PSYCHOSOCIAL INTEGRITY

Concepts of Mental Health and Mental Illness

Biochemical research
• Study of the brain and its functioning has helped researchers understand which parts of the brain are involved in each mental
illness
• Medications are now more effective as a result of a better understanding of neurotransmitters and their functioning
• Major neurotransmitters include: norepinephrine, dopamine, serotonin, and gamma-aminobutyric acid (GABA)
• Neuroimaging through positron emission tomography (PET scan) or the computed tomography (CT scan) and magnetic
resonance imaging (MRI scan) allow researchers and diagnosticians to study the brain without surgery
Genetic research
• Currently, no type of genetic testing can tell whether a person will develop mental illnesses; not enough is known about which
gene variations contribute to them or the degree to which other factors contribute
• Familial and genetic factors are part of many major psychiatric illnesses, including bipolar disorder and schizophrenia
Psychological theories
1. Psychoanalytic theory
• developed by Sigmund Freud
• introduced concept of the mind as a structure incorporating the id, ego and superego
• part of each persona's mental functioning is conscious and part unconscious
• treatment includes helping make the unconscious conscious
• defense mechanisms are used to defend the ego from conflicts between the id and superego
Defense mechanisms can be categorized based on how primitive they are
• Primitive defense mechanisms
• Can be very effective short-term, but less effective over the long run
• Often used by children
• Examples
• denial
• regression
• acting out
• dissociation
• compartmentalization
• projection
• reaction formation
• Less primitive, more mature defense mechanisms
• repression
• displacement
• intellectualization
• rationalization
• undoing
• Mature defense mechanisms are more focused on helping a person cope and be at peace with themselves and
those around them
• sublimation
• compensation
• assertiveness

Common Defense
Description Example
Mechanisms

A short man becomes assertively verbal and

Extra effort in one area to offset real
or imagined lack in another area; it
Compensation
helps reinforce a person's self-
esteem and self-image
excels in business
In order to compensate for her lack of cooking
skills will say, "I may not know how to cook, but I
can sure do the dishes!"

A mental conflict is expressed A woman becomes blind after seeing her

Conversion
through physical symptoms husband with another woman

Denial Treating obvious reality factors as A mother refuses to believe her child has been
though they do not exist because diagnosed with leukemia, and states, "she just
they are consciously intolerable has the flu"
Common Defense
Description
Mechanisms
Transferring unacceptable feelings
Displacement aroused by one object to another,
more acceptable substitute
Walling off specific areas of the
Dissociation
personality from consciousness
A conscious distortion of
Fantasy unconscious wishes and need to
obtain satisfaction
Becoming stagnated in a level of
Fixation emotional development in which one
is comfortable
Subconsciously attributing to oneself
Identification
qualities of others
Use of thinking, ideas, or intellect to
Intellectualization
avoid emotions
Introjection Incorporating the traits of others
Unconsciously projecting one's own
Projection unacceptable qualities or feelings
onto others
Justifying behaviors, emotions,
Rationalization motives, considered intolerable
through acceptable excuses
Reaction Expressing unacceptable wishes or
Example
A functioning alcoholic denies s/he has a drinking
problem, pointing out how well s/he functions in
her/his job and relationships
An adolescent lashes out at parents after not
being invited to party
A person who gets angry at his boss, but can't
express his anger for fear of being fired will come
home and kick the dog or start an argument with
someone else
An adolescent talks about failing grades as if they
belong to someone else and jokes about it
People who have a history of any kind of
childhood abuse often suffer from some form of
dissociation
A student nurse fails the critical care exam and
daydreams about her heroic role in a cardiac
arrest
A sixty year old man who dresses and acts as if
he were still in the 1960's
An Elvis impersonator
A parent becomes extremely knowledgeable
about child's diabetes
A wife of a substance abuser knows about
enabling behaviors yet continues to report his
absence on Monday morning as an "illness"
A husband's symptoms mimic his wife's before
she died
A woman who is jealous of another woman's
wealth accuses her of being a gold-digger
A student who has sexual feelings towards a
teacher, tells her friends that the teacher is
"coming on to her"
"I didn't get chosen for the team because the
coach plays favorites."
I woman who was head-over-heels in love with a
guy, who then dumps her, will say, "I knew he was
a loser"
A recovered smoker preaches about the dangers
 Common Defense
Description Example
Mechanisms

of second hand smoke

A woman who is very angry with her boss and

Formation behavior by opposite overt behavior
would like to quit her job may instead be overly
kind and generous toward her boss and express
a desire to keep working there forever

A four year old insists on climbing into crib with

Retreating to an earlier and more younger sibling
Regression comfortable emotional level of
development After moving to a new home, a 5 year-old starts
wetting the bed

Unconscious, deliberate forgetting of

An adolescent "forgets" appointment with
Repression unacceptable or painful thoughts,
counselor to discuss final grades
impulses, feelings or acts

