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Occupational Therapy
Aster Ghulam
BScN Year II
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
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
Goals
satisfaction in life’s chosen role and in the activities that support function of these roles.
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
The Craig handicap assessment and reporting technique reflect the language of
The registration to normal living index is an easy to use. Items assessment that
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
Many assessment of health related quality of life have been developed for use with
Observation of the activities identified by the client as problems should be done at the
Many people may have strong feeling of modesty regarding personal care. Those
independence measurement.
the area of self care, sphincter control, mobility locomotion, communication and
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
Occupational Therapy 4
communication. Each area is broken down into task and task is broken down in step
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
feeding bowel and bladder control. The safety assessment of function and the
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
Assessment of Motor and Process Skills – the assessment of motor and process skill
simultaneously assess performance of instrumental activities daily living takes and the
task.
Occupational Therapy 5
Occupational Therapy
Aster Ghulam
BScN Year II
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.
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
Occupational Therapy 7
Memory
Occupational Therapy 8
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
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.
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Tromblhy, C.A. and Radomski, M.V. (2001). Occupational therapy for physical
Stress
ACN III
Aster Ghulam
BScN Year II
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
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
The response of any individual to stress depends upon the following major factors.
Aggression
Impatient
Anxiety
Fear
Anger
Fight
- Imbalance diet.
- Excessive smoking
- Excessive alcohol.
Financial Factors
Unemployment.
Poverty
Price hike.
Physiological Factors
Adolescence
Pregnancy.
Overwork.
Marriage
Divorce.
Frustration
Fails to attain goals. Frustration is associated with motivation. The more motivated, more
Conflict
Physical Factors
General illness
Pain
Disease
Injury
Starvation
Physical handicap.
Medication
Hospitalization
Operation
Chemical stress
Individual perception
Environmental Factors
Psychiatric Assessment
Presenting Problems
Physical dimension
- No history of any other illness except, anger, guilt, sometimes weeping, lack
• Daily Activities
• Sexuality Pattern
- Unmarried.
Intellectual dimension
Emotional dimension
Social dimension
• Decreased concentration.
Spiritual dimension
• Sometimes praying.
Appearance
• Young girl.
• Small height.
• Healthy.
Behavior
• Decrease concentration.
• Rapid walking.
Communication
• Slow speaking.
• Low volume.
Cognitive pattern
• Loose memory
• Remote
• Disorganized.
Sensory perceptions
• Thinking impaired.
Nursing Diagnosis
Anxiety.
Ineffective coping.
Social isolation.
Short-term Goals
Long-term Goals
Interventions Rationales
• When you approach the client, be • The client’s fear may be triggered by
nonthreatening and professional. authority figures or other
characteristics.
• 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.
• 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.
Interventions Rationales
• 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.
• 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.
• 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 verbalized the knowledge of illness, treatment plan, and safe use of
medications.
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Schizophrenia
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
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.
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,
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
Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing,
57:101-113.
Personality Disorders
Bushra Sultana
Mrs. Mustaqima Begum
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.
into different types on the basis of major characteristics. All individuals are roughly classified
Type A Personality – people with this type of personality tend to be hard driving,
They tend to talk rapidly and give single word immediate answers, with acceleration
They show tense posture and usually sit on the edge of the chair.
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.
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.”
ICD-10 – used by WHO, deals with whole system and accounts for the course of
disease.
Axis.
personality disorder.
Common traits – these are typical exhibit dramatic, emotional and erotic behavior.
personality disorder.
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
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.
Helgeland, et al. (2005) conducted a research and expected the following hypothesis
to be confirmed.
disorders.
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
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.
personality disorders in women but not in men. Disruptive behavior disorders were
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
Daisy Nasreen
Dated: _______________
Happiness, sadness, excitement,
dramatic shifts in mood from the highs of mania to the lows of major depression.
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,
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.
Biological Causes
significant role. A person with this inherited vulnerability may develop bipolar disorder in
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
bipolar disorder. Some researchers believe that the biological clock that regulates our sleep-
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
Major Life Event - such as getting married, going away to college, or starting a new
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.
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,
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.
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,
Poor judgments.
Difficulty in sleeping.
Inability to concentrate.
Aggressive behavior.
Problem in concentrating.
Irritability.
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
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,
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
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
Diagnostic Criteria
The major depressive episode is not better accounted for by Schizoafective Disorder
There has never been a manic episode, a mixed episode or a hypomanic episode. This
episodes are substance or treatment induced or due to the direct physiological effects
Therapeutic Modalities
Pharmaceutical
- Effective for regulating mood and improve for indication for mania.
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
considered when drug therapy has failed, when the patient is at high risk for suicide or
hallucinations.
High success rates for treating both unipolar and bipolar depression and
Supportive Psychotherapy
patients with severe forms of depressive illness. Bachelor (1996) and Bloch (1979)
hospitalizations.
• Promote the best use of available support from family and friends.
Nursing Intervention
• Setting boundaries.
• Focus on what they can do rather what they can not do.
• Elimination pattern.
Communication
• Listen attentively.
Reinforcement of Reality
• Do not encourage.
• Focus on reality.
• Reinforcement of reality.
Nursing Diagnosis
Provide opportunities for the patient express feelings about self and illness.
Conclusion
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,
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
supportive psychotherapy - with medication treatment is most appropriate for patients with
Daisy Nasreen
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
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
Interventions Rationales
• 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
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
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
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
A person with depression loses energy and can describe recurring thought of death or
World Health Organization has predicted that by 2020 depression will be the second
Female gender.
Postpartum period.
Medical comorbidity.
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.
Antihypertensive.
Antimicrobials.
Anti-Parkinsonian drugs.
Anti-Psychotic drugs.
Cardiovascular agents.
Furrowed brow.
Depressed mood.
Loss of pleasure or interest in all or nearly all of one’s usual activities and past times.
Feeling of guilt.
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.
Two neurotransmitters are correlated with depression that are, Serotonin and
norepinephrine.
The second function is rather famous for its sympathetic nervous system control that
The diagnostic criteria for depression includes a self-rating depression scale (SDS) for
• Heterocyclic antidepressants.
