Neeb's Fundamentals of Mental Health Nursing

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4TH EDITION Neeb’s Fundamentals of Mental Health Nursing

Linda M. Gorman, RN, MN, PMHCNS-BC, FPCN Clinical Nurse Specialist/Nursing Consultant Private Practice Studio City, California Robynn F. Anwar, MST, MSN, Ed Nursing Faculty/CNA and Multi-Skilled Coordinator Camden County College, Camden Campus Camden, New Jersey 2993_FM_i-xvi 14/01/14 5:31 PM Page ii

F.A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2014 by F. A. Davis Company Copyright © 1997, 2001, 2006, by F.A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Lisa B. Houck Director of Content Development: Darlene D. Pedersen Project Editor: Jacalyn C. Clay Electronic Project Editor: Sandra A. Glennie Illustration and Design Manager: Carolyn O’Brien As new scientiﬁc information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), edi- tors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Gorman, Linda M., author. Neeb’s fundamentals of mental health nursing / Linda M. Gorman, Robynn F. Anwar. — Fourth edition. p. ; cm. Fundamentals of mental health nursing Preceded by: Fundamentals of mental health nursing / Kathy Neeb. 3rd ed. c2006. Includes bibliographical references and index. ISBN 978-0-8036-2993-6 (pbk. : alk. paper) I. Anwar, Robynn F., author. II. Neeb, Kathy, 1952- Fundamentals of mental health nursing. Preceded by (work): III. Title. IV. Title: Fundamentals of mental health nursing. [DNLM: 1. Mental Disorders—nursing. 2. Nursing, Practical. 3. Psychiatric Nursing—methods. WY 160] RC440 616.89’0231—dc23 2013021696 Authorization to photocopy items for internal or personal use, or the internal or personal use of speciﬁc clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1169-2/04 0 + $.25. 2993_FM_i-xvi 14/01/14 5:31 PM Page iii

To Corie, who saw me as an author many years ago. (LG)

To Mayme, I realize how much easier this journey would have been if you were here. Wasim and Andrea, I appreciate your belief in my abilities. “Mom Bessie,” who renewed her practical nurse license at age 94. Linda, thank you for being my mentor through this process. Shirley, Toni, and Ted—Thank you. (RA) 2993_FM_i-xvi 14/01/14 5:31 PM Page iv 2993_FM_i-xvi 14/01/14 5:31 PM Page v

Preface

eeb’s Fundamentals of Mental Health Chapters 1 to 9 provide the basics of Nursing is a psychiatric nursing text mental health nursing concepts, with an N tailored specifically to the needs of emphasis on communication. Chapters 10 the LVN/LPN student. We understand that to 22 are “clinical” chapters in that they many students at this level of preparation cover specific diagnoses and/or populations. do not have the opportunity for clinical ex- Many of the chapters include the following perience in a psychiatric setting, but they will new or enhanced key features: encounter patients with mental health issues in their rotations. Students will encounter • Neeb’s Tip will give a “clinical pearl” that patients and their families with psychiatric succinctly describes a key take-away from diagnoses as well as a variety of psychosocial the chapter. issues and behaviors that challenge them. This • Critical Thinking Questions are expanded text will provide the basic knowledge and and interspersed in the chapters to empha- skills to address many of these challenges, size a concept and challenge the student to with an emphasis on communication. This apply the concept just covered. Many of new edition also brings enhancements via the these include case-based scenarios. Internet through DavisPlus. • Toolbox provides additional resources for Our goal with this text is to provide basic students who want more information. information about mental health theories, These can be further explored on the personality development, coping and com- book’s Web site. munication styles, psychiatric diagnoses, and • Pharmacology Corner in Chapters 10 to 20 nursing actions, all as they pertain to the prac- and 22 covers important current informa- tice of the LVN/LPN. tion about medications used for the spe- The impact of psychiatric disorders con- cific population that will pertain to the tinues to be a concern in the United States. LVN/LPN scope of practice. Depression, anxiety, eating disorders, and • Clinical Activities are suggestions for the substance abuse continue to be major health student to utilize when caring for patients problems. How society responds to debilitat- with a particular disorder. ing mental illness has been the subject of • Classroom Activities include suggestions much debate. Clearly the need for nurses to for projects or actions that students have education in caring for people with and faculty can use in the classroom mental health issues is essential. to enhance learning. The Fourth Edition of Neeb’s Fundamentals • Case Studies are in-depth, with questions of Mental Health Nursing brings new authors to help the student apply knowledge who have expanded on the foundations that learned in the chapter. Kathy Neeb created so successfully in the first • Multiple Choice Questions—At least three editions. The new authors bring broad 10 questions are provided at the end of experience in psychiatric nursing, education, the chapters, with the answers/rationales and clinical practice. New chapters in this in Appendix A. Additional NCLEX Fourth Edition include postpartum issues questions are on the book’s Web site. as well as separate chapters on depressive • Sample Care Plans are provided in the and bipolar disorders. We have added more clinical chapters. features to enhance the concepts and make • Appendix E, which is new, matches com- them more meaningful and current. mon behaviors with nursing diagnoses.

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vi Preface

Internet-based enhancements include pod- LVN/LPN student will not be using the casts, updated references, and other resources Manual routinely, a familiarity with the such as drug monographs and Neeb’s blog. terminology that is used by other health-care Neeb’s blog will provide an opportunity for professionals is essential. The chapter titles the student to reﬂect on learning and experi- reflect the new terminology where changes ences that can be shared with others. For have been made. the instructor, this Fourth Edition provides We, as practitioners and educators in the access to PowerPoint presentations, test bank field of mental health, have seen the impact questions, and other expanded features. of mental health issues on our patients and This edition coincides with the publica- society. We hope that the students who tion of the DSM-5, Diagnostic and Statistical utilize this book will gain a new perspective Manual for Mental Disorders by the American that includes up-to-date knowledge as well Psychiatric Association that was published as empathy for the suffering these disorders in 2013. The terminology used throughout can cause. We hope this book will con- this edition reflect the changes in this tribute to knowledgeable and compassion- major psychiatric reference. Although the ate LVNs/LPNs. 2993_FM_i-xvi 14/01/14 5:31 PM Page vii

Reviewers

PATTI ALFORD, RN, BSBM DEBORAH B. HARRIS, BSN, MSN, RN Instructor Director, Practical Nursing Program Kilgore College Valley Vocational Technical Center Longview, Texas Fishersville, Virginia

RUTH FEE BLACKMORE, MSN, RN, CNOR EULA JACKSON, ADN, BS, MSN, CNE, PHD Faculty of Nursing Nursing Facilitator/Clinical Instructor Isabella Graham Hart School of Practical Reid State College and University of Phoenix Nursing Evergreen, Alabama Rochester, New York LINDA JOHNSON, RN, PHN, MSN, DHA RENEÉ T. BURWELL, AASN, BSN, MSED, EDD Assistant Director Vocational Nursing Program Coordinator of Health Science Programs Los Medanos College Charlotte Technical Center Pittsburg, California Port Charlotte, Florida ETHEL JONES, EDS, DSN, RN, CNE JOYCE CANAVAN, BS ED, MSN, RN Nursing Instructor Mental Health, Lead Instructor H. Councill Trenholm State Technical College Anamarc College Montgomery, Alabama El Paso, Texas TAMMY KRELL, MSN, RN TAMMIE COHEN, RN, BSN Coordinator of PN Program Nursing Instructor, Faculty Advisor Chairperson Western Wyoming Community College Western Suﬀolk BOCES Evanston, Wyoming Northport, New York SUSAN R. LEFERSON, RN, BSN, MSBA, COHC WENDY C. FARR, RN, BSN, MSN ED, INS Nurse Educator Practical Nursing Instructor Medical Careers Institute, School of Health Southern Crescent Technical College Sciences of ECPI University Thomaston, Georgia Manassas, Virginia

BRIAN FONNESBECK, RN, MN, BSN, ADN RIMINA LEWIS, MSN/ED, RN Associate Professor of Nursing and Health Sciences Instructor, Practical Nurse Program Lewis-Clark State College Savannah Technical College Lewiston, Idaho Savannah, Georgia

CHERYL GILBERT, RN, BHA GAYLA LOVE, MSN, BSN, RN, CCM Assistant Director, Vocational Nursing Program Program Coordinator, Practical Nursing Chaﬀey College, Chino Campus Southern Crescent Technical College Chino, California Griﬃn, Georgia

PEGGY GRADY, RN, ASN KIMBERLY K. MCCLURE, MSN, RN Assistant Director, PN Program Vocational Nursing Instructor Clinical Instructor Victoria College Southern Crescent Technical College Victoria, Texas Griﬃn, Georgia

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viii Reviewers

CAROL A. MILLER, BSN PHYLLIS ROWE, DNP, RN, ANP Nursing Instructor Professor, Nursing Southeastern Technical Institute Riverside City College Easton, Massachusetts Riverside, California

JOHN H. NAGELSCHMIDT, MSN, RN ELLEN SANTOS, MSN, RN, CNE Nursing Instructor Instructor of Practical Nursing Assabet Valley Regional Technical High School Assabet Valley Regional Technical School Marlborough, Massachusetts Marlborough, Massachusetts

DIANA NOBLEZA, MSN, RN JUDITH M. SHAFFER, RN, BSN, MSN ED Instructor and CFO STUDENT Pinelands School of Practical Nursing & Allied Practical Nursing Educator Health, Inc. ECPI University Toms River, New Jersey Raleigh, North Carolina

SALLIE NOTO, RN, MS, MSN CLAUDIA STOFFEL, MSN, RN, CNE Director, CTC School of Practical Nursing Professor of Nursing, Practical Nursing Program Career Technology Center Coordinator Scranton, Pennsylvania West Kentucky Community and Technical College MARY A. OLSON, MA, RN Paducah, Kentucky PN Program Director St. Paul College KENDRA STRENTH, RN, MSN, DNP, BC Saint Paul, Minnesota Instructor Bishop State Community College KRISTI PFEIL, MSN, RN Mobile, Alabama VN Nursing Faculty Victoria College BARBARA TAYLOR, RN, MSN Victoria, Texas LPN Instructor Walton Career Development Center MARYELLEN PICCHIELLO, MS, RN DeFuniak Springs, Florida LPN Instructor Ocean County Vocational Technical School SANDRA D. THOMPSON, RN Toms River, New Jersey Coordinator Mercer County Technical Education Center JENNIFER PONTO, RN, BSN Princeton, West Virginia Instructor, Vocational Nursing South Plains College PEGGY VALENTINE, RN, BSN, MSNC Levelland, Texas Director of Nursing Skyline College CINDY PRICE, MSN, RN Roanoke, Virginia Practical Nurse Instructor Mid-East Career and Technology Center FAYE WARNER, RN, MSN Zanesville, Ohio LPN Instructor Kaynor Regional High School CYNTHIA ROBERTS, MS, RN Waterbury, Connecticut Program Director Isabella Graham Hart School of Practical Nursing Rochester General Health System Rochester, New York 2993_FM_i-xvi 14/01/14 5:31 PM Page ix

Consultants to Previous Editions

BRENDA AGEE, RN, MSN CHRISTINE D. HERDLICK, RN, BA Nursing Instructor Nursing Instructor Delaware Technical and Community College Marshalltown Community College Georgetown, Delaware Marshalltown, Iowa

ETHEL AVERY, RN, MSN, EDS DEBRA HODGE Instructor Licensed Practical Nursing H. Councill Trenholm State Technical College West Virginia Academy of Careers and Montgomery, Alabama Technology Beckley, West Virginia SHARON M. ERBE, RN, BSN, MSN(C) Nursing Coordinator PHYLLIS LILLY, RN, BSN WSWHE BOCES Instructor Hudson Falls, New York Isabella Graham Hart School of Practical Nursing GLORIA FERRITTO, RN, BSN, PHN Rochester General Hospital Assistant Director, Vocational Nursing Program Rochester, New York Maric College Vista, California MAUREEN L. MCGARY, RN, MSN, NP-C Former Program Head, Practical Nursing FRANCES FRANCIS, RN, BS Virginia Western Community College Practical Nursing Instructor Wirtz, Virginia Hazard Regional Technology Center Hazard, Kentucky BETTY RICHARDSON, RN, PHD, LPC, LMFT, CS, CNAA SUE GARLAND, RN, MSN, ARNP Instructor, Practical Nursing Program Division Chair, Allied Health and Related Austin Community College Technologies Austin, Texas Practical Nursing Program Coordinator Big Sandy Community and Technical College ROBIN A. SPIDLE, RN, PHD Paintsville, Kentucky Payson, Arizona

NANCY T. HATFIELD, RN, BSN, MA JUDY STAUDER, RN, MSN Instructor, Practical Nursing Program Coordinator Career Enrichment Center Practical Nursing Program of Canton City Albuquerque Public Schools Schools Albuquerque, New Mexico Canton, Ohio

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Acknowledgments

e want to acknowledge our Devel- opment Editor, Julie P. Scardiglia. WJulie guided us through the writing process. Her enthusiasm, encouragement and, of course, her attention to detail kept us on track throughout the revision process. Her suggestions, responsiveness, availability for many conference calls, and organization skills helped us produce a revision that taps into today’s student’s needs. She worked closely with us every step of the writing process. We are thankful for all her help. Jacalyn Clay, our Project Editor from F.A. Davis, provided us with the support and resources to develop a project that expands on Kathy Neeb’s original ideas. We appreciate all the guidance she provided to us.

—LINDA GORMAN ROBYNN ANWAR

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Table of Contents

unit 1 Foundations for Mental Health Nursing chapter 1 History of Mental Health Nursing 3 The Trailblazers 3 The Facilities 8 The Breakthroughs 8 The Laws 11 chapter 2 Basics of Communication 15 Communication Theory 16 Types of Communication 16 Challenges to Communication 19 Therapeutic Communication 21 Adaptive Communication Techniques 28 chapter 3 Ethics and Law 33 Professionalism 33 Ethics 34 Conﬁdentiality 38 Responsibility 41 Accountability 41 Abiding by the Current Laws 41 Patients’ Rights 42 Patient Advocacy 45 Community Resources 45 chapter 4 Developmental Psychology Throughout the Life Span 51 Developmental Theorists: Newborn to Adolescence 52 Developmental Theorists: Adolescence to Adulthood 56 Stages of Human Development 63 chapter 5 Sociocultural Influences on Mental Health 75 Culture 75 Ethnicity 78 Nontraditional Lifestyles 79 Homelessness 81 Economic Considerations 82 Abuse 83 Poor Parenting 83 chapter 6 Nursing Process in Mental Health 89 Step 1: Assessing the Patient’s Mental Health 90 Step 2: Nurses Diagnosis: Deﬁning Patient Problems 95 Step 3: Planning (Short- and Long-Term Goals) 95 Step 4: Implementations/Interventions 96 Step 5: Evaluating Interventions 100 chapter 7 Coping and Defense Mechanisms 105 Coping 105 Defense Mechanisms 107

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xiv Table of Contents

chapter 8 Mental Health Treatments 113 Psychopharmacology 114 Milieu 123 Psychotherapies 123 Terrorism 136 Legal Considerations 137 chapter 9 Complementary and Alternative Treatment Modalities 143 Mind, Body, and Belief 144 Common Complementary and Alternative Treatments 144 Primary Sensory Representation 152

unit 2 Threats to Mental Health chapter 10 Anxiety, Anxiety-Related, and Somatic Symptom Disorders 159 Anxiety Disorders 160 Etiology of Anxiety and Stress 161 Diﬀerential Diagnosis 161 Types of Anxiety and Anxiety-Related Disorders 162 Medical Treatment of People With Anxiety-Related Disorders 167 Alternative Interventions for People With Anxiety and Anxiety-Related Disorders 168 Nursing Care for People With Anxiety and Anxiety-Related Disorders 168 Somatic Symptom and Related Disorders 170 chapter 11 Depressive Disorders 181 Types of Depressive Disorders 181 Etiology of Depressive Disorders 185 Treatment of Depressive Disorders 185 Nursing Care of the Patient With Depressive Disorders 186 chapter 12 Bipolar Disorders 193 Characteristics of Bipolar Disorders 193 Etiology of Bipolar Disorders 195 Treatment of Bipolar Disorders 196 Nursing Care of the Patient With Bipolar Disorders 198 chapter 13 Suicide 205 The Reality of Suicide 205 Etiology of Suicide 207 Treatment of Individuals at Risk for Suicide 208 Nursing Care of the Suicidal Patient 209 chapter 14 Personality Disorders 217 Types of Personality Disorders 218 Psychiatric Treatment of Personality Disorders 223 Nursing Care of Patients With Personality Disorders 223 chapter 15 Schizophrenia Spectrum and Other Psychotic Disorders 231 Symptoms 233 Etiology of Schizophrenia 234 Psychiatric Treatment of Schizophrenia 235 Nursing Care of the Schizophrenic Patient 238 2993_FM_i-xvi 14/01/14 5:31 PM Page xv

Table of Contents xv

chapter 16 Neurocognitive Disorders: Delirium and Dementia 245 Delirium 245 Dementia 247 Nursing Care of Patients With Delirium and Dementia 253 chapter 17 Substance Use and Addictive Disorders 261 Alcohol 264 Other Substances 270 Nursing Care of Patients With Substance Use Disorders (Including Alcohol) 278 chapter 18 Eating Disorders 287 Anorexia Nervosa 287 Bulimia 290 Similarities Between Anorexia and Bulimia 292 Morbid Obesity 292 Nursing Care of Patients With Eating Disorders 294

unit 3 Special Populations chapter 19 Childhood and Adolescent Mental Health Issues 303 Depression, Bipolar Disorder, and Suicide in Children and Adolescents 304 Attention Deﬁcit/Hyperactivity Disorder 308 Autism Spectrum Disorder 312 Conduct Disorder 315 chapter 20 Postpartum Issues in Mental Health 323 Postpartum Blues 323 Postpartum Depression 324 Postpartum Psychosis 326 Nursing Care of Women With Postpartum Mental Disorders 328 chapter 21 Aging Population 335 Alzheimer’s Disease and Other Cognitive Alterations 338 Cerebrovascular Accident (Stroke) 338 Depression in the Elderly 339 Medication Concerns 340 Paranoid Thinking 340 Insomnia 341 End-of-Life Issues 342 Social Concerns 343 Nursing Skills for Working With Older Adults 344 Restorative Nursing 345 Palliative Care 347 chapter 22 Victims of Abuse and Violence 353 The Abuser 354 The Victim 355 Categories of Abuse 356 Treatment of Abuse 361 Nursing Care of Victims of Abuse 362 2993_FM_i-xvi 14/01/14 5:31 PM Page xvi

xvi Table of Contents Appendices appendix A Answers and Rationales 370 appendix B Agencies That Help People Who Have Threats to Their Mental Health 387 appendix C Organizations That Support the Licensed Practical/Vocational Nurse 388 appendix D Standards of Nursing Practice for LPN/LVNs 390 appendix E Assigning Nursing Diagnoses to Client Behaviors 393 Glossary 395 Index 405 2993_Ch01_001-014 14/01/14 5:16 PM Page 1

UNIT 1 Foundations for Mental Health Nursing 2993_Ch01_001-014 14/01/14 5:16 PM Page 2 2993_Ch01_001-014 14/01/14 5:16 PM Page 3

CHAPTER 1 History of Mental Health Nursing

Learning Objectives Key Terms 1. Identify the major trailblazers to mental health nursing. • American Nurses 2. Know the basic tenets or theories of the contributors to Association (ANA) mental health nursing. • Asylum 3. Deﬁne three types of treatment facilities. • Deinstitutionalization 4. Identify three breakthroughs that advanced mental health • Free-standing treatment nursing. centers 5. Identify the major laws and provisions of each that inﬂuenced • National Association mental health nursing. for Practical Nurse Education and Service (NAPNES) • National Federation of Licensed Practical Nurses (NFLPN) • National League for Nursing (NLN) • Nurse Practice Act • Psychotropic • Standards of care

■ The Trailblazers were the nurses who took the risks? Who were the ones who spoke out on behalf of the For centuries, nurses have been many things patient and the profession? In times when to many people. People have nurses to thank nursing was considered only “women’s work,” for cooking, cleaning, and ministering to and when women were not politically active, those who fought battles. the major trailblazers were female. Long before people knew what aerobic or anaerobic microorganisms were, nurses knew Florence Nightingale when to open or close the windows. Nurses Florence Nightingale (1820–1910) (Fig. 1-1). helped women give birth to their young and has been called the founder of nursing. Her nursed the babies when mothers were unable story and her contributions are numerous to or when mothers died during or shortly enough to fill many volumes. She was born after giving birth. The first flight attendants of wealth and was highly educated. When she were nurses. For centuries, nurses have gone was very young, she realized she wanted to be about the business of caring for people, but a nurse, which did not please her parents. they have not always done that quietly. Who Conditions in hospitals were poor, and her

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4 UNIT 1 | Foundations for Mental Health Nursing

The tidal wave of deeper souls Into our inmost being rolls, And lifts us unawares Out of all meaner cares. Honour to those whose words or deeds Thus help us in our daily needs, And by their overflow Raise us from what is low! Thus thought I, as by night I read Of the great army of the dead, The trenches cold and damp, The starved and frozen camp, The wounded from the battle-plain, In dreary hospitals of pain, Figure 1-1 Florence Nightingale at work during the Crimean War. The cheerless corridors, The cold and stony floors. Lo! in that house of misery parents wanted her to pursue a life as wife, A lady with a lamp I see mother, and society woman. Pass through the glimmering gloom, Florence worked hard to educate herself And flit from room to room. in the art and science of nursing. Her And slow, as in a dream of bliss, mission to help the British soldiers in the The speechless sufferer turns to kiss Crimean War earned her respect around the Her shadow, as it falls world as a nurse and administrator. This was Upon the darkening walls. no easy task because many of the soldiers at As if a door in heaven should be the Barrack Hospital at Scutari resented her Opened and then closed suddenly, intelligence and did what they could to The vision came and went, undermine her work. The light shone and was spent. The relationship between sanitary con- On England’s annals, through the long ditions and healing became known and Hereafter of her speech and song, accepted due to her observations and dili- That light its rays shall cast gence. Within 6 months of her arrival in From portals of the past. Scutari, the mortality rate dropped from A Lady with a Lamp shall stand 42.7% to 2.2% (Donahue, 1985, p. 244). In the great history of the land, She insisted on proper lighting, diet, clean- A noble type of good, liness, and recreation. She understood that Heroic womanhood. the mind and body work together and Nor even shall be wanting here that cleanliness, the predecessor to today’s The palm, the lily, and the spear, sterile techniques, is a major barrier to infec- The symbols that of yore tion and promotes healing. She carefully Saint Filomena bore. observed and documented changes in the She was a crusader for the improvement of conditions of the soldiers, which led to care and conditions in the military and civil- her adulation as “The Lady with the ian hospitals in Britain. Among her books are Lamp” (from the poem “Santa Filomena” Notes on Hospitals (1859), which deals with by H. W. Longfellow). the relationship of sanitary techniques to Santa Filomena medical facilities; Notes on Nursing (1859), by Henry Wadsworth Longfellow which was the most respected nursing text- Whene’er a noble deed is wrought, book of the day; and Notes on Matters Affect- Whene’er is spoken a noble thought, ing the Health, Efficiency and Hospital Our hearts, in glad surprise, Administration of the British Army (1857) To higher levels rise. (Donahue, 1985, p. 248). 2993_Ch01_001-014 14/01/14 5:16 PM Page 5

CHAPTER 1 | History of Mental Health Nursing 5

The first formal nurses’ training pro- or “psychiatric hospitals” to care for the men- gram, the Nightingale School for Nurses, tally ill. There is a monument to her that sym- opened in 1860. The goals of the school bolized her efforts on the Women’s Heritage were to train nurses to work in hospitals, Trail in Boston. to work with the poor, and to teach. This meant that students cared for people in Linda Richards their homes, an idea that is still gaining While Dorothea Dix was working for politi- in popularity and professional opportunity cal help in mental health, a nurse named for nurses. Florence Nightingale died at Linda Richards (1841–1930) (Fig. 1-3) was the age of 90. pushing to upgrade nursing education. She was the first American-trained nurse, and in Dorothea Dix 1882 she opened the Boston City Hospital Dorothea Dix (1802–1887) (Fig. 1-2) was a Training School for Nurses to teach the schoolteacher, not a nurse. She believed that specialty of caring for the mentally ill. By people did not need to live in suffering and 1890, more than 30 asylums in the United that society at large had a responsibility to aid States had developed schools for nurses. those less fortunate. Her primary focus was Linda Richards was among the first nurses the care of prisoners and the mentally ill. She to teach and work seriously with planning lobbied in the United States and Canada for and developing nursing care for patients. In the improvement of standards of care for the cooperation with the American Nurses mentally ill and even suggested that the gov- Association (ANA) and the National League ernments take an active role in providing help for Nursing (NLN), she was instrumental in with finances, food, shelter, and other areas developing textbooks specifically for nurses of need. She learned that many criminals were that had stated objectives for outcomes of also mentally ill, a theory that is borne out nursing education and patient care. in studies today. Because of the efforts of Dorothea Dix, 32 states developed asylums

Linda Richards America's First Trained Nurse Born in Potsdam, 1841

Figure 1-2 Dorothea Dix. Figure 1-3 Linda Richards. 2993_Ch01_001-014 14/01/14 5:16 PM Page 6

6 UNIT 1 | Foundations for Mental Health Nursing Harriet Bailey The first textbook focusing on psychiatric nursing was written in 1920 by Harriet Bailey. It included guidelines for nurses who provided care for those with a mental illness. Bailey understood that nurses caring for these patients needed proper training. After she published her book, the NLN began requiring all student nurses have a clinical rotation in a psychiatric setting (Videback, 2013). Effie Jane Taylor Effie Jane Taylor (Fig. 1-4) initiated the first psychiatric program of study for nurses, in 1913. She is also well known for her development and implementation of patient-centered care, putting emphasis on the emotional and intellec- Figure 1-5 Mary Mahoney. tual life of the patient. Effie Taylor received a diploma in nursing from Johns Hopkins School of Nursing, later to become a nursing professor Americans in the field of nursing. An award in psychiatry (American Association for the in her name is presented at the annual ANA History of Nursing, Inc., 2007). convention to a person who has worked to Mary Mahoney promote equal opportunity for minorities in nursing. During her career, it was necessary to Mary Mahoney (1845–1926) (Fig. 1-5) is open separate schools of nursing for African considered to be America’s first African- American students because they were banned American professional nurse. Her contribu- from the schools for white students. Two of tions were primarily in home care and in the these separate schools were Spelman Seminary promotion of the acceptance of African (currently known as Spelman College) in Georgia and Tuskegee Institute in Alabama. Hildegard Peplau Dr. Hildegard Peplau (1909–1999) (Fig. 1-6) was a nurse ahead of her time. She believed that nursing is multifaceted and that the nurse must educate and promote wellness as well as deliver care to the ill. In her book, Interpersonal Relations in Nursing (1952), Dr. Peplau brought together some interpersonal theories from psychiatry and melded them with theories of nursing and communication. She believed that nurses work in society—not merely in a hospital or clinic— and that they need to use every opportunity to educate the public and follow role models in physical and mental health. Peplau saw the nurse as:

Figure 1-4 Eﬃe Jane Taylor. (From Yale Univer- 1. Resource person. Provides information. sity, Harvey Cushing/John Hay Whitney Medical 2. Counselor. Helps patients to explore their Library.) thoughts and feelings. 2993_Ch01_001-014 14/01/14 5:16 PM Page 7

CHAPTER 1 | History of Mental Health Nursing 7

Rutgers University to provide training for clinical nurse specialists for psychiatric nursing. Hattie Bessent In the early 1980s, the National Institute of Mental Health granted money to be used for the education and research of minority nurses who were choosing to upgrade to master’s and doctorate levels of practice. Hattie Bessent (Fig. 1-7) is credited with the development and directorship of that program. In 2008 the ANA presented Dr. Bessent with its Hall of Fame Award.

■ ■ ■ Critical Thinking Question The “trailblazers” were risk takers. One of the professional responsibilities of nursing is to try to give something back to our profession. How will you, as an individual, become a trailblazer? What direction should nursing as a whole take Figure 1-6 Hildegard Peplau. to strengthen the profession? What criteria should be important when deciding what level of preparation in nursing should allow the nurse to be a specialist in mental health? 3. Surrogate. By role-playing or other means helps the patient to explore and identify feelings from the past. ■ ■ ■ Classroom Activity 4. Technical support. Coordinates professional • Have students (and colleagues) research trail- services (Peplau, 1952). blazers in nursing and, on an assigned day, come to class with a prop and a brief explana- In addition to this, she believed in build- tion of the trailblazers and their contributions ing a collaborative therapeutic relationship to nursing. between the nurse and the patient. In her book she cites four stages of this relationship (Peplau, 1952): 1. Orientation. Patient feels a need and a will to seek out help. 2. Identification. Expectations and perceptions about the nurse-patient relationship are identified. 3. Exploration. Patient will begin to show motivation in the problem-solving process, but some testing behaviors may be seen; patient may have a need to “test” the nurse’s commitment to his/her individual situation. 4. Resolution. Focus is on the patient’s developing self-responsibility and showing personal growth. In 1954, the first graduate-level nursing program was developed by Dr. Peplau at Figure 1-7 Hattie Bessent. 2993_Ch01_001-014 14/01/14 5:16 PM Page 8

8 UNIT 1 | Foundations for Mental Health Nursing ■ The Facilities People who have mental illnesses are everywhere; popular statistics say that about one in every three Americans will experience some form of mental illness at some point in life. The trailblazers in nursing realized that mental illness is different from medical-surgical disorders. They understood that each person’s mind is truly unique and therefore nurses need information and training specific to those illnesses. To help meet those needs, they took action to improve the quality of care for Figure 1-8 ByBerry, later to be renamed those patients. This was not enough, however, Philadelphia State Hospital. and it became evident that persons with moderate to severe mental disorders were often better served through care in special facilities. Today, hospitals handle patients with psychological needs according to the size of Asylums the hospital and its resources. To comply with These special facilities were called asylums, regulations surrounding mental health issues, which Webster Online, in part, defines as in smaller communities these patients may be “1: a place of refuge; 2: protection given to seen in a hospital emergency room and then criminals and debtors; 3: an institution for referred to other clinics or hospitals. Commu- the care of the needy or sick and especially of nities large enough to support such programs the insane.” Patients in asylums were fre- may provide in-house mental health treat- quently treated less than humanely. Custodial ment as well as outpatient treatment and care was provided, but patients were often aftercare. Metropolitan areas commonly pro- heavily medicated. Nutritional and physical vide treatment via several options, including care was minimal, and often these patients hospitals and free-standing treatment centers. were volunteered for various forms of experi- mentation and research. Free-Standing Facilities One of the largest asylums in the United Free-standing treatment centers may be States was known as ByBerry, later to be recalled detoxification (detox) centers, crisis named Philadelphia State Hospital (Fig. 1-8). centers, or similar names. Most people are This facility reportedly provided inhumane familiar with the Betty Ford Center. Many treatment to its patients. With the onset of free-standing treatment centers provide care deinstitutionalization and due to the poor ranging from crisis-only to more traditional conditions, this facility saw its last patient 21-day stays. As with the Betty Ford Center, in 1990. a stay can last up to 120 days. This, too, depends largely on the size and needs of the Hospitals individual community. More discussion on As treatment facilities evolved, the term the types of treatment facilities occurs in the asylum and the connotations associated with section on The Laws. it became unpopular. In 1753, Pennsylvania Hospital established a facility to treat those ■ The Breakthroughs with mental disorders. The hospital was established by Dr. Thomas Bond and It was not until 1937 that formal clinical Benjamin Franklin. Until the Community rotations in mental health began for nurses. Mental Health Act of 1963 was passed, Today, these rotations are required for stu- housing of this clientele was primarily han- dents in nursing programs, but students in dled by individual state hospital systems. practical or vocational nursing are usually 2993_Ch01_001-014 14/01/14 5:16 PM Page 9

CHAPTER 1 | History of Mental Health Nursing 9

exposed to mental health theory and very a large decline in population. It became short observational experiences. In 1955, costly to run these large buildings and con- theory relating to mental health nursing tinue to employ staff. The combination of became a requirement for licensure for all these effects, as well as new laws pertaining nurses. to the care of the mentally ill, resulted in a Throughout the 1800s and early 1900s, movement called deinstitutionalization. progress was made in developing humane, People who had formerly required long effective treatment of mental illnesses. With hospital stays were now able to leave the the best knowledge available to them as institutions and return to their communities. a profession, nurses were forward thinkers Once discharged, some went to group homes in providing specialized care to people and others to their own homes. Deinstitu- unfortunate enough to have illnesses that tionalization was and still is a controversial were somehow different from the tubercu- issue, but it was a huge step in returning a losis, smallpox, and influenza that filled sense of worth, ability, and independence to hospitals. There was one major difference, those who had been dependent on others for however: Medicines existed to help in treat- their care for so long. ing those diseases. At that time, no one had been able to find pharmacologic help for ■ ■ ■ Critical Thinking Question people with emotional, behavioral, or phys- The laws have said that people who have mental ical brain disorders. That would change in illnesses should be treated using the least restric- the 1950s. tive alternative. Deinstitutionalization allows these people to live among us in the community. Psychotropic Medications Consider the following scenario: Your city has just purchased the house next door to you, and the In the early 1950s, chemists were experi- plan is to develop this into a halfway house for menting with combinations of chemicals women who have been child abusers. You are the and their effects on people. In 1955, a group parent of a 3-year-old and you are also a mental of psychotropic medications called pheno - health nurse. What would you do? What are your thiazines was discovered to have the effect of thoughts and feelings about this situation? calming and tranquilizing people. One well known phenothiazine is Thorazine. What a world of possibility this opened for people Nursing Organizations and living with and caring for those with mental Recommendations disorders! Suddenly it was possible to control A natural progression from the break- behavior to a degree, and patients were able throughs that were happening in nursing to function more independently. Other forms was the development of organizations for of therapy became more effective because nurses. The American Nurses Association patients were able to focus differently. Some (ANA) is recognized as an organization for patients improved so dramatically that it was registered nurses (RNs). One of its goals is no longer necessary for them to remain to promote standardization of nursing prac- hospitalized and dependent on others. tice in the United States. It also promotes Between the mid-1950s and the mid-1970s, the certification of nurses who meet specific the number of patients hospitalized with criteria. The concept of psychiatric nurse mental illnesses in the United States was cut specialists, clinicians, or advanced practice approximately in half, mainly because of the nurses is a result of the work of the ANA. use of psychotropic drugs. The American Psychiatric Nurses Associa- tion provides leadership in recommending Deinstitutionalization standards of care for nurses who care for The use of phenothiazines (see Chapter 8) people with mental illness. This organization became so effective that state hospitals invites nurses who are RN-prepared. Further and other facilities dedicated to the care and information can be obtained at its Web site, treatment of people with mental illness saw www.apna.org. 2993_Ch01_001-014 14/01/14 5:16 PM Page 10

10 UNIT 1 | Foundations for Mental Health Nursing

■ ■ ■ Classroom Activity and LVNs. NAPNES is a multidisciplinary • List the standards of psychiatric/mental health organization of individuals, facilities, and clinical nursing practice and give an example schools that advocate for professional prac- of a nursing behavior or action that correlates tice of practical and vocational nursing. Visit with each standard. the NAPNES Web site at www.napnes.org (www.nursingworld.org/scopeandstandardsof- practice) to read the NAPNES position paper, dated July 18, 2004, “Supply, Demand and Use of Licensed Practical Nurses.”

The National League for Nursing evolved | from the National League for Nursing Educa- Tool Box  Organizations for Practical and Vocational Nurses tion and became known as the NLN in 1952. National Federation of Licensed Practical NLN is the accrediting agency for many Nurses, Inc. (NFLPN) schools of nursing across the United States www.nflpn.org with its specific focus on nursing education. National Association for Practical Nurse Every state has adopted its own code or set Education and Service, Inc. (NAPNES) of rules by which all nurses are expected to www.napnes.org perform. This is called theNurse Practice Act and is based on federal guidelines that have been adapted to the needs of the individual The National Coalition of Ethnic Minority state. The Nurse Practice Act is discussed in Nurse Associations (NCEMNA) is made up more detail in Chapter 3. of five national ethnic nurse associations: Sigma Theta Tau is an honor society Asian American/Pacific Islander Nurses Asso- for nurses who have shown special talents ciation, Inc. (AAPINA), National Alaska in research or leadership. It is open to Native American Indian Nurses Association, baccalaureate-degree nursing students, grad- Inc. (NANAINA), National Association of uate students in nursing, and leaders in the Hispanic Nurses, Inc. (NAHN), National nursing community. Black Nurses Association, Inc. (NBNA), and Specific to the licensed practical/vocational Philippine Nurses Association of America, nurse are two organizations: National Feder- Inc. (PNAA). Goals include advocating for ation of Licensed Practical Nurses (NFLPN) equity and justice in nursing and health care and National Association for Practical Nurse for ethnic minority populations and endorse- Education and Service (NAPNES). NFLPN ment of best practice models for nursing prac- welcomes licensed practical nurses (LPNs), tice, education, and research for minority licensed vocational nurses (LVNs), and practical/ populations. More information can be located vocational nursing (PN) students in the at its Web site, www.ncemna.org. United States. In September 1991, a new The American Assembly for Men in category of affiliate membership was estab- Nursing (AAMN) provides a framework for lished to allow those who have an interest male nurses, as a group, to meet to discuss in the work of NFLPN but who are neither and influence factors that affect men as LPNs nor PN students to join. The NFLPN nurses. Among its objectives is to encourage has a published set of Nursing Practice Stan- men of all ages to become nurses and join dards for the LPN (Appendix D). The standards together with all nurses in strengthening can be found online at www.nflpn.org/ and humanizing health care. The organiza- practice-standards4web.pdf. tion also supports men who are nurses to NAPNES was founded by practical nurse grow professionally and demonstrate the educators in 1941 and identifies itself as the increasing contributions being made by world’s oldest nursing organization dedicated men in the nursing profession. As do the exclusively to the promotion of quality nurs- other professional organizations, AAMN ing service through the practice of LPNs advocates for continued research, education, 2993_Ch01_001-014 14/01/14 5:16 PM Page 11

CHAPTER 1 | History of Mental Health Nursing 11

and dissemination of information about nursing in general. But mental health has men’s health issues, men in nursing, and remained a challenge. There were ethical con- nursing knowledge at the local and national siderations that had not surfaced in earlier levels. years. Psychotropic and (also known as psychoactive) medications were benefiting many patients but had their own problems as well; Tool Box | Nursing Organizations side effects were not always pleasant. More ANA: American Nurses Association: www.nursingworld.org/ drugs were being developed, and more ques- APNA: American Psychiatric Nurses tions arose: How much is too much to give Association: people? Do we keep them completely se- www.apna.org/ dated? People were asking which was worse: NLN: National League for Nursing: the illness or the medication? People are still www.nln.org/ asking that question. Other concerns have NFLPN: National Federation of Licensed arisen, for example, how some psychotropic Practical Nurses: drugs are associated with diabetic mellitus. www.nflpn.org/ Nonetheless, it was necessary to begin reg- NAPNES: National Association for Practical ulating the health-care industry a bit more. Nurse Education and Services: A series of laws governing various aspects of www.napnes.org/ care for persons with mental illnesses were NCEMNA: National Coalition of Ethnic Minority Nurse Associations: passed. The laws have changed somewhat www.ncemna.org/ and have been renamed in some cases, but the AAPINA: Asian American / Pacific Islander collective intention is to provide funding, Nurses Association, Inc.: treatment, and ethical care for this segment www.aapina.org/ of society. NANAINA: National Alaska Native American Indian Nurses Association: ■ ■ ■ www.geronurseonline.org/ (see partner Critical Thinking Question Your employer has announced that your com- organizations) pany is changing its medical insurance policy. NAHN: National Association of Hispanic The company will be providing you with a set Nurses: amount of money to spend on insurance bene- www.nahnnet.org/ fits. The three insurance services you have to NBNA: National Black Nurses Association: choose from offer either family coverage or www.nbna.org/ mental health services. You are a single parent PNAA: Philippine Nurses Association of with two preschoolers. You also have a diagnosis America: of bipolar disorder for which you need medica- www.mypnaa.org/ tions, therapy, and periodic hospitalization. What will you choose? AAMN: American Assembly for Men in Nursing: http://aamn.org/ Hill-Burton Act In 1946, Senators Lister Hill and Harold Appendix C of this text provides more Burton collaborated and created the contact information for these and other agen- Hill-Burton Act, a federal law. It was the first cies designed to promote and assist nurses, major law to address mental illness. It pro- particularly at the LPN and LVN level of vided money to build psychiatric units in preparation. hospitals. Today, the many soldiers returning from the Afghanistan war who suffer from ■ THE LAWS post-traumatic stress disorder know they will not be turned away because of financial Over the years many changes and advance- difficulties, as the Hill-Burton Act protects ments have been made in medicine and those who have no insurance coverage. 2993_Ch01_001-014 14/01/14 5:16 PM Page 12

12 UNIT 1 | Foundations for Mental Health Nursing

National Mental Health Act Tool Box | Community Mental Health of 1946 Act 1963 www.mass.gov/eohhs/gov/departments/ The National Mental Health Act of 1946 dmh/about-the-department-of-mental- was a result of the first Congress held after health.html World War II. It provided money for nursing Omnibus Budget Reconciliation Act and several other disciplines for training and www.gpo.gov/fdsys/pkg/BILLS-103hr research in areas pertaining to improving 2264enr/pdf/BILLS-103hr2264enr.pdf treatment for the mentally ill. The National Institute of Mental Health (NIMH) was established as part of the National Mental to be identified as “clients” who purchase Health Act of 1946. The NIMH continu- services from health-care providers. Persons ously updates the public on mental health of very young or very old age or persons with issues. Since 1999, NIMH has been research- certain physical, intellectual, or communica- ing autism. The agency also started the Army tion difficulties became politically recognized Study to Assess Risk and Resilience in Service as “vulnerable.” The outcome was the devel- Members (Army Starrs). The Army Starrs will opment of the Patient Bill of Rights, which is look at the many factors that will be facing discussed in more detail in Chapter 3. those who had to encounter battle.

Community Mental Health ■ ■ ■ Clinical Activity Centers Act of 1963 Discussion Questions: In clinical post-conference, The Community Mental Health Centers Act discuss your answers to these questions. 1. Identify ways that (a) the delivery of psychiatric/ resulted from President John F. Kennedy’s mental health nursing and (b) roles, functions, concern for the treatment of the mentally ill. activities, and settings have changed. Its main purpose was to provide a full set of 2. What issues or trends do you perceive in services to the people living in a particular psychiatric/mental health in the future. community. These services were to include inpatient care, outpatient care, emergency care, and education. This was to be a national effort, funded federally at first. The goal was ■ ■ ■ Key Concepts for the centers to generate enough services 1. Mental health nursing has a long and so that, eventually, the community could rich history. It has evolved from very support it financially. rudimentary skills before the time of In 1981, the bill was amended in Congress. Florence Nightingale to the specialty Called the Omnibus Budget Reconciliation area of nursing today. Act (OBRA), it allows money to be allocated differently. There is currently less money avail- 2. Patients with mental illness are treated in able in the federal budget, and that money can many different types of facilities, depend- be withheld at any time. Unfortunately, with ing on the diagnosis and the availability the turmoil in the insurance and health-care of care in the particular community. delivery systems today, mental health benefits 3. The 1950s were important years in the are often among the first services to be cut mental health field. The first psychotropic back or eliminated. medications were developed, making Patient Bill of Rights it possible for people to return to their homes and communities (deinstitutional- In 1980, the image of the patient was chang- ization). These medications also allowed ing. The Civil Rights Movement of the 1960s other treatment forms to be used more was giving way to the provision of rights for effectively. all groups of people. Patients were beginning 2993_Ch01_001-014 14/01/14 5:16 PM Page 13

CHAPTER 1 | History of Mental Health Nursing 13

4. Nurses at all levels of preparation are Henry, G.W. (1921). Nursing mental disease, by integral parts of the mental health Harriet Bailey, R.N. Bangor, Maine, 175 pages. treatment team. Our observations, (New York: The Macmillan Company, 1920). The American journal of psychiatry, 77(3), documentation, and interpersonal 473–474. Retrieved from www.focus. skills make nurses effective tools in psychiatryonline.org/data/Journals patient care. Peplau, H.E. (1952). Interpersonal Relations in 5. Since 1955, all nursing curriculums Nursing. New York: GP Putnam’s Sons. are required to provide mental health Longfellow, H.W. (1857) Santa Filomena. The Atlantic Monthly, 1(1) 22–23. theory. Verghese, M. (2010). Essentials of Psychiatric and 6. A series of laws over the past 50 years Mental Health Nursing. 3rd ed., pp. 254–255. have provided for money, education, Kalk, New Delhi: Elsevier. research, and improvements in the care Videbeck, S. L. (2013). Psychiatric-Mental Health of the mentally ill. Financial diﬃculties Nursing. 6th ed. Philadelphia: Lippincott Williams & Wilkins. in the insurance and health-care indus- Webster Online (2004). www.merriam-webster. tries contribute to cutbacks in money com and services for care and treatment of the mentally ill. WEB SITES Famous Nurses www.pulseuniform.com/nursing/famous-nurses.asp REFERENCES Hill Burton Act www.hhs.gov/ocr/civilrights/understanding/Medical American Association for the History of Nursing, %20Treatment%20at%20Hill%20Burton%20Funded Inc, (2007). Euphemia (eﬃe) jane taylor. %20Medical%20Facilities/index.html Retrieved from www.aahn.org/gravesites/ Mental Health Issues taylor.html. www.nami.org Donahue, M.P. (1985). Nursing, the Finest Art. National Institute of Mental Health St. Louis: CV Mosby. www.nih.gov/about/almanac/organization/NIMH.htm 2993_Ch01_001-014 14/01/14 5:16 PM Page 14

14 UNIT 1 | Foundations for Mental Health Nursing Test Questions Multiple Choice Questions 1. The main goal of deinstitutionalization 6. The following nursing organizations was to: speciﬁcally represent minority nurses. a. Let all mentally ill people care for (select all that apply) themselves. a. NACE b. Return as many people as possible to a b. AAPINA “normal” life. c. NAPNES c. Keep all mentally ill people in locked d. PNAA wards. e. NANAINA d. Close all community hospitals. 7. In the past facilities that housed patients 2. A major breakthrough of the 1950s that who were needy, sick, or insane were assisted in the deinstitutionalization known as: movement was: a. Detox centers a. The Community Mental Health b. Asylums Centers Act c. Outpatient clinics b. The Nurse Practice Act d. Hospitals c. The development of psychotropic 8. What institute was established as result medications of the National Mental Health Act of d. Electroshock therapy 1946? 3. The set of regulations that dictates the a. NLN scope of nursing practice is called: b. NFLPN a. National League for Nursing c. Hill-Burton Act b. American Nurses Association d. NIMH c. Patient Bill of Rights 9. Florence Nightingale’s focus in the d. Nurse Practice Act Crimean War was: 4. As a result of deinstitutionalization and a. Mental health changes in the health-care delivery system, b. Upgrading education nurses can expect to care for people with c. Clean environment mental health issues in which of the d. Writing care plans following settings? 10. The ﬁrst psychotropic medications were a. Psychiatric hospitals only introduced in the: b. Outpatient settings only a. 1950s c. Medical-surgical hospital settings b. 1930s d. All of the above c. 1980s 5. Which of the following trailblazers in d. 1920s nursing was not a nurse? a. Hildegard Peplau b. Linda Richards c. Harriet Bailey d. Dorothea Dix 2993_Ch02_015-032 14/01/14 5:16 PM Page 15

CHAPTER 2 Basics of Communication

Learning Objectives Key Terms 1. Identify three components needed to communicate. • Aggressive 2. Differentiate between effective and ineffective communication communication. • Aphasia 3. Identify six types of communication. • Assertive 4. Identify five challenges to communication. communication 5. Identify common blocks to therapeutic communication. • Communication 6. Identify common techniques of therapeutic communication. • Communication block 7. Identify five adaptive communication techniques. • Dysphasia 8. Define key terms. • Hearing-impaired • Ineffective communication • Laryngectomy • Message • Neurolinguistic programming (NLP) • Nonverbal communication • Receiver • Sender • Social communication • Therapeutic communication • Verbal communication • Visually impaired

uman beings communicate. Every- wrong. What is really being communicated thing people do or say has a message here? Hand a meaning. Sometimes, the People of different cultures communicate words and the actions send different mean- differently. Men and women communicate ings to different people. For example: Sally differently. Hearing-impaired people com- and Jim meet for shift report in the morning. municate differently from people who are Sally’s eyes are red and swollen, and she is not hearing impaired. A hearing-impaired unusually quiet. Jim asks her if something person may use a hearing aid, technology, is wrong, and she responds, “No, everything is and amplifiers. People in the medical profes- just fine.” Jim has observed some changes sions communicate differently from people in Sally’s behavior and appearance. Sally in business professions by using terminology has verbally communicated that nothing is which relates to the medical profession rather

15 2993_Ch02_015-032 14/01/14 5:16 PM Page 16

16 UNIT 1 | Foundations for Mental Health Nursing than to the business world. People commu- ■ Types of Communication nicate all the time in everything they do. Communication is an ongoing process of Verbal and Written sending and receiving messages. Communication ■ Communication Theory Verbal communication is the process of exchanging information by the spoken or Sender, Receiver, and written word. It is, therefore, the subjective part of the process. In the example given Interpretation of Message earlier, Sally’s reply that “everything is just One of the challenging parts of communi- fine” is an example of verbal communication. cating with others is that the process re- The expertise a nurse develops in the areas of quires three parts: a sender, a message, written and verbal communication is largely and a receiver (Fig. 2-1). That means the responsible for the credibility of that nurse. sender is only partially responsible for the Critical thinking is essential to understanding communication. Sally cannot totally control Sally’s reply. Jim’s interpretation of her message. Sally is the sender, sending a message to Jim, the receiver, in the above scenario. Neeb’s In a discussion class on the topic of As it turns out, Sally is a victim of severe ■ Tip words and gestures and what they allergies. She was visiting her friend who has mean, one African American female cats. Sally is very allergic to them, and the student spoke up. She shared with redness and swelling were symptoms of her the class that “gals” in her world allergic response. She simply did not wish was a demeaning term relating to to burden Jim with her problem during shift the degrading role of the African report, so she opted to respond by telling him American woman in history. It is everything was “just fine.” important to know that the meaning of a word can change from one generation to the next. In the 1950s ■ ■ ■ Classroom Activity and 1960s, being part of the “guys” • What was your initial interpretation of what Sally or the “gals” was a good thing. was communicating? On what did you base your It demonstrated acceptance and interpretation? What “spoke” louder to you: Sally’s belonging to one’s social group. words or her actions and appearance? What is the danger in making this assumption about Sally’s message? Nonverbal Communication Nonverbal communication is more subtle, It is very important for the sender and receiver but it is the greatest influence on commu- to double-check the message. In nursing, this nication. It consists of people’s actions, tone is crucial because nurses use their own profes- of voice, the way they use their body, and sional “language”; when dealing with the their facial expressions. It is more subjective health and safety of patients, nurses need to since nonverbal communication can be be very sure that there are not “mixed” or interpreted many different ways by the re- “missed” messages. ceiver (Fig. 2-2). In the example above, Sally’s body language communicated that she was not “fine.” Sender Sends Message to Receiver This points out the need to be careful with hand gestures that can be misinterpreted. Many people use hand gestures when Figure 2-1 A basic flow of communication. speaking. People do it often without thinking. 2993_Ch02_015-032 14/01/14 5:16 PM Page 17

CHAPTER 2 | Basics of Communication 17

People must be ready to learn from each other every day. Nurses need to be prepared to make known those terms or gestures that are uncomfortable for them and their patients. They must make a conscious effort not to use those words when in the company of those they may offend (Box 2-1.) Aggressive and Assertive Communication The termsaggressive and assertive are sometimes used interchangeably in American cul- Figure 2-2 Nonverbal communication is ture, but they have very different meanings. estimated to be 70% of the message we send. The old saying is true: A picture is worth a Aggressive Communication thousand words! Aggressive communication is communication that is not self-responsible. Aggressive However, making the “OK” sign with one’s statements most often begin with the word fingers, which is normally a sign of encour- “you.” Aggressive communication, like aggres- agement, agreement, or congratulations, is a sive behavior, is meant to harm another per- vulgarity in some cultures. son. It is a form of the defense mechanism projection, or blaming, and it attempts to put the responsibility for the interaction on the other person. Aggressive communication Cultural Considerations is also highly subjective as demonstrated in Identify the diverse cultures and generations nonverbal communication. in your community and define a gesture EXAMPLE that you use that means something different to others. “You make me so angry when you don’t help with the housework!”

l Box 2-1 Examples of Communication With Cultural Implications Words that are seemingly harmless to some people can be very hurtful to others. People do not usually know that until they take the time to ask! These are the examples of communication that may have different cultural implications. How many more can your class identify? • Eye contact with strangers or those in perceived positions of power or respect is not considered appropriate among some populations. • Hand gestures may communicate different meanings to different groups of people. • Slang terms may be inappropriate or offensive, or may exclude people who do not understand the meaning of the word. • Gender-reference terms such as “you guys” when the group is mixed or not male. • Terms such as “master” and “slave” frequently used in computer-related issues may offend African American people and others. • African American women displayed in subservient roles. • Distortion or omission of important developments in the lives of African Americans. • Pictures or photographs that do not portray accurate skin tones, hair texture, and physical features of certain ethnic groups. 2993_Ch02_015-032 14/01/14 5:16 PM Page 18

18 UNIT 1 | Foundations for Mental Health Nursing Assertive Communication Therapeutic Communication Assertive communication, on the other In therapeutic communication, the nurse hand, is self-responsible. Assertive state- understands that in order to acquire cer- ments begin with the word “I.” They deal tain desired information from the patient, with thoughts and feelings, and they deal with unique techniques of communication will honesty. have to be instituted. They will be individu- EXAMPLE alized to the patient as well as to the mental health disorder. Therapeutic communication “I feel angry when you don’t help with the is a language of its own. It requires testing housework!” new methods of communicating and new Assertive behavior and communication are ways of listening. Therapeutic communica- also techniques of personal empowerment. tion is purposeful: Nurses are trying to de- People choose to think or feel a certain way; termine the patient’s needs. Sometimes, for others do not have the power to make people various reasons, the patient is not comfort- think or feel anything they do not choose to able sharing his or her needs and concerns. think or feel. To be able to say “I think” or At those times, it is up to the nurse to try to “I feel” keeps people in control of their emo- uncover the problem by using two tools: tions, yet it allows honest, open expression of techniques of therapeutic communication the feelings they have as a result of someone and “active” or “purposeful” listening (or else’s behavior. Still, the feelings and thoughts “listening between the lines”). The tech- belong to the person choosing them, not to niques and blocks to them will be discussed anyone else. at the end of this chapter. In addition it is essential to identify the components of any mental health disorder to provide effective ■ ■ ■ Critical Thinking Question Write one feeling statement and one thinking therapeutic communication. statement for the following situation: A co-worker who is a BSN-prepared nurse is routinely coming Neurolinguistic Programming late to work and overstaying breaks, causing Neurolinguistic programming (NLP) is a patients to have unsafe care and you to have form of communication developed prima- extra work. You speak to your nurse manager, who appears to ignore your concerns, so you rily by Milton Erickson, a hypnotherapist; approach the co-worker. John Grinder, a psychologist and linguistics professor; and Richard Bandler, a mathe- matician and editor (Grinder & Bandler, 1981). It is a way of framing statements and Social Communication questions while attempting effective com- People usually alter their style of communi- munication. One of the theory’s tenets, not cating according to who is receiving the unlike other communication theories, is message. Social communication is the day- that humans cannot fail to communicate. to-day interaction people have with personal The theory builds on the idea that humans acquaintances. For example, teenagers usually tend to communicate in basically three ways: communicate with their peer group in a hearing, seeing, and touching. Choice of different manner than they do with their par- wording can make a difference in how the ents. So, too, do nurses communicate differ- words a nurse says to a patient are actually ently with their patients than they do with “heard” by that patient, as communication their friends or family. must have a sender and a receiver. NLP is Nurses may use slang or “street language,” one method being taught to health-care and they may be less literal and purposeful in providers to assist in the successful comple- their social interactions. Quite simply, social tion of the communication loop. interaction has a different purpose than a NLP is not hypnosis; it is a form of com- nurse’s professional communication. munication. NLP can be used in conjunction 2993_Ch02_015-032 14/01/14 5:16 PM Page 19

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with hypnosis and other treatment modali- while having laryngitis; signing a check ties. In most states, hypnosis can only be per- while your arm is in a cast; or reading traffic formed legally by professionals specially signs after your eyes were dilated. These are trained and licensed to do so. uncomfortable situations, but for the most Further explanation and some simple part, they are temporary. What about pa- examples of NLP phrasing are provided in tients and coworkers for whom disabilities Chapter 9. are permanent? People Who Are Hearing- ■ ■ ■ Critical Thinking Question Impaired Turn the following aggressive statements into assertive statements. The nurse must be very patient when com- • “You make me so angry when you stop at the municating with people who are hearing- bar before you come home.” impaired. A nurse needs to be aware that the • “You always take the ‘easy’ assignment, and that’s hearing-impaired person’s frustration is even not fair.” greater than that of the nurse in trying to • “Mark always gets the days off he asks for; why can’t I?” communicate. Try to establish a trusting, team-approach relationship with hearing- impaired patients. Let them know you will try whatever it takes for you to be able to under- ■ Challenges to stand each other. Find out what has worked for that person in the past. Communication Not all hearing-impaired people use sign Communicating is something that humans language; some use lipreading. However, often take for granted—until they no longer lipreading may be inaccurate and could lead can do it: for example, answering the telephone to incorrect communication. Sometimes writing a note or providing the patient with a journal is an effective way to communicate ■ ■ ■ Clinical Activity with a person who is deaf or hard of hearing. Community Resources Worksheet Keep in mind the key factor is communica- Contact a community agency in your commu- tion and not the patient’s grammatical or nity. Explain that you are a student nurse and that spelling abilities. you are trying to determine the resources available in your community. People Who Are Visually 1. Your name:______2. Name of agency: Impaired 3. Who are the target groups for this agency? When a person is visually impaired, the a. Gender b. Age nonverbal part of communication can be a c. Specific disabilities, such as speech, hearing, challenge. Nursing is a highly affective art, and visual or other impairments. so certain nonverbal cues, such as tone of 4. How do people access this agency? voice, body position, and facial expressions, 5. What are the agency’s fees for services? “speak” most strongly to patients. How does 6. What types of insurance does the agency accept? a sightless person or someone who is severely 7. What hours is the agency open? impaired visually interpret these nonverbal 8. Do people need appointments to come to this cues? agency? Nurses must learn to become detail- 9. Where does the agency keep patient oriented storytellers. It is important to learn records? 10. What is your impression of this agency? to describe to a visually impaired patient the 11. Would you feel comfortable coming to this location of the call signal, what the call signal agency or referring a patient here? Why or sounds like, what the people in the hall are why not? laughing at, why the voices suddenly switch to a whisper when another person enters the 2993_Ch02_015-032 14/01/14 5:16 PM Page 20

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room, and who has just entered. Imagine (“voice box”). Imagine what it would be like walking into a crowded lunchroom, and to be able to speak one day and have no voice everybody stops speaking. How does that at all the next. The larynx is a body part that feel? Similarly, sightless people cannot see is very much taken for granted. How do such a wave of the hand or see when someone people answer the phone? How does a person leaves or enters a room; these events must be order a pizza? How would such people express verbalized. their emotions? Call for help? Patient teaching takes on a new dimen- sion because it involves physically moving, People With Language touching, or verbally explaining in much Differences more detail than usual. Learning to eat can be difficult for a newly sightless person. Today’s society is global. Even though English Usually, the teaching involves relating the is the predominant language in the United food position to the numbers on a clock States, it may not be the primary language for face. Sightless patients need to rely on their many of the people nurses work with and care other senses to compensate for the eyes they for. As a nurse, you may ﬁnd yourself in an cannot use. area where you are the one who does not Sometimes individuals have more than one speak the primary language. How will you need to be considered when the nurse com- communicate? How will you ensure safe care municates with them. For example, some of your patients? If the physician with a thick people are both hearing impaired and visually accent gives a verbal order, how will you know impaired. When communicating with these you have heard it correctly? What about those individuals, a nurse needs to be creative. people who say they are speaking English, but Investigate methods that have worked for you are not able to understand them? It can this person in the past and explore methods be very embarrassing and potentially insulting such as a conversation board or printing the for all parties involved. Techniques for ensur- message on the person’s palm. ing understanding are discussed at the end of As emphasized in any nursing fundamen- this chapter. tals class, when beginning and exiting the patient’s room, the nurse needs: to identify People Who Have Aphasic/ him-/herself, explain what procedure is being Dysphasic Disorders performed, make sure the patient is safe, and A person with aphasia/dysphasia has identify when leaving. either no speech or great difficulty with speech. The amount of speech a patient People Who Have possesses is related to many things, such Laryngectomies as age, cause of difficulty, and severity of Some people live with partial or total involvement. There are different types of laryngectomy—the removal of their larynx aphasia (Table 2-1).

l Table 2-1 Types of Aphasia Types of Aphasia Description Expressive Diﬃculty expressing himself or herself in written or verbal forms of communication Receptive Diﬃculty interpreting or understanding written or verbal forms of communication. Global Combination of receptive and expressive forms of aphasia 2993_Ch02_015-032 14/01/14 5:16 PM Page 21

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It is up to the physician and the speech Before reviewing therapeutic communi- therapist to determine the cause and extent of cation techniques, ineffective ones will be involvement, but the nurse will be part of the reviewed. There is an old saying that “the plan of care. This will be a very individualized road to defeat is paved with good inten- type of communication skill. Patients may tions.” Sometimes, nurses’ good intentions know that the nurse has asked them for the get them in trouble with their communica- comb; they may think they are handing tion skills. Nurses can sometimes uninten- the nurse the comb, but they actually hand tionally set themselves up for ineffective the nurse the coffee cup. A patient may try to communication. The following is a list read aloud a passage from a book, but what of ways nurses “block,” or impede, helpful comes out of the patient’s mouth may be a interactions with patients: long line of obscenities. The patient would be 1. These are very embarrassed if he or she knew what was False reassurance/social clichés. phrases nurses use in an effort to sound said. The nurse must be very understanding supportive. In social communication and willing to try repeatedly to have correct they sound friendly, but in a therapeutic communication with persons with various relationship they invalidate the patient’s forms of aphasia. Nurses also must remember concerns. that any “nasty words” are not to be taken personally; chances are very good that those EXAMPLE EFFECT ON PATIENT words are really a sincere attempt by the “Don’t worry! • Tells patient his or her patient to say, “Thank you, nurse.” See the Everything will concerns are not valid section headed “Adaptive Communication be just fine.” • May jeopardize patient’s Techniques.” trust in nurse 2. These, too, are ■ ■ ■ Minimizing/belittling. Classroom Activity used socially to try to relieve the ten- • Contact a representative from Americans with Disabilities, your state’s Services for the Blind, or sions of others. There is security in any of your local agencies that serve populations numbers, and sharing that many people with special communication needs. Invite some- are experiencing the same thing as the one from one of these agencies to be a guest individual is somehow supposed to speaker. make the problem seem lighter. In therapeutic use, the implications are different. ■ ■ ■ Clinical Activity In a clinical rotation, assign students (simulate if EXAMPLE EFFECT ON PATIENT in the classroom) to care for a person with a com- “We have all • Implies that the patient’s munication challenge. Have the students describe felt that way feelings are not special. how they altered their usual communication patterns to work with this individual. sometimes.” 3. “Why?” This simple word needs to be eliminated in therapeutic interactions. ■ Therapeutic “Why” connotes disapproval or dis- Communication pleasure. “Why ask why?” is a good question for the health-care provider It is possible to have a helping, therapeutic to remember. The patient often does conversation with most people, but it takes not know “why” and can end up feeling some practice. These “techniques” need to be responsible for providing an answer practiced in much the same way that one anyway. The nurse often needs to know learns any other language: by hearing them, “why,” but there are other ways to ask practicing them, and making them part of that are less stress-producing for the one’s professional (and social) vocabulary. patient. 2993_Ch02_015-032 14/01/14 5:16 PM Page 22

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EXAMPLE EFFECT ON PATIENT “Can you,” “Will you,” “Are they,” and “Why did you • Patient feels obligated “May I.” It does not help to add please, refuse your to answer something he as in “Please, may I ask you a question?” breakfast?” or she may not wish to or “Will you please take out the trash?” answer or may not be This courtesy still leaves the possibility able to answer for the receiver to say “yes” or “no.” The • Probes in an abrasive please makes it sound more polite in way social venues, but the same questions can be made assertive and therapeutic 4. Advising. Alcoholics Anonymous some- by stating or asking for what one wants times uses the statement, “Don’t ‘should’ (“I need to ask you a question” or on yourself.” Nurses also must not “Please take out the trash”). “should” on their patients. This sets the stage for expectations that the patient The general rule for making an open-ended may not be able to meet. It also sets question from a closed-ended question is to up, in the patient’s mind, some sort of simply drop off the first one or two words. value system that puts the nurse’s value This can also be accomplished by adding as the “right” one. It can sound very words like how and what to the beginning of judgmental. the question. Closed: “Can I help you?” EXAMPLE EFFECT ON PATIENT Open: “How can I help you?” or “What “You should eat • Places a value on the can I do to help you?” more.” action EXAMPLE EFFECT ON PATIENT “If I were you, • Gives the idea that the I would take nurse’s values are the “Can you tell me • Allows a “yes” or “no” those pills so “right” ones how you feel?” answer I would feel • Sounds parental “Do you smoke?” • Discourages further better.” “Can I ask you a exploitation of the few questions?” topic 5. Agreeing or disagreeing. Socially, people • Discourages patient agree or disagree for several reasons. from giving information Sometimes people are just expressing their opinion. Sometimes they are try- 7. Providing the answer with the question. ing to make a favorable impression. This is a technique that television inter- Therapeutically, it is wise for nurses viewers use frequently. The interviewee to avoid statements that express their may say, “The interviewer put words own opinions or values. Even though into my mouth.” For instance, a ques- some situations appear similar, there tion that answers itself is, “Didn’t you may be factors, which make them know that the committee would reject different. the proposal?” Occasionally, the body language of the interviewer or the sender EXAMPLE EFFECT ON PATIENT may influence the answer. A better way “You were wrong • Places a “right” or to ask this question is, “What were your about that.” “wrong” on the action thoughts about how the committee “I think you’re might react?” right.” EXAMPLE EFFECT ON PATIENT 6. Closed-ended questions. These are forms of “Are you afraid?” • Combines a closed- questions that make it possible for a one- “Didn’t the food ended question with a word “yes” or “no” answer. They discour- taste good?” solution age the patient from giving full answers “Do you miss • Discourages patient to the questions. Closed-ended questions your mom from providing his or are those that start with such phrases as today?” her own answers 2993_Ch02_015-032 14/01/14 5:16 PM Page 23

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8. Changing the Subject. Nurses sometimes patient to determine the best way to help the do this inadvertently. When schedules patient help himself or herself. If the nurse are busy and several patients need a can look at the relationship with that attitude, nurse’s attention at the same time, the there is no “right” or “wrong,” because each nurse’s agenda takes over, and the nurse person is different. No two patients are the starts to see to personal needs. It is very same, so what is helpful to each one is “right” easy for a nurse to give a quick answer to for that patient. a patient’s question and then proceed EXAMPLE EFFECT ON PATIENT with one’s own agenda. Unfortunately, that may send the message to the patient “That’s the way • Can sound judgmental that the nurse does not care or that this to think about it! • Can set the patient up problem is not worthy of a nurse’s time. Good for you!” for failure if the approval This patient may be reluctant to offer “That’s not a or disapproval does not more information to that nurse in the good idea.” help; can lower the future. nurse’s credibility Changing the subject may also reflect the Techniques of Therapeutic/ nurse’s comfort (or discomfort) level with the subject. If the nurse just experienced the Helping Communication death of a loved one from a heart attack, for Hildegard Peplau envisioned the nurse as a example, it may be very uncomfortable to “tool” for ensuring positive interpersonal answer a patient’s questions about recovery relationships with patients. Nurses are with and prognosis following his or her bypass the patient for approximately 8–12 hours surgery. The nurse may answer quickly and daily. Compare that with the amount of time move on to a more comfortable topic, such a physician is able to spend with the patient, as, “Well, your physician has advanced your and it is easy to see how the nurse becomes diet; that’s good news!” the therapeutic tool that helps the patient help himself or herself. This observation was EXAMPLE EFFECT ON PATIENT noted by Florence Nightingale in her book, The patient is • Discounts the Notes on Nursing (Nightingale, originally pub- asking a question importance of the lished in 1859). about his/her patient’s need to Patients develop a different kind of rap- prognosis and explore personal port with nurses because they learn to trust the nurse thoughts and feelings them. Although nurses’ technical skills are responds with, • May be a reflection very important and must never be allowed “Did the doctor of the nurse’s own to get rusty, it is the appropriate use of say anything discomfort level with their verbal and nonverbal communication about discharging this topic skills that cements the relationship with you today?” patients and that ultimately promotes their healing. 9. This is similar Approving or Disapproving. The previous section pointed out some of to minimizing or agreeing. The patient the bad habits of conversation. It is now perceives a value system that puts the time to learn new effective methods of com- nurse in the position of the expert, and, munication. These will feel awkward at first, in many ways, the nurse is. That puts a but with practice and trust, they will help big responsibility on a nurse’s shoulders, improve the quality of interactions not only however, and that responsibility includes with patients, but in most interpersonal being supportive without being judg- communication as well. They are “tricks of mental or portraying a personal idea of the trade” that may be as small as a one-word what is right or wrong, good or bad. change in the way a sentence or request is The nurse is in a partnership of sorts with presented, but they get a lot of mileage in the patient. The nurse collaborates with the the way people respond. 2993_Ch02_015-032 14/01/14 5:16 PM Page 24

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Neeb’s The listed communication methods in different ways. The American vocabu- ■ Tip will not all work for all people in lary pronounces many words the same all circumstances, but if you use but spells them differently. them faithfully you will see improve- English is a very complex language to ments in the way you relate to learn. Some people use terms very literally. your patients and in the way they Nursing is a profession that is filled with respond to you. inference and nuance; it is highly affective. Because of that, it is very important to clarify terms with patients and other workers. Nurses 1. Reflecting, repeating, parroting. This tech- must be sure that the terms they choose are nique seems to be the easiest to learn and correct and mean the same thing to all parties therefore is used the most often. Parrots involved in the interaction. The technique is are often trained to repeat words or easy to learn: Simply asking “When you say phrases, such as “Polly want a cracker?” ‘I can’t do that,’ what do you mean?” is one way of clarifying a statement. The patient Reflecting, repeating, and parroting refer may mean “I am not physically able” or “I am to this technique because that is what the not morally able” or “I do not know how to nurse does: He or she picks a word or phrase do that” or any number of things that the that seems to be a key word or idea in what word can’t may mean. If the nurse does not the patient is trying to communicate. It some- try to clarify that simple word, she could times involves a degree of guessing on the part incorrectly infer the patient’s level of ability of the nurse to check out the perceived mes- or cooperation. sage. For instance, if the patient says, “I want to get out of here; everyone is against me,” the EXAMPLE EFFECT ON PATIENT nurse has several options for checking the “When you say • Encourages patient to main concern of the patient. The nurse will ‘tired,’ do you restate the comment repeat a word or phrase from the patient’s mean it in a • Improves chances that statement to reflect, or parrot, whatever is physical way the message sent is the perceived to be the main concern. The nurse or an emotional message received could say “Everyone?” or “Against you?” to way?” try to encourage the patient to expand on 3. These are the these ideas. Caution: Because this technique Open-ended questions. might seem obvious to the patient, use par- essence of successful nurse-patient roting sparingly. It will not take the patient communication. They are also among too many times of hearing his or her words the hardest techniques to learn, because repeated before perhaps suggesting that the people are constantly bombarded with nurse look into having a good audiometric incorrect usage in social interaction and examination! in the world of talk shows and news reporters. EXAMPLE EFFECT ON PATIENT One of the goals of helping communica- Patient: “I’m so • Encourages exploring tion is to get the patient to participate, so it is tired of all of this.” the meaning of the important that the nurse present questions in Nurse: “Tired?” statement a way that will encourage the patient to pro- • Caution: Use sparingly, vide information without the nurse’s sounding can be irritating if persistent or intrusive. Such a perception by overused. the patient will be a major interference in 2. Clarifying terms. People live and work future attempts at communication. The nurse in a global society. Nurses interact with needs to be able to detect cues provided by the many different people as patients and patient when they would like to discontinue coworkers. Nurses sometimes use words communication. 2993_Ch02_015-032 14/01/14 5:16 PM Page 25

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In some instances, “yes” or “no” may be all These two examples show ways to be the nurse needs to know or all that the patient assertive, direct, and self-responsible while is capable of responding at the time. In those still maintaining politeness and allowing instances, closed-ended questions may be the patient to have some control over his or used until the patient is able to provide more her care. information. Otherwise, open-ended ques- EXAMPLE EFFECT ON PATIENT tions will get more productive results. “Mrs. Smith, • States purpose for the EXAMPLE EFFECT ON PATIENT I need to ask you interaction “How are you • Discourages “yes” or a few questions, • Keeps speaker assertive feeling today?” “no” answers please.” and self-responsible “What can • Encourages patient to “I want to switch I do to help, express self in his or shifts with Mary Mr. Jones?” her own terms next Tuesday, please.” Using open-ended questions can be helpful 5. Identifying thoughts and feelings. This is in understanding the patient’s pain level. Ask- another difficult technique to master. ing the patient “Are you in Pain?” (closed- Because words, which convey thoughts ended question) may not bring an accurate and feelings, are used incorrectly more picture. Depending on the patient’s culture or frequently than not, it is hard to rein- religious preference, or both, “pain” may or force proper usage. The rule is simple: may not be acceptable. The patient may A feeling is an emotion. A “feeling state- answer “yes” or “no” on the basis of those be- ment” must identify an emotion that liefs. If Ms. Green has a chemical dependency one is experiencing or is trying to explore that has not been shared with you, she may with a patient. For example, “I feel say “yes” to get the benefit of the pain med- proud that I earned this promotion” or ication. Pain is a very individual experience “I feel frightened to walk alone at night.” and is subjective. What one person considers to be extreme pain, another might brush off A thought is an opinion, idea, or fact that as a minor irritation. The closed-ended nature one wishes to express. “I think I deserve this of this question does not require the patient promotion” and “I think security needs to be to provide useful, measurable information improved in the parking area” are examples of that allows the nurse to be helpful or thera- “thinking statements.” peutic. A more helpful form of this question “I feel security needs to be improved in the would be in an open-ended format, such as, parking area” and “I feel the patient needs a “Ms. Green, on a scale of 0 to 10, how do you different pain medication” are incorrect uses rate your pain?” or “Ms. Green, please tell me of the word “feel.” There is no emotion iden- about your pain.” tified in these statements. “Feeling” is certainly implied, but implied thoughts and feelings 4. Asking for what you need or want. This need to be clarified to avoid mistaken conclu- relates to the discussion on assertive versions. In both of these statements “feel” should sus aggressive communication. Nurses be replaced with “think” for correct usage. can ask for what is needed and wanted Using words pertaining to thought and from patients and coworkers and still feeling correctly will minimize the amount of maintain a pleasant, professional tone time the nurse must spend clarifying and will of voice. This technique requires the maximize the quality of the interaction. In the user to start the sentence with the words mental health specialty, it becomes even more “I want” or “I need.” Taking the direct important for the nurse to use such terms approach with people is usually the safest appropriately to help the patient identify way to be sure that the receiver gets the and label his or her emotions and thoughts to message the sender intended to send. facilitate therapy. 2993_Ch02_015-032 14/01/14 5:16 PM Page 26

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EXAMPLE EFFECT ON PATIENT your pet when you think you’d like to talk “I feel angry • Helps the patient to about it.” when you are identify and label Socially, chances are that the nurse might not honest thoughts and emotions take the “sympathy” option, which would be with me.” • May give insight to appropriate with people who are not patients. “I think honesty underlying concerns Patients need the nurse to be sensitive but still is important in or complications of be the helper. The “empathy” option is more all relationships.” healing appropriate in most therapeutic situations. EXAMPLE EFFECT ON PATIENT 6. Using empathy. Empathy is also tied into feelings. There is a big difference between “It must feel • Acknowledges patient’s sympathy and empathy. Sympathy is used very demeaning feelings socially when people wish to share emo- when others are • Keeps nurse in position of tional experiences. It is not a therapeutic dishonest.” control and helpfulness technique because it involves experienc- “I can only ing the emotion. Empathy involves iden- imagine how tifying emotions without experiencing difficult this the emotion. Nurses need to use empathy has been.” with patients. They need to be able to 7. Silence. Silence serves many functions identify the emotion and relate to it while in communication, yet many people are keeping the focus on the patient’s needs. very uncomfortable with it. American so- Nurses must help patients deal with their ciety seems to value conversation. People feelings and still maintain professional use vocabulary and the ability to talk control of the situation; the nurse needs about a variety of topics as a measure of to remain the helper. intelligence and social grace. Watch what Sympathy often allows both persons to be- happens at a social gathering or in the come emotionally invested in the moment. break room when a short silence occurs. The focus is shared by both people. In thera- Often, people fidget nervously or make peutic relationships, the focus must remain “small talk” just to break the silence. on the patient. Silence, as a therapeutic technique of com- Consider the following situation: A nurse munication, serves two main purposes: First, notices a patient crying in the lounge. The it allows the nurse and the patient a short nurse wants to help, so he approaches the time to collect their thoughts and, second, it patient, sits down, and offers his assistance. shows patience and acceptance on the part of The patient tells the nurse of the news that the nurse. Sitting quietly for a period of time, that she just found out that her pet died. The usually 2 to 3 minutes, and maintaining an pet had been her “family” since her divorce. open body posture sends the message that the The pet had always “been there for her,” and nurse is willing to wait if the patient has more the pet has died while she has been in the to say or that the nurse accepts the fact that hospital and could not be there. The nurse’s the interaction may be over for the present. response options are: Silence can be just as powerful and effective Sympathy: Remembering his own favorite as any verbal interaction. pet who died, the nurse says, “I understand Caution: Do not allow the silence to go on your feelings; my pet died suddenly, too.” too long. If nothing has been said by either OR party within 2 to 3 minutes, it is wise to sug- Empathy: Remembering his own pet gest to the patient that it might be time for a who died, the nurse allows himself to feel rest. Then the nurse should take cues from the that pain and then says, “I am so sorry. It patient’s response. Perhaps the conversation must be very painful to lose something will begin again, or maybe the patient will be you feel so close to. I’d like to hear about grateful for the suggestion to rest. Either way, 2993_Ch02_015-032 14/01/14 5:16 PM Page 27

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the nurse can let the patient know that he or Using this combination of offering assis- she is there if the patient wants to talk again tance and asking an open-ended question at another time. serves several purposes: The nurse has maintained rapport and has gotten Mrs. Brown to EXAMPLE EFFECT ON PATIENT divulge her level of prior knowledge, and the Sit quietly near • Shows the nurse is nurse has let Mrs. Brown know that the nurse the patient comfortable with presumes she has had a conversation with the whatever the patient physician. What if Mrs. Brown hesitates or says and willing to tells the nurse outright that the physician has hear more not been in yet? The nurse should use the • Allows both to collect techniques of stating his or her needs and their thoughts using empathy, and tell the patient very honestly, “Mrs. Brown, I can sense your frustra- Neeb’s Silence demonstrates that the nurse tion, but I cannot legally (or ethically) give ■ Tip is willing to hear more. you that information until you and your physician have discussed it first. I’ll be happy to call your physician to let her know that you 8. This is very different Giving information. wish to see her as soon as possible. After you from the communication block of giving have talked, I’ll be happy to answer any ques- advice. Giving information relates to the tions you may have.” helping relationship because it involves a form of teaching. EXAMPLE EFFECT ON PATIENT As mentioned earlier, physicians are usu- “Mrs. Brown, • Increases rapport ally with their patients for very short periods I would be glad • Eases patient’s anxiety of time, whereas nurses are usually with the to explain this • Honestly confirms that same patients for an 8–12 hour shift. It is very diagnosis to you. the physician has given natural for nurses and patients to have more Tell me what the prior information quality time for talking. This is one reason doctor has said, • Suggests collaboration patient teaching is becoming a bigger part of and I’ll clarify it a nurse’s responsibility in all levels of nursing. for you any way Nurses provide information in all phases I can.” of hospitalization, from preoperative teaching 9. Using general leads. This is a method of to discharge planning. It involves using pam- encouraging the person to continue phlets, videos, resource manuals, or other speaking. It lets the speaker know that resource persons. one is listening and interested in hearing more. The technique is fairly simple: Neeb’s Most state nurse practice acts still It involves verbal and usually nonverbal ■ Tip place the stipulation that the nurse communication. Examples of general may not legally give information to leads are saying “Yes?” while maybe rais- the patient before the physician has ing the eyes, “Go on” while maintaining given the initial information. This eye contact and possibly nodding the means that nurses may not give lab head in an affirmative motion, or just reports, read diagnostic information, saying “and then?” if the person pauses talk about possible treatments, and in the middle of a statement or concern. so forth until these have first been discussed between physician and EXAMPLE EFFECT ON PATIENT patient. How do nurses know this “Go on” while • Feels valued and has occurred? Nurses use therapeu- nodding head listened to tic techniques that allow them to and maintaining ask questions that get results. eye contact 2993_Ch02_015-032 14/01/14 5:16 PM Page 28

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10. Stating implied thoughts and feelings. speech-read (also called lip-read)? Is he or she This takes a combination of skills. It reliant on a hearing aid? What is the emo- requires using some guessing (as in tional attitude of the patient? reflecting), using empathy, and making Communicating can be very frustrating an observation about a behavior or for hearing-impaired patients as well as for condition the nurse sees in the patient. the nurse. Hearing-impaired patients often use sign language, but most “hearing” people This technique is helpful in initiating do not know sign language. Sometimes writ- conversation that might be difficult to start ing with pencil and paper is effective, but it with other techniques. It is hard to deny that is slow. Speech reading is helpful to some something is not right when someone identi- hearing-impaired people, but it is not always fies a specific behavior or action that supports accurate. Because many words that look the the suggestion that something is different same are in fact very different in meaning, about the patient. Nurses are assessing their and because not all speaking people say patient’s physical and emotional states all words the same way (because of dialect or the time. different primary language from that of the When a patient is reluctant to share this hearing-impaired person), speech reading can situation, the nurse can preface the question be misleading at best. with an observation and then follow with an educated guess at the emotion that is being experienced. Tool Box | This Web site can be used to access American Sign Language vocabulary: EXAMPLE EFFECT ON PATIENT http://commtechlab.msu.edu/sites/aslweb/ “Ms. Johnson, • Lets the patient know browser.htm you’re not smiling you are paying attention today like you to him or her usually do. I sense • Identifies a specific People Who Are Visually something is behavior or change in Impaired bothering you. behavior, which lowers Adaptive devices such as audio books, Braille- How can I help?” the chance of denying it prepared computers, and seeing-eye dogs can • Patient hears that the be extremely helpful. The type of adaptive nurse cares and wishes device depends on the type and severity of the to help impairment. Technology has provided some methods, such as the ability to change the ■ Adaptive Communication font size on a computer up to 500%. Visually impaired people often have heightened senses Techniques of hearing, touch. Some populations of people, such as those mentioned in the previous section, require Neeb’s Do not assume that visually impaired special considerations when nurses are com- ■ Tip people may be hearing impaired, municating with them. These are some ways too. It usually is not necessary to talk of facilitating communication with people slower or louder to a person with a who live with certain disabilities or who have visual impairment. varied amounts of ability. People Who Have People Who Are Hearing- Laryngectomies Impaired Technology has developed several different When communicating with a patient who is aids that amplify the vibrations of speech. For hearing-impaired, it is important to know the some patients with laryngectomies, placing extent of the impairment. Does the person an amplifier over the area of the larynx and 2993_Ch02_015-032 14/01/14 5:16 PM Page 29

CHAPTER 2 | Basics of Communication 29

talking will produce a buzzing sound that for each patient. The physician and speech replicates their former voice. It is a monotone pathologist or therapist are excellent resource sound, but it greatly improves the ability of people to help in deciding what type of these patients to communicate in a more adaptive technique will be the most effec- natural manner. Not everyone can use these tive. The nurse’s documentation of the devices, however. Some people need to rely responses of a patient to the various tech- on communication boards and pictures to niques will also help in these decisions. communicate. Some people make use of new Techniques range from changing the rate computer-assisted devices. The patient will be or pitch of speech to using objects, pictures, in close contact with a speech therapist. spelling boards, or computerized equipment Nurses need to be involved with the therapist if the patient has access to them (Fig. 2-3). as well, so that the patient has continuity of However, nurses should not answer for the therapy and good evaluation of the ability to patient. Finishing sentences or trying to play use the devices. The patient’s plan of care guessing games with people who have these needs to identify how the speech therapist types of disorders is usually not in the best in- treatment plan can continue when the patient terest of the patient. It may take a longer time is discharged from therapy. The goal is to re- for these patients to process the information store the person to his or her surgical maximal ability of speech. It can be a frightening and frustrating time for the patient and the health- care team, but the rewards are great when ABCDEF speech, at whatever level, begins to return. GH I JKL People With Language Differences MNOPQR Honesty is the best policy here. This discus- S T U VWX sion comes up in several sections of this text, but it is much better to apologize and admit YZ End of Period. when one is not receiving the sender’s mes- word sage. Serious mistakes can be made when one 123456 assumes the meaning of the message. It is also important to remember that communicating 7890YES NO is often a highly cultural activity; people are not always comfortable asking for correction or clariﬁcation from someone of a diﬀerent gender, age, or social or professional status. Using assertive, honest communication skills will usually get positive results.

Neeb’s As a caregiver, the nurse needs to ■ Tip practice active listening. When not positive about the meaning of a message, ask!

People Who Have Aphasic/ Dysphasic Disorders This is another area that oﬀers many options for adaptive techniques. Nurses must be aware Figure 2-3 Picture board for patients with of the type and degree of aphasia/dysphasia aphasia. 2993_Ch02_015-032 14/01/14 5:16 PM Page 30

30 UNIT 1 | Foundations for Mental Health Nursing

and get the answer out. Be patient. When the 5. Nurses need to be aware of what blocks patient is getting frustrated or is truly unable therapeutic communication. to respond properly, it may be because the words the nurse used were unfamiliar or 6. Nurses need to be aware what techniques maybe too much time has passed and the pa- to use to encourage eﬀective, helping tient has forgotten the question. Gentle hints communication with patients. or rephrasing the question may be enough to 7. Special techniques are used when com- help the patient. It may be just one word that municating with populations who have makes the diﬀerence between the patient’s special communication needs. being successful or not. Communication in all forms is essential to the work of a nurse. Taking the time to learn and use these techniques can make relation- REFERENCES ships with patients and coworkers very pleas- Grinder, J., and Bandler, R. Trance Formations— ant and rewarding. Neuro-Linguistic Programming and the Struc- ture of Hypnosis, Moab, Utah: Real People Press, 1981. ■ ■ ■ Key Concepts Nightingale, F. (1969). Notes on Nursing: What It Is, and What It Is Not. New York: Dover 1. Humans cannot not communicate. Inter- Publications. personal communication is a complex Townsend, M.C. (2012) Psychiatric Mental process. Health Nursing. 7th ed. Philadelphia: F.A. Davis. 2. Therapeutic or helping communication is a language that is learned and shared WEB SITES by nurses. It is a purposeful skill that Communication requires practice. http://www.natcom.org/discipline 3. People communicate verbally and non- Therapeutic Communication http://nursingplanet.com/pn/therapeutic_communi- verbally. Nonverbal communication cation.html sends a stronger message than verbal Laryngectomy Speech communication. http://emedicine.medscape.com/article/883689- 4. Communication can be assertive or overview Hard of Hearing aggressive. Assertive statements are the www.ada.gov/hospcombrscr.pdf more helpful of the two; they start with Neurolinguistic Programming the word “I.” Aggressive statements are http://infed.org/mobi/neuro-linguistic-programming- designed to place responsibility on learning-and-education-an-introduction/ another person. They start with the word “you.” 2993_Ch02_015-032 14/01/14 5:16 PM Page 31

CHAPTER 2 | Basics of Communication 31 Test Questions Multiple Choice Questions 1. Which of the following is an example of a 6. Your patient has refused all of your therapeutic, open-ended question? attempts to care for him. You say: a. “Why did you do that, Mrs. Jones?” a. “I’d like to help you; what can I do?” b. “How can I help you, Mr. Thompson?” b. “Why don’t you like me?” c. “Can I help you, Ms. Greene?” c. “What is the matter with you?” d. “Please, can I ask you a question, Mark?” d. “You must do this; physician’s orders!” 2. The purpose of “therapeutic communica- 7. Your patient is Jewish and refuses to eat tion” is to: non-kosher food. You say: a. Develop a friendly, social relationship a. “I will ask the dietitian to come and with the patient. talk with you.” b. Develop a parental, authoritarian b. “The dietitian will come to see you.” relationship with the patient. c. “It’s the best we can do. You need c. Develop a helping, purposeful relation- to eat.” ship with the patient. d. “You’re right. The hospital food does d. Develop a cool, businesslike relation- leave much to be desired!” ship with the patient. 8. Your patient is commenting that the 3. You observe a patient in the family physician has not been in to visit for lounge. She appears to be talking to her- two days. You say: self. You want to find out what is wrong. a. “I hate it when that happens!” Your best approach to her might be: b. “What do you need to know?” a. “Who are you talking to?” c. “Well, he is very busy!” b. “Please stop talking. You are disturbing d. “You feel ignored by your physician?” the other people.” 9. Your patient, who is usually very c. “I saw your lips moving. Can you tell talkative, does not respond to you me what you are talking about?” when you enter the room. You say: d. “Why are you talking to yourself?” a. “Ms. Smith, you are so quiet this 4. Your patient asks you the results of his afternoon. Is something bothering blood tests. You respond: you?” a. “They are all negative.” b. “Ms. Smith, is something bothering b. “Why do you want to know?” you?” c. “I think you should wait until your c. “Can I help you?” physician comes in.” d. “Why are you so quiet this d. “I am not able to tell you right now, afternoon?” but I will call your physician and have 10. Ms. Smith responds to your question her stop in to explain them to you.” (see #9), “I feel like nobody cares.” You 5. Your patient is a single parent who has just respond: been diagnosed with terminal cancer. She is a. “Why do you say that?” concerned about returning to work and asks b. “Like nobody cares? Please try to many questions. Finally, the patient says, describe the emotion you are truly “What do you think I should do?” You say: ‘feeling.’” a. “I think you should just stay busy.” c. “Ms. Smith, you’re wrong about that. b. “I wouldn’t worry about it.” Of course we care.” c. “What are your thoughts about d. “Ms. Smith, maybe the doctor can returning to work?” change the dosage of your medica- d. “Oh, you’ll be just fine. There are lots tion. You’ll feel better.” of people worse off than you.” 2993_Ch02_015-032 14/01/14 5:16 PM Page 32 2993_Ch03_033-050 14/01/14 5:17 PM Page 33

CHAPTER 3 Ethics and Law

Learning Objectives Key Terms 1. Define professionalism. • Accountability 2. Demonstrate understanding of the Nurse Practice Act. • Advocacy 3. State the importance of honesty and accuracy in verbal • Civil law reporting and written documentation. • Commitment 4. State the importance of confidentiality. • Confidentiality 5. Define HIPAA and its role in health-care delivery. • Culture 6. Define the Joint Commission and its role in health-care • Culture of nurses delivery. • Doctrine of privileged 7. Explain the Good Samaritan Act. information 8. Explain involuntary commitment. • Ethics 9. Define patient advocacy. • Health Insurance Portability and Accountability Act (HIPAA) • Intentional • Patient Bill of Rights • Professional • Proxemics • Responsibility • Tort • Unintentional

■ Professionalism are considered professional nurses; the licensed practical nurse (LPN) or licensed Professional is a word with many different vocational nurse (LVN) is considered a non- meanings. Merriam-Webster Online defines professional. In areas with union represen- professional as an adjective meaning “charac- tation in nursing, the two levels usually terized by or conforming to the technical or belong to separate organizations. Some ethical standards of a profession.” It may be a nursing groups believe that only RNs who term that requires a nurse to rely on the ther- are baccalaureate-prepared and beyond are apeutic communication skill of clarifying. considered professional. Nursing is a profession. Nurses care for Nevertheless, all nurses are expected to be- patients and perform designated services have in a professional manner; they are to per- for a salary. As a profession, however, the form at the highest level of preparation they different levels of nursing disagree as to have achieved. Nurses are to abide by federal, who is a “professional nurse.” All nurses restate, and local guidelines. Another aspect ceive pay for their work, yet it is commonly of professionalism is the duty to stay in- accepted that only registered nurses (RNs) formed in the nursing field. Participating

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34 UNIT 1 | Foundations for Mental Health Nursing in professional organizations and continuing Standards of Care education programs is important. The National Federation of Licensed Practical Professional behavior is maintained despite Nurses (NFLPN) has adopted Standards any personal problems a nurse is experienc- of Nursing Practice for LPNs/LVNs (see ing. A nurse’s personal problems are to be Appendix D). These standards include a code handled outside of the work environment. of conduct. The American Nurses Association Nurses are expected to be respectful of the be- (ANA) has written a variety of standards of liefs of their patients and coworkers and not care covering topics important to the nursing to force their personal beliefs on others at profession. Some of these are relevant to work. Nurses are expected to perform hon- LVNs/LPNs. The purpose of the ANA is estly. They are expected to report any infrac- fostering high standards of nursing practice, tions they notice in other nurses. In short, promoting the rights of nurses in the work- nurses are expected to behave and perform in place, projecting a positive and realistic view a manner that promotes the pride and repu- of nursing, and lobbying Congress and regu- tation of the nursing profession, and not as a latory agencies on health-care issues affecting detriment to that profession. nurses and the public. A set of Standards of Psychiatric–Mental Health Clinical Nursing ■ ■ ■ Critical Thinking Question Practice, written by the American Psychiatric You are an LPN or an LVN on the surgical unit of Nurses Association (APNA), is available at the county hospital. In shift report, you are told that you will be getting a new postoperative patient the APNA Web site as well as ANA Web site. within the hour. When the patient arrives, a police The revised standards are to be published in officer is in attendance. The officer tells you that 2014. this patient is a suspect in a homicide. The officer instructs you to report anything the patient says to you. When you begin your postoperative vital Tool Box | ANA materials can be accessed at: signs, the patient says, “Nurse, I shot the guy and he www.nursingworld.org deserved it. I’ll do it again if I have to. I can tell you, Standards of Psychiatric–Mental Health because you can’t tell anyone!” How will you handle Clinical Nursing Practice draft Web site: this situation? www.apna.org/fi les/public/12-11-20-P M H _ N ursing_ Scope_ and_ Standards_ for_ P ublic_ Comment.pdf ■ Ethics Part of being a professional is to conduct oneself in an appropriate and ethical man- Nurse Practice Act ner. Nurses deal with ethical issues on a daily Nurses must be aware of their state’s Nurse basis, so it is important to consider one’s Practice Act and perform within its parame- own values and professional ethics. The ters. The Nurse Practice Act dictates the ac- Codes of Ethics of the American Nurses ceptable scope of nursing practice for the Association and the National Federation different levels of nursing. When a nurse is of Licensed Practical Nurses (Appendix D) questioning whether or not to perform a cer- have established guidelines for the nursing tain skill or perhaps is accused of wrongdoing, profession. These guidelines provide a frame- the Nurse Practice Act typically is consulted work for action rather than give answers to to find out if that nurse is performing at the questions. accepted level of preparation. For example, if a state does not allow the LPN/LVN to Tool Box | The Code of Ethics from supervise patient care yet an LPN or LVN is the American Nurses Association can be the only licensed staff on duty on the night reviewed at: shift, the Nurse Practice Act for that state www.nursingworld.org/codeofethics may have been ignored, and that nurse could be held liable for damages in a court of law. 2993_Ch03_033-050 14/01/14 5:17 PM Page 35

CHAPTER 3 | Ethics and Law 35

This can be an ethical dilemma as well. It series of check marks and arrows to indicate may be the facility’s interpretation that it is assessments of all systems have been made. permissible to allow that LPN/LVN to func- The nurse then initials the check marks and tion as supervisor if an RN is on call. This arrows and uses a full signature at the bottom may or may not be the interpretation of the of the page. Only situations outside of the es- particular state. The Board of Nursing in a tablished normal parameters are mentioned particular state can give the answer. Any nurse in some sort of nurse’s note. Although this has the right and responsibility to make that type of charting saves time, it is sometimes phone call. challenged legally because it is not always enough documentation. Yet flow sheet charting is gaining popularity in documenting ■ ■ ■ Classroom Activity health care. • In Appendix E, review NFLPN Nursing Practice Many facilities use flow-sheet charting, Standards Legal/Ethical Status. Write a paragraph on how each of these standards relates to a prac- and an increasing number are using electronic tical/vocational nurse. programs designed for patient charting that are specific for a facility. “Epic” is one of the electronic programs used by many facilities.

Accuracy Neeb’s The nurse needs to be proficient in The ultimate goal of the helping person in ■ Tip reading, writing, and spelling skills. health care is to “do no harm.” Safety for their Nursing programs use a system patients and themselves must be in nurses’ including testing to determine if thoughts at all times. nursing candidates are proficient Harm can be described as intentional or in reading, writing, and math prior unintentional and falls under the category to being admitted into a program of a tort, which relates to civil law. Civil (e.g., HESI’s, TEAS V). Not only might laws protect patients/persons and their gaps in reading, writing, and spell- property. ing be a source of extreme embar- A nurse’s best defense is the quality of ver- rassment to the nurse, but they are bal and written communication. In her book, also unacceptable as professional, Legal, Ethical, and Political Issues in Nursing, safe nursing practice. It is important Tonia Aiken indicates that spelling errors are to note as well that this is a much crucial in liability cases, as they reflect on a more common problem in the nurse’s general ability to care for patients. United States than one might think Legally, the general assumption is “if it is not and that it is not just people from charted, it has not been done.” Some situa- other countries who experience this tions can impede nurses’ efforts at accuracy in difficulty. Basic computer skills are charting. First of all, nurses are busy. Patient also increasingly required. care is the primary focus of a nurse’s workday. Many times, it seems that the shift is over be- It is imperative that the nurse take (sub- fore it starts. Charting may be scaled down to junctive) as much time as necessary to carry a minimum, especially if the employer does out complete, accurate documentation on not pay for overtime. As accurate charting is each patient. A nurse’s competency to practice part of nursing care, this became the rationale nursing can be questioned if for some reason for developing different types of charting. the documentation is subpoenaed in a court Some facilities use a form of charting that case and spelling and grammar are of poor may be called “charting by exception.” This quality according to American standards. type of documentation is based on flow-sheet All agencies have an established method charting. Normal values, the guidelines for for verbal reporting. It may be a taped shift which are established at the facility, are writ- report, a grand rounds type of report, or a ten on the chart form, and the nurse uses a one-on-one report with the patient’s care 2993_Ch03_033-050 14/01/14 5:17 PM Page 36

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plan. Again, it is important for the nurse to what he or she wants to hear.” Honesty is a spend as much time as needed to get the mes- concept that can be highly cultural. sage from his or her day’s work to the receiver The professional choice is always to tell the for the oncoming shift. Be thorough but as truth. It may be painful, frightening, or embar- concise as possible. It is usually standard pro- rassing to admit personal conflicts or errors or cedure to discuss vital signs, physical assess- omissions in patient care, but nurses will avoid ments, any visits from physicians or visitors, further potential harm to their patient as well as new orders, responses to medications and to their professional reputation by admitting to treatments, and any change in condition. mistakes and taking the appropriate corrective An area that is sometimes forgotten is the measures. Nurses are human. Despite their mental, emotional, and behavioral status of best efforts and multiple medication checks, the patient, especially on a medical surgical nurses make mistakes. Recognizing them, ad- unit. Usually, the patient’s mental, emotional, mitting them, and taking corrective measures to and behavioral status is mentioned only if ensure the patient’s safety are the signs of sound something seems inappropriate. Physical heal- judgment and professional nursing behavior. ing is to a large extent a result of attitude and Honesty can also mean the difference between emotional condition; therefore, nurses should keeping and losing your nursing license. include the patient’s psychological status in their verbal report. A nurse should always Impaired Nurses check with the incoming nurse to be sure that Inappropriate use and misuse of mind-altering there are no further questions and inform that chemicals such as alcohol or prescription and nurse of anything he may not have completed. nonprescription drugs can render a nurse legally unsafe. Continuing to practice nursing while using these chemicals displays unpro- ■ ■ ■ Critical Thinking Question fessional behavior and poor judgment. A You are the nurse who is supervising care on the shift 2100 to 0700. Another nurse who works this nurse in this situation who is fearful of losing shift routinely has poor-quality charting. Nothing his or her license or unable to seek help may is hidden or omitted from the chart, but it contains consider inaccurate charting, omission of many misspelled words and many grammatical certain charting, or blatant lying about a sit- errors. You decide to “keep the peace” and say uation as a way to remain employed. The nothing because you get along well with this nurse and the patients like the individual. Patient patient’s safety is not the nurse’s primary con- X falls out of bed on your shift, and the family sues cern when this happens. Most states have for negligence. The other nurse is found incompe- developed programs to assist impaired nurses tent by virtue of written documentation that the as a way to protect the public. According to lawyers cannot decipher. To your dismay, you are the Recovery and Monitoring Program also implicated as the supervising nurse on that shift because you did nothing to improve the (RAMP) in New Jersey, if a health profes- quality of this nurse’s writing skills. What are your sional is impaired and working with patients, feelings? What might this mean for you? What an occupational hazard eventually will occur, will your defense be to the court? How will you possibly causing an injury or even a death. handle this differently in the future?

■ ■ ■ Critical Thinking Question Honesty You are working on an Oncology unit, and a nurse who has been considered reliable and account- It may seem insulting to discuss honesty and able by all of his/her coworkers in the past is now integrity with nursing students. After all, suspected of some type of impairment due to re- honesty, or “veracity” as it is also called, is one cent changes in behavior. This nurse frequently of the qualities of professionalism. The dis- offers to give your patients pain medicines if you are busy. The nurse’s coworkers have noted that cussion is necessary, though, because honesty immediately before or after giving a narcotic, the means different things to different people. It nurse usually has to use the bathroom. How may mean “surviving” or “helping someone would you approach this situation? less able than myself” or “telling the physician 2993_Ch03_033-050 14/01/14 5:17 PM Page 37

CHAPTER 3 | Ethics and Law 37 Culture of Nurses of professionalism and basic tenets of communication. A commonly accepted definition of culture The field of study called proxemics is includes nonphysical traits, rituals, values, also cultural. Proxemics concerns space, and traditions that are handed down from time, and waiting, which are all influenced generation to generation. Nursing is an occu- by one’s culture. If you have ever traveled pation that passes its professional values, rit- between the northern and southern tier of uals, and traditions from generation to the United States, you may have noticed generation (Fig. 3-1). The affective, or attitu- a cultural difference in time and waiting. dinal, components of nursing are behaviors People in the northern states tend to be that nurses typically learn from role modeling much more rushed. They may watch the other nurses. This concept spawned the term clock in restaurants, in classrooms, and culture of nurses (Neeb, 1994). while on hold on the telephone. In the As mentioned earlier, nurses live and southern states, life is a bit slower-paced. work in a global community. Nurses were That hamburger does not have to be served born and raised in many different places. in 2 minutes; people just wait and relax. They have different ideas about politics and This is not an issue of right or wrong, good social issues. However, when nurses come or bad. It is an issue of differences in the together as a profession, they meld these way people are acculturated. ideas into consistent behaviors to provide For nurses from countries in which time- their patients with the best possible care. liness is not an issue, punching a time clock Nurses may need to give up some personal or serving a medication within the allotted ideas while working to make the whole of time may not be a priority. As nurses know, nursing greater than the sum of its parts. however, this sort of timeliness is a very im- This means that skills such as spelling and portant part of nursing culture. A patient who grammar that may be “correct” or actually is in pain and asks for a pain medication considered unimportant in personal situa- expects the nurse to be prompt with it. If tions are not acceptable for practicing the nurse replies, “I’ll be there in a minute,” the nursing in the United States (Aiken, 2004). patient might hear the word “minute” and This is not an issue of labeling a nurse’s take it quite literally. After all, the patient is personal or cultural belief system as right, the one in need. It may actually have taken wrong, good, or bad. Rather, it means the nurse 15 minutes to return with the med- that nurses must remember the components ication, and in that time he or she may have answered two more call signals, helped someone to the bathroom, and taken a physician’s order. However, that patient who is waiting for the medication knows only that the nurse did not return in a minute. Depending on that patient’s culture, he may have used the call signal immediately after 1 minute passed or may feel it is grossly disrespectful to ask again and thus suffer silently. Space and distance also constitute a big part of nursing culture. Nurses must touch patients in order to do their jobs. Nurses Figure 3-1 The culture of nursing. Through role modeling, professional values, rituals, make full body assessments, catheterize, give and traditions are passed from one generation suppositories, and perform prenatal and post- of nurses to the next. (From Sorrell and Redmond natal checks. Male and female nurses work on (2007): Community-Based Nursing Practice: male and female patients. In a way, nurses Learning Through Students’ Stories. Philadelphia: become desensitized to these functions, as F.A. Davis Company, with permission.) they become a routine part of their jobs. 2993_Ch03_033-050 14/01/14 5:17 PM Page 38

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Some patients are very timid and modest. The doctrine of privileged information In some cultures, strangers may not touch is a bond between patient and physician. strangers in certain ways, and these individuals Under this doctrine, the physician has the may prefer to have family members perform right to refuse to answer certain questions those tasks. Some nurses feel uncomfortable (e.g., in a court of law) and can cite “privi- waking postoperative patients for their routine leged physician-patient information.” Nurses vital signs check because in their culture it is are usually not included in this relationship. not proper to awaken sick people; it is proper If information is requested of nurses in a legal to let them sleep and not disturb them. Nurses situation, they must answer as truthfully as need to be aware of four types of spaces: they can. How does one maintain honesty public, social, personal, and intimate. Nurses and confidentiality at the same time? First are often in intimate space in their practice, and foremost, a nurse should communicate especially when giving direct care. honestly to the patient that he or she cannot Proxemics is a very complex field of study; make promises. When the nurse senses that this discussion has touched only on some the patient is revealing information that is basics. It is important for nurses to under- potentially legally sensitive, it is a good idea stand, however, that the concepts of space, to tell the patient right away that nurses are time, and waiting are highly cultural in their not protected by the doctrine of privileged in- interpretation. formation. The nurse should tell the patient that he or she can call the physician, but if the patient still chooses to share such informa- Tool Box | 2011 A guide to cross-cultural etiquette and understanding can be found at tion, a good technique is to tell the patient www.culturecrossing.net/ the information will have to be shared with a supervisor or others involved in the patient’s treatment. The 1976 case of Tarasoff vs. Nurses must work together for the better- Regents of the University of California is the ment of patient care. When in doubt, ask. standard for the doctrine of privileged infor- Learn from each other. There is no better way mation. The doctrine also protects intended for personal and professional enrichment. victims of patients who may be hospitalized or incarcerated. A nurse should inform the ■ Confidentiality patient that only those parts of the conversation that are directly related to his or her care Confidentiality is so important that it is will be shared, but that if information is singled out as one of the federal and state requested by a legal representative, the nurse patient rights. Confidential means (1): marked will be required to answer. by intimacy or willingness to confide; (2): private, secret (confidential information); (3): en- Neeb’s When you sense that the patient trusted with confidences, and (4): containing ■ Tip is telling you information that is information whose unauthorized disclosure potentially legally sensitive, it is a could be prejudicial to the national interest good idea to tell the patient right (Merriam-Webster online). away that you as a nurse are not Trusting a friend with a secret only to hear protected by the Doctrine of Privi- that secret had been repeated to someone else leged Information. is a break in confidentiality. In a manner of speaking, a patient’s diagnosis and plan of Temptations are common, especially for care are a secret to everyone but the patient the student nurse. It is fun and exciting to and the health-care team; this information is learn new information and to see your skills very private and must be kept that way. But making a difference in someone’s recovery. It what happens when the patient shares some- is easy to start chatting about your experi- thing that must be passed on? ences to another student or to a staff nurse, 2993_Ch03_033-050 14/01/14 5:17 PM Page 39

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but be careful. The person nearby (e.g., in the elevator with you) may be a friend or family member. Unless specifically indicated by the patient, these people do not ordinarily have rights to information about the patient. There are many horror stories about innocent conversations that were overheard by the “wrong” people, which resulted in negative consequences to the patient and/or the nurse involved. Whoever said hospitals were quiet places probably never worked in one. Nurses and Figure 3-2 Maintaining privacy is a patient physicians talk often, and usually not quietly. right and conveys caring to the patient. “Dr. X is on the phone about Mrs. D’s bowel (Photograph by Wendy Hope.) surgery,” calls the unit coordinator to the nurse across the hall. “Is Mr. B’s insulin up “cheat sheet” was found on the floor. The yet?” asks the nursing assistant from the report sheet had fallen from a nurse’s pocket kitchenette. “Nurse Y needs to know.” This and had been picked up by a patient’s family happens not only in the hospital, but also in member. This person could have brought the physicians’ offices. Consider a situation in a paper to the desk immediately and the story physician’s office where a nurse shouts from would have ended there, but that was not the the front desk that she just received Mrs. A’s case. At the end of the shift, the family mem- urine specimen results. “My goodness! ber brought the piece of paper to the nurse in Mrs. A has enough E. coli in her urine to kill charge. None of the items on the list had been a horse.” Unfortunately for Mrs. A, she was carried out, according to the family member the last person to enter the office with the last who had been there the greater part of the day. name starting with an “A”. The physician’s of- Unfortunately for the nurse, the tasks had fice was not equipped with a glass partition been charted as being completed. This display between the waiting room and the front desk. of unprofessional and irresponsible behavior How many other patients or people pass- was one thing; the family member maining through the area might have heard those tained, however, that anyone could have interchanges? How would the patient feel if picked up that piece of paper and learned he or she knew that personal information many personal things about the patient. It had been handled so thoughtlessly? Remem- contained information not only about that ber that patients can interpret messages dif- patient but perhaps information about other ferently than a nurse. These breaches of patients assigned to that nurse. The family confidentiality happen all the time, but that member sued for breach of confidentiality and does not make them acceptable. Nurses won the suit. Granted, this is a drastic example must take the extra steps required to give or of what can happen, and laws regarding receive information quietly to the appropri- these situations vary from state to state. The ate people (Fig. 3-2). story emphasizes that nurses must be careful Charts, too, can put confidentiality at risk. with patient information of any kind and How many eyes may have seen a chart acci- always maintain honesty in documentation. dentally left open when the nurse went to In these days of computerized, paperless doc- answer a call signal? What about the report umentation, nurses are vulnerable to breeches sheet? Some nurses call these sheets their of confidentiality. The Health Insurance “brain’s cheat sheet.” Nurses should be sure to Portability and Accountability Act of 1996 keep their reports with them at all times. Here (HIPAA) and the Joint Commission (JC) are is an example how a simple act of dropping a intimately involved in documentation and piece of paper led to a major event. The nurse’s privacy issues. 2993_Ch03_033-050 14/01/14 5:17 PM Page 40

40 UNIT 1 | Foundations for Mental Health Nursing Health Insurance Portability consent (discussed in the Crisis Intervention and Accountability Act section in Chapter 8). The Health Insurance Portability and Joint Commission Accountability Act of 1996 (HIPAA) was The Joint Commission (JC) is the leading developed by the Department of Health national accrediting body of health-care and Human Services to provide national organizations. Earning accreditation by the standards pertaining to the electronic trans- Joint Commission indicates commitment to mission and communication of medical quality on a daily basis within the entire information between patients, providers, facility. Two other goals of a JC accreditation employers, and insurers. HIPAA allows are reducing the risk of undesirable patient more control on the part of the patient outcomes and encouraging continuous as to what part of his or her information is improvement. Originally established to sur- disclosed. It addresses the security and pri- vey hospitals, the accreditation can now be vacy involved with medical records and how achieved by long-term care facilities, mental that information is identified and passed health agencies, home health, and hospices to between care providers. For example, Social provide quality care, including mental health Security numbers, which were routinely and substance abuse treatment to children, used as a patient identifier in the recent adolescents, and adults. Accredited facilities past, now are either not used or are used in and clinics have demonstrated compliance some manner that is difficult to track, such with the highest standards of clinical care and as a partial number or a backward number. administrative quality. HIPAA was implemented in April of 2003. In 2004, the JC established the National Some areas of health care, such as workers’ Patient Safety Goals (NPSG). These goals are compensation, are either exempt from revised annually. Sentinel events, identifying HIPAA rules or are slightly less stringent in the sources of hospital acquired infections the passing of information. (HAI), ensuring two-patient identiﬁers, and a list of “dangerous abbreviations” are among these goals. ■ ■ ■ Clinical Activity During your clinical rotation, observe the facility’s Health Insurance Portability and Accountability Act (HIPAA) policy. Where is the policy located? Tool Box | Joint Commission Web site at: Note during your clinical experience if the www.j ointcommission.org HIPAA policy is violated by whom and how many times. National Patient Safety Goals: www.j ointcommission.org/standards_ information/npsgs.aspx

In June of 2004, the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration ■ ■ ■ Critical Thinking Question Center for Substance Abuse Treatment pub- You have just started working on the medical unit in your hospital. You have been assigned a lished a 25-page document entitled “The female patient called “Ms. X.” You are curious Conﬁdentiality of Alcohol and Drug Abuse about the fact that Ms. X is not using her real Patient Records Regulation and the HIPAA name. While reading her chart, you learn she is Privacy Rule: Implications for Alcohol and in an abusive relationship. You see the warning Substance Abuse Programs.” The document that “Ms. X’s husband is not allowed in the unit at any time.” When you go to meet the patient, is located at www.samhsa.gov. It carefully you are shocked; Ms. X is your next-door neigh- details what can and cannot be disclosed bor. What do you do? What do you say to her and strongly emphasizes the patient’s rights husband? What do you say when your family (discussed later in this chapter) and the asks you, “What happened?” necessity for the patient’s signed informed 2993_Ch03_033-050 14/01/14 5:17 PM Page 41

CHAPTER 3 | Ethics and Law 41 ■ Responsibility more assertively. The responsibility nurses have for each other professionally may be Responsibility is a key concept at all levels of different from the kind they have for their nursing practice; however, responsibility does patients, but it is every bit as important, for not necessarily mean independence. Respon- it ultimately affects the quality of care nurses sibility for the professional RN can mean dif- are able to give. ferent things than it does for the LPN/LVN. Nurses are expected to know their scope of ■ Accountability practice for their state. Responsibility means performing to the best of one’s ability within Accountability is part of working indepen- the boundaries of that scope of practice. dently within his/her scope of practice. A Sometimes this means knowing when to say nurse is accountable for his/her own actions. “No.” Sometimes it means calling the state Being accountable is important in all settings, governing agency to ask specific questions. including hospital, long-term care, home care, Responsible behavior for a nurse also office setting, and psychiatric facilities. It means keeping his or her personal life in a means knowing when to ask for help, finding manageable state. “Nurse, heal thyself” is a reference to refresh the memory, or looking not an unrealistic statement. Nurses need to up a medication that is not familiar. It means be physically and emotionally prepared to be doing everything the nurse possibly can to en- helpful to patients, and this cannot be done sure that he/she is providing the safest, most if one’s personal health is neglected. Nobody accurate care to patients. It means that when wants to be tended by a nurse who is not the nurse says he will follow through with an sleeping well or is preoccupied with personal order or a request, he will do so. problems. A good rule for nurses is to follow the recommendations in their personal lives ■ ■ ■ Critical Thinking Question that they would give to their patients. You depend on the other staff members to come It is the nurse’s responsibility to commu- to work. What happens when you must work nicate with patients and coworkers. Nurses one or two people short? Who really suffers as a must be alert to changes in patients’ condi- result? How do you feel when your “buddy” or helper overstays a break or mealtime? What is tions, both physical and psychological. The your response to that? How does that affect the actions nurses perform, the observations they amount of time your patients may have needed? make, and the documentation they complete What about your ability to perform safely when are the most effective ways to be helpful and you are filling in for someone who is not there? to ensure continuity of care for patients. Nurses also have a responsibility to their coworkers. Agencies have different ways of or- ■ Abiding by the Current ganizing the way nurses perform their jobs. Some agencies practice “team” nursing, and Laws some assign primary-care patients for whom the nurse is responsible for managing care Good Samaritan Laws during the entire hospitalization. Some facil- Good Samaritan laws offer immunity for ities use a “buddy” system to ensure help for citizens who stop to help someone in need of lifting and to cover the patient load during medical help. Nurses, physicians, and other breaks or meetings. Regardless of the system medically trained personnel may not always used, each nurse is in some way interdepen- be protected by Good Samaritan laws. dent on other staff members. The Good Samaritan law came out of tort Nurses also have a responsibility to com- law. A tort is a “a wrongful act other than a municate effectively with coworkers. Being breach of contract for which relief may be familiar with the techniques of communica- obtained in the form of damages or an tion discussed in Chapter 2 will ensure that injunction” (Merriam-Webster Online). The nurses are able to address these behaviors Good Samaritan law varies from state to 2993_Ch03_033-050 14/01/14 5:17 PM Page 42

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state, so it is important to understand the embarrassing to be labeled “mentally ill”; this implication of this law in your state. The basis diagnosis can follow a person for life and for all Good Samaritan laws, however, is that affect his or her personal and professional a third party cannot be charged with negli- relationships. Being diagnosed with a mental gence unless help is given recklessly or that illness could possibly hinder a person from person makes the situation significantly attaining life insurance. It is no wonder that worse, according to the guidelines for that sometimes people allow themselves to be hos- particular state. pitalized for a mental illness only as a last resort. Patients who agree to voluntary treatment are legally allowed to sign themselves Tool Box | Link to Good Samaritan laws in out; this is often discouraged by the treatment other states: staff except under certain situations, and it www.heartsafeam.com/pages/faq _ good_ samaritan is possible for the staff to institute an involuntary commitment for a patient if they consider him or her to be potentially dangerous. Voluntary and involuntary commitment Involuntary Commitment is discussed again in Chapter 8. Each state has its own regulations about Nurses must be aware of all laws and cir- people who need to be hospitalized against cumstances affecting the commitment. They their will. This action is reserved for people must maintain the physical and emotional exhibiting behavior that makes them poten- safety of the patient during the time of tially dangerous to themselves or to others. hospitalization. Confidentiality is crucial. The average length of time for involuntary Educating the public will be helpful in con- commitment is approximately 48 to 72 hours tinuing to eliminate the negative implications but could be more or less depending on state of issues surrounding mental illness. law. During this time, the person is observed and examined by the medical and nursing ■ Patients’ Rights staff. The patient has full ability to exercise his or her rights under the Patient Bill of Rights In the 1960s, civil rights was at the forefront. in that state. At the end of the legal “hold,” Gaining rights for oppressed people of many the patient chooses either to leave or to stay backgrounds was actively sought by groups for further treatment. Most of the time, the such as the American Civil Liberties Union patient realizes a need for help and stays. (ACLU). It was largely due to the efforts of Sometimes it is the professional opinion of this group that civil rights were addressed for the treatment team that the patient remains people in prisons and for those warehoused a threat to self or the community but that the in institutions for the mentally ill. patient cannot make the appropriate decision. By the 1980s, the Patient Bill of Rights This then becomes an issue of proving incom- became a requirement for people receiving care petence and becomes part of the legal system. in a facility, as well as for the health-care workers providing that care. These requirements Voluntary Commitment vary from state to state but are based on federal Most patients who are hospitalized for some guidelines and are supported in most states. type of mental illness are there voluntarily; Agencies in states subscribing to a Patient Bill that is, at some point they realized they of Rights are to have the rights listed and needed help. It does not mean they will be displayed in a prominent place in the facility. happy to be there, of course. There remains a Patients are to be informed of the implications stigma in the United States about being hos- of their rights and are to be given a copy of the pitalized for problems relating to a person’s Bill of Rights upon admission to the health- emotions or behavior. Many times, society care facility. This also is mandated when care assumes that these disorders are weaknesses is provided in the home. Table 3-1 lists fre- in character rather than illnesses. It can be quently adopted patient rights. 2993_Ch03_033-050 14/01/14 5:17 PM Page 43

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l Table 3-1 Most Frequently Adopted Patient Rights Patient Right Description Nursing Considerations 1. Treatment in the Patients are not to be Patients are not to be hospitalized if they least restrictive held in any stricter can be treated as outpatients and are not alternative conditions than to be kept in lockup if not dangerous, and their behavior or so on. Check the agency protocol and physi- diagnosis warrants. cian’s orders for the individual patient. You must still maintain safety for the patient and others. 2. Freedom from Restraining can be Be aware of the individual’s diagnosis and corre- restraints and with either physical lating orders. seclusion (except or chemical restraints. • Make accurate observations and documenta- in emergencies) Many areas require tion about the patient’s physical and behav- specific diagnosis- ioral response to restraint. related restraint • One guideline is to check circulatory func- orders. tion every half hour and to exercise and reposition the patient in restraint at least every 2 hours. 3. Give or refuse All patients have the Nurses can reinforce the physician’s explanation consent for right to say yes or no of treatment. Examine the patient’s understand- medications/ to treatments that ing; if there is little or no understanding of treat- treatments affect them. This must ment, the nurse needs to have the physician (including be informed consent, return and explain again to the patient and electroconvulsive meaning the patient significant others. therapy and fully understands the psychosurgery) treatment, potential outcomes, and potential effects of refusal. 4. Possess and have Anything of a per- Carefully document any teaching about safety access to personal sonal nature that the of personal items. If your local laws allow, have belongings patient wishes to the patient sign a waiver of responsibility for remain with him or personal items. her must be given to the patient. 5. Daily exercise Patient needs some Exercise is according to patient’s ability and form of physical activity order. Exercise can range from passive activity at least once range of motion (PROM) to the most strenuous daily. activity the patient can safely perform. 6. Visitors Patient can visit with Determine at time of intake who will be visiting anyone he or she regularly. In cases of family concern over certain chooses. people the patient may wish to visit, safety must be a key issue. At times, nurses may need to monitor visits and visitors. Carefully document the patient’s emotional and physical outcome of visits.