A young woman who hated school becomes a

Diversion of unacceptable instinctual teacher
Sublimation drives into personally and socially
acceptable areas Sublimation can be done with humor (telling a
light-hearted story or joke) or fantasy
2. Interpersonal theory
• originally developed by Harry Stack Sullivan
• personality develops according to the client's perception of how others view them
• a healthy personality is the result of healthy relationships
• Hildegard Peplau, who is considered to be the "mother of psychiatric nursing," was influenced by this theory
• she wrote Interpersonal Relations in Nursing, which became the foundation for the nurse-client relationship
• according to Peplau, the nurse-client relationship is one in which
• the client receives unconditional acceptance
• the relationship between nurse and client is client-centered
• the relationship is developed according to the client's perceived readiness
3. Psychosocial developmental theory
• developed by Erik Erikson
• describes eight psychosocial stages of development in the human life cycle
• development is successful if the person is able to resolve the conflict that arises during each stage
• if the person does not effectively resolve the conflict, then development is arrested at that stage
4. Cognitive behavioral theory (CBT)
• focuses on the premise that a person's thoughts control their behavior
• if a client is feeling or behaving in an unwanted way, then it is important to identify the thoughts that are causing these
feelings or behaviors
• the treatment is for the client to replace the current thoughts with ones that produce a more desirable outcome
• CBT is used to help clients manage symptoms of their illness and live a fuller life
5. Behavioral theory
• symptoms of mental illness are the result of learned behavior
• through the use of positive and negative reinforcement unacceptable learned behavior can be replaced by a more desired
behavior
• symptoms of phobias, sexual dysfunction, and eating disorders are some of the mental illnesses currently treated using
behavioral therapy
• assertiveness training and desensitization are commonly used behavioral techniques
Develop cultural self-awareness - respect the beliefs that are different from those of the nurse
• religion - an organized system of beliefs about a higher power
• spirituality - beliefs about the essence of being
• Be familiar with common practices of common religions including value systems, diet, beliefs surrounding death
• Catholic
• Protestant
• Jewish
• Muslim
• Hindu
• Buddhist
• Mormon
• Christian Scientist
• Jehovah Witness
• Seek personal spiritual support for clients who are in distress
• chaplain service
• consider HIPAA and client's wishes
• Recognize that research supports the importance of spiritual support; several studies indicate that prayer improves
health status
Cultural Awareness and Cultural Competence
1. Develop cultural self-awareness and respect cultural differences of others
• consider culture as different from race or ethnicity alone
• determine the cultural beliefs of the client especially related to health practices
2. Be familiar with various cultural practices
• folk healing of rural populations
• native American practices
• complementary & integrative health therapies
3. Determine any healing practices the client uses, prescribed or unprescribed
• use non-judgmental approach
• observe for positive or negative interactions of traditional (allopathic) therapy with complementary & integrative health
therapies
• document all practices and therapies
Types of grief
• anticipatory grief: person learns of impending loss and responds with processes of mourning, coping, interaction, planning,
and psychosocial reorganization
• disenfranchised grief: person experiences a loss that is not or cannot be openly acknowledged, publicly mourned, or socially
supported
• complicated grief: a result of a sudden loss
Mourning: process used to resolve grief
Bereavement: a state of grieving
Theory of Grief:
Elizabeth Kubler-Ross (1969): Five Stages of Grief; the griever might move through these stages in a varied way with the
ultimate goal being the acceptance of the loss.
1. Denial
• unconscious avoidance which varies from a brief period to the remainder of life
• allows one to mobilize defenses to cope
• positive adaptive responses - verbal denial; crying
• maladaptive responses - no crying, no acknowledgement of loss
2. Anger
• expresses the realization of loss
• may be overt or covert
• positive adaptive responses - verbal expressions of anger
• maladaptive responses - persistent guilt or low self esteem, aggression, self destructive ideation or behavior
3. Bargaining
• an attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in
near future
• maladaptive responses - bargains for unrealistic activities or events in distant future
4. Depression and Withdrawal
• sadness resulting from actual and/or anticipated loss
• positive adaptive response - crying, social withdrawal
• maladaptive responses - self-destructive actions, despair
5. Acceptance
• resolution of feelings about death or other loss, resulting in peaceful feelings
• positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business
• John Bowlby (1961 & 1980): Four stages of separation and loss; individuals progress through these stages, at their
own pace, in any order, in an attempt to resolve their loss.
• Shock and numbness
• Searching and yearning
• Disorientation
• Reorganization and resolution
• Erich Lindemann (1944): Describes grief as a syndrome that includes a common range of physical symptoms, i.e.,
tightness of throat, shortness of breath, and other pain, along with a range of emotional responses. His research is
based on a sample of primarily young survivors of sudden and traumatic loss.
• Shock
• Acute mourning
• Resolution of grief
• William Worden (1991): Describes four tasks in the grieving process; once these tasks have been completed, grief
is assumed to have been resolved.
• Accept the reality of the loss
• To work through the pain of grief
• To adjust to the changed environment (in which the deceased is missing)
• To emotionally relocate the deceased and move on with life
• Tagliaferre and Harbaugh (2002)
• Expanded on Worden's model of grief
• Proposed five tasks
• acknowledge the loss
• feel the impact
• acquire temporary substitutes
• detach from the relationship
• reconstruct a new life
Nursing interventions in grief
• support client's effective coping mechanisms
• don't take client's responses personally
• listen attentively
• support client with problem-solving and decision-making as indicated
• encourage the client and/or significant others to express their feelings and concerns
• utilize therapeutic touch as appropriate
• assist in discussions of future plans as appropriate
Tasks of mourning (common to the models of grief): R E A L
Real - accept that the loss is real
Experience the emotions associated with the loss
Adjust or re-adjust to life and activities
Let go and move on with one's own life
Therapeutic relationship
• Definition: a relationship that is established between a health care professional and a client for the purpose of assisting the
client with problem solving, grief counseling, teaching regarding illness or situation
• Relationship consists of
• a nurse who possesses the skills and ability to provide counseling, crisis intervention, health teaching, etc.
• the client who seeks help for some problem
Phases of the nurse-client relationship :
Initiating or orientation phase
• Establishes trust and rapport
• Establishes a contract (including time, place and duration of sessions)
• Discusses parameters of the relationship
• Identifies the problem and expectations, i.e., goal-setting and plan of action
• Explore feelings
• Discusses confidentiality and termination parameters
• Usually an anxious time for both client and nurse
• Client may be late for the session
• Client may exhibit anxious mannerisms
• Nurse's own anxiety may prompt nurse to use techniques that block communication
• Working phase
• Boundaries of the relationship are accepted by the client and the nurse and a therapeutic relationship is established
• Nurse uses therapeutic communication techniques (avoiding non-therapeutic communication), including active listening skills
(S-O-L-E-R):
• S = Sit squarely facing the client
• O = Observe an open posture
• L = Lean forward toward the client
• E = Establish eye contact (with cultural considerations)
• R = Relax
• Teaches coping mechanisms
• Client identifies problems, develops insights to the problems
• Client learns adaptive coping and problem-solving skills
• Evaluates effectiveness of interventions
• Termination phase
• Actually begins with the first session and ends when identified treatment goals are met
• Anticipate problems of termination
• Client may become too dependent on nurse
• Client may recall previous separation experiences and feelings of rejection, depression, and/or abandonment
• Evaluates outcomes, reassessing the problems, goals, and interventions if needed
• Client and nurse express thoughts and feelings about termination
Five characteristics of nurse-client relationship
• Mutual definition - the nurse and client define the relationship together
• Goal direction - purpose, time, and place are specific
• Specified boundaries - in time, space, content, and confidentiality
• Therapeutic communication - nurse creates trust and open communication by these interpersonal techniques
• Nurse helps client toward resolution
Types of therapeutic interventions
• Individual (or one-on-one) therapy
• Group therapy
• Family therapy
• Milieu therapy
• Occupational therapy
The non-compliant client
• Behavior characteristics - does not cooperate with the treatment plan
• does not take prescribed medication
• continues activities restricted by provider of care, such as smoking, drinking, gambling, risk taking behaviors
• does not follow prescribed activities, such as exercise, adequate rest, healthy diet
Nursing interventions
explore the reasons for non-compliance:
• lack of understanding - reinforce teaching
• lack of family support - involve family and support groups
• medication side effects - refer to provider of care
• finances and access - refer to Social Services
• negative attitude toward treatment - encourage expression
• express genuine concern for client
• discuss improvement potential
Stress management
• Stress: a universal phenomenon; requires change or adaptation so that the person can maintain equilibrium
• Stress can be internal or external
• Nature of stressor involves
• intensity
• scope
• duration
• other stressors - their number and nature
• Categories of stressors - and examples
• physical - drugs or alcohol
• psychological - such as adolescent emotional upheaval, or unexpressed anger
• social - isolation, interpersonal loss
• cultural - ideal body image
• microbiologic - infection
• The greater the stressor as perceived by the client, the greater the stress response
Stress response involves both localized and general adaptation :
Stage 1: Alarm Reaction
• Exposure to adverse stimulus; body mobilized to resist in form of compensatory behavior
• Fight or flight response
• increased cardiac output
• increased heart rate
• increased respiratory rate
• dilated pupils
• increased mental alertness
• Sympathetic nervous system response
• increased epinephrine
• increased blood flow to skeletal muscle
• involves increased arterial blood pressure
• increased norepinephrine
• Posterior pituitary (increased ADH)
• increased water reabsorption
• decreased urine output
• Anterior pituitary (increased ACTH)
• increased cortisol secretion
• body turns fat and proteins into glycogen
• increased protein catabolism
• increased fat catabolism
• increased aldosterone secretion
• body reabsorbs more sodium, more water
• kidneys produce less urine
• kidneys secrete more potassium
• Stage 2: Resistance
• When stimulus is excessive or prolonged, alarm and mobilization give way to resistance
• Body adapts to stressors
• Stabilization
• Hormonal levels return to normal
• Parasympathetic nervous system activates
• Stage 3: Exhaustion
• Physiological response as noted in alarm reaction

Physical response
Decreased immune response, with suppression of T cells and atrophy of thymus
Depletion of adrenal glands and hormone production
Enlargement of lymph nodes and dysfunction of lymphatic system
• If stressor continues, energy wanes and body weakens
• Decreased energy levels
• Decreased physiologic adaptation
• Death
PANIC Episode:

P - palpitations
A - abdominal distress
N - nausea
I - increased perspiration
C - chest pain, chills, choking
STRESS INDICATORS:
Behavior patterns
• Substance use/abuse
• Changes in eating habits
• Changes in activity
• Mood
• Loss of self esteem
• Feelings of inadequacy
• Increased irritability
• Crying
• Cognitive effects of stress
• Lack of motivation
• Forgetfulness
• Tendency to make mistakes
• Decreased productivity
• Poor judgment
• Inability to concentrate
• Preoccupation
 Physiologic Indicators of Stress
• Increased Blood Pressure
• Tachycardia
• Tachypnea
• Sweaty palms
• Cold hand and feet
• Decreased urine output
• Dilated pupils
• Change in appetite
• Nausea, vomiting, diarrhea
• Headache
• Restlessness
• Insomnia
• Muscle tension
Stress may be considered as any physical, chemical, or emotional factor that causes bodily or mental unrest. Since stress is
a part of normal life, it's impossible to eliminate stress; instead, individuals should learn to manage stress. The following list
includes some of the more commonly used stress reduction strategies.
• Balanced diet
• Adequate rest
• Regular physical exercise
• Relaxation techniques
• Breathing exercises
• Meditation
• Progressive muscle relaxation (PMR)
• Prayer
• Guided imagery
• Relaxation response
• Yoga
• Biofeedback
• Hypnosis or self-hypnosis
• Humor
• Therapeutic touch or massage
• Social support
• Spirituality
• Crisis intervention
• Cognitive restructuring
• Nurse and client analyze client's appraisal of stressors
• Emphasis is on restructuring client's unrealistic or negative thinking

Crisis intervention
• Definition: an acute, temporary state of severe personality disorganization with an extreme state of emotional turmoil; usual
coping mechanisms and resources fail
• Types
1. acute crisis: client temporarily loses control; panic state
• emotional reactions are overwhelming
• decision making and problem solving abilities are inoperative
• thinking is scattered
• social isolation
• immobilization (unable to act)
2. exhaustion crisis
• under emergency conditions
• person has lost effective coping
• cannot continue to function
3. shock crisis
• sudden external change
• causes release of emotions
• overwhelms client
(Four) phases of crisis response - average crisis is four to six weeks (may vary widely)
1. vulnerable state
2. precipitating event
• developmental change - maturational crisis
• a life change - situational crisis
• loss of loved one or job - situational crisis
• environmental disaster or war - adventitious crisis
3. acute crisis
4. reorganization
Findings
• mild to severe anxiety
• anger
• crying, social isolation, helplessness
• impaired cognitive processes; inability to concentrate; confusion
• insomnia
• regression
• nausea and vomiting
Treatment - brief supportive interventions focused on the phase of crisis
• objective - help the client through the current crisis
• allow free discharge of emotions
• enhance client's cognitive processes
• pharmacologic: trazodone (Desyrel), alprazolam (Xanax)
• therapies: occupational and recreational
Nursing interventions in crisis
• provide a quiet, restful environment
• empower the client to solve problems
• allow the client to express feelings and emotions
• determine and correct any misperceptions about the crisis being experienced by the client
• help the client to identify support systems and alternative solutions
• help the client to deal with long term impact of crisis
• encourage relaxation strategies, e.g., deep breathing, imagery
• assist the client in the development of new coping skills
• cognitive behavior therapy
• administer medications as ordered
• nursing response to violent situations
• set consistent limits
• inform of consequences
• use seclusion and restraints, as indicated
• get support and assistance
• position self for an escape path
SUICIDE
Epidemiology
• women attempt more than men
• men are more often successful
• second leading cause of death in adolescence
SUICIDE WARNIGS:
• Previous suicide attempt
• Threatening to commit suicide
• Giving away prized possessions
• Collecting and discussing information on suicide methods
• Expressing hopelessness, helplessness, and anger at self or world
• Death or depression in talk, writing, or artwork
• Client states or suggests s/he would not be missed
• Client expresses no hope for the future
• Self-mutilation
• Recent loss of friend or family member through natural death, accident or suicide; other major loss such as job or
divorce
• Acute personality changes such as unusual withdrawal or aggressiveness, moodiness, or taking risks
• Sudden change in academic performance, truancy, or running away
• Physical symptoms such as insomnia or excessive sleeping, headaches, stomach aches
• Use or increased use of potentially addictive substances
• Low self esteem; feeling worthless, ashamed, guilty, self-hating
• Putting affairs in order, tying up loose ends, changing a will
The SAD PERSONS scale can be used to assess suicide risk.
S = sex (gender)
A = age
D = depression
 P = prior attempts
E = ETOH (or drug dependent)
R = rational thought (loss of) or psychosis
S = support (lack of)
O = organized plan
N = no spouse
S = sickness/stress
Treatment
• objective: to treat the condition that underlies the suicidal thoughts
• pharmacologic: antidepressants, antianxiety, and/or antipsychotics
• suicide precautions:
Suicide precautions are started immediately by the medical or nursing staff when a client verbalizes and/or makes an overt
suicidal attempt, including self-mutilation attempts or has history.
• Ask client exactly how she/he would commit suicide.
• Assess how lethal the attempt would be, and how quickly it could be carried out.
• There are generally two levels of suicide precautions:
• Minimal
• Strict
• Minimal suicide precautions
• Staff will make visual contact with the client every 15 minutes and document
• The client will reside in a designated area to provide close observation during waking hours
• The client will sleep in an area where close observation can be provided
• Nursing staff will conduct a search for contraband each shift while client is awake; this must be documented
• All packages and clothes brought in to the client are carefully inspected by the nursing staff in the presence of the client
• Pass privileges or participating in off-unit activities are not allowed until the suicide precautions are discontinued
• Inspect the client's mouth after giving medication in tablet form to make sure it has been swallowed; liquid concentrates are
preferable
• Strict suicide precautions
• One-to-one supervision
• The client can never be more than an arm-length away (approximately six feet)
• The client is accompanied by an assigned staff member during bathing, showering and shaving
• the staff member remains outside the bathroom door, with the door slightly ajar
• all attempts should be made to assign same gender caregivers to client
• During waking hours, the client will reside in a designated area
• The client will sleep in an area where close observation can be provided
• Remove all harmful objects from the environment
• The client will eat on the unit without sharp utensils (usually plastic)
• Keep electrical cords to a minimum length
• Keep all windows locked and if possible keep client in room with unbreakable glass in windows
• Certain items of clothing, e.g., belts, drawstring pants, shoes with laces, etc., may be prohibited if these items present a
potential danger
• Staff will conduct a client search for contraband each shift while the client is awake; this must be documented
• Pass privileges or participating in off-unit activities are not allowed until the suicide precautions are discontinued
• Inspect the client's mouth after giving medication in tablet form to make sure it has been swallowed; liquid concentrates are
preferable
Nursing interventions
• administer medications as ordered
• check mouth to be certain client swallows oral medications (or given liquid oral preparation)
• institute suicide precautions
• encourage relaxation strategies
• encourage appropriate expression of emotions
• redirect or set limits on ruminations about suicide or previous attempts
• help client explore stressors and coping mechanisms
• help client explore alternative behaviors
Abuse, maltreatment and neglect
• Definitions: any recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse or
exploitation; or an act or failure to act which presents an imminent risk of serious harm
types
• abuse and neglect: child physical abuse, child sexual abuse, child neglect, child psychological abuse
• adult maltreatment and neglect: spouse or partner violence (physical or sexual), spouse or partner neglect, spouse of partner
abuse (psychological), adult abuse by nonspouse or nonpartner
• abuse may be physical, sexual, emotional (or psychological); abandonment of children; substance abuse
Etiology
• biological theories: neurophysiological, biochemical, genetic influences; disorders of the brain
• psychological theories: psychodynamic theory and learning theory
• sociocultural theories
Findings
• abusers: blame the victim, are jealous and controlling, demonstrate poor impulse control; low self-esteem; have unrealistic
expectations; are frequently victims of abuse themselves and have a history of past battering
person suffering from abuse:
• battered women: low self-esteem, accept the blame; feelings of guilt, anger, fear, shame; isolated from family and support
systems
• specific symptoms of abuse: physical (broken bones or dislocations, welts and/or bruises, burns, inappropriate bald spots;
signs of being restrained); sexual (bruising or bleeding in genital or anal area; pain or itching in genital area; genitourinary
infection; evidence of sexual intercourse) and emotional (rocking, sucking, or mumbling)
• symptoms of neglect: malnutrition; extremes in behavior and learning disorders in child; social isolation; unattended medical
problems; unwashed; inappropriately dressed; has attempted suicide
cycle of abuse
• phase I: the tension-building phase
• phase II: the acute battering incident
• phase III: the "honeymoon" phase (calm, loving, respite)
Treatment
• crisis intervention: remove victim from source of abuse and treat injuries, infections
• family therapy
• Nursing interventions
• ensure privacy
• limit the number of different health care workers
• provide information about any procedure before beginning
• offer support
• carefully document all signs of abuse or neglect
• assist client with identifying resources and support services
• stress the importance of safety
• contact protective services
• file appropriate reports
THERAPEUTIC COMMUNICATIONS
Consider the developmental level, culture, spiritual and emotional aspects, and physical condition of the client
• Focus on actual objective behaviors, not on subjective inferences
• Focus on description, not on judgment
• Share information and explore alternatives, instead of offering advice and solutions
• Focus on how and what and not "why"
• For confused or disoriented clients, focus on reality orientation
• Ask open-ended questions and seek information
• Focus on nursing interventions
It is composed of verbal and non-verbal techniques that the nurse uses to focus on the client's needs
• Verbal message = content
• Nonverbal message = process
• Goal: to achieve congruence between the two