(Pevler, 1999).
• Works quickly.
Depression 60
Psychological Treatment
Conclusion
symptoms that signify the presence of pathologic disturbance or change in four areas;
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
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,
Main obstacles in treatment are lack of time for proper assessment, lack of sources,
References
Obsessive-Compulsive Disorder
Farzana Kouser
BScN Year II
Obsess thoughts are persistent, intrusive thoughts that are troublesome to the client,
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
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
Epidemiology
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,
Anxiety
Ineffective coping
Depression 63
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
Depression
Depression 64
Karim Bux
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
Use simple, direct sentences and It will encourage the client to express her
ask open ended questions. feelings.
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.
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.
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
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
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
Future Consideration
A client suffering from depression requires long term management and follow up for
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
References
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Therapeutic Communication
Advanced Concept of Nursing III
Khar-un-nisa
Dated: _______________
Introduction
let go of judgment accept our own imperfection and have a desire to connect with others
many people daily and success depends upon effective interpersonal skills.”
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.
client during which the nurse focuses on the client’s specific needs to promote an effective
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
society seems to be harmful to esteem and destroys intimacy (Sears, 2004). Similarly,
Zychowicz, reported the factors influencing communication are: culture, perceptions and
(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,
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
to grasp, effective method to get the root of conflict, violence and pain peacefully. The
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).
reassurance, changing the subject, being judgmental, giving directions, excessive questioning,
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
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
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
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
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.
Formulating a plan of action – asking the client to consider kinds of behavior likely
Giving information – making available the facts that the client needs.
Suggesting collaboration – offering to share, to strive, to work with the client for his
or her benefit.
statement of fact.
Interpreting – asking to make conscious that which is unconscious, telling the client
behaviors.
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
Ask colleagues for feedback about your communication style. Ask them how they
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.
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
bounding, self-disclosure, use of touch, and active listening and observation skills.
enhance patient care and interactions with family and patients through the concept of
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.
14(1):19-25.
Khar-un-nisa
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,
Her mother also stated that signs and symptoms observed by her include depress
feeling of tiredness, unknown fear, negative thinking, headache, persistent backache, chest
Interventions Rationales
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.
Therapeutic Communication
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
desires, feeling of tiredness, unknown fear, negative thinking, headache, persistent backache,
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
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
between the nurse and client during which the nurse focuses on the client’s specific needs to
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
One should get the feedback when a client state that “I feel better and relax, as you are
Learning
I had learned that clients need to resolve whatever they are dealing with on an
clients having psychiatric disorders and others too and to say that therapeutic communication
Assists and educates clients to select choices which will support positive changes in
Future Consideration
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
Melanie_Sears/Therapeutic_Communication.
Schultz, J.M., & Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Anger
Musarrat Begum
Anger is a reaction to an inner emotion and not planned action. It is also stated that “It
often a response to the perception of threat due to a physical conflict, injustice, negligence,
humiliation or betrayal.
Actively – in the case of active emotion, the angry person “Lashes out” verbally or
physically at a target.
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
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
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,
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
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.
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
Signs and symptoms of anger include: heightened blood pressure, increase of stress
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
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
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
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
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
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
Musarrat Begum
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
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
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
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
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.
Anxiety Disorder
Mariam Fozia
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
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
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
thinking behavior and physiological activity. Included in this category are panic disorders
disorder generalized anxiety disorder specific phobia, social phobia obsessive compulsive
Physical Symptoms
Gastrointestinal
• Dry mouth.
• Difficulty in swallowing.
• Epigastric discomfort.
• Aerophagy.
Respiratory
• Difficulty in inhaling.
• Over breathing.
Cardiovascular
• Palpitations.
Genitorurinary
• Increased frequency.
• Failure of erection.
• Lack of libido.
• Blurred vision.
• Dizziness.
• Headache.
Anxiety Disorder 98
• Sleep disturbance.
Psychological Symptoms
• Irritability.
• Difficulty in concentrating.
• Distractibility.
• Restlessness.
• Sensitivity to noise.
• Depersonalization.
• Derealization.
Anxiety Disorder 99
Causative Factors
of anxiety disorders.
A genetic factor.
The anxiety disorder represents a conflict between two divergent drives or desires that
Environmental factors.
Treatment
psychotherapies. During the past several decades, there has been a increasing
enthusiasm for focused time limited therapies that address ways of coping with
personal vulnerabilities.
Pharmacotherapy
Combination Treatment
Some clients with anxiety disorders may benefit both from psychotherapy and
combinations are not uniformly necessary and are probably more cost effective when
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
Essentials of Diagnosis
both.
Conclusion
Stress, fear and anxiety all tend to be interactive. The principle components of anxiety
disturbances are common. Anxiety may be free floating resulting in acute anxiety attacks.
References
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Mariam Fozia
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,
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
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
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
Future Consideration
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
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Culture
ACN III
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.
belongingness and a common social heritage that is passed from one generation to the next.
group have similar physical characteristics as blood group, facial features, and color of skin,
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,
religious organization, and communities. Media such as radio, TV, internet etc are powerful
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
Social Relations – explains the importance and structure of friendships, gender roles
and class.
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
Characteristics of Culture
culture is:
Learned pattern of behaviors are acquired as children imitate adults and develop
Not inherited or innate, but, it is integrated throughout all the interrelated components.
Shared by every one who belongs to the cultural group. Behavioral patterns are not
group, regardless of whether beliefs are written down or spoken. Cultural beliefs are
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
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
Asian American believes that disease is due to Yin and Yong. They also view as
Native American believes that illnesses are due to use of witchcraft can.
Culture 110
voodoo. In this view, an individual might ascribe illness to evil spirits or to a curse by
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.
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.
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
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
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
Ethnic or racial background. Where did the client group originate, and how does that
Language and communication patterns. What is the preferred language spoken, and
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,
Biological factors. Are there physical or genetic traits unique to the ethnic or racial
Religious beliefs and practices. What are the group’s religious beliefs, and how do
Health beliefs and practices. What are the group’s beliefs and practices regarding
Nursing Diagnosis
Anxiety
Decisional conflict
Fear
Grieving, anticipatory
Noncompliance
Pain
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.