Continued 2993_Ch03_033-050 14/01/14 5:17 PM Page 44

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l Table 3-1 Most Frequently Adopted Patient Rights—cont’d Patient Right Description Nursing Considerations 7. Writing materials Paper, pencils, pens, Unless contraindicated for safety reasons, nurses and so forth must be can assist in ensuring that these items are avail- available to patients. able at all times. If safety is an issue (e.g., stab- bing self or others with a sharp object), this condition needs to be noted in charting. 8. Uncensored Mail must not be If patient is unable to physically open the mail mail opened before the or if there is concern that cognitively the patient patient receives it. will lose a check, for example, the nurse or another agent of the facility may witness the opening of the mail. Arrangements can be made with a family member or guardian to sign checks or see to the patient’s affairs if the patient is unable to do so. 9. Courts and Legal access remains Patients can call an attorney at any time. Nurses attorneys intact for anyone and agency representatives may be asked to who is hospitalized, help them. In cases when this seems inappropri- whether voluntarily ate, patient, staff, and family can discuss alterna- or involuntarily. tives in a family conference. Any outcomes need to be incorporated into the care plan and documented. 10. Employment Wages are not to Under certain legal conditions, compensation compensation be withheld during may be withheld for reasons other than a stay in hospitalization. a health-care facility. This would be confidential information but must be incorporated into the care plan and documentation. 11. Confidentiality Information about Discussion of the patient’s condition must take (records, treatment, the patient is to be place only in designated places and with desig- and so on) kept secure and nated persons. private. • Many states have cautioned nurses against giving any information regarding the patient over the telephone. In some states, a nurse can be in jeopardy of losing a license for releasing information over the phone. • Be careful of the wording in your charting. • Release information only to those people who are specifically required or legally entitled to have it. 12. Be informed of Patients must have The nurse or the facility representative will these rights full understanding of explain in detail the meaning of these rights their civil rights while for the patient. Depending on your local law under facility care. and agency policy, the patient may be asked to sign a document stating that these rights have been explained. Usually, a copy is then kept with the patient record and the patient keeps a personal copy. 2993_Ch03_033-050 14/01/14 5:17 PM Page 45

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In addition to these frequently adopted a moral, legal, and ethical responsibility to patient rights, some states have adopted a set report known or suspected abuse of people of patient rights for psychiatric patients. who cannot care for themselves. Part of a These rights may include the patient’s right to: nurse’s scope of practice is to be a voice, or an advocate, for the patients under his or her • Marry or divorce care. This is the meaning of patient advocacy. • Sue or be sued Sometimes the nurse is just not sure if • Be actively involved in his or her care abuse is occurring. It is usually better to err • Be employed if possible on the side of safety for a patient and to • Retain licenses (driver’s license, license to report the concern to a supervisor. In most practice one’s profession) areas, it is acceptable to contact the investigating agency directly. Regardless of the pro- ■ ■ ■ Clinical Activity cedure a nurse chooses to report his or her Ask one of the nurses on staff: Where are patient concerns, always check the agency’s policy files kept? How do you maintain confidentiality? and procedure for such reporting and for the documentation that is required.

In 1990, the U.S. Congress passed the ■ Community Resources Patient Self-Determination Act (PSDA), which all health-care agencies must follow. PSDA According to the provisions of the Commu- includes the following patient rights: nity Mental Health Centers Act, every community offers some form of help to people in 1. The right to facilitate their own health need. This help can be in the form of hospital care decisions emergency rooms, shelters, crisis centers, or 2. The right to accept or refuse medical social service offices. Most communities have treatment a list available for the asking. Clinics and hos- 3. The right to make an advance health care pitals provide lists to people who are at risk directive or who ask for the resources. Depending on the facility’s policies, the nurse may be able to ■ ■ ■ Clinical Activity help patients choose a community resource to Compare the current year and the year when access after discharge. Be sure to provide the Patient Bill of Rights became effective. Inter- information on fees for the services provided view a nurse who was working in the field prior to the bill’s passage and a nurse working after the by the individual agencies. They vary greatly bill’s passage. Determine how the Bill of Rights in relation to offered services, fees, and ac- has affected or changed their interactions with ceptable insurance. Some are free, whereas patients. some provide assistance on a “sliding scale” or according to ability to pay. Many states have reduced resources for mental health care in ■ Patient Advocacy the past two decades, which has contributed to many societal problems as well as frustra- With the emergence of the Patient Bill of tion for nurses. This situation needs to be Rights, patient advocates and patient om- addressed. It is important for nurses to iden- budsmen began speaking out for patients’ tify what resources are available through col- needs. These individuals are either volunteers leagues within their agency. within the community or paid workers from If a patient is unaware of community re- an agency whose job is to ensure that patients, sources at the time of discharge, the nurse can especially those considered vulnerable, are suggest that, if the time comes, the patient being treated in a safe, legal manner. can find resources online or in the local phone Everyone is responsible for reporting abuse book. The nurse can also inform the patient and neglect of those who are considered vul- that it is always acceptable to call the local nerable. Nurses and health-care workers have hospital to request a list. Shelters for victims 2993_Ch03_033-050 14/01/14 5:17 PM Page 46

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of abuse usually are not advertised; these are and to the credibility of the nurse. A kept conﬁdential to maintain safety for the nurse will be judged by correct spelling people who need them. and grammar (American format) in a court case. A nurse’s competency can ■ ■ ■ be questioned if his or her spelling and Key Concepts grammar are poor. 1. It is the nurse’s responsibility to know 4. Cultural considerations such as space, the Code of Ethics and standards of time, waiting, language, and touch nursing practice for the state in which (to name a few) are important parts of he or she is practicing. They will vary the nurse-patient relationship. They are from state to state. also important in the culture of nursing. 2. Collaborative practice means working A nurse’s personal beliefs may be diﬀer- together with all levels of nursing and all ent from the standards that are part of ancillary disciplines to provide the best the culture of nurses. possible care for the patient. 5. The patient’s well-being and wishes, the 3. Honesty in nursing practice and excel- state Nurse Practice Act, and agency lence in verbal and written communica- policy dictate how nurses can care for the tion are crucial to the care of the patient patient in a safe and respectful manner.

CASE STUDY 1. Nurse P, LPN, had worked for Agency family member noticed that the patient X, a nursing home in a small Midwestern was missing an amount of cash and a community, for 10 years. Over the years, wedding ring, which the patient kept in Nurse P gained the trust and respect of the purse “for safe-keeping.” The patient everyone she worked with or cared for on recalled asking Nurse P to retrieve the the job. Nurse P’s reputation was very glasses from the purse. Other patients and good in the community as well. On one staﬀ had also seen Nurse P in the patient’s particular day, a patient asked Nurse P, purse. The case went to small claims court. “Go to my purse and get my glasses, would Nurse P was found guilty and was made you please?” This apparently had happened to pay restitution. In addition, Nurse P’s many times before, so Nurse P sensed no license to practice nursing in that state was reason for concern. Several hours later, a revoked.

1. What could Nurse P have done to avoid this situation? 2. What are your thoughts about this situation? For the patient? For Nurse P? For the “fairness” of the situation? 3. What are your feelings about this situation? 4. What are Nurse P’s chances of becoming licensed again? In her state? In another state? What would the situation be if this were your state? 2993_Ch03_033-050 14/01/14 5:17 PM Page 47

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REFERENCES The Joint Commission www.jointcommission.org Aiken, T. D. (2004). Legal, Ethical, and Political Issues in Nursing. 2nd ed. Philadelphia: RAMP www.njsna.org/displaycommon.cfm?an=1& FA Davis. subarticlenbr=40 American Nurses Association. (2001). American Public Health Law Nurses Association Code of Ethics for Nurses www.publichealthlaw.net/Reader/docs/Tarasoff.pdf with Interpretive Statements. Washington, National Patient Safety Goals D.C.: American Nurses Publishing. www.ispn-psych.org/docs/standards/scope- Fossett, B., and Nadler-Moodie, M. (2004). standards-draft.pdf Psychiatric Principles and Applications for Patient and Physician Relationship General Patient Care. 4th ed. Brockton, MA: http://depts.washington.edu/bioethx/topics/physpt. Western Schools. html Kelly-Heidenthat, P., and Marthaler, M. T. HIPAA (2005). Delegation of Nursing Care. Canada: www.hhs.gov/ocr/privacy/Community Mental Health Thomas Delmar Learning. Centers Act Merriam-Webster. (2012). Retrieved from history.nih.gov/research/downloads/PL88-164.pdf www.merriam-webster.com/ Tarasoff Decision National Federation of Licensed Practical http://www.adoctorm.com/docs/tarasoff.htm Nurses. (2003). Nursing Practice and Stan- dards. Raleigh, NC. Neeb, K. (1994, October). The culture of nurses. Nursingworld Journal, 20, 1.

WEB SITES Nursing Standards www.ncsbn.org/regulation/boardsofnursing The Nurse Practice Act www.nursingworld.org/MainMenuCategories/Tools/ State-Boards-of-Nursing-FAQ.pdf 2993_Ch03_033-050 14/01/14 5:17 PM Page 48

48 UNIT 1 | Foundations for Mental Health Nursing Test Questions Multiple Choice Questions 1. The code of behavior that combines new nurse forgot my medication this professional expectations that border on morning. It’s my heart medication and legal issues is called: I need it. Would you get it for me?” You a. Commitment see the medication has been charted b. Ethics already. Your next action would be: c. Nurse Practice Act a. Refuse the patient, telling her, “You’re d. Patient Bill of Rights mistaken, Mrs. G. That medication is 2. The document that defines the scope of signed for, so you must have gotten it.” nursing practice in each state is called: b. Give Mrs. G her heart medication and a. Commitment assume she is right. b. Ethics c. Call the physician. c. Nurse Practice Act d. Inform your supervisor of the entire d. Patient Bill of Rights situation. 3. The set of rules designed to protect 6. The Health Insurance Portability and patients and others who are described Accountability Act: as “vulnerable” is called: a. Requires patients to be treated in a. Doctrine of Privileged Information designated regional treatment centers. b. Collaborative practice b. Approves of patient records being c. Nurse Practice Act transported in personal vehicles by d. Patient Bill of Rights medical staff. c. Allows patients to have some say in 4. Sandra is an RN who is working with what medical information can be you. Sandra is from the local pool/registry divulged and to whom. and you are the staff LPN or LVN at the d. Prohibits all transmission of medical facility. You see Sandra charting her med- records electronically. ications and treatments before she admin- isters them. Choose the best therapeutic 7. Mr. Ouch has just had bilateral total knee communication technique to use when replacement. He is in your transitional approaching Sandra. care unit. He repeatedly calls out in pain, a. “Why are you doing that?” disturbing the other residents, yet he re- b. “I am concerned about the legality and fuses to take the prescribed pain medica- safety of charting before giving medication, stating, “You’re all just trying to tions, Sandra.” knock me out.” You: c. “You know it is wrong to chart before a. Shut his door, leaving him alone with giving the medications.” some privacy until he settles. d. “You really shouldn’t do that, Sandra.” b. Offer another pain relief technique, realizing he has the right to refuse 5. A few hours later, Sandra gets sick and medication. goes home. You know that she charted c. Have additional staff come to the before giving her medications, and you room to assist while you administer a saw her passing some medications. You prescribed injection. are not sure who got their medications d. Inform him his behavior is not appro- and who did not. Mrs. G, a patient who priate and is disruptive to others, and is alert and oriented and a reliable histo- that he needs to stop calling out. rian for herself, sees you and says, “That 2993_Ch03_033-050 14/01/14 5:17 PM Page 49

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8. The licensed vocational nurse/licensed 10. Mr. B. is a 65-year-old attorney who has practical nurse (LPN/LVN) knows that been admitted to your ﬂoor for blood his or her scope of practice includes all work and neurological examinations. of the following except: He is loud and verbally demanding of a. Administering nursing care under the the staﬀ. He says, “I know my rights. direction of a registered nurse (RN) You nurses have to do whatever I ask. b. Documenting the patient’s data It’s your job.” The nurse responds: c. Independently ordering medications a. “That is not one of your rights, Mr. B.” for the patient b. “You are taking time away from other d. Assisting the physician or registered patients, Mr. B.” nurse with more complex care and c. “The Patient’s Bill of Rights does make procedures some provisions, Mr. B. Let me sit 9. The patient is semiconscious and is in and talk with you about those rights.” need of emergency surgery to relieve a d. “Why are you so angry, Mr. B?” subdural hematoma. The nurse knows that: a. Emergency situations do not require prior consent. b. He or she must obtain written consent for invasive procedures. c. This is not a function of the LPN/ LVN; the nurse should call his or her supervisor. d. The patient must be alert in order to obtain informed consent. 2993_Ch03_033-050 14/01/14 5:17 PM Page 50 2993_Ch04_051-074 14/01/14 5:18 PM Page 51

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Learning Objectives Key Terms 1. Identify major theories of personality development from • Accommodation newborn through adult development. • Assimilation 2. Identify developmental tasks from prenatal development • Autonomy through death, according to the major theorists. • Behavior 3. Identify possible outcomes of ineﬀective development, • Behavioral theorist according to the major theorists. • Ego 4. Identify the ﬁve stages of grief/death according to Kübler-Ross. • Id • Lunar month • Maslow’s Hierarchy of Needs • Menarche • Operant conditioning • Psychoanalytic • Psychosexual • Puberty • Superego • Unconscious

he study of developmental psychology The characteristics may cover beliefs from sev- encompasses the study of human eral of the individual theorists you will study. growth and development, which is T Neeb’s Remember, these are only theories. a specialty subdivision of psychology. This chapter covers only the very basics of human ■ Tip Many scientific studies have been development. A sample of the main theorists performed in the specific disci- in the field of child development is presented, plines; however, it has yet to be along with others whose theories are applied proven that any one is true for every- more in the areas of adult personality develop- one in every instance. Each person is ment. For the separate developmental age unique. Individuals are subjected to groups, a chart is shown delineating the general different factors such as genetics physical and behavioral traits that are com- and environment, which may affect monly seen in these age groups (pages 64-68). development.

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Each person develops at his or her own Bear in mind that the life span of young pace. While reading and learning about these Western Europeans during these years was theories, compare them with your personal much shorter than it is today, so that 12 years experiences and observations, as well as with of age seemed much older than it does by the patient assessments you will be perform- today’s standards. ing. Some theorists may have more validity to One of Freud’s main tenets, or beliefs, is you than others. that behaviors resulting from ineffective personality development are unconscious. He be- ■ ■ ■ Critical Thinking Question lieved that ineffective personality development Do other cultures use any of these developmental was in some way related to the relationship of theories when observing human development? the child to the parent and that it was related to what he called psychosexual development. Freud’s theories have validity for some ■ Developmental people today, but others denounce them. Although the reader is not expected to “con- Theorists: Newborn vert” to any of the theories discussed in this to Adolescence text, it is necessary to have a working knowledge of the main theories of personality de- Sigmund Freud (1856–1939) velopment. Freud is of particular interest The theories of Sigmund Freud (Fig. 4-1) are because, in addition to his highly debated considered controversial in today’s world. Sig- ideas, he was the first to also offer a reasonably mund Freud was an Austrian neurologist. He organized method of treatment. Because he believed, after observing behaviors of chil- was the first publicized theorist, all other the- dren, that the personality was developed as ories have evolved as a result of his. Sigmund early as age 5 years and fully developed by age Freud’s beliefs surface in almost every topic 12 years. He said that the personality must covered in this text. All other theorists com- develop in a certain way and at strictly de- pare their theories with Freud’s, either in fined ages and that failure to progress in this agreement or in opposition. manner would certainly lead to dysfunction. Table 4-1 shows Freud’s psychosexual or psychoanalytic stages of development. In- cluded in the table are some of the expected behaviors Freud thought one might witness as a child passes through these ages. The last column lists some behaviors that have been suggested as outcomes of failure to progress through his idea of proper personality development. Discussion of Freud and his theories continues later in this chapter. Erik Erikson (1902–1994) Erik Erikson (Fig. 4-2) was a psychoanalyst and a follower of Freud. Erikson took Freud’s main concepts and expanded them to include nonphysical criteria. Erikson understood that people are individuals and that no matter how young the person, everyone is different. Erikson’s observations indicated a variable that was different from the psychosexual and age- specific theory offered by Freud. That variable is called an emotional component. Table 4-2 Figure 4-1 Sigmund Freud. shows Erikson’s Eight Stages of Development. 2993_Ch04_051-074 14/01/14 5:18 PM Page 53

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l Table 4-1 Freud’s Stages of Development (Psychoanalytic or Psychosexual Stages) Examples of Stage of Approximate Unsuccessful Development Ages Tasks/Characteristics Task Completion Oral Birth–18 months Use mouth and tongue to deal Smoking, alcoholism, with anxiety (e.g., sucking, obesity, nail biting, feeding) drug addiction, difficulty trusting Anal 18 months–3 Muscle control in bladder, Constipation, perfec- years rectum, anus provides sensual tionism, obsessive- pleasure and parent pleasing; compulsive disorder toilet training can be a crisis Phallic 3–6 years • Learn sexual identity and Homosexuality, awareness of genital area as transsexuality, sexual source of pleasure; conflict identity problems in ends as child represses urge general, difficulty and identifies with same-sex accepting authority parent • Electra Complex: “Penis envy”—Daughter wants father for herself; discovers boys are different from her • Oedipus Complex: Son wants mother to himself; father is a rival Latency 6–12 years Quiet stage in sexual develop- Inability to conceptu- ment; learns to socialize alize; lack of motivation in school or job Genital 12 years– Sexual maturity and satisfac- Frigidity, impotence, adulthood tory relationships with the premature ejaculation, opposite sex serial marriages, unsatisfactory relationships

Frequently, his stages are identiﬁed by the ■ ■ ■ Clinical Activity words highlighted in the column headed Select an adult patient during your clinical experi- Developmental Tasks. Note that the develop- ence, and compare his biological age with Erikson’s mental tasks are always listed as contradictions developmental stages. Is your patient’s age appro- (i.e., trust versus mistrust) of each other. This priate to his developmental task? • Young Adult is one way that Erikson indicated his ideas • Adulthood about emotional ﬂuctuation in people. • Maturity

■ ■ ■ Classroom Activity • Describe which of the following stages you have experienced according to Erik Erikson: Jean Piaget (1896–1980) • Adolescence • Young Adult Jean Piaget (Fig. 4-3) was a Swiss psychologist • Adulthood whose outlook on development was com- • Maturity pletely diﬀerent from those of his colleagues Freud and Erikson. Piaget’s theory is called 2993_Ch04_051-074 14/01/14 5:18 PM Page 54

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according to the expected ability for that organism. Piaget believed that intelligence consists of coping with the environment (Dennis & Hassol, 1983). He believed that a person must complete each stage of development before he or she can progress to the next stage. Table 4-3 on page 56 shows the four stages of Piaget’s theory of development.

■ ■ ■ Critical Thinking Question Jamie is 2 years old. Jamie’s parents are becoming frustrated because Jamie is “so naughty.” They say that Jamie is always saying “No!” and “Mine!” They say that Jamie is fascinated by playing with the dirty diapers. They feel responsible for what they believe is “disgusting” behavior and wonder what they are doing “wrong.” They are quick to point out that “Jamie’s older sibling never did these things. Is there something wrong with us? Is there something wrong with Jamie? Please help us!” Figure 4-2 Erik Erikson.

Cognitive Development. Cognitive means the Lawrence Kohlberg ability to reason, make judgments, and learn. (1927–1987) Piaget believed that development was not as Lawrence Kohlberg (Fig. 4-4) believed in much a part of chronological age as of expe- Piaget’s theories, but he perceived that very riential age. Piaget was so sure of his ideas that young people have the ability to understand he said they were applicable to any living or- and judge right and wrong. Kohlberg’s theory ganism; the catch is to make the observations is therefore called the Development of Moral and comparisons about the cognitive process Judgment.

l Table 4-2 Erikson’s Eight Stages of Development Examples of Approximate Developmental Unsuccessful Task Stage Ages Tasks Examples Completion Sensory Birth– Trust vs. mistrust Nurturing people Suspiciousness, 18 months build trust in the trouble with per- newborn. sonal relationships Muscular 1–3 years Autonomy vs. “No!”—Toddler Low self-esteem, de- shame and doubt learns environment pendency (on sub- can be manipulated. stances or people) Locomotor 3–6 years Initiative vs. guilt Child learns Passive personality, assertiveness strong feelings of can manipulate guilt environment— disapproval leads to guilt in the toddler. Latency 6–12 years Industry vs. Creativity or shyness Unmotivated, inferiority develops. unreliable 2993_Ch04_051-074 14/01/14 5:18 PM Page 55

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l Table 4-2 Erikson’s Eight Stages of Development—cont’d Examples of Approximate Developmental Unsuccessful Task Stage Ages Tasks Examples Completion Adolescence 12–20 years Identity vs. role Individual integrates Rebellion, substance confusion life experiences or abuse, difficulty keep- becomes confused. ing personal relationships; may regress to child-play behaviors Young Adult 18–25 years Intimacy vs. Main concern is Emotional immatu- isolation developing intimate rity; may deny relationship with need for personal another. relationships Adulthood 21–45 years Generativity vs. Focus is on estab- Inability to show stagnation lishing family and concern for anyone guiding the next but self generation. Maturity 45 years– Integrity vs. Individual accepts Has difficulty deal- death despair own life as fulfilling; ing with issues of if not, he or she aging and death; becomes fearful of may have feelings death. of hopelessness

Neeb’s Caution: Morality, the ideas that ■ Tip people consider to be “right” and “wrong,” is highly cultural.

Kohlberg was a professor at Harvard Uni- versity for many years. He developed and published his theory of moral development in 1958 as his doctoral thesis. It was based on some of the ideas of Jean Piaget. His true interest was in the mechanisms people use to justify their decisions. Although he was interested in the morality of his subjects, he was especially interested in how people support their decisions. He studied only male subjects ranging in age from 10 to 16 years. Kohlberg’s theory is expressed in three levels. Each level has two sections. Table 4-4 shows these stages. Kohlberg believed that these stages build on the learning achieved from the stage before it. Therefore, the stages must be experienced in the exact order, and one is not to back- track, or revert to a previous stage. Part of his belief was that moral development can be promoted via formal education. In fact, there is a mild resurgence of Kohlberg’s theory emerging in some classroom environments today. Kohlberg’s theory has been criticized Figure 4-3 Jean Piaget. 2993_Ch04_051-074 14/01/14 5:18 PM Page 56

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l Table 4-3 Developmental Theory of Jean Piaget Stage Approximate Age Expected Ability Sensorimotor Birth–2 years • Uses senses to learn about self • Schemata develop, which are plans or ways of learning to assimilate and accommodate. They include the behaviors of looking, hearing, and sucking. Preoperational 2–7 or 8 years 2–4 years: • Thinks in mental images • Symbolic play • Develops own languages 4–7 or 8 years: • Egocentrism—sees only own point of view but cannot do this until age 7 or 8. With age, this ability develops. Concrete 8–12 years • Ability for logical thought increases. Operational • Moral judgment begins to develop. • Numbers and spatial ability become more logical. Formal 12 years–adult • Develops adult logic. Operations • Able to reason things out. • Able to form conclusions. • Able to plan for future. • Able to think in concepts or abstracts.

responses that daily problems and stressors can produce. Psychologist Carol Gilligan published a book in 1982 indicating that boys, girls, men, and women are all able to feel compassion and morality but that the genders process their morality from diﬀerent perspectives, a variable that was not considered in Kohlberg’s study.

■ ■ ■ Classroom Activity • As a class, develop a safety checklist for toddlers/ preschool-age children. This checklist can be used as a tool for new parents, day-care providers, or others in your community.

■ Figure 4-4 Lawrence Kohlberg. Developmental Theorists: Adolescence on the grounds that it is sexist and culturally to Adulthood biased. It indicates that some cultures and peoples never progress to the highest level Sigmund Freud (1856–1939) and suggests that behaviors that are accept- In addition to his ﬁve psychosexual stages of able in some cultures are “wrong.” Kohlberg’s development, Sigmund Freud had a model theory also does not consider the emotional for the components of personality. He said 2993_Ch04_051-074 14/01/14 5:18 PM Page 57

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l Table 4-4 Lawrence Kohlberg’s Theory of Development of Moral Reasoning Why We Should What If We Do Stage “Right” Behaviors Do “Right” Not Do “Right” Level I: Preconventional 1. Punishment Do not do it if it To avoid punishment I will be punished and and obedience will result in and to see what one I do not like that. orientation punishment. can “get away with” 2. Concerned with It is “right” if I (or if To help me get my I will lose recognition having own we) get something needs and wants for the importance of needs met I want out of it. fulﬁlled “others.” Level II: Conventional 3. ”Good boy, good “Good” means Self and others think we Avoiding “blame” is girl” orientation living up to what is are “good.” more ethical than expected of us. getting a “reward.” 4. ”Law and order” “Right” means It maintains social “Law” will have less obeying the laws structure. importance than the and rules. will of “society.” Level III: Postconventional ( Principled Level) 5. Social Contact “Right or good” We blend together for May become aware is behaving accord- the greatest good and that “moral” and “legal” ing to a general the welfare of all. may not be the same consensus. 6. Universal “good” Universal rules of Live within the universal Few people reach this justice and equality “good” according to according to Kohlberg. for all prevail. This is own conscience. Therefore, in his own the “ideal” accord- manual, the latest revi- ing to Kohlberg. sions do not measure this stage.

that the personality consists of three parts: the to id. Ego keeps id under control (in a mentally id, the ego, and the superego. Remember that healthy individual) by responding in an Freud believed that all the components of unconscious form of a “now, wait a minute” human behavior are set in the unconscious. attitude. For example, perhaps you had an The behaviors may appear to be very purpose- exam that was in a subject you felt fairly con- ful and deliberate, but in Freud’s theories, they fident about, so you chose to study less than are supposedly responses to situations of you would for other exams. You went partying which people are not aware. with friends for the weekend instead. Think Id is the part of the personality that is about this as id behavior. As you entered the concerned with the gratification of self. The testing area, a gnawing feeling started to enter sayings “pleasure principle” or “if it feels good, your consciousness. You sensed “butterflies” do it!” are attitudes that arose from those who in the pit of your stomach. You saw the first believe that all people have underdeveloped question on the exam and your mind went ids. These individuals promote the idea that temporarily blank. That is the ego response. It’s people need to allow the id to take care of telling you there are two sides to every situa- “me, myself, and I.” tion. In this scenario, the ego is telling the id, Ego, in Freud’s world, had a different con- “Hmm. Maybe you aren’t quite as confident as notation from the modern-day common use of you thought you were!” And the id says, “This the word. Ego, as Freud taught, is the balance test was made just for me.” 2993_Ch04_051-074 14/01/14 5:18 PM Page 58

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The third part of the personality theory of that a person’s childhood contributed and Sigmund Freud is the superego. Thesuperego influenced a child’s personality in later life. could be called the “killjoy” of the personality. Horney believed that safety and security are It is the conscience. It is the part of the per- important factors in a child’s life. Without sonality that allows people to determine what it in their earlier years, difficult behaviors is right, wrong, good, and bad. The values could be the results. Horney emphasized exhibited by the superego are not to be con- that it is the responsibility of the parents to fused with the same terms used by Lawrence provide that safe and secure environment Kohlberg; according to Freud, having these (Dewey, 2007). values is not a matter of choice or of learning. A person who is well-adjusted, or mentally Ivan Pavlov (1849–1936) and healthy, has all three components of the per- B. F. Skinner (1904–1990) sonality, according to Freud. Freud would Pavlov and Skinner worked on “conditioning,” expect anyone in whom any of the compo- or manipulating, behaviors. They are called nents is absent or out of balance to display behavioral theorists because they believed maladaptive behaviors. Defense mechanisms that working with different behaviors and have been associated strongly with Freud’s different stimuli could obtain different re- theories. Discussion of these defense mecha- sponses. Behavior modification is a direct nisms and maladaptive behaviors is found in result of their work. later chapters of this book. Pavlov (Fig. 4-6) worked on involuntary responses. His well-known study was carried Karen Horney (1885–1952) out with dogs, steaks, and a bell. When the Karen Horney (Fig. 4-5) was a psychoanalyst dogs saw a choice piece of meat, they salivated and one of the very few early female theo- in preparation for eating it. Pavlov incorpo- rists. Her ideas were very close to those of rated the ringing of a bell when the meat was Freud; however, she believed that the causes presented so that, in time, the researcher rang of abnormal behaviors or mental illness were related to ineffective mother-child bonding. Karen Horney developed the psychoanalytic social theory where she strongly believed

Figure 4-5 Karen Horney. Figure 4-6 Ivan Pavlov. 2993_Ch04_051-074 14/01/14 5:18 PM Page 59

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the bell and the dogs’ association of meat with around in and contained an apparatus for the the sound of the bell stimulated the salivation animal to operate voluntarily in response to response. This was a great breakthrough in the different stimuli. There are three main parts study of causes of behavior and ways in which to Skinner’s theory: response, stimulus, and behavior can be manipulated. reinforcer. Table 4-5 defines these parts. B. F. Skinner (Fig. 4-7) worked on operant Skinner’s theory led to the development of conditioning, which is based on voluntary re- behavior modification. It is possible to “mod- sponses. Operant conditioning, very simply ify” or change any behavior by using appro- stated, means taking a behavior and operating priate stimuli and reinforcers to obtain the on it by changing the variables or conditions desired behavior. surrounding the behavior. Skinner is known Both positive and negative behaviors can for the “Skinner boxes” in which he kept the be changed. Today, it is generally believed that animals he studied. These so-called boxes positive reinforcing is the most effective way were cages big enough for the animal to move of changing a behavior. Pointing out the positive qualities in a person or patient or focusing on the abilities (positive) rather than the disabilities (negative) seems to yield the best results. For instance, pretend that the behavior a supervisor wants to operate on is getting a particular coworker to arrive to work on time. The supervisor has two possible paths to follow: One is positive reinforcing; the other, negative reinforcing. EXAMPLES Negative: “Nurse M, you are routinely late for work. This is very difficult on your patients and on the rest of the staff. One more instance of being late, and you will be fired.” Positive: “Nurse M, you are still occasionally late for work. I have noticed, however, that you have been late only three times this month. If you continue to improve your timeliness, I will be able to give you a raise at Figure 4-7 B. F. Skinner. your next review.”

l Table 4-5 Operant Conditioning: B. F. Skinner Skinner’s Theory Explanation Response Any movement or observable behavior that is to be studied. The response is measured for frequency, duration, and intensity (e.g., chicken rings bell in cage). Stimulus The event that immediately precedes or follows the operant behavior. The object is to ﬁnd the stimulus that gets the chicken to ring the bell (e.g., food, noise, boredom). Reinforcer A variable that will cause the operant behavior to repeat predictably or increase in frequency. Sometimes this is called a “reward.” The reinforcer has to be meaningful to the person whose behavior is being “operated” on (e.g., chicken pecks bell and food drops into tray; when chicken wants food, it knows that pecking the bell will produce food). 2993_Ch04_051-074 14/01/14 5:18 PM Page 60

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The positive reinforcement method seems times this hierarchy is depicted as a large to give some dignity and positive self-regard triangle or a staircase to help visualize the pro- to the employee. It allows the employee to gression from the “basic” needs to the understand the consequences and to make “higher” needs of people (Fig. 4-9). The steps choices about being late. It will then be up are as follows: to the supervisor to follow through with 1. Physiological needs whichever consequences are earned by Nurse 2. Safety and security M. In the 1960s, positive reinforcement 3. Love and belonging was used with chickens as a form of enter- 4. Self-esteem tainment on New Jersey’s Atlantic City 5. Self-actualization boardwalk. Abraham Maslow (1908–1970) Physiological Needs These are elements people need to survive: Abraham Maslow (Fig. 4-8) is one of a group food, water, oxygen, clothing, absence of of theorists described as person-centered, extremes in temperature, ability for body patient-centered, or humanist. Person-centered excretions, and sexual activity. These are con- theories involve observing and treating the sidered necessary for life to continue. Without whole person. Nursing is highly centered in food, clothing, and a shelter that is clean and the person-centered and behaviorist theo- of a comfortable temperature, an individual ries. One of the main ideals embraced by could die; without sexual activity, the species the nursing profession is Maslow’s Hierar- could die. The physiological needs can be con- chy of Needs. This hierarchy, or orderly sidered needs for survival. When preparing a progression of development, takes in the plan of care for a patient, if the physiological physical components of personality devel- needs are not categorized as a priority, he/she opment as well as the emotional compo- will not survive. Can the patient proceed to nents. Self-esteem is a tenet of humanistic the next level of the hierarchy pyramid with- psychology. out water or ﬂuids? Can the patient survive Maslow’s Hierarchy of Needs has ﬁve lev- without oxygen? Can the patient survive with- els. Maslow said that one must pass through out elimination? These are the questions that these stages in order and that it is not possible a nurse must ask when doing a patient assess- for a person to move up to the next level until ment. Being able to identify what takes prior- the previous level has been mastered. Many ity can assist the nurse while taking the National Council Licensure Examination (NCLEX) as well as providing patient care. Maslow’s theory is an important component of the nursing discipline. Safety and Security It is important that people feel safe and free of fear. When individuals feel comfortable that their physical needs are being met, they begin to feel a sense of safety that they can maintain their survival. Bear in mind that having these basic needs met does not necessarily mean living in wealth or with steady employment. People who live on the street for whatever reason learn to survive and are proud of their ability to survive in conditions that most people would consider Figure 4-8 Abraham Maslow. deplorable. For some people, street life is a 2993_Ch04_051-074 14/01/14 5:18 PM Page 61

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SELF- ACTUALIZATION (The individual possesses a feeling of self- fulfillment and the realization of his or her highest potential.)

SELF-ESTEEM ESTEEM OF OTHERS (The individual seeks self-respect and respect from others, works to achieve success and recognition in work, and desires prestige from accomplishments.)

LOVE AND BELONGING (Needs are for giving and receiving of affection, companionship, satisfactory interpersonal relationships, and identification with a group.)

SAFETY AND SECURITY (Needs at this level are for avoiding harm, maintaining comfort, order, structure, physical safety, freedom from Figure 4-9 Maslow’s Hierarchy of fear, and protection.) Needs. (From Townsend (2011): Essentials PHYSIOLOGICAL NEEDS of Psychiatric Mental Health Nursing, 5th ed. (Basic fundamental needs include food, water, air, sleep, exercise, Philadelphia: F.A. Davis Company, with elimination, shelter, and sexual expression.) permission.)

choice, and they meet the criteria of Maslow’s something special and good about me.” Find- hierarchy. ing that “something” and learning to accept, appreciate, and acknowledge one’s positive Love and Belonging traits is the goal of the fourth need of It is a popular belief within psychology that Maslow’s hierarchy: esteem or self-esteem. loneliness is a major cause of depression. Self-esteem is the ability to be confident Quotes such as “Man does not live by bread that one is a person with good qualities and alone” and “No man is an island” have im- that others know and appreciate these quali- plied this for many years, and it is now being ties. This sounds easier to achieve than it often borne out scientifically. People need to feel is. When someone compliments a person on loved, appreciated, and part of a group. The a new piece of clothing, a haircut, or a job opening song in the television comedy well done, what is that person’s usual re- “Cheers” expresses the importance of every- sponse? “Oh, this old thing? Do you really one knowing each other’s name and being think so? I think it’s way too short now” or happy that you are there. The focus of that “It was nothing, really” are responses people sense of love and belonging may change over often give. In addition to the effect it has on the life span. For babies and young children, effective communication, responding in this the love needs to come from parents or other manner does not show positive self-esteem. caregivers; in adolescence and adulthood, the One of the most difficult things for people to focus may change to a significant life partner do is to learn to say “Thank you” when given or a peer group, or both. Regardless of the a compliment. “Thank you” not only ac- developmental stage of life, people need to knowledges the other person’s positive regard feel loved. for a quality one possesses, but it reinforces to one’s “self” that “Yes, I did do that well and I Self-Esteem do deserve the recognition.” Unfortunately, The “higher” needs begin with the idea that people sometimes interpret this simple re- “If I am loved by someone, there must be sponse as “false pride” and consider it to be 2993_Ch04_051-074 14/01/14 5:18 PM Page 62

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in poor taste to acknowledge themselves in a positive manner. Women have been socialized this way for years, and although there has been some improvement over the past 20 years, there is much work yet to be done in this area. Self-Actualization The fifth and final rung on Maslow’s hierarchy ladder is called self-actualization. This means achievement, taking risks, and working to one’s individual potential. The self- actualized person is a problem solver. Situa- tions can be creatively dealt with when a person is confident enough to stretch the limits of ability. Taking the risk to stretch boundaries by joining the nursing profession is an example of seeking out self-actualization. Figure 4-10 Carl Rogers. (Courtesy of Bonnie Even though it may not feel comfortable yet, Drumwright, PhD, Gold River, CA.) it is a process for self-improvement. Gender differences have been a subject of discussion since the beginning of time. Men he or she lives in. He did not think it was ap- and women have always said that they just do propriate to put a value on another person’s not understand each other. Proof of that exists perception of the world, so he said that every now. Scientists can truthfully, confidently, person deserved to be treated with respect and nonjudgmentally say that “Yes, there are and “unconditional positive regard” just by differences in the way men and women think, virtue of being a human being. communicate, and process life.” Psychologist He also differed from Maslow in the area Carol Gilligan studied this phenomenon of self-actualization. Rogers believed that self- (Gilligan, 1982). She hypothesized that one actualization is the basic motivator for people of these fundamental differences appears to and that all people have a built-in desire to affect Maslow’s hierarchy: women tend to achieve their capabilities. value relationships as a basic need, and men Nursing practice is based very strongly in tend to value achievement as a basic need. Rogers’ theory. His eight steps to being a This is not an issue of right or wrong; no helping person are listed in Table 4-6. value statement is being made. It is important, however, that nurses who are observing Carl Jung (1875–1961) and collecting data on their patients under- Although he broke from some of Freud’s stand that differences in patient attitudes ideas, Carl Jung (Fig. 4-11), a Swiss psychol- and responses to treatment may be related to ogist, also believed in the effects of the uncon- gender. scious mind. He included in his definition of “unconscious” both repressed personal Carl Rogers (1902–1987) experiences and representations of universal Carl Rogers (Fig. 4-10) was also a person- human experiences, those experiences all centered or humanistic psychologist. Although people have. He used different terminology he believed that all people need to be “prized to describe the various parts of human per- and loved,” his theory is a bit different from sonality, and he believed that healthy person- Maslow’s. The phrase associated with Carl alities are a balance between the conscious Rogers is “unconditional positive regard.” and the unconscious. “Self” to Jung meant Rogers believed that each individual may the deep, inner part of people. He believed have different ideas about life and the world that males and females are different organisms 2993_Ch04_051-074 14/01/14 5:18 PM Page 63

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l Table 4-6 Rogers’ Eight Steps Empathy “Walk in another’s shoes.” Respect Care for patient as a person, not just a patient. Genuineness Helper is a sincere/authentic role model. Concreteness Identify patient’s feelings by careful listening and stereotyping. Confrontation Discuss discrepancies in behavior. Self-Disclosure Share self, as is appropriate to situation. Immediacy of Relationships Helper selectively shares own feelings. Self-Exploration The more we explore ourselves, the greater/better the coping/ adapting.

Source: Prochaska, J. O. (1984). Systems of Psychotherapy. Paciﬁc Grove, CA: Brooks-Cole.

■ Stages of Human Development Nurses are entrusted with caring for people of all ages. Many nursing program mission statements refer to the concept that nursing must cover a continuum of experiences throughout the life span. It becomes the nurse’s responsibility to have a working knowledge of the main physical and behavioral changes that can be expected within certain age groups. It is also important to have some idea of the complications that might occur if developmental tasks are not completed successfully. This is called the study of Figure 4-11 Carl Jung. developmental psychology. Table 4-7 identifies the life stages, some of the expected major physical development, expected behav- but that each contains part of the other. The ioral development, and possible outcomes of human endocrine system shows that men failure to meet certain developmental tasks. have traces of female hormones and women This chart incorporates traits from all the have traces of male hormones. To Jung, it log- theorists identified in this text. It is not a sub- ically followed that this fact affects the way stitute for knowing the concepts of the indi- each person develops his or her personality. vidual theorists. Therefore, he used the term “anima” to de- Life is an accumulation of experiences. scribe the feminine tendencies in men and the Some of those are positive and some are not. term “animus” to describe the male character- Each person has to deal with gains and losses istics in women. as he or she travels through life. Patients may “Mask” is a word Jung used to define the be in different stages of loss with their illness. part of the personality that one presents Each age group has its own set of gains and socially. It hints at the idea that one’s inner- losses. Learning to deal with these ups most self may be different from his or her and downs early in life can make the more public self. significant experiences less difficult to cope (Text continued on page 68) 2993_Ch04_051-074 14/01/14 5:18 PM Page 64

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l Table 4-7 Overall View of Human Development Age Range (ages vary somewhat Expected Expected Potential Outcome according Physical Behavioral of Ineffective Life Stage to theorist) Development Development Development Prenatal Conception • Cells differenti- • Fetus kicks and • Threats to mother’s through ate (specialize) may respond health of primary 10th lunar by the end of to stimuli such as concern (e.g., smok- month the first familiar voices, ing, drugs, malnutri- (lunar month trimester. music. tion); mother’s = 28 days) • Intrauterine prenatal habits conditions of seem to have a mother may strong influence affect prenatal on the developing development. baby. • Alcohol consumption during pregnancy of special concern; can lead to a condition called fetal alcohol syndrome (FAS), which can cause physical anomalies as well as cognitive, emotional, and behavioral complications in child. Newborn 1st month • May have flat- • Bonding (e.g., • Angry crying of life tened nose, touching, talking) • Mistrust unevenly of parents and • Withdrawal shaped head, baby is said to be • Stress, which bruises from crucial to develop- slows further the passage ment of trust. development through the • Sucking reflex birth canal; • Can see these physical 7–10 inches characteristics • Likes bright colors will change over • Likes to be talked to the first month • Prefers female of life. voices • Likes touch, cud- dling, rocking, and the like • Will not be “spoiled” by this attention • Can hold head up for a few seconds • Follows light with eyes 2993_Ch04_051-074 14/01/14 5:18 PM Page 65

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l Table 4-7 Overall View of Human Development—cont’d Age Range (ages vary somewhat Expected Expected Potential Outcome according Physical Behavioral of Ineffective Life Stage to theorist) Development Development Development Infant 2nd month– Infants are all very 2–4 months: • Poor parent-child 1 1 /2 years of much alike (physi- • Begins to laugh relationship life cally and develop- • Follows people’s can lead to mis- mentally) until the movements with trust and poor age of 10 months. eyes self-concept. Failure-to-thrive 5–7 months: • syndrome • Holds head erect • Separation anxiety • Turns head toward voices • Babbles/coos • Drinks from a cup 8–10 months: • Sits up alone • Says “mama,” “dada”; understands “no” and “bye-bye” 1 Toddler 1 /2–3 years • Long trunk • Toilet training • Anger • Short legs • Learning sex roles • Regression 3 • Brain about /4 by copying behav- • Reversion to infant- of full size in iors of same-sex age behaviors order to be able parent to support fu- • Self-centered ture growth and • Does not share development • Wants things now • Walking • Both boys and girls learning autonomy (independence) by using the word “no” • Assimilation, which is taking in and processing of information via the senses • Accommodation, which is the ability to adjust to new information or situations

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l Table 4-7 Overall View of Human Development—cont’d Age Range (ages vary somewhat Expected Expected Potential Outcome according Physical Behavioral of Ineffective Life Stage to theorist) Development Development Development Preschool 3–6 years • Medical and • Cognitive devel- • Enuresis—the (Early dental examina- opment is a pri- involuntary bed- Childhood) tions important mary activity; wetting in pre- • Nutrition can many questions; school and school- be challenging; “Why” a frequently age children who children are used word. have been toilet starting to pick • Socializes trained; often due and choose their • Play important for to poor personal favorite foods; self-expression relationships time to start and anxiety relief • Encopresis— teaching good • Reading is the involuntary bowel nutrition. best parent-child movements in the • Lead poisoning activity. same population still a threat: it • Aggressive behav- as enuresis tastes sweet ior (roughhousing) and may still be • Active imagination found in some possibly leading to older plumbing nightmares or in old paint • Mixed feelings layers in housing about going to units. school School Age 6–12 years • Body thinning • Learning to share • Shyness and/or out and growth • Peer group activi- fear of school if slowing ties important trust and auton- temporarily • Beginning to show omy have not • Forming friend- acceptance of developed fully; ships with same- moral issues by may be a result of sex friends questions and not being included • Losing baby discussions in peer groups; has teeth and gain- • Reversibility: the been deﬁned as a ing permanent ability to put “silent prison” teeth things in an order • Gangs—can be the • By age 6, brain or sequence or to result of negative almost full size; group things types of peer neurological according to groups system develops common traits • Stuttering— from head down repetitive or pro- • By age 6 or 7, longed sounds or vision at its peak speech ﬂow that is • Vision and hear- interrupted; seems ing screening to happen four usually begun times more often by the time the in boys: may be child enters stress-related school • Agility increases 2993_Ch04_051-074 14/01/14 5:18 PM Page 67

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l Table 4-7 Overall View of Human Development—cont’d Age Range (ages vary somewhat Expected Expected Potential Outcome according Physical Behavioral of Ineffective Life Stage to theorist) Development Development Development School Age • Scoliosis (lateral • Accidents—the —cont’d curvature of leading cause of the spine) death in children; screening possi- teaching safety to bly encouraged families and chil- • Late childhood dren is important. (10–11 years • Child abuse/ old)—beginning neglect noted of sexual devel- more frequently; all opment, espe- health-care person- cially in girls, who nel have the duty now are matur- to report abuse or ing about 2 years suspected abuse ahead of boys (discussed in more • Colds frequent, detail in Chapters 5 due to social and 22). habits Adolescent 12–18 years • Growth spurt • Learning • Anorexia/bulimia (musculoskeletal independence frequent dangers system) • Learning self- for males as well as • Endocrine sys- sufficiency females; usually tem maturing • Learning new from white, mid- (hormones) social roles dle-class families • Secondary sex • Mood swings • Males who mature characteristics • Boredom later seem to have developing • Introspection the hardest time (facial and • Preoccupation adjusting. underarm hair, with body image • Suicide a major males’ shoulders • Own “language” concern for this broaden, females’ • Peer group very age group, usually hips broaden important—teens because of feeling and breasts need intimacy unimportant and develop) • Possible experi- not being taken • Puberty— mentation with seriously by adults individual is alcohol, drugs, sex capable of • Communication reproducing between parent • Menarche— and adolescent female’s first crucial menstrual • Talking on phone/ period, which internet for hours happens around age 11–15 (it is important to know that nutrition and exercise affect this)

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l Table 4-7 Overall View of Human Development—cont’d Age Range (ages vary somewhat Expected Expected Potential Outcome according Physical Behavioral of Ineffective Life Stage to theorist) Development Development Development Young Adult 18–35 years • Body usually in • Intimacy the main • Problems with de- optimal physical task to accomplish veloping intimacy condition • Schooling and • Difficulty leaving career planning parent's homes important • Marriage and family decisions made Adult 30–60 years • Gradual decline • Generativity, or • Disappointment in hearing and passing down val- with own visual acuity ues and skills to the achievements/ • Body beginning next generation next generation to shorten (personally and • Stress demands somewhat as professionally)— from different musculature and a major task of the generations bone structure adult change • Lung and cardiac capacity beginning to decrease somewhat Older Adult 60 years– • Visual and hear- • Acceptance of • Fear of death and death ing acuity con- limitations on dying tinue to decline independence • Difficulty with • Body becomes and physical retirement— susceptible to ability identity is often an increasing • Acceptance of associated with number of phys- the idea of death career ical and emo- and beginning to • Depression relating tional illnesses prepare for it to aging, loss of • Acceptance of friends, and so on retirement • Increases in stress throughout the life span

with. Overuse of defense mechanisms (see ■ ■ ■ Classroom Activity Chapter 7) can be curtailed with eﬀective • As a class, develop a teaching plan that could stress-management techniques, which can be be used with children who are experiencing learned very early in life. It is important for the divorce of their parents. The checklist should be detailed enough to accommodate nurses to understand the developmental age-appropriate communication and informa- stages throughout life, and this includes the tion. The class might prefer to do a separate end of life. The process of death and dying is checklist for each developmental group. one that all people will face at some point. 2993_Ch04_051-074 14/01/14 5:18 PM Page 69

CHAPTER 4 | Developmental Psychology Throughout the Life Span 69 Death and Dying Losing a loved one at any age or for any reason is a difficult experience. Separation, loss, and grief are human conditions that are unavoidable. Today’s world presents conflicting phe- nomena. People have a better quality of life and better health care than ever before. Because of this, the average life expectancy is 78.7 years (CDC–National Center for Health Statistics). On the other hand, people exist in a fast- paced and competitive society, which causes high levels of stress and encourages people to Figure 4-12 Elisabeth Kübler-Ross. make unhealthy choices in their diets and (Courtesy of Ken Ross, Scottsdale, AZ.) lifestyles. This results in people dying of myocardial infarctions in their 30s and 40s. Au- Her idea implies that the end result of expe- tomobile accidents and recreational activities riencing the five stages of grief or dying is the are taking the lives of children at higher num- ability to die in peace and with dignity. These bers than ever before. According to the Centers stages apply to the dying people and those for Disease Control and Prevention (CDC), they leave behind and to other major losses violence is a global cause of death. Even though in life. These stages are listed in Table 4-8. people know intellectually that they will die, Death, and the activities that accompany they often struggle with death as if it is unex- it for the dying person and those left behind, pected. We have been called a “death-denying is not only physiological; it is also deeply society.” rooted in cultural and spiritual tradition. Just Psychologist Dr. Elisabeth Kübler-Ross as every person is unique in life, so will the (Fig. 4-12), who died in 2004 at age 78, was rituals surrounding the activities of death be a leader in the study of the process of death very personal and individual. and dying. She made her reputation by learn- Dr. Kübler-Ross emphasized the impor- ing about the activities of the mind and body tance of communicating throughout the dying at and around the time of death. Her initial process. People who are in comas or in the end studies were based on only 200 subjects, all stage of death may not be able to respond to of whom had cancer; yet her theory has verbal cues or participate in conversation, but survived and has spanned more than 40 years. it is widely believed that they continue to hear

l Table 4-8 Five Stages of Grief/Death and Dying by Dr. Elisabeth Kübler-Ross Stage Key Words Expected Behaviors Denial “Not me!” Refuses to believe that death is coming; states “That doctor doesn’t know what he/she is talking about!” Anger “Why me?” Expresses envy, resentment, and frustration with younger people and/or those who are not dying Bargaining “If I could have one May become very religious or “good” in an eﬀort to more chance . . .” gain another chance at life or more time to live Grief/Depression Realizes that “bargain- Becomes depressed, weepy; may “give up,” quit ing” is not working and taking medications, quit eating, and so forth death is approaching Acceptance “OK . . . but I don’t have Enters a state of expectation; may begin to call to like it!” family members near; needs to complete “unﬁn- ished business”; prepares spiritually to die 2993_Ch04_051-074 14/01/14 5:18 PM Page 70

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what is going on in their environment. For this state’s recognition of an advance directive or reason, nurses must be careful in talking to the “living will” (where the wishes of the dying patient and the family, even immediately after person are placed on a legal document, the patient’s death. Again, people from some signed by the person while competent, and cultures and religions believe that the “spirit” witnessed), and the family’s wishes. Advance or “soul” remains in the room for a period of directives also identify who the decision time after death. Regardless of the belief sys- maker(s) will be if the person is unable to tem, it is a sign of respect to the patient and speak for him/herself. the significant others to include the patient in Euthanasia (sometimes called “mercy the conversation and continue to speak in killing”) is illegal in the United States, but terms of the reality of the situation. “physician-assisted suicide” (also called aid in dying) is now legal in some states. These Dr. Kübler-Ross’ theory also empha- Neeb’s topics will continue to be debated. Competent ■ sizes the fact that hearing is the last Tip adults have the right to decline any medical sense to leave a person before death. treatment even if it hastens death. All of these Children go through the same stages as can bring out strong emotions for families adults; and as with adults, they may need and the nurse who is caring for people at the special help to come to terms with losing a end of their lives. Nurses need to be educated loved one. The help nurses give to younger about the ethical and legal considerations patients must be age-appropriate. Infants and around providing end of life care. toddlers may not be able to understand what The nurse’s responsibilities at the patient’s happened, but they do sense the change. death vary from state to state. For instance, Keep their routine as normal as possible. Pro- in some states nurses are allowed to provide them with physical closeness and a safe nounce the death of a patient; in other states environment. this must be done only by a physician. Death Children from 2 to 6 years of age may have is defined differently from state to state. Phys- the sense that death is reversible. How often ical signs such as vital signs, skin color and do they see cartoon characters “die” and then temperature, presence or absence of activity immediately return to animated life? When on electroencephalogram (EEG) and electro- the reality that grandmother or grandfather cardiogram (ECG), and the ability to be is not coming back to life is understood, it is viable, or to live without mechanical assis- important that the child understands that tance, are criteria used by states to define he or she did not cause the death of the death. It is the nurse’s responsibility to know loved one. the legal definition of death in the state in Children ages 6 to 12 are at varying which he or she is working. degrees of understanding. It is important to allow and encourage children to talk about ■ ■ ■ Critical Thinking Question their feelings. Recent incidents of violence Your patient is in a monogamous homosexual involving this age group have provided the relationship and is in the final stage of life. Death is imminent, but the patient is still alert and opportunity for grief counselors to intervene oriented. Family and partner are in the room. The with children who have survived the ordeals. patient asks you to ask the physician to “put me Teens are bridging the gap from childhood to sleep.” The patient’s partner weeps but sup- to adulthood and may respond to grief and ports the request; the family members threaten loss as an adult at times and then as children. to sue if the physician does “any such thing.” What are your thoughts and feelings about this Provide structure, routine, and an environ- request? What will you do to help the patient? ment in which they may freely express their The family? The partner? What if this were your thoughts and feelings. parent or child who was about to die? What When caring for dying patients, the nurse would you think and feel then? needs to be aware of the existence of and 2993_Ch04_051-074 14/01/14 5:18 PM Page 71

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■ ■ ■ Key Concepts 2. Dr. Elisabeth Kübler-Ross developed a theory of ﬁve stages that people go 1. There are many theories about personal- through when they are grieving or dying. ity development in human beings. Although others have presented theories Although they are only theories, there on this topic, hers remains the most are strong indications of validity in all commonly accepted theory in nursing. of them. The licensed practical nurse (LPN) and the licensed vocational 3. Each person is an individual and will go nurse (LVN) must have a working through stages of development or grief at knowledge of some of the more com- his or her own pace. These theories are monly accepted theories of human guidelines to help nurses understand development throughout the life what patients may experience as they span. go through certain stages in their lives.

CASE STUDY Mr. Y, a 24-year-old construction worker, conversations were held in his room while suﬀered a traumatic brain injury after he was in the coma. When he awakened falling from scaﬀolding when his safety from the coma, he was able to tell most of equipment failed. He was comatose for what was said. He wondered why “nobody 8 days. During this time, family and answered me when I talked to you.” He friends kept a constant vigil. His wife especially wanted to reassure his wife that was 6 months pregnant and fearful about “Nothing would keep me from seeing that having to raise the baby alone. Many baby!”

1. What suggestions could a nurse have made to the family of this patient regarding patients who are comatose? 2. How can a nurse help the patient who has concerns about “memories” he or she acquired while in a coma (e.g., what is real and what is not, what things might have been said in conﬁdence, and so forth)?

REFERENCES Dennis, L.B., and Hassol, J. (1983). Introduction Barry, P. D. (2002). Mental Health and Mental to Human Development and Health Issues. Illness. 7th ed. Philadelphia: JB Lippincott. Philadelphia: WB Saunders. Barger, R. N. (2000). A Summary of Lawrence Dewey, R. (2007). Karen Horney’s theory. Retrieved Kohlberg’s Stages of Moral Development. Notre from www.intropsych.com/ch11_personality/ Dame, IN: University of Notre Dame. karen_horneys_theory.html Centers for Disease Control and Prevention. Gilligan, C. (1982). In a Diﬀerent Voice: Psycho- National Center for Health Statistics. (n.d.). logical Theory and Women’s Development. Retrieved from www.cdc.gov/nchs/fastats/ Cambridge, MA: Harvard University Press. lifexpec.htm Kübler-Ross, E. (1969). On Death and Dying. Centers for Disease Control and Prevention. New York: Macmillan. (n.d.). Retrieved from www.cdc.gov/ Lickona, T. (1991). Educating for Character: violenceprevention/globalviolence/index. How Our Schools Can Teach Respect and html Responsibility. New York: Bantam. 2993_Ch04_051-074 14/01/14 5:18 PM Page 72

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WEB SITES Horney www.muskingum.edu/~psych/psycweb/history/ Kübler-Ross horney.htm www.nlm.nih.gov/changingthefaceofmedicine/ www.learning-theories.com/ physicians/biography_189.html http://currentnursing.com/nursing_theory/theory_ Skinner www.simplypsychology.org/operant-conditioning. of_psychosocial_development.html html Piaget http://webspace.ship.edu/cgboer/piaget.html 2993_Ch04_051-074 14/01/14 5:18 PM Page 73

CHAPTER 4 | Developmental Psychology Throughout the Life Span 73 Test Questions Multiple Choice Questions 1. A 4-year-old patient comes into the clinic 5. The infant mortality rate is highest in with her father. She is being checked for mothers who are: a recurring ear infection. As you prepare a. Over 35 years old her to see the physician, she says to you, b. Over 30 years old “I love my Daddy. I’m going to marry c. Under 20 years old him like Mommy someday!” Which one d. Under 15 years old of Freud’s stages of development is she 6. The term anima from Carl Jung’s theory most likely demonstrating? describes: a. Genital a. Male characteristics in women b. Oral b. Feminine characteristics in men c. Anal c. Male characteristics in men d. Phallic d. Feminine characteristics in women 2. Patient Y is 20 years old. Y is a perfection- 7. According to Erikson’s theory, the devel- ist and very routine-oriented. Freudian opmental task stage a 3- to 6-year-old theorists would say that Patient Y did needs to accomplish is: not successfully complete which of the a. Identity following stages of development? b. Industry a. Genital c. Intimacy b. Oral d. Initiative c. Anal d. Phallic 8. Infants seem to be very much alike (developmentally) until the age of: 3. Patient Y (from question 2) is being treated a. 2 months by a behavioral psychologist. When Patient b. 6 months Y begins to miss meals and activities be- c. 10 months cause of the need to complete routines d. 12 months perfectly, the staﬀ is to intervene. Patient Y failed to come to dinner on your shift. You 9. A toddler’s ability to take in or acknowl- go to check on the patient and see Y care- edge changes in the environment is fully placing personal items in a special called: place in the bathroom. Your best response a. Adjustment to Y from a behavioral and therapeutic b. Assimilation background would be: c. Accommodation a. “Y, where were you at dinner tonight?” d. Autonomy b. “Y, you blew it. You didn’t come to 10. The parents of a 2-year-old arrive at the dinner and you know what that means: hospital to visit the child. The child is in no pass for the weekend.” the play room and ignores the parents c. “Y, I am just here to remind you it is during the visit. This 2-year-old behavior dinnertime.” indicates: d. “Y, it is not appropriate to miss dinner. a. The child is withdrawn What is the consequence of that, b. The child is more interested in playing according to your care plan?” with other children 4. In prenatal development, cell diﬀerentiation c. The child has adjusted to the hospital- is normally completed by the end of the: ized setting a. First trimester d. A normal pattern b. Second trimester c. Third trimester d. First lunar month 2993_Ch04_051-074 14/01/14 5:18 PM Page 74 2993_Ch05_075-088 14/01/14 5:18 PM Page 75

CHAPTER 5 Sociocultural Influences on Mental Health

Learning Objectives Key Terms 1. Define culture. • Abuse 2. Identify factors to consider when assessing culture and • Culture ethnicity. • Ethnicity 3. Differentiate between religion and spirituality. • Ethnocentrism 4. Define ethnicity. • Homeless 5. Identify parenting styles. • Parenting 6. Differentiate between abuse and neglect. • Prejudice 7. Define stereotype. • Religion 8. Define prejudice. • Stereotype 9. Define homelessness. 10. Identify some possible reasons for homelessness. 11. Identify nursing care for people who are homeless.

any professionals in the field of ■ Culture psychology believe that social and Mcultural environments have a great Culture is a term that is often misused. Cul- influence on the way people develop and ture is a shared way of life, the combination process life. They believe that positive or neg- of traditions and beliefs that make a group of ative social and cultural experiences early people bond together (also see Chapter 3). in life result in similar positive or negative Culture is not based on one’s color of skin or behavior and beliefs in adulthood. country of origin. For example, in the 1960s, a group of young people who were speaking Neeb’s Part of the nurse’s role is to learn out against the politics and morals of their ■ Tip about traits that are common parents began living in groups (Fig. 5-1). The among people and those that are area they chose to start this movement was different. It is important to under- the Haight-Ashbury district in San Francisco. stand people’s customs and beliefs They called themselves “hippies,” and they to avoid unrealistic expectations of shared a way of life that consisted of exper- patients. imenting with drugs; living together without being married (or “free love,” as it was termed); dressing in ripped, dirty clothing; Culture and ethnicity are among the topics not cutting their hair; and doing just about that are said to have the greatest influence on everything else that was opposite to the values people throughout their life span. of the “older generation.” This group believed

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Tool Box | Transcultural Nursing Assessment Tool www.culturediversity.org/assesmnt.htm

■ ■ ■ Clinical Activity While preparing a care plan for an assigned patient, ask the patient about his or her culture. Determine if any of the patient’s traditions or beliefs have been included in the plan of care.

Figure 5-1 The hippies of the 1960s represented their own unique culture. A psychoanalyst named Karen Horney (see Chapter 4) proposed the theory that some cultural traditions and beliefs cause in loving everyone, regardless of race, creed, disturbances in personal relationships and and color—as long as the individual em- that this can lead to some forms of emotional braced the beliefs of the group. The group’s disturbances. Today, one can look at other symbols were the daisy and the peace sign, groups who have a shared belief system and a and “flower power” and “power to the people” shared way of life. Madeleine Leninger, a represented some of the ideals they followed. nurse theorist, also realized the importance of Much to the chagrin of the over-30 age transcultural nursing. Leninger established group, these young people fit the definition the Culture Care Theory. It was while caring of a “culture.” It was called a “subculture” for children that she found how their behav- or “counterculture” at the time. Today, the ior needs were related to their culture; with- “goth” statement many youth are making out understanding each of these cultures, may be equated to the statements of their par- functioning as a health-care provider was ents or grandparents in the 1960s. difficult (Leininger, 2006)

■ ■ ■ Clinical Activity As a class, formulate a list of 10 questions you can Neeb’s Nurses may discover that when it use during your clinical experience while doing ■ Tip comes to being knowledgeable assessments on someone of a diﬀerent culture or about other cultures, they have been alternative lifestyle. Questions are subject to the living in a glass jar—only seeing instructor’s approval. other cultures but unaware of how to interact with them. Religious beliefs are often included in discussions of culture; however, it is important to note that the religion is not usually the culture. Bringing cultural competence to patient For people who practice Judaism or Islam, the care is a primary responsibility of the nurse. relationship between their religious beliefs and Culturally diverse nursing care takes into their cultural beliefs is so entwined that it is account the following areas: communication, hard to separate those traits. However, the hip- space, social organization, time, environmen- pie group mentioned earlier contained people tal control and biological variation according raised in many diﬀerent religions. to the Transcultural Assessment Model devel- Religion is the belief in a higher power. This oped by Giger and Davidhizar (Giger, 2013). belief system can be very strong—so strong that Culturally diverse care means the nurse is people have fought wars over religion and even adapting care in a manner congruent with the now continue to wage war in the name of patient’s culture. religion. Rituals or worship services are usually 2993_Ch05_075-088 14/01/14 5:18 PM Page 77

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l Box 5-1 Cultural Assessment—Questions to Ask • Where was the patient born? If the patient is an immigrant, how long has he or she been in this country? • What is the patient’s ethnic aﬃliation? How strong is the ethnic identity? • Who are the patient’s major support people? Does patient live in an ethnic community? • Who in the family takes responsibility for health concerns and decisions? • Are there any activities in which the patient may decline to participate because of culture or religious taboos? • Does the patient have any special food preferences, or food refusals because of culture or religion? • What are the patient’s primary and secondary languages, and speaking and reading abilities? • What is the patient’s religion, what is its importance in daily life, and what are current practices? • What is the patient’s economic situation? Is income adequate for his or her needs? • What are the patient’s health beliefs and practices? • What are the patient’s perceptions of the health problems and expectations of health care?

Source: Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company.

■ ■ ■ Critical Thinking Question Native Americans into one large group; there Your patient is from a different country and speaks are many nations and many tribes, each only minimal English. Your translator has seen the with its own set of beliefs. One belief is that patient and has gone over the hospital routines, certain numbers are sacred to some Native rules, and patient’s rights. The patient’s mother Americans, and they may attribute special insists on staying in the room 24 hours a day and refuses to let you perform assessments and care qualities to the four directions of north, for the patient. The patient is in pain, but the south, east, and west. mother will not allow pain medication to be Spirituality and religion are extremely given. The patient will not accept the food from important to some patients and unimportant the hospital. You smell food cooking and enter or nonexistent to others, although both are the room to find the mother cooking on a hot plate, which is a fire code violation. What can you different. Nurses must be comfortable talking do in this situation? to patients about their religious and spiritual needs without pushing personal values on patients. A patient’s success at recuperating included in organized religions. Religion is from an illness or a surgical procedure may be often the subject of stereotype. A stereotype is deeply tied to his or her spirituality. Nurses a fixed notion or conviction about a group of who are not comfortable in these situations people or a situation. should offer to call the chaplain in the facility or a spiritual leader of the patient’s choice. Religions involve items considered sacred. ■ ■ ■ Classroom Activity • Interview a person whose religion is different Such items may include books (e.g., Bible, from your own. You may use the interview Koran), jewelry (brooch, pin, or cross), the format from Chapter 6. Present the interview person’s dress (headwear, loose-fitting cloth- results orally or in writing to the class. Discuss ing), or other type of personal effects. It is what you thought you knew about the religion generally believed that patients should be prior to the interview. Discuss what you learned after the interview. Review literature on that allowed to keep these items when possible. In specific religion and compare the information situations in which a patient may be in poor from the interview. mental health and possession of these items is of actual or potential danger to the patient or others in the area, it may be necessary to Native Americans are an example of a remove the items. If that becomes necessary, group that worships different gods or spirits. enlisting the assistance of a representative Of course, it is improper to categorize all from the particular religion may be helpful. 2993_Ch05_075-088 14/01/14 5:18 PM Page 78

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perfect position to teach and model inter- Tool Box | Religion Diversity www.bbc.co.uk/religion/religions/ personal relationships and, it is hoped, to make great strides in eliminating prejudg- ment of others. Health care may not be completely free ■ ■ ■ Classroom Activity • Have a culture awareness day presentation. of guilt in the area of race. A study was con- Describe the following traditions for your religion ducted at Emory University School of Med- or culture: icine in Atlanta, Georgia (Todd et al., 2000). • Foods For 40 months, researchers studied 217 • Music patients who sought treatment for long bone • Weddings • Death practices fractures. Of these patients, 127 were black • Myths and 90 were white. Patients with this type of fracture usually require some type of pain medication. The study showed that, even though the injuries and pain levels were ■ Ethnicity similar, 43% of the black patients received no pain medication, compared to 26% of Ethnicity defines one’s more personal traits white patients. The study could not deter- and identifies a person with his or her shared mine the exact rationale for the outcome. heritage. Language, country of origin, and Did some patients refuse medication? Did skin color are parts of one’s ethnicity. There some not ask? Was it a cultural choice? can be different ethnic groups within a cul- Did medical staff make assumptions about ture. For example, a blonde, blue-eyed woman drug misuse in some people? Nurses should exhibits physical characteristics of her ethnic be wary of statistics and be careful about background. However, these characteristics silent stereotypes. say little about her culture; that would require speaking to her and obtaining some information. People are generally very proud of their ■ ■ ■ Critical Thinking Question culture and ethnicity. Many communities Should a patient’s identification bracelet specify if have festivals that celebrate their different the patient has insurance coverage? If the patient does not have any coverage, will the care be the cultures and ethnic groups. These festivals do same as if the patient had coverage? much to educate the community about the various people living together in it. Some- times one can learn a lot about a group of people from the kind of food they eat, and The hurt of prejudice has led to an emer- these celebrations are usually overflowing gence of ethnocentrism, which is when people with foods of the particular group. believe that their particular ethnic or religious group has rights and benefits over and above those of others. Gangs, supremacist groups, Neeb’s Education can help eliminate prej- and terrorist groups may have had their roots ■ Tip udice, which is judging a person or in hate and prejudice. situation before all the facts are Sadly, society is reminded of the plight known. Prejudice is a destructive of the Jewish people, who lived through the behavior; it is hurtful and it shuts horror of concentration camps. The United the door on the enrichment of the States shows the scars of the inhumane treat- society. ment of the African and African American people, who have been fighting for their civil Laws in the United States are intended rights for over 200 years. And it remains a to minimize displays of prejudice relating to topic of debate today. The validity of affirma- race, creed, gender, age, and so on. Unfor- tive action is being questioned and, in fact, tunately, it is impossible to legislate the being called by some a form of discrimination beliefs of individual people. Nurses are in a against other people. In 2008 the citizens of 2993_Ch05_075-088 14/01/14 5:18 PM Page 79

CHAPTER 5 | Sociocultural Influences on Mental Health 79 the United States elected their first African ■ Nontraditional Lifestyles American president, which gave many hope that some social scars will heal. Religion, cul- The definition of “family” is changing (Fig. 5-2). ture, and ethnicity, as well as prejudice caused Gay marriage and civil unions have opened by any of those characteristics, are personal very active debates. In June 2013, the and deeply felt by members of the respective U.S. Supreme Count knocked down the groups. It is important to keep the lines of Defense of Marriage Act to pave the way for communication open. People learn by sharing federal recognition of same sex marriages. with each other, so it is much better to ask a Same-sex marriages are now legal in many person about something than to make an states. It is becoming more common in assumption about it. Making such an assump- schools and clinics for children to have “two tion is stereotyping, which can end a helping mommies” or “two daddies.” People with relationship between nurse and patient. lesbian, gay, bisexual, and transgender (LGBT) Many mental health professionals believe lifestyles are “out” in the open and living life that people raised in an atmosphere of preju- as normally as the more traditional father/ dice and stereotype tend to become angry, mother/children families of decades earlier. All hateful, and aggressive adults. There is no age groups are affected. However, despite signs proof that all people who are subjected to of increased acceptance, LGBT individuals as prejudice and stereotype develop into adults well as their families may still struggle with with such negative attitudes. This is one of the facing being “different.” dangers in reading statistics on these topics: People have been leading different lifestyles Statistics can be very misleading and can in all along but were far less comfortable profess- fact support the negative stereotypes. ing it in years past. Aging happens to all, regardless of lifestyle preference. By the year 2030, according to the National Gay and ■ ■ ■ Classroom Activity Lesbian Task Force, there will be approxi- • Interview a person who is from a culture different from your own. You may use the interview mately four million gay elders requiring format from Chapter 6. Present the results orally social services and living in long-term care or in writing. This will reinforce the information facilities. How will that change the way nurses presented in Chapter 6, as well as provide first- provide care? Overtly, probably very little; hand information pertinent to this chapter. good nursing care will remain good nursing care. However, nurses may need to learn to alter their communication style to ask for and accept people’s preferences for roommate, l Box 5-2 Enhancing Cultural type of clothing to wear, or activities to Sensitivity attend. Activities may cross gender barriers in a different way than they do today. Who • Know your own attitudes, values, and shares bathrooms may become a different pri- beliefs. ority. Clearly, in the not too distant future, • Be aware of your own ethnocentrism. nurses practicing in clinics and long-term care • Be aware of your own prejudices that may or assisted living facilities can expect some influence your assessment. • Maintain an open mind and seek out more changes in the clientele as well as the way in information about your patient’s culture, which those people will require assistance. beliefs, and values. Additionally, more individuals are choos- • Communicate your interest about the ing to start and raise families as single parents. patient’s beliefs and values. Parents are adopting children from other • Approach the patient as an individual. countries, other ethnicities, and other races. Avoid assuming that all people from one One family may now include parents and sib- cultural background hold the same beliefs. lings with assorted skin tones and languages. Source: Gorman and Sultan (2008). Psychosocial Nursing for General The global family is rapidly and constantly Patient Care, 3rd ed. Philadelphia: F.A. Davis Company. evolving. 2993_Ch05_075-088 14/01/14 5:18 PM Page 80

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A B

C D

Figure 5-2 The deﬁnition of “family” is changing. A, Traditional family, with a mother, father, and their biological children. B, Single-parent family. (Courtesy of Robynn Anwar.) C, Gay couple and child. (Photograph by Creatas.) D, “Blended” family, in which each spouse has his or her own children, whom they bring into a new family. 2993_Ch05_075-088 14/01/14 5:18 PM Page 81

CHAPTER 5 | Sociocultural Influences on Mental Health 81 ■ Homelessness Homelessness is not a mental illness (Fig. 5-3). It receives brief mention in this text because many of the people in the United States who are homeless also have some threat to their mental health. The picture of the homeless population is as varied as those who have homes. Some people are working full-time but are homeless. They might be victims of the economy, foreclosures, or other situations not related in any way to having a mental illness. Since 2008, tent cities Figure 5-4 Tent city for the homeless in have appeared across America (Fig. 5-4). A Camden, New Jersey. (Courtesy of Robynn small number of people choose to live on the Anwar.) streets. Others have been forced to live on the street or in a shelter as a result of forces out of is linked to the rising cost of rental housing and their control. poverty (National Coalition for the Homeless, Many more of the homeless are suffering 2009). Because of the diagnosis, the availability from a variety of mental illnesses. Some people of benefits for the mentally ill, and the nature are homeless as an indirect result of the health- of the illnesses, people with certain illnesses care delivery system. Approximately one-third have a difficult time trying to live independ- of the homeless population in the United ently with their illness. They end up out of States is mentally ill, with many more having work, out of money, and out of a home. They substance abuse issues (Mental Health Asso- may be noncompliant with their medications, ciation of Colorado). The rise in homelessness have no access to getting refills, lose the medication, or have it stolen on the streets. A large number of people who use community-based mental health services are the poor, especially the homeless poor (Barry, 2002). Tragically, many of the homeless are also veterans. Serv- ices are available through Veterans Affairs, but the person may have challenges in how to access them.

■ ■ ■ Critical Thinking Question You are the only source of income for your family. You are laid oﬀ because of a merger of two agencies. How long can you survive with no income? How will you pay for insurance? Jobs are not plen- tiful; the outlook for comparable employment in the near future is bleak. How close are you to living on the street? What will be the plan of action for you and your family?

In the 1950s, deinstitutionalization led to the discharging of people who were techni- Figure 5-3 Homelessness is not a mental ill- cally able to be “in the community” but who ness, but many homeless people face threats were not always able to cope with the stresses to their mental health. (Courtesy of Telecom of caring for themselves, caring for their Pioneers, Nova 5 Chapter #5, Brooklyn, NY.) families, and maintaining employment. For 2993_Ch05_075-088 14/01/14 5:18 PM Page 82

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some mentally ill people, this kind of pressure Shelters of varying types exist in many and competition is the factor that keeps them cities. They are funded and staffed in different ill. The Urban Institute Study of 2000 estimates ways. For example, some are church funded there are approximately 3.5 million people and some rely on grants and underwriting by annually who are homeless. Approximately large businesses. Some are completely oper- one-third of those are children (Box 5-3.) ated by volunteers and some have some paid In 1987, the Health Resources and Ser - staff. Depending on the resources available, vices Administration–Health Care for the shelters for homeless people provide anything Homeless (HRSA–HCH) was formed to pro- from meals and overnight shelter to health vide information and help create plans to help care, dental care, and assistance with job the homeless. The problem is that funding of placement. federal programs depends on statistics, and it Often, however, behavioral conditions exist is extremely difficult to get accurate numbers in such shelters. Homeless people may be because they change markedly approximately required to stay drug- and alcohol-free and to every 2 months (Society Magazine, 1994). show proof that they are compliant with med- Patients may be brought to a facility through ications or some other criteria to help them the emergency department or by a law enforce- return to an improved lifestyle. ment agency. Sometimes medication is given to What techniques do nurses need to help stabilize the patient, and he or she is returned patients who may be homeless and physically to the community; other times the patient is or mentally compromised? admitted to a medical unit. Unfortunately, 1. Treat the whole person, not the sometimes the mental health issue is overlooked homelessness. because of the health-care provider's focus 2. Treat the person as any other patient. being on physical health. 3. Maintain all patient rights. ■ Economic Considerations l Box 5-3 Homeless in America. Who Are They? A study by Eron and Peterson in 1982 found that the lower the socioeconomic status, the Approximate higher the incidence of abnormal behavior Group Percentage Families with children 23% in U.S. society. That statement, however, is (2007) not completely accurate. The study showed Children under the age 39% that the statement applies more strongly to of 18 (2003) patients with schizophrenia than it does to People between the 25% those with mood disorders. The implication ages of 25–34 (2004) is that there are always other variables People ages 55–64 besides socioeconomic status. For example, (2004) 6% people who live in poverty or underprivi- Single females (2007) 65% leged circumstances will very likely have Single males (2007) 35% greater stressors than will people of higher Veterans of wars (served 40% in the armed forces) socioeconomic status. So, is it the lack of African American (2006) 42% money or increased stress that leads to the Caucasian (2006) 38% disorder? Such questions make it very diffi- Hispanic (2006) 20% cult, if not impossible, to make absolute Native American (2006) 4% statements about the correlation between Asian (2006) 2% disease and any variable. Behaviorists em- Note: These numbers are approximations phasize that people always have a choice. If and will vary according to the study and the the foregoing statements about poverty and area of the country. illness were completely true, then it would Source: National Coalition for the Homeless (2009). Who is Homeless? follow that all people in that same circum- Retrieved from http://nationalhomeless.org/factsheets/who.html. stance would be mentally ill. 2993_Ch05_075-088 14/01/14 5:18 PM Page 83

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However, this is simply not the case. What was parented. That means all the cultural and variable causes some people to be ill and others religious values that have been planted in one not to be ill? Is it choice? Is it genetic? Is it parent’s belief systems are brought out in the learned behavior? This is part of the intrigue open and blended with those values from of the study of the mind. the other parent’s upbringing. Then, it is up to the parents to take one day at a time and ■ Abuse learn from their mistakes. Sometimes parenting is learned from friends and neighbors. Abuse is misuse of a person, substance, or Sometimes schools, health-care facilities, and situation. Sometimes people say that they communities offer classes for parents. cannot be abusing because they know what they are doing. This is not true. Anyone who ■ ■ ■ Critical Thinking Question misuses or overuses a person, a substance, or You are home one evening and you hear the a situation (such as gambling or power) is 18-month-old child of your upstairs neighbors. displaying abusive behavior. The child has been crying for 3 hours. You have Some individual forms of abuse are dis- heard no footsteps in the apartment. The answering machine picks up each time you attempt to cussed in Chapter 22. Abuse in general is a call. You become concerned and call the building growing phenomenon in society. People de- supervisor to open the apartment. When you get bate about whether a higher incidence of in, you find unsanitary conditions, and the parents abuse exists now or whether people are just are not in the apartment. You look outside and talking about it more openly. Violence is a see the parents several apartments down, partying with friends. What are your responsibilities? learned behavior. It is well documented that How will you respond to the parents? Whom will in the majority of physical abuse situations, you notify? The parents tell you to mind your own the abuser was abused at some point. business. What will you say to them? What will When it comes to substance abuse, the you do if it happens again? findings are not quite as conclusive. Some studies indicate that this type of abuse may be genetic, learned, or possibly due to a Reactions to altered parenting styles are chemical imbalance in the body. A phenom- varied. Again, there is no “perfect” situation enon called the “addictive personality” is or guarantee of being “good” parents. Parent- defined as grouping abuse disorders together. ing is stressful. No matter what patients are It is important for nurses to understand that concerned about during their hospitalization, there may be more than one cause for a it is almost certain that their children will be particular mental health problem. Good a paramount focus of attention. Nurses can communication and data-collecting skills will help parents not only through the stress of help the nurse find potential causes for each being hospitalized and apart from their chil- patient’s mental health problem. dren, but also with the stresses of parenting in general by helping parents choose healthy ■ lifestyles. Good nutrition, moderate exercise, Poor Parenting and “adult time” apart from the children can be effective stress relievers. What is a “good” parent? Is it the parent who Diana Baumrind (1971) has classified lets the child do anything the child wants? Is three different types of parents. They are it the parent who buys all the newest fads for described as follows: the child? Is it the parent who teaches strict values and ethics? Maybe it is the parent who 1. Authoritarian parent: This parent sets up is with the child at all times. Parenting is the very strict rules. The child has little or method of raising children that is used by par- no voice in family decisions. This style ents or other primary caregivers. Parenting is of parenting is evidenced by novelty a learned behavior; it is not an innate skill. So, clothing imprinted with the saying, how do parents learn to be parents? Typically, “Because I’m the Mommy/Daddy, that’s one tends to parent based on the way he or she why!” This authoritarianism can lead 2993_Ch05_075-088 14/01/14 5:18 PM Page 84

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to a rebellious, hostile child who may ■ ■ ■ Clinical Activity enter adulthood angry, violent, unwill- Choose someone you know who is a parent. ing to obey laws, and unable to make This can be a family member, friend, neighbor, consistent decisions. or anyone you feel comfortable with. Using the 2. Authoritative parent: This style of parenting parenting definitions of Diana Baumrind, identify what basic parenting style you think this has firm, consistent rules and limits, while parent uses. allowing for discussion and occasional flex- ibility of those rules according to special circumstances. Children are allowed some freedom, within set limits, and some voice ■ ■ ■ Key Concepts in decisions. Researchers think that this is the preferred style of parenting. It offers a 1. Culture, ethnicity, sexual orientation, balance between rules and responsibilities, and religion are deeply rooted human which allows the child to learn to make experiences. They are not “good” or appropriate choices and accept the out- “bad”; they are different for each indi- comes of those choices. vidual or group of individuals who 3. Permissive parent: This is the type of claim membership in that culture, parent many adolescents wish they had. ethnic group, or religion. This style of parenting provides little 2. People have many more similarities than structure and few guidelines. The child they have differences. It is important for is not sure of his or her boundaries. If nurses to concentrate on the similarities one does not learn boundaries, it be- among people and to be comfortable comes difficult to learn how to control asking questions about the background oneself and how to behave in certain of their patients and coworkers. Role situations. Permissive parents can be in modeling cooperative relationships can danger of being accused of neglect. The be very helpful in teaching others about parent acts as the child’s friend rather cultural sensitivity. than the parent of the child.

CASE STUDY Harold is a 76-year-old nursing home who can participate in his care. He no resident. He has type 1 diabetes and gives longer meets the criteria for skilled-care himself his own insulin. He has the diagno- nursing. A decision must be made about sis of paranoid schizophrenia but has been his future, as he will no longer be eligible asymptomatic for 1 year. Harold is also a to remain in this nursing home. Harold severe alcoholic, and he periodically leaves wishes to be his own advocate and is found the nursing home against medical advice to be legally capable of making his own and is gone for 2 to 3 days. He has friends decisions. The outcome for this patient is “on the street” because, before being insti- that he chooses to “take my chances” and tutionalized, that is where he lived. Harold return to the streets. He has not been seen goes to the local shelter for meals and again by any of the nursing home staﬀ. No knows he can go to the hospital to get his further information is available about this insulin. He has no family in the vicinity patient.

1. Considering Maslow’s Hierarchy of Needs, how would you classify Harold? 2. What are the arguments both for and against his decision to leave the nursing home? 3. Do you consider Harold to be mentally healthy and competent? Why or why not? 2993_Ch05_075-088 14/01/14 5:18 PM Page 85

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REFERENCES Merriam-Webster. (2012). Merriam-Webster; an Encyclopedia Britannica Company. Retrieved Barry, P.D. (2002). Mental Health and Mental from www.merriam-webster.com/dictionary/ Illness. 7th ed. Philadelphia: J. B. Lippincott. homeless Baumrind, D. (1971). Current patterns of National Coalition for the Homeless. (2009). parental authority. Developmental psychology Who is homeless? http://nationalhomeless.org/ (monograph 1), 4, 1–103. factsheets/who.html Cummins, H.J. (June 22, 2003). Coming out, Purtilo, R., and Haddad, A. (2002). Health moving on. Minneapolis, MN: Star Tribune. Professional and Patient Interaction. 6th ed. Eron, L.D., and Peterson, R.A. (1982). Abnor- Philadelphia: W.B. Saunders mal behavior: Social approaches. In M.R. Social science and the citizen: Counting home- Rosenzweig and L.W. Porter (Eds.), Annual less (1994, November/December). Society review of psychology 33, 231–65. Magazine. Galanti, G. (1991). Caring for Patients From Todd, K.H., Deaton, C., D’Adamo, A. P., and Diﬀerent Cultures—Case Studies From Goe, L. (2000). Ethnicity and analgesic American Hospitals. Philadelphia: University practice. Annals of emergency medicine, 35, of Pennsylvania Press. 11–16. Giger, JN. (2013). Transcultural Nursing. St Louis: Mosby. Gorman, L.M., and Sultan, D.F. (2008). Cul- WEB SITES tural considerations. In Psychosocial Nursing Cultural Competence for General Patient Care. 3rd ed., pp. 49–56. www.nooruse.ee/e-ope/mitmek_oendus/transcultural_ Philadelphia: F.A. Davis. nursing.pdf Kaplan, B.J. (November 2002). Gay elders face Homelessness uncomfortable realities in LTC. Caring for the http://nationalhomeless.org/factsheets/who.html Ages, American Medical Directors Association Culture (November 2002), Vol. 3, No. 11. www.uniteforsight.org/cultural-competency/module1 Leininger, M. (2006). Part one: Madeleine M. Parenting Leininger’s theory of culture care diversity www.oberlin.edu/faculty/ndarling/lab/psychbull.pdf and universality. In M. Parker (Ed.), Nursing www.devpsy.org/teaching/parent/baumrind_styles. Theories and Nursing Practice. 2nd ed., html pp. 309–320. Philadelphia: F.A Davis. Gay and Lesbian Task Force Martin, M.L. (2000). Ethnicity and Analgesic http://ngltf.org/ Practice: An Editorial. Annals of emergency Religion medicine, 35, 77–81. www.religionfacts.com/ Mental Health Association of Colorado. Home- lessness. www.mhacolorado.org/file_depot/ 0-10000000/Homelessness.pdf 2993_Ch05_075-088 14/01/14 5:18 PM Page 86

86 UNIT 1 | Foundations for Mental Health Nursing Test Questions Multiple Choice Questions 1. The concepts of space, time, and waiting 6. Parents accompany their ill 8-year-old are: child to the clinic. The child was diag- a. Religious nosed last month with type 1 diabetes b. Cultural and is insulin dependent. The parents c. Economic admit they are not administering the d. Ethnic insulin, as their religious beliefs do not 2. The condition of judging a person or allow foreign substances in any form situation before all the facts are known is for any reason. A check of the patient’s called: chart clearly indicates that diabetes a. Hatred teaching had been done with this family b. Abuse unit at last month’s visit. Your initial c. Prejudice nursing action is: d. Stereotype a. Report the parents for child endangerment, as nurses are mandatory 3. Homelessness is being blamed, in part, on: reporters. a. Deinstitutionalization b. Inform the parents that this child b. Access to community services could die without the required c. Mental illness insulin. d. All of the above c. Leave the room and call a doctor or 4. Nurses who care for patients who are RN to the room stat. homeless understand that in the United d. Collect information pertaining to what States: the religion would allow and facilitate a. Homelessness is classified as a mental discussion with the doctor. illness. 7. When collecting data during an intake b. Approximately one-third of the home- interview, the nurse understands: (select less are mentally ill. all that apply) c. All the homeless have some form of a. Most homeless people are unemployed. mental illness. b. Culture is a shared belief system. d. People must be mentally ill to choose c. Prejudice exists within the health-care to be homeless. delivery system. 5. A patient is admitted with the diagnosis d. There is no correlation between of paranoid behavior. The patient claims mental illness and the condition of to be of a religion requiring the wearing homelessness. of very heavy necklaces. You research the 8. The most common reasons for homeless- religion and determine this to be true, ness include: (select all that apply) but the patient has been seen violently a. Economic setbacks flinging a necklace at his or her room- b. Lack of ambition and laziness mate. Your best nursing action is: c. Major health expenses a. Call an assistance code. d. Desire to live independently b. Remove all religious items. E. Mental health c. Do nothing: it is his or her religious right. 9. Language, country of origin, and skin d. Enlist the assistance of a religious color define: representative to negotiate removal a. Religion of the item(s) in question. b. Culture 2993_Ch05_075-088 14/01/14 5:18 PM Page 87

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c. Ethnocentrism b. The parents are always reminding the d. Ethnicity child that they are the parents. 10. Diana Baumrind describes authoritative c. The child has a minimum amount of parenting as: guidelines. a. The child has little or no voice in any d. The child has rules and has limits set. of the family’s decisions. 2993_Ch05_075-088 14/01/14 5:18 PM Page 88 2993_Ch06_089-104 14/01/14 5:19 PM Page 89

CHAPTER 6 Nursing Process in Mental Health

Learning Objectives Key Terms 1. Define the role of the LPN/LVN in the five steps of the nursing • Affect process. • Awareness 2. Identify the components of a mental health status • Data collection assessment. • Evaluation 3. State the need for the nursing process in mental health issues. • Formal teaching 4. State the concepts of patient interviewing. • Implementation 5. Prepare a patient interview. • Informal teaching 6. Collaborate in creating a nursing process for a given, hypo- • Judgment thetical patient. • Memory 7. State the concepts of patient teaching. • Mood 8. Prepare and implement a teaching exercise. • North American Nursing Diagnosis Association (NANDA) • Nursing diagnosis • Nursing Interventions Classification (NIC) • Nursing Outcomes Classification (NOC) • Nursing process • Orientation • Patient interview • Patient teaching • Plan of care • Scope of practice • Subjective • Thinking/cognition

he nursing process is a tool used produce a favorable outcome for the patient. throughout all areas and levels of nurs- In preparing to care for the patient with the Ting (Fig. 6-1). The nursing process use of the nursing process, the nurse will need is a formula for nurses to provide individual to incorporate critical thinking to arrive at the patient care and learn how to organize and planned outcome. It is part of the culture of implement that care in a systematic, universal nurses to be part of a positive outcome. way. The nursing process also allows the nurse Scope of practice, determines that the reg- to determine if the plan and interventions istered nurse (RN) and the licensed practical

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Nursing Assessment Planning Intervention Evaluation diagnosis

Figure 6-1 Steps in the nursing process.

nurse/licensed vocational nurse (LPN/LVN) best choices concerning that person. Nurses play different roles in the nursing process. In collect data about the patient and his or her the early 1950s, Hildegard Peplau (Chapter 1) condition. In most cases, this is accomplished hypothesized that nurses are a tool best with the help of a form that is used by the utilized in relationship to the patient and the facility. Nurses also use nonverbal communi- environment and in collaboration with other cation skills to assess the patient’s attitude, nurses and health-care professionals. She tone of voice, facial expression, and so on. stressed the phases of a working relationship The problem with many of these generic that included a termination phase where forms is that they are written in closed-ended nurses prepare both themselves and their format. They are very impersonal and may patients for termination of the relationship. not reflect the specific information needed Her model is still widely used in nursing about that patient. process and nursing practice today. It is during the data collection/assessment part of the nursing process that the mental sta- Neeb’s LPNs/LVNs should know and under- tus exam is performed. The mental status exam ■ Tip stand their scope of practice in order is a series of questions and activities that check to provide safe and effective health eight areas: the patient’s (1) level of awareness care. and orientation, (2) appearance and behavior, (3) speech and communication, (4) mood and affect, (5) memory, (6) thinking/cognition, In the early 1970s, the American Nurses (7) perception, and (8) judgment. These Association (ANA) developed Standards of examinations are of varying lengths and Practice for RN and LPN/LVN prepared formats, but they all assess the patient’s mental nurses. The association differentiated between capabilities. the RN’s role and the LPN’s role in the nursing Table 6-1 lists areas to be included in a process. Individual state Nurse Practice Acts mental status examination. It also suggests the and Boards of Nursing may also offer their type of assessment made and ideas for ques- own interpretation of the ANA guidelines tions or commands used by members of the relating to the role and scope of practice for health-care team to make the assessments, as the LPN/LVN prepared nurse in the nursing well as some parameters for responses of a process. The following provides step-by-step person with normal and abnormal mental implementation of the nursing process. functioning. ■ Step 1: Assessing the Patient’s Mental Health Tool Box | Mental Health Status Examina- tions Components Assessment is the first step in the nursing www.ncbi.nlm.nih.gov/books/N BK 320/ process. The role of the LPN/LVN in Step 1 is to assist with the assessment. The registered nurse is responsible for the initial assessment There are many ways to improve the when the patient is admitted or transferred in quality of data collection. Two ideas for im- a facility. Data collection is made during proving data collection in the form of inter- every contact a nurse has with a patient. It is views are listed here. Remember, this is not essential to the well-being of the patient and an exhaustive list of reasons to interview in assisting the medical team in making the patients. For the purposes of this text, the 2993_Ch06_089-104 14/01/14 5:19 PM Page 91

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l Table 6-1 Mental Health Status Examination Suggested Methods Alterations Area of Type of of Assessment and to Normal Assessment Assessment Normal Parameters Assessment Appearance Objective and Clean, hair combed; clothing Displays either subjective intact and appropriate to weather unusual apathy observations or situation. or concern about such as dress, Teeth in good repair. appearance. hygiene, pos- Posture erect. ture; and about Cooperates with health-care the patient’s personnel. actions and reactions to health-care personnel. Behavior Objective Cooperates with health-care Displays uncoopera- personnel. tive, hostile, or suspicious-type behaviors toward health-care personnel. Level of Subjective and Awareness is measured on a con- Outcome is not Awareness objective assess- tinuum that ranges from uncon- within normal limits ment of the pa- sciousness to mania. “Normal if the patient is diffi- tient’s degree of alertness” is the desired behavior. cult to arouse and alertness (wake- There is usually a standard guide- keep awake or finds fulness). line for helping with this assess- it difficult to feel ment, but subjective observations calm. can be documented as well, if the patient cannot stay awake for even short intervals or is overly active and has difficulty staying in one place for any period of time. Orientation The degree of Orientation measures the person’s Abnormal results of patient’s knowl- ability to know who he or she is, orientation are the edge of self. where he or she is, and the day patient’s inability to and time, usually within 1 or correctly answer 2 days of the actual day and time. questions pertaining Measurement techniques are to the patient or to accomplished by asking the commonly known patient, “What is your name?” social information. “Where are you right now?” and “Tell me what the day and date are.” Asking “Who is the president of the United States?” is used here as well. Nurses frequently document this as “oriented ×3,” but it is best to also write down the objective data on which this routine answer is based.

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l Table 6-1 Mental Health Status Examination—cont’d Suggested Methods Alterations Area of Type of of Assessment and to Normal Assessment Assessment Normal Parameters Assessment Thinking/ Subjective Formal testing may be undertaken Behaviors including Content of assessment of by the psychologist or psychiatrist flight of ideas, loose Thought what the patient to determine the patient’s general associations, phobias, is thinking and thought content and pattern. delusions, and obses- the process the Nurses may contribute to the sions may become patient uses in assessment of thought by docu- apparent. These thinking. menting statements the patient alterations in “normal” makes regarding daily cares and thought processes routines. are defined and discussed in future chapters that relate to specific illnesses. Memory Subjective Recent memory: Recall of events Inability to accurately assessment of that are immediately past or up to perform recent or the mind’s ability within 2 weeks before the assess- remote recall exer- to recall previ- ment. One measurement tech- cises within parame- ously known re- nique is to verbally list five items. ters; may indicate cent and remote After 1 minute, patient should be symptoms of delirium (long-term) able to recall 4–5 of those items. or dementia. information. Continue with assessment and at 5 minutes, patient should be able to recall 3–4 of the items. Remote memory: Recall of events of the past beyond 2 weeks prior to assessment. Patients are often asked questions pertaining to where they were born, where they went to grade school, and so on. Speech and Objective and Patient can coherently produce Limited speech Ability to subjective as- words appropriate to age and production; rate of Communicate sessment of as- education. speech is inconsis- pects of patient’s Rate of speech reflects other tent with other psy- use of verbal psychomotor activity (e.g., faster chomotor activity. and nonverbal if patient is agitated). Volume is not appro- communication. Volume is not too soft or too loud. priate to situation Stuttering, repetition of words, (speaks at a very loud and words that the patient “makes volume even when up” (neologisms) are also assessed. asked to speak more quietly). Stuttering, word repetition, or neologisms may indicate physical or psychological illness. 2993_Ch06_089-104 14/01/14 5:19 PM Page 93

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l Table 6-1 Mental Health Status Examination—cont’d Suggested Methods Alterations Area of Type of of Assessment and to Normal Assessment Assessment Normal Parameters Assessment Mood and Subjective and Mood is the stated emotional Mood and affect do Affect objective assess- condition of the patient and not match (e.g., facial ment of the should fluctuate to reflect situa- expression does not patient’s stated tions as they occur. change when stating feelings and Facial expression and body lan- opposite feelings). emotions. guage (affect) should match Affect measures (be congruent with) stated mood. the outward Affect should change to fluctuate expression of with the changes in mood. those feelings. Abstract Subjective Give patient a “proverb” to inter- Patient cannot inter- Thinking/ assessment of a pret, such as “You can’t teach an pret the sayings in an Judgment patient’s ability old dog new tricks.” Patient should acceptable manner. to make appro- be able to give some sort of Patient cannot priate decisions acceptable interpretation such as complete problem- about his or her “old habits are hard to break” or “it solving questions situation or to is hard to learn something new.” appropriately. understand Or give the patient a situation to The patient might concepts. solve (judgement). answer very literally, For example, ask the patient what “Dogs can’t learn he or she would do if a small child anything when they were lost in a store. An appropri- get old” or “I would ate response might be “to call the go through the manager” or “to try to calm the child’s pockets to child.” see if there were any phone numbers in them.” Perception Assesses the way All five senses are monitored for Presence of halluci- a person experi- interaction with the patient’s nations and illusions. ences reality. reality. These are discussed Assessment is Patient’s insight into his or her further in Chapter 15. based on the condition is also assessed. Individuals who are patient’s state- not within normal ments about his boundaries of judg- or her environment or insight will ment and the not be able to state behaviors associ- understanding of the ated with those origin of the illness statements. and the behaviors Nurses and associated with it. health-team members must document this often-subjective information in objective terms. 2993_Ch06_089-104 14/01/14 5:19 PM Page 94

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word interview pertains to any nurse-patient ■ ■ ■ Critical Thinking Question interaction that requires a nurse to obtain Pick a student partner to interview. Select any specific information from a patient. The topic and develop a 5-minute interview. Write it patient interview is usually the primary twice: once with only closed-ended questions method of data gathering. It is important to and aggressive statements, and once with only open-ended questions and assertive statements. collect data about the whole person. Data Compare the two versions. How was it diﬀerent related to thoughts and feelings are as im- as the interviewer and how was it diﬀerent for portant to any nurse-patient interview as the the interviewee? physical data collected.

■ ■ ■ Classroom Activity profitable experience for both the nurse and • Group activity: Discuss the normal parameters the patient. presented and your perception of what is normal in light of the mental health status examination. 2. Helping Interview The helping interview is used to determine or isolate a particular concern of the patient and to help the patient learn to help herself or 1. Intake/Admission Interview himself (Fig. 6-2). Patients may trust nurses Most facilities have developed standard in- because nurses have built a rapport with them terview forms that suit their particular and are usually more easily accessible than needs. The forms are written in a very physicians. It is always important to remem- matter-of-fact way and are usually in a ber, though, not to help to the point of inter- closed-ended format (Chapter 2). Patients fering with the patient’s ability to help herself who are frightened, angry, or just too ill at or himself. the moment may easily refuse to answer Consider a situation in which the patient is those closed-ended questions. The patient not progressing according to a “normal” post- may have heard the questions before and operative course. The nurse notices the patient feel frustrated by what he or she perceives weeping and senses that a need is not being to be inefficiency or poor communication met. The nurse can use this opportunity and among the staff when the same questions observation to begin obtaining information are repeated. This can set up both the nurse and the patient for a difficult time. It is up to the nurse to rephrase the questions in an open-ended format that will seem more individualized to the patient. EXAMPLE Standard form: “Do you smoke or use alcohol? _____ YES _____ NO.” Nurse interviewer: “I am required to provide you with information about the hospital’s policies on the use of tobacco and alcohol.” This statement might then be followed by the standard closed-ended question, “Do you use any tobacco or alcohol?” Figure 6-2 The helping interview allows the nurse to determine a patient’s special Questions can be changed from the needs and concerns. (From Williams and closed-ended type to open-ended in most Hopper (2011). Understanding Medical-Surgical cases. Practice and patience on the part of Nursing, 4th ed. Philadelphia: F.A. Davis Company, the nurse interviewer will make this a more with permission.) 2993_Ch06_089-104 14/01/14 5:19 PM Page 95

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from the patient that may help explain the Tool Box | Nursing Diagnoses: delayed postoperative progress. http://www.nanda.org Guidelines for Nurse-Patient Helping Interview It is the registered nurse’s responsibility to 1. Be honest: Tell the patient the purpose of assimilate the data that has been collected the interview. and choose one or more potential nursing 2. Be assertive: If the interview is mandatory diagnoses for the patient. The LPN/LVN (e.g., intake, preoperative), the patient needs to understand the function of the must understand that it is required. nursing diagnosis. In collaborative nursing Contract for a mutually acceptable time practice, LPN/LVNs can make suggestions to conduct the interview so that the pa- and offer rationales to the RN that may be tient will be aware of the time involved. incorporated into the patient’s plan of care. 3. Be sensitive: Sometimes the questions are An emerging format for writing a diagnos- very difficult or embarrassing for the pa- tic statement for a patient’s plan of care is the tient to answer. The nurse should assure P.E.S. Model. The components of this model the patient that he or she understands the are: P, the problem or need; E, the etiology or patient’s feelings and that the information cause; and S, the signs, symptoms, or risk fac- shared by the patient is part of the pa- tors. The nurse blends these components into tient’s medical record. Only the patient, a “neutral” statement that avoids value-laden the patient’s designee, and people who are or judgmental language. The nursing diagno- involved in his or her caregiving will have sis is not a medical diagnosis as used by physi- access to this information. cians. Rather it is a common language among 4. Use empathy: The nurse should let the nurses to help clarify the patient’s needs (see patient know that he or she is interested Appendix E, Assigning Nursing Diagnoses to in what is being said and that the nurse Client Behaviors). is there to be helpful. Acknowledge the patient’s feelings but do not judge the ■ Step 3: Planning (Short- patient. 5. Use open-ended questions: Personalize the and Long-Term Goals) questions as much as possible. Use this The LPN/LVN role is again as a partner in time to discuss and clarify as much infor- care planning. The ANA believes that the RN mation as you can to avoid having to has the primary responsibility for this step of repeat parts of the interview later. the nursing process. Planning care involves ■ setting short-term and long-term goals from Step 2: Nursing the patient’s perspective, not from the nurse’s Diagnosis: Defining perspective. It is for this reason that the Patient Problems patient and significant others must be involved in the plan of care. Recovery will hap- Processing the collected data is a function of pen much more quickly if the patient plays the registered nurse, according to the ANA. an active role in decision making and does Once data is collected, nursing diagnoses are not have the impression that treatment is identified. Nursing diagnoses are a universal being done to or for him or her but rather language on which the interventions are collaboratively with the person. based. There are different models or theories Prioritizing the goals is the second part of of nursing diagnosis that may be used and planning care. This is one area in which the recommended by your work setting. These patient and the nurse might not see things include nursing diagnoses published by the the same way. Nurses and patients look at the North American Nursing Diagnosis Asso- same problem from two different perspec- ciation (NANDA). tives, and the patient’s priority may be quite 2993_Ch06_089-104 14/01/14 5:19 PM Page 96

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different from the nurse’s priority. Whenever prior teaching. Relaying information about possible, the patient’s priority should be implementation (putting the care plan into considered. When there is a threat to life or action) and patient progress to the RN will health that is a direct response to the patient’s provide the information the team needs to priority, however, the nurse must intervene offer the best possible care for the patient. and explain the reason that the patient’s Nurses also need to understand and specify wishes will have to wait a while. the rationale (reason) for the implementa- The aim of selecting goals that will im- tions that are selected and be prepared to ex- prove mental health status is to keep the plain them to patients and families provided mind-body connection intact. It is estimated the patient consents to their involvement. that about 95% of physical healing is related Table 6-2 provides information about the to a positive mental attitude (PMA). It will nursing process. be of great help to the patient if the nurse States differ in the role the LPN plays in is able to detect alterations in that mental outcome statements or performing an evalu- attitude and set goals with the patient to ation of interventions. In much the same maintain the best outlook and strongest pos- way NANDA developed problem or nursing sible effective coping skills. In planning the diagnostic standards, work is being done to patient’s goals, there should be a short-term standardize outcome statements. Nursing and long-term goal for the patient. Both goals Interventions Classification (NIC) is a com- should be realistic and measurable with a tar- prehensive standardized language. It provides get date for them to be completed. a number of direct and indirect intervention labels with definitions and possible nursing ■ Step 4: Implementations/ actions. The interventions address general practice and specialty areas (Doenges and Interventions Moorhouse, 2003). The LPN’s role is to assist with identifying and carrying out the specific steps that will ■ ■ ■ Clinical Activity help the patient reach the goals. Nurses are If your clinical affiliates will allow, arrange to shadow able to provide input about new interven- a nurse from the mental health unit. Write a summary of the following experience: tions that may be helpful, and the LPN/LVN • Observations of the nurse-patient relationship is often the person who begins to help adapt • Communication style certain procedures to assist the patient. A • Understanding nurse may use this opportunity to conduct • Patient responses some new patient teaching or to reinforce

l Table 6-2 The Nursing Process Nursing Diagnosis Implementation/ Assessment (NANDA) Planning Intervention Evaluation Subjective/ Relates to Planning the Deﬁnes what actions Patient’s outcome. Objective the assess- patient’s the nurse/health-care The nurse/health-care ment data outcome: provider will provide. provider can deter- to deter- Short-term The nurse/health-care mine if the plan and mine how goals provider should be the interventions the nurse Long-term goals able to provide a provide the expected will plan Must be: rationale for each outcome. Determine for the care Measurable and action/treatment which interventions needed. realistic with provided. can be terminated. target dates. 2993_Ch06_089-104 14/01/14 5:19 PM Page 97

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Tool Box | The nursing process is a system- legal ramifications to teaching as well. Even atic approach in providing care. with standardized teaching tools, nurses still http://nursingworld.org/E speciallyF orY ou/ need to be aware of some principles of teach- W hat-is-N ursing/Tools-Y ou-N eed/ ing and learning. Nurses have an advantage Thenursing process.html in teaching because, with the exception of nursing diagnosis, the same format they learned for nursing process can be used for setting up a teaching plan. ■ ■ ■ Critical Thinking Question Teaching in any form is most effective Your state Nurse Practice Act allows you, the LPN/ when it is started as soon as possible after LVN, to oversee care and function as a charge nurse, as long as a registered nurse is on call. Your admission. Nurses teach patients in different medical patient has gone out on a 3-hour pass ways. Teaching falls under the categories of with relatives and returns to your agency refusing either formal teaching or informal teaching. to perform the guidelines as stated in the care Formal teaching is any situation in which plan. Your patient is argumentative but answers a class is scheduled or a specific objective questions appropriately. Your data collection includes fruity odor on breath, mood swings, and must be met. The instructor is often a staff hunger. You need to re-evaluate and revise the nurse who has worked in the specific area care plan but are unable to make contact with the being taught. Formal teaching involves a RN on call. What would you consider to be appro- nurse instructor and one or more patients. priate nursing diagnoses? What interventions can Usually a preset curriculum is used in these you perform and still remain within your state’s scope of nursing practice? classes. The time to teach in the formal setting will most likely be limited by the facility according to staffing needs, because the nurse instructor probably also has a patient assign- Patient Teaching ment. Examples of formal teaching include Many implementations or interventions that diabetic teaching and back-care classes. are helpful to the patient involve patient teaching. Frequently, facilities have special ■ ■ ■ Classroom Activity teams or departments to carry out certain • Divide the class into groups of five. Each group teaching (e.g., diabetes education), but teaching should provide a presentation of the steps in is becoming a bigger part of a nurse’s respon- the nursing process using different learning sibility. This is true at all levels of nursing styles. preparation. The doctor is still responsible for the initial information given, but the nurse does the “fine-tuning” required to send pa- Informal teaching, or adjunctive teaching, tients home safely. Nurses teach about medica- happens anytime, anywhere, whenever the tions, coping strategies, adaptive equipment, patient needs information. The patient may and anything else the patient requires, not only see the nurse in the hall, or the nurse may no- for the period of hospitalization, but also for tice that the patient is working with the the time when the patient leaves the facility. colostomy bag in his room or reading the ex- Individual states and facilities set the guidelines ercise pamphlet. These are excellent times to regarding teaching responsibilities for doctors reinforce what the patient has learned or to and nurses. make gentle suggestions for improving his or Everyone needs a little help to get started her technique. with teaching, regardless of what sort of teaching will be done. Like the forms used for ■ ■ ■ the patient interviews, the facility may use Clinical Activity Review the medication chart of your assigned standardized classes or teaching sheets. This patient and provide an informal teaching about practice helps ensure that continuity exists in one of the medications. Write the outcome of the teaching and that the critical information has informal teaching. been given to the patient. There are some 2993_Ch06_089-104 14/01/14 5:19 PM Page 98

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Principles of Learning nurse-teacher will need to adapt the care Nurse-teachers need a basic understanding of plan to meet a particular patient’s need. the principles of learning and teaching. Some A nurse-teacher who is not comfortable of these principles are listed here: with the material will be less helpful to the patient than one who can individual- 1. Each person learns differently. Some ize the curriculum to the various needs people process information visually, of the class. others by hearing, and still others by 3. Have a teaching plan: A good teaching hands-on (tactile) learning. plan will improve a nurse’s confidence 2. Each person learns at his or her own pace. and delivery of the material. A teaching The larger the class, the more levels of plan is constructed in much the same ability the nurse will have to work with. way as the nursing process. A very simple Some patients catch on more quickly than format, such as APIE for the nursing others. process, may be easily transformed into 3. People learn best when the information a teaching format. An example of the is meaningful to them. Nurses should APIE format follows. think of their own education: The things • A = Assessment. What is the need for they are interested in are the things they the teaching? Who are the patients? work harder at. Subjects that they do not How much time is available? Assessing like seem to be hard or boring, yet they the need to teach can be as simple as are required for graduation. Patients may one or two statements. For example, not see the importance of the class that “Good afternoon, everyone. My name they may be required to attend as a crite- is Sandy. This is the class about bipolar rion for discharge. care, and it is open to anyone diagnosed 4. Learning is most effective when the in- with bipolar disease.” Assessment can formation is presented in small segments. also be enhanced by the use of a pre-test This may be dictated by the facility, but or questions to the class to determine when the nurse can be flexible, it is best their past knowledge in this area. to present only as much as the patient • P = Plan. In true nursing process, can absorb. this is often called the goal. Nurse- 5. Success breeds success: Positive reinforce- teachers need to ask themselves a ment will help the patient succeed at few questions, such as: What do you learning the required task. The stronger plan to accomplish in the session? the positive reinforcement, the greater How do you think you will do it? the learning. Once patients have been Again, this can be accomplished in successful, they will want to continue one or two statements. For example, to learn. “This is the first in a series of three classes, and the task for today is to Neeb’s Active listening enables the nurse to ■ focus on the patient’s strengths. learn about the different types of Tip appliances and equipment you have available to you.” What is accomplished in the first session is consid- Principles of Teaching ered as a short-term goal and the 1. Know the patients: What are their abili- accomplishments in the third session ties? What is their prior level of knowl- will be the long-term goal. edge? What are the cultural or language • I = Implementation. This is the step- differences of the patients in the class? by-step method nurse-teachers use to 2. Know the material: It is not as important accomplish the plan. It is similar to to give a perfect lecture or demonstration the implementation portion of the as it is to be able to interpret the ques- nursing process. The nurse-teacher tions patients may have. Sometimes the will have as many or as few steps as 2993_Ch06_089-104 14/01/14 5:19 PM Page 99

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needed. In prepared curricula, the the teaching. This requires familiarity with steps are written out, but it may or some commonly used methods of teaching. may not be necessary to perform each Teachers tend to teach according to the step. This will depend on the patient method of learning they prefer. For instance, group. Chances are good that a class if nursing students prefer lecture classes, they or skill will never be taught exactly the probably feel most comfortable teaching in a same way twice. There will, however, lecture format. If a specific nursing instructor be critical items that nurses need to was particularly helpful to a nurse as a stu- cover with all patients to meet legal dent, the nurse may prefer to role-model that and safety issues. teacher’s methods when teaching patients. No • E = Evaluation. In a teaching plan, teaching method is better or worse than any nurses evaluate the patient’s learning other method. What makes the difference as well as the teaching performance. is the learning style of the patients and the Some questions that nurse-teachers rapport that nurses build with them. Because need to reflect on for this part of the classes in facilities generally have more than teaching plan are: How do you know one “pupil,” the nurse-teacher will need to be the patient has grasped the concepts able to use different methods of presenting. and skills from the class? What do you Because people’s personalities are different, look for? Do you need to ask for a each group will have a different dynamic and return demonstration? Does it need to each class will be different. be perfect? How did you do? Did you The typical methods used in health teach- achieve the plan? Did you have enough ing are lecture and demonstration. time? Too much time? What will you 1. Lecture: This is a method designed for do differently next time? How did information giving. It is unilateral; the your students evaluate the session? nurse talks, and the patients listen. It is Evaluation criteria may change from interactive only when there is some form time to time as well. of question-answer period or brainstorm- 4. Be flexible: To the extent that the facility’s ing. Lecturing is an excellent method program allows, be familiar enough of introducing a topic to patients and with the material to be able to build in giving them some theory. It is a way to extra practice time for the tactile learn- explain the significance so the material ers, extra videos for the visual learners, becomes meaningful. or time to review verbally for the auditory learners. Be able to teach in several In preset programs, the lectures are usually different styles. prepared in either text or outline form, so 5. Be able to evaluate the learning: In health the nurse-teacher has to invest minimal time teaching in the facility, evaluation can be researching, writing, or setting up for the in the form of a question-answer session, lectures. Lecture classes may include videos, a short quiz, or a return demonstration. slides, or charts. Learning from the lecture 6. Plan to allow a few minutes after the class method is traditionally evaluated through for questions: Even though the nurse may quizzes or question-and-answer sessions. Be- ask for and welcome questions during cause not all patient participants are comfort- the session, there are always people who able answering in a group, it may be difficult are not comfortable asking questions in a to assess how much learning each individual group. These people will want your time achieves. in private, so allow some time to clarify Not everyone has the same learning their concerns at the time or to set up a Neeb’s ■ style. time to help individuals later in the day. Tip

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introductory lecture. For visual and tac- know something, he or she should admit tile learners, it is a preferred method of it. The nurse should look up the informa- learning. tion and either bring it to the individual who asked or bring it to the next session In prepared programs, the demonstration of the class. outline will be provided. The nurse-teacher is • Have fun! Teaching can be a very reward- responsible for having the equipment ready for ing part of nursing. There is no better way each patient. In diabetic teaching, for example, to reinforce nursing knowledge than to the nurse needs to have ready the syringes, teach it to someone else. It is one way of sterile saline for injection, gloves, injection pad, being generative, and it is one way in and any other equipment that the agency uses. which nurses can keep the nursing culture Demonstrations are effective because, after alive. the initial demonstration, the nurse-teacher can have the individual perform a return ■ demonstration. One-on-one help can be pro- Step 5: Evaluating vided if needed. This allows the nurse to make Interventions more objective assessments of the patient’s learning and therefore predict the patient’s In this final step of the nursing process, the ability to safely perform the technique after LPN/LVN plays an assisting role. The LPN/ discharge. It also allows the nurse to individ- LVN’s observations and documentation ualize the technique or provide options to the about the effect of the interventions on the patient. patient and progress in attaining the goal Evaluation for this method of teaching is are of great importance. Accuracy in verbal usually the return demonstration. The nurse and written reporting of the patient’s watches each patient perform the technique at progress will help determine whether the a level that is safe for the patient to perform interventions are helpful or whether they when at home and not under the guidance of need to be re-evaluated and changed. In some the health-care professional. If a home care instances, some of the interventions can be nurse is assigned to the patient, patient teach- terminated, depending on the patient’s ing continues; the nurse also teaches the family progress (DeWit, 2009) or significant others. Nursing Outcomes Classification (NOC) is also a standardized language, which provides Additional Patient Teaching outcome statements; a set of indicators de- Tips scribing specific patient, caregiver, family, or • It is customary to assess eye contact and community states related to the outcome; and to equate eye contact with interest and a five-point measurement scale to facilitate attentiveness. It is important for the tracking patients across care settings. It can nurse-teacher to remember that this is a help demonstrate patient progress even when cultural behavior. Not all cultures believe outcomes are not fully met. NOC also is that eye contact is a positive thing; in- applicable in all care settings and specialties deed, many cultures consider direct meet- (Doenges and Moorhouse, 2003). ing of eyes a sign of blatant disrespect for people who are older or in a position of respect or authority. Nurses and teachers ■ ■ ■ Critical Thinking Question are respected in those cultural groups, Select a topic to teach the class. This can be any and it would be a mistake on the part of topic with which you are comfortable. You have the nurse to assume that the lack of direct 10 minutes (classroom instructor may choose own time limit) to teach your topic. Develop a eye contact is a sign of disinterest in or teaching plan. Teach your topic. Evaluate your disrespect for the material. teaching. What would you do differently the • Be honest: Nobody said a nurse must have next time? all the answers. If a nurse-teacher does not 2993_Ch06_089-104 14/01/14 5:19 PM Page 101

CHAPTER 6 | Nursing Process in Mental Health 101

■ ■ ■ Key Concepts nurses need a basic knowledge of both skills. Individual states and facilities set 1. Nursing process is an example of collabo- the guidelines for teaching within the rative nursing practice. RNs are primarily scope of the nurse’s practice. responsible for the steps of the nursing process; LPN/LVN-prepared nurses 4. Nursing process is a helpful tool for assist in data collection, planning, imple- preparing a teaching plan. menting, and evaluating the nursing 5. The ANA has set guidelines that dic- process. tate the roles of the RN and the LPN/ 2. The nursing process format can be used LVN in collaborating in the nursing by other health-care disciplines to create process. a care plan. 6. New models for collaborative nursing 3. Nurses are conducting more interviewing and nursing outcome statements are and teaching on a daily basis. Entry-level being developed.

CASE STUDY Mark is a 15-year-old student who has reliable source of information about recently quit attending his high school himself at this time. classes. Mark has always been a straight-A The physician notiﬁes Mark’s parents student who participated in many social and explains that Mark may have several and athletic activities at his school. conditions, including but not limited to Today, Mark’s friend Tony brings Mark serum hepatitis. to the clinic that is part of your commu- Meanwhile, you continue to admit nity’s hospital. Tony tells you, “Mark got Mark to the hospital for further testing in with a bad group. He’s been doing’ and medical care. He is placed in enteric the stuff real bad. He’s been doing the isolation as a precaution. An IV is started needles and the smoking. He’s been with and you begin to explain the hospital me for two days, man, and he’s real sick. routines to Mark. After you tell him that Help him.” he must remain in his room for now and You and the physician undertake an as- that his visitors will be limited during sessment of Mark and ﬁnd that he has yel- the time of the isolation precautions, lowing of his sclera. He has a fruity odor he becomes angry. He conveys to you on his breath and is vomiting copiously. that this is “an invasion of his privacy” Mark’s level of consciousness is guarded; and that “you nurses are all part of the he is in and out of coherence and is not a conspiracy.”

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REFERENCES Nursing Process http://nursingworld.org/EspeciallyForYou/What- DeWit, S. (2009). Fundamental Concepts and is-Nursing/Tools-You-Need/Thenursingprocess.html Skills for Nursing. 3rd ed., pp. 48–55. Mental Status Exam Philadelphia: Elsevier. www.dshs.wa.gov/manuals/socialservices/sections/ Doenges, M.E., and Moorhouse, M.F. (2012). MSE_GUIDELINES.shtml Application of Nursing Process and Nursing Patient Teaching Diagnosis: An Interactive Text for Diagnostic www.upmc.com/patients-visitors/education/pain- Reasoning. 4th ed. Philadelphia: F.A. Davis control/pages/default.aspx Company. Martin, D.C. (1990). The Mental Status Exami- nation. Retrieved from http://www.ncbi. nlm.nih.gov/books/NBK320/ Townsend, M.C. (2012). Psychiatric Mental Health Nursing, 7th ed., Philadelphia: F.A. Davis Company.