Catego
Technique Definition/Explanation
ry

Non- Recognizing the other person without inserting your own values or judgments. May
Acceptance
verbal be verbal or nonverbal; with or without understanding

Consciously receiving the client's message. Includes listening actively, responsibly,

Listening
and seriously

Empathy Experiencing another's feeling temporarily; truly being with and understanding
 Catego
Technique Definition/Explanation
ry

another through active listening

Using silence Suspending talk for a therapeutic reason

Neutral
Showing interest and involvement without saying anything else
response

Eye contact As appropriate to the client's culture

Sharing personal information at an opportune moment to convey understanding or

Self-disclosure
to role model behavior

Putting into words vague ideas or unclear thoughts of the client. Purpose is to help
Clarification
nurse understand, or invite the client to explain

Repeating to the client the main thought he has expressed to indicate the nurse is
Restating
listening and interested; may encourage the client to elaborate

Verbal
Refocusing Picking up on central topics or "cues" given by the client

Open-ended Asking questions that cannot be answered "yes" or "no", which are used to
questions broaden conversational opportunities and to enable communication

Incomplete
Encouraging the client to continue with phrases such as, "go on..."
sentences

Focusing Helping the client to explore a specific topic

Nontherapeutic communication minimizes the feelings of the client and impair the nurse-client relationship.

Nontherapeutic
Communication Definition/Explanation
Technique

"Why don't you..."

"I think you should..."

Giving advice
Telling the client what to do. Giving an opinion or making decisions for the client.
Implies the client cannot handle life decisions and that the nurse is accepting
responsibility for client.

"I wouldn't worry about it."

"Everything will be just fine."

False reassurance
Using cliches, pat answers, cheery words and comforting statements as an attempt to
reassure client.

Client: "I'd like to die."

Changing the subject Nurse: "Did you have visitors last night?"

Introducing new topics inappropriately; may result from poor listening skills.
 Nontherapeutic
Communication Definition/Explanation
Technique

Responding in a way that either focuses attention on the nurse instead of the client,
Social response
or is not goal-directed on behalf of the client.

Invalidation Ignoring or denying the client's thoughts or feelings.

Talking rapidly, changing subjects or asking for more information than can be
Overloading
absorbed at one time; for example, asking two questions at once.

Underloading Remaining silent and unresponsive, not picking up cues and failing to give feedback.

"Please stay calm" but voice is shrill

Incongruence
Sending verbal and nonverbal messages that contradict one another; often called a
double message.

Giving one's own opinion, evaluating , moralizing or implying one's own values by
Value judgments
using words such as "should," "ought," "good," or "bad."
Findings of nontherapeutic communication
• efforts to change the subject - client may not understand what the nurse is saying
• lack of questions - client may not understand what was said
• nonverbal cues - blank expression, lack of eye contact
Nursing interventions and therapeutic communication
• use simple sentence structure and gestures while talking
• use visual aids
• discuss one topic at a time
• use the same words when you repeat a topic
• go from simple to complex, or familiar to unfamiliar
• use any words you know in the client's language
• use a medical interpreter service for verbal communication - avoid using family members as interpreters
• obtain phrase books or use flash cards
• ask open-ended questions
Cultural interpretations
• silence
• (appropriate and therapeutic) touch
• (culturally-appropriate) eye contact
Clients with Hearing Loss
Findings of hearing loss
• speech deterioration
• indifference
• social withdrawal
• suspicion
• tendency to dominate conversation
• misinterpretation of what is said
• lack of response to direct questioning
Nursing interventions
• speak slowly and distinctly; do not shout
• face client directly
• make sure your face is clearly visible
• before the discussion, tell client the topic you are going to discuss
• insure that client has access to hearing aid and that it is functional
• keep sentences short and simple
• use written information to enhance spoken word
• use lower tone of voice
Clients with Aphasia
• Injured cerebral cortex blocks some language-related functions
• Types of aphasia
• global aphasia - the most severe form of aphasia where individuals cannot read, write, or understand speech
• Broca's aphasia ("non-fluent" aphasia) - speech is limited mainly to short utterances of less than four words; the client may
understand speech and be able to read but has limited writing ability
• Wernicke's aphasia ("fluent" aphasia) - inability to understand the meaning of spoken words and reading and writing is
impaired; able to speak but sentences do not hang together and speech may consist of mostly jargon
Nursing interventions
• face client and establish eye contact
• avoid completing client's statements
• use gestures, pictures, and communication boards
• limit conversation to practical matters
• use the same words and gestures for objects
• keep background noise to a minimum and turn off competing sounds, e.g., radio, television
• do not shout or speak loudly
• give the client time to understand and respond
• if client has problems speaking, ask "yes" or "no" questions
Clients post-CVA
• Approach client from side of intact field of vision
• Remind client to turn head in direction of visual loss to compensate for loss of visual field
• Explain location of object when placing it near the client
• Always put client care items in same places
• Put objects within client's reach, and on unaffected side
• Encourage client to repeat sounds of the alphabet
• Speak slowly and clearly
• Use simple sentences with gestures or pictures
• Reorient client to time, place, and situation
• Provide familiar objects
• Minimize distractions
• Repeat and reinforce instructions
Clients with Dementia
• Be calm and unhurried
• Keep conversations short and focused
• Do not ask the client to make decisions
• Use "yes" or "no" questions
• Be consistent
• Avoid distractions
• Use reality orientation techniques
Anxiety disorders
• Definition: a condition in which a person has excessive fear and anxiety and related behavioral disturbances
• types: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia,
generalized anxiety disorder (GAD)
• depression and substance abuse may occur with an anxiety disorder
Etiology
• not known; may have a genetic link
• stress may contribute to the development of GAD
Findings
• main symptom is frequent worry or tension for at least 6 months, even when there is little or no clear cause; usually related to
family, other relationships, work, school, money, health
• even when aware that worries or fears are stronger than appropriate for the situation, a person with GAD still has difficulty
controlling them
• other symptoms: problem concentrating; fatigue; irritability; problems falling or staying asleep or
restless sleep; restlessness when awake; upset stomach; sweating; difficulty breathing; muscle tension
• Diagnostics
• physical exam and mental health assessment
• laboratory tests to rule out other conditions that may cause similar symptoms
• Treatment
• talk therapy
• medications
antidepressants
• SSRIs: fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa)
• SNRI: venlafaxine (Effexor) is commonly used to treat GAD
• bupropion (Wellbutrin)
• tricyclic antidepressants: imipramine (Tofranil) is prescribed for panic disorder and GAD
• MAOIs: phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan)
• anti-anxiety: buspirone (Buspar) for GAD
• beta-blockers: propranolol (Inderal)
• benzodiazepines: clonazepam (Klonopin) for social phobia and GAD, lorazepam (Ativan) for panic disorder,
alprazolam (Xanax) for panic disorder and GAD
• stress and relaxation techniques, yoga, acupuncture; kava
Nursing interventions
• provide non-demanding environment
• acknowledge client’s feelings
• do not force contact with feared item or situation
• provide distracting activities
• use relaxation techniques
• identify triggers
• encourage client to take responsibility for self-care
• client (and family) teaching
• the nature of the illness
• management of the illness
• medication management
• stress management strategies
• teach ways to interrupt escalating anxiety
• support services, including crisis hotline, support groups, individual psychotherapy
Bipolar & Related Disorders
• Definition: a condition in which a person has episodes of depression and periods of being extremely happy or being cross
and irritable; it includes changes in activity and energy as well as mood
• types of disorders: bipolar I, bipolar II, cyclothymic
• cycle: episodes of depression are more common than episodes of mania
Etiology: not known; but it occurs more often in relatives of people with bipolar disorder
• affects men and women equally
• usually starts between ages 15 and 25
• common triggers of a manic episode: childbirth, medications (antidepressants or steroids), insomnia, recreational drug use
Findings
• manic phase may last days to months: easily distracted, little need for sleep, poor judgment, poor temper control, reckless
behavior and lack of control (such as excessive drinking, drug use, sex with many partners, spending sprees), expansive or
irritable mood (racing thought, talking a lot, false beliefs about self or abilities), very involved in activities
• depressive episodes are more common than mania and may include: daily low mood or sadness, difficulty concentrating,
remembering or making decisions, eating problems (loss of appetite and weight loss or overeating and weight gain), fatigue
or lack of energy, feeling worthless, hopeless or guilty, loss of pleasure in activities once enjoyed, loss of self-esteem,
thoughts of death or suicide, trouble of getting to sleep or sleeping too much, pulling away from friends or activities that were
once enjoyed
• Diagnostics: physical exam and mental health assessment
Treatment
medications
• mood stabilizers
• lithium
• anticonvulsants: valproic acid (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), oxcarbazepine (Trileptal)
• antidepressants (SSRIs): fluoxetine (Prozac), sertraline (Zoloft)
• atypical antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal), ziprasidone (Geodon), clozapine
(Clorazil), lurasidone (Latuda)
• electroconvulsive therapy (ECT)
• support programs and talk therapy
• hospitalization for severe manic or depressive episode
Nursing interventions
• prevent self-injury and suicide (Suicide Precautions)
mania:
• offer high protein, high calorie finger foods, supplements for weight loss/malnutrition
• set limits on manipulative behavior
• positive reinforcement for appropriate behavior
• reduce stimuli
client (and family) teaching
• the nature of the illness
• causes of bipolar disorder
• cyclic nature of the illness
• symptoms of depression and mania
management of the illness
• medication management
• lithium: symptoms of toxicity, importance of regular blood tests
• side effects
• adverse effects
• importance of not stopping medication
• assertive techniques
• anger management
• electroconvulsive therapy
• support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial assistance
Depressive disorders
• Definition: characterized by the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes
that significantly affect the individual’s capacity to function for weeks or longer; types include disruptive mood dysregulation,
major depressive disorder, persistent depressive disorder (formerly called dysthymia), premenstrual dysphoric disorder
• Etiology
• exact cause is not known; most likely it's due to a combination of genetic, biological, environmental and psychological factors
• alcohol or drug abuse, hypothyroidism or chronic pain, medications (steroids), sleeping problems, and stressful life events
are associated with depression
• Findings
• agitation, restlessness, and irritability, anger; becoming withdrawn or isolated, fatigue and lack of energy, feeling hopeless
and helpless, worthless, guilty, self-hate; loss of interest or pleasure in activities that were once enjoyed; sudden change in
appetite, thoughts of death or suicide; trouble concentrating; trouble sleeping or sleeping too much
• severe depression can also be accompanied by hallucinations and delusions

