, spend at least two minutes every

hour with patient.
 Initiate referrals to support groups prior to discharge.

Depression409
NURSING CARE PLAN
Name: Miss. Saira
Age 20 Years
Sex Female
Assessment Nursing Expected Intervention Rationale Evaluation

Diagnosis Outcome
Depression410
Subjective Data Short term goals • Encourage patient to • Assist patient to examine social Short term
Saira was brought to Psychiatric unit by The client will • Patient will

her parent. According to her parent, she participate in daily express how she feels by experience and verbalize
was alright two months back. Her activities. scheduling at least 10 feelings and encourage verbalize satis-
engagement broken and she also failed minutes, twice a day focus therapeutic relationship. faction with
in her BA examination. After this Long term goals on this topic. quantity and
incident, she is feeling difficulty in falling The client will be • Evaluate patient communi- • Improve communication skills. quality of social
interaction.
asleep, anorexia and weight loss. She is able to initiate cation skills and help him
not taking part in any activity and mostly interaction with or her to find alternative • Will communi-
lives alone, calm and quite. She does others to maintain ones during interaction cate and parti-
not share with others. Sometimes she relationship and with patient. cipate with
complains headache, chest and back social life.
pain and indigestion. • Help patient obtain a • Help patient to see that no one is others
community
and
realistic perception of self perfect and improves self-
Objective Data by focusing on and concept. • Will reestablish
A 20 years, young girl sitting on bed enhancing strength during or maintain
quiet depressed mode, without facial conferences with patient. relation-ships
expression, loss of concentration, • Allow patient to choose • Promote self-confidence in and a social life
and also
feeling of guilt, unwashed and social interactions for role social situations by allowing
uncombed hair, wrinkled, uncoordinated establish
play for 10 minutes twice a practice in a safe environment. support system.
clothes. Her speech is slow and bodies day time.
movement looking lethargic. No hope is
seen in her eyes. • Involve patient in daily • Improve self-concept, and Long term
care to help the patient to increase motivation. Decrease Patient participates
Vital Signs make decision about own feeling of powerlessness. in normal daily
• Blood Pressure 100/70 mmHg care. activities and
normal routine life.
• Temperature 97 °F • If patient is in isolation, • Avoids feeling of total isolation
• Pulse 88 bpm spend at least two minutes for patient.
every hour with patient.
• Initiate referrals to support • Patient contact with community
groups prior to discharge. group to interact to decrease
social isolation.
References
1. White Lois (2001). Foundation of Nursing. 6th Edition. USA; pp
1181-1186.
nd
2 Edition. USA; p 621.
3. Schultz JM and Videbeek SL. Psychiatric Nursing.
7th Edition; pp 178-179.
4. Jhon Wolk. Essential of Clinical Psychiatric. 3rd Edition.
5. Townsend Marry C (1941). Psychiatric Mental Nursing.
7. http://www.apa.org/pubinfo/depression.html.
8. http://www.yahoo.com/yahooseach/depression.
9. Http://www.google.com/googlesearch/depression.
10. http://www.google.com. Scott J (2001). Cognitive therapy for
depression. B Med Bulletin; 57:101-113.

Jamshoro Sindh
Family Therapy

(Assignment # 1)
Violet Barkat
BScN Year II
Mrs. Munira A. Ali

The family is the basic unit of society composed of two or more individuals who
come together to share common beliefs and values. The bounding factor of the family is that
of commitment. The individual within the family may be related by marriage, blood or
adoption. The form or structure of an individual family may very greatly. In addition to the
traditional nuclear family, family may be composed of people not related by blood or
marriage living together as a family group.
Family therapy is a second specialty treatment modality, practiced by a nurse with a
master’s degree and specialized training in family therapy. This family therapist treats the
family as a unit or assists in individual in coping more effectively with family issues.
Families are important to nurses because families are the context in which individuals live,
and they are units to be analyzed. Family therapy is particularly useful in the situations when
an individual is struggling with family as well as personal issues, when a family needs
professional assistance in understanding the client’s perspective or coping with difficult
feelings and when family unit is the focus of treatment, for example, in a divorce situation.
Family Forms and Types
 Nuclear – A father, mother and at least one child living together but apart from both
sets of their parents.
 Extended – three or more generation including married brothers and sisters and their
families.
 Three Generation – Any combination of first, second and third generation members
living within household.
 Dyad – Any two members, typically husband and wife living alone without children.
 Single Parent – Divorced, never married, separated or widowed man or woman with
at least one child. Most single parent families are headed by woman.
 Step-Parent – One or both spouses divorced or widowed and remarried into a family
with at least one child.
 Blended or Reconstituted – A combination of two families with children from one or
both families and sometimes children of the newly married couple.
 Single Adult Living Alone – An increasingly common occurrence for the newer-
married, divorced or widowed.
 Cohabiting – An unmarried couple living together.
 No Kin – A group of at least two people who have no legalized or blood ties but who
share a relationship and exchange support.
 Compound – One man or woman with several spouses.
 Gay – A homosexual couple living together with or without children.
 Commune – More than one monogamous couple sharing financial and social
resources.
 Group Marriage – All individuals married to each other and considered parents of all
the children.
Family Therapy
Family therapy as a treatment modality began in the 1950s and blossomed over the
next two decades into a primary treatment modality. Early family theorists used biologically
based treatment of clients and their families. The compared the family system to the human
body, system failure in one part of the body affects other body systems.
General principles of natural systems theory include the following.
 Every subsystem is a part of a larger system. Individuals are part of a larger family
system and families are part of a larger community system influenced by its culture,
politics, and environmental changes.

 The system is more than the sum of its parts. The whole can be understood only by
looking at the pattern of relationships within the system rather than looking at
individual parts in isolation.
 Living systems demonstrate equifinality – the ability to achieve the same final goal in
a variety of ways.
 Systems strive for homeostasis – the tendency of systems to be self-regulating.
Through a variety of mechanisms, systems maintain coherence within the system
when challenges arise from the environment.
 Systems have feedback loops defined as “the process by which a system gets the
information necessary to self-correct in its effort to maintain a steady state or move
toward a pre-programmed goal.
Bowen’s Family Systems Model
Bowen viewed the basic forces shaping family functional behavior as:
 Multigenerational transmission process.
 Differentiation of self.
 Triangles.
 Nuclear family emotional system.
 Family projection process.
 Emotional cut-off.
 Sibling position.
 Societal regression
 Spirituality.
Treatment
Bowen family therapists view themselves as coaches to the family. The role of the
therapist is to help the family decrease its anxiety, gain a broader perspective on problems,
and become aware of the ways emotional reactivity influences individual and family
functioning. Coaching people to define self, that is, to develop a more solid self in the face of
forces to fuse with others, is one of the main strategies.
Starting with a genogram:
 A Bowen family therapist gathers information that helps the family members look at
relationships between family process and events, track multigenerational patterns and
connect with important relationships.
 Education, questioning, analogies, and observations are techniques the coach uses to
attempt to maintain a neutral position, massage anxiety, and define self to the family.
In this school of thought, the therapist considers it essential that each client continue
to work on her or his own level of differentiation while concurrently participating in
family therapy. Bowen advocated looking at what goes on between people rather than
what goes on within them as the focus of treatment.
 The client or family seeking family therapy is views as a partner in the process of
looking at the family unit and in assuming full responsibility for his or her feelings.
 Bowen therapist educates individual family members about triangles and coaches
them to talk directly with each other rather than triangling in another family member
to defuse their anxiety.
 By coaching people to become aware of their own emotional process within the
family.
Minuchin’s Structural Theory
Salvador Minuchin’s (1974) structural theory of family looks at three essential
elements of family organization: structure, subsystems and boundaries. According to