WEB SITES Nursing Diagnosis NANDA; http://www.nanda.org Nursing Classiﬁcations (NIC & NOC) www.ncvhs.hhs.gov/970416w6.htm 2993_Ch06_089-104 14/01/14 5:19 PM Page 103

CHAPTER 6 | Nursing Process in Mental Health 103 Test Questions Multiple Choice Questions 1. The nursing process is a method for: 6. According to ANA, the RN is the pri- a. Systematic organization and imple- mary person for developing this part of mentation of patient care the care plan: b. Documenting patient needs a. Nursing diagnosis c. Differentiating the RN role from the b. Implementation/interventions LPN/LVN role c. Evaluation d. Data collection d. Assessment 2. You are assisting in collecting data on a 7. Which of the following is/are part of new patient in your unit. The physician the principles of teaching? (select all that suspects alcohol abuse. You want to learn apply) the patient’s history and frequency of a. Being flexible alcohol use. Your best choice for collect- b. Evaluate the learning ing these data might be to ask: c. Teach without a teaching plan a. “Do you use alcohol?” d. Know the patient b. “How often do you get drunk?” 8. The Mental Health Status Examination c. “How many times a week would you includes: (select all that apply) say you drink alcohol?” a. Memory d. “Why do you use alcohol? It’s bad b. Judgment for you.” c. Mood and tone 3. When conducting patient teaching, the d. Mood and affect best method to evaluate the success of e. Level of awareness and orientation the patient is: 9. NANDA is responsible for: a. Lecture a. Interventions b. Redemonstration b. Implementation c. Implementation c. Appearance d. Assessment d. Nursing diagnosis 4. The mental status exam takes place in 10. Dianne was sitting in her hospital bed what part of the nursing process? holding the orange given to her to prac- a. Assessment tice her insulin injections. When the b. Plan nurse entered the room, Dianne asked c. Implementation when she was going to inject herself d. Evaluation instead of the orange. This statement 5. Which of the following are components indicates that Dianne is ready for: of the planning part of the nursing a. Discharge to home process? (select all that apply) b. More time injecting the orange a. Short-term goals c. Informal teaching b. Long-term goals d. Formal teaching c. Subjective d. Objective e. Evaluation 2993_Ch06_089-104 14/01/14 5:19 PM Page 104 2993_Ch07_105-112 14/01/14 5:19 PM Page 105

CHAPTER 7 Coping and Defense Mechanisms

Learning Objectives Key Terms 1. Define coping. • Adaptation 2. Differentiate between effective and ineffective coping. • Coping 3. Define defense (coping) mechanisms. • Defense mechanisms 4. Identify main defense mechanisms. • Effective coping • Ineffective coping

■ Coping goals of a change in behavior emphasize demonstration of specific effective coping “Deal with it.” “Get a grip.” “Don’t make a skills. Biology plays a role in coping in the mountain out of a molehill.” These are pieces presence of some psychiatric disorders. What of advice that most people have heard or have is an effective coping skill, and how do nurses given at some point. But what do they mean? observe and measure it? What is coping? Coping is the way one adapts to a stressor psychologically, physically, Tool Box | Managing Stress and behaviorally. It is the ability one develops www.webmd.com/balance/stress- to deal consciously with problems and stress. management/stress-management- topic-overview Neeb’s As a health-care provider, it important ■ to realize that coping is individualized. Tip Effective coping skills are those that are specifically identified to offer healthy choices Individuals have different methods of to the patient. For example, it is very com- coping or dealing with their stressors. What mon to see patients use a variety of coping makes some people very successful at han- mechanisms to help deal with hospitalization. dling stress and others not successful at all? Hospitalization is a stressful experience for What allows some people to have a drink or patients and families, with so many unknown run to reduce their stress and causes others to and unfamiliar things, noises, and interrup- become addicted to the same behavior? The tions. The patient may not understand the answers to these questions are, of course, illness or the implications of the treatment complex. plan. Mealtimes may be different from the Cultures, religions, and individual belief routine at home. The patient’s plans are dis- systems seem to be the lead factors in this rupted, financial status is altered, and there is mystery. Personal choices also play a support- a possible temporary loss of independence. ing role. It is not the value of a behavior that Effective coping can be more challenging to nurses observe; it is the desired outcome that a one-income family. Allowing the patient is important. The short-term and long-term and his or her family members to be active 105 2993_Ch07_105-112 14/01/14 5:19 PM Page 106

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participants in the treatment plan will in- then provide information that will reinforce crease the patient’s ability to use effective cop- the patient’s positive feelings. Providing hon- ing skills (Fig. 7-1). The patient should be est, positive feedback about the patient’s included in the decision making as to which progress in a given lifestyle change will let the new behaviors are acceptable and which ones patient know that others are noticing the hard are not. Practicing these new behaviors in a work that he or she has done. safe place, such as a hospital or organized Think about when you are verbaliz- group setting, is the secret to success. This will Neeb’s ■ ing your thoughts and feelings and probably require a lifestyle change for the pa- Tip thinking, “Just listen to me and vali- tient, and it will be hard work. As the saying date what I am saying.” This is no dif- goes, “Old habits die hard,” but old habits can ferent from what the patient expects die and healthy new ones can replace them. when expressing his or her thoughts This process of effective coping is sometimes and feelings. called adaptation. Allowing the patient to “practice” the new coping techniques will Often, the dividing line between effective promote confidence and decrease the stress and ineffective coping is in the degree of that can accompany change. The patient will tension and the past experience with it. For adapt to the stress by using the new tools. instance, a little worry or anxiety can be a Chapters 8 & 9 will introduce the reader to positive thing. A bride making preparations other interventions that can be used for cop- for her wedding is stressed, but the expecta- ing effectively with stress. tion is that the outcome will be positive. Most of the time when there is a little tension, ■ ■ ■ Clinical Activity people are more alert and ready to respond. Assist in a group session and provide instructions and demonstrate a relaxation technique. Ask for The “fight or flight” mechanism can actually feedback after the session. help people adapt to a new situation. Too much worry begins to cloud the consciousness and interferes with a person’s ability to One of the most helpful actions a nurse make appropriate choices and recall the new can take is to actively listen to the patient’s adaptive tools he or she has learned (Fig. 7-2). thoughts and feelings about the stressor and For example, a bride can become paralyzed with all the decisions to be made and then become unable to proceed, demonstrating ineffective coping (see below). Ineffective coping is when the techniques people try are not successful or are hazardous. People often allow themselves to fall into habits that give them the illusion of coping. For example, a person might have a drink every time an experience is frustrating. People usually have difficulty understanding that they are using ineffective methods of coping. Ineffective coping is one’s rationale for his or her behavior. These habits are called defense mechanisms. Figure 7-1 Involving patients and their families in the treatment plan can go a ■ ■ ■ Critical Thinking Question long way toward reducing the stress of Imagine that you are admitted into the hospital hospitalization. (From Williams and Hopper with an undetermined illness. Describe how it (2011). Understanding Medical-Surgical Nursing, would affect you financially, as a student, and as a 4th ed. Philadelphia: F.A. Davis Company, with parent, and the stress each situation would create. permission.) 2993_Ch07_105-112 14/01/14 5:19 PM Page 107

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■ ■ ■ Classroom Activity • List three situations that were very uncomfortable for you. What defense mechanisms did you use? How will you respond to each of these situations in a more eﬀective manner? • List three situations in which you observed someone else using defense mechanisms. How can you help him or her to cope in a more eﬀec- tive manner?

tend to have their own repertoire of them and to use them (unconsciously) over and over. Periods of high stress are not the times to try something new, so the psyche uses the old “standbys” to get over yet another hump in life. Some of the commonly used defense mechanisms are shown in Table 7-1.

■ ■ ■ Critical Thinking Question Nurse D, LVN, has been routinely calling in “sick” on his weekends to work. This has created a hardship for the patients and the staff. On Monday, Nurse D reports for the assigned work shift but is called to the nurse manager’s office. The nurse manager Figure 7-2 A little anxiety can be positive informs Nurse D of the pattern that has devel- in some situations. oped in his attendance and gives him a chance to explain the situation. Nurse D says, “Well, I am a single parent and I need to take care of my chil- ■ dren. You should assign single people without Defense Mechanisms families to work the weekends. If you cared a little more about your employees, we wouldn’t have Defense mechanisms are mental pressure to call in so often.” valves. Defense mechanisms give the illusion Nurse D is quiet for a second and then says that they are helping to alleviate a person’s with a shaky voice, “You make me so nervous that stress level, when in reality they mask the I’ve started needing a couple of drinks at night so stress and may actually end up increasing it. I can sleep. I could quit drinking any time, if you’d just let me have my weekends off.” Defense mechanisms come out of the ego What defense mechanisms do you hear Nurse mechanism of Freud’s theory of personality. D using? How many of them have you used? If Although they appear to be very purposeful, you were the nurse manager, what would you say they exist, for the most part, on the uncon- to Nurse D? Using three of the suggested nursing scious level. diagnoses listed in Appendix E, complete a nursing process for Nurse D. The purpose of defense mechanisms is to reduce or eliminate anxiety. Surprisingly, when used in very small doses, they can be helpful. It is when they are overused that ■ ■ ■ Classroom Activity they become ineffective and can lead to a • In a group, watch a television newscast as assigned breakdown of the personality. Again, people by the instructor. Pick one topic. Each group should are not born with these behaviors; they are watch its assigned newscast at the assigned time. learned as responses to stress. Many times, 1. Identify all of the defense mechanisms you can within that news interview. they are developed by the time people are 2. In what ways do hearing defense mechanisms 10 years old. change the way you may listen to and process Because the main purpose of defense what you hear in the media? mechanisms is to decrease anxiety, people 2993_Ch07_105-112 14/01/14 5:19 PM Page 108

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l Table 7-1 Commonly Used Defense Mechanisms Mechanism Description Examples Denial • Usually the ﬁrst defense • The alcoholic states, “I can quit learned and used. any time I want to.” • Unconscious refusal to see • Is not consciously lying. reality. Repression • An unconscious burying or Demonstrating emotions toward “forgetting” mechanism. a person, but unable to identify • Excludes or withholds from the speciﬁc reason. people’s consciousness events or situations that are unbearable. • A step deeper than “denial.” Dissociation • Painful events or situations • Patient who had been sexually are separated or dissociated abused as a child describes the from the conscious mind. situation as if it happened to a • Could be described as an friend or sibling. out-of-body experience. • Police visit parent to inform parent of death of child in car accident. Parent tells police, “That’s impossible. My child is upstairs asleep. You must have the wrong house.” Rationalization Substituting acceptable rea- • “I failed the test because the sons for the true reasons for teacher wrote bad questions.” personal behavior because • “The patient kept interrupting admitting true reasons is too me so I got distracted and he threatening. caused me to make a mistake." Compensation Making up for something a • A small boy who wants to be a person perceives as an inade- basketball center; instead be- quacy by developing some comes an honor roll student. other desirable trait. • The physically unattractive person who wants to model instead becomes a famous designer. Reaction Formation Similar to compensation, except • The small boy who wants to (Overcompensation) the person usually develops the be a basketball center becomes opposite trait. a political voice to decrease the emphasis of sports in the elementary grades. • The physically unattractive person who wants to be a model speaks out for eliminating beauty pageants. Regression • Emotionally returning to an • Children who are toilet trained earlier time in life when there beginning to wet themselves. was far less stress. • During serious illness, a patient • Commonly seen in patients exhibits behavior more appro- while hospitalized. Note: priate for a younger develop- Everyone does not go back to mental age, such as excessive the same developmental age. dependency. This is highly individualized. 2993_Ch07_105-112 14/01/14 5:19 PM Page 109

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l Table 7-1 Commonly Used Defense Mechanisms—cont’d Mechanism Description Examples Sublimation Unacceptable traits or • Burglar teaches home safety characteristics are diverted classes. into acceptable traits or • Person who is potentially physi- characteristics. cally abusive becomes a professional sports figure. • People who choose to not have children run a day-care center. Projection Attributing feelings or im- • Wife tells patient's nurse, "My pulses unacceptable to husband is worried about going oneself to others. home." (Wife is the one who worried.) • Young soldier is fearful of upcoming deployment and says, "Those other guys are a bunch of cowards." Displacement The “kick-the-dog syndrome.” Parent loses job without notice; Transferring anger and hostility goes home and verbally abuses to another person or object spouse, who unjustly punishes that is perceived to be less child, who slaps the dog. powerful. Restitution (Undoing) Makes amends for a behavior • Giving a treat to a child who one thinks is unacceptable. is being punished for a Makes an attempt at reducing wrong-doing. guilt. • The person who finds a lost wallet with a large amount of cash, does not return the wallet, but puts extra in the collection plate at the next church service. Isolation Emotion that is separated from “I wasn’t really angry; just a little the original feeling. upset.” Conversion Reaction Anxiety is channeled into physi- • Nausea develops the night before cal symptoms. Note: Often, the a major exam, causing the person symptoms disappear soon after to miss the exam. the threat is over. • Nausea may disappear soon after the scheduled test is finished. Avoidance Unconsciously staying away “I can’t go to the class reunion from events or situations that tonight. I’m just so tired, I have might open feelings of aggres- to sleep.” sion or anxiety. Scapegoating Blaming others "I didn't get the promotion because you don't like me." 2993_Ch07_105-112 14/01/14 5:19 PM Page 110

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■ ■ ■ Key Concepts REFERENCES Gorman, L.M., and Sultan, D.F. (2008). 1. Stress and people’s responses to it are Psychosocial Nursing. 3rd ed. Philadelphia: very individualized. People are not F.A. Davis. stressed by the same things, nor do they Townsend, M.C. (2012). Psychiatric Mental deal with their stress in the same ways. Health Nursing. Philadelphia: F.A. Davis. 2. Defense mechanisms are believed to be part of the ego of Freud’s description WEB SITES of personality. They are based in the Defense Mechanisms unconscious, for the most part, but http://psychcentral.com/lib/2007/15-common- defense-mechanisms/all/1/ they can appear to be very deliberate. Freud and the Ego Development 3. Use of defense mechanisms for a short http://psychology.about.com/od/eindex/g/ period can be helpful. The mechanisms def_ego.htm www.childstudy.net/cdw.html act like a pressure valve and allow the www.childstudy.net/FREUD.html psyche to put the stress into perspective. Coping Mechanisms If the patient then deals with the prob- http://changingminds.org/explanations/ lem, the outcome can be an eﬀective behaviors/coping/coping.htm coping technique; if not successful, the patient’s anxiety level may increase. 2993_Ch07_105-112 14/01/14 5:19 PM Page 111

CHAPTER 7 | Coping and Defense Mechanisms 111 Test Questions Multiple Choice Questions 1. A person who always sounds as though he and in tears. Today, Tara bought two or she is making excuses is displaying: expensive concert tickets for her daugh- a. Denial ter and a friend. This is an example of: b. Fantasy a. Denial c. Rationalization b. Undoing d. Transference c. Symbolization 2. The alcoholic who says, “I don’t have a d. Conversion problem. I can quit any time I want to; 7. Shirley, a 70-year-old woman, went to I just don’t want to” is displaying: a photo shoot for a portrait. As soon as a. Denial the photographer began to photograph b. Fantasy Shirley, she started to display signs of c. Dissociation regression by: (select all that apply) d. Transference a. Posing as a young adolescent 3. Your young male patient who tells you b. Posing as her mother that he may not be big enough for the c. Pouting when poses were suggested basketball team, but says “that’s no by the photographer problem because I’m a 4.0 student and d. Stopping the session to make two on the principal’s list” is displaying: ponytails, one on each side of her a. Denial head b. Transference 8. After receiving disappointing news c. Dissociation about a job promotion, John stated, d. Compensation “I didn’t get the promotion because 4. Mr. V becomes angry that Mrs. V spent I write with my left hand.” This is an the whole day shopping with her friends. example of: Upon her return home, he hits her and a. Avoidance tells her, “It’s your own fault. Stay home b. Regression once in a while!” Mr. V is displaying: c. Projection a. Repression d. Denial b. Regression 9. Eﬀective coping skills are described as: c. Dissociation a. Being able to make choices that are d. Projection healthy and individualized 5. You overhear someone jokingly repeating b. The excessive usage of any defense the social cliché, “Stop Smoking, Lose mechanism Weight, Exercise, Die Anyway” as he c. Imitating the coping behavior of orders a big burger and super-sized fries. others That cliché is an example of: d. Working on the problem until totally a. Rationalization exhausted b. Repression 10. The use of defense mechanisms is related c. Regression to what part of Freud’s personality the- d. Rebellion ory? (select all that apply) 6. Yesterday, Tara became drunk and inap- a. Id propriate at a family function. Tara’s b. Ego 16-year-old daughter was embarrassed c. Superego 2993_Ch07_105-112 14/01/14 5:19 PM Page 112 2993_Ch08_113-142 14/01/14 5:20 PM Page 113

CHAPTER 8 Mental Health Treatments

Learning Objectives Key Terms 1. Describe a therapeutic milieu. • Akathisia 2. Identify classifications of psychotropic medications. • Antidepressants 3. Identify uses, actions, side effects, and nursing considerations • Antimanic agents for selected classifications of psychotropic medications. • Antiparkinson agents 4. Describe psychoanalysis. • Antipsychotics 5. Describe behavior modification. • Behavior modification 6. Identify the nurse’s role in counseling. • Cognitive 7. Describe three types of counseling. • Counseling 8. Describe electroconvulsive therapy and the nurse’s role in it. • Crisis 9. Identify the five phases of crisis and the nurse’s role in them. • Dystonia 10. Define and discuss terrorism as it relates to mental health in • Electroconvulsive today’s world. therapy (ECT) • Hypnosis • Milieu • Monoamine oxidase inhibitors (MAOI) • Person-centered • Psychoanalysis • Psychopharmacology • Rational-emotive therapy (RET) • Stimulants • Tardive dyskinesia

eople who have alterations to their Neeb’s Accurate and timely observations mental health have special needs. ■ Tip and data collection by the nurse PWhen emotional health is threatened, may be the instrument that keeps many other daily activities can be altered as the patient from traveling a swift well. Cognitive ability (the ability to think downward spiral. rationally and to process those thoughts) can be decreased. Emotional responses can Patients can develop a sense of helplessness be decreased or even absent in some condi- and hopelessness about themselves and their tions. These alterations can be extremely conditions. Nurses can be the tools that help frightening to a patient who may already the patient regain control. A nurse may be ob- feel unable to control his or her life; this serving the patient’s treatments and therapies can lead to a deepening of the mental dis- or may be an active part of them. Either way, order or even the development of another the nurse will be making observations about disorder. the patient’s reactions and participating in the

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plan of care. This chapter discusses some of schizophrenia and other acute or chronic the more frequently used methods for treating psychotic behavior including violent or po- alterations in mental health. tentially violent behavior. Antipsychotics are classified as typical or atypical. Typical an- ■ Psychopharmacology tipsychotic agents treat the positive symptoms of schizophrenia, such as hallucinations, Since the introduction of the phenothiazines delusions, and suspiciousness. Atypical an- in the 1950s, the number of medications tipsychotic agents reduce the negative symp- available for treating patients who have men- toms of schizophrenia, such as flat affect, tal health disorders, comprising the field of social withdrawal, and difficulty with abstract psychopharmacology, has increased greatly. thinking. (See Chapter 15 for further discus- The reasons for using medications are twofold: sion of these symptoms.) First, the medications control symptoms, thus Side Effects: Antipsychotics have many un- helping the patient to feel more comfortable pleasant side effects. Sometimes people are re- emotionally. Second, the medications are luctant to take these medications because they usually used in connection with some other are afraid that the side effects will be worse type of therapy. The patient is generally more than the illness. Some of these side effects are receptive and able to focus on therapy if med- photosensitivity (especially with Thorazine), ications are also used. Several classifications darkening of the skin from increased pigmen- of psychoactive drugs (also referred to as tation, anticholinergic effects such as dry psychotropics) are discussed below; however, mouth, and a group of side effects called ex- there are far too many drugs to discuss each trapyramidal symptoms (EPS). There is less one individually in this text. In most cases, risk of EPS with the atypical agents, but early only the most common information is pre- observation and reporting of any possible EPS sented about a medication. Nurses should are crucial to minimizing these effects on the consult a pharmacology or drug reference patient. The EPS include: book for more specific information before 1. Drug-induced parkinsonism (pseudo- administering these medications or instruct- parkinsonism). Symptoms appear 1 to ing patients on their use. 8 weeks after the patient begins the medication. The major symptom is akinesia Tool Box | What is psychopharmacology? (muscle weakness), shuffling gait, drool- www.ascpp.org/resources/information- ing, fatigue, mask-like facial expression, for-patients/what-is-psychopharmacology/ tremors, and muscle rigidity. 2. Akathisia. Symptoms appear 2 to 10 weeks after the patient starts taking the medica- Antipsychotics (Neuroleptics/ tion. Symptoms are agitation and motor restlessness, and they seem to appear more Major Tranquilizers) frequently in women. There is no absolute Action: Typical antipsychotic agents act on the reason for this, but it is suggested that it central nervous system (CNS). Their main ac- may be due to hormonal interaction with tion is to block the dopamine receptors. the medication. Dopamine is a neurochemical that the human 3. Dystonia. Symptoms appear 1 to 8 weeks body contains naturally. However, if it is over- after the patient starts taking the medica- produced or utilized incorrectly, it can cause tion. Symptoms manifest as bizarre someone to exhibit psychotic behavior. Atyp- distortions or involuntary movements ical antipsychotic agents block both serotonin of any muscle group. Tongue, eyes, face, (a neurochemical) and dopamine. neck (torticollis), or any larger muscle Uses: Antipsychotics are used to treat psy- mass can become tightened into an un- chotic behavior such as schizophrenia and natural position or have irregular spastic other disorders. The antipsychotic will treat movements. 2993_Ch08_113-142 14/01/14 5:20 PM Page 115

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4. Tardive dyskinesia (TD). Symptoms Antipsychotic medication should be disappear within 1 to 8 weeks after the continued slowly. If medication is ordered patient starts taking the medication. The once daily, teaching patients to take the frequently seen manifestations are rhyth- medication 1 to 2 hours before going to bed mic, involuntary movements that look works well and promotes sleep. Antacids de- like chewing, sucking, or licking motions. crease the absorption of antipsychotics, so Frowning and blinking constantly are these types of medications should be taken also common. TD is irreversible. 1 to 2 hours after oral administration of antipsychotics. Neuroleptic malignant syndrome (NMS) Box 8-1 provides some of the most com- is an uncommon but potentially fatal reaction monly used antipsychotic agents. to treatment with neuroleptic medications. Also see Chapter 15, Table 15-6, Compar- Symptoms include muscle rigidity, hyper- ison of Side Effects Among Typical and Atyp- pyrexia, fluctuations in blood pressure, and ical Antipsychotic Agents. altered level of consciousness. Early recognition and immediate medical care are impor- Antiparkinson Agents tant. Some antipsychotics, such as Clozaril, are known to cause serious blood dyscrasias and (Anticholinergics) require regular monitoring of blood counts. Action: Antiparkinson agents (also called an- Contraindications: Antipsychotics should ticholinergics) (Fig 8-1) inhibit the action of be used carefully in patients who are hyper- acetylcholine. Acetylcholine increases as sensitive to medications or who have brain dopamine decreases at its receptor sites (the damage or blood dyscrasias. cholinergic effect). When the amount of Nursing Considerations: acetylcholine available to interact with dopamine is decreased, there is a better bal- • Careful teaching by doctors and nurses ance between the two neurochemicals, and can help the patient to understand that the symptoms of parkinsonism decrease. these are very strong medications. Uses: Antiparkinson agents help decrease • The possibility of seizures increases in the effects of drug-induced and non–drug- patients who require antipsychotic induced symptoms of parkinsonism that often medications. occur with antipsychotics. • Observe for any sign of EPS or NMS Side Effects: Blurred vision, dry mouth, and carefully monitor blood work for dizziness, drowsiness, confusion, tachycardia, abnormal results. urinary retention, constipation, and changes • Careful instruction to the patient and in blood pressure. family regarding wearing a wide-brimmed Contraindications: Patients with known hy- hat, covering all exposed skin, and using a persensitivity should not use these medications. sunscreen when in the sun will help lessen chances of the patient’s suffering sunburn, especially if the patient is using Thorazine. • Temperature extremes should be avoided. l Box 8-1 Commonly Used • Patients should be taught to avoid alcohol. Antipsychotic Agents • Over-the-counter (OTC) medication and Typical: Thorazine (chlorpromazine), Haldol other products should not be taken with- (haloperidol), Stelazine (trifluoperazine), out doctor approval. Mellaril (trioridazine), Loxitane (loxapine), • It is important to instruct the patient not Prolixin (fluphenazine), Moban (molindone), to alter the dose without first discussing it Navane (thiothixene), Serentil (mesoridazine), with the doctor. Trilafon (perphenazine); • Occasionally, the patient might experience Atypical: Risperdal (risperidone), Clozaril some gastric distress with oral antipsy- (clozapine), Seroquel (quetiapine), Zyprexa chotics, so give them to the patient with (olanzapine), Geodon (ziprasidone), and food or milk. Abilify (aripiprazole) 2993_Ch08_113-142 14/01/14 5:20 PM Page 116

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ANTIPARKINSON AGENTS Inhibits the action of acetylcholine. Acetylcholine increases as dopamine decreases at its receptor sites. When the amount of acetylcholine available to interact with dopamine is decreased, there is a better balance between the two neurochemicals, and the symptoms of parkinsonism decrease.

USES SIDE EFFECTS NURSING PATIENT TEACHING Decrease the effects Blurred vision, dry CONSIDERATIONS Use hard, sugarless of drug-induced and mouth, dizziness, Should be avoided in candy to combat the non–drug-induced drowsiness, children under 12 effects of dry mouth. symptoms of confusion, tachycardia, years of age. Increase dietary parkinsonism. urinary retention, Use with caution with roughage to maintain constipation, and the elderly. bowel functioning. changes in blood Blood pressure should May cause drowsiness, pressure. be monitored carefully. so should not drive or operate equipment until the response to medication is established.

Figure 8-1 Antiparkinson agents.

People with glaucoma, myasthenia gravis, pep- Antianxiety Agents (Anxiolytics/ tic ulcers, prostatic hypertrophy, or urine retention should not take these medications. Minor Tranquilizers) These agents should be avoided in children Action: Antianxiety agents depress activities of under the age of 12 years and used with cau- the cerebral cortex (Fig. 8-2). tion with the elderly. Uses: Antianxiety agents decrease the effects of stress, anxiety, and mild depression. Neeb’s Assess if your patient has glaucoma. They can be used preoperatively to help pro- ■ Tip mote sedation. Side Effects: The use of antianxiety agents can cause physical and psychological depend- Nursing Considerations: ence. Other side effects include drowsiness, • Monitor blood pressure carefully (at least lethargy, fainting, postural hypotension, nau- every 4 hours when beginning treatment). sea, and vomiting. If discontinued abruptly, • Encourage using hard, sugarless candy or severe side effects, including nausea, hypoten- saliva substitute to combat the effects of sion, and fatal grand mal seizures, can occur dry mouth. anywhere from 12 hours to 2 weeks after the drug is stopped. Box 8-2 provides some of the most com- Contraindications: Patients with known monly used antiparkinson agents. hypersensitivity should not use these medications. People with a history of chemical l Box 8-2 Commonly Used dependency are not good candidates for this Antiparkinson Agents classification of drug because of the potential for addiction. Akineton (biperiden), Cogentin (benztropine), Nursing Considerations: Artane (trihexyphenidyl), Mirapex (pramipex- ole), Benadryl (diphenhydramine) • Nurses should monitor blood pressure before and after giving this medication 2993_Ch08_113-142 14/01/14 5:20 PM Page 117

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ANTIANXIETY DRUGS Depress activities of the cerebral cortex.

USES SIDE EFFECTS NURSING PATIENT TEACHING Decrease the effects of Can cause physical CONSIDERATIONS Teach the patient and stress or mild and psychological Administer family that it is not depression without dependence, intramuscular (IM) safe to drive or use causing sedation. drowsiness, lethargy, dosages deeply, alcohol while using fainting, postural slowly, and into large this classification of hypotension, nausea, muscle masses. medication. and vomitting. Z-track method of IM Instruct to change administration is positions slowly. preferred. Discontinue slowly.

Figure 8-2 Antianxiety drugs.

and monitor for signs of orthostatic Antidepressants (Mood hypotension, especially if taking tricyclics Elevators) (Townsend, 2012). • The patient should rise slowly from sitting Antidepressants have several subgroups and or lying positions to prevent a sudden different drug references that subdivide the drop in blood pressure. antidepressants differently. There are similari- • When possible, these types of drugs ties and differences among the subgroups should be given at bedtime to help (Fig. 8-3). Antidepressants generally take promote sleep, minimize side effects, several weeks to see a change in mood. and allow a more normal daytime Selective Serotonin Reuptake routine. • Administer intramuscular (IM) dosages Inhibitors (SSRIs) (Bicyclic deeply and slowly into large muscle Antidepressants) masses. The Z-track method of IM Action: These drugs increase the availability of administration is preferred. serotonin, which is decreased in the brains of • It is important to teach the patient and depressed individuals. family that it is not safe for the patient Uses: Treatment of depression, anxiety, ob- to drive or use alcohol while using this sessive disorders, impulse control disorders. classification of medication. Side Effects: Potential for increased suicidal tendencies, sedation, dry mouth, agitation, Box 8-3 provides some of the most com- postural hypotension, headache, arthralgia, monly used antianxiety agents. dizziness, insomnia, confusion, and tremors. Contraindications: Patients with known hypersensitivity should not use these medica- l Box 8-3 Commonly Used tions. People using monoamine oxidase Antianxiety Agents inhibitors (MAOIs) or who are within 14 days of discontinuing MAOIs should not use these Xanax (alprazolam), BuSpar (buspirone), medications. People using certain herbal prepa- Librium (chlordiazepoxide), Serax (oxazepam), rations including but not limited to St. John’s Klonopin (clonazepam), Valium (diazepam), Ativan (lorazepam), and Atarax or Vistaril wort, ginseng, brewer’s yeast, vitamin B6, and (hydroxyzine) ginkgo biloba should not use SSRIs without consulting their physician. 2993_Ch08_113-142 14/01/14 5:20 PM Page 118

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ANTIDEPRESSANTS Medications that acts to prevent, cure, or alleviate mental depression.

USES SIDE EFFECTS NURSING PATIENT TEACHING Treatment of Drowsiness, dry mouth, CONSIDERATIONS Instruct to protect from depression and some agitation, postural Encourage patients to sunburn. anxiety disorders. hypotension, vertigo, continue taking the Teach to change constipation, urine medication during this positions slowly. retention, weight gain, time, although they Teach diet restrictions blurred vision, may not feel any with MAOIs. photosensitivity, and change in their mood suicidal tendencies. for up to 3 weeks after Use other medications beginning the only with physician medication. approval. Discontinue slowly. Observe for suicidal ideation.

Figure 8-3 Antidepressants.

Note: In October 2004, producers of SSRIs Box 8-4 were required by the F.D.A. to place a boxed- l Commonly Used SSRI in warning on the medication container cau- Agents tioning about the danger of increased risk of Celexa (citalopram), Prozac (fluoxetine), suicidal tendencies in children, adolescents, Zoloft (sertraline), Luvox (fluvoxamine), Paxil and young adults while taking this medication. (paroxetine), Lexapro (escitalopram) Nursing Considerations: • Do not abruptly discontinue the medica- Tricyclic Antidepressants tion, except under the supervision of a Action: These drugs increase the level of sero- health-care provider. Serotonin syndrome, tonin and norepinephrine, thereby increasing which includes altered mental status, the ability of the nerve cells to pass informa- restlessness, tachycardia, and labile blood tion to each other. Patients with depressive pressure, can occur with abrupt discontin- disorders generally have decreased amounts of uation as well as when SSRIs are com- these two neurochemicals. bined with some other medications. Uses: Treatment of symptoms of depres- • Caution should be used with driving or sion, including (but not limited to) sleep dis- activities that require alertness. turbances, sexual function disturbances, • Alcohol and CNS depressants should be changes in appetite, and cognitive changes. avoided. Side Effects: Sedation, lethargy, dry mouth, • Hard, sugarless candy or saliva substitute constipation, tachycardia, postural hypoten- can be used to treat dry mouth. sion, urine retention, blurred vision, weight • The patient should change positions gain, and changes in blood glucose. slowly to avoid a sudden drop in blood Contraindications: Patients with known pressure. hypersensitivity should not use these med- • Monitor the patient for suicide ideation. ications. Women who are pregnant or Box 8-4 provides some of the most com- breastfeeding and individuals with kidney monly used SSRI agents. disease, liver disease, or a recent myocardial 2993_Ch08_113-142 14/01/14 5:20 PM Page 119

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infarction should not take these medica- Serotonin Norepinephrine tions. Anyone who has asthma, seizure dis- Reuptake Inhibitors (SNRIs) orders, schizophrenia, benign prostatic Action: These drugs increase the availability of hypertrophy, or alcoholism should use tri- serotonin and norepinephrine, which are de- cyclic antidepressants with extreme caution. creased in the brains of depressed individuals. Nursing Considerations: The uses, contraindications, side effects, • Patients should not stop using these med- and nursing considerations for the SNRI an- ications abruptly. tidepressants are similar to those for SSRIs. • Medications (including over-the-counter Box 8-7 provides some of the most com- medications such as cold preparations) monly used SNRI agents. that contain antihistamines, alcohol, sodium bicarbonate, benzodiazepines, Monoamine Oxidase Inhibitors and narcotic analgesics can increase the (MAOIs) effects of tricyclic antidepressants. Action: Monoamine oxidase inhibitors • Nicotine, barbiturates, and the hypnotic (MAOIs) prevent the metabolism of neuro- chloral hydrate decrease the effect of the transmitters by an enzyme, monoamine oxi- tricyclic antidepressant. dase. Too much monoamine oxidase can lead • Serotonin syndrome can occur if combined to destructive, psychotic behaviors. with St John’s wort. Uses: MAOIs are generally used for patients Box 8-5 provides some of the most com- with varied types of depression who have not monly used tricyclic antidepressant agents. been helped by other antidepressants. Side Effects: Postural hypotension, photosen- Tetracyclic Antidepressants sitivity (sunburn potential), headache, dizziness, (Heterocyclic Antidepressants) memory impairment, tremors, fatigue, insomnia, weight gain, and sexual dysfunction. The actions, uses, contraindications, side Contraindications: Patients with known hy- effects, and nursing considerations for the persensitivity should not use these medica- tetracyclic antidepressants are similar to those tions. MAOI medications should be given for SSRIs. carefully to patients who have asthma, con- Box 8-6 provides some of the most com- gestive heart failure, cerebrovascular disease, monly used tetracyclic antidepressant agents. glaucoma, blood pressure conditions, schizophrenia, alcoholism, liver or kidney disorders, or severe headaches, as well as to those who l Box 8-5 Commonly Used Tricyclic are over 60 years old or pregnant. There are Antidepressant Agents many drug-drug interactions that may occur if MAOI agents are combined with other Elavil (amitriptyline), Tofranil (imipramine), medications. Other prescriptions and over- Pamelor or Aventyl (nortriptyline), Asendin the-counter products should be taken only (amoxapine), Norpramin (desipramine), after consulting a doctor or a pharmacist. Anafranil (clomipramine), Sinequan (doxepin), Surmontil (trimipramine), Vivactil (protiptyline) Nursing Considerations: • Teach patients to avoid foods containing the amino acid tyramine, a precursor of norepinephrine, while taking these l Box 8-6 Commonly Used Tetracyclic Antidepressant Agents l Box 8-7 Commonly Used SNRI Agents Ludiomil (maprotiline), Wellbutrin or Zyban (bupropion), Remeron (mirtazapine), Desyrel Serzone (nafazodone), Effexor (venlafaxine), (trazodone) Cymbalta (duloxetine) 2993_Ch08_113-142 14/01/14 5:20 PM Page 120

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medications. MAOIs block the metabo- information as possible to allow the patient lism of tyramine, resulting in increased to make safe, informed choices. norepinephrine. A hypertensive crisis Box 8-9 provides nursing considerations may occur. Foods containing significant for all antidepressants. amounts of tyramine include • Aged cheese (cheddar, Swiss, provolone, Antimanic Agents (Mood blue cheese, parmesan) Stabilizing Agents) • Avocados (guacamole) Lithium carbonate was the drug of choice for • Yogurt, sour cream treatment and management of bipolar mania • Chicken and beef livers, pickled herring, for many years. In recent years, several other corned beef antimanic agents (Fig. 8-4) have become • Bean pods treatment options. Other medications being • Bananas, raisins, and figs used as mood stabilizers include some anti- • Smoked and processed meat (salami, convulsants and calcium channel blockers. pepperoni, and bologna) • Yeast supplements Lithium Carbonate • Chocolate Action: The exact action of lithium is not • Meat tenderizers (MSG), soy sauce completely known at this time. It is not me- • Beer, red wines, and caffeine tabolized by the body. One hypothesis about Box 8-8 provides some of the most com- the action of lithium is that there seems to be monly used MAOI agents. a connection between lithium and constancy of sodium concentration, which might help Alternative Treatments regulate and moderate information along the for Depression nerve cells, thus preventing mood swings. An- People are seeking alternatives to the prescrip- other possibility is that lithium increases the tion antidepressant drugs available through reuptake of norepinephrine and serotonin, traditional western medicine. Some reasons thereby decreasing hyperactivity. they seek alternatives include cultural prefer- Uses: Lithium is used for the manic phase ences, cost of medications, insurance issues, of bipolar disorder and sometimes for other and unpleasant side effects they may experi- depressive or schizoaffective disorders. ence with the medications they have used. Side Effects: Side effects can be numerous. One such alternative is a chemical called Some of the more common ones are thirst and SAMe (“sammy”). SAMe is a combination of dry mouth, nausea and vomiting, abdominal an amino acid (methionine) and ATP. It is pain, and fatigue. used as an antidepressant and sold in the United States as a dietary supplement. Other alternative forms of therapy are explored in l Box 8-9 Nursing Considerations Chapter 9. for All Antidepressants The nurse’s role is the same with these alternative choices as it is with prescription • Reinforce the teaching that these medica- medications. Nurses must encourage their tions take several weeks to become effec- patients to discuss the use of supplements tive. Encourage patients to continue taking with their physicians and to provide as much the medication during this time, although they may not feel any change in their mood right away. • All antidepressant medications should be ta- l Box 8-8 Commonly Used MAOI pered gradually rather than abruptly discon- Agents tinued to prevent withdrawal symptoms. • It is imperative that all patients receiving Nardil (phenelzine), Parnate (tranylcypromine), antidepressant medications be monitored Marplan (isocarboxazid) for suicide potential throughout treatment. 2993_Ch08_113-142 14/01/14 5:20 PM Page 121

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ANTIMANIC AGENTS

USES SIDE EFFECTS NURSING PATIENT TEACHING To stabilize the manic Thirst, dry mouth, CONSIDERATIONS Instruct patient to have phase in bipolar fatigue, nausea, Observe for signs of periodic lab tests to disorder. abdominal pain, toxicity: severe monitor lithium blood tremors, headache, diarrhea, muscle levels. drowsiness, and weakness, persistent Teach patient to have confusion. nausea and vomiting, adequate fluid and and seizures. sodium intake. Dehydration and fever Teach patient the signs can cause toxicity. of toxicity and to notify the physician if any indication of toxicity. Hard, sugarless candy can be helpful for dry mouth and thirst. Instruct patient that pregnancy and breastfeeding are not recommended while taking these medications.

Figure 8-4 Antimanic agents.

Contraindications: Consistent with those of taught to inform the physician immedi- the other categories listed earlier. ately if they are ill. Nursing Considerations: • Hard, sugarless candy can be helpful to decrease dry mouth and thirst. • Encourage patients to keep all appointments for blood work and evaluation of Box 8-10 provides some of the most com- drug effectiveness. Therapeutic serum lev- monly used forms of Lithium els are between 0.5 and 1.2 mEq/L for most patients (1.0 to 1.5 in acute mania). Anticonvulsants Symptoms of lithium toxicity begin to Action: The action of anticonvulsants in the appear at blood levels greater than treatment of bipolar disorder is not clear. 1.5 mEq/L. Signs of toxicity include se- Uses: These drugs stabilize the manic vere diarrhea, persistent nausea and vom- episodes in bipolar disorders. iting, muscle weakness, tremors, blurred Side Effects: Nausea, vomiting, indigestion, vision, slurred speech, and seizures. drowsiness, dizziness, prolonged bleeding, • Lithium crosses the placenta and milk headache, confusion. barriers, so women of childbearing years Contraindications: Patients with known hy- may need to be counseled regarding the persensitivity or with bone marrow suppression effects of this drug on their pregnancy should not use these medications. Caution and breastfeeding. • Dehydration and fevers can cause increased danger of toxicity. l Box 8-10 Commonly Used forms • Adequate fluid and sodium intake are es- of Lithium sential. Patients should not decrease their Eskalith, Lithonate, Lithane, Lithobid (all are dietary intake of salt (unless instructed to lithium carbonate) do so by the physician) and should be 2993_Ch08_113-142 14/01/14 5:20 PM Page 122

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should be used with patients with renal, cardiac, used calcium channel blockers are Calan or or liver disease. Caution should also be used Isoptin (verapamil). with the elderly and children. Nursing Considerations: Stimulants Stimulants (Fig. 8-5) are readily available over • Do not stop the medication abruptly. the counter as well as by prescription. They • The medication should be tapered when are found over the counter in diet prepara- therapy is discontinued. tions, pills to prevent sleep, cigarettes, and • Teach patients to avoid alcohol. caffeinated beverages such as coffee, energy • Nonprescription medications should not drinks, and soda. They are used medically be used without doctor approval. to combat narcolepsy and attention-deficit/ • Patients should not drive or operate dan- hyperactivity disorder in children. gerous equipment until the effects of the Amphetamines are one type of stimulant. medication are known. Amphetamines can be abused, and they have Box 8-11 provides some of the most com- many “street names,” including “uppers,” monly used anticonvulsant agents. “speed,” and “bennies.” The ease with which they are available should not diminish the power and Calcium Channel Blockers potential danger of the drug (see Chapter 17). The action, uses, side effects, contraindica- Action: Stimulants provide direct stimula- tions, and nursing considerations are similar tion of the central nervous system (CNS). to those for anticonvulsants. Postural hy- Uses: These drugs promote alertness, dimin- potension and bradycardia are additional ish appetite, and combat narcolepsy (sleep dis- side effects. The patient should rise slowly order related to abnormal rapid eye movement from sitting or lying positions to prevent a sleep). They are used in the treatment of sudden drop in blood pressure. Commonly attention-deficit/hyperactivity disorder (ADHD). Side Effects: Increased or irregular heartbeat, hypertension, hyperactivity, dry mouth, hand l Box 8-11 Commonly Used tremor, rapid speech, diaphoresis, confusion, Anticonvulsant Agents depression, seizures, suicidal ideation, and Tegretol (carbamazepine), Depakene (valproic insomnia. acid), Depakote (divalproex) Contraindications: Patients with known hypersensitivity should not use these medications.

STIMULANTS A substance that increases performance temporally.

USES SIDE EFFECTS NURSING PATIENT TEACHING Promotes alertness, Rapid or irregular CONSIDERATIONS Diabetic patients diminishes appetite, heartbeat, Tolerance, physical should monitor insulin and combats hypertension, and psychological carefully and inform narcolepsy. hyperactivity, hand dependence, the physician of any Treatment of attention- tremor, rapid speech, especially with long- changes. deficit/hyperactivity confusion, depression, term use. Patients should use disorder (ADHD). seizures, and suicidal Amphetamines can extreme caution when thoughts. cause changes in driving or operating insulin requirements in machinery. diabetic patients.

Figure 8-5 Stimulants. 2993_Ch08_113-142 14/01/14 5:20 PM Page 123

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Pregnant or lactating women should not use who goes to an event such as a concert or a this classification of drugs. Because these are ballgame that he does not feel excited about. chemicals that increase stimulation of the CNS That person might begin screaming or singing and respiratory systems, they should not be along and generally getting into the spirit of given to people who are alcoholic, manic, or things shortly after arriving at the event. who display suicidal or homicidal ideations. People who have heart disease or glaucoma ■ ■ ■ Critical Thinking Question also should not use these drugs because of the You are to go on an assigned unit in a mental potential effect of the medications. Elderly health floor to monitor a group discussing anger. You are feeling apprehensive and fearful about people and patients who have diabetes, hyper- being on the same unit as these patients. De- tension, or other cardiovascular conditions scribe how you might feel after hearing how the should use these drugs cautiously and with patients’ home life relates to this anger. careful monitoring. Nursing Considerations: The milieu is the setting that will provide • Tolerance and physical and psychological safety and help during the patient’s stay. The dependence can occur with CNS stimu- milieu therapy is intended to combine the lants, especially with long-term use. social and the therapeutic environments. In • Do not discontinue medication abruptly. that way, every contact between nurse and • Monitor for suicide potential. patient gives the opportunity for a thera- • Diabetic patients who take amphetamines peutic interaction. The milieu must be com- should be informed that the ampheta- fortable and safe. Patients need to feel mines may cause changes in their insulin accepted as they learn new behaviors. It is requirements. best to have the milieu as appropriate to the • These medications can also cause changes situation as possible. Obviously, nurses can- in judgment; therefore, people should be not move walls and change decorating counseled to use extreme caution when themes in the hospital, but they can allow driving or operating equipment and the patient to choose the room for therapy should avoid these activities if possible. or move to an area where the patient is more • Encourage frequent rinsing of the mouth comfortable. If the patient is on a psychi- with water or use of hard, sugarless candy atric unit rather than a medical or surgical or saliva substitute to relieve dry mouth. unit, he or she is usually allowed to walk Box 8-12 provides some of the most com- from area to area on the unit. A nurse can monly used stimulant agents. keep the area calm and quiet and arrange for roommate changes if needed. There are ■ Milieu many things a nurse can and must do to maintain a milieu that is conducive to a pa- One of the areas that nurses have some control tient’s progress. As the patient progresses, over is the therapeutic environment itself. In the milieu will be changed to allow the pa- mental health terminology, this therapeutic en- tient to take on more responsibility. vironment is called the milieu, or therapeutic milieu. It is believed that the environment has ■ Psychotherapies an effect on behavior. Think about a person Psychotherapy (Fig. 8-6) is the term used to describe the form of treatment chosen by the l Box 8-12 Commonly Used psychologist or psychiatrist or other mental Stimulant Agents health therapist to treat an individual. The goals of psychotherapy are to: Dexedrine (dextroamphetamine), Desoxyn (methamphetamine), Ritalin (methylphenidate), 1. Decrease the patient’s emotional Adderal (dextroamphetamine/amphetamine) discomfort. 2. Increase the patient’s social functioning. 2993_Ch08_113-142 14/01/14 5:20 PM Page 124

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PSYCHOTHERAPIES Therapies selected by a psychologist or psychiatrist.

USES DESIRED OUTCOMES NURSING PATIENT TEACHING For treatment of 1. Patient states CONSIDERATIONS Practice new coping various alterations to improvement in Positive reinforcement behaviors. mental health. emotional discomfort. of patient’s progress. Help patient develop 2. Patient returns to Honest communication. insight into his or her comfortable social illness. functioning. 3. Patient behaves in a manner appropriate to the situation.

Figure 8-6 Psychotherapies.

3. Increase the patient’s ability to behave or It is typical for the psychoanalyst to be po- perform in a manner appropriate to the sitioned at the head of the patient and slightly situation. behind, so that the patient cannot see the therapist. This decreases any kind of nonverbal These goals are achieved in a variety of ways, communication between the two people. The including therapeutic relationships, open and patient is typically on the “couch,” relaxed and honest venting of feelings and thoughts, allow- ready to focus on the therapist’s instructions. ing the patient to practice new coping skills, Some of the techniques used in psycho- helping the patient to gain insight into the analysis are as follows. problem, and consistency in the team approach to the patient’s care and treatment. Pos- itive reinforcement of progress is encouraged. Free Association Some therapies may be focused on gaining in- In free association, the patient is allowed to sight into the reasons for current behavior and say whatever comes to mind in response to a others are more focused on changing speciﬁc word that is given by the therapist. For exam- behaviors. ple, the therapist might say “mother” or Several types of therapy are typically used. “blue,” and the patient would give a response, Nurses may or may not be actively involved also typically one word, to each of the words in the therapy, but to provide continuity in the therapist says. the care of the patient, they must understand The therapist then looks for a theme or the basic ideas of the types of therapy. pattern to the patient’s responses. So, if the patient responds “evil” to the word “mother” Psychoanalysis or “dead” to the word “blue,” the therapist Psychoanalysis is the form of therapy that might pick up one potential theme, but if the originated from the theories of Sigmund patient responds “kind” and “true” to the Freud. In psychoanalysis, the focus is on the words “mother” and “blue,” the therapist cause of the problem, which is buried some- might hear a completely diﬀerent theme. The where in the unconscious. The therapist theme may give the therapist an idea of the tries to take the patient into the past in an cause of the patient’s emotional disturbance. effort to determine where the problem began. Chances are, according to Freud, Dream Analysis that the problem is related to poor parent- Because Freudians believe that behavior is child relationships and ineffective psycho- rooted in the unconscious and that dreams are sexual development. a manifestation of the troubles people repress, 2993_Ch08_113-142 14/01/14 5:20 PM Page 125

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what better way to get an idea of the problem than to monitor and interpret dreams? The patient is asked to keep a “dream log.” He/she is asked to awaken immediately after a dream and to write down the dream details right away in a notebook kept next to the bed. This is easier said than done, as many people remember only bits and pieces of a dream upon awakening. Psychoanalysts believe that dreams truly are the mirror to the unconscious and that it is possible to train the self to awaken long enough to record the dream. The dreams are then interpreted in much the same way as free association. Significant people or situations in the dreams are explored with the patient, and possible meanings are offered by the therapist. Hypnosis Many people are afraid of hypnosis. For many years, it was reputed to be quackery and presented in stage shows in which people did Figure 8-7 In hypnotherapy, a patient in a things such as cluck like chickens, which state of very deep relaxation is guided by the served as entertainment. Granted, this sort of therapist. thing can happen. Fraternity and sorority members love to invite stage performers to hypnotize pledgees during rush. Certainly, suggestions and typically include positive, people like the entertainer David Copperfield affirming statements for the patient to think have made comfortable livings with hypnosis. about as well as instructions to help the per- Hypnotherapy, as professional therapists son accomplish self-hypnosis. prefer to call it, is used for certain people in Of course, just as there are unethical peo- certain instances. It is not a magic solution to ple in all walks of life, a small number of ther- problems. It takes practice on the part of the apists may abuse this relationship, although patient. It can, however, be a very effective it is very uncommon. People do not generally tool for unlocking the unconscious or for lose control when under hypnosis; they will, searching further into a technique called “past in most cases, still realize what is comfortable life regression.” and acceptable to them personally, and they Hypnosis is very deep relaxation. A person will not allow themselves to go deeper into who has listened to a relaxation tape and felt hypnosis or to perform behaviors that they the effects of it or who has driven a car and no- find objectionable. ticed that 20 minutes have passed that he or Hypnosis and hypnotherapy are discussed she cannot account for has been hypnotized. in more depth in Chapter 9. In hypnotherapy, the relaxation is guided by the therapist, who has been trained in Catharsis techniques of trance formation and who Catharsis is “the act of purging” or “elimi- then asks certain questions of the patient or nation of a complex (problem) by bringing uses guided imagery to help picture the sit- it to consciousness and affording it expres- uation in an effort to find the cause of the sion” (Merriam-Webster Online, 2013). In problem (Fig. 8-7). At the end of the session, psychoanalysis, the therapist helps the pa- the therapist will leave some helpful hints for tient see the root of the problem and then, the patient. These are called posthypnotic by talking or expressing feelings, allows 2993_Ch08_113-142 14/01/14 5:20 PM Page 126

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the patient to learn to evacuate this problem However, anyone who has tried to lose weight from the psyche. This can take place in con- or stop smoking might have a rebuttal to that junction with other forms of psychotherapy. theory. Psychoanalysis is undertaken on a one- Behavior can be changed, according to be- on-one basis between patient and therapist. havior modification theory, by either positive The nurse can be helpful in the treatment or negative reinforcement. Positive reinforce- process by allowing the patient to talk about ment is the act of rewarding the patient with the experiences in therapy and by carefully something pleasant when the desired behav- documenting the patient’s responses. ior has been performed. For instance, if Mrs. P has the habit of using foul language Behavior Modification in an attempt to have a need met, it might The treatment method known asbehavior be assumed that the desired behavior change modification is based on the theories of would be for her to come to a staff member the behavioral theorists (Skinner, Pavlov, and and ask quietly for what she needs. Mrs. P others). It is a common treatment modality loves to be outside but is not allowed out used in multiple treatment settings (Fig. 8-8). except at supervised times. A suitable positive The purpose of behavior modification is to reinforcer might be to allow 15 additional eliminate or greatly decrease the frequency of minutes outdoors when she remembers to identified negative behaviors. One of the ask for her needs quietly. Generally, when the basic beliefs of behavior modification is that unacceptable behavior is exhibited by Mrs. P, whenever a behavior is removed, it must be the staff would either ignore it (because cor- replaced by another behavior. Therefore, re- recting it would in itself be a form of rein- placing the negative behaviors with ones that forcing the behavior) or quietly tell her that are more desirable is a major function of this is not acceptable behavior and then acknowl- type of psychotherapy. edge her only when the desired change has As Skinner and Pavlov showed, behaviors been demonstrated. can be learned and unlearned. The process of finding the appropriate stimuli and reinforcers ■ ■ ■ Classroom Activity determines the effectiveness of the change in • Write out one behavior you personally would like behavior. According to some behaviorists, it to change. Include what a person could give you takes approximately 20 repetitions of a behav- to create a change. ior to make it a part of a person’s lifestyle.

BEHAVIOR MODIFICATION Variables are manipulated for behavioral changes.

USES DESIRED OUTCOMES NURSING PATIENT TEACHING To remove or greatly Positive reinforcement CONSIDERATIONS Communication skills diminish behaviors of new behaviors. Positive reinforcement are important. that are inappropriate Clearly stated of new behaviors. Ensure patient’s or unhealthy. expectations and Clearly stated understanding of the appropriate behaviors. expectations and reasons for the Consistently upholding appropriate behaviors. changes in behavior. the patient’s care plan. Consistently upholding the patient’s care plan.

Figure 8-8 Behavior modiﬁcation. 2993_Ch08_113-142 14/01/14 5:20 PM Page 127

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Negative reinforcement is interpreted by considered a questionable alternative to other some as punishment. Great care must be kinds of treatment. taken when performing behavior modification with certain populations of people. It can Cognitive Therapies look like an infraction of the Patient Bill of Rights and could be reported by someone Rational-Emotive Therapy who does not understand the situation. (RET) Negative reinforcement is the act of re- Dr. Albert Ellis, a “reformed” psychoanalyst, sponding to the undesired behavior by taking and other cognitive therapists have developed away a privilege or adding an unwanted re- theories proposing that people teach them- sponsibility. Critics of the legal system in this selves to be ill because of the way they think country sometimes cite imprisonment and about their situations. Cognitive means “of, re- capital punishment as forms of negative rein- lating to, or being conscious of mental activity forcement. Parents who “ground” a child after (as thinking, remembering, learning or using the child behaves unacceptably are using neg- language)” (Merriam-Webster Online, 2013). ative reinforcement; requiring that child to Cognitive therapy emphasizes ways of rethink- perform extra household tasks for a stated pe- ing situations. The therapist confronts the pa- riod of time is reinforcing the fact that the tient with certain behaviors and then works negative behavior has consequences. The out ways of thinking about them differently. child may not repeat the negative behavior Rational-emotive therapy (RET) is one of after either of these parental choices. the best-known cognitive therapies (Fig. 8-9). Whatever option is chosen, it is important Dr. Ellis’s theory is based on an A-B-C to have the behaviors and consequences format: clearly stated. In a facility, this will be incor- • A is the activating event, or the subject of porated into the plan of care. At home, it can the faulty thinking. be stated in family meetings, agreed upon ver- • B is the belief system a person has adopted bally by the family members, or made known about the activating event. by some other method of clear communica- • C is the consequence to continuing the tion. The patient must have the ability to un- belief system. derstand the ramifications of the behavior to be changed and the purpose for the type of Dr. Ellis has made up terminology that he consequence that is chosen. If the person is uses with his therapy, such as “musturba- not capable of understanding the situation or tion” (the act of insisting that something is not able to remember due to some other must go a certain way), “awfulizing” (the be- problem, behavior modification could be lief that something is not just inconvenient

COGNITIVE THERAPY: RATIONAL-EMOTIVE THERAPY (RET) Dr. Albert Ellis

USES DESIRED OUTCOMES NURSING PATIENT TEACHING For any mental health Patient will be able to CONSIDERATIONS Perform “homework.” alteration that is remain “undisturbed” Patients will probably Avoid the words consciously controlled. as a result of not be inpatients. “must” and “should.” rethinking activating events, belief system, and consequences.

Figure 8-9 Cognitive therapy: rational-emotive therapy. 2993_Ch08_113-142 14/01/14 5:20 PM Page 128

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or unpleasant, but the extreme of “awful”), psychodynamic psychotherapy in that the and “catastrophizing” (at which point, one therapist and the patient will actively work to- has lost control of the situation). In RET, gether to help the patient recover from the there are no “musts” or “shoulds.” Feeling mental illness. People who seek CBT can ex- sad about an unpleasant experience (such as pect their therapist to be problem-focused and the death of a loved one) is acceptable and goal-directed in addressing the challenging normal, but becoming depressed about the symptoms of mental illnesses. Because CBT is death is “awfulizing” and therefore consid- an active intervention, one can also expect to ered by him to be unhealthy. do homework or practice outside of sessions. It is common for RET to be performed in RET and other forms of cognitive therapies groups. The patients are given homework to are gaining in popularity because usually they complete in the period between sessions. The are significantly more short-term than psycho- expected outcome is that patients will no analysis and therefore less costly to the patient. longer “disturb ourselves by the way we think” (Ellis, 1988). Person-Centered/Humanistic Therapy ■ ■ ■ Clinical Activity Theorists Abraham Maslow and Carl Rogers Throughout your clinical experience, observe pa- are most frequently credited with the concept tients on the unit when they are instructed by the of person-centered, or humanistic, therapy health-care provider that they “must or should” behave in a specific manner. During clinical post- (Fig. 8-10). In this form of treatment, all conferences, discuss these episodes and whether caregivers are to focus on the whole person the outcome was negative. and to work in the “present.” It is not important in humanistic treatment to understand the cause of the problem or what happened An offshoot of RET is known as cognitive in the person’s past; what is important is the behavior therapy (CBT). CBT is behavioral here and now. therapy that focuses on examining the relationships between thoughts, feelings, and be- Unconditional Positive Regard haviors. By exploring patterns of thinking that This is the phrase used by therapists who fol- lead to self-destructive actions and the beliefs low Rogerian theory. Unconditional positive that direct these thoughts, people with mental regard means full, nonjudgmental acceptance illness can modify their patterns of thinking of the patient as a person. It also means that to improve coping. CBT is a type of psy- the patient must work at accepting himself or chotherapy that is different from traditional herself. Being self-aware and having feelings

PERSON-CENTERED/ HUMANISTIC THERAPY Abraham Maslow and Carl Rogers

USES DESIRED OUTCOMES NURSING PATIENT TEACHING All aspects of patient Patient will feel CONSIDERATIONS Remain centered in care. accepted as a human, Maintain the three the present. All forms of mental which will allow patient basic qualities of Practice accepting health alterations. to be self-aware and Rogerian theory self unconditionally. self-accepting. 1. Empathy 2. Unconditional positive regard 3. Genuineness.

Figure 8-10 Person-centered/humanistic therapy. 2993_Ch08_113-142 14/01/14 5:20 PM Page 129

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that are congruent (equal) to that self-concept may be asked to facilitate (lead) a group discus- are some of the goals of humanistic therapy. sion sometimes. If nurses have the opportunity, Rogers believed that people who care for they should take it. It is very interesting to see other people must have three qualities. These the dynamics of the group and the way the qualities are: facilitator guides patients through issues. • Empathy (the ability to identify with the Neeb’s These are confidential sessions, even patient’s feelings without actually experi- ■ Tip if they are group oriented. Patients encing them with the patient) are there to work; others are there by • Unconditional positive regard invitation for special reasons. • Genuineness (honesty) Although nurses may not be active partic- Pastoral or Cultural Counseling ipants in the actual therapy sessions with their Some people prefer to obtain assistance or patients, it is important for nurses to main- counseling from their church or spiritual lead- tain these three qualities in all therapeutic re- ers (Fig. 8-12). Sessions are often free, or on a lationships. When a patient feels betrayed, it “free-will” or “ability to pay” status. The person usually results in deterioration of the nurse- who provides therapy in this time or circum- patient relationship and loss of credibility for stance may or may not be trained in traditional the nurse in that situation. mental health theories and modalities. In some Christian faiths, nurses may have an Counseling opportunity to serve in ways they could not in a Counseling is licensed and regulated differently traditional setting. For example, “parish nurses” not only state by state, but also sometimes mu- are licensed nurses who work through their nicipality by municipality (Fig. 8-11). Some church and perform tasks ranging from simply states require that a person be prepared at a PhD visiting a homebound church member to actu- level to practice therapy independently; in some ally performing care and counseling or referrals areas, only certain types of therapy are licensed. for that individual. Depending on the particular Nurses prepared at an LPN/LVN level or at an church organization, nurses who serve as parish RN level can, in some localities, practice forms nurses may serve in a volunteer capacity or in a of treatment. It is up to nurses to do the appro- paid position. Training sessions are offered in priate research to determine their rights, respon- some locales for nurses who wish to provide this sibilities, and regulations in their locality, if service, although many churches do not yet re- counseling is a path they wish to pursue. Nurses quire formal training for all their nurses. may be asked or required to accompany their Nurses may be in a position to counsel pa- patients to counseling sessions at times. They tients of their cultural or religious groups

COUNSELING

USES DESIRED OUTCOMES NURSING PATIENT TEACHING All forms of mental Patient will gain insight CONSIDERATIONS Patient must work at health alterations. to situation and May be facilitator. gaining confidence receive tools to make Nurse-counselor to try options. changes in his or her licensing requirements life. vary by state. Confidentiality is mandatory.

Figure 8-11 Counseling. 2993_Ch08_113-142 14/01/14 5:20 PM Page 130

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PASTORAL COUNSELING OR CULTURAL COUNSELING

USES DESIRED OUTCOMES NURSING PATIENT TEACHING All forms of mental Patient gains tools CONSIDERATIONS Patient works with health alterations. from a religious/cultural May act as “parish teaching from background to be able nurse” (or similar title) religious or cultural to make changes in his representative of a affiliation to regain or her life. specific religion or mental health. cultural group in home visits or health facility visits. May be a paid or volunteer position.

Figure 8-12 Pastoral or cultural counseling.

when the patient enters the health-care system. patients of the opposite sex. Women of Here are some examples: Islamic faith often wear a hijab (head covering) that completely covers the hair. • Patients who profess Judaism, especially if those individuals observe kosher practices, Neeb’s As a health-care provider, acknowl- may have concerns about dietary selections, ■ Tip edge and validate patients’ beliefs may refuse to have certain procedures done regarding their religion or culture. between sundown Friday and sundown Saturday, and may insist on being admitted • Some Native American patients may have to a Jewish hospital if one is available. healing traditions that conflict with tradi- • Patients of Islamic faith follow rituals that tional Western medicine. Remember that may conflict with schedules and routines it is not appropriate to label all Native within the hospital. Prayer times are pro- Americans as one group; many tribes scribed by their faith and are strictly fol- have their own unique beliefs and tradi- lowed; therefore, medication times, tions. Shamans, healers, and medicine treatment times, or attendance at therapy men are examples of people who may may meet with some conflict on the part be present in the room with the Native of that patient. Prayers can be postponed American patient. in case of a conflict in schedules. Islamic belief follows holy times that are different from the traditional holidays or holy days ■ ■ ■ Critical Thinking Question celebrated in the social calendar in the Maya is a new employee on your medical floor. Maya is Muslim. She has been given permission to United States or those traditionally cele- wear her hijab. Maya “disappears” at odd times in brated within Christianity or Judaism. addition to her assigned breaks. Today is excep- Also, the patient may have some dietary tionally busy. Staffing is short, and there are new concerns; those of Islamic faith observe patients on the floor. The patient in the private halal practices, which is similar to the room down the hall is deteriorating; she has the potential for stroke and is waiting to be trans- Judaism practice of kosher foods. Patients ferred to the Emergency Department. Where is of both faiths may have some concerns Maya? You find her on her knees deep in prayer. with the contents of their medications, You try to tell her that things are very critical right such as gel caps. Nurses need to be aware now. She is needed; can’t she pray later? Maya of the potential conflicts between hospital tells you she needs to pray now and that she will only be a few more minutes. What priorities must routines and the religious obligations of be addressed? Whose priorities are they? What their patients. Nurses of Islamic faith may potential problems could arise from this situation? find that one of their challenges working What are some potential resolutions? within their belief system is caring for 2993_Ch08_113-142 14/01/14 5:20 PM Page 131

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Table 8-1 examines a number of concepts (AA) and similar 12-step groups are well- that may aﬀect certain cultural groups’ will- established, ongoing groups. They are held ingness to seek and comply with mental not only in the treatment facility, but also in health treatment. the community. Meeting times are established and published so that people know when Group Therapy and how to access them. As a rule, AA meet- Group therapy is a very broad topic. Groups ings are “closed” meetings; that is, only alco- are formed for many reasons; they can be holics are welcome. Sometimes, maybe once ongoing or short-term, depending on the a month or once quarterly, a meeting is ad- needs of the patients or the type of disorder. vertised as “open,” so that other interested Group therapy can include formal psy- persons (and students) are welcome. Many chotherapy groups where patients meet with people who have experienced alcoholism or a therapist regularly as part of their treatment. other chemical dependencies have beneﬁted Self-help programs are also a form of group from this 12-step approach to healing, and it therapy. For example, Alcoholics Anonymous is said that this type of peer group help is the

l Table 8-1 Concepts That May Affect Certain Cultural Groups’ Seeking or Complying With Mental Health Treatment Caucasian • Stigma remains attached to mental illness but is weakening somewhat. • Generally have more access to health insurance and to mental health professionals. • Tend to be more receptive to taking medications than other groups may be. African • More likely than whites to receive initial treatment for mental health in American emergency rooms (it is thought this may be because this population delays treatment). • Approximately 20% of African Americans do not have health insurance. • More likely to receive treatment from primary health-care provider rather than a mental health specialist. • If any treatment is rendered, it may be substandard. • Statistics may be skewed to show overrepresentation of African Americans having mental illness. Hispanic • Mental illness among Hispanics is about equal to that of Caucasians. • Currently the highest group not having health insurance. • Language barriers. • Young Hispanics tend to have higher rates of depression, anxiety disorders, and suicide. • Hispanics born in the United States tend to be diagnosed with a mental illness more frequently than those born in Mexico. Native • Suicide rate approximately 50% higher than that of the general U.S. Americans population. • Mental health treatment options very limited. • Lack of research into mental health issues for Native Americans. Also difficult to design and provide effective mental health care. • Cultural stigmas. Asian • Cultural stigmas; depending on the group, the stigma is expressed Americans differently. • Language barriers. • Tend to seek mental health services at lower rates than Caucasians. • Goal is to restore balance in life; often accomplished through exercise or diet rather than a mental health system.

Oﬃce of Minority Health. (2013). Accessed at http://minorityhealth.hhs.gov 2993_Ch08_113-142 14/01/14 5:20 PM Page 132

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most beneﬁcial for this type of illness. Other types of support groups may have diﬀerent formats.

Tool Box | Alcohol Anonymous (AA) www.aa.org

■ ■ ■ Clinical Activity Attend an open AA meeting. Describe your views about AA prior to attending and write about your feelings after attending..

Group therapy also includes family therapy. Family counseling sessions are often set up with individual therapists with a specialty in the problem area for that family. It is expected that the whole family attend, but there may be times when only certain members are asked to attend or when the individuals will “break out” with another therapist and then return to the family group later. Figure 8-13 This obviously happy couple is Marriage counseling is set up either with an a reminder that people can find creative, ef- individual counselor or in a group with other fective ways to manage conflicts within their relationships. A therapist may help them couples. Many times, peer counselors are used. with suggestions, but they must try those These are people who have experienced similar suggestions themselves and find what works obstacles in their marriage and found creative, for them. (Courtesy of Robynn Anwar.) effective ways to manage their conflicts (Fig. 8-13). Sometimes, people choose to seek help from a spiritual leader. It is important for some patients. They envision the old movies us to remember that the therapists and coun- in which the patient flopped relentlessly selors are tools. They do not heal the patient; on the table. Fortunately, that is a no longer the patient heals himself or herself. Patients the case. must take the suggestions given by the thera- Because of these misperceptions, it is im- pist, try them, and see what works for them. portant for health-care providers to educate Nurses can help patients by reinforcing the others (Fig. 8-14). Patients are generally given good work they do in learning to keep them- a sedative before the treatment. Nurses care- selves healthy. Nurses can also help by remind- fully monitor blood pressure and pulse before ing patients gently that they do their own and after treatment. The amount of electricity healing. Sometimes, when the road to healing used is individualized to the patient. A treat- gets rocky, patients may use the therapist as a ment usually lasts only a few minutes, and scapegoat. Rather than agree or disagree with if one is slow to look, he or she might miss the patient, the nurse needs to remember the seeing a patient’s so-called convulsion. Often, therapeutic communication skills, empathize only a toe or a finger may twitch slightly; with the hard work that is being done by the there are no more uncontrolled seizures on patient, and encourage the patient to discuss the treatment table. the frustration with the therapist. ECT has a few side effects that can be fairly unpleasant. The patient may feel con- Electroconvulsive Therapy fused and forgetful immediately after the Electroconvulsive therapy (ECT), or elec- treatment. This can be from a combination of troshock therapy, as it is sometimes still called, the ECT itself and the pretreatment medica- is a form of treatment that is frightening to tion. If there has been a stronger seizure, the 2993_Ch08_113-142 14/01/14 5:20 PM Page 133

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ELECTROCONVULSIVE THERAPY (ECT)

USES DESIRED OUTCOMES NURSING PATIENT TEACHING Depression or Patient will state and CONSIDERATIONS May be disoriented schizophrenia that exhibit appropriate Monitor vitals before after treatment. does not respond to mood and affect or a and after treatment. May lose short-term other treatments. measurable Maintain safety after memory. improvement in mood the treatment. Side effects last and affect. Premedicate if about 24 hours. ordered.

Figure 8-14 Electroconvulsive therapy.

patient may have some muscle soreness. Reminding the patient to empty his or her Patients are secured with restraints during the bladder and to remove dentures, contact treatment, however, so movement is minimal. lenses, hairpins, and so on is also important. Because of the possibility of confusion and Ensuring that the patient is kept safe after forgetfulness, it is common to restrict the pa- therapy is also a major concern. tient’s activity for 24 hours after a treatment, and it is recommended that the nurse stay Humor Therapy with the patient until the patient is oriented Many studies have been done over the years and able to care for himself or herself. ECT showing the eﬀects of smiles, hugs, and is not used indiscriminately as it once was. laughter on mental health as well as physical Today, it is used when other therapies have conditions such as cancer (Fig. 8-15). The not been helpful, and it is usually reserved for movie Patch Adams, based on a real-life doc- severe or long-term depression and certain tor, portrayed the potential of humor therapy. types of schizophrenia. Viewers saw breakthroughs take place in pa- The nurse’s responsibilities include careful tients previously thought untreatable. monitoring of vital signs and accurate docu- Humor therapy uses many modalities, mentation relating to the patient’s subjective from clowns to movies to just 10 good “belly and objective response to the treatment. The laughs” daily. Whatever the medium, laughter patient should have nothing by mouth alters outlooks and neurochemical produc- (NPO) for at least 4 hours before a treatment. tion. Patients can show remarkable progress.

HUMOR THERAPY

USES DESIRED OUTCOMES NURSING PATIENT TEACHING All forms of mental Patients respond and CONSIDERATIONS Patient identifies how health alterations and react to the humor. Assist in determining humor improves physical conditions. Patients interact. appropriate patients. situations. Patients may show Assist in humor Patient helps in improvement in “application.” seeking out physical condition. opportunities to apply humor in his or her life.

Figure 8-15 Humor therapy. 2993_Ch08_113-142 14/01/14 5:20 PM Page 134

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In fact, this kind of intervention has brought including mental health units and long-term responses such as singing, hand clapping, and care facilities. Pet therapy benefits children, laughter from dementia patients who do not adolescents and adults with therapeutic effects. usually respond to other programming. Neeb’s After reviewing the various modali- Neeb’s The danger in humor therapy is that ■ Tip ties for treating mental health disor- ■ Tip what some people find funny, others ders: if you were using one of the find offensive. Be sensitive to varied modalities, could you discuss it as reactions. Remember some people easily as if you were talking about a are fearful of clowns. vitamin?

Smiles are always appropriate. A brave Crisis Intervention nurse wearing a red rubber nose when walking into the room of an appropriate patient PHASES OF CRISIS might ease that person’s pain—either mental Although crisis is a highly individual situa- or physical—even if only for a short while. tion, most experts agree that people experi- Humor is important for nurses as well as for encing a crisis pass through the five phases the patient, since caring for others on a daily described in Table 8-2. basis can create unwarranted stresses. Crisis can happen at any time to anyone. It can involve one’s child, next-door neighbor, or Pet Therapy patient. Crisis is defined in several ways. In the Pet therapy has been found to reduce stress in health fields, a crisis is a sudden, unexpected patients. Unfortunately, not everyone can event in a person’s life that drastically changes have a pet, due to finances, allergies, or living his or her routine. Crisis has been defined as a arrangements. state in which the body is out of homeostasis. The well-renowned Dr. Oz sees pet therapy It is thought of as a situation in which a person as a stress reliever, especially for lack of social may “lose control of feelings and thoughts, interaction, such as the loss of a significant thus experiencing an extreme state of emo- other. Pets are not judgmental. According to the tional turmoil” (Shives and Isaacs, 2002). National Institutes of Health (NIH), pet ther- A person in crisis is at risk for physical and apy can be used in several health-care settings, emotional harm inflicted by self or by others.

l Table 8-2 The Five Phases of Crises Phase Behaviors Precrisis Person feels “fine.” Will often deny stress level and, in fact, state a feeling of well-being. Impact Person feels anxiety and confusion. May have trouble organizing personal life. High stress level. Person will acknowledge feeling stress but may minimize its severity. Crisis Person denies problem is out of control. Withdraws or rationalizes behaviors and stress. Uses defense mechanism of projection frequently. This may last varied amounts of time. Adaptive Crisis is perceived in a positive way. Anxiety decreases. Person attempts to regain self-esteem and is able to start socializing again. Person is able to do some positive problem solving. Postcrisis Surprisingly, both positive and negative functioning may be seen. Person may have developed a more positive, effective way of coping with stress or may show ineffective adaptation, such as being critical, hostile, depressed, or may use food or chemicals such as alcohol to deal with what has happened. 2993_Ch08_113-142 14/01/14 5:20 PM Page 135

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Examples of people who may be experiencing at a different level than it would be from a law a crisis are those who have lost a job suddenly enforcement or emergency dispatch viewpoint. or were divorced recently, are in an abusive Since this text is meant to be an overview to relationship, have experienced the death of a prepare nurses at an entry level of practice, we loved one, or are contemplating or attempt- will look at the goals of crisis intervention from ing suicide. An important concept to remem- a health-care perspective. ber is that each person has a different set of 1. Ensure safety: Assess the situation. If the stressors and a different way of dealing with nurse or the patient is in physical danger, stress. What is a crisis for one person may be the nurse should signal for help. The nurse simply a minor nuisance for another person. should not leave the patient unless danger to Many employers recognize the potential the nurse is imminent. It may sound harsh, for crisis and offer some type of employee as- but the nurse will be no good to anyone if sistance program (EAP). The service is confi- he or she is hurt, or worse. The nurse must dential, and usually the initial call is free to take care of his or her own safety, and then the employee. EAPs vary in what they are able take care of the patient’s safety. to provide and may act as a referral service for 2. Diffuse the situation: Nurses should do this the employee. Nurses should ask the patient verbally, when at all possible. A person in if his or her employer provides this benefit. crisis is most likely not in control of his or her thoughts, feelings, or actions. Physical GOALS OF CRISIS INTERVENTION attempts at restraining or calming are best Nurses often have the unique opportunity of left until all verbal attempts have been often being present for the first three phases of made, and only when there is enough help the crisis and not for the outcome (Fig. 8-16). to do it safely for the patient and the staff. In many agencies, nurses are not involved with 3. Determine the problem: The nurse should longer term treatment, but they may very easily attempt to find out from the patient’s be the ones who walk into the room during a viewpoint the cause of the crisis. It is suicide attempt or who may take the call at the very important that the nurse not push nursing station from a distraught parent who is the patient for any reason and remain about to hurt his or her child. calm during the intervention. The last The goals of crisis intervention change ac- thing a patient in crisis needs is a nurse cording to the degree of treatment in which the in panic. There is time for nurses to nurse will be involved. Crisis intervention for talk about their feelings when the the health-care provider is obviously provided patient is safe.

CRISIS INTERVENTION

USES DESIRED OUTCOMES NURSING PATIENT TEACHING For states of extreme Patient returns to CONSIDERATIONS Determine stressors. emotional or physical pre-crisis (or higher) Assess for the level of Work with new coping turmoil in which level of functioning. crisis patient is techniques. patients feel out of experiencing. Access support control of self or Assess suicide system before stress situation. potential. reaches crisis. Use verbal and nonverbal communication skills to diffuse situation.

Figure 8-16 Crisis intervention. 2993_Ch08_113-142 14/01/14 5:20 PM Page 136

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4. Decrease the anxiety level: The nurse’s ■ ■ ■ Classroom Activity adrenaline level will probably be at an • Look in your city’s telephone book for agencies all-time high, but it won’t be even close that handle crisis intervention. Contact one in to that of the person in crisis. The nurse person. Inform the agency that this is a school should make every attempt to reassure project and you wish to ask them a few questions, such as: Whom does the agency service? the patient that he or she is in a safe What are its hours of operation? How is the place. The nurse should gently but firmly agency funded? What does the emergency care tell the patient that he or she is con- cost the patient? Who is its staff? Write a short re- cerned, wants to help, and will do what- port of your findings. If possible, appoint some- ever is possible to make the situation one to compile all the information so that each student nurse has a “starter set” to be able to more comfortable but that the patient’s help others. help and cooperation are needed. Caution: Nurses must be very careful with physical contact at this point. Touch as a non- Crisis, if treated in an appropriate and verbal communication skill may be timely way, is usually temporary. Crisis inter- interpreted inaccurately as aggression or vention theories are changing to try to keep sexual innuendo by a patient whose up with the current concepts of illness. thoughts and feelings are in turmoil. Nevertheless, people will always be experienc- 5. Return the patient to pre-crisis (or better) ing crisis. When crisis happens, it is impor- level of functioning: A nurse may or may tant that the person who is there to help not be able to calm the patient to the understand that this is a very frightening point that he or she is able to under- time for the person in turmoil. Nurses must stand what just happened. It might understand that they are in a special position take a longer-term session of treatment as they have some knowledge of crisis and to help the patient gain that kind of communication skills and are able to help, insight. No matter what level of inter- yet they must always be aware of the legal vention the patient requires, the ulti- ramifications of intervention. mate goal is for him or her to learn the skills necessary to cope with stress in ■ a more positive way than before the Terrorism crisis. Much of that learning will come September 11, 2001, changed life in the from the role modeling from the nurses. United States. Citizens of the United States Quite often the most effective techniques became aware of a way of life experienced rou- are nonverbal where actions speak louder tinely by some of the country’s global neigh- than words. bors. Suicide bombers, anthrax, sarin gas, and tainted water and food sources—American ■ ■ ■ Critical Thinking Question citizens suddenly had a new kind of connec- With a student partner, role-play one or more of the following potential crises (or think up your tion to those in other countries who have been own). Think about your communication tech- falling victim to terror for generations. Reality niques. Do they change when dealing with crisis? was attached to what many Americans knew If so, how? What about your nonverbal communi- only from movies or the evening news. That cation techniques? way of life, that behavior, is called terrorism. • Parent whose child has been abducted at the mall Terror, according to Webster Online (2013), • Man who calls the clinic, stating he has just killed is “1: a state of intense fear; 2a: one that in- his wife spires fear, b: a frightening aspect, c: a cause • Woman who is frantically seeking shelter from an of anxiety, d: an appalling person or thing; abusive relationship 3: violence (as bombing) committed by • You find a friend of your adolescent daughter slashing her wrists. groups in order to intimidate a population or • Alcoholic, the main wage earner for the family, government into granting their demands.” who has just been fired from his job Some words, such as fear and anxiety, which are used to define terrorism are also 2993_Ch08_113-142 14/01/14 5:20 PM Page 137

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symptoms of many mental illnesses. Perhaps Exactly what a nurse is able to do depends the most frightening part of this definition is greatly on his or her locale, level of prepara- that humans do not always know the source tion, state’s nurse practice act, and comfort of the terror and thus are unable to defend level. Staying within the legal parameter of themselves. They may feel a loss of personal one’s nursing licensure is of major impor- control over their life and safety. It is difficult tance; nurses should do only what they know for adults to accept and deal with what has and what is legal. The truth is that anyone can become an ever-present possibility in what sue anyone for anything. The good news is Americans had always assumed was a safe that most states will find in favor of the med- place to live. How, then, do people help their ical professional who has, in good faith and children to process the potential dangers in in accordance with his or her licensure, made the world at the same time they are moving an effort to help a person in a crisis situation. through the normal stages of growth and de- The Good Samaritan law protects nurses as velopment? How can people convey the mes- well. The Good Samaritan law does not gen- sage that while bad things happen, people are erally cover nurses within the confines of their basically good and not to fear them? How do employment, however; only when acting to adults, parents, teachers, and health-care assist in a crisis or emergency situation are professionals prepare to help others who ex- nurses protected. perience crisis, post-traumatic stress, depression, and other potential effects of terror? Remember: Crisis intervention has Suggestions will be offered in various chapters Neeb’s ■ Tip something in common cardiopul- throughout this text; however, to borrow an monary resuscitation (CPR): Once a idea from the sports world, the best defense nurse starts and makes that com- is a good offense. Nurses need to be ready for mitment to help, he/she cannot quit the possibility of patients experiencing some until physically unable to continue. effect of terrorism and must be willing to dis- Starting to provide help and then cuss the situation with that patient. As with changing one’s mind can be inter- so many other areas of nursing, it means preted as neglect or abandonment, nurses must take stock of their own thoughts and in such an instance, the nurse and feelings about the topic. could be found at fault. ■ Legal Considerations The Patient’s Perspective: What happens to The Nurse's Perspective: Today’s society is a the patient experiencing the crisis? Because of litigious one. It is easy to be tempted to stay the nature of crisis, the patient probably does uninvolved when people call out for help. In not have a valid insight into the situation. The some states, nurses, physicians, and anyone patient is very likely to be concerned about else in the health fields are required by law to personal safety. On top of that, fear and in- help. Some localities require health-care pro- ability to perceive the situation as it really is fessionals to post identifying insignia on their will interfere with communication. In most vehicles. Most states do not require this yet, instances, the medical staff will encourage the but many are considering it. This puts nurses patient to accept some form of treatment. The in a sensitive position. Nurses want to help, patient then has two choices: voluntary or in- but nursing curriculum at the entry level pro- voluntary commitment. vides very little in the way of hands-on crisis Voluntary treatment happens when the pa- intervention techniques. What if something tient gives informed consent to be hospital- goes wrong? Crisis intervention literature sug- ized or accept some formal treatment gests that nurses risk a higher liability if they program. Informed consent means that the fail to try to help. In other words, it is safer patient has been made aware of his or her be- legally for a nurse to do something to help haviors, the implications of the behaviors, and than to do nothing. expectations from the treatment. Informed 2993_Ch08_113-142 14/01/14 5:20 PM Page 138

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consent can be verbal, nonverbal, or written. Bill of Rights and most often the patient Implied consent allows people who are uncon- keeps a copy of the rights. scious to be treated in such a way as to pre- The Community Mental Health Centers serve life. If the patient is an adult of legal age Act made provisions for community-based who is considered to be competent in the eyes treatment. Communities develop centers and of the law (or an adolescent who has acquired provide treatment according to the needs of the legal emancipation), this patient can also sign area; not all centers provide all types of treat- himself or herself out at any time. ment or 24-hour service. However, the com- Involuntary commitment varies somewhat munity is supposed to provide some method of from state to state. Many states have the emergency psychiatric treatment to help people capability to place a “hold” on the patient, in crisis as well as those who are chronically usually for 48 to 72 hours. During this time, mentally ill. These centers can be in the form the patient is conﬁned to the treatment set- of freestanding crisis centers or walk-in clinics, ting. Usually, a social worker is assigned to and many are connected with the community visit the patient and act as an advocate for hospital. In reality though, many communities him or her. The goal of the hold period is for may have minimal resources to provide these the patient to see the need for help with his services, so nurses should know what is avail- or her crisis and then consent to voluntary able in their communities treatment. If, at the end of the hold period, the patient does not consent to treatment, ■ Summary he or she is free to leave the facility, as long as no other manifestation of crisis has sur- Table 8-3 summarizes treatment modalities faced during the hold. that may be used alone or in conjunction In either instance, patients maintain all with medications to treat a wide variety of civil rights while in the treatment setting. mental health issues. The common uses and The patient is covered under the Patient's desired outcomes are covered.

l Table 8-3 Summary of Commonly Used Treatment Modalities Treatment Modality Uses Desired Outcomes Psychotherapy For treatment of various 1. Patient states improvement in alterations to mental emotional discomfort. health. 2. Patient returns to comfortable social functioning. 3. Patient behaves in a manner appropriate to the situation. Behavior To remove or greatly di- Former undesirable behaviors have been Modiﬁcation minish behaviors that are replaced by new, healthy behaviors. inappropriate or unhealthy. Rational-Emotive Short-term, problem- Patient will be able to remain “undis- Therapy (RET)/ focused therapy for any turbed” as a result of rethinking activating Cognitive mental health alteration events, belief system, and consequences. Behavior that is consciously Therapy(CBT) controlled. Person-Centered/ All aspects of patient care. Patient will feel accepted as a human, Humanistic All forms of mental health which will allow patient to be self-aware alterations. and self-accepting. Patient will gain insight into the situation and receive tools to make changes in his or her life. 2993_Ch08_113-142 14/01/14 5:20 PM Page 139

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l Table 8-3 Summary of Commonly Used Treatment Modalities—cont’d Treatment Modality Uses Desired Outcomes Pastoral All forms of mental health Patient gains tools from a religious/ Counseling alterations. cultural background to be able to make or Cultural changes in his or her life. Counseling Group Therapy Many uses, including Patient gains knowledge that there are family, couples, self-help. others with similar problems. Patient learns from peers and helps others. Electro-Convulsive Depression or schizophre- Patient will state and exhibit appropriate Therapy (ECT) nia that does not respond mood and aﬀect or a measurable to other treatments. improvement in mood and aﬀect. Humor Therapy All forms of mental health Patients respond and react to the humor. alterations and physical Patients interact. conditions. Patients may show improvement in physical condition. Crisis Intervention For states of extreme emo- Patient returns to precrisis (or higher) tional or physical turmoil in level of functioning. which patients feel out of control of self or situation.

■ ■ ■ Key Concepts and type of illness. Counselors may be licensed and the nurse’s role in counsel- 1. The place in which treatment is given ing regulated differently from state to must be conducive to therapy. Milieu is state and municipality to municipality. the word used to describe the environ- Counseling is given individually or ment of the treatment area. in group settings, according to the 2. Psychopharmacology is very important situation. to the effective treatment of the patient. 5. ECT is used for specific situations. Pre- There are many classifications of psychoac- medication is usually ordered. It is the tive medications and many individual role of the nurse to monitor vital signs, medications within each classification. It is maintain safety, and document post- the nurse’s responsibility to consult a drug treatment observations. reference regarding all the psychotropic medications they give their patients. It also 6. Crisis intervention is very individualized. is part of the nurse’s role to reinforce teach- Crisis has five phases, and each person ing about the medications to the patient. experiences them differently. 3. Psychotherapy, sometimes in conjunction 7. Employee support systems are becoming with medications, is often used to treat more accessible through employers. They patients. There are several methods of psy- are confidential and free or reasonably chotherapy, including psychoanalysis, be- priced. havior modification, rational-emotive 8. Pastoral or cultural counseling may be therapy, and humanistic, or person- the treatment of choice for an individual. centered, therapy. Nurses must do all they can to help the 4. Counseling is carried out in different patient receive care that is personally ways, depending on the patient’s needs meaningful. 2993_Ch08_113-142 14/01/14 5:20 PM Page 140

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CASE STUDY Andrea, an emergency room nurse from responders are directing Andrea and her San Diego, is on vacation with her friend. friend away from the site. Andrea tells them Andrea selected a road trip to a major theme she is a nurse and offers to help. At this park. There are two adults and two children moment, her help is not wanted, but all are in the vehicle. They are about minutes from directed to a “holding” area. The children, the gate, Andrea sees smoke on the horizon. whose ages are 4 and 13 (Olivia and Trinity), The radio in the vehicle alerts Andrea and are crying and asking Andrea questions her friend that the theme park has just about the smoke. If you were Andrea, what experienced an explosion. Details are would your emotional response be? How sketchy, but there are numerous injuries. would you answer and calm the children? The park has been closed. As Andrea and After a few minutes, the police accept her friends approach what was the entrance Andrea’s offer to help the wounded. The to the park, they witness many individuals children become hysterical at Andrea's leav- running, injured, and crying. People are ing the vehicle, yet Andrea feels responsible on fire and rolling. There is a very unpleas- to help. What should Andrea do? What ant odor. Police, firefighters, and first stages of crisis is she experiencing?

REFERENCES Treatment. 6th ed. Philadelphia: Lippincott Williams and Wilkins CNN.com/Health. Report: Minorities lack Shives, L.R., and Isaacs, A. (2002). Basic Concepts proper mental health care. Dr. David Satcher, of Psychiatric–Mental Health Nursing. 5th ed. U.S. Surgeon General. August 27, 2001. Philadelphia: JB Lippincott. Deglin, J.F., Vallerand, A.H., and Sanoski, C.A. Townsend, M.C. (2012). Essentials of Psychi- (2011). Davis’s Drug Guide for Nurses. 12th ed. atric and Mental Health Nursing. 7th ed. Philadelphia: F.A. Davis. Philadelphia: F.A. Davis. Ellis, A. (1988). A Guide to Rational Living. Venes, D. (2013). Taber’s Cyclopedic Medical From the video series Thinking Allowed. Dictionary. 22nd ed. Philadelphia: F.A. Davis. Oakland, CA: InnerWork. Webster Online. (2005). www.merriam-webster. Meadows, M. (1997, September). Closing the com Gap: Mental Health and Minorities. Cultural Considerations in Treating Asians. A Newslet- ter of the Office of Minority Health. WEB SITES Oﬃce of Minority Health. (2013). Accessed at http://minorityhealth.hhs.gov Psychotherapies www.nimh.nih.gov/health/topics/psychotherapies/ Oz, M.C., and Roizen, M.F. (2008). That Lovin’ index.shtml Feeling. In You Being Beautiful: The Owner’s www.apa.org/helpcenter/understanding-psychotherapy. Manual to Inner and Outer Beauty (p. 292). aspx New York: Free Press. Pet Therapy Sadock, B.J., and Sadock, V.A. (2008). Kaplan http://consensus.nih.gov/1987/1987HealthBeneﬁts and Sadock’s Concise Handbook of Clinical Petsta003html.htm Psychiatry. Philadelphia. Lippincott Williams Psychotropic Medications and Wilkins. www.nami.org/Template.cfm?Section=Policymakers_ Sadock, B.J., Sadock, V.A. (2013). Kaplan & Toolkit&Template=/ContentManagement/ Sadock’s Pocket Handbook of Psychiatric Drug HTMLDisplay.cfm&ContentID=18971 2993_Ch08_113-142 14/01/14 5:20 PM Page 141

CHAPTER 8 | Mental Health Treatments 141 Test Questions Multiple Choice Questions 1. Which of the following is not a behavior 5. Psychopharmacology (psychotropic drug noted in the crisis phase of crisis? therapy) is used: a. Denial a. As a cure for mental illness b. Feeling of well-being b. Only to control violent behavior c. Use of projection c. To alter the pain receptors in the brain d. Rationalization d. To decrease symptoms and facilitate 2. One of the first statements a nurse might other therapies make to a person who has been abused 6. Avoiding such foods as bananas, cheese, might be: and yogurt should be emphasized to a. “Why didn’t you leave the first time patients who are taking: you were attacked?” a. Prozac b. “Do you want to prosecute or not?” b. Lithium c. “What do you think made that person c. MAOIs hit you?” d. Tricyclic antidepressants d. “You’re safe here. I would like to 7. The goals of crisis intervention include help you.” all of the following except: 3. A therapeutic environment (milieu) is a. Safety best defined as: b. Increasing anxiety a. An environment in which a patient c. Taking care of the precipitating is under a 72-hour hold event b. An environment that is locked and d. Return to pre-crisis or better level supervised of functioning c. An environment that is structured to 8. In order for psychotherapy to be decrease stress and encourage learning effective, it is necessary to do all of new behavior the following except: d. An environment that is designed to a. Encourage the patient to repress be homelike for persons who are feelings. hospitalized for life b. Reinforce appropriate behavior. 4. Which of the following is false regarding c. Establish a therapeutic patient-staff ECT? relationship. a. It is used to treat depression and d. Assist patient to gain insight into schizophrenia. problem. b. It is used to stop convulsive seizures. c. Fatigue and disorientation are immediate side effects. d. Memory will gradually return. 2993_Ch08_113-142 14/01/14 5:20 PM Page 142

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Test Questions cont. 9. Your patient, Mrs. L, is on your unit 10. James is a 13-year-old who has been for bowel resection. She is exhibiting transferred to your medical-surgical unit signs of nervousness and anxiety, which after being stabilized in the ED. He slit she attributes to the upcoming surgery. both wrists and took an overdose of his You note from her record that she has Wellbutrin. You know medications such a history of ethyl alcohol (ETOH) as Wellbutrin: abuse. Which of the following classiﬁca- a. Are antidepressants and should have tions of drugs would be potentially ad- stopped his suicidal impulse dictive for her? b. Have no particular nursing considera- a. Lithium salts tions for children and adolescents b. Antianxiety drugs c. Are antidepressants and may have an c. Antipsychotic drugs increase in the suicidal ideation for d. Anticholinergics children and adolescents d. Are not eﬀective as antidepressants for children or adolescents 2993_Ch09_143-156 14/01/14 5:20 PM Page 143

CHAPTER 9 Complementary and Alternative Treatment Modalities

Learning Objectives Key Terms 1. Differentiate between alternative and complementary • Alternative medicine medicine. • Aromatherapy 2. Identify integrative medicine. • Beliefs 3. Identify the concept of the mind-body connection. • Biofeedback 4. Identify support for patient beliefs and models. • Complementary 5. Identify three alternative and complementary treatment medicine modalities. • Holistic 6. Identify three types of massage. • Hypnotherapy 7. Differentiate between trance and sleep. • Integrative medicine 8. Identify the three primary channels of experience. • Mind-body connection 9. Define key terms. • Models • Placebo • Presupposition • Rapport • Reflexology • Reiki • Trance

edicine is a rapidly evolving field, additional options. In general, alternative and sometimes it is tempting for practices/medicines replace those of conven- Mthe nurse to assume that every tional medicine, and complementary methods patient is knowledgeable about the current are used together with traditional treatments. state of the art. For some patients, conven- Many of these have been used for centuries. tional Western medicine is not the only These present different choices to the phar- course. Many factors affect a patient’s choice maceutical products dispensed at the local of treatment modalities; education, experi- pharmacy. Often, these methods differ con- ence, economic status, belief system, and siderably from what is acceptable medical care culture are a few considerations. in Western culture. Complementary or alter- There are many other means of treating ill- native methods may lack extensive scientific ness and promoting good health in addition research to prove their effectiveness or even to traditional medicine. Complementary their safety according to the standards of con- and alternative medicine (CAM) presents ventional medicine. Those practices that do

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have at least some research validating that based on beliefs, values, education, and expe- they are safe and do work comprise integra- rience. Models are pictures or ideas that peo- tive medicine, which provides the best ple form in their minds to explain how things of both worlds. work. Models help people understand and An alternative practice, for example, would interact with others and their environment, be to use an herbal preparation to combat de- and they help people to formulate beliefs. pression instead of physician-ordered prescrip- To a large extent, a person’s beliefs will de- tion medication. A complementary treatment termine the success of a given treatment. This might consist of using biofeedback to reduce can be plainly seen when a placebo medica- the symptoms of anxiety associated with mention is given and is effective in relieving symp- tal illness while the patient continues to par- toms like severe pain, even though the placebo ticipate in psychotherapy and take antianxiety is no more than a sugar pill. This illustrates medications. Both approaches address a key that what the patient believes and expects the concept in alternative and complementary placebo to do can be more important than the medicine: the mind-body connection. actual composition of the tablet. Even though the nurse might not be ■ directly involved in the application of a com- Mind, Body, and Belief plementary or alternative treatment, support- The ways in which people’s minds and bodies ing the patient’s cultural and belief systems is are interconnected stretch beyond the obvious an important role in helping him or her move physical world in which people live. First, forward on a path to wellness. Each patient will there is the brain, an organ directly connected have a different level of acceptance of various to the body by tissue such as nerves and blood complementary and alternative approaches. vessels. The brain is contained within the How nonjudgmental, open, and accepting of bony cavity of the skull, which constitutes its different ideas for the success of the different protection and support. Themind represents methods is up to the patient. The nurse can the cognitive, emotional, and logical re- ease that process by also remaining nonjudg- sponses that make people individual human mental, open, and accepting and at the same beings. The mind is clearly more than just the time being aware of any safety concerns for the brain, the sum of its cells, chemicals, electrical patient. activity, and connections. As always, the boundaries of legal and It may seem strange to think that there was acceptable nursing practice vary from state to ever a question about the interconnectedness state. Nurses need to check with their state’s of the mind and the body. It has long been board of nursing or other regulating agencies known that disease affects the mind, but con- to determine acceptable standards of practice ventional medicine has only recently started in regard to using alternative, integrative, and to accept that the reverse is also true, that the complementary therapies. mind affects the disease. People’s thoughts and emotions affect the way their bodies ■ Common function, even on a cellular level. Thisholistic Complementary and view makes complementary and alternative medicine increasingly popular choices for the Alternative Treatments treatment of all types of illness, including mental disorders. Biofeedback Important to the effectiveness of any type Stress-related anxiety is the common element of treatment are the patient’s beliefs. Nursing of disorders relating to mental illness. It is requires respect for the beliefs and values of known that the direct effects of sustained stress other people and cultures as fundamental to can be devastating (see Chapter 7, Coping and good practice. It is useful to remember that Defense Mechanisms). In a critical moment or everyone has a different way of viewing the progressively over time, the biological response world. Everyone forms models of the world to stress can impair the cognitive function of 2993_Ch09_143-156 14/01/14 5:20 PM Page 145

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the mind and cloud a person’s thinking. Pro- Biofeedback is being used with good longed stress can lead to emotional anguish results for conditions including insomnia, that is experienced as fear, anxiety, anger, and some types of seizures, functional nausea and depression. Prolonged stress can also lead to vomiting, tinnitus, and phantom limb pain. exhaustion and possible death. Anxiety con- As with other forms of therapy, biofeedback tributes to physical symptoms—many of which practitioners must be aware of functional or can be reduced or controlled by biofeedback even psychological symptoms that are actually techniques. Biofeedback is a training program caused by organic problems and require dif- designed to develop one’s ability to control the ferent treatment. It may not be appropriate autonomic nervous system. While biofeedback to use biofeedback to treat extreme or acute only recently has become a complementary states of mental illness, like severe depression, medical therapy, it has been widely accepted mania, agitation, schizophrenia, paranoia, by traditionalists in the West because of its use obsessive-compulsive disorder (OCD), delir- of scientific measuring devices and proven ium, and identity or dissociative disorders. techniques. Critics have pointed out that the major effects The primary purpose of biofeedback train- from biofeedback can be more economical and ing is to teach patients to recognize tension easily obtained through relaxation training. within the body and to respond with relax- Patients with strong faith they can influ- ation (Fig. 9-1). Typically, training for ence their own health are the most likely to patients takes place in a series of one-hour ses- be successful at mastering biofeedback. The sions, sometimes spaced a week apart. The experience of gaining control of one’s physical patient is taught to obtain a deep level of reactions can have a tremendous effect on relaxation as a means to control a light, how the person will view stressful situations buzzer, image, or a video game, to which he in the future. As an educational tool for more or she is attached by electrodes and cables. skeptical patients, learning biofeedback can The machine is then gradually adjusted to demonstrate that they have a great deal more greater sensitivity, and the patient learns control over their responses and symptoms improved control. When training is com- than they first expected. pleted, all that is needed to obtain relaxation and symptom resolution at any time or place Aromatherapy is recall of the particular thought and feeling Aromatherapy may well be one of the oldest that worked in the clinic. methods used to treat illness in human beings. Related to herbal therapy, aromatherapy provides treatment by both the direct pharmacological effects of aromatic plant substances and the indirect effects of certain smells on mood and affect. Throughout human history and in many cultures, there are accounts of the use of aromatics to treat varying forms of illness. Applied in salves or ointments, used in incense, reduced to essential oils for topical application, or even ingested, these substances often appeal to patients who are seeking a “natural” approach to healing People’s response to the sense of smell has strong significance in their lives. People associate certain aromas with certain situations, Figure 9-1 Biofeedback training teaches conditions, and emotional states. Many indi- patients to recognize tension and respond viduals are able to relive particularly strong with relaxation. (Courtesy of Santé Rehabilitation memories when exposed to an aroma that was Group, Euless, TX) present when the remembered event occurred. 2993_Ch09_143-156 14/01/14 5:20 PM Page 146

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For example, the fragrance of baking cookies also perceived by the public to be better, or or apple pie reminds some people of being at safer, because they can be purchased over the home and even experiencing some of the emo- counter and do not require a trip to the doc- tions connected to that memory. The ability tor’s office. There are literally hundreds of for a particular smell to create positive alter- products available to consumers seeking relief ations in mood makes aromatherapy attractive through herbal and nutritional means. to many people and has created a large market in everyday products designed to evoke calm Neeb’s Belief plays a considerable role in and well-being. Scented candles and personal ■ Tip the acceptance and use of these care products like bath oils, shampoos, and products. body lotions are especially popular. With rapid changes in society since World Treatment for anxiety-based mental illness War II has come people’s awareness that their and depression using aromatics like lavender, lives are no longer as pastoral, calm, and idyl- thyme, gardenia, and other botanicals is be- lic as they would like to remember them to coming a more acceptable adjunct to conven- be. This awareness became more evident after tional methods. It is important to be aware the events of September 11, 2001. In a world that the oils and plant matter used in aro- full of processed food, the quality of modern matherapy can be toxic if improperly admin- nutrition has come into question, and there istered and should be kept out of the reach is growing conviction that artificial additives of children and the cognitively impaired. lack the ability to provide the basics needed Applied to skin, many plant oils are caustic for good health. or can trigger an allergic reaction. The nurse Daily, people are assured in the popular should observe and assess to determine if the press and the news media that the solution products used are effective and if there are any to many of their problems can be found in side effects noted. As with all alternative treat- nutritional and herbal supplements. Lack of ment, it is advisable to find a competent and cortisol has been blamed for weight gain, and knowledgeable practitioner to benefit fully taking compounds rich in HGH (human from the potential of aromatherapy. growth hormone) has been credited with reversing aging. Infomercials tout the benefits ■ ■ ■ Classroom Activity of taking coral calcium and even improving • Bring several different aromatic herbs into class, sexual performance with herb-based prepara- pass them around, and have each student sniff tions. The Internet is flooded with supple- the plant or a form of the plant. Students should discuss their immediate feelings after inhaling ments that promise to improve people’s lives the aromas. by making them healthier and stronger. Some herbs have been researched and proven in their effectiveness in treating disease conditions. This should not be surprising, for Herbal and Nutritional many modern medications were developed Therapy from herbal and other botanical origins. Growing steadily in the United States today Native Americans knew the value of the inner is the use of herbal compounds and nutri- bark of the willow tree, gathered and used for tional supplements to treat illness. The pop- its ability to reduce fever and ease pain. They ularity of self-treatment with herbs is in large also used foxglove in their sweat lodges to part due to the desire of many people to energize the frail and restore vitality to the return to a simpler lifestyle and as a means to elderly. Little did they know that the salicylate avoid costly prescription medications. Most in willow bark and digitalis in foxglove were herbal products are considered nutritional the reasons for their effectiveness. supplements rather than medications, so There is a tradition in Europe of using these products avoid regulation by the Food herbal medications and nutritional supple- and Drug Administration (FDA). They are ments to treat disease. For example, people in 2993_Ch09_143-156 14/01/14 5:20 PM Page 147

CHAPTER 9 | Complementary and Alternative Treatment Modalities 147 Germany routinely plant and harvest herbs in Massage, Energy, and Touch their garden plots to create remedies for com- Widespread among complementary and mon ailments. Some herbal preparations are alternative treatment methods are modalities available there only by a doctor’s prescription, centered on manipulating the body’s energy and others can only be obtained through a fields. Massage in one form or another has licensed pharmacist. In the United States, the probably been known to man since before the use of fresh or garden-grown herbs is discour- dawn of history. Touch and movement are es- aged because of the difficulty in determining sential to life and well-being in both physical the strength of the active compounds pro- and psychological ways. Massage is the duced by plants under different growing con- manipulation of the body using methodical ditions. Europeans are guided by generations pressure, friction, and kneading. People are of experience and practice to safely use avail- shaped, almost literally, by their childhood able botanicals. experiences of touching. An infant has limited Unfortunately, the belief in the relative sensory discrimination but will react posi- safety of herbs is a misunderstanding that has tively to being cuddled and held, and even to caused much concern among health-care the feel of a snugly wrapped blanket. providers. Deciding on an appropriate dose is difficult, because herbal preparations do not Tool Box | Types of Massage Therapy have to conform to any specific guidelines www.massagetherapy.com/glossary/index .php regulating strength or purity. People tend to think that if a small amount of the product is effective, more is better still. Some herbs are Massage has evolved into many variations very toxic, particularly in pure form. Many as a result of its success (Fig. 9-2). Use of herbs interact negatively with prescription touch is common to many different treatment medications. This point demonstrates the approaches, but there can be great variation need for the nurse to include direct questions in philosophical, theoretical, and practical to the patient about the use of any CAMs. ideas about how touch is applied. Western Nurses need to be able to teach their patients variations of massage include Swedish, which the importance of consulting with a physician was developed in the early nineteenth century before beginning any sort of herbal therapy. and is the type most people are familiar with. Table 9-1 describes the five most often used It is characterized by long, smooth strokes herbal medications and nutritional supple- that go toward the direction of the heart. ments in the treatment of mental illness in The manipulation of specific body sites to this country. relax muscle groups is known as trigger point massage. Conventional medical science has During the admission interview, Neeb’s generated a similar trigger point therapy in ■ ask the patient if he or she is taking Tip which injections of steroids are applied at any alternative or complementary these key areas in place of massage to both products. Some of these may be relax the muscle group and reduce local in- contraindicated with medications flammation. ordered by the physician. Of course, there are also other means of massage available. Rolfing is a therapy designed to realign the body with gravity Tool Box | The National Institutes of Health through fascial manipulation, a vigorous form division called the National Center for Comple- mentary and Alternative Medicine (NCCAM) of bodywork that is finding increasing accept- is an excellent resource for obtaining informa- ance. Eastern massage traditions have fol- tion on a specific CAM, including scientific lowed a different path. It is widely believed data if available. This is available at among Eastern practitioners that the body is www.nccam.nih.gov/ governed by energy paths, called meridians. This energy is perceived as the life force, or 2993_Ch09_143-156 14/01/145:20PMPage148 148 l Table 9-1 Common Herbal and Dietary Therapies

Specific Active Usual Side Contra- Drug/Food Inter- Patient Therapy Ingredients Dose Uses Effect Indications actions Teaching Ginkgo Biloba Ginkgentin, 120–140 mg Short-term Bleeding, Pregnant May increase the ef- Do not use if on Ginkolic acid PO daily, memory loss contact or breast- fects of anticoagulant Coumadin or depending though research dermatitis, feeding, and antiplatelet drugs. aspirin. on what is is conflicting as nausea, children; use Avoid foods contain- Works well for treated; to benefits vomiting, cautiously ing large amounts of people over divide into diarrhea, for patient tyramine: aged meat 50 as well as 2–3 equal headache; taking anti- and cheese, red wine, younger adults. doses rarely, coagulants, pickled herring, May take subdural MAOI med- yogurt, raisins, sour 6–8 weeks to hematoma, ications cream, and other experience seizures because foods high in tyra- benefits. (especially Ginkgo mine; also OTC cold Use with some in children) Biloba can and flu preparations. fruits and nuts can act as an cause a poison MAOI ivy-like reaction. Kava Kava Kavapyrones, 10–110 mg Antidepressant, Drowsiness, Pregnancy, Do not use with: Symptom relief Piper methys- PO dried kava antianxiety, changes in breastfeeding Alcohol: increases risk may occur in as ticum, Kava extract three antipsychotic, reflex and Skin yellow- of kava toxicity. little as 1 week. pepper times daily, to use as sleep judgment, ing from Alprazolam: risk for Potential for or freshly aide nausea, accumula- coma exists. significant ad- prepared kava muscle tion of plant CNS depressants: kava verse reactions beverages, weakness, pigment potentiates these. when using kava. 400–900 g blurred can occur in Levodopa: can in- Alcohol and CNS weekly vision, chronic use. crease Parkinson-like medications are decreased Liver disease symptoms. Phenobar- enhanced with platelet bital: can increase kava. counts, effects. decreased urea and bilirubin levels, 2993_Ch09_143-156 14/01/145:20PMPage149

dry skin, is a dopamine antagonist St. John’s Wort Hypericum 300 mg PO Antidepressant Severe Pregnant or MAOIs, antidepres- Avoid prolonged perforatum three times photosensi- breastfeed- sants, digoxin, birth exposure to daily for 4–6 tivity, dry ing, children; control pills sunlight. weeks mouth, use cau- May increase the constipa- tiously for effects of MAOIs, tion, GI patient OTC flu and cold upset, sleep taking anti- medications, distur- coagulants, alcohol; do not bances, MAOI use with restlessness medication these types of chemicals. Omega 3 Fatty Alpha- 1–2 g PO Depression, Loose Use cau- May increase effects If taking anti- Acids (Dietary linolenic acid daily for postpartum stools with tiously for of anticoagulants coagulant drugs Supplement) (ALA), docosa- health, depression, higher patients or high doses of hexaenoic cognitive bipolar doses; taking anti- aspirin, practice acid (DHA), enhancement disorder, “fishy” reflux coagulants good safety. The and eicosa- anxiety, oils may increase pentaenoic dementia clotting time. acid (EPA) 3:2 EPA to DHA (fish oil) Sam-E (Supple- s-adenosyl-L- See manufac- Depression Mild and Can cause Patients with ment for methionine turer’s transient mania in bipolar disorder Naturally specifications anxiety, patients with should not use Produced and use as insomnia, bipolar except under Body directed by a heartburn, disorder; supervision of Substance physician loose rule out physician. Enteric bowels before coated prepara- beginning tions may reduce treatment. gastric upset. 149 Source: Spidle, R.A. (2006). Alternative and Complementary Treatment Modalities. In Neeb, K. (2006). Fundamentals of Mental Health Nursing. Philadelphia, F.A. Davis, pp. 164–166. National Center for Complementary & Alternative Medicine at http://nccam.nih.gov 2993_Ch09_143-156 14/01/14 5:20 PM Page 150

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Japanese form of acupressure that uses pressure from the fingers to free energy flow. Reflexology is also based upon the belief that energy pathways and zones cross the body, connecting vital organs and body parts (Fig. 9-3). Reflexologists use massage of the feet to act upon these pathways, unblocking and renewing the energy flow. Therapeutic touch also deserves mention. Reiki is representative of methods of touch healing that are often associated with massage. Reiki is a term that means “universal life energy” and refers to the process whereby this energy is drawn along the body’s meridians. Unlike methods that use physical movement, pressure, or massage to unblock these chan- Figure 9-2 Massage can be an effective tool nels, Reiki uses the flow of life energy itself for relieving tension. (Courtesy of everything- to accomplish the task. Practitioners are jersey.com) “attuned” to the energy channels and can manipulate them hands-on, hands just above the body, or even at a distance. Reiki tech- chi, ki, or prana. When the life force is niques can even be employed as part of a obstructed, emotional and physical illnesses more traditional massage session to enhance result. Various types of pressure, massage, and the physical benefits of the massage. Reiki has other techniques are employed along these been demonstrated to increase warmth in the meridians to release the flow of chi, restore areas being treated and also to produce relax- balance, and improve health. Shiatsu is a ation in the subject.

Brain

Ear Glands Eye Nose Sinuses Throat Lungs

Shoulder Thalamus Shoulder

Diaphragm Heart Liver Spleen Gallbladder Stomach Kidneys Adrenal glands Pancreas Spine Colon Colon Bladder

Appendix Small intestine

Pelvis/buttock Pelvis

Sciatic nerve Figure 9-3 Reﬂexology foot diagram. 2993_Ch09_143-156 14/01/14 5:20 PM Page 151

CHAPTER 9 | Complementary and Alternative Treatment Modalities 151 Hypnotherapy hypnosis. In some states a therapist must be certified or licensed, but in others no one Hypnotherapy is one of the most controver- but a psychologist, psychiatrist, medical doc- sial complementary and alternative modali- tor, or other professional may practice the ties. Hypnosis is a means for entering an techniques. altered state of consciousness, and in this Milton H. Erickson, M.D. (1901–1980), state, using visualization and suggestion to was one of the best-known figures in the bring about desired changes in behavior and development of hypnosis for modern therapeu- thinking. Called trance, people enter this tic purposes. Dr. Erickson was a victim of polio, state of focused attention every day. The Eng- which left him partially paralyzed. He had little lish language even contains references to this strength in his arms and upper body and was common experience of “zoning out.” Trance confined to a wheelchair. As if that were not is not sleep but rather describes a state of enough, he was dyslexic, tone-deaf, color-blind, mind wherein a person is less aware of what and had heart problems. Left alone during long is going on around him or her and instead is periods of illness, Erickson became a master of very focused on an internal experience, like a observation and learned that subtle changes in memory or an imagined event. facial expression, skin color, nuance of voice, Everyone responds to suggestion to some and physical posture could tell him much about extent. A person who is watching television a person’s inner state. and wants a snack after seeing commercials for Dr. Erickson structured his therapeutic a favorite fast-food restaurant has responded approach to patients in a new way. He refused to suggestion. Fortunately, people’s minds fil- to allow his own past disabilities ruin his living ter out suggestions that are unacceptably dan- of life to its fullest and therefore refused to let gerous so they are not persuaded to imitate old problems get in the way of his patients’ some of the more unsafe things seen on TV. enjoyment of living. Erickson ignored the past Neeb’s A hypnotherapist uses suggestion, history of presenting patients, preferring ■ Tip both direct and indirect, to help the instead to focus on present and future outpatient create change. comes. In one classic case, Erickson gave the task of tending violets to a woman with depres- The general public has been subjected to an sion. Combined with other therapeutic sugges- enormous amount of misinformation about tions, she was kept too busy and involved in hypnosis by stage hypnotists, movies, and her community to remain depressed. books. As a result, hypnotherapy is widely Traditional hypnotherapy and psychother- misunderstood and wrongly feared by many apy center on diagnosing problems and treat- people. Watching a stage hypnotist appear to ing symptoms. Erickson promoted well-being, make a volunteer cluck like a chicken or dance and study of his methods has challenged a on a table certainly does not inspire confi- whole new generation of hypnotherapists to dence in hypnosis as a therapeutic tool. It is do the same. Later, John Grinder and Richard very hard for some people to overcome these Bandler would develop the field of neurolin- fears, especially the stubborn belief in the guistic programming (NLP), based in large myth that hypnosis is somehow “mind con- part upon their study of the extraordinary trol” exercised for evil (or entertainment) pur- sensory acuity of Milton Erickson. poses by the therapist. Whereas some researchers and practition- Neurolinguistic Programming ers contend that hypnosis cannot stand on Investigating the techniques and methods its own as a treatment modality, others are of many successful therapists, Bandler and equally convinced that even lay practitioners Grinder searched for ways to make psy- can deliver effective therapy with a mini- chotherapy more consistently effective. It was mum of training and practice. No doubt this through these explorations that they realized controversy will continue, as there are at that language cues could be used to under- present few regulations governing the use of stand how an individual experiences his or her 2993_Ch09_143-156 14/01/14 5:20 PM Page 152

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world. Using those cues, a practitioner can People observe their world through distinct help patients change their experiences and re- channels of experience, tending to prefer one spond to problems in a different way. Unlike channel over another, but eventually using them traditional hypnosis, neurolinguistic pro- all for important cues and sensory information gramming (NLP) does not use lengthy trance about their environment and other people. sessions and instead depends upon patients to take an active part in their treatment. When ■ Primary Sensory John Grinder and Richard Bandler began developing NLP, they based this extraordinary Representation new type of therapy on a basic set of ideas, or The three primary methods of sensory repre- presuppositions. sentation are the visual, auditory, and kines- Presuppositions are the assumptions peo- thetic channels (seeing, hearing, and touching). ple make when forming communication. Of course, people also use taste and smell to They are most often not spoken or written, gather information, but these paths are rarely but understood within the context of what is the most important channel, and they are gen- being communicated. For example, if the erally ignored. statement “I am so happy today!” is made, the Paying attention to speech patterns gives presupposition, or unspoken assumption, is the practitioner a starting point for meaning- that the speaker is not normally happy. Peo- ful communication with the patient. The ple’s daily communications are filled with most obvious way to do this is to listen to the such assumptions, things that they take for predicates a person uses while describing granted. NLP differs from other therapies in thoughts and ideas. The practitioner can then that there is no presupposition that the pa- determine positive rapport if the person tient is somehow “broken” and requires “fix- favors sight, hearing, or touch and match ing.” Instead, practitioners are taught that those predicates, using the same language pat- patients are whole individuals who already terns to create a starting point for meaningful possess the internal resources they need to re- communication. Recognizing these patterns cover from their illness. All that is required is can help improve a nurse’s communication to direct the patient to those resources and with patients. Table 9-2 illustrates types of enable their use. word patterns people use.

l Table 9-2 Representational System Predicates Visual (Seeing) Auditory (Hearing) Kinesthetic (Touch) an eyeful clear as a bell all washed up appears to me clearly expressed boils down to beyond the shadow call on chip off the old block of a doubt bird’s-eye view describe in detail come to grips with catch a glimpse of earful control yourself clear cut express yourself cool, calm, collected dim view give an account of firm foundations eye to eye give me your ear get a handle on get a perspective on grant an audience get in touch with scope out heard voices hand in hand hazy idea hidden message hang in there horse of a different color hold your tongue hold on 2993_Ch09_143-156 14/01/14 5:20 PM Page 153

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l Table 9-2 Representational System Predicates—cont’d Visual (Seeing) Auditory (Hearing) Kinesthetic (Touch) in light of idle talk hold it in view of inquire into keep your shirt on make a scene keynote speaker know how mental image loud and clear lightheaded mind’s eye manner of speaking moment of panic naked eye pay attention to pain in the neck paint a picture power of speech pull some strings photographic memory outspoken sharp as a tack plainly seen rings a bell slipped my mind pretty as a picture to tell the truth start from scratch sight for sore eyes unheard of underhanded under pressure

Of course, just about everyone uses all three to the message that is being sent. This is a forms of predicates at one time or another. powerful tool in creating and maintaining The most important thing to remember is to rapport, the foundation to a therapeutic match the dominant, or most used, form. relationship.

EXAMPLES ■ ■ ■ Clinical Activity (Visual) Interact with a patient to determine if the person favors sight, hearing, or touch. Afterward, commu- Mary: “I can’t picture myself getting any nicate with patient on his or her level. In post- better.” conference, share with fellow students if this Nurse: “In light of your progress, see your- enhanced your rapport with the patient. self going back to school. How does that look to you?” (Auditory) ■ Summary James: “I’ve heard that the doctor is tuned in to the newest treatments.” Nursing practice is evolving and is incorpo- Nurse: “He can describe those in detail to rating “alternative” or “complementary” ther- you. I’ll tell him you want to hear apies into traditional care delivery systems about them.” (Table 9-3). State boards of nursing can determine at what level and scope of practice (Kinesthetic) nurses should provide the alternative therapy. Diane: “I couldn’t come to grips with the situation. I was under too much pressure all the time.” Tool Box | In 2003, the Minnesota Board of Nurse: “It is hard to get in touch with what’s Nursing adopted guidelines and statements for important when you feel that way.” appropriate use of complementary therapy in Minnesota. Those guidelines can be found at These exchanges demonstrate communica- http://mn.gov/health-licensing-boards/ tion on more than one level. By using the nursing/licensees/practice/integrative- same language used by the patient, the nurse therapies. can establish that she or he is listening closely 2993_Ch09_143-156 14/01/14 5:20 PM Page 154

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l Table 9-3 Alternative Therapies Alternative Alternative Therapy Nutritional Therapy and Lifestyle Herbal Herbal Hands -on Therapy Disorder Mind-Body Experience Anxiety √ √ √ √ √ Arthritis √ √ √ √ √ Asthma √ √ √ √ √ Cancer √ √ √ √ Prevention and Treatment Congestive √ √ √ √ √ Heart Failure Coronary Heart √ √ √ √ Disease Depression √ √ √ √ √ Diabetes √ √ √ √ √ GERD √ √ √ √ √ Gastrointestinal √ √ √ √ √ Problems Migraine √ √ √ √ √ Headache Tension √ √ √ √ √ Headache Hepatitis √ √ √ √ √ Hypercholes- √ √ √ √ √ terolemia Hypertension √ √ √ √ √ Irritable Bowel √ √ √ √ √ Syndrome Musculoskeletal √ √ √ √ √ Problems Upper √ √ √ √ √ Respiratory Infection Urinary Tract √ √ √ √ √ Infection

Source: Adapted from Complementary and alternative medicine. (2009). In D. Venes (Ed.), Taber’s cyclopedic medical dictionary (21st ed., pp. 2540–2552). Philadelphia, F.A. Davis. 2993_Ch09_143-156 14/01/14 5:20 PM Page 155

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■ ■ ■ Key Concepts 9. Hypnotherapy and neurolinguistic programming are two prominent 1. Alternative and complementary treat- modalities that address mental and bod- ments provide options for patients other ily illness by empowering change in the than those offered by conventional patient’s thought patterns. Both tightly (Western) medicine. Alternative modali- focus on communication patterns and ties are used instead of, and complemen- the patient-therapist relationship. tary are used in addition to, conventional practices. 2. The mind-body connection is an impor- REFERENCES tant concept in all types of medical treat- Complementary and alternative medicine. ment. Disease and wellness affect the (2009). In D. Venes (Ed.), Taber’s Cyclopedic whole person. Holistic treatments ad- Medical Dictionary. 21st ed., pp. 2540–2552. Philadelphia: F.A. Davis. dress both the illness and the person. F.Y.I.—A Publication of the Minnesota Board of 3. An individual has beliefs, based upon his Nursing (2003). Complementary therapies. or her model of the world. These beliefs Spring/Summer 2003, 19(1), 7. must be respected by the nurse. National Center for Complementary and Alterna- tive Medicine. Available at http://nccam.nih.gov 4. Anxiety is common to disorders relating Skidmore-Roth, L. (2010). Mosby’s Handbook to mental illness. Prolonged stress and of Herbs and National Supplements. 4th ed. anxiety lead to physical as well as mental St. Louis: Mosby-Elsevier. and emotional afflictions.