• Individual Health
- Loss of appetite and history of constipation from one week with frequent
urination.
any drug.
- Doesn’t meet her relatives and friends and not take part in any activity.
Depression 116
• Sexuality
Emotional Dimension
• She was very anxious about ignorance and negative behavior of other against
Intellectual Dimension
other. Delusion, auditory hallucination present and decreased decision making and
Social Dimension
Spiritual Dimension
• Believes on faith, folk remedies, herbal medicines, religious healing, and rituals.
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
Behavior
• Co-operative to health worker, delayed response with slow motor behavior, gait
Communication
• Slow communications with low volume, interrupted and slurred and speech.
Cognitive
Thought Process
Sensory Perception
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
Planning
Short-term Goals
• The client will verbalize increased adaptation to change in health status within a
week.
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
Long-term Goals:
• The client will demonstrate the behavior and thinking according to develop
• The client will demonstrate plan for using alternate ways of dealing with stress
• The client will maintain satisfying relationship in the community and on job.
• The community leader will verbally express more positive thoughts regarding
Evaluation
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
The client has demonstrated the behavior and thinking according to develop effective
The client has demonstrated plan for using alternate ways of dealing with stress and
The client was taking her treatment effectively and taking care of her mother and was
The client and family verbally indicated a more positive adaptation and agreed to
References
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Bulletin; 57:101-113.
Depression
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
Depression
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.
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 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.
Emotional Dimension
• She is very anxious about failure, and broken engagement, worrying about future
and with depressed mood. Look fearful, helpless, and feeling of insecurity and.
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.
Depression131
Tab: Diamecron 1 x OD
Tab: Depex 40 mg BD
Tab: Xanax 1 mg HS
Depression133
NURSING CARE PLAN
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.
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.
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.
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.
Carpenito, L.J. (1997). Nursing Diagnosis: Application to Clinical Practice.
7th Edition. Lippincott Philadelphia.
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.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Care Plans.7th Edition. Lippincott Philadelphia.
Shives, L.R. and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health
Nursing. 5th Edition. Lippincott Philadelphia.
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.
HIV AIDS
ACN III
Mukhtari Sardar
BScN Year II
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
Definition
General Transmission
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.
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
sexual contact, parenteral exposure to infected blood or blood products, and perinatal
Standard Precautions
Hand washing
Gloves
Gown
Environmental control
Linen
Patient placement.
Precautions, Droplet Precautions, and Contact Precautions. They can be used singularity or in
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
Respiratory Manifestations
Tuberculosis.
Gastrointestinal Manifestations
Oral Candidiasis.
Wasting Syndrome
Therapeutic Communication140
Oncologic Manifestations
Kaposi’s Sarcoma.
B-Cell Lymphomas.
Neurologic Manifestations
HIV Encephalopathy.
Cryptococcus neoformans
Depressive Manifestations
Integumentary Manifestations
Endocrine Manifestations.
Psychiatric Assessment
Age: 21 Years
Sex Female
Presenting Problems
Physical dimension
- She spend whole day with talking and walking here and there.
• Sexual Pattern
Intellectual dimension
Social dimension
• Suspicious concept.
Emotional dimension
• Aggressive behavior.
• Anxiety.
• Fear
Spiritual dimension
Appearance
• Poor grooming.
• Malnourished.
Behavior
• Decrease concentration.
Psychomotor Behavior
• Is not good.
Communication
• Amount
- Logic – interrupted.
- Clarity – clear.
Thought process
Therapeutic Communication143
Cognitive pattern
• Loose memory
• Remote
Sensory perceptions
• Illusion is present.
• Thinking impaired.
Ensight
• Absent.
Nursing Diagnosis
Diarrhea.
Abdominal cramps.
Anticipatory grieving.
Anxiety.
Ineffective coping.
Therapeutic Communication144
Social isolation.
Short-term Goals
Long-term Goals
Interventions Rationales
Interventions Rationales
Evaluation
The client maintained body weight and reported no additional weight loss.
The client identified and avoided foods that irritate the gastrointestinal tract.
Therapeutic Communication147
References
Agency for Health Care Policy and Research (1994). Evaluation and management of
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Therapeutic Communication
Mukhtari Sardar
BScN Year II
which clients are able to tell the story of their journey and the nurse is able to provide
experiences and the life events that led up to their current circumstances, they give voice to
Definition
related purpose that develops as a continuous interaction between nurse and patient.
Purposes
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.
Responsibility for the structure and conduct of the conversation is ultimately the
nurse’s.
The focus of the conversation is always on the needs and concerns of the patient.
Therapeutic Communication150
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.
The physical setting, timing, and therapeutic approach all can influence the sending
Physical Setting – use the room for each session away from the mainstream of
activity.
interaction.
Asking questions.
• Open-Ended Questions.
• Closed-Ended Questions.
• Focused Questions.
Therapeutic Communication151
Advocacy – is a broad concept that recognized as an essential role for the psychiatric
nurse.
dimensions that finds expression through actions designed to promote the health and
well-being of client.
a goal.
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
capture the inner struggle of the client, bring together different aspects of the client’s
Authenticity – means being real with the patient, not hiding behind the mask of
professionalism.
Therapeutic Communication
Mukhtari Sardar
BScN Year II
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
Interventions Rationales
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
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Tromblhy, C.A. and Radomski, M.V. (2001). Occupational therapy for physical
Aging People
ACN III
Muhammad Yousaf
BScN Year II
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
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
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
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
Disorientation
Poor memory
Liable mood
Anxiety
Schizophrenia
Meaningless character.
Poor judgment
Assessment Criteria
Physical dimension:
• Family history
- Sleep pattern is very disturbed; some time takes day nap and also lesser
activity.
• Emotion dimension
- Aggression.
- Egocentricity.
- Racism.
- Sexism
- Complaining critical
• Intellectual dimension
- Decreased self-esteem.