Minuchin, structure refers to how the family is organized and the interdependent functioning
of its subsystems as the major determinants of individual behaviors. Subsystem defined
subgroups of people within the family who connect with each other to perform different
family functions. Family systems have boundaries or imaginary walls, both around them and
between their subsystems. These boundaries are invisible emotional limits that regulate the
amount and intensity of interpersonal contact. Boundaries that are permeable and clear,
allowing information to flow in and out, lead to open healthier systems. Boundaries that are
impermeable shut the system off from information, resources, and sources of support.
With a structural approach, the therapist’s role is an active one. The therapist actively
challenges the maladaptive reactive transactional patterns to help the family system explore
and develop a different level of homeostasis, one in which boundaries are reasonable,
consistent, and open to emotional input from others without being compromised.
According to Goldenberg and Goldenberg (1996), the goals of treatment are:
 To help families develop clearly defined generational boundaries.
 To establish a common front on important family issues, such as discipline, and
realistic behavioral standards for family members.
 To help open communication pathways and to redefine pathological coalitions that
exclude interdependency among all family members.
A structural therapist would help Ben to take a more active role with Margie and
would coach Marian to allow more emotional space for this to occur. The therapist might
suggest homework assignments for Ben to take time with Margie alone. Another strategy
would be to work out, with both parents, a united front in parenting Margie and time together,
apart from Margie, to rebuild their spousal subsystem.
Psychoeducation, a Prevention Tool

Psychoeducation is a family therapy tool that is becoming increasingly popular as a
strategy to reduce risk factors associated with the development of behavioral symptoms.
Examples of situations in which this would be appropriate include are:
 Information and training about a specific area of family life, such as communication
skills training or parent effectiveness training.
 Information and support to families dealing with specific stress or crises, such as a
family support group for Alzheimer’s disease.
 Prevention and enrichment, such as premarital counseling, for families not in crisis.
Process
The first interview can take place in a hospital, a psychiatric assessment center, a
clinic, a mental health center or the home. The first interview sets the stage for the family to
begin to see a family problem rather than an individual concern. The initial interview has
many purposes. Information about family dynamics and family history must be obtained.
Practical concerns such as phone numbers, health insurance information, and other health
care sources are addressed. The family may come to the session wanting to talk about the
problem and expecting that one session will even determine a solution. Most often, the
therapist must help family members broaden perception to include the whole family. At
times, family members are anxious or angry, and this first session is used to help them
become calmer. The therapist’s challenge is to remain neutral and yet connect with each
family member. As each member for a perception of the problem and indicate that all family
members are important.
What Client’s Need to Know?
 How do I decide if our problems could be helped with family therapy?
 How do I know the theoretical orientation of the therapist, and does it matter?
 Is therapy covered under my insurance and how much will it cost?

 What can I expect to happen during the first session?
 How long will therapy take?

Three parts to genogram construction must be considered:
 Mapping family structure.
 Recording family information.
 Delineating family relationships.
Family Therapy Interventions
 Teach the family members to decrease anxiety by focusing on thinking rather than
feeling.
 Broaden the family members’ perspectives by mapping the multigenerational family
system, gathering facts, and reframing individual interpretations.
 Manage your own self by monitoring your anxiety.
 Identify the primary triangles and teach the family members to manage themselves
within them.
 Track the family emotional process.
 Teach the family to explore connecting to others and healing cut-offs.
 Coach the family toward identifying possible solutions that come from family
members.
 Help family members monitor and become more aware of individual reactions to
emotional triggers.
 Increase awareness by teaching the family concepts of family functioning.
 Coach family members toward defining self.
 Maintain neutrality.
Jamshoro Sindh
Family Therapy
ACN III Major NCP

(Assignment # 2)
Violet Barkat
BScN Year II
Mrs. Munira A. Ali

NURSING CARE PLAN
TITILE: Ineffective Coping
 Ambivalence regarding Short-term Goals:  Observe the client’s eating,  The client may be unaware The client has
decisions or choices.  The client will identify drinking and elimination of physical needs or may verbalized
Ineffective coping
 Disturbances in normal stress, anxieties, and patterns, and assist the client ignore feelings of hunger, decrease feeling of
functioning due to conflicts. as necessary. thirst, the urge to defecate, fear, guilt and
obsessive thoughts or  The client will verbalize and so forth. anxiety.
compulsive behaviors. realistic self-evaluation.
 Inability to tolerate  The client will establish  Assess and monitor the  Limiting noise and other The client has
deviations from a balance of rest, sleep client’s sleep patterns, and stimuli will encourage rest expressed feeling
standards and activity. prepare him or her for and sleep. Comfort nonverbally in
 Rumination. bedtime by decreasing measures and sleep safe manner.
 Low self-esteem Long-term Goals: stimuli, giving a backrub, and medications will enhance
 Feelings of  The client will identify other comfort measures or the client’s ability to relax
worthlessness alternative methods of medications. and sleep.
 Lack of insight dealing with stress and
anxiety.  You may need to allow extra  The client’s thoughts or
 Difficulty or slowness
 The client will complete time, or the client may need to ritualistic behaviors may
completing daily living
daily routine activities. be verbally directed to interfere with or lengthen
activities because of
 The client will verbalize accomplish activities of daily the time necessary to
ritualistic behavior
knowledge of illness, living (personal hygiene, perform tasks.
treatment plan, and safe preparation for sleep and so
use of medications. forth).
 The client will maintain
adequate physiologic  Encourage the client to try to  Gradually reducing the
functioning. gradually decease the frequency of compulsive
frequency of compulsive behaviors will help
behaviors. Work with the diminish the client’s
client to identify a baseline anxiety and encourage
frequency and keep a record success.
of the decrease.
Family Therapy423
 As the client’s anxiety • The client may need to The client has
decreases and as a trust learn ways to manage established a balance of
relationship builds, talk anxiety so he or she can rest, sleep and activity.
with the client about his or deal with it directly. This
her thoughts and behavior will increase the client’s The client has identified
and the client’s feelings confidence in managing alternative methods of
about them. Help the anxiety and other feelings. dealing with anxiety.
client identify alternative
methods for dealing with
anxiety.
 Convey honest interest in • Your presence and interest

and concern for the client. in the client convey your
acceptance of the client.
Clients do not benefit from
flattery or undue praise, but
genuine praise that the
client has earned can foster
self-esteem.
 Provide opportunities for • The client may be limited

the client to participate in in the ability to deal with
activities that are easily complex activities or in
accomplished or enjoyed relating to others. Activities
by the client; support the that the client can
client for participation. accomplish and enjoy can
enhance self-esteem.
 Teach the client and • The client and family or

family or significant significant others may have
others about the client’s little or no knowledge
illness, treatment or about these.
medications.
…Therapy424
References
2nd Edition.
USA.

Jamshoro Sindh
Substance Abuse
ACN III
Violet Barkat
…Therapy425
BScN Year II
Mrs. Ruth K. Alam

…Therapy426
Substance use has taken for many centuries. It is not a new problem for society. A
substance is a drug, legal or illegal, that may cause physical or mental impairment with the
great increase in world’s population. There are more people involved in substance abuse.
Today’s speed of travel and communication had facilitated the broad distribution of
substance. Substance disorders may be classified as intoxication, abuse or dependence
(addiction).
Definition
Abuse is the misuse, excessive or improper use of a substance. Dependence
(addiction) is reliance on a substance to such a degree that abstinence causes functional
impairment. The person has no control over use of the substance and feels pleasure only
when using the substance.
Factors Related to Substance Abuse or Drug Abuse
There are many factors that interact to influence a person’s substance abuse. Many
people who have stopped substance abuse relapse (return to a previous behavior or condition)
because of there same factors. These factors may be categorized as individual, family,
lifestyle, environmental factors and developmental factors.
Individual Factors – Genetic factors are being research as a possible reason for a
person’s susceptibility to substance abuse. Research has produced some evidence to suggest
the presence of an abnormal chromosome in addicted individuals. This does not guarantee
addiction but may predispose the person to addiction. The variations in the intensity of the
flow of neurotransmitters may cause to addiction.
Psychologists have looked for factors that predict adolescent abuse of drug and
alcohol. Researchers have discovered that certain personality factors in childhood are
associated with late heavy drug use.