Diagnostics
• physical exam and mental health assessment
• blood and urine test to rule out other medical conditions with symptoms similar to depression
Treatment
medications - antidepressants
• SSRIs: fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro)
• SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta)
• bupropion (Wellbutrin)
• tricyclics, tetracyclics, and MAOIs may also be used
talk therapy
• cognitive behavioral therapy - to teach how to fight off negative thoughts
• psychotherapy - to help to understand the issues that may be behind thoughts and feelings
• group therapy - to share with other who have like problems
• electroconvulsive therapy (ECT)
• light therapy - to relieve symptoms in the winter time (seasonal affective disorder or SAD)
• acupuncture, stress and relaxation techniques, massage, meditation, yoga, Tai Chi, Qigong, SAMe
● Due to its short half-life (and few drug interactions), Zoloft is the drug of choice for treating depression in the elderly.
Conversely, due to its long half life, PROzac is a better choice for children.
Nursing interventions
• watch for suicidal behavior in children, teens, young adults (suicide warning signs and suicide precautions)
• encourage participation in goal setting and decision-making for own care
• encourage client to explore and verbalize feelings and perceptions
• monitor sleep, eating and self-care activities
• client (and family) teaching
• the nature of the illness
• management of the illness
• medication management
• side effects to report to the health care provider
• importance of taking medications regularly
• length of time to take effect
• diet (specifically for MAOIs)
• AVOID concurrent use of natural remedies (St. John's wort and certain antidepressants can lead to serotonin syndrome)
• assertiveness techniques
• stress management strategies
• way to increase self-esteem
• electroconvulsive therapy (ECT)
• support services, including suicide hotline number; support groups; legal and financial assistance
Feeding & eating disorders
• Definition: characterized by a persistent disturbance of eating or eating-related behavior that results in the altered
consumption or absorption of food and that significantly impairs physical health or psychosocial functioning
• types: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge-eating
disorder
serious medical complications can develop over time:
• anorexia - severe malnutrition, low potassium levels, heart problems, confusion
• bulimia nervosa - constipation, dehydration, dental cavities, electrolyte imbalances, hemorrhoids, pancreatitis, swelling of the
throat, tears of the esophagus
Etiology
• not known
• risk factors for anorexia include having an anxiety disorder as a child; having a negative self-image; having certain social or
cultural ideas about health and beauty; trying to be perfect or overly focused on rules
Findings
• anorexia nervosa - severely limiting food intake; cutting food into small pieces and moving around the plate; refusing to eat
around other people; exercising all the time; using diuretics, enemas and laxatives and diet pills; blotchy or yellow, dry skin
covered with fine hair; depression, dry mouth; extreme sensitivity to cold; loss of bone strength; muscle wasting and loss of
body fat
• bulimia nervosa - eat large amounts of high-calorie foods, usually in secret; forced vomiting; cavities or gingivitis and enamel
of teeth may be worn away or pitted due; excessive exercise; broken blood vessels in the eyes; dry mouth; using laxatives,
enemas or diuretics; small cuts and calluses across the tops of the finger joints (from forcing oneself to vomit) known as
Russell’s sign
Diagnostics
• anorexia nervosa - laboratory tests to help find the cause of weight loss or to determine damage done by weight loss
including albumin, bone density test, CBC, ECG, electrolytes, kidney function tests, liver enzyme tests, total protein, thyroid
function tests, urinalysis
• bulimia nervosa - dental exam
• general
• physician exam and mental health assessment, including family history
• clinician-administered tests, such as Eating Disorder Examination (EDE), Yale-Brown-Cornell Eating Disorder Scale (YBC-
EDS)
• self-reports, such as Diagnostic Survey for Eating Disorders (DESD), Eating Attitudes Test (EAT), Eating Disorders
Questionnaire (EDQ) and many others
• Treatment
anorexia
• hospitalization may be needed; follow-up with day treatment program
• increasing social activity, reducing the amount of physical activity, using schedules for eating (nutritional rehabilitation)
• refeeding programs
• medications: antidepressants such as the SSRI fluoxetine (Prozac) (regardless if the client is depressed or not)
• talk therapy, including cognitive behavioral therapy, group therapy, and family therapy; support groups
bulimia
• a stepped approach, including support groups, cognitive behavioral therapy, and nutritional therapy
• medications: antidepressants such as the SSRI fluoxetine (Prozac)
• support groups, such as Overeaters Anonymous and American Anorexia/Bulimia Association
Nursing interventions
• establish adequate/appropriate nutritional intake
• correct fluid and electrolyte imbalance
• assist client to develop realistic body image and to improve self-esteem
• provide support and involve significant others (including family) in treatment program
• participate in total treatment program with other disciplines
• client (and family) teaching
the nature of the illness
• symptoms of the illness
• causes of eating disorder
• effects of the illness or condition on the body
management of the illness
• principles of nutrition
• importance of expressing fears and feelings
• alternative coping strategies, relaxation techniques, problem-solving skills
• correct administration of prescribed medications
• indication for and side effects of medications
• when to contact health care provider
• support services, such as Overeaters Anonymous, National Association of Anorexia Nervosa and Associated Disorders
(ANAD), the American Anorexia/Bulimia Association, Inc.
Neurodevelopmental disorders
• Definition: characterized by developmental deficits that produce impairments of personal, social, academic, or occupational
functioning; typically manifested before a child enters grade school
• types: intellectual disability (intellectual developmental disorder), global developmental delay, language disorders (including
stuttering), autism spectrum disorder, attention-deficit/hyperactivity disorder, learning disorder, tic disorder
• requires assessing both cognitive capacity (IQ) and adaptive functioning
Etiology
• autism spectrum disorder: exact causes are not known
• linked to abnormal biology and chemistry in the brain
• diet, digestive tract changes, mercury poisoning are also considered
• can be associated with other disorders of the brain, such as fragile X syndrome, tuberous sclerosis
• attention deficit hyperactivity disorder (ADHD): not known; probably due to a combination of genetics and environmental
factors
Findings
• autism spectrum disorder
• difficulties in pretend play, social interactions, verbal and nonverbal communication
• overly sensitive in sight, hearing, touch, smell, or taste
• have unusual distress when routines are changed, perform repeated body movements, show unusual attachments to objects
• attention deficit hyperactivity disorder (ADHD): symptoms fall into 3 groups
• inattentiveness
• hyperactivity
• impulsivity
• Public Law 111-256, Rosa’s law: replaced the term “mental retardation” with “intellectual disability”. “Intellectual
Developmental Disorder" reflects the World Health Organizations’ classification system of “functioning, disability, and health
(ICF).”
Diagnostics
autism spectrum disorder
• complete physical and neurologic exam
• hearing evaluation (for delay in language milestones)
• blood lead test
• genetic testing (for chromosome abnormalities)
• metabolic testing
• screening tests, such as the Checklist for Autism in Toddlers [CHAT] or Autism Screening Questionnaire) and evaluation of
autism (using the Autism Diagnostic Interview-revised (ADI-R); Autism Diagnostic Observation Schedule (ADOS); Childhood
Autism Rating Scale (CARS); Gilliam Autism Rating Scale; pervasive Developmental Disorders Screening Test-Stage 3
attention deficit hyperactivity disorder (ADHD)
• complete physical and neurologic exam
• diagnosis is based on a pattern of the symptoms
• many children have at least one other developmental or mental health problem such as a mood, anxiety or substance use
disorder, a learning disability, or a tic disorder