• Social dimension
• Spiritual dimension
Appearance
Behavior
• Unable to talk properly.
• Talkative.
• Tremor present.
• Motor Behavior
Communication Pattern
• Illogical speech.
Cognitive pattern
• Loose memory
• Remote
Thought process
• Delusion
Sensory perception
• Tactile hallucination
Ensight
• Partially absent.
Nursing Diagnosis
Anxiety.
Short-term Goals
Long-term Goals
Interventions Rationales
• Assess the level of anxiety. • For baseline data and to know the
cause.
• Speak slowly and calmly and monitor • To provide calm environment and
anxiety and relationship to activity events. help the client to understand her
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.
Evaluation
Client was using coping mechanism effectively and was ready to participate and face
dalfordl@airmail.net.
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Crises Intervention
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
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
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,
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,
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
Human organism
↓
Stressful event State of equilibrium Stressful event
↓
State of disequilibrium
↓
Need to restore equilibrium
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
place victims at high risk for maladaptive coping or even for being immobilized, the presence
actively mobilizing resources and support network. Such mobilization provides the needed
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
regain control is an important strategy. Assisting the victim in solving problem within the
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
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
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
Personality Disorder
Naseem Akhter
BScN Year II
Personality Disorder
ACN III Practical Scenario
(Assignment # 1)
Naseem Akhter
BScN Year II
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
Types
Etiology
Behavioral problems
Loss of parent
Symptoms
Anxiety
Depression
Poor adjustment
Impaired thoughts
Aggressive behavior
Suicidal behavior
Extreme stress
Beliefs in superstition
Powerless
Delusions
Nursing Diagnoses
Ineffective coping
Impaired adjustment
Social isolation
Powerlessness
General Intervention
Personality disorders are at increase risk for suicide and self-injury. Ensuring the
Build trust relationship and minimize manipulative behavior. The client safety is
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 the client positive feedback when he or she is able to express anger verbally or
in non-destructive manner.
Liaquat University of Medical and Health Sciences
Jamshoro Sindh
Personality Disorder
Naseem Akhter
BScN Year II
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
Types
Etiology
Behavioral problems
Loss of parent
Symptoms
Anxiety
Depression
Poor adjustment
Impaired thoughts
Aggressive behavior
Suicidal behavior
Extreme stress
Beliefs in superstition
Powerless
Delusions
Nursing Diagnoses
Ineffective coping
Impaired adjustment
Social isolation
Powerlessness
General Intervention
Personality disorders are at increase risk for suicide and self-injury. Ensuring the
Build trust relationship and minimize manipulative behavior. The client safety is
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 the client positive feedback when he or she is able to express anger verbally or
in non-destructive manner.
References
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Bulletin; 57:101-113.
Sexuality
ACN III
Naseem Akhter
BScN Year II
evoked and must be consider because it is basic to everyone, sexuality may be a factor with
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
Definition
Sexuality is defined as the characteristic quality of the male and female reproductive
elements.
behavior.
Problems of Sexuality
A change in sexual habits and feelings, such as first sexual activities, marriage or loss
of a sexual partner.
Menopausal symptoms.
Chromosomal abnormalities
Psychosis
Stages of Human Psychosexual Development
Stages Characteristics
Factors
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.
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
Limited Information - Provide the person and significant other with information on
the effects certain situations (e.g., pregnancy) conditions (e.g., cancer) and treatments
Intensive Therapy - Refers people who need more help to appropriate health care
Assessment
Sexual orientation/preference
Physical Dimension
partner.
- How has your health problem affected your ability to function as a wife,
- How has your health problem affected your ability to function sexually?
• Sexuality
- Body changes.
Emotional Dimension
Intellectual Dimension
Social Dimension
Socially interaction with the partner, interpersonal relationship with the partner, trust
Spiritual Dimension
Religious beliefs in regard to sexual behavior and sexual knowledge, sexual concerns
Nursing Diagnoses
Sexuality dysfunction
Related Diagnoses
Postrauma syndrome
Deficient knowledge
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
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
The client will identify practices and coping patterns that will help her/his to achieve
desire.
Interventions Rationales
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.
Encourage client to identify and discuss the By recognizing and discussing own
feelings about the parents and the feelings and changing behavior.
subsequent relationships.
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.
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.
Assess the client’s understanding of the It is important that ask to discuss the
information presented. information.
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
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
Brunner and Suddarth, D.S. (1988). Textbook of Medical-Surgical Nursing. (6th ed.).
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Nahid Jamal
Introduction
cognition that interferes with daily living. Causes are biochemical or psychological
Nurse should be cautioned when using this diagnosis as a (waste basket) diagnosis. All
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
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
Conclusion
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
Future Consideration
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
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
References
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Family Therapy
Nahid Jamal
Introduction
Family therapy is based on family system theory, which understands living organisms.
Identifying client.
Extended family field – nuclear family – grand parents and other members at the
other issues.
family to understand and improve the way family members interact with each other and
resolve conflicts.
Influence the orientation of the family identify and values towards health, eating
Financial problems.
Substance abuse.
Parenting skills.
Family therapy may include nonfamily members such as school teacher, other health
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
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.
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
involves all the members of a nuclear or extended family. Family therapy understands,
References
Suicide
ACN III
Parveen Akhter
BScN Year-II Student
College of Nursing, JPMC
Madam Yasmin
Suicide 205
OBJECTIVES
1. Define suicide.
3. Enumerate causes.
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
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.
Causes
2. Early trauma.
5. Unresolved loss.
6. History of abuse.
1. Depression.
2. Delusions.
3. Guilt.
4. Paranoid thoughts.
5. Social withdrawal.
8. Irritability.
9. Feeling of exhausted.
10. Headaches.
14. Constipation.
Biological Theories
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
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.
ACN III
Riffat Yasmin
BScN Year II
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
Definition
significance loss or change such as natural disaster, accident, or crime in which many people
Risk Factor
Job or status.
Termination of a relationship.