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Family Factors – Drug abuse, especially in the adolescent seems to be related to
family relationship. Close family relationship with the parents involved in their children’s
activities, appear to discourage substance abuse. Families with positive relationships between
parents and children generally have less use of drugs. The parents seemed uninterested in
their children and often had little contact with them, all the time neglecting, rejecting, not
give praise and deal of blaming and criticism, the children especially adolescent, so that they
gradually start using drugs.
Lifestyle – All dimensions of a person’s life that influence how that person lives are
termed as lifestyle. First is the physical dimension, which includes food, clothing, shelter and
health care. The second is the social dimension, which includes friends, organizations and
activities with others. Third is the intellectual/emotional dimension, which includes
education, parental support of education, self-esteem and how the individual is treated by
others. The fourth dimension is spiritual and includes a belief in a “higher being” caring and
compassion for others, and being in touch with the inner self. Substance abuse or dependence
may be the coping mechanism used by an individual who has problems in any dimension of
lifestyle.
Environmental Factors – There are many environmental factors that may encourage
or predispose an individual to substance abuse. The social environment in which persons find
themselves, the groups, clubs, gangs and other organizations influence the acceptance or
rejection of substance abuser. The stress in a person’s life including accidents, disability,
illnesses, stressful family relations, frequent job changes, divorce, death or precarious
financial conditions may be too much for that person to handle. The maladaptive coping of
substance abuse offers temporary relief because the symptoms of the stressors are reduced
substance abuse is reinforced. Social traditions, especially in the use of alcohol may open the
doors for abuse in certain individuals.

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Developmental Factors – Many individual have not had good role models in their life.
They have not learned to identify with others and do not understand that their behavior effect
others. Not learning skills and attitudes of problems solving leaves the individual unable to
apply personal resources to situations and escape seems the only answer. Substance provides
the escape. Learning the interpersonal skills of self-discipline, self-control and self-
assessment help the individual to cope with tension and stress. These skills also work to
prevent dishonesty with self. A lack of interpersonal skills results in dishonesty with others,
resistance to feedback and inability to share feelings and give or accept. Help individuals who
do not view themselves as empowered may choose drug use as a means of gratification.
Types of Substance Abuse
 Heroin addict.
 Alcohol.
 Cigarettes.
 Chares.
 Benzodiazepines drug (Antianxiety and Sleep pills).
 Antiinsect chemicals.
 Ghotteka.
 Many other excessive things used.
Assessment
 Bizarre behavior.
 Regressive behavior.
 Loss of ego boundaries (inability to differentiate self from the external environment)
 Disorientation.
 Disorganized, illogical thinking.
 Flat or inappropriate affect.

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 Feelings of anxiety, fear, or agitation.
 Aggressive behavior toward others or property.
Nursing Diagnosis
Disturbed personality related to substance abuse.
Short-term Goals
The client will:
 Be free from the habit of substance abuse.
 Not harm others or destroy property.
 Establish contact with reality.
 Verbalize decreased psychotic symptoms and feelings of anxiety, agitation and
so forth.
 Participate in the therapeutic milieu.
 Increase contact with other.
 Demonstrate increased interpersonal contract.
Long-term Goals
The client will:
 Take medications as prescribed.
 Express feelings in an acceptable manner.
 Cope effectively with the illness.
 Continue compliance with prescribed regimen.
 Maintain on-going interpersonal relationships that are satisfying.

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• Reassure the client that the environment • The client is less likely to feel
is safe by briefly and simply explaining threatened if the surroundings are
routines, procedures and so forth. known.
• Protect the client from harming himself • Client safety is a priority. Self-
or herself or others. destructive ideas may come from
hallucination or delusions.
• Remove the client from the group if his • The benefit of involving the client
or her behavior becomes too bizarre, with the group is outweighed by
disturbing or dangerous to others. the group’s need for safety and
protection.
• Help the client’s group accept the • The client’s group benefits from
client’s “strange” behavior. Give simple awareness of others’ need and can
explanations to the client’s group as help the client by demonstrating
needed. empathy.
• Consider the other clients’ needs. Plan • Remember that other clients have
for at least one staff member to be their own needs and problems. Be
available to other clients if several staff careful not to give attention only
members are needed to care for this to the “sickest” client.
client.
• Explain to other clients that they have • Other clients may interpret verbal
not done anything to warrant the client’s or physical threats as personal or
verbal or physical threats; rather, the may feel that they are doing
threats are the result of the client’s something to bring about the
illness. threats.
• Set limits on the client’s behavior when • Limits are established by others
he or she is unable to do so. Do not set when the client is unable to use
limits to punish the client. internal controls effectively.
• Decrease excessive stimuli in the • The client is unable to deal with

environment. The client may not excess stimuli. The environment
respond favorably to competitive should not be threatening to the
activities or large groups if he or she is client.
actively psychotic.
• Be aware of PRN medications and the • Medication can help the client
client’s varying need for them. gain control over his or her own
behavior.
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• Reorient the client to person, place, and • Repeated presentation of reality is

time as indicated. concrete reinforcement for the
client.
• Spend time with the client when he or • Your physical presence is reality.
she is unable to respond coherently. Nonverbal caring can be conveyed
Convey your interest and caring. even when verbal caring is not
understood.
• Make only promises that you can • Breaking your promise can result
realistically keep in increasing the client’s mistrust.
• Limit the client’s environment to • Unknown boundaries or a

enhance his or her feelings of security. perceived lack of limits can foster
insecurity in the client.
• Help the client establish what is real and • The unreality of psychosis must
unreal. Validate the client’s real not be reinforced; reality must be
perceptions, and correct the client’s reinforced. Reinforced ideas and
misperceptions in a matter of fact behavior will recur more
manner. Do not argue with the client, frequently.
but do not give support for
misperceptions.
• Be simple, direct and concise when • The client is unable to process

speaking to the client. complex ideas effectively.
• Talk with the client about simple, • The client’s ability to deal with
concrete things; avoid ideological or abstractions is impaired.
theoretical discussions.
• Initially, assign the same staff members • Consistency can reassure the
to work with the client. client.
• Begin with one-to-one interactions, and • Initially, the client will better
then progress to small groups as tolerate and deal with limited
tolerated. contact.
• Establish and maintain a daily routine; • The client’s ability to adapt to

explain any variation in this routine to change is impaired.
the client.
• Set realistic goals. Set daily goals and • Unrealistic goals will frustrate the
expectations. client. Daily goals are short term
and easier for the client to
accomplish.
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• Make the client aware of your • The client must know what is
expectations for him or her. expected before he or she can
work toward meeting those
expectations.
• At first, do not offer choices to the • The client’s ability to make

client. Instead, approach the client in a decisions is impaired. Asking the
directive manner. client to make decisions at this
time may be very frustrating.
• Gradually, provide opportunities for the • The client needs to gain

client to accept responsibility and make independence as soon as he or she
personal decisions. is able. Gradual addition of
responsibilities and decisions give
the client a greater opportunity for
success.
Evaluation
 Client has verbalized feelings in an acceptable manner and coping effectively with the
illness.
 Client established contact with reality.
 Client has demonstrated the optimal level of functioning.

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References
2nd Edition.
USA.

Jamshoro Sindh
Cognitive Behavioral Therapy

(Assignment # 1)
Zafar Iqbal
BScN Year II
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Mrs. Munira A. Ali

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Cognitive-behavioral therapy combines two very effective kinds of psychotherapy,
cognitive therapy and behavior. It approaches to treatment useful for the patients
experiencing ineffective individual coping, fear, and powerlessness and self-concept
disturbance. It based on the notion that the way we think about something influences the way
we behave and feel. Negative patterns of thinking tend to be automatic and pervasive,
coloring individuals’ perceptions of the world around them and affecting their mood and self-
esteem. Cognitive-behavioral therapy used often and successfully with depressed patients
suggests that the depressed unrealistic negative thought processes are central to becoming and
To understand the term cognitive-behavioral therapy it is necessary to go through the
definitions of terms cognitive theory and behavior.
Cognitive Theory
Cognitive theory seeks to help clients understand how negative and conflicting
thought patterns influence their appraisals of certain situations, with the result that their
emotional reactions to these situations – such as anger, depression, and fear – are exaggerated
or inappropriate.
Nurses in the teaching-learning, reasoning, understanding and remembering can use
principles of cognitive learning. Thought and memory enter into every cognitive action.
Cognitive therapy offers a way of effecting behavioral and emotional change through analysis
and revision of the client’s thinking and perception.
Behavior
According to Wolpe, behavior is a conditioned response, that is, a response, which has
been rewarded. Many behaviors become habits, which are established, long-standing patterns
of response to stimuli. Maladaptive behaviors are thought to have begun in response to
uncomfortable levels of anxiety and to have been rewarded by decreased anxiety.