• Treatment
autism spectrum disorder - treatment is most successful when it is geared toward the child's particular needs
• applied behavior analysis (ABA)
• medications - to treat aggression, anxiety, attention problems, extreme compulsions; hyperactivity, impulsiveness, irritability,
mood swings, sleep difficulties, tantrums
• risperidone (Risperdal) - an antipsychotic approved to treat children ages 5-16 for irritability and aggression
• SSRIs
• divalproex (Depakote) - an anticonvulsant also used to treat the manic phase of bipolar disorder
• mood stabilizers
• stimulants, such as methylphenidate (Ritalin, Concerta)
• diet - some children respond to gluten-free or casein-free diet
• various therapies, including occupational therapy, physical therapy, speech-language therapy, vision therapy and sensory
integration therapy
• support groups
attention deficit hyperactivity disorder (ADHD) - partnership between health care provider and client; if client is a child,
then parents and teachers are involved
• set specific appropriate goal
• medication: psychostimulants (stimulants), including methylphenidate(Ritalin, Concerta), amphetamine (Adderall),
dextroamphetamine (Dexedrine), lisdexamfetamine dimesylate (Vyvanse)
• various therapies, including talk therapy, behavioral therapy (to teach healthy behaviors and how to manage disruptive
behaviors)
• support groups
Nursing interventions
• consistent daily schedule
• limit distractions
• clear and consistent rules for child
• encourage, praise and reward independent achievement
• assess the client’s mental status
• client (and family) teaching
• the nature of the illness
• management of the illness
• medication management
• side effects
• length of time to take effect
• what to expect from the medication
• explain drug "holiday" (for ADHD)
• AVOID over-the-counter medication
• importance of not stopping medication
• importance of sleep
• importance of good nutrition
• problem-solving skills
• support services, including support groups; legal and financial assistance
• Obsessive-compulsive and related disorders
• Definition: an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations
(obsessions), or behaviors that make them feel driven to do something (compulsions)
• types: obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding, trichotillomania disorder (hair pulling),
excoriation disorder (skin-picking)
• OCD does not usually progress into another disease but there can be long-term complications, such as excessive hand
washing can cause skin breakdown and compulsive hair pulling can lead to hair loss
Etiology: not known; however, factors that may play a role include head injury, infections and abnormal brain function
Findings
• obsessions or compulsions that are not due to medical illness or drug use
• obsessions or compulsions cause major distress or interfere with everyday life; not doing the obsessive rituals can cause
great anxiety; the person recognizes the behavior is excessive and unreasonable
• many people with OCD may have other psychiatric comorbid disorders, including mood and anxiety disorders, eating
disorders, ADHD
Diagnostics
• physical exam and mental health assessment
• Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to define range and severity of symptoms
Treatment
• medications
• antidepressants
• tricyclic: clomipramine (Anafranil) is used to treat OCD
• SSRIs: such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa)
• antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal)
• mood stabilizers: carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal)
• cognitive behavior therapy (exposure and response prevention or ERP)
• deep brain stimulation (when OCD does not respond to other treatments)
Nursing interventions
• promote a predictable, structured schedule
• avoid engaging in power struggles
• identify triggers to ritualistic behaviors
• initially allow time for rituals and then begin to limit
• provide positive reinforcement for non-ritualistic behavior
• client (and family) teaching
• the nature of the illness
• management of the illness
• medication management, including side effects, length of time to take effect and what to expect
• stress management strategies
• teach ways to interrupt escalating anxiety
• support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial assistance
Personality disorders
• Definition: an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the
individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads
to distress or impairment
• types: general personality, paranoid personality, schizoid personality, schizotypal personality, antisocial personality, borderline
personality, histrionic personality, narcissistic personality, avoidant personality, dependent personality, obsessive-compulsive
personality
• complications include imprisonment, drug abuse, violence, suicide
Etiology: not known
• may be related to genetic factors and environmental factors, for example, subjected as a child to abuse, alcoholic parents,
etc.
• more men than women are affected
• fire-setting and cruelty to animals during childhood are linked to the development of antisocial personality
• Findings: may be able to act witty and charming; be good at flattery and manipulating other people’s emotions;
break the law repeatedly; disregard the safety of self and others; have problems with substance abuse; lie, steal and
fight often; show no guilt or remorse; are often angry or arrogant
• Diagnostics: psychological evaluation to assess history and severity of symptoms
Treatment: difficult to treat; people usually start treatment when required by court action
• behavioral treatment
• talk therapy
• medication can be used to treat symptoms of anxiety, anger, impulsiveness
Nursing interventions
• protect client and others from harm
• provide low environmental stimuli
• observe behavior
• set limits and provide structured environment
• gradually encourage appropriate expression of anger
• client (and family) teaching
• the nature of the illness
• management of the illness
• medication management, including side effects
• relaxation techniques
• participation in therapy
• support services, including financial and legal assistance