5. Biofeedback is a technique that teaches WEB SITES the patient to recognize and control Biofeedback stress responses in the body. It is widely Association for Applied Psychophysiology and accepted because of its use of scientific Biofeedback: www.aapb.org measuring devices to demonstrate the Biofeedback Certification Institute of America: effectiveness of the treatment. www.bcio.org Mind Body Connection 6. Aromatherapy uses a person’s emotional http://familydoctor.org/familydoctor/en/ response to smell as well as the pharma- prevention-wellness/emotional-wellbeing/ cological effects of various fragrant botan- mental-health/mind-body-connection-how- ical and other substances to treat illness. your-emotions-affect-your-health.html Aromatherapy 7. Herbal and nutritional therapies are be- National Association for Holistic Aromatherapy: coming more prevalent as the public em- www.naha.org braces “natural” healing. Many modern Massage American Massage Therapy Association: medications have evolved from unculti- www.amtamassage.org vated botanical products. Relative safety Reflexology and effectiveness is still in question, as Association of Reflexologists: www.reflexology.org the industry is largely unregulated, with International Institute of Reflexology: no set standards for these products. www.reflexology-usa.net Reiki 8. Other types of alternative and comple- www.holistic-online.com/Reiki/hoI_Reiki_home.htm mentary therapy focus on manipulation, Milton Erickson strengthening, and removing blockage Milton Erickson Foundation: from the free flow of energy in the www.erickson-foundation.org human body. Massage and therapeutic Neurolinguistic Programming touch modalities are successful groups www.holistic-online.com/hol_neurolinguistic.htm of both stand-alone and adjunctive National Center for Complementary and treatment for disease. Alternative Medicine http://nccam.nih.gov 2993_Ch09_143-156 14/01/14 5:20 PM Page 156

156 UNIT 1 | Foundations for Mental Health Nursing Test Questions Multiple Choice Questions 1. Alternative therapy modalities are used: 6. Of the following, which are either com- a. Infrequently, as they have no value to plementary or alternative modalities? patients today a. ECT, Reiki, rolfing b. In combination with conventional b. Hypnotherapy, shiatsu, antianxiety therapies medications c. In place of conventional therapies c. NLP, psychotherapy, SAM-e d. Only when there is no hope for d. Aromatherapy, biofeedback, massage recovery 7. Mr. Douglas wants to know more about 2. A treatment modality used with massage therapy. Which one of the conventional medical therapies is: following is not a massage modality? a. A medical approach a. Reiki b. A model approach b. Trigger point c. A holistic approach c. Rolfing d. A complementary approach d. Swedish 3. When traditional medicine is combined 8. Which of the following is false about with less traditional methods, it is: trance? a. Integrative medicine a. It is an altered state of consciousness, b. Exclusive medicine just like sleep. c. Based on the physician’s opinions b. Humans move in and out of trance d. Biofeedback states during the day. 4. The mechanism that describes thought c. It is a state of relaxed awareness. and expectation affecting health is: d. Trance is a common experience even a. A complementary therapy if you are not aware of it. b. A misconception that is dangerous to 9. Which of the following statements the patient indicates a visual channel preference c. An integrated therapy for information? d. The mind-body connection a. “That really feels good! My gut feeling 5. Mrs. Lucas is telling you about her ideas is that it will work!” for curing her depression by taking herbal b. “It sounds good to me; this idea is medication. She is convinced that because worth paying attention to.” St. John’s wort is a natural product, it c. “I can see the solution, and clearly is better for her than her prescription it will work.” therapy. You should: d. “I smell a rat. I think the whole thing a. Quickly get the drug handbook and stinks.” show her she is wrong. 10. Which of the following should be b. Remain open and supportive. avoided when communicating with a c. Point out to her that herbal therapy is mentally ill patient? contraindicated. a. Having an expectation that the patient d. Suggest some available brands for her will get better to use. b. Making the presupposition that the patient will not improve c. Taking the time to convey respect for the patient d. Demonstrating through your expression and posture that you are listening 2993_Ch10_157-180 14/01/14 5:21 PM Page 157

UNIT 2 Threats to Mental Health 2993_Ch10_157-180 14/01/14 5:21 PM Page 158 2993_Ch10_157-180 14/01/14 5:21 PM Page 159

CHAPTER 10 Anxiety, Anxiety-Related, and Somatic Symptom Disorders

Learning Objectives Key Terms 1. Define anxiety disorders. • Anxiety 2. Identify the changes in DSM-5 and how they relate to current • Compulsion anxiety disorders • Conversion 3. Identify the new classified anxiety disorders. • Dysmorphophobia 4. State physical and behavioral symptoms of anxiety disorders. • Eustress 5. Identify treatment modalities for anxiety disorders. • Free-floating anxiety 6. Identify nursing interventions in anxiety disorders. • Generalized anxiety 7. Define the difference in diagnosing somatic symptom disorders disorder and diagnosing somatic symptoms • Hypochondriasis 8. Identify medical treatments for people with somatic • “La belle indifference” symptoms and related disorders. • Malingering 9. Identify nursing interventions for people with somatic • Obsession symptoms and related disorders. • Obsessive-compulsive disorder (OCD) • Panic disorder • Phobia • Post-traumatic stress disorder • Primary gain • Secondary gain • Signal anxiety • Somatization • Somatoform disorder • Somatoform pain disorder • Stress • Stressor • Survivor guilt

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160 UNIT 2 | Threats to Mental Health ■ Anxiety Disorders Stress produces anxiety. Stress is everywhere in today’s society. Most often, stress is associated with negative situations, but the good things that happen to people, such as weddings and job promotions, also produce stress. This stress from positive experiences, such as becoming newly married, promoted at work, or something similar, is called eustress. It can produce just as much anxiety as the negative stressors. A stressor is any person or situation that produces anxiety responses. Stress and stressors are different for each person; therefore, it is important that the nurse ask what the stress producers are for that patient. What is extremely stressful for one person (driving in rush hour traffic, for example) might be relaxing to someone else (go with the traffic flow and relax after a busy day). Figure 10-1 Anxiety ranges in severity from mild Anxiety can be described as an uncomfort- through panic. “The Scream,” a famous painting able feeling of dread that is a response to ex- by Norwegian artist Edvard Munch, depicts a treme or prolonged periods of stress. According person in a very high state of anxiety. to Gorman and Sultan (2008), anxiety is an unpleasant feeling of tension, apprehension, and uneasiness or a diffuse feeling of dread or response to a known stressor (e.g., “Finals are unexplained discomfort. only a week away and I’ve got that nagging nau- The four commonly accepted levels of sea again.”). Both types of anxiety are involved anxiety are: in the various anxiety disorders. Nurses working with children and teenagers • Mild must be aware that they also experience anxiety • Moderate and stress. They may not be able to verbalize • Severe their feelings, and they may display symptoms • Panic differently than adults do. Some indicators of Hildegard Peplau teaches that a mild amount stress and anxiety in these age groups include of anxiety is a normal part of being human and decline in school performance, changes in eat- that it is necessary to change and develop new ing habits and sleeping patterns, and with- ways of coping with stress (Fig. 10-1). drawal from friends and usual activities. Nurses Anxiety may also be influenced by one’s can be instrumental in screening children and culture. It may be acceptable for some people adolescents for signs of anxiety. to acknowledge and discuss stress, but others The Diagnostic & Statistical Manual, 5th may believe that one should keep personal edition (DSM-5, 2013) has made a number problems to oneself. This can be a challenge of revisions to anxiety disorders from the to the nurse during an assessment. 4th edition known as DSM-IV-TR (2000). Anxiety is usually referred to in one of two These will be noted in this chapter. In ways: free-floating anxiety and signal anxiety. DSM-5, some disorders that were previously Free-floating anxiety is described as a feeling of listed as anxiety disorders, including post- impending doom. The person might say some- traumatic stress disorder and obsessive com- thing like “I just know something bad is going pulsive disorder, have now been listed under to happen if I go on vacation,” without knowing new categories. In this text these will be when or where the event might occur. Signal discussed in the section “Types of Anxiety and anxiety, on the other hand, is an uncomfortable Anxiety-Related Disorders” in this chapter. 2993_Ch10_157-180 14/01/14 5:21 PM Page 161

CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 161 ■ Etiology of Anxiety they placed the participants into individual, private hotel rooms. Several days later, they and Stress tested the individuals for symptoms. People who had described themselves as happier, con- Psychoanalytic theory says that there is a con- tented types of personalities demonstrated flict between the id and the superego, which cold/flu symptoms only one third as often as causes anxiety. At some time in the individual’s the individuals who did not use those kinds of development, this conflict was repressed but words to describe themselves and their stress emerged again in adulthood. When conflict level. This is one study. Experts do not know all emerges, patients realize they have “failed,” and of the variables, but it does make a fairly strong the manifestations of anxiety are once again felt. argument for a positive correlation between Biologically the basic stress response is called emotional stress and physical illness. the fight-or-flight response and contributes to The LPN/LVN will frequently encounter feelings of anxiety. In this response to stress the stress in medical-surgical patients. Physical and blood vessels constrict because epinephrine and emotional symptoms can interrelate. It is im- norepinephrine have been released. Blood pres- portant for nurses to recognize the relationship sure rises. If the body adapts to the stress, hor- between physical and emotional responses to mone levels adjust to compensate for the stress. Nurses can be instrumental in gaining epinephrine-norepinephrine release, and the accurate planning and interventions for their body functions return to homeostasis. If patients by providing accurate assessment and the body does not adapt to the stress, there are documentation of the patient’s symptoms as his many long-term health problems that can be or her body adapts to stress. Table 10-1 gives created including lowered immunity, heart dis- examples of medical conditions and the effects ease, and many other conditions (Fig. 10-2). of the body’s adaptation response to stress. Studies are continually being conducted trying to correlate the condition of stress to physical illness. In 2002, researchers at Carnegie ■ Differential Diagnosis Mellon University in Pittsburgh (Cohen, 2003) studied 334 paid individuals. They introduced Differentiating normal anxiety from an anxiety a rhinovirus into the participants’ noses. Then disorder can be challenging. Because so many symptoms are associated with anxiety disorders, it is important for people to have a complete • “Fight or flight” physical workup before being checked for these • Blood vessels constrict disorders. The symptoms of anxiety disorders CRISIS • Norepinephrine and are listed with each of the specific disorders (see epinephrine released and section “Types of Anxiety Disorders”). Symp- blood pressure rises toms of anxiety disorders can mimic those seen in diabetes, cardiac problems, medication side • Hormone levels adjust effects, electrolyte imbalances, or physical ADAPTATION • Body functions return trauma. The physician must rule out a systemic to homeostasis infection or an allergy that might be related to chills or swallowing difficulty. Hot flashes, OR which can occur in some anxiety states, could be related to a fever or to menopause. The • Immune system becomes challenged physician must always consider the possibility • Lymph nodes increase of drug or alcohol abuse as partial causes for the EXHAUSTION in size symptoms. Certainly, more than one condition • Potential for cardiac and can occur simultaneously. A psychiatric evalu- renal failure ation is often needed to confirm a diagnosis of • Death may occur an anxiety disorder. Common symptoms of anxiety can be Figure 10-2 General Adaptation Syndrome present in many other conditions. It is easy to (GAS) model of stress. see how mistakes in diagnosing can happen. 2993_Ch10_157-180 14/01/14 5:21 PM Page 162

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l Table 10-1 Adaptation Responses to Stress and the Outcome of Stress on the Body Stress-Related Body’s Adaptation Outcome of Stress Medical Condition to the Stress on the Body Lowered Immunity Interferes with effectiveness of Increased susceptibility to colds, the body’s antibodies; possibly viruses, and other illnesses related to interactions among the hypothalamus, pituitary gland, adrenal glands, and the immune system. Burnout Associated with stress-related Emotional detachment depression. Migraine, Cluster, and Tightening skeletal muscles, Nausea, vomiting, tight feeling in Tension Headaches dilating of cranial artery. or around head and shoulders, tinnitus, inability to tolerate light, weakness of a limb Hypertension Role of stress is not positively Resistance to blood flow known but is thought to con- through the cardiovascular tribute to hypertension by nega- system, causing pressure on the tively interacting with the arteries; can lead to stroke, heart kidneys and endocrine system. attack, and kidney failure. Coronary Artery Stressor increases the amount of Constricted coronary vessels, in- Disease epinephrine and norepinephrine. creased pulse and respirations Cancer Same mechanisms that lower Lowered immunity may allow for immunity. overcolonization of opportunis- tic cancer cells. Asthma Automatic nervous system stim- Wheezing, coughing, dyspnea, ulates mucus, increases blood apprehension; may lead to respi- flow, and constricts bronchial ratory infections, respiratory fail- tubes; may be associated with ure, and/or pneumothorax. other stress-related conditions such as allergy and viral infection.

Symptoms of anxiety may include: Formerly found with anxiety was Obsessive- Compulsive Disorder (OCD) and Post- • Muscle aches Traumatic Stress Disorder (PTSD). In this • Shakes chapter, revisions from DSM-IV-TR will be • Palpitations mentioned periodically as a comparison. • Dry mouth • Nausea ■ Types of Anxiety and • Vomiting • Diarrhea Anxiety-Related • Hot ﬂashes Disorders • Chills • Polyuria Generalized Anxiety • Insomnia Disorder (GAD) • Diﬃculty swallowing In generalized anxiety disorder, the anxiety DSM-5 has made changes in some disor- (also referred to as “excessive worry” or “severe ders that were once categorized under anxiety. stress”) itself is the expressed symptom. It is 2993_Ch10_157-180 14/01/14 5:21 PM Page 163

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diagnosed when excessive worry is related Neeb’s Panic symptoms can develop sud- to two or more things and lasts 6 months ■ Tip denly and unexpectedly in the sus- or longer. ceptible person. People with history Patients who have GAD may display any of panic disorder need to be pre- number of symptoms. The DSM-IV-TR lists pared to identify early signs in the 18 symptoms of anxiety, and the patient must hope that they can gain some con- show six or more in order to be considered to trol before the symptoms are out of have GAD. DSM-5 has reduced the symp- control. toms to include at least 3 of the following: • Restlessness • Easily fatigued Phobia • Difficulty concentrating or mind going This is the most common of the anxiety disor- blank ders. Phobia is defined as an “irrational fear.” • Irritability The person is very aware of the fear and even of • Muscle tension the fact that it is irrational, but the fear contin- • Sleep disturbances ues. People develop phobias to many different These symptoms become pervasive as the things—approximately 700 different things, in person is unable to control the worry and fact (Box 10-1). Snakes, spiders, enclosed spaces, other symptoms. All aspects of life become in- and the number 13 are some of the more com- volved. This disorder can be debilitating. mon phobias (Fig. 10-3). People also develop phobias of things such as caring for their children (because they might hurt them) and eating Neeb’s Generalized anxiety disorder can be in places other than their own home. ■ Tip paralyzing and impact all areas of a The psychoanalytic view of phobias that person’s life. the fear is not necessarily from the object itself but rather a displaced, unconscious fear that Panic Disorder is displaced on the object/event such as a Panic disorder is a recurrent condition that is a snake or height. Learning theory views pho- state of extreme fear that cannot be controlled. bias as learned responses. When the person It is an abrupt surge of intense fear or discom- avoids the phobic object, fears is escaped and fort that reaches a peak in a short period of that is a powerful reward. Most phobias start time. It can lead to intense fear and worry about in childhood but people can develop them it happening again. It is also referred to as later in life. In older people it is common is “panic attack,” and people may not consider it see fear of falling or choking. to be a serious disorder initially. In the past, panic disorder was linked to agoraphobia. DSM-5 now has them as two separate disorders. Box 10-1 Some traits of panic disorder include: l Some Common Specific Phobias • Fear (usually of dying, losing control of oneself, or of “going crazy”) Acrophobia: Fear of height • Dissociation (a feeling that it is happening Ailurophobia: Fear of cats to someone else or not happening at all) Carcinomatophobia: Fear of cancer Decidophobia: Fear of making decisions • Nausea Nyctophobia: Fear of darkness • Diaphoresis Odontophobia: Fear of teeth or dental • Chest pain surgery • Increased pulse Scoleciphobia: Fear of worms • Shaking Thanatophobia: Fear of death • Unsteadiness Source: Adapted from Townsend (2012). Essentials of Psychiatric • Feelings of being suffocated or unable to Mental Health Nursing, 7th ed. Philadelphia: F.A. Davis Company, catch one’s breath with permission. 2993_Ch10_157-180 14/01/14 5:21 PM Page 164

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Social phobias are those in which people avoid social situations as a result of fear of humiliation or being judged negatively. This reaction is out of proportion to the situation. There are correlations between people with this type of phobia and self-medicating with alcohol and/or drugs. EXAMPLE Social phobias: The fear of speaking in public and the fear of using public facilities such as bathrooms or laundromats are examples of social phobias. A Specific phobias include having an irrational fear of a specific object or situation. These are the classic phobias that most people are familiar with. EXAMPLE Specific phobias: Claustrophobia (fear of enclosed places), hematophobia (fear of blood), and acrophobia (fear of heights).

Tool Box | For a comprehensive list of phobias go to B http://phobialist.com/# A-

Figure 10-3 A, Fear of snakes (ophidiophobia), and B, fear of spiders (arachnophobia), are two ■ ■ ■ Clinical Activity of the most common phobias. (Courtesy of the When your hospitalized patient has a phobia University of Texas Libraries, The University of Texas such as agoraphobia, anticipation of the patient’s at Austin.) reaction to leaving his/her room for testing must be addressed with the patient to prevent distress. It is not uncommon for more than one phobia to develop in a person. They most often begin in childhood, perhaps repeated Obsessive-Compulsive into a traumatic event. Phobias have three subcategories: agora- Disorder phobia, social phobia, and speciﬁc phobias. Obsessive-compulsive disorder (OCD) is Agoraphobia is the irrational fear of reoccurring thoughts, ideas, and actions being in open spaces and being unable to that interfere with a person’s daily ability to leave or being very embarrassed if leaving function. DSM-5 no longer categorizes is required. OCD as an anxiety disorder but puts it in its own category. This disorder is now be- EXAMPLE lieved to be a neurological short circuit that Agoraphobia: People who fear shopping causes repetitive behaviors. A genetic link in large malls or who fear going to among families who display OCD has also sporting events may actually fear the been suggested. OCD is different than possibility of being unable to escape obsessive compulsive personality disorder. in the event of an accident. See Chapter 14. 2993_Ch10_157-180 14/01/14 5:21 PM Page 165

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OCD has two components: the obses- ■ ■ ■ Critical Thinking Question sion (repetitive thought, urge, or emotion) Tommy has come to your clinic with numerous and the compulsion (repetitive act that cracks on his hands, which are bleeding and very may appear purposeful). It is not uncom- sore. Tommy tells you that he just has to wash his mon for people to be double and triple hands all the time. His mother says he will wash for 2 to 3 hours at a time, and he will not stop checking that doors are locked before one when she tells him to. The physician has diag- is able to sleep or leave the house. When nosed Tommy with OCD and has explained the these obsessive thoughts and compulsive illness to Tommy and his mother. When the physi- actions begin to prevent a person from cian leaves the room, Tommy’s mother begins to sleeping or leaving the house, it becomes cry: “What did he just say? What am I supposed to do? What did I do wrong that Tommy got this OCD. The person with this kind of disor- illness?” What will you tell her? What areas will you der is unable to stop the thought or the explore with her? action. Behaviors become very ritualistic (Fig. 10-4). Behaviors in patients with OCD vary. Some people wash their hands unceasingly. ■ ■ ■ Classroom Activity Others have a strict ritual that, if interrupted, • See the movie As Good as It Gets for a depiction of OCD. requires starting over from the beginning. Some people have to check something or clean something over and over. People with this disorder tend to be perfectionistic and ■ ■ ■ Clinical Activity very rule-oriented. When caring for a patient with OCD, identify what Physical symptoms also vary. If the person the staﬀ has been doing to accommodate the is prevented from performing the obsession patient’s obsessions and compulsions. or compulsion, the anxiety converts itself into somatic (body-related) symptoms. A related disorder to OCD is hoarding dis- Post-Traumatic Stress order. This is a new disorder in DSM-5. Disorder Hoarding disorder is severe distress caused by Post-traumatic stress disorder (PTSD) is persistent diﬃculties discarding or parting developed in response to an unexpected with possessions. emotional or physical trauma that could not be controlled. A victim of PTSD will probably have reoccurring, intrusive, disturbing memories of the incident that may last over a period of time. This disorder was once viewed as an anxiety problem in DSM-IV-TR, but the current view is that it belongs in a new category—Trauma and Stress or Related Disorders (DSM-5, 2013). So now it is viewed less as an anxiety problem and more related to the physical and emotional responses to a trauma. One reason for this change is the increasing recognition that people suffering from PTSD often are more Figure 10-4 Compulsive behaviors include troubled with pervasive sadness, aggressive refusing to step on a crack in the sidewalk. behaviors, and dissociative symptoms such The behavior is very ritualistic, and perform- as flashbacks than anxiety symptoms. Young ing the action reduces the person’s anxiety. children can also suffer from PTSD. (Courtesy of the National Institute of Mental Health, People who have fought in wars, who have Bethesda, MD.) been raped, or who have survived violent 2993_Ch10_157-180 14/01/14 5:21 PM Page 166

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storms or other actual or threatened traumatic PTSD symptoms may appear immediately events are examples of those who are suscep- or be repressed until years later. Symptoms of tible to suffering from this disorder. Police, PTSD can include: fire, and rescue personnel are at risk for PTSD • “Flashbacks,” in which the person may when they see victims of violence and de- relive and act out the traumatic event struction whom they cannot help. The assault • Social withdrawal on the United States during the attacks on the • Nightmares World Trade Center towers, the Pentagon, • Insomnia and the passengers and crew on the ill-fated • Feelings of low self-esteem as a result of flight in Pennsylvania on September 11, the event 2001, has brought new attention to the con- • Changes in the relationship with a signifi- dition of post-traumatic stress disorder. The cant other and difficulty forming new horror of witnessing tragedy such as this now relationships reaches anyone with a television or Internet; • Irritability and outbursts of anger toward such a person can also suffer from PTSD. another person or situation, apparently People in countries far away are able to expe- for no obvious reason rience tragedy in “real time.” Certainly those • Depression citizens who were on the scene and attempt- • Distress when thinking about the event ing to save lives, saw destruction the likes of • Making efforts to avoid reminders of which most of us, hopefully, will never expe- the event rience directly. They and their families will deal with the post-traumatic effects of that Self-medicating with alcohol and other day for some time to come. substances to treat the discomfort is a concern with many patients. The evaluation process should include a substance abuse assessment ■ ■ ■ Critical Thinking Question Think for a moment where you and your family and treatment if needed. members were on September 11, 2001. Think Trust and communication and listening about the things you felt and shared with each skills are very important tools for nurses who other at that time. Do you feel as though you have patients with PTSD. Encouraging ex- might have experienced a mild, moderate, or pression of thoughts and feelings surrounding severe PTSD from 911? Magnify that as you think, “what if I were the the experience and the survivor guilt is an im- one standing on that sidewalk watching people portant first step in the patient’s ability to die or jump from those buildings, wanting to help identify the source of the problem and begin and knowing I couldn’t?” Dramatic? Maybe. Realis- the process of healing (Fig. 10-5). It is impor- tic? Yes. And just a very slight taste of the intensity tant to validate the patient’s feelings regarding of the fears and flashbacks people with PTSD experience. the situation. Honesty and genuineness in communicating with these patients will help to build a working rapport. A term associated with PTSD is “survivor Family members and significant others guilt.” This is the feeling of guilt expressed by such as spouses can suffer from the effects of survivors of a traumatic event. A Vietnam vet- PTSD as well. Often, these people experience eran may say, “Why me? Why did that lady the same trauma, even though they were not and her kids get blown away and I lived? They present for the original event. The term “vic- didn’t deserve that.” Another concern associ- arious trauma” may apply in this situation. ated with PTSD is the suicide rate among military who served in the wars. Since the ■ ■ ■ Classroom Activity • Watch the movies “Coming Home” and “The Best Afghanistan war began, there has been a rise Years of Our Lives” to get a perspective of the in suicide among military, suggesting that return to civilian life after war. PTSD is a factor. This population continues • Watch the movie "Nuts" about trauma after rape to be in need for more mental health services and incest. (Drummond, 2012). 2993_Ch10_157-180 14/01/14 5:21 PM Page 167

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■ ■ ■ Critical Thinking Question ■ Medical Treatment of Jeanne is a 21-year-old single woman admitted for pneumonia. Her social history indicates that People With Anxiety and she survived a house fire when she was 10 years Anxiety-Related Disorders old and that her twin sister died in that fire. Today is the day for the monthly fire drill at the Treatment is individualized to the patient and hospital. You note that Jeanne is not in her bed. You are unable to find her during the drill. After may include one or more of the following: the drill, you search her room and find her sit- psychopharmacology, individual psychother- ting on the floor of the closet. She is wrapped in apy, group therapy, systematic desensitization, a blanket and is crying. She does not respond to hypnosis, imagery, relaxation exercises, and your verbal cues. What do you think is happen- biofeedback. ing to her? What illness might she have? How will you get her out of the closet? What can you Psychotherapy includes individual treatment, do to help her? group therapy, and systematic desensitization

Pharmacology Corner Medications are being used effectively to control chronic anxiety. The most common are anti-anxiety medications, which include benzodiazepines. See Table 10-2 for a list of common anti-anxiety medications. The benzodiazepines are commonly used and are effective in most cases. Use of the antianxiety drugs is short-term whenever possible because of the strong potential for dependency. Individuals with anxiety disorders who are chemically dependent are managed with other medications having calming qualities but not the same high potential for addiction as the anti-anxiety drugs. Hydrox- yzine hydrochloride (Atarax) and clonidine (Catapres) are examples. The antidepressant class of selective serotonin reuptake inhibitors (SSRIs) is being used as primary treatment in many cases of GAD, panic disorders, social phobias, OCD, and PTSD. For example, the FDA has approved fluoxetine, paroxetine, and fluvoxamine for treatment of OCD. Sometimes higher doses of the drugs than are used with depression are needed, so close monitoring of Figure 10-5 Encouraging the patient’s expression of thoughts and feelings about the side effects is important. For PTSD, paroxe- traumatic experience, as in this painting, is tine and sertraline have been approved by the an important first step in identifying the FDA. Panic disorders have been successfully problem and beginning the healing process. treated with paroxetine, fluoxetine, and ser- (Courtesy of the National Institute of Mental Health, traline. Dosing increases must be done slowly Bethesda, MD.) as these patients are especially sensitive to overstimulation from these medications. More research in under way to identify more effective medications for these conditions. 2993_Ch10_157-180 14/01/14 5:21 PM Page 168

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method of relaxation. Biofeedback done Table 10-2 Commonly Used l effectively alters the brain to a slower wave Anti-Anxiety frequency and can actually increase the im- Medications mune response for humans. The patient Alprazolam (Xanax) should discuss with the doctor if biofeedback Buspirone (BuSpar) is appropriate. The nurse may assist with pro- Chlordiazepoxide (Librium) viding information and resources. Clonazepam (Klonopin) Clonidine (Catapres) Hypnotherapy Diazepam (Valium) Hypnosis, done by a qualified, licensed ther- Hydroxyzine (Atarax) apist, may be helpful. It will assist the patient Lorazepam (Ativan) in relaxation. Some people joke about “going Oxazepam (Serax) to my happy place,” but there is validity in Prazepam (Centrax) finding pleasure or a lighthearted memory. Zolpidem (Ambien) Patients need to continue to take time to do the relaxation as directed by the therapist. Hypnosis is not a “one-time” therapy. It, like techniques to help the patient experience the biofeedback, needs to be done routinely to be anxiety-producing situation in a controlled effective. The nurse’s role may be as simple as environment and integrate the painful feelings to remind the patient to find quiet time for associated with the anxiety. Patients concentrate this, or if the patient is being seen as an out- on esteem needs and reality. patient, the nurse may ask the patient how frequently she or he has been able to do the ■ Alternative Interventions self-hypnosis and what kind of results the for People With Anxiety patient has experienced thus far. and Anxiety-Related Additional Alternative Disorders Interventions The following may provide additional relief: Aromatherapy • Stress and relaxation techniques Essential oils, such as peppermint or eucalyp- • Yoga tus, are popular aids in relaxation. Methods of • Acupuncture application include using diffusers (machines • Kava that turn the oil into droplets that diffuse into the air), placing a drop on a piece of clothing, ■ Nursing Care for People or applying directly to the skin, such as the temple area. Patients can purchase these essen- With Anxiety and Anxiety- tial oils and equipment at specialty stores, Related Disorders some bath oil supply stores, or even in some pharmacies. There are online resources as well. Common nursing diagnoses for people with Prescriptions are not needed, but patients anxiety and anxiety-related disorders: should be cautioned to use essential oils in • Anxiety, coping, ineffective very small amounts (drops at a time) and that • Fear some in dividuals may experience allergic • Thought process, disturbed responses, especially if the oils are applied • Violence, risk for directly to the skin. General Interventions Biofeedback 1. Maintain a calm milieu: Patients who Biofeedback is a form of behavior modifica- have anxiety disorders need to have a tion. It is a system of progressive relaxation. calm and safe treatment area. Minimiz- There are many tapes and products on the ing the stimuli helps the patient to market to assist patients in this “do-it-yourself” keep centered and focused. 2993_Ch10_157-180 14/01/14 5:21 PM Page 169

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2. Maintain open communication: Encour- treatment plan, or to other people and age the patient to verbalize all thoughts situations should be documented. The and feelings. Honesty in dealing with data collected and documented will patients helps them learn to trust others allow the nurse to provide accurate and increases their self-esteem. Patients feedback. will feel the value that nurses have in that 5. Encourage activities: Activities that are relationship. Observe the patient’s non- enjoyable and nonstressful help the verbal communication. As previously patient in several ways. Activities pro- stated, affect and body language often re- vide a diversion, give the patient time veal more about a patient’s thoughts and to concentrate on something other feelings than the words that are spoken. than the anxiety-producing situation, 3. Observe for signs of suicidal thoughts: Pa- and give an opportunity to provide tients with anxiety disorders, especially positive feedback to the patient about those suffering with PTSD, are at risk the progress he or she is making. These for suicide as a result of feelings of low activities should be purposeful, not just self-esteem or decreased self-worth. “busy work.” The patient should not be Nurses must be alert to this possibility put in a situation of competition as a and should observe and confront the result of activities. Competition could patient and document any suspicions increase the anxiety and be counterpro- or statements the patient expresses. ductive to treatment. 4. Document any changes in behavior: Any change, no matter how small, can be Table 10-3 summarizes the types of anxiety significant to the patient’s care. Positive and related disorders, the general symptoms, or negative alterations in the way a and common nursing actions for them, and patient responds to the nurse, to the Table 10-4 outlines a Nursing Care Plan for

l Table 10-3 Nursing Care for Patients With Anxiety and Related Disorders Disorders Symptoms Nursing Actions Generalized Muscle aches, shakes, • Provide calm milieu Anxiety Disorder palpitations, dry mouth, • Open communication done calmly nausea, chills, vomiting, and clearly hot ﬂashes, polyuria, • Focus on brief messages diﬃculty swallowing, • Teach early signs of escalating anxiety feeling of dread • Suicide precautions if the person indicates any self-destructive thoughts • Document behavior changes • Encourage activities • Promote deep breathing and other relaxation methods • Reassurance Panic Disorder Fear, dissociation, nau- Same as above sea, diaphoresis, chest • Stay with patient during attack pain, increased pulse, shaking, unsteadiness, paralysis Phobia Irrational fear of a Same as above particular object or • Focus on nonthreatening topics situation • Reassure about patient’s safety

Continued 2993_Ch10_157-180 14/01/14 5:21 PM Page 170

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l Table 10-3 Nursing Care for Patients With Anxiety and Related Disorders—cont’d Disorders Symptoms Nursing Actions Obsessive-Compulsive Repeated thoughts Same as above Disorder and/or repeated actions • Allow patient to express the anxiety • Recognize and accept need for obsessions and compulsions • Allow time for rituals • Provide structured schedule and give patient some control • Explore alternative methods of anxiety reduction Post-Traumatic “Flashbacks,” social with- Same as above Stress Disorder drawal, low self-esteem, • Keep patient oriented to the present relationships that may • Encourage patient and signiﬁcant change or be diﬃcult to others to attend groups for patients form, irritability, anger with PTSD seemingly for no reason, • Encourage patient to talk about trau- depression, chemical matic events if he/she is able dependency

l Table 10-4 Nursing Care Plan for Patient With Anxiety Assessment/ Nursing Interventions/ Data Collection Diagnosis Plan/Goal Nursing Actions Evaluation Patient is: Anxiety Demonstrates a • Calm environment Patient appears • Restless sense of increased • Promote relax- more relaxed • Irritable comfort ation techniques and verbalizes • Pacing including deep more positive • Hyperventilating breaths outcomes • Verbalizing • Soothing music negative thoughts • Verbalize reassur- and expecting ance about cur- a calamity rent situation resolving

a patient with anxiety. See Figure 10-6 concept SSD is characterized by somatic symptoms map care plan for panic disorder and GAD. that are either very distressing or result in signiﬁcant disruption of functioning, as well as ■ Somatic Symptom excessive and disproportionate thoughts, feelings, and behaviors regarding those symptoms. and Related Disorders To be diagnosed with SSD, the individual must be persistently symptomatic (typically at least Somatic Symptom Disorder for 6 months). It is a category of disorders in (SSD) DSM-5 as well as a speciﬁc diagnosis. Somatic refers to the body. The new term so- In the past the term somatoform disorders matic symptom disorders (SSD) replaces the was more associated with physical symptoms old term somatoform disorders in DSM-5. with no organic cause. This still may be 2993_Ch10_157-180 14/01/14 5:21 PM Page 171

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Panic Disorder and Generalized Anxiety Disorder

S & Sx: S & Sx: • Palpitations • Verbalizes lack • Sweating of control over • Dyspnea life situation • Chest pain • Nonparticipation • Dizziness in decisions of • Paresthesia personal care

Nsg. Dx: Nsg. Dx: Panic Anxiety Powerlessness

Nursing Actions: Nursing Actions: • Stay with client; offer • Encourage client to take reassurance of safety responsibility for • Remain calm aspects of own care • Use simple explanations • Assist client to set • Low stimuli environment realistic goals • Tranquilizers, as ordered • Identify areas of control • Encourage verbalization • Encourage verbalization of current situation of aspects of life not • Teach ways to interrupt within client's control escalating anxiety

Medical RX: Alprazolam 0.5 mg tid

Outcomes: Outcomes: • Client recognizes • Client performs signs and symptoms activities of daily of escalating anxiety living independently and intervenes to • Client makes indepen- prevent panic dent decision regard- • Client uses adaptive ing life situation activities (exercise, • Client accepts relaxation) to aspects of life out maintain anxiety at of his/her control manageable level

Figure 10-6 Concept map care plan for panic disorder and generalized anxiety disorder. (From Townsend (2011): Essentials of Psychiatric Mental Health Nursing, 5th ed. Philadelphia: F.A. Davis Company, with permission.) 2993_Ch10_157-180 14/01/14 5:21 PM Page 172

172 UNIT 2 | Threats to Mental Health the case in SSD but is not required. A promi- Differential Diagnosis nent feature is excessive focus on one’s physical People with somatic disorders present many symptoms, that interferes with one’s daily challenges in obtaining an accurate diagnosis. functioning. These symptoms may or may not Nurses must be alert to physical illness that may be associated with an actual medical condition. actually be causing the symptoms. Multiple For example, a patient with a small sore seeks sclerosis, for example, can present with many multiple opinions out of fear of skin cancer. and varied symptoms that may be as yet undi- Despite negative biopsies, the patient keeps agnosed. Discuss with the patient’s medical checking it, talking about it, and seeking other doctor all possibilities for physical illness rather possible providers who might offer other tests than a somatoform disorder. These patients can despite great financial burden. In SSD high end up being subjected to many tests, proce- levels of worry about one’s health becomes the dures, and even surgeries with no improvement central focus in the person’s life even to the in symptoms. It is important to avoid labeling point of becoming the person’s identity. These a person with SSD just because a physical basis patients are high users of the health-care sys- for symptoms cannot be found. tem, often seeking out different specialists and testing. So nurses will encounter these patients more often in nonpsychiatric settings. There is Somatic Symptom Related a definite anxiety component to this disorder Disorders as the individual worries excessively. Although In addition to SSD, several related disorders distress is normal with a new symptom, exag- are covered in this text including conversion gerated responses before a diagnosis would be disorder, illness anxiety disorder, and factitious a factor in considering SSD diagnosis. In the disorder. In DSM-IV-TR additional diagnoses past the term hypochondriasis might be used included dysmorphophobia and somatoform to describe someone with SSD. A patient who pain disorder. focuses extensively on physical symptoms is sometimes referred as suffering from somati- Conversion Disorder zation or somatizing. Conversion reaction, as defined in the defense mechanisms (see Chapter 7), is converting Etiology of Somatic Symptom anxiety into a physical symptom. Conversion Disorder disorder is the illness that emerges from over- Biologically, research has been conducted use of this mechanism. In conversion disorder, concerning the possibility of a genetic or there is a loss or decrease in physical function- biological predisposition to somatic difficul- ing that cannot be explained by any known ties. For example some individuals may have medical disorder or pathophysiological mech- increased sensitivity to pain. Early childhood anism. Paralysis and blindness are two of the traumatic experiences are also associated with more common examples of this disorder. It is SSD. Psychological theories include physical common for the dysfunction to somehow be symptoms rooted in unconscious mecha- deeply connected to denial and to a prior neg- nisms that develop to deny, repress, or atively perceived experience (e.g., someone displace anxiety. who loses the sense of vision after watching a pornographic movie). Age of onset is usually adolescence and young adulthood, but it can occur later in life as well. Conversion disorder Cultural Considerations is also referred to as Functional Neurological How an individual experiences a bodily Symptom Disorder. The rationale is that per- sensation can be linked to one’s cultural sons diagnosed with Functional Neurological perspective. Some symptoms may be more Symptom Disorder will likely be seen by a or less acceptable to acknowledge in dif- neurologist. ferent cultures. The symptoms, although not supportive of organic disease, are very real to the patient. 2993_Ch10_157-180 14/01/14 5:21 PM Page 173

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The nurse should not convey to a patient the symptoms of the illness, while the person that he or she thinks the patient is “faking” with illness anxiety disorder is afraid he or she the illness; it is real to the patient. The patient will get a serious disease. is truly experiencing the symptoms. Even though the patient is concerned enough Factitious Disorder about the symptoms to consult a physician, Falsification of medical or psychological signs he or she may give the impression of really and symptoms in oneself or others is called a not caring about the problem. “La belle in- factitious disorder. The diagnosis requires difference” is the clinical term used to de- demonstrating that the individual is taking se- scribe this condition. cretive actions to misrepresent, simulate or The belief about this disorder is that the cause signs or symptoms of illness or injury in symptom, e.g., the paralysis or blindness, is al- the absence of obvious external rewards. When lowing the patient to avoid a situation that is the individual falsifies information for another unacceptable to him or her. This unacceptable as in a child or pet, the diagnosis is factitious situation is the source of extreme anxiety, disorder imposed on another or by proxy. which is converted into the dysfunction. The dysfunction, then, is relieving the anxiety. This is called primary gain and is believed to be the ■ ■ ■ Critical Thinking Question function of the paralysis or blindness. Second- Penny is a 35-year-old married mother of three ary gain is the extra benefits one may acquire children, ages 2 years, 3 years, and 4 months. She works as a clerk in a large office. She has been as a result of staying ill. Secondary gain in- visiting the clinic regularly since her last preg- cludes extra emotional support such as sympa- nancy. She is experiencing severe, intermittent thy and love or financial benefits. Much of this pain in her right arm and left foot. The pain does is occurring at the unconscious level. not interfere with her life as a wife and mother, Malingering is a situation for achieving and she is not able to detect any kind of pattern to the pain. She tells you that she is not espe- personal gain that differs from the others cially concerned about the pain. “When it gets mentioned. Malingering is a conscious effort too bad for me, my husband cooks and cleans to avoid unpleasant situations. The patient the kitchen.” “fakes” or pretends to have the symptoms. Penny says that she thinks the source of her pain is related to “the day I banged my right hip real hard on the door of the copy machine.” She ■ ■ ■ Critical Thinking Question also has begun expressing concern that things are Will the DSM-5 change reduce the social negativ- going so well for her that she “just has the feeling ity associated with the word hypochondriasis? that something terrible is about to happen.” What is your preliminary impression of Penny’s illness? What other information might you want to obtain from Penny? Illness Anxiety Disorder In this disorder somatic symptoms are not present or if present, are only mild in intensity. The person’s distress is not from the physical Medical Treatment of Patients complaint itself but rather from his/her anxiety about the meaning, significance, or cause of With Somatic Symptom the complaint. Historically these patients are and Related Disorders often referred to popularly as hypochondriacs. Patients with these disorders are usually admit- These people are sometimes referred to as “pro- ted to a medical unit rather than a psychiatric fessional patients.” Hypochondriasis has been unit. Treatment focuses on the symptoms, a recognized, official diagnosis according to which more than likely are medical in nature. DSM-IV-TR. In DSM-5 hypochondriasis was The patient does not generally display unusual changed to Illness Anxiety Disorder. or unmanageable behavior that indicates the A major difference between illness anxiety need for mental health unit admission. disorder and conversion disorder is that the Treatment is, of course, individualized person with conversion disorder focuses on for each patient. Once a somatic disorder is 2993_Ch10_157-180 14/01/14 5:21 PM Page 174

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diagnosed, the ongoing involvement of a Table 10-5 Commonly Used psychiatrist is helpful to give insight to l managing this patient. Some approaches Medications for that may be used to treat these disorders in- Somatic Symptom clude individual and group psychotherapy, and Related Disorders hypnosis and relaxation techniques. It is Medications are ordered judiciously for beneficial for the therapist to help the pa- these disorders. When a medication is used, tient express the underlying cause of the it is generally an antidepressant or an antianxiety. Hypnosis can be very effective in anxiety agent. making this determination. Behavior mod- Amitriptyline (Elavil) ification can be effective if the patient is Bupropion (Wellbutrin) prone to secondary gains from the somatic Doxepin (Sinequan) symptoms. Methods of stress management Fluoxetine (Prozac) are also taught as the person learns new Paroxetine (Paxil) ways to handle anxiety. Patients may resist Sertraline (Zoloft) accepting that their problem has a strong Trazodone (Oleptro) psychological or emotional component and therefore cannot understand how a paralyzed limb or pain has anything to do with in addition to biofeedback, hypnosis, relax- anxiety. People who have a somatic symp- ation, and imagery. tom disorder may feel insulted, become re- sistive to treatment, and search for other Massage ways to explain the physical problem. Massage therapies are believed to not only re- Alternative Interventions lieve tensions and discomforts in the musculoskeletal system, but also may assist with for Patients With Somatic blood and lymph flow. Massage may be effec- Symptom and Related tive, especially with medication, to assist the Disorders patient to overcome physical symptoms. Alternative treatment of choice is related to Caution should be used, however, not to the particular condition or symptom set. actually emphasize the body complaint and Choices may include the following treatments reinforce the illness. Herbal/Nutritional Supplements It is possible that a patient is experiencing a Pharmacology Corner nutritional deficiency or possibly a condition Medications are used sparingly because such as arthritis along with the somatoform these patients typically have a history of disorder. Herbs or supplements geared to the being overprescribed. When medications are specific pain issue may help the patient to ordered for a patient, the classifications of experience less pain, either physically or choice are usually selective serotonin reup- psychologically. take inhibitors (SSRIs) (e.g., fluoxetine); Nursing Care of the Patient other antidepressants, particularly the tricyclics, such as imipramine; anti-anxiety With Somatic Symptom drugs; or combinations of these medica- and Related Disorders tions. At this time, if medications are con- Common nursing diagnoses include the sidered, SSRIs are greatly preferred over the following: other classes of antidepressants and probably should be first-line agents. See Table 10-5 • Anxiety for medications commonly used to treat • Coping, ineffective somatic symptom and related disorders. • Sensory perception, disturbed • Thought processes, disturbed 2993_Ch10_157-180 14/01/14 5:21 PM Page 175

CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 175

Table 10-6 summarizes the symptoms and that nothing life-threatening is causing the nursing interventions for the somatic symptom symptoms. The nurse has said that the staﬀ is disorders discussed previously. Figure 10-7 is attempting to help the patient but has a concept map of somatoform disorders. stopped short of promising improvement or of “curing” the patient. Communication Skills Honesty in dealing with the patient is very Socialization and Group important. Gaining trust that will encourage Activities the patient to verbalize thoughts and feelings Keeping the patient focused on other topics about the physical and emotional aspects of may help in the recovery. Nurses will this type of disorder is crucial. Do not dis- involve the patient in the goal setting and count the patient’s disorder. An example of a interventions of the care plan. Aiding the way to be honest about the situation follows. patient in learning assertive communication skills can be helpful. Working with other EXAMPLE health-care staff in occupational therapy, Nurse: “Ms. P, your physician can ﬁnd no recreational therapy, and social activities can physical or life-threatening conditions also act to divert the patient’s focus from the at this time. We will continue to ob- dysfunction. serve and examine you. We will make every attempt to help you improve.” Support In this way, the patient understands that It is important for the nurse caring for patients nothing is showing up in the tests that have with somatoform disorders to remember been made to this point. The person hears to pay attention to the patient but not to

l Table 10-6 Nursing Care for Patients With Somatic Symptom and Related Disorders Type Symptoms Nursing Interventions Somatic Symptom • High level of anxiety about • Listen to patient’s concerns but then Disorder health focus on other issues • Excessive time and energy • Promote trust devoted to symptoms • Encourage patient to express • May or may not have an or- self about other issues than the ganic disorder symptoms Conversion • Loss or decrease in physical • Use therapeutic communication Disorder functioning that seems to skills. have a neurological connec- • Encourage therapy (occupational tion (paralysis, blindness) therapy, physical therapy, etc.). • Indiﬀerence to the loss of • Provide emotional support. function • Respond to the patient’s symptoms • Primary and secondary gain as real. Illness Anxiety • “Professional patient” • Do not reinforce the symptom. Disorder • Intense fear of becoming • Be nonjudgmental. seriously ill • Continue to focus on trusting • Preoccupation with the idea relationship. of being seriously ill and not being helped—may be concerned about not being taken seriously or evaluated properly 2993_Ch10_157-180 14/01/14 5:21 PM Page 176

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Somatoform Disorders

S & Sx: S & Sx: S & Sx: S & Sx: • Physical • Repressed • Past • Loss or complaints anxiety experience alteration to • Absence of • Learned with life- physical function pathophysiology maladaptive threatening • Repressed • Focus on self coping skills illness to self severe anxiety and physical (pain) or significant symptoms others

Nsg Dx: Nsg Dx: Nsg Dx: Nsg Dx: Ineffective Chronic Pain Fear (of having Disturbed Sensory Coping a serious disease) Perception

Nursing Actions: Nursing Actions: Nursing Actions: Nursing Actions: • Ongoing assessment • Ongoing assessment • Ongoing assessment • Assess level of • Accept that symptom is • Accept that pain is real • Refer all new physical disability real to the client to the client complaints to • Encourage performance • Identify personal gains • Provide pain physician at level of ability • Fulfill client’s needs medication • Limit amount of time • Assess level of • Do not give positive • Provide comfort client discusses disability reinforcement to measures symptoms • Maintain symptoms • Distract client with • Encourage nonjudgmental attitude • Discuss client activities verbalization of fears • Assist client as fears/anxieties • Identify adaptive associated required • Teach adaptive coping coping strategies with illness with self-care deficits strategies • Role-play more • Give positive adaptive coping reinforcement for strategies independent performance

Medical RX: Amitriptyline 50 mg qd for chronic pain

Outcomes: Outcomes: Outcomes: Outcomes: • Client recognizes • Client recognizes • Client decreases • Performs self-care signs of signs of rumination about independently escalating anxiety escalating anxiety physical symptoms • Demonstrates more • Client is able to • Client connects pain • Fear of serious illness adaptive coping intervene before the to onset of anxiety has diminished strategies exacerbation of • Client is able to cope • Client uses adaptive • Discusses feeling physical symptoms adaptively without coping mechanisms associated with experiencing pain the stressful event

Figure 10-7 Concept map care plan for somatoform disorder. (From Townsend (2011): Essentials of Psychiatric Mental Health Nursing, 5th ed. Philadelphia: F.A. Davis Company, with permission.) 2993_Ch10_157-180 14/01/14 5:21 PM Page 177

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reinforce the symptom. The nurse should al- reinforcing the problem. Nurses should docu- ways make a thorough head-to-toe assessment. ment all ﬁndings in a matter-of-fact way. This shows the patient that the nurse is con- Patients need to know that they are being cerned for the patient’s health but will not taken seriously, even though they may not be focusing on the area of dysfunction or agree with the medical ﬁndings of their illness.

■ ■ ■ Key Concepts 4. Somatic symptom disorder is characterized by somatic symptoms that are either 1. Anxiety disorders have many common very distressing or result in signiﬁcant characteristics. Psychoanalytic theories disruption of functioning, as well as ex- propose that it is important to find the cessive and disproportionate thoughts, underlying cause of the anxiety. Biologi- feelings, and behaviors regarding those cal theories postulate that the causes symptoms. The symptoms may or may are not the primary concern, but rather not have an organic cause. the physical reasons may result in the anxiety. 5. Treatment and nursing care for patients with somatoform disorders may be diﬃcult 2. Medications and therapies should be and long-term, as these are chronic disor- individualized for the patient. ders. Patients may use the defense mecha- 3. Trust and communication techniques are nisms of denial and conversion reaction. important tools for the nurse caring for a 6. DSM-5 (2013) is the current major for patient with an anxiety disorder. Main- psychiatry. taining a calm milieu is also essential.

CASE STUDY A patient comes for his scheduled appoint- infected with something serious, since his ment with Dr. Sneeze. The patient is a symptoms do not seem to subside. Dr. Sneeze well-known politician. He has been the delivers the news to the patient that he is subject of negative press in recent months. “healthy.” His examination and lab work His main symptoms are general malaise, do not show any physical illness, and the sneezing, chronic headache, and “feeling doctor suggests perhaps the symptoms are like I have a constant cold.” Dr. Sneeze or- “most likely viral in nature and probably ders blood work and a chest x-ray and does stress and anxiety related.” Dr. Sneeze a complete physical exam of the patient. suggests the patient take over-the-counter You have collected vital signs and the medications for his symptoms and ﬁnd health history when you roomed the pa- methods to reduce his stress. Dr. Sneeze tient. The patient does not have a young leaves the room. The patient expresses his family at home but is on the road cam- extreme disappointment at not being given paigning and meeting his constituents “something to take” and asks you to explain almost daily. He believes he has become to him how stress can give one a cold.

1. How will you respond to the patient’s request for medication? 2. What are your thoughts about the patient’s expectation for receiving medications? How will you discuss that with him? 3. What alternatives (for example, dietary, herbal, etc.) can you discuss with him or ask the doctor to discuss with him? 2993_Ch10_157-180 14/01/14 5:21 PM Page 178

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REFERENCES Sierpina, V.S. (2001). Integrative Health Care— Complementary and Alternative Therapies for American Psychiatric Association. (2000). the Whole Person. Philadelphia: F.A. Davis. Diagnostic and Statistical Manual of Mental Somatic symptom disorders. (2012). In American Disorders IV-Text Revision. Washington DC, Psychiatric Association DSM-5 Development. Author. (Known as DSM-IV-TR.) Retrieved from www.dsm5.org/proposedrevision/ American Psychiatric Association. (2013). Pages/SomaticSymptomDisorders.aspx Diagnostic and Statistical Manual of Mental Townsend, M. (2008). Essentials of Psychiatric Disorders 5. Washington, DC, Author. and Mental Health Nursing. 4th ed., p. 389. (Known as DSM-5.) Philadelphia: F.A. Davis. Anderson, R.A. (2001). Clinician’s Guide to Townsend, M. (2012). Essentials of Psychiatric and Holistic Medicine. New York: McGraw-Hill. Mental Health Nursing: Concepts of Care in Braiker, H. (2002). September 11 Syndrome. Evidence-Based Practice. 7th ed. Philadelphia: New York: McGraw-Hill. F.A. Davis. Cohen, S. (2003). Sociability and Susceptibility to the Common Cold. Washington, DC: Carnegie Mellon University (copyright WEB SITES American Psychological Society), 14(5) Anxiety September 2003. www.adaa.org/ﬁnding-help/treatment/complementary- David, J., and Kupfer, M. (n.d.). Retrieved from alternative-treatment http://www.dsm5.org/Pages/Default.aspx http://www.drugs.com/condition/anxiety.html Drummond, K. (2012). Army suicides: July deaths Stress Theory set a magic new record. Forbes. Retrieved from www.currentnursing.com/nursing_theory/Selye’s_ www.forbes.com/sites/katiedrummond/2012/0 stress_theory.html 8/16/army-suicide-rate/ PTSD Gorman, L.M. and Sultan, D.F. (2008). Psy- Ptsd.va.gov for Veteran’s Administration Resources for chosocial Nursing for General Patient Care. PTSD Philadelphia: F.A. Davis. www.nami.org/Template.cfm?Section=posttraumatic_ stress_disorder Nicholson, R.A. (2003). Chill Out: Anger Can Give You a Headache. St. Louis, MO: Saint Conversion Disorder http://emedicine.medscape.com/article/805361- Louis University. overview Shives, L., and Isaacs, A. (2002). Basic Concepts of Psychiatric-Mental Health Nursing. 5th ed. Philadelphia: JB Lippincott. 2993_Ch10_157-180 14/01/14 5:21 PM Page 179

CHAPTER 10 | Anxiety, Anxiety-Related, and Somatic Symptom Disorders 179 Test Questions Multiple Choice Questions 1. Your significant other is a veteran of the 6. Which of the following is true regarding war in Iraq. It is very difficult for him or a phobic disorder? her to drive through a parking ramp be- a. It involves repetitive actions. cause “There are people hiding behind b. It involves a loss of identity. the pillars! They have guns! Be careful!” c. It results in sociopathic behavior. This person is most likely experiencing: d. It is an irrational fear that is not a. Auditory hallucinations changed by logic. b. Flashbacks 7. In obsessive-compulsive disorder, a com- c. Delusions of grandeur pulsion is: d. Free-floating anxiety a. A repetitive thought 2. Ms. T cannot leave her home without b. A repetitive action checking the coffee pot numerous times. c. A repetitive fear This makes her late to many functions, d. A repetitive illusion and she misses engagements on occasion 8. The medication(s) of choice for the because of it. Ms. T probably is suffering treatment of OCD is (are): (select all from what kind of disorder? that apply) a. Generalized anxiety disorder a. Paxil (paroxetine) b. Phobia b. Prozac (fluoxetine) c. Post-traumatic stress disorder c. Luvox (fluvoxamine) d. Obsessive-compulsive disorder d. Effexor (venlafaxine) 3. Mr. L has a severe fear of needles. He is 9. The three subcategories of phobia hospitalized on your medical unit. The include all EXCEPT: lab technician enters to draw blood for a. Agoraphobia the routine CBC, and Mr. L begins to cry b. Social phobia out, “Get away from me! I can’t breathe! c. Acrophobia I’m having a heart attack!” Your first d. Specific phobia response to Mr. L would be: a. “I’ll take your vital signs and call my 10. Which of the following are NOT supervisor.” nursing intervention(s) for people with b. “Why do you think you’re having a anxiety disorders? (select all that apply) heart attack, Mr. L?” a. Maximize stimuli to create diversion c. “Don’t worry. She’s done this many from the anxiety. times before.” b. Encourage the patient to verbalize all d. “Mr. L, relax. Take a few deep breaths. thoughts and feelings. I’ll stay with you.” c. Observe the patient’s nonverbal communication for data on a patient’s 4. Which of the following is not an anxiety thoughts and feelings. disorder? (select all that apply) d. Observe for signs of suicidal thoughts. a. Panic disorder e. Document only positive changes in b. Obsessive-compulsive disorder behavior. c. Multiple personality disorder f. Discourage activities; activities might d. Agoraphobia only increase a patient’s anxiety level. 5. A patient with an obsessive-compulsive disorder is: a. Suspicious and hostile b. Flexible and adaptable to change c. Extremely frightened of something d. Rigid in thought and inflexible with routines and rituals 2993_Ch10_157-180 14/01/14 5:21 PM Page 180 2993_Ch11_181-192 14/01/14 5:22 PM Page 181

CHAPTER 11 Depressive Disorders

Learning Objectives Key Terms 1. Deﬁne depressive disorders. • Depression 2. Identify three types of depressive disorders. • Dysthymic disorder 3. Describe common physical and behavioral symptoms of • Major depressive disorder major depressive disorder. • Mood 4. Identify treatment modalities for depressive disorders. 5. Describe key nursing care interventions for depressive disorders.

eeling down, discouraged, and depressed is something all people experience at Cultural Considerations Fsome time in their lives. Periods of emo- Depression crosses all cultures and tional highs and lows are normal. Depressive socioeconomic groups. However, depres- disorders are very different from a transient sive disorders may be misdiagnosed or bout of the “blues” or depressed mood. underdiagnosed in some cultures due to Depression is a painful and debilitating illness language barriers and lack of access to that affects all areas of one’s life. There are sev- mental health services. This is particularly eral types of depression that are collectively true in cultures that are more fearful of called depressive disorders. These can change being “labeled” with a psychiatric diagno- or distort the way a person sees himself, his life, sis. Some cultures may express depressive and those around him. People who suffer from symptoms as physical symptoms, such as depression usually see everything with a more fatigue and headache, while others may negative attitude. They cannot imagine that be more prone to speak in psychological any problem or situation can be solved in a terms of sadness and guilt. positive way. Depression can take a variety of forms and affect all age groups. Depressive disorders all have similar symptoms that vary by duration, timing and presumed etiology. to work, sleep, study, eat, and enjoy once- It is more common in women, but men pleasurable activities. These symptoms must with depression may be underdiagnosed last at least 2 weeks and very often last much (Figure 11-1). See Box 11-1 for list of general longer to receive this diagnosis. Major depres- facts about depressive disorders. sion is disabling and prevents a person from functioning normally. Some people may ex- ■ Types of Depressive perience only a single episode of depression within their lifetime, but more often a person Disorders has multiple episodes. Major depressive disorder affects approximately 5% to 8% of the Major Depressive Disorder U.S. population age 18 and older annually. A Major depressive disorder, or major depression, person has a 16.6% chance of developing a is characterized by a combination of symptoms major depressive disorder in one’s lifetime that severely interfere with a person’s ability (Kessler, 2005).

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Major depressive disorder is characterized by a classic cluster of symptoms. Behavioral and physical symptoms include: Five or more of the following for at least a 2-week period that represent a change in functioning: • Sad mood • Sleep pattern disturbances • Increased fatigue • Increased agitation • Feelings of guilt or worthlessness • Weight loss or gain Figure 11-1 Depression is less reported • Decreased interest in pleasurable activi- in the male population, but this may be ties (anhedonia) caused by male tendency to mask • Decreased ability to think, remember, emotional disorders with behaviors such as or concentrate alcohol abuse. • Recurrent thoughts of death or suicide These symptoms are often the same behaviors someone experiences in a low period of l Box 11-1 General Information his or her life, but the duration and intensity About Depressive are increased (Figures 11-2 and 11-3). Disorders • Common not only in the United States but Tool Box | Clinicians use a number of also internationally. depression scales to follow the severity of • Most common reason for seeking out the patient’s symptoms over time. These mental health professional. include: • Nearly twice as many women as men 1. Beck Depression Inventory, are affected by a depressive disorder www.ibogaine.desk.nl/graphics/ annually. However, men frequently 3639 b1c_2 3.pdf_ suffer from depression that may be 2. Hamilton Depression Rating Scale, masked. www.psy-world.com/online_ hamd.htm • The elderly are prone to depression often related to multiple losses and decline of health, among other variables. • Depressive disorders are being diagnosed Differentiating a grief response to a earlier in life than they were in previous major life loss from major depressive disorder generations, including in children and can be difficult as some of the symptoms, adolescents. such as sadness, insomnia, and poor appetite, • Because symptoms can be hidden and vague, the primary physician is often the may resemble a depressive episode. See first to identify depression. Table 11-1 for tips to differentiate grief from • Symptoms often go unrecognized and depression. can be a factor in poor work performance, family conflict, and substance abuse. Neeb’s A period of depression following the • Once one is diagnosed with a depressive ■ Tip death of a loved one is normal. disorder, there is a high probability of When this response goes on longer recurrence. than expected and interferes with a person’s self-esteem, it may indicate Source: Adapted from Kessler et al. (2005): “Major Depressive Disorders Among Adults—National Institute of Mental Health.” a depressive disorder. 2993_Ch11_181-192 14/01/14 5:22 PM Page 183

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depressive disorder. It aﬀects approximately 5% to 6% of the U.S. population age 18 and older at some point in their lifetimes (Kessler, 2005). It often begins in childhood, adolescence, or early adulthood. About 40% of adults with dysthymic disorder also meet criteria for major depressive disorder or bipolar disorder. Dysthymic disorder is characterized by a depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years and 1 year in children. These symptoms are less severe than those of major depressive disorder but have gone on for long periods. Symptoms often include: • Poor appetite or overeating Figure 11-2 Sadness becomes depression • Insomnia or hypersomnia when it lasts a long time and interferes with • Low energy or fatigue day-to-day functioning. • Low self-esteem • Poor concentration or diﬃculty making decisions • Feelings of hopelessness

■ ■ ■ Critical Thinking Question Describe the behaviors that would diﬀerentiate dysthymic disorder from major depressive disorder.

Postpartum Depression Postpartum “blues” is a common response a few days after giving birth and may be related to fatigue, hormone changes, and anxiety. It resolves in a short time with rest and support. Postpar- tum depression, also called postpartum onset depression, occurs up to 6 months after childbirth Figure 11-3 Insomnia is a common symptom and is a much more serious condition. Postpar- of depression. tum onset depression is classified as a major depressive disorder with the same classic cluster of Neeb’s The classic image of a depressed symptoms as above with the addition of lack of ■ Tip person does not fit all patients. Some interest in the baby, which can progress to rejec- may have more of the physical signs, tion of the baby and lead to a psychotic state. A such as loss of appetite, insomnia, patient suffering from this disorder needs inten- and early morning wakening, and sive treatment with medications and psychother- not display the outward sadness that apy. See Chapter 20 for more information. is usually associated with depression. Major Depressive Disorder With Seasonal Pattern Dysthymic Disorder Previously called seasonal affective disorder Dysthymic disorder is a less severe form of (SAD), this is a depression associated with depression that is characterized by its chronic seasonal patterns. Symptoms generally are nature. It is sometimes called persistent exacerbated during the winter months and 2993_Ch11_181-192 14/01/14 5:22 PM Page 184

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l Table 11-1 Differentiating Grief From Depression Uncomplicated Grief Major Depression Reaction • Labile • Mood consistently low • Heightened when thinking • Prolonged, severe symptoms of loss lasting more than 2 months Behavior • Variable, shifts from sharing • Completely withdrawn or fear pain to being alone of being alone • Variable restriction of pleasure • Persistent restriction of pleasure Sleep Patterns • Periodic episodes of inability • Wakes early morning to sleep Anger • Often expressed • Turned inward Sadness • Varying periods • Consistently sad Cognition • Preoccupied with loss • Focused on self • Self-esteem not as aﬀected • Feels worthless; has negative self-image History • Generally no history of • History of depression or other depression psychiatric illness Responsiveness • Responds to warmth and • Hopelessness support • Limited response to support • Avoids socializing Loss • Recognizable, current • Often not related to an identiﬁed loss

Source: Adapted from Ferszt (2006): How to distinguish between grief and depression? Nursing, 36(9), 60–61; Brown-Saltzman (2006). Transforming the Grief Experience. In Johnson, Gorman, Bush (eds.). Psychosocial Nursing along the Cancer Continuum, 2nd ed., pp. 293–314, Oncology Nursing Press: Pittsburgh, PA.

subside during the spring and summer. This ■ ■ ■ Clinical Activity type of depression is thought to be related to Review your depressed patient’s risk factors, in- the hormone melatonin. During months of cluding medications and medical conditions that longer darkness, there is increased production could contribute to the depression. of melatonin that seems to trigger depressive symptoms in some people. ■ ■ ■ Critical Thinking Question Your patient with Stage II lung cancer shows signs Substance-Induced of depression. Besides the emotional stress of Depressive Disorder having cancer, what other factors could be Substance-induced depressive disorder is de- contributing to the depression? pressed mood from the physiological eﬀects of withdrawal, intoxication, or after exposure to a substance. This can include drugs of abuse such and 11-3 for medical conditions associated as alcohol, opioids, sedatives, and anti-anxiety with depression and medications that con- medications as well as exposure to toxins. tribute to depression. Premenstrual Dysphoric Depressive Disorder Disorder Associated With Another This form of depressive disorder was added to Medical Condition the Diagnostic and Statistical Manual 5th This condition is characterized by a prominent edition in 2013. The features include a con- and persistent depression that is judged to be sistent pattern of markedly depressed mood, the result of direct physiological eﬀects of a excessive anxiety, and mood swings during general medical condition. See Boxes 11-2 the week prior to menses, which start to 2993_Ch11_181-192 14/01/14 5:22 PM Page 185

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levels of these neurotransmitters, giving strong Box 11-2 Medical Conditions l credibility to these theories. Family history re- Associated With mains an important risk factor indicating ge- Depression netic links. Psychological theories have focused • Stroke (especially frontal lesions) on personal history of deprivation, trauma, • Myocardial infarction and significant loss. Classic psychoanalytic the- • Adrenal disorders ory views depression as the reaction to the loss • Dementia of a significant person who has been both • Diabetes hated and loved. An individual can also be • Cancer prone to low self-esteem and a sense of help- • Hypothyroidism lessness due to environmental factors and have • Brain tumors a tendency toward depression. Physical illness • Parkinson’s disease and medications are also frequent contributors • Multiple sclerosis to depressive symptoms. • Chronic pain • Chronic kidney disease ■ Treatment of Depressive Source: From Gorman and Sultan (2008): Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, Disorders with permission. Treatment involves a combination of pharmacological and psychotherapeutic approaches. Box 11-3 l Drugs That Can Cause This approach has the best outcomes. The ad- Depression vent of so many new antidepressants has pro- Antihypertensive Cancer chemothera- vided many more opportunities for successful agents including: peutic agents treatment (see Pharmacology Corner). Indi- • Reserpine including: vidual psychotherapy to address past losses • Beta blockers • Vincristine and stressors, short-term cognitive behavioral • Methyldopa • Vinblastine therapy to develop new strategies to alter neg- Oral contraceptives • Interferon ative thinking, and group therapy to address Steroids • Procarbazine socialization and poor self-esteem can all be Psychoactive agents • L-asparaginase helpful. For the patient with severe depression Benzodiazepines Alcohol who does not respond to drugs or psychother- Anabolic steroids Amphetamine or Amphotericin-B cocaine withdrawal apeutic approaches, electroconvulsive therapy Opioids is sometimes suggested. It can be used in conjunction with other modalities such as med- Source: From Gorman and Sultan (2008): Psychosocial Nursing for ication. People may have a therapeutic session General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission. of 6–10 treatments over 4–8 weeks. Patients are given sedation prior to the treatment. The side effect of memory loss is frequently seen. improve after the onset of menses and then become minimal or absent after menses. Alternative Treatments ■ Light Therapy Etiology of Depressive Light therapy is being prescribed and used suc- Disorders cessfully in the treatment of depression with seasonal pattern. It consists of special lights to be Depressive disorders are complex and may have multiple etiologies. Biochemical theories have become more important with the identi- ■ ■ ■ Classroom Activity • Arrange for a psychiatrist to talk to the class fication of insufficiency of neurotransmitters, about psychotherapy and pharmacotherapy in especially norepinephrine and serotonin. These depressive disorders. insufficiencies may be the result of inherited or • Arrange for a hospital social worker to discuss environmental factors. The effectiveness of an- depression with physical illness. tidepressants seems to result from enhancing 2993_Ch11_181-192 14/01/14 5:22 PM Page 186

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used for certain amounts of time during the day. effects in some patients with mild depression. Also, exposure to natural light has been shown St. John’s wort probably should not be used to reduce depression and increase alertness. with selective serotonin reuptake inhibitors (SSRIs) or monoamine oxide inhibitors Herbal and Nutritional Therapy (MAOIs) (Skidmore-Roth, 2010). General dietary changes such as avoiding caffeine, sugar, and alcohol or adding servings ■ of whole grains and vegetables may help a Nursing Care of the person with mild depression. Herbs such as Patient With Depressive St. John’s wort, kava, gingko, fish oil, and SAMe Disorders have been shown to provide antidepressant Common nursing diagnoses with this population include the following: Pharmacology Corner • Hopelessness Antidepressants are the medications of • Self-care deficit choice in treating depressive disorders. See • Self-esteem, disturbed, deficit Table 11-2 for the categories of antidepres- • Social interaction, impaired sants. They are also used to treat depression associated with bipolar disorders, schizophre- General Nursing Interventions nia, and dementia. Selected agents may be used to treat anxiety disorders and bulimia as • Identify small, achievable goals the patient well. Some of the target symptoms that anti- can meet. Provide support and encourage- depressants may treat include sadness, inabil- ment. Break down tasks into small parts ity to experience pleasure, change in appetite, for the severely depressed patient. For insomnia, restlessness, poor concentration, example, rather than encouraging the and negative thoughts. These medications patient to get dressed, have the patient work to increase concentration of neurotrans- focus on putting on a t-shirt. mitters such as serotonin and norepineph- • Encourage the patient to speak about his rine. The early antidepressants were called or her concerns without judgment. Use tricyclics and MAOIs. The newer antidepres- open-ended questions, such as “Tell me sants, including SSRIs, SNRIs, and hetero- what concerns you today.” Avoid blanket cyclics, also called tetracyclics, have much reassurance like “you are doing fine” or better side-effect profiles. The anticholinergic minimizing the patient’s feelings as in actions of tricyclics and the rigid dietary “you’re lucky you have a job.” This might restrictions needed for MAOIs often limit the alienate a patient who is not feeling fine. use of these medications, but they can still be Help a patient who verbalizes hopeless- effective for some patients who are resistant ness to focus on describing his feelings to the other categories. These medications all and concerns. Then discuss one concern require several weeks of use before some im- at a time to prevent it from being over- provement in depression can be expected; whelming for the patient. they should not be stopped abruptly. These • Encourage independence. medications are all oral preparations. Some- • Avoid activities that might tax memory or times combinations of antidepressants may concentration if the patient is struggling be prescribed. See Chapter 8 for more infor- with these. mation on these medications. • Monitor patient compliance with antide- When severely depressed patients are pressants. Include education about started on antidepressants, they need close potential side effects and not to expect monitoring. As the drugs take effect, the results for several weeks. person’s mood begins to lift and he or she • Encourage participation in activities to re- may have the increased energy to imple- duce time spent ruminating on negative ment a suicide plan. thoughts. • Promote a trusting relationship. 2993_Ch11_181-192 14/01/14 5:22 PM Page 187

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l Table 11-2 Antidepressants Drug Category Examples Important Considerations Tricyclics amitriptyline (Elavil), Major side effects are anticholinergic symp- nortriptyline (Pamelor), toms requiring close monitoring. Symptoms desipramine (Norpramine) include: dry mouth, urinary retention, constipation, blurred vision, sedation. Use with extreme caution in the elderly. SSRIs (selective paroxetine (Paxil), sertraline SSRI withdrawal syndrome can occur with serotonin reuptake (Zoloft), fluoxetine (Prozac) sudden discontinuation; includes dizziness, inhibitors) nausea, cholinergic rebound (salivation, loose stool) SNRIs (serotonin duloxetine (Cymbalta), Monitor for insomnia, restlessness norepinephrine venlafaxine (Effexor) reuptake inhibitors) Heterocyclics bupropion (Wellbutrin), Monitor for dizziness, headache, mirtazapine (Remeron), tachycardia trazodone (Oleptro) MAOIs (monoamine phenelzine (Nardil), Serious, potentially fatal hypertensive crisis oxidase inhibitors) tranylcypromine (Parnate), may occur in presence of foods high in isocarboxazid (Marplan) tyramine (aged cheeses, red wine, smoked and processed meats). Special diet must be followed.

Source: Adapted from Townsend (2012), Gorman & Sultan (2008), and Pederson & Leahy (2010).

• Encourage the patient to challenge nega- physician immediately. See Chapter 13 for tive thoughts. For example, identify an more interventions for suicidal patients. alternative solution to one problem, and Table 11-3 provides the nursing care plan encourage one example such as why the for depressed patients. patient is a good parent. • Promote physical activity where possible, for example, ambulating in the hall twice ■ ■ ■ Clinical Activity a day. Focusing on physical activity can • Review effective interventions used by the nurs- promote the patient’s sense of well-being. ing team to approach the depressed patient. • Promote the patient’s self-esteem by identi- • Identify small goals that the depressed patient has achieved. fying improvements or recent successes. The depressed patient may tend to focus only on negatives. As antidepressant drugs take effect, • If a patient gives any clues of contemplating Neeb’s ■ Tip the patient may initially feel more suicide, notify other team members and the energized before the mood lifts. A suicidal patient can be at increased risk during this period because he or she Neeb’s Depressive disorders can contribute has more energy to initiate a suicide ■ Tip to confusion and social withdrawal plan while still feeling hopeless. Any in the elderly and can lead to misdi- patient who is suicidal should be agnosis of dementia (sometimes closely monitored during the first few called pseudodementia). These pa- weeks on antidepressants. All antide- tients need multidisciplinary assess- pressants carry a black box warning ment to obtain the correct diagnosis from the FDA about increased risk of and treatment. suicidality in children and adolescents. 2993_Ch11_181-192 14/01/14 5:22 PM Page 188

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l Table 11-3 Nursing Care Plan for the Depressed Patient Data Nursing Collection Diagnosis Plan/Goal Interventions Evaluation Withdrawn, Impaired To participate in Spend time with patient Track refusing to social conversation with each day without pres- frequency of leave his interaction nurse once a day. sure or demands. Ask patient talking room Establish a trust- questions that do not with others. ing relationship. require demanding Verbalizes answers. Accept periods concerns to of silence. nurse. Encourage participation in structured activities if possible to reduce pressure on patient to “perform.”

■ ■ ■ Clinical Activity ■ ■ ■ Key Concepts Review the side-effect profile of your patient’s antidepressants and incorporate teaching as 1. Depressive disorders are treatable, and appropriate to promote patient compliance. most people respond positively to the appropriate medications. 2. Major depressive disorder is a debilitating ■ ■ ■ Critical Thinking Question illness that often recurs in one’s lifetime. A patient is complaining of nausea and dizziness. 3. Depression is the most common reason for In reviewing the medications from home, the patient has been taking paroxetine for 5 years. seeking out a mental health professional The patient is now NPO due to surgery. What do 4. Mood disorder due to a general medical you need to know about this medication that could be a factor in the patient’s postoperative condition is frequently seen in physically recovery? ill patients in the hospital. 5. Nursing care of the depressed patient should include promotion of self-esteem and socialization. ■ ■ ■ Critical Thinking Question Identify some of the differences in side-effect 6. Antidepressants are very effective in treat- profiles from tricyclic antidepressants and from ing depression, but side-effect profiles may SSRIs. require a change in drug as needed. 2993_Ch11_181-192 14/01/14 5:22 PM Page 189

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CASE STUDY Marge is a 55-year-old single woman who approached her with concern. Marge has works as a librarian. Over the past few agreed to see her physician for a checkup. months she has had increasing difficulty in Marge presents to the doctor with a de- sleeping, poor concentration, and an over- pressed appearance. On specific question- whelming sense of sadness. Her mother ing she reports feeling that she no longer died 1 year earlier, and Marge attributed feels competent in her job despite ad- these changes to a grief reaction. However, vanced degrees and certification and over as time has gone on, the symptoms have 20 years’ experience. These feelings have become more distressing. She has stopped increased over the past 3 months and occur exercising, has turned down social invita- daily. tions, and spends most of her time alone at The physician considers major depres- home. She has begun missing work because sive disorder as a diagnosis and prescribes of oversleeping, and her supervisor has paroxetine.

1. What teaching would you provide to the patient about the antidepressant? 2. What other forms of treatments might be proposed? 3. What other concerns would you have for this patient?

REFERENCES National Institute of Mental Health. Major Retrieved American Psychiatric Association. (2000). Depressive Disorders Among Adults. from http://mentalhealth.gov/statistics/ Diagnostic and Statistical Manual of Mental 1MDD_ADULT.shtml . Washington DC, Disorders IV-Text Revision Pederson, D.D., and Leahy, L.G. (2010). Author. (Known as DSM-IV-TR) Pocket Psych Drugs. Philadelphia: F.A. Davis. American Psychiatric Association. (2013). Diagnos- Sadock, B.J., and Sadock, V.A. (2007). Synopsis of tic and Statistical Manual of Mental Disorders 5. Washington, DC, Author. (Known as DSM-5) Psychiatric/Behavioral Sciences/Clinical Psychiatry. Philadelphia: Lippincott Williams & Wilkins. Brown-Saltzman, K. (2006). Transforming the Skidmore-Roth, L. (2010). Grief Experience. In R.C. Johnson, L.M. Mosby’s Handbook 4th ed. Gorman, and N.J. Bush (Eds.). of Herbs and Natural Supplements. Psychosocial St. Louis: Mosby-Elsevier. 2nd Nursing Along the Cancer Continuum. Townsend, M.C. (2012). ed., pp. 293–314. Pittsburgh, PA: Oncology Psychiatric Mental Health 7th ed. Philadelphia: F.A. Davis. Nursing Press. Nursing. Ferszt, G. G. (2006). How to distinguish between WEB SITES grief and depression? Nursing, 36(9), 60–61. Gelenberg, A. J. (2010). Practice Guideline for National Institute of Mental Health the Treatment of Patients With Major Booklet on Depression Depressive Disorder. 3rd ed. American Psychi- www.nimh.nih.gov/health/publications/depression/ atric Association. Retrieved from http:// complete-index.shtml psychiatryonline.org/content.aspx?bookid= National Alliance on Mental Illness: 28§ionid=1667485#654166 What is Depression? Gorman, L., and Sultan, D. (2008). Psychosocial www.nami.org/Template.cfm?Section=depression Nursing for General Patient Care. 3rd ed. American Psychological Association: Philadelphia: F.A. Davis. Depression Kessler, R.C., Berglund, P., and Demler, O. www.apa.org/topics/depress/index.aspx (2005). Lifetime prevalence and age-of-onset American Psychiatric Association Major distributions of DSM-IV disorders in the Depressive Disorder Guidelines National Comorbidity Survey Replication. http://psychiatryonline.org/content.aspx?bookid=28& Archives of general psychiatry, 62(6), 593–602. sectionid=1667485#654166 2993_Ch11_181-192 14/01/14 5:22 PM Page 190

190 UNIT 2 | Threats to Mental Health Test Questions Multiple Choice Questions 1. Ms. S is admitted to your medical unit 5. The nursing interventions for a patient with a diagnosis of dehydration and a with major depression would include all history of depression. She tells you, “I of the following except: just can’t eat. I’m not hungry.” Your best a. Active listening skills therapeutic response would be: b. Maintaining safe milieu a. “You aren’t hungry?” c. Encouraging adequate nutrition b. “If you can’t eat, what is that candy bar d. Reassuring the patient everything will wrapper doing in your bed?” be “just fine” c. “Why aren’t you hungry?” 6. Your new patient is taking an MAOI for d. “You really should try to eat some real severe depression. What would you tell food.” the Dietary Department about her 2. Your patient has a diagnosis of major de- upcoming meals? pressive disorder and has been started on a. No caffeine sertraline (Zoloft) 50 mg bid. After tak- b. No processed lunch meat ing the medications for three days, the c. No extra salt patient says, “I don’t think this medicine d. Gluten-free diet is working. I don’t want to take it any 7. Your patient with major depressive disor- longer.” What would be your best der isolates herself in her room for the response? whole day. You find her sitting and star- a. I’ll let your doctor know and he may ing out the window. What is the best order a different medication. therapeutic response when you walk in b. These medications usually take a few the room? weeks to bring about an improvement a. “Come with me. It’s time for group to your symptoms. therapy.” c. The important thing now is getting b. “I’d like to introduce you to other you more involved in patient activities. patients.” d. It is important to eat a more balanced c. “What are you thinking about?” diet to help this medication work. d. Make frequent short visits to her room 3. Your patient appears withdrawn and and just sit there. depressed. Which of the following would 8. Your patient, Mr. A, had a recent myocar- not be an effective intervention? dial infarction and open heart surgery a. Develop a trust. with an uncomplicated recovery. His wife b. Show acceptance. tells you that Mr. A has changed and is c. Be judgmental. now uncommunicative, sad, and discour- d. Be honest. aged about the future. How would you 4. The nurse who is assessing a patient with respond to Mrs. A? major depression would expect to observe a. I’ll let the doctor know. which of the following symptoms? b. This is normal. I would just ignore it a. Euphoria for now. b. Extreme fear c. Tell me more about the changes in his c. Extreme sadness behavior. d. Positive thinking d. We should get a psychiatric consult. 2993_Ch11_181-192 14/01/14 5:22 PM Page 191

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Test Questions cont. 9. Mrs. J has been diagnosed with dys- 10. Which of the following is not true about thymic disorder and has been taking depression? paroxetine for 3 years. On arrival in your a. It is more common in men than in mental health clinic, she presents very women. differently than on her last visit. She is b. It is common after myocardial infarc- cheerful, energetic, and talkative. Previ- tion. ously she had been fatigued and negative. c. Grief after a major loss can mimic What should you do? depression. a. Encourage the patient to no longer d. Children and adolescents can suffer take her antidepressant. from depression. b. Get more information from the patient about how she is feeling. c. Recommend that she not be seen in the clinic today. d. Talk with the patient’s husband to confirm these behavior changes. 2993_Ch11_181-192 14/01/14 5:22 PM Page 192 2993_Ch12_193-204 14/01/14 5:24 PM Page 193

CHAPTER 12 Bipolar Disorders

Learning Objectives Key Terms 1. Describe three different types of bipolar disorders. • Bipolar disorder 2. Describe factors that make bipolar disorder difficult to • Cyclothymic diagnose. • Hypomania 3. Describe nursing interventions for behaviors associated • Mania with mania. 4. List three medications useful in treatment of bipolar disorders and the potential side effects of each. 5. Describe two teaching points for bipolar patients on mood stabilizers.

■ Characteristics of Bipolar with bipolar disorder. Patients may also abuse alcohol or other substances in an eﬀort to Disorders self-medicate to feel better. Bipolar disorder can be confused with depression, personality Bipolar disorder (previously known as manic disorders, schizophrenia, substance abuse, depression) is characterized by marked shifts and anxiety disorders. Clues that the illness is in mood, energy, and ability to function, often bipolar disorder include early onset, family with profound depressions to periods of hy- history of bipolar disorder, recurrent depres- peractivity or mania with periods of normalcy. sions, repeated loss of eﬃcacy of antidepres- The common forms of bipolar disorders in- sants, and hyperactivity during depressive clude bipolar I, bipolar II, and cyclothymic, episodes (Akiskai, 2009). as well as several others. These are listed in See Box 12-1 for general information Table 12-1. Bipolar disorders are often hard to about bipolar disorders. diagnose until the behavior becomes exaggerated, such as grandiosity, high-risk behaviors, Manic Phase violence. During hypomania phases (less The manic phase may last from days to months severe hyperactivity), a person may be highly and cause marked disruption of occupational productive, so this disorder might not get and social functioning. It can include the diagnosed. Some highly creative people, such following symptoms: as Ernest Hemingway and Jackson Pollock, had this disorder. Cyclothymic disorder is a • Easily distracted chronic disorder marked by multiple episodes • Little need for sleep (may feel rested after of hypomania and depression. 3 hours of sleep) Mania episodes (also known as manic) are • Poor temper control, easily agitated and characterized by a distinct period of abnor- irritable mality and persistently elevated, expansive, or • Reckless behavior and lack of self-control, irritable mood. Extreme mania can include including: psychotic behaviors such as hallucinations • Drinking, and/or drug use, binge eating and delusions. There is a high risk of suicide • Poor judgment

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l Table 12-1 Forms of Bipolar Disorders Type Description Bipolar I The classic image of bipolar disorder—a full syndrome of manic symptoms and most likely depression episodes Bipolar II At least one bout of major depression with episodic occurrence of hypomania. This patient may never have experienced a full episode of mania. Cyclothymic A chronic mood disturbance of at least 2 years (one year in children) duration involving numerous episodes of hypomania and depressed mood but of less intensity. Bipolar disorder due to Prominent and persistent disturbance in mood characterized another medical condition by mania that is a direct result of physiological eﬀects of a general medical condition Substance/medication - Disturbance characterized by elevated, expansive mood with induced bipolar disorder or without depression that is the direct result of the physiological eﬀects of a substance, e.g., alcohol, amphetamines, cocaine, heavy metals

Source: Adapted from Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (2013), American Psychiatric Association; and Townsend (2012), Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. Philadelphia: F.A. Davis Company, with permission.

l Box 12-1 General Facts About Bipolar Disorders • 3.9% of the American population will suffer from this disorder in their lifetime. • Affects males and females at approximately the same rate. • Episodes may or may not be associated with periods of depression • It is usually initially diagnosed between ages 15 and 24. • After the first episode, there is a high risk of recurrence. • Some have periodic episodes separated by years, and others have much more frequent cycles. Figure 12-1 Depiction of bipolar disorder. • There is strong evidence for a genetic/ inherited link, but a specific genetic defect has not yet been identified. • Sex with many partners (promiscuity) • Occurs in children but is difficult to diag- • Spending sprees nose. Symptoms can be confused with • Very elevated mood attention-deficit/hyperactivity disorder or • Excess activity (hyperactivity) substance abuse. • Increased energy Sources: NIMH: www.nimh.nih.gov/health/publications/bipolar- • Racing thoughts, flight of ideas disorder/complete-index.shtml . Kessler RC, Chiu WT, Demler O, • Talking a lot Walters EE. Prevalence, severity, and comorbidity of twelve- • Very high self-esteem (false beliefs month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 about self or abilities) Jun;62(6):617–27. • Very involved in activities 2993_Ch12_193-204 14/01/14 5:24 PM Page 195

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In the early phase of a manic episode, an in- • Eating problems dividual can become more engaging and out- • Loss of appetite and weight loss going with high achievement, energy, and • Overeating and weight gain success. As a manic phase accelerates, this in- • Fatigue or lack of energy dividual can become frenzied and out of con- • Feeling worthless, hopeless, or guilty trol, leading to impaired decision making and • Loss of pleasure in activities once enjoyed even altered appearance. For example, females • Loss of self-esteem experiencing a manic episode may apply their • Thoughts of death and suicide make-up in a distorted manner, especially lip- • Trouble getting to sleep or sleeping too stick. The person may be more reckless in other much areas such as business decisions and potentially • Pulling away from friends or activities hazardous actions. The individual in a manic that were once enjoyed phase may be prone to abuse substances such The conversion to manic phase from the as tranquilizers and/or alcohol to sleep and depressed phase may appear quickly. Some- control some aspects of this behavior. Sub- times the two phases of manic and depres- stance abuse may also trigger bipolar disorders. sion overlap. They may occur together or The presence of substance abuse with bipolar quickly one after the other in what is called disorder increases the negative outcomes and a mixed state. can confuse the illness presentation. Neeb’s Patients in a manic phase can go Tool Box | General Behavior Inventory, ■ Tip for days without sleep and not which has been useful as a self-report monitor- feel tired. ing tool in bipolar disorder, is found in Depue, R. A., Slater, J. F., Wolfstetter-Kausch, H., Klein, D., Goplerud, E., & Farr, D. (1981). A ■ ■ ■ Classroom Activity behavioral paradigm for identifying persons at • Watch films depicting people with bipolar disor- risk for bipolar depressive disorder: A concep- der, including Pollack and Lust for Life. tual framework and five validation studies. Journal of Abnormal Psychology, 90, 381–437. Mood Disorder Questionnaire: Five-question Depressed Phase screening tool: The depressed phase of bipolar disorder is www1.nmha.org/bipolar/q uestionnaire.cfm similar to those described for major depressive disorders in Chapter 11. The following symptoms may be seen: ■ ■ ■ Critical Thinking Question Your patient on the surgical unit has a diagnosis of • Low mood or sadness cyclothymic disorder. Describe what behaviors • Difficulty concentrating, remembering, or you might expect postoperatively. making decisions

■ Etiology of Bipolar Cultural Considerations Disorders • Bipolar disorder is more common in higher socioeconomic groups. Biological theories predominate as the cause of • As with other psychiatric disorders, mis- bipolar disorder. Studies indicate this disorder diagnosis can occur due to misunder- is caused by an imbalance in neurotransmit- stood practices and language barriers. ters, particularly norepinephrine, dopamine, Bipolar disorder can be misdiagnosed as and serotonin. Increased levels are believed to schizophrenia when culturally accepted be present in manic episodes and decreased behaviors are misunderstood. in depressive ones. A genetic link has also been demonstrated through family studies. A 2993_Ch12_193-204 14/01/14 5:24 PM Page 196

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combination of genetics and biochemical fac- (Hirschfeld, 2008). Medications, the most tors, along with environmental triggers such common being mood stabilizers, are the pri- as stressful life events, may present the most mary treatment. These can be used during an comprehensive picture. Medical conditions exacerbation as well as for control of fre- and medications can trigger an episode in sus- quency and intensity of future episodes (see ceptible people. See Box 12-2 for drugs and the Pharmacology Corner). medical conditions that can precipitate a Treatment should include psychotherapy manic state. in combination with medications to reduce the severity of relapse and promote medica- ■ ■ ■ Critical Thinking Question tion compliance. Early diagnosis is also con- Your new patient on the substance abuse unit has sistent with improved outcomes. Patients are a diagnosis of bipolar disorder I as well as alcohol sometimes resistant to taking these medica- use disorder. How would alcohol use contribute to symptoms in bipolar I? tions when they have stabilized due to potential side effects. Therefore, education on medication compliance is an essential part of the treatment plan. After a manic phase, ■ Treatment of Bipolar psychotherapy and family therapy may help patients and families cope with the shame and Disorders long-term effects of the manic phase. During Treatment for bipolar disorder often starts a manic phase, the patient may have hurt emergently when family members realize the loved ones emotionally with words and ac- patient is in a mania state. People are more tions. As life becomes flatter and less exciting likely to seek treatment for themselves during without mania, the patient may need support depressive phases than during manic phases. to cope with life with less highs and more When someone is in a state of euphoria, he stability. It is common for patients to use al- or she is less prone to accepting treatment and cohol and sedative drugs to try to sleep during less likely to think there is a need for it manic episodes as well as stimulants during

Pharmacology Corner l Box 12-2 Drugs and Physical Mood stabilizers are the cornerstone treat- Illnesses That Can ment of bipolar disorders. See Table 12-2 Cause Manic States for a listing of mood stabilizer medications. Drug Related Infections These include lithium and a number of anticonvulsants including carbamazepine, Steroids Influenza valproic acid, and lamotrigine. These medica- Levodopa Q fever tions often are a lifelong regimen. People with Amphetamines St. Louis encephalitis bipolar disorder may also continue on antide- Tricyclic Red-like infections pressants and may require anti-anxiety and/or antidepressants antipsychotic drugs such as olanzapine during Monoamine oxidase Hyperthyroidism the acute manic phase. The antipsychotic inhibitors aripiprazole is also used to treat bipolar Methylphenidate Multiple sclerosis disorder. Many patients will continue on Cocaine Systemic lupus more than one medication to remain in erythematosus remission. Patients must be counseled to report side effects rather than stop medications Thyroid hormone Brain tumors abruptly. If side effects are too distressing, Stroke alternative medication combinations can be Source: Adapted from Gorman and Sultan (2008), Psychosocial prescribed. See Chapter 8 for additional Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis information on mood stabilizers. Company, with permission. 2993_Ch12_193-204 14/01/14 5:24 PM Page 197

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l Table 12-2 Mood Stabilizers Drug Category Drug Examples Important Considerations Lithium Carbonate Lithium, Eskalith, Lithobid Toxic symptoms can occur even at normal blood levels, so monitoring of adverse effects must be ongoing. May take several weeks to achieve full therapeutic effect. Used with caution in the frail elderly who are at risk for dehydration. Rapid discontinuation can increase risk of relapse. Patient needs to report all other medications to avoid drug interactions. Anticonvulsants carbamazepine (Tegretol), Monitor CBC for possible blood dyscrasias. gabapentin (Neurontin), Increased risk for suicide. May take several valproic acid (Depakene), weeks to take effect. lamotrigine (Lamictal)

Source: Adapted from Townsend (2012), Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. Philadelphia: F.A. Davis Company, with permission.

depressive phases, so substance abuse coun- can cause tremors, confusion, seizures, coma, seling may be part of the treatment plan. and even death. Early warning signs of toxicity Treatment should also include monitoring include nausea, vomiting, and sedation. See adequate fluid and food intake, as these can Table 12-3 for signs of lithium toxicity. Lithium become compromised during all phases of takes about 7–10 days to reach the desired effect this disorder. and is only available orally. In the early phases of a manic episode, al- A variety of anticonvulsants are used as mood ternative treatment that includes herbs such stabilizers. Regular CBCs to monitor for anemia as chamomile and valerian can help with mild and blood dyscrasias are an important part of anxiety and insomnia. the follow-up and patient teaching. Each anti- Lithium requires close monitoring, including convulsant has a specific side-effect profile, so regular blood levels. Therapeutic levels are be- this should be incorporated in patient teaching. tween 0.5 and 1.2 mEq/L for most patients (1.0 Compliance with medication regimen is and 1.5 in acute mania). There is a narrow range an ongoing issue with bipolar patients. If between therapeutic and toxic levels, so close monitoring is needed. The blood levels can become elevated in dehydration, profuse sweating, l Table 12-3 Signs of Lithium and chronic diarrhea leading to toxicity. Toxicity Toxicity Serum Levels Symptoms Neeb’s Lithium has a FDA black box warning 1.5–2.0 mEq/L Blurred vision, ataxia, ■ Tip that toxicity can occur at doses close tinnitus, nausea, vomit- to therapeutic levels. It should be pre- ing, diarrhea scribed when there are resources to 2.0–3.5 mEq/L Excessive output of provide ongoing blood tests. dilute urine, increased tremors, muscle irritability, confusion Lithium toxicity can develop quickly, 3.5 mEq/L Seizures, coma, oliguria, Neeb’s arrhythmias, cardiovas- ■ especially in dehydration. Patient Tip cular collapse education must be an ongoing process so patients are reminded to Source: Adapted from Townsend (2012), Psychiatric Mental Health monitor themselves. Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. Philadelphia: F.A. Davis Company, with permission. 2993_Ch12_193-204 14/01/14 5:24 PM Page 198

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they are in a euphoric state, they may believe ■ ■ ■ Critical Thinking Question they don’t need medications. When they are A 29-year-old patient with a history of bipolar I in remission, they may be more concerned disorder is NPO for surgery. He is routinely taking about side effects and stop their medications. lithium and lamotrigine. Since he is unable to take Patient teaching and follow-up counseling these medications, what concerns would you have and what would you monitor? continue as part of the nursing care of these patients. See Table 12-4 for the side effects of mood stabilizers. ■ Nursing Care of the Neeb’s Bipolar patients on medications Patient With Bipolar ■ Tip should be counseled to use birth control as many of these medications Disorders are not safe to use in pregnancy. Common nursing diagnoses for patients with Patients need to be counseled to bipolar disorder include the following: speak with their physicians about associated risks. • Anxiety • Coping, ineffective • Nutrition, imbalanced: less than body Neeb’s Anticonvulsant drugs have an ad- requirements ■ Tip verse effect of increased risk of suici- • Self-care deficit dality. Patients taking such drugs • Sleep pattern, disturbed must be monitored closely for • Thought process, disturbed worsening depression and suicidal thoughts or behaviors. General Nursing Interventions • Provide clear, firm limits. Clearly define Cultural Consideration what is expected and what is not allowed. Ethnically diverse populations may metab- For example, if the patient needs to olize medications differently. pace, set a specific area where that can be done; if he is talking too loudly, point

l Table 12-4 Side Effects of Mood Stabilizing Agents Side Effects Medication Nursing Implications Drowsiness, dizziness, Lithium, anticonvulsants Educate patient on safety, driving. Determine if dosing schedule allows evening dose. Dry mouth Lithium Sugarless candies, saliva substitute GI upset Lithium, anticonvulsants Administer meds with meals. Fine hand tremors Lithium Report to MD, dosage adjustment may be needed, avoid caﬀeine. Polyuria, dehydration Lithium Monitor I&O and weight. Weight gain Lithium Need to maintain adequate sodium even if reducing calories. Increased suicide risk Anticonvulsants Monitor for worsening depression, suicide risk.

Source: Adapted from Townsend (2012), Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed., pp. 622–623. Philadelphia: F.A. Davis Company, with permission. 2993_Ch12_193-204 14/01/14 5:24 PM Page 199

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this out and encourage the need to lower ■ ■ ■ Critical Thinking Question his voice. A 45-year-old patient with a long history of bipo- • Focus on reality, especially when the lar II disorder has been in remission for 5 years. patient describes grandiose ideas. Present She tells you she has stopped taking her valproic reality without arguing with patient. acid because she feels so good and the medication prevented her from losing weight. How • Remove hazardous objects from the should you respond? patient’s room. Promote safety for all involved in the patient’s care by identifying signs of increasing potential for violence. ■ ■ ■ Clinical Activity Identify the family support network for the bipolar • Reduce external stimulation such as extra- patient and ensure that they are knowledgeable neous noise. on monitoring signs of manic episodes. • Provide an outlet for excess energy by letting the patient pace or exercise. • Encourage activities that don’t require a Table 12-5 provides the nursing care plan lot of concentration for patients with bipolar disorders. • Encourage patient compliance with medication regimens and lab testing. • Take the time to establish a relationship ■ ■ ■ Classroom Activity • Review the drug categories for treatment of with the patient to promote a sense of bipolar disorder and develop patient teaching safety. materials for each. • Identify ways to ensure the patient is eating and drinking adequately; for example, provide food that is easy to eat on the move. ■ ■ ■ Key Concepts • Encourage the patient to complete thoughts or actions rather than jumping 1. Bipolar disorders can include severe de- from item to item. pressions with periods of extreme mania, • If the patient is depressed, see the nursing as well as severe depressions with minor interventions in Chapter 11. bouts of mania. 2. The manic phase can last for days, weeks, Neeb’s Patients can move quickly from or months and cause severe disruption in ■ Tip social, affable, highly energetic, all areas of functioning. fun behavior to angry, violent 3. Lithium remains a recognized treatment behavior. for bipolar disorder and requires monitoring of blood levels to ensure safety. Neeb’s Patients in a manic phase exhibit 4. A number of new medications to treat ■ Tip poor insight and judgment, so this bipolar disorder are now used as well, provides a challenge to nurses to including many anticonvulsants. manage inappropriate behavior. 5. Ongoing medication management is challenging as the euphoric patient will often deny the need for these medications. ■ ■ ■ Clinical Activity • Monitor lithium levels. 6. Primary nursing interventions for a • Review potential medication side eﬀects that patient in mania include maintenance can contribute to the patient’s symptoms as well of safety, promotion of health, and as compliance with mood stabilizers. medication compliance. 2993_Ch12_193-204 14/01/14 5:24 PM Page 200

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l Table 12-5 Nursing Care Plan for Patients With Bipolar Disorders Nursing Data Collection Diagnosis Plan/Goal Interventions Evaluation Inappropriate Ineﬀective Patient will Calmly point out to Patient is able behavior including coping display more patient what behavior is to control one loud conversation, socially accept- not appropriate, e.g., behavior for a swearing, able behaviors “you’re talking too loud set period of domineering again.” Avoid sounding time. angry or judgmental. Set limits on swearing. Do not argue, bargain, or threaten patient. Explore how the patient can vent his frustration/energy in more socially acceptable ways. Provide alternative ways to express self.

CASE STUDY Jonathan is a 30-year-old single attorney lot of attention in the office for a recent living in New York City. He recently joined successful litigation. However, his assistant a prestigious law firm and is anxious to notes he is increasingly irritable and de- make a strong impression with the partners. manding, often changing from charming to He has a long history of success in life, in- angry at the slightest frustration. A woman cluding graduating from a top law school in the office reports him to the superiors for with excellent scores, making a large in- inappropriate sexual advances. When he is come, and having many friends and associ- brought into the office to discuss the allega- ates. He is gregarious and always seems to tions, he explodes and storms out of the be the center of attention wherever he is. office. Later that night he is arrested in a His new position is more stressful than his bar for fighting with a patron and tells the previous jobs were. He has been sleeping police he is friends with the chief of police only 2 to 3 hours a night and then coming and will get the officer fired. in to the office at 4 a.m. to keep up with Jonathan is brought to the ER by the the workload. He drinks heavily at night to police and acknowledges he had been diag- try to sleep and uses stimulants in the nosed with bipolar disorder in college but morning to keep going. He has received a stopped taking his lithium a year ago.

1. What other information would you need to know regarding what type of bipolar disorder he has? 2. What were the early signs that Jonathan was escalating into a manic phase? 3. What questions would you ask him regarding his history? 2993_Ch12_193-204 14/01/14 5:24 PM Page 201

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REFERENCES Sorrel, J.M. (2011). Caring for older adults with bipolar disorder. Akiskai, H.S. (2009). Mood disorders: Treatment Journal of psychosocial nursing (7), 21–25. of bipolar disorder. In B.J. Sadock, V.A. and mental health services, 49 Townsend, M.C. (2012). Sadock, and P. Ruiz. (Eds.), Psychiatric Mental Kaplan & Sadock’s 7th ed. Philadelphia: . 9th ed., Health Nursing. Comprehensive textbook of Psychiatry F.A. Davis. pp. 1743–1813. Philadelphia: Wolters Ward, T. D. (2011). The lived experience of Kluwer/Lippincott Williams and Wilkins. adults with bipolar disorder and comorbid Carson, V.B., and Yambor, S.L. (2012). Manag- substance abuse disorder. ing patients with bipolar disorder at home. Issues in mental health nursing 32(1), 22–27. Home health nurse 30(5), 280–91. Gorman, L.M. and Sultan, D.F. (2008). Psychosocial Nursing for General Patient Care. 3rd ed. Philadelphia: F.A. Davis. WEB SITES Kessler, R.C., Chiu, W.T., and Demler, O. National Alliance for the Mentally Ill infor- (2005). Prevalence, severity, and comorbidity mation on bipolar disorder of twelve-month DSM-IV disorders in the www.nami.org/Content/NavigationMenu/Mental_ National Comorbidity Survey Replication. Illnesses/Bipolar1/Home_-_What_is_Bipolar_ Archives of general psychiatry, 62(6):617–627. Disorder_.htm McMurrach, S. (2012). Course outcomes and National Institute of Mental Health psychosocial interventions for ﬁrst-episode https://infocenter.nimh.nih.gov/subject.cfm? mania. Bipolar disorders 14(6), 1–12. category=1000 National Institutes of Mental Health. Bipolar American Psychiatric Association disorder. Retrieved from www.nimh.nih.gov/ Guidelines for Bipolar Disorders health/topics/bipolar-disorder/index.shtml http://psychiatryonline.org/guidelines.aspx 2993_Ch12_193-204 14/01/14 5:24 PM Page 202

202 UNIT 2 | Threats to Mental Health Test Questions Multiple Choice Questions 1. Mrs. A is admitted to the medical/surgical 5. Which of the following drugs is NOT unit with a diagnosis of dehydration and classified as mood stabilizer? pneumonia. She has a history of bipolar a. Carbamazepine disorder and is controlled on lithium. As b. Olanzapine her nurse, you know you must: c. Valproic acid a. Treat her carefully because she may d. Gabapentin become catatonic. 6. Your manic patient says, “Everything b. Observe for signs of lithium toxicity I do is great.” How should you respond? from dehydration. a. “Yes, I am happy for you.” c. Alert the other staff of the “psych” b. “Is there a time in your life when patient on the unit. things didn’t go as planned?” d. Treat the medical illness only. c. “No one can be great at everything.” 2. Mrs. D has an appointment with the d. “Keep it up.” doctor. She began taking lithium one 7. Your manic patient has lost 5 pounds month ago as prescribed. She now states and is underweight. Which meal is most that her mouth and lips are constantly appropriate? dry and she sometimes feels confused. a. Grilled chicken and baked potato She says, “I stagger like I’m drunk some- b. Spaghetti and meatballs times when I walk.” You suspect: c. Chili and crackers a. She is drinking to combat her depres- d. Chicken fingers and French fries sion. b. She is making it up to get different 8. A newly admitted patient in an acute medications. manic state has a nursing diagnosis of c. She took too much lithium. risk for injury related to hyperactivity. d. She is dehydrated. Which nursing intervention is most appropriate? 3. Marge is a 68-year-old woman with a a. Place the patient in a room with an- long history of bipolar disorder I. She is other hyperactive patient. brought to the emergency room by her b. Have the patient sit in his room while sister, who reports that Marge has been you review all the rules of the unit. increasingly agitated, is unable to sleep, c. Administer antipsychotic medication and told her daughter that the mayor was as ordered prn by the physician. calling her for advice on running the city. d. Reinforce previously learned The behavior is an example of: coping mechanisms to calm the a. Delusions of grandeur patient down. b. Delusions of persecution c. Auditory hallucinations 9. Which statement is most true about d. Schizophrenia bipolar disorder? a. Bipolar disorders all follow the same 4. The physician orders lithium carbonate pattern of behavior. 600 mg tid for a newly diagnosed bipolar b. Bipolar disorders always include patient. The therapeutic blood level for periods of major depression. acute mania is: c. Manic depression is the same as a. 1.0–1.5 mEq/L hypomanic disorder. b. 10–15 mEq/L d. Patients with bipolar II have major c. 0.5–1.0 mEq/L depression with hypomanic symptoms. d. 5–10 mEq/L 2993_Ch12_193-204 14/01/14 5:24 PM Page 203

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Test Questions cont. 10. Which category of medication would 11. What is cyclothymic disorder? not be given to a patient with bipolar a. A chronic mood disorder of at least disorder? 2 years a. Stimulant b. A one-time event of hypomania b. Antidepressant c. A continuous state of hypomania for c. Antipsychotic 2 years d. Anti-anxiety d. A chronic depression for 2 years 2993_Ch12_193-204 14/01/14 5:24 PM Page 204 2993_Ch13_205-216 14/01/14 5:24 PM Page 205

CHAPTER 13 Suicide

Learning Objectives Key Terms 1. Identify main populations at risk for suicide. • Lethality 2. Identify myths and truths about suicide. • Suicide 3. Identify warning signs of suicide. • Suicide attempt 4. Identify nursing care for people who are suicidal. • Suicide contract 5. Describe the management of a suicidal patient in the acute • Suicide ideation hospital. • Suicide pact • Survivor of suicide

■ The Reality of Suicide • Suicide crosses all cultural, age, gender, race, and socioeconomic groups. Suicide is defined as self-inflicted death, with • The actual ratio of attempts to completed evidence that the person intended to die. Many suicides is probably at least 10 to 1. people experience momentary self-destructive • A high percentage of people who complete thoughts during a bout of depression or a set- suicide have made a previous attempt. back in life, but they do not take action on • The risk of completed suicide is more than these thoughts. Thinking about suicide does 100 times greater than average in the first not mean the individual will act on those year after an attempt—80 times greater thoughts; however, anyone who talks about, for women, 200 times greater for men, threatens, or makes a suicide attempt must be 200 times greater for people over 45, and taken seriously. Because suicide is viewed as un- 300 times greater for white men over 65. acceptable in Western culture, it generates anx- • Suicide rates are highest in the age group iety that has led to a number of myths. See of 45–54 years, with the over-85 group Table 13-1 for a list of common myths. close behind (Fig. 13-1). Here are some important facts about sui- • Veterans returning from war have a higher cide in the United States: rate of suicide than civilians. • Suicide is the third leading cause of death • Suicide is the 10th leading cause of death among adolescents and young adults. in the United States, accounting for more • Suicide pacts or copycat suicides among than 1% of all deaths. some adolescent groups have been seen in • More people die from suicide than from some communities. homicide. • Single auto crashes are generally investi- • More years of life are lost to suicide than gated as possible suicides. to any other single cause except heart dis- • 8.3% of adults have serious thoughts of ease and cancer. suicide during any year. • 37,000 Americans died by suicide in • The most common methods of suicide 2010, which included four times as include firearms, hanging, and overdose. many men as women; an additional Thelethality of suicide methods is a factor 500,000 Americans attempt suicide in the assessment of the patient. Men more annually. commonly use the highly lethal methods of 205 2993_Ch13_205-216 14/01/14 5:24 PM Page 206

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l Table 13-1 Clearing Up the Myths About Suicide Myth Truth Asking people about their Most people are not afraid to talk about their thoughts of suicidal thoughts will make committing suicide and are usually grateful that someone is them more likely to act on them. available and cares. Talking can reduce the sense of isolation. All people who attempt suicide People can become overwhelmed with life circumstances have a psychiatric disorder. without having a psychiatric disorder. A person who talks about Approximately 80% of individuals who attempt or complete suicide will not do it. suicide give some deﬁnite verbal or indirect clues. As many as 50% have seen their physician within the previous month, often with vague somatic complaints. A person who attempts suicide Almost 75% of those individuals who complete suicide have will not try again. attempted it at least once before. People who attempt suicide are Many individuals are ambivalent and are using the suicide as always determined to die. a cry for help. People who attempt suicide Even if the suicide attempt is manipulative, the individual just want attention. may go on to complete the suicide. As the person becomes less As the depression begins to lift, the individual’s energy level depressed, the risk of suicide can increase before feelings of hopelessness are relieved. Once decreases. the individual makes the decision that suicide is an eﬀective solution to the problems, his or her mood may even elevate.

Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.

• For every person who commits suicide, six persons on average are left behind as survivors of suicide. (References include: National Center for Health Statistics Suicide and Self-Inﬂicted Injury, 2012; Mental Health America: Suicide, 2012; National Health and Nutrition Exami- nation Survey, 2010; Substance Abuse and Mental Health Services Administration News- room, 2012; CDC Morbidity and Mortality Weekly Report, 2013.)

■ ■ ■ Classroom Activity • Discuss factors that contribute to suicide in today’s society. • Discuss the impact on yourself of suicide of well-known people.

Figure 13-1 Older adults often have diﬃculty Suicide remains a major public health coping with loss, loneliness, and depression, and they have very high rates of suicide. problem, and all nurses must be familiar with risk factors, warning signs, and interventions to provide support to individuals at risk. ﬁrearms and hanging, accounting for their Suicide can be a long-planned action or an im- higher death rate. Those who overdose have pulsive act when the person is overwhelmed. a greater chance of surviving because they People with a variety of psychiatric disorders, receive treatment if found in time. including depression, bipolar disorder, anxiety 2993_Ch13_205-216 14/01/14 5:24 PM Page 207

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Cultural Considerations l Box 13-1 Risk Factors for Suicide White males constitute the largest group of Risk factors for suicide include the following: suicides. Native American males are also at • More than 90% of people who die by high risk. African American females tend to suicide have a mood disorder and/or a have a lower rate (Goldston, 2008). Some substance abuse disorder. Mood disorder can include depression or bipolar disorder. groups are less prone to suicide based on • Suicide risk can increase at the beginning religion; for example, Roman Catholics. of treatment with antidepressants as the Some cultures, however, are more tolerant return of energy brings increased ability to than others of suicide. act out self-destructive thoughts. • Alcohol is involved in many suicides. • Prior suicide attempt disorders, personality disorders, and sub- • Family history of mental disorder, substance abuse, may consider suicide. Drugs or stance abuse, family violence, sexual abuse, alcohol can contribute to accidental overdoses or suicide • Exposure to the suicidal behavior of others, when the individual’s judgment is impaired such as family members, peers, or media or be part of the self-destructive cycle. The ﬁgures Diagnostic and Statistical Manual of Mental • Poor support system Disorders (DSM-5) has created a new cate- • Grief from recent loss gory, named Suicidal Behavior Disorder, for • Untreated symptoms in terminal illness an individual who has initiated a behavior Source: From U.S. Public Health Service (1999) and Centers for Disease with the expectation that it would lead to Control and Prevention (2010). the individual’s own death within the last 24 months. Psychotic individuals can also experience hallucinations in which they believe hopelessness, shame, and guilt; and humili- they are being told to kill themselves by voices ation, have been linked to suicidal ideation. or powers outside of themselves. Being alert to Suicide may be viewed by some as a relief signals that the patient is at risk for suicide re- from overwhelming suffering (physical or quires good observation skills and communi- emotional); some see it as a way to reunite cation with the patient and health-care team. with a loved one who has died. A psychotic individual may view suicide as a way to stop hallucinations, or the hallucinations may be ■ ■ ■ Critical Thinking Question telling the patient to commit suicide. Your teenager tells you a friend swore her to See Box 13-1 for a list of common risk fac- secrecy that she was going to kill herself because tors for suicide. her boyfriend rejected her. Your teen asks you not to tell anyone. What action should you take? Suicide crosses all age groups. See Chapter 19 for more information on suicidal behavior in children and adolescents. Older adults, especially those facing health issues and multiple ■ Etiology of Suicide losses, may be at risk for suicide. It is common for suicidal older adults to have seen a health- Research shows that the risk for suicide is as- care provider in the prior year, so identifying any sociated with changes in brain chemicals risk factors in elderly patients is an important called neurotransmitters, including serotonin. part of the care plan. White elderly men are Decreased levels of serotonin have been found known to have one of the highest suicide rates. in people with depression, impulsive disorders, a history of suicide attempts, and suicide The Warning Signs of Suicide victims (National Institute of Mental Health One of these signs does not necessarily mean Statistics on Suicide, 2012). the person is considering suicide, but several Psychological factors, such as anger of them may signal a call for help. Eight out turned on oneself; an overwhelming sense of of 10 people considering suicide give some 2993_Ch13_205-216 14/01/14 5:24 PM Page 208

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sign of their intentions, so these warning signs way. Television, movies, and computer can save lives if recognized in time. People games that show death often do so in a who talk about suicide, threaten suicide, or way that is glamorous or humorous. call suicide crisis centers are 30 times more Young people may not make the connec- likely to kill themselves. Suicidal people often tion between the fantasy of the media and reach out for help and generally retain some the reality of life, or they become so ambivalence or contradictory feelings experi- caught up in seeking revenge or making enced simultaneously. Consequently, getting others suffer that they do not consider the help to someone who is considering suicide finality of what they are attempting. can save a life. Most people who consider 2. Person starts giving away personal items: suicide have some level of ambivalence. When someone has made the decision to The suicide warning signs from the National terminate his or her own life, it becomes Center for Health Statistics on Suicide include no longer necessary to keep certain things. the following: Some people will even attempt to give • Verbal suicide threats, such as “You’d be away a beloved pet. However, these indi- better off without me,” “Maybe I won’t be viduals do want those items cared for. In around,” or “I won’t be here when you an attempt to “tie up loose ends,” they come back to work” decide who will get certain items. The • Expressions of hopelessness and helpless- items will be given away for reasons other ness and the inability to see alternatives than “because I am going to kill myself,” • Previous suicide attempts although people sometimes use that hon- • Talking about suicide methods to which est approach and are not taken seriously. the person has access Usually, these people will simply say that • Saving pills it is time to clean out a certain room or • Asking questions/researching about differ- that they no longer need a certain item ent methods of committing suicide and they would like it to go to a special • Daring or risk-taking behavior friend. Individuals may also write or • Personality changes change a will when contemplating suicide. • Depression 3. Person starts talking about death and sui- • Lack of interest in future plans cide or becomes preoccupied with learning about these things: Curiosity about death (National Center for Health Statistics is not unusual. People tend to be curious Suicide and Self-Inflicted Injury, 2012) about what they do not know. When this Other warning signs may include the curiosity becomes a preoccupation and a following: single thought for the patient, it signals 1. Noticeable improvement in mood occurs: that the patient has ideas of attempting When this happens in a suicidal person, it suicide. Reporting this to the charge is often a sign that the person has made nurse and documenting the concerns are the decision that has been causing per- required. sonal conflict. The pain that is being experienced will soon be over for that person. ■ ■ ■ Classroom Activity The feelings of those who will be left be- Movies with suicide themes include The Hours and hind may or may not be a consideration. Whose Life Is It Anyway? It has been said that suicide is the ultimate controller. For some people, this may be the only situation they have felt they could ■ Treatment of Individuals control in their lives. Some people are not at Risk for Suicide concerned about the survivors because their own pain overrides that of others. Suicide is a major public health concern. Pre- Some people, especially younger ones, vention is focused on identifying people who may view death in a more romanticized display the warning signs and risk factors, and 2993_Ch13_205-216 14/01/14 5:24 PM Page 209

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providing them with support and interventions. Anyone who talks about suicide must Pharmacology Corner be taken seriously and interventions insti- Suicidal patients may benefit from taking tuted immediately to address her or his con- anti-anxiety medication, such as lorazepam, cerns and problems. Individual and group to reduce feelings of intense anxiety or dis- psychotherapy; emergency psychiatric care tress. In addition, antipsychotic and anti- such as hotlines and on-call mental health manic medications may be prescribed as professionals; pharmacological treatment for needed for patients with bipolar or psy- depression, psychosis, and anxiety; and inpa- chotic disorders. If antidepressants are being tient hospitalization if the person is at high started, it is important to remember that it risk for suicide are some of the approaches. will take a number of weeks to lift depres- Patients who make multiple suicide attempts sion, so other interventions must be used in need ongoing psychotherapy to address their the interim to prevent suicide. Antidepres- issues and impulses. Patients at low to mod- sants could actually increase suicide risk if erate risk for suicide can be followed as out- the patient gets a sudden burst of energy to patients with adequate support built in the act out the plan before the depression lifts. treatment plan, such as family and friends, However, untreated depression puts the pa- suicide contracts, medications, and regular tient at greater risk, so antidepressants are mental health appointments. generally seen as protection against suicide. Family and friends of anyone who com- Patients at high risk for suicide may need mits suicide need special support. These indi- to have medications administered in liquid viduals are referred to as survivors of suicide or parenteral form to avoid “cheeking” and and are at risk for long-term emotional dis- hoarding pills that could be collected to use tress, especially related to guilt and anger and for an overdose. Outpatients should be their elusive search for “why?” The stigma of given only a few days’ supply of any med- suicide adds to the complexity of a lifetime of ication that could potentially be used in a trying to recover. Support groups are available suicide attempt. Overdosing on antidepres- in many communities for survivors of suicide. sants is a highly lethal method of suicide, so caution must be taken with how these are Tool Box | dispensed for someone at high risk. • Suicidology.org has many resources for Adequate symptom management for suicidal patients, their families, and profes- pain and other distressing symptoms must sionals, including support programs for be provided to the patient with a serious or survivors: terminal illness. A patient’s belief that his or www.suicidology.org/suicide-survivors her symptoms cannot be controlled could • National Suicide Prevention Lifeline offers a be a contributing factor in hopelessness and 24/7 free and confidential, nationwide net- suicide. work of crisis centers: 1-800-273-TALK (8255) • Federal government mandated suicide pre- • Anxiety vention hotline number: 1-888-SUICIDE • Coping, ineffective (1-888-784-2433) • Self-concept, disturbed • Spiritual distress • Thought processes, altered ■ Nursing Care of the Nursing responsibilities for patients who Suicidal Patient are suicidal are many. The goal, of course, is Common nursing diagnoses in those at risk always to prevent the suicide. Because the for suicide include the following: nurse may not know when suicide potential exists, especially for a first attempt, using ex- • Hopelessness cellent observational skills and communication • Violence to self, risk for skills is mandatory. Nurses are bound (under 2993_Ch13_205-216 14/01/14 5:24 PM Page 210

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the Meier v. Ross General Hospital case) to ■ ■ ■ Clinical Activity report any reasons they have to suspect the • If your patient has been identified as suicidal, patient may be suicidal. Nurses must report review the care plan for all the safety measures in their observations to their team and document place for this patient. actions in the health-care record. A nurse • Review policies from assigned hospitals on how to manage suicidal patients. should never take the responsibility of helping a suicidal person on his or her own. Once a nurse suspects suicidal ideation, informing all 3. Communication: Ask outright if the patient members of the health-care team is essential so is considering suicide and, if so, how and appropriate treatment and patient safety can when. Asking a patient to talk about suici- be ensured. If a patient is considered suicidal, dal thoughts does not enhance the chance the following interventions can be helpful. of completing a suicide. Rather, it demon- General Nursing Interventions strates caring and acknowledges his or her value as a person. Ask if the patient has at- 1. Monitoring frequently: Check on the suici- tempted suicide in the past. In addition, be dal patient frequently but avoid a pre- prepared to talk to the patient about his or dictable routine and ensure that the her feelings, work to reframe hopelessness, patient is checked during extra-busy times and assist in problem solving to identify like shift change. If the patient is actively alternative solutions to problems the suicidal, a psychiatric consultation will be patient views as insurmountable. When required and the patient may be placed on talking to someone who is suicidal, avoid 1:1 precautions until the patient can be platitudes like “think what this would do to moved to an appropriate treatment set- your children.” Often the suicidal person is ting. On 1:1 precautions the nurse will be so immersed in feelings of hopelessness and required to accompany and remain with isolation that he is unable to identify with the patient in the bathroom. Nurses must how others are feelings. In addition, the pa- follow their agency policies on providing tient may view that the family will be better safety for the suicidal patient. off without him. When working on prob- 2. Safety: Keep any potentially harmful items lem solving, break down one problem into away from the patient, such as knives, manageable steps rather than looking at the scissors, glass, razor blades, belts, nail files, whole picture, which can be overwhelming. electrical cords, and even linens. Inform Most people who are suicidal have ambiva- visitors of this so they do not bring items lent or mixed feelings about taking action. patient may request. Ensure that windows Supporting the reasons the person does not cannot be opened. The room may need to want to commit suicide can help the per- be searched periodically, and the patient son to reevaluate the situation. may need a body search and close monitoring in the bathroom. It is common for patients who are at very high risk for sui- Neeb’s • If you suspect someone is suicidal, cide to wear paper gowns and to have ■ Tip be direct in asking about his or her paper bedding. Large objects that can be plans. used to break a window also need to be • Suicide is an emotional subject and removed. Plastic trash bags should not be great care must be taken with any- used in the patient’s room. one who expresses suicidal ideation. Report any suicidal ideation or be- Tool Box | American Association of Suicidol- havior immediately. ogy Guidelines for Inpatient and Residential • The hopelessness experienced by Patients Known to Be at Elevated Risk for a suicidal patient can be draining Suicide at: and overwhelming for the nurse. http://www.suicidology.org/c/document_ Recognize that team members library/get_ fi le? folderId= 266& name= need extra support when working D LF E -613.pdf with anyone who is suicidal. 2993_Ch13_205-216 14/01/14 5:24 PM Page 211

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■ ■ ■ Clinical Activity ■ ■ ■ Critical Thinking Question If your patient has a history of suicide attempts, Your 85-year-old patient is a recent widower. He is discuss any concerns with your instructor. in the hospital for recovery from a recent fall. He tells you he wants to go home so he can be with his wife. How would you respond to that statement?

4. Contract: The treating team may want to consider making a suicide contract with ■ ■ ■ Critical Thinking Question the patient. This is a written agreement Your patient with multiple chronic health prob- between the patient and the treating lems has been diagnosed by the psychiatrist as team where the patient agrees to inform actively suicidal. She is too ill to be transferred to the psychiatric unit. Describe what actions the the team before taking any action to team should take to prevent a suicide attempt on harm him- or herself. See the Toolbox to your medical surgical unit. access a sample contract. A contract is helpful for some patients who are waver- ing on what to do. Table 13-2 provides the nursing care plan for suicidal patients.

Tool Box | Example of suicide contract at ■ ■ ■ Classroom Activity www.suicide.org/no-suicide-contracts.html Obtain information about local suicide prevention programs such as counseling centers and hotlines.