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According to Miller and Dollard, behavior reflects a way of coping with conflict and
its associated anxiety. There are two kinds of conflicts. An avoidance-avoidance conflict
occurs when one must choose between two undesirable alternatives. An approach-avoidance
conflict occurs when one has ambivalent feelings about an object: one wishes,
Therapy
Any treatment designed to remove health problems or disability or to cure an illness.
Types
 Cognitive therapy.
 Behavioral psychotherapy.
 Pharmacotherapy.
 Pscychotherapy, large and small group therapy.
 Family therapy.
 Milieu therapy.
Cognitive Therapy
Cognitive therapy teaches the client about their thinking patterns that they can change
their reaction to the situation that causes anxiety. These thinking negative thoughts distortion
are treated change with positive thinking through cognitive therapy. It based on the ways
people perceive the event rather than the event itself and the person’s emotional response. In
this way they develop the belief about themselves that later become activated, which
stimulate automatic cognitive interpretation to maintain the validity of these core belief.
People develop intermediate belief that supports the core belief. These therapy depend on the
principle of learning and recognized learning as internal process cannot be observed directly
because the change occur in the person’s ability to respond in particular situation. Change in
the behavior is reflection of the internal change. An individual, who learn new behavior is
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contingent on four variables; attention, retention motor reproduction and incentive. To learn
the behavior through modeling, the individual: (1) directed attention toward target behavior,
(2) intellectual ability to retain an image of model behavior and (3) physical capacity to
reproduce the behavior.
Beck (1976) postulated that negative thoughts and cognitive distortions contribute and
perpetuate the patient’s emotional difficulties and moods that in turn prevent the goal
achievement. Cognitive distortion and negative thoughts are includes:
 Arbitrary inference – draw the conclusion about event without any evidence.
 Selective abstraction – draw the conclusion on the basis of one fact rather than the
considering all the facts.
 Over generalization – conclusion on the basis of single event or fact.
 Magnification and Minimization.
 In exact Labeling – draw conclusion on the emotional basis rather than the fact.
The goal of cognitive therapy is to train the client to recognize these automatic
negative thoughts, distortion and attributes. This therapy assesses these distortions and
educate about dealing them that contribute the problem.
Behavior Therapy
Behavior therapy is a mood of treatment that focus on modifying observable and at
least principle, quantifiable behavior by means of systematic manipulation of environment
and variable thoughts to be functionally related to the behavior. Behaviorists believe that
problem behavior ore learned and therefore can be eliminated or replaced by desirable
behavior through new learning experience.
Behavior therapy is the therapeutic modality, which address the observable behavior.
Teaching approach based on the stimulus response pattern of the conditioning and
reinforcement. Behavior therapy depends on the observational learning model, which take
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place when one sees others reward or punishment for their actions. The behavior
methodologies are based on three theoretical approaches to learning, which focus on the ways
learning occur. All these approaches facilitate the client journey toward learning. Learning
includes: (1) learning through simple association (to observation or event occur frequently
each become associated with others, which improve learning), (2) classical behavior
conditioning (cues used to stimulate desire behavioral change), (3) operant conditioning
refers to any voluntary behavior which affected by reinforcement, punishment and extinction.
Too much reinforcement stops the desire behavior.
Steps in application of behavior principle are: (1) assessment about behavioral
problem (which include the client self report, application of appropriate test and direct
observation of client’s behavior), (2) defining the problem (think of behavior, which switch
the behavior or emotional influence it), and (3) target the behavior (consider those activities,
which interfere the behavior, which effect the client’s functioning).
It is effective in the stress of hospitalization unexpected medical procedure, unfamiliar
hospital routines, restricted freedom can precipitate variety of behavioral responses in the
clients that can impair the nurse-client relationship. Behavior such as non-compliance,
manipulation, aggression and violence are generally treated with behavior therapy.
Principle of behavior therapy includes: (1) faulty learning can result in psychiatric
disorders, (2) behavior is modified through the application of principles of learning,
(3) maladaptive behavior is considered to be deficient or excessive, (4) one’s social
environment is source of stimuli that support symptoms. Therefore, it also can support
changes in behavior through appropriate treatment measures.
Behavior therapy techniques include: (1) behavior medication (stimulus elicits
response), and (2) systematic desensitization (like live with dog).

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In the psycho-behavior therapy approaches are used to change the observable
behavior, such as: (1) aversion therapy uses unpleasant or noxious stimuli to change
inappropriate behavior, (2) cognitive behavior therapy uses confrontation as a means of
helping clients restructure irrational beliefs and behavior, (3) assertiveness training, clients
are taught how to appropriately relate to others using frank, honest, and direct expressions,
whether these are positive or native in nature, (4) implosive therapy or flooding is the
opposite of systematic desensitization. Persons are exposed to intense forms of anxiety
producers, either in imagination or in real life, and (5) limit setting provide a framework for
the client to function in, and enable the client to learn make requests. Eventually the client
learns to control his/her own behavior.
Cognitive Behavior Therapy
Cognitive-behavior therapy uses confrontation as a means of helping clients
restructure irrational beliefs and behavior. The therapist confronts the client with a specific
irrational thought process and helps to rearrange maladaptive thinking, perceptions or
attitudes. It is considered as a choice of treatment for depression and adjustment difficulties
and based on the notion that the way we think about something influences the way we behave
and feel. Negative patterns of thinking tend to be automatic and pervasive, coloring
individual’s perceptions of the world around them and affecting their mood and self-esteem.
Cognitive behavioral therapy, used often and successfully with depressed older
people, suggests that the depressed elder’s unrealistic negative thought processes are central
to becoming and staying depressed (Belsky 1984). Its approaches can be integrated, using the
social-learning concept as a framework. It focuses on symptoms and thought processes
(rather than a hypothetical unconscious cause) and fosters a sense of self-responsibility and
self-control, the patients are often receptive and willing to try it.
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A comparison of Cognitive Therapy and Behavioral Therapy can be observed through
the following given table.
Similarities
Formulate symptoms in behavioral terms, Same
and design specific set of operations to
alter maladaptive behavior.
Collaborate with and coach client Same

regarding reactive responses.
Seek to alleviate overt symptoms or Same

behavioral problems directly.
Stress here and now, not the past.
Differences
Use induced and spontaneous images to Apply techniques of systematic
identify misconceptions and test distorted desensitization by inducing a
views against reality. predetermined sequence of images
alternating with periods of relaxation.
Modify attitudes, beliefs, or modes of Modify behavior directly (through

thinking that influence behavior. reciprocal inhibition, systematic
desensitization and so on).
Modify ideational content (e.g., irrational Modify behavior directly.

premises and inferences) to aid change in
behavior.

cognitive structures (schemas) that
influence client’s perceptions,
interpretations, and images.
Problems Addressed through Cognitive Behavior Therapy
Cognitive-behavioral therapy is a clinically and research proven break through in
mental health care, which is used in the following conditions.
 Depression and mood swings.
 Shyness and social anxiety.
 Panic attacks and phobias.