Assessment
Physical dimension
• Denial of loss
• Denial of feeling
Social dimension
• Gilt feeling
• Crying
• Anxiety
• Agitation
• Fatigue
• Sleep disturbance.
• Accident proneness.
• Depressive behavior
• Withdrawn behavior
Spiritual dimension
Nursing Diagnosis
Dysfunctional grieving.
Risk for other directed violence.
Short-term Goals
Long-term Goals
Interventions Rationales
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.
Interventions Rationales
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.
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
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Bulletin; 57:101-113.
ACN III
Riffat Yasmin
BScN Year II
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
Definition
significance loss or change such as natural disaster, accident, or crime in which many people
Risk Factor
Job or status.
Termination of a relationship.
Assessment
Physical dimension
• Denial of loss
• Denial of feeling
Social dimension
• Gilt feeling
• Crying
• Anxiety
• Agitation
• Fatigue
• Sleep disturbance.
• Accident proneness.
• Depressive behavior
• Withdrawn behavior
Spiritual dimension
Nursing Diagnosis
Dysfunctional grieving.
Risk for other directed violence.
Short-term Goals
Long-term Goals
Interventions Rationales
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.
Interventions Rationales
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.
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
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Bulletin; 57:101-113.
Delusional Disorder
belief that is limited to a specific area of thought and not related to any organic or major
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
Jealous - The client believes that a spouse is not a true. The client may fallow the
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
Etiology
No clear etiology has been identified but severe stress, hearing impairment and low
Epidemiology
Delusion disorder are most prevalent in people 40to 55 years old, thought the age of
Nursing Diagnosis
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
Encourage the client to use his or her contact person as often as needed. It may be
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Bulletin; 57:101-113.
Delusional Disorder
Sharifa Bibi
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
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
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
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
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
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
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Self Awareness
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
According to Locke (1689), personal identity (the self) depends on consciousness not
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.
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
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
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
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
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.
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
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.
processing and self awareness. Self awareness appears to be process in the superior
frontal gyrus.
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
that it is not always present, and is not sought after. Self awareness remains a critical mystery
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
OBJECTIVES
to:
Definition
Definition
2. Human spirits.
the ends of the universe, the center of the earth and even
http://en.wikipedia.org/wiki/Self-awareness.
Shamim Lawrence
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,
Self esteem is defined as, “the state in which an individual experiences or is at risk of
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
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
presentation, posture, eye contact movements, self abusive behavior (nail biting), lack of self
Analysis
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
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
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
Future Consideration
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
Schizophrenia
ACN III
Sultan Mohammad
Madam Yasmin
OBJECTIVES
9. Define Schizophrenia.
1. Genetic
• Twin studies.
• Adoption studies.
2. Biochemical
3. Physiological Influences
• Viral infection.
• Anatomical abnormalities.
• Histological changes.
• Physical condition.
4. Psychological
5. Environmental Influences
Medical Management
• Interpersonal therapy.
• Problem solving.
• Psychodynamic therapy.
Scenario
Critical Thinking Skills
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.
Shagufta Majeed
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
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
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
with all health team members, I took permission from the Head Nurse to go the
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
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
Analysis
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
some but not all care measures by supervising others who assist clients and by
Schizophrenia
According to the Orem, nursing care is necessary when the client is unable to
determines whey a client is unable to meet these needs and what must be done to
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
Future Consideration
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
References
Process and Practice, (5th ed.). New Jersey: Prentice Hall Health.
Cognitive-Behavioral Therapy
ACN III
Shahnawaz
BScN Year-II Student
College of Nursing, JPMC
Madam Yasmin
OBJECTIVES
COGNITIVE-BEHAVIORAL THERAPY
Introduction
Definitions
Cognitive Theory
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-Behavioral Therapy 298
Cognitive-Behavioral Therapy
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.
Cognitive-Behavioral Therapy 301
Nursing Diagnoses
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
Nursing Intervention
Psychological Intervention
Scenario
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.
Cognitive-Behavioral Therapy 309
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.
JAMSHORO SINDH
Cognitive-Behavioral Therapy
ACN III
Shahnawaz
BScN Year-II Student
College of Nursing, JPMC
Madam Yasmin
OBJECTIVES
COGNITIVE-BEHAVIORAL THERAPY
Introduction
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.
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.
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.
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.
Cognitive-Behavioral Therapy 314
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.
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.
Cognitive-Behavioral Therapy 315
Cognitive-Behavioral Therapy
Risk Factors
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.
19. Shyness and social anxiety.
20. Panic attacks and phobias.
21. Obsessions and compulsions.
22. Chronic anxiety or worry.
23. Post traumatic stress symptoms.
24. Eating disorders and obesity.
25. Insomnia and other sleep problems.
26. Difficulty establishing staying in relationship.
27. Problem with marriage or other relationship.
28. Job career of school difficulty.
29. Feeling stressed out.
30. Insufficient self-esteem.
31. In educate coping skills self- or ill-chosen method of
coping.
32. Passivity – Procrastination and “passive aggression”.
33. Substance abuse co-dependency and “enabling”.
34. Trouble keeping feeling such as anger sadness, fear,
guilt, shame, eagerness, excitement, etc. within bounds.
35. Over-inhibition of feeling or expression.
Cognitive-Behavioral Therapy 319
Nursing Diagnoses
Types of Distraction
1) Visual distraction.
iv) Reading or watching television.
v) Watching a baseball game.
vi) Guided imagery.
2) Auditory distraction.
iii) Humor.
iv) Listening to music.
3) Tactile distraction.
iv) Slow, rhythmic breathing.
v) Massage.
vi) Holding or stroking a pet or toy.
4) Intellectual distraction
iv) Crossword puzzles.
v) Card games (e.g. bridge)
vi) 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.
322 Cognitive-Behavioral Therapy
Nursing Intervention
Psychological Intervention
Scenario
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.
22. Harber, Hoskins and Leach (1978). Behavioral and
Cognitive Theory and Application In: Comprehensive
Psychiatric Nursing. 3rd Edition. USA; pp 467-484.
23. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-397-
50642-2; pp 386-390.