Patients who are terminally ill may ver- 5. : Any patient with Neeb’s Discharge planning ■ balize vague suicidal thoughts such as suicidal ideation needs close follow-up at Tip “I would kill myself if my pain gets too time of discharge from the hospital. bad.” Encourage your patient to talk Mental health follow-up, hotline numbers, about fears and discomforts. Patients involving family/friends in the discharge with good symptom management are plan, and ensuring that discharge prescrip- much less likely to think about suicide. tions are dispensed in small amounts are some things to be incorporated in the plan. (Guptill, 2011; Puskar & Urda, 2011; ■ ■ ■ Clinical Activity Rittenmeyer, 2012; Sun, 2011). When administering medications to suicidal patients, consider having a colleague with you to See Box 13-2 for suggestions on talk- double-check that the patient has swallowed ing with a suicidal patient to evaluate the pills. lethality.

l Box 13-2 Talking With a Suicidal Patient to Evaluate Lethality 1. Do you think about hurting or killing yourself? If yes 2. Do you have a plan? How have you considered doing it? If yes 3. Do you think you may or will do something to act on your thoughts? If yes, where and when? Do you feel you have control over your own behavior? 4. Do you have the means available (such as rope, rolled-up sheet, gun, saved-up pills [note lethality of plan])? 5. Have you ever tried to harm yourself in the past? If yes, how? Did you expect to survive? 6. Are you willing to contract or notify staﬀ whenever you feel you may act on these thoughts? Our side of the contract is to be available and actively help you during these times. If the patient denies having a suicide plan, ask about other plans for the future and support systems. 1. What do you see yourself doing in a week, in a month, and in a year from now? 2. Do you feel optimistic or pessimistic about the future? 3. Do you have family members or friends with whom you can freely discuss your problems?

Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission. 2993_Ch13_205-216 14/01/14 5:24 PM Page 212

l Table 13-2 Nursing Care Plan for Suicidal Patients Assessment/ Interventions/ Data Nursing Nursing Collection Diagnosis Plan/Goal Actions Evaluation Patient Hopelessness Verbalize Listen to patient’s concerns Patient agrees describes possible and worries. to try one hopelessness; solutions Avoid minimizing them. alternative unable to view to current Help patient identify one solution to the future in problems problem and discuss alter- recent a positive native ways to view it. problem. manner; denies Provide a diﬀerent perspective options on the problems. to resolve Appeal to the patient’s am- dilemmas; bivalence by stressing reasons verbalizes he does not want to do this. suicide as only Describe a recent situation alternative where you observed the patient being successful.

■ ■ ■ Key Concepts skills, including working collaboratively with team members to keep the patient safe. 1. Suicide is the 10th leading cause of death in this country and remains a serious 3. The most common psychiatric diagnoses public health problem. All nurses must for suicidal patients include depression be aware of risk factors and warning and substance abuse. signs for suicide in their patients and 4. Most people considering suicide have take action as needed. some ambivalence, so they will often 2. Caring for a suicidal patient requires ex- leave clues as to their plans. cellent observation and communication

CASE STUDY Jeff is a 54-year-old man who is recently di- irritable, and much less sociable. They call vorced with four grown children. He is living him to go out, but he repeatedly declines. alone in a furnished apartment and was re- One friend calls Jeff’s ex-wife to tell her that cently laid off from his accounting job. He Jeff called him and was quite emotional, say- spends most days alone and has started drinking he feels guilty for the way he treated her ing in the morning. He recently got a DUI and his children over the years. Jeff told the and had to give up his driver’s license. He has friend he feels like a failure in life and won- been a hunter all his life and has a variety of ders if his kids would be better off if he were guns in a local storage unit. He has several not around. The friend tells Jeff’s ex-wife that close friends who report that Jeff is depressed, he believes Jeff is thinking of moving away.

1. With the information presented, what signs would suggest that Jeff may be suicidal? 2. What suggestions would you give Jeff’s ex-wife and his friend to address potential suicidal ideation? 3. If Jeff’s ex-wife brought him to your mental health clinic, what information would you want to know initially? 2993_Ch13_205-216 14/01/14 5:24 PM Page 213

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REFERENCES U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. American Psychiatric Association. (2013). 2012. Office of the Surgeon General (U.S.): Diagnostic and Statistical Manual of Mental National Action Alliance for Suicide . Washington, DC, Author. Disorders 5 Prevention (U.S.). Washington D.C.: (Known as DSM-5) US Department of Health and Human Centers for Disease Control and Prevention Services, September 2012. http://www.ncbi. (2013). Suicide Among Adults Aged 35–64 nlm.nih.gov/books/NBK109922/ Years United States 1999–2010. Morbidity Puskar, K., and Urda, B. (2011). Examining the 6/13/13. http://www.cdc. and mortality report efficacy of no-suicide contracts in inpatient gov/mmwr/preview/mmwrhtml/mm6217a1. psychiatric settings: implications for psychiatric htm?s_cid=mm6217_w nursing. (12), Centers for Disease Control and Prevention. Issues in mental health nursing, 32 785–788. (2010). Violence Prevention. Retrieved from Rittenmeyer, L. (2012). Assessment of risk for www.cdc.gov/ViolencePrevention/suicide/risk in-hospital suicide and aggression in high- protectivefactors.html dependency care environments. Critical Care Gelenberg A.J., et al. (2010). Practice Guideline nursing in clinics of North America, 24(1), for the Treatment of Patients with Major 41–51. 3rd ed. American Depressive Disorder. Substance Abuse and Mental Health Services Psychiatric Association. Retrieved from Administration Behavioral Health, http://psychiatryonline.org/content.aspx?boo United States, 2012 at http://samhsa/gov kid=28§ionid=1667485#654166 Sun, F.K. (2011). A concept analysis of suicidal Goldston, D.B., et al. (2008). Cultural consider- behavior. (5), ation in adolescent suicide prevention and Public health nursing, 28 458 468. psychosocial treatment. – American psychologist, U.S. Public Health Service. The surgeon 14–31. 63, general’s call to action to prevent suicide. Gorman, L., and Sultan, D. (2008). P sychosocial Washington D.C.: US Department of Health 3rd ed. Nursing for General Patient Care. and Human Services, 1999. Retrieved from Philadelphia: F.A. Davis. www.surgeongeneral.gov/library/calltoaction/ Guptill, J. 2011. After an attempt: caring for the default.htm. suicidal patient on the medical-surgical unit. Medical-surgical nursing, 20(4), 163–167. Mental health America: Suicide. 2012. Retrieved WEB SITES from www.nmha.org/go/suicide National Suicide Prevention Lifeline National Center for Health Statistics suicide and www.suicidepreventionlifeline.org self-inflicted injury. 2012. Retrieved from National Alliance on Mental Illness www.cdc.gov/nchs.fastfacts/suicide.htm www.Nami.org National Health and Nutrition Examination Suicide Prevention Advocacy network Survey. 2010. Retrieved from www.cdc.gov/ http://capwiz.com/spanusa/home/Alliance of Hope nchs/nhanes.htm for Suicide Survivors National Institute of Mental Health statistics on allianceofhope.org/ suicide. 2012. Retrieved from www.nimh. Suicide Prevention, awareness, and support gov/health/publications/suicide-in-the-us- www.suicide.org statistics-and-prevention/index.shtml American Association of Suicidology has National Strategy for Suicide Prevention: Goals resources on multiple topics and Objectives for Action: A report of the www.Suicidology.org 2993_Ch13_205-216 14/01/14 5:24 PM Page 214

214 UNIT 2 | Threats to Mental Health Test Questions Multiple Choice Questions 1. A nursing intervention that is appropriate 5. Your charge nurse tells you that Mr. P for a patient who is suicidal is: must be placed on suicide precautions. a. Report the patient to the police. The first intervention you begin is: b. Ignore the patient’s suicidal comments, a. Place Mr. P in a locked unit. considering them “attention getting.” b. Begin one-on-one observation at least c. Tell the patient that he or she “has so every 15 minutes. much to live for!” c. Call the security code over the public d. Listen to the patient’s concerns and address system. worries d. Allow Mr. P to shave and carry out his 2. A person is more likely to commit suicide bedtime care. when he or she: 6. Further discussion with Mr. P reveals he a. Is in deepest depression is of a religious sect that believes there is b. Has a sudden lift from previous honor in dying for one’s religion. He does depressed mood not understand why everyone is so afraid c. Is confused to die in this country. As his nurse, you: d. Is feeling loved and appreciated a. Document the discussion and remove 3. Your patient tells you, “I am just a burden. the suicide precautions, citing religious Everyone would be better off if I was freedom. dead.” Nurses are aware that: b. Encourage him to present his beliefs at a. Suicide talk is just an attention-getting group tomorrow. device. c. Document the discussion but tell him b. Suicide is an impulsive act; it is not that the suicide precautions remain in thought out. effect. c. Suicidal talk or ideation can lead to d. Thank him for his explanation and suicidal behavior. bring him his next dose of medication. d. Suicidal people seldom really attempt 7. Which of the following people is at suicide. highest risk for suicide based on the 4. Mr. P is brought to the hospital by his information provided? wife. She states that he has been treated a. Nancy is a 33-year-old mother of two for depression recently, but that tonight who just lost her mother in a motor he said, “You and the kids don’t need me vehicle accident. messing up your lives.” Mr. P tells you b. Jim is a 68-year-old man who is a he has been thinking about suicide for recent widower and has a long history some time now. A nursing diagnosis for of alcohol abuse. Mr. P would be: c. Carol, age 18, has a long history of a. Knowledge deficit related to family sickle cell disease and is depressed over needs chronic pain and the inability to attend b. Ineffective individual coping as her prom. evidenced by manipulation of wife’s d. Hans is a 55-year-old man with end feelings stage pancreatic cancer who is entering c. Anxiety related to hospitalization a hospice program. d. Potential for violence, self-directed, as evidenced by stating suicidal thoughts 2993_Ch13_205-216 14/01/14 5:24 PM Page 215

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Test Questions cont.

8. Susan is 27 years old and has been 10. The fact that Susan is telling you she has admitted from the ED with an overdose another plan indicates what? of an antidepressant. She tells you, “My a. She is reaching out for help and is boyfriend broke up with me and I can’t ambivalent about wanting to die. live without him.” What is your best b. She is committed to her suicide plan. response? c. She is psychotic. a. “You are young. You will ﬁnd someone d. She needs antidepressants started else.” right away. b. “Forget him. You can do better than him. He isn’t worth losing your life for.” c. “Why did he break up with you?” d. “You must have been feeling very sad when he told you.” 9. The next day, Susan tells you that she has another plan to “ﬁnish the job when I get out of here. Please don’t tell anyone.” What would be your best response? a. “You are safe here.” b. “What are you planning to do?” c. “I won’t tell anyone if you promise not to do anything to yourself.” d. “I was hoping you were feeling better.” 2993_Ch13_205-216 14/01/14 5:24 PM Page 216 2993_Ch14_217-230 14/01/14 5:25 PM Page 217

CHAPTER 14 Personality Disorders

Learning Objectives Key Terms 1. Deﬁne and diﬀerentiate between personality and personality • Antisocial personality disorder. disorder 2. Describe three personality disorders as designated by DSM-5. • Avoidant personality 3. Describe two behavioral symptoms of each of these three per- • Borderline personality sonality disorders. • Dependent personality 4. Identify nursing interventions for these three disorders. disorder 5. Discuss some of the challenges in caring for a patient with • Histrionic personality borderline personality disorder. disorder • Narcissistic personality • Obsessive-compulsive personality disorder • Paranoid personality disorder • Personality • Personality disorder • Schizoid personality disorder • Schizotypal personality disorder • Self-mutilating behavior

ersonality is defined as the complex in different areas of life do they become per- characteristics that distinguish an indi- sonality disorders. Personality disorders are Pvidual. It includes one’s thoughts, feel- frequently seen in the general population and ings, and attitudes. Personality traits are may coexist with other psychiatric disorders. enduring patterns of perceiving, relating to, It is common that more than one personality and thinking about the environment and disorder exists in these patients. Patients with oneself that are exhibited in a wide range these disorders can present challenges for of social and personal contexts. Personality the nurse as maladaptive mechanisms includ- development occurs in response to a number ing manipulation are used to cope with the of biological and psychological influences. stresses of their illnesses. Theorists include Erik Erikson.Personality disorders occur when these traits become inflexible and maladaptive, and cause either sig- Cultural Considerations nificant functional impairment or subjective Personality development is impacted by distress (Townsend, 2012). Most people dis- culture. Thoughts, feelings, and attitudes play some traits of these disorders from time are influenced by the cultural values to time, but only when they are consistent be- surrounding people. haviors that contribute to some dysfunction 217 2993_Ch14_217-230 14/01/14 5:25 PM Page 218

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There are 10 personality disorders as de- of other people. The person displays consis- scribed in DSM-5. These 10 disorders are tent mistrust of others’ motives. These indi- grouped in 3 clusters based on their similarities. viduals may seem “normal” in their speech and activity, except for the fact that they feel 1. Cluster A (Behaviors described as odd) people treat them unfairly. People with para- • Paranoid personality disorder noid personality disorder are prone to filing • Schizoid personality disorder lawsuits when they feel wronged in some way. • Schizotypal personality disorder They also seem to be hypersensitive to activity 2. Cluster B (Behaviors described as dramatic) in their environment. They tend to be • Antisocial personality disorder guarded and secretive since they can’t trust • Borderline personality disorder others. They may have difficulty maintaining • Histrionic personality disorder focused eye contact, for example, because • Narcissistic personality disorder they are so alert to other activity around 3. Cluster C (Behaviors described as them. People with paranoid personality anxious or fearful) disorder are not easily able to laugh at them- • Avoidant personality disorder selves; they take themselves very seriously. • Dependent personality disorder They may not show tender emotions and may • Obsessive-compulsive personality seem cold and calculating in their relation- disorder ships. They are reluctant to confide in others. Generally, the personality disorders include They tend to take comments, events, and one or more of the following traits: situations very personally. They have an excessive need to be self-sufficient which can • Negative affect: frequently experiences create challenges if they become ill. As a negative emotions general rule this person would probably avoid • Detachment: withdrawal from others the health-care system if possible. • Antagonism: difficult to get along with Patients with paranoid personality disorder • Disinhibition: impulsive are not psychotic and do not have hallucinations • Inflexible and delusions; they are, however, suspicious of Personality disorders often have their roots other people and situations. The suspiciousness in difficult relationships with parental figures. may cross into other areas of the person’s life. Though each disorder has its own dynamics, For instance, it may be very challenging to enlist this relationship is the thread that runs the cooperation of a person with this disorder through all of them. Genetics may be a factor when it comes to taking medications if the in some of these disorders as well. patient suspects ulterior motives. Paranoid personality seems to have a high ■ ■ ■ Classroom Activities incidence of occurrence within families with • Watch films that include people with personality schizophrenia, which supports the theories of disorders and discuss characteristics: One Flew the geneticists. Difficult parental relationships Over the Cuckoo’s Nest (antisocial), Fatal Attraction (borderline), Wall Street (narcissistic). where the child is used as a scapegoat for par- • Share experiences of people you have known ents’ aggression can be a contributor as well. who exhibit various personality disorders. Cultural Considerations ■ Types of Personality Members of minority groups or immi- Disorders grants may be prone to some paranoid traits due to their unfamiliarity with soci- Cluster A ety’s rules and expectations. This would not be considered a paranoid personality Paranoid Personality Disorder disorder unless it becomes pervasive and Individuals with paranoid personality present creates more problems for the person. with behaviors of suspiciousness and mistrust 2993_Ch14_217-230 14/01/14 5:25 PM Page 219

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Schizoid Personality Disorder schizophrenia, giving strength to genetic and People with schizoid personality disorder have biological factors. a pattern of detachment from social relationships and a restricted range of expression of Tool Box | Psych Central overview on emotions in interpersonal settings. They may schizotypal personality disorder: appear shy and introverted. They have trouble psychcentral.com/disorders/sx 33.htm developing friendships. They tend to respond in a very serious, factual manner that is pleasant but not warm or inviting. They may be Cluster B described by others as cold. It is unusual to see patients hospitalized for Antisocial Personality Disorder this disorder because they are so quiet that the This group of people probably causes the great- disorder often goes unnoticed. They often are est amount of trouble for society. Sometimes described by others as “loners.” It is common referred to as sociopathic, people with this dis- to see people with this type of personality order have a disregard for the rights of others. become very engrossed in books. The books It often leads them to a path of violating rules, may be a substitute for human companion- lying, stealing, participating in a variety of ship. Partly because of this aversion to social illegal activities, and other infringements of the interaction, people with schizoid personalities law. The disorder seems to affect males more tend to be very intellectual and can be very frequently than females and affects about 1% successful in life if they choose a career that of the U.S. population (Lenzenweger, M. F., fits their personality. They may appear indif- Lane, M. C., Loranger, A. W., & Kessler, R. C. ferent to the approval or criticism of others. [2007]). The serial killer Ted Bundy is one of It is believed that ineffective and unemo- the best-known sociopaths. As these individu- tional parenting may contribute to this als end up in the court systems, they may be- disorder. A family history of schizophrenia or come part of the health-care system to avoid schizotypal personality disorder supports a legal consequences or due to court order. These genetic link. individuals have difficulty handling frustration and anger. They seldom feel affection, loyalty, Schizotypal Personality Disorder guilt, or remorse and show very little concern Behavior in this disorder is often odd and ec- for the rights or feelings of anyone else. It is centric but not to the level of schizophrenia rare that they display true remorse for their (see Chapter 15). Although under stress, this acts. People who have this disorder are also at person may decompensate with psychotic high risk for substance abuse. In addition, a symptoms such as delusions and hallucina- pattern of impulsiveness and irresponsibility tions. Aloof and isolated, these individuals are major features, with actions poorly often appear to be in their own world with lan- planned. This type of person has difficulty with guage and gestures that only they understand close relationships and may move from jobs and reduced capacity for close relationships. and relationships frequently. Often appearing blank and apathetic, their In spite of the inability to feel or show af- emotional responses may seem inappropriate. fection, patients with antisocial/sociopathic They also may display paranoia and social personality disorder are usually gregarious, in- anxiety. Diagnosis is made by a mental health telligent, and likable but can quickly move to professional who looks at symptoms and aggression if frustrated. Most people with this life history. disorder are able to control their behavior out Origins of this disorder may include poor of fear of punishment; only those with relationships with parental figures where there extreme cases are unable to do so. is discomfort with affection and closeness, Because people with antisocial personality leading to distrust in personal relationships. disorder are frequently highly intelligent, In addition, this disorder is more common they learn the “jargon” of psychology and among first-degree relatives of people with know how to manipulate it. Those with 2993_Ch14_217-230 14/01/14 5:25 PM Page 220

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antisocial personality disorder are difficult to 20% of psychiatric inpatients (BPD Resource treat as the individual often has little moti- Center, 2012). Borderline personality disor- vation to change. der (also known as BPD) is much more It is widely believed that the roots of this common in females. “Instability” is often the disorder stem from dysfunctional parenting first word one thinks of when considering and family life. This may be from a permissive BPD. Individuals with this disorder often ex- or authoritarian parenting style that does not hibit both clinging and distancing behavior include guidelines for appropriate social be- as they struggle with fears of separation and havior and includes abuse. A chaotic family abandonment. They are known for intense life is often found. This personality disorder and chaotic relationships as well as self- may be displayed in childhood with signs of destructive, impulsive, and dramatic coping. callousness and lack of empathy. Some evi- A chronic sense of emptiness, poor self-image, dence also exists that there may be brain ab- and excessive self-criticism are part of this normalities in how the individual processes disorder. These individuals operate using in- emotions. Childhood bullying and cruelty, grained behavior patterns that involve manip- animal abuse, as well as manipulative behav- ulating others to achieve their goals to reduce iors are seen at an early age. Individuals may anxiety. These patients may also utilizeself- have been diagnosed with conduct disorder mutilating behaviors, including self-inflicted before age 15 (see Chapter 19). These behav- cuts (known as cutting), which usually are not iors can run in families, so a genetic link is performed with suicidal intent. The cutting also suspected. can be a way to reduce tension, inflict pain to validate one’s feelings and challenge a perva- Patients with antisocial personality Neeb’s sive sense of emptiness, or seek attention. ■ can be challenging as they can use Tip Substance abuse is also often a factor as the unscrupulous means to accomplish person tries to control the anxiety. their goals without the staff realizing The origins of BPD can include coming it. Rather than telling the patient, from an abusive background and a childhood “you shouldn’t do that,” reword to where one was dismissed by authority figures. “you are expected to ...” to establish Poor relationships with parental figures where clear expectations that you are not the child grows up facing issues around aban- negotiating. donment and dependency are often seen. De- fense mechanisms of denial, projection, and ■ ■ ■ Critical Thinking Question splitting (inability to integrate positive and You are working on a substance abuse unit. When negative feelings at the same time) are known you walk on the unit, you see a patient named to be commonly used. Splitting is manifested Brad with a number of nursing staff. He is telling by a patient who needs to see others as all funny anecdotes about celebrities, and many of good or all bad. For example, a nurse who is the nurses seem to be enjoying themselves. Brad caring during one shift may become to the is quite handsome and charming. After this occurrence, Brad asks one of the nurses for a special patient the idealized “perfect” nurse, and then privilege to take a walk off the unit. How would the nurse who sets limits on another shift is you advise this nurse to handle this request? called “mean.” When the nurse denies the patient’s request, he quickly changes from charming to cruel as he Recognizing staff splitting is essential insults the nurse and then knocks over a lamp. Neeb’s How should the staff respond? ■ Tip for good care of the patient. If a patient complains about other staff members, never encourage him or her. Rather, point out that the patient Borderline Personality Disorder needs to address the concerns with This diagnosis is the most frequent personal- the individual and not complain ity disorder seen in the clinical setting, mak- about staff members to others. Avoid ing up 2%–6% of the general population and taking sides or acting as intermediary. 2993_Ch14_217-230 14/01/14 5:25 PM Page 221

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Tool Box | AHRQ National Guidelines Clearinghouse on borderline personality disorder: www.guideline.gov/content.aspx ? id= 14327 & search= borderline+ personality# Section420

■ ■ ■ Clinical Activity When you are informed that your patient has a borderline personality, get specific information on interventions that the team has been using to avoid getting in the middle of conflict between the patient and staff. Figure 14-1 Self-inflicted lacerations on teenage girl’s arms.

Neeb’s Though cutting behaviors are more ■ Tip common in adolescents, they can maintaining close, intimate relationships is occur in adults. common despite the gregarious and seductive behaviors. This disorder is more common in women. Tool Box | Borderline Personality Disorder Childhood experience of needing to be dra- pamphlet for patients and families: matic to get recognition or needs met, lack of www.nimh.nih.gov/health/topics/border- feedback from parents about appropriate be- line-personality-disorder/index .shtml havior all contribute to the development of BPD Central with information for patients this disorder. and families: www.bpdcentral.com/ Neeb’s Histrionic traits do not mean the ■ Tip person has histrionic personality disorder. To have the disorder, the person would have consistent ■ ■ ■ Critical Thinking Question problems functioning in life as a A 25-year-old woman is admitted from the ER to your unit with superficial cuts on both arms, a result of these traits. high blood alcohol level, and a complaint that she was attacked by her boyfriend. She is emotional and angry. As you sit with her to complete the ad- Narcissistic Personality Disorder mission, she shares with you that she cut her arms to get her boyfriend to “love” her. You are called Those who have this disorder tend to display out of the room. When you return, the patient an exaggerated impression of self with an yells at you and says she wants another nurse. She inflated sense of self-importance. They are does not trust you. preoccupied with fantasies of unlimited suc- This patient was diagnosed with borderline cess. Another characteristic is limited ability personality. Describe why she may have reacted so negatively to you when you returned to the room. to empathize with others’ problems because they see everything through their own eyes. They also tend to be hypersensitive when they receive criticism. They have a tendency to Histrionic Personality Disorder overestimate their abilities, are attention This disorder is characterized by dramatic, excessive, extroverted behavior in someone who has a pattern of strong emotions. Excessive Cultural Considerations attention seeking, seductive and provocative Cultural background can dictate social be- behaviors are additionally seen. Some may de- havior. So this should be taken into con- scribe the person as theatrical. They are known sideration when a diagnosis of histrionic to be highly distractible and even flighty. disorder is being made. Delaying gratification is difficult. Difficulty in 2993_Ch14_217-230 14/01/14 5:25 PM Page 222

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seeking, and are surprised if they do not re- Dependent Personality Disorder ceive admiration from others. While project- Dependent personality is a pervasive and ex- ing an image of invulnerability, their deep cessive need to be taken care of that leads to sense of emptiness is hidden from others. submissive and clinging behaviors and fears These individuals have difficulty maintaining of separation. These behaviors tend to elicit close relationships. caregiving response in others including People with this disorder will seem to take nurses. People with dependent personality criticism lightly. In reality, deep feelings of disorder want others to make decisions for anger, resentment, and poor self-esteem are them and tend to feel inferior and sug- being repressed. Friends will be chosen ac- gestible, with a sense of self-doubt. These cording to how good they make the person individuals tend to appear helpless and to with the narcissistic personality feel. avoid responsibility. On the other hand, in- Often these people are children of narcis- dividuals with this disorder tend to take sistic parental figures who were critical and de- everything to heart and go out of their way manding of their children. The children then to satisfy people they feel close to and try to model their behavior. Narcissistic traits are change those personality traits that people particularly common in adolescents though criticize. they will not necessarily have the personality There seems to be an inordinate amount of disorder. fear among people who experience dependent personality disorder. It may be the fear of crit- ■ ■ ■ Critical Thinking Question icism that brings about the inability to make You are working on a psychiatric unit, and your decisions. Inability to make decisions can be patient with narcissistic disorder tells you that she plans to get the lead in a play once she leaves the severe enough as to limit a person’s ability to hospital. She tells you she has always been success- have meaningful social interactions. In addi- ful in every audition she has had. What concerns tion recognition that overuse of dependency would you have for this patient? How would you behaviors can lead to a disturbed nurse- respond to her statements? patient relationship. Seriously overprotective parents who discourage independence and promote de- Cluster C pendence in the child for the parents’ needs can be a contributing factor. Chronic phys- Avoidant Personality Disorder ical illness in childhood can predispose to These individuals are extremely sensitive and this disorder. may avoid social situations to protect themselves from possible rejection. However, these people also have a strong need to be accepted. Often Cultural Considerations labeled shy, these individuals are awkward in Nurses must be cautioned here because social situations. They often view others as crit- the behaviors that have been discussed as ical. They want a close relationship but avoid it symptomatic of dependent personality because of fear of being rejected. Characteristics disorder are behaviors and conditions that include low self-esteem, avoidance of close rela- are expected in certain cultures, especially tionships, anxiety, and anhedonia, or lack of among females. pleasure in life. They are very hesitant to engage in new activities due to fear of failure. Highly critical parental figures are believed to be the Obsessive-Compulsive origin. There also may be a hereditary link. Personality Disorder Neeb’s The patient with avoidant personal- These individuals are disciplined and rigid ■ Tip ity disorder desperately wants social to an extreme. They are meticulous and de- contact but goes to lengths to dis- mand accuracy and discipline in others. courage it out of fear of rejection. They are preoccupied with details, rules, and 2993_Ch14_217-230 14/01/14 5:25 PM Page 223

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order. They display a stubborn streak in order to maintain control so things are done Pharmacology Corner their way. They may appear polite and for- Many patients with these disorders experi- mal but can be autocratic and critical with ence anxiety, so anti-anxiety medications are others. They demonstrate persistence at tasks often prescribed. Borderline patients have long after the behavior has ceased to be func- been treated with SSRIs (selective serotonin tional or effective and continuance of the reuptake inhibitors) to manage impulsivity. same behavior despite repeated failures or Antipsychotics may be used with patients obvious annoyance by others. The fear of with psychotic features such as schizotypal making mistakes can lead to an inability to disorders. For patients prone to violence, an- make any decisions. tipsychotics may also be needed. Because The origins include overcontrolling par- many of these patients are susceptible to ents, and the disorder does run in families. substance abuse to self-medicate, close mon- This personality disorder diﬀers from what is itoring of drug abuse should be included in known as OCD (obsessive-compulsive disor- the treatment plan. der). OCD is a disorder that is characterized by obsessions and compulsions in an eﬀort to maintain control (Chapter 10). Neeb’s Compliance with a prescribed med- ■ Psychiatric Treatment ■ Tip ication regimen can be challenging. of Personality Disorders Some may have a tendency to avoid following instructions or act Because these personality disorders become impulsively. engrained early in life, treatment is often difficult. People with personality disorders may not seek treatment as part of their ■ ■ ■ Critical Thinking Question disorder until the disorder drains their Your patient with a diagnosis of avoidant personality requests alprazolam before group therapy coping reserves. At times they will demon- session. Describe what this medication accom- strate resistance to treatment. Treatment plishes for the patient and alternative approaches may be pushed on them after a crisis or due in place of medication. to entrance into the legal system. Psy- chotherapy, cognitive behavior therapy, and group therapy may be useful in some situations. Maintaining a long-standing ■ Nursing Care of Patients trusting relationship with a therapist can With Personality be advantageous. Medications to treat anxiety, depression, and delusions are often Disorders used. Family members of people with Common nursing diagnoses with personality personality disorders often benefit from disorders include the following: family therapy and psycho-education around coping with them. • Coping, defensive • Personal identity, disturbed Neeb’s Though people with personality dis- • Self-esteem, disturbed ■ Tip orders may not seek mental health • Self-mutilation, risk for treatment, they often use the • Social interactions, impaired health-care system for other prob- • Violence, self-directed, risk for lems. Patients with personality disorders present many challenges to nurses. These patients may display Neeb’s Nurses need to display much pa- rigid behavior patterns and be so- ■ Tip tience and acceptance as part of the cially inappropriate. care plan. 2993_Ch14_217-230 14/01/14 5:25 PM Page 224

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General Nursing Interventions ■ ■ ■ Clinical Activities for Personality Disorders • Be alert to possible manipulation or staﬀ splitting; patients may view nursing students See Table 14-1 for a summary of nursing in- as being more vulnerable and try to take terventions for each personality disorder advantage of them. and Table 14-2, which details the nursing • At the same time, make eﬀorts to avoid stereo- care plan for patients with borderline typing or judging such patients based on information that they have a personality disorder. personality.

l Table 14-1 Nursing Interventions for Personality Disorders Type Symptoms Nursing Interventions Antisocial • Requires immediate self-gratification • Promote positive, healthy interper- • Often in trouble with the law sonal relationships • Has difficulty handling frustration • Monitor for violent behaviors and anger • Provide feedback on negative • Seldom feels affection, loyalty, guilt, behaviors or remorse • Encourage appropriate expression • Shows very little concern for the of angry feelings rights or feelings of others • Support analysis of feelings • Good at manipulating others for • Point out impact of manipulative personal gain behavior • High risk for substance abuse • Avoid negotiating rewards • Usually gregarious, charming, • Set limits intelligent, and likable Avoidant • Avoids social situations • Promote self-esteem by acknowl- • Preoccupied with thoughts of being edging any success rejected or criticized • Encourage participation in support- • Low self-esteem ive social situations • Avoids new activities for fear of being • Provide emotional support embarrassed • Teach calming techniques to use to deal with anxiety • Reinforce strengths Borderline • Moods unstable and changeable • Remain calm in presence of pa- • Uncertainty regarding self-concept tient’s drama • Substance abuse • Build trusting relationship • Suicide attempts • Set limits and establish clear ground • Anhedonia rules that are followed by everyone • Difficulty handling strong emotion • Establish therapeutic communication • Bored and empty feelings • Demonstrate positive role modeling • Fear of being alone • Monitor for self-destructive behaviors • Self-destructive behaviors • Provide safety/security • Self-mutilation • Communicate a consistent plan of • Manipulative care among all staff • Encourage patient to verbalize feelings rather than act them out • Avoid power struggles • Involve family and friends in treatment plan 2993_Ch14_217-230 14/01/14 5:25 PM Page 225

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l Table 14-1 Nursing Interventions for Personality Disorders—cont’d Type Symptoms Nursing Interventions Dependent • Dependent and submissive • Allow patient to make some deci- • Want others to make decisions for sions for his or her treatment them • Reinforce the patient’s decisions • Tend to feel inferior and suggestible • Encourage patient to make truthful, and have a sense of self-doubt positive self-statements each shift • Tend to appear helpless and avoid • Recognize patient's insecurities and responsibility anxieties. • Tend to take everything to heart— will go out of their way to satisfy people they feel close to and try to change those personality traits that people criticize • Inordinate amount of fear Histrionic • Dramatic • Support healthy coping • Emotional • Reassurance • Provocative • Support consistent healthy • Suggestible relationships • Give appropriate feedback Narcissistic • Exaggerated self-image • Encourage patient to learn to ac- • Appears self-centered cept limitations in self and others • Lacks empathy for others’ problems • Give patient feedback on how oth- • Expresses need for self-importance ers are responding to patient • Takes criticism lightly but in reality • Prepare patient for possible setbacks represses feelings of anger and • Recognize the patient is very sensi- resentment tive to hurt feelings • Sense of entitlement • Encourage the patient to talk about • Cheerful, carefree mood which can his or her vulnerabilities quickly change to distress if criticized Obsessive- • Rigid behavior • Understand patient’s fears and be Compulsive • Preoccupied with rules flexible as to his/her needs • Formal • Allow patient to make simple • Perfectionistic decisions with limited choices • Intense fear of making mistakes • Establish trusting, supportive • Though calm on outside, dealing relationship with intense conflict and hostility • Discuss alternative strategies for dealing with new situations • Support healthy coping mechanisms to deal with stress Paranoid • Suspicious and mistrustful of other • Avoid situation that the patient may people perceive as demeaning • May seem “normal” in speech and ac- • Encourage trusting relationship tivity • Encourage verbalizing one's • Believe that people treat them perceptions of the situations unfairly • Reinforce trusting behaviors • Hypersensitive to activity in the • Acknowledge other possible expla- environment nations for others motives • Difficult to maintain focused eye contact

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l Table 14-1 Nursing Interventions for Personality Disorders—cont’d Type Symptoms Nursing Interventions • Not easily able to laugh at themselves • Take themselves very seriously • May not show tender emotions • May seem cold and calculating in their relationships • Tend to take comments, events, situations personally • Few social interactions • Loners • Appear to be shy and introverted Schizoid • Detached • Acceptance of behavior • Chooses solitary activities • Encourage appropriate brief social • Avoids social situations interactions • Loner • Meet patient on his/her own • Often excel in ﬁelds where limited terms interaction needed • Help patient understand how behaviors may contribute to satisfactory relationships Schizotypal • Eccentric behavior • Brief, concrete conversations that • Inappropriate aﬀect are focused on reality • Aloof • Acceptance of behavior • Psychotic symptoms under stress • Encourage appropriate social behaviors • Recognize need for personal space • Reinforce reality gently

l Table 14-2 Nursing Care Plan for Patients With Borderline Personality Disorder Assessment/ Nursing Interventions/ Evaluation Data Collection Diagnosis Plan/Goal Nursing Actions Criteria After drinking Risk for Verbalize alterna- Provide safe, secure Able to de- heavily, got in self- tive coping mech- environment; scribe alterna- physical ﬁght directed anisms when Convey accept- tive coping with acquaintance, violence under stress ance of patient as a mechanisms; then made person; Able to utilize attempt at Discuss alternative these coping cutting wrists ways to express mechanisms anxiety, irritation; next time in Identify alternative a stressful actions to reduce situation destructive impulses 2993_Ch14_217-230 14/01/14 5:25 PM Page 227

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■ ■ ■ Key Concepts 4. People with personality disorders often present challenges to nursing staff when 1. Personality disorders are maladaptive re- receiving care for physical ailments due sponses to personality development. to their challenging behaviors, which can include poor interpersonal skills, nega- 2. People with personality disorders are sel- tive emotions, and inflexibility. dom hospitalized for them. They do not see a need for obtaining help and are not 5. Common traits of people with personal- always taken seriously by the medical ity disorders include socially inappropri- community. ate behavior, negative emotions, and difficulty with close relationships. 3. Borderline personality disorder is the most common one seen in the mental health setting.

CASE STUDY Marsha is a 25-year-old woman who is She describes a chaotic childhood in brought to the emergency room by her which her mother was away a lot and girlfriend after threatening to take sleep- Marsha moved around to live with a variety ing pills when her boyfriend broke off of relatives. She barely finished high school their relationship. On questioning Marsha, and has struggled to find unskilled jobs. she acknowledges a long history of prob- On interviewing her you find her cheer- lems. She has made multiple suicide ful and charming. She does not appear attempts, which include cutting her arms depressed. When you leave the room to at- and taking handfuls of sleeping pills. tend to another patient, she cries out that Each attempt occurred after a rejection she is being ignored. She calls multiple by a boyfriend or in earlier years by her friends to visit in the ER so she will not be parents. Marsha describes falling in love alone, thus creating a chaotic environment easily and a history of intense relation- that must be monitored by security. ships that often are discontinued by the Her long-term psychiatrist comes to see man after Marsha becomes increasingly her and tells you she is treating Marsha for clinging and demanding. borderline personality disorder.

1. Which behaviors in this case study are indicative of this diagnosis? 2. What treatment options are used to treat this disorder? 3. What medications would you expect her to have prescribed?

REFERENCES BPD Resource Center. Retrieved from http:// bpdresourcecenter.org/factsStatistics.html American Psychiatric Association. (2013). Cloninger, C.R., and Surakic, D.M. (2009). Diagnostic and Statistical Manual of Mental Personality disorders. In B. J. Sadock, . Washington, DC, Author. Disorders 5 V.A. Sadock, & P. Ruiz (Eds.), (Known as DSM-5) Kaplan & ARHQ National Guidelines Clearing House, Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Wolters Kluwer/ Borderline Personality Disorder. (2009). Lippincott Williams & Wilkins. Retrieved from http://www.guideline.gov/ Lenzenweger, M.F., Lane, M. C., and Loranger, content.aspx?id=14327&search=borderline+ A. W. (2007). DSM-IV personality disorders personality#Section420 2993_Ch14_217-230 14/01/14 5:25 PM Page 228

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in the National Comorbidity Survey Replica- NIH Information About Personality tion. Biological psychiatry, 62(6), 553–564. Disorders Puskar, K. R., et al. (2006). Self-cutting behavior http://www.nlm.nih.gov/medlineplus/personality in adolescents. Journal of emergency nursing disorders.html 32(5), 444–446. Antisocial Personality Townsend, M. (2012). Psychiatric Mental Health http://www.nlm.nih.gov/medlineplus/ency/article/ Nursing. 7th ed. Philadelphia: F.A. Davis. 000921.htm Paranoid Personality Disorder WEB SITES http://www.nlm.nih.gov/medlineplus/ency/article/00093 8.htm National Alliance on Mental Illness Informa- tion on Borderline Personality Disorder http://www.nami.org/Template.cfm?Section=By_ Illness&Template=/TaggedPage/TaggedPageDisplay.cfm &TPLID=54&ContentID=44780 2993_Ch14_217-230 14/01/14 5:25 PM Page 229

CHAPTER 14 | Personality Disorders 229 Test Questions Multiple Choice Questions 1. When setting limits with patients with 5. A patient who is in trouble with the law personality disorders, the consequences to would probably have which of the follow- those limits should be set: ing personality disorders? a. When the behavior is done a. Narcissistic b. Just before the nurse anticipates the b. Schizoid behavior c. Antisocial c. When the staff or family complains d. Borderline about the behavior 6. Patients who display very bizarre behavior d. When the limit is set most likely have which of the following 2. David, 30 years old, comes to your unit types of personality disorder? for treatment of multiple broken bones a. Narcissistic following a car accident. He is friendly b. Schizotypal and flirtatious but very demanding. As c. Antisocial you take your data from him, you learn d. Borderline that the police have been looking for him 7. Which intervention describes an impor- for petty theft. He laughs and says, “Like tant component in treatment of personal- they don’t have better things to do!” He ity disorders? states he has changed jobs three times in a. Antidepressants are most effective with the past year and has just broken off his most personality disorders. second engagement. His former fiancée is b. Inpatient psychiatric hospitalization is visiting and privately tells you that you particularly effective. need to be careful because “he doesn’t al- c. Self-awareness by the nurse is necessary ways tell the truth.” You suspect which of to ensure a therapeutic relationship. the following personality disorders? d. Long-term psychoanalysis is the a. Paranoid treatment of choice. b. Dependent c. Antisocial 8. Your patient has been admitted with a di- d. Schizoid agnosis of bilateral pneumonia. You have trouble communicating with this patient, 3. A primary mechanism used by people who is pouty and is demanding of your with personality disorders is: constant attention. She talks for long peri- a. Manipulation ods about the smallest details of her life. b. Depression Besides the pneumonia, you ask the physi- c. Projection cian if the patient has a history of which d. Euphoria of the following personality disorders? 4. For the patient with a personality disor- a. Schizoid der, which of the following behaviors b. Antisocial would be the most difficult for the pa- c. Narcissistic tient to comply with? d. Borderline a. Listening to music b. Abiding by the rules in the hospital c. Playing volleyball d. Developing a friendship 2993_Ch14_217-230 14/01/14 5:25 PM Page 230

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Test Questions cont.

9. Nursing care for people with personality 10. You are caring for a 25-year-old male disorders includes all of the following who has been admitted for infections except: that resulted from self-inﬂicted burns. a. Unconditional positive regard This is not the ﬁrst admission for this b. Trust young man, but he is new to you as a c. Limit setting new nurse on the unit. You have not d. Vague communication (to decrease read his entire chart, but you suspect he feelings of inferiority) has a history of which one of the following personality disorders? a. Narcissistic b. Borderline c. Schizoid d. Passive-aggressive 2993_Ch15_231-244 14/01/14 5:25 PM Page 231

CHAPTER 15 Schizophrenia Spectrum and Other Psychotic Disorders

Learning Objectives Key Terms 1. Define schizophrenia. • Catatonia 2. Differentiate between positive and negative symptoms seen • Delusions in schizophrenia. • Echolalia 3. Identify two other psychotic disorders. • Echopraxia 4. Identify treatment modalities for people with schizophrenia. • Extrapyramidal 5. Describe catatonic features in schizophrenia symptoms (EPS) 6. Identify nursing care for people with schizophrenia. • Hallucinations • Illusions • Psychosis • Schizophrenia • Schizoaffective disorder • Schizophrenia spectrum disorder

he term schizophrenia (which literally condition continues. As a chronic illness, means “split mind”) was first used by schizophrenia is characterized by remissions TSwiss psychiatrist Eugen Bleuler and exacerbations throughout one’s life. The (Fig. 15-1). Schizophrenia is a serious, first psychotic break often responds well to chronic, psychiatric disorder characterized by treatment, but the relapse rate is high and the impaired reality testing, hallucinations, delu- person may become increasingly disabled. sions, and limited socialization. It is a psy- Schizophrenic individuals are vulnerable chotic thought disorder where hallucinations to substance abuse as they self-medicate to and delusions dominate the patient’s think- control their symptoms, contributing to ing, leading to confusing and bizarre behav- co-occurring disorder (see Chapter 17). iors. People with schizophrenia have a “split” These patients can also be at risk for suicide, between their thoughts and their feelings and which may be manifested as voices telling between their reality and society’s reality, the person to kill her/himself or a means to which can lead to unusual and frightening be- end suffering. haviors. Schizophrenia is a frequent cause for DSM-5 now categorizes schizophrenia under long psychiatric hospitalizations. The suffer- the global title of schizophrenia spectrum ing for a schizophrenic patient and his/her disorders (2013). In the past, schizophrenia family can last a lifetime as this crippling was divided into five subtypes of catatonic,

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Neeb’s Sudden onset of hallucinations and ■ Tip delusions requires quick action to identify the cause. Causes can include medical conditions, metabolic changes, and drug reactions.

■ ■ ■ Classroom Activities • View and discuss movies that feature schizophrenic characters, including A Beautiful Mind and I Never Promised You a Rose Garden.

■ ■ ■ Critical Thinking Question Your patient has a diagnosis of schizophreniform disorder. How is this diﬀerent from a diagnosis of schizophrenia?

l Table 15-1 Other Disorders With Schizophrenic Figure 15-1 Eugen Bleuler (1857–1940) was a Features Swiss psychiatrist who coined the term schizophrenia and contributed to the understanding of Type Characteristics the disorder. Delusional Delusions without the Disorder other symptoms or disabilities of schizophrenia Schizoaffective Symptoms of schizophre- delusional, disorganized, undifferentiated, and nia along with symptoms residual, but in 2013 these were eliminated. of major depression or The new term of schizophrenia spectrum dis- manic episode that re- orders reflects a gradient of psychopathology quires treatment of both that a patient can experience from least to most disorders severe. Disorders such as schizophreniform and Schizophreniform Schizophrenia symp- schizoaffective would be the less severe forms. toms without the level of See Table 15-1 for other disorders with schiz- impairment of function- ophrenic features. ing usually seen in schizophrenia and lasting In addition, psychoses can occur in bipolar more than 1 month and disorder and major depression. Another psy- fewer than 6 months chotic disorder is brief psychotic disorder, Schizotypal A personality disorder which includes postpartum psychosis (see characterized by odd Chapter 20) as well as psychosis due to sub- and eccentric behavior stance abuse or medical conditions. Medical that does not decom- conditions that can contribute to psychoses pensate to the level of include brain tumors, CNS infections, delir- schizophrenia (see ium, and endocrine disorders. All of these dis- Chapter 14) orders, though not schizophrenia, have some Source: Adapted from Diagnostic and Statistical Manual of Mental of the same symptoms but different etiology Disorders, 5th Edition (Copyright 2013). American Psychiatric and duration of disability. Association, Townsend (2012), and Goldberg (2007). 2993_Ch15_231-244 14/01/14 5:25 PM Page 233

CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 233

Frequently, schizophrenia is initially diagnosed in adolescents and younger adults between the ages of 16 and 35 with the occurrence of the ﬁrst psychotic break, though later onset does occur. A common scenario is a young person who has left home for college or the military and suddenly exhibits psychotic behavior (Fig. 15-2), though premorbid personality may indicate this individual was withdrawn, had problems with social relationships, and exhibited possible antisocial behavior. Schizophrenia is rare in young children. The National Institute of Mental Health (NIMH) estimates that nearly 3 million Americans will develop schizophrenia during the course of their lives. That is about 1.1% of the U.S. population (National Institute of Mental Health, 2012).

Figure 15-2 Schizophrenia can create extreme ■ ■ ■ Classroom Activities distress. • Contact a local NAMI (National Alliance on Mental Illness) support group and attend a meeting if possible. symptoms are those found among people who do not have the disorder but are missing or lacking among individuals with schizo- ■ Symptoms phrenia and reflect a lessening or loss of normal functions. These may include avolition • The presence of delusions, hallucinations, (a lack of desire or motivation to accomplish and/or disorganized speech for a signifi- goals), lack of desire to form social relation- cant portion of time during a 1-month ships, inappropriate social behavior such as period. At least one of these must be pacing or rocking, and blunted affect and present for the diagnosis. emotion. These symptoms make holding a job, • Grossly abnormal motor behavior and/ forming relationships, and other day-to-day or negative symptoms (see below for functions especially difficult for people with explanation) schizophrenia. • One or more areas of functioning, such as Positive symptoms are those that are found work, school, personal relationships, or among people with schizophrenia but not self-care, are impaired. Some disturbance present among those who do not have the dis- needs to be evident for at least 6 months. order. They reflect an excess or distortion of • Schizophrenia can also have features of normal functions such as delusions, thought catatonia, which include any of the fol- disorders, and hallucinations. People with lowing: motor immobility to stupor, ex- schizophrenia may hear voices other people cessive motor activity, peculiar voluntary don’t hear or believe other people are reading movements, and echolalia or echopraxia. their minds, controlling their thoughts, or Schizophrenia’s symptoms are typically de- plotting to harm them. Other positive symptoms can include magical thinking (belief that scribed as “negative” or “positive.” Negative one’s thoughts can control others), neologisms (invents new words that only have meaning to the individual), concrete thinking (literal in- Cultural Considerations terpretation of the environment), loose asso- Schizophrenia crosses all races and cultures. ciations (ideas shift from unrelated one to another), echopraxia (repeating movements of 2993_Ch15_231-244 14/01/14 5:25 PM Page 234

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Cultural Considerations l Table 15-3 Recognizing Hallucinations One’s culture often influences the content of hallucinations and delusions. Familiar- Affected Sense Example ity with the patient’s culture can provide Visual “I watch gypsies bring insight into the origin of some of these different babies to my behaviors. apartment each night.” Auditory (most “The voices are calling common) me a prostitute.” others), and echolalia (parrot-like repeating Tactile “When I touched my words spoken by others). Most schizophrenics arm, I could tell my arm have a mixture of both positive and negative is made of stone.” symptoms. Olfactory “I don’t want to stay in See Tables 15-2 and 15-3 for lists of com- that room. I can smell mon delusions and hallucinations. the odors of the people who died there.” Neeb’s Schizophrenia is a debilitating and ■ painful lifelong disease for the pa- Gustatory “I taste milk in my Tip mouth all the time.” tient and family requiring long-term management and compassion. Kinesthetic (bodily “It feels as if the rats in movement or my head are eating up sense) my brain.” ■ ■ ■ Critical Thinking Question Your schizophrenic patient tells you that his Source: Adapted from Gorman and Sultan (2008). Psychosocial mother has communicated with him that he Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis needs to leave the hospital right now to help save Company, with permission. the mayor from peril. What type of delusions and hallucinations is this patient experiencing? ■ Etiology of Schizophrenia No single cause has been identified, but it is l Table 15-2 Common Delusions now known that schizophrenia is a brain disorder. Disruption of neurotransmitters, in- Delusion Example cluding dopamine, has been identified. Some Grandeur (belief of “I am Napoleon dysfunction in neuron functioning has also exaggerated Bonaparte.” been found. Some cerebral changes in the importance) brain have also been suggested in the limbic Paranoia (belief of “The FBI is following system and prefrontal cortex. These factors deliberate harassment me and wants to may contribute to the problems with atten- and persecution) kill me.” tion and information processing. The person Reference (belief that “Those people on the thoughts and the TV show are behavior of others talking to me.” is directed toward self) Cultural Considerations Physical sensations “I have no blood Behaviors that may be normal in some (belief that parts of in me.” cultures can be confused with psychotic body are diseased, behavior. For example, speaking in tongues distorted, or missing) and talking to spirits may be normal Thought insertion “The devil made behavior in some cultures. If psychotic me say that.” behavior is suspected, it is important to Source: Adapted from Gorman and Sultan (2008). Psychosocial obtain information on what is normal Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis behavior for the culture of your patient. Company, with permission. 2993_Ch15_231-244 14/01/14 5:25 PM Page 235

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is unable to filter stimuli, leading to disorganization of mental functioning. While Pharmacology Corner family dysfunction may exist, it appears that Antipsychotic medications are key to a pa- psychological factors by themselves do not tient’s returning to a stable state. Once cause this condition. There is also evidence achieved, maintenance therapy is established of genetic predisposition, and the most sig- to prevent exacerbations. Most schizophren- nificant risk factor is having a close relative ics will relapse once off their medications, so with this disorder. incorporating a plan for medication compliance is essential. Once established on appro- ■ Psychiatric Treatment priate medications, the patient is usually of Schizophrenia more open to counseling and supportive interventions. It can take time to establish A comprehensive, multidisciplinary treat- the appropriate medication and dosages so ment plan including pharmacotherapy, so- the patient and family must be monitored cial support, social/life skills training, closely. Some patients may require longer self-help groups, and family therapy can be periods of trials for months or even years to helpful to maintain the patient effectively. find the best available medication, the right Gaining life skills to deal with everyday dosage, and manageable side-effect profile. challenges, occupational training, and fam- A trial of any one medication should last for ily education have been helpful. Intensive a substantial period, usually 6 to 8 weeks, individual psychotherapy is generally not as unless intolerable side effects occur early. effective, but reality-based therapy to promote trust can be incorporated into the plan. Ongoing support can promote com- These agents are generally used to treat the pliance with antipsychotic medications. positive symptoms of schizophrenia. Atypical Management of antipsychotic medications antipsychotics have been available since the is generally the primary treatment. See 1990s and are weaker dopamine receptor an- Pharmacology Corner. tagonists but more potent antagonists of serotonin receptors. New atypicals are added Tool Box | Brief Psychiatric Rating Scale to the market regularly. These drugs treat (BPRS)—Standardized tool to track response both the positive and negative symptoms to treatment: and generally have fewer side effects. Even http://www.public-health.uiowa.edu/icmha/ though the atypical agents have a better side- outreach/screening.html effect profile for long-term treatment, the Treating Schizophrenia Guideline from typical or older agents may be chosen for American Psychiatric Association: short-term management of psychosis or http://psychiatryonline.org/content.aspx ? long-term management of symptoms that bookid= 28 & sectionid= 166309 3 do not respond to the atypical agents. See Table 15-4 for a list of the common typical and atypical antipsychotics with their side- effect profile. Most of these agents are avail- ■ ■ ■ Classroom Activities • Invite a local mental health professional to class able only in oral form. A few are available as to discuss the treatment approaches to schizo- a long-acting injection that is given every phrenic patients in your community. few weeks. These include haloperidol, fluphenazine, and risperidone. These can be effective if a patient refuses or is unable to Most people respond to one of the typical take oral medications. Some medications or atypical agents to a degree at the first psy- come in liquid forms or quick dissolving chotic episode. Typical antipsychotics have tablets, which can also be useful if the pa- been around since the 1950s and work by tient is not cooperative with taking oral blocking postsynaptic dopamine receptors. medication. 2993_Ch15_231-244 14/01/14 5:25 PM Page 236

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l Table 15-4 Comparison of Side Effects Among Typical and Atypical Antipsychotic Agents Anti- Orthostatic Weight Class Generic Name EPS Sedation cholinergic Hypotension Gain Typicals Chlorpromazine 3 4 3 4 * (Thorazine) Fluphenazine 5 2 2 2 (Prolixin) Haloperidol 5 2 2 2 (Haldol) Loxapine 3 2 2 2 * (Loxitane) Perphenazine 4 2 2 2 * (Trilafon) Pimozide 4 2 3 2 * (Orap) Prochlorperazine 3 2 2 2 * (Compazine) Thioridazine 2 4 4 4 * (Mellaril) Thiothixene 4 2 2 2 * (Navane) Triﬂuoperazine 4 2 2 2 * (Stelazine) Atypicals Aripiprazole 1 2 1 3 2 (Abilify) Asenapine 1 3 1 3 4 (Saphris) Clozapine 1 5 5 4 5 (Clozaril) Iloperidone 1 3 2 3 3 (Fanapt) Lurasidone 1 3 1 3 3 (Latuda) Olanzapine 1 3 2 2 5 (Zyprexa) Palperidone 1 2 1 3 2 (Invega) Quetiapine 1 3 1 3 4 (Seroquel) Risperidone 1 2 1 3 4 (Risperdal) Ziprasidone 1 3 1 2 2 (Geodon)

Key: 1=Very low, 2=low, 3=moderate, 4=high, 5=very high +Weight gain occurs, but incidence is unknown. Source: From Townsend (2012): Psychiatric Mental Health Nursing,7th ed. Philadelphia: F.A. Davis, with permission. 2993_Ch15_231-244 14/01/14 5:25 PM Page 237

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■ ■ ■ Critical Thinking Question Neeb’s Extrapyramidal symptoms can be You realize your schizophrenic patient has been ■ Tip devastating to quality of life. Close “cheeking” his risperidone (hiding the pill in his monitoring to treat these and pre- cheek). What might be some of the reasons the vent long-term consequences must patient is doing this? Identify two alternatives for be part of the treatment plan. taking this medication.

Managing the side effects of antipsychotics Tool Box | Abnormal Involuntary Move- can promote patient compliance. Typical an- ment Scale (AIMS): This tool is a rating scale tipsychotics are more prone to extrapyramidal developed by the National Institute of Mental symptoms (EPS) as well as anticholinergic Health to measure involuntary movements as- effects, though the drugs can be particularly ef- sociated with tardive dyskinesia (available at: fective in controlling psychotic symptoms. See www.atlantapsychiatry.com/forms/AIM S.pdf Box 15-1 and Table 15-5 for lists of extrapyramidal and anticholinergic side effects. Ex- trapyramidal symptoms are generally managed with anticholinergic drugs such as benztropine, biperiden, trihexyphenidyl, dopaminergic ag- ■ ■ ■ Clinical Activity onists such as amantadine, or antihistamines • Review chart for CBC results if the patient is on clozapine. such as diphenhydramine. • Review chart for evidence of side effects of an- The atypicals are generally less associated tipsychotic medications. with extrapyramidal symptoms than the typ- • Discuss management of side effects with patient ical agents, but there is a wide range of other and his/her family. side effects, so close monitoring of the prescribed drug is essential. Some atypicals are prone to anticholinergic effects. Serious side effects in specific atypicals can include re- ■ ■ ■ Critical Thinking Question duced seizure threshold, blood dyscrasias, and Your patient with schizophrenia has been taking cardiac arrhythmias. One of the most serious clozapine for 2 years. He is now in the hospital and is agranulocytosis, which is a rare blood com- is NPO awaiting an appendectomy. What con- plication of clozapine requiring close moni- cerns would you have that the patient has been without his medications for 2 days? Why is the MD toring of the white blood cell count. The monitoring his WBC counts closely? specific side effects of the atypicals must be reviewed and monitored whenever these drugs are ordered.

l Box 15-1 Extrapyramidal Side Neeb’s Compliance to antipsychotics re- Effects ■ Tip mains a lifelong challenge for the • Dystonia: muscle rigidity, torticollis (neck schizophrenic patient and his/her turned in awkward angle) family. It is important to regularly • Pseudoparkinsonism or dyskinesia: stiff- monitor medication compliance ness, tremors, shuffling gait and the current side-effect profile. • Akathisia: restlessness, inability to sit still Education must be reinforced each • Tardive dyskinesia: late onset movement time the patient is seen in any disorder that includes lip smacking, health-care setting. grimacing, tongue protrusion 2993_Ch15_231-244 14/01/14 5:25 PM Page 238

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some control to look at alternative ways Table 15-5 Anticholinergic Effects l to view reality. Symptom Action • Work to slowly build trust in small ways. Dry mouth Offer sugarless candy, good Avoid overreacting to patient’s bizarre oral hygiene, saliva substitute behavior or appearance Orthostatic Instruct patient to get out of • Maintain a calm, consistent environment hypotension bed slowly, monitor BP with a regular routine • Constipation Promote high-fiber diet, flu- Even though he/she appears to be in an- ids, stool softeners, laxatives other world, continue to include the patient as needed in conversations and activities. Acknowledge Urinary Instruct patient to report his/her presence and importance. retention symptoms promptly • Focus on reality, e.g., rather than listen to a long monologue about a delusion, talk Dry eye Lubricant eye drops about the schedule for the day. Source: Adapted from Gorman and Sultan (2008). Psychosocial • Never argue with the patient about what Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis he or she is experiencing. Company, with permission. • Incorporate Quality and Safety Education for Nurses (QSEN) competencies to maintain a safe environment for the psychotic ■ patient (qsen.org), e.g., remove sharp Nursing Care of the objects, provide adequate supervision. Schizophrenic Patient • Take action to provide medications before agitation escalates. Make sure there are The nursing care of the schizophrenic patient orders for prn medications for agitation. requires knowledge and compassion. Com- • Never reinforce hallucinations, delusions, mon nursing diagnoses for the schizophrenic or illusions. An example of an inappropri- patient include: ate response is, “Jesus wants you to take • Self-care deficit these pills," That response reinforces the • Sensory perception, disturbed delusion about Jesus. • Social isolation • Avoid whispering or laughing when the pa- • Thought processes, disturbed tient cannot hear the whole conversation; • Violence, risk for such behavior can promote paranoia. • Avoid putting the patient into situations General Nursing that are competitive or embarrassing. Interventions • Build trust by using therapeutic commu- • Watch for clues that patient is hallucinat- nication skills. ing, e.g., darting eyes, mumbling to self, • If the patient is catatonic, provide for basic staring at a vacant wall for long periods. physical needs and safety, and make brief You can also ask the patient if he is hear- supportive contacts with the patient with- ing voices. out pressuring the patient to communicate. • If the patient is hallucinating, your response Table 15-6 provides the nursing care plan could be, “I don’t see the devil standing for patients with schizophrenia. there, but I understand how upsetting this is for you.” In this way you are acknowledging what the patient is experiencing with- Neeb’s It is important for the nurse to avoid out reinforcing it as your reality. ■ Tip reinforcing psychotic thinking, as in • If your patient is delusional, reinforce re- delusions. For example, avoid asking ality, “that man works for the hospital not the patient what “they” are telling the FBI,” “Yes, there was a man at the the patient. Rather, let the patient nurse’s station, but I did not hear him talk know you are concerned but do not about you.” Remind the patient he has hear these voices. 2993_Ch15_231-244 14/01/14 5:25 PM Page 239

CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 239

Remember that schizophrenic pa- Neeb’s Tool Box | National Institute of Mental ■ Tip tients are often very concrete Health information for Patients and Families thinkers, so it is important to speak on Schizophrenia: clearly and plainly. Make only one http://www.nimh.nih.gov/health/topics/ request at a time. schizophrenia/index .shtml

■ ■ ■ Classroom Activity • Have a mental health counselor from a local clinic present information on managing schizo- ■ ■ ■ Critical Thinking Question phrenia to your class. Your 19-year-old patient with a new diagnosis of schizophrenia begins yelling “Stay away, don’t touch me” as you walk into his room. His mother is in the room and is trying to comfort the patient. What approaches might be helpful for the patient See Table 15-7 for interventions for patients and his mother? with schizophrenia who are hallucinating.

l Table 15-6 Nursing Care Plan of the Schizophrenic Patient Data Nursing Interventions/ Evaluation Collection Diagnosis Plan/Goal Nursing Actions Criteria Patient is mumbling Social Patient will spend • Approach Patient will par- to himself, looks isolation time in a social patient for brief ticipate in unit suspiciously at staﬀ, activity. periods in a non- activity once a avoids contact with threatening day. staﬀ, other people manner. avoid patient. • Avoid touching patient without asking permission. • Talk about concrete unit activities. • Demonstrate acceptance of patient’s behavior and appearance by avoiding reacting to bizarre behavior. Point out possible alternative behaviors once relationship established. 2993_Ch15_231-244 14/01/14 5:25 PM Page 240

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l Table 15-7 Suggested Interventions for Patients With Schizophrenia Who Are Hallucinating Suggested Action Rationale 1. ”Mr. R, I don’t see any bugs. It is time 1. This lets the patient know you heard him for lunch. I will walk to the dining room but brings him immediately into the reality with you.” of time of day and the need to go to the dining room. 2. ”I see a crack in the wall, Mr. R. It is 2. This is in response to a probable illusion. harmless; you are safe. Susan is here It lets the patient know that you see some- to take you down to Occupational thing. It validates his fear but tells him Therapy now.” what you see and then moves him into the here and now. 3. ”I know that your thoughts seem very 3. Again, you are validating the patient’s con- real to you, Ms. C, but they do not seem cern without exploring and focusing on logical to me. I would like you to come to the delusion. your room and get dressed now, please.” 4. ”Ms. C, It appears to me that you are 4. This is a method of validating your impres- listening to someone. Are you hearing sion of what you see. This is as far as you voices other than mine?” will go into exploring what she may be hearing. 5. ”Thank you, Ms. C. I want to help you 5. In this statement, you respond to her in focus away from the other voices. I am real; the present and reinforce her response to they are not. Please come with me to the you. This response attempts to redirect her reading room.” thinking.

Source: Adapted from Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.

■ ■ ■ Key Concepts gradient of less to more severe conditions. Schizophrenia is usually diagnosed in a 1. Schizophrenia is a chronic, serious, often person’s late teens and young adulthood debilitating psychiatric disorder that im- but often continues for the rest of the pacts all aspects of the patient’s life and patient's life. his/her loved ones. 5. Hallucinations and delusions are exam- 2. Schizophrenia is now known to be a ples of positive symptoms that present brain disorder. challenges to all health-care professionals. 3. Not all psychoses are schizophrenia. 6. The main treatment for schizophrenia re- Other psychotic disorders can include mains antipsychotic medications. Be- brief psychotic disorder, psychosis in cause of the side-eﬀect proﬁle of these bipolar disorder, substance abuse, and medications, close monitoring is needed major depression. to achieve the best outcomes and patient compliance. 4. Schizophrenia is now viewed as a spectrum disorder, which means there is a 2993_Ch15_231-244 14/01/14 5:25 PM Page 241

CHAPTER 15 | Schizophrenia Spectrum and Other Psychotic Disorders 241

CASE STUDY Ralph is a 20-year-old college student who is reported to his parents that he needed admitted to your psychiatric facility by his immediate hospitalization. parents. Ralph is in his second year at an The parents report that Ralph had a out-of-state college. Over the past 6 months, normal childhood and never displayed any he has been exhibiting increasingly bizarre unusual behavior until the last year. The behavior, such as walking the halls of his parents tell you they feel guilty that they dorm at night knocking on doors, asking did not monitor his behavior more closely strange questions, mumbling to himself, and in the last few months. sleeping on the ﬂoor during the day. He has On meeting Ralph he avoids eye contact also been exhibiting disruptive behaviors in and appears to be talking to someone he class. Students report being afraid of him sees in the corner of the room. When his and he has become increasingly isolated. parents walk into the room, he begins hit- Most recently he became violent in the ting his head repeatedly against the wall. school cafeteria. Then the school counselor

1. How should you respond to Ralph when ﬁrst meeting him? 2. How would you respond to the parents’ fears? 3. What medications might be useful for this patient?

REFERENCES interventions for schizophrenia and the margin- alization of person-centered alternatives. American Psychiatric Association. (2000). Issues in Mental Health Nursing. 33(2),127–132. Diagnostic and Statistical Manual of Mental National Institutes of Mental Health. Schizophrenia. Washington DC, Disorders IV-Text Revision. Retrieved from http://www.nimh.nih.gov/ Author. (Known as DSM-IV-TR) statistics/1SCHIZ.shtml American Psychiatric Association. (2013). Dia - Townsend, M. (2012). Psychiatric Mental Health gnostic and Statistical Manual of Mental Dis - Nursing. 7th ed. Philadelphia: F.A. Davis. orders 5. Washington, DC, Author. (Known as DSM-5) Bauer, S.M., et al. (2011). Culture and the WEB SITES prevalence of hallucinations in schizophrenia. National Alliance on Mental Illness: Infor- Comprehensive psychiatry, 52(3), 319–325. mation on schizophrenia for patients, Collier, E. (2011). Schizophrenia in older adults. families and professionals Journal of psychosocial nursing and mental www.nami.org/Content/ContentGroups/Illnesses/ health services, 49(8), 17–21. Onset_Schizophrenia.htm Goldberg, R J. (2007). Practical Guide to the National Institute of Mental Health: What Care of the Psychiatric Patient. 3rd ed. Is Schizophrenia? St Louis: Mosby-Elsevier. www.nimh.nih.gov/health/publications/ Gorman, L., and Sultan, D. (2008). Psychosocial schizophrenia/index.shtml Nursing for General Patient Care. 3rd ed. QSEN Philadelphia: F.A. Davis. http://qsen.org/about-qsen/ Harris, B.A. (2012). Schizophrenia. A critical nursing perspective of pharmacological 2993_Ch15_231-244 14/01/14 5:25 PM Page 242

242 UNIT 2 | Threats to Mental Health Test Questions Multiple Choice Questions 1. Brian, an 18-year-old with schizophrenia, 5. Which of the following is not a sign of has a negative attitude, is delusional, hears untreated schizophrenia? voices, and is withdrawing from others. A a. Loss of reality nursing intervention that is appropriate for b. Living in one’s own world promoting activity for Brian is: c. Maintaining satisfactory performance a. Tell him “the voices” told you he on the job should participate in the weekly party. d. Delusions, hallucinations b. Remind him that he does not want to 6. A nursing intervention for a person with get worse by sitting alone. schizophrenia is to: c. Tell him he must join the party; it is a. Reinforce the hallucinations. part of his care plan. b. Keep the person oriented to reality and d. Invite him to join in the party. to the present. 2. Shawna is a 22-year-old woman who has c. Encourage the patient to begin episodes of extreme muscle rigidity and psychoanalysis. hyperexcitability. She sometimes repeats a d. Encourage competitive activities. word or a phrase over and over. Attempts 7. Mr. S states, “Look at the snakes on the to move her are met with even more mus- ceiling.” You see some cracks in the cle resistance. What is she exhibiting? plaster. Mr. S is experiencing a (an): a. Catatonia a. Hallucination b. Disorganized schizophrenia b. Illusion c. Brief psychotic disorder c. Delusion d. Schizotypal personality d. Flashback 3. Mr. G is calling out, “Nurse!” When you 8. Your best response to Mr. S might be: arrive in his room, he tells you to be care- a. “How many snakes do you see, Mr. S?” ful of the snake in the corner. You do b. “Yes, I see them, too. Let’s go to the not see anything in the corner. Mr. G is dayroom.” experiencing a (an): c. “I see some cracks in the plaster, but I a. Hallucination do not see snakes. Let’s go to the day b. Attention-getting behavior room.” c. Illusion d. “I don’t think your medication is work- d. Delusion ing. I’ll call the doctor.” 4. Of the following responses, which would 9. A patient who repeats a word or part of a be your best response to Mr. G regarding word over and over might be said to have the snake? which of the following symptoms? a. “Don’t worry; I’ll get rid of it.” (You a. Echolalia pretend to remove the snake.) b. Echopraxia b. “I don’t see a snake; what else do you c. Echocardia see that isn’t there?” d. Word salad c. “I don’t see a snake. It is time for your group meeting. I’ll walk with you to the meeting room.” d. “Where is it? I hate snakes. Let’s get out of here.” 2993_Ch15_231-244 14/01/14 5:25 PM Page 243

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Test Questions cont.

10. An individual stands on the train track 12. The primary goal in working with an ac- with the train coming nearer. The per- tively psychotic, suspicious patient is to: son exclaims, “I am invincible! The train a. Improve her relationship with her parents will not hurt me.” This is an example of: b. Encourage participation in individual a. Delusions of grandeur psychotherapy b. Echolalia c. Decrease her anxiety and increase trust c. Sensory hallucinations d. Promote healthy living habits d. Extrapyramidal symptoms 13. The most current thinking on the cause 11. Which of the following pairs of symp- of schizophrenia is: toms are closely associated with EPS? a. A brain disorder a. Muscle rigidity and protruding b. Primarily a disturbed mother/child tongue relationship b. Overly emotional, depressed c. Brain damage caused by the mother’s c. Shuﬄing gait and depression use of tranquilizers during pregnancy d. Fatigue and painful joints d. Alternation in opioid receptors 2993_Ch15_231-244 14/01/14 5:25 PM Page 244 2993_Ch16_245-260 14/01/14 5:26 PM Page 245

CHAPTER 16 Neurocognitive Disorders: Delirium and Dementia

Learning Objectives Key Terms 1. Describe the differences between delirium and dementia. • Agnosia 2. Define neurocognitive disorders. • Agraphia 3. List the most common forms of dementia. • Alzheimer’s disease 4. List common causes of delirium. • Apraxia 5. Describe effective treatments for each. • Chemical restraint • Delirium • Dementia • Mild neurocognitive disorder • Neurocognitive disorder • Nocturnal delirium • Physical restraint • Pseudodementia • Vascular dementia

eurocognitive disorder is the new memory deficit, language disturbance, and/or global term that includes the diag- perceptual disturbance. Delirium may in- Nnoses of delirium and dementia clude alterations in sleep-wake cycle, including (DSM-5, 2013). In the past these were re- hypervigilant state to stupor. The patient may ferred to as organic mental syndromes and exhibit nocturnal delirium, known as sundown- disorders by the American Psychiatric Associ- ing, when confusion and agitation increase at ation. The disorders in this category all in- dusk. See Table 16-1 for types of delirium with clude deficits in cognitive function. common symptoms. Delirium usually develops quickly and often fluctuates throughout the day. ■ Delirium The condition often resolves once the cause is identified and treated. Delirium should be con- Delirium is an acute reaction to underlying sidered when the person exhibits sudden onset of physiological (e.g., toxins, drug reactions, illness) confusion, memory impairment, incoherence, or psychological stress (e.g., sensory overload). It fluctuating levels of consciousness, sleep-wake is a temporary condition that is characterized by cycle disruption, hallucinations, and/or delusions. a disturbance in attention (i.e., reduced ability to Delirium is an extremely common condi- direct, focus, sustain, and shift attention) and tion seen in the acute hospital, nursing home, orientation to the environment. For example, and home settings, particularly in the elderly. the patient may need questions repeated due to DSM-5 reports that delirium occurs in 15%– inattention, is easily distracted, or needs repeated 53% of older individuals postoperatively and orientation to the situation. It can also include 70%–87% of those in ICU. The condition also 245 2993_Ch16_245-260 14/01/14 5:26 PM Page 246

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l Table 16-1 Types of Delirium Hypoactive- Hyperactive- Assessments Hypoalert Hyperalert Mixed Level of alertness Lethargic, falls asleep Overly attentive Alternates between hyper- between questions, to cues alert and hypoalert states diﬃcult to arouse within hours or days Motor activity Decreased activity Moves quickly Alternates within one episode of delirium Ability to follow Follows a simple May be combat- Alternates between hypoac- commands command, e.g., lift ive, pulls at tubes, tive and hyperactive states, your foot tries to climb out may be unpredictable Is passively of bed cooperative Thinking ability Diﬃculty in Easily distracted, Alternates between hypoac- focusing attention, Rambles tive and hyperactive states disorganized May mumble, in an unpredictable manner swear, or yell

Source: Adapted from Forrest et al. (2007) and Gorman & Sultan (2008).

contributes to mortality. DSM-IV-TR reports that 15% of elderly people die within one Pharmacology Corner month of an episode of delirium. Common Prescribing medications to control delirium causes can include electrolyte imbalance, poor symptoms is risky because these medications oxygenation, medication side effects or misuse, can mask or compound the confusion and urinary tract infections, and dehydration. See agitation. However, at times low-dose an- Table 16-2 for a more comprehensive list of tipsychotic medications such as haloperidol, causes. Identifying the cause can be challenging risperdal, and olanzapine may be needed to in people with complex medical conditions, as address agitation. The benefits of the med- multiple factors may contribute to the delirium. ications must be weighed against the possible Substance-induced delirium is a separate cate- side effects. Generally, anti-anxiety medica- gory when delirium developed during or within tions like lorazepam should be avoided as a month after severe intoxication or withdrawal they further confuse the picture of alterations from a substance capable of producing delirium. in consciousness. Treatment of Delirium Neeb’s Your patient with delirium needs Treatment of delirium must be focused on ■ Tip to be monitored closely. He can finding and treating the cause. Often symp- appear normal at times and then toms of delirium can resolve quickly once the suddenly become agitated and try appropriate treatment for the cause is begun. to get out of bed unsupervised. Supportive interventions to maintain patient safety, control agitation, prevent further complications, and reorient can be very helpful. ■ ■ ■ Critical Thinking Question An 81-year-old woman is admitted from the ER with a diagnosis of delirium manifested by acute ■ ■ ■ Clinical Activity confusion, rambling speech, and new onset of If your patient has a delirium diagnosis or exhibits incontinence. Her husband reports this all started a sudden change in consciousness and/or behav- 24 hours ago after several episodes of diarrhea. ior, review his or her medical record for possible She had recently been in the hospital for compli- causes, including medication side effects, recent cations from diabetes. List the possible causes of lab results, and recent infections. delirium that should be evaluated. 2993_Ch16_245-260 14/01/14 5:26 PM Page 247

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l Table 16-2 Causes of Delirium Biological Factors Other Factors Hypoxia Medication side effect Nutritional deficiencies, e.g., iron, B12 Anesthesia reaction Electrolyte imbalances, e.g., calcium Overdose of medication Hypoglycemia/hyperglycemia Substance abuse/withdrawal, e.g., alcohol, Renal failure, hepatic encephalopathy cannabis, opioids, anxiolytics, sedatives Sepsis and other infections including UTI Sensory overload and deprivation Metabolic disorders, e.g., acid-base imbalance Head trauma Medication or anesthesia reaction Hypothyroidism Cardiac insufficiency Primary brain disorders, e.g., brain tumors, Parkinson’s disease Pain

Source: Gorman & Sultan (2008) and Townsend (2012).

■ Dementia 1906 as a form of impairment of brain function (Fig. 16-1). Alzheimer’s disease accounts Dementia is defined as a gradual loss of pre- for 60%–80% of dementias. It is estimated vious levels of cognitive functioning, which that 13% of Americans over 65 years old have can include memory, language, executive this diagnosis and incidence increases with age. functions (includes organizing), and attention The impact on society is a major one as people in a state of being fully alert. In DSM-5 it is are living longer. It is not reversible. Alzheimer’s classified as a major neurocognitive disorder. disease is the sixth leading cause of death in In contrast to delirium, dementia is a slowly the United States. The cause of death is often progressive condition that eventually impacts aspiration pneumonias, infections, and com- all aspects of mental and social functioning. plications from falls, which are all outcomes Primary dementias, including Alzheimer’s disease, are those where the dementia itself is the major cause. Secondary dementia, including vascular and HIV-related, is caused by another disease or condition. Depression is a common disorder in the elderly. Sometimes depression can mimic dementia; in that case, it is referred to as pseudodementia. Depression in the elderly can be confused with dementia with the following symptoms: • Forgetfulness • Little effort to complete responsibilities • Limited communication One differentiation is that the depressed patient generally remains oriented to time and place, unlike the dementia patient.

Alzheimer’s Disease Figure 16-1 Alois Alzheimer (1864–1915) This most common form of dementia was was a German neurologist who ﬁrst identiﬁed initially recognized by Dr. Alois Alzheimer in Alzheimer’s disease in 1906. 2993_Ch16_245-260 14/01/14 5:26 PM Page 248

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of immobility, swallowing disorders, and mal- Box 16-2 Warning Signs of nutrition that are present in late stages of the l disease (Alzheimer’s Association, Alzheimer’s Alzheimer’s Disease Disease 2013 Facts and Figures, 2013). See 1. Asking the same question over and over Box 16-1 for the symptoms of Alzheimer’s again. disease and Box 16-2 for warning signs. 2. Repeating the same story, word for word, again and again. 3. Losing one’s ability to pay bills or balance Tool Box | Review the government’s one’s checkbook. National Plan to Address Alzheimer’s Disease 4. Getting lost in familiar surroundings, or (2012) at misplacing household objects. http://aspe.hhs.gov/daltcp/napa/N atlP lan. 5. Relying on someone else, such as a shtml spouse, to make decisions or answer questions they previously would have handled themselves. In addition to symptom assessment, the 6. Finding it hard to remember things. diagnosis of Alzheimer’s disease is made by 7. Losing things or putting them in odd MRI or PET scan, which can detect physical places. and chemical changes in the brain. The Source: Adapted from National Institute on Aging (2012). Alzheimer's changes seen in the brain include development Disease Fact Sheet. of plaque (chemical deposits made of degen- erating nerve cells and proteins called beta acetylcholine is reduced as well. Some of the amyloid) and tangles (malformed nerve cells). medications that are being used to slow the These plaques and tangles are greatly increased progression of this disease increase the level in someone with this form of dementia. As of acetylcholine. There are genetic markers they increase, they create a toxic environment for some forms of this disease. Research is for normal brain cells. It is known that an ongoing as to the causes of these brain changes enzyme used to produce the neurochemical (Fig. 16-2). A rare form of the disease is genetic and accounts for less than 5% of cases. Other specific causes are still unclear. l Box 16-1 Symptoms of Alzheimer’s The presence of the diagnosis of mild neu- Disease rocognitive disorder (previously called mild cognitive impairment) is a risk factor. Mild • Memory loss that disrupts daily life neurocognitive disorder is a condition in • Challenges in planning or solving problems which a person has mild deficits with mem- (executive functions) ory, language, or another essential cognitive • Difficulty completing familiar tasks at home, ability. The person begins making changes in at work, or at leisure his/her life to compensate for these, and it • Confusion with time or place begins to affect daily living. Mild cognitive • Trouble understanding visual images and spatial relationships disorder is not normal aging. • New problems with words in speaking or Many people fear that forgetfulness is writing a sign of developing Alzheimer’s disease. • Misplacing things and losing the ability to See Table 16-3 for the differences between retrace steps Alzheimer’s disease and normal aging. • Decreased or poor judgment • Withdrawal from work or social activities The Stages of Alzheimer’s Disease • Changes in mood and personality Alzheimer’s disease has been divided into stages. • Agnosia: loss of ability to recognize objects • Agraphia: difficulty writing and drawing STAGE 1: NO IMPAIRMENT • Apraxia: inability to carry out motor activi- (NORMAL FUNCTION) ties despite intact motor function The person does not experience any mem- Source: Adapted from Alzheimer’s Association and Townsend (2012). ory problems. An interview with a medical 2993_Ch16_245-260 14/01/14 5:26 PM Page 249

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l Table 16-3 Differentiating Alzheimer’s Disease From Normal Aging Alzheimer’s Disease Normal Aging Making poor Making a bad decision judgments and once in a while A decisions a lot of the time Problems taking Missing a monthly care of monthly payment bills Losing track of the Forgetting which day date or time of it is and remembering year it later Trouble having a Sometimes forgetting conversation which word to use B Misplacing things Losing things from often and being time to time Extreme Shrinkage of Severely unable to ﬁnd Cerebral Cortex Enlarged them Ventricles Source: The National Institute on Aging. Retrieved from www.nia. nih.gov/alzheimers/publication/understanding-alzheimers- disease/what-are-signs-alzheimers-disease

symptoms of dementia can be detected during a medical examination or by friends, family, Extreme or coworkers. Shrinkage of C Hippocampus STAGE 3: MILD COGNITIVE DECLINE (EARLY-STAGE ALZHEIMER’S CAN BE Figure 16-2 Changes in the Alzheimer’s DIAGNOSED IN SOME BUT NOT ALL brain. A. Metabolic activity in a normal brain. INDIVIDUALS WITH THESE SYMPTOMS) B. Diminished metabolic activity in Alzheimer’s diseased brain. C. Late-stage Alzheimer’s disease Friends, family, or coworkers begin to notice with generalized atrophy and enlargement of difficulties. During a detailed medical inter- the ventricles. (Source: Alzheimer’s Disease Education view, doctors may be able to detect problems & Referral Center, A Service of the National Institute in memory or concentration. Common stage on Aging.) 3 difficulties include: • Noticeable problems coming up with the professional does not show any evidence of right word or name symptoms of dementia. • Trouble remembering names when introduced to new people STAGE 2: VERY MILD COGNITIVE • Having noticeably greater difficulty per- DECLINE (MAY BE NORMAL AGE- forming tasks in social or work settings RELATED CHANGES OR EARLIEST SIGNS • Forgetting material that one has just OF ALZHEIMER’S DISEASE) read The person may feel as if he or she is having • Losing or misplacing a valuable object memory lapses—forgetting familiar words • Increasing trouble with planning or or the location of everyday objects. But no organizing 2993_Ch16_245-260 14/01/14 5:26 PM Page 250

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STAGE 4: MODERATE COGNITIVE • Remember their own name but have DECLINE (MILD OR EARLY-STAGE difficulty with their personal history ALZHEIMER’S DISEASE) • Distinguish familiar and unfamiliar faces At this point, a careful medical interview but have trouble remembering the name should be able to detect clear-cut symptoms of a spouse or caregiver in several areas: • Need help dressing properly and may, without supervision, make mistakes such • Forgetfulness of recent events as putting pajamas over daytime clothes • Impaired ability to perform challenging or shoes on the wrong feet mental arithmetic—for example, counting • Experience major changes in sleep backward from 100 by 7s patterns—sleeping during the day and • Greater difficulty performing complex becoming restless at night tasks, such as planning dinner for guests, • Need help handling details of toileting paying bills, or managing finances (for example, flushing the toilet, wiping • Forgetfulness about one’s own personal or disposing of tissue properly) history • Have increasingly frequent trouble • Becoming moody or withdrawn, espe- controlling their bladder or bowels cially in socially or mentally challenging • Experience major personality and behav- situations ioral changes, including suspiciousness and delusions (such as believing that their STAGE 5: MODERATELY SEVERE caregiver is an impostor) or compulsive, COGNITIVE DECLINE (MODERATE OR repetitive behavior like hand-wringing or MID-STAGE ALZHEIMER’S DISEASE) tissue shredding Gaps in memory and thinking are noticeable, • Tend to wander or become lost and individuals begin to need help with day- to-day activities. At this stage, those with STAGE 7: VERY SEVERE COGNITIVE Alzheimer’s may: DECLINE (SEVERE OR LATE-STAGE ALZHEIMER’S DISEASE) • Be unable to recall their own address or telephone number, or the high school or In the final stage of this disease, individuals college from which they graduated lose the ability to respond to their environ- • Become confused about where they are or ment, to carry on a conversation, and, even- what day it is tually, to control movement. They may still • Have trouble with less challenging mental say words or phrases. At this stage, individuals arithmetic; e.g., counting backward from need help with much of their daily personal 40 by subtracting 4s or from 20 by 2s care, including eating or using the toilet. They • Need help choosing proper clothing for may also lose the ability to smile, to sit with- the season or the occasion out support, and to hold their head up. Re- • Still remember significant details about flexes become abnormal. Muscles grow rigid. themselves and their family Swallowing is impaired. • Still require no assistance with eating or (Reprinted with permission, Alzheimer’s using the toilet Association.) Neeb’s Alzheimer’s disease is a progressive STAGE 6: SEVERE COGNITIVE DECLINE ■ illness that will eventually lead to (MODERATELY SEVERE OR MID-STAGE Tip the patient’s death. The nurse should ALZHEIMER’S DISEASE) be aware of signs of late-stage Memory continues to worsen, personality Alzheimer’s disease (Stage 7) when changes may take place, and individuals need hospice care may be an appropriate extensive help with daily activities. At this referral. Signs such as bedbound, stage, individuals may: incontinent, multiple infections, aspi- • Lose awareness of recent experiences as rations can indicate the patient is well as of their surroundings appropriate for hospice care. 2993_Ch16_245-260 14/01/14 5:26 PM Page 251

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■ ■ ■ Classroom Activity • View and discuss recent movies that address dementia, including Iron Lady, The Savages, and The Notebook.

Tool Box | The mini-mental state exam (MMSE) is a widely used test of cognitive function. It is a 30-point questionnaire used extensively with dementia patients to track changes over time. Available online at http://en.wikipedia.org/wiki/M ini% E 2% 8 0% Figure 16-3 Alzheimer’s disease makes a tremen- 9 3mental_ state_ ex amination. dous impact on the family.

Treatment of Alzheimer’s Disease Neeb’s People with early-stage Alzheimer’s No treatment is available to stop the deteri- ■ Tip disease should be encouraged to oration of brain cells in Alzheimer’s disease. complete an advance directive so The U.S. Food and Drug Administration they can document their wishes for (FDA) has currently approved ﬁve drugs that care and treatment as the disease temporarily slow worsening of symptoms for progresses. about 6 to 12 months (see the Pharmacology Corner). However, researchers around the world are studying numerous treatment strategies that may have the potential to Pharmacology Corner change the course of the disease. Approxi- mately 75 to 100 experimental therapies Cholinesterase inhibitors are the class of aimed at slowing or stopping the progres- medications used in treatment of early to sion of Alzheimer’s are in clinical testing in moderate Alzheimer’s disease. They are ef- human volunteers (Alzheimer’s Association, fective for only about half of the individuals Alzheimer’s Disease 2013 Facts and Figures, who take them. These drugs act by inhibit- 2013). ing acetylcholinesterase, which increases the In addition to the medications, supportive concentrations of acetylcholine in the brain. care, maintaining safety, prevention of infec- They have been found to slow the process of tions, and caregiver support are the major dementia in some people but not control it. interventions. Once diagnosed, the patient Another medication, memantine, is used in and his/her family need to develop a plan to moderate to severe Alzheimer’s disease. It provide care as the disease progresses. This is works as a receptor antagonist of N-methyl- important in the early stages so the patient D-aspartate (NMDA) and has been shown can participate in decisions about future care to slow down progression of cognitive de- while he/she still can. For example, identify- cline and daily functioning in some patients ing options for home caregivers or facilities in with more advanced disease. The two types the area based on the patient’s wishes can be of drugs may be given together in some documented early on. Family members of cases. See Table 16-4 for the cholinesterase Alzheimer’s patients need to be prepared for inhibitors used to treat Alzheimer’s demen- what to expect as it progresses (Fig. 16-3). tia. Early treatment with these medications with mild neurocognitive disorder may be helpful. ■ ■ ■ Clinical Activity When extreme agitation requires the use If your patient has dementia, talk with patient’s of antipsychotic medications in dementia family about how they are coping. Continued 2993_Ch16_245-260 14/01/14 5:26 PM Page 252

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Pharmacology Corner— Neeb’s It can be challenging to give oral ■ Tip medications to dementia patients. cont’d An effective strategy is to crush the patients, it must be recognized that the pills and put them in sweet foods FDA has ordered black-box warnings on like pudding. atypical antipsychotics due to increased risk of death in the elderly with psychotic be- Neeb’s Close monitoring of side effects haviors associated with dementia. These ■ Tip of all medications can be challeng- deaths were cardiovascular related. In 2008 ing as the patient may not be able all typical antipsychotics were added to this to tell you what he/she is experi- warning. Therefore close monitoring is encing e.g., dry mouth, itching, required when any of these medications constipation. are used. This presents a dilemma to the clinician. These medications can control behavior and promote safety, but there is a ■ ■ ■ Critical Thinking Question risk for untoward effects. Generally, the Your 72-year-old patient with advanced dementia adage “start low and go slow” when using has been screaming all night, calling for her mother. All attempts to console her are ineffective. any medications in this population is Every time someone walks by her room, her particularly true. screaming increases. You have orders for several Other medications to treat depression, medications to control agitation, including anxiety, and insomnia may be utilized. Be- haloperidol and lorazepam. Before administering cause depression and anxiety are especially one of these, what should you consider? common if the person is aware of the decline, these medications can be very helpful. Be aware that paradoxical reactions (drug ■ ■ ■ Clinical Activity has opposite effect than what it is intended Monitor side effects of any medications your for) sometimes occur in the elderly with patient is taking. Your observation is most impor- anti-anxiety medications. tant as your patient may not be able to verbalize about symptoms. Managing anxiety with these medications can be useful to reduce the patient’s suffering and disruptive behaviors. Other Forms of Dementia The second most common form of dementia is vascular and is caused by small strokes l Table 16-4 Cholinesterase which over time result in interruption of Inhibitors blood flow to the brain. Vascular dementia is sometimes referred to as multi-infarct de- Cholinesterase mentia. Progression of this form of dementia Inhibitor Side Effects can vary from Alzheimer’s disease depending Tacrine (Cognex) Dizziness, headache, on the occurrence of vascular events, i.e., GI upset progression of dementia occurs with each Donepezil (Aricept) Insomnia, dizziness, new stroke. So an individual with vascular headache, GI upset dementia can remain stable for longer peri- Rivastigmine Dizziness, headache, ods if there are no new strokes. There are a (Excelon) fatigue number of other forms of dementia includ- Galantamine Dizziness, headache, ing dementia associated with Parkinson’s (Razadyne) GI upset disease, Lewy bodies, substance abuse, HIV, and traumatic brain injury among others. Source: Adapted from Townsend (2012): Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. These dementias can also exist in the mild Philadelphia: F.A. Davis Company, with permission. neurocognitive disorder forms as in mild 2993_Ch16_245-260 14/01/14 5:26 PM Page 253

CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 253 neurocognitive disorder due to HIV infec- ■ Nursing Care of Patients tion as an example. Each of these forms of dementia has its own unique components With Delirium and in addition to core diagnostic features of Dementia dementia. Common nursing diagnoses in patients Differential Diagnosis of with delirium and dementia include the Delirium and Dementia following: A new patient presenting with confusion and • Anxiety agitation can sometimes be misdiagnosed. • Injury, risk for Symptoms of delirium and dementia can • Memory, impaired seem similar, especially on ﬁrst meeting a • Self-care deﬁcit patient. See Table 16-5 and Box 16-3 to dif- • Sensory perception, disturbed ferentiate between delirium and dementia • Sleep pattern, disturbed and common factors leading to misdiagnosis. • Thought processes, disturbed

l Table 16-5 Characteristics of Delirium and Dementia Delirium Dementia • Fluctuating levels of awareness and • Slow, insidious onset with less ﬂuctuation of symptoms symptoms • Sudden onset • Deterioration of cognitive abilities • Clouding of consciousness • Impaired long- and short-term memory • Perceptual disturbances (hallucinations, (memory impairment always present) illusions) • Personality changes • Memory disturbance, more often for • May focus on one thing for a long time recent events • Often irreversible • Highly distractible • Reversibility possible with treatment

Source: Adapted from Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.

l Box 16-3 Factors That Contribute to Misdiagnosis in Dementia and Delirium • Some symptoms of dementia and delirium are similar. • Several causes may occur simultaneously to bring about dementia. • Delirium occurring in a patient with a dementia can exacerbate already existing symptoms. • Health-care personnel may harbor unfounded beliefs that serious memory deficits, confusion, and other progressive intellectual deficits are a normal part of the aging process. • Health-care personnel may harbor unfounded beliefs that confusion always indicates Alzheimer’s disease in an older patient. • Confusion and behavioral changes may be the first signs of medical illness in the elderly. • Head injuries and other conditions causing brain tissue trauma may present with symptoms similar to those of dementia. • Confusion is an adverse reaction to many medications.

Source : Gorman, L., Raines, M., & Sultan, D. (1989): Psychosocial Nursing for the Nonpsychiatric Nurse. Philadelphia: F.A. Davis Company. Table 8.1, page 131. 2993_Ch16_245-260 14/01/14 5:26 PM Page 254

254 UNIT 2 | Threats to Mental Health General Nursing Interventions 4. Use clear, simple verbal communication: Sensory overload is a common experi- The nursing interventions for patients with ence for patients experiencing delirium either or both of these diagnoses are based and dementia. To avoid a behavioral on the patient’s symptoms. “short circuit,” it is a good idea to use 1. Collect data: Collect information on vital simple communication and activity in signs, medications used by the patient, the room. Keep the area quiet. Keep circumstances immediately preceding curtains drawn or partially open; keep symptoms, and any other information televisions and radios off or at a very the patient or person who may be ac- low volume. The stimulation can be companying the individual can provide. adjusted according to the patient’s Note anything that is considered to be a tolerance. Focus on one task at a time. change in the patient’s condition. Ques- Do not give the patient two to three tion family/caregivers on interventions instructions at the same time. that have been useful in the past. 5. Allow time for patient to respond: The 2. Stay calm: Be ready for anything. Patients ability to function cognitively and with symptoms of delirium and/or physically is diminished when a person dementia can be very changeable. No is in delirium or dementia. Nurses and matter what the situation, nurses must other health-care workers must remem- diffuse the situation calmly and return ber to plan to allow more time for per- the situation to safety. It is very impor- forming care. Patience is an important tant to make every attempt to maintain intervention. This can be frustrating the patient’s dignity during periods of ex- for caregivers, but by following this citability. Due to memory deficits, these plan the patient will have more oppor- patients can exhibit impulsive behaviors tunities to remain independent and and labile emotions as they forget the reduce his/her anxiety. This will make context of the situation. The nurse re- the nurse’s job easier with better maining calm will reinforce maintaining outcomes. a calm environment. 6. Use touch when appropriate: It is impossible not to touch this group of Neeb’s A patient with early to moderate patients. There is a danger for misinter- ■ Tip dementia may suffer intense anxiety pretation of that touch, however. Peo- due to confusion and awareness of ple who have a threat to their ability losing his/her memory. This can be to process and understand information the cause of agitation and paranoia. may not remember the situation as it actually happened. They may have forgotten the episode of incontinence and 3. Do not argue: Patients with dementia not understand why “that nurse had and/or delirium have cognitive impair- to touch me there!” Having a second ment. They do not have the capacity to person—another nurse or a family make rational decisions during the agi- member—in the room can be a helpful tated episode. Attempting to model the protection for both the nurse and the desired behavior or simply waiting a few patient. Documenting all actions and minutes and attempting the verbal inpatient responses very carefully is also struction again may prove to be successful necessary. techniques. These patients may no longer 7. Wandering: Patients in a state of delir- have the filters to control their behavior ium or dementia may wander. This is or act in a socially acceptable manner. a major safety risk that frequently Distraction can be helpful in some cases. encourages nurses to request restraint Be aware that patients may use disruptive orders from the physician. Restraints behaviors such as swearing, insulting should only be used as last resort others as a way to express frustration. when alternative interventions are 2993_Ch16_245-260 14/01/14 5:26 PM Page 255

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unsuccessful. Interventions to use ear- maintain the patient’s dignity and allow lier include: him or her to do as much independ- • Providing a safe environment where ently as able. the patient can walk or pace 9. Provide adequate stimulation: It is as • Distracting patient to other activities detrimental to understimulate people • Putting up large signs in the area re- with cognitive disorders as it is to over- minding patient of his room or areas load them. The brain needs some en- off limits couragement to activate. This will be a • Using alarms on the patient or to off- “trial-and-error” situation between the limit areas (e.g., exit door to stairwell) nurse and the patient, and it will be • Engaging family and volunteers to different for every patient. Some success closely watch the patient’s movements has been made with music, pets, art, When the physician has ordered re- and physical therapies. straints, the nursing responsibilities include 10. Maintain appropriate milieu: People liv- careful observation and documentation of ing with irreversible, progressive demen- alternative interventions that have been tia require special attention to the milieu. tried. Physical restraints are defined as any Acceptance is mandatory. In dementia, physical method of restricting an individ- nurses should not emphasize “reality ual’s freedom of movement, activity, or nor- orientation” such as repeated attempts mal access to his/her body and cannot be to ask or remind patient of his name, the easily removed. For physical restraints, each year, and current location—especially in state has guidelines for how often to check, later stages of the disease. Changes in the release, and reposition or exercise the pa- brain will not allow the memory to func- tient. Assessing for signs of dermal ulcers tion successfully and may, in fact, cause and stiffness of muscles helps to maintain the patient to experience frustration, feel skin integrity and full range of motion. agitation, and increase acting-out behav- Chemical restraints are defined as the use iors if “reality orientation” is emphasized. of a medication as a restriction to manage Reality orientation may be helpful in the patient’s behavior or restrict the patient’s delirium and early stages of dementia freedom of movement, and are not a stan- where the patient gains a sense of com- dard treatment or dosage for the patient’s fort from being reoriented, but with condition. Again, each state may have short-term memory gaps this may be guidelines on the use of chemical restraints. helpful only for a brief time. For chemical restraints, the nurse must doc- Having old photos of the patient ument the effect of the medication and any or familiar smells such as perfume or possible side effects. Many medications favorite foods in the environment can have side effects, such as confusion, restless- have a reassuring effect. Many dementia ness, and forgetfulness, and may be coun- facilities ask families to bring in special terproductive for people with delirium and personal items such as photos or memen- dementia. Medications should not be used tos that can be housed in a “memory as a substitute for appropriate activities, box” in the patient’s room to provide a programming, and personal interaction. calming influence from familiar items. 8. Assist with ADLs as appropriate to the situ- 11. Emotional support: The patient often ex- ation: The nurse will be doing as much periences anxiety as he/she realizes loss of for the patient physically as the individ- mental abilities. The person can become ual condition requires. For temporary panicky when disoriented. A consistent, delirium and early stages of dementia, calm environment is important. Patients the nurse may only have to use some ver- can also suffer from depression, especially bal cues as to what the patient needs to in early stages when the full impact of do. For deeper delirium and later stages the progressive disease is made. Family of dementia, performing total care for caregivers also need much support as the patient may be necessary. Always caring for this patient is exhausting. They 2993_Ch16_245-260 14/01/14 5:26 PM Page 256

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often need assistance in identifying Neeb’s Family members must be provided support groups and resources for addi- ■ Tip information on being a caregiver tional caregivers and facilities. and how to cope with the long- See Table 16-6 for the nursing care plan of term emotional strain. confused patients. Tool Box | The 36-Hour Day: A Family Guide to Caring for Persons With Alzheimer Cultural Considerations Disease, Related Dementing Illnesses, and Memory Loss in Later Life (3rd Edition) by The type of care the family wants for the Mace and Rabin is a must read for family dementia patient will be influenced by caregivers. culture. In some cultures the family will maintain the patient in the home no matter how difficult the care. Incorporating Neeb’s Review agency policies on use of important cultural values in the discharge ■ Tip restraints. Be aware of alternatives plan is essential. to restraints that are useful with the Language barriers can also add to com- patient. plications in understanding the dementia patient’s needs, especially if the patient is in ■ ■ ■ Classroom Activity a facility. It is important for these patients • Arrange a visit to a local dementia facility. Inter- to have access to people who speak the view the staff to learn how they do this work same language and have similar cultural ex- every day. periences to enhance reality orientation and • Identify local resources such as support groups correctly assess cognitive function. or adult day care for people with dementia.

l Table 16-6 Nursing Care Plan of the Confused Patient Nursing Data Collection Diagnosis Goal Interventions Evaluation Confused as to Disturbance Reduced • Encourage family to Patients will time, place in sensory episodes of provide familiar items have periods Becomes perception agitation in patient’s room, e.g., of calmness. agitated when old photos, mementos. eﬀorts made to • Place a large sign on reorient patient door to identify patient’s room, bathroom. • Spend time with patient to reminisce about an important event in the past. • Play music or TV shows that are meaningful from patient’s past. • Judge whether reorient- ing patient regularly is eﬀective. If it increases agitation, then avoid this. • Distract the patient with concrete activities like sorting papers of the same color. 2993_Ch16_245-260 14/01/14 5:26 PM Page 257

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■ ■ ■ Critical Thinking Question 3. Alzheimer’s disease is by far the most In report you are told that your 90-year-old patient common form of dementia. with moderate dementia has been awake all night, pacing the floor. In the morning you find him sound 4. Alzheimer’s disease is a terminal illness asleep at 10 a.m. What should be your plan for the which has a tremendous impact on the day shift? patient’s family and society. The next day, this patient is very agitated and repeatedly insists on walking out the unit door. The 5. Other causes of dementia include MD leaves an order for soft restraints to prevent vascular insufficiency, substance abuse, wandering. Before applying these, what interven- and Parkinson’s disease. tions should you try? 6. Medications such as anti-anxiety and antipsychotics often have a side effect of ■ ■ ■ confusion and should be chosen carefully Key Concepts in people with dementia. Medications 1. Delirium is a frequent diagnosis in the are chosen to treat specific behaviors; acute hospital setting due to complex they are not a substitute for more direct medical conditions, medication side interventions. effects, and sensory overload. 7. Care of the dementia patient should 2. Delirium is usually reversible once the focus on maintenance of safety, preven- cause is identified; dementia is usually tion of infection, and family support. irreversible.

CASE STUDY Mrs. G is 84-year-old widow who lives her refrigerator and sees very little food. He alone. She has episodes of anxiety and asks her what she eats, and she says “yogurt.” paranoia in her apartment. She calls her She cannot think of anything else. She re- son at odd hours, telling him that a neigh- ports fear of using the stove so she only bor is spying on her. Despite these episodes eats cold foods. He looks at her mail and she seems to function normally and is able notices a past due notice on her water bill. to care for herself. Her son reports that her She says she is sure she paid that. He is get- memory seems to be getting poorer, and ting concerned and takes her to a geriatric he notices that she leaves notes to herself physician for an evaluation. Mrs. G has around the apartment reminding her to been a widow for 2 years. lock the door, brush her teeth, or water the The physician does a complete assessment plants. He also notices that she looks as in the oﬃce and orders an MRI. A diagnosis though she has lost weight recently, though of early to moderate stage Alzheimer’s disease she tells him she is eating well. He looks in is made.

1. What actions would you suggest the patient and her son institute at this time? 2. How would you diﬀerentiate between dementia and depression? 3. What safety measures need to be implemented? 2993_Ch16_245-260 14/01/14 5:26 PM Page 258

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REFERENCES nih.gov/alzheimers/publication/alzheimers- disease-fact-sheet Alzheimer’s Association. (2013). Alzheimer’s Dis- Rabins, P., et al. (2007). Practice Guidelines for ease 2013 Facts and Figures (Vol. 2). Chicago: Alzheimer’s Association. www.alz.org/ the Treatment of Patients With Alzheimer’s Dis- 2nd alzheimers_disease_facts_and_ﬁgures.asp ease and Other Dementias in Late-Life. ed. Retrieved from http://psychiatryonline.org/ Alzheimer’s Association. Stages of Alzheimers guidelines.aspx disease. Retrieved from alz.org/alzheimers_ Stanley. M., Blair, K.A., and Beare, P.G. (2005). disease_stages_of_alzheimers.asp Gerontological Nursing: Promoting Successful American Psychiatric Association. (2000). Dia - Aging With Older Adults. 3rd ed. Philadelphia: gnostic and Statistical Manual of Mental Dis - F.A. Davis. Washington DC, orders IV-Text Revision. Townsend, M.C. (2012). Author. (Known as DSM-IV-TR) Psychiatric Mental Health Nursing. 7th ed. Philadelphia: F.A. Davis. American Psychiatric Association. (2013). Dia - gnostic and Statistical Manual of Mental Dis - orders 5. Washington, DC, Author. (Known WEB SITES as DSM-5) The Alzheimer’s Association has chapters Forrest, J., Willis, L., and Holm, K. (2007). throughout the country and provides many re- Recognizing quiet delirium. American Journal sources and local support groups for caregivers. Nursing, 107(4), 35–39. http://www.alz.org Gorman, L., Raines, M., and Sultan, D. (1989). National Institute on Aging, Alzheimer’s Psychosocial Nursing for the Nonpsychiatric Disease Education and Referral Center Nurse. Philadelphia: F.A. Davis. http://www.nia.nih.gov/alzheimers/publication/ Gorman, L., & Sultan, D. (2008). Psychosocial alzheimers-disease-fact-sheet Nursing for General Patient Care. 3rd ed. Psychiatry online guidelines for dementia Philadelphia: F.A. Davis. http://psychiatryonline.org/content.aspx?bookid=28& National Institute on Aging. (2012). Alzheimer’s sectionid=1679489 Disease fact sheet. Retrieved from www.nia. 2993_Ch16_245-260 14/01/14 5:26 PM Page 259

CHAPTER 16 | Neurocognitive Disorders: Delirium and Dementia 259 Test Questions Multiple Choice Questions 1. You are working the night shift in your 4. Donepezil (Aricept) is a medication surgical unit. Ms. Y, one day postopera- approved for the treatment of symptoms tive for total hip replacement, is taking of Alzheimer’s-type dementia. Nurses several medications for pain, along with must be alert to which of the following an antibiotic. She is 70 years old and side eﬀects? presented as alert and oriented prior to a. Tachycardia surgery. She lives independently. Ms. Y b. Insomnia suddenly begins screaming and thrashing c. Mania in bed, begging you to “Get the spiders d. Weight gain out of my bed!” What is the best explana- 5. Which statement is not true about tion for Ms. Y’s behavior? Alzheimer’s disease? a. Delusions a. It is a dementia disorder. b. Delirium b. It may occur in middle to late life. c. Dementia c. It is a chronic disease. d. Sepsis d. It is caused by hardening of the arteries. 2. The best nursing intervention for you, the 6. Which of the following would you expect LPN/LVN, to help Ms. Y is: to see in a patient who is diagnosed with a. Inform the charge nurse and doctor neurocognitive disorder? immediately. a. Intact memory b. Turn on the light and ask her where b. Appropriate behavior the spiders are. c. Disorganization of thought c. Stop her pain medications. d. Orientation to person, place, and time d. Check her medical record for a diagnosis of mental illness. 7. Ms. P has been admitted to your unit with a diagnosis of right tibial fracture. 3. Mr. H has been admitted to your nursing Her emergency department notes say that home in Stage 6 Alzheimer’s disease. His she fell at home. She admits to having “a wife is crying and says to you, “Nurse, lot to drink” over the past week. She is when will he get better? I don’t know disoriented to time, forgets where she is what I will do without him home. Why momentarily, is easily distracted, and has can’t the doctor ﬁx him?” Your best re- a short attention span. She does not an- sponse to Mrs. H is: swer questions appropriately. Her family a. “Hopefully with time he will improve.” reports that her behavior has been more b. “Maybe you should stop visiting for a and more erratic over the past 6 months few days and then you’ll feel better.” with periods of confusion. Her son re- c. “You sound really worried. Tell me ports she has been a heavy drinker all her what the doctor has told you about his life. She is probably experiencing: condition.” a. Delusions d. “Mrs. H, your doctor has explained b. Delirium that Mr. H will not get better. You c. Dementia need to make a plan for the future.” d. Dilemma 2993_Ch16_245-260 14/01/14 5:26 PM Page 260

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Test Questions cont. 8. Your patient, who is recovering from an 9. Mr. F is brought in by a family member exacerbation of an AIDS-related infec- who expresses concern over his memory tion, is opting to be treated by family and loss. The physician diagnosed the patient friends at home. The family has expressed with vascular dementia (multi-infarct concern because they sense a change in dementia). You realize this disorder: the patient’s cognitive abilities. Part of the a. Is irreversible discharge teaching for this family might b. May progress rapidly or slowly include: c. Indicates the patient has most likely a. “It’s nothing, really. Patients sometimes experienced more than one CVA get confused in the hospital.” d. All of the above b. “Keep an eye on him. You don’t want 10. The use of reality orienting techniques is him to start wandering.” usually helpful with which patient? c. “You’re concerned about the change a. Patient in Stage 7 Alzheimer’s disease in his ability to remember things? Let b. Patient with advanced vascular dementia me call the doctor for you. This is c. Elderly patient who is confused and something that you need to discuss screaming out for her mother together.” d. Patient who is recovering from delir- d. “I thought something was strange!” ium and seems more relaxed when reminded of where she is 2993_Ch17_261-286 14/01/14 5:26 PM Page 261

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Learning Objectives Key Terms 1. Describe substance use disorder and how it impacts society. • Addiction 2. Define co-dependency. • Alcohol abuse 3. Define co-occurring disorders. • Alcohol dependence 4. Identify common medical treatments for addictive disorders. • Alcoholism 5. Identify nursing interventions for patients with addictive • Binge drinking disorders. • Co-dependency • Co-occurring disorder • Detoxification • Dysfunctional • Psychoactive drugs • Substance abuse • Substance dependence • Tolerance • Withdrawal

ind- or mood-altering substances recent years its use has become much less ac- have been used throughout human ceptable in U.S. society (Fig. 17-1). Mhistory. Today these include alco- Substance abuse is a major health problem hol, sedatives/hypnotics, narcotic analgesics, in the United States. Overall 14.6% of stimulants, hallucinogens, and cannabis as the population has had a substance abuse dis- well as psychoactive drugs. Most of these order at some time in their lives (Kessler, categories of substances can be and are used Berglund et al., 2005). Substance abuse con- legally and therapeutically. They all have tributes to higher health-care costs, signiﬁcant the strong potential to be abused and to disability, and suicide attempts (Cook & become addictive. These substances taken in Alegría, 2011). The National Survey on Drug excess activate the brain’s reward system and Abuse and Health conducts an annual survey can lead to neglecting normal activities in of Americans’ use of alcohol and other sub- favor of seeking out this substance again and stances and provides the following data from again. 2011. People use these substances for a variety of reasons: to relieve physical and emotional • 8.7% of Americans age 12 or older were pain, relax, elevate mood, enhance socializa- current (past month) illicit drug users, tion, improve alertness, and alter perceptions meaning they had used an illicit drug of reality. Alcohol and caﬀeine are probably during the month prior to the survey in- the most used socially acceptable substances. terview. Illicit drugs include marijuana/ Tobacco was also part of that group, but in hashish, cocaine (including crack), 261 2993_Ch17_261-286 14/01/14 5:26 PM Page 262

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Generally, substance use becomes a problem when it: 1. Interferes with normal functioning 2. Continues despite negative consequences 3. Hurts others Substance abuse and substance depen - dence have been traditionally separated as two distinct diagnoses. Because these two desig- nations are sometimes confusing and difficult to differentiate, the DSM-5 (2013) has combined abuse and dependence into substance use disorder with a graded clinical severity of mild, moderate, and severe. In addition to substance use disorder, there are diagnostic categories for substance-induced intoxication and withdrawal. Each category has specific criteria to be met to be given the diagnosis for each substance. At least two criteria are required to make a diagnosis for a particular substance use disorder. However because the Figure 17-1 As this poster says, nicotine is an addiction, and it can be the most difficult one terms “abuse” and “dependence” are so com- to overcome. (Courtesy of the National Institute mon in today’s culture, they will still be used on Drug Addiction, National Institutes of Health, throughout this chapter along with substance Bethesda, MD.) use disorder. People with psychiatric disorders com- heroin, methamphetamines, hallucino- monly abuse many drugs and alcohol as a way gens, inhalants, or prescription-type to self-medicate to reduce feelings of anxiety, in- psychotherapeutics used nonmedically; somnia, depression, loneliness, rapid thoughts, marijuana remains the most widely used frightening hallucinations, and other distressing illegal drug. symptoms. Commonly referred to as a co- • An estimated 20.6 million persons (8% occurring disorder (also called dual diagnosis), of the population age 12 or older) were this form of substance use disorder adds classified with substance dependence or additional complications to the psychiatric abuse in the past year based on criteria diagnosis in terms of daily management, treat- specified in the Diagnostic and Statistical ment, and recovery. Co-occurring disorders are Manual of Mental Disorders, 4th edition the rule rather than exception when working (DSM-IV-TR). with a patient with a psychiatric disorder. • Of these, 2.6 million were classified with Co-occurring disorders can start with self- dependence or abuse of both alcohol and medicating to treat symptoms of a psychiatric illicit drugs, 3.9 million had dependence diagnosis, or substance abuse can be the initial or abuse of illicit drugs but not alcohol, diagnosis that leads to other psychiatric disor- and 14.1 million had dependence or ders as a complication. See Figures 17-2 and abuse of alcohol but not illicit drugs. 17-3 on pages 263 and 264. Outcomes for treatment are more effective when the substance use treatment is integrated into the treat- Tool Box | National Survey on Drug Use ment for the psychiatric disorder (Clark, 2012). and Health: Summary of National Findings: Health-care professionals are not immune www.samhsa.gov/data/N SD U H /2k11R esults/ to problems with alcohol and drugs. In fact, NS D U H results2011.pdf they tend to abuse alcohol or prescribed drugs. Since they do not fit the image of a 2993_Ch17_261-286 14/01/14 5:26 PM Page 263

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■ ■ ■ Critical Thinking Question You are working in an outpatient mental health Cultural Considerations clinic. A new patient with a long history of schizo- Substance abuse crosses all cultures and phrenia tells you he needs to leave the clinic for an hour to meet someone who gives him “special ethnic groups. Some groups are known to medicines” that he calls herbs to help him sleep. have a higher incidence that may reflect What concerns would you have? What action genetic risk and/or cultural patterns. For would you take? example, Native Americans have a high rate of alcoholism. Genetic factors that predispose them to poor metabolism of Neeb’s All psychiatric patients should alcohol as well as other factors such as ■ Tip be screened for substance abuse unemployment and poverty are contribu- disorders. tors. Asians have a lower rate of substance abuse. Genetic intolerance for alcohol substance abuser, it can be easier for health- creating an unpleasant sensation may care professionals to deny the problem. Many be a factor in the lower incidence of states have developed drug diversion pro- alcoholism (Townsend, 2012). grams to provide confidential treatment and rehabilitation. • The same (or a closely related) substance is taken to relieve or avoid withdrawal ■ ■ ■ Classroom Activity • Movies that address substance abuse include symptoms (e.g., alcohol and tranquilizers Days of Wine and Roses, Lost Weekend, I’m Dancing to sleep) as Fast as I Can, 28 Days, and Flight. • The substance is often taken in larger • Obtain information on how your state addresses amounts or over a longer period than was substance abuse in nurses. intended (analgesics originally used for pain relief then continued when source of pain resolved) Some of the characteristics of progressive • There is a persistent desire or unsuccessful substance use disorder include (American effort to cut down or control substance use Psychiatric Association, 2000, 2013): • A great deal of time is spent in activities • A need for markedly increased amounts of necessary to obtain the substance (e.g., vis- the substance to achieve intoxication or iting multiple doctors or driving long dis- desired effect (tolerance) tances to a source), in use of the substance, • Markedly diminished effect with contin- or to recover from its effects ued use of the same amount of the sub- • Important social, occupational, or recre- stance (tolerance) ational activities are given up or reduced • There is a characteristic withdrawal syn- because of substance use (e.g., quitting drome for the substance school, giving up a favorite sport)

Mental Substance Further disorder abuse decline

Mental Substance disorder such Further abuse as psychosis, decline disorder depression Figure 17-2 Common pathways in co-occurring disorders. 2993_Ch17_261-286 14/01/14 5:26 PM Page 264

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occasions and religious ceremonies. Eight per- Alcoholism Worsening depression cent of Americans are dependent on alcohol at any one time (Kessler, Berglund et al., 2005). It is quickly absorbed in the body with initial effects of intoxication producing relaxation, euphoria, and loss of inhibition. Self– The legal blood level of intoxication is 0.08– Worsening medication 0.10 g/dL in most states (known as blood depression to function alcohol level). Higher levels of alcohol produce the central nervous system depressant qualities that lead to staggering gait, labile Increasing emotions, incoherent speech, poor judgment, alcohol to sleep and belligerent/aggressive behavior, and eventually can lead to coma and respiratory depression in extremely high levels (greater than Figure 17-3 An example of the cycle of decline in co-occurring disorders. 0.4 g/dL). Alcohol content varies with the type of beverage. The same amount of alcohol is present in: • The substance use is continued despite knowledge of having a persistent or recur- • 12 ounces of most beers rent physical or psychological problem • 5 ounces of wine that is likely to have been caused or exac- • 1.5 ounces of 80-proof distilled spirits erbated by the substance (e.g., current such as whiskey or vodka cocaine use despite recognition of cocaine- induced depression, or continued drink- Neeb’s For most adults, low risk alcohol use ing despite recognition that an ulcer was ■ Tip —up to fourteen drinks per week for made worse by alcohol consumption) men and seven drinks per week for • Failure to fulfill major role obligations women and older people—causes at work, school, or home (e.g., repeated few, if any, problems (National Insti- absences or poor work performance re- tute of Alcohol Abuse and Alco- lated to substance use; substance-related holism “Rethinking Drinking”). absences, suspensions, or expulsions from school; neglect of children or household) Alcoholism is defined as a chronic illness • Recurrent substance use in situations in characterized by compulsive and uncontrolled which it is physically hazardous (e.g., consumption of alcoholic beverages usually to driving an automobile or operating a the detriment of the drinker’s health, personal machine when impaired by substance use) relationships, and social standing. Addiction • Recurrent substance-related legal prob- to alcohol has been referred to as alcohol de- lems (e.g., arrests for substance-related pendence, alcohol abuse, and now alcohol disorderly conduct) use disorder. • Continued substance use despite having Given the same amount of alcohol, women persistent or recurrent social or interper- have higher blood alcohol concentrations than sonal problems caused or exacerbated by men, even with size taken into consideration. the effects of the substance (e.g., argu- Differences in fat and body water content lead ments with spouse about consequences of to women being more prone to long-term ef- intoxication, physical fights) fects of heavy alcohol use (Fig. 17-4) (National ■ Institute of Alcohol Abuse and Alcoholism). Alcohol Early signs of serious problems with alcohol use in men and women can include: As the most commonly abused substance worldwide, alcohol is readily available in most • Drinking in secret cultures and is often included in important • Drinking first thing after waking up 2993_Ch17_261-286 14/01/14 5:26 PM Page 265

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Neeb’s Any alcohol use in children and ■ Tip teens is a cause for concern. They may access alcohol from their homes or homes of acquaintances, at parties, or by buying it with fake identification or from older friends. Seeing their parents drinking may give a double message to children or teens who are eager to be grown up. Experimenting with alcohol by adolescents is common, and it is difficult to know which ones will move to a lifetime of struggles with alcohol. A high percentage of adult alcoholics started drinking as teenagers, so any sign Figure 17-4 The use—and abuse—of alcohol of alcohol use by a child or teen occurs in person of all ages, races, and cultural must be addressed and needs backgrounds, and in women as well as men. parental intervention. (Courtesy of the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD.) Impact on the Family • Gulping the first drink • Preoccupation with alcohol Family members and friends often develop • Onset of blackouts (lapses in memory re- protective behaviors, sometimes called co- sulting from persistent heavy drinking) dependency or enabling to control, hide, or deny the alcoholic’s behavior to maintain a In 2011, nearly one-quarter (23.1%) of sense of normalcy for the family. These can persons aged 12 or older participated in binge include finding excuses for the drinker’s alco- drinking (National Survey on Drug Use and hol use, covering up the drinker’s unacceptable Health by Substance Abuse and Mental behavior, and self-blame for the drinking. Co- Health Services Administration, 2011). Binge dependency may be seen with use of other drinking is defined as having five or more substances besides alcohol. drinks (four drinks for women) on the same Alcoholism is a family disease. More than occasion on at least one day. Binge drinking half of all adults have a family history of can lead to serious health consequences from alcoholism or problem drinking, and one in alcohol poisoning when alcohol reaches toxic four children grow up in a home where some- levels, as well as risky behaviors when under one drinks too much (National Institute of its influence. Alcohol Abuse and Alcoholism).