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 Obsessions and compulsions.
 Chronic anxiety or worry.
 Post traumatic stress symptoms.
 Eating disorders and obesity.
 Insomnia and other sleep problems.
 Difficulty establishing staying in relationship.
 Problem with marriage or other relationship.
 Job career of school difficulty.
 Feeling stressed out.
 Insufficient self-esteem.
 In educate coping skills self- or ill-chosen method of coping.
 Passivity – Procrastination and “passive aggression”.
 Substance abuse co-dependency and “enabling”.
 Trouble keeping feeling such as anger sadness, fear, guilt, shame, eagerness,
excitement, etc. within bounds.
 Over-inhibition of feeling or expression.
Factors Affecting during Cognitive Behavior Therapy
 Listening and talking.
 Release of emotions.
 Giving information.
 Providing rationale.
 Prestige suggestions.
 Therapeutic relationship.
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Purpose of Therapies
 Attempt to change the behavior in direct way.
 To analyze conditions creating fears.
 To decrease tension, disturbance, fear, superstitious and social and sexual problems.
 The exchange the thinking process towards complex to simple by conversation, but
not to emphases in past events. Only focus on the present situation and plan for future.
 Ability to deal with problems.
 Relief from emotional disturbance and change antisocial behavior.
Cognitive Interventions
 To increase the client’s sense of control over his/her goals and behavior.
 To increase the client’s self-esteem.
 To assist the client in modifying his/her negative expectations.
 Task of the nurse to move the client beyond his/her limiting preoccupation to other
aspects of his/her world, which is related to it.
 Nursing actions may then focus on modifying the client’s thinking. Depressed clients
are noticeably dominated by negative thought.
 In many cognitive behavioral pain relies strategies are also used to relieve stress, such
as progressive relaxation, guided imagery, therapeutic touch and biofeedback.
Behavioral Interventions
 Nursing interventions focus on activating the client in a realistic, goal directed way.
 The implication is that the client can change, which instills hope.
 Complete successfully tasks tend to enhance the client’s self-esteem.
 They help restructure a system.
 They test the flexibility of a person or system and reveal areas of resistance to change.
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Psychological Interventions
Psychological interventions in psychosis have been found to produce positive
responses in about 50% cases however, isolating the determinant factors that predict
improved psychotic symptomatology have not been clearly demonstrated. Psychotic
symptomatology refers to a broad range of features commonly associated with various
Generally, symptom management is achieved by enabling the client to link feelings
and patterns of thinking and connect them to subjective distress and life disruption. This is
usually done by examining the evidence in support of and against the distressing belief, using
reasons and logic to find an acceptable explanation and challenging habitual patterns of
thinking. The necessary collaboration and assessment is therapeutic in itself and the added
focus and direction provided by specific interventions serves to guide and develop practice.
Psychological preparation of children for surgery using behavioral strategies (e.g.,
relaxation and training in coping skills) has been beneficial in reducing postoperative anxiety
and distress and generally improving psychological adjustment.

Jamshoro Sindh
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Cognitive Behavioral Therapy
ACN III Major NCP

(Assignment # 2)
Zafar Iqbal
BScN Year II
Mrs. Munira A. Ali

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Patient Name: Kulsoom D/o Mazarle Age: 22 Years Sex: Female
Status: Single Occupation: Domestic work/Factory labor.
Diagnosis: Conversion Disorder (Psychogenic hiccup) /Somatoform disorder.
Presenting Complaint:
 Nonstop hiccup
 Tremors in hands.
 Sleeplessness
 Decrease intake behavior.
 Difficulty in develop and establish relationship on job and with relatives.
The client was admitted through Accident & Emergency Department on 16-10-2006
with above mentioned complaint. She has suffered from this condition 5 times in last one
year. This is the 6th attack. Patient has got education up to Matric and presently is jobless. She
has got more severe symptoms after her mother got accident.
General Physical Examination
No any abnormal physical findings.
Young woman, tall build, well dressed, looking fearful, tense and feeling of
uncertainty, shaking of hands and mouth movement. Mood is depressed. No hallucation and
delusion present. The client is oriented with time, place and person and her speech normal.
 Family history
- No history of any disease in family. However, mother has got accident and has
fracture of femur and now she on bed at home. Father has died since two
years. She has no brother. No one is present to take care of her mother.
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- No history of drug use in the family.
- No any mental illness in family.
 Individual history
- No any physical illness present.
 Activity of Daily Living
- She is jobless. She spends most of time in home in stitching clothes and home
work/domestic work.
- She is not taking proper diet now. She is weak and tall.
- She cannot sleep properly.
- She takes less part in leisure activities.
- She did not take any drug, alcohol or tobacco.
 Sexuality
- Unmarried, cycle present.
 Fearful
 Helpless
 Worrying about mother.
 Feeling of insecurity
 Jobless.
 Repeatedly concerning about mother illness.
 Loss of problem solving skill and left job.
 Hopeless
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 Go to get help from religious leader.
 Use home remedies.
 Not God blaming about illness.
 Inability to develop relationship at job and with relatives.
 She did know her capabilities.
 She takes less part in occasions.
 She cannot cope with job environment, so she left job.
 She is independent but family depends on her.
 Appearance
Young 22 years, tall built lady wearing neat and appropriate clothes, maintaining her
hygiene and looking worry and fearful. Decrease eye contact.
 Behavior
 Social – calm and less talkative. No answer hostile behavior.
 Motor Behavior – decrease activity and wall
 Level of activity – retarded and restless
 Abnormal Movement
 Tremors in hands
 Nonstop hiccups.
 Communication
 Decrease communication with others.
 Poverty of speech and slurred with hiccups.
 Cognitive
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 Oriented to time, place and person.
 Poor in judgment and in decision making.
 Thought Process
Thought process was intact. No delusion and illusion present but no thought stopping.
 Mood - Severe depress mood, ‘I want to weep but no tear is coming.’
 Objective – looking depress and worry.
 Sensory Perception
Five senses are intact. No hallucination and illusion present.
 Ensight - is present.
Inability to
Difficulty to develop meet daily
relation on job and with need Apprehension
relatives, denial her and Worrying
weaknesses about mother
illness
Love and seeking help Kulsoom Depress, thought

behavior after death of father Diagnosis stopping and
and sickness of mother
Tremors in Conversion disorder sleeplessness
Difficulty in
hands with communication
nonstop hiccups Distort perception, with others
attributes with
decrease diet
intake
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NURSING CARE PLAN
TITILE: Ineffective Individual Coping
Subjective Data: Short-term Goals:  Assess and determine the  For baseline data for The client has
Client verbalized that I am  The client will identify client strength and weak- future planning to help verbalized that I
Ineffective individual coping related to disease process as evidence by difficulty to

worrying about my mother. the stressor and learn nesses to develop the the client. have identify the
There is no one to care her. I the strategy to cope with method that successful and stressor and start
have difficult to cope with job them within 5 days. level of adaptation in future. to use strategy to
environment and I have left my  Client will identify  Encourage the client to  Ventilating feeling can cope with them.
job. I don’t know what I do. alternative ways of ventilate his/her feelings. help the client to identify, Now I am going
dealing with stress, Convey your acceptance of accept and work through on job and
Objective Data: emotional problem and the client’s feeling. the feeling and to remain maintaining
A 22 years old client was participate in the treat- nonjudgmental. routine relation-
admitted in Psychiatric unit with ment program within 5  Set with the client many  Communication of the ship with all
a complaint of conversion days. times to discuss the current concerns and supportive people.
disorder. She has nonstop
cope with life events.
concern, feelings, know her environment can facilitate