24. Elsevier Nam Boodiri (2005). Cognitive Therapy In:
Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal
Electric Press Delhi; p 347,
25. Townsend Marry C (1941). The nursing process across
the life span In: Psychiatric Mental Nursing. pp 893-896.
26. 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.
27. http://www.google.com. Scott J (2001). Cognitive therapy
for depression. B Med Bulletin; 57:101-113.
28. 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.
29. http://www.yahoo.com. Bush JW. The Basis of Cognitive
Behavior Therapy.
30. 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.
327 Cognitive-Behavioral Therapy
his sleep commode, or offer bedpan at the sleep cycle during the night.
Objective Data pattern. 09:00 PM. night. • He was able
Mr. Jim, a 58 years old male come in
Psychiatric OPD with complain of Long term goals
• Maintain room temperature at • Environment temperature to discuss his
i.e., the most conducive to feelings with
disturbed sleep pattern related to 68 to 72°F.
depression.. He looks irritate and drozy. • Will demons- sleep. his sister and
brother-in-law
His walking is imbalance. He looks pale trated at least 6
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted and had
and week with slow speak. sleep. decided to
uninterrupted therapeutics prior to 09:00 PM.
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.
• 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.
Cognitive-Behavioral Therapy 328
Cognitive-Behavioral Therapy
ACN III
Shahnawaz
BScN Year-II Student
College of Nursing, JPMC
Madam Yasmin
OBJECTIVES
COGNITIVE-BEHAVIORAL THERAPY
Introduction
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.
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.
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.
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.
Cognitive-Behavioral Therapy 332
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.
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.
Cognitive-Behavioral Therapy 333
Cognitive-Behavioral Therapy
Risk Factors
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.
36. Shyness and social anxiety.
37. Panic attacks and phobias.
38. Obsessions and compulsions.
39. Chronic anxiety or worry.
40. Post traumatic stress symptoms.
41. Eating disorders and obesity.
42. Insomnia and other sleep problems.
43. Difficulty establishing staying in relationship.
44. Problem with marriage or other relationship.
45. Job career of school difficulty.
46. Feeling stressed out.
47. Insufficient self-esteem.
48. In educate coping skills self- or ill-chosen method of
coping.
49. Passivity – Procrastination and “passive aggression”.
50. Substance abuse co-dependency and “enabling”.
51. Trouble keeping feeling such as anger sadness, fear,
guilt, shame, eagerness, excitement, etc. within bounds.
52. Over-inhibition of feeling or expression.
Cognitive-Behavioral Therapy 337
Nursing Diagnoses
Types of Distraction
1) Visual distraction.
vii) Reading or watching television.
viii) Watching a baseball game.
ix) Guided imagery.
2) Auditory distraction.
v) Humor.
vi) Listening to music.
3) Tactile distraction.
vii) Slow, rhythmic breathing.
viii) Massage.
ix) Holding or stroking a pet or toy.
4) Intellectual distraction
vii) Crossword puzzles.
viii) Card games (e.g. bridge)
ix) 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.
340 Cognitive-Behavioral Therapy
Nursing Intervention
12. Allow use of toilet articles brought from home, play soft
music or relaxation tapes at rest or bedtime.
Psychological Intervention
Scenario
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.
31. Harber, Hoskins and Leach (1978). Behavioral and
Cognitive Theory and Application In: Comprehensive
Psychiatric Nursing. 3rd Edition. USA; pp 467-484.
32. Walker JI. Essentials of Clinical Psychiatry. ISBN 0-397-
50642-2; pp 386-390.
33. Elsevier Nam Boodiri (2005). Cognitive Therapy In:
Concise Textbook of Psychiatric. 2nd Edition. Raj Kamal
Electric Press Delhi; p 347,
34. Townsend Marry C (1941). The nursing process across
the life span In: Psychiatric Mental Nursing. pp 893-896.
35. 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.
36. http://www.google.com. Scott J (2001). Cognitive therapy
for depression. B Med Bulletin; 57:101-113.
37. 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.
38. http://www.yahoo.com. Bush JW. The Basis of Cognitive
Behavior Therapy.
39. 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.
345 Cognitive-Behavioral Therapy
his sleep commode, or offer bedpan at the sleep cycle during the night.
Objective Data pattern. 09:00 PM. night. • He was able
Mr. Jim, a 58 years old male come in
Psychiatric OPD with complain of Long term goals
• Maintain room temperature at • Environment temperature to discuss his
i.e., the most conducive to feelings with
disturbed sleep pattern related to 68 to 72°F.
depression.. He looks irritate and drozy. • Will demons- sleep. his sister and
brother-in-law
His walking is imbalance. He looks pale trated at least 6
to 8 hours of
• Schedule all patient’s • Promotes uninterrupted and had
and week with slow speak. sleep. decided to
uninterrupted therapeutics prior to 09:00 PM.
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.
• 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.
Panic Disorder346
Shagufta Rani
Dated: ______________
Panic Disorder347
Definition
The mental status examination is the most important diagnostic tool a psychiatrist has
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.
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
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
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
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
(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
Thought Process – record the patient’s thought process information. The process of
topics), racing (rapid thoughts), tangential (departure from topic with no return), neologism
(creating new words), circumstantial (being vague), word salad (nonsensical responses e.g.,
(talking in riddles), thought blocking (speech is halted). Take all of these things into account
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
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
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
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).
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
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
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
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
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
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
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
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;
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
interview. The level of intellectual functioning based upon patient’s educational history,
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
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.
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.
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,
Chief Complaint – this is the patient’s problem or reason for the visit. Most often, this
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
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
Family History – list any psychiatric or medical illness, and methods of treatment
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
Conclusion
They mental status examination and history are the most important diagnostic tools.
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
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
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.
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
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
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.
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
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
Heart palpitation.
Tingling sensation.
Sweating.
Trembling or shaking.
Feeling of choking.
Feeling of unreality.
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.
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.
Most of the people suffering from agoraphobia avoids to public places like shopping
mall, theaters, buses, supermarket, trains, stores, subways, planes, tunnels, elevators,
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?