Neeb’s Binge drinking in college age adults ■ Tip may be seen as a rite of passage for ■ ■ ■ Critical Thinking Question many, but it can lead to serious Your patient is a 16-year-old girl admitted from the ER with moderate injuries from a car accident. damage and even death. Students She was the driver. The other teens in the car were and parents need to be advised of also injured. The patient is awake and tells you the eﬀects of toxic levels of alcohol. that her parents cannot know that she had had a Many colleges now provide speciﬁc “couple of drinks” at a party just prior to driving information to students about the her friends home. How would you respond? Should the parents be told? Does that make you risk of alcohol poisoning from binge an enabler if you choose not to share this? drinking. 2993_Ch17_261-286 14/01/14 5:26 PM Page 266

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Tool Box | Adult Children of Alcoholics Etiology of Alcohol Abuse (ACOA) has support groups for people who Alcoholism runs in families. Biological off- grew up in a dysfunctional family related to spring of alcoholic parents have a significantly alcoholism: greater incidence of alcoholism than offspring www.adultchildren.org/ of non-alcoholic parents. This supports the genetic theories. The genes a person inherits partially explain this pattern, but lifestyle Alcohol’s Impact on Health is also a factor. Currently, researchers are Alcoholism is the third leading cause of working to discover the actual genes that put preventable death in the United States people at risk for alcoholism. The link be- (Kessler, Berglund et al., 2005; Kessler, Demler tween depression and alcoholism also suggests et al., 2005). It can become a chronic medical biological factors. These facts support the illness. Heavy drinking contributes to heart view of alcoholism as a disease. Recent devel- disease, some cancers, liver failure, and stroke opments in medications to treat alcoholism as it affects most organs in the body. It leads demonstrate the role of biological cravings to to more complications in the presence of di- induce a sense of well-being (see Pharmacol- abetes. It also contributes to countless traffic ogy Corner for Alcohol Abuse). Disturbance accidents, falls, domestic violence, suicides, in neural pathways that establish a biological participating in risky activities, industrial craving to induce well-being is one of the the- accidents, and other unsafe activities as judg- ories. Social factors, stress, and how readily ment is impaired. Alcohol abuse is often available alcohol is also are factors that may unrecognized and undertreated in the over increase the risk for alcoholism. Growing up 65 age group. Whether a lifelong pattern or a in a home where alcohol is used as a major new coping mechanism in facing problems, coping mechanism for stress also puts a per- heavy drinking can be confused with demen- son at risk. But, just because alcoholism tends tia, mask depression, and contribute to falls or to run in families does not mean that a child fires in the home. Alcohol can also contribute of an alcoholic parent will automatically be- to adverse reactions to many medications. Fetal come an alcoholic too. Some people develop alcohol syndrome includes physical, mental, alcoholism even though no one in their fam- and/or learning disabilities in a child exposed ily has a drinking problem. to alcohol in utero. Alcohol Withdrawal It is estimated that about 25% of admissions | Tool Box  The National Institute on Alcohol to the acute hospital are alcohol related Abuse and Alcoholism has information on research and the current picture of alcohol use in (National Institute of Alcohol Abuse and the United States. Alcoholism). Nurses will see patients who are http://niaaa.nih.gov/ known alcoholics and those where the diagnosis is not known. Awareness of the signs of alcohol withdrawal is essential for all nurses. Neeb’s Long-term alcohol abuse can con- Signs include: ■ Tip tribute to a form of dementia in • Autonomic hyperactivity (high blood later life. pressure, tachycardia, fever) • Hand tremor Tool Box | Use the CAGE questionnaire • Insomnia as a four-question tool to identify problems • Nausea and/or vomiting with alcohol use. CAGE questionnaire is • Anxiety found at: • Transient visual, tactile, or auditory hallu- http://www.integration.samhsa.gov/clinical- cinations or illusions practice/sbirt/CAG E _ q uestionaire.pdf • Early signs of delirium • Grand mal seizures 2993_Ch17_261-286 14/01/14 5:26 PM Page 267

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Withdrawal symptoms can occur as early ■ ■ ■ Classroom Activity as 8 hours after the last drink in a heavy • Role-play with classmates how to ask patients drinker. Analgesics and recovery from anes- about their alcohol and drug use. thesia can precipitate a withdrawal reaction. It may look like a classic delirium. Screening patients about alcohol use is increasingly ■ ■ ■ Clinical Activity common as part of the routine admission Any patient who indicates a history of problems assessment in the general hospital. with alcohol should be monitored for withdrawal.

Neeb’s The U.S. Preventative Services Task ■ Tip Force (2012) recommends that pri- Tool Box | The Clinical Institute Withdrawal mary care providers screen for alco- Assessment for Alcohol Scale, known popularly hol abuse in all adults and pregnant at CIWA-Ar, is a useful tool used by many women to identify problem drinkers hospitals to monitor patients at risk for with- earlier. drawal syndrome. Available at Sullivan, J. T., et al. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute withdrawal Questions that can be asked routinely on assessment for alcohol scale. British Journal of admission to identify patients at risk for with- Addiction, 84, 1353–7 and at: drawal include: http://ireta.org/sites/ireta.sitesq uad.net/fi les/ CIW A-Ar.pdf. • How often do you drink alcohol? • How much do you usually drink? • When was the last time you used alcohol or any drug? ■ ■ ■ Critical Thinking Question Your 80-year-old patient is two days post-op • Have you had any problems because of recovering from a fractured hip. Until now, her drinking or drug use? recovery has been routine. She calls you to her bedside and looks anxious and tremulous. She tells you that a glass of wine would help make her Neeb’s The routine admission questions more comfortable. What would you do? ■ Tip noted above can also be used to screen for use of other substances. Neeb’s An individual desperate for alcohol Withdrawal symptoms are generally most ■ Tip may take alcohol-based medications intense on the second day of abstinence. The like cough syrup to control withdrawal. physician can order a detoxification regimen that will prevent or reduce the alcohol- induced delirium. Withdrawal from alcohol Treatment of Alcoholism is very uncomfortable but generally not life Perhaps the single most effective treatment for threatening. Generally, withdrawal is managed alcoholism is Alcoholics Anonymous (AA). with longer acting CNS depressants such as AA is a nationwide organization begun in diazepam and chlordiazepoxide, which have 1935 by two alcoholic men who bonded and anticonvulsant actions and are relatively safe. vowed to support each other through recov- These are administered routinely and tapered ery. AA has groups in most communities and down over several days. Fluids, vitamins, and internationally. It is run by alcoholics, but electrolyte replacement are also part of the there is no leader in the group. treatment plan. One of the main tenets of AA is anonymity. Withdrawal can induce an extreme form People identify themselves by first names only. of delirium sometimes referred to as delirium Someone usually starts the topic or introduc- tremens or “DTs,” evidenced by impaired tions or asks an opening question, but the consciousness and memory as well as halluci- group runs itself. It is based on twelve steps, nations and severe tremors. and frequently one step is discussed each 2993_Ch17_261-286 14/01/14 5:27 PM Page 268

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week or on a designated week per month. Tool Box | A Brief Guide to Alcoholics AA meetings are closed—that is, nobody except Anonymous is available at the alcoholics themselves are allowed to attend. http://aa.org/lang/en/catalog.cfm? origpage= There is usually a group that has an open meet- 18 & product= 8 t ing monthly or quarterly. If the meeting is listed as open, any interested person may attend. There are corresponding groups for families ■ ■ ■ Classroom Activity of the alcoholic (Al-Anon) and a special group • Attend an open meeting of Alcoholics Anony- for teenagers (Alateen). Adult Children of Al- mous and identify how the meeting provided coholics (ACoA) is a branch of AA formed for support to the attendees. people who are now adults but grew up in an alcoholic home and were not able to get help at the time. These groups all follow a similar model. One of the slogans of AA is “One Day at a Table 17-1 lists the twelve steps of AA Time.” Members of AA believe that they are (Alcoholics Anonymous, 1981). Other twelve- always in a state of recovery, not that they have step groups serving other dependency needs, recovered. Recovery from alcoholism is a process. including narcotics, cocaine, and gambling, With very few exceptions, an alcoholic who is have modeled themselves after the AA model. recovering cannot ever have another drink, or he or she risks returning to the abusive patterns. Other forms of treatment often include Neeb’s AA is usually a lifetime commitment. family therapy, short-term hospitalization for ■ Tip It is known internationally and the detoxiﬁcation, and individual and group ther- person can reach out to any group apy to learn new coping mechanisms. Life when away from home without alcohol presents many challenges to

l Table 17-1 The Twelve Steps and Twelve Traditions of Alcoholics Anonymous The Twelve Steps of Alcoholics The Twelve Traditions of Alcoholics Anonymous Anonymous 1. We admitted we were powerless over 1. Our common welfare should come first; per- alcohol—that our lives had become sonal recovery depends upon A.A. unity. unmanageable. 2. For our group purpose, there is but one 2. Came to believe that a Power greater than ultimate authority—a loving God as He may ourselves could restore us to sanity. express Himself in our group conscience. Our 3. Made a decision to turn our will and our leaders are but trusted servants; they do not lives over to the care of God as we under- govern. stood Him. 3. The only requirement for A.A. membership 4. Made a searching and fearless moral is a desire to stop drinking. inventory of ourselves. 4. Each group should be autonomous except 5. Admitted to God, to ourselves and to in matters affecting other groups of A.A. as a another human being the exact nature of whole. our wrongs. 5. Each group has but one primary purpose— 6. Were entirely ready to have God remove to carry its message to the alcoholic who still all these defects of character. suffers. 7. Humbly asked Him to remove our short- 6. An A.A. group ought never endorse, finance, comings. or lend the A.A. name to any related facility 8. Made a list of all persons we had harmed or outside enterprise, lest problems of and became willing to make amends to money, property, and prestige divert us from them all. our primary purpose. 2993_Ch17_261-286 14/01/14 5:27 PM Page 269

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l Table 17-1 The Twelve Steps and Twelve Traditions of Alcoholics Anonymous—cont’d The Twelve Steps of Alcoholics The Twelve Traditions of Alcoholics Anonymous Anonymous 9. Made direct amends to such people wher- 7. Every A.A. group ought to be fully self- ever possible, except when to do so supporting, declining outside contributions. would injure them or others. 8. Alcoholics Anonymous should remain 10. Continued to take personal inventory and forever non-professional, but our service when we were wrong promptly admitted it. centers may employ special workers. 11. Sought through prayer and meditation to 9. A.A., as such, ought never be organized; but improve our conscious contact with God, we may create service boards or committees as we understood Him, praying only for directly responsible to those they serve. knowledge of His will for us and the 10. Alcoholics Anonymous has no opinion on power to carry that out. outside issues; hence the A.A. name ought 12. Having had a spiritual awakening as the never be drawn into public controversy. result of these steps, we tried to carry this 11. Our public relations policy is based on message to alcoholics and to practice attraction rather than promotion; we these principles in all our aﬀairs. need always maintain personal anonymity at the level of press, radio, and ﬁlms. 12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

Source: The Twelve Steps and Twelve Traditions are reprinted with permission of Alcoholics Anonymous World Services, Inc. (A.A.W.S.). Permission to reprint the Twelve Steps and Twelve Traditions does not mean that A.A.W.S. has reviewed or approved the contents of this publication, nor that AA agrees with the views expressed herein. AA is a program of recovery from alcoholism only—use of the Twelve Steps and Twelve Traditions in connection with programs and activities that are patterned after AA but address other problems, or in any other non-AA context, does not imply otherwise.

the alcoholic. It can include reorganizing one’s life around different friends and social activities Pharmacology Corner and repairing family relationships. Pharmaco- Three drugs have been approved by the logical therapy is also part of treatment. See Food and Drug Administration to treat Pharmacology Corner under Alcohol. alcoholism. Many other approaches are being researched. ■ ■ ■ Critical Thinking Question 1. Disulfiram (Antabuse) was the first Your friend stopped drinking about one year ago medicine approved for the treatment of after she was in a car accident in which she was driving impaired with her three-year-old in the alcohol abuse and alcohol dependence. car. She has been attending AA regularly. She is It works by causing a severe adverse re- now going through a divorce and tells you she is action when someone taking the med- so stressed and depressed that she has no more ication consumes alcohol. This reaction energy to get to the AA meetings. What would be includes palpitations, nausea and vom- your concerns? How can you help her? iting, severe headache, and shortness of breath with exposure to any alcohol. 2. Naltrexone is sold under the brand ■ ■ ■ Critical Thinking Question names Revia and Depade. An extended- Your 35-year-old patient is being treated for alcohol- release form of naltrexone is marketed related liver disease. He tells you he stopped drinking under the trade name Vivitrol. These last month but is worried about his relationship with his fiancée, who is a heavy drinker. What would be drugs works by blocking the “high” your concerns? What suggestions can you make? that people experience when they drink alcohol or take opioids like Continued 2993_Ch17_261-286 14/01/14 5:27 PM Page 270

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Pharmacology Corner— l Table 17-2 Commonly Used cont’d Medications for Withdrawal heroin and cocaine so it blocks the “reward” when taking a drink or the Management of opioid. Alcohol and Other 3. Acamprosate (Campral) works by reduc- Substances ing the cravings for alcohol for some- Alcohol Withdrawal one who is in recovery. Chlordiazepoxide (Librium) See Table 17-2 for medications com- Diazepam (Valium) monly used to manage withdrawal. Oxazepam (Serax) Nutritional supplements (vitamins, magnesium, thiamine) Anticonvulsants such as carbamazepine, valproic acid Any patient on Antabuse must be Neeb’s Serotonin reuptake inhibitors (SSRIs) such as ■ Tip advised to avoid taking any sub- paroxetine, sertraline to treat anxiety and stance with an alcohol base, includ- depression ing cough syrups and mouthwashes. Opioid Withdrawal The patient should carry information Naltrexone (Revia) so emergency personnel know this Naloxone information. Nalmefene (Revex) Buprenorphine Buprenorphine and naloxone (Suboxone) Clonidine (Catapres) ■ ■ ■ Critical Thinking Question Your 50-year-old patient on Antabuse tells you he Heroin Withdrawal and Maintainence is thinking of having a drink to test his response Methadone hydrochloride (Dolophine) when he goes out on pass. What would you ad- Stimulants vise this patient? What actions should you take Chlordiazepoxide (Librium) after hearing this information? Haloperidol (Haldol)

■ Other Substances methamphetamines has been a problem as are “club drugs,” including ecstasy, ketamine, There are a wide variety of substances that are and rohypnol (Fig. 17-5). Club drugs are abused. See Table 17-3 for a summary of the short-acting benzodiazepines that are slipped effects of commonly abused substances. Signs into an alcoholic drink, causing the unsus- and symptoms of substance use disorders vary pecting victim to become incapacitated and as to the type of drug. Poly-drug use is com- unable to resist a sexual assault. The form of mon and can create a confusing clinical pic- methamphetamine known as crystal meth is ture. The individual may use one drug to produced illegally from ephedrine and creates counteract or enhance the effects of the first a highly addictive stimulant that is usually drug. Drugs are often combined with alcohol. smoked. A new drug referred to as “bath For example, cocaine users commonly use salt” has recently been receiving national at- alcohol to get to sleep or calm down. Many tention. This stimulant can produce a para- drug and alcohol combinations have a syner- noia reaction. gistic effect that can be life threatening. Pat- DSM-5 now categorizes each substance by terns of drug use vary as new substances are substance-induced intoxication and with- discovered. Nurses should be aware of newer drawal disorders. Each disorder has its own drugs that may be used by their patient pop- criteria for diagnosing based on the specific ulation. For example, in some communities substance used. A diagnosis of substance use (Text continued on page 276) 2993_Ch17_261-286 14/01/145:27PMPage271

l Table 17-3 Comparing Commonly Abused Substances Drug Intoxication Overdose Withdrawal Nursing Considerations Amphetamines, Signs: Euphoria, high Signs: Ataxia, high Signs: Depression, agitation, • Crystal meth made from ephedrine including Dexedrine, energy, impaired judg- temperature, seizures, insomnia, confusion, vivid & pseudoephedrine products methamphetamine ment, anxiety, weight hypertension, arrhyth- dreams followed by • Tolerance can develop fairly rapidly (crystal meth) loss, anorexia, increased mias, respiratory distress, extreme lethargy • User often also uses alcohol and libido, aggressive be- cardiovascular collapse, Treatment: Antidepressants, other substances to relax havior, paranoia, panic coma, brain damage, counseling, suicide • May cause a paradoxical reaction disorders, insomnia, and death precautions in children delusions (often seen Treatment: Supportive • May be used initially to lose weight with long-term use) • Crystal meth users prone to dental problems • Withdrawal is difficult and relapse is common • Remains in urine for up to 3 days Cannabis, including Signs: Euphoria; Signs: Extreme paranoia, Signs: Irritability, anxiety, • Most widely used illicit drug marijuana and intensified perceptions; psychosis, delirium insomnia, anorexia, restless- • Impaired judgment may contribute hashish impaired judgment and Treatment: Antipsychotics ness, tremors, fever, to accidents motor ability; increased headache • Respiratory damage from inhaled appetite; weight gain, Treatment: Supportive substances can occur sinusitis, and bronchitis • Legal in some states for medical with chronic use; reasons anxiety, paranoia; red • Remains in urine for up to 7 days conjunctiva • May exacerbate psychiatric symptoms in mentally ill patients • May negatively affect fertility • May therapeutically reduce nausea and vomiting, intraocular pressure, and stimulate appetite Continued 271 2993_Ch17_261-286 14/01/145:27PMPage272

272 l Table 17-3 Comparing Commonly Abused Substances—cont’d Drug Intoxication Overdose Withdrawal Nursing Considerations Cocaine, including Signs: Euphoria, Signs: High temperature, Signs: Fatigue, vivid dreams, • Crack is smoked or injected IV; crack grandiosity, sexual pupil dilation, tachycardia, depression, anxiety, suicidal has a rapid onset and high excitement, impaired seizures, arrhythmias, behavior. bradycardia dependency rate judgment, insomnia, transient venospasms Treatment: Support • Tolerance develops rapidly anorexia; nasal perforation possibly causing MI or counseling, antidepressants • Cocaine is inhaled, snorted, or associated with inhaled CVA, coma, death injected IV route; psychosis associ- Treatment: Supportive • High risk of acquiring HIV, hepatitis, ated with long-term bacterial endocarditis, and os- abuse teomyelitis from shared IV needles or promiscuous sexual relations • May be used to control appetite Hallucinogens, Signs: Dilated pupils, Signs: Panic, suicidality, Signs: re-experiencing • Flashbacks can occur for up to including LSD, diaphoresis, palpitations, psychosis with perceptual symptoms 5 years psilocybin, and tremors, enhanced hallucinations, cerebral • Could precipitate a psychiatric mescaline perceptions of colors, tissue damage, seizures, disorder in susceptible persons sounds, depersonaliza- hyperthermia, death tion, grandiosity Treatment: Diazepam or chloral hydrate; quiet environment antipsychotics Inhalants, including Signs: Euphoria, impaired Treatment: Supportive Signs: None • Most available substance for glue, gasoline, judgment, blurred vision, younger children cleaning solutions, unsteady gait, nausea/ • Intoxication period is brief (15– aerosol propellants vomiting, wheezing, 45 minutes) like deodorants or hypoxia • Can cause permanent CNS damage hair spray, and paint • Death from aspiration of emesis thinner can occur • May be difficult to detect specific substance used • Particularly irritating and/or flam- mable substances can cause trauma and burns in nose, mouth, and airways 2993_Ch17_261-286 14/01/145:27PMPage273

Nicotine, including Signs: Produces a sense Signs: Tachycardia, hyper- Signs: Insomnia, depression, • Monitor for weight gain cigarettes, chewing of anxiety reduction, tension, abnormal irritability, anxiety, poor • Monitor for hypotension with tobacco, and relief from depression, dreams concentration, increased clonidine nicotine gum or and satisfaction appetite • Hospitalized smoker may need patch Treatment: Transdermal nicotine replacement to control nicotine patches in decreas- withdrawal ing doses, nicotine gum, nicotine nasal spray, and clonidine for severe anxiety, behavioral modiﬁcation. Long-term smokers may need to remain on nicotine therapy for some time. New medications now available (see Pharmacology Corner) Opioids, including Signs: Euphoria, analgesia, Signs: Dilated pupils, Signs: Yawning, insomnia, • High risk of acquiring HIV, hepati- heroin, morphine, slurred speech, drowsi- respiratory depression, anorexia, irritability, rhinor- tis, bacterial endocarditis, and os- meperidine, ness, impaired judgment, seizures, cardiopul- rhea, muscle cramps, chills, teomyelitis from shared IV needles OxyContin, constricted pupils monary arrest, coma, nausea, and vomiting, feel- • May be obtained illegally or propoxyphene, death ings of doom and panic through prescription abuse hydrocodone, and Treatment: Naloxone, Treatment: Detoxiﬁcation, • At high risk for overdose after detox codeine supportive possibly with clonidine if the same pre-detox dose is taken for severe anxiety and • Monitor for hypotension with methadone, naloxone, clonidine and/or buprenorphine • Abuse of Suboxone is a growing to block euphoria problem Continued 273 2993_Ch17_261-286 14/01/145:27PMPage274 274

l Table 17-3 Comparing Commonly Abused Substances—cont’d Drug Intoxication Overdose Withdrawal Nursing Considerations Phencyclidine Signs: Impulsive behavior, Signs: Hallucinations, Signs: None • Have adequate staff available (PCP, angel dust) impaired judgment, psychosis, seizures, because behavior is unpredictable belligerent behavior, respiratory arrest, stroke and patient may become violent. assaultive behavior, Treatment: Gastric lavage; • Drugs remain in urine for several ataxia, muscle rigidity, cranberry juice or am- weeks nystagmus, hyperten- monium chloride to • Avoid using phenothiazines sion, numbness or acidify urine (if awake); because they can potentiate the diminished response to quiet environment; effects of PCP pain haloperidol or diazepam; fluids Sedatives, Signs: Relaxation, Slurred Signs: Hypotension, Signs: Insomnia, tachycardia, • Abrupt barbiturate withdrawal can hypnotics, and speech, labile mood, nystagmus, stupor, hand tremor, agitation, be life-threatening antianxiety drugs inappropriate sexual cardio-respiratory panic disorder, nausea and • Alcohol will potentiate drug effects including behavior, loss of depression, renal failure, vomiting, anxiety, tinnitus and can contribute to overdose barbiturates and inhibitions, drowsiness, seizures (barbiturates) (with benzodiazepines), • Cross-tolerance may develop benzodiazepines impaired memory coma, death seizures, and cardiac arrest between alcohol and other CNS Treatment: Benzodi- Treatment: Detoxification depressants. azepine antagonist using gradually reduced • Shorter-acting benzodiazepines (flumazenil); induce dosages of a similar drug, have a greater risk of producing vomiting, if awake; anticonvulsants, and addiction and more severe re- activated charcoal; support and counseling bound anxiety than longer-acting cardio-respiratory support ones 2993_Ch17_261-286 14/01/145:27PMPage275

Club Drugs Signs: Euphoria, muscle Signs: Confusion, halluci- Signs: Not physiologically • Can cause memory loss and brain including ecstasy relaxation, poor judgment nations, severe anxiety, addictive, but psychological damage (MDMA), rohypnol, hypertension, seizures, dependence can cause ketamine high temperature depression, ﬂashbacks Treatment: Supportive Steroids (anabolic), Signs: Dramatic increase Signs: Liver damage, Signs: Depression, fatigue, • Masculinization of women and including in muscle mass, irritability, increased cholesterol, anorexia, decreased libido feminization of men is common testosterone, increased blood sugar, hypertension, paranoia, • May be self-injected stanozolol, acne, edema from ﬂuid hostility, hyperactivity, • Repeated use can produce oxymetholone retention, unwanted manic symptoms dependence symptoms secondary sex Treatment: Supportive characteristics

Source: Adapted from Gorman & Sultan (2008) and Townsend (2012, DSM-5). 275 2993_Ch17_261-286 14/01/14 5:27 PM Page 276

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• Change in sleep patterns • Increased isolation • Irritability • Mood swings Lifelong struggles with substance use often begin in childhood and adolescence. Younger brains are thought to be more vulnerable to the addiction cycle. Therefore, intervention with young people is essential to prevent addiction. Children and teens are still developing judgment and decision-making skills, so they may be swayed to try things as part of Figure 17-5 “Homemade” methamphetamine peer pressure or to self-medicate. tablets. (Courtesy of Drug Enforcement Agency, U.S. Department of Justice, Washington, D.C.) ■ ■ ■ Critical Thinking Question Your 15-year-old nephew has been arrested for pos- disorder is based on a pattern of continued session of a prescription analgesic that he stole from use despite substance-related problems. a friend’s parent’s medicine cabinet. You had noticed Use of opioid drugs for nonmedical use is a that recently he had more mood swings than usual, growing problem. This can include the use of had been doing poorly in school, and was increas- pain medication to achieve a high or to relax ingly irritable. What other signs would you look for that he is using these drugs? What concerns would rather than for physical pain relief. Desperate you have for his future? actions such as stealing drugs from family/ friends, forging prescriptions, and doctor shopping are signs that the person needs help. Peo- ple with chronic pain who regularly take Tool Box | The Drug Abuse Screening Tool, analgesics may be at increased risk to misuse known as DAST, is used in some settings. The prescribed analgesic at times of stress, new 20-question self-screening tool is available at onset of more medical problems, and mental www.integration.samhsa.gov/clinical- health issues. They need to be educated on the practice/screening-tools appropriate use of these medications and monitored closely (Pergolizzi et al., 2012). Older adults are more likely to abuse prescription tranquilizers, sedatives, and analgesics. Etiology of Substance Use Substance Use in Children Disorders and Teens The causes of substance use disorders are similar to those of alcohol abuse, but with the Children and teens can also be at risk for wide variety of drugs abused, there are some substance disorders. The use of inhalants, differences. Biological theories look at the role including household items such as hair spray of specific brain dysfunction and view addic- and aerosol whipped cream, is most common tion as a brain disease. A drug will stimulate in children. These easily obtained substances a specific brain pathway that includes an can contribute to sudden changes in behavior. altered state and brain changes leading to Cough syrups and prescription drugs from craving this drug again. Cocaine has been parents are other sources for children and studied the most, and it is believed that teens. Signs of substance use in children and cocaine abusers have a deficiency of dopamine teens can include: and norepinephrine that creates more craving. • Change in functioning at school Other mind-altering drugs may be influenced • Loss of interest in sports by different pathways. 2993_Ch17_261-286 14/01/14 5:27 PM Page 277

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Psychological factors include use of drugs to relieve feelings of depression, anxiety, and Cultural Considerations low self-esteem. Sociocultural theories look at Disparities in availability of treatment for the impact of peer group and culture on the substance-related disorders for some eth- use of specific drugs. nic groups and those of lower socioeconomic status have led to greater problems Treatment of Substance in some communities (Cook & Alegría, Use Disorders 2011). As with alcoholism, the twelve-step program provides an important treatment and support for the individual with substance abuse. The People who take drugs intravenously are at same philosophy of acknowledging one’s risk of HIV, sexually transmitted diseases, and powerlessness over a substance and the im- hepatitis from infected needles. Treatment for portance of group support are the foundation substance abuse should include a medical of these programs. work-up for these potential problems as well In addition, some people benefit from in- as education on prevention. patient drug rehabilitation programs, which can include detoxification depending on the drug. Family therapy, individual psychother- ■ ■ ■ Clinical Activity apy, peer counseling with former addicts, and • Review the medical record for what substances group therapy can also be helpful in many your patient was abusing, the last time they were cases. Cognitive behavior therapy (CBT) can used, and the potential complications. also be useful. This approach is a short-term • Your patient who is an IV drug abuser should be therapy that emphasizes learning the connec- screened for HIV, sexually transmitted diseases, and hepatitis. tion between stressors and symptoms, teach- • Education may need to be provided on prevention ing new coping skills, and challenging of these diseases. distorted thinking. Most substance abuse programs involve the family in the treatment plan. Heroin addiction may be treated with methadone maintenance when a long-acting ■ ■ ■ Classroom Activity opioid is taken daily to avoid the withdrawal • Identify resources for drug abusers in your community, such as methadone maintenance symptoms without the high from taking programs and halfway houses for recovering other opioids. See the Pharmacology Corner addicts. for other medications used to treat addictions and withdrawal. It is now commonplace for employers to request a drug screening of a urine or hair sam- ■ ■ ■ Critical Thinking Question ple as a condition of employment or as a You work at a methadone clinic and see the same patients daily for their medication dose. routine test while employed. Many companies You notice that one patient arrives disheveled have struggled with drug abuse with their em- with slurred speech. What actions should ployees and have found this to be a deterrent. you take? In the hospital setting, awareness of a patient’s past substance abuse history is important information to prevent/control withdrawal syndromes. In addition, a recovering substance ■ ■ ■ Critical Thinking Question abuser may be hesitant to take analgesics or You are asked to submit a urine test as a condition of employment for a new job at a local hospital. tranquilizers for fear of returning to a past What is your response to this request? What lifestyle. It is important to work with the are the pros and cons of this for employer and patient to address these fears and identify employee? alternative interventions if possible. 2993_Ch17_261-286 14/01/14 5:27 PM Page 278

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to help with nicotine withdrawal in addition Pharmacology Corner to nicotine replacement in the form of A variety of medications are used in the lozenges or patches. treatment of substance use disorders. Phar- Herb and plant products to treat distress- macology can be used in some cases to re- ing symptoms may be helpful and include place the illicit substance, as in methadone chamomile, valerian, kava kava, and St. John’s (see below), or to reduce the drug cravings wort. The last is contraindicated if the pa- by interacting with the receptor system in tient is taking antidepressants, narcotics, or the brain affected by the substance. Exam- amphetamines. ples include buprenorphine and naloxone Commonly used medications to treat for opioid addiction. These substances also withdrawal are covered in Table 17-2. reduce the physical signs of withdrawal. Medications are used in detoxification Neeb’s The Clinical Institute Withdrawal programs for many drugs, including opioids, ■ Tip Assessment for Alcohol Scale, known barbiturates, sedatives, and tranquilizers. They popularly at CIWA-AR, is also a use- are used to control withdrawal symptoms and ful tool used by many hospitals to discourage continued use of the abused sub- monitor patients at risk for with- stance. Most are used for only short periods drawal syndromes from opioids until withdrawal is complete; however, in and benzodiazepines. some cases, they may be used for longer periods to control cravings for the drug. Methadone, a synthetic narcotic that resem- ■ ■ ■ Clinical Activity bles morphine and heroin but does not pro- • Review agency policy on the management of drug withdrawal regimens. duce the euphoric effects, is used daily on a • Identify coping mechanisms your substance long-term basis to treat heroin addiction. Both abusing patient uses to cope with stress now physical and psychological dependence are that he/she is not using. maintained on methadone, but the euphoric • Monitor for potential complications during effects of heroin are blocked. Patients usually detoxification. make daily trips to a methadone clinic to obtain the drug. Buprenorphine, an opioid with ■ ■ ■ Critical Thinking Question agonist and antagonist action, has been used as Your 19-year-old patient is admitted for surgery an alternative to methadone. Naltrexone also after he broke his ankle in a car accident. His sister reduces the euphoric sensation from narcotics, confides in you that he has been taking frequent and clonidine decreases discomfort during doses of the tranquilizer lorazepam that he was narcotic withdrawal. The newest opioid with- taking from his mother’s prescription. He has asked her to bring these to the hospital. The patient’s sis- drawal treatment uses Suboxone (buprenor- ter has them but now wonders if that is the right phine and naloxone). Addiction specialists thing to do. What concerns would you have about must be certified to prescribe this regimen. this drug? What action should you take? Patients on this medication must be monitored closely if they have conditions that require use of analgesics. Administering analgesics could ■ Nursing Care of Patients precipitate a withdrawal syndrome. With Substance Use Benzodiazepines and sedative withdrawal is more risky because of the risk for seizures Disorders (Including and delirium. Tapering the dose of the iden- Alcohol) tified or similar drug, along with anticonvulsants and antidepressants, is usually used. Common nursing diagnoses in patients Withdrawal from stimulants may require with substance-related disorders include the use of tranquilizers and antidepressants. following: Bupropion and varenicline (Chantix) work • Coping, ineffective in combination with behavioral treatments • Denial, ineffective 2993_Ch17_261-286 14/01/14 5:27 PM Page 279

CHAPTER 17 | Substance Use and Addictive Disorders 279 • Family coping: compromised General Nursing Interventions • Injury, risk for Caring for patients with a variety of substance • Sleep pattern, disturbed use disorders requires patience, knowledge, • Thought processes, disturbed teamwork, and compassion. These patients • Violence, risk for present many challenges as there can be many People who abuse drugs, alcohol, and complications related to the substance itself other substances often use similar coping and/or the withdrawal process. In addition, the mechanisms to deal with their problems. See same coping mechanisms the patient has used Table 17-4 for a list of common coping styles for years to hide the addiction and problems it used by substance users. Understanding these created are often still in use. These can include coping mechanisms can help professionals denial, manipulative behavior, and rationaliza- understand behaviors and identify appropri- tion. The nurse may be in a role of limit setter ate interventions. and rule enforcer, which can be challenging.

l Table 17-4 Common Coping Styles of Substance Abusers Coping Style Definition Behaviors Denial Person minimizes or does not • “I only have two drinks a day; I acknowledge the problem or could stop any time.” the results of the problem • Refuses to admit drug problems even when strong evidence is that are obvious to others. presented. • Family may participate in denial by covering up the problems created by the abuser. Projection Blames others for his or her • Avoids taking responsibility for drinking and substance abuse. own unacceptable behavior. • “My brother is the one with the problem. He drinks more than I do.” • “I’d stop if everyone would leave me alone.” Rationalization Justiﬁes intolerable behavior • Excuses reinforce denial. by giving plausible excuses. • “My kids are always in trouble. They make me take these pills” • “I only drink beer.” Minimizing Avoids conﬂict by reducing • Places less value on the behavior the impact of the behavior. and the impact of the problem. • “You worry too much.” • “I’m not hurting anyone.” Manipulation Plays one person against • Convinces one or two people another in order to get one’s that he or she will improve if they way or cover up or avoid a will help. problem. • If he or she fails, it is the fault of the helper. Grandiosity Maintains a sense of superi- • Lacks concern for others’ feelings. ority and irresponsibility particularly evident when intoxicated.

Source: Adapted from Gorman and Sultan (2008): Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission. 2993_Ch17_261-286 14/01/14 5:27 PM Page 280

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The nurse may also be faced with patients who Neeb’s Recognize that maintaining sobriety are intoxicated on the substance. This can ■ Tip or abstinence from drugs or alcohol mean dealing with oﬀensive, abusive behaviors is a lifelong process. During periods that require maintenance of safety for all in- of stress or illness, the urge to use volved as well as limit setting. these substances can increase. The See Table 17-5 for speciﬁc interventions patient needs added supports at related to alcohol and drug abuse disorders. these times

Neeb’s Patients with a substance abuse history ■ Tip often refuse analgesics for fear this will lead to abusing the substance again. Neeb’s People with a drug abuse past may Working with the patient to try alter- ■ Tip have learned to use charm and ma- nate methods of pain control as well as nipulation to get the drugs they are appropriate ordering of analgesics by seeking. Family, friends, and health- the physician (e.g., use of long-acting care providers may have diﬃculty opioids rather than injectable to re- trusting them in recovery because of duce the high) can be helpful. being taken advantage of in the past.

l Table 17-5 Problems With Substance Abuse: Symptoms and Nursing Interventions Types Symptoms Nursing Interventions Alcohol Abuse • Inability to cut down or stop • Communicate honestly using • Assist patient in identifying • Daily use common thoughts and feelings • Binges that last 2 days or more • Convey acceptance of individual • Blackouts, which increase • Challenge rationalizations or denial • Impaired social function with reality • May use drugs in addition to • Encourage participation in support alcohol to manage symptoms groups and maintain consistency • Increase in alcohol tolerance with new behaviors learned in • Drinking in “secret” group • Preoccupation with alcohol • Confront use of maladaptive • Gulping first drink defense mechanism • Inability to discuss problems • Support any acknowledgement of • Loss of control the abuse • Rationalization of drinking • Support and give positive • Failure in efforts to control reinforcement of progress drinking • Set firm limits as needed • Grandiose and aggressive • Provide information about behavior substance abuse, causes, and • Trouble with family, employer treatment • Self-pity • Monitor for withdrawal syndromes • Loss of outside interests and complications from substance • Unreasonable resentment abuse • Neglecting food • Support of drug/alcohol-free lifestyle • Tremors (hands) • Recognize that patient may have • Morning drinking setbacks with drinking but • Prolonged intoxication encourage to restart treatment • Physical and moral deterioration • Avoid any enabling of patient's • Impaired thinking bad behavior 2993_Ch17_261-286 14/01/14 5:27 PM Page 281

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l Table 17-5 Problems With Substance Abuse: Symptoms and Nursing Interventions—cont’d Types Symptoms Nursing Interventions • Free-floating anxiety • Obsession with drinking • Constant use of alibis Substance Use • Similar to alcohol abuse with • See “Alcohol Abuse” addition of: • Encourage patient to be tested for • Red, watery eyes HIV if drug use included use of • Runny nose needles • Hostility • Monitor drug testing if ordered • Paranoia • Be aware of attempts to manipu- • Needle tracks on arms or legs late you • Erratic, unpredictable behavior • Risky behaviors including stealing, lying to obtain drug • May use alcohol too to self-medicate for symptoms • Other symptoms depending on drug being used Co-dependence • Significant others beginning to • Encourage participation in lose their own sense of identity assertiveness classes and purpose, existing solely for • Promote self-care and problem the abuser solving • Actions of significant others • Encourage attendance at support taking away opportunity for user groups to take responsibility for his or • Challenge rationalizations/denial her own actions about substance abuser • Lowered self-esteem • Help person identify self- • Taking part in actions that are destructive patterns self-destructive and reinforce • Encourage activities to promote drug seeker’s/drinker’s problems self-esteem and individuality

The nursing care plan for a patient abusing Neeb’s Denial is a powerful coping mech- alcohol is provided in Table 17-6. ■ Tip anism common in alcohol and substance use disorders that gets ■ ■ ■ Critical Thinking Question reinforced by the eﬀects of the sub- Your 45-year-old patient is admitted to the hospital stance. Patients may minimize the with multiple injuries that she states she sustained eﬀects of the substance abuse even in a fall at home. When the husband of the patient when presented with objective data arrives, he smells of alcohol, is belligerent, and de- like a blood alcohol level or toxicol- mands his wife be released. After security asks him to leave, the wife tells you that he has never acted ogy screen. Look for slightest indica- like this before and she is sorry she upset him by tion of insight and emphasize that telling him their son acted out in school. She de- rather than support the denial. nies he hurt her and says that she tripped down the stairs because she left some of the younger son’s toys there. You wonder if the wife is covering up her husband’s drinking problem as an enabler. What would you consider as possible nursing diagnoses for this patient? If the husband comes back, what actions should you consider? 2993_Ch17_261-286 14/01/14 5:27 PM Page 282

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l Table 17-6 Nursing Care Plan for Patients Abusing Alcohol Assessment/ Nursing Interventions/ Evaluation Data Collection Diagnosis Plan/Goal Nursing Actions Criteria • History of heavy Ineﬀective Acknowledges Demonstrate Patient drinking denial drinking is out acceptance by acknowledges • Minimizes of control avoiding criticism or need for help negative Asks for help judgment of his Patient attends eﬀects of behavior AA meeting drinking Identify recent Patient shares • Denies concern inconsistencies in his one emotion about recent behavior erratic behavior Help patient identify • Blames his feelings/events that spouse lead to recent binge for recent Foster problem solving argument to identify new ways to cope with stress Provide information about Alcoholics Anonymous Set limits on manipulative behavior Promote taking responsibility for hurting spouse’s feelings

■ ■ ■ Key Concepts 5. Co-dependency is often seen in family and friends of substance abusers as they 1. Substance abuse and dependence are try to help the person by covering up or growing disorders in the United States enabling addictive behaviors. with wide ranging impacts on health, safety, and family life. 6. Longer-acting tranquilizers are used as the initial treatment to detoxify from 2. Poly-drug use is common as the person alcohol. tries to self-medicate to decrease discomforts from another drug. This contributes 7. Serious complications from alcohol abuse to more complications and possible syner- include heart disease, liver failure, and gistic eﬀects that can be life-threatening. some cancers. 3. Dependency on a substance occurs when 8. Acute withdrawal is commonly seen one is unable to control its use, even while in the acute hospital setting when the knowing that it interferes with normal patient is without the abusing substance functioning and more of the substance is for hours or days. required to produce the desired eﬀects. 9. Nursing management of patients with 4. The presence of substance abuse with a substance use disorders requires keen psychiatric disorder is called a co-occurring observation, setting limits, involvement disorder or dual diagnosis. It is commonly of the family, and compassion. seen in the psychiatric population and needs to be included in the screening. 2993_Ch17_261-286 14/01/14 5:27 PM Page 283

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CASE STUDY Jim is a 26-year-old ﬁrst-year resident in friend based on his back pain. As time medicine at a large university hospital. His went on, he needed more pain medication father and mother are both physicians, and to sleep and then started taking a pill he felt pressure to graduate from medical during his shift when he felt jumpy. school with high honors. He struggled Colleagues reported Jim was irritable throughout medical school to maintain and at other times almost euphoric. He was passing grades but achieved more success in called in by his supervisor when he made a his last year as he realized how much he prescribing error. Jim felt he needed more wanted to be a doctor when he was work- Vicodin to function and then he would not ing with patients. After graduation, he make errors. Then Jim’s friend said he could ranked high enough to be selected for a not write any more prescriptions for him. residency at a prestigious hospital. During This friend suggested he pursue pain man- medical school, he was in a car accident agement referral. Jim was not interested that left him with residual back pain, and pursued other routes to get pain med- which he managed with yoga and occa- ication, including writing his own prescrip- sional ibuprofen. tions to a fake patient. He had a minor car Once his residency began, he was work- accident when he fell asleep at the wheel. ing long hours. Often on his feet for long When he returned home from work one hours, his back pain increased. He no day, the police arrived with a warrant for longer had time for yoga and ibuprofen unlawful prescription writing. A local was no longer helping. He had an old pre- pharmacist had become suspicious and scription for Vicodin, which he took at reported it to the police. night when he was not on call. It helped Jim is now in police custody. Jim’s father him sleep and be more rested to function and his hospital supervisor arrived and well at the hospital. He obtained a pre- proposed a drug treatment program. Jim scription for more Vicodin from a doctor agreed.

1. Upon entering your drug treatment facility, what information would you want to know in the admission proﬁle about Jim’s drug use? 2. In reviewing Jim’s case study, at what point did the Vicodin use turn from therapeutic to substance abuse? 3. Identify two interventions you would use initially to support Jim.

REFERENCES Gorman, L., and Sultan, D. (2008). Psychosocial American Psychiatric Association. (2000). Diag- Nursing for General Patient Care. 3rd ed. nostic and Statistical Manual of Mental Disorders Philadelphia: F.A. Davis. IV-Text Revision. Washington DC, Author. Kessler, R.C., Berglund, P., and Demler, O. (Known as DSM-IV-TR) (2005). Lifetime prevalence and age-of-onset American Psychiatric Association. (2013). Diagnos- distributions of DSM-IV disorders in the tic and Statistical Manual of Mental Disorders 5. National Comorbidity Survey Replication. Washington, DC, Author. (Known as DSM-5) Arch Gen Psychiatry, 62(6), 593–602. doi: Clark, H. Prevention and impact of co-occurring 62/6/593 [pii] 10.1001/archpsyc.62.6.593 disorders. Retrieved from www.nami.org/ Kessler, R.C., Demler, O., and Frank, R.G. MSTemplate.cfm? (2005). Prevalence and treatment of mental Cook, B.L., and Alegría, M. (2011). Racial-ethnic disorders, 1990 to 2003. N England Journal disparities in substance abuse treatment: The of Medicine, 352(24), 2515–2523. role of criminal history and socioeconomic sta- Ling, W., Mooney, L., and Wu, L.T. (2012). tus. Psychiatric Services, 62(11), 1273–1281. Advances in opioid antagonist treatment for 2993_Ch17_261-286 14/01/14 5:27 PM Page 284

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opioid addiction. Psychiatric Clinics of North Townsend, M. (2012). Psychiatric Mental Health America, 35(2), 297–308. Nursing. 7th ed. Philadelphia: FA Davis. Lingford-Hughes, A.R., Welch, S., and Peters, L. U.S. Preventive Services Task Force. (2012). U.S. (2012). Evidence-based guidelines for the Preventive Services task force issues draft rec- pharmacological management of substance ommendation on screening & behavioral abuse, harmful use, addiction and comorbid- counseling to reduce alcohol misuse. Retrieved ity: recommendations from BAP. Journal of from www.uspreventiveservicestaskforce.org Psychopharmacology, 26(7) 899–952. National Institute of Alcohol Abuse and Alco- WEB SITES holism. (2010). Rethinking drinking. Retrieved http://niaaa.nih.gov/publications/brochures- All the support programs for substance abuse and-fact-sheets have web sites with resources including how National Survey on Drug Use and Health. (2012). to locate a nearby group and 24-hour-a-day Results from the 2011 National Survey on support. These include: Drug Use and Health: Summary of national Ca.org Cocaine Anonymous ﬁndings. Retrieved from www.samhsa.gov/ Aa.org Alcoholics Anonymous data/NSDUH/2k11Results/NSDUHresults Na.org Narcotics Anonymous 2011.pdf Al-anon.org Al-anon for loved ones of alcoholics Pergolizzi, J.V., Gharibo, C., and Passik, S. National Institute of Alcohol Abuse and (2012). Dynamic risk factors in the misuse alcoholism of opioid analgesics. Journal of Psychosomatic www.niaaa.nih.gov/ Research, 72(6), 443–451. Alcohol and substance abuse help for veterans Stewart, S., and Conrod, P. (2008). Anxiety and www.mentalhealth.va.gov/substanceabuse.asp Substance Abuse Disorders: The Vicious Cycles National Institute on Drug Abuse of Comorbidity. New York: Springer. http://www.drugabuse.gov 2993_Ch17_261-286 14/01/14 5:27 PM Page 285

CHAPTER 17 | Substance Use and Addictive Disorders 285 Test Questions Multiple Choice Questions 1. The defense mechanism most frequently c. “Sally, why do you keep lying for Susie? demonstrated by the chemically dependent Just because she’s in trouble doesn’t person is: mean you have to cover up for her.” a. Undoing d. “Susie, this is just a stage you’re going b. Rationalization through. Everybody does it; it’s not a c. Denial big deal. You’re young! Have fun!” d. Reaction formation 6. Sally and Susie seek treatment. Susie is 2. Nurses know that alcohol functions as a: treated as an inpatient and Sally as an out- a. CNS depressant patient. The nurse planning discharge b. CNS stimulant teaching from their programs will encour- c. Major tranquilizer age them to: d. Minor tranquilizer a. Attend weekly AA and Al-Anon 3. The patient who is experiencing delirium meetings. tremens is most likely to exhibit which of b. Check back into the hospital unit weekly. the following symptoms? c. Attend weekly sessions with the a. Tremors psychologist. b. Auditory hallucinations d. Attend weekly Adult Children of c. Confusion Alcoholics meetings together. d. All of the above 7. Your patient admits to using an illegal 4. Sally and Susie are twins. They are 20 years substance daily, thinking about it when old. Susie has a habit of drinking too not actually using it, and spending a lot much when they go out, and this has been of time ﬁguring out where to get it. This more frequent. They were out celebrating patient could have: their birthday last night, and this morning a. A delusion Susie is vomiting. Sally calls her sister’s b. DTs teacher. “Susie is really ill. I think she has c. An addiction the ﬂu; anyway, she can’t come to school d. Dementia today. She said she has a test today and an 8. One of the major skills a person/family assignment that she was supposed to pick can learn during substance abuse treat- up. I can come in and get the assignment ment is: for her. When can she make up the test?” a. Honest communication Sally’s behavior might indicate: b. Co-dependency a. Collaboration c. Denial b. Compensation d. Scapegoating c. Lying 9. Your spouse has been an alcoholic for d. Co-dependency many years. She/he has been sober for the 5. You are Sally and Susie’s friend. A thera- last two years but has begun drinking peutic response to them might be: again. She/he drives drunk. You fear for a. “Sally and Susie, you are really going to your spouse’s life, so you begin driving get in trouble if you keep partying like him/her places. You are displaying what that. It’s bad for you.” kind of behavior? b. “Sally and Susie, I care for you both, a. Dry drunk but Susie, you misuse alcohol. You b. Co-dependent both need help. Sally, you are not help- c. Compassionate ing Susie by ‘taking care’ of her; she d. Tough love needs to do it herself.” 2993_Ch17_261-286 14/01/14 5:27 PM Page 286

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Test Questions cont.

10. Which of the following medications is 12. A patient is suspected of methampheta- most likely to be ordered for a patient mine abuse. What symptom would you experiencing alcohol withdrawal? be most likely to see? a. Haloperidol a. Weight loss b. Chlordiazepoxide b. Incontinence c. Methadone c. Weight gain d. Chlorpromazine d. GI bleed 11. Your patient just attended her first AA meeting. Which statement reflects she understands the purpose of AA? a. “Once I dry out, I know I can have an occasional drink.” b. “If I lose my job, AA can help me find another one.” c. “AA is only for people who have hit bottom.” d. “AA can help me stay sober.” 2993_Ch18_287-300 14/01/14 5:27 PM Page 287

CHAPTER 18 Eating Disorders

Learning Objectives Key Terms 1. Define anorexia. • Anorexia nervosa (also 2. Describe the similarities and differences between anorexia called anorexia) and bulimia. • Binge eating disorder 3. Define morbid obesity. • Body image 4. Discuss bariatric or “weight loss” surgery. • Body mass index (BMI) 5. Identify populations at risk for eating disorders. • Bulimia 6. Identify possible causes of eating disorders. • Morbid obesity 7. Describe nursing interventions for patients with eating disorders. • Obesity • Purging

ieting is a national obsession, espe- ■ ■ ■ Classroom Activity cially with women. Numerous fit- • Discuss with classmates their experiences with Dness clubs are filled with individuals eating disorders in themselves or friends. trying to attain the idealized thin, muscular body. The Barbie doll became the idealized female body shape for several generations. or overeating. Rather, they are psychiatric Extreme thinness is increasingly common in disorders with substantial emotional and models and celebrities. It seems that it has physical consequences. become accepted behavior to be obsessed with body weight and shape and to view food ■ as a source of stress. Self-esteem and happi- Anorexia Nervosa ness in young girls are often linked to weight The termanorexia (as used in anorexia ner- and body shape. When this social influence vosa) is really a misnomer because this condi- is combined with certain biological, psycho- tion has very little to do with reduced appetite. logical, and family dynamic factors, it could It has more to do with the person’s morbid fear be the beginning of an eating disorder, in- of obesity causing anxiety and obsessive fear cluding anorexia nervosa and bulimia ner- of losing control of food intake. In fact, the vosa (Yager & Andersen, 2005). Obesity and person is often hungry and views the discom- morbid obesity are not considered eating fort of hunger as a reminder of the deprivation disorders, but their effects often lead to he or she needs to inflict on himself or herself. emotional distress. Eating disorders have Only in the late stages is appetite actually lost. little to do with simply not eating enough The distortedbody image causes the patient to have a personal view as fat even though Tool Box | The National Eating Disorders appearing emaciated (Fig. 18-1). No amount Association Information and Referral hotline of weight loss relieves the anxiety, causing is 800-931-2237 and web site at: this deadly cycle to continue. Complications www.nationaleatingdisorders.org can continue for years, even after successful treatment.

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combination. Successful treatment is mea - sured by weight gain, return of menstruation (usually absent in anorexic women), and reduced number of compulsive behaviors. Full recovery of weight, growth and development, menstruation, and normal eating behavior occurs in at least 50%–70% of treated adolescents (Yager & Anderson, 2005). The increased awareness of this disorder is leading many to receive earlier treatment, which improves the prognosis. Symptoms of Anorexia Nervosa Some of the behaviors, signs, and symptoms associated with anorexia nervosa are listed in Box 18-1.

Tool Box | Four questions to help screen for Figure 18-1 In anorexia nervosa, patients view eating disorders by Cotton, Ball, & Robinson their bodies in a distorted way. (Photograph are available at: by Stockbyte.) www.ncbi.nlm.nih.gov/pmc/articles/P M C 149 48 02/. Neeb’s Body image is a very personal per- ■ Tip spective. When working with patients with eating disorders, take the time to learn about how they view Cultural Considerations their bodies. Avoid stereotyping and Anorexia nervosa is most common in reacting emotionally to their ap- higher socioeconomic classes. pearance. The fact that they look thin to you does not mean that is how they see themselves. l Box 18-1 Behaviors, Signs, and Women have a 0.3%–1.0% lifetime risk of Symptoms of Anorexia suﬀering from anorexia nervosa. Men have a Nervosa prevalence of 1/10th of that risk (Hoek & van Hoeken, 2003; Yager & Andersen, 2005). • Excessive weight loss, usually more than Anorexia nervosa is viewed by many experts as 25% of body weight prior to dieting representing struggles with autonomy and sex- • Refusal to maintain normal weight uality. Onset generally peaks in the early to late • Intense fear of being fat • Restricting food intake often to only teens (Anderson & Yager, 2009). Poorer prog- 200–300 calories per day nosis is associated with an older age of onset, a • Excessive exercise lower minimum weight, and vomiting. • Obsessive thoughts Anorexic patients will go to great extremes • Perfectionist to deprive themselves of food and use meth- • Absence of menstrual cycle ods such as excess exercise to burn up calories • Distorted body image and purging. Purging, which causes elec- • Physical signs can include slow pulse rate, trolyte imbalance and arrhythmias through electrolyte imbalances, fatigue, dry skin inducing vomiting or overuse of laxatives, is and lanugo (ﬁne body hair) usually combined with compulsive exercise Source: Adapted from Gorman & Sultan (2008), Townsend (2012), to accelerate weight loss, making a lethal and Anderson & Yager (2009). 2993_Ch18_287-300 14/01/14 5:28 PM Page 289

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Extreme weight loss is usually hidden to approach as they are relieved they no longer avoid exposure of the illness. Some ways the have to make decisions about food; however, individual achieves this are by wearing baggy the team must consider the ethics of involun- clothes, moving food around on the plate to tary re-feeding. Every effort must be made for give the impression of eating, exercising in the patient to eat voluntarily (American Psy- secret, not eating unless certain demands chiatric Association, 2006). Others become about food combinations are met, or giving more anxious and resentful with forced re- excuses for not eating, such as snacking before feeding and need to try to take more drastic dinner. Once weight loss is exposed, the in- measures to take control of their intake by, for dividual often objects to treatment and denies example, hiding weights in clothes to feign the seriousness of the condition in an effort weight gain or changing drip rates on tube to continue to control the illness. feedings. Total parenteral nutrition can be associated with many complications, so is Etiology of Anorexia Nervosa usually avoided if possible. Causes of anorexia nervosa include genetic Behavior programs often include building and biological factors along with psychological in rewards for weight gain and restrictions for ones. Dopamine regulation and dysfunction weight loss as well as keeping a food diary. of the hypothalamus are viewed as important Therapeutic approaches should focus on in- contributors. Psychological theory suggests creasing socialization and self-esteem. Suc- that the core of anorexia is the child’s fear cessful treatment has focused on the goals of of maturing and unconscious avoidance of returning to normal weight, stopping abnor- developmental tasks. By not eating, the person mal eating behaviors, dismantling unhealthy forestalls sexual development and remains a thoughts, treating comorbidities, and plan- child in the family. Other dynamics include ning for relapse prevention (Anderson & overly demanding parents and profound dis- Yager, 2009). The dietary regimen generally turbance in the mother/child relationship. promotes slow, steady weight gain of no more Anorexia can represent a way to maintain con- than 3 pounds per week ( Yager & Anderson, trol over parental figures. Anorexia requires a 2005). strong need to control one’s intake, which counteracts feelings of loss of control and avoidance of conflict. Neeb’s Patients with anorexia often have a ■ Tip strong need to control their environ- Treatment of Anorexia ment, leading to power struggles Nervosa with the nurses. Treatment generally focuses on a collaborative approach between the following: internal medicine; behavioral approaches; nutrition Neeb’s It is very stressful to care for a patient counseling; individual, group, and family ■ Tip who refuses to eat. Nurses caring therapy; and pharmacological management. for these patients may experience Specialized inpatient treatment programs are frustration and anxiety as no matter available in some areas. what they do, the patient will not Mortality rate for anorexia can be high, eat. Collaborating with the interdis- with serious complications including bone ciplinary team is essential. loss, heart failure, serious arrhythmias, and electrolyte imbalances. Close medical monitoring is essential for the patient with this dis- ■ ■ ■ Classroom Activity order. A patient with severe anorexia may • Obtain information about local eating disorders require long-term hospitalization with some treatment programs and review and discuss with form of artificial nutrition if severely malnour- classmates. ished. Some anorexics do better with this 2993_Ch18_287-300 14/01/14 5:28 PM Page 290

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■ ■ ■ Clinical Activity Monitor electrolytes of your patient with anorexia nervosa.

■ ■ ■ Critical Thinking Question Parents bring in their 14-year-old daughter, Amanda, to your primary care oﬃce to seek help. Amanda appears pale and thin despite being dressed in a long, baggy dress. As you prepare her for her physical exam by the nurse practitioner, you are shocked by her thin body. Her spine and ribs are most prominent, she has no breasts, and her skin is dry with a ﬁne layer of hair over her body. Amanda asks you if you think she is fat. How would you respond?

■ Bulimia Bulimia (also called bulimia nervosa) is binge eating followed by purging in an effort to control weight. Binging is eating large quan- tities of food at one sitting. The binge eating is followed by purging, usually in the form of Figure 18-2 Bulimic woman vomiting after self-induced vomiting, though laxatives and eating a large meal. diuretics can also be used. The purging is often a result of the shame and guilt of the binge. Bulimia was officially designated as a It is common that these behaviors are hidden psychiatric disorder in 1980 and is harder to for years. It affects a larger cross section of diagnose than anorexia. Many of the behav- the population than anorexia does. Those iors are in private, and the person may appear with bulimia rapidly consume huge amounts to be a normal weight to others (Fig. 18-2). of food—as much as 8,000 calories in a 2-hour period several times daily. Bulimia, like anorexia, tends to be manifested during Pharmacology Corner: adolescence. The binge may be triggered by a stressful event, feelings about weight and Anorexia appearance, hunger from dieting, or negative There are no medications to specifically self-image. Many celebrities have acknowl- treat anorexia, but medications can be use- edged a history of bulimia which has given ful to help manage some of the behaviors, this disorder more public attention. This dis- for example, anxiety and depression as well order is much more common in females as obsessive-compulsive behaviors, which though does exist in males. can be seen in some anorexics. Fluoxetine (Prozac) as well as other SSRIs have been used in some cases; however, side-effect Cultural Considerations profiles can be high due to the patient being underweight. Anti-anxiety medica- Bulimia tends to occur in cultures where tions given prior to meals have been useful thinness is highly valued and where there for some. is an abundance of food. 2993_Ch18_287-300 14/01/14 5:28 PM Page 291

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Binge eating disorder is recognized by on dieting and how to control their weight. psychiatry as a disorder on its own. Individu- Their self-concept is closely tied to their als with this disorder are more often obese or appearance. exhibit fluctuations in weight. This diagnosis is believed to be more common than anorexia Etiology of Bulimia or bulimia. Binge eating disorder is character- Because bulimia has close ties to depression, ized by eating large amounts of food rapidly bulimics may have abnormalities in levels of when not hungry, eating alone, and experi- serotonin. An impaired satiety mechanism encing feelings of disgust and guilt after also could be a factor as the person may not overeating. The person with binge eating dis- recognize when he/she has had enough to order generally does not purge. To receive this eat. Psychological theories include low self- diagnosis the binging must occur at least once esteem, presence of conflict in parental rela- per week for 3 months. tionships, and family history of alcoholism and abuse. These individuals are more likely Neeb’s People with bulimia often keep their to have comorbid psychiatric disorders, such ■ Tip disorder secret and are only found as borderline personality disorder, panic dis- out when a friend or relative finds order, substance use disorder, and major evidence of purging behaviors such depression. Childhood obesity may be a con- as vomiting or laxatives. tributing factor. Treatment of Bulimia Symptoms of Bulimia The patient must acknowledge the disorder. Box 18-2 lists the most common symptoms Bulimics may suffer in silence for years be- of bulimia. Bulimic individuals often are fore acknowledging the need for treatment. very self-conscious about their weight and Individual, group, and family therapy are appearance, and may focus a lot of their time important components of treatment to gain insight into feelings that lead up to the need to binge as well as to treat depression or l Box 18-2 Behaviors, Signs, and other disorders. Keeping a food diary with Symptoms of Bulimia associated feelings is a common behavioral approach. Complications of bulimia include • Extreme dieting electrolyte imbalance, dehydration, and tears • Use and abuse of laxatives or syrup of in the gastric or esophageal mucosa that re- ipecac (to induce vomiting) quire involvement of internal medicine and • Use and abuse of diuretics • Obsession with food and eating dentistry. The support group Overeaters • Poor self-concept Anonymous has been helpful for bulimics. • Thoughts of harming self • Routine use of bathroom immediately after eating ■ ■ ■ Critical Thinking Question • Erosion of tooth enamel or hoarseness Your friend Carole constantly talks about her from vomiting weight. She needs frequent reassurance that she • Extreme sensitivity to body shape and is attractive, but then criticizes herself for being weight fat. She is not overweight in your opinion. She is • Poor self-concept part of group that meets monthly at a restaurant • More likely to appear normal weight or for drinks and dinner. You notice that she eats a slightly overweight very large, high-calorie meal each time but visits Impulsive the restroom two to three times during the • evening. You are wondering if she has bulimia. • Feeling depressed, guilty, worthless What else would you look for to consider bulimia? Source: Adapted from Gorman & Sultan (2008) and Townsend What concerns would you have for her? (2012). 2993_Ch18_287-300 14/01/14 5:28 PM Page 292

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Pharmacology Corner: ■ Morbid Obesity Bulimia Morbid obesity often leads to a lifetime of Because of the high correlation with de- emotional, social, and physical problems. pression, patients with bulimia are often Potential health problems include a wide on SSRI antidepressants. Some antidepres- range of chronic conditions, including hyper- sants, including fluoxetine, paroxetine, tension, cardiac problems, diabetes, respiratory and fluvoxamine, are particularly helpful insufficiency, and joint and back disorders. if there are obsessive-compulsive features Risk of death increases with a body mass with the bulimia. Other medications to index (BMI) greater than 30. (See Box 18-3 treat additional psychiatric disorders such to determine BMI.) Nutritional deficiencies as anxiety disorder, substance abuse, and are also extremely common because the obese bipolar disorder may be used as well. person may lack a well-balanced diet or experience protein deficiencies related to crash dieting. Obesity is not classified as a psychiatric disorder, but it may include features ■ Similarities Between of binge eating disorder and depression. Anorexia and Bulimia Society often views morbidly obese individuals as undesirable. They may be abused by There are many similarities between these strangers and treated with contempt by family two eating disorders, and long-term anorex- members. Even health-care professionals may ics may develop bulimia in later life. See view them as emotionally disturbed, though Table 18-1 for a summary of the differences there is no increased incidence of psychopathol- between them. ogy in morbidly obese people. Others may

l Table 18-1 Comparison of Anorexia Nervosa and Bulimia Anorexia Nervosa Bulimia Epidemiology • More than 95% female • 90% female • Younger adolescent onset • Young adult onset more likely fairly rare • 2–3 times more frequent than anorexia Appearance • Emaciated • Normal or overweight • Below normal weight • Weight ﬂuctuations Family • Rigid, perfectionistic • More overt conﬂict • Overprotection Behavior • Introverted • Impulsive • Socially isolated • More histrionic, acting out • High achiever • Depressed • Excessive exercise Signs • Cachexia • Dehydration • Hair loss • Chronic hoarseness • Amenorrhea • Chipmunk facies (parotid gland • Dry skin enlargement) • Pedal edema Prognosis • 5%–18% mortality rate • Death is rarer • Frequent lifelong problems • Lifelong problems with food with food • Bulimia • Depression

Source: Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission. 2993_Ch18_287-300 14/01/14 5:28 PM Page 293

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time to talk with the client, and a belief that Box 18-3 Example of Body Mass l this recommendation will not make any dif- Index Calculation ference. Yet it has been found that a client is BMI = Weight (in kilograms) ÷ Height in more likely to try to lose weight if he or she meters squared is advised to do so by a health-care profes- Example: sional. However, extremely obese people may What is the BMI of a 180-pound woman who avoid regular medical care because of shame is 5 feet tall (60 inches)? about their weight. The U.S. Preventive Serv- First convert pounds to kilograms and inches ices Task Force has recommended that health- to meters: care providers identify people with a BMI 180 pounds ÷ 2.2= 81.81 kg greater than 30 and refer them for weight loss 60 inches = 1.52 meters 1.52 x 1.52 = 2.31 (meters squared) counseling (2012). 81.81 ÷ 2.31 = 35.41 BMI Obesity in children and teens is a serious health concern in the United States and glob- ally. Long-term emotional eﬀects include depression, social isolation, poor self-esteem, Tool Box | BMI Calculator: and poor academic performance. These can www.bmi-calculator.net/ (also see Box 18 -3) lead to lifelong problems (Cornette, 2008). All nurses will encounter morbidly obese patients in their practices. Sensitivity to the patient’s fears, embarrassment, and coping Cultural Considerations mechanisms should be incorporated in the Morbid obesity aﬀects all ages and races, treatment plan. Having properly sized equip- although it is much more common in ment like wheelchairs and beds and scales can lower socioeconomic groups. Obesity is avoid embarrassment. equally distributed between men and Etiology of Morbid Obesity women. Childhood obesity is also considered a national health problem that can Causes of morbid obesity are complex. Genetic lead to a lifetime of problems. factors are considered a predisposing factor. Abnormalities in the brain related to satiety, abnormalities of the thyroid gland, and de- view these individuals as lazy, unkempt, and creased insulin production are some of the lacking in self-control. Many experts promote many factors that may contribute to morbid viewing these individuals as having a chronic obesity. Psychological theories include ten- illness rather than a cosmetic problem. dency toward depression and use of food to Morbidly obese people face discrimination comfort oneself related to past traumas such as particularly in the workplace because they are sexual abuse. Overeating as a learned response viewed as less healthy, less diligent, and less in- to stress, tension, and boredom, along with telligent than their thinner peers. Certainly, a sedentary lifestyle and poor nutrition, must with this kind of reaction, it is no wonder that be incorporated into the complex picture. these people often experience poor self-esteem, Treatment of Morbid Obesity feelings of isolation and helplessness, and loss Obesity is a complex issue, and any weight- of control. Morbidly obese individuals often loss program needs to include a multidisci- have subjected themselves to many weight-loss plinary approach. The U.S. Preventative strategies only to regain the weight, which in- Services Task Force (2012) developed federal creases the stress on the body. guidelines for clinicians to help their patients Some educators have noted that fewer than lose weight. It recommends that successful 50% of health-care professionals advise obese weight-loss programs need to include: patients to lose weight (Goldsmith, 2000). Reasons for this low percentage include dis- • Behavioral management activities such as comfort about addressing the subject, lack of setting weight-loss goals 2993_Ch18_287-300 14/01/14 5:28 PM Page 294

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• Improving diet or nutrition and increasing ■ ■ ■ Critical Thinking Question physical activity Your 35-year-old patient is in the hospital for • Addressing barriers to change; self- complications from a recent abdominal surgery. monitoring This man weighs more than 400 pounds. He is • Strategizing how to maintain lifestyle withdrawn and appears depressed. When you bring in his dinner tray, he tells you to take it changes. away as he does not want to eat because the When these measures have been unsuc- doctor told him he has to lose 100 pounds quickly. How should you respond? What cessful, some people pursue surgical inter- options can be given to this patient? ventions, called bariatric surgery. The most common surgeries are the lap band and the gastric bypass. The lap band creates restric- ■ tion of the stomach using a silicone band, Nursing Care of Patients which can be adjusted by addition or re- With Eating Disorders moval of saline through a port placed just under the skin. This operation can be per- Common nursing diagnoses in patients with formed laparoscopically. In gastric bypass, eating disorders include the following: a small stomach pouch is created with a • Body image, disturbed stapler device and connected to the distal • Coping, ineffective small intestine. Generally, bariatric surgery • Nutrition, imbalanced: less than body is considered only for people with a BMI requirements greater than 40 or for those with a BMI • Powerlessness greater than 35 with serious medical compli- • Self-esteem, disturbed cations related to the excess weight, such as diabetes. After weight loss surgury, patients need support and education to adjust to their new bodies. Pharmacology Corner: Behavioral approaches to address triggers Morbid Obesity for overeating can be part of counseling. In 2012 the FDA approved two weight loss Self-help groups like Overeaters Anonymous drugs—the first new drugs in more than or Weight Watchers can be a major source of 12 years. Qsymia (formerly called Qnexa) support. Web-based support programs to combines the appetite suppressant phenter- manage weight are increasingly popular. These mine and the anti-seizure/migraine drug support programs can be helpful even after topiramate. Phentermine was once widely bariatric surgery. prescribed as the “phen” part of the fen- phen weight loss drug that was popular in the 1990s. This combination was with- ■ ■ ■ Clinical Activity drawn from the market after its use was Attend an Overeater’s Anonymous meeting in linked to high blood pressure in the lungs your community. and heart valve disease. The problems were related to the “fen” or fenfluramine part of the combination, not the phentermine. The other drug approved for weight loss Cultural Considerations is Belviq (lorcaserin), which promotes a small amount of weight loss with fewer side Some cultures are more accepting of obe- effects by activating serotonin receptors that sity than others. Knowing the patient’s affect appetite. Both of these new drugs cultural group can give some insight into should not be used in pregnancy. Xenical is whether obesity is considered a problem the only other FDA-approved weight loss to the patient. drug and is sold over the counter as Alli. 2993_Ch18_287-300 14/01/14 5:28 PM Page 295

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• Nutrition, imbalanced: more than body the caloric intake or the healthy food requirements choices, not the weight change. How nurses word the reinforcement can be General Nursing Interventions crucial to the patient’s willingness to continue the plan of care (Berkman et 1. Gaining the Promote positive self-concept: al., 2006; Crisafulli, Von Holle, & Bulik, patient’s trust and giving positive rein- 2008; Silber, Lyster-Mensh, & DuVal, forcement for the progress the patient 2011). makes will help the patient learn to 4. Anxiety over change his or her lifestyle. Promote self-acceptance: one’s body image is a frequent contrib- 2. Nurses who Promote healthy coping skills: utor to distress in these patients. Pro- understand that developing healthy coping moting self-acceptance, feedback, and skills is time consuming and difficult for realistic expectations are all important. anyone with an eating disorder are able to Encourage the patient to think about demonstrate confidence that the patient accomplishments unrelated to body can change. Empathy for the depth of weight. these disorders will help gain the patient’s trust and cooperation. The nurse must be See Table 18-2 for specific interventions careful not to be manipulated into nega- for each eating disorder. tive behaviors by the patient with anorexia. Setting limits on behavior is part of the plan of care. Having the patient consis- ■ ■ ■ Critical Thinking Question You are caring for a 21-year-old woman with tently stay within those limits is part of anorexia nervosa. She is in the hospital receiving teaching new lifestyle behaviors. enteral feedings due to extreme weight loss. She 3. Promote adequate nutrition: The physi- just started eating small amounts of food as well. cian and dietitian or nutritionist will When you walk in the room, you see the patient meet with the patient to discuss calorie staring at her tray and looking very anxious. She tells you, “Take this away.” How should you respond? and nutrient requirements. Most of these What factors might have triggered this reaction? patients will have nutritional deficiencies— even those who are overweight. Nurses are responsible for monitoring the The nursing care plan for patients with eat- patient’s ability and willingness to con- ing disorders is provided in Table 18-3. sume the specified amount of food. Usually, smaller and more frequent meals are tolerated better than the traditional ■ ■ ■ Classroom Activity three larger meals. For a person with • If caring for an anorexic patient, review the care an aversion to food, presenting a large plan so consistent behavioral approaches are tray of food can be overwhelming and followed. • Review recommendations from the nutritionist. discouraging. Positive reinforcement • For the morbidly obese patient, identify ahead for complying with caloric intake can of time what resources are available to assist in be helpful. Note: When implementing patient care, for example, scale, bed, proper size this type of behavior modification, the wheelchair, and proper size patient gown. nurse would be better served to praise 2993_Ch18_287-300 14/01/14 5:28 PM Page 296

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l Table 18-2 Nursing Interventions for Eating Disorders Type Nursing Interventions Anorexia Nervosa • Promote positive self-concept and healthy body image. • Promote healthy coping skills. • Promote adequate nutrition. • Support patient being open about fears and concerns. • Report any evidence of patient sabotaging treatment plan. • Encourage patient to talk about his/her body image and promote realistic image. • Allow some control in decision making. • Monitor patient during meal times and right after for support for anxiety as well as to control sabotage. • Monitor for hiding food. • Establish goals with patient and team for weight gain. • Establish appropriate behaviors in terms of exercise and food preparation. • Avoid focusing on food all the time. Encourage other interests. Bulimia Nervosa • Approach with positive, realistic expectations of food intake. • Help patient identify feelings when he or she gets the urge to binge or purge. • Encourage eating in public. • Monitor for eating in secret. • Provide support during meals and discourage use of bathroom after eating. • Promote a realistic body image by discussing how patient views self. • Help patient identify feelings associated with eating. • Incorporate ways to promote improved self-concept. Morbid Obesity • Work with patient, family, physician, and dietitian to formulate healthy meal plans. • Encourage patient to participate in groups to promote acceptance of self and development of self-esteem. • Make eﬀorts to promote improved self-concept. • Respect privacy. • Work with patient to identify small, achievable goals in weight loss plan. • Encourage keeping a diary of food intake. • Discuss feelings associated with eating. • Work with team to develop a realistic exercise regimen. • Help patient look at weight loss in small increments rather than total weight loss goal. • Promote dignity by being sensitive to patient’s appearance in public. • Plan ahead to right-size equipment available, such as wheelchairs. • Promote positive self-image and acceptance of body by emphasizing personal traits other than weight. • Continue to provide support and education after weight loss surgery.

l Table 18-3 Nursing Care Plan for Patients With Anorexia Nursing Assessment Diagnosis Goal Interventions Evaluation Emaciated Body image Refers to Avoid overreacting or insincere response Makes one patient disturbance her body to self-deprecating comments. positive or describes in a more Rather, listen to patient and then less negative self as fat; positive comment on how you see her. comment Wears baggy way Encourage discussion of positive traits. about herself clothes 2993_Ch18_287-300 14/01/14 5:28 PM Page 297

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■ ■ ■ Key Concepts 4. Eating disorders are serious and can be fatal as a result of malnutrition and 1. Eating disorders of one type or another electrolyte disturbances. aﬀect large numbers of people in the 5. Eating disorders may be related to emo- United States. tional or physical causes. Obesity may 2. Though most common in women, have genetic and emotional causes. anorexia and bulimia are increasingly 6. Nursing interventions for eating disorder common in men. center on promoting self-esteem and 3. Bariatric surgery is becoming far more trust. common than in years past. There are many physical and emotional considerations required when caring for patients undergoing this surgery.

CASE STUDY Penny is a 22-year-old woman who has night she becomes increasing anxious. recently graduated from college. She has Penny has kept bags of cookies and potato struggled with her weight all her life. She chips hidden and often eats entire packages frequently refers to herself as fat and unat- of these items. While she is eating these tractive though her weight appears normal items, she reports feeling relaxed, but for her height. Friends frequently encour- shortly after, her stomach aches and she age her to be more accepting of herself. She feels anxious and guilty. She often reduces is currently job hunting and spends most her anxiety by sticking her ﬁnger down her days at a coﬀee shop searching for jobs on throat to induce vomiting. After vomiting, her computer. She rarely eats during the she collapses in bed and often cries herself day, but while alone in her apartment at to sleep.

1. What disorder is Penny most likely suﬀering from? 2. How could Penny get help for her eating disorder? 3. If Penny came to your mental health clinic, what nursing interventions should be considered?

REFERENCES Berkman, N.D., Bulik, C.M., and Brownley, K.A. (2006). Management of eating disor- American Psychiatric Association. (2006). ders. Treatment of patients with eating disorders. Evidence Report/Technology Assessment 1–166. (7 Suppl), (Full Report) (135), American Journal of Psychiatry 163 Cornette, R. (2008). The emotional impact of 4–54 obesity on children. Worldviews of Evidence- American Psychiatric Association. (2013). Dia - Based Nursing, 5(3), 136–141. gnostic and Statistical Manual of Mental Dis - Cotton, M.A., Ball, C., and Robinson, P. Washington, DC, Author. (Known orders 5. (2003). Four simple questions to help screen as DSM-5) for eating disorders. Anderson, A.E., & Yager, J. (2009). Eating Journal of General Inter- (1), 53–56. disorders. In B.J. Sadock, V.A. Sadock, & P. nal Medicine 18 Crisafulli, M.A., Von Holle, A., and Bulik, C.M. Ruiz (Eds.), Kaplan & Sadock’s Comprehensive (2008). Attitudes towards anorexia nervosa: 9th ed. Philadelphia: Textbook of Psychiatry. The impact of framing on blame and stigma. Wolters Kluwer/Lippincott Williams & Wilkins. 2993_Ch18_287-300 14/01/14 5:28 PM Page 298

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International Journal of Eating Disorders, Yager, J., and Andersen, A.E. (2005). Clinical 41(4), 333–339. practice. Anorexia nervosa. New England Goldsmith, C. (2000). Obesity: Epidemic of the Journal of Medicine, 353(14), 1481–1488. 21st century. Newsweek, May 8, 2000. Gorman, L., and Sultan, D. (2008). Psychosocial WEB SITES Nursing for General Patient Care. 3rd ed. Philadelphia: FA Davis. National Institute of Mental Health provides Hoek, H.W., and Van Hoeken, D. (2003). Re- information on diagnosis and treatment of view of the prevelance and incidence of eating eating disorders. disorders. International Journal of Eating www.nimh.nih.gov/health/publications/eating- Disorders, 34(4), 383–396. disorders/index.shtml Ogden, C., and Carroll, M. (2010). Prevalence Eating Disorder Referral and Information of overweight, obesity and extreme obesity Center with speciﬁc information on males among adults through 2007-8. Retrieved with eating disorders: from cdc.gov/nchs/fastats/overwt.htm www.edreferral.com/males_eating_disorders.htm Silber, T.J., Lyster-Mensh, L.C., and DuVal, J. National Alliance on Mental Illness with (2011). Anorexia nervosa: Patient and detailed information on eating disorders: family-centered care. Pediatric Nursing, http://www.nami.org/Content/NavigationMenu/ 37(6), 331–333. Inform_Yourself/About_Mental_Illness/By_Illness/ Townsend, M. (2012). Psychiatric Mental Health Eating_Disorders.htmWeight Control Information Nursing. 7th ed. Philadelphia: F.A. Davis. Center through the National Associations U.S. Preventive Services Task Force. (2012). of Diabetes, Digestive, and Kidney Disease www.win.niddk.nih.gov/ Screening for and management of obesity in adults. Retrieved from www.uspreventive - National Eating Disorders Association pro- servicestaskforce.org/uspstf11/obeseadult/ vides a hotline and information for patients obesesum.htm with eating disorders and their families. Yager J. (2006). Treatment of Patients With Eating www.nationaleatingdisorders.org/ Disorders. 3rd ed. Retrieved from http:// Overeaters Anonymous psychiatryonline.org/content.aspx?bookid= overeatersanonymous.org 28§ionid=1671334 2993_Ch18_287-300 14/01/14 5:28 PM Page 299

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Test Questions. Multiple Choice Questions 1. The eating disorder that is characterized 5. A key nursing intervention to help as an aversion to food is called: patients with eating disorders is: a. Morbid obesity a. Let the patient know he or she will be b. Bulimia nervosa watched closely at mealtimes. c. Anorexia nervosa b. Have the patient chart his or her own d. Pica intake and output. 2. Your patient with anorexia is admitted to c. Lock the patient’s bathroom door for your medical surgical unit for malnutri- 2 hours after meals. tion. She tells you she does not want to d. Encourage the patient to express eat when her tray is delivered. Which underlying feelings about food, statement is the best response? body image, and self-worth. a. “The doctor said you will need a 6. Bulimia nervosa is characterized by all the feeding tube if you don’t eat.” following except: b. “Tell me what happens to you when a. Binging on food you see the food tray.” b. Purging the food after eating it c. “I will ask the doctor to order an c. Being able to control eating pattern appetite stimulant.” d. Obsession with body shape and size d. “You have to eat or you will starve.” 7. Donald has just been admitted to your 3. Your 19-year-old patient has a diagnosis surgical unit. He has just had stomach of anorexia nervosa. You notice that she stapling surgery. You prepare your list for seems to spend more time playing with postoperative care and include therapeu- her food than eating it. You know that tic communication statements such as: patients with anorexia: a. “You must be so relieved to be on your a. Will eat normally if ignored way to being thin.” b. Fear being fat b. “What is the ﬁrst meal you plan to eat?” c. Have an accurate body image c. “I’m interested to know if the rest of d. Will binge and purge your family is also heavy.” 4. An appropriate nursing diagnosis for a d. “I’m here to help you any way I can.” patient with anorexia might be: 8. It is Donald’s second postoperative day. a. Altered nutrition; less than required He is scheduled to have his ﬁrst oral amount, as evidenced by distress in liquids. As you check on his progress at eating lunch, you note he has not touched his b. Altered nutrition; more than required food. “I’m afraid to eat,” he tells you. amount, as evidenced by eating meals Your response might be: of 2000 calories or more six to seven a. “It’s OK for you to eat now. You won’t times per day choke.” c. Altered body image as evidenced by b. “Afraid to eat, meaning. . .?” stating the wish that others look as c. “It’s important that you eat, or the good as the patient doctor may need to order the IV d. Fluid excess related to increased weight feedings again.” gain d. “Why are you afraid to eat?” 2993_Ch18_287-300 14/01/14 5:28 PM Page 300

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Test Questions cont.

9. Your new admission, a 14-year-old female, 10. In bulimia, the purging is done to presents with multiple symptoms includ- achieve which of the following? ing recent extreme dieting, use of laxatives a. Feelings of euphoria at getting rid and diuretics, thoughts of suicide, impul- of the food sive behavior, and erosion of the enamel b. A need to gain attention on her teeth. The patient’s medical diag- c. A release of tension followed by nosis most likely is: depression and guilt a. Anorexia nervosa d. A way to gain control b. Binge eating c. Bulimia nervosa d. Morbid obesity 2993_Ch19_301-322 14/01/14 5:28 PM Page 301

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CHAPTER 19 Childhood and Adolescent Mental Health Issues

Learning Objectives Key Terms 1. Identify child and adolescent populations at risk for mental • Attention-deficit/ health disorders. hyperactivity disorder 2. Describe the impact of autism spectrum disorder on the (ADHD) family. • Autism spectrum 3. Define three mental health conditions of childhood/adolescent disorder age groups. • Bipolar disorder 4. Identify treatment modalities used in childhood/adolescent • Bullying age groups. • Conduct disorder 5. Identify two medications used to treat attention-deficit/ • Cyberbullying hyperactivity disorder. • Hyperactivity 6. Identify age-appropriate nursing care for two selected mental • Impulsivity health issues.

oday, children are displaying behav- may encounter. The frequency of divorce, iors and being diagnosed with mental less traditional family roles, and parents Tdisorders that two or three genera- working outside of the home has led to a tions ago were nonexistent or at least not so generation that must cope with stresses ear- readily observed in society. Many factors lier in life. Many children are dealing with contribute to this, including greater access anxieties that were unknown in previous to mental health information by parents generations, which contributes to a variety and teachers. However, stresses on children of disorders. today are much different than in previous Children and adolescents are at risk for generations and are contributing as well. developing many of the same mental health The fast pace of life, the Internet, social disorders as adults. Family history of sub- media, continuous exposure to news, instant stance abuse, schizophrenia, and bipolar dis- access to information, and exposure to vio- order will impact the development of mental lence at a young age all lead to children health problems in children and adolescents. growing up more quickly and having to deal Family dynamics will inﬂuence the develop- with many issues that previous generations ment of many disorders as well. never addressed until they were much older. The Centers for Disease Control and The growing trend toward bullying and Prevention’s National Health and Nutrition especially cyberbullying, where the Internet Examination Survey (NHANES) data show is used to embarrass or shame peers, has that approximately 13% of children ages 8 added another stressor that young people to 15 had a diagnosable mental disorder

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304 UNIT 3 | Special Populations within the previous year (CDC, 2013). The ■ Depression, Bipolar most common disorder among this age group is attention-deficit/hyperactivity disorder Disorder, and Suicide (ADHD), which affects 8.5% of this popu- in Children and lation. This is followed by mood disorders Adolescents broadly at 3.7% and major depressive dis - order specifically at 2.7%. Other less com- Depression mon disorders include conduct, anxiety, and eating disorders. Mental disorders in Children and adolescents do exhibit symp- children can lead to a lifetime of problems toms of major depressive and dysthymic dis- including poor peer relationships, problems orders. The symptoms are the same as in the in school, substance use and risk-taking adult illness (see Chapter 11). In addition to behaviors as well as being more likely to the classic general symptoms of depression, develop a chronic psychiatric illness. Forty children may exhibit a change in their school percent of children with mental disorders routines, such as truancy or dropping sports/ will develop a second one (CDC, 2013). Of clubs, changes in sleep habits, and extreme concern is that many children do not get ad- irritability. They may become inattentive, equate early treatment, perhaps due to de- experience a drop in grades, lose interest, or nial on the part of parents and teachers; lack become anxious about being at school. Ado- of mental health services, especially in the lescents who become depressed may show all schools; lack of funding; and stigma. This of the classic symptoms of depression and chapter will discuss depression, bipolar dis- those connected with childhood but may also order, suicide, ADHD, autism spectrum dis- be trying to deal with changes happening in order, and conduct disorder. their bodies, hormones adjusting, and social role and peer group changes. Adolescent Neeb’s • The parents of children with any symptoms of depression may include rebel- ■ Tip mental health disorder are under lion, intense ambivalence, anger, rage, pes- tremendous stress. This stress may simism, and low self-esteem (Figs. 19-1 and be expressed as frustration, irritabil- 19-2). Estimates are that 8.2% of youths ity, extreme fatigue, depression, and between ages 12 and 17 suﬀer from major increased use of alcohol/drugs. depression in the past year, with girls at twice the risk (SAMHSA National Survey on Drug Use and Health, 2008). In children, it is believed that the major factor in development • Other siblings in the home are also Neeb’s of depression is family inﬂuence. If parents ■ at high risk for acting out, as they Tip are depressed, the children are three times often feel ignored with all the at- more likely to be depressed than their age- tention on their sibling with the mates. Environment and biochemical imbal- mental health disorder. ances in the brain are also possible causes.

| ■ ■ ■ Tool Box  National Institute of Mental Classroom Activity Health Information on Childhood and Ado- • Participate/volunteer in a pediatric camp for lescent Depression: children and teens with emotional problems. www.nimh.nih.gov/health/topics/depression/ depression-in-children-and-adolescents.shtml

■ ■ ■ Clinical Activity Review the patient’s medical chart for family his- Neeb’s Depression in children and teens tory and social worker’s notes on family dynamics ■ may be masked as withdrawn, anti- and coping when caring for a child with mental Tip health issues. social behavior; avoiding school; or loss of conﬁdence. 2993_Ch19_301-322 14/01/14 5:28 PM Page 305

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Figure 19-2 Children who are depressed may seem bored and unusually irritable. Figure 19-1 Adolescent symptoms of depression may include rebellion, intense ambivalence, anger, rage, pessimism, and low self-esteem. improved treatment. Interestingly, in the past, children who were diagnosed with bipolar disorder (perhaps inaccurately) had Bipolar Disorder a greater tendency toward anxiety and de- Bipolar disorder is more difficult to diagnose pression as adults rather than bipolar symp- in childhood and may be confused with con- toms. DSM-5 has a new diagnostic category duct disorder or attention-deficit/hyperactivity under Depressive Disorders named Disrup- disorder (ADHD). Some experts think bipolar tive Mood Dysregulation Disorder. This disorder has been overdiagnosed in children disorder is characterized by severe temper and teens. DSM-5 requires bipolar disorder to outbursts with irritable or angry mood in at include distinct episodes of mania that differ least two settings in children but no clear from baseline personality with or without de- manic episodes. This new diagnostic cate- pression episodes. (See Chapter 12 for more gory may include some children that were information on bipolar disorder.) Children previously diagnosed as bipolar. Substance with bipolar disorder generally do not have the use could also contribute to symptoms of typical cycling of mania to depression as seen this disorder. in adults. Some behaviors associated with Children and teens with any of the follow- childhood mania include episodes of: ing need a thorough evaluation by a child psychiatrist to obtain an accurate diagnosis: • Hyperactivity extreme mood swings of depression and hy- • Grandiose delusions peractivity, delusions of grandeur, pressured • Irritability speech, euphoria, and decreased need for • Rapid speech/racing thoughts sleep. Accurate diagnosis is essential so the • Reduced need and desire for sleep appropriate medications and other treatments Hopefully, more accurate diagnosis of can be started. As with adults, the major bipolar disorder in children will lead to contributor to this disorder is family history. 2993_Ch19_301-322 14/01/14 5:28 PM Page 306

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and transgender youths are at especially Tool Box | NIH brochure for children and teens and their parents on bipolar disorder: high risk as they struggle with fitting in www.nimh.nih.gov/health/publications/ with their peers. Gender dysphoria, also bipolar-disorder-in-children-and-teens-easy- known as gender identity disorder, where to-read/who-develops-bipolar-disorder.shtml the child or teen is struggling with his/her sexual identity, can increase the risk for depression and suicide. Suicide Signs of suicide risk can include: Suicide is the second leading cause of death • Talking a lot about death in teenagers (Fig. 19-3). The frequency of • Asking questions about death suicide attempts in adolescents has taken an • Giving away possessions alarming increase in recent years. Eleven • Artwork or play with death themes and a half percent of females and 5.4% of • Loss of interest in friends/sports males of high school age have attempted • Evidence of substance abuse suicide (National Institute of Mental Health • Poor sleeping habits Statistics on Suicide, 2012). Peer pressures • Expression of hopelessness, self-hate with the increased use of social media and • Previous suicide attempts the presence of bullying have left some vulnerable teens viewing their lives as hopeless. Young people’s methods of suicide may In addition, young people may view suicide be similar to those of adults, for example, in a more romanticized way and be desensi- using firearms or hanging, but also include tized to death, which may be a contributor impulsive acts (especially common in young in suicide pacts. Depression and bipolar children) such as jumping out of a window disorders are major contributors to suicide or running in front of cars. As with adults, risk, but others, including substance abuse talking about suicide and previous attempts and ADHD, can also be factors. Younger are common warnings that must be taken children can also attempt suicide and may seriously. think of it as a magical way to get back at parents or others. Lesbian, gay, bisexual, Neeb’s Children can be very sensitive to re- ■ Tip jection, which can lead to suicidal thoughts and impulsive acts. Any time a child mentions any thought about suicide, investigate fully. Never minimize his/her concerns.

■ ■ ■ Clinical Activity Be aware of your patient’s changes in behavior that can signal exacerbation of depression, bipolar disorder, or suicidal intent.

Cultural Considerations Figure 19-3 Suicides among teenagers are growing alarmingly. Many of the teens who These conditions cross all ethnic groups. attempt suicide state feelings of anger and In the past, these disorders were less fre- frustration about not being listened to or not quently diagnosed in non-Caucasian soci- being taken seriously as the reason for their ety, but now parents and the education action. (Courtesy of Centers for Disease Control and system are more informed to improve Prevention, National Center for Injury Prevention earlier identiﬁcation across all groups. and Control, Atlanta, GA.) 2993_Ch19_301-322 14/01/14 5:28 PM Page 307

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■ ■ ■ Critical Thinking Question Your new patient is a 10-year-old boy who has just Pharmacology Corner: been admitted to the pediatric unit after being Depression, Bipolar hit by a car. His injuries are not life threatening. A Disorder, and Suicide neighbor told the paramedics she saw the boy run into the street right at the car. She thought he Antidepressants are not always helpful and did it on purpose in a suicide attempt. The boy’s can be dangerous in the younger age group parents report he has been bullied by two older with depression. In September 2004, the boys lately and has been very upset, but they refuse to consider this a suicide attempt. What Food and Drug Administration (FDA) of other information would you want to know about the United States recommended that a the patient and family? What interventions should strong caution be placed on antidepressant the staff consider for this boy? medications for children and teenagers due to increased risk of suicide. The caution that suicide can be a side effect of antidepressants led to the black box warning that is now on Treatment of Children and all antidepressants. Doctors and parents Adolescents With Depression, need to weigh the benefits against potential Bipolar Disorder, and Suicide risks of using these medications. SSRIs Treatment of depression and bipolar disorder including fluoxetine and escitalopram have in these age groups is challenging. Group ther- been approved for treatment in adolescents. apy, family therapy, individual psychotherapy, Monoamine oxidase inhibitors (MAOIs) and partial or day-hospital programs have are not often used because of the food con- been shown to be helpful for many in this age traindications associated with them. Some group. Treatment should focus on strengthen- tricyclic antidepressants can cause cardiac ing coping skills and support. Parental in- arrest and death in children and adolescents. volvement is essential for recovery. Psycho- Still, medications may be needed and should education focuses on teaching patients and be used cautiously and monitored carefully. parents life skills, communication, problem Bipolar disorder is treated with mood sta- solving, and early signs of relapse to cope with bilizers as in adults as well as with antipsy- these disorders. chotics if needed. See Chapter12. Children Any sign of suicide risk in a child/teen and adolescents may need to remain on requires immediate intervention including medications for years, so accurate diagnosis psychiatric evaluation. See Chapter 13 for and long-term management of side effects specific interventions. is essential. Suicidal behavior is treated with antidepressants and anti-anxiety medications. See Chapter 13. Neeb’s Denial of a child’s suicide risk can When children are diagnosed with a ■ Tip lead to tragedy when the call for serious psychiatric disorder early in life, the help is not recognized out of a belief long-term side effects of effective medica- that a child would not attempt tions are a major concern and must be suicide. weighed with the potential benefits. Parents may be faced with difficult choices and will need counseling and support as these deci- Tool Box | Compassionate Friends is a sions are needed. national support program for parents whose children have died, including those who have died from suicide. Information on Surviving Tool Box | FDA black box warning info on Your Child’s Suicide: antidepressants: www.compassionatefriends.org/Brochures/ www.fda.gov/D rugs/D rugSafety/Information surviving_y our_c hilds_s uicide.aspx byD rugClass/U CM 09 627 3 2993_Ch19_301-322 14/01/14 5:28 PM Page 308

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Neeb’s Ensure that parents are familiar with 5. Encourage the completion of simple tasks. ■ Tip all potential side effects and required Give the child honest feedback on all monitoring for their child. successes. 6. Provide a safe environment where the child feels comfortable to share fears and Nursing Care of Children and concerns and has an outlet for pent-up Adolescents With Depression, energy and frustration. Bipolar Disorder, and Suicidal 7. Respond to any self-destructive behavior Behavior with concern and action to maintain safety. Encourage the child who has self- Common nursing diagnoses for children destructive thoughts to talk with an adult. and adolescents with depression include the Children should be taught to never keep following: secret another’s suicidal plan. • Anxiety See Chapters 11, 12, and 13 for more in- • Coping, ineffective terventions for depressive disorders, bipolar • Hopelessness disorders, and suicide. See Nursing Care Plan • Injury, risk for in Table 19-1. • Self-esteem, low General Nursing Interventions ■ ■ ■ Critical Thinking Question 1. Communicate honestly and effectively The mother of your 14-year-old patient who has and at an age-appropriate level. been admitted after a suicide attempt asks to talk 2. Identify limits and boundaries. Explain to you. She is understandably quite distressed and what is appropriate behavior and what asks you to make sure the doctor starts her son on an antidepressant. What teaching needs to be is not acceptable. Be clear and concise. given to the family about antidepressants and Place the emphasis in the “positive.” For teens who have suicidal thoughts? example, to an angry individual a nurse might say, “You may hit the punching bag in the gym, but not another person.” 3. Focus on child/adolescent’s strengths. They ■ Attention-Deficit/ should be structured but able to flex fre- Hyperactivity Disorder quently with the child/adolescent’s needs. 4. Support the individual; encourage verbal- Attention-deficit/hyperactivity disorder (ADHD) ization of feelings and thoughts. Do not is a pattern of behavior involving inattention minimize the child’s fears and concerns. and/or hyperactivity/impulsivity. For this di- Young children especially can benefit agnosis the child must display symptoms in from art therapy to express their feelings. more than one setting for example at home,

l Table 19-1 Nursing Care Plan for the Depressed Child Nursing Data Collection Diagnosis Plan/Goal Intervention Evaluation Child is increas- Low self- Child will Encourage the child to Child returns ingly isolated, esteem demonstrate talk about his fears and to one activity refusing to go to increased insecurities in a supportive he previously school, drops out feelings of setting without judgment; enjoyed; of sports, is irrita- self-worth Plan activities that provide Able to ver- ble, reports feeling opportunities for success; balize his unable to meet Avoid minimizing his fears; strengths and teachers’ and par- Give immediate feedback successes ents’ expectations on any successes 2993_Ch19_301-322 14/01/14 5:28 PM Page 309

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in church, at school, or while in the shopping Box 19-1 Symptoms of ADHD mall. This disorder leads to problems in so- l cial, education, and/or work performance. It Inattentive symptoms: is grouped under Neurodevelopmental Dis- 1. Fails to give close attention to details or orders in DSM-5. The diagnosis is generally makes careless mistakes in schoolwork made by the age of 12. ADHD can continue 2. Has difficulty keeping attention during into adulthood, and generally adults with tasks or play ADHD remember having behavior problems 3. Does not seem to listen when spoken to by the age of 12. About half of children with directly ADHD continue to have troublesome symp- 4. Does not follow through on instructions toms of inattention or impulsivity as adults. and fails to finish schoolwork, chores, or duties in the workplace However, adults are often more capable of 5. Has difficulty organizing tasks and activities controlling behavior and masking difficulties. 6. Avoids or dislikes tasks that require sus- ADHD in children younger than age seven is tained mental effort (such as schoolwork) a bit more challenging to diagnose, since the 7. Often loses toys, assignments, pencils, younger child is prone to shorter attention as books, or tools needed for tasks or a result of the child’s developmental stage. activities ADHD is more common in males and does 8. Is easily distracted seem to have a pattern of running in families. 9. Is forgetful The troublesome behaviors must be present Hyperactivity/Impulsivity symptoms: for at least 6 months to a degree that is mal- 1. Fidgets with hands or feet or squirms in adaptive and inconsistent with developmental seat level to confirm this diagnosis. 2. Leaves seat when remaining seated is The symptoms of ADHD are divided expected into inattentive and hyperactivity/impulsivity 3. Runs about or climbs in inappropriate (Box 19-1). Children can have one or situations both categories of symptoms to receive 4. Has difficulty playing quietly this diagnosis. 5. Is often “on the go,” acts as if “driven by a motor” ADHD can be confused with depression, 6. Talks excessively lack of sleep, learning disabilities, bipolar dis- 7. Blurts out answers before questions have order, tic disorders, and general behavior been completed problems. Every child suspected of having 8. Has difficulty waiting for his/her turn ADHD should be carefully examined by a 9. Interrupts others doctor to rule out other possible conditions Source: Adapted from Diagnostic and Statistical Manual of Mental or reasons for the behavior before pursuing a Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association.

diagnosis with other professionals such as Cultural Considerations teachers, psychologists, and other therapists. In the past, ADHD was diagnosed mainly Because children with ADHD put great in Caucasians and under recognized in demands on family life, they may be at other ethnic groups. Now with improved higher risk for punitive responses from par- diagnostic tools and more awareness, this ents and teachers, which can increase their disorder is recognized in many ethnic distress. The presence of ADHD puts the groups. Cultural norms also need to be child at risk for a lifetime of maladaptive taken into consideration when determin- behaviors and impaired social relationships, ing what is considered “normal” behavior so early identification and treatment are im- for children within a particular group. portant. In addition, children with ADHD Children need to be assessed in their na- are prone to substance abuse, depression, tive language to avoid confusion about anxiety, conduct disorders, and learning dis- their concerns. abilities. Children with this disorder are generally of average or above-average intelligence 2993_Ch19_301-322 14/01/14 5:28 PM Page 310

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but do not always perform at their level of school and home life can make a difference. intelligence. This can include a system of rewards and con- A definitive cause of ADHD has not been sequences to help guide their child’s behavior confirmed. See Box 19-2 for list of potential and handle disruptive behaviors. Support causes. Combinations of organic, genetic, and groups can help parents connect with others environmental factors may put a person at who have similar problems. Parents need on- higher risk. It is common that parents of the going support programs. ADHD child showed signs of hyperactivity in their childhoods, indicating a strong genetic Tool Box | National Institute of Mental component. Abnormal levels of neurotransmit- Health ADHD publication: ters are associated with many of the symptoms www.nimh.nih.gov/health/publications/ of ADHD, as is abnormal brain function. attention-defi cit-hyperactivity-disorder/ Chaotic family life is also a factor. Some children how-is-adhd-treated.shtml have benefitted from diet modifications such as Children and Adults with ADHD (CHADD) eliminating foods like milk products or sugar. provides resources to children and parents: www.Chadd.org

■ ■ ■ Clinical Activity Identify triggers in the environment that lead to your ADHD patient’s disruptive behavior. Pharmacology Corner: Attention-Deficit/ Hyperactivity Disorder Treatment of Children and Medications are the most common treatment Adolescents With Attention- approach. As with other illnesses affecting Deficit/Hyperactivity Disorder young people, use of medication is contro- Though medications are commonly used to versial. Physicians must consider the physical treat ADHD, they should be used in com- maturity of a child’s brain, liver, and kidneys bination with other therapies. Psychotherapy as well as the child’s ability to handle other for the child and family is often helpful, effects of medication before prescribing. along with cognitive behavior therapy that Psychostimulants (also known as stimu- focuses on learning new coping mechanisms. lants) are the most commonly used ADHD The child needs to learn the consequences drugs. Although these drugs are called stimu- of impulsive behavior and identify alterna- lants, they actually have a calming effect on tives, and learn how to improve social skills. people with ADHD by increasing the levels Close involvement of the child’s teachers can of neurotransmitters. These medications can help with learning and behavior. increase the child’s ability to concentrate and Parents need to develop skills to address reduce hyperactivity and impulsiveness. New their child’s disruptive behaviors. A structured long-acting formulations, liquids, powders that can be sprinkled on food, and transdermal patches are available for some of these l Box 19-2 Possible Causes of ADHD medications to help with compliance. The • Genetics—family history is a strong predictor major side effects of these agents include over- • Altered secretion of neurotransmitters like stimulation, restlessness, insomnia, anorexia, dopamine weight loss, headache, and irritability • Altered brain anatomy (Roman, 2011). See Table 19-2 for the com- • Prenatal exposure to alcohol mon pharmacological treatment of ADHD. • Exposure to lead Nursing considerations for children on • Reaction to food dyes, additives, sugar stimulant medications include: • Chaotic family life • Administer after eating or with meals to Source: Adapted from National Institutes of Mental Health (2012) reduce effect on appetite. and Townsend (2012). 2993_Ch19_301-322 14/01/14 5:28 PM Page 311

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• Injury, risk for Pharmacology Corner: • Self-concept, alteration in Attention-Deficit/ • Self-esteem Hyperactivity • Social interaction, impaired Disorder–cont’d • Generally administer them no later than General Nursing Interventions 6 hours before bedtime to avoid inter- 1. Effective communication: Therapeutic ference with sleep. communication with the child/adolescent • The school nurse and teachers should and the involved family members is be informed that the child needs the always indicated. Teaching/modeling medications. skills to assist with interpersonal family • Some schools require the school nurse communication is helpful. to administer the medications. 2. Assist with behavior modification tools: • Monitor adolescents who may share Limit setting, reward systems, and medications with others. positive reinforcement may be helpful. • Monitor the child’s weight and blood Facilitate agreement between the par- pressure. ents and child/adolescent regarding • Prepare parents to monitor for impact what will be used as the reward, what on the child’s growth. is fair, and what the consequence to inappropriate behavior will be. Consis- tency among all parties is crucial in Neeb’s Children may avoid taking their this modality. ■ Tip medication out of fear or anger, or to 3. Promote self-esteem: Help the child com- avoid side effects. They may hide it plete a task and reward with praise or from their parents or school nurse, so other rewards. Give positive feedback close monitoring and promoting for all appropriate behavior. Teach alter- open communication are important. native behaviors. It can be helpful to break down tasks into small steps to reduce frustration from poor attention Nursing Care of Children and span. Reinforce socially acceptable be- Adolescents With Attention- havior rather than giving a lot of atten- Deficit/Hyperactivity Disorder tion to negative behaviors. 4. Low stimulation environment: Identify Common nursing diagnoses for children and the signs when behavior is beginning adolescents with attention-deficit/hyperactivity to escalate and intervene to reduce stim- disorder include the following: ulation. Physical activity can be a good • Coping, ineffective outlet for pent-up energy, followed by a • Family coping, compromised quieter environment.

l Table 19-2 Common Pharmacological Treatment of ADHD Drug Category Drugs Psychostimulants Dextroamphetamine/amphetamine (Adderal) Methylphenidate (Ritalin, among other trade names) Nonstimulant Atomoxetine (Strattera) Miscellaneous Bupropion (Wellbutrin) Clonidine

Source: Adapted from Townsend (2012): Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice, 7th ed. Philadelphia: F.A. Davis Company, with permission. 2993_Ch19_301-322 14/01/14 5:28 PM Page 312

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5. Reinforce information about medications: in social communication and social interac- The physician should discuss the effects tion with problems in maintaining relation- and side effects of any medications or- ships as well as repetitive patterns of behavior. dered. Family members may have fur- It is called a spectrum disorder because it ther questions for nurses. Be prepared can be present in a mild form with some to assist with clarification about the peculiar behaviors and mild social isolation medication(s). Stress the importance but otherwise normal behavior; or to the of compliance with the regimen to the other extreme it can be severe, with profound child and parents. disability in all aspects of life. Asperger’s 6. Promote a safe environment as these chil- syndrome is a mild form of ASD. Autism dren are susceptible to falls and accidents. spectrum disorder is a neurodevelopmental 7. Family support and education: Living with disorder in DSM-5. It must be present from a child with ADHD can be very stressful infancy or early childhood but may not be for a family. detected until later because of minimal social (Pati, 2011; Primich & Iennaco, 2012) demands and support from parents or caregivers in early years. ■ ■ ■ Critical Thinking Question Your 6-year-old patient has recently been diag- ■ ■ ■ Classroom Activity nosed with ADHD. The patient’s mother tells you • View the movie Rainman about an adult with she has been giving him Ritalin at bedtime so he autism. will sleep better. What teaching would you provide to the mother to minimize side effects for the patient? Neeb’s DSM-5 now views autism spectrum ■ Tip disorder to include what was previously known as Asperger’s syndrome, ■ ■ ■ Critical Thinking Question though this is a term that is still com- Your neighbor comes to you for advice with her monly used. These individuals have 10-year-old child. He is failing in school, unable less problems with language and to concentrate, and becomes very antsy in class. Your neighbor wants to change his school as she cognition than more severe forms of thinks the teacher is at fault. What suggestions ASD. This syndrome was originally would you make? named after an Austrian pediatrician who first described it. Sometimes these people are referred to as hav- ■ ■ ■ Classroom Activity ing high functioning autism. • Identify local resources for ADHD in your community. • Ask a local elementary school teacher or school Tool Box | Pediatric screening tools for nurse to discuss management of a child with autism at the CDC Autism Spectrum Disor- ADHD in the classroom. ders Web site: www.cdc.gov/ncbddd/autism/hcp-screening. html ■ Autism Spectrum Disorder The single most common symptom or Autism spectrum disorder (ASD) is a gen- manifestation of ASD is impaired social eral term that includes classic autism and interaction. Learning disabilities, avoiding Asperger’s syndrome. These disorders are making eye contact, and inability to make now classified as ASD rather than treated as friends or respond to other people’s emotions separate disorders (DSM-5). ASD is a com- are other symptoms. Children with this dis- plex developmental disorder of brain function order may twirl their hair and/or perform accompanied by intellectual and behavioral self-injuring or self-mutilating behaviors, deficits characterized by persistent difficulties such as biting themselves or hitting their 2993_Ch19_301-322 14/01/14 5:28 PM Page 313

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head on objects. Repetitive patterns can in- Disease Control and Prevention, “Autism clude excessive adherence to routines, ritual- Spectrum Disorders,” 2012). This is a 78% istic behavior, and repetitive speech or motor increase from 2002, reflecting the increased patterns such as rocking or spinning. awareness of parents and doctors to the early Children with ASD commonly exhibit the signs. ASD affects males three to four times following symptoms: more frequently than it affects females. Sadly, at this point in time, it is not curable • No response to their name by 12 months and most individuals will require lifelong • Not pointing at objects to show interest treatment. Children with severe autism are (e.g., not pointing at an airplane ﬂying considered disabled for life. Autism should over) by 14 months not be confused with or misdiagnosed as • Not playing “pretend” games (e.g., pre- schizophrenia, although some behaviors may tending to “feed” a doll) by 18 months be similar. • Avoiding eye contact and wanting to be Causes of autism are not conﬁrmed. Ge- alone netics, viral infections, and chemicals found • Having trouble understanding other in the environment are suspected causes or people’s feelings or talking about their contributors to development of autism. For own feelings parents with one autistic child, there is about • Delayed speech and language skills a 5% chance of having a second child with • Repeating words or phrases over and over autism. Serotonin levels have been shown (echolalia) to be diminished in the left frontal lobe of • Giving unrelated answers to questions many with autism. Fragile X syndrome, con- • Getting upset by minor changes genital rubella, exposure to some medications • Obsessive interests in utero, and tuberous sclerosis have been • Flapping their hands, rocking their body, suggested as possible causes of ASD. The or spinning in circles increased incidence of ASD has led to more • Unusual reactions to the way things emphasis on research. sound, smell, taste, look, or feel • Appearing to be in their own world Some people continue to believe (Adapted from CDC Facts about ASD, Neeb’s ■ Tip that autism is caused by childhood 2012) vaccines. This has led some parents To make the diagnosis, doctors may also to refuse vaccines for their infants, look at failure to meet certain developmental which can expose them to nor- tasks, such as a baby not babbling or per- mally preventable illnesses and forming gestures (pointing, grasping, etc.) contribute to endangerment of by age 12 months, or, at any age, losing others. If parents are concerned any language or social skills that had been about vaccines, encourage them acquired. Sometimes the child may appear to discuss their concerns with to have normal development and then stop the physician before making any gaining new skills. There are several inven- decisions. tories that the physician, psychologist, or psychiatrist might administer to help with diagnosing. Parents often notice the signs Tool Box | National Institute of Health Fact Sheet on Autism: by age 2 when the child is not developing www.ninds.nih.gov/disorders/autism/detail_ language skills and/or showing difficulty autism.htm with social interaction as in not making eye Services for people with autism and Asperger’s contact or makes repetitive nonpurposeful syndrome provide resources and support: movements. aspergersyndrome.org The incidence of ASD is on the rise. The CDC Fact Sheet about ASD CDC reports that 1 in 88 U.S. children www.cdc.gov/ncbddd/autism/facts.html have autism spectrum disorder (Centers for 2993_Ch19_301-322 14/01/14 5:28 PM Page 314

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Cultural Considerations Pharmacology Corner: ASD has been underdiagnosed in the Autism Spectrum Disorder Latino and black populations due to lack Research trials for drugs to treat autism are of awareness by parents and health-care ongoing, but so far there is no definitive professionals. This has led to later diag - pharmacological treatment. Doctors may nosis and treatment in these populations. prescribe medication for difficult symptoms Previously viewed as a disorder mainly such as deliberate self-injury, aggression, in Caucasian children, more resources are and uncontrollable temper tantrums. The now available to identify and treat this FDA has approved the use of risperidone disorder in other races. (Risperdal) and aripiprazole (Abilify) for children with these symptoms. Patients on these medications require close monitoring. Treatment of Children and The dosage is based on the weight of the Adolescents With Autism child and clinical response. Spectrum Disorder Although there is no cure for autism at this time, early identification is important. Early ■ ■ ■ Clinical Activity Review possible side effects of any medications intervention services help children from birth your ASD patient is taking. Reinforce education to 3 years old learn important skills and enon medications to parents and the patient. hance development by taking advantage of the brain’s ability to adapt. Services can include therapy to help the child Nursing Care of Children talk, walk, and interact with others. Many new and Adolescents With Autism treatment programs that incorporate intensive speech, occupational, and physical therapies as Spectrum Disorder well as behavioral training and management Common nursing diagnoses for children and may be appropriate for some. These are home- adolescents with autism include the following: and school-based intensive programs that have • Injury, risk for shown some success. Therapies may incorporate • Self-care deficit a structured reward system for responding to • Social interaction, impaired people. Each child must be evaluated individu- • Verbal communication, impaired ally for the best treatment. There are also many unproven treatments that parents will pursue in General Nursing Interventions a desperate effort to treat their child. 1. Maintain safety: Therapists may prescribe Neeb’s Having a child with ASD creates special equipment or even special cloth- ■ Tip tremendous physical, emotional, and ing, such as helmets and arm covers, to financial stress on the family. These help maintain safety. The goal of this in- families need information on all re- tervention is to discourage and prevent sources available in the community. self-destructive behavior. Assisting parents to identify situations that may trigger the unwanted behavior is also helpful Neeb’s Parents may be desperate for alter- in preventing or de-escalating the behav- ■ Tip native treatments and may share ior. Monitor the child closely and remove approaches that you find question- any items in the environment that may able. It is important to maintain cause injury. their trust and encourage them to 2. Reinforce medical and counselor teaching: be open to standard medical treat- Work with the parents and child on ment and investigate thoroughly social skills. Provide praise and positive any alternative approach. reinforcement for both the parents and 2993_Ch19_301-322 14/01/14 5:28 PM Page 315

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child. Technology is assisting with inter- 7. Parental support: Having an autistic ventions for some patients. Virtual real- child affects the entire family on a daily ity equipment and tablet computers are basis. They need support and resources. being used in some settings and with See Nursing Care Plan in Table 19-3. some success to help with teaching and behavioral training. The child may be able to relate more to these images than ■ ■ ■ Clinical Activity through interaction with others. Pet • If your ASD patient is hospitalized, encourage therapy, where a child can interact with his or her family to bring in familiar objects and advise staff about usual routines. a dog, cat, or through horseback riding, • Talk with a social worker about potential support has shown success. resources for the parents and siblings in the home. 3. Maintain effective communication with all parties: Speak to the child or adolescent in simple, direct, age-appropriate ■ ■ ■ Classroom Activity language. Acceptance of behavior is • Identify ASD resources in your community important. Ensure that the family and and invite some representatives to your class others involved in the day-to-day care to discuss. of the patient feel comfortable discussing • Arrange an observation in a school for children concerns. with special needs such as autism. 4. Maintain consistency of caregivers: The child may do better with familiar people. Try to reduce the amount of stimulation ■ ■ ■ Critical Thinking Question from strangers. Keep expectations realis- An 8-year-old boy diagnosed with autism is admit- tic, and recognize that progress is slow ted to your pediatric unit for an upcoming surgery. When you walk into his room, he is standing in the and regression to previous behaviors may corner staring at one spot and does not respond occur, especially under stress. Support to your greeting. Identify two approaches you independence where possible. would use to make contact with him. 5. Avoid overstimulating the child: Deter- mine if the child becomes more stressed with physical contact. The child may ■ Conduct Disorder be uncomfortable with being touched. Check with the family on what the child Conduct disorder is a disorder of childhood will accept. and adolescence that involves long-term 6. Establish a routine schedule with the (chronic) behavior problems associated with child that all staff follows as much as physical aggression, defiance, rule breaking, possible. and disturbed peer relationships. Sometimes

l Table 19-3 Nursing Care Plan for the Autistic Child Nursing Data Collection Diagnosis Plan/Goal Intervention Evaluation 8-year-old autistic Impaired verbal Child will • Assign consistent Child has boy in the hospital communication demonstrate caregivers reduced is frequently one alternative • Ask parents to bring frequency banging his head behavior indicat- in familiar objects of head on the wall and ing reaction to from home and banging does not speak caregiver, e.g., review usual routine to any of the staﬀ facial expression, • Give positive feed- eye contact back for alternative behaviors 2993_Ch19_301-322 14/01/14 5:28 PM Page 316

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these children are viewed as “bad” or delin- that are sometimes seen in conduct disorder quent rather than having a psychiatric disor- including callousness and lack of remorse. der. These children exhibit a repetitive and When a person with conduct disorder has persistent pattern of behavior in which the these traits, he/she is harder to treat. Conduct basic rights of others or major age-appropriate disorder may be preceded by oppositional societal norms or rules are violated. Conduct defiant disorder (ODD) in some children, disorder is now categorized under Disruptive, which is a pattern of negativistic and hostile Impulse Control and Conduct Disorders in behavior toward authority figures. DSM-5. The diagnosis of conduct disorder is Causes/contributing factors to conduct based on the presence of a pattern of aggres- disorder include a variety of factors: sive behavior to people and/or animals, de- • Victim of child abuse/neglect struction of property, deceitfulness, or theft • Drug addiction or alcoholism in the and/or serious violation of rules. The diagno- parents sis is much more common among boys. The • Family conflicts onset can be in childhood or adolescence. For • Genetic defects an accurate diagnosis, the behavior must be • Poverty far more extreme than simple adolescent re- • Exposure to toxins bellion or boyish enthusiasm. It is a pattern • Head trauma, brain disorder of behavior; a one-time incident does not • Prenatal exposure to cocaine diagnose the condition. Some behavior pat- • History of attention-deficit/hyperactivity terns might be bullying, displaying or using disorder a weapon, arson, lying, fighting, animal abuse, • Substance abuse truancy from school, chronic rule breaking, and running away from home (Fig. 19-4). Treatment of Children and Careful screening and medical testing are Adolescents With Conduct important, as much change is happening developmentally in this age group. Conduct Disorder disorder has been known to be a precursor of Medical treatment for conduct disorder first in- bipolar disorder and/or antisocial personality cludes a thorough assessment. Sometimes, there in adulthood for some. Conduct disorder can is an underlying medical condition in conduct occur with or be confused with ADHD, disorder, such as closed head injury or a seizure mood disorders, and learning disabilities. disorder. The physician will need to assess and DSM-5 has noted several specific patterns treat the underlying disorder as well as the behaviors associated with the conduct disorder. Once the diagnosis is made, treatment includes counseling for the parents and family as well as the affected child. A child psychiatrist can work with the patient to address past traumas and anger issues. Parenting skills, consistency in limit setting, and progressing maturity of the child may, over time, often lessen or eliminate the behaviors of conduct disorder, especially as the child moves out of adolescence. Parent Management Training is an approach that teaches skills to parents about more effective ways to respond to episodes of aggression. Figure 19-4 Recurrent bullying is a behavior Teachers need to have skills to address these that may indicate a conduct disorder, and it issues. Residential treatment is sometimes pre- can be found among both boys and girls. scribed for children with this disorder. Group (Courtesy of U.S. Department of Health and Human therapy of some form can help the child relate Services, Office of Women’s Health, Fairfax, VA.) more appropriately to his/her peer group. 2993_Ch19_301-322 14/01/14 5:29 PM Page 317

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■ ■ ■ Clinical Activity Nursing Care of Children and When your patient has conduct disorder, recog- Adolescents With Conduct nize possible contributing factors, which can include ADHD, child abuse, substance abuse, Disorder and lack of parental guidance. Common nursing diagnoses for children and adolescents with conduct disorder include the Neeb’s It is important to maintain a calm but following: ■ ﬁrm approach that does not com- Tip • Coping, defensive municate fear or avoidance. The child • Injury, risk for may have learned to use aggressive • Other-directed violence, risk for behavior to keep people away and • Self-esteem, disturbed maintain power over others. • Social interaction, impaired

Tool Box | American Academy of Child and General Nursing Interventions Adolescent Psychiatry has information on 1. Maintain safety: Maintaining physical Conduct Disorder Resources With Practice safety and psychological and emotional Parameters at safety is the primary nursing interven- www.aacap.org/cs/ConductD isorder.R esource Center tion for children and adolescents who have conduct disorder. 2. Communicate honestly and effectively: Neeb’s Parents of a child with conduct dis- Communicate at an age-appropriate ■ Tip order are faced with many stresses as level the behaviors that are acceptable. they must deal with others who are Communicate the effect that inappro- hurt by their child as well as the priate behavior has on others around the child’s behavior. They need resources child. Communicate the consequences to help them, such as legal, emo- of inappropriate behavior and, most tional, and financial. importantly, be consistent with enforc- ing those consequences. Recognize that the child may have poor skills in social ■ ■ ■ Critical Thinking Question Ben is 11 years old and was brought to your mental situations and may need coaching or health clinic by his single mother after the school positive reinforcement. has expelled him for repeated “bullying” of younger 3. Assist with behavior modification tools: children. One of the children attempted suicide Limit setting, reward systems, and after being repeatedly humiliated by Ben. Ben’s positive reinforcement may be helpful. mother is desperate for help and tells you she wants to turn Ben into the juvenile authorities to Set realistic expectations according to institutionalize him. What would you say to this the child’s age and ability level. Consis- mother? What other options might be appropriate? tency among all parties is crucial. 4. Model and educate the family with respect to appropriate roles: In other words, parents need to be parents. The child needs Pharmacology Corner: to be the child. The parent should be in Conduct Disorder “control” of the situation. The child has Medications such as antipsychotic risperi- input; negotiation is healthy, depending done can contribute to symptom control for on the age of the child, but the child extreme agitation. These work most effec- does not always “win.” When the child tively along with counseling. ADHD med- does not “win” and behavior limits are ications such as stimulants, along with exceeded or violated, the consequences antidepressants and clonidine, have been for the inappropriate behavior must be used with success for some. enacted. Parents may find this difficult and exhausting. They will need support 2993_Ch19_301-322 14/01/14 5:29 PM Page 318

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and positive reinforcement from the Recently, black box warnings have been nurse and medical or counseling staff. applied to certain antidepressants when When the child is involved in hurting used with children and adolescents; others or in risky behaviors, the adults some antidepressants may actually have to take control to stop these increase the chance for suicide. behaviors. 5. Reinforce information about medications: 3. Incidence of autism spectrum disorder The physician should discuss the effects has shown a dramatic increase in the last and side effects of any medications or- few years. It is a serious disorder that has dered. Family members may have further lifelong effects. questions for nurses. Be prepared to assist 4. Parents, family members, and other with clarification about medications. primary caregivers need to be involved in the treatment of children and adoles- ■ ■ ■ Key Concepts cents. Consistency of care is crucial. Parents may need counseling in order 1. Children and adolescents do experience to become more effective in their role threats to their mental health. They have as parents. the same illnesses as adults but may 5. ADHD and conduct disorders present manifest them in different ways. Some challenges to nurses working with chil- illnesses continue into adulthood. dren and teens. 2. Medications and therapy are effective for a great many people in these age groups.

CASE STUDY Sharon, a 15-year-old girl, was brought to stealing money from other students’ lock- your family practice clinic by her mother. ers. When asked about her behavior at Her mother explained that Sharon was sus- home, Sharon reports that her mother fre- pended from school for assaulting a teacher quently “gets on my nerves” and, at those and needed a “doctor’s evaluation” before times, Sharon leaves the house for several she could return to class. The history reveals days. The family history indicates that that this is Sharon’s tenth school suspension Sharon’s father was incarcerated for auto during the past 3 years. She has previously theft and assault. Sharon’s mother fre- been suspended for ﬁghting, carrying a quently leaves Sharon and her 8-year-old knife to school, smoking marijuana, and brother unsupervised overnight.

1. Given this information, what suggestions could be made to help this mother cope with the teen’s behavior? How would you approach Sharon on ﬁrst meeting her? 2. What possible diagnoses do you think would be considered?