hiccup, tremors in hands, and Long-term Goals:
perception about stressor development of the
sleeplessness. Looking  The client will demons- and help to realize and face coping behavior. The client was
worrying, depress with non- trate the behavior and reality. taking her
reality thinking and avoid to thinking according to treatment
 Involve the client as much  Assess the client and
face life situation. She had less develop coping plan and
possible in her treatment. promote the sense of the effectively and
eye contact with low mood and use it effectively till
Provide with achievable control and responsibility. taking care of
unable to solve her own discharge her mother and
task, goal and activities, and
problems.  The client will verbalize opportunity to make was using
plan for using alternate decision. coping plan and
Vital signs: ways of dealing with
 Convey your interest in the  Your presence demons- strategy
Blood Pressure: 100/60 mmHg stress and emotional
client and approach her for trate interest and caring effectively. The
Pulse Rate: 100 beat/min problems when they
interaction at least once per and convey the client client was also
Resp. Rate: 22 per min. occur after discharge. getting help
shift or allow visit to your continued caring.
Investigation  The client will maintain from community
significant others.
Hb: 10 mg/dl satisfying relationship in frequently..
Na: 135 mEq/dl the community and on
K: 3 mg/dl job.
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 Provide the opportunity for the client to express emotion and fears to  Client need to develop skills and replace the behavior and create the
release tension and help the client identify the situation which would supportive environment.
promote more comfortable feeling.
 Be alert to the client’s behaviors, especially decreased communication,  These behaviors may indicate the client decision to commit suicide.
conversations about death, low frustration tolerance, dependence,
disinterest in surrounding and concealing feelings.
 Do not joke about death, belittle the client’s wishes or feelings, or make  Client ability to understand and use obstruction
insensitive remarks such as every body want to live to change behavior.
 Assess the client with achievable task, goal, and opportunities to make  To assess the client, promote positive self-esteem and sense of control.
decision.
 Allow the client to discover and develop solution that the best fit her  To develop new behavior to solve her problem and improve the self-esteem.
concern. The nurse role is to provide assistance and feedback encourage
to creative approaches to problem behavior.
 Teach relaxation techniques such as exercise, yoga, deep breathing,  Reduce the stress and provide alternative coping strategies.
imaginary to decrease physical tension.
 Teach the client the social skills and encourage her to practice with staff  Client may lack skills and confidence in social interaction, this contributes
members and other clients. Give the client feedback regarding the social to the clients anxiety or social isolation
interaction.
 Assist the client in modifying her negative thoughts and thinking with  To facilitate the care.
positive thoughts and reduce the factors which cause such behavior.
 Encourage the client to pursue personal interest, hobbies and  Recreational activities can help increase the client social inter and may
recreational activities. provide social action.
 Encourage the client to identify and develop relationship with  Increase the client support system may help decrease future suicidal
supportive people outside the hospital environment. behavior.
 Assist the client to identify and use available support system before the  Procedure to reach the short-term and long-term goal.
discharge from hospital and help to use the plan of care and in the
community
Community Violence451
References
 Boodiri, E.N. (2005). Cognitive Therapy In: Concise Textbook of Psychiatric.
2nd Edition. Raj Kamal Electric Press Delhi.
 Cox, H.C., Hinz, M.D., Lubno, M.A., Newfield, S.A., Ridenour, N.A.,
Salater, M.M., Sridaromount, K.L. (1996). Clinical Applications of Nursing
Diagnosis – Adult, Child, Women’s, Psychiatric, Gerontic, and Home Health
Considerations. McGraw Hill New York.
 Harber, Hoskins and Leach (1978). Behavioral and Cognitive Theory and
Application In: Comprehensive Psychiatric Nursing. 3rd Edition. USA.
 Rebraca, S.L. and Ann, I. (2002). Cognitive Behavioral Therapy In: Basic
Concepts of Psychiatric-Mental Health Nursing. 5th Edition. Lippincott Williams
and Wilkins Philadelphia.
 http://www.google.com. Bryant, R.A., Sackville, T., Dang, T.S., Moulds, M.,
Guthrie, R. (1999). Treating Acute Stress Disorder: An Evaluation of Cognitive
Behavior Therapy and Supportive Counseling Techniques.
 http:/www.google.com. Scott, J. (2001). Cognitive therapy for depression. B Med
Bulletin; 57:101-113.

Jamshoro Sindh
Community Violence
ACN III
Zafar Iqbal
BScN Year II
Mrs. Ruth K. Alam

Abuse of the children, elder and women as from youth become a great health problem
and great deal of the public concern effecting individuals, all ethnic and socioeconomic
background. Violence includes child abuse, work place violence, sexual harassment, abuse
and rape, elder abuse, youth violence, transcultural consideration and dating violence.
Community violence is a complex term that has been used to refer to wide range of events
including riots, sniper attacks, gang wars, drive-by shootings, workplace assaults, terrorist
attacks, torture, bombings, ware, ethnic cleansing, and widespread sexual, physical and
emotional abuse. Another includes domestic violence, refers to abuse between two adults in a
romantic relationship, child sexual and physical abuse refers to violence between a child and
an adult.
Definition
Violence is defined as an act (from a pinch or a slap to murder) carried out with the
intention of causing physical pain or injury to another person.
According to WHO and Krug et al (2002), community violence is defined as “the
intentional use of physical force or power, threatened or actual, against oneself, another
person, or against a group or community that either results in or has a high likelihood of
resulting in injury, death, psychological harm, maldevelopment or deprivation.”
Types
Violence is not limited to the random and senseless murders that occur on the streets,
it affects families – women, children and elders, friends and neighbors. Violence can be
categorized into three, based on the relationship between the perpetrator(s) and the victim(s),
settings where it occurs, i.e. within the family or the community. These are: Self-directed
violence includes suicidal behavior and self-harm; Interpersonal violence includes violence
inflicted against one individual by another, or by a small group of individuals, like family and
intimate partner violence between family members, and intimate partners, including child
abuse and elder abuse. This often takes place in the home and community violence involving
violence between people who are not related, and who may or may not know each other
(acquaintances and strangers). It generally takes place outside the home in public places;
Collective violence includes violence inflicted by large groups such as states, organized
political groups, militia groups or terrorist organizations.
The community violence based on various places:
 Work place violence – in some organizations, management used various methods to
psychological threat on their workers/employees to achieve specific goals in a limited
time period. On the other hand some colleagues also use psychological, physical and
emotional methods of threat and even homicide to achieve their personal goals,
interests, and benefits.
 School violence – the students are at higher risk for a school-associated violent death
includes those from racial and ethnic minorities (Kachur et al; 1996).
 Dating violence – adolescents can experience violence within the context of a dating
relationship. Person in a relationship uses abusive behaviors to demonstrate power or
control over the other persons. It includes physical violence, sexual assault, and verbal
or emotional abuse.
Domestic Violence
It can be defined as a pattern of abusive behavior in any relationship that is used by
one partner to gain or maintain power and control over another intimate partner. It also refers
to abuse between two adults in a romantic relationship. Domestic violence can happen to
anyone regardless of race, age, sexual orientation, religion, or gender. It affects people of all
socioeconomic backgrounds and education levels and occurs in both opposite-sex and same-
sex relationships and can happen to intimate partners who are married, living together or
dating. Children population can be affected more than adults one. Domestic violence mostly
present in the following forms:
 Physical Abuse – includes hitting, slapping, shoving, grabbing, pinching, biting, etc.
Physical abuse also includes denying a partner medical care or forcing alcohol or drug
use.
 Sexual Abuse – includes coercing or attempting to coerce any sexual contact or
behavior without consent, which may be in form of marital rape, attacks on sexual
parts of the body, forcing sex after physical violence or treating one in a sexually
demeaning manner.
 Emotional Abuse – includes undermining an individual’s sense of self-worth and/or
self-esteem. It consists of criticism, diminishing one’s abilities, name-calling, or
damaging one’s relationship with his or her children.
 Economic Abuse – making or attempting to make an individual financially dependent
by maintaining total control over financial resources, withholding one’s access to
money, or forbidding one’s attendance at school or employment.
 Psychological Abuse – includes causing fear by intimidation; threatening physical
harm to self, partner, children, or partner’s family or friends; destruction of pets and
property; and forcing isolation from family, friends or school and/or work.
Domestic violence mostly occurs as a matter of power and control
Child Abuse
The physical or mental injury, sexual abuse, negligent treatment, or maltreatment of a
child under the age of 18 by a person who is responsible for the child’s welfare under
circumstances, which indicate that the child’s health or welfare is harmed or threatened
thereby.
Types
Maltreatment of children usually falls into the following general areas.
 Physical abuse.
 Neglect – is an act of omission and refer to parent’s or other person failure to
(1) meets a dependent basic need such as proper food, clothing, shelter, medical care,
schooling or attention, (2) provide safe living condition, (3) provide physical or
emotional care, and (4) provide supervision. It can occur in three levels i.e., in the
home, institution and the society.
Elder Abuse
Elder abuse is a vide spread problem. Most frequent abusers of the elderly are adult
children. The typical victim is female with average age limit of 76, depends upon the abuser
for basic needs, and mentally or physically impaired. It may occur in variety of setting such
as homes and general hospital.
Youth Violence
Youth violence perpetrates acts of violence against others or themselves or destructive
family relationship pattern. Youth violence and homicide remained largely unaddressed by
our health care system. It involved age 15 to 20 years. They involve gang related violence.
Workplace Violence
It is defined as repeated unwanted communication or approaches that induced fear in
the victim (Wiseman, 1999).
The work setting has not been immune from rash of aggressive outburst. The major
crimes of the work place are homicide, assault, rape, robbery are frequent visitors to our work
sites including health care setting. Other regularly violence faced includes police officer,
security guard, taxi drivers, prisoner guarders, and high school teacher.
Workplace violence can be classified as:
 Type I: Incidence of the violence act performed by someone with no relationship.
 Type II: Incidence of the violence acts or threats by someone who received services
from the workplace.
 Type II: Incidence of violence acts from formal employee, supervisor, manager or
relative.
It also include sexual harassment, abuse and rape at workplace and can be defined as
any well come sexual advance or conduct on the job that creates an intimidating or offensive
work environment. Rape is considered a universal crime against woman.
Predatory Violence
Predatory violence, in which an individual tries to take something of value using
physical threats or direct violence and interpersonal conflicts, in which two acquaintances are
involved in a violent altercation with the intent to harm each other. It may be expressive or
instrumental. However, both types include brutal acts such as shootings, rapes, stabbings, and
beatings.
Factors Causing Community Violence
The various beliefs for causing community violence includes few costs of family
violence, absence of effective social control, family and social structure that support violence
and structural inequality of the family. The risk factors promoting community violence
includes low socioeconomic status, gang affiliation, media (action movies, etc.), trends of
violation of law, war, political issues and disputes, people with aggressive behavior and
psychiatric illness, older age, females, children, alcohol and drug, abuse as mutual combat,
religion and spirituality, etc.
 For child, it includes rental stress, marital problems, financial difficulties, parent child
conflict, neurological impairment, various psychiatric disorders, in which individuals
are unable to control impulsive behavior, poor communication skills. Learn abusive
behavior.
 For elder, physical and mental disability, financial independency, personality conflict,
societal attitude towards aging, and caregiver frustration.
 At the workplace, such as angry dissatisfied consumers, clients with certain, domestic
batterers, women with premenstrual tension, fearing of loss of job, and career
criminals. Certain cultural practices place women at risk for abuse. Drug abuse and
alcohol.
Effects of Violence
Violence effects can be experienced in the community in the following ways:
 Children display disorganized or agitated behavior and have nightmares that may
include monsters. They become withdrawn, fearful, and aggressive. They may regress
to earlier behaviors such as sucking their thumbs and bed-wetting, and they may
develop separation anxiety and also engage in play that compulsively reenacts the
violence.
 Adolescents experience nightmares and intrusive thoughts about the trauma. Trauma-
related reactions can include impaired self-esteem and body image, learning
difficulties, acting out or risk taking behaviors such as running away, drug or alcohol
use, suicide attempts and inappropriate sexual activities.
 Women are vulnerable to domestic violence as they are bound by traditional and
cultural ideology from leaving an abusive spouse or from seeing themselves as a
victim, which can be resulted in behavioral and psychological changes, bruises,
suicidal thoughts, feeling of worthlessness, and feeling the need to account for every
hour of the day to her mate.
The cycle of abuse experience usually occurs in three predictable stages; 1) increasing
tension; 2) explosion of anger and 3) loving reconciliation (the honeymoon phase).