Schizophrenia Spectrum & Other Psychotic Disorders

• Definition: a lifelong condition that makes it hard to think clearly, to tell the difference between what is real and not real, to
have normal emotional responses and to act normally in social situations
• types: schizophrenia, psychotic disorders, schizotypal (personality) disorder
• defined by abnormalities in one or more of the following: delusions, hallucinations, disorganized speech
• complications: having schizophrenia increases the risk of developing problems with drugs or alcohol, physical illness (due to
inactive lifestyle and medication side effects), suicide

Etiology: not known; there may be a genetic factor

• affects about 1% of the world population
• usually first diagnosed in late teens to early 20s
 Findings: symptoms develop slowly over months or years
• early symptoms: may include irritable or tense feelings, trouble concentrating, trouble sleeping
• later symptoms: involve thinking, emotions, and behavior, including: bizarre behaviors, hallucinations, isolation, reduced
emotion, problems paying attention, delusions, “loose associations”
Diagnostics
• physical exam and mental health assessment
• brain scans (CT or MRI)
• laboratory tests to rule out other conditions with similar symptoms
Treatment
• hospitalization during acute episodes
medications
• antipsychotics
• typical: chlorpromazine (Thorazine), haloperidol (Haldol), perphenazine, fluphenazine
• atypical: clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon),
aripiprazole (Ability), paliperidone (Invega), lurasidone (Latuda)
• antiparkinsonism agents: used to counteract the extrapyramidal side effects (tardive dyskinesia) of many antipsychotic
medications
• support programs, including family therapy
• behavioral techniques, such as social skills training, job training
• Typical, or conventional, antipsychotics
• Available since the mid-1950's
• Actions: dopamine levels in the brain are reduced, which decreases the positive symptoms of schizophrenia (but also causes
serious side effects)
• Atypical antipsychotics
• Developed in the 1990's
• Significant decrease in the side effects of extrapyramidal symptoms, tardive dyskinesia
• Clozapine may cause agranulocytosis (loss of white blood cells); none of the other atypical antipsychotics cause
agranulocytosis
• Actions
• limit neurotransmitter dopamine, but works on specific dopamine pathways which allow them to decrease both positive and
negative symptoms with fewer side effects
• limit neurotransmitter serotonin and increase neurotransmitter gamma-aminobutyric acid (GABA)
•

Medication name -
Type of Antipsychotic Side Effects
generic

chlorpromazine agitation

agranulocytosis
thioridazine
anticholenergic
trifluoperazine
orthostatic hypotension
Typical (conventional) fluphenazine
antipsychotics extrapyramidal symptoms, e.g., rigidity, persistent muscle
spasms, tremors, restlessness
thiothixene
sedation
haloperidol
tardive dyskinesia (TD), due to long-term use

molindone malignant syndrome

•

Atypical (second generation) clozapine sedation

antipsychotics
insomnia
risperido
ne
 olanzapi
ne

quetiapin
e

aripipraz
ole
(major) weight gain (which increases a person's risk of developing
diabetes and high cholesterol)
paliperid
one dizziness