REFERENCES Beck-Little, R., and Catton, G. (2011). Child and adolescent suicide in the United States: American Academy of Child and Adolescent a population at risk. Journal of Emergency Psychiatry. (2008). The depressed child. Nursing, 37(6), 587–589. Retrieved from http://aacap.org/cs/root/ Black, D.W., and Andreasen, N C. (2011). facts_for_families/the_depressed_child Introductory Textbook of Psychiatry. 5th ed. American Psychiatric Association. (2013). Diagnos- Washington D.C.: American Psychiatric tic and Statistical Manual of Mental Disorders 5. Publishing. Washington, DC, Author. (Known as DSM-5) 2993_Ch19_301-322 14/01/14 5:29 PM Page 319

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Centers for Disease Control and Prevention. nih.gov/health/publications/attention-deficit- (2012). Autism Spectrum Disorders. Re- hyperactivity-disorder/how-is-adhd-treated. trieved from http://www.cdc.gov/ncbddd/ shtml autism/index.html Pati, A. (2011). Early assessment and diagnosis Centers for Disease Control and Prevention. for children with hyperactivity disorder. (2012). Facts about ASD. http://www.cdc Nursing Children and Young People, 23(7), 5. .gov/ncbddd/autism/facts.html Primich, C., and Iennaco, J. (2012). Diagnosing Centers for Disease Control and Prevention. adult attention-deficit hyperactivity disorder: (2013). Mental health surveillance among The importance of establishing daily life con- children—United States, 2005–2011. Mor - texts for symptoms and impairments. Journal bidity and mortality reports, May 17, 2013. of Psychiatric and Mental Health Nursing, Cooper, G.D., Clements, P.T., and Holt, K. 19(4), 362–373. (2011). A review and application of suicide Roman, M.W. (2011). New additions to the prevention programs in high school settings. psychopharmacopia: Extended release formu- Issues Mental Health Nursing, 32(11), lations. Issues in Mental Health Nursing, 696–702. 32(11), 717–719. Goldberg, R.J. (2007). Practical Guide to the Shimshock, C.M., Williams, R.A., and Sullivan, Care of the Psychiatric Patient. 3rd ed. B.J. (2011). Suicidal thought in the adoles- St. Louis: Mosby Elsevier. cent: Exploring the relationship between Kowatch, R.A., et al. (2005). Treatment guide- known risk factors and the presence of suici- lines for children and adolescents with bipo- dal thought. Journal of Child and Adolescent lar disorder: Child Psychiatric Workgroup Psychiatric Nursing, 24(4), 237–244. on Bipolar Disorder. Journal of the American Substance Abuse and Mental Health Services Academy of Child Adolescent Psychiatry, 44(3), Administration (SAMHSA). (2008). 213–235. SAMHSA’s national survey on drug use Lack, C.W., and Green, A.L. (2009). Mood and health: Youth depression. Retrieved from disorders in children and adolescents. Journal http://www.samhsa.gov/data/2k8State/Ch6.htm of Pediatric Nursing, 24(1), 13–25. Substance Abuse and Mental Health Services Lynch, E. (2010). Making sense of autism. Administration (SAMHSA). (2012). National Nursing Standards, 25(2), 18–19. Survey on Drug Use and Health at http://www McCann, T.V., Lubman, D.I., and Clark, E. .samhsa.gov (2012). The experience of young people with Townsend, M.C. (2012). Psychiatric Mental Health depression: A qualitative study. Jornal of Psy- Nursing. 7th ed. Philadelphia: F.A. Davis. Chiatry and Mental Health Nursing, 19(4), 334–340. WEB SITES McKinney, E.S. (2009). Maternal-Child Nursing. 3rd ed. St. Louis: W.B. Saunders. Autism Society National Health and Nutrition Examination www.autism-society.org Survey. (2010). Retrieved from http://www Children and Adults with ADHD .cdc.gov/nchs/nhanes.htm CHADD.org National Institute of Mental Health. (2010). Bullying Major depressive disorders in children. www.stopbullying.gov/ Retrieved from http://www.nimh.nih.gov/ Health-care information for children, teens, statistics/1MDD_CHILD.shtml and parents National Institute of Mental Health (2012). kidshealth.org Statistics on suicide. Retrieved from http:// National Alliance on Mental Illness www.nimh.nih.gov/health/publications/ nami.org suicide-in-the-us-statistics-and-prevention/ American Academy of Child and Adolescent index.shtml Psychiatry has detailed information on a National Instititues of Mental Health. (2012). variety of children’s disorders What is attention deficit hyperactivity aacap.org disorder? Retrieved from http://www.nimh. 2993_Ch19_301-322 14/01/14 5:29 PM Page 320

320 UNIT 3 | Special Populations Test Questions Multiple Choice Questions 1. An 8-year-old child is in the waiting 5. Which of the following groups of med- room. This child has a diagnosis of con- ications are most commonly used with duct disorder. You call another patient ADHD? to the room but notice this child begin- a. CNS depressants ning to act out inappropriately. Your first b. CNS stimulants concern and nursing action would be: c. Antidepressants a. Ask the parent to take the child d. Antipsychotics outside until they are called for their 6. Martin is 7 years old and has a diagnosis appointment. of ADHD. He has broken his arm and b. Provide an environment of safety for requires surgery to have it set. You are the the child and parent. nurse doing the admission checklist with c. Change the rooming order and take Martin and his family. You know that this parent and child ahead of the people with ADHD: patient just called. a. Have normal or above average d. Wait a few minutes; the child will intelligence probably calm down soon. b. Are impulsive 2. The child with autism has difficulty with c. Are inattentive or easily distracted trust. With this in mind, which of the d. All of the above following nursing actions would be most 7. The single most common symptom of appropriate? autism is: a. Encourage staff to hold the child as a. Strong ability to make friends much as possible. b. Impaired social functioning b. Support different staff caring for child c. Appropriate emotional responses so she gets used to other people. d. Achieving and maintaining age- c. Encourage the same staff person to care appropriate developmental tasks for the child each day. d. Avoid talking to the child so she will 8. The parents of 6-year-old Anna say, “Nurse, not be fearful of you. why us? The doctors tell us Maria has the most difficult of all childhood develop- 3. Your 5-year-old patient is not talking to mental disorders to cure. What did we do you or the social workers. You suggest wrong? What can we do for her?” Your giving her some toys and drawing best response might be: materials. Your rationale for this is: a. “The doctor is correct.” a. It gives you one less person to work b. “Her medications should help calm her with at the moment. somewhat.” b. You know children can be bribed. c. “We have specialists here who can help c. You think she might talk if she were you. I will call someone.” distracted. d. “Maybe she will outgrow the autism.” d. Children often communicate feelings through their play. 4. Which of the following activities is most helpful for a child with ADHD? a. Checkers b. Pool c. Video games d. Volleyball 2993_Ch19_301-322 14/01/14 5:29 PM Page 321

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Test Questions cont.

9. Which of the following parental traits 10. What is the major concern in administer- would be most likely to predispose to ing antidepressants to depressed children? conduct disorder in the child? a. Side eﬀect of dry mouth may aﬀect a. Overprotective parents appetite. b. Parents with very high expectations of b. The child may not want to swallow academic excellence these pills. c. Chaotic home life with both parents c. The child is at higher risk for suicide. being heavy drinkers d. The child needs to stop drinking milk d. One parent with a physical disability with these medications. 2993_Ch19_301-322 14/01/14 5:29 PM Page 322 2993_Ch20_323-334 14/01/14 5:29 PM Page 323

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Learning Objectives Key Terms 1. Differentiate between postpartum blues and postpartum • Postpartum blues depression. • Postpartum depression 2. Define postpartum psychosis. • Postpartum psychosis 3. Discuss nursing interventions for new mothers who are feeling depressed. 4. Discuss possible side effects of psychotropic medications during pregnancy and breastfeeding.

ven though childbirth is exhilarating ■ Postpartum Blues for most women, postpartum blues is Ea common and normal reaction right Postpartum blues (sometimes called tran- after birth. On the other extreme are major sient depressive symptoms) is an extremely psychiatric disorders of postpartum depres- common response to the sudden changes sion and postpartum psychosis that are much immediately after childbirth. It occurs in rarer and much more serious. Other issues can about 70% of new mothers (Pillitteri, 2007). include grief response after fetal demise and The major cause is believed to be the plum- birth of a sick/imperfect baby. An example is meting levels of estrogen and progesterone giving birth to an infant that does not meet right after birth. The greater the hormone the mother’s expectations, including an infant shift, the greater chance of developing post- of the wrong sex or one who is physically chal- partum blues (Elder, 2004). Other factors lenged. All of these can contribute to poor include fatigue and stress of delivery along bonding with the infant that can aﬀect the with the immediate postpartum responsibil- health of the whole family (Pillitteri, 2007). ities. Symptoms include tears, rapid mood shifts, anxiety, and feeling overwhelmed. The symptoms typically peak at the fourth Cultural Considerations or fifth day after birth and resolve by day 10 Postpartum mental disorders cross all cul- (Ricci, 2007). The disorder is generally self- tures. Each culture has expected behaviors limiting and does not reflect psychopathol- of new mothers, and knowledge of these ogy or the care the mother is able to provide can make for more accurate screening of to the new baby. The presence of postpartum possible psychiatric disorders. blues does increase the risk for postpartum major depression.

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324 UNIT 3 | Special Populations Treatment of Postpartum Blues depression in women in the general population peaks in the 25–44 age group. The Postpartum blues requires no psychiatric symptoms are the ones typically seen in de- treatment. Families should be educated dur- pression (see Chapter 11) with the addition ing the prenatal period of the frequency of of impaired ability to care for the baby. The this transient condition. Emotional support, majority of sufferers of postpartum depres- compassion, and rest generally help resolve sion have had some type of mental health this problem in a matter of days. If the blues disorder earlier in life, such as a depression. go on for a longer period of time (as in more The new mother may hide the symptoms for than 2 weeks), there is evidence of intense fear of being viewed as a bad mother. It is anxiety about the infant, agitation, feelings of not uncommon for the depression to begin inadequacy, and being overwhelmed most of during pregnancy so this disorder is some- the time. More intervention is needed. This times referred to as depression with peripar- could signal that postpartum blues has moved tum onset. The symptomsmust occur within into postpartum depression. 6 months of delivery and be noticeable for at least 2 weeks to be given this diagnosis. ■ ■ ■ Critical Thinking Question This depression can lead to denial of the Your postpartum patient is ready to be discharged infant, inability to care for the infant, and home. Her family is surrounding her, and they are all thrilled that she had a healthy baby boy. The even thoughts of hurting the infant, as well new mother keeps crying and asks her family to as suicidal thoughts or acts in rare, extreme leave her alone. They are shocked and wonder cases. why she is not happy. What would you tell the The strongest risk factor is depression in a family? How would you help the patient? previous pregnancy or postpartum depression. See Box 20-1 for symptoms of postpar- Neeb’s New mothers and their families need tum depression and Box 20-2 for factors that ■ Tip to be prepared for postpartum blues contribute to postpartum depression. and reassured that the mother’s response is not abnormal. New mothers may not verbalize their feelings Tool Box | Edinburgh Postnatal Depression out of fear of appearing to be a bad Scale (EPDS) at: mother. http://www.perinatalweb.org/index .php? option= content& task= view& id= 8 6 This 10-item self-assessment tool can be ■ ■ ■ Clinical Activity used by the new mother to monitor her • Incorporate support, reassurance, and rest in the symptoms of depression. care of the new mother. • Provide education and resources, such as a lactation consultant, if needed, to this patient. Tool Box | National Alliance on Mental Ill- ness Fact Sheets on Pregnancy and Depression: http://www.nami.org/Content/N avigation- ■ ■ ■ Classroom Activity M enu/Inform_ Y ourself/About_ M ental_ Illness/ Promote discussion with classmates who are By_I llness/P regnancy_a nd_D epression.htm mothers about their feelings during the postpartum period.

■ Postpartum Depression Cultural Considerations The Edinburgh Postnatal Depression Scale Postpartum depression is a serious disorder is also available in Spanish: that occurs in about 10% of births (Pillitteri, http://www.perinatalweb.org/index .php? 2007). Some feel this condition is underdiag- option= content& task= view& id= 8 6 nosed and undertreated particularly because 2993_Ch20_323-334 14/01/14 5:29 PM Page 325

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Cultural Considerations Treatment of Postpartum Depression Perinatalweb.org has resources for women Postpartum depression is a serious disorder from diﬀerent ethnic groups to address their that requires treatment. Early intervention concerns about postpartum depression. is associated with a good prognosis. When the diagnosis of postpartum depression is made, the mother is usually placed on l Box 20-1 Symptoms of Postpartum antidepressants and begins some form of Depression psychotherapy. If the new mother is breastfeeding, she may be reluctant to take med- • Anxiety ications. See the Pharmacology Corner for • Irritability • Loss of interest in new baby more information on the risks associated • Views infant as demanding with antidepressants. Discussion with the • Withdrawn physician and pharmacist can be helpful • Irrational guilt to determine the risk to the baby. Some • Sleep disturbances women may continue psychotherapy only, • Loss of appetite pursue alternative treatments such as light • Inability to concentrate therapy, or choose to stop breastfeeding. • Feels inept at caring for baby The woman should be followed closely • Does not feel bond or love of new baby for at least 6 months after successful treat- • Excessive anxiety over baby’s health ment. During treatment the family must • Feelings of worthlessness be involved to provide support and ensure • Poor concentration • Loss of appetite safety of the baby and mother. Treatment will help with establishing a healthy bond Note: For a postpartum depression diagnosis, between the mother and baby. If left the symptoms must persist for at least 2 weeks. untreated, this depression can continue Source: Adapted from (Berga, S. L., Parry, B. L., & Moses-Kolka, E. L. for months or even years. The mother (2009). Psychiatry and Reproductive Medicine. In B. J. Sadock, V. should be aware that once she is diagnosed A. Sadock, & P. Ruiz (eds.). Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (9th ed.), pp. 2539–62. Philadelphia: Lippin- with postpartum depression, she is at high cott Williams & Wilkins; Pillitteri, A. (2007). Maternal and Child risk for recurrence of it with subsequent Health Nursing: Care of Childbearing and Childrearing Families pregnancies. (5th ed). Philadelphia: Lippincott Williams & Wilkins; A new mother who has any symptoms of or is at risk for postpartum depression should l Box 20-2 Contributing Factors to take steps right away to get help. Some helpful tips if a mother is experiencing early Postpartum Depression signs of postpartum depression include (U.S. • Hormone ﬂuctuations National Library of Medicine, 2010; Pearlstein • Personal and/or family history of depression et al., 2009): or any mood disorder • History of premenstrual dysphoric • Ask for help in caring for the baby disorder • Talk about these concerns with the • Stressful relationship with partner patient’s doctor and nurses • Lack of social support • Talk about one's feelings • Major life stressors around the pregnancy • Avoid making major life changes during • Ambivalence about the pregnancy pregnancy or right after delivery • Sleep disturbance • Encourage realistic expectations of • Medical problems during the pregnancy or herself just after birth • Take time to get out of the house without • History of a troubled childhood • Pregnancy under age 20 the baby, visit with friends, spend time • Abuse of alcohol, illegal substances alone with partner, participate in exercise program 2993_Ch20_323-334 14/01/14 5:29 PM Page 326

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• Join a support group with other new The earliest signs of postpartum psychosis mothers are: • Ensure adequate rest, e.g., sleep when the • Restlessness baby is sleeping, arrange for child care so • Irritability mother can sleep • Insomnia • Comply with any treatment recommendations for depression These can progress quickly to: • Rapidly shifting moods ■ ■ ■ Critical Thinking Question • Erratic or disorganized behavior You are working in a postpartum clinic. Your new • Delusions of grandeur or persecution patient is 4 weeks post-delivery. Her husband approaches you with concerns about why is his wife • Extreme impulsivity so tired and irritable. On further questioning, he • Disorganized speech and behavior tells you she is in bed most of the day and family • Hallucinations members are caring for the baby. What would you • Disorientation/confusion ask the patient when you see her for the initial screening? Delusional beliefs are common and often center on the infant, as in the infant is evil or the infant can read the mother’s mind. Audi- ■ ■ ■ Clinical Activity tory hallucinations that instruct the mother • Be aware of your postpartum patient’s history to harm herself or her infant may also occur. and family history for psychiatric disorders. The mother may deny the existence of the • Review current and past psychiatric medications. child, leading to not caring for the infant. Risk for infanticide, as well as suicide, is significant in this population (Massachusetts ■ General Hospital Center for Women’s Mental Postpartum Psychosis Health, 2010). Postpartum psychosis is a psychiatric emer- In addition to bipolar disorder, postpartum gency. It is sometimes called puerperal psy- psychosis can also be categorized as Brief Psy- chosis. It is rare as it occurs in about 0.1–0.2% chotic Disorder with postpartum onset in of pregnancies (Berga, Parry, & Moses-Kolka, someone without a psychiatric history (DSM 2009). The majority of women with this disor- -5, 2013). Postpartum depression can also der have had symptoms of mental illness before move to a psychosis with paralyzing depression pregnancy. It is most common in first pregnan- with hallucinations and delusions in rare cases. cies and is generally evident within a few weeks Postpartum psychosis right after delivery of delivery. This disorder occurs most frequently needs to be differentiated from delirium. Delir- in women with a history of bipolar disorder ium could be a reaction to many factors during pre-pregnancy. Postpartum psychosis can actu- delivery such as anesthesia dehydration. ally be an episode of bipolar illness. See Chapter 12 for detailed information on bipolar disorder. Tool Box | National Alliance on Mental In fact, postpartum recovery time is considered Illness has information on bipolar disorder a high-risk period for bipolar disorder recur- and pregnancy at: rence in at-risk women (Sharma & Pope, www.nami.org/Content/N avigationM enu/ 2012). Any woman with a history of bipolar M ental_I llnesses/Bipolar1/P regnancy_a nd_ Bipolar_ D isorder.htm disorder should be monitored closely during pregnancy as recurrence of mania symptoms may occur. Women with a history of bipolar disorder are usually advised to discontinue Treatment of Postpartum lithium and some other bipolar medications Psychosis due to possible adverse effects on the fetus. This Immediate medical and psychiatric treatment puts the woman at high risk for recurrence. See must be instituted when postpartum psychosis the Pharmacology Corner for more information. is diagnosed (Fig. 20-1). Severe overactivity 2993_Ch20_323-334 14/01/14 5:29 PM Page 327

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■ ■ ■ Critical Thinking Question You are doing a home health 6-week follow-up visit for a postpartum patient with a history of bipolar disorder. When you walk in the house, the patient is agitated and tells you the baby is driving her crazy and she wants to get rid of him. What would you do?

Pharmacology Corner Figure 20-1 New mother with postpartum Treatment of postpartum depression and psychosis is hearing distressing voices. psychosis usually requires psychoactive medications. Concern about the safety of and delusions may require rapid tranquil- these medications to the infant during ization by antipsychotic drugs. Mood stabi- pregnancy and during breastfeeding is a lizing drugs such as lithium are also useful major issue in treatment. Informed deci- in treatment and possibly for prevention of sions by the new mother as to the burden episodes in women at high risk (i.e., women and benefit of medications require thor- who have already experienced manic or psy- ough patient education. In other words, if chotic episodes). Immediate safety of the in- the medications prevent serious disorders fant must be determined. In some cases are they worth the risk to the baby. Some electroconvulsive (electroshock) treatment concerns include: is used. If the woman exhibits signs of • Antidepressants are excreted in breast psychosis during pregnancy, antipsychotic milk. The infant could be subject to the medications may need to be started. The drug’s side effects. The antidepressants family needs to consult with experts about that have been identified as safest to the possible risks to the fetus from these the infant include paroxetine, sertraline, medications. and nortriptyline (ACOG Committee The location of treatment is an issue; Practice Bulletin, 2008). These have hospitalization is disruptive to the family. It been found to have minimal side effects is possible to treat moderately severe cases to the infant. The woman should be at home, where the sufferer can maintain on the lowest dose possible and time her role as a mother and build up her rela- breastfeeding so that it does not occur tionship with the newborn. This requires when concentration of the antidepres- the presence, around the clock, of compe- sants is high. The infant should be tent adults (such as father or grandparent) monitored closely for side effects and and frequent visits by professional staff. If normal growth. hospital admission is necessary, there are • Some studies report the fetus is at in- advantages in conjoint mother and baby creased risk for complications when admission; however, multiple factors must exposed to antidepressants during be considered in the subsequent discharge pregnancy. So starting antidepressants plan to ensure the safety and healthy devel- during pregnancy or during subsequent opment of both the baby and mother. This pregnancies, must be discussed in detail plan often involves a multidisciplinary with the physician. team structure to follow up on the mother, • Since the risk for postpartum depres- the baby, their relationship, and the entire sion and psychosis in women with a family. Family therapy is essential in the history of bipolar disorder is high, treatment process as family members may considerations about continuing mood be traumatized by the patient’s bizarre behavior. Continued 2993_Ch20_323-334 14/01/14 5:29 PM Page 328

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Pharmacology Corner— ■ Nursing Care of Women cont’d With Postpartum Mental stabilizers during pregnancy must be Disorders discussed and the risks and benefits Nursing diagnoses for women with postpar- weighed. Risks to the fetus may in- tum mental disorders include the following: clude a number of congenital malformations, especially with lithium. In • Anxiety addition, the pregnant woman on • Coping, ineffective lithium is more vulnerable to lithium • Injury, risk for toxicity due to fluid shifts. The psychi- • Sleep pattern disturbance atrist should be consulted for alterna- • Thought processes, disturbed tive medications if the woman wishes • Violence to self/others, risk for to become pregnant. • For women with bipolar disorder, General Nursing Interventions breastfeeding may be problematic. First is the concern that on-demand 1. Safety: Maintain safety of the patient and breastfeeding may significantly disrupt her infant. Any risk factors for this disorder the mother’s sleep and thus may in- need to be identified early in the pregnancy crease her vulnerability to relapse as a routine part of prenatal care. Anyone during the acute postpartum period. at risk should be monitored closely and the Second, there have been reports of patient and family educated on what to toxicity in nursing infants related to look for. If the patient or infant is at any exposure to various mood stabilizers, risk, immediate action must be taken to including lithium and carbamazepine, protect them. Safety also involves educat- in breast milk. Lithium is excreted ing the new mother about risks associated at high levels in the mother’s milk. with psychiatric medications. Exposure to carbamazepine and val- 2. Compassion and support: Adequate sup- proic acid in the breast milk has been port for the new family must be in place. associated with hepatotoxicity in the Helping the family with options for the nursing infant (Massachusetts General mother to get enough rest, resources for Hospital Center for Women’s Mental infant care, and support groups should Health, 2010). be in place. • Antipsychotic and anti-anxiety medica- 3. Ongoing monitoring for high-risk pa- tions are often needed to treat psychosis tients: Be aware that patients with any as well as depression. The psychiatrist history of mental disorders, substance will identify those with less risk to the abuse, and family conflict are at higher mother and infant. Antipsychotics are risk for postpartum mental disorders. generally viewed as having less risk to This information should be identified mother and infant (Berga, Parry, & during pregnancy so adequate support Moses-Kolka, 2009). and prevention strategies can be implemented. Listen to family members who may observe the mother’s behavior. Home health visits should be arranged Tool Box | An excellent Web site for moni- for any mother at high risk for postpar- toring the current knowledge about medica- tum psychiatric disorders. The patient’s tions and breastfeeding is psychiatrist needs to be involved in the http://tox net.nlm.nih.gov> ; click on treatment plan. “ LactM ed.” 4. Education: The new family needs education about the stresses of pregnancy and 2993_Ch20_323-334 14/01/14 5:29 PM Page 329

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childbirth. Education of the new family Neeb’s Women often have unrealistic ex- about postpartum blues and its transient ■ Tip pectations of themselves with a new nature should be included in childbirth baby, thinking that other women are classes and doctor visits. Also, education better mothers. on infant care and breastfeeding can reassure the mother of her skills. Lactation consultants can be help- 5. Because the use Neeb’s Medication management: ■ ful as a new mother may feel inad- of psychiatric medications in this popu- Tip equate if having difficulty with lation involves some risks, providing breastfeeding. support and education is essential. 6. Further Interventions: See Chapters 10,11,12, and 15 for speciﬁc interven- ■ ■ ■ Clinical Activity tions for anxiety, depression, mania, and • Obtain information on how psychiatric disorders psychosis. are addressed in local obstetrics clinics. • Obtain information on local support groups for new mothers. Tool Box | PEP (Postpartum Education for Parents) Warmline: (805) 564-3888. Post- partum Distress Support 24/7 The nursing care plan for patients with postpartum issues is provided in Table 20-1. Neeb’s Monitor coping mechanisms and ■ Tip evidence of family conﬂict in prenatal visits to give information on how the mother will react after birth.

l Table 20-1 Nursing Care Plan for Patients With Postpartum Disorders Nursing Behaviors Diagnosis Goals Interventions Evaluation New mother is Ineffective Patient will Provide support and Patient verbal- avoiding caring coping verbalize her reassurance. izes feelings of for new baby for feelings. Communicate your competence in the first 6 weeks. She will spend observations to MD. caring for baby. She has verbalized more time caring Educate patient and Patient and baby feelings of inade- for baby. family about postpar- remain safe. quacy and lack of She will verbalize tum depression. Patient partici- attachment to new optimism regard- Encourage patient to pates in treat- baby. ing caring for complete small tasks ment plan. She cries frequently new baby. in caring for baby. and expresses Family will main- Reinforce successes feelings that baby tain safe environ- in baby care. would be better ment for patient Assist family in main- off without her. and baby. taining adequate caregiving for baby. Educate on treatment options for this depression. 2993_Ch20_323-334 14/01/14 5:29 PM Page 330

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■ ■ ■ Key Concepts 4. Postpartum psychosis is a rare disorder and often associated with a history of 1. Postpartum blues are a very common bipolar disorder. reaction to plummeting hormones right after delivery. These blues generally do 5. Pharmacological treatment of these dis- not require any psychiatric treatment. orders may be associated with risks during pregnancy and breastfeeding. 2. Women with postpartum blues that go on for more than 2 weeks should be 6. Any pregnant woman with a history evaluated for postpartum depression. of psychiatric disorders should have psychiatric follow-up. 3. Postpartum depression is often associated with a previous history of mood disorders.

CASE STUDY Janice is a 21-year-old experiencing her ﬁrst her behavior 4 weeks ago when she became pregnancy. She lives with the father of the more withdrawn and tearful. The boyfriend baby and has additional support from her said she told him she does not want to mother and grandmother. Janice has a his- think about the baby and does not want to tory of substance abuse, including cocaine participate in preparations. She says she is and opioids, as well as depression, but she too tired to think about it. The boyfriend denies any drug use during the pregnancy. works long hours to make ends meet and She is in her 8th month of pregnancy. conﬁdes in you that he does not know what Upon arrival at the clinic, she appears tear- they will do when the baby comes, if she ful, unkempt, and sad. Her boyfriend tells remains in this condition. He is considering you she has been sleeping for days and does having Janice’s mother take the baby if this not talk to him. He noticed a big change in continues.

1. Given this information, what would be your primary concern for Janice? 2. What would you ask Janice when you go in to see her? 3. What support options should be recommended for the boyfriend/father?

REFERENCES Kaplan & Sadock’s Comprehensive Textbook of ACOG Committee on Practice Bulletins— Psychiatry. 9th ed. pp. 2539–62. Philadelphia: Obstetrics. ACOG Practice Bulletin: Clinical Lippincott Williams & Wilkins. management guidelines for obstetrician- Elder, C. R. (2004). Beyond baby blues. gynecologists number 92. Use of psychiatric Nursing Spectrum. Retrieved from nsweb. medications during pregnancy and lactation. nuirsingspectrum.com/ce/ce72.htm Obstet Gynecol. 2008(111), 1001–1020. Henshaw, C., & Cox, J. (2004). Post natal blues. American Psychiatric Association. (2013). Dia - J Psychosomatic Obstetrics and Gynecology 25, gnostic and Statistical Manual of Mental Disor- 267–72. ders 5. Washington, DC, Author. (Known as Massachusetts General Hospital Center for DSM-5) Women’s Mental Health (2010). Postpartum Berga, S. L., Parry, B. L., & Moses-Kolka, E. L. Psychiatric Disorders. Retrieved from http:// (2009). Psychiatry and Reproductive Medicine. www.womensmentalhealth.org/specialty- In B. J. Sadock, V. A. Sadock, & P. Ruiz (eds.). clinics/postpartum-psychiatric-disorders/ 2993_Ch20_323-334 14/01/14 5:29 PM Page 331

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McCoy, S, J. (2011). Postpartum depression. U.S. National Library of Medicine. (2010). South Med J 104(2), 128–32. Post Partum Depression. Retrieved from McKinney, E. S., James, S. R., Murray, S. S., www.ncbi.nlm.nih.gov/pubmedhealth/ Ashwill, J. W. (2009). Maternal-Child PMH0004481/ Nursing. 3rd ed. St. Louis: Saunders. Pearlstein, T., Howard, M., Salisbury, A., & WEB SITES Zlotnick, C. Postpartum depression. Am J Postpartum Health Alliance oﬀers informa- Obstet Gynecol. 2009(200), 357–364. tion for families after the delivery of a baby. Pillitteri, A. (2007). Maternal and Child Health www.postpartumhealthalliance.org Nursing: Care of Childbearing and Childrear- Postpartum Support International (PSI). ing Families. 5th ed. Philadelphia: Lippincott Williams & Wilkins. The purpose of PSI is to increase awareness Ricci, S. S. (2007). Essentials of Maternity, among public and professional communities Newborn and Women’s Health Nursing. about the emotional changes that women ex- Philadelphia: Lippincott Williams & perience during pregnancy and postpartum. Wilkins. http://postpartum.net Sharma, V., & Pope, C. J. (2012). Pregnancy National Alliance on Mental Illness and bipolar disorder. J Clinical Psychiatry, http://www.nami.org/Content/NavigationMenu/ 73(11):1447-55. Inform_Yourself/About_Mental_Illness/By_Illness/ Pregnancy_and_Depression.htm Townsend MC (2012). Psychiatric Mental Health Nursing. 7th ed. Philadelphia: FA Davis. 2993_Ch20_323-334 14/01/14 5:29 PM Page 332

332 UNIT 3 | Special Populations Test Questions Multiple Choice Questions 1. Which statement reflects postpartum 5. Which of the following is a good nursing psychosis? intervention for a new mother with post- a. “I wish my baby had more hair.” partum blues? b. “My baby has evil eyes.” a. “Let your mother take care of the baby c. “I don’t think I will be good at for the first few days.” breastfeeding.” b. “Recognize that it is normal to feel d. “I am exhausted and want to sleep very emotional right after the baby is rather than see the baby right now.” born.” 2. Which of the following statements best c. “Let’s ask the doctor to order an anti- reflects postpartum blues? depressant to start today.” a. “I wonder if I will be good at d. “It is important to stop crying around breastfeeding.” your new baby.” b. “I wish the baby had never been born.” 6. You are caring for a woman who has just c. “I am exhausted so I won’t feed the had a stillbirth. Which of the following baby this morning.” statements reflects an understanding of d. “I can’t stop crying every time I look at grief after loss of a baby? the baby.” a. “You’re young; you can have more 3. Which of the following is true about children.” postpartum blues? b. “It’s best to put this behind you.” a. The blues start several months after the c. “Would you like to have some private baby is born. time with the baby’s body?” b. The blues occur in the majority of d. “I will leave you alone so you can have women a few days after childbirth. privacy to grieve by yourself.” c. The diagnosis of postpartum blues is a 7. Which of the following is a sign that psychiatric diagnosis. postpartum blues is progressing to d. The postpartum blues are usually a depression? precursor to poor bonding with the a. The new mother is crying for the first infant. 4 days after delivery. 4. What is the most important risk factor b. The new mother verbalizes anxiety and for postpartum depression? fear that she feels nothing for her new a. Past history of depression in a previous baby 2 weeks after delivery. pregnancy c. The new mother tells you that she has b. History of pre-eclampsia in a previous heard from her deceased grandmother pregnancy that the baby is evil. c. History of conflict within the family d. The new mother wants to sleep for during the pregnancy long periods 2 days after delivery. d. The baby being born with multiple anomalies 2993_Ch20_323-334 14/01/14 5:29 PM Page 333

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Test Questions cont.

8. What is the major risk factor of mood 10. What of the following is true about stabilizers during pregnancy? postpartum psychosis? a. Contributes to pre-eclampsia a. It is a medical emergency. b. Increased risk of malformations in b. It may be evidence of bipolar disorder. neonate c. The baby’s safety may be compromised. c. Increased risk of postpartum depression d. All of the above d. Increased cholesterol levels postpartum 9. Which of the following is true about postpartum depression? a. It is more common than postpartum blues. b. It is less common in Hispanic women. c. It can be safely treated with antidepressants. d. Diet and exercise can usually improve it. 2993_Ch20_323-334 14/01/14 5:29 PM Page 334 2993_Ch21_335-352 14/01/14 5:29 PM Page 335

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Learning Objectives Key Terms 1. Discuss concepts of aging. • Ageism 2. Deﬁne ageism. • Cerebrovascular disease 3. Discuss social trends in the aging population. • Elder abuse 4. Identify ﬁve mental challenges of the older adult. • Elderly 5. Identify medical treatment for the older adult. • Geriatrics 6. Identify nursing actions for general care of older patients. • Gerontology • Insomnia • Omnibus Budget Reconciliation Act (OBRA) • Palliative care • Restorative nursing

erontology means the study of older When children are 10 years old, they adults. Geriatrics is the branch of cannot wait to be 16 so they can drive a car. Gmedicine caring for older adults. The Sixteen-year-olds want to be 18 so they can study of older adults is a specialty in nursing. be out on their own. When they turn 30, the With more and more North Americans reach- idea of time passing begins to take on a differ- ing age 65 within the next 10 to 15 years, learn- ent tone for some people. In a society that ing the complications, abilities, and best ways promotes the image of youth, many people of to assist that population is a very timely study. this age see youth vanishing. They might feel According to the Administration on Aging they are not as fast or as thin or as healthy as of the Department of Health and Human they were in their 20s. Still, they see healthy, Services, “The population of 65+ will increase happy people over age 65 working, recreating, from 35 million in 2000 to 55 million in 2020.” and socializing. Life expectancy in the United States is in the 76 for men and the early 81for Aging begins at the moment of Neeb’s women (World Health Organization, 2011). ■ birth. Tip So, what is this process of aging? Aging happens to everyone, and nobody has control over it. It is a condition of time ■ ■ ■ Classroom Activity passing. It is also a condition that researchers • Develop three age range groups in your class are beginning to redefine: What is “old age”? and describe what you have in common with the people in your age group. ■ ■ ■ Critical Thinking Question How do you define your current perception of age-young, young-old, old, or old-old, and what The majority of people over 65 are intel- are you using to measure age? What is your view lectually intact and able to care for themselves when you meet people in each of these groups? (Fig. 21-1). Only about 0.4% of people over age 65 live in institutional setting such as 335 2993_Ch21_335-352 14/01/14 5:29 PM Page 336

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nursing home or to a family member’s home. Coronary disease such as arteriosclerosis and respiratory disorders such as pneumonia occur more frequently in this age group, and patients are less responsive to the treatments than younger people are. Older people are sicker longer. Nutrition is challenged. Elderly people may not be able to aﬀord to buy nutritious foods, and the food they do prepare does not taste as it once did because their taste buds are less sensitive. It is essential that this aging group have all of their survival needs met. A phenomenon called ageism, which is occurring in the United States, is discrimination against a group of people on the basis of their age. It assumes that most older people are inca- pable of functioning in and contributing to society. What thoughts arise as one sees that the car ahead of him is being driven by an older person who can barely see over the steering wheel?

Figure 21-1 Most older adults are indepen - dent and fully able to care for themselves. ■ ■ ■ Classroom Activity (Courtesy of Robin Anwar.) • Answer the following questions and share your responses to the questions with your classmates: How I will look at 75 years of age? Will I be independent? nursing homes (Administration on Aging, What will I be doing at 75? 2011). These numbers are slowly on the rise as children of the 1950s and 1960s (often referred to as “baby boomers”) enter advanced The retirement age has changed drasti- age. Older people are usually basically men- cally as a result of the economy and Social tally healthy; that is, they are able to accept Security benefits. The expected age for re- and deal with the changes and losses they are tirement is currently 67 for people currently experiencing. in the workforce to attain full retirement Of course, many challenges are involved benefits. Those who have retired from their with aging. People aging normally may expe- careers can live a comfortable life provided rience a loss in visual and hearing acuity. their retirement funds are adequate (U.S. Many of these individuals live on fixed in- Social Security Administration, Retirement comes that are not adequate to meet their Planner: Full Retirement Age, 2012). needs for housing, food, and health care. Whereas people now may conceivably Safety is also an issue. Criminals are finding change careers at least five times during their that older adults are easy targets and are rob- working years, the elderly people of today bing and mugging them in higher numbers most likely had one or two jobs over their life- than in generations past. For aging adults, the time and worked 20–30 years at each job. need to face death becomes more of a reality. That job probably represented a large part of Certain illnesses become more prevalent as the person’s identity, and retirement may lead one ages. Alzheimer’s disease (see Chapter 16) to feelings of low self-esteem and depression may become more prominently manifested in when the person has to redefine who he or she an older person, rendering the individual in- is. Self-esteem is viewed as a need according capable of caring for himself or herself and to Maslow, and something that was sought possibly requiring a major lifestyle changes. after in youth and provides, prestige, and This can include the individual’s move to a power (Green, 2000). 2993_Ch21_335-352 14/01/14 5:29 PM Page 337

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Retirement also means a decrease in in- The Omnibus Budget Reconciliation come, which can have a negative impact on a Act (OBRA) is a federal act that provides person’s lifestyle. Today many elderly people standards of care for older adults. One of the have to make a choice whether to buy groceries provisions of OBRA is ensuring proper assess- or purchase their prescribed medication. ment of elderly people. The need for intimacy never leaves us. As human beings, the need to love and be loved is one of the primary needs for survival of the Tool Box | Information About Elders and individual and the species (Fig. 21-2). As peo- Mental Health Services http://www.asaging.org/blog/aca-could- ple age and spouses and friends die, who is beneﬁ t-elders-mental-health-problems- there to love older people? Prospects for mar- will-it riage are slim. Children and grandchildren may live on the opposite side of the country. In addition, older adults may be forced to live with their adult children, which is not always the It is for this reason that only registered ideal situation. Older individuals are at risk for nurses (RNs) may conduct or coordinate elder abuse (physical and emotional abuse of initial assessments of elderly individuals. The older people) by their children or caregivers. LPN/LVN role is to assist the registered nurse Elder abuse is discussed further in Chapter 22. through active listening and competent ob- Aging has many challenges, yet most indi- servation. This responsibility is especially im- viduals are able to cope with the changes portant in long-term care facilities since the brought about by aging and progress through role of the LPN/LVN is to administer routine this life stage with dignity. They are proud of and prn medications. Other health-care team their families and their personal accomplish- members assist with the registered nurse’s as- ments. They can see the contributions that sessment by providing input as to the resi- they have passed on to others. People who have dent’s ability and responses to the treatment learned to adapt to change throughout life plan. OBRA also set the standards for provid- have the best chances of progressing through ing education for the majority of nurse’s aides old age with the same kind of resilience. who are employed by long-term care facilities; Older adults with mental illness whether the Department of Health and Senior Services these were diagnosed earlier in life or are a regulates the curriculum. new diagnosis face many challenges on top of Nurses are caring for the older individual the aging process. For example an elderly per- not only in the health-care facility but also in- son with schizophrenia, generalized anxiety creasingly in the privacy of the person’s own disorder, or a personality disorder will need home (Fig. 21-3). Multidisciplinary teams are added support as the person declines.

Figure 21-3 Increasingly, nurses are caring for older adults in their own homes. (From Sorrell Figure 21-2 Pets can fulﬁll the need for com- and Redmond (2007): Community-Based Nursing panionship and intimacy in an older person’s Practice: Learning Through Students’ Stories. Philadelphia: life. (Courtesy of Robin Anwar.) F.A. Davis Company, with permission.) 2993_Ch21_335-352 14/01/14 5:29 PM Page 338

338 UNIT 3 | Special Populations assisting and monitoring the physiological ■ Cerebrovascular needs of the elderly in the home. Because it is believed that people will stay healthier and Accident (Stroke) maintain more control of their lives if they A cerebrovascular accident (CVA), or stroke, is can stay in their own homes, the home health a medical disorder that has implications for industry is growing. One of the primary con- mental health workers. A CVA is a devastating cerns for nurses and others caring for older and frightening experience for the patient and adults is to help them maintain a good quality family. The probability of a CVA in the elderly of life. Nurses caring for patients in their is higher. Depending on the location and size of homes need to be aware of some of the major the brain and blood vessel involvement, many mental and emotional disturbances they may physical and cognitive functions may be tem- encounter, as well as the physical diagnoses of porarily or permanently affected (Fig. 21-4). the patient. The elderly are prone to a number Some of the mental health issues associated with of major disorders that impact their emo- CVA are depression and aphasia. tional well-being. These are covered in the next sections (Box 21-1). Depression Associated ■ With CVA Alzheimer’s Disease Patients realize the losses associated with their and Other Cognitive stroke. They may not be able to express them Alterations verbally or physically, but they do realize that they cannot do things independently. Self- As stated in Chapter 16, when a person has esteem decreases as they realize they may be been diagnosed with Alzheimer’s disease, it has most likely been taking its toll on the in- Left-side infarct Right-side infarct dividual for many years. It is in the later stages that the debilitating effects are most observable. This disease may necessitate the person’s leaving the home she has lived in all of her adult life. It may mean living apart from a spouse whom she may not appear to remember. Socializing will be curtailed because of the inability to relate to others easily. Alzheimer’s disease has an impact not only on the patient but also on all the people in that person’s life, which may include the health-care provider. Further information on Alzheimer’s disease Right-sided weakness Left-sided weakness or and the care of patients with this disorder is or paralysis paralysis included in Chapter 16. Aphasia (in left–brain- Impaired dominant clients) judgement/safety risk Depression related to Unilateral neglect more l Box 21-1 Some Concerns of Aging disability common common Adults Indifferent to disability Alzheimer’s disease and other cognitive Figure 21-4 The location of a stroke is a key impairments factor in the physical and cognitive functions Cerebrovascular (stroke) that may be affected. A stroke on the left side Depression of the brain affects the right side of the body; Medication concerns a stroke on the right side of the brain affects Paranoid thinking the left side of the body. (From Williams and Insomnia Hopper (2011). Understanding Medical-Surgical End of Life issues Nursing, 4th ed. Philadelphia: F.A. Davis Company, with permission.) 2993_Ch21_335-352 14/01/14 5:29 PM Page 339

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incontinent, unable to eat independently, or The physician and speech therapist will de- unable to communicate with their families. termine the proper plan of speech therapy. Depression may develop. They worry about Nurses need to closely follow this plan and the effect of their stroke not only on them- document the patient’s progress and emotional selves but also on their spouses and other fam- responses to speech therapy. ily members. Will this be permanent or only temporary? Will it happen again? How long will I be this way? ■ ■ ■ Critical Thinking Question As these worries become more pronounced, You are celebrating your retirement when the the patient may become more depressed. The room goes dark. You wake up in a busy room with physicians, nurses, and therapists will try to lights and noise and many people. You think you explain these concerns to the patient and fam- recognize some of them and you try to call out to them, but they just stand there and look at you. ily, but the patient may still feel out of control Someone you do not know is trying to say some- of his or her destiny. Nurses may see the pa- thing to you and keeps shining a flashlight in your tient crying and refusing to perform tasks that eye. Your life partner is crying. What happened to he or she could do after the stroke. The patient you? Why is nobody answering you? What are you may avoid eye contact with the nurse or refuse feeling now? What do you wish someone would do to help you? to interact with family members. All these behaviors may indicate depression in the patient who has had a CVA. By recognizing and confronting these behaviors, the nurse can ■ help the patient understand that the nurse is Depression in the really there to help and is concerned with the Elderly patient’s thoughts and feelings. Being honest and generous with positive It is not “normal” to feel depressed all the reinforcement for attempts to overcome the time despite the fact the person is getting feelings of depression will also be helpful older. Major depression in the elderly popu- in building the patient’s confidence and self- lation can show itself differently than in other esteem. age groups. In addition to the information discussed in Chapter 11, nurses observing Aphasia and assisting elderly people should collect Aphasia, a speech disorder that may be found subjective and objective data for physical in patients who have had a CVA, is classified symptoms that can mask depression, e.g., as expressive, receptive, and/or global (see confusion, constipation, headaches, and other Chapter 2). A patient with aphasia may need body aches. Often these patients will discuss to learn to talk all over again. Communication these physical symptoms rather than admit to is such a basic need that the nurse and the pa- being depressed. tient must work at any threat to this ability These symptoms are similar to other afflic- very diligently. The nurse should give the per- tions common in the elderly population, such son time to speak, write, or show what is as drug side effects (Box 21-2), electrolyte needed, and praise him or her for all efforts to imbalances, and dementia. Nurses must get communicate. One communication technique accurate information, document it, and be that is effective, especially in expressive aphasia, certain that appropriate medical care is is to associate the object with the word. The obtained to rule out other ailments. more senses a person can engage, the better the reinforcement for the learning. ■ ■ ■ Clinical Activity Patience is mandatory. The goal of During clinical preconference at a nursing home, Neeb’s determine how many residents have been diag- ■ communicating with a person who Tip nosed as depressed. Develop a care plan that will has aphasia is to keep him/her in- address depression. volved in the recovery. 2993_Ch21_335-352 14/01/14 5:29 PM Page 340

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to immediately mark on a calendar the appro- Box 21-2 Common Drug Side Effects l priate date and time a dose is taken. In this for Elderly Patients way, the patient can double-check that the Dry Mouth medications are taken correctly and will be Constipation less anxious about it. Also, new technology is Orthostatic hypotension available to create reminder alarms. Urinary complications Nurses also must be aware of the patient’s Confusion/disorientation/mental sluggishness weight, nutrition, and activity levels. It is very fatigue easy for older people to become toxic from Mood swings/irritability their medications, regardless of whether they are at home or in a facility. Patients with drug toxicity or overdose can present with symp- ■ toms similar to those of a mental illness or Medication Concerns other physical illness. It is not uncommon for The process of pharmacokinetics is slower and a proper dose of a medication for an older less complete in older people. Because circu- adult to be as little as 25% of the “usual” rec- latory, hepatic, and renal function start to de- ommended adult dose. It is the nurse’s respon- crease normally with age, it is easier for these sibility to ask specific questions of the doctor persons to become toxic. Adverse effects of regarding medication doses. many medications are more likely to develop Similarly, side effects to medications can in the elderly. Nurses who work in facilities look like other symptoms. Nurses can teach that care for older adults must be very alert to patients and families about this possibility. the effects of the medications they give their Table 21-1 shows some of the common side patients as well as to the possible signs of side effects of drugs on older people, disorders that effects and toxicity. The nurse needs to report may have similar symptoms, and some nurs- any concerns to his or her charge nurse imme- ing actions that can be taken and taught to diately and document observations accurately. the patient. If the state allows a licensed practical nurse/ licensed vocational nurse (LPN/LVN) to con- ■ Paranoid Thinking tact the physician by telephone, the LPN or LVN will also take that responsibility. Paranoid thinking may be a result of fear about Patients who live at home may lose track the social environment. As stated earlier, cer- of their medication routine. They may forget tain people see elderly persons as “easy marks.” to take medications or forget they have taken What was once a situation that was not threat- them and take another dose. Many pills look ening (such as a walk around the block) can alike. When visual acuity is lessened and become very frightening for the person who lighting inadequate, patients may mistake one has slowed reaction time and diminished pill for another—for example, they may take physical capacity for self-protection. Paranoid, two lanoxin tablets instead of one lanoxin and fearful thinking can be a defense mechanism one furosemide, especially if they put all of against these kinds of disabilities, making the their medications in one container. These fear the reason to avoid leaving the house. This types of mistakes can be lethal. self-imposed isolation can bloom into feelings To help with this situation, nurses have of loneliness, which can lead to illness that systems available for teaching patients and is more serious. Validate what the person is families. Containers are available for planning expressing, even when it has taken the form of which medications are taken at what time, being paranoid. Investigate the person’s fearful enabling the nurse and patient to set up the thinking. Age-related hearing loss (presbycusis) patient’s medications for a week or longer and and vision loss as well as early onset of demen- for different times of day. If the patient is re- tia can all contribute to paranoid thinking. liable, this will serve as a reminder to take a Paranoid thinking can also occur when a pa- particular dose. If the patient still needs some tient is entering a long-term care facility and is reassurance, the nurse can instruct the patient exposed to new caregivers and a roommate. 2993_Ch21_335-352 14/01/14 5:29 PM Page 341

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l Table 21-1 Common Drug Side Effects and Nursing Actions for Elderly Patients* Side Effect Other Possibilities Nursing Actions Dry Mouth • Stress response; electrolyte 1. Offer sips of water or ice chips. imbalance 2. Offer hard, sugar-free candy (such as • Vitamin B deficiency lemon drops) if patient is able to suck on them without choking. 3. Provide oral care with light application of lubricant such as petroleum jelly; saliva substitute. 4. Review lab work or call physician. Constipation • Fluid and nutritional 1. Assess diet for fiber and fluid intake. deficiency, hemorrhoids, 2. Assess area for signs of hemorrhoids or rectal pain or other inflammation. • Hypothyroidism 3. Assess need for laxatives as ordered by physician. 4. Discuss need for physical activity as condition warrants. Orthostatic • Heart disorders 1. Assess vital signs. Hypotension • Dehydration 2. Teach patient how to get out of bed or chair slowly. 3. Tell patient to stay sitting for a few minutes until dizziness goes away. Urinary • Prostate problems 1. You must: Keep track of frequency, Complications • Bladder problems amount, color, and odor of urine, and • Uterus problems abdominal girth. • Urinary tract infections 2. Report signs of urinary tract infection • Cancers to physician. Confusion/ • Hypoglycemia 1. Give sweetened drink. If patient is Disorientation/ • Head injury (e.g., fall) still confused after 10 minutes, call Mental • Infection/fever physician. Sluggishness • Depression 2. Check vital signs and signs of infection. • Vitamin deficiency 3. Attempt to validate whether patient • Transient ischemic attack (TIA) has had recent head trauma. • Brain tumor • Dehydration • Alcohol and/or tranquilizer use Fatigue • Infectious process 1. Assess vital signs. • Anemia 2. Assess stress level. • Hypothyroidism 3. Encourage activity if appropriate. • Stress 4. Assess sleep pattern. • Narrowing of coronary arteries Mood Swings/ • Psychological disorders 1. Use verbal and nonverbal communi- Irritability • Electrolyte imbalances cation skills to assess cause. 2. Request lab work.

*Always report these side eﬀects to the charge nurse, document carefully, and notify the physician if that is allowed for LPN/LVN practice in your state.

■ Insomnia pain, urinary incontinence, napping during the day, or sometimes a condition nicknamed Insomnia, or inability to sleep, is seen fre- “sundowner syndrome,” in which the person quently in the older adult. It can be a result of turns around daytime and nighttime hours. many conditions, including depression, fear, These people sleep much of the day and are 2993_Ch21_335-352 14/01/14 5:29 PM Page 342

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wide awake and active during the night. This means to them. It is the nurse’s responsibility syndrome is sometimes seen in patients who and privilege to be able to help someone have Alzheimer’s disease. Lack of rapid eye through this stage of life according to that movement (REM) sleep from insomnia can individual’s needs and wants. have negative effects on anyone, even con- One issue a patient may experience is wid- tributing to psychotic behavior. To someone owhood. The surviving spouse must learn to with Alzheimer’s disease or other cognitive live independently or face an alternative form problems, the effects of insomnia can intensify of housing. Finances and household chores may the symptoms of the cognitive disorder. have been “gender-specific” in that relationship, The nurse needs to concentrate on keeping and now the surviving person is forced to as- communication open with these patients. sume responsibilities formerly done by the de- Nurses will need to be sure that they and their ceased. The subjects of dating and working may patients are using words in the same way. For become delicate issues for the survivor: Families instance, if the patient says, “I do not sleep at may have strong opinions about what the night because I am worried,” the word wor- newly widowed person “should” do. Nurses can ried should be explored. What is the patient play an advocacy role with widowed persons. worried about? What can be done to elimi- Active listening skills, validating the person’s nate the worry? How severe is the worry? thoughts and feelings, and offering information Using a 1 to 5 rating scale, the nurse can more about various services available to widowed per- objectively document the impact of the sons are skills that can be very helpful. “worry” on the patient. In addition, the nurse Nurses can be effective in helping people should ask the patient about his or her defi- through the dying process. Death of the body nition of not sleeping all night; perhaps the as everyone knows it is inevitable. People need patient had taken naps throughout the night. to know it is “OK” to die. Elisabeth Kübler- Ross and others who teach about death and ■ End-of-Life Issues dying tell us that helping people to resolve life issues can help them to die with peace and dig- Life can end at any age; however, death is more nity. Again, nurses who choose to work in hos- common among the older population. Nurses pice, home care, and long-term care settings who work in areas such as long-term care, home have a special opportunity to be there for peo- care, or hospice have a great opportunity to learn ple at this very important stage of life. Using about and assist people with end-of-life issues. humor and laughter appropriately, maintain- These opportunities also exist when working in ing the hope patients may still have, and reas- acute hospitals and clinics. It may not be feasible suring them that they will not be forgotten for professional counselors to meet the needs of after death are some good techniques nurses older adults dealing with these profound issues. can learn to use to help people prepare to die. Many people in this population will prefer the Elisabeth Kübler-Ross’s five stages of grieving services of their own spiritual leader, but since continue to be taught and used in nursing pro- the duties of many such leaders are overwhelm- grams. Not everyone experiences each step nor ing, the appropriate clergy may not be available in the order listed (Kübler-Ross,1969): at the moment of immediate need. However, nurses are there, and they have all the tools 1. Denial needed to be the helpers. 2. Anger 3. Bargaining 4. Depression Nurses must take self-inventory of Neeb’s 5. Acceptance ■ Tip their beliefs surrounding the subjects of death and dying. Nurses must not ignore the incidence of suicide among the aging populations. This It is also very important for nurses to dis- chapter has alluded to many losses that peo- cuss and understand their patients’ religious ple are likely to face as they age. Compound and cultural beliefs about what the end of life the sadness of losing jobs, friends, and other 2993_Ch21_335-352 14/01/14 5:29 PM Page 343

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aspects of earlier life with physical illness and altered physical ability, and it may become clearer why some elders feel helpless or hopeless and opt for suicide. According to the National Institute of Mental Health, persons age 65 and older rate of suicide is higher than the national average for all age groups. They account for approximately 13% of the U.S. population, yet they accounted for 14.3% of all suicide deaths in the United States in the year 2007. The highest rates were found in white men age 85 and older. Follow the screening suggestions provided Figure 21-5 The demographic changes in the American population mean that a more in Chapter 13 when considering the possi- ethnically and culturally diverse group will be bility that an older person may be at risk for seeking assistance in long-term care facilities. suicide. Nurses must be ready to offer culturally sensitive care. ■ Social Concerns see much younger family members than they Older adults, like younger adults, in today’s might anticipate. The upcoming older genera- world may find themselves in financial trou- tion is very diverse. Those of varied ethnic and ble. Many are facing financial challenges liv- cultural backgrounds will be seeking assistance ing on fixed incomes. Many exist only on in long-term care facilities (Fig. 21-5). Nurses Social Security benefits. Retirement age has must be prepared to learn about older patients’ increased over the years, and politicians are customs, ask the proper questions upon intake discussing raising it yet again, potentially re- data collecting, and be ready to offer care acquiring people to continue working longer cording to customs that may be different from before they become eligible to receive the their own and different from those they were Medicare and/or Social Security benefits they trained in. have earned. This will impact future generations. Perhaps today’s seniors have inadequate ■ ■ ■ Classroom Activity personal and supplemental insurance, so they • Divide the class into five groups. Each group will not seek medical help when they need it. represents a decade from the past 50 years. Each They may find their heat and power cut off group should list the music, television shows, due to inability to pay utilities on their fixed and fads popular during their assigned decade and add to a chart. income. Most municipalities are enacting laws and emergency funds to help avoid this life-threatening situation. Nurses can help provide the necessary information to help el - ■ ■ ■ Clinical Activity Using the chart developed in the classroom activity, ders who are opting to remain at home or in ask your patients to provide more information assisted living. about music, television shows, and fads they As baby boomers age, nurses will see a sig- believed were popular during those times. nificant increase in this demographic they are caring for. The average age of patients will be older, and the concerns nurses face will relate One of the cultural demographics to con- more frequently to issues pertaining to people sider is the group of elders who have lived a in the final stages of life. gay or bisexual lifestyle. Nurses need to antic- It is worth mentioning again at this time ipate issues surrounding grooming, room- that the family unit of the older population mates, bathroom-sharing, family preferences, may have a different look as well. People are and potentially even a different definition opting to have children later in life. Nurses may of “appropriate behavior” for those with a 2993_Ch21_335-352 14/01/14 5:29 PM Page 344

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different lifestyle. Individuals may be reluc- that the person is called socially. Nurses should tant to share this type of information unless not do this until invited to do so, however. nurses communicate acceptance. The nurse’s Also, it is not acceptable to assign nicknames role will need to become even more flexible. such as granny or honey arbitrarily to patients. Nurses will need to be very open with their In home care and long-term care, there is a communication and with the type of ques- danger of becoming too familiar. The facility tions they must learn to ask in order to pro- becomes the residents’ home, and they become vide the best care to all entrusted to their care. friendly with each other. This informal atmosphere sometimes spreads among the staff. This ■ Nursing Skills for Working is a time when nurses must remember their professional role. They can be pleasant and With Older Adults friendly while still being professional. The following are some general skills a nurse should learn to use to more effectively work ■ ■ ■ Critical Thinking Question with the elderly population. You refer to an 87-year-old resident as “grandmom,” 1. yet the resident does not have any children as a Respect: In the United States, a hand- result of several miscarriages. Describe the emo- shake is a sign of respect and coopera- tional effect this title might have on the patient. tion. It is usually given at the beginning and ending of business meetings, and it is customary to shake hands at more Under no circumstances should an older formal social functions or when being adult be treated as a child. As abilities dimin- introduced to someone new. Shaking the ish and the older adult begins to become in- hand of an elderly patient will convey re- continent and loses the ability to feed and spect and cooperation and is an effective dress himself or herself, some caregivers take way to begin the nurse-patient partner- on a parental role. It can be easy to deal with ship. There are citizens and residents of an elderly person as one would deal with a the United States whose culture does not child. Elderly patients have had careers and participate in hand shaking, but this raised families. They are now adults who have does not mean they lack respect for special needs in order to help them maintain others. If you sense that shaking hands their adult dignity. is not acceptable to that patient, then communicate to others that this action should not be used. Neeb’s It is important to remember that the ■ Tip elderly is a population of people Using the proper name of the patient also who have been and still are produc- shows respect for that person. “Mr. Washington” tive members of society. or “Mrs. Jones” is the best way to address the patient. If the patient prefers, the nurse may call him or her by the first name or the name 2. Goal setting: When preparing the plan of care with an older patient, nurses must remember to discuss goals that are l Box 21-3 Skills for Working With measurable and attainable. Self-esteem Older Adults and pride in one’s accomplishments are as important when one is 80 as they were • Respect when one was 20. Success breeds success, • Goal setting and meeting small goals is an encourage- • Patience and understanding ment to the older person to attempt Humor • bigger goals. The patient will see that • Safety • Independence the nurse was there to help reach that • Acceptance goal and, again, the relationship will strengthen. 2993_Ch21_335-352 14/01/14 5:29 PM Page 345

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3. Patience and understanding: Older 6. Independence: The older adult should be patients who have some challenge to allowed to perform without assistance as their physical or cognitive functioning much as possible. Do not assume that may be slower to respond to verbal cues the older person is unable to do things and may not be able to sprint down the independently. Follow the guidelines on halls at the pace that nurses generally the patient’s care plan. If the level of care travel. Be patient and recognize the care is complete, then provide complete care. may take longer than expected. Plan for If the level of care indicates the patient this. Nurses should convey the message needs partial or complete care, then that they have plenty of time (even honor those directions. This is one of though they may not). The patient who the fallacies in long-term care: Too much feels burdensome will be less likely to focus is placed on the staff to provide attempt activities or collaborate in the care by a specific time and not on pro- plan of care. He or she will be very sen- moting independence. On the other sitive to any nonverbal communication hand, nurses should offer assistance as expressed by the nurses. It is important necessary. Nurses should let the patient during these times that the nurse’s ver- know that they would like to help in bal and nonverbal responses are congru- whatever way they can. Because of the ent. It is therefore important to focus loss in hearing and visual acuity that entirely on that person at that time. often accompanies aging, nurses may Acknowledge any accomplishment, need to arrange for adaptive equipment however small. The focus should be on that can help the patient to maintain as the residents’ strengths and not their much independence as possible with weaknesses. daily activities. 7. Acceptance: In rapidly increasing num- Neeb’s Not everyone appreciates humor, bers, people of diverse backgrounds and ■ Tip and not everyone finds humor in lifestyles are approaching the time of life the same things. that may require living in long-term care centers or assisted living communities. 4. Humor: Humor that is appropriate to Those who will be caring for this diverse the age and condition of the patient will population must be in touch with their help smooth over some of the harder own thoughts and feelings about work- times for the nurse and the patient. ing with groups of people and must be prepared to flex care to meet their needs. Nurses should take their cues about humor from the patient. If the patient jokes about a Neeb’s Remember that humans are situation, it is probably acceptable to go along ■ Tip much more alike than they are with the humor.Never embarrass or make fun different. of the patient. Taking a situation in stride at the patient’s suggestion, however, can be a Basic human needs as defined by Maslow very healthy mechanism for dealing with and others are important for all groups of some of the hardships associated with aging. people. Table 21-2 summarizes some of the 5. Safety: Ensuring safety in the care facility concerns of aging adults and techniques and teaching safety to the patient who nurses can use to more effectively help this remains at home are very important. population. With vision, hearing, and other senses losing accuracy, it is easier for the older ■ Restorative Nursing person to misjudge space, sound, and temperature. This could lead to falls, Restorative nursing is part of rehabilitation burns, and inability to hear the doorbell and focuses on maintaining dignity and or the telephone ringing. achieving optimal function for patients and 2993_Ch21_335-352 14/01/14 5:29 PM Page 346

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l Table 21-2 Concerns of Aging Adults and Helping Techniques Factors Associated With This Concern Concern Helping Techniques Alzheimer’s • Debilitating effects are observable. Respect for the individual Disease • Patients may need to leave the Realistic goal setting and Other home they have lived in all of their Maintaining patience and Cognitive adult lives; living apart from a understanding Impairments spouse. Effective communication; allowing • Socializing will be curtailed. time for the patient to respond Appropriate use of humor Teaching and promoting safety Promoting independence Cerebrovascular • Physical and cognitive functions See “Alzheimer’s Disease” Accident (stroke) may be temporarily or permanently Allowing venting of emotions affected. Assisting with communication • Depression is evident. techniques • Aphasia may be present. Allowing patient to verbalize; not automatically answering for patient Depression • Symptoms may be different from See “Alzheimer’s Disease” those in other age groups. Allowing venting of thoughts and • Constipation; headaches, other feelings pains, and fatigue may be Teaching about patient’s indicators. medications • Difficulty breathing for which Encouraging involvement in group there is no diagnosis may occur. activities as able Focus on positives Medication • Pharmacokinetics is slower and Providing patient with information Concerns less complete. about medication • Circulatory and renal function is Instructing patient to notify physician decreased. immediately if signs of side effects • It becomes easier for elderly occur people to experience side effects or become toxic. • Patients who live at home may forget to take medications or forget they have taken them and take another dose. • Visual acuity is lessened; patients may mistake one pill for another. • Nurse should advise patient to maintain weight, nutrition, and activity levels. Paranoid • Fear about the environment Allowing venting of feelings Thinking • Slowed reaction time and Not reinforcing the paranoid thoughts diminished physical capacity Speaking in terms of the “here and now” • Feelings of loneliness and isolation Provide aids for hearing and vision loss Insomnia • Depression, fear, pain, urinary Discussing underlying feelings incontinence, napping during the Teaching relaxation methods day are common. Encouraging patient to seek • Decreased REM sleep can medical evaluation contribute to psychotic behavior; Discourage daytime napping insomnia can intensify the Keep sleep diary symptoms of cognitive disorders. 2993_Ch21_335-352 14/01/14 5:29 PM Page 347

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in residents’ condition that cannot be proven to be medically unavoidable are not allowed. Including restorative nursing care in a patient’s care plan can prevent declines in condition that occur gradually, over time, such as loss of mobility, contractures, and loss of self-care ability. Restorative nursing is to be provided to any resident, regardless of his or her cognitive ability: The resident with dementia and the transitional care resident recuperating from knee surgery are equally in need of restorative nursing services.

■ Palliative Care Palliative care is specialized care for people with serious illness that focuses on addressing management of uncomfortable symptoms and the stress of advanced illness. It is about keeping patients and families comfortable and promoting the best quality of life Figure 21-6 Restorative nursing is concerned that one can provide to someone facing an with providing individualized restorative exercise to help patients achieve maximum advanced illness. It is often associated with function and maintain their dignity. the last phase of life but it can begin earlier in the course of serious illness. Hospice is a specialized aspect of palliative care. Hospice residents (Fig. 21-6). Some articles refer to care is specialized services for a patient with restorative nursing as “good, old-fashioned a terminal illness with less than 6 months to nursing care”—arguably a subjective state- live. In addition to working with grief and ment, and likely related to the professional bereavement with the patient and significant age of the writer. Goals include indepen- persons in that patient’s life, nurses choosing dence, promoting self-esteem for the patient, to work in a palliative setting will need to and allowing the patient to maintain as much be comfortable with issues such as pain, control over his or her life and daily living symptom management, sedation and opioid activities as possible. medication, artificial nutrition and hydra- Most skilled nursing facilities are required tion, assisted suicide, and coordinating or to provide at least one designated nursing as- providing complementary therapies. In ad- sistant and nurse who are specially trained dition, nurses will need to sharpen their and part of the “restorative” team. They work communication skills and be very cognizant in conjunction with physical therapy and re- of religious, cultural, ethical, and legal issues, habilitation departments to provide individ- especially surrounding an individual’s wishes ualized restorative exercise and training to and advance care planning as the end of life assist residents to achieve their maximum approaches. ability. It is widely documented that the preferred Restorative nursing is also part of a long- place of death of a patient is in his or her own term care facility’s documentation and reim- home. Sometimes that is not possible. Because bursement requirements. State and federal of that, many long-term care facilities are surveys grade the facility on its restorative pro- designing special units dedicated for pallia- gram. OBRA long-term care laws require that tive care. Organizations such as The Center to residents either maintain or improve their Advance Palliative Care are attempting to show condition at the time of admission. Declines the need for hospital-based and out-patient 2993_Ch21_335-352 14/01/14 5:29 PM Page 348

348 UNIT 3 | Special Populations palliative care, as well. Palliative care can be ■ ■ ■ Key Concepts provided in the acute hospital, long-term care facilities, and in the home. 1. The concept of old age is changing. Nurses are receiving special training and People are living longer and better after certification in this new specialty area. The age 65. Older patients are being cared for good news is that LPN/LVN nurses are in facilities and in their homes. Diversity more than welcome into the fold. To en- among aging persons is on the rise. Nurses courage LPN/LVN nurses to participate in must be prepared to flex the care required palliative nursing, the Hospice and Pallia- to provide the best care possible to many tive Nurses Association (HPNA) has devel- different groups of elders. Nurses have an oped a set of competencies that can be active part in helping the patient maintain purchased online (see the Web sites list at a good quality of life. end of this chapter). Certification as a hos- 2. Normal conditions of aging include pice and palliative nurse (CHPLN) is also diminished hearing, vision, and other available. sensory acuity. Alzheimer’s disease and other cognitive disorders are not considered a part of normal aging. Tool Box | Palliative Training Tools http://www.capc.org/ 3. Afflictions affecting the older adult can be mental or physical, or a combination of these. Medication side effects and drug toxicity can share the same symptoms as disorders that affect the elderly | Tool Box Information on certification for population. Accuracy of observation, LPN/LVNs in hospice and palliative nursing is documentation, and prompt reporting available at: www.nbchpn.org are crucial to a nurse’s responsibility in HPNA has a position statement on the value caring for elderly people. Excellent of the LVN/LPN in hospice and palliative communication skills are necessary. nursing, which is available at 4. Palliative care and hospice provide spe- http://hpna.org/D isplayP age.aspx ? Title= P osition Statements cialized care for people facing advanced and terminal illnesses.

CASE STUDY Mr. Jacobs is admitted as a new resident in CHF and has an order for acetaminophen your nursing home. He is 76 years old and with hydrocodone for pain. has a diagnosis of congestive heart failure Five days later, Mr. Jacobs has had a (CHF). He has fallen at home several times change in mood. His family comes to visit recently, and his adult children are con- and finds that he is combative and forget- cerned that he will become seriously in- ful. One of his children is crying. She looks jured. They have told him he needs to “go at you and says, “What have you done to there for a while until you get stronger.” him? He’s never been like this before.” They tell the staff, confidentially, that they What thoughts cross your mind? How do plan this to be a permanent placement and you respond to the personal attack? How will be selling Mr. Jacobs’s home to pay for will you attempt to resolve this situation? his care. Mr. Jacobs will be started on How would you like to be treated if you digoxin, furosemide, and potassium for the were the family member? 2993_Ch21_335-352 14/01/14 5:30 PM Page 349

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REFERENCES Townsend, M.C. (2012) Psychiatric and Mental Health Nursing. Philadelphia: F.A. Davis Administration on Aging (2011). A profile of U.S. Social Security Administration. (2012). Retire- Older Americans 2011. Retrieved at http:// ment planner; full retirement age. Retrieved from www.aoa.gov/Aging_Statistics/Profile/2011/ http://www.ssa.gov/retire2/retirechart.htm 4.aspx World Health Organization. (2011). Interna- Barry, P. D. (2002). Mental Health and Mental tional Life Expectancy List. Retrieved at Illness. 7th ed. Philadelphia: JB Lippincott. http://en.wikipedia.org/wiki/List_of_ Ferrell, B. R., and Coyle, N. (2010). Textbook countries_by_life_expectancy of Palliative Nursing. New York: Oxford University Press. Furman, J. (2005, May 10). The impact of the WEBSITES president’s proposal on social security solvency Center to Advance Palliative Care and the budget. Retrieved from http://www. http://www.capc.org cbpp.org/cms/?fa=view&id=261 International Association for Hospice and Green, C. D. (2000, August). Classics in the Palliative Care history of psychology. Retrieved from http:// www.hospicecare.com psychclassics.yorku.ca/Maslow/motivation.htm National Hospice and Palliative Care Kaplan, B. J. (November 2002). Gay Elders Face Organization Uncomfortable Realities in LTC. Caring http://www.nhpco.org/ for the Ages (American Medical Directors Hospice and Palliative Nurses Association Association), Vol. 3, No. 11. http://hpna.org Kessler, D. (n.d.). The five stages of grief—Elisabeth National Advisory Council on Aging Kübler-Ross & David Kessler. Retrieved from http://www.nia.nih.gov/about/naca http://grief.com/the-five-stages-of-grief/ Minnesota Board of Aging Koffman, J., and Higginson, I. J. (2004). Dying www.mnaging.org/Alzheimer’s Association to Be Home? Preferred location of death of http://www.alz.org/alzheimers_disease_what_is_ first-generation Black Caribbean and native- alzheimers.asp born White patients in the United Kingdom. Restorative Nursing Journal of Palliative Medicine, 7(5):, 628–636. www.restorativenursing.com Kübler-Ross, E. (1969). On Death and Dying. Elisabeth Kübler-Ross Foundation New York: Touchstone. http://www.ekrfoundation.org/ National Institute of Mental Health (2012). National Institute on Aging Suicide in the U.S.: Statistics and Prevention http://www.nia.nih.gov/ (NIH Publication No. 06-4594). Retrieved National Board for Certification of Hospice from http://www.nimh.nih.gov/health/ and Palliative Care Nurses publications/suicide-in-the-us-statistics- http://www.nbchpn.org and-prevention/index.shtml Minnesota Board on Aging. (November 2002). Spotlight on Aging: A Newsletter for Seniors and Their Families. St. Paul. 2993_Ch21_335-352 14/01/14 5:30 PM Page 350

350 UNIT 3 | Special Populations Test Questions Multiple Choice Questions 1. One effective communication technique 5. “Losses” that are associated with the for assisting a patient with aphasia is: process of aging frequently cause: a. Try to guess the word or finish the a. Presbycusis sentence. b. Depression b. Associate the word with the object. c. Dementia c. Tell the patient to think about it while d. CHF you make the bed. 6. When an older patient begins to show d. None of the above. signs of dementia, physicians and nurses 2. According to OBRA, who is responsible should assess all of the following except: for completing the assessment of an older a. Medication routines adult? b. Nutritional intake a. All health staff c. Circulatory function b. Nursing assistants d. Behaviors assumed to be part of “normal c. LPN/LVN aging” d. RN 7. The speech impairment that affects many 3. Mrs. Brown, who is usually alert and people who have had a stroke is called: oriented, is showing signs of confusion. a. Affect Her vital signs are all within normal b. Aphasia limits. She has recently been started on c. Autism furosemide for congestive heart failure. d. Ageism The nurse suspects: 8. Nurses understand that one of the rea- a. Just normal aging sons that older people become toxic from b. Stroke their prescription medications is: c. Medication side effect a. Drugs are metabolized faster in older d. Depression people. 4. A 73-year-old patient in your long-term b. Drugs are metabolized slower in older care center has become withdrawn and people. cranky. You try to find a method to initi- c. Drugs are ineffective in older people. ate communication and activity with the d. Drugs need to be ordered in stronger patient. Which of the following state- doses for older people. ments is the best choice to try communi- 9. Your patient is admitted with bruises on cating with your patient? his head and upper arms. His son is with a. “Why are you staying over here by him and jokes about the bruises, stating, yourself?” “Dad is getting so clumsy. He falls out of b. “Your daughter wants you to make his wheelchair a lot.” You glance at the friends here.” patient, who says nothing, is looking c. “I need a partner for the card game; I’d down, and is avoiding eye contact. You like to have you be my partner.” become alert for the possibility of: d. “The doctor said the more you do, the a. Blood dyscrasias better off you’ll be.” b. Vitamin deficiency c. Elder abuse d. Self-inflicted wounds 2993_Ch21_335-352 14/01/14 5:30 PM Page 351

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Test Questions cont. 10. The federal law that mandates special 12. In the orientation class mentioned care and assessment skills for the older above, you notice one of the housekeep- population is called: ers crying. She shares with the group a. OBE that her grandmother has “old timer’s or b. OPRAH something and she doesn’t remember me c. COBRA anymore.” You respond to her: d. OBRA a. “It must be diﬃcult for you to see 11. When orienting new nursing assistants your grandmother with Alzheimer’s and other staﬀ to your long-term care disease.” facility, you remind them: b. “It’s called Alzheimer’s disease. Many a. Memory loss is a normal part of of our residents have that illness.” aging. c. “How old is your grandmother?” b. Memory loss is not a normal part of d. “Who else has a relative with aging. Alzheimer’s?” c. Stress decreases as people age. d. All of the above 2993_Ch21_335-352 14/01/14 5:30 PM Page 352 2993_Ch22_353-369 14/01/14 5:30 PM Page 353

CHAPTER 22 Victims of Abuse and Violence

Learning Objectives Key Terms 1. Define abuse. • Abuser 2. Define victim. • Child abuse 3. Differentiate among different kinds of abuse. • Date rape 4. Identify characteristics of an abuser. • Domestic violence 5. Identify nursing care to help survivors of abuse. • Economic abuse • Elder abuse • Emotional abuse • Incest • Neglect • Physical abuse • Rape • Respite care • Safe house • Sexual abuse • Sexual harassment • Shaken baby syndrome • Survivor • Verbal abuse • Victim

buse and violence are unfortunately Physical abuse includes any action that commonplace in today’s society. The causes physical harm to another person. Hit- A news, television dramas, and movies ting; burning; withholding food, water, and expose people to more violence than they did other basic needs; and other activities that go in the past. Violence in the workplace, road beyond accidental contact are all considered rage, and school violence are commonplace. physical abuse. A rule of thumb for deﬁning Violence in the home is on the increase. Child the line between an accident and physical abuse, domestic violence, and elder abuse are abuse is when the recipient says, “Stop. You’re examples of family violence that take a terrible hurting me,” or something similar. If the ac- toll on society. All of these have tremendous tivity stops and does not repeat itself, that be- negative eﬀects. More than 50% of Americans havior may well have been just an accident. If have experienced violence in the family the behavior persists, if the request to stop is (Carson & Smith DiJulio, 2006). Abuse can ignored or mocked by the perpetrator, or if take the form of physical, emotional, sexual, the activity is repeated in future situations, and economic abuse, as well as neglect. there is a strong chance that the perpetrator

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is guilty of abuse. Neglect can include failure are learned behaviors. Children who to provide for the basic needs of someone grow up witnessing violence in the home who is dependent on the caregiver, e.g. a child, and perhaps their community are sensi- elderly parent. Emotional abuse can include tized to believe that this is the right be- verbal abuse, humiliation, excessive criticism, havior, and they will very likely continue and lack of emotional support. Sexual abuse such actions into adulthood. Abusers can include rape as well as any inappropriate retreat to these childhood memories and sexual contact without consent. resort to abuse when they are stressed. Victims are often too fearful or ashamed They may never have developed skills to report abuse, become adept at hiding the to solve problems or deal with conflict. signs, and/or use massive denial to convince Rather, they learned that violence is the themselves that the abuse is not that bad. way to achieve a goal. This contributes to the abuse cycle, which • Low self-esteem/need for power: Abusers can go unnoticed by outsiders. Health-care often have a poor self-image. They feel professionals must be vigilant to recognize frustrated and minimized as persons. They the overt and covert signs of abuse. Every have poor interpersonal relationships and state mandates that suspected child abuse may not have had their ideas and accom- be reported, and many states are enacting plishments validated by people important similar laws for domestic violence and elder to them. Close relationships are difficult abuse. The Joint Commission expects the because others become afraid of the accredited institutions to provide assessment abuser. Therefore, they resort to physical, of potential victims of abuse. Nurses are in verbal, or emotional abuse of others in a key position to identify and offer help to a an attempt to bring a personal sense of potential victim. power and importance to themselves. Sexual abuse is almost always not about ■ The Abuser sex; it is about conquering and winning. It is about demeaning another human being The abuser is usually in a position of domi- in order to feel a sense of strength. It is a nance or power over a potential victim. The short-term “fix” for the abuser and following may cause a person to abuse another: a lifelong scar for the abused. The abuser may also be isolated and lack a support • History of being a victim: “Violence system in dealing with stress. begets violence. People—especially • Impairment from alcohol/substance use: children—tend to imitate what they see” Committing abusive acts while under (Rubin, Peplau, and Salovey, 1993). That the influence of a substance is a major statement remains the belief of researchers contributor to violence. When a person’s today. It is accepted that (except in rare judgment is impaired and his/her ability situations with a genetic or biological con- to control impulses is altered, a person nection) violence, aggression, and abuse who is prone to these acts may abuse others. Easy access to weapons while impaired adds to the risk associated Cultural Considerations with substance abuse. Abuse crosses all cultures, ethnic, and • Biological theories: Brain disorders, socioeconomic groups. At times some be- alteration in brain function, and genetic haviors may appear abusive to us but are influences may also be factors in indi- culturally appropriate. For example, there viduals with a greater tendency toward can be man’s expectation of a wife’s sub- violence. servience in some cultures. This needs to • Other factors: The abuser may also be be taken into consideration before assum- under stress (e.g., poverty) and have ing she is being abused. limited access to support resources to deal with problems, limited coping 2993_Ch22_353-369 14/01/14 5:30 PM Page 355

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mechanisms to deal with conflict, and they think and feel, or to speak out for difficulty trusting others. what they need and want, may not be able to call up the strength they need to How can an abuser be identified? Abusers ward off an attack. They may be easily may present with some of the following traits manipulated by the abuser into believing in connection with a victim: either that they deserved the attack or • Inconsistent explanation of injuries of the that the abuser is truly repentant and will victim not abuse again. They will begin to make • Failure to show empathy for the victim up reasons to excuse the abuser’s behav- • Demand to take victim home and refusal ior and may accept the responsibility for of hospitalization for the injured victim the abuser’s actions. • Speaks for the victim 2. Reliance on the abuser: People who are re- • Criticizes the victim liant on the abuser for financial support • Abuses family pets as well as emotional and physical support are vulnerable to attacks from the abuser. Because abuse in a family is often Neeb’s This holds true for all age groups of peo- ■ hidden, recognize that it can be Tip ple who are abused. difficult to identify an abuser. See Table 22-1 for characteristics of vic- ■ tims of child abuse, domestic violence, and The Victim elder abuse. Health-care professionals often see victims of abuse without realizing it. Though victims of abuse have a broad range Patients who are abused may be fearful of of traits, the two most common include: sharing this information but may leave 1. Low self-esteem: People who have not clues. Box 22-1 lists common warning signs learned to be assertive and to say what of abuse.

l Table 22-1 Characteristics of Victims of Abuse Type of Victim Characteristics Child; all ages, with greatest • Self-blame for family conﬂict risk under age 4 (including • Low self-esteem infants) and for fatalities • Fear of parent or caretaker under 2 years of age • Cheating, lying, low achievement in school • Signs of depression, helplessness • One child sometimes singled out in family due to being labeled as “diﬃcult,” product of unwanted pregnancy, reminds the parents of someone they dislike or even themselves, prematurity (inhibited parent-child bonding), chronic illness Domestic/spouse/intimate • Low self-esteem partner • Self-blame for partner’s actions • Sense of helplessness to escape abuse • Isolation from family and friends • Views self as subservient to partner • Economic dependence on abuser Elder • Older than 75 years of age • Mentally or physically impaired • Isolated from others • Female

Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission. 2993_Ch22_353-369 14/01/14 5:30 PM Page 356

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l Box 22-1 Common Warning Signs of Abuse • Delay in seeking treatment for injuries, minimizing injuries • History of being accident prone • Pattern of injuries not accidental looking; for example, identical burns on bottom of feet, identical injuries on both sides of head • Multiple injuries in varying stages of healing • Conﬂicting stories from victim and abuser about cause of injury • Inconsistency between history and injury • Unusual, even bizarre explanation for injuries • Repeated visits to emergency rooms or clinics • Previous report of abuse • Patient reporting abuse • Patient fearful of caregiver or partner • Visits variety of doctors, emergency rooms for treatment to avoid a record of treatment

Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.

■ ■ ■ Clinical Activity birth to 2 years have the highest death rate. Re- If your patient has been the victim of abuse, ported cases of child abuse have steadily in- obtain information from the team on the abuser creased over the last few years, but many cases and how to handle this person if he or she is are not reported. Children are a most vulnera- present. ble segment of the population because they depend on others for all their needs. Parents are the most common abusers (80% of reported cases). See Box 22-2 for signs of child abuse. ■ ■ ■ Classroom Activity • Ask members of local law enforcement to speak Parents who abuse a child may have unre- to your class about the types of abuse they see alistic expectations of a child, such as being in your community and the options for victims able to control crying or following instructions of abuse. perfectly. Shaken baby syndrome is a form of • Identify local abuse hotlines and local domestic child abuse that occurs when a caregiver shakes violence shelters. a baby in an eﬀort to stop crying, which contributes to infant deaths each year (Center for Disease Control and Prevention, 2010). Some- ■ Categories of Abuse times a child with special needs or emotional problems is singled out for abuse as the parents’ The most common categories of abuse include frustration tolerance is more severely tested. child abuse, sexual abuse, domestic violence (spousal abuse), and elder abuse. l Box 22-2 Signs of Child Abuse Child Abuse Child exhibits some of the following: Child abuse includes physical, emotional, and sexual abuse, as well as neglect. It occurs at • Fear of returning home • Antisocial behavior, such as lying or stealing all socioeconomic levels. The U.S. Children’s • Fear and anxiety when asked about injuries Bureau tracks reports of child abuse nation- • Going to lengths to hide injuries wide and reported that 9.1 per 1000 children • Lack of reaction to frightening event were reported as abused or neglected in 2011. • Unexplained, unusual injuries Abuse includes neglect (75% reported cases), • Changes in behavior, school performance physical abuse (15% of reported cases), and • Neglect—malnutrition, lack of medical care sexual abuse (10% of reported cases). The Source: Adapted from Gorman and Sultan (2008). Psychosocial youngest children (birth to 1 year) have the Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis highest rates of victimization and those from Company, with permission. 2993_Ch22_353-369 14/01/14 5:30 PM Page 357

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though the child may hate the abusive situation, he or she never gets an opportunity to observe healthy parenting or to learn adaptive coping mechanisms to deal with frustration without violence. Other long-term eﬀects of being a victim of child abuse include low self-esteem, high risk for substance abuse, tendency toward depression, diﬃculty trusting in close relationships, and violent lifestyle including crime. Incarcerated youths frequently have a history of being abused and neglected.

■ ■ ■ Critical Thinking Question A 4-year-old child with autism is admitted to your unit from the ER with burns on both hands and bruises on one arm. The child’s parents are at the bedside and very concerned. They have told the doctors that the child reached up and put her hands in a pot of hot water on the stove. How would you react to these parents? Describe factors Figure 22-1 Maybe it’s not your child who that might indicate this could be child abuse. needs a time out.

Each year, newborns are abandoned or even killed when new mothers panic. Many Tool Box | National Child Abuse Hotline: states have passed laws for safe surrender 800 4 A Child sites of newborns if a mother is unable to keep her child. Rather than abandoning an infant through neglect, mothers can leave Sexual Abuse the infant at community locations that often include hospitals and fire stations. Many Sexual abuse is violent or nonviolent sexual at-risk teenagers who might be pregnant are contact or sexual activity that is not wanted often not aware of this law, so community by the receiver. It is generally inflicted on education that reaches teens in their com- someone the abuser considers less powerful munities must be provided to prevent ne - physically or emotionally. The abuser is usu- glect, abandonment, and often death of ally a close, significant figure in the abused these infants. person’s life and knows how to manipulate the potential victim into submission. It can Neeb’s It is important to know the law in involve unwanted advances, inappropriate ■ Tip your state regarding safe surrender sexual contact, sexual harassment, and rape. sites. This information must be dis- Girls are the most frequent victims of seminated to pregnant teens and childhood sexual abuse. Eighty percent of sex- other women. ually abused children know their abuser, and about 50% of cases involve a parent or care- An early sign of child abuse in the victim giver (Mulryan, Cathers, & Fagin, 2000). can be changes in behavior and school per- Long-term effects of sexual abuse include fear formance. Another sign can be abuse of fam- of intimacy, sexual problems, eating disorders, ily pets by the child. Children may try to deal and an overwhelming sense of powerlessness. with the situation by controlling another Children may feel threatened, be confused being or seeking an outlet for their anger about their feelings, and question if this ac- through a more vulnerable victim. tivity is right. The abuser is usually a trusted Victims of child abuse are at an increased person initially to the child, which adds to the risk of becoming abusers as adults. Even confusion. Children do not always have the 2993_Ch22_353-369 14/01/14 5:30 PM Page 358

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words to express what is happening to them. ■ ■ ■ Critical Thinking Question They may also be so fearful that they say The nurse from the local grammar school calls nothing. They may fear other family members your clinic asking for help. She tells you a parent will be hurt if they speak up. Victims may of a 6-year-old has accused the teacher of sexually block out the memory of these incidents until molesting her child. The nurse does not know later in life, when a major event or trauma what to do. What would be your first action? triggers memory recall. Exploiting children in pornography has been increasing with access to the Internet and is another facet of sexual Domestic Violence abuse. Signs of sexual abuse in children could include frequent urinary tract infections; Domestic violence takes many forms, in- torn, bloody underclothing; and sudden cluding physical, emotional, sexual, and onset of sexually related behavior in addition economic abuse. Domestic violence is also to other signs of child abuse as listed above. called spousal or intimate partner abuse or Incest is defined as sexual activity between violence. One in every four women will persons so closely related that they are forbid- experience domestic violence in her lifetime den by law to marry. The most frequent occur- (CDC, 2010). Domestic violence can in- rence of incest is in girls under 18, although volve physical injury, use of intimidation, it can happen to persons of any age group denigration, and control, which can include (National Center for Victims of Violent restricting access to family finances. Crimes, 2012). Though most often domestic abuse in- Rape is forcible, degrading, nonconsensual volves women, men can also be victims. sexual intercourse accompanied by violence They may be less prone to report it out of and intimidation. It often goes unreported. embarrassment, so the frequency of this is When a victim does seek medical care, most less known. hospital emergency rooms and urgent care This type of abuse often incorporates the centers have rape kits to assist in proper col- children. For example, an abusive domestic lection of evidence such as sperm, hair, and partner might say, “If you go out with your other fibers that may be compared with others friends tonight, I’ll see to it that your kids are to identify a suspect. It is important that the taken away; you’re unfit to be their mother person who was raped not clean up before (father) if you go out at night and leave going to the emergency department. Although them. You do not deserve them!” Or “Leave, evidence must be kept intact, one of the and when you get back the kids and I will be victim’s first instincts is to “wash away” the gone and you won’t see them again!” The incident both physically and psychologically children are used as a way to control and in- by showering. Nurses should discourage that timidate. This type of button pushing is very activity until evidence and DNA sources effective at negatively controlling someone’s can be collected. Date rape (also known as behavior out of fear of the consequences. acquaintance rape) most frequently occurs Abusers also use the family pet as a means to among teens and young adults. control; for example, “I will kill the dog if An alarming reality in the United States is you leave me.” that rape happens to elderly people. That Pediatricians and veterinarians receive population is often assaulted in their private training on identifying signs of domestic residences and in long-term care and assisted violence since they may observe clues of a living facilities. troubled family. In a 2001 study of women visiting a pediatric clinic, researchers found that more than 16%, or 553 mothers, had ■ ■ ■ Clinical Activity been physically abused at some point in their Ensure that appropriate tests are completed as part of the workup for victim of sexual abuse (e.g., lifetime. The researchers strongly encourage screening for STIs or sexually transmitted infections, screening for domestic violence as part of the pregnancy test, HIV test). office intake protocol (Parkinson, Adams, & Emerling, 2001). 2993_Ch22_353-369 14/01/14 5:30 PM Page 359

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The abuse cycle in domestic violence has • Lack of support; does not know where to been shown to follow a pattern that was go if he/she left abuser originally identified by Walker in 1979. • Religious beliefs; will not consider divorce • Denial; thinks of the good times and 1. Tension-building: The recipient of the hopes that things can improve so there abuse is compliant, believing that in can be good times again some way he or she is at fault and deserves the abuse. These individuals Because it is common that a woman remain accepting and continue to be Neeb’s ■ Tip may return to a domestic violence supportive even though they know the situation, staff need to understand behavior is inappropriate. The victim they cannot push a patient to leave is probably using denial as a defense the abuser. It has to come from the mechanism. The perpetrator is using victim. It may take multiple episodes verbal abuse and minor beating, and before the patient is able to leave. also is aware that the behavior is not appropriate. In assessing for domestic violence, some 2. Acute battering incident: The victim signs that a patient might be a victim include: senses that the beating is coming and injuries while pregnant when there is resent- may even provoke it to get it over with. ment of a pregnancy, wearing clothes and Some triggering event occurs, which makeup to cover up injuries, lack of care for may be something minor like a miscom- own chronic illnesses, social isolation, use of munication or dropping a dish. The vic- alcohol or drugs to cover hurt, acting guilty tim may try to hide and will probably for seeking medical treatment, and history not seek help until the next day, if at all. of rape. Sutherland, Fantasia, Fontenot, and The police may be called, but by the time Harris (2012) recommend the following they arrive, the victim may have already questions be incorporated in screening for forgiven the perpetrator. This kind of intimate partner violence. physical abuse usually happens in private. 1. Have you ever been abused or threatened 3. Honeymoon: The perpetrator is contrite, by your partner? loving, and very sad about the incident 2. In the past year, have you been physically of abuse that has occurred. He or she hurt by someone? may well try to make amends with gifts. 3. Have you ever been forced to have sex? The abuser promises to get help but only after discussing how the abuse has taught Tool Box | National Domestic Violence the other a lesson, such as “Don’t make Hotline: 1_800_799_SAFE(7233) me mad!” The victim wants desperately to believe this, will forgive the perpetrator, and will begin to think that the rela- ■ ■ ■ Critical Thinking Question tionship will return to “normal.” The Your pregnant patient has been admitted with a victim is still very much in love with the broken ankle from a fall. When you walk into the perpetrator and believes this love will room, the woman is crying on the phone telling conquer all and the abuse will stop. someone she is sorry and it will not happen again. What would be your first action in response to This cycle of domestic violence leads to the hearing this? often-asked question: Why does a victim of domestic violence stay in the relationship? Some of the most common reasons for stay- Elder Abuse ing include: Elder abuse includes neglect as well as physi- • Fear of retaliation for self or children cal, sexual, and emotional abuse. Exploitation • Fear of loss of custody of children of the person’s financial reserves by family, • Dependent financially on the abuser hired help, or strangers is economic abuse 2993_Ch22_353-369 14/01/14 5:30 PM Page 360

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(sometimes called fiduciary abuse). Elder Caregivers of dementia patients should be abuse can occur in the home or in residential counseled about dealing with the stress of facilities. Elder abuse affects 10% of the geri- this role. They need to be given resources for atric population. (National Center on Elder support and respite care. Local programs Abuse, 2013; Gray-Vickrey, 2000). This prob- such as through the Alzheimer’s Association lem is greatly underreported and will continue or local senior centers may offer support to increase as the population grows older. groups and caregiver resources to help pre- One problem in reporting it is the incon- vent elder abuse. sistency of laws defining elder abuse. Some Specific examples of elder abuse can states do not include neglect, psychological include: abuse in their definition, so it is essential • Hitting for nurses to be aware of how elder abuse is • Shoving defined in the state where they are working • Social isolation or reside. Because the abuser is often the • Leaving in soiled linens victim’s caregiver, even including the elderly • Withholding food/water spouse, victims rarely report the abuse. They • Inappropriate restraints fear reprisals or abandonment because they • Threats are dependent on the caregiver. Society’s lack • Being forced to sign over financial affairs, of interest in elderly people may add to the change a will underreporting. • Sexual molestation Caring for a loved one with a cognitive • Insulting impairment increases a caregiver’s risk for engaging in abusive behaviors (VandeWeerd, See Box 22-3 for the characteristics of Paveza, & Fulmer, 2005). Caregivers with no victims and abusers in elder abuse. history of being an abuser can reach a point of frustration and fatigue that leads to behaviors they would normally find unacceptable, such as slapping or degrading their loved one. Elder abuse can also be difficult to detect by professionals because common signs such as bruising and skin tears may be common in older populations. The patient with dementia is particularly vulnerable because he or she is unable to speak up or will not be believed because of his or her intermittent confusion. Neeb’s Economic or fiduciary abuse can be ■ Tip evidenced when a patient gives hired caregivers liberal access to personal financial information. It is important to determine that the patient is doing this voluntarily and is competent to make reasonable decisions.

Tool Box | Fifteen Questions and Answers About Elder Abuse at: http://www.nlm.nih.gov/medlineplus/ elderabuse.html Figure 22-2 Could she be a victim of elder abuse? 2993_Ch22_353-369 14/01/14 5:30 PM Page 361

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l Box 22-3 Characteristics of Victims and Abusers in Elder Abuse Victim • Evidence of malnutrition, dehydration, poor hygiene, pressure ulcers, not receiving needed medical care • Unusual injuries such as twisting fractures, cigarette burns on face or back, perforated eardrums from being slapped • Evidence of sexually transmitted infections, unusual genital injuries • Deterioration in mental status including confusion and depression • Sudden lack of funds in person who previously had resources • Frail, dependent, possible mental impairment requiring care from family member or hired help • Extreme dependency, attachment to new caregiver • Evidence of inappropriate use of restraints Abuser • Often lives with victim, lacks resources to live elsewhere • Refusal to allow diagnostic tests, hospitalization • Often much younger than patient • Cashes victim’s social security or pension checks • Sudden, intense involvement with patient with little input from other family members • Discourages patient from contacting others • Evidence of drug or alcohol abuse or mental illness • Expects dependent elder to meet his or her needs • Caregiver overwhelmed with patient’s care needs, demonstrates frustration and resentment, isolated with limited assistance • Elderly spouse with dementia • Coerces senior to change will to his or her beneﬁt • Shows no guilt or rationalizes actions

Source: From Gorman and Sultan (2008). Psychosocial Nursing for General Patient Care, 3rd ed. Philadelphia: F.A. Davis Company, with permission.

■ ■ ■ Critical Thinking Question ■ Treatment of Abuse You are working in home health care. You visit your 90-year-old patient in her home. The Victims of abuse often require immediate daughter, who is the caregiver, is not home. The crisis intervention and then long-term door to the house is unlocked and the patient is tied in bed with a restraint. You call your super- psychological help. The immediate crisis visor, and the daughter walks in as you are on intervention may include getting out of the the phone. The daughter is frantic and tells you abusive situation. she had to leave for a while to buy groceries. Some strategies for crisis intervention that She had no one to watch her mother. What ac- your agency may arrange include: help in tions should you take? Should this be reported as elder abuse? providing a domestic violence shelter, ar- ranging respite care for an overwhelmed caregiver of a child or elderly parent, immediate social work referral for options if ■ ■ ■ Classroom Activity patient cannot return home, and contacting • Research the elder abuse laws in your state. law enforcement. Domestic violence shelters • Identify resources for caregivers of dementia or safe houses are available in major cities patients in your community. • Talk to staﬀ at local nursing homes and assisted where women can bring children and even living centers to ﬁnd out how they address pets and be protected from the abuser. The potential elder abuse. locations of these shelters are confidential so the victim can feel safe. Victims may need 2993_Ch22_353-369 14/01/14 5:30 PM Page 362

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advice on how to seek out help without Neeb’s Victims of abuse may seek out drugs arousing the suspicion of their abuser. For ■ Tip or alcohol to self-medicate feelings example, victims may have their computers of fear, anxiety, and shame. Sub- and cell phones tracked by a suspicious stance use may be the initial symp- abuser. Anyone who is sexually abused may tom that brings the victim to a need testing for sexually transmitted infec- health-care provider. tions, HIV, and pregnancy. Children and teens also need evaluation for substance abuse if they were exposed to drugs as part of the abuse. Children exposed to sexual ■ Nursing Care of Victims abuse need access to specialists in the field. of Abuse Repression of trauma can lead to a lifetime of emotional problems, so therapy is very Common nursing diagnoses for the victims important. Play and art therapy can be im- of abuse include the following: portant tools for children to communicate • Anxiety their feelings. • Caregiver role strain Abusers and victims need specialized coun- • Family coping, disabling seling programs as well as access to support • Parenting, impaired resources such as local and national hotlines. • Post-trauma response Ongoing individual and group psychotherapy • Powerlessness is often part of the treatment plan for both • Violence, risk for as well. Mandated therapy for abusers who are convicted of crimes may be part of their General Nursing Interventions rehabilitation. Treatment for abusers can in- 1. Ensure safety: The survivor of abuse clude resources for parenting skills and anger will be confused and fearful. The nurse management. needs to reassure the patient that everything possible is being done to ensure his/her safety. Social work involvement Tool Box | Parents Anonymous is a national is essential. The nurse should obtain a organization for parents with issues around list of people who are considered “safe” child abuse. It is based on the Alcoholics Anonymous model. by the patient, and ask if the patient http://P arentsanonymous.org would like those people to be called. If the patient wishes to press charges, offer assistance with making the appropriate phone calls. Call for assistance from a physician and counselor if none ■ ■ ■ Classroom Activity is in the immediate area. Alert security • Identify local parenting education programs. staff members according to agency protocol to prevent the alleged abuser from causing more harm. Maintain a calm milieu. If the abuse victim is a young child or frail elder who cannot Pharmacology Corner speak for himself or herself, immediate Victims of abuse may need medications for involvement of the interdisciplinary anxiety and depression. Both victims and team is essential to determine the next abusers may have issues around substance steps. Providing a safe, calm, secure en- abuse. Abusers may need medications to vironment will reassure the patient. manage substance abuse, control angry im- 2. Know your own thoughts and feelings pulses, and manage anxiety. about abuse: The nurse is responsible for helping the patient through this initial 2993_Ch22_353-369 14/01/14 5:30 PM Page 363

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horrifying experience. A nurse who has with abuse and violence. Familiarity been abused or who has been an abuser with these policies and procedures will may find it difficult to be therapeutic for help save time and convey confidence. the patient. Nurses should remember The patient may be confused and embar- that they may be treating the survivor as rassed about the situation. It may well well as the abuser. Nurses are responsible have taken every bit of courage the per- to help all patients. Abusers are in need son had just to get to the facility. The of help as much as the person who is nurse’s smooth handling of the situation abused. It is worthwhile to mention may provide the extra bit of confidence that nurses face stressful situations daily. the victim needs to actually go through Nurses must also be aware of their own with the examination. Collection of safety and avoid putting themselves in physical evidence, observations, and a risky situation if a potential abuser screening questions may be part of the threatens violence to someone reporting nurse’s role in potential abuse cases. In the abuse. most jurisdictions, with the exception of persons legally classified as “vulnerable,” Neeb’s Suspecting someone of abuse can notification of police, taking of pictures, ■ Tip lead to stress for the health-care etc., may only be done with the patient’s team. It is important to have a team consent. plan of care when working with a Many hospitals and trauma centers have potential abuser. One nurse should some sort of abuse-advocacy program. A rep- not carry all the burden of this diffi- resentative should be contacted immediately cult situation. Seek out support from to visit the victim. The abuse program repre- coworkers. sentative will be able to offer support and provide information on safe houses and other 3. Remain nonjudgmental/show empathy: services that may be available to the victim This is a crisis situation in many ways. and his or her children. Recalling communication skills and Nurses who are caring for a survivor of helping the patient to verbalize any abuse need to be aware of their state’s law concerns, thoughts, and feelings are regarding children who may have witnessed crucial. Remaining technically correct the abuse. In some states, a child who sees in performing any procedures or sample or hears abuse is also considered to have collections is imperative to avoid con- been abused. Nurses and other health-care tamination. Maintaining professional- providers are most likely mandated reporters ism and confidentiality for both the and, as such, find themselves in an ethical survivor and the abuser is mandatory. bind: They want to help and support the Calling for help from counselors, patient/survivor; however, they must tell advocates, or people chosen by the pa- that individual that if a child saw or heard tients will help maintain a calm milieu. the abuse, the nurse must, as a mandated Nurses are not expected to condone reporter, report this fact to the child protec- or accept the action but to respect and tion agency. The patient/survivor may be help the person, regardless of the situa- forced, in a sense, not to divulge the whole tion. If a patient who may be a victim situation to the nurse. wishes to return home with a possible The physician or counselor will discuss abuser, the nurse can offer support, treatment options with the survivor and the education, and resources but cannot abuser. Legal counsel may be requested force a patient into different actions. as well. A law enforcement agency may be 4. Know your agency policy and use your present also. Nurses now can take a more resources: Every health-care agency has its advocacy-oriented role for the patient. Be own policies and procedures for dealing supportive. 2993_Ch22_353-369 14/01/14 5:30 PM Page 364

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Neeb’s Whenever you suspect abuse, get ■ ■ ■ Classroom Activity ■ Tip other staﬀ members involved, includ- • Consider an open discussion with classmates ing your supervisor, social worker, about their experiences with any kind of abuse. and physician. Each person can use a diary format to write experiences and feelings to keep private or share with others if they wish. See Table 22-2 for a nursing care plan for a child who may be the victim of abuse. See Table 22-3 for a review of nursing in- ■ ■ ■ Clinical Activity terventions for victims of various types of Be aware of your emotional reaction when deal- abuse. ing with patients who are victims of abuse or abusers.

l Table 22-2 Nursing Care Plan for a Potentially Abused Child Nursing Data Collection Diagnosis Goal Interventions Evaluation Child admitted with Family coping, Keep child • Ensure the • Child remains broken bones, burns disabling safe and child’s safety safe. of unclear etiology. provide per agency • Parent ac- Child abuse by intervention policy as ﬁrst knowledges parent is suspected for parent. priority. stressors and by health-care team. • Establish a agrees to help. trusting • Safe, appropri- relationship ate discharge with child plan is in and parent. place. • Monitor parent interactions with child. • Demonstrate acceptance. • Explain all procedures thoroughly to child and parent. • Encourage parent to talk about stresses. • Ensure that appropriate people are contacted regarding reporting possible abuse. 2993_Ch22_353-369 14/01/14 5:30 PM Page 365

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l Table 22-3 Nursing Interventions for Victims of Abuse Type of Abuse Indicators of Abuse Nursing Interventions Sexual • Violent or nonviolent sexual con- • Carefully use rape kit and preserve tact or activity that is not wanted evidence. by the receiver that could include: • Provide safety and privacy. foreplay, touching, kissing, and • Be nonjudgmental. mutual masturbation, as well as • Show empathy. oral sex and intercourse • Be advocate for patient. • Frequent bladder or vaginal • Maintain calm milieu. infections • Know own thoughts and feelings • Bloody underwear regarding abuse and abuser. • Evidence of “incest”—sexual inter- • Know agency policies. course between persons so closely • Assist with contacting outside related that marriage is illegal agencies (e.g., lawyer, clergy), as • Evidence of rape—forcible, de- requested by patient. grading, nonconsensual sexual intercourse accompanied by violence and intimidation • “Date rape”—seen frequently in high school and college students (belief surrounding date rape is that the person who pays for the date is entitled to sex from the other person) Physical • Any actions that cause physical • Provide safety. harm to another, such as: • Be nonjudgmental. • Hitting • Show empathy and reassurance. • Burning • Take the time to develop trusting • Withholding food, water, and relationship. other basic needs • Be advocate for patient. • Other activities that go beyond • Maintain calm milieu. accidental contact • Reinforce self-esteem. • Request to stop ignored or • Reinforce that victims should not mocked by the perpetrator blame themselves for the abuse. • Activity repeating itself in future • Know own thoughts and feelings situations regarding abuse and abuser. • Frequent visits to emergency • Know agency policies. department (for all forms of • Assist with contacting outside abuse) agencies (e.g., lawyer, clergy), • Excessive bruising or bruising on as requested by patient. unusual areas of body • Involve agency social worker. • Withdrawal from friends and social groups Emotional • Willful use of words or actions that • Same as for physical abuse undermine self-esteem—includes • Counter patient’s self-depreciating the “silent treatment” (causes the comments. other person to guess at the • Reinforce positive traits. problem) and other types of game playing, name calling, frequent degrading and harsh and/or cruel criticism

Continued 2993_Ch22_353-369 14/01/14 5:30 PM Page 366

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l Table 22-3 Nursing Interventions for Victims of Abuse—cont’d Type of Abuse Indicators of Abuse Nursing Interventions Child Abuse/ • Sexual, physical, and/or emotional • Same as for physical abuse Neglect abuse—act of commission (doing) • Encourage use of play and art or omission (not doing) for child to express feelings. • Victim may believe that abuse is • Provide touch and support if child’s own fault the child will accept. • Child confused about what is • If child uncomfortable being happening and why touched, respect that and • Abuser often larger, more provide support in other ways. powerful than the child, which • Accept that child may be is intimidating mistrustful. • Excessive absences from school • Child may display inappropriate behaviors, e.g., sexual Domestic • Physical, emotional, sexual, and • Same as for physical abuse Violence “button-pushing” kinds of abuse • Recognize that victim may • Most typically reported by women return to abuser initially. • Kept isolated from friends and family • Help identify possible threats • Withdrawal from friends and social that victim is facing, e.g., child groups custody, loss of ﬁnancial security. • Use of substance abuse to cover distress Elder • Victim is usually dependent on • Same as for physical abuse abuser in some way • Listen to patient’s concerns and • May be slapped, burned, tripped, report them even if patient is neglected, humiliated confused. • Can include economic abuse where • Provide follow-up in the home. victim’s funds are misused or stolen

■ ■ ■ Key Concepts 4. Nurses must be sensitive to the needs of the abused person as well as those 1. Abuse takes many forms and is being re- of the abuser. Careful attention to ported in higher numbers annually. physical assessment, communication, 2. Victims of abuse are often in a vulnerable and emotional support are components position to their abusers, who may have of nursing care for people who are suf- the need to exert power and control. fering the effects of abuse. 3. Abuse happens in all age and socioeco- 5. The nurse has a responsibility to know nomic groups. Men can also be victims, state laws regarding one’s obligation to though this is believed to be underre- report evidence of child abuse, domestic ported. The youngest children are the violence, and elder abuse. most vulnerable to abuse. 2993_Ch22_353-369 14/01/14 5:30 PM Page 367

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CASE STUDY Mrs. Jones leaves your long-term care facil- with skin tears on both arms and bruises ity for a weekend with her daughter and over her right eye and on her right cheek. son-in-law. She seems apprehensive but She is crying. Her daughter says, “Doesn’t tells you, “I just worry that I’m a bother to that look awful? Gram took a tumble from them.” You bathed her and helped her the toilet. “Gram” says nothing until her pack, and now you document that she is daughter leaves, then says to you, “I worry gone until Sunday afternoon and that you about her. Her husband is a nice man, but are concerned about her apprehension. You he gets so mad at us sometimes. I really note no other physical or mental abnor- can’t blame him; he has a lot on his mind, malities. Sunday afternoon, she returns and I can’t give them any more money.”

1. What are your responsibilities according to your facility? According to the state? Accord- ing to your personal belief system? 2. How would you proceed?

REFERENCES Tjaden, P., & Thoennes, N. (2000). National In- stitute of Justice and the Centers for Disease Carson, V. B., & Smith-Dijulio, K. (2006). Family Control and Prevention. “Extent, Nature and violence. In E. M. Varcarolis, V. B. Carson, Consequences of Intimate Partner Violence: & N. C. Shoemaker (Eds.). Foundations of Findings from the National Violence Against Psychiatric Mental Health Nursing. 5th ed., Women Survey.” p. 512. Philadelphia: Saunders. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Administration for Children and Families, Ad- (2010). Preventing Shaken Baby Syndrome. ministration on Children, Youth and Families, Retrieved from www.cdc.gov/Concussion/ Children’s Bureau. (2012). Child Maltreatment pdf/Preventing_SBS_508-a.pdf 2011. Available from http://www.acf.hhs.gov/ Centers for Disease Control and Prevention. programs/cb/research-data-technology/ (2010). National Intimate Partner and Sexual statistics-research/child-maltreatment Violence Survey. Retrieved from http:// Vandeweerd, C., Paveza, G.J., & Gulmer, T. www.cdc.gov/violenceprevention/pdf/cdc_ (2005). Abuse and neglect in older adults nisvs_overview_insert_final-a.pdf with Alzheimer’s disease. Nursing Clinics of Gray-Vickery, P. (2000). Combating abuse, Part 1: North America, 41, 43–56. Vandeweerd Protecting the older adult. Nursing 30, 34–38. Walker, L. (1979). The battered woman. New The Joint Commission retrieved at http://www. York: Harper & Row. jointcommission.org/ Mulryan, K., Cathers P., & Fagin, A. (2000). Combating abuse part II: Protecting the WEB SITES child. Nursing, 30, 39–45. National Center for Victims of Crimes National Center on Elder Abuse. (2013). Ncvc.org Retrieved from http://www.ncea.aoa.gov/ National Center on Elder Abuse Library?Data/index.aspx http://www.Ncea.aoa.gov National Center for Victims of Violent Crimes. U.S. National Library of Medicine infor- Retrieved from www.ncvc.org mation on elder abuse Parkinson, G.W., Adams, R.C., & Emerling, http://www.nlm.nih.gov/medlineplus/elderabuse.html F.G. (2001). Maternal domestic violence The National Domestic Violence Hotline screening in an office-based pediatric practice. http://www.thehotline.org/ Pediatrics 108(3):E43. Child Welfare Information Gateway Rubin, Z., Peplau, H., & Salovey, P. (1993). https://www.childwelfare.gov/preventing/ Psychology. Boston: Houghton-Mifflin. Safe Surrender Sites information Sutherland, M. A., Fantasia, H. C., Fontenot, H., https://www.childwelfare.gov/systemwide/laws_ & Harris, A. L. (2012). Safer sex and partner policies/statutes/safehaven.cfm violence in a sample of women. Journal for Nurse Practitioners, 8, 717–24. 2993_Ch22_353-369 14/01/14 5:30 PM Page 368

368 UNIT 3 | Special Populations Test Questions Multiple Choice Questions 1. When caring for someone who has been 5. A 38-year-old female presents to urgent abused, the nurse can be therapeutic by: care. She has a 3-year-old and a 4-year-old a. Showing empathy child with her. She is frightened and badly b. Ensuring safety bruised. “He’ll kill us all if he knows we c. Contacting counselors and advocates came here,” she screams. You: d. All of the above a. Ask her to please not scream—she is 2. Which of the following is the best ap- alarming the other patients. proach when caring for a rape victim? b. Ask, “Who will kill you?” a. Ask why it happened. c. Bring her and her children to a room b. Document the information in the immediately. patient’s own words. d. Ask her to sit for a moment while you c. Oﬀer to take the patient home after contact someone who can provide your shift. safety for her. d. Ask what the victim was wearing. 6. Mrs. Smith arrives for her appointment. 3. When a survivor of abuse and the She has had a positive home pregnancy abuser both present at your facility, test and suspects she is pregnant. She your responsibility is to care for the: has a black eye and a lacerated upper lip, a. Survivor only and admits her husband hit her because b. Abuser only “I did something stupid. I fell asleep and c. Both people supper burned. It’s my fault. He works d. Neither one; call the physician hard. He deserves a decent meal. I’m OK.” You tell her: 4. Mrs. X has been caring for her mother a. “Nobody deserves to be hit. Here is at home. Mrs. X’s mother has stage three the name of an organization that can Alzheimer’s disease and is requiring more help.” of Mrs. X’s time. Mrs. X says to you, b. “You need to leave him right away “I just don’t know what to do. I can’t before he hurts your baby too.” stand it anymore. I love my mother, c. “Why do you stay and let him do but I don’t have any time for myself and that?” I can’t aﬀord a nursing home.” You say: d. “Has he done this before?” a. “Mrs. X, hang in there. Things have a way of working out.” b. “Why don’t your sisters and brothers help out a little?” c. “There are agencies that provide respite care for people in your situation. If you like, I could tell the social worker that you would like some information on this service.” d. “It’s got to be hard to put up with this all day when you aren’t trained for it.” 2993_Ch22_353-369 14/01/14 5:30 PM Page 369

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Test Questions cont.