The Cycle of Violence
Assessment
Assessment of the victim of abuse or violence requires that the nurse display
sensitivity, empathy and confidentiality and privacy also necessary. Initial assessment have
included psychological history taking, assessment of psychiatric symptoms, neurocognitive
functioning and anti-social traits, report of the violence occurrence, substance abuse and
quality of life of the community.
Various scales and instruments used for assessment are as under:
 Violence assessments based on the individual’s self-report of violence or its absence.
 Positive and Negative Symptom Scales to assess positive and negative psychiatric
symptoms.
 Quantified Neurological Scale.

 General demographic historical information for each subject including history of past
psychiatric hospitalizations.
 Lehman’s quality of Life Scale – a structured interview to evaluate important situation
including examining general life satisfaction, daily activities and functioning, family,
social relations, finances, work and school, legal and safety issues and health.
To victim of violence can be assessed in terms of:
• In my community’s street gathering places, housing, family and home
environment was favorable for gang and drug mafia and for street crime.
In my selected family the husband was offender as a drug abuser with
aggressive behavior, wife and children were victims.
No evidence of any physical problem found in the family. Elder brother used
drug since last three years. Husband has aggressive behavior and drug abuse
and gang relation.
• Individual victim and child history
Neighbors witnessed for physical abuse, evidenced by the presence of cuts,
bruises, punched, sexually victimized and deprived from leisure activities.
 Emotional and Intellectual Dimension
Use abuser threat and verbal expression, physical aggression, name calling and using
bad language for relatives, threatened to not tell about the abuse, inability to express
feeling, frustration, threatened to be killed, and divorce. Female looked helpless and
fearful.
Abuser mostly not involve in religious activities, but female believe and prayer to
God. She also has belief on magic for healings and folk medicine in the home.
Abuser not allowed to the victim and children to meet their parents and relatives.
Abuser also not participates or takes responsibilities in the family related activities.
Sometime he brings strangers to the home and relation to bad people.
 Mental Status Examination of Offender, Victim and Children
• Appearance
Wearing old stitched clothes, with sad, avoid to maintain eye contact and tell
something. Children health conditions were not good.
• Behavior
Offender looking aggressive, agitate, restless and female was hostile. He
frightened and threatened them many times. During verbal communication
offender becomes reactive and ready for physical abuse to wife.
• Communication
Female was speaking in slow and low voice with poverty of speech but
offender was interrupted her.
• Thought Process
Offender thought that his wife discussed him everywhere and even left home
to meet relatives without obtaining permission from him. Female express her
emotions and verbalized to suicidal thought or left home.
• Mood
She was looking worried and depressed.
• Sensory Perception
Offender believed that she gave valuable things to her relatives.

6. Ensight
• Present
Problems Related to Violence
Violence includes adjustment disorder with anxiety, adjustment disorder with
depressed mood, major depressive disorder, dysthymic disorder, generalized anxiety disorder,
alcohol dependence and abuse, other substance related disorders. The related nursing
diagnose are anxiety, ineffective individual coping, altered family process, fear, spiritual
distress, and hopelessness.
Priority of Nursing Diagnosis
Nursing diagnosis includes powerlessness, anxiety, an ineffective individual coping,
fear, risk for violence and hopelessness.
Medical Diagnose
Adjustment disorder with anxiety
 Powerlessness related to inability to control violent home situation as evidenced by
physical injury and feelings of dissatisfaction over present life situation.
Goal Planning
 Short-term goals
- Client will identify safe and supportive environment.
- Client will identify two strategies to breakout cycle of abuse.
 Long-term goals
- Client will deal with any life threatening and physical injuries.
- Client will experience comfort and power from other resources.
- Client will identified component of safety plan checklist.
- Individual will develop system to avoid abusive behavior and threatening.
 Reassure the client for her safety and provide calm and safe environment throughout
hospitalization.
Safety is the primary goal for both the client and children when abuse occurs.
 Determine and make arrangement for safety of woman and children. Can they stay
with a relative, or does the child and woman protective service need to be contacted?
Safety is the primary goal for both the client and children when abuse occurs.
 Explore the effects of abuse on children and adequacy of their health care.
It is important to be an advocate not only for the abuse mother but also for the
children.
 Conduct assessment in private, being especially attentive of a nonjudgmental and
gentle approach.
This type of approach maintains the client’s self-esteem.
 Encourage the client to see comfort from religious resources.
Spiritual distress is real for the abuse. It becomes difficult for them to pray or feel that
God is loving, powerful force in their lives.
 Provide privacy and support for any other additional measures such as medication and
visual imagery and support services (address context of shelter relative or significant
other).
Spiritual distress is real for the abuse. It becomes difficult for them to pray or feel that
God is loving, powerful force in their lives.
 Plan care on daily basis and involve the client. It includes his/her like/dislike, routine
according to client own pace and schedule.
Allow the client to have control over environment and attributes.
Evaluation
 Client verbalized that she has regained control on her life and to live in environment
free of violence.
 Client has increase self-concept, reduce feeling of guilt and fear and establish
effective family coping skills