ziprasido hypotension
ne
agranulocytosis (clozapine only)
Nursing interventions
• establish therapeutic relationship - build trust, be honest and dependable
• avoid touching the client without warning
• observe for signs of hallucinations but do not reinforce hallucinations - orient client to reality
• encourage independence in ADLs but intervene as needed
• give recognition and positive reinforcement for appropriate interactions with others
• prevent injury to others, self-injury and suicide (suicide precautions)
• monitor for side effects of medications
• assist with setting realistic goals
• client (and family) teaching
• the nature of the illness
• management of the illness
• medication management
• medication side effects
• importance of not stopping medications
• when to contact health care provider
• relaxation techniques and stress management strategies
• skills training, such as social skills training and daily living skills training
• support services, including financial and legal assistance; support groups; respite care
• Substance-related and Addictive Disorders
• Definition: substance use disorder is a maladaptive pattern of substance use leading to clinical significant impairment or
distress; characterized by addiction, craving, tolerance, withdrawal
• many different classes of drugs including cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and anxiolytics,
stimulants
• often co-occurring mental illness and substance abuse
• potential complications include bacterial endocarditis, depression, overdose, cancer (mouth and stomach cancer are
associated with alcohol abuse), HIV, memory or concentration problems, problems with the law, relapse of drug abuse,
unsafe sexual practices
A. Narcotic withdrawal - the signs and symptoms of narcotic withdrawal generally include those that are opposite of the
drug's intended medical effects
• May resemble a severe flu-like illness
• runny nose, watery eyes
• lacrimation
• abdominal cramping
• leg cramping
• piloerection (gooseflesh)
• nausea
• vomiting
• diarrhea
• Severe anxiety to panic; irritability
• Confusion
• Piloerection (gooseflesh)
• Tremors
• Loss of appetite
• Muscle aches or cramps
• Tachycardia
• Hypertension
• Increased respirations
• Increased temperature
• Insomnia
• Yawning
• Neonatal withdrawal: A large percentage of babies delivered from pregnant women who use narcotics experience neonatal
withdrawal, a potentially fatal condition
B. Alcohol withdrawal - alcohol withdrawal is a continuum of signs and symptoms ranging from simple tremulousness to
delirium tremens (refer to assessment tool below)
• Mild withdrawal symptoms
• tremulousness
• insomnia
• anxiety
• hyperreflexia
• diaphoresis
• mild autonomic hyperactivity
• gastrointestinal upset
• Moderate withdrawal symptoms
• intense anxiety
• tremors
• insomnia
• headache
• tremors - especially of the hands
• agitation
• sweating - especially the palms of the hands or the face
• tachycardia
• nausea and vomiting
• abdominal cramps
• diaphoresis
• visual or tactile hallucinations
• Severe withdrawal = delirium tremens (DTs)
• confusion
• disorientation
• agitation
• visual, tactile hallucinations, also known as alcoholic hallucinosis
• alcohol withdrawal seizures, also referred to as "rum fits"
• severe autonomic hyperactivity:
• tremulousness
• tachycardia
• tachypnea
• hyperthermia
• diaphoresis
C. Sedative-hypnotic withdrawal syndrome - chronic use of benzodiazepines, barbiturates, and other sedative or
hypnotics produce withdrawal symptoms on discontinuation resembling those of alcohol withdrawal
• Weakness, nausea and vomiting
• Hypertension, tachycardia, orthostatic hypotension
• Gross tremors
• Agitation
• Anxiety
• Disorientation
• Hallucinations, delirium
• Convulsions
D. Stimulant withdrawal - after chronic use of amphetamines, methamphetamines, Ritalin
• Behavior - sedated; apathy
• Psychomotor activity - retarded
• Mood or affect - depressed or irritable
• Speech - nonspontaneous
• Thought processes or content - linear at times with suicidal ideation and drug craving
• Memory - likely to be impaired due to sleep deprivation, associated fatigue, decreased attention and irritability
• Cravings
E. Hallucinogen withdrawal
• No withdrawal symptoms reported
• Flashbacks can occur episodically after use
F. Marijuana withdrawal - long term abuse can lead to addiction and withdrawal symptoms
• Irritability
• Insomnia
• Loss of appetite
• Tremors
• Perspiration
• Nausea
• Etiology: not known; however, genetics, the action of the drug, peer pressure, emotional distress, anxiety,
depression or another mental health problem can contribute to use/abuse
• Findings
• stimulants: alertness with increased vigilance, a sense of well-being and euphoria; talkative, flight of ideas, insomnia,
anorexia, tachycardia, hypertension, pupillary dilation
• opioids: symptoms of mild-to-moderate intoxication include drowsiness, pupillary constriction, slurred speech; for overdose,
respiratory depression, stupor and coma
• depressants: drowsiness, relaxation, decreased inhibition, incoordination, slurred speech, staggered walk, respiratory
depression
• specific to chronic alcohol use: anemia, cirrhosis, esophagitis, delirium tremens, hepatomegaly, malabsorption syndrome,
Wernicke-Korsakoff syndrome
• non-specific: continuing to use drugs even when health, work, or family are being harmed; episodes of violence/ hostility
when confronted about drug use; lack of control over drug use; making excuses to use drugs; missing work or school or
decrease in performance; need for daily or regular drug use to function; neglecting to eat; not caring for physical appearance;
no longer taking part in activities because of drug use; secretive behavior to hide drug use
• Diagnostics
• physical exam and mental health assessment
• laboratory tests including toxicology screens on blood and urine samples, CBC, electrolytes; liver enzyme tests, hepatitis viral
testing, HIV testing, blood cultures; also ECG, CT scan
• other tests: naloxone challenge test (for opioid abuse)
• questionnaires, including Michigan Alcoholism Screening Test (MAST), Cage Questionnaire
• Treatment
• begins with recognizing the problem
• detoxification
• alcohol
• benzodiazepines and antipsychotic medications to treat acute phase
• disulfiram (Antabuse) alcohol abuse deterrent
• naltrexone (Revia) or nalmefine (Revek) - lower cravings for and less pleasure from drinking
• opioids: methadone, clonidine (Catapres) and buprenorphine (Buprenex)
• treat malnutrition; treat vitamin and mineral deficiencies (folate, B12, vitamin A, calcium) as needed
• treat infectious diseases
• support
• counseling
• support groups, such as Narcotics Anonymous, Alcoholics Anonymous, Smart Recovery, Lifering Recovery
• after-care (abstinence)
• Nursing interventions
during acute withdrawal
• protect client from harm
• monitor vital signs
• seizure precautions
• consult dietitian
• participate in total treatment program with other disciplines
during abstinence
• provide emotional support
• support development of new coping skills
• set limits on manipulative behavior
• provide positive feedback for delayed gratification and using adaptive coping strategies
client (and family) teaching
the nature of the illness
• effects of substance on the body
• ways in which use of substance affects life
management of the illness
• activities to substitute for substance in times of stress
• relaxation techniques
• problem-solving skills
• essentials of good nutrition, including vitamins supplements
support services, including financial and legal assistance; alcoholics anonymous (or other support group specific to the
abused substance); one-to-one support person
Trauma- and stressor-related disorders (PTSD)
• Definition: a type of anxiety disorder in which there has been exposure to a traumatic or stressful event that involved the
threat of injury or death; types include reactive attachment, disinhibited social engagement, posttraumatic stress (PTSD),
acute stress, adjustment
• Etiology: not known
• traumatic events, such as an assault, car accidents, domestic abuse, natural disasters, prison stay, rape, terrorism, war,
cause someone to develop PTSD
• the body keeps releasing the stress hormones and chemicals
• Findings of PTSD
3 main issues
• reliving the event, which disturbs day-to-day activity
• avoidance
• hyperarousal
• may also have guilt about the event (survivor guilt)
• symptoms of anxiety, stress and tension
• Diagnostics
• physical exam and mental health assessment
• blood tests to rule out other illnesses
• PTSD is diagnosed when someone has symptoms for at least 30 days
• assessment tools, including the Clinician-Administered PTSD Scale (CAPS); Brief Interview for Posttraumatic Disorder
(BIPD), Acute Stress Disorder Interview (ASDI)
• Treatment of PTSD
• cognitive behavioral therapies
• eye movement desensitization and reprocessing (EMDR)
• hypnotherapy
• medications:
• the only FDA-approved medication are SSRIs: sertraline (Zoloft) and paroxetine (Paxil)
• "off label" medications: other antidepressants (for example, fluoxetine [Prozac]), mood stabilizers and anxiolytics
(benzodiazepines)
• Nursing interventions for PTSD
• establish trust
• encourage verbalization about the trauma when ready
• stay with client during periods of flashbacks and nightmares
• discuss coping strategies
• assess for self-destructive ideas or behavior, including suicide warnings
• assess for maladaptive coping (such as substance abuse)
• client (and family) teaching
• the nature of the illness
• management of the illness
• medication management, including side effects, length of time to take effect and what to expect from the medication
• stress management
• teach ways to interrupt escalating anxiety
• support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial assistance
• Other disorders
A. Disruptive, impulse-control, and conduct disorders
• these disorders include conditions involving problems in the self-control of emotions and behaviors
• this group of disorders includes: oppositional defiant disorder, intermittent explosive disorder, conduct disorder, antisocial
personality disorder, pyromania, kleptomania
B. Dissociative disorders
• these disorders are characterized by a disruption of and/or discontinuity in the normal integration consciousness, memory,
identify, emotion, perception, body representation, motor control, and behavior
• this group of disorders includes: dissociative identify disorder, dissociative amnesia, personalization/derealization disorder
C. Elimination disorders
• these disorders involve the inappropriate elimination of urine or feces and are usually first diagnosed in childhood or
adolescence
• this group of disorders includes: enuresis (repeated voiding of urine into inappropriate places) and encopresis (repeated
passage of feces into inappropriate places)
D. Neurocognitive disorders (NCD)
• this category encompasses the group of disorders in which the primary clinical deficit is in cognitive function, and that are
acquired rather than developmental and represent a decline from a previously attained level of functioning
• this group of disorders includes: Alzheimer’s disease; vascular NCD; NCD with lewy bodies; NCD due to Parkinson’s
disease, traumatic brain injury, HIV infection, Huntington’s disease, prion disease
• formerly referred to as “dementia, delirium, amnestic, and other cognitive disorders”
E. Sleep-wake disorders
• individuals with these disorders typically present with sleep-wake complaints of dissatisfaction regarding the quality, timing,
and amount of sleep; resulting daytime distress and impairment are core features
• this group of disorders includes: insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders,
circadian rhythm sleep-wake disorders, non-rapid eye movement sleep arousal disorders, nightmare disorder, rapid eye
movement sleep behavior disorder, restless legs syndrome
F. Sexual dysfunctions
• sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant
disturbance in a person’s ability to respond sexually or to experience sexual pleasure; an individual may have several
disturbances at the same time
• this group of disorders includes: delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual
interest/arousal disorder, premature ejaculation
G. Somatic symptom and related disorders
• somatic symptoms are associated with significant distress and impairment
• this group of disorders includes: somatic symptom disorder, illness anxiety disorder, conversion disorder, factitious disorder
H. Paraphilic disorders
• a condition in which a person's sexual arousal and gratification depend on fantasizing about and engaging in sexual behavior
that is atypical and extreme
• this group of disorders includes: voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism
disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, transvestic disorder
I. Gender dysphoria - a condition in which a person feels that there is a mismatch between his/her biological sex
and gender identify
• Other significant conditions

Note: these conditions are not specified as mental disorders; however, they are clinically significant because they affect
mental disorders:
• Abuse and neglect: child physical abuse, child sexual abuse, child neglect, child psychological abuse
• Relational problems: problems related to family upbringing and primary support group
• Adult maltreatment and neglect: spouse or partner violence (physical or sexual), spouse or partner neglect, spouse of partner
abuse (psychological), adult abuse by nonspouse or nonpartner
• Educational and occupational problems
• Housing and economic problems
• Other problems related to the social environment, such as living alone, acculturation, social exclusion, rejection,
discrimination
• Problems related to crime interaction with the legal system: victims of crime, conviction in civil or criminal proceedings without
imprisonment, imprisonment, problems related to release from prison, problems with legal circumstances