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
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
Event Related Potential (ERP) is a component of EEG, when person has a thought or
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.
neurotransmitters. Side effects include dry mouth, blurred vision, difficulty in urinating,
constipation, increase heart rate, sweating, sleep disturbance, hypotension, dizziness, fatigue,
the neurotransmitter systems. Side effects include addictive interfere with cognitive and motor
sensation, etc.
Panic Disorder361
By Relaxation Exercises:
Relaxation exercises can be used to combat the everyday anxiety and the tension
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
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
Nursing Intervention
References
Practice guideline for treatment of patient with panic disorder. American Psychiatric
Association. 1998.
Objectives
Define teacher.
Subject:
Level of students: BScN-II
Topic: Demonstration of various teaching styles.
Venue: Classroom CoN,
JPMC, Karachi.
Sajida Siddique
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
Heart palpitation.
Tingling sensation.
Feeling of choking.
Feeling of unreality.
Fear of dying.
Insomnia,
Lack of concentration,
Irritability
Nightmares.
Pupil dilation
Going crazy.
verbalization.
Anorexia
Nausea/vomiting
Diarrhea/urge to defecate
Dry mouth/throat.
Diagnosis Consideration
Neuropsychological test.
Intelligence test.
EEG
PET.
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
Planning
Tricyclic Antidepressants.
By Relaxation Exercises:
Expected Outcomes
Communicates appropriately.
Nursing Interventions
Unfamiliar environment
Age-related fears
Unfamiliar environment
Orient to environment using simple explanation.
Threat to self-esteem
Distorted perceptions
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
identified.
Safety feelings increase when a person identifies with another person who has
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
Fear can become anxiety fear becomes internalized and serves to disorganize instead
of becoming adaptive.
physiologic and psychological systems react with equal intensity to the perceived
Evaluation
loss of independence.
Apologized for shouting and belittling behavior; verbalized ways in which she used
Established own schedule for ADL and dressing changes; consulted with physical
goal for living situation. Identified changes that had occurred since hospital
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
Practice guideline for treatment of patient with panic disorder. American Psychiatric
Association. 1998.
Sajida Siddique
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
Panic Disorder
Reflection
Introduction
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
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
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
Panic Disorder
ACN III
Sultan Salahuddin
BScN Year-II Student
College of Nursing, JPMC
Panic Disorder379
Madam Yasmin
OBJECTIVES
PANIC DISORDER
Introduction
Definition
3) Pheochromocytomas.
5) Hypoglycemia.
6) Caffeine intoxication.
4) Benzodiazepines
Duration of Treatment
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.
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.
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
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.
41. Harber, Hoskins and Leach (1978). Comprehensive
Psychiatric Nursing. 3rd Edition. USA; p 623.
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.
44. Carson Verna Benner. Mental Health Nursing.
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.
Depression
ACN III
Safrunisa
BScN Year II Student
College of Nursing, JPMC
Madam Yasmin
OBJECTIVES
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.
8. Anhedonia.
Levels of Depression
Severe Depression
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
Tricyclic Antidepressants
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.
Assessment
Temperature: 97°F
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
Family Therapy
Violet Barkat
BScN Year II
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
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
feelings and when family unit is the focus of treatment, for example, in a divorce situation.
Nuclear – A father, mother and at least one child living together but apart from both
Extended – three or more generation including married brothers and sisters and their
families.
Three Generation – Any combination of first, second and third generation members
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
Single Adult Living Alone – An increasingly common occurrence for the newer-
No Kin – A group of at least two people who have no legalized or blood ties but who
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.
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,
looking at the pattern of relationships within the system rather than looking at
Living systems demonstrate equifinality – the ability to achieve the same final goal in
a variety of ways.
Systems have feedback loops defined as “the process by which a system gets the
Bowen viewed the basic forces shaping family functional behavior as:
Differentiation of self.
Triangles.
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
A Bowen family therapist gathers information that helps the family members look at
relationships between family process and events, track multigenerational patterns and
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
family therapy. Bowen advocated looking at what goes on between people rather than
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
By coaching people to become aware of their own emotional process within the
family.
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.
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,
strategy to reduce risk factors associated with the development of behavioral symptoms.
Information and training about a specific area of family life, such as communication
Information and support to families dealing with specific stress or crises, such as a
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
How do I know the theoretical orientation of the therapist, and does it matter?
Teach the family members to decrease anxiety by focusing on thinking rather than
feeling.
Identify the primary triangles and teach the family members to manage themselves
within them.
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.
Maintain neutrality.
Liaquat University of Medical and Health Sciences
Jamshoro Sindh
Family Therapy
Violet Barkat
BScN Year II
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
Date Assessment Nursing Goal/Planning Nursing Intervention Rationale Evaluation
(Data Statement) Diagnosis
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.
References
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Substance Abuse
ACN III
Violet Barkat
…Therapy425
BScN Year II
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
(addiction).
Definition
impairment. The person has no control over use of the substance and feels pleasure only
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,
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
Psychologists have looked for factors that predict adolescent abuse of drug and
alcohol. Researchers have discovered that certain personality factors in childhood are
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
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
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
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.
Heroin addict.
Alcohol.
Cigarettes.
Chares.
Antiinsect chemicals.
Ghotteka.
Assessment
Bizarre behavior.
Regressive behavior.
Loss of ego boundaries (inability to differentiate self from the external environment)
Disorientation.
Nursing Diagnosis
Short-term Goals
so forth.
Long-term Goals
Interventions Rationales
• 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.
• 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.
…Therapy431
Interventions Rationales
• 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.
• 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.
• 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.
• 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.
…Therapy432
Interventions Rationales
• 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.
Evaluation
Client has verbalized feelings in an acceptable manner and coping effectively with the
illness.
References
Carson, V.B. (2000). Mental Health Nursing. The Nursing Patient Journey.
2nd Edition.
Harber, Hoskins and Leach (1978). Comprehensive Psychiatric Nursing. 3rd Edition.
USA.