Domestic Violence Prevention
Effected individuals and families is the key preventing the problems by helping the
community leader to develop expertise to prevent community violence. They can help
religious, educational and health care leaders and organizations set up relief centers and
shelters and psychological services near the site of the violence. On international basis,
various Community Violence Prevention Projects were started, which aims to strengthen and
support the work of groups dedicated to addressing community violence by facilitating the
exchange of knowledge and experiences among those working on issues of gun violence,
sexual assault, domestic and family violence, and youth violence. The project strives to build
a network of service and advocacy organizations that can help each other more effectively
confront these problems. The project focuses on promoting preventive activities that go
beyond responding to incidences of violence to tackle the causes of community violence.
Domestic Violence Prevention Model

Nurse Role in Violence Prevention
Nursing responses to abuse are best analyzed by looking at three levels of preventions
that are primary, secondary and tertiary.
In the primary prevention, the nursing role is that of a community educator on the
problems of battering and risk factors that place a woman at risk for battering and available
community resources and services for women who are at risk for or are experiencing
battering. Education is essential in preventing abuse. Nurses must work to heighten the
public’s awareness of the extent and seriousness of battering. Nurses have been particularly
effective in the areas of community education, lobbying and national policy. The secondary
prevention includes all the screening activities within the community focusing on formal
abuse assessment of women who seek care in emergency department, informal referrals
among concerned friends and family members and referrals for abuse by health providers in
other settings, such as mental health clinics, women’ health clinics and drug treatment
centers. The tertiary prevention includes guiding the women toward examining her feelings,
helping them to look at their situation realistically, supporting during the decision-making
and through any crises and providing them with the opportunities to express their anger and
to work through their depression.
Nurses play important roles in shelters both in salaried and volunteer positions. The
nurse’s role includes:
 Assessing health status of the residents.
 Intervening to meet the health needs of residents
 Developing and coordinating programs designed to address the developmental and
health needs of children.
 Servicing as a resource to shelter staff regarding access to other community services.
 Offering support and guidance to the residents.

 Serving as a health teacher on important topics.
 Serving on the advisory board of the shelter.
 Teaching in violence experience.
 Act as a facilitator for the following responses:
i) Asking the women if abuse is occurring.
ii) Identifying behavior and seriousness of abuse.
iii) Expressing belief in the women’s stories and telling the men to stop abuse.
iv) Help to identify services available, organizations, shelters and resources.
 Help to inhibit the responses by:
i) Demonstrating anger or irritation and blaming.
ii) Advising the women to accept battering as better than nothing.
iii) Withholding help until leaves her abuser.
iv) Not responding to abuser and advising to leaving him.
Abused children usually required long-term therapeutic support in the following
areas:
 Providing corrective emotional experiences that allow the development of trust and
empathy.
 Teaching cognitive strategies such as thought-stopping, clarification, reframing
beliefs, and linking stress directly to the trauma of abuse.
 Desensitizing the fearful child to involvement with others.
 Role playing focused to teach the child to discriminate threatening exploitive behavior
from safe behavior in others.
 Training in empathy skills.
 Teaching relaxation and using psychopharmacological aids in achieving relaxation.
Nursing interventions specific to violence includes:

 To develop a relationship with a victim who exhibits violent or threatening behaviors
by examine your own feelings first, approach with empathy, demonstrate respect for
victim, respect victim private space and listen respectfully.
 To assess the victim health status by asking the questions very gently, regarding
suicidal, homicidal or other destructive thoughts, anger rejection and frustration,
duration and pattern of the aggressive behavior, drug abuse and access for bruises,
lacerations, healed wound, hygiene, and identify social support system.
 To teach the patient and/or the patient’s caregiver/significant others by avoiding
threatening behaviors, recognizing violence earlier, removing self and others around
the patient as a safety measure, explain importance, purposes and side effects of
medication, relationship between medication and behavior control steps when get
angry, stress management exercises and techniques, maintaining safety and spiritual
help.
 To demonstrate skills for the patient and/or caregiver by use stress management
techniques, compliance with the medication regimen and plan of care, thought
stopping techniques and other cognitive strategies and coping skills and safety
measures.
 Being a part of this plan of care, the other health professional might need to carry out
following tasks:
i) Responsible for the overall plan of care.
ii) Assist the victim in access to community resources.
iii) Trained the social worker.
iv) Ensure the victim maintains compliance in order to psychiatric treatment.

Occupational Therapy470
References
 Carson Zee B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
 National Domestic Violence Hotline, National Center for Victims of Crime and
WomensLaw.org.
 Population Reference Bureau. Domestic Violence In: 1998 Women of Our World.
Nursing. (5th ed.). Philadelphia Lipponcott.
 Steadman, H., Mulvey, E., Monahan, J., et al. (1998). Violence by People Discharged
from acute Psychiatric inpatient facilities and by others in the same neighborhoods.
Arch Gen Psy; 55:393-401.

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Occupational Therapy 1

Liaquat University of Medical and Health Sciences

College of Nursing, JPMC

ACN III Practical Scenario

Mrs. Munira A. Ali

Professional with a baccalaureate degree in occupational therapy uses creative and

hospital and community.

decision and performing everyday activities.

The goal of occupation therapy is to enable individual to achieve competency and

Assessing Task and Activities

Occupational therapists use variety of assessment tools to measure baseline and

discharge performance in tasks and activities of importance to client.

assess community integration.

international classification of impairment, disability and handicap.

focuses on participation in community activities important to person.

developed for use of who have brachia injury.

people with chronic illness.

Activities of Daily Living

 It generally includes mobility at home feeding, dressing, bathing, grooming, toileting,

basic communication and personal hygiene.

time of day. When these activities are normal done if possible.

feelings should be respected. If many activities are evaluated by functional

The Katz Index evaluated sex functions.

 Functional Independence Measure uses a seven point’s scale to evaluate 18 items in

social cognition is function independence measure is intended to measure disability. It

is effectiveness. Functional Independence Measure has good to excellent reliability

also predict functional status at discharge and length of stay.

dressing, elimination, mobility, bathing, hygiene, eating and emergency telephone

by step simple behavioral items.

 Functional Status Index – Jette (1980) assessed level of performance, degree of

performance and safety of activities of daily living concurrently. It is process of

standardization assesses independence and required supervision in bathing, dressing,

environment for rehabilitation.

 Instrumental Activities of Daily Living – include meal planning preparation service

activities of daily living takes in most rehabilitation programs.

(Fisher 1993-1995) is an innovative assessment through which the therapist can

motor and process performance component that contribute to completion of these

Liaquat University of Medical and Health Sciences

College of Nursing, JPMC

ACN III Major NCP

Mrs. Munira A. Ali

According to this situation, we will perform her functional instrument measures.

Bathing/Hygiene self-care deficit.

 Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health

Nursing. 5th Edition. Lippincott Philadelphia.

Care Plans.7th Edition. Lippincott Philadelphia.

dysfunction. 5th Edition. Lippincott Philadelphia.

College of Nursing, JPMC

Mrs. Ruth K. Alam

wellness of both client and nurses.

is considered a stressor. Stressor s can be internal or external. A stressor is a stimulus that

evokes the need to adopt.

Factors Effecting Stress Responses

 Emotional factors – much stress occurs through emotions, such as:

 Loss of something valuable.

 Diet – contributes to physical stress

- Malnutrition and over nutrition.

 Major Event in Life

 Death of close relative or friends.

 Moving to new home/place.

frustration we experienced when goal is blocked.

 Work related stress.

 Maladjustment in family, poor working conditions, inadequate facilities, unreasonable