7. Your 20-year-old female patient in the 9. A woman who was sexually assaulted emergency department has multiple cuts, 6 months ago has been attending a bruises, and burns. When you ask how support group for rape victims. She has she got these, she is vague and says she is learned that the most likely reason the just clumsy. She tells you she is anxious to man raped her is: get home to her boyfriend so he will not a. He was high and did not know what get angry that she is away from home, he was doing. but hopes she can get a prescription for b. He had a need to control her and a tranquilizer. What does this response dominate her. indicate to you? c. She met him in a bar and was a. She has an anxiety disorder. impaired when they went to her b. She is accident prone. apartment. c. She may be caught up in the cycle of d. He had a strong need for sex. abuse. 10. Which of the following is not an exam- d. She has a substance abuse problem. ple of economic abuse in the elderly? 8. A young woman is brought into the a. Caregiver is using a patient’s ATM ER after a sexual assault. Your primary card for personal use. nursing intervention should be: b. Patient’s son is asking to see patient’s a. Help her bathe and clean up to make will. her feel more relaxed. c. Caregiver is encouraging patient to b. Discuss the importance of follow-up no longer see her son and daughter. treatment for possible sexually transmit- d. Hired caregiver is named power of ted disease. attorney for ﬁnances for his elderly c. Provide her with physical and emotional patient. support during evidence collection. d. Give her a list of community resources. 2993_App-A_370-386 14/01/14 5:14 PM Page 370

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4. d. Deinstitutionalization and changes in CHAPTER 1 the health-care delivery system en- History of Mental Health Nursing courage people with mental health issues to be treated in a variety of 1. b. The main goal of deinstitutionalization was to allow as many people as possi- health-care settings. Nurses will care ble to return to the community and for patients with mental illnesses in lead as normal a life as they could. Not all of the settings listed. all mentally ill people would be able to 5. d. Dorothea Dix is the only one on this do that because of the severity of their list who is not a nurse. illnesses. On the other hand, not all 6. b, d, e. AAPINA represents Asian mentally ill people had to be kept in American and Pacific Islander locked units, nor do they today. Com- nurses; PNAA represents munity hospitals were to be kept open, Philippine nurses; NANAINA but many state hospitals closed be- represents Alaska Native cause of the decline in census. American Indian nurses. 2. c. The development of psychotropic 7. b. Asylums were originally described (psychoactive) medications in the 1950s as places of refuge. The meaning is was a keystone to allowing people to much different today. return to their homes. The Commu- nity Mental Health Centers Act came 8. d. The National Institute of Mental about 10 years later. The Nurse Prac- Health was established in 1946. tice Act dictates the scope of practice 9. c. Florence Nightingale recognized the for nurses; and electroshock therapy, relationship between sanitary condi- now called electroconvulsant therapy, tions and healing. took place in hospitals. 10. a. Phenothiazines were the first psy- 3. d. The Nurse Practice Act, which is writ- chotropics drugs introduced in the ten specifically for each state, is the set 1950s. of regulations that dictates the scope of nursing practice. The NLN and CHAPTER 2 the ANA are national nursing associations that set recommendations for the Basics of Communication practice, education, and well-being of 1. b. This option offers assistance in a way nurses. The Patient Bill of Rights is a that encourages the patient to say what document to protect the patient. he or she needs. Option A used the Nurses must know the parameters of word “why,” which has negative conno- this document for ethical practice, but tations. C is closed-ended and allows a it does not dictate the scope of nursing “yes” or “no” answer. D is also closed- practice. ended. Adding the “please” does not make it a correctly formatted question. 370 2993_App-A_370-386 14/01/14 5:14 PM Page 371

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2. c. Nurse-patient communication is pur- stating what he or she needs at the poseful and helpful. Option A would moment. B uses the word “why,” change the focus of the nurse-patient and C has a very authoritarian tone. relationship and lower the chances for D is a command that is very authori- a successful therapeutic relationship. tarian and even threatening. Sometimes nurses and patients do 7. a. Here, the nurse tells the patient that become friends, but this cannot get he or she understands the special con- in the way of the professional relation- cerns of the religion and culture of ship of the nurse to the patient. B sug- Judaism but does not make a promise gests that the nurse is somehow “the that the dietitian will come, which boss.” Patients sometimes have that would build false hope. Option B is perception, but the nurse is really a incorrect because it does make that “partner” in collaboration with the promise. C does not give any indica- patient. D suggests a distance that tion that compromise is possible or would place the nurse too far from that the nurse is “hearing” the true the patient emotionally. It would be concern. D is agreeing and is a block difficult to discuss some of the inti- to therapeutic communication. mate details the patient needs to discuss if the relationship is too distant 8. d. This is stating an implied thought and formal. or feeling. The nurse is checking out the fact that the patient is feeling 3. c. This option combines an observation ignored. Option A makes light of the with a closed-ended question. In this patient’s concern to see the physician. instance, it can be effective. Even with B is not helpful for the patient and the closed-ended question, it is the shows no sensitivity for the patient’s best of the four choices. Option A im- desire to see the physician. C is a plies playing into a hallucination and block because it shows disapproval assumes that the patient intends to be for the patient’s concern and sides talking to someone else. B is intended with the physician rather than the to quiet the patient by using guilt. patient. Asking the patient to be quiet will discourage the patient from wanting to 9. a. This option is more correct than B confide in you. D uses the word “why” because it offers an observation be- without prefacing it with an observa- fore using a closed-ended question. tion, thus opening up the possibility B and C are simply closed-ended of the patient’s feeling defensive. questions. D is an observation, but it uses “why,” which tends to leave 4. d. This option honestly tells the patient people feeling defensive. that you cannot give that information. The physician must explain the results 10. b. “I feel like” is not a “feeling” state- first. Option A oversteps the bound- ment at all, but rather a thought aries of the nurse. B uses the “why” statement. There is no emotion word. C gives advice, by using the identified. Option B encourages word “should.” the nurse and patient to explore what emotional response is being 5. c. This puts the conversation back to the experienced by the patient in a safe patient and allows venting of concerns. environment. Options A and C are Options A and B give advice; D gives nontherapeutic techniques. Option false reassurance and also belittles the D is nontherapeutic in many ways: patient’s concerns. changes the subject, does not reflect 6. a. This is correct because it tells the what the patient has said, and im- patient the nurse is concerned yet plies the nurse is not interested in leaves the patient responsible for pursuing the patient’s feelings. 2993_App-A_370-386 14/01/14 5:14 PM Page 372

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CHAPTER 3 regulation relating to other areas of confidentiality and how files are Ethics and Law shared among providers. It does not 1. b. Ethics is a code of professional expec- force anyone to treat in a particular tations that does not have legal force facility, but it would raise questions behind it. The issues border on legal about transporting records in per- implications, but ethics comes more sonal vehicles, etc. out of expectations that patients have 7. b. Offer another pain relief technique. of nurses than out of actual legal Mr. Ouch does have the right to re- bounds. fuse medication. He also has the 2. c. Each state has a Nurse Practice Act right to privacy, but the option pro- that defines the scope of practice for vided borders on punitive and may RNs, LPNs, and LVNs in that state. be a threat to patient safety. It is also 3. d. The Patient Bill of Rights is designed appropriate to discuss acceptable be- to define the rights of all patients in havior and the effect he is having on health-care facilities. These will change the other residents—just not now. somewhat from state to state. People Wait for a time when he is reasonably who are institutionalized for some comfortable and willing to negotiate reason may be termed “vulnerable” treatment. Bringing in more staff and because they may be unable to speak performing an invasive technique is for themselves or provide for their own not only threatening, but it violates safety. All who care for people in these many of the Patient Bill of Rights. facilities must treat them in accordance 8. c. The LPN/LVN works under the with the Patient Bill of Rights. direction of the registered nurse or 4. b. This is an honest, assertive technique physician and cannot order medica- that shows one nurse voicing a con- tion independently. It is not accept- cern to another nurse. Options A, C, able practice for the LPN/LVN by and D are all forms of blocks to thera- the Nurse Practice Act. peutic communication. 9. c. It is the LPN/LVN’s responsibility to 5. d. Most Nurse Practice Acts require that contact his/her supervisor. LPNs follow the chain of command. 10. c. Mr. B should have received a copy of In this situation, speaking with the the Bill of Rights. The nurse can re- nurse in charge is the best choice. view to which right the patient is re- Option A is a block to therapeutic ferring and discuss why he felt his communication because it is argumen- rights have been violated. tative and voices disagreement with the patient. B is not safe: Even though CHAPTER 4 it is always important to listen to patients, a nurse must never assume the Developmental Psychology patient is right. C is inappropriate at Throughout the Life Span this time; it must first be determined 1. d. This patient is demonstrating the that an error has occurred. Once this Electra complex, which is part of the is established, the RN or the LPN, if phallic stage of Freud’s developmental allowed by state and/or agency policy, stages. should inform the physician. 2. c. Unsuccessful completion of the anal 6. c. The Health Insurance Portability and stage would lead to these behaviors Accountability Act allows patients to and to more serious disorders, ac- have a greater say in how their records cording to psychoanalytic theory. are shared and with whom. It also has These people would be termed “anal 2993_App-A_370-386 14/01/14 5:14 PM Page 373

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retentive” in some social and profes- 16–20 years. “Intimacy” (the stage at sional circles today. which the main concern is developing 3. d. This option states that Y’s behavior is intimate relationships with others) not appropriate and lets Y tell you that begins at approximately age 18 and the consequences have been discussed. continues through approximately Y is able to make a choice. Options A age 25. and B sound harsh and threatening 8. c. It is believed that infants develop in and are not helpful forms of commu- a very similar rate and pattern (physi- nicating. C is very close to letting the cally, behaviorally, and cognitively) nurse “care-take” for Y. In behavior until the age of 10 months. Again, modification, Y would most likely be this is based on generalizations; there responsible for his or her own actions are always exceptions (e.g., a child and choices. who is longer than most of his or her 4. a. Cell differentiation, the process whereby particular age group because of the cells “specialize” into their particular gene pool from parents who are taller type, is generally complete by the than the average). end of the first trimester (third lunar 9. b. Assimilation is the process of taking month). in and processing information. It 5. d. Women are successfully having chil- is generally learned by experiencing dren at young ages; however, it is through the senses. “Accommoda- generally believed that a woman’s tion” is the process of working with body is not completely mature until the information that has been assimi- the age of 18 years. Because the young lated and making that information a woman’s body is not completely ma- working part of the toddler’s daily ture, it is difficult to sustain her health life. “Autonomy” is the stage or task and the life of the fetus. Therefore, in- Erikson believes a toddler should be fant mortality as well as danger to the achieving. “Adjustment” is a general mother’s health is greatest before this term related to change. It is not age. Older women are next in line as always a healthy response to change. a risk group for infant mortality be- 10. d. According to Jean Piaget, the 2-year-old cause of changing hormones that can child is in the preoperational stage, jeopardize the woman’s ability to sup- where the child is demonstrating port a fetus and carry it to term. Cer- interest in something other than tainly, there are exceptions in both parents. of these age groups regarding pregnancy and successful delivery. These CHAPTER 5 are broad, general beliefs that are held among many in the medical and nurs- Sociocultural Influences on Mental ing community. Health 6. b. Option A describes “animus,” the 1. b. Proxemics, or spatial distances vary balance to the female, according to among the cultures. What is comfort- Jung. able and appropriate for some is not appropriate for others. 7. d. According to Erikson, the stage or task for children in the 3- to 6-year-old 2. c. Prejudice means to “pre-judge.” It is group is the stage or task of “initia- making a decision about a person, situ- tive.” The stage or task of “industry” ation, etc., prior to having all necessary (the stage at which integration of life information. experiences or the confusion of those 3. b. Homelessness is not a mental illness experiences develops) covers ages but may be a condition of mental 2993_App-A_370-386 14/01/14 5:14 PM Page 374

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illness. It is difficult for this popula- CHAPTER tion of people to access the health-care 6 and community services available. Nursing Process in Mental Health 4. b. Approximately one-third of the home- 1. a. Nursing process is a systematic way less in the United States are mentally ill. of collecting data to have consistency 5. d. Enlist the assistance of a religious rep- in patient care. Options B and C resentative to negotiate removal of the are incorrect, even though nurses do item(s) in question. Other safety ac- document patient needs and RN and tions may also be required, but right LPN/LVN roles are different in the now, relating to this individual at his nursing process. Patient needs are not or her spiritual level is necessary not usually documented as part of the only for the patient’s religious freedom nursing process per se. D is incorrect of expression, but also to get him or because the nurse needs to know the her to be able to cooperate with addi- difference between medical and nurs- tional nursing actions. ing care prior to writing the nursing process. Only nursing care is incorpo- 6. d. Actually, all of the responses are cor- rated into the nursing process. rect. Nurses are mandatory reporters for suspected abuse/neglect/endan- 2. c. This is the best choice of those listed. germent of children. Certainly, the It asks what you need to know, but it child could ultimately die from un- asks from the patient’s perspective. It is controlled diabetes. It is appropriate less judgmental than the other choices. to call the RN and MD to the exam 3. b. Return demonstration (redemonstra- room, but a stat call would not be tion) is the best method for evaluating necessary. You are there: The best the patient’s learning. Option A is a choice is to sit with the family for a method of teaching. C and D are steps time, gain their trust, and collect in the nursing process and steps in more information that could be developing a teaching plan. used to modify the care plan or as- 4. a. Mental status examinations are made sist the MD in appropriate referrals as part of the assessment or data col- for the best care of this child and lection part of the nursing process. family. 5. a, b. Planning is the third component in 7. b, c, d. Many homeless fall into the “work- the Nursing Process. In the planning ing poor” category and are actually process the nurse plans measurable working full-time jobs. Approxi- and realistic goals, both for long and mately one-third of the homeless short term. also have a mental illness, quite often schizophrenia. 6. a. The registered nurse initiates the nursing diagnosis from the patient’s data 8. a, c, e. Though mental illness is a com- collection or assessment. The LPN/ mon cause of homelessness, the LVN can assist in this step. economy and loss of assets from health-care expenses has been 7. a, b, d. The principle of teaching enhances contributing factors for some. the patient’s understanding of the nurses’ rationale for the specific 9. d. Ethnicity is defined by a personal interventions in their care. trait or common characteristics relating to a specific group of people. 8. a, b, d, e. Tone is not part of the mental status exam. 10. d. Authoritative parenting focuses on the setting of rules and limits setting 9. d. The North American Nursing Diagno- by the child. sis Association (NANDA) is a universal 2993_App-A_370-386 14/01/14 5:14 PM Page 375

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and systematic approach in defining a Posing as an adolescent reminded person’s needs according to his/her her of being young and innocent. assessment using nursing diagnosis. Shirley knew when she pouted at 10. d. Formal teaching occurs when the an earlier age that she got her way patient is ready. The nurse can then and was considered cute. prepare a teaching plan. The nurse 8. c. John blamed the search committee, will also schedule a specific time for who are all right handed, for denying teaching and feedback of the learned him the job instead of the possibility information. of not being qualified. 9. a. For healthy outcomes, a person has CHAPTER 7 to have effective coping to engage in Coping and Defense Mechanisms selecting appropriate choices. 1. c. Rationalization is the defense mecha- 10. a, b, c. The personality is made up of nism that sounds like “excuses.” these three components according to Freud’s theory. 2. a. Denial is the refusal to accept situations for what they really are. This is CHAPTER 8 a classic example of denial. 3. d. This child is using compensation, Mental Health Treatments which is finding some other strength 1. b. Options A, C, and D are commonly that will make up for a real or imag- seen in the crisis (or third) phase of ined inadequacy. crisis; feeling of well-being is observed 4. d. He is “blaming” his wife for his actions in the pre-crisis phase of crisis, when rather than taking responsibility for his the patient thinks and states that thoughts, feelings, and actions. everything is “fine.” 5. a. Rationalization. Certainly, eating a 2. d. The patient needs to know that he or meal of burgers and fries does not she is away from the stress, even if it is depict mental illness. Even though only temporary. The person may not the person may be joking, and there be able to think rationally, and to hear is an element of truth, this statement that safety and help are being offered depicts an “excuse” for one’s behavior can be the start of stress reduction and and choice of menu selection. intervention. The following explain why the other options are not correct. 6. b. Undoing. This is a tricky one. Many A: “Why” needs to be avoided when may have chosen C, Symbolization. possible to decrease the chance of the The reason this would be more likely statement sounding judgmental and an example of “undoing” is because allowing the patient to feel defensive. Tara is trying to make up for a nega- B: Besides the fact that this is a closed- tive behavior that affected her daugh- ended question, the person may not ter. While words have not been know the answer to this. It may, in spoken, there is not really an “emo- fact, be one of the major causes of the tion” that is being represented, as stress that led to the crisis. C: This is would be the case in symbolization. an open-ended statement and will be Rather, Tara seems to be offering the valid to ask—later. As one of the first tickets to “undo” the embarrassment questions a person in crisis hears, it she caused her daughter by her drunk can lead to increased confusion and and inappropriate public behavior. guilt. He or she might not have a clue 7. a, c, d. Shirley is returning to a time as to what led to the attack or may be when her stress level was minimal. blaming himself or herself needlessly. 2993_App-A_370-386 14/01/14 5:14 PM Page 376

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Because nobody deserves to be abused, 8. a. Repression is a defense mechanism asking the question of the person ex- and is therefore counterproductive in periencing crisis can sound as though therapy. All other choices are correct. the nurse thinks the perpetrator had 9. b. The antianxiety drugs are potentially just cause to abuse. addictive. Patients with addictive ten- 3. c. Milieu is the therapeutic environment. dencies may become addicted to these It should be stress-free, or at least min- medications more easily than they imally stress-producing, and should would to drugs from other categories. make the patients feel comfortable to 10. c. Antidepressants all carry a FDA black practice new, healthy behaviors. It box warning that these medications might be locked, depending on the may increase suicide risk in children patients, but it is not required to be. and adolescents. The patients will not usually be hospitalized “for life” (however, some might CHAPTER 9 be); a 72-hour-hold situation should have a milieu that corresponds to the Alternative and Complementary needs of the patient being held. Treatment Modalities 4. b. ECT is not used to treat convulsive 1. c. The definition of an alternative therapy disorders. That is a mistake people is one that is used in place of conven- make because of the name “electrocon- tional medicine. Option A suggests vulsive therapy.” The treatment causes that such therapy has no value, which a light seizure but does not treat seizure is very dependent upon the patient’s disorders. Options A, C, and D are all beliefs. Option B is the definition of true about ECT. complementary therapies. Option D 5. d. The use of psychoactive medications is incorrect; many cultures and people can change the person’s ability to use alternative modalities as first-line think and process information and treatment for all types of illness. help him or her to feel different about 2. d. Complementary therapies are used the situation, which may allow other with conventional medicine. Option therapies to work in adjunct to the A is vague; medical treatment is not medication, to help the person toward defined simply by Western standards. wellness. These medications do not Option B is incorrect because a cure mental illness. They are used for model refers to a picture an idea. more than just violent behavior, and Option C infers that conventional although they may have an effect on medicine is holistic, when in fact it pain receptors, that is a side effect is disease-oriented. rather than a primary use for this 3. a. Integrative refers to the use of conven- group of medications. tional and less traditional methods 6. c. Patients treated with the MAOI group in harmony. Option B is incorrect of medications should avoid certain because such combinations are not foods and beverages that contain tyra- exclusive to any one belief system. mine to avoid hypertensive crisis. Option C would leave the decision 7. b. One of the goals of crisis intervention making to a physician without patient is to decrease anxiety. The person may input, which is not holistic. Biofeed- feel a temporary increase in anxiety back, option D, is a complementary (e.g., at the time of being arrested or therapy. taken to the “detox” center), but that 4. d. The mind-body connection correctly should resolve fairly quickly with effec- describes why belief and expectation tive intervention. have an effect on health and disease. 2993_App-A_370-386 14/01/14 5:14 PM Page 377

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Option A is an incorrect definition; 10. b. Presupposing, or assuming, that the complementary therapies are used with patient will not improve will directly conventional medicine. Option B is an and indirectly negatively affect the opinion based on the notion that the thoughts, feelings, and actions of the mind and body operate independently nurse as well as the patient. Often of one another. Option C describes a mentally ill patients are more sensitive treatment modality rather than a to unspoken assumption, especially mechanism. when it is communicated nonverbally. 5. b. Regardless of the nurse’s own feelings, Options A, C, and D will positively remaining open and supportive en- impact unspoken communication and courages communication and rapport. improve chances for better rapport. Option A would have the effect of de- stroying rapport by making Mrs. Lucas CHAPTER 10 wrong for her beliefs. Option C might Anxiety, Anxiety-Related Disorders, be an observation better reported to and Somatic Symptom Disorders the physician for his decision. Option D would have the LPN/LVN perform- 1. b. The vividness of the description suggests ing well outside of his or her scope of that the person is having a flashback. practice in most states. Auditory hallucinations would most likely involve “voices” or “hearing” the 6. d. Aromatherapy, biofeedback, and mas- guns. Delusions of grandeur might sage are either alternative or comple- cause the person to go after the people mentary. In options A, B, and C, ECT with guns, while being unarmed himself (electroconvulsive therapy), antianxiety or herself. Free-floating anxiety would medications, and psychotherapy are be less descriptive. The person would considered conventional. not know the cause of the anxiety. 7. a. Reiki is a therapy involving energy 2. d. Repetitive behavior that interferes with manipulation and unblocking energy daily functioning is indicative of OCD. flow. Options B, C, and D are all forms of massage therapy. 3. d. This is the best of the four choices because you are simply stating for the 8. a. Trance is an altered state of con- patient to relax. You are helping him sciousness, but it is assuredly not reoxygenate and refocus and you are sleep. Much of the therapeutic value calming him by offering to stay with of the work done in trance is lost if him. It also buys you some time to the client falls asleep. Options B, C, make a visual assessment. Option A and D are all correct statements would be appropriate nursing actions, about trance. but not as the first priority. Your first 9. c. This statement uses “see” and “clearly” action needs to be calming the patient to communicate that the speaker and continuing to assess. B and C are prefers a visual channel. Through the nontherapeutic responses. predicates “feels good” and “gut feel- 4. c, d. Multiple personality disorder (also ing” in option A, the speaker reveals known as dissociative identity disor- a kinesthetic channel preference. In der) is considered to be a dissocia- option B, the speaker demonstrates tive disorder rather than an anxiety an auditory preference through the disorder. Some theorists believe that predicates “sounds good” and “paying the dissociative disorders are also attention to.” Option D reflects the anxiety disorders, but most are now rarely used olfactory preference; many differentiating the two types of dis- practitioners treat these predicates as orders. Obsessive compulsive disor- kinesthetic for therapeutic purposes. der has traditionally been classified 2993_App-A_370-386 14/01/14 5:14 PM Page 378

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as an anxiety disorder but that has CHAPTER changed in DSM-5 since it is now 11 known to be neurologically based. Depressive Disorders 5. d. Rigid and inflexible behaviors are 1. a. This is selective reflecting. You have characteristic of OCD. These persons repeated the patient’s exact words in a would like to be able to control those way that encourages her to either ex- behaviors, but without treatment it is plain herself or rephrase her response very difficult for them. They are not in some way. Options B, C, and D are usually hostile, unless they are pre- all blocks to therapeutic communica- vented from performing the obses- tion. B is challenging her, C uses the sion or compulsion, because that word “why,” and D is giving advice. decreases the anxiety. 2. b. Selective serotonin reuptake inhibitors 6. d. Phobia is an irrational fear that like Zoloft typically take anywhere cannot be changed by reason or from 2–6 weeks to impact target symp- logic. The patient usually under- toms like sadness, low energy, loss of stands it is irrational, but the fear appetite, and negative thoughts. remains. 3. c. Communicating in a judgmental 7. b. A compulsion is a repetitive act; an manner is always a block to therapeu- obsession is a repetitive thought. tic, helping relationships. 8. a, b, c. Luvox (fluvoxemine), Prozac 4. c. Major depression usually manifests (fluoxetine), and Paxil (paroxe- itself with symptoms of extreme sad- tine) are the current drugs of ness that is the prevalent mood for a choice for OCD. Venlafaxine is period of at least 2 weeks. Euphoria also used in treating many men- would be more indicative of bipolar tal disorders. So be careful! All depression. sound similar and are spelled 5. d. This is false reassurance, which is similarly. never appropriate in therapeutic rela- 9. c. Acrophobia is a form of specific tionships. The other choices are all phobia since it is fear of a specific appropriate nursing interventions for situation (heights). a person who is depressed. 10. a, e, and f are NOT appropriate nursing 6. b. Patients taking monoamine oxidase interventions. Stimuli should inhibitors (MAOIs) must avoid be diminished to decrease the processed foods to avoid a hyperten- stressors present. All changes sive crisis. in behavior and responses to 7. d. Rather than pressure the patient to treatment should be docu- socialize, sitting with the patient mented. Activities should be shows acceptance and readiness to encouraged, but only those listen when patient talks. that are enjoyable and do not produce additional stress. 8. c. Though symptoms of depression are People need to acknowledge quite normal, using an open-ended the stressors and deal with sentence demonstrates concern about them. Avoiding or creating the changes in behavior. “diversion” is not the best 9. b. You want to know more about the nursing care. Creating an en- patient’s changes in behavior before vironment where individuals jumping into a plan of action. feel comfortable and want to 10. a. Though men frequently suffer from participate in activities is depression, it is more common in more therapeutic. women. 2993_App-A_370-386 14/01/14 5:14 PM Page 379

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The other choices contain incorrect CHAPTER 1 2 information. Bipolar Disorders 10. a. Stimulants could easily precipitate a 1. b. Dehydration can precipitate serious manic episode or intensity a current side effects from lithium, including one. All the others may be utilized tremors, seizures, and coma. effectively. 2. d. One of the main side effects of lithium 11. a. Cyclothymic disorder is a chronic is dehydration and fluid and elec- mood disturbance of at least a 2-year trolyte imbalance. Her dry lips, stag- duration involving numerous episodes gering gait, and feeling confused of hypomania and depressed mood could all be symptoms dehydration but of less intensity. and sodium depletion. We don’t have enough information about this situa- CHAPTER 13 tion to know if other factors are involved, such as taking incorrect dose. Suicide 1. d. Teaching skills to help the patient deal 3. a. Delusions of grandeur are evidenced by the patient believing that the mayor with the problems of day-to-day life is seeking out her opinion. This is unwill be helpful in the long run. Option likely and demonstrates an unrealistic B is a mistake made by people who be- sense of self importance. lieve the myth that some suicide attempts are not serious. C is a block to 4. a. 1.0–1.5 mEq/L is the therapeutic therapeutic communication (disagree- serum concentration for acute mania. ing) and may give false hope. The For maintenance the level is usually patient does not see that there is much lower. to live for, or the suicide would proba- 5. b. Olanzapine is an antipsychotic. It may bly not have been attempted. A is also be used in the treatment of psychotic incorrect because reporting the patient behavior in bipolar disorder but may to the police is not required in most be used in combination with a mood communities and could be a threat to stabilizer. the patient. 6. b. By encouraging the patient to reflect 2. b. People are more likely to carry out the on past disappointments, you are en- suicide when they appear to feel better. couraging focus on what the person This is when they have the energy to has been through. At the same time create a plan and carry it out. When you are not negating the positive feel- they are deeply depressed or confused, ing he/she has now. Neither are you they often are not able to think clearly reinforcing unrealistic thinking. enough to do these things. When people feel loved and appreciated, they are 7. d. The manic patient needs foods that are easy to eat while pacing or moving less likely to think about suicide. This around. The other foods require the may be a temporary feeling on their patient to sit down for a meal, and the part, however. patient may not be able to do that. 3. c. If a person is talking about suicide, the possibility for carrying it out is very 8. c. Given these choices, this patient would benefit from medication to help pre- real and must be taken seriously. In vent injury from hyperactivity. very few situations is suicidal ideation a manipulative or attention-seeking 9. d. To be given the diagnosis of Bipolar II behavior. Suicide may be an impulsive the individual must have recurrent act but the person is usually thinking depression with bouts of hypomania. about it for some time. 2993_App-A_370-386 14/01/14 5:14 PM Page 380

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4. d. This man has definite potential for CHAPTER self-harm. He is not attempting 14 to manipulate his wife’s feelings, Personality Disorders although she may feel that he is. 1. d. Consequences should always be stated 5. b. Your first action is to place the at the time the limits are set, to inpatient on one-on-one observation. crease consistency. The problems with Some facilities accomplish this by options A through C are as follows. A: having staff perform rounds at a When the behavior occurs, the patient minimum of every 15 minutes; most may be testing, but if the conse- facilities assign a staff person to stay quences are not known, the patient with the patient. There is no need has not been given enough informa- to place the patient in a locked unit tion to make an appropriate choice. B: at this time, nor is it appropriate Anticipating a behavior is presuming, to publicize the precautions to the and you may be presuming incor- whole facility. It would not be appro- rectly. This sets up negative expecta- priate to give him his razor, as this tions from the patient. C: The limits could be an implement he could use should not be set for the convenience to perform the suicide. of the staff or family or anyone but the 6. c. Document the discussion but explain patient. Family should be involved in that the precautions remain in effect. the care plan if the patient is agreeable. It is for his safety and the safety of 2. c. David is most likely displaying signs others that the precautions are policy, of antisocial personality disorder evi- generally. You may thank him for denced by information that he tends sharing his beliefs, and depending on to lie, has committed a crime, and his where he is in his treatment, it may patterns with job and personal rela- become appropriate for him to share tionships. He is not exhibiting signs his belief system with others. of suspiciousness or paranoia, nor is 7. b. Older men who live alone with a his- he behaving in a dependent manner. tory of alcohol abuse are at one of the 3. a. Manipulation is used frequently by highest risks for suicide. Though any patients with personality disorders. of the other examples could be suici- This mechanism can be used with dal they do not represent the most other disorders but it is a primary frequent statistically. mechanism in personality disorders. 8. d. This response is supportive and em- 4. d. Interpersonal relationships are among pathetic. Responses A and B reflect the most difficult activities for a per- insensitivity to the patient’s distress. son with a personality disorder to de- Asking the question of response C velop. They can participate in group has nothing to do with the depth of activities because they can excel and distress this patient must have felt, bring attention and gratification to so it inappropriate. themselves, but developing a close per- 9. b. By asking the patient directly what sonal relationship is very difficult. she plans to do you are gaining im- 5. c. Antisocial (sociopathic) personality portant information and communi- is usually the type of disorder in which cating your concern to the patient. a person would be in trouble with Since she told you her plan, you the law. know she is reaching out for help. 6. b. Schizotypal personality disorder is 10. a. By reaching out to you, she is commu- characterized by bizarre and unusual nicating her mixed feelings about sui- behaviors—some of which may be also cide and is indirectly asking for help. seen in schizophrenia. 2993_App-A_370-386 14/01/14 5:14 PM Page 381

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7. c. The nurse needs to understand how reality. The other responses play into he/she reacts to the challenging the hallucination or border on belit- behaviors exhibited by people with tling the patient. personality disorders. Medications, 5. c. Patients with schizophrenia do not long-term therapy, and in-patient function well in society without treat- hospitalization are rarely eﬀective. ment. Even with treatment, some 8. c. Characteristics of narcissistic person- patients have a diﬃcult time. The ality include exaggerated sense of self- “reality” of schizophrenic people is importance and lack of concern for their own reality and not the reality the nurse’s time. of the rest of society. 9. d. Vague communication is not accept- 6. b. It is important always to deal with able. Honesty and clarity in commu- reality and the present when dealing nication are always necessary. The with people with schizophrenia. Never patient may feel inferior, which may reinforcing hallucinations and directing be part of the manipulation. The people away from situations that are nurse needs to confront the feelings stressful or competitive are also impor- of inferiority or any others that the tant. ECT is not a nursing function. patient might state. 7. b. This time you are dealing with an 10. b. Borderline personality. This group illusion. There is something on the tends to engage in self-mutilating ceiling, and the patient is misinter- behaviors. preting what is there. 8. c. Once again, maintaining honesty and CHAPTER 15 reality is the best response. Schizophrenia Spectrum and Other 9. a. Echolalia is the behavior or symptom Psychotic Disorders of catatonic schizophrenia involving 1. d. Inviting the patient to the party brings the patient repeating a word or part of a him into the present and allows him word or phrase over and over. Ecopraxia to make the choice for himself. This is repetitive movement or actions. will help increase self-esteem and di- 10. a. Delusions of grandeur include believ- minish other symptoms. Option A ing one is not subject to the laws of begins to reinforce the hallucinations, nature. which is never appropriate for nurses. 11. a. Muscle rigidity and protruding tongue B and C are forms of demands, which are classic symptoms of EPS in addi- may cause the patient to revert to neg- tion to restlessness and tremors. ative and possibly aggressive behaviors. 12. c. Decreasing anxiety and promoting 2. a. Shawna’s symptoms are consistent with trust are both realistic goals. Both of patients who have catatonic schizo- these are a process that can be helped phrenia. Option D, schizotypal, is a over time. type of personality disorder but not actually a form of schizophrenia. 13. a. We now know that schizophrenia is a brain abnormality. 3. a. This is an example of a hallucination. The patient is seeing something that is CHAPTER 16 not there. There is nothing actually visible that could be misinterpreted Neurocognitive Disorders: Delirium as a snake; if there were, this would and Dementia be an illusion. 1. b. Delirium is probably the best choice, 4. c. This is the honest response, and it since the patient presented as alert focuses on returning the patient to and oriented before surgery. Nothing 2993_App-A_370-386 14/01/14 5:14 PM Page 382

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indicates dementia at this point. She is physician, who must be the one to not delusional; she is having a halluci- give the initial information. You have nation. The dilemma may be in what maintained dignity for all, while the nurse chooses to do next. behaving professionally. 2. a. Your best action is to call your charge 9. d. Vascular or multi-infarct dementia is nurse and/or physician immediately. usually the result of several smaller Your state Nurse Practice Act will dic- strokes. The patient has usually had tate whom you should call first. Turn- conditions such as high blood pres- ing on the light may be helpful, but sure for quite some time. The condi- asking about the spiders plays into the tion displays many of the same hallucination, which is not therapeu- behaviors as other types of dementia tic. Stopping the patient’s pain med- but is also usually irreversible. ications is not an independent nursing 10. d. The patient with delirium receives function; you need to make that call the greatest benefit from reorientation to the physician first. Checking her techniques. In advanced dementia, medical record should have been done repeated attempts at orientation can earlier, and it will not be helpful to her contribute to anxiety. right now. 3. c. By reflecting back to Mrs. H your ob- CHAPTER 17 servation, you are promoting good communication and emotional support. Substance Use and Addictive The other choices are all blocks to ther- Disorders apeutic or helping communication. 1. c. Denial is the most common defense 4. b. Aricept can cause insomnia. It can also mechanism used by people who are cause bradycardia not tachycardia. chemically dependent. Rationalization is also used by some patients. 5. d. Although Alzheimer’s type dementia is not a result of aging or arteriosclerosis, 2. a. Alcohol is a CNS depressant that can these conditions may be present in lead to impaired judgment, confusion, addition to the dementia. lethargy, and coma in large amounts, The “high” that people feel is tempo- 6. c. You would expect to see memory and rary and very misleading. other cognitive processes impaired in someone with an organic mental disor- 3. d. Tremors, confusion, and hallucinations der. The person will probably not be are the classic symptoms of delirium oriented to at least one of the three tremens. spheres of person, place, or time. 4. d. Sally may very well be codependent in 7. b. These symptoms are consistent with a her sister’s alcohol abuse. Sally is tak- person’s having delirium. The admis- ing responsibility for Susie’s behavior sion of alcohol use adds to this conclu- instead of having Susie take care of sion. Time or decompensation of herself. memory and behavior might change 5. b. This response addresses both sisters this initial diagnosis to a form of de- and tells them they both need help. mentia. Alcohol-related dementia can It is honest and caring, and puts the develop in someone with a long his- responsibility on them to help them- tory of alcoholism. selves through this situation. 8. c This is the best option. You are showing 6. a. Susie should be encouraged to attend concern for the patient, the family, and weekly AA meetings and Sally to at- their situation. You have stated the im- tend weekly Al-Anon meetings. We do plied message and offered to get the not know from the information if they 2993_App-A_370-386 14/01/14 5:14 PM Page 383

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are adult children of alcoholics. There 4. a. A nutritional deficit, and probably is no need to check into the unit a fluid imbalance, exists in patients weekly, but they can be told that it is who are anorectic. The fluid imbal- acceptable to call or check in if they ance is caused by the lack of intake choose to do so. The psychologist will and perhaps vomiting. There is also tell them the meeting schedule; this a body image disturbance, but it is a would not be a nursing function for negative self-perception rather than discharge planning. a positive one. 7. c. These behaviors are the classic ones 5. d. Unlocking the feelings surrounding that indicate an addiction. an eating disorder can be very helpful 8. a. Honest communication is necessary to the patient and treatment team. for the person and family to heal. Focusing on the food and the destructive behaviors associated with the food 9. b. Codependent. In an effort to be caring, puts the emphasis on the wrong area. you are inadvertently making excuses and encouraging the drinking behavior. 6. c. Patients with bulimia nervosa cannot control their eating. They binge and 10. b. Chlordiazepoxide is often used to purge, and they are overly concerned safely detoxify a person from heavy and preoccupied with body shape alcohol use. It is relatively safe and and size. reduces the risk for complications from alcohol such as seizures. 7. d. This statement conveys your desire to help with ANY concern this patient 11. d. Alcoholics Anonymous is a lifelong may have postoperatively. The other commitment as one admits power- options do show a concern and inter- lessness over alcohol and remains in est in this patient, but focusing on need of this support. food and weight may limit the pa- 12. a. Methamphetamine abuse often tient’s willingness to offer other needs. includes appetite suppression and The patient may also not be ready to weight loss. talk about weight yet. This is a hope- ful yet traumatic step for many. CHAPTER 18 8. b. This response is a combination of the Eating Disorders therapeutic techniques of parroting and open-ended question. It uses the 1. c. Anorexia nervosa is the fear of food. patient’s words and leaves the question Bulimia nervosa is termed “binge eat- open for Donald to elaborate. The ing.” Pica is an eating disorder seen in other choices are nontherapeutic and young children. do not allow for patient expression. 2. b. This response is therapeutic— 9. c. These are the classic symptoms of demonstrating your efforts to help bulimia. the patient identify the feelings she experiences when trying to eat. Reponses 10. c. After binging, the person seeks a re- A and D are threats, and appetite stimu- lease of tension related to shame and lants are not useful since the disorder guilt by purging. is unrelated to appetite. CHAPTER 19 3. b. Patients who have anorexia have an intense fear of being fat. They have an Childhood and Adolescent Mental inaccurate sense of their size and body Health Issues image and will not develop normal 1. b. Safety for children with conduct disor- eating patterns without much help der is primary in importance. Chances and behavior modification. are that the child will not settle 2993_App-A_370-386 14/01/14 5:14 PM Page 384

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quickly, and asking the parent to leave 9. c. Chaotic home life is a common thread with the child is not a supportive ac- in children with conduct disorder. tion for either the parent or child. 10. c. The FDA has issued a black box 2. c. Exposing the child to one new person warning on all antidepressants to rather than several will help the child monitor children and teens for sui- develop a relationship. More than one cide when taking these medications. person and touching the child may increase anxiety. Isolating the child at CHAPTER 20 the same time will reinforce fears. Postpartum Issues in Mental Health 3. d. Children often act out or draw pictures about what is troubling them. Offering 1. b. Projecting evilness onto the infant is toys or drawing materials and observ- a sign of postpartum psychosis. The ing the child discreetly can tell you other responses are all normal reflec- much about what he or she has experi- tions of anxiety about the baby or the enced. It may also serve as a diversion, mother. but offering toys or drawing materials 2. d. Highly labile emotions related to the is meant to encourage self-expression baby are a common sign of postpar- rather than serve as a diversion from tum blues. Response B and C are signs the situation. of more serious disorders that could 4. d. Physical activity is a good outlet for impact the infant’s care. Response A is the ADHD child. Checkers and video a normal concern of a new mother. games are too sedentary, and pool 3. b. Postpartum blues usually start a few requires concentration that may be days after birth. These blues are com- difficult for the child. mon and not a psychiatric diagnosis 5. b. CNS stimulants are effective with nor reflect problems in bonding. ADHD to increase levels of neuro- 4. a. Postpartum depression is closely related transmitters to elicit a calming effect. to depression in a previous pregnancy. 6. d. All of these choices apply to ADHD. The other choices may be factors that could contribute to depression but are 7. b. The most common symptom of autism not the most important cause. The is impaired social functioning. The pa- other responses are not appropriate. tient does not make strong friendships. Antidepressants are not needed for Emotions may be completely opposite postpartum blues. of what would be appropriate, and the patient may achieve an appropriate 5. b. Giving the new mother information developmental task and then regress, on this being a normal response is an or may not achieve appropriate devel- important intervention. opmental tasks at all. 6. c. This response demonstrates sensitivity 8. c. This is the best choice of the options for the need to grieve this loss. The listed, because it implies the nurse other responses demonstrate insensitiv- heard the parents’ concerns and recog- ity to the depth of the loss. nized the need to get them appropriate 7. b. This statement is concerning that this help right away. The other options are new mother may be progressing to either nontherapeutic or provide false depression or some other disorder. hope to the parents. They may sound More follow-up and support is needed. polite but are not helpful for the par- Response C could be an indicator of ents, who are concerned they did a postpartum psychosis. A and D are something wrong and want to know more likely to associated with postpar- how they can help their child. tum blues. 2993_App-A_370-386 14/01/14 5:14 PM Page 385

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8. b. Mood stabilizers have been linked to can also change after a stroke, but malformations in neonates. that is not a speech difficulty. 9. c. Antidepressants are an effective treat- 8. b. Drugs are metabolized more slowly ment of postpartum depression. The in older people, which results in a cu- other responses are inaccurate. Diet mulative effect that leads to toxicity. and exercise may be helpful in depres- 9. c. These could be symptoms of elder sion but would not be the major treat- abuse. The location of the bruises is ment for this psychiatric disorder. consistent with shaking or beating. 10. d. All of these choices must be addressed The lack of eye contact or verbal rein postpartum psychosis. This is an sponse indicates that the patient may emergency for safety of the newborn. fear. More investigation is needed that the beatings might get worse. CHAPTER 21 10. d. OBRA stands for Omnibus Budget Aging Population Reconciliation Act. It establishes standards for the care of the older adult. 1. b. Reinforce the word by showing or handling the object. Trying to guess the 11. b. Progressive memory loss is not a nor- word or finishing the patient’s sentence mal part of aging. When memory loss can be frustrating and insulting and is apparent, more evaluation of the can discourage the patient from at- causes and nursing interventions to tempting to communicate. Asking the deal with it are important. patient to think about the word while 12. a. Providing support to a coworker is you do something else is distracting. most important. The other choices 2. d. Federal regulations require that the are more clinical questions. assessment be conducted by an RN for purposes of consistency. All other CHAPTER 22 people on the health-care team supply Victims of Abuse and Violence input and documentation to assist with the assessment. 1. d. Showing empathy for the patient, offering to provide further assistance, 3. c. Medication side effect would be the and reassuring safety will help the most obvious possibility, as the medica- patient to trust you and probably to tion is a recent change in routine, and be more comfortable and compliant normal vital signs should help rule out with examinations. the possibility of a recent stroke. De- pression is a more distant possibility. 2. b. Getting a statement in the patient’s own words and documenting it in the 4. c. You have been assertive and told the medical record are required. Option patient what you wanted in a way that A is information that the patient may encouraged the patient to participate not know. The word “why” is counter- in a specific activity. This also supports productive in therapeutic communica- the person’s self-esteem. tion. C is not recommended for reasons 5. b. The losses experienced as people age of liability for both the nurse and the are frequent causes of depression. patient. It is most likely a violation of 6. d. Dementia is not a part of normal your agency policy as well as a violation aging. Other possibilities for unusual of professional ethics. Option D is in- behavior should be ruled out before appropriate as it has nothing to do with diagnosing a person with dementia. the rape. 7. b. Aphasia is the speech complication 3. c. You need to be helpful to both people. that often results from stroke. Affect You will need to take care of the physical 2993_App-A_370-386 14/01/14 5:14 PM Page 386

386 APPENDIX A | Answers and Rationales

and emotional health of both patients, be true, but she has to make that de- and you will do it according to the decision on her own. The organization gree of immediacy called for. A physi- you offered her in option A may assist cian must be called if one is not in the with that as well. “Why” is a nonther- area, but until he or she arrives, your apeutic response. Asking if he’s done nursing care, observation, and docu- that before does make an attempt at mentation will help ensure the best gathering information and showing possible care for the patients. concern, but the more immediate 4. c. You let Mrs. X know that you hear need now is to support her and offer her concern and need for help. You her some options for assistance. are offering the best help you can at 7. c. There is evidence to indicate the pos- the moment, while allowing her to sibility of the abuse cycle. All the make the decision about speaking to other responses may be accurate, but the social worker. there is not enough information to 5. c. While some patients may express determine this. This woman may displeasure at someone going ahead, believe she must return to the home most will realize something is terribly where abuse is probably occurring. wrong. Apologize for their inconven- 8. c. Physical and emotional support is the ience and have someone assist them most important initial intervention. as soon as possible. Attending to this The other interventions may be woman, her immediate needs, and needed later in the visit. those of her children is the best nurs- 9. b. Rape is an act of violence and not ing choice. You may also let her know related to sexual desire. that someone will be in who can help her with safety issues, but it is impor- 10. b. The son may need to see the will to tant to get her in a quiet, safe room. obtain information for financial plan- After all, the perpetrator may be right ning of patient’s resources. Responses behind her. She knows that. A and C indicate the caregiver is over- stepping his/her boundaries. Would 6. a. You are showing empathy, being non- need more information to determine judgmental, and offering the patient if response D is appropriate. assistance. Offering to her that she needs to leave sounds helpful and may 2993_App-B_387-387 14/01/14 5:15 PM Page 387

APPENDIX B Agencies That Help People Who Have Threats to Their Mental Health

1. National Institute of Mental Health 6. American Association of Retired (NIMH) Persons (AARP) 6001 Executive Boulevard, Room 8184, Widowed Persons Services MSC 9663 Social Outreach and Support Bethesda, MD 20892-9663 1909 K Street NW (301) 443-4513; 1-866-615-6464; Washington, DC 20049 301-443-8431 (TTY) (202) 728-4370 Fax: (301) 443-4279 www.aarp.org www.nimh.nih.gov 7. National Hospice & Palliative Care 2. Depression and Bipolar Support Organization (NHPCO) Alliance 1731 King Street 730 Franklin Street, Suite 501 Alexandria, VA 22314 Chicago, IL 60610-7224 Phone: (703) 837-1500; Fax: (703) (800) 826-3632; Fax: (312) 642-7243 837-1233 www.dbsalliance.org www.nhpco.org 3. National Alliance on Mental Illness* 8. Child Abuse Prevention Association 3803 N. Fairfax Drive 503 E. 23rd Street Arlington, VA 22203 Independence, MO 64055 Main: (703) 524-7600; (816) 252-8388; Fax (816) 252-1337 Helpline: (800) 950-6264; www.childabuseprevention.org Fax: (703) 524-9094 9. National Council of Alcohol and www.nami.org Drug Dependence *Most states have a chapter of Alliance for the Mentally Ill (AMI) 217 Broadway, Suite 712 as well. New York, NY 10007 4. Child Welfare Information Gateway Hope Line: (800) NCACALL; FAX: www.childwelfare.gov/ (212) -269-7510 5. Mental Health America (formerly www.ncadd.org known as National Mental Health 10. Alcoholics Anonymous Association) Mailing Address: 2001 N. Beauregard Street, 12th Floor A.A. World Services, Inc. Alexandria, VA 22311 P.O. Box 459, Grand Central Station Phone: (800) 969-6642; Fax: (703) New York, NY 10163 684-5968 (212) 870-3400 www.mentalhealthamerica.net http://aa.org 387 2993_App-C_388-389 14/01/14 5:15 PM Page 388

APPENDIX C Organizations That Support the Licensed Practical/ Vocational Nurse

The following is a partial list of organizations relationships. Some states have local associa- that support and foster the role of the licensed tions of NFLPN. practical/vocational nurse in the United States. 3. American Psychiatric Nurses Association 1. National Association for Practical Nurse (APNA) Education and Service (NAPNES) 3141 Fairview Park Drive, Suite 625 1940 Duke Street, Suite 200 Falls Church, VA 22042 Alexandria, VA 22314 (855) 863-APNA (2762); Fax: (855) (703) 933-1003; Fax: (703) 940-4089 883-APNA (2762) www.napnes.org www.apna.org/membership NAPNES is the oldest association that ad- APNA is a resource for psychiatric mental vocates the practice, education, and regulation health nursing. It offers affiliate memberships of practical and vocational nurses, practical for LPN/LVNs. nurse educators, practical nursing schools, prac- 4. American Association for Men in Nursing tical nursing educators, and students. NAPNES P.O. Box 130330 has consistent state members througout the Birmingham, AL 35213 U.S. Publications: Journal of Practical Nursing. (205) 956-0146; Fax: (205) 956-0149 2. National Federation of Licensed Practical www.aamn.org Nurses (NFLPN) Founded in 1973, the purpose of AAMN 111 West Main Street, Suite 100 is to provide a framework for nurses, as a Garner, NC 27529 group, to meet, and to discuss and influence (919) 779-0046; Fax: (919) 779-5642 factors that affect men as nurses. Check the www.nflpn.org Web site for local chapter information. The Mission of the National Federation of 5. NCEMNA, National Coalition of Ethnic Licensed Practical Nurses, Inc., is to foster Minority Nurse Associations Inc. high standards of nursing care and promote 6101 West Centinela Avenue, Suite 378 continued competence through education/ Culver City, CA 90230 certification and lifelong learning, with a (310) 258-9515; Fax: (310) 258-9513 focus on public protection. www.ncemna.org NFLPN is committed to quality and NCEMNA is a national collaboration of professionalism in the delivery of nursing ethnic minority nurse associations. The site care, working with other organizations and provides announcements about NCEMNA’s groups in a cooperative progressive spirit unique programs and activities, as well as direct to build strong professional and public links to each member association’s Web site.

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APPENDIX C | Organizations That Support the Licensed Practical/Vocational Nurse 389

6. National Association of Hispanic Nurses, The National Black Nurses Association’s Inc. (NAHN) mission is to provide a forum for collective ac- Mailing Address: 6301 Ranch Drive, tion by black nurses to investigate, define, and Little Rock, AR 72223 advocate for the health-care needs of African DC Office: 750 First Street NE, Suite Americans and to implement strategies that 700, Washington, DC 20002 ensure access to health care that is equal to or 501-367-8616 | fax 501-227-5444 | above health-care standards of the larger society. www.nahnnet.org 8. Philippine Nurses Association of America, NAHN promotes the professionalism and Inc. (PNAA) dedication of Hispanic nurses by providing 8303 Windfern Road equal access to educational, professional, and Houston, TX 77040 economic opportunities for Hispanic nurses. www.mypnaa.org 7. National Black Nurses Association, Inc. PNAA upholds the positive image and (NBNA) welfare of its constituent members, promotes 8630 Fenton Street, Suite 330 professional excellence, and contributes to Silver Spring, MD 20910-3803 significant outcomes to health care and soci- (301) 589-3200; Fax: (301) 589-3223 ety as well as unifies Filipino-American nurses www.nbna.org in the United States and its territories. 2993_App-D_390-392 14/01/14 5:15 PM Page 390

APPENDIX D Standards of Nursing Practice for LPN/LVNs

■ National Federation ■ NFLPN Nursing Practice of Licensed Practical Standards Nurses (NFLPN) Code for Licensed Practical/ Introductory Statement Definition: Practical/vocational nursing means Vocational Nurses the performance for compensation of authorized acts of nursing that utilize specialized • Know the scope of maximum utilization knowledge and skills and that meet the health of the LPN/LVN as specified by the nurs- needs of people in a variety of settings under ing practice act and function within its the direction of qualified health professionals. scope. Scope: Practical/vocational nursing com- • Safeguard the confidential information prises the common case of nursing and, there- acquired from any source about the fore, is a valid entry into the nursing profession. patient. Opportunities exist for practicing in a • Provide health care to all patients regard- milieu where different professions unite their less of race, creed, cultural background, particular skills in a team effort for one com- disease, or lifestyle. mon objective—to preserve or improve an • Refuse to give endorsement to the sale individual patient’s functioning. and promotion of commercial products or Opportunities also exist for upward mo- services. bility within the profession through academic • Uphold the highest standards in personal education and for lateral expansion of knowl- appearance, language, dress, and demeanor. edge and expertise through both academic • Stay informed about issues affecting the and continuing education. practice of nursing and delivery of health care and, where appropriate, participate in Standards government and policy decisions. Education • Accept the responsibility for safe nursing The licensed practical/vocational nurse: practice by keeping oneself mentally and physically fit and educationally prepared 1. Shall complete a formal education pro- to practice. gram in practical nursing approved by the • Accept the responsibility for membership appropriate nursing authority in a state. in NFLPN and participate in its efforts to 2. Shall successfully pass the National maintain the established standards of Council Licensure Examination for nursing practice and employment policies Practical Nurses. that lead to quality patient care. 3. Shall participate in initial orientation within the employing institution.

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APPENDIX D | Standards of Nursing Practice for LPN/LVNs 391

Legal/Ethical Status • Implementation: The plan for nursing The licensed practical/vocational nurse: care is put into practice to achieve the stated goals and includes: 1. Shall hold a current license to practice nurs- • Observing, recording, and reporting ing as an LPN/LVN in accordance with the significant changes which require law of the state wherein employed. intervention or different goals 2. Shall know the scope of nursing practice • Applying nursing knowledge and authorized by the Nursing Practice Act skills to promote and maintain in the state wherein employed. health, to prevent disease and dis- 3. Shall have a personal commitment to ability, and to optimize functional fulfill the legal responsibilities inherent capabilities of an individual patient in good nursing practice. • Assisting the patient and family with 4. Shall take responsible actions in situations activities of daily living and encour- wherein there is unprofessional conduct aging self-care as appropriate by a peer or other health-care provider. • Carrying out therapeutic regimens 5. Shall recognize and have a commitment and protocols prescribed by an RN, to meet the ethical and moral obligations physician, or other persons author- of the practice of nursing. ized by state law 6. Shall not accept or perform professional • Evaluations: The plan for nursing care responsibilities which the individual and its implementations are evaluated knows (s)he is not competent to perform. to measure the progress toward the stated goals and will include appropri- Practice ate persons and/or groups to determine: The licensed practical/vocational nurse: • The relevancy of current goals in relation to the progress of the indi- 1. Shall accept assigned responsibilities vidual patient as an accountable member of the health- • The involvement of the recipients of care team. care in the evaluation process 2. Shall function within the limits of • The quality of the nursing action in educational preparation and experience the implementation of the plan as related to the assigned duties. • A reordering of priorities or new 3. Shall function with other members of goal setting in the care plan the health-care team in promoting and 5. Shall participate in peer review and other maintaining health, preventing disease evaluation processes. and disability, caring for and rehabilitat- 6. Shall participate in the development of ing individuals who are experiencing an policies concerning the health and nurs- altered health state, and contributing to ing needs of society and in the roles and the ultimate equality of life until death. functions of the LPN/LVN. 4. Shall know and utilize the nursing process in planning (assessing [data gath- ■ Continuing Education ering]), implementing, and evaluating health services and nursing care for the The licensed practical/vocational nurse: individual patient or group. • Planning (assessing [data gathering]): 1. Shall be responsible for maintaining the The planning of nursing includes: highest possible level of professional • Assessment of health status of the indi- competence at all times. vidual patient, the family, and commu- 2. Shall periodically reassess career goals nity groups and select continuing education activities • An analysis of the information gained which will help to achieve these goals. from assessment 3. Shall take advantage of continuing edu- • The identification of health goals cation opportunities which will lead to 2993_App-D_390-392 14/01/14 5:15 PM Page 392

392 APPENDIX D | Standards of Nursing Practice for LPN/LVNs

personal growth and professional devel- 2. Shall present personal qualifications that opment. are indicative of potential abilities for 4. Shall seek and participate in continuing practice in the chosen specialized nursing education activities which are approved area. for credit by appropriate organizations, 3. Shall present evidence of completion such as the NFLPN. of a program or course that is approved by an appropriate agency to provide the knowledge and skills necessary for ■ NFLPN Specialized effective nursing services in the specialized field. Nursing Practice 4. Shall meet all of the standards of practice Standards as set forth in this document. (Reference: NFLPN, Nursing Practice Stan- The licensed practical/vocational nurse: dards for the Licensed Practical/Vocational 1. Shall have had at least one year’s experi- Nurse (2003) available at www.nflpn.org/ ence in nursing at the staff level. practice-standards4web.pdf.) 2993_App-E_393-394 14/01/14 5:15 PM Page 393

APPENDIX E Assigning Nursing Diagnoses to Client Behaviors

Common behaviors are matched with examples of corresponding nursing diagnoses.

Behavior Nursing Diagnosis Aggression, hostility Risk for injury; Risk for other directed violence Anorexia or refusal to eat Impaired nutrition: less than body requirements Anxious behavior Anxiety Body image issues such as negative Disturbed body image attitude toward body part Confusion, memory loss Impaired memory; Confusion; Disturbed thought processes Delusions Disturbed thought processes Denial of problems Ineffective denial Depressed mood Disturbed self-esteem; Disturbed self-concept; Grieving; Hopelessness Detoxification, withdrawal from substances Risk for injury Difficulty sleeping Disturbed sleep pattern Difficulty with interpersonal relationships Impaired social interactions Expresses anger at God Spiritual distress Expresses lack of control over personal Powerlessness situation Flashbacks, nightmares, obsession with Post-trauma response traumatic experience Hallucinations Disturbed sensory perceptions; Disturbed thought processes Highly critical of self Disturbed self-esteem Inability to meet basic needs Self-care deficit Loose associations or flight of ideas Disturbed thought processes Manic hyperactivity Risk for injury, disturbed thought processes Manipulative behavior Ineffective coping; Impaired social interactions Overeating, compulsive Risk for imbalanced nutrition: more than body requirements Phobias Anxiety; Fear Continued

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394 APPENDIX E | Assigning Nursing Diagnoses to Client Behaviors

Behavior Nursing Diagnosis Physical symptoms as coping behavior Ineffective coping Potential or anticipated loss of significant Grieving entity Projection of blame, rationalization of Defensive coping failures, denial of personal responsibility Ritualistic behaviors Anxiety; Ineffective coping Inappropriate sexual behaviors Impaired social interaction Self-inflicted injuries (non–life-threatening) Self-mutilation; Risk for self-mutilation Stress in caring for another person Caregiver role strain; Compromised family coping Substance use as a coping behavior Ineffective coping; Ineffective denial Suicidal gestures, threats, ideation Risk for violence to self; Hopelessness Suspiciousness Disturbed thought process; Ineffective coping Violent behavior Risk for violence; Ineffective coping; Risk for injury Withdrawn behavior Social isolation

Source: Adapted from Townsend (2012): Psychiatric Mental Health Nursing, 7th ed. Philadelphia: F.A. Davis Company, with permission. 2993_Glos_395-404 14/01/14 5:30 PM Page 395

■

Glossary

Abuse: Physical, verbal, or emotional Alzheimer’s disease: A form of progressive mistreatment of self or others; misuse dementia. of chemicals, food, or other substances. American Nurses Association (ANA): A Abuser: One who mistreats others. national nursing organization established Accommodation: Process of adjusting one’s for registered nurses. schema to fit changing situations (Piaget). American Psychiatric Nurses Association Accountability: When a health-care worker (APNA): A national nursing association accepts responsibility for any actions dedicated to psychiatric mental health performed while caring for a patient. nursing. Adaptation: The effective coping to changes Anhedonia: Inability to experience pleasure. that are external and internal. Anorexia nervosa: Serious aversion to food, Addiction: A chronic brain disease character- which can lead to malnutrition and death. ized by compulsive and maladaptive use of Also called anorexia. a substance or behavior (e.g., gambling). Antidepressant: Classification of psy- Advocacy: Act of ensuring that patients, choactive medication used to treat especially those classified as “vulnerable,” depression. are being treated in a safe, legal manner. Antimanic agent: Classification of psy- Affect: The outward display or expression of choactive medication used to treat manic a feeling or mood. behavior, such as in bipolar disorder. Ageism: Form of discrimination against Antiparkinson agent: Classification of people on the basis of age. medication used to treat the symptoms Aggressive communication: Form of com- of both drug-induced and non-drug- munication that hurts another and is not induced parkinsonism. self-responsible (“you” statements). Antipsychotics: Classification of psychoac- Agnosia: Loss of ability to recognize objects. tive medications used to treat psychotic Agraphia: Difficulty writing and drawing. behavior found in disorders such as Akathisia: Restlessness; an urgent need for schizophrenia and organic brain movement. disorders. Alcohol abuse: Compulsive use of alcohol Antisocial personality disorder: A pat- usually lasting 1 month or longer. tern of irresponsible, exploitive, and Alcohol dependence: Improper use of guiltless behavior with tendency to alcohol with impairment of social or fail to conform to the law and exploit occupational functioning, which leads to and manipulate others for personal signs of tolerance or withdrawal. gain. Popularly known as sociopathic Alcoholism: A complex, progressive disease personality. characterized by significant physical, Anxiety: Feelings of uneasiness or social, and/or mental impairment apprehension. directly related to alcohol dependence Aphasia: Inability to communicate through and addiction. speech caused by brain dysfunction. Alternative medicine: Modalities that Apraxia: Inability to carry out motor activities replace those of conventional medicine. despite intact motor function. 395 2993_Glos_395-404 14/01/14 5:30 PM Page 396

396 Glossary

Aromatherapy: Related to herbal therapy; Biofeedback: Method of teaching patients provides treatment by both direct phar- to recognize tension within the body and macological effects of the aromatic plant to respond with relaxation. substances and indirect effects of certain Bipolar disorder: A disorder characterized by smells on mood and affect. mood swings from profound depression to Assertive communication: Self-responsible extreme euphoria with intervening periods statements that begin with the word “I” of normalcy. and deal with thoughts, feelings, and Body image: Individual’s perception of his honesty. or her body. Assimilation: Taking in, processing, incor- Body mass index (BMI): An approximation porating new information (Piaget). of body fat based on a calculation of Asylum: Old term for institution for the care weight divided by the square of one’s of the needy, especially the mentally ill. height in adults. Attention-deficit/hyperactivity disorder Borderline personality: A disorder charac- (ADHD): The display of a persistent terized by a pattern of intense and chaotic pattern of inattention and/or hyperactiv- relationships with emotional instability ity-impulsivity that is more frequent and and tendency toward self-destructive severe than is typically observed in individ- behavior. uals at a comparable level of development. Bulimia: Eating disorder in which a Autism spectrum disorder: A group of person experiences eating binges along disorders that are characterized by im- with purging. Also called bulimia pairment in several areas of development, nervosa. including social interaction, skills, and Bullying: A form of aggressive behavior interpersonal communication. manifested by the use of force or coercion Autonomy: Development of a sense of self to affect others, particularly when the and independence (Erikson). behavior is habitual and involves an Avoidant personality: An individual with imbalance of power. extreme sensitivity to rejection leading to Catatonia: Rigidity and inflexibility of mus- avoidance of social contacts. cles, resulting in immobility or extreme Awareness: Having a realization, perception, agitation. or knowledge. Cerebrovascular disease: A disorder of the Behavior: Any action or activity that can be blood vessels related to the brain. observed. Chemical restraint: The use of medication Behavior modification: Form of treatment as a restriction to manage behavior or in which variables are manipulated to en- restrict patient freedom of movement. courage and reinforce desired behavioral Child abuse: The physical, emotional, or changes. sexual mistreatment of children. Behavioral theorist: Scientists who have Civil law: Body of laws dealing with rights of developed theories about human thought private citizens. and behavior including Watson, Pavlov, Codependency: Maladaptive coping be- and Skinner. haviors that reinforce another person’s Beliefs: Concepts, opinions, and ideas that addictive behavior by allowing that per- are accepted as true and are usually not son to avoid consequences of his/her exactly the same for each individual. actions. Also called enabling. Binge drinking: Episodic, excessive drinking. Cognitive: Pertaining to the thought Four or more alcoholic drinks (for women) process and the ability to think. or five or more alcoholic drinks (for men) Cognitive Behavior Therapy (CBT): Psy- on the same occasion on at least one day. chotherapeutic approach that combines Binge eating disorder: Recurrent episodes behavior therapy with cognitive psychol- of binge eating that leads to feelings of ogy, It is a problem-focused and action- distress. Not associated with purging. oriented short-term therapy. 2993_Glos_395-404 14/01/14 5:30 PM Page 397

Glossary 397

Collaborative: Form of care in which nurses episodes of hypomania and depressed work together and with other disciplines mood. for the betterment of patient care. DSM-IV: Diagnostic and Statistical Manual Commitment: The act of forced hospitaliza- of Mental Disorders, 4th ed. tion, frequently against the patient’s will DSM-5: Diagnostic and Statistical Manual when the patient's safety is compromised. of Mental Disorders, 5th edition. Major Communication: Method of transmitting psychiatric reference by the American messages between a sender and a receiver. Psychiatric Association. Can be verbal or nonverbal. Data collection: Gathering of information Communication block: Method of commu- about a patient; part of nursing process. nication that impedes helpful interactions Date rape: Unwanted sexual intercourse with patients. between people who are aqcuainted and Community Mental Health Centers in which the party who pays for the date Act of 1963: A result of President expects sex in return. John F. Kennedy’s concern for the treat- Defense mechanisms: Group of behaviors ment of the mentally ill. used to reduce or eliminate anxiety. Complementary medicine: A wide variety Unconsciously falling into habits that of alternative practices such as acupunc- give the illusion of coping but produce ture and hypnosis that are recognized and ineffective results. accepted by mainstream medicine; done Deinstitutionalization: A policy in which in conjunction with traditional medicine. people who had formerly required long Compulsion: Unwanted, repetitive urge hospital stays became able to leave the to perform or the actual performance of institutions and return to their commu- a behavior. nities and homes. Conduct disorder: A repetitive and persis- Delirium: Acute brain syndrome; rapid tent pattern of behavior in which the basic onset of cognitive impairments such as rights of others or major age-appropriate loss of memory and disorientation. societal norms or rules are violated. Delirium tremens (DTs): Form of delirium Confidentiality: The act of maintaining from withdrawal from alcohol in which privacy of patient information. the person experiences, among other Conversion: Transference of anxiety into symptoms, tremors, hallucinations, physical symptoms. delirium, and diaphoresis. Co-occurring disorder: Existence of both a Delusion: Fixed, false belief relating usually substance abuse disorder and a serious to persecution or grandeur. mental illness. Also called dual diagnosis. Dementia: Gradual progression and deteri- Coping: The act of successfully adapting psy- oration of cognitive functioning that chologically, physically, and behaviorally interferes with memory, language, and/or to problems or stressors. executive functions, such as organizing Counseling: One of several forms of therapy. and abstraction. Also referred to as major Crisis: A state of psychological disequilibrium. neurocognitive disorder. Culture: Nonphysical traits, rituals, values, Dependent: Relying on another person or and traditions that are handed down to substance. others from generation to generation. Dependent personality disorder: Charac- Culture of nurses: Professional values, rituals, terized by a pervasive and excessive need and traditions passed down from one to be taken care of. generation of nurses to the next. Depression: An alteration in mood that is Cyberbullying: The use of the Internet and expressed by feelings of sadness, despair, social media to harm other people in a and pessimism. deliberate, repeated, and hostile manner. Detoxification: The process of withdrawal of Cyclothymic: Characterized by chronic the substance through supervised medical mood disturbance involving numerous interventions to prevent complications. 2993_Glos_395-404 14/01/14 5:30 PM Page 398

398 Glossary

Dissociate: To separate a strong emotional depression or schizophrenia not respond- response from the consciousness. ing to other forms of treatment. A Dissociative disorders: Disruption and or current is passed through the patient, discontinuity in the normal integration resulting in mild seizure and temporary of consciousness, memory, identity. This amnesia. category includes dissociative identify Emotional abuse: Willful use of words or disorder (multiple personality). actions that undermine another person’s Doctrine of Privileged Information: A bond self-esteem. between patient and physician. Under this Empathy: Therapeutic communication tech- doctrine, the physician has the right to re- nique of understanding another person’s fuse to answer certain questions (e.g., in emotion without actually experiencing the a court of law) and can cite “privileged emotion. physician-patient information.” Ethics: The basic concepts and fundamental Domestic violence: Intentionally inflicting moral principles that govern conduct. or threatening physical injury or cruelty Ethnicity: The condition of identifying to one’s partner. Also known as intimate with an ethnic group. partner abuse, spouse abuse. Ethnocentrism: When individuals believe Dysfunctional: Having abnormal or that their particular ethnic or religious ineffective function in mental health group has rights and benefits over those pertaining to coping and relationships. of others. Dysmorphophobia: Preoccupation with an Eustress: Type of stress that results from imagined defect in appearance. positive experiences (experiences such as Dysphasia: Difficulty in speaking. raises, promotions). Dysthmic disorder: A chronic form of Evaluation: Part of nursing process that depression with somewhat milder symp- summarizes nursing interventions and toms than major depressive disorder. the outcomes. Dystonia: A disorder in which the symp- Extrapyramidal symptoms (EPS): A vari- toms manifest as bizarre distortions or ety of responses associated with drugs involuntary movements of any muscle that antagonize the dopamine receptors group. outside the pyramidal tract, causing a Echolalia: Repetition of phrases, words, or variety of effects including tremors and part of a word; often part of catatonia. rigidity. Echopraxia: Repeating the movements of Feeling: Emotion. others. Feeling statement: Statement that must Economic abuse: Using another’s resources identify an emotion that one is experi- for one’s own personal gain without per- encing or trying to explore (e.g., “I feel mission or making the victim financially proud” or “I feel frightened”). dependent on the abuser. Also called Formal teaching: Teaching that is planned fiduciary abuse. and scheduled. Effective coping: Skills that reduce tension Free-floating anxiety: Anxiety that has no and do not create more problems for an identifiable cause; feeling of “impending individual. doom.” Ego: Second part of Freud’s personality devel- Free-standing treatment centers: Treatment opment, balancing the id; the ego meets centers that provide care ranging from and interacts with the outside world. crisis care to traditional 21-day stays. They Elder abuse: Physical, emotional, or sexual may be called detoxification (detox) centers, abuse of older adults. crisis centers, or other similar terms. Elderly: Pertaining to older people, often Generalized anxiety disorders: An anxiety described as people over 65 years old. disorder that has no identifiable cause Electroconvulsive therapy (ECT): Electro- and that is characterized by excessive convulsive therapy, reserved for types of worry or severe stress and a feeling of 2993_Glos_395-404 14/01/14 5:30 PM Page 399

Glossary 399

“impending doom;” it typically lasts severe enough to cause marked impair- 6 months or longer. ment in social or occupational function- Geriatrics: Branch of medicine that deals ing. Also known as hypomanic episode. with the illnesses and treatment of elderly Id: First part of Freud’s personality theory, people. which is preoccupied with self-gratification. Gerontology: The study of aging and old age. Illusion: A misperception of a real external Hallucination: False sensory perception; stimulus. can affect any of the five senses. Implementation: Part of the nursing process Health-illness continuum: Theory that that identifies specific actions a nurse will physical and mental health and illness do to help a patient meet a goal; nursing fluctuate somewhat on a daily basis, while intervention. staying within a social norm of behavior. Impulsivity: The trait of acting without re- Health Insurance Portability and Account- flection and thought to the consequences. ability Act (HIPAA): Regulations devel- Incest: Sexual activity between people who oped by the Department of Health and are so closely related that marriage is illegal. Human Services to provide national Ineffective communication: A breakdown standards pertaining to the transmission either in the sender’s process of delivery and communication of medical informa- of a message or how that message is tion among patients, providers, employers, received. and insurers. Ineffective coping: The use of coping skills Hearing impaired: A loss of hearing function that do not reduce tension and/or that that may be congenital or due to normal are hazardous to an individual. aging or other causes. It interferes with Informal teaching: Teaching that is provided communication between the sender and at unplanned or unscheduled times. the receiver. Insidious: Referring to onset that is so Hill-Burton Act: The first major act or law gradual it is hardly noticed. to address mental illness in the U.S. It Insomnia: Difficulty sleeping. provided money to build psychiatric units Integrative medicine: The combination in hospitals. of conventional and less traditional Histrionic personality disorder: Associated treatment methods. with extreme dramatic, excessive behaviors Intentional: An act that may result in injury in someone who has a pattern of strong or property damage, and that is deter- emotions. mined to be planned or deliberate. Holistic view: Viewing a person as a whole. Judgment: Subjective assessment of a patient’s Homeless: The state of being without a ability to make appropriate decisions. permanent place of residency or home. “La belle indifférence”: Inappropriate lack Hyperactivity: Excessive psychomotor ac- of concern for symptoms. tivity that may be purposeful or aimless. Laryngectomee: Person who has had a Hypochondriasis: Condition of unrealistic or laryngectomy. exaggerated concern over minor symptoms. Laryngectomy: Partial or total removal of Hypnosis: Form of therapy that is meant to the larynx (“voice box”). produce a state of increased relaxation Lethality: The level of risk of death in the and increases openness to suggestions for suicide method. behavior modification. Lunar month: Twenty-eight–day cycle in Hypnotherapy: The means for entering an prenatal development. altered state of consciousness, and in this Major depressive disorder: Psychiatric illness state, the use of visualization and sugges- characterized by depressed mood or loss of tion to bring about desired changes in interest or pleasure in usual activities that behavior and thinking. impacts one’s life for at least 2 weeks. Hypomania: A mild form of mania that is Malingering: Deliberate faking or exagger- associated with hyperactivity but is not ating of symptoms. 2993_Glos_395-404 14/01/14 5:30 PM Page 400

400 Glossary

Mania: Predominant mood that is elevated, service through the practice of licensed expansive, or irritable with frenzied motor practical nurses (LPN) and licensed activity. Also known as manic episodes. vocational nurses (LVN). Maslow’s Hierarchy of Needs: An orderly National Federation of Licensed Practical progression of development that takes in Nurses (NFLPN): An organization in the physical components of personality the United States formed for practical/ development as well as the emotional vocational nursing students. components. National League for Nursing (NLN): An Memory: Mental function that enables a organization that emphasizes nursing person to store and recall information. education, development, and leadership. Menarche: First menstrual period. National Mental Health Act of 1946: Part Mental health: State of being able to func- of the result of the first Congress to be tion with successful adaptation to stressors. held after World War II, providing money Mental illness: Disorders characterized for training and research in nursing care by dysregulation of mood, thought, (and other patient care disciplines) to im- and/or behavior as recognized by the prove care for people with mental illnesses. Diagnostic and Statistical Manual of Neglect: Deliberate deprivation of necessary Mental Disorders. and available resources such as medical or Message: Information that may be verbal or dental care. non-verbal and that is transmitted from Neurocognitive disorder: A disorder char- the sender. It is part of the communication acterized by deficits in thinking, memory, process. and/or judgment Mild cognitive disorder: Less severe form Neurolinguistic programming (NLP): of cognitive impairment than dementia. The theory that language cues can be Milieu: Environment for treating patients. used to understand how an individual Mind-body connection: An interconnec- experiences his or her world, allowing a tion of the mind and body in which the practitioner to help a patient change her mind influences the body’s responses. or his experience and respond to prob- Models: Pictures or ideas that we form in lems in a different way; uses visual, our minds to explain how things work. auditory and kinesthetic channels. They help us understand and interact Nocturnal delirium: Increased confusion and with other people and our environment, agitation at dusk. Also called sundowning. and help us to formulate beliefs. Nonverbal communication: Actions, the Monoamine oxidase inhibitor (MAOI): way we use our body, and facial expres- Group of antidepressant medications that sion that are used in communications. work by blocking the enzyme monoamine North American Nursing Diagnosis oxidase. Association (NANDA): A nursing Mood: An individual’s sustained emotional organization that establishes and oversees tone, which influences behavior, person- standardized language for nurses to im- ality, and perception. prove communication and outcomes. Morbid obesity: Condition of being Nurse Practice Act: An act based on federal abnormally overweight; weight that is guidelines adapted to the needs of indi- 100 pounds or more above established vidual states that dictates the acceptable norms. scope of practice for the different nursing Narcissistic personality: A disorder that levels. displays exaggerated self-love and self- Nursing diagnosis: Nonmedical statement importance. of an existing or potential problem. National Association for Practical Nurse Nursing Interventions Classification Education and Service (NAPNES): The (NIC): A comprehensive standardized world’s oldest nursing organization, it is language of intervention labels and devoted to promoting quality nursing possible nursing actions. 2993_Glos_395-404 14/01/14 5:30 PM Page 401

Glossary 401

Nursing Outcomes Classification (NOC): Parkinsonism: Group of symptoms that A standardized language that provides mimic Parkinson's Disease including outcome statements and a set of indica- tremors and rigidity. tors that describe the specific patient, Patient Bill of Rights: Federal and state caregiver, family, or community states guidelines to ensure the civil rights of related to outcome. people who are entrusted to the care Nursing process: Established system of data of health-care providers in hospitals, collecting and care planning performed nursing homes, and so on. by nurses. Patient interview: An interaction between Nurse Practice Act: Act that dictates the the patient or client and the health-care acceptable scope of nursing practice for provider in order to collect patient data. the different levels of nursing. Patient teaching: Any set of planned educa- Obesity: A body mass index greater than 30. tion activities designed to improve patients Omnibus Budget Reconciliation Act health behaviors and health status. (OBRA): A federal act that provides Person-centered: Humanistic theory of standards of care for older adults. unconditional positive regard for the Obsession: Repetitive thought that cannot person, involving treatment of the whole be ignored by the patient. person rather than just the illness. Obsessive Compulsive Disorder (OCD): Personality: Sum of the behaviors and The presence of obsessions and compul- character traits of a person. sions that the individual feels compelled Personality disorder: Nonpsychotic, to think about and perform that interfere maladaptive behavior that is used to with daily functioning. satisfy the self. Obsessive-compulsive personality disorder: Phobia: Irrational fear. Characterized by preoccupation with Physical abuse: Any actions by omission or rules, orderliness, and control. commission that cause physical harm to Operant conditioning: A method of learning another. that occurs through rewards and punish- Physical restraint: Any physical method of ments for desired or undesired behaviors. restricting an individual’s freedom of Orientation: Measurement of knowledge movement, activity, or normal access of person, place, and time in the mental to his/her body that cannot be easily health assessment. removed. Palliative care: Specialized care that focuses Placebo: A neutral, inactive agent given in on patients with advanced illness and place of medication that produces symp- their families by providing expert symptom relief or other desired effects based tom management and the promotion of upon the patient’s expectations and the best quality of life. beliefs. Panic disorder: Condition of having one or Plan of care: Nursing process and medical more panic attacks, followed by the fear orders that dictate a patient’s daily care. of having others. Postpartum blues: A transient, self-limiting Paranoid personality disorder: Consistent period of sadness that occurs in a woman pattern of suspiciousness and mistrust immediately after the birth of her baby. that interferes with functioning in Postpartum depression: A clinical depres- society. sion that occurs in a woman shortly after Paraphilic disorders: Intense and persistent the birth of her baby. sexual interest that goes outside the Postpartum psychosis: A sudden onset of bounds of usual behavior. These include psychotic symptoms that occurs in a pedophilia, exhibitionism, voyeurism, woman after the birth of her baby. and sadism. Post-traumatic stress disorder: Reaction to Parenting: Raising children; referring to witnessing or experiencing severe trauma styles of raising children. that was not expected (e.g., rape, war). 2993_Glos_395-404 14/01/14 5:30 PM Page 402

402 Glossary

Prejudice: Prejudging people or situations Reiki: A form of energy work incorporating before knowing all the facts. touch that manipulates the client’s energy Presupposition: Assumptions we make along body meridians or pathways. when forming communication. Religion: Set of beliefs about one’s spiritual- Primary gain: Relief of anxiety by use of ity, rituals, and worship. defense mechanisms or the act of remain- Respite care: Relief supplied to primary ing physically or mentally unhealthy. caregivers. Professional: Referring to performing a Responsibility: Accountability. skill for pay. Restorative: Pertaining to rehabilitation Proxemics: Study of spatial relationships that focuses on maintaining dignity and including space, time, and waiting, which achieving optimal function. are all influenced by one’s culture. Safe house: Specified “secret” place for people Pseudodementia: Depression in the elderly who are being abused to go for shelter. that mimics dementia. Schizo-affective disorder: A disorder mani- Psychoactive (psychotropic) drugs: Any fested by schizophrenic behaviors with drug that alters mood, perception, a strong element of mood disorders, in- mental functioning, and/or behavior. cluding depression or mania. Psychoanalysis: Method of psychotherapy Schizoid personality disorder: A pattern of based in Freudian theory; uses free associ- extreme detachment from social relation- ation and dream interpretation as part of ships and a restricted range of emotional the treatment. Treatment in this style is responses. usually long-term. Schizophrenia: Serious mental health Psychopharmacology: Medications as they disorder characterized by impaired com- are used and prescribed for mental illness. munication, alteration of reality, and Psychosexual: Referring to Freud’s theory of deterioration of personal and vocational personality and development in which be- functioning. havior is related to the sexual gratification Schizophrenia spectrum disorder: The or lack of it received in early development. gradient of psychopathology seen in Psychosis: A mental state in which there is a schizophrenia from least to most severe. severe loss of contact with reality. Schizotypal personality disorder: A per- Puberty: Stage of development at which sonality disorder characterized by odd sexual organs mature and one is capable and eccentric behaviors but not to the of reproducing. degree of schizophrenia. Purging: The act of attempting to rid the Scope of practice: Terminology used by body of calories by self-induced vomiting national and state/provincial licensing or the excessive use of laxatives or diuretics. boards for various professions that defines Rape: Violent sexual act that is performed the procedures, actions, and processes that against one’s will. are permitted for the licensee. Rapport: The matching of speech patterns Secondary gain: Response to illness that using auditory, kinesthetic, and visual results in attention, monetary benefits, references, which provide a starting point and the like. for meaningful communication. Self-mutilating behavior: Deliberate, self- Rational-emotive therapy (RET): Form injurious behavior such as cutting with of therapy involving a rational balance the intent of causing nonfatal injury to between thinking and feeling. attain the relief of tension. Receiver: The recipient of a message (infor- Sender: The party who transmits a message mation) sent by a sender. (information) to a receiver. Reflexology: Massage and manipulation of Sexual abuse: Unwanted sexual contact. the feet that acts upon energy pathways Sexual harassment: Unwanted sexual innu- in the body, unblocking and renewing endo, often inflicted by a workplace supe- the energy flow. rior on an employee or a subordinate. 2993_Glos_395-404 14/01/14 5:30 PM Page 403

Glossary 403

Shaken baby syndrome: A condition that Suicide: The act of purposefully taking one’s results from an infant’s being shaken own life. violently by the extremities or shoulders, Suicide attempt: Any act with the intention usually out of frustration and rage over of taking one’s own life in which the in- the child’s crying. dividual survived. Signal anxiety: Stress response to a known Suicide contract: Contract between the pa- stressor. tient and nurse (or significant other) in Social communication: The day-to-day inter- which the patient will call the designated action with personal acquaintances. Slang person when the patient has thoughts of or “street language” may be used. Less lit- suicide. eral and purposeful in social interactions. Suicide ideation: Thoughts about harming Sociopathic: See antisocial personality disorder. oneself. Somatic: Relating to or affecting the body. Suicide pact: Agreement made among a Somatic symptom disorders: A persistent group of people (often adolescents) to kill pattern of excessive and disproportionate themselves together. thoughts, feelings, and/or behaviors re- Superego: Third part of Freud’s personality lated to somatic symptoms. theory; the conscience, which deals with Somatization: Emotional turmoil that is morality. expressed by physical symptoms, often Survivor: One(s) remaining after the death loss of functioning of a body part. of another. Somatoform disorder: Physical discomfort Survivor guilt: Feeling of guilt at being a that resembles a medical condition that has survivor; often seen in post-traumatic no logical explanation or medical basis. stress disorder. Somatoform pain disorder: Anxiety that Survivor of suicide: Family or friend of an results in severe pain when no physical individual who commits suicide. cause can be found. Sympathy: Nontherapeutic technique of expe- Standards of care: Guidelines established riencing the emotion along with the patient. by specific health-care organizations with Tardive dyskinesia (TD): Involuntary the expectation that care being provided movements due to side effects of some does not fall below the minimum expec- antipsychotic drugs. tations of these organizations. Therapeutic communication: Communica- Stereotype: A general opinion or belief. tion that attempts to determine a patient’s Stimulants: Classification of medication needs. Also called active or purposeful that directly stimulates the central communication. nervous system. Thinking/cognition: The mental action or Stress: Emotional strain or anxiety. process of acquiring knowledge and un- Stressor: Condition that produces stress in derstanding through thought, experience, an individual. and the senses. Subjective: Based on personal feelings or Thought: An opinion, idea, or plan that is beliefs; often relates to patients reporting formed in one's mind. symptoms in their own words. Tolerance: The need for increasingly larger Substance abuse: The maladaptive and con- or more frequent doses of a substance to sistent use of a substance accompanied by obtain the desired effects. recurrent and significant negative conse- Tort: An action that wrongly causes harm to quences such as interpersonal, social, another but is not a crime and is dealt occupational, and legal problems. with in civil court. Substance dependence: A cluster of cogni- Trance: A state of altered awareness of a tive, behavioral, and physiological symp- client’s surroundings that brings the indi- toms that indicate that the individual vidual’s focus of attention to an internal continues use of the substance despite experience, such as a memory or an significant substance-related problems. imagined event. 2993_Glos_395-404 14/01/14 5:30 PM Page 404

404 Glossary

Unconscious: Referring to ideas and behav- Verbal communication: Process of exchang- iors that are concealed from awareness. ing information by the spoken or written Unintentional: An act that may result in word; the objective part of the process of injury or property damage and that is communication. determined to be accidental. Victim: A person who is harmed by another. Vascular dementia: Dementia caused by Visually impaired: Describes a person disruption in blood ﬂow to brain, as in with loss of complete or partial visual strokes. functioning. Verbal abuse: Method of harming an- Withdrawal: Negative physiological and other by using degrading, harsh, or psychological reactions that occur when foul language. a substance is reduced or no longer taken. 2993_Index_405-416 14/01/14 5:31 PM Page 405

■

Index

Advice, giving, as communication block, 27 A Advocacy, definition of, 395 AA (Alcoholics Anonymous), 267–268, 268t–269t, 387 Affect, definition of, 395 AAMN (American Association for Men in Nursing), 10, 388 Ageism, definition of, 395 AAPINA (Asian American/Pacific Islander Nurses Aggressive communication, 17, 395 Association), 10 Aging population, 335–348 AARP (American Association of Retired Persons), 387 abuse. See Elder abuse Abuse and violence, victims of, 353–366 Alzheimer’s disease, 338, 346t abuser cerebrovascular accident (stroke), 338–339, 338f, 346t characteristics of, 354–355 aphasia, 339 definition of, 395 depression associated with CVA, 338–339 child abuse, 356–357 cognitive impairments, 338, 346t nursing care plan, 364t depression, 339, 346t nursing interventions, 366t drug side effects, 340, 341t signs of, 356 end-of-life issues, 342–343 child neglect insomnia, 341–342, 346t nursing interventions, 366t medication concerns, 340, 341t, 346t domestic violence, 358–359 nursing skills for working with older adults, nursing interventions, 366t 344–345, 346t pattern typically followed, 359 overview, 335–338, 348 elder abuse, 359–361, 360f palliative care, 347–348 characteristics of victims and abusers, 361t paranoid thinking, 340, 346t economic abuse, 359–360 restorative nursing, 345, 347, 347f nursing interventions, 366t social concerns, 343–344, 343f emotional abuse, 354 Agnosia, definition of, 395 nursing interventions, 365t Agoraphobia, 164 neglect, 353, 366t Agraphia, definition of, 395 nursing care, 362–366 Ailurophobia, 163 general nursing interventions, 362–364, Akathisia, 114, 395 365t–366t Alcohol abuse, 264–270 nursing care plans, 364t–366t definition of, 395 nursing diagnoses, 362 etiology, 266 overview, 83, 353–354, 395 impact on health, 266 physical abuse, 353 impact on the family, 265 nursing interventions, 365t nursing care plan, 282t sexual abuse nursing interventions, 280t–281t nursing interventions, 365t treatment, 267–270, 268t–270t treatment, 361–362 withdrawal, 266–267, 270t respite care, 361 Alcohol dependence, 264, 395 safe houses, 361 Alcoholics Anonymous (AA), 267–268, 268t–269t, 387 verbal abuse, 354 Alcoholism, definition of, 264, 395 victims, characteristics of, 355, 355t Alternative and complementary treatment, 143–155 warning signs, 356t anxiety disorders, 168 Abuse, substance. Substance use and addictive disorders See aromatherapy, 145–146, 168 Accommodation, 65t, 395 biofeedback, 144–145, 145f, 168 Accountability, 41, 395 definitions Accuracy, 35–36 alternative medicine, 395 Acrophobia, 163–164 complementary medicine, 397 Adaptation, definition of, 395 herbal and nutritional therapy, 146–147, Addiction, definition of, 395 148t–149t, 174 Addictive disorders. Substance use and addictive See hypnotherapy, 151, 168 disorders massage, energy, and touch, 147, 150, 150f, 174 ADHD (attention-deficit/hyperactivity disorder), 308–312 mind, body, and belief, 144 definition of, 396 neurolinguistic programming, 151–152 nursing care, 311–312 overview, 143–144, 153, 154t, 155 treatment, 310–311 primary sensory representation, 152–153, 152t–153t Adolescents. Children and adolescents See somatic symptom and related disorders, 174 Adult stage of human development, 68t 405 2993_Index_405-416 14/01/14 5:31 PM Page 406

406 Index

Alzheimer, Alois, 248, 248f calcium channel blockers, 122 Alzheimer’s disease, 247–252, 338 definition of, 395 definition of, 395 lithium, 120–121, 121f, 197t differentiating from normal aging, 249t commonly used forms of lithium, 121 overview, 247–248, 249f nursing considerations, 121 stages, 248–251 toxicity, 197, 197t 1: no impairment (normal function), 248–249 nursing considerations, 121f 2: very mild cognitive decline, 249 side effects, 198t 3: mild cognitive decline, 249 Antiparkinson agents (anticholinergics), 115–116, 116f 4: moderate cognitive decline, 250 commonly used agents, 116 5: moderately severe cognitive decline, 250 definition of, 395 6: severe cognitive decline, 250 nursing considerations, 116, 116f 7: very severe cognitive decline, 250 Antipsychotics (neuroleptics/major tranquilizers), 114–115 symptoms, 248 commonly used agents, 115 treatment, 251–252, 251f, 252t atypical, 115 warning signs, 248 typical, 115 American Association for Men in Nursing (AAMN), 10, 388 definition of, 395 American Association of Retired Persons (AARP), 387 nursing considerations, 114–115, 236t–238t American Nurses Association (ANA), 5, 9, 34, 90, 395 side effects, 114–115, 236t–238t American Psychiatric Nurses Association (APNA), 9, 388, 395 Antisocial personality disorder, 219–220 Standards of Psychiatric–Mental Health Clinical Nursing definition of, 395 Practice, 34 nursing interventions, 224t Amphetamines, 271t Anxiety disorders, 159–170 Anabolic steroids, 275t alternative interventions, 168 Anhedonia, 182 aromatherapy, 168 definition of, 395 biofeedback, 168 Anorexia nervosa, 287–290 hypnotherapy, 168 definition of, 395 definition of anxiety, 160, 395 etiology, 289 differential diagnosis, 161–162, 161–163 nursing care plan, 296t DSM-5 revisions to anxiety disorders, 160, 162–163 similarities to bulimia, 292, 292t etiology of anxiety and stress, 161, 161f, 162t symptoms, 288–289 generalized anxiety disorder (GAD), 162–163, 171f treatment, 289 medical treatment, 167–168 Answers to test questions, 370–386 medications, 167, 168t Antabuse (disulfiram), 269–270 nursing care, 168–170, 169t–170t, 171f Antianxiety agents (anxiolytics/minor tranquilizers), nursing care plan, 170t 116–117, 117f nursing diagnoses, 168 nursing considerations, 116–117, 117f obsessive-compulsive disorder (OCD), 164–165, Anticholinergics, 115–116, 116f 165f commonly used agents, 116 overview, 160, 160f, 177 definition of, 395 panic disorder, 163, 171f nursing considerations, 116, 116f phobia, 163–164, 164f Anticholinergic side effects of antipsychotics, 238t post-traumatic stress disorder (PTSD), 165–166, Anticonvulsants, 121–122 167f commonly used agents, 122 Anxiolytics/minor tranquilizers, 116–117, 117f nursing considerations, 121–122 nursing considerations, 116–117, 117f Antidepressants (mood elevators), 117–120 Aphasia, definition of, 395 alternative treatments for depression, 120 Aphasic/dysphasic disorders commonly used agents, 117 communication challenges, 20–21, 29–30, 339 definition of, 395 picture board for patients, 29f monoamine oxidase inhibitors (MAOIs), 119–120 types of aphasia, 20t commonly used agents, 120 APIE format, 98–99 nursing considerations, 119–120 A = assessment, 98 nursing considerations, 120 P = plan, 98 overview, 118f I = implementation, 98–99 selective serotonin reuptake inhibitors (SSRIs, E = evaluation, 99 bicyclic antidepressants), 117–118 APNA (American Psychiatric Nurses Association), nursing considerations, 118, 118f 9, 388, 395 serotonin norepinephrine reuptake inhibitors (SNRIs), 119 Standards of Psychiatric–Mental Health Clinical Nursing commonly used agents, 119 Practice, 34 tetracyclic antidepressants (heterocyclic antidepressants), 119 Apraxia, definition of, 395 commonly used agents, 119 Arachnophobia, 164f tricyclic antidepressants, 118–119 Aromatherapy, 145–146 commonly used agents, 119 anxiety disorders, 168 nursing considerations, 119 definition of, 396 Antimanic agents (mood stabilizing agents), 120–123 Asian American/Pacific Islander Nurses Association anticonvulsants, 121–122 (AAPINA), 10 commonly used agents, 122 Assertive communication, 18, 396 nursing considerations, 121–122 Assessing the patient’s mental health, 90–95 2993_Index_405-416 14/01/14 5:31 PM Page 407

Index 407

Assimilation, 65t, 396 Bullying, 303, 396–397 Asylums, 8, 396 ByBerry (Philadelphia State Hospital), 8, 8f Attention-deficit/hyperactivity disorder (ADHD), 308–312 definition of, 396 nursing care, 311–312 C treatment, 310–311 Calcium channel blockers, 122 Autism spectrum disorder, 312–315 Cannabis, 271t definition of, 396 Carcinomatophobia, 163 nursing care, 314–315 Catatonia, 233 treatment, 314, 316t definition of, 396 Autonomy, 65t, 396 Catharsis, 125–126 Avoidance, 109t Cerebrovascular accident (stroke), 338–339, 338f Avoidant personality, definition of, 396 aphasia, 339 Avoidant personality disorder, 222 depression associated with, 338–339 nursing interventions, 224t Cerebrovascular disease, definition of, 396 Awareness, 90, 91t Charting, 35 definition of, 395 by exception, 35 flow-sheet charting, 35 legality challenges, 35 B Chemical restraint, definition of, 396 Bailey, Harriet, 6 Chi, 150 Behavior, definition of, 396 Child Abuse Prevention Association, 387 Behavioral theorists, 58 Children and adolescents, 303–318 Behavior modification, 126–127, 126f adolescent stage of human development, 67t definition of, 396 attention-deficit/hyperactivity disorder (ADHD), 308–312 Beliefs, definition of, 396 nursing care, 311–312 Bessent, Hattie, 7, 7f possible causes, 310 Bicyclic antidepressants, 117–118 symptoms, 309 nursing considerations, 118, 118f treatment, 310–311 Binge drinking, 265, 396 autism spectrum disorder, 312–315 Binge eating disorder, 291, 396 nursing care, 314–315, 315t Biofeedback, 144–145, 145f bullying and cyber bullying, 303 anxiety disorders, 168 child abuse, 356–357, 364t definition of, 396 nursing care plan, 364t Bipolar disorders, 193–200 nursing interventions, 366t characteristics, 193–195, 194t signs of, 356 cyclothymic disorder, 193, 194t conduct disorder, 315–318 depressed phase, 195 nursing care, 317–318 hypomania phases, 193 treatment, 316–317 manic phase, 193–195 depression, bipolar disorder, and suicide, 304–308 children and adolescents, 305 bipolar disorder, 305 definition of, 396 depression, 304, 305f etiology, 195–196 nursing care, 308, 308t drugs that can cause manic states, 196 suicide, 306–307, 306f nursing care, 198–199 treatment, 307 general nursing interventions, 198–199 developmental psychology of, 52–63. See also nursing care plan, 200t Developmental psychology nursing diagnoses, 198 neglect, 366t overview, 199 overview, 303–304, 318 treatment, 196–198, 197t–198t substance use and addictive disorders, 276 Bisexual lifestyle, 79 suicide, 306–307, 306f Bleuler, Eugen, 231, 232f Child Welfare Information Gateway, 387 Blues, postpartum, 323–324 Civil law, 35, 396 definition of, 401 Civil unions, 79 treatment, 324 Claustrophobia, 164 Body image, 287, 288f Club drugs, 270, 275t definition of, 396 Cluster A, personality disorders, 218–219 Body mass index (BMI), 292 paranoid personality disorder, 218 definition of, 396 schizoid personality disorder, 219 Borderline personality, definition of, 396 schizotypal personality disorder, 219 Borderline personality disorder, 220–221, 226t Cluster B, personality disorders, 219–222 nursing care plan, 226t antisocial personality disorder, 219–220 nursing interventions, 224t borderline personality disorder, 220–221 Bulimia, 290–292 histrionic personality disorder, 221 definition of, 396 narcissistic personality disorder, 221–222 etiology, 291 Cluster C, personality disorders, 222–223 similarities to anorexia, 292, 292t avoidant personality disorder, 222 symptoms, 291 dependent personality disorder, 222 treatment, 291–292 obsessive-compulsive personality disorder, 222–223 2993_Index_405-416 14/01/14 5:31 PM Page 408

408 Index

Cocaine, 272t Conversion reaction, 109t Co-dependency, 265, 281t, 396 Co-occurring disorders (dual diagnosis) Cognitive behavior therapy (CBT), 128, 138t definition of, 397 Cognitive, definition of, 396 substance use and addictive disorders, 262, 263f–264f Cognitive Development theory (Piaget), 54 Coping, definition of, 397 Cognitive impairments, 338 Coping and defense mechanisms, 105–110 Cognitive therapies, 127–128 coping, 105–106, 106f–107f cognitive behavior therapy (CBT), 128, 138t effective, 105–106 rational-emotive therapy (RET), 127–128, 127f ineffective, 106 Collaborative, definition of, 396 defense mechanisms, 107–110 Commitment, definition of, 396 commonly used, 108t–109t Communication, 15–30 overview, 110 aggressive, 17 Counseling, 129–132 assertive, 18 definition of, 397 challenges to, 19–21, 28–30 group therapy, 131–132 aphasic/dysphasic disorders, 20–21, 20t, 29–30, 29f overview, 129f hearing-impaired, 19, 28 pastoral or cultural counseling, 129–131, 130f, 131t, 132f language differences, 20, 29 Crisis, definition of, 397 laryngectomies, 20, 28–29 Crisis intervention, 134–136 visually impaired, 19–20, 28 goals, 135–136, 135f communication theory, 15 nursing considerations, 135f cultural implications, examples of, 17 phases of crisis, 134–135, 134t definition of, 16, 396 Cultural or pastoral counseling, 129–131, 130f, 131t, 132f ineffective, 21–23 Culture, 75–77, 75f 1. false reassurance/social clichés, 21 definition of, 397 2. minimizing/belittling, 21 Culture of nurses, 37–38, 38f 3. “why?”, 21–22 definition of, 397 4. advising, 22 Cyberbullying, 303, 397 5. agreeing or disagreeing, 22 Cyclothymic, definition of, 397 6. closed-ended questions, 22 Cyclothymic disorder, 193, 194t 7. providing the answer with the question, 22 8. changing the subject, 23 9. approving or disapproving, 23 D neurolinguistic programming, 18–19 Data collection, 90, 397 nonverbal, 16–17, 17f Date rape, 358, 397 overview, 15–16, 30 Death and dying, 69–70 social, 18 Decidophobia, 163 therapeutic/helping, 18, 21–28 Defense mechanisms, 107–110 1. reflecting, repeating, parroting, 24 commonly used, 108t–109t 2. clarifying terms, 24 definition of, 397 3. open-ended questions, 24–25 Deinstitutionalization, 9, 397 4. asking for what you need or want, 25 Delirium, 245–246 5. identifying thoughts and feelings, 25–26 causes, 247t 6. using empathy, 26 definition of, 397 7. silence, 26–27 differential diagnosis, 253, 253t 8. giving information, 27 treatment, 246 9. using general leads, 27 types, 246t 10. stating implied thoughts and feelings, 28 Delirium tremens (DTs), 267, 397 techniques, 23–28 Delusional disorder, 232t types of communication, 16 Delusions Communication block, definition of, 396 common, 234t Community Mental Health Centers Act of 1963, 12, 396–397 definition of, 397 Community resources, 45–46 Dementia, 247–253 Compensation, 108t Alzheimer’s disease. See Alzheimer’s disease Complementary medicine, 143 definition of, 397 definition of, 397 differential diagnosis, 253, 253t See also Alternative and complementary treatment miscellaneous types, 252–253 Compulsion, 165, 397 vascular dementia, 252, 403 Conduct disorder, 315–318 Denial, 108t, 279t definition of, 397 Dependent, definition of, 397 nursing care, 317–318 Dependent personality disorder, 222 treatment, 316–317 nursing interventions, 225t Confidentiality, 38–39, 39f Depressed phase, bipolar disorders, 195 definition of, 397 Depression and Bipolar Support Alliance, 387 doctrine of privileged information, 38 Depressive disorders, 181–189 Conversion, definition of, 397 associated with another medical condition, 184–185 Conversion disorder, 172–173 associated with cerebrovascular accident (stroke), nursing care, 172–173175t 338–339 2993_Index_405-416 14/01/14 5:31 PM Page 409

Index 409

children and adolescents, 304, 305f Dysmorphophobia, definition of, 397 cultural considerations, 181 Dysphasia, definition of, 397 definition of, 397 Dysphasic/aphasic disorders drugs that can cause, 185 communication challenges, 20–21, 29–30, 339 dysthymic disorder, 183 picture board for patients, 29f elderly patients, 339 types of aphasia, 20t etiology, 185 Dysthymic disorder, 183, 397 major depressive disorder, 181–183, 183f Dystonia, 114, 397 differentiating grief from, 182, 184t major depressive disorder with seasonal pattern, 183–184 E nursing care, 186–188 Eating disorders, 287–297 general nursing interventions, 186–187 anorexia nervosa, 287–290 nursing care plan, 188t etiology, 289 nursing diagnoses, 186 nursing interventions, 296t overview, 181, 182f, 188 similarities to bulimia, 292, 292t postpartum, 183, 324–326 symptoms, 288–289 treatment, 325–326 treatment, 289 premenstrual dysphoric disorder, 184–185 binge eating disorder, 291 substance-induced depressive disorder, 184 bulimia, 290–292 treatment, 185–186 etiology, 291 alternative treatment, 186 nursing interventions, 296t medications, 186, 187t similarities to anorexia, 292, 292t Detoxification, 268, 397 symptoms, 291 Developmental psychology, 51–71 treatment, 291–292 adolescence to adulthood, 56–63 morbid obesity, 292–294 Freud, 56–58 etiology, 293 Horney, 58, 58f nursing interventions, 296t Jung, 62–63, 63f treatment, 293–294 Maslow, 60–62, 60f–61f nursing care, 294–296 Pavlov, 58–59, 58f general nursing interventions, 295, 296t Rogers, 62, 62f, 63t nursing care plan, 296t Skinner, 58–60, 59f, 59t nursing diagnoses, 294 newborn to adolescence, 52–56 overview, 287, 297 Erikson, 52–53, 54f, 54t–55t Echolalia, definition of, 398 Freud, 52, 52f, 53t Echoparaxia, definition of, 398 Kohlberg, 54–56, 56f, 57t Economic abuse, 359–360 Piaget, 53–54, 55f definition of, 398 overview, 51–52, 71 Economic considerations, 82–83 stages of human development, 63–70 ECT (electroconvulsive therapy), 132–133, 132f adolescent, 67t definition of, 398 adult, 68t Effective coping, definition of, 398 death and dying, 69–70 Ego, definition of, 398 infant, 65t Elder abuse, 359–361, 360f newborn, 64t characteristics of victims and abusers, 361t older adult, 68t definition of, 398 prenatal, 64t economic abuse, 359–360 preschool (early childhood), 66t nursing interventions, 366t school age, 66t–67t Elderly. See Aging population toddler, 65t Electroconvulsive therapy (ECT), 132–133, 132f young adult, 68t definition of, 398 Displacement, 109t Ellis, Albert, 127 Dissociate, definition of, 397 Emotional abuse, 354 Dissociation, 108t definition of, 398 Disulfiram (Antabuse), 269–270 nursing interventions, 365t Dix, Dorothea, 5, 5f Empathy, 26, 398 Doctrine of privileged information, 38, 397 End-of-life issues, 342–343 Domestic violence, 358–359 Energy, massage, and touch, 147, 150, 150f definition of, 397 “Epic” charting program, 35 nursing interventions, 366t EPS (extrapyramidal symptoms), 114–115, pattern typically followed, 359 236–237 Dream analysis, 124–125 akathisia, 114 Drug-induced parkinsonism, 114 definition of, 398 DTs (delirium tremens), 267 drug-induced parkinsonism, 114 definition of, 397 dystonia, 114 Dual diagnosis, 262, 263f–264f. See also Co-occurring tardive dyskinesia, 115 disorders Erikson, Erik, 52–53, 54f, 54t–55t Dysfunctional, definition of, 397 eight stages of development, 54t–55t 2993_Index_405-416 14/01/14 5:31 PM Page 410

410 Index

Ethics and law, 11–12, 33–46 Geriatrics, 335 abiding by current laws, 41–42 definition of, 398 Good Samaritan laws, 41–42 Gerontology, 335 involuntary commitment, 42 definition of, 398 voluntary commitment, 42 Gilligan, Carol, 62 accountability, 41 Global aphasia, 20t accuracy, 35–36 Glossary, 395–403 charting, legality challenges to, 35 Good Samaritan laws, 41–42 Community Mental Health Centers Act of 1963, 12 Grandiosity, 279t community resources, 45–46 Grief, differentiating from depression, 182, 184t confidentiality, 38–39, 39f Grief/death and dying, stages of, 69–70, 69t culture of nurses, 37–38, 38f children, 70 ethics, 34, 398 elderly, 342 Health Insurance Portability and Accountability Act Group therapy, 131–132 (HIPAA), 40, 398 Hill-Burton Act, 11 H honesty, 36 Hallucinations impaired nurses, 36 definition of, 398 Joint Commission (JC), 40 recognizing, 234t National Mental Health Act of 1946, 12 Hallucinogens, 272t NFLPN Nursing Practice Standards, 391 Harm, intentional and unintentional, 35 Nurse Practice Act, 34–35 Health-illness continuum, definition of, 398 overview, 46 Health Insurance Portability and Accountability Act patient advocacy, 45 (HIPAA), 40, 398 Patient Bill of Rights, 12, 42, 401 Hearing impaired, 15 patients’ rights, 42–45, 43t–44t communication challenges, 19, 28 professionalism, 33–34 definition of, 398 psychotherapies and, 137–138 Helping interview, 94–95, 94f responsibility, 41 Hematophobia, 164 standards of care, 34 Herbal and nutritional therapy, 146–147, 148t–149t Ethnicity, 78–79 depressive disorders, 186 definition of, 398 somatic symptom and related disorders, 174 Ethnocentrism, 78 Heterocyclic antidepressants, 119 definition of, 398 commonly used agents, 119 Eustress, 160 Hierarchy of Needs (Maslow), 60, 61f, 391 definition of, 398 love and belonging, 61 Evaluation, definition of, 398 physiological needs, 60 Expressive aphasia, 20t safety and security, 60–61 Extrapyramidal symptoms (EPS), 114–115, 236–237 self-actualization, 62 akathisia, 114 self-esteem, 61–62 definition of, 398 Hill-Burton Act, 11, 398 drug-induced parkinsonism, 114 HIPAA (Health Insurance Portability and dystonia, 114 Accountability Act), 40, 398 tardive dyskinesia, 115 History, 3–13 breakthroughs, 8–11 F deinstitutionalization, 9 Factitious disorder, 173 nursing organizations and recommendations, 9–11 Feeling, definition of, 398 psychotropic medications, 9 Feeling statement, definition of, 398 facilities, 8 Fiduciary abuse, 359 asylums, 8 Fight-or-flight response, 161, 161f free-standing facilities, 8 Flow-sheet charting, 35 hospitals, 8 Formal teaching, 97, 398 laws, 11–12 Free association, 124 Community Mental Health Centers Act of 1963, 12 Free-floating anxiety, 160 Hill-Burton Act, 11 definition of, 398 National Mental Health Act of 1946, 12 Free-standing treatment centers, 8, 398 Patient Bill of Rights, 12, 42, 401 Freud, Sigmund, 52, 52f, 53t, 56–58 overview, 12–13 psychoanalytic or psychosexual stages of trailblazers, 3–7 development, 52, 53t Bailey, 6 Bessent, 7, 7f Dix, 5, 5f G Mahoney, 6, 6f Gay lifestyle, 79 Nightingale, 3–5, 4f Gay marriage, 79 Peplau, 6–7, 7f Generalized anxiety disorder (GAD), 162–163, 171f, 398 Richards, 5, 5f nursing care, 169t Taylor, 6, 6f 2993_Index_405-416 14/01/14 5:31 PM Page 411

Index 411

Histrionic personality disorder, 221 nursing interventions, 225t L La belle indifférence, 173, 399 Holistic view, definition of, 398 Language differences and communication challenges, Homeless, definition of, 398 20, 29 Homelessness, 81–82, 81f Laryngectomee, definition of, 399 deinstitutionalization and, 82–83 Laryngectomy nursing techniques, 82 communication challenges, 20, 28–29 Honesty, 36 definition of, 399 Horney, Karen, 58, 58f Learning, principles of, 98 Hospice and Palliative Nurses Association (HPNA), 348 Legal matters. Ethics and law Hospitals, 8 See Lesbian, gay, bisexual, and transgender (LGBT) Humanist theories, 60 lifestyles, 79 Humor therapy, 133–134, 133f Lethality, definition of, 399 Hyperactivity, definition of, 398 Light therapy Hypnosis, 125, 125f depressive disorders, 186 definition of, 399 Lithium, 120–121, 121f, 197, 197t Hypnotherapy, 151 commonly used forms of lithium, 121 anxiety disorders, 168 nursing considerations, 121 definition of, 399 toxicity, 197, 197t Hypochondriasis, 172–173 Longfellow, H.W., 4 definition of, 399 Love and belonging Hypomania, definition of, 399 Maslow’s Hierarchy of Needs, 61 Lunar month, definition of, 399 I Id, definition of, 399 M Illness anxiety disorder, 173 Mahoney, Mary, 6, 6f nursing care, 175t Major depressive disorder, 181–183, 183f Illusions, 238, 399 definition of, 399 Impaired nurses, 36 differentiating grief from, 182, 184t Implementations/interventions, 96–100 Major tranquilizers. See Antipsychotics definition of implementation, 399 Malingering, 173 evaluating, 100 definition of, 399 nursing process, 96t Mania, definition of, 399 patient teaching, 97–100 Manic phase, bipolar disorders, 193–195 principles of learning, 98 Manipulation, 279t principles of teaching, 98–100 Maslow, Abraham, 60–62, 60f–61f Impulsivity, definition of, 399 Hierarchy of Needs, 60, 61f, 391 Incest, 358 love and belonging, 61 definition of, 399 physiological needs, 60 Ineffective communication, definition of, 399 safety and security, 60–61 Ineffective coping, definition of, 399 self-actualization, 62 Infant stage of human development, 65t self-esteem, 61–62 Informal teaching, 97, 399 Massage, energy, and touch, 147, 150, 150f Inhalants, 272 Memory, definition of, 399 Insidious, definition of, 399 Menarche, 67t Insomnia definition of, 399 definition of, 399 Mental health, definition of, 399 elderly patients, 341–342 Mental Health America, 387 Intake/admission interview, 94 Mental health status examination, 91t–93t Integrative medicine, definition of, 399 Mental illness, definition of, 399 Intentional, definition of, 399 Message, 16, 399 Involuntary commitment, 42 Methamphetamine, 271t, 276f Isolation, 109t Mild neurocognitive disorder, 248 Milieu, 123 definition of, 399 J Mind, body, and belief, 144 Joint Commission (JC), 40 Mind-body connection, definition of, 399 Judgment, definition of, 399 Minimizing, 279t Jung, Carl, 62–63, 63f Minor tranquilizers, 116–117, 117f nursing considerations, 116–117, 117f K Models, definition of, 399 Ki, 150 Monoamine oxidase inhibitors (MAOIs), 119–120 Kohlberg, Lawrence, 54–56, 56f, 57t commonly used agents, 120 development of moral reasoning, 54–56, 57t definition of, 399 Kübler-Ross, Elisabeth, 69–70, 69f, 69t nursing considerations, 119–120 stages of grief/death and dying, 69–70, Mood, definition of, 399 69t, 342 Mood stabilizing agents. See Antimanic agents 2993_Index_405-416 14/01/14 5:31 PM Page 412

412 Index

Morbid obesity, 292–294 NHPCO (National Hospice & Palliative Care definition of, 400 Organization), 387 etiology, 293 NIC (Nursing Interventions Classifications), 97–98 treatment, 293–294 definition of, 400 Myths concerning suicide, 206t Nicotine, 273t Nightingale, Florence, 3–5, 4f NIMH (National Institute of Mental Health), 12 N NLN (National League for Nursing), 5, 10, 400 NAHN (National Association of Hispanic Nurses), 10, 389 NOC (Nursing Outcome Classifications) NANDA (North American Nursing Diagnosis definition of, 400 Association), 95, 400 Nocturnal delirium, 245 NAPNES (National Association for Practical Nurse definition of, 400 Education and Service), 10, 388, 400 Nontraditional lifestyles, 79–80, 80f Narcissistic personality, definition of, 400 Nonverbal communication, 16–17, 17f Narcissistic personality disorder, 221–222 definition of, 400 nursing interventions, 225t North American Nursing Diagnosis Association (NANDA), National Alaska Native American Indian Nurses 95, 400 Association (NANAINA), 10 Nurse Practice Act, 10, 34–35 National Alliance on Mental Illness, 387 definition of, 400 National Association for Practical Nurse Education and Nursing diagnosis, 95 Service (NAPNES), 10, 388, 400 common behaviors and corresponding nursing National Association of Hispanic Nurses (NAHN), 10, 389 diagnoses, 393–394 National Black Nurses Association (NBNA), 10, 389 definition of, 400 National Coalition of Ethnic Minority Nurse Nursing interventions, 281t Associations (NCEMNA), 10, 388 Nursing Interventions Classifications (NIC), 96 National Council of Alcohol and Drug Dependence, 387 definition of, 400 National Federation of Licensed Practical Nurses (NFLPN), Nursing organizations, history of, 9–11 10, 34, 388, 400 Nursing Outcome Classifications (NOC), 97 Code for Licensed Practical/Vocational Nurses, 390 definition of, 400 Standards of Nursing Practice, 34, 390–392 Nursing process in mental health, 89–101, 90f, 96t National Hospice & Palliative Care Organization definition of, 400 (NHPCO), 387 overview, 89–90, 90f, 101 National Institute of Mental Health (NIMH), 12, 387 step 1: assessing the patient’s mental health, 90–95 National League for Nursing (NLN), 5, 10, 400 helping interview, 94–95, 94f National Mental Health Act of 1946, 12, 400 intake/admission interview, 94 National Mental Health Association, 387 mental health status examination, 90, 91t–93t NBNA (National Black Nurses Association), 10, 389 step 2: nursing diagnosis: defining patient NCEMNA (National Coalition of Ethnic Minority Nurse problems, 95 Associations), 10, 388 step 3: planning (short- and long-term goals), Neglect, 353, 366t 95–96 definition of, 400 step 4: implementations/interventions, 96–100 Neurocognitive disorders, 245–257 nursing process, 96t definition of, 400 patient teaching, 97–100 delirium, 245–246 principles of learning, 98 causes, 247t principles of teaching, 98–100 differential diagnosis, 253, 253t step 5: evaluating interventions, 100 treatment, 246 Nyctophobia, 163 types, 246t dementia, 247–253 Alzheimer’s disease. See Alzheimer’s disease O differential diagnosis, 253, 253t Obesity, definition of, 400 miscellaneous types, 252–253 OBRA (Omnibus Budget Reconciliation Act), vascular dementia, 252, 403 337, 400 nursing care, 253–257 Obsession, 165 general nursing interventions, 254–256 definition of, 400 nursing care plan, 256t Obsessive-compulsive disorder (OCD), 164–165, 165f nursing diagnoses, 253 definition of, 400 overview, 245, 257 compulsion, 165 Neuroleptic malignant syndrome, 115 nursing care, 170t Neuroleptics. See Antipsychotics obsession, 165 Neurolinguistic programming, 18–19, 151–152 Obsessive-compulsive personality disorder, 222–223 definition of, 400 definition of, 400 presuppositions, 152 nursing interventions, 225t Newborn stage of human development, 64t Odontophobia, 163 NFLPN (National Federation of Licensed Practical Nurses), Older adults. See Aging population 10, 34, 388, 400 Omnibus Budget Reconciliation Act (OBRA), Code for Licensed Practical/Vocational 337, 400 Nurses, 390 Operant conditioning, 59, 59t Standards of Nursing Practice, 34, 390–392 Ophidiophobia, 164f 2993_Index_405-416 14/01/14 5:31 PM Page 413

Index 413

Opioids, 273t carcinomatophobia, 163 Orientation, definition of, 400 claustrophobia, 164 common, list of, 163 decidophobia, 163 P definition of, 401 Palliative care, 347–348 hematophobia, 164 definition of, 400–401 nursing care, 169t Panic, definition of, 401 nyctophobia, 163 Panic disorder, 163, 171f odontophobia, 163 nursing care, 169t ophidiophobia, 164f Paranoid personality disorder, 218 scoleciphobia, 163 nursing interventions, 225t–116t social phobias, 164 Paranoid thinking in older adults, 340 thanatophobia, 163 Parenting, 83–84 Physical abuse, 353 authoritarian, 83–84 definition of, 401 authoritative parents, 84 nursing interventions, 365t definition of, 401 Physical restraint, definition of, 401 permissive parents, 84 Physician-assisted suicide, 70 poor, 83–84 Physiological needs Pastoral or cultural counseling, 129–131, 130f, 131t, 132f Maslow’s Hierarchy of Needs, 60 Patient advocacy, 45 Piaget, Jean, 53–54, 55f Patient Bill of Rights, 12, 42, 401 developmental theory of, 56t Patient interview, 94 Placebos, 144, 401 definition of, 401 Planning (short- and long-term goals), 95–96 Patients’ rights, 42–45 Plan of care, 95, 401 most frequently adopted, 43t–44t PNAA (Philippine Nurses Association of America), 10 Patient Bill of Rights, 12, 42, 401 Positive regard, unconditional, 128–129 Patient Self-Determination Act (PSDA), 45 Postpartum issues, 323–330 for psychiatric patients, 45 nursing care, 328–329 Patient teaching, 97–100 general nursing interventions, 328–329 Pavlov, Ivan, 58–59, 58f nursing care plan, 329t Peplau, Hildegard, 6–7, 7f, 160 nursing diagnoses, 328 collaborative therapeutic relationship, 7 overview, 323, 330 nursing functions, 6–7 postpartum blues, 323–324, 401 Personality, definition of, 401 treatment, 324 Personality disorders, 217–227 postpartum depression, 183, 324–326, 401 cluster A, 218–219 contributing factors, 325 paranoid personality disorder, 218 symptoms, 325 schizoid personality disorder, 219 treatment, 325–326 schizotypal personality disorder, 219 postpartum psychosis, 326–328, 401 cluster B, 219–222 treatment, 326–328 antisocial personality disorder, 219–220 Post-traumatic stress disorder (PTSD), 165–166, 167f borderline personality disorder, 220–221 definition of, 401 histrionic personality disorder, 221 nursing care, 170t narcissistic personality disorder, 221–222 Prana, 150 cluster C, 222–223 Prejudice, 78, 401 avoidant personality disorder, 222 Premenstrual dysphoric disorder, 184–185 dependent personality disorder, 222 Prenatal infants, stage of human development, 64t obsessive-compulsive personality disorder, 222–223 Preschool children (early childhood), stage of human definition of, 401 development, 66t nursing care, 223–226 Presuppositions, 152, 401 general nursing interventions, 224t–226t Primary gain, 173 nursing care plan for borderline personality disorder, 226t definition of, 401 nursing diagnoses, 223 Primary sensory representation, 152–153, 152t–153t overview, 217–218, 227 Professional, definition of, 401 psychiatric treatment, 223 Professionalism, 33–34 Person-centered, definition of, 401 Projection, 109t, 279t Person-centered/humanistic therapy, 60, 128–129, 128f Proxemics, 37–38 unconditional positive regard, 128–129 definition of, 401 Pet therapy, 134 PSDA (Patient Self-Determination Act), 45 Phencyclidine, 274t Pseudodementia, 247 Philadelphia State Hospital (ByBerry), 8, 8f definition of, 401 Philippine Nurses Association of America (PNAA), 10, 389 Psychoactive (psychotropic) drugs, 9, 114, 261 Phobias, 163–164, 164f definition of, 401 acrophobia, 163–164 Psychoanalysis, 124–125 agoraphobia, 164 definition of, 401 ailurophobia, 163 dream analysis, 124–125 arachnophobia, 164f free association, 124 2993_Index_405-416 14/01/14 5:31 PM Page 414

414 Index

psychoanalytic or psychosexual stages of development Religion, 76–77 (Freud), 52, 53t definition of, 402 psychoanalytic social theory (Horney), 58 Repression, 108t Psychopharmacology, 114–123 Respite care, 361, 402 antianxiety agents (anxiolytics/minor tranquilizers), Responsibility, 41, 402 116–117, 117f Restitution (undoing), 109t antidepressants (mood elevators). See Antidepressants Restorative, definition of, 402 (mood elevators) Restorative nursing, 345, 347, 347f antimanic agents (mood stabilizing agents). See RET (rational-emotive therapy), 127–128, 127f, 401 Antimanic agents (mood stabilizing agents) Richards, Linda, 5, 5f antiparkinson agents (anticholinergics), 115–116, 116f Rogers, Carl, 62, 62f antipsychotics (neuroleptics/major tranquilizers), 114–115 eight steps to being a helping person, 62, 63t definition of, 401 Rolfing, 147 stimulants, 122–123, 122f Psychosexual, definition of, 401 Psychosis, 232 S definition of, 401 Safe house, 361, 402 postpartum, 326–328, 401 Safety and security treatment, 326–328 Maslow’s Hierarchy of Needs, 60–61 Psychotherapies, 123–136 SAMe, 120 behavior modification, 126–127, 126f, 138t Scapegoating, 109t catharsis, 125–126 Schizoaffective disorder, 232t, 402 cognitive therapies, 127–128 Schizoid personality disorder, 219 cognitive behavior therapy (CBT), 128, 138t nursing interventions, 226t rational-emotive therapy (RET), 127–128, 127f, 138t Schizophrenia spectrum and other psychotic disorders, counseling, 129–132 231–241 group therapy, 131–132, 138t definition of, 402 overview, 129f delusions, common, 234t pastoral or cultural counseling, 129–131, 130f, 131t, etiology, 234–235 132f, 138t hallucinations, recognizing, 234t crisis intervention, 134–136, 138t nursing care, 238–240 goals, 135–136, 135f nursing care plans, 239t–240t phases of crisis, 134–135, 134f nursing diagnoses, 238 electroconvulsive therapy (ECT), 132–133, 132f, 138t nursing interventions, 238–239, 240t humor therapy, 133–134, 138t other disorders with schizophrenic features, 232t hypnosis, 125, 125f overview, 231–234, 232t, 233f, 240 legal considerations, 137–138 psychiatric treatment, 235, 237 overview, 124–125, 124f, 138–139, 138t–139t side effects of antipsychotic agents, 236t–238t person-centered/humanistic therapy, 128–129, 128f, 138t symptoms unconditional positive regard, 128–129 negative, 233–234 pet therapy, 134 positive, 233–234 psychoanalysis, 124–125 Schizophreniform disorder, 232t dream analysis, 124–125 Schizotypal personality disorder, 219, 232t free association, 124 definition of, 402 Psychotropic (psychoactivve) medications, 9, 114, 261 nursing interventions, 226t definition of, 401 School age children, stage of human development, 66t–67t PTSD (post-traumatic stress disorder), 165–167, 167f Scoleciphobia, 163 definition of, 401 Scope of practice, 89 nursing care, 170t Secondary gain, 173 Puberty, 67t, 401 definition of, 402 Purging, 288, 401 Sedatives, hypnotics, and antianxiety drugs (commonly abused), 274t Selective serotonin reuptake inhibitors (SSRIs, bicyclic R antidepressants), 117–118 Rape, 358, 401 nursing considerations, 118, 118f Rapport, 152 Self-actualization definition of, 401 Maslow’s Hierarchy of Needs, 62 Rational-emotive therapy (RET), 127–128, 127f Self-mutilating behavior, 220, 221f, 402 definition of, 401 Sender, 16, 402 Rationalization, 108t, 279t Serotonin norepinephrine reuptake inhibitors (SNRIs), 119 Reaction formation (over-compensation), 108t commonly used agents, 119 Receiver, 16, 401 Sexual abuse, 357–358 Receptive aphasia, 20t definition of, 402 Reflexology, 150, 150f nursing interventions, 365t definition of, 402 Sexual harassment, 357 Regression, 108t definition of, 402 Reiki, 150 Shaken baby syndrome, 356, 402 definition of, 402 Shiatsu, 150 2993_Index_405-416 14/01/14 5:31 PM Page 415

Index 415

Signal anxiety, 160, 402 Substance use and addictive disorders, 261–283 Skinner, B.F., 58–60, 59f, 59t alcohol, 264–270 operant conditioning, 59, 59t etiology of abuse, 266 SNRIs (serotonin norepinephrine reuptake inhibitors), 119 etiology of alcohol abuse, 266 commonly used agents, 119 impact on health, 266 Social communication, 18, 402 impact on the family, 265 Social phobias, 164 nursing care plan, 282t Sociocultural influences on mental health, 75–84 nursing interventions, 280t–281t abuse, 83 symptoms, 280t–281t cultural assessment questions, 77 treatment, 267–270, 2268t–270t cultural sensitivity, enhancing, 79 withdrawal, 266–267, 270t culture, 75–77, 75f children and teens, 276 economic considerations, 82–83 co-occuring disorders (dual diagnosis), 262, ethnicity, 78–79 263f–264f homelessness, 81–82, 81f etiology, 276–277 nontraditional lifestyles, 79–80, 80f nursing care, 278–282 overview, 75, 84 coping styles of substance abusers, 279t poor parenting, 83–84 diagnoses, 278–279 Sociopathic, definition of, 402 general nursing interventions, 279–281, Somatic symptom and related disorders, 170–177 280t–281t alternative interventions, 174 nursing care plan, 282 herbal/nutritional supplements, 174 overview, 261–264, 282 massage, 174 substances other than alcohol, 270–276, medical treatment, 173–174 271t–275t medications, 174t amphetamines, 271t nursing care, 174–177, 175t, 176f anabolic steroids, 275t communication skills, 175 cannabis, 271t socialization and group activities, 175 club drugs, 275t support, 175, 177 cocaine, 272t nursing diagnoses, 174 hallucinogens, 272t overview, 177 inhalants, 272 somatic symptom disorder (SSD), 170, 172 methamphetamine, 271t, 276f differential diagnosis, 172 nicotine, 273t etiology, 172 nursing interventions, 281t nursing care, 175t opioids, 273t somatic symptom related disorders, 172–173 phencyclidine, 274t conversion disorder, 172–173, 175t sedatives, hypnotics, and antianxiety drugs, 274t factitious disorder, 173 symptoms, 281t illness anxiety disorder, 173, 175t tobacco, 261, 262f Somatization, definition of, 402 treatment, 277–278 Somatoform disorder, 170, 402 Suicide, 205–212 Somatoform pain disorder, 402 attempts, 205 SSRIs (selective serotonin reuptake inibitors), 117–118 children and adolescents, 306–307, 306f nursing considerations, 118, 118f cultural considerations, 207 Standards of care, 5, 34 definition of, 402 definition of, 402 etiology, 207–208 Standards of nursing practice for LPNs/LVNs, 390–392 risk factors, 207 National Federation of Licensed Practical Nurses warning signs, 207–208 (NFLPN) Code for Licensed Practical/ lethality, 205–206, 211 Vocational Nurses, 390 methods, 206–207 NFLPN Nursing Practice Standards, 390–392 myths concerning, 206t NFLPN Specialized Nursing Practice Standards, 392 nursing care, 209–212 Stereotype, 77 general nursing interventions, 210–211 definition of, 402 nursing care plan, 212t Stimulants, 122–123, 122f nursing diagnoses, 209 commonly used agents, 123 talking with suicidal patient to evaluate lethality, 211 definition of, 402 overview, 205–207, 206f, 212 nursing considerations, 123 pacts, 205 Stress, definition of, 402 risk factors, 207 Stress adaptation responses, 162t treatment of individuals at risk, 208–209 Stressor, 160, 402 Suicide attempt, definition of, 402 Stroke, 338–339, 338f Suicide contract, definition of, 402 aphasia, 339 Suicide ideation, definition of, 403 depression associated with, 338–339 Suicide pact, definition of, 403 Sublimation, 109t Sundowner syndrome (nocturnal delirium), 245, 341 Substance abuse, definition of, 402 Superego, definition of, 403 Substance dependence, definition of, 402 Survivor, definition of, 403 Substance-induced depressive disorder, 184 Survivor guilt, 166, 403 2993_Index_405-416 14/01/14 5:31 PM Page 416

416 Index

Survivor of suicide, definition of, 403 antiparkinson agents (anticholinergics), 115–116, Swedish massage, 147 116f Sympathy, 26, 403 antipsychotics (neuroleptics/major tranquilizers), 114–115 stimulants, 122–123, 122f T psychotherapies. See Psychotherapies Tarasoff vs. Regents of the University of California, 38 Tricyclic antidepressants, 118–119 Tardive dyskinesia (TD), 115, 403 commonly used agents, 119 Taylor, Effie Jane, 6, 6f nursing considerations, 119 Teaching, principles of, 98–100 Twelve-step groups, 268, 268t–269t Terrorism, 136–137 Test question answers and rationales, 370–386 Tetracyclic antidepressants (heterocyclic antidepressants), 119 U commonly used agents, 119 Unconscious, definition of, 403 Thanatophobia, 163 Unconscious behaviors, 52 Therapeutic/helping communication, 18, 21–28, 403 Unintentional, definition of, 403 techniques, 23–28 Thought, definition of, 403 Tobacco, 261, 262f V Toddler stage of human development, 65t Vascular dementia, 252, 403 Tolerance, 263, 403 Verbal abuse, 354, 403 Tort, 35, 403 Verbal communication, definition of, 403 Touch, massage, and energy, 147, 150, 150f Victim, definition of, 403 Trance, definition of, 403 Victims of abuse, characteristics of, 355, 355t Tranquilizers Violence. See Abuse and violence, victims of Visually impaired people major. See Antipsychotics minor, 116–117, 117f communication challenges, 19–20, 28 Transgender lifestyle, 79 definition of, 403 Treatments, 113–140 Voluntary commitment, 42 milieu, 123 overview, 113–114 W psychopharmacology, 114–123 Warning signs of suicide, 207–208 antianxiety agents (anxiolytics/minor tranquilizers), Withdrawal, 263 116–117, 117f definition of, 403 antidepressants (mood elevators). See Antidepressants (mood elevators) antimanic agents (mood stabilizing agents). See Y Antimanic agents (mood stabilizing agents) Young adult stage of human development, 68t

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