Schultz, J.M. and Videbeek, S.L. (2004). Lippincott’s Manual of Psychiatric Nursing
Zafar Iqbal
BScN Year II
…Therapy434
cognitive therapy and behavior. It approaches to treatment useful for the patients
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
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.
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
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
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
Types
Cognitive therapy.
Behavioral psychotherapy.
Pharmacotherapy.
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
…Therapy437
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
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
Arbitrary inference – draw the conclusion about event without any evidence.
Selective abstraction – draw the conclusion on the basis of one fact rather than the
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
Behavior Therapy
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 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
…Therapy438
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.
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,
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
environment is source of stimuli that support symptoms. Therefore, it also can support
behavior, such as: (1) aversion therapy uses unpleasant or noxious stimuli to change
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
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
restructure irrational beliefs and behavior. The therapist confronts the client with a specific
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
(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.
…Therapy440
Similarities
Formulate symptoms in behavioral terms, Same
and design specific set of operations to
alter maladaptive behavior.
Insufficient self-esteem.
Trouble keeping feeling such as anger sadness, fear, guilt, shame, eagerness,
Release of emotions.
Giving information.
Providing rationale.
Prestige suggestions.
Therapeutic relationship.
…Therapy442
Purpose of Therapies
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.
Cognitive Interventions
To increase the client’s sense of control over his/her goals and behavior.
Task of the nurse to move the client beyond his/her limiting preoccupation to other
Nursing actions may then focus on modifying the client’s thinking. Depressed clients
In many cognitive behavioral pain relies strategies are also used to relieve stress, such
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.
They test the flexibility of a person or system and reveal areas of resistance to change.
…Therapy443
Psychological Interventions
responses in about 50% cases however, isolating the determinant factors that predict
psychiatric disorders.
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.
relaxation and training in coping skills) has been beneficial in reducing postoperative anxiety
Zafar Iqbal
BScN Year II
Presenting Complaint:
Nonstop hiccup
Tremors in hands.
Sleeplessness
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.
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.
Psychiatric Assessment
Physical dimension
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.
…Therapy446
Individual history
- 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.
Sexuality
Emotional dimension
Fearful
Helpless
Feeling of insecurity
Jobless.
Intellectual dimension
Spiritual dimension
Hopeless
…Therapy447
Social dimension
Appearance
Young 22 years, tall built lady wearing neat and appropriate clothes, maintaining her
Behavior
Abnormal Movement
Tremors in hands
Nonstop hiccups.
Communication
Cognitive
…Therapy448
Thought Process
Thought process was intact. No delusion and illusion present but no thought stopping.
Sensory Perception
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
Interventions Rationales
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
Cox, H.C., Hinz, M.D., Lubno, M.A., Newfield, S.A., Ridenour, N.A.,
Harber, Hoskins and Leach (1978). Behavioral and Cognitive Theory and
Rebraca, S.L. and Ann, I. (2002). Cognitive Behavioral Therapy In: Basic
Bulletin; 57:101-113.
Community Violence452
Community Violence
ACN III
Zafar Iqbal
BScN Year II
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
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
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
Community Violence454
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
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,
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
control over the other persons. It includes physical violence, sexual assault, and verbal
or emotional abuse.
Domestic Violence
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
Community Violence455
dating. Children population can be affected more than adults one. Domestic violence mostly
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.
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.
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.
Community Violence456
Child Abuse
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
Physical abuse.
(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
Community Violence457
emotional care, and (4) provide supervision. It can occur in three levels i.e., in the
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
Youth Violence
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
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.
Type II: Incidence of the violence acts or threats by someone who received services
Type II: Incidence of violence acts from formal employee, supervisor, manager or
relative.
Community Violence458
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
Predatory Violence
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.
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,
For child, it includes rental stress, marital problems, financial difficulties, parent child
are unable to control impulsive behavior, poor communication skills. Learn abusive
behavior.
For elder, physical and mental disability, financial independency, personality conflict,
At the workplace, such as angry dissatisfied consumers, clients with certain, domestic
batterers, women with premenstrual tension, fearing of loss of job, and career
Community Violence459
criminals. Certain cultural practices place women at risk for abuse. Drug abuse and
alcohol.
Effects of Violence
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
Women are vulnerable to domestic violence as they are bound by traditional and
suicidal thoughts, feeling of worthlessness, and feeling the need to account for every
The cycle of abuse experience usually occurs in three predictable stages; 1) increasing
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
functioning and anti-social traits, report of the violence occurrence, substance abuse and
Positive and Negative Symptom Scales to assess positive and negative psychiatric
symptoms.
General demographic historical information for each subject including history of past
psychiatric hospitalizations.
including examining general life satisfaction, daily activities and functioning, family,
social relations, finances, work and school, legal and safety issues and health.
Physical Dimension
environment was favorable for gang and drug mafia and for street crime.
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
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.
Spiritual Dimension
Community Violence462
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.
Social Dimension
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.
• Appearance
Wearing old stitched clothes, with sad, avoid to maintain eye contact and tell
• Behavior
• Communication
Female was speaking in slow and low voice with poverty of speech but
• 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
• Mood
• Sensory Perception
6. Ensight
• Present
Community Violence464
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
Medical Diagnose
Goal Planning
Short-term goals
Long-term goals
- Client will deal with any life threatening and physical injuries.
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.
Community Violence465
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.
gentle approach.
Spiritual distress is real for the abuse. It becomes difficult for them to pray or feel that
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
Plan care on daily basis and involve the client. It includes his/her like/dislike, routine
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
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
Nursing responses to abuse are best analyzed by looking at three levels of preventions
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
Nurses play important roles in shelters both in salaried and volunteer positions. The
iii) Expressing belief in the women’s stories and telling the men to stop abuse.
areas:
Providing corrective emotional experiences that allow the development of trust and
empathy.
Role playing focused to teach the child to discriminate threatening exploitive behavior
by examine your own feelings first, approach with empathy, demonstrate respect for
To assess the victim health status by asking the questions very gently, regarding
duration and pattern of the aggressive behavior, drug abuse and access for bruises,
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:
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.